Poststroke epilepsy in long-term survivors of primary intracerebral hemorrhage.

OBJECTIVE: To identify the incidence and predisposing factors for development of poststroke epilepsy (PSE) after primary intracerebral hemorrhage (PICH) during a long-term follow-up. METHODS: We performed a retrospective study of patients who had had their first-ever PICH between January 1993 and January 2008 in Northern Ostrobothnia, Finland, and who survived for at least 3 months. These patients were followed up for PSE. The associations between PSE occurrence and sex, age, Glasgow Coma Scale (GCS) score on admission, hematoma location and volume, early seizures, and other possible risk factors for PSE were assessed using the Cox proportional hazards regression model. RESULTS: Of the 615 PICH patients who survived for longer than 3 months, 83 (13.5%) developed PSE. The risk of new-onset PSE was highest during the first year after PICH with cumulative incidence of 6.8%. In univariable analysis, the risk factors for PSE were early seizures, subcortical hematoma location, larger hematoma volume, hematoma evacuation, and a lower GCS score on admission, whereas patients with infratentorial hematoma location or hypertension were less likely to develop PSE (all variables p < 0.05). In multivariable analysis, we found subcortical location (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.35-3.81, p < 0.01) and early seizures (HR 3.63, 95% CI 1.99-6.64, p < 0.01) to be independent risk factors, but patients with hypertension had a lower risk of PSE (HR 0.54, 0.35-0.84, p < 0.01). CONCLUSIONS: Subcortical hematoma location and early seizures increased the risk of PSE after PICH in long-term survivors, while hypertension seemed to reduce the risk.

Risk for All-cause and Traumatic Death in Head Trauma Subjects: A Prospective Population-based Case-control Follow-up Study.

OBJECTIVE: To investigate long-term mortality for subjects with acute head trauma. BACKGROUND: It is not known why long-term mortality after head trauma without traumatic brain injury is elevated. METHODS: All subjects admitted to Oulu University Hospital emergency room in 1999 with an acute head trauma (n = 737) were followed up until February 2014 and compared with age and sex-matched general population controls (n = 2196). Dates and causes of death were obtained from the official Cause-of-Death Statistics. Cox proportional hazard regression models and Kaplan-Meier survival curves were used to identify predictors for alcohol-related, nonalcohol-related, and all-cause death. RESULTS: Alcohol-related deaths were more frequent among the subjects with head trauma (27.8%) than among the population controls (6.9%). Head trauma with or without traumatic brain injury (TBI) shortened mean life expectancy by 8.7 years and by as much as 13 years if only those without TBI were considered. The risk of alcohol-related death was 7-fold (hazard ratio 6.79; 95% confidence interval, 3.94-11.71) among subjects without TBI as compared with general population. Of all future deaths among these cases 17.1% were because of a new trauma, a significantly higher frequency (P < 0.005) than that observed in the general population (3% of all deaths). Alcohol-related cause of death was significantly more common among the subjects who were under the influence of alcohol at the time of the index trauma than among the sober subjects. CONCLUSIONS: Head trauma subjects without TBI have an elevated risk of alcohol-related death. Alcohol-related traumas are a major cause of death among these subjects.

Head Trauma with or without Mild Brain Injury Increases the Risk of Future Traumatic Death: A Controlled Prospective 15-Year Follow-Up Study.

Patients who have recovered from traumatic brain injury (TBI) show an increased risk of premature death. To investigate long-term mortality rates in a population admitted to the hospital for head injury (HI), we conducted a population-based prospective case-control, record-linkage study, All subjects who were living in Northern Ostrobothnia, and who were admitted to Oulu University Hospital in 1999 because of HI (n=737), and 2196 controls matched by age, gender, and residence randomly drawn from the population of Northern Ostrobothnia were included. Death rate and causes of death in HI subjects during 15 years of follow-up was compared with the general population controls. The crude mortality rates were 56.9, 18.6, and 23.8% for subjects having moderate-to-severe traumatic brain injury (TBI), mild TBI, and head injury without TBI, respectively. The corresponding approximate annual mortality rates were 6.7%, 1.4%, and 1.9%. All types of index HI predicted a significant risk of traumatic death in the future. Subjects who had HI without TBI had an increased risk of both death from all causes (hazard ratio 2.00; 95% confidence interval 1.57-2.55) and intentional or unintentional traumatic death (4.01, 2.20-7.30), compared with controls. The main founding was that even HI without TBI carries an increased risk of future traumatic death. The reason for this remains unknown and further studies are needed. To prevent such premature deaths, post-traumatic therapy should include an interview focusing on lifestyle factors.

