Cerebral infarction of arterial origin and haematological causation: the Lausanne experience and a review of the literature

INTRODUCTION: Hematological diseases are seldom found as the etiology of ischemic strokes, but are frequently investigated by expensive laboratory tests after a first cerebral vascular event. METHODS: In the Lausanne Stroke Registry, we retrospectively reviewed the cases of patients hospitalized between 1979 and 2001 for a first ischemic arterial stroke which was attributed to a hematological etiology. Of 4697 patients, 22 (0.47 per cent) had a stroke due to one of the following hematological pathology: polycythemia vera (4), secondary polycythemia (4), essential thrombocytemia (2), secondary thrombocytosis (4), multiple myeloma (1), CIVD (1), protein S deficiency (1), antiphospholipid antibody syndrome (4), moderate homocysteinemia (1). A literature review was undertaken for each hemopathy. CONCLUSION: In light of the results of these data, we concluded that a complete blood count provides sufficient hematological screening for the majority of patients hospitalized for an arterial stroke. The antiphospholipid antibody syndrome is a rare cause of cerebral infarction, which needs to be investigated in young patients, in cases of multiple or recurring stroke or in the presence of a typical history. Inherited thrombophilias are not a significant risk factor for arterial cerebral infarction and their investigation is only warranted for a sub-group of young patients with a cryptogenic stroke, in which group the prevalence is slightly increased. Moderate homocysteinemia must be considered as a cerebrovascular risk factor of minor importance, but potentially treatable by a substitution of vitamin B12, B6 and folates. The efficacy of this substitution in the prevention of cardiovascular events needs yet to be demonstrated.     

Cardioembolic vs. noncardioembolic strokes in atrial fibrillation: frequency and effect of antithrombotic agents in the stroke prevention in atrial fibrillation studies

BACKGROUND: While atrial fibrillation (AF) increases the risk of cardioembolic stroke, some ischemic strokes in AF patients are noncardioembolic. OBJECTIVES: To assess ischemic stroke mechanisms in AF and to compare their responses to antithrombotic therapies. METHODS: On-therapy analyses of ischemic strokes occurring in 3,950 participants in the Stroke Prevention in Atrial Fibrillation I-III clinical trials. Strokes were classified by presumed mechanism according to specified neurologic features by neurologists unaware of antithrombotic therapy. RESULTS: Of 217 ischemic strokes, 52% were classified as probably cardioembolic, 24% as noncardioembolic, and 24% as of uncertain cause (i.e., 68% of classifiable infarcts were deemed cardioembolic). Compared to those receiving placebo or no antithrombotic therapy, the proportion of cardioembolic stroke was lower in patients taking adjusted-dose warfarin (p = 0.02), while the proportion of noncardioembolic stroke was lower in those taking aspirin (p = 0.06). Most (56%) ischemic strokes occurring in AF patients taking adjusted-dose warfarin were noncardioembolic vs. 16% of strokes in those taking aspirin. Adjusted-dose warfarin reduced cardioembolic strokes by 83% (p < 0.001) relative to aspirin. Cardioembolic strokes were particularly disabling (p = 0.05). CONCLUSIONS: Most ischemic strokes in AF patients are probably cardioembolic, and these are sharply reduced by adjusted-dose warfarin. Aspirin in AF patients appears to primarily reduce noncardioembolic strokes. AF patients at highest risk for stroke have the highest rates of cardioembolic stroke and have the greatest reduction in stroke by warfarin.     

