Leonhard Seyfang

Functional recovery after ischemic stroke—A matter of age Data from the Austrian Stroke Unit Registry

Objective: To analyze the association between patient age and good functional outcome after ischemic stroke with special focus on young patients who were numerically underrepresented in previous evaluations. Methods: Of 43,163 ischemic stroke patients prospectively enrolled in the Austrian Stroke Unit Registry, 6,084 (14.1%) were ≤55 years old. Functional outcome was available in a representative subsample of 14,256 patients free of prestroke disability, 2,223 of whom were 55 years or younger. Herein we analyzed the effects of age on good functional outcome 3 months after stroke (modified Rankin Scale score ≤2). Results: Good outcome was achieved in 88.2% (unadjusted probability) of young stroke patients (≤55 years). In multivariable analysis, age emerged as a significant predictor of outcome independent of stroke severity, etiology, performance of thrombolysis, sex, risk factors, and stroke complications. When the age stratum 56–65 years was used as a reference, odds ratios (95% confidence interval [95%CI]) of good outcome were 3.4 (1.9–6.4), 2.2 (1.6–3.2), and 1.5 (1.2–1.9) for patients aged 18–35, 36–45, and 46–55 years and 0.70 (0.60–0.81), 0.32 (0.28–0.37), and 0.18 (0.14–0.22) for those aged 66–75, 76–85, and >85 years (p < 0.001). In absolute terms, the regression-adjusted probability of good outcome was highest in the age group 18–35 years and gradually declined by 3.1%–4.2% per decade until age 75 with a steep drop thereafter. Findings applied equally to sexes and patients with and without IV thrombolysis or diabetes. Conclusions: Age emerged as a highly significant inverse predictor of good functional outcome after ischemic stroke independent of stroke severity, characteristics, and complications with the age-outcome association exhibiting a nonlinear scale and extending to young stroke patients. Neurology® 2012;78:279–285

Early clinical worsening in patients with TIA or minor stroke: The Austrian Stroke Unit Registry

Objective: TIA is associated with a substantial short-term risk of stroke and is thus increasingly recognized as an unstable condition necessitating full medical attention. Our study sought to assess the rate of and predictors for early deterioration after TIA or minor stroke in a large nationwide survey among Austrian stroke units. Methods: Of the 29,287 patients prospectively enrolled in the Austrian Stroke Unit Registry (2003–2008), 8,291 presenting with a TIA or minor ischemic stroke, defined by an NIH Stroke Scale (NIHSS) score <4, were included in the current evaluation. Worsening was defined as clinical deterioration during stroke unit stay by ≥2 points on the NIHSS. Results: A total of 374 patients (4.5%) experienced early clinical worsening during a mean stroke unit stay of 2.97 days (median 2 [interquartile range,1–4] days). In a multivariate stepwise regression analysis hypertension, diabetes, cardiac decompensation, acute infection, and stroke etiology emerged as independent risk predictors for early deterioration. The ABCD2 score could be estimated in a subgroup of 3,886 subjects and closely correlated with the risk of neurologic worsening. Conclusions: Our study revealed a high rate of early clinical deterioration (4.5%) among 8,291 patients with TIA or minor stroke despite immediate admission to specialized stroke units. Predictors for neurologic deterioration apart from diabetes, hypertension, and the estimated ABCD2 score were stroke etiology, reinforcing the relevance of an immediate diagnostic workup, and coexistent acute infection and cardiac decompensation, both conditions necessitating adequate attention in the emergency setting.

