International trends in stroke mortality: 1970-1985

Utilizing multi-user virtual reality to bring clinical therapy into stroke survivors' homes

INTRODUCTION

Lifespans after the occurrence of a stroke have been lengthening, but most stroke survivors will experience chronic impairment. Directed, repetitive practice may reduce deficits, but clinical access is often limited by a variety of factors, such as transportation.

PURPOSE OF THE STUDY

To introduce a multiuser virtual reality platform that can be used to promote therapist-client interactions when the client is at home.

METHODS

The Virtual Environment for Rehabilitative Gaming Exercises encourages exploration of the hand workspace by enabling multiple participants, located remotely and colocated virtually, to interact with the same virtual objects in the shared virtual space. Each user controls an avatar by corresponding movement of his or her own body segments. System performance with stroke survivors was evaluated during longitudinal studies in a laboratory environment and in participants' homes. Active arm movement was tracked throughout therapy sessions for both studies.

RESULTS

Stroke survivors achieved considerable arm movement while using the system. Mean voluntary hand displacement, after accounting for trunk displacement, was greater than 350 m per therapy session for the Virtual Environment for Rehabilitative Gaming Exercises system. Compliance for home-based therapy was quite high, with 94% of all scheduled sessions completed. Having multiple players led to longer sessions and more arm movement than when the stroke survivors were trained alone.

CONCLUSIONS

Multiuser virtual reality offers a relatively inexpensive means of extending clinical therapy into home and enabling family and friends to support rehabilitation efforts, even when physically remote from each other.

Predictors for the use of traditional Chinese medicine among inpatients with first-time stroke: a population-based study

BACKGROUND

Stroke is one of the major causes of death and disability. The treatments that are provided to patients during hospitalization after an acute stroke are very important in stabilizing their medical condition and enabling the recovery of their motor functions. However, limited information is available regarding the use of traditional Chinese medicine (TCM) during hospitalization for first-time stroke patients. The researchers aimed to investigate the factors affecting TCM use and to provide clinicians with comprehensive information on TCM use among first-time stroke inpatients in Taiwan.

METHODS

The researchers collected and analyzed data, including patient characteristics, TCM use, and TCM prescription patterns, from the National Health Insurance Research Database in Taiwan for first-time stroke inpatients between 2006 and 2012.

RESULTS

Among the 89,162 first-time stroke patients, 7455 were TCM users, and 81,707 were TCM nonusers. The predictors for TCM use were as follows: age, 45-64 or < 45 years; men; living in a level 2, 4, or 7 urbanized area; insured amount ≥ 576 USD per month; ischemic stroke; hospitalized for first-time stroke for 8-14 days, 15-28 days, or ≥ 29 days; stroke severity index score 0-9 or 10-19; Charlson-Deyo comorbidity index score 0 or 1-2; hospitalization in a regional or community hospital; receiving rehabilitation; and previous experience with outpatient TCM use. An increase in the number of TCM users was observed from 2006 to 2012. Furthermore, 68.8-79.7% of TCM users used acupuncture only, while 17.8-26.1% used both acupuncture and Chinese herbal medicine.

CONCLUSIONS

An increasing number of first-time stroke patients have been choosing TCM as a complementary treatment during hospitalization. Moreover, TCM use is associated with demographic, clinical, and socioeconomic characteristics. These findings may help clinicians comprehensively understand the trend and the important factors affecting TCM utilization among patients who are hospitalized due to first-time stroke.

[Surgical policy of managing patients with concomitant atherosclerotic lesions of the internal and common carotid arteries]

AIM

The purpose of this study was to investigate the natural course of stenosis of the common carotid artery (CCA) after carotid endarterectomy, as well as the long-term outcomes of various methods of reconstruction of the internal carotid artery (ICA) in patients with extended atherosclerotic lesions.

PATIENTS AND METHODS

Presented herein are the remote retrospective and prospective results of carotid endarterectomy in a total of 78 patients with concomitant atherosclerotic lesions of carotid arteries. Depending on the degree of CCA stenosis, the patients were divided into 2 groups. Group One (n=25): stenosis of the internal carotid artery (ICA) of more than 70% and haemodynamically insignificant (30-35% stenosis) but extended (from 3.0 to 5.0 cm (Q1, Me, Q3); 3.5 cm, 4.0 cm, 5.0 cm) stenosis of the CCA. These patients underwent carotid endarterectomy (CEA) from the ostium of the ICA, during which an atherosclerotic plaque was not completely removed from the CCA because the stenosis was extended but haemodynamically insignificant. Group Two (n=53): stenosis of the ICA of more than 70% and haemodynamically significant, extended (from 7.0 to 10.0 cm (Q1, Me, Q3); 7.5 cm, 8.0 cm, 9.0 cm) stenosis of the CCA. The patients of this group were subjected to various methods of operative intervention on the ICA and CCA: carotid endarterectomy (ECA) combined with open endarterectomy from the CCA with plasty using the primary suture (n=23); carotid endarterectomy and alloreconstruction of the CCA (n=10); simultaneous eversion endarterectomy from the ICA and CCA (n=20). The remote period of follow up of patients ranged from 14 to 24 months ((Q1, Me, Q3; 19 months, 22 months, 24 months). The differences were statistically insignificant (Mann-Whitney U-test, p=0.881).

RESULTS

In the remote postoperative period, 32% of Group One patients after previously performed carotid endarterectomy were found to have an increase in the degree of stenosis of the CCA up to a haemodynamically significant one (70% and more), thus suggesting progression of the atherosclerotic process. In Group Two patients, after plasty of the CCA with the primary suture, 21.7% of patients were diagnosed as having restenosis of the reconstruction zone up to 30%, with no neurological deficit. 20% of patients after carotid endarterectomy and alloreconstruction of the CCA were diagnosed as having restenosis of the reconstruction zone more than 70% and acute impairment of cerebral circulation with a lethal outcome. The patients after simultaneous eversion endarterectomy form the ICA and CCA in the intraoperative and postoperative periods had neither restenosis of the reconstruction zone nor neurological deficit.

