[Clinical profile and non-recreational methamphetamine abuse (shabu) among stroke patients in the Philippine population]. / Perfil clínico y abuso de metanfetamina no recreativa (shabú) entre los pacientes con ictus en la población filipina.

INTRODUCTION: Chronic non-recreational use of methamphetamine (shabu) is increasing among the Filipino population in Barcelona. The Asian population presents a different stroke pattern, with a higher incidence of haemorrhage, and different vascular risk factors and health behaviours. The objective of this study is to describe the stroke profile and incidence of methamphetamine use in patients of Filipino origin admitted to our centre. PATIENTS AND METHODS: Demographic data, vascular risk factors, clinical data and prognosis were recorded. Methamphetamine exposure was analysed in plasma samples collected on admission, which were then analysed by liquid chromatography-mass spectrometry. RESULTS: Of a total of 6,418 stroke patients, 73 (1.1%) were identified as being of Filipino origin. The mean age was 54.4 ± 12.1 years, 54% were male and the stroke was ischaemic in 64.4% of cases. Arterial hypertension was the main risk factor. Ten (13.7%) patients tested positive for methamphetamine and amphetamine. These results confirm recent substance use prior to the stroke, mostly in men (80%). In patients who were consumers, 60% had a haemorrhagic stroke, with a poor functional prognosis at three months in 55.6% of patients. CONCLUSIONS: In our setting, patients of Filipino ethnicity admitted for stroke related to the consumption of shabu belonged a younger age bracket, with a lower prevalence of vascular risk factors and a predominance of the haemorrhagic subtype. Methamphetamine testing in Filipino stroke patients is recommended due to the high prevalence of methamphetamine use in our country.

TITLE: Perfil clínico y abuso de metanfetamina no recreativa (shabú) entre los pacientes con ictus en la población filipina.Introducción. En la población filipina de Barcelona está aumentando el consumo crónico no recreativo de metanfetaminas (shabú). La población asiática presenta un patrón de ictus diferente, con mayor incidencia de hemorragias, y diferentes factores de riesgo vascular y conductas de salud. El objetivo es describir el perfil de ictus e incidencia de consumo de metanfetaminas en pacientes de origen filipino ingresados en nuestro centro. Pacientes y métodos. Se registraron datos demográficos, factores de riesgo vascular, datos clínicos y pronóstico. Se analizó la exposición a metanfetamina en muestras de plasma recogidas en el ingreso, que se analizaron por cromatografía líquida-espectrometría de masas. Resultados. Del total de 6.418 pacientes con ictus, se identificó a 73 pacientes filipinos (1,1%). La edad media era de 54,4 ± 12,1 años, el 54% eran hombres y el ictus era isquémico en el 64,4%. La hipertensión arterial fue el principal factor de riesgo. Diez (13,7%) pacientes dieron positivo a metanfetamina y anfetamina. Estos resultados confirman un consumo reciente de sustancias previo al ictus, principalmente en hombres (80%). En pacientes consumidores, un 60% presentaba un ictus hemorrágico, con mal pronóstico funcional a tres meses en el 55,6% de los pacientes. Conclusiones. En nuestro medio, los pacientes de etnia filipina ingresados por ictus en relación con consumo de shabú presentaron un perfil de edad más joven, con menor prevalencia de factores de riesgo vascular y predominio del subtipo hemorrágico. Se recomienda la determinación de metanfetamina en los pacientes filipinos con ictus debido a la alta prevalencia del consumo de metanfetamina en nuestro país.

Perfil clínico y abuso de metanfetamina no recreativa (shabú) entre los pacientes con ictus en la población filipina / Clinical profile and non-recreational methamphetamine abuse (shabu) among stroke patients in the Philippine population

Introducción En la población filipina de Barcelona está aumentando el consumo crónico no recreativo de metanfetaminas (shabú). La población asiática presenta un patrón de ictus diferente, con mayor incidencia de hemorragias, y diferentes factores de riesgo vascular y conductas de salud. El objetivo es describir el perfil de ictus e incidencia de consumo de metanfetaminas en pacientes de origen filipino ingresados en nuestro centro. Pacientes y métodos Se registraron datos demográficos, factores de riesgo vascular, datos clínicos y pronóstico. Se analizó la exposición a metanfetamina en muestras de plasma recogidas en el ingreso, que se analizaron por cromatografía líquida-espectrometría de masas. Resultados Del total de 6.418 pacientes con ictus, se identificó a 73 pacientes filipinos (1,1%). La edad media era de 54,4 ± 12,1 años, el 54% eran hombres y el ictus era isquémico en el 64,4%. La hipertensión arterial fue el principal factor de riesgo. Diez (13,7%) pacientes dieron positivo a metanfetamina y anfetamina. Estos resultados confirman un consumo reciente de sustancias previo al ictus, principalmente en hombres (80%). En pacientes consumidores, un 60% presentaba un ictus hemorrágico, con mal pronóstico funcional a tres meses en el 55,6% de los pacientes. Conclusiones En nuestro medio, los pacientes de etnia filipina ingresados por ictus en relación con consumo de shabú presentaron un perfil de edad más joven, con menor prevalencia de factores de riesgo vascular y predominio del subtipo hemorrágico. Se recomienda la determinación de metanfetamina en los pacientes filipinos con ictus debido a la alta prevalencia del consumo de metanfetamina en nuestro país. (AU)

