Post‐stroke depression: can we predict its development from the acute stroke phase?

Objectives – To identify possible predictive factors for post‐stroke depression (PSD) in the acute phase of stroke. Methods – The study design was prospective, observational cohort study of patients with acute cerebral infarction (CI). Neurological and neuropsychological evaluations were conducted within the first 10 days from the onset of stroke and repeated at the 3‐month follow‐up. DSM‐IV criteria were used to define PSD. Results – From a total of 85 patients with CI, 59 patients completed the 3‐month follow‐up and 17 of them (28.8 %) fulfilled PSD criteria at the 3‐month follow‐up. Melancholy index of the Hamilton Depression Rankin Scale (HDRS) was associated with a risk three times greater than that of PSD at the 3‐month follow‐up in the univariate analysis (OR 3.07; 95% CI 1.53–6.16; P = 0.002) with no significant influence of stroke severity or the location of brain infarction (right or left side). The receiver operating characteristic curves pointed to a melancholy index ≥1.5 as the optimal cut‐off level associated with the development of PSD at the 3‐month follow‐up. Conclusions – Melancholy index of the HDRS ≥1.5 could be a useful clinical tool to detect patients with acute stroke at high risk of developing PSD.     

Post-stroke fatigue and return to work: a 2-year follow-up

Andersen G, Christensen D, Kirkevold M, Johnsen SP. Post‐stroke fatigue and return to work: a 2‐year follow‐up.
Acta Neurol Scand: 2012: 125: 248–253.
© 2011 John Wiley & Sons A/S. Background – Post‐stroke fatigue may affect the ability to return to work but quantitative studies are lacking. Method – We included 83 first‐ever stroke patients <60 years and employed either full‐time (n = 77) or part‐time (n = 6) at baseline. The patients were recruited from stroke units at Aarhus University Hospital between 2003 and 2005 and were followed for 2 years. Fatigue was assessed by the Multidimensional Fatigue Inventory. Pathological fatigue was defined as a score ≥12 on the General Fatigue dimension. Return to paid work was defined as working at least 10 h per week. Data were analyzed using multivariable logistic regression. Results – A total of 58% of patients had returned to paid work after 2 years. The adjusted Odds Ratio (OR) for returning to paid work was 0.39 (95% confidence interval (CI) 0.16–1.08) for patients with a General Fatigue score ≥12 at baseline. Persisting pathological fatigue after 2 years of follow‐up was associated with a lower chance of returning to paid work [adjusted OR 0.29 (95% CI 0.11–0.74)]. Higher scores of General Fatigue at follow‐up also correlated negatively with the chance of returning to paid work when analyzing fatigue on a continuous scale (adjusted OR 0.87, 95% CI 0.80–0.94 for each point increase in General Fatigue). Conclusions – Post‐stroke fatigue appears to be an independent determinant of not being able to resume paid work following stroke.     

Reduced severity of strokes in patients with silent brain infarctions

Background: Silent brain infarctions (SBIs), leukoaraiosis (LA), and microbleeds (MBs) are ischaemic silent radiologic abnormalities that act as predictors of subsequent strokes. This study investigated the independent effect of silent radiologic abnormalities on initial stroke severity and short‐term outcome. Methods: A consecutive series of patients who had their first ischaemic stroke within 72 h of symptom onset were included. Demographic and clinical characteristics were collected on admission, and magnetic resonance imaging was performed to evaluate the ischaemic lesion, SBI, LA, and MB. Factors potentially associated with lower initial stroke severity (admission NIH Stroke Scale 0–5) and good short‐term outcome (discharge NIH Stroke Scale 0–5, modified Rankin Scale 0–1) were validated by multivariate analysis. Results: Silent brain infarctions were noted in 82 (45%) of the 182 patients. Although there were no statistically significant differences in stroke subtypes and lesion location, univariate analysis revealed that patients with SBI had reduced stroke severity (P = 0.005) and infarction volume (P = 0.001). After adjusting for covariates, the presence of SBI was independently associated with lower stroke severity and good short‐term outcome when the NIH Stroke Scale was used as dependent variable (OR 3.368, 95% CI 1.361–8.332, P = 0.009; OR 3.459, 95% CI 1.227–9.755, P = 0.019, respectively). However, the presence of SBI lost significance when the discharge‐modified Rankin Scale was used as dependent variable (P = 0.058). Conclusion: Amongst silent radiologic abnormalities, SBI was the only predictor of reduced stroke severity and infarct volume. Silent brain infarction deserves more attention in evaluating stroke severity.     

