[Acute management of ischemic stroke in 2017]

Medical versus neurosurgical treatment in ICH patients: a single center experience

BACKGROUND AND AIMS

The effect of surgical treatment for spontaneous intracerebral hemorrhage (ICH) remains uncertain. We conducted an observational retrospective cohort study on supra-centimeter spontaneous ICH treated with either neurosurgical or conservative management. The baseline demographics and risk factors were correlated with in-hospital mortality and 3 and 6-month survival rates stratified by management.

METHODS

We included all patients with evidence of spontaneous ICH > 1 cm detected by CT and admitted between august 2020 and march 2021 to the "SMM" Hospital in Perugia.

RESULTS

Onehundredandtwentytwo patients were included in the study, and 45% (n.55) were surgically treated. The mean age was 71.9 ± 15.3, and 61% (n.75) were males. Intra-hospital mortality ended up being 31% (n.38), 3 months-survival was 63% (n.77) and 6 months-survival was 60% (n.73). From the multivariate analysis of the surgical patients versus medical patient, we observed that the surgical patients were younger (67.5 ± 14.9 vs 75.5 ± 14.7 y; OR 0.87; Cl 95% 0.85-0.94; p 0.001), with greater ICH volume at the onset (61 ± 39.4 cc vs 51 ± 64 cc; OR 1.03; Cl 95% 1.005-1.07; p 0.05), more midline shift (7.61 ± 5.54 mm vs 4.09 ± 5.88 mm; OR 1.37; Cl 95% 1.045-1.79; p 0.023), and a higher ICH score (3 vs 2 mean ICH score; OR 21.12; Cl 95% 2.6-170.6; p 0.004). Intra-hospital mortality in the surgical group and in the conservative treatment group was respectively 33% vs 30%, 3 month-survival was 64% vs 63% and 6 month- survival were 60% in both groups.

CONCLUSIONS

Our patient cohort shows no overall benefit from surgery over conservative treatment, but surgical patients were younger and had larger ICH volume.

Ischemic stroke risk factors not included in the CHADS-VASC score in patients with non-valvular atrial fibrillation

BACKGROUND

In patients with atrial fibrillation, the CHA2DS2-VASC score guides stroke prevention using anticoagulants, but it is an imperfect score. Other potential risk factors such as renal failure, the type of atrial fibrillation, active smoking, cancer, sleep apnea or systemic inflammation have less well been investigated.

OBJECTIVE

To assess the impact of these factors on ischemic stroke risk in patients with non-valvular atrial fibrillation.

METHODS

On a population of 248 patients (124 patients with acute ischemic stroke and 124 controls), we performed a logistic regression to assess the impact of multiple non-classic risk factors for the prediction of acute ischemic stroke. Their impact on mortality was assessed by performing a survival analysis.

RESULTS

A high CHA2DS2-VASc score (OR 1.75; 95% CI 1.13-2.70; p = 0.032), treatment with anticoagulants (OR 0.19; 95% CI 0.07-0.51; p < 0.001) and permanent atrial fibrillation (OR 6.31; 95% CI 2.46-16.19; p < 0.001) were independently associated with acute ischemic stroke. Renal failure and chronic obstructive pulmonary disease predicted a higher mortality. After adjusting for age, sex, the CHA2DS2-VASc score and the use of anticoagulants, the only risk factor predictive for acute ischemic stroke was the permanent type of AF (OR: 8.0 [95% CI 2.5-25.5], p < 0.001).

CONCLUSIONS

The CHA2DS2-VASc score, the absence of anticoagulants and the permanent type of atrial fibrillation were the main predictive factors for the occurrence of acute ischemic stroke. Larger studies are necessary for conclusive results about other factors.

The Role of Potential Oxidative Biomarkers in the Prognosis of Acute Ischemic Stroke and the Exploration of Antioxidants as Possible Preventive and Treatment Options

Ischemic strokes occur when the blood supply to a part of the brain is interrupted or reduced due to arterial blockage, and it often leads to damage to brain cells or death. According to a myriad of experimental studies, oxidative stress is an important pathophysiological mechanism of ischemic stroke. In this narrative review, we aimed to identify how the alterations of oxidative stress biomarkers could suggest a severity-reflecting diagnosis of ischemic stroke and how these interactions may provide new molecular targets for neuroprotective therapies. We performed an eligibility criteria-based search on three main scientific databases. We found that patients with acute ischemic stroke are characterized by increased oxidative stress markers levels, such as the total antioxidant capacity, F2-isoprostanes, hydroxynonenal, total and perchloric acid oxygen radical absorbance capacity (ORACTOT and ORACPCA), malondialdehyde (MDA), myeloperoxidase, and urinary 8-oxo-7,8-dihydro-2′-deoxyguanosine. Thus, acute ischemic stroke is causing significant oxidative stress and associated molecular and cellular damage. The assessment of these molecular markers could be useful in diagnosing ischemic stroke, finding its causes, predicting its severity and outcomes, reducing its impact on the cellular structures of the brain, and guiding preventive treatment towards antioxidant-based therapy as novel therapeutic alternatives.

Ischemic stroke in Morocco: a systematic review

Background

The aim of this systematic review is to determine the epidemiological and etiological profiles, the influential factors of the prehospital delay, thrombolysis management, the acute and 3-month mortality rate and the genetic aspect of ischemic stroke in Morocco.

Methods

The present work is a systematic review that was conducted according to the recommendations of the “Preferred reporting items for systematic reviews and meta-analysis”. We used Pubmed, Sciencedirect, Scopus, Clinicalkey, and Google scholar databases for the raking of the gray literature during the time frame 2009 and 2018. The protocol of the review was registered in the PROSPERO register (CRD42018115206).

These studies were analyzed based on: Age, sex ratio, risk factors, etiological profile according to Trial of ORG classification 10,172 in Acute Stroke Treatment, prehospital delay average and its influential factors, thrombolyzed patients’ proportion, acute and 3-month mortality and the genetic factors of ischemic stroke in Morocco.

Results

Twenty-nine (n = 29) studies were selected. The average age ranged from 49 ± 15.2 to 67.3 ± 9.9 years old. Moreover, we reported male predominance within all ages in 13 studies. High blood pressure, diabetes, smoking and heart disease were the four identified main risk factors by the prementioned studies. Atherosclerosis and cardioembolic were the main described etiologies of cerebral ischemia, and the average prehospital time ranged from 26 to 61.9 h. The proportion of thrombolysed patients ranged from 1.8% to 2.9%, the mortality rate varied in the acute phase from 3 to 13%, and the 3-month mortality ranged from 4.3 to 32.5%. It is also important to highlight that most of these studies, which were conducted in hospital environment, have a reduced sample size and no confidence interval.

Conclusions

Ischemic stroke is affecting more likely the young population with male predominance. Moreover, the long prehospital delay and the low proportion of thrombolysed patients are alarming. This indicates the need to investigate in depth the key factors influencing the access to care for Moroccan patients in order to improve the management of this neurologic deficit in Morocco.