Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies

Educational levels and the functional dependence of ischemic stroke survivors

We evaluated the functional dependence of stroke survivors from the Study of Stroke Mortality and Morbidity, using the Rankin Scale. Out of 355 ischemic stroke survivors (with a mean age of 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days. These predictors were: low levels of education [illiterate vs. ≥ 8 years of education, multivariate odds ratio (OR) = 3.7; 95% confidence interval (95%CI): 1.60-8.54] and anatomical stroke location (total anterior circulation infarct, OR = 16.9; 95%CI: 2.93-97.49). Low levels of education and ischemic brain injury influenced functional dependence in these stroke survivors. Our findings reinforce the necessity of developing strategies for the rehabilitation of stroke patients, more especially in formulating specific strategies for care and treatment of stroke survivors with low socioeconomic status.

Modelling the efficiency of local versus central provision of intravenous thrombolysis after acute ischemic stroke

BACKGROUND AND PURPOSE

Prehospital redirection of stroke patients to a regional center is used as a strategy to maximize the provision of intravenous thrombolysis. We developed a model to quantify the benefit of redirection away from local services that were already providing thrombolysis.

METHODS

A microsimulation using hospital and ambulance data from consecutive emergency admissions to 10 local acute stroke units estimated the effect of redirection to 2 regional neuroscience centers. Modeled outcomes reflected additional journey time and accuracy of stroke identification in the prehospital phase, and the relative efficiency of patient selection and door-needle time for each local site compared with the nearest regional neuroscience center.

RESULTS

Thrombolysis was received by 223/1884 emergency admissions. Based on observed site performance, 68 additional patients would have been treated after theoretical redirection of 1269 true positive cases and 363 stroke mimics to the neuroscience center. Over 5 years redirection of this cohort generated 12.6 quality-adjusted life years at a marginal cost of £6730 ($10,320, €8347). The average additional cost of a quality-adjusted life year gain was £534 ($819, €673).

CONCLUSIONS

Under these specific circumstances, redirection would have improved outcomes from thrombolysis at little additional cost.

First-Year Outcomes after Stroke Rehabilitation: A Multicenter Study in Thailand

Stroke affects the long-term quality of life and the well-being of patients and families. Stroke patients gain benefits from rehabilitation. Authors reported 1-year outcomes of stroke rehabilitation in 327 patients registered to the Thai Stroke Rehabilitation Registry. The outcomes included death rate, readmission rate, functional ability score (Barthel Index, BI), and factors affecting BI score. Of 327 patients, 214 (65.4%) had adequate follow-up data for analysis. The average age was 62.1 ± 12.5 years, and 57.9% were male. The mortality rate was 2.5% and the readmission rate was 11.2%. The number of the patients who could function independently increased from 5.5% at discharge to 22.9% and 25.5% at month 6 and month 12, respectively. The change in functional ability level of 214 patients included improvement (51.5%), deterioration (12.8%), and equivocal (35.7%). The low functional score at month 12 was significantly correlated with longer length of stay (LOS), longer onset to admission interval, and higher depression score at month-12. In conclusion, approximately half of the patients had an improvement in the disability level for at least one grade at 1-year follow-up. The low functional score by the end of the first year is associated with longer LOS during the first admission, delay in rehabilitation program, and psychological depression.

Impact of double-blind vs. open study design on the observed treatment effects of new oral anticoagulants in atrial fibrillation: a meta-analysis

BACKGROUND

The prospective, randomized, open, blinded endpoint evaluation (PROBE) design has been proposed as a valid alternative to the double-blind (DB) design for trials comparing new oral anticoagulants (NOAs) with INR-adjusted vitamin K antagonists in patients with non-valvular atrial fibrillation (NVAF).

OBJECTIVES

To determine whether the observed treatment effects of NOAs in patients with NVAF differ between PROBE/open-label trials and DB trials.

METHODS

All phase II or III trials were eligible. The main efficacy and safety outcomes were stroke/systemic embolism (SSE) and major bleeding, respectively. Other outcomes included ischemic SSE, hemorrhagic stroke, intracranial and extracranial bleeding, myocardial infarction, and all-cause and cardiovascular mortality. Interaction (Cochran's chi-squared test) between PROBE and DB designs was tested.

RESULTS

Thirteen studies (61 620 patients) were included. For SSE, a greater treatment effect of NOAs vs. INR-adjusted warfarin was observed in PROBE trials (RR 0.76, CI 0.65-0.89) compared with DB trials (RR 0.88, CI 0.78-0.98), but the interaction test was non-significant (P = 0.16). A significant 67% enhancement of treatment effect was found with PROBE/open-label trials compared with DB trials (interaction test, P = 0.05) for hemorrhagic stroke. No other interaction was significant. A non-significant interaction (P = 0.07) between oral direct thrombin inhibitors (RR 0.33; 0.22-0.51) and factor Xa inhibitors (RR 0.54; 0.40-0.72) was seen. No heterogeneity was found for any outcome.

