Spike count and morphology in the classification of epileptiform discharges.

Purpose: The purpose of this study is to investigate the impact of Bergen Epileptiform Morphology Score (BEMS) and interictal epileptiform discharge (IED) candidate count in EEG classification. Methods: We included 400 consecutive patients from a clinical SCORE EEG database during 2013-2017 who had focal sharp discharges in their EEG, but no previous diagnosis of epilepsy. Three blinded EEG readers marked all IED candidates. BEMS and IED candidate counts were combined to classify EEGs as epileptiform or non-epileptiform. Diagnostic performance was assessed and then validated in an external dataset. Results: Interictal epileptiform discharge (IED) candidate count and BEMS were moderately correlated. The optimal criteria to classify an EEG as epileptiform were either one spike at BEMS > = 58, two at > = 47, or seven at > = 36. These criteria had almost perfect inter-rater reliability (Gwet's AC1 0.96), reasonable sensitivity of 56-64%, and high specificity of 98-99%. The sensitivity was 27-37%, and the specificity was 93-97% for a follow-up diagnosis of epilepsy. In the external dataset, the sensitivity for an epileptiform EEG was 60-70%, and the specificity was 90-93%. Conclusion: Quantified EEG spike morphology (BEMS) and IED candidate count can be combined to classify an EEG as epileptiform with high reliability but with lower sensitivity than regular visual EEG review.

A New Score for Sharp Discharges in the EEG Predicts Epilepsy.

PURPOSE: A challenge in EEG interpretation is to correctly classify suspicious focal sharp activity as epileptiform or not. A predictive score was developed from morphologic features of the first focal sharp discharge, which can help in this decision. METHODS: From a clinical standard EEG database, the authors identified 2,063 patients without a previous epilepsy diagnosis who had a focal sharp discharge in their EEG. Morphologic features (amplitude, area of slow wave, etc.) were extracted using an open source one-click algorithm in EEGLAB, masked to clinical classification. A score was developed from these features and validated with the clinical diagnosis of epilepsy over 2 to 6 years of follow-up. Independent external validation was performed in Kural long-term video-EEG monitoring dataset. RESULTS: The score for the first focal sharp discharge had a moderate predictive performance for the clinical designation as the EEG being epileptiform (area under the receiver operating characteristics curve = 0.86). Best specificity was 91% and sensitivity 55%. The score also predicted a future epilepsy diagnosis (area under the receiver operating characteristics curve = 0.70). Best specificity was 86% and sensitivity 38%. Validation on the external dataset had an area under the receiver operating characteristics curve = 0.80. Clinical EEG identification of focal interictal epileptiform discharges had an area under the receiver operating characteristics curve = 0.73 for prediction of epilepsy. The score was based on amplitude, slope, difference from background, slow after-wave area, and age. Interrater reproducibility was high (ICC = 0.91). CONCLUSIONS: The designation of the first focal sharp discharge as epileptiform depends on reproducible morphologic features. Characteristic features were amplitude, slope, slow after-wave area, and difference from background. The score was predictive of future epilepsy. Halford semiquantitative scale had similar diagnostic performance but lower reproducibility.

Respiratory symptoms and mortality in four general population cohorts over 45 years.

OBJECTIVE: This study assessed the association between respiratory symptoms and mortality in four cohorts of the general population in Norway aged 15-75 years and in selected subgroups in the pooled sample. METHODS: The study comprised 158,702 persons, who were drawn randomly from the Norwegian population register. All subjects received a standardized, self-administered questionnaire on 11 respiratory symptoms between 1972 and 1998, with follow-up of death until December 31, 2017. Analyses were performed on 114,380 respondents. RESULTS: The hazard of death was closely associated with sex, age, and education. The hazard ratios (HR) for death and the 95% confidence intervals (CI) by risk factors were similar in the four cohorts. After adjustment for demographic and environmental, modifiable factors, the HR for death was 1.90 (95% CI 1.80-2.00) for breathlessness score 3, 1.28 (1.21-1.37) for cough/phlegm score 5 and 1.09 (1.05-1.14) for attack of breathlessness/wheeze score 2 compared to the referent (no symptom), respectively. The cough/phlegm score was associated with death in current smokers but not in never smokers or ex-smokers. Breathlessness score was associated with death in men and women. CONCLUSION: Among persons aged 45-75 years, respiratory symptoms were significant predictors of all cause mortality. Education and smoking habits influenced only the associations between coughing and mortality. The associations were independent of study sites.

