Prognostic value of blood pressure in acute stroke

The impact of blood pressure variation on mortality and symptomatic intracerebral hemorrhage in acute stroke patients after thrombolysis

Blood pressure variation (BPV) is a known risk factor for unfavorable stroke outcomes. However, little is known about the association between BPV and short-term outcomes in stroke patients after receiving thrombolytic therapy, namely, recombinant tissue plasminogen activator (rt-PA). We conducted a cross-sectional study in the specialized stroke unit of a tertiary-level hospital. Stroke patients who were eligible for rt-PA were enrolled. Blood pressure (BP) was measured every 4 h for 24 h. The SD, coefficient of variation (CV) and successive variation (SV) of both SBP and DBP were calculated. The final outcomes were symptomatic intracerebral hemorrhage (sICH) or in-hospital death from neurologic complications. A total of 278 patients (49.6% men) were enrolled, mean age was 65 years. The final outcomes were reported in 33 patients (11.9%). All systolic and diastolic BPV profiles were associated with the final outcome. Odds ratios (95% confident interval) were SD, 1.07 (1.02-1.13); CV, 1.10 (1.03-1.18) and SV, 1.05 (1.01-1.09) for SBP, and SD, 1.10 (1.02-1.19); CV, 1.08 (1.01-1.16) and SV, 1.09 (1.02-1.15) for DBP. After adjustment for conventional risk factors, SD, CV and SV of SBP, and SD and SV of DBP were still significantly associated with the final outcome. In conclusion, in-hospital systolic (SD, SV and CV) and diastolic (SV, SD) BPV profiles were associated with death and sICH in stroke patients after rt-PA therapy.

General Anesthesia-Related Drop in Diastolic Blood Pressure May Impact the Long-Term Outcome in Stroke Patients Undergoing Thrombectomy

Background: Several factors affect the efficacy of endovascular thrombectomy (EVT); however, the anesthesia-related factors have not been fully explored. We aimed to identify independent predictors of outcome by analyzing procedural factors based on a multicentric stroke registry. Methods: Data of consecutive patients with acute ischemic stroke (AIS) were extracted from the prospective STAY ALIVE stroke registry. Demographic, clinical, and periprocedural factors including hemodynamic values were analyzed in patients undergoing thrombectomy with either general anesthesia (GA) or conscious sedation (CS). Independent predictors of outcome both at 30 and 90 days based on the modified Rankin Scale (mRS: 0−2 as favorable outcome) were also explored. Results: A total of 199 patients (GA: 76 (38%) vs. CS: 117 (59%); in addition, six patients were converted from CS to GA) were included. The minimum value of systolic, diastolic, and mean arterial pressure was significantly lower in the GA compared to the CS group, and GA was associated with a longer onset to EVT time and a higher drop in all hemodynamic variables (all, p < 0.001). A higher drop in diastolic blood pressure (DBP) was even independently associated with a poor 90-day outcome (p = 0.024). Conclusion: A GA-related drop in DBP may independently predict a poor long-term outcome in stroke patients undergoing thrombectomy.

Factors Influencing Functional Outcome at Discharge: A Retrospective Study on a Large Sample of Patients Admitted to an Intensive Rehabilitation Unit

OBJECTIVE

Functional outcome represents the most central objective of rehabilitation programs. Understanding which factors could affect functional status at discharge is crucial for the planning of appropriate treatments in both neurologic and orthopedic patients. The aim of this study was to investigate which clinical and demographic variables, collected at the patient's admission, could influence the functional outcome, assessed by the modified Barthel Index (mBI), at discharge.

DESIGN

A retrospective study was conducted on a large cohort (n = 3548) of orthopedic and neurologic patients. Functional, demographic, and clinical records at patient admission and mBI score at discharge were collected. General linear model analysis was performed to assess the influence of these variables on functional outcome at discharge.