CONCLUSIONS

Our meta-analysis showed no significant interaction of study design for the main efficacy and safety outcomes. However, the non-significantly exaggerated reduction in SSE suggests interdependence of treatment effect and PROBE design, especially for hemorrhagic stroke.

Predictors of long-term survival among first-ever ischemic and hemorrhagic stroke in a Brazilian stroke cohort

BACKGROUND

Few studies have examined both ischemic and hemorrhagic stroke to identify prognostic factors associated to long-term stroke survival. We investigated long-term survival and predictors that could adversely influence ischemic and hemorrhagic first-ever stroke prognosis.

METHODS

We prospectively ascertained 665 consecutive first-ever ischemic and hemorrhagic stroke cases from "The Study of Stroke Mortality and Morbidity" (The EMMA Study) in a community hospital in São Paulo, Brazil. We evaluated cardiovascular risk factors and sociodemographic characteristics (age, gender, race and educational level).

RESULTS

We found a lower survival rate among hemorrhagic cases compared to ischemic stroke cases at the end of 4 years of follow-up (52% vs. 44%, p = 0.04). The risk of death was two times higher among people with ischemic stroke without formal education. Also, we found consistently higher risk of death for diabetics with ischemic stroke (HR = 1.45; 95% CI = 1.07-1.97) compared to no diabetics. As expected, age equally influenced on the high risk of poor survival, regardless of stroke subtype.

CONCLUSIONS

For ischemic stroke, the lack of formal education and diabetes were significant independent predictors of poor long-term survival.

Greater stroke severity predominates over all other factors for the worse outcome of cardioembolic stroke

BACKGROUND

Cardioembolic (CE) strokes are more disabling and more fatal than non-CE strokes. Multiple prognostic factors have been recognized, but the magnitude of their relative contributions has not been well explored.

METHODS

Using a prospective stroke outcome database, we compared the 3-month outcomes of CE and non-CE strokes. We assessed the relative contribution of each prognostic factor of initial stroke severity, poststroke complications, and baseline characteristics with multivariable analyses and model fitness improvement using -2 log-likelihood and Nagelkerke R2.

RESULTS

This study included 1233 patients with acute ischemic stroke: 193 CE strokes and 1040 non-CE strokes. Compared with the non-CE group, CE group had less modified Rankin Scale (mRS) 0-2 outcomes (47.2% versus 68.5%; odds ratio [95% confidence interval], .41 [.30-.56]), less mRS 0-1 outcomes (33.7% versus 53.5%; .44 [.32-.61]), more mRS 5-6 outcomes (32.1% versus 10.9%; 3.88 [2.71-5.56]), and higher mortality (19.2% versus 5.2%; 4.33 [2.76-6.80]) at 3 months. When adjusting either baseline characteristics or poststroke complications, the outcome differences between the 2 groups remained significant. However, adjusting initial National Institute of Health Stroke Scale (NIHSS) score alone abolished all outcome differences except for mortality. For mRS 0-2 outcomes, the decrement of -2 log-likelihood and the Nagelkerke R2 of the model adjusting initial NIHSS score alone approached 70.2% and 76.7% of the fully adjusting model.

CONCLUSION

Greater stroke severity predominates over all other factors for the worse outcome of CE stroke. Primary prevention and more efficient acute therapy for stroke victims should be given top priorities to reduce the burden of CE strokes.

Activities of daily living dependency and disease-specific mortality during 12-year follow-up in an 80-year-old population

BACKGROUND AND AIMS

Although total mortality is likely to be higher in elderly individuals with frailty or impaired activities of daily living (ADL), little is known about the relationships between disease-specific mortality and ADL dependency in the elderly. Therefore, we examined whether 12-year disease-specific mortality may be associated with ADL dependency in an 80-year-old population.

METHODS

In 1998, of 1,282 community-dwelling residents of Japan's Fukuoka Prefecture, 824 (64.3 %) (309 males and 515 females) participated, the remaining 458 subjects did not participate, and their deaths and causes of death were followed up for 12 years after the baseline examination. ADL dependency was determined according to the guidelines for disabled elderly from the Health, Labor, and Welfare Ministry of Japan, and ADL dependency was measured only at baseline.

RESULTS

During the 12-year follow-up, 506 died, 276 did not die, and 42 were lost. Of the 506 who died, 128 died due to cardiovascular disease, 96 to respiratory tract disease, 87 to cancer, and 51 to senility. The subjects were classified into three groups as follows: ADL-1 (independent group, n = 600), ADL-2 (almost-independent group, n = 113), and ADL-3 (dependent group, n = 93).Total-cause mortality was 2.8 times higher in ADL-3 subjects, respiratory disease mortality was 4.1 times higher in ADL-3 subjects, and senility mortality was 5.7 times higher in ADL-3 subjects than in ADL-1 subjects, after adjusting for various confounding factors. There was no association between mortality due to cancer or cardiovascular disease and ADL dependency.

