Joan Massons

Cerebral infarction in diabetes: Clinical pattern, stroke subtypes, and predictors of in-hospital mortality

BackgroundTo compare the characteristics and prognostic features of ischemic stroke in patients with diabetes and without diabetes, and to determine the independent predictors of in-hospital mortality in people with diabetes and ischemic stroke.MethodsDiabetes was diagnosed in 393 (21.3%) of 1,840 consecutive patients with cerebral infarction included in a prospective stroke registry over a 12-year period. Demographic characteristics, cardiovascular risk factors, clinical events, stroke subtypes, neuroimaging data, and outcome in ischemic stroke patients with and without diabetes were compared. Predictors of in-hospital mortality in diabetic patients with ischemic stroke were assessed by multivariate analysis.ResultsPeople with diabetes compared to people without diabetes presented more frequently atherothrombotic stroke (41.2% vs 27%) and lacunar infarction (35.1% vs 23.9%) (P < 0.01). The in-hospital mortality in ischemic stroke patients with diabetes was 12.5% and 14.6% in those without (P = NS). Ischemic heart disease, hyperlipidemia, subacute onset, 85 years old or more, atherothrombotic and lacunar infarcts, and thalamic topography were independently associated with ischemic stroke in patients with diabetes, whereas predictors of in-hospital mortality included the patients age, decreased consciousness, chronic nephropathy, congestive heart failure and atrial fibrillationConclusionIschemic stroke in people with diabetes showed a different clinical pattern from those without diabetes, with atherothrombotic stroke and lacunar infarcts being more frequent. Clinical factors indicative of the severity of ischemic stroke available at onset have a predominant influence upon in-hospital mortality and may help clinicians to assess prognosis more accurately.

Trends in Risk Factors, Stroke Subtypes and Outcome

Background: Prospective stroke registries allow analyzing important aspects of the natural history of acute cerebrovascular events. Using the Sagrat Cor Hospital of Barcelona Stroke Registry, we aimed to determine trends in risk factors, stroke subtypes, prognosis and in-hospital mortality over 19 years in hospitalized stroke patients. Methods: The study population consisted of 2,416 first-ever stroke patients (ischemic stroke, n = 2,028; intracerebral hemorrhage, n = 334) included in the stroke registry up to December 31, 2004. Temporal trends in stroke patient characteristics for the periods 1986–1992, 1993–1998 and 1999–2004 were assessed. Results: Age was significantly different among the analyzed periods (p < 0.001), showing an increment in older patients throughout time. Hypertension (p = 0.001), diabetes (p = 0.004), ischemic heart disease (p = 0.002) and atrial fibrillation increased (p = 0.000) as opposed to heavy smoking (p = 0.000) and history of TIA (p = 0.025). The mortality rate and the length of hospital stay decreased (p = 0.001), whereas transfer to convalescent/rehabilitation units increased (p = 0.001). Conclusions: An improvement in acute-stroke management and possibly evolution of cerebrovascular risk factors is reflected by changes in the risk factors and outcome of first-ever stroke patients admitted to a stroke unit over a 19-year time span.

Clinical Features and Functional Outcome of Intracerebral Hemorrhage in Patients Aged 85 and Older

The importance of studies of older stroke victims is growing because of the changes in the age structure of Western populations. We determined demographic characteristics, clinical features, neuroimaging data, and outcome of acute spontaneous intracerebral hemorrhage occurring in people aged 85 and older.

Pretreatment with statins improves early outcome in patients with first-ever ischaemic stroke: a pleiotropic effect of statins or a beneficial effect of hypercholesterolemia?

BackgroundData from different studies suggest a favourable association between pretreatment with statins or hypercholesterolemia and outcome after ischaemic stroke. We examined whether there were differences in in-hospital mortality according to the presence or absence of statin therapy in a large population of first-ever ischaemic stroke patients and assessed the influence of statins upon early death and spontaneous neurological recovery.MethodsIn 2,082 consecutive patients with first-ever ischaemic stroke collected from a prospective hospital-based stroke registry during a period of 19 years (1986-2004), statin use or hypercholesterolemia before stroke was documented in 381 patients. On the other hand, favourable outcome defined as grades 0-2 in the modified Rankin scale was recorded in 382 patients.ResultsEarly outcome was better in the presence of statin therapy or hypercholesterolemia (cholesterol levels were not measured) with significant differences between the groups with and without pretreatment with statins in in-hospital mortality (6% vs 13.3%, P = 0.001) and symptom-free (22% vs 17.5%, P = 0.025) and severe functional limitation (6.6% vs 11.5%, P = 0.002) at hospital discharge, as well as lower rates of infectious respiratory complications during hospitalization. In the logistic regression model, statin therapy was the only variable inversely associated with in-hospital death (odds ratio 0.57) and directly associated with favourable outcome (odds ratio 1.32).ConclusionsUse of statins or hypercholesterolemia before first-ever ischaemic stroke was associated with better early outcome with a reduced mortality during hospitalization and neurological disability at hospital discharge. However, statin therapy may increase the risk of intracerebral haemorrhage, particularly in the setting of thrombolysis.