Interictal epileptiform discharges vary across age groups.

OBJECTIVE: To investigate whether the occurrence and morphology of interictal epileptiform discharges (IEDs) in scalp-EEG change by age. METHODS: 10,547 patients who had a standard or sleep deprived EEG recording reported using the SCORE standard were included. 875 patients had at least one EEG with focal IEDs. Focal IED morphology was analyzed by age using quantitative measures in EEGLAB and by visual classification based on the SCORE standard. We present distributions of IED measures by age group, with medians, interquartiles, 5th and 95th percentiles. RESULTS: Focal IEDs occurred most frequently in children and elderly. IED morphology and localization depended on age (p < 0.001). IEDs had higher amplitudes, sharper peaks, larger slopes, shorter durations, larger slow-wave areas and wider distributions in children. These morphological characteristics diminished and the IEDs became more lateralized with increasing age. Spike asymmetry was stable across all age groups. CONCLUSIONS: IEDs have age-dependent characteristics. A spike detector, human or computer, should not operate with the same set of thresholds for patients at various age. With increasing age, focal IEDs are less sharp, have lower amplitudes, have less prominent slow-waves and they become more lateralized. Our findings can help EEG readers in detecting and correctly describing IEDs in patients of various age. SIGNIFICANCE: EEG readers should always consider patient age when interpreting interictal epileptiform discharges.

Visual EEG reviewing times with SCORE EEG.

OBJECTIVE: Visual EEG analysis is the gold standard for clinical EEG interpretation and analysis, but there is no published data on how long it takes to review and report an EEG in clinical routine. Estimates of reporting times may inform workforce planning and automation initiatives for EEG. The SCORE standard has recently been adopted to standardize clinical EEG reporting, but concern has been expressed about the time spent reporting. METHODS: Elapsed times were extracted from 5889 standard and sleep-deprived EEGs reported between 2015 and 2017 reported using the SCORE EEG software. RESULTS: The median review time for standard EEG was 12.5 min, and for sleep deprived EEG 20.9 min. A normal standard EEG had a median review time of 8.3 min. Abnormal EEGs took longer than normal EEGs to review, and had more variable review times. 99% of EEGs were reported within 24 h of end of recording. Review times declined by 25% during the study period. CONCLUSION: Standard and sleep-deprived EEG review and reporting times with SCORE EEG are reasonable, increasing with increasing EEG complexity and decreasing with experience. EEG reports can be provided within 24 h. SIGNIFICANCE: Clinical standard and sleep-deprived EEG reporting with SCORE EEG has acceptable reporting times.

Standardized computer-based organized reporting of EEG: SCORE - Second version.

Standardized terminology for computer-based assessment and reporting of EEG has been previously developed in Europe. The International Federation of Clinical Neurophysiology established a taskforce in 2013 to develop this further, and to reach international consensus. This work resulted in the second, revised version of SCORE (Standardized Computer-based Organized Reporting of EEG), which is presented in this paper. The revised terminology was implemented in a software package (SCORE EEG), which was tested in clinical practice on 12,160 EEG recordings. Standardized terms implemented in SCORE are used to report the features of clinical relevance, extracted while assessing the EEGs. Selection of the terms is context sensitive: initial choices determine the subsequently presented sets of additional choices. This process automatically generates a report and feeds these features into a database. In the end, the diagnostic significance is scored, using a standardized list of terms. SCORE has specific modules for scoring seizures (including seizure semiology and ictal EEG patterns), neonatal recordings (including features specific for this age group), and for Critical Care EEG Terminology. SCORE is a useful clinical tool, with potential impact on clinical care, quality assurance, data-sharing, research and education.

Causes and Predictors for Hospital Readmission after Ischemic Stroke.

