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PubMed2006

The epidemiology of post-stroke epilepsy according to stroke subtypes.

OBJECTIVES: Strokes represent the most common etiology of epilepsy in patients over the age of 60 years, with an incidence of 2-4% occurring in different studies. MATERIALS AND METHODS: In this observational study, 1,428 patients were included who had stroke and were admitted to our Stroke Unit between the years 1996 and 2005. RESULTS: Overall, 51 patients had post-stroke epilepsy (3.6%). Post-ischemic epilepsy occurred in 70.6% of the patients, post-hemorrhagic epilepsy occurred in 21.6% of the patients and epilepsy following venous infarctions occurred in 7.8% of all post-stroke epilepsy patients. Of 1,327 patients having ischemic stroke, 36 patients (2.7%), 11 out of 86 patients with hemorrhagic stroke (12.8%) and 4 of 15 patients with venous infarctions (26.6%) developed epilepsy. Compared with stroke patients without epilepsy, hemorrhagic (P<0.001) and venous infarctions were more common in patients with post-stroke epilepsy (P<0.001). The right hemisphere and the middle cerebral artery (MCA) territory were most commonly observed in ischemic and hemorrhagic stroke patients. CONCLUSIONS: Our results indicate that post-stroke epilepsy is more common among patients who have experienced venous infarctions. Hemorrhagic and venous infarctions are more commonly encountered in post-stroke epilepsy patients. Atherosclerotic and cardioembolic strokes were similar to those that occurred in post-stroke epilepsy patients. Localizations in post-stroke epileptic patients showed that the majority occurred in the right hemisphere, in the territory of the MCA. However, prospective, multicentered studies are needed for a better understanding of the epidemiology and social impact of post-stroke epilepsy.

Adult↗

PubMed2001

Suicidal ideas in stroke patients 3 and 15 months after stroke.

Patients with stroke may have an increased risk of suicide. We sought to examine the frequency and clinical correlates of suicidal ideas 3 and 15 months after stroke. The study group comprised 286 of 486 consecutive patients aged 55-85 years who at 3 and 15 months after ischemic stroke completed a detailed medical, neurological and radiological stroke evaluation, structured measures of cognition (Mini Mental State Examination), emotion (Beck Depression Inventory, BDI), disability (Rankin scale), and assessment of dependent living. Suicidal ideas were present in 9.8% (n = 28) at 3 months' follow-up and in 14.0% (n = 40) at 15 months' follow-up. The patients with suicidal ideas were more depressed measured by BDI both at 3 (17.0 vs. 7.9, p < 0.001) and 15 months (20.5 vs. 8.5, p < 0.001) after stroke compared to the patients without suicidal ideas. Patients with suicidal ideas had more often a history of a stroke already before the index stroke (35 vs. 18.3%, p = 0.0154), right-sided stroke (60.0 vs. 41.9%, p = 0.0323), they were more disabled according to the Rankin scale (2.4 vs. 1.9; p = 0.0035) and more dependent in living (45.0 vs. 27.2%, p = 0.023) 15 months after stroke. An independent correlate of suicidal ideas 15 months after stroke was history of prior stroke (OR 2.4; 95% CI 1.14-4.97) in logistic regression analysis. The frequency of suicidal ideas increased with the time elapsed from stroke. Recurrent strokes, depressive symptoms, more disabling stroke and right-sided stroke correlated to suicidal ideas at 15 months after stroke. Early identification of these risk factors may lead to effective therapeutic intervention.

Aged↗

PubMed2004

Frequency and risk factors of vascular cognitive impairment three months after ischemic stroke in china: the Chongqing stroke study.

