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.     

Prevalence of stroke in Parkinson's disease: a postmortem study.

The results of previous epidemiological studies of the relationship between Parkinson's disease and stroke have been conflicting; some showing a reduced risk of ischaemic and haemorrhagic stroke during life, and others indicating an increased likelihood of stroke-related death. We compared the frequency of cerebral infarcts and haemorrhages at postmortem in 100 cases of pathologically verified idiopathic Parkinson's disease and 100 age-matched control brains. No significant differences were found in the numbers of infarcts or haemorrhages or stroke-related deaths between the two groups. Our findings do not indicate either a protective effect against stroke, or a greater susceptibility to death from stroke, in the population studied.     

Depression after minor stroke: prevalence and predictors

Background and purpose: Post‐stroke depression (PSD) is one of the most frequent complications of stroke, with a prevalence ranging 20–60%. As PSD seems to be related to stroke severity, we hypothesized that the prevalence of PSD would be lower in patients with minor stroke. Methods: We investigated the prevalence and predictors of PSD over a 30‐month follow‐up period in a cohort of patients with minor ischaemic stroke (NIHSS ≤ 5). Results: We enrolled 105 patients (mean age 64.38 ± 11.2 years, M/F 69/36). PSD was diagnosed in 43 (41%) patients, 40 (93%) of whom had dysthymia; 22% of patients were already depressed at 1 month. The most frequent depressive symptoms (DSs) were working inhibition, indecisiveness, and fatigability. Patients who developed PSD were less educated (P = 0.044) and diabetic (P = 0.006). After excluding patients that were already depressed at 1 month, we performed a logistic regression model to detect predictors of PSD. Crying (P = 0.012, OR 1.067, CI 0.269–4.553) and guilt (P = 0.007, OR 0.037, CI 0.02ì03–0.401) at baseline were two DSs found to be significantly correlated with PSD. Higher educational level (P = 0.022, OR 0.084, CI 0.010–0.698) and diabetes (P = 0.007, OR 14.361, CI 2.040–101.108) were the risk factors significantly correlated with PSD. Conclusion: Post‐stroke depression is frequent even in patients with minor stroke. Early detection of DSs might help to predict long‐term development of PSD. No correlation was observed between lesion site or side and the development of PSD.     

Prevalence of disabling spasticity 1 year after first-ever stroke

Objective:  To estimate the prevalence of disabling spasticity (DS) 1 year after first-ever stroke.
Design:  Cross-sectional survey 1 year after first-ever stroke.
Methods:  Patients above 18 years from one county with first-ever stroke were identified by use of the national stroke registry. A representative sample of 163 patients was created and 140 of these were followed up. Assessments of motor function and ability with the modified Ashworth Scale, the modified Rankin Scale (mRS), the Barthel Index (BI) and clinical evaluation were performed in order to identify patients with spasticity-related disability.
Results:  The observed prevalence of any spasticity was 17% and of DS 4%. Patients with DS scored significantly worse than those with no DS on the mRS ( P  = 0.009) and the BI ( P  = 0.005). DS was more frequent in the upper extremity, correlated positively with other indices of motor impairment and inversely with age. There was an independent effect of severe upper extremity paresis (OR 22, CI 3.9–125) and age below 65 years (OR 9.5, CI 1.5–60).
Conclusions:  The prevalence of DS after first-ever stroke is low but corresponds to a large number of patients and deserves further attention with regards to prevention and treatment .     

Prevalence of insomnia symptoms: results from an urban district in Ankara,Turkey

Objective. Characteristics of insomnia symptoms in Turkey are not well established. The goal of this study was to determine the prevalence of insomnia and related symptoms in an urban district of Turkey. Method. The study was carried out in Ankara, in an urban district with a population of 2665. Out of the 1332 people in the sample, 1034 in the 15–65 age range were included in the study. Interviews were conducted according to the “Sleep Disorders Assessment Questionnaire” developed by the researchers. The Insomnia Severity Index (ISI) was also given to the subjects with a sleep problem to measure the subjective quality and quantity of insomnia symptoms. Results and conclusion. A total of 29.4% of all participants reported a sleep problem, out of which 23.7% defined one or more of the insomnia symptoms which included difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS), early morning awakening (EMA), non-restorative sleep (NRS) and sleep deprivation (SD). Insomnia risk was found to be significantly increased with age, female sex, smoking and chronic medical illness. A total of 75.9% of participants who reported insomnia symptoms did not seek medical help for their complaint. According to the ISI, among the subjects with insomnia symptoms, 79 (32.2%) had subthreshold insomnia, 43 (17.6%) had clinical insomnia, 12 (4.9%) had severe clinical insomnia, while 88 (35.9%) did not score in the range indicating insomnia. The findings are discussed in the light of previous research and in relation to sociocultural factors emphasizing the need for public education on sleep disorders as medical conditions.     

