Jose Antonio Egido

Quality of life among stroke survivors evaluated 1 year after stroke: experience of a stroke unit.

Background and Purpose We sought to study overall and domain-specific quality of life in stroke survivors 1 year after stroke and to identify variables that could predict quality of life after stroke. Methods We followed up for 1 year a cohort of 118 patients consecutively admitted to our stroke unit at San Carlos University Hospital in Madrid, Spain. The final series at 1-year follow-up consisted of 90 survivors (41 women and 49 men; mean age, 68 years; range, 32 to 90 years). A cross-sectional, descriptive design was developed. Patients completed a questionnaire that included socioeconomic variables, Hamilton Rating Scale for Depression, Sickness Impact Profile (SIP), Short Form 36, Frenchay Index, Barthel Index, Rankin Scale, and Scandinavian Stroke Scale. Independent variables were sex, age, functional status, motor impairment, and depression. We developed an ANOVA model for statistical analysis. Results We interviewed 79 patients with ischemic and 11 with hemorrhagic stroke. Thirty-eight percent of patients scored in the depressed range. Variables related to depression were status as a housewife, female sex, inability to work because of disability, and diminished social activity (P <0.0001). Mean total SIP (24.3), SIP psychosocial dimension (27.5), and SIP physical dimension (21.2) were correlated with disability, female sex, motor impairment, and depression (P <0.0001). Conclusions Functional status and depression were identified as predictors of quality of life. Patients independent in their activities of daily living suffered from a deterioration of the psychosocial dimension of the SIP.

Quality of Life after Stroke: The Importance of a Good Recovery

Background: Health-related quality of life (HRQoL) is a recognized and important outcome after stroke. An increased survival and the presence of moderate impairment in long-term stroke survivors impact their HRQoL. Methods: HRQoL measures and HRQoL determinants in stroke survivors are reviewed. Results: Stroke is the leading cause of long-term disability in western countries. Specific HRQoL scales have been developed in the last years, such as the Stroke Impact Scale, the Stroke Specific Quality of Life Scale, the Stroke and Aphasia HRQoL Scale, and the Burden of Stroke Scale. Disability and poststroke depression are consistent determinants of HRQoL. Other determinants include female sex, coping strategies, and social support. Poststroke depression affects HRQoL, functional recovery, cognitive function and healthcare use in stroke survivors. Stroke caregivers have lower HRQoL, greater prevalence of stress and depression, economical burden, and changes in social relationships. Advancing age and anxiety in patients and caregivers, high dependency and poor family support identify caregivers at risk of adverse outcomes. Conclusions: Physical and psychosocial well-being is greatly affected in stroke survivors and their caregivers.

Predicting the Risk of Symptomatic Intracerebral Hemorrhage in Ischemic Stroke Treated With Intravenous Alteplase Safe Implementation of Treatments in Stroke (SITS) Symptomatic Intracerebral Hemorrhage Risk Score

Background and Purpose— Symptomatic intracerebral hemorrhage (SICH) is a serious complication in patients with acute ischemic stroke treated with intravenous thrombolysis. We aimed to develop a clinical score that can easily be applied to predict the risk of SICH. Methods— We analyzed data from 31 627 patients treated with intravenous alteplase enrolled in the Safe Implementation of Treatments in Stroke (SITS) International Stroke Thrombolysis Register. The outcome measure was SICH per the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) definition: a Type 2 parenchymal hemorrhage with deterioration in National Institutes of Health Stroke Scale score of ≥4 points or death. Univariate risk factors associated with the outcome were entered into a logistic regression model after stratification of continuous variables. Adjusted ORs for the independent risk factors were converted into points, which were summated to produce a risk score. Results— We identified 9 independent risk factors for SICH: baseline National Institutes of Health Stroke Scale, serum glucose, systolic blood pressure, age, body weight, stroke onset to treatment time, aspirin or combined aspirin and clopidogrel, and history of hypertension. The overall rate of SICH was 1.8%. The risk score ranged from 0 to 12 points and showed a >70-fold graded increase in the rate of SICH for patients with a score ≥10 points (14.3%) compared with a score of 0 point (0.2%). The prognostic discriminating capability by C statistic was 0.70. Conclusions— The SITS SICH risk score predicts large cerebral parenchymal hemorrhages associated with severe clinical deterioration. The score could aid clinicians to identify patients at high as well as low risk of SICH after intravenous alteplase.

Estrogens as neuroprotectants against ischemic stroke.