INTRODUCTION Chronic non-recreational use of methamphetamine (shabú) is increasing among the Filipino population in Barcelona. The Asian population presents a different stroke pattern, with a higher incidence of haemorrhage, and different vascular risk factors and health behaviours. The objective of this study is to describe the stroke profile and incidence of methamphetamine use in patients of Filipino origin admitted to our centre. PATIENTS AND METHODS Demographic data, vascular risk factors, clinical data and prognosis were recorded. Methamphetamine exposure was analysed in plasma samples collected on admission, which were then analysed by liquid chromatography-mass spectrometry. RESULTS Of a total of 6,418 stroke patients, 73 (1.1%) were identified as being of Filipino origin. The mean age was 54.4 ± 12.1 years, 54% were male and the stroke was ischaemic in 64.4% of cases. Arterial hypertension was the main risk factor. Ten (13.7%) patients tested positive for methamphetamine and amphetamine. These results confirm recent substance use prior to the stroke, mostly in men (80%). In patients who were consumers, 60% had a haemorrhagic stroke, with a poor functional prognosis at three months in 55.6% of patients. CONCLUSIONS In our setting, patients of Filipino ethnicity admitted for stroke related to the consumption of shabú belonged a younger age bracket, with a lower prevalence of vascular risk factors and a predominance of the haemorrhagic subtype. Methamphetamine testing in Filipino stroke patients is recommended due to the high prevalence of methamphetamine use in our country. (AU)

[Cross-cultural adaptation to Spanish of the Signs of Depression Scale (SODS) to the early assessment of mood in patients admitted to a Stroke Unit]. / Adaptación transcultural al español de la Signs of Depression Scale (SODS) para la evaluación precoz del estado de ánimo en pacientes ingresados en una unidad de ictus.

INTRODUCTION: Stroke hospitalization negatively affects mood. Clinical guidelines recommend early evaluation of mood disorders. However, there is no consensus on the most appropriate scale in Spanish language. AIM: The objective of the study is the cross-cultural adaptation of the Signs of Depression Scale (SODS) in patients admitted to the stroke unit of the Hospital del Mar. MATERIALS AND METHODS: The work scheme for transcultural adaptation into Spanish was: a) direct translation; b) reconciliation and synthesis of translations; c) reverse translation into English; d) consensus of the back-translated version with original author; e) cognitive interrogation; f) revision and consensus version in Spanish; g) reading test, spelling, and grammar check; h) final version. Analysis and descriptive summary of the adaptation process was performed. RESULTS: There were no differences between direct translation versions. The back-translation version was accepted by the author of the original questionnaire. A convenience sample of patients with/without aphasia (n = 22) was included for cognitive interview from which no major problems were identified in the implementation of the questionnaire. Inclusive language was used in the final version. CONCLUSION: The transcultural adaptation of the scale allows in a simple and early way the evaluation mood in patients admitted to the stroke unit. The Spanish version is equivalent to the original instrument. This adaptation can be incorporated into care in the Stroke Unit and is extrapolated to other Spanish-speaking centres.

TITLE: Adaptación transcultural al español de la Signs of Depression Scale (SODS) para la evaluación precoz del estado de ánimo en pacientes ingresados en una unidad de ictus.Introducción. La hospitalización por ictus afecta negativamente al estado de ánimo. Las guías clínicas recomiendan evaluar precozmente el estado de ánimo. Sin embargo, no existe consenso sobre la escala más apropiada en idioma español. Objetivo. El objetivo del estudio es realizar una adaptación transcultural de la Signs of Depression Scale en pacientes ingresados en la unidad de ictus. Materiales y métodos. El esquema de trabajo de la adaptación transcultural al español fue: a) traducción directa; b) conciliación y síntesis de las traducciones; c) traducción inversa al inglés; d) consenso de la versión retrotraducida; e) interrogatorio cognitivo; f) revisión y versión consensuada en español; g) prueba de lectura, revisión ortográfica y gramatical, y h) versión final. Se realizó un análisis y un resumen descriptivo del proceso de adaptación transcultural. Resultados. Las versiones de traducción directa no presentaron diferencias. La versión de la traducción inversa fue aceptada por la autora del cuestionario original. Para el interrogatorio cognitivo se incluyó una muestra por conveniencia de 22 pacientes con/sin afasia a partir de la cual no se identificaron problemas en la aplicación del cuestionario. Se utilizó un lenguaje inclusivo en la versión final. Conclusiones. La versión española es equivalente al instrumento original. La adaptación transcultural de la escala permite, de forma sencilla y precoz, la evaluación del estado de ánimo en pacientes con ictus. Esta adaptación se puede incorporar en los cuidados en la unidad de ictus y es extrapolable a otros centros de habla hispana.

A parsimonious score with a free web tool for predicting disability after an ischemic stroke: the Parsifal Score.

