Intracerebral hemorrhage versus infarction: stroke severity, risk factors, and prognosis

Chest wall kinematics in patients with hemiplegia

Owing to difficulties in measuring ventilation symmetry, good evidence of different right/left respiratory movements has not yet been provided. We investigated VT differences between paretic and healthy sides during quiet breathing, voluntary hyperventilation, and hypercapnic stimulation in patients with hemiparesis. We studied eight patients with hemiparesis and nine normal sex- and age-matched subjects. Right- and left-sided VT was reconstructed using optoelectronic plethysmography. In control subjects, no asymmetry was found in the study conditions. VTs of paretic and healthy sides were similar during quiet breathing, but paretic VT was lower during voluntary hyperventilation in six patients and higher during hypercapnic stimulation in eight patients (p = 0.02). The ventilatory response to hypercapnic stimulation was higher on the paretic than on the healthy side (p = 0.012). In conclusion, hemiparetic stroke produces asymmetric ventilation with an increase in carbon dioxide sensitivity and a decrease in voluntary ventilation on the paretic side.

Smoking and the risk of hemorrhagic stroke in men

BACKGROUND AND PURPOSE

Smoking is an established risk factor for ischemic stroke and subarachnoid hemorrhage (SAH), but the impact of smoking on intracerebral hemorrhage (ICH) is less clear.

METHODS

Prospective cohort study among 22,022 US male physicians participating in the Physicians' Health Study. Incidence of stroke was measured by self-report and confirmed by medical record review. We used Cox proportional-hazards models to evaluate the association of smoking with risk of total hemorrhagic stroke, ICH, and SAH. We categorized smoking into 4 groups: never, past, or current smokers of <20 or of >or=20 cigarettes per day.

RESULTS

During 17.8 years of follow-up, 108 ICHs and 31 SAHs occurred. Never smokers and past smokers had equal rates of ICH and SAH. Current smokers of <20 cigarettes per day had multivariable-adjusted relative risks of 1.65 (95% CI, 0.61 to 4.50) for total hemorrhagic stroke, 1.60 (95% CI, 0.50 to 5.07) for ICH, and 1.75 (95% CI, 0.24 to 13.09) for SAH when compared with never smokers. Current smokers of >or=20 cigarettes had relative risks of 2.36 (95% CI, 1.38 to 4.02) for total hemorrhagic stroke, 2.06 (95% CI, 1.08 to 3.96) for ICH, and 3.22 (95% CI, 1.26 to 8.18) for SAH when compared with never smokers.

CONCLUSIONS

This prospective study suggests an increased risk of total hemorrhagic stroke, ICH, and SAH in current cigarette smokers with a graded increase in risk that depended on how many cigarettes were smoked. The effect of smoking on ICH is of about the same magnitude as the effect of smoking on ischemic stroke. Our results add to the multiple health benefits that can be accrued by abstaining from cigarette smoking.

Clinical discriminators between acute brain hemorrhage and infarction: a practical score for early patient identification

New treatments for acute stroke require a rapid triage system, which minimizes treatment delays and maximizes selection of eligible patients. Our aim was to create a score for assessing the probability of brain hemorrhage among patients with acute stroke based upon clinical information. Of 1805 patients in the Stroke Data Bank, 1273 had infarction (INF) and 237 had parenchymatous hemorrhage (HEM) verified by CT. INF and HEM discriminators were determined by logistic regression and used to create a score. ROC curve was used to choose the cut-point for predicting HEM (score </= 2), with sensitivity of 76% and specificity of 83%. External validation was done using the NOMASS cohort. Although the use of a practical score by emergency personnel cannot replace the gold-standard brain image differentiation of HEM from INF for thrombolytic therapy, this score can help to select patients for stroke trials and pre-hospital treatments, alert CT scan technicians, and warn stroke teams of incoming patients to reduce treatment delays.

Cocaine use and the likelihood of nonfatal myocardial infarction and stroke: data from the Third National Health and Nutrition Examination Survey

BACKGROUND

Numerous case series have implicated cocaine use as a cause of both myocardial infarction (MI) and stroke on the basis of the temporal relationship between drug use and event onset. Increasing cocaine use in the US population, especially in younger individuals, mandates a more extensive investigation of this relationship.

METHODS AND RESULTS

We determined the association of cocaine use with self-reported physician diagnosis of MI or stroke in a nationally representative sample of 10 085 US adults aged 18 to 45 years who participated in the Third National Health and Nutrition Examination Survey. A total of 46 nonfatal MIs and 33 nonfatal strokes were reported. After adjusting for differences in age, sex, race/ethnicity, education, hypertension, diabetes mellitus, cholesterol level, body mass index, and cigarette smoking, persons who reported frequent lifetime cocaine use had a significantly higher likelihood of nonfatal MI than nonusers (odds ratio, 6.9; 95% confidence interval, 1.3 to 58) but not stroke. In this age group, the population-attributable risk percent of frequent cocaine for nonfatal MI was estimated as 25%.

