Clinical Neurology and Neurosurgery 120 (2014) 124–128
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Intravenous thrombolysis in acute ischemic stroke due to occlusion of internal carotid artery – A Serbian Experience with Thrombolysis in Ischemic Stroke (SETIS) Zeljko Zivanovic a,b,∗ , Slobodan Gvozdenovic b , Dejana R. Jovanovic c,d , Aleksandra Lucic-Prokin a,b , Jelena Sekaric b , Sonja Lukic b , Timea Kokai-Zekic b , Marija Zarkov a,b , Milan Cvijanovic a,b , Ljiljana Beslac-Bumbasirevic c,d , Petar Slankamenac a,b , on behalf of SETIS Investigation Group a
Medical Faculty, University of Novi Sad, Novi Sad, Serbia Department of Neurology, Clinical Center of Vojvodina, Novi Sad, Serbia Medical Faculty, University of Belgrade, Belgrade, Serbia d Department of Neurology, Clinical Center of Serbia, Belgrade, Serbia b c
a r t i c l e
i n f o
Article history: Received 14 December 2013 Received in revised form 24 January 2014 Accepted 6 March 2014 Available online 15 March 2014 Keywords: Intravenous thrombolysis Internal carotid artery Occlusion Outcome SETIS
a b s t r a c t Objective: The benefit of intravenous thrombolysis in patients with internal carotid artery (ICA) occlusion is still unclear. The aim of this study was to assess the influence on outcome of intravenous thrombolysis in patients with ICA occlusion comparing to those without it. Methods: Data were from the national register of all acute ischemic stroke patients treated with intravenous thrombolysis in Serbia. Patients with nonlacunar anterior circulation infarction were included and were divided into two groups, those with and those without ICA occlusion. We compared the differences in demographic characteristics, risk factors, baseline NIHSS score, early neurological improvement, 3-month functional outcome, complications and death between these two groups. Results: Among 521 included patients there were 13.4% with ICA occlusion. Group with ICA occlusion had more males (82.9% vs. 60.5%; p = 0.0008), and more severe stroke (baseline NIHSS score 15.3 vs. 13.6; p = 0.004). Excellent functional outcome (mRS 0–1) at 3 months was recorded in 32.9% patients with ICA occlusion and in 50.6% patients without (p = 0.009), while favorable functional outcome (mRS 0–2) was recorded in 50.0% of patients with ICA occlusion vs. 60.1% without (p = 0.14). Death occurred in 12.9% patients with ICA occlusion and in 17.3% patients without it (p = 0.40). There was no significant difference in rate of symptomatic ICH between the two groups (1.4% vs. 4.2%; p = 0.5). Multivariate logistic regression analysis showed that ICA occlusion was associated with the absence of early neurological improvement (p = 0.03; OR 1.78, 95% CI 1.05–3.04). However, the presence of ICA occlusion was not significantly associated with an unfavorable outcome at 3-month (p = 0.44; OR 1.24, 95% CI 0.72–2.16) or with death (p = 0.18; OR 0.57, 95% CI 0.25–1.29). Conclusion: The patients with ICA occlusion treated with intravenous thrombolysis have a worse outcome than patients without it. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Intravenous (IV) administration of recombinant tissue plasminogen activator (rtPA) is still the only approved treatment for acute ischemic stroke (AIS), which improves the outcome if given
∗ Corresponding author at: Department of neurology, Emergency Center, Clinical Center of Vojvodina, Hajduk Veljka 1, 21000 Novi Sad, Serbia. Tel.: +381 638329117. E-mail address: [email protected] (Z. Zivanovic). http://dx.doi.org/10.1016/j.clineuro.2014.03.008 0303-8467/© 2014 Elsevier B.V. All rights reserved.