CONCLUSION

32% of patients after previously performed carotid endarterectomy with the presence of extended, but haemodynamically insignificant stenosis of the CCA (30-35% stenosis) in the postoperative period were found to have progression of the atherosclerotic lesion in the form of an increased degree of stenosis up to haemodynamically significant (more than 70%), thus requiring repeat reconstructive operation. Therefore, in patients presenting with concomitant atherosclerotic lesions of the carotid arteries it is appropriate to carry out operative intervention simultaneously on the ICA and CCA, which would make it possible to considerably improve the remote postoperative results of reconstructive interventions on the carotid basin in this cohort of patients. A comparative study of the outcomes of various methods of reconstruction of carotid arteries in patients with concomitant atherosclerotic lesions of the ICA and CCA demonstrated that simultaneous eversion endarterectomy from the ICA and CCA resulted in good postoperative parameters: absence of restenosis and neurological deficit in the remote period of follow up.

Trajectories of memory, language, and visuoperceptual problems in people with stroke during the first year and controls in Colombia

AIM

Neuropsychological normative data for Latin America have been recently published, and for Colombia, in particular, but longitudinal neuropsychological outcomes after stroke have not yet been examined in this global region. The purpose of the current study was to compare functioning of individuals with stroke in Colombia, South America during the first year post-stroke to healthy controls across neuropsychological assessments of memory, language, and visuoperceptual impairments.

METHOD

A sample of 50 individuals with stroke (mean age = 51.58) and 50 matched healthy controls (mean age = 51.54) from Colombia were included in this study. Because of a lack of access to health services, individuals with stroke did not receive any inpatient or outpatient cognitive or behavioral rehabilitation. Participants were assessed on 10 visuoperceptual, language, and memory tasks at 3, 6, and 12   months.

RESULTS

Trajectories of neuropsychological performance were significantly worse among individuals with stroke than healthy controls across every index. Further, hierarchical linear models suggested that although both individuals with stroke and controls generally improved over time on these assessments, the improvements among individuals with stroke were often of no greater magnitude than the improvements seen in controls, suggesting extremely low levels of rehabilitation gains in Colombia. Only three of the 10 neuropsychological assessments did a significant time*group interaction occur, suggesting greater gains for the stroke group than controls.

CONCLUSION

These findings suggest profound disparities in post-stroke cognitive functioning in Colombia compared to other more developed global region and underscore the importance of comprehensive cognitive rehabilitation services for individuals with stroke in Colombia and other similar global regions. Implications for rehabilitation Because this study found only negligible cognitive improvements beyond practice effects over the first year after stroke in Colombia among individuals without access to acute rehabilitation, it is imperative that comprehensive cognitive rehabilitation services be implemented immediately during the acute rehabilitation period. Memory, language, and visuoperceptual training strategies can be implemented for people with stroke in underserved global regions as part of the standard of care for stroke rehabilitation. Cognitive rehabilitation strategies should be adapted into Spanish and pilot tested in Latin America to ensure cultural equivalence. Culturally competent cognitive rehabilitation strategies should be tailored based on varied educational and literacy levels.

Stroke in Northern Sweden

Background: Stroke is one of the most common causes of death and long-term disability worldwide. Although stroke mortality has decreased in most industrialized countries, there are populations, particularly in East Europe, in which the mortality has increased. The WHO initiated, 20 years ago, the MONICA Project. The aim of the study was to measure trends in coronary heart disease and stroke and to assess the extent to which these were related to changes in known risk factors. Design: The Northern Sweden MONICA stroke study started in 1985 and is still ongoing. All individuals with an acute stroke in the age group 25 - 74 years have been included in the stroke register. Death certificates, discharge records, and GPs' records are screened and validated using strict MONICA criteria. Results: Stroke event rates (first ever and recurrent stroke) per 100,000 and year in the age group 25 - 74 years varied little over the years. Between 1985 and 1998 the annual incidence varied between 318 and 372 in men and between 195 and 240 in women, with no secular trends at all. The 28-day case fatality decreased in both men and women, from 19% to 11%. Logistic regression analyses showed a risk reduction in dying from stroke to 0.55 (p<0.0001) the last year compared with the first, with an absolute annual reduction in case fatality of 3%, in both men and women. In international comparison Northern Sweden shows an intermediately high incidence and one of the lowest case fatality rates of all participating populations. The incidence in subarachnoid haemorrhage was among the highest. Conclusion: The ongoing decline in stroke mortality in Sweden is driven exclusively by declining case fatality, whereas event rates (first ever and recurrent stroke) have remained the same since 1985. This, together with more people entering advanced, stroke-prone age groups, implies that the burden of stroke will continue to increase in Sweden.

WITHDRAWN: Chuanxiong preparations for preventing stroke

The Editor/CRG withdrew this review as the current author team is unable to progress to the final stage of the review update. The editors consider this title as low priority for the current portfolio of the Heart Group and therefore this title is not open to a new author team.

The editorial group responsible for this previously published document have withdrawn it from publication.

Design and Evaluation of an Actuated Exoskeleton for Examining Motor Control in Stroke Thumb

Chronic hand impairment is common following stroke. This paper presents an actuated thumb exoskeleton (ATX) to facilitate research in examining motor control and hand rehabilitation. The ATX presented in this work aims to provide independent bi-directional actuation in each of the 5 degrees-of-freedom (DOF) of the thumb using a novel flexible shaft based mechanism that has 5 active DOF and 3 passive DOF. A prototype has been built and experiments have been conducted to measure the allowable workspace at the thumb and evaluate the kinematic and kinetic performance of the ATX. The experimental results show that the ATX is able to provide individual actuation at all 5 thumb joints with high joint velocity and torque capacities. Further improvement and future work are discussed.