Helicopter Transport of Stroke Patients and Its Influence on Thrombolysis Rates: Data From the Austrian Stroke Unit Registry

Background and Purpose— Acute stroke management requires minimization of prehospital time. This study addresses the value of helicopter transport compared with other means of transportation to a stroke unit and compares their rates of thrombolysis on a nationwide basis. Methods— Prospective data collection and prespecified evaluation of data from 32 stroke units between 2003 and 2009 were used. We distinguished between patients transported either directly to a stroke unit or transferred indirectly via a peripheral hospital. Thus, there were 6 transport groups: helicopter emergency service (HEMS) direct and indirect, ambulance accompanied by an emergency physician direct and indirect, and ambulance without physician direct and indirect. Demographic and clinical factors, time delays, and rates of thrombolysis of patients transported by helicopter were compared with factors of patients transported otherwise. Results— Of 21 712 ischemic stroke patients, 905 patients (4.1%) were transported by helicopter. Of these, 752 patients (3.4%) were transported by direct HEMS, and 153 patients (0.7%) were transported by indirect HEMS. Thrombolysis rates were highest for HEMS (24% direct, 29% indirect) transport, followed by ambulance accompanied by an emergency physician (18% direct, 15% indirect). The probability of receiving thrombolysis was highest for indirect HEMS transport (OR 3.6, 2.2–6.0), followed by indirect ambulance accompanied by an emergency physician transport (OR 1.5, 1.1–1.9). The shortest times, 90 minutes or less from stroke onset to hospital arrival, were achieved with direct AMBP and direct HEMS transport. Conclusions— The shortest hospital arrival times and highest thrombolysis rates were seen in ischemic stroke patients transported by helicopter.

Stroke Thrombolysis: Having More Time Translates Into Delayed Therapy Data From the Austrian Stroke Unit Registry

Background and Purpose— Efficacy of intravenous thrombolysis in acute ischemic stroke declines with increasing time to treatment initiation. Previous small-scale studies suggested that the earlier patients arrive, the longer it takes to administer recombinant tissue plasminogen activator. Methods— Of 32 529 patients with stroke prospectively enrolled in the Austrian Stroke Unit Registry (2004 to 2009), 3287 received intravenous thrombolysis and 2663 of them were eligible for the current analysis. Results— Median (interquartile range) onset-to-door and door-to-needle times were 70 (50 to 100) and 50 (35 to 70) minutes. Of note, both time intervals were inversely correlated with each other. After adjustment for multiple stroke characteristics, the door-to-needle time of patients arriving in the hospital within the first hour after stroke onset was 6.9 minutes (P<0.001) and 13.9 minutes (P<0.001) longer than those for patients arriving between 61 to 120 and 121 to 180 minutes. Findings were consistent in subgroups. Conclusions— Early hospital arrival translates into a significant delay in the application of intravenous thrombolysis among patients with acute stroke. This finding calls for concerted measures to ensure that all patients with stroke are treated with the same urgency irrespective of the time available.

Sex-Related Differences of Acute Stroke Unit Care: Results From the Austrian Stroke Unit Registry

Background and Purpose— Sex-related differences in quality of acute stroke care are an important concern with limited data available, specifically regarding stroke unit (SU) setting. We used the prospective nationwide Austrian SU registry to address this issue. Methods— Our analysis covered an 8-year time period (January 2005 to December 2012) during which all patients with transient ischemic attack or ischemic stroke admitted to 1 of 35 Austrian SU had been captured in the registry. These data were analyzed for age-adjusted preclinical and clinical characteristics and quality of acute stroke care in men and women. In addition, we assessed the outcome at 3 months in multivariate analysis. Results— A total of 47 209 individuals (47% women) had received SU care. Women were significantly older (median age: 77.9 versus 70.3 years), had higher pre-existing disability and more severe strokes. Correcting for age, no significant sex-related differences in quality of care were identified with comparable onset-to-door times, times to and rates of neuroimaging, as well as door-to-needle times and rates of intravenous thrombolysis (14.5% for both sexes). Despite equal acute stroke care and a comparable rate of neurorehabilitation, women had a worse functional outcome at 3-month follow-up (modified Rankin scale 3–5: odds ratio, 1.26; 95% confidence interval [1.17–1.36]), but a lower mortality (odds ratio, 0.70; 95% confidence interval [0.78–0.88]) after correcting for confounders. Conclusions— We identified no disproportions in quality of care in the acute SU setting between men and women, but the outcome was significantly different. Further studies on the poststroke period including socioeconomic aspects are needed to clarify this finding.

