Jan P. Bembenek

Deep venous thrombosis in acute stroke patients.

Deep venous thrombosis (DVT) is a complication of stroke. Our aim was to determine the frequency of DVT in patients with acute stroke, risk factors for its development, and its influence on the 3-month outcome. A total of 323 consecutive patients with acute stroke were enrolled. We performed ultrasound imaging within 7 days after stroke. Deep venous thrombosis was found in 8.7% of patients, only in those with ischemic stroke. Patients with DVT were more frequently female (71.4% vs 49.5%), had prestroke Modified Rankin scale (mRS) 3 to 5 (42.9% vs 15.3%), elevated C-reactive protein (CRP) serum level (65.4% vs 32.5%), and a trend toward elevated serum fibrinogen level (85.7% vs 70.1%; P = .08). In a multivariate analysis, elevated CRP (odds ratio [OR] 3.15) and prestroke disability (OR 2.89) were independent risk factors for DVT. Deep venous thrombosis occurs in <10% of patients with acute stroke and does not significantly affect the 3-month outcome. Prestroke dependency and elevated CRP level at baseline are independent risk factors for DVT.

Temporal trends in vascular risk factors and etiology of urban Polish stroke patients from 1995 to 2013

BACKGROUND Despite estimates about general trends in stroke epidemiology worldwide, there are only a few reports of detailed longitudinal data and none of them reflects the economic transition that occurred in Central and Eastern Europe over the last two decades. The aim of this study was to investigate long term trends in risk factors and their pre-stroke control as well as acute stroke clinical presentation and etiology in Polish urban setting. METHODS This is a retrospective registry-based analysis of consecutive acute stroke patients from a highly urbanized area (Warsaw, Poland) admitted to a single stroke center between 1995 and 2013. Patients were divided into four time periods: 1995-1999 (n=529), 2000-2004 (n=1253), 2005-2009 (n=1320) and 2010-2013 (n=871). RESULTS During the study period 3973 first-ever stroke patients were admitted. The proportion of ischaemic strokes (88.2% to 90.9%) and male patients (45.2% to 46.2%) remained stable throughout the whole study period. Admitted patients became older (72, 73, 74 and 76years, consecutive time periods), were more likely to be diagnosed with hypertension (from 61.1% to 72.8%) and disable (84.3% to 67.4%) prior to stroke. There was an increase in pre-stroke use of antihypertensives in patients with hypertension (from 77.8% to 90.5%), antiplatelets in patients with coronary artery disease (from 33.9% to 56.5%), vitamin K antagonists in patients with atrial fibrillation (from 6.3% to 39.8%) and statins (from 7.6% to 26.3%). There was a decrease in mean stroke severity (9, 11, 8 and 6 points on the National Institutes of Stroke Scale) on admission and the proportion of strokes attributed to small-vessel disease (22.0%, 20.0%, 10.6% and 8.3%). CONCLUSIONS Over the last two decades the profile of urban Polish stroke patients has changed significantly and it can be attributed to marked economic improvement in Poland since 1990s. Increasing age and better management of pre-existing vascular risk factors were accompanied by decreasing stroke severity and lower proportion of strokes attributed to small-vessel disease.

How many Patients might Receive Thrombolytic Therapy in the Light of the ECASS-3 and IST-3 Data?:

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Fibrin clot characteristics in acute ischaemic stroke patients treated with thrombolysis: the impact on clinical outcome

Fibrin clot properties in acute ischaemic stroke (AIS) are unfavourably altered, including faster formation of denser and poorly lysable fibre networks. We investigated clot properties in AIS patients treated with recombinant tissue plasminogen activator (rtPA) and their impact on clinical outcome. In 74 consecutive AIS patients eligible for rtPA treatment, we assessed ex vivo plasma fibrin clot formation, permeability (Ks), and rtPA-induced lysis, along with peak thrombin generation, fibrinolysis proteins and inhibitors at three time points - on admission, after 24 hours and 3 months since stroke. Clinical outcome was assessed using the NIHSS and mRS scores. Compared with the pretreatment values, fibrin networks assessed 24 hours since thrombolysis were formed more slowly (+20.5 % lag phase on turbidimetry), were less compact (+36.9 % Ks), composed of thinner fibres (-10.6 % lower maximum absorbancy [ΔAb]), which were lysed more rapidly (-20.8 % clot lysis time [CLT] and +7.1 % the rate of rtPA-induced D-dimer release from clots [D-Drate]). Thrombin generation and fibrinolysis proteins remained elevated. Lower ΔAb (<0.86 at 405 nm), shorter CLT (<105 min), and higher D-Drate (>0.072 mg/l/min) assessed at baseline predicted good outcome (mRS 0-2) at 3 months after adjustment for age and fibrinogen. Logistic regression adjusted for potential confounders showed that good outcome at 3 months was predicted by pretreatment D-Drate, while pretreatment CLT predicted excellent outcome (mRS of 0-1). In conclusion, formation of denser fibrin clots displaying impaired lysability and pattern of their changes induced by thrombolysis may affect clinical outcome in AIS patients.

