No Impact of Body Mass Index on Outcome in Stroke Patients Treated with IV Thrombolysis BMI and IV Thrombolysis Outcome

Low body mass index patients have worse outcomes after mechanical thrombectomy

BACKGROUND

There is evidence that frailty is an independent predictor of worse outcomes after stroke. Similarly, although obesity is associated with a higher risk for stroke, there are multiple reports describing improved mortality and functional outcomes in higher body mass index (BMI) patients in a phenomenon known as the obesity paradox. We investigated the effect of low BMI on outcomes after mechanical thrombectomy (MT).

METHODS

We conducted a retrospective analysis of 231 stroke patients who underwent MT at an academic medical center between 2020-2022. The patients' BMI data were collected from admission records and coded based on the Centers for Disease Control and Prevention (CDC) obesity guidelines. Recursive partitioning analysis (RPA) in R software was employed to automatically detect a BMI threshold associated with a significant survival benefit. Frailty was quantified using the Modified Frailty Index 5 and 11.

RESULTS

In our dataset, by CDC classification, 2.6% of patients were underweight, 27.3% were normal BMI, 30.7% were overweight, 19.9% were class I obese, 9.5% were class II obese, and 10% were class III obese. There were no significant differences between these groups. RPA identified a clinically significant BMI threshold of 23.62 kg/m2. Independent of frailty, patients with a BMI ≤23.62 kg/m2 had significantly worse overall survival (P<0.001) and 90-day modified Rankin Scale (P=0.027) than patients above the threshold.

CONCLUSIONS

Underweight patients had worse survival and functional outcomes after MT. Further research should focus on the pathophysiology underlying poor prognosis in underweight MT patients, and whether optimizing nutritional status confers any neuroprotective benefit.

Obesity in acute ischaemic stroke patients treated with intravenous thrombolysis therapy

OBJECTIVES

This article aimed to analyze the relationship between obesity and the efficacy of acute ischaemic stroke patients treated with IVT.

BACKGROUND

Stroke causes morbidity and mortality in large numbers of individuals annually. Intravenous thrombolysis (IVT)with recombinant tissue plasminogen activator (r-tPA) is currently the only approved by the FDA for treatment of acute ischaemic stroke. Researchers have focused on studying the mechanisms associated with ischaemic stroke. Obesity is an established vascular risk factor with increasing prevalence and a huge impact on public health worldwide. It is an independent predictor for ischaemic stroke with a 4% risk increase for each unit augmentation in body mass index (BMI). Therefore, obese patients will constitute an increasing subgroup of candidates for IVT. However, its impact on prognosis in acute ischaemic stroke patients with intravenous thrombolysis did not reach a consensus conclusion.

METHODS

Systematic literature search of PUBMED databases published before August 2020, was performed to identify studies addressing the role of obesity in acute ischaemic stroke patients treated with IVT. Studies included randomized clinical trials, observational studies, guideline statements, and review articles.

CONCLUSIONS

Obesity may be related to long-term prognosis of large group of AIS patients treated with IVT. It depends on the scale of clinical study samples, follow-up time, and evaluation criteria.

Risk factors of hemorrhagic transformation in acute ischaemic stroke: A systematic review and meta-analysis

Background

Hemorrhagic transformation (HT) following reperfusion therapies for acute ischaemic stroke often predicts a poor prognosis. This systematic review and meta-analysis aims to identify risk factors for HT, and how these vary with hyperacute treatment [intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT)].

Methods

Electronic databases PubMed and EMBASE were used to search relevant studies. Pooled odds ratio (OR) with 95% confidence interval (CI) were estimated.

