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Journal de Medecine Vasculaire Apr 2020About 20 to 30% of ischemic strokes are related to non-valvular atrial fibrillation. This type of situation is particularly at risk for both recurrence of the ischemic... (Review)
Review
About 20 to 30% of ischemic strokes are related to non-valvular atrial fibrillation. This type of situation is particularly at risk for both recurrence of the ischemic event and the hemorrhagic transformation of this stroke. The timing of the introduction or going back to the anticoagulant therapy in these patients remains a difficult issue, with a complex benefit-risk balance that needs to be assessed. Randomized controlled studies are lacking and current recommendations do not allow for clear decision making. The administration of a curative anticoagulant within 72 hours after the event is not recommended in the absence of demonstrated efficacy in preventing recurrence at this stage and because of the risk of intracerebral hemorrhage. This attitude can nevertheless be qualified by a transient accident or ischemic accident of very small size, and in the absence of any other risk factor for intra- or extra-cerebral hemorrhage. From the 4th day, after an appropriate case by case evaluation, the introduction of anticoagulant would be possible within a time which will remain at the appreciation of the medical teams. If the patient's risk of an intracerebral hemorrhage or general bleeding is transiently increased, it will be preferable to wait at least 2 weeks after the stroke. If this risk persists in the long term, the decision of the administration or not of an anticoagulant will have to be made with a multidisciplinary consultation. Vitamin K antagonists or direct oral anticoagulants may be prescribed as first-line therapy for the prevention of recurrence of ischemic stroke in a non-valvular atrial fibrillation patient. The choice will be based on the clinical and biological data of each patient. Direct oral anticoagulants have not shown superiority in the prevention of ischemic recurrence but open up new prospects for earlier treatment if their lesser risk of bleeding is confirmed after further studies.
Topics: Aged; Anticoagulants; Atrial Fibrillation; Brain Ischemia; Clinical Decision-Making; Comorbidity; Drug Administration Schedule; Female; Hemorrhage; Humans; Male; Middle Aged; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome
PubMed: 32265018
DOI: 10.1016/j.jdmv.2020.01.153 -
JAMA Network Open Sep 2022Because stroke causes diverse functional deficits, understanding the long-term recovery pattern of each functional domain may inform prognosis and therapeutic strategies.
IMPORTANCE
Because stroke causes diverse functional deficits, understanding the long-term recovery pattern of each functional domain may inform prognosis and therapeutic strategies.
OBJECTIVE
To observe long-term changes in functional status and residual disability in survivors of first-time stroke.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. Between August 2012 and May 2015, 7858 of 10 636 screened patients with first-time strokes from 9 district hospitals in Korea provided informed consent to participate. Data were analyzed from September 2021 through February 2022.
EXPOSURE
First-time stroke.
MAIN OUTCOMES AND MEASURES
Study data include multifaceted face-to-face functional assessments obtained at 8 to 9 points until 60 months after stroke onset. The Korean Mini-Mental State Examination (K-MMSE), Fugl-Meyer Assessment, Functional Ambulatory Category, American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale, and Short Korean version of the Frenchay Aphasia Screening Test were performed from 7 days to 60 months after stroke. The Korean Modified Barthel Index was measured from 3 months to 60 months after stroke.
RESULTS
A total of 4443 patients (2649 men [59.62%]; mean [SD] age 62.13 [12.43] years) who underwent repeated functional assessments for 60 months after stroke (3508 patients with ischemic and 935 patients with hemorrhagic stroke) were included. Overall, functions plateaued between 12 and 18 months after stroke and declined after 30 months; for example, mean (SD) K-MMSE improved from 7 days (22.89 [7.89]) to 12 months (26.03 [5.48]) (P < .001), plateaued until 36 months (26.03 [5.84]), and decreased to 48 months (26.02 [5.82]) (P < .001). Interaction associations were found between time after stroke and age, stroke severity, and stroke type in functional assessment outcomes. For example, mean (SE) FMA for ages 65 years or younger vs older than 65 years was 81.64 (0.63) vs 80.69 (0.68) at 7 days and 91.28 (0.47) vs 88.46 (0.58) at 6 months (P for interaction < .001), and for IS vs HS, it was 84.46 (0.47) vs 69.02 (1.24) at 7 days and 91.20 (0.38) vs 85.51 (0.98) at 6 months (P for interaction < .001). Mean (SE) FMA was 94.39 (0.21) at 7 days and 97.57 (0.14) at 6 months for mild stroke, 44.69 (1.18) at 7 days and 70.43 (1.21) at 6 months for moderate stroke, and 13.22 (0.99) at 7 days and 48.07 (2.62) at 6 months for severe stroke (P for interaction < .001). Factors associated with activities of daily living independence at 60 months included older age (β per 1-year increase = -0.35; standard error [SE], 0.03; P < .001), male sex (β = 2.12; SE, 0.73; P = .004), and hemorrhagic stroke type (β vs ischemic stroke = 2.35; SE, 0.81; P = .004).
