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Vilionskis A, Korv J. Editorial: Quality of stroke care: what could be improved, and how? Front Neurol 2023; 14:1250872. [PMID: 37497011 PMCID: PMC10368399 DOI: 10.3389/fneur.2023.1250872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023] Open
Affiliation(s)
| | - Janika Korv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
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2
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Wang X, Wang X, Ma J, Jia M, Wu L, Li W, Li C, Wu C, Ren C, Chen X, Zhao W, Ji X. Association between the time of day at stroke onset and functional outcome of acute ischemic stroke patients treated with endovascular therapy. J Cereb Blood Flow Metab 2022; 42:2191-2200. [PMID: 35791272 PMCID: PMC9670006 DOI: 10.1177/0271678x221111852] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
To investigate the association between time-of-day of stroke onset and functional outcome in patients with acute ischemic stroke(AIS) treated with endovascular thrombectomy(EVT). AIS patients treated with EVT between January 2013 and December 2018 were recruited and divided them into four 6-h interval groups according to the time-of-day of stroke onset. A total of 438 patients were enrolled, 3-month favorable outcome were achieved in 58.6%, 43.7%, 36.6%, and 30.5% of patients in the 00:00-06:00, 06:00-12:00, 12:00-18:00, and 18:00-24:00 groups, respectively (adjusted OR 0.61, 95% CI 0.40-0.93; p = 0.020). Compared with the 18:00-24:00 interval, patients in the 00:00-06:00 interval (adjusted OR 4.01, 95%CI 1.02-15.80, p = 0.047) and the 06:00-12:00 interval (adjusted OR 3.24, 95% CI 1.09-9.64, p = 0.034) were more likely to achieve favorable outcome. The time-of-day of stroke onset was not associated with 3-month mortality (adjusted p = 0.829), symptomatic intracerebral hemorrhage (sICH, adjusted p = 0.296), or early successful recanalization (adjusted p = 0.074). In conclusion, in AIS patients treated with EVT, those onsets either between 00:00 and 06:00 or between 06:00 and 12:00 appeared to be associated with a higher proportion of favorable outcomes at 3 months, but the time-of-day at stroke onset was not associated with the incidence of sICH, rate of early successful recanalization, or 3-month mortality.
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Affiliation(s)
- Xian Wang
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Xiaoyin Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jin Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Milan Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Longfei Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weili Li
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Chen
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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3
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Nursi A, Padrik M, Nursi L, Pähkel M, Virkunen L, Küttim-Rips A, Taba P. Adaption and validation of the Mississippi Aphasia Screening Test to Estonian speakers with aphasia. Brain Behav 2019; 9:e01188. [PMID: 30569561 PMCID: PMC6346641 DOI: 10.1002/brb3.1188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/15/2018] [Accepted: 11/23/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The Mississippi Aphasia Screening Test (MAST) is a brief screening tool for assessing the expressive and receptive language abilities of patients with aphasia. The goal of this study was to adapt and validate the MAST into the Estonian language. The discriminant validity and internal consistency of the test were examined, as well as its sensitivity and specificity. METHODS The MASTest was administered in 50 left hemisphere stroke patients with aphasia (LHA+ group) in the acute phase after the stroke and 126 healthy volunteers in a control group (CG), stratified by age and level of education. Nonparametric tests were used to get normative values, compare the values of the MASTest scores between the LHA+ group and the CG, and to assess the discriminant validity, internal consistency, sensitivity, and specificity of the MASTest. RESULTS The summary scores: total score (MASTest-T), expressive score (MASTest-E), and receptive score (MASTest-R) correlated with age and educational level, and the normative values were adjusted accordingly. The LHA+ group showed more impairment than the CG in all subtests and summary scores. The internal reliability of the MASTest was high for the whole sample and LHA+ group. The sensitivity and specificity of the MASTest using the 5th percentile were 74% and 94%, respectively, but using receiver operating characteristic (ROC) analysis, it was 89% and 80%. CONCLUSION The MASTest is a valid screening tool for evaluating expressive and receptive language abilities in Estonian patients with aphasia in early stroke. The MASTest is the first validated aphasia screening test for Estonian-speaking people, who number less than one million worldwide.
