Acute stroke outcome: effects of stroke type and risk factors

Cognitive reserve in the recovery and rehabilitation of stroke and traumatic brain injury: A systematic review

Objective: Cognitive reserve (CR) is the brain's ability to cope with changes related to aging and/or disease. Originally introduced to explain individual differences in the clinical manifestations of dementia, CR has recently emerged as a relevant construct in stroke and traumatic brain injury (TBI). This systematic review aims to investigate whether CR could predict post-stroke and TBI clinical recovery and rehabilitation outcomes, and how different variables used to estimate CR (i.e., proxies) are related to the prognosis and effectiveness of rehabilitation in these clinical populations. Method: A search was made in Pubmed, Embase, and PsycInfo for articles published until 12 January 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol guidelines. Results: 31 studies were included after completing all screening stages. Overall, results show that a higher CR was associated with a better prognosis and a more effective rehabilitation in most of the clinical aspects considered: cognitive functioning, functional, occupational, and socio-emotional abilities, as well as psychiatric and neurological scales. Conclusions: A higher CR seems to be associated with a more favorable prognosis and a better rehabilitation outcome after stroke and TBI. Results suggest that CR should be taken into account in clinical practice to make more accurate predictions about recovery and effectiveness of rehabilitation. However, some inconsistencies suggest the need for further investigations, possibly using multiple proxies for CR.

Perceptions of self-rated health among stroke survivors: a qualitative study in the United Kingdom

Background

Self-rated health predicts health outcomes independently of levels of disability or mood. Little is known about what influences the subjective health experience of stroke survivors. Our aim was to investigate stroke survivors’ perceptions of self-rated health, with the intention of informing the design of interventions that may improve their subjective health experience.

Methods

We conducted semi-structured interviews with a purposive sample of 28 stroke survivors recruited from a stroke unit and follow-up outpatient clinic, 4–6 months after stroke, to explore what factors are perceived to be part of self-rated health in the early stages of recovery. Qualitative data were analysed using a thematic analysis approach to identify underlying themes.

Results

Participants’ accounts show that stroke survivors’ perceptions of self-rated health are multifactorial, comprising physical, psychological and social components. Views on future recovery after stroke play a role in present health experience and are shaped by psychosocial resources that are influenced by past experiences of ill-health, dispositional outlook such as degree of optimism, a sense of control and views on ageing.

Conclusions

Severity of physical limitations alone does not influence perceptions of self-rated health among stroke survivors. Self-rated health in stroke survivors is a multidimensional construct shaped by changes in health status occurring after the stroke, individual characteristics and social context. Understanding the factors stroke survivors themselves associate with better health will inform the development of effective approaches to improve rehabilitation and recovery after stroke.

The Prevalence of Self-Reported Stroke in the Australian National Eye Health Survey

BACKGROUND AND PURPOSE

The study aimed to determine the prevalence of and risk factors for self-reported stroke in Indigenous and non-Indigenous Australians.

RESEARCH DESIGN AND METHODS

In this national eye study, 1738 Indigenous Australians (41.1% male) aged 40-92 years and 3098 non-Indigenous Australians (46.4% male) aged 50-98 years from 30 randomly selected sites, stratified by remoteness, were recruited and examined. Sociodemographic information and a history of stroke, diabetes, and ocular health were obtained using an interviewer-administered questionnaire.

RESULTS

The crude prevalence of self-reported stroke was 5.04% (156 of 3098, 95% confidence interval: 4.29%-5.87%) for non-Indigenous Australians and 8.75% (152 of 1738, 95% confidence interval: 7.46%-10.17%) for Indigenous Australians (P < .0001). The age-adjusted prevalence of self-reported stroke for non-Indigenous and Indigenous Australians was 4.23% and 12.72%, respectively. The prevalence of stroke increased significantly with age for both Indigenous (odds ratio = 1.06 per year, P ≤ .001) and non-Indigenous Australians (odds ratio = 1.04 per year, P ≤ .001), with the Indigenous prevalence being higher than that of the non-Indigenous group at every age.

CONCLUSIONS

The prevalence of self-reported stroke was 3 times higher in Indigenous Australians than in non-Indigenous Australians. This disparity is consistent with previous reports, highlighting the need for intensified prevention and support services to reduce the burden of stroke on Indigenous Australians.

Clinical findings for fungal infections caused by methylprednisolone injections

BACKGROUND

Since September 18, 2012, public health officials have been investigating a large outbreak of fungal meningitis and other infections in patients who received epidural, paraspinal, or joint injections with contaminated lots of methylprednisolone acetate. Little is known about infections caused by Exserohilum rostratum, the predominant outbreak-associated pathogen. We describe the early clinical course of outbreak-associated infections.

METHODS

We reviewed medical records for outbreak cases reported to the Centers for Disease Control and Prevention before November 19, 2012, from the six states with the most reported cases (Florida, Indiana, Michigan, New Jersey, Tennessee, and Virginia). Polymerase-chain-reaction assays and immunohistochemical testing were performed on clinical isolates and tissue specimens for pathogen identification.

