Objectives: To compare the urodynamic characteristics of patients with hemorrhagic stroke and those with cerebral ischemic stroke patients at Bachmai Hospital in 2016 - 2017. Subject and method: A descriptive prospective study on 84 stroke patients (26 with hemorrhagic stroke and 58 with local ischemic stroke) meeting inclusion criteriants at Bach Mai hospital in 2016-2017.
Journal of military phrmaco-medicine nO7-2017 COMPARISON OF URODYNAMIC CHARACTERISTICS IN CEREBRAL HEMORRHAGE AND ISCHEMIC STROKE PATIENTS AT BACH MAI HOSPITAL IN 2016 - 2017 Do Dao Vu*; Nguyen Thanh Xuan** SUMMARY Objectives: To compare the urodynamic characteristics of patients with hemorrhagic stroke and those with cerebral ischemic stroke patients at Bachmai Hospital in 2016 - 2017 Subject and method: A descriptive prospective study on 84 stroke patients (26 with hemorrhagic stroke and 58 with local ischemic stroke) meeting inclusion criteria Results: Urodynamic tests showed that the group of hemorrhagic stroke patients had a higher rate of overactive bladder than that in ischemic stroke patients (p < 0.05, χ2 test) The bladder maximum capacity and residual volume of the hemorrhagic stroke patients were significantly higher than those of ischemic stroke patients (p < 0.05, Mann Whitney test) Conclusion: It is necessary to have urodynamic investigation to evaluate the functions of bladder in stroke patients with incontinence These tests can help categorize and manage their symptoms of lower urinary tracts * Keywords: Urodynamics; Stroke; Cerebral hemorrhage; Ischemic stroke INTRODUCTION Bladder dysfunctions are common in stroke patients, so the assessment of their bladder function and treatment for those with bladder dysfunctions should be considered as a vital part of the daily rehabilitation [1, 2, 3, 4, 5, 6] Urinary incontinence was found in a half of patients who had survived after stroke within days, and 29% of those had urinary retention after month Bladder dysfunction in acute cerebellar stroke were researched extensively However, the correlation between types of stroke (ischemic and hemorrhagic stroke) with urodynamic results is not well understood Therefore, we conducted the study with the aim: To compare urodynamic characteristics between patients with ischemic and those with hemorrhagic stroke at Bachmai Hospital during 2016 - 2017 SUBJECTS AND METHOD Subjects * Inclusion criteria: - Ischemic and hemorrhagic stroke diagnosed by a neurologist - Determined by computerized tomography (CT) or magnetic resonance imaging (MRI) - Stroke of at least one month - Patients maintain awareness and can cooperate with medical staff * Bachmai Hospital ** Vietnam Military Medical University Corresponding author: Do Dao Vu (dodaovurehabi@yahoo.com) Date received: 11/07/2017 Date accepted: 08/08/2017 127 Journal of military parmaco-medicine n07-2017 * Exclusion criteria: * Urodynamic investigation procedure: - Having concomitant diseases such as diabetes mellitus; history of pelvic surgery; spinal cord injury; benign prostatic hyperplasia and other neuropathy Patients in obstetric posture A 2-lumen - Patients with urinary tract infections or lower urinary tract disorders was completely emptied Continuous bladder - The patient or family member did not agree to participate in the study sterile saline at room temperature * Time and location of the study: The study was conducted in Urodynamic Unit, Bachmai Hospital from - 2016 to - 2017 the urge to urinate and could delay or have Method * Study design: Prospective descriptive study * Sample size and sample selection: Sample size: 84 patients who met the inclusion criteria Sample selection: The study selected purposefully all stroke patients with urinary incontinence for month and above who met the inclusion criteria and were referred for urodynamic investigation * Materials and research tools: Laborie’s urodynamic machines manufactured in Canada; sample of research case history and agreement to participate in research * Assessment indicators: Age, gender, CT/MRI lesion location, urodynamic parameters: bladder volume, volume of urinary continence, volume of urinary residual, bladder compliance, involuntary contraction, peak urinary flow (Qmax), average peak urinary flow (Qavg); overactive and underactive bladder 128 8-french catheter was placed through the urethra into the