Results

A total of 120 studies were included. Atrial fibrillation and NIHSS score were common predictors for any intracerebral hemorrhage (ICH) after reperfusion therapies (both IVT and EVT), while a hyperdense artery sign (OR = 2.605, 95% CI 1.212-5.599, I ² = 0.0%) and number of thrombectomy passes (OR = 1.151, 95% CI 1.041-1.272, I ² = 54.3%) were predictors of any ICH after IVT and EVT, respectively. Common predictors for symptomatic ICH (sICH) after reperfusion therapies were age and serum glucose level. Atrial fibrillation (OR = 3.867, 95% CI 1.970-7.591, I ² = 29.1%), NIHSS score (OR = 1.082, 95% CI 1.060-1.105, I ² = 54.5%) and onset-to-treatment time (OR = 1.003, 95% CI 1.001-1.005, I ² = 0.0%) were predictors of sICH after IVT. Alberta Stroke Program Early CT score (ASPECTS) (OR = 0.686, 95% CI 0.565-0.833, I ² =77.6%) and number of thrombectomy passes (OR = 1.374, 95% CI 1.012-1.866, I ² = 86.4%) were predictors of sICH after EVT.

Conclusion

Several predictors of ICH were identified, which varied by treatment type. Studies based on larger and multi-center data sets should be prioritized to confirm the results.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=268927, identifier: CRD42021268927.

Body mass index has a non-linear association with three-month outcomes in men with acute ischemic stroke: An analysis based on data from a prospective cohort study

Objective

Despite reports of a connection between body mass index (BMI) and stroke outcome, the findings remain debatable. In this investigation, we sought to determine whether BMI was associated with the probability of 3-month unfavorable outcomes in patients with acute ischemic stroke (AIS).

Methods

This is a second analysis based on a cohort study. 1,897 people with AIS who were treated at a hospital in South Korea from January 2010 to December 2016 were included in the study. The linear relationship between BMI and unfavorable outcomes for AIS patients was evaluated using a binary logistic regression model. The generalized additive model (GAM) and smoothed curve fitting (penalized spline approach) were employed to see if there was a non-linear association between BMI and unfavorable outcomes in patients with AIS.

Results

The binary logistic regression model did not detect any statistically significant correlation between BMI and unfavorable outcomes in AIS patients after controlling for variables. The association between them, however, was non-linear, with the BMI inflection point occurring at 23.07 kg/m2. Each 1 kg/m2 rise in BMI on the left side of the inflection point was linked to a 12% lower risk of unfavorable outcomes (OR= 0.88, 95% CI: 0.82 to 0.96, p = 0.003). We stratified the AIS patients by gender to further explore their relationship. The results showed a specific non-linear relationship and saturation effect of BMI (kg/m2) with 3-month unfavorable outcomes in male patients but not in female patients. The inflection point for BMI was 23.35 kg/m2. When BMI was below 23.35 kg/m2 in men with AIS, BMI was inversely associated with unfavorable outcomes (OR=0.89,95% CI:0.80-0.98).

Conclusion

A particular non-linear connection and saturation effect between BMI (kg/m2) and 3-month unfavorable outcomes were present in male patients with AIS but not in females. 23.35 kg/m2 was the BMI's inflection point. The probability of unfavorable outcomes was substantially and inversely associated with BMI in men with AIS when it was less than 23.35 kg/m2. Men with AIS should have a BMI of no less than 23.35 kg/m2 to reduce the probability of unfavorable outcomes following AIS.

The relationship between nutritional status at the time of stroke on adverse outcomes: a systematic review and meta-analysis of prospective cohort studies

CONTEXT AND OBJECTIVE

The impact of existing malnutrition on stroke outcomes is poorly recognised and treated. Evidence was systematically reviewed and quantified by meta-analysis.

METHODS

MEDLINE, EMBASE and Web of Science were searched from inception to 11 January 2021 and updated in July. Prospective cohort studies, in English, evaluating anthropometric and biomarkers of nutrition on stroke outcomes were included. Risk of bias was assessed using the Scottish Intercollegiate Guidelines Network checklist.

RESULTS

Twenty-six studies (n = 156 249) were eligible (follow-up: One month-14 years). Underweight patients had increased risk of long-term mortality (adjusted hazard ratio = 1.65,1.41-1.95), whilst overweight (0.80,0.74-0.86) and obese patients (0.80,0.75-0.85) had decreased risk compared to normal weight. Odds of mortality decreased in those with high serum albumin (odds ratio = 0.29,0.18-0.48) and increased with low serum albumin (odds ratio = 3.46,1.78-6.74) compared to normal serum albumin (30-35 g/L). Being malnourished compared to well-nourished, as assessed by the Subjective Global Assessment (SGA) or by a combination of anthropometric and biochemical markers increased all-cause mortality (odds ratio = 2.38,1.85-3.06) and poor functional status (adjusted odds ratio = 2.21,1.40-3.49).