Thrombolysis in Patients With Mild Stroke Results From the Austrian Stroke Unit Registry

Background and Purpose— Apart from missing the approved time window of 4.5 hours, one frequent cause for withholding recombinant tissue plasminogen activator (rt-PA) treatment in patients with ischemic stroke is presentation with mild deficit on admission. We analyzed in a large cohort of patients whether rt-PA treatment is beneficial for this group of patients. Methods— From a total of 54 917 patients with ischemic stroke prospectively enrolled in the Austrian Stroke Unit Registry, 890 patients with mild deficit defined as ⩽5 points in the National Institutes of Health Stroke Scale treated with and without rt-PA were matched for age, sex, prestroke disability, stroke severity, hypertension, diabetes mellitus, hypercholesterolemia, stroke cause, and clinical stroke syndrome. Functional outcome was assessed using the modified Rankin Scale at 3 months. For data visualization, weighted averages of outcome differences were computed for all age severity combinations and mapped to a color. For quantification of effect sizes, numbers need to treat were calculated. Results— rt-PA–treated patients with mild deficit had a better outcome after 3 months compared with matched cases without rt-PA treatment (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.17–1.89; P<0.001). In rt-PA–treated patients with mild deficit, the numbers need to treat ranged from 8 to 14. Improvement achieved by rt-PA treatment was observed along the entire age range. Conclusions— In our study, intravenous rt-PA treatment was beneficial for patients with mild deficit. Given the observational nature of these results, our data might serve as an incentive for future randomized controlled trials to provide a basis for optimal patient selection.

Multidomain Lifestyle Interventions for the Prevention of Cognitive Decline After Ischemic Stroke: Randomized Trial

Background and Purpose— Cognitive impairment occurs in ⩽30% of all stroke survivors. However, effective therapies aimed at preventing poststroke cognitive decline are lacking. We assessed the efficacy of a multidomain intervention on preventing cognitive decline after stroke. Methods— In this randomized, observer-blind trial patients were recruited within 3 months after an acute stroke in 5 Austrian neurological centers. Patients were assigned to a 24-month lifestyle-based multidomain intervention or standard stroke care. Primary outcomes were the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-cog) and occurrence of cognitive decline in the composite scores of at least 2 of 5 cognitive domains at 24 months. Results— A total of 101 patients were randomized into multi-intervention and 101 into standard care during June 2010 and November 2012. Of them, 76 patients in the intervention group and 83 in the control group were included in the final intention-to-treat analysis. At 24 months, 8 of 76 (10.5%) patients in the intervention group and 10 of 83 (12.0%) patients in the control group showed cognitive decline corresponding to a relative risk reduction of 0.874 (95% confidence interval, 0.364–2.098). The change in ADAS-cog from baseline to 24 months was not different either (median 0 [IQR, −1 to 2] in both groups; P=0.808). Conclusions— This trial found no benefit of 24-month multidomain intervention with focus on improvement in lifestyle and vascular risk factors on the incidence of poststroke cognitive decline in comparison with standard stroke care. Studies with a larger sample size are needed. Clinical Trial Registration— URL: http://clinicaltrials.gov. Unique identifier: NCT01109836.