Long‐term outcome in posterior cerebral artery stroke

Introduction: Previous studies on posterior cerebral artery (PCA) strokes focused mainly on topography and underlying pathophysiology. However, there are no data on long‐term prognosis and its association with the localization of the infarct. Methods: All consecutive PCA strokes registered in the Athens Stroke Outcome Project between 01/1998 and 12/2009 were included in the analysis. The New England Posterior Circulation Registry criteria were applied to classify them in relation to topography: (i) pure PCA infarcts, including pure cortical‐only and combined cortical/deep PCA infarcts (groups A and B respectively), and (ii) PCA‐plus strokes, including cortical‐only and combined cortical/deep PCA strokes with ≥1 concomitant infarcts outside PCA territory (groups C and D respectively). Patients were prospectively followed up to 10 years after stroke. Results: Amongst 185 (8.1%) PCA patients that were followed up for 49.6 ± 26.7 months, 98 (53%), 24 (13%), 36 (19.5%), and 27 (14.6%) were classified in group A, B, C, and D, respectively. Infections and brain edema with mass effect were more frequently encountered in PCA‐plus strokes compared to pure PCA (P < 0.05 and <0.01 respectively). At 6 months, 56% of cortical‐only PCA patients had no or minor disability, compared to 37%, 36%, and 26% in the other groups (P = 0.015). The 10‐year probability of death was 55.1% (95%CI: 42.2–68.0) for pure PCA compared to 72.5% (95%CI: 58.8–86.2) for PCA‐plus (log‐rank 14.2, P = 0.001). Long‐term mortality was associated with initial neurologic severity and underlying stroke mechanism. Conclusions: Patients with pure PCA stroke have significantly lower risk of disability and long‐term mortality compared to PCA strokes with coincident infarction outside the PCA territory.     

Ethnic differences in stroke recurrence

OBJECTIVE: To determine whether stroke recurrence and the effect of recurrence on mortality differ by ethnicity. METHODS: Using methods from the Brain Attack Surveillance in Corpus Christi project, we prospectively identified first-ever ischemic strokes from emergency department logs and hospital admissions (January 2000 to December 2004). Recurrent strokes and deaths were identified for the same period. Cumulative probability of stroke recurrence was estimated. Cox proportional hazards models were used to examine ethnic differences in recurrence and to examine the relation among ethnicity, recurrence, and mortality. RESULTS: During the time interval, 1,345 first-ever ischemic strokes were validated. Median age of patients was 72 years; 53% were Mexican American (MA). There were 126 recurrent strokes. Cumulative risk for recurrence at 30 days and 1 year was 2.6 and 7.5%, respectively. MAs had higher risk for stroke recurrence (risk ratio, 1.57; 95% confidence interval, 1.05-2.34) compared with non-Hispanic white patients, adjusted for demographics, stroke risk factors, and stroke severity. Stroke recurrence was related to mortality to a similar extent across ethnic groups (non-Hispanic white patients: risk ratio, 3.32; 95% confidence interval, 2.07-5.32; MAs: risk ratio, 2.35; 95% confidence interval, 1.42-3.88). INTERPRETATION: MAs had higher stroke recurrence risk compared with non-Hispanic white patients. Stroke recurrence had an important impact on mortality. Efforts to reduce stroke recurrence in MAs are needed.     

Is there any circadian variation consequence on acute case fatality of stroke? Takashima Stroke Registry,Japan (1990–2003)

Turin TC, Kita Y, Rumana N, Nakamura Y, Takashima N, Ichikawa M, Sugihara H, Morita Y, Hirose K, Okayama A, Miura K, Ueshima H. Is there any circadian variation consequence on acute case fatality of stroke? Takashima Stroke Registry, Japan (1990–2003).
Acta Neurol Scand: 2012: 125: 206–212.
© 2011 John Wiley & Sons A/S. Background – Circadian periodicity in the onset of stroke has been reported. However, it is unclear whether this variation affects the acute stroke case fatality. Time of the day variation in stroke case fatality was examined using population‐based stroke registration data. Methods – Stroke event data were acquired from the Takashima Stroke Registry, which covers a stable population of ≈55,000 in Takashima County in central Japan. During the period of 1990–2003, there were 1080 (549 men and 531 women) cases with classifiable stroke onset time. Stroke incidence was categorized as occurring at night (midnight‐6 a.m.), morning (6 a.m.‐noon), afternoon (noon‐6 p.m.), and evening (6 p.m.‐midnight). The 28‐day case fatality rates and 95% confidence intervals (95% CI) were calculated by gender, age, and stroke subtype across the time blocks. After adjusting for gender, age at onset, and stroke severity at onset, the hazard ratios for fatal strokes in evening, night, and morning were calculated, with afternoon serving as the reference. Results – For all strokes, the 28‐day case fatality rate was 23.3% (95% CI:19.4–27.6) for morning onset, 16.9% (95% CI:13.1–21.6) for afternoon onset, 18.3% (95% CI:13.6–24.1) for evening onset, and 21.0% (95% CI:15.0–28.5) for the night onset stroke. The case fatality for strokes during the morning was higher than the case fatality for strokes during afternoon. This fatality risk excess for morning strokes persisted even after adjusting for age, gender, and stroke severity on onset in multivariate analysis. Conclusion – In the examination of circadian variation of stroke case fatality, 28‐day case fatality rate tended to be higher for the morning strokes.     