Estrogens have proven vasoprotective properties against atherosclerosis that depend on the direct effect on vascular smooth muscle and endothelium and on systemic actions that imply serum lipids, coagulation and fibrinolytic cascades, vasoactive proteins and antioxidant systems. They also have neuroprotective effects against cerebral ischemia that include antioxidant and anti-inflammatory effects, modulation of protein synthesis, inhibition of apoptosis and trophic effects and preservation of microvascular blood flow in the ischemic area. Estrogenic actions depend on activation of specific estrogen receptors that modulate gene expression and produce long-term effects on vascular endothelial and smooth muscle cells, neurons and glia, on interaction with plasma membrane sites that produce rapid non-genomic actions and also on receptor-independent mechanisms. This paper reviews what it is known about the mechanisms underlying the vaso- and neuroprotective effects of estrogens. Experimental and clinical evidences of such protective effects are also discussed. Therapeutical implications for stroke prevention and treatment derived from the available evidence are considered.

In-Hospital Stroke Treated With Intravenous Tissue Plasminogen Activator

Background and Purpose— In-hospital strokes (IHSs) are potential candidates for thrombolysis. We analyzed the treatment procedures, safety, and efficacy of intravenous tissue plasminogen activator (IV-tPA) in IHSs compared with out-of-hospital strokes (OHSs). Methods— This study was based on a multicenter prospective registry of patients treated with IV-tPA divided into IHSs and OHSs. We recorded intrahospital delays and stroke outcomes. Results— Among 367 patients treated with IV-tPA, 30 were IHSs. Baseline characteristics were similar except for a greater proportion of diabetes (36.7% vs 17.5%, P=0.01), cardiac failure (16.7% vs 5.3%, P=0.014), and atrial fibrillation (33.3% vs 17.5%, P=0.034) in IHSs than OHSs. In-hospital delays were significantly longer in IHSs for door-to-computed tomography time (39.5±18.7 vs 22.6±19.7 minutes, P<0.0001) and computed tomography-to-treatment time (92.0±26.1 vs 65.4±25.8 minutes, P<0.0001). No differences were observed in safety or efficacy. Conclusions— In-hospital procedures for thrombolysis proceed more slowly in IHSs than in OHSs. Thrombolysis is safe and efficient in IHS.

Recurrent transient ischaemic attack and early risk of stroke: data from the PROMAPA study

Background Many guidelines recommend urgent intervention for patients with two or more transient ischaemic attacks (TIAs) within 7 days (multiple TIAs) to reduce the early risk of stroke. Objective To determine whether all patients with multiple TIAs have the same high early risk of stroke. Methods Between April 2008 and December 2009, we included 1255 consecutive patients with a TIA from 30 Spanish stroke centres (PROMAPA study). We prospectively recorded clinical characteristics. We also determined the short-term risk of stroke (at 7 and 90 days). Aetiology was categorised using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification. Results Clinical variables and extracranial vascular imaging were available and assessed in 1137/1255 (90.6%) patients. 7-Day and 90-day stroke risk were 2.6% and 3.8%, respectively. Large-artery atherosclerosis (LAA) was confirmed in 190 (16.7%) patients. Multiple TIAs were seen in 274 (24.1%) patients. Duration <1 h (OR=2.97, 95% CI 2.20 to 4.01, p<0.001), LAA (OR=1.92, 95% CI 1.35 to 2.72, p<0.001) and motor weakness (OR=1.37, 95% CI 1.03 to 1.81, p=0.031) were independent predictors of multiple TIAs. The subsequent risk of stroke in these patients at 7 and 90 days was significantly higher than the risk after a single TIA (5.9% vs 1.5%, p<0.001 and 6.8% vs 3.0%, respectively). In the logistic regression model, among patients with multiple TIAs, no variables remained as independent predictors of stroke recurrence. Conclusions According to our results, multiple TIAs within 7 days are associated with a greater subsequent risk of stroke than after a single TIA. Nevertheless, we found no independent predictor of stroke recurrence among these patients.

