Cohort Of Stroke Patients Research Articles

Modelo de costos asociados al ataque cerebrovascular y los eventos adversos en pacientes con fibrilación auricular no valvular tratados con warfarina

ObjectiveThe aim of this study is to estimate the number and direct medical cost of cerebrovascular accident (stroke) and the adverse events in patients on warfarin due to atrial fibrillation. MethodsA budget impact analysis methodology was used to estimate the number of cases and cost of the events. The target population was based on Colombian population information, as well as the rates of use of warfarin according to risk and the distribution of its therapeutic time range. The events were estimated base on reported probabilities, and the costs used in the model were calculated from a cohort of stroke patients that was performed in the Cardiovascular Foundation of Colombia. ResultsThe target population consisted of 84,623 patients in 1 year. The total cost the strokes and bleeding was €10,426,275.28 ($36 852 236 476 million COP (Note: 3,500 /3,000Colombian Pesos (COP) = 1 Euro approx). The total cost strokes was €1,415,903.61 ($5 004 588 241 COP). The total costs of intracranial and gastrointestinal bleeding was €3,359,894.66 ($11 875 730 234 COP) and €5,445,106.17 ($19 246 023 614 COP), respectively. Retroperitoneal bleeding, epistaxis (nosebleeds) and urinary tract bleeding was €208,200.05 ($735 894 387 COP). The sensitivity analysis showed that an adjustment of 10% in the therapeutic time ranges could save €1,191,651.52 ($4 211 957 037 COP). ConclusionsThe cost of the cerebrovascular accident and the adverse effects due to warfarin is large. However, an adjustment in the therapeutic range times could save costs, which means patient lives.

Abstract 275: The Association of Gout with an Increased Risk of Hypertension and Diabetes Mellitus Among Stroke Survivors in New Zealand: An Observational Study Using Routinely-collected Electronic Health Data

Background: There is a paucity of data relating to the association of gout with the occurrence of hypertension and diabetes mellitus in patients with stroke. This study aimed to determine the association of gout with the risk of hypertension and diabetes mellitus in a cohort of stroke patients from Auckland, New Zealand. Methods: A cross-sectional study was conducted among stroke survivors in South and East Auckland, New Zealand from the years 2010 to 2014. Electronic health record data were collected and analysed using SPSS version 23. Multivariate logistic regression modelling adjusted for age, gender, and ethnicity was conducted to determine the association of gout with the risk of hypertension and diabetes mellitus in patients discharged with a diagnosis of stroke. Results: The age-, gender-, and ethnicity-adjusted odds ratio (OR) for having hypertension and diabetes mellitus among stroke survivors with gout history were: 3.25 [95% confidence interval (CI) 1.32-8.03] and 1.94 (95% CI 1.12-3.36), respectively. Måori stroke survivors with gout history had the highest risk of having diabetes mellitus with age- and gender-adjusted OR of 5.10 (95% CI 1.90-18.93). Conclusion: The findings from this study suggest gout may be independently associated with an increasedrisk of hypertension and diabetes mellitus in patients with stroke. Måori who are the indigenous population of New Zealand show a greater risk of diabetes mellitus associated with a gout history compared to other populations. This finding highlights the importance of the need for further research on the association of gout with hypertension and diabetes mellitus.

Post-stroke Pathway: Analysis and Link With One Year Sequelae in a French Cohort of Stroke Patients

Post-stroke Pathway: Analysis and Link With One Year Sequelae in a French Cohort of Stroke Patients

Cost-effectiveness of new oral anticoagulants and warfarin in atrial fibrillation from adverse events perspective

