Swallowing function after stroke: prognosis and prognostic factors at 6 months.
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BACKGROUND AND PURPOSE: Swallowing dysfunction (dysphagia) is common and disabling after acute stroke, but its impact on long-term prognosis for potential complications and the recovery from swallowing dysfunction remain uncertain. We aimed to prospectively study the prognosis of swallowing function over the first 6 months after acute stroke and to identify the important independent clinical and videofluoroscopic prognostic factors at baseline that are associated with an increased risk of swallowing dysfunction and complications. METHODS: We prospectively assembled an inception cohort of 128 hospital-referred patients with acute first stroke. We assessed swallowing function clinically and videofluoroscopically, within a median of 3 and 10 days, respectively, of stroke onset, using standardized methods and diagnostic criteria. All patients were followed up prospectively for 6 months for the occurrence of death, recurrent stroke, chest infection, recovery of swallowing function, and return to normal diet. RESULTS: At presentation, a swallowing abnormality was detected clinically in 65 patients (51%; 95% CI, 42% to 60%) and videofluoroscopically in 82 patients (64%; 95% CI, 55% to 72%). During the subsequent 6 months, 26 patients (20%; 95% CI, 14% to 28%) suffered a chest infection. At 6 months after stroke, 97 of the 112 survivors (87%; 95% CI, 79% to 92%) had returned to their prestroke diet. Clinical evidence of a swallowing abnormality was present in 56 patients (50%; 95% CI, 40% to 60%). Videofluoroscopy was performed at 6 months in 67 patients who had a swallowing abnormality at baseline; it showed penetration of the false cords in 34 patients and aspiration in another 17. The single independent baseline predictor of chest infection during the 6-month follow-up period was a delayed or absent swallowing reflex (detected by videofluoroscopy). The single independent predictor of failure to return to normal diet was delayed oral transit (detected by videofluoroscopy). Independent predictors of the combined outcome event of swallowing impairment, chest infection, or aspiration at 6 months were videofluoroscopic evidence of delayed oral transit and penetration of contrast into the laryngeal vestibule, age >70 years, and male sex. CONCLUSIONS: Swallowing function should be assessed in all acute stroke patients because swallowing dysfunction is common, it persists in many patients, and complications frequently arise. The assessment of swallowing function should be both clinical and videofluoroscopic. The clinical and videofluoroscopic features at presentation that are important predictors of subsequent swallowing abnormalities and complications are videofluoroscopic evidence of delayed oral transit, a delayed or absent swallow reflex, and penetration. These findings require validation in other studies. (+info)
Plasticity of language-related brain function during recovery from stroke.
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BACKGROUND AND PURPOSE: This study was undertaken to correlate functional recovery from aphasia after acute stroke with the temporal evolution of the anatomic, physiological, and functional changes as measured by MRI. METHODS: Blood oxygenation level-dependent contrast and echo-planar MRI were used to map language comprehension in 6 normal adults and in 2 adult patients during recovery from acute stroke presenting with aphasia. Perfusion, diffusion, sodium, and conventional anatomic MRI were used to follow physiological and structural changes. RESULTS: The normal activation pattern for language comprehension showed activation predominately in left-sided Wernicke's and Broca's areas, with laterality ratios of 0.8 and 0.3, respectively. Recovery of the patient confirmed as having a completed stroke affecting Broca's area occurred rapidly with a shift of activation to the homologous region in the right hemisphere within 3 days, with continued rightward lateralization over 6 months. In the second patient, in whom mapping was performed fortuitously before stroke, recovery of a Wernicke's aphasia showed a similar increasing rightward shift in activation recruitment over 9 months after the event. CONCLUSIONS: Recovery of aphasia in adults can occur rapidly and is concomitant with an activation pattern that changes from left to a homologous right hemispheric pattern. Such recovery occurs even when the stroke evolves to completion. Such plasticity must be considered when evaluating stroke interventions based on behavioral and neurological measurements. (+info)
Hemiosteoporosis after severe stroke, independent of changes in body composition and weight.
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BACKGROUND AND PURPOSE: Fractures are a serious complication after stroke, and the risk of hip fractures among stroke patients is increased 2 to 4 times versus a reference population. Fractures after stroke are probably caused by the development of hemiosteoporosis and the high incidence of accidental falls. The aim of this study was to investigate the development of hemiosteoporosis in relation to other changes in body composition during the first year after severe stroke. METHODS: The study included 24 patients with extensive paresis after stroke. Bone mineral content (BMC) and fat and lean mass were assessed 1, 4, 7, and 12 months after stroke onset by a dual-energy x-ray absorptiometer. RESULTS: The loss of total body BMC was significant during the first year after stroke (-1.6%; P<0.05), but there were no significant changes in total lean or fat mass. At inclusion, there were no significant differences between sides in lean or fat mass or BMC, but during follow-up, BMC of the affected side decreased significantly compared with the same side at inclusion (-7.5%; P<0.01). Side differences in fat mass became significant between legs (9.3%; P<0.001) and whole sides (4. 8%; P<0.01). There were only minor side changes in lean mass. Loss of BMC was independent of weight changes. CONCLUSIONS: During the first year after severe stroke, patients developed pronounced hemiosteoporosis. This was not associated with general changes in lean or fat mass. The development of hemiosteoporosis was independent of weight changes after stroke. (+info)
Hemorrhage after an acute ischemic stroke.MAST-I Collaborative Group.