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Affiliation(s)
- Aaro Nursi
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia.,Department of Neurology, Tartu University Hospital, Tartu, Estonia
| | - Marika Padrik
- Institute of Education, University of Tartu, Tartu, Estonia
| | - Liisa Nursi
- Department of Neurology, Tartu University Hospital, Tartu, Estonia
| | - Maarja Pähkel
- Institute of Education, University of Tartu, Tartu, Estonia
| | - Liis Virkunen
- Institute of Education, University of Tartu, Tartu, Estonia
| | | | - Pille Taba
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia.,Department of Neurology, Tartu University Hospital, Tartu, Estonia
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Ding J, Bai Z, Zhou D, Li X, Rajah GB, Ding Y, Han J, Ji X, Meng R. Circadian rhythms may not influence the outcomes of thrombolysis in patients with ischemic stroke: A study from China. Chronobiol Int 2018; 35:1533-1542. [PMID: 29993298 DOI: 10.1080/07420528.2018.1494602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Circadian rhythms can affect physical or mental activities as well as the time of stroke onset. The impact of circadian rhythms on acute ischemic stroke (AIS) patients treated by recombinant alteplase (rt-PA) is still incongruent. This study aims to consider whether the outcomes of thrombolysis differ depending on stroke onset time and rt-PA infusion time in patients with AIS. A total of 447 AIS patients, who underwent rt-PA intravenous infusion within 4.5 hours after stroke onset, were enrolled in this study consecutively from June 2010 through December 2016. All of the patients were grouped based on the stroke onset time and rt-PA infusion time into two exact 12-hour intervals as daytime (06:01-18:00) and nighttime (18:01-06:00) and further divided into four subgroups at 6-hour time intervals (00:01-06:00, 06:01-12:00, 12:01-18:00 and 18:01-24:00). Major neurological improvement at 1 hour, 24 hours and 7 days, 7-day mortality rate and 24-hour hemorrhage transformation was recorded. The results showed that a total of 295 patients (66.4%) appeared with AIS and 252 (56.4%) were treated during daytime. Higher NIHSS at admission was observed when stroke occurred in nighttime, especially during 00:01-06:00. Patients with stroke onset in nighttime especially during 18:01-24:00 had a significant shorter onset-door time and onset-needle time. No differences of the major neurological improvement at 1 hour, 24 hours and 7 days, 24-hour hemorrhagic transformation and 7-day fatality rate were found among either 12-hour time frames or 6-hour time frames according to the time of stroke onset or rt-PA infusion. In conclusion, there was no evidence to predict that circadian rhythms could influence the outcomes of AIS patients treated with rt-PA in China, although stroke onset during nighttime might aggravate neurological impairment before treatment. Further, multicenter and prospective clinical trials with larger number of subjects are still needed to draw more reliable conclusions.
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Affiliation(s)
- Jiayue Ding
- a Departments of Neurology and Neurosurgery , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China
| | - Zhuoxuan Bai
- c Department of Intensive Care Unit , Ninth Hospital of Xi'an , Xi'an , China
| | - Da Zhou
- a Departments of Neurology and Neurosurgery , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China
| | - Xiangyu Li
- d Department of Neurology , Tianjin Huanhu Hospital , Tianjin , China
| | - Gary Benjamin Rajah
- e Department of Neurosurgery , Wayne State University School of Medicine , Detroit , MI , USA
| | - Yuchuan Ding
- b Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China.,e Department of Neurosurgery , Wayne State University School of Medicine , Detroit , MI , USA
| | - Jie Han
- f Department of Neurology Intensive Care Unit , First Affiliated Hospital of Dalian Medical University , Dalian , China
| | - Xunming Ji
- a Departments of Neurology and Neurosurgery , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China
| | - Ran Meng
- a Departments of Neurology and Neurosurgery , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China
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Toudou Daouda M, Bouchal S, Chtaou N, Midaoui A, Souirti Z, Belahsen F. Thrombolysis Alert in Hassan II University Teaching Hospital of Fez (Morocco): A Prospective Study of 2 Years. J Stroke Cerebrovasc Dis 2018; 27:1100-1106. [PMID: 29290532 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/05/2017] [Accepted: 11/18/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Thrombolysis alert (TA) is a procedure triggered every time a patient consults for sudden focal neurological deficit within 4.5 hours. OBJECTIVE We aimed to determine firstly the etiological profile of TA and secondly to evaluate the delays in the management not only of thrombolyzed patients but also of nonthrombolyzed patients to determine the intrahospital delays to optimize. METHODS Patients aged over 18 years who consulted for sudden focal neurological deficit within 4.5 hours for whom a TA has been triggered were included. Patients admitted within 4.5 hours for which a TA has not been triggered were not included. Patients with sudden focal neurological deficit who consulted more than 4.5 hours, but for whom TA has been triggered, were also included. RESULTS We included 313 patients. The average onset-to-door time was 125.59 ± 62.78 minutes with an average National Institutes of Health Stroke Scale scores of 11.29 ± 5.98. The average door-to-imaging time was 28.36 ± 20.62 minutes. Ischemic stroke (IS) was the most common cause (70.3%), followed by hemorrhagic stroke (11.8%). Other nonstroke causes (stroke mimics) represented 17.9% of cases. They were seizures (46.4%), conversion disorders (26.8%), hypoglycemia (10.7%), brain tumors (10.7%), chronic subdural hematoma (1.8%), carbon monoxide intoxication (1.8%), and cavernoma (1.8%). Forty-six patients had been thrombolyzed. The average door-to-needle time was 90.89 ± 34.48 minutes. After 3 months, 52.1% of thrombolyzed patients were autonomous (modified Rankin scale between 0 and 2). Two patients had died (4.3%), all in the first week after the IS. CONCLUSION Our study shows that efforts need to be made at the extra-hospital and intra-hospital level to improve delays to increase the proportion of the thrombolyzed patients.