CONCLUSION

Regular cocaine use was associated with an increased likelihood of MI in younger patients. Approximately 1 of every 4 nonfatal MIs in persons aged 18 to 45 years was attributable to frequent cocaine use in this survey. Behavior modification by public awareness and education may reduce the cardiovascular morbidity associated with cocaine use.

[Different vascular risk factor profiles in ischemic stroke versus intracerebral hemorrhage: a study in 1,702 consecutive patients with acute stroke]

BACKGROUND

To characterize the vascular risk factor profiles in ischemic stroke and in intracerebral hemorrhage.

PATIENTS AND METHOD

The study population consisted of 1,473 consecutive ischemic stroke patients and 229 consecutive intracerebral hemorrhagic patients collected in the Sagrat Cor Hospital of Barcelona Stroke Registry over a 10-year period. The prevalence of vascular risk factors in ischemic stroke and in intracerebral hemorrhage was analyzed by means of univariate analysis and a logistic regression model.

RESULTS

Hypertension was present in 52% of ischemic stroke patients and in 60.7% of intracerebral hemorrhagic patients. The pattern of risk factors associated with ischemic stroke included valve heart disease (OR = 5.96; 95% CI, 1.42-24.88), transient ischemic attack (OR = 4.16; 95% CI, 2-8.64), atrial fibrillation (OR = 2.95; 95% CI, 1.88-4.64), previous brain infarct (OR = 2.58; 95% CI, 1.53-4.35), ischemic heart disease (OR = 2.55; 95% CI, 1.41-4.62), hyperlipidemia (OR = 2.12; 95% CI, 1.32-3.4), hypertension (OR = 0.64; 95% CI, 0.48-0.87), chronic liver disease (OR = 0.32; 95% CI, 0.14-0.73), previous cerebral hemorrhage (OR = 0.24; 95% CI, 0.09-0.64) and oral anticoagulant therapy (OR = 0.11; 95% CI, 0.03-0.36).

CONCLUSIONS

Different potentially modifiable vascular risk factors profiles were identified in ischemic versus hemorrhagic stroke.

Effects of subdural haematoma on sensorimotor functioning and spatial learning in rats

Twenty per cent of all strokes are haemorrhagic in character and are associated with severe disturbances in sensorimotor behaviour and cognition. Although spontaneous recovery of pre-stroke functioning occurs in some cases, the process is demanding, slow, and often incomplete. A first step in the preclinical testing of new putative, neuroprotective and recovery-supporting therapeutics is to validate animal models of brain injury. In a series of four experiments we evaluated the behavioural impairments and the time course of recovery of functional deficits in rats with an experimentally induced subdural haematoma. We found that unilateral subdural haematoma resulted in dysfunction in both simple reflexive (experiment 1) and skilled sensorimotor behaviour (experiment 2). Reflexive behaviour did not recover, or recovered only marginally, and neither did the deficits in skilled forepaw use. Bilateral subdural haematoma impaired the learning and memory performance of adult (experiment 3) and old rats (experiment 4) in the Morris water escape task. Considering the diversity of the deficits found in our experiments, we conclude that different models are needed to cover the broad range of deficits seen in stroke patients.

Evidence for apoptosis after intercerebral hemorrhage in rat striatum

The overall hypothesis that cell death after intracerebral hemorrhage is mediated in part by apoptotic mechanisms was tested. Intracerebral hemorrhage was induced in rats using stereotactic infusions of 0.5 U of collagenase (1-microL volume) into the striatum. After 24 hours, large numbers of TUNEL-positive stained cells with morphologies suggestive of apoptosis were present in the center and periphery of the hemorrhage. Double staining with Nissl and immunocytochemical labeling with antibodies against neuronal nuclei and glial fibrillary acidic protein suggested that these TUNEL-positive cells were mostly neurons and astrocytes. Electrophoresis of hemorrhagic brain extracts showed evidence of DNA laddering into approximately 200-bp fragments. Western blots showed cleavage of the cytosolic caspase substrate gelsolin. The density of TUNEL-positive cells at 24 and 48 hours after hemorrhage was significantly reduced by treatment with the broad-spectrum caspase inhibitor zVADfmk. It was unlikely that apoptotic changes were due to neurotoxicity of injected collagenase because TUNEL-positive cells and DNA laddering were also obtained in an alternative model of hemorrhage where autologous blood was infused into the striatum. Furthermore, equivalent doses of collagenase did not induce cell death in primary neuronal cultures. These results provide initial evidence that apoptotic mechanisms may mediate some of the injury in brain after intracerebral hemorrhage.

