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Supanc V, Sonicki Z, Vukasovic I, Solter VV, Zavoreo I, Kes VB. The role of classic risk factors and prothrombotic factor gene mutations in ischemic stroke risk development in young and middle-aged individuals. J Stroke Cerebrovasc Dis 2013; 23:e171-6. [PMID: 24189452 DOI: 10.1016/j.jstrokecerebrovasdis.2013.09.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/27/2013] [Accepted: 09/24/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND In young individuals, a genetically predisposing hypercoagulability and classic modifying risk factors can act synergistically on the ischemic stroke risk development. The aim of the study was to compare the prevalence of classic vascular risk factors and polymorphisms of the G20210A coagulation factor II (prothrombin), Arg506Glu coagulation factor V Leiden, C677T methylenetetrahydrofolate reductase (MTHFR), and 4G/5G plasminogen activator inhibitor-1 (PAI-1) and the impact of these gene mutations and classic vascular risk factors on the overall stroke risk in individuals aged 55 years or younger. METHODS The study included 155 stroke patients aged 55 years or younger and 150 control subjects. Stroke prevalence and odds ratio (OR) were assessed for the following parameters: G20210A prothrombin, Arg506Glu factor V Leiden, C677T MTHFR, and 4G/5G PAI-1 polymorphisms; total number of study polymorphisms in a particular subject (genetic sum); and classic vascular risk factors of hypertension, obesity, diabetes mellitus, cigarette smoking, hypercholesterolemia, hypertriglyceridemia, and elevated levels of low-density lipoprotein (LDL) cholesterol and very low-density lipoprotein cholesterol. RESULTS The prevalence of hypertension (P < .001), smoking (P < .001), decreased HDL cholesterol levels (P < .001), obesity (P = .001), elevated LDL cholesterol (P = .036), C677T MTHFR polymorphism (P < .001), and genetic sum was significantly higher in the group of stroke patients. The following parameters were found to act as independent risk factors for ischemic stroke: decreased HDL cholesterol level (P < .001; OR 4.618; 95% confidence interval [CI] 2.381-8.957); hypertension (P = .001; OR 2.839; 95% CI 1.519-5.305); obesity (P = .040; OR 2.148; 95% CI 1.036-4.457); smoking (P = .001; OR 2.502; 95% CI 1.436-4.359); and genetic sum as a continuous variable (P < .01; OR 2.307; 95% CI 1.638-3.250). CONCLUSIONS Gene mutations of the procoagulable and proatherosclerotic factors investigated exerted a synergistic action in the development of overall risk of ischemic stroke in young and middle-aged individuals.
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Affiliation(s)
- Visnja Supanc
- University Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb.
| | - Zdenko Sonicki
- Department of Medical Statistics, Epidemiology, and Medical Informatics, Andrija Stampar School of Public Health, University of Zagreb School of Medicine, Zagreb
| | - Ines Vukasovic
- University Department of Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Vesna V Solter
- University Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb
| | - Iris Zavoreo
- University Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb
| | - Vanja B Kes
- University Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb
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Ramalle-Gomara E, Ruiz E, Serrano M, Bártulos M, González MÁ, Matute B. Hospital Discharges and Mortality Registries: 2 Complementary Databases for the Epidemiological Surveillance of Stroke. J Stroke Cerebrovasc Dis 2013; 22:e441-5. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.04.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 04/24/2013] [Accepted: 04/29/2013] [Indexed: 11/26/2022] Open
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Correia M, Magalhães R, Silva MR, Matos I, Silva MC. Stroke types in rural and urban northern portugal: incidence and 7-year survival in a community-based study. Cerebrovasc Dis Extra 2013; 3:137-49. [PMID: 24348498 PMCID: PMC3843922 DOI: 10.1159/000354851] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM Differences in stroke incidence and mortality between regions could stem from differences in the incidence of particular stroke types and long-term prognosis. The aim of this study was to investigate whether different risk profiles and stroke types underlie the difference in stroke incidence and patient long-term survival in rural and urban populations. METHODS All suspected first-ever-in-a-lifetime strokes occurring between October 1998 and September 2000 in 37,290 residents of rural municipalities and in 86,023 individuals living in the city of Porto were entered into a population-based registry. Standard definitions of stroke types and overlapping comprehensive sources of information were used for patient identification. Patients were examined by neurologists at 3 months, 1 year and 7 years after the index event. RESULTS From a total of 688 patients included (226 in rural and 462 in urban areas), 76.2% had an ischaemic stroke (IS; 75.3 vs. 77.9%), 16.1% a primary intracerebral haemorrhage (PICH; 16.3 vs. 14.6%) and 3.3% a subarachnoid haemorrhage (SAH; 2.7 vs. 3.7%); in 4.4% (4.9 vs. 4.1%), the stroke type could not be determined. The annual incidence rate per 1,000 was 2.13 (95% CI, 1.95-2.31), 0.45 (95% CI, 0.37-0.53), 0.09 (95% CI, 0.06-0.14) and 0.12 (95% CI, 0.08-0.17), respectively. The age-specific rural/urban incidence rate ratios for IS in the youngest group (<55 years) was 0.27 (95% CI, 0.11-0.69), increasing to 1.47 (95% CI, 1.07-2.01) for those aged 65-74 years and to 1.87 (95% CI, 1.39-2.52) for those between 75 and 84 years. Rural compared to urban patients with an IS were predominantly men, had a prevalence ratio (PR) of 1.28 (95% CI, 1.05-1.56), were 65 years or older (PR = 1.18; 95% CI, 1.08-1.30) and had in general a lower prevalence of risk factors. There was no evidence of rural/urban differences in 28-day case fatality for the stroke types, although IS tended to be less fatal among urban patients (10.3 vs. 13.1%), whereas PICH (33.3 vs. 24.2%) and SAH (35.3 vs. 16.7%) were less fatal among rural patients. Independently of rural/urban residence, predictors of poor survival after the acute phase (28 days) were age >65 years (HR = 3.57; 95% CI, 2.6-4.9), diabetes (HR = 1.5; 95% CI, 1.2-1.9), ischaemic heart disease (HR = 1.8; 95% CI, 1.3-2.6), atrial fibrillation (HR = 1.5; 95% CI, 1.1-2.0) and smoking habits (HR = 1.6; 95% CI, 1.1-2.3). CONCLUSIONS The age pattern of IS incidence marks the difference between rural and urban populations; the youngest urban and the oldest rural residents were at a higher risk. Although patients from rural areas were older, the relatively lower prevalence of simultaneously occurring risk and prognostic factors among them as well as the similar management of rural and urban patients may justify why rurality is not associated with long-term survival.
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Affiliation(s)
- Manuel Correia
- Serviço de Neurologia, Hospital de Santo António - Centro Hospitalar do Porto, Portugal ; UNIFAI, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Rui Magalhães
- UNIFAI, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Mário Rui Silva
- Serviço de Neurologia, Hospital de S. Pedro - Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Mirandela, Portugal
| | - Ilda Matos
- Serviço de Neurologia, Hospital de Mirandela - Centro Hospitalar do Nordeste, Mirandela, Portugal
| | - Maria Carolina Silva
- UNIFAI, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
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Raida Z, Hundahl CA, Nyengaard JR, Hay-Schmidt A. Neuroglobin over expressing mice: expression pattern and effect on brain ischemic infarct size. PLoS One 2013; 8:e76565. [PMID: 24098534 PMCID: PMC3788103 DOI: 10.1371/journal.pone.0076565] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/28/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Stroke is a major cause of death and severe disability, but effective treatments are limited. Neuroglobin, a neuronal heme-globin, has been advocated as a novel pharmacological target in combating stroke and neurodegenerative disorders based on cytoprotective properties. Using thoroughly validated antibodies and oligos, we give a detailed brain anatomical characterization of transgenic mice over expressing Neuroglobin. Moreover, using permanent middle artery occlusion the effect of elevated levels of Neuroglobin on ischemic damage was studied. Lastly, the impact of mouse strain genetic background on ischemic damage was investigated. PRINCIPAL FINDINGS A four to five fold increase in Neuroglobin mRNA and protein expression was seen in the brain of transgenic mice. A β-actin promoter was used to drive Neuroglobin over expression, but immunohistochemistry and in situ hybridization showed over expression to be confined to primarily the cortex, hippocampus, cerebellum, and only in neurons. The level and expression pattern of endogenous Neuroglobin was unaffected by insertion of the over expressing Ngb transgene. Neuroglobin over expression resulted in a significant reduction in infarct volume 24 hours after ischemia. Immunohistochemistry showed no selective sparing of Neuroglobin expressing cells in the ischemic core or penumbra. A significant difference in infarct volume was found between mice of the same strain, but from different colonies. SIGNIFICANCE In contrast to some previous reports, Neuroglobin over expression is not global but confined to a few well-defined brain regions, and only in neurons. This study confirms previous reports showing a correlation between reduced infarct volume and elevated Neuroglobin levels, but underlines the need to study the likely contribution from compensatory mechanisms to the phenotype following a genetic perturbation. We also stress, that care should be taken when comparing results where different mouse strains and colonies have been used due to large genetic background contribution to the observed phenotype.
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Affiliation(s)
- Zindy Raida
- Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- * E-mail: (ZR); (CAH); (AH-S)
| | - Christian Ansgar Hundahl
- Centre of Excellence for Translational Medicine, University of Tartu, Tartu, Estonia
- * E-mail: (ZR); (CAH); (AH-S)
| | - Jens R. Nyengaard
- Stereology and Electron Microscopy Laboratory, Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University, Aarhus, Denmark
| | - Anders Hay-Schmidt
- Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- * E-mail: (ZR); (CAH); (AH-S)
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Tveiten A, Ljøstad U, Mygland Å, Naess H. Leukoaraiosis is Associated with Short- and Long-term Mortality in Patients with Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2013; 22:919-25. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.01.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 01/25/2013] [Accepted: 01/28/2013] [Indexed: 11/30/2022] Open
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Ramalle-Gomara E, Ruiz E, Serrano M, Bartulos M, Gonzalez MA, Matute B. Validity of discharge diagnoses in the surveillance of stroke. Neuroepidemiology 2013; 41:185-8. [PMID: 24051447 DOI: 10.1159/000354626] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 07/22/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Hospital administrative data have been suggested as a valuable cost-effective tool for providing information about the stroke burden. Nevertheless, the choice of the diagnosis codes has been a critical issue in the development of case ascertainment algorithms. METHODS In this study, the Minimum Basic Data Set administrative database was used to analyze the accuracy of different ICD-9-CM algorithms based on the neurologist's clinical judgement as the 'gold standard'. RESULTS The most accurate algorithm observed in our study involved the selection of ICD-9-CM codes 430-438 in the primary diagnosis. It yielded a sensitivity of 96.1%, a specificity of 87.5% and a positive predictive value of 82.5%. CONCLUSIONS The Minimum Basic Data Set is a valuable source to evaluate stroke frequency when using an accurate algorithm to select events.
