Decreased severity of brain infarct can in part explain the decreasing case fatality rate of stroke.

BACKGROUND AND PURPOSE: Case fatality rates for stroke has declined in most Western industrialized countries during recent decades. One possible explanation for this is a decrease in the severity of stroke symptoms. We therefore sought evidence for a change in stroke severity and its relationship with case fatality rates. METHODS: We compared the severity of symptoms among first-ever stroke patients in 2 population-based prospective stroke registers maintained during 1972 to 1973 and 1989 to 1991 in Finland. Patients who were evaluated by study assistants or the investigator during the first week after the onset of symptoms were included in the study, and their severity of symptoms was assessed with the use of comparable scales modified from the Scandinavian Stroke Scale. RESULTS: A total of 244 and 594 patients were registered, and a portion of them (155 [63.5%] and 360 [60.6%]) were included in the analyses in the registers for Espoo-Kauniainen from 1972 to 1973 and for 4 separate districts in Finland from 1989 to 1991, respectively. The death rates during the first week among those who were not included did not differ between the registers. The severity of symptoms decreased significantly between the registers in both patients with brain infarct or intracerebral hemorrhage but not in those with subarachnoid hemorrhage. The severity of symptoms was an independent factor of case fatality at 1 month. CONCLUSIONS: The severity of symptoms of brain infarcts has decreased and can in part explain the decreased case fatality rate of stroke in Finland. However, the change in patients with intracerebral hemorrhage may be overestimated due to undiagnosed intracerebral hemorrhages in the first register resulting from the lack of brain CT.

Post-stroke depression and functional recovery in a population-based stroke register. The Finnstroke study.

Post-stroke depression and functional outcome were examined in a population-based stroke register active in four different districts (total population, 134 804) in Finland. Five hundred and ninety four first time strokes were registered. Beck's depression inventory (BDI), with ten as the cutoff point for depression, was applied to 321 of 423 survivors after three months and to 311 of 390 survivors after 12 months. Functional outcome was measured with the Barthel Index (BI) and the Rankin Scale (RS). One hundred and fifty one of 321 (47.0%) and 147 of 311 (47.3%) patients were depressed after three and 12 months, respectively. Depression at three months was associated with poor functional outcome at the one-year follow-up (P = 0.001 for the BI and the RS). On the other hand, poor functional outcome at three months was associated with depression after one year (P = 0.004 and 0.002 for the BI and the RS, respectively). Patients who were depressed at three months were more often in institutional care between three and 12 months later than non-depressed patients (P = 0.005). Post-stroke depression is associated with poor functional recovery of patients. If depression were diagnosed and treated early, it might help patients to recover more completely and/or faster, which could save community healthcare resources by avoiding or shortening the time of institutional care or reducing the need for home care.

Depression after stroke: results of the FINNSTROKE Study.

