G V Osseby

Ischaemic stroke subtypes and associated risk factors: a French population based study

Background: There is little reliable population based information about the distribution of risk factors among the various ischaemic stroke subtypes, even though determining risk factor profiles is of major importance to develop targeted preventive strategies. Methods: The distribution of first ever ischaemic stroke subtypes was established in a prospective population based study conducted in Dijon, France (152u2009606 inhabitants). Cases were collected between January 2005 and December 2006, and were classified using TOAST classification. Vascular risk factors were recorded to determine a risk factor profile for each subtype. Results: 332 patients with first ever ischaemic stroke (150 men and 182 women) were recorded. Adjusted incidence to world population was 54/100u2009000/year. The distribution of ischaemic stroke subtypes was as follows: 119 (35.8%) cases of large artery atherosclerosis, 89 (26.8%) small artery occlusions, 81 (24.4%) cardioembolisms and 43 (13%) other and undetermined causes. The most frequent vascular risk factor was hypertension, irrespective of the ischaemic stroke subtype, with a total prevalence of 62%. Using multivariate regression, a positive association between cardioembolism and age (OR 1.051; 95% CI 1.026 to 1.076; p<0.001) was demonstrated and between small artery occlusion and either high blood pressure (OR 1.86; 95% CI 1.06 to 3.27; pu200a=u200a0.03) or hypercholesterolaemia (OR 2.23; 95% CI 1.33 to 3.76; pu200a=u200a0.02). Conclusion: This comprehensive prospective population based study has demonstrated that vascular risk factors exhibit a particular distribution according to the ischaemic stroke subtypes. These findings, as well as the great frequency of hypertension among stroke patients, have implications for prevention strategies, the design of clinical trials and the organisation of health care services.

Stroke in the Very Old: Incidence, Risk Factors, Clinical Features, Outcomes and Access to Resources – A 22-Year Population-Based Study

Background: For several years, the burden of stroke in very old patients has been increasing in western countries. Nevertheless, we have little information about this new challenge in individuals ≧80. Methods: We ascertained all first-ever strokes in the population of Dijon, France (150,000 inhabitants), from 1985 to 2006. The incidence of stroke, risk factors, clinical presentation, resource mobilization and 1-month outcome were evaluated in individuals ≧80 and compared to the data obtained in younger patients. Results: We collected 1,410 first-ever strokes in people ≧80 years (39%) versus 2,130 in those <80 years. The incidence was 997/100,000, and 68/100,000, respectively. Over the 22 years, the incidence of stroke in individuals ≧80 years rose significantly. A lower prevalence of diabetes, hypercholesterolemia and alcohol intake, as well as a higher prevalence of hypertension, atrial fibrillation, previous myocardial infarction and use of prestroke antiplatelet agents were noted in patients ≧80 years. The clinical presentation was severer and the 1-month outcome in terms of case fatality and handicap was worse, despite improvements observed over time. Finally, in patients ≧80 years, the use of CT scan, MRI, cervical Doppler, angiography and carotid surgery were significantly lower than for younger patients. Length of stay >30 days was more frequent, and discharge to prestroke residence was less common. However, all these improved between the first and the last study periods. Conclusions: Our findings have important implications not only for clinical management but also for initiating preventive strategies and health policy.

Epidemiology of ischemic stroke from atrial fibrillation in Dijon, France, from 1985 to 2006

Background: Atrial fibrillation (AF) is strongly associated with age, and epidemiologic studies are needed to evaluate the impact of both aging of the population and the use of anticoagulant therapy in patients with AF on the incidence of cardioembolic stroke with AF (CE/AF stroke). Methods: We evaluated trends in incidence rates, risk factors, prestroke therapy, and survival in CE/AF stroke from a prospective population-based registry, from 1985 to 2006. Results: A total of 3,064 ischemic strokes, including 572 (18.7%) CE/AF strokes, were recorded. Over the 22 years, a decrease in the incidence of overall CE/AF stroke was noted (incidence rate ratio 0.9858, 95% confidence interval [CI] 0.9731–0.9986; p = 0.03). We observed a higher prevalence of previous AF, previous myocardial infarction, and patients aged >70 years in CE/AF stroke (p < 0.0001) whereas hypercholesterolemia was more prevalent in other ischemic strokes (p = 0.003). A significant increase in the use of anticoagulants and antiplatelet agents was noted, and was particularly pronounced for CE/AF stroke with previous AF. For CE/AF stroke, survival rates were 72% at 1 month (95% CI 0.68–0.76), 52% at 1 year (95% CI 0.48–0.56), and 43% at 2 years (95% CI 0.39–0.48), and remained lower than those of other ischemic stroke. Conclusions: The decrease in the incidence of cardioembolic/atrial fibrillation stroke in our study was probably due to a slight increase in the utilization of antithrombotic therapy in patients with atrial fibrillation, but the use of such therapies will have to increase further because of the expected aging of the population in coming years. AF = atrial fibrillation; CE = cardioembolic; CI = confidence interval; IRR = incidence rate ratios.