Multiple modifiable risk factors for first ischemic stroke: a population-based epidemiological study

The aims of this epidemiological population-based cohort study were to examine the prevalence of the multiple modifiable vascular risk factors, their distribution patterns and outcomes among a Bulgarian urban population. A total of 500 volunteers, 200 men and 300 women, without clinical signs and symptoms of cerebrovascular disease, aged 50-79 years, were enrolled in the study. A structured questionnaire, physical examination, electrocardiogram records, a battery of laboratory tests and carotid duplex scanning were employed. Three or more modifiable vascular risk factors were detected in 52% (260/500) of the subjects. Dyslipidemias, hypertension, obesity, cigarette smoking and cardiac diseases were found to be the most prevalent single risk factors. Asymptomatic carotid stenosis (ACS) of 50% or greater was detected in 8.8% (23/260) of the volunteers examined. After a 2-year follow-up, 2.7% (7/260) of the persons with modifiable vascular risk factors reached the end point transient ischemic attacks (TIAs), ischemic stroke and myocardial infarction. The following combinations of risk factors among the subjects enrolled in the study were significantly associated with these outcomes: hypertension and cardiac diseases (OR = 6.82; 95% CI, 1.21-38.41), cardiac diseases and obesity (OR = 6.13; 95% CI, 1.27-29.72), ACS and high low-density lipoprotein (LDL) cholesterol levels (OR = 11.11; 95% CI, 1.58-78.29). The identification of subjects with multiple vascular risk factors may be important for primary medical or surgical stroke prevention.     

进展性脑卒中相关因素临床研究

目的探讨并总结诱发进展性脑卒中的主要相关危险因素,为临床治疗提供参考依据。方法将我院自2009-02—2011-06收治的进展性脑卒中54例病人作为观察组;随机抽取同期我院收治的非进展性卒中52例病人作为对照组,对比分析2组脑卒中病人主要危险因素。结果 54例进展性脑卒中病人中存在高血压者38例,占70.5%,52例对照组中存在高血压26例,占50.4%,2组病例数相比差异具有统计学意义(P<0.05);观察组患高血糖36例,占65.9%;对照组患高血糖19例,占35.7%,2组病例数相比差异具有统计学意义(P<0.05);观察组有高胆固醇42例,而对照组为34例,2组相比差异无统计学意义(P>0.05)。观察组中感染11例,占19.7%,对照组感染7例,占12.6%,2者感染率相比差异具有统计学意义(P<0.05);观察组病人颈部血管狭窄27例,其中18例为颈动脉,9例为椎动脉,对照组动脉狭窄11例,其中8例为颈动脉,3例为椎动脉,2组相比差异具有统计学意义(P<0.01)。结论高血压、高血糖、近期感染以及动脉粥样狭窄是诱发进展性脑卒中的主要危险因素,临床上应给予足够重视。     

Ischemic stroke in young adults I. Analysis of the etiological subgroups

An ischemic stroke (IS) group including 386 patients under 50 years old is analysed taking into account different etiological subgroups and comparing risk factors against a control group of 100 people. The series points out the presence of 66.1% patients included in the inconclusive-atherothrombosis group, of which 22.7% had defined criteria of atheromatosis, while 11.6% were diagnosed of lacunar infarct. 13.5% of cases were considered as cardiac origin embolisms, and 14.1% were affected of mitral valve prolapse. The migraine group includes 4.9% of the patients while 17.6% belong to the miscellaneous group. The comparison of each of these groups with the control group showed significant differences for family history of stroke, personal history of peripheral arteriopathy, tobacco, arterial hypertension and previous IS.     

