Alexandra Dachenhausen

Dysphagia Bedside Screening for Acute-Stroke Patients. The Gugging Swallowing Screen

Background and Purpose— Acute-onset dysphagia after stroke is frequently associated with an increased risk of aspiration pneumonia. Because most screening tools are complex and biased toward fluid swallowing, we developed a simple, stepwise bedside screen that allows a graded rating with separate evaluations for nonfluid and fluid nutrition starting with nonfluid textures. The Gugging Swallowing Screen (GUSS) aims at reducing the risk of aspiration during the test to a minimum; it assesses the severity of aspiration risk and recommends a special diet accordingly. Methods— Fifty acute-stroke patients were assessed prospectively. The validity of the GUSS was established by fiberoptic endoscopic evaluation of swallowing. For interrater reliability, 2 independent therapists evaluated 20 patients within a 2-hour period. For external validity, another group of 30 patients was tested by stroke nurses. For content validity, the liquid score of the fiberoptic endoscopic evaluation of swallowing was compared with the semisolid score. Results— Interrater reliability yielded excellent agreement between both raters (&kgr;=0.835, P<0.001). In both groups, GUSS predicted aspiration risk well (area under the curve=0.77; 95% CI, 0.53 to 1.02 in the 20-patient sample; area under the curve=0.933; 95% CI, 0.833 to 1.033 in the 30-patient sample). The cutoff value of 14 points resulted in 100% sensitivity, 50% specificity, and a negative predictive value of 100% in the 20-patient sample and of 100%, 69%, and 100%, respectively, in the 30-patient sample. Content validity showed a significantly higher aspiration risk with liquids compared with semisolid textures (P=0.001), therefore confirming the subtest sequence of GUSS. Conclusions— The GUSS offers a quick and reliable method to identify stroke patients with dysphagia and aspiration risk. Such a graded assessment considers the pathophysiology of voluntary swallowing in a more differentiated fashion and provides less discomfort for those patients who can continue with their oral feeding routine for semisolid food while refraining from drinking fluids.

Insular Involvement Is Associated with QT Prolongation: ECG Abnormalities in Patients with Acute Stroke

Purpose: Aim was to assess the frequencies of electrocardiographic (ECG) abnormalities, including QT prolongation, in acute stroke patients and their association with stroke severity, stroke subtype and location, and cardiovascular risk factors. Methods: Prospectively, admission 12-lead ECG findings, stroke characteristics, cardiovascular risk factors, and potential QT-prolonging factors were collected in 122 consecutive patients with acute stroke. Results: Eighty-four patients (69%) had ECG abnormalities, most frequently ST changes in 34%, QT prolongation in 31%, and atrial fibrillation in 27% of them. Insular involvement and prior stroke independently predicted QT prolongation in small infarcts (insular involvement OR 0.12, 95% CI 0.02–0.74, p = 0.022; prior stroke OR 0.20, 95% CI 0.06–0.70, p = 0.012). Conclusion: Continuous ECG monitoring and assessment of the QT interval should be mandatory in patients with acute stroke.

Silent Brain Infarcts and Transient Ischemic Attacks A Three-Year Study of First-Ever Ischemic Stroke Patients: The Klosterneuburg Stroke Data Bank

BACKGROUND AND PURPOSE We undertook to study the clinical relevance of silent strokes and history of transient ischemic attacks (TIAs) and their individual and combined effects on outcome variables of neurological and epidemiological interest in first-ever stroke patients. METHODS We performed univariate and multivariate analyses of data prospectively collected in the Klosterneuburg Stroke Data Bank, a hospital-based registry in Austria that includes a 3-year follow-up program. RESULTS Of 728 patients (mean age, 68 +/- 10 years) with a first-ever ischemic stroke, 110 (15%) had had a previous TIA, and 66/618 (11%) patients did not have a history of TIA but showed evidence of silent brain infarct on CT. Outcome variables of neurological interest were not significantly different between groups, including time between stroke and study entry, activities of daily living status at first presentation, median time of hospitalization, 30-day mortality, or 3-year mortality. Univariate analyses of epidemiologically important risk factors showed either history of TIA or evidence of silent infarct to be more frequently associated with hypertension (P = .007). Cox models of survival showed that neither history of TIA nor evidence of silent infarct were significantly associated with an increase in 3-year mortality. CONCLUSIONS Over a period of 3 years, neither history of TIA nor evidence of silent infarct diagnosed at the time of the presenting major stroke in first-ever ischemic stroke patients exert an important influence on neurological or epidemiological outcome variables.