CONCLUSIONS

We found an independent association between ADL dependency and mortality due to all causes, respiratory disease or senility, but no association with mortality due to cancer or cardiovascular disease. These findings suggest that improving ADL dependency may reduce all mortality and mortality due to respiratory disease or senility.

Stroke rehabilitation: recent advances and future therapies

Despite advances in the acute management of stroke, a large proportion of stroke patients are left with significant impairments. Over the coming decades the prevalence of stroke-related disability is expected to increase worldwide and this will impact greatly on families, healthcare systems and economies. Effective neuro-rehabilitation is a key factor in reducing disability after stroke. In this review, we discuss the effects of stroke, principles of stroke rehabilitative care and predictors of recovery. We also discuss novel therapies in stroke rehabilitation, including non-invasive brain stimulation, robotics and pharmacological augmentation. Many trials are currently underway, which, in time, may impact on future rehabilitative practice.

A model of cost-effectiveness of tissue plasminogen activator in patient subgroups 3 to 4.5 hours after onset of acute ischemic stroke

STUDY OBJECTIVE

The European Cooperative Acute Stroke Study III (ECASS III) showed that recombinant tissue plasminogen activator (rtPA) administered 3 to 4.5 hours after acute ischemic stroke led to improvement in patient disability versus placebo. We evaluate the long-term incremental cost-effectiveness of rtPA administered 3 to 4.5 hours after acute ischemic stroke onset versus no treatment according to patient clinical and demographic factors.

METHODS

We developed a disease-based decision analytic model to project lifetime outcomes of patients post-acute ischemic stroke from the payer perspective. Clinical data were derived from the ECASS III trial, longitudinal cohort studies, and health state preference studies. Cost data were based on Medicare reimbursement and other published sources. We performed probabilistic sensitivity analyses to evaluate uncertainty in the analysis.

RESULTS

rtPA in a hypothetical cohort resulted in a gain of 0.07 years of life (95% credible range 0.0005 to 0.17) and 0.24 quality-adjusted life-years (95% credible range 0.01 to 0.60) and a difference in cost of $1,495 (95% credible range -$4,637 to $6,100) compared with placebo. The incremental cost-effectiveness ratio for all patients was $6,255 per quality-adjusted life-year gained; for patients younger than 65 years, cost saving; for patients aged 65 years or older, $35,813 per quality-adjusted life-year; for patients with baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 9, $16,322 per quality-adjusted life-year; for patients with NIHSS score 10 to 19, $37,462 per quality-adjusted life-year; and for patients with NIHSS score greater than or equal to 20, $2,432 per quality-adjusted life-year. The majority of other subgroups such as sex, history of stroke, and history of hypertension were either cost saving or cost-effective, with the exceptions of diabetes and atrial fibrillation.

CONCLUSION

The results indicate that rtPA in the 3- to 4.5-hour therapeutic window provides improvement in long-term patient outcomes in most patient subgroups and is a good economic value versus no treatment.

Outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 70 years old

Objective

Malignant middle cerebral artery (MCA) infarction occurs in 10% of all ischemic strokes and these severe strokes are associated with high mortality rates. Recent clinical trials demonstrated that early decompressive craniectomy reduce mortality rates and improves functional outcomes in healthy young patients (less than 61 years of age) with a malignant infarction. The purpose of this study was to assess the efficacy of decompressive craniectomy in elderly patients (older than 70 years of age) with a malignant MCA infarction.

Methods

Between February 2008 and October 2011, 131 patients were diagnosed with malignant MCA infarctions. We divided these patients into two groups: patients who underwent decompressive craniectomy (n = 58) and those who underwent conservative care (n = 73). A cut-off point of 70 years of age was set, and the study population was segregated into those who fell above or below this point. Mortality rates and functional outcome scores were assessed, and a modified Rankin Scale (mRS) score of > 3 was considered to represent a poor outcome.

Results

Mortality rates were significantly lower at 29.3% (one-month mortality rate) and 48.3% (six-month mortality rate) in the craniectomy group as compared to 58.9% and 71.2%, respectively, in the conservative care group (p < 0.001, p = 0.007). Age (≥70 years vs. < 70 years) did not statistically differ between groups for the six-month mortality rate (p = 0.137). However, the pre-operative National Institutes of Health Stroke Scale (NIHSS) score did contribute to the six-month mortality rate (p = 0.047).

Conclusion

Decompressive craniectomy is effective for patients with a malignant MCA infarction regardless of their age. Therefore, factors other than age should be considered and the treatment should be individualized in elderly patients with malignant infarctions.

Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis

BACKGROUND

Recombinant tissue plasminogen activator (rt-PA, alteplase) improved functional outcome in patients treated soon after acute ischaemic stroke in randomised trials, but licensing is restrictive and use varies widely. The IST-3 trial adds substantial new data. We therefore assessed all the evidence from randomised trials for rt-PA in acute ischaemic stroke in an updated systematic review and meta-analysis.

METHODS

We searched for randomised trials of intravenous rt-PA versus control given within 6 h of onset of acute ischaemic stroke up to March 30, 2012. We estimated summary odds ratios (ORs) and 95% CI in the primary analysis for prespecified outcomes within 7 days and at the final follow-up of all patients treated up to 6 h after stroke.