Objectivenew oral anticoagulants (apixaban, dabigatran and rivaroxaban) are the newest advance for stroke's risk reduction in atrial fibrillation. These are as effective as warfarin in preventing stroke/systemic embolism, but exists heterogenic outcomes as gastrointestinal hemorrhage, mortality reduction, minor and major haemorrhage (adverse events). Despite of this, there is a lack of cost-effectiveness models focused on adverse events. Methodsa cost-effectiveness analysis with a third payer perspective, interventions included were apixaban, dabigatran, warfarin and rivaroxaban. Discount rate of 3%, and 10 years of temporal horizon. The Markov model is an international, validated, and modified to assess better adverse events. Major assumptions, patients with mild and moderate stroke returns to oral anticoagulation, patients with moderate and severe hemorrhage do not returns to oral anticoagulation. Probabilities and QALYs, taken from a cost-effectiveness analysis published. Costs, information from a cohort of stroke patients. Software, TreeAge pro™ and Excel™. Resultsoverall results, 1.48 QALYs, $17 916 USD for apixaban, 1.49 QALYs, $18 122 USD for dabigatran, 1.32 QALYs, $21 966 USD for warfarin and 1.24 QALYs, $24 547 USD for rivaroxaban. The ICER for apixaban compared to dabigatran was $12 988 USD. Negative ICER for warfarin and rivaroxaban, shows that are dominated alternatives (less benefits and more costs). Apixaban is cost-effective at 70% and dabigatran at 30% of iterations in the probabilistic sensitivity analysis. Conclusionsapixaban and dabigatran are cost-effective alternatives, apixaban is the most cost-effective alternative from adverse events perspective. Warfarin shows better results than rivaroxaban to prevent stroke in atrial fibrillation from adverse events perspective.

Walking adaptability for targeted fall-risk assessments

Background: Most falls occur during walking and are due to trips, slips or misplaced steps, which suggests a reduced walking adaptability. The objective of this study was to evaluate the potential merit of a walking-adaptability assessment for identifying prospective fallers and risk factors for future falls in a cohort of stroke patients, Parkinson’s disease patients, and controls (n = 30 for each group).Research question: Does an assessment of walking-adaptability improve the identification of fallers compared to generic fall-risk factors alone?Methods: This study comprised an evaluation of subject characteristics, clinical gait and balance tests, a quantitative gait assessment and a walking-adaptability assessment with the Interactive Walkway. Subjects’ falls were registered prospectively with falls calendars during a 6-month follow-up period. Generic and walking-related fall-risk factors were compared between prospective fallers and non-fallers. Binary logistic regression and Chi-square Automatic Interaction Detector analyses were performed to identify fallers and predictor variables for future falls.Results: In addition to fall history, obstacle-avoidance success rate and normalized walking speed during goal-directed stepping correctly classified prospective fallers and were predictors of future falls. Compared to the use of generic fall-risk factors only, the inclusion of walking-related fall-risk factors improved the identification of prospective fallers.Significance: If cross-validated in future studies with larger samples, these fall-risk factors may serve as quick entry tests for falls prevention programs. In addition, the identification of these walking-related fall-risk factors may help in developing falls prevention strategies.

CCR5 Is a Therapeutic Target for Recovery after Stroke and Traumatic Brain Injury

We tested a newly described molecular memory system, CCR5 signaling, for its role in recovery after stroke and traumatic brain injury (TBI). CCR5 is uniquely expressed in cortical neurons after stroke. Post-stroke neuronal knockdown of CCR5 in pre-motor cortex leads to early recovery of motor control. Recovery is associated with preservation of dendritic spines, new patterns of cortical projections to contralateral pre-motor cortex, and upregulation ofCREB and DLK signaling. Administration of a clinically utilized FDA-approved CCR5 antagonist, devised for HIV treatment, produces similar effects on motor recovery post stroke and cognitive decline post TBI. Finally, in a large clinical cohort of stroke patients, carriers for a naturally occurring loss-of-function mutation in CCR5 (CCR5-Δ32) exhibited greater recovery of neurological impairments and cognitive function. In summary, CCR5 is a translational target for neural repair in stroke and TBI and the first reported gene associated with enhanced recovery in human stroke.

The association of gout with an increased risk of hypertension and diabetes mellitus among stroke survivors in New Zealand: A cross-sectional study using routinely collected electronic health data.