within 4.5 h after symptom onset [1,2]. Nowadays, IV thrombolytic therapy with rtPA is recommended as standard treatment for AIS by most clinical practice guidelines [3,4]. However, various factors affect the outcome in AIS patients treated with thrombolytic therapy, such as age, sex, baseline neurological deficit, onset-totreatment time (OTT), glucose level on admission, early signs of ischemic lesions on computed tomography (CT) before therapy, early arterial recanalization, etc. [5,6]. One of these factors is also occlusion of the internal carotid artery (ICA), which may lead to extensive infarction and carries the risk of an extremely poor
Z. Zivanovic et al. / Clinical Neurology and Neurosurgery 120 (2014) 124–128
prognosis, with high mortality and morbidity rates [7]. Several previous studies reporting that the patients with AIS and ICA occlusion had a poorer clinical outcome and a lower recanalization rate after IV thrombolysis compared with patients with an MCA occlusion suggest that IV rtPA is not effective in patients with ICA occlusion [8–10]. However, determination of the site of vascular occlusion is not a prerequisite for thrombolytic treatment and patients with ICA occlusion who present with AIS within 4.5 h of symptom onset are currently treated with IV rtPA [2]. Nevertheless, whether these patients have benefit from IV thrombolytic therapy remains controversial [9,10]. The objective of this study was to assess the influence on the outcome of IV thrombolysis in patients with extracranial ICA occlusion (eICAo) compared to those without eICAo in a cohort of patients with anterior circulation infarction.
2. Methods For the purpose of the present study we analyzed the data collected in the Serbian Experience with Thrombolysis in Ischemic Stroke (SETIS) register. SETIS is a prospective, ongoing, multicenter, open, and observational register of all patients in Serbia who have received IV rtPA for AIS. This register continuously monitors the safety and efficacy of IV thrombolysis in Serbia. Patients with AIS are treated with IV thrombolysis according to the protocol based on the recommendations of the European guideline [3]. The methods of data collection were described in detail in our previous report [11]. In the period from February 2006 to December 2012, a total of 783 thrombolytic patients were enrolled in the SETIS register. The following data were recorded: patient’s age, gender, risk factors, stroke severity assessed by the National Institutes of Health Stroke Scale (NIHSS score), OTT, neuroimaging findings, early CT signs of ischemic lesions assessed by Alberta Stroke Program Early CT Score (ASPECT score) [6], treatment complications, and outcome. A clinically identifiable subtype of cerebral infarction was defined according to the Oxford Community Stroke Project (OCSP) classification [12]. Stroke etiologies were defined according to the modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification [13]. Complications in the form of intracranial bleeding were categorized using the ECASS trial definitions for hemorrhagic infarction (HI1, HI2), and parenchymal hemorrhage (PH1, PH2), as well as symptomatic intracranial hemorrhage (ICH) [2]. Outcomes were measured by the NIHSS score after 24 h and by the modified Rankin score (mRS) for functional outcome after 90 days. Early neurological improvement (ENI) was defined as NIHSS score equal to 0 or improvement by four or more points 24 h after receiving rtPA. Excellent functional outcome after three months was considered mRS 0–1, while favorable functional outcome, meaning functional independence, was considered mRS 0–2. In the present study we included only patients with an anterior non-lacunar stroke, who clinically presented with partial (PACI) or total (TACI) anterior circulation infarction [12]. Patients were divided into two groups, those with and those without eICAo. An eICAo was diagnosed using carotid duplex ultrasound (CDU) examination, CT angiography (CTA), or magnetic resonance angiography (MRA). Carotid artery status was assessed at presentation by CDU or CTA, or mostly during first few days of hospitalization by CDU, CTA or MRA (median 2.0 days; range 1–23 days). When there was a significant finding, and when the clinical interest required, carotid duplex ultrasound was repeated or an angiography method was performed additionally (CTA or MRA). Descriptive statistics for baseline and demographic data were based on the presence or absence of an eICAo. All the baseline characteristics, outcomes and complication events were compared
125
between the two groups. Two-sample Student t-test was used for comparisons of continuous variables and 2 test or Fisher’s exact test for proportions. A p value of less than 0.05 was regarded as statistically significant. Multiple logistic regression analysis was used to evaluate the predictors of main outcomes by using variables such as the presence of eICAo, age, gender, baseline NIHSS score, ASPECT score, OTT, level of glycemia and mean arterial pressure (MAP) on admission, and the presence of risk factors (atrial fibrillation, hypertension, diabetes mellitus, hyperlipidemia, smoking, chronic heart failure). Ninety-five percent confidence intervals (CI) were calculated for odds ratio (OR). Data were analyzed with the SPSS/PC Win package version 17.0.
