Mohamed Al-Khaled

MRI findings and stroke risk in TIA patients with different symptom durations

Objective: To determine the frequency of acute infarction detected by diffusion-weighted imaging (DWI)-MRI and stroke risk in TIA patients with different symptom duration in a population-based study. Methods: During a 54-month period (starting November 2007), 3,724 admitted patients (mean age, 67 ± 14 years; 45% women) with transient neurologic symptoms lasting <24 hours from 15 hospitals were included. All patients underwent DWI-MRI during hospitalization. Results: Of 3,724 patients, 1,166 showed an acute infarction (32.2%; 95% confidence interval [CI], 30.8%–33.8%) and 88 (2.4%; 95% CI, 1.9%–2.9%) had a stroke during hospitalization (7 days). Stroke risk was higher in patients with tissue-positive DWI than in those with tissue-negative DWI (4.5% vs 1.5%, respectively; p < 0.001). Logistic regression analysis revealed that stroke risk was correlated with positive DWI (odds ratio [OR], 3.1; 95% CI, 2.0–4.8; p < 0.001), atrial fibrillation (OR, 2.1; 95% CI, 1.3–3.5; p = 0.001), and symptom duration <1 hour (OR, 1.5; 95% CI, 1.0–2.4; p = 0.042). Patients with symptoms lasting <1 hour had a lower rate of acute infarction than those with symptoms lasting ≥1 hour (24% vs 36%, respectively; p < 0.001), whereas stroke risk did not differ between the groups (2.8% vs 2.1%, respectively; p = 0.22). Stroke risk was higher after tissue-positive events than tissue-negative ones in patients with symptom duration <1 hour (5.2% vs 2.0%, respectively; p = 0.002) and in those with symptom duration ≥1 hour (4.1% vs 1.1%, respectively; p < 0.001). Conclusion: Stroke risk was higher after tissue-positive events than tissue-negative ones in TIA patients with different symptom duration.

Statin treatment in patients with acute ischemic stroke.

Background and purpose We aimed to investigate the association of statin treatment with outcomes in patients with acute ischemic stroke. Methods Over a 4.5-year period (starting November 2007), 12 781 patients (mean age, 72·8 ± 12·6 years; 48·6% women) with acute ischemic stroke from 15 hospitals in Schleswig-Holstein, Germany, were enrolled in a population-based study and prospectively evaluated. The primary outcomes were the mortality during hospitalization and the disability (modified Rankin Scale score ≥2) at discharge from hospital. The secondary outcomes were the mortality and disability at three-months after discharge. Results A total of 7535 patients (59%) with acute ischemic stroke were treated with statins. During hospitalization (mean, nine-days), the in-hospital mortality rate (4·7%; 95% confidence interval, 4·3–5·1%) was lower in patients treated with statins than in those without statins (2·3% vs. 7·9%, respectively; P < 0·001). At three-months after discharge, the mortality rate (6·9%; 95% confidence interval, 6·4–7·5%) was lower in patients treated with statins than in those without statins (5·0% vs. 10·6%, respectively; P < 0·001). Adjusted logistic regression analysis showed that statin treatment was associated with reduced rates of in-hospital mortality (odds ratio, 0·39; 95% confidence interval, 0·31–0·48; P < 0·001) and three-month mortality (odds ratio, 0.47; 95% confidence interval, 0·34–0·63; P < 0·001). A comparison of the patient groups revealed that patients on statins were likely to have lower disability rates at discharge (59% vs. 67%, respectively; P < 0·001) and after three-months (33% vs. 42%, respectively; P < 0·001) in patients who had survived the stroke. Conclusion Statin treatment may improve the outcomes in patients with acute ischemic stroke. Further studies are necessary to confirm this finding.

Dysphagia in Patients with Acute Ischemic Stroke: Early Dysphagia Screening May Reduce Stroke-Related Pneumonia and Improve Stroke Outcomes.

