1
|
Kunoh K, Bizen H, Fujii K, Nakashima D, Kimura D. Using Machine Learning to Study Factors Affecting Discharge Destination in Recovery Units. Cureus 2024; 16:e70916. [PMID: 39502989 PMCID: PMC11537482 DOI: 10.7759/cureus.70916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2024] [Indexed: 11/08/2024] Open
Abstract
BACKGROUND In recent years, machine learning has been developed in the medical community to construct multidimensional datasets consisting of many variables and perform simultaneous factor analysis. OBJECTIVE This study aimed to construct a multidimensional dataset of 50 items by incorporating supervised machine learning in a random forest algorithm to predict whether patients will be discharged home or to a facility after a stroke. METHODS Thirty patients hospitalized with cerebrovascular diseases who were subsequently discharged were considered as the study subjects. The dataset used for analysis consisted of attributes such as characteristics (three items), physical and cognitive functions (seven items), functional independence measure (FIM) (18 items), blood data (16 items), and social characteristics (six items). The discharge destination variable was either a home or a facility. Machine learning was used to extract factors important for this classification. The accuracy of the random forest was calculated by five-fold cross-validation. The mean decrease Gini, a measure of importance in classification, was calculated for each fold. RESULTS The results indicated that FIM, a measure of activities of daily living (ADL), and cognitive function, including memory, which strongly influenced the prediction equation, were important factors in the proposed algorithm. The results of the analysis revealed that the algorithm predicted home discharge or institutionalization with 87.1% accuracy. CONCLUSION Through this study, ADL and cognitive function were identified as important factors in predicting home discharge for patients with cerebrovascular disease.
Collapse
Affiliation(s)
- Kenta Kunoh
- Department of Rehabilitation, Yamada Hospital, Gifu, JPN
| | - Hiroki Bizen
- Department of Occupational Therapy, Kansai University of Health Sciences, Osaka, JPN
| | - Keisuke Fujii
- Department of Rehabilitation Occupational Therapy, Suzuka University of Medical Science, Suzuka, JPN
| | - Daiki Nakashima
- Department of Rehabilitation, Naragakuen University, Nara, JPN
| | - Daisuke Kimura
- Department of Occupational Therapy, Nagoya Women's University, Aichi, JPN
| |
Collapse
|
2
|
Addisu ZD, Mega TA. Clinical Characteristics and Treatment Outcomes of Acute Ischemic Stroke with Atrial Fibrillation Among Patients Admitted to Tertiary Care Hospitals in Amhara Regional State: Retrospective-Cohort Study. Vasc Health Risk Manag 2023; 19:837-853. [PMID: 38145253 PMCID: PMC10748565 DOI: 10.2147/vhrm.s447936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/13/2023] [Indexed: 12/26/2023] Open
Abstract
Background Atrial fibrillation (AF) is the leading cause of a surge in hospital expenses for the treatment of strokes. However, evidence regarding clinical features and survival of patients admitted with acute ischemic stroke (AIS) plus AF in Ethiopia is lacking. Objective We assess clinical characteristics, survival, and predictors of mortality of patients with acute ischemic stroke and atrial fibrillation among patients admitted to Tertiary Care Hospitals in Amhara regional state. Methods A retrospective cohort study was done on patients diagnosed with AIS who received care at Tibebe Ghion and Felege Hiwot hospitals from November 2018 to November 2021. Data were analyzed using SPSS version 25. Cox regression analysis was used to identify predictors of in-hospital mortality. Kaplan-Meier analysis was used to identify survival rates and mean survival time. The hazard ratio was used as a measure of the strength of the association and statistical significance was declared at p-value <0.05. Results Of 378 patients with AIS, 58.7% were male. AF was diagnosed in 102 (26.9%) patients. Compared with patients without AF, patients with AF were more likely to have Glasgow Coma Scale <8 (83.3 vs 4%), valvular heart disease (56.9 vs 4.7%), and coronary heart disease (11.8 vs 4%). Patients with AF had a significant incidence of in-hospital mortality (38 per 1000 vs 17 per 1000) person-days. Glasgow Coma Scale <8: (AHR=12.69, 95% CI: [2.603-61.873]), aspirational pneumonia (AHR=2.602, 95% CI: 1.085-6.242), acute renal failure (AHR=6.114, 95% CI: [1.817-20.576]), hypokalemia (AHR=1.179, 95% CI: [1.112,-3.373]), atrial fibrillation (AHR=1.104, 95% CI: [1.015-5.404]), HIV/AIDS (AHR=8.302, 95% CI: [1.585-43.502]) and chronic liver disease (AHR=4.969, 95% CI: [1.192-20.704]) were indicators of in-hospital mortality. Conclusion In the current study, hospital mortality was greater in AIS associated with atrial fibrillation. Stroke-related complications were significant predictors of mortality. Hence, effective strategies should be in place to curb the impacts of these factors.
Collapse
Affiliation(s)
- Zenaw Debasu Addisu
- Department of Pharmacy, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Teshale Ayele Mega
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| |
Collapse
|
3
|
Yang L, Gao K, Shi RJ, Qin YN, Huang XR, Gao YJ, Zheng XP. Fibrosis-4 index is closely associated with clinical outcomes in acute cardioembolic stroke patients with nonvalvular atrial fibrillation. Intern Emerg Med 2023; 18:2209-2222. [PMID: 37891451 DOI: 10.1007/s11739-023-03394-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 08/08/2023] [Indexed: 10/29/2023]
Abstract
Liver cirrhosis is a confirmed risk factor for poor prognosis of stroke; however, the contribution of clinically inapparent liver fibrosis to cardioembolic stroke (CES) and its outcomes are poorly understood. This study aimed to investigate the associations between liver fibrosis-measured by the Fibrosis-4 (FIB-4) score-and stroke severity and short-term clinical outcomes of patients with acute CES due to nonvalvular atrial fibrillation (NVAF). A total of 522 patients were followed for a median of 90 days. We calculated the FIB-4 score and defined liver fibrosis as follows: likely advanced fibrosis (FIB-4 > 3.25), indeterminate advanced fibrosis (FIB-4, 1.45-3.25), and unlikely advanced fibrosis (FIB-4 < 1.45). Logistic regression analysis and Cox regression analysis were used to investigate the relations between the FIB-4 score and stroke severity, major disability at discharge, and all-cause mortality. Among these 522 acute CES patients with NVAF, the mean FIB-4 score (2.28) on admission reflected intermediate fibrosis, whereas liver enzymes were largely normal. In multivariate regression analysis, patients with advanced liver fibrosis were more likely to have a higher risk of severe stroke (OR = 2.21, 95% CI 1.04-3.54), major disability at discharge (OR = 4.59, 95% CI 1.88-11.18), and all-cause mortality (HR = 1.25, 95% CI 1.10-1.56) than their counterparts. Regarding sex, these associations were stronger in males but not significant in females. In patients with acute CES due to NVAF, advanced liver fibrosis is associated with severe stroke, major disability, and all-cause death. Our findings indicate that early screening and management of liver fibrosis may decrease stroke severity and risk of death in patients with NVAF, especially for male patients. Consequently, FIB-4 > 3.25 of male patients should receive ultrasound elastography to further determine the degree of liver fibrosis.
