Context: The focus of thrombolytic therapy in acute stroke has been on favorable outcome at 3 months. Few studies have analyzed outcome at 24 hours. An early and reliable prediction of poor outcome has implications fo...Context: The focus of thrombolytic therapy in acute stroke has been on favorable outcome at 3 months. Few studies have analyzed outcome at 24 hours. An early and reliable prediction of poor outcome has implications for clinical management and discharge planning. Abstract:Objective: To evaluate predictors of lack of improvement at 24 hours after receiving alteplase and their relationship with poor outcome at 3 months. Design, Setting, and Participants: Prospective cohort of consecutive patients with acute stroke who received alteplase and were admitted to a university hospital from January 1999 to March 2003. Participants were recruited from 2 academic centers in a major city in Ontario and 33 affiliated hospitals from 7 counties. Main Outcome Measures: Lack of improvement defined as a difference between the National Institutes of Health Stroke Scale score at baseline and at 24 hours of 3 points or less. Poor outcome at 3 months defined by a modified Rankin Scale score of 3 to 5 or death. Results: Among 216 patients with acute stroke who were treated with alteplase, 111 (51.4% ) had a lack of improvement at 24 hours. After adjusting for age, sex, and stroke severity, baseline glucose level on admission (odds ratio [OR] 2.89; 95% confidence interval [CI], 1.40- 5.99 for a glucose level > 144 mg/dL [ > 8 mmol/L]), cortical involvement (OR, 2.66; 95% CI, 1.36- 5.20), and time to treatment (OR, 1.01; 95% CI, 1.0- 1.02 for each 1 minute increase in time to treatment) were independent predictors of lack of improvement. At 3 months, 43 patients (20.2% ) had died; of the 170 survivors, 75 patients (44% ) had poor outcomes. After adjusting for age, sex, and stroke severity, lack of improvement at 24 hours was an independent predictor of poor outcome (OR, 12.9; 95% CI, 5.7- 29.6)- and death (OR, 7.5; 95% CI, 2.9- 19.6). Patients with a lack of improvement had longer lengths of hospitalization (14.5 vs 9.6 days; P=.02). Conclusions: Among patients with acute stroke treated with thrombolytic therapy, lack of improvement at 24 hours is associated with poor outcome and death at 3 months. Elevated glucose level, time to thrombolytic therapy, and cortical involvement were predictors of lack of improvement.展开更多
Background: Use of medications with vasoconstrictive or vasodilatory effects can potentially affect the risk for vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Methods: Using International Classification of...Background: Use of medications with vasoconstrictive or vasodilatory effects can potentially affect the risk for vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Methods: Using International Classification of Diseases-9 diagnostic codes followed by medical record review, the authors identified 514 patients with SAH admitted between 1995 and 2003 who were evaluated for vasospasm between days 4 and 14. The authors determined risks for vasospasm, symptomatic vasospas m, and poor clinical outcomes in patients with documented pre-hemorrhagic use o f calcium channel blockers, beta-receptor blockers, ACE inhibitors, aspirin, se lective serotonin reuptake inhibitors (SSRIs), non-SSRI vasoactive antidepressa nts, or statins. Results: Vasospasm developed in 62%, and symptomatic vasospasm in 29%of the cohort. On univariate analysis, the risk for all vasospasm tended to increase in patients taking SSRIs (p=0.09) and statins (p=0.05); SSRI use in creased the risk for symptomatic vasospasm (p=0.028). The Cochran-Armitage tren d test showed that the proportion of patients taking SSRIs and statins increased significantly across three wors ening categories (none, asymptomatic, symptomatic) of vasospasm. Logistic regres sion analysis showed that SSRI use tended to predict all vasospasm (O.R. 2.01 [0 .91 to 4.45]), and predicted symptomatic vasospasm (O.R. 1.42 [1.06 to 4.33]) . Statin exposure increased the risk for vasospasm (O.R. 2.75 [1.16 to 6.50]), perh aps from abrupt statin withdrawal (O.R. 2.54 [0.78 to 8.28]). Age < 50 years, Hunt-Hess grade 4 or 5, and Fisher Group 3 independently predicted all vasospasm, symptomatic vasospasm, poor discharge clinical status, and death. Conclusion: Selective serotonin reuptake inhibitor and statin users have a higher risk for su barachnoid hemorrhagerelated vasospasm. Whether the underlying disease indicatio n, direct actions, or rebound effects from abrupt drug withdrawal account for th e associated risk warrants further investigation.展开更多