RESULTS

Of 328 patients without peripheral-joint infection who were included in this investigation, 265 (81%) had central nervous system (CNS) infection and 63 (19%) had non-CNS infections only. Laboratory evidence of E. rostratum was found in 96 of 268 patients (36%) for whom samples were available. Among patients with CNS infections, strokes were associated with an increased severity of abnormalities in cerebrospinal fluid (P<0.001). Non-CNS infections were more frequent later in the course of the outbreak (median interval from last injection to diagnosis, 39 days for epidural abscess and 21 days for stroke; P<0.001), and such infections developed in patients with and in those without meningitis.

CONCLUSIONS

The initial clinical findings from this outbreak suggest that fungal infections caused by epidural and paraspinal injection of a contaminated glucocorticoid product can result in a broad spectrum of clinical disease, reflecting possible variations in the pathogenic mechanism and in host and exposure risk factors. (Funded by the Centers for Disease Control and Prevention.).

What determines the self-rated health of older individuals with stroke compared to other older individuals? A cross-sectional analysis of the Medical Research Council Cognitive Function and Aging Study

BACKGROUND

Poor self-rated health has been associated with poorer objective health outcomes across a range of conditions including stroke. Identification of factors associated with poor self-rated health in stroke survivors has received little attention compared to that in other older individuals. This study identifies determinants of self-rated health in older individuals with or without a history of stroke participating in the population-representative MRC Cognitive Function and Aging Study (MRC CFAS).

METHODS

The MRC CFAS is a multicentred longitudinal survey of a population representative sample of people in their 65th year and older at baseline. Baseline interview included questions about functional disability, psychiatric history, independent living status, social interactions, and cognitive function. Multiple logistic regression was used to determine associations between demographic, physical, cognitive, psychological and social factors with poor self-rated health among those with and without stroke.

RESULTS

After excluding those with impaired cognitive function, 776 individuals out of 11,957 reported a stroke. Factors associated with self-rated health were similar between those with or without a stroke in older individuals. Poorer self-rated health in those who had suffered a stroke was associated predominantly with the presence of comorbidity with diabetes (OR 3.5; 95% CI 1.5-8.1) and not "getting out and about" (OR 2.6; 95% CI 1.7-4.1) even after adjustment for disability levels and for depression. In those without a stroke the most important determinants were disability (OR 3.9; 95% CI 3.2-4.8) and not "getting out and about" (OR 2.9; 95% CI 2.5-3.3). The presence of disability was less strongly associated with poor self-rated health in those with a history of stroke than those without due to a substantially higher reporting of poor self-rated health in the non-disabled stroke group than the non-disabled stroke-free group, while those with disabilities reported poor self-rated health irrespective of stroke status.

CONCLUSIONS

Self-rated health is determined by a range of psychological and social factors in addition to disability in older patients with stroke. Addressing social integration and mobility out of the home is an important element of rehabilitation for older people with stroke as well as those without.

An analysis of the risk factors and the outcomes of cerebrovascular diseases in northern India

INTRODUCTION

Stroke is a growing epidemic in the developing countries. The risk factors of stroke are the same as those of atherosclerosis, but the relative incidences of the various risk factors keep changing with time and cultural and environmental factors. So, a periodic analysis should be done.

AIMS AND OBJECTIVE

The generation of the data which pertained to the clinical profile of stroke in our institution by using the WHO Steps Stroke Manual, version 2 and to make note of the risk factors and the correlation of the outcome with the Glasgow's Coma Scale (GCS) at admission and with the Modified Rankin Scale (MRS) on the 28th day.

MATERIAL AND METHODS

A prospective study was conducted on 157 cases of stroke patients who were admitted to the Medicine Department of a tertiary care institute during June 2011 through June 2012.

OBSERVATIONS

Amongst the 157 cases (92 males and 65 females), 86 % were above 40 years of age and this was the most prevalent age group in the age range of 51-60 years. The risk factor analysis showed hypertension as the most prevalent risk factor, followed by diabetes cum hypertension. Hemiplegia/hemi paresis was the most common presentation, followed by aphasia. Radiological studies showed that ischaemic strokes were the most frequent ones, followed by haemorrhagic strokes (71 vs. 29 %). Amongst the ischaemic infarcts, the anterior circulation infarct was the most frequent one. The outcome was poor with haemorrhagic strokes and in those who were presented with a GCS of less than 3. The overall mortality was 22.29 %. A significant residual deficit (MRS >3) was seen in 49.7 % of the patients.

CONCLUSIONS

There is a need for prospective representative population based surveys viz. the WHO Stroke Steps 2 and 3.Public health measures are essential to enhance the awareness about the importance of knowing the risk factors. Hence, the message which has to be percolated to the masses is - stroke is a 'brain attack' that is preventable.

Association of total serum cholesterol with functional outcome following home care rehabilitation in Italian patients with stroke

BACKGROUND

Stroke is a disabling disease. In elderly populations, stroke is the third leading cause of death and the primary cause of reduction in or loss of functional ability and personal autonomy. Possible associations between levels of total serum cholesterol (TC) and both incidence of stroke and functional outcomes after rehabilitation are still under study.

OBJECTIVE

To detect positive and negative prognostic factors associated with functional outcomes in first-time stroke patients admitted to an integrated home care rehabilitative program.

METHODS

This study enrolled 141 patients with a first-time stroke who were admitted to a home care rehabilitation program. Primary outcome measures were the Barthel activities of daily living (ADL) and mobility indices at the beginning and end of the rehabilitative treatment. The impact of TC and other demographic and clinical variables was analyzed using bivariate and multivariate logistic regression analyses.