CONCLUSION

Nutritional status at the time of stroke predicts adverse stroke outcomes.

Association between abnormal body weight and stroke outcome: A meta-analysis and systematic review

BACKGROUND AND PURPOSE

To test the hypothesis that "obesity paradox" exists in stroke patients, we conducted a meta-analysis and systematic review on the association between abnormal body weight (obesity, overweight, or underweight) and the outcome of different types of stroke.

METHODS

This meta-analysis and systematic review was performed in conformity to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines in Appendix S2. Studies investigating the association between abnormal body weight and the outcome of different types of stroke were searched for in the PubMed and Embase databases from their inception to 20 March 2021.

RESULTS

Thirty-three articles including 84,660 patients were included in this study. Obesity and overweight were associated with longer survival in mixed-stroke patients (acute ischemic stroke [AIS] combined with one or more other stroke subtypes) than was normal weight, whereas underweight was related to shorter survival; the pooled hazard ratios (HRs) of mortality were 0.77 (95% confidence interval [CI] = 0.71-0.83) for obesity, 0.76 (95% CI = 0.72-0.80) for overweight, and 1.71 (95% CI = 1.56-1.87) for underweight. However, only obesity was associated with longer survival in AIS patients compared with normal weight, and underweight was related to shorter survival; the pooled HR of mortality was 0.75 (95% CI = 0.64-0.88) for obesity and 1.53 (95% CI = 1.27-1.85) for underweight. After merging mixed-stroke and AIS patients, we obtained similar results as in mixed-stroke patients.

CONCLUSIONS

Our results suggested that in patients with mixed stroke or AIS, obesity was associated with a longer survival time than normal weight, whereas underweight was associated with a shorter survival time.

Maximum intravenous alteplase dose for obese stroke patients is not associated with greater likelihood of worse outcomes

BACKGROUND

IV alteplase is a primary treatment for acute ischemic stroke (AIS) at a weight-based dose (WBD) of 0.9 mg/kg and maximum dose (MD) of 90 mg. There are conflicting data regarding outcomes for those weighing ≥100 kg. There is also a paucity of data in Hispanics. The prevalence of adult obesity in the US has progressively increased; hence, the percentage of patients receiving the maximum dose also is expected to rise. We examined differences between patients treated with WBD vs. MD.

METHODS

A retrospective review of our center's Get With The Guidelines-Stroke database was performed for IV alteplase cases between October 2013-February 2017. Selection criteria included age ≥18 years, IV alteplase administration, and a recorded measured weight. Patients were dichotomized into WBD group weighing <100 kg and MD group weighing ≥100 kg. Categorical variables were analyzed using Chi square tests and continuous variables were analyzed using independent samples t-tests. Multivariable logistic regression analysis was performed to determine whether MD in combination with other variables was associated with poor outcomes.

RESULTS

There were 328 patients included in the study, 38 (11.6%) received MD. Proportions of younger, male, and non-Hispanic were higher in the MD group. There were no statistically significant differences for initial NIHSS, discharge modified Rankin Scale (mRS), 90-day mRS, symptomatic intracerebral hemorrhage (sICH), or systemic hemorrhage between groups.

CONCLUSION

One in ten patients thrombolysed for the treatment of AIS received MD. In a predominantly Hispanic population, those who received MD and WBD had similar rates of sICH, discharge disposition, and functional outcome (mRS) at discharge and at 90 days. Limitations include small sample size and attrition for the 90-day mRS.

Thrombolysis for massive pulmonary embolisms in morbid obesity: a multisite case-control study

Massive or high-risk pulmonary embolism (PE) confers significant mortality risk and systemic thrombolysis is widely accepted as the first-line treatment in patients without contraindications [1]. High-risk PE in patients with morbid obesity presents unique challenges concerning initial treatments and interventions; in particular, uncertainty over efficacy of weight-based dose adjustments and bleeding complications with antithrombotic therapy [2]. With increasing prevalence of obesity and its independent association with venous thromboembolism (VTE) [3], addressing challenges in management in this patient population has become increasingly relevant. This study evaluated the efficacy and safety of systemic thrombolysis given for massive PE in morbidly obese patients compared to a matched cohort of patients with normal body mass index (BMI).