Plaque Assessment in the Management of Patients with Asymptomatic Carotid Stenosis

The continued occurrence of stroke despite advances in medical therapy for asymptomatic carotid stenosis (ACS) strongly indicates that individual response to medical therapy may vary widely. This article reviews the literature that identifies MR imaging and ultrasound plaque features which are seen in patients at increased risk of future cardiovascular events. Imaging can identify plaque phenotype that is the most amendable to intensive medical therapy. There is also good evidence that plaque imaging can measure the individual response to medical therapy and the lack of response identifies a high-risk group of ACS patients.

Impact of stroke etiology on clinical symptoms and functional status

OBJECTIVE

The aim of this study is to investigate the differences between hemorrhagic and ischemic stroke patients in terms of clinical and functional features.

METHODS

Medical records of the patients with stroke were analyzed retrospectively. The patients' demographic characteristics, stroke etiology, time interval after the event, comorbid illness and functional status were recorded.

RESULTS

The stroke etiology was ischemia for 60 (36 male/24 female) (75%) patients, and haemorrhage for 20 (10 male/10 female) (25%) patients. Patients with ischemic stroke were classified as Group 1, and patients with hemorrhagic stroke were classified as Group 2. The mean age for Group 1 was 62.2±13.2, and 55.8±17.1 years for Group 2 (p=0.592). In Group 1, 33 (55%) patients, and in Group 2, 11 (55%) patients were primary school graduates (p=0.984). Localization of the lesion was in the right side for 33 (55%) patients in Group 1, and for 15 (75%) patients in Group 2 (p=0.372). The mean time interval after event for Group 1 was 7 months (0-211 days), and for Group 2 it was 14.5 (1-420 days) months (p=0.592). FIM score for Group 1 was 71.9±28.0, and 68.1±21.0 for Group 2 (p=0.575). The mean Brunnstrom score for upper extremity was 3.5 for Group 1, 3 for Group 2, (p=0.866), and for lower extremity, it was 3.5 for Group 1, and 3 for Group 2 (p=0.143). Spasticity was present in 45 (75%) patients in Group 1, and in 12 (60%) patients in Group 2 (p=0.311). In Group 1 51 (85%) of the patients and 18 (95%) patients had a history of comorbid disease (p=0.554).

CONCLUSION

Etiology of stroke is thought to be not effective on the patient's clinical and functional status.

Current status of stroke epidemiology in Greece: a panorama

Although strokes have been documented since about 3 millennia, they remain today as one of the leading causes of mortality, as well as of subsequent serious long-term physical and mental morbidity, among patients in many different countries all over the world. Greece presents an increase in mortality rates according to World Health Organization, and this fact underlines the need for early diagnosis and treatment, as well as, the need to implement effective prevention strategies for strokes. This review makes an effort to describe the current status of stroke epidemiological features, as well as to present the risk factors prevalent in Greece. The incidence rate is 261-319/100,000 based on the recent population based registry. Stroke appears to be more prevalent in men than in women, and the mean age of stroke onset in Greece is at 70 years of age. Hypertension, atrial fibrillation, dyslipidaemia and diabetes mellitus are the major risk factors of stroke in the Greek population, while smoking is the most commonly documented modifiable risk factor in young adults with ischemic stroke. Similar to other parts of the world, ischemic stroke is the most common stroke type. The 28-day case fatality rate for men and women was 26.5%. The mean in-hospital cost per stroke patient was 3624.9 € and the mean rehabilitation cost of outpatients with stroke was 5553.3 €, while the cost proportion of hemorrhagic stroke is higher when compared to ischemic stroke. Stroke is a devastating condition with recognized challenges in identifying effective prevention programs. In Greece, limited data exists regarding the epidemiology of strokes. As a result, the need to conduct new studies and researches across the country is well documented.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Prestroke alcohol consumption and smoking are not associated with stroke severity, disability at discharge, and case fatality

BACKGROUND

Heavy alcohol consumption and smoking are known risk factors for stroke, but their influence on stroke severity and outcome may also be important. We tested if alcohol consumption and smoking relate to initial stroke severity, disability at discharge from hospital, and outcome at 30 days and at 1 year in 1049 patients of the Mures-Uzhgorod-Debrecen database.

METHODS

Initial stroke severity was scored by the National Institutes of Health Stroke Scale. Case fatality and the modified outcome scale of the First International Stroke Trial were used to assess outcome. We used multiple regression analysis.

RESULTS

Before their stroke, 24.5% were smokers and 24.7% admitted regular alcohol consumption. Neither smoking nor alcohol consumption status was associated with initial stroke severity. Case fatalities at discharge, at 30 days, and at 1 year were 12.2%, 16.9%, and 28.3%, respectively. Initial stroke severity, hemorrhagic subtype, and age in men over 60 years were strong predictors of outcome. We did not find significant difference among alcohol consumers and nonconsumers in 30-day and in 1-year case fatality in all stroke patients and in ischemic stroke patients. In hemorrhagic stroke, there was a nonsignificant tendency for higher case fatality among alcohol consumers (39.5% versus 26.4%, P > .2, at 30 days and 48.8% versus 35.8%, P > .2, at 1 year). Smoking did not influence significantly the outcome at 30 days and at 1 year.

CONCLUSION

Despite being risk factors, prestroke smoking and alcohol consumption do not have a significant influence on stroke severity and on short- and long-term outcome.