FINDINGS

In up to 12 trials (7012 patients), rt-PA given within 6 h of stroke significantly increased the odds of being alive and independent (modified Rankin Scale, mRS 0-2) at final follow-up (1611/3483 [46·3%] vs 1434/3404 [42·1%], OR 1·17, 95% CI 1·06-1·29; p=0·001), absolute increase of 42 (19-66) per 1000 people treated, and favourable outcome (mRS 0-1) absolute increase of 55 (95% CI 33-77) per 1000. The benefit of rt-PA was greatest in patients treated within 3 h (mRS 0-2, 365/896 [40·7%] vs 280/883 [31·7%], 1·53, 1·26-1·86, p<0·0001), absolute benefit of 90 (46-135) per 1000 people treated, and mRS 0-1 (283/896 [31·6%] vs 202/883 [22·9%], 1·61, 1·30-1·90; p<0·0001), absolute benefit 87 (46-128) per 1000 treated. Numbers of deaths within 7 days were increased (250/2807 [8·9%] vs 174/2728 [6·4%], 1·44, 1·18-1·76; p=0·0003), but by final follow-up the excess was no longer significant (679/3548 [19·1%] vs 640/3464 [18·5%], 1·06, 0·94-1·20; p=0·33). Symptomatic intracranial haemorrhage (272/3548 [7·7%] vs 63/3463 [1·8%], 3·72, 2·98-4·64; p<0·0001) accounted for most of the early excess deaths. Patients older than 80 years achieved similar benefit to those aged 80 years or younger, particularly when treated early.

INTERPRETATION

The evidence indicates that intravenous rt-PA increased the proportion of patients who were alive with favourable outcome and alive and independent at final follow-up. The data strengthen previous evidence to treat patients as early as possible after acute ischaemic stroke, although some patients might benefit up to 6 h after stroke.

FUNDING

UK Medical Research Council, Stroke Association, University of Edinburgh, National Health Service Health Technology Assessment Programme, Swedish Heart-Lung Fund, AFA Insurances Stockholm (Arbetsmarknadens Partners Forsakringsbolag), Karolinska Institute, Marianne and Marcus Wallenberg Foundation, Research Council of Norway, Oslo University Hospital.

The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial

BACKGROUND

Thrombolysis is of net benefit in patients with acute ischaemic stroke, who are younger than 80 years of age and are treated within 4·5 h of onset. The third International Stroke Trial (IST-3) sought to determine whether a wider range of patients might benefit up to 6 h from stroke onset.

METHODS

In this international, multicentre, randomised, open-treatment trial, patients were allocated to 0·9 mg/kg intravenous recombinant tissue plasminogen activator (rt-PA) or to control. The primary analysis was of the proportion of patients alive and independent, as defined by an Oxford Handicap Score (OHS) of 0-2 at 6 months. The study is registered, ISRCTN25765518.

FINDINGS

3035 patients were enrolled by 156 hospitals in 12 countries. All of these patients were included in the analyses (1515 in the rt-PA group vs 1520 in the control group), of whom 1617 (53%) were older than 80 years of age. At 6 months, 554 (37%) patients in the rt-PA group versus 534 (35%) in the control group were alive and independent (OHS 0-2; adjusted odds ratio [OR] 1·13, 95% CI 0·95-1·35, p=0·181; a non-significant absolute increase of 14/1000, 95% CI -20 to 48). An ordinal analysis showed a significant shift in OHS scores; common OR 1·27 (95% CI 1·10-1·47, p=0·001). Fatal or non-fatal symptomatic intracranial haemorrhage within 7 days occurred in 104 (7%) patients in the rt-PA group versus 16 (1%) in the control group (adjusted OR 6·94, 95% CI 4·07-11·8; absolute excess 58/1000, 95% CI 44-72). More deaths occurred within 7 days in the rt-PA group (163 [11%]) than in the control group (107 [7%], adjusted OR 1·60, 95% CI 1·22-2·08, p=0·001; absolute increase 37/1000, 95% CI 17-57), but between 7 days and 6 months there were fewer deaths in the rt-PA group than in the control group, so that by 6 months, similar numbers, in total, had died (408 [27%] in the rt-PA group vs 407 [27%] in the control group).

INTERPRETATION

For the types of patient recruited in IST-3, despite the early hazards, thrombolysis within 6 h improved functional outcome. Benefit did not seem to be diminished in elderly patients.

FUNDING

UK Medical Research Council, Health Foundation UK, Stroke Association UK, Research Council of Norway, Arbetsmarknadens Partners Forsakringsbolag (AFA) Insurances Sweden, Swedish Heart Lung Fund, The Foundation of Marianne and Marcus Wallenberg, Polish Ministry of Science and Education, the Australian Heart Foundation, Australian National Health and Medical Research Council (NHMRC), Swiss National Research Foundation, Swiss Heart Foundation, Assessorato alla Sanita, Regione dell'Umbria, Italy, and Danube University.