Collapse
Affiliation(s)
- Lei Yang
- Department of Cardiology, The First Affiliated Hospital of Xi'an Jiao Tong University, 277 Yanta West Road, Xi'an, 710061, China
| | - Ke Gao
- Department of Cardiology, The First Affiliated Hospital of Xi'an Jiao Tong University, 277 Yanta West Road, Xi'an, 710061, China
| | - Rui-Juan Shi
- Department of Cardiology, The First Affiliated Hospital of Xi'an Jiao Tong University, 277 Yanta West Road, Xi'an, 710061, China
| | - Yu-Nan Qin
- Department of Cardiology, The First Affiliated Hospital of Xi'an Jiao Tong University, 277 Yanta West Road, Xi'an, 710061, China
| | - Xiao-Rui Huang
- Department of Cardiology, The First Affiliated Hospital of Xi'an Jiao Tong University, 277 Yanta West Road, Xi'an, 710061, China
| | - Ya-Jie Gao
- Department of Cardiology, The First Affiliated Hospital of Xi'an Jiao Tong University, 277 Yanta West Road, Xi'an, 710061, China
| | - Xiao-Pu Zheng
- Department of Cardiology, The First Affiliated Hospital of Xi'an Jiao Tong University, 277 Yanta West Road, Xi'an, 710061, China.
| |
Collapse
|
4
|
Parikh NS, Basu E, Hwang MJ, Rosenblatt R, VanWagner LB, Lim HI, Murthy SB, Kamel H. Management of Stroke in Patients With Chronic Liver Disease: A Practical Review. Stroke 2023; 54:2461-2471. [PMID: 37417238 PMCID: PMC10527812 DOI: 10.1161/strokeaha.123.043011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Chronic liver disease (CLD) is a highly prevalent condition. There is burgeoning recognition that there are many people with subclinical liver disease that may nonetheless be clinically significant. CLD has a variety of systemic aberrations relevant to stroke, including thrombocytopenia, coagulopathy, elevated liver enzymes, and altered drug metabolism. There is a growing body of literature on the intersection of CLD and stroke. Despite this, there have been few efforts to synthesize these data, and stroke guidelines provide scant guidance on this topic. To fill this gap, this multidisciplinary review provides a contemporary overview of CLD for the vascular neurologist while appraising data regarding the impact of CLD on stroke risk, mechanisms, and outcomes. Finally, the review addresses acute and chronic treatment considerations for patients with stroke-ischemic and hemorrhagic-and CLD.
Collapse
Affiliation(s)
- Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
| | | | - Mu Ji Hwang
- Department of Neurology, Brown University, Providence, RI (M.J.H.)
| | - Russel Rosenblatt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine (R.R.), Weill Cornell Medicine, New York, NY
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas (L.B.V.)
| | - Hana I Lim
- Division of Hematology and Oncology, Department of Internal Medicine.(H.I.L.), Weill Cornell Medicine, New York, NY
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
| |
Collapse
|
5
|
Dobesh PP, Fermann GJ, Christoph MJ, Koch B, Lesén E, Chen H, Lovelace B, Dettling T, Danese M, Ulloa J, Danese S, Coleman CI. Lower mortality with andexanet alfa vs 4-factor prothrombin complex concentrate for factor Xa inhibitor-related major bleeding in a U.S. hospital-based observational study. Res Pract Thromb Haemost 2023; 7:102192. [PMID: 37753225 PMCID: PMC10518480 DOI: 10.1016/j.rpth.2023.102192] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 09/28/2023] Open
Abstract
Background Well-designed studies with sufficient sample size comparing andexanet alfa vs 4-factor prothrombin complex concentrate (4F-PCC) in routine clinical practice to evaluate clinical outcomes are limited. Objectives To compare in-hospital mortality in patients hospitalized with rivaroxaban- or apixaban-related major bleeding who were treated with andexanet alfa or 4F-PCC. Methods An observational cohort study (ClinicalTrials.gov identifier: NCT05548777) was conducted using electronic health records between May 2018 and September 2022 from 354 U.S. hospitals. Inclusion criteria were age ≥18 years, inpatient admission with diagnosis code D68.32 (bleeding due to extrinsic anticoagulation), a record of use of the factor Xa inhibitors rivaroxaban or apixaban, andexanet alfa or 4F-PCC treatment during index hospitalization, and a documented discharge disposition. Multivariable logistic regression on in-hospital mortality with andexanet alfa vs 4F-PCC was performed. The robustness of the results was assessed via a supportive propensity score-weighted logistic regression. Results The analysis included 4395 patients (andexanet alfa, n = 2122; 4F-PCC, n = 2273). There were 1328 patients with intracranial hemorrhage (ICH), 2567 with gastrointestinal (GI) bleeds, and 500 with critical compartment or other bleed types. In the multivariable analysis, odds of in-hospital mortality were 50% lower for andexanet alfa vs 4F-PCC (odds ratio [OR], 0.50; 95% CI, 0.39-0.65; P < .01) and were consistent for both ICH (OR, 0.55; [0.39-0.76]; P < .01) and GI bleeds (OR, 0.49 [0.29-0.81]; P = .01). Similar results were obtained from the supporting propensity score-weighted logistic regression analyses. Conclusion In this large observational study, treatment with andexanet alfa in patients hospitalized with rivaroxaban- or apixaban-related major bleeds was associated with 50% lower odds of in-hospital mortality than 4F-PCC. The magnitude of the risk reduction was similar in ICH and GI bleeds.