BACKGROUND: Most of the models to predict prognosis after an ischemic stroke include complex mathematical equations or too many variables, making them difficult to use in the daily clinic. We want to predict disability 3 months after an ischemic stroke in an independent patient not receiving recanalization treatment within the first 24 h, using a minimum set of variables and an easy tool to facilitate its implementation. As a secondary aim, we calculated the capacity of the score to predict an excellent/devastating outcome and mortality. METHODS: Eight hundred and forty-four patients were evaluated. A multivariable ordinal logistic regression was used to obtain the score. The Modified Rankin Scale (mRS) was used to estimate disability at the third month. The results were replicated in another independent cohort (378 patients). The "polr" function of R was used to perform the regression, stratifying the sample into seven groups with different cutoffs (from mRS 0 to 6). RESULTS: The Parsifal score was generated with: age, previous mRS, initial NIHSS, glycemia on admission, and dyslipidemia. This score predicts disability with an accuracy of 80-76% (discovery-replication cohorts). It has an AUC of 0.86 in the discovery and replication cohort. The specificity was 90-80% (discovery-replication cohorts); while, the sensitivity was 64-74% (discovery-replication cohorts). The prediction of an excellent or devastating outcome, as well as mortality, obtained good discrimination with AUC > 0.80. CONCLUSIONS: The Parsifal Score is a model that predicts disability at the third month, with only five variables, with good discrimination and calibration, and being replicated in an independent cohort.

Ultra-early continuous cardiac monitoring improves atrial fibrillation detection and prognosis of patients with cryptogenic stroke.

BACKGROUND AND PURPOSE: Subclinical atrial fibrillation (AF) is known to underlie a number of cases of cryptogenic stroke (CrS). However, there is need to define the most effective strategy for AF detection. The diagnostic usefulness was analysed of a strategy based on ultra-early continuous monitoring in patients with CrS in terms of AF detection, oral anticoagulation treatment and stroke recurrence, in comparison to a standard outpatient strategy. METHODS: Patients with ischaemic stroke of undetermined origin and confirmed to be cryptogenic after extensive work-up were searched for AF with (i) a conventional strategy (historical cohort, n = 101) with serial electrocardiograms and 24-h Holter monitoring or (ii) an ultra-early monitoring strategy with insertable cardiac monitor (ICM) implanted before discharge (prospective cohort, n = 90). AF episodes lasting >1 min, anticoagulant treatment and stroke recurrence were recorded. RESULTS: During admission, AF was similarly detected in both cohorts (24% of patients). After discharge (mean follow-up 30 ± 10 months), AF detection rates were 17/80 (21.3%) and 38/65 (58.5%) for patients in the conventional versus the ultra-early ICM group (P < 0.001). Up to 41% of AF cases in the ICM cohort were detected within the first month. Oral anticoagulation was initiated in 37.6% versus 65.5% (P < 0.001) and stroke recurrence was recorded in 10.9% versus 3.3% (P 0.04) in the conventional versus the ICM cohort. CONCLUSIONS: Pre-discharge ICM implant allows detection of AF during follow-up in up to 58% of selected patients with CrS. Compared to a conventional strategy, ultra-early ICM implant results in higher anticoagulation rates and a decrease in stroke recurrence.

Estudio descriptivo de los stroke mimics después de un estudio neurovascular completo / Description of stroke mimics after complete neurovascular assessment

Introducción: Un porcentaje de casos diagnosticados inicialmente como infartos isquémicos son de causa no cerebrovascular o stroke mimics (SM). Los datos publicados al respecto son heterogéneos y, generalmente, con cohortes pequeñas. Objetivo: Nuestro objetivo es establecer qué enfermedades cursan como SM, definir sus características epidemiológicas y clínicas e identificar el porcentaje de casos tratados con fibrinólisis. Métodos: Registro prospectivo de los eventos considerados cerebrovasculares desde junio del 2005 a abril del 2015, analizando datos demográficos, factores de riesgo cardiovascular, activación de Código Ictus e ingreso, severidad (NIHSS), destino al alta, morbilidad (mRS) y tratamiento recibido. Se han comparado los ictus isquémicos con los SM. Se excluyeron las hemorragias intracraneales, subaracnoideas y las causas de SM detectables en la TC inicial. Resultados: Sobre 4.570 casos, 404 (8,8%) son SM. Los pacientes con SM son más jóvenes (70,3 vs. 74 años, p < 0,0001), tienen menos factores de riesgo cardiovascular y fibrilación auricular (13 vs. 34%, p < 0,0001), una menor puntuación en NIHSS (2 vs. 4, p < 0,0001) y menos afasia (9,4 vs. 19,6%, p < 0,02) y disfagia (1,2 vs. 17%, p < 0,0001). En los SM se activan menos códigos ictus (28 vs. 40%, p < 0,0001) y requieren menos días de ingreso (4,9 vs. 7,8; p<0,0001) y menos ingresos en la unidad de ictus (47 vs. 60%, p < 0,0001). Los SM son dados de alta a domicilio con mayor frecuencia (95 vs. 62%, p < 0,0001) y con menor discapacidad (mRS 0-2; 76 vs. 54%, p < 0,0001). Un 4,7% de los SM recibieron fibrinólisis. La primera causa de SM fueron las crisis epilépticas (26%). Conclusiones: Los SM supusieron el 8,8% de los ingresos con diagnóstico inicial de ictus isquémico. Los SM tienen características demográficas, clínicas y pronósticas diferentes, siendo la epilepsia la etiología más frecuente. Pese a recibir atención urgente especializada, 19 pacientes (4,7%) fueron trataron con fibrinólisis

