1
|
Leskelä J, Putaala J, Martinez-Majander N, Tulkki L, Manzoor M, Zaric S, Ylikotila P, Lautamäki R, Saraste A, Suihko S, Könönen E, Sinisalo J, Pussinen P, Paju S. Periodontitis, Dental Procedures, and Young-Onset Cryptogenic Stroke. J Dent Res 2024; 103:494-501. [PMID: 38623924 PMCID: PMC11047014 DOI: 10.1177/00220345241232406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Periodontitis is associated with an increased risk of ischemic stroke, and the risk may be particularly high among young people with unexplained stroke etiology. Thus, we investigated in a case-control study whether periodontitis or recent invasive dental treatments are associated with young-onset cryptogenic ischemic stroke (CIS). We enrolled participants from a multicenter case-control SECRETO study including adults aged 18 to 49 y presenting with an imaging-positive first-ever CIS and stroke-free age- and sex-matched controls. Thorough clinical and radiographic oral examination was performed. Furthermore, we measured serum lipopolysaccharide (LPS) and lipotechoic acid (LTA) levels. Multivariate conditional regression models were adjusted for stroke risk factors, regular dentist visits, and patent foramen ovale (PFO) status. We enrolled 146 case-control pairs (median age 41.9 y; 58.2% males). Periodontitis was diagnosed in 27.5% of CIS patients and 20.1% of controls (P < 0.001). In the fully adjusted models, CIS was associated with high periodontal inflammation burden (odds ratio [OR], 95% confidence interval) with an OR of 10.48 (3.18-34.5) and severe periodontitis with an OR of 7.48 (1.24-44.9). Stroke severity increased with the severity of periodontitis, having an OR of 6.43 (1.87-23.0) in stage III to IV, grade C. Invasive dental treatments performed within 3 mo prestroke were associated with CIS, with an OR of 2.54 (1.01-6.39). Association between CIS and invasive dental treatments was especially strong among those with PFO showing an OR of 6.26 (1.72-40.2). LPS/LTA did not differ between CIS patients and controls but displayed an increasing trend with periodontitis severity. Periodontitis and recent invasive dental procedures were associated with CIS after controlling for multiple confounders. However, the role of bacteremia as a mediator of this risk was not confirmed.
Collapse
Affiliation(s)
- J. Leskelä
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
| | - J. Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - N. Martinez-Majander
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - L. Tulkki
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - M. Manzoor
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
| | - S. Zaric
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King’s College London, London, UK
| | - P. Ylikotila
- Neurocenter, Turku University Hospital, University of Turku, Turku, Finland
| | - R. Lautamäki
- Heart Centre, Turku University Hospital, University of Turku, Turku, Finland
| | - A. Saraste
- Heart Centre, Turku University Hospital, University of Turku, Turku, Finland
| | - S. Suihko
- Department of Medicine, Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - E. Könönen
- Institute of Dentistry, University of Turku, Turku, Finland
| | - J. Sinisalo
- Department of Medicine, Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - P.J. Pussinen
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
- School of Medicine, Institute of Dentistry, University of Eastern Finland, Kuopio, Finland
| | - S. Paju
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
| |
Collapse
|
2
|
Lindgren E, Krzywicka K, de Winter MA, Sánchez van Kammen M, Heldner MR, Hiltunen S, Aguiar de Sousa D, Mansour M, Canhão P, Ekizoglu E, Rodrigues M, Silva EM, Garcia-Esperon C, Arnao V, Aridon P, Simaan N, Silvis SM, Zuurbier SM, Scutelnic A, Sezgin M, Alasheev A, Smolkin A, Guisado-Alonso D, Yesilot N, Barboza MA, Ghiasian M, Leker RR, Arauz A, Arnold M, Putaala J, Tatlisumak T, Coutinho JM, Jood K. A scoring tool to predict mortality and dependency after cerebral venous thrombosis. Eur J Neurol 2023. [PMID: 37165521 DOI: 10.1111/ene.15844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND We developed a prognostic score to predict dependency and death after cerebral venous thrombosis (CVT) to identify patients for targeted therapy in future clinical trials.. METHODS We used data from the International CVT Consortium. We excluded patients with pre-existent functional dependency. We used logistic regression to predict poor outcome (modified Rankin Scale 3-6) at 6 months and Cox regression to predict 30-day and 1-year all-cause mortality. Potential predictors derived from previous studies were selected with backward stepwise selection. Coefficients were shrunken using Ridge regression to adjust for optimism in internal validation. RESULTS Of 1454 patients with CVT, the cumulative number of deaths was 44 (3%) and 70 (5%) for 30 days and 1 year, respectively. Of 1126 patients evaluated regarding functional outcome, 137 (12%) were dependent or dead at 6 months. From the retained predictors for both models, we derived the SI2 NCAL2 C score utilizing the following components: absence of female Sex-specific risk factor, Intracerebral hemorrhage, Infection of the central nervous system, Neurologic focal deficits, Coma, Age, lower Level of hemoglobin (g/L), higher Level of glucose (mmol/L) at admission, and Cancer. C-statistics were 0.80 (95%CI 0.75-0.84), 0.84 (95%CI 0.80-0.88) and 0.84 (95%CI 0.80-0.88) for the poor outcome, 30 days and 1 year mortality model, respectively. Calibration plots indicated good model fit between predicted and observed values. The SI2 NCAL2 C score calculator is freely available at www.cerebralvenousthrombosis.com. CONCLUSIONS The SI2 NCAL2 C score shows adequate performance for estimating individual risk of mortality and dependency after CVT but external validation of the score is warranted.
