Mortality after stroke

ECASS-II was designed to test a lower dose of rt-PA (0.9 mg/kg) during the same 0-6-hours time period after stroke onset, using similar inclusion criteria as in ECASS-I. ° The primary endpoint was the proportion with a favorable outcome on the mRS scale (defined as a score of 0 or 1). There was no difference in this outcome between rt-PA-treated and placebo controls (40% vs. 37%, p = 0.28). A separate analysis of the 158 subjects enrolled within 3 hours of stroke onset also showed no difference in the proportion with a favorable outcome (42% vs. 38%, p = 0.63) this result, however, must be treated with caution because in ECASS-II there was a substantially lower number of patients treated within 3 hours of stroke onset, compared to the 1995 NINDS rt-PA study. Parenchymal hematoma on post-treatment CT was seen in 12% of rt-PA-treated and 3% of placebo patients (p < 0.001). The 90-day mortality rate was 11 % for the rt-PA group and 11 % for the placebo group (p = 0.54). Protocol violations were much less frequent in ECASS-II compared to ECASS-I (9% vs. 18%), probably because of standardized training in CT interpretation at the study sites. 

Bateman BT, Schumacher HC, Boden-Albala B, Berman ME, Mohr JP, Sacco RL, Pile-Spellman J. Eactors associated with in-hospital mortality after administration of thrombolysis in acute ischemic stroke patients An analysis of the nationwide inpatient sample 1999 to 2002. Stroke. 2006 37 440-446. 

In rodent stroke models, statin pretreatment has been shown to reduce infarct volumes and improve outcomes. Similarly, several clinical studies have shown that prior statin use reduced the severity of acute ischemic stroke and myocardial infarction. Recent studies indicate that beneftt can be achieved even when treatment is initiated after the onset of symptoms. In rodents, atorvastatin and simvastatin have been shown to reduce the growth of ischemic lesions, enhance functional outcome, and induce brain plasticity when administered after stroke onset. A retrospective analysis of the population-based Northern Manhattan Stroke Study (NOMASS) showed that patients using lipid-lowering agents at the time of ischemic stroke have a lower incidence of in-hospital stroke progression and reduced 90-day mortality rates. Retrospective analysis of data of the phase III citicoline trial showed... 

Woo J, Lam CW, Kay R, Wong AH, Teoh R, Nicholls MG. The influence of hyperglycemia and diabetes melhtus on immediate and 3-month morbidity and mortality after acute stroke. Arch Neurol 1990 47 1174-1177. 

The timing of CEA after ischemic stroke has been a controversial issue. In 1969, the Joint Study of Extracranial Arterial Occlusion reported 42% mortality after CEA in patients with neurological deficits of less than 2 weeks duration, compared with 5% mortality in patients with more than 2 weeks of symptoms. Early evidence also demonstrated an increased risk of intracerebral hemorrhage after early CEA in patients with acute stroke. This led to the conclusion that most complications occurred with early surgical intervention, and resulted in a traditional 4-6 week delay for CEA after an acute stroke. In retrospect, however, there were major problems with patient selection in these earlier reports. Many of the patients... 

More recent reports conclude that early CEA after a nondisabling ischemic stroke can be performed with perioperative mortality and stroke rates comparable to those of delayed CEA. In a subgroup analysis by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) investigators, 42 patients who underwent early CEA (<30 days after stroke) were compared with 58 patients who underwent delayed CEA (>30 days), and no overall difference was demonstrated in the perioperative stroke rate (4.8% vs. 5.2%). Another recent prospective randomized study of 86 patients showed no difference in either perioperative stroke (2% in both groups) or survival rates (mean 23 months follow-up) between patients randomized to early or delayed CEA. ... 

The Safety of Tirofiban in Acute Ischemic Stroke (SaTIS) trial examined 250 patients 6-22 hours after stroke onset treated with tirohban infusion or placebo for 48 hours. No increase in ICH was reported in the active group. Although no beneht in early functional recovery was observed, 5-6-month mortality was lower in the tirohban-treated group (relative risk reduction (RRR) 27%, 95% Cl 0.08-0.95, p = 0.03). 

Kammersgaard LP, Jorgensen HS, Rungby JA, Reith J, Nakayama H, Weber UJ, Houth J, Olsen TS. Admission body temperature predicts long-term mortality after acute stroke the Copenhagen Stroke Study. Stroke 2002 33(7) 1759-1762. 

Cucciara BL, Kasner SE, WoUt DA, Lyden PD, Knappertz VA, Ashwood T, Odergren T, Nordlund A CLASS-I Investigators. Early impairment in consciousness predicts mortality after hemispheric ischemic stroke. Crit Care Med 2004 32(1) 241-245. 