BACKGROUND: Frequency of poststroke cognitive impairment is high in western countries, and the risk factors of poststroke cognitive impairment have not been fully understood yet. We sought to examine the frequency and risk factors of cognitive impairment after ischemic stroke in a large stroke cohort of China. METHODS: A total of 434 consecutive patients with ischemic stroke were enrolled. The cognitive status before and 3 months after stroke was evaluated using the Informant Questionnaire on Cognitive Decline in the Elderly and the Mini-Mental State Examination, respectively. Poststroke cognitive impairment was defined as cognitive impairment with concomitant stroke, stroke-related cognitive impairment was defined as cognitive impairment developing after index stroke, and cognitive impairment after first-ever stroke was defined as cognitive impairment developing after first-ever stroke. Logistic regression analysis was used to find the risk factors of cognitive impairment after stroke. RESULTS: (1) Frequency of poststroke cognitive impairment was 37.1%, that of stroke-related cognitive impairment was 32.2%, and that of cognitive impairment after first-ever stroke was 29.6%. (2) The patients with cognitive impairment more often had older age, low educational level, atrial fibrillation, prior stroke, everyday drinking, left carotid territory infarction, multiple lesions, embolism, and dysphasia. (3) The factors associated with poststroke cognitive impairment in logistic regression analysis were age (OR 1.215, 95% CI 1.163-1.268), low educational level (OR 2.023, 95% CI 1.171-3.494), prior stroke (OR 5.130, 95% CI 2.875-9.157), everyday drinking (OR 2.013, 95% CI 1.123-3.607), dysphasia (OR 3.994, 95% CI 1.749-9.120), and left carotid territory infarction (OR 2.685, 95% CI 1.595-4.521). CONCLUSIONS: Cognitive impairment is common 3 months after ischemic stroke in Chinese people. Risk factors for poststroke cognitive impairment include age, low educational level, everyday drinking, prior stroke, dysphasia, and left carotid territory infarction.

Aged↗

PubMed2006

Subtypes and one-year survival of first-ever stroke in Chinese patients: The Nanjing Stroke Registry.

BACKGROUND: Morbidity and mortality of stroke have been investigated extensively in Western populations, while data concerning case fatality and cause of death after stroke are very limited in mainland China. This study aimed to analyze the 1-year survival and predictors of case fatality in Chinese patients with first-ever stroke. METHODS: Subjects are patients registered in the Nanjing Stroke Registry Program. Information concerning cardiovascular risk factors and stroke characteristics were collected, and patients were followed after registration. Ischemic strokes were classified according to TOAST criteria as large-artery atherosclerosis (LAA), cardiac embolism stroke (CES), small-vessel stroke (SVS), or other determined and undetermined causes (UND). One-year case fatality was analyzed by the Kaplan-Meier method, and predictors of case fatality were evaluated by the Cox proportional hazards model. RESULTS: A total of 752 patients with first-ever stroke were included, of which 142 (18.9%) were identified as intracerebral hemorrhage (ICH), 120 (16.0%) as LAA, 123 (16.4%) as SVS, 160 (21.3%) as CES and 216 (28.7%) as UND. The overall survival rate was 86.4% at the end of the 1-year follow-up. Patients with SVS have the highest survival rate (92.7%), followed by UND (89.4%), CES (88.1%) and LAA (84.2%). Patients with ICH have the lowest survival rate (76.8%). Survival rates of patients with different subtypes of stroke presented a significant difference (chi2 = 19.3, p < 0.001). For patients deceased during the first year after the index stroke, 33.3% of deaths were caused by the first stroke, 18.6% by recurrent stroke, 16.7% by cardiovascular comorbidities, 14.7% by nonvascular conditions and 16.7% died of undetermined causes. Advanced age, hypertension, hyperlipidemia, diabetes mellitus (DM), atrial fibrillation (AF), history of transient ischemic attack and cigarette smoking were associated with an increased risk of death 1 year after stroke. CONCLUSIONS: The case fatality rate and predictors for mortality of Chinese patients with first-ever stroke are similar to those reported for other populations. The significant influence of cardiovascular disease on the first-year survival rate emphasizes the importance of acute stroke management and control of hypertension, DM, AF and other predictors for decreasing case fatality and improving prognosis.

Adult↗

PubMed2003

Stroke in South America: a systematic review of incidence, prevalence, and stroke subtypes.

BACKGROUND AND PURPOSE: Stroke is a leading cause of mortality and disability in South America because of an increase in life expectancy and changes in the lifestyle of the population. Because epidemiological and clinical characteristics of stroke vary according to regional factors, we need to know the peculiarities of stroke on this continent. METHODS: We performed a systematic review of articles on stroke in South America, with emphasis on those providing information on the incidence and prevalence of stroke (community-based studies) and the pattern of stroke subtypes (hospital-based studies). RESULTS: Seven papers provided information on stroke epidemiology; 11 gave data on the pattern of stroke subtypes. Community-based studies showed crude stroke prevalence rates ranging from 1.74 to 6.51 per 1000 and annual incidence rates from 0.35 to 1.83 per 1000. Hospital-based stroke registries consistently reported a high frequency of intracranial hemorrhages, which accounted for 26% to 46% of all strokes. Among patients with cerebral infarctions, intracranial atherosclerotic lesions and small-vessel disease have been common pathogenic mechanisms underlying the stroke. In most studies, hypertensive arteriolopathy was the most common cause of both infarctions and hemorrhages. CONCLUSIONS: Stroke has been poorly studied in South America. Available data suggest that the prevalence and incidence of stroke are lower than in developing countries. The pattern of stroke subtypes seems to be different from that reported in other regions of the world, with a higher frequency of cerebral hemorrhages, small-vessel disease, and intracranial atherosclerotic lesions. Such differences may be related to genetic, environmental, or sociocultural factors and to differences in the control of stroke risk factors.