Rate of stroke recurrence in patients with primary intracerebral hemorrhage

BACKGROUND AND PURPOSE

Primary intracerebral hemorrhage (PICH) is a devastating illness with high early mortality. Hypertension is a major risk factor both for ischemic cerebrovascular disease and for intracranial hemorrhage. Survivors of PICH are at risk for both recurrent hemorrhage and ischemic cerebrovascular disease. We sought to determine the rate of recurrence of ICH or cerebral ischemia in a cohort of PICH patients at the Toronto Hospital, Toronto, Canada.

METHODS

A retrospective search of computerized hospital records from 1986 to 1996 for patients with a discharge diagnosis of intracerebral hemorrhage (International Classification of Diseases, Ninth Revision-Clinical Modification [ICD-9-CM] code 431) was conducted to identify the index cases. Charts were abstracted for demographic and clinical characteristics. CT scans, MR scans, or radiologist reports were reviewed. To determine recurrence, the database was linked to the Ontario Provincial Government Vital Statistics Registry and to the Canadian Institute for Health Information database of hospital discharge abstracts. Logistic regression analysis was used to identify predictive factors for mortality after PICH. A Cox proportional hazards model was fitted to identify predictive factors for recurrent ICH or stroke.

RESULTS

A total of 746 charts were identified by computer search. After abstraction, 423 index patients with PICH were identified. Of these, 27.4% died in the first 30 days of their admission. Predictors of death were age, intraventricular rupture of hemorrhage, and trilobar hemorrhage. The recurrence rate for PICH was 2.4% (95% CI 1.4% to 3. 9%) per year, whereas the recurrence rate for ischemic cerebrovascular disease was 3.0% (95% CI 1.8% to 4.7%) per year. The only significant predictor of readmission for ICH was lobar location of the index hemorrhage, with a hazard ratio of 3.8 (95% CI 1.2 to 12.0).

CONCLUSIONS

PICH has a high 30-day mortality rate. Survival from the initial insult portends a moderate risk of recurrence of 2. 4% per year for PICH and 3.0% per year for ischemic cerebrovascular disease. Patients with PICH are at risk for both ischemic stroke or TIA and recurrent hemorrhage; thus, PICH may be a marker for ischemic stroke. Patients with lobar hemorrhage have a 3.8-fold increased risk of recurrent ICH.

Body temperature correlates with functional outcome and the lesion size of cerebral infarction

INTRODUCTION

Experimental studies have demonstrated that mild hyperthermia exacerbates ischemia-induced neuronal injury.

MATERIAL AND METHODS

We examined the relationship between body temperature and functional outcome in 183 patients suffering from cerebral infarction, and admitted within 24 h from the onset of stroke. Patients' functional capacities in daily life were evaluated by Rankin's score before the attack (RS0), on the day of admission (RS1), and 3 months after the onset of stroke (RS90).

RESULTS

RS90 showed an independent correlation with RS0, RS1, age, infarct size and maximum body temperature recorded within the first 7 days from the onset of stroke by multivariate analysis. History of previous cerebrovascular accidents, atrial fibrillation, hemorrhagic transformation, infection, and a hypothalamic lesion showed significant associations with RS90 by the Mann-Whitney U-test, but not by multivariate analysis. Infarct size correlated with body temperature, atrial fibrillation, and hemorrhagic transformation.

CONCLUSION

Body temperature correlated well with both functional outcome and infarct size in patients with an acute cerebral infarction.

Predictive model of functional independence in stroke patients admitted to a rehabilitation programme

OBJECTIVE

To develop a prognostic model to estimate the probability of patients being independent in ambulation and in activities of daily living (ADL) after six months of stroke.

DESIGN

Cohort analytical study.

SETTING

Rehabilitation departments of two district general hospitals.

SUBJECTS

Ninety-two consecutive stroke patients admitted to a rehabilitation programme.

MAIN OUTCOME MEASURES

Independent ambulation was defined as a Functional Ambulation Classification (FAC) > or =4, and the independence in ADL as a Barthel Index (BI) > or =285. All patients were assessed on admission to rehabilitation, and in the first, second, third, fourth and six months after stroke.