This case–control study assessed efficacy and safety of systematic thrombolysis in morbidly obese patients with massive pulmonary embolisms. Thrombolysis at conventional doses seems to have similar efficacy and bleeding rates in morbidly obese patients.https://bit.ly/38ZqJr4

Obesity and Stroke: Does the Paradox Apply for Stroke?

Historically, obesity has been identified as one of the most important risk factors for developing cardiovascular diseases including stroke; however, a theory called "The Obesity Paradox" has been recently considered. The paradoxical theory is that obese or overweight patients (according to body mass index score) can have better outcomes compared to leaner or malnourished patients. The paradox was initially discovered in patients with heart failure. The purpose of this manuscript was to investigate whether this paradox also applies to stroke patients, according to information available in the current literature.

Does Body Mass Index Impact the Outcome of Stroke Patients Who Received Intravenous Thrombolysis?

BACKGROUND

We sought to investigate the effect of obesity and BMI on functional outcome and rate of symptomatic intracranial hemorrhage (sICH) in a large sample of patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT).

METHODS

In a single-center retrospective, but prospectively collected data, study of patients with AIS treated with IVT in a 10-year period, patients were placed into groups based on their BMI defined as underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), or obese (<30 kg/m2). The rate of sICH and discharge modified Rankin Scale (mRS) were compared between the groups using logistic regression analysis.

RESULTS

In a total of 834 patients who received IVT for AIS during a 10-year period, 224 (27.0%) were obese. Obese patients did not have a higher rate of sICH after IVT for AIS on the unadjusted or adjusted analysis (adjusted OR 0.95, 95% CI 0.48-1.88). We did not find an association between obesity and poor functional outcome at discharge (adjusted OR 0.76, 95% CI 0.53-1.09).

CONCLUSIONS

After adjusting for confounding factors such as age, baseline National Institute of Health Stroke Scale (NIHSS), and comorbidities, obesity was not associated with an unfavorable functional outcome at discharge nor with a higher risk of sICH in patients with AIS treated with IVT.

Effect of intravenous thrombolysis in stroke depends on pattern of intracranial internal carotid artery calcification

BACKGROUND AND AIMS

The pattern of intracranial internal carotid artery calcification (ICAC) has been identified as an effect modifier of endovascular treatment in patients with acute ischemic stroke, but it is unclear whether it modifies the effect of intravenous thrombolysis. The purpose of this study was to evaluate the association between intravenous thrombolysis and 90-day clinical outcome, follow-up infarct volume, intracranial hemorrhage and recanalization across different patterns of ICAC.

METHODS

Patients with acute ischemic stroke were selected from the Dutch acute stroke study, a prospective multicenter observational cohort study. ICAC pattern was determined on admission thin-slice non-contrast CT and categorized as absent, intimal, medial or indistinguishable. The primary outcome was the ordinal 90-day modified Rankin Scale. Other outcomes included follow-up infarct volume, intracranial hemorrhage, recanalization and collateral status. Associations were quantified with regression analyses and stratified by ICAC pattern.

RESULTS

Of 982 patients, 609 (62%) received intravenous thrombolysis and 381 (39%) had a 90-day modified Rankin Scale of 3-6. Intravenous thrombolysis was associated with a lower 90-day modified Rankin Scale in the group without ICAC (adjusted OR 0.3; 95%-CI 0.1-0.9) and in the group with a medial ICAC pattern (adjusted OR 0.5; 95%-CI 0.3-0.8), but not in the groups with intimal (adjusted OR 0.9; 95%-CI 0.5-1.5) or indistinguishable patterns (adjusted OR 0.6; 95%-CI 0.2-1.8). The associations between intravenous thrombolysis and follow-up infarct volume and intracranial hemorrhage were not significant for any of the ICAC pattern groups. Intravenous thrombolysis was only associated with recanalization in the group with a medial ICAC pattern (adjusted OR 3.5; 95%-CI 1.2-11.0). Compared to an intimal ICAC pattern, a medial ICAC pattern was associated with good collateral status (adjusted OR 2.6; 95%-CI 1.1-6.0).