Collapse
Affiliation(s)
- Paul P. Dobesh
- University of Nebraska Medical Center, College of Pharmacy, Omaha, Nebraska, USA
| | - Gregory J. Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | | | | | | | | | | | | | - Mark Danese
- Outcomes Insights, Agoura Hills, California, USA
| | - Julie Ulloa
- Outcomes Insights, Agoura Hills, California, USA
| | | | - Craig I. Coleman
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Evidence-based Practice Center, Hartford Hospital, Hartford, Connecticut, USA
| |
Collapse
|
6
|
Chen K, Pan Y, Xiang X, Meng X, Yao D, Lin L, Li X, Wang Y. The nonalcoholic fatty liver risk in prediction of unfavorable outcome after stroke: A nationwide registry analysis. Comput Biol Med 2023; 157:106692. [PMID: 36924734 DOI: 10.1016/j.compbiomed.2023.106692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/31/2023] [Accepted: 02/14/2023] [Indexed: 03/05/2023]
Abstract
Few researches have looked at the relationship between nonalcoholic fatty liver disease (NAFLD) at the time of admission and the long-term outcomes of patients suffering from acute ischemic stroke (AIS). We aimed to probe the relationship between NAFLD risk evaluated by NAFLD indices and long-term endpoints, along with the prognostic value of merging NAFLD indices with established risk markers for the prognosis of AIS patients. The fatty liver index (FLI) and the Hepatic steatosis index (HSI) were used to evaluate NAFLD risk in the Third China National Stroke Registry (CNSR-III), a large, prospective, national, multicenter cohort registry study. NAFLD was defined as FLI ≥35 for males and FLI ≥ 20 for females, as well as HSI>36. Death or major disability (modified Rankin Scale score ≥3) were the primary outcomes following the beginning of a stroke. On patient outcomes, the prognostic performance of two objective NAFLD parameters was evaluated. NAFLD was detected in 32.10-51.90% of AIS patients. After 1-year, 14.5% of the participants had died or suffered a severe outcome. After controlling for known risk factors, NAFLD was associated with a modest probability of adverse outcome (odds ratio,0.72[95% CI, 0.61-0.86] for FLI; odds ratio,0.68[95% CI, 0.55-0.85] for HSI). The inclusion of the two NAFLD indicators in the conventional prediction model was justified by the integrated discrimination index, continuing to increase the model's overall predictive value for long-term adverse outcomes. NAFLD risk was linked to a lower risk of long-term death or major disability in people with AIS. The predictive value of objective NAFLD after AIS was demonstrated in our study.
Collapse
Affiliation(s)
- Keyang Chen
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China; School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Research Units of Clinical Translation of Cell Growth Factors and Diseases Research, Chinese Academy of Medical Science, Wenzhou Medical University, Wenzhou, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xianglong Xiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dongxiao Yao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Li Lin
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, China; Research Units of Clinical Translation of Cell Growth Factors and Diseases Research, Chinese Academy of Medical Science, Wenzhou Medical University, Wenzhou, China
| | - Xiaokun Li
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, China; Research Units of Clinical Translation of Cell Growth Factors and Diseases Research, Chinese Academy of Medical Science, Wenzhou Medical University, Wenzhou, China.
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, 2019RU018, China.
| | | |
Collapse
|
7
|
Kim J, Jang W. Safety of prescribed herbal medicines for hepatic and renal function of polypharmacy patients with stroke: A single-center retrospective study. Medicine (Baltimore) 2022; 101:e32147. [PMID: 36482592 PMCID: PMC9726389 DOI: 10.1097/md.0000000000032147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In Korea, herbal medicines (HMs) are primarily used to treat diseases. Patients with stroke are generally older and take several conventional medicines (CMs) to address other underlying diseases, which is known as polypharmacy. Therefore, there is a growing concern about hepatotoxicity and nephrotoxicity due to drug interactions between HMs and CMs. Therefore, this study retrospectively investigated liver and renal tests in patients with stroke treated with polypharmacy to clarify the safety of simultaneous HM and CM administration. The medical records of 111 patients with stroke treated at a single center and who met the inclusion criteria between March 1, 2017, and March 1, 2022, were reviewed. The HMs and HM prescription frequency, CMs, and liver and kidney test results were recorded. Additionally, the Roussel Uclaf Causality Assessment Method and Kidney Disease Improving Global Outcome scores were documented, which are standard criteria for assessing liver and kidney injury, respectively. The study included 53 men and 58 women (average age: 67.8 years). On average, the patients took 6 types of CMs. No patient showed liver injury during the co-administration of CMs and HMs. Only 1 patient had initial hepatic damage but recovered after taking HMs. Furthermore, 2 patients had liver test abnormalities 2 times the upper limit of normal, possibly from Seogyeong-tang and atorvastatin, with Roussel Uclaf Causality Assessment Method scale scores of 3 and 5, respectively. No patient had a renal injury. HM is safe for patients with stroke taking multiple CMs. However, consulting an HM expert is essential to avoid hepatotoxicity, nephrotoxicity, and other adverse effects. These results highlight the benefits of Korea's dual medical system.
Collapse
Affiliation(s)
- JunSeok Kim
- Department of Cardiovascular and Neurologic Diseases of Korean Internal Medicine, Daegu Haany University Korean Medicine Hospital, Daegu, Republic of Korea
| | - WooSeok Jang
- Department of Cardiovascular and Neurologic Diseases of Korean Internal Medicine, Daegu Haany University Korean Medicine Hospital, Daegu, Republic of Korea
- * Correspondence: Wooseok Jang, Department of Cardiovascular and Neurologic Diseases of Korean Internal Medicine, Daegu Haany University Korean Medicine Hospital, 136, Sincheondong-ro, Suseong-gu, Daegu 42158, Republic of Korea (e-mail: )
| |
Collapse
|
8
|
Bender M, Haferkorn K, Tajmiri-Gondai S, Uhl E, Stein M. Fibrinogen to Albumin Ratio as Early Serum Biomarker for Prediction of Intra-Hospital Mortality in Neurosurgical Intensive Care Unit Patients with Spontaneous Intracerebral Hemorrhage. J Clin Med 2022; 11:jcm11144214. [PMID: 35887976 PMCID: PMC9316478 DOI: 10.3390/jcm11144214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/14/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The prognostic value of the fibrinogen to albumin ratio on intrahospital mortality has been investigated in patients with cardiovascular disease, cancer, sepsis, and ischemic stroke; however, it has not been investigated for neurosurgical patients with spontaneous intracerebral hemorrhage (ICH). The present study investigates the impact of the fibrinogen to albumin ratio upon admission for intrahospital mortality in neurosurgical intensive care unit (ICU) patients with spontaneous ICH. Methods: A total of 198 patients with diagnosis of spontaneous ICH treated from 10/2008 to 12/2017 at our ICU were retrospectively analyzed. Blood samples were drawn upon admission, and the patients’ demographic, medical data, and cranial imaging were collected. Binary logistic regression analysis was performed to identify independent prognostic factors for intrahospital mortality. Results: The total rate of intrahospital mortality was 35.4% (n = 70). In the multivariate regression analysis, higher fibrinogen to albumin ratio (OR = 1.16, CI = 1.02−1.31, p = 0.03) upon admission was an independent predictor of intrahospital mortality in neurosurgical ICU patients with ICH. Moreover, a fibrinogen to albumin ratio cut-off level of >0.075 was related to increased intrahospital mortality (Youden’s index = 0.26, sensitivity = 0.51, specificity = 0.77). Conclusion: A fibrinogen to albumin ratio > 0.075 was significantly associated with increased intrahospital mortality in ICH patients.