Influence of 100% and 40% oxygen on penumbral blood flow, oxygen level, and T2*-weighted MRI in a rat stroke model

Accurate imaging of the ischemic penumbra is a prerequisite for acute clinical stroke research. T(2)(*) magnetic resonance imaging (MRI) combined with an oxygen challenge (OC) is being developed to detect penumbra based on changes in blood deoxyhemoglobin. However, inducing OC with 100% O(2) induces sinus artefacts on human scans and influences cerebral blood flow (CBF), which can affect T(2)(*) signal. Therefore, we investigated replacing 100% O(2) OC with 40% O(2) OC (5 minutes 40% O(2) versus 100% O(2)) and determined the effects on blood pressure (BP), CBF, tissue pO(2), and T(2)(*) signal change in presumed penumbra in a rat stroke model. Probes implanted into penumbra and contralateral cortex simultaneously recorded pO(2) and CBF during 40% O(2) (n=6) or 100% O(2) (n=8) OC. In a separate MRI study, T(2)(*) signal change to 40% O(2) (n=6) and 100% O(2) (n=5) OC was compared. Oxygen challenge (40% and 100% O(2)) increased BP by 8.2% and 18.1%, penumbra CBF by 5% and 15%, and penumbra pO(2) levels by 80% and 144%, respectively. T(2)(*) signal significantly increased by 4.56% ± 1.61% and 8.65% ± 3.66% in penumbra compared with 2.98% ± 1.56% and 2.79% ± 0.66% in contralateral cortex and 1.09% ± 0.82% and -0.32% ± 0.67% in ischemic core, respectively. For diagnostic imaging, 40% O(2) OC could provide sufficient T(2)(*) signal change to detect penumbra with limited influence in BP and CBF.

Carotid MRI: a tool for monitoring individual response to cardiovascular therapy?

Stroke remains a leading cause of morbidity and mortality. While stroke-related mortality has declined over the past four decades, data indicate that the mortality rate has begun to plateau. This change in trend may be attributable to variation in individual response to therapies that were derived from population-based studies. Further reductions in stroke mortality may require individualized care governed by directly monitoring the effects of cardiovascular therapy. In this article, carotid MRI is considered as a tool for monitoring in vivo carotid atherosclerotic disease, a principal etiology of stroke. Carotid MRI has been previously utilized to identify specific plaque features beyond luminal stenosis that are predictive of transient ischemic attack and stroke. To gain perspective on the possibility of monitoring plaque change within the individual, clinical trials and natural history studies that have used serial carotid MRI are considered. Data from these studies indicate that patients with a lipid-rich necrotic core with or without intraplaque hemorrhage may represent the desired phenotype for monitoring treatment effects in the individual. Advances in tissue-specific sequences, acquisition resolution, scan time, and techniques for monitoring inflammation and mechanical forces are expected to enable earlier detection of response to therapy. In so doing, cost-effective multicenter studies can be conducted to confirm the anticipated positive effects on outcomes of using carotid MRI for individualized care in patients with carotid atherosclerosis. In accordance, carotid MRI is poised to emerge as a powerful clinical tool for individualized management of carotid atherosclerotic disease to prevent stroke.

Exercise training improves walking function in an African group of stroke survivors: a randomized controlled trial

Objective: To evaluate the effects of treadmill walking and overground walking exercise training on recovery of walking function in an African group of stroke survivors.

Design: Prospective, randomized controlled study.

Setting: Outpatient stroke rehabilitation unit in a tertiary hospital.

Subjects: Sixty patients with chronic stroke (≥3 months).

Intervention: All subjects received individual outpatient conventional physiotherapy rehabilitation for 12 weeks. In addition, subjects in Group A ( n = 20) received treadmill walking exercise training (TWET) while those in Group B ( n = 20) received overground walking exercise training (OWET). Those in Group C (control) ( n = 20) received conventional physiotherapy rehabilitation only.

Main measures: Outcome measures were (i) 10-metre walk time (10MWT) test and (ii) six-minute walk distance (6MWD) test. These were evaluated at entry into the study and at the end of every four weeks. Paired t-tests were used to evaluate the significance of the difference between pre-training and post-training scores on the two measures ( P < 0.05).

Results: Subjects in the TWET group recorded 22.6 ± 1.5% decrease in 10MWT and 31.0 ± 4.3% increase in 6MWD; those in the OWET group made 26.8 ± 1.3% and 45.2 ± 4.6% improvement in 10MWT and 6MWD respectively. Subjects in the control group made 2.2 ± 0.7% and 2.9 ± 0.8% improvement in the two functions. These changes were significant for the TWET and OWET groups ( P < 0.05).

Conclusion: This study indicated that treadmill and overground walking exercise training programmes, combined with conventional rehabilitation, improved walking function in an African group of adult stroke survivors. Therefore, professionals who conduct stroke rehabilitation programmes should utilize exercise training to optimize patient outcomes.

Lifetime risk of stroke and impact of hypertension: estimates from the adult health study in Hiroshima and Nagasaki

Very few reports have been published on lifetime risk (LTR) of stroke by blood pressure (BP) group. This study included participants in the Radiation Effects Research Foundation Adult Health Study who have been followed up by biennial health examinations since 1958. We calculated the LTR of stroke for various BP-based groups among 7847 subjects who had not been diagnosed with stroke before the index age of 55 years using cumulative incidence analysis adjusting for competing risks. By 2003, 868 subjects had suffered stroke (512 (58.9%) were women and 542 (62.4%) experienced ischemic stroke). BP was a significant factor in determining risk of stroke for men and women, with distributions of cumulative risk for stroke significantly different across BP groups. The LTR of all-stroke for normotension (systolic BP/diastolic BP < 120/80 mm Hg), prehypertension (120-139/80-89 mm Hg), stage 1 hypertension (140-159/90-99 mm Hg) and stage 2 hypertension (> 160/100 mm Hg) were 13.8-16.9-25.8-25.8% in men and 16.0-19.9-24.0-30.5% in women, respectively (P < 0.001 among BP groups in both sexes). The estimates did not differ significantly (P = 0.16) between normotensive and prehypertensive subjects. One in five Japanese atomic bomb survivor subjects experienced stroke over their lifetime from the age of 55 years. Long-term stroke risks were elevated in those with hypertension (> 140/90 mm Hg) at any of the index ages of 45, 55, 65 and 75 years.