The Deleterious Effect of Admission Hyperglycemia on Survival and Functional Outcome in Patients With Intracerebral Hemorrhage

Background and Purpose— We aimed to evaluate the association between blood glucose (BG) levels at admission and both functional outcome at discharge and 1-month mortality after intracerebral hemorrhage (ICH). Methods— All cases of first-ever ICH were identified from the population-based Stroke Registry of Dijon, France from 1985 to 2009. Clinical and radiological information was recorded. BG was measured at admission. Multivariate analyses were performed using logistic and Cox regression models. Multiple imputation was used as a sensitivity analysis. Results— We recorded 465 first-ever ICH. BG at admission was obtained in 416 patients (89.5%) with a median value of 6.92 mmol/L. In multivariate analyses, BG in the highest tertile (≥8.6 mmol/L) was an independent predictor of functional handicap (odds ratio, 2.51; 95% CI, 1.43–4.40; P=0.01) and 1-month mortality (hazard ratio, 2.51; 95% CI, 1.23–2.43; P=0.002). The results were consistent with those obtained from multiple imputation analyses. Conclusions— Admission hyperglycemia is associated with poor functional recovery at discharge and 1-month mortality after ICH. These results suggest a need for trials that evaluate strategies to lower BG in acute ICH.

Trends in the Incidence of Transient Ischemic Attacks, Premorbid Risk Factors and the Use of Preventive Treatments in the Population of Dijon, France from 1985 to 2004

Background: We describe the epidemiological trends of transient ischemic attack (TIA) in a 20-year population-based pilot study. Methods: Trends in the incidence, risk factors and pre-TIA use of preventive treatments for TIA were observed from 1985 to 2004 according to the classic definition in the population of the city of Dijon, France (150,000 inhabitants). Results: The raw and standardized incidence of TIA were stable over time. We observed a significant increase in the mean age at TIA onset in women only. The prevalence of hypercholesterolemia and diastolic blood pressure ≧90 mm Hg among patients with TIA increased significantly. This contrasts with falls in smoking and in history of previous myocardial infarction. Conclusion: The stability of classic TIA incidence, despite the rise in the proportion of elderly people, and the increase in the mean age at onset in women may be considered as a medical progress.

Trends in case-fatality rates in hospitalized nontraumatic subarachnoid hemorrhage: results of a population-based study in Dijon, France, from 1985 to 2006.

BACKGROUNDSubarachnoid hemorrhage accounts for 2% to 5% of all strokes and is associated with high morbidity and mortality rates. Reports in the literature show that case-fatality rates vary with time and according to geographical area. OBJECTIVEThe objective of the study was to evaluate the case-fatality rates in subarachnoid hemorrhage at 1 and 6 months and to determine trends in these rates over 22 years using a population-based registry. METHODSThe Dijon Stroke Registry has enabled us to perform a comprehensive analysis of subarachnoid hemorrhage diagnosed in a population of >150 000 inhabitants hospitalized between 1985 and 2006 in the Dijon University Hospital, which has both a neurosurgery unit and a neuroradiology unit. Diagnosis was based on clinical and neuroimaging features and, when necessary, on lumbar puncture. RESULTSCase-fatality rates for hospitalized subarachnoid hemorrhages at 1 and 6 months were 15.59% (95% confidence interval [CI], 9.37–25.34) and 16.84% (95% CI, 10.33–26.78), respectively. From 1985 to 1995, case-fatality rates for SAH at 1 and 6 months were 17.1% (95% CI, 8.1–34.2) and 17.7% (95% CI, 9.6–31.3), whereas from 1996 to 2006, they were 20.2% (95% CI, 10.2–37.8) and 19.7% (95% CI, 11.1–33.6), respectively. CONCLUSIONCase-fatality rates for hospitalized subarachnoid hemorrhages in this population-based study remained stable over 22 years, suggesting that this stroke subtype is still a very severe disease despite early management. Most deaths occurred during the first 30 days. Further work is necessary to evaluate levels of prehospital case-fatality in our population-based registry.