Collapse
|
9
|
Predicting 10-year stroke mortality: development and validation of a nomogram. Acta Neurol Belg 2022; 122:685-693. [PMID: 34406610 PMCID: PMC9170668 DOI: 10.1007/s13760-021-01752-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/12/2021] [Indexed: 11/02/2022]
Abstract
Predicting long-term stroke mortality is a clinically important and unmet need. We aimed to develop and internally validate a 10-year ischaemic stroke mortality prediction score. In this UK cohort study, 10,366 patients with first-ever ischaemic stroke between January 2003 and December 2016 were followed up for a median (interquartile range) of 5.47 (2.96-9.15) years. A Cox proportional-hazards model was used to predict 10-year post-admission mortality. The predictors associated with 10-year mortality included age, sex, Oxfordshire Community Stroke Project classification, estimated glomerular filtration rate (eGFR), pre-stroke modified Rankin Score, admission haemoglobin, sodium, white blood cell count and comorbidities (atrial fibrillation, coronary heart disease, heart failure, cancer, hypertension, chronic obstructive pulmonary disease, liver disease and peripheral vascular disease). The model was internally validated using bootstrap resampling to assess optimism in discrimination and calibration. A nomogram was created to facilitate application of the score at the point of care. Mean age (SD) was 78.5 ± 10.9 years, 52% female. Most strokes were partial anterior circulation syndromes (38%). 10-year mortality predictors were: total anterior circulation stroke (hazard ratio, 95% confidence intervals) (2.87, 2.62-3.14), eGFR < 15 (1.97, 1.55-2.52), 1-year increment in age (1.04, 1.04-1.05), liver disease (1.50, 1.20-1.87), peripheral vascular disease (1.39, 1.23-1.57), cancers (1.37, 1.27-1.47), heart failure (1.24, 1.15-1.34), 1-point increment in pre-stroke mRS (1.20, 1.17-1.22), atrial fibrillation (1.17, 1.10-1.24), coronary heart disease (1.09, 1.02-1.16), chronic obstructive pulmonary disease (1.13, 1.03-1.25) and hypertension (0.77, 0.72-0.82). Upon internal validation, the optimism-adjusted c-statistic was 0.76 and calibration slope was 0.98. Our 10-year mortality model uses routinely collected point-of-care information. It is the first 10-year mortality score in stroke. While the model was internally validated, further external validation is also warranted.
Collapse
|
10
|
Wang H, Wu J, Yang X, Liu J, Tao W, Hao Z, Wu B, Liu M, Zhang S, Wang D. Liver fibrosis indices associated with substantial hematoma expansion in Chinese patients with primary intracerebral hemorrhage. BMC Neurol 2021; 21:478. [PMID: 34879856 PMCID: PMC8656098 DOI: 10.1186/s12883-021-02494-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/12/2021] [Indexed: 02/08/2023] Open
Abstract
Background Whether liver fibrosis is associated with increased risk for substantial hematoma expansion (HE) after intracerebral hemorrhage (ICH) is still uncertain. We evaluated the association between various liver fibrosis indices and substantial HE in a Chinese population with primary ICH. Methods Primary ICH patients admitted to West China Hospital within 24 h of onset between January 2015 and June 2018 were consecutively enrolled. Six liver fibrosis indices were calculated, including aspartate aminotransferase (AST)-platelet ratio index (APRI), AST/alanine aminotransferase ratio-platelet ratio index (AARPRI), fibrosis-4 (FIB-4), modified fibrosis-4 (mFIB-4), fibrosis quotient (FibroQ) and Forns index. Substantial HE was defined as an increase of more than 33% or 6 mL from baseline ICH volume. The association of each fibrosis index with substantial HE was analyzed using binary logistic regression. Results Of 436 patients enrolled, about 85% showed largely normal results on standard hepatic assays and coagulation parameters. Substantial HE occurred in 115 (26.4%) patients. After adjustment, AARPRI (OR 1.26, 95% CI 1.00-1.57) and FIB-4 (OR 1.15, 95% CI 1.02-1.30) were independently associated with substantial HE in ICH patients within 24 h of onset, respectively. In ICH patients within 6 h of onset, each of the following indices was independently associated with substantial HE: APRI (OR 2.64, 95% CI 1.30-5,36), AARPRI (OR 1.55, 95% CI 1.09-2.21), FIB-4 (OR 1.35, 95% CI 1.08-1.68), mFIB-4 (OR 1.09, 95% CI 1.01-1.18), FibroQ (OR 1.08, 95% CI 1.00-1.16) and Forns index (OR 1.37, 95% CI 1.10-1.69). Conclusions Liver fibrosis indices are independently associated with higher risk of substantial HE in Chinese patients with primary ICH, which suggesting that subclinical liver fibrosis could be routinely assessed in such patients to identify those at high risk of substantial HE. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02494-0.
Collapse
Affiliation(s)
- Huan Wang
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Jiongxing Wu
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Xue Yang
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Junfeng Liu
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Wendan Tao
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Zilong Hao
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Bo Wu
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Ming Liu
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Shihong Zhang
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Deren Wang
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China.
| |
Collapse
|
11
|
Hao R, Qi X, Xia X, Wang L, Li X. Temporal trend of comorbidity and increasing impacts on mortality, length of stay, and hospital costs of first stroke in Tianjin, North of China. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:63. [PMID: 34583749 PMCID: PMC8477574 DOI: 10.1186/s12962-021-00316-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke patients have a high incidence of comorbidity. Previous studies have shown that comorbidity can impact on the short-term and long-term mortality after stroke. METHODS Our study aimed to explore the trend of comorbidity among patients with first stroke from 2010 to 2020, and the influence of comorbidity on admission mortality, length of stay and hospitalization costs. 5988 eligible patients were enrolled in our study, and divided into 4 comorbidity burden groups according to Charlson comorbidity index (CCI): none, moderate, severe, very severe. Survival analysis was expressed by Kaplan-Meier curve. Cox regression model was used to analyze the effect of comorbidity on 7-day and in-hospital mortality. Generalized linear model (GLM) was used to analyze the association between comorbidity and hospitalization days and cost. RESULTS Compared to patients without comorbidity, those with very severe comorbidity were more likely to be male (342, 57.7%), suffer from ischemic stroke (565, 95.3%), afford higher expense (Midian, 19339.3RMB, IQR13020.7-27485.9RMB), and have a higher in-hospital mortality (60, 10.1%). From 2010 to 2020, proportion of patients with severe and very severe comorbidity increased 12.9%. The heaviest comorbidity burden increased the risk of 7-day mortality (adjusted hazard ratio, 3.51, 95% CI 2.22-5.53) and in-hospital mortality (adjusted hazard ratio, 3.83, 95% CI 2.70-5.45). Patients with very severe comorbidity had a 12% longer LOS and extra 27% expense than those without comorbidity. CONCLUSIONS Comorbidity burden showed an increasing trend year in past eleven years. The heavy comorbidity burden increased in-hospital mortality, LOS, and hospitalization cost, especially in patients aged 55 years or more. The findings also provide some reference on improvement of health care reform policies and allocation of resources.