RESULTS

Age and Short Portable Mental Status Questionnaire (SPMSQ) score were negatively associated with functional outcome. In contrast, elevated TC was positively associated with a better home rehabilitative treatment outcome. Barthel index score at admission was negatively associated with outcomes assessed by the Barthel ADL index and age with outcomes assessed by the Barthel mobility index. In a multivariate logistic regression analysis, SPMSQ score and elevated TC were significantly associated with outcome. Specifically, higher SPMSQ scores were negatively associated with better rehabilitative treatment outcomes, whereas elevated TC was positively associated.

CONCLUSIONS

Elevated TC seems to be associated with better functional outcomes in patients with first-time stroke.

Recorded Categories of Non-Principal Diagnoses in Victorian Public Hospital Transient Ischaemic Attack and Stroke Admissions

Information about the number and types of non-principal diagnoses (NPDs) would make an important contribution to prediction of outcome and hence patient management. The study reported here is based on analysis of three fiscal years of the Victorian public hospital transient ischaemic attack (TIA) and stroke admissions. The incidence of NPDs and co-occurrence of NPD-associated prefix categories (that identify the onset or relevance of each condition to the episode) are described in each of the broad stroke subtypes. The distributions of length of stay and in-hospital deaths in the cohorts without and with NPDs and in the various prefix categories are determined. The study also compares the age and gender distribution in the various subpopulations of interest. The importance of collecting complete and accurate data on nature of NPDs and its potential in describing the complexity of presentation are discussed.

Risk Factors for Short-Term Mortality in Older Subjects with Acute Ischemic Stroke

BACKGROUND

Stroke is the third cause of death in older individuals living in Western Countries. The identification of predictors for mortality after stroke has a major importance for clinicians in order to allow the implementation of therapeutic and preventive strategies.

OBJECTIVE

To evaluate the association between clinical and laboratory parameters and 30-days total mortality in a large sample of older patients with stroke.

METHODS

469 older patients (median age: 80.0 years) consecutively hospitalized for acute ischemic stroke were enrolled. The data recorded included: (1) clinical features of stroke; (2) routine clinical chemistry analyses; (3) medical history, and (4) 12-lead ECG. All patients underwent computed tomography scan of the brain. Stroke type was classified by the Oxfordshire Community Stroke Project system.

RESULTS

130 subjects died within 30 days after stroke, with an overall mortality of 27.7%. At univariate analysis, altered levels of consciousness (ALC), congestive heart failure, atrial fibrillation, previous stroke, high blood glucose, fibrinogen and blood sedimentation rate levels, higher white blood cell count, lower serum albumin and iron levels were associated with mortality. Multivariate logistic regression analysis indicated that short-term mortality was associated with ALC (OR: 11.80; CI 95%: 5.50-24.00), congestive heart failure (OR: 3.06; CI 95%: 1.04-8.80), and age (OR: 1.04; CI 95%: 1.002-1.09) independent of gender, previous stroke, AF, fasting blood glucose, serum albumin, serum iron, and white blood cell count. In patients with ALC (high-mortality rate: 63.6%), only hyperglycemia (III vs. I tertile, OR: 9.60; CI 95%: 1.65-52.50) was associated with mortality after multivariate adjustment.

CONCLUSION

Our study highlights the role of ALC and congestive heart failure in the short-term prognostic stratification of older patients with acute ischemic stroke. Furthermore, our results support the value of post-stroke hyperglycemia as a marker for short-term mortality also in advanced age, and particularly in the presence of ALC and in nondiabetic individuals.

Diabetes and stroke: Part one—Risk factors and pathophysiology

Diabetes is a major risk factor for stroke and is associated with an increase in overall stroke mortality. The metabolic syndrome associated with insulin resistance is also a significant risk factor for stroke. The etiology of stroke in diabetics is frequently microvascular disease from fibrinoid necrosis, which causes small subcortical infarcts designated as lacunar strokes. Diabetics also have an increased incidence of large vessel intracranial vascular disease. Although strict control of blood sugar has not been shown to reduce the overall incidence of stroke in diabetics, careful management of other associated risk factors, particularly hypercholesterolemia and hypertension, are imperative for the prevention of stroke in diabetic patients.

Spontaneous intracerebral haemorrhages-warfarin as a risk factor

The primary objective of this study was to evaluate the incidence of warfarin use in 156 consecutive patients presenting to a single tertiary referral centre with spontaneous intracerebral haemorrhage. Our study found that 11% of patients (16/159) presenting with spontaneous intracerebral haemorrhage were on warfarin for prophylactic anticoagulation at time of presentation. Comparison was made to other published Australian data with regard to the incidence of warfarin use in patients presenting with spontaneous intracerebral haemorrhage. Patient outcomes were also examined.

Stroke: a review with an African perspective

The frequency of stroke and stroke-associated mortality are higher in Blacks than in other races. Several of the known risk factors for stroke, such as hypertension, diabetes and obesity, are more common in Blacks than Whites, and sickle-cell disease and HIV infection are stroke risk factors with particular relevance to Africans. Although the facilities for accurate stroke diagnosis and classification are unavailable in most parts of Africa, careful analysis of the clinical features can minimize the rates of misdiagnosis and misclassification. The high levels of stroke-attributable morbidity and mortality observed in Africans could be markedly reduced by instituting primary and secondary preventive measures and by educating health-care professionals on stroke-management strategies.