CONCLUSIONS

Intravenous thrombolysis was significantly associated with favorable clinical outcome and successful recanalization in the group with a medial ICAC pattern, but not in the group with an intimal ICAC pattern.

Prior Stroke in PFO Patients Is Associated With Both PFO-Related and -Unrelated Factors

Background and Purpose: To identify factors associated with prior stroke at presentation in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO).

Methods: We studied cross-sectional data from the International PFO Consortium Study (NCT00859885). Patients with first-ever stroke and those with prior stroke at baseline were analyzed for an association with PFO-related (right-to-left shunt at rest, atrial septal aneurysm, deep venous thrombosis, pulmonary embolism, and Valsalva maneuver) and PFO-unrelated factors (age, gender, BMI, hypertension, diabetes mellitus, hypercholesterolemia, smoking, migraine, coronary artery disease, aortic plaque). A multivariable analysis was used to adjust effect estimation for confounding, e.g., owing to the age-dependent definition of study groups in this cross-sectional study design.

Results: We identified 635 patients with first-ever and 53 patients with prior stroke. Age, BMI, hypertension, diabetes mellitus, hypercholesterolemia, coronary artery disease, and right-to-left shunt (RLS) at rest were significantly associated with prior stroke. Using a pre-specified multivariable logistic regression model, age (Odds Ratio 1.06), BMI (OR 1.06), hypercholesterolemia (OR 1.90) and RLS at rest (OR 1.88) were strongly associated with prior stroke.Based on these factors, we developed a nomogram to illustrate the strength of the relation of individual factors to prior stroke.

Conclusion: In patients with CS and PFO, the likelihood of prior stroke is associated with both, PFO-related and PFO-unrelated factors.

Challenges of Thrombolysis in a Developing Country: Characteristics and Outcomes in Peru

BACKGROUND

The availability of intravenous tissue plasminogen activator (IV-tPA) remains limited worldwide, especially in low-income countries, where the burden of disability due to ischemic stroke is the highest.

AIMS

To evaluate outcomes and safety of IV-tPA at the only Peruvian reference institute for neurologic diseases.

METHODS

We conducted a prospective, observational study of stroke patients who received IV-tPA between 2009 and 2016. We assessed characteristics associated with good outcome (modified Rankine scale 0-2) at 3 months using a multivariate regression model; and factors correlated with clinical improvement (delta National Institute of Health Stroke Scale (NIHSS)) using linear regression.

RESULTS

Only 1.98% (39/1,1962) of patients presenting with ischemic stroke received IV-tPA. Nearly half (41%) were younger than 60 years, 56.4 % were men, and most strokes were cardioembolic (46.2%). The majority (64.1%) were treated within 3-4.5 hours. The median NIHSS on admission and discharge was 9 and 4, respectively; 42.1% of patients had an mRS of 0-1 at 3 months. Three patients (7.7%) developed hemorrhagic conversion, and 1 patient died (2.6%). Patients with good outcomes had lower pretreatment systolic blood pressure (138.9 versus 158.1 mm Hg, P < .007), fewer complications during hospitalization (5 versus 9 events, P < .001), shorter hospital stay (14 versus 21 days, P < .03) and, paradoxically, longer last known well -to-door times (148.3 versus 105 minutes, P < .0022). Clinical improvement was associated with shorter door-to-tPA times and obesity.

CONCLUSIONS

Our findings indicate that IV-tPA has similar safety and outcomes compared to developed countries. All internal metrics (door-to-tPA, door-to-CT, and CT-to-tPA time) improved over time, highlighting areas for future implementation science studies to further expedite the administration of IV-tPA.

Metabolic Syndrome Predicts Poor Outcome in Acute Ischemic Stroke Patients After Endovascular Thrombectomy

BACKGROUND AND AIMS

The metabolic syndrome (MetS) is believed to contribute to a higher probability of developing cardiovascular diseases. This study aimed to investigate whether MetS could predict the prognosis in ischemic stroke patients after endovascular thrombectomy (EVT).