Background and Purpose - The length of stay (LOS) is the main cost- determining factor for inpatients with acute stroke. Although studies have identified variables associated with LOS, few have analyzed predictors of ...Background and Purpose - The length of stay (LOS) is the main cost- determining factor for inpatients with acute stroke. Although studies have identified variables associated with LOS, few have analyzed predictors of longer stay after receiving thrombolytic therapy for acute stroke. Methods - We studied all consecutive acute stroke patients receiving intravenous recombinant tissue plasminogen activator (rtPA) admitted to the London Health Sciences Center, in London, Ontario, Canada, from 1999 to 2003. Longer stay was defined as LOS ≥ 7days after admission. Demographic as well as baseline clinical, laboratory, and imaging variables were analyzed to identify predictors of LOS. Significant variables were entered into a multivariate logistic regression analysis. Results - Among 216 acute stroke patients receiving rtPA, the median LOS was 6 days. LOS was >7 days in 102 (49% ) patients. Age ≥ 70 (odds ratio [OR], 2.2; 95% CI, 1.2 to 4.0), lack of improvement at 24 hours (OR, 2.5; 95% CI, 1.4 to 4.4), prestroke modified Rankin Scale ≥ 2 (OR, 2.4; 95% CI, 1.2 to 4.9), baseline National Institutes of Health Stroke Scale score ≥ 15 (OR, 9.4; 95% CI, 3.2 to 27.6), cortical involvement (OR, 2.2; 95% CI, 1.2 to 3.9), and new infarction on the control computed tomography (CT; OR, 2.8; 95% CI, 1.4 to 5.9) were independent predictors of longer stay. Conclusions - Lack of improvement at 24 hours after rtPA, cortical involvement, and new infarction on the 24- hour CT scan are relevant variables that can independently affect the LOS. These new variables may be useful for establishing policy in relation to the organization and planning of the health care system.展开更多
文摘Context: The focus of thrombolytic therapy in acute stroke has been on favorable outcome at 3 months. Few studies have analyzed outcome at 24 hours. An early and reliable prediction of poor outcome has implications for clinical management and discharge planning. Abstract:Objective: To evaluate predictors of lack of improvement at 24 hours after receiving alteplase and their relationship with poor outcome at 3 months. Design, Setting, and Participants: Prospective cohort of consecutive patients with acute stroke who received alteplase and were admitted to a university hospital from January 1999 to March 2003. Participants were recruited from 2 academic centers in a major city in Ontario and 33 affiliated hospitals from 7 counties. Main Outcome Measures: Lack of improvement defined as a difference between the National Institutes of Health Stroke Scale score at baseline and at 24 hours of 3 points or less. Poor outcome at 3 months defined by a modified Rankin Scale score of 3 to 5 or death. Results: Among 216 patients with acute stroke who were treated with alteplase, 111 (51.4% ) had a lack of improvement at 24 hours. After adjusting for age, sex, and stroke severity, baseline glucose level on admission (odds ratio [OR] 2.89; 95% confidence interval [CI], 1.40- 5.99 for a glucose level > 144 mg/dL [ > 8 mmol/L]), cortical involvement (OR, 2.66; 95% CI, 1.36- 5.20), and time to treatment (OR, 1.01; 95% CI, 1.0- 1.02 for each 1 minute increase in time to treatment) were independent predictors of lack of improvement. At 3 months, 43 patients (20.2% ) had died; of the 170 survivors, 75 patients (44% ) had poor outcomes. After adjusting for age, sex, and stroke severity, lack of improvement at 24 hours was an independent predictor of poor outcome (OR, 12.9; 95% CI, 5.7- 29.6)- and death (OR, 7.5; 95% CI, 2.9- 19.6). Patients with a lack of improvement had longer lengths of hospitalization (14.5 vs 9.6 days; P=.02). Conclusions: Among patients with acute stroke treated with thrombolytic therapy, lack of improvement at 24 hours is associated with poor outcome and death at 3 months. Elevated glucose level, time to thrombolytic therapy, and cortical involvement were predictors of lack of improvement.
