The impact of blood pressure hemodynamics in acute ischemic stroke: a prospective cohort study.

OBJECTIVE: To assess relationships between blood pressure hemodynamic measures and outcomes after acute ischemic stroke, including stroke severity, disability and death. METHODS: The study cohort consisted of 189 patients who presented to our emergency department with ischemic stroke of less than 24 hours onset who had hemodynamic parameters recorded and available for review. Blood pressure (BP) was non-invasively measured at 5 minute intervals for the length of the patient's emergency department stay. Systolic BP (sBP) and diastolic BP (dBP) were measured for each patient and a differential (the maximum minus the minimum BP) calculated. Three outcomes were studied: stroke severity, disability at hospital discharge, and death at 90 days. Statistical tests used included Spearman correlations (for stroke severity), Wilcoxon test (for disability) and Cox models (for death). RESULTS: Larger differentials of either dBP (p = 0.003) or sBP (p < 0.001) were significantly associated with more severe strokes. A greater dBP (p = 0.019) or sBP (p = 0.036) differential was associated with a significantly worse functional outcome at hospital discharge. Those patients with larger differentials of either dBP (p = 0.008) or sBP (0.007) were also significantly more likely to be dead at 90 days, independently of the basal BP. CONCLUSION: A large differential in either systolic or diastolic blood pressure within 24 hours of symptom onset in acute ischemic stroke appears to be associated with more severe strokes, worse functional outcome and early death.

Clinical significance of serum zinc levels in cerebral ischemia.

Background. Zinc mediates several vital physiological, enzymatic and cellular functions. The association between serum zinc and stroke outcome has not been previously evaluated. Methods. This single center retrospective study was conducted on consecutive stroke (n = 158) and TIA (n = 74) patients. We sought to determine whether serum zinc concentrations in patients with acute ischemic strokes were associated with stroke severity and poor functional status at discharge, respectively. Results. Overall, out of the 224 patients analyzed (mean age 67 years), 35.7% patients had low zinc levels (65 mcg/dL). Patients with stroke (n = 152) were more likely to have low zinc levels (OR = 2.62, CI 1.92-3.57, P < .003) compared to patients with TIA (n = 72). For patients with stroke (n = 152), multivariate analysis showed that low serum zinc levels (OR 2.82, CI 1.35-5.91, P = .035) and strokes with admission severe strokes (NIHSS > 8) (OR 2.68, CI 1.1-6.5, P = .03) were independently associated with poor functional status (MRS > 3) at discharge from the hospital. Conclusion. Low serum zinc concentrations are associated with more severe strokes on admission and poor functional status at discharge.

An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack.

STUDY OBJECTIVE: We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack. METHODS: This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days. RESULTS: The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days. CONCLUSION: The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification.

Worse outcome after stroke in patients with obstructive sleep apnea: an observational cohort study.

To evaluate the risk and presence of obstructive sleep apnea (OSA) in patients presenting with acute ischemic stroke, and examine the correlation of OSA with age, sex, ischemic stroke subtype, disability, and death, a prospective cohort study was conducted in all consecutive patients presenting with acute ischemic stroke between June 2007 and March 2008. Exclusion criteria were age < 18 years, refusal of consent for the study, and incomplete questionnaire. The Berlin Sleep Questionnaire was used to identify patients at high risk for OSA. A total of 174 patients with acute ischemic stroke were included; 130 (74.7%) had a modified Rankin Scale (mRS) score ≥ 3 at dismissal, and 11 patients (6.3%) died within 1 month. The Berlin Sleep Questionnaire identified 105 patients (60.4%) at high risk for OSA, along with 7 patients (4%) with a previous diagnosis of OSA. Those with a previous diagnosis of OSA were more likely to die within the first month after stroke (relative risk, 5.3; 95% confidence interval, 1.4-20.1) compared with those without OSA. Patients at high risk for OSA did not demonstrate increased mortality at 30 days (P = 1.0). In multivariate analysis, after adjusting for age and National Institutes of Health Stroke Scale score, previous diagnosis of OSA was an independent predictor of worse functional outcome, that is, worse mRS score at hospital discharge (P = .004). The mRS score was 1.2 points higher (adjusted R², 40%) in those with OSA. Our findings suggest that patients considered at high risk for ischemic stroke should be screened for OSA, the prevalence of which may be as high as 60%. Those with definitive diagnosis of OSA before stroke are at increased risk of death within the first month after an acute ischemic stroke.

Statins in ischemic stroke: just low-density lipoprotein lowering or more?

BACKGROUND: Statins have been shown to improve the functional outcome of patients after an ischemic stroke. We hypothesized that daily statin intake improves functional outcome after an acute ischemic stroke in patients with low-density lipoprotein (LDL) less than or equal to 100 mg/dL. METHODS: This was a prospective cohort study during a 22-month period of patients presenting with an acute ischemic stroke and lipid profiles measured. The functional disability was determined using modified Rankin scale score (0-2 good outcome, 3-6 bad outcome) at discharge. Chi-square test for binary data and nonparametric tests for nonnormally distributed variables were used for analysis. RESULTS: Of 508 patients, 207 presented with an LDL of 100 mg/dL or less and were included in the analysis. There was no significant difference in admission stroke severity (National Institutes of Health Stroke Scale [NIHSS]; P = .18), age (P = .31), and sex (P = .06) between those taking statins and not taking statins. Patients with LDL less than or equal to 100 mg/dL and taking statins (n = 100) were significantly more likely to have a good functional outcome (odds ratio 1.91; 95% confidence interval 1.05-3.47) when compared with those not on the medication. After adjusting for age, sex, and NIHSS, statin intake still predicted a better functional outcome (P < .0001). CONCLUSION: Daily statin intake appears to result in a better functional outcome after an ischemic stroke in patients with ideal LDL levels (

Validation of a new coma scale, the FOUR score, in the emergency department.

OBJECTIVE: Full Outline of Unresponsiveness (FOUR) score has previously been validated scale in the Neurosciences Intensive Care Unit. In this study, we sought to validate the use of FOUR score in the emergency department (ED) using non-neurology staff. We also compared its performance to the Glasgow Coma Scale (GCS) and correlated it to functional outcome at hospital discharge and overall survival. METHODS: We prospectively rated 69 patients with initial neurologic symptoms presenting to the ED. Three types of examiners performed the FOUR score: ED physician, ED resident, and ED nurse. Patients were followed through hospital discharge; functional outcome was measured using modified Rankin Score (mRS). RESULTS: Interrater reliability for FOUR score and GCS was excellent (respectively, kappa(w) = 0.88 and 0.86). Both FOUR score and GCS predicted functional outcome, and overall survival with and without adjustment for age, sex, and alertness group. CONCLUSION: The FOUR score can be reliably used in the ED by non-neurology staff. Both FOUR score and GCS performed equally well, but the neurologic detail incorporated in the FOUR score makes it more useful in management and triage of patients.