Livia Candelise

Stroke-unit care for acute stroke patients: an observational follow-up study

BACKGROUND Large numbers of stroke patients arrive at hospital at a very early stage, and effective treatments for the acute phase of the disease are available. However, evidence that patients with acute stroke benefit from stroke-unit care is scarce. Our aim was to determine whether admission to a stroke unit, rather than a conventional ward, affected the outcome of patients with acute stroke. METHODS We did an observational follow-up study of 11 572 acute stroke patients hospitalised within 48 h of the onset of symptoms either in a stroke unit (n=4936) or in a conventional ward (6636). Patients were identified retrospectively from discharge records from 260 Italian hospitals. The primary outcome was mortality or disability (Rankin score greater than two), assessed prospectively by independent, masked assessors 2 years after admission. Analyses were adjusted for patient characteristics and clustered at the hospital level. FINDINGS Overall, 1576 patients died in hospital; 2169 died during the follow-up period. 347 patients were lost to follow-up. Compared with conventional-ward care, stroke-unit care was associated with a reduced probability of death or being disabled at the end of follow-up (odds ratio 0.81, 95% CI 0.72-0.91; p=0.0001). The potential benefit was significant across all age ranges and clinical characteristics, except for unconsciousness. No specific elements of setting, organisation, or process of care were associated with outcome. INTERPRETATION Admission to a stroke-unit ward with dedicated beds and staff within 48 h of onset should be recommended for all patients with acute stroke.

Steriods for multiple sclerosis and optic neuritis: a meta-analysis of randomized controlled clinical trials

Abstract We conducted a meta-analysis of randomized controlled clinical trials on steroid treatment for multiple sclerosis and optic neuritis. Of the 25 trials comparing steroids and controls without steroid treatment that we identified 12 were selected for this review. A meta-analysis was conducted to calculate the overall odds ratio across the studies for the numbers of patients without functional improvement and with new relapses. The trials included a total of 1714 patients: 998 with multiple sclerosis and 716 with optic neuritis. Any type of corticosteroids or adrenocorticotropic hormone (ACTH) treatment was considered, as was any dosage, route of administration, and length of treatment. Main outcome measures were: (a) number of multiple sclerosis patients who did not improve by at least one point on the EDSS or equivalent scale, or number of optic neuritis patients without complete recovery of visual acuity at 8 or 30 days and at longer follow-up; (b) number of multiple sclerosis patients with at least one new relapse, or number of optic neuritis patients in whom definite multiple sclerosis was diagnosed at longer follow-up. We found that corticosteroids or ACTH produced a significant improvement in disability or visual acuity at 30 days (odds ratio 0.49; 95 % CI 0.37–0.64). The improvement was not statistically significant at longer follow-up (0.85; 95 % CI 0.67–1.09). The treatment did not significantly reduce the number of patients with relapses (0.74; 95 % CI 0.54–1.01). Both low and high doses were effective for 30-day improvement, but only high-dose and short-term therapy were factors that identified subgroups with some reduction in the risk of new relapse. However, the power of the statistical analysis to detect a reliable difference in the subgroups was low. Steroid treatment is therefore effective in accelerating short-term recovery in patients with multiple sclerosis or optic neuritis. Whether steroids are also effective in reducing the risk of relapse, and the optimal dose and length of treatment must still be determined.

