Bente Thommessen

Electrocardiographic and troponin T changes in acute ischaemic stroke.

Background.  The mechanisms explaining morphological electrocardiogram (ECG) changes and increased troponin T (TnT) in acute stroke are unclear. The aims of the present study were to assess the prevalence of ECG and TnT changes in acute ischaemic stroke, to investigate whether ischaemic‐like ECG changes correlate to a rise in TnT and to examine whether ECG changes and elevated TnT predict a poor short‐time outcome.

Well-being and instrumental activities of daily living after stroke

Objective: To explore the relationship between subjective well-being and competence in instrumental activities of daily living after stroke. Design: Cross-sectional with evaluation at six months post stroke. Subjects: Eighty-two patients admitted to an acute stroke unit, of whom 64 were seen at six months. The mean age was 77.5 years, 55% were females and 55% were living alone. Main outcome measures: The General Health Questionnaire (GHQ-20 version), a well-being scale, was factor analysed and yielded three dimensions, named ‘coping’, ‘anxiety’ and ‘satisfaction’ that served as main outcomes. Results: Explanatory variables were the four subscales of the Nottingham IADL scale, the Ullevaal Aphasia Screening test, urinary continence and demographics. Structural equation modelling showed that the GHQ dimension ‘satisfaction’ related significantly to the Nottingham subscale ‘leisure activities’ (β = -0.38, p= 0.01), whereas ‘coping’ was indirectly associated with ‘leisure activities’ by its correlation with ‘satisfaction’ (R= 0.26, p= 0.01). None of the outcomes were statistically associated with aphasia, continence or the background variables. Conclusion: ‘Leisure activities’ demonstrated the strongest association to subjective well-being as expressed by the ‘satisfaction’ dimension. In stroke rehabilitation leisure activities should be addressed when assessing function and planning intervention.

Predictors of outcome of rehabilitation of elderly stroke patients in a geriatric ward

Purpose: To identify predictors of outcome after 12 months in elderly stroke patients rehabilitated in a geriatric ward. Design: Prospective with evaluation in the subacute phase and after 12 months. Setting: Geriatric ward and outpatient clinic. Subjects: All stroke patients admitted from the acute unit to a geriatric ward for rehabilitation during a 16-month period (n = 171). Main outcome measures: Place of living, mortality and social functioning (Frenchay Activities Index) 12 months following stroke. Results: Age, urinary incontinence and cognitive function were significantly associated with place of living (home versus nursing home) 12 months post stroke in bivariate analyses. However, using multivariate logistic regression analyses, only age (p = 0.005) and urinary incontinence at baseline (p = 0.028) remained independent predictors of place of living. Mortality during the first year was significantly predicted by urinary incontinence and gender (men doing worse), whereas the Barthel Activities of Daily Living (ADL) Index sumscore was the only significant independent predictor of social activities. Conclusion: Urinary incontinence at baseline seems to be a most important predictor of outcome 12 months post stroke in geriatric patients. However, with regard to social activities (Frenchay Activities Index), functional impairment in the initial phase as reflected by the Barthel ADL Index supersedes other predictors.

Acute phase predictors of subsequent psychosocial burden in carers of elderly stroke patients.

The objective was to describe the psychosocial burden experienced by informal carers of elderly stroke victims, and to identify its predictors among baseline characteristics of the patients. From a prospective study of 171 elderly stroke patients admitted to a geriatric ward for rehabilitation in the acute phase, 68 patients living at home with a primary caregiver were identified 6 months after the stroke. At baseline, all the patients were assessed with respect to motor function, cognitive function, global handicap and activities of daily living, and after 6 months the caregivers were assessed, using the Relatives’ Stress Scale. According to this, the most frequent impacts were worries that an accident might befall their relatives, that they had to reorganise their household routines and further, that their social life and ability to take holidays had been reduced. Impaired cognitive function was the only baseline patient characteristic that predicted a subsequent psychosocial burden on the carer. Special attention should be paid to elderly stroke patients initially assessed with impaired cognitive function and their caregivers.

Outcome After Mobilization Within 24 Hours of Acute Stroke A Randomized Controlled Trial

Background and Purpose— Very early mobilization (VEM) is considered to contribute to the beneficial effects of stroke units, but there are uncertainties regarding the optimal time to start mobilization. We hypothesized that VEM within 24 hours after admittance to the hospital would reduce poor outcome 3 months poststroke compared with mobilization between 24 and 48 hours. Methods— We conducted a prospective, randomized, controlled trial with blinded assessment at follow-up. Patients admitted to the stroke unit within 24 hours after stroke were assigned to either VEM within 24 hours of admittance or mobilization between 24 and 48 hours (control group). Primary outcome was the proportion of poor outcome (modified Rankin scale score, 3–6), whereas secondary outcomes were death rate, change in neurological impairment (National Institutes of Health Stroke Scale score), and dependency (Barthel Index 0–17). Results— Fifty-six patients were included (mean age±SD, 76.9±9.4 years), 27 were in the VEM group and 29 were in the control group. VEM patients had nonsignificant higher odds (adjusted for age and National Institutes of Health Stroke Scale score on admission) of poor outcome (OR, 2.70; 95% CI, 0.78–9.34; P=0.12), death (OR, 5.26; 95% CI, 0.84–32.88; P=0.08), and dependency (OR, 1.25; 95% CI, 0.36–4.34; P=0.73). The control group, having milder strokes (National Institutes of Health Stroke Scale score±SD: control group, 7.5±4.2; VEM, 9.2±6.5; P=0.26), had better neurological improvement (P=0.02). Conclusions— We identified a trend toward increased poor outcome, death rate, and dependency among patients mobilized within 24 hours after hospitalization, and an improvement in neurological functioning in favor of patients mobilized between 24 and 48 hours. Very early or delayed mobilization after acute stroke is still undergoing debate, and results from ongoing larger trials are required.