BackgroundThere is a paucity of data relating to the association of gout with the occurrence of hypertension and diabetes mellitus in patients with stroke. This study aimed to determine the association of gout with the risk of hypertension and diabetes mellitus in a cohort of stroke patients from Auckland, Aotearoa New Zealand.MethodsA cross-sectional study was conducted among stroke survivors in South and East Auckland, New Zealand from the years 2010 to 2014. Electronic health record data were collected and analysed using Statistical Package for Social Science version 23. Multivariate logistic regression modelling adjusted for age, gender, and ethnicity was conducted to determine the association of gout with the risk of hypertension and diabetes mellitus in patients discharged with a diagnosis of stroke.ResultsThe age-, gender-, and ethnicity-adjusted odds ratio for having hypertension and diabetes mellitus among stroke survivors with gout history were 3.25 (95% confidence interval 1.32–8.03) and 1.94 (95% confidence interval 1.12–3.36), respectively. Māori stroke survivors with gout history had the highest risk of having diabetes mellitus with age- and gender-adjusted odds ratio of 5.10 (95% confidence interval 1.90–18.93).ConclusionThe findings from this study suggest gout may be independently associated with an increased risk of hypertension and diabetes mellitus in patients with stroke. Māori who are the indigenous population of New Zealand show a greater risk of diabetes mellitus associated with a gout diagnosis compared to other populations. This finding highlights the importance of the need for further research with Māori stroke survivors and other indigenous populations.

Baseline characteristics of the 1149 patients recruited into the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) randomized controlled trial.

High blood pressure is common in acute stroke and associated with a worse functional outcome. Glyceryl trinitrate, a nitric oxide donor, lowers blood pressure in acute stroke and may improve outcome. Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) tested the feasibility of performing a UK multicenter ambulance-based stroke trial, and the safety and efficacy of glyceryl trinitrate when administered by paramedics before hospital admission. Paramedic-led ambulance-based multicenter prospective randomized single-blind blinded-endpoint parallel-group controlled trial of transdermal glyceryl trinitrate (given for four days) versus sham in patients with ultra-acute (<4 h) presumed stroke. Data are number (%), median (interquartile range) or mean (standard deviation). Recruitment ran from October 2015 to 31 May 2018. A total 1149 patients were recruited from eight UK ambulance services and taken to 54 acute hospitals. Baseline characteristics include: mean age 73 (15) years; female 555 (48%); median time from stroke to randomization 70 (45, 115) min; face-arm-speech scale score 2.6 (0.5); and blood pressure 162 (25)/92 (18) mmHg. The final diagnosis was ischemic stroke 52%, hemorrhagic stroke 13%, Transient Ischemic Attack (TIA) 9%, and mimic 25%. The main trial results will be presented in quarter 4 2018. The results will also be included in updated Cochrane systematic reviews, and individual patient data meta-analyses of all relevant randomized controlled trials. It was feasible to perform a multicenter ambulance-based ultra-acute stroke trial in the UK and to treat with glyceryl trinitrate versus sham. The relatively unselected cohort of stroke patients is broadly representative of those admitted to hospital in the UK. ISRCTN26986053.

Pathogenic variants in the ABCC6 gene are associated with an increased risk for ischemic stroke.

