Heikki Numminen

Depression After Stroke Results of the FINNSTROKE Study

BACKGROUND AND PURPOSE We compared the incidence and severity of depression at 3 and 12 months after stroke in patients and their chief caregivers (spouses, 63%; children, 37%) in four districts of Finland, two with and two without after-hospital-discharge interventional programs (outpatient rehabilitation and activities of the local divisions of the Finnish Heart Association [FHA]). A population-based stroke register was used, and factors influencing depression were analyzed. METHODS A stroke register of patients recruited over 2 years in four different districts (total population, 134804) in Finland; 594 first-ever strokes were registered. Becks Depression Inventory (BDI), with 10 as the cutoff point for depression, was applied to 321 of 423 survivors and 195 caregivers at 3 months and to 311 of 390 survivors and 184 caregivers at 12 months in the districts with and without interventional programs. RESULTS At 3 months, fewer patients in the districts with active programs (41%) were depressed than in the control districts (54%) (odds ratio, 0.59; 95% confidence interval, 0.37 to 0.94), and the difference was maintained at 12 months (42% versus 55%) (odds ratio, 0.55; 95% confidence interval, 0.34 to 0.88). Univariate risk factors for depression at 3 months were female sex and severe prognostic score at the onset of stroke (< or = 14 points) on the Scandinavian Stroke Scale (SSS). Only SSS prognostic score and age emerged as significant independent contributors to depression on both linear and logistic multivariate analyses. There was no significant difference in the depression rate of caregivers between districts with active programs (42%) and those without such programs (41%) at 3 months; at 12 months the results were the same (39% in districts with active programs versus 42% in those without such programs). However, at 12 months there were significantly more severely depressed caregivers in districts without active programs than in districts with such programs (P.036). Poor Rankin scale score (grades III through V) and severe SSS long-term score (< or = 42 points) at 3 months among the patients were associated with depression of the caregivers at 3 months in the univariate analysis. Poor Rankin Scale score of the patients was independently associated with the depression of their caregivers at 3 months on multivariate logistic regression analysis. CONCLUSIONS Depression was common among stroke survivors and among their caregivers at 3 months, and its rate did not decrease at 1-year follow-up. The lower depression rate in districts with active programs compared to those without supports the idea that outpatient rehabilitation and support provided by local divisions of the FHA may be an effective way of decreasing the rate of depression after stroke.

Cigarette smoking and alcohol consumption as risk factors for aneurysmal subarachnoid hemorrhage.

Background and Purpose Aneurysmal subarachnoid hemorrhage is a serious disease despite recent improvements in medical and surgical treatment. Hence, identification of modifiable risk factors for subarachnoid hemorrhage is important. Methods We compared the smoking and drinking habits of 278 consecutive patients with aneurysmal subarachnoid hemorrhage, aged 15–60 years (145 men and 133 women) with those of 314 hospitalized control patients (164 men and 150 women) who did not differ in regard to age, day of onset of symptoms, and acuteness of disease onset. Results Multiple logistic regression analysis showed that recent alcohol intake and smoking, but not hypertension, were significant independent risk factors for hemorrhage. After adjustment for age, hypertension, and smoking status, men who had consumed 1–40, 41–120, or >120 g of alcohol within the 24 hours preceding the onset of illness had a relative risk of hemorrhage of 0.3 (95% confidence interval [CI], 0.1–0.8), 2.5 (95% CI, 1.1–5.5), and 4.5 (95% CI, 1.5–12.9), respectively, compared with men who had consumed 0 g. Women who had consumed 1–40 or >40 g of alcohol had a risk of hemorrhage of 0.4 (95% CI, 0.2–0.8) and 6.4 (95% CI, 2.3–17.9), respectively, compared with women without use of alcohol. Heavily smoking (>20 cigarettes per day) men and currently smoking women had adjusted relative risks of hemorrhage of 7.3 (95% CI, 3.8–14.3) and 2.1 (95% CI, 1.2–3.6), respectively, compared with men who had never smoked and with women who were not current smokers. Higher levels of erythrocyte mean corpuscular volume in patients with subarachnoid hemorrhage than in control subjects supported the notion of different smoking and drinking habits. Conclusions Recent heavy alcohol intake and current smoking seem to be independent risk factors for aneurysmal subarachnoid hemorrhage.