Collapse
Affiliation(s)
- E Lindgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - K Krzywicka
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M A de Winter
- Department of Internal Medicine, UMC, Utrecht, Utrecht, the Netherlands
| | - M Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - S Hiltunen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - D Aguiar de Sousa
- Stroke Centre, Centro Hospital Universitário Lisboa Central, Lisbon, Portugal
- CEEM and Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - M Mansour
- Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | - P Canhão
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria/CHULN; University of Lisbon, Lisbon, Portugal
| | - E Ekizoglu
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M Rodrigues
- Department of Neurology. Hospital Garcia de Orta, Almada, Portugal
| | - E M Silva
- Department of Neurology. Hospital Garcia de Orta, Almada, Portugal
| | - C Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - V Arnao
- U.O.C. Neurologia con Stroke Unit A.R.N.A.S. Civico, Palermo, Italy
| | - P Aridon
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D), University of Palermo, Palermo, Italy
| | - N Simaan
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S M Silvis
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S M Zuurbier
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - M Sezgin
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A Alasheev
- Department of Neurology, Sverdlovsk, Yekaterinburg, Russia
| | - A Smolkin
- Department of Neurology, Sverdlovsk, Yekaterinburg, Russia
| | - D Guisado-Alonso
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - N Yesilot
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M A Barboza
- Neurosciences Department, Hospital Dr. R.A. Calderón Guardia, CCSS, San José, Costa Rica
| | - M Ghiasian
- Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | - R R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Arauz
- Instituto Nacional de Neurologia and Neurocirugia Manuel Velasco Suarez, Mexico-City, Mexico
| | - M Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - J Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - T Tatlisumak
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - J M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - K Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
3
|
Eriksson MI, Syreeni A, Sandholm N, Dahlström EH, Gordin D, Tatlisumak T, Putaala J, Groop PH, Martola J, Thorn LM. Haptoglobin genotype and its relation to asymptomatic cerebral small-vessel disease in type 1 diabetes. Acta Diabetol 2023; 60:749-756. [PMID: 36856861 PMCID: PMC10148779 DOI: 10.1007/s00592-023-02059-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/20/2023] [Indexed: 03/02/2023]
Abstract
AIM Cerebral small-vessel disease (SVD) is prevalent in type 1 diabetes and has been associated with the haptoglobin variant allele Hp1. Contrarily, the Hp2-allele has been linked to cardiovascular disease and the role of haptoglobin-genotype in asymptomatic SVD is unknown. We, therefore, aimed to evaluate the alleles' association with SVD. METHODS This cross-sectional study included 179 neurologically asymptomatic adults with type 1 diabetes (women 53%, mean age 39 ± 7 years, diabetes duration 23 ± 10 years, HbA1c 8.1 ± 3.2% [65 ± 12 mmol/mol]). Examinations included genotyping (genotypes Hp1-1, Hp2-1, Hp2-2) by polymerase chain reaction, clinical investigation, and magnetic resonance brain images assessed for SVD manifestations (white matter hyperintensities, cerebral microbleeds, and lacunar infarcts). RESULTS SVD prevalence was 34.6%. Haptoglobin genotype frequencies were 15.6% (Hp1-1), 43.6% (Hp1-2), and 40.8% (Hp2-2). Only diastolic blood pressure differed between the genotypes Hp1-1, Hp1-2, and Hp2-2 (81 [74-83], 75 [70-80], and 75 [72-81] mmHg, p = 0.019). Haptoglobin genotype frequencies by presence versus absence of SVD were 16.1%; 46.8%; 37.1% versus 15.4%; 41.9%; 42.7% (p = 0.758). Minor allele frequencies were 39.5% versus 36.3% (p = 0.553). Hp1 homozygotes and Hp2 carriers displayed equal proportions of SVD (35.7% vs 34.4%, p > 0.999) and SVD manifestations (white matter hyperintensities 14.3% vs 17.9%, p = 0.790; microbleeds 25.0% vs 21.9%, p = 0.904; lacunar infarcts 0% vs 3.6%, p > 0.999). Hp1-1 was not associated with SVD (OR 1.19, 95% CI 0.46-2.94, p = 0.712) when adjusting for age, blood pressure, and diabetic retinopathy. CONCLUSIONS Although the SVD prevalence was high, we detected no significant association between SVD and haptoglobin-genotype.
Collapse
Affiliation(s)
- M I Eriksson
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, Haartmaninkatu 8, 00290, Helsinki, Finland
- Research Program in Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
| | - A Syreeni
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, Haartmaninkatu 8, 00290, Helsinki, Finland
- Research Program in Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
| | - N Sandholm
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, Haartmaninkatu 8, 00290, Helsinki, Finland
- Research Program in Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
| | - E H Dahlström
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, Haartmaninkatu 8, 00290, Helsinki, Finland
- Research Program in Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
| | - D Gordin
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, Haartmaninkatu 8, 00290, Helsinki, Finland
- Research Program in Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
- Minerva Institute for Medical Research, Helsinki, Finland
| | - T Tatlisumak
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience/Neurology, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - J Putaala
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, Haartmaninkatu 8, 00290, Helsinki, Finland.
- Research Program in Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland.
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - J Martola
- Department of Clinical Neuroscience, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L M Thorn
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, Haartmaninkatu 8, 00290, Helsinki, Finland
- Research Program in Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
4
|
Lehto M, Haukka J, Halminen O, Mustonen P, Putaala J, Linna M, Aro A, Hartikainen J, Airaksinen KEJ. Prevalence of atrial fibrillation – a comprehensive nationwide analysis in Finland. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Prevalence of atrial fibrillation (AF) is strongly associated with age, and with longer life-time expectancy number of AF patients is worldwide strongly increasing. However, nationwide prevalence of AF is not known when primary care data as well is accessible.
Purpose
The FinACAF-study is a nationwide registry study including of all AF patients searched from all available national health care registers. To our knowledge, this is the first nationwide AF study including both primary, secondary, and tertiary health care register data. The aim of this study was to assess the prevalence of AF in unselected nationwide population in Finland.
Methods
In the FinACAF study we gathered data of all AF patients (hospitalizations and outpatient specialist visits and primary health care, and National Reimbursement Register) from all national health care registers from 01st January 2004 to 31st December 2018. The annual prevalence on December 31st of each year 2007–2018 was calculated as the cumulative number of patients alive with AF divided by the number of Finnish population on the last day of that year. The prevalence is presented for population ≥20 years, and with the entire population as the background population, as well as for populations ≥65 years, and ≥75 years.
Results
In total, 411,387 patients with the diagnosis of AF were documented during 2004–2018 in Finland. The number of adult patients with AF at the end of the study period in 2018 was 226,847, corresponding to an AF prevalence of 5.2% in the age group ≥20 years. The prevalence in the total Finnish population was 4.1%. The prevalence rates increased remarkably with increasing age and were higher in men compared to women (5.9% vs. 4.6%, p<0.001) in all age groups (Figure 1). The prevalence of AF in the adult population increased remarkably from 2.5% in 2007 to 5.2% in 2018 (p<0.001) (Figure 2). Among the population ≥65 years the prevalence in 2018 was 15.3%, and in the elderly, ≥75 years the prevalence of AF was 23.4%.
Conclusions
Based on comprehensive, nationwide data – also including the primary care – we observed extremely increasing prevalence of AF in the older population, as well as remarkably increasing prevalence of AF over time.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District
Collapse
Affiliation(s)
- M Lehto
- Helsinki University Hospital , Helsinki , Finland
| | - J Haukka
- University of Helsinki , Helsinki , Finland
| | - O Halminen
- University of Helsinki , Helsinki , Finland
| | - P Mustonen
- Turku University Hospital , Turku , Finland
| | - J Putaala
- Helsinki University Hospital , Helsinki , Finland
| | - M Linna
- University of Eastern Finland , Kuopio , Finland
| | - A Aro
- Helsinki University Hospital , Helsinki , Finland
| | | | | |
Collapse
|
5
|
Kouki E, Salmela B, Haukka J, Halminen O, Karlsson E, Mustonen P, Putaala J, Linna M, Aro A, Hartikainen J, Airaksinen KEJ, Lehto M. Characteristics of incident atrial fibrillation patients – a nationwide register-based study with information from primary-, secondary- and tertiary care. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a current prevalence of 4.1% in Finland. Many of the comorbidities associated with AF are known risk factors for the arrhythmia and vice versa, as well as contributors to the risk of stroke and other AF related adverse events. A generally used evaluation method for the risk of stroke is the clinical risk factor -based CHA2DS2-VASc score, but other thromboembolic risk factors also exist.