RESULTS

Prognostic factors were identified by means of a multivariate survival analysis using Cox regression. Three variables were predictors for a FAC > or =4: (1) The patients in the motor (M), motor-sensitive (MS) and motor-sensitive with hemianopsia (MSH) groups (relative risk (RR) 5.43 of M with respect to MSH, and 2.41 of MS to MSH). (2) A Motricity Index >25 (RR 3.19). (3) An age <70 years old (RR 1.99). For a BI > or =85 three predictors were selected: (1) The classification M-MS-MSH (RR 6.02 M to MSH, and 1.52 MS to MSH). (2) An initial BI >20 (RR 3.45); the highest contribution in the achievement of an initial BI >20 was bowel and bladder continence. (3) The antecedent of previous independence (RR 2.68). The predictive models, constructed by means of multiple logistic regression correctly classified 77% and 79% of the patients who obtained FAC > or =4 and a BI > or =85 respectively.

CONCLUSIONS

The syndromic classification M, MS and MSH, together with other routinely available data, such as the Motricity Index, BI, the age and the previous functionality, can be used to obtain a patient prognosis level with regard to ambulation and ADL independence.

What determines good recovery in patients with the most severe strokes? The Copenhagen Stroke Study

BACKGROUND AND PURPOSE

Even patients with the most severe strokes sometimes experience a remarkably good recovery. We evaluated possible predictors of a good outcome to search for new therapeutic strategies.

METHODS

We included the 223 patients (19%) with the most severe strokes (Scandinavian Stroke Scale score <15 points) from the 1197 unselected patients in the Copenhagen Stroke Study. Of these, 139 (62%) died in the hospital and were excluded. The 26 survivors (31%) with a good functional outcome (Barthel Index >/=50 points) were compared with the 58 survivors (69%) with a poor functional outcome (Barthel Index <50 points). The predictive value of the following factors was examined in a multivariate logistic regression model: age; sex; a spouse; work; home care before stroke; initial stroke severity; blood pressure, blood glucose, and body temperature on admission; stroke subtype; neurological impairment 1 week after onset; diabetes; hypertension; atrial fibrillation; ischemic heart disease; previous stroke; and other disabling disease.

RESULTS

Decreasing age (odds ratio [OR], 0.50 per 10-year decrease; 95% CI, 0.25 to 0.99; P=0.04), a spouse (OR, 3.1; 95% CI, 1.1 to 8. 8; P=0.03), decreasing body temperature on admission (OR, 1.8 per 1 degrees C decrease; 95% CI, 1.1 to 3.1; P=0.01), and neurological recovery after 1 week (OR, 3.2 per 10-point increase in Scandinavian Stroke Scale score; 95% CI, 1.1 to 7.8; P=0.01) were all independent predictors of good functional outcome.

CONCLUSIONS

Patients with the most severe strokes who achieve a good functional outcome are generally characterized by younger age, the presence of a spouse at home, and early neurological recovery. Body temperature was a strong predictor of good functional outcome and the only potentially modifiable factor. We suggest that a randomized controlled trial be undertaken to evaluate whether active reduction of body temperature can improve the generally poor prognosis of patients with the most severe strokes.

Survival and outcome after endotracheal intubation for acute stroke

OBJECTIVE

To assess survival and functional outcome in patients endotracheally intubated after ischemic stroke (IS) or spontaneous intracerebral hemorrhage (ICH).

BACKGROUND

Endotracheal intubation is both a necessary life support intervention and a measure of severity in IS or ICH. Knowledge of associated clinical variables may improve the estimation of early prognosis and guide management in these patients.

METHODS

We reviewed 131 charts of patients with IS or ICH who were admitted to the Neurosciences Intensive Care Unit at Duke University Medical Center between July 1994 and June 1997 and required endotracheal intubation. Stroke risk factors, stroke type (IS or ICH) and location (hemispheric, brainstem, or cerebellum), circumstances surrounding intubation, neurologic assessment (Glasgow Coma Score [GCS] and brainstem reflexes), comorbidities, and disposition at discharge were documented. Survivors were interviewed for Barthel Index (BI) scores.

RESULTS

Survival was 51% at 30 days and 39% overall. Variables that significantly correlated with 30-day survival in multivariate analysis included GCS at intubation (p = 0.03) and absent pupillary light response (p = 0.008). Increase in the GCS also correlated with improved functional outcome measured by the BI (p = 0.0003). In patients with IS, age and GCS at intubation predicted survival, and in patients with ICH, absent pupillary light response predicted survival.

CONCLUSIONS

Predictors for mortality differ between patients with IS and ICH; however, decreased level of consciousness is the most important determinant of increased mortality and poor functional outcome. Absent pupillary light responses also correspond with a poor prognosis for survival, but further validation of this finding is needed.

Recovery of arm function in patients with paresis after traumatic brain injury

OBJECTIVE

To characterize the frequency of recovery of arm paresis in patients with traumatic brain injury (TBI) admitted to rehabilitation.

