Cerebrovascular Effects of Cilostazol in Patients With Atherosclerotic Disease

Comparison of Clinical Scores for Predicting Stroke-Associated Pneumonia After Acute Ischemic Stroke

Objectives

To compare the discrimination and calibration of six risk scoring systems in the assessment of patients with stroke-associated pneumonia (SAP) after acute ischemic stroke.

Methods

The validation cohort was derived from the Third China National Stroke Registry. SAP was diagnosed according to the criteria for hospital-acquired pneumonia of the Centers for Disease Control and Prevention. The area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow goodness-of-fit test were used to assess discrimination and calibration.

Results

A total of 12,071 patients were included in the study and 606 (5.02%) patients were diagnosed with in-hospital SAP after ischemic stroke. The AUROC of the six clinical scores ranged from 0.660 to 0.752. In the pairwise comparison, the AIS-APS score (0.752, 95% CI = 0.730-0.773, p < 0.001) showed significantly better discrimination than the other risk models, except the PASS score. The AIS-APS score had the largest Cox and Snell R 2 for in-hospital SAP after ischemic stroke. In the subgroup analysis, among patients over 61 years of age, all TOAST subtypes except small vessel disease, length of hospital stay longer than 8 days, male and female sex, different groups stratified by admission NIHSS score and time from onset to arrival, the AIS-APS score showed better discrimination than other risk models with regard to SAP after AIS.

Conclusions

Our study compared the discrimination and calibration of the Kwon Pneumonia Score, A2DS2 score, PANTHERIS score, AIS-APS score, ISAN score, and PASS score in SAP identification; of these, the AIS-APS score showed the best performance.

Update on Cilostazol: A Critical Review of Its Antithrombotic and Cardiovascular Actions and Its Clinical Applications

Cilostazol, a phosphodiesterase III inhibitor, has vasodilating and antiplatelet properties with a low rate of bleeding complications. It has been used over the past 25 years for improving intermittent claudication in patients with peripheral artery disease (PAD). Cilostazol also has demonstrated efficacy in patients undergoing percutaneous revascularization procedures for both PAD and coronary artery disease. In addition to its antithrombotic and vasodilating actions, cilostazol also inhibits vascular smooth muscle cell proliferation via phosphodiesterase III inhibition, thus mitigating restenosis. Accumulated evidence has shown that cilostazol, due to its "pleiotropic" effects, is a useful, albeit underutilized, agent for both coronary artery disease and PAD. It is also potentially useful after ischemic stroke and is an alternative in those who are allergic or intolerant to classical antithrombotic agents (eg, aspirin or clopidogrel). These issues are herein reviewed together with the pharmacology and pharmacodynamics of cilostazol. Large studies and meta-analyses are presented and evaluated. Current guidelines are also discussed, and the spectrum of cilostazol's actions and therapeutic applications are illustrated.

Repeated hypotensive episodes with fluctuating symptoms in a patient with acute pontomedullary infarction

Dysfunction of cardiovascular regulation, including arterial hypotension, is a rare complication of acute ischemic stroke. We report a patient with an acute pontomedullary infarction who frequently had severe hypotensive episodes. A 78-year-old diabetic man suddenly developed faintness and left hemiparesis. MRI revealed a fresh infarct at the right pontomedullary region, including (or adjacent to) the rostral ventrolateral medulla. During the initial few weeks, urination and head-up tilts frequently induced hypotensive episodes accompanied by systolic blood pressure drops of up to 60 mmHg that were accompanied by fluctuating symptoms. In conclusion, pontomedullary stroke should be considered as a possible cause of hypotension accompanied by fluctuation of neurological symptoms during acute stroke.