Purpose
To better understand current AF population, this study describes characteristics, comorbidities, medication, and laboratory values of Finnish AF patients at the time of first AF diagnosis.
Methods
The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide register-based cohort study in which AF patient data has been linked from several Finnish health care- and national registers, with information from primary-, secondary-, and tertiary care. This substudy consists of patients over 20 years old with available laboratory data and an incident AF diagnosis (ICD-10 I48) between 1/1/2010–31/12/2018 in any of the used registers.
Results
Within the study period 143,455 patients with a new AF were registered. The mean age at time of diagnosis was 69.1 years for men and 76.3 years for women. The mean CHA2DS2-VASc score when entering the cohort was 3.48 (SD 1.88), and 84.9% of the cohort had at least one of the comorbidities included in the CHA2DS2-VASc score. The most prevalent comorbidities and medications of the cohort are shown in the figure, and a more comprehensive look is presented in the table. The medications listed have been in use during the year before cohort entry.
Conclusion
Atrial fibrillation does not come alone. Almost all patients diagnosed with AF have previous comorbidities and medications. Future analysis will provide information on how these evolve after AF diagnosis and elucidate their association with different endpoints.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District
Collapse
Affiliation(s)
- E Kouki
- University of Helsinki , Helsinki , Finland
| | - B Salmela
- Paijat-Hame Central Hospital , Lahti , Finland
| | - J Haukka
- University of Helsinki , Helsinki , Finland
| | | | - E Karlsson
- University of Helsinki , Helsinki , Finland
| | - P Mustonen
- Turku University Hospital , Turku , Finland
| | - J Putaala
- Helsinki University Hospital , Helsinki , Finland
| | - M Linna
- University of Eastern Finland , Kuopio , Finland
| | - A Aro
- Helsinki University Hospital , Helsinki , Finland
| | | | | | - M Lehto
- Helsinki University Hospital , Helsinki , Finland
| |
Collapse
|
6
|
Itainen-Stromberg S, Lehto M, Halminen O, Putaala J, Haukka J, Mustonen P, Linna M, Kalatsova K, Aro A, Hartikainen J, Airaksinen KEJ. Risk of stroke and transient ischemic attack after elective cardioversion of atrial fibrillation: a nationwide study in Finland. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cardioversion is routinely used to restore sinus rhythm in patients with atrial fibrillation (AF). Elective cardioversion (ECV) is associated with an increased risk of thromboembolic complications even during adequate oral anticoagulation (OAC).
Purpose
The aim was to analyze the incidence of ischemic stroke and transient ischemic attack (TIA) after first-ever ECV of AF in patients using guideline-recommended OAC.
Methods
This nationwide register-based study includes all (N=9625) AF patients undergoing their first-ever ECV between 2012 and 2018 in Finland. Data was obtained from the Finnish health care registers, including both primary and special health care. The risk of stroke and TIA within 30 days after ECV were estimated in patients using OAC.
Results
The mean age of patients was 68 (±9.9) years, 61.2% were men, and the mean CHA2DS2-VASc score was 2.6 (±1.6, range 0–9). Warfarin was used in 6245 (64.9%) and non-vitamin K oral anticoagulants in 3380 (35.1%) cardioversions, of which 1453 (15.1%) was rivaroxaban, 1246 (12.9%) apixaban, 635 (6.6%) dabigatran, and 46 (0.5%) edoxaban. Twenty-nine (0.3%; 95% confidence interval [CI] 0.2–0.4%) ischemic strokes or TIAs occurred within 30 days after ECV (median 3 days, interquartile range 2.0–8.5) (Figure 1 and Table 1). In warfarin-treated patients experiencing stroke or TIA, the mean INR value before ECV and at the time of stroke or TIA were 2.5 (±0.5) and 2.5 (±0.5), respectively. One of the patients had INR-value <2.0 before ECV and at the time of stroke and one patient had INR value <2.0 before ECV.
Conclusion
In our nationwide study, the rate of stroke and TIA after first-ever ECV was low (0.3%) in all OAC groups.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District
Collapse
Affiliation(s)
| | - M Lehto
- Helsinki University Hospital , Helsinki , Finland
| | | | - J Putaala
- Helsinki University Hospital , Helsinki , Finland
| | - J Haukka
- University of Helsinki , Helsinki , Finland
| | - P Mustonen
- Turku University Hospital , Turku , Finland
| | - M Linna
- University of Eastern Finland , Kuopio , Finland
| | - K Kalatsova
- Helsinki University Hospital , Helsinki , Finland
| | - A Aro
- Helsinki University Hospital , Helsinki , Finland
| | | | | |
Collapse
|
7
|
Jolkkonen S, Aro A, Haukka J, Halminen O, Putaala J, Linna M, Mustonen P, Hartikainen J, Airaksinen J, Lehto M. Gastrointestinal bleeding preceding new-onset atrial fibrillation - results from the nationwide FinACAF study. Europace 2022. [DOI: 10.1093/europace/euac053.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District Funding The Finnish Foundation of Cardiovascular Research
Introduction
Initiation of oral anticoagulation (OAC) in case of a new-onset atrial fibrillation (AF) requires assessment of bleeding history. Gastrointestinal (GI) bleedings are among the most common bleeding events.
Purpose
We aimed to assess clinical characteristics and initiation of OAC in patients with new-onset AF and a history of previous GI bleeding.
Methods
The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide study among AF patients conducted as a retrospective register-based linkage study combining data from several Finnish health care registers. The study population consists of all patients diagnosed with AF between the years 2010-2018 and with laboratory data available. Patients were identified from nationwide primary care and reimbursement registries and hospitalization records. OAC purchases at 90 days from cohort entry were obtained from the National Prescription Register upheld by the Social Insurance Institution of Finland.
Results
134 242 patients from the initial FinACAF cohort were included in this substudy. Of these, 6543 (4.9%) patients had a history of GI bleeding. Those with GI bleeding were more often male (52.6%), older (mean age 76.6 ± 11.4 vs 72.4 ± 13.1 years), and had more comorbidities. They also had lower blood hemoglobin (mean 124.9 ± 21.3 vs 135.8 ± 18.4 g/l) and higher serum creatinine (mean 99.7 ± 75.8 vs 87.5 ± 52.7 µmol/l) levels than patiens without preceding GI bleeding. Furthermore, initiation of OAC medication was less frequent in the GI bleeding group (46.9% vs 58.6%).