Time Trends in Patient Characteristics Treated on Acute Stroke-Units Results From the Austrian Stroke Unit Registry 2003–2011

Background and Purpose— Demographic changes, increased awareness of vascular risk factors, better diagnostic, progress in medical care, and increasing primary stroke prevention influence the profile of patients admitted to stroke-units. Changes in patient population and stroke type have important consequences on outcome and management at stroke-units. Methods— Data from the national database of the Austrian Stroke Unit Registry were analyzed for time-trends in demography, risk factors, cause, and stroke severity. Results— Data of 48 038 ischemic and 5088 hemorrhagic strokes were analyzed. Between 2003 and 2011, median age increased significantly for ischemic strokes from 68 to 71 years in men and from 76 to 78 years in women, respectively. Ischemic stroke patients showed significantly increased rates of hypertension, hypercholesterolemia, and atrial fibrillation. In hemorrhagic strokes an increase for hypercholesterolemia and cardiac diseases other than atrial fibrillation and myocardial infarction were only found in men. A small but significant decrease in stroke severity was found for ischemic strokes from 4 to 3 points on the National Institutes of Health Stroke Scale in men and from 5 to 4 in women, and for hemorrhagic strokes from 9 to 6 points in men and from 9 to 7 in women. Cardioembolic strokes increased slightly, whereas macroangiopathy decreased. Conclusions— Significant time trends were seen for characteristics of ischemic and hemorrhagic stroke patients admitted to acute stroke-units in Austria. These include trends for older age and toward milder strokes with more cardioembolic causes. This signals a need for increased resources for managing multimorbidity and enabling early mobilization.

Myocardial Infarction as a Complication in Acute Stroke: Results from the Austrian Stroke Unit Registry

Background: Patients with transient ischemic attack (TIA) and stroke have an increased risk for subsequent cardiac events including myocardial infarction (MI), which might be associated with a worse clinical outcome. Rapid identification of stroke patients at higher risk for MI might foster intensified cardiac monitoring or certain therapeutic strategies. However, information regarding acute MI as a complication of stroke in the very acute phase is limited. Moreover, there are no systematic data on the occurrence of MI following intracerebral hematoma. We thus aimed to assess the frequency, clinical characteristics and short-term outcome of patients suffering from acute MI in the stroke unit setting. Methods: We analyzed 46,603 patients from 32 Austrian stroke units enrolled in the prospective Austrian Stroke Unit Registry because of TIA/acute stroke over a 6-year period (January 1, 2007 to January 13, 2013). A total of 41,619 patients (89.3%) had been treated for TIA/ischemic stroke and 4,984 (10.7%) for primary intracerebral hemorrhage (ICH). Acute MI was defined according to clinical evaluation, ECG findings and laboratory assessments. Patients with evidence for MI preceding the cerebrovascular event were not considered. Results: Overall, 421 patients (1%) with TIA/ischemic stroke and 17 patients (0.3%) with ICH suffered from MI during stroke unit treatment for a median duration of 3 days. Patients with TIA/ischemic stroke and MI were significantly older, clinically more severely affected and had more frequently vascular risk factors, atrial fibrillation and previous MI. Total anterior circulation and left hemispheric stroke syndromes were more often observed in MI patients. Patients with MI not only suffered from worse short-term outcome including a higher mortality (14.5 vs. 2%; p < 0.001) at stroke unit discharge, but also acquired more stroke complications like progressive stroke and pneumonia. Multivariate analyses identified previous MI and stroke severity at admission (according to the National Institutes of Health and Stroke Scale score) as factors independently associated with the occurrence of MI on the stroke unit. Conclusions: While quite rare in the acute phase after stroke, MI is associated with a poor short-term outcome including a higher mortality. Patients with previous MI and severe stroke syndromes appear to be at particular risk for MI as an early complication in the stroke unit setting. Further studies are needed to determine whether increased vigilance and prolonged (cardiac) monitoring or certain therapeutic approaches could improve the outcome in these high-risk patients.

Diabetes and thrombolysis for acute stroke: a clear benefit for diabetics

Diabetes is a predictor for poor outcome after thrombolysis in stroke patients, and early post‐stroke glycaemia is associated with higher rates of post‐thrombolytic symptomatic intracerebral haemorrhages (SICHs). Diabetic stroke patients may nevertheless profit from thrombolysis. Here, we compared outcome data of matched thrombolysed and non‐thrombolysed diabetic and non‐diabetic stroke patients from a national database.