Association of seasonal serum 25-hydroxyvitamin D levels with disability and relapses in relapsing-remitting multiple sclerosis.

BACKGROUND/OBJECTIVES: The aim of this study was to evaluate the association of serum 25-hydroxyvitamin D (25(OH)D) with disability and frequency of relapses in relapsing-remitting multiple sclerosis (MS) patients. SUBJECTS/METHODS: The study included 184 patients with relapsing-remitting MS who were receiving immune-modulating drugs and no vitamin D supplementation. The concentration of 25(OH)D was measured in February and August 2014. The level of disability was assessed twice according to the Expanded Disability Status Scale (EDSS). The patients were divided into two groups: EDSS 0.0-2 and 2.5-4. The control group comprised 58 age- and sex-matched healthy subjects. The 25(OH)D levels were compared with the occurrence of relapses and the level of disability. RESULTS: Mean serum 25(OH)D concentrations were significantly lower in winter in both MS patients and controls. Winter level of 25(OH)D was significantly lower in severe MS cases (EDSS 2.5-4.0) than in mild cases (EDSS 0.0-2.0) (P=0.022), and in the controls (P=0.008), especially in females (r=0.38, P=0.0015). Logistic regression analysis showed the winter serum 25(OH)D was significantly associated with MS (odds ratio 0.925; 95% confidence interval, 0.822-0.970). Serum 25(OH)D levels were significantly lower in MS patients with relapses than in those without relapses both in winter, and in summer. CONCLUSIONS: Hypovitaminosis D was more prevalent during winter than summer, both in the sample group and the control, especially in female MS patients with higher levels of disability. Low vitamin D levels are associated with a more severe course of disease and an increased number of relapses.

Efficacy of cerebral thrombolysis in an extended 'time window'.

WHAT IS KNOWN AND OBJECTIVE: Cerebral systemic thrombolysis (i.v. thrombolysis) with tissue-type plasminogen activator (rt-PA) is the only proven medical therapy for ischaemic stroke. The use of i.v. thrombolysis up to 4·5 h from stroke onset was approved in certain countries in 2008, but its safety and efficacy have not been fully determined to date. OBJECTIVE: To assess the long-term outcome and complication rate of i.v. thrombolysis performed in the extended 'time window'. METHODS: The study included 403 ischaemic stroke patients consecutively treated with i.v. thrombolysis from 2006 to 2012 at three comprehensive stroke centres in Poland. The long-term outcome and the haemorrhagic complications' (HC) rate were compared between subgroups of patients treated within 3 vs. 3-4·5 h from stroke onset. RESULTS AND DISCUSSION: About 132 (32·75%) patients were treated between 3 and 4·5 h from stroke onset. Neurological deficits tended to be more severe in patients treated ≤3 than in those treated 3-4·5 h (National Institutes of Health Stroke Scale, NIHSS 12 vs.10 points; P = 0·053); however, the ratio of patients with a favourable outcome (mRS 0-2 points) and mortality did not differ between the two groups (53·9 vs. 58·3, P = 0·39 and 17·7 vs. 21·2, P = 0·39, respectively). The rate of HC also did not differ between the two groups (18·8% vs. 15·1%, P = 0·46). WHAT IS NEW AND CONCLUSION: The efficacy of i.v. thrombolysis routinely performed in an extended 'time window' is not reduced when compared to procedures performed within 3 h from symptom onset.

Safety of intravenous thrombolysis for acute ischaemic stroke including concomitant neoplastic disease sufferers - experience from Poland.

BACKGROUND: Ischaemic stroke (IS), brain haemorrhage and cerebral venous thrombosis can occur as an early and late complication of cancer in the clinical course. Cancer patients are at increased risk for stroke from direct and indirect effects of their malignancy. AIMS: The aim of our study was to evaluate the relationship between neoplastic disease and the long-term outcome, mortality and the presence of haemorrhagic complications in patients with acute IS treated with i.v. thrombolysis. METHODS: We retrospectively evaluated the demographic and clinical data of 495 Caucasian patients with acute IS and 40 patients with IS and concomitant neoplastic disease who were consecutively treated from 2006 to 2013 in two experienced stroke centres. RESULTS: In analysed group, there were 7.8% of patients with cancer [50.0% male, mean age 72.3 ± 9.3; National Institutes of Health Stroke Scale - 13 (range 9.5-17)]. Cancer was diagnosed before i.v.-thrombolysis in 28 (70.0%) patients. After 3 months of follow up, 60% of patients were independent (mRS 0-2) compared with the group of patients without cancer - 55% (p = 0.54), 17.5% died (18.4%; p = 0.89), 12.4% suffered haemorrhagic transformation (HT) (17.6%; p = 0.41) and 2.5% experienced SICH (4.4%; p = 0.56, respectively). Other clinical complications were not found. A multivariate analysis showed no impact of neoplastic disease on unfavourable outcomes [modified Rankin scale 3-6)] after 3 months (p = 0.15). CONCLUSION: Intravenous thrombolysis performed in Caucasian stroke patients with past or current neoplastic diseases, but not in the course of chemo- and radiotherapy, can be a safe and effective method of treatment. In making decision on the thrombolytic treatment, the risk of bleeding complications and the life expectancy should be assessed.