Headache at stroke onset: the Lausanne Stroke Registry.

Within 12 hours of stroke onset 2506 patients with first ever stroke admitted to the Lausanne Stroke Registry were questioned about headache. Eighteen per cent of the patients reported headache, 14% with anterior circulation stroke and 29% with posterior circulation stroke (p < 0.001). Headache was reported by 16% of the patients with infarct and 36% of those with haemorrhage (p < 0.001). The prevalence of headache was 9% with lacunar infarct, 15% with middle cerebral artery territory infarct, 37% with infratentorial haemorrhage, and 36% with supratentorial haemorrhage. The most common topography of pain was frontal (41%), followed by diffuse headache (27%; p < 0.001). Diffuse (41%) or occipital (30%) headache was particularly frequent with posterior circulation stroke, whereas frontal headache was associated with anterior circulation stroke (51%; p < 0.001). Headache in stroke may be explained in part by involvement of blood vessels (acute distention or distortion) and mechanical (stretch of haemorrhage) stimulation of intracranial nociceptive afferents. Stroke due to dissection was strongly associated with headache (p < 0.001), whereas embolic (cardiac, artery to artery) stroke was more common without headache (p < 0.001), emphasising the role of extracranial v intracranial arteries in the genesis of headache at stroke onset. Moreover, dual trigeminal-vascular and cervical-vascular system involvement in causing headache may explain the lack of correspondence with the "rules of referral" in up to 38% of the cases.     

The Lausanne Stroke Registry: analysis of 1,000 consecutive patients with first stroke

We present epidemiologic, etiologic, and clinical data for 1,000 consecutive patients with a first stroke (cerebral infarction or hemorrhage) admitted to the Centre Hospitalier Universitaire Vaudois since 1982. The patients were evaluated using a standard protocol of tests (computed tomography, Doppler ultrasonography, and electrocardiography in all patients, as well as angiography and specific cardiac investigations in selected patients). Each case was coded prospectively into a computerized registry. We believe that the Lausanne Stroke Registry is the first registry with complete computed tomography and Doppler ultrasonography data on all patients, which allows correlation between clinical findings, presumed etiology, and stroke location. Although the Lausanne Stroke Registry is not population-based, it gives a good estimate of the stroke-related problems in patients admitted to a primary-care center since our hospital is the sole acute-care facility for stroke in the Lausanne area.     

Pure monoparesis: a particular stroke subgroup?

BACKGROUND: Acute stroke presenting as monoparesis is rare, with a pure motor deficit in the arm or leg extending to an isolated facial paresis. OBJECTIVE: To raise the question if acute stroke presenting as monoparesis is a different entity from stroke with a more extensive motor deficit. PATIENTS: In the Lausanne Stroke Registry (1979-2000), 195 (4.1%) of 4802 patients met the clinical criteria for pure monoparesis involving the face (22%), arm (63%), or leg (15%). RESULTS: In the vast majority of cases (> 95%), monoparesis corresponded to ischemic stroke with a favorable outcome, with initial computed tomography scans or magnetic resonance images showing no signs of hemorrhage. The lesion for a facial deficit was most frequently located subcortically (internal capsule); for an arm deficit, in the superficial middle cerebral artery; and for a leg deficit, in the anterior cerebral artery territory. In pure monoparesis, only 17% of the patients had more than 1 risk factor as compared with 26% of those with bimodal and trimodal hemiparesis and with 46% of all patients with stroke other than those with pure motor stroke. The only frequent risk factor was hypertension (53%); however, this frequency was no different from that in other patients with stroke. No major stroke etiology could be identified in any of the 3 subgroups of monoparesis. CONCLUSION: Our finding of a wide range of stroke localization and etiology in monoparesis without any particular subgroup suggests that no specific plan of investigation can be recommended for these patients.     