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Association between CRP gene polymorphism 717A/G, C-reactive protein and neurological deficit in ischemic stroke. J Clin Neurosci 2013; 21:574-7. [PMID: 24231564 DOI: 10.1016/j.jocn.2013.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Revised: 02/05/2013] [Accepted: 06/15/2013] [Indexed: 11/22/2022]
Abstract
Inflammatory components play an important role in the pathogenesis of arteriosclerosis, one of the main causes of stroke. Blood C-reactive protein (CRP) level is connected with the severity of neurological deficit and disability after stroke. Production of CRP depends on CRP gene polymorphism. This study enrolled 125 patients with ischemic stroke. CRP 717A/G polymorphism was tested in all patients along with an assay of CRP levels measured on the first and tenth day after stroke onset. Neurological deficit on admission and before discharge from hospital was evaluated according to National Institutes of Health Stroke Scale (NIHSS), and then associated with CRP levels and the CRP polymorphism. The CRP 717AA genotype was the most frequent, observed in 53.6% of patients; AG genotype in 40%, and GG genotype in 6.4%. Carriers of the 717GG genotype had a significantly higher CRP level on the first day after stroke versus heterozygotes (p=0.023). The improvement in neurological state evaluated with the NIHSS was significantly better in CRP 717AA patients in comparison with other CRP 717 genotypes (p=0.035). A higher level of CRP on the first day after ischemic stroke was slightly associated with the CRP 717AG genotype. The CRP 717AA genotype promotes improvement of neurological state in patients with ischemic stroke.
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108
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Schmidt S, Scholz M, Obermayer K, Brandt SA. Patterned Brain Stimulation, What a Framework with Rhythmic and Noisy Components Might Tell Us about Recovery Maximization. Front Hum Neurosci 2013; 7:325. [PMID: 23825456 PMCID: PMC3695464 DOI: 10.3389/fnhum.2013.00325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 06/12/2013] [Indexed: 12/02/2022] Open
Abstract
Brain stimulation is having remarkable impact on clinical neurology. Brain stimulation can modulate neuronal activity in functionally segregated circumscribed regions of the human brain. Polarity, frequency, and noise specific stimulation can induce specific manipulations on neural activity. In contrast to neocortical stimulation, deep-brain stimulation has become a tool that can dramatically improve the impact clinicians can possibly have on movement disorders. In contrast, neocortical brain stimulation is proving to be remarkably susceptible to intrinsic brain-states. Although evidence is accumulating that brain stimulation can facilitate recovery processes in patients with cerebral stroke, the high variability of results impedes successful clinical implementation. Interestingly, recent data in healthy subjects suggests that brain-state dependent patterned stimulation might help resolve some of the intrinsic variability found in previous studies. In parallel, other studies suggest that noisy “stochastic resonance” (SR)-like processes are a non-negligible component in non-invasive brain stimulation studies. The hypothesis developed in this manuscript is that stimulation patterning with noisy and oscillatory components will help patients recover from stroke related deficits more reliably. To address this hypothesis we focus on two factors common to both neural computation (intrinsic variables) as well as brain stimulation (extrinsic variables): noise and oscillation. We review diverse theoretical and experimental evidence that demonstrates that subject-function specific brain-states are associated with specific oscillatory activity patterns. These states are transient and can be maintained by noisy processes. The resulting control procedures can resemble homeostatic or SR processes. In this context we try to extend awareness for inter-individual differences and the use of individualized stimulation in the recovery maximization of stroke patients.
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Affiliation(s)
- Sein Schmidt
- Neurology, Vision and Motor Systems Research Group, Charité - Universitätsmedizin Berlin , Berlin , Germany
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Busch M, Schienkiewitz A, Nowossadeck E, Gößwald A. Prävalenz des Schlaganfalls bei Erwachsenen im Alter von 40 bis 79 Jahren in Deutschland. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013; 56:656-60. [DOI: 10.1007/s00103-012-1659-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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110
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Tummers JFMM, Schrijvers AJP, Visser-Meily JMA. A qualitative study of stakeholder views on the effects of provider payment on cooperation, quality of care and cost-containment in integrated stroke care. BMC Health Serv Res 2013; 13:127. [PMID: 23557401 PMCID: PMC3623662 DOI: 10.1186/1472-6963-13-127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 02/27/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke services are a form of integrated care which have been introduced in many countries, including the Netherlands, to improve health outcomes and processes of care by connecting the acute, rehabilitative, and chronic phases of stroke care. Limited research exists on the effects of payment systems on the functioning of integrated care services from the perspectives of those involved in providing, planning and contracting the care. This qualitative study identified stakeholder views on i) challenges in integrated stroke care associated with fee-for-service systems; ii) other possible financing models for stroke care, and iii) challenges in the implementation of an integrated financing mechanism for stroke care. METHODS Twenty-four participants were interviewed using face-to-face audio-recorded semi-structured interviews. Respondents were purposively selected from five stakeholder groups; care providers, health care managers, health insurers, experts and patient representatives. Transcribed data were coded and analysed to generate themes relating to the study aims. RESULTS Respondents mentioned the following challenges associated with the current fee-for-service system; inappropriate incentives for cooperation, efficiency and improving quality and the inability to exert steering power at the level of the stroke service. In addition, care is not patient-centred and the financing system is inflexible.The respondents mentioned several solutions for the challenges, but there was no consensus amongst them. Regarding the implementation of integrated financing, respondents mentioned the following general challenges; a) the foundations of the financing system are incompatible with integrated financing, b) co-morbidity and c) the lack of evidence on the effect of integrated financing. Stroke-specific challenges were; a) the diverse patient population, b) a non-uniform care trajectory, c) unclear division of responsibility for the overall care and d) different stages of development among stroke services. CONCLUSIONS This study provides new knowledge on stakeholder perception of the effect of payment systems and financial incentives on cooperation processes, quality of care and cost-containment in integrated stroke care. The results show that fee-for-service does not provide the right incentives for the integration of stroke care. We recommend to perform financial experiments for integrated stroke care.
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Affiliation(s)
- Johanneke F M M Tummers
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
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111
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Scalp acupuncture for stroke recovery: A systematic review and meta-analysis of randomized controlled trials. Eur J Integr Med 2013. [DOI: 10.1016/j.eujim.2012.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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112
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Kazadi A, Sibon I, Lafitte M, Pucheu Y, Renou P, Rouanet F, Couffinhal T. Intérêt d’un programme court de prise en charge globale de l’athérosclérose sur la réduction du risque vasculaire à distance d’un infarctus cérébral. Rev Neurol (Paris) 2013; 169:314-20. [DOI: 10.1016/j.neurol.2012.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 08/10/2012] [Accepted: 09/05/2012] [Indexed: 11/17/2022]
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113
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Janes F, Gigli GL, D'Anna L, Cancelli I, Perelli A, Canal G, Russo V, Zanchettin B, Valente M. Stroke incidence and 30-day and six-month case fatality rates in Udine, Italy: a population-based prospective study. Int J Stroke 2013; 8 Suppl A100:100-5. [PMID: 23521830 DOI: 10.1111/ijs.12000] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stroke incidence in high-income countries is reported to decrease, and new data on stroke incidence and outcome are needed to design stroke services and to ameliorate stroke management. METHODS This study is part of a two-year prospective community-based registry of all cerebrovascular events in the district of Udine (153,312 inhabitants), Friuli-Venezia Giulia region, northeast of Italy, between 1 April 2007 and 31 March 2009. Overlapping sources for case finding were used, combining hot and cold pursuit. RESULTS We identified 784 stroke cases, 640 (81.6%) incident. The crude overall annual incidence rate per 100,000 residents was 256 (95% confidence interval 241-271) for all strokes and 209 (95% confidence interval 195-223) for first-ever strokes. Incidence rate for first-ever strokes was 181 (95% confidence interval 155-211) after adjustment to the 2007 Italian population and 104 (95% confidence interval 88-122) compared with the European standard population. Incidence rates for first-ever strokes was 215 (196-235) for women, 202 (183-223) for men. Crude annual incidence rates per 100,000 population were 167 (153-178) for ischemic stroke, 31 (26-37) for intracerebral hemorrhage, 8.1 (5.7-11.4) for sub-arachnoid hemorrhage, and 4.6 (2.8-7.1) for undetermined stroke. Overall case fatality rates for first-ever stroke were 20.6% at 28 days and 30.2% at 180 days. CONCLUSIONS Our study shows incidence rates higher than previously reported in our region but not supporting the view of higher incidence rates in Northern than in Southern Italy. Results contribute to time-trends analysis on epidemiology, useful for dimensioning services in Italy and show the persistence of a gap between the outcome of stroke in Italy and that of the best performing European countries, urging to adopt better stroke management plans.