文摘Background: Use of medications with vasoconstrictive or vasodilatory effects can potentially affect the risk for vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Methods: Using International Classification of Diseases-9 diagnostic codes followed by medical record review, the authors identified 514 patients with SAH admitted between 1995 and 2003 who were evaluated for vasospasm between days 4 and 14. The authors determined risks for vasospasm, symptomatic vasospas m, and poor clinical outcomes in patients with documented pre-hemorrhagic use o f calcium channel blockers, beta-receptor blockers, ACE inhibitors, aspirin, se lective serotonin reuptake inhibitors (SSRIs), non-SSRI vasoactive antidepressa nts, or statins. Results: Vasospasm developed in 62%, and symptomatic vasospasm in 29%of the cohort. On univariate analysis, the risk for all vasospasm tended to increase in patients taking SSRIs (p=0.09) and statins (p=0.05); SSRI use in creased the risk for symptomatic vasospasm (p=0.028). The Cochran-Armitage tren d test showed that the proportion of patients taking SSRIs and statins increased significantly across three wors ening categories (none, asymptomatic, symptomatic) of vasospasm. Logistic regres sion analysis showed that SSRI use tended to predict all vasospasm (O.R. 2.01 [0 .91 to 4.45]), and predicted symptomatic vasospasm (O.R. 1.42 [1.06 to 4.33]) . Statin exposure increased the risk for vasospasm (O.R. 2.75 [1.16 to 6.50]), perh aps from abrupt statin withdrawal (O.R. 2.54 [0.78 to 8.28]). Age < 50 years, Hunt-Hess grade 4 or 5, and Fisher Group 3 independently predicted all vasospasm, symptomatic vasospasm, poor discharge clinical status, and death. Conclusion: Selective serotonin reuptake inhibitor and statin users have a higher risk for su barachnoid hemorrhagerelated vasospasm. Whether the underlying disease indicatio n, direct actions, or rebound effects from abrupt drug withdrawal account for th e associated risk warrants further investigation.
文摘Background and Purpose - The length of stay (LOS) is the main cost- determining factor for inpatients with acute stroke. Although studies have identified variables associated with LOS, few have analyzed predictors of longer stay after receiving thrombolytic therapy for acute stroke. Methods - We studied all consecutive acute stroke patients receiving intravenous recombinant tissue plasminogen activator (rtPA) admitted to the London Health Sciences Center, in London, Ontario, Canada, from 1999 to 2003. Longer stay was defined as LOS ≥ 7days after admission. Demographic as well as baseline clinical, laboratory, and imaging variables were analyzed to identify predictors of LOS. Significant variables were entered into a multivariate logistic regression analysis. Results - Among 216 acute stroke patients receiving rtPA, the median LOS was 6 days. LOS was >7 days in 102 (49% ) patients. Age ≥ 70 (odds ratio [OR], 2.2; 95% CI, 1.2 to 4.0), lack of improvement at 24 hours (OR, 2.5; 95% CI, 1.4 to 4.4), prestroke modified Rankin Scale ≥ 2 (OR, 2.4; 95% CI, 1.2 to 4.9), baseline National Institutes of Health Stroke Scale score ≥ 15 (OR, 9.4; 95% CI, 3.2 to 27.6), cortical involvement (OR, 2.2; 95% CI, 1.2 to 3.9), and new infarction on the control computed tomography (CT; OR, 2.8; 95% CI, 1.4 to 5.9) were independent predictors of longer stay. Conclusions - Lack of improvement at 24 hours after rtPA, cortical involvement, and new infarction on the 24- hour CT scan are relevant variables that can independently affect the LOS. These new variables may be useful for establishing policy in relation to the organization and planning of the health care system.