Ischemic stroke causes a high mortality and morbidity worldwide. It results from a complex interplay of incompletely known environmental and genetic risk factors. We investigated the ABCC6 gene as a candidate risk factor for ischemic stroke because of the increased ischemic stroke incidence in the autosomal recessive disorder pseudoxanthoma elasticum, caused by biallelic pathogenic ABCC6 variants, the higher cardiovascular risk in heterozygous carriers and the established role of ABCC6 dysfunction in myocardial ischemia. We established segregation of a known pathogenic ABCC6 variant (p.[Arg1314Gln]) in 11/19 family members of an ischemic stroke patient in a large multigenerational family suffering from ischemic stroke and/or cardiovascular disease at a relatively young age. In an independent case-control study in 424 ischemic stroke patients and 250 healthy controls, pathogenic ABCC6 variants were 4.9 times more frequent (P = 0.036; 95% CI 1.11-21.33) in the ischemic stroke patient cohort. To study cellular consequences of ABCC6 deficiency in the brain, immunostaining of brain sections in Abcc6-deficient mice and wild-type controls were performed. An upregulation of Bmp4 and Eng and a downregulation of Alk2 was identified in Abcc6-/- mice, suggesting an increase in apoptosis and angiogenesis. As both of these processes are induced in ischemia, we propose that a pro-ischemic state may explain the higher risk to suffer from ischemic stroke in patients carrying a pathogenic ABCC6 variant, as this may lower the threshold to develop acute ischemic events in these patients. In conclusion, this study identified heterozygous ABCC6 variants as a risk factor for ischemic stroke. Further, dysregulation of Bmp (Bmp4, Alk2) and Tgfβ (Eng) signaling in the brain of Abcc6-/- mice could lead to a pro-ischemic state, lowering the threshold to develop acute ischemic events. These data demonstrate the importance of a molecular analysis of the ABCC6 gene in patients diagnosed with cryptogenic ischemic stroke.

Application of Machine Learning to Automated Analysis of Cerebral Edema in Large Cohorts of Ischemic Stroke Patients.

Cerebral edema contributes to neurological deterioration and death after hemispheric stroke but there remains no effective means of preventing or accurately predicting its occurrence. Big data approaches may provide insights into the biologic variability and genetic contributions to severity and time course of cerebral edema. These methods require quantitative analyses of edema severity across large cohorts of stroke patients. We have proposed that changes in cerebrospinal fluid (CSF) volume over time may represent a sensitive and dynamic marker of edema progression that can be measured from routinely available CT scans. To facilitate and scale up such approaches we have created a machine learning algorithm capable of segmenting and measuring CSF volume from serial CT scans of stroke patients. We now present results of our preliminary processing pipeline that was able to efficiently extract CSF volumetrics from an initial cohort of 155 subjects enrolled in a prospective longitudinal stroke study. We demonstrate a high degree of reproducibility in total cranial volume registration between scans (R = 0.982) as well as a strong correlation of baseline CSF volume and patient age (as a surrogate of brain atrophy, R = 0.725). Reduction in CSF volume from baseline to final CT was correlated with infarct volume (R = 0.715) and degree of midline shift (quadratic model, p < 2.2 × 10−16). We utilized generalized estimating equations (GEE) to model CSF volumes over time (using linear and quadratic terms), adjusting for age. This model demonstrated that CSF volume decreases over time (p < 2.2 × 10−13) and is lower in those with cerebral edema (p = 0.0004). We are now fully automating this pipeline to allow rapid analysis of even larger cohorts of stroke patients from multiple sites using an XNAT (eXtensible Neuroimaging Archive Toolkit) platform. Data on kinetics of edema across thousands of patients will facilitate precision approaches to prediction of malignant edema as well as modeling of variability and further understanding of genetic variants that influence edema severity.

P28. The functional role of the anterior intraparietal sulcus for recovery of hand function in chronic stroke patients – A combined fMRI-TMS study