CONCLUSIONS AND RELEVANCE
This study found that long-term recovery patterns in multifaceted functional domains differed from one another and varied by patient age, stroke severity, and stroke type. Understanding the diversity of long-term functional recovery patterns and factors associated with these outcomes in survivors of stroke may help clinicians develop strategies for effective stroke care and rehabilitation.
Topics: Activities of Daily Living; Aged; Cohort Studies; Hemorrhagic Stroke; Humans; Male; Middle Aged; Stroke; Stroke Rehabilitation; Survivors; United States
PubMed: 36149652
DOI: 10.1001/jamanetworkopen.2022.33094 -
Journal of Stroke and Cerebrovascular... 2014Estimates for the average cost of stroke have varied 20-fold in the United States. To provide a robust cost estimate, we conducted a comprehensive analysis of the... (Comparative Study)
Comparative Study
BACKGROUND
Estimates for the average cost of stroke have varied 20-fold in the United States. To provide a robust cost estimate, we conducted a comprehensive analysis of the hospitalization costs for stroke patients by diagnosis status and event type.
METHODS
Using the 2006-2008 MarketScan inpatient database, we identified 97,374 hospitalizations with a primary or secondary diagnosis of stroke. We analyzed the costs after stratifying the hospitalizations by stroke type (hemorrhagic, ischemic, and other strokes) and diagnosis status (primary and secondary). We employed regressions to estimate the impact of event type and diagnosis status on costs while controlling for major potential confounders.
RESULTS
Among the 97,374 hospitalizations (average cost: $20,396 ± $23,256), the number with ischemic, hemorrhagic, or other strokes was 62,637, 16,331, and 48,208, respectively, with these types having average costs, in turn, of $18,963 ± $21,454, $32,035 ± $32,046, and $19,248 ± $21,703. A majority (62%) of the hospitalizations had stroke listed as a secondary diagnosis only. Regression analysis found that, overall, hemorrhagic stroke cost $14,499 more than ischemic stroke (P < .001). For hospitalizations with a primary diagnosis of ischemic stroke, those with a secondary diagnosis of ischemic heart disease (IHD) had costs that were $9836 higher (P < .001) than those without IHD.
CONCLUSIONS
The costs of hospitalizations involving stroke are high and vary greatly by type of stroke, diagnosis status, and comorbidities. These findings should be incorporated into cost-effective strategies to reduce the impact of stroke.
Topics: Adolescent; Adult; Age Factors; Comorbidity; Hospital Costs; Hospitalization; Humans; Middle Aged; Models, Economic; Outcome and Process Assessment, Health Care; Risk Factors; Stroke; Time Factors; Treatment Outcome; United States; Young Adult
PubMed: 23954598
DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.017 -
Stroke May 2013Fiber intake is associated with reduced stroke risk in prospective studies, but no meta-analysis has been published to date. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND PURPOSE
Fiber intake is associated with reduced stroke risk in prospective studies, but no meta-analysis has been published to date.
METHODS
Multiple electronic databases were searched for healthy participant studies reporting fiber intake and incidence of first hemorrhagic or ischemic stroke, published between January 1990 and May 2012.