Prediction of in-hospital mortality after first-ever stroke: the Lausanne Stroke Registry.

We aimed to study in-hospital mortality after a first-ever stroke (brain infarction or parenchymatous hemorrhage) and to determine its predictors using easily obtainable variables. The main outcome measure was vital status at hospital discharge. Clinical features and type of stroke, with a particular emphasis on age, stroke topography and presumed causes of stroke, were studied in 3362 consecutive patients from the Lausanne Stroke Registry. Overall mortality was 4.8%. Brain hemorrhage mortality was 14.4% (48/333) and brain infarction mortality was 3.70% (112/3029). Localizations with high mortality included infratentorial (17.5%) and deep hemispheric (15.9%) territories for brain hemorrhage and, for brain infarction, multiple localizations in the posterior circulation (18.4%) and large middle cerebral artery territory (15.5%). Presumed causes of stroke associated with high mortality included saccular aneurysm (58.3%) and hypertensive arteriopathy (13.0%) for brain hemorrhage and, for brain infarction, dissection (10.4%), arteritis (8.3%), hematologic conditions (6.7%) and coexisting arterial and cardiac sources of embolism (5.2%). Multivariate logistic analysis showed that impaired consciousness on admission and limb weakness were good predictors of mortality for brain hemorrhage, while impaired consciousness and the cumulative effect of progressive worsening, limb weakness, left ventricular hypertrophy, past history of cardiac arrhythmia and previous transient ischemic attack were predictors of mortality for brain infarction. Age was not an independent predictor of stroke mortality, but for brain infarction the number of cumulative factors considered in the model increased with age. Our study shows that several factors associated with death risk are available during the first few hours after onset of stroke. Age alone is not critical, although its interaction with other factors should be considered.     

COVID-19 and Stroke Recurrence by Subtypes: A Propensity-Score Matched Analyses of Stroke Subtypes in 44,994 Patients

BackgroundCerebrovascular diseases (CVDs), including varying strokes, can recur in patients upon coronavirus disease 2019 (COVID-19) diagnosis, but risk factor stratification based on stroke subtypes and outcomes is not well studied in large studies using propensity-score matching. We identified risk factors and stroke recurrence based on varying subtypes in patients with a prior CVD and COVID-19.MethodsWe analyzed data from 45 health care organizations and created cohorts based on ICDs for varying stroke subtypes utilizing the TriNetX Analytics Network. We measured the odds ratios and risk differences of hospitalization, ICU/critical care services, intubation, mortality, and stroke recurrence in patients with COVID-19 compared to propensity-score matched cohorts without COVID-19 within 90-days.Results22,497 patients with a prior history of CVD within 10 years and COVID-19 diagnosis were identified. All cohorts with a previous CVD diagnosis had an increased risk of hospitalization, ICU, and mortality. Additionally, the data demonstrated that a history of ischemic stroke increased the risk for hemorrhagic stroke and transient ischemic attack (TIA) (OR:1.59, 1.75, p-value: 0.044*, 0.043*), but a history of hemorrhagic stroke was associated with a higher risk for hemorrhagic strokes only (ORs 3.2, 1.7, 1.7 and p-value: 0.001*, 0.028*, 0.001*). History of TIA was not associated with increased risk for subsequent strokes upon COVID-19 infection (all p-values: ≥ 0.05).ConclusionsCOVID-19 was associated with an increased risk for hemorrhagic strokes and TIA among all ischemic stroke patients, an increased risk for hemorrhagic stroke in hemorrhagic stroke patients, and no associated increased risk for any subsequent strokes in TIA patients.     

