Hemorrhagic Subtypes Research Articles

A Stepwise Approach to Stroke Surveillance in Brazil: the EMMA (Estudo de Mortalidade E Morbidade Do Acidente Vascular Cerebral) Study

Stroke mortality rates in Brazil are the highest in the Americas. Deaths from cerebrovascular disease surpass coronary heart disease. To verify stroke mortality rates and morbidity in an area of São Paulo, Brazil, using the World Health Organization Stepwise Approach to Stroke Surveillance. We used the World Health Organization Stepwise Approach to Stroke Surveillance structure of stroke surveillance. The hospital-based data comprised fatal and nonfatal stroke (Step 1). We gathered stroke-related mortality data in the community using World Health Organization questionnaires (Step 2). The questionnaire determining stroke prevalence was activated door to door in a family-health-programme neighbourhood (Step 3). A total of 682 patients 18 years and above, including 472 incident cases, presented with cerebrovascular disease and were enrolled in Step 1 during April-May 2009. Cerebral infarction (84.3%) and first-ever stroke (85.2%) were the most frequent. In Step 2, 256 deaths from stroke were identified during 2006-2007. Forty-four per cent of deaths were classified as unspecified stroke, 1/3 as ischaemic stroke, and 1/4 due to haemorrhagic subtype. In Step 3, 577 subjects over 35 years old were evaluated at home, and 244 cases of stroke survival were diagnosed via a questionnaire, validated by a board-certified neurologist. The population demographic characteristics were similar in the three steps, except in terms of age and gender. By including data from all settings, World Health Organization stroke surveillance can provide data to help plan future resources that meet the needs of the public-health system.

Ecological Analysis of Long-Term Exposure to Ambient Air Pollution and the Incidence of Stroke in Edmonton, Alberta, Canada

Long-term air pollution effects on stroke incidence have not been examined extensively. We investigated the associations between ambient pollution and the incidence of stroke, as well as stroke subtypes, in a northern Canadian city surrounded by energy-sector pollution sources. Stroke data from an administrative database from 2003 through 2007 were used to estimate annual incidence rates within small geographic regions within Edmonton, Canada. Air pollution levels for each region were estimated from continuous fixed-site monitoring stations in and around Edmonton. We fit models estimating stroke risk in relation to pollution levels; risks were adjusted for age, sex, income, social deprivation, and other factors. Between 2003 and 2007, the average 5-year concentration of NO(2) and CO was positively associated with the incidence of stroke, particularly for hemorrhagic and nonhemorrhagic stroke subtypes (NO(2): hemorrhagic stroke relative risk=1.46; 95% CI, 1.19-1.80; nonhemorrhagic stroke relative risk=1.36; 95% CI, 1.19-1.56). However, these estimates of risk diminished after controlling for the ecological measures of income and deprivation. Adjustment for ecologically derived indices of smoking, hypertension, and body mass index did not alter the estimates of risk in any meaningful way. Although long-term NO(2) and CO levels were positively associated with a higher incidence of stroke in the entire study area, the risk estimates were strongly attenuated by household income levels. Further research that incorporates individual-level risk factor data would improve our understanding of the relation of longer-term exposures to ambient air pollution and stroke outcomes.

Comparison of Outcomes after Intracerebral Hemorrhage and Ischemic Stroke

Intracerebral hemorrhage (ICH) is associated with a greater average initial stroke severity, higher mortality, and poorer long-term neurologic outcomes than ischemic stroke. The purpose of this study was to determine whether the poorer prognosis of ICH is independent of initial stroke severity. We analyzed data from the Glycine Antagonist in Neuroprotection (GAIN) Americas trial, in which 1604 non-obtunded patients with acute stroke were treated within 6 hours of symptom onset irrespective of hemorrhagic (N = 237) versus ischemic (N = 1367) subtype. Multiple logistic regression analysis was performed to evaluate predictors of mortality and neurologic outcome (modified Rankin scale [mRS] score of 0-1 v 2-6 at 3 months) adjusting for baseline National Institutes of Health Stroke Scale score, stroke risk factors, clinical and demographic characteristics, and gavestinel treatment group. Multiple linear regression techniques were used to assess the impact of various predictors on the full mRS score at 3 months. ICH significantly increased the odds of a poor neurologic outcome (odds ratio 1.94, 95% confidence interval 1.23-3.06) and was independently associated with a mean 0.25-point increase in the 3-month mRS score (P = .04). ICH had no effect on mortality compared with ischemic stroke (odds ratio 1.01, 95% confidence interval .68-1.49) after adjusting for initial stroke severity (National Institutes of Health Stroke Scale score) and other baseline characteristics. Among conscious stroke patients, ICH is an independent predictor of poor neurologic outcome, nearly doubling the odds of long-term disability. However, ICH is not associated with higher mortality compared with ischemic stroke after adjusting for initial stroke severity and other baseline characteristics.