Adolescent↗

PubMed2000

Comparison of risk factors for stroke incidence and stroke mortality in 20 years of follow-up in men and women in the Renfrew/Paisley Study in Scotland.

BACKGROUND AND PURPOSE: The aim of this study was to relate risk factors in middle-aged men and women to stroke incidence (defined by having a hospital discharge with a main diagnosis of stroke) and compare this with the associations between risk factors and stroke mortality. METHODS: In the early to mid-1970s, when they were 45 to 64 years of age, 7052 men and 8354 women from the Renfrew/Paisley prospective cohort study in Scotland were screened. Risk factors measured included blood pressure, blood cholesterol and glucose, respiratory function, cardiothoracic ratio, smoking habit, height, body mass index, preexisting coronary heart disease, and diabetes. These were related to stroke incidence over 20 years of follow-up. RESULTS: Diastolic and systolic blood pressure, smoking, cardiothoracic ratio, preexisting coronary heart disease, and diabetes were positively related to stroke incidence for men and women, whereas adjusted FEV(1) (forced expiratory volume in 1 second) and height were negatively related. Cholesterol was not related to stroke. Glucose for nondiabetic subjects had a U-shaped relationship with stroke. Body mass index was not clearly related to stroke, although participants with the highest body mass index had the highest stroke rate. Former smokers had similar stroke rates to never-smokers. Tests between the associations of risk factors and stroke incidence revealed these were not statistically different from the associations with stroke mortality. CONCLUSIONS: The risk factors had a similar effect on stroke incidence as on stroke mortality. Epidemiological studies with information on stroke mortality are likely to give results applicable to stroke incidence.

Blood Glucose↗

PubMed2006

The contribution of a comprehensive stroke unit to the outcome of Chinese stroke patients.

INTRODUCTION: There are significant differences in stroke patterns and risk factors for cerebrovascular disease between Chinese subjects and Caucasians. The outcome of stroke unit care in a Chinese population has not been described in the medical literature. The present study aims to evaluate the outcome of stroke unit care in Chinese subjects. METHODS: By prospective comparative research, Chinese patients treated in the stroke unit were group-matched with those treated in the general medical ward by age, gender, premorbid functional status (by the Barthel Index), National Institute of Health Stroke Scale score, and stroke types. From April 2001 to April 2002, a total of 188 patients in the stroke unit group and 177 patients in the general ward group were recruited in the study. The main outcome measures included mortality at 28 and 120 days, and the length of inpatient stay. RESULTS: Stroke unit care significantly reduced mortality of patients with acute stroke after 28 and 120 days. After 28 days, mortality was 3.3 percent and 17.2 percent for the stroke unit group and general ward group, respectively (p-value is equal to or less than 0.01); whereas after 120 days, mortality was 5.0 percent and 24.7 percent for the stroke unit group and general ward group, respectively (p-value is equal to or less than 0.001). The stroke unit care was demonstrated, by logistic regression analysis, to have contributed to the reduction of mortality at 120 days (p-value is 0.014). At 28 days, there was only a trend for stroke unit care to contribute to the reduction of mortality by logistic regression analysis (p-value is 0.067). By Kaplan-Meier survival curves (log rank statistic is 10.46, p-value is 0.001) and a Cox regression (hazard ratio 0.253, 95 percent confidence interval 0.085 to 0.754, p-value is 0.014), the stroke unit care was further found to reduce mortality significantly. The mean length of inpatient stay of the stroke unit group was 37.1 days, while that of the general medical ward group was 69.3 days (p-value is equal to or less than 0.001). CONCLUSION: Chinese subjects receiving comprehensive stroke unit care are associated with less mortality and shorter length of hospital stay than those having conventional care in general medical wards.

Acute Disease↗

PubMed1994

Declining trends in incidence, case-fatality and mortality of stroke in three geographic areas of Finland during 1983-1989. Results from the FINMONICA stroke register.