Association of non‐diabetic hyperglycemia with autonomic shift in acute ischaemic stroke

Background and purpose: The etiology of hyperglycemia in acute stroke remains controversial. It is unclear whether hyperglycemia arises as an epiphenomenon of stroke or as a reflection of underlying diabetes. Autonomic shift to sympathetic overactivity has been repeatedly observed in acute stroke. We hypothesize that hyperglycemia in acute stroke relates to autonomic imbalance and that the respective deleterious effects on stroke outcome may be cross‐linked. Methods: A total of 75 non‐diabetic patients with ischaemic stroke were included in a prospective study. Glucose levels at admission, fasting glucose, and glucose profiles were recorded. Autonomic function was quantified by the assessment of spontaneous baroreflex sensitivity (BRS) using a cross‐correlation method. Demographic and clinical data including stroke volumes and admission National Institute of Heath Stroke Scale scores were included into the analysis. Functional outcome at 90 days was assessed using the modified Rankin Scale. Results: Hyperglycemia was correlated with decreased BRS independent of stroke severity or volume (r = ?0.46, P < 0.001). In two separate regression models, glucose levels and BRS independently predicted unfavorable outcome at 3 months (OR = 1.06, CI = 1.02–1.11, P = 0.004 and OR = 0.75, CI = 0.56–0.99, P = 0.04). However, combining the models, only glucose levels (OR = 1.06, CI = 1.02–1.11, P = 0.004) remained independent predictor of outcome at 3 months. Conclusions: We observed an association between hyperglycemia and decreased BRS in non‐diabetic patients, suggesting that hyperglycemic reaction in acute stroke may reflect stroke‐related autonomic changes. Moreover, outcome effects of autonomic changes and hyperglycemia seem to be interdependent, putatively having the sympatho‐vagal imbalance as common underlying mechanism. The possible therapeutic relevance of this finding warrants further studies.     

Intravenous thrombolysis in patients with stroke attributable to small artery occlusion

Background: Intravenous thrombolysis (IVT) for stroke seems to be beneficial independent of the underlying etiology. Recent observations raised concern that IVT might cause harm in patients with strokes attributable to small artery occlusion (SAO). Objective: The safety of IVT in SAO‐patients is addressed in this study. Methods:  We used the Swiss IVT databank to compare outcome and complications of IVT‐treated SAO‐patients with IVT‐treated patients with other etiologies (non‐SAO‐patients). Main outcome and complication measures were independence (modified Rankin scale ≤2) at 3 months, intracranial hemorrhage (ICH), and recurrent ischaemic stroke. Results: Sixty‐five (6.2%) of 1048 IVT‐treated patients had SAO. Amongst SAO‐patients, 1.5% (1/65) patients died, compared to 11.2% (110/983) in the non‐SAO‐group (P = 0.014). SAO‐patients reached independence more often than non‐SAO‐patients (75.4% versus 58.9%; OR 2.14 (95% CI 1.20–3.81; P = 0.001). This association became insignificant after adjustment for age, gender, and stroke severity (OR 1.41 95% CI 0.713–2.788; P = 0.32). Glucose level and (to some degree) stroke severity but not age predicted 3‐month‐independence in IVT‐treated SAO‐patients. ICHs (all/symptomatic) were similar in SAO‐ (12.3%/4.6%) and non‐SAO‐patients (13.4%/5.3%; P > 0.8). Fatal ICH occurred in 3.3% of the non‐SAO‐patients but none amongst SAO‐patients. Ischaemic stroke within 3 months after IVT reoccurred in 1.5% of SAO‐patients and in 2.3% of non‐SAO‐patients (P = 0.68). Conclusion: IVT‐treated SAO‐patients died less often and reached independence more often than IVT‐treated non‐SAO‐patients. However, the variable ‘SAO’ was a dependent rather than an independent outcome predictor. The absence of an excess in ICH indicates that IVT seems not to be harmful in SAO‐patients.     