The Italian Longitudinal Study on Aging (ILSA): Design and methods

The Italian Longitudinal Study on Aging (ILSA) is a population-based, longitudinal study of the health status of Italians aged 65–84 years. The main objectives of ILSA are the study of the prevalence and incidence rates of common chronic conditions in the older population, and the identification of their risk and protective factors. ILSA is also designed to assess age-associated physical and mental functional changes. A random sample of 5632 individuals, stratified by age and gender using the equal allocation strategy, was identified on the demographic lists of the registry office of eight municipalities: Genova, Segrate (Milano), Selvazzano-Rubano (Padova), Impruneta (Firenze), Fermo (Ascoli Piceno), Napoli, Casamassima (Bari), and Catania. An extensive investigation, including interviews, physical exams, and laboratory tests, was conducted at baseline to identify the presence of cardiovascular disease (ischemic heart disease, hypertension, congestive heart failure, arrhythmia, intermittent claudication), diabetes, impaired glucose tolerance, thyroid dysfunction, dementia, parkinsonism, stroke, and peripheral neuropathy, as well as assess physical and mental functional status. The baseline examination was carried out between March 1992 and June 1993; a second comprehensive examination will begin in March 1995. An interim hospital discharge data survey and a mortality survey are currently ongoing to assess the hospitalization rate and the cause-specific mortality rate in this study cohort. (Aging Clin. Exp. Res. 6: 464-473, 1994)

Mortality in acute stroke with atrial fibrillation. The Italian Acute Stroke Study Group.

We compared 211 consecutive patients who had acute ischemic hemispheric stroke and atrial fibrillation with 837 consecutive patients who had stroke without atrial fibrillation. The atrial fibrillation group included a higher frequency of women, older subjects, and those with a severe neurologic deficit, abnormal computed tomogram, and elevated heart rate. The 1-month case-fatality rate in the atrial fibrillation group was 27% while that in the group without atrial fibrillation was 14%. The 6-month case-fatality rates in the two groups were 40% and 20%, respectively. The risk of death attributable to atrial fibrillation, adjusted for the effect of other prognostic factors, was significant at 1 month (relative risk = 1.55) and at 6 months (relative risk = 1.74). The causes of death were equally distributed in the two groups during both the acute and subacute phases. We conclude that atrial fibrillation is a negative prognostic factor in patients hospitalized for acute stroke. Nevertheless, cerebral embolism alone does not completely explain the increase in mortality for stroke patients with atrial fibrillation. Other associated pathogenetic mechanisms must also be taken into account.

A randomized trial of aspirin and sulfinpyrazone in patients with TIA.

In a double-blind multicenter study, 124 patients with transient ischemic attacks were randomly allocated to one of two groups treated with aspirin (ASA) or sulfinpyrazone respectively. Patients were followed up to assess the relative efficacy of the two treatments in the prevention of the outcomes of stroke, myocardial infarction, vascular death, and worsening or no improvement of TIAs. No significant difference was observed between the two treatments at the end of the follow-up period. Statistical analysis revealed a significant interaction of sex, treatment, and occurrence of events. Analysis of the results according to sex showed that male patients treated with ASA had a highly significant benefit (p less than 0.001) with a 53% risk reduction for further events. In female patients, sulfinpyrazone showed a favorable trend which was not statistically significant.

Recurrent ischemic attacks in two young adults with lupus anticoagulant.

Two young adults with lupus anticoagulant had multiple attacks of cerebrovascular ischemia in different arterial territories. Cerebral angiography was normal. One patient had a new episode during anticoagulant therapy, but has remained asymptomatic on antiplatelet treatment. In the other, further events occurred during treatment with platelet-inhibiting drugs, but there have been no recurrences with adequate anticoagulant therapy. Lupus anticoagulants are possible causes of otherwise unexplained thromboembolic events. Due to the variable mode of action of these immunoglobulins, platelet-inhibiting drugs may in some cases be considered as a prophylactic alternative to anticoagulant treatment.

Hypercoagulability in acute stroke Prognostic significance

To evaluate the clinical significance of hemostatic abnormalities in acute stroke, we studied coagulation and platelet function in 70 patients with recent cerebral infarction or hemorrhage and in 45 age-matched controls. Higher levels of one-stage factor VIII coagulant activity, fibrinopeptide A (FPA), and beta-thromboglobulin were associated with the occurrence of stroke. All hemostatic test results were remarkably similar in patients with ischemic and hemorrhagic stroke. FPA levels and size of the lesion on CT were the only variables independently predicting mortality in a multivariate regression analysis. Our findings demonstrate that hypercoagulability is an important prognostic factor in stroke and lend support to clinical trials of drugs interfering with the coagulation system in the early phase of cerebral ischemia.

