Differences in carotid artery atherosclerosis between men and women in the early phase after ischemic event

Objectives There is little data about sex differences in carotid atherosclerosis in the early phase after an ischemic event. The aim of this study was to examine the carotid artery atherosclerosis differences between men and women in early phase after TIA or stroke. Methods Consecutive patients with recent ischemic event, admitted during the first week after symptom onset were examined with ultrasound. Sex differences in degree of stenosis, number of plaques and plaque morphology were compared. Plaque morphology was assessed by gray-scale median (GSM), according to which lower values were associated with hemorrhagic/necrotic core indicating plaque instability. Results Of the 316 patients with ischemic events, 196 (50.5% male) entered the study. Men had more often moderate as well as severe ipsilateral carotid stenosis (12.1% vs 7.2% for moderate and 12.1% vs 2.1% for severe; p=0.024). Men had more often the largest plaque hypoechogenic contralateral (62.6% vs 37.1%, p=0.0008), but not ipsilateral. Men had 3 or more hypoechogenic plaques (24.2% vs 4.1%, p=0.0001; 17.2% vs 4.1%, p<0.0001) both ipsi and contralateral respectively. Male sex was a risk factor for having 3 or more ipsilateral hypoechogenic plaques (p=0.002, OR=20 CI 95% [5.5–75]. Conclusions Men had more often carotid stenosis and higher number of hypoechogenic plaques

Spolne razlike u raspodjeli rizičnih čimbenika, težini i ishodu ishemijskog moždanog udara

The aim of the study was to identify differences in baseline characteristics and outcomes of men and women with acute ischemic stroke. Ischemic stroke was confirmed by CT scan or autopsy in patients admitted to the 2nd Department of Neurology, Institute of Psychiatry and Neurology in Warsaw, Poland from 1995 to 2007. Male and female patients were compared for risk factors, state of activity prior to stroke, stroke type according to Oxfordshire Community Stroke Project classification, diagnostic test findings, and early 30-day outcome. Data on 1379 women and 1155 men admitted with ischemic stroke were analyzed. The mean age of female and male patients was 74.3 and 68.8 years, respectively. Women were more often disabled prior to stroke, hypertensive, diagnosed with atrial fibrillation or heart failure, and had impaired consciousness at admission, whereas men were more likely to smoke, abuse alcohol and have a history of myocardial infarction or transient ischemic attack. A higher percentage of female stroke patients suffered from total anterior circulation syndrome than males (21.2% and 14.0%, respectively). Internal carotid artery stenosis over 70% was reported in 10.8% of women and 19.1% of men. The 30-day mortality and poor outcome rates were significantly higher in women than men (17.2% vs. 13.1% and 59.9% vs. 46.2%). After adjusting for casemix in multivariate analysis, female sex was independently associated with a higher risk of an early poor outcome. In conclusion, the risk factor distribution, clinical characteristics, diagnostic test findings, and early outcomes were different between female and male ischemic stroke patients. Female sex was associated with poorer prognosis, indicating that more intensive acute and long-term global care may be needed to improve the outcome among female stroke patients.Cilj studije bio je utvrditi razlike u osnovnim značajkama i ishodu između muškaraca i žena s akutnim ishemijskim moždanim udarom. Ishemijski moždani udar potvrđen je kompjutorskom tomografijom ili pri autopsiji u bolesnika primljenih na Drugi neurološki odjel Zavoda za psihijatriju i neurologiju u Varšavi, Poljska, od 1995. do 2007. godine. Bolesnici i bolesnice uspoređeni su u odnosu na rizične čimbenike, stanje aktivnosti prije moždanog udara, vrst moždanog udara prema klasifikaciji Oxfordshire Community Stroke projekta, nalaze dijagnostičkih pretraga i rani 30-dnevni ishod. Analizirali su se podatci za 1379 žena i 1155 muškaraca s ishemijskim moždanim udarom. Srednja dob bolesnica bila je 74,3 godine, a bolesnika 68,8 godina. Žene su češće imale invalidnost prije moždanog udara, kao i hipertenziju, atrijsku fibrilaciju ili srčano zatajenje, te poremećaj svijesti kod prijma, dok je kod muškaraca češće zabilježena navika pušenja, zlouporaba alkohola te povijest infarkta miokarda ili prolaznog ishemijskog napadaja. Bolesnice su u većem postotku patile od sindroma ukupne prednje cirkulacije nego muškarci (21,2% prema 14,0%). Stenoza unutarnje karotidne arterije veća od 70% zabilježena je u 10,8% žena i 19,1% muškaraca. Smrtnost unutar 30 dana i stope lošeg ishoda bile su značajno više u žena negoli u muškaraca (17,2% prema 13,1%, odnosno 59,9% prema 46,2%). Nakon prilagodbe za casemix u multivarijatnoj analizi ženski spol bio je neovisno udružen s većim rizikom za rani loš ishod. U zaključku, raspodjela rizičnih čimbenika, te kliničke značajke, nalazi dijagnostičkih pretraga i rani ishodi razlikovali su se između muških i ženskih bolesnika s ishemijskim moždanim udarom. Ženski spol bio je udružen s lošijom prognozom, ukazujući na potrebu intenzivnije akutne i dugoročne opće skrbi kako bi se poboljšao ishod bolesti među bolesnicama s ishemijskim moždanim udarom

