Clinical outcome of cardioembolic stroke treated by intravenous thrombolysis.

INTRODUCTION: Cardioembolic stroke (CS) in patients without thrombolytic treatment is associated with a worse clinical outcome and higher mortality compared to other types of stroke. The aim of this study was to determine the clinical outcome of CS in patients treated by intravenous thrombolysis (IVT). MATERIAL AND METHODOLOGY: Data of patients from the SITS-EAST register (Safe Implementation of Treatments in Stroke) were analyzed in patients who received IVT treatment from 2000 to April 2014. The effect of the stroke etiology according to ICD-10 classification on outcome was analyzed using a univariate and multivariate analysis. The outcomes were assessed as follows: excellent clinical outcome (modified Rankin scale (mRS) 0-1) at 3 months, the rate of symptomatic intracranial hemorrhage (sICH), mortality, and improvement at 24 hours after IVT. RESULTS: Data of 13 772 patients were analyzed. CS represented 30% of all strokes. The mean age of patients with CS, atherothrombotic stroke, lacunar stroke, and other stroke was 70.8, 66.7, 66.2, and 63.3 years, respectively (P < .001). Severity of stroke on admission by median NIHSS score was 13 points in patients with CS, 12 points - in atherothrombotic stroke, 7 points - in lacunar stroke, and 10 points-in other stroke types (P < .001). No difference in mortality was detected among atherothrombotic and CS; however, atherothrombotic strokes had higher odds of sICH [OR = 1.63 (95% CI: 1.07-2.47), P = .023], lower odds of early improvement [OR = 0.79 (95% CI: 0.72-0.86), P < .001], and excellent clinical outcome [OR = 0.77 (95% CI: 0.67-0.87), P < .001] compared with CS. CONCLUSIONS: Cardioembolic strokes are not associated with increased mortality. Patients with CS are less likely to have sICH and have better outcome after IVT.

Effect of prestroke antiplatelets use on first-ever ischaemic stroke severity and early outcome.

OBJECTIVES: We aimed to investigate whether prior use of antiplatelet agents (AP) may be associated with lower severity and improved short-term outcome of the first-ever acute ischaemic stroke. METHODS: This was a retrospective, case-control study based on a prospective hospital stroke registry covering consecutive acute stroke patients admitted to a single stroke centre in highly urbanised area (Warsaw, Poland) between 1995 and 2013. Patients receiving oral anticoagulants were excluded from the analysis. Statistical analysis included multiple regression and logistic regression adjusted for age, sex, hypertension, atrial fibrillation, congestive heart failure, diabetes, coronary heart disease and history of myocardial infarction. RESULTS: During the study period, there were 3036 eligible patients, of whom 879 (29%) received AP before stroke onset. Patients from the AP group were older and more often burdened with stroke risk factors. There were no differences in baseline stroke severity, hospital mortality and proportion of patients alive and independent at discharge. However, AP turned out to be independently associated with lower NIHSS score on admission (ß = -0.045, p = 0.008) and increased odds for being alive and independent at discharge (odds ratio 1.36, 95% CI: 1.13-1.67) and decreased odds for in-hospital mortality (odds ratio 0.77, 95% CI: 0.59-0.99). CONCLUSIONS: Our findings provide further evidence supporting modest benefit of AP therapy on the course and outcome of first-ever ischaemic stroke. Further large studies are needed to confirm this effect.

The prestroke use of vitamin K antagonists for atrial fibrillation - trends over 15 years.