Improved survival of patients with warfarin-associated intracerebral haemorrhage: a retrospective longitudinal population-based study.

BACKGROUND: Warfarin-associated intracerebral haemorrhage carries poor outcome due to rapid haemorrhage growth. Reversal of warfarin anticoagulation with prothrombin complex concentrate has been implemented as an acute treatment option for these subjects. AIM: We investigated whether survival of subjects with warfarin-associated intracerebral haemorrhage had improved after implementation of reversal of warfarin anticoagulation with prothrombin complex concentrate. METHODS: We identified all subjects with warfarin-associated intracerebral haemorrhage during 1993-2008 among the population of Northern Ostrobothnia, Finland. From 2004 onwards, prothrombin complex concentrate was used in Oulu University Hospital, the only hospital treating intracerebral haemorrhage subjects in the region, to counteract the effect of warfarin in subjects with warfarin-associated intracerebral haemorrhage. We compared the outcomes of subjects admitted during 1993-2003 and 2004-2008 and those treated and not treated with prothrombin complex concentrate. We also explored the predictors for one-year survival of the warfarin-associated intracerebral haemorrhage subjects. RESULTS: We identified altogether 181 subjects who had intracerebral haemorrhage while on warfarin. One-year survival was significantly (P = 0·031) higher for the 60 subjects admitted during 2004-2008 (43·3%) than for the 121 admitted before 2004 (30·6%). In multivariable analysis, prothrombin complex concentrate treatment reduced one-year case fatality (hazard ratio 0·52, 95% confidence interval 0·29-0·93). Thromboembolic complications did not occur more frequently among those treated with prothrombin complex concentrate. CONCLUSION: The survival of warfarin-associated intracerebral haemorrhage subjects among the population of Northern Ostrobothnia has improved likely because of introduction of prothrombin complex concentrate.

Predictive value of C-reactive protein for the outcome after primary intracerebral hemorrhage.

OBJECT: Primary intracerebral hemorrhage (ICH) carries high morbidity and mortality rates. Several factors have been suggested as predicting the outcome. The value of C-reactive protein (CRP) levels in predicting a poor outcome is unclear, and findings have been contradictory. In their population-based cohort, the authors tested whether, independent of confounding factors, elevated CRP levels on admission (< 24 hours after ictus) are associated with an unfavorable outcome. METHODS: The authors identified all patients who suffered primary ICH between 1993 and 2008 among the population of Northern Ostrobothnia, Finland, and from the laboratory records they extracted the CRP values at admission. Independent predictors of an unfavorable outcome (moderate disability or worse according to the Glasgow Outcome Scale at 3 months) were tested by unconditional logistic regression in a model including all the well-established confounding factors and CRP on admission. RESULTS: Of 961 patients, 807 (84%) had CRP values available within 24 hours of admission, and multivariable analysis showed elevated CRP at that point to be associated with an unfavorable outcome (OR 1.41 per 10 mg/L [95% CI 1.09-1.81], p < 0.01), together with diabetes mellitus (OR 1.99 [95% CI 1.09-3.64], p < 0.05), age (1.06 per year [95% CI 1.04-1.08], p < 0.001), low Glasgow Coma Scale score (0.75 per unit [95% CI 0.67-0.84], p < 0.001), hematoma size (1.05 per ml [95% CI 1.03-1.07], p < 0.001), and the presence of an intraventricular hemorrhage (2.70 [95% CI 1.66-4.38], p < 0.001). Subcortical location predicted a favorable outcome (0.33 [95% CI 0.20-0.54], p < 0.001). CONCLUSIONS: Elevated CRP on admission is an independent predictor of an unfavorable outcome and is only slightly associated with the clinical and radiological severity of the bleeding.

Immediate, early and late seizures after primary intracerebral hemorrhage.