Underfunding of Stroke Research A Europe-Wide Problem

Background and Purpose— Previous studies in the United States and the United Kingdom have shown that stroke research is underfunded compared with coronary heart disease (CHD) and cancer research despite the high clinical and financial burden of stroke. We aimed to determine whether underfunding of stroke research is a Europe-wide problem. Methods— Data for the financial year 2000 to 2001 were collected from 9 different European countries. Information on stroke, CHD, and cancer research funding awarded by disease-specific charities and nondisease-specific charity or government-funded organizations was obtained from annual reports, web sites, and by direct communication with organizations. Results— There was marked and consistent underfunding of stroke research in all the countries studied. Stroke funding as a percentage of the total funding for stroke, CHD, and cancer was uniformly low, ranging from 2% to 11%. Funding for stroke was less than funding for cancer, usually by a factor of ≥10. In every country except Turkey, funding for stroke research was less than that for CHD. Conclusions— This study confirms that stroke research is grossly underfunded, compared with CHD and cancer, throughout Europe. Similar data have been obtained from the United States suggesting that relative underfunding of stroke research is likely to be a worldwide phenomenon.

Multidomain Lifestyle Interventions for the Prevention of Cognitive Decline After Ischemic Stroke: Randomized Trial

Background and Purpose— Cognitive impairment occurs in ⩽30% of all stroke survivors. However, effective therapies aimed at preventing poststroke cognitive decline are lacking. We assessed the efficacy of a multidomain intervention on preventing cognitive decline after stroke. Methods— In this randomized, observer-blind trial patients were recruited within 3 months after an acute stroke in 5 Austrian neurological centers. Patients were assigned to a 24-month lifestyle-based multidomain intervention or standard stroke care. Primary outcomes were the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-cog) and occurrence of cognitive decline in the composite scores of at least 2 of 5 cognitive domains at 24 months. Results— A total of 101 patients were randomized into multi-intervention and 101 into standard care during June 2010 and November 2012. Of them, 76 patients in the intervention group and 83 in the control group were included in the final intention-to-treat analysis. At 24 months, 8 of 76 (10.5%) patients in the intervention group and 10 of 83 (12.0%) patients in the control group showed cognitive decline corresponding to a relative risk reduction of 0.874 (95% confidence interval, 0.364–2.098). The change in ADAS-cog from baseline to 24 months was not different either (median 0 [IQR, −1 to 2] in both groups; P=0.808). Conclusions— This trial found no benefit of 24-month multidomain intervention with focus on improvement in lifestyle and vascular risk factors on the incidence of poststroke cognitive decline in comparison with standard stroke care. Studies with a larger sample size are needed. Clinical Trial Registration— URL: http://clinicaltrials.gov. Unique identifier: NCT01109836.

Epidemiologie des Schlaganfalls

ZusammenfassungTrotz Abnahme der Sterblichkeit durch Schlaganfall in den westlichen, industrialisierten Ländern kommt es zu einer Zunahme der Inzidenz vor allem in den Enwicklungsländern, damit wird Schlaganfall weltweit zu einer wachsenden globalen gesundheitlichen Belastung. In Österreich ist die Mortalität zwischen 1970 und 1994 auf die Hälfte zurückgegangen und liegt bei etwa 100 pro 100 000 Einwohner pro Jahr. Die Inzidenzrate liegt bei etwa 200–300 pro 100000 Einwohner und wird voraussichtlich in den nächsten Jahren gering ansteigen. Schlaganfallrezidive werden im ersten Jahr mit 6–12% angenommen und in den Folgejahren mit 5–8%. Daten aus dem Österreichischen Schlaganfallregister, das prospektiv alle Schlaganfälle registrierte, die an 15 Stroke Units behandelt worden waren, zeigten, daß die Mortalität nach 3 Monaten 11,7% beträgt und 40% ausgeprägte oder mäßige Residualbehinderungen im Alltag aufweisen.SummaryIn spite of the decrease in stroke mortality in industrialized western countries an increase of stroke incidence is expected especially in developing countries. Thus, within the next years, stroke will lead to a growing global health bürden. In Austria, mortality has decreased between 1970 and 1994 by half and has now reached a rate of 100 per 100000 inhabitants per year. Incidence rates amount to 200–300 per 100000 inhabitants per year. Recurrent stroke rates are estimated to occur at a rate of 6–12% within the first year and 5–8% within the following years. Data from the Austrian Stroke Unit Registry comprise data compiled in 15 stroke units and show that the 3 month mortality is 11,7% and 40 % show pronounced or moderate residual disabilities.

Time Trends in Patient Characteristics Treated on Acute Stroke-Units Results From the Austrian Stroke Unit Registry 2003–2011

Background and Purpose— Demographic changes, increased awareness of vascular risk factors, better diagnostic, progress in medical care, and increasing primary stroke prevention influence the profile of patients admitted to stroke-units. Changes in patient population and stroke type have important consequences on outcome and management at stroke-units. Methods— Data from the national database of the Austrian Stroke Unit Registry were analyzed for time-trends in demography, risk factors, cause, and stroke severity. Results— Data of 48 038 ischemic and 5088 hemorrhagic strokes were analyzed. Between 2003 and 2011, median age increased significantly for ischemic strokes from 68 to 71 years in men and from 76 to 78 years in women, respectively. Ischemic stroke patients showed significantly increased rates of hypertension, hypercholesterolemia, and atrial fibrillation. In hemorrhagic strokes an increase for hypercholesterolemia and cardiac diseases other than atrial fibrillation and myocardial infarction were only found in men. A small but significant decrease in stroke severity was found for ischemic strokes from 4 to 3 points on the National Institutes of Health Stroke Scale in men and from 5 to 4 in women, and for hemorrhagic strokes from 9 to 6 points in men and from 9 to 7 in women. Cardioembolic strokes increased slightly, whereas macroangiopathy decreased. Conclusions— Significant time trends were seen for characteristics of ischemic and hemorrhagic stroke patients admitted to acute stroke-units in Austria. These include trends for older age and toward milder strokes with more cardioembolic causes. This signals a need for increased resources for managing multimorbidity and enabling early mobilization.