Significance of microbleeds in patients with transient ischaemic attack

Background and purpose: The aim of this study was to determine the prognostic significance of microbleeds in TIA‐patients. In patients with a transient ischaemic attack (TIA), the prognostic value of microbleeds is unknown. Methods: In 176 consecutive TIA patients, the number, size, and location of microbleeds with or without acute ischaemic lesions were assessed. We compared microbleed‐positive and microbleed‐negative patients with regard to the end‐point stroke within 3 months. Results: Four of the seven patients with subsequent stroke had microbleeds. Microbleed‐positive patients had a higher risk for stroke [odds ratios (OR) 8.91, 95% CI 1.87–42.51, P < 0.01] than those without microbleeds. Microbleed‐positive patients with accompanying acute ischaemic lesions had a higher stroke risk than those with neither an acute ischaemia nor a microbleed (OR 6.20, 95% CI 1.10–35.12; P = 0.04). Conclusion: Microbleeds alone or in combination with acute ischaemic lesions may increase the risk for subsequent ischaemic stroke after TIA within 3 months.     

Ginsenoside-Rd improves outcome of acute ischaemic stroke - a randomized, double-blind, placebo-controlled, multicenter trial

Background and purpose: Ginsenoside‐Rd is a receptor‐operated calcium channel antagonist and has shown promise as a neuroprotectant in our phase II study. As an extended work, we sought to confirm its efficacy and safety of Ginsenoside‐Rd in patients with acute ischaemic stroke. Methods: We conducted a randomized, double‐blind, placebo‐controlled trial involving 390 patients with acute ischaemic stroke in a 3:1 ratio to receive a 14‐day intravenous infusion of Ginsenoside‐Rd or placebo within 72 h after the onset of stroke. Our primary end‐point was the distribution of disability scores on the modified Rankin scale (mRs) at 90 days. Results: The efficacy analysis was based on 386 patients (Ginsenoside‐Rd group: 290; placebo group: 96). Ginsenoside‐Rd significantly improved the overall distribution of scores on the mRs, as compared with the placebo (P = 0.02; odds ratios [OR], 1.74; 95% confidence interval [CI], 1.08–2.78). There were significant differences between the two groups when we categorized the scores into 0–1 vs. 2–5 (P = 0.01; OR, 2.32; 95% CI, 1.23–4.38; 66.8% vs. 53.1%). It also improved the National Institutes of Health Stroke Scale (NIHSS) at 15 days [P < 0.01; least squares mean (LSM), ?0.77; 95% CI, ?1.31 to ?0.24]. Mortality and rates of adverse events were similar in the two groups. Conclusions: Ginsenoside‐Rd improved the primary outcome of acute ischaemic stroke and had an acceptable adverse‐event profile.     

Strokes in paroxysmal atrial fibrillation have more favorable outcome than in permanent atrial fibrillation

Background – Permanent (ptAF) and paroxysmal (pxAF) atrial fibrillation carry similar risk of ischemic stroke (IS). Objective – Our aim was to compare the course of IS due to ptAF and pxAF. Methods – A prospective, single‐center study was conducted in patients with AF and acute IS with 6‐month follow‐up. Results – We included 178 patients: 70 (39%) with pxAF and 108 (61%) with ptAF. Compared with patients with ptAF, patients with pxAF more often presented with subcortical, mainly lacunar strokes (21% vs 8%, P = 0.01) and were less frequently dependent at discharge (16% vs 42%, P < 0.001) and after 6 months (16% vs 20%, P < 0.001). Strokes in patients with pxAF were more frequently categorized as non‐cardioembolic (35% vs 18%, P = 0.01). In the multivariate analysis, after adjustment for confounding factors (diabetes, chronic heart failure, high risk of thromboembolism and lack of prestroke anticoagulation), ptAF was an important risk factor for unfavorable short‐term (OR 5.4; P < 0.01) and long‐term outcomes (OR 2.6, P = 0.01) of IS. In all patients with AF, the occurrence of non‐cardioembolic stroke was related to a reduced risk of dependence or death in short‐term outcome (OR 0.4, P = 0.04) and marginally influenced long‐term outcome (OR 0.49, P = 0.09). Conclusions – The present study suggests that, compared with patients with ptAF, ISs in patients with pxAF have better outcomes.     