Declining Incidence and Mortality Rates of Stroke in Finland From 1972 to 1991 Results of Three Population-Based Stroke Registers

BACKGROUND AND PURPOSE We aimed to determine trends in stroke incidence, mortality rates, case-fatality rates, and their relation in Finland. METHODS We compared the results of three population-based stroke registers that included first-ever strokes in people aged > or = 15 years. Two registers were kept in Espoo-Kauniainen, the first in 1972 to 1973 (EK 72-73) and the second in 1978 to 1980 (EK 78-80). The present register of the Finnish Heart Association (FHA 89-91) was kept in four districts in Finland in 1989 to 1991. RESULTS The age-adjusted incidence rates were 240.9, 174.4, and 191.6, and the 1-year mortality rates were 121.9, 77.0, and 65.3 in the EK 72-73, EK 78-80, and FHA 89-91 registers, respectively. The overall decline from 1972 to 1991 was 20% in the stroke incidence rate and 46% in the stroke mortality rate. One-month case-fatality rates decreased from 34.8% to 29.4% in the EK 72-73 and EK 78-80 registers and to 23.3% in the present register. CONCLUSIONS The decline in the stroke incidence rate during the 1970s stabilized during the late 1980s and early 1990s; however, the case-fatality rate is still decreasing. Their combined effects may explain the continuing decline in stroke mortality.

Two years of Finnish Telestroke Thrombolysis at spokes equal to that at the hub

Background: Official guidelines on stroke promote the use of telemedicine via bidirectional videoconferencing equipment, which provides a valid and reliable means of facilitating thrombolysis delivery to patients in distant or rural hospitals. Methods: The present prospective cohort study describes the characteristics and 3-month outcome of the thrombolysis patients treated in 5 community hospitals served by the Helsinki University Central Hospital (HUCH) in a telestroke network during 2007 to 2009. The characteristics and outcome of telestroke thrombolysis patients are compared with consecutive thrombolysis patients (n = 985) treated at HUCH. Results: A total of 106 consecutive telestroke consultations in 2 years led to IV thrombolysis in 61 patients (57.5%). The median NIH Stroke Scale score was 10 (range 3–26), onset to treatment time 120 minutes (interquartile range [IQR] 49), length of consultation 25 minutes (IQR 18) if the consultation led to thrombolysis and 15 minutes (IQR 10) if not (p = 0.032). The rate of symptomatic intracranial bleedings was 6.7% (4/60) according to the National Institute of Neurological Disorders and Stroke definition. Half (28/57) of the thrombolysis patients with complete follow-up data had a favorable outcome (modified Rankin Scale [mRS] 0–2) and a third (17/57) had an excellent recovery (mRS 0–1). Thus the patients treated with thrombolysis based on teleconsultation had similar outcome with those treated at HUCH (mRS 0–2: 49.1% vs 58.1%, p = 0.214 and mRS 0–1: 17/57 [29.4%] vs 352/957 [36.8%], p = 0.289). Conclusions: A special feature of the Finnish pilot is the high percentage of consultations leading to thrombolytic treatment with features and results very similar to on-site thrombolysis at the neurologic emergency room of HUCH.

The Effect of Acute Ingestion of a Large Dose of Alcohol on the Hemostatic System and Its Circadian Variation

BACKGROUND AND PURPOSE Heavy binge drinking may trigger the onset of embolic stroke and acute myocardial infarction, but the underlying mechanisms are unclear. The effects of binge drinking on the hemostatic system and its circadian variation have not been investigated. We investigated the effects of an acute intake of a large dose of alcohol (1.5 g/kg). METHODS Twelve healthy, nonsmoking men participated in sessions where they were served ethanol in fruit juice or served fruit juice alone and, lying in a supine position, were followed up for 12 to 24 hours. The treatments were randomized and separated from each other by a 1-week washout period. Blood and urine were collected for hemostatic measurements. RESULTS The urinary excretion of the platelet thromboxane A(2) metabolite 2, 3-dinor-thromboxane B(2) was significantly (P<0.05) greater during the night after an evening intake of alcohol than during the control night. A smaller increase was observed during the daytime after an intake of alcohol in the morning. The effects on the endothelial prostacyclin metabolite 2,3-dinor-6-ketoprostaglandin F(1alpha) excretion were negligible. A 7-fold increase in plasminogen activator inhibitor 1 activity was observed after both morning (P<0. 05) and evening (P<0.01) intakes of alcohol. CONCLUSIONS This is the first study to suggest that acute ingestion of a relatively large but tolerable dose of alcohol transiently enhances thromboxane-mediated platelet activation. The observations also demonstrate alcohol-induced changes in the normal circadian periodicity of the hemostatic system in subjects not accustomed to consumption of alcohol.