Combined clinical and imaging information as an early stroke outcome measure

BACKGROUND AND PURPOSE

Imaging information has been proposed as a potential surrogate outcome in stroke clinical trials. The purpose of this study was to determine whether an early outcome measure combining clinical and imaging information is better than either alone in predicting 3-month outcome in acute ischemic stroke patients.

METHODS

Clinical information (National Institutes of Health Stroke Scale) and imaging information (CT infarct volume), measured at 1 week from 201 patients from the Randomized Trial of Tirilazad Mesylate in Acute Stroke (RANTTAS) study, were used in a multivariable logistic regression analysis to predict excellent and devastating 3-month outcome. The combined models were compared with the infarct volume models and the clinical models. Discrimination, calibration, and change in global model chi-square were assessed.

RESULTS

The combined models and models using clinical information alone had areas under the receiver operating characteristic curves that did not differ significantly (probability value = 0.092 to 0.4), ranging from 0.83 to 0.95. The imaging alone models performed less well (P<0.005) and had areas under the receiver operating characteristic curves that ranged from 0.70 to 0.80.

CONCLUSIONS

The National Institutes of Health Stroke Scale at 1 week is highly predictive of 3-month outcome in ischemic stroke patients. The addition of 1-week infarct volume does not improve the accuracy of the predictive model.

A practical stroke severity scale predicts hospital outcomes

GOAL

To develop a practical severity scale (Wake Forest Stroke Severity Scale [WFSSS]) to predict acute hospital outcomes and resource use after acute ischemic stroke based on the admission neurologic exam.

BACKGROUND

A useful scheme enabling physicians and other health care providers to stratify stroke severity on admission to predict acute hospital outcomes and improve efficiency of inpatient care has not been described.

METHODS

The study subjects consisted of 271 consecutive acute stroke patients admitted to the neurology department from July 1995 to June 1996 who were prospectively examined and whose stroke severity was classified on the basis of admission neurologic exam (level of consciousness, strength, dysphasia, neglect, and gait) as mild, moderate, or severe, based on the WFSSS. National Institutes of Health stroke scale (NIHSS) was performed early in admission (70% within 24 hours). Discharge disposition (home, inpatient rehabilitation [rehab], skilled nursing facility [SNF], or death); length of stay (LOS); and hospital charges were associated with initial stroke severity ratings using chi-square and Kruskal-Wallis tests.

RESULTS

Fifty-percent (136) of strokes were classified as mild, 22% (60) as moderate, and 28% (75) as severe. Initial severity ratings were significantly related to discharge disposition, LOS, and hospital charges (all P values <.001).

CONCLUSIONS

A practical clinical severity scale (WFSSS) for acute ischemic stroke patients based on admission neurologic examination predicts hospital disposition, LOS, and hospital charges, and may allow more accurate severity-adjusted comparisons among institutions.

Influence of hyperglycemia on stroke mortality

BACKGROUND

The influence of hyperglycemia on stroke mortality is controversial. The aim of this study was to investigate the prognostic role of hyperglycemia and diabetes on short-term and long-term mortality in patients with acute ischemic stroke.

METHODS

This retrospective cohort study included 416 acute ischemic stroke patients admitted to a tertiary hospital between July 1, 1995 and June 30, 1997. In-hospital mortality and 1-year mortality after discharge were the outcomes of the study. All patients were classified into four groups according to the glucose status and history of diabetes: group 1, normoglycemic without diabetes; group 2, normoglycemic with diabetes; group 3, hyperglycemic with diabetes and group 4, hyperglycemic without diabetes. Cochrane-Armitage trend test was used to assess the trend of mortality across the 4 groups. The influence of hyperglycemia on in-hospital and 1-year mortality were studied by logistic regression and Cox proportional hazards regression adjusting for confounders.

RESULTS

The Cochrane-Armitage trend test showed there was a strong trend towards increasing in-hospital mortality across groups 1 to 4 (P < .001). Hyperglycemia without a history of diabetes was an independent predictor of in-hospital mortality, odds ratio 3.0 (95% confidence interval: 1.1-8.3; P = .035). Hyperglycemia (with or without diabetes) did not predict in-hospital mortality significantly. Neither hyperglycemia per se nor hyperglycemia without a history of diabetes were significant in predicting 1-year mortality.

CONCLUSION

Hyperglycemia without diabetes is independently associated with higher in-hospital mortality in patients with acute ischemic stroke. There was a trend to increasing in-hospital mortality across groups 1 to 4.

Subarachnoid haemorrhage: epidemiology, risk factors, and treatment options

The present review focuses on subarachnoid haemorrhage (SAH) secondary to the rupture of an intracranial aneurysm, a condition with a high case fatality rate. Additionally, many of the surviving patients are left with significant disabilities. Risk factors for aneurysmal SAH include both genetic and acquired conditions. The most common presenting symptom is sudden onset of severe headache. Since headache is very common in the general population, it is not unusual that SAH is misdiagnosed at its onset with often catastrophic consequences. Unlike other acute neurological disorders such as brain injury, in which patient outcome is closely related to the extent of the injury occurring at the time of the trauma, patients with aneurysmal SAH are at risk of subsequent deterioration from 'avoidable' complications such as rebleed, vasospasm, hydrocephalus, and several other non-neurological general medical complications. Thus, the critical care management of the patient with SAH is of utmost importance in order to maximise the chances of satisfactory recovery. Although surgical clipping of the ruptured aneurysm remains the gold standard therapy, with the continuing refinement of endovascular techniques, a new, 'less invasive' option is now available, especially for patients considered poor surgical candidates.