Stroke mortality has decreased during the last decade in many industrialized countries, but there has been no clear evidence for a decline in the incidence of stroke. The present study analyzes the trends in the incidence, mortality and case-fatality of stroke in Finland from 1983 to 1989. We used data from the FINMONICA stroke register, a community based register collecting information on all suspected stroke cases aged 25-74 in three geographical areas of Finland. Annual attack rate, incidence, mortality and case-fatality rates were calculated for all strokes and for different subcategories of stroke. A linear regression model was applied to calculate the yearly trends of these rates. In men, the attack rate of stroke was 336/100,000 in 1983 and 310/100,000 in 1989 (-8% during the observation period); incidence declined from 269/100,000 in 1983 to 236/100,000 in 1989 (-12%); mortality declined from 82/100,000 to 64/100,000 (-22%), and case-fatality declined from 25% to 21% (-18%). Also among women similar declining trends were observed (-11%, -13%, -16%, and -10% respectively), but they were not statistically significant. In both incidence and mortality of stroke, the decline was seen in all age groups. Incidence and mortality of cerebral infarction declined similarly to all strokes. A large fall in the incidence (-24% in both men and women) and mortality (-38% in men and -27% in women) of subarachnoid haemorrhage was also observed. An increasing trend, although not significant, was instead observed for cerebral haemorrhage. First stroke and especially first cerebral infarction contributed most to the decline in case-fatality. The availability of computerized brain tomography improved from 18% in 1983 to 60% in 1989. We observed a fall in the incidence, mortality, and case-fatality of stroke during 1983-1989. Among the subtypes of stroke, cerebral infarction contributed most to the decline, but the data suggested also a declining trend in the incidence and mortality of subarachnoid haemorrhage, observed now for the first time in Finland since the 1960s. The fall in the incidence of stroke was not as steep during the 1980s as it was during the 1970s; Finland is anyhow the only European country which has reported a decreasing trend in stroke incidence during the 1980s. We need now to investigate how much the decline in the classical risk factors for stroke observed in Finland during the last two decades predicts the observed trends.

Adult↗

PubMed1994

Prognosis of young adults with ischemic stroke. A long-term follow-up study assessing recurrent vascular events and functional outcome in the Iowa Registry of Stroke in Young Adults.

BACKGROUND AND PURPOSE: Information about the long-term prognosis of young adults with ischemic stroke is limited. Therefore, we performed a follow-up assessment of 296 patients with ischemic stroke who are enrolled in the Iowa Registry of Stroke in Young Adults. We studied young adults (age, 15 to 45 years) who were referred to a tertiary medical center for management of ischemic stroke between July 1, 1977, and January 1, 1992. METHODS: Follow-up assessments were performed by means of questionnaires, examinations, telephone interviews, review of medical records, and reports from personal physicians. Data about risk factors, coincident medical diseases, etiology of stroke, treatment, recurrent stroke, other vascular events, and deaths were collected. Outcomes were rated with the Glasgow Outcome Scale, Barthel Index, National Institutes of Health stroke scale, and the Mini-Mental State Examination. Quality of life was assessed with the SF-36 Health Status questionnaire. RESULTS: Follow-up information about the status of 10 patients was limited except that they were alive. Twenty-one patients (7%) died as the result of their initial stroke, and another 40 patients (14%) died during a mean follow-up of 6.0 years. None of the patients aged 25 years or younger at the time of stroke died during follow-up. Mortality was significantly higher among patients who had a stroke secondary to large-vessel stroke and it was significantly lower in patients with stroke of unknown etiology than in patients with stroke of other causes (relative risk [RR], 1.7; 95% confidence limits [CL], 1.0 to 2.7; and RR, 0.1; CL, 0 to 0.6; respectively). Recurrent strokes occurred in 23 patients (9%) and were fatal in 9. Another 37 patients were treated by a cardiologist during follow-up; 3 had had a myocardial infarct. Fourteen additional patients needed major vascular surgery. Outcomes with the Glasgow Outcome Scale and Barthel Index were generally favorable. Still, only 49% of patients were still alive, were not disabled, had not suffered from recurrent vascular events, or had not undergone major vascular surgery. Only 42% of survivors had returned to work. A majority of survivors reported emotional, social, or physical residuals that lessened the quality of life. CONCLUSIONS: The risks of recurrent vascular events in young adults who have had ischemic stroke are considerable. In addition, a majority of survivors will have residual emotional, social, or physical impairments that hamper employment or lower the quality of life. Further research on the quality of life for young adults who survive stroke is needed.