bladder and was fixed with a medical bandage when the bladder pressure measurement at 30 mL/min with Bladder filling ended when the patient had urine leaking or reported any discomfort After completing the filling phase, patients were asked to urinate * Diagnostic criteria: - Brain strokes were diagnosed according to the WHO definition - Maximum normal bladder volume 300 - 500 mL [3] - Urodynamic criteria: Normal Qmax ≥ 15 mL/s; compliance: 20 - 40 mL/cmH2O; involuntary contraction when bladder pressure changes ≥ 15 cmH2O during bladder filling [1] * Data processing: Statistical analysis using statistical software Stata 14.0 Mann - Whitney test is used to compare differences for quantitative variables; Fisher exact test, χ2 test were used to test qualitative variables The value of p < 0.05 was statistically significant * Ethical research: The research was approved by the Medical Ethics Board of Bachmai Hospital Journal of military phrmaco-medicine nO7-2017 RESULTS Table 1: Characteristics of research subjects Hemorrhagic stroke (n = 26) Ischemic stroke (n = 58) Male, n (%) 13 (50%) 35 (60.3%) Female, n (%) 13 (50%) 23 (39.7%) Age (mean ± SD) 63.5 ± 3.7 66.3 ± 5.4 > 0.05 Duration of illness (week)/(mean ± SD) 13.3 ± 12.7 16.2 ± 16.8 > 0.05 Features p > 0.05 There was no difference between two groups of local hemorrhagic stroke and ischemic stroke in age, sex and duration of illness (p > 0.05, χ2 test, Mann - Whitney test) Table 2: Distribution of lesions in cerebral stroke Lesion location Hemorrhagic stroke (n = 26) Ischemic stroke (n = 58) p (15.4%) 15 (25.9%) > 0.05 (3.8%) (12.1%) > 0.05 Temporal lobes 5(19.2%) (10.3%) > 0.05 Occipital lobe (11.5%) (10.3%) > 0.05 Thalamas (19.2%) 13 (22.5%) > 0.05 Midbrain (30.9%) 11 (18.9%) > 0.05 Frontal lobe Parietal lobes In terms of lesion locations diagnosed by CT/MRI, no difference was found between two groups of local hemorrhagic stroke and ischemic stroke (p > 0.05, Fisher exact test) Table 3: Results of urodynamic study in stroke patients Hemorrhagic stroke (n = 26) Ischemic stroke (n = 58) p Maximum bladder capacity (mL) (mean ± SD) 423.3 ± 114.2 317.2 ± 75.0 < 0.05 Urinary volume (mL) (mean ± SD) 178.5 ± 89.3 192.4 ± 75.2 > 0.05 Residual volume after urination (mL) (mean ± SD) 254.1 ± 139.5 130.9 ± 86.3 < 0.05 Qmax (mL/s) (mean ± SD) 13.3 ± 2.1 12.4 ± 2.5 > 0.05 Qavg (mL/s) (mean ± SD) 5.9 ± 1.2 5.7 ± 1.6 > 0.05 Bladder compliance (ml/cmH2O) (mean ± SD) 47.2 ± 10.1 24.5± 7.9 < 0.05 PdetQmax (cmH2O) (mean ± SD) 30.3 ± 9.3 42.1± 8.9 > 0.05 (33%) 33 (57%) > 0.05 Parameter Bladder involuntary contraction (%) The hemorrhagic stroke group had a maximum bladder volume of 423.3 mL, residual volume of 254.1 mL which were higher than those of the ischemic stroke groups with 317.2 mL and 130.9 mL, respectively The difference was statistically significant (p < 0.05, Mann - Whitney test) 129 Journal of military parmaco-medicine n07-2017 Table 4: Bladder dysfunction based on urodynamic results Features Hemorrhagic stroke (n = 26) Ischemic stroke (n = 58) (34.6%) 41 (70.7%) 17 (65.4%) 17 (29.3%) Overactive bladder p < 0.05 Underactive bladder Patients with cerebral hemorrhage having underactive bladder accounted for 65.4% while the ischemic stroke group with overactive bladder was 70.7% Differences in bladder dysfunction between two groups were statistically significant (p < 0.05, χ2 test) DISCUSSION Strokes are serious neurological events, depending on the extent to which they can temporarily or permanently affect survivors in terms of speech, awareness, movement and urinary control [5] Urinary retention often occurs in the early days after stroke due to loss of reflex contraction of the bladder, a consequence of cerebellar stroke [4] Over time, about 38 - 60% of patients with cerebellar stroke progressively progress to the polyuria, nocturia, urgency which may be accompanied by frequency that patients cannot control [7] From the results of the study, we found no difference between hemorrhagic and ischemic groups in terms of age, sex, duration of illness and CT/MRI lesion location (p > 0.05, χ2 test; Mann - Whitney test) Table showed a significant difference between hemorrhagic and ischemic groups in the frequency of urinary emptying disorder (urinary residual volume) and frequency of urinary retention disorder (maximal bladder capacity) (p < 0.05, Mann - Whitney test) This was explained by neurasthenia after stroke caused by toxic cells and cerebral edema Cerebral toxoplasmosis occurred in the early hours of ischemia 130 and is detected as a decrease in diffusional water content This lasted for to days, then increased when the retina edema appeared However, decreased diffusional water content also appears in acute cerebral hemorrhage Unlike ischemia, the amount of diffused water due to cerebral hemorrhage was reduced even after 100 days after the onset of stroke Cytotoxic cerebral edema persists and affects the urinary control function [9] Furthermore, cerebral hemorrhage due to hypertension causes intracranial haemorrhage and cerebral edema The mechanism, degree of cerebral edema, and the consequences of differences between ischemia and cerebral hemorrhage can cause differences in bladder dysfunction when studying urodynamics According to table 4, we found that 41/58 patients (70.7%) with ischemic stroke had overactive bladder and 17/58 (29.3%) underactive bladder In contrast, in the hemorrhagic group, only 9/26 (34.6%) developed overactive bladder and 17/26 patients (65.4%) underactive bladder This finding was similar to the study by Burney et al [2] when assessing the effects of cerebral stroke on the lower urinary tract by urodynamic exploration Results showed Journal of military phrmaco-medicine nO7-2017 that 4/40 (10%) of ischemic stroke patients had underactive bladder, but up to 17/20 (85%) patients of overactive bladder tract dysfunction: A prospective correlation of the site of brain injury with urodynamic findings J Urol 1996, 156, pp.1748-1750 CONCLUSIONS Dmochowski R Cystometry Urol Clin North Am 1996, 23, pp.243-252 Comparison of urodynamic results showed that patients with ischemic stroke (70.7%) had a higher rate of overactive bladder than those with hemorrhagic stroke (34.6%) and vice versa (p < 0.05, χ2 test) The maximal bladder volume, urinary residual volume in the hemorrhagic group (423.3 mL and 254.1 mL) was significantly higher than those in the ischemic group (317.2 mL and 130.9 mL) (p < 0.05, Mann - Whitney test) Based on the above observations, it is necessary to conduct a urodynamic study to evaluate bladder function in stroke patients with a history of urinary incontinence to classify and manage lower urinary tract symptoms, which avoids complications for this group of patients REFERENCES Abrams P, Cardozo L, Fall M et al The standardization of terminology of lower urinary tract function: Report from the standardization subcommittee of the international continence society Neurourol Urodyn 2002, 21, pp.167-78 Burney T.L, Senapati M, Desai S et al Acute cerebrovascular accident and lower urinary Hald T, Bradley WE The nervous control of the urinary bladder In: Hald T, editor The urinary bladder: Neurology and Urodynamics Baltimore: Williams & Wilkins 1982, pp.48-57 Kong K.H, Young S Incidence and outcome of poststroke urinary retention: A prospective study Arch Phys Med Rehabil 2000, 81, pp.1464-1467 Kolominski-Rabas P, Hilz M.J, Neundoerfer B et al Impact of urinary incontinence after stroke: Results from a prospective populationbasted study register Neurourol Urodyn 2003, 22, pp.322-327 Kuo H.C Therapeutic effects of suburothelial injection of Botulinum toxin for neurogenic detrusor overactivity due to chronic cerebrovascular accident and spinal cord lesions Urolog 2006, 67, pp.232-236 Roth E.J, Harvey R.L Rehabilitation of stroke syndromes In: Braddom RL, editor Physical Medicine and Rehabilitation 2nd edition Philadelphia: WB Saunders 2000, pp.1117-1163 Simard J.M, Kent T.A, Chen M et al Brain oedema in focal ischaemia: molecular pathophysiology and theoretical implications Lancet Neurol 2007, 6, pp.258-268 131 ... group of patients REFERENCES Abrams P, Cardozo L, Fall M et al The standardization of terminology of lower urinary tract function: Report from the standardization subcommittee of the international... conduct a urodynamic study to evaluate bladder function in stroke patients with a history of urinary incontinence to classify and manage lower urinary tract symptoms, which avoids complications... urodynamic investigation * Materials and research tools: Laborie’s urodynamic machines manufactured in Canada; sample of research case history and agreement to participate in research * Assessment indicators: