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Infections and Ischemic Stroke Outcome  [PDF]
Katarzyna Grabska,Gra?yna Gromadzka,Anna Cz?onkowska
Neurology Research International , 2011, DOI: 10.1155/2011/691348
Abstract: Background. Infections increase the risk of ischemic stroke (IS) and may worsen IS prognosis. Adverse effects of in-hospital infections on stroke outcome were also reported. We aimed to study the prevalence of pre- and poststroke infections and their impact on IS outcome. Methods. We analysed clinical data of 2066 IS patients to assess the effect of pre-stroke and post-stroke infections on IS severity, as well as short-term (up to 30 days) and long-term (90 days) outcome. The independent impact of infections on poor outcome (death, death/dependency) was investigated by use of logistic regression analysis. The effect of antibiotic therapy during hospitalization on the outcome was also assessed. Results. Pre-stroke infections independently predicted worse short-term outcome. In-hospital infections were associated with worse short-term and long-term IS prognosis. Antibacterial treatment during hospitalization did not improve patients' outcome. Conclusions. Prevention of infections may improve IS prognosis. The role of antibiotic therapy after IS requires further investigations. 1. Introduction Infections preceding the ischemic stroke (IS), as well as infections occurring in the acute phase of IS, are a frequent phenomenon [1, 2]. Chronic infections of both viral and bacterial etiology and coexistent vascular inflammatory state promote atherosclerosis, contributing to an increased cerebrovascular risk [3, 4]. The association of prestroke acute infectious events, in particular, respiratory tract infections, with increased risk of stroke [5], especially of cardioembolic and atherothrombotic etiology, was reported [2, 6]. Some authors suggest that prestroke infections are related not only to the risk but also to IS severity [7, 8]. On the other hand, stroke severity and lesion location are associated with the risk of in-hospital (post-stroke) infections. For example, patients with brainstem or diffuse cerebral lesions characterize with an increased risk of respiratory tract infection, that frequently results from dysphagia [9, 10]. It seems possible that post-stroke infectious events are favoured by the stroke-induced immunodepression [2]. The impact of post-stroke infections on IS outcome is the next important issue [11]. Some authors describe an association of post-stroke infections with poor patients’ outcome [12–14]. According to the presented data, a proper treatment of stroke-related infections may improve patients’ outcome. Until now some reports suggest that therapy with antibiotics in the acute phase of stroke (even in patients without the obvious
Effect of pre-stroke use of ACE inhibitors on ischemic stroke severity
Magdy Selim, Sean Savitz, Italo Linfante, Louis Caplan, Gottfried Schlaug
BMC Neurology , 2005, DOI: 10.1186/1471-2377-5-10
Abstract: We retrospectively studied 126 consecutive patients presenting within 24 hours of ischemic stroke onset, as confirmed by diffusion-weighted magnetic resonance imaging (DWI). We calculated the NIHSS score at presentation, as the primary measure of clinical stroke severity, and categorized stroke severity as mild (NIHSS [less than or equal to] 7), moderate (NIHSS 8–13) or severe (NIHSS [greater than or equal to] 14). We analyzed demographic data, risk-factor profile, blood pressure (BP) and medications on admissions, and determined stroke mechanism according to TOAST criteria. We also measured the volumes of admission diffusion- and perfusion-weighted (DWI /PWI) magnetic resonance imaging lesions, as a secondary measure of ischemic tissue volume. We compared these variables among patients on ACEI and those who were not.Thirty- three patients (26%) were on ACE-inhibitors. The overall median baseline NIHSS score was 5.5 (range 2–21) among ACEI-treated patients vs. 9 (range 1–36) in non-ACEI patients (p = 0.036). Patients on ACEI prior to their stroke had more mild and less severe strokes, and smaller DWI and PWI lesion volumes compared to non-ACEI treated patients. However, none of these differences were significant. Predictably, a higher