Clinical study of 99 patients with pure sensory stroke

ObjectiveWe report a clinical description of pure sensory stroke based on data collected from a prospective acute stroke registry.MethodsFrom 2500 acute stroke patients included in a hospital-based prospective stroke registry over a 12-year period, 99 were identified as having pure sensory stroke.ResultsPure sensory stroke accounted for 4.7% of all acute stroke patients, 5.4% of acute ischemic stroke, and 17.4% of lacunar syndromes. Complete hemisensory syndrome was present in 80 patients and incomplete hemisensory syndrome in 19 (cheiro-oral syndrome 12, cheiro-oral-pedal 6, isolated oral syndrome 1). The lacunar hypothesis was fulfilled in 88% of patients. Atherothrombotic infarction occurred in 8 patients, intracerebral hemorrhage in 3, and stroke of undetermined cause in 1. Hemorrhagic pure sensory stroke was diagnosed in 1% of all cases of hemorrhagic stroke (n=270) in the database. Outcome was good (in-hospital mortality 0%, symptom-free at discharge 41.5 %). After multivariate analysis, absence of disability at discharge, hypertension, diabetes, hyperlipidemia, and thalamic (56.5 %) and corona radiata (4 %) locations were clinical and topographic variables significantly associated with pure sensory stroke.ConclusionsPure sensory stroke is an infrequent cerebrovascular syndrome, in which the lacunar hypothesis is supported. Most patients had thalamic lacunar infarction. Incomplete hemisensory syndromes were also caused by a lacunar infarct in 84% of patients. Hemorrhagic pure sensory stroke accounted only for 3% of the cases. The prognosis is good with striking similarity to other lacunar strokes. There are important differences between pure sensory stroke and nonlacunar strokes.

Recurrent lacunar infarction following a previous lacunar stroke: a clinical study of 122 patients

Objective: To determine clinical variables related to recurrent lacunar infarction following a previous lacunar stroke. Methods: A total of 122 out of 733 consecutive patients with lacunar infarction collected from a hospital based registry between 1986 and 2004 were readmitted because of a recurrent lacunar infarction. In a subset of 59 patients, cognition was assessed using the Mini-Mental State Examination (MMSE). Predictors of lacunar infarction recurrence were assessed by logistic regression analysis. Results: First lacunar infarction recurrence occurred in 101 patients (83%) and multiple recurrences in 21. The mean time between first ever lacunar infarction and recurrent lacunes was 58.3 months (range 2–240). In the subset of 59 patients in whom cognition was studied, cognitive impairment, defined as an MMSE score <24, was detected in 16% (8/49) of patients with first lacunar infarction recurrence and in 40% (4/10) of those with multiple lacunar infarction recurrences. In the multivariate analysis, hypertension (odds ratio 2.01, 95% CI 1.23 to 3.30) and diabetes (odds ratio 1.62, 95% CI 1.07 to 2.46) were significant predictors of lacunar stroke recurrence, whereas hyperlipidaemia was inversely associated (odds ratio 0.52, 95% CI 0.30 to 0.90). Conclusions: Hypertension and diabetes were significant factors related to recurrent lacunar infarction. Hyperlipidaemia appeared to have a protective role. Cognitive impairment was a frequent finding in patients with multiple lacunar infarction recurrences.

Clinical study of 39 patients with atypical lacunar syndrome

The aim of this study was to describe the clinical characteristics of atypical lacunar syndrome (ALS) based on data collected from a prospective acute stroke registry. In total, 2500 acute stroke patients were included in a hospital based prospective stroke registry over a 12 year period, of whom 39 were identified as having ALS and radiologically proven (by computed tomography or magnetic resonance imaging) lacunes. ALS accounted for 1.8% of all acute stroke patients, 2.1% of acute ischaemic stroke, and 6.8% of lacunar syndromes. ALS included dysarthria facial paresis (n = 12) or isolate dysarthria (n = 9), isolated hemiataxia (n = 4), pure motor hemiparesis with transient internuclear ophthalmoplegia (n = 4), pure motor hemiparesis with transient subcortical aphasia (n = 3), unilateral (n = 2) or bilateral (n = 3) paramedian thalamic infarct syndrome, and hemichorea hemiballismus (n = 2). Atypical lacunar syndromes were due to small vessel disease in 96% of patients. Atherothrombotic infarction occurred in one patient and cardioembolic infarct in another, both presenting pure dysarthria. Outcome was good (in hospital mortality 0%, symptom free at discharge 28.2%). After multivariate analysis, the variables of speech disturbances, nausea/vomiting, ischaemic heart disease, and sensory symptoms were found to be significantly associated with ALS. In conclusion, atypical lacunar syndrome is an infrequent stroke subtype (one of each 14 lacunar strokes). ALS occurred in 6.8% of lacunar strokes. Isolated dysarthria or dysarthria facial paresis were the most frequent presenting forms. The prognosis of this infrequent non-classic lacunar syndrome is good.

