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Lin J, Ruan S, Sun W, Dong L, Li S, Huang Q, Mao X, Zhang J, Zou K, Zhang H, Huang P, Fang P, Li X, Fan Y, Hong D. A novel score to predict progression in anterior circulation single subcortical infarction patients. Ann Clin Transl Neurol 2024; 11:791-799. [PMID: 38303588 DOI: 10.1002/acn3.52003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE Progressive infarction (PI) has a negative effect on functional prognosis. Our study aimed to develop and validate a risk score for predicting PI in patients with anterior circulation single subcortical infarction (ACSSI). METHODS Between January 2020 and October 2022, we retrospectively enrolled 638 eligible patients with ACSSI. Two-thirds of the eligible patients were randomly allocated to the training cohort (n = 425). Another resampling sample was formed through the bootstrap method and was used as the validation group (n = 425). Multivariate logistic regression analysis was used to identify the independent factors associated with PI. Each factor was then point assigned based on β-coefficient and a risk scoring system was developed. This scoring system was internally validated through 1000-bootstrap resamplings. The C-statistic and Hosmer-Lemeshow test were used to assess model discrimination and calibration. RESULTS PI occurred in 121 patients, accounting for 19.0% of the total patients. A 7-point NTS score system based on the initial NIHSS score, triglyceride-glucose index, and the number of infarct slices on axial diffusion-weighted imaging was developed. The NTS score showed good discrimination and calibration in the training cohort (C-statistic = 0.686; p value of Hosmer-Lemeshow test = 0.797) and validation cohort (C-statistic = 0.681; p value of Hosmer-Lemeshow test = 0.451). The three risk levels for predicting PI in the training and validation cohorts based on NTS score were as follows: low (0-2, 9.6% vs. 9.3%), intermediate (3-5, 28.2% vs. 26.7%), and high risk (6-7, 60.2% vs. 57.4%). INTERPRETATION The NTS score is a valid and convenient risk score for predicting PI in ACSSI patients.
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Affiliation(s)
- Jing Lin
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Shiying Ruan
- Jiangxi Medical Center for Critical Public Health Events, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Weipeng Sun
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Liangbin Dong
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Shumeng Li
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Qin Huang
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Xiaocheng Mao
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Jinchong Zhang
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Keji Zou
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Hudie Zhang
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Pengcheng Huang
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Pu Fang
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Xiaobing Li
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
| | - Yuhua Fan
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510080, China
| | - Daojun Hong
- Department of Neurology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330000, China
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Senda J, Ito K, Kotake T, Mizuno M, Kishimoto H, Yasui K, Katsuno M, Nishida Y, Sobue G. Investigation of inpatient convalescent rehabilitation outcomes in branch atheromatous disease. J Stroke Cerebrovasc Dis 2023; 32:106937. [PMID: 36621120 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 01/09/2023] Open
Abstract
PURPOSE We investigated inpatient convalescent rehabilitation outcomes of Branch atheromatous disease (BAD). SUBJECTS AND METHODS The subjects were 116 patients with lenticulostriate artery territory - BAD (LSA-BAD) and 29 with paramedian pontine artery territory - BAD (PPA-BAD). For all patients, the National Institutes of Health Stroke Scale (NIHSS), Functional Independence Measure (FIM) scores, and Brunnstrom recovery stages (BRS) of the upper limb, fingers, and lower limb were measured on admission and at discharge. RESULTS There were no significant differences in clinical characteristics on admission between the LSA-BAD and PPA-BAD groups. The neurological severity of PPA-BAD, as measured by the NIHSS, was significantly milder compared with that of LSA-BAD upon admission (p = 0.015) and at discharge (p = 0.001). Patients with LSA-BAD had significantly less improvement in the BRS of the upper limb (p = 0.001), fingers (p < 0.001), and lower limb (p = 0.007) at discharge. Furthermore, they had significantly smaller changes in BRS between admission and discharge for the upper limb (p = 0.033) and fingers (p = 0.014) compared with patients with PPA-BAD. The improvement in BRS for patients with LSA-BAD tended to be limited to two stages; however, both patients with LSA-BAD and PPA-BAD saw sufficient gains in FIM at discharge. CONCLUSION Rehabilitation outcomes following BAD in the convalescent period should be assessed in terms of improvements in pure-motor hemiparesis and activities of daily living. Furthermore, the disturbance patterns in the corticospinal tract by ischemic stroke lesions may be different between LSA-BAD and PPA-BAD.