Index functional status 30 d after stroke. The results showed that only the severity of neurological deficit predicted greater 30-d mortality in these patients. Patients with hyperthermia on the first day of hospitalization had increased mortality and worse functional status at 30 d, but increased temperature was not an independent predictor of mortality 30 d after PICH. In a study to assess typical early onset complications following ischemic stroke, Weimar et al. (5) looked at a cohort of 3866 patients from 14 neurology departments with an acute stroke unit. In the first week following admission, increased intracranial pressure (ICP) and recurrent cerebral ischemia were the most frequent complications, along with fever, severe hypertension, and pneumonia. Similar concerns are also found in cardiac surgery patients in whom perioperative stroke occurred (6). 

Deprivation. In the UK, both stroke incidence and poor outcome after stroke are greater in areas of socioeconomic disadvantage (Kaplan and Keil 1993 Avendano et al. 2004). This is partly because poverty is associated with adverse health behaviors and risk factors such as smoking (Hart et al. 2000a). There is also evidence that poor maternal and infant health is associated with increased mortality from stroke in later life (Barker 1995 Martyn et al. 1996). However, the adverse effect of socioeconomic deprivation also appears to be cumulative throughout life (Davey Smith et al. 1997 Hart et al. 2000b). 

Stroke induces an acute stress response—i.e., over-activation of the sympathetic nervous system and increased corticosteroid levels (with resultant neutrophiha and lymphocytopenia). This in turn leads to depressed immunity and altered immune responses during the acute phase of stroke and may predispose patients to infections, particularly pneumonia, which is the commonest cause of mortality after the first few days of stroke (Meisel et al., 2005). In the clinical setting, increased total white cell counts and neutrophilia, which correlate with infarct size, are independently associated with worse outcome after stroke. Recently a massive and early activation of the systemic immnne system has been shown to occur also in experimental stroke (Offner et al., 2006). 

Carpentier AC, Constable RT, Schlosser MJ et al. (2001) Patterns of functional magnetic resonance imaging activation in association with structural lesions in the rolandic region a classification system. J Neurosurg 94 946-954 Carter LP, Gumerlock MK (1995) Steal and cerebral arteriovenous malformations. Stroke 26 2371-2372 Castel JP, Kantor G (2000) Postoperative morbidity and mortality after microsurgical exclusion of cerebral arteriove-... 

The Penumbra stroke system (Penumbra Inc., San Leandro, CA) includes two different revascularization options (1) thrombus debulking and aspiration may be achieved by a reperfusion catheter that aspirates the clot while a separator device fragments it, and (2) direct thrombus extraction may be performed by a ring retriever while a balloon guide catheter is used to temporarily arrest flow. This system has been tested in a pilot trial in Europe. Twenty patients (mean NIHSS 21) with a total of 21 vessel occlusions (7 ICA, 5 MCA, and 9 Basilar) were treated up to 8 hours after symptom onset. Recanalization prior to lA lysis was achieved in all cases (48% TIMI 2 52% TIMI 3). Seven patients were also treated with lA UK or rt-PA. Good outcome at 30 days (defined as mRS < 2 or NIHSS 4-point improvement) was demonstrated in 42%. The mortality rate was 45%, but there were no device-related deaths. There was one asymptomatic SAH and three symptomatic ICHs. A prospective, single-arm, multicenter trial is being conducted in the United States and Europe currently. 

Schwab et al. Stroke 1999 30(5) 1153 Prospective pilot study moderate hypothermia in severe stroke and ICP 25 of 25 tx with hypothermia Hypothermia to 33-34°C with cooling blankets in pts with compete MCA infarct and ICP monitor 44% mortality, all by herniation after secondary rise in ICP after rewarming period. Good control of ICP during hypothermia period. Forty percent rate of pneumonia... 

Mickel, H.S., Vaishnav, Y.N., Kempski, O., von Lubitz, D., Weiss, J.F. and Feuerstein, G. (1987). Breathing 100% oxygen after global ischemia in Mongolian gcrbils results in increased lipid peroxidation and increased mortality. Stroke 18, 426-430. 

The interest in dietary flavonoids has grown in the last 15 years after the publication of the study of Hertog et al. [1993] showing an inverse correlation between dietary consumption of flavonols and flavones and reduced incidence and mortality from ischemic heart disease. Most prospective epidemiological studies carried out have found a similar relationship regarding ischemic heart disease while a possible inverse relationship with stroke is less clear [Hertog et al., 1997 Knekt et al., 1996 Rimm et al., 1996 Yochum et al., 1999 Hirvonen et al., 2001 Arai et al., 2000 Mursu et al., 2008], The meta-analysis... 

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