Predictors of stroke outcome

Recent literature has identified many of the important factors helpful in predicting outcome even at the very acute stage of stroke. Demographic factors, risk factors, clinical exam findings, clinical scales laboratory tests, and neuroimaging all provide important information that can assist the clinician in predicting outcome. Specific factors seem to influence the effect of stroke treatments such as thrombolysis. Consideration of these factors is important when treatment decisions such as thrombolysis are being contemplated. New techniques such as eco-planar MR Imaging are now being developed that seem extremely accurate in predicting outcome. These techniques represent the "crystal ball" of predicting stroke outcome.

A predictive risk model for outcomes of ischemic stroke

BACKGROUND AND PURPOSE

The great variability of outcome seen in stroke patients has led to an interest in identifying predictors of outcome. The combination of clinical and imaging variables as predictors of stroke outcome in a multivariable risk adjustment model may be more powerful than either alone. The purpose of this study was to determine the multivariable relationship between infarct volume, 6 clinical variables, and 3-month outcomes in ischemic stroke patients.

METHODS

Included in the study were 256 eligible patients from the Randomized Trial of Tirilazad Mesylate in Acute Stroke (RANTTAS). Six clinical variables and 1-week infarct volume were the prespecified predictor variables. The National Institutes of Health Stroke Scale, Barthel Index, and Glasgow Outcome Scale were the outcomes. Multivariable logistic regression techniques were used to develop the model equations, and bootstrap techniques were used for internal validation. Predictive performance of the models was assessed for discrimination with receiver operator characteristic (ROC) curves and for calibration with calibration curves.

RESULTS

The predictive models had areas under the ROC curve of 0.79 to 0.88 and demonstrated nearly ideal calibration curves. The areas under the ROC curves were statistically greater (P<0.001) with both clinical and imaging information combined than with either alone for predicting excellent recovery and death or severe disability.

CONCLUSIONS

Combined clinical and imaging variables are predictive of 3-month outcome in ischemic stroke patients. Demonstration of this relationship with acute clinical variables and 1-week infarct information supports future attempts to predict 3-month outcome with all acute variables.

Functional status of cortical and subcortical nonhemorrhagic stroke survivors and the effect of lesion laterality

The purpose of this study is to examine the effects of cortical and subcortical infarcts and lesion laterality on the functional status of stroke survivors. Medical records of 72 stroke survivors admitted to an acute inpatient rehabilitation facility with a single nonhemorrhagic lesion were retrospectively reviewed. Multivariate analysis of variance was used to assess the effects of lesion level and hemisphere on admission and discharge Functional Independence Measure (FIM) and FIM gain. Admission FIM-Total and its subdimensions exhibited significant overall level (Wilk's lambda = 2.5; P = 0.03) and hemisphere-specific (Wilk's lambda = 2.3; P = 0.04) effects. Significant interaction between factors was noted only for the communication subdimension. Significant level and hemisphere-specific main effects were noted for admission FIM-Total (P < 0.01 and P = 0.02, respectively). There were significant level-specific main effects for self-care (P = 0.01) and mobility (P = 0.03) and hemisphere and level-specific main effects for communication (P < 0.01 and P < 0.01, respectively) and social cognition (P = 0.02 and P = 0.01, respectively). Discharge FIM-Total and its subdimensions exhibited significant overall level (Wilk's lambda = 2.5; P = 0.03) and hemisphere-specific (Wilk's lambda = 3.4; P = 0.01) effects. Discharge FIM subdimensions did not exhibit significant interaction between factors. Discharge FIM-Total was significant with respect to lesion level (P = 0.01) but not with respect to hemisphere (P = 0.08). There was a significant level-specific main effect for self-care (P = 0.01) and level and hemisphere-specific main effects for communication (P < 0.01 and P < 0.01, respectively) and social cognition (P = 0.01 and P = 0.01, respectively). FIM gain scores did not exhibit significant level (Wilk's lambda = 1.1; P = 0.36) or hemisphere-specific (Wilk's lambda = 1.4; P = 0.24) effects. The data suggest that the lesion level and hemisphere are important determinants of the function of nonhemorrhagic stroke survivors during inpatient rehabilitation.

Identification of stroke prone patients by panoramic radiography

Stroke (cerebrovascular accident, CVA) is the third leading cause of death and an important cause of hospital admission and long term disability in Australia. Atherosclerotic lesions at the bifurcation of the common carotid artery are the most common cause of stroke. On occasion these lesions are partially calcified and visible on a conventional panoramic dental radiograph. The atheroma may appear either as a nodular radiopaque mass or as two radiopaque vertical lines within the soft tissues of the neck at the level of the lower margin of the third cervical vertebra (C3). These opacities are separate and distinct from the hyoid bone and variably appear above or below it. Dentists should scrupulously review the panoramic radiographs of all individuals over age 55 with medical histories of hypertension, diabetes mellitus, hypercholesteraemia and coronary artery disease, or whose behaviour includes smoking, ethanol abuse, or dietary indiscretion coupled with overweight and a sedentary lifestyle which are known to be associated with atherosclerosis and stroke.