BACKGROUND: Effective anticoagulation with vitamin K antagonists (VKAs) is the standard of stroke prevention in patients with non-valvular atrial fibrillation (AF). Although, everyday practice is becoming increasingly guideline-driven, proper anticoagulation is still problematic. We aimed to investigate changes in the use of VKAs for stroke prevention in patients with AF admitted because of acute stroke over a period of 15 years. METHODS: We analysed consecutive acute stroke patients admitted to our centre between June 1995 and December 2010. Data were prospectively collected in a detailed stroke registry. We distinguished between three periods: 1995-2000 (used as reference for comparisons), 2001-2005 and 2006-2010. RESULTS: The AF rate prior to stroke was similar in ischaemic stroke patients (1995-2000: 25%, 2001-2005: 24%, 2006-2010: 24%) but increased in patients with intracerebral haemorrhage (ICH) (6%, 11%, 19%, p = 0.003 since 2006). The proportion of patients with AF using VKAs before stroke has became higher in ischaemic stroke (10%, 16%, 28%, p < 0.001 since 2006) with non-significant trend in ICH (0%, 33%, 45%). The proportion of ischaemic strokes occurring in patients with AF using VKAs with INR < 2 tended to increase over time (58%, 83%, 80.3%). There was also tendency towards increasing proportion of ICHs occurring in patients with AF over treated with VKAs (INR > 3). CONCLUSIONS: The prescription rate of VKA for stroke prevention appears to be improving. However, because of a high proportion of patients on non-therapeutic INR, the proportion of cardioembolic ischaemic strokes remains stable. It may suggest that everyday use of VKAs is still far from optimal.

Routine serum C-reactive protein and stroke outcome after intravenous thrombolysis.

OBJECTIVES: The clinical usefulness of blood biomarkers in acute stroke is not yet fully established, especially after thrombolytic therapy. Our aim was to investigate the association between routine serum C-reactive protein (CRP) measured within 24 h after admission and outcome in ischaemic stroke patients treated with intravenous thrombolysis, adjusting for a history of recent infection. METHODS: We analysed the data of consecutive stroke patients who received intravenous alteplase in our centre between October 2003 and December 2011, collected in a detailed prospective registry. Routine serum CRP was measured within 24 h from admission; concentration >5 ng/ml was considered elevated. RESULTS: Serum CRP was measured in 341 of 406 stroke patients treated with alteplase. Patients with elevated CRP (135/341, 42.5%) compared to those with normal CRP values, were significantly older, more frequently presented with a preexisting disability, comorbidities and suffered more severe strokes. They had a higher proportion of symptomatic intracranial haemorrhage according to ECASS II definition (7.2% vs 1.6%, P = 0.010), higher 3-month mortality (25.6% vs 11.3%, P = 0.001), and were less frequently alive and independent after 3 months (45.9% vs 63.7%, P = 0.002). However, those associations were not confirmed after adjustment for age, stroke severity, diabetes, congestive heart failure, lack of prestroke disability and signs of recent infection. CONCLUSIONS: According to our findings, elevated routine serum CRP measured within 24 h after admission does not seem to independently affect the outcome in patients receiving intravenous thrombolysis for stroke. However, further studies of blood samples taken directly before the treatment are needed.

D-penicillamine versus zinc sulfate as first-line therapy for Wilson's disease.

BACKGROUND AND PURPOSE: To compare the course of treatment in patients with symptomatic Wilson's disease (WD) receiving either D-penicillamine (DPA) or zinc sulfate (ZS) as first-line therapy. METHODS: In all, 143 consecutive patients diagnosed with symptomatic WD from January 2005 to December 2009, followed until December 2010, were included. The decision about first-line therapy was made individually after discussion with the patient. Physicians had no clear preference of one drug over the other. Data were analyzed in subgroups with predominantly neurological (DPA, 35; ZS, 21) and hepatic (DPA, 36; ZS, 51) presentation of WD. RESULTS: According to Kaplan-Meier analysis, neurological WD patients scheduled for DPA had a similar probability of not remaining on first-line therapy as patients receiving ZS (20% vs. 24% at the end of follow-up), with adjusted odds ratio (OR) of 0.9 (95% CI 0.2-3.5). In patients with hepatic WD, this probability was significantly higher for DPA (31% vs. 12%; adjusted OR 3.0, 95% CI 0.9-9.9), especially in the first 6 months. Early worsening occurred only in neurological WD patients, with no differences between both treatment groups (35% vs. 19%; OR 2.8, 95% CI 0.7-10.8). Neurological improvement and decrease of liver enzymes were achieved with similar frequency. Compliance with DPA was better in hepatic (97% vs. 80%) but not in neurological patients (91% vs. 81%). Drug adverse effects were more common on DPA (15% vs. 3%). CONCLUSIONS: DPA and ZS are effective in the majority of WD patients. Neither therapy appears to be clearly superior. Therefore ZS may be considered a reasonable alternative to DPA as a first-line therapy.