BACKGROUND AND PURPOSE: We compared the incidence and severity of depression at 3 and 12 months after stroke in patients and their chief caregivers (spouses, 63%; children, 37%) in four districts of Finland, two with and two without after-hospital-discharge interventional programs (outpatient rehabilitation and activities of the local divisions of the Finnish Heart Association [FHA]). A population-based stroke register was used, and factors influencing depression were analyzed. METHODS: A stroke register of patients recruited over 2 years in four different districts (total population, 134804) in Finland; 594 first-ever strokes were registered. Beck's Depression Inventory (BDI), with 10 as the cutoff point for depression, was applied to 321 of 423 survivors and 195 caregivers at 3 months and to 311 of 390 survivors and 184 caregivers at 12 months in the districts with and without interventional programs. RESULTS: At 3 months, fewer patients in the districts with active programs (41%) were depressed than in the control districts (54%) (odds ratio, 0.59; 95% confidence interval, 0.37 to 0.94), and the difference was maintained at 12 months (42% versus 55%) (odds ratio, 0.55; 95% confidence interval, 0.34 to 0.88). Univariate risk factors for depression at 3 months were female sex and severe prognostic score at the onset of stroke (< or = 14 points) on the Scandinavian Stroke Scale (SSS). Only SSS prognostic score and age emerged as significant independent contributors to depression on both linear and logistic multivariate analyses. There was no significant difference in the depression rate of caregivers between districts with active programs (42%) and those without such programs (41%) at 3 months; at 12 months the results were the same (39% in districts with active programs versus 42% in those without such programs). However, at 12 months there were significantly more severely depressed caregivers in districts without active programs than in districts with such programs (P.036). Poor Rankin scale score (grades III through V) and severe SSS long-term score (< or = 42 points) at 3 months among the patients were associated with depression of the caregivers at 3 months in the univariate analysis. Poor Rankin Scale score of the patients was independently associated with the depression of their caregivers at 3 months on multivariate logistic regression analysis. CONCLUSIONS: Depression was common among stroke survivors and among their caregivers at 3 months, and its rate did not decrease at 1-year follow-up. The lower depression rate in districts with active programs compared to those without supports the idea that outpatient rehabilitation and support provided by local divisions of the FHA may be an effective way of decreasing the rate of depression after stroke.

Declining incidence and mortality rates of stroke in Finland from 1972 to 1991. Results of three population-based stroke registers.

BACKGROUND AND PURPOSE: We aimed to determine trends in stroke incidence, mortality rates, case-fatality rates, and their relation in Finland. METHODS: We compared the results of three population-based stroke registers that included first-ever strokes in people aged > or = 15 years. Two registers were kept in Espoo-Kauniainen, the first in 1972 to 1973 (EK 72-73) and the second in 1978 to 1980 (EK 78-80). The present register of the Finnish Heart Association (FHA 89-91) was kept in four districts in Finland in 1989 to 1991. RESULTS: The age-adjusted incidence rates were 240.9, 174.4, and 191.6, and the 1-year mortality rates were 121.9, 77.0, and 65.3 in the EK 72-73, EK 78-80, and FHA 89-91 registers, respectively. The overall decline from 1972 to 1991 was 20% in the stroke incidence rate and 46% in the stroke mortality rate. One-month case-fatality rates decreased from 34.8% to 29.4% in the EK 72-73 and EK 78-80 registers and to 23.3% in the present register. CONCLUSIONS: The decline in the stroke incidence rate during the 1970s stabilized during the late 1980s and early 1990s; however, the case-fatality rate is still decreasing. Their combined effects may explain the continuing decline in stroke mortality.

Thyroid status of patients receiving long-term anticonvulsant therapy assessed by peripheral parameters: a placebo-controlled thyroxine therapy trial.

Thyroid hormone concentrations and measures reflecting thyroid function were studied in sera from 35 patients receiving long-term phenytoin (PHT) or carbamazepine (CBZ) therapy. The mean concentrations of T4, FT4, FT3, and rT3, but not T3, of these patients were significantly lower than those of 19 controls of similar age and sex distribution. The mean serum thyrotropin (TSH) concentration was slightly but significantly higher in patients than in controls, but the serum TSH response to TRH was not significantly increased. In patients, the higher mean clinical diagnostic index of hypothyroidism (CDI-HT: -20.3 +/- 19.1 vs. -33.7 +/- 8.5, p < 0.05) and higher ratio of preejection period to left ventricular ejection time (PEP/LVET: 0.343 +/- 0.065 vs. 0.334 +/- 0.030, p < 0.05) than in controls were compatible with tissue hypothyroidism. However, comparison of the mean levels of alanine aminotransferase (ALAT), creatine kinase (CK), creatinine, triglycerides, cholesterol, high-density lipoprotein (HDL) cholesterol, osteocalcin, procollagen type III aminoterminal propeptide, and somatomedin-C showed no significant differences between patients and controls. The increased mean angiotensin convertase and sex hormone-binding globulin (SHBG) levels, typical of hyperthyroidism, were probably caused by drug effects. Fourteen patients with a subnormal FT4 concentration in serum participated in a double-blind thyroxine treatment cross-over study. Neither the mean CDI-HT score, nor the systolic time intervals were significantly different between the thyroxine and placebo periods. Five patients benefited subjectively from the treatment. On the basis of all data from the cross-sectional and thyroxine treatment studies, we conclude that patients receiving anticonvulsant drugs chronically are eumetabolic and do not need thyroxine supplementation.