Patient characteristics of the study population including age, sex, comorbidities, OAC medication and laboratory findings are shown in Figures 1 and 2.
Conclusions
Patients with AF and preceding GI bleeding are vulnerable to rebleeding events. This may affect decision-making of clinicians, leading to more infrequent initiation of OAC medications.
Collapse
Affiliation(s)
- S Jolkkonen
- Jyvaskyla Central Hospital, Department of Internal Medicine, Jyvaskyla, Finland
| | - A Aro
- Helsinki University Hospital, Heart and Lung Center and University of Helsinki, Helsinki, Finland
| | - J Haukka
- University of Helsinki, Helsinki, Finland
| | - O Halminen
- Aalto University, Department of Industrial Engineering and Management, Espoo, Finland
| | - J Putaala
- Helsinki University Hospital, Department of Neurology and University of Helsinki, Helsinki, Finland
| | - M Linna
- University of Eastern Finland, Department of Health and Social Management, Kuopio, Finland
| | - P Mustonen
- Turku University Hospital, Turku, Finland
| | - J Hartikainen
- University of Eastern Finland, Institute of Clinical Medicine, Kuopio, Finland
| | | | - M Lehto
- Helsinki University Hospital, Heart and Lung Center and University of Helsinki, Helsinki, Finland
| |
Collapse
|
8
|
Aro A, Haukka J, Halminen O, Putaala J, Linna M, Mustonen P, Hartikainen J, Airaksinen J, Lehto M. CHA2DS2-VASc score and the risk of death in atrial fibrillation. Europace 2022. [DOI: 10.1093/europace/euac053.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Sigrid Juselius Foundation
Background
Atrial fibrillation (AF) is recognized as a major public health problem due to increased mortality, morbidity and risk of stroke. Advanced age and burden of other comorbidities are potential contributors to AF development and adverse outcomes. Clinical risk factor based CHA2DS2-VASc score is widely used to assess thromboembolic risk in AF, but mortality risk associated with different CHA2DS2-VASc scores is not established.
Purpose
Using data from a nationwide AF registry study including comorbidities and outcomes of unselected AF patients, we wanted to study whether CHA2DS2-VASc score could be useful in estimating prognosis in newly diagnosed AF patients.
Methods
New-onset AF patients in Finland 2007-2017 were identified from comprehensive national registries. Comorbidities were gathered from individualized registry data on drug reimbursements and from ICD-10 diagnoses during hospitalizations and outpatient visits in primary and specialist care. These were used to create CHA2DS2-VASc risk score for each AF patient at cohort entry, including data on heart failure, hypertension, age, diabetes, stroke, vascular disease and sex. Patients were followed until the end of 2018 from the causes of death registry, which records every death in the country. All-cause mortality in each CHA2DS2-VASc category per 1000 person-years was determined, and relative risk (RR) of death according to the CHA2DS2-VASc category was calculated.
Results
A total of 229 357 patients with new-onset AF (mean age 73.2 ± 13.2 years, 50.0% female) were identified. Distribution of CHA2DS2-VASc score among these individuals is shown in Table. Mortality increased significantly with rising CHA2DS2-VASc risk score points, as demonstrated in Table. Compared to CHA2DS2-VASc 0, those with 2 points had a RR 2.9 (95%CI 2.7-3.1), 3 points RR 5.0 (4.7-5.3), 4 points RR 8.0 (7.5-8.4), 5 points RR 11.0 (10.4-11.7) and >5 points RR 14.8 (14.0-15.7) for all-cause mortality.
Conclusions
In new-onset AF, mortality increased drastically with increasing age and comorbidities as depicted in the CHA2DS2-VASc score. Besides assessing thromboembolic risk, CHA2DS2-VASc score seems to be useful in estimating survival of AF patients.
Collapse
Affiliation(s)
- A Aro
- Helsinki University Hospital, Helsinki, Finland
| | - J Haukka
- University of Helsinki, Helsinki, Finland
| | | | - J Putaala
- Helsinki University Hospital, Helsinki, Finland
| | - M Linna
- Aalto University, Helsinki, Finland
| | - P Mustonen
- Turku University Hospital, Turku, Finland
| | | | | | - M Lehto
- Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
9
|
Aro A, Haukka J, Halminen O, Putaala J, Linna M, Mustonen P, Hartikainen J, Airaksinen J, Lehto M. Mortality and causes of death after new-onset atrial fibrillation: a nationwide study. Europace 2022. [DOI: 10.1093/europace/euac053.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Sigrid Juselius Foundation
Introduction
Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, and its prevalence is increasing with aging population. AF is associated with increased cardiovascular morbidity and mortality, but the prognosis of newly detected AF in the general population is not well established.
Purpose
Using data from the large FinACAF-study, a comprehensive nationwide retrospective cohort study including all diagnosed Finnish AF patients, we studied one-year mortality after new-onset AF in the general population and determined the causes of death of deceased AF patients.
Methods
All patients with new-onset AF in Finland 2007-17 were identified from nationwide primary care and reimbursements registries and hospitalization records. Baseline characteristics of these patients were determined, and their survival was followed from registries for one year. Principal cause of death was determined from death certificate’s International Classification of Diseases (ICD-10) Codes.
Results
A total of 229 321 patients with first-diagnosed AF were identified (50.0% female). Mean age of men and women with new-onset AF was 69.4 ± 13.4 and 77.1 ± 11.8 years, respectively (p<0.001 for difference). In men and women, hypertension had been diagnosed in 68.0% vs 80.4% (p<0.001), congestive heart failure in 15.4% vs 19.3% (p<0.001), diabetes in 22.5% vs 20.7% (p<0.001) and vascular disease in 27.2% vs 24.8% (p<0.001), respectively. Prior stroke or transient ischemic attack had occurred in 14.0% of men and 16.8% of women (p<0.001).
During the one-year follow-up, 11.6% of men and 13.7% of women died (Figure). Most common cause of death in these patients was ischaemic heart disease (26.2% of all deaths), followed by malignancies (17.4%) and dementia (12.4%). Cerebrovascular diseases were responsible for 10.8% of mortality.
Conclusion
In this population-based nationwide study, we demonstrated that one-eight of patients with new AF died within one year of the diagnosis. Ischaemic heart disease was most frequent cause of death.
