Amanda K. Gilligan

Quality of Life After Stroke The North East Melbourne Stroke Incidence Study (NEMESIS)

Background and Purpose— Health-related quality of life (HRQoL) data are scarce from unselected populations. The aims were to assess HRQoL at 2 years poststroke, to identify determinants of HRQoL in stroke survivors, and to identify predictors at stroke onset of subsequent HRQoL. Methods— All first-ever cases of stroke in a population of 306 631 over a 1-year period were assessed. Stroke severity, comorbidity, and demographic information were recorded. Two-year poststroke HRQoL was assessed using the Assessment of Quality of Life (AQoL) instrument (deceased patients score=0). Handicap, disability, physical impairment, depression, anxiety, living arrangements, and recurrent stroke at 2 years were documented. If necessary, proxy assessments were obtained, except for mood. Linear regression analyses were performed to identify factors independently associated with HRQoL. Results— Of 266 incident cases alive at 2 years, 225 (85%) were assessed. The mean AQoL utility score for all survivors was 0.47 (95% CI, 0.42 to 0.52). Almost 25% of survivors had a score of ≤0.1. The independent determinants of HRQoL in survivors were handicap, physical impairment, anxiety and depression, disability, institutionalization, dementia, and age. The factors present at stroke onset that independently predicted HRQoL at 2 years poststroke were age, female sex, initial NIHSS score, neglect, and low socioeconomic status. Conclusions— A substantial proportion of stroke survivors have very poor HRQoL. Interventions targeting handicap and mood have the potential to improve HRQoL independently of physical impairment and disability.

Determinants of Handicap after Stroke: The North East Melbourne Stroke Incidence Study (NEMESIS)

Background and Purpose— Handicap, although more relevant to the patient than impairment or disability, has received little attention in people with stroke. The aim of this study was to identify, in an unselected population, factors determining handicap at 2 years after stroke. Methods— All first-ever cases of stroke in a population of 306 631 over a 1-year period were assessed. Stroke severity, comorbidity, and demographic information was recorded. Among survivors, 2-year poststroke handicap was assessed with the London Handicap Scale. Disability, physical impairment, depression, anxiety, living arrangements, and recurrent stroke at 2 years were documented. If necessary, proxy assessments were obtained, except for mood. Linear regression analyses were performed to identify factors independently associated with handicap. First, all assessments (proxy and nonproxy) were examined; then, the nonproxy assessments were used to examine the effects of mood. Results— Of 266 patients with incident stroke who were alive at 2 years, 226 (85%) were assessed. Significant determinants of handicap on univariable analysis were age, female sex, socioeconomic status, alcohol intake, stroke subtype, initial stroke severity; 2-year physical impairment, disability, depression and anxiety scores; institutionalization; and recurrent stroke. On multivariable analysis, the independent determinants of handicap were age and 2-year physical impairment and disability. In analysis restricted to nonproxy data, depression and anxiety were also independently associated with handicap. Conclusions— Age, concurrent disability, and physical impairment were more important determinants of handicap than other demographic factors or initial stroke severity. Because depression and anxiety were independently associated with handicap, their treatment may potentially reduce handicap in stroke patients.

Sex differences in presentation, severity, and management of stroke in a population-based study

Objectives: Women may have poorer outcomes after stroke than men because of differences in their acute management. We examined sex differences in presentation, severity, in-hospital treatment, and early mortality in a cohort of first-ever-in-a-lifetime stroke patients. Methods: Data were collected from May 1, 1996, to April 30, 1999, in the North East Melbourne Stroke Incidence Study. Stroke symptoms, prestroke medical history, in-hospital investigations, admission and discharge medications, initial stroke severity, and 28-day mortality were recorded. Multivariable regression was used to estimate sex differences in treatment, investigations, and 28-day mortality. Results: A total of 1,316 patients were included. Women were older (mean age 76 ± 0.6 vs 72 ± 0.6, p < 0.01), had more severe strokes (median NIH Stroke Scale score 6 vs 5, p < 0.01), and more likely to experience loss of consciousness (31% vs 23%, p = 0.003) and incontinence (22% vs 11%, p = 0.01) than men. Women were less often on lipid-lowering therapy on admission. Echocardiography and carotid investigations were less frequently performed in women due to greater age and stroke severity. Women had greater 28-day mortality (32% vs 21%, p < 0.001) and stroke severity (44% vs 36%, p = 0.01) than men, but adjustment for age, comorbidities, and stroke severity (for mortality only) completely attenuated these associations. Conclusion: Sex differences seen in this study were mostly explained by womens older age, greater comorbidity, and stroke severity. The reasons for differences according to age may need further examination.