Stroke: Highlights of Selected Articles

Executive functions are cognitive processes essential for controlling goal-oriented behavior and responding to new and novel situations. Executive function includes the processes of planning, initiation, organization, inhibition, problem solving, self-monitoring, and error correction. It has been estimated that ≈75% of stroke survivors experience impaired executive function (executive dysfunction), resulting in reduced capacity to regain independence in activities of daily living, particularly when new movement strategies are necessary to compensate for limb weakness. A variety of cognitive rehabilitation interventions are implemented within clinical practice in an attempt to improve executive function and, consequently, independence with activities of daily living.1 To determine the effects of cognitive rehabilitation on executive dysfunction for adults with stroke or other nonprogressive acquired brain injuries. We searched: …

Risk of premature stroke in recent immigrants (PRESARIO)

New immigrants to North America, most of whom are under age 50 years, exhibit fewer risk factors for cardiovascular disease than their native-born counterparts, yet the stress of resettlement may conceivably place them at higher risk of stroke. We determined the risk of acute stroke associated with recency of immigration. We completed a population-based matched cohort study in Ontario, the largest province in Canada, from April 1, 1995, to March 31, 2007. Overall, 965,829 new immigrants were matched to 3,272,393 long-term residents by year of birth, sex, and location. New immigrants were identified as new recipients of universally available public health insurance, and long-term residents were those insured for 5 years or longer. The mean age of the participants at study entry was about 34 years and the total number of observed strokes was 6,216 after a median duration of follow-up of about 6 years. The incidence rate of acute stroke was 1.69 per 10,000 person-years among new immigrants and 2.56 per 10,000 person-years among long-term residents (crude hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.62-0.71). After adjusting for age, income quintile, urban vs rural residence, history of hypertension, diabetes mellitus and smoking, and number of health insurance claims, the HR for stroke was 0.69 (95% CI 0.64-0.74). Similar risk estimates were seen for both ischemic and hemorrhagic stroke subtypes. New immigrants appear to be at lower risk of premature acute stroke than long-term residents. This finding does not appear to be explained by the availability of health care services or income level.

Lack of association between dietary protein intake and risk of stroke among middle-aged men

Prospective cohort studies in Japanese populations have shown an inverse association between dietary protein and stroke risk. However, this association has not been examined among any study populations of US men. Our objective was to examine the relation between dietary protein and risk of stroke in men who participated in the Health Professionals Follow-Up Study. A total of 43,960 men who were free of cardiovascular disease and cancer at baseline were included in the analysis. Dietary protein (total, animal, and vegetable) was assessed with the use of a food-frequency questionnaire at 5 time points during the follow-up period of 1986-2004. Cox proportional hazards models were used to calculate multivariate relative risks and 95% CIs, which represented the effect of the substitution of protein for an equal percentage of energy from carbohydrate. During 18 y of follow-up there were 1057 incident stroke events (638 ischemic, 171 hemorrhagic, and 248 of unknown type). For total stroke, the relative risk for the top quintile of percentage energy from protein compared with the bottom was 1.14 (95% CI: 0.90, 1.43; P for linear trend: 0.43) for total protein, 1.11 (95% CI: 0.87, 1.41; P for linear trend: 0.52) for animal protein, and 0.82 (95% CI: 0.60, 1.12; P for linear trend: 0.17) for vegetable protein. The results were similar when ischemic and hemorrhagic stroke subtypes were considered separately. In contrast to studies in Japanese populations, this study did not show a statistically significant association between total, animal, or vegetable protein and risk of stroke in this population of US men.

Migraine and risk of haemorrhagic stroke in women: prospective cohort study

Objectives To examine the association between migraine and migraine aura status with risk of haemorrhagic stroke. Design Prospective cohort study. Setting Women’s Health Study, United States. Participants 27 860 women...

