Nelda M. Garcia

Early care limitations independently predict mortality after intracerebral hemorrhage

Objective: Intracerebral hemorrhage (ICH) is associated with a high early mortality rate. We examined the impact of early do not resuscitate (DNR) orders and other limitations in aggressive care on mortality after ICH in a community-based study. Methods: Cases of spontaneous ICH from 2000 to 2003 were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project, with deaths ascertained through 2005. Charts were reviewed for early (<24 hours from presentation) DNR orders, withdrawal of care, or deferral of other life sustaining interventions, analyzed together as combined DNR (C-DNR). Multivariable Cox-proportional hazards models were used to examine the association between short- and long-term all-cause mortality and early C-DNR, adjusted for demographics and established predictors of mortality after ICH. Results: Of 18,393 subjects screened for cerebrovascular disease, 270 non-traumatic ICH cases were included. Cumulative mortality risk was 0.43 at 30 days and 0.55 over the study course. Early C-DNR was noted in 34% of cases and was associated with a doubling in the hazard of death both at 30 days (hazard ratio [HR] 2.17, 95% CI 1.38, 3.41) and at end of follow-up (HR 1.92, 95% CI 1.29, 2.87) despite adjustment for age, gender, ethnicity, Glasgow Coma Scale, ICH volume, intraventricular hemorrhage, and infratentorial hemorrhage. Conclusions: Early care limitations are independently associated with both short- and long-term all-cause mortality after intracerebral hemorrhage (ICH) despite adjustment for expected predictors of ICH mortality. Physicians should carefully consider the effect of early limitations in aggressive care to avoid limiting care for patients who may survive their acute illness.

Stroke Risk After Transient Ischemic Attack in a Population-Based Setting

Background and Purpose— Stroke risk after transient ischemic attack (TIA) has not been examined in an ethnically diverse population-based community setting. The purpose of this study was to identify stroke risk among TIA patients in a population-based cerebrovascular disease surveillance project. Methods— The Brain Attack Surveillance in Corpus Christi (BASIC) Project prospectively ascertains stroke and TIA cases in a geographically isolated Southeast Texas County. The community is approximately half Mexican American and half nonHispanic white. Cases are validated by board-certified neurologists using source documentation. Cumulative risk for stroke after TIA was determined using Kaplan–Meier estimates. Cox proportional hazards regression was used to test for associations between stroke risk after TIA and demographics, symptoms, risk factors, and history of stroke/TIA. Results— BASIC identified 612 TIA cases between January 1, 2000, and December 31, 2002; 60.9% were female and 48.0% were Mexican American. Median age was 73.8 years. Stroke risk within 2 days, 7 days, 30 days, 90 days, and 12 months was 1.64%, 1.97%, 3.15%, 4.03%, and 7.27%, respectively. Stroke risk was not influenced by ethnicity, symptoms, or risk factors. Conclusions— Using a population-based design, we found that early stroke risk after TIA was less than previously reported in this bi-ethnic population of Mexican Americans and nonHispanic whites. Approximately half of the 90-day stroke risk after TIA occurred within 2 days.

Persistent ischemic stroke disparities despite declining incidence in Mexican Americans

To determine trends in ischemic stroke incidence among Mexican Americans and non‐Hispanic whites.

Emergency department evaluation of ischemic stroke and TIA: The BASIC Project

Objective: To identify demographic and clinical variables of emergency department (ED) practices in a community-based acute stroke study. Methods: By both active and passive surveillance, the authors identified cerebrovascular disease cases in Nueces County, TX, as part of the Brain Attack Surveillance in Corpus Christi (BASIC) Project, a population-based stroke surveillance study, between January 1, 2000, and December 31, 2002. With use of multivariable logistic regression, variables independently associated with three separate outcomes were sought: hospital admission, brain imaging in the ED, and neurologist consultation in the ED. Prespecified variables included age, sex, ethnicity, insurance status, NIH Stroke Scale score, type of stroke (ischemic stroke or TIA), vascular risk factors, and symptom presentation variables. Percentage use of recombinant tissue plasminogen activator (rt-PA) was calculated. Results: A total of 941 Mexican Americans (MAs) and 855 non-Hispanic whites (NHWs) were seen for ischemic stroke (66%) or TIA (34%). Only 8% of patients received an in-person neurology consultation in the ED, and 12% did not receive any head imaging. TIA was negatively associated with neurology consultations compared with completed stroke (odds ratio [OR] 0.35 [95% CI 0.21 to 0.57]). TIA (OR 0.14 [0.10 to 0.19]) and sensory symptoms (OR 0.59 [0.44 to 0.81]) were also negatively associated with hospital admission. MAs (OR 0.58 [0.35 to 0.98]) were less likely to have neurology consultations in the ED than NHWs. Only 1.7% of patients were treated with rt-PA. Conclusions: Neurologists are seldom involved with acute cerebrovascular care in the emergency department (ED), especially in patients with TIA. Greater neurologist involvement may improve acute stroke diagnosis and treatment efforts in the ED.

