Jens Benemann

Predictive value of the Essen Stroke Risk Score and Ankle Brachial Index in acute ischaemic stroke patients from 85 German stroke units

Background: Risk stratification can contribute to individualised optimal secondary prevention in patients with cerebrovascular disease. Objective: To prospectively investigate the prediction of the Essen Stroke Risk Score (ESRS) and a pathological Ankle Brachial Index (ABI) in consecutive patients hospitalised with acute ischaemic stroke or transient ischaemic attack (TIA) in 85 neurological stroke units throughout Germany. Methods: 852 patients were prospectively documented on standardised case report forms, including assessment of ESRS and ABI. After 17.5 months, recurrent cerebrovascular events, functional outcome or death could be assessed in 729 patients predominantly via central telephone interview. Results: After discharge from the documenting hospital, recurrent stroke occurred in 41 patients (5.6%) and recurrent TIA in 15 patients (2.1%). 52 patients (7.1%) had died, 33 (4.5%) from cardiovascular causes. Patients with an ESRS ⩾3 (vs <3) had a significantly higher risk of recurrent stroke or cardiovascular death (9.7% vs 5.1%; odds ratio (OR) 2.00, 95% confidence interval (CI) 1.08 to 3.70) and a higher recurrent stroke risk (6.9% vs 3.7%; OR 1.93, 95% CI 0.95 to 3.94). Patients with an ABI ⩽0.9 (vs >0.9) had a significantly higher risk of recurrent stroke or cardiovascular death (10.4% vs 5.5%; OR 2.00, 95% CI 1.12 to 3.56) and a higher recurrent stroke risk (6.6% vs 4.6%; OR 1.47, 95% CI 0.76 to 2.83). Conclusion: Our prospective follow-up study shows a significantly higher rate of recurrent stroke or cardiovascular death and a clear trend for a higher rate of recurrent stroke in patients with acute cerebrovascular events classified as high risk by an ESRS ⩾3 or a pathological ABI.

Development and validation of the Essen Intracerebral Haemorrhage Score

Background: Spontaneous intracerebral haemorrhage (ICH) accounts for the highest in-hospital mortality of all stroke types. Nevertheless, outcome is favourable in about 30% of patients. Only one model for the prediction of favourable outcome has been validated so far. Objective: To describe the development and validation of the Essen ICH score. Methods: Inception cohorts were assessed on the National Institutes of Health stroke scale (NIH-SS) on admission and after follow up of 100 days. On the basis of previously validated clinical variables, a simple clinical score was developed to predict mortality and complete recovery (Barthel index after 100 days ⩾95) in 340 patients with acute ICH. Subscores for age (<60 = 0; 60–69 = 1; 70–79 = 2; ⩾80 = 3), NIH-SS level of consciousness (alert = 0; drowsy = 1; stuporose = 2; comatose = 3), and NIH-SS total score (0–5 = 0; 6–10 = 1; 11–15 = 2; 16–20 = 3; >20 or coma = 4) were combined into a prognostic scale with <3 predicting complete recovery and >7 predicting death. The score was subsequently validated in an external cohort of 371 patients. Results: The Essen ICH score showed a high prognostic accuracy for complete recovery and death in both the development and validation cohort. For prediction of complete recovery on the Barthel index after 100 days, the Essen ICH score was superior to the physicians’ prognosis and to two previous prognostic scores developed for a slightly modified outcome. Conclusions: The Essen ICH score provides an easy to use scale for outcome prediction following ICH. Its high positive predictive values for adverse outcomes and easy applicability render it useful for individual prognostic indications or the design of clinical studies. In contrast, physicians tended to predict outcome too pessimistically.

Prediction of Recurrent Stroke and Vascular Death in Patients With Transient Ischemic Attack or Nondisabling Stroke. A Prospective Comparison of Validated Prognostic Scores

Background and Purpose— Several predictive scores have been developed and validated for stratifying cerebrovascular patients based on the risk of future (cerebro)vascular events. We aimed to prospectively compare the predictive accuracy of the Essen Stroke Risk Score, Stroke Prognostic Instrument, Hankey score, and the Life Long After Cerebral ischemia score. Methods— Between August 2005 and December 2006, we included 2381 patients from 10 German stroke centers with an acute nondisabling ischemic stroke or transient ischemic attack and with prospective assessment of clinical variables for calculation of the predictive scores. A total of 1897 patients (79.7%) could be followed up for a median of 1 year. To evaluate the performance of each model, we calculated the area under the curve by receiver operating characteristic. In addition, we used the recommended cutoff values for calculation of sensitivity and specificity for stroke or the combined outcome of stroke or cardiovascular death. Results— The Kaplan–Meier estimate for the overall annual stroke risk was 4.8% and for recurrent stroke or cardiovascular death 6.6%. We could confirm the predictive value of all 4 previously developed scores with a marginally superior performance of the SPI-II. Conclusions— In patients with acute nondisabling ischemic stroke or transient ischemic attack, all 4 scores are able to stratify the risk of recurrent stroke or the combined outcome. Simple point scores (Essen Stroke Risk Score, Stroke Prognostic Instrument) may help to raise awareness for medical prevention in clinical routine and increase compliance with risk factor modification.