METHODS

Between January 2016 and September 2019, patients treated with EVT due to large vessel occlusions in anterior circulation were prospectively recruited. MetS was defined using the International Diabetes Federation criteria after admission. The primary outcome was a 3-month poor outcome (modified Rankin scale score of 3-6). Secondary outcomes included symptomatic intracranial hemorrhage (sICH) and mortality at 3 months. Multivariable logistic regression models were used to assess the relationship between MetS and clinical outcomes.

RESULTS

A total of 248 patients were enrolled (mean age, 66.7 years; 37.5% female) and 114 (46.0%) met with the MetS criteria. The median National Institutes of Health Stroke Scale score was 15.0. There were 131 (52.8%) patients achieving the poor outcome at 3 months, among which 26 (10.5%) patients developed sICH. The mortality at 3 months was 19.0% (47/248). In multivariable analysis, MetS was significantly correlated to poor outcome (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.29-4.78, P = 0.014). The risk for poor outcome was positively associated with the increased number of MetS components (OR 1.78; 95% CI 1.39-2.35, P = 0.001). No significant findings were found in the association of MetS with sICH and mortality.

CONCLUSION

Our data demonstrated that MetS was associated with poor prognosis in acute ischemic patients treated with EVT.

Clinical Variables and Genetic Risk Factors Associated with the Acute Outcome of Ischemic Stroke: A Systematic Review

Stroke is a complex disease and one of the main causes of morbidity and mortality among the adult population. A huge variety of factors is known to influence patient outcome, including demographic variables, comorbidities or genetics. In this review, we expound what is known about the influence of clinical variables and related genetic risk factors on ischemic stroke outcome, focusing on acute and subacute outcome (within 24 to 48 hours after stroke and until day 10, respectively), as they are the first indicators of stroke damage. We searched the PubMed data base for articles that investigated the interaction between clinical variables or genetic factors and acute or subacute stroke outcome. A total of 61 studies were finally included in this review. Regarding the data collected, the variables consistently associated with acute stroke outcome are: glucose levels, blood pressure, presence of atrial fibrillation, prior statin treatment, stroke severity, type of acute treatment performed, severe neurological complications, leukocyte levels, and genetic risk factors. Further research and international efforts are required in this field, which should include genome-wide association studies.

Body Mass Index and Clinical Outcomes in Large Vessel Occlusion Acute Ischemic Stroke after Endovascular Therapy

Background and Purpose

Several reports have described lower mortality rates in overweight or obese patients as compared to normal weight ones. In the past decade, several studies have investigated the phenomenon, commonly known as the obesity paradox, with mixed results thus far. We sought to determine whether outcomes differ between patients with large vessel occlusion strokes (LVOS) after endovascular therapy (ET) according to their body mass index (BMI).

Methods

We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients that underwent ET for acute LVOS were categorized according to their BMI into 4 groups: (1) underweight (BMI < 18.5), (2) normal weight (BMI = 18.5-25), (3) overweight (BMI = 25-30), and (4) obese (BMI > 30). Baseline characteristics, procedural radiological as well as outcome parameters where compared.

Results

A total of 926 patients qualified for the study, of which 20 (2.2%) were underweight, 253 (27.3%) had a normal weight, 315 (34%) were overweight, and 338 (36.5%) were obese. When compared with normal weight (reference), overweight patients were younger, had higher rates of dyslipidemia and diabetes and higher glucose levels, while obese patients were younger, less often smokers, and had higher rates of hypertension and diabetes and higher glucose levels. Other baseline and procedural characteristics were comparable. The rates of successful reperfusion (modified treatment in cerebral ischemia, 2b-3), parenchymal hematomas, 90-day good clinical outcomes (modified Rankin scale, 0-2), and 90-day mortality were comparable between groups. On multivariate analysis, BMI was not associated with good outcomes nor mortality.

Conclusion

In patients treated with mechanical thrombectomy, BMI is not associated with outcomes. However, patients who are overweight or obese have more comorbidities and a higher stroke risk and, thus, should strive for a normal weight.

