| This article is composed of three parts.The first part is a prospective cohort study on risk factors of stroke-associated pneumonia and functional recovery and outcome trajectory in patients with Intracerebral hemorrhage(ICH).In a single-center prospective cohort study,a total of 670 patients with spontaneous Intracerebral hemorrhage(ICH)were included to explore the risk factors of stroke-associated pneumonia(SAP),and to observe the functional recovery trajectory for 180 days,drawing the outcome trajectory of different cohorts of patients with ICH after the acute period.The results shows that The probability of stroke-associated pneumonia was 56.4% in patients with ICH,and Dysphagia(OR = 2.73,95%CI 1.46-5.12,P=0.002),admission NIHSS score(OR = 1.09,95%CI 1.05-1.12,P= <0.001),Baseline hematoma volume(OR = 1.02,95%CI 1.01-1.04,P=0.01),mannitol use(OR = 1.88,95%CI 1.10-3.24,P=0.02),surgical treatment(OR = 2.53,95%CI 1.11-5.75,P=0.03),endotracheal tube(OR = 2.49,95%CI 1.16-5.37,P=0.02)and length of stay in ICU(OR = 1.10,95%CI0.03-1.17,P= <0.001)was an independent risk factor for developing SAP.For the first time,the "polarization" pattern of nerve function recovery after the acute phase of patients with intracerebral hemorrhage was proposed.It confirmed that SAP significantly increases the poor prognosis and mortality in patients with ICH and that this adverse effect continues until day 180 after ICH.It was also found that the occurrence of SAP may delay the recovery rate of neurological function in patients with ICH.The second part is an external cohort validation trial of the predictive value of different scoring systems for the development of SAP after ICH.A total of 677 patients with ICH were included,and patients were divided into different cohorts according to the length of stay and discovery to treatment time to test the ability of 6 major score prediction systems to predict the risk of SAP in patients with ICH.The results shows that the PASS and pneumonia score scoring systems showed better ability of SAP recognition in all cohorts,and the ISAN scoring system had lower predictive power for SAP than other scoring systems in all cohorts.For patients with 72 hours,ICH-APS-A,ICH-APS-B,ICH-LR2S2 and ISAN were less predictive for SAP than the PASS and pneumonia score scoring systems.The five major scoring systems,ICH-APS-A,ICH-APS-B,ICH-LR2S2,PASS and pneumonia score,all showed better predictive power for SAP in the ICH cohorts at ONT 24 hours and ONT> 24 hours.The third part is a retrospective cohort study about Neutrophil percentage to albumin ratio is associated with stroke-associated pneumonia and poor outcome in patients with spontaneous intracerebral hemorrhage.We retrospective analyzed our prospective database of consecutive ICH patients who were admitted to the First Affiliated Hospital of Chongqing Medical University from January 2016 to September 2021.Multivariable logistic regression models were used to investigate the association between NPAR,SAP,and functional outcome.Receiver operating characteristic(ROC)curve analysis was conducted to identify the optimal cutoff of NPAR to discriminate between good and poor outcomes in ICH patients.A total of 918 patients were included.Multivariate regression analysis showed that higher NPAR on admission was an independent predictor of SAP(adjusted odds ratio: 2.45;95% confidence interval,1.56-3.84;P<0.001) and was associated with increased risk of poor outcome(adjusted odd ratio:1.72;95% confidence interval,1.03-2.90;P=0.040)in patients with ICH.In ROC analysis,an NPAR of 2 was identified as the optimal cutoff value to discriminate between good and poor functional outcomes.The results confirmed that Higher NPAR is independently associated with SAP and poor functional outcome in patients with ICH.Our findings suggest that early prediction of SAP is feasible by using a simple biomarker NPAR.At the end of the article,we did a review of the pathogenesis and predictors of stroke-associated pneumonia in hemorrhagic stroke patients,which mainly summarizes the pathogenesis,predictive indicators and prediction score scales of hemorrhagic stroke-associated pneumonia.The pathogenesis of SAP is dominated by aspiration,stroke-induced immune suppression(SIDS),and lung-brain interactions.A summary of predictors of stroke-associated pneumonia include human monocyte DR antigen(m HLA-DR),monocyte / lymphocyte ratio(MLR),neutrophil /lymphocyte ratio(NLR),T lymphocyte subset,heart rate variability(HRV),etc.The current reported scoring and prediction systems include ICH-APS score,ISAN score,VHA score,PASS score,ACDD 4 score,pneumonia scale(The pneumonia score),ICH-LR2S2 score,Braden scale,etc.It aims to provide a theoretical basis for early evaluation and predict