Differential Characteristics of Ischemic and Hemorrhagic Stroke in Patients with Cerebral Small Vessel Disease.

BACKGROUND: Small vessel disease (SVD) is the underlying anatomical substrate for both lacunar infarction and subcortical hemorrhage. AIM: To assess predictive factors of ischemic or hemorrhagic stroke in patients with cerebral SVD. MATERIALS AND METHODS: Prospective hospital-based stroke registry ("The Sagrat Cor Hospital of Barcelona Stroke Registry") in an acute-care teaching hospital in Barcelona, Spain. From 4597 acute stroke patients included in the stroke registry over a 24-year period, 440 cases of lacunar stroke and 210 of subcortical intracerebral hemorrhage were selected. Demographics, clinical characteristics, risk factors, and early outcome were compared. Predictors of lacuna versus subcortical hemorrhage were assessed by multivariate analyses. RESULTS: In a logistic regression model based on demographics, risk factors, clinical features and outcome, dyslipidemia (odds ratio [OR] 2.06 (95% confidence interval (CI) 1.17-3.62) and diabetes (OR 1.97, 95% CI 1.19-3.26) were independent risk factors for lacunar infarction. Anticoagulation therapy (OR 0.05, 95% CI 0.01-0.28), sudden onset (OR 0.51, 95% CI 0.33-0.78), motor symptoms (OR 0.44, 95% CI 0.26-0.76), headache (OR 0.23, 95% CI 0.12-0.41), altered consciousness (OR 0.10, 95% CI 0.05-0.21), respiratory complications (OR 0.19, 95% CI 0.08-0.46), and in-hospital death (OR 0.08, 95% CI 0.02-0.36) were predictors of subcortical hemorrhage. CONCLUSION: Identification of differential clinical and prognostic profile between ischemic and hemorrhagic consequences of underlying cerebral SVD is useful for risk stratification in the current process pursuing precision medicine.

Importancia del perfil cardiovascular en la mortalidad hospitalaria de los infartos cerebrales / Importance of cardiovascular risk profile for in-hospital mortality due to cerebral infarction

Introducción y objetivos. Analizar el perfil cardiovascular y su pronóstico en los infartos cerebrales y sus subtipos etiológicos. Métodos. Se efectúa un análisis retrospectivo de una serie clínica de 2.704 pacientes con infartos cerebrales procedentes de un registro hospitalario de ictus ingresados entre 1986 y 2004 (770 trombóticos, 763 cardioembólicos, 733 lacunares, 324 indeterminados y 114 inhabituales). Se compara el perfil cardiovascular de cada subtipo etiológico y su influencia con la mortalidad hospitalaria mediante un análisis multivariable. Resultados. La hipertensión arterial (HTA) se presentó en el 55,5%, seguida por la fibrilación auricular (FA) (29,8%) y la diabetes mellitus (23,4%). La mortalidad hospitalaria fue del 12,9% y estaba relacionada con la FA (odds ratio [OR] = 2,33; intervalo de confianza [IC] del 95%, 1,84-2,96) y la insuficiencia cardiaca (OR = 1,96; IC del 95%, 1,33-2,89). El perfil cardiovascular asociado a la mortalidad estaba formado en los trombóticos, por la insuficiencia cardiaca (OR = 2,87; IC del 95%, 1,45-5,71), la FA (OR = 1,80; IC del 95%, 1,09-2,96) y la edad (OR = 1,06; IC del 95%, 1,04-1,08); en los cardioembólicos, por la enfermedad vascular periférica (OR = 2,18; IC del 95%, 1,17-4,05), el infarto cerebral previo (OR = 1,75; IC del 95%, 1,16-2,63), la insuficiencia cardiaca (OR = 1,71; IC del 95%, 1,01-2,90) y la edad (OR = 1,06; IC del 95%, 1,04-1,08), y en los infartos indeterminados, por la HTA (OR = 3,68; IC del 95%, 1,78-7,62) y la edad (OR = 1,05; IC del 95%, 1,01-1,09). Conclusiones. Cada subtipo etiológico de infarto cerebral presenta un perfil cardiovascular propio. El perfil cardiovascular asociado a la mortalidad también es diferente en cada subtipo de infarto cerebral. Palabras clave: Isquemia cerebral. Factores de riesgo. Mortalidad. Hipertensión arterial. Fibrilación auricular. Registros de ictus (AU)