percentage of patients on ACEI had a history of heart failure (p = 0.03). Age, time-to-imaging or neurological evaluation, risk-factor profile, concomitant therapy with lipid lowering, other antihypertensives or antithrombotic agents, or admission BP were comparable between the two groups.Our results suggest that ACE-inhibitors may reduce the clinical severity of stroke, as measured by NIHSS score. Further, larger-scale, prospective studies areneeded to validate our findings, and to elucidate the mechanism(s) of ACEImediated benefits in patients with ischemic stroke.Data from the heart outcomes prevention evaluation study (HOPE) suggest that angiotensin-converting enzyme inhibitors (ACEI) are effective in prevention of ischemic stroke,
Effect of Heart Failure on Acute Ischemic Stroke Severity  [PDF]
Taha Kamel Alloush, Mahmoud Haroun Ibrahim, Nahed Salah El-Dein Ahmed, Ghada Samir El-Shahed, Lobna M. El-Nabil El-Sayed, Mohamed Hamdy Ibrahim, Hosam Ahmed Azmy
Open Journal of Medical Imaging (OJMI) , 2014, DOI: 10.4236/ojmi.2014.43014
Objectives: To assess the impact of heart failure diseases on stroke severity and short term (1 month mortality). Materials and Methods: Totally, 200 patients admitted to Ain Shams university specialized hospital, were diagnosed clinically to have acute ischemic stroke within 3 days. History taking about previous heart disease was taken, and full general and neurological examinations were done. Full metabolic profile, cardiac examination and investigations were done. Carotid duplex, MRI stroke protocol and lastly clinical reevaluation using NIH Stroke Scale (NIHSS) after 1 month from stroke onset were done. Results: Patients with systolic dysfunction (EF ≤ 40%) had lacunar infarction in 18.75% of cases, partial anterior circulation infarction in 62.5% of cases, posterior circulation infarction in 6.25% of cases and total anterior circulation infarction in 12.5% of cases. Leucoaraiosis was present in 87% of cases and significant intracranial vessel stenosis was showed in 87.5% who had done MRI. Their median NIHSS score at admission was 10.5 with IQR of 5 - 21 and at follow-up it was 5 with IQR of 2.5 - 10.5. At follow-up 22.7% (5 patients) were dead. Conclusion: Systolic dysfunction (EF < 40) i.e. heart failure has no significant effect on stroke severity and 1 month follow up prognosis.
Effect of Atrial Fibrillation on Acute Ischemic Stroke Severity  [PDF]
Taha Kamel Alloush, Mahmoud Haroun Ibrahim, Nahed Salah El Dein Ahmed Ibrahim, Ghada Samir El-Shahed, Lobna Mohamed Nabil El-Sayed, Mohamed Hamdy Ibrahim, Hosam Ahmed Azmy
Open Journal of Medical Imaging (OJMI) , 2014, DOI: 10.4236/ojmi.2014.42013
Objectives: To assess the impact of atrial fibrillation on stroke severity and short-term (1 month) mortality. Materials and Methods: Totally 200 patients admitted to Ain Shams University Specialized Hospital were recruited and diagnosed clinically to have acute ischemic stroke within 3 days. Patients with hemorrhagic infarctions were excluded. History taking about previous heart disease was taken, full general and neurological examinations were done. Full metabolic profile, full cardiac investigations, carotid duplex, MRI brain stroke protocol with initial clinical evaluation and after 1 month re-evaluation using (NIHSS ) scale. Results: All patients underwent transthoracic echocardiography which revealed absence of “A” wave corresponding to atrial fibrillation in 33 patients (16.5%). Those Patients with atrial fibrillation had a median NIHSS score of 11.00 with IQR of 6.00 - 18.50 at admission and 6.00 with IQR of 2.00 - 14.50 after one month. Patients with atrial fibrillation showed significantly higher NIHSS at admission than patients in sinus rhythm, P < 0.05. Magnetic resonance imaging findings showed that MRA showed significant intracranial vessel stenosis in 117 (79.1%) patients. 51 (34.4%) patients had lacunar infarction, 65 (43.9%) patients had partial anterior circulation infarction, 25 (16.2%) patients had posterior circulation infarction and 7 (4.7%) patients had total anterior circulation infarction. 111 (75%) patients showed leucoaraiosis. Conclusion: Atrial fibrillation was found not to have significantly statistical effect on stroke severity and short term mortality.