Current management and risk of recurrent stroke in cerebrovascular patients with right-to-left cardiac shunt.

Background: Right-to-left cardiac shunt (RLS) is considered a risk factor for stroke, especially in patients aged <55 years. We aimed to investigate the current management and prognosis in consecutive patients with RLS and otherwise cryptogenic cerebrovascular events. Methods: In total, 1,126 patients with cryptogenic stroke or TIA were included from 17 German neurology departments. During a mean follow-up of 28.4 months, we assessed current antithrombotic medication, percutaneous device closure (PDC) and recurrent cerebrovascular events in 899 patients (79.8%). Stroke recurrence was compared between 548 patients without RLS and 351 patients with RLS under various prevention regimens. Results: RLS was detected in 35.9% of cryptogenic cerebrovascular patients, but could not be evaluated as an independent predictor for recurrent stroke (adjusted HR 1.6, 95% CI: 0.9–2.7). In RLS-positive patients, the Kaplan-Meier estimate for stroke during the first year was 4.1% (95% CI: 1.9–6.3%) and 1.7% (95% CI: 0.9–2.4%) per year thereafter. At the last follow-up before recurrent stroke or end of study, 117 RLS-positive patients (33.3%) had received a PDC, 154 (43.9%) were receiving antiplatelets, 63 (17.9%) received anticoagulation, and 17 (4.8%) received none of the above. No association with recurrent stroke was found for the secondary preventive regime. Conclusion: Our multicenter hospital-based cohort study confirmed low recurrent event rates in RLS patients with otherwise cryptogenic stroke or TIA, as well as a great heterogeneity of current management. Despite the lack of scientific evidence, a substantial number of RLS-positive patients underwent PDC for secondary stroke prevention.

Recurrent Stroke after Lobar and Deep Intracerebral Hemorrhage: A Hospital-Based Cohort Study

Background: Recurrent stroke rates after intracerebral hemorrhage (ICH) vary widely between observational studies due to differences in ICH etiology and risk for thromboembolic events. We therefore aimed to assess the patient characteristics and prognosis after deep and lobar ICH in a well-characterized, multicenter, hospital-based cohort. Methods: Patients were prospectively documented in 13 German neurological stroke centers. Of 744 patients with spontaneous ICH discharged alive, 516 (69.4%) gave informed consent and 496 (66.7%) could be followed up by central telephone interview over a mean duration of 2 years. Results: In patients with deep ICH, the Kaplan-Meier estimate for stroke during the first year was 5.8% (95% CI 2.9–8.7) and the overall annual rate (calculated over a 3-year period) was 2.9% (95% CI 1.6–4.1). In patients with lobar ICH, the Kaplan-Meier estimate for stroke during the first year was 7.8% (95% CI 3.1–12.5) and the overall annual rate was 7.2% (95% CI 3.8–10.6). At the last follow-up before recurrent stroke or end of study, 141 patients (28.4%) overall received antiplatelet agents, and 12 (2.4%) received oral anticoagulation. No difference could be found for recurrent ICH under antiplatelet agents versus no antithrombotic medication. Conclusion: The risk of recurrent stroke after lobar ICH remains high beyond the first year, whereas it decreases after 1 year in patients with deep ICH. Antiplatelets are prescribed in a considerable number of patients even though the risk-benefit ratio after ICH remains unknown.

Development and validation of a prognostic model to predict recovery following intracerebral hemorrhage.

ContextWhile several models have been developed to predict mortality following intracerebral hemorrhage (ICH), the functional outcome and its predictors in surviving patients have been poorly investigated so far.ObjectivesTo identify predictors and validate a prognostic model for independent functional outcome in patients with acute ICH.DesignAn inception cohort was assessed on the National Institutes of Health Stroke Scale (NIH–SS) at admission and followed–up after 100 days.Setting11 neurological departments with an acute stroke unit.Patients207 consecutive patients who were neither comatose nor intubated at admission within 6 hours after ICH and with complete follow–up.ResultsAfter 100 days, 40 patients (19.3 %) had died, 78 (37.7%) had regained functional independence (Barthel Index ≥ 95) and 89 (43%) had survived but not recovered. In these patients, age and the NIH–SS total score were identified as independent predictors for functional independence after 100 days. With the predefined cut–off value, the prognosis of 79.8% of all patients could be predicted accurately upon validation in an independent data set of 173 non–comatose patients with acute ICH.ConclusionOur study provides a validated prognostic model for prediction of complete recovery following ICH which could be very useful for the design of clinical studies.

