Estimates of outcomes up to ten years after stroke: analysis from the prospective South London Stroke Register

Natural history, predictors and outcomes of depression after stroke: systematic review and meta-analysis

BACKGROUND

Depression after stroke is a distressing problem that may be associated with other negative health outcomes.

AIMS

To estimate the natural history, predictors and outcomes of depression after stroke.

METHOD

Studies published up to 31 August 2011 were searched and reviewed according to accepted criteria.

RESULTS

Out of 13 558 references initially found, 50 studies were included. Prevalence of depression was 29% (95% CI 25-32), and remains stable up to 10 years after stroke, with a cumulative incidence of 39-52% within 5 years of stroke. The rate of recovery from depression among patients depressed a few months after stroke ranged from 15 to 57% 1 year after stroke. Major predictors of depression are disability, depression pre-stroke, cognitive impairment, stroke severity and anxiety. Lower quality of life, mortality and disability are independent outcomes of depression after stroke.

CONCLUSION

Interventions for depression and its potential outcomes are required.

Prevalence of poststroke cognitive impairment: South London Stroke Register 1995-2010

BACKGROUND AND PURPOSE

Stroke is a common long-term condition with an increasing incidence as the population ages. This study evaluates temporal changes in the prevalence of cognitive impairment after first-ever stroke stratified by sociodemography, vascular risk factors, and stroke subtypes, up to 15 years after stroke.

METHODS

Data were collected between 1995 and 2010 (n=4212) from the community-based South London Stroke Register covering an inner-city multiethnic population of 271 817 inhabitants. Patients were assessed for cognitive function using Abbreviated Mental Test or Mini-Mental State Examination at the onset, 3 months, and annually thereafter. All estimates were age adjusted to the European standard.

RESULTS

The overall prevalence of cognitive impairment 3 months after stroke and at annual follow-up remained relatively unchanged at 22% (24% [95% CI, 21.2-27.8] at 3 months; 22% [17.4-26.8] at 5 years to 21% [3.6-63.8] at 14 years). In multivariate analyses, the poststroke prevalence ratio of cognitive impairment increased with older age (2% [1-3] for each year of age), ethnicity (2.2 [1.65-2.89]-fold higher among black group) and socioeconomic status (42% [8-86] increased among manual workers). A significant, progressive trend of cognitive impairment was observed among patients with small vessel occlusion and lacunar infarction (average annual percentage change: 10% [7.9-12.8] and 2% [0.3-2.7], respectively, up to 5 years after stroke).

CONCLUSIONS

The prevalence of cognitive impairment after stroke remains persistently high over time, with variations being predominantly explained by sociodemographic characteristics. Given population growth and ageing demographics, effective preventive strategies and poststroke surveillance are needed to manage survivors with cognitive impairment.

Time course of depression and one-year prognosis of patients with stroke in mainland China

AIMS

To investigate the incidence of depression at different time points within the first year after stroke in mainland China and to identify risk factors related to a poor 1-year prognosis in stroke patients.

METHODS

Subjects with acute cerebrovascular diseases were recruited and enrolled from 56 hospitals in mainland China between April 2008 and April 2010. Demographic data, previous disease history, and clinical data were collected. Four follow-up visits were occurred within the first year after stroke. The modified Rankin Scale ≥ 2 represents an unfavorable prognosis. Depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition and was divided into persistent, recurrent and transient types.

RESULTS

The 1-year cumulative incidence of depression in stroke patients was 41.8%. Logistic regression analysis showed that the 1-year prognosis level was associated with age, disability before onset, neurological functional deficit level at admission, and a range of depression types. The odds ratio for persistent depression is the highest (OR = 7.615, P < 0.0001, 95% confidence interval 5.011-11.572).

CONCLUSIONS

In our study, depression occurred in >40% of patients within the first year after stroke. Persistent depression is the first independent determinant of prognosis during the first year after stroke.

Training Memory Self-efficacy in the Chronic Stage After Stroke

Background. Stroke patients with a low memory self-efficacy (MSE) report more memory complaints than patients with a high MSE. Objective. The aim of this study was to examine the effect of a memory-training program on MSE in the chronic phase after stroke and to identify which patients benefit most from the MSE training program. Methods. In a randomized controlled trial, the effectiveness of the MSE training program (experimental group) was compared with a peer support program (control group) in chronic stroke patients. The primary outcome was MSE, measured using the Metamemory-In-Adulthood Questionnaire. Secondary outcomes included depression, quality of life, and objective verbal memory capacity. Changes in outcomes over the intervention period were compared between both groups. Demographic and clinical variables were studied as potential predictors of MSE outcome in the experimental group. Results. In total, 153 patients were included: mean age = 58 years (standard deviation [SD] = 9.7), 54.9% male, and mean of 54 months (SD = 37) after stroke. Of these, 77 were assigned to the training and 76 to the control group. Improvement of MSE ( B = 0.40; P = .019) was significantly greater in the training than in the control group. No significant differences were found for the secondary outcomes. An increase in MSE after training was predicted by a younger age ( B = −0.033; P = .006) and a better memory capacity ( B = 0.043; P = .009), adjusted for baseline MSE. Conclusions. MSE can be improved by the MSE training program for stroke patients. Younger patients and patients with a better memory capacity benefit most from the MSE training program (Dutch Trial Register: NTR-TC 1656).

Anxiety and depression after stroke: a 5 year follow-up

PURPOSE

The aim was to document the prevalence and predictors of anxiety and depression 5 years after stroke, across four European centres.

METHOD

A cohort of 220 stroke patients was assessed at 2, 4 and 6 months and 5 years after stroke. Patients were assessed on the Hospital Anxiety and Depression Scale and measures of motor function and independence in activities of daily living.