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Affiliation(s)
- Francesco Janes
- Department of Experimental and Clinical Medical Sciences, University of Udine Medical School, Udine, Italy; Department of Neurosciences, 'S. Maria della Misericordia' University Hospital, Udine, Italy
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Dehghani Firoozabadi M, Kazemi T, Sharifzadeh G, Dadbeh S, Dehghan P. Stroke in birjand, iran: a hospital-based study of acute stroke. IRANIAN RED CRESCENT MEDICAL JOURNAL 2013; 15:264-8. [PMID: 23984011 PMCID: PMC3745760 DOI: 10.5812/ircmj.4282] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 06/24/2012] [Accepted: 09/13/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke, or cerebrovascular accident (CVA), is the second leading cause of death in the world and based on the World Health Organization (WHO) report in 2006, it is responsible for 9.9% of all deaths in the world which over 85% of these deaths occurred in developing countries. OBJECTIVES The aim of this study was to investigate the data related to the frequency, risk factors, types and mortality of stroke in Birjand city. PATIENTS AND METHODS A retrospective cohort of consecutive patients with diagnosed stroke who were admitted to hospital (the only neurological center of Birjand) between 2002 and 2008 was designed. A stroke was defined according to clinical features and CT-scan which was confirmed by agreement of a staff neurologist. Collected data included date of admission, age, sex, and hospital outcome as well as related risk factors. RESULTS Totally, 1219 stroke (85.4% ischemic type) with the mean age of 69.6 ± 12.9 years and female: male ratio of 1.09 was included in over 6 years. The stroke hospital admission rates were 48.6 and 103.4 /100,000 population /year in the first and the last year of the study, respectively. There was an increasing trend in stroke incidence rate during the study (P < 0.01). The most common epidemiological risk factors for stroke in our region were hypertension, cardiac diseases, a history of stroke, diabetes mellitus, dyslipidemia, and smoking (54.7, 24.4, 20.1, 14.9, 12.2, and 9%, respectively). Overall in-hospital mortality rate was 17.1%. CONCLUSIONS The stroke hospital admission rate might be increasing in Birjand. Therefore, health care administrators and public health authorities must work harder to promote the knowledge and practice of society about the stroke related risk factors and prevention methods.
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Affiliation(s)
| | - Toba Kazemi
- Birjand Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Science, Birjand, IR Iran
- Corresponding author: Toba Kazemi, Birjand Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Science, Birjand, IR Iran. Tel: +98-5614443001-9, Fax: +98-5614433004, E-mail:
| | | | - Somayeh Dadbeh
- Student Research Committee, Birjand University of Medical Science, Birjand, IR Iran
| | - Parvaneh Dehghan
- Student Research Committee, Birjand University of Medical Science, Birjand, IR Iran
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Rolfs A, Fazekas F, Grittner U, Dichgans M, Martus P, Holzhausen M, Böttcher T, Heuschmann PU, Tatlisumak T, Tanislav C, Jungehulsing GJ, Giese AK, Putaala J, Huber R, Bodechtel U, Lichy C, Enzinger C, Schmidt R, Hennerici MG, Kaps M, Kessler C, Lackner K, Paschke E, Meyer W, Mascher H, Riess O, Kolodny E, Norrving B, Rolfs A, Ginsberg M, Hennerici MG, Kessler C, Kolodny E, Martus P, Norrving B, Ringelstein EB, Rothwell PM, Venables G, Bornstein N, deDeyn P, Dichgans M, Fazekas F, Markus H, Rieß O, Biedermann C, Böttcher T, Brüderlein K, Burmeister J, Federow I, König F, Makowei G, Niemann D, Rolfs A, Rösner S, Zielke S, Grittner U, Martus P, Holzhausen M, Fazekas F, Enzinger C, Schmidt R, Ropele S, Windisch M, Sterner E, Bodamer O, Fellgiebel A, Hillen U, Jonas L, Kampmann C, Kropp P, Lackner K, Laue M, Mascher H, Meyer W, Paschke E, Weidemann F, Berrouschot J, Stoll A, Rokicha A, Sternitzky C, Thomä M, DeDeyn PP, Sheorajpanday R, De Brabander I, Yperzeele L, Brouns R, Oschmann P, Pott M, Schultes K, Schultze C, Hirsekorn J, Jungehulsing GJ, Villringer A, Schmidt W, Liman T, Nowe T, Ebinger M, Wille A, Loui H, Objartel A, übelacker A, Mette R, Jegzentis K, Nabavi DG, Crome O, Bahr D, Ebke M, Platte B, Kleinen C, Mermolja Gunther K, Heide W, Pape O, Hanssen JR, Stangenberg D, Klingelhofer J, Schmidt B, Schwarz S, Schwarze J, Frandlih L, Iwanow J, Steinbach I, Krieger D, Boysen G, Leth Jeppesen L, Petersen A, Reichmann H, Becker U, Dzialkowski I, Hentschel H, Lautenschlager C, Hanso H, Gahn G, Ziemssen T, Fleischer K, Sehr B, McCabe DJH, Tobin O, Kinsella J, Murphy RP, Jander S, Hartung HP, Siebler M, Bottcher C, Kohne A, Platzen J, Brosig TC, Rothhammer V, Henseler C, Neumann-Haefelin T, Singer OC, Ermis U, dos Santos IMRM, Schuhmann C, van de Loo S, Kaps M, Allendorfer J, Tanislav C, Brandtner M, Muir K, Dani K, MacDougall N, Smith W, Rowe A, Welch A, Fazekas F, Schrotter G, Krenn U, Horner S, Pendl B, Pluta-Fuerst A, Trummer U, Kessler C, Chatzopoulos M, v Sarnowski B, Schminke U, Link T, Khaw A, Nieber E, Zierz S, Muller T, Wegener N, Wartenberg K, Gaul C, Richter D, Rosenkranz M, Krützelmann AC, Hoppe J, Choe CU, Narr S, Magnus TU, Thomalla G, Leypoldt F, Otto D, Lichy C, Hacke W, Barrows RJ, Tatlisumak T, Putaala J, Curtze S, Metso M, Willeit J, Furtner M, Spiegel M, Knoflach MH, Prantl B, Witte OW, Brämer D, Günther A, Prell T, Herzau C, Aurich K, Deuschl G, Wodarg F, Zimmermann P, Eschenfelder CC, Levsen M, Weber JR, Marecek SM, Schneider D, Michalski D, Kloppig W, Küppers-Tiedt L, Schneider M, Schulz A, Matzen P, Weise C, Hobohm C, Meier H, Langos R, Urban D, Gerhardt I, Thijs V, Lemmens R, Marcelis E, Hulsbosch C, Aichner F, Haring HP, Bach E, Machado Candido J, e Silva AA, Lourenco M, de Sousa AIM, Derex L, Cho TH, Díez-Tejedor E, Fuentes B, Martínez-Sanchez P, Pérez-Guevara MI, Hamer H, Metz A, Hallenberger K, Müller P, Baron P, Bersano A, Gattinoni M, Vella N, Mallia M, Jauss M, Adam L, Heidler F, Gube C, Kiszka M, Dichgans M, Karpinska A, Mewald Y, Straub V, Dörr A, Zollver A, Ringelstein EB, Schilling M, Borchert A, Preuth N, Duning T, Kuhlenbäumer G, Schulte D, Rothwell PM, Marquardt L, Schlachetzki F, Boy S, Mädl J, Ertl GM, Fehm NPR, Stadler C, Benecke R, Dudesek A, Kolbaske S, Lardurner G, Sulzer C, Zerbs A, Lilek S, Walleczek AM, Sinadinowska D, Janelidze M, Beridze M, Lobjanidze N, Dzagnidze A, Melms A, Horber K, Fink I, Liske B, Ludolph AC, Huber R, Knauer K, Hendrich C, Raubold S, Czlonkowska A, Baranowska A, Blazejewska-Hyzorek B, Lang W, Kristoferitsch W, Ferrari J, Ulrich E, Flamm-Horak A, Lischka-Lindner A, Schreiber W, Demarin V, Tranjec Z, Bosner-Puretic M, Jurašić MJ, Basic Kes V, Budisic M, Kopacevic L. Acute Cerebrovascular Disease in the Young. Stroke 2013; 44:340-9. [PMID: 23306324 DOI: 10.1161/strokeaha.112.663708] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.
Methods—
Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.
Results—
Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).
Conclusions—
Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.
