Visual field defect after ischemic stroke-impact on mortality

OBJECTIVES

We aimed to investigate the impact of visual field defects (VFD) on mortality in ischemic stroke patients.

MATERIALS AND METHODS

All patients with acute infarction and a clinically detected VFD from February 2006 to December 2013 in the NORSTROKE Registry (n = 506) were included and compared with ischemic stroke patients with normal visual fields (n = 2041). A record of patients who had died per ultimo April 2015 was obtained from the central registry at Haukeland University Hospital.

RESULTS

Patients with VFD were significantly older (75.0 vs 69.8, P < .001) than patients with normal visual fields. The majority of patients with VFD was male, had higher cardiovascular morbidity prestroke, and were more likely to have shorter median time from symptom onset to admission (1.7 hours vs 2.7 hours, P < .001). Baseline National Institute of Health Stroke Scale (NIHSS) score was higher (12.7 vs 3.5, P < .001) as was modified Rankin Scale (mRS) score (3.5 vs 1.9, P < .001) and Barthel Index was lower (51.9 vs 84.8, P < .001) day 7. VFD was associated with increased mortality on Kaplan-Meier plots. Hazard ratio was significantly higher for patients with VFD after adjusting for age, sex, employment prior to infarction, married prior to infarction, institutionalization prior to infarction, prior myocardial infarction, atrial fibrillation, smoking, Barthel Index score and i.v. thrombolysis with Cox regression (hazard ratios [HR] 1.30, CI 1.07-1.56, P = .007).

CONCLUSIONS

Having a visual field defect after ischemic stroke is independently associated with increased mortality. This should be addressed when selecting candidates for thrombolysis and in the rehabilitation process.

Less thrombolysis in posterior circulation infarction-a necessary evil?

OBJECTIVES

Patients with posterior circulation infarction (PCI) have more subtle symptoms than anterior circulation infarction (ACI) and could come too late for acute intervention. This study aimed to describe the clinical presentation, management, and outcome of PCI in the NORSTROKE registry.

METHODS

All patients with PCI admitted to the Department of Neurology at Haukeland University Hospital and registered in the NORSTROKE database 2006-2013 were included (n=686). Patients with ACI (n=1758) were used for comparison.

RESULTS

Patients with PCI were younger (68.2 vs 71.8, P<.001), had longer median time from symptom onset to admission (3.8 hours vs 2.2 hours, P<.001), and were less likely to arrive at hospital within 4.5 hours from symptom onset (56.2% vs 72.5%, P<.001, ictus known). Patients with PCI scored lower on baseline National Institute of Health Stroke Scale (NIHSS) total score (3.2 vs 6.3, P<.001), and lower or equally on all items of NIHSS, except for ataxia in two limbs. Patients with PCI were less likely to receive i.v. thrombolytic treatment (9.9% vs 21.5%, OR 0.66, CI 0.47-0.94). On day 7, patients with PCI scored lower on NIHSS (2.8 vs 4.9, P<.001), modified Rankin Scale (2.0 vs 2.3, P<.001), and higher on Barthel Index (84.5 vs 76.0, P<.001).

CONCLUSIONS

Our study is, to our knowledge, the largest series reporting comprehensively on PCI verified by diffusion-weighted imaging. PCI patients are younger than ACI and have better outcome. PCI and ACI are equally investigated in the acute setting, but thrombolysis rates remain 50% lower in PCI.

Age dependency of ischaemic stroke subtypes and vascular risk factors in western Norway: the Bergen Norwegian Stroke Cooperation Study

OBJECTIVES

Age dependency of acute ischaemic stroke aetiology and vascular risk factors have not been adequately evaluated in stroke patients in Norway. Aims of this study were to evaluate how stroke subtypes and vascular risk factors vary with age in a western Norway stroke population.

MATERIALS AND METHODS

Patients aged 15-100 years consecutively admitted to our neurovascular centre with acute ischaemic stroke between 2006 and 2012 were included. The study population was categorized as young (15-49 years), middle-aged (50-74 years) or elderly (≥ 75 years). Stroke aetiology was defined by TOAST criteria. Risk factors and history of cardiovascular disease were recorded.

RESULTS

In total, 2484 patients with acute cerebral infarction were included: 1418 were males (57.3%). Mean age was 70.8 years (SD ± 14.9), 228 patients were young, 1126 middle-aged, and 1130 were elderly. The proportion of large-artery atherosclerosis and of small-vessel occlusion was highest among middle-aged patients. The proportion of cardioembolism was high at all ages, especially among the elderly. The proportion of stroke of other determined cause was highest among young patients. Some risk factors (diabetes mellitus, active smoking, angina pectoris, prior stroke and peripheral artery disease) decreased among the elderly. The proportions of several potential causes increased with age.

