Prevalence, Severity, and Predictors of Poststroke Depression in a Prospective Cohort of Jordanian Patients

Poststroke depression (PSD) is common and remains a significant risk factor for poor outcomes. This prospective study is aimed at assessing the prevalence, severity, and predictors of PSD among Jordanian stroke survivors. A total of 151 patients who were consequently admitted to a tertiary teaching hospital with ischemic or hemorrhagic strokes were enrolled. Participants were screened on admission for premorbid depression using the PHQ-9 questionnaire; then, screening for PSD was repeated one and three months after stroke using the same tool. Depression prevalence at each screening was reported, and logistic regression analysis was conducted to evaluate for significant predictors. PHQ-9 scores suggestive of depression were reported by 15%, 24.83%, and 17.39% of respondents on admission and after one and three months, respectively. Scores suggesting severe depression were reported by 0.71%, 2.13%, and 6.52% of respondents, respectively. Significant predictors of PSD were having chronic kidney disease, current smoking status, moderate or severe disability (mRS score) at stroke onset, and severe dependence (BI) after one month ( p values 0.007, 0,002, 0.014, and 0.031, respectively). Patients with secondary and high school education levels were less likely to get depression compared with illiterate patients ( p 0.042). This study showed that nearly one in four Jordanian stroke survivors experienced PSD after one month. In contrast, while the overall PSD prevalence declined towards the end of follow-up period, patients who remained depressed showed a tendency towards higher PSD severity.

Poststroke Erectile Dysfunction in Cameroon: Prevalence, Associated Factors, and Quality of Life

Background. Stroke is a severe disease due to its morbidity-mortality. It is the first cause of acquired disability including erectile dysfunction (ED). The purpose of this study was to determine the prevalence of ED in stroke patients at the Douala General Hospital, to identify associated factors and to evaluate their quality of life. Materials and Methods. A cross-sectional study was conducted over a period of seven months from November 2016 to May 2017 on two groups of patients in neurology, cardiology, and endocrinology units of the Douala General Hospital (Cameroon): stroke patients (stroke+) and nonstroke patients (stroke-). We collected sociodemographic and clinical data using a preestablished questionnaire. Erectile function was assessed using International Index of Erectile Function (IIEF-5). Associated and predictive factors were determined using univariate and multivariate analyses. Results were significant for a p value < 0.05. Results. A total of 269 patients were included, among them 87 stroke+ (32.34%) and 182 stroke- (67.66%) (controlled group). The mean age was 56.37 ± 12.89 years and 57.18 ± 10.24 years of stroke+ and stroke-, respectively ( p = 0.608 ). Prevalence of poststroke ED was 64.4% ( OR = 3.41 , 95% CI: 1.99-5.82, p < 0.001 ). The average time of occurrence of the poststroke ED was 5 ± 5.85 months. Diabetes and dyslipidemia were the predictive factors of occurrence of poststroke ED. Depression was found both in stroke+ with ED and stroke+ without ED with no difference ( p = 0.131 ). Conclusion. About two-thirds of stroke patients developed ED. Diabetes and dyslipidemia were predictive factors of ED in stroke patients.

Implications of the Presence of Hyperdense Middle Cerebral Artery Sign in Determining the Subtypes of Stroke Etiology

Background. Identifying stroke subtypes is crucial in choosing appropriate treatment, predicting outcomes, and managing recurrent stroke prevention. Objectives. To study the association of hyperdense middle cerebral artery sign (HMCAS) on noncontrast computed tomography (NCCT) brain and subtypes of stroke etiology. Methods. This is a retrospective hypothesis testing study. Patients aged 18 or over who had middle cerebral artery occlusion symptoms with HMCAS with verification on brain NCCT and received intravenous thrombolysis between January 2016 and June 2019 were enrolled. The demographic data, clinical outcomes, stroke subtypes, and characteristics of HMCAS were collected from medical records. Results. Ninety-nine out of 299 enrolled patients presented with HMCAS. The most common stroke subtype was cardioembolism (59%). Of the baseline characteristics, hypertension was more common in cases of large-artery atherosclerosis (LAA) (86.4%), and atrial fibrillation (AF) was the highest in cardioembolism (44.8%). HMCAS disappearance in cardioembolism was lowest compared to LAA and others (63% vs. 91% vs. 94.7%, respectively). The univariable analysis found that HMCAS disappearance is significantly associated with all stroke subtypes (Odds ratio, 95% confidence interval 10.58, 1.31-85.43; P = 0.027 for other and 5.88, 1.24-27.85; P = 0.026 for LAA). Multinomial logistic regression found that body weight and hypertension were associated with the LAA subtype. AF and intracranial hemorrhage (ICH) were associated with cardioembolism. Conclusion. The most likely diagnosis from the presence of HMCAS is cardioembolism, but the definite stroke etiologic subtype can not be identified. Combining the patient risk factors, including body weight, hypertension, and AF, with HMCAS and its characteristics will predict stroke subtypes more accurately.