Apathy in acute stroke patients

Background and purpose: Apathy is a frequent disturbance in stroke patients. The aim of this case–control study was to elucidate whether apathy: (i) was secondary to stroke or related to hospitalization, (ii) was related to thalamic and striatocapsular stroke lesions, (iii) was independent from cognitive impairment and depression in the acute phase of stroke, (iv) was associated with clinical and demographical variables and (v) was associated with a worse functional outcome at discharge. Methods: We assessed a sample of 94 consecutive patients with an acute (≤4 days) stroke (22 intracerebral haemorrhages, 72 cerebral infarcts), and a control group of 50 patients with acute coronary syndrome, with the 10‐item Apathy Evaluation Scale‐Clinical. We related apathy with cognition (MMSE), depression (Montgomery Åsberg Depression Rating Scale) and with outcome (modified Rankin Scale). Results: Apathy was present in 36 (38.3%) acute stroke patients but was also frequent in patients with acute coronary syndrome (24%). Stroke patients were more inaccurate in understanding their problems than patients with acute coronary syndrome (P = 0.005). Logistic regression identified cerebral haemorrhage (OR = 3.5), low educational level (OR = 4.7) and a trend of right hemispherical lesion (OR = 3.0) as independent predictors for apathy (R² = 32.3%). Cognitive impairment and depression were not associated to apathy. Apathy was associated with a worse outcome (P = 0.03). Conclusion: Apathy was frequent in acute stroke patients, and it was predicted by acute intracerebral haemorrhage and right hemispherical acute stroke lesion.     

Predictors for 5-year survival in a prospective cohort of elderly stroke patients

Whiting R, Shen Q, Hung WT, Cordato D, Chan DKY. Predictors for 5‐year survival in a prospective cohort of elderly stroke patients.
Acta Neurol Scand: 2011: 124: 309–316.
© 2011 John Wiley & Sons A/S. Objectives – To examine predictors for 5‐year survival in elderly stroke patients. Materials and Methods – Prospective cohort study of 186 consecutive acute stroke patients aged ≥65 years admitted to Bankstown‐Lidcombe Hospital, Australia 03/2002 to 03/2003. All subjects were followed up in 2007/8, at 5 years post‐stroke, for outcome measures. Logistic regression analysis was performed to predict 5‐year survival using covariables, including functional status, age, stroke type and severity and vascular risk factors. Patients lost to follow‐up (n = 20) were excluded from the analyses. Results – One hundred patients (60%) were dead at study end. Predictors for survival in final logistic regression model were as follows: Glasgow Coma Scale (GCS) on admission (OR 1.49, 95%CI 1.1–2.0, P = 0.01), preadmission functional independence measure (FIM) score (OR 1.04, 95%CI 1.0–1.1, P = 0.01), age (OR 0.93, 95%CI 0.87–0.98, P = 0.01) and atrial fibrillation (OR 0.43, 95% CI 0.19–0.95, P = 0.04). For 5‐year survivors, mean Modified Rankin Scale was 3.1 ± 1.5, total FIM score 85 ± 32, mini‐mental state examination (MMSE) 22 ± 8 and Hospital Anxiety and Depression (HAD) scores 5.4 ± 3.4 and 5.2 ± 3.9, respectively. FIM cognition score was significantly lower at 5 years when compared to baseline (24 ± 8 vs 29 ± 8, P < 0.05) (all scores expressed as mean ± SD). In contrast, MMSE, HAD and total FIM scores were not significantly different at 5 years when compared to baseline. Conclusions – The study identified lower GCS on admission, lower preadmission FIM score, age and atrial fibrillation as negative predictors for 5‐year survival following stroke.     

