Impact of pre-stroke dependency on outcome after endovascular therapy in acute ischemic stroke.

BACKGROUND AND PURPOSE: Current demographic changes indicate that more people will be care-dependent due to increasing life expectancy. Little is known about impact of preexisting dependency on stroke outcome after endovascular treatment (EVT). METHODS: We compared prospectively collected baseline and outcome data of previously dependent vs. independent stroke patients (prestroke modified Rankin Scale score of 3-5 vs. 0-2) treated with EVT. Outcome measures were favorable 3-month outcome (mRS ≤ 3 for previously dependent and mRS ≤ 2 for independent patients, respectively), death and symptomatic intracranial hemorrhage (sICH). RESULTS: Among 1247 patients, 84 (6.7%) were dependent before stroke. They were older (81 vs. 72 years of age), more often female (61.9% vs. 46%), had a higher stroke severity at baseline (NIHSS 18 vs. 15 points), more often history of previous stroke (32.9% vs. 9.1%) and more vascular risk factors than independent patients. Favorable outcome and mortality were to the disadvantage of independent patients (26.2% vs. 44.4% and 46.4% vs. 25.5%, respectively), whereas sICH was comparable in both cohorts (4.9% vs. 5%). However, preexisting dependency was not associated with clinical outcome and mortality after adjusting for outcome predictors (OR 1.076, 95% CI 0.612-1.891; p = 0.799 and OR 1.267, 95% CI 0.758-2.119; p = 0.367, respectively). CONCLUSION: Our study underscores the need for careful selection of care-dependent stroke patients when considering EVT, given a less favorable outcome observed in this cohort. Nonetheless, EVT should not systematically be withheld in patients with preexisting disability, since prior dependency does not significantly influence outcome.

Obesity paradox in stroke - Myth or reality? A systematic review.

BACKGROUND AND PURPOSE: Both stroke and obesity show an increasing incidence worldwide. While obesity is an established risk factor for stroke, its influence on outcome in ischemic stroke is less clear. Many studies suggest a better prognosis in obese patients after stroke ("obesity paradox"). This review aims at assessing the clinical outcomes of obese patients after stroke by performing a systematic literature search. METHODS: The reviewers searched MEDLINE from inception to December 2015. Studies were eligible if they included outcome comparisons in stroke patients with allocation to body weight. RESULTS: Twenty-five studies (299'750 patients) were included and none was randomised. Ten of 12 studies (162'921 patients) reported significantly less mortality rates in stroke patients with higher BMI values. Seven of 9 studies (92'718 patients) ascertained a favorable effect of excess body weight on non-fatal outcomes (good clinical outcome, recurrence of vascular events). Six studies (85'042 patients) indicated contradictory results after intravenous thrombolysis (IVT), however. Several methodological limitations were observed in major part of studies (observational study design, inaccuracy of BMI in reflecting obesity, lacking body weight measurement, selection bias, survival bias). CONCLUSION: Most observational data indicate a survival benefit of obese patients after stroke, but a number of methodological concerns exist. No obesity paradox was observed in patients after IVT. There is a need for well-designed randomized controlled trials assessing the effects of weight reduction on stroke risk in obese patients.

[Obesity Paradox and Stroke]. / Adipositas-Paradoxon und Hirnschlag.

The obesity paradox suggests that overweight and obese patients of older age may have higher survival rates after stroke as compared to normalweight patients. However, the results need a cautious interpretation due to selection bias, treatment bias and different patients' characteristics. Moreover, randomized studies that prove a benefit of weight reduction are still lacking. As obesity is an independet risk factor for stroke, weight reduction should still be recommended in overweight patients. Randomized-controlled studies are needed to prove the effect of weight reduction on morbidity and mortality after stroke.