Justification of hospital days and discharge delays in a non-selected population of acute stroke patients

Using a published protocol, we evaluated a non-selected population of stroke patients to identify unnecessary days of hospitalisation in the Department of Neurology at the Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. This study was undertaken to determine whether physicians can modify the non-medically justified hospital days. We prospectively studied 118 patients with stroke admitted to our Department over a period of 5 months. Each day spent on the ward was placed in one of two categories: those due to medical reasons (1,391 hospital days) and those due to non-medical reason (518 days). Using a previously published protocol, 74 parameters were evaluated. Delays in obtaining examinations or a specialist's consultation accounted for a small proportion of waiting days (1.9% of total hospital days), which was greater in patients who were not disabled (0.9% of hospital days) than in patients with total dependence (0.2% of hospital days). The delays resulted mainly from awaiting transfer either to another department or to a nursing home. The length of stay increased with severity of dependence. However, the number of days spent for transfer to a nursing home was also relatively high in the non-dependent patient group (42% of hospital days). This study demonstrates that neurologists cannot easily influence the length of stay in hospital. It also corroborates the need to develop short- and long-term chronic care facilities to facilitate the transfer of patients once there are no further medical reasons for staying in hospital.

The Copenhagen Stroke Study experience

The Copenhagen Stroke (COST) Study was a prospective, consecutive, community-based study of 1,197 patients with acute stroke who underwent acute stroke care and rehabilitation in a stroke unit setting. This article reviews the results of this study with respect to (1) the effect of organized stroke care and rehabilitation, (2) neurological outcome and functional outcome of stroke in relation to initial stroke severity and functional disability, (3) recovery of upper-extremity function and walking, (4) time course of neurological and functional recovery relative to initial stroke severity, (5) mechanisms of stroke recovery, and (6) the effect on stroke recovery of various demographic, medical, and pathophysiological factors, such as stroke in progression, spontaneous reperfusion age, diabetes, blood glucose on admission, stroke type (hemorrhage/infarction), silent infarction, and leuco-araiosis.

Changes in cerebral tissue perfusion during the first 48 hours of ischaemic stroke: relation to clinical outcome

BACKGROUND

One major therapeutic strategy to minimise the extent of infarction after ischaemic stroke is to improve early reperfusion using thrombolytic agents. However, reperfusion may be hazardous and the period during which reperfusion may have a beneficial effect on tissue and clinical outcome is not known.

METHODS

Fifty three patients were studied with serial cerebral perfusion (99mTcHMPAO SPECT) during the first 48 hours of ischaemic stroke to determine if changes in tissue perfusion during this time were prognostically significant. Single and multiple linear regression non-parametric analyses were used to include other factors during the same period which may influence outcome.

RESULTS

In univariate analysis age, neurological score at admission, SPECT perfusion defect size in the first 24 hours, and percentage change in cerebral tissue perfusion at 24-48 hours (all P < 0.01) correlated significantly with the Barthel score at three months. In multiple linear regression analysis only age (P < 0.01) and percentage change in cerebral tissue perfusion at 24-48 hours (P < 0.01) provided independent prognostic information at three months.

CONCLUSIONS

Changes in cerebral tissue perfusion during the first 48 hours of ischaemic stroke are significant outcome predictors and therapeutic effort aimed at increasing perfusion during this period seem to be justified.

Cerebrovascular disorders in patients with diabetes mellitus

Diabetes mellitus is a risk factor for ischemic, but not hemorrhagic stroke. The frequency of transient ischemic attacks is not increased in patients with diabetes compared to the general population. Diabetes mellitus is associated with higher mortality, worse functional outcome, more severe disability after stroke and a higher frequency of recurrent stroke. Diabetes is not associated with an increased size of cerebral infarction. Controversy exists regarding whether hyperglycemia adversely affects stroke outcome or primarily reflects stroke severity. Cerebral blood flow disturbances, impaired cerebrovascular reactivity, and damage to large and small extra- and intracranial cerebral vessels have been found in humans and animals with diabetes. Combinations of some or all of these factors may underlie the high incidence and worse outcome of stroke in patients with diabetes. Knowledge of these pathophysiologic factors will assist in the design of future intervention strategies.

Functional outcome of hemorrhagic and nonhemorrhagic stroke patients after in-patient rehabilitation

Differences in functional prognosis for patients with hemorrhagic and nonhemorrhagic strokes are unclear. The purpose of this study is to compare the functional outcome of hemorrhagic and nonhemorrhagic stroke patients after inpatient stroke rehabilitation. By retrospective review, 25 hemorrhagic stroke patients were matched with 25 nonhemorrhagic stroke patients on the basis of age and onset to admission interval. Discharge Functional Independence Measure (FIM), FIM gain, FIM efficiency, length of stay (LOS), and discharge disposition were compared. Admission FIM, gender, and comorbidities were similar between the two groups. There were no differences in discharge FIM, FIM gain, and discharge to home rates between groups. However, the hemorrhagic group had a significantly shorter LOS (31.7 v 37.6 days; P = 0.05) with higher FIM-total efficiency (0.84 v 0.60; P = 0.02). The FIM-motor scale accounted for most of the gains in efficiency (0.71 v 0.53; P = 0.05) with no significant difference in FIM-cognition efficiency between groups. Post hoc analysis revealed that onset to admission interval was a strong predictor of LOS (r = 0.62; P < 0.0001). Hemorrhagic stroke patients appear to exhibit functional gains somewhat faster than nonhemorrhagic counterparts. Confirmation of these preliminary findings must await future studies.