Subtypes and one-year survival of first-ever stroke in Chinese patients: The Nanjing Stroke Registry

BACKGROUND: Morbidity and mortality of stroke have been investigated extensively in Western populations, while data concerning case fatality and cause of death after stroke are very limited in mainland China. This study aimed to analyze the 1-year survival and predictors of case fatality in Chinese patients with first-ever stroke. METHODS: Subjects are patients registered in the Nanjing Stroke Registry Program. Information concerning cardiovascular risk factors and stroke characteristics were collected, and patients were followed after registration. Ischemic strokes were classified according to TOAST criteria as large-artery atherosclerosis (LAA), cardiac embolism stroke (CES), small-vessel stroke (SVS), or other determined and undetermined causes (UND). One-year case fatality was analyzed by the Kaplan-Meier method, and predictors of case fatality were evaluated by the Cox proportional hazards model. RESULTS: A total of 752 patients with first-ever stroke were included, of which 142 (18.9%) were identified as intracerebral hemorrhage (ICH), 120 (16.0%) as LAA, 123 (16.4%) as SVS, 160 (21.3%) as CES and 216 (28.7%) as UND. The overall survival rate was 86.4% at the end of the 1-year follow-up. Patients with SVS have the highest survival rate (92.7%), followed by UND (89.4%), CES (88.1%) and LAA (84.2%). Patients with ICH have the lowest survival rate (76.8%). Survival rates of patients with different subtypes of stroke presented a significant difference (chi2 = 19.3, p < 0.001). For patients deceased during the first year after the index stroke, 33.3% of deaths were caused by the first stroke, 18.6% by recurrent stroke, 16.7% by cardiovascular comorbidities, 14.7% by nonvascular conditions and 16.7% died of undetermined causes. Advanced age, hypertension, hyperlipidemia, diabetes mellitus (DM), atrial fibrillation (AF), history of transient ischemic attack and cigarette smoking were associated with an increased risk of death 1 year after stroke. CONCLUSIONS: The case fatality rate and predictors for mortality of Chinese patients with first-ever stroke are similar to those reported for other populations. The significant influence of cardiovascular disease on the first-year survival rate emphasizes the importance of acute stroke management and control of hypertension, DM, AF and other predictors for decreasing case fatality and improving prognosis.     

Recurrence after ischemic stroke in chinese patients: impact of uncontrolled modifiable risk factors

BACKGROUND: Data concerning stroke occurrence and recurrence in China are extremely rare. This study was designed to analyze determinants of stroke recurrence in a cohort of Chinese patients. METHODS: Subjects were patients with ischemic stroke registered in the Nanjing Stroke Registry Program. Modifiable risk factors for stroke were identified and stratified into 3 levels: without, controlled and uncontrolled. Cox proportional hazard model was used to detect influence factors for stroke recurrence. RESULTS: First-year recurrence rate was 11.2% in the registered patients. Hypertension, atrial fibrillation (AF) and smoking were associated with increased risk of recurrence. Controlling hypertension and AF each halved recurrent risk (p < 0.001). Ceasing smoking for more than 1 year reduced hazard ratio of recurrence from 1.71 to 1.39 (p < 0.05). Controlling blood sugar level in diabetics did not significantly change recurrent risk (hazard ratio, 1.69 vs. 1.64, p > 0.05). CONCLUSIONS: The recurrence rate is higher in Chinese patients with ischemic stroke compared with the one reported in western populations. Failure to control some modifiable risk factors in Chinese patients may be responsible for this discrepancy.     