Intravenous recombinant tissue plasminogen activator for acute stroke in Poland: an analysis based on the Safe Implementation of Thrombolysis in Stroke (SITS) Registry

OBJECTIVES

Intravenous thrombolysis was conditionally approved in the European Union (EU) in 2002, under the requirement of entering all patients into Safe Implementation of Thrombolysis in Stroke - Monitoring Study (SITS-MOST). Countries not belonging to the EU by 2002, i.e. Poland were invited to enter data into the SITS International Stroke Thrombolysis Registry (SITS-ISTR). The aim of this study is to compare the safety and efficacy of thrombolysis in the Polish SITS-ISTR stroke patient population with patients registered in SITS-MOST.

METHODS

481 patients in Poland were reported between 2003 and 2007. Baseline and outcome data of Polish patients were compared with SITS-MOST.

RESULTS

Most of the baseline characteristics did not differ between the groups. The most important was the onset-to-needle and door-to-needle times were significantly longer in Polish patients, 150 vs 136 min and 82 vs 68 min, respectively (P < 0.001). The symptomatic intracranial haemorrhage and independence rates at 3 months were similar in both populations. Polish patients had a significantly higher 3-month mortality rate, 18.6% vs 11.3% (P < 0.001).

CONCLUSIONS

Because of higher mortality the study implies the need to improve the organization of thrombolysis services and provides the rationale to continue the monitoring of treatment in Poland.

Ten Years of Stroke Programmes in Poland: Where Did we Start? Where Did we Get To?

Risk factors and a high stroke mortality rate are a heavy stroke burden on Central and Eastern European countries. The 1995 Helsingborg Declaration outlined the aim of the coming decade was to improve patient care. In Poland it led to the foundation of the National Stroke Prevention and Treatment Programme, (1998-2008) which later became part of the National Cardiovascular Disease Prevention and Treatment Programme. The aim: Improve acute and postacute management Implement innovative therapies Develop poststroke rehabilitation, and Monitor epidemiology.

Establishing and equipping stroke units has raised their number from three to 111. Thrombolysis for stroke and carotid angioplasty and stenting procedures were supported and supervised. The needs in poststroke rehabilitation were assessed and services have improved due to the support of the programme. Continuous monitoring of patient care proved that the mortality and disability rates have decreased and the quality of treatment has improved.

Trends in mortality from stroke in Austria, 1980-2008

BACKGROUND

Worldwide, stroke is the third most common cause of death in developed countries with declining death rates. In 1997 Austria established a national system of acute-care stroke units; their impact on stroke mortality has not yet been determined.

METHODS

We assessed stroke mortality using Austrian national statistical data from Statistics Austria for the period 1980-2008. Deaths were coded using ICD-9 (430-438) or ICD-10 (I60-I69). We stratified age-standardized results by sex and stroke subtype (hemorrhagic or ischemic stroke). We also used join-point regression models (joined linear segments from Poisson regression models) to identify changes in the slope of age-specific mortality trends in selected age groups (50-59 years, 60-69 years, 70-79 years, and 80+ years) for both stroke subtypes in both sexes.

RESULTS

After adjustment for age, we found a decline in all strokes combined (-77.3% for males, -76.7% for females), and in hemorrhagic strokes and ischemic strokes considered separately, and for both sexes and all age groups. Mortality from ischemic stroke showed a steady rate of decline over the entire time period, while join-point analysis showed that, in general, for all age groups, both males and females showed differing patterns of changes in mortality from hemorrhagic strokes before 1997-2000 and a steeper decline after that period.

CONCLUSIONS

Mortality from stroke declined in Austria between 1980 and 2008. Whether the establishment of acute stroke units had an impact on stroke mortality in this period remains unclear. Future studies should evaluate stroke-related changes in quality of life, as acute stroke units may have a greater impact on quality of life than on overall mortality.

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.

Cerebrolysin for acute ischaemic stroke

BACKGROUND

Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from pigs' brain tissue which has proposed neuroprotective and neurotrophic properties. It is widely used in the treatment of acute ischaemic stroke in Russia and China.

OBJECTIVES

To assess the benefits and risks of cerebrolysin for treating acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (February 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2009), MEDLINE (1966 to February 2009), EMBASE (1974 to February 2009), LILACS (1982 to February 2009), Science Citation Index (1940 to February 2009), SIGLE Archive (1980 to March 2005), and a number of relevant Russian Databases (1988 to February 2009). We also searched reference lists, ongoing trials registers and conference proceedings.

SELECTION CRITERIA

Randomised controlled trials comparing cerebrolysin with placebo or no treatment in patients with acute ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Three review authors independently applied the inclusion criteria, assessed trial quality and extracted the data.

MAIN RESULTS

We included one trial involving 146 participants. There was no difference in death (6/78 in the cerebrolysin group versus 6/68 in the placebo group; risk ratio (RR) 0.87, 95% confidence interval (CI) 0.29 to 2.58) or in the total number of adverse events (16.4% versus 10.3%; RR 1.62, 95% CI 0.69 to 3.82) between the treatment and control groups.

AUTHORS' CONCLUSIONS

There is not enough evidence to evaluate the effect of cerebrolysin on survival and dependency in people with acute ischaemic stroke. High-quality and large-scale randomised controlled trials may help to gain a better understanding of the potential value of cerebrolysin in acute ischaemic stroke.

