Etiology of intracerebral hemorrhage during pregnancy or puerperium: A nationwide study

BACKGROUND AND PURPOSE

Intracerebral hemorrhage during pregnancy or puerperium (pICH) is one of the leading causes of maternal death worldwide. However, limited epidemiological data exist on the etiology and outcomes of pICH, which is required to guide prevention and treatment.

METHODS

A retrospective nationwide cohort study and a nested case-control study was performed in Finland 1987-2016. We identified women with incident pICH by linking the Medical Birth Register (MBR) and the Hospital Discharge Register (HDR). The clinical details were collected from patient records. Three matched controls with a pregnancy without ICH were selected for each case from the MBR.

RESULTS

In total, 49 pICH cases were identified. Half of these cases occurred during pregnancy, and the other half during peripartum and puerperium. Based on the SMASH-U (structural vascular lesion, medication, amyloid angiopathy, systemic disease, hypertension, undetermined) classification, 35.4% of the patients had a systemic disease, most commonly preeclampsia, eclampsia, or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome; 31.3% had a structural vascular lesion; 31.3% had an undetermined etiology; and one patient (2.1%) had hypertension. The most important risk factor was hypertensive disorders of pregnancy (HDP; odds ratio = 3.83, 95% confidence interval = 1.60-9.15), occurring in 31% of the cases. Maternal mortality was 12.5%, and 20.9% of the surviving women had significant disability (modified Rankin Scale = 3-5) 3 months after the pICH. Women with systemic disease had the worst outcomes.

CONCLUSIONS

Even in a country with a comprehensive pregnancy surveillance system, the maternal mortality rate for pICH is high, and the sequelae are severe. Early recognition and treatment of the key risk factor, HDP, is crucial to help prevent this serious pregnancy complication.

Pregnancy-associated stroke and the recurrence of stroke and other complications in subsequent pregnancies: Population-based retrospective cohort study

OBJECTIVE

To examine the outcomes of the subsequent pregnancies from women with a previous pregnancy-associated stroke (PAS) in comparison to matched controls.

DESIGN

Population-based retrospective cohort study.

SETTING AND POPULATION

All women with a PAS in Finland 1987-2016 (n = 235) and controls (n = 694).

METHODS

We identified all subsequent deliveries and induced and spontaneous abortions for women with a previous PAS and their matched controls from the Medical Birth Register and the Hospital Discharge Register until 2016. The number, course and outcomes of the subsequent pregnancies were compared. Patient records were studied for PAS recurrence.

MAIN OUTCOME MEASURES

PAS recurrence and pregnancy complications.

RESULTS

Women with a previous PAS had fewer subsequent deliveries: 73 (31.1%) women had 122 deliveries in all, whereas 303 (47.3%) of the controls had 442 deliveries (age-adjusted odds ratio [OR] 0.54, 95% CI 0.38-0.76). Hypertensive disorders of pregnancy (HDP) (17.2% versus 5.7%, age-adjusted OR 4.0, 95% CI 1.7-9.3), especially chronic hypertension (age-adjusted OR 5.9, 95% CI 1.5-24.7), and any diabetes during pregnancy (24.6% versus 14.5%, age-adjusted OR 2.0, 95% CI 1.1-3.8) were more common in cases. Regarding HDP, the difference between groups was explained by underlying factors such as index pregnancy HDP (multivariable OR 2.4, 95% CI 0.8-6.7). PAS recurred in four cases (5.5%).

CONCLUSIONS

Subsequent pregnancies of women with a history of PAS are more often complicated with hypertensive disorders of pregnancy and any diabetes during pregnancy. PAS recurrence risk is considerable.

Etiology and risk factors of ischemic stroke during pregnancy and puerperium: A population-based study

INTRODUCTION

Ischemic stroke (IS) is an uncommon, but potentially life-changing, complication of pregnancy. The aim of this study was to analyze the etiology and risk factors of pregnancy-associated IS.

PATIENTS AND METHODS

We collected a population-based retrospective cohort of patients diagnosed with IS during pregnancy or puerperium in Finland from 1987 to 2016. These women were identified by linking the Medical Birth Register (MBR) with the Hospital Discharge Register. Three matched controls were selected from MBR for each case. The diagnosis and temporal relationship of IS to pregnancy, and clinical details were verified from patient records.

