Incidence and outcome of cerebrovascular disease in Perth, Western Australia

Analysis of 30-day stroke mortality in a community-based registry in Warsaw, Poland

Between January 1, 1991, and December 31, 1992, in the upper Mokotow district of Warsaw, Poland (population 182,285), 462 first-ever-in-a-lifetime (FEL) strokes were registered, 12% (55/462) with parenchymatous intracerebral hemorrhages (PICH) and 88% (407/462) with ischemic strokes. Confirmation by either computed tomography or autopsy was made in 72.3% of cases. The overall 30-day case fatality rate (CFR) for FEL strokes was 40% (186/462), 60% for PICH (33/55), and 38% for ischemic stroke (153/407). Of the 186 patients who died within 30 days of their FEL stroke, 49% (91) underwent full autopsy examination. Fifty-two percent of these 91 patients were found to have died from direct neurological sequelae, 21% from cardiac causes, 17% from pneumonia, 5.6% from septicemia, 2.2% from pulmonary emboli, and 2.2% from metastatic cancer. Despite our high 30-day stroke CFR compared with Western Europe and North America, mechanisms of death were similar.

Stroke subtypes and risk factors in patients living in southern Seoul, Korea: the impact of hypertension control on stroke subtypes

BACKGROUND AND PURPOSE

The prevalence of hypertension (HT) does not explain the relatively high incidence of hemorrhagic stroke in Korea and other Asian countries, and whether HT has a greater impact on development of the intracerebral hemorrhage (ICH) than cerebral infarction (CI) remains unclear. It may be speculated that the adequacy of HT control is related to the subtype differences. The present study was aimed to elucidate (1) whether various risk factors exert a different impact on stroke subtypes and (2) whether the adequacy of HT control in patients with a previous history of HT is related to different subtypes in stroke patients from southern Seoul, Korea.

METHODS

We prospectively studied 602 consecutive patients with acute stroke (CI and ICH) admitted to the Asan Medical Center and analyzed their stroke subtypes and risk factors. The mode of HT treatment before the stroke onset was specifically asked. We examined whether various risk factors were related to subtype differences in these patients. We also attempted, in patients with a prior history of HT, to see whether the mode of HT control was related to the subtype differences.

RESULTS

75.8% of the patients had CI (large vessel infarction 33.8%, small vessel infarction 22.1%) and 24.2% had ICH; 75% of the patients had HT of whom the presence of HT was previously unidentified in 8%. Previous treatment of HT was considered adequate in 32.4% and inadequate in the others. On multiple logistic analysis, diabetes mellitus and alcohol drinking were independently related to CI (v ICH), whereas HT did not favor any stroke subtypes. However, in patients with a prior history of HT, previous mode of HT control was a significant factor related to subtype differences in a way that inadequate treatment favored ICH. There were no specific risk factors that independently discriminate large vessel infarction versus small vessel infarction.

CONCLUSIONS

Apparently, HT was not a risk factor that preferentially favors any specific stroke subtypes in patients from southern Seoul. However, in patients with HT, previous mode of HT control was an important factor influencing the subtypes. Inadequate treatment of HT may play a role, at least in part, on the relatively prevalent ICH and hence the greater significance of stroke as a cause of death in Korea compared with Western countries.

Stroke in Qatar: a first prospective hospital-based study of acute stroke

BACKGROUND

Stroke is a major cause of morbidity and mortality in Qatar.

OBJECTIVES

The aim of our study was to determine types of strokes, the associated risk factors, clinical presentation, outcome, and time to hospital admission among Qatari and non-Qatari patients as well as young and nonyoung patients.

METHODS

We conducted a hospital-based prospective observational study including all patients admitted to Hamad Medical Corporation with first-ever stroke from September 15, 2004, to September 14, 2005. A stroke was defined according to World Health Organization criteria.

RESULTS

Stroke was confirmed in 270 patients of whom 217 (80.4%) had ischemic stroke and 53 (19.6%) had hemorrhagic stroke. Male patients predominated in all types of stroke. The main risk factors for stroke were hypertension and diabetes, whereas lacunar infarct was the most common subtype of ischemic stroke. Risk factor profiles were similar between Qatari and non-Qatari patients except for hypercholesterolemia, which was observed with a higher frequency in Qatari compared with non-Qatari patients with ischemic stroke. There were significant differences between the young and nonyoung patients with ischemic stroke with respect to risk factors, ejection fraction, ventricular wall-motion abnormalities, time to hospital admission, and outcome. Most patients arrived at the hospital more than 3 hours from stroke onset because of unawareness of stroke symptoms. The overall in-hospital mortality was 9.3%.