Adolescent↗

PubMed1995

Improved survival of stroke patients during the 1980s. The Minnesota Stroke Survey.

BACKGROUND AND PURPOSE: The underlying reasons for the decline in stroke mortality in the United States are not well understood and have been the subject of ongoing debate. This study was undertaken to determine whether survival of hospitalized stroke patients has changed during the 1980s, thereby contributing to the decline in stroke mortality during that period. METHODS: For the years 1980, 1985, and 1990, we obtained listings of discharge diagnoses from hospitals in the Minneapolis-St Paul metropolitan area and identified all hospitalizations with a discharge diagnosis code of acute cerebrovascular disease according to the International Classification of Diseases, 9th Revision. A 50% random sample of men and women aged 30 to 74 years was selected in each survey for detailed medical record abstraction. Standardized sets of criteria for stroke were then used to validate acute stroke events throughout the 1980s. Each of the three period cohorts of hospitalized stroke patients (1980, 1985, and 1990) was followed for at least 2 years for all-cause mortality end point. RESULTS: A total of 1853 patients met minimal criteria for acute stroke: 564 patients in 1980, 598 patients in 1985, and 691 patients in 1990. Controlling for age, the odds of death within 2 years after stroke were approximately 40% lower in 1990 than in 1980. The relative odds of 2-year death in 1990 (versus 1980) were 0.65 (95% confidence interval, 0.47 to 0.89) and 0.60 (95% confidence interval, 0.42 to 0.85) for men and women, respectively. The improved survival was evident in the short term (28 days) as well as for stroke patients who survived that period. Analysis according to stroke subtype revealed that improved survival of ischemic stroke and specifically of stroke with no apparent cardioembolic source largely accounted for the overall trend. The prognosis of stroke patients who were admitted in a comatose state has not changed during that decade. CONCLUSIONS: Despite the absence of any clear major advances in acute stroke therapy, survival of stroke patients substantially improved during the 1980s. The underlying reasons for this unexpected yet remarkable trend remain uncertain but may include improved supportive and rehabilitative care of stroke victims as well as a change in the natural history of the disease.

Adult↗

PubMed1997

Comparison of stroke features and disability in daily life in patients with ischemic stroke aged 55 to 70 and 71 to 85 years.

BACKGROUND AND PURPOSE: This study compared stroke features and poststroke disability in two age groups of patients with ischemic stroke: younger (55 to 70 years) and older (71 to 85 years). Stroke has an impact on daily living in many areas, but whether risk factors, stroke features, and poststroke disability differ between young and old patients with stroke is not so well established. METHODS: A cohort of 486 ischemic stroke patients aged 55 to 85 years admitted consecutively to the Helsinki University Central Hospital (Finland) between December 1, 1993, and March 31, 1995, were examined 3 months after the index stroke. Structured medical, neurological, and radiological (MRI or CT) examinations, mental status, and emotional examination and interview of a close informant were done. Prestroke and poststroke activities of daily living were assessed with five scales: the Index of ADL, Instrumental Activities of Daily Living Scale, Functional Activities Questionnaire, Blessed Functional Activities Scale, and Barthel Index. RESULTS: History of cardiac failure (P < .001), atrial fibrillation (P < .001), and cardioembolic stroke (P = .011) was more frequent in the older age group, whereas stroke due to large-artery atherosclerosis (P = .048) was more common in the younger age group. The older patients more often had major dominant stroke syndrome (P = .018). Comparison of activities of daily living before and after stroke showed that the older age group deteriorated significantly more than the younger age group after adjustment for sex, education, and living conditions (Barthel Index, P = .005; other scales, P < .0001). CONCLUSIONS: The stroke patients in young and old age groups had different risk profiles and stroke features. The older stroke patients were more dependent and disabled beforehand, and after stroke they were relatively even more dependent than the patients in the younger age group. Because older patients already constitute the majority of stroke victims, the importance of early active diagnosis, treatment, rehabilitation, and guidance is stressed.

Activities of Daily Living↗

PubMedDate not supplied

[Changes of protein S100B serum concentration during ischemic and hemorrhagic stroke in relation to the volume of stroke lesion].