Disability-adjusted life years analysis: implications for stroke research

Stroke is a prototype disorder that disables as well as kills people. The disability-adjusted life years (DALY) metric developed by the World Health Organization to measure the global burden of disease integrates healthy life years lost due to both premature mortality and living with disability. Accordingly, it is well suited to stroke research. The DALY has previously been applied only to large but relatively crude population-level data analyses, but now it is possible to calculate the DALY lost in individual stroke patients. Measuring each patient's stroke outcome with DALY lost has expanded its application to the analysis of treatment effect in acute stroke trials, delineating the poststroke complication impact, the differential weighting of discrete vascular events, and estimating a more refined stroke burden in a specific population. The DALY metric has several advantages over conventional stroke outcome measures: 1) Since the DALY measures the burden of diverse health conditions with a common metric of life years lost, stroke burden and benefits of stroke interventions can be directly compared to other health conditions and their treatments. 2) Quantifying stroke burden or interventional benefits as the life years lost or gained makes the DALY metric more intuitively accessible for public and health system planners. 3) As a continuous, equal-interval scale, the DALY analysis might be statistically more powerful than either binary or ordinal rank outcome analyses in detecting the treatment effects of clinical trials. 4) While currently employed stroke outcome measures take one-time snapshots of disability or mortality and implicitly indicate long-term health impact, the DALY explicitly indicates the burdens of living with disability for an individual's remaining life.

Burden of ischemic stroke in Korea: analysis of disability-adjusted life years lost

Background and Purpose

Disability-adjusted life years (DALY), incorporating both disability and mortality, has been widely employed to measure regional and global burdens of stroke. Thus far, the DALY lost to stroke in a population has been estimated using only the crude population-level data; no previous study has incorporated refined data from stroke registries. The aim of this study was to integrate the stroke registry data and the population-level incidence data to project the nationwide DALY lost to ischemic stroke.

Methods

From the data of two large ischemic stroke registries, we derived an average DALY lost due to ischemic stroke for each of the following age groups: <45, 45-54, 55-64, 65-74, 75-84, and ≥85 years. The nationwide ischemic stroke incidence for each age group was extracted from a cardiovascular and cerebrovascular surveillance study that analyzed the 2004 Korean Health Insurance database.

Results

The average DALY lost due to ischemic stroke for the age groups <45, 45-54, 55-64, 65-74, 75-84, and ≥85 years was 5.07, 4.63, 4.35, 3.88, 2.88, and 1.73, respectively. By multiplying the incidence and the average DALY lost, the nationwide DALY lost was determined to be 9,952 for those <45 years, 24,608 for 45-54 years, 50,682 for 55-64 years, 88,875 for 65-74 years, 52,089 for 75-84 years, and 8,192 for ≥85 years, respectively. The projected nationwide DALY lost due to 64,688 ischemic strokes in 2004 was 234,399 (121,482 for men and 113,244 for women), and the DALY lost per 100,000 person-years was 483 (500 for men and 469 for women).

Conclusions

Incidence data from a population study and DALY values derived from stroke registries can be integrated to provide a more refined projection of the nationwide burden of ischemic stroke. In Korea, more than 230,000 years of healthy life are being lost annually due to ischemic stroke, and hence prompt action is imperative.

Fatigue after stroke: baseline predictors and influence on survival. Analysis of data from UK patients recruited in the International Stroke Trial

Background and Purpose

Little is known about the associations of post-stroke fatigue or its influence on survival. The vitality component of the Short Form 36 (SF-36) is a valid and reliable measure of post-stroke fatigue. We sought to identify associates of post-stroke fatigue and determine whether fatigue predicted survival.

Methods

We used SF-36 vitality scores obtained by postal questionnaires from 1080 UK patients randomised in the International Stroke Trial, at a mean of 64 weeks after stroke onset. We used logistic regression to explore factors at randomisation which predicted SF-36 vitality at follow-up, and the relationship between SF-36 vitality and both SF-36 mental health and SF-36 emotional role function at follow-up. We used Cox proportional hazards to explore the influence of SF-36 vitality at follow-up on subsequent survival, using four different statistical models for handling missing data.

Results

Female sex, increasing age, lower mental health and lower emotional role function scores were associated with greater degrees of fatigue after stroke (i.e. lower vitality scores) but these factors explained <30% of the variance (R²) in fatigue. In two models, fatigue at follow-up was associated with shorter subsequent survival.

Conclusion

Increasing age, female sex, emotional role function and mental health were associated with increased fatigue at a mean of 64 weeks after stroke onset, but explained less than 30% of the variance. Fatigue was associated with reduced subsequent long-term survival in 2/4 models. Further work is needed to identify the biological substrate of fatigue and to clarify its influence on survival.

Stroke discharges from a rehabilitation unit: 1-year and 5-year domicile outcomes. Function is important

BACKGROUND

Stroke units save lives, reduce disability and increase the chances of the person returning to their own home. Following the introduction of a stroke rehabilitation unit, we assessed the durability of stroke discharges over a 1-year period and predictors of early 'failed' home discharges. Stability of discharge domicile and survival over 5 years was also reviewed.

