Vomiting Should Be a Prompt Predictor of Stroke Outcome
Vomiting Should Be a Prompt Predictor of Stroke Outcome
First, and most importantly, the HR adjusted for age, sex, systolic and diastolic blood pressures and paresis were high in patients with vomiting in stroke as a whole and in each three subtype of stroke. Kaplan–Meier survival curves showed that survival rates for the first 30 days after the event were worse in the patients with vomiting than in those without vomiting. Log-rank tests proved that those differences were statistically significant regardless of subtypes.
The findings suggest that vomiting at stroke onset could be a prompt predictor of early death after stroke. Vomiting is an outstanding symptom that is noticeable by patients' family and emergency care staff. In contrast to other symptoms, such as headache and nausea, vomiting is a symptom that can be assessed even in patients with disturbed consciousness. Vomit is also often noticeable on patients' clothes. Patients who have vomited should be paid more attention immediately. Although vomiting cannot indicate the precise location or the nature of the lesion, such as ischaemic or haemorrhagic, it often suggests the massive effect of the lesion. Vomiting should be a good candidate for predicting the outcome of a stroke applicable in a clinical setting, especially during the acute phase. The clinical usefulness of this, however, would depend on whether recognition of this as a poor prognostic indicator could lead to earlier treatment so that may improve the prognosis. Although this study did not cover the treatments, the relationship between vomiting at the onset of stroke and mortality should provide valuable information to identify patients who could benefit most from intensive care at the earliest stage. The emergency physician is advised to pay more attention to patients with vomiting and to try to prevent complications including aspiration pneumonia, which may be caused by vomiting.
Second, the study showed the frequency of vomiting was different among stroke subtypes. Although vomiting is not a specific symptom for a certain type of stroke, it was more common in haemorrhagic than in ischaemic stroke, in agreement with previous investigations. This study added the information that vomiting was about 1.5 times more frequently seen in SAH than in CH. The treatment of infarction, in which restoration of circulation is important, is the exact opposite to treating haemorrhage in which bleeding needs to be arrested. An obvious conclusion from this study is that vomiting should alert the emergency physician to the possibility of haemorrhage, because that is three to four times more likely to be the case, especially when CT or MRI is not available.
Third, we investigated the relations between vomiting and other characteristics of stroke patients. There was no significant difference in age and sex between the patients with vomiting and patients without vomiting. Both systolic and diastolic blood pressures were higher in patients with vomiting than in patients without vomiting, and this was most noticeable in haemorrhagic stroke. Vomiting showed an association with hypertension at the first examination but not with hypertension history. Causes of vomiting in stroke are not fully clarified, but may probably include brain oedema and/or increased intracranial hypertension, which may also elevate blood pressure. Vomiting was more often seen in patients without paresis than in patients with paresis in CI.
First, inherent limitations of the stroke registry for the entire prefecture are difficult to avoid. There may be missing data for stroke patients; for example, patients who died before arriving at hospitals and patients who went to hospital outside of the prefecture. Patients with mild symptoms might not have visited hospitals and patients with atypical symptoms might not have been diagnosed as such, and subsequently might not have been registered.
Second, we did not investigate the direct causes of death in this study. Viitanen et al reported that the dominant causes of death, as verified by autopsy, were cerebrovascular disease in the first week, pulmonary embolism in the second to fourth week, bronchopneumonia during the second and third months and cardiac disease.
Third, vomiting could be influenced by meals, relapsed time after meals, and even transportation by ambulance.
With all these limitations, however, a significant bias that affects the major conclusion, that vomiting at the onset of stroke correlates with early mortality regardless of stroke subtype, is unlikely, because the study is based on a large cohort and this has sufficient statistical power.
Discussion
First, and most importantly, the HR adjusted for age, sex, systolic and diastolic blood pressures and paresis were high in patients with vomiting in stroke as a whole and in each three subtype of stroke. Kaplan–Meier survival curves showed that survival rates for the first 30 days after the event were worse in the patients with vomiting than in those without vomiting. Log-rank tests proved that those differences were statistically significant regardless of subtypes.
The findings suggest that vomiting at stroke onset could be a prompt predictor of early death after stroke. Vomiting is an outstanding symptom that is noticeable by patients' family and emergency care staff. In contrast to other symptoms, such as headache and nausea, vomiting is a symptom that can be assessed even in patients with disturbed consciousness. Vomit is also often noticeable on patients' clothes. Patients who have vomited should be paid more attention immediately. Although vomiting cannot indicate the precise location or the nature of the lesion, such as ischaemic or haemorrhagic, it often suggests the massive effect of the lesion. Vomiting should be a good candidate for predicting the outcome of a stroke applicable in a clinical setting, especially during the acute phase. The clinical usefulness of this, however, would depend on whether recognition of this as a poor prognostic indicator could lead to earlier treatment so that may improve the prognosis. Although this study did not cover the treatments, the relationship between vomiting at the onset of stroke and mortality should provide valuable information to identify patients who could benefit most from intensive care at the earliest stage. The emergency physician is advised to pay more attention to patients with vomiting and to try to prevent complications including aspiration pneumonia, which may be caused by vomiting.
Second, the study showed the frequency of vomiting was different among stroke subtypes. Although vomiting is not a specific symptom for a certain type of stroke, it was more common in haemorrhagic than in ischaemic stroke, in agreement with previous investigations. This study added the information that vomiting was about 1.5 times more frequently seen in SAH than in CH. The treatment of infarction, in which restoration of circulation is important, is the exact opposite to treating haemorrhage in which bleeding needs to be arrested. An obvious conclusion from this study is that vomiting should alert the emergency physician to the possibility of haemorrhage, because that is three to four times more likely to be the case, especially when CT or MRI is not available.
Third, we investigated the relations between vomiting and other characteristics of stroke patients. There was no significant difference in age and sex between the patients with vomiting and patients without vomiting. Both systolic and diastolic blood pressures were higher in patients with vomiting than in patients without vomiting, and this was most noticeable in haemorrhagic stroke. Vomiting showed an association with hypertension at the first examination but not with hypertension history. Causes of vomiting in stroke are not fully clarified, but may probably include brain oedema and/or increased intracranial hypertension, which may also elevate blood pressure. Vomiting was more often seen in patients without paresis than in patients with paresis in CI.
Limitations
First, inherent limitations of the stroke registry for the entire prefecture are difficult to avoid. There may be missing data for stroke patients; for example, patients who died before arriving at hospitals and patients who went to hospital outside of the prefecture. Patients with mild symptoms might not have visited hospitals and patients with atypical symptoms might not have been diagnosed as such, and subsequently might not have been registered.
Second, we did not investigate the direct causes of death in this study. Viitanen et al reported that the dominant causes of death, as verified by autopsy, were cerebrovascular disease in the first week, pulmonary embolism in the second to fourth week, bronchopneumonia during the second and third months and cardiac disease.
Third, vomiting could be influenced by meals, relapsed time after meals, and even transportation by ambulance.
With all these limitations, however, a significant bias that affects the major conclusion, that vomiting at the onset of stroke correlates with early mortality regardless of stroke subtype, is unlikely, because the study is based on a large cohort and this has sufficient statistical power.
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