Impact of psychiatric comorbidity on the severity, short-term functional outcome, and psychiatric complications after acute stroke

BACKGROUND AND PURPOSE

The comorbidity of psychiatric disorders and cerebrovascular disease appears to be complex with underlying bidirectional influences. Hitherto, research has focused mainly on the evaluation of stroke risk in particular psychiatric disorders; only a few studies have assessed their role in the acute natural history of stroke. The aim of this study was to provide a perspective on psychiatric premorbidity and its impact on stroke severity, psychiatric complications during the initial treatment phase, and the short-term functional outcome of stroke.

PATIENTS AND METHODS

We retrospectively studied the impact of a predocumented psychiatric diagnosis (PDPD) on stroke severity, short-term functional outcome, and psychiatric complications in a sample of 798 patients consecutively admitted for acute ischemic or hemorrhagic stroke by performing a chart review. Group comparisons (PDPD vs non-PDPD) with adjustment for covariates were carried out either using multivariate analysis of variance or logistic regression analysis.

RESULTS

More severe strokes (ie, mean National Institute of Health Stroke Scale score on admission 10.1±7.9 vs 7.5±7.4; F(10,796)=18.5, p<0.0001) and higher prevalence of poor outcome (73.7 vs 54.9%; OR: 2.6, standard error: 0.5, z=4.82, p<0.0001) was found in patients with a documented psychiatric diagnosis at the time of stroke, as well as a higher rate of psychiatric complications during the initial treatment phase (46.7 vs 28.9%; OR: -0.78, z=4.59, p<0.0001).

CONCLUSION

Our data have clinical implications in that they call for identification of psychiatric premorbidity or comorbidity through careful history-taking and particularly close monitoring for psychiatric complications with respect to their potentially negative impact on outcome after stroke.

Association of higher waist circumference with milder stroke severity in acute ischaemic stroke

OBJECTIVES

Although higher body mass index (BMI) was reported to be associated with increased stroke incidence, having a higher BMI is known to be associated with better clinical outcomes after stroke. However, BMI has shown conflicting associations with baseline stroke severity. The aim of our study was to assess the relationship between waist circumference (WC) at admission and baseline stroke severity among patients with ischaemic stroke.

METHODS

The WC of acute stroke patients was divided into sex-specific quartiles. Baseline stroke severity was categorised as mild [National Institutes of Health Stroke Scale (NIHSS) score 0-4], moderate (NIHSS score 5-10), and severe (NIHSS score ≥11). Multinomial logistic regression was used and reference categories were men or women in the lowest sex-specific WC quartiles who had experienced a mild stroke.

RESULTS

A total of 637 female and 766 male patients were included. The adjusted OR of severe stroke were 1.3 (95% CI, 0.7-2.4) for male patients in the third WC quartile, 0.7 (95% CI, 0.3-1.5) for male patients in the second WC quartile, and 0.4 (95% CI, 0.2-0.8) for male patients in the top WC quartile. The adjusted OR of severe stroke for female patients in the third WC quartile, the second WC quartile, and the top WC quartile were 0.8 (95% CI, 0.4-1.5), 0.4 (95% CI, 0.2-0.9), and 0.7 (95% CI, 0.3-1.3), respectively.

DISCUSSION

Higher WC at admission is associated with milder baseline stroke severity among patients with acute ischaemic stroke.

ABBREVIATIONS

BMI: body mass index; CE: cardioembolism; CI: confidence interval; LAA: large-artery atherosclerosis; NIHSS: National Institutes of Health Stroke Scale; OR: odds ratio; SAO: small-artery occlusion; WC: waist circumference.

Cerebrovascular Disease: Consequences of Obesity-Induced Endothelial Dysfunction

Despite the well-known global impact of overweight and obesity in the incidence of cerebrovascular disease, many aspects of this association are still inconsistently defined. In this chapter we aim to present a critical review on the links between obesity and both ischemic and hemorrhagic stroke and discuss its influence on functional outcomes, survival, and current treatments to acute and chronic stroke. The role of cerebrovascular endothelial function and respective modulation is also described as well as its laboratory and clinical assessment. In this context, the major contributing mechanisms underlying obesity-induced cerebral endothelial function (adipokine secretion, insulin resistance, inflammation, and hypertension) are discussed. A special emphasis is given to the participation of adipokines in the pathophysiology of stroke, namely adiponectin, leptin, resistin, apelin, and visfatin.