RESULTS

A total of 97 women (median age 30.7 years) were identified as having pregnancy-associated IS. The most common etiologies based on TOAST classification were cardioembolism in 13 (13.4%), other determined in 27 (27.8%) and undetermined in 55 (56.7%) patients. Fifteen patients (15.5%) had embolic strokes of undetermined sources. The most important risk factors were pre-eclampsia, eclampsia, gestational hypertension, and migraine. IS patients had more frequently traditional and pregnancy-related stroke risk factors than the controls (OR 2.38, 95% CI 1.48-3.84) and the risk of IS multiplied with the number of risk factors (4-5 risk factors: OR 14.21, 95% CI 1.12-180.48).

DISCUSSION AND CONCLUSION

Rare causes and cardioembolism were frequent etiologies for pregnancy-associated IS, but in half of the women, the etiology remained undetermined. The risk of IS increased with the number of risk factors. Surveillance and counseling of pregnant women, especially with multiple risk factors, is crucial for the prevention of pregnancy-associated IS.

Subarachnoid Hemorrhage During Pregnancy and Puerperium: A Population-Based Study

BACKGROUND

Pregnancy-related subarachnoid hemorrhage (pSAH) is rare, but it causes high mortality and morbidity. Nevertheless, data on pSAH are limited. The objectives here were to examine the incidence trends, causes, risk factors, and outcomes of pSAH in a nationwide population-based cohort study in Finland covering 30 years.

METHODS

We performed a retrospective population-based cohort study and nested case-control study in Finland for the period 1987-2016 (Stroke in Pregnancy and Puerperium in Finland). The Medical Birth Register was linked to the Hospital Discharge Register to identify women with incident stroke during pregnancy or puerperium. A subcohort of women with SAH is included in this analysis. The temporal connection of SAH to pregnancy and clinical details were verified from patient records.

RESULTS

The unadjusted incidence of pSAH was 3.21 (95% CI, 2.46-4.13) per 100 000 deliveries. No significant increase occurred in the incidence throughout the study period. However, the age of the mother had a significant increasing effect on the incidence. In total, 77% of patients suffered an aneurysmal pSAH, resulting in death in 16.3% of women and with only 68.2% achieving good recovery (modified Rankin Scale score 0-2) at 3 months. Patients with nonaneurysmal pSAH recovered well. The significant risk factors for pSAH were smoking (odds ratio, 3.27 [1.56-6.86]), prepregnancy hypertension (odds ratio, 12.72 [1.39-116.46]), and pre-eclampsia/eclampsia (odds ratio, 3.88 [1.00-15.05]).

CONCLUSIONS

The incidence of pSAH has not changed substantially over time in Finland. The majority of pSAH cases were aneurysmal and women with aneurysm had considerable mortality and morbidity. Counseling of pregnant women about smoking cessation and monitoring of blood pressure and symptoms of pre-eclampsia are important interventions to prevent pSAH.

Early recovery of frontal EEG slow wave activity during propofol sedation predicts outcome after cardiac arrest

AIM OF THE STUDY

EEG slow wave activity (SWA) has shown prognostic potential in post-resuscitation care. In this prospective study, we investigated the accuracy of continuously measured early SWA for prediction of the outcome in comatose cardiac arrest (CA) survivors.

METHODS

We recorded EEG with a disposable self-adhesive frontal electrode and wireless device continuously starting from ICU admission until 48 h from return of spontaneous circulation (ROSC) in comatose CA survivors sedated with propofol. We determined SWA by offline calculation of C-Trend® Index describing SWA as a score ranging from 0 to 100. The functional outcome was defined based on Cerebral Performance Category (CPC) at 6 months after the CA to either good (CPC 1-2) or poor (CPC 3-5).

RESULTS

Outcome at six months was good in 67 of the 93 patients. During the first 12 h after ROSC, the median C-Trend Index value was 38.8 (interquartile range 28.0-56.1) in patients with good outcome and 6.49 (3.01-18.2) in those with poor outcome showing significant difference (p < 0.001) at every hour between the groups. The index values of the first 12 h predicted poor outcome with an area under curve of 0.86 (95% CI 0.61-0.99). With a cutoff value of 20, the sensitivity was 83.3% (69.6%-92.3%) and specificity 94.7% (83.4%-99.7%) for categorization of outcome.

CONCLUSION

EEG SWA measured with C-Trend Index during propofol sedation offers a promising practical approach for early bedside evaluation of recovery of brain function and prediction of outcome after CA.

Stroke in Pregnancy and Puerperium: Validated Incidence Trends With Risk Factor Analysis in Finland 1987-2016

OBJECTIVE

To investigate whether previously reported increasing incidence of pregnancy-associated stroke (PAS) is observed in chart-validated register data in Finland. In an exploratory analysis, we studied risk factors for PAS.

