Non-cardioembolic TIA and ischemic stroke: Implications of severity.

OBJECTIVES: Our purpose was to explore major vascular and bleeding outcomes in relation to risk and severity scores (ABCD2 or NIHSS) in patients with transient ischemic attack (TIA) or acute ischemic stroke (AIS). METHODS: This nationwide observational study was based on data from 4 national registries. Outcomes were assessed by Kaplan-Meier and Cox regression analyses. RESULTS: The total cohort comprised 21 268 patients (median age 73 years, 47.6% females). Based on ABCD2-score, the TIA-population (n = 10 174) was divided into low-risk (0-3 p, n = 3463) and high-risk (4-7 p, n = 6711). Based on NIHSS-score, the AIS-population (n = 11 454) was divided into minor (0-5 p, n = 8596), moderate (6-10 p, n = 1630) and severe (≥11 p, n = 1228). During follow-up (mean 1.7 years), the composite endpoint of stroke, myocardial infarction or death occurred in 3572 (16.5%) of all the patients, and major bleeding in 668 (3.1%) patients. Using low-risk TIA as reference, the adjusted hazard ratios (HR, 95% CI) of the composite endpoint were 1.41 (1.23-1.62) for high-risk TIA, 1.94 (1.70-2.22) for minor, 2.86 (2.45-3.34) for moderate and 4.18 (3.57-4.90) for severe stroke. When analyzed separately, the association with increased risk remained significant for stroke and death, but not for myocardial infarction. The HR of major bleeding were 1.31 (0.99-1.73) for high-risk TIA, 1.49 (1.13-1.95) for minor, 1.54 (1.08-2.21) for moderate and 2.10 (1.44-3.05) for severe stroke. CONCLUSIONS: This study confirms the association between severity of the index ischemic stroke and risk of future major vascular and bleeding events, and highlights the increased risk also for patients with high-risk TIA.

Cardiovascular risk factors and TIA characteristics in 19,872 Swedish TIA patients.

BACKGROUND: Transient ischemic attack (TIA) constitutes a major risk factor for stroke, making TIA patients an important group for secondary intervention. The aim of this study was to account for risk factor prevalence in TIA patients and analyze the association between TIA characteristics and risk factors. METHODS: We included 20,871 TIA events in 19,872 patients who were registered in the Swedish Riksstroke registry during the years 2010 through 2012. Data from other Swedish registers were used for comparison. The following variables were analyzed: age, sex, diabetes mellitus, atrial fibrillation (AF), cigarette smoking, and antihypertensive treatment. RESULTS: Compared to the general population (based on data retrieved from Sweden's national public health survey 'Health on equal terms'), TIA patients more often had diabetes mellitus (prevalence ratio, PR = 2.3), AF without oral anticoagulants (OAC) (PR = 2.8), and AF on OAC (PR = 1.6). Blood pressure medication was less prevalent among TIA patients than in the general population (PR = 0.57). Increasing age was associated with longer attacks. CONCLUSIONS: The fact that diabetes mellitus, atrial fibrillation, and smoking are more common in TIA patients than in the general population suggests that these factors are risk factors for TIA, even if causal relations cannot be proven. The relation between increasing age and longer attacks possibly reflects an increased proportion of embolic TIAs, or impaired recovery ability. Our results also suggest a significant proportion of untreated hypertension cases in the population.

Validation of the Swedish inpatient and cause-of-death registers in the context of stroke.

BACKGROUND: Quality follow-up within stroke care is important in times when stroke prevalence is increasing and health care funds are limited. Administrative data, such as data from the inpatient register (IPR) and the cause-of-death register (CDR) are often used for this purpose, but the validity of such data has not been ascertained. METHODS: During the year 1999-2000, a community-based stroke register was established in a Swedish municipality. Data from that register was compared with two administrative registers, the IPR and the CDR. RESULTS: Using multiple overlapping data sources, 377 patients with first-ever stroke were found in the community-based register. Forty-four of these (12%) were missing in the IPR/CDR. Non-hospitalized patients were less likely to be registered in the IPR/CDR, as were patients who were not initially treated in a stroke unit. Stroke severity was lower among non-registered patients. Thirty patients (8%) in the IPR/CDR were misclassified as stroke patients. CONCLUSIONS: Quality follow-up within stroke care could be biased or have low comparability, when administrative data are used. Great caution should be taken when data are derived from the inpatient and cause-of-death registers, and more validation work needs to be carried out in the context of stroke.