The Lombardia Stroke Unit Registry: 1-year experience of a web-based hospital stroke registry

This paper presents methodological aspects of the Lombardia Stroke Registry. At the registry start-up, 36 recruiting centres were identified according to a regional survey. The registry recruits consecutive patients with acute stroke or transient ischaemic attacks (TIAs). A 3-month follow-up was planned to correlate acute care with outcomes. On 31st December 2007, data concerning 6,181 patients discharged alive were available. The registry aims at measuring performance parameters, identifying guidelines non-compliance and analysing care processes. In this first phase, 30% of the Lombardia acute stroke and 10% of TIA patients have been enrolled, thus the sample can be considered informative for the disease care in the region. The proportion of completed data items is very high with very small differences among items. The following critical points were highlighted: (1) lack of data input staff for 30% of centres, and (2) difficulty of obtaining the informed consent for post-discharge follow-up.

Salivary neuron specific enolase: an indicator for neuronal damage in patients with ischemic stroke and stroke-prone patients

BACKGROUND

The blood-brain barrier is compromised in patients with stroke. The release of neuro-biochemical protein markers, such as neuron specific enolase (NSE) into the circulation may allow the pathophysiology and prognosis of patients with cerebrovascular diseases to be evaluated further. The present study was designed to measure the marker of neuronal damage, NSE, in saliva and serum of patients with acute ischemic stroke and patients with stroke related diseases as a diagnostic and/or monitoring tool for early prediction of ischemic stroke.

METHODS

Salivary and serum NSE concentrations were measured in 150 individuals. Fifty were patients recently diagnosed as having ischemic stroke, 75 were gender and age-matched risk-group patients (patients with hypertension, type 2 diabetes and ischemic heart disease). Another 25 were gender and age-matched healthy controls.

RESULTS

Salivary and serum NSE concentrations were significantly higher than that of healthy controls. The cut-off threshold for salivary NSE of 3.7 microg/L was optimum, showing 80% accuracy for differentiation of ischemic stroke from normal individuals.

CONCLUSIONS

Salivary NSE (alone or in combination with serum) can be used as a valuable diagnostic and possibly prognostic tool for measurement of neuronal damage in patients with stroke and stroke-related diseases.

Chuanxiong preparations for preventing stroke

BACKGROUND

Stroke is a major healthcare problem and is one of the leading causes of death and serious long-term disability. Prevention of stroke is considered an important strategy. Chuanxiong is traditionally used in China in the treatment and prevention of stroke. In recent years, Chinese researchers have developed new patented Chuanxiong preparations.

OBJECTIVES

To assess the effects and safety of Chuanxiong preparations in preventing stroke in high-risk adults.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2008, Issue 1), MEDLINE (1950 to March 2008), EMBASE (1980 to March 2008), AMED (1985 to March 2008), Chinese Biomedical Database (CBM) (1975 to March 2008), China National Knowledge Infrastructure (CNKI) (1994 to March 2008), and the VIP Database (1989 to March 2008). Trials registers were searched for ongoing studies. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) studying the effects of Chuanxiong preparations in preventing stroke were included.

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected studies for inclusion and two reviewers independently extracted data. Authors of identified RCTs were telephoned to confirm the randomisation procedure. Outcomes assessed included: stroke, composite cardiovascular outcomes, changes in cardiovascular and cerebrovascular haemodynamic indices and adverse events. Peto odds ratio (OR) with 95% confidence intervals (CI) were calculated for dichotomous variables and mean differences for continuous outcomes.

MAIN RESULTS

Three RCTs (5042 participants) were included. One higher quality study (4415 participants) compared Nao-an capsule with aspirin for primary prevention in high-risk stroke populations. Nao-an capsule appeared to reduce the incidence of stroke compared with aspirin (OR 0.56 95% CI 0.33 to 0.96). One study of low methodological quality indicated that a self-prepared Xifenwan tablet reduced the incidence of stroke in people with transient ischaemia attack (TIA) (OR 0.18, 95% CI 0.04 to 0.78). The remaining low quality study indicated that "apoplexy 2 preventing dry ointment powder" appeared to reduce both fatal stroke and incidence of stroke (OR 0.21, 95% CI 0.10 to 0.43, and OR 0.28, 95% CI 0.16 to 0.49, respectively).

AUTHORS' CONCLUSIONS

Nao-an capsule may be a choice for the primary prevention of stroke. However, the design of the study providing this evidence means that there was potential for results to have been affected by bias from the way participants may have been selected, or from investigators' conflicts of interests. There was a lack of description of the methodology in the two other studies therefore evidence from these was considered too weak to draw any firm conclusions. Further high quality research is required.

The Debrecen Stroke Database: demographic characteristics, risk factors, stroke severity and outcome in 8088 consecutive hospitalised patients with acute cerebrovascular disease

BACKGROUND

High stroke mortality in central-eastern European countries might be due to higher stroke incidence, more severe strokes or less effective acute care than in countries with lower mortality rate. Hospital databases usually yield more detailed information on risk factors, stroke severity and short-term outcome than population-based registries.

PATIENTS AND METHODS

The Debrecen Stroke Database, data of 8088 consecutively hospitalised patients with acute cerebrovascular disease in a single stroke centre in East Hungary between October 1994 and December 2006, is analysed. Risk factors were recorded and stroke severity on admission was scored by the Mathew stroke scale. The modified Glasgow outcome scale was used to describe patient condition at discharge.

RESULTS

Mean age was 68+/-13 years, 11.4% had haemorrhagic stroke. The rate of hypertension on admission was 79% in men, and 84% in women, 40.3% of men and 19.8% of women were smokers, and 34% of all patients had a previous cerebrovascular disease in their history. Case fatality was 14.9%, and 43% had some disability at discharge. Outcome at discharge was worse with higher age, higher glucose, higher blood pressure, higher white cell count and erythrocyte sedimentation rate and more severe clinical signs on admission. In multivariate analysis admission blood pressure lost its significance in predicting outcome.