The Clinical Development of Cerebrolysin: New Approaches in Stroke Studies: A Commentary to The Cars Study

Additional efficacious treatment options for stroke are urgently needed as thrombolysis and endovascular thrombectomy are too rarely utilised due to the narrow time window. This article reviews the clinical profile of Cerebrolysin® (EVER Pharma, Austria), a well-documented compound indicated for the treatment of acute stroke, which has also shown promising results in neurorecovery. Well-conducted clinical trials have shown strong and encouraging treatment signals, either as a single therapy or in combination with recombinant tissue plasminogen activator. This review focusses on the latest research results, especially on the randomised, controlled CARS study, which combined pharmacological and rehabilitation therapy. Furthermore, this study reached the primary endpoint at Day 90 in the Action Research Arm Test and showed significant improvements in modified Rankin Scale (mRS) at Day 90. The same applies to important secondary endpoints such as the National Institutes of Health Stroke Scale (NIHSS) at Day 21 (early benefit). CARS is a rehabilitation study with a larger sample size and gives neurologists as well as rehabilitation specialists renewed confidence in this class of neuroprotective/ neurorecovery-enhancing compounds. Furthermore, ongoing research projects like CREGS-S are discussed, a large-scale prospective registry that adds valuable real-world data to the existing portfolio of Cerebrolysin studies