Ten-year risk for myocardial infarction in patients with first-ever stroke: a community-based study.

BACKGROUND: Stroke and coronary heart disease (CHD) share common risk factors. The risk for stroke patients to have a myocardial infarction (MI) has not been fully explored. METHODS: Three hundred and seventy-seven first-ever stroke patients were ascertained prospectively. The 10-year incidence of MI was examined by register searches. The results were compared to the general Swedish population. Predictors for MI were identified using univariate and multivariate analysis. RESULTS: The cumulative incidence of MI over 10 years was 25.0/100 (95% confidence interval (CI), 19.5-31.5), 26.5 for men, (95% CI, 18.9-45.8) and 23.4 for women (95% CI, 16.0-32.9). Compared to the general population, the relative risk for stroke patients having a MI was 1.6 for men (95% CI, 1.12-2.37) and 1.9 for women (95% CI, 1.27-2.90). In multivariate analysis, CHD before the stroke (MI, angina pectoris, coronary artery bypass grafting, or percutaneous transluminal coronary angioplasty) and peripheral artery disease were significant predictors for MI. CONCLUSION: The risk for MI is significantly higher, for both male and female stroke patients, compared to the general population. Stroke patients with previous CHD and peripheral artery disease are at highest risk. Stroke patients should receive adequate secondary prevention, and cardiac complaints must be taken seriously.

Comparison of 90-day case-fatality after ischemic stroke between two different stroke outcome registries using propensity score matching analysis.

BACKGROUND: It has not been clarified whether the disparity in ischemic stroke outcome between populations is caused by ethnic and geographic differences or by variations in case mix. Propensity score matching (PSM) analysis can overcome some analytical problems but is rarely used in stroke outcome research. This study was to compare the ischemic stroke case-fatality between two PSM cohorts of Sweden and Korea. METHODS: Prognostic variables related to baseline characteristics and stroke care were included in our PSM model. Then, we selected 7675 Swedish and 1220 Korean patients with ischemic stroke from each stroke registers and performed one-to-one matching based on propensity scores of each patient. RESULTS: After PSM, all measured variables were well balanced in 1163 matched subjects, and the 90-day case-fatality was identical 6.2% (HR 0.997, 95%CI 0.905-1.099) in Sweden and Korea. CONCLUSIONS: No difference is found in the 90-day case-fatality in propensity score-matched Swedish and Korean patients with ischemic stroke.

A review on sex differences in stroke treatment and outcome.

BACKGROUND: Beyond epidemiological differences, it has been controversial whether any important sex differences exist in the treatment of stroke. In this review paper, the following areas are covered: thrombolysis, stroke unit care, secondary prevention, surgical treatment, and rehabilitation. Additionally, symptoms at stroke onset, as well as outcome measures, such as death, dependency, stroke recurrence, quality of life, and depression are reviewed. METHODS: Search in PubMed, tables-of-contents, review articles, and reference lists after studies that include information about sex differences in stroke care. RESULTS: Ninety papers are included in this review. Women suffer more from cortical and non-traditional symptoms. Men and women benefit equally from thrombolysis and stroke unit care. Women with cardioembolic strokes may benefit more from anticoagulant therapy. Most studies have not found any tendency towards sexism in the choice of treatment. Post-stroke depression and low quality-of-life seem to be more common among women. Mortality rates are higher among men in some studies, while long-term ADL-dependency seems to be more common among women. CONCLUSIONS: Sex differences in stroke treatment and outcome are small, with no unequivocal proof of sex discrimination. Women have less favourable functional outcome because of higher age at stroke onset and more severe strokes.

A national stroke quality register: 12 years experience from a participating hospital.

Registration of all hospitalized stroke patients is practiced in Sweden in order to assess care quality. Data in this register, Riks-Stroke (RS), may be biased due to incomplete registration. The purpose of this paper was to report changes in stroke outcome in relation to fluctuations in registration. Patients registered in RS at a hospital during the period 1994-2005 were analyzed. Case fatality at 28 days, living conditions, and activities of daily living (ADL) performance at 3 months were correlated to the number of patients registered and follow-up frequency. A total of 4994 stroke cases were registered during the period. A high annual registration rate was significantly correlated to a high case fatality ratio. A low annual follow-up rate was associated with a low proportion of patients living in their own home without any need of help. Quality parameters are sensible for selection bias, which make them difficult to compare over time and between hospitals. We suggest that by weighing outcome data against stroke severity, safer conclusions may be drawn. Additionally, hospitals considering setting up quality registers should make every effort to attain complete case ascertainment at all times, including patients managed outside the hospital, in order to avoid selection bias.