Stroke in children: inherited and acquired factors and age‐related variations in the presentation of 48 paediatric patients

Stroke is relatively rare in children and the clinical presentation of paediatric stroke is often subtle. Numerous predisposing risk factors are known, and these can be both inherited and acquired. They include cardiac disease, vascular abnormalities, endothelial damage, infectious diseases, collagen tissue diseases, certain inborn errors of metabolism and anticardiolipin antibody, lupus anticoagulant and deficiencies of protein C, protein S, antithrombin or plasminogen. In addition, abnormal activated protein C resistance (or Factor V Leiden), Factor II G20219A variant, and the thermolabile variant of methylenetetrahydrofolate reductase (MTHFR C677T) need to be considered. To explore the prevalence of different predisposing conditions in paediatric stroke patients, we evaluated 48 patients, including subjects with ischaemic and haemorrhagic stroke subtypes. Only 7 out of 48 (14.5%) had no recognizable risk factors: the majority of paediatric stroke patients had pre-existing risk factors that predisposed to the condition. The major genetic risk factor in our series of patients was homozygosity for the MTHFR C677T mutation (7 out of 48 patients); three more patients were found to be heterozygous for the Factor V Leiden mutation. Acquired predisposing conditions were present in 23 out of 48 patients and included pulmunar stenosis, head trauma, hyperlipidaemia and varicella infection. A total of 17 patients had both genetic and acquired predisposing factors. Our results emphasize that multiple predisposing risk factors commonly predispose to paediatric stroke. In addition, the primary clinical presentation appeared to differ between the older and younger children: hemiparesis was the typical presentation in children <1 year of age while seizure predominated in older children.

Endothelial Nitric Oxide Synthase Tagging Single Nucleotide Polymorphisms and Recovery From Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a hemorrhagic stroke subtype with a poor recovery profile. Cerebral vasospasm (CV), a narrowing of the cerebral vasculature, significantly contributes to the poor recovery profile. Variation in the endothelial nitric oxide (NO) synthase (eNOS) gene has been implicated in CV and outcome after SAH. The purpose of this project was to explore the potential association between three eNOS tagging single nucleotide polymorphisms (SNPs) and recovery from SAH. We included 195 participants with a diagnosis of SAH and DNA and 6-month outcome data available but without preexisting neurologic disease/deficit. Genotyping was performed using an ABI Prism 7000 Sequence Detection System and TaqMan assays. CV was verified by cerebral angiogram independently read by a neurosurgeon on 118 participants. Modified Rankin Scores (MRS) and Glasgow Outcome Scale (GOS) scores were collected 6 months posthemorrhage. Data were analyzed using descriptive statistics, analysis of variance (ANOVA) and chi-square analysis as appropriate. The sample was primarily female (n=147; 75.4%) and White (n=178; 91.3%) with a mean age of 54.6 years. Of the participants with CV data, 56 (47.5%) developed CV within 14 days of SAH. None of the SNPs individually were associated with CV presence; however, a combination of the three variant SNPs was significantly associated with CV (p=.017). Only one SNP (rs1799983, variant allele) was associated with worse 6-month GOS scores (p<.001) and MRS (p<.001). These data indicate that the eNOS gene plays a role in the response to SAH, which may be explained by an influence on CV.

Homocysteine-Lowering Therapy and Stroke Risk, Severity, and Disability

Elevated total homocysteine is associated with a higher risk of cerebrovascular disease. It is not known whether lowering homocysteine impacts on stroke risk, both in terms of severity and ischemic vs hemorrhagic stroke subtypes. Our aim was to determine whether vitamin therapy reduces the risk of ischemic and hemorrhagic stroke, as well as stroke-related disability. We analyzed stroke outcomes among participants of the Heart Outcomes Prevention Evaluation 2 (HOPE 2) trial that randomized 5522 adults with known cardiovascular disease to a daily combination of 2.5 mg of folic acid, 50 mg of vitamin B6, and 1 mg of vitamin B12, or matching placebo, for 5 years. Among 5522 participants, stroke occurred in 258 (4.7%) individuals during a mean of 5 years of follow-up. The geometric mean homocysteine concentration decreased by 2.2 micromol/L in the vitamin therapy group and increased by 0.80 micromol/L in the placebo group. The incidence rate of stroke was 0.88 per 100 person-years in the vitamin therapy group and 1.15 per 100 person-years in the placebo group (hazard ratio [HR], 0.75; 95% CI, 0.59-0.97). Vitamin therapy also reduced the risk of nonfatal stroke (HR, 0.72; 95% CI, 0.54-0.95) but did not impact on neurological deficit at 24 hours (P=0.45) or functional dependence at discharge or at 7 days (OR, 0.95; 95% CI, 0.57-1.56). In subgroup analysis, patients aged younger than 69 years, from regions without folic acid food fortification, with higher baseline cholesterol and homocysteine levels, and those not receiving antiplatelet or lipid-lowering drugs at enrollment had a larger treatment benefit. Lowering of homocysteine with folic acid and vitamins B6 and B12 did reduce the risk of overall stroke, but not stroke severity or disability.

