Andreas Terént

Sex Differences in Stroke Epidemiology : A Systematic Review

Background and Purpose— Epidemiological studies, mainly based on Western European surveys, have shown that stroke is more common in men than in women. In recent years, sex-specific data on stroke incidence, prevalence, subtypes, severity and case-fatality have become available from other parts of the world. The purpose of this article is to give a worldwide review on sex differences in stroke epidemiology. Methods— We searched PubMed, tables-of-contents, review articles, and reference lists for community-based studies including information on sex differences. In some areas, such as secular trends, ischemic subtypes and stroke severity, noncommunity-based studies were also reviewed. Male/female ratios were calculated. Results— We found 98 articles that contained relevant sex-specific information, including 59 incidence studies from 19 countries and 5 continents. The mean age at first-ever stroke was 68.6 years among men, and 72.9 years among women. Male stroke incidence rate was 33% higher and stroke prevalence was 41% higher than the female, with large variations between age bands and between populations. The incidence rates of brain infarction and intracerebral hemorrhage were higher among men, whereas the rate of subarachnoidal hemorrhage was higher among women, although this difference was not statistically significant. Stroke tended to be more severe in women, with a 1-month case fatality of 24.7% compared with 19.7% for men. Conclusions— Worldwide, stroke is more common among men, but women are more severely ill. The mismatch between the sexes is larger than previously described.

Sex Differences in Management and Outcome After Stroke A Swedish National Perspective

Background and Purpose— It is disputed whether there are sex differences in management and outcome after stroke; early studies have shown inconsistent results. The objective of this study was to verify and explain differences between men and women in management and outcome after stroke in a national perspective. Methods— In 2001, 20 761 stroke patients were registered in Riks-Stroke, the national quality register for stroke care in Sweden in which all 84 hospitals participate. Data from 9 hospitals that had reported <70% of the estimated stroke events were excluded from analyses, leaving 19 547 patients (9666 women, 9881 men) at 75 hospitals for the present analyses. Results— Women were older than men (77.8 versus 73.2 years). After age adjustment, female patients were more often disabled, living at home with community support, or in institutions before the stroke. They also had a different cardiovascular risk factor profile. Case fatality ratios during the first 3 months were similar in men and women. After 3 months, more women were physically and mentally impaired and dependent on other persons. Female patients with atrial fibrillation received oral anticoagulants less often than men. Even after multiple adjustments for differences between sexes, female sex was independently associated with institutional living 3 months after the stroke (odds ratio, 1.2; 95% confidence interval, 1.0 to 1.4). Conclusions— Women have a worse prestroke condition. Except for case fatality ratios, they also have a worse outcome after stroke after adjustment for other prognostic factors. There are also sex differences in the medical management of stroke that need to be rectified.

Expression of Vascular Endothelial Growth Factor (VEGF) and its Receptors (Flt-1 and Flk-1) following Permanent and Transient Occlusion of the Middle Cerebral Artery in the Rat

Vascular endothelial growth factor (VEGH) is a known endothelial mitogen and a potent enhancer of vascular permeability although its role in focal cerebral ischemia is still not completely understood. The present report describes the immunohistochemical distribution of VEGF and its 2 receptors, Flt-1 and Flk-1 at day 1 and 3 following permanent and transient middle cerebral artery occlusion (MCAO) in the rat. A bilateral increase in VEGF immunoreactivity, Particularly in neurons and blood vessels, was seen in both the experimental designs by day 1. By day 3, the immunoreactivity was restricted chiefly to the lesion side, where reaction was most prominent in the border zones of the infarcts. Immunoreaction to VEGF was more pronounced in cases of permanent MCAO than in transient MCAO.Flt-1 reaction was increased in neurons, gilal and endothelial cells after both transient and permanent MCAO. Immunoreactivity to Flk-1 was prominent in glial cells and was present to some extent in endothelial cells. These findings indicate an early upregulation of VEGF and its receptors after permanent as well as transient focal cerebral ischemia in the rat.

Epidemiology of Stroke in Innherred, Norway, 1994 to 1996 Incidence and 30-Day Case-Fatality Rate

BACKGROUND AND PURPOSE In Norway, as well as other industrialized countries, mortality from stroke has declined over the past decades. Data on stroke morbidity are lacking. This study was conducted to determine the incidence, case fatality, and risk factors of stroke in a defined Norwegian population. METHODS During the period 1994 to 1996, a population-based stroke registry collected uniform information about all cases of first-ever and recurrent stroke occurring in people aged > or = 15 years in the region of Innherred in the central part of Norway (target population 70,000), where the prevalence of cardiovascular risk factors was screened in 1984 to 1986 and 1995 to 1997. RESULTS During the 2 years of registration (September 1, 1994, to August 31, 1996), 432 first-ever (72.8%) and 161 recurrent (27.2%) strokes were registered. The crude annual incidence rate was 3.12/1000 (2.85/1000 for males and 3.38/1000 for females). Adjusted to the European population, the annual incidence rate of first-ever stroke was 2.21/1000. The annual incidence rate of cerebral infarction was 2.32/1000, intracerebral hemorrhage 0.32/1000, subarachnoid hemorrhage 0.19/1000, and unspecified stroke 0.38/1000. The 30-day case-fatality rate was 10.9% for cerebral infarction, 37.8% for intracerebral hemorrhage, and 50.0% for unspecified stroke. Fourteen percent of the patients were found outside the hospital, and only 50% of the suspected stroke cases in the hospital (at admission or reviewed discharge diagnosis of ICD-9 codes 430 to 438) fitted the final inclusion criteria. CONCLUSIONS This first population-based stroke register in Norway revealed incidence rates of stroke similar to other Scandinavian countries, and comparison between other European countries did not indicate regional variations within Western Europe.