Seizures associated with propofol anesthesia.

Propofol is a new, fast-acting intravenous (i.v.) anesthetic. Involuntary movements or epileptic seizures have occurred during or after propofol-induced anesthesia in approximately 50 reported cases; a third of the patients have had epilepsy. We report 5 patients with seizures in association with propofol anesthesia. A female epileptic patient developed severe status epilepticus; the other patients with short-lasting seizures had no previous epilepsy. Although propofol has been used in treatment of patients of status epilepticus, the risk of precipitation of epileptic seizures warrants consideration especially when planning anesthesia for epileptic patients.

Epilepsy after stroke.

A retrospective follow-up of 200 consecutive stroke patients [ischemic brain infarction (IBI) 157, intracerebral hemorrhage (ICH) 20, subarachnoid hemorrhage (SAH) 23] who were in need of ambulatory rehabilitation was conducted for a mean period of 40 months after stroke. Epilepsy developed in 33 (17%) patients. The occurrence of epilepsy was 14% in IBI, 15% in ICH, and 35% in SAH. Significantly more patients developed epilepsy in the SAH group than in the IBI group (8 of 23 vs. 22 of 157, p less than 0.05). Of the 33 patients, 15% had their first seizures within the first 2 weeks after stroke, and 55% developed epilepsy in 6 months. Forty-eight percent of the patients had generalized seizures. Antiepileptic drug (AED) treatment was started in 28 of 33 patients, of whom 17 still had seizures during follow-up. Epilepsy was an important consequence of stroke among patients who needed rehabilitation, especially in SAH patients. In most, this was due to arterial spasm leading to IBI.

A controlled study with taltrimide and sodium valproate: valproate effective in partial epilepsy.

Taltrimide was compared with valproate and placebo in 17 patients with intractable epilepsy being on carbamazepine monotherapy. Taltrimide (400 mg/day), valproate (1000 mg/day) or placebo were added to the treatment for periods of 3 months using a randomized cross-over design. Serum carbamazepine concentrations remained within the therapeutic range throughout the trial. Thirteen patients completed the study. In partial epilepsy of 7 the seizure frequency was reduced by 27% during valproate (p less than 0.05), compared with placebo, while no improvement was found during taltrimide. In 6 with primary generalized epilepsy, the number of seizures was reduced by 49% during taltrimide and by 38% during valproate, but neither effect was significant, compared with placebo. Headache was reported by 3 patients while on taltrimide. One with hypersensitivity history developed petecchiae and nasal bleeding during taltrimide and, therefore, the treatment was stopped. The three other interruptions were independent of taltrimide. Thus, the only statistically significant effect in this study was that of valproate in partial epilepsy.

A double-blind study comparing oxcarbazepine and carbamazepine in patients with newly diagnosed, previously untreated epilepsy.

