J Clin Neurol.  2011 Dec;7(4):197-202. 10.3988/jcn.2011.7.4.197.

Predictors of Poor Outcome in Patients with Acute Cerebral Infarction

• Dougu N
• Takashima
• Sasahara E
• Taguchi Y
• Toyoda S
• Hirai T
• Nozawa T
• Tanaka K
• Inoue H

• KMID: 2179004
• DOI: http://doi.org/10.3988/jcn.2011.7.4.197

Abstract

BACKGROUND AND PURPOSE
Plasma D-dimer levels are elevated during the acute phase of cerebral infarction (CI). We investigated whether the D-dimer level on admission and other clinical characteristics could be used to predict the poor outcome of patients with acute CI.
METHODS
The clinical characteristics and plasma D-dimer levels measured within 3 days of onset were compared according to outcome among patients with acute CI.
RESULTS
In total, 359 consecutive patients (mean age, 71.8 years) were examined, of which 174 had a poor outcome [score on the modified Rankin scale (mRS) > or =3] at 30 days after hospitalization. The mean mRS score was higher and a poor outcome was observed more frequently among women than among men (p<0.001 for each). The proportions of women, cardioembolism, atrial fibrillation, advanced age (> or =75 years), prior history of CI or transient ischemic attack, and elevated D-dimer level (> or =1.0 microg/mL) were significantly higher among patients with a poor outcome than among those with a good outcome. A multivariate analysis showed that elevated D-dimer level [> or =1.0 microg/mL; odds ratio (OR), 2.45; 95% confidence interval (95% CI), 1.52-3.89; p<0.01], advanced age (OR, 1.93; 95% CI, 1.21-3.07; p<0.01), and female gender (OR, 1.75; 95% CI, 1.08-2.83; p=0.02) were independent predictors of a poor outcome.
CONCLUSIONS
Certain clinical characteristics (gender and advanced age) and an elevated D-dimer level upon admission can be used to predict the outcome of patients with acute CI at 30 days after hospitalization.

Keyword

cerebral infarction; D-dimer; stroke; outcomes; atrial fibrillation; gender

MeSH Terms

Atrial Fibrillation
Cerebral Infarction
Female
Fibrin Fibrinogen Degradation Products
Hospitalization
Humans
Ischemic Attack, Transient
Male
Multivariate Analysis
Odds Ratio
Plasma
Stroke
Fibrin Fibrinogen Degradation Products

Reference

1. Kitamura A, Iso H, Iida M, Naito Y, Sato S, Jacobs DR, et al. Trends in the incidence of coronary heart disease and stroke and the prevalence of cardiovascular risk factors among Japanese men from 1963 to 1994. Am J Med. 2002. 112:104–109.

2. Appelros P, Nydevik I, Viitanen M. Poor outcome after first-ever stroke: predictors for death, dependency, and recurrent stroke within the first year. Stroke. 2003. 34:122–126.

3. Di Carlo A, Lamassa M, Baldereschi M, Pracucci G, Basile AM, Wolfe CD, et al. Sex differences in the clinical presentation, resource use, and 3-month outcome of acute stroke in Europe: data from a multicenter multinational hospital-based registry. Stroke. 2003. 34:1114–1119.

4. Howard G, Walker MD, Becker C, Coull B, Feibel J, McLeroy K, et al. Community Hospital-based Stroke Programs: North Carolina, Oregon, and New York. III. Factors influencing survival after stroke: proportional hazards analysis of 4219 patients. Stroke. 1986. 17:294–299.

5. Turaj W, Slowik A, Wnuk M, Szczudlik A. Gender-related differences in diagnostic evaluation and outcome of ischemic stroke in Poland. Stroke. 2009. 40:980–982.

6. Lewsey JD, Gillies M, Jhund PS, Chalmers JW, Redpath A, Briggs A, et al. Sex differences in incidence, mortality, and survival in individuals with stroke in Scotland, 1986 to 2005. Stroke. 2009. 40:1038–1043.