Background: Dysphagia is associated with poor outcome in stroke patients. Studies investigating the association of dysphagia and early dysphagia screening (EDS) with outcomes in patients with acute ischemic stroke (AIS) are rare. The aims of our study are to investigate the association of dysphagia and EDS within 24 h with stroke-related pneumonia and outcomes. Methods: Over a 4.5-year period (starting November 2007), all consecutive AIS patients from 15 hospitals in Schleswig-Holstein, Germany, were prospectively evaluated. The primary outcomes were stroke-related pneumonia during hospitalization, mortality, and disability measured on the modified Rankin Scale ≥2-5, in which 2 indicates an independence/slight disability to 5 severe disability. Results: Of 12,276 patients (mean age 73 ± 13; 49% women), 9,164 patients (74%) underwent dysphagia screening; of these patients, 55, 39, 4.7, and 1.5% of patients had been screened for dysphagia within 3, 3 to <24, 24 to ≤72, and >72 h following admission. Patients who underwent dysphagia screening were likely to be older, more affected on the National Institutes of Health Stroke Scale score, and to have higher rates of neurological symptoms and risk factors than patients who were not screened. A total of 3,083 patients (25.1%; 95% CI 24.4-25.8) had dysphagia. The frequency of dysphagia was higher in patients who had undergone dysphagia screening than in those who had not (30 vs. 11.1%; p < 0.001). During hospitalization (mean 9 days), 1,271 patients (10.2%; 95% CI 9.7-10.8) suffered from stroke-related pneumonia. Patients with dysphagia had a higher rate of pneumonia than those without dysphagia (29.7 vs. 3.7%; p < 0.001). Logistic regression revealed that dysphagia was associated with increased risk of stroke-related pneumonia (OR 3.4; 95% CI 2.8-4.2; p < 0.001), case fatality during hospitalization (OR 2.8; 95% CI 2.1-3.7; p < 0.001) and disability at discharge (OR 2.0; 95% CI 1.6-2.3; p < 0.001). EDS within 24 h of admission appeared to be associated with decreased risk of stroke-related pneumonia (OR 0.68; 95% CI 0.52-0.89; p = 0.006) and disability at discharge (OR 0.60; 95% CI 0.46-0.77; p < 0.001). Furthermore, dysphagia was independently correlated with an increase in mortality (OR 3.2; 95% CI 2.4-4.2; p < 0.001) and disability (OR 2.3; 95% CI 1.8-3.0; p < 0.001) at 3 months after stroke. The rate of 3-month disability was lower in patients who had received EDS (52 vs. 40.7%; p = 0.003), albeit an association in the logistic regression was not found (OR 0.78; 95% CI 0.51-1.2; p = 0.2). Conclusions: Dysphagia exposes stroke patients to a higher risk of pneumonia, disability, and death, whereas an EDS seems to be associated with reduced risk of stroke-related pneumonia and disability.

Short-term risk and predictors of stroke after transient ischemic attack

BACKGROUND Transient ischemic attack (TIA) is a marker of stroke, especially in the early phase following this event. The aims of this study are to determine the short-term risk of stroke and to evaluate the independent predictors of stroke in patients with TIA who are hospitalized within 48 hours after symptom onset. METHODS During a 36-month period (beginning in November 2007), 3554 patients (mean age: 70.5 ± 13 years; 49.9% female; mean NIHSS score: 1.4 ± 2.5) from 15 hospitals suffering from TIA were prospectively evaluated. RESULTS Of the 3554 patients, 43 (1.2%) suffered from stroke during hospitalization (6.5 ± 4.3 days). We identified the following independent predictors for stroke after TIA: male sex (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.3-5; P=0.008), age ≥65 years (OR, 4.7; 95% CI, 1.4-15; P=0.01), hyperlipidemia (OR, 2.4; 95% CI, 1.2-4.8; P=0.015), and dysarthria (OR, 2; 95% CI, 1.1-5.0; P=0.038). CONCLUSION Patient characteristics (male sex, age, and hyperlipidemia) and TIA symptom (dysarthria) may be useful in defining stroke after TIA in patients who were hospitalized with TIA.

Stroke-Associated Pneumonia in Thrombolyzed Patients: Incidence and Outcome

BACKGROUND Stroke-associated pneumonia often negatively influences the prognosis of stroke patients. The aims of this study were to determine the frequency of pneumonia and to investigate the correlation between pneumonia and prognosis in stroke patients receiving intravenous thrombolysis with recombinant tissue plasminogen activator (IV thrombolysis). METHODS Between 2008 and 2013, 538 consecutive stroke patients (mean age, 72 ± 13 years; 50.4% women) receiving IV thrombolysis at the Department of Neurology, University of Lübeck, were investigated. RESULTS Pneumonia occurred among 122 patients (23%; 95% confidence interval [CI], 19.1-26.2). Pneumonia patients were older (76 versus 71 years; P < .001), more severely affected at admission (National Institutes of Health Stroke Scale [NIHSS] score, 13 versus 9; P < .001), and more likely to have atrial fibrillation (54% versus 42%; P = .02) than patients without pneumonia. They had also a longer hospitalization (15 versus 10 days; P < .001). Using logistic regression analysis, the occurrence of pneumonia was associated with male sex (odds ratio [OR], 1.9; 95% CI, 1.2-3.1; P = .006), neurologic deficit severity (NIHSS score ≥10; OR, 4.4; 95% CI, 2.5-7.4; P < .0019), previous stroke (OR, 1.5; 95% CI, 1.0-2.2; P = .06), and occurrence of symptomatic intracerebral hemorrhage (OR, 1.6; 95% CI, 1.0-3.2; P = .048). Mortality rates (in-hospital mortality [18.9% versus 7.0; P < .0019]; 3-month mortality [34.3% versus 10.6%; P < .001], and 12-month mortality [53.6% versus 19.6%; P < .001]) were higher in pneumonia patients than those without. A favorable outcome (modified Rankin Scale score ≤2) was more likely in patients without pneumonia than those with pneumonia (42% versus 7%; P < .001). CONCLUSION Pneumonia was correlated with increased age, male sex, neurologic deficit severity, and a less favorable prognosis.