Off-label intravenous thrombolysis in acute stroke

Background and purpose:  Therapy for stroke with intravenous tissue plasminogen activator (IV‐tPA) is hampered by tight licensing restrictions; some of them have been discussed in recent literature. We assessed the safety and effectiveness of off‐label IV‐tPA in the clinical settings. Methods:  Retrospective analysis of all the patients treated with IV‐tPA at our Stroke Unit. Patients were divided into two groups by licence criteria [on‐label group (OnLG), off‐label group (OffLG)]. Primary outcome measures were symptomatic intracranial haemorrhages (sICH), major systemic haemorrhages, modified Rankin scale (mRS) and mortality rate at 3 months. Results:  Five hundred and five patients were registered, 269 (53.2%) were assigned to OnLG and 236 (46.9%) to OffLG. Inclusion criteria for the OffLG were aged >80 years (129 patients), time from onset of symptoms to treatment over 3 h (111), prior oral anticoagulant treatment with International Normalised Ratio ≤ 1.7 (41), combination of previous stroke and diabetes mellitus (14), surgery or severe trauma within 3 months of stroke (13), National Institutes of Health Stroke Scale score over 25 (11), intracranial tumours (5), systemic diseases with risk of bleeding (7) and seizure at the onset of stroke (2). No significant differences were identified between both groups regarding the proportion of sICH (OnLG 2.2% vs. OffLG 1.6%, P = 0.78) or the 3‐month mortality rate (11.1% vs. 19%: odds ratio (OR), 1.49; 95% CI, 0.86–2.55; P = 0.14). Multivariate analysis showed no significant differences in functional independence at 3 months between both groups (mRS <3 64.3% vs. 50.4%: OR mRS >2 1.7; 95% CI, 0.96–2.5; P = 0.07). Conclusion:  Intravenous thrombolysis may be safe and efficacious beyond its current label restrictions.     

Risk factors for periodic breathing in acute stroke: tracheobronchial infection

Background and purpose: Despite evidence from clinical and population studies, the aim of the present study was to suggest that multiple factors contribute to periodic breathing (PB). However, little information has been focused on episodes of tracheobronchial infections (TBI) preceding PB onset. Methods: Thirty subjects with acute stroke who had PB and 41 subjects with acute stroke that of a sex‐ and age‐matched control group without PB were retrospectively evaluated. Stroke location, extent of stroke (demonstrated on CT or MRI), and characteristics of TBI before PB were assessed. PB diagnosis was carried out using a portable device and a pulse oximeter. Risk factors for patients with PB were compared with those without PB by univariate and multivariate analysis. Results: Twenty‐four TBI in 30 patients with PB and 11 TBI in 41 patients with non‐PB were diagnosed. There was no significant difference in age, sex, body mass index, stroke type, stroke location, or underlying diseases between the two groups (P > 0.05). There was a significant difference in snoring, first recurrent stroke, Glasgow Coma Scale, congestive heart failure, TBI, and inflammatory responses between the PB and non‐PB group (P < 0.05). Multiple logistic regression analyses showed a difference in the prevalence of snoring (OR = 10.813, CI = 2.131–54.866, P < 0.01), TBI (OR = 5.313, CI = 1.241–22.740, P < 0.05), and inflammatory responses (OR = 7.315, CI = 1.253–43.123, P < 0.05) between the two groups. Conclusions: In addition to snoring, TBI and inflammatory responses are the two independent predictors for PB in patients with acute stroke. Clinicians should be encouraged to systematically evaluate TBI and inflammatory responses before PB in patients with acute stroke.     

Serum cholesterol levels and survival after rtPA treatment in acute stroke

Background: According to the reverse epidemiology hypothesis, high cholesterol levels might be protective and associated with greater survival rates under certain conditions. In stroke patients, a clear correlation between lipid levels and mortality after ischaemic and hemorrhagic strokes has been demonstrated. The aim of this study was to analyze the impact of lipid levels on 3‐month mortality in patients with ischaemic stroke (IS) homogeneously treated with intravenous rtPA and admitted to a monitored acute stroke unit. Methods: Retrospective analysis of a prospective cohort of 220 patients with an IS treated with rtPA within the first 4.5 h in a single tertiary hospital from January 2005 to August 2010. Results: Mortality at 3 months was 15.0%. Univariate analysis showed that age, NIHSS at admission, heart failure, and atrial fibrillation were directly related to 3‐month mortality; cholesterol, triglycerides, and low density lipoprotein were inversely associated. The death rate by cholesterol level was 5.5% for the highest tertile (>192 mg/dl), 13.7% for the middle (192–155 mg/dl), and 25.7% for the lowest (<155 mg/dl), P = 0.003. Multivariate analysis showed that amongst the lipid determinations, only cholesterol [OR: 0.985 (95% CI: 0.972–0.998), P = 0.021] was inversely associated with 3‐month mortality. The ‘protective’ effect of cholesterol was independent of stroke severity and remained significant in non‐lacunar strokes. Conclusions: Survival of stroke patients receiving current, most effective medical treatment is related to blood cholesterol levels, with an inverse relationship between cholesterol and mortality. The mechanism of this apparently paradoxical situation remains unexplained but merits further research.     