7. Appelros P, Stegmayr B, Terént A. Sex differences in stroke epidemiology: a systematic review. Stroke. 2009. 40:1082–1090.

8. Eriksson M, Glader EL, Norrving B, Terént A, Stegmayr B. Sex differences in stroke care and outcome in the Swedish national quality register for stroke care. Stroke. 2009. 40:909–914.

9. Smith DB, Murphy P, Santos P, Phillips M, Wilde M. Gender differences in the Colorado Stroke Registry. Stroke. 2009. 40:1078–1081.

10. Reid JM, Dai D, Gubitz GJ, Kapral MK, Christian C, Phillips SJ. Gender differences in stroke examined in a 10-year cohort of patients admitted to a Canadian teaching hospital. Stroke. 2008. 39:1090–1095.

11. Fukuda M, Kanda T, Kamide N, Akutsu T, Sakai F. Gender differences in long-term functional outcome after first-ever ischemic stroke. Intern Med. 2009. 48:967–973.

12. Petrea RE, Beiser AS, Seshadri S, Kelly-Hayes M, Kase CS, Wolf PA. Gender differences in stroke incidence and poststroke disability in the Framingham heart study. Stroke. 2009. 40:1032–1037.

13. Dougu N, Takashima S, Sasahara E, Taguchi Y, Toyoda S, Hirai T, et al. Differential diagnosis of cerebral infarction using an algorithm combining atrial fibrillation and D-dimer level. Eur J Neurol. 2008. 15:295–300.

14. Barber M, Langhorne P, Rumley A, Lowe GD, Stott DJ. D-dimer predicts early clinical progression in ischemic stroke: confirmation using routine clinical assays. Stroke. 2006. 37:1113–1115.

15. Welsh P, Barber M, Langhorne P, Rumley A, Lowe GD, Stott DJ. Associations of inflammatory and haemostatic biomarkers with poor outcome in acute ischaemic stroke. Cerebrovasc Dis. 2009. 27:247–253.

16. Tombul T, Atbas C, Anlar O. Hemostatic markers and platelet aggregation factors as predictive markers for type of stroke and neurological disability following cerebral infarction. J Clin Neurosci. 2005. 12:429–434.

17. Squizzato A, Ageno W, Finazzi S, Mera V, Romualdi E, Bossi A, et al. D-dimer is not a long-term prognostic marker following acute cerebral ischemia. Blood Coagul Fibrinolysis. 2006. 17:303–306.

18. Di Napoli M, Papa F. Villa Pini Stroke Data Bank Investigators. Inflammation, hemostatic markers, and antithrombotic agents in relation to long-term risk of new cardiovascular events in first-ever ischemic stroke patients. Stroke. 2002. 33:1763–1771.

19. Rallidis LS, Vikelis M, Panagiotakos DB, Liakos GK, Krania E, Kremastinos DT. Usefulness of inflammatory and haemostatic markers to predict short-term risk for death in middle-aged ischaemic stroke patients. Acta Neurol Scand. 2008. 117:415–420.

20. Lip GY, Blann AD, Farooqi IS, Zarifis J, Sagar G, Beevers DG. Sequential alterations in haemorheology, endothelial dysfunction, platelet activation and thrombogenesis in relation to prognosis following acute stroke: The West Birmingham Stroke Project. Blood Coagul Fibrinolysis. 2002. 13:339–347.

21. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001. 285:2864–2870.

22. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993. 24:35–41.

23. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988. 19:604–607.

24. Jüttler E, Schweickert S, Ringleb PA, Huttner HB, Köhrmann M, Aschoff A. Long-term outcome after surgical treatment for space-occupying cerebellar infarction: experience in 56 patients. Stroke. 2009. 40:3060–3066.

25. Ueda T, Sakaki S, Kumon Y, Ohta S. Multivariable analysis of predictive factors related to outcome at 6 months after intra-arterial thrombolysis for acute ischemic stroke. Stroke. 1999. 30:2360–2365.