Stroke Severity Is the Major Player in Post-Stroke Urinary Tract Infection in Patients with First Ever Ischemic Stroke  [PDF]
Hassan Mohamed Elnady, Hemaid Mostafa Azab, Mohamed Abdelmonem Said, Alaa-Eldin Sedky Bekheet, Ashraf Khodeary, Ahmed Ata Ali
Neuroscience & Medicine (NM) , 2018, DOI: 10.4236/nm.2018.92010
Abstract: Background: Urinary tract infections UTIs occur repeatedly after stroke and are related to bad outcomes with increased rates of deterioration in neurological state during hospitalization, death or long term disability as well as increased length of hospitalization. Factors found to predict UTI include stroke severity, depressed consciousness level, increased post-void residual urine volume, and diabetes mellitus. Stroke severity appears to be the most important predictor of infection risk. We aimed to determine the risk factors associated with UTI after acute stroke, and its association with outcome. Subjects and Methods: This is prospective cohort study. We analysed clinical data of 100 patients with first ever ischemic stroke. We assessed risk factors for UTI, as well as clinical outcome. Results: Urinary tract infection was found in 72% of our subjects. On univariate analysis, patients with UTI were more likely to have had a more severe stroke, more likely to be catheterized and more likely to have a higher serum creatinine level. The multivariate analysis revealed that greater stroke severity was independently associated with increased risk of developing UTI. Greater stroke severity measured by CSS was independently associated with unfavorable outcome on discharge. Conclusion: UTI is common after acute stroke. It is associated with more severe stroke.
Admission C – reactive protein after acute ischemic stroke is associated with stroke severity and mortality: The 'Bergen stroke study'
Titto T Idicula, Jan Brogger, Halvor Naess, Ulrike Waje-Andreassen, Lars Thomassen
BMC Neurology , 2009, DOI: 10.1186/1471-2377-9-18
Abstract: We prospectively studied 498 patients with ischemic stroke who were admitted within 24 hours after the onset of symptoms. CRP and NIH stroke scale (NIHSS) were measured at the time of admission. Short-term functional outcome was measured by modified Rankin scale (mRS) and Barthel ADL index (BI) 7 days after admission. Patients were followed for up to 2.5 years for long-term mortality and future vascular events data.The median CRP at admission was 3 mg/L. High CRP was associated with high NIHSS (p = 0.01) and high long-term mortality (p < 0.0001). After adjusting for confounding variables, high CRP remained to be associated with high NIHSS (p = 0.02) and high long-term mortality (p = 0.002). High CRP was associated with poor short-term functional outcomes (mRS > 3; BI < 95) (p = 0.01; p = 0.03). However, the association was not significant after adjusting for confounding variables including stroke severity (p = 0.98; p = 0.88). High CRP was not associated with future vascular events (p = 0.98).Admission CRP is associated with stroke severity and long-term mortality when measured at least 24 hours after onset. There is a crude association between high CRP and short-term functional outcome which is likely secondary to stroke severity. CRP is an independent predictor of long-term mortality after ischemic stroke.There is growing evidence that C-reactive protein (CRP), a peripheral marker of inflammation, is also a marker of generalized atherosclerosis [1]. This relationship between inflammation and atherosclerosis make CRP a potential marker for prognosis after vascular events and a potential predictor of future vascular events.Large population-based studies show that high CRP is a risk factor for future cardiovascular events [2-4]. The recent JUPITER trial shows that the use of rosuvastatin in patients with high CRP has a significant impact both in reducing the CRP level and in lowering future vascular events [5]. This indicates the role of inflammation in atherogenesis
Association between Statin Use and Short-Term Outcome Based on Severity of Ischemic Stroke: A Cohort Study  [PDF]
Bo Song, Yilong Wang, Xingquan Zhao, Liping Liu, Chunxue Wang, Anxin Wang, Wanliang Du, Yongjun Wang
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0084389
Abstract: Background Statins reportedly improve clinical outcomes for ischemic stroke patients. However, it is unclear whether the contribution of statin treatment varies depending on the severity of stroke. We sought to investigate the relationship between statin use and the outcome of acute first-ever ischemic stroke patients stratified by stroke severity. Methods A total of 7,455 acute first-ever ischemic stroke patients without statin treatment before onset were eligible from the China National Stroke Registry. A National Institutes of Health Stroke Scale (NIHSS) score of 0 to 4 was defined as minor stroke, and a NIHSS score of >4 was defined as non-minor stroke. We analyzed the association between statin use during hospitalization and mortality as well as functional outcome (measured by a modified Rankin Scale score of 0–5) at 3 months after onset using multivariable logistic regression models. Results A total of 3,231 (43.3%) patients received statin treatment during hospitalization. Multivariable analysis showed that statin use during hospitalization decreased mortality of ischemic stroke patients (OR, 0.51; 95%CI, 0.38–0.67), but did not improve poor functional outcomes (OR, 0.95; 95CI%, 0.81–1.11) at 3 months. The interaction between statin use and stroke severity was significant both in dependence and death outcome (P = 0.04 for dependence outcome, P = 0.03 for death outcome). After stratification by stroke severity, statin use during hospitalization decreased the mortality of stroke (OR, 0.44; 95%CI, 0.31–0.62) and poor functional outcome (OR, 0.73; 95%CI, 0.57–0.92) at 3 months in the non-minor stroke group. Conclusions Statin use during hospitalization may improve the clinical outcome of acute first-ever ischemic stroke depending on the severity of stroke. Non-minor stroke patients may obtain benefit from statin treatment with improvements in poor functional outcomes and mortality.