Trends in hospital admission for stroke in Calgary

BACKGROUND: Stroke incidence has fallen since 1950. Recent trends suggest that stroke incidence may be stabilizing or increasing. We investigated time trends in stroke occurrence and in-hospital morbidity and mortality in the Calgary Health Region. MEthods: All patients admitted to hospitals in the Calgary Health Region between 1994 and 2002 with a primary discharge diagnosis code (ICD-9 or ICD-10) of stroke were included. In-hospital strokes were also included. Stroke type, date of admission, age, gender, discharge disposition (died, discharged) and in-hospital complications (pneumonia, pulmonary embolism, deep venous thrombosis) were recorded. Poisson and simple linear regression was used to model time trends of occurrence by stroke type and age-group and to extrapolate future time trends. RESULTS: From 1994 to 2002, 11642 stroke events were observed. Of these, 9879 patients (84.8%) were discharged from hospital, 1763 (15.1%) died in hospital, and 591 (5.1%) developed in-hospital complications from pneumonia, pulmonary embolism or deep venous thrombosis. Both in-hospital mortality and complication rates were highest for hemorrhages. Over the period of study, the rate of stroke admission has remained stable. However, total numbers of stroke admission to hospital have faced a significant increase (p=0.012) due to the combination of increases in intracerebral hemorrhage (p=0.021) and ischemic stroke admissions (p=0.011). Sub-arachnoid hemorrhage rates have declined. In-hospital stroke mortality has experienced an overall decline due to a decrease in deaths from ischemic stroke, intracerebral hemorrhage and sub-arachnoid hemorrhage. CONCLUSIONS: Although age-adjusted stroke occurrence rates were stable from 1994 to 2002, this is associated with both a sharp increase in the absolute number of stroke admissions and decline in proportional in-hospital mortality. Further research is needed into changes in stroke severity over time to understand the causes of declining in-hospital stroke mortality rates.     

Stroke and ischemic heart disease mortality trends in Brazil from 1979 to 1996

Stroke and ischemic heart disease (IHD) mortality rates were analyzed in Brazilian subjects older than 30 years of age from 1979 to 1996. Population estimates were based on census surveys. Mortality data were obtained from the Ministry of Health. For stroke, the age-adjusted death rate (ADR) dropped from 200 to 164 and from 168 to 130 deaths/100,000 population in men and women, respectively (p < 0.001), in the interval study. For IHD, the ADR dropped from 194 to 164 and from 119 to 105 deaths/100,000 population in men and women, respectively (p < 0.001), in the same time period. Mortality from stroke and IHD combined was greater in men for all age groups (p < 0.001). Stroke was the most frequent cause of death in both women and men except for men aged between 40 and 69 years, in whom IHD was more common. Stroke and IHD were the main causes of death in the Brazilian population.     

Encephalopathy only stroke codes (EoSC) do not result in rt-PA treatments

BackgroundIsolated mental status changes as a presenting sign (EoSC+), are not uncommon stroke code triggers. As stroke alerts, they still require the same intensive resources be applied. We previously showed that EoSC+ strokes (EoSC+ Stroke+) account for 0.1–0.2% of all codes. Whether these result in thrombolytic treatment (rt-PA), and the characteristics/ risk factor profiles of EoSC+ Stroke+ patients, have not been reported.MethodsRetrospective analysis of stroke codes from an IRB approved registry, from 2004 to 2018, was performed. EoSC+ was defined as a NIHSS>0 for Q1a, 1b, or 1c with remaining elements scored 0. Characteristics and risk factors were compared for EoSC+, EoSC−, EoSC+ Stroke+, and rt-PA (EoSC+ Stroke+TPA+) patients.ResultsEoSC+ occurred in 55/2982 (1.84%) of all stroke codes. EoSC+ Stroke+ occurred in 8/55 (14.5%) of EoSC+ codes and 8/2982 (0.27%) of all stroke codes. 6/8 (75%) of EoSC+ Stroke+ scored NIHSS=1. When comparing EoSC++versus EoSC−, Hispanic ethnicity (p=0.009), hypertension (p=0.02), and history of stroke/TIA (p=0.002) were less common in EoSC+. No demographic/risk factor differences were noted for EoSC+ Stroke+ vs. EoSC+ Stroke−. No cases of rt-PA eligibility/treatment were noted. In EoSC+ Stroke+ analysis, imaging positive stroke/intracranial hemorrhage was noted on only 3 cases (3/2982=0.10% of all stroke codes) and none were posterior stroke.ConclusionsEoSC+ rarely results in stroke/TIA (0.27%) or stroke (0.10%), and in our analysis never (0%) resulted in rt-PA. Sub-analysis did not show missed rt-PA or posterior strokes. Understanding characteristics, and knowing that EoSC+ Stroke+ patients are unlikely to receive rt-PA, may help triage stroke resources.     