BACKGROUND: Readmission after stroke is frequent, but limited data are available in Europe. This study aimed at assessing frequencies, causes, and factors associated with early and late unplanned readmissions within 1 year after discharge from ischemic stroke hospitalization. METHODS: All surviving ischemic stroke patients admitted to the Department of Neurology, Haukeland University Hospital, Norway, between July 1, 2007, and June 30, 2012, were followed from discharge until August 1, 2012. Information on readmissions was collected by medical chart reviews. Logistic regression was performed to assess factors associated with early (≤90 days) and late (91-365 days) readmission. RESULTS: Of 1175 patients discharged alive, 18.8% were readmitted within 90 days, and 24.5% were readmitted between day 91 and 365. Most frequent causes were infections, recurrent ischemic stroke, other cardiovascular events, and events related to index stroke. Early readmission was associated with older age, impaired physical function, atherosclerotic etiology of index stroke, and a higher risk factor burden. Late readmission was associated with older age and prior myocardial infarction. Early readmitted patients had shorter length of index admission, poorer physical function and higher frequencies of atherosclerotic etiology of index stroke, atrial fibrillation, and complications with infection during the index admission compared to patients readmitted late. CONCLUSIONS: Readmission after ischemic stroke is frequent, especially in the early period after discharge. Diagnoses and predictors varied according to time point for readmission, reflecting different underlying mechanisms for causes of readmission. Causes of early readmission may include a prothrombotic state and disposition for recurrent infections.

Association between visceral, cardiac and sensorimotor polyneuropathies in diabetes mellitus.

AIMS: Gastrointestinal complaints are common in diabetes mellitus. However, its association to peripheral sensorimotor and autonomic neuropathies is not well investigated. The aim was to assess skin, muscle, bone and visceral sensitivity in diabetes patients with sensorimotor neuropathy, and correlate these with gastrointestinal symptoms and degree of cardiac autonomic neuropathy. METHODS: Twenty patients with sensorimotor neuropathy (65% type 2 diabetes, aged 58.3±12.0 years, diabetes duration 15.8±10.0 years) and 16 healthy controls were recruited. Cutaneous sensitivity to von Frey filaments, mechanical allodynia, muscle/bone/rectosigmoid sensitivities, and heart rate variability were examined. Gastrointestinal symptom scores (PAGI-SYM) and health-related quality of life (SF-36) were also recorded. RESULTS: Patients displayed hypesthesia to von Frey filaments (p=0.028), but no difference to muscle and bone pain sensitivities. Also, patients were hyposensitive to multimodal rectal stimulations (all p<0.05), although they suffered more gastrointestinal complaints. Heart rate variability was reduced in the patient cohort. Rectal mechanical and cutaneous sensitivities correlated (p<0.001), and both were associated with heart rate variability as well as PAGI-SYM and SF-36 scores (p<0.01). CONCLUSIONS: In diabetic sensorimotor neuropathy there is substantial evidence of concomitant cutaneous, cardiac and visceral autonomic neuropathies. The neuropathy may reduce quality of life and explain the higher prevalence of gastrointestinal complaints.

Unified EEG terminology and criteria for nonconvulsive status epilepticus.

The diagnosis of nonconvulsive status epilepticus (NCSE) relies largely on electroencephalography (EEG) findings. The lack of a unified EEG terminology, and of evidence-based EEG criteria, leads to varying criteria for and ability to diagnose NCSE. We propose a unified terminology and classification system for NCSE, using, as a template, the Standardised Computer-based Organised Reporting of EEG (SCORE). This approach integrates the terminology recently proposed for the rhythmic and periodic patterns in critically ill patients, the electroclinical classification of NCSE (type of NCSE) and the context for the pathologic conditions and age-related epilepsy syndromes. We propose flexible EEG criteria that employ the SCORE system to assemble a database for determining evidence-based EEG criteria for NCSE.

Standardized computer-based organized reporting of EEG: SCORE.