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Affiliation(s)
- Joe Senda
- Department of Neurology and Rehabilitation, Komaki City Hospital, Komaki, Japan; Division of Rehabilitation, Kami-iida Rehabilitation Hospital, Nagoya, Japan.
| | - Keiichi Ito
- Division of Rehabilitation, Kami-iida Rehabilitation Hospital, Nagoya, Japan
| | - Tomomitsu Kotake
- Division of Rehabilitation, Kami-iida Rehabilitation Hospital, Nagoya, Japan; Department of Physiology, Graduate School of Health Sciences, Toyohashi Sozo University, Toyohashi, Japan
| | - Masanori Mizuno
- Division of Rehabilitation, Kami-iida Rehabilitation Hospital, Nagoya, Japan
| | - Hideo Kishimoto
- Division of Rehabilitation, Kami-iida Rehabilitation Hospital, Nagoya, Japan
| | - Keizo Yasui
- Department of Neurology, Japanese Red Cross Aichi Medical Center Nagoya Second Hospital, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Nishida
- Division of Rehabilitation, Nagoya University Hospital, Nagoya, Japan; Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Gen Sobue
- Graduate School of Medicine, Aichi Medical School, Nagakute, Japan
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Christidi F, Tsiptsios D, Sousanidou A, Karamanidis S, Kitmeridou S, Karatzetzou S, Aitsidou S, Tsamakis K, Psatha EA, Karavasilis E, Kokkotis C, Aggelousis N, Vadikolias K. The Clinical Utility of Leukoaraiosis as a Prognostic Indicator in Ischemic Stroke Patients. Neurol Int 2022; 14:952-980. [PMID: 36412698 PMCID: PMC9680211 DOI: 10.3390/neurolint14040076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Stroke constitutes a major cause of functional disability with increasing prevalence among adult individuals. Thus, it is of great importance for both clinicians and stroke survivors to be provided with a timely and accurate prognostication of functional outcome. A great number of biomarkers capable of yielding useful information regarding stroke patients' recovery propensity have been evaluated so far with leukoaraiosis being among them. Literature research of two databases (MEDLINE and Scopus) was conducted to identify all relevant studies published between 1 January 2012 and 25 June 2022 that dealt with the clinical utility of a current leukoaraiosis as a prognostic indicator following stroke. Only full-text articles published in English language were included. Forty-nine articles have been traced and are included in the present review. Our findings highlight the prognostic value of leukoaraiosis in an acute stroke setting. The assessment of leukoaraiosis with visual rating scales in CT/MRI imaging appears to be able to reliably provide important insight into the recovery potential of stroke survivors, thus significantly enhancing stroke management. Yielding additional information regarding both short- and long-term functional outcome, motor recovery capacity, hemorrhagic transformation, as well as early neurological deterioration following stroke, leukoaraiosis may serve as a valuable prognostic marker poststroke. Thus, leukoaraiosis represents a powerful prognostic tool, the clinical implementation of which is expected to significantly facilitate the individualized management of stroke patients.
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Affiliation(s)
- Foteini Christidi
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Dimitrios Tsiptsios
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
- Correspondence:
| | - Anastasia Sousanidou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Stefanos Karamanidis
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Sofia Kitmeridou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Stella Karatzetzou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Souzana Aitsidou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Konstantinos Tsamakis
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London, London SE5 8AF, UK
| | - Evlampia A. Psatha
- Department of Radiology, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Efstratios Karavasilis
- Medical Physics Laboratory, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Christos Kokkotis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Konstantinos Vadikolias
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
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Lin J, Mao X, Liao Y, Luo S, Huang Q, Song Z, Li S, Li C, Qiu Y, Wu Y, Zhu M, Li X, Yu Q, Hong D. A lesion extending three or more slices as a predictor of progressive infarction in anterior circulation small subcortical infarction. Front Neurol 2022; 13:926187. [PMID: 36277920 PMCID: PMC9579366 DOI: 10.3389/fneur.2022.926187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
Progressive infarction (PI) is common in small subcortical infarction and may lead to a poor outcome. The purpose of our study is to identify neuroimaging predictors for PI. From April 2017 to December 2020, we enrolled 86 patients with an anterior circulation subcortical infarction within 48 h after onset. Progressive infarction was defined by an increase of ≥ one point in motor power or ≥ two points in the total National Institute of Health Stroke Scale score within 7 days after admission and further confirmed by diffusion-weighted imaging (DWI). To identify predictors, demographic characteristics, clinical information, laboratory date, and neuroimaging characteristics were evaluated. The infarct size and infarct slice number were measured by DWI. We found that thirty-one patients (36%) had PI. In a univariate analysis, the patients with PI had higher levels of triglyceride, lower levels of blood urea nitrogen and prothrombin time, and a higher frequency of infarct slice number ≥ three compared to the patients without PI. After logistic regression stepwise adjustment for all considered relevant confounders, infarct slice number ≥ three slices proved to be independently associated with PI (OR = 4.781, 95% CI 1.677–13.627; OR = 4.867, 95% CI 1.6–14.864; OR = 3.584, 95% CI 1.034–12.420). Our study showed that a lesion extending ≥ three slices on DWI is an independent predictor for progressive infarction in patients with anterior circulation small subcortical infarction.
