Palle Møller Pedersen

Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome

BACKGROUND In laboratory animals, cerebral ischaemia is worsened by hyperthermia and improved by hypothermia. Whether these observations apply to human beings with stroke is unknown. We therefore examined the relation between body temperature on admission with acute stroke and various indices of stroke severity and outcome. METHODS In a prospective and consecutive study 390 stroke patients were admitted to hospital within 6 h after stroke (median 2.4 h). We determined body temperature on admission, initial stroke severity, infarct size, mortality, and outcome in survivors. Stroke severity was measured on admission, weekly, and at discharge on the Scandinavian Stroke Scale (SSS). Infarct size was determined by computed tomography. Multiple logistic and linear regression outcome analyses included relevant confounders and potential predictors such as age, gender, stroke severity on admission, body temperature, infections, leucocytosis, diabetes, hypertension, atrial fibrillation, ischaemic heart disease, smoking previous stroke, and comorbidity. FINDINGS Mortality was lower and outcome better in patients with mild hypothermia on admission; both were worse in patients with hyperthermia. Body temperature was independently related to initial stroke severity (p < 0.009), infarct size (p < 0.0001), mortality (p < 0.02), and outcome in survivors (SSS at discharge) (p < 0.003). For each 1 degrees C increase in body temperature the relative risk of poor outcome (death or SSS score on discharge < 30 points) rose by 2.2 (95% CI 1.4-3.5) (p < 0.002). INTERPRETATION We have shown that, in acute human stroke, an association exists between body temperature and initial stroke severity, infarct size, mortality, and outcome. Only intervention trials of hypothermic treatment can prove whether this relation is causal.

Aphasia after Stroke: Type, Severity and Prognosis

Aim: To determine the types, severity and evolution of aphasia in unselected, acute stroke patients and evaluate potential predictors for language outcome 1 year after stroke. Methods: 270 acute stroke patients with aphasia (203 with first-ever strokes) were included consecutively and prospectively from three hospitals in Copenhagen, Denmark, and assessed with the Western Aphasia Battery. The assessment was repeated 1 year after stroke. Results: The frequencies of the different types of aphasia in acute first-ever stroke were: global 32%, Broca’s 12%, isolation 2%, transcortical motor 2%, Wernicke’s 16%, transcortical sensory 7%, conduction 5% and anomic 25%. These figures are not substantially different from what has been found in previous studies of more or less selected populations. The type of aphasia always changed to a less severe form during the first year. Nonfluent aphasia could evolve into fluent aphasia (e.g., global to Wernicke’s and Broca’s to anomic), whereas a fluent aphasia never evolved into a nonfluent aphasia. One year after stroke, the following frequencies were found: global 7%, Broca’s 13%, isolation 0%, transcortical motor 1%, Wernicke’s 5%, transcortical sensory 0%, conduction 6% and anomic 29%. The distribution of aphasia types in acute and chronic aphasia is, thus, quite different. The outcome for language function was predicted by initial severity of the aphasia and by the initial stroke severity (assessed by the Scandinavian Stroke Scale), but not by age, sex or type of aphasia. Thus, a scoring of general stroke severity helps to improve the accuracy of the prognosis for the language function. One year after stroke, fluent aphasics were older than nonfluent aphasics, whereas such a difference was not found in the acute phase.

Prevalence and Risk Factors of Incontinence After Stroke The Copenhagen Stroke Study

Background and Purpose The purpose of this study was to investigate in a community-based population the prevalence of both urinary (UI) and fecal (FI) incontinence and to analyze risk factors by means of multivariate analysis. Methods Included were 935 acute stroke patients admitted consecutively during 19 months. We evaluated UI and FI using subscores of the Barthel Index during the hospital stay and at 6-month follow-up. Results On admission, the proportions of patients with full UI, partial UI, and no UI were 36%, 11%, and 53%, respectively (8%, 11%, and 81% at 6-month follow-up). The proportions of patients with full FI, partial FI, and no FI on admission were 34%, 6%, and 60%, respectively (5%, 4%, and 91% at 6-month follow-up). By multivariate analysis, significant risk factors for UI and FI were age, severity of stroke, diabetes, and comorbidity of other disabling diseases. Conclusions On admission in the acute state, almost half of an unselected stroke population have UI and/or FI. The proportion ...

