XVII. European Stroke Conference
Nice, France

Oral Session:

Longterm outcome of stroke
Date: Thursday 15 May 2008  
Time: 16:30 - 16:40 -  Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany

01
Two-year cardiovascular event rates of the cerebrovascular disease subpopulation within the REduction of Atherothrombosis for Continued Health (REACH)
J. Roether    J.-L.Mas    E. Touze    M. Alberts    M. Hill    G. Steg    D. Bhatt    P. Wilson    F. Aichner    S. Goto
On behalf of the REACH Registry Investigators

Klinikum Minden, Hanover Medical School

GERMANY

Background: Few studies report cardiovascular (CV) event rates in "real-world" stable outpatients with stroke and/or transient ischemic attack (TIA). The two-year event rates of 18,189 cerebrovascular disease (CVD) patients within the REduction of Atherothrombosis for Continued Health (REACH) Registry are reported. Methods: The REACH Registry is an international, prospective, observational registry of >68,000 patients from 44 countries, at risk of, or with established atherothrombotic disease (CVD, coronary artery disease, peripheral arterial disease). For this study we focused on 18,189 patients in the REACH Registry with CVD (stroke and/or TIA) who were followed for two years. Two-year CV event incidence rates in stroke and TIA patient populations are presented. Results: Two-year data demonstrate high event rates of stroke (including stroke and TIA) and TIA (only) patients in this stable population (over 50% had qualifying stroke or TIA more than one year ago; Table 1). The risk of stroke, myocardial infarction (MI) and death at two years among those with stroke and TIA at entry was 11.48% for the total CVD population. Patients with a history of stroke (and TIA) are at a considerably higher risk and the incidence of major adverse cardiac events (MACE) is very high (>20%). Event rates and predictors for events will be presented by geographic location, patient type, and physician specialty. Discussion: The risk of major secondary ischemic events, including CV death, is very high in individuals with previous stroke and/or TIA. Improved ischemic risk reduction management of CVD patients is required to prevent both morbid events and associated hospitalizations.

 
http://www.eurostroke.org/ni_graphics/t_aid3021

Longterm outcome of stroke
Date: Thursday 15 May 2008  
Time: 16:40 - 16:50 -  Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany

02
Significant variation in quality of life after acute ischaemic stroke between western countries: data from the ‘Tinzaparin in Acute Ischaemic Stroke Trial’ (TAIST)
L.J.Gray    N. Sprigg    P.M.W.Bath                                                 
on behalf of the TAIST Investigators

Institute of Neuroscience, University of Nottingham

UNITED KINGDOM

Background: Multiple studies have reported that functional outcome (death or dependency) varies significantly between countries. However, differences in quality of life (QoL) after stroke by country have yet to be reported. Methods: TAIST was a randomised controlled trial assessing the safety and efficacy of tinzaparin versus aspirin in patients with acute ischaemic stroke across 11 countries. Counties were grouped into 5 geographical regions - British Isles (Ireland, UK), Franco (Belgium, France), North America (Canada), North-West Europe (Germany, Netherlands), and Scandinavia (Denmark, Finland, Norway, Sweden). QoL was measured at 180 days post randomisation using the short-form 36 health survey, which assesses QoL across eight physical and mental domains. The relationship between region and each domain was assessed using ordinal regression adjusted for treatment assignment, case mix and service quality relative to the British Isles. Results: 1,220 survivors were included in this analysis. Significant differences in QoL were present between the countries: North West Europe rated their QoL highest in terms of physical functioning, physical role, bodily pain and vitality in comparison to the other regions. Relative to the British Isles QoL for the physical domain was 77% higher in Franco countries, and 400% higher in North West Europe; similarly social functioning was 75% higher in Franco countries and 340% higher in Scandinavia. Franco countries scored significantly lower for emotional role and mental health compared to the British Isles (Odds Ratio (OR) 0.49 95% confidence interval (CI) 0.26-0.92, and OR 0.41 95% CI 0.23-0.72 respectively). Conclusions: QoL varies considerably between countries, even when adjusted for prognostic case mix variables and measures of care quality. Differing health care systems, and the management of patients with acute stroke, may contribute to these findings.