Prehospital delay in acute stroke and TIA

Background Early management improves outcome in acute stroke. This study was designed to assess the prehospital path from symptom onset to arrival in hospital and to identify factors associated with prehospital delay. Methods A prospective study was conducted including patients with acute ischaemic stroke, intracerebral haemorrhage and transient ischaemic attack admitted to hospital. Time intervals for prehospital delay, background data, severity, type of first medical contact and mode of transport were recorded. Univariate and multivariate analyses were performed to identify factors influencing prehospital delay. Results A total of 440 patients were included, with a mean age of 71.4±13.0 years (44.3% female subjects), consisting of 65.9% patients with ischaemic stroke, 11.4% with intracerebral haemorrhage and 22.7% with transient ischaemic attack. The median time from symptom onset to admission was 3.0 h (179 min; IQR 77–542). The median decision delay was 1.5 h (92 min, IQR 25–405) and accounted for 55.1% (median value) of the prehospital delay. 310 (70.5%) patients arrived by ambulance. In the multivariate linear regression analysis, high National Institute of Health Stroke Scale score (p<0.001), transport by ambulance (p<0.001) and lower age (p=0.048) were significantly associated with early admission. Conclusions Severe strokes, use of ambulance and lower age are associated with reduced prehospital delay. The present study shows that more than half of the delay is caused by the hesitation to contact medical services. Public information campaigns should focus on fast symptom recognition and the importance of immediately contacting the Emergency Medical Services upon symptom onset.

TOAST criteria applied in acute ischemic stroke

Background –  Etiological subclassification of ischemic stroke has become increasingly important, as new therapeutic agents have been introduced. The aim of this study was to assess the inter‐rater reliability of the TOAST classification applied in the acute setting, and further to evaluate the criterion validity of the TOAST classification in discriminating between small vessel disease and other etiologies.

Validity of the Aphasia Item from the Scandinavian Stroke Scale

We studied the validity of the aphasia item of a widely used stroke scale – the Scandinavian Stroke Scale (SSS) – in discriminating between aphasia and normal language function in 33 stroke patients of an acute stroke unit. They were assessed by a nurse using the aphasia item from the SSS and by a speech and language therapist carrying out a full evaluation of the language function. The latter served as the ‘gold standard’. The agreement between the nurses’ and the speech and language therapist’s scoring was good (weighted kappa = 0.74, 95% CI 0.51–0.97), and the sensitivity and specificity of the SSS aphasia item were also satisfactory. However, the predictive value of a positive test was as low as 0.55 (95% CI 0.23–0.83), indicating nearly every second of the positives being false positive. Using the aphasia score of the SSS as a diagnostic aid for aphasia after stroke results in a high rate of false positives and inflates the prevalence figures for aphasia in epidemiological studies of stroke.

Cognitive impairments in acute lacunar stroke.

Background –  The present study investigated the prevalence of cognitive deficits in acute lacunar stroke, validated the Mini Mental State Examination (MMSE) in detecting cognitive impairments in lacunar patients, and identified predictors of such deficits.

Multifactorial Vascular Risk Factor Intervention to Prevent Cognitive Impairment after Stroke and TIA: A 12-month Randomized Controlled Trial

Objectives Vascular risk factor control may not only prevent stroke but also reduce the risk of dementia. We investigated whether a multifactorial intervention program reduces the incidence of cognitive symptoms one-year after stroke and transient ischemic attack in first ever stroke patients without cognitive decline prior to the stroke. Materials and methods Patients suffering their first ever stroke were included in this randomized, evaluator-blinded, controlled trial with two parallel groups. Baseline examination included extensive assessment of exposure to vascular risk factors and cognitive assessments regarding memory, attention, and executive function. After discharge, patients were allocated to either intensive vascular risk factor intervention or care as usual. The primary end points were changes in trail-making test A and 10-word test from baseline to 12 months follow-up. Results One hundred ninety-five patients were randomized. The difference between groups in trail-making test A, adjusted for baseline measurements, was 3·8 s (95% confidence interval: −4·2 to 11·9; P = 0·35) in favor of the intervention group. The difference between groups in the 10-word recall test was 1·1 words (95% confidence interval: −0·5 to 2·7; P = 0·17) in favor of the intervention group. We did not observe any differences in the secondary outcomes of incident dementia or mild cognitive impairment. Conclusions We could not demonstrate cognitive effects of an intensive risk factor intervention at one-year poststroke. Longer follow-up and a more heterogeneous study sample might have lead to larger effects. More effective methods for managing the risk of further cognitive decline after stroke are needed.