3. Results From a total of 783 patients with symptoms of AIS who were treated with IV rtPA in Serbia over the period of seven years, we excluded patients with stroke mimics (n = 11), patients with posterior circulation infarct (POCI) (n = 99), patients with lacunar stroke (LACI according to OCSP classification) (n = 122) and patients with incomplete data (n = 30). Among the 521 included patients, there were 70 (13.4%) patients with eICAo and 451 (86.6%) patients without it. An eICAo was verified by CDU in 97.1% of patients (68/70) and confirmed by CTA in 32.9% (23/70) and MRA in 38.6% (27/70). Patients’ demographic and baseline characteristics, OTT, presence of risk factors, subtype and etiology of stroke in these two groups of patients are shown in Table 1. The average age was similar in both groups (59.5 ± 10.1 years vs. 61.1 ± 12.3 years; p = 0.31) and there were significantly more male patients in the group with eICAo (82.9% vs. 60.5%; p = 0.0008). The average OTT was similar in the groups (160.3 ± 44.3 vs. 160.2 ± 45.5 min). Patients with eICAo had a more severe stroke according to the baseline NIHSS score (15.3 ± 4.0 vs. 13.6 ± 4.7; p = 0.004), the ASPECT score (9.1 ± 0.95 vs. 9.4 ± 0.97; p = 0.08), and the OCSP classification (71.4% of patients with TACI in the group with eICAo vs. 49.2% in the group without it; p = 0.001). Among the risk factors, only atrial fibrillation was significantly more frequent in the group without eICAo (31.9% vs. 11.4%; p = 0.0005). The overall distribution of functional outcomes at 3 months measured by mRS, in patients with and without eICAo is shown in Fig. 1. The proportions of outcomes and complications between these two groups are shown in Table 2. Early neurological improvement was more often observed in patients without eICAo, but it was not significantly (p = 0.06). Furthermore, the percentage of patients with an excellent functional outcome (mRS score 0–1) at three months was significantly higher in group without eICAo (p = 0.009), while the percentage of patients with a favorable functional outcome (mRS score 0–2), was also higher in this group, but not significantly (p = 0.14). Death occurred in more patients without eICAo (p = 0.40), as well as hemorrhagic complication. However, there was no statistically significant difference in symptomatic ICH (1.4% vs. 4.2%; p = 0.5). Multivariate logistic regression analysis showed that the presence of eICAo was not significantly associated with an unfavorable outcome (mRS 3–6) at three months (p = 0.44; OR 1.24, 95% CI 0.72–2.16) or with death (p = 0.18; OR 0.57, 95% CI 0.25–1.29). The predictors of 3-month unfavorable outcome (mRS 3–6) were: an older age (p = 0.02; OR 1.02; 95% CI 1.00–1.04), a higher NIHSS score on admission (p < 0.0001; OR 1.18; 95% CI 1.13–1.24), a lower ASPECT score (p = 0.003; OR 0.74; 95% CI 0.60–0.90), and diabetes mellitus as a risk factor (p = 0.015; OR 1.93; 95% CI 1.14–3.28), while the predictors of mortality (mRS score 6) were: an older age (p < 0.0001; OR 1.07; 95% CI 1.04–1.10), a higher NIHSS score on admission (p < 0.0001; OR 1.12; 95% CI 1.05–1.19), and a higher level of glycemia on admission (p = 0.01; OR 1.14; 95% CI 1.03–1.25).
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Z. Zivanovic et al. / Clinical Neurology and Neurosurgery 120 (2014) 124–128
Table 1 Baseline and demographic patient characteristics according to presence of ICA occlusion. With ICA occlusion, n = 70 Demographic Age, years Sex, males
12.9%
Without ICA occlusion, n = 451
p (significance)
90%
59.5 ± 10.1 58 (82.9%)
61.1 ± 12.3 293 (60.5%)
0.31 0.0008
80%
8 (11.4%) 57 (81.4%) 11 (15.7%) 25 (35.7%)
144 (31.9%) 350 (77.6%) 68 (15.1%) 172 (38.1%)
0.0005 0.57 0.89 0.80
17.3%
5.7% 6.2% 14.3%
Risk factors Atrial fibrillation Hypertension Diabetes mellitus Hyperlipoproteinemia Smoking Chronic cardiomyopathy Without risk factors
16 (22.9%) 8 (11.4%)
Current stroke Stroke subtype, TACI [17] Stroke side, left hemisphere NIHSS score on admittance ASPECT score Other medical condition MAP on admittance, mmHg Glycemia on admittance, mmol/l OTT, min
100%
95 (21.1%) 67 (14.9%)
0.85 0.56
7 (10.0%)
23 (5.1%)
0.17
50 (71.4%)
222 (49.2%)
0.001
38 (54.3%)
230 (51.0%)
0.70
15.3 ± 4.0
13.6 ± 4.7 9.4 ± 0.97
0.08
107.5 ± 14.5
106.4 ± 13.9
0.55
7.2 ± 2.4
7.1 ± 2.6
0.67
160.3 ± 44.3
160.2 ± 45.5
10.9% 60%
17.1%
17.1%
40%
18.4% 30% 17.1% 20% 29.5%
0.99
10% 50 (71.4%)
97 (21.5%)
7 (10.0%) 9 (12.9%) 4 (5.8%)
176 (39.0%) 22 (4.9%) 156 (34.6%)
mRS 6 mRS 5 mRS 4 mRS 3 mRS 2 mRS 1 mRS 0
12.2%
50%
0.004
9.1 ± 0.95
Ethiology [18] Large artery atherosclerosis Cardioembolism Other Undetermined
5.5%
70%
15.7%
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Intravenous thrombolysis in acute ischemic stroke due to occlusion of internal carotid artery – A Serbian Experience with Thrombolysis in Ischemic Stroke (SETIS) Zeljko Zivanovic a,b,∗ , Slobodan Gvozdenovic b , Dejana R. Jovanovic c,d , Aleksandra Lucic-Prokin a,b , Jelena Sekaric b , Sonja Lukic b , Timea Kokai-Zekic b , Marija Zarkov a,b , Milan Cvijanovic a,b , Ljiljana Beslac-Bumbasirevic c,d , Petar Slankamenac a,b , on behalf of SETIS Investigation Group a
Medical Faculty, University of Novi Sad, Novi Sad, Serbia Department of Neurology, Clinical Center of Vojvodina, Novi Sad, Serbia Medical Faculty, University of Belgrade, Belgrade, Serbia d Department of Neurology, Clinical Center of Serbia, Belgrade, Serbia b c
a r t i c l e
i n f o
Article history: Received 14 December 2013 Received in revised form 24 January 2014 Accepted 6 March 2014 Available online 15 March 2014 Keywords: Intravenous thrombolysis Internal carotid artery Occlusion Outcome SETIS
a b s t r a c t Objective: The benefit of intravenous thrombolysis in patients with internal carotid artery (ICA) occlusion is still unclear. The aim of this study was to assess the influence on outcome of intravenous thrombolysis in patients with ICA occlusion comparing to those without it. Methods: Data were from the national register of all acute ischemic stroke patients treated with intravenous thrombolysis in Serbia. Patients with nonlacunar anterior circulation infarction were included and were divided into two groups, those with and those without ICA occlusion. We compared the differences in demographic characteristics, risk factors, baseline NIHSS score, early neurological improvement, 3-month functional outcome, complications and death between these two groups. Results: Among 521 included patients there were 13.4% with ICA occlusion. Group with ICA occlusion had more males (82.9% vs. 60.5%; p = 0.0008), and more severe stroke (baseline NIHSS score 15.3 vs. 13.6; p = 0.004). Excellent functional outcome (mRS 0–1) at 3 months was recorded in 32.9% patients with ICA occlusion and in 50.6% patients without (p = 0.009), while favorable functional outcome (mRS 0–2) was recorded in 50.0% of patients with ICA occlusion vs. 60.1% without (p = 0.14). Death occurred in 12.9% patients with ICA occlusion and in 17.3% patients without it (p = 0.40). There was no significant difference in rate of symptomatic ICH between the two groups (1.4% vs. 4.2%; p = 0.5). Multivariate logistic regression analysis showed that ICA occlusion was associated with the absence of early neurological improvement (p = 0.03; OR 1.78, 95% CI 1.05–3.04). However, the presence of ICA occlusion was not significantly associated with an unfavorable outcome at 3-month (p = 0.44; OR 1.24, 95% CI 0.72–2.16) or with death (p = 0.18; OR 0.57, 95% CI 0.25–1.29). Conclusion: The patients with ICA occlusion treated with intravenous thrombolysis have a worse outcome than patients without it. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Intravenous (IV) administration of recombinant tissue plasminogen activator (rtPA) is still the only approved treatment for acute ischemic stroke (AIS), which improves the outcome if given
∗ Corresponding author at: Department of neurology, Emergency Center, Clinical Center of Vojvodina, Hajduk Veljka 1, 21000 Novi Sad, Serbia. Tel.: +381 638329117. E-mail address: [email protected] (Z. Zivanovic). http://dx.doi.org/10.1016/j.clineuro.2014.03.008 0303-8467/© 2014 Elsevier B.V. All rights reserved.
within 4.5 h after symptom onset [1,2]. Nowadays, IV thrombolytic therapy with rtPA is recommended as standard treatment for AIS by most clinical practice guidelines [3,4]. However, various factors affect the outcome in AIS patients treated with thrombolytic therapy, such as age, sex, baseline neurological deficit, onset-totreatment time (OTT), glucose level on admission, early signs of ischemic lesions on computed tomography (CT) before therapy, early arterial recanalization, etc. [5,6]. One of these factors is also occlusion of the internal carotid artery (ICA), which may lead to extensive infarction and carries the risk of an extremely poor
Z. Zivanovic et al. / Clinical Neurology and Neurosurgery 120 (2014) 124–128
prognosis, with high mortality and morbidity rates [7]. Several previous studies reporting that the patients with AIS and ICA occlusion had a poorer clinical outcome and a lower recanalization rate after IV thrombolysis compared with patients with an MCA occlusion suggest that IV rtPA is not effective in patients with ICA occlusion [8–10]. However, determination of the site of vascular occlusion is not a prerequisite for thrombolytic treatment and patients with ICA occlusion who present with AIS within 4.5 h of symptom onset are currently treated with IV rtPA [2]. Nevertheless, whether these patients have benefit from IV thrombolytic therapy remains controversial [9,10]. The objective of this study was to assess the influence on the outcome of IV thrombolysis in patients with extracranial ICA occlusion (eICAo) compared to those without eICAo in a cohort of patients with anterior circulation infarction.