Introduction and objectives. To investigate cardiovascular risk profiles and their prognostic implications in patients with different subtypes of cerebral infarction. Methods. The study involved the retrospective analysis of data from a hospital stroke registry on 2704 consecutive CI patients who were admitted between 1986 and 2004. Of the 2704 strokes recorded, 770 were classified as thrombotic, 763 as cardioembolic, 733 as lacunar, 324 as undetermined, and 114 as atypical. Multivariate analysis was used to compare cardiovascular risk profiles in each subtype and their influence on inhospital mortality. Results. Arterial hypertension (AH) was present in 55.5%, atrial fibrillation (AF) in 29.8%, and diabetes mellitus in 23.4%. The in-hospital mortality rate was 12.9%, and in-hospital mortality was independently associated with AF (odds ratio [OR]=2.33; 95% confidence interval [CI], 1.84-2.96), and heart failure (HF) (OR=1.96; 95% CI, 1.33-2.89). In patients with thrombotic stroke, the cardiovascular risk factors associated with in-hospital mortality were HF (OR=2.87; 95% CI, 1.45-5.71), AF (OR=1.80; 95% CI, 1.09-2.96) and age (OR=1.06; 95% CI, 1.04-1.08). In patients with cardioembolic stroke, they were peripheral vascular disease (OR=2.18; 95% CI, 1.17-4.05), previous cerebral infarction (OR=1.75; 95% CI, 1.16-2.63), HF (OR=1.71; 95% CI, 1.01-2.90), and age (OR=1.06; 95% CI, 1.04-1.08). In those with undetermined stroke, they were AH (OR=3.68; 95% CI, 1.78-7.62) and age (OR=1.05; 95% CI, 1.01-1.09). Conclusions. Each cerebral infarction etiologic subtype was associated with its own cardiovascular risk profile. Consequently, the cardiovascular risk factors associated with mortality were also different for each ischemic stroke subtype (AU)

Importance of cardiovascular risk profile for in-hospital mortality due to cerebral infarction.

INTRODUCTION AND OBJECTIVES: To investigate cardiovascular risk profiles and their prognostic implications in patients with different subtypes of cerebral infarction. METHODS: The study involved the retrospective analysis of data from a hospital stroke registry on 2704 consecutive CI patients who were admitted between 1986 and 2004. Of the 2704 strokes recorded, 770 were classified as thrombotic, 763 as cardioembolic, 733 as lacunar, 324 as undetermined and 114 as atypical. Multivariate analysis was used to compare cardiovascular risk profiles in each subtype and their influence on inhospital mortality. RESULTS: Arterial hypertension (AH) was present in 55.5%, atrial fibrillation (AF) in 29.8%, and diabetes mellitus in 23.4%. The in-hospital mortality rate was 12.9%, and in-hospital mortality was independently associated with AF (odds ratio [OR]=2.33; 95% confidence interval [CI], 1.84-2.96), and heart failure (HF) (OR=1.96; 95% CI, 1.33-2.89). In patients with thrombotic stroke, the cardiovascular risk factors associated with in-hospital mortality were HF (OR=2.87; 95% CI, 1.45-5.71), AF (OR=1.80; 95% CI, 1.09-2.96) and age (OR=1.06; 95% CI, 1.04-1.08). In patients with cardioembolic stroke, they were peripheral vascular disease (OR=2.18; 95% CI, 1.17-4.05), previous cerebral infarction (OR=1.75; 95% CI, 1.16-2.63), HF (OR=1.71; 95% CI, 1.01-2.90), and age (OR=1.06; 95% CI, 1.04-1.08). In those with undetermined stroke, they were AH (OR=3.68; 95% CI, 1.78-7.62) and age (OR=1.05; 95% CI, 1.01-1.09). CONCLUSIONS: Each cerebral infarction etiologic subtype was associated with its own cardiovascular risk profile. Consequently, the cardiovascular risk factors associated with mortality were also different for each ischemic stroke subtype.