BACKGROUND AND PURPOSE: Biochemical markers offer a new strategy in the diagnosis, estimation of clinical prognosis and monitoring of treatment in patients with brain damage. At present, two specific brain originated proteins play a major role: S100B protein and neuron-specific enolase (NSE). S100B comes from astrocytes and NSE has been found in neuronal cytoplasm. The aim of this study was to evaluate dynamics of protein S100B level changes in blood in stroke patients. MATERIAL AND METHODS: The material consisted of 67 patients, 53 with ischemic stroke (mean age 67.7) and 14 with hemorrhagic stroke (mean age 66.7). The diagnosis of stroke was made on the basis of clinical symptoms and computed tomography (CT). Plasma concentration of S100B was measured using the immunoluminometric test (Lia-Mat Sangtec 100(R)) on the 1st, 3rd, 7th and 14th day after stroke onset. RESULTS: The highest levels of protein S100B were found in ischemic stroke predominantly on the 3rd day and in hemorrhagic stroke on the 1st day. The concentrations of protein S100B were similar in ischemic and hemorrhagic stroke on the 3rd, 7th and 14th day but they were significantly higher on the 1st day in hemorrhagic stroke. Serum levels of protein S100B after stroke onset have shown a correlation with infarct volume, especially in patients with large or medium stroke. In small stroke lesions, concentrations of protein S100B were under the cut-off level. In hemorrhagic stroke protein S100B levels were higher in patients with midline shift visible in brain CT, but the differences were not significant. CONCLUSIONS: Ischemic and hemorrhagic strokes lead to release of protein S100B into the blood. A good correlation between the release pattern of S100B and volume of vascular lesion has been found. S100B protein is the marker of brain damage during stroke. It is possible to use protein S100B measurements in monitoring the stroke treatment.

Aged↗

PubMedDate not supplied

Cholesterol, diastolic blood pressure, and stroke: 13,000 strokes in 450,000 people in 45 prospective cohorts. Prospective studies collaboration.

Individual studies of stroke have not clearly answered two questions: on the relation, if any, between total blood cholesterol and stroke; and on how the strength of the relation between diastolic blood pressure and stroke varies with age. The associations of blood cholesterol and diastolic blood pressure with subsequent stroke rates were investigated by review of 45 prospective observational cohorts involving 450,000 individuals with 5-30 years of follow-up (mean 16 years, total 7.3 million person-years of observation), during which 13,397 participants were recorded as having had a stroke. Most of these were fatal strokes in studies that recorded only mortality and not incidence, but about one-quarter were from studies that recorded both fatal and non-fatal strokes. After standardization for age, there was no association between blood cholesterol and stroke except, perhaps, in those under 45 years of age when screened. This lack of association was not influenced by adjustment for sex, diastolic blood pressure, history of coronary disease, or ethnicity (Asian or non-Asian). However, because the types of the strokes were not centrally available, the lack of any overall relation might conceal a positive association with ischaemic stroke together with a negative association with haemorrhagic stroke. When the highest and the lowest of the six blood pressure categories were compared, the difference in usual diastolic blood pressure was 27 mm Hg (102 vs 75 mm Hg), and there was a fivefold difference in stroke risk. This fivefold difference was seen both in those with a pre-existing history of coronary heart disease and in those without it. The proportional difference in stroke risk, however, was more extreme in middle than in old age. Among those aged < 45, 45-64, and 65+ when screened, the differences in the relative risks of stroke (between the highest diastolic blood pressure category and a combination of the lowest two categories) were tenfold, fivefold, and twofold, respectively. However, because the absolute stroke risks are greater in old age, the absolute differences in the annual stroke rates showed an opposite pattern, being 2, 5, and 8 per thousand, respectively. This suggests that the effects of therapeutic blood pressure reductions should be assessed separately in middle age and in old age.

Age Factors↗

PubMed1996

The effect of stroke and stroke prophylaxis with aspirin or warfarin on quality of life.

BACKGROUND: Because most strokes cause neurological impairment rather than death, stroke prophylaxis may improve quality of life more than length of life. Thus, an understanding of how stroke and stroke prophylaxis affect quality of life is central to clinical decision making for many patients. METHODS: We elicited quality-of-life estimates, known as utilities, for 3 degrees of severity of anticipated stroke-mild, moderate, and major- and for stroke prophylaxis with either warfarin sodium or aspirin therapy. We used the time tradeoff and standard gamble methods to elicit these utilities from 83 patients who had atrial fibrillation. RESULTS: Seventy patients completed the interview successfully. Their utilities for stroke ranged from worse than death (< 0) to as good as current health (1.0). The median utilities for mild, moderate, and major stroke were 0.94, 0.07, and 0.0, respectively. Although the median utilities decreased with increasing severity of stroke (P < .001), there was high interpatient variability within each degree of stroke severity. For example, 7 subjects (10%) rated a major stroke above 0.5, while 58 subjects (83%) rated it as equal to or worse than death. In contrast to the stroke utilities, the median utilities for warfarin and aspirin therapy were high-0.997 and 1.0, respectively. However, the interpatient variability for warfarin therapy was also important: 11 patients (16%) with atrial fibrillation rated the utility of warfarin therapy so low that their quality-adjusted life expectancy would be greater with aspirin. CONCLUSION: Patients' utilities for stroke prophylaxis and anticipated stroke vary substantially. Many patients view the quality of life with major stroke as tantamount to or worse than death. These findings highlight the relevance of incorporating patient preferences when choosing stroke prophylaxis.