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Affiliation(s)
- Jing Lin
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaocheng Mao
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yunfang Liao
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Si Luo
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qin Huang
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ziwei Song
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shumeng Li
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chengjin Li
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuexin Qiu
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, China
| | - Yuhang Wu
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, China
| | - Min Zhu
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaobing Li
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qiulong Yu
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Qiulong Yu
| | - Daojun Hong
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Daojun Hong
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Yang T, Deng Q, Jiang S, Yan YY, Yuan Y, Wu SM, Zhang ST, Sun JY, Wu B. Cognitive impairment in two subtypes of a single subcortical infarction. Chin Med J (Engl) 2021; 134:2992-8. [PMID: 34908257 DOI: 10.1097/CM9.0000000000001938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Single subcortical infarction (SSI) is caused by two main etiological subtypes, which are branch atheromatous disease (BAD) and cerebral small vessel disease (CSVD)-related SSI. We applied the Beijing version of the Montreal Cognitive Assessment (MoCA-BJ), the Shape Trail Test (STT), and the Stroop Color and Word Test (SCWT) to investigate the differences in cognitive performance between these two subtypes of SSI. Methods: Patients with acute SSIs were prospectively enrolled. The differences of MoCA-BJ, STT, and SCWT between the BAD group and CSVD-related SSI group were analyzed. A generalized linear model was used to analyze the associations between SSI patients with different etiological mechanisms and cognitive function. We investigated the correlations between MoCA-BJ, STT, and SCWT using Spearman's correlation analysis and established cut-off scores for Shape Trail Test A (STT-A) and STT-B to identify cognitive impairment in patients with SSI. Results: This study enrolled a total of 106 patients, including 49 and 57 patients with BAD and CSVD-related SSI, respectively. The BAD group performances were worse than those of the CSVD-related SSI group for STT-A (83 [60.5–120.0] vs. 68 [49.0–86.5], P = 0.01), STT-B (204 [151.5–294.5] vs. 153 [126.5–212.5], P = 0.015), and the number of correct answers on Stroop-C (46 [41–49] vs. 49 [45–50], P = 0.035). After adjusting for age, years of education, National Institutes of Health Stroke Scale and lesion location, the performance of SSI patients with different etiological mechanisms still differed significantly for STT-A and STT-B. Conclusions: BAD patients were more likely to perform worse than CSVD-related SSI patients in the domains of language, attention, executive function, and memory. The mechanism of cognitive impairment after BAD remains unclear.