Clinical study of 35 patients with dysarthria-clumsy hand syndrome

Objectives: Although dysarthria-clumsy hand syndrome (DCHS) is a well known and infrequent lacunar syndrome, there are few data regarding the spectrum of associated clinical characteristics, anatomical site of lesion, and aetiopathogenetic mechanisms. We report a clinical description of this subtype of lacunar stroke based on data collected from a prospective acute stroke registry. Methods: From 2500 acute stroke patients included in a hospital based prospective stroke registry over a 12-year period, 35 patients were identified as having DCHS. Results: DCHS accounted for 1.6% of all acute stroke patients (35/2110), 1.9% of acute ischaemic stroke (35/1840), and 6.1% of lacunar syndromes (35/570) admitted consecutively to a neurology department and included in the stroke registry over this period. The results supported the lacunar hypothesis in 94.3% of patients (n = 33). Atherothrombotic and cardioembolic infarction occurred in only one patient each (2.9%). No patient with DCHS had an intracerebral haemorrhage. Outcome was good (mortality in hospital 0%, symptom free at discharge 45.7%). After multivariate analysis, absence of limitation at discharge, limb weakness but not cerebellar-type ataxia, and internal capsule (40%), pons (17%), and corona radiata (8.6%) location were significantly associated with DCHS. Conclusions: DCHS is a rare cerebrovascular syndrome, and supports the criteria of the lacunar hypothesis. The majority of patients in this study had internal capsule infarcts. The prognosis is good with striking similarity compared with other types of lacunar strokes. There are important differences between DCHS and non-lacunar strokes. Internal capsule and pons are the most frequent cerebral sites.

Cheyne-stokes respiration in patients with first-ever lacunar stroke.

The aim of this single-center prospective study was to assess the presence of Cheyne-Stokes respiration (CSR) and CSR-related variables in 68 consecutive patients with radiologically proven first-ever lacunar stroke undergoing a respiratory sleep study using a portable respiratory polygraph within the first 48 hours of stroke onset. CSR was diagnosed in 14 patients (20.6%). Patients with CSR as compared with those without CSR showed a significantly higher mean (standard deviation, SD) apnea-hypopnea index (AHI) (34.9 (21.7) versus 18.5 (14.4), P = 0.001) and central apnea index (13.1 (13.8) versus 1.8 (3.4), P = 0.0001) as well as higher scores of the Barthel index and the Canadian Neurological scale as a measure of stroke severity, and longer hospital stay. CSR was present in one of each five patients with lacunar stroke. The presence of CSR was associated with a trend towards a higher functional stroke severity and worse prognosis.

Importance of Cardiovascular Risk Profile for In-Hospital Mortality Due to Cerebral Infarction

INTRODUCTION AND OBJECTIVES To investigate cardiovascular risk profiles and their prognostic implications in patients with different subtypes of cerebral infarction. METHODS The study involved the retrospective analysis of data from a hospital stroke registry on 2704 consecutive CI patients who were admitted between 1986 and 2004. Of the 2704 strokes recorded, 770 were classified as thrombotic, 763 as cardioembolic, 733 as lacunar, 324 as undetermined and 114 as atypical. Multivariate analysis was used to compare cardiovascular risk profiles in each subtype and their influence on inhospital mortality. RESULTS Arterial hypertension (AH) was present in 55.5%, atrial fibrillation (AF) in 29.8%, and diabetes mellitus in 23.4%. The in-hospital mortality rate was 12.9%, and in-hospital mortality was independently associated with AF (odds ratio [OR]=2.33; 95% confidence interval [CI], 1.84-2.96), and heart failure (HF) (OR=1.96; 95% CI, 1.33-2.89). In patients with thrombotic stroke, the cardiovascular risk factors associated with in-hospital mortality were HF (OR=2.87; 95% CI, 1.45-5.71), AF (OR=1.80; 95% CI, 1.09-2.96) and age (OR=1.06; 95% CI, 1.04-1.08). In patients with cardioembolic stroke, they were peripheral vascular disease (OR=2.18; 95% CI, 1.17-4.05), previous cerebral infarction (OR=1.75; 95% CI, 1.16-2.63), HF (OR=1.71; 95% CI, 1.01-2.90), and age (OR=1.06; 95% CI, 1.04-1.08). In those with undetermined stroke, they were AH (OR=3.68; 95% CI, 1.78-7.62) and age (OR=1.05; 95% CI, 1.01-1.09). CONCLUSIONS Each cerebral infarction etiologic subtype was associated with its own cardiovascular risk profile. Consequently, the cardiovascular risk factors associated with mortality were also different for each ischemic stroke subtype.