Incidence of stroke and mortality due to stroke after acute coronary syndrome

ObjectivesStroke is a known complication after myocardial infarction (MI) and it is associated with increased mortality. We aimed to establish the true cumulative incidence of stroke and its subtypes and the associated mortality in a contemporary setting among patients treated for acute coronary syndrome (ACS).Materials and methodsA retrospective registry study based on the data of 8,049 consecutive patients treated for ACS in a sole provider of specialized cardiac and neurologic care for a catchment area of over 0.5 million residents between 2007 and 2018. Incident strokes and their subtypes were identified by in-depth review of written hospital records, hospital discharge registry data and causes of death registry data maintained by Statistics Finland up until December 31^st 2020.ResultsDuring a median follow-up of 5.8 years (IQR 3.2-9.0) 570 ACS patients suffered a stroke. The cumulative incidences of stroke for first week, first month, first year and at thirteen years were: 0.8 %, 1.1 %, 2.2 % and 10.3 %. In long-term, patients with different ACS subtypes had similar cumulative incidence of strokes, although the incidence of in-hospital strokes was highest among myocardial infarction patients. Stroke mortality rate was 32.5 % (n=185/570). The majority (88.8 %) of strokes were ischemic with the proportion being most substantial for in-hospital strokes (95.6 %).ConclusionsThe risk of stroke among patients treated for ACS and the related mortality are still notable in a contemporary setting. A distinctive majority of strokes following ACS were ischemic especially early on after ACS.     

Fall in the Proportion of Atherothrombotic Strokes During the Last Decade

ObjectiveTo determine the proportion of subtypes of ischemic strokes, vascular risk factors and treatment prior to stroke between 1997 and 2018 in a single institution in Argentina.MethodsDemographics, risk factors, medications and TOAST subtypes were assessed and compared in ischemic stroke patients admitted during two periods of time, 1997-2007 (P1) and 2008-2018 (P2).ResultsThere were 2747 patients (64% men, aged 67 ±15 years), 920 subjects in P1 and 1827 in P2. Age and gender distribution did not change over time. Proportion of large artery atherothrombotic strokes decreased from 29% in P1 to 14% in P2 (p <0.0001) and small vessel strokes from 15% to 11% (p <0.05). Cardioembolic and undetermined strokes increased from 17 to 25% (p <0.0001) and from 30% to 41% (p <0.0001), respectively. There were no changes in stroke of other etiologies (9% in both periods). Detection of atrial fibrillation increased from 14% to 19% (p<0.001). Use of medications prior to stroke increased for aspirin from 27% to 45% (p <0.0001), for antihypertensive drugs from 26% to 62% (p <0.0001), for statins from 14% to 42% (p<0.0001) and for anticoagulants from 4% to 9% (p<0.0001).ConclusionsThe proportion of strokes associated to large and small vessel atherosclerosis is declining in our population with an increase in the proportion of cardioembolic and undetermined strokes. Better management of risk factors and higher prevalence and/or better screening for atrial fibrillation could explain, at least in part, these findings.     