Presentation of intracerebral haemorrhage in a community

Background: Studies on intracerebral haemorrhage (ICH) from tertiary care centres may not be an accurate representation of the true spectrum of disease presentation. Objective: To describe the clinical and imaging presentation of ICH in a community devoid of the referral bias of an academic medical centre; and to investigate factors associated with lower Glasgow coma scale (GCS) score at presentation, as GCS is crucial to early clinical decision making. Methods: The study formed part of the BASIC project (Brain Attack Surveillance in Corpus Christi), a population based stroke surveillance study in a bi-ethnic Texas community. Cases of first non-traumatic ICH were identified from years 2000 to 2003, using active and passive surveillance. Clinical data were collected from medical records by trained abstractors, and all computed tomography (CT) scans were reviewed by a study physician. Multivariable linear regression was used to identify clinical and CT predictors of a lower GCS score. Results: 260 cases of non-traumatic ICH were identified. Median ICH volume was 11 ml (interquartile range 3 to 36) with hydrocephalus noted in 45%. Median initial GCS score was 12.5 (7 to 15). Hydrocephalus score (p = 0.0014), ambient cistern effacement (p = 0.0002), ICH volume (p = 0.014), and female sex (p = 0.024) were independently associated with lower GCS score at presentation, adjusting for other variables. Conclusions: ICH has a wide range of severity at presentation. Hydrocephalus is a potentially reversible cause of a lower GCS score. Since early withdrawal of care decisions are often based on initial GCS, recognition of the important influence of hydrocephalus on GCS is warranted before withdrawal of care decisions are made.

Intracerebral hemorrhage mortality is not changing despite declining incidence

Objective: To determine trends in incidence and mortality of intracerebral hemorrhage (ICH) in a rigorous population-based study. Methods: We identified all cases of spontaneous ICH in a South Texas community from 2000 to 2010 using rigorous case ascertainment methods within the Brain Attack Surveillance in Corpus Christi Project. Yearly population counts were determined from the US Census, and deaths were determined from state and national databases. Age-, sex-, and ethnicity-adjusted incidence was estimated for each year with Poisson regression, and a linear trend over time was investigated. Trends in 30-day case fatality and long-term mortality (censored at 3 years) were estimated with log-binomial or Cox proportional hazards models adjusted for demographics, stroke severity, and comorbid disease. Results: A total of 734 cases of ICH were included. The age-, sex-, and ethnicity-adjusted ICH annual incidence rate was 5.21 per 10,000 (95% confidence interval [CI] 4.36, 6.24) in 2000 and 4.30 per 10,000 (95% CI 3.21, 5.76) in 2010. The estimated 10-year change in demographic-adjusted ICH annual incidence rate was −31% (95% CI −47%, −11%). Yearly demographic-adjusted 30-day case fatality ranged from 28.3% (95% CI 19.9%, 40.3%) in 2006 to 46.5% (95% CI 35.5, 60.8) in 2008. There was no change in ICH case fatality or long-term mortality over time. Conclusions: ICH incidence decreased over the past decade, but case fatality and long-term mortality were unchanged. This suggests that primary prevention efforts may be improving over time, but more work is needed to improve ICH treatment and reduce the risk of death.

Fast Food and Neighborhood Stroke Risk

To investigate the association between the number of fast food restaurants and ischemic stroke in neighborhoods.