Compliant treatment with anti-copper agents prevents clinically overt Wilson's disease in pre-symptomatic patients.

BACKGROUND AND PURPOSE: Wilson's disease (WD) is an inherited copper metabolism disorder that leads to dysfunction of affected tissues, mostly in the liver and brain. Anti-copper treatment should prevent clinically overt WD in pre-symptomatic patients but this has not been supported by strong evidence. Our aim was to evaluate the long-term effectiveness of treatment in clinically pre-symptomatic patients, with particular emphasis on patient compliance with treatment. METHODS: Data were analyzed for 87 consecutive patients with no clinical symptoms of WD who were identified between 1957 and 2009 by family screening. All of them since diagnosis were treated with either zinc sulphate (Zn) (66.7%) or D-penicillamine (DPA) (33.3%). RESULTS: During a median follow-up of 12 years (range 3-52), 55 (63%) patients remained without clinical symptoms, 13 (15%) developed neuropsychiatric symptoms and 21 (24%) developed hepatic dysfunction, including five deaths from hepatic failure. Non-compliance for at least three consecutive months was observed in 39 patients, and in 29 cases this extended for more than 12 months. Multivariate analysis showed that the odds of developing symptomatic WD were independently increased by non-compliance (odds ratio 24.0, 95% confidence interval 6.0-99.0). According to Kaplan-Meier analysis patients who were compliant to treatment had a significantly higher likelihood of remaining symptom-free, and their overall survival was similar to the survival rate observed in the general population. CONCLUSION: The use of anti-copper agents in clinically pre-symptomatic patients diagnosed with WD allows clinically overt disease to be effectively prevented. However, compliance with therapy is extremely important.

Do silent infarcts modify the effect of thrombolysis for stroke?

OBJECTIVES: Silent brain infarcts (SBI) are a common finding both in stroke-free patients and in patients after a cerebrovascular incident. They are considered a risk factor for subsequent symptomatic strokes. However, their influence on outcome in stroke patients treated with thrombolysis is not established. Our aim was to identify the prevalence of SBI in acute ischaemic stroke patients undergoing routine intravenous thrombolysis and evaluate the association between their presence on pretreatment computed tomography (CT) and outcome. MATERIAL AND METHODS: We systematically reviewed CT images and clinical records of consecutive patients treated with thrombolysis because of a first-ever stroke between 1 November 2003 and 31 July 2009 in a single stroke centre. We have analysed the frequency of SBI and their influence on outcome. RESULTS: Silent brain infarcts were present on 82/175 (47%) baseline CT scans. Patients with SBI were significantly older (74 vs 67 years), and more frequently had diabetes (19.5% vs 11.8%) and hyperlipidaemia (37.8% vs 21.5%). There were no significant differences in the ratio of ICH (18.3% vs 14.0%), 3-month mortality (24.7% vs 15.1%) and death or disability (50.6% vs 40.9%), which was also confirmed in a multivariate analysis adjusted for other clinical variables. CONCLUSIONS: In this study, SBI were not associated with increased risk of ICH nor worse outcome after treatment with rt-PA for stroke. SBI should not be considered an argument against initiating thrombolysis, but further studies are needed to fully understand their association with thrombolysis for stroke.