The Epidemiology of Stroke in Northern Palestine: A 1-Year, Hospital-Based Study

Although stroke is one of the leading causes of morbidity and mortality worldwide, no studies on stroke were reported from Palestine. The objective of this study was to identify the risk factors and incidence rates of stroke in a well-defined area in north Palestine (i.e., the district of Nablus) with 362,159 native Palestinian inhabitants. All patients admitted to Al-Watani governmental hospital from September 2006 to August 2007 and given the diagnosis of acute stroke were included in the study. Diagnosis of stroke was confirmed by computerized tomography scan. Demographic characteristics and clinical data pertaining to the patients were obtained from their medical files. A total of 186 patients with stroke (95 female and 91 male) were identified during the study. The average age of the patients was 69.09 +/- 10.9 years. Among the total patients, 112 had a first-ever stroke (FES) and 74 had recurrent stroke (RS). Hypertension, diabetes mellitus, and renal dysfunction were the most common risk factors with comparable prevalence in both FES and RS. The majority of patients (153; 82.3%) had ischemic stroke subtype whereas 33 (17.7%) had hemorrhagic stroke subtype. The overall (FES + RS) annual crude incidence rate of stroke was 51.4 per 100,000 persons whereas the annual crude incidence rate of FES was 31 per 100,000 persons. The age-adjusted incidence rates were 54.5 (FES) and 89.8 (FES and RS). The overall inhospital mortality was 21% and was higher in patients with RS than in those with FES. Modifiable risk factors were common among patients with stroke. Better control of these risk factors might decrease incidence of stroke and all consequences thereafter. Incidence rate and inhospital mortality of stroke reported in this study were within the range reported from other Arab countries.

Retinal pigment epithelial tears after single administration of intravitreal bevacizumab for neovascular age-related macular degeneration

To analyse retinal pigment epithelial (RPE) tears following single administration of intravitreal bevacizumab for neovascular age-related macular degeneration (AMD) during early follow-up. Interventional, retrospective, non-comparative case series included 397 patients (409 eyes) of the 746 consecutive patients that met the eligibility criteria. Standardized visual acuity testing, fluorescein angiography, and optical coherence tomography were performed. Data collected included status of the fellow eye, previous treatment, subtypes of choroidal neovascularization (CNV), size and composition of the lesion. Multiple linear regression modelling was used to explore the effect of baseline parameters on the RPE tears. Primary end point was occurrence of RPE tears within 6 weeks after therapy. Fifteen of the 409 eyes (3.6%) developed RPE tear (95% confidence interval: 2.2-6.0, odds ratio: 26.3). The statistical modelling showed significant association between RPE tear and occult without classic CNV/predominantly haemorrhage vspredominantly/minimal classic CNV (P=0.019), as well as medium or large (>4 disc area) vssmall size of the total lesion (P=0.038). Previous treatment and status of the fellow eye did not statistically influence the risk of RPE tears. An RPE tear can develop in up to 3.6% of eyes with neovascular AMD following single administration of intravitreal bevacizumab in a short-term follow-up. Medium and large lesion size and occult without classic and predominantly haemorrhagic subtype of CNV were important predictive factors. Preoperative assessment of the lesion characteristics may help in identifying the risk of individual patients with neovascular AMD before intravitreal bevacizumab treatment.