Clinical Trial Registration Information—
URL:
http://www.clinicaltrials.gov
.Unique identifier: NCT00414583
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Affiliation(s)
- Arndt Rolfs
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Franz Fazekas
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Ulrike Grittner
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Martin Dichgans
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Peter Martus
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Martin Holzhausen
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Tobias Böttcher
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Peter U. Heuschmann
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Turgut Tatlisumak
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Christian Tanislav
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Gerhard J. Jungehulsing
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Anne-Katrin Giese
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Jukaa Putaala
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Roman Huber
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Ulf Bodechtel
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Christoph Lichy
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Christian Enzinger
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Reinhold Schmidt
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Michael G. Hennerici
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Manfred Kaps
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Christof Kessler
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Karl Lackner
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Eduard Paschke
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Wolfgang Meyer
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Hermann Mascher
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Olaf Riess
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Edwin Kolodny
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Bo Norrving
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - A Rolfs
- University of Rostock, Rostock, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - I Federow
- University of Rostock, Rostock, Germany
| | - F König
- University of Rostock, Rostock, Germany
| | - G Makowei
- University of Rostock, Rostock, Germany
| | - D Niemann
- University of Rostock, Rostock, Germany
| | - A Rolfs
- University of Rostock, Rostock, Germany
| | - S Rösner
- University of Rostock, Rostock, Germany
| | - S Zielke
- University of Rostock, Rostock, Germany
| | - U Grittner
- Department of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany
| | - P Martus
- Department of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany
| | - M Holzhausen
- Department of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany
| | - F Fazekas
- Dept of Neurology, Medical University of Graz, Graz, Austria
| | - C Enzinger
- Dept of Neurology, Medical University of Graz, Graz, Austria
| | - R Schmidt
- Dept of Neurology, Medical University of Graz, Graz, Austria
| | - S Ropele
- Dept of Neurology, Medical University of Graz, Graz, Austria
| | | | | | | | | | - U Hillen
- (Essen, Germany) immunohistochemistry
| | - L Jonas
- (Rostock, Germany) electron-microscopy
| | | | - P Kropp
- (Rostock, Germany) headache and pain
| | | | - M Laue
- (Rostock, Germany) electron-microscopy
| | | | - W Meyer
- (London) epidemiology and neuropsychiatry
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - W Schmidt
- Berlin – Charite/Germany, University
| | - T Liman
- Berlin – Charite/Germany, University
| | - T Nowe
- Berlin – Charite/Germany, University
| | - M Ebinger
- Berlin – Charite/Germany, University
| | - A Wille
- Berlin – Charite/Germany, University
| | - H Loui
- Berlin – Charite/Germany, University
| | | | | | - R Mette
- Berlin – Charite/Germany, University
| | | | | | | | - D Bahr
- Berlin – Neukolln/Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - G Gahn
- Dresden/Germany, University
| | | | | | - B Sehr
- Dresden/Germany, University
| | | | | | | | | | | | | | | | | | - A Kohne
- Dusseldorf/Germany, University
| | | | | | | | | | | | - OC Singer
- Frankfurt am Main/Germany, University
| | - U Ermis
- Frankfurt am Main/Germany, University
| | | | | | | | - M Kaps
- Giessen/Germany, University
| | | | | | | | - K Muir
- Glasgow/United Kingdom, University
| | - K Dani
- Glasgow/United Kingdom, University
| | | | - W Smith
- Glasgow/United Kingdom, University
| | - A Rowe
- Glasgow/United Kingdom, University
| | - A Welch
- Glasgow/United Kingdom, University
| | | | | | - U Krenn
- Graz/Austria, Medical University
| | - S Horner
- Graz/Austria, Medical University
| | - B Pendl
- Graz/Austria, Medical University
| | | | | | | | | | | | | | - T Link
- Greifswald/Germany, University
| | - A Khaw
- Greifswald/Germany, University
| | | | | | | | | | | | - C Gaul
- Halle/Germany, University
| | | | | | | | | | | | - S Narr
- Hamburg/Germany, University
| | | | | | | | - D Otto
- Hamburg/Germany, University
| | - C Lichy
- Heidelberg/Germany, University
| | - W Hacke
- Heidelberg/Germany, University
| | | | | | | | | | - M Metso
- Helsinki/Finland, University
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - A Metz
- Marburg/Germany, University
| | | | | | | | | | | | | | | | - M Jauss
- Muhlhausen/Thuringen/Germany
| | - L Adam
- Muhlhausen/Thuringen/Germany
| | | | - C Gube
- Muhlhausen/Thuringen/Germany
| | | | | | | | | | | | - A Dörr
- Munich/Germany, University
| | | | | | | | | | | | | | | | | | | | | | | | - S Boy
- Regensburg/Germany, University
| | - J Mädl
- Regensburg/Germany, University
| | - GM Ertl
- Regensburg/Germany, University
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - A Melms
- Tubingen/Germany, University
| | | | - I Fink
- Tubingen/Germany, University
| | - B Liske
- Tubingen/Germany, University
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Daviet JC, Bonan I, Caire J, Colle F, Damamme L, Froger J, Leblond C, Leger A, Muller F, Simon O, Thiebaut M, Yelnik A. Therapeutic patient education for stroke survivors: Non-pharmacological management. A literature review. Ann Phys Rehabil Med 2012; 55:641-56. [DOI: 10.1016/j.rehab.2012.08.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 08/20/2012] [Accepted: 08/22/2012] [Indexed: 11/17/2022]
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Díaz-Guzmán J, Egido JA, Gabriel-Sánchez R, Barberá-Comes G, Fuentes-Gimeno B, Fernández-Pérez C. Stroke and transient ischemic attack incidence rate in Spain: the IBERICTUS study. Cerebrovasc Dis 2012; 34:272-81. [PMID: 23095851 DOI: 10.1159/000342652] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 08/13/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In Spain, stroke is a major public health concern, but large population-based studies are scarce and date from the 1990s. We estimated the incidence and in-hospital mortality of stroke through a multicentered population-based stroke register in 5 geographical areas of Spain, i.e. Lugo, Almería, Segovia, Talavera de la Reina and Mallorca, representing north, south, central (×2) and Mediterranean areas of Spain, respectively, the aim and novelty being that all methodologies were standardized, and diagnoses were verified by a neurologist using neuroimaging techniques. METHODS The register identified subjects >17 years of age who suffered a first-ever stroke or transient ischemic attack (TIA) between 1 January and 31 December 2006. Stroke and TIA were defined according to the WHO criteria. The Lausanne Stroke Registry definitions were used to classify ischemic stroke subtypes, as follows: (1) large-artery atherosclerosis (LAA); (2) cardioembolism (CE); (3) lacunar stroke or small-artery occlusion (SAO); (4) stroke of other infrequent cause (SIC), and (5) stroke of undetermined cause (UND). We used several complementary data sources such as hospital discharge registers, emergency room registers and primary care surveillance systems. RESULTS In the 1-year study period, we identified 2,700 first-ever cerebrovascular episodes (53% men; 2,257 strokes + 443 TIA episodes). Brain CT in the acute stage was performed in 99% of cases. Of a total of 2,257 stroke patients, 1,817 (81%) had cerebral infarction, 350 (16%) had intracerebral hemorrhage, 59 (3%) had subarachnoid hemorrhage (SAH) and 31 (1%) had unclassifiable stroke. The overall unadjusted annual incidence for all cerebrovascular events was 187 per 100,000 [95% confidence interval (CI) 180-194; incidence for men: 202, 95% CI 189-210; incidence for women: 187, 95% CI 180-194]. The subtype of ischemic stroke could be determined in 1,779 patients and was classified as LAA in 624 (35%), CE in 352 (20%), SAO in 316 (18%), SIC in 56 (3%) and UND in 431 (24%). The incidence rates per 100,000 (95% CI) standardized to the 2006 European population were as follows: all cerebrovascular events, 176 (169-182); all stroke (non-TIA), 147 (140-153); TIA, 29 (26-32); ischemic stroke, 118 (112-123); intracerebral hemorrhage, 23 (21-26), and SAH, 4.2 (3.1-5.2). Incidence rates clearly increased with age in both genders, with a peak at or above 85 years of age. The in-hospital mortality was 14%. CONCLUSIONS Our results show that the incidence of stroke and TIA in Spain is moderate compared to other Western and European countries. However, it is expected that these figures will change due to progressively aging populations.
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Affiliation(s)
- Jaime Díaz-Guzmán
- Stroke Unit, Neurology Department, University Hospital Doce de Octubre, Complutense Faculty of Medicine, ES–28045 Madrid, Spain. jdiaz.hdoc @ salud.madrid.org
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Vivancos J, Gilo F, Frutos R, Maestre J, García-Pastor A, Quintana F, Roda JM, Ximénez-Carrillo A, Díez Tejedor E, Fuentes B, Alonso de Leciñana M, Alvarez-Sabin J, Arenillas J, Calleja S, Casado I, Castellanos M, Castillo J, Dávalos A, Díaz-Otero F, Egido JA, Fernández JC, Freijo M, Gállego J, Gil-Núñez A, Irimia P, Lago A, Masjuan J, Martí-Fábregas J, Martínez-Sánchez P, Martínez-Vila E, Molina C, Morales A, Nombela F, Purroy F, Ribó M, Rodríguez-Yañez M, Roquer J, Rubio F, Segura T, Serena J, Simal P, Tejada J. Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment. Neurologia 2012; 29:353-70. [PMID: 23044408 DOI: 10.1016/j.nrl.2012.07.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 07/11/2012] [Accepted: 07/13/2012] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.
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Abstract
Alteplase (Actilyse(®), Activase(®)) is a recombinant tissue-type plasminogen activator that activates plasminogen directly to plasmin. It is the only pharmacological treatment currently approved for patients with acute ischaemic stroke. This article reviews the efficacy and tolerability of alteplase, focusing on data relevant to treatment between 0 and 4.5 hours after onset of stroke, and summarizes its pharmacological properties. Well designed clinical trials showed that alteplase administered within 3 hours (in the NINDS trial) and between 3 and 4.5 hours (in the ECASS III trial) after stroke onset significantly improved clinical outcomes at 90 days relative to placebo. Alteplase was generally well tolerated in these trials, with no significant difference observed between alteplase and placebo recipients in the 90-day mortality rates, despite significantly higher incidences of any and symptomatic intracranial haemorrhages in alteplase recipients. These results were generally supported by those of the SITS-MOST and SITS-ISTR observational studies, which showed that alteplase was effective and generally well tolerated when administered within 4.5 hours of stroke onset in routine clinical practice. However, results from SITS-ISTR indicated that the safety and functional outcomes were generally less favourable when alteplase was administered 3-4.5 hours after stroke onset than within 3 hours of stroke onset. Additionally, results from pooled analyses of randomized clinical trials indicated that the benefit of alteplase therapy over placebo decreased as the time between stroke onset and treatment initiation increased, with no significant benefit observed when treatment was initiated >4.5 hours after stroke onset. Moreover, the odds of mortality increased as the time between stroke onset and treatment initiation increased. Thus, the greatest benefit of alteplase therapy is gained with early treatment. Based on these results, current EU labelling and treatment guidelines recommend that alteplase should be administered as early as possible within 4.5 hours of symptom onset in patients with acute ischaemic stroke. However, recent results from a meta-analysis and IST-3 suggest that some patients may benefit from treatment up to 6 hours after stroke onset. Patients for whom alteplase therapy is contraindicated as per current EU licensing criteria, such as those aged >80 years, may also benefit from therapy. Further randomized trials of alteplase administered >4.5 hours after stroke in selected patients are required to confirm these findings.
