Aimo Rissanen

A randomized, double-blind, placebo-controlled trial of nimodipine in acute ischemic hemispheric stroke.

Background and Purpose A randomized, double‐blind, placebo‐controlled multicenter trial was conducted to test the hypothesis that nimodipine would improve the functional outcome in acute ischemic hemispheric stroke. Methods A total of 350 patients were randomized to nimodipine 120 mg/d PO or matching placebo for 21 days. Randomization was stratified by onset of therapy, age, and stroke severity. Treatment was begun within 48 hours of onset. The patients had neurological evaluation on admission, on days 1, 7, and 21, and at 3 and 12 months. The primary end points were Rankin grade, neurological score, and mobility at 12 months. Results We did not find any differences in the functional outcome between the treatment groups or between the stratified subgroups. We were also unable in post hoc analyses to find any groups of patients who benefited from nimodipine. During the first month and at 3 months the case‐fatality rate was higher in the nimodipine‐treated patients than in those on placebo (P=.004 and P=.030, respectively), but at the 1‐year follow‐up this difference had lost statistical significance. During the first week nimodipine had a statistically significant lowering effect on both systolic (P=.005) and diastolic (P=.013) blood pressure. Conclusions Nimodipine did not improve the functional outcome of acute ischemic hemispheric stroke. The early case‐fatality rate was higher in the nimodipine group, possibly due to the blood pressure‐lowering effect of nimodipine. (Stroke. 1994;25:1348‐1353.)

Factors Delaying Hospital Admission After Acute Stroke

BACKGROUND AND PURPOSE Clinical trials of new drugs that reverse neurological deficits when used in the first hours of stroke onset suggest that early hospital admission is important. We analyzed a database of patients with acute stroke to determine the factors that delay hospital admission. METHODS We analyzed all patients with their first stroke during 1993 in the province of Central Finland (population, 256 000). Patients referred to the Central Hospital, the only tertiary referral hospital in the area, were included in the study. RESULTS Of the patients with first stroke, 363 (79%) were admitted to the Central Hospital. The stroke subtype was confirmed in 356 (98%) patients with CT scan, and the patient population included 272 (75%) with brain infarction, 51 (14%) with intracerebral hemorrhage, and 40 (11%) with subarachnoid hemorrhage. The most important factor associated with a delay in reaching the hospital was the referral pattern. The median delay was 2 hours for patients brought directly to the Central Hospital, 8 hours if a physician at the local health center was consulted, and 47 hours if the patient was first admitted to the health center for observation. Other factors associated with a delay were ischemic stroke and stroke onset in the evening or night or during the weekend. CONCLUSIONS The majority of patients who are candidates for acute stroke trials arrive at the hospital after prolonged delays for multiple reasons. Public and medical personnel education could result in signficant reduction in these delays.

Effectiveness of Primary and Comprehensive Stroke Centers PERFECT Stroke: A Nationwide Observational Study From Finland

Background and Purpose— Previous studies show better outcomes for patients with stroke receiving care in stroke units, but many different stroke unit criteria have been published. In this study, we explored whether stroke centers fulfilling standardized Brain Attack Coalition criteria produce better patient outcomes than hospitals without stroke centers. Methods— We did an observational register–linkage study of all patients with ischemic stroke treated in Finland between 1999 and 2006. After exclusion of recurrent strokes and nonanalyzable patients, we included 61 685 consecutive patients treated in 333 hospitals classified in national audits either as Comprehensive Stroke Centers, Primary Stroke Centers, or General Hospitals according to Brain Attack Coalition criteria. Primary outcome measures were case-fatality and being in institutional care 1 year after stroke. Results— Care in stroke centers was associated with lower 1-year case-fatality and reduced institutional care compared with General Hospitals. The number-needed-to-treat to prevent 1 death or institutional care at 1 year was 29 for Comprehensive Stroke Centers and 40 for Primary Stroke Centers versus General Hospitals. Patients treated in stroke centers had lower mortality during the entire follow-up of up to 9 years and their median survival was increased by 1 year. Conclusions— This study shows a clear association between the level of acute stroke care and patient outcome and supports use of published criteria for primary and comprehensive stroke centers.