The electroencephalography (EEG) signal has a high complexity, and the process of extracting clinically relevant features is achieved by visual analysis of the recordings. The interobserver agreement in EEG interpretation is only moderate. This is partly due to the method of reporting the findings in free-text format. The purpose of our endeavor was to create a computer-based system for EEG assessment and reporting, where the physicians would construct the reports by choosing from predefined elements for each relevant EEG feature, as well as the clinical phenomena (for video-EEG recordings). A working group of EEG experts took part in consensus workshops in Dianalund, Denmark, in 2010 and 2011. The faculty was approved by the Commission on European Affairs of the International League Against Epilepsy (ILAE). The working group produced a consensus proposal that went through a pan-European review process, organized by the European Chapter of the International Federation of Clinical Neurophysiology. The Standardised Computer-based Organised Reporting of EEG (SCORE) software was constructed based on the terms and features of the consensus statement and it was tested in the clinical practice. The main elements of SCORE are the following: personal data of the patient, referral data, recording conditions, modulators, background activity, drowsiness and sleep, interictal findings, "episodes" (clinical or subclinical events), physiologic patterns, patterns of uncertain significance, artifacts, polygraphic channels, and diagnostic significance. The following specific aspects of the neonatal EEGs are scored: alertness, temporal organization, and spatial organization. For each EEG finding, relevant features are scored using predefined terms. Definitions are provided for all EEG terms and features. SCORE can potentially improve the quality of EEG assessment and reporting; it will help incorporate the results of computer-assisted analysis into the report, it will make possible the build-up of a multinational database, and it will help in training young neurophysiologists.

The effects of fatigue, pain, and depression on quality of life in ischemic stroke patients: the Bergen Stroke Study.

BACKGROUND: Many patients with cerebral infarction suffer from symptoms such as pain, fatigue, and depression. The aim of this study was to evaluate these symptoms in relation to health-related quality of life (HRQoL) on long-term follow-up. MATERIALS AND METHODS: All surviving stroke patients admitted to the Stroke Unit, Haukeland University Hospital, Norway between February 2006 and November 2008 were sent a questionnaire, including a visual analog pain scale, Fatigue Severity Scale, Depression Subscale of Hospital Anxiety and Depression Scale, Barthel Index, and three measures of HRQoL--15D, EuroQol, and EuroQol Visual Analogue Scale--at least 6 months after stroke onset. Cox regression survival analysis, including EQ-5D, was performed by November 2009. RESULTS: The questionnaire was returned by 328 patients. All three symptoms were reported by 10.1% of the patients, and 26% reported two symptoms. There was a significant association between worse HRQoL scores and an increasing number of cooccurring symptoms for all three HRQoL scores. Fatigue, depression, pain, functional state, and sleeping disorder on follow-up accounted for 58%-83% of the variability in HRQoL, depending on which HRQoL scale was used. Cox regression analysis showed that mortality was associated with a low EuroQol score (P = 0.016). CONCLUSION: Pain, fatigue, and depression were common symptoms among these stroke patients and, to a large extent, they determined the patients' HRQoL. Low HRQoL was associated with increased mortality.

The triad of pain, fatigue and depression in ischemic stroke patients: the Bergen Stroke Study.

BACKGROUND: Many patients with cerebral infarction suffer from symptoms such as pain, fatigue and depression. Most studies focus on single symptoms, but these symptoms often occur together. Whereas symptom clusters have been studied in cancer patients, little is known about different symptom clusters in patients with cerebral infarction. The aim was to evaluate clusters of co-occurring symptoms in the long term. We hypothesized that patients with cerebral infarction display distinct symptom clusters. Furthermore, we hypothesized that multiple co-occurring symptoms have an adverse effect on patients. METHODS: All consecutive patients with acute stroke (the index stroke) admitted to the Stroke Unit, Department of Neurology, Haukeland University Hospital, between February 2006 and July 2008, were prospectively registered in a database. Prior risk factors (including diabetes mellitus, hypertension, smoking, coronary heart disease, atrial fibrillation and prior stroke), prior depression and stroke severity (modified Rankin Scale (mRS) score on day 7) were registered. Patients with cerebral infarction were sent a questionnaire including a visual analogue pain scale (VAS), Fatigue Severity Scale (FSS), depression subscale of the Hospital Anxiety, Depression Scale (HADS-D) and Barthel Index at least 6 months after stroke onset. RESULTS: The questionnaire was returned by 328 patients (response rate 60%). All three symptoms were reported by 10.1%. Pain and fatigue among nondepressed patients were reported by 19.6%. Pain and depression among nonfatigued patients were reported by 2.0%. Depression and fatigue, and no pain were reported by 4.4%. Single symptoms were reported by 31% whereas 33% reported no symptoms. VAS, FSS and HADS-D score severity increased with the number of co-occurring symptoms. Logistic regression analyses showed that two or three symptoms (versus no symptoms) was associated with high mRS score on day 7 (p = 0.02), prior stroke (p = 0.002), prior diabetes mellitus (p = 0.005) and prior depression (p < 0.001). CONCLUSIONS: Symptom clusters are frequent in patients with cerebral infarction. Fatigue was associated with pain and depression whereas there was little association between depression and pain in nonfatigue patients, indicating distinct symptom clusters. The severity of symptoms increased with the number of co-occurring symptoms.

