Disorders of consciousness are frequent in the acute stroke. Strokes which produce disorders of consciousness comprise cerebral infarct and hemorrhage involving extensive areas of both hemispheres, either restricted regions: bilateral mesial regions, paramedian diencephalon, and upper brainstem. Patients who develop disorders of consciousness, ranging from somnolence to stupor and coma, need immediate admission to the intensive care unit [
Determine the severity of stroke and mortality in relation to the type of disturbance of consciousness in patients in the acute phase of stroke and determine the outcome of patients with disorders of consciousness.
We retrospectively analyzed 201 patients with acute stroke at the Department of Neurology, University Clinical Center Tuzla, in the period from July 1st to December 31st 2008. The stroke was confirmed in all patients by computed tomography within 24 hours after hospitalization. Respondents were divided according to age, sex, type of stroke (ischemic and haemorrhagic), hemispheric location of stroke (left, right and both hemispheres), and presence of complications of diabetes and hypertension. Disorders of consciousness are divided into quantitative and qualitative. Assessment of disorders of consciousness is performed by Glasgow Coma Scale (GCS) [
Statistical analysis was performed using the SPSS ver. 17.0 (Chicago, IL, USA). To assess the statistical significance of difference between the results obtained, Student's
Fifty-four patients had disorders of consciousness in acute phase of stroke (26.9%). Patients with disorders of consciousness on admission (19.9 ± 9.5 versus 7.9 ± 5.1,
Stroke severity in patients with and without disorders of consciousness on admission and discharge.
Stroke severity | Patients without disorders of consciousness | Patients with disorders of consciousness |
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|
±SD |
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±SD | ||
NIHSS score at admission | 147 | 7.9 | 5.1 | 54 | 19.9 | 9.5 |
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NIHSS score at discharge | 141 | 4.3 | 3.9 | 24 | 11.4 | 10.5 |
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There was no statistically significant differences in the severity of stroke at admission (
Stroke severity in patients with qualitative and quantitative disorders of consciousness on admission and discharge.
Stroke severity | Patients with quantitative disorders of consciousness | Patients with qualitative disorders of consciousness |
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---|---|---|---|---|---|---|---|
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±SD |
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±SD | ||
NIHSS score at admission | 28 | 20.7 | 10.3 | 26 | 18.1 | 8.6 | 0.3 |
NIHSS score at discharge | 10 | 12.3 | 13.4 | 14 | 11.2 | 9.2 | 0.8 |
Mortality was significantly higher in patients with disorders of consciousness (55.6% : 4.1%,
Mortality of patients with disorders of consciousness in the acute phase of stroke.
Patients | Mortality | ||||||
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Died | Survivors | Total |
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||||
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% |
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% |
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% | ||
Patients with quantitative disorders of consciousness | 16 | 61.5 | 10 | 38.5 | 26 | 100.0 | 0.8 |
Patients with qualitative disorders of consciousness | 14 | 50.0 | 14 | 50.0 | 28 | 100.0 | |
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Patients with disorders of consciousness | 30 | 55.6 | 24 | 44.4 | 54 | 100.0 |
|
Patients without disorders of consciousness |
6 | 4.1 | 141 | 95.9 | 147 | 100.0 | |
| |||||||
Total | 36 | 17.9 | 165 | 82.1 | 201 | 100.0 |
*: Chi-square test.
Patients had disturbances of consciousness were significantly more complications (
The incidence of complications in patients with and without disturbances of consciousness in the acute phase of stroke.
Patients | |||||||
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With disorders of consciousness | Without disorders of consciousness | Total |
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||||
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% |
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% |
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% | ||
With complications | 23 | 50.0 | 23 | 50.0 | 46 | 100.0 | < |
Without complications | 31 | 20.0 | 124 | 80.0 | 155 | 100.0 | |
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Total | 54 | 26.9 | 147 | 73.1 | 199 | 100.0 |
*: Chi-square test.
There was no statistically significant difference between patients with and without disturbances of consciousness in relation to the localization of hemispheric stroke (
Direct logistic regression was performed to assess the impact of several factors on the likelihood that patients will die. The model contains two independent variables (complications and type of stroke). Full model (all predictors) was not statistically significant, meaning that the model does not distinguish between those respondents who did and those who did not die, and there is no statistically significant influence of the analyzed predictors of their death (Table
Survival of patients with disorders of consciousness in the acute phase of stroke.
Predictors | Patients with disorders of consciousness | |||||||||
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Died | Survivors | Total | OR |
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% |
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% |
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% | 95% CI for OR | ||||
With complications | 11 | 36.7 | 12 | 50.0 | 23 | 100.0 | 0.5 | 0.17 | 1.67 | 0.3 |
Without complications | 19 | 63.3 | 12 | 50.0 | 31 | 100.0 | ||||
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Ischemic stroke | 21 | 70.0 | 22 | 91.7 | 43 | 100.0 | 0.2 | 0.004 | 1.06 | 0.06 |
Haemorrhagic stroke | 9 | 30.0 | 2 | 8.3 | 11 | 100.0 |
*Cox
There are several limitations of our study. This was a pilot study, and the small number of participants means that a larger study is needed to assess the association between delirium poststroke and long-term prognosis in more detail. In our institution we have an established treatment protocol for decompressive craniotomy, a stroke unit and thrombolysis was adopted shortly after conducting this research. Specific neuropsychological assessment of qualitative disturbances of consciousness is not made, and both are reduced to a common type of these disorders in the acute phase of stroke, delirium according to DSM criteria.
Previous studies dealing with severity of stroke and mortality are not observed in relation to the type of disturbance of consciousness in patients in the acute phase of stroke. Coma related to hemorrhagic stroke (HS) (CGS < 5) carried a short-term case fatality of 86%, and specific predictors of death were a CGS below 5, anisocoria, abnormal flexion (decorticate) or no response to pain, and absent or only one brainstem reflex [
Results in our study are similar to the above-mentioned studies. The contribution of our research is that we have demonstrated that disorders of consciousness in the acute phase of stroke significantly affect the severity of stroke and poorer outcome of patients.
In the acute phase of stroke patients with disorders of consciousness have a more severe stroke and higher mortality compared to patients without disorders of consciousness. There is no difference in mortality and the severity of stroke between patients with quantitative and qualitative disorders of consciousness. In the acute phase of stroke complications were significantly more frequent in patients with disorders of consciousness, and consciousness disorders in hemorrhagic stroke. There is no statistically significant effect of specific predictors of survival in patients with disorders of consciousness.