CONCLUSIONS

In this large Hungarian stroke unit database hypertension on admission, smoking and previous cerebrovascular disease were more frequent than in most western databases. These findings indicate major opportunities for more efficient stroke prevention in this and probably other eastern European countries.

Functional restoration for the stroke survivor: informing the efforts of engineers

As bioengineers begin to notice the importance of therapy in the recovery from stroke and other brain injuries, new technologies will be increasingly conceived, adapted, and designed to improve the patient's road to recovery. What is clear from engineering history, however, is that the best engineering efforts are often built on strong scientific foundations. In an effort to inform engineers with the necessary background on cutting edge research in the field of stroke and motor recovery, this article summarizes the views of several experts in the field as a result of a workshop held in 2006 on the topic. Here we elaborate on several areas relevant to this goal, including the pathophysiology of stroke and stroke recovery, the biomechanics, the secondary peripheral changes in muscle and other tissue, and the results of neuroimaging studies. One conclusion is that the current state of knowledge is now ripe for research using machines but that highly sophisticated robotic devices may not yet be needed. Instead, what may be needed is basic evidence that shows a difference in one therapeutic strategy over another.

Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review

This systematic review of population-based studies of the incidence and early (21 days to 1 month) case fatality of stroke is based on studies published from 1970 to 2008. Stroke incidence (incident strokes only) and case fatality from 21 days to 1 month post-stroke were analysed by four decades of study, two country income groups (high-income countries and low to middle income countries, in accordance with the World Bank's country classification) and, when possible, by stroke pathological type: ischaemic stroke, primary intracerebral haemorrhage, and subarachnoid haemorrhage. This Review shows a divergent, statistically significant trend in stroke incidence rates over the past four decades, with a 42% decrease in stroke incidence in high-income countries and a greater than 100% increase in stroke incidence in low to middle income countries. In 2000-08, the overall stroke incidence rates in low to middle income countries have, for the first time, exceeded the level of stroke incidence seen in high-income countries, by 20%. The time to decide whether or not stroke is an issue that should be on the governmental agenda in low to middle income countries has now passed. Now is the time for action.

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.

Vinpocetine for acute ischaemic stroke

BACKGROUND

Vasoactive and neuroprotective drugs such as vinpocetine are used to treat stroke in some countries.

OBJECTIVES

To assess the effect of vinpocetine in acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched February 2007), MEDLINE (1966 to February 2007) and Scopus (1960 to February 2007). We also searched the Internet Stroke Center Stroke Trials Registry, Google Scholar, the science-specific search engine Scirus and Wanfang Data, the leading information provider in China. We contacted researchers in the field and four pharmaceutical companies that manufacture vinpocetine. Searches were complete to February 2007.

SELECTION CRITERIA

Unconfounded randomised trials of vinpocetine compared with placebo, or any other reference treatment, in people with acute ischaemic stroke. We included trials if treatment started no later than 14 days after stroke onset.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria. One review author extracted the data, which was then checked by the second review author. We assessed trial quality. The primary outcome measure was death or dependency.

MAIN RESULTS

We included two trials, involving a total of 70 participants. Data for 63 participants were reported in the two trials combined. The rate of death or dependency did not differ between the treatment and placebo groups at one and three months. The 95% confidence intervals for the outcome measures were wide and included the possibility of both significant benefit and significant harm. No adverse effects were reported.

AUTHORS' CONCLUSIONS

There is not enough evidence to evaluate the effect of vinpocetine on survival or dependency in patients with acute ischaemic stroke.

Frequency of stroke types at an emergency hospital in Natal, Brazil

We performed a cross-sectional study of stroke type frequency at a local emergency hospital, in Natal, Brazil. The sample consisted of all patients who were admitted to an emergency hospital with a presumptive diagnosis of stroke. Of the 416 patients, 328 were studied, 88 were excluded for not meeting inclusion criteria, 74.7% (n= 245) had ischemic stroke 17.7% (n=58) had intracerebral hemorrhage, 7.6% (n=25) had subarachnoid hemorrhage; 173 were men (52.7%). Mean age was 64.1 years. The intrahospital mortality rate was 10.2%, 17.2% and 36% for ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage, respectively. The most prevalent modifiable risk factor was hypertension for ischemic stroke (67.6%) and hemorrhage stroke (57.8%). Logistic regression analysis identified diabetes (OR=3.70; CI=1.76-7.77) as independent risk factor for ischemic stroke. The ischemic stroke was most common type of stroke. Hypertension and diabetes were important risk factors for stroke.

Risk factors of young ischemic stroke in Qatar

OBJECTIVES

There is limited information about risk factors of young ischemic stroke in Qatar. The aim of this study was to describe the risk factors and subtypes of young ischemic stroke among Qatari and non-Qatari residents.

PATIENTS AND METHODS

Hospital based prospective observational study involving all young adults (15-45 years of age) admitted to Hamad General Hospital with first-ever ischemic stroke from September 2004 to September 2005. A stroke was defined according to WHO criteria.

RESULTS

Stroke was confirmed in 40 (32 males and 8 females). Their ages ranged from 17 to 44 years (mean 37.1+/-13.27). Thirty (75%) of the patients were non-Qatari. The most common risk factors were hypertension 16 (40%), diabetes mellitus 13 (32.5%), hypercholesterolemia 11 (27.5%), smoking 11 (27.5%), and alcohol intake 9 (22.5%). Regarding stroke subtypes, lacunar stroke syndrome (LACS) was diagnosed in 17 (42.5%), total anterior circulation stroke syndrome (TACS) in 16 (40%), partial anterior circulation stroke syndrome (PACS) in 5 (12.5%) and posterior circulation stroke syndrome (POCS) in 2 (5%). Partial anterior circulation stroke syndrome (PACS) was observed with a higher frequency in Qatari patients compared with non-Qataris (p=0.009), whereas total anterior circulation stroke syndrome (TACS) was observed more in non-Qatari than in Qatari patients (p=0.03). Average hospital stay was 18 days. In-hospital mortality was 2.5%.