Clinical Outcomes after Intravenous Alteplase in Elderly Patients with Acute Ischaemic Stroke: A Retrospective Analysis of Patients Treated at a Tertiary Neurology Centre in England from 2013 to 2018

Intravenous thrombolysis with alteplase within 4.5 hours from symptom onset is a well-established treatment of acute ischaemic stroke (AIS). The aim was to compare alteplase for AIS between patients aged >80 and ≤80 years in our registry data, from 2013 to 2018. Mechanical thrombectomy cases were excluded. We assessed clinical outcomes over the six-year period and between patients aged over 80 and ≤80 years, using measures including the discharge modified Rankin Scale (mRS), 24-hour National Institutes of Health Stroke Scale (NIHSS) improvement, and symptomatic intracerebral haemorrhage (sICH) rate. Of a total of 805 AIS patients who received intravenous alteplase, 278 (34.5%) were over 80 years old, and 527 (65%) were younger. 616 (76.5%) received thrombolysis ≤ 3 hours after symptom onset and 189 (23.5%) within 3-4.5 hours. Median baseline mRS and NIHSS of the elderly cohort were 1 (IQR 0-5) and 13 (IQR 2-37), respectively, compared to the younger cohort 0 (IQR 0-5) and 9 (IQR 0-29). The sICH rate was 7.2% in the elderly and 4.6% in those ≤80 years, p = 0.05 . NIHSS improved within 24 hours in 34% of the elderly cohort compared to 35% in the younger cohort. At hospital discharge, the mortality rate was 9% in the elderly cohort compared to the 6% in the younger cohort, p = 0.154 . 25% of patients aged >80 years had mRS ≤ 2 compared to 47% in the younger patients ( p < 0.0001 ). In conclusion, thrombolysis in elderly patients results in clinical improvement comparable to younger patients.

Association between Oral Pathology, Carotid Stenosis, and Oral Bacterial DNA in Cerebral Thrombi of Patients with Stroke

Background and purpose. Risk of acute ischemic stroke has been associated with carotid artery atherosclerosis as well as with periodontal disease. We studied whether oral pathology or carotid atherosclerosis was associated with the presence and quantity of bacterial DNA in their aspirated thrombi. Methods. Thrombus aspirates and control arterial blood were taken from 71 patients (70.4% male; mean age, 67.4 years) with acute ischemic stroke. Tooth pathology was registered using CT scans. Carotid stenosis was estimated with CTA and ultrasonography. The presence of bacterial DNA from aspirated thrombi was determined using quantitative PCR. We also analyzed the presence of these bacterial DNAs in carotid endarterectomies from patients with peripheral arterial disease. Results. Bacterial DNA was found in 59 (83.1%) of the thrombus aspirates (median, 8.6-fold). Oral streptococcal DNA was found in 56 (78.9%) of the thrombus aspirates (median, 5.1-fold). DNA from A. actinomycetemcomitans and P. gingivalis was not found. Most patients suffered from poor oral health and had in median 19.0 teeth left. Paradoxically, patients with better oral health had more oral streptococcal DNA in their thrombus than the group with the worst pathology ( p = 0.028 ). There was a trend (OR 7.122; p = 0.083 ) in the association of ≥50% carotid artery stenosis with more severe dental pathology. Oral streptococcal DNA was detected in 2/6 of carotid endarterectomies. Conclusions. Stroke patients had poor oral health which tended to associate with their carotid artery stenosis. Although oral streptococcal DNA was found in thrombus aspirates and carotid endarterectomy samples, the amount of oral streptococcal DNA in thrombus aspirates was the lowest among those with the most severe oral pathology. These results suggest that the association between poor oral health and acute ischemic stroke is linked to carotid artery atherosclerosis.

