Stroke in the young: access to care and outcome; a Western versus eastern European perspective

The impact of age and 24-h blood pressure on arterial health in acute ischemic stroke patients: The Norwegian stroke in the young study

The impact of age and 24‐h ambulatory blood pressure (ABPM) on arterial stiffness and carotid intima‐media thickness (cIMT) in ischemic stroke patients younger than 60 years of age is poorly explored. A total of 385 acute ischemic stroke patients (aged 49.6±9.7 years, 68% men) were prospectively included and grouped in younger (15–44 years, n = 93) and middle‐aged (45–60 years, n = 292). Arterial stiffness was measured by carotid‐femoral pulse wave velocity (PWV), and cIMT by carotid ultrasound. 24‐h ABPM was recorded. The middle‐aged stroke patients had higher prevalence of smoking, hypertension, diabetes mellitus, metabolic syndrome and hypercholesterolemia, and had higher PWV and cIMT (all p < .05). In multivariable linear regression analyses adjusted for sex, BMI, smoking, diabetes mellitus, total cholesterol, high‐density lipoprotein cholesterol, triglycerides, eGFR, systolic BP and concomitant antihypertensive treatment, 1SD (4.4 years) higher age was associated with higher PWV (β = 0.44,R² = 0.46, p < .001) in the younger group, and with higher mean cIMT (β = 0.16, R² = 0.21, p = .01) in the middle‐aged group. In the middle‐aged group, 24‐h pulse pressure had a significant association with PWV (β = 0.18, R² = 0.19, p = .009), while the association with cIMT was attenuated (β = 0.13, R² = 0.16, p = .065). 24‐h diastolic BP was associated with higher cIMT in the middle‐aged group (β = 0.24, p < .001, R² = 0.23), but not with PWV in either age groups. Among ischemic stroke patients < 60 years, higher age was associated with increased arterial stiffness for patients up to age 44 years, and with cIMT in middle‐aged patients. 24‐h pulse pressure was associated with arterial stiffness, and 24‐h diastolic BP was associated with cIMT only in middle‐aged patients.

Association of Adipocytokines With Carotid Intima Media Thickness and Arterial Stiffness in Obstructive Sleep Apnea Patients

Objective: Obstructive sleep apnea (OSA) results in increased carotid intima-media thickness (IMT) and arterial stiffness; however, the association between adipocytokines and IMT/arterial stiffness in OSA patients is unclear. Methods: We enrolled 95 normal weight and overweight, not obese, participants from May 2018 to December 2018 in this study. All subjects underwent a carotid artery ultrasound examination and polysomnography. Blood samples were used to determine serum chemerin, adiponectin, SFRP5, and apelin levels. Correlations between two quantitative variables were assessed using the Pearson or Spearman coefficient. Stepwise models of multiple linear regression analysis were performed to assess the independent relationships. Result: IMT in OSA patients was significantly higher than in the non-snorers. There were significant differences in the arterial stiffness parameters such as distensibility coefficient (DC), compliance coefficient (CC), and pulse wave velocity (PWV). SFRP5 level was lower in OSA patients than in non-snorers. Adiponectin correlated with CC, DC, and PWV among OSA patients; however, the relationship disappeared after a multivariable adjustment. Age was independently associated with all quantitative IMT and stiffness indices. AHI and minimum oxygen saturation (Mini SaO₂) were independently related to arterial stiffness. Conclusion: The quantitative IMT and carotid arterial elasticity were significantly worse among OSA patients. Age was the main independent factor correlated with quantitative IMT and arterial stiffness, and AHI and mini SaO₂ were associated factors. There were no relationships between aforementioned adipocytokines and quantitative IMT/carotid arterial stiffness.

Long-term health-related quality of life, survival and costs by different levels of functional outcome six months after stroke

INTRODUCTION

Information about the impact of functional outcome after stroke is currently missing on health-related quality of life, survival and costs. This information would be valuable for health economic evaluations and for allocation of resources in stroke health care.

PATIENTS AND METHODS

Data on 297 Swedish patients included in the Third International Stroke Trial were analysed including functional outcome at six months (measured by Oxford Handicap Scale), health-related quality of life up to 18 months (EQ-5D-3L) and survival up to 36 months. We used record linkage to collect data on costs up to 36 months, using national patient registers.

RESULTS

Patients with a better functional outcome level at six months had a significantly better health-related quality of life at 18 months (p < 0.05), better long-term survival (p < 0.05) and lower costs (p < 0.001), for all time points up to 36 months. The difference in costs was mainly due to differences in days spent in hospital (p < 0.005).

DISCUSSION

This study showed an association between functional outcome at six months and health-related quality of life up to 18 months, and costs up to 36 months.