METHODS

We performed a retrospective population-based cohort study and nested case-control study in Finland from 1987 to 2016. The Medical Birth Register (MBR) was linked to the Hospital Discharge Register to identify women with incident stroke (ischemic stroke, cerebral venous thrombosis, intracerebral or subarachnoid hemorrhage) during pregnancy or puerperium. Cases were verified from patient records. Incidence of PAS over the study period in 5-year age groups and pregnancy/postpartum period was calculated per number of deliveries. Three matched controls were selected for each case from MBR to compare risk factors.

RESULTS

After chart review, 29.6% (257 of 868) of cases were PAS. The incidence of PAS was 14.5 (95% confidence interval [CI] 12.8-16.3) per 100,000 deliveries. Incidence increased from 11.1 to 25.2 per 100,000 deliveries from 1987 to 1991 to 2012 to 2016 (p < 0.0001). Incidence increased by age from 9.8 to 29.9 per 100,000 deliveries from 20 to 24 years to >40 years of age (p < 0.0001). During the early postpartum period, incidence was 5-fold greater compared to the first trimester. Maternal mortality was 6.6%. In the multivariable-adjusted model, smoking beyond 12 gestational weeks (odds ratio [OR] 1.8, 95% CI 1.2-2.7), migraine (OR 16.3, 95% CI 5.3-49.8), and hypertensive disorders of pregnancy (OR 4.0, 95% CI 2.5-6.3) were the most important risk factors for PAS.

CONCLUSION

PAS incidence is increasing, stressing the importance of careful pregnancy surveillance and risk factor management, particularly in older expectant mothers and extending to puerperium.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that smoking beyond 12 gestational weeks, migraine, and hypertensive disorders of pregnancy are associated with an increased risk of PAS.

Postoperative cognitive change after cardiac surgery predicts long-term cognitive outcome

OBJECTIVES

Postoperative cognitive dysfunction (POCD) is a common consequence of coronary artery bypass grafting. However, domain-specific associations between postoperative changes and long-term performance are poorly known. The aim of this study was to investigate whether domain-specific cognitive changes after cardiac surgery predict long-term cognitive outcome.

MATERIALS AND METHODS

We assessed 100 patients (86 men, mean age 60) before coronary artery bypass grafting, with re-examinations after one week, three months, and a mean of 6.7 years. The extensive neuropsychological test battery was organized into seven functional cognitive domains. Cognitive decline and improvement were defined with the reliable change index derived from 17 matching healthy controls. Analyses were adjusted for baseline cognitive performance, age, gender, education and cardiovascular risks factors.

RESULTS

On group level, one week after surgery 71% patients showed cognitive decline and 9% improvement in any functional domain, as compared to preoperative results. Three months postsurgery, decline was observed in 47% and improvement in 25% of patients. Executive functioning was the most sensitive domain to both decline and improvement. Postoperative dysfunction predicted long-term cognitive deterioration six years after operation, particularly in the domain of executive functioning.

CONCLUSIONS

POCD after coronary artery bypass grafting is an essential risk factor for long-term deterioration and an indication for neuropsychological follow-up. Assessment of change in executive functioning after coronary artery bypass grafting may help to identify patients at risk for unfavorable long-term outcome.

SiPP (Stroke in Pregnancy and Postpartum): A prospective, observational, international, multicentre study on pathophysiological mechanisms, clinical profile, management and outcome of cerebrovascular diseases in pregnant and postpartum women

Rationale

Cerebrovascular diseases associated with pregnancy and postpartum period are uncommon; however, they can have an important impact on health of both women and foetus or newborn.

Aims

To evaluate the frequency, characteristics and management of cerebrovascular events in pregnant/postpartum women, to clarify pathophysiological mechanisms underlying the occurrence of these events including biomolecular aspects, and to assess the short- and long-term cerebrovascular and global cardiovascular outcome of these patients, their predictors and infant outcome.

Methods and design

This is an observational, prospective, multicentre, international case-control study. The study will include patients with cerebrovascular events during pregnancy and/or within six months after delivery. For each included case, two controls will be prospectively recruited: one pregnant or puerperal subject without any history of cerebrovascular event and one non-pregnant or non-puerperal subject with a recent cerebrovascular event. All controls will be matched by age, ethnicity and type of cerebrovascular event with their assigned cases. The pregnant controls will be matched also by pregnancy weeks/trimester. Follow-up will last 24 months for the mother and 12 months for the infant.