RESULTS

The results reported a significant effect of mBI score at admission (P < 0.0001), age (P < 0.0001), and time from the acute event (P < 0.0001) on mBI score at discharge. Moreover, the disease type (neurologic or orthopedic) adjusted by sex (male or female) and presence of different impairments (cognitive and behavioral impairments) and complications (hypertension and cardiovascular diseases) significantly influenced mBI score at discharge (P < 0.05) (R2 = 0.497). No significant interactions between other factors were found (P > 0.05).

CONCLUSION

Several prognostic factors should be considered when planning an appropriate tailored rehabilitation program.

Effects of vascular compression on the rostral ventrolateral medulla for blood pressure variability in stroke patients

BACKGROUNDS

Vascular compression of the rostral ventrolateral medulla (RVLM) has been associated with hypertension or blood pressure (BP) variability. For acute ischemic stroke patients, increased BP variability may cause poor functional outcomes. We tested the hypothesis that RVLM compression was associated with increased BP variability or stroke outcome in acute ischemic stroke patients.

METHODS

Acute ischemic stroke patients (n = 622) with 24-h ambulatory BP monitoring during the subacute phase of stroke (median 9 days from onset) were retrospectively studied. Variability in BP was evaluated with the SD and coefficient of variation of SBP and DBP. The morning surge was also evaluated. The presence of RVLM compression was evaluated using time-of-flight three-dimensional MRI. A poor outcome was defined as a modified Rankin Scale score of 3-6 at 3 months.

RESULTS

Patients with RVLM compression (n = 213) had significantly higher 24-h SBP mean, 24-h SBP SD, 24-h SBP coefficient of variation, 24-h DBP mean, 24-h DBP SD, and 24-h DBP coefficient of variation values and a higher prevalence of morning surge than those without (n = 409). Multiple regression analysis revealed that RVLM compression was associated with increased SBP variability, DBP variability, and morning surge. Despite the significant association between RVLM compression and BP variability, RVLM compression was not associated with poor stroke outcome.

CONCLUSION

Although RVLM compression was closely associated with BP variability in the subacute ischemic stroke phase, an effect of RVLM compression on stroke outcome was not observed.

Anesthetic Management of Emergency Endovascular Thrombectomy for Acute Ischemic Stroke, Part 1: Patient Characteristics, Determinants of Effectiveness, and Effect of Blood Pressure on Outcome

In the United States, stroke ranks fifth among all causes of death and is the leading cause of serious long-term disability. The 2018 American Heart Association stroke care guidelines consider endovascular thrombectomy to be the standard of care for patients who have acute ischemic stroke in the anterior circulation when arterial puncture can be made within 6 hours of symptom onset or within 6-24 hours of symptom onset when specific eligibility criteria are satisfied. The aim of this 2-part review is to provide practical perspective on the clinical literature regarding anesthesia care of patients treated with endovascular thrombectomy. Part 1 (this article) reviews the development of endovascular thrombectomy and the determinants of endovascular thrombectomy effectiveness irrespective of method of anesthesia. The first aim of part 1 is to explain why rapid workflow and maintenance of blood pressure are necessary to help support the ischemic brain until, as a result of endovascular thrombectomy, reperfusion is accomplished. The second aim of part 1, understanding the nonanesthesia factors determining endovascular thrombectomy effectiveness, is necessary to identify numerous biases present in observational reports regarding anesthesia for endovascular thrombectomy. With this background, in part 2 (the companion to this article), the observational literature is briefly summarized, largely to identify its weaknesses, but also to develop hypotheses derived from it that have been recently tested in 3 randomized clinical trials of sedation versus general anesthesia for endovascular thrombectomy. In part 2, these 3 trials are reviewed both from a functional outcomes perspective (meta-analysis) and a methodological perspective, providing specifics regarding anesthesia and hemodynamic management. Part 2 concludes with a pragmatic approach to anesthesia decision making (sedation versus general anesthesia) and acute phase anesthesia management of patients treated with endovascular thrombectomy.

Association between blood pressure and acute phase stroke case fatality rate: a prospective cohort study

OBJECTIVE

ed to investigate the association between blood pressure and acute phase stroke lethality in a Brazilian intensive care unit.