CONCLUSIONS

Hypertension and diabetes mellitus were the main risk factors for stroke in Qatar, whereas lacunar infarct was the most common subtype. Significant differences between the young and nonyoung patients were observed with respect to risk factors, ejection fraction, ventricular wall-motion abnormalities, time to hospital admission, and outcome.

Ethnic Variations in Risk Factor Profile, Pattern and Recurrence of Non-Cardioembolic Ischemic Stroke

BACKGROUND

Ischemic stroke is influenced by ethnic and geographical variations. The aim of this study was to identify the risk factor profiles, subtypes and recurrence of non-cardioembolic ischemic stroke for the two largest subpopulations, the Arab and South Asians, at the only stroke-admitting hospital in Qatar.

METHODS

Data on stroke patients admitted to Hamad Medical Corporation from January through December 2001 were reviewed in January 2005. Only patients with non-cardioembolic ischemic stroke and complete work-up were included.

RESULTS

A total of 303 patients with ischemic non-cardioembolic stroke fit the entry criteria. Sixty seven percent of the overall patient population (sex ratio 2:6, M/F) was of Arab origin, and 32% were South Asians. Hypertension was the most commonly encountered risk factor followed by dyslipidemia, diabetes mellitus, and obesity. Significant differences between the Arab and South Asian subgroup of patients were observed with respect to number of risk factors and occurrence of obesity and diabetes. Carotid artery stenotic lesions, ventricular wall motion abnormalities and stroke recurrence were observed with a higher frequency in the Arab subgroup of patients compared with the South Asians. The majority of strokes were lacunar hemispheric strokes (68%), followed by lacunar brainstem strokes (15%) and large-vessel hemispheric infarctions (10%). Patients with a previous history of stroke had a higher frequency of carotid artery stenosis (p = 0.05) and risk of stroke recurrence (p = 0.04).

CONCLUSIONS

Unlike in other studies originating from the Arabian Gulf, lacunar stroke is the most common subtype of non-cardioembolic ischemic stroke in both the Arabs and South Asians in Qatar. Significant ethnic differences in age of occurrence, risk factor profile, and cardiovascular variables were observed.

Trends in Five-Year Survival and Risk of Recurrent Stroke after First-Ever Stroke in the Perth Community Stroke Study

BACKGROUND

Few studies provide information on trends in the long-term outcome of stroke. We aimed to determine trends in survival and recurrent stroke, over 5 years after first-ever stroke, for 2 cohorts of patients enrolled in the Perth Community Stroke Study in 1989-90 and 1995-96.

METHODS

For 12-month periods beginning February 1989 and February 1995, all individuals with an acute stroke who were resident in a geographically-defined and representative region of Perth, Western Australia, were registered and followed-up prospectively 5 years after the index event.

RESULTS

The 5-year cumulative risk of death was 59% (95% confidence interval (CI) 53%, 65%) and 58% (95% CI 52%, 65%) for the 1989-90 and 1995-96 cohorts, respectively (p = 0.94). The 5-year cumulative risk of first recurrent stroke was 32% (95% CI 25%, 40%) and 23% (95% CI 16%, 30%) for the 1989-90 and 1995-96 cohorts, respectively (p = 0.07).

CONCLUSIONS

Although no statistically significant improvement occurred in 5-year survival after first-ever stroke in Perth between 1989-90 and 1995-96, there was a statistically nonsignificant trend towards a smaller cumulative risk of recurrent stroke over 5 years after a first-ever stroke. Serial community-based studies of the incidence and outcome of stroke are an important means of monitoring the translation of proven preventive interventions to improvements in population health.

The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis

OBJECTIVE

To estimate the proportion of patients with aneurysmal subarachnoid hemorrhage (SAH) who die before receiving medical attention.

METHODS

We performed a systematic literature review.

RESULTS

Eighteen population-based studies between 1965 and 2001 described the incidence of death from SAH before the patients received medical attention. The combined overall risk of sudden death was 12.4% (95% confidence interval, 11-14%). Patient level analysis was possible for two studies. No significant association between age and sudden death was identified. Aneurysms in the posterior circulation had an estimated probability of sudden death of 44.7% (95% confidence interval, 7.4-86%). Statistical sensitivity analysis was performed to examine some possible causes for the heterogeneity between the studies. Study factors statistically associated with a higher rate of sudden death include origin in England, computed tomographic scans not available for diagnosis, inclusion of patients with SAH from arteriovenous malformations, lower or not stated rate of autopsy for deaths in the community, and a higher rate of patients with confirmed aneurysms.