METHODS

A 6-month cohort of all discharges was followed for 5 years. Changes in domicile, including entry into institutional care, were recorded out to 5 years or until death. Predictors of early (3 months) and later (1 year) discharge stability were assessed.

RESULTS

There were 142 discharges. Fifty-eight (76%) of those who returned home were still at home 12 months later. In contrast, there was a high mortality of dependent patients who were discharged to high dependency care (9 (29%) and 13 (42%) at 3 and 12 months, respectively). The chance of an early failed discharge was associated with lower functional ability on discharge (P= 0.012). Lower function on discharge was also independently associated with death in the next 12 months (P < 0.0001). At 5 years the mortality for the whole sample was 55% (78 of 141) and 38 (61%) of the survivors still lived in the community whereas 24 (39%) resided in institutional care.

CONCLUSION

Functional ability on discharge is a key predictor of ability to remain at home as well as survival and therefore every effort should be made to maximize function.

The prognostic factors that influence long-term survival in acute large cerebral infarction

OBJECTIVE

We retrospectively evaluated the prognostic factors that can influence long-term survival in patients who suffered acute large cerebral infarction.

METHODS

Between June 2003 and October 2008, a total of 178 patients were diagnosed with a large cerebral infarction, and, among them, 122 patients were alive one month after the onset of stroke. We investigated the multiple factors that might have influenced the life expectancies of these 122 patients.

RESULTS

The mean age of the patients was 70±13.4 years and the mean survival was 41.7±2.8 months. The mean survival of the poor functional outcome group (mRS≥4) was 33.9±3.3 months, whereas that of the good functional outcome group (mRS≤3) was 58.6±2.6 months (p value =0.000). The mean survival of the older patients (≥70 years) was 29.7±3.4 months, whereas that of the younger patients (<70 years) was much better as 58.9±3.2 months (p value=0.000). Involvement of ACA or PCA territory in MCA infarction is also a poor prognostic factor (p value=0.021). But, other factors that are also known as significant predictors of poor survival (male gender, hypertension, heart failure, atrial fibrillation, diabetes mellitus, a previous history of stroke, smoking, and dyslipidemia) did not significantly influence the mean survival time in the current study.

CONCLUSION

Age (older versus younger than 70 years old) and functional outcome at one month could be critical prognostic factors for survival after acute large cerebral infarction. Involvement of ACA or PCA territory is also an important poor prognostic factor in patients with MCA territorial infarction.

Cost-effectiveness of recombinant tissue plasminogen activator in the management of acute ischemic stroke: a systematic review

BACKGROUND AND PURPOSE

This work was undertaken to review the current cost-effectiveness analysis data on thrombolysis by intravenous (IV) therapy with recombinant tissue plasminogen activator (rtPA) for acute ischemic stroke.

METHODS

PubMed was searched for articles published between 1995 and 2008. The cost-effectiveness analysis data from eight eligible studies were reviewed, paying particular attention to their modeling assumptions and the quality of the source data.

RESULTS

THE REVIEWED STUDIES WERE FROM SIX COUNTRIES: USA (n=2), UK (n=2), Canada (n=1), Australia (n=1), Spain (n=1), and Denmark (n=1); most were performed from the healthcare-system and/or societal perspectives. IV rtPA was associated with an acceptable increase in short-term cost [range: US$ 36-236/patient; US$ 29,148-55,591/quality-adjusted life-years (QALYs)], and a net long-term cost saving that was higher from a societal perspective (range: -US$ 12,043 to -US$ 630/patient; -US$ 207,253 to -US$ 21,938/QALYs) than from a healthcare-system perspective (range: -US$ 5,811 to -US$ 5,415/patient; -US$ 41,137 to -US$ 4,662/QALYs).

CONCLUSIONS

IV rtPA seems to be a cost-effective strategy for the management of acute ischemic stroke, and might reduce the associated healthcare costs as well as patients' disabilities. Further cost-effectiveness research and the development of a public health strategy are warranted to optimize the use of rtPA in Korea.

A case report exploring activity intensity in inpatient rehabilitation after stroke

Background and Purpose. Inpatient rehabilitation in countries other than the United States (US) has been described as a time where patients are often not engaged in intensive physical activity. The purpose of this case report is to explore the amount and intensity of physical activity provided in inpatient rehabilitation after stroke in the US. Methods. This study presents a case report of a person admitted to an inpatient rehabilitation unit after sustaining a first stroke. A customized data collection tracked type of activity, activity intensity and social interaction every 5 minutes during the rehabilitation day. Results. 74 percent of the day was spent in low intensity, often seated, physical activity; 14% of the day was spent resting or sleeping. Only 2.91% the day was spent in moderate or high intensity activity with a mobility focus. Conclusions. Consistent with other studies, this case report suggests a relatively low physical demand to rehabilitation delivered in inpatient stroke rehabilitation. This case begins to raise questions about optimized rehabilitation parameters for acute stroke rehabilitation.