Longterm outcome of stroke
Date: Thursday 15 May 2008  
Time: 16:50 - 17:00 -  Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany

03
Withdrawn
A. Terent    S. Åsberg    K. Henriksson    B. Farahmand    K. Asplund    B. Norrving    B. Stegmayr    P.O.Wester    K. Hulter Åsberg       
 

The Stroke unit at Uppsala University Hospital

SWEDEN

Withdrawn

Longterm outcome of stroke
Date: Thursday 15 May 2008  
Time: 17:00 - 17:10 -  Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany

04
Patient and Carer experiences of community-based stroke care in ireland: the Irish National Audit of Stroke Care (INASC).
A. Hickey    F. Horgan    H. McGee    D. O'Neill                                          
on behalf of the INASC team

Royal College of Surgeons in Ireland

IRELAND

Background: The high level of physical and psychological morbidity following stroke is associated with significant burden for patients and carers. An important input to improving quality of stroke care is to ask people with stroke about their experiences. This study sought to document patient and carer experiences of stroke services and provides first evidence on the status of community-based stroke service provision in Ireland. Methods: Stroke patients discharged from four nationally representative hospitals in Ireland, stratified by age (+65), sex and time since stroke (6-12 months or 24-36 months), and their carers, were selected. Quality of care was assessed with questions from the UK Healthcare Commission National Patient Survey (2005), alongside standardised measures of functional ability (Barthel Index), depression (HADS) and vulnerability (Vulnerable Elders Survey). Similar measures were used with the carer group. Results: 139 patients (55% response) and 72 carers (80% female; 69% response) participated. Almost half of patients (47%) had travelled to hospital using private transport at the time of stroke. No patients had been managed in hospital in a stroke unit. A majority of patients reported poor communication at the time of discharge from hospital, 67% not receiving a designated contact name. Community rehabiliation was not available in some cases, particularly for some disciplines (e.g., psychological and speech and language services). 30% of patients scored in the depressed range and 57% were classified as vulnerable, significantly moreso for women (χ2=5.93, p<0.05). 15% of carers scored in the depressed range, with 11% classified as vulnerable. Discussion: Overall, patients and carers reported variable experiences of community stroke care in Ireland. While a majority were satisfied with hospital based care, many were unable to obtain needed rehabilitation and support services once discharged home. Given that a majority of patients with stroke are discharged to the community, optimisation of community-based stroke care is central to minimising disability and maximising quality of life after stroke.

Longterm outcome of stroke
Date: Thursday 15 May 2008  
Time: 17:10 - 17:20 -  Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany

05
Sex differences in survival and functional outcome after stroke – the South London Stroke Register
M.A.Busch    P.U.Heuschmann    Ö. Saka    C.D.A.Wolfe                                          
 

King's College London

UNITED KINGDOM

BACKGROUND: Recent studies suggest that women may have poorer stroke outcome, but data with regard to specific outcomes are conflicting. We investigated sex differences in stroke outcome and examined the contributions of other patient characteristics using a hierarchical conceptual framework. METHODS: Data were collected from the South London Stroke Register, a population-based register of first-ever stroke in London, UK. All registered patients were prospectively followed up annually for up to 10 years. Sex differences in survival and dependence (Barthel Index <20) at 1 year were assessed by hierarchical Cox regression and logistic regression analyses, adjusted for sociodemographics, comorbidities, stroke severity and service use. RESULTS: Of 2874 patients with stroke in 1995-2004, 1447 (50.4%) were women (mean age 73.8y vs 67.4y in men). In survival analysis, women had a 42% higher risk of death (hazard ratio (HR) 1.42; 95% CI 1.29-1.56) and half of this effect was mediated through age (age-adjusted HR 1.20; 95% CI 1.09-1.32). The effect of sex remained almost unchanged after additional adjustment for sociodemographics and comorbidities, but was no longer significant after further adjusting for stroke severity. Surviving women were more often dependent at 1 year than men (OR 1.76; 95% CI 1.42-2.17). This effect of sex decreased after adjusting for age (age-adjusted OR 1.58; 95% CI 1.27-1.98), was not further mediated through sociodemographics or comorbidities, but again partly mediated through stroke severity (OR 1.40; 95% CI 1.06-1.85). CONCLUSION: The poorer survival of women after stroke observed in this study can mainly be attributed to higher age and stroke severity, while their poorer functional outcome cannot be fully explained by the included variables.

