Peter Appelros

Sex Differences in Stroke Epidemiology : A Systematic Review

Background and Purpose— Epidemiological studies, mainly based on Western European surveys, have shown that stroke is more common in men than in women. In recent years, sex-specific data on stroke incidence, prevalence, subtypes, severity and case-fatality have become available from other parts of the world. The purpose of this article is to give a worldwide review on sex differences in stroke epidemiology. Methods— We searched PubMed, tables-of-contents, review articles, and reference lists for community-based studies including information on sex differences. In some areas, such as secular trends, ischemic subtypes and stroke severity, noncommunity-based studies were also reviewed. Male/female ratios were calculated. Results— We found 98 articles that contained relevant sex-specific information, including 59 incidence studies from 19 countries and 5 continents. The mean age at first-ever stroke was 68.6 years among men, and 72.9 years among women. Male stroke incidence rate was 33% higher and stroke prevalence was 41% higher than the female, with large variations between age bands and between populations. The incidence rates of brain infarction and intracerebral hemorrhage were higher among men, whereas the rate of subarachnoidal hemorrhage was higher among women, although this difference was not statistically significant. Stroke tended to be more severe in women, with a 1-month case fatality of 24.7% compared with 19.7% for men. Conclusions— Worldwide, stroke is more common among men, but women are more severely ill. The mismatch between the sexes is larger than previously described.

Poor Outcome After First-Ever Stroke Predictors for Death, Dependency, and Recurrent Stroke Within the First Year

Background and Purpose— The purpose of this study was to define predictors of poor outcome after a first-ever stroke. We studied risk factors and stroke severity at baseline in relationship to death, dependency, and stroke recurrence within a year after the event. Methods— The study included a community-based cohort of first-ever stroke patients. Subarachnoid hemorrhage was not included. All patients (n=377) were subjected to investigations regarding risk factors. Stroke severity was evaluated with the National Institutes of Health Stroke Scale, and dependency was defined according to the modified Rankin Scale. Multivariate regression models were used to analyze predictors of survival, dependency, and stroke recurrence. The following independent variables were used: age, sex, cohabitation status, cigarette smoking, dementia, hypertension, ischemic heart disease, heart failure, atrial fibrillation, diabetes mellitus, transitory ischemic attack, peripheral atherosclerosis, and stroke severity. Results— The 1-year mortality was 33%. After 1 year, 37% of the survivors were dependent; 9% of survivors had a recurrent stroke within a year. Dementia, age, stroke severity, and atrial fibrillation were associated with death within a year. Dependency was associated with age, stroke severity, and heart failure. Stroke recurrence was predicted by age and dementia. Conclusions— In addition to age and stroke severity, heart diseases and dementia before the stroke seem to have an impact on mortality and recurrence after 1 year. Finding and, when possible, treating these prestroke conditions may affect stroke morbidity and mortality favorably.

How to identify potential fallers in a stroke unit: validity indexes of 4 test methods.

OBJECTIVE The aim of this study was to describe general characteristics of patients with stroke who have a tendency to fall and to determine whether certain test instruments can identify fallers. METHODS Patients treated in a stroke unit during a 12-month period were included. At inclusion assessments were made with Berg Balance Scale Berg Balance Scale, Stops Walking When Talking, Timed Up & Go (TUG) and diffTUG. At follow-up 6 or 12 months later, patients who had fallen were identified. RESULTS During the time from discharge to follow-up on 159 patients, 68 patients fell and 91 did not. Fallers fell more often during their initial hospital stay, used sedatives more often and were more visually impaired, compared with non-fallers. The Berg Balance Scale, Stops Walking When Talking and TUG results differed between fallers and non-fallers. The combined results of Berg Balance Scale and Stops Walking When Talking increased the possibility of identifying fallers. CONCLUSION Berg Balance Scale, Stops Walking When Talking and TUG can be used to evaluate which patients have a tendency to fall in order to carry out preventive measures. Berg Balance Scale can be used in all patients. Stops Walking When Talking can give additional information if the patient is able to walk. TUG is a possible choice, but fewer patients can perform it.

Neglect and anosognosia after first-ever stroke: incidence and relationship to disability.