γ knife surgery versus reoperation for recurrent glioblastoma multiforme.

BACKGROUND: The optimal management of patients with recurrent glioblastoma multiforme (GBM) is a subject of controversy. These patients may be candidates for both reoperation and/or gamma knife surgery (GKS). Few studies have addressed the role of GKS for relapsing gliomas, and the results have not been compared with reoperation. To validate the efficacy and safety of GKS, we compared the survival and complication rates of GKS and reoperation for recurrent GBMs. METHODS: This study retrospectively reviewed 77 consecutive patients with histopathologically confirmed GBMs retreated for recurrent GBM between 1996 and 2007. Thirty-two patients underwent GKS, 26 reoperation and 19 both procedures. RESULTS: The median time from the second intervention to tumor progression was longer after GKS than after resection, P = 0.009. Median survival after retreatment was 12 months for the 51 patients receiving GKS compared with 6 months for reoperation only (P = 0.001, hazard ratio [HR] 2.4), and 19 months versus 16 months from the time of primary diagnosis (P = 0.021, HR 1.8). A multivariate analysis adjusted for possible confounding factors (tumor volume, recursive partitioning analysis class, neurological deficits, time to recurrence, adjuvant therapy, and tumor location) showed significantly longer survival for patients treated with GKS, both from retreatment (P = 0.013, HR 4.1) and from primary diagnosis (P = 0.002, HR 5.8). The adjusted results were still significant after separate analysis according to tumor volume <5 mL, 5 to 20 mL, and >20 mL. The complications rate was 9.8% after GKS and 25.2% after reoperation. CONCLUSIONS: GKS may be an alternative to open surgery for small GBMs at the time of recurrences, with a significantly lower complication rate and a possible survival benefit compared with reoperation.

Fatigue among stroke patients on long-term follow-up. The Bergen Stroke Study.

BACKGROUND: To evaluate characteristics and mortality related to post-stroke fatigue (PSF). METHODS: All surviving stroke patients admitted to the Stroke Unit, Haukeland University Hospital, between February 2006 and November 2008 were sent a postal questionnaire including the Fatigue Severity Scale (FSS), the hospital anxiety and depression scale (HADSD), and the Barthel Index (BI) at least 6 months after stroke onset. Survival among patients returning the questionnaire was determined by November 2009. PSF was defined as FSS score ≥5. RESULTS: Among 377 patients returning the questionnaire, 42.3% had PSF. Logistic regression showed that PSF was independently associated with pre-stroke depression, leucoaraiosis, myocardial infarction, diabetes mellitus, pain, and sleeping disturbances. Mean FSS score was lower among TIA patients than among patients with minor cerebral infarction (patients with BI=100) (P=.002). Cox regression analysis showed mortality to be associated with PSF. CONCLUSION: There is a multifactorial basis for PSF suggesting different therapy options. Cerebral lesions may cause PSF in some patients. Post-stroke fatigue is associated with higher mortality.

Serum uri acid: neuroprotection in thrombolysis. The Bergen NORSTROKE study.