[The estimated incidence and case fatality rate of ischemic and hemorrhagic cerebrovascular disease in 2002 in Catalonia]. / Estimación de la incidencia poblacional y la mortalidad de la enfermedad cerebrovascular establecida isquémica y hemorrágica en 2002.

INTRODUCTION AND OBJECTIVES: The aim of this study was to obtain an estimate of the incidence of cerebrovascular disease (CVD) in the Spanish population in 2002. METHODS: The study involved data on patients aged over 24 years for the year 2002 contained in both the death register and the Minimum Basic Data Set from 65 of the 84 Catalan general hospitals (i.e., 90.7% of all acute hospital beds in Catalonia). Total and age-adjusted mortality rates, cumulative incidence, and hospitalization rates, and the 28-day case fatality rate for CVD in the Catalan population were calculated after cases of traumatic and transient disease had been excluded. RESULTS: The unadjusted CVD mortality rate per 100,000 population aged over 24 years in Catalonia was 92 in men and 119 in women. The age-adjusted rates were 58 (95% confidence interval or CI, 56-61) and 43 (95% CI, 41-44), respectively. The cumulative incidence of CVD per 100,000 population was 218 (95% CI, 214-221) in men and 127 (95% CI, 125-128) in women. The unadjusted 28-day case fatality rate in the population was 36.2%: 30.3% in men and 42.0% in women. Some 62.5% of patients (57.2% of men and 66.4% of women) died from CVD outside hospital. CONCLUSIONS: These findings indicate that CVD mortality and incidence rates in Catalonia are among the lowest in developed countries. More than half of the deaths that took place within 28 days after the onset of symptoms occurred outside hospital.

Estimación de la incidencia poblacional y la mortalidad de la enfermedad cerebrovascular establecida isquémica y hemorrágica en 2002 / The estimated incidence and case fatality rate of ischemic and hemorrhagic cerebrovascular disease in 2002 in Catalonia

Introducción y objetivos. Se pretende obtener una aproximación a la incidencia poblacional de las enfermedades cerebrovasculares (ECV) en el año 2002. Métodos. Se han combinado los datos del Registro de Mortalidad y el Registro del Conjunto Mínimo Básico de Datos de 65 de los 84 hospitales generales catalanes durante el año 2002 (el 90,7% de las camas de hospitalización aguda), de los pacientes de más de 24 años. Se han estimado las tasas poblacionales de mortalidad, incidencia acumulada y hospitalización, brutas y estandarizadas por edad, y la mortalidad a los 28 días por ECV, excluidas las traumáticas y la transitoria, en Cataluña. Resultados. La tasa bruta de mortalidad por 100.000 de ECV en Cataluña en mayores de 24 años fue de 92 en varones y 119 en mujeres, y la estandarizada por edad, 58 (intervalo de confianza [IC] del 95%, 56-61) y 43 (IC del 95%, 41-44), respectivamente. Las tasas de incidencia acumulada de ECV fueron 218 (IC del 95%, 214-221) en varones y 127 (IC del 95%, 125-128) en mujeres. La letalidad poblacional cruda a 28 días fue del 36,2% (el 30,3% en varones y el 42,0% en mujeres). El 62,5% de los pacientes (el 57,2% de los varones y el 66,4% de las mujeres) murió por ECV fuera de los hospitales. Conclusiones. Los resultados indican que la mortalidad y la incidencia de ECV en Cataluña se sitúan entre las más bajas de los países desarrollados. Más de la mitad de las muertes ocurridas en los 28 días siguientes al inicio de los síntomas se produce fuera de los hospitales (AU)