CONCLUSION

Functional outcome six months after stroke is an important determinant of health-related quality of life, survival and costs over 36 months. Effective interventions aimed at reducing short-term disability levels are therefore also expected to reduce the overall burden of stroke.

Clinical signs in young patients with stroke related to FAST: results of the sifap1 study

OBJECTIVES

The present study aimed to evaluate the frequency of warning signs in younger patients with stroke with a special regard to the 'FAST' scheme, a public stroke recognition instrument (face, arm, speech, timely).

SETTING

Primary stroke care in participating centres of a multinational European prospective cross-sectional study (Stroke in Young Fabry Patients; sifap1). Forty-seven centres from 15 European countries participate in sifap1.

PARTICIPANTS

5023 acute patients with stroke (aged 18-55 years) patients (96.5% Caucasians) were enrolled in the study between April 2007 and January 2010.

PRIMARY AND SECONDARY OUTCOME MEASURES

sifap1 was originally designed to investigate the relation of juvenile stroke and Fabry disease. A secondary aim of sifap1 was to investigate stroke patterns in this specific group of patients. The present investigation is a secondary analysis addressing stroke presenting symptoms with a special regard to signs included in the FAST scheme.

RESULTS

4535 patients with transient ischaemic attack (TIA; n=1071), ischaemic stroke (n=3396) or other (n=68) were considered in the presented analysis. FAST symptoms could be traced in 76.5% of all cases. 35% of those with at least one FAST symptom had all three symptoms. At least one FAST symptom could be recognised in 69.1% of 18-24 years-old patients, in 74% of those aged 25-34 years, in 75.4% of those aged 35-44 years, and 77.8% in 45-55 years-old patients. With increasing stroke severity signs included in the FAST scheme were more prevalent (National Institute of Health Stroke Scale, NIHSS<5: 69%, NIHSS 6-15: 98.9%, NIHSS>15: 100%). Clustering clinical signs according to FAST lower percentages of strokes in the posterior circulation (65.2%) and in patients with TIA (62.3%) were identified.

CONCLUSIONS

FAST may be applied as a useful and rapid tool to identify stroke symptoms in young individuals aged 18-55 years. Especially in patients eligible for thrombolysis FAST might address the majority of individuals.

STUDY REGISTRATION

The study was registered in http://www.clinicaltrials.gov (No. NCT00414583).

Lessons from everyday stroke care for clinical research and vice versa: comparison of a comprehensive and a research population of young stroke patients

Background

Translating knowledge derived from medical research into the clinical setting is dependent on the representativeness of included patients. Therefore we compared baseline data of patients included in a recent large study addressing young stroke in comparison to a large representative stroke registry.

Methods

We analysed baseline data of 5023 patients (age 18-55 years) with an acute cerebrovascular event included in the sifap1 (Stroke in Young Fabry Patients) study. For comparison 17007 stroke patients (age 18-55 years) documented (2004-2010) in a statutory stroke registry of the Institute of Quality Assurance Hesse of the Federal State of Hesse (GQH), Germany.

Results

Among 17007 juvenile (18-55 years) patients identified in the GQH registry 15997 had an ischaemic stroke or TIA (91%) or an intracranial haemorrhage (9%). In sifap1 5023 subjects were included. Sex distribution was comparable (men: 59% sifap1 versus 60.5% GQH) whereas age differed between the groups: median age was 46 years in sifap1 versus 49 years in GQH. Slightly higher percentages for diabetes mellitus and hypertension in the GQH registry were noted. There were no differences in stroke severity as assessed by NIHSS (median 3) and mRS (median 2). In patients with ischaemic stroke or TIA (n = 4467 sifap1; n = 14522 GQH) higher rates of strokes due to small artery occlusion and atherosclerosis occurred in older age groups; cardioembolism and strokes of other determined cause occurred more frequently in younger patients.

Conclusions

The comparison of baseline characteristics between the sifap1 study and the GQH registry revealed differences mainly determined by age.

Acute Cerebrovascular Disease in the Young

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

The psychology of stroke in young adults: the roles of service provision and return to work

Literature about the psychological consequences of stroke in those under 65 is reviewed focussing on services and work. Despite similarities, young and old survivors have different experiences and needs. These are attributable to the effects of stroke on age-normative roles and activities, self-image, and the young person's stage in the life-cycle, especially family and work. "Hidden" cognitive impairments, a disrupted sense of self, and the incongruity of suffering an "older person's" disease are salient. Young survivors benefit from services, but experience lack of congruence between their needs and service philosophy, methods, and aims, and consequently have unmet needs. Employment is psychologically salient, and the evidence about return rates, factors that affect return, and the adequacy of employment-related service provision is reviewed. Specific and general recommendations are made for increasing congruence between young survivors' needs and service provision and also for facilitating their return to work.