BACKGROUND: A possible synergic role of serum uric acid (SUA) with thrombolytic therapies is controversial and needs further investigations. We therefore evaluated association of admission SUA with clinical improvement and clinical outcome in patients receiving rt-PA, early admitted patients not receiving rt-PA, and patients admitted after time window for rt-PA. METHODS: SUA levels were obtained at admission and categorized as low, middle and high, based on 33° and 66° percentile values. Patients were categorized as patients admitted within 3 hours of symptom onset receiving rt-PA (rt-PA group), patients admitted within 3 hours of symptom onset not receiving rt-PA (non-rt-PA group), and patients admitted after time window for rt-PA (late group). Short-term clinical improvement was defined as the difference between NIHSS on admission minus NIHSS day 7. Favorable outcome was defined as mRS 0 - 3 and unfavorable outcome as mRS 4 - 6. RESULTS: SUA measurements were available in 1136 patients. Clinical improvement was significantly higher in patients with high SUA levels at admission. After adjustment for possible confounders, SUA level showed a positive correlation with clinical improvement (r = 0.012, 95% CI 0.002-0.022, p = 0.02) and was an independent predictor for favorable stroke outcome (OR 1.004; 95% CI 1.0002-1.009; p = 0.04) only in the rt-PA group. CONCLUSIONS: SUA may not be neuroprotective alone, but may provide a beneficial effect in patients receiving thrombolysis.

Expression of the progenitor marker NG2/CSPG4 predicts poor survival and resistance to ionising radiation in glioblastoma.

Glioblastoma (GBM) is a highly aggressive brain tumour, where patients respond poorly to radiotherapy and exhibit dismal survival outcomes. The mechanisms of radioresistance are not completely understood. However, cancer cells with an immature stem-like phenotype are hypothesised to play a role in radioresistance. Since the progenitor marker neuron-glial-2 (NG2) has been shown to regulate several aspects of GBM progression in experimental systems, we hypothesised that its expression would influence the survival of GBM patients. Quantification of NG2 expression in 74 GBM biopsies from newly diagnosed and untreated patients revealed that 50% express high NG2 levels on tumour cells and associated vessels, being associated with significantly shorter survival. This effect was independent of age at diagnosis, treatment received and hypermethylation of the O(6)-methylguanine methyltransferase (MGMT) DNA repair gene promoter. NG2 was frequently co-expressed with nestin and vimentin but rarely with CD133 and the NG2 positive tumour cells harboured genetic aberrations typical for GBM. 2D proteomics of 11 randomly selected biopsies revealed upregulation of an antioxidant, peroxiredoxin-1 (PRDX-1), in the shortest surviving patients. Expression of PRDX-1 was associated with significantly reduced products of oxidative stress. Furthermore, NG2 expressing GBM cells showed resistance to ionising radiation (IR), rapidly recognised DNA damage and effectuated cell cycle checkpoint signalling. PRDX-1 knockdown transiently slowed tumour growth rates and sensitised them to IR in vivo. Our data establish NG2 as an important prognostic factor for GBM patient survival, by mediating resistance to radiotherapy through induction of ROS scavenging enzymes and preferential DNA damage signalling.

[Patients with acute cerebral infarction admitted to stroke unit]. / Pasienter med akutt hjerneinfarkt innlagt i slagenhet.

BACKGROUND: Treatment of acute cerebral infarction has greatly improved over the last 15 years. The purpose of this article is to describe patients with acute cerebral infarction admitted to a stroke unit from a geographically well defined population between 2007 and 2009. MATERIAL AND METHOD: All patients were included aged over 15 years with acute cerebral infarction living in a well defined geographical area and admitted to Haukeland University Hospital between August 2007 and October 2009. Risk factors, neurological status, treatment, complications, results of evaluation, and outcome were registered in a stroke database (Bergen Stroke Registry). Data on mortality as of November 2009 were provided by the official population registry. RESULTS: In total, 553 patients with acute cerebral infarction were included: 260 (47%) females and 293 (53%) men. The mean age was 74.2 years. The incidence of patients admitted with acute cerebral infarction was 105 per 100,000 citizens per year. Thrombolysis was administered to 15%. Duplex sonography of neck vessels disclosed plaques in 68%. Atrial fibrillation was known before admission in 20%. Evaluation disclosed atrial fibrillation in another 12%. Recurrence of cerebral infarction occurred in 1% during the hospital stay. Estimated survival after one year was 82%. CONCLUSION: The incidence of acute cerebral infarction in Bergen is low. Systematic evaluation discloses risk factors with therapeutic consequences in many patients.