Introduction: A considerable percentage of events initially diagnosed as ischaemic stroke have non-cerebrovascular causes; these are called stroke mimics (SM). Currently available evidence about these events is heterogeneous and comes from studies with small samples. Objective:The purpose of our study is to identify conditions that may present as SM, define their epidemiological and clinical characteristics, and determine the percentage of cases of SM treated with intravenous fibrinolysis. Methods: Prospective study including all patients admitted to a tertiary university hospital between June 2005 and April 2015 with a diagnosis of acute stroke. We analysed demographic data, cardiovascular risk factors, time from code stroke activation to admission, stroke severity (NIHSS), final destination after discharge, degree of disability (mRS), and treatment. We compared SM and ischaemic strokes. We ruled out patients with intracranial haemorrhage, subarachnoid haemorrhage, or other causes of SM that may be detected on the baseline CT scan. Results: Four hundred four of the 4,570 included patients (8.8%) were found to have SM. Patients with SM were younger (70.3 vs. 74, P <. 0001), less likely to exhibit cardiovascular risk factors and atrial fibrillation (13 vs. 34%, P < .0001), scored lower on the NIHSS at baseline (2 vs. 4, P<.0001), and included fewer cases of aphasia (9.4 vs. 19.6%, P < .02) and dysphagia (1.2 vs. 17%, P < .0001) than patients with stroke. SM caused fewer code stroke activations (28 vs. 40%, P < .0001). Patients with SM required shorter hospital stays (4.9 vs. 7.8 days, P < .0001), were less frequently admitted to the stroke unit (47 vs. 60%, P < .0001) and more frequently discharged home (95 vs. 62%, P < .0001), and had better outcomes (mRS scores 0-2; 76 vs. 54%, P <. 0001). Intravenous fibrinolysis was administered to 4.7% of these patients. Epileptic seizures were the most frequent cause of SM (26%). Conclusions: In our sample, 8.8% of all diagnoses of ischaemic stroke were SM. These events have different demographic, clinical, and prognostic characteristics; epilepsy is the most common aetiology. Despite receiving specialised emergency care, 19 patients with SM (4.7%) were treated with intravenous fibrinolysis

Description of stroke mimics after complete neurovascular assessment. / Estudio descriptivo de los stroke mimics después de un estudio neurovascular completo.

INTRODUCTION: A considerable percentage of events initially diagnosed as ischaemic stroke have non-cerebrovascular causes; these are called stroke mimics (SM). Currently available evidence about these events is heterogeneous and comes from studies with small samples. OBJECTIVE: The purpose of our study is to identify conditions that may present as SM, define their epidemiological and clinical characteristics, and determine the percentage of cases of SM treated with intravenous fibrinolysis. METHODS: Prospective study including all patients admitted to a tertiary university hospital between June 2005 and April 2015 with a diagnosis of acute stroke. We analysed demographic data, cardiovascular risk factors, time from code stroke activation to admission, stroke severity (NIHSS), final destination after discharge, degree of disability (mRS), and treatment. We compared SM and ischaemic strokes. We ruled out patients with intracranial haemorrhage, subarachnoid haemorrhage, or other causes of SM that may be detected on the baseline CT scan. RESULTS: Four hundred four of the 4,570 included patients (8.8%) were found to have SM. Patients with SM were younger (70.3 vs. 74, P<.0001), less likely to exhibit cardiovascular risk factors and atrial fibrillation (13 vs. 34%, P<.0001), scored lower on the NIHSS at baseline (2 vs. 4, P<.0001), and included fewer cases of aphasia (9.4 vs. 19.6%, P<.02) and dysphagia (1.2 vs. 17%, P<.0001) than patients with stroke. SM caused fewer code stroke activations (28 vs. 40%, P<.0001). Patients with SM required shorter hospital stays (4.9 vs. 7.8 days, P<.0001), were less frequently admitted to the stroke unit (47 vs. 60%, P<.0001) and more frequently discharged home (95 vs. 62%, P<.0001), and had better outcomes (mRS scores 0-2; 76 vs. 54%, P<.0001). Intravenous fibrinolysis was administered to 4.7% of these patients. Epileptic seizures were the most frequent cause of SM (26%). CONCLUSIONS: In our sample, 8.8% of all diagnoses of ischaemic stroke were SM. These events have different demographic, clinical, and prognostic characteristics; epilepsy is the most common aetiology. Despite receiving specialised emergency care, 19 patients with SM (4.7%) were treated with intravenous fibrinolysis.

Alcohol overuse and intracerebral hemorrhage: characteristics and long-term outcome.

BACKGROUND AND PURPOSE: Alcohol overuse (AOu) is considered an important risk factor for spontaneous intracerebral hemorrhage (ICH). The clinical and outcome characteristics of these patients (AOu-ICH) are not well known. METHODS: All patients with ICH admitted to a single university tertiary stroke center were prospectively studied from May 2005 to May 2015. Demographic profiles, radiologic characteristics and clinical outcomes of patients with acute ICH and previous AOu (>40 g/day or >300 g/week) were analyzed. RESULTS: During the study period, 555 patients with spontaneous primary ICH met the inclusion criteria. A total of 81 patients (14.6%) reported AOu (24.3% of men vs. 3.1% of women; P < 0.0001; mean age, 63 years old for AOu vs. 74 years old for non-AOu; P < 0.0001). Of the classic cardiovascular risk factors, only smoking was associated with AOu (63% vs. 12.2% of non-AOu; P < 0.0001). Initial severity and hematoma volume were similar in both groups, with no observed differences in stroke care or in-hospital medical complications. Patients with AOu had worse outcome (modified Rankin Scale score, 3-6 points) than patients without AOu at 3 months [odds ratio (OR), 2.50; 95% confidence interval (CI), 1.32-4.75; P = 0.005] and 12 months (OR, 2.47; 95% CI, 1.23-5.00; P = 0.011). A similar trend was observed at 5 years (OR, 2.48; 95% CI, 0.96-6.39; P = 0.059). CONCLUSIONS: Alcohol overuse was present in 14.6% of patients with ICH, who were predominantly male, smokers and a mean of 11 years younger than the non-AOu group. Despite a lack of differences in initial clinical severity, stroke care and early medical complications, patients with AOu had worse short- and long-term outcomes.

