Brynjar Fure

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.

Early Post-Stroke Cognition in Stroke Rehabilitation Patients Predicts Functional Outcome at 13 Months

Objective: To identify prognostic factors associated with functional outcome at 13 months in a sample of stroke rehabilitation patients. Specifically, we hypothesized that cognitive functioning early after stroke would predict long-term functional outcome independently of other factors. Methods: 163 stroke rehabilitation patients underwent a structured neuropsychological examination 2–3 weeks after hospital admittance, and their functional status was subsequently evaluated 13 months later with the modified Rankin Scale (mRS) as outcome measure. Three predictive models were built using linear regression analyses: a biological model (sociodemographics, apolipoprotein E genotype, prestroke vascular factors, lesion characteristics and neurological stroke-related impairment); a functional model (pre- and early post-stroke cognitive functioning, personal and instrumental activities of daily living, ADL, and depressive symptoms), and a combined model (including significant variables, with p value <0.05, from the biological and functional models). Results: A combined model of 4 variables best predicted long-term functional outcome with explained variance of 49%: neurological impairment (National Institute of Health Stroke Scale; β = 0.402, p < 0.001), age (β = 0.233, p = 0.001), post-stroke cognitive functioning (Repeatable Battery of Neuropsychological Status, RBANS; β = –0.248, p = 0.001) and prestroke personal ADL (Barthel Index; β = –0.217, p = 0.002). Further linear regression analyses of which RBANS indexes and subtests best predicted long-term functional outcome showed that Coding (β = –0.484, p < 0.001) and Figure Copy (β = –0.233, p = 0.002) raw scores at baseline explained 42% of the variance in mRS scores at follow-up. Conclusions: Early post-stroke cognitive functioning as measured by the RBANS is a significant and independent predictor of long-term functional post-stroke outcome.

Association between ApoE ε4 and Cognitive Impairment after Stroke

Background and Purpose: The understanding of the contribution of genetic factors to cognitive impairment after stroke is incomplete. The aim of the study was to examine whether the apolipoprotein E ε4 allele (ApoE ε4) is a risk factor for cognitive impairment in the early phase after stroke. Methods: The sample comprised 152 Norwegian stroke rehabilitation inpatients (mean age 76.8 years, SD 10.5) examined at a mean of 18.3 days (SD 13.4) after hospital admission. Post-stroke cognitive impairment was assessed with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The following proposed risk factors were analysed: ApoE genotype, demographics (age, sex, education), pre-stroke cognitive reduction [Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)], pre-stroke vascular factors (including previous stroke), stroke characteristics (type, location), and neurological stroke-related impairment [National Institutes of Health Stroke Scale (NIHSS)]. Cognitive impairment was defined as an RBANS total index score ≤1.5 SD below the mean. Multiple logistic regression analyses were performed to find risk factors for post-stroke cognitive impairment. Results: Four variables were found to be independent risk factors for cognitive impairment after stroke: ApoE ε4 (OR = 3.7; 95% CI = 1.2–11.6), IQCODE score ≥3.44 (OR = 9.2; 95% = CI 2.3–37.2), total or partial anterior stroke syndromes (OR = 3.2; 95% CI = 1.3–8.0), and NIHSS total score >5 (OR = 7.3; 95% CI = 2.7–19.7). No association between ApoE ε4 and pre-stroke cognitive reduction (IQCODE) was found. Conclusions: The presence of one or two ApoE ε4 alleles may be a significant independent risk factor for cognitive impairment in the early phase after stroke.

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.

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.

Incidence and subtypes of MCI and dementia 1 year after first-ever stroke in patients without pre-existing cognitive impairment.

Background: Post-stroke dementia is defined as any dementia occurring after stroke, and includes vascular, degenerative and mixed dementia. The aim of this study was to assess the incidence of dementia and mild cognitive impairment (MCI) one year after stroke in a population free from pre-stroke cognitive decline, and to investigate the different aetiological subtypes of post-stroke dementia and MCI, using a novel method of subclassification in order to separate vascular causes of MCI or dementia from a neurodegenerative disease. Methods: All patients with a first-ever stroke and TIA admitted to the stroke unit of Asker and Bærum Hospital were invited. After 12 months, dementia and MCI were diagnosed. Sub-classification was made using MRI findings, the results of biomarkers in cerebrospinal fluid and the patients’ clinical cognitive profile. Results: 36 (19.6%) patients developed dementia during the first year after stroke and 69 (37.5%) developed MCI. Fourteen (13.3%) were diagnosed as suffering from degenerative cognitive disease, 34 (32.4%) from vascular cognitive disease, and 57 (54.3%) from mixed disease. Conclusion: Fifty-seven percent suffered from cognitive impairment one year after stroke and only one third from isolated vascular cognitive disease. Post-stroke cognitive impairment is complex with a high coexistence of vascular and degenerative changes.

Hospital managers’ need for information in decision-making – An interview study in nine European countries

Assessments of new health technologies in Europe are often made at the hospital level. However, the guidelines for health technology assessment (HTA), e.g. the EUnetHTA Core Model, are produced by national HTA organizations and focus on decision-making at the national level. This paper describes the results of an interview study with European hospital managers about their need for information when deciding about investments in new treatments. The study is part of the AdHopHTA project. Face-to-face, structured interviews were conducted with 53 hospital managers from nine European countries. The hospital managers identified the clinical, economic, safety and organizational aspects of new treatments as being the most relevant for decision-making. With regard to economic aspects, the hospital managers typically had a narrower focus on budget impact and reimbursement. In addition to the information included in traditional HTAs, hospital managers sometimes needed information on the political and strategic aspects of new treatments, in particular the relationship between the treatment and the strategic goals of the hospital. If further studies are able to verify our results, guidelines for hospital-based HTA should be altered to reflect the information needs of hospital managers when deciding about investments in new treatments.

Effect on anxiety and depression of a multifactorial risk factor intervention program after stroke and TIA: a randomized controlled trial

Objectives: Depression and anxiety related to stroke are caused by vascular lesions and psychological reactions. Treatment of vascular and modifiable behavioral risk factors reduces the risk of stroke and may also reduce the risk of emotional changes after stroke. We aimed to investigate whether a multifactorial risk factor intervention program in patients with first-ever stroke or transient ischemic attack (TIA) can influence post-stroke anxiety and depressive symptoms in patients one year post-stroke. Method: The study population consisted of first-ever stroke and TIA patients allocated in a randomized, evaluator-blinded, controlled trial to care as usual or a structured and multidisciplinary follow-up including intensive treatment of vascular risk. The primary endpoint (cognition) has previously been reported. The secondary endpoint, reported here, was changes in the Hospital Anxiety and Depression Scale (HADS) from baseline to 12-month follow-up. Results: One hundred and ninety-five patients were randomized. The estimated difference between treatment groups, in changes in HADS, from baseline to 12 months was −1.32 (95% confidence interval: −2.61, −0.04; P = 0.044) in favor of the intervention group. One year post-stroke, 4/85 (4.7%) patients in the intervention group and 12/89 (13.5%) in the control group suffered from depression (P = 0.045), while 7/85 (8.2%) patients in the intervention group and 13/89 (14.6%) patients in the control group suffered from anxiety (P = 0.19). Conclusion: A structured, multidisciplinary, multifactorial risk factor program including vascular risk factor management may be associated with reduced HADS scores and a lower prevalence of depressive symptoms one year after stroke.

Cognitive impairment and the role of the ApoE ε4-allele after stroke—a 13 months follow-up study

To examine the relationship between the ApoE ε4 allele and cognitive impairment 13 months after stroke.