Introduction After stroke, neuroimaging studies frequently show increased activation of contralesional regions such as the primary motor cortex (M1) and the anterior intraparietal sulcus (aIPS) during movements of the impaired hand ( Rehme et al., 2012 ). There is evidence that these areas may adopt either supportive or disturbing implications for motor control, depending on multiple factors, such as age, stroke severity, and lesion location ( Di Pino et al., 2014 ). Importantly, previous research has mainly focused on investigating this question in the contralesional M1, while other areas involved in motor control, such as the aIPS have often been neglected despite considerable changes in post-stroke activity. Hence, we here examined the role of both ipsi- and contralesional aIPS for recovered motor function in the chronic phase post stroke using neuronavigated ‘online-TMS’ guided by individual fMRI activation maps. Methods First, we assessed structural and functional MRI data of chronic stroke patients and age-matched controls. During fMRI, participants performed an index finger tapping task to localize motor-related activation. The coordinates of peak activity in bilateral aIPS were identified in each participant and subsequently used as stimulation targets to apply short trains of rTMS (10 Hz trains, 90% of resting motor threshold, rMT) time locked to hand movements of different complexity: Participants performed (i) index finger tapping, (ii) pointing between two targets, and (iii) reach-to-grasp movements while ipsilateral M1, aIPS, or contralateral aIPS were transiently disturbed by rTMS. Sham stimulation served as control with the coil being tilted over the parieto-occipital vertex. Task performance was measured using a 3D motion analysis system (Zebris). Results TMS interference with aIPS contralateral to the moving hand led to altered kinematics across all tasks modulating finger tapping amplitudes, pointing accuracy and maximum grip aperture during grasping, highlighting the role of this region for hand motor control in patients and healthy controls. In contrast, interference with aIPS and M1 ipsilateral to the moving hand revealed differential effects in patients. Preliminary data suggest distinct roles of these contralesional areas for recovered hand function in chronic stroke. Conclusions The present findings provide proof-of-principle for the use of fMRI-guided TMS allowing to assess target regions’ functions for hand motor control on the single-subject level. Implementing this approach in a larger cohort of stroke patients provides a promising strategy to individually characterize maladaptive or supportive roles in bilateral aIPS and the contralesional M1 in relation to patient’s motor impairment and lesion topology.

Abnormal admission kidney function predicts higher mortality in stroke patients

Objectives:To to investigate the impact of abnormal kidney function on stroke outcome.Methods:This was a retrospective cohort of stroke patients admitted to King Abdulaziz University Hospital in Kingdom of Saudi Arabia between 2010 and 2014. Serum creatinine and urine protein were collected at admis-sion. We defined proteinuria as urine protein dipstick ≥+1. Estimated glomerular filtration (eGFR) rate was calculated by Modification of Diet in Renal Disease Study equation in mL/min/1.73m2. Abnormal kidney disease was defined as Creatinine>126 mg/dl or eGFR<60. Clinical characteristics and outcomes including one-year mortality and 30-day readmission were compared between patients with versus (vs.) without abnormal kidney function and/or proteinuria.Results:Out of 548 patients, 507 had creatinine measurement at admission and 193 patients had ab-normal kidney function. These patients tended to be older (median age 67 years vs. 60.5 for those with normal kidney function), men (66.7% vs. 54.3%), and hypertensive (96% vs. 88%). Diabetes prevalence did not differ between the 2 groups. Proteinuria was not associ-ated with future mortality. Abnormal kidney function was a significant predictor of post-stroke one-year mortality (adjusted OR=2.5, 95% CI=1.4 to 4.6; p-value=0.003).Conclusion:Abnormal kidney function doubled the risk of one-year mortality post stroke in our cohort. High-risk groups, including older hypertensive men, could be targeted for aggressive moni-toring and early treatment of risk factors.

Importance of Angiogenin and Endothelial Progenitor Cells After Rehabilitation Both in Ischemic Stroke Patients and in a Mouse Model of Cerebral Ischemia.

Background: Rehabilitation therapy is the only available treatment for stroke survivors presenting neurological deficits; however, the underlying molecules and mechanisms associated with functional/motor improvement during rehabilitation are poorly understood.Objective: Our aim is to study the modulation of angiogenin and endothelial progenitor cells (EPCs) as repair-associated factors in a cohort of stroke patients and mouse models of rehabilitation after cerebral ischemia.Methods: The clinical study included 18 ischemic strokes admitted to an intensive rehabilitation therapy (IRT) unit, 18 non-ischemic controls and brain samples from three deceased patients. Angiogenin and EPCs were measured in blood obtained before and up to 6 months after IRT together with an extensive evaluation of the motor/functional status. In parallel, C57BL/6 mice underwent middle cerebral artery occlusion, and the pasta matrix reaching-task or treadmill exercises were used as rehabilitation models. Angiogenin RNA expression was measured after 2 or 12 days of treatment together with cell counts from EPCs cultures.Results: Brain angiogenin was identified in both human and mouse tissue, whereas serum levels increased after 1 month of IRT in association with motor/functional improvement. EPC populations were increased after stroke and remained elevated during follow-up after IRT. The mouse model of rehabilitation by the task-specific pasta matrix exercise increased the number of EPCs at 2 days and increased angiogenin expression after 12 days of rehabilitation.Conclusions: Angiogenin and EPCs are modulated by rehabilitation after cerebral ischemia, suggesting that both angiogenin and EPCs could serve as biomarkers of improvement during rehabilitation or future therapeutic targets.