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Affiliation(s)
| | - Siham Bouchal
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco
| | - Naima Chtaou
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco; Laboratory of Epidemiology, Clinical Research, and Health Community, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdallah University, Fez, Morocco
| | - Aouatef Midaoui
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco; Laboratory of Epidemiology, Clinical Research, and Health Community, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdallah University, Fez, Morocco
| | - Zouahyr Souirti
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco; Clinical Neuroscience Laboratory, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez, Morocco; Sleep Medicine Center, Hassan II University Teaching Hospital, Fez, Morocco
| | - Faouzi Belahsen
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco; Laboratory of Epidemiology, Clinical Research, and Health Community, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdallah University, Fez, Morocco
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Reuter B, Sauer T, Gumbinger C, Bruder I, Preussler S, Hacke W, Hennerici MG, Ringleb PA, Kern R, Stock C. Diurnal Variation of Intravenous Thrombolysis Rates for Acute Ischemic Stroke and Associated Quality Performance Parameters. Front Neurol 2017; 8:341. [PMID: 28785239 PMCID: PMC5519519 DOI: 10.3389/fneur.2017.00341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/29/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction Based on data from the Baden-Wuerttemberg stroke registry, we aimed to explore the diurnal variation of acute ischemic stroke (IS) care delivery. Materials and methods 92,530 IS patients were included, of whom 37,471 (40%) presented within an onset-to-door time ≤4.5 h. Daytime was stratified in 3-h time intervals and working vs. non-working hours. Stroke onset and hospital admission time, rate of door-to-neurological examination time ≤30 min, onset-/door-to-imaging time IV thrombolysis (IVT) rates, and onset-/door-to-needle time were determined. Multivariable regression models were used stratified by stroke onset and hospital admission time to assess the relationship between IVT rates, quality performance parameters, and daytime. The time interval 0:00 h to 3:00 h and working hours, respectively, were taken as reference. Results The IVT rate of the whole study population was strongly associated with the sleep–wake cycle. In patients presenting within the 4.5-h time window and potentially eligible for IVT stratification by hospital admission time identified two time intervals with lower IVT rates. First, between 3:01 h and 6:00 h (IVT rate 18%) and likely attributed to in-hospital delays with the lowest diurnal rate of door-to-neurological examination time ≤30 min and the longest door-to-needle time Second, between 6:01 h and 15:00 h (IVT rate 23–25%) compared to the late afternoon and evening hours (IVT rate 27–29%) due to a longer onset-to-imaging time and door-to-imaging time. No evidence for a compromised stroke service during non-working hours was observed. Conclusion The analysis provides evidence that acute IS care is subject to diurnal variation which may affect stroke outcome. An optimization of IS care aiming at constantly high IVT rates over the course of the day therefore appears desirable.
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Affiliation(s)
- Björn Reuter
- Department of Neurology and Geriatrics, Helios Klinik Müllheim, Müllheim, Germany.,Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Freiburg, Germany
| | - Tamara Sauer
- Department of Neurology, Universitätsmedizin Mannheim, Heidelberg University, Heidelberg, Germany
| | | | - Ingo Bruder
- Office for Quality Assurance in Hospitals (GeQiK), Baden-Wuerttembergische Hospital Association, Stuttgart, Germany
| | - Stella Preussler
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Michael G Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, Heidelberg University, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Rolf Kern
- Department of Neurology, Klinikum Kempten, Kempten, Germany
| | - Christian Stock
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
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Length of stay in emergency department and cerebral intravenous thrombolysis in community hospitals. Eur J Emerg Med 2017; 24:208-216. [DOI: 10.1097/mej.0000000000000330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- A H V Schapira
- Department of Clinical Neurosciences, UCL Institute of Neurology, London, UK.