DESIGN

Retrospective review identifying a cohort of patients with moderate or severe arm paresis after TBI followed at least 6 months postinjury.

SETTING

Freestanding acute rehabilitation hospital TBI unit.

PATIENTS AND METHODS

Forty-four patients with moderate to severe arm paresis were selected from 264 consecutive admissions and characterized by injury pathology subtype, injury severity (duration of unconsciousness [loss of consciousness, LOC] and posttraumatic amnesia [PTA]), age, and level of paresis according to Brunnstrom Stages of Recovery (BS 1 to 6). Patient groups with and without arm paresis were compared according to these variables (t tests and chi(2)).

MAIN OUTCOME MEASURES

Recovery of arm paresis to isolated motor function (BS 5 or 6) and time to achieve recovery. Recovered and nonrecovered patients were compared (Mann-Whitney, t tests, and chi(2)) on injury severity, initial level of paresis, age, time to rehabilitation admission, and pathology subtype. Time to recovery was compared for patients at different levels of initial paresis, ranges of LOC, and pathology subtypes (Mann-Whitney and Kruskal-Wallis tests).

RESULTS

Forty-four patients (17%) had moderate (BS 3 to 4) or severe (BS 1 to 2) paresis at rehabilitation admission. They were more severely injured than nonparetic patients based on longer LOC (p < .002) and PTA (p < .009). Thirty-six patients (82%) recovered by 6 months; 72% of these recovered by 2 months. If still paretic at 2 months, only 56% recovered. Mean recovery time was 6.9 weeks (SD, 6.1) from injury. Time to recovery was best predicted by initial level of paresis and injury severity (r2 = .48), but not age. Patients with diffuse injury tended towards a more protracted recovery (7.9 weeks, SD 6.5) than patients with focal injury (4.2 weeks, SD 3.9) (p = .08) and only those with diffuse injury showed further recovery after 3 months.

CONCLUSIONS

Arm paresis after TBI is relatively infrequent. Most patients recover by 2 months but later recovery is possible, especially in patients with primarily diffuse brain damage. Recovery is highly related to initial impairment, injury severity, and distribution of brain injury.

In-patient rehabilitation after stroke: outcome and factors associated with improvement

A study aimed at examining the outcome of activities of daily living (ADL) of patients undergoing geriatric stroke rehabilitation was performed. Background and admission data of 99 patients surviving the acute phase and needing further hospital rehabilitation were registered. Forty per cent of the patients improved their ADL ability. The logistic regression modelling with the dichotomous dependent variable improvement versus no improvement showed the following factors associated with improvement: a diagnosis of intracerebral haemorrhage, male sex, high postural stability score at the admission and cohabitation. In conclusion, the most severely affected stroke patients, especially patients with intracerebral haemorrhage, have a great potential for improving their ADL. The results of the logistic regression model can serve as a useful guide when it comes to identifying patients that stand a fair chance of improving during their rehabilitation stay. Equally important, patients with a poor rehabilitation prognosis who may need intensified rehabilitation efforts to achieve optimum improvement can now be identified.

Stroke units versus general medical wards, I: twelve- and eighteen-month survival: a randomized, controlled trial

BACKGROUND AND PURPOSE

The long-term effect on survival of treatment in stroke units is still under debate. The hypothesis that a stroke unit with short length of stay increases 1-year and 18-month survival rates was tested in this study.

METHODS

A quasi-randomized, controlled study was undertaken among 802 patients > or =60 years old admitted to the Central Hospital of Akershus in Norway with a diagnosis of stroke between January 1, 1993, and February 1, 1995. All patients with onset of symptoms <24 hours before admittance were included and enrolled and were followed until death or to the end of the observation 18 months after stroke. Patients were allocated to a stroke unit (n=364) or a general medical ward (n=438).

RESULTS

Case fatality within the first 10 days was 8.2% among patients in the stroke unit and 15.1% among patients in the general medical ward (P=.0019). One-year survival among patients treated in the stroke unit was 70.6% and in the general medical wards 64.6% (P=.026); 18-month survival rates were 65.1% and 58.0%, respectively (P=.021). Among patients with cerebral hemorrhage, 10-day case fatality was 24.5% and 51.6% (P=.004) in favor of the stroke unit.

CONCLUSIONS

Stroke units increase survival rates among stroke patients compared with general medical wards. The effect on survival occurs early after the stroke and sustains during at least 18 months of observation.