CONCLUSION

The proportion of stroke subtypes and vascular risk factors are age dependent. Age 50-74 years constitutes the period in life where cardiovascular risk factors become manifest and stroke subtypes change.

Can the cardiovascular family history reported by our patients be trusted? The Norwegian Stroke in the Young Study

Background and purpose

Family history (FH) is used as a marker for inherited risk. Using FH for this purpose requires the FH to reflect true disease in the family. The aim was to analyse the concordance between young and middle‐aged ischaemic stroke patients' reported FH of cardiovascular disease (CVD) with their parents' own reports.

Methods

Ischaemic stroke patients aged 15–60 years and their eligible parents were interviewed using a standardized questionnaire. Information of own CVD and FH of CVD was registered. Concordance between patients and parents was tested by kappa statistics, sensitivity, specificity, predictive values and likelihood ratios. Regression analyses were performed to identify patient characteristics associated with non‐concordance of replies.

Results

There was no difference in response rate between fathers and mothers (P = 0.355). Both parents responded in 57 cases. Concordance between patient and parent reports was good, with kappa values ranging from 0.57 to 0.7. The patient‐reported FH yielded positive predictive values of 75% or above and negative predictive values of 90% or higher. The positive likelihood ratios (LR+) were 10 or higher and negative likelihood ratios (LR−) were generally 0.5 or lower. Interpretation regarding peripheral arterial disease was limited due to low parental prevalence. Higher age was associated with impaired concordance between patient and parent reports (odds ratio 1.05; 95% confidence interval 1.01–1.09; P = 0.020).

Conclusions

The FH provided by young and middle‐aged stroke patients is in good concordance with parental reports. FH is an adequate proxy to assess inherited risk of CVD in young stroke patients.

Visual impairment in stroke patients--a review

Approximately 30% of all stroke patients suffer from post-stroke visual impairment. Hemianopia is the most common symptom, but also neglect, diplopia, reduced visual acuity, ptosis, anisocoria, and nystagmus are frequent. Partial or complete recovery of visual disorders can occur, but many patients suffer permanent disability. This disability is often less evident than impairment of motor and speech functions, but is negatively correlated with rehabilitation outcome and can lead to a significant reduction in day-to-day functioning. To be visually impaired after stroke reduces quality of life and causes social isolation because of difficulties in navigating/orientating in the surroundings. A thorough diagnosis including targeted examination and later follow-up with eye examination and perimetry is essential in order to establish the extent of the visual impairment and to select the best rehabilitation strategy. Patients seem to profit from visual rehabilitation focused on coping strategies.

Diagnosis and rehabilitation of visual field defects in stroke patients: a retrospective audit

OBJECTIVE

Visual field defects (VFD) after stroke can cause significant disability and reduction in quality of life. Adequate diagnosis of VFD and referral to visual rehabilitation are important to improve outcome. Our aim was to conduct a retrospective clinical audit to investigate how neurologists detect and follow up VFD in stroke patients in a university hospital in Norway.

METHODS

All patients registered in the Bergen NORSTROKE Registry from February 2006 to May 2009 with (1) occipital lobe infarctions and (2) non-occipital infarction and clinically detected VFD were included in the study. Their medical records were reviewed for referral to perimetry for examination of VFD and for referral to a visual rehabilitation program within the first year after brain injury.

RESULTS

Of 353 patients, 34 (9.6%) were referred to perimetry and 8 (2.3%) to visual rehabilitation. Patients referred to perimetry were younger (65.1 vs. 74.7 years, p < 0.001), had lower modified Rankin Scale scores (2.53 vs. 3.47, p = 0.003), and scored lower on the National Institutes of Health Stroke Scale upon admission (6.68 vs. 13.90, p < 0.001). Men were more often referred to perimetry than women (73.5 vs. 26.5%, p < 0.001), and those referred were younger (61.2 vs. 75.8 years, p = 0.03).

CONCLUSIONS

Only few patients were referred to perimetry, and even fewer were offered visual rehabilitation. Age and gender were negative predictors for referral. Neurologists' awareness of the significant disability related to VFD must be increased. Focused diagnostics on visual impairment and early referral to a visual rehabilitation program should be mandatory in stroke unit services.