Dehydration Status is Associated With More Severe Hemispatial Neglect After Stroke

Abstract

Background Many stroke patients are clinically dehydrated at the time of hospital presentation, which could lead to an increase in blood viscosity and alteration in cerebral perfusion. Impaired cerebral perfusion can cause hemispheric dysfunction, which can be rapidly quantified with bedside tests of hemispatial neglect. We hypothesized that hospitalized patients with laboratory markers consistent with dehydration or a volume contracted state (VCS) would have more severe cerebral dysfunction defined by greater degree of neglect. Methods Subjects were a consecutive series of right-handed patients with acute right hemispheric stroke admitted within the Johns Hopkins Health System. All participants had clinical syndrome and MRI consistent with acute infarction. The primary definition of a VCS was a urea/creatinine ratio greater than 15; with secondary definition including urine specific gravity over 1.010. Acute infarct volume was measured on magnetic resonance imaging. Neglect was evaluated using a standardized battery of bedside tests. Results Of 201 patients meeting inclusion criteria, 131/201 (65%) had elevated BUN/creatinine ratios at admission. Approximately 61% (122/201) had some degree of neglect. Elevated BUN/Creatinine ratio was associated with an increased odds of severe neglect in unadjusted models (OR 4.1, 95% CI 1.2, 14.4), with loss of significance in adjusted models (OR 4.43, (95% CI 0.99, 19.8) after adjustment for age, infarct volume, sex, and NIHSS score. Conclusions Our data suggest that patients who are in a VCS at the time of stroke may have more frequent and severe neglect, with attenuation of results after adjustment for factors related to stroke size and age. If proven clinically relevant, a formalized rehydration strategy based on objective lab markers may represent an opportunity for improvement in outcome with low cost, broadly available treatment for acute stroke patients.

Pilot study of volume contracted state and hospital outcome after stroke

“…This study expands on prior studies in that this series, conducted at a comprehensive stroke center, includes only MRI-confirmed ischemic stroke patients, reports PWI in the volume contracted and euvolemic groups, and measures amount of IV fluids administered. These findings support prior reports in the literature [3][4][5][6][7][8][9][10] and suggest a potential opportunity for improvement in our hydration strategy for patients who are volume contracted at the time of presentation with ischemic stroke. This study also validates results from several prior reports demonstrating that a large percentage of ischemic stroke patients are volume contracted at the time of their stroke.…”

Recent advances in the management of transient ischemic attacks

“…For example, isotonic crystalloid solutions can easily be administered to TIA patients as soon as they arrive in the ED. Not only is this inexpensive and low-risk step in line with the existing guidelines for the early management of acute ischemic stroke 108 but it also addresses the fact that approximately 50% of stroke patients present with measurable dehydration 109 – 115 . Along the same lines, any patient with TIA should be given "best medical management" of oxygenation, careful blood pressure control, and serum glucose regulation, just as if they had suffered a bona fide ischemic stroke 108 .…”

A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications

“…The presence of dehydration at the time of admission following ischaemic stroke is associated with increased incidence of severe disability or death [122,139,140]. The development or progression of dehydration during hospitalisation for ischaemic stroke is associated with increased risk of stroke evolution [141,142], risk of secondary infection [143], increased length of stay [143], more severe hemi-spatial neglect [144] and increased cost [145]. Evidence from a few small interventional trials in this setting suggest that post-admission rehydration regimens aimed at the reduction of BUN:Cr ratios may reduce stroke evolution [141], improve collateral cerebral perfusion [146] and reduce length of stay [143].…”