Haematoma evacuation does not improve outcome in spontaneous supratentorial intracerebral haemorrhage: a case-control study

Surgical intervention in supratentorial intracerebral haemorrhage (ICH) is still controversial. We assessed the value of haematoma evacuation with a case-control study. 145 consecutive patients with supratentorial spontaneous ICH without tumour or vascular abnormalities were analysed. Haematoma evacuation was performed in 24 patients. Age, sex, Glasgow Coma Scale (GCS), level of consciousness, pupillary reaction on admission, localisation, aetiology and volume of the haematoma, presence of ventricular blood, and Glasgow Outcome Scale (GOS) on discharge were analysed. From statistical analysis 40 patients > 80 years and with haematoma volume < 10 ml, who were always treated conservatively, were excluded. Prognostic factors retained from a multiple regression model with the dichotomised GOS scale (GOS 1-3, 4 + 5) as response variable were GCS, haematoma volume and location. The only difference between all medically treated and "operated" patients was haematoma volume, which was larger in the "operated" patients. All 24 evacuated cases could be matched to a medically treated control regarding age, haematoma volume and location, GCS, and pupillary reaction. Significant differences between the two groups could not be detected. Outcome was not different between the two groups. After separating the sample into patients with and without ventricular haemorrhage, there was no different outcome between the two groups either. We conclude that haematoma evacuation did not improve outcome in supratentorial spontaneous ICH. Since haematomas were evacuated mainly in clinically deteriorating patients, our data suggest that the only effect of haematoma evacuation is to stop progressive deterioration rather than to improve overall clinical outcome.

Sleep-disordered breathing in patients with acute supra- and infratentorial strokes. A prospective study of 39 patients

BACKGROUND AND PURPOSE

Although recent studies suggest a high prevalence of obstructive sleep apnea (OSA) in patients with acute stroke, a systematic characterization of sleep-disordered breathing based on the severity and topography of stroke has not been performed.

METHODS

We prospectively studied 39 noncomatose adult subjects (15 women, 24 men; mean age, 57 years) with a first acute stroke. Sleep history, cardiovascular risk factors, stroke severity as estimated by the Scandinavian Stroke Scale, and extent of stroke demonstrated on a computed tomographic or magnetic resonance imaging scan of the brain were assessed. Polysomnography was performed a mean of 10 days (range, 1 to 49 days) after stroke onset. Monitoring of breathing during wakefulness, non-rapid eye movement sleep, and rapid eye movement sleep included measurements of nasal/oral airflow, respiratory effort, and oxygen saturation.

RESULTS

Breathing was abnormal during wakefulness in 7 (18%) subjects and during sleep in 26 (67%). Obstructive sleep apnea (apnea-hypopnea index > 10) was found in 14 subjects, Cheyne-Stokes-like breathing was observed in 4, and a combination of obstructive sleep apnea and Cheyne-Stokes-like breathing was observed in 7. Sustained tachypnea and ataxic breathing were rare. No significant differences were found in age, body mass index, history of snoring or hypersomnia, or stroke topography or severity between subjects with and without sleep-disordered breathing. Prevalence and severity of breathing disturbances were also similar between patients with supratentorial stroke (n = 28) and those with infratentorial (n = 11) stroke.

CONCLUSIONS

Sleep-disordered breathing is frequent in patients with acute stroke, rarely has localizing value, and can also be found in patients with mild neurological deficits. Respiratory disturbances in stroke victims can be explained only in part by topography and extension of acute brain damage.

Seizures in acute stroke: predictors and prognostic significance. The Copenhagen Stroke Study

BACKGROUND

Despite the common occurrence of seizures during the early phase of stroke (ES), the effect of ES on prognosis is not known. We determined the relationships between ES and stroke outcome and identified predictors of ES.

METHODS

In this community-based study, we prospectively and consecutively studied 1197 patients with acute stroke. We determined the number and type of seizures, initial stroke severity, infarct size, mortality, and outcome in survivors. Stroke severity was measured on admission, weekly, and at discharge using the Scandinavian Stroke Scale (SSS). Multiple logistic and linear regression outcome analyses included relevant confounders and potential predictors, including age, gender, stroke severity on admission, atrial fibrillation, ischemic heart disease, diabetes, blood glucose level on admission, claudication, and hypertension.

RESULTS

Fifty patients (4.2%) had seizures within 14 days of the stroke. In the multivariate analyses, only initial stroke severity was related to ES; stroke type and lesion localization were not related. For each 10-point increase in stroke severity (SSS score), the relative risk of ES increased by a factor of 1.65 (95% confidence interval, 1.4 to 1.9) (P < .0001). ES did not influence the risk of death during hospital stay (P = .56). In survivors, ES was related to a better outcome, equivalent to an increased SSS score of 5.7 points (SE [b] = 1.8; P = .002).