Poznavanje činjenica o moždanom udaru među bolesnicima bez moždanog udara

The aim of the study was to evaluate the knowledge among patients at non-neurologic wards about the risk factors for stroke, warning signs, and initial actions that must be taken when a stroke occurs. Data were collected from 75 inpatients suffering from a range of diseases, mean age 49.57±14.87 years. Study subjects were asked to fill in a standardized questionnaire containing 46 questions subdivided into two sections. The answers concerning warning symptoms, risk factors, causes of stroke, and initial action were quasi-quantified according to an arbitrary scoring system. Of 75 patients, only 5.3% were not aware of any medical risk factor, and 12% were not aware of any warning signals. On the other hand, only 2.6% and 10.66% of subjects listed correctly all risk factors and warning signs, respectively. Anyhow, many patients gave wrong answers. Most respondents (89.54%) would choose a desirable action if stroke was suspected. The scores for knowledge about stroke were better among higher educated respondents and among women. The factors such as belonging to a high-risk group for stroke, age, and other characteristics did not influence the score. Family, friends, and mass media provided major sources of the patients’ knowledge. It is concluded that, despite the fact that the respondents knew a lot about stroke, the nature of stroke and the problems involved often caused confusion or misunderstanding. Further public education is needed to increase the awareness of the warning signals and risk factors, especially among patients who are at an increased risk of stroke.Cilj ispitivanja bio je procijeniti poznavanje činjenica o moždanom udaru, znakovima upozorenja i hitnim mjerama koje treba poduzeti u slučaju moždanog udara, među bolesnicima ne-neuroloških odjela. Prikupljeni su podaci za 75 bolnički liječenih osoba zbog različitih bolesti, srednje dobi 49,57±14,87 godina. Ispitanici su bili zamoljeni da ispune standardizirani upitnik koji je sadržavao 46 pitanja podijeljenih u dvije skupine. Odgovori su se odnosili na simptome upozorenja, rizične čimbenike, uzroke moždanog udara i prve mjere koje valja poduzeti u slučaju moždanog udara, a bili su polukvantificirani prema proizvoljnom bodovnom sustavu. Od 75 bolesnika, samo ih 5,3% nije bilo upoznato ni s kojim medicinskim rizičnim čimbenikom, dok ih 12% nije poznavalo bilo koji znak upozorenja. S druge strane, samo je 2,6% odnosno 10,66% ispitanika ispravno navelo sve rizične čimbenike i znakove upozorenja, dok su mnogi ispitanici naveli krive odgovore. Većina ispitanika(89,54%) odabrala bi prave mjere u slučaju sumnje na moždani udar. Osobe višeg obrazovanja i žene polučile su bolji bodovni rezultat glede znanja o moždanom udaru. Čimbenici kao što su pripadanje visoko rizičnoj skupini za moždani udar, starosna dob i druga obilježja nisu imala utjecaj na bodovni rezultat. Obitelj, prijatelji i sredstva javnog priopćavanja bili su glavni izvori znanja za ispitanike. Zaključujemo kako, usprkos činjenici da su ispitanici znali dosta o moždanom udaru, narav moždanog udara i s njim povezani problemi često izazivaju zbunjenost ili krivo tumačenje. Potrebna je daljnja izobrazba javnosti kako bi se poboljšalo raspoznavanje znakova upozorenja i rizičnih čimbenika, poglavito među bolesnicima s povećanim rizikom za moždani udar

Dysregulated Choline, Methionine, and Aromatic Amino Acid Metabolism in Patients with Wilson Disease: Exploratory Metabolomic Profiling and Implications for Hepatic and Neurologic Phenotypes.

Wilson disease (WD) is a genetic copper overload condition characterized by hepatic and neuropsychiatric symptoms with a not well-understood pathogenesis. Dysregulated methionine cycle is reported in animal models of WD, though not verified in humans. Choline is essential for lipid and methionine metabolism. Defects in neurotransmitters as acetylcholine, and biogenic amines are reported in WD; however, less is known about their circulating precursors. We aimed to study choline, methionine, aromatic amino acids, and phospholipids in serum of WD subjects. Hydrophilic interaction chromatography-quadrupole time-of-flight mass spectrometry was employed to profile serum of WD subjects categorized as hepatic, neurologic, and pre-clinical. Hepatic transcript levels of genes related to choline and methionine metabolism were verified in the Jackson Laboratory toxic milk mouse model of WD (tx-j). Compared to healthy subjects, choline, methionine, ornithine, proline, phenylalanine, tyrosine, and histidine were significantly elevated in WD, with marked alterations in phosphatidylcholines and reductions in sphingosine-1-phosphate, sphingomyelins, and acylcarnitines. In tx-j mice, choline, methionine, and phosphatidylcholine were similarly dysregulated. Elevated choline is a hallmark dysregulation in WD interconnected with alterations in methionine and phospholipid metabolism, which are relevant to hepatic steatosis. The elevated phenylalanine, tyrosine, and histidine carry implications for neurologic manifestations and are worth further investigation

Noninfectious complications of acute stroke and their impact on hospital mortality in patients admitted to a stroke unit in Warsaw from 1995 to 2015