Longterm outcome of stroke
Date: Thursday 15 May 2008  
Time: 17:20 - 17:30 -  Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany

06
Long-term follow-up after first-ever stroke among the Besançon registry: mortality and recurrence of vascular events
P. Decavel    E.   Medeiros    E.   Revenco    T.   Moulin                                          
 

University Hospital, Besancon

FRANCE

Background: Regional healthcare networks have been established to optimise care provision in France. The objective of this study was to evaluate the impact of implementaion of a regional stroke unit on long term outcome in terms of mortality and recurrence after eighteen months after a first stroke. Method: We compared three different periods (1987-1994: first period; 1998-2002: second period; 2003-2006: third period) corresponding respectively to unstructured stroke care, the period in which a structured hospial stroke unit was set up and the period in which the regional network was established. During the three periods, all patients presenting a first-ever stroke (infarction, haematoma or transient ischaemic attack – TIA) hospitalised in the University Hospital in Besançon were prospectively entered into a patient registry and evaluated using standard diagnostic criteria. Outcome was analysed during the first 18 months post-stroke and adjusted according to age, sex and stroke sub-types. Results: We analysed 6877 patients, whose mean age was 73 years and of whom 55% were men. Of these, 4770 presented an infarction, 765 a haematoma and 1295 a TIA. The cohorts differed betwen the three periods in terms of gender (p = 0.596) and stroke subtypes (p< 0.001). The mortality rate at one month after stroke for the three periods was 15.9%, 11.7% and 6.6% (p=0.000) respectively. Eighteen months after stroke, the long-term survival rate was 87%, 90% and 94%. The rate of recurrence of vascular events could only be assessed for the last two periods: 4.5% and 2.60%. Conclusion: This study suggests that patient management within structured regional stroke networks has a positive impact both on immediate mortality and on long-term survival in Besançon.

Longterm outcome of stroke
Date: Thursday 15 May 2008  
Time: 17:30 - 17:40 -  Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany

07
ALBUMIN-CORRECTED SERUM CALCIUM CONCENTRATIONS AND LONG-TERM MORTALITY IN PATIENTS WITH ACUTE STROKE.
R. Schwartz    S. Apel    Y. Schwammenthal    O. Merzeliak    R. Tsabari    D. Orion    D. Tanne                     
 

Sheba Medical Center and Tel Aviv University

ISRAEL

Background- Calcium may influence the molecular pathways of neuronal death. Our aim was to examine the association between serum calcium and albumin-corrected calcium levels and stroke outcome in a large prospective cohort of unselected patients with acute stroke. Methods- In a prospective cohort study, consecutive patients hospitalized due to acute stroke (ischemic or intracerebral hemorrhage) throughout a large medical center were systematically assessed and followed for 1-year. Baseline total and albumin-corrected serum calcium levels were collapsed into quintiles and associations with stroke severity and outcomes examined. ORs (95%CI) adjusted for age, gender, stroke type, stroke severity, anemia, chronic kidney disease, malignancy, chronic heart failure, and prior disability were estimated. Results- Among 785 patients (mean age 71+/-13 yrs, 58% males) rates of severe stroke (baseline NIHSS>10) by quintiles of albumin-corrected calcium levels were: Q-I (<8.84) 33%, Q-II (8.84-9.13) 26%, Q-III (9.14-9.31) 29%, Q-IV (9.32-9.61) 22%, and Q-V (>9.61 mg/dL) 32%; p=0.008. After adjustment for differences in baseline characteristics, a U-shaped relationship between albumin-corrected calcium levels and mortality was observed. Using Q-IV as the reference, the adjusted ORs for 1-months mortality were: for Q-I 3.38 (1.38-8.31), Q-II 1.38 (0.51-3.76), Q-III 1.16 (0.44-3.08) and Q-V 1.58 (0.63-3.95). The adjusted ORs for 1-year mortality were: for Q-I 2.08 (0.96-4.58), Q-II 1.38 (0.61-3.14), Q-III 1.21 (0.52-2.79) and Q-V 2.55 (1.22-5.47). No significant associations were observed with long-term disability (Barthel Index<75). Discussion- Serum calcium concentrations are early markers of stroke severity and outcome in acute stroke. Findings suggest a U-shaped association between albumin-corrected calcium concentrations and long-term mortality after acute stroke.