The Study of Cost-Effectiveness of Rivaroxaban versus Warfarin in Patients with Atrial Fibrillation Who Developed Ischemic Stroke

Introduction. Rivaroxaban is a new anticoagulant providing benefits for the treatment of patients with atrial fibrillation (AF). This study is aimed at evaluating the cost-effectiveness of rivaroxaban compared to warfarin in patients with AF. Method. This economic evaluation study was conducted among 144 selected nonrandomly patients who were treated with rivaroxaban or warfarin and suffered from AF leading to stroke, in the stroke ward of Shiraz Nemazee Hospital in 2019. The final and clinical (intermediate) outcomes were QALYs and no bleeding and prevention of ischemic stroke, respectively. The study was performed from the social perspective, and a deterministic one-way sensitivity analysis was conducted to identify the effects of uncertainty. The analysis of the collected data was carried out using SPSS18 and TreeAge software. Results. Patients who received rivaroxaban had lower costs ($ 25275 vs. $ 26554) and higher QALYs (0.5 vs. 0.33) compared to those taking warfarin. Bleeding and stroke occurred in (9 vs. 40) and (1 vs. 3) patients in the rivaroxaban and warfarin groups, respectively, and there was a significant decrease in the incidence of bleeding in the rivaroxaban group (81.9% vs 44.4%). Thus, rivaroxaban in all the outcomes was cheaper and more effective than warfarin. The one-way sensitivity analysis confirmed the robustness of the results. Conclusions. Considering the incremental cost-effectiveness ratio, rivaroxaban is more cost-effective and can be a dominant alternative. Therefore, it is suggested to use rivaroxaban as the first priority in AF patients because rivaroxaban reduces costs and increases clinical outcomes compared with warfarin.

Developing a Predictive Tool for Hospital Discharge Disposition of Patients Poststroke with 30-Day Readmission Validation

After short-term, acute-care hospitalization for stroke, patients may be discharged home or other facilities for continued medical or rehabilitative management. The site of postacute care affects overall mortality and functional outcomes. Determining discharge disposition is a complex decision by the healthcare team. Early prediction of discharge destination can optimize poststroke care and improve outcomes. Previous attempts to predict discharge disposition outcome after stroke have limited clinical validations. In this study, readmission status was used as a measure of the clinical significance and effectiveness of a discharge disposition prediction. Low readmission rates indicate proper and thorough care with appropriate discharge disposition. We used Medicare beneficiary data taken from a subset of base claims in the years of 2014 and 2015 in our analyses. A predictive tool was created to determine discharge disposition based on risk scores derived from the coefficients of multivariable logistic regression related to an adjusted odds ratio. The top five risk scores were admission from a skilled nursing facility, acute heart attack, intracerebral hemorrhage, admission from “other” source, and an age of 75 or older. Validation of the predictive tool was accomplished using the readmission rates. A 75% probability for facility discharge corresponded with a risk score of greater than 9. The prediction was then compared to actual discharge disposition. Each cohort was further analyzed to determine how many readmissions occurred in each group. Of the actual home discharges, 95.7% were predicted to be there. However, only 47.8% of predictions for home discharge were actually discharged home. Predicted discharge to facility had 15.9% match to the actual facility discharge. The scenario of actual discharge home and predicted discharge to facility showed that 186 patients were readmitted. Following the algorithm in this scenario would have recommended continued medical management of these patients, potentially preventing these readmissions.

Predicting Independence 6 and 18 Months after Ischemic Stroke Considering Differences in 12 Countries: A Secondary Analysis of the IST-3 Trial