Background Medical complications often worsen the prognosis after stroke. Our aim was to investigate the association between particular noninfectious complications and hospital mortality of acute stroke patients admitted to an urban Polish stroke center, and changes in their occurrence from 1995 to 2015. Methods This is a retrospective analysis of 5174 consecutive patients admitted for acute ischemic stroke or cerebral hemorrhage to a Polish urban stroke center between 1995 and 2015. The occurrence of complications was reported for years 1995–2000 (n=883), 2001–2006 (n=1567), 2006–2010 (n=1539) and 2011–2015 (n=1183). Odds ratios (OR) with 95% confidence interval (95% CI) for stroke unit death were calculated after adjustment for age, congestive heart failure (CHF), pre-existing disability, stroke type and baseline neurological deficit in three different time periods. Results Over time there was a significant decrease in the occurrence of myocardial infarction (MI) (2.2%, 1.4%, 1.0% and 0.3%, respectively), exacerbated CHF (4.6%, 5.1%, 2.6% and 2.0%) and deep vein thrombosis (DVT) (4.6%, 2.7%, 1.2% and 1.1%). Adjusted odds for stroke unit death were increased by myocardial infarction (MI) (OR 17.5, 95% CI: 8.5–35.7), exacerbated CHF (OR 15.0, 95% CI: 9.8–23.0), pulmonary embolism (PE) (OR 11.5, 95% CI: 6.1–21.6), gastrointestinal bleeding (OR 9.2, 95% CI: 4.4–18.9) and recurrent stroke (OR 5.4, 95% CI: 3.1–9.3). Conclusions Over the last two decades Polish urban stroke units may have achieved a significant reduction of the occurrence of some noninfectious complications (i.e. MI, exacerbated CHF and DVT). However, the list of conditions associated with stroke unit mortality includes not only MI and exacerbated CHF but also PE, gastrointestinal bleeding and recurrent stroke

A Prospective Community-Based Study of Stroke in Warsaw, Poland

Background and Purpose Poland is a Country with High Morbidity and Mortality Rates from Cardiovascular Diseases. No Recent Studies Have Evaluated the Contribution of Cerebrovascular Diseases to This Morbidity and Mortality. Our Aim Was to Accurately Determine Stroke Incidence Rates in Warsaw, Poland. Methods a 2-Year Prospective and Population-Based Stroke Registry Was Maintained for Health Care Units 2 and 3 in Warsaw, Poland (Population, 182 285). Case Subjects Were Ascertained by Surveying Hospital Admissions, Outpatient Visits, and Death Certificates. Results during the 2 Years of the Study (1991 to 1992), 633 Cases of First-Event Strokes Were Registered, 462 of Which Were First Ever in a Lifetime. Computed Tomography or Necropsy Was Performed in 72% of First-Ever Stroke Cases. the Crude Annual Incidence Rate for First-Ever Stroke Was 127/100 000 (95% Confidence Intervals, 111 to 145); the Rate Standardized to the European Population Was 111 (95% Confidence Intervals, 96 to 128). Our Incidence Rates for First-Event Strokes Were Found to Be in the Middle of the Range among Other First-Event Studies. When Comparing Our First-Ever Stroke Incidence Rates with Those of Comparable Studies Performed throughout Europe, They Were Found to Be Similar for Groups Aged Younger Than 65 Years But Lower in the Older Age Groups. the Distribution of Ischemic and Hemorrhagic Stroke Subtypes Was Similar to that of Other Countries. Conclusions This First Population-Based Prospective Stroke Registry in Poland Showed that Incidence Rates Were Not High Compared with Other Studies throughout Europe and the World. These Stroke Incidence Rates Are Not a Large Contributing Factor to High Cardiovascular Morbidity Rates in Poland. © 1994 American Heart Association, Inc. All Rights Reserved

Early stroke-related deep venous thrombosis: risk factors and influence on outcome

Deep venous thrombosis (DVT) is a serious complication of various medical conditions including acute stroke. Our aim was to identify the occurrence of early stroke-related DVT, risk factors for its development and the influence on outcome. The study involved consecutive patients admitted to our center due to acute ischaemic (n = 278) or haemorrhagic (n = 12) stroke during a 16-month period. We collected data on their pre-stroke health status, neurological deficit on admission and baseline serum CRP and fibrinogen level. Ultrasonographic imaging was performed at the 3rd (IQR: 2–4) and 9th (IQR: 8–9) day after stroke. Patients thrombosis occurring between the first and second examination comprised the newly developed early stroke-related DVT group. We found DVT in 8.0% (24/299) of patients at initial evaluation. Newly developed DVT was present in 3.0% (9/299) of patients, and was predominantly distal (7 of 9 cases). It was associated with elevated serum CRP level (OR 8.75; 95%CI: 1.61–47.6), which was verified in a model adjusted for stroke severity and pre-stroke dependency (3–5 pts. in mRS). In a multivariate model, newly developed DVT significantly increased the risk of 3-month mortality (OR 12.4; 95%CI: 1.72–89.4), without affecting the combined risk of dependency and death (OR 2.57; 95%CI: 0.39–17.0). Early stroke-related DVT is an infrequent complication. However, it may be an independent risk factor for 3-month mortality. Increased serum CRP level combined with normal fibrinogen level seems predictive for development of DVT. It may be reasonable to provide those patients with additional DVT prophylaxis