Changes in pre-hospital management of vascular risk factors among patients admitted due to recurrent stroke in Poland from 1995 to 2013.

Introduction The aim of this study was to investigate long-term trends in secondary stroke prevention through management of vascular risk factors directly before hospital admission for recurrent stroke. Material and methods This is a retrospective registry-based analysis of consecutive recurrent acute stroke patients from a highly urbanized area (Warsaw, Poland) admitted to a single stroke center between 1995 and 2013 with previous ischemic stroke. We compared between four consecutive time periods: 1995–1999, 2000–2004, 2005–2009 and 2010–2013. Results During the study period, 894 patients with recurrent strokes were admitted (18% of all strokes), including 867 with previous ischemic stroke (our study group). Among those patients, the proportion of recurrent ischemic strokes (88.1% to 93.9%) (p = 0.319) and males (44% to 49.7%) (p = 0.5) remained stable. However, there was a rising trend in patients’ age (median age of 73, 74, 76 and 77 years, respectively). There was also an increase in the use of antihypertensives (from 70.2% to 83.8%) (p = 0.013), vitamin K antagonists (from 4.8% to 15.6%) (p = 0.012) and statins (from 32.5% to 59.4%) (p < 0.001). Nonetheless, 21% of patients did not receive any antithrombotic prophylaxis. Tobacco smoking pattern remained unchanged. Conclusions Our data indicate a clear overall improvement of secondary stroke prevention. However, persistent use of antithrombotic drugs and tobacco smoking after the first ischemic stroke is constantly suboptimal.

Early stroke-related DVT is more than just DVT diagnosed early after stroke onset

Deep vein thrombosis (DVT) is a serious complication of stroke, which may result in pulmonary embolism (PE) and increase mortality. It occurs in 1-75% of patients, depending on the applied methodology (ranging from clinical symptoms to I fibrinogen scanning) [1]. In a recent large clinical trial (n=2518) proximal DVT was diagnosed in 10% of immobile stroke patients allocated to graduated compression stockings (GCS) and 10.5% in the control group [2]. Our study was designed to identify the frequency of DVT in consecutive acute stroke patients and evaluate its impact on outcome. Additionally, we wanted to distinguish between DVT that was certainly developed during the hospital stay and DVT diagnosed early after stroke butmost likely being a pre-existing condition. This is the first study addressing the issue of stroke-related DVT from this perspective.

Infections Diagnosed after Admission to a Stroke Unit and Their Impact on Hospital Mortality in Poland from 1995 to 2015

BACKGROUND Implementation of modern stroke unit care might have attenuated the negative effect of infections on stroke outcome. Our aim was to investigate changes in the occurrence of pneumonia and urinary infections diagnosed after admission to experienced Polish stroke center between 1995 and 2015, and their association with hospital mortality. MATERIALS AND METHODS This is a retrospective registry-based analysis of consecutive patients with acute stroke from highly urbanized area (Warsaw, Poland) in years 1995-2015. A total of 5174 patients were divided to 4 time periods: 1995-2000 (n = 883), 2001-2006 (n = 1567), 2006-2010 (n = 1539), and 2011-2015 (n = 1183). Odds ratios (ORs) for hospital death were calculated after adjustment for age, congestive heart failure, preexisting disability, stroke type, and baseline neurological deficit, separately in years 1995-2015, 1995-2000, and 2011-2015. RESULTS Over time there was a significant decrease in the proportion of patients diagnosed with pneumonia (20%, 19%, 9%, and 15%, respectively) or urinary tract infection (29%, 21%, 24%, and 18%, respectively) and in the proportion of patients having body temperature of 38.0°C or higher at least once within first 7 days of hospital stay (20%, 20%, 13%, and 13%, respectively), without significant change in the use of antibiotics (range 35%-37%). Hospital mortality was strongly predicted by pneumonia (OR 3.6-4.2) and fever (OR 2.7-4.7) but not urinary infections. CONCLUSIONS Over the last 2 decades there was a decrease in the proportion of patients with acute stroke diagnosed with pneumonia or urinary tract infection during stroke unit stay. Hospital death was strongly predicted by pneumonia and fever but no by urinary infections.