Summary

To better understand causes and outcomes of uncommon conditions like pregnancy/postpartum-related cerebrovascular events, the development of multisite, multidisciplinary registry-based studies, such as the Stroke in Pregnancy and Postpartum study, is needed in order to collect an adequate number of patients, draw reliable conclusions and give definite recommendations on their management.

Pregnancy-associated stroke -a systematic review of subsequent pregnancies and maternal health

Background

Pregnancy-associated stroke is a rare but life-threatening event, with an estimated incidence of 30/100000 deliveries. Data on the risk of stroke recurrence and the risk of other adverse pregnancy outcomes are essential for adequate counselling and surveillance in subsequent pregnancies. The aim of this systematic review is to describe the implications of a pregnancy-associated stroke for the future health of these women.

Methods

We searched Ovid Medline, PubMed, Cochrane Library and CINAHL for articles published in 1980–2018. Articles including women with pregnancy-associated stroke and information on at least one of the following outcomes were included: 1) recurrence of stroke during subsequent pregnancy, 2) number and course of subsequent pregnancies and their outcomes and 3) subsequent cardiovascular health.

Results

Twelve articles were included in the review, with six providing information on subsequent pregnancies, four on subsequent maternal health and two on both. The included articles varied greatly in terms of study design, length of follow up and reported outcomes. We found 252 women with pregnancy-associated stroke for whom the outcomes of interest were reported: 135 women with information on subsequent pregnancies and 123 women with information on future health. In total, 55 pregnancies after stroke were found. In the majority of studies, the incidence of pregnancy complications was comparable to that of the general population. The risk of stroke recurrence during pregnancy was 2%. Data on subsequent health of these women were limited, and the quality of the data varied between the studies.

Conclusions

Data on subsequent pregnancies and health of women with a history of pregnancy-associated stroke are limited. Further research on this topic is essential for adequate counselling and secondary prevention.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2339-y) contains supplementary material, which is available to authorized users.

Fatal Tick-Borne Encephalitis Virus Infections Caused by Siberian and European Subtypes, Finland, 2015

In most locations except for Russia, tick-borne encephalitis is mainly caused by the European virus subtype. In 2015, fatal infections caused by European and Siberian tick-borne encephalitis virus subtypes in the same Ixodes ricinus tick focus in Finland raised concern over further spread of the Siberian subtype among widespread tick species.

Intellectual disability in children aged less than seven years born moderately and late preterm compared with very preterm and term-born children - a nationwide birth cohort study

BACKGROUND

Prematurity has been shown to be associated with an increased risk of intellectual disability (ID).

METHOD

The aim was to establish whether the prevalence of ID, defined as significant limitations in both intellectual (intelligence quotient below 70) and adaptive functioning among moderately preterm (MP; 32⁺⁰ -33⁺⁶  weeks) and late preterm (LP; 34⁺⁰ -36⁺⁶  weeks) infants, is increased compared with that in term infants (≥37⁺⁰  weeks). Antenatal and neonatal risk factors for ID among gestational age groups were sought. The national register study included all live-born infants in Finland in 1991-2008, excluding those who died before one year age, or had any major congenital anomaly or missing data. A total of 1 018 256 infants (98.0%) were analysed: very preterm (VP; <32⁺⁰  weeks, n = 6329), MP (n = 6796), LP (n = 39 928) and term (n = 965 203).

RESULTS

By the age of seven years, the prevalence of ID was 2.48% in the VP group, 0.81% in the MP group, 0.55% in the LP group and 0.35% in the term group. Intracranial haemorrhage increased the ID risk in all groups. Male sex and born small for gestational age predicted an increased risk in all but the MP group.

CONCLUSIONS

The prevalence of ID decreased with increasing gestational age. Prevention of intracranial haemorrhages may have a beneficial effect on the neurodevelopmental outcomes of neonates.

Cardiovascular risk factors and glucose tolerance in midlife and risk of cognitive disorders in old age up to a 49-year follow-up of the Helsinki businessmen study

PURPOSE

The purpose of this study is to compare midlife predictors of old age dementia with or without concomitant atherosclerotic cardiovascular disease (ASCVD).

DESIGN

In the Helsinki Businessmen Study (men born in 1919-1934, n = 3309), death certificates (n = 1885) during up to 49-year follow-up (through 31 December 2013) were screened for dementia (n = 365) and ASCVD, and categorized as (1) AD without ASCVD ("pure" AD, n = 93), (2) AD + ASCVD (n = 126), (3) vascular dementia (VD, n = 82), (4) other or undefined etiology (n = 64). Using Cox analyses, death without dementia and dementia types were compared for the prediction by midlife ASCVD risk factors. Men without diagnosed dementia during follow-up were used as reference.