Introduction and objectives. The aim of this study was to obtain an estimate of the incidence of cerebrovascular disease (CVD) in the Spanish population in 2002. Methods. The study involved data on patients aged over 24 years for the year 2002 contained in both the death register and the Minimum Basic Data Set from 65 of the 84 Catalan general hospitals (i.e., 90.7% of all acute hospital beds in Catalonia). Total and age-adjusted mortality rates, cumulative incidence, and hospitalization rates, and the 28-day case fatality rate for CVD in the Catalan population were calculated after cases of traumatic and transient disease had been excluded. Results. The unadjusted CVD mortality rate per 100,000 population aged over 24 years in Catalonia was 92 in men and 119 in women. The age-adjusted rates were 58 (95% confidence interval or CI, 56-61) and 43 (95% CI, 41-44), respectively. The cumulative incidence of CVD per 100,000 population was 218 (95% CI, 214-221) in men and 127 (95% CI, 125-128) in women. The unadjusted 28-day case fatality rate in the population was 36.2%: 30.3% in men and 42.0% in women. Some 62.5% of patients (57.2% of men and 66.4% of women) died from CVD outside hospital. Conclusions. These findings indicate that CVD mortality and incidence rates in Catalonia are among the lowest in developed countries. More than half of the deaths that took place within 28 days after the onset of symptoms occurred outside hospital (AU)

Ischemic stroke in patients with intermittent claudication: a clinical study of 142 cases.

The clinical features, risk factors, neuroimaging findings, and outcome of acute ischemic stroke were assessed in patients with intermittent claudication. Data from 142 patients with ischemic stroke and intermittent claudication were collected from a prospective hospital-based stroke registry in which 2500 consecutive acute stroke patients attended over a 12-year period. Ischemic stroke in patients with intermittent claudication accounted for 7.7% of all ischemic strokes (n = 1840). Ischemic stroke with and without intermittent claudication showed a similar in-hospital mortality rate (16% vs 14%) and absence of functional limitation at hospital discharge (20.5% vs 18.5%). Ischemic stroke patients with intermittent claudication showed a significantly shorter length of stay than patients without symptomatic peripheral arterial disease (14.6 vs 18.8 days, p < 0.05). Ischemic heart disease, transient ischemic attack (TIA), renal dysfunction, and watershed infarct were significant independent predictors of ischemic stroke in patients with intermittent claudication. Although cerebral infarction in patients with intermittent claudication showed a clinical profile suggestive of poor outcome, the prognosis was similar to that of ischemic stroke without intermittent claudication.

Predicting spontaneous early neurological recovery after acute ischemic stroke.

We assessed predictors of spontaneous early neurological recovery after acute ischemic stroke by means of multivariate analysis in a cohort of 1,473 consecutive patients treated at one academic center. At hospital discharge, spontaneous neurological improvement or good outcome was defined as grades 0-2 of the Rankin scale, and poor outcome (no improvement or in-hospital death) as grades 3-5. Spontaneous recovery of neurological deficit at the time of discharge from the hospital was observed in 16% of patients with cerebral infarction (n = 238). Dysarthria-clumsy hand syndrome improved in 44% of patients and was the only variable significantly associated with in-hospital functional recovery in three logistic regression models that in addition to lacunar syndromes, included demographic variables, cardiovascular risk factors, and clinical variables [odds ratio (OR) 2.56], neuroimaging findings (OR 2.48), and outcome data (OR 2.39), respectively. Clinical factors related to severity of infarction available at stroke onset have a predominant influence upon in-hospital outcome and may help clinicians to assess prognosis more accurately. Our work gives a contribution into prognostic factors after acute ischemic stroke. With regard to patterns of stroke, dysarthria-clumsy hand syndrome was a significant predictor of spontaneous in-hospital recovery in ischemic stroke patients.