Stroke in an Elderly Population: Incidence and Impact on Survival and Daily Function The Italian Longitudinal Study on Aging

Background: Epidemiological data are essential to estimate the burden of stroke.We evaluated stroke incidence in older Italians and the effect of first-ever stroke on survival and activities of daily living (ADL). Methods: The analysis was performed in the Italian Longitudinal Study on Aging (ILSA) sample, consisting of 5,632 individuals aged 65–84. The ILSA aims at major cardiovascular and neurological age-associated diseases. The baseline survey was performed in 1992 to detect prevalent diseases. The longitudinal examination started on September 1995 aiming at incidence, function and survival. Results: Complete follow-up data were achieved for 77% of the baseline stroke-free cohort (4,164 persons; 50.9% males; mean age 74.5 ± 5.7 years). Incidence for first-ever stroke was 9.51 (95% CI: 7.75–11.27) per 1,000 person years and 12.99 (95% CI: 10.99–14.98) including recurrent stroke (total incidence). Crude mortality was 49.2% among first stroke patients and 15% among persons without stroke. The first-ever stroke mortality risk ratio, adjusted for demographics and comorbidity, was 2.40 (95% CI: 1.62–3.54). In survivors, impairment of at least one ADL was present in 67.6% of first-ever stroke patients vs. 31.6% of individuals without stroke. The comorbidity-adjusted OR was 2.63 (95% CI: 1.20–5.78) in the total cohort, and 4.00 (95% CI: 1.39–11.46) in individuals without disability at baseline. Conclusions: The ILSA provides the first data on stroke incidence in Italy on a national basis. Overall, 153,000 new cases can be expected annually in the Italian elderly population. First-ever stroke still has a strong effect on survival and function of older persons.

Genetic polymorphisms for the study of multifactorial stroke

Single‐gene disorders explain only a minority of stroke cases. Stroke represents a complex trait, which is usually assumed to be polygenic. On this topic, the role of a wide number of candidate genes has been investigated in stroke through association studies, with controversial results. Therefore, it is difficult for the clinician to establish the validity and the level of clinical applicability of the previously reported associations between genetic factors and stroke. This review is an update and an extensive analysis of the more recent association studies conducted in stroke. We evaluated a number of studies on several candidate genes (including F5, F2, FGA/FGB/FGG, F7, F13A1, vWF, F12, SERPINE1, ITGB3/PLA1/PLA2/ITGA2B, ITGA2, GP1BA, ACE, AGT, NOS3, APOE, LPL, PON1, PDE4D, ALOX5AP, MTHFR, MTR, and CBS), providing a final panel of genes and molecular variants. We categorized this panel in relation to the degree of association with stroke, supported by the results of meta‐analyses and case–control studies. Our findings could represent a useful tool to address further molecular investigations and to realize more detailed meta‐analyses. Hum Mutat 29(6), 776–795, 2008.

Hemorrhage After an Acute Ischemic Stroke

Background and Purpose—Hemorrhagic transformation is frequently seen on CT scans obtained in the subacute phase of ischemic stroke. Its prognostic value is controversial. Methods—We analyzed 554 patients with acute ischemic stroke enrolled in the Multicenter Acute Stroke Trial–Italy (MAST-I) study in whom a second CT scan was performed on day 5. Presence of 1) intraparenchymal hemorrhages (hematoma or hemorrhagic infarction), 2) extraparenchymal bleeding (intraventricular or subarachnoid) and 3) cerebral edema (shift of midline structure, sulcal effacement or ventricular compression) alone or in association were evaluated. Death or disability at 6 months were considered as “unfavorable outcome.” Results—Patients who developed intraparenchymal hemorrhages, extraparenchymal bleeding, or cerebral edema had unfavorable outcome (83%, 100%, and 80%, respectively), but multivariate analysis demonstrated that only extraparenchymal bleeding (collinearity) and cerebral edema (OR=6.8; 95% CI, 4.5 to 10.4) were signi...