RESULTS

At 5 years, the prevalence of anxiety was 29% and depression 33%, with no significant differences between centres. The severity of anxiety and depression increased significantly between 6 months and 5 years. Higher anxiety at 6 months and centre were significantly associated with anxiety at 5 years, but not measures of functional recovery. Higher depression scores at 6 months, older age and centre, but not measures of functional recovery, were associated with depression at 5 years.

CONCLUSIONS

Anxiety and depression were more frequent at 5 years after stroke than at 6 months. There were significant differences between four European centres in the severity of anxiety and depression. Although the main determinant of anxiety or depression scores at 5 years was the level of anxiety or depression at 6 months, this accounted for little of the variance. Centre was also a significant predictor of mood at 5 years. There needs to be greater recognition of the development of mood disorders late after stroke and evaluation of variation in management policies across centres.

[Thalamic Stroke and Associated Behavior Disorders. Possibilities for Integral Management: Case Report]

INTRODUCTION

Since ancient Greece, cerebrovascular accidents have been described with no variation. Even today, they are still a catastrophic event in the lives of patients with a high risk of disabling sequelae.

METHODOLOGY

Case report of a 56-year male patient with thalamic ischemia.

RESULTS

The intervention with integral strategies involving pharmacological management and cognitive interventions was decisive for the satisfactory evolution of the patient.

CONCLUSIONS

The management of patients with cerebrovascular accidents cannot be limited to the emergency room. Pharmacological advances in programs and cognitive intervention methods provide intervention tools from the very beginning of the stroke thus reducing the impact of long-term sequelae, and consequently enabling a better reintegration of the patient to his family.

[Long-term survival of ischemic stroke]

OBJECTIVE

Ischemic stroke is a serious vascular disease whose long term prognosis in all of its dimensions is not known. We have studied the long-term survival and its predictors after a first episode of acute ischemic stroke (atherothrombotic and cardioembolic).

PATIENTS AND METHODS

A retrospective cohort study was made of patients with a first episode of ischemic stroke. The ictus was classified into atherothrombotic, cardioembolic, lacunar and undetermined. Patients were followed up for 10 years.

RESULTS

A total of 415 cases (60% men) with mean age of 68.4 years, were included. Mean follow-up was 66 months (95% CI: 24-108 months). Overall survival at 10 years was 55.4% (54.9-55.9) (atherothrombotic, 57.7% vs cardioembolic, 43.7%, P=.002). In the multivariate analysis, variables related to mortality in acute ischemic stroke were age, chronic renal failure, dyslipidemia, history of heart failure, atrial fibrillation (AF), presenting as hemiplegia, signs of acute ischemia and perilesional edema in the brain scan on hospital admission. Involvement of the territory of right middle cerebral artery and treatment with statins were associated to a better prognosis.

CONCLUSIONS

Survival of patients after ischemic stroke at ten year is over 40%, and atherothrombotic stroke as a better prognosis than cardioembolic one.

Identifying the long-term needs of stroke survivors using the International Classification of Functioning, Disability and Health

OBJECTIVES

To investigate how contextual factors, as described by the World Health Organisation's International Classification of Functioning, Disability and Health (ICF), impact on stroke survivors' functioning and how needs are perceived in the long term after stroke.

METHODS

Semi-structured interviews were conducted with 35 participants between 1 and 11 years after stroke. Data were analysed thematically using the ICF conceptual framework.

RESULTS

Long-term needs related to activities of daily living, social participation, mobility aids, home adaptations, housing, financial support, rehabilitation, information and transport. Participants identified a range of ICF environmental and personal factors including 'support and relationships,' 'products and technology,' 'services, systems and policies,' 'attitudes,' life experiences, social position and personal attitudes. Interactions between these contextual factors shaped functioning and how long-term needs were perceived. Social support from family and friends was a key facilitator of functioning for most participants, buffering the impact of disabilities and mediating perceived needs. Needs were not always stroke specific as many participants experienced other health problems.

DISCUSSION

The ICF framework was useful to investigate how contextual factors shaped functioning and mediated perceived long-term needs. Development of services to meet long-term needs among stroke survivors should consider the range of environmental and personal factors affecting how needs are perceived.

Interventional stroke therapies in the elderly: are we helping?

BACKGROUND AND PURPOSE

It is unclear whether endovascular therapies for the treatment of AIS are being offered or are safe in older adults. The use and safety of endovascular interventions in patients older than 75 years of age were assessed.

MATERIALS AND METHODS

A retrospective review of patients with AIS 75 years or older (n = 37/1064) was compared with a younger cohort (n = 70/1190) by using an established data base. Admission and discharge NIHSS scores, rates of endovascular treatment, SICH, in-hospital mortality, and the mBI were assessed.

RESULTS

Rates of endovascular treatments were significantly lower in older patients (5.9% in the younger-than-75-year versus 3.5% in the older-than-75-year cohort, P = .007). Stroke severity as measured by the NIHSS score was equivalent in the 2 age groups. The mBI at 12 months was worse in the older patients (mild or no disability in 52% of the younger-than-75-year and 22% in the 75-year-or-older cohort, P = .006). Older patients had higher rates of SICH (9% in younger-than-75-year versus 24% in the 75-year-or-older group, P = .04) and in-hospital mortality (26% in younger-than-75-year versus 46% in the 75-year-or-older group, P = .05).

CONCLUSIONS

Patients older than 75 years of age were less likely to receive endovascular treatments. Older patients had higher rates of SICH, disability, and mortality. Prospective randomized trials are needed to determine the criteria for selecting patients most likely to benefit from acute endovascular therapies.