Brainstem leukoaraiosis independently predicts poor outcome after ischemic stroke.

BACKGROUND AND PURPOSE: Increased supratentorial white matter hyperintensities volume (S-WMHV) has been reported to be a predictor of worse outcome in patients with acute ischemic stroke (AIS). However, few studies have focused on less common locations, such as brainstem white matter hyperintensities (B-WMH), and their relationship to S-WMHV. This study aimed to examine whether B-WMH affect clinical outcome after AIS or transient ischemic attack (TIA). METHODS: Based on magnetic resonance imaging evidence, B-WMH were evaluated in 313 prospectively identified patients with AIS/TIA and registered as absent or present. Standardized S-WMHV was quantified using a validated volumetric image analysis and natural log-transformed (Log_S-WMHV). Poor outcome was defined as a modified Rankin Scale score of 3-6 at 3 months after the index event. RESULTS: Brainstem white matter hyperintensities were detected in 57 (18.2%) patients. In unadjusted analyses for outcome, the presence of B-WMH was associated with worse outcome, compared with patients without B-WMH (P = 0.034). In multivariate analysis controlling for age, atrial fibrillation, stroke severity, reperfusion therapies and Log_S-WMHV, only B-WMH [odds ratio (OR), 2.46; P = 0.021] and stroke severity (OR, 1.23; P < 0.001) remained independently associated with unfavourable 90-day modified Rankin Scale score. Patients with B-WMH were older (OR, 1.06; P < 0.001) and tended to have more hyperlipidaemia (OR, 2.21; P = 0.023) and peripheral arterial disease (OR, 2.57; P = 0.031). CONCLUSIONS: Brainstem white matter hyperintensities are an independent predictor of poor outcome after AIS/TIA and this relationship persists after adjustment for important prognostic factors. Our results also show that leukoaraiosis in this location identifies patients with a specific risk factor profile, suggesting differences in the underlying pathogenesis.

Ultra-early hematoma growth in antithrombotic pretreated patients with intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Patients with acute intracerebral hemorrhage (ICH) pretreated with antithrombotic drugs may have increased early hematoma growth, which would increase mortality risk. The effect of antiplatelet (AP) and vitamin K antagonist (VKA) pretreatment on ultra-early hematoma growth (uHG) and its relationship with mortality in patients with acute supratentorial ICH was analyzed. METHODS: This is an observational retrospective study of a prospective register of 197 ICH patients with first computed tomography (CT) scan taken <6 h from ICH symptom onset. ICH volume was calculated by the ABC/2 formula and uHG by the baseline ICH volume/onset-to-CT time (ml/h) formula. The uHG analysis took into account the patient's pretreatment (none, AP or VKA) and the relationship between uHG and very-early (first 24 h) and 3-month mortality. RESULTS: In the pretreatment group, 50 (25.4%) patients were treated with AP and 37 (18.8%) with VKA. The median (interquartile range 25-75) uHG was 19.7 ml/h (2.9-44.8) for AP pretreated patients, 16.2 ml/h (5.1-42.5) for VKA pretreated patients and 8.4 ml/h (2.4-21.8) for non-pretreated patients, P = 0.019. The uHG was higher in patients with very-early [42.1 ml/h (20.1-79.6)] and total 3-month mortality [28.0 ml/h (15.8-52.5)] compared with survivors [3.9 ml/h (1.5-10.4)], P < 0.0001. Adjusted by ICH severity and previous functional status, uHG was an independent factor related to very-early (P = 0.028) and total 3-month mortality (P = 0.014). CONCLUSIONS: Patients pretreated with antithrombotics have much higher uHG, which would explain the increased mortality in these patients compared to untreated patients.

Sex-related differences in abdominal obesity impact on ischemic stroke risk.

BACKGROUND AND PURPOSE: The objective of our study was to evaluate sex differences in the impact of weight and abdominal obesity on the risk of ischemic stroke. METHODS: We included 388 patients with ischemic stroke (aged <75 years) assessed consecutively in our hospital and 732 controls matched by age and sex. Vascular risk factors and anthropometric data (waist circumference, weight and height) were recorded. The impact of three anthropometric variables [body mass index (BMI), waist circumference and waist to height ratio] on ischemic stroke risk was calculated. These variables were divided into quartiles for a comprehensive comparison between cases and controls, stratified by sex and adjusted in logistic regression by age and vascular risk factors. Further logistic regression using dummy variables was performed to evaluate the association between BMI-adjusted abdominal obesity and stroke risk. RESULTS: Increased BMI was not associated with increased stroke risk overall or in women, but was a protective factor in men [P = 0.03; odds ratio (OR), 0.59 (0.37-0.94)]. Abdominal obesity was a risk factor for stroke in women, in both waist circumference [P < 0.001; OR, 5.79 (3.10-10.85)] and waist to height ratio [P < 0.001; OR, 3.61 (1.99-6.54)] analyses, but was not significant in men. When considered independently of BMI, abdominal obesity was a risk factor in both sexes, but the strength of the association was significantly higher in women. CONCLUSIONS: Increased BMI was related to a lower risk of stroke in men. Abdominal obesity was associated with ischemic stroke in women. The impact of abdominal obesity on stroke risk differs by sex.

Detección de ictus intrahospitalario: evaluación de resultados de un programa de formación y entrenamiento a personal médico y de enfermería / Detecting in-hospital stroke: Assessment of results from a training programme for medical personnel

Introducción: El ictus intrahospitalario (IIH) es frecuente, pero su atención preferente no está bien establecida en muchos centros hospitalarios. En nuestro centro, como medida de calidad asistencial, se intentó reorganizar la atención al IIH mediante un programa de formación teórica y entrenamiento a profesionales sanitarios no implicados habitualmente en el manejo de pacientes con ictus, para optimizar la detección y el tratamiento del IIH. Se evalúan resultados del programa de formación. Métodos: Estudio prospectivo longitudinal de intervención. Se elaboró un programa de formación a personal médico y enfermería. Se registró a los pacientes con IIH pre (PRE) y posformación (POST) (6 meses cada grupo) y se evaluaron los datos de incidencia, datos epidemiológicos, motivo de ingreso y servicio, etiología, severidad, tiempo hasta evaluación por Neurología, tratamiento recanalizador (trombólisis intravenosa/intravascular), criterios de exclusión en no tratados y pronóstico (mortalidad/discapacidad) en ambos grupos. Resultados: Se identificó a 60 pacientes con IIH, con una edad media de 75,3 ± 12,5, 41% hombres; 19 PRE/41 POST. Sin diferencias entre grupos en el tiempo de evaluación, el tratamiento o la morbimortalidad. El 68,3% de ellos fueron evaluados en < 4,5 h, de los cuales solo fue posible administrar tratamiento recanalizador en 6 pacientes (10%), debido fundamentalmente a dependencia previa (26%) y comorbilidad (13%). Conclusiones: El programa de formación realizado permite un mayor número de activaciones de código ictus intrahospitalario. Sin embargo, en el periodo evaluado, esto no se tradujo en mayor porcentaje de pacientes tratados o mejor pronóstico, probablemente debido a la discapacidad previa y comorbilidad elevada en esta serie

Introduction: In-hospital stroke (IHS) is a frequent event, but its care priority level is not well established in many hospitals. IHS care at our centre has been redefined by implementing a training programme for medical personnel not usually involved in stroke management, in order to optimise IHS detection and treatment. This study evaluates results from the training programme. Methods: Prospective longitudinal intervention study. Neurologists experienced in vascular diseases developed a training programme for medical personnel. We recorded incidence, epidemiological data, reason for hospitalisation, department, aetiology, severity (NIHSS), time from symptom onset to neurological assessment, use of endovascular thrombolysis, exclusion criteria for untreated patients, and 90-day outcome (mortality/disability) in 2 patient groups: patients experiencing IHS in the 6 months before (PRE) and the 6 months after the training programme (POST). Results: Sixty patients were included (19 PRE, 41 POST) with a mean age of 75.3 ± 12.5; 41% were male. There were no differences between groups regarding assessment time, treatment administered, or morbidity/mortality. Overall, 68.3% of the patients were assessed in < 4.5 hours; however, only 6 patients (10%) were able to undergo endovascular therapy. This situation was mainly due to pre-existing disability (26%) and comorbidity (13%). Conclusions: More IHS code activations were recorded after the training programme. However, that increase was not accompanied by a higher percentage of treated patients or improvements in patient prognosis during the study period, and these findings could probably be explained by the high rates of pre-existing disability and comorbidity in this series

Detecting in-hospital stroke: Assessment of results from a training programme for medical personnel.

INTRODUCTION: In-hospital stroke (IHS) is a frequent event, but its care priority level is not well established in many hospitals. IHS care at our centre has been redefined by implementing a training programme for medical personnel not usually involved in stroke management, in order to optimise IHS detection and treatment. This study evaluates results from the training programme. METHODS: Prospective longitudinal intervention study. Neurologists experienced in vascular diseases developed a training programme for medical personnel. We recorded incidence, epidemiological data, reason for hospitalisation, department, aetiology, severity (NIHSS), time from symptom onset to neurological assessment, use of endovascular thrombolysis, exclusion criteria for untreated patients, and 90-day outcome (mortality/disability) in 2 patient groups: patients experiencing IHS in the 6 months before (PRE) and the 6 months after the training programme (POST). RESULTS: Sixty patients were included (19 PRE, 41 POST) with a mean age of 75.3 ± 12.5; 41% were male. There were no differences between groups regarding assessment time, treatment administered, or morbidity/mortality. Overall, 68.3% of the patients were assessed in < 4.5hours; however, only 6 patients (10%) were able to undergo endovascular therapy. This situation was mainly due to pre-existing disability (26%) and comorbidity (13%). CONCLUSIONS: More IHS code activations were recorded after the training programme. However, that increase was not accompanied by a higher percentage of treated patients or improvements in patient prognosis during the study period, and these findings could probably be explained by the high rates of pre-existing disability and comorbidity in this series.