Blood Pressure in Relation to the Incidence of Cerebral Infarction and Intracerebral Hemorrhage

Data regarding the association between blood pressure level and incidence of stroke subtype, especially primary intracerebral hemorrhage (PICH) subtypes, is sparse. This population-based study explored the relationship between blood pressure and the incidence of cerebral infarction, and PICH, with lobar and nonlobar location. Risk factors were assessed in 27,702 men and women without prior stroke from the city of Malmö, Sweden. Mean age was 58.1 years. In all, 701 subjects had stroke (613 cerebral infarction and 88 PICH) during the follow-up period (mean, 7.5 years). The age- and sex-standardized incidences of cerebral infarction in subjects with hypertension grade 3 (>or=180/110 mm Hg) and normal blood pressure (<140/90 mm Hg) were 6.8 and 1.7 per 1000 person-years, respectively. Compared with the normotensive group, the adjusted relative risk of cerebral infarction was 3.4 (95% CI: 2.6 to 4.5) in subjects with hypertension grade 3. The corresponding incidences of lobar PICH were 0.5 versus 0.08 per 1000 person-years, respectively (adjusted relative risk: 9.2, 95% CI: 2.6 to 32.6) and for nonlobar PICH 1.6 versus 0.09 per 1000 person-years, respectively (adjusted relative risk: 25.9, 95% CI: 8.2 to 82.3). The incidence of hemorrhagic and ischemic stroke increased progressively with increasing blood pressure. Although hypertension was associated with substantially higher incidence rates and absolute numbers of cerebral infarction, which is most important in the public health perspective, the relationship with nonlobar PICH was strongest in terms of relative risks.

Are Mood Disorders a Stroke Risk Factor?

See related article, pages 16–21 A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between depression and many neurological illnesses, and that mood disorders can affect the course of the diseases.1 Depression commonly occurs after a stroke, with an estimated prevalence as high as 30% in the first year after the event.2 It is well known that poststroke depression affects quality of life, functional recovery, cognitive function and health care use in stroke survivors.3 Inversely, does any association exist between a history of a previous affective disorder and future risk of cardiovascular events? Recent prospective studies have shown an association between depression and incidence of hypertension,4,5 coronary heart disease,6,7 and cardiovascular mortality.8–11 In the Multiple Risk Factor Intervention Trial, 12 866 men were followed for 18 years; those with greater depressive symptoms, as measured by the Center for Epidemiologic Studies Depression Scale (CES-D), were associated with a significant higher risk of cardiovascular mortality (hazard ratio=1.21; 95% CI, 1.03 to 1.41; P <0.05) and stroke mortality (hazard ratio= 2.03; 95% CI, 1.20 to 3.44; P <0.01).12 The NHANES I Epidemiologic Study13 showed that individuals reporting 5 or more symptoms of depression at baseline were 50% more likely to die of a stroke-related cause during a 29-year follow-up. The Baltimore Epidemiologic Catchment Area Study showed that individuals with a history of depressive disorder, measured with the diagnostic interview schedule, were 2.6 times more likely to report stroke.14 Depressive symptoms, measured by the Zung Self-rating Depression Scale, were also associated with an increased incidence of ischemic stroke in a Japanese 10-year follow study.15 Self-reported depression scores significantly predicted stroke in an Australian cohort of people …

Risk Factors and Stroke Subtypes: Results of Five Consecutive Years of the Perugia Stroke Registry

To understand the etiopathogenetic mechanisms of stroke and to target prevention, we need to know how risk factors differ among etiological subtypes. Our aims were to determine the different profile of risk factors for ischemic and hemorrhagic stroke subtypes in our cohort from the Perugia Hospital-Based Stroke Registry. We analyzed the characteristics and the different risk factors of 2,395 first-ever consecutive stroke patients admitted to the Perugia Hospitals in the period between January 1, 1998 and December 31, 2002. The prevalence of cerebrovascular risk factors in each stroke subtype was analyzed independently and compared with other subtypes of stroke pooled together by means of univariate analysis and logistic regression models. Hypertension occurred in 61% of patients; familial history of stroke in 41.6%; vascular disease in 27.2%; embolic heart disease in 22.3%; cigarette smoking in 21.6%. Different potentially modifiable risk factors profiles were identified for each ischemic subtype of stroke, while in hemorrhagic lobar stroke subtypes, only male gender was an independent risk factor.