Depression and young age impact on hip fracture subsequent to stroke: A population-based cohort study.

The purpose of this study is to identify whether depression and other associated factors in stroke are related to subsequent hip fracture. There are very few studies that focus on depression and demographic impact on subsequent hip fracture after a stroke. This a retrospective cohort study design. The Taiwan Longitudinal Health Insurance Database between 1997 and 2010 was used. Two stroke patient cohorts were analysed: (1) depression within 1year after newly diagnosed strokes; (2) without depression within 1year after newly diagnosed strokes. Demographic characteristics, comorbidities, and hip fracture were compared using the Fine and Gray regression model for subdistribution hazard ratios. Patients with depression showed a higher risk of hip fracture (95% CI, 0.99-1.66). Depression was associated with increased risk of hip fracture for patients below 50years old (95% CI, 1.45-7.34). Comorbidities and gender showed no significant correlation with hip fracture risk in the depressed or nondepressed groups. Poststroke depression was a significant contributor to hip fracture in patients who suffered strokes and had more negative impact on the younger population, regardless of the gender and presence of comorbidities.

Differences in and Determinants of Prehospital Delay Times among Stroke Patients—1994 Versus 2012

Prehospital delay is a challenge for stroke treatment and the delivery of time-critical treatments. Few studies have examined secular trends in prehospital delay, and results vary. This study investigates how prehospital delay among Norwegian stroke patients has changed over the last 2 decades. We compared time from symptom onset to admission in 2 cohorts of stroke patients admitted to Akershus University Hospital, Norway, in 1994 (n = 550) and 2012 (n = 522), and constructed predictive models for arrival within 3 hours for each cohort. More patients arrived within 3 hours of symptom onset in 2012 compared to 1994 (proportion, 47.1% versus 19.3%, P < .001), also after adjusting for age, sex, and baseline differences; odds ratio (OR) was 5.14 (95% confidence interval [CI] 3.69-7.15). Stroke severity was the only predictor examined that was independently associated with early arrival during both periods. For patients with moderate strokes the overall OR was 2.06 (95% CI 1.41-3.00) and for severe strokes 4.52 (95% CI 2.97-6.87), compared to those with mild strokes. In the 1994 cohort additional predictors of early arrival were living with others and not being admitted from nursing home. Prehospital delay in Norway has decreased considerably over the last 2 decades and since the availability of time-critical treatments. However, there is still an urgent need to reduce the number of delayed admissions as a large proportion of patients continue to arrive too late to benefit from these treatments. Patients with severer strokes were predicted to have earlier arrival.

Impact of stroke-associated pneumonia on mortality, length of hospitalization, and functional outcome.