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Cappellari M, Bovi P, Moretto G. Circadian variation in the effect of intravenous thrombolysis after non-lacunar stroke. J Thromb Thrombolysis 2015; 38:253-9. [PMID: 24402193 DOI: 10.1007/s11239-013-1041-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The onset of non-lacunar stroke symptoms has a circadian variation, with a higher risk in the early morning hours and lower risk during the nighttime period, but this circadian distribution has not been clearly established on the effect of intravenous (IV) thrombolysis. The aim of the present study was to assess whether the time interval based on time of Alteplase IV infusion may influence the effect of treatment in patients with non-lacunar stroke. We conducted an analysis on prospectively collected data of 476 non-lacunar stroke patients treated with IV thrombolysis. To identify a possible circadian variation in the effect of Alteplase IV infusion, we used the following outcome measures: major neurological improvement (NIH stroke scale [NIHSS] score decrease of ≤8 points from baseline or NIHSS score of 0 at 24 h), and hemorrhagic transformation according to European Cooperative Acute Stroke Study trial definition within 24 h. Multivariate analysis showed that ORs for major neurological improvement were lower in patients who started IV thrombolysis in the 6 AM-noon interval (OR 0.35, 95% CI 0.16-0.74, p = 0.006) and noon-6 PM interval (OR 0.40, 95% CI 0.20-0.81, p = 0.010), whereas ORs for hemorrhagic transformation were lower in patients who started IV thrombolysis in the noon-6 PM interval (OR 0.29, 95% CI 0.12-0.67, p = 0.004) and in the 6 PM-midnight interval (OR 0.26, 95% CI 0.11-0.62, p = 0.002), compared with midnight-6 AM interval. The effect of Alteplase IV infusion could show a circadian variation in patients with non-lacunar stroke. After comparison with the midnight-6 AM interval, thrombolysis could be more safe from noon to midnight, and less effective from 6 AM to 6 PM.
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Affiliation(s)
- Manuel Cappellari
- Stroke Unit, Division of Neurology, Department of Neuroscience, Azienda Ospedaliera Univarsitaria Integrata Verona, Piazzale A. Stefani 1, 37126, Verona, Italy,
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Raj K, Bhatia R, Prasad K, Srivastava MVP, Vishnubhatla S, Singh MB. Seasonal differences and circadian variation in stroke occurrence and stroke subtypes. J Stroke Cerebrovasc Dis 2014; 24:10-6. [PMID: 25284717 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.051] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 07/16/2014] [Accepted: 07/23/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND India is a subtropical country with clear seasonal variations in weather conditions. Seasonal and circadian variation in occurrence of subtypes of cerebrovascular disease has been of interest in several studies from different countries and climate zones, but discrepant results have made the conclusions unclear. The aim of the present study was to observe the seasonal and circadian variation in the occurrence of stroke and its subtypes among our population. METHODS This was a cross-sectional observational study based on new cases and past cases of stroke on follow-up, conducted between January 2011 and December 2012 in the Department of Neurology, at the All India Institute of Medical Sciences, New Delhi, India. The date and time of onset of the stroke was recorded. The categorization of months into season was in accordance with the Indian Meteorological Department guidelines. The time of onset was distributed into 6 hourly intervals. Statistical calculations were performed using Stata version 12.1 and SPSS version 20. RESULTS A total of 583 patients were included for the study. The rate of occurrence of stroke was highest in the late morning 0600-1159 hours (P value <.001) compared with other times of the day, regardless of gender or age for both ischemic and hemorrhagic strokes. It was lowest in late evening (1800-2359 hours) quadrant compared with other quadrants. Although there was no significant difference found by dichotomizing the groups into two 6-month periods, there was an increasing trend in number of patients with stroke during the months November-February. There was no difference in stroke occurrence between the types of stroke or within each type among different seasons with different temperatures. Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification of ischemic strokes also did not show any association with season or circadian rhythm. CONCLUSIONS There is a significant increase in occurrence of strokes between 0600 and 1159 hours and lowest between 1800-2359 hours. No significant variation in stroke occurrence or subtype for any of the seasons was observed.
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Affiliation(s)
- Kishan Raj
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
| | - Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Mamta Bhushan Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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