Recent Alcohol Consumption, Cigarette Smoking, and Cerebral Infarction in Young Adults

BACKGROUND AND PURPOSE The role of recent heavy drinking of alcohol as a risk factor for ischemic brain infarction is unclear. We investigated this problem in young adults, in whom even a thorough workup often fails to reveal any predisposing factor. METHODS This was a hospital-based case-control study comprising 75 consecutive subjects aged 16 to 40 years with first-ever ischemic brain infarction and 133 control subjects from the same hospital who were group-matched with the case patients for age, sex, day of the onset of symptoms, and acuteness of disease onset. RESULTS Multiple logistic regression analysis showed that alcohol intake exceeding 40 g of ethanol within the 24 hours preceding disease onset was a significant independent risk factor for brain infarction among both men (odds ratio [OR], 6.0; 95% confidence interval [CI], 1.8 to 20.3) and women (OR, 7.8; 95% CI, 1.0 to 60.8). Cigarette smoking was not found to be an independent risk factor in the model, whereas among men arterial hypertension was (OR, 6.2; 95% CI, 1.5 to 24.7). CONCLUSIONS We conclude that very recent alcohol drinking, particularly drinking for intoxication, may trigger the onset of brain infarction in young adults and that there might be a variety of mechanisms behind this effect.

Acute ethanol ingestion increases platelet reactivity: is there a relationship to stroke?

The effects of ethanol ingestion on ADP-induced platelet aggregation and associated thromboxane formation were studied in the platelet-rich plasma of 10 healthy male volunteers, each serving as his own control. Ethanol caused a transient decrease in threshold concentration of ADP to produce irreversible aggregation. Over a wide range of ADP total platelet aggregation was increased. In the presence of irreversible aggregation, formation of thromboxane B2 rose from 303 +/- 56 to 950 +/- 212 fmol per 10(7) platelets (p less than 0.01). The effects lasted as long as ethanol was present in blood, did not significantly correlate to blood ethanol levels and exhibited great individual variation. It remains to be proved, whether these observations could contribute to the increased risk of ischemic brain infarction associated with acute ethanol ingestion.

Alcohol intake and the risk of stroke.

Alcohol consumption has been reported to have both beneficial and harmful effects on the incidence of stroke. Different drinking habits may explain the diversity of the observations, but this is still unclear. We reviewed recent clinical and epidemiological studies to find out whether alcohol intake could increase or decrease the risk for stroke. By a systematic survey of literature published from 1989 to 1997, we identified 14 case–control studies addressing alcohol as a risk factor for haemorrhagic and ischaemic stroke morbidity and fulfilling the following criteria: the type of stroke was determined by a head computerised tomography scan on admission or at autopsy; and alcohol consumption was verified using structured questionnaires or by personal interviews. In some studies, adjustment for hypertension abolished the independent role of alcohol as a risk factor. On the other hand, the studies covering even recent alcohol intake showed in many cases that heavy drinking is an independent risk factor for most stroke subtypes, and that the risk may decrease relatively rapidly after the cessation of alcohol abuse. In some studies, regular light to moderate drinking seemed to be associated with a decreased risk for ischaemic stroke of atherothrombotic origin. In conclusion, recent heavy alcohol intake seems to be an independent risk factor for all major subtypes of stroke. The ultimate mechanisms leading to the increased risk are unclear. The significance of alcohol as a risk factor has been demonstrated in young subjects because they are more often heavy drinkers than the elderly. Several factors to explain the beneficial effect of light to moderate drinking have been proposed.