the occurrence of SAP in patients with hemorrhagic stroke and improve the treatment level of ICH.PART Ⅰ: A PROSPECTIVE COHORT STUDY ON THE RISK FACTORS OF STROKE-ASSOCIATED PNEUMONIA AND THE 180-DAY FUNCTIONAL RECOVERY AND OUTCOME TRAJECTORY IN PATIENTS WITH INTRACEREBRAL HEMORRHAGEObjective: To investigate the risk factors of stroke-associated pneumonia after cerebral hemorrhage and observe the functional recovery and the 180-day outcome trajectory of patients through a single center prospective cohort study.Methods: Patients with Intracerebral hemorrhage(ICH)admitted to the The Third Affiliated Hospital of Chongqing Medical University from March 1,2020 to May 31,2022 were prospectively included.Clinical data of patients were collected.The primary outcome was stroke-associated pneumonia(SAP),and the secondary outcome were 30-day m RS Score,90-day m RS Score and 180-day m RS Score.The clinical data of patients were statistically analyzed to explore the risk factors of SAP in patients with ICH,and observe the neurological function recovery and outcome trajectory for 180 days.Results: A total of 670 patients with spontaneous intracerebral hemorrhage(ICH)were included,of which 378(56.4%)patients were diagnosed with stroke-associated pneumonia.Multivariate logistic regression analysis showed dysphagia(OR = 2.73,95%CI:1.455-5.118,P=0.002),admission NIHSS score(OR = 1.09,95%CI:1.05-1.12,P<0.001),Baseline hematoma volume(OR = 1.02,95%CI:1.01-1.04,P=0.01)Surgical treatment(OR = 2.53,95%CI:1.11-5.75,P=0.03)tracheal intubation(OR = 2.49,95%CI:1.16-5.37,P=0.02)and ICU stay(OR = 1.1,95%CI:03-1.17,P <0.001)was an independent risk factor for the development of SAP.The analysis of the neurological recovery of patients shows that the neurological recovery of patients with ICH showed a "polarization" pattern,that is,the number of patients with m RS score 0 and6 was increasing,while the number of patients in the middle gradually decreased.The number of patients with an m RS score of 6 increased more in the SAP group.In the outcome trajectory analysis of 180 days,it was found that the neurological recovery of patients with ICH and SAP was faster in the period of 30 to 90 days,and gradually stabilized after that,but the mortality rate showed a slow growth trend.Conclusions: Patients with ICH were found to be at higher risk of stroke-associated pneumonia.Dysphagia,admission NIHSS score,baseline hematoma volume,surgical treatment,endotracheal intubation and length of stay in ICU were independent risk factors for the development of SAP.Neurological recovery in patients with ICH showed a "polarization" pattern.The occurrence of SAP significantly increases the adverse prognosis and mortality rate in patients with ICH,and this adverse effect continues until day 180 after the onset of ICH.The occurrence of SAP may delay the rate of recovery of neurological function in patients with ICH.PART Ⅱ:EXTERNAL VALIDATION OF THE PREDICTIVE VALUE OF DIFFERENT SCORING SYSTEMS FOR STROKE-ASSOCIATED PNEUMONIA AFTER INTRACEREBRAL HEMORRHAGE(ICH)Objective: To compare the predictive value of different scoring systems for the development of stroke-associated pneumonia(SAP)after Intracerebral hemorrhage(ICH)through a single-center prospective cohort study.Methods: Patients with acute ICH who were hospitalized in the neurological disease Center of the Third Affiliated Hospital of Chongqing Medical University from March 1,2020 to May 31,2022,and clinical data from admission to discharge were collected.The SAP prediction scores were calculated for all the cases.The optimal cut-off value and the area under the curve(AUC)of these scoring systems were evaluated against the receiver operating characteristic(ROC)curves,and the area under the curve(AUC)was compared pairwise using the De Long method.Results: A total of 677 patients with spontaneous Intracerebral hemorrhage(ICH)were included.In the overall cohort,pneumonia score(AUC:0.857(0.828-0.883);Sen:0.737;Spe: 0.889)showed a good predictive power,PASS(PASS-pneumonia score Difference of area under curve(95%CI of difference):0.00728(-0.00916-0.0237);P=0.3852),ICH-LR2S2(ICH-LR2S2-pneumonia score Difference of area under curve(95%CI of difference):0.008(-0.0158-0.0318);P=0.5093)and ICH-APS-B(ICH-APS-B-pneumonia score Difference of area under curve(95%CI of difference): 0.0134(-0.0103-0.0371);P=0.2663)is comparable to the predictive power of pneumonia score for SAP;In the cohort of patients with 72 hours of hospital stay,PASS(AUC:0.887(0.776-0.955);Sen:0.781;Spe: 0.846)shows good predictive power,pneumonia score(PASS-pneumonia score Difference of area under curve(95%CI of difference):0.0625(-0.0275-0.153);P=0.1736)is comparable to the prediction power of the P AAS for SAP;In the cohort of