Steff Lewis

Inflammatory markers and poor outcome after stroke: a prospective cohort study and systematic review of interleukin-6

In a prospective cohort study of patient outcomes following stroke, William Whiteley and colleagues find that markers of inflammatory response are associated with poor outcomes. However, addition of these markers to existing prognostic models does not improve outcome prediction.

Impact of functional status at six months on long term survival in patients with ischaemic stroke : prospective cohort studies

Objective To estimate the impact on long term survival of functional status at six months after ischaemic stroke. Design Prospective cohort study. Settings Three cohorts: Oxfordshire community stroke project, Lothian stroke register, and the first international stroke trial (in the United Kingdom). Participants 7710 patients with ischaemic stroke registered between 1981 and 2000 and followed up for a maximum of 19 years. Main outcome measures Functional status at six months after stroke assessed with modified Rankin scale or “two simple questions.” Mortality during follow-up. Survival analysis with Kaplan-Meier curves, log rank test, and Cox’s regression model. Results In a combined analysis of all three cohorts, among patients who survived to assessment six months after the index stroke, the subsequent median length of survival among those independent in daily living and those dependent was 9.7 years (95% confidence interval 8.9 to 10.6) and 6.0 years (5.7 to 6.4), respectively. In a combined analysis of the Oxfordshire and Lothian cohorts, subsequent median survival fell progressively from 12.9 years (10.0 to 15.9) for patients with a Rankin score of 0-1 at six months after the stroke to 2.5 years (1.4 to 3.5) for patients with a Rankin score of 5. All previously stated differences in median survival were significant (log rank test P<0.001). The influence of functional outcome on survival remained significant (P<0.05) in each cohort after adjustment for relevant covariates (such as age, presence of atrial fibrillation, visible infarct on computed tomography, subtype of stroke) in a Cox’s regression model. Conclusion Functional status six months after an ischaemic stroke is associated with long term survival. Early interventions that reduce dependency at six months might have positive effects on long term survival.

The third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke

BackgroundIntravenous recombinant tissue plasminogen activator (rt-PA) is approved for use in selected patients with ischaemic stroke within 3 hours of symptom onset. IST-3 seeks to determine whether a wider range of patients may benefit.DesignInternational, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rt-PA in acute ischaemic stroke. Suitable patients must be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracerebral haemorrhage. With 1000 patients, the trial can detect a 7% absolute difference in the primary outcome. With3500 patients, it can detect a 4.0% absolute benefit & with 6000, (mostly treated between 3 & 6 hours), it can detect a 3% benefit.Trial proceduresPatients are entered into the trial by telephoning a fast, secure computerised central randomisation system or via a secure web interface. Repeat brain imaging must be performed at 24–48 hours. The scans are reviewed blind by expert readers. The primary measure of outcome is the proportion of patients alive and independent (Modified Rankin 0–2) at six months (assessed via a postal questionnaire mailed directly to the patient). Secondary outcomes include: events within 7 days (death, recurrent stroke, symptomatic intracranial haemorrhage), outcome at six months (death, functional status, EuroQol).Trial registrationISRCTN25765518

Relationship Between Pattern of Intracranial Artery Abnormalities on Transcranial Doppler and Oxfordshire Community Stroke Project Clinical Classification of Ischemic Stroke

BACKGROUND AND PURPOSEnThe Oxfordshire Community Stroke Project (OCSP) devised a simple classification for acute stroke based on clinical features only, which is of value in predicting prognosis. We investigated whether the pattern of intracranial vascular abnormalities is related to the clinical syndrome.nnnMETHODSnPatients with acute ischemic stroke were classified by a stroke physician as having total or partial anterior circulation infarct (TACI or PACI, respectively), lacunar infarct (LACI), or posterior circulation infarct (POCI). Color-coded power transcranial Doppler was done whenever possible. Intracranial arterial velocities were compared in the 4 subtypes of ischemic stroke after adjustment for age and time to transcranial Doppler.nnnRESULTSnMiddle cerebral artery velocity was abnormal (hyperemia, reduced velocity, occlusion, or focal stenosis) in 38 of 69 TACIs (55%), 50 of 171 PACIs (29%), and 20 of 236 LACIs or POCIs (8%) (P<0.001). Velocity in the A1 segment of the anterior cerebral artery was reversed in 12 of 69 TACIs (17%), 20 of 171 PACIs (12%), and 8 of 236 LACIs or POCIs (3%) (P<0.001). Basilar artery velocity was abnormal in 8 of 121 POCIs (7%) compared with 5 of 355 (1%) of the other subtypes (P=0.005). Vertebral artery velocity was abnormal (reduced velocity, occlusion, stenosis) in 20 of 121 POCIs (17%) compared with 20 of 355 others (6%) (P=0.01).nnnCONCLUSIONSnIntracranial arterial abnormalities were related to OCSP clinical subtype. Therefore, it is possible to stratify patients according to OCSP classification in trials of new treatments in which treatment effectiveness may depend on the underlying pattern of arterial pathology and before any arterial imaging is available.