Two hundred and thirty-five patients suffering from newly diagnosed epilepsy were randomly allocated to treatment with either oxcarbazepine or carbamazepine in a double-blind multi-centre study. After a titration phase (between 4 and 8 weeks), the optimal individual dose of trial medication was determined and treatment with that dose was continued for another 48 weeks. The criteria for assessment were: efficacy--seizure frequency, EEG tracings, global evaluation; tolerability--side effects observed by the patient or the investigator, laboratory tests; other assessments--blood pressure and heart rate, carbamazepine and 10,11-dihydro-10-hydroxycarbamazepine trough serum levels. The results of the study showed the following: no significant difference in seizure frequency between oxcarbazepine and carbamazepine; no correlation between the therapeutic effect and the EEG findings in either treatment group; oxcarbazepine caused significantly fewer (P = 0.04) 'severe' side effects than carbamazepine; global evaluation of tolerability demonstrated a trend towards the better tolerability of oxcarbazepine; no correlation was observed between either efficacy or tolerability and the actual serum trough levels of antiepileptic drugs; clinically relevant abnormal laboratory test findings were observed in 2 patients, both on carbamazepine. The authors consider oxcarbazepine to be a valuable alternative to carbamazepine, particularly in patients who develop side effects which prevent optimal seizure control.

Quality of life 4 years after stroke.

The quality of life for 46 stroke survivors under the age of 65 years in a stroke register was studied 4 years after their first stroke. A questionnaire covering four domains of life (working conditions, activities at home, family relationships, and leisure time activities) was used for investigation of the quality of life. The results showed that in spite of a good recovery in terms of discharge from the hospital, activities of daily living, and return to work, the quality of life of most patients (83%) had not been restored to the prestroke level. Deterioration among the several domains of life ranged from 39% to 80%, the lowest being in the domain of activities at home and the highest in the domain of leisure time activities. Hemispheral localization of the lesion, paresis, coordination disturbances, and especially subjective tendency to depression were highly correlated with a deterioration in the quality of life. Dependence in activities of daily living and an inability to return to work were also associated with the lack of restoration. Our results suggest that much more attention should be paid to the quality of life of stroke patients.

Dementia after stroke.

The aim of this 4-year follow-up study was to find out how often dementia appears after stroke in unselected material. All patients younger than 65 years (52) still alive 4 years after stroke in a stroke register (total 255 patients) were studied neurologically and neuropsychologically. Three patients with brain infarction filled the criteria for mild dementia. This is more than was to be expected. All 3 demented patients could be classified as multi-infarct dementia. The findings concerning dementia are discussed.

The profile of recovery from stroke and factors influencing outcome.

The recovery from stroke of 154 survivors out of 255 stroke patients was analyzed. The outcomes documented were: discharge from hospital, activities of daily living (ADL) and return to work. A clear improvement in neurological and neuropsychological deficits was seen from the acute stage to three months, and this continued to twelve months, but to a lesser degree. 69% and 78% respectively, of the patients were at home three and twelve months after stroke. Independence in ADL increased from 32% acutely to 62% and 68% by three and twelve months, respectively. Of those gainfully employed prior to stroke, 55% had returned to work after twelve months. As a group, SAH patients seemed to recover better, but, for those that could be age-matched with infarction patients, there was no difference in outcome. Old age, acute stage hemiparesis, impairment of intelligence and memory, visuoperceptual deficits, nonadequate emotional reactions, and living alone all had a major negative influence on outcome. This study suggests that neurological and neuropsychological deficits, as well as emotional reactions, influence the outcomes after stroke, and all should be taken into consideration in prognosis.

An association between epileptic seizures and increased serum bacterial antibody levels.

Increased serum levels of a variety of bacterial antibodies were more common in unselected patients with recent epileptic seizures than in healthy control subjects (17/29 versus 2/31; p less than 0.001). In most of these cases no infections were recognized clinically or bacteriologically. Although infections have been considered as one of the possible provocations for the manifestation of epileptic seizures, the demonstrated strong association may give a new approach to the pathogenetic mechanisms of epileptic seizures or may mean a nonspecific immune response. The explanation for the higher antibody titers in epileptic patients and their etiologic significance are uncertain, but these results also suggest that epileptic seizures may very often be triggered by bacterial infections even when no clinically apparent bacterial infection has been recognized.

Diagnosis of epilepsy.