Neurological, Functional, and Cognitive Stroke Outcomes in Mexican Americans

Background and Purpose— Our objective was to compare neurological, functional, and cognitive stroke outcomes in Mexican Americans (MAs) and non-Hispanic whites using data from a population-based study. Methods— Ischemic strokes (2008–2012) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from patient or proxy interviews (conducted at baseline and 90 days poststroke) and medical records. Ethnic differences in neurological (National Institutes of Health Stroke Scale: range, 0–44; higher scores worse), functional (activities of daily living/instrumental activities of daily living score: range, 1–4; higher scores worse), and cognitive (Modified Mini-Mental State Examination: range, 0–100; lower scores worse) outcomes were assessed with Tobit or linear regression adjusted for demographics and clinical factors. Results— A total of 513, 510, and 415 subjects had complete data for neurological, functional, and cognitive outcomes and covariates, respectively. Median age was 66 (interquartile range, 57–78); 64% were MAs. In MAs, median National Institutes of Health Stroke Scale, activities of daily living/instrumental activities of daily living, and Modified Mini-Mental State Examination score were 3 (interquartile range, 1–6), 2.5 (interquartile range, 1.6–3.5), and 88 (interquartile range, 76–94), respectively. MAs scored 48% worse (95% CI, 23%–78%) on National Institutes of Health Stroke Scale, 0.36 points worse (95% CI, 0.16–0.57) on activities of daily living/instrumental activities of daily living score, and 3.39 points worse (95% CI, 0.35–6.43) on Modified Mini-Mental State Examination than non-Hispanic whites after multivariable adjustment. Conclusions— MAs scored worse than non-Hispanic whites on all outcomes after adjustment for confounding factors; differences were only partially explained by ethnic differences in survival. These findings in combination with the increased stroke risk in MAs suggest that the public health burden of stroke in this growing population is substantial.

Differences in intracerebral hemorrhage between Mexican Americans and non-Hispanic whites.

Background: Mexican Americans (MAs) have higher incidence rates of intracerebral hemorrhage (ICH) than non-Hispanic whites (NHWs). The authors present clinical and imaging characteristics of ICH in MAs and NHWs in a population-based study. Methods: This work is part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. Cases of nontraumatic ICH were identified from 2000 to 2003. Multivariable logistic regression was used to assess the independent associations between ethnicity and ICH location (lobar vs nonlobar) and volume (≥30 vs <30 mL), adjusting for demographics and baseline clinical characteristics. Logistic regression was also used to determine the association between ethnicity and in-hospital mortality, adjusting for confounders. Results: A total of 149 MAs and 111 NHWs with ICH were identified. MAs were younger (70 vs 77, p < 0.001), more often male (55% vs 42%, p = 0.04), had a lower prevalence of atrial fibrillation (2.0% vs 13%, p < 0.001), and a higher prevalence of diabetes (39% vs 19%, p < 0.001). MA ethnicity was independently associated with nonlobar hemorrhage (OR 2.08, 95% CI: 1.15, 3.70). MAs had over two times the odds of having small (<30 mL) hemorrhages compared with NHWs (OR = 2.41, 95% CI: 1.31, 4.46). NHWs had higher in-hospital mortality, though this association was no longer significant after adjustment for ICH volume, location, age, and sex. Conclusions: There are significant differences in the characteristics of ICH in MAs and NHWs, with MA patients more likely to have smaller, nonlobar hemorrhages. These differences may be used to examine the underlying pathophysiology of ICH.

Brainstem infarction and sleep-disordered breathing in the BASIC sleep apnea study

BACKGROUND Association between cerebral infarction site and poststroke sleep-disordered breathing (SDB) has important implications for SDB screening and the pathophysiology of poststroke SDB. Within a large, population-based study, we assessed whether brainstem infarction location is associated with SDB presence and severity. METHODS Cross-sectional study was conducted on ischemic stroke patients in the Brain Attack Surveillance in Corpus Christi (BASIC) project. Subjects underwent SDB screening (median 13days after stroke) with a well-validated cardiopulmonary sleep apnea-testing device (n=355). Acute infarction location was determined based on review of radiology reports and dichotomized into brainstem involvement or none. Logistic and linear regression models were used to test the associations between brainstem involvement and SDB or apnea/hypopnea index (AHI) in unadjusted and adjusted models. RESULTS A total of 38 participants (11%) had acute infarction involving the brainstem. Of those without brainstem infarction, 59% had significant SDB (AHI⩾10); the median AHI was 13 (interquartile range (IQR) 6, 26). Of those with brainstem infarction, 84% had SDB; median AHI was 20 (IQR 11, 38). In unadjusted analysis, brainstem involvement was associated with over three times the odds of SDB (odds ratio (OR) 3.71 (95% confidence interval (CI): 1.52, 9.13)). In a multivariable model, adjusted for demographics, body mass index (BMI), hypertension, diabetes, coronary artery disease, atrial fibrillation, prior stroke/transient ischemic attack (TIA), and stroke severity, results were similar (OR 3.76 (95% CI: 1.44, 9.81)). Brainstem infarction was also associated with AHI (continuous) in unadjusted (p=0.004) and adjusted models (p=0.004). CONCLUSIONS Data from this population-based stroke study show that acute infarction involving the brainstem is associated with both presence and severity of SDB.