Collapse
Affiliation(s)
- A Aro
- Helsinki University Hospital, Helsinki, Finland
| | - J Haukka
- University of Helsinki, Helsinki, Finland
| | | | - J Putaala
- Helsinki University Hospital, Helsinki, Finland
| | - M Linna
- Aalto University, Helsinki, Finland
| | - P Mustonen
- Turku University Hospital, Turku, Finland
| | | | | | - M Lehto
- Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
10
|
Luojus A, Halminen O, Mustonen P, Putaala J, Haukka J, Linna M, Itainen-Stromberg S, Tiili P, Kinnunen J, Niiranen J, Hartikainen J, Niemi M, Kuoppala J, Airaksinen J, Lehto M. Use of antihypertensive medication before diagnosis of atrial fibrillation in Finland – results from the nationwide FinACAF -study. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background and aims
Long-standing arterial hypertension increases the risk of cardiovascular morbidity including atrial fibrillation (AF), coronary heart disease and renal failure. Arterial hypertension is the most common aetiologic factor associated with the development of AF and is also the most prevalent co-morbid cardiovascular disease in patients with AF. Coexisting arterial hypertension together with AF increases further the risk of stroke, heart failure and overall mortality.
The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) -study is a nationwide retrospective register-based AF study that combines data from several Finnish health care registers. In this sub-study, we characterized the use of antihypertensive medications in patients with new-onset AF.
Methods
This sub-study included all adult new-onset AF patients of the FinACAF study from January 2007 to December 2018. Patients were excluded if they were under 18 years of age, had any oral anticoagulant purchase in the year prior to AF diagnosis, or had diagnosis of AF or warfarin purchases between the years 2004–2006.
Appropriate data such as anonymized study ID's, ICD-10 diagnoses, and drug purchases (dates, ATC-codes, amounts) were obtained from the National Prescription Register as well as the Finnish Hospital and Primary care registers. The antihypertensive medication purchases from the year preceding the AF diagnosis were analysed and identified by appropriate ATC-codes. Purchases one-month prior to the new-onset AF diagnosis were excluded from in order to avoid confounding by any medication changes due to AF diagnosis.
Results
Of 229,282 patients with new-onset AF 164,527 (71.8%) had purchased antihypertensive medication during the year prior to the AF diagnosis. The most common antihypertensive drugs used were beta blockers (n=108,510; 47.3%), ACE-inhibitors or angiotensin receptor blockers (n=104,840; 45.7%), diuretics (n=79,270; 34.6%) and selective calcium channel blockers (n=61,610; 26.9%). Diltiazem was purchased by 2,001 patients (0.9%) and verapamil by 1,508 patients (0.7%). At the beginning of the study period, beta-blockers were the most widely used antihypertensive agents, but between 2007 and 2018, RAAS-inhibitors (ACE inhibitors and ARB blockers) became the most widely used group of antihypertensive drugs (Figure 1).
Conclusion
Most Finnish new-onset AF patients had at least one pre-existing antihypertensive medication in use before the diagnosis of AF. Beta blockers were the most common antihypertensives until the latest years when RAAS-inhibitors became the most prescribed antihypertensive agents, whereas the use of diltiazem and verapamil was marginal in the treatment of hypertension before the AF diagnosis.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Helsinki and Uusimaa Hospital District research fundThe Finnish Foundation for Cardiovascular Research Figure 1. Annual use of antihypertensive medication among Finnish new-onset AF patients prior to diagnosis. Annual number of new-onset AF patients plotted for reference.
Collapse
Affiliation(s)
- A Luojus
- Helsinki University Hospital, Helsinki, Finland
| | | | - P Mustonen
- Turku University Hospital, Turku, Finland
| | - J Putaala
- Helsinki University Hospital, Helsinki, Finland
| | - J Haukka
- University of Helsinki, Helsinki, Finland
| | - M Linna
- Aalto University, Espoo, Finland
| | | | - P Tiili
- Helsinki University Hospital, Helsinki, Finland
| | - J Kinnunen
- Helsinki University Hospital, Helsinki, Finland
| | - J Niiranen
- Helsinki University Hospital, Helsinki, Finland
| | | | - M Niemi
- University of Helsinki, Helsinki, Finland
| | - J Kuoppala
- University of Helsinki, Helsinki, Finland
| | | | - M Lehto
- Helsinki University Hospital, Helsinki, Finland
| | | |
Collapse
|
11
|
Lehto M, Haukka J, Halminen O, Mustonen P, Putaala J, Linna M, Kinnunen J, Kouki E, Luojus A, Tiili P, Itainen-Stromberg S, Aro A, Niiranen J, Hartikainen J, Airaksinen J. Incidence of atrial fibrillation. A comprehensive nationwide analysis in Finland. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Atrial fibrillation (AF) is a chronic condition, and once diagnosed, most of the patients need life-long treatment for AF; rate and rhythm control for symptom relief and oral anticoagulation to mitigate the associated risk of stroke. Incidence of AF is strongly associated with age, and with longer life-expectancy the number of AF patients is worldwide rapidly increasing.
Purpose
The FinACAF study is a nationwide registry study including all AF patients searched from comprehensive national health care registers. To our knowledge, FinACAF is the first nationwide study including both primary, secondary, and tertiary health care register data. The aim of this study was to assess the incidence of new-onset AF in unselected nationwide population in Finland.
Methods
In the FinACAF study we gathered data (hospitalizations, outpatient specialist and primary health care visits, and drug reimbursement) from all national health care registers to identify new-onset AF patients from 01st January 2004 to 31st December 2018.
To minimize the risk of misclassification, we considered a patient to have incident AF only if the new-onset AF diagnosis emerged after 1st January 2007 allowing at least three years of registration in Finnish health care registers without diagnosis of AF. Furthermore, patients with warfarin prescriptions during 2004–2006 were excluded. Raw incidence rates (1/100 000) were calculated using the total number of incident AF cases during a given year as numerator, and the total number of Finnish population free of AF on the last day of that year as denominator. The age-standardized incidence rates (1/100 000) were calculated using the total number of new-onset AF cases per year compared to the Nordic population free of AF age distribution.
Results
In total, 411 080 patients with the diagnosis of AF were documented during 2004–2018 in Finland, and the number of new-onset AF patients during 2007–2018 was 256 323. The incidence of AF in relation to age is shown in the Figure 1, and the increasing incidence with advancing age is outstandingly seen. Incidence of AF was more than 2000/100 000 in the population 80 years or older. The incidence of new-onset AF in the whole Finnish population increased during the study period from 330/100 000 and peaked to 456/100 000 in 2018. However, after adjustment for age, the age-adjusted AF incidence remained unchanged during 2007–2018 (Figure 2), but an obvious leap in the incidence emerged during 2011–2013 when the national primary care register was established.