patients with a length of stay> 72 hours,ICH-LR2S2(AUC:0.865(0.835-0.891);Sen:0.814;Spe: 0.806)shows good predictive power,ICH-APS-A(ICH-APS-A-ICH-LR2S2 Difference of area under curve(95%CI of difference):0.0171(-0.000421-0.0347);P=0.0558),ICH-APS-B(ICH-APS-B-ICH-LR2S2 Difference of area under curve(95%CI of difference):0.00619(-0.00713-0.0195);P=0.3623),PASS(ICH-LR2S2-PASS Difference of area under curve(95%CI of difference):0.00724(-0.0107-0.0251);P=0.4278)and pneumonia score(ICH-LR2S2-pneumonia score Difference of area under curve(95%CI of difference): 0.0025(-0.0217-0.0267);P=0.84)is comparable to the predictive power of ICH-LR2S2 for SAP;In the cohort of patients at 24 hours of ONT,pneumonia score(AUC:0.832(0.791-0.867);Sen:0.731;Spe:0.858)shows good predictive power,ICH-APS-A(ICH-APS-A-pneumonia score Difference of area under curve(95%CI of difference):0.0109(-0.0193-0.0410);P=0.4801),ICH-APS-B(ICH-APS-B-pneumonia score Difference of area under curve(95%CI of difference):0.017(-0.0176-0.0515);P=0.3359),ICH-LR2S2(ICH-LR2S2-pneumonia score Difference of area under curve(95%CI of difference):0.0144(-0.0207-0.0495);P=0.4213)and PASS(PASS-pneumonia score Difference of area under curve(95%CI of difference):0.018(-0.00659-0.0427);P=0.1512)is comparable to the predictive power of pneumonia score for SAP;In the cohort of patients with ONT> 24 hours,ICH-LR2S2(AUC:0.874(0.816-0.919);Sen:0.787;Spe: 0.838)shows good predictive power,ICH-APS-A(ICH-APS-A-ICH-LR2S2 Difference of area under curve(95%CI of difference):0.0215(-0.00663-0.0496);P=0.1343),ICH-APS-B(ICH-APS-B-ICH-LR2S2 Difference of area under curve(95%CI of difference):0.00959(-0.0172-0.0363);P=0.4823),PASS(ICH-LR2S2-PASS Difference of area under curve(95%CI of difference):0.00298(-0.0289-0.0349);P=0.8544)and pneumonia score(ICH-LR2S2-pneumonia score Difference of area under curve(95%CI of difference): 0.0161(-0.0238-0.0559);P=0.4297)is comparable to the predictive power of ICH-LR2S2 for SAP,There was no statistically significant difference(P> 0.05).ISAN(AUC:0.755-0.815)The prediction accuracy of SAP was relatively low in all cohorts,and the difference between the area under the curve(ROCAUC)and the optimal score was statistically significant(P <0.05).Conclusions: The PASS and pneumonia score scoring systems showed better recognition ability for SAP in all cohorts,and the ISAN scoring system had lower predictive power for SAP than other scoring systems in all cohorts.For patients with 72 hours,ICH-APS-A,ICH-APS-B,ICH-LR2S2 and ISAN were less predictive for SAP than the PASS and pneumonia score scoring systems.The five major scoring systems,ICH-APS-A,ICH-APS-B,ICH-LR2S2,PASS and pneumonia score,all showed better predictors of SAP in the ICH cohort with ONT at24 hours and ONT> 24 hours.PART Ⅲ: NEUTROPHIL PERCENTAGE TO ALBUMIN RATIO IS ASSOCIATED WITH STROKE-ASSOCIATED PNEUMONIA AND POOR OUTCOME IN PATIENTS WITH SPONTANEOUS INTRACEREBRAL HEMORRHAGEObjective: The purpose of this study was to investigate the diagnostic performance of the neutrophil percentage-to-albumin ratio(NPAR)for predicting stroke-associated pneumonia(SAP)and functional outcome in patients with intracerebral hemorrhage(ICH).Methods: We retrospective analyzed our prospective database of consecutive ICH patients who were admitted to the First Affiliated Hospital of Chongqing Medical University from January 2016 to September 2021.We included subjects with a baseline computed tomography available and a complete NPAR count performed within 6h of onset.The patients’ demographic and radiological characteristics were analyzed.Poor outcome was defined as a modifed Rankin Scale score of 4-6 at 90 days.Multivariable logistic regression models were used to investigate the association between NPAR,SAP,and functional outcome.Receiver operating characteristic(ROC)curve analysis was conducted to identify the optimal cutoff of NPAR to discriminate between good and poor outcomes in ICH patients.Results: A total of 918 patients were included.Of those,316(34.4%)had SAP,and 258(28.1%)had poor outcomes.Multivariate regression analysis showed that higher NPAR on admission was an independent predictor of SAP(adjusted odds ratio: 2.45;95% confidence interval,1.56-3.84;P<0.001)and was associated with increased risk of poor outcome(adjusted odd ratio:1.72;95% confidence interval,1.03-2.90;P=0.040)in patients with ICH.In ROC analysis,an NPAR of 2 was identified as the optimal cutoff value to discriminate between good and poor functional outcomes.Conclusion: Higher NPAR is independently associated with SAP and poor functional outcome in patients with ICH.Our findings suggest that early prediction of SAP is feasible by using a simple biomarker NPAR. |
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