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The Impact of Body Mass Index on the Thrombolytic Treatment of Acute Ischemic Stroke

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      Background: Body weight and body mass index (BMI) are regularly assessed factors in stroke patients for manifold reasons. However, their potential role specifically in intravenous thrombolysis has not been thoroughly examined. Methods: Data from 865 consecutive acute ischemic stroke patients treated with intravenous thrombolysis were analyzed. Patients were divided into different BMI categories (underweight, normal weight, overweight, obese) and compared based on the following factors: time window of treatment, clinical scores National Institute of Health Stroke Scale Score (NIHSS), modified Rankin scale (mRS) on admission and discharge, risk factors, stroke characteristics and thrombolysis complications. Recombinant tissue plasminogen activator (rtPA) doses relative to body weight and blood volume were also assessed. In a separate analysis, patients weighing up to 100 and >100 kg were compared. Results: Eighteen patients (2.1%) were underweight, 336 (38.8%) overweight, 194 (22.4%) obese and 317 (36.7%) had normal weight. Higher BMI category was associated with younger age, thrombolytic treatment later than 4.5 h, arterial hypertension, diabetes and higher relative rtPA dose relative to blood volume (p < 0.001). There were no significant differences concerning NIHSS and mRS scores or thrombolysis complications. Forty-six patients (5.3%) weighed over 100 kg. They were younger (p = 0.002) and treated later than patients under 100 kg (p < 0.001). Mean rtPA dose relative to body weight and to blood volume was significantly lower (0.7 vs. 0.9 mg/kg, p < 0.001 and 13 vs. 13.9 mg/l, p < 0.001). There was a marginal difference in NIHSS score improvement ≥4 points (26.1 vs. 40.2%, p = 0.038); otherwise, no outcome differences were found. Conclusion: BMI category does not significantly influence clinical outcome after thrombolysis. However, relevant NIHSS improvement was found more often in patients weighing up to 100 kg compared to those over 100 kg. Interestingly, patients with higher BMI or weight >100 kg were thrombolysed later than other patients.

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      Most cited references 15

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      Classification and pathogenesis of cerebral hemorrhages after thrombolysis in ischemic stroke.

      Brain hemorrhage after ischemic stroke is a serious complication of treatment; however, its pathology is poorly understood. A classification based on brain imaging may help to better understand and avoid causal factors. Review of the results of controlled randomized trials and the available literature. Hemorrhagic infarctions have no impact on clinical outcome and are probably not associated with the thrombolytic itself and the type of reperfusion strategy. They are associated with the extent of ischemic damage and most probably to an ischemic vasculopathy. Parenchymal hematomas are often clinically relevant. Their incidence is affected by the thrombolytic itself, the type, and probably the time point of reperfusion strategy. The loss of hemostatic control seems important in their pathogenesis. Extraischemic hematomas (remote from the infarct), unique or multiple, suggest pre-existing brain pathology, especially cerebral amyloid angiopathy. The radiological description of 3 different types of brain hemorrhage is useful to better understand the specific pathology and the impact on clinical outcome. It may help to avoid clinically relevant brain hemorrhages.
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        Reducing prehospital delay in acute stroke.

        Despite the proven benefits of thrombolysis for patients presenting with acute ischemic stroke, only a limited number of patients receive thrombolytic therapy. The reason for the low treatment rate is that thrombolysis is only effective a few hours after the onset of ischemic stroke, so delays in patients being admitted to hospital and being diagnosed mean that the therapeutic window is often missed. Major factors that lead to prehospital delay include the general public's lack of knowledge of stroke symptoms and their poor understanding of the appropriate course of action following a stroke. Indeed, the patients who arrive early in hospital tend to be those who recognize the symptoms of stroke and take them seriously. Deficiencies in the identification of stroke by emergency medical services and general practitioners also contribute to prehospital delay. Aggressive, combined educational programs aimed at the general public, general practitioners, and medical and paramedical hospital staff can lead to increased stroke treatment rates. In this Review, we explore the extent of prehospital delay in stroke, identify the factors that affect the time taken for patients to reach hospital, and describe strategies designed to reduce the delay.
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          The impact of body mass index on mortality after stroke.

          Little is known about the contribution of obesity to the higher mortality risk among stroke survivors. We assessed the independent association between body mass index (BMI) and mortality among stroke survivors. Cross-sectional and prospective data from a nationally representative survey of noninstitutionalized civilian U.S. population aged 25 or older (n=20 050) with a baseline history of stroke (n=644) followed up from survey participation (1988-1994) through mortality assessment in 2000. Relationships between BMI and mortality attributable to all causes or cardiovascular causes were examined after adjusting for established prognosticators after stroke. Stroke survivors were more likely to be overweight (BMI 25 to 29 kg/m2) or obese (BMI > or =30 kg/m2 than those without stroke (64.3% versus 53.2%, P=0.003). In multivariable analysis, overall risk for all-cause mortality increased per kg/m2 of higher BMI (P=0.030), but an interaction between age and BMI (P=0.009) revealed that the association of higher BMI with mortality risk was strongest in younger individuals and declined linearly with increasing age, such that in the elderly, overweightness and obesity had a protective effect. The results were similar for the cardiovascular mortality outcome. Higher BMI after stroke is associated with a greater risk of all-cause and cardiovascular death among younger individuals. Younger stroke survivors may especially benefit from more vigorous efforts to monitor and treat obesity.

            Author and article information

            Department of Neurology, Universitaetsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
            Cerebrovasc Dis
            Cerebrovascular Diseases
            Cerebrovasc Dis
            S. Karger AG (Basel, Switzerland karger@ )
            July 2016
            14 May 2016
            : 42
            : 3-4
            : 240-246
            Cerebrovasc Dis 2016;42:240-246
            © 2016 S. Karger AG, Basel

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            Tables: 3, References: 24, Pages: 7
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