Stroke-associated pneumonia (SAP) is common and associated with adverse outcomes. Data on its impact beyond 1year are scarce. This observational study was conducted in a cohort of stroke patients admitted consecutively to a tertiary referral center in the east of England, UK (January 2003-April 2015). Logistic regression models examined inpatient mortality and length of stay (LOS). Cox regression models examined longer-term mortality at predefined time periods (0-90days, 90days-1year, 1-3years, and 3-10years) for SAP. Effect of SAP on functional outcome at discharge was assessed using logistic regression. A total of 9238 patients (mean age [±SD] 77.61±11.88years) were included. SAP was diagnosed in 1083 (11.7%) patients. The majority of these cases (n=658; 60.8%) were aspiration pneumonia. After controlling for age, sex, stroke type, Oxfordshire Community Stroke Project (OCSP) classification, prestroke modified Rankin scale, comorbidities, and acute illness markers, mortality estimates remained significant at 3 time periods: inpatient (OR 5.87, 95%CI [4.97-6.93]), 0-90days (2.17 [1.97-2.40]), and 91-365days (HR 1.31 [1.03-1.67]). SAP was also associated with higher odds of long LOS (OR 1.93 [1.67-2.22]) and worse functional outcome (OR 7.17 [5.44-9.45]). In this cohort, SAP did not increase mortality risk beyond 1year post-stroke, but it was associated with reduced mortality beyond 3years. Stroke-associated pneumonia is not associated with increased long-term mortality, but it is linked with increased mortality up to 1year, prolonged LOS, and poor functional outcome on discharge. Targeted intervention strategies are required to improve outcomes of SAP patients who survive to hospital discharge.

Optimizing Cardiac Out-Put to Increase Cerebral Penumbral Perfusion in Large Middle Cerebral Artery Ischemic Lesion-OPTIMAL Study.

In unsuccessful vessel recanalization, clinical outcome of acute stroke patients depends on early improvement of penumbral perfusion. So far, mean arterial blood pressure (MAP) is the target hemodynamic parameter. However, the correlations of MAP to cardiac output (CO) and cerebral perfusion are volume state dependent. In severe subarachnoid hemorrhage, optimizing CO leads to a reduction of delayed ischemic neurological deficits and improvement of clinical outcome. This study aims to investigate the effect of standard versus advanced cardiac monitoring with optimization of CO on the clinical outcome in patients with large ischemic stroke. The OPTIMAL study is a prospective, multicenter, open, into two arms (1:1) randomized, controlled trial. Sample size estimate: sample sizes of 150 for each treatment group (300 in total) ensure an 80% power to detect a difference of 16% of a dichotomized level of functional clinical outcome at 3 months at a significance level of 0.05. Study outcomes: the primary endpoint is the functional outcome at 3 months. The secondary endpoints include functional outcome at 6 months follow-up, and complications related to hemodynamic monitoring and therapies. The results of this trial will provide data on the safety and efficacy of advanced hemodynamic monitoring on clinical outcome. The trial was approved by the leading ethics committee of Freiburg University, Germany (438/14, 2015) and the local ethics committees of the participating centers. The study is performed in accordance with the Declaration of Helsinki and the guidelines of Good Clinical Practice. It is registered in the German Clinical Trial register (DRKS; DRKS00007805). Dissemination will include submission to peer-reviewed professional journals and presentation at congresses. Hemodynamic monitoring may be altered in a specific stroke patient cohort if the study shows that advanced monitoring is safe and improves the functional outcome.

The impact of anger in adherence to treatment and beliefs about disease 1year after stroke.

Anger is a frequent neuropsychiatric symptom after stroke, which can disrupt treatment and recovery, in particular by affecting adherence behaviour to treatment and health care education. This study aimed to follow-up a cohort of stroke patients 12 months after their stroke to describe the presence of anger, compare levels and profile of acute and post-acute anger and analyse its impact on the adherence to treatment and beliefs about stroke. We followed (13.3months mean follow-up) 91 stroke patients with a standardized protocol, using State-Trait Anger Expression Inventory-2 (STAXI-2) to assess the frequency and profile of anger and its components and one questionnaire to measure adherence to treatment and health education (meaning on the treatment) (Adh-T). We used as explanatory variables socio-demographic, clinical, stroke type and location information collected during the acute phase. Anger-state was detected in 15 (17%) patients, while anger-trait was present in 7 (8%) patients. The best regression model revealed that trait-anger, stroke location (posterior infarcts), and impact of stroke sequels were independent predictive factors for anger (R 2=43%). Patients with higher levels of anger expression had lower adherence rates, independently of the adherence dimension. In the chronic phase after stroke anger was related with posterior lesions, the impact of stroke consequences and anger as a personality trait. The detection and monitoring of anger could eventually prevent the negative impact of anger in care, especially in adherence to rehabilitation and secondary prevention.