CONCLUSIONS

The decisive factor of ES was initial stroke severity. ES per se was not related to mortality. Surprisingly, in survivors, ES predicted a better outcome. We explain this finding by a relatively larger ischemic penumbra in patients who have an ES after a stroke.

Acute stroke care and rehabilitation: an analysis of the direct cost and its clinical and social determinants. The Copenhagen Stroke Study

BACKGROUND AND PURPOSE

Stroke represents a major economic challenge to society. The direct cost of stroke is largely determined by the duration of hospital stay, but internationally applicable estimates of the direct cost of acute stroke care and rehabilitation on cost-efficient stroke units are not available. Information regarding social and medical factors influencing the length of hospital stay (LOHS) and thereby cost is needed to direct cost-reducing efforts.

METHODS

We determined the direct cost of stroke in the prospective, consecutive, and community-based stroke population of the Copenhagen Stroke Study by measuring the total LOHS in the 1197 acute stroke patients included in the study. All patients had all their acute care and rehabilitation on a dedicated stroke unit. Neurological impairment was measured by the Scandinavian Stroke Scale. Local nonmedical factors affecting the LOHS, such as waiting time for discharge to a nursing home after completed rehabilitation, were accounted for in the analysis. The influence of social and medical factors on the LOHS was analyzed in a multiple linear regression model.

RESULTS

The average LOHS was 27.1 days (SD, 44.1; range, 1 to 193), corresponding to a direct cost of $12.150 per patient including all acute care and rehabilitation. The LOHS increased with increasing stroke severity (6 days per 10-point increase in severity; P < .0001) and single marital status (3.4 days; P = .02). Death reduced LOHS (22.0 days; P < .0001). Age, sex, diabetes, hypertension, claudication, ischemic heart disease, atrial fibrillation, former stroke, other disabling comorbidity, smoking, daily alcohol consumption, and the type of stroke (hemorrhage/infarct) had no independent influence on LOHS.

CONCLUSIONS

Acute care and rehabilitation of unselected patients on a dedicated stroke unit takes on average 4 weeks. In general, comorbidity such as diabetes or heart disease does not increase LOHS. Efforts to reduce costs should therefore aim at reducing initial stroke severity or improving the rate of recovery.

Intracerebral hemorrhage in blacks. Risk factors, subtypes, and outcome

BACKGROUND AND PURPOSE

Blacks are at a higher risk for intracerebral hemorrhage (ICH) than whites; however, few data are available regarding the demographic and clinical characteristics of ICH among blacks.

METHODS

We determined the frequency of risk factors, etiologic subtypes, and outcome among consecutive black patients admitted with nontraumatic ICH to a university-affiliated public hospital.

RESULTS

The most common risk factors in the 403 black patients with ICH were preexisting hypertension (77%), alcohol use (40%), and smoking (30%). Among the 91 nonhypertensive patients, 21 (23%) were diagnosed with hypertension after onset. Compared with women, men had a younger age of onset (54 versus 60 years; P < .001) and higher frequency of alcohol use (54% versus 22%; P < .001) and smoking (39% versus 17%; P < .001). ICH secondary to hypertension (n = 311) and of undetermined etiology (n = 73) were the most common subtypes in blacks. Patients aged 65 years and older (compared with those aged 15 to 44 years; P = .001) and women (compared with men; P = .02) were more likely to be dependent at discharge.

CONCLUSIONS

Primary preventive strategies are required to reduce the high frequency of modifiable risk factors predisposing to ICH in blacks.

Medical therapy for intracerebral hematoma with the gamma-aminobutyric acid-A agonist muscimol

BACKGROUND AND PURPOSE

No therapy has been rigorously proven effective for intracerebral hematoma, although surgery is frequently used for some types of lobar hemorrhages. Since intracerebral mass causes significant ischemia in surrounding brain, we reasoned that anti-ischemia therapy might improve outcome after experimental hematoma.

METHODS

We stereotaxically injected varying doses of bacterial collagenase into the caudate nucleus of rats. Four hours later we administered intravenously 2 mg/kg muscimol, a potent agonist of the gamma-aminobutyric acid-A receptor (n = 20); 1 mg/kg MK-801, an antagonist of the N-methyl-D-aspartate receptor (n = 17); or saline (n = 28). Forty-eight hours after collagenase injection we rated each animal using a standard rodent neurological examination. The ratings were compared with the amounts of injected collagenase by the quantal bioassay procedure. Brains were then prepared for histomorphometry and brain volumes estimated.