Perception of stroke in Croatia – knowledge of stroke signs and risk factors amongst neurological outpatients

Background and purpose:  The aim of this hospital-based survey was to determine baseline stroke knowledge in Croatian population attending the outpatient services at the Department of Neurology.
Methods:  A multiple choice questionnaire was designed, divided into three sections: (i) demographic data, (ii) knowledge of stroke risk factors and stroke signs and (iii) actions the patients would undertake if confronted with risk of stroke and information resources regarding health.
Results:  The analysis included 720 respondents (54.9% women). The respondents most frequently indicated stroke symptoms as following: speech disorder 82%, paresthesiae on one side of the body 71%, weakness of arm or leg 55%, unsteady gait 55%, malaise 53%, monocular loss of vision 44%. The risk factors most frequently identified were hypertension 64%, stress 61%, smoking 59%, elevated lipids 53%, obesity 52%, coagulation disorder 47%, alcoholism 45%, low-physical activity 42%, elderly age 39%, cardiac diseases 38%, weather changes 34%, drugs 33% and diabetes 32%. If confronted with stroke signs 37% of respondents would consult the general practitioner and 31% would call 911 or go to a neurologist. Amongst patients with a risk factor, only diabetics were aware that their risk factor might cause stroke ( P  < 0.001). Respondents with lowest education had the least knowledge regarding stroke signs ( P  < 0.01).
Discussion:  The results of this study indicate that respondents showed a fair knowledge about stroke signs and risk factors for stroke. The results of our study will help to create and plan programmes for improvement of public health in Croatia.     

Risk of stroke after bereavement—a systematic literature review

Several studies have suggested that psychological stress may increase the risk of stroke. However, this link remains a controversial issue because of conflicting findings. Bereavement, the loss of a close relative, is considered a severely stressful life event. Increased risk of stroke could thus be expected after bereavement if stress plays a causal role. We aimed to evaluate the association between bereavement and stroke by performing a systematic review of the existing literature. The literature search was conducted according to the PRISMA guidelines for systematic reviews. A search in Medline and Embase identified eligible studies, which were reviewed by two researchers independently according to specific inclusion criteria. We included six studies: five cohort studies and one case‐crossover study. Five studies found that loss of a first‐degree relative was associated with a 1.1‐ to 2.4‐fold higher risk of stroke. However, one study found a statistically significant overall risk only for women. Five studies evaluated the risk of stroke according to time since the loss; one study found no association, two studies indicated short‐term effect, one study indicated long‐term effect, and one study indicated both short‐term and long‐term effect. Three studies stratified their analysis by sex; two found higher association in bereaved women than men. Our systematic review suggests that bereavement‐related stress is associated with a higher risk of stroke. As relatively few studies were identified, new studies are needed to verify this association. These should aim to quantify the risk, describe the effect of time since bereavement, and identify risk‐modifying factors.     

Ischemic stroke in young adults. II. Analysis of risk factors in the etiological subgroups

A prospective study on 386 consecutive patients affected of ischemic stroke (IS) has been analysed in relation to etiologies, comparing them with a control group of 100 people. The atherotrombotic etiology subgroups are associated with family history of stroke, risk factors, atheromatosis, occlusive peripheral arteriopathy, previous of stroke, high levels of hematocrit and hemoglobin, impaired lipid fractions and high levels of uric acid. The cardiac embolism etiology subgroups are associated with the presence of personal history of stroke, just as the mitral valva prolapse (MVP) patients group. The migraine group is significantly related with the intake of oral contraceptives.     

Young ischemic stroke in Tunisia: a multicentric study

Purpose: There is wanting data regarding young ischemic stroke in developing countries, especially in Tunisia. The purpose of this study was to investigate risk factors and etiologies of young ischemic stroke in Tunisian and make a comparison with previous reports. Materials and methods: A total of 102 young ischemic stroke patients (15–45 years old) were admitted, between January 1996 and August 2007, to 11 departments of internal medicine in different Tunisian hospitals. The risk factors for stroke were documented and assessed. Diagnosis workup consisted of anamnesis, complete physical examination and extensive laboratory, radiologic, immunologic, neurologic and cardiologic examination. Stroke etiologies were classified according the Trial of ORG 10172 in acute stroke treatment. Results: There were 42 men (41.2%) and 60 women (58.89%) with a mean age at onset of 35.7 years. As regards stroke subtype, large-artery atherosclerosis was diagnosed in 6.9% of cases, cardioembolism in 11.8%, small-vessel occlusion in 8.8%, other determined etiology in 37.3% and undetermined etiology in 35.3%. Concerning the traditional risk factors, smoking (31.4%), hypertension and diabetes mellitus (12.7% for each one) and a family history of stroke (10.8%) were the most common. The mean follow-up period was 30.5 months. Conclusions: In our study, traditional risk factors were not-so-uncommon in young adults with ischemic stroke suggesting that prevention can go through controlling these factors. Stroke of other determined etiology was the most common among our patients, so that a broad and detailed diagnostic workup is crucial to puzzle out the etiology for more and better stroke prevention.     