Aproximación al conocimiento de las bases genéticas del ictus. Consorcio español de genética del ictus / Exploring the genetic basis of stroke. Spanish stroke genetics consortium

El presente artículo revisa la evolución de los estudios en genética del ictus desde la aproximación por gen candidato hasta los recientes estudios de genome wide association. Se destaca la complejidad de esta afección por sus muy variados mecanismos etiopatogénicos, las dificultades que comporta el estudio de su componente genético y las soluciones que se han aportado. Se subraya en especial el valor de las colaboraciones entre distintos centros, ya sea de manera puntual o sobre todo a través de la creación de consorcios estables. Esta estrategia actualmente se hace imprescindible a la hora de realizar estudios de alta calidad científica que permitan seguir avanzando en el conocimiento de las bases genéticas del ictus tanto en etiología, como en tratamiento y prevención

This article provides an overview of stroke genetics studies ranging from the candidate gene approach to more recent studies by the genome wide association. It highlights the complexity of stroke owing to its different aetiopathogenic mechanisms, the difficulties in studying its genetic component, and the solutions provided to date. The study emphasises the importance of cooperation between the different centres, whether this takes places occasionally or through the creation of lasting consortiums. This strategy is currently essential to the completion of high-quality scientific studies that allow researchers to gain a better knowledge of the genetic component of stroke as it relates to aetiology, treatment, and prevention

Automated and accurate carotid bulb detection, its verification and validation in low quality frozen frames and motion video.

AIM: Carotid intima-media thickness (cIMT) measurements during clinical trials need to have a fixed reference point (also called as bulb edge points) in the anatomy from which the cIMT can be measured. Identification of the bulb edge points in carotid ultrasound images faces the challenge to be detected automatically due to low image quality and variations in ultrasound images, motion artefacts, image acquisition protocols, position of the patient, and orientation of the linear probe with respect to bulb and ultrasound gain controls during acquisition. METHODS: This paper presents a patented comprehensive methodology for carotid bulb localization and bulb edge detection as a reference point. The method consists of estimating the lumen-intima borders accurately using classification paradigm. Transition points are located automatically based on curvature characteristics. Further we verify and validate the locations of bulb edge points using combination of several local image processing methods such as (i) lumen-intima shapes, (ii) bulb slopes, (iii) bulb curvature, (iv) mean lumen thickness and its variations, and (v) geometric shape fitting. RESULTS: Our database consists of 155 ultrasound bulb images taken from various ultrasound machines with varying resolutions and imaging conditions. Further we run our automated system blindly to spot out the bulbs in a mixture database of 336 images consisting of bulbs and no-bulbs. We are able to detect the bulbs in the bulb database with 100% accuracy having 92% as close as to a neurologists's bulb location. Our mean lumen-intima error is 0.0133 mm with precision against the manual tracings to be 98.92%. Our bulb detection system is fast and takes on an average 9 seconds per image for detection for the bulb edge points and 4 seconds for verification/validation of the bulb edge points.

Exploring the genetic basis of stroke. Spanish stroke genetics consortium.

This article provides an overview of stroke genetics studies ranging from the candidate gene approach to more recent studies by the genome wide association. It highlights the complexity of stroke owing to its different aetiopathogenic mechanisms, the difficulties in studying its genetic component, and the solutions provided to date. The study emphasises the importance of cooperation between the different centres, whether this takes places occasionally or through the creation of lasting consortiums. This strategy is currently essential to the completion of high-quality scientific studies that allow researchers to gain a better knowledge of the genetic component of stroke as it relates to aetiology, treatment, and prevention.

Comparison between CHADS2 and CHA2 DS2 -VASc score in a stroke cohort with atrial fibrillation.

BACKGROUND AND PURPOSE: In patients with atrial fibrillation (AF), stroke risk stratification schemes have been developed to optimize antithrombotic treatment. The CHADS(2) score is frequently used but has limitations. The CHA(2) DS(2) -VASc score improves risk prediction. Our objectives are to describe CHADS(2) and CHA(2) DS(2) -VASc score distribution in a cohort of patients with AF and first-ever ischaemic stroke (FIS) and to identify differences in embolic risk stratification. METHODS: Our cohort included 589 patients with FIS, previous modified Rankin score ≤ 3, and non-valvular AF. We recorded demographic data, vascular risk factors, and antithrombotic pre-treatment. The CHADS(2) and CHA(2) DS(2) -VASc scores were calculated according to clinical status before stroke onset. RESULTS: In 186 (31.6%) patients, AF was previously unknown. Of patients with known AF and CHADS(2) ≥ 2 (n=320), only 103 (32.2%) were taking anticoagulants; more than half of these patients had an INR <2. The CHADS(2) score placed 142 (24.1%) patients in the low-intermediate risk (score ≤ 1) category compared with 21 (3.6%) with CHA(2) DS(2) -VASc, P < 0.001. Applying CHA(2) DS(2) -VASc reclassified 121 (85.2%) subjects in the CHADS(2) low-intermediate risk category as high risk (≥ 2), an indication for anticoagulants. Of the 21 patients who suffered a stroke despite their low CHA(2) DS(2) -VASc score (≤ 1), seven (33.3%) reported alcohol overuse, and six (28.5%) had a concomitant stroke etiology. CONCLUSIONS: About 25% of FIS patients with AF had a CHADS(2) score ≤ 1. Despite the high CHADS(2) score of our population, few patients received the recommended antithrombotic treatment according to their thromboembolic risk. Using the CHA(2) DS(2) -VASc schema significantly increased the percentage of patients indicated for anticoagulation.

Serum cholesterol levels and survival after rtPA treatment in acute stroke.