Long-term mortality and risk of stroke after transient ischemic attack: a hospital-based cohort study.

BackgroundStroke and mortality rates in patients with transient ischemic attack (TIA) differ widely between community-based studies and research cohorts. Our aim therefore was to provide a reliable estimate for TIA patients treated in German neurology departments with an acute stroke unit.MethodsA total of 1951 consecutively admitted TIA patients were prospectively documented in 13 centers and 1480 (75.9 %) gave consent for long-term follow-up. During a mean follow-up of 23.4 months, we assessed recurrent cerebrovascular events and cause of death in 1448 patients via standardized telephone interview including confirmation of endpoint events by the treating physician.ResultsOverall 94 patients (6.5 %) suffered a stroke and 118 patients (8.1 %) died, 21 due to stroke. The Kaplan-Meier estimate for stroke during the first year was 4.4 % (95 % CI 3.2–5.6 %) which corresponds to a relative risk of 9.5 (95 % CI 7.4–12.3) compared to the population-based stroke incidence in Germany. The annual rates after the first year were 2.2 % (95 % CI 1.7–2.7 %) for stroke and 3.2 % (95 % CI 2.7–3.8 %) for death. Independent predictors for stroke during follow-up were age and previous cerebrovascular events. The ABCD2 score did not provide any meaningful prediction of stroke risk at 90 days.ConclusionWhile the in-hospital risk of stroke was low, long-term stroke rates in our well-defined multicenter hospital-based cohort were comparable to a large randomized trial. In patients with a well-established diagnosis of TIA, only age and previous cerebrovascular events seem to constitute independent predictors for stroke during long-term follow-up.

Adherence and Quality of Oral Anticoagulation in Cerebrovascular Disease Patients with Atrial Fibrillation

Background/Aims: Low rates and poor quality of oral anticoagulation (OAC) have been reported in patients with atrial fibrillation (AF). We therefore sought to investigate the prescription patterns at discharge, adherence and quality of OAC in cerebrovascular disease patients with AF. Methods: Consecutive ischemic stroke (IS) and transient ischemic attack (TIA) patients were prospectively documented in 11 German stroke centers. A central telephone follow-up after 1–2 years assessed the current antithrombotic medication and results of coagulation checks. Results: Of 1,463 surviving patients with AF, 30.5% were discharged on OAC and 13.9% on high-dose heparin. Of 329 AF patients discharged on OAC and with consent for follow-up, 88.7% of surviving patients were still on OAC at the follow-up. Of these, 52.7% reported coagulation values out of the therapeutic range during the preceding 3 months. A recurrent IS was seen in 9 patients (2.1%/year) and an intracranial hemorrhage in 2. Conclusion: We found an important underuse of OAC following TIA or IS mainly in older patients and with greater stroke-related disability. Although the reported coagulation checks showed an only moderate rate within therapeutic ranges, safety and efficacy of OAC in this cohort seem comparable to previous randomized and observational trials in AF patients.

Prognosis after Cryptogenic Cerebral Ischemia in Patients with Coagulopathies

Background/Aim: Prognosis and optimal secondary prevention in ischemic stroke patients with coagulopathies remain unclear. The goal of this prospective observational multicenter study was to determine the risk of recurrence in cryptogenic stroke patients with either no or defined coagulopathies under various prevention regimens. Methods: A total of 429 patients from 14 German stroke centers with an acute cryptogenic ischemic stroke or transient ischemic attack in whom specialized coagulation testing for inherited and acquired coagulopathies (factor V Leiden mutation/resistance to activated protein C, prothrombin mutation, deficiencies of protein C, protein S, antithrombin III, anticardiolipin IgG antibodies, lupus anticoagulant) had been performed were included. Biannual follow-up in 339 (79%) of these patients assessed recurrent cerebrovascular events and secondary prevention therapy during a mean period of 2.5 years. Results: A defined coagulopathy was detected in 89 patients with follow-up, whereas no coagulopathy could be found in 250 patients with follow-up (control group). The Kaplan-Meier estimate for recurrent ischemic stroke or transient ischemic attack after 3 years was 13.6% (95% CI: 5.9–21.2%) in patients with a coagulopathy compared to 9.3% (95% CI: 5.4–13.2%) in controls, which was not significant after adjustment for potential risk factors by Cox regression analysis. Only a previous cerebrovascular ischemic event was an independent predictor for risk of recurrence in coagulopathy and control patients. Conclusions: Our observational data do not indicate a significantly increased risk for recurrent cerebrovascular events in cryptogenic stroke patients with a coagulopathy or any significant influence of the type of antithrombotic treatment.