Factors affecting the occurrence of symptomatic intracerebral haemorrhage after intravenous thrombolysis depending on the haemorrhage definition.

BACKGROUND AND PURPOSE: Symptomatic intracerebral haemorrhage (sICH) remains the most feared complication of systemic thrombolysis in patients with ischaemic stroke. The aim of the study was to analyze the impact of different factors on the occurrence of sICH, depending on definition used. MATERIAL AND METHODS: We retrospectively evaluated the influence of several factors on the occurrence of sICH (according to definitions used in ECASS2, SITS-MOST and NINDS studies) in 200 patients treated with systemic thrombolysis from 2006 to 2011. Multivariate analysis of impact of individual variables on the occurrence of haemorrhagic transformation (HT) and parenchymal haemorrhage type 2 (PH2) were performed. RESULTS: Haemorrhagic transformation occurred in 35 cases (17.5%). SICH was found in 10 cases according to ECASS2, in 7 cases according to SITS and in 13 cases according to NINDS. Older age was related to higher risk of sICH, regardless which definition was used (ECASS2: p = 0.014, SITS-MOST: p = 0.048, NINDS: p = 0.008), and female sex was related to higher risk of sICH according to NINDS and ECASS2 definition (p = 0.002 and p = 0.04, respectively). Blood glucose level and high NIHSS score (> 14 pts) were found as risk factor of sICH in ECASS2 definition (p = 0.044 and p = 0.03, respectively). In multivariate logistic regression higher NIHSS scores were associated with HT independent of age, gender and glucose level (p = 0.012). Multivariate analysis showed no impact of age, gender, severity of stroke and glucose level on presence of PH2. CONCLUSIONS: Definition of sICH can determine variables that are related to a high risk of this complication. In our study most factors correlated with sICH using the ECASS2 definition.

The efficacy and safety of intravenous thrombolysis with alteplase in the treatment of ischaemic stroke in a rural hospital.

BACKGROUND AND PURPOSE: Ongoing evaluation of the results of thrombolytic therapy in patients with ischaemic stroke (IS) in regions with different health care organization is absolutely crucial for making this method of treatment safer and efficient. The aim of this study was to analyse the efficacy and safety of treatment with intravenous alteplase in patients with acute IS in a rural hospital. MATERIAL AND METHODS: Between 2006 and 2011, 1392 pa-tients with IS were treated (including 200 patients treated with alteplase; 14.37%). In patients treated with alteplase, we analysed the influence of several variables on the functional status after 3 months according to the modified Rankin Scale (mRS), case-fatality rate during 3 months after onset and symptomatic intracerebral haemorrhage (SICH). RESULTS: In the studied population, good outcome (mRS 0-2) at 3 months was related to younger age (p = 0.001), male sex (p = 0.02) and low scores (< 15 points) on the National Institutes of Health Stroke Scale (NIHSS) (p < 0.0001). Deaths within 3 months were related to older age (p = 0.027), female sex (p = 0.004), severity of stroke measured by NIHSS score (p < 0.0001) and presence of radiological signs of previous stroke in baseline computed tomography (CT)(p = 0.002). Patients with SICH had higher mean age (p = 0.014) and higher severity of neurological deficit measured on the NIHSS scale (p = 0.03). CONCLUSIONS: The indications for intravenous thrombolysis in patients with IS should be strictly analysed so that the treatment is effective and safe especially in older patients, patients with greater severity of neurological symptoms and patients with old post-stroke lesions in baseline CT.

Intravenous rt-PA in patients with ischaemic stroke and renal dysfunction.

OBJECTIVE: Renal dysfunction (RD) increases risk for ischaemic stroke (IS). The impact of RD on the effects of iv-thrombolysis in the Caucasian population has not been fully determined. AIMS: To evaluate the associations between RD and the outcome of iv-thrombolysis in Caucasian patients with IS. METHODS: The observational, multicentre study included 404 patients with IS who were treated with iv-thrombolysis. RD was defined as estimated glomerular filtration rate ≤ 60 ml/min/1.73 m(2). Outcome was assessed with modified Rankin Score at 3 months after the stroke onset. RESULTS: Medians baseline NIHSS score did not differ between groups of patients with and without RD (12.0 vs. 11.0 pts, p=0.33). Unfavourable outcome was found in 52.1% of patients with and in 41.2% of patients without RD (p=0.05), mortality was higher in patients with RD (29.9% vs. 14.3%, p<0.001), and the presence of haemorrhagic transformation (HT) did not differ between the groups (17.1% vs. 17.1% respectively, p=0.996). A multivariate analysis showed no impact of RD on the unfavourable outcome (OR 0.98; 95%CI 0.88-1.10), mortality (OR 0.92; 95%CI 0.81-1.05) or presence of HT (OR 1.03; 95%CI 0.90-1.18). CONCLUSIONS: We found no impact of RD on the safety and efficacy of iv-thrombolysis in Caucasian patients with IS.