BACKGROUND: Seizures after primary intracerebral hemorrhage (PICH) are significant and treatable complications, but the factors predicting immediate, early and late seizures are poorly known. We investigated characteristics and outcome with special reference to occurrence and timing of a first seizure among consecutive subjects with PICH. METHODS: A population-based study was conducted in Northern Ostrobothnia, Finland, in 1993-2008 that included all patients with a first-ever primary ICH without any prior diagnosis of epilepsy. Immediate (<24h after admission), early (1-14 days) and late (>2 weeks) seizures were considered separately. RESULTS: Out of a total of 935 ICH patients, 51 had immediate, 21 early and 58 late seizures. The patients with seizures were significantly younger than the others and more often had a subcortical hematoma location (p<0.05). Lifestyle factors did not differ between the groups. The risk factors for immediate seizures in multivariable analysis were a low Glasgow coma scale score (GCS) on admission, subcortical location and age inversely (p<0.01). The only independent risk factor for early seizures was subcortical location (p<0.001), whereas subcortical location (p<0.001), age inversely (p<0.01) and hematoma evacuation (p<0.05) independently predicted late seizures. Immediate and early seizures predicted infectious complications (p<0.05). CONCLUSIONS: Patients with subcortical hematoma and of younger age are at risk for immediate seizures after primary ICH irrespective of hematoma size. Patients with immediate and early seizures more often had infectious complications. Surgery increases the risk of a late seizure after ICH.

Association between warfarin combined with serotonin-modulating antidepressants and increased case fatality in primary intracerebral hemorrhage: a population-based study.

OBJECT: Patients receiving oral anticoagulants run a higher risk of cerebral hemorrhage with a poor outcome. Serotonin-modulating antidepressants (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) are frequently used in combination with warfarin, but it is unclear whether this combination of drugs influences outcome after primary intracerebral hemorrhage (PICH). The authors investigated case fatality in PICH among patients from a defined population who were receiving warfarin alone, with aspirin, or with serotonin-modulating antidepressants. METHODS: Nine hundred eighty-two subjects with PICH were derived from the population of Northern Ostrobothnia, Finland, for the years 1993-2008, and those with warfarin-associated PICH were eligible for analysis. Their hospital records were reviewed, and medication data were obtained from the national register of prescribed medicines. Kaplan-Meier survival curves were drawn to illustrate cumulative case fatality, and a Cox proportional-hazards analysis was performed to demonstrate predictors of death. RESULTS: Of the 176 patients eligible for analysis, 17 had been taking aspirin and 19 had been taking SSRI/SNRI together with warfarin. The 30-day case fatality rates were 50.7%, 58.8%, and 78.9%, respectively, for those taking warfarin alone, with aspirin, or with SSRI/SNRI (p = 0.033, warfarin plus SSRI/SNRI compared with warfarin alone). Warfarin combined with SSRI/SNRI was a significant independent predictor of case fatality (adjusted HR 2.10, 95% CI 1.13-3.92, p = 0.019). CONCLUSIONS: Concurrent use of warfarin and a serotonin-modulating antidepressant, relative to warfarin alone, seemed to increase the case fatality rate for PICH. This finding should be taken into account if hematoma evacuation is planned.

Predictors of new-onset seizures: a 10-year follow-up of head trauma subjects with and without traumatic brain injury.

BACKGROUND: It is not known whether alcohol-related head trauma predicts the new-onset seizures, particularly alcohol-related seizures. OBJECTIVE: We investigated risk factors for new-onset seizures in a cohort of 739 head trauma subjects. METHODS: All subjects with head trauma attending Oulu University Hospital during 1999, including children and very old people but excluding persons with previous seizures and/or neurological diseases, were enrolled and followed up until the end of 2009. The Finnish National Hospital Discharge Register was used to identify all visits due to seizures during the 10-year follow-up. Dates of death were obtained from the official Cause-of-Death Statistics. Cox proportional hazard regression models and Kaplan-Meier survival curves were used to identify predictors of new-onset seizures. RESULTS: New-onset seizures were observed in 42 out of the 739 subjects (5.7%). An alcohol-related index injury (adjusted HR 2.50, 95% CI 1.30 to 4.82, p=0.006), moderate-to-severe traumatic brain injury (TBI) as the index trauma (3.13, 1.46 to 6.71, p=0.003) and preceding psychiatric disease (3.23, 1.23 to 9.21, p=0.028) were significant predictors of new-onset seizures during the follow-up after adjustment for age and sex. An alcohol-related index injury was the only independent predictor of the occurrence of an alcohol-related new-onset seizure (adjusted HR 12.13, 95% CI 2.70 to 54.50, p=0.001), and these seizures (n=19) developed more frequently among subjects without (n=14) than with (n=5) TBI. CONCLUSIONS: We conclude that alcohol-related head trauma predicts new-onset seizures, particularly alcohol-related seizures. A brief intervention is needed in order to prevent the development of alcohol-related seizures.