Deaths from stroke in US children, 1979 to 1998

BACKGROUND: Studies have documented declining mortality from stroke in adults over the past two decades, with black adults at greater risk of death from stroke than whites in all years. As these findings have been attributed to control of stroke risk factors that are less important in children, trends and demographics of childhood stroke mortality are of interest, but have not been explored. METHODS: The authors analyzed death certificate data for ischemic and hemorrhagic stroke (subarachnoid hemorrhage [SAH] and intracerebral hemorrhage [ICH]) in children under 20 years of age in the United States for the years 1979 through 1998, covering approximately 1.5 billion person-years. RESULTS: Childhood mortality from stroke declined by 58% overall, with reductions in all major subtypes (ischemic stroke decreased by 19%; SAH, by 79%; ICH, by 54%). Black ethnicity was a risk factor for mortality from all stroke types (relative risk 1.74 for ischemic stroke; 1.76 for SAH; 2.06 for ICH; p < 0.0001 for all types). Male sex was a risk factor for mortality from SAH (relative risk 1.30, p < 0.0001) and ICH (relative risk 1.21, p < 0.0001), but not from ischemic stroke (relative risk 1.02, p = 0.76). CONCLUSIONS: Mortality from stroke in US children has decreased dramatically over the last 20 years. Black children are at greater risk of death from all stroke types than are white children. As control of known stroke risk factors is unlikely to account for declining stroke mortality and ethnic differences in children, unrecognized stroke risk factors may be important.     

The effect of thrombolysis on short-term improvement depends on initial stroke severity

A large number of parameters have been identified as predictors of early outcome in patients with acute ischemic stroke. In the present work we analyzed a wide range of demographic, metabolic, physiological, clinical, laboratory and neuroimaging parameters in a large population of consecutive patients with acute ischemic stroke with the aim of identifying independent predictors of the early clinical course. We used prospectively collected data from the Acute Stroke Registry and Analysis of Lausanne. All consecutive patients with ischemic stroke admitted to our stroke unit and/or intensive care unit between 1 January 2003 and 12 December 2008 within 24 h after last-well time were analyzed. Univariate and multivariate analyses were performed to identify significant associations with the National Institute of Health Stroke Scale (NIHSS) score at admission and 24 h later. We also sought any interactions between the identified predictors. Of the 1,730 consecutive patients with acute ischemic stroke who were included in the analysis, 260 (15.0%) were thrombolyzed (mostly intravenously) within the recommended time window. In multivariate analysis, the NIHSS score at 24 h after admission was associated with the NIHSS score at admission (β = 1, p < 0.001), initial glucose level (β = 0.05, p < 0.002) and thrombolytic intervention (β = −2.91, p < 0.001). There was a significant interaction between thrombolysis and the NIHSS score at admission (p < 0.001), indicating that the short-term effect of thrombolysis decreases with increasing initial stroke severity. Thrombolytic treatment, lower initial glucose level and lower initial stroke severity predict a favorable early clinical course. The short-term effect of thrombolysis appears mainly in minor and moderate strokes, and decreases with increasing initial stroke severity.     

Mortality and causes of death after first ischemic stroke: the Northern Manhattan Stroke Study.

OBJECTIVE: To analyze the early and long-term causes of death after first ischemic stroke in the multiethnic northern Manhattan community. METHODS: In the prospective, population-based Northern Manhattan Stroke Study, 980 patients with first ischemic stroke (mean age 70 years; 56% women; 49% Caribbean Hispanic, 31% black, 20% white) were followed for a mean of 3 years. Causes of death were classified as vascular (incident stroke, recurrent stroke, cardiac) or nonvascular. Life table analyses were used to assess mortality risks among different race-ethnic groups. Early (< or =1 month) vs long-term (> 1 month to 5 years) causes of death were compared. RESULTS: Among the 980 patients followed, 278 (28%) died; 47 (5%) died during the first month. Cumulative mortality risk was 5% at 1 month, 16% after 1 year, 29% after 3 years, and 41% after 5 years. The proportion of vascular deaths among all deaths was 75% at 1 month and 43% thereafter (p = 0.001). Stroke, either incident (53%) or recurrent (4%), caused early deaths in 57% and long-term deaths in 14% (p = 0.001). Overall mortality risks did not differ significantly among race-ethnic groups. However, the proportion of incident stroke-related early deaths was 85% in Caribbean Hispanic patients, 33% in white patients, and 25% in black patients (p = 0.002). CONCLUSIONS: Among patients with first ischemic stroke, incident stroke is the leading cause of early deaths. A large proportion of long-term deaths are nonvascular in origin. Despite similar overall mortality rates in race-ethnic groups, our data suggest a higher incident stroke-related early mortality among Caribbean Hispanics.