Heikki Palomäki

SNORING AND CEREBRAL INFARCTION

The association of snoring with cerebral infarction was tested in a case-control study of 50 male patients with cerebral infarction and 100 male patients with other disorders. Cerebral infarction was significantly associated with habitual (almost always or always) snoring; the risk ratio of cerebral infarction between those who did and did not snore habitually was 10.3 (95% confidence limits 3.5-30.1). The corresponding risk ratio was 2.8 (95% CL 1.3-5.8) for snoring often, almost always, or always compared with snoring occasionally or never, but the association was still significant. The association was also found when age and body mass index were taken into account.

Poststroke Depression: An 18-Month Follow-Up

Background and Purpose— This prospective study was designed to examine the course, associates, and predictors of depressive symptoms during the first 18 months after stroke. Methods— A total of 100 patients were followed up for 18 months after stroke. Depressive symptoms were assessed at 2 weeks and 2, 6, 12, and 18 months after stroke with the Beck Depression Inventory and the Hamilton Rating Scale for Depression, and diagnoses were performed using criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised. Stroke severity was assessed with the Scandinavian Stroke Scale and cognitive functions with a comprehensive neuropsychological battery. Patients participated in a randomized clinical trial of antidepressive medication. Results— In all, 54% of patients felt at least mildly depressive at some time during the follow-up; 46% of those who were depressive during the first 2 months were also depressive at 12 and/or 18 months. Only 12% of patients were depressive for the first time at 12 or 18 months. The male sex was associated with a more negative change in depressive symptoms during the follow-up. Older age was associated with depressive symptoms during the first 2 months, stroke severity from 6 to 12 months, and the male sex at 18 months. Depressive symptoms were unrelated to the lesion location. Conclusions— Depressive symptoms are frequent and they often have a chronic course. Depression is associated with stroke severity and functional impairment, and with the male sex at 18 months. Attention should be focused on the long-term prognosis of mood disturbances and adaptation.

Snoring and the risk of ischemic brain infarction.

To determine if a history of snoring is a risk factor for brain infarction, I conducted a case-control study of risk factors for ischemic stroke using 177 consecutive male patients aged 16-60 (mean 49) years with acute brain infarction. For each patient I chose an age-matched (+/- 6 years) male control. Arterial hypertension, coronary heart disease, snoring (habitually or often), and heavy drinking (greater than 300 g/wk) were risk factors in the stepwise multiple logistic regression analysis. The odds ratio of snoring for brain infarction was 2.13. By McNemars test this association increased strongly if a history of sleep apnea, excessive daytime sleepiness, and obesity were all present with snoring (odds ratio 8.00). My study indicates that snoring may be a risk factor for ischemic stroke, possibly because of the higher prevalence of an obstructive sleep apnea syndrome among snorers than nonsnorers.

Where and How Should Elderly Stroke Patients Be Treated? A Randomized Trial

BACKGROUND AND PURPOSE Elderly stroke patients in particular are at risk of receiving less than optimal care. We studied the effects of the department care (medicine versus neurology) on the outcome of elderly stroke patients in a randomized controlled trial with 1-year follow-up. METHODS A total of 243 consecutive patients aged 65 years or older with acute stroke were randomized to receive care in the Departments of Medicine or the Department of Neurology of a university teaching hospital with a referral area of 1.1 million. The outcome was assessed by mortality, length of hospital stay, ability to live at home on discharge, Barthel Index, and Rankin grades at 1 year. RESULTS There were no differences in sex and age, severity or type of stroke, other diseases, or social factors between the two groups. One-year mortality was 21% in both patients treated by the Departments of Medicine and those treated by the Department of Neurology. Patients treated by the Department of Neurology were discharged an average of 16 days earlier (24 versus 40 days). The length of hospital stay of patients aged younger than 75 years differed significantly (P = .02). Patients randomized to neurological wards more often went directly home (75% versus 62%; P = .03), and their functional status was better as assessed with Barthel Index and Rankin grades at 1 year (P = .02 and P = .03, respectively). Independent predictors of a better functional outcome and shorter hospital stay by stepwise multivariate analysis included management by the Department of Neurology. CONCLUSIONS Well-organized management of elderly stroke patients was associated with a better outcome. It was also the more economical alternative.