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BACKGROUND AND PURPOSE: Hemorrhagic transformation is frequently seen on CT scans obtained in the subacute phase of ischemic stroke. Its prognostic value is controversial. METHODS: We analyzed 554 patients with acute ischemic stroke enrolled in the Multicenter Acute Stroke Trial-Italy (MAST-I) study in whom a second CT scan was performed on day 5. Presence of 1) intraparenchymal hemorrhages (hematoma or hemorrhagic infarction), 2) extraparenchymal bleeding (intraventricular or subarachnoid) and 3) cerebral edema (shift of midline structure, sulcal effacement or ventricular compression) alone or in association were evaluated. Death or disability at 6 months were considered as "unfavorable outcome." RESULTS: Patients who developed intraparenchymal hemorrhages, extraparenchymal bleeding, or cerebral edema had unfavorable outcome (83%, 100%, and 80%, respectively), but multivariate analysis demonstrated that only extraparenchymal bleeding (collinearity) and cerebral edema (OR=6.8; 95% CI, 4.5 to 10.4) were significant independent prognostic findings. Unfavorable outcome correlated with size of intraparenchymal hemorrhage (chi2 for trend=30.5, P<0.0001). Nevertheless, when a large hematoma was present the negative effect was mostly due to concomitant extraparenchymal bleeding (chi2=51.6, P<0.0001), and when hemorrhagic infarction was detected the negative effect was mostly explained by the association with cerebral edema (chi2=36.6, P<0.0001). CONCLUSIONS: Extraparenchymal bleeding and cerebral edema are the main prognostic CT scan findings in the subacute phase of ischemic stroke. Stroke patients with a high risk for developing these 2 types of brain damage should be identified. Measures to prevent and adequately treat their development should be implemented. (+info)
A standardized MRI stroke protocol: comparison with CT in hyperacute intracerebral hemorrhage.
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BACKGROUND AND PURPOSE: Diagnostic imaging in hyperacute ischemic stroke has been revolutionized by the introduction of diffusion- and perfusion-weighted MRI (DWI and PWI). CT, however, is still needed to exclude intracerebral hemorrhage (ICH). The purpose of our study was to determine the diagnostic accuracy of a standardized, multimodal MRI (mMRI) stroke protocol in the qualitative and quantitative assessment of hyperacute ICH (<6 hours). METHODS: We investigated 9 patients with hyperacute ICH with CT followed immediately by a standardized mMRI stroke protocol (DWI, PWI [T2*-WI], FLAIR, T2-WI, and MRA). The time interval between MRI and symptom onset ranged from 3 hours to 5 hours 45 minutes. We analyzed and compared the size of the hematoma on CT and all mMRI images by semiautomatic volumetry. RESULTS: ICH was unambiguously identified on the basis of all mMRI sequences. With increasing susceptibility effect (T2*-WI), the ICH, appearing as an area of hyperintensity with central signal loss, became qualitatively most evident. Regarding quantitation, T2*-WI overestimated (median and mean difference, 18.9%/17.8%; SD final sigma=24.4%) and DWI correlated best (median and mean difference, 3.97%/-4.36%; SD final sigma=37. 42%) with hematoma size on CT. CONCLUSIONS: Multimodal stroke MRI is as reliable as CT in the assessment of hyperacute ICH. Therefore, additional CT is no longer necessary to rule out ICH in hyperacute stroke. The use of mMRI alone in the diagnostic workup of a hyperacute stroke patient saves time and costs while rendering all the critical information needed to initiate an optimal treatment. (+info)
Association of hyperdense middle cerebral artery sign with clinical outcome in patients treated with tissue plasminogen activator.