Atrial time and voltage dispersion are both needed to predict new-onset atrial fibrillation in ischemic stroke patients

BackgroundAtrial fibrillation (AF) is a known risk factor for ischemic stroke. Electrocardiographic predictors of AF in population studies such as the Framingham Heart Study, as well as in hypertensive patients have demonstrated a predictive value of the P-wave duration for development of AF. QRS vector magnitude has had a predictive value in ventricular arrhythmia development. We aimed to assess the value of the three-dimensional P-wave vector magnitude and its relationship to P-wave duration for prediction of new-onset AF after ischemic stroke.MethodsFirst-ever ischemic stroke patients without AF at inclusion in the Lund Stroke Register were included. Measurements of P wave duration (Pd), QRS duration, corrected QT interval, and PQ interval were performed automatically using the University of Glasgow 12-lead ECG analysis algorithm. The P-wave vector magnitude (Pvm) was calculated automatically as the square root of the sum of the squared P-wave magnitudes in leads V6, II and one half of the P-wave amplitude in V2 ( sqrt{PV{6}^2+{PII}^2+{left({0.5}^{ast }PV2right)}^2} ), based on the P-wave magnitude (Pvm) as defined by the visually transformed Kors’ Quasi-orthogonal method.ResultsThe median age was 73 (IQR 63–80) years at stroke onset (135 males, 92 females). Multivariate predictors of new-onset atrial fibrillation included age > 65 years, hypertension, and Pd/Pvm. A cut-off value of 870 ms/mV gave sensitivity, specificity, positive and negative predictive values of 51, 79, 30 and 87%, respectively. The Pd/Pvm was the only ECG predictor of AF with a significant multivariate hazard ratio of 2.02 (95% CI 1.18 to 3.46, p = 0.010).ConclusionP-wave dispersion as measured by the Pd/Pvm was the only ECG parameter measured which independently predicted subsequent AF identification in a cohort of stroke patients. Further prospective studies in larger cohorts are needed to validate its clinical usefulness.

One-Year Incidence, Time Trends, and Predictors of Recurrent Ischemic Stroke in Sweden From 1998 to 2010: An Observational Study.

Recent data on the incidence, time trends, and predictors of recurrent ischemic stroke are limited for unselected patient populations. Data for ischemic stroke patients were obtained from The Swedish Stroke Register (Riksstroke) between 1998 and 2009 and merged with The Swedish National Inpatient Register. A reference group of patients was created by Statistics Sweden. The ischemic stroke patient cohort was divided into 4 time periods. Recurrent ischemic stroke within 1 year was recorded until 2010. Kaplan-Meier and Cox regression analyses were performed to study time trends and predictors of ischemic stroke recurrence. Of 196 765 patients with ischemic stroke, 11.3% had a recurrent ischemic stroke within 1 year. The Kaplan-Meier estimates of the 1-year cumulative incidence of recurrent ischemic stroke decreased from 15.0% in 1998 to 2001 to 12.0% in 2007 to 2010 in the stroke patient cohort while the cumulative incidence of ischemic stroke decreased from 0.7% to 0.4% in the reference population. Age >75 years, prior ischemic stroke or myocardial infarction, atrial fibrillation without warfarin treatment, diabetes mellitus, and treatment with β-blockers or diuretics were associated with a higher risk while warfarin treatment for atrial fibrillation, lipid-lowering medication, and antithrombotic treatment (acetylsalicylic acid, dipyridamole) were associated with a reduced risk of recurrent ischemic stroke. The risk of recurrent ischemic stroke decreased from 1998 to 2010. Well-known risk factors for stroke were associated with a higher risk of ischemic stroke recurrence; whereas, secondary preventive medication was associated with a reduced risk, emphasizing the importance of secondary preventive treatment.