RESULTS

ASCVD risk factors predicted death without dementia during follow-up. Midlife cholesterol was higher in AD + ASCVD and VD as compared with men surviving to old age without known dementia. None of the midlife factors including cholesterol and glucose tolerance predicted pure AD, but midlife cholesterol predicted AD + ASCVD, both as a continuous (hazard ratio [HR] per SD 1.24, 95% CI, 1.04-1.47), and dichotomous variable (cutpoint 6.5 mmol/L; HR 1.67, 95% CI, 1.16-2.40).

CONCLUSION

Midlife cholesterol predicted dementia with vascular features, but midlife vascular risk factors and glucose intolerance were not related to pure Alzheimer disease without concomitant atherosclerotic cardiovascular disease. Key messages Heterogenous etiology of dementia, which in old age is usually a clinical diagnosis, may confound the role of long-term risk factors. In a longitudinal study with autopsy records, midlife cholesterol predicted dementia with features of atherosclerotic cardiovascular disease but not "pure" Alzheimer disease Glucose tolerance in midlife was not associated with pure Alzheimer's disease.

Cutting the Prehospital On-Scene Time of Stroke Thrombolysis in Helsinki

Background and Purpose—

Significant portion of the prehospital delay consists of minutes spent on the scene with the patient. We implemented a training program for the emergency medical services personnel with the aim to optimize the on-scene time (OST) and to study the impact of different elements of prehospital practice to the OST duration.

Methods—

In this prospective interventional study, key operational emergency medical service performance variables were analyzed from all thrombolysis candidates transported to the Helsinki University Hospital emergency department. The catchment period was 4 months before and 4 months after the implementation.

Results—

One hundred and forty-one patients were managed as thrombolysis candidates before and 148 patients after the training program implementation. The OST duration for the groups was 25 (20.5–31) and 22.5 (18–28.5) minutes, respectively ( P <0.001). Physician consultations via telephone were associated with a longer (odds ratio 0.546 [0.333–0.893]) and advanced life support training with a shorter OST (odds ration 1.760 [1.070–2.895]).

Conclusions—

Implementation of the emergency medical services training program successfully decreased the OST of thrombolysis candidates by 10%. Higher expertise level of the ambulance crew was associated with shorter OST, and decisions to consult a physician via telephone were reflected by longer OST.

Undetermined stroke with an embolic pattern--a common phenotype with high early recurrence risk

INTRODUCTION

Undetermined strokes with an embolic pattern (USEP) represent a common phenotype. We assessed their frequency and compared USEP with cardioembolic stroke with a known source and non-cardioembolic stroke etiology.

METHODS

Study patients were 540 consecutive ischemic stroke patients admitted to Helsinki University Hospital with primary end-point of recurrent stroke in a 21-month follow-up. Cox regression adjusting for CHA2DS2-VASc and anticoagulation estimated the risk of USEP on recurrent stroke.

RESULTS

A total of 229 (42.4%) patients had a non-cardioembolic stroke etiology, 184 (34.1%) had a cardioembolic stroke with a known source, and 127 (23.5%) were classified as USEP. USEP patients had less diabetes and prior TIA, with more severe symptoms than the non-cardioembolic stroke cases. They were younger, had fewer comorbidities, and less severe symptoms than the cardioembolic stroke patients. Cumulative risk of recurrent stroke was 10.0% (95% CI 4.1%-15.9%) for USEP, 5.0% (1.1%-8.9%) for cardioembolic strokes, and 5.0% (3.0%-7.0%) for non- cardioembolic strokes (P = 0.089). USEP associated with a higher risk of recurrent stroke compared to non-cardioembolic strokes (hazard ratio 2.36, 95% CI 1.02-5.47; P = 0.046) and cardioembolic stroke with a known source (1.83, 1.07-3.14; P = 0.028).

CONCLUSIONS

Despite their younger age and more favorable risk factor profile compared with other phenotypes, USEP exhibited a high risk of stroke recurrence.

Stroke in women - oral contraception, pregnancy, and hormone replacement therapy

Stroke is a devastating disease affecting millions of people worldwide every year. Female stroke victims have higher mortality rates and they do not re-cover as well as men. Women's longevity and different vascular risk factor burden like a larger prevalence of atrial fibrillation play a role. Women also have unique risk factors such as oral contraception, pregnancy, estrogen decrease after the menopause and hormone replacement therapy, which should all be evaluated and taken into consideration in treatment decisions both in the acute phase of stroke and in secondary prevention. In this review, the evidence regarding these hormonal aspects and the risk of stroke in women are evaluated. The relevant guidelines are studied and research gaps identified. Future topics for research are recommended and current treatment possibilities and their risks discussed.