Hemineglect in acute stroke--incidence and prognostic implications. The Copenhagen Stroke Study.

Widely different incidences have been found for hemineglect in acute stroke, and there is no agreement on the consequences of hemineglect for activities of daily living recovery. We assessed acute admission visuo-spatial and personal hemineglect in a prospective, community-based study of 602 consecutive stroke patients. Hemineglect was found in 23%. Functional outcome was assessed with the Barthel Index (BI), length of rehabilitation, mortality, and rate of discharge to independent living. The independent influence of hemineglect on outcome was analyzed with multiple linear and logistic regression analysis also including functional and neurologic scores on admission, age, gender, previous stroke, comorbidity, anosognosia, orientation, and aphasia. Marital status was also included in the analysis of determinants of discharge to independent living. Hemineglect had no independent influence on admission BI, discharge BI, length of hospital stay used for rehabilitation, mortality, or rate of discharge to independent living. It is concluded that hemineglect per se has no negative prognostic influence on functional outcome.

Orientation in the acute and chronic stroke patient: Impact on ADL and social activities. The copenhagen stroke study☆☆☆

OBJECTIVES To determine the influence of initially lowered orientation on rehabilitation outcome in stroke patients, and how decreased orientation 6 months after stroke influences ADL and social activities. DESIGN Prospective, consecutive, and community based. SETTING A stroke unit receiving all acute stroke patients from a well-defined catchment area. All stages of rehabilitation were completed within the unit. PATIENTS 524 patients with acute stroke. MAIN OUTCOME MEASURES Basic ADL assessed by the Barthel Index (BI) at discharge; discharge placement; higher level ADL and social functions assessed by the Frenchay Activity Index(FAI) at a 6-month follow-up. RESULTS The independent influence of orientation in acute stroke on rehabilitation outcome was analyzed with multiple linear and logistic regression models, using initial stroke severity (Scandinavian Neurologic Stroke Scale), initial BI, age, sex, comorbidity, prior stroke, and marital status as covariates. A one-point decrease in orientation decreased BI with 9 points (coefficient b=8.66, SE(b)=1.02,p<.0001) and reduced the likelihood (1.49, 95% CI: 1.05 to 2.11) of discharge to independent living (b=.40, SE(b)=.18,p=.026). Follow-up examinations 6 month poststroke showed that decreased orientation at this point still exerted a marked, negative influence on ADL and social functions (BI: coefficient b=12.06, SE(b)=1.95,p<.0001; FAI: coefficient b=6.28, SE(b)=1.42,p<.0001). CONCLUSION The level of orientation influences basic ADL and higher level ADL and social activities in acute as well as chronic stroke. This finding suggests that rehabilitation of memory and attention might be relevant in stroke patients with impaired orientation.

Comprehensive assessment of activities of daily living in stroke. The Copenhagen Stroke Study.

OBJECTIVE To assess activities of daily living (ADL) in stroke in a comprehensive way. The Barthel Index (BI) is widely used in stroke research, but is limited because it measures basic ADL functions only. This study sought to determine whether the Frenchay Activities Index (FAI) is a good choice for supplementary assessment of higher order ADL functions. DESIGN Prospective and consecutive. SETTING Follow-up investigation 6 months after stroke of patients who were admitted to, and completed rehabilitation at, a stroke unit. PATIENTS 437 patients with strokes. MAIN OUTCOME MEASURES Factor analysis of the BI, FAI, and the Scandinavian Neurological Stroke Scale (SSS); distribution characteristics of a comprehensive, combined ADL scale. RESULTS Five factors were found. One factor comprised all items from the BI and all the motor items from the SSS, but no items from the FAI. The FAI loaded on three other factors. Finally, orientation and speech from the SSS loaded on a separate factor. A combined score consisting of the BI total score and a simple transformation of the FAI total score had a much improved distribution without strong ceiling or floor effects. CONCLUSIONS The FAI supplements the BI with minimal overlap in content. A combined total score has a distribution that makes it very usable for research in stroke outcome and stroke rehabilitation effect.