Risk Factors for Spontaneous Intracerebral Hemorrhage

BACKGROUND AND PURPOSE Spontaneous intracerebral hemorrhage has remained a serious disease despite recent improvements in medical treatment. This study was designed to identify modifiable risk factors for intracerebral hemorrhage. METHODS Health habits, previous diseases, and medication of 156 consecutive patients with intracerebral hemorrhage aged 16 to 60 years (96 men and 60 women) were compared with those of 332 hospitalized control patients (192 men and 140 women) who did not differ from case subjects in respect to age, day of onset of symptoms, or acuteness of disease onset. RESULTS After adjustment for sex, age, hypertension, body mass index, smoking status, and alcohol consumption during the last week, patients who had consumed 1 to 40, 41 to 120, or > 120 g of alcohol within the 24 hours preceding the onset of illness had a relative risk (95% confidence interval) of hemorrhage of 0.3 (0.2 to 0.7), 4.6 (2.2 to 9.4), and 11.3 (3.0 to 42.8), respectively, compared with those who had consumed 0 g. In addition, alcohol intake within 1 week before the onset of illness, excluding use within the last 24 hours, increased the risk of hemorrhage; adjusted risks were 2.0 (1.1 to 3.5) for 1 to 150 g, 4.3 (1.6 to 11.7) for 151 to 300 g, and 6.5 (2.4 to 17.7) for > 300 g compared with 0 g. The adjusted risk of hypertension for hemorrhage was 6.6 (3.9 to 11.3). Previous heavy alcohol consumption and current cigarette smoking were not independent risk factors for hemorrhage, but anticoagulant treatment was (P < .01). Erythrocyte mean corpuscular volume and gamma-glutamyl transferase values were also higher in patients with intracerebral hemorrhage than in control subjects. CONCLUSIONS Recent moderate and heavy alcohol intake as well as hypertension and likely also anticoagulant treatment seem to be independent risk factors for intracerebral hemorrhage.

Depression Among Caregivers of Stroke Survivors

Background and Purpose— We aimed to assess the prevalence of depressive symptoms among caregivers of stroke survivors and to determine which patient- or stroke-related factors are associated with and can be used to predict caregiver depression during an 18-month follow-up after stroke. Methods— We examined 98 caregivers of 100 consecutive patients experiencing their first ischemic stroke in Helsinki University Central Hospital. The caregivers were interviewed at the acute phase and at 6 months and 18 months. Depression was assessed with the Beck Depression Inventory. The neurological, functional, cognitive, and emotional status of the patients was assessed 5× during the follow-up with a comprehensive test battery. Results— A total of 30% to 33% of all caregivers were depressed during the follow-up; the rates were higher than those of the patients. At the acute phase, caregiver depression was associated with stroke severity and older age of the patient, and at 18 months the older age of the patient was associated with depression of the spouses. In later follow-up, caregiver depression was best predicted by the caregiver’s depression at acute phase. Conclusions— Identifying those caregivers at highest risk for poor emotional outcome in follow-up requires not only assessment of patient-related factors but also interview of the caregiver during the early poststroke period.

A randomized, double-blind, placebo-controlled trial of nimodipine in acute ischemic hemispheric stroke.

Background and Purpose A randomized, double‐blind, placebo‐controlled multicenter trial was conducted to test the hypothesis that nimodipine would improve the functional outcome in acute ischemic hemispheric stroke. Methods A total of 350 patients were randomized to nimodipine 120 mg/d PO or matching placebo for 21 days. Randomization was stratified by onset of therapy, age, and stroke severity. Treatment was begun within 48 hours of onset. The patients had neurological evaluation on admission, on days 1, 7, and 21, and at 3 and 12 months. The primary end points were Rankin grade, neurological score, and mobility at 12 months. Results We did not find any differences in the functional outcome between the treatment groups or between the stratified subgroups. We were also unable in post hoc analyses to find any groups of patients who benefited from nimodipine. During the first month and at 3 months the case‐fatality rate was higher in the nimodipine‐treated patients than in those on placebo (P=.004 and P=.030, respectively), but at the 1‐year follow‐up this difference had lost statistical significance. During the first week nimodipine had a statistically significant lowering effect on both systolic (P=.005) and diastolic (P=.013) blood pressure. Conclusions Nimodipine did not improve the functional outcome of acute ischemic hemispheric stroke. The early case‐fatality rate was higher in the nimodipine group, possibly due to the blood pressure‐lowering effect of nimodipine. (Stroke. 1994;25:1348‐1353.)

Snoring as a risk factor for sleep-related brain infarction.