Neglect and anosognosia are serious consequences of stroke. Authors have found great variations in their incidence and their relationship to disability has been unclear. We studied the incidence of neglect and anosognosia within the scope of a population-based stroke-incidence study, and also evaluated their impact on disability. Four tests of visuo-spatial neglect, four tests of personal neglect, and an anosognosia questionnaire were used. Sixty-two patients (23%) of the study group had visuo-spatial neglect according to our definition, 21 patients (8%) had personal neglect, and 48 (17%) showed signs of anosognosia. Using a multiple logistic regression model, we found that both neglect and anosognosia influenced disability. To ascertain the true incidence of neglect and anosognosia after stroke, it is necessary to use a community-based study design, where cases treated outside the hospital are included. Some of the variability found in previous incidence studies is likely to be explained by not using such a design.

The Riks-Stroke story: building a sustainable national register for quality assessment of stroke care.

Background Riks-Stroke, the Swedish Stroke Register, is the worlds longest-running national stroke quality register (established in 1994) and includes all 76 hospitals in Sweden admitting acute stroke patients. The development and maintenance of this sustainable national register is described. Methods Riks-Stroke includes information on the quality of care during the acute phase, rehabilitation and secondary prevention of stroke, as well as data on community support. Riks-Stroke is unique among stroke quality registers in that patients are followed during the first year after stroke. The data collected describe processes, and medical and patient-reported outcome measurements. The register embraces most of the dimensions of health-care quality (evidence-based, safe, provided in time, distributed fairly and patient oriented). Result Annually, approximately 25 000 patients are included. In 2009, approximately 320 000 patients had been accumulated (mean age 76-years). The register is estimated to cover 82% of all stroke patients treated in Swedish hospitals. Among critical issues when building a national stroke quality register, the delicate balance between simplicity and comprehensiveness is emphasised. Future developments include direct transfer of data from digital medical records to Riks-Stroke and comprehensive strategies to use the information collected to rapidly implement new evidence-based techniques and to eliminate outdated methods in stroke care. Conclusions It is possible to establish a sustainable quality register for stroke at the national level covering all hospitals admitting acute stroke patients. Riks-Stroke is fulfilling its main goals to support continuous quality improvement of Swedish stroke services and serve as an instrument for following up national stroke guidelines.

Predictors of Severe Stroke Influence of Preexisting Dementia and Cardiac Disorders

Background and Purpose— There is little research into the impact of prestroke dementia on stroke severity and short-term mortality. We included prestroke dementia, along with other risk factors, to determine independent predictors of stroke severity and early death in a community-based stroke study. Methods— All patients (n=377) with a first-ever stroke were evaluated in terms of risk factors. Registration took place over a 12-month period. Stroke severity was evaluated with the National Institutes of Health Stroke Scale. Predictors of severe stroke and early death were analyzed in logistic regression models. The following independent variables were used: age, sex, living alone, arterial hypertension, ischemic heart disease, heart failure, atrial fibrillation, diabetes mellitus, transient ischemic attack, cigarette smoking, peripheral atherosclerosis, and dementia. Results— Risk factors for stroke were found in 82% of the patients. Heart failure, atrial fibrillation, and dementia were associated with more severe strokes. Dementia, atrial fibrillation, heart failure, and living alone were associated with death within 28 days of the event. Conclusions— These results raise the question of whether certain high-risk patients, ie, patients with atrial fibrillation, heart failure, and dementia, can benefit from more aggressive primary and secondary stroke prevention measures.

High Incidence Rates of Stroke in Örebro, Sweden: Further Support for Regional Incidence Differences within Scandinavia