2. Methods For the purpose of the present study we analyzed the data collected in the Serbian Experience with Thrombolysis in Ischemic Stroke (SETIS) register. SETIS is a prospective, ongoing, multicenter, open, and observational register of all patients in Serbia who have received IV rtPA for AIS. This register continuously monitors the safety and efficacy of IV thrombolysis in Serbia. Patients with AIS are treated with IV thrombolysis according to the protocol based on the recommendations of the European guideline [3]. The methods of data collection were described in detail in our previous report [11]. In the period from February 2006 to December 2012, a total of 783 thrombolytic patients were enrolled in the SETIS register. The following data were recorded: patient’s age, gender, risk factors, stroke severity assessed by the National Institutes of Health Stroke Scale (NIHSS score), OTT, neuroimaging findings, early CT signs of ischemic lesions assessed by Alberta Stroke Program Early CT Score (ASPECT score) [6], treatment complications, and outcome. A clinically identifiable subtype of cerebral infarction was defined according to the Oxford Community Stroke Project (OCSP) classification [12]. Stroke etiologies were defined according to the modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification [13]. Complications in the form of intracranial bleeding were categorized using the ECASS trial definitions for hemorrhagic infarction (HI1, HI2), and parenchymal hemorrhage (PH1, PH2), as well as symptomatic intracranial hemorrhage (ICH) [2]. Outcomes were measured by the NIHSS score after 24 h and by the modified Rankin score (mRS) for functional outcome after 90 days. Early neurological improvement (ENI) was defined as NIHSS score equal to 0 or improvement by four or more points 24 h after receiving rtPA. Excellent functional outcome after three months was considered mRS 0–1, while favorable functional outcome, meaning functional independence, was considered mRS 0–2. In the present study we included only patients with an anterior non-lacunar stroke, who clinically presented with partial (PACI) or total (TACI) anterior circulation infarction [12]. Patients were divided into two groups, those with and those without eICAo. An eICAo was diagnosed using carotid duplex ultrasound (CDU) examination, CT angiography (CTA), or magnetic resonance angiography (MRA). Carotid artery status was assessed at presentation by CDU or CTA, or mostly during first few days of hospitalization by CDU, CTA or MRA (median 2.0 days; range 1–23 days). When there was a significant finding, and when the clinical interest required, carotid duplex ultrasound was repeated or an angiography method was performed additionally (CTA or MRA). Descriptive statistics for baseline and demographic data were based on the presence or absence of an eICAo. All the baseline characteristics, outcomes and complication events were compared
125
between the two groups. Two-sample Student t-test was used for comparisons of continuous variables and 2 test or Fisher’s exact test for proportions. A p value of less than 0.05 was regarded as statistically significant. Multiple logistic regression analysis was used to evaluate the predictors of main outcomes by using variables such as the presence of eICAo, age, gender, baseline NIHSS score, ASPECT score, OTT, level of glycemia and mean arterial pressure (MAP) on admission, and the presence of risk factors (atrial fibrillation, hypertension, diabetes mellitus, hyperlipidemia, smoking, chronic heart failure). Ninety-five percent confidence intervals (CI) were calculated for odds ratio (OR). Data were analyzed with the SPSS/PC Win package version 17.0.