Conclusions
In 2018 the incidence of AF per the whole population was 456/100 000. Based on very novel data and including all the known, diagnosed AF patients in Finland, this is the highest reported incidence rate of AF. Incidence of AF is strongly age-dependent, but the age-standardized incidence was not significantly changed from 2007 to 2018.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District research fundThe Finnish Foundation for Cardiovascular Research The incidence of AF in relation to ageAge-adjusted annual incidence of AF
Collapse
Affiliation(s)
- M Lehto
- Helsinki University Hospital, Helsinki, Finland
| | - J Haukka
- University of Helsinki, Helsinki, Finland
| | | | - P Mustonen
- Turku University Hospital, Turku, Finland
| | - J Putaala
- Helsinki University Hospital, Helsinki, Finland
| | - M Linna
- Aalto University, Helsinki, Finland
| | - J Kinnunen
- Helsinki University Hospital, Helsinki, Finland
| | - E Kouki
- Helsinki University Hospital, Helsinki, Finland
| | - A Luojus
- Helsinki University Hospital, Helsinki, Finland
| | - P Tiili
- Helsinki University Hospital, Helsinki, Finland
| | | | - A Aro
- Helsinki University Hospital, Helsinki, Finland
| | - J Niiranen
- Helsinki University Hospital, Helsinki, Finland
| | | | | | | |
Collapse
|
12
|
Jyrkila H, Kaartinen K, Martola L, Halminen O, Haukka J, Linna M, Mustonen P, Putaala J, Helin T, Kouki E, Luojus A, Tiili P, Hartikainen J, Airaksinen K, Lehto M. Renal function and use of medication preceding new-onset atrial fibrillation – results from the nationwide FinACAF study. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and aims
Chronic kidney disease (CKD) is a global public health problem with an increasing number of patients due to obesity, hypertension, diabetes, and aging. CKD is an independent risk factor for atrial fibrillation (AF) and the incidence of AF in patients with CKD is two- to threefold higher compared to the general population. The relationship between CKD and AF is bidirectional, and the incidence of renal insufficiency is higher in patients with AF. Both AF and CKD are associated with increased risk of stroke and systemic thromboembolism, as well as an increased bleeding risk. The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide study among AF patients conducted as a retrospective register-based linkage study combining data from several Finnish health care registers. We aimed to characterize demographics and medications of patients with new-onset AF included FinACAF according to stages of renal function.
Method
The FinACAF study includes data from 411000 patients covering all Finnish AF patients from 1 January 2004 to 31 December 2018. Using national unique personal identification numbers, individual patients' data from ten nationwide population registries and six regional laboratory databases were linked together. The inclusion criteria of this substudy were all patients 20 years or older with a new-onset AF diagnosis between January 2010 and December 2018 and a measured estimated glomerular filtration rate (eGFR) within the proximity of the AF diagnosis. Drug purchases (date, Anatomical Therapeutic Chemical (ATC) codes, and amount) were obtained from the National Prescription Register upheld by the Social Insurance Institution of Finland.
Results
147001 patients from the initial FinACAF cohort were included in this substudy. The mean age at the time of AF diagnosis was 73 years (range 20 to 107 years), 48.9% of the patients were female. The mean age of AF patients increased in various stages of glomerular filtration at the cohort entry during 2010–2018. Baseline medications are shown in Table. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) at the cohort entry decreased from 27.4% to 22.1% during 2010–2018 (p<0.001).
Conclusions
Medications were used increasingly with worsening renal function, except for NSAIDs.
NSAIDs use remained remarkably high in all stages of renal function, albeit much less with the lowest eGFRs. The number of patients with lipid-lowering medication was unexpectedly low considering the high cardiovascular risk in patients with impaired renal function.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): This work was supported by Aarne Koskelo Foundation, Yrjö Jahnsson Foundation, The Finnish Foundation for Cardiovascular Research, and Helsinki and Uusimaa Hospital District research fund (TYH2019309).
Collapse
Affiliation(s)
- H Jyrkila
- Helsinki University Hospital and University of Helsinki, Department of Nephrology and Heart and Lung Center, Helsinki, Finland
| | - K Kaartinen
- Helsinki University Hospital and University of Helsinki, Department of Nephrology, Helsinki, Finland
| | - L Martola
- Helsinki University Hospital and University of Helsinki, Department of Nephrology, Helsinki, Finland
| | - O Halminen
- Aalto University, Department of Industrial Engineering and Management, Espoo, Finland
| | - J Haukka
- University of Helsinki, Faculty of Medicine, Helsinki, Finland
| | - M Linna
- Aalto University, Department of Industrial Engineering and Management, Espoo, Finland
| | - P Mustonen
- Central Finland Health Care District, Department of Internal Medicine, Jyvaskyla, Finland
| | - J Putaala
- Helsinki University Hospital and University of Helsinki, Department of Neurology, Helsinki, Finland
| | - T Helin
- University of Helsinki and HUSLAB, Helsinki University Hospital, Clinical Chemistry and Coagulation Disorders Unit, Helsinki, Finland
| | - E Kouki
- Helsinki University Hospital and University of Helsinki, Heart and Lung Center, Helsinki, Finland
| | - A Luojus
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - P Tiili
- Helsinki University Hospital and University of Helsinki, Heart and Lung Center and Department of Neurology, Helsinki, Finland
| | - J Hartikainen
- Kuopio University Hospital and University of Eastern Finland, Heart Center, Department of Cardiology, Kuopio, Finland
| | - K.E.J Airaksinen
- Turku University Hospital and University of Turku, Department of Cardiology, Turku, Finland
| | - M Lehto
- Helsinki University Hospital and University of Helsinki, Heart and Lung Center, Helsinki, Finland
| | | |
Collapse
|
13
|
Lehmonen L, Pirinen J, Putaala J, Martinez-Majander N, Kuusisto J, Sinisalo J, Jarvinen V. Magnetic resonance imaging derived cardiac first pass perfusion in cryptogenic ischemic stroke in the young. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Up to 50% of ischemic strokes in adults aged between 18 and 50 are cryptogenic by nature. Heart has been a hypothesised source.
Purpose: Purpose of the study was to investigate the wash in and wash out of gadolinium based contrast agent in the left atrial appendage, and cardiac chambers in first pass cardiac magnetic resonance imaging.
Methods
The study comprised 30 patients with first-ever cryptogenic ischemic stroke and 30 age and gender matched stroke-free controls included in the prospective multicenter study Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers and Outcome (SECRETO; NCT01934725). Cardiac magnetic resonance imaging was performed on all participants with a 1.5T magnetic resonance system. Dynamic contrast enhanced T1 weighted first pass perfusion images were acquired in the superior vena cava, the left atrial appendage (Fig. 1), and the left ventricle. The images were analyzed for time-intensity curves (Fig. 2), and results were normalised to individual heart rate. Arrival times, peak times, areas under the curves, relative blood flows (defined as area under the curve/full width at half maximum), and maximum and minimum rates of bolus wash in / wash out were calculated.