A population-based study on combined markers for early Parkinson's disease.

The prerequisite for an earlier diagnosis of Parkinsons disease (PD) are markers that are both sensitive and specific for clinically definite PD and its prediagnosic phases. Promising candidates include enlarged hyperechogenicity of the substantia nigra (SN+) on transcranial sonography (TCS) and hyposmia. However, despite good sensitivity and specificity, both markers have yet failed to yield reliable predictions. We pursue the possibility of combined use in an ongoing population‐based cohort. Subjects were recruited from 10,000 inhabitants of Luebeck/Germany aged 50 to 79 years and additional PD patients from our outpatient clinic. After neurological examination, 715 subjects were grouped into clinically definite PD (n = 106), possible prediagnostic PD (ppPD; n = 73), and a control group subdivided into healthy individuals (n = 283) and controls with diseases other than PD (n = 253). Subjects underwent TCS and smell testing. Sensitivity and specificity of SN+ and hyposmia were good for PD; however, positive predictive values (PPV) of both SN+ (5.2%) and olfaction (2.5%) were low. At least one positive/both positive markers were present in 33%/1% of healthy controls, 33%/2% of diseased controls, 62%/7% of ppPD, and 94%/51% of PD. When combining SN+ and hyposmia, PPV increased to 17.6%, with a sensitivity of 51% and a specificity of 98%. Both SN+ and hyposmia offer good enrichment towards PD and ppPD, are stable against other diseases, and the combination of markers highly increases specificity. However, if the combination of SN+ and hyposmia were used as criterion for PD diagnosis, almost half of clinically definite PD and more than 90% of ppPD would have been missed.

The prognostic impact of the stroke unit concept after transient ischemic attack

BACKGROUND AND PURPOSE Transient ischemic attack (TIA) is associated with high short-term risk of stroke, especially in the early phase following the event. Data about the impact of the early hospitalization in a stroke unit on patients with TIA are sparse. This study compares the prognostic impact of the stroke unit concept with conventional care on patients with TIA. METHODS During a 30-month period (beginning April 2005), 878 patients (mean age, 70±12years; 44.3% female) with TIA admitted within 24h of symptom onset were prospectively evaluated. The adjusted logistic regression analyses were used to estimate the odds ratio for the stroke risk during hospitalization and the 90-day mortality. RESULTS Of 878 patients, 591 (67.3%) were treated in the stroke unit, and 287 (32.7%) underwent conventional care. Patients receiving stroke-unit care had significantly higher rates of cranial computed tomography (96.3% vs. 88.1%; P<.001) and brain-supplying artery ultrasound (97.1% vs. 91.3%; P<.001) investigations. The stroke risk during hospitalization was 1.7% in patients treated in stroke unit and 2.4% in patients received a conventional care. A relevant difference between the groups was not found (1.7% vs. 2.4%; P=.45). The 90-day mortality rate was 1.7% in the stroke unit group compared to 2.2% in the conventional care group (1.7% vs. 2.2%; P=.66). The adjusted logistic regression analyses revealed no difference in stroke rates (odds ratio, 0.68; 95% confidence interval, 0.24-1.9) and in the 90-day mortality (odds ratio, 0.63; 95% confidence interval, 0.2-1.96) between the stroke unit concept and conventional care. CONCLUSION The prognostic impact of the stroke unit care for patients with transient ischemic attack appears to be similar to that of the conventional care. Further randomized studies are needed to investigate the impact of stroke-unit care on patients with transient ischemic attack.