Noninfectious complications of acute stroke and their impact on hospital mortality in patients admitted to a stroke unit in Warsaw from 1995 to 2015

BACKGROUND Medical complications often worsen the prognosis after stroke. Our aim was to investigate the association between particular noninfectious complications and hospital mortality of acute stroke patients admitted to an urban Polish stroke center, and changes in their occurrence from 1995 to 2015. METHODS This is a retrospective analysis of 5174 consecutive patients admitted for acute ischemic stroke or cerebral hemorrhage to a Polish urban stroke center between 1995 and 2015. The occurrence of complications was reported for years 1995-2000 (n=883), 2001-2006 (n=1567), 2006-2010 (n=1539) and 2011-2015 (n=1183). Odds ratios (OR) with 95% confidence interval (95% CI) for stroke unit death were calculated after adjustment for age, congestive heart failure (CHF), pre-existing disability, stroke type and baseline neurological deficit in three different time periods. RESULTS Over time there was a significant decrease in the occurrence of myocardial infarction (MI) (2.2%, 1.4%, 1.0% and 0.3%, respectively), exacerbated CHF (4.6%, 5.1%, 2.6% and 2.0%) and deep vein thrombosis (DVT) (4.6%, 2.7%, 1.2% and 1.1%). Adjusted odds for stroke unit death were increased by myocardial infarction (MI) (OR 17.5, 95% CI: 8.5-35.7), exacerbated CHF (OR 15.0, 95% CI: 9.8-23.0), pulmonary embolism (PE) (OR 11.5, 95% CI: 6.1-21.6), gastrointestinal bleeding (OR 9.2, 95% CI: 4.4-18.9) and recurrent stroke (OR 5.4, 95% CI: 3.1-9.3). CONCLUSIONS Over the last two decades Polish urban stroke units may have achieved a significant reduction of the occurrence of some noninfectious complications (i.e. MI, exacerbated CHF and DVT). However, the list of conditions associated with stroke unit mortality includes not only MI and exacerbated CHF but also PE, gastrointestinal bleeding and recurrent stroke.

A survey to establish current methods of venous thromboembolism prophylaxis in stroke patients practiced by Polish neurologists

Introduction Venous thromboembolism (VTE) is associated with considerable morbidity and mortality in stroke patients. The purpose of our survey was to establish the current methods of VTE prophylaxis practiced by Polish neurologists. We also aimed to determine whether there is enough variation in practice to justify the development of an evidence-based guideline for VTE prevention. Material and methods Postal self-administered questionnaires about VTE prophylactic methods practiced by Polish neurologists were sent to 218 neurological wards where stroke is treated. If no response was received, the questionnaire was faxed and finally we attempted to obtain information by telephone. Results One hundred and seventy-six (80.7%) stroke centers of 218 responded. The majority (137/176; 77.8%) of centers had a stroke unit. The median admission rate of surveyed wards was estimated to be 320 patients/year (range from 20 to 1000 patients/year). The most common method of VTE prophylaxis reported was low molecular weight heparin (LMWH) (98.9%), and the least common was intermittent pneumatic compression (IPC) (6.8%). Centers admitting ≥ 200 patients/year (70.7% vs. 45%; p = 0.039), and those with stroke units (95 vs. 20; p = 0.031) were more willing to join a randomized trial evaluating any of the methods. All the centers participating in the survey reported a need for a detailed VTE prophylaxis guidelines. Conclusions The LMWH is the predominant VTE prophylaxis strategy for stroke patients practiced by Polish neurologists. Due to the variation of methods used in VTE prophylaxis it might be reasonable to further specify this section of stroke treatment guidelines.

The association between routine serum C-reactive protein and outcome in ischemic stroke patients treated with intravenous alteplase

WCN 2013 No: 1779 Topic: 3 — Stroke Long-term imaging follow-up in patients with adequately coiled basilar tip aneurysms is essential to timely detect late reopening M. van Eijck, W.J. van Rooij, M. Sluzewski, G. Roks. St. Elisabeth Ziekenhuis, Tilburg, The Netherlands Background and objective: Reopening after coiling at mid-term follow-up is more frequent in basilar tip aneurysms than in aneurysms at other locations. To quantify this phenomenon of late reopening, we performedMRA at 3 T in a cohort of patients with basilar tip aneurysms coiled between 1994 and 2005, that were adequately occluded at shortor mid-term and had no imaging follow-up in the last 7 years. Patients and methods: Between 1994 and 2005, 148 patients with basilar tip aneurysms were coiled. In 2012, 29 were deceased and 56 had prolonged imaging follow-up after previous reopening and/or retreatment. Of the remaining 63 patients, 11 were untraceable, 11 were not eligible because of contra-indications for MRI or poor clinical condition, and 9 refused follow-up MRA. Finally, 32 patients with adequately coiled basilar tip aneurysms and without imaging follow-up in the last 7 years were scheduled for MRA follow-up after a mean of 12.8 years (median 12.7, range 7–19 years). Results: Of 32 patients, 31 had MRA and 1 patient had angiography after a rebleed 5 days before scheduled MRA. Four of 32 patients (12.5%) had late reopening of the coiled basilar tip aneurysm requiring additional coiling. Conclusions: Basilar tip aneurysms that are adequately occluded at shortor mid-term after treatment may reopen (and rebleed) many years later with a frequency of 1 in 8 in this cohort. In patients with coiled basilar tip aneurysms, prolonged imaging follow-up at regular intervals is recommended to timely detect late reopening. doi:10.1016/j.jns.2013.07.930 Abstract — WCN 2013 No: 2320 Topic: 3 — Stroke The association between routine serum C-reactive protein and outcome in ischemic stroke patients treated with intravenous alteplase WCN 2013 No: 2320 Topic: 3 — Stroke The association between routine serum C-reactive protein and outcome in ischemic stroke patients treated with intravenous alteplase M.A. Karlinski, J. Bembenek, K. Grabska, A. Kobayashi, A. Baranowska, T. Litwin, A. Czlonkowska. 2nd Department of Neurology, Medical University of Warsaw, Warsaw, Poland; Interventional Stroke Treatment Centre, Institute of Psychiatry and Neurology, Medical University of Warsaw, Warsaw, Poland; Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland Background: The clinical usefulness of blood biomarkers in acute stroke is not yet fully established, especially after intravenous thrombolysis. Objective: Our aim was to investigate the association between routine serum C-reactive protein (CRP) measured very early after stroke and outcome in patients treated with intravenous thrombolysis, adjusting for a history of recent infection. Patients and methods:We analyzed the data of consecutive patients treated with intravenous alteplase in our center between October 2003 and December 2011. The information was prospectively collected in a detailed registry. Patients or their proxies were additionally interviewed for a history of an infectious event during 7 days before stroke onset. Routine serum CRP was measured within 24 h from admission, concentration N5 ng/ml was considered elevated. Results: Serum CRP was measured in 341/406 patients treated with intravenous rt-PA. Patients with elevated CRP (135/341, 42.5%) compared to those with normal CRP values, were significantly older, more frequently presented with a pre-existing disability, comorbidities and suffered more severe strokes. They had a higher proportion of symptomatic intracranial hemorrhage according to ECASS II definition (7.2% vs 1.6%, p = 0.010), higher 3-month mortality (25.6% vs 11.3%, p = 0.001), and were less frequently alive and independent after 3 months (45.9% vs 63.7%, p = 0.002). However, those associations were not confirmed in a multivariate analysis. Conclusions: Routine serum CRP determined very early after stroke may be helpful in establishing long-term prognosis for patients treated with intravenous thrombolysis. Elevated CRP seems to coexist with other factors associated with poor outcome. doi:10.1016/j.jns.2013.07.931 Abstract — WCN 2013 No: 2422 Topic: 3 — Stroke Cerebral perfusion changes in symptomatic and asymptomatic patients with carotid artery stenosis WCN 2013 No: 2422 Topic: 3 — Stroke Cerebral perfusion changes in symptomatic and asymptomatic patients with carotid artery stenosis A. Sergeeva, R. Konovalov, M. Krotenkova, M. Piradov. Radiology, Research Center of Neurology, Russian Academy of Medical Sciences, Moscow, Russia; Intensive Care, Research Center of Neurology, Russian Academy of Medical Sciences, Moscow, Russia Background: Optimal strategy of ischemic stroke prevention in symptomatic and asymptomatic patients with severe internal carotid artery (ICA) stenosis may depend on the impairment of cerebral hemodynamics. Objective: To evaluate changes in cerebral perfusion, measured with CT perfusion imaging, in symptomatic and asymptomatic patients with ICA stenosis N70%. Patients and methods: We studied 39 patients with unilateral carotid artery stenosis N70% (19 symptomatic and 20 asymptomatic patients, median age 67 years; study group) and 40 otherwise healthy subjects with mild hypertension (median age 60 years; control group). Patients underwent CT perfusion at the level of the basal ganglia and semioval center. Mean transit time (MTT), cerebral blood volume (CBV), and cerebral blood flow (CBF) were calculated in the middle cerebral artery area. Results: In symptomatic patients MTT and CBV values were significantly different in study vs. control group (median MTT: 7.1 s vs 4.4 s, p b 0.01; median CBV: 3.4 ml/100 g vs. 3.7 ml/100 g, p b 0.05, respectively). In asymptomatic patients only MTT increased significantly in study group (5.7 s vs 4.4 s, p b 0.01, respectively). Conclusion: Both symptomatic and asymptomatic patients with carotid stenosis N70% demonstrated deterioration of cerebral perfusion. The pattern of changes may indicate that cerebral blood flow autoregulation is more severely impaired in symptomatic patients than in asymptomatic ones. This may lead to the more weighted approach to the stroke prevention. doi:10.1016/j.jns.2013.07.932 Abstracts / Journal of the Neurological Sciences 333 (2013) e215–e278 e239