Years of optimum health lost due to complications after acute ischemic stroke: disability-adjusted life-years analysis

BACKGROUND AND PURPOSE

Complications after stroke increase disability or death. The disability-adjusted life-year (DALY) metric, developed by the World Health Organization to measure the global burden of disease, integrates both mortality and disability. Widely used in population-level data analyses, it has not been applied to individual patient-level data captured in outcome registries.

METHODS

We analyzed patient-level data from the outcome registry of 1254 consecutive patients with acute ischemic stroke enrolled between September 1, 2004, and August 31, 2005, in South Korea. For each subject, we calculated DALY lost due to the qualifying stroke and then analyzed additional DALY lost due to complications after stroke.

RESULTS

For 1233 patients with available 3-month outcomes, the average DALY lost due to the index stroke was 3.82 (95% CI, 3.68 to 3.96). Any complications, neurological complications, and medical complications occurred in 34.0%, 20.8%, and 24.0%, respectively. The additional DALYs lost associated with any, neurological, and medical complications were 2.11 (95% CI, 1.78 to 2.44), 2.15 (95% CI, 1.72 to 2.59), and 1.99 (95% CI, 1.59 to 2.40), respectively. Patients with 1 complication had 1.52 (95% CI, 1.15 to 1.89) additional DALY lost, and those with >or=2 complications had 2.69 (95% CI, 2.18 to 3.20) additional DALY lost.

CONCLUSIONS

Early poststroke complications deprive patients of approximately 2 years of optimum health. Greater numbers of complications are associated with greater loss of healthy life-years. DALY analysis quantifies the burden of poststroke complications with a uniform metric potentially useful for health system planners.

Prognostic Value of Copeptin

Background and Purpose— An accurate long-term outcome prediction may improve management of stroke patients. We investigated the ability of copeptin to predict 1-year outcome in stroke patients.

Methods— In this preplanned post hoc analysis, the National Institutes of Health Stroke Scale score and copeptin levels were measured on admission in a cohort of patients with ischemic stroke. The primary end point was functional outcome (modified Rankin Scale score <3 or 3–6) after 1 year. The secondary end point was all-cause mortality.

Results— Of 362 patients, 341 (94.2%) completed the 1-year follow-up, 146 (43%) patients had an unfavorable functional outcome, and 66 (20%) died. Multivariate logistic-regression analysis adjusted for age and National Institutes of Health Stroke Scale score showed that copeptin was an independent predictor of functional outcome (odds ratio=4.00; 95% CI, 1.94–8.19) and death (odds ratio=2.68; 95% CI, 1.24–5.82). The area under the receiver operating characteristic curve of copeptin was 0.72 (95% CI, 0.67–0.77) for functional outcome and 0.74 (95% CI, 0.69–0.78) for mortality. Copeptin improved the area under the receiver operating characteristic curve of the National Institutes of Health Stroke Scale score for functional outcome from 0.70 (95% CI, 0.64–0.74) to 0.76 (95% CI, 0.71–0.82; P =0.002) and for mortality from 0.74 (95% CI, 0.69–0.78) to 0.78 (95% CI, 0.71–0.85; P =0.04).

Conclusions— Copeptin levels are a useful, complementary tool to predict functional outcome and mortality 1 year after stroke.

Clinical Trial Registration— ISCTRN 00390962; clinicaltrials.gov No. NCT00390962.

Thromboembolism in atrial fibrillation

Thromboembolism is a severe complication in atrial fibrillation. This overview presents thromboembolic disease as a single entity, ranging from stroke through mesenteric ischemia to acute limb ischemia. The PubMed, Embase, and Cochrane databases were systematically searched for the terms "atrial fibrillation" and "thromboembolism" in reports published from January 1986 to September 2009. The information of 10 evidence-based practice guideline documents and 61 further sources was systematically extracted. In atrial fibrillation, the average annual stroke risk is increased by 2.3% (lethality 30%). The annual incidence of acute mesenteric ischemia is 0.14% (lethality 70%), and that of acute limb ischemia is 0.4% (lethality 16%). In total, approximately 80% of embolism-related deaths are from stroke and 20% from other systemic thromboembolism. The ischemic symptoms generally have an acute onset but may mimic other diseases, particularly in mesenteric ischemia. Early diagnosis and treatment can limit or even prevent tissue infarction. Guideline-recommended therapy with aspirin or warfarin reduces the thromboembolic risk. Suitable patients may optimize their warfarin therapy by self-monitoring of the international normalized ratio (INR). New oral and parenteral anticoagulants with more stable pharmacokinetics are being developed. In conclusion, atrial fibrillation predisposes to thromboembolism. If ischemic stroke or systemic thromboembolism occurs, early diagnosis and treatment can improve outcomes. The thromboembolic risks are reduced by guideline-adherent antithrombotic therapy with warfarin or aspirin. Future directions may include self-monitoring of the international normalized ratio and novel anticoagulants.