Dissémination leptoméningée après chirurgie d’un adénocarcinome de l’ethmoïde

INTRODUCTIONnAlthough rare, adenocarcinoma is the most frequent neoplasm of the ethmoid sinus and must be regarded as an occupational disease secondary to chronic wood dust exposure. Few cases with neurological metastasis have been reported.nnnCASE REPORTnWe report the cases of two patients who developed a multiple cranial nerve disorder for the first case and a cauda equina syndrome for the second, after ethmoid adenocarcinoma surgery.nnnCONCLUSIONnDiagnosis of carcinomatous meningitis is difficult and is based on clinical data, CSF analysis and gadolinium-enhanced T1-weighted brain and spinal cord MRI. The implication of surgery is discussed. Prognosis of such a disorder is poor.

Bilateral optic neuropathy revealing Sjögren's syndrome.

INTRODUCTIONnThe central nervous system involvement has been reported in 20% of cases of primary Sjogrëns syndrome (SS), a chronic autoimmune disease characterized by a disorder of the exocrine glands secondary to progressive lymphocyte infiltration. Classically described neurological manifestations include sensorimotor deficits, aseptic meningitis or meningoencephalitis, multiple sclerosis-like syndromes and myeolopathies.nnnOBSERVATIONnWe report here the case of a 53-year-old woman who exhibited rapidly progressive visual loss, disclosing bilateral optic neuropathy, as an uncommon initial symptom of primary SS. Examination of CSF revealed associated aseptic meningitis. Because of the lack of efficacy of the first treatment by intravenous corticosteroids, monthly intravenous cyclophosphamide was quickly introduced. After six months, significant visual recovery was observed.nnnCONCLUSIONnOptic neuropathies have been rarely reported as the initial symptom revealing primary Sjogrën syndrome, and bilateral simultaneous lesions remain exceptional.

NeuroépidémiologieLes accidents vasculaires cérébraux : ce qui a changé au début du xxie siècleWhat has changed for stroke at the beginning of the 21st century

INTRODUCTIONnStriking developments in stroke epidemiology, initially based on the results of the Framingham study, have greatly improved our neuroepidemiological knowledge of the disease.nnnSTATE OF ARTnThe development of stroke registries has made it possible to evaluate the descriptive epidemiology of stroke and its evolution. With the increasing use of CT-scan, MRI, and either cardiac or vascular imaging, the diagnosis of stroke and its subtypes has been made easier. Over the last 20 years, a decrease in the incidence and mortality of stroke has been observed in Western countries. In contrast, in Dijon, which has the only population-based stroke registry in France, stable incidence rates have been reported. However, over the same period, age at stroke onset has risen by five years in men and eight years in women, which is probably related to both population aging and improvements in primary prevention and general health. The reported decrease in case-fatality rates suggests better acute management of stroke patients, and explains in part the increase in the prevalence of stroke. In addition, the assessment of vascular risk factors has demonstrated that high blood pressure remains the principal risk factor for both ischemic and hemorrhagic stroke, and that antihypertensive treatment is able to reduce stroke incidence.nnnPERSPECTIVESnEpidemiology studies could make it possible to measure the impact of new therapeutic strategies applied in both primary and secondary prevention.nnnCONCLUSIONnPrevention, diagnosis, and acute treatment of stroke have considerably improved, but cerebrovascular diseases together with myocardial infarction remain the leading cause of death. Despite the absence of a rise in the incidence of stroke, its prevalence has increased. This is due to the decrease in case-fatality rates. As a consequence, there is an urgent need to organize health networks around stroke. Moreover, the rise in stroke-free life expectancy is a positive finding that reflects improvements in prevention.

Réunion commune de la SFN et de la SFNV 8–10 octobre 2008Les accidents vasculaires cérébraux du sujet âgé : ce que nous a appris l’épidémiologie du sujet jeuneStroke in elderly: What have we learned from stroke epidemiology in younger people

Stroke in the elderly has more major differences compared to young people: it is the first complication of atherothrombosis disease associated with the following risk factors: hypertension, diabetes, hypercholesterolemia, tobacco consumption and sleep apnea syndrome; AVC is the first consequence of atrial fibrillation; from a clinical point of view, seizure at the onset of the stroke is more frequent; prognosis is characterized by a high risk of dementia (20%); primary and secondary prevention is very efficacious even in very old patients, not only on the risk of stroke, but also on the risk of dementia; time trends at Dijon show a slight decrease of incidence rates of stroke only over 85 years, while prevention of stroke has taken advantage of real progress in precocious diagnosis and innovative treatments. In contrast, we observed a decrease of case-fatality rates at any day with a delay in age of onset of stroke, reaching five years in men and eight years in women, suggesting an increase of life expectancy without stroke, reflecting a certain efficacy of prevention.