Essential in the diagnosis of epilepsy are repeated seizures due to discharge of electrical activity in the brain neurons, occurring without massive provocation. It is important to differentiate between epileptic seizures from syncopal reactions, cardiac dysrhythmias, vascular causes, metabolic disturbances, and psychogenic seizures. The type of seizure should always be established. It is of utmost importance to find the primary etiology of the seizure and to clarify the role of predisposing factors and the risk for seizure recurrence. Numerous important technical advances in the last few years have been of great benefit in the examination of patients with suspected epilepsy. It is worth keeping in mind, however, that the diagnosis of epilepsy is a clinical diagnosis, and it is not proper to speak of epilepsy until the patient has had two or more epileptic seizures within a relatively short interval and without massive provocation.

Outcome of stroke in the Espoo--Kauniainen area, Finland.

A prospective study of all stroke cases in the Espoo--Kauniainen area (population 113 000) in South-Finland was carried out during 1972 and 1973 by the WHO stroke register method. 286 stroke patients were registered; 61% of them had a brain infarction, 16% an intracerebral haemorrhage and 15% a subarachnoid haemorrhage. The total incidence was 200/100 000/year after age adjustment of the results to the population of Finland. The incidence of subarachnoid haemorrhage, 23.9/100 000/year was especially high. The mortality within three months was 40%, and that after median follow-up periods of four and six years was 62% and 67% respectively. In the intracerebral haemorrhage group the 3-month mortality was very high (72%), but it did not change during the follow-up period. In the subarachnoid haemorrhage group the 3-month mortality was 43%, which increased slightly, but in the brain infarction group the 3-month mortality of 30% increased steadily up to 66% during the follow-up period. The causes of death after the acute stage were cardiovascular as often as cerebrovascular. After four and six years, 71% of the survivors were fully independent in activities of daily living. After four years 21% had even returned to work. 16% of the survivors were still working after six years.

Aortic dissection and paraparesis.

3 cases of dissecting aneurysm of the aorta and paraparesis are presented. 1 patient had an ascending dissection of acute onset with paraplegia but without pain. He was treated conservatively but the patient died. At autopsy a large coronary infarction was also found in the area of the right coronary artery, which was compressed at the starting point of the dissection. The second patient had momentary intensive chest pain and reversible paraparesis, and a descending dissection was seen in aortic angiography. He received hypotensive treatment and was symptomless when last seen 9 months after onset. The third patient had momentary intensive chest and back pain without any other symptoms. A descending dissection was found in aortic angiography and an operation was performed. During the operation the aorta was occluded for 57 min, which was too long for the medullary circulation and permanent paraplegia was the result. Modern diagnostic and therapeutic possibilities are discussed.

Chronic bilateral subdural haematoma in adults.

Twenty-nine patients with chronic bilateral subdural haematomas were surgically treated during 1966 to 1977. Twenty-four of them (83%) had a history of head injury, which caused unconsciousness in eight cases. The mean interval from trauma to operation was eleven weeks. The mean age of the patients was 60 years. The prevalence of the most commonly encountered symptoms and signs was: headache 72%, mental symptoms 48%, papilloedema 41%, vertigo 31%, nausea 28%, reduced consciousness 28%, walking difficulties 24%, hemiparesis 24%, and paraparesis 14%. The aggregate thickness of haematomas was 34 mm, 36 mm, and 40 mm in age groups of 20--39, 40--59, and over 60 years, respectively. All patients were operated on, four of them only unilaterally. Three patients in the whole series died. Two of them had been operated upon only on one side in the first session, the haematoma of the other side being evacuated 8 1/2 hours and four days later, respectively. Unilateral operation is likely to cause severe distortion of the midline structures and the brain stem and thus aggravates the cerebral situation. Therefore the necessity of simultaneous evacuation of the haematomas on both sides is stressed. The reason for the death of the third patient was delay in diagnosis. All three patients who died belonged to the group of eight patients with a reduced level of consciousness before surgery. Twenty-three of the survivors were fully independent in their daily lives, and three needed some help after operative treatment.