BACKGROUND: According to the reverse epidemiology hypothesis, high cholesterol levels might be protective and associated with greater survival rates under certain conditions. In stroke patients, a clear correlation between lipid levels and mortality after ischaemic and hemorrhagic strokes has been demonstrated. The aim of this study was to analyze the impact of lipid levels on 3-month mortality in patients with ischaemic stroke (IS) homogeneously treated with intravenous rtPA and admitted to a monitored acute stroke unit. METHODS: Retrospective analysis of a prospective cohort of 220 patients with an IS treated with rtPA within the first 4.5 h in a single tertiary hospital from January 2005 to August 2010. RESULTS: Mortality at 3 months was 15.0%. Univariate analysis showed that age, NIHSS at admission, heart failure, and atrial fibrillation were directly related to 3-month mortality; cholesterol, triglycerides, and low density lipoprotein were inversely associated. The death rate by cholesterol level was 5.5% for the highest tertile (>192 mg/dl), 13.7% for the middle (192-155 mg/dl), and 25.7% for the lowest (<155 mg/dl), P = 0.003. Multivariate analysis showed that amongst the lipid determinations, only cholesterol [OR: 0.985 (95% CI: 0.972-0.998), P = 0.021] was inversely associated with 3-month mortality. The 'protective' effect of cholesterol was independent of stroke severity and remained significant in non-lacunar strokes. CONCLUSIONS: Survival of stroke patients receiving current, most effective medical treatment is related to blood cholesterol levels, with an inverse relationship between cholesterol and mortality. The mechanism of this apparently paradoxical situation remains unexplained but merits further research.

Acute brain MRI-DWI patterns and stroke recurrence after mild-moderate stroke.

Brain ischemic lesions identified by diffusion-weighted imaging (DWI) have been shown to predict high risk of early future ischemic events in patients with transient ischemic attacks and minor stroke. The aim of this study is to analyze different brain MRI-DWI patterns in patients with mild-moderate stroke to define acute patterns related with a higher risk of stroke recurrence in long-term follow-up (from 6 to 36 months). Retrospective review of case series from a prospective stroke record including 253 patients with mild-moderate stroke (NIHSS from 1 to 7) and acute MRI-DWI lesions. MRI-DWI lesions were analyzed to determine clinically relevant lesions, based on the number, location, age and affected arterial territories. We defined three patterns: (1) multiple versus single lesions; (2) single deep versus single cortical lesions; and (3) single lesions versus multiple lesions affecting different arterial territories and/or of different age. The impact of these patterns on recurrence was analyzed by Cox regression analysis. 38 patients (15.0%) suffered a recurrence. Univariate analysis showed the risk of recurrence for each pattern. Pattern 1: patients with multiple lesions had greater risk of recurrence than those with single lesions (28.2 vs. 9.9%; OR: 3.75 (95% CI: 1.76-7.27), p < 0.0001). Pattern 2: patients with single cortical lesions had higher risk than those with deep lesions (14.3 vs. 6.7% OR: 2.33 (95% CI: 0.86-6.33), p < 0.089). Pattern 3: patients with multiple DWI in different territories or different age had the highest recurrence rate (30.6%), OR: 4.01 (95% CI: 1.70-9.47), p < 0.001, compared to patients with single lesions. Cox regression analysis adjusted by possible confounders, showed that for pattern 1 the OR for recurrence was 2.49 (95% CI: 1.27-4.89), p = 0.008; for pattern 2, OR:1.99 (95% CI: 0.74-5.37), p = 0.17; for pattern 3, OR: 2.85 (95% CI: 1.31-6.15), p = 0.008. Brain MRI-DWI patterns assessed in the acute phase of mild-moderate stroke are useful to identify those patients at high risk of recurrence.

Outcome of intracerebral haemorrhage patients pre-treated with statins.

BACKGROUND: Statins treatment may have potential clinical impact in vascular disease beyond cholesterol lowering. Its benefits have been documented in cerebral ischaemia and in subarachnoid haemorrhage. In intracerebral haemorrhage (ICH), experimental models in statin-treated animals have better outcome than non-treated ones, but in humans the relationship is unclear. We investigated whether patients treated with statins before the onset of intracerebral haemorrhage have a better outcome at 3 months than patients without statins pre-treatment. METHODS: Retrospective review of primary intracerebral haemorrhage case series from a prospective stroke register. We recorded demographics, vascular risk factors, previous statin treatment, Glasgow coma scale (GCS) at onset, ICH scale, hematoma volume and location, ventricular extension of the hematoma, and functional outcome at 3 months. The effect of prior statin treatment on good outcome (modified Rankin scale [mRS] 0 to 2) was analysed by logistic regression analysis. RESULTS: We included 269 patients (age 71.9 +/- 12.4, mean +/- SD, 152 males). Thirty-four patients (12.6%) were on prior statin treatment when admitted. There were no differences in fasting serum cholesterol and triglycerides levels between the statin pre-treated groups and the group without statin pre-treatment. Multivariate regression analysis showed a significant association between age (OR: 0.95; CI 0.92-0.97), ICH volume (OR: 0.96; CI 0.94-0.98), GCS (OR: 1.55; CI 1.21-1.98), pre-treatment with statins (OR: 4.21; CI 1.47-12.17; P = 0.008), and good outcome at 3 months. CONCLUSIONS: Statins pre-treatment of patients with intracerebral haemorrhage may provide better functional outcome at 3 months of acute onset.