CONCLUSION

The combined overall estimated risk of sudden death was 12.4% for aneurysmal SAH and 44.7% for posterior circulation aneurysms. However, there are several sources of heterogeneity or possible bias in the reported studies. Further information on patient and aneurysm characteristics is required.

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.

[Epidemiology of cerebrovascular disease in Joinville, Brazil. An institutional study]

The paucity of epidemiologic data, and the previous impression of high incidence of cerebrovascular disease in Brazil, made us elaborate a prospective institutional study in Joinville, Brazil, with objective of identifying first and recurrent episodes in stroke. This study occurred from March 1995 to March 1996. We evaluated during the first episode of stroke: incidence, mortality and fatality-case ráte (in 30 days lethality), frequency of risk factor, time in hospital and distribution of cerebral infarcts by pathological subtypes. In this period, 429 patients with stroke were registered, 320 with the first episode. 98% of all the patients were submited to at least one computed tomography scanning. The episodes of cerebral infarcts were divided in pathological sub-types. Results showed that the annual incidence adjusted to the age of first stroke episode was 156/100,000. The distribution by diagnosis was: 73.4% for cerebral infarct, 18.4% for cerebral hemorrhage and 7.5% for subarachnoid hemorrhage. The annual standard mortality rate was 25/100,000. The fatality case global rate in 30 days was 26%. Hypertension, previous stroke and diabetes were the most frequent risk factors. Only 25% of the patients were assisted within three hours of the onset of stroke. We concluded that the incidence rate of first episode of stroke is high in institutionalized patient in Joinville, Brazil. The mortality and fatality--case rates are similar to the ones of other populations.

Therapeutic strategies for atrial fibrillation. The value of decision analysis

In the absence of randomized, controlled trials of low-dose amiodarone in atrial fibrillation or a randomized, controlled trial of ventricular rate control versus antifibrillatory therapy, a Markov decision analysis is useful in comparing different therapeutic strategies for atrial fibrillation. The decision analysis described compared warfarin, quinidine, and low-dose amiodarone in patients with asymptomatic or minimally symptomatic chronic, persistent atrial fibrillation. This model suggests that electrical cardioversion followed by low-dose amiodarone is a relatively safe, effective alternative to long-term warfarin therapy.

Specific cardiological evaluation after focal cerebral ischemia

Purpose of this study was to define a subgroup of TIA/stroke patients who should be examined by transthoracal and transesophageal echocardiography or Holter-electrocardiography to identify those with cardiogenic brain embolism reliably; 300 consecutive patients with acute focal brain ischemia underwent a standardized diagnostic protocol for the evaluation of the etiology including, clinical examination by a cardiologist and routine electrocardiography, Holter-electrocardiography, transthoracal and transesophageal echocardiography. 188 patients had a potential cardiac source of embolism. In particular echocardiography was diagnostic in 163 patients, and Holter-electrocardiography 10; 159 of these 188 patients (84.6%) had competitive etiologies, predominantly large vessel atherosclerosis. In 136 patients cardiogenic brain embolism was assumed as quite definite or possible. To identify these patients reliably, transthoracal and transesophageal echocardiography would have been necessary in 89% of the entire group of patients (all with clinically cardiological abnormalities, pathological routine ECG, without vascular risk factors, or no atherosclerosis in duplex sonography), and Holter-electrocardiography in 54%.

The epidemiology of stroke and transient ischaemia in Brisbane, Australia

This study presents the crude and age-adjusted annual incidence rates and diagnostic classifications of acute strokes and identified transient ischaemia cases in persons 25 years and over in an urban population slightly over one million. Ot the total of 2676 hospital admissions 1244 were stroke patients (the other 89 were unsubstantiated, 144 were resident outside the incidence area, 555 were asymptomatic lesions and 644 were TIA admissions); 139 patients were in chronic care facilities; 134 were managed in their own homes by their medical practitioners, with 84 certified community and 455 medical practitioners' reported deaths giving a total of 2056 strokes. Including the TIAs treated at home and admissions to hospitals there were 1877 TIAs (population at risk 660,598). The overall age-adjusted incidence rate for stroke was 1.22 or 40 percent of the crude rate per 1000 persons at risk, while the overall TIA age-adjusted rate was 1.20 or 43 percent. Aetiological classifications revealed thrombosis 0.46, embolism 0.09, intracerebral haemorrhage 0.19, subaracnoid 0.14, and acute but ill-defined events were 0.34 per 1000 persons. Early mortality was 32 percent with a significant winter peak with incidence unrelated to mean ambient temperature.