Aged↗

PubMed2000

Anticoagulants for preventing recurrence following ischaemic stroke or transient ischaemic attack.

BACKGROUND: After a first stroke, further vascular events (especially myocardial infarction and recurrent stroke) are common and often fatal. OBJECTIVES: The objective of this review was to assess the effect of prolonged anticoagulant therapy following presumed non-embolic ischaemic stroke or transient ischaemic attack. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register. We contacted companies marketing anticoagulant agents. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing anticoagulant therapy, for at least one month, with control in people with previous non-embolic presumed ischaemic stroke or transient ischaemic attack. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS: Nine trials involving 1214 patients were included. The quality of all trials was poor. All pre-dated routine computerised tomography scanning and use of the International Normalised Ratio to monitor anticoagulation. Anticoagulant therapy did not significantly reduce the odds of death or dependency (two trials, odds ratio 0.83, 95% confidence interval 0.52 to 1.34). Death from any cause (odds ratio 0.95, 95% confidence interval 0.72 to 1.23), and death from vascular causes (odds ratio 0.86, 95% confidence interval 0.66 to 1.13) were not significantly different between treatment and control across all nine trials. Anticoagulant therapy did not reduce the risk of recurrent stroke (odds ratio 0.79, 95% confidence interval 0.56 to 1.13). However, fatal intracranial haemorrhage increased (odds ratio 2.54, 95% confidence interval 1.19 to 5.45), as did major extracranial haemorrhage (odds ratio 4.87, 95% confidence interval 2.50 to 9.49). This means anticoagulant therapy caused 11 additional fatal intracranial haemorrhages and 25 additional major extracranial haemorrhages per year for every 1000 patients given anticoagulant therapy. REVIEWER'S CONCLUSIONS: There appears to be no clear benefit from long-term anticoagulant therapy in people with non-embolic presumed ischaemic stroke or transient ischaemic attack. There appears to be a significant bleeding risk associated with anticoagulant therapy.

Anticoagulants↗

PubMed2005

American Heart Association and American Stroke Association national survey of stroke risk awareness among women.

BACKGROUND: Stroke is the third leading cause of death in the United States and a major cause of morbidity in women. Awareness of risk may be an important first step in stroke prevention. The purpose of this study was to assess knowledge and awareness about stroke in a nationally representative sample of women. METHODS AND RESULTS: An American Heart Association-sponsored telephone survey using random-digit dialing was conducted in June and July of 2003. Respondents were 1024 women > or =25 years of age, including an oversampling of racial/ethnic minorities (68% white, 12% black, 12% Hispanic). Participants were given a standardized questionnaire about heart disease and stroke risk. Only 26% of women > or =65 years of age reported being well informed about stroke, even though this group carries the highest incidence of stroke. Overall, 20% of women stated that they worried a lot about stroke. Among women aged 25 to 34 years, 37% stated that they were not at all informed about stroke, which was significantly higher than for women between 45 and 64 years (13%, P<0.05) and those > or =65 years of age (14%, P<0.05). More Hispanics reported being not at all informed about stroke compared with whites (32% versus 19%, P<0.05) and blacks (32% versus 20%, P<0.05). More white women were aware that at the onset of a stroke, treatment could be given to break up blood clots compared with blacks (92% versus 84%, P<0.05) and Hispanics (92% versus 79%, P<0.05). Correct identification of the warning signs of stroke was low among all racial/ethnic and age groups. More white respondents correctly identified sudden 1-sided weakness or numbness of the face or a limb as a warning sign compared with Hispanics (39% versus 29%, P<0.05). Whites identified difficulty talking or understanding speech as a sign of stroke significantly more often than did Hispanics (29% versus 17%, P<0.05). CONCLUSIONS: Results of this national survey document that awareness and knowledge about stroke is suboptimal among women, especially among racial/ethnic minorities, who are at highest risk. These data support the need for targeted educational programs about stroke risk and symptoms and underscore the importance of public health programs to improve awareness of stroke among women.