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Hansson EE, Beckman A, Wihlborg A, Persson S, Troein M. Satisfaction with rehabilitation in relation to self-perceived quality of life and function among patients with stroke - a 12 month follow-up. Scand J Caring Sci 2012; 27:373-9. [PMID: 22804807 DOI: 10.1111/j.1471-6712.2012.01041.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Stroke causes complex disability and function, and perceived quality of life has been shown to correlate with satisfaction with care as well as with life in general among stroke patients. The aim of this study was to study the relation of satisfaction with how rehabilitation was provided with self-perceived quality of life, self-perceived function and rehabilitation received, 12 months after the incidence. METHOD The subjects were assessed 12 months after the onset of stroke. The Barthel index was used to measure function, and the EuroQol-5D to measure quality of life. To measure satisfaction with how rehabilitation was provided, a questionnaire from the Swedish Stroke Register was used. RESULTS Two hundred and eighty-three patients participated in the follow-up, 137 women and 146 men, aged between 42 and 95 years (mean age 75.2, SD 11.8). For the majority of patients rehabilitation was initiated at in-hospital care (directly after onset). One hundred and sixty-eight patients considered that rehabilitation was well provided for. Sixty-six regarded that the rehabilitation was only partly provided for and 35 that it was not provided for at all. High value on Barthel Index was associated with satisfaction with how rehabilitation was provided for (OR 2.81). Also, rehabilitation on three or more levels was negatively associated with satisfaction with rehabilitation provision (OR 0.24) and so was being male (OR 0.49). CONCLUSION In this study, patients with higher values on Barthel Index were more satisfied with how rehabilitation was provided for. However, male patients and patients who received rehabilitation on three or more levels of care were less satisfied. Given the assumption that patients with more severe dysfunction after stroke are being rehabilitated on more levels, this might imply that it is not the amount of rehabilitation that gives satisfaction but the patients self-perceived function after rehabilitation.
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Affiliation(s)
- Eva Ekvall Hansson
- Department of Clinical Sciences in Malmö/Family Medicine, Lund University, Malmö, Sweden.
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Bonzini M, Ferrario MM, Bertù L, Bono G, Vidale S, Veronesi G, Chambless L, Cesana GC. Temporal trends in ischemic and hemorrhagic strokes in Northern Italy: results from the cardiovascular monitoring unit in Northern Italy population-based register, 1998-2004. Neuroepidemiology 2012; 39:35-42. [PMID: 22777532 DOI: 10.1159/000338293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 03/11/2012] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND We compared rates and case fatality from a population-based stroke register in Northern Italy between 1998 and 2004 to assess changes over time and to evaluate changes in case diagnosis and management. METHODS The WHO Multinational Monitoring of Trends and Determinants in Cardiovascular Disease criteria were used to identify suspected fatal or nonfatal events occurring among residents 35-74 years of age. Data on in-hospital treatments, symptoms and diagnostic tools were extracted. Out-of-hospital deaths were also investigated. The annual average relative change (ARC) in death rate, attack rate and case fatality were derived from Poisson models. RESULTS Death rates due to ischemic stroke (IS) decreased [men: ARC -12.7, 95% confidence interval (CI) -21.3 to -3.2; women: ARC -14.0, 95% CI -23.3 to -3.5]. These reductions are attributable to decreases in case fatality; attack rates of nonfatal IS increased (men: ARC 3.6, 95% CI 0.5-6.7; women: ARC 4.1, 95% CI 0.0-8.2). IS patients showed a higher prevalence of dyslipidemia and hypertension and underwent MRI more frequently in 2004. Both findings may explain the increased proportions of less severe cases. Case fatality and attack rates for hemorrhagic strokes (HS) were stable, with an observed increased prevalence of patients under anticoagulant/antiplatelet treatments. CONCLUSIONS In this low-IS-incidence population, death rates decreased substantially during the investigated period. More accurate diagnostic tools increase the probability of detecting less severe cases. HS remains a frequently fatal disease with a stable incidence.
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Affiliation(s)
- M Bonzini
- Research Center in Epidemiology and Preventive Medicine, Insubria University, Varese, Italy
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Kelly PJ, Crispino G, Sheehan O, Kelly L, Marnane M, Merwick A, Hannon N, Ní Chróinín D, Callaly E, Harris D, Horgan G, Williams EB, Duggan J, Kyne L, McCormack P, Dolan E, Williams D, Moroney J, Kelleher C, Daly L. Incidence, event rates, and early outcome of stroke in Dublin, Ireland: the North Dublin population stroke study. Stroke 2012; 43:2042-7. [PMID: 22693134 DOI: 10.1161/strokeaha.111.645721] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The World Health Organization has emphasized the importance of international population-based data for unbiased surveillance of stroke incidence and outcome. To date, few such studies have been conducted using recommended gold-standard ascertainment methods. We conducted a large, population-based stroke study in Dublin, Ireland. METHODS Using gold-standard ascertainment methods, individuals with stroke and transient ischemic attack occurring over a 12-month period (December 1, 2005-November 30, 2006) in North Dublin were identified. Disability was assessed using the modified Rankin score and stroke severity (<72 hours) by the National Institutes of Health Stroke Scale. Stroke-related deaths were confirmed by review of medical files, death certificates, pathology, and coroner's records. Crude and standardized (to European and World Health Organization standard populations) rates of incidence, risk factors, severity, and early outcome (mortality, case-fatality, disability) were calculated, assuming a Poisson distribution for the number of events. RESULTS Seven hundred one patients with new stroke or transient ischemic attack were ascertained (485 first-ever stroke patients, 83 recurrent stroke patients, 133 first-ever transient ischemic attack patients). Crude frequency rates (all rates per 1000 person-years) were: 1.65 (95% CI, 1.5-1.79; first-ever stroke), 0.28 (95% CI, 0.22-0.35; recurrent stroke), and 0.45 (95% CI, 0.37-0.53; first-ever transient ischemic attack). Age-adjusted stroke rates were higher than those in 9 other recent population-based samples from high-income countries. High rates of subtype-specific risk factors were observed (atrial fibrillation, 31.3% and smoking, 29.1% in ischemic stroke; warfarin use, 21.2% in primary intracerebral hemorrhage; smoking, 53.9% in subarachnoid hemorrhage; P<0.01 for all compared with other subtypes). Compared with recent studies, 28-day case-fatality rates for primary intracerebral hemorrhage (41%; 95% CI, 29.2%-54.1%) and subarachnoid hemorrhage (46%; 95% CI, 28.8%-64.5%) were greater in Dublin. CONCLUSIONS Using gold-standard methods for case ascertainment, we found high incidence rates of stroke in Dublin compared with those in similar high-income countries; this is likely explained in part by high rates of subtype-specific risk factors.
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Affiliation(s)
- Peter J Kelly
- Neurovascular Unit for Applied Translational and Therapeutics Research, Mater University Hospital/Dublin Academic Medical Centre, Dublin, Ireland.
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Kazemi-Bajestani SMR, van der Vlugt M, de Leeuw FE, Blankensteijn JD, Bredie SJH. A high prevalence of carotid artery stenosis in male patients older than 65 years, irrespective of presenting clinical manifestation of atherosclerotic diseases. Angiology 2012; 64:281-6. [PMID: 22584247 DOI: 10.1177/0003319712445374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study investigated the prevalence of carotid artery stenosis (CS) and the association with various risk factors in male patients (>65 years) diagnosed with cardiovascular diseases. Duplex sonography of the carotid arteries was performed in 434 of 473 eligible patients of whom 118 (27.8%) patients had significant CS ≥50%. The prevalence and severity of CS did not differ between patients who presented with neurological symptoms or acute coronary syndrome/peripheral artery disease (30.8% vs 25.9%, respectively). Among patients with CS, a higher rate of current smoking, a higher systolic blood pressure, and a lower glomerular filtration rate were observed compared with patients without CS. A history of coronary artery bypass graft was a significant predictor of the presence of CS (P = .003, odds ratio [OR] = 2.70 [1.40-5.19]). The prevalence of CS in elderly males with manifest atherosclerotic disease is high, irrespective of presenting clinical manifestation.
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Casadio M, Sanguineti V. Learning, retention, and slacking: a model of the dynamics of recovery in robot therapy. IEEE Trans Neural Syst Rehabil Eng 2012; 20:286-96. [PMID: 22531822 DOI: 10.1109/tnsre.2012.2190827] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Quantitative descriptions of the process of recovery of motor functions in impaired subjects during robot-assisted exercise might help to understand how to use these devices to make recovery faster and more effective. Linear dynamical models have been used to describe the dynamics of sensorimotor adaptation. Here, we extend this formalism to characterize the neuromotor recovery process. We focus on a robot therapy experiment that involved chronic stroke survivors, based on a robot-assisted arm extension task. The results suggest that modeling the recovery process with dynamical models is feasible, and could allow predicting the long-term outcome of a robot-assisted rehabilitation treatment.
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Affiliation(s)
- Maura Casadio
- Rehabilitation Institute of Chicago, Chicago, IL 60611, USA.
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Epidemiology and the global burden of stroke. World Neurosurg 2012; 76:S85-90. [PMID: 22182277 DOI: 10.1016/j.wneu.2011.07.023] [Citation(s) in RCA: 374] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/24/2011] [Accepted: 07/16/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Stroke remains one of the most devastating of all neurological diseases, often causing death or gross physical impairment or disability. As numerous countries throughout the world undergo the epidemiological transition of diseases, trends in the prevalence of stroke have dramatically changed. METHODS All major international epidemiological articles published during the past 20 years addressing the global burden of stroke were reviewed. A focus was placed upon better defining current and future trends in surveillance, incidence, burden of disease, mortality, and costs associated with stroke internationally. RESULTS Despite the fact that various surveillance systems are used to identify stroke and its sequela around the world, it is clear that stroke remains one of the top causes of mortality and disability-adjusted life-years (DALYs) lost globally. Concerning trends include the increase of stroke mortality and lost DALYs in low- and middle-income countries. The global economic impact of stroke may be dire if effective preventive measures are not implemented to help decrease the burden of this disease. CONCLUSION The global burden of stroke is high, inclusive of increasing incidence, mortality, DALYs, and economic impact, particularly in low- and middle-income countries. The implementation of better surveillance systems and prevention programs are needed to help track current trends as well as to curb the projected exponential increase in stroke worldwide.