The Western Sydney Stroke Risk in the Elderly Study. A 5-year prospective study

Aging of the Australian population, as in other developed nations, will ensure that stroke remains one of the most important causes of death and disability. The Stroke Risk in the Elderly (SITE) study aims to measure prospectively the independent contribution of dietary, sociodemographic, blood lipid, blood pressure, and hemostatic factors to risk of stroke and other cardiovascular outcomes. The target population included all independently living men and women aged 65 years and over, residents in several retirement villages in western metropolitan Sydney, New South Wales, Australia. The study cohort consists of 225 men and 787 women, selected as a convenience sample from all eligible residents in the local government areas (LGAs) adjacent to Westmead Hospital. Participants attended a baseline session to complete dietary, life-style, medical, and sociodemographic questionnaires. Anthropomorphic variables and blood pressure were measured. Blood was taken for measurement of serum lipid, glucose, and hemostatic factors. Questionnaire results were compared with an age/sex-stratified, randomly selected sample drawn from the community (in the same LGAs), in order to quantify potential sampling and selection biases. The study cohort will be followed for a minimum of 5 years. The attendance rate of eligible residents for a baseline medical, dietary, life-style, and sociodemographic assessment was 72% for males and 69% for females. The study cohort was older, better educated, less ethnically diverse, and among women, less likely to have ever been married compared to people aged over 65 years in the comparison group. The baseline results suggest that hemostatic factors may be of importance in assessing risk of cardiovascular disease, (CVD), particularly in older men.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke care in the next decades: a projection derived from a community-based study in Umbria, Italy

Recently published data show that stroke incidence is not longer declining, while case fatality rates has had a less pronounced fall in recent years than in the past. Projections of the increasing number of elderly people, combined with the greater risk of stroke in old age, suggest that in the forthcoming decades we will be faced with an increased request of health resources for patients with stroke. We have therefore used data from a community-based study on stroke incidence and outcome to project the number of first ever strokes, death from stroke and handicap from stroke in Italy, up to the year 2016. Results show that incidence will increase by 22.2%, and death at 6 months from first ever stroke by 29%. However, since patients already handicapped for other reasons are more likely to die from their stroke, the net number of newly handicapped persons will only increased by 5%. These results suggest that in the next decades the major increase in request of health care resources will result from the acute event and the immediate post-ictal phase, and not from the management of chronic handicap after a stroke.

Ascertaining the true incidence of stroke: experience from the Perth Community Stroke Study, 1989-1990

OBJECTIVE

To determine the age and sex specific incidence, and case fatality of stroke in Perth, Western Australia.

DESIGN AND SETTING

A population-based descriptive epidemiological study.

SUBJECTS

All residents of a geographically defined segment of the Perth metropolitan area (population 138,708) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, inclusive.

MAIN OUTCOME MEASURES

Definite acute "first-ever-in-a-lifetime" (first-ever) and recurrent stroke classified according to standard definitions and criteria.

RESULTS

During the 18-month study period, 536 stroke events occurred among 492 patients, 69% of which were first-ever strokes. The crude annual event rate for all strokes was 258 (95% confidence interval 231-285) per 100,000, and the overall case fatality at 28 days was 24% (95% CI, 20%-28%). The crude annual incidence for first-ever strokes was 178 (95% CI, 156-200) per 100,000; 189 (95% CI, 157-221) per 100,000 in males and 166 (95% CI, 136-196) per 100,000 in females. The corresponding rates, age-adjusted to the "world" population, were 132 (95% CI, 109-155) for males and 77 (95% CI, 60-94) for females.

CONCLUSIONS

In contrast to mortality rates for ischaemic heart disease, the incidence of stroke in Australia appears little different from that for several other Western countries. For both males and females the incidence of stroke rises exponentially with increasing age. Although the sex-dependent difference in the risk of stroke is greatest in middle age, males are at greater risk of stroke even among the most elderly. To determine the incidence of stroke accurately, population-based studies of stroke need exhaustive and overlapping sources of case ascertainment. If only cases admitted to hospital had been used, we would have underestimated the rate of stroke among the most elderly by almost 40%. We estimate that approximately 37,000 people, about 50% of whom are over the age of 75, suffer a stroke each year in Australia.