Diagnosis and management of Marchiafava-Bignami disease: a review of CT/MRI confirmed cases.

OBJECTIVE: Marchiafava-Bignami disease (MBD) is a rare condition mainly associated with alcoholism, although it may be mimicked by several other disorders that cause corpus callosum lesions. Our objective was to identify helpful features for differential diagnosis and assess whether any treatment can be recommended. METHODS: We reviewed 122 reports containing data on 153 subjects with confirmed MBD that was associated with either alcoholism or malnutrition, and 20 reports with data on 53 subjects with conditions mimicking MBD. All the cases had been verified antemortem by brain imaging. Unconditional logistic regression was used to demonstrate factors that were associated with the outcome of MBD. RESULTS: The mimicking conditions were differentiated from MBD by the occurrence of solitary and rapidly disappearing splenial lesions; fewer signs and symptoms with exception of seizures, hemiparesis and tetraparesis; nystagmus; and rapid and complete recovery. MBD occurred most frequently among alcoholics, but it was also reported in 11 non-alcoholics (7.2% of all the MBD cases). A better outcome was observed among those who were treated within 2 weeks after onset of symptoms with parenteral thiamine (p=0.033). CONCLUSIONS: As thiamine deficiency is frequently associated with alcoholism, malnutrition and prolonged vomiting; we recommend prompt treatment of MBD with parenteral thiamine in such subjects. Recovery should be followed by repeated neuropsychological and MRI examinations, preferably using diffusion tensor imaging.

Mortality from traumatic brain injury after reduction of alcohol prices: a population-based study from northern Finland.

AIMS: Traumatic brain injury (TBI) is the leading cause of death after trauma, and alcohol is a major risk factor for TBI. In Finland, alcohol taxes were cut by one third in 2004. This resulted in a marked increase of alcohol consumption. We investigated whether increased alcohol consumption influenced the number of fatal TBIs. METHODS: All (n = 318) fatal TBIs were identified from medico-legal reports during the years 1999, 2006 and 2007 among the residents of Oulu Province, Finland. Mortality rates were compared before and after alcohol price reduction. Alcohol involvement based on the presence of alcohol in body fluids and/or alcohol-related diseases recorded in death certificates. RESULTS: The proportion of alcohol-related TBI deaths of all TBI deaths increased (from 1999 to 2007) among middle-aged people from 48% to 91% (p = 0.001) but decreased among young adults from 74% to 41% (p = 0.015). The overall TBI mortality rate did not increase. Fatal TBIs due to falls were significantly more commonly alcohol-related in 2006-2007 than in 1999 (p = 0.003) and accumulated among middle-aged people. CONCLUSIONS: After the price reduction, alcohol-related fatal TBIs increased most among middle-aged people, and they were frequently caused by fall accidents. The reduction of alcohol prices did not increase the total number of fatal TBIs. Middle-aged and elderly subjects with TBI should be routinely asked for alcohol drinking and those with hazardous drinking habits should be guided for alcohol intervention.

A population based study of outcomes after evacuation of primary supratentorial intracerebral hemorrhage.