Stroke Units, Tissue Plasminogen Activator, Aspirin and Neuroprotection: Which Stroke Intervention Could Provide the Greatest Community Benefit?

Background: Although a number of acute stroke interventions are of proven efficacy, there is uncertainty about their community benefits. We aimed to assess this within a defined population. Methods: Eligibility for tissue plasminogen activator (tPA), aspirin, stroke unit management and neuroprotection were assessed among incident stroke cases within the community-based North East Melbourne Stroke Incidence Study. Results: Among 306,631 people, there were 645 incident strokes managed in hospital. When eligible patients were extrapolated to the Australian population, for every 1,000 cases, 46 (95% CI 17–69) could have been saved from death or dependency with stroke unit management, 6 (95% CI 1–11) by using aspirin, 11 (95% CI 5–17) or 10 (95% CI 3–16) by using tPA at 3 and 6 h, respectively. Conclusions: Although tPA is the most potent intervention, management in stroke units has the greatest population benefit and should be a priority.

Baseline Blood Pressure but Not Early Computed Tomography Changes Predicts Major Hemorrhage After Streptokinase in Acute Ischemic Stroke

Background and Purpose— Intracerebral hemorrhage is the most serious complication of thrombolytic therapy for stroke. We explored factors associated with this complication in the Australian Streptokinase Trial. Methods— The initial CT scans (≤4 hours after stroke) of 270 patients were reviewed retrospectively by an expert panel for early signs of ischemia and classified into the following 3 categories: no signs or ≤1/3 or >1/3 of the vascular territory. Hemorrhage on late CT scans was categorized as major or minor on the basis of location and mass effect. Stepwise, backward elimination, multivariate logistic regression analysis was used to identify risk factors for each hemorrhage category. Results— Major hemorrhage occurred in 21% of streptokinase (SK) and 4% of placebo patients. Predictors of major hemorrhage were SK treatment (odds ratio [OR], 6.40; 95% CI, 2.50 to 16.36) and elevated systolic blood pressure before therapy (OR, 1.03; 95% CI, 1.01 to 1.05). Baseline systolic blood pressure >165 mm Hg in SK-treated patients resulted in a >25% risk of major secondary hemorrhage. Early ischemic CT changes, either ≤1/3 or >1/3, were not associated with major hemorrhage (OR, 1.58; 95% CI, 0.65 to 3.83; and OR, 1.11; 95% CI, 0.45 to 2.76, respectively). Minor hemorrhage occurred in 30% of the SK and 26% of the placebo group. Predictors of minor hemorrhage were male sex, severe stroke, early CT changes, and SK treatment. Ninety-one percent of patients with major hemorrhage deteriorated clinically compared with 23% with minor hemorrhage. Conclusions— SK increased the risk of both minor and major hemorrhage. Major hemorrhage was also more likely in patients with elevated baseline systolic blood pressure. However, early CT changes did not predict major hemorrhage. Results from this study highlight the importance of baseline systolic blood pressure as a potential cause of hemorrhage in patients undergoing thrombolysis.

Greater Incidence of Both Fatal and Nonfatal Strokes in Disadvantaged Areas: The Northeast Melbourne Stroke Incidence Study

Background and Purpose— Greater stroke mortality has been reported among lower socioeconomic groups. We aimed to determine whether fatal, nonfatal, and overall stroke incidence varied by socioeconomic status. Methods— All suspected strokes occurring in 22 postcodes (population of 306 631) of Melbourne, Australia, during a 24-month period between 1997 and 1999 were found and assessed. Multiple overlapping sources were used to ascertain cases with standard clinical definitions for stroke. Socioeconomic disadvantage was assigned in 4 bands from least to greatest using an area-based measure developed by the Australian Bureau of Statistics. Results— Overall stroke incidence (number per 100 000 population per year), adjusted to the European population 45 to 84 years of age, increased with increasing socioeconomic disadvantage: 200 (95% CI, 173 to 228); 251 (95% CI, 220 to 282); 309 (95% CI, 274 to 343); and 366 (95% CI, 329 to 403; &khgr;2 for ranks; P<0.0001). Similar incidence patterns were observed for both fatal and nonfatal stroke. Nonfatal stroke contributed most to this incidence pattern: 146 (95% CI, 122 to 169); 181 (95% CI, 155 to 207); 223 (95% CI, 194 to 252); and 280 (95% CI, 247 to 313; &khgr;2 for ranks; P<0.0001). Conclusions— In this population-based study, both fatal and nonfatal stroke incidence increased with increasing socioeconomic disadvantage. The greater contributor to this incidence pattern was nonfatal stroke incidence. This may have implications for service provision to those least able to afford it. Area-based identification of those most disadvantaged may provide a simple and effective way of targeting regions for stroke prevention strategies.