Risk factors for and incidence of subtypes of ischemic stroke

The TOAST classification divides patients with ischemic stroke into five subgroups according to the presumed etiological mechanism. The aims of the present study were to evaluate the distribution of the different etiological stroke subtypes in a hospital-based sample of stroke patients, and to investigate the association between important risk factors and stroke subtypes. A total of 210 patients with a first-ever ischemic stroke admitted to the stroke unit of Asker and B?rum Hospital in Norway between February 2007 and July 2008 were enrolled in the study. Information on vascular risk factors was collected at admittance, examination of neurological deficits was carried out during their stay, and classification was made according to the TOAST criteria. According to the TOAST classification, 24 (11.4%) of the patients suffered from large vessel disease, 66 (31.4%) from cardioembolic disease, 66 (31.4%) from small vessel disease and 54 (25.7%) from a stroke of undetermined etiology. The presence of hyperlipidemia and atrial fibrillation varied significantly between the different subtypes. In multivariate analyses, hyperlipidemia [odds ratio (OR) 2.46, 95% confidence interval (CI) 1.32-4.60] and current smoking (OR 2.06, 95% CI 1.04-4.08) were the only variables that were related to small vessel disease. Small vessel disease was observed more frequently and large vessel disease less frequently than previously reported. Small vessel disease was significantly associated with hyperlipidemia and current smoking. Our study supports the view that the etiology of lacunar strokes is multifactorial.     

进展性缺血性脑卒中影响因素的前瞻性研究

目的 探讨进展性缺血性脑卒中的危险因素.方法 前瞻性登记急性缺血性脑卒中患者并收集其临床资料.依据欧洲进展性卒中诊断标准将患者分组,对可能影响卒中进展的因素进行比较及多因素Logistic逐步回归分析.结果 共有569例患者纳入研究,其中127例归入进展性卒中组,442例归入非进展性卒中组.进展性卒中组患者的病程、伴糖尿病、心房纤颤史及脑卒中史、入院时发热、高血糖、合并并发症、入院时美国国立卫生研究院卒中量表及格拉斯哥昏迷量表评分与非进展性卒中组比较差异有统计学意义(均P<0.1).多因素Logistic逐步回归分析显示,糖尿病(RR=2.625,95%CI:1.422～4.844)、发热(RR=0.192,95%CI:0.075～0.491)、合并并发症(RR=2.442,95%CI:1.394～4.279)、神经功能缺损中度(RR=5.602,95%(CI:2.789～11.251)及重度(RR=24.734,95%CI:4.218～145.052)是进展性卒中的独立危险因素.结论 糖尿病、发热、合并并发症、中及重度神经功能缺损是缺血性脑卒中进展的独立危险因素.     

Inadequate management of cerebrovascular risk factors in participants of a public stroke prevention program in Austria

The aim of our investigation was to identify frequencies and treatment quality of stroke risk factors in participants of a stroke prevention program in the province of Salzburg (Austria). A total of 9356 participants free of previous stroke were classified in three risk categories for suffering from ischemic stroke within the next 10 years and analyzed referring to history, therapy, and treatment quality of cerebrovascular risk factors. A total of 6519 (69.7%) participants were classified to be at low (<10%), 2232 (23.9%) at intermediate (10-20%) and 605 (6.5%) at high risk (>20%). Elevated blood pressure with the need for follow-up investigations was found in 5193 persons (55.5%); of 3713 (39.7%) persons with a history of hypertension, 3204 (86.3%) are under medical treatment, which is sufficient only in 765 patients (23.9%). Similar results were present for other well documented modifiable risk factors. In the investigated population there is high presence of stroke risk factors with inadequate treatment in most cases.