Background and Purpose: As a basis for comparison of differences in stroke incidence in Scandinavian countries, a community-based stroke register was established in Örebro in the centre of Sweden. Methods: All first-ever cases of stroke were registered during a 12-month period 1999–2000. The study population was 123,503. The WHO definition of stroke was used. Cases were searched inside as well as outside hospital. Multiple overlapping sources and ‘hot pursuit’ technique were used in the process of case ascertainment. Results: 388 cases of first-ever stroke were found, corresponding to a crude incidence rate of 314 (95% CI, 283–348) per 100,000 per year, 337 (95% CI, 294–386) for females, and 289 (95% CI, 248–336) for males. Adjusted to the European population, the corresponding rates were 254 (95% CI, 227–284) per 100,000 per year, 273 (95% CI, 238–311) for females and 232 (95% CI, 206–261) for males. The overall 28-day case-fatality rate was 19% (95% CI, 15–23). The case-fatality rates for the different subtypes of stroke were as follows: brain infarction, 10%; intracerebral haemorrhage, 20%; subarachnoidal haemorrhage 45%, and undetermined pathological type 56%. Conclusions: The present study as well as other studies in northern and middle Scandinavia show significantly higher incidence rates than studies from other regions. The crude incidence rate, reflecting the age distribution of the population, is even higher, indicating a burden to the community that is rather increasing than decreasing.

Differing Risk Factor Profiles of Ischemic Stroke Subtypes: Evidence for a Distinct Lacunar Arteriopathy?

Background and Purpose— Differences in risk factor profiles between lacunar and other ischemic stroke subtypes may provide evidence for a distinct lacunar arteriopathy, but existing studies have limitations. We overcame these by pooling individual data on 2875 patients with first-ever ischemic stroke from 5 collaborating prospective stroke registers that used similar, unbiased methods to define risk factors and classify stroke subtypes. Methods— We compared risk factors between lacunar and nonlacunar ischemic strokes, altering the comparison groups in sensitivity analyses, and incorporated these data into a meta-analysis of published studies. Results— Unadjusted and adjusted analyses gave similar results. We found a lower prevalence of cardioembolic source (adjusted odds ratio, 0.33; 95% CI, 0.24 to 0.46), ipsilateral carotid stenosis (odds ratio, 0.21; 95% CI, 0.14 to 0.30), and ischemic heart disease (odds ratio, 0.75; 95% CI, 0.58 to 0.97) in lacunar compared with nonlacunar patients but no difference for hypertension, diabetes, or any other risk factor studied. Results were robust to sensitivity analyses and largely confirmed in our meta-analysis. Conclusions— Hypertension and diabetes appear equally common in lacunar and nonlacunar ischemic stroke, but lacunar stroke is less likely to be caused by embolism from the heart or proximal arteries, and the lower prevalence of ischemic heart disease in lacunar stroke provides additional support for a nonatherosclerotic arteriopathy causing many lacunar ischemic strokes. Our findings have implications for how clinicians classify ischemic stroke subtypes and highlight the need for additional research into the specific causes of and treatments for lacunar stroke.

Characteristics of the National Institute of Health Stroke Scale: Results from a Population-Based Stroke Cohort at Baseline and after One Year

Background: The National Institute of Health Stroke Scale (NIHSS) results at baseline and after 1 year have never before been accounted for within an unselected population-based stroke sample. Neither has it been shown which individual items in the scale are the most important ones for the outcome in terms of death or dependency after 1 year. Methods: The subjects were all patients within a municipality who had their first-ever non-subarachnoidal stroke during 1 year (n = 377). Impairment was evaluated at baseline (within 24–48 h) and after 1 year with the 15-item version of the NIHSS. At the 1-year follow-up, the Modified Rankin Scale was used in order to determine which patients were dependent. Predictors of death and dependency were analysed in logistic regression models. The different NIHSS items, age and gender were used as independent variables. Results: The median NIHSS score was 6 (interquartile range 3–12) at baseline and 1 (interquartile range 0–3) at the 1-year follow-up, when 33% of the patients had died. Of patients scoring less than 4 on baseline NIHSS, 75% were functionally independent after 1 year. Seventeen per cent were functionally dependent and 8% were dead. Independent predictors of death were: age, questions, commands, gaze, alertness and sensation. Independent predictors of dependency were: age, commands, alertness and motor leg. Conclusions: Baseline NIHSS predicts the outcome after 1 year at the group level. Age and any reduction of the level of consciousness on arrival were associated with bad outcome after 1 year.

A review on sex differences in stroke treatment and outcome

Appelros P, Stegmayr B, Terént A. A review on sex differences in stroke treatment and outcome.
Acta Neurol Scand: 2010: 121: 359–369.
© 2009 The Authors Journal compilation