Decreased Severity of Brain Infarct Can in Part Explain the Decreasing Case Fatality Rate of Stroke

BACKGROUND AND PURPOSE Case fatality rates for stroke has declined in most Western industrialized countries during recent decades. One possible explanation for this is a decrease in the severity of stroke symptoms. We therefore sought evidence for a change in stroke severity and its relationship with case fatality rates. METHODS We compared the severity of symptoms among first-ever stroke patients in 2 population-based prospective stroke registers maintained during 1972 to 1973 and 1989 to 1991 in Finland. Patients who were evaluated by study assistants or the investigator during the first week after the onset of symptoms were included in the study, and their severity of symptoms was assessed with the use of comparable scales modified from the Scandinavian Stroke Scale. RESULTS A total of 244 and 594 patients were registered, and a portion of them (155 [63.5%] and 360 [60.6%]) were included in the analyses in the registers for Espoo-Kauniainen from 1972 to 1973 and for 4 separate districts in Finland from 1989 to 1991, respectively. The death rates during the first week among those who were not included did not differ between the registers. The severity of symptoms decreased significantly between the registers in both patients with brain infarct or intracerebral hemorrhage but not in those with subarachnoid hemorrhage. The severity of symptoms was an independent factor of case fatality at 1 month. CONCLUSIONS The severity of symptoms of brain infarcts has decreased and can in part explain the decreased case fatality rate of stroke in Finland. However, the change in patients with intracerebral hemorrhage may be overestimated due to undiagnosed intracerebral hemorrhages in the first register resulting from the lack of brain CT.

Symptomatic Intracranial Hemorrhage After Stroke Thrombolysis Comparison of Prediction Scores

Background and Purpose— Several prognostic scores have been developed to predict the risk of symptomatic intracranial hemorrhage (sICH) after ischemic stroke thrombolysis. We compared the performance of these scores in a multicenter cohort. Methods— We merged prospectively collected data of patients with consecutive ischemic stroke who received intravenous thrombolysis in 7 stroke centers. We identified and evaluated 6 scores that can provide an estimate of the risk of sICH in hyperacute settings: MSS (Multicenter Stroke Survey); HAT (Hemorrhage After Thrombolysis); SEDAN (blood sugar, early infarct signs, [hyper]dense cerebral artery sign, age, NIH Stroke Scale); GRASPS (glucose at presentation, race [Asian], age, sex [male], systolic blood pressure at presentation, and severity of stroke at presentation [NIH Stroke Scale]); SITS (Safe Implementation of Thrombolysis in Stroke); and SPAN (stroke prognostication using age and NIH Stroke Scale)-100 positive index. We included only patients with available variables for all scores. We calculated the area under the receiver operating characteristic curve (AUC-ROC) and also performed logistic regression and the Hosmer–Lemeshow test. Results— The final cohort comprised 3012 eligible patients, of whom 221 (7.3%) had sICH per National Institute of Neurological Disorders and Stroke, 141 (4.7%) per European Cooperative Acute Stroke Study II, and 86 (2.9%) per Safe Implementation of Thrombolysis in Stroke criteria. The performance of the scores assessed with AUC-ROC for predicting European Cooperative Acute Stroke Study II sICH was: MSS, 0.63 (95% confidence interval, 0.58–0.68); HAT, 0.65 (0.60–0.70); SEDAN, 0.70 (0.66–0.73); GRASPS, 0.67 (0.62–0.72); SITS, 0.64 (0.59–0.69); and SPAN-100 positive index, 0.56 (0.50–0.61). SEDAN had significantly higher AUC-ROC values compared with all other scores, except for GRASPS where the difference was nonsignificant. SPAN-100 performed significantly worse compared with other scores. The discriminative ranking of the scores was the same for the National Institute of Neurological Disorders and Stroke, and Safe Implementation of Thrombolysis in Stroke definitions, with SEDAN performing best, GRASPS second, and SPAN-100 worst. Conclusions— SPAN-100 had the worst predictive power, and SEDAN constantly the highest predictive power. However, none of the scores had better than moderate performance.