Collapse
Affiliation(s)
- Ruixiao Hao
- Department of Neurology, The Second Hospital of Tianjin Medical University, 23 Pingjiang Road, Tianjin, 300211, China
| | - Xuemei Qi
- Department of Neurology, The Second Hospital of Tianjin Medical University, 23 Pingjiang Road, Tianjin, 300211, China
| | - Xiaoshuang Xia
- Department of Neurology, The Second Hospital of Tianjin Medical University, 23 Pingjiang Road, Tianjin, 300211, China
| | - Lin Wang
- Department of Geriatrics, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xin Li
- Department of Neurology, The Second Hospital of Tianjin Medical University, 23 Pingjiang Road, Tianjin, 300211, China.
| |
Collapse
|
12
|
Thompson KP, Nelson J, Kim H, Weinsheimer SM, Marchuk DA, Lawton MT, Krings T, Faughnan ME. Utility of modified Rankin Scale for brain vascular malformations in hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2021; 16:390. [PMID: 34538258 PMCID: PMC8451134 DOI: 10.1186/s13023-021-02012-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Approximately 10% of hereditary hemorrhagic telangiectasia (HHT) patients harbour brain vascular malformations (VMs). Intracranial hemorrhage (ICH) from brain VMs can lead to death or morbidity, while treatment options for brain VMs also have associated morbidity. The modified Rankin Scale (mRS) may provide an approach to identifying HHT-brain VM patients with poor outcomes, and their predictors. We aimed to measure the relationship between mRS score and brain VM, brain VM number, as well as other aspects of HHT, at enrollment and during prospective follow-up. Methods 1637 HHT patients (342 with brain VMs) were recruited from 14 HHT centres of the Brain Vascular Malformation Consortium since 2010 and followed prospectively (mean = 3.4 years). We tested whether the presence of brain VM, other HHT organ involvement, and HHT mutation genotype were associated with worse mRS scores at baseline and during follow-up, using linear mixed models, adjusting for age, sex, and year of visit. Results Presence of brain VMs was not associated with worse mRS score at baseline and there was no significant worsening of mRS with prospective follow-up in these patients; 92% had baseline mRS of 0–2. HHT-related gastrointestinal (GI) bleeding was associated with worse mRS scores at baseline (0.37, 95% CI 0.26–0.47, p < 0.001), as were history of anemia (0.35, 95% CI 0.27–0.43, p < 0.001) and liver VMs (0.19, 95% CI 0.09–0.30, p < 0.001). Presence of pulmonary arteriovenous malformations (AVMs) was not associated with worse mRS scores at baseline. mRS score was not associated with either HHT genotype (Endoglin vs ACVRL1). Only GI bleeding was associated with a significantly worsening mRS during prospective follow-up (0.64, 95% CI 0.21–1.08, p = 0.004). Conclusion Most HHT-brain VM patients had good functional capacity (mRS scores 0–2) at baseline that did not change significantly over 3.4 mean years of follow-up, suggesting that mRS may not be useful for predicting or measuring outcomes in these patients. However, HHT patients with GI bleeding, anemia history or liver VMs had worse mRS scores, suggesting significant impact of these manifestations on functional capacity. Our study demonstrates the insensitivity of the mRS as an outcomes measure in HHT brain VM patients and reinforces the continued need to develop outcomes measures, and their predictors, in this group.
Collapse
Affiliation(s)
- K P Thompson
- Toronto HHT Centre, St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - J Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - H Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - S M Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - D A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA
| | - M T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - T Krings
- Division of Neurosurgery, Department of Medical Imaging, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neuroradiology, Toronto Western Hospital, Univeristy Health Network, Toronto, Canada
| | - M E Faughnan
- Toronto HHT Centre, St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Canada. .,Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada.
| | | |
Collapse
|
13
|
ElHabr AK, Katz JM, Wang J, Bastani M, Martinez G, Gribko M, Hughes DR, Sanelli P. Predicting 90-day modified Rankin Scale score with discharge information in acute ischaemic stroke patients following treatment. BMJ Neurol Open 2021; 3:e000177. [PMID: 34250487 PMCID: PMC8231000 DOI: 10.1136/bmjno-2021-000177] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/30/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To understand variability in modified Rankin Scale scores from discharge to 90 days in acute ischaemic stroke patients following treatment, and examine prediction of 90-day modified Rankin Scale score by using discharge modified Rankin Scale and discharge disposition. MATERIALS AND METHODS Retrospective analysis of acute ischaemic stroke patients following treatment was performed from January 2016 to March 2020. Data collection included demographic and clinical characteristics and outcomes data (modified Rankin Scale score at discharge, 30 days and 90 days and discharge disposition). Pearson's χ2 test assessed statistical differences in distribution of modified Rankin Scale scores at discharge, 30 days and 90 days. The predictive power of discharge modified Rankin Scale score and disposition quantified the association with 90-day outcome. RESULTS A total of 280 acute ischaemic stroke patients (65.4% aged ≥65 years, 47.1% female, 60.7% white) were included in the analysis. The modified Rankin Scale score significantly changed between 30 and 90 days from discharge (p<0.001) after remaining stable from discharge to 30 days (p=0.665). The positive and negative predictive values of an unfavourable long-term outcome for discharge modified Rankin Scale scores of 3-5 were 67.7% (95% CI 60.4% to 75.0%) and 82.0% (95% CI 75.1% to 88.8%), and for non-home discharge disposition were 72.4% (95% CI 64.5% to 80.2%) and 74.5% (95% CI 67.8% to 81.3%), respectively. CONCLUSIONS Discharge modified Rankin Scale score and non-home discharge disposition are good individual predictors of 90-day modified Rankin Scale score for ischaemic stroke patients following treatment.