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Mehnert U, Nehiba M. [Neuro-urological dysfunction of the lower urinary tract in CNS diseases: pathophysiology, epidemiology, and treatment options]. Urologe A 2012; 51:189-97. [PMID: 22331072 DOI: 10.1007/s00120-011-2796-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The lower urinary tract (LUT) is regulated by a complex neural network that is subject to supraspinal control. Neurological disorders, especially of the central nervous system (CNS), can rapidly lead to disruption of this control. Multiple sclerosis, Parkinson's disease, multiple system atrophy, and stroke are neurological disorders which quite frequently cause dysfunction of the LUT. With respect to the pathophysiology of bladder dysfunction in CNS diseases there are various hypotheses regarding the individual disorders: disturbances of neural communication between the frontal cortex and pontine micturition center, between the pontine micturition center and the lumbosacral parts of the spinal cord, and between the basal ganglia, thalamus, and anterior cingulate gyrus appear to play a pivotal role in the development of bladder dysfunction. The symptoms and urodynamic presentation of LUT dysfunction can vary considerably depending on the disease and disease progression and can change in the course of the disease. The incidence and prevalence of LUT dysfunctions rise with increasing progression of the underlying neurological disease.Various conservative, minimally invasive, and open surgical procedures are available to prevent harmful sequelae and to improve the quality of life of these patients. As yet, however, few data exist on most of the treatment options in cases of the above-mentioned CNS diseases. Intermittent self-catheterization and antimuscarinic medications are among the most important conservative treatment options. Injection of botulinum neurotoxin type A into the detrusor muscle and increasingly sacral or pudendal neuromodulation are among the most important minimally invasive treatment options. Surgical methods include reconstructive continent or incontinent urinary diversion.When planning therapy the patient's current needs and neurological limitations as well as possible disease progression must be taken into consideration. It is often advisable to consult with and enlist the cooperation of the attending neurologist when planning treatment.
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Affiliation(s)
- U Mehnert
- Urologische Klinik, Marienhospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Widumer Straße 8, 44627 Herne, Deutschland.
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Sienkiewicz-Jarosz H, Zatorski P, Ryglewicz D, Bienkowski P. Reasons for quitting smoking in patients with first-ever ischemic stroke. Eur Addict Res 2012; 18:275-8. [PMID: 22760163 DOI: 10.1159/000338280] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 03/16/2012] [Indexed: 11/19/2022]
Abstract
Ninety-eight cigarette smokers with ischemic stroke were recruited between December 2006 and December 2008 in an urban hospital. Smoking status and reasons for quit attempts after stroke were assessed at 3-month follow-up. 73% of patients (72/98) made at least one quit attempt between stroke onset and the follow-up visit. 47% of quit attempters (34/72) declared that stroke was the major reason for quitting. The patients reporting stroke as the major reason for quitting were more likely to be abstinent at the follow-up as compared to the patients who did not (61.8 vs. 36.8%). The study suggests that some motives for quitting smoking are associated with a higher chance for short-term abstinence in stroke patients.
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Sposato LA, Saposnik G. Gross Domestic Product and Health Expenditure Associated With Incidence, 30-Day Fatality, and Age at Stroke Onset. Stroke 2012; 43:170-7. [DOI: 10.1161/strokeaha.111.632158] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Luciano A. Sposato
- From the Vascular Research Institute at INECO Foundation (L.A.S.), Department of Neurology at INECO, Stroke Center at the Institute of Neurosciences, University Hospital, Favaloro Foundation, Buenos Aires, Argentina; and the Stroke Outcomes Research Center (G.S.), Li Ka Shing Knowledge Institute, Departments of Medicine and Health Policy Management and Evaluation (HPME) and the Institute for Clinical Evaluative Sciences (ICES), St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Gustavo Saposnik
- From the Vascular Research Institute at INECO Foundation (L.A.S.), Department of Neurology at INECO, Stroke Center at the Institute of Neurosciences, University Hospital, Favaloro Foundation, Buenos Aires, Argentina; and the Stroke Outcomes Research Center (G.S.), Li Ka Shing Knowledge Institute, Departments of Medicine and Health Policy Management and Evaluation (HPME) and the Institute for Clinical Evaluative Sciences (ICES), St Michael's Hospital, University of Toronto, Ontario, Canada
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Tveiten A, Ljøstad U, Mygland Å, Thomassen L, Pripp AH, Naess H. Intracerebral Hemorrhage in Southern Norway – A Hospital-Based Incidence Study. Eur Neurol 2012; 67:240-5. [DOI: 10.1159/000336299] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 01/08/2012] [Indexed: 11/19/2022]
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Sander D, Poppert H, Sander K, Etgen T. Primärprävention des Schlaganfalls – Was ist neu? AKTUELLE NEUROLOGIE 2011. [DOI: 10.1055/s-0031-1295470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Affiliation(s)
- D. Sander
- Klinik für Neurologie, Benedictus Krankenhaus Tutzing
- Neurologische Klinik des Klinikums rechts der Isar, Technische Universität München
| | - H. Poppert
- Neurologische Klinik des Klinikums rechts der Isar, Technische Universität München
| | - K. Sander
- Neurologische Klinik des Klinikums rechts der Isar, Technische Universität München
- Klinik für Psychosomatik, Schön Klinikum Berchtesgadener Land
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[Development of mortality and morbidity of vascular diseases: variations between coronary heart disease and stroke]. DER NERVENARZT 2011; 82:145-6, 148-50, 152. [PMID: 21286677 DOI: 10.1007/s00115-010-3110-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Cardiovascular diseases represent a central challenge for our health care system because of their individual and societal consequences. The manuscript compares the current development of mortality and morbidity of coronary heart disease and stroke in Germany. RESULTS Coronary heart diseases are one of the leading causes of death and one of the major causes for adult disability. In Germany the average life expectancy has increased by more then 2 years per decade within recent years. The greatest contribution to the increase in life expectancy between 1980 and 2002 in Germany was attributed in previous studies to the decline in mortality rates of cardiovascular diseases; for example in Germany 134,648 persons died in 2008 from coronary heart disease (ICD-10 I20-I25) and 63,060 persons from stroke (ICD-10 I60-I64) compared to 178,759 persons and 90,241 persons in 1998, respectively. Statistical models from other countries estimated that the decrease in coronary heart disease mortality is attributed by about 40% to better treatment and by about 60% to changes in risk factors in the population. Comparable data for stroke are lacking. CONCLUSION Despite the substantial knowledge on cardiovascular diseases in Germany a continuous and timely documentation of their determinants, time trends of risk factors and impact regarding mortality and morbidity is compulsory to assess the effectiveness of initiated population health measures and to identify future options for improving prevention and treatment of cardiovascular diseases in Germany.
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Wellwood I, Wu O, Langhorne P, McKevitt C, Di Carlo A, Rudd AG, Wolfe CDA. Developing a tool to assess quality of stroke care across European populations: the EROS Quality Assessment Tool. Stroke 2011; 42:1207-11. [PMID: 21474805 DOI: 10.1161/strokeaha.110.598938] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE There are significant differences in the provision of care and outcome after stroke across countries. The European Registers of Stroke study aimed to develop, test, and refine a tool to assess quality of care. METHODS We used a systematic review and grading of evidence for stroke care across the clinical pathway and developed and field-tested a quality tool that was delivered by post and later by site visit at 7 centers. Items were refined by using an algorithm that took into account the level of evidence, measurement properties, and consensus of opinion obtained using, the Delphi techniques. RESULTS The tool included 251 items across 11 domains, of which 214 items could be categorized by any level of evidence. Overall agreement between postal and site visit modes of delivery was acceptable (κ=0.77), with most items having a κ>0.5. The refinement process resulted in 2 practical versions of the tool (93 items and 22 items). Positive responses to items in the tool indicated implementation of evidence-based stroke care. In field testing, the proportion of positive responses to evidence-based items ranged from 43% to 79% across populations. Proportions of different types of evidence being implemented were similar: high quality 62%, limited quality 72%, and expert opinion 54% across the populations. More than half (4 of 7) of the centers provided stroke unit care and thrombolysis, but availability and access to inpatient rehabilitation varied significantly, with poor access to community follow-up for rehabilitation and medical management. CONCLUSIONS The European Registers of Stroke Quality Assessment Tool has potential to be used as a framework to compare services and promote increased implementation of evidence-based care.
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Affiliation(s)
- Ian Wellwood
- Division of Health and Social Care Research, King's College London, King's College Hospital NHS Foundation Trust, Guy's Campus, 7th Floor, Capital House, 42 Weston St, London SE1 3QD, UK.
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The epidemiology of cardiovascular disease in primary care. the Zona Franca Cohort study in Barcelona, Spain. Rev Esp Cardiol 2011; 63:1261-9. [PMID: 21070722 DOI: 10.1016/s1885-5857(10)70251-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Knowledge about the incidence of cardiovascular disease in Spain is limited, particularly about emergent conditions such as peripheral arterial disease and heart failure. The objective of this study was to determine the incidence of these conditions in a primary care setting. METHODS A prospective population-based cohort study was carried out in two health centers in Barcelona, Spain. It included 931 randomly selected individuals, aged 35 to 84 years, without cardiovascular disease who were followed for 10 years. We assessed the incidence of ischemic heart disease (i.e. myocardial infarction and angina), cerebrovascular disease (i.e. stroke and transient ischemic attack), peripheral arterial disease of the lower extremities, and heart failure. RESULTS The most frequently occurring condition was ischemic heart disease (cumulative incidence, 6.1%), followed by cerebrovascular disease (4.3%), heart failure (3.0%), and peripheral arterial disease (1.9%). These conditions were more frequent in patients aged >65 years (cumulative incidence, 9.6%, 8.9%, 4.6% and 3.1%, respectively). The most frequent comorbid conditions were ischemic heart disease and cerebrovascular disease. The incidence of acute myocardial infarction was greater in men (P< .001), but there was no significant difference for other conditions. The adjusted incidence (European population) per 100,000 inhabitants per year in men and women, respectively, was: 605 and 115 for acute myocardial infarction; 238 and 220 for angina; 300 and 327 for stroke; 125 and 115 for transient ischemic attack; 136 and 178 for peripheral arterial disease; and 219 and 267 for heart failure. CONCLUSIONS The incidence of cardiovascular disease was lower than in other developed countries. Disease occurred more frequently in patients aged >65 years. Ischemic heart disease remained the most common, with heart failure being a notable emergent condition.