Social competence in children with epilepsy--a review

This systematic review focuses on definitions of social competence and assessment methods and provides an overview of the main findings in childhood epilepsy. A total of 45 studies drawn from MEDLINE and PsycINFO (1998-2010) and their reference lists met the selection criteria. Social competence was not defined in the studies reviewed. The study samples varied and consisted mostly of school-aged children. The majority of the studies focused on social adjustment and addressed problems in this area. Little is known about other aspects of social competence, namely social skills or social performance. A broader perspective on and definition of the assessment of social competence in children with epilepsy are proposed. More studies of the abilities underlying social competence, such as social and socio-cognitive skills, are needed in order to gain insight into the developmental pathways of social competence and protective factors for later development.

Intravenous thrombolysis for acute ischemic stroke patients presenting with mild symptoms

BACKGROUND

Thrombolysis of ischemic stroke patients presenting with mild symptoms is controversial.

AIM

We aimed to describe the clinical outcome and frequency of infarcts and symptomatic intracerebral hemorrhages on follow-up imaging of such thrombolysis-treated patients.

METHODS

Our cohort included 1398 consecutive ischemic stroke patients treated with intravenous thrombolysis at the Helsinki University Central Hospital, years 1995-2010. We analyzed the patients according to baseline National Institutes of Health Stroke Scale: ≤2, 3-4, 5-6, and >6. In our institution, visualization of an artery occlusion or perfusion deficit is required for thrombolysis with National Institutes of Health Stroke Scale ≤ 2. We used univariate and multivariable methods to describe the cohort and study associations between the variables. Excellent three-month outcome was defined as modified Rankin Scale 0-1.

RESULTS

Fifty-eight (4·1%) patients were treated with National Institutes of Health Stroke Scale ≤ 2, another 194 (13·6%) with 3-4 points, and 236 (16·5%) with 5-6 points. With National Institutes of Health Stroke Scale ≤ 2, 45 (78%) of the patients had excellent three-month outcome, achieved in 116 (59%) patients with National Institutes of Health Stroke Scale 3-4, in 130 (55%) with National Institutes of Health Stroke Scale 5-6, and in 241 (26%) with National Institutes of Health Stroke Scale > 6. Frequencies of symptomatic intracerebral hemorrhage (European Cooperative Acute Stroke Study-2) were 0%, 2·6%, 2·1%, and 8·1%, and visible infarcts on follow-up imaging 48%, 43%, 48%, and 74%, respectively. In patients with baseline National Institutes of Health Stroke Scale ≤ 6, poor outcome was associated with previous stroke, diabetes, elevated admission blood glucose, and development of intracerebral hemorrhage.

CONCLUSIONS

Half of patients presenting with National Institutes of Health Stroke Scale 0-6 developed an infarction despite thrombolysis, and 40% had poor outcome, which was associated with glucose metabolism and hemorrhagic complications. Managing thrombolysis candidates with mild symptoms warrants individual consideration often supported by multimodal imaging.

Two years of Finnish Telestroke: thrombolysis at spokes equal to that at the hub

BACKGROUND

Official guidelines on stroke promote the use of telemedicine via bidirectional videoconferencing equipment, which provides a valid and reliable means of facilitating thrombolysis delivery to patients in distant or rural hospitals.

METHODS

The present prospective cohort study describes the characteristics and 3-month outcome of the thrombolysis patients treated in 5 community hospitals served by the Helsinki University Central Hospital (HUCH) in a telestroke network during 2007 to 2009. The characteristics and outcome of telestroke thrombolysis patients are compared with consecutive thrombolysis patients (n = 985) treated at HUCH.

RESULTS

A total of 106 consecutive telestroke consultations in 2 years led to IV thrombolysis in 61 patients (57.5%). The median NIH Stroke Scale score was 10 (range 3-26), onset to treatment time 120 minutes (interquartile range [IQR] 49), length of consultation 25 minutes (IQR 18) if the consultation led to thrombolysis and 15 minutes (IQR 10) if not (p = 0.032). The rate of symptomatic intracranial bleedings was 6.7% (4/60) according to the National Institute of Neurological Disorders and Stroke definition. Half (28/57) of the thrombolysis patients with complete follow-up data had a favorable outcome (modified Rankin Scale [mRS] 0-2) and a third (17/57) had an excellent recovery (mRS 0-1). Thus the patients treated with thrombolysis based on teleconsultation had similar outcome with those treated at HUCH (mRS 0-2: 49.1% vs 58.1%, p = 0.214 and mRS 0-1: 17/57 [29.4%] vs 352/957 [36.8%], p = 0.289).