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Jang SH, Park SW, Kwon DH, Park H, Sohn SI, Hong JH. The Length of an Infarcted Lesion Along the Perforating Artery Predicts Neurological Deterioration in Single Subcortical Infarction Without Any Relevant Artery Stenosis. Front Neurol 2020; 11:553326. [PMID: 33133005 PMCID: PMC7550690 DOI: 10.3389/fneur.2020.553326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 08/31/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Seong Hwa Jang
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Sang-Won Park
- Department of Neurology, Daegu Fatima Hospital, Daegu, South Korea
| | - Doo Hyuk Kwon
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
- *Correspondence: Jeong-Ho Hong
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Im K, Ju H, Lee M, Joo BE, Kwon KY, Roh H, Ahn MY, Hwang HW, Lee KB. Recent glycemic control can predict the progressive motor deficits of acute subcortical infarction with diabetes or prediabetes. Neurol Sci 2020; 42:285-291. [PMID: 32737806 DOI: 10.1007/s10072-020-04634-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 07/27/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE The predictors of progressive motor deficits in acute subcortical infarctions are still controversial. It is not known whether glycemic control influences on stroke progression. METHODS A total of 268 consecutive patients with diabetes or prediabetes who had acute (< 24 h) subcortical infarction were enrolled. (1) All patients were divided into 4 groups by quartile of glycated hemoglobin (HbA1c). (2) Only the patients with diabetes were divided by effective glycemic control. Progressive motor deficits were prospectively captured and defined as an increase of motor score ≥ 1 on the upper or lower limb items of the National Institute of Health Stroke Scale within 72 h from stroke onset. RESULTS Progressive motor deficits occur in 8/78 (10.3%) for ≤ 5.9, 15/61 (24.6%) for 6.0-6.4, 16/62 (25.8%) for 6.5-7.4, and 30/67 (44.8%) for ≥ 7.5. In diabetic patients alone, those occur in 5/37 (13.5%) for ≤ 6.5, 10/42 (23.8%) for 6.6-7.0, 12/42 (28.6%) for 7.1-8.0, and 24/50 (48.0%) for ≥ 8.1. An adjusted OR of progressive motor deficits was 2.61 (95% confidence interval [CI] 0.98-7.00, P = .056) for 6.0-6.4, 3.42 (95% CI 1.27-9.18, P = .015) for 6.5-7.4, and 6.65 (95% CI 2.38-18.62, P < .001) for ≥ 7.5. In diabetic patients alone, those were 3.15 (95% CI 0.89-11.15, P = .075) for 6.6-7.0, 2.90 (95% CI 0.79-10.61, P = .107) for 7.1-8.0, and 4.17 (95% CI 1.07-16.25, P = .038) for ≥ 8.1. The optimal cutoff value of HbA1c was 6.65% in discriminating progressive motor deficits. CONCLUSION Increased HbA1c was associated with higher incidence of progressive motor deficits in acute subcortical infarction with diabetes and prediabetes.
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Affiliation(s)
- Kayeong Im
- Departments of Neurology, Soonchunhyang University School of Medicine, 59 Daesakwan-ro, Yong san-gu, Seoul, 04401, South Korea
| | - Hyunjin Ju
- Departments of Neurology, Soonchunhyang University School of Medicine, 59 Daesakwan-ro, Yong san-gu, Seoul, 04401, South Korea
| | - Mina Lee
- Departments of Neurology, Soonchunhyang University School of Medicine, 59 Daesakwan-ro, Yong san-gu, Seoul, 04401, South Korea
| | - Byung-Euk Joo
- Departments of Neurology, Soonchunhyang University School of Medicine, 59 Daesakwan-ro, Yong san-gu, Seoul, 04401, South Korea
| | - Kyum-Yil Kwon
- Departments of Neurology, Soonchunhyang University School of Medicine, 59 Daesakwan-ro, Yong san-gu, Seoul, 04401, South Korea
| | - Hakjae Roh
- Departments of Neurology, Soonchunhyang University School of Medicine, 59 Daesakwan-ro, Yong san-gu, Seoul, 04401, South Korea
| | - Moo-Young Ahn
- Departments of Neurology, Soonchunhyang University School of Medicine, 59 Daesakwan-ro, Yong san-gu, Seoul, 04401, South Korea
| | - Hye-Won Hwang
- Departments of Neurology, Soonchunhyang University School of Medicine, 59 Daesakwan-ro, Yong san-gu, Seoul, 04401, South Korea
| | - Kyung Bok Lee
- Departments of Neurology, Soonchunhyang University School of Medicine, 59 Daesakwan-ro, Yong san-gu, Seoul, 04401, South Korea.