Stroke Monitoring on a National Level PERFECT Stroke, a Comprehensive, Registry-Linkage Stroke Database in Finland

Background and Purpose— Stroke databases are established to systematically evaluate both the treatment and outcome of stroke patients and the structure and processes of stroke services. Comprehensive data collection on this common disease is resource-intensive, and national stroke databases often include only patients from selected hospitals. Here we describe an alternative national stroke database. Methods— We established a nationwide stroke database with multiple administrative registry linkages at the individual-patient level. Information on comorbidities; treatments before, during, and after stroke; living status; recurrences; case fatality; and costs were collected for each hospital-treated stroke patient. Results— The current database includes 94 316 patients with incident stroke between January 1999 and December 2007, with follow-up until December 2008. Annually, 10 500 new patients are being added. One-year recurrence was 13% and case fatality was 27% during the study period. In 2007, 86% of patients survived 1 month and 77% were living at home at 3 months, but the proportion treated in stroke centers (62%) or with nationally recommended secondary preventive medication after ischemic stroke (49%) was still suboptimal. Conclusions— In comparison with other national stroke databases, our method enables higher coverage and more thorough follow-up of patients. Information on long-term recurrences, case fatality, or costs is not often included in national stroke databases. Our database has low maintenance costs, but it lacks detailed data on in-hospital processes. Use of national administrative data, where such linkage is possible, saves resources, achieves high rates of long-term follow-up, and allows for comprehensive monitoring of the burden of the disease.

Trends in treatment and outcome of stroke patients in Finland from 1999 to 2007. PERFECT Stroke, a nationwide register study.

Abstract Introduction: This article in this supplement issue on the Performance, Effectiveness, and Costs of Treatment episodes (PERFECT) project describes trends in Finnish stroke treatment and outcome. Material and Methods: The PERFECT Stroke study uses multiple national registry linkages at individual patient level to produce a national stroke database with comprehensive follow-up of all hospital-treated stroke patients in Finland. Results: There were 94,316 incident stroke patients treated in Finnish hospitals from 1999 to 2007. Lengths-of-stays decreased after ischemic stroke (IS), and increased after intracerebral (ICH) and subarachnoid (SAH) hemorrhage. Ten-year survival improved in IS (hazard ratio 0.75; 95% CI 0.71–0.79) and ICH patients (0.88; 0.79–0.97), increasing median survival by 2 and 1 life-years respectively. This has translated into more days spent home among IS patients, but not among ICH patients. Treatment by neurologists improved the survival of IS (odds ratio [OR] 1.77; 95% CI 1.70–1.84) and ICH patients (OR 1.55; 95% CI 1.40–1.69), and treatment by neurosurgeons of SAH patients (OR 2.66; 95% CI 2.25–3.16), the effects were further improved by care in specialized stroke centers. Discussion: The survival of Finnish IS and ICH patients has improved. Specialized acute care was associated with improved outcome.

Direct Costs of Patients With Stroke Can Be Continuously Monitored on a National Level Performance, Effectiveness, and Costs of Treatment Episodes in Stroke (PERFECT Stroke) Database in Finland

Background and Purpose— Treatment of stroke consumes a significant portion of all healthcare expenditure. We developed a system for monitoring costs from individual patient data on a national level in Finland. Methods— Multiple national administrative registers were linked to gain episode-of-care data on all hospital-treated patients with incident stroke over the years 1999 to 2007 (n=94 316). Inpatient and specialist outpatient costs were evaluated with a cost database, long-term care costs with fixed prices, and medication costs with true retail prices. Results— For the patients of Year 2007, the mean 1-year costs after an ischemic stroke were

Glucose tolerance in amyotrophic lateral sclerosis.

29 580, after an intracerebral hemorrhage

Blood pressure, nimodipine, and outcome of ischemic stroke

36 220, and after a subarachnoid hemorrhage

Decreasing incidence of stroke in central Finland, 1985-1993

42 570, valued in Year 2008 US dollars. Only part of these costs are attributable to stroke, because the annual costs prior to stroke were significant,

Economic burden of stroke and the evaluation of new therapies

8900 before ischemic stroke,