CONCLUSIONS

A special feature of the Finnish pilot is the high percentage of consultations leading to thrombolytic treatment with features and results very similar to on-site thrombolysis at the neurologic emergency room of HUCH.

Characteristics and outcome of ischemic stroke patients who are free of symptoms at 24 hours following thrombolysis

BACKGROUND

A part of ischemic stroke patients score 0 on the National Institutes of Health Stroke Scale (NIHSS) within 24 h following thrombolysis. Their clinical characteristics and long-term outcome are poorly studied. We report a single-center assessment of such patients.

METHODS

The cohort comprises 874 consecutive patients from the Helsinki Stroke Thrombolysis Registry, out of whom 113 scored 0 on 24-hour NIHSS. We analyzed their baseline demographic, clinical and radiological characteristics and 3-month outcome (modified Rankin Scale, mRS). Associations between the study parameters were tested by multivariate analysis.

RESULTS

Patients with a 24-hour NIHSS score = 0 (n = 113) were younger than the rest of the population (n = 761; median: 65.6 vs. 71.5 years; p < 0.001), their NIHSS score on admission was lower (median: 5 vs. 10; p < 0.001), as was their glucose level (median: 6.2 vs. 6.7 mmol/l; p = 0.02). The onset-to-treatment time was similar in both groups (median: 120 vs. 115 min; p = 0.89). Patients with a 24-hour NIHSS score = 0 more often achieved an excellent outcome (mRS scores: 0-1; 81 vs. 31%; p < 0.001) and had lower mortality (1.8 vs. 11.8%; p < 0.01). One third of these patients had a brain infarction visible on 24-hour imaging. Lower baseline NIHSS score and younger age were independently associated with 24-hour NIHSS score = 0, which, in turn, was independently associated with excellent 3-month outcome.

CONCLUSIONS

Patients with an NIHSS score = 0 at 24 h following thrombolysis are younger, have milder symptoms and have a lower glucose level on admission. They achieve more often excellent outcome and lower mortality. Still, 8% of them required help in daily activities or were dead at 3 months (mRS scores: 3-6).

Off-label thrombolysis is not associated with poor outcome in patients with stroke

BACKGROUND AND PURPOSE

Numerous contraindications included in the license of alteplase, most of which are not based on scientific evidence, restrict the portion of patients with acute ischemic stroke eligible for treatment with alteplase. We studied whether off-label thrombolysis was associated with poorer outcome or increased rates of symptomatic intracerebral hemorrhage compared with on-label use.

METHODS

All consecutive patients with stroke treated with intravenous thrombolysis from 1995 to 2008 at the Helsinki University Central Hospital were registered (n=1104). After excluding basilar artery occlusions (n=119), the study population included 985 patients. Clinical outcome (modified Rankin Scale 0 to 2 versus 3 to 6) and symptomatic intracerebral hemorrhage according to 3 earlier published criteria were analyzed with a logistic regression model adjusting for 21 baseline variables.

RESULTS

One or more license contraindications to thrombolysis was present in 51% of our patients (n=499). The most common of these were age >80 years (n=159), mild stroke National Institutes of Health Stroke Scale score <5 (n=129), use of intravenous antihypertensives prior to treatment (n=112), symptom-to-needle time >3 hours (n=95), blood pressure >185/110 mm Hg (n=47), and oral anticoagulation (n=39). Age >80 years was the only contraindication independently associated with poor outcome (OR, 2.18; 95% CI, 1.27 to 3.73) in the multivariate model. None of the contraindications were associated with an increased risk of symptomatic intracerebral hemorrhage.

CONCLUSIONS

Off-license thrombolysis was not associated with poorer clinical outcome, except for age >80 years, nor with increased rates of symptomatic intracerebral hemorrhage. The current extensive list of contraindications should be re-evaluated when data from ongoing randomized trials and observational studies become available.