Risk Factors for Primary Intracerebral Hemorrhage

Purpose: In this population-based study, risk factors for primary intracerebral hemorrhage (PICH) and PICH subtypes were explored in a nested case-control design. Method: Risk factors were determined in 22,444 men and 10,902 women (mean age 47 years) who participated in a health-screening programme between 1974 and 1991. 147 subjects with CT or autopsy-verified first-ever PICH during the follow-up period (mean 14 years) were compared with 1,029 stroke-free controls, matched for age, sex and screening-year. Results: As compared to controls, PICH cases had significantly higher blood pres- sure (135/91 vs. 127/85 mm Hg), triglycerides (1.7 vs. 1.4 mmol/l), BMI (25.5 vs. 24.8) and shorter stature (1.73 vs. 1.74 m). Diabetes (6.9 vs. 2.8 %) and history of psychiatric morbidity (19.7 vs. 11.0 %) were more common in PICH cases and more of them were living alone (35.4 vs. 25.5%). After adjustment in a backward logistic regression model, high systolic blood pressure, diabetes, high triglycerides, short stature and psychiatric morbidity remained significantly associated with PICH. As compared to the control group, high systolic blood pressure was significantly associated both with nonlobar and lobar PICH. Diabetes and psychiatric morbidity were associated with nonlobar PICH. Smoking doubled the risk for lobar PICH, but was unrelated to nonlobar PICH. Conclusion: In this prospective population-based study, hypertension, diabetes, height, triglycerides and psychiatric morbidity were risk factors for PICH. Smoking was a risk factor for lobar PICH only.

Recommendations for the Establishment of Stroke Systems of Care

Stroke continues to be a significant cause of morbidity and mortality in the United States. Approximately 700 000 Americans have a new or recurrent stroke each year, and stroke remains the third leading cause of death in the United States when considered independently from other cardiovascular diseases. Stroke also remains a leading cause of serious, long-term disability in the United States.1 Major advances have been made during the past several decades in stroke prevention, treatment, and rehabilitation. Despite successes in delivering effective new therapies, significant obstacles remain in ensuring that scientific advances are consistently translated into clinical practice. In many instances, these obstacles can be related to a fragmentation of stroke-related care caused by inadequate integration of the various facilities, agencies, and professionals that should closely collaborate in providing stroke care. There is increased emphasis on improving the components of stroke care, including recommendations from the Brain Attack Coalition for primary stroke centers and a formal process provided through the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for the certification of primary stroke centers.2–4 It is critically important to look carefully at how the distinct components can be better integrated into systems of stroke care. The American Stroke Association (ASA), a division of the American Heart Association (AHA), is dedicated to improving stroke prevention, treatment, and rehabilitation through research, education, advocacy, and the development and application of scientifically based standards and guidelines. The ASA convened a multidisciplinary group, the Task Force on the Development of Stroke Systems, to describe the current fragmentation of stroke care, to define the key components of a stroke system, and to recommend methods for encouraging the implementation of stroke systems. The term “stroke system” is used in this article to avoid the corporate and financial connotations associated with the words “network” and …

Retraso extrahospitalario e intrahospitalario en el tratamiento del ictus

Only a minority of patients with acute stroke are eligible for fibrinolysis, and the main reason for this is that time runs out and goes beyond the therapeutic window. The chief delay occurs prior to arrival at the hospital, but there is also a nosocomial delay, which has received far less attention. The purpose of our study was to describe the data on delays occurring before and after arrival at the hospital in a sample of patients with acute stroke, and to analyse possible associated factors, including the overload on health care services in the Emergency department, an aspect that has not previously been evaluated. Epidemiological data, times of delays before and after entering the hospital, means of transport used and the health care workload in the Emergency department of the day of admission were collected for all the stroke patients admitted to the Stroke Unit of the Hospital General Universitario de Alicante throughout the period under study. From an initial sample of 460 patients, 423 were finally included in the study, with a mean delay before and after admission to hospital of 3.99 and 2.36 hours, respectively. Use of an ambulance and the haemorrhagic and transient ischemic attack subtypes were linked to a shorter delay before reaching the hospital, and arrival during the night shift was the only factor associated to a longer delay once inside the hospital. In our environment, there is a need to establish strategies aimed at shortening the times stroke patients take to reach the hospital and the time that elapses before they are attended.

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Interobserver Agreement in the Classification of Stroke in the Women’s Health Study

Accurate classification of stroke events is essential in large cohort studies of risk factor assessment and in treatment trials such as the Women's Health Study (WHS). Based on medical record review, we assessed interrater reliability in stroke classification and disability status in the WHS using the kappa statistic. During 7.0 years of follow-up, 271 incident strokes occurred, of which 133 were reclassified. There was excellent interrater agreement in the diagnosis of major stroke types, hemorrhagic subtypes, and degree of disability, as well as substantial agreement in the definition of the vascular territory involved. Only moderate agreement was reached in the classification of ischemic subtypes. Major stroke types, degree of disability, and vascular territory involved can be reliably classified on the basis of a review of medical records in the WHS, whereas classification of ischemic stroke subtypes needs further refinement of diagnostic criteria.