Longterm outcome of stroke
Date: Thursday 15 May 2008  
Time: 17:40 - 17:50 -  Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany

08
Long-Term Follow-Up after Suboccipital Decompressive Craniectomy for Malignant Cerebellar Infarction
T. Pfefferkorn    U. Eppinger    J. Linn    A. Straube    T. Birnbaum    M. Dichgans    S. Grau                     
 

Klinkum Grosshadern, University of Munich

GERMANY

Background and Purpose: Suboccipital decompressive craniectomy is a life-saving intervention for patients with malignant cerebellar infarction. However, long-term outcome has not been systematically analyzed. Patients and Methods: In this monocentric retrospective study we reviewed the charts of all consecutive patients that were treated by suboccipital decompressive craniectomy for malignant cerebellar infarction in our institution between 1996 and 2006. Prior to surgery, all patients presented with space-occupying cerebellar infarction and a declining level of consciousness. Outcome data in survivors were obtained by telephone (modified Rankin Scale) and SF-36 questionnaires (quality of life). Results: A total of 57 patients were identified. The mean age was 59.2 years (27-81 years). Five patients were lost for follow-up. In the remaining 52 patients, the mean follow-up interval was 4.3 years (1-11 years). Twenty-one patients (40.4%) had died, 15 (29%) within the first six months after surgery. Among the 31 long-term survivors, functional outcome was good in 26 (mRS of 0-3: 84%) and poor in five patients (mRS of 4-5: 16%). All but two patients (94%) expressed retrospective contentment with the surgical intervention. The data on quality of life are pending and will be presented at the conference. Conclusions: The majority of survivors after suboccipital decompressive craniectomy for malignant cerebellar infarction have a good long-term functional outcome. Retrospectively, almost all of them are content with having received this treatment.

Longterm outcome of stroke
Date: Thursday 15 May 2008  
Time: 17:50 - 18:00 -  Room: Rhodes
Chair: T. Karapanayiotides, Greece and J. Röther, Germany

09
Posttraumatic Stress Disorder Explains Reduced Quality of Life in SAH Patients in both the Short and Long-term.
A.J.Noble    T. Schenk                                                        
 

Durham University

UNITED KINGDOM

Background: Subarachnoid haemorrhage (SAH) frequently has a drastic long-term impact on patients' health-related quality of life (QoL). Neurological problems alone cannot explain the reduced QoL. Here we examine whether posttraumatic stress disorder (PTSD) and fatigue can provide a satisfactory explanation for this reduced QoL in both the short- and long-term. Methods: We prospectively studied a representative sample of 105 patients with spontaneous, non-traumatic SAH. Patients were examined twice, firstly at 3 months post-ictus and again at 13 months post-ictus. Examinations included assessments of PTSD, fatigue, sleep, cognitive and physical outcome and QoL. In addition, patients’ coping skills were assessed. Regression analyses were performed to identify the best predictors for the patients’ QoL and PTSD. Results: 37% of patients met the diagnostic criteria for PTSD at both assessment points. This is a staggering four-fold increase when compared to the incidence rate in the general population. Fatigue in SAH patients was also consistently higher than in matched controls. PTSD was the best predictor for mental QoL – the domain most persistently impaired – in both the short- and long-term. It also helped predict physical QoL levels reported more than one year post-haemorrhage. Moreover, PTSD was consistently linked to increased levels of sleep problems and therefore to increased levels of fatigue. To establish the cause of PTSD a logistic regression was performed. This showed that maladaptive coping was the best predictor of PTSD. Discussion: PTSD explains why SAH patients with relatively good clinical outcome, nevertheless have persistently reduced QoL. PTSD also explains to a great extent patients’ chronic fatigue. Patients’ levels of fatigue were at times in fact, even higher than in cancer patients undergoing chemotherapy. The findings suggest that since poor coping skills seem to be the main cause of PTSD, teaching patients better coping skills early on might prevent PTSD, fatigue and the resulting drop in QoL.