Stroke phenotype in cannabis users among young adults with ischemic stroke

Background and purpose

Incidence of ischemic stroke in young adults has been steadily increasing over the past 20 years. One hypothesis to explain this phenomenon is the increase in the use of illicit drugs, including cannabis. However, the mechanisms and the clinical presentation of ischemic stroke associated with cannabis use are unclear. The objective of this study was to describe the phenotype of ischemic stroke in cannabis users compared to nonusers among a population of young adults with a first-ever ischemic stroke.

Methods

Patients aged 18–54 years consecutively hospitalized in a university department of neurology for a first-ever ischemic stroke from January 2017 to July 2021 were included. Drug use over the past year was assessed by a semistructured interview, and the stroke phenotype was described using the ASCOD classification.

Results

A total of 691 patients, including 78 of 691 (11.3%) cannabis users, were included. Cannabis use was independently associated with potential A1 (odds ratio [OR] = 3.30, 95% confidence interval [CI] = 1.45–7.5, p = 0.004) and uncertain A2 (OR = 13.1, 95% CI = 2.89–59.4, p < 0.001) atherosclerotic cause of stroke after adjustment for vascular risk factors including tobacco and other drug use. Moreover, the association of atherosclerosis and cannabis use was significant for frequent (OR = 3.13, 95% CI = 1.07–8.6, p = 0.030) and daily cannabis use (OR = 4.43, 95% CI = 1.40–13.4, p = 0.008), but not for occasional use.

Conclusions

We found a significant, independent, and graded association of cannabis use with the atherosclerotic stroke phenotype.     

A population‐based case–control study of 1250 stroke deaths in rural Bangladesh

Background and purpose:  There are limited population‐based studies to determine the risk factors for stroke in Bangladesh. Methods:  A health and demographic surveillance system has been maintained in Matlab, Bangladesh (population 223 886, 142 villages in 2008). All adult stroke and injury deaths (2005–2008) were monitored by verbal autopsy. Risk factors for stroke deaths were calculated using a multivariable logistic regression model with adult injury deaths as controls. Results:  A total of 1250 stroke deaths (51% women; mean age 72.3 years, range 20–101) occurred out of 4955 total deaths and were compared with 246 adult injury deaths (47% women, mean age 55.8 years, range 20–100). The population‐attributable mortality of stroke was 25.2% based on the verbal autopsy instrument and 17.8% when accounting for the reported sensitivity and specificity of a similar verbal autopsy instrument that has been validated for stroke death. Risk of stroke death was significantly increased with hypertension (OR 7.94, 95% CI 4.44–15.54, P < 0.001), diabetes mellitus (OR 2.54, 1.21–6.21, P = 0.02), and betel consumption (OR 2.36, 1.45–3.80, P < 0.001) when adjusted for age and sex. An increased risk was not observed with heart disease (OR 1.37, 0.45–5.95, P = 0.62), cigarette smoking (OR 1.41, 0.82–2.45, P = 0.22), tobacco powder (OR 1.15, 0.30–7.64, P = 0.86), or cigar/hookah pipe smoking 0.94 (0.45–2.18, P = 0.88) when adjusted for age and sex. There were more strokes in winter (December–March) than summer (June–September) (P < 0.001). Conclusions:  There is a high modifiable burden of risk factors for adult stroke deaths in rural Bangladesh, most notably including hypertension. Betel consumption may be an under‐recognized risk factor for stroke death.     