Serum YKL-40 Levels Correlate with Infarct Volume, Stroke Severity, and Functional Outcome in Acute Ischemic Stroke Patients  [PDF]
Hyun Young Park, Chang-Duk Jun, Se-Jeong Jeon, See-Sung Choi, Hak-Ryul Kim, Dan-Bee Choi, Seongae Kwak, Hak-Seung Lee, Jin Sung Cheong, Hong-Seob So, Young-Jin Lee, Do-Sim Park
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0051722
Abstract: Background and Purpose YKL-40 is associated with various neurological disorders. However, circulatory YKL-40 levels early after onset of acute ischemic stroke (AIS) have not been systematically assessed. We aimed to identify the temporal changes and clinical usefulness of measuring serum YKL-40 immediately following AIS. Methods Serum YKL-40 and C-reactive protein (CRP) levels were monitored over time in AIS patients (n = 105) and compared with those of stroke-free controls (n = 34). Infarct volume and stroke severity (National Institutes of Health Stroke Scale; NIHSS) were measured within 48 hours of symptom onset, and functional outcome (modified Rankin Scale; mRS) was measured 3 months after AIS. Results Within 12 hours of symptom onset, levels of YKL-40 (251 vs. 41 ng/mL) and CRP (1.50 vs. 0.96 μg/mL) were elevated in AIS patients compared to controls. The power of YKL-40 for discriminating AIS patients from controls was superior to that of CRP (area under the curve 0.84 vs. 0.64) and YKL-40 (r = 0.26, P<0.001) but not CRP levels were correlated with mRS. On day 2 of admission (D2), YKL-40 levels correlated with infarct volume and NIHSS. High YKL-40 levels predicted poor functional outcome (odds ratio 5.73, P = 0.03). YKL-40 levels peaked on D2 and declined on D3, whereas CRP levels were highest on D3. Conclusions Our results demonstrate serial changes in serum YKL-40 levels immediately following AIS and provide the first evidence that it is a valid indicator of AIS extent and an early predictor of functional outcome.