Collapse
Affiliation(s)
- Andrew K ElHabr
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Jason Wang
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Mehrad Bastani
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | | | - Michele Gribko
- Department of Neurology, North Shore University Hospital at Manhasset, Manhasset, New York, USA
| | - Danny R Hughes
- School of Economics, Georgia Institute of Technology, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
| | - Pina Sanelli
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| |
Collapse
|
14
|
Parikh NS, Jesudian A, Kamel H, Hanley DF, Ziai WC, Murthy SB. Liver Fibrosis and Perihematomal Edema Growth in Primary Intracerebral Hemorrhage. Neurocrit Care 2021; 34:983-989. [PMID: 32808155 PMCID: PMC7887133 DOI: 10.1007/s12028-020-01081-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/06/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Liver disease is associated with altered serum osmolality, increased thrombin generation, and systemic inflammation, all of which may contribute to perihematomal edema (PHE) after intracerebral hemorrhage (ICH). We evaluated the association between a validated liver fibrosis index and PHE growth in a cohort of patients with primary ICH. METHODS We performed a retrospective cohort study using data from the Virtual International Stroke Trials Archive-ICH. We included adult patients with primary ICH presenting within 6 h of symptom onset. The exposure of interest was the Fibrosis-4 (FIB-4) score, a validated liver fibrosis index; this was modeled as a continuous variable. The primary outcome was absolute PHE growth over 96 h. Secondary outcomes were absolute admission and 96-h PHE volumes. We used multiple linear regression models adjusted for established determinants of PHE. In a secondary analysis, the FIB-4 score was modeled as a categorical variable to compare patients with versus without liver fibrosis. RESULTS Among 354 patients with ICH, 8% had evidence of liver fibrosis based on a validated cutoff. The FIB-4 score was not associated with PHE growth in unadjusted (β, 0.03; 95% CI, - 0.01 to 0.12) or adjusted models (β, 0.04; 95% CI, - 0.03 to 0.13). In a secondary analysis treating FIB-4 as a categorical variable, patients with liver fibrosis did not have greater PHE growth than those without liver fibrosis. FIB-4 score was also not associated with absolute admission or 96-h PHE volumes. CONCLUSIONS In a multicenter cohort of patients with primary intracerebral hemorrhage, a liver fibrosis score was not associated with PHE volume or growth.
Collapse
Affiliation(s)
- Neal S Parikh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine/New York Presbyterian Hospital, 420 E 70th St, 4th Floor, New York, NY, 10021, USA.
| | - Arun Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine/New York Presbyterian Hospital, 420 E 70th St, 4th Floor, New York, NY, 10021, USA
| | - Daniel F Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Wendy C Ziai
- Department of Neurology, Neurosurgery and Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine/New York Presbyterian Hospital, 420 E 70th St, 4th Floor, New York, NY, 10021, USA
| |
Collapse
|
15
|
Yuan CX, Ruan YT, Zeng YY, Cheng HR, Cheng QQ, Chen YB, He WL, Huang GQ, He JC. Liver Fibrosis Is Associated With Hemorrhagic Transformation in Patients With Acute Ischemic Stroke. Front Neurol 2020; 11:867. [PMID: 33013622 PMCID: PMC7512114 DOI: 10.3389/fneur.2020.00867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/07/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Hemorrhagic transformation (HT) is a frequent, often asymptomatic event that occurs after acute ischemic stroke (AIS). Liver fibrosis, usually subclinical, is common and crucial in the development of liver disease. We aimed to investigate the association between liver fibrosis and HT in patients with AIS. Methods: We performed a single-center and retrospective study. A total of 185 consecutive participants with HT and 199 age- and sex-matched stroke patients without HT were enrolled in this study. We calculated one validated fibrosis index—Fibrosis-4 (FIB-4) score—to assess the extent of liver fibrosis. HT was detected by routine CT or MRI and was radiologically classified as hemorrhagic infarction type 1 or 2 or parenchymal hematoma type 1 or 2. HT was also classified into asymptomatic or symptomatic. We used logistic regression models adjusted for previously established risk factors to assess the risks for HT. Results: The median FIB-4 score was significantly higher among patients who developed HT than among those without HT, whereas standard hepatic assays were largely normal. Patients were assigned to groups of high FIB-4 score and low FIB-4 score based on the optimal cutoff value. Compared with the subjects in the low-FIB-4-score group, incidence of HT for the high-FIB-4-score group was significantly higher. After adjustment for potential confounders, the patients with high FIB-4 score had 3.461-fold risk of HT in AIS compared to the patients with low FIB-4 score [odds ratio, 3.461 (95% CI, 1.404–8.531)]. Conclusion: Liver fibrosis, measured by FIB-4 score, was independently associated with the risk of HT in AIS patients.
Collapse
Affiliation(s)
- Cheng-Xiang Yuan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi-Ting Ruan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ya-Ying Zeng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hao-Ran Cheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qian-Qian Cheng
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Yun-Bin Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei-Lei He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Gui-Qian Huang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jin-Cai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| |
Collapse
|
16
|
Cappellari M, Pracucci G, Forlivesi S, Saia V, Limbucci N, Nencini P, Inzitari D, Da Ros V, Sallustio F, Vallone S, Bigliardi G, Zini A, Vinci SL, Dell'Aera C, Bracco S, Cioni S, Tassi R, Bergui M, Naldi A, Carità G, Azzini C, Casetta I, Gasparotti R, Magoni M, Castellan L, Finocchi C, Menozzi R, Scoditti U, Causin F, Viaro F, Puglielli E, Casalena A, Ruggiero M, Biguzzi S, Castellano D, Cavallo R, Lazzarotti GA, Orlandi G, Sgreccia A, Denaro MF, Cavasin N, Critelli A, Ciceri EFM, Bonetti B, Chiumarulo L, Petruzzelli M, Pellegrino C, Carimati F, Burdi N, Prontera MP, Auteri W, Petrone A, Guidetti G, Nicolini E, Ganci G, Sugo A, Filauri P, Sacco S, Squassina G, Invernizzi P, Nuzzi NP, Corato M, Amistà P, Gentile M, Barbero S, Schirru F, Craparo G, Mannino M, Simonetti L, Mangiafico S, Toni D. Direct thrombectomy for stroke in the presence of absolute exclusion criteria for thrombolysis. J Neurol 2020; 267:3731-3740. [PMID: 32712865 DOI: 10.1007/s00415-020-10098-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/15/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Intravenous thrombolysis (IVT)-ineligible patients undergoing direct thrombectomy tended to have poorer functional outcome as compared with IVT-eligible patients undergoing bridging therapy. We aimed to assess radiological and functional outcomes in large vessel occlusion-related stroke patients receiving direct thrombectomy in the presence of absolute exclusion criteria for IVT vs relative exclusion criteria for IVT and vs non-exclusion criteria for IVT. METHODS A cohort study on prospectively collected data from 2282 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke cohort for treatment with direct thrombectomy (n = 486, absolute exclusion criteria for IVT alone; n = 384, absolute in combination with relative exclusion criteria for IVT; n = 777, relative exclusion criteria for IVT alone; n = 635, non-exclusion criteria for IVT). RESULTS After adjustment for unbalanced variables (model 1), ORs for 3-month death was higher in the presence of absolute exclusion criteria for IVT alone (vs relative exclusion criteria for IVT alone) (1.595, 95% CI 1.042-2.440) and in the presence of absolute exclusion criteria for IVT alone (vs non-exclusion criteria for IVT) (1.235, 95% CI 1.014-1.504). After adjustment for predefined variables (model 2: age, sex, pre-stroke mRS ≤ 1, NIHSS, occlusion in the anterior circulation, onset-to-groin time, and procedure time), ORs for 3-month death was higher in the presence of absolute exclusion criteria for IVT alone (vs relative exclusion criteria for IVT alone) (1.235, 95% CI 1.014-1.504) and in the presence of absolute exclusion criteria for IVT alone (vs non-exclusion criteria for IVT) (1.246, 95% CI 1.039-1.495). No significant difference was found between the groups as regards any type of intracerebral hemorrhage and parenchymal hematoma within 24 h, successful and complete recanalization after procedure, and modified Rankin Scale score 0-2 at 3 months. After adjustment for predefined variables of model 2, ORs for death were higher in the presence of recent administration of IV heparin (OR: 2.077), platelet count < 100,000/mm3 (OR: 4.798), bacterial endocarditis (OR: 15.069), neoplasm with increased hemorrhagic risk (OR: 6.046), and severe liver disease (OR: 6.124). CONCLUSIONS Radiological outcomes were similar after direct thrombectomy in patients with absolute, relative, and non- exclusion criteria for IVT, while an increase of fatal outcome was observed in the presence of some absolute exclusion criterion for IVT.