METHODS

This was an observational, prospective cohort study of hemorrhagic and ischemic stroke intensive care patients. The primary outcome was all-cause mortality during the first seven days.

RESULTS

There were 146 patients, aged 66 ± 13.4 years, 56% men, 89% Caucasian, 69% had ischemic stroke, and 80% were hypertensive. The median of the National Institutes of Health Stroke Scale score was 16. There were 101 ischemic stroke patients and 45 hemorrhagic stroke patients. In the ischemic stroke patients, logistic regression analysis identified low systolic blood pressure as an independent ominous prognostic factor and the optimal cut off was a mean of systolic blood pressure ≤ 131 mmHg during the first 48 hours from admission for prediction of death. No association was found for hemorrhagic stroke.

CONCLUSIONS

There was a negative association between systolic blood pressure and case fatality ratio of acute phase stroke in ischemic stroke intensive care patients.

No Association Observed Between Blood Pressure Variability During the Acute Phase of Ischemic Stroke and In-Hospital Outcomes

BACKGROUND

Recent data suggest that blood pressure (BP) variability confers increased cardiovascular risk independently of BP. We aimed to evaluate the association between BP variability during the acute phase of ischemic stroke and the in-hospital outcome.

METHODS

We prospectively studied 608 consecutive patients admitted with acute ischemic stroke (39.5% males, age: 79.1±6.6 years). Variability in BP was assessed with the SD and with the coefficient of variation of systolic (SBP) and diastolic BP (DBP) during the first 2 and the first 3 days of hospitalization. The outcome was assessed with dependency rates at discharge and with in-hospital mortality.

RESULTS

Patients who were dependent at discharge did not differ from patients who were independent in any index of BP variability. Independent predictors of dependency at discharge were age (relative risk (RR) 1.17, 95% confidence interval (CI) 1.09-1.25, P < 0.001), history of prior ischemic stroke (RR 2.08, 95% CI 1.02-4.24, P = 0.04), and National Institutes of Health Stroke Scale (NIHSS) at admission (RR 1.64, 95% CI 1.44-1.86, P < 0.001). Patients who died during hospitalization did not differ in any index of BP variability from patients who were discharged. DBP at admission was independently and directly associated with in-hospital mortality (RR 1.06, 95% CI 1.03-1.09, P < 0.001). Other independent predictors of in-hospital mortality were history of atrial fibrillation (RR 3.30, 95% CI 1.46-7.49, P = 0.004) and NIHSS at admission (RR 1.18, 95% CI 1.13-1.23, P < 0.001).

CONCLUSIONS

Our data do not support the hypothesis of an association between BP variability and in-hospital outcomes among patients admitted for ischemic stroke.

Lower Intraprocedural Systolic Blood Pressure Predicts Good Outcome in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke

BACKGROUND

It is unknown if intraprocedural blood pressure (BP) influences clinical outcomes and what BP parameter best predicts outcomes in acute ischemic stroke (AIS) patients who undergo intra-arterial therapy (IAT) for emergent large vessel occlusion.

METHODS

We retrospectively reviewed 147 patients who underwent IAT for anterior circulation AIS from January 2008 to December 2012 at our institution. Baseline demographics, stroke treatment variables, and detailed intraprocedural hemodynamic variables were collected.