Dyslipidemia, elevated LDL cholesterol and reduced nocturnal blood pressure dipping denote lacunar strokes occurring during nighttime

Previous studies have shown a peak occurrence of ischemic stroke in the morning but no consistent finding has been attributed to this. Focused on lacunar strokes we performed a prospective study with a detailed diagnostic protocol including parameters of recent infection, indicators of sleep apnea and cerebral vasoreactivity (CVR), aimed at defining differences in risk profiles between diurnal and nocturnal strokes. Consecutively we included 33 nocturnal and 54 diurnal strokes. Baseline characteristics, known risk factors, stroke severity and topology were not different between groups. The mean low‐density lipoprotein (LDL) cholesterol level was significantly higher amongst patients with nocturnal strokes (133.3 ± 35.2 mg/dl vs. 115.5 ± 39.8 mg/dl; P = 0.04), as well as the proportion of patients with any dyslipidemia (94% vs. 77.8%; P = 0.047). Twenty‐four‐hour blood pressure recordings showed a reduced nocturnal decrease of blood pressure in subjects with strokes that occurred between 10 pm and 6 am in comparison with those whose strokes occurred between 6 am and 2 pm (5.0 ± 7.3% vs. 11.0 ± 6.7%; P = 0.049). No significant differences were found for parameters of recent infection (including seroreactivity against Chlamydia pneumoniae and cytomegalovirus), CVR, indicators of sleep apnea and the degree of white matter disease assessed by magnetic resonance tomography. Dyslipidemia, especially elevated LDL cholesterol is more prevalent in nocturnal lacunar strokes especially when combined with a reduced nocturnal dipping of blood pressure. This risk factor profile can be regarded as an additional target for stroke prevention.

Prevention of poststroke cognitive decline: ASPIS – a multicenter, randomized, observer‐blind, parallel group clinical trial to evaluate multiple lifestyle interventions – study design and baseline characteristics

Background Cognitive impairment after stroke is a considerable burden to patients and their caregivers and occurs in one-third of stroke survivors. No strategy to prevent cognitive decline after stroke exists thus far. Established vascular risk factors have been associated with cognitive decline and may be a target for therapeutic interventions in stroke survivors. Aim To test whether intensive multifactorial non-pharmacologic interventions based on lifestyle modification can reduce the risk of cognitive decline in patients who recently suffered ischemic stroke. Methods A randomized, controlled, multicenter, observer-blind trial was designed. The reference group obtains stroke care according to standard guidelines. The intervention group additionally receives intensive control and motivation for better compliance with prescribed evidence-based medication, regular blood pressure measurements, healthy diet, regular physical activity and cognitive training. Primary outcomes are the rate of cognitive decline at 24 months, assessed by a neuropsychological test battery and the cognitive subscale of the Alzheimers Disease Assessment Scale. Results 202 patients (29% women), aged 62 ± 9 years, were recruited during 2010 to 2012. Stroke related impairment at inclusion was low (mean National Institutes of Health Stroke Scale: 1.9±1.8, median modified Rankin Scale: 1 (0-1)). At baseline, groups did not differ significantly in demographic, clinical or lifestyle characteristics. Conclusion The recruitment was successful and the groups are balanced regarding potential confounding variables. The study will provide essential data about the feasibility and efficacy of lifestyle intervention after stroke in order to develop a new approach to prevent cognitive decline in patients with mild ischemic stroke.

Psychosocial Distress, an Underinvestigated Risk Factor for Stroke

See related article, p 367. Sometimes we have to look at the obvious. Modifiable risk factors for stroke have been identified and their control has been proven to be effective. Although frequent risk factors, such as hypertension, heart disease, and diabetes mellitus, contribute strongly to stroke incidence, they do not explain all incident cases. Therefore, the search of new risk factors is ongoing. To many physicians and patients, it is obvious that stressful life events play a role, especially, when they become a chronic and heavy burden in private life, for instance a severe disease occurring in a close relative or the sudden loss of a next-of-kin, and also changes in professional life can play a role, such as career disappointments or loss of job. It is quite obvious that such events are potentially harmful and change the outlook of everyone affected by them. Although some persons may adapt themselves more easily to such changes, others develop adjustment disorders and this burden develops a distressing quality, which increases the risk of suffering a stroke. Such factors causing psychosocial distress have been correlated with major depression, type A behavior, stressful life events, unemployment, caregiver …