Cortical excitability and recovery curve analysis in generalized epilepsy

Article abstract Seven untreated patients with idiopathic generalized epilepsy were studied with recovery curve analysis using transcranial magnetic stimulation and compared with 16 controls. Patients had a shorter period of inhibition of the test response following a conditioning stimulus and demonstrated a period of increased facilitation of the test response at interstimulus intervals of 200 to 300 msec, which was similar to the mean interdischarge interval of spike-wave activity on EEG. This provides further evidence of cortical hyperexcitability in idiopathic generalized epilepsy.

Incidence of Stroke Subtypes in the North East Melbourne Stroke Incidence Study (NEMESIS): Differences between Men and Women

Background and Purpose: Incidence rates of stroke subtypes may be imprecise when samples are small. We aimed to determine the incidence of stroke subtypes in a large geographically defined population. Methods: Multiple overlapping sources were used to ascertain all strokes occurring in 22 postcodes (population of 306,631) of Melbourne, Australia, between 1997 and 1999. Stroke subtypes were defined by CT, MRI and autopsy. The Mantel-Haenszel age-adjusted rate ratio (MH RR) was used to compare incidence rates between men and women. Results: We identified 1,421 strokes among 1,337 residents, 1,035 (72.8%) being first-ever strokes. Incidence (number/100,000 population/year), adjusted to the European population 45–84 years, was 197 (95% confidence interval, CI, 169–224) for ischemic stroke (IS), 47 (95% CI 33–60) for intracerebral haemorrhage (ICH) and 19 (95% CI 10–27) for subarachnoid haemorrhage (SAH). Compared with women, men in this age group had a greater incidence of IS (MH RR 1.65, 95% CI 1.39–1.96, p < 0.0001) and ICH (MH RR 1.46, 95% CI 1.01–2.10, p = 0.0420), but lesser rates of SAH (MH RR 0.34, 95% CI 0.16–0.69, p = 0.0031). Conclusions: In this population-based study, the incidence of IS and ICH was greater among men than women, while women had a greater incidence of SAH. More effort may need to be directed at modifying risk factors for IS and ICH in men.

Is FAST stroke smart? Do the content and language used in awareness campaigns describe the experience of stroke symptoms?

Background Public education campaigns for stroke are used worldwide. However, there are few published evaluations of such campaigns. Aim This cross-sectional study examined patient and bystander awareness of two Australian campaigns, ‘FAST’ (face, arm, speech, time) and ‘Signs of Stroke’, and evaluated the campaigns ability to identify stroke and to describe the symptom experience. Methods Interviews were conducted with either stroke patients or a key bystander for consecutive eligible cases admitted to two metropolitan hospitals between August 2006 and April 2008. Participants were asked to describe awareness of the FAST campaign, the symptoms experienced and to evaluate the symptom descriptions of Signs of Stroke against their own experience. Results A total of 100 patients and 70 bystanders were interviewed for 170 cases (71% of eligible cases). Only 12% of those interviewed were aware of the FAST campaign, and of these few (19%) were able to recall all FAST symptoms, with only one bystander using the FAST assessments to identify stroke. At least one FAST symptom was reported by 84% and one Signs of Stroke symptom by 100%. Less than half of those experiencing ‘weakness or paralysis’ thought this description exactly described their experience. Common descriptors of symptoms were: face or mouth droop or drop; trouble using, coordinating or moving arm, hand or leg; trouble walking or standing; numbness; and slurring or loss of speech. Conclusion Awareness of the FAST and Signs of Stroke campaigns was low, with poor recall and little use of the FAST assessments. Some symptom descriptions used in the campaign were not reflective of the symptom experience. The content and language of these campaigns could be improved to portray stroke symptoms more realistically.

Perfusion‐Derived Dynamic 4D CT Angiography Identifies Carotid Pseudo‐Occlusion in Hyperacute Stroke

Differentiation between true acute tandem occlusion involving the extracranial internal carotid artery (ICA) from pseudotandem occlusion with a patent extracranial ICA has important prognostic and therapeutic implications. We explored the utility of perfusion‐derived 4‐dimensional CT angiogram (4D‐CTA) in identifying carotid pseudo‐occlusion in a single‐center pilot study.