Collapse
Affiliation(s)
- Manuel Cappellari
- USD Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Piazzale A. Stefani 1, 37126, Verona, Italy.
| | | | - Stefano Forlivesi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | | | | | | | | | | | | | - Stefano Vallone
- Ospedale Civile S.Agostino-Estense-University Hospital, Modena, Italy
| | - Guido Bigliardi
- Ospedale Civile S.Agostino-Estense-University Hospital, Modena, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | | | | | - Sandra Bracco
- Ospedale S. Maria delle Scotte-University Hospital, Siena, Italy
| | - Samuele Cioni
- Ospedale S. Maria delle Scotte-University Hospital, Siena, Italy
| | - Rossana Tassi
- Ospedale S. Maria delle Scotte-University Hospital, Siena, Italy
| | - Mauro Bergui
- Città della Salute e della Scienza-Molinette, Turin, Italy
| | - Andrea Naldi
- Città della Salute e della Scienza-Molinette, Turin, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Bruno Bonetti
- USD Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Piazzale A. Stefani 1, 37126, Verona, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | - Pietro Filauri
- Presidio Ospedaliero SS. Filippo e Nicola, Avezzano, Italy
| | - Simona Sacco
- Presidio Ospedaliero SS. Filippo e Nicola, Avezzano, Italy
| | - Guido Squassina
- Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | | | | | | | | | - Mauro Gentile
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | | | | | | | | | - Luigi Simonetti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | | | | |
Collapse
|
17
|
Parikh NS, Kamel H, Navi BB, Iadecola C, Merkler AE, Jesudian A, Dawson J, Falcone GJ, Sheth KN, Roh DJ, Elkind MS, Hanley DF, Ziai WC, Murthy SB. Liver Fibrosis Indices and Outcomes After Primary Intracerebral Hemorrhage. Stroke 2020; 51:830-837. [PMID: 31906832 PMCID: PMC7048169 DOI: 10.1161/strokeaha.119.028161] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/09/2019] [Indexed: 02/06/2023]
Abstract
Background and Purpose- Cirrhosis-clinically overt, advanced liver disease-is associated with an increased risk of hemorrhagic stroke and poor stroke outcomes. We sought to investigate whether subclinical liver disease, specifically liver fibrosis, is associated with clinical and radiological outcomes in patients with primary intracerebral hemorrhage. Methods- We performed a retrospective cohort study using data from the Virtual International Stroke Trials Archive-Intracerebral Hemorrhage. We included adult patients with primary intracerebral hemorrhage presenting within 6 hours of symptom onset. We calculated 3 validated fibrosis indices-Aspartate Aminotransferase-Platelet Ratio Index, Fibrosis-4 score, and Nonalcoholic Fatty Liver Disease Fibrosis Score-and modeled them as continuous exposure variables. Primary outcomes were admission hematoma volume and hematoma expansion. Secondary outcomes were mortality, and the composite of major disability or death, at 90 days. We used linear and logistic regression models adjusted for previously established risk factors. Results- Among 432 patients with intracerebral hemorrhage, the mean Aspartate Aminotransferase-Platelet Ratio Index, Fibrosis-4, and Nonalcoholic Fatty Liver Disease Fibrosis Score values on admission reflected intermediate probabilities of fibrosis, whereas standard hepatic assays and coagulation parameters were largely normal. After adjusting for potential confounders, Aspartate Aminotransferase-Platelet Ratio Index was associated with hematoma volume (β, 0.20 [95% CI, 0.04-0.36]), hematoma expansion (odds ratio, 1.6 [95% CI, 1.1-2.3]), and mortality (odds ratio, 1.8 [95% CI, 1.1-2.7]). Fibrosis-4 was also associated with hematoma volume (β, 0.27 [95% CI, 0.07-0.47]), hematoma expansion (odds ratio, 1.9 [95% CI, 1.2-3.0]), and mortality (odds ratio, 2.0 [95% CI, 1.1-3.6]). Nonalcoholic Fatty Liver Disease Fibrosis Score was not associated with any outcome. Indices were not associated with the composite of major disability or death. Conclusions- In patients with largely normal liver chemistries, 2 liver fibrosis indices were associated with admission hematoma volume, hematoma expansion, and mortality after intracerebral hemorrhage.
Collapse
Affiliation(s)
- Neal S. Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Arun Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Jesse Dawson
- Department of Cerebrovascular Medicine, University of Glasgow, United Kingdom
| | - Guido J. Falcone
- Department of Neurology, Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - Kevin N. Sheth
- Department of Neurology, Division of Neurocritical Care & Emergency Neurology, Yale University, New Haven, CT
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Mitchell S.V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Daniel F. Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wendy C. Ziai
- Department of Neurology, Neurosurgery and Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| |
Collapse
|
18
|
Structural changes in liver under conditions of experimental hemorrhagic stroke. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2019. [DOI: 10.2478/cipms-2019-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
The article describes the results of histological and morphometric studies of liver in Balb/c mice with hemorrhagic stroke. The hemorrhagic stroke was modeled in the animals by administering autoblood in volume of 0.1 ml in the right hemisphere, and within 5, 10 and 30 days an analysis of structural changes in the liver was performed. Progressive changes were established in terms of 5-10 days of the experiment. This consisted of changes in the sinusoidal capillaries and notable changes in the central veins of the liver lobuli. Herein, acute dilatation and erythrocytal stasis were most pronounced around the lumen of the central veins, while hepatocytes with signs of necrosis (severe cytoplasmic swelling, vacuolar dystrophic changes) were detected in the sinusoid capillaries. The results of the morphometry indicated an increase in the area of the nucleus and the cells caused by intracellular swelling, domination of euchromatin and decrease of total density of chromatin in nuclei. Partial regression of the diameter of sinusoidal capillaries and the area of hepatocytes were detected on the 30th day of the experiment. The changes in the sinusoidal capillaries of the liver lobules are assessed as secondary to stroke, as well as to changes in organ microcirculation, and are associated with dystrophic changes in the hepatocytes.