Thrombolysis for ischaemic stroke and glioblastoma multiforme: a case report

Objective: To report the uncomplicated use of systemic thrombolysis for stroke in a patient with a misdiagnosed glioblastoma multiforme mimicking brain ischaemia and to suggest that new clinical situations question the stated exclusion criteria for intravenous thrombolysis. Patient: A 57-year-old male presented at the emergency room with a sudden aphasia. Measurement and main results: After Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) exclusion criteria were ruled out, intravenous alteplase was administered. The patient presented with tonic–clonic seizures 17 min after perfusion completion, requiring phenytoine administration. Additional computed tomography scan did not show haemorrhagic transformation or brain oedema. A left temporal lobe glioblastoma multiforme was diagnosed after magnetic resonance imaging and neurosurgery. The patient became asymptomatic on the seventh day. Conclusion: Any history of central nervous system neoplasm is considered a contraindication to thrombolysis, but the true risk of systemic thrombolysis-precipitated intracranial bleeding is unknown. Further data are needed to establish real haemorrhage risk in this clinical condition.

Benefits of Modifying the Predictive Factors of Stroke Recurrence

The risk of stroke recurrence is high. With annual rates of around 4%, accumulative rates of 40% are reached within 10 years. Despite being underestimated, the risk is highest in the early stages; around 12% in the first year. The most important etiological subtypes have different levels of risk; the highest being for atherothrombotic infarction and the lowest for lacunar infarction. Each etiology has its own risk factors. For example, in carotid stenosis, the grade of stenosis, ulceration, and plaque morphology, silent infarction on neuroimaging, coexistence of intracranial disease, or microemboli detected on transcranial Doppler, all have predictive value for stroke recurrence. There is a paucity of data on the risk factors for intracranial stenosis. In cardioembolism due to atrial fibrillation age, coexistence of hypertension or diabetes, and echocardiographic data predict recurrence. Risk factors for recurrence do not parallel those for first stroke. Diabetes is the most consistent risk factor for recurrence in different studies, while control of hypertension has been shown to be effective in the prevention of recurrences. Among the inflammatory markers, C-reactive protein is the most effective in prediction of recurrence. Elevated levels of homocysteine also predict recurrence, but attempts to improve risk by the modification of these levels have, to date, been unsuccessful. To be effective, the modification of predictive factors needs to be multifactorial and should be taken into account corresponding to each etiological type. More research is needed on biological markers to establish their clinical relevance and the benefit of targeting them for therapeutic modification.

Intravenous Thrombolytic Treatment in the Oldest Old

Background and Purpose. Intravenous thrombolysis using tissue plasminogen activator is safe and probably effective in patients >80 years old. Nevertheless, its safety has not been specifically addressed for the oldest old patients (≥85 years old, OO). We assessed the safety and effectiveness of thrombolysis in this group of age. Methods. A prospective registry of patients treated with intravenous thrombolysis. Patients were divided in two groups (<85 years and the OO). Demographic data, stroke aetiology and baseline National Institute Health Stroke Scale (NIHSS) score were recorded. The primary outcome measures were the percentage of symptomatic intracranial haemorrhage (SICH) and functional outcome at 3 months (modified Rankin Scale, mRS). Results. A total of 1,505 patients were registered. 106 patients were OO [median 88, range 85–101]. Female sex, hypertension, elevated blood pressure at admission, cardioembolic strokes and higher basal NIHSS score were more frequent in the OO. SICH transformation rates were similar (3.1% versus 3.7%, P = 1.00). The probability of independence at 3 months (mRS 0–2) was lower in the OO (40.2% versus 58.7%, P = 0.001) but not after adjustment for confounding factors (adjusted OR, 0.82; 95% CI, 0.50 to 1.37; P = 0.455). Three-month mortality was higher in the OO (28.0% versus 11.5%, P < 0.001). Conclusion. Intravenous thrombolysis for stroke in OO patients did not increase the risk of SICH although mortality was higher in this group.

Stroke preceding autoimmune encephalitis with neuronal potassium channel antibody.

Autoimmune encephalitis related to voltage-gated potassium channel (VGKC) antibodies can occur as a complication of cancer but, more frequently, as a non-paraneoplastic disorder. The prompt recognition and treatment could mitigate the morbidity associated with this entity, but the broad-spectrum of neurological manifestations often makes the diagnosis a challenge. The authors describe, here, a unique case of autoimmune encephalitis related to VGKC antibodies preceded by an ischaemic stroke. Conditions associated with the stroke (infection, seizures, metabolic disturbances) had delayed the diagnosis. The authors suggest that autoimmune encephalitis needs to be taken into consideration as part of a differential diagnosis in patients with prolonged encephalopathy following an ischaemic stroke. Infection may trigger an inflammatory response. In addition, the rupture of blood brain barrier that occurs in stroke may have a pathogenic role by allowing antibodies to gain access to the central nervous system.