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BACKGROUND AND PURPOSE: The hyperdense middle cerebral artery sign (HMCAS) is a marker of thrombus in the middle cerebral artery. The aim of our study was to find out the frequency of the HMCAS, its association with initial neurological severity and early parenchymal ischemic changes on CT, its relevance to clinical outcome, and the efficacy of intravenous recombinant tissue plasminogen activator (rtPA) in patients with the HMCAS. METHODS: Secondary analysis of the data from 620 patients who received either rtPA or placebo in the European Cooperative Acute Stroke Study I (ECASS I), a double-blind, randomized, multicenter trial. The baseline CT scans were obtained within 6 hours from the onset of symptoms. Functional and neurological outcomes were assessed using the modified Rankin Scale and the Scandinavian Stroke Scale at day 90. RESULTS: We found an HMCAS in 107 patients(17.7%). The initial neurological deficit was more severe in patients with the HMCAS than in those lacking this sign (P<0.0001). Early cerebral edema and mass effect were also more common in patients with the HMCAS (P<0.0001). The HMCAS was related to the risk of poor functional outcome (grade of 3 to 6 on the modified Rankin Scale) on univariate analysis: 90 patients (84%) with the HMCAS and 310 patients (62%) lacking this sign were dependent or dead at day 90 (P<0.0001). However, this association was no longer significant in a logistic model accounting for the effect of age, sex, treatment with rtPA, initial severity of neurological deficit and early parenchymal ischemic changes on CT. Patients with the HMCAS who were given rtPA had better neurological recovery than those who received placebo (P=0.0297). CONCLUSIONS: The HMCAS is associated with severe brain ischemia and poor functional outcome. However, it has no significant independent prognostic value when accounting for the effect of initial severity of neurological deficit and of early parenchymal ischemic changes on CT. Patients with the HMCAS may benefit from intravenous rtPA. (+info)
Confusional state in stroke: relation to preexisting dementia, patient characteristics, and outcome.
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BACKGROUND AND PURPOSE: Acute confusional state (ACS) is frequent in hospitalized stroke patients. We previously showed that 16% of patients admitted for a stroke have preexisting dementia. The extent to which preexisting cognitive decline is associated with a risk of ACS at the acute stage of stroke remains to be systematically examined. The aim of this study was to evaluate the prevalence of ACS in acute stroke patients, to study the influence of preexisting cognitive decline and other patient characteristics, and to evaluate the influence of ACS on outcome. METHODS: We diagnosed ACS using DSM-IV criteria and the Delirium Rating Scale with a cutoff of 10 in 202 consecutive stroke patients aged 40 years or older (median age, 75 years; range, 42 to 101 years). Cognitive functioning before stroke was assessed with the Informant Questionnaire on Cognitive Decline in the Elderly. RESULTS: Forty-nine stroke patients (24.3%; 95% CI, 18.3% to 30.2%) had an ACS during hospitalization. Using logistic regression analysis, we found preexisting cognitive decline (P=0.006) and metabolic or infectious disorders (P=0.008) to be independent predictors of ACS. Functional, but not vital, prognosis was worse in patients with ACS at discharge and 6 months after stroke. CONCLUSIONS: ACS occurs in one fourth of stroke patients older than 40 years. Its occurrence requires inquiry for a preexisting cognitive decline, which usually remains unrecognized in the absence of a systematic evaluation. (+info)
Extracorporeal rheopheresis in the treatment of acute ischemic stroke: A randomized pilot study.
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BACKGROUND AND PURPOSE: Extracorporeal rheopheresis is a safe method to optimize hemorheology. Our aim was to determine whether treatment with extracorporeal rheopheresis in patients with acute ischemic hemispheric stroke improves cerebral perfusion as assessed with serial 99mTc-ethyl-cysteinate-dimer single-photon emission CT (99mTc-ECD SPECT). We also investigated how clinical outcome is associated with treatment and imaging results. METHODS: Thirty-three patients (mean age, 64+/-10 years) with acute ischemic hemispheric stroke were included in a prospective, randomized, parallel group pilot study. First treatment with or without extracorporeal rheopheresis took place within 12 hours after the onset of symptoms and was repeated 3 times at intervals of 24 hours. Hemorheological parameters were measured before and after each session. Each patient underwent 99mTc-ECD SPECT immediately before treatment, 6 to 8 hours after treatment, and after 5 days. A semiquantitative SPECT graded scale was used to measure depth and extent of activity deficits and thus to quantify the perfusion deficit. RESULTS: Seventeen patients were actively treated with extracorporeal rheopheresis, and 16 patients did not receive extracorporeal rheopheresis. After 3 months, no differences were found in the functional or neurological outcome. Despite a rapid, sustained decrease of plasma viscosity and erythrocyte aggregation in the rheopheresis group, there was no significant difference in the SPECT graded scale after therapy between the 2 groups. Patients with early reperfusion (decrease in the SPECT graded scale >25% 6 to 8 hours after therapy compared with the baseline examination) experienced a better functional outcome (Modified Rankin Scale) after 3 months compared with patients without reperfusion (P=0.04). CONCLUSIONS: Since quantitative flow mapping and clinical follow-up did not reveal any differences between patients who were treated with extracorporeal rheopheresis and controls, it appears very unlikely that extracorporeal rheopheresis enhances reperfusion after acute cerebral ischemia. (+info)