We studied 177 consecutive male patients aged 16-60 years with brain infarction verified by neuroradiology and analyzed the time of onset of stroke symptoms related to sleep and the role of possible or known risk factors for brain infarction. Brain infarction occurred relatively more often during the first 30 minutes after awakening than at any other time. In multiple stepwise logistic regression analyses, snoring was the only independent risk factor differentiating stroke occurring during sleep and stroke occurring either during sleep or during the first 30 minutes after awakening from stroke occurring at other times of the day. The risk ratios were 2.65 (95% confidence interval 1.32-5.29, p less than 0.005) and 3.16 (95% confidence interval 1.61-6.22, p less than 0.001), respectively. Other factors tested were age, arterial hypertension, diabetes mellitus, smoking, alcohol consumption, and body mass index. Arterial hypertension seemed to have an additive effect on the independent risk caused by snoring.

Regular light-to-moderate intake of alcohol and the risk of ischemic stroke. Is there a beneficial effect?

Background and Purpose To evaluate the association between different patterns of alcohol consumption and the risk of ischemic stroke in young or middle-aged men. Methods One hundred fifty-six patients and 153 control subjects were included in this case-control study. The pattern and the estimated average weekly intake of alcohol were assessed using a structured questionnaire. The pattern of drinking was defined as regular (daily or almost daily) or irregular (up to three times per week), and the weekly amount of consumption was defined as nondrinking, light-to-moderate drinking (up to 150 g/wk), moderate drinking (>150 to 300 g/wk), and heavy drinking (>300 g/wk). Multiple stepwise logistic regression models were used, and adjustments were carried out for potential confounders. Results Heavy alcohol intake associated with an increased risk of stroke (odds ratio, 4.45; 95% confidence interval, 1.09 to 18.1), whereas the risk tended to be reduced in light-to-moderate drinkers (odds ratio, 0.54; 95% confidence interval, 0.28 to 1.05). Accounting for the pattern of alcohol intake in addition to the average weekly amount in grams, regular light-to-moderate drinking showed a significant inverse association with stroke (odds ratio, 0.12; 95% confidence interval, 0.02 to 0.65), and an irregular pattern of consumption attenuated this association. Based on the same multivariate analyses, other significant independent risk factors for stroke were arterial hypertension, coronary heart disease, and history of snoring, whereas the contributions of age, diabetes mellitus, smoking, and body mass index proved to be nonsignificant. Conclusions Light-to-moderate alcohol intake appears to have an inverse association with the risk of ischemic stroke. The beneficial effect appears to be most prominent if the consumption of alcohol is regular and evenly distributed throughout the week, whereas a sporadic or an occasional pattern of drinking seems to weaken the association. This study also supports the role of heavy drinking as an independent risk factor for ischemic stroke.

Assessment of Depression After Stroke A Comparison of Different Screening Instruments

Background and Purpose— Assessing poststroke depression may be complicated by aphasia, other cognitive deficits, and several somatic stroke-related symptoms. We studied the possible differences in performance of some commonly used instruments in screening depression after stroke. Methods— We compared the Beck Depression Inventory, Hamilton Rating Scale for Depression, Visual Analogue Mood Scale, proxy assessment, and Clinical Global Impression of the nursing and study personnel, together with Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised diagnosis, in assessing depression after stroke in a follow-up study of 100 patients. The patients were studied at 2 weeks and at 2, 6, 12, and 18 months after stroke. Results— The feasibility rates of all assessment instruments studied were fairly similar, but the prevalence rates differed according to the assessment instruments, varying from the lowest rates with a Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised-based diagnosis up to 3-fold with caregiver ratings. The sensitivity and specificity against the Diagnostic and Statistical Manual of Mental Disorders criteria were acceptable with the Clinical Global Impression, Beck Depression Inventory, and Hamilton Rating Scale for Depression, mostly in the range of 0.70 to 1.00. The caregiver ratings were higher than the patient ratings (P<0.001) and correlated with the caregiver’s own Beck Depression Inventory (0.60 to 0.61, P<0.001). The Visual Analogue Mood Scale was not a sensitive instrument (sensitivity, 0.20 to 0.60) and did not correlate with the Beck Depression Inventory during the first year after stroke. Conclusions— Beck Depression Inventory, Hamilton Rating Scale for Depression, and Clinical Global Impression assessment by professionals, in addition to the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised diagnosis, are useful in assessing depression, but none of these instruments clearly stood apart from the others. Proxy ratings should be used with caution, and the use of the Visual Analogue Mood Scale among patients with aphasia and other cognitive impairments cannot be recommended.