Adult↗

PubMed2005

Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks.

BACKGROUND: Non-valvular atrial fibrillation (AF) carries an increased risk of stroke. Antiplatelet therapy (APT) is proven effective for stroke prevention in most patients at high-risk for vascular events, but its value for primary stroke prevention in patients with non-valvular AF merits separate consideration because of the suspected cardioembolic mechanism of most strokes in AF patients. OBJECTIVES: To assess the efficacy and safety of long-term APT for primary prevention of stroke in patients with chronic non-valvular AF. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (searched August 2004). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to June 2004), and the reference lists of recent review articles. We also contacted experts working in the field to identify unpublished and ongoing trials. SELECTION CRITERIA: Randomized trials comparing long-term APT with placebo or control in patients with non-valvular AF and no history of transient ischemic attack (TIA) or stroke. A sensitivity analysis included one additional randomized trial involving primary prevention with aspirin plus very low dose warfarin. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials for inclusion and extracted data for each outcome. Unpublished data were obtained from trial investigators. MAIN RESULTS: Three trials tested aspirin in dosages ranging from 75 mg to 325 mg per day and 125 mg every other day to placebo (in two trials) or control (in one trial) in 1965 AF patients without prior stroke or TIA. The mean duration of follow up averaged 1.3 years per participant. Aspirin was associated with non-significant lower risks of all stroke (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.47 to 1.07), ischemic stroke (OR 0.70, 95% CI 0.46 to 1.07), all disabling or fatal stroke (OR 0.86, 95% CI 0.50 to 1.49) and all-cause death (OR 0.75, 95% CI 0.54 to 1.04). The combination of stroke, myocardial infarction or vascular death was significantly reduced (OR 0.71, 95% CI 0.51 to 0.97 ). No increase in intracranial hemorrhage or major extracranial hemorrhage was observed. AUTHORS' CONCLUSIONS: Aspirin appears to reduce stroke and major vascular events in patients with non-valvular AF similar to its effect in other high-risk patients (ie by about 25%). For primary prevention among AF patients with an average stroke rate of 4% per year, about 10 strokes would likely be prevented yearly for every 1000 AF patients given aspirin.

Aspirin↗

PubMed2004

Hospital cost of ischemic stroke and intracerebral hemorrhage in Japanese stroke centers.

BACKGROUND: In Japan, the healthcare expenditure has increased to 8.0% of the gross domestic products in 2001. Stroke care is costly. OBJECTIVE: To examine hospital costs and clinical outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) in Japanese stroke centers. DESIGN: A prospective non-interventional multi-center study. SETTING: Ten Japanese stroke centers. STUDY PERIOD: Fourteen months between October 2000 and December 2001. PATIENTS: Patients were those who were consecutively hospitalized with acute IS or ICH within 72 h of onset, excluding subarachnoid hemorrhage. Stroke was defined as focal neurological deficits lasting more than 24 h and the relevant lesions were to be confirmed by brain CT and/or MRI. METHODS: We examined demography, in-hospital cares, length of hospital stay, clinical outcomes at discharge, and direct hospital medical costs including physician's fees. The hospital medical cost data were collected from official hospital medical cost charts for reimbursement to the healthcare insurance systems. RESULTS: There were a total of 1113 patients with a mean age of 70 years, of whom 913 (82%) patients had an IS and 200 (18%) patients had an ICH. The 317 patients (28%) experienced a recurrent stroke. Patients with ICH had the higher baseline stroke severity, resulting in longer hospitalization (39 days for IS and 46 days for ICH; P<0.001), lower independence rate at discharge (55 and 40%; P<0.001), higher mortality rate (5 and 10%; P=0.03), and higher medical costs (US dollar 8662 and US dollar 10,260; P<0.001) than those with IS. Patients with recurrent stroke had significantly older age, higher stroke severity, and lower independence rate at discharge than those with first-ever stroke. The length of stay, in-hospital mortality, and hospital medical costs were similar among first-ever and recurrent strokes. In subtype of IS, patients with cardioembolic stroke had the worst neurological deficits, poorest outcomes, and highest medical costs. The hospital costs had a greatest association with length of stay. CONCLUSIONS: Stroke care is costly in Japan. ICH is more likely to impose substantial physical and economic burden than IS. Because the cares of both first-ever and recurrent stroke were costly, primary and secondary prevention of stroke is important on the healthcare aspects.

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