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Liao CH, Liao NC, Chen WH, Chen HC, Chang MH, Tsuei YS, Shen CC, Yang SF, Chen PL. Penumbra volume predicts unfavorable outcome in patients with acute minor stroke or transient ischemic attack. J Chin Med Assoc 2020; 83:551-556. [PMID: 32371664 DOI: 10.1097/jcma.0000000000000342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A subgroup of patients with acute minor stroke (AMS) or transient ischemic attack (TIA) become disabled due to disease progression (DP) or recurrent stroke within 3 months. The aim of this article is to identify the risk factors for DP in AMS/TIA patients. In the literature, no studies focused on computed tomography perfusion (CTP) in AMS/TIA patients at the acute stage. METHODS This retrospective study included patients with AMS or TIA (onset of symptoms ≤4.5 hours, baseline National Institutes of Health Stroke Scale [NIHSS] score of 0-4). DP was defined as a deterioration of NIHSS score of ≥2 points during hospitalization or modified Ranking Scale ≥2 at 3-month follow-up. Clinical data and imaging results were retrieved and measured for statistical analysis. RESULTS From 2011 to 2017, total 135 patients were eligible for further analysis: 28 patients (20.7%, DP group) and 107 patients (79.3%, non-DP group). The DP group had significantly higher larger penumbra volumes (p = 0.028). In univariate model of the logistic regression, patients with the following risk factors tended to have unfavorable outcome: female gender, higher HbA1c, chronic kidney disease stage ≥3b, intracranial atherosclerosis, and penumbra volume were associated unfavorable outcome, but larger deadcore volume was not. In further multivariate analysis, only penumbra volume >5 cm (p = 0.049, odds ratio [OR] = 3.21, 95% CI: 1.00-10.27) had the statistical significance. The cut-point value of the penumbra volume for unfavorable outcome in AMS/TIA patients was 4.73 cm. CONCLUSION One fifth of the AMS/TIA patients had unfavorable outcome at 90 days. In CTP performed within 4.5 hours after the onset of AMS/TIA, the penumbra volume (>5 cm) was a significant risk factor for DP, and the cut-point value was 4.73 cm. Further studies could be designed to involve this subgroup of patients for more aggressive treatment.
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Affiliation(s)
- Chih-Hsiang Liao
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Division of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Surgery, Taichung Veterans General Hospital Chiayi Branch, Chiayi, Taiwan, ROC
| | - Nien-Chen Liao
- Division of General Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Wen-Hsien Chen
- Division of Neuro-radiology, Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Hung-Chieh Chen
- Division of Neuro-radiology, Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ming-Hong Chang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Division of General Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Yuang-Seng Tsuei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Division of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chiung-Chyi Shen
- Division of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Po-Lin Chen
- Division of General Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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Obata K, Kinoshita M, Sato K, Chin M, Yamagata S, Ikeda A, Shindo K. Branch atheromatous disease has a stronger association with late-onset epileptic seizures than lacunar infarction in Japanese patients. J Int Med Res 2020; 48:300060519831572. [PMID: 30841770 PMCID: PMC7140214 DOI: 10.1177/0300060519831572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate the relationship between late-onset epileptic seizures and
non-cortical infarction (namely, lacunar infarction and branch atheromatous
disease [BAD]) in Japanese patients. Methods We reviewed the medical records and brain magnetic resonance imaging findings
of all patients with ischemic stroke admitted to the Departments of
Neurology, Neurosurgery, and Stroke Unit at Kurashiki Central Hospital from
1 January 2011 to 31 December 2012. Patients with lacunar infarction and BAD
were enrolled; those with cortical and brain stem ischemic lesions were
excluded. We analyzed the clinical features of patients who developed
late-onset epileptic seizures after cerebral infarction. Results Eighty-five patients with lacunar infarction and 99 patients with BAD were
enrolled. Four patients with BAD subsequently developed epileptic seizures
(2.2% of total patients, 4.0% of patients with BAD), whereas no patients
with lacunar infarction developed epileptic seizures. All patients with
epileptic seizures had infarction involving the basal ganglia or thalamus.
Three of them had multiple cerebral microbleeds, and two had dementia. Conclusions Patients with BAD, but not with lacunar infarction, might have a higher risk
of developing epileptic seizures than the general population. Non-cortical
infarctions with involvement of the basal ganglia or thalamus may increase
the risk of subsequent late-onset epileptic seizures.