Intracerebral hemorrhage versus infarction: stroke severity, risk factors, and prognosis

The purpose of this study was to compare stroke severity, risk factors, and prognosis in patients with intracerebral hemorrhage versus infarction. We prospectively studied 1,000 unselected patients with acute stroke of a verified type in the Copenhagen Stoke Study. Neurological deficits and functional disabilities were evaluated weekly from the time of acute admission throughout the rehabilitation period. Eighty-eight (9%) had intracerebral hemorrhage. The relative frequency of intracerebral hemorrhage rose exponentially with increasing stroke severity. In multivariate analyses, stroke type had no influence on mortality, neurological outcome, functional outcome, or the time course of recovery. Initial stroke severity was the all-important prognostic factor. The relative importance of hypertension and blood pressure on admission was not greater for intracerebral hemorrhage than for infarction. No preponderance was found between type of stroke and sex, age, and smoking. Diabetes, ischemic heart disease, and elevated serum total cholesterol level all favored cerebral infarction as opposed to intracerebral hemorrhage. We conclude that the type of stroke per se has no influence on stroke prognosis in general; the extent of the injury is decisive. The poorer prognosis in patients with intracerebral hemorrhage is due to the increase in frequency of intracerebral hemorrhage with increasing stroke severity. The likelihood of cerebral infarction occurring as opposed to intracerebral hemorrhage seems increased fivefold in stroke patients with diabetes. Hypertension and blood pressure on admission were not predictors of stroke type.

Comparative correlations of HMPAO SPECT indices, neurological score, and stroke subtypes with clinical outcome in acute carotid infarcts

BACKGROUND AND PURPOSE

The prognostic value of single-photon emission computed tomography (SPECT) remains controversial. The aim of this study was to compare the prognostic value of stroke severity, stroke subtypes, and SPECT indices and to determine which predictive factors have an independent effect on clinical outcome.

METHODS

We studied 55 consecutive patients with acute (< 12 hours) carotid infarct within 36 hours of symptom onset with SPECT. Clinical presentation was assessed by the Canadian Neurological Scale and stroke subtypes. SPECT indices were the degree and size of hypoperfusion and crossed cerebellar diaschisis as assessed by a semiquantitative analysis. Outcome was evaluated by the functional status and mortality (Rankin Scale score at 1 month).

RESULTS

The Rankin Scale score correlated with the degree (r = .580; P < .00001) and size (r = .616; P < .00001) of hypoperfusion. The mean degree and size of hypoperfusion were significantly higher in patients with poor outcome. Crossed cerebellar diaschisis had no significant predictive value. Statistical analysis determined threshold values for the Canadian Neurological Scale score and the degree and size of hypoperfusion for the functional status and mortality. The degree and size of hypoperfusion had no higher performance than the Canadian Neurological Scale score. The negative predictive value was excellent for both clinical and SPECT indices. Multivariate analysis selected only the size of hypoperfusion as an independent predictor for the functional status (P = .004) and the Canadian Neurological Scale score for mortality (P = .009).

CONCLUSIONS

SPECT performed within 36 hours of onset predicts clinical outcome, but different clinical and SPECT indices with threshold values should be chosen according to the relevant outcome end point.

Predicting survival for 1 year among different subtypes of stroke. Results from the Perth Community Stroke Study

BACKGROUND AND PURPOSE

Few studies have evaluated the factors influencing or predicting long-term survival after stroke in an unselected series of patients in whom the underlying cerebrovascular pathology is clearly defined. Moreover, the relative importance of risk factors for stroke, including sociodemographic and premorbid variables, has not been described in detail.

METHODS

The study cohort consisted of 492 patients with stroke who were registered with a population-based study of acute cerebrovascular disease undertaken in Perth, Western Australia, during an 18-month period in 1989 and 1990. Objective evidence of the pathological basis of the stroke was obtained in 86% of cases, and all deaths among patients during a follow-up of 1 year were reviewed.

RESULTS

One hundred twenty patients (24%) died within 28 days of the onset of stroke. Among the different subtypes of stroke, the 1-year case fatality (mean, 38%) varied from 6% and 16% for boundary zone infarction and lacunar infarction, respectively, to 42% and 46% for subarachnoid hemorrhage and primary intracerebral hemorrhage, respectively. Using Cox proportional-hazards analysis, a predictive model was developed on 321 patients with acute stroke (test sample). The best model contained five baseline variables that were independent predictors of death within 1 year: coma (relative risk [RR], 3.0; 95% confidence interval [CI], 1.1 to 8.4), urinary incontinence (RR, 3.9; 95% CI, 1.4 to 10.6), cardiac failure (RR, 6.5; 95% CI, 2.8 to 15.1), severe paresis (RR, 4.9; 95% CI, 1.6 to 15.5), and atrial fibrillation (RR, 2.0; 95% CI, 1.1 to 3.5). The sensitivity, specificity, and negative predictive value of this model for predicting death were 90%, 83%, and 95%, respectively. When applied to a second randomly selected validation sample of 171 events, sensitivity was 94%, specificity 62%, and negative predictive value 92%, indicating stability of the model.