Results
The wash in of the contrast agent bolus was similar in patients and controls. Arrival times and peak timings showed similar characteristics in patients and controls in the left atrial appendage (arrival time: 12.4 [2.3] vs. 13.5 [3.6] cardiac cycles, p = 0.657; peak time: 19.6 [5.1] vs. 19.8 [6.9] cardiac cycles, p = 0.929) and the left atrium (arrival time: 12.2 [2.8] vs. 13.0 [3.6] cardiac cycles, p = 0.535; peak time: 18.7 [5.5] vs. 18.1 [5.2] cardiac cycles, p = 0.790). Areas under under the curves and relative blood flows were similar in patients and controls. A significant difference between patients and controls was found in the wash out rate of gadolinium in the left ventricle (-28 [11] vs. -36 [13] 1/cardiac cycles, p = 0.012), indicating slightly slower wash out in the patients.
Conclusions
Cryptogenic ischemic stroke in the young is not associated with prolonged blood flow in the left atrial appendage or left atrium. There were no significant differences in the first pass perfusion between subjects and healthy controls. However, there might be a slight tendency for stagnation of blood flow in the left ventricles of cryptogenic stroke patients.
Collapse
Affiliation(s)
- L Lehmonen
- Radiology, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Pirinen
- Clinical Physiology and Nuclear Medicine, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - N Martinez-Majander
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - J Kuusisto
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - J Sinisalo
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - V Jarvinen
- Clinical Physiology and Nuclear Medicine, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
14
|
Lehto M, Halminen O, Haukka J, Linna M, Mustonen P, Putaala J, Itainen-Stromberg S, Kinnunen J, Kouki E, Luojus A, Niiranen J, Penttila T, Tiili P, Hartikainen J, Airaksinen JEK. All you want to know about the arrhythmia: A comprehensive, nationwide registry study of atrial fibrillation in Finland. Europace 2021. [DOI: 10.1093/europace/euab116.528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District Funding The Finnish Foundation for Cardiovascular Research
OnBehalf
FinACAF
Introduction
The number of atrial fibrillation (AF) patients is increasing, and thus, the socio-medico-economic impact of AF is exploding. Up-to-date, multifaceted data about the characteristics of AF patients, their treatments, and outcomes are urgently needed.
Purpose
The aim of the Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is to evaluate the incidence and prevalence of AF, risk of stroke, thromboembolic complications, myocardial infarction, major bleeding events, and mortality in AF patients using comprehensive nationwide registries regulated by law. Assessment of the socio-medico-economic aspects of AF and the effect of socio-economic factors on the AF treatment play a central role in this study.
Methods
The FinACAF study collects data from 411 000 patients covering all Finnish AF patients from 1st January 2004 to 31st December 2018. Using national unique personal identification number, individual patient data from ten nationwide population registries and six regional laboratory databases (∼282000, 77 % of the patients) are linked together. All the register data were obtained during Q1-Q2/2020. The main results will be expected during Q1-2/2021.
Results
Since the introduction of the national primary care register in 2012, 9% of all AF patients were identified outside hospital care registers. The total number of AF patients on 31st December 2018 was 227 114, which translates to an AF prevalence of 4.1% in Finland (population of 5 517 900).
The Table represents the registries used in the FinACAF study.
Conclusions
The FinACAF study records all patient contacts with the health care institutions and organizations, as well as incomes and places of domicile. Thus, the database allows a unique possibility to investigate the epidemiology and socio-medico-economic impact of AF as well as the cost effectiveness of different AF management strategies in a completely unselected, nationwide population. This data will markedly help "leading with data" when the increasing number of AF patients are treated. The registries used in the FinACAF study Register Registry Information obtained Finnish Care Register for Health Care: Primary, Hospital and Social care registries National Institute for Health and Welfare Diagnosis (ICD-10), procedure codes and date; non-hospital institutionalizations National Prescription Register, National Reimbursement Register The Social Insurance Institution of Finland Drug purchases (date, ATC codes, amount), Reimbursement decisions for chronic diseases (date, ICD-10) National Causes of Death Register, The Register of Completed Education and Degrees Statistics Finland Deaths and causes of deaths (ICD-10), Education and socio-economic status National Cancer Registry (1st Jan 1950 to 31st Dec 2018) Finnish Cancer Registry National registry of all cancer cases (e.g. date, ICD-O-3, TNM) Population Register, Tax register Population Register Center, Tax Administration Places of domicile, Income and taxes Laboratory databases (1st Jan 2010 to 31st Dec 2018) Six largest regional laboratory databases INR and other relevant laboratory measurements
Collapse
Affiliation(s)
- M Lehto
- Helsinki University Hospital, Helsinki, Finland
| | | | - J Haukka
- Tampere University, Tampere, Finland
| | - M Linna
- Aalto University, Helsinki, Finland
| | - P Mustonen
- Turku University Hospital, Turku, Finland
| | - J Putaala
- Helsinki University Hospital, Helsinki, Finland
| | | | - J Kinnunen
- Helsinki University Hospital, Helsinki, Finland
| | - E Kouki
- Helsinki University Hospital, Helsinki, Finland
| | - A Luojus
- Helsinki University Hospital, Helsinki, Finland
| | - J Niiranen
- Helsinki University Hospital, Helsinki, Finland
| | - T Penttila
- Tampere University Hospital, Tampere, Finland
| | - P Tiili
- Helsinki University Hospital, Helsinki, Finland
| | | | | |
Collapse
|
15
|
Kouki E, Halminen O, Haukka J, Linna M, Mustonen P, Putaala J, Itainen-Stromberg S, Kinnunen J, Aro A, Niiranen J, Penttila T, Tiili P, Hartikainen J, Airaksinen JEK, Lehto M. Scraping up CHA2DS2-VASc - defining components of the acronym in a nationwide registry study. Europace 2021. [DOI: 10.1093/europace/euab116.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital district Finnish foundation for cardiovascular research
Introduction
Atrial fibrillation (AF) is a major cause of ischemic stroke. The risk of stroke is strongly associated with age, sex and comorbidities of the patients. Therefore, it is crucial that the comorbidities are consistently recorded in medical records as well as health care registries.
Purpose
This study aims to evaluate the prevalence of the comorbidities related to AF stroke risk in Finnish nationwide population registries, and assess how the use and combination of these registries affect the calculated CHA2DS2-VASc risk score. The comorbidities evaluated were Hypertension, Diabetes, Stroke or TIA, Heart Failure, and Vascular Disease.
Methods
The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study collected data on all Finnish AF patients from 1st January 2004 to 31st December 2018. Due to the initiation of the national primary care register in 2012, this substudy uses the data of patients with a new AF diagnosis during 2012-2018 (n = 168 353). Using a unique personal identification code, individual patient data were linked from the Finnish national health care registries "AvoHILMO" (primary care) and "HILMO" (secondary and tertiary care), National Prescription Register (ATC codes of purchased medication) and the National Reimbursement Register for reimbursed medication upheld by the Social Insurance Institute (KELA).