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Affiliation(s)
- Kaoru Obata
- Department of Neurology, Kurashiki Central Hospital, Okayama, Japan
| | - Masako Kinoshita
- Department of Neurology, Utano National Hospital, National Hospital Organization, Kyoto, Japan
| | - Kazuaki Sato
- Department of Neurology, Kurashiki Central Hospital, Okayama, Japan
| | - Masaki Chin
- Department of Stroke Unit, Kurashiki Central Hospital, Okayama, Japan
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Sen Yamagata
- Department of Stroke Unit, Kurashiki Central Hospital, Okayama, Japan
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Katsuro Shindo
- Department of Neurology, Kurashiki Central Hospital, Okayama, Japan
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10
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Naess H, Thomassen L, Waje-Andreassen U, Glad S, Kvistad CE. High risk of early neurological worsening of lacunar infarction. Acta Neurol Scand 2019; 139:143-149. [PMID: 30229856 DOI: 10.1111/ane.13029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/27/2018] [Accepted: 09/12/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate factors associated with neurological worsening among patients with lacunar or non-lacunar infarction admitted within 3 hours and between 3 and 24 hours after stroke onset. METHODS All patients admitted to Haukeland university hospital between 2006 and 2016 with acute cerebral infarction on MRI and admission within 24 hours were included. Repeated National Institute of Health Stroke Scale (NIHSS) scoring was performed in all patients whenever possible. Neurological worsening during the hospital stay was defined as NIHSS score increase ≥3 compared to NIHSS score on admission. RESULTS In patients with lacunar infarction admitted within 3 hours of onset, neurological worsening was associated with low NIHSS score on admission, low body temperature, and leukoaraiosis, whereas only internal carotid artery stenosis or occlusion was associated with neurological worsening in non-lacunar infraction. For patients admitted 3-24 hours after onset, neurological worsening was associated with low body temperature, high systolic blood pressure, and short time from onset to admission in patients with lacunar infarction, whereas high systolic blood pressure, high NIHSS score on admission, middle cerebral artery occlusion, and high blood glucose were associated with neurological worsening in patients with non-lacunar infarction (all P < 0.05). CONCLUSIONS Lacunar infarctions with minor neurological deficits within 3 hours of stroke onset are at high risk of neurological worsening especially if concomitant low body temperature and leukoaraiosis.
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Affiliation(s)
- Halvor Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Centre for age-related medicine; Stavanger University Hospital; Stavanger Norway
| | - Lars Thomassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Ulrike Waje-Andreassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Solveig Glad
- Department of Neurology; Haukeland University Hospital; Bergen Norway
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11
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Jiang J, Huang X, Zhang Y, Deng W, Shen F, Liu J. Total MRI burden of cerebral vessel disease correlates with the progression in patients with acute single small subcortical strokes. Brain Behav 2019; 9:e01173. [PMID: 30506998 PMCID: PMC6346414 DOI: 10.1002/brb3.1173] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/27/2018] [Accepted: 10/29/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The patients of single small subcortical strokes (SS) commonly have neurological worsening with risk factors, and mechanisms remain unclear. Asymptomatic lacunes, white matter lesions, cerebral microbleeds, and enlarged perivascular spaces are MRI markers of cerebral small vessel disease (cSVD). Previous studies mostly explored the association between the neurological deterioration and presence of above markers separately. The relationship between progressive single small SS and the simultaneous presence of multiple markers of cSVD has not been fully identified. We aimed to investigate whether total burden of cSVD detected with MRI was associated with progressive small SS in this study. METHODS Patients with single small SS (2.0 cm in diameter) were prospectively recruited during January 2016 and May 2018. Progression was defined as worsening by ≥1 point in National Institutes Health Stroke Scale (NIHSS) motor score within 72 hr from onset. The presence and burden of cSVD were determined by brain MRI, producing a score between 0 and 4. Besides, the patients' characteristics, clinical data, medical treatments during hospitalization stay were collected and statistically analyzed. Associations with progression were tested with forward stepwise regression analyses. RESULTS Fifty-seven (35.6%) patients underwent progression. No significant difference was observed in the distribution of any single vascular risk factor and its related laboratory data among these patients. After adjustment for age, sex, NIHSS score at admission, and time from stroke to MRI in separate models, severe WMHs (OR = 4.892; 95% CI = 2.011-11.904, p = 0.016), moderate- and high-grade basal ganglia EPVS (OR = 2.970; 95% CI = 1.861-6.121, p = 0.009), and total cSVD score (OR = 3.359; 95% CI = 2.016-5.599, p = 0.010) were associated with progression. CONCLUSION This study demonstrated that total MRI cSVD burden was independently associated with progression after single small subcortical strokes.