RESULTS

We found that the ED50 for collagenase (amount of enzyme that renders 50% of the subjects abnormal) was 0.77 +/- 0.09 U in saline-treated subjects. Treatment with muscimol significantly increased the ED50 to 1.2 +/- 0.21 U, for a potency ratio of 1.55 +/- 0.34 (t = 1.7, P < .05). MK-801 did not affect outcome. Volume of hematoma was significantly correlated with amount of injected collagenase (n = 33, r = .64, P < .001). Volumes of basal ganglia and white matter were significantly reduced by hemorrhage, and muscimol partially ameliorated this.

CONCLUSIONS

We conclude that muscimol significantly improves neurological outcome after intracerebral hematoma.

Cerebral blood flow velocity and pulsation in neonatal respiratory distress syndrome and periventricular hemorrhage

The present study addressed the hypotheses that cerebral ischemia and/or excessive cerebral blood pulsation contribute to periventricular hemorrhage in preterm newborns with respiratory distress and that the pulse width is a valuable tool to estimate the contribution of cerebral blood pulsation. These hypotheses were tested by following preterm newborns at risk for respiratory distress and periventricular hemorrhage. We monitored for cerebral blood flow velocity (CBFV), cerebral pulse width, and cerebral pulsatility index; for patent ductus arteriosus, capillary Pco2, heart rate (HR) and behavior; and for the occurrence of respiratory distress and periventricular hemorrhage (PVH). The data obtained were analyzed with linear regression with the mode of respiration (spontaneous or supported) and postnatal age as additional covariates. We observed that (a) respiratory distress, either uncomplicated or complicated by PVH, correlates with a low CBFV and a high cerebral pulsatility index; (b) PVH also correlates with a high cerebral pulse width; (c) the increased pulse width precedes the onset of the hemorrhage; and (d) these CBF alterations can be partly attributed to ductal shunting and are ameliorated by mechanical ventilation.

Acute stroke with atrial fibrillation. The Copenhagen Stroke Study

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia and a major risk factor for stroke. Many physicians remain reluctant to provide stroke prevention by anticoagulant therapy especially for elderly individuals with AF. Using multivariate regression analyses, we studied the characteristics and the prognosis of stroke in patients with AF.

METHODS

The study is part of the Copenhagen Stroke Study, a prospective, community-based study of 1197 patients with acute stroke treated on a stroke unit from the time of acute admission to the end of rehabilitation. Initial stroke severity was measured by the Scandinavian Neurological Stroke Scale (SSS). Neurological and functional outcomes were evaluated by the SSS and the Barthel Index.

RESULTS

AF was diagnosed in 18% of the patients. AF increased steeply with age in the stroke population, from 2% in patients < 50 years old, 15% in patients in their 70s, and 28% in patients in their 80s, to 40% in patients > or = 90 years of age. In a multivariate analysis AF was associated with age (odds ratio [OR], 2.0 per 10-year increase; 95% confidence ratio [CI], 1.6 to 2.6), ischemic heart disease (OR, 3.4; 95% CI, 2.4 to 4.8), previous stroke (OR, 1.8; 95% CI, 1.2 to 2.6), and systolic blood pressure (OR, 0.93 per 10-mm Hg increases; 95% CI, 0.88 to 0.99), but not with sex, diabetes, hypertension, previous transient ischemic attack, or silent infarction on computed tomography. Patients with AF had a higher mortality rate (OR, 1.7; 95% CI, 1.2 to 2.5), longer hospital stays (50 days versus 40 days, P < .001), and a lower discharge rate to their own homes (OR, 0.60; 95% CI, 0.44 to 0.85). Neurological and functional outcomes were markedly poorer in patients with AF. Poorer outcome was exclusively explained by initially more-severe strokes.

CONCLUSIONS

Stroke in patients with AF is generally more severe and outcome markedly poorer than in patients with sinus rhythm. This accentuates the importance of anticoagulant treatment of individuals with AF. A lower blood pressure in the acute stage of stroke may contribute to the increased stroke severity in patients with AF.

The Copenhagen Stroke Study experience

The Copenhagen Stroke (COST) Study was a prospective, consecutive, community-based study of 1,197 patients with acute stroke who underwent acute stroke care and rehabilitation in a stroke unit setting. This article reviews the results of this study with respect to (1) the effect of organized stroke care and rehabilitation, (2) neurological outcome and functional outcome of stroke in relation to initial stroke severity and functional disability, (3) recovery of upper-extremity function and walking, (4) time course of neurological and functional recovery relative to initial stroke severity, (5) mechanisms of stroke recovery, and (6) the effect on stroke recovery of various demographic, medical, and pathophysiological factors, such as stroke in progression, spontaneous reperfusion age, diabetes, blood glucose on admission, stroke type (hemorrhage/infarction), silent infarction, and leuco-araiosis.