Plasma and cerebrospinal fluid substance P in post-stroke patients with depression

Aims: To investigate the correlation between the incidence of post‐stroke depression (PSD) and the levels of substance P (SP) in the plasma and cerebrospinal fluid (CSF). Methods: Ninety‐one stroke patients were divided into PSD (n = 46) and post‐stroke (without depression) groups (n = 45). PSD must have occurred 2–4 weeks after the onset of the stroke and was determined by the Hamilton Rating Scale for Depression (HAMD). In addition, the subjects were divided into anterior (n = 67) and posterior circulation stroke groups (n = 24) based on the location of the focus as determined by computed tomography. All recruited patients were graded by the National Institutes of Health Stroke Scale (NIHSS). Results: The results included the following findings: (i) the level of plasma SP in the PSD group (58.47 ± 14.39) was higher than that of the PS group (36.98 ± 9.49; P = 0.000), while the level of CSF SP in the PSD group (72.13 ± 13.06) was higher than that of the post‐stroke group (37.30 ± 12.57; P = 0.03); (ii) the level of plasma SP was positively correlated with the HAMD and NIHSS score; (iii) the level of plasma SP (38.45 ± 12.23), the HAMD score (9.08 ± 8.72), and the NIHSS score (3.25 ± 1.90) of the anterior stroke group (51.21 ± 16.27, 17.46 ± 15.96, and 6.91 ± 3.30, respectively) were higher than those of the posterior stroke group (38.45 ± 12.23, 9.08 ± 8.7, and 3.25 ± 1.90, respectively; P = 0.017, P = 0.001, and P = 0.000, respectively). Conclusions: SP in the plasma and CSF of patients exhibited a close correlation with neural damage and the incidence of PSD. This study also suggested that anterior hemispheric strokes may play a significant role in development of PSD.     

Time course and risk factors of post‐stroke fatigue: a prospective cohort study

Background: Post‐stroke fatigue (PSF) often occurs after stroke and has a negative impact on the rehabilitation process. Several studies focused either on short‐ or on long‐term PSF and their relations with stroke characteristics. However, possible pre‐stroke risk factors such as history of depression, pre‐existent white matter lesions or brain atrophy were usually not taken into account. Therefore, the precise mechanisms underlying PSF remain still unclear. This study was aimed at assessing the possible contributions of (pre‐)stroke factors to both short‐term PSF and its course over time. Methods: This study pertains to 108 patients with an acute cerebral infarction. PSF was rated by the Checklist Individual Strength at 2 months and 1.5 year post‐stroke. The relation between (pre‐)stroke factors and PSF was assessed with multivariate regression analysis. Results: The prevalence of baseline PSF was 35% and at follow‐up 33%. Older age had a protective effect on PSF at baseline (OR 0.95; 95% CI 0.91–0.98), whereas post‐stroke depressive symptoms and infratentorial infarctions were related to an increased risk for PSF (OR 1.40; 95% CI 1.21–1.63 and OR 4.69; 95% CI 1.03–21.47, respectively). Baseline fatigue was related to an increased risk of PSF at follow‐up (OR 1.15; 95% CI 1.09–1.22). Conclusions: Predictors for baseline fatigue were younger age, post‐stroke depressive symptoms, and infratentorial infarctions. Baseline fatigue did predict fatigue outcome over time, suggesting that early interventions might be useful to prevent deteriorated PSF.     

Thrombolytic therapy for acute stroke in Austria: data from the Safe Implementation of Thrombolysis in Stroke (SITS) register

Background: We aimed at determining the safety and efficacy of IV alteplase in Austrian versus non‐Austrian centres as documented in the Internet‐based registers Safe Implementation of Thrombolysis for Stroke – MOnitoring STudy (SITS‐MOST) and – International Stroke Thrombolysis Register (SITS‐ISTR). Methods: We analysed patient data entered in the registers SITS‐MOST and SITS‐ISTR in the period December 2002 to 15 November 2007. Results: Compared to the non‐Austrian cohort (n = 15153), the Austrian cohort (n = 896) was slightly older [median, interquartile range (IQR): 70, 60–77 years vs. 69, 60–76 years, P = 0.05] and included more women (44.6% vs. 41.0%, P = 0.03). Austrian patients had a significantly shorter stroke onset‐to‐treatment time (OTT; median, IQR: 135, 105–160 min vs. 145, 115–170 min, P < 0.0005). Symptomatic intracerebral haemorrhages were observed in 1.6% of Austrian and 1.7% of non‐Austrian patients (P = 0.82). At 3 months, 50.8% of Austrian and 53.0% of non‐Austrian patients were independent (P = 0.23), but death was less frequent in Austrian patients (12.1% vs. 14.9%, P = 0.03). Multivariate analyses adjusted for demographic and baseline characteristics confirmed lower mortality at 3 months in the Austrian cohort (odds ratio 0.81, 95% confidence intervals 0.71–0.92, P = 0.001). Longer OTT was associated with increased mortality at 3 months, with a hazard ratio of 1.02 (95% CI 1.01–1.03; P = 0.005) for each 10‐min increase in OTT. Conclusions: The implementation of intravenous alteplase for acute stroke has been safe and efficacious in Austrian centres. OTT and mortality were significantly lower in Austrian patients compared to non‐Austrian SITS centres.     