Frequency, Determinants, and Consequences of Anosognosia in Acute Stroke

Anosognosia is a well-known symptom after stroke but its frequency following acute stroke is not known and knowledge of its impact on functional outcome is limited. This prospective study included 566 consecutive, unselected, acute stroke patients. Anoso gnosia was evaluated on acute admission using the test of Bisiach et al. (1986), stroke severity with the Scandinavian Neurological Stroke Scale (SNSS), and activities of daily living (ADLs) with the Barthel Index (BI). Multiple linear and logistic regres sion analyses were done to find the influence of anosognosia on the outcome of stroke per se. The frequency of anosognosia was 21% on acute admission. The lesion was located in the right hemisphere in 81% of the patients. Anosognosia was seen more frequently following cortical vs. subcortical lesions but showed no significant rela tionship to any of the four cortical lobes. The presence of anosognosia per se predicted 11.5 points less in discharge BI, increased the likelihood of death during the hospital stay by a factor of 4.4, and reduced the likelihood of discharge to independent living in survivors by 0.43. Anosognosia is common in acute stroke, has a profound influence on the prognosis, and indicates patients needing special encouragement and assistance with mobilization.

Functional and Neurological Outcome of Stroke and the Relation to Stroke Severity and Type, Stroke Unit Treatment, Body Temperature, Age, and Other Risk Factors: The Copenhagen Stroke Study

Abstract Knowledge of neurological and functional outcome is essential when dealing with the treatment and rehabilitation of patients with stroke. This article describes functional and neurological outcome and speed of recovery in relation to initial stroke severity. Recovery of specific functions such as walking, upper extremity function, bowel and bladder, and language is also described. Detailed information about factors important to recovery including body temperature, blood glucose, stroke in progression, stroke type, and treatment on a dedicated stroke unit is given. The article is based on information from the 1,197 patients with acute stroke included in the community-based Copenhagen Stroke Study. All these patients had all their treatment and rehabilitation on a dedicated stroke unit regardless of their age, stroke severity, and premorbid condition.

The Communicative Effectiveness Index: Psychometric properties of a Danish adaptation

The study investigated the psychometric characteristics of a Danish adaptation and translation of the Communicative Effectiveness Index (CETI). A total of 68 patients with left hemisphere strokes, who had aphasia on admission, were assessed with the CETI at least 1 year after stroke, when 53 of them were still aphasic. Language functions were also assessed with the Western Aphasia Battery (WAB) in 65 and the Porch Index of Communicative Abilities (PICA) in 33 patients. After about 4 months 19 patients were retested in order to compare sensitivity to chance in language function. Activities of daily living were assessed with the Barthel Index (BI) and the Frenchay Activities Index (FAI), and depression was assessed with an illustrated, seven-item visual-analogue scale in a subset of the patients. Reliability measured as internal consistency was satisfactory and on the level of the original standardisation. The 3 month test–retest reliability was lower than in the WAB and the PICA when measured by correlation coefficients, but this might express real communication improvements in some patients that are not reflected in their aphasia scores. Concerning validity, the CETI had high correlations with WAB and PICA. Factor analysis suggests two factors which are interpreted as: (1) ability to formulate spoken language; and (2) ability to communicate by nonverbal means. It is concluded that the CETI can be adapted to other languages without major problems. Its general validity as a measure of functional communication is supported by the analysis of the translated version.

The Impact of Aphasia on ADL and Social Activities After Stroke: The Copenhagen Stroke Study

We conducted this study to determine whether the presence of aphasia at the time of acute admission impedes functional improvement of stroke patients and if chronic aphasia aggravates the detrimental effects of stroke on daily life functioning. Six hun dred fifty consecutive stroke patients were examined at the time of admission to hos pital, at discharge after completed acute care and rehabilitation, and six months post- stroke followup. We used the aphasia subscale of the Scandinavian Neurologic Stroke Scale, the Barthel Index (BI), and the Frenchay Activity Index (FAI). Multiple lin ear and logistic regression analyses showed that initial aphasia had a small and clini cally irrelevant influence on functional improvement and it had no influence on dis charge to independent living when controlled for initial functional status, stroke severity, comorbidity, prior stroke, age, sex, and marital status. Similar analyses showed that chronic aphasia per se had no independent influence on either the BI score or the FAI six months post-stroke. Although aphasia is a significant handicap after stroke, it does not seem to affect functional independence after stroke, nor to be of impor tance for ADL and social functions as measured by BI and FAI in a more chronic stage following stroke.