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Affiliation(s)
- Jingwen Jiang
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojun Huang
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Zhang
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiping Deng
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fanxia Shen
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianrong Liu
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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12
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Oji S, Tomohisa D, Hara W, Tajima T, Suzuki M, Saito A, Yoshida N, Nomura K. Mean Platelet Volume Is Associated with Early Neurological Deterioration in Patients with Branch Atheromatous Disease: Involvement of Platelet Activation. J Stroke Cerebrovasc Dis 2018; 27:1624-1631. [PMID: 29428328 DOI: 10.1016/j.jstrokecerebrovasdis.2018.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 01/04/2018] [Accepted: 01/13/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The most attentive clinical problem in patients with branch atheromatous disease (BAD) is early neurological deterioration (END). Although the platelet activation (PA) is involved in pathogenesis, the relationship between PA and END has remained unclear. We investigated clinical data including mean platelet volume (MPV, fL) as a marker for PA to identify clinically useful biomarkers for END. METHODS A total of 64 patients with BAD were investigated retrospectively, and divided into 2 groups based on whether neurologic symptoms deteriorated or not: BAD with and without END (END and non-END). The END was defined as patients with point increase of 1 or greater in the National Institutes of Health Stroke Scale (NIHSS); non-END was defined as those without such increase. Clinical features such as NIHSS, modified Rankin scale (mRS), laboratory data including MPV, lesion size (LS, mm) on admission, and treatments were compared between the 2 groups. RESULTS Of 64 patients, 17 cases had an END. The median values of NIHSS, mRS, MPV, and LS on admission were significantly greater in END than in non-END (P < .05, respectively). There was no correlation of MPV with NIHSS, mRS and LS, respectively. The median values of MPV were significantly higher in END than in non-END and control (P < .05, respectively). A receiver operating characteristic curve indicated a value of 10.1 as cutoff level for MPV to discriminate between END and non-END. CONCLUSIONS High MPV values on admission may be an independent biomarker for END. Physicians should pay more careful attention to END in BAD showing MPV values higher than 10.1 on admission.
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Affiliation(s)
- Satoru Oji
- Saitama Medical Center, Saitama Medical University Kawagoe, Saitama, Japan.
| | - Dembo Tomohisa
- Saitama Medical Center, Saitama Medical University Kawagoe, Saitama, Japan
| | - Wataru Hara
- Saitama Medical Center, Saitama Medical University Kawagoe, Saitama, Japan
| | - Takashi Tajima
- Saitama Medical Center, Saitama Medical University Kawagoe, Saitama, Japan
| | - Masato Suzuki
- Saitama Medical Center, Saitama Medical University Kawagoe, Saitama, Japan
| | - Akane Saito
- Saitama Medical Center, Saitama Medical University Kawagoe, Saitama, Japan
| | - Norihito Yoshida
- Saitama Medical Center, Saitama Medical University Kawagoe, Saitama, Japan
| | - Kyoichi Nomura
- Saitama Medical Center, Saitama Medical University Kawagoe, Saitama, Japan
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13
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Takahashi Y, Yamashita T, Morihara R, Nakano Y, Sato K, Takemoto M, Hishikawa N, Ohta Y, Manabe Y, Abe K. Different Characteristics of Anterior and Posterior Branch Atheromatous Diseases with or without Early Neurologic Deterioration. J Stroke Cerebrovasc Dis 2017; 26:1314-1320. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/22/2017] [Accepted: 02/02/2017] [Indexed: 11/25/2022] Open
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14
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Pidaparthi L, Kotha A, Aleti VR, Kohat AK, Kandadai MR, Turaga S, Shaik JA, Alladi S, Kanikannan MA, Rupam B, Kaul S. Factors influencing nonadministration of thrombolytic therapy in early arrival strokes in a university hospital in Hyderabad, India. Ann Indian Acad Neurol 2016; 19:351-5. [PMID: 27570387 PMCID: PMC4980958 DOI: 10.4103/0972-2327.179976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND It is a well-known fact that very few patients of stroke arrive at the hospital within the window period of thrombolysis. Even among those who do, not all receive thrombolytic therapy. OBJECTIVE The objectives of this study were to determine the proportion of early arrival ischemic strokes (within 6 h of stroke onset) in our hospital and to evaluate the causes of nonadministration of intravenous and/or intraarterial thrombolysis in them. MATERIALS AND METHODS Data of all early arrival acute stroke patients between January 2010 and January 2015 were included. Factors determining nonadministration of intravenous and/or intraarterial thrombolysis in early arrival