Vascular cognitive syndromes: relation to stroke etiology and topography

Background – Cognitive syndromes (CS) after stroke may be important to measure and monitor for management and emerging therapies. Aim – To describe the spectrum and frequency of CSs in the first month after stroke and to relate these to stroke etiology and topopgraphy. Methods – A validated cognitive examination was administered during the first month of stroke presentation and analyzed according to five large‐scale networks for cognition and correlated with neuropsychological tests. A multivariate analysis was performed to determine association of CSs with etiology (TOAST classification), topography and neurological deficit by National Institute of Health Stroke Score (NIHSS). Results – Of a total of 2105 patients, one or more patients with CS was present in 1569/1796 (87%) stroke patients vs 112/309 (36%, P ≤ 0.001) transient ischemic attack (TIA) patients. The frequency of frontal network syndromes (FNS) was 908/1796 (51%), left hemisphere network (LH) syndromes 646/1796 (36%), right hemisphere (RH) network syndromes 275/1796 (15.3%), occipitotemporal network (OT) syndromes 107/1796 (6%), hippocampal limbic (HL) network syndromes 397/1796 (22%) and miscellaneous (M) syndromes 481/1796 (27%). Stroke etiology and their signature CS by multivariate analyses revealed significant associations for LH with cardioembolism (OR 1.61, P = 0.0029), FNS and ‘other’ etiology (OR 1.96, P ≤ 0.0001) and HL also for ‘other’ etiology (OR 1.57, P = 0.0026). Coma (OR 2.95, P ≤ 0.0001) and encephalopathy (OR 2.82, P ≤ 0.0001) were both associated significantly with hemorrhage. A left hemisphere lesion was associated with LH CSs (OR 9.26, P ≤ 0.0001). An FNS was associated with frontal lesions (OR 5.19, <0.0001) as well as subcortical lesions (OR 1.91, P ≤ 0.0001). The M group of CS was associated with subtentorial (OR 1.86, P = 0.0283) and right hemisphere lesions (OR 2.47, P ≤ 0.0001). The LH and RH syndromes had the highest NIHSS and differed significantly from all others. Conclusions – (1) CSs are present in the vast majority of stroke patients. (2) Particular stroke etiological subtypes are associated with specific CS. (3) Certain signature CS results from lesions that relate to the major anatomical cognitive networks.     

Human Cytomegalovirus Linked to Stroke in a Chinese Population

Aim: Human cytomegalovirus (HCMV) is implicated in several cardiovascular disorders, including atherosclerosis, coronary heart disease, and cardiac transplant arteriopathy. We aimed to evaluate the relationship between HCMV and stroke. Methods: Real‐time polymerase chain reaction (PCR) and ELISA were performed on plasma samples isolated from 200 patients diagnosed with stroke and 200 controls. All participants belonged to the Stroke Hypertension Investigation in Genetics (SHINING) study. Results: HCMV seropositivity was higher in the stroke group than in controls (55.0% vs. 23.5%; P < 0.0001). The presence of HCMV DNA increased the risk of stroke (unadjusted odds ratio [OR], 3.98; 95% confidence interval [CI], 2.59 to 6.11; P < 0.0001). Risks were also increased for the subtypes ischemic stroke (unadjusted OR, 4.01; 95% CI, 2.57–6.24; P < 0.0001) and hemorrhagic stroke (unadjusted OR, 3.80; 95% CI, 1.64–8.78; P= 0.0018). Increased risk with HCMV remained significant after adjustment for age, sex, body mass index, hypertension, and smoking (ischemic stroke: adjusted OR, 4.07; 95% CI, 2.52–6.32; P < 0.0001; hemorrhagic stroke: adjusted OR, 3.88; 95% CI, 1.61–9.36; P= 0.0026). Conclusions: We demonstrate a novel link between HCMV infection and stroke. These findings may provide important insights into the pathogenesis of stroke.