3. Results From a total of 783 patients with symptoms of AIS who were treated with IV rtPA in Serbia over the period of seven years, we excluded patients with stroke mimics (n = 11), patients with posterior circulation infarct (POCI) (n = 99), patients with lacunar stroke (LACI according to OCSP classification) (n = 122) and patients with incomplete data (n = 30). Among the 521 included patients, there were 70 (13.4%) patients with eICAo and 451 (86.6%) patients without it. An eICAo was verified by CDU in 97.1% of patients (68/70) and confirmed by CTA in 32.9% (23/70) and MRA in 38.6% (27/70). Patients’ demographic and baseline characteristics, OTT, presence of risk factors, subtype and etiology of stroke in these two groups of patients are shown in Table 1. The average age was similar in both groups (59.5 ± 10.1 years vs. 61.1 ± 12.3 years; p = 0.31) and there were significantly more male patients in the group with eICAo (82.9% vs. 60.5%; p = 0.0008). The average OTT was similar in the groups (160.3 ± 44.3 vs. 160.2 ± 45.5 min). Patients with eICAo had a more severe stroke according to the baseline NIHSS score (15.3 ± 4.0 vs. 13.6 ± 4.7; p = 0.004), the ASPECT score (9.1 ± 0.95 vs. 9.4 ± 0.97; p = 0.08), and the OCSP classification (71.4% of patients with TACI in the group with eICAo vs. 49.2% in the group without it; p = 0.001). Among the risk factors, only atrial fibrillation was significantly more frequent in the group without eICAo (31.9% vs. 11.4%; p = 0.0005). The overall distribution of functional outcomes at 3 months measured by mRS, in patients with and without eICAo is shown in Fig. 1. The proportions of outcomes and complications between these two groups are shown in Table 2. Early neurological improvement was more often observed in patients without eICAo, but it was not significantly (p = 0.06). Furthermore, the percentage of patients with an excellent functional outcome (mRS score 0–1) at three months was significantly higher in group without eICAo (p = 0.009), while the percentage of patients with a favorable functional outcome (mRS score 0–2), was also higher in this group, but not significantly (p = 0.14). Death occurred in more patients without eICAo (p = 0.40), as well as hemorrhagic complication. However, there was no statistically significant difference in symptomatic ICH (1.4% vs. 4.2%; p = 0.5). Multivariate logistic regression analysis showed that the presence of eICAo was not significantly associated with an unfavorable outcome (mRS 3–6) at three months (p = 0.44; OR 1.24, 95% CI 0.72–2.16) or with death (p = 0.18; OR 0.57, 95% CI 0.25–1.29). The predictors of 3-month unfavorable outcome (mRS 3–6) were: an older age (p = 0.02; OR 1.02; 95% CI 1.00–1.04), a higher NIHSS score on admission (p < 0.0001; OR 1.18; 95% CI 1.13–1.24), a lower ASPECT score (p = 0.003; OR 0.74; 95% CI 0.60–0.90), and diabetes mellitus as a risk factor (p = 0.015; OR 1.93; 95% CI 1.14–3.28), while the predictors of mortality (mRS score 6) were: an older age (p < 0.0001; OR 1.07; 95% CI 1.04–1.10), a higher NIHSS score on admission (p < 0.0001; OR 1.12; 95% CI 1.05–1.19), and a higher level of glycemia on admission (p = 0.01; OR 1.14; 95% CI 1.03–1.25).
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Z. Zivanovic et al. / Clinical Neurology and Neurosurgery 120 (2014) 124–128
Table 1 Baseline and demographic patient characteristics according to presence of ICA occlusion. With ICA occlusion, n = 70 Demographic Age, years Sex, males
12.9%
Without ICA occlusion, n = 451
p (significance)
90%
59.5 ± 10.1 58 (82.9%)
61.1 ± 12.3 293 (60.5%)
0.31 0.0008
80%
8 (11.4%) 57 (81.4%) 11 (15.7%) 25 (35.7%)
144 (31.9%) 350 (77.6%) 68 (15.1%) 172 (38.1%)
0.0005 0.57 0.89 0.80
17.3%
5.7% 6.2% 14.3%
Risk factors Atrial fibrillation Hypertension Diabetes mellitus Hyperlipoproteinemia Smoking Chronic cardiomyopathy Without risk factors
16 (22.9%) 8 (11.4%)
Current stroke Stroke subtype, TACI [17] Stroke side, left hemisphere NIHSS score on admittance ASPECT score Other medical condition MAP on admittance, mmHg Glycemia on admittance, mmol/l OTT, min
100%
95 (21.1%) 67 (14.9%)
0.85 0.56
7 (10.0%)
23 (5.1%)
0.17
50 (71.4%)
222 (49.2%)
0.001
38 (54.3%)
230 (51.0%)
0.70
15.3 ± 4.0
13.6 ± 4.7 9.4 ± 0.97
0.08
107.5 ± 14.5
106.4 ± 13.9
0.55
7.2 ± 2.4
7.1 ± 2.6
0.67
160.3 ± 44.3
160.2 ± 45.5
10.9% 60%
17.1%
17.1%
40%
18.4% 30% 17.1% 20% 29.5%
0.99
10% 50 (71.4%)
97 (21.5%)
7 (10.0%) 9 (12.9%) 4 (5.8%)
176 (39.0%) 22 (4.9%) 156 (34.6%)
mRS 6 mRS 5 mRS 4 mRS 3 mRS 2 mRS 1 mRS 0
12.2%
50%
0.004
9.1 ± 0.95
Ethiology [18] Large artery atherosclerosis Cardioembolism Other Undetermined
5.5%
70%
15.7%