Do Early Seizures Indicate Survival of Patients with Nontraumatic Intracerebral Hemorrhage

Background and Purpose: Early seizures (ESs) in patients with nontraumatic spontaneous intracerebral hemorrhage (sICH) are a frequent complication. The aims of this study were to determine the frequency of ESs in patients with sICH and to investigate the association of ESs with outcomes in a monocenter study. Methods: During a 5-year period (2009-2013), 484 consecutive patients (mean age 72.3 ± 12.6; female sex 51%) with sICH who were admitted to the Department of Neurology at the University of Lübeck, Germany were enrolled and prospectively evaluated. Results: A total of 52 patients (10.7%; 95% CI 8-14) experienced ESs during a mean hospitalization of 12 days. Patients with ESs were less affected on the National Institutes of Health Stroke Scale at admission than those without ESs (7 vs. 10; p = 0.02). With the exception of the localization of hemorrhage (p = 0.008), differences in the baseline characteristics between patients with ESs and those without ESs were not found. The logistic regression analysis revealed an increased ES rate in patients with cortical hemispheric sICH (OR 3.5; 95% CI 1.8-6.7; p < 0.001). During hospitalization, 109 patients (23%) died and the in-hospital mortality was lower in patients with ESs than those without (9.6 vs. 24.0%, respectively; p = 0.02). An association between ESs and good functional outcome on the modified Rankin Scale ≤2 was not found (p = 0.3). Conclusion: ESs appear to be correlated with hemorrhage localization and associated with survival of the sICH.

Use of cranial CT to identify a new infarct in patients with a transient ischemic attack

Research on infarct detection by noncontrast cranial computed tomography (CCT) in patients with transient ischemic attack (TIA) is sparse. However, the aims of this study are to determine the frequency of new infarcts in patients with TIA, to evaluate the independent predictors of infarct detection, and to investigate the association between a new infarct and early short‐term risk of stroke during hospitalization. We prospectively evaluated 1533 consecutive patients (mean age, 75.3 ± 11 years; 54% female; mean National Institutes of Health Stroke Scale [NIHSS] score, 1.7 ± 2.9) with TIA who were admitted to hospital within 48 h of symptom onset. A new infarct was detected by CCT in 47 (3.1%) of the 1533 patients. During hospitalization, 17 patients suffered a stroke. Multivariate logistic regression analysis revealed the following independent predictors for infarct detection: NIHSS score ≥10 (odds ratio [OR], 4.8), time to CCT assessment >6 h (OR 2.2), and diabetes (OR 2.3). The evidence of a new infarct was not associated with the risk of stroke after TIA. The frequency of a new infarct in patients with TIA using CCT is low. The use of the CCT tool to predict the stroke risk during hospitalization in patients with TIA is found to be inappropriate. The estimated clinical predictors are easy to use and may help clinicians in the TIA work up.

TIA-Treatment: Stroke Units versus General Wards Mono-Center Study

Background and Purpose: Transient ischemic attack (TIA) is associated with a high short-term risk of stroke. The aim of this study is to compare the diagnostic evaluation, therapeutic procedures, and secondary prevention strategies in TIA patients who were directly admitted to a stroke unit (SU) and received semi-intensive care in comparison to those who were treated in general wards (GW) in a mono-center study. Methods: During a 6-year period (2008-2013), 1114 TIA patients who were admitted to the Department of Neurology at the University of Schleswig-Holstein, campus Lubeck, were evaluated in a mono-center study. Results: A total of 604 (57%) TIA patients were admitted to the SU, whereas 453(37%) patients were admitted to the GW. Patients with a TIA who were undergoing treatment in an SU were significantly younger (69.1 vs. 71.0 years; P=0.023) and had higher rates of paresis (30.1 vs. 21.8%; p<0.003), hypertension (79.7 vs. 74.3%; P=0.042) and hypercholesterolemia (57.2 vs. 46.7%; P=0.001) than those who were undergoing treatment in the GW. Patients in SUs received significantly higher rates of carotid revascularization for symptomatic carotid stenosis (5.8% vs. 0.4%; P<0.001), dysphagia screening (47.6 vs. 27.3%; P<0.001), speech therapy (33.0 vs. 14.8%; P<0.001), and physiotherapy (51.0 vs. 37.2%; P<0.001) in comparison to those admitted to GWs. The TIA etiology; cardioembolism was significantly more common (18.0 vs. 12.7%; P=0.037) in patients treated in stroke unit, whereas the undetermined etiology of TIA was significantly less diagnosed in patients who were admitted to SI-SU than those treated in CC (50. vs. 58%; P=0.037). Carotid revascularization for symptomatic stenosis was more performed in patients who underwent stroke unit care than those who were treated in general wards (5.8 vs. 0.4%, P<0.001). Conclusion: TIA-Treatment in the SU appears to be correlated with more diagnostic and therapeutic procedures in comparison to care in general wards.