strokes were analyzed. RESULTS Out of 2,593 stroke patients, only 145 (5.6%) patients presented within 6 h of stroke onset and among them 118 (81.4%) patients had ischemic stroke and 27 (18.6%) patients had hemorrhagic stroke. A total of 89/118 (75.4%) patients were thrombolyzed. The reasons for nonadministration of thrombolysis in the remaining 29 patients were analyzed, which included unavoidable factors in 8/29 patients [massive infarct (N = 4), hemorrhagic infarct (N = 1), gastrointestinal bleed (N = 1), oral anticoagulant usage with prolonged international normalized ratio (INR) (N = 1), and recent cataract surgery (N = 1)]. Avoidable factors were found for 21/29 patients, include nonaffordability (N = 7), fear of bleed (N = 4), rapidly improving symptoms (N = 4), mild stroke (N = 2), delayed neurologist referral within the hospital (N = 2), and logistic difficulty in organizing endovascular treatment (N = 2). CONCLUSION One-fourth of early ischemic stroke patients in our study were not thrombolyzed even though they arrived within the window period. The majority of the reasons for nonadministration of thrombolysis were potentially preventable, such as nonaffordability, intrahospital delay, and nonavailability of newer endovascular interventions.
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Affiliation(s)
- Lalitha Pidaparthi
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Anitha Kotha
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Venkat Reddy Aleti
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Abhijeet Kumar Kohat
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Mridula R Kandadai
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Suryaprabha Turaga
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Jabeen A Shaik
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Suvarna Alladi
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Meena A Kanikannan
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Borgohain Rupam
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
| | - Subhash Kaul
- Department of Neurology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, Telangana, India
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Lee K, Jung K, Park C, Kim J, Lee S, Chu K, Kim M, Lee SK, Roh J. Increased arterial pulsatility and progression of single subcortical infarction. Eur Radiol 2017; 27:899-906. [DOI: 10.1007/s00330-016-4486-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 06/13/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
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16
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Robba C, Bacigaluppi S, Cardim D, Donnelly J, Bertuccio A, Czosnyka M. Non-invasive assessment of intracranial pressure. Acta Neurol Scand 2016; 134:4-21. [PMID: 26515159 DOI: 10.1111/ane.12527] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 11/29/2022]
Abstract
Monitoring of intracranial pressure (ICP) is invaluable in the management of neurosurgical and neurological critically ill patients. Invasive measurement of ventricular or parenchymal pressure is considered the gold standard for accurate measurement of ICP but is not always possible due to certain risks. Therefore, the availability of accurate methods to non-invasively estimate ICP has the potential to improve the management of these vulnerable patients. This review provides a comparative description of different methods for non-invasive ICP measurement. Current methods are based on changes associated with increased ICP, both morphological (assessed with magnetic resonance, computed tomography, ultrasound, and fundoscopy) and physiological (assessed with transcranial and ophthalmic Doppler, tympanometry, near-infrared spectroscopy, electroencephalography, visual-evoked potentials, and otoacoustic emissions assessment). At present, none of the non-invasive techniques alone seem suitable as a substitute for invasive monitoring. However, following the present analysis and considerations upon each technique, we propose a possible flowchart based on the combination of non-invasive techniques including those characterizing morphologic changes (e.g., repetitive US measurements of ONSD) and those characterizing physiological changes (e.g., continuous TCD). Such an integrated approach, which still needs to be validated in clinical practice, could aid in deciding whether to place an invasive monitor, or how to titrate therapy when invasive ICP measurement is contraindicated or unavailable.
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Affiliation(s)
- C. Robba
- Neurosciences Critical Care Unit; Addenbrooke's Hospital; Cambridge United Kingdom
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
| | - S. Bacigaluppi
- Department of Neurosurgery; Galliera Hospital; Genova Italy
| | - D. Cardim
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
| | - J. Donnelly
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
| | - A. Bertuccio
- Department of Neurosurgery; S. George's Hospital; University of London; United Kingdom
| | - M. Czosnyka
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
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