Severity of leukoaraiosis correlates with clinical outcome after ischemic stroke

BACKGROUND

Leukoaraiosis (LA) is closely associated with aging, a major determinant of clinical outcome after ischemic stroke. In this study we sought to identify whether LA, independent of advancing age, affects outcome after acute ischemic stroke.

METHODS

LA volume was quantified in 240 patients with ischemic stroke and MRI within 24 hours of symptom onset. We explored the relationship between LA volume at admission and clinical outcome at 6 months, as assessed by the modified Rankin Scale (mRS). An ordinal logistic regression model was developed to analyze the independent effect of LA volume on clinical outcome.

RESULTS

Bivariate analyses showed a significant correlation between LA volume and mRS at 6 months (r = 0.19, p = 0.003). Mean mRS was 1.7 +/- 1.8 among those in the lowest (< or =1.2 mL) and 2.5 +/- 1.9 in the highest (>9.9 mL) quartiles of LA volume (p = 0.01). The unfavorable prognostic effect of LA volume on clinical outcome was retained in the multivariable model (p = 0.002), which included age, gender, stroke risk factors (hypertension, diabetes mellitus, atrial fibrillation), previous history of brain infarction, admission plasma glucose level, admission NIH Stroke Scale score, IV rtPA treatment, and acute infarct volume on MRI as covariates.

CONCLUSIONS

The volume of leukoaraiosis is a predictor of clinical outcome after ischemic stroke and this relationship persists after adjustment for important prognostic factors including age, initial stroke severity, and infarct volume.

Cost-effectiveness of warfarin: trial versus "real-world" stroke prevention in atrial fibrillation

BACKGROUND AND PURPOSE

Previous cost-effectiveness analyses analyzed warfarin for stroke prevention in randomized trial settings. Given the complexities of warfarin treatment, cost-effectiveness should be examined within a real-world setting.

METHODS

Our model followed patients with atrial fibrillation at moderate to high risk of stroke through primary and recurrent ischemic stroke, hemorrhages--intracranial and extracranial, and the resulting disability. Four scenarios were examined: (1) all patients start on warfarin with perfect control, that is, international normalized ratio (INR) values always within range; (2) all patients start on warfarin with trial-like control, where INR can fall outside the recommended range; (3) all patients start on warfarin with real-world INR control; and (4) real-world prescription (and control) of warfarin, aspirin, or neither for warfarin-eligible patients. Reported warfarin discontinuation rates were used. Main outcomes were total number of events, quality adjusted life years, and costs in a US setting.

RESULTS

The total number of primary and recurrent ischemic strokes in a 1,000-patient cohort (age 70 years, lifetime analysis) was 626, 832, 984, and 1,171 in scenarios 1 to 4, respectively. The corresponding mean quality adjusted life years per patient were 7.21, 6.92, 6.75, and 6.67 for scenarios 1 to 4, respectively. Costs per patient were $68,039, $77,764, $84,518, and $87,248 in scenarios 1 to 4, respectively. If "perfect" adherence to warfarin was assumed, except for discontinuations for clinical reasons, strokes would decrease to 503, 737, 909, and 1,120 in scenarios 1 to 4, respectively.

CONCLUSIONS

Clinical and cost outcomes are strongly dependent on the quality of anticoagulation and rates of warfarin discontinuation. Clinicians should work to improve both. Policy makers should use real-world INR control and warfarin discontinuation rates when assessing cost-effectiveness.

Chronic atrial fibrillation: Incidence, prevalence, and prediction of stroke using the Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack (CHADS2) risk stratification scheme

BACKGROUND

The aim of the study is to estimate the incidence and prevalence of chronic AF (cAF) in the United Kingdom and test the accuracy of the CHADS2 score for stroke prediction.

METHODS

The General Practice Research Database was used to identify patients aged 40+ years diagnosed with cAF and control patients. Harrell's C-statistic was used to test possible improvements in CHADS2.

RESULTS

The study population included 51,807 cAF patients. The incidence of cAF increased by age and was higher in men than women. The prevalence of cAF has increased over time. The excess 5-year risk for stroke in cAF patients correlated well with CHADS2 as follows: score 0, 1.9% (95% CI 1.6-2.1); 1, 3.0% (95% CI 2.7-3.3); 2, 4.7% (95% CI 4.3-5.1); 3, 7.2% (95% CI 6.6-7.9); 4, 10.5% (95% CI 9.4-11.5); 5, 13.9% (95% CI 12.2-15.5); and 6, 15.8% (95% CI 13.5-18.1). Adding sex, the extension of age categories and reweighing of established risk factors improved CHADS2 accuracy (C-statistic 0.68-0.72). Applying the reclassification resulted in a substantial number of patients changing stroke risk category.

CONCLUSION

Atrial fibrillation is a prevalent and growing problem, which significantly increases the risk of ischemic stroke. The CHADS2 score is a good predictor of the stroke risk but could be improved.

Functional status and long term outcome of stroke

Despite undoubted progress, we still have much to do