Route of feeding as a proxy for dysphagia after stroke and the effect of transdermal glyceryl trinitrate: data from the efficacy of nitric oxide in stroke randomised controlled trial

Post-stroke dysphagia is common, associated with poor outcome and often requires non-oral feeding/fluids. The relationship between route of feeding and outcome, as well as treatment with glyceryl trinitrate (GTN), was studied prospectively. The Efficacy of Nitric Oxide in Stroke (ENOS) trial assessed transdermal GTN (5 mg versus none for 7 days) in 4011 patients with acute stroke and high blood pressure. Feeding route (oral = normal or soft diet; nonoral = nasogastric tube, percutaneous endoscopic gastrostomy tube, parenteral fluids, no fluids) was assessed at baseline and day 7. The primary outcome was the modified Rankin Scale (mRS) measured at day 90. At baseline, 1331 (33.2%) patients had non-oral feeding, were older, had more severe stroke and more were female, than 2680 (66.8%) patients with oral feeding. By day 7, 756 patients had improved from non-oral to oral feeding, and 119 had deteriorated. Non-oral feeding at baseline was associated with more impairment at day 7 (Scandinavian Stroke Scale 29.0 versus 43.7; 2p < 0.001), and worse mRS (4.0 versus 2.7; 2p < 0.001) and death (23.6 versus 6.8%; 2p = 0.014) at day 90. Although GTN did not modify route of feeding overall, randomisation ≤6 hours of stroke was associated with a move to more oral feeding at day 7 (odds ratio = 0.61, 95% confidence intervals 0.38, 0.98; 2p = 0.040). As a proxy for dysphagia, non-oral feeding is present in 33% of patients with acute stroke and associated with more impairment, dependency and death. GTN moved feeding route towards oral intake if given very early after stroke

Continuing versus stopping prestroke antihypertensive therapy in acute intracerebral hemorrhage: a subgroup analysis of the efficacy of nitric oxide in stroke trial

Background and purpose: More than 50% of patients with acute intracerebral haemorrhage (ICH) are taking antihypertensive drugs before ictus. Although antihypertensive therapy should be given long term for secondary prevention, whether to continue or stop such treatment during the acute phase of ICH remains unclear, a question that was addressed in the Efficacy of Nitric Oxide in Stroke (ENOS) trial. Methods: ENOS was an international multicenter, prospective, randomized, blinded endpoint trial. Among 629 patients with ICH and systolic blood pressure between 140 and 220 mmHg, 246 patients who were taking antihypertensive drugs were assigned to continue (n = 119) or to stop (n = 127) taking drugs temporarily for 7 days. The primary outcome was the modified Rankin Score at 90 days. Secondary outcomes included death, length of stay in hospital, discharge destination, activities of daily living, mood, cognition, and quality of life. Results: Blood pressure level (baseline 171/92 mmHg) fell in both groups but was significantly lower at 7 days in those patients assigned to continue antihypertensive drugs (difference 9.4/3.5 mmHg, P < .01). At 90 days, the primary outcome did not differ between the groups; the adjusted common odds ratio (OR) for worse outcome with continue versus stop drugs was .92 (95% confidence interval, .45- 1.89; P = .83). There was no difference between the treatment groups for any secondary outcome measure, or rates of death or serious adverse events. Conclusions: Among patients with acute ICH, immediate continuation of antihypertensive drugs during the first week did not reduce death or major disability in comparison to stopping treatment temporarily