BACKGROUND AND PURPOSE: The role of surgery after primary intracerebral hemorrhage (ICH) is controversial. To explore whether hematoma evacuation after ICH had improved short-term survival or functional outcome we conducted a retrospective observational population-based study. METHODS: We identified all subjects with primary ICH between 1993 and 2008 among the population of Northern Ostrobothnia, Finland. Hematoma evacuation was carried out by using standard craniotomy or through a burr hole. We compared mortality rates and functional outcomes of patients with hematoma evacuation with those treated conservatively. RESULTS: Of 982 patients with verified ICH during the study period, 127 (13%) underwent hematoma evacuation. Surgically treated patients were significantly younger (mean±SD, 63±11 vs. 70±12 years; p<0.001), had larger hematomas (66±36 vs. 28±40 ml; p<0.001), lower Glasgow Coma Scale scores (median, 11 vs. 14; p<0.001) and more frequently subcortical hematomas (68% vs. 24%; p<0.001) than those treated conservatively. In multivariable analysis, hematoma evacuation independently lowered 3-month mortality (adjusted hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.43-0.88; p<0.03), particularly among patients aged≤70 years with ≥30 ml supratentorial hematomas (adjusted HR, 0.26; 95% CI, 0.14-0.49; p<0.001). However, poor outcome was not improved by surgery (adjusted odds ratio 0.71; 95% CI 0.29-1.70). CONCLUSIONS: Improved 3-month survival was observed in patients who had undergone hematoma evacuation relative to patients not undergoing evacuation particularly in the subgroup of patients aged≤70 years with ≥30 ml supratentorial hematomas. Surgery might improve outcome if cases could be selected more precisely and if performed before deterioration.

Predictors for recurrent primary intracerebral hemorrhage: a retrospective population-based study.

BACKGROUND AND PURPOSE: Underlying comorbidities, previous strokes, and medication may increase the risk for primary intracerebral hemorrhage (PICH) and its recurrence. The aim of this study was to determine the independent predictors for recurrent PICH. METHODS: We identified 961 subjects with first-ever PICH from 1993 to 2008 among the population of Northern Ostrobothnia, Finland. Hospital and death records were reviewed and data on drug use were obtained from the national register of prescribed medicines. Kaplan-Meier survival curves and Cox proportional hazards models were used to demonstrate predictors for recurrence of PICH. RESULTS: Total follow-up time of the 961 patients was 3481 person-years. During the follow-up time, 58 subjects had altogether 68 recurrent PICHs. The annual average incidence of first recurrence was 1.67%. Cumulative 5- and 10-year incidence rates were 9.6% and 14.2%, respectively. In univariable analysis, history of ischemic stroke, diabetes mellitus, and aspirin use were associated with a higher recurrence rate. In multivariable analysis, only previous ischemic stroke (adjusted hazard ratio, 2.22; 95% confidence interval, 1.22-4.05; P=0.009) independently predicted PICH recurrence. Diabetes mellitus tended to increase (adjusted hazard ratio, 2.38; 95% confidence interval, 0.98-5.80; P=0.056), whereas treated hypertension tended to decrease (0.45, 0.20-1.01; P=0.054) the risk for fatal recurrent PICH. CONCLUSIONS: Previous ischemic stroke independent of confounding factors may increase the risk for PICH recurrence.

Fibrinolytic activity and platelet function in subjects with obstructive sleep apnoea and a patent foramen ovale: is there an option for prevention of ischaemic stroke?

Obstructive sleep apnoea (OSA) carries an increased risk of ischaemic stroke, but the underlying mechanism is not clear. As right-to-left shunting can occur through a patent foramen ovale (PFO) during periods of apnoea, we investigated nocturnal changes in fibrinolytic activity and platelet function in subjects who had OSA with or without PFO and in controls. We determined plasminogen activator inhibitor 1 (PAI-1) activity and antigen and platelet activation parameters. The severity of OSA was verified by polygraphy and PFO was detected by ear oximetry. We found a higher PAI-1 activity and antigen and a lower ratio of 2,3-dinor-PGF(1α) to 2,3-dinor-TXB(2) in the subjects with OSA than in the controls. Linear regression analysis showed the apnoea-hypopnoea index (ß-coefficient, 0.499; P = 0.032) and PFO (ß-coefficient, 0.594; P = 0.015) to be associated independently with PAI-1 activity in the morning, while the increment in PAI-1:Ag from evening to morning was significantly associated with the presence of PFO (r(s) = 0.563, P = 0.002). Both OSA and PFO reduce fibrinolytic activity during nocturnal sleep. We hypothesize that subjects having both OSA and PFO may develop a more severe prothrombotic state during sleep than those having either OSA or PFO alone.

Mortality of harmful drinkers increased after reduction of alcohol prices in northern Finland: a 10-year follow-up of head trauma subjects.