Previous Leisure-Time Physical Activity Dose Dependently Decreases Ischemic Stroke Severity  [PDF]
Dominique Deplanque,Isabelle Masse,Christian Libersa,Didier Leys,Régis Bordet
Stroke Research and Treatment , 2012, DOI: 10.1155/2012/614925
Abstract: In the present subanalysis of a cross-sectional study showing the favorable effect of prior transient ischemia, leisure-time physical activity, and lipid-lowering drug therapy on stroke severity, we aimed to evaluate whether previous physical activity was dose dependently associated to minor stroke (NIHSS 0–3) and to identify possible underlying factors. Among 362 consecutive patients, less severe stroke was related to weekly exercise duration prior to stroke (no exercise: 36.1%; <2 hours: 49.3%; 2–5 hours: 58.8%; >5 hours: 64.0%; ). Only weak and moderate exercise practices were protective (weak: 50.0%; moderate: 79.3%; heavy: 22.2%; ). Such a beneficial effect was observed independently of age and was associated with a trend to a lower frequency of arterial hypertension, alcohol abuse, and a better metabolic profile. Besides other therapeutic approaches, physical activity may be a simple way to decrease cerebral ischemia severity. 1. Introduction Meta-analyses of epidemiologic studies have consistently suggested the risk reduction of both ischemic and hemorrhagic strokes when practicing regular physical activity [1–3]. Such a preventive effect, that may be more important in men than in women [3], could be very impressive, since the relative risk of stroke incidence and mortality could be reduced from 25% (cohort studies) to up to 64% (case-control studies) in active individuals as compared to nonactive counterparts [1, 2]. Several plausible mechanisms by which physical activity might reduce stroke risk has been discussed as reducing blood pressure or improving lipid profiles, endothelial function, and haemostatic and inflammatory parameters [1]. Beyond the decrease of stroke incidence, it could also be postulated that physical activity could lead to the reduction of stroke severity, since both experimental and clinical data provide some arguments about a possible preventive neuroprotection [4–8]. In a previously published study [6], we showed that previous leisure-time physical activity as well as prior transient ischemic attack and lipid-lowering drugs therapy are independent predictors of lesser stroke severity and better short-term outcome. In this context, at least 2 other studies provide similar results, but little is known about the possible underlying mechanisms [7, 8]. In the present analysis, we aimed to focus on the impact of previous leisure-time physical activity on initial stroke severity. To provide some explanations about such a possible beneficial effect, we analyzed patients’ clinical and biological profiles. Taking into account both
Role of Interleukin-6 Correlated to C. pneumoniae Infection as a Biomarker for Prediction of Stroke Severity in Young Patients with Acute Ischemic Stroke  [PDF]
M. V. Padma Srivastava,Ashu Bhasin,Rama Chaudhry,Sakshi Sharma,S. Vivekanandhan,Rohit Bhatia,Manjari Tripathi
Asian Journal of Neuroscience , 2014, DOI: 10.1155/2014/649106
Abstract: Background. Stroke in young is the leading cause of morbidity and mortality in the Indian subcontinent with a reported incidence of 15–30% of all stroke patients. The mechanisms for stroke in the young may include unconventional risk factors such as infections. Causative role of C. pneumoniae infection in patients with acute ischemic stroke (AIS) remains unresolved till date, although the link between C. pneumoniae and cerebrovascular disease has been investigated in many studies. This study examined the upregulation of IL-6 after acute cerebral ischemia and correlated the same with the C. pneumoniae antibody titres (IgG, IgA, and IgM). Methods. We studied blood samples from eighty ( ) acute stroke patients and healthy age- and sex-matched controls. Venous blood samples were drawn within one week from the onset of stroke. Detection of IgA, IgG, and IgM antibodies to C. pneumoniae was done with a validated microimmunofluorescence (MIF) technique from 5?mL of serum in all subjects. Interleukin-6 was estimated with sandwich ELISA method. Results. The IL-6 levels were elevated in patients with a mean 28.9 ± 8.6?pg/mL as compared to 4.7 + 1.8?pg/mL in healthy age-matched controls (95% CI: 37.7 to 78.4; ). On correlation of IL-6 to stroke severity, it was found that 30 patients with NIHSS between 0 and 15 had mean IL-6 of 24.6?pg/mL and 50 patients had NIHSS of 18.8 (severely affected) with a mean IL-6 of 43.8?pg/mL. On multivariate analysis after adjusting for sex, hypertension, diabetes mellitus, smoking, and alcohol, the IgA seropositivity yielded an adjusted OR for stroke (4.72; 95% CI: 1.61, 13.83; ), while IgG seropositivity did not show a statistically significant result. We also observed that 81% of cases were seropositive for IgA versus 32% of controls ( ) followed by IgG, as 52.7% of cases were seropositive versus 17.3% of controls ( ). Multiple regression analysis was done with IL-6 as dependent variable to antibody with IL-6 as dependent variable to Cp-IgA, Cp-IgG, and IgM with 10.4% change in the IL-6 titres showing statistical significant result = 3.32, . Conclusions. IL-6 has important role after acute ischemic stroke and is correlated with stroke severity and may correlate to acute or chronic infectious states with C. pneumonia. 1. Introduction Young stroke patients constitute 15–30% of all stroke patients in India, to that of 3.0–8.5% of all stroke patients reported from the West [1]. Stroke in young, including stroke in children and young adults (<45 years), is an important cause of morbidity throughout the world, especially in developing
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