Prevalence of disabling spasticity 1 year after first‐ever stroke

Objective:  To estimate the prevalence of disabling spasticity (DS) 1 year after first‐ever stroke.

Rapid Emergency Medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients

Objectives.  To evaluate the predictive accuracy of the scoring system Rapid Acute Physiology score (RAPS) in nonsurgical patients attending the emergency department (ED) regarding in‐hospital mortality and length of stay in hospital (LOS), and to investigate whether the predictive ability of RAPS could be improved by extending the system.

Cost of stroke in Sweden: An incidence estimate

OBJECTIVES: To estimate the excess cost of stroke in Sweden and the potential costs that could be avoided by preventing first-ever strokes.METHODS: We adopted the incidence approach for estimating ...

The Riks-Stroke story: building a sustainable national register for quality assessment of stroke care.

Background Riks-Stroke, the Swedish Stroke Register, is the worlds longest-running national stroke quality register (established in 1994) and includes all 76 hospitals in Sweden admitting acute stroke patients. The development and maintenance of this sustainable national register is described. Methods Riks-Stroke includes information on the quality of care during the acute phase, rehabilitation and secondary prevention of stroke, as well as data on community support. Riks-Stroke is unique among stroke quality registers in that patients are followed during the first year after stroke. The data collected describe processes, and medical and patient-reported outcome measurements. The register embraces most of the dimensions of health-care quality (evidence-based, safe, provided in time, distributed fairly and patient oriented). Result Annually, approximately 25 000 patients are included. In 2009, approximately 320 000 patients had been accumulated (mean age 76-years). The register is estimated to cover 82% of all stroke patients treated in Swedish hospitals. Among critical issues when building a national stroke quality register, the delicate balance between simplicity and comprehensiveness is emphasised. Future developments include direct transfer of data from digital medical records to Riks-Stroke and comprehensive strategies to use the information collected to rapidly implement new evidence-based techniques and to eliminate outdated methods in stroke care. Conclusions It is possible to establish a sustainable quality register for stroke at the national level covering all hospitals admitting acute stroke patients. Riks-Stroke is fulfilling its main goals to support continuous quality improvement of Swedish stroke services and serve as an instrument for following up national stroke guidelines.

Acupuncture and Transcutaneous Nerve Stimulation in Stroke Rehabilitation: A Randomized, Controlled Trial

Background and Purpose— In small trials with control groups that receive no intervention, acupuncture has been reported to improve functional outcome after stroke. We studied effects of acupuncture and transcutaneous electrical nerve stimulation on functional outcome and quality of life after stroke versus a control group that received subliminal electrostimulation. Methods— In a multicenter randomized controlled trial involving 7 university and district hospitals in Sweden, 150 patients with moderate or severe functional impairment were included. At days 5 to 10 after acute stroke, patients were randomized to 1 of 3 intervention groups: (a) acupuncture, including electroacupuncture; (b) sensory stimulation with high-intensity, low-frequency transcutaneous electrical nerve stimulation that induces muscle contractions; and (c) low-intensity (subliminal) high-frequency electrostimulation (control group). A total of 20 treatment sessions were performed over a 10-week period. Outcome variables included motor function, activities of daily living function, walking ability, social activities, and life satisfaction at 3-month and 1-year follow-up. Results— At baseline, patients in each group were closely similar in all important prognostic variables. At 3-month and 1-year follow-ups, no clinically important or statistically significant differences were observed between groups for any of the outcome variables. The 3 treatment modalities were all conducted without major adverse effects. Conclusions— When compared with a control group that received subliminal electrostimulation, treatment during the subacute phase of stroke with acupuncture or transcutaneous electrical nerve stimulation with muscle contractions had no beneficial effects on functional outcome or life satisfaction.

Predictors of Severe Stroke Influence of Preexisting Dementia and Cardiac Disorders

Background and Purpose— There is little research into the impact of prestroke dementia on stroke severity and short-term mortality. We included prestroke dementia, along with other risk factors, to determine independent predictors of stroke severity and early death in a community-based stroke study. Methods— All patients (n=377) with a first-ever stroke were evaluated in terms of risk factors. Registration took place over a 12-month period. Stroke severity was evaluated with the National Institutes of Health Stroke Scale. Predictors of severe stroke and early death were analyzed in logistic regression models. The following independent variables were used: age, sex, living alone, arterial hypertension, ischemic heart disease, heart failure, atrial fibrillation, diabetes mellitus, transient ischemic attack, cigarette smoking, peripheral atherosclerosis, and dementia. Results— Risk factors for stroke were found in 82% of the patients. Heart failure, atrial fibrillation, and dementia were associated with more severe strokes. Dementia, atrial fibrillation, heart failure, and living alone were associated with death within 28 days of the event. Conclusions— These results raise the question of whether certain high-risk patients, ie, patients with atrial fibrillation, heart failure, and dementia, can benefit from more aggressive primary and secondary stroke prevention measures.