CONCLUSIONS

Although the case fatality, timing, and cause of death vary considerably among the different pathological subtypes of stroke, simple clinical measures that reflect the severity of the neurological deficit and associated cardiac disease at onset independently predict death by 1 year and may help to direct management.

Stroke in patients with diabetes. The Copenhagen Stroke Study

BACKGROUND AND PURPOSE

Although diabetes is a strong risk factor for stroke, it is still unsettled whether stroke is different in patients with and without diabetes. This is true for stroke type, stroke severity, the prognosis, and the relation between admission glucose levels and stroke severity/mortality.

METHODS

This community-based study included 1135 acute stroke patients (233 [20%] had diabetes). All patients were evaluated until the end of rehabilitation by weekly assessment of neurological deficits (Scandinavian Stroke Scale) and functional disabilities (Barthel Index). A computed tomographic scan was performed in 83%.

RESULTS

The diabetic stroke patient was 3.2 years younger than the nondiabetic stroke patient (P < .001) and had hypertension more frequently (48% versus 30%, P < .0001). Intracerebral hemorrhages were six times less frequent in diabetic patients (P = .002). Initial stroke severity, lesion size, and site were comparable between the two groups. However, mortality was higher in diabetic patients (24% versus 17%, P = .03), and diabetes independently increased the relative death risk by 1.8 (95% confidence interval [CI], 1.04 to 3.19). Outcome was comparable in surviving patients with and without diabetes, but patients with diabetes recovered more slowly. Mortality increased with increasing glucose levels on admission in nondiabetic patients independent of stroke severity (odds ratio, 1.2 per 1 mmol/L; CI, 1.01 to 1.42; P = .04). This was not the case in diabetic patients.

CONCLUSIONS

Diabetes influences stroke in several aspects: in age, in subtype, in speed of recovery, and in mortality. Increased glucose levels on admission independently increase mortality from stroke in nondiabetic but not in diabetic patients. The effect of reducing high admission glucose levels in nondiabetic stroke patients should be examined in future trials.

Hematologic abnormalities occur in both cortical and lacunar infarction

BACKGROUND AND PURPOSE

Primary hematologic abnormalities are a rare but established cause of ischemic stroke. In addition, activation of hemostatic parameters is often present during the acute phase of stroke. However, it is uncertain whether these abnormalities occur in both cortical and lacunar infarction; this study aimed to further assess this issue.

METHODS

Hematologic parameters (prothrombin, activated partial thromboplastin, thrombin clotting, and euglobulin lysis times; and fibrinogen, fibrinopeptide A, antithrombin III, protein C, protein S, and plasminogen levels) were measured in 19 patients within 48 hours of the onset of acute cerebral infarction. These patients included 10 with cortical infarcts and 9 with lacunar infarcts, as determined by standard clinical and radiological criteria.

RESULTS

Five patients with lacunar infarction and 7 patients with cortical infarction demonstrated raised fibrinopeptide A levels, indicating enhanced thrombin activity. Fibrinolysis, assessed by the euglobulin lysis time, was impaired in 6 of 9 patients with lacunar infarction and in 2 of 10 patients with cortical infarction. Lupus anticoagulants were detected in 3 patients with lacunar infarction and in 1 patient with cortical infarction. Three patients in each group displayed decreased antithrombin III function, and 1 patient with a lacunar infarction had a low protein C level.

CONCLUSIONS

Primary hematologic disorders and secondary hemostatic derangements may occur in patients with either cortical or lacunar infarction.

Cerebral hypoperfusion in stroke prognosis and brain recovery

BACKGROUND AND PURPOSE

The value of acute cerebral blood flow measurements in stroke prognosis is controversial. No previous study has determined whether acute perfusion deficits independently add to a validated clinical prognostic score. We aimed to compare the value of acute hypoperfusion deficits with a quantitative clinical score in stroke prognosis and to correlate the changes in perfusion with brain recovery.

METHODS

Volumetric analysis of regional hypoperfusion was performed in 38 patients with middle cerebral infarction within 72 hours of onset by use of single photon emission computed tomography and 99mTc hexamethylpropylene amine oxime. Stroke severity was assessed by the Canadian Neurological Score and Barthel Index. Allen's prognostic score was determined acutely in all patients. Clinical outcome was evaluated in 36 of 38 patients, of whom 18 had repeat blood flow studies.

RESULTS

Acute hypoperfusion correlated with both the outcome Barthel Index (P < .001, r = -.61) and Canadian Neurological Score (P < .001, r = -.64). Allen's score correlated better with both the outcome Barthel Index (P < .001, r = .80) and Canadian Neurological Score (P < .001, r = .81). Acute hypoperfusion deficits, after allowing for Allen's score, independently predicted neurological but not functional outcome. Despite overall neurological improvement, mean hypoperfusion increased on the repeat blood flow studies (P < .05).

CONCLUSIONS

Volumetric analysis of acute regional hypoperfusion within 72 hours of onset predicts stroke outcome after 3 months, but Allen's score is a better prognostic method. Neurological recovery is not associated with chronic infarct reperfusion.