CONCLUSION

The risk factors of ischemic stroke in young adults are numerous. The most common were hypertension, diabetes mellitus, hypercholesterolemia, smoking and alcohol intake. Only one Indonesian male patient with POCS died in the hospital.

Epidemiology of stroke in Europe: Geographic and environmental differences

The development of stroke registries has allowed the accumulation of a wealth of data on the descriptive epidemiology of stroke and its evolution in space and in time. For instance, there has been an observed decrease of stroke incidence and mortality in Western Countries during the past 20 years. The use of brain imaging technologies including CT scan and MRI, along with improved cardiac and vascular imaging, has allowed better identification of risk factors for stroke. Hypertension remains the main risk factor for both ischemic and hemorrhagic strokes, and its treatment is effective in reducing first-ever and recurrent stroke incidence. Major medical progress has been achieved in the development of effective medications for hypertension control in the last 2 decades. Despite these advances, we observe large differences in the incidence and mortality rates of stroke throughout the European community. In this review we pose some questions regarding the possible reasons for these differences and we analyze the issue of environmental factors such as meteorological factors and pollution as stroke risk factors.

Stroke in Qatar: a one-year, hospital-based study

BACKGROUND AND PURPOSE

Stroke is a major health problem in Qatar, yet no stroke studies have been reported from this region. This hospital-based study was conducted to determine the types and the 30-day fatality rate of stroke. The data were collected from the only hospital in Qatar and, therefore, are considered to be community-based estimations.

METHODS

Clinical information was collected from discharge records of all patients with International Classification of Diseases, 9th Revision, (ICD 9) codes 430 to 438 from January 1 to December 31, 1997. Identification of cases included review of death certificates and brain computed tomography (CT) records for the same period.

RESULTS

First-ever stroke was found in 217 patients (157 men and 60 women). The overall incidence rate was 41 per 100,000 inhabitants per year (95% CI, 30.2-52.4/100,000/year) and 238/100,000/year for the population over 45 years old. The age standardized incidence was 57.5 per 100,000 inhabitants per year (95% CI, 43.1-73.8). The crude incidence for native Qataris was 75 per 100,000 inhabitants per year. The mean age of patients experiencing their first stroke was 57 years. Thirty-nine (18%) patients were younger than 45 years. Clinical subtypes of stroke were ischemic (80%), intracerebral hemorrhage (19%), and subarachnoid hemorrhage (1%). Risk factors included hypertension (63%), diabetes mellitus (42%), ischemic heart disease (17%), and atrial fibrillation (4.5%). The overall patient fatality rate at 30 days was 16%.

CONCLUSION

Stroke incidence in Qatar is lower than in other countries; a low incidence of subarachnoid hemorrhage was noted. The low mean age of stroke patients reflects the demographic characteristics of the population in Qatar. The high percentage of stroke patients suffering from hypertension and diabetes reflects the high prevalence of these risk factors in the population.

Warfarin and low-dose aspirin for stroke prevention from severe intracranial stenosis

Management of symptomatic, intracranial, large-arterial atherosclerosis is controversial. We assessed the safety and efficacy of combining warfarin and low-dose aspirin to prevent stroke from intracranial atherosclerotic stenosis failing prior treatment with either aspirin or warfarin. Patients with severe intracranial stenosis were prescribed combination therapy, warfarin (international normalized ratio [INR] 2 to 3) and aspirin 81 mg daily. Ten men and six women treated with combination therapy had one recurrent ischemic event during 382 months of therapy. No patient suffered a myocardial infarction or sudden vascular death. No serious hemorrhagic complication occurred. The combination of warfarin and low-dose aspirin seems safe and effective in preventing recurrent stroke from symptomatic, intracranial, large-arterial occlusive disease after failure with either aspirin or warfarin monotherapy.

Frequency and Significance of Cardiac Sources of Embolism in the TOAST Classification

BACKGROUND

This study was aimed at determining the frequency and coexistent patterns of high- and medium-risk cardiac sources of embolism (CSE) as defined by the Trial of ORG 10172 in the Acute Stroke Treatment (TOAST) classification system and at investigating how identified CSE contributed to this classification.

METHODS

We analyzed data from 2,482 patients with acute cerebral infarctions who registered in the Yonsei Stroke Registry over a 10-year period. Cardiac sources were divided into high- and medium-risk groups based on the TOAST classification.

RESULTS

Of the 2,482 patients, 1,130 (46%) underwent echocardiographic studies. At least one CSE was detected in 629 patients (25%). Atrial fibrillation was the most common high-risk CSE. Patent foramen ovale, spontaneous echo contrast and congestive heart failure comprised most of the medium-risk CSE. Atrial fibrillation frequently accompanied coexistent CSE (69%) such as spontaneous echo contrast, congestive heart failure, and left atrial/appendage thrombus, while patent foramen ovale was detected in isolation in more than 90% of the patients. Patients with a high-risk CSE were more likely to be diagnosed with cardioembolism (83%) than patients with only a medium-risk CSE (58%).

CONCLUSIONS

Our study elucidated the frequency and various coexistent patterns of CSE in Korean stroke patients as defined by the TOAST classification system. In addition, we have demonstrated a higher correlation between high-risk CSE and cardioembolism than with medium-risk CSE and cardioembolism.