Results
The average CHA2DS2-VASc risk score when entering the cohort, and including information from all registries, equaled 2.91 for men (mean age 70.0 years) and 4.42 for women (mean age 76.9 years). The highest prevalence of diabetes and hypertension were found based on the National Reimbursement Register (ATC codes). Stroke or TIA and heart failure were identified almost exclusively based on secondary and tertiary hospital records.
The table represents our results.
Conclusion
Comprehensive registry analysis of AF patients requires the inclusion of both hospital and medication data. The role of primary care information was limited. Comorbidity and CHA2DS2-VASc weight Total Prevalence Primary care ICD-10 codes Primary care ICPC-2 codes Secondary and tertiary care ICD-10 codes ATCcodes Medication reimbursement codes Hypertension 1 82%137 317 28%47 337 13%21 427 39%66 252 77%130 400 7%10 957 Diabetes 1 24%41 017 13%22 666 13%22 547 14%23 793 21%35 942 12%20 295 Stroke or TIA 2 17%28 653 4%6 254 1%1 968 16%27 379 - - Heart Failure 1 18%29 827 5%7 630 1%1 398 16%26 366 - 1%1 908 Vascular Disease1 28%47 420 12%19 581 2%3 265 25%41 647 - 7%11 802 Average CHA2DS2-VASc contribution 1.86 0.65 0.31 1.26 0.99 0.26 The prevalence of the comorbidities and average CHA2DS2-VASc risk score contribution by registry and combined.
Collapse
Affiliation(s)
- E Kouki
- Helsinki University Hospital, Helsinki, Finland
| | | | - J Haukka
- Tampere University, Tampere, Finland
| | - M Linna
- Aalto University, Helsinki, Finland
| | - P Mustonen
- Turku University Hospital, Turku, Finland
| | - J Putaala
- Helsinki University Hospital, Helsinki, Finland
| | | | - J Kinnunen
- Helsinki University Hospital, Helsinki, Finland
| | - A Aro
- Helsinki University Hospital, Helsinki, Finland
| | - J Niiranen
- Helsinki University Hospital, Helsinki, Finland
| | - T Penttila
- Tampere University Hospital, Tampere, Finland
| | - P Tiili
- Helsinki University Hospital, Helsinki, Finland
| | | | | | - M Lehto
- Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
16
|
Afifi K, Bellanger G, Buyck PJ, Zuurbier SM, Garcia-Esperon C, Barboza MA, Costa P, Escudero I, Renard D, Lemmens R, Hinteregger N, Fazekas F, Jimenez-Conde J, Giralt-Steinhauer E, Hiltunen S, Arauz A, Pezzini A, Montaner J, Putaala J, Weimar C, Schlamann M, Gattringer T, Tatlisumak T, Coutinho JM, Demaerel P, Thijs V. Correction to: Features of intracranial hemorrhage in cerebral venous thrombosis. J Neurol 2020; 267:3299-3300. [PMID: 32785839 DOI: 10.1007/s00415-020-10082-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The original version of this article unfortunately contained mistakes. The correct information is given below.
Collapse
Affiliation(s)
- K Afifi
- Department of Neurology, Menoufia University, Al Minufya, Menoufia, Egypt.,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia
| | - G Bellanger
- Department of Neuroradiology, Purpan University Hospital, Toulouse, France.,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia
| | - P J Buyck
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - S M Zuurbier
- Department of Neurology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - C Garcia-Esperon
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - M A Barboza
- Stroke Department, Instituto Nacional de Neurología Y Neurocirugía Dr. Manuel Velasco Suárez, México City, México
| | - P Costa
- Department of Head and Neck, Neurology Clinic, University of Brescia, Brescia, Italy
| | - I Escudero
- Neurology Department, University Hospital Virgen del Rocio, Sevilla, Spain.,Neurovascular Lab, Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - D Renard
- Department of Neurology, Nîmes University Hospital, Nîmes, France
| | - R Lemmens
- Department of Neurosciences, Experimental Neurology and Leuven Institute for Neuroscience and Disease (LIND), KU Leuven-University of Leuven, Leuven, Belgium.,Laboratory of Neurobiology, Center for Brain and Disease Research, VIB, Leuven, Belgium.,Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - N Hinteregger
- Department of Radiology, Division of Neuroradiology, Vascular and Interventional Radiology, Medical University of Graz, Graz, Austria
| | - F Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - J Jimenez-Conde
- Department of Neurology, Neurovascular Research Group, IMIM-Hospital del Mar, Barcelona, Spain.,Universitat Autònoma de Barcelon, Barcelona, Spain
| | - E Giralt-Steinhauer
- Department of Neurology, Neurovascular Research Group, IMIM-Hospital del Mar, Barcelona, Spain.,Universitat Autònoma de Barcelon, Barcelona, Spain
| | - S Hiltunen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - A Arauz
- Stroke Department, Instituto Nacional de Neurología Y Neurocirugía Dr. Manuel Velasco Suárez, México City, México
| | - A Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic University of Brescia, Brescia, Italy
| | - J Montaner
- Neurovascular Lab, Instituto de Biomedicina de Sevilla, Sevilla, Spain.,Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - J Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - C Weimar
- Institute of Medical Informatics, Biometry and Epidemiology and Department of Neurology, University Hospital Essen, Essen, Germany
| | - Marc Schlamann
- Institute for Diagnostic and Interventional Radiology, University of Cologne, Cologne, Germany
| | - T Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - T Tatlisumak
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,Department of Clinical Neuroscience/Neurology, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - P Demaerel
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - V Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia. .,Department of Neurology, Austin Health, Heidelberg, VIC, Australia.
| |
Collapse
|
17
|
Silvis SM, Reinstra E, Hiltunen S, Lindgren E, Heldner MR, Mansour M, Ghiasian M, Jood K, Zuurbier SM, Groot AE, Arnold M, Barboza MA, Arauz A, Putaala J, Tatlisumak T, Coutinho JM. Anaemia at admission is associated with poor clinical outcome in cerebral venous thrombosis. Eur J Neurol 2020; 27:716-722. [PMID: 31883169 PMCID: PMC7155011 DOI: 10.1111/ene.14148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/22/2019] [Indexed: 01/28/2023]
Abstract
Background and purpose Anaemia is associated with poor clinical outcome after ischaemic and haemorrhagic stroke. The association between anaemia and outcome in patients with cerebral venous thrombosis (CVT) was examined. Methods Consecutive adult patients with CVT were included from seven centres. Anaemia at admission was scored according to World Health Organization definitions. Poor clinical outcome was defined as a modified Rankin Scale score 3–6 at last follow‐up. A multiple imputation procedure was applied for handling missing data in the multivariable analysis. Using binary logistic regression analysis, adjustments were made for age, sex, cancer and centre of recruitment (model 1). In a secondary analysis, adjustments were additionally made for coma, intracerebral haemorrhage, non‐haemorrhagic lesion and deep venous system thrombosis (model 2). In a sensitivity analