Jiann-Der Lee

Predictors of Clinical Deterioration during Hospitalization following Acute Ischemic Stroke

Background/Aims: A number of risk factors for early worsening of neurological symptoms have been identified. We aimed to evaluate the influence of hemorheologic, biochemical, and metabolic factors on neurological deterioration during hospitalization following acute ischemic stroke and develop a model of neurological deterioration. Methods: Worsening of stroke was defined as a deleterious increase in NIH Stroke Scale (NIHSS) score of ≧4 points during hospitalization. We performed multivariate logistic regression analysis and constructed a prediction model based on chart data of 2,398 patients admitted at five medical centers; 203 of the patients had worsening of stroke and 2,186 had not. Results: The results of multivariate logistic regression analysis showed that hemoglobin (odds ratio: 0.529) and albumin (odds ratio: 0.024) were significantly associated with stroke deterioration, as were the modified Rankin Scale on emergency department admission (odds ratio: 4.956) and length of hospitalization (odds ratio: 1.201). After adjusting for age, gender and NIHSS on emergency department admission, only hemoglobin (odds ratio: 0.894, 95% confidence interval: 0.814–0.981, p = 0.018) was associated with worsening. Conclusion: Hemoglobin and albumin were found to be risk factors for persistent neurological deterioration during hospitalization following acute ischemic stroke, suggesting that blood viscosity may be related to neurological deterioration.

Clinical features and outcomes of spinal cord infarction following vertebral artery dissection: a systematic review of the literature

Abstract Objective: Spinal cord infarction (SCI) is a rare complication of vertebral artery dissection (VAD). Its clinical features and outcomes have not yet been well documented. Methods: In addition to reporting a case with bilateral SCI caused by left VAD, we performed a systematic review of the literature conducted through a PubMed search. Results: A total of 17 cases were reviewed (nine men and eight women). The average age was 40·5±14·6 years. In addition to neck pain or headache (88%), patients with VAD-associated SCI often presented with a sensory level (76%) or Brown–Séquard syndrome (53%). The most common regions of dissection were at the V1 or proximal V2 segments, and the infarcted area of SCI was mainly located at C2–C5 levels. Regarding the vascular territory, posterior spinal artery infarction was noted in 29% of patients, spinal sulcal artery infarction in 42%, and anterior spinal artery (ASA) watershed infarction in 29%. Eleven patients (65%) had a good outcome and six patients (35%) had a poor outcome (including one mortality; 6%). Smoking, age above 50 years, and ASA watershed infarction were associated with a poor outcome, while spinal sulcal artery infarction was associated with a good outcome. Conclusion: Neck pain or headache is an important warning symptom of VAD, and the presence of a concomitant sensory level or Brown–Séquard syndrome is helpful for the early diagnosis of SCI caused by VAD. One-third of patients had a poor outcome, and smoking, old age, and ASA watershed infarction represented important risk factors.

Shortened Activated Partial Thromboplastin Time Is Associated With Acute Ischemic Stroke, Stroke Severity, and Neurological Worsening

BACKGROUNDnThe role played by hemostasis in the pathogenesis of ischemic strokes is still controversial. The activated partial thromboplastin time (APTT) measures the time necessary to generate fibrin from initiation of the intrinsic pathway. In the present study, we looked for a possible association of ischemic strokes with the shortened APTT.nnnMETHODSnThe study population consisted of 154 patients with acute ischemic strokes who had been admitted from December 2013 to December 2014 to the Department of Neurology, Chiayi Chang Gung Memorial Hospital, and 71 control subjects with no history of stroke.nnnRESULTSnIn a univariate risk analysis, shortened APTT was associated with an odds ratio (OR) for acute ischemic strokes of up to 1.86 (95% confidence interval [CI], 1.06-3.29, P = .031). In a multivariate analysis using a logistic regression model including age, sex, hypertension, diabetes mellitus, and shortened APTT, shortened APTT was still found to significantly add to the risk of ischemic stroke (OR = 2.12 with 95% CI, 1.13-3.98, P = .020). Shortened APTT was also associated significantly with neurological worsening (OR = 3.72 with 95% CI 1.03-13.5, P = .046). As for stroke severity, shortened APTT was associated with an OR for moderate/severe stroke of up to 3.42 (95% CI, 1.53-7.61, P = .003).nnnCONCLUSIONnShortened APTT is a prevalent and independent risk factor for ischemic stroke, stroke severity, and neurological worsening after acute stroke.

Utilization of Statins Beyond the Initial Period After Stroke and 1‐Year Risk of Recurrent Stroke

Background In‐hospital discontinuation of statins has been linked to poorer early stroke outcomes, but the consequences of postdischarge discontinuation or dose reduction of statin treatment are unknown. The objective of this study was to explore the effects of statin discontinuation or statin dose reduction on recurrent stroke risk. Methods and Results We conducted a nationwide cohort study using the data from the Taiwan National Health Insurance Research Database. Our source population comprised all patients who were prescribed a statin within 90 days of discharge after an ischemic stroke between 2001 and 2012. Patients were categorized into 3 groups: statin‐discontinued, statin‐reduced, and statin‐maintained. Cox proportional hazard models were used to estimate the hazard ratios and 95%CIs of recurrent stroke during 1‐year follow‐up in the groups who discontinued statins or reduced statin dose compared with the group who maintained statins as the reference. Among the 45 151 ischemic stroke patients meeting criteria, during the day‐90 to day‐180 period, 7.0% were on reduced statin therapy, and 18.5% were not on any statin therapy. Compared with maintained‐statin intensity therapy, discontinuation of statins was associated with an increased hazard of recurrent stroke (adjusted hazard ratio 1.42, 95%CI 1.28‐1.57), whereas reduced‐statin dose was not associated with an additional risk (adjusted hazard ratio 0.94, 95%CI 0.78‐1.12). Propensity‐matching analysis obtained similar results. Conclusions Discontinuation of statin therapy between 3 and 6 months after an index ischemic stroke was associated with a higher risk of recurrent stroke within 1 year after statin discontinuation.

Hypoalbuminemia and Not Hyperhomocysteinemia as a Risk Factor for Dementia in Hemodialysis Patients

BACKGROUNDnThe most common causes of morbidity and mortality in uremic patients are cardiovascular disease and central nervous system dysfunction. However, the exact causes of dementia in uremic patients remain unclear. This study attempted to determine which risk factors are associated with dementia in hemodialysis patients.nnnMETHODSnIn total, 147 chronic uremic patients receiving regular hemodialysis treatment were recruited. Data for risk factors regarding cardiovascular disease and dementia, such as hypertension, diabetes mellitus, smoking, age, illiteracy, serum levels of albumin, cholesterol, triglycerides, and homocysteine, and liver function, were recorded. The Mini-Mental Status examination was used to assess mental function, and the Hachinski ischemic scale was applied to differentiate among dementia types. The diagnosis of dementia was based on criteria from the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition.nnnRESULTSnTwenty-six patients were diagnosed as manifesting dementia. Of all patients with dementia, 21 had a Hachinski score of 0 to 4, and 5 had a score of 7 to 10. In a multiple logistic regression analysis, low serum albumin and illiteracy were significantly associated with dementia. However, no difference existed between the two groups in terms of homocysteine levels.nnnCONCLUSIONSnThis study demonstrated that uremic patients were prone to nonvascular dementia. We conclude that hypoalbuminemia and not hyperhomocysteinemia is a risk factor for dementia in hemodialysis patients.

Causes of Death in Different Subtypes of Ischemic and Hemorrhagic Stroke

Causes of death in both ischemic stroke (IS) and hemorrhagic stroke (HS) subtypes are not comprehensively studied. Between 2008 and 2011, we enrolled 11 215 first-ever stroke patients from the Stroke Registry of Chang-Gung Healthcare System and linked these data to the national death registry. The main causes of death in each stroke subtype were assessed. Patients with HS had higher overall mortality than IS (32.0% vs 18.1%, P < .001). In IS subtypes, large-artery atherosclerosis plus cardioembolism had the worst mortality (40.7%, P < .001). Stroke was the leading cause of death in both IS and HS within the first year. Stroke remained the major cause of death in HS, but cancer was the leading cause of death in IS after the first year. After excluding the patients with previous cancer history, cancer was still an important cause of death in IS and HS, particularly in the IS subtypes of small vessel occlusion, stroke of undetermined etiology, and transient ischemic attack.

Derivation and Validation of a Scoring System for Intravenous Tissue Plasminogen Activator Use in Asian Patients

BACKGROUND AND PURPOSEnAs Chinese Asian populations have an increased risk of intracerebral hemorrhage (ICH) after intravenous tissue plasminogen activator (IV tPA), we aimed to design a rapid, clinically applicable risk scoring system to predict ICH and functional outcomes after IV tPA treatment in Asian ischemic stroke patients.nnnMETHODSnFrom January 2009 to December 2012, consecutive acute ischemic stroke patients treated with IV tPA recruited from the Stroke Registry in Chang Gung Healthcare System (SRICHS) in Taiwan and the National University Hospital of Singapore (NUHS) acute stroke database were used to create and validate a scoring system. Nomogram was created for ICH and 3-month mortality.nnnRESULTSnIn total, 932 patients were included in the study: 386 from SRICHS for the derivation of scoring system and 546 from NUHS to validate it. We used nomograms to assign weightage to the scoring system. The presence of atrial fibrillation, glucose level, and the National Institutes of Health Stroke Scale (NIHSS) score were significantly associated with the risk of ICH. Age, NIHSS score, hyperlipidemia, and the presence of post-tPA ICH were significantly associated with mortality. The areas under the curve of derivation and validation cohorts were .663 and .662 for ICH, and .808 and .790 for mortality, respectively.nnnCONCLUSIONSnThe scoring system using nomograms can provide a fast, practical, and user-friendly tool that allows physicians to predict the risk of ICH and functional outcomes with IV tPA treatment in a clinical setting.

Prediction of in-hospital stroke mortality in critical care unit

BackgroundCritical stroke causes high morbidity and mortality. We examined if variables in the early stage of critical stroke could predict in-hospital mortality.MethodsWe recruited 611 ischemic and 805 hemorrhagic stroke patients who were admitted within 24xa0h after the symptom onset. Data were analyzed with independent t test and Chi square test, and then with multivariate logistic regression analysis.ResultsIn ischemic stroke, National Institutes of Health Stroke Scale (NIHSS) score (OR 1.08; 95xa0% CI 1.06–1.11; Pxa0<xa00.01), white blood cell count (OR 1.11; 95xa0% CI 1.05–1.18; Pxa0<xa00.01), systolic blood pressure (BP) (OR 0.49; 95xa0% CI 0.26–0.90; Pxa0=xa00.02) and age (OR 1.03; 95xa0% CI 1.00–1.05; Pxa0=xa00.03) were associated with in-hospital mortality. In hemorrhagic stroke, NIHSS score (OR 1.12; 95xa0% CI 1.09–1.14; Pxa0<xa00.01), systolic BP (OR 0.25; 95xa0% CI 0.15–0.41; Pxa0<xa00.01), heart disease (OR 1.94; 95xa0% CI 1.11–3.39; Pxa0=xa00.02) and creatinine (OR 1.16; 95xa0% CI 1.01–1.34; Pxa0=xa00.04) were related to in-hospital mortality. Nomograms using these significant predictors were constructed for easy and quick evaluation of in-hospital mortality.ConclusionVariables in acute stroke can predict in-hospital mortality and help decision-making in clinical practice using nomogram.

Choices for long-term hypertensive control in patients after first-ever hemorrhagic stroke: a nationwide cohort study

Background: To compare the long-term clinical outcomes of different antihypertensive drugs in stable patients after acute hemorrhagic stroke (HS). Methods: From January 2001 to December 2013, patients with first-ever primary HS were identified in the National Health Insurance Research Database, Taiwan. Patients with traumatic intracerebral hemorrhage and secondary HS were excluded. Those with first-ever HS were recruited and classified into three groups: (1) angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB); (2) calcium channel blocker (CCB); and (3) other antihypertensive drugs (comparison) groups. Propensity score matching was used to balance the distribution of baseline characteristics, stroke severity, and medications between any two of the three groups. A validation study was performed using the databank of the Stroke Registry in Chang-Gung Healthcare System to reduce the bias. Primary outcomes were recurrent HS, ischemic stroke, any stroke, and all-cause mortality. Results: Compared to the comparison group, the ACEI/ARB group [35.4% versus 39.3%; hazard ratio (HR), 0.84; 95% confidence interval (CI), 0.74–0.95] and CCB group (33.0% versus 41.9%; HR, 0.72; 95% CI, 0.64–0.81) had a lower risk of all-cause mortality during long-term follow up. The CCB group had a similar risk of all-cause mortality to the ACEI/ARB group. Risks of recurrent HS, ischemic stroke, or any stroke were not different between the study groups. Conclusions: Antihypertensive drug class could be important to long-term outcomes in HS patients in addition to the target control of blood pressure. Both ACEIs/ARBs and CCBs are associated with lower risks of all-cause mortality. Our results may be applied to inform future research on hypertensive control in HS patients.

Genomic screening of Fabry disease in young stroke patients: the Taiwan experience and a review of the literature

Fabry disease is an X‐linked disease, and enzyme‐based screening methods are not suitable for female patients.