OBJECTIVE: Alcohol-related mortality may be influenced by the level of alcohol consumption. We investigated the effect of alcohol price reduction on mortality in a cohort of 827 subjects with head injury. METHODS: We used the Finnish National Hospital Discharge Register to identify all diagnoses recorded during hospital and health center visits for survivors of the index injury during a follow-up of 10 years. Mortality data were gathered from death records obtained from the Official Cause-of-Death Statistics. Cox proportional hazards model was used to identify independent predictors for death. Kaplan-Meier survival curves were used to characterize the effect of alcohol price reduction on mortality of harmful and non-harmful drinkers. RESULTS: Alcohol-related deaths increased after the reduction of alcohol prices on March 1, 2004. Subjects recorded as harmful drinkers during the follow-up period were significantly (p < 0.001) more likely than others to die after the price reduction. Older age (HR 1.06, 95% CI 1.05-1.07), moderate-to-severe brain injury (HR 2.39, 95% CI 1.59-3.60) and harmful drinking recorded after the index trauma (HR 2.59, 95% CI 1.62-4.62) were significant (p < 0.001) predictors for death. CONCLUSION: We conclude that a political decision to lower the price of alcohol may cause a significant increase in the death rate of harmful drinkers.

Mild traumatic brain injury diagnosis frequently remains unrecorded in subjects with craniofacial fractures.

BACKGROUND: Traumatic brain injuries (TBI) in subjects with craniofacial fractures are usually diagnosed by emergency room physicians. We investigated how often TBI remains unrecorded in these subjects, and whether diagnostic accuracy has improved after the implementation of new TBI guidelines. METHODS: All subjects with craniofacial fractures admitted to Oulu University Hospital in 1999 and in 2007 were retrospectively identified. New guidelines for improving the diagnostic accuracy of TBI were implemented between 2000 and 2006. Clinical symptoms of TBI were gathered from notes on hospital charts and compared to the recorded diagnoses at discharge. Logistic regression was used to identify independent predictors for TBI to remain unrecorded. RESULTS: Of 194 subjects with craniofacial fracture, 111(57%) had TBI, 40 in 1999 and 71 in 2007. Fifty-one TBIs (46%) remained unrecorded at discharge, 48 being mild and 3 moderate-to-severe. Subjects with unrecorded TBI were significantly less frequently referred to follow-up visits. Failures to record the TBI diagnosis were less frequent (29/71, 41%) in 2007 than in 1999 (22/40, 55%), but the difference was not statistically significant. The most significant independent predictor for this failure was the clinical specialty (other than neurology/neurosurgery) of the examining physician (p<0.001). The subject's alcohol intoxication did not hamper the diagnosis of TBI. CONCLUSIONS: TBIs remain frequently unrecorded in subjects with craniofacial fractures. Recording of mild TBI slightly but insignificantly improved after the implementation of new guidelines.

Effect of increased warfarin use on warfarin-related cerebral hemorrhage: a longitudinal population-based study.

BACKGROUND AND PURPOSE: Warfarin use has rapidly increased with the aging of the population. We investigated the temporal trends in the incidence and outcome of warfarin-related intracerebral hemorrhages (ICHs) in a defined population. METHODS: We identified all subjects with first-ever primary ICH during 1993 to 2008 among the population of Northern Ostrobothnia, Finland. The number of warfarin users was obtained from the national register of prescribed medicines kept by the Social Insurance Institution of Finland. We calculated the annual incidence of warfarin-related ICHs, 28-day case fatality, and deaths from the primary bleed. RESULTS: The proportion of warfarin users among the population increased 3.6-fold from 0.68% in 1993 to 2.28% in 2008. Of a total of 982 patients with ICH, 182 (18.5%) had warfarin-related ICH. One-year survival rate after onset of stroke was 35.2% among warfarin users and 67.9% among nonusers. The annual incidence (P=0.062) and 28-day case fatality of warfarin-related ICHs (P=0.002) decreased during the observation period. Warfarin users were older (mean difference 6.6; 95% CI, 5.0 to 8.1; P<0.001) than nonusers. Admission international normalized ratio values above the therapeutic range (2.0 to 3.0) decreased through the observation period, suggesting improved control of anticoagulant therapy over time. CONCLUSIONS: The annual incidence and case fatality of warfarin-related ICHs decreased, although the proportion of warfarin users almost quadrupled in our population.