Prediction of length of stay for stroke patients.

OBJECTIVES: To examine the factors that influence acute and total length of stay (LOS) for stroke patients. MATERIALS AND METHODS: The basis of this investigation was a population-based cohort of first-ever stroke patients (n = 388). Subjects were survivors of the initial hospitalization (n = 295). Age, sex, social factors, risk factors, dementia, stroke type, and stroke severity, measured with the NIH stroke scale (NIHSS), were registered. RESULTS: Mean acute LOS was 12 days and mean total LOS was 29 days. Independent predictors of acute LOS were stroke severity, lacunar stroke, prestroke dementia, and smoking. Independent predictors of total LOS were stroke severity and prestroke activities of daily living (ADL) dependency. The NIHSS items that best correlated with LOS were paresis, unilateral neglect and level of consciousness. CONCLUSIONS: Stroke severity is a strong and reliable predictor of LOS. The results of this study can be used as a baseline for evaluating cost-effectiveness of stroke care changes, e.g. organizational changes or evaluation of new drugs.

Anosognosia versus unilateral neglect. Coexistence and their relations to age, stroke severity, lesion site and cognition.

The aim of this study was to examine the association between anosognosia and unilateral neglect (UN), with special focus on age, stroke severity, lesion location and pre-stroke dementia. The basis of this investigation was a population-based stroke incidence study. Anosognosia was assessed using a questionnaire, and UN using a three-item version of the Behaviour Inattention Test, the Baking Tray Task and a test of personal neglect. Stroke severity was assessed using the NIH stroke scale. Patients with anosognosia were older, and they more often had pre-stroke dementia than patients having UN only. No particular lesion localization was associated with anosognosia, while UN was strongly associated with previously defined lesion sites, often in the parietal lobe. There was a borderline significance regarding stroke severity in patients having anosognosia compared with those with UN only. Patients with anosognosia had higher mortality than patients without, but when controlled for age and stroke severity, this effect was not independent. While UN is closely associated with 'classical' lesion sites, anosognosia is a condition that more often occurs in a previously impaired brain. For anosognosia, lesion location appears to be less important. Anosognosia also tends to occur with larger strokes.

Changes in Mini Mental State Examination score after stroke: lacunar infarction predicts cognitive decline.

Stroke and cognitive impairment are inter-related. The purpose of this study was to show the natural evolution of cognitive performance during the first year after a stroke, and to show which factors that predict cognitive decline. Subjects were patients with a first-ever stroke who were treated in a stroke unit. A total of 160 patients were included. At baseline patients were evaluated with regard to stroke type, stroke severity, pre-stroke dementia and other risk factors. Mini Mental State Examinations (MMSE) were performed after 1 week and after 1 year. Patients had a median increase of 1 point (range -8 to +9) on the MMSE. Thirty-two pre cent of the patients deteriorated, 13% were unchanged, and 55% improved. Lacunar infarction (LI) and left-sided stroke were associated with a failure to exhibit improvement. Patients with LI had an average decline of 1.7 points, whilst patients with other stroke types had an average increase of 1.8 points. Most stroke survivors improve cognitively during the first year after the event. The outcome for LI patients is worse, which suggests that LI may serve as a marker for concomitant processes that cause cognitive decline.

Characteristics of Mini-Mental State Examination 1 year after stroke.

OBJECTIVES: The Mini-Mental State Examination (MMSE) is commonly used to evaluate cognition after stroke. The purpose of this study was to describe the properties of MMSE in relation to different stroke characteristics. MATERIALS AND METHODS: Subjects were survivors (n = 253) of a population-based cohort who had had a first-ever stroke 1 year earlier. At baseline, patients were evaluated with regard to stroke type, stroke severity, unilateral neglect, and prestroke dementia. The 1-year follow-up included an MMSE, a functional evaluation according to the modified Rankin Scale (MRS) and a question regarding subjective memory problems. RESULTS: The mean MMSE was 24.9. Patients with lacunar infarction scored 26.6. Impact of hemisphere localization was insignificant. Twenty-nine percent of the patients had cognitive impairment (cut-off <24). After adjustment for age and education, 16% had cognitive impairment; 41% of the patients had subjective memory problems. The kappa-value between subjective memory problems and dichotomized MMSE was 0.21. Patients with cognitive impairment scored at average 1.8 higher on the MRS. CONCLUSIONS: If cut-off is used, the MMSE should be adjusted for age and education; otherwise the prevalence of cognitive impairment may be overestimated. Cognitive impairment heavily influences functional outcome. Subjective memory problems correlate poorly with MMSE. The impact of hemisphere location may previously have been overestimated.