RESULTS
Eight cohort studies from the United States, northern Europe, Australia, and Japan met inclusion criteria. Total dietary fiber intake was inversely associated with risk of hemorrhagic plus ischemic stroke, with some evidence of heterogeneity between studies (I(2); relative risk per 7 g/day, 0.93; 95% confidence interval, 0.88-0.98; I(2)=59%). Soluble fiber intake, per 4 g/day, was not associated with stroke risk reduction with evidence of low heterogeneity between studies, relative risk 0.94 (95% confidence interval, 0.88-1.01; I(2)=21%). There were few studies reporting stroke risk in relation to insoluble fiber or fiber from cereals, fruit, or vegetables.
CONCLUSIONS
Greater dietary fiber intake is significantly associated with lower risk of first stroke. Overall, findings support dietary recommendations to increase intake of total dietary fiber. However, a paucity of data on fiber from different foods precludes conclusions regarding the association between fiber type and stroke. There is a need for future studies to focus on fiber type and to examine risk for ischemic and hemorrhagic strokes separately.
Topics: Dietary Fiber; Fruit; Humans; Incidence; Risk; Stroke; Vegetables
PubMed: 23539529
DOI: 10.1161/STROKEAHA.111.000151 -
Neurology Sep 2002Resistance to insulin-mediated glucose uptake by peripheral tissues is a cardinal defect in type 2 diabetes mellitus. Insulin resistance is also common among nondiabetic... (Review)
Review
BACKGROUND AND PURPOSE
Resistance to insulin-mediated glucose uptake by peripheral tissues is a cardinal defect in type 2 diabetes mellitus. Insulin resistance is also common among nondiabetic individuals, and may be an important risk factor for stroke in both populations. The authors review the definition, epidemiology, and treatment of insulin resistance.
METHODS
The authors searched Medline (1977-2001) and reviewed bibliographies to identify pertinent English-language publications.
RESULTS
Insulin resistance is present in most patients with type 2 diabetes. It is also common among elderly persons, certain ethnic groups, and persons with hypertension, obesity, physical deconditioning, and vascular disease. The principal pathophysiologic defect is impaired intracellular signaling in muscle tissue leading to defective glycogen synthesis. Insulin resistance is associated with numerous metabolic, hematologic, and cellular events that promote atherosclerosis and coagulation. The association between insulin resistance and risk for stroke has been examined in four case-control studies and five prospective observational cohort studies. Six of the nine studies are methodologically sound and provide evidence that insulin resistance is associated with risk for stroke.
CONCLUSION
Insulin resistance may be a prevalent risk factor for stroke. New drugs can safely reduce insulin resistance and may have a role in stroke prevention.
Topics: Animals; Humans; Insulin Resistance; Risk Factors; Stroke
PubMed: 12349850
DOI: 10.1212/wnl.59.6.809 -
BMC Medicine Nov 2016Whether light-to-moderate alcohol consumption is protective against stroke, and whether any association differs by stroke type, is controversial. We conducted a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Whether light-to-moderate alcohol consumption is protective against stroke, and whether any association differs by stroke type, is controversial. We conducted a meta-analysis to summarize the evidence from prospective studies on alcohol drinking and stroke types.
METHODS
Studies were identified by searching PubMed to September 1, 2016, and reference lists of retrieved articles. Additional data from 73,587 Swedish adults in two prospective studies were included. Study-specific results were combined in a random-effects model.
RESULTS
The meta-analysis included 27 prospective studies with data on ischemic stroke (25 studies), intracerebral hemorrhage (11 studies), and/or subarachnoid hemorrhage (11 studies). Light and moderate alcohol consumption was associated with a lower risk of ischemic stroke, whereas high and heavy drinking was associated with an increased risk; the overall RRs were 0.90 (95 % CI, 0.85-0.95) for less than 1 drink/day, 0.92 (95 % CI, 0.87-0.97) for 1-2 drinks/day, 1.08 (95 % CI, 1.01-1.15) for more than 2-4 drinks/day, and 1.14 (95 % CI, 1.02-1.28) for more than 4 drinks/day. Light and moderate alcohol drinking was not associated with any hemorrhagic stroke subtype. High alcohol consumption (>2-4 drinks/day) was associated with a non-significant increased risk of both hemorrhagic stroke subtypes, and the relative risk for heavy drinking (>4 drinks/day) were 1.67 (95 % CI, 1.25-2.23) for intracerebral hemorrhage and 1.82 (95 % CI, 1.18-2.82) for subarachnoid hemorrhage.
CONCLUSION
Light and moderate alcohol consumption was inversely associated only with ischemic stroke, whereas heavy drinking was associated with increased risk of all stroke types with a stronger association for hemorrhagic strokes.
Topics: Adult; Alcohol Drinking; Female; Humans; Intracranial Hemorrhages; Male; Prospective Studies; Risk Factors; Stroke; Sweden
PubMed: 27881167
DOI: 10.1186/s12916-016-0721-4 -
International Journal of Stroke :... Aug 2011Case fatality of first ischaemic stroke has improved markedly during the past two decades. Aims To investigate whether stroke patients with type 2 diabetes have shared...
BACKGROUND
Case fatality of first ischaemic stroke has improved markedly during the past two decades. Aims To investigate whether stroke patients with type 2 diabetes have shared this favourable development.
METHODS
Nation-wide registers were used to identify all patients with type 2 diabetes in Finland during 1988-2002. All first ischaemic strokes among them and also among all nondiabetic persons were identified from the National Hospital Discharge Register and the Causes of Death Register. Trends over time were calculated, for age-standardised case fatality of first stroke events, separately for two time periods: 0-27 and 28-364 days after the onset of stroke. These trends were compared between patients with type 2 diabetes and nondiabetic patients.
RESULTS
Altogether, 23,097 first-ever ischaemic strokes were recorded among 222,940 persons with type 2 diabetes. The 28 day case fatality was 1.1-1.3 times higher, and the one-year case fatality of 28 day survivors was 1.4-2.2 times higher in patients with type 2 diabetes compared with nondiabetic patients. A significant decline in case fatality trends was observed, but the trends did not differ between type 2 diabetes and nondiabetic patients.
CONCLUSIONS
The study revealed a positive development in survival after the first stroke event in persons with type 2 diabetes, similar to the development in nondiabetic persons. However, the level of case fatality has remained higher in patients with type 2 diabetes.
Topics: Adult; Aged; Aged, 80 and over; Diabetes Mellitus, Type 2; Female; Finland; Humans; Male; Middle Aged; Prognosis; Registries; Stroke
PubMed: 21609411
DOI: 10.1111/j.1747-4949.2010.00567.x -
Neurology Jan 2024Studies suggest that clonal hematopoiesis of indeterminate potential (CHIP) may increase risk of hematologic malignancy and cardiovascular disease, including stroke....
BACKGROUND AND OBJECTIVES
Studies suggest that clonal hematopoiesis of indeterminate potential (CHIP) may increase risk of hematologic malignancy and cardiovascular disease, including stroke. However, few studies have investigated plausible environmental risk factors for CHIP such as radon, despite the climate-related increases in and documented infrequency of testing for this common indoor air pollutant.The purpose of this study was to estimate the risk of CHIP related to radon, an established environmental mutagen.
METHODS
We linked geocoded addresses of 10,799 Women's Health Initiative Trans-Omics for Precision Medicine (WHI TOPMed) participants to US Environmental Protection Agency-predicted, county-level, indoor average screening radon concentrations, categorized as follows: Zone 1 (>4 pCi/L), Zone 2 (2-4 pCi/L), and Zone 3 (<2 pCi/L). We defined CHIP as the presence of one or more leukemogenic driver mutations with variant allele frequency >0.02. We identified prevalent and incident ischemic and hemorrhagic strokes; subtyped ischemic stroke using Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria; and then estimated radon-related risk of CHIP as an odds ratio (OR) and 95% CI using multivariable-adjusted, design-weighted logistic regression stratified by age, race/ethnicity, smoking status, and stroke type/subtype.
RESULTS
The percentages of participants with CHIP in Zones 1, 2, and 3 were 9.0%, 8.4%, and 7.7%, respectively ( = 0.06). Among participants with ischemic stroke, Zones 2 and 1 were associated with higher estimated risks of CHIP relative to Zone 3: 1.39 (1.15-1.68) and 1.46 (1.15-1.87), but not among participants with hemorrhagic stroke: 0.98 (0.68-1.40) and 1.03 (0.70-1.52), or without stroke: 1.04 (0.74-1.46) and 0.95 (0.63-1.42), respectively ( = 0.03). Corresponding estimates were particularly high among TOAST-subtyped cardioembolism: 1.78 (1.30-2.47) and 1.88 (1.31-2.72), or other ischemic etiologies: 1.37 (1.06-1.78) and 1.50 (1.11-2.04), but not small vessel occlusion: 1.05 (0.74-1.49) and 1.00 (0.68-1.47), respectively ( = 0.10). Observed patterns of association among strata were insensitive to attrition weighting, ancestry adjustment, prevalent stroke exclusion, separate analysis of driver mutations, and substitution with 3 alternative estimates of radon exposure.
DISCUSSION
The robust elevation of radon-related risk of CHIP among postmenopausal women who develop incident cardioembolic stroke is consistent with a potential role of somatic genomic mutation in this societally burdensome form of cerebrovascular disease, although the mechanism has yet to be confirmed.
Topics: Humans; Female; Clonal Hematopoiesis; Risk Factors; Stroke; Radon; Women's Health; Ischemic Stroke
PubMed: 38170948
DOI: 10.1212/WNL.0000000000208055 -
Journal of Neurologic Physical Therapy... Mar 2009Damage to motor areas of the brain caused by stroke can produce devastating motor deficits, including aberrant control of force. Reorganization of brain function is a... (Review)
Review
BACKGROUND AND PURPOSE
Damage to motor areas of the brain caused by stroke can produce devastating motor deficits, including aberrant control of force. Reorganization of brain function is a fundamental mechanism involved in recovery of motor control after stroke, and recent advances in neuroimaging have enabled study of this reorganization. This review focuses on neuroimaging studies that have examined reorganization of brain function during force production and force modulation after stroke.
METHODS
The type and extent of reorganization after stroke were characterized by three factors: severity of injury, time after stroke, and impact of therapeutic interventions on brain activation during force production. Twenty-six studies meeting the inclusion criteria could be identified in MEDLINE (1980-2007).
RESULTS
Relevant characteristics of studies (lesion location, chronicity of stroke, and motor task) and mapping techniques varied. During force production, increased activation in secondary motor areas occurred in persons with more severe strokes. Reduced recruitment of secondary motor areas during force production was found as a function of increased time since stroke. During force modulation, increased activation in motor areas occurred with greater force generation. Persons with more severe stroke showed greater activation with increasing force compared with persons with less severe stroke. Alteration of brain activation during and after rehabilitative interventions was identified in some studies.
DISCUSSION AND CONCLUSION
This systematic review establishes that reorganization of brain function during force production and force modulation can occur after stroke. These findings imply that therapeutic strategies may target brain reorganization to improve force control and functional recovery after stroke.
Topics: Brain; Electroencephalography; Functional Laterality; Humans; Magnetic Resonance Imaging; Motor Activity; Psychomotor Performance; Recovery of Function; Severity of Illness Index; Stroke; Stroke Rehabilitation; Time Factors
PubMed: 19265770
DOI: 10.1097/NPT.0b013e31819824f0 -
Continuum (Minneapolis, Minn.) Apr 2014This review provides an overview of emergent evaluation of the stroke patient with an emphasis on practical issues regarding ischemic stroke treatment. (Review)
Review
PURPOSE OF REVIEW
This review provides an overview of emergent evaluation of the stroke patient with an emphasis on practical issues regarding ischemic stroke treatment.
RECENT FINDINGS
The IV recombinant tissue-type plasminogen activator (rtPA) treatment window has been expanded from 3 to 4.5 hours from symptom onset. The evidence for better outcomes with more rapid initiation of reperfusion therapies is very strong. Adjunctive endovascular therapy has not been shown to benefit all patients with moderate or severe strokes, and investigations are underway to identify subgroups that may benefit from this approach. Endovascular therapy should be considered for patients who are ineligible for IV rtPA and can begin treatment within 6 hours of stroke onset.
SUMMARY
Effective emergent evaluation of a stroke patient requires well-organized systems that maximize speed of assessment and administration of appropriate therapies, including IV rtPA and endovascular therapies.
Topics: Brain Ischemia; Endovascular Procedures; Fibrinolytic Agents; Humans; Stroke; Time Factors; Tissue Plasminogen Activator; Treatment Outcome
PubMed: 24699481
DOI: 10.1212/01.CON.0000446101.44302.47