Clinical study of lacunar infarcts in non-hypertensive patients.

Lacunar infarcts in non-hypertensive patients have been scantly assessed. The objective of this study was to determine clinical features of lacunar infarct in patients without hypertension (n = 91) in comparison with characteristics of lacunar infarcts occurring in patients with hypertension (n = 283) collected from a prospective hospital-based stroke registry in which 2000 patients with acute stroke are included. Predictors of lacunar infarct in patients without hypertension were assessed by multiple logistic regression analysis. The group of non-hypertensive patients with lacunar infarction showed a significantly higher frequency of male gender, age 85 years or older, history of atrial fibrillation, chronic obstructive pulmonary disease and diabetes mellitus, and a significantly lower frequency of female gender and absence of limitation at hospital discharge than hypertensive patients with lacunar infarct. Differences between hypertensive and non-hypertensive patients in relation to frequency of the different lacunar syndromes were not observed. After multivariate analysis, age 85 years or older (odds ratio 3.13), diabetes (odds ratio 2.57), and male gender (odds ratio 1.99) seemed to be independent factors associated with lacunar infarct in patients without hypertension. Lacunar infarct in non-hypertensive patients showed some differential clinical features compared to the remaining lacunar infarctions because it occurred more frequently in male patients aged 85 years or older. In this group, diabetes was the most important modifiable risk factor. These results suggest an earlier effect of arteriopathy caused by hypertension favoring lacunar brain ischemia, whereas in non-hypertensive patients, arteriopathy responsible for small vessel disease would take a more prolonged time in causing lacunar infarction.

Clinical features and functional outcome of intracerebral hemorrhage in patients aged 85 and older.

OBJECTIVES: The importance of studies of older stroke victims is growing because of the changes in the age structure of Western populations. We determined demographic characteristics, clinical features, neuroimaging data, and outcome of acute spontaneous intracerebral hemorrhage occurring in people aged 85 and older. DESIGN: Prospective collection of data from a hospital-based registry. SETTING: Sagrat Cor Hospital of Barcelona (an acute care, 350-bed teaching hospital serving a population of approximately 250,000). PARTICIPANTS: Between January 1986 and December 1995, data were collected on 2,000 stroke patients admitted consecutively to the department of neurology (25 beds and an acute stroke unit). MEASUREMENTS: For the purpose of this study, all cases of intracerebral hemorrhage were selected (n = 229). Demographic data, clinical features, neuroimaging findings, and outcome variables (in-hospital mortality and medical complications developed during hospitalization)in patients aged 85 and older (n = 28) were compared with patients who were younger than age 85 (n = 201). Distinctive clinical features of intracerebral hemorrhage in very old people were assessed by multivariate analysis. RESULTS: Intracerebral hemorrhage was diagnosed in 11% of subjects aged 85 and older included in the stroke registry and accounted for 12% of all cases of intracerebral hemorrhage. Very old people with intracerebral hemorrhage showed a significantly higher frequency of female gender (75% vs 32%, P < .005), altered consciousness (64% vs 43%, P < .05), multiple topographic involvement (29% vs 13%, P < .03), undetermined etiology of bleeding (50% vs 27%, P < .02), moderate or severe neurological deficit at hospital discharge (89% vs 58%, P < .005), and in-hospital mortality (50% vs 27%, P < .01) than younger people. After multivariate analysis, female sex (odds ratio (OR) = 3.2,95% confidence interval (CI) - 1.27-7.99) and moderate or severe neurological deficit at hospital discharge (OR =4.75, 95% Cl = 1.36-16.55) were independent clinical factors associated with intracerebral hemorrhage in very old people. CONCLUSIONS: Patients aged 85 and older with intra-cerebral hemorrhage showed some peculiar clinical features and poorer outcome, including higher in-hospital mortality and moderate or severe neurological deficit at hospital discharge, than younger patients with intracerebral hemorrhage.