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Risselada R, de Vries LM, Dippel DWJ, van Kooten F, van der Lugt A, Niessen WJ, Firouzian A, Stricker BHC, Sturkenboom MCJM. Incidence, treatment, and case-fatality of non-traumatic subarachnoid haemorrhage in the Netherlands. Clin Neurol Neurosurg 2011; 113:483-7. [PMID: 21420782 DOI: 10.1016/j.clineuro.2011.02.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Revised: 02/05/2011] [Accepted: 02/12/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Non-traumatic subarachnoid haemorrhage (SAH) is a devastating disorder and in the majority of cases it is caused by rupture of an intracranial aneurysm. No actual data are available on the incidence of non-traumatic SAH and aneursymal SAH (aSAH) in the Netherlands and little is known about treatment patterns of aSAH. Our purpose was therefore to assess the incidence, treatment patterns, and case-fatality of non-traumatic (a)SAH within the Dutch general population. METHODS Two population based data sources were used for this retrospective cohort study. One was the nationwide hospital discharge registry (National Medical Registration, LMR). Cases were patients hospitalized for SAH (ICD-9-code 430) in 2001-2005. The second source was the Integrated Primary Care Information (IPCI) database, a medical record database allowing for case validation. Cases were patients with validated non-traumatic (a)SAH in 1996-2006. Incidence, treatment, and case-fatality were assessed. RESULTS The incidence rate (IR) of non-traumatic SAH was 7.12 per 100,000 PY (95%CI: 6.94-7.31) and increased with age. The IR of aSAH was 3.78 (95%CI: 2.98-4.72). Women had a twofold increased risk of non-traumatic SAH; this difference appeared after the fourth decade. Non-traumatic SAH fatality was 30% (95%CI: 29-31%). Of aSAH patients 64% (95%CI: 53-74%) were treated with a clipping procedure, and 26% (95%CI: 17-37%) with coiling. CONCLUSION Non-traumatic SAH is a rare disease with substantial case-fatality; rates in the Netherlands are similar to other countries. Case-fatality is also similar as well as age and sex patterns in incidence.
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Affiliation(s)
- R Risselada
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Scherbakov N, Doehner W. Sarcopenia in stroke-facts and numbers on muscle loss accounting for disability after stroke. J Cachexia Sarcopenia Muscle 2011; 2:5-8. [PMID: 21475676 PMCID: PMC3063875 DOI: 10.1007/s13539-011-0024-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Stroke is the third leading cause of death and the leading cause of disability in Western countries. More than 60% of patients remain disabled, 50% of patients suffer from some hemiparesis and 30% remain unable to walk without assistance. The skeletal muscle is the main effector organ accountable for disability in stroke. This disability is, however, traditionally attributed to the brain injury itself and less attention is paid to structural, metabolic and functional aspects of muscle tissue. Hemiparetic stroke leads to various muscle abnormalities. A combination of denervation, disuse, inflammation, remodelling and spasticity account for a complex pattern of muscle tissue phenotype change and atrophy. While the molecular mechanisms of muscle degradation after stroke are only incompletely understood, a stroke-related sarcopenia may be concluded. Reinnervation, fiber-type shift, disuse atrophy and local inflammatory activation are only some of the key features to be addressed. Despite the importance for optimum post stroke recovery, stroke-related sarcopenia is not recognised in current guidelines for stroke therapy and rehabilitation. A total of not more than 500 patients forms the basis for all available evidence on clinical muscle changes after stroke. A lack of robust evidence on muscle pathology after stroke and on treatment strategies becomes apparent that needs to be addressed in an interdisciplinary integrated approach.
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Affiliation(s)
- Nadja Scherbakov
- Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Wolfram Doehner
- Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Department of Cardiology, Charité University Medicine, Berlin, Germany
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Icks A, Scheer M, Genz J, Giani G, Glaeske G, Hoffmann F. Stroke in the diabetic and non-diabetic population in Germany: relative and attributable risks, 2005-2007. J Diabetes Complications 2011; 25:90-6. [PMID: 20619691 DOI: 10.1016/j.jdiacomp.2010.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 05/17/2010] [Accepted: 05/28/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Reduction of cardiovascular events has been declared to be a main objective in diabetes care. Little is known about incidences of stroke in the diabetic compared to the non-diabetic population and its trend. We evaluated nationwide incidence of stroke in the diabetic compared to the non-diabetic populations as well as relative and attributable stroke risks due to diabetes in Germany. METHODS Using data of a statutory health insurance (1.6 million members in Germany), we assessed all first strokes in 2005-2007. We estimated sex/age-specific and standardised incidence of strokes in the diabetic and non-diabetic populations and relative and attributable risks due to diabetes. RESULTS A total of 6160 subjects had a first stroke [66.6% male, mean age (S.D.)=67.0 (13.9) years]; 31.4% had diabetes. Incidence per 100,000 person years (standard: 2004 German population) in the diabetic and non-diabetic populations, respectively, is as follows: men: 476 [95% confidence interval (CI)=438-514] and 255 (95% CI=243-266); women: 342 (95% CI=305-378) and 173 (95% CI=163-182). Age-standardised relative risks are as follows: 1.9 (95% CI=1.7-2.0) in men and 2.0 (95% CI=1.8-2.2) in women. The following are attributable risks among exposed: 0.46 (95% CI=0.41-0.51) in men and 0.49 (95% CI=0.43-0.55) in women; population attributable risks are as follows: 0.14 (95% CI=0.11-0.16) in men and 0.14 (95% CI=0.11-0.17) in women. CONCLUSIONS In this nationwide study, we found the stroke risk in the diabetic population to be still significantly increased compared to the non-diabetic population. The risk increase seems to be as high as earlier observations in other countries, despite large efforts to improve diabetes care.
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Affiliation(s)
- Andrea Icks
- Department of Public Health, Center for Health and Society, Heinrich-Heine-University, Düsseldorf, Germany.
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Wawrzyńczyk M, Pierzchała K, Braczkowska B, Mańka-Gaca I, Kumor K, Borowski D, Grodzicka-Zawisza L, Zejda J. Estimates of stroke incidence and case fatality in Zabrze, 2005–2006. Neurol Neurochir Pol 2011; 45:3-10. [DOI: 10.1016/s0028-3843(14)60053-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sienkiewicz-Jarosz H, Gtuszkiewicz M, Pniewski J, Niewada M, Członkowska A, Wolfe C, Ryglewicz D. Incidence and case fatality rates of first-ever stroke – comparison of data from two prospective population-based studies conducted in Warsaw. Neurol Neurochir Pol 2011; 45:207-12. [DOI: 10.1016/s0028-3843(14)60073-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kulesh SD, Filina NA, Frantava NM, Zhytko NL, Kastsinevich TM, Kliatskova LA, Shumskas MS, Hilz MJ, Schwab S, Kolominsky-Rabas PL. Incidence and Case-Fatality of Stroke on the East Border of the European Union. Stroke 2010; 41:2726-30. [DOI: 10.1161/strokeaha.110.596916] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sergey D. Kulesh
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
| | - Nina A. Filina
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
| | - Nataliya M. Frantava
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
| | - Natallia L. Zhytko
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
| | - Tatsiana M. Kastsinevich
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
| | - Liudmila A. Kliatskova
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
| | - Mechyslovas S. Shumskas
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
| | - Max J. Hilz
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
| | - Stefan Schwab
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
| | - Peter L. Kolominsky-Rabas
- From the Department of Neurology (S.D.K.), Grodno State Medical University, Grodno, Belarus; the Department of Neurology (M.J.H., S.S., P.L.K.-R.), University Hospital Erlangen, Erlangen, Germany; the Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH; P.L.K.-R.), University of Erlangen–Nurnberg, Erlangen, Germany; the Stroke Neurological Department (N.A.F., N.M.F., N.L.Z.), Grodno City Clinical Hospital No. 1, Grodno, Belarus; the Department of Neurology (T.M.K
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Veenith TV, Din AH, Eaton DMJ, Burnstein RM. Perioperative care of a patient with stroke. Int Arch Med 2010; 3:33. [PMID: 21092134 PMCID: PMC3012661 DOI: 10.1186/1755-7682-3-33] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 11/20/2010] [Indexed: 12/01/2022] Open
Abstract
Strokes and TIAs, with their high cumulative mortality and morbidity rates, are occurring with increasing frequency in western population 14. As such, it is vital for clinicians to provide optimal medical management in the perioperative period for those patients with this common neurological problem. This review aims to highlight the importance of the perioperative period and the stages of pre-optimization that can be taken by the multi-disciplinary team to aid this 171819. The evidence suggests that there are significant physiological advantages to early invasive monitoring and high dependency care in these complex patients. These cohort of patients are at increased risk of development of respiratory, gastrointestinal, nutritional and electrolyte disturbances so a constant vigil should be exercised in early recognition and treatment.
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Affiliation(s)
- Tonny V Veenith
- Division of Anaesthesia, University of Cambridge, Cambridge, CB2 2QQ, UK
| | - Asmat H Din
- Division of Anaesthesia, University of Cambridge, Cambridge, CB2 2QQ, UK
| | - Danielle MJ Eaton
- Division of Anaesthesia, University of Cambridge, Cambridge, CB2 2QQ, UK
| | - Rowan M Burnstein
- Division of Anaesthesia, University of Cambridge, Cambridge, CB2 2QQ, UK
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Khellaf M, Quantin C, d'Athis P, Fassa M, Jooste V, Hervieu M, Giroud M, Béjot Y. Age-period-cohort analysis of stroke incidence in Dijon from 1985 to 2005. Stroke 2010; 41:2762-7. [PMID: 21071719 DOI: 10.1161/strokeaha.110.592147] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Variations in stroke incidence could be explained by changes in vascular and environmental factors that affect the risk of stroke and changes in risk factors that are present in early life. The aim of this study was to identify and measure the effects of 3 interrelated factors, age, calendar period of stroke onset, and birth year cohort, on the incidence rates of stroke from 1985 through 2005. METHODS Age-period-cohort models were used to analyze stroke incidence in Dijon from 1985 to 2005 from a population-based registry that collects data on all stroke patients whatever the type of management, in the public hospital, private hospitals, or at home, in the population of Dijon (150,000 inhabitants). RESULTS For ischemic stroke, the incidence rose with time in men depending not only on age, but also on the period and cohort effects (P = 0.017). For women, the incidence only depended on age (P < 0.001; incidence rate ratio, 1.085; 95% CI, 1.081 to 1.089). For hemorrhagic stroke, the rise in the incidence with time depended only on age in men, whereas in women, it depended on age, period, and cohort effects (P = 0.019). CONCLUSIONS Age, birth cohort, and calendar period contain relevant information to define and explain trends in stroke incidence rates over a long period.