Trends in treatment and outcome of stroke patients in Finland from 1999 to 2007. PERFECT Stroke, a nationwide register study.

INTRODUCTION: This article in this supplement issue on the Performance, Effectiveness, and Costs of Treatment episodes (PERFECT) project describes trends in Finnish stroke treatment and outcome. MATERIAL AND METHODS: The PERFECT Stroke study uses multiple national registry linkages at individual patient level to produce a national stroke database with comprehensive follow-up of all hospital-treated stroke patients in Finland. RESULTS: There were 94,316 incident stroke patients treated in Finnish hospitals from 1999 to 2007. Lengths-of-stays decreased after ischemic stroke (IS), and increased after intracerebral (ICH) and subarachnoid (SAH) hemorrhage. Ten-year survival improved in IS (hazard ratio 0.75; 95% CI 0.71-0.79) and ICH patients (0.88; 0.79-0.97), increasing median survival by 2 and 1 life-years respectively. This has translated into more days spent home among IS patients, but not among ICH patients. Treatment by neurologists improved the survival of IS (odds ratio [OR] 1.77; 95% CI 1.70-1.84) and ICH patients (OR 1.55; 95% CI 1.40-1.69), and treatment by neurosurgeons of SAH patients (OR 2.66; 95% CI 2.25-3.16), the effects were further improved by care in specialized stroke centers. DISCUSSION: The survival of Finnish IS and ICH patients has improved. Specialized acute care was associated with improved outcome.

Direct costs of patients with stroke can be continuously monitored on a national level: performance, effectiveness, and Costs of Treatment episodes in Stroke (PERFECT Stroke) Database in Finland.

BACKGROUND AND PURPOSE: Treatment of stroke consumes a significant portion of all healthcare expenditure. We developed a system for monitoring costs from individual patient data on a national level in Finland. METHODS: Multiple national administrative registers were linked to gain episode-of-care data on all hospital-treated patients with incident stroke over the years 1999 to 2007 (n = 94,316). Inpatient and specialist outpatient costs were evaluated with a cost database, long-term care costs with fixed prices, and medication costs with true retail prices. RESULTS: For the patients of Year 2007, the mean 1-year costs after an ischemic stroke were $29 580, after an intracerebral hemorrhage $36,220, and after a subarachnoid hemorrhage $42,570, valued in Year 2008 U.S. dollars. Only part of these costs are attributable to stroke, because the annual costs prior to stroke were significant, $8900 before ischemic stroke, $7600 before intracerebral hemorrhage, and $4200 before subarachnoid hemorrhage. Older patients with ischemic stroke, and, among patients with ischemic stroke and subarachnoid hemorrhage, women, incurred higher costs. The mean estimated lifetime costs were $130,000 after ischemic stroke or intracerebral hemorrhage and $80,000 after subarachnoid hemorrhage. Annually $1.6 billion is spent in the care of Finnish patients with stroke, which equals to 7% of the national healthcare expenditure, or 0.6% of the gross domestic product. Costs of patients with stroke are increasing with prolonged survival and the aging population. CONCLUSIONS: Treatment of patients with stroke is a large national investment. Setting up a nationwide system for continuous monitoring of stroke costs is feasible. Cost data should optimally be evaluated in conjunction with effectiveness and performance indicators.

Alcohol consumption, blood pressure, and the risk of stroke.

A synergistic effect of alcohol and hypertension has been suggested to increase the risk for stroke. However, the contribution of alcohol-induced hypertension to stroke morbidity and mortality may be greater than observed, because the effects of different drinking patterns have not been separately investigated. Alcohol-induced transient peaks in systolic blood pressure may predispose to stroke. Recent studies have measured time trends of blood pressure elevations in relation to alcohol consumption. They found a significant morning surge in blood pressure, which was related to alcohol intake in a dose-dependent manner and was independent of smoking. Men with a severe form of hypertension showed a 12-fold increased risk for cardiovascular disease mortality associated with heavy binge drinking. Binge drinking is a significant risk factor for stroke. Hypertensive patients should be warned about the risks of alcohol and urged to avoid binge drinking because of an increased risk for all subtypes of stroke.