26. Whiteley W, Chong WL, Sengupta A, Sandercock P. Blood markers for the prognosis of ischemic stroke: a systematic review. Stroke. 2009. 40:e380–e389.

27. Herman B, Leyten AC, van Luijk JH, Frenken CW, Op de Coul AA, Schulte BP. Epidemiology of stroke in Tilburg, the Netherlands The population-based stroke incidence register: 2 Incidence, initial clinical picture and medical care, and three-week case fatality. Stroke. 1982. 13:629–634.

28. Brønnum-Hansen H, Davidsen M, Thorvaldsen P. Danish MONICA Study Group. Long-term survival and causes of death after stroke. Stroke. 2001. 32:2131–2136.

29. Roquer J, Campello AR, Gomis M. Sex differences in first-ever acute stroke. Stroke. 2003. 34:1581–1585.

30. Glader EL, Stegmayr B, Norrving B, Terént A, Hulter-Asberg K, Wester PO, et al. Sex differences in management and outcome after stroke: a Swedish national perspective. Stroke. 2003. 34:1970–1975.

31. Gray LJ, Sprigg N, Bath PM, Boysen G, De Deyn PP, Leys D, et al. Sex differences in quality of life in stroke survivors: data from the Tinzaparin in Acute Ischaemic Stroke Trial (TAIST). Stroke. 2007. 38:2960–2964.

32. Paolucci S, Bragoni M, Coiro P, De Angelis D, Fusco FR, Morelli D, et al. Is sex a prognostic factor in stroke rehabilitation? A matched comparison. Stroke. 2006. 37:2989–2994.

33. Takano K, Yamaguchi T, Uchida K. Markers of a hypercoagulable state following acute ischemic stroke. Stroke. 1992. 23:194–198.

34. Kataoka S, Hirose G, Hori A, Shirakawa T, Saigan T. Activation of thrombosis and fibrinolysis following brain infarction. J Neurol Sci. 2000. 181:82–88.

35. Feinberg WM, Erickson LP, Bruck D, Kittelson J. Hemostatic markers in acute ischemic stroke. Association with stroke type, severity, and outcome. Stroke. 1996. 27:1296–1300.

36. Montaner J, Perea-Gainza M, Delgado P, Ribó M, Chacón P, Rosell A, et al. Etiologic diagnosis of ischemic stroke subtypes with plasma biomarkers. Stroke. 2008. 39:2280–2287.

37. Berge E, Friis P, Sandset PM. Hemostatic activation in acute ischemic stroke. Thromb Res. 2001. 101:13–21.

38. Ageno W, Finazzi S, Steidl L, Biotti MG, Mera V, Melzi D'Eril G, et al. Plasma measurement of D-dimer levels for the early diagnosis of ischemic stroke subtypes. Arch Intern Med. 2002. 162:2589–2593.

39. Fisher M, Francis R. Altered coagulation in cerebral ischemia. Platelet, thrombin, and plasmin activity. Arch Neurol. 1990. 47:1075–1079.

40. Tohgi H, Kawashima M, Tamura K, Suzuki H. Coagulation-fibrinolysis abnormalities in acute and chronic phases of cerebral thrombosis and embolism. Stroke. 1990. 21:1663–1667.

41. Ay H, Arsava EM, Gungor L, Greer D, Singhal AB, Furie KL, et al. Admission international normalized ratio and acute infarct volume in ischemic stroke. Ann Neurol. 2008. 64:499–506.

42. Wakita M, Yasaka M, Minematsu K, Yamaguchi T. Effects of anticoagulation on infarct size and clinical outcome in acute cardioembolic stroke. Angiology. 2002. 53:551–556.

43. Jin L, Jin H, Zhang G, Xu G. Changes in coagulation and tissue plasminogen activator after the treatment of cerebral infarction with lumbrokinase. Clin Hemorheol Microcirc. 2000. 23:213–218.