[Treatment of cerebrovascular disease in a comprehensive stroke unit]. / Behandling av cerebrovaskulære sykdommer i slagenhet.

BACKGROUND: Development of stroke units during the last decade has changed management of patients with stroke. The aim of this study is to assess unselected patients admitted to an acute stroke unit with respect to daily functioning (neurological deficits), treatment and 7-day outcome. MATERIAL AND METHODS: All patients with suspected neurovascular disease were admitted to the stroke unit as emergencies. Patients with confirmed cerebrovascular disease were prospectively included in the Bergen Stroke Study in the period 1 February 2006-30 April 2009. Patients who had other diagnoses were not included, but their diagnoses were prospectively recorded in a 3 month-period. RESULTS: 49.8% of the patients had other diagnoses than acute stroke. Of 1101 patients with neurovascular disease; 10% had transient ischemic attacks, 79% had ischemic and 10% had hemorrhagic stroke. On admission, 72% of the patients had none or minor neurological deficits. After one week 63% of the patients were independent, 25% needed long-term rehabilitation and 10% were bedridden. INTERPRETATION: Most patients in our study had mild deficits and first of all need an exact diagnostic work-up, acute and prophylactic treatment. Rehabilitation is important for a minority of patients.

High proportion of lacunar strokes at night: the Bergen stroke study.

The main objective of this study was to investigate the circadian distribution of subtypes of ischemic stroke. The time of onset of stroke in consecutive stroke patients was registered and categorized into the following time intervals: midnight-6 am, 6 am-noon, noon-6 pm, and 6 pm-midnight. Patients with unknown onset of stroke were categorized as woke up with stroke, found with stroke by others, and miscellaneous. Patients who woke up with stroke, were included in the midnight-6 am interval. Stroke subtypes were categorized according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria and as lacunar or embolic stroke based on diffusion-weighted magnetic resonance imaging (DWI). The study group comprised 1101 patients who sustained ischemic stroke between February 2006 and March 2008. The proportion of lacunar stroke, defined according to both the TOAST criteria and DWI findings, was significantly higher in the midnight-6 am interval compared with the other time intervals. In our study group, the prevalence of lacunar strokes was highest at night.

Post-stroke pain on long-term follow-up: the Bergen stroke study.

The objective of this study is to evaluate characteristics and mortality related to long-term post-stroke pain (PSP). All surviving stroke patients admitted to the Stroke Unit, Haukeland University Hospital, between February 2006 and July 2009 received a postal questionnaire including the fatigue severity scale (FSS), the hospital anxiety and depression scale (HADSD), the Barthel index (BI), and questions regarding location of pain and pain severity at least 6 months after onset of stroke. Survival among patients returning the questionnaire was determined by November 2009. Stroke severity was defined by the modified Rankin score (mRS), 7 days after stroke onset. About 30% of the 408 patients had moderate to severe PSP. On logistic regression, PSP was associated with females (odds ratio (OR) = 2.1, p = 0.002), lower age (OR = 0.98, p = 0.04), fatigue (OR = 3.1, p < 0.001), sleep disturbances (OR = 3.3, p < 0.001), and mRS 3-5 (OR = 1.9, p = 0.03). Among patients with pareses (persistent or transient), there was no difference between paretic and non-paretic side as to frequency of limb pain on follow-up (p = 0.91). By November 2009, 26 patients had died. Cox regression analysis showed that mortality was associated with PSP (hazard ratio (HR) = 2.4, p = 0.040), high age (HR = 1.07, p = 0.001), males (HR = 2.5, p = 0.04), and low BI (HR = 0.97, p < 0.001). In conclusion, our study indicates a multifactorial basis for post-stroke pain. The main new findings were that the frequencies of pain were similar in paretic and non-paretic limbs and that long-term mortality was associated with post-stroke pain.