Collapse
|
19
|
Cirrhosis and risk of stroke: A systematic review and meta-analysis. Atherosclerosis 2018; 275:296-303. [DOI: 10.1016/j.atherosclerosis.2018.06.876] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/07/2018] [Accepted: 06/20/2018] [Indexed: 12/25/2022]
|
20
|
Zhang X, Qi X, Yoshida EM, Méndez-Sánchez N, Hou F, Deng H, Wang X, Qiu J, He C, Wang S, Guo X. Ischemic stroke in liver cirrhosis: epidemiology, risk factors, and in-hospital outcomes. Eur J Gastroenterol Hepatol 2018; 30:233-240. [PMID: 29189394 DOI: 10.1097/meg.0000000000001011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are reportedly more prone to develop hemorrhagic stroke, thereby increasing the risk of death. However, the effect of ischemic stroke on liver diseases remains unclear. In addition, few studies have explored the risk factors for ischemic stroke in patients with liver cirrhosis. Our study aimed to explore the epidemiology, risk factors, and in-hospital outcomes of ischemic stroke in a large cohort of hospitalized patients with cirrhosis. PATIENTS AND METHODS In this single-center observational study, we retrospectively reviewed the medical records of patients with liver cirrhosis admitted to our hospital from January 2011 to June 2014. A diagnosis of ischemic stroke was further identified. RESULTS Of the 2444 patients with liver cirrhosis, 160 had ischemic stroke, including 128 patients with previous ischemic stroke and 32 patients with new-onset ischemic stroke during their hospitalizations. Compared with patients with cirrhosis without ischemic stroke, those with ischemic stroke were significantly older; had a significantly higher proportion of arterial hypertension and a significantly lower proportion of hepatitis B virus infection; had significantly higher white blood cell, platelet, blood urea nitrogen, and triglyceride levels; and had significantly lower alanine aminotransferase and aspartate aminotransferase levels and prothrombin time. The in-hospital mortality was significantly higher in patients with ischemic stroke than in those without [8.80% (14/160) vs. 3.2% (72/2284), P=0.001]. CONCLUSION Ischemic stroke was often observed in patients with cirrhosis, and it significantly increased the in-hospital mortality. The association of inflammation, coagulation disorders, and viral hepatitis with development of ischemic stroke in liver cirrhosis should be further evaluated in prospective cohort studies.
Collapse
Affiliation(s)
- Xintong Zhang
- Department of Gastroenterology, Liver Cirrhosis Study Group
- Postgraduate College, Fourth Military Medical University, Xi'an, China
| | - Xingshun Qi
- Department of Gastroenterology, Liver Cirrhosis Study Group
| | - Eric M Yoshida
- Division of Gastroenterology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Feifei Hou
- Department of Gastroenterology, Liver Cirrhosis Study Group
| | - Han Deng
- Department of Gastroenterology, Liver Cirrhosis Study Group
| | - Xiaoxi Wang
- Department of Gastroenterology, Liver Cirrhosis Study Group
| | - Jing Qiu
- Department of Neurology, General Hospital of Shenyang Military Area, Shenyang
| | - Chao He
- Department of Neurology, General Hospital of Shenyang Military Area, Shenyang
| | - Shuang Wang
- Department of Neurology, General Hospital of Shenyang Military Area, Shenyang
- Postgraduate College, Fourth Military Medical University, Xi'an, China
| | - Xiaozhong Guo
- Department of Gastroenterology, Liver Cirrhosis Study Group
| |
Collapse
|
21
|
Morotti A, Marini S, Lena UK, Crawford K, Schwab K, Kourkoulis C, Ayres AM, Edip Gurol M, Viswanathan A, Greenberg SM, Anderson CD, Rosand J, Goldstein JN. Significance of admission hypoalbuminemia in acute intracerebral hemorrhage. J Neurol 2017; 264:905-911. [PMID: 28283821 PMCID: PMC7436338 DOI: 10.1007/s00415-017-8451-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 01/01/2023]
Abstract
Low levels of serum albumin may increase the risk of infections and mortality in critically ill patients. We tested the hypothesis that admission hypoalbuminemia predicted infectious complications and poor outcome in subjects with acute intracerebral hemorrhage (ICH). We analyzed a single center cohort of ICH patients collected between 1994 and 2015. Pneumonia, urinary tract infection and sepsis were retrospectively identified, according to validated criteria. Serum albumin was measured on admission and hypoalbuminemia was defined as total albumin ≤3.5 g/dL. The association between albumin levels, infections, and mortality at 90 days was tested with multivariable logistic regression analyses. A total of 2010 patients were included (median age 74 years, 54.5% males) of whom 444 (22.1%) had hypoalbuminemia on admission and 763 (38%) died within 90 days. The frequency of pneumonia, urinary tract infection, and sepsis was 19.9, 15.1, and 2.7%, respectively. Hypoalbuminemic patients had lower admission Glasgow coma scale, higher frequency of intraventricular hemorrhage and were more likely to have a history of chronic kidney or liver disease. After adjustment for potential confounders, hypoalbuminemia was an independent predictor of pneumonia [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.34-2.33, p < 0.001] and sepsis (OR 2.29, 95% CI 1.22-4.30, p = 0.010). Low levels of albumin were also independently associated with higher mortality at 90 days (OR 1.78, 95% CI 1.30-2.44, p < 0.001). In conclusion, early hypoalbuminemia is common and predicts poor outcome in ICH patients. Increased susceptibility to pneumonia and sepsis may be the pathophysiological mechanism underlying this association.
Collapse
Affiliation(s)
- Andrea Morotti
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, USA.
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA.
| | - Sandro Marini
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, USA
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Umme K Lena
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Katherine Crawford
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Kristin Schwab
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Christina Kourkoulis
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Alison M Ayres
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - M Edip Gurol
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Anand Viswanathan
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Steven M Greenberg
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Christopher D Anderson
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, USA
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, USA
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, USA
- J. P. Kistler Stroke Research Center, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, USA
| |
Collapse
|