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Affiliation(s)
- Meheni Khellaf
- University Hospital and Faculty of Medicine of Dijon, University of Burgundy, Burgundy, France
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Baena-Díez JM, Vidal-Solsona M, Byram AO, González-Casafont I, Ledesma-Ulloa G, Martí-Sans N. Epidemiología de las enfermedades cardiovasculares en atención primaria. Estudio Cohorte Zona Franca de Barcelona. Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70296-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kelly-Irving M, Mulot S, Inamo J, Ruidavets JB, Atallah A, Lang T. Improving stroke prevention in the French West Indies: limits to lay knowledge of risk factors. Stroke 2010; 41:2637-44. [PMID: 20884867 DOI: 10.1161/strokeaha.110.592659] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We sought to evaluate lay knowledge and understanding of cardiovascular diseases in the French West Indies. METHODS In 2007, a cross-sectional study of 1005 randomly selected men and women (54%) age 25 to 74 years from Guadeloupe and stratified by sex, age, and region was established to ascertain the population's knowledge and awareness of chronic diseases. Questions were asked about the respondent's knowledge of cardiovascular risk factors as well as their opinions and beliefs about measures to prevent these diseases. RESULTS Knowledge about stroke prevention in this sample was lower than for heart disease, with 69% of women and 65% of men reporting that precautions can be taken to avoid a stroke versus 84% and 77%, respectively, for heart disease. "Avoid stress" was the most commonly cited stroke prevention measure, with 35% of women and 27% of men reporting it. The first spontaneous item cited for heart disease prevention was "physical exercise or sport," reported by 47% of women and 45% of men. We hypothesize that knowledge of stroke and stroke risk factors is poor in Guadeloupe or that it reflects culturally adapted health promotion messages from doctors. CONCLUSIONS Knowledge and awareness were found to be lower for stroke than for heart diseases. Changes in health promotion strategies are required in the French West Indies to improve the population's overall awareness of these diseases and to narrow the gap between knowledge and practice.
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Di Carlo A, Lamassa M, Wellwood I, Bovis F, Baldereschi M, Nencini P, Poggesi A, Cramaro A, Pescini F, Lucente G, Wolfe CDA, Inzitari D. Stroke unit care in clinical practice: an observational study in the Florence center of the European Registers of Stroke (EROS) Project. Eur J Neurol 2010; 18:686-94. [PMID: 20840380 DOI: 10.1111/j.1468-1331.2010.03207.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Randomized trials and meta-analyses indicate positive effects of stroke unit (SU) care on survival and dependency of patients with stroke. However, data on the advantages of SU in 'real-world' settings are limited. We prospectively assessed, in a large University Hospital, the effect of SU versus other conventional wards (OCW) care on all-cause mortality, death or dependency, death or institutionalization. METHODS In a prospective observational study in the European Registers of Stroke Project, patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, 3-month and 1-year survival, and functional outcome. RESULTS Overall, 355 patients (54.1% men, mean age 73.4 ± 14.5 years) were registered, 140 (39.4%) admitted to the SU, and 215 (60.6%) to OCW. OCW patients were older, whilst SU patients had more severe strokes according to NIHSS (P for trend = 0.025). SU patients were significantly more often treated by specialists in stroke medicine, stroke nurses, physiotherapists and speech therapists (all P < 0.001), psychologists (P = 0.025), dietitians (P < 0.001), and social workers (P = 0.003). MRI, carotid, and transcranial Doppler were significantly more often performed in SU patients (all P < 0.001). Intravenous fluids (P = 0.003) and intravenous anticoagulation (P < 0.001) were more often prescribed in SU. Controlling for case-mix, SU significantly reduced 1-year mortality (P = 0.020), death or dependency at 3 months (P = 0.006) and 1 year (P = 0.043), and death or institutionalization at 3 months (P = 0.001) and 1 year (P = 0.009). CONCLUSIONS We confirmed the benefits of SU care in a clinical setting. Further analyses should define the contribution of individual components of care to stroke outcome.
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Affiliation(s)
- A Di Carlo
- Institute of Neurosciences, Italian National Research Council Department of Neurological and Psychiatric Sciences, University of Florence, Florence, Italy.
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Abstract
Poststroke depression (PSD) in elderly patients has been considered the most common neuropsychiatric consequence of stroke up to 6-24 months after stroke onset. When depression appears within days after stroke onset, it is likely to remit, whereas depression at 3 months is likely to be sustained for 1 year. One of the major problems posed by elderly stroke patients is how to identify and optimally manage PSD. This review provides insight to identification and management of depression in elderly stroke patients. Depression following stroke is less likely to include dysphoria and more likely characterized by vegetative signs and symptoms compared with other forms of late-life depression, and clinicians should rely more on nonsomatic symptoms rather than somatic symptoms. Evaluation and diagnosis of depression among elderly stroke patients are more complex due to vague symptoms of depression, overlapping signs and symptoms of stroke and depression, lack of properly trained health care personnel, and insufficient assessment tools for proper diagnosis. Major goals of treatment are to reduce depressive symptoms, improve mood and quality of life, and reduce the risk of medical complications including relapse. Antidepressants (ADs) are generally not indicated in mild forms because the balance of benefit and risk is not satisfactory in elderly stroke patients. Selective serotonin reuptake inhibitors are the first choice of PSD treatment in elderly patients due to their lower potential for drug interaction and side effects, which are more common with tricyclic ADs. Recently, stimulant medications have emerged as promising new therapeutic interventions for PSD and are now the subject of rigorous clinical trials. Cognitive behavioral therapy can also be useful, and electroconvulsive therapy is available for patients with severe refractory PSD.
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Affiliation(s)
- Johan Lökk
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
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Purroy F, Piñol-Ripoll G, Quílez A, Sanahuja J, Brieva L, Suárez Luis I. Validación de las escalas ABCDI y ABCD2I en el registro de pacientes con ataque isquémico transitorio de Lleida (REGITELL). Med Clin (Barc) 2010; 135:351-6. [DOI: 10.1016/j.medcli.2009.10.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 10/12/2009] [Accepted: 10/20/2009] [Indexed: 11/17/2022]
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Palm F, Urbanek C, Rose S, Buggle F, Bode B, Hennerici MG, Schmieder K, Inselmann G, Reiter R, Fleischer R, Piplack KO, Safer A, Becher H, Grau AJ. Stroke Incidence and Survival in Ludwigshafen am Rhein, Germany. Stroke 2010; 41:1865-70. [DOI: 10.1161/strokeaha.110.592642] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Considerable locoregional differences in stroke incidence exist even within countries. Based on data from a statewide stroke care quality monitoring project, we hypothesized a high stroke incidence mainly among younger age groups in the industrial city of Ludwigshafen am Rhein, Germany. To test this hypothesis and to provide data on stroke incidence and case-fatality rates, a population-based stroke register was initiated.
Methods—
The Ludwigshafen Stroke Study is a prospective ongoing population-based stroke register among the 167 906 inhabitants of Ludwigshafen am Rhein. Starting on January 1, 2006, standard definitions and multiple overlapping methods of case ascertainment were used to identify all patients with incident stroke or transient ischemic attack.
Results—
In 2006 and 2007, 1231 cases with stroke or transient ischemic attack including 725 patients with first-ever stroke were identified. The crude annual incidence rate per 1000 for first-ever stroke was 2.16 (95% CI 2.10 to 2.32). After age adjustment to the European population, incidence for first-ever stroke was 1.46 (95% CI 1.35 to 1.57; men: 1.63; 95% CI 1.46 to 1.81; women: 1.29; 95% CI 1.15 to 1.43). Crude annual incidence rates per 1000 were 1.86 for ischemic stroke, 0.19 for intracerebral hemorrhage, 0.05 for subarachnoid hemorrhage, and 0.05 for undetermined stroke. Case-fatality rates for first-ever stroke were 13.6%, 16.4%, and 23.2% at Days 28, 90, and 365, respectively.
Conclusions—
High crude incidence rates in our study reflect the rising burden of stroke in our aging population. Age-adjusted incidence rates were somewhat higher than those reported by recent studies from Western Europe, mainly due to higher incidence in subjects <65 years.
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Affiliation(s)
- Frederick Palm
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Christian Urbanek
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Steffen Rose
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Florian Buggle
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Barbara Bode
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Michael G. Hennerici
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Kirsten Schmieder
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Gerhard Inselmann
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Rainer Reiter
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Robert Fleischer
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Karl-Otto Piplack
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Anton Safer
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Heiko Becher
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
| | - Armin J. Grau
- From the Department of Neurology (F.P., C.U., S.R., F.B., B.B., A.J.G.), Klinikum Ludwigshafen, Ludwigshafen, Germany; the Departments of Neurology (M.G.H.) and Neurosurgery (K.S.), University of Heidelberg, Universitätsklinikum Mannheim, Mannheim, Germany; the Department of Internal Medicine (G.I.), Marienkrankenhaus Ludwigshafen, Ludwigshafen, Germany; the Department of Internal Medicine (R.R.), Guter-Hirte Ludwigshafen, Ludwigshafen, Germany; the CNS-Center for Neurology Mannheim (R.F.),
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Armario P, Sierra C. Control de la hipertensión arterial, variabilidad de la presión arterial e ictus. HIPERTENSION Y RIESGO VASCULAR 2010. [DOI: 10.1016/j.hipert.2010.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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