Objectives. This study is aimed at identifying the best clinical model to predict poststroke independence at 6 and 18 months, considering sociodemographic and clinical characteristics, and then identifying differences between countries. Methods. Data was retrieved from the International Stroke Trial 3 study. Nine clinical variables (age, gender, severity, rt-PA, living alone, atrial fibrillation, history of transient ischemic attack/stroke, and abilities to lift arms and walk) were measured immediately after the stroke and considered to predict independence at 6 and 18 months poststroke. Independence was measured using the Oxford Handicap Scale. The adequacy, predictive capacity, and discriminative capacity of the models were checked. Countries were added to the final models. Results. At 6 months poststroke, 35.8% ( n = 1088 ) of participants were independent, and at 18 months, this proportion decreased to 29.9% ( n = 747 ). Both 6 and 18 months poststroke predictive models obtained fair discriminatory capacities. Gender, living alone, and rt-PA only reached predictive significance at 18 months. Poststroke patients from Poland and Sweden showed greater chances to achieve independence at 6 months compared to the UK. Poland also achieved greater chances at 18 months. Italy had worse chances than the UK at both follow-ups. Discussion. Six and eight variables predicted poststroke independence at 6 and 18 months, respectively. Some variables only reached significance at 18 months, suggesting a late influence in stroke patients’ rehabilitation. Differences found between countries in achieving independence may be related to healthcare system organization or cultural characteristics, a hypothesis that must be addressed in future studies. These results can allow the development of tailored interventions to improve the outcomes.

Impact of the COVID-19 Pandemic on Acute Ischemic Stroke Presentation, Treatment, and Outcomes

Introduction. The World Health Organization declared COVID-19 a global pandemic last year. While a clear impact of COVID-19 on the declining stroke volume has been reported, its overall impact on stroke presentation and clinical outcomes has not been established. The purpose of this study was to assess the impact of COVID-19 on acute ischemic stroke volume, presentation, treatment, and outcomes at comprehensive stroke centers. Methods. A retrospective review of patients with a discharge diagnosis of acute ischemic stroke from the Get With The Guidelines database was performed from January 1, 2019, to July 1, 2020. The following time periods were defined: Pre-COVID (January/February), Peak-COVID (March/April), and Post-COVID (May/June). Bivariate analyses were performed comparing the 2020 and 2019 time periods to determine differences in stroke volume, presentation, treatment, and outcomes. Results. Stroke volumes were significantly lower during the Peak-COVID period in 2020 compared to that in 2019, with an absolute decline of 49.5% ( P < 0.001 ). Patients were more likely to present after 24 hours from last known well during the 2020 Peak-COVID period ( P = 0.03 ). However, there was not a significant difference in the rate of treatment with either the tissue plasminogen activator (tPA) or mechanical thrombectomy during the Peak-COVID period. Interestingly, relative treatment rates increased during the 2020 Post-COVID period to 11.4% ( P = 0.01 ). Conclusions. The overall ischemic stroke volume decreased during the pandemic, and patients had a tendency to present later, beyond eligible treatment windows. However, rates of treatment, patient demographics, and stroke outcomes did not significantly change when compared to the prior year.

Value of Perfusion CT in the Prediction of Intracerebral Hemorrhage after Endovascular Treatment

Background. Intracerebral hemorrhage (ICH) is a serious complication of endovascular treatment (EVT) in stroke patients with large vessel occlusion (LVO) and associated with increased morbidity and mortality. Aims. Identification of radiological predictors is highly relevant. We investigated the predictive power of computed tomography perfusion (CTP) parameters concerning ICH in patients receiving EVT. Methods. 392 patients with anterior circulation LVO with multimodal CT imaging who underwent EVT were analyzed. CTP parameters were visually evaluated for modified ASPECTS regions and compared between patients without ICH, those with hemorrhagic infarction (HI), and those with parenchymal hematoma (PH) according to the ECASS criteria at follow-up imaging and broken down by ASPECTS regions. Results. 168 received intravenous thrombolysis (IV-rtPA), and 115 developed subsequent ICH (29.3%), of which 74 were classified as HI and 41 as PH. Patients with HI and PH had lower ASPECTS than patients without ICH and worse functional outcome after 90 days ( p < 0.05 ). In 102 of the 115 patients with ICH, the deep middle cerebral artery (MCA) territory was affected with differences between patients without ICH, those with HI, and those with PH regarding cerebral blood volume (CBV) and blood-brain barrier permeability measured as flow extraction product (FED) relative to the contralateral hemisphere ( p < 0.05 ). Patients with PH showed larger perfusion CT infarct core than patients without ICH ( p < 0.01 ). Conclusion. None of the examined CTP parameters was found to be a strong predictor of subsequent ICH. ASPECTS and initial CTP core volume were more reliable and may be useful and even so more practicable to assess the risk of subsequent ICH after EVT.