Recovery from unilateral neglect after right-hemisphere stroke.

PURPOSE: To show the recovery process for different forms of unilateral neglect (UN)--including personal neglect and neglect of far space--in relationship to impairment, disability, cognition and mood. METHOD: Patients were tested at 2-4 weeks, at 6 months and at 1 year. We used the Behaviour Inattention Test and a test for personal neglect. We also used the NIH Stroke Scale, the Functional Independence Measure (FIM), the Mini-Mental State Evaluation and the Geriatric Depression Scale. RESULTS: Peripersonal neglect diminishes within 6 months, but complete recovery occurred in only 13%. The prognosis for personal neglect and neglect of far space is better, with a recovery ratio at 6 months of 52% and 46%, respective. The correlations between UN and FIM are high. A few patients deteriorate in the absence of recurrent stroke. CONCLUSIONS: For clinical purposes, it is practical to postpone UN evaluation until a couple of weeks after a stroke. Many of the patients who then have UN are likely to retain their UN, although many will improve. Patients with UN should receive special attention in the rehabilitation phase, as well as at discharge. One explanation of the worsening of UN seen in some patients, may be continuing cerebral atherosclerosis.

Assessing unilateral neglect: shortcomings of standard test methods.

INTRODUCTION: When investigating the incidence of unilateral neglect in a first-ever stroke population, we found that some patients showed clinical signs of neglect, but managed to pass our tests. The purpose of this paper is to describe the nature of such signs, and analyse why test instruments were insufficiently corresponding to those signs. METHOD: One hundred and thirty-one consecutive patients with first-ever stroke in a community-based sample were evaluated for the presence of unilateral neglect. We used a test battery consisting of tests for visuo-spatial neglect, personal neglect, and anosognosia. Twenty cases of neglect were discovered by standard methods. We asked our collaborators at the wards to report any behavioural abnormality reminiscent of neglect present in patients who had normal test results. Such patients were evaluated clinically. RESULTS: Nine cases with neglect-like symptoms were discovered. Our clinical evaluation of the nine patients indicated several possible explanations for their behavioural abnormalities, including motor neglect, neglect for far extrapersonal space, disturbances of proprioception, and spatial disturbances other than neglect. CONCLUSION: Standard neglect tests do not cover all clinical forms of neglect. It is therefore important not to rely completely on test instruments when diagnosing neglect. More versatile test instruments are desired.

Case ascertainment in stroke studies: the risk of selection bias.

OBJECTIVES: The purpose was to compare the completeness of case ascertainment in two stroke registers, one local population-based, the other a national quality register (Riks-Stroke), and to examine if patient characteristics could be affected by selection bias. MATERIAL AND METHODS: By the way of linking and matching computer files, the completeness of case ascertainment was evaluated. RESULTS: In the local stroke incidence study 377 patients were included. Of them, 63% were reported to the hospital-based national quality register. The case-fatality was lower in the national register. A larger proportion of the patients in the national register appeared to have been treated in a stroke unit and undergone rehabilitation, and computerized tomography seemed to have been performed in a larger proportion. CONCLUSIONS: Because of selection bias, outcome data get skewed when case ascertainment does not embrace all stroke cases. A community-based stroke register is the golden standard when measuring stroke incidence.

[For whom is training after stroke most beneficial? Selection method exists and should be used]. / Vem har mest nytta av träning efter slaganfallet? Selektionsinstrument finns, och bör användas.

In the light of recent Swedish health care cost cuts, this review addresses the need of limiting stroke rehabilitation to those it will benefit most. In many prognostic stroke studies, end-points have been adopted that vary as to time and place--e.g., duration of hospitalisation or discharge to a nursing home. Even modest improvement in ability may significantly enhance quality of life, but is not necessarily associated with beneficial effects on lifestyle or the length of hospital stay. Accordingly, we need to use reliable tests with more realistic end-points. The use of the Functional Independence Measure (FIM) and the Katz ADL scale as prognostic instruments is discussed.