RESULTS

The entire cohort consisted of 81 (55%) females with a mean age of 66.9 ± 15.6 years and a median National Institutes of Health Stroke Scale (NIHSS) score of 16 (IQR 11-21). Thirty-six (24.5%) patients died during hospitalization, 25 (17%) achieved a 30-day modified Rankin Scale score of 0-2, and 24 (16.3%) suffered symptomatic parenchymal hematoma type 1/2 hemorrhage. Patients who achieved a good outcome had a significantly lower admission NIHSS score, a higher baseline CT ASPECTS score, and a lower rate of ICA terminus occlusions. Successful recanalization was more frequent in the good-outcome group, while symptomatic hemorrhages occurred only in poor-outcome patients. The first systolic BP (SBP; 146.5 ± 0.2 vs. 157.7 ± 25.6 mm Hg, p = 0.042), first mean arterial pressure (MAP; 98.1 ± 20.8 vs. 109.7 ± 20.3 mm Hg, p = 0.024), maximum SBP (164.6 ± 27.6 vs. 180.9 ± 18.3 mm Hg, p = 0.0003), and maximum MAP (125.5 ± 18.6 vs. 138.5 ± 24.6 mm Hg, p = 0.0309) were all significantly lower in patients who achieved good outcomes. A lower maximum intraprocedural SBP was an independent predictor of good outcome (adjusted OR 0.929, 95% CI 0.886-0.963, p = 0.0005). Initial NIHSS score was the only other independent predictor of a good outcome.

CONCLUSION

Lower intraprocedural SBP was associated with good outcome in patients undergoing IAT for AIS, and maximum SBP was an independent predictor of good outcome. SBP may be the optimal hemodynamic variable to monitor intraprocedurally during IAT and may predict outcome.

Elevated diastolic but not systolic blood pressure increases mortality risk in hypertensive but not normotensive patients with acute ischemic stroke

BACKGROUND

The relationship between blood pressure (BP) at admission for acute ischemic stroke and outcome is controversial. We aimed to assess whether only systolic BP (SBP), only diastolic BP (DBP), both or neither predict outcome and whether these associations differ between patients with and without a history of hypertension.

METHODS

We prospectively studied all patients who were admitted with acute ischemic stroke (n = 415; 39.5% males, age 78.8 ± 6.6 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). The outcome was evaluated with dependency at discharge (modified Rankin scale between 2 and 5) and in-hospital mortality.

RESULTS

In the total study population, independent predictors of dependency at discharge were age, history of prior ischemic stroke, and NIHSS score at admission. Independent predictors of in-hospital mortality were DBP at admission and NIHSS score at admission. In patients with a history of hypertension (n = 343), independent predictors of dependency at discharge were age and NIHSS score at admission whereas independent predictors of in-hospital mortality were DBP at admission and NIHSS score at admission. In patients without a history of hypertension (n = 72), the only independent predictor of dependency at discharge and in-hospital mortality was the NIHSS score at admission.

CONCLUSIONS

Higher DBP at admission predict in-hospital mortality in patients with acute ischemic stroke whereas SBP in the acute phase is not associated with short-term outcome. The relationship between DBP at admission and outcome appears to be more prominent in hypertensive patients.

Blood Pressure as an Independent Prognostic Factor in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Blood pressure is elevated in most patients during acute ischemic stroke, but the prognostic significance of this is unclear as the current data yield conflicting results.

METHODS

Admission blood pressure from the 1281 patients in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) was analyzed for prognostic significance as well as the risk of hemorrhagic transformation. We also examined weighted-average blood pressure over seven days, and the impact of a 30% change in blood pressure in 24 hours. Patients with severe hypertension were excluded from the TOAST trial.

RESULTS

Increasing systolic blood pressure (SBP) on admission, but not diastolic (DBP) or mean arterial pressure (MAP) was predictive of poor outcome, but this effect was not significant after adjustment for other know prognostic factors. Increasing weighted-average SBP and MAP over seven days were predictive for poor outcome, but a 30% change in blood pressure over 24 hours was not.

CONCLUSIONS

Admission blood pressure is not an independent prognostic factor in acute ischemic stroke, but the weighted-average of SBP and MAP over seven days probably does have predictive value with higher values having a worse prognosis. A prospective trial of blood pressure control during acute stroke is needed.

Low blood pressure during the acute period of ischemic stroke is associated with decreased survival

OBJECTIVES

There is no agreement on optimal blood pressure (BP) level during the acute phase of stroke, because studies on the relation between BP and stroke outcome have shown contradicting results. The aim of this study was to compare the relationship of admission, maximal, discharge BP and its components during hospitalization for the first-ever acute ischemic stroke with total mortality after stroke.

METHODS

In 532 consecutive patients (mean age 66 ± 10 years, 59% of men) hospitalized for their first-ever ischemic stroke, the association between BP and total mortality during a median follow-up of 66 weeks (interquartile range 33-119 weeks) was analyzed.

RESULTS

In multivariate analysis, both admission mean BP (MBP) and discharge SBP quartiles were independent predictors of mortality and outperformed other parameters of BP. After multivariate adjustments, patients with admission MBP below 100 mmHg had a higher risk of death than those with MBP between 100-110 and 110-121 mmHg, whereas the risk of mortality did not differ from the group with admission MBP above 122 mmHg. Similarly, patients with discharge SBP below 120 mmHg had an increased risk of death as compared to groups with SBP between 120-130 and 130-141 mmHg, whereas the risk of death was similar to that with discharge SBP above 141 mmHg.

CONCLUSION

Among patients hospitalized for their first-ever ischemic stroke, the risk of all-cause death is significantly increased in those with admission MBP below 100 mmHg and discharge SBP below 120 mmHg, even after adjustments for other confounders.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates.

METHODS

Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm.

RESULTS

The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.

CONCLUSIONS

Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

The Effect of Transdermal Glyceryl Trinitrate on 24 h Ambulatory Blood Pressure in Acute/Subacute Stroke

Background

High blood pressure is a common complication in acute stroke and is associated with a poor outcome.

Aims

This study assesses the effects of transdermal glyceryl trinitrate on 24 h ambulatory blood pressure in patients with recent stroke.

Methods

One hundred and seven patients with acute ischaemic or haemorrhagic stroke were included. The patients had been enrolled in one of two trials of transdermal glyceryl trinitrate (5 mg daily) or placebo/control, and underwent 24 h ambulatory blood pressure monitoring (56 glyceryl trinitrate, 51 control). Ambulatory blood pressure data were analysed using area under the curve for the entire 24 h, and day and night periods. Nocturnal dipping was defined as a decline in systolic blood pressure >10%. Comparisons of blood pressure between groups were performed by analysis of covariance (ANCOVA) with adjustments for trial and baseline measure.

Results

In comparison with control, glyceryl trinitrate significantly lowered 24 h blood pressure (systolic blood pressure/ diastolic blood pressure 9·4/4·8 mmHg, P < 0·001/0·001, n = 104), daytime blood pressure (8·7/4·2, P < 0·001/ < 0·001, n = 103) and night-time blood pressure (6·9/1·7, P = 0·008/0·458, n = 86). Only 86 patients (glyceryl trinitrate 45, placebo/control 41) had sufficient night blood pressure measurements to assign dipping status; 28 were dippers (12 glyceryl trinitrate, 16 control) and 58 were nondippers (33 glyceryl trinitrate, 25 control); glyceryl trinitrate significantly lowered systolic but not diastolic blood pressure in both dippers and nondippers. Treatment with glyceryl trinitrate increased the daytime heart rate (4·8 beats/min) but not the night-time heart rate. Patients whose blood pressure did not dip at night had a worse functional outcome at three-months.

Conclusions

Transdermal glyceryl trinitrate (5 mg) significantly lowered 24 h blood pressure by 9/5 mmHg (equivalent to a 6% reduction) in both dipping and nondipping patients with acute/subacute stroke. This reduction in blood pressure is clinically relevant and is unlikely to be excessive.

Long-Term Outcome as Function of Blood Pressure in Acute Ischemic Stroke and Effects of Thrombolysis

BACKGROUND

While baseline blood pressure (BP) is a known predictor of 90-day residual deficit after acute ischemic stroke, the effect of thrombolysis on this relationship has not been described. To study the interaction and to find intervals of prognostic significance, the functional forms of this predictive relationship should be found and compared for recombinant tissue plasminogen activator (rt-PA)- and placebo-treated patients of the first European Cooperative Acute Stroke Study.

METHODS

We studied the 615 patients with acute ischemic hemispheric stroke randomized and treated in the first European Cooperative Acute Stroke Study. Endpoints were fatal outcome within and favorable outcome (no or negligible long-term handicap on the modified Rankin Scale scores 0 or 1) after 90 +/- 14 days. Functional relationships with baseline BP were estimated fully nonparametrically as moving averages of occurrences of either outcome among placebo- and rt-PA-treated patients, separately. Visual findings were corroborated by conventionally stratified logistic regression.

RESULTS

For favorable outcome, an S-shaped functional relationship with baseline systolic BP (SBP) was found with an averaged incremental rate around 10% per 1 mm Hg increase in baseline SBP between 140 and 160 mm Hg, among rt-PA and placebo patients. Similar results were obtained for diastolic BP (DBP) between 80 and 90 mm Hg. Odds ratios in favor of rt-PA were 1.96 (95% CI: 1.02-3.78) and 2.87 (95% CI: 1.36-6.04) for SBP and DBP in these intervals, respectively. For mortality, visible markedly lower risks in the placebo group between 120 and 140 and between 160 and 180 mm Hg SBP were confirmed with adjusted OR of 2.47 (95% CI: 1.09-5.64) and 9.73 (95% CI: 2.02-46.82), respectively.

CONCLUSIONS

Patients benefited from rt-PA in terms of no or negligible handicap after 90 days, without excess risk of death, with baseline SBP between 140 and 160 mm Hg or baseline DBP between 80 and 90 mm Hg.

Blood pressure management in acute stroke: a long-standing debate

Although elevated blood pressure (BP) levels are a common complication of acute stroke, whether of ischaemic or haemorrhagic type, a long-standing debate exists regarding the management of post-stroke hypertension. In the absence of solid, randomised data from controlled trials, the current observational evidence allows different approaches, since theoretical arguments exist for both lowering BP in the setting of acute stroke (reduce the risk of stroke recurrence, of subsequent oedema formation, of rebleeding and haematoma expansion in patients with cerebral bleeding) as well as leaving raised BP levels untreated (avoid reduction in cerebral perfusion pressure and blood flow to viable ischaemic tissue in the absence of normal autoregulation). The present review will summarize the evidence for and against the therapeutic manipulation of BP in acute stroke provided by the currently available observational studies and randomised trials, consider the ongoing clinical trials in this area and address the present recommendations regarding this conflicting issue.

The effect of admission physiological variables on 30 day outcome after stroke

INTRODUCTION

Potentially modifiable physiological variables may influence stroke prognosis but their independence from modifiable factors remains unclear.

METHODS

Admission physiological measures (blood pressure, heart rate, temperature and blood glucose) and other unmodifiable factors were recorded from patients presenting within 48 hours of stroke. These variables were compared with the outcomes of death and death or dependency at 30 days in multivariate statistical models.

RESULTS

In the 186 patients included in the study, age, atrial fibrillation and the National Institutes of Health Stroke Score were identified as unmodifiable factors independently associated with death and death or dependency. After adjusting for these factors, none of the physiological variables were independently associated with death, while only diastolic blood pressure (DBP) > or = 90 mmHg was associated with death or dependency at 30 days (p = 0.02).

CONCLUSIONS

Except for elevated DBP, we found no independent associations between admission physiology and outcome at 30 days in an unselected stroke cohort. Future studies should look for associations in subgroups, or by analysing serial changes in physiology during the early post-stroke period.

U-shaped relationship between mortality and admission blood pressure in patients with acute stroke

OBJECTIVE

To evaluate the relationship between systolic blood pressure (SBP) or diastolic blood pressure (DBP) on admission and early or late mortality in patients with acute stroke.

DESIGN

Prospective study of hospitalized first-ever stroke patients over 8 years.

SETTING

Stroke unit and medical wards in a University hospital.

SUBJECTS

A total of 1121 patients admitted within 24 h from stroke onset and followed up for 12 months.

MAIN OUTCOME MEASURES

Mortality at 1 and 12 months after stroke in relation to admission SBP and DBP.

RESULTS

Early and late mortality in patients with acute ischaemic or haemorrhagic stroke in relation to admission SBP and DBP followed a 'U-curve pattern'. After adjusting for known outcome predictors, the relative risk of 1-month and 1-year mortality associated with a 10-mmHg SBP increase above 130 mmHg (U-point of the curve) increased by 10.2% (95% CI: 4.2-16.6%) and 7.2% (95% CI: 2.2-12.3%), respectively. For every 10 mmHg SBP decrease, below the U-point, the relative risk of 1-month and 1-year mortality rose by 28.2% (95% CI: 8.6-51.3%) and 17.5% (95% CI: 3.1-34.0%), respectively. Low admission SBP-values were associated with heart failure (P < 0.001) and coronary artery disease (P = 0.006), whilst high values were associated with history of hypertension (P < 0.001) and lacunar stroke (P < 0.001). Death due to cerebral oedema was significantly (P = 0.005) more frequent in patients with high admission SBP-values, whereas death due to cardiovascular disease was more frequent (P = 0.004) in patients with low admission SBP-values.

CONCLUSION

Acute ischaemic or haemorrhagic stroke patients with high and low admission BP-values have a higher early and late mortality. Coincidence of heart disease is associated with low initial BP-values. Death due to neurological damage from brain oedema is associated with high initial BP-values.

Registration of stroke through the Belgian sentinel network and factors influencing stroke mortality

INTRODUCTION

Stroke is one of the leading causes of death. Belgian stroke mortality rates are only available from the death certificates notification.

OBJECTIVES

To estimate stroke incidence, mortality and case fatality, to compare our figures with those available from the death certificates notification and from neighboring countries, and identifying factors influencing survival.

METHODS

A nationwide prospective registration by 178 Belgian general practitioners recording all cerebrovascular events in 1998-1999. All events, including those for which medical care was immediately found in hospital, were included.

RESULTS

The yearly age-and-gender-adjusted stroke attack rates were estimated at 185 cases per 100,000 inhabitants (95% CI = 169-202). After 12 months, 47% of the patients died, resulting in an estimated yearly stroke mortality rate of 88 per 100,000 inhabitants (95% CI = 73-105). The case fatality rate among men (39%; 95% CI = 29-51) was lower than among women (50%; 95% CI = 39-63) (p < 0.05). In a forward stepwise logistic regression diabetes, stroke history, hemorrhagic stroke, coma, swallow deficit and urinary incontinence had a negative influence on stroke survival. Treated hypertension had a beneficial effect on survival.

CONCLUSIONS

Stroke mortality rates estimated by the sentinel practices are fairly comparable with those based on the death certificates notification. The stroke attack rates correspond with those of neighboring countries. The role of treated hypertension on the outcome of strokes remains controversial in this registration.

Is there a side predilection for cerebrovascular disease?

In studies on carotid artery intima-media thickness and stroke, researchers implicitly assume that cerebrovascular abnormalities show a symmetrical distribution. To evaluate whether there is a difference in intima-media thickness between the 2 carotids, we compared left and right common carotid artery intima-media thickness as measured by B-mode ultrasonography in a group of 102 untreated hypertensive patients. This yielded a significant difference between both sides (left, 0.75+/-0.11 mm; right, 0.71+/-0.11 mm; P<0.001). This was associated with a higher cross-sectional area of the intima-media complex and a higher flow velocity at the left side. Arterial diameters, however, were not different. We also assessed whether there is a side preference with respect to cerebrovascular accidents. To this end, we explored our population-based Stroke Registry of 1843 subjects and indeed found a significantly higher incidence of nonlacunar cerebrovascular stroke at the left side, whereas lacunar infarcts were symmetrically distributed. Our findings suggest a predilection for cerebrovascular disease at the left side, which may be related to greater hemodynamic stress and intimal damage in the left carotid artery.