[Current diagnosis and treatment of TIA]

A TIA (Transient Ischemic Attack) is a sudden onset transient cerebral or retinal ischemic symptom. The definition of TIA has evolved from a time-based (< 24 hours) towards tissue-based. This requires brain scanning either with a computer tomography or magnetic resonance imaging. The benefit of urgent etiological work-up and immediate start of secondary preventive medications has been shown in two independent open studies, in which eight out of ten ischemic strokes could be prevented after a TIA. The risk of ischemic stroke is highest in the two days following a TIA. This puts a huge demand on both the patients and their doctors in the recognition of a TIA. The patient needs to be referred on an emergency basis to a specialized centre with adequate investigational facilities.

Social competence of preschool children with epilepsy

The aims of this study were to describe the social competence of 3- to 6-year-old children with epilepsy (n=26) compared with that of age- and gender-matched healthy controls (n=26). Social competence was assessed with the Vineland Social Maturity Scale, Conners' Parent Rating Scales-Revised, and the Child Behavior Checklist. The results indicate that the children with epilepsy, especially with complicated epilepsy, had fewer age-appropriate social skills and more attention and behavior problems than the healthy children, as reported by parents. It is possible that the lack of age-appropriate social skills and the presence of attention problems predispose to behavioral problems. Also, epilepsy-related factors impaired the achievement of social competence. This study shows that the preschool children with complicated, early-onset epilepsy are at increased risk of difficulties in social competence.

Valsalva maneuver as migraine inducer: a case report of a woman with patent foramen ovale and an ischemic stroke

The association between patent foramen ovale, ischemic stroke, and migraine with aura is well known. It is, however, complicated and generates a considerable debate about the features and clinical consequences of the phenomenon. We report a case of a woman for whom patent foramen ovale has possibly acted as an inducer of both migraine attacks and ischemic stroke.

Antithrombotic Treatment in the Prevention of Ischemic Stroke

Approximately 5.7 million people died from stroke in 2005 [1]. According to World Health Organization estimates, figures are predicted to increase to 23 million first-ever strokes, 77 million stroke survivors, 61 million disability adjusted life years (DALYs) and 7.8 million deaths in the next 20 years [2]. Heart disease and stroke are leading causes of DALYs lost and deaths worldwide [3]. Over 70 % of ischemic strokes are first events, which makes primary prevention immensely important. The treatments for acute ischemic stroke have emerged during the last decade and there is growing evidence of efficacy and importance of secondary prevention. We foresee that patients at high risk of vascular events could reduce their risk by 75 to 80 % through optimal prevention strategies including a combination of lifestyle changes and medical therapy [4]. In this review, we will focus on the aspects of antithrombotic treatment of ischemic stroke (IS) in the primary and secondary prevention.

Low cholesterol, mortality, and quality of life in old age during a 39-year follow-up

OBJECTIVES

We assessed the impact of serum cholesterol level in early midlife on total mortality during up to 39 years of follow-up and on the quality of life (QoL) in old age.

BACKGROUND

Total effects of low serum cholesterol on health have been in dispute, especially in elderly persons, and there are few data on the long-term effects of low cholesterol on QoL.

METHODS

The cohort consisted of 3,277 healthy businessmen age 30 to 45 years at baseline (1960s). In addition to baseline, serum cholesterol values were available for part of the cohort in 1974, 1986, and 2000. The QoL was assessed in 80.9% of survivors (n = 1,820, mean age 73 years) with a RAND-36 (SF-36) QoL questionnaire in 2000. Mortality up to 2002 (n = 1,173) was retrieved from national registers.

RESULTS

Cholesterol was clearly reduced in survivors during follow-up, except in the lowest baseline serum cholesterol group. Baseline cholesterol predicted 39-year total mortality in a graded manner (p < 0.0001), and a value < or =5.0 mmol/l was associated with a 25% reduction in total mortality. In old age, the physical component summary score of RAND-36 was significantly (p = 0.02) higher (better) in the lowest baseline cholesterol group; no difference was found in the mental component summary score (p = 0.51).

CONCLUSIONS

Low serum cholesterol level in midlife predicted not only better survival but also better physical function and QoL in old age, without adversely affecting mental QoL.

Secondary Prevention of Ischemic Stroke

Stroke strikes often suddenly, causes long-term disability and death, and is a huge economical burden for the society, not to mention the human tragedy for the patient and the family. At least 15% of stroke survivors will have a second stroke during the next five years, quarter of which prove out to be fatal within four weeks. Secondary prevention of ischemic stroke (IS) targets at reducing stroke recurrence by means of 1) detection and modification of risk factors, 2) antithrombotic or anticoagulant treatment, and 3) surgical interventions for selected patient subgroups. In this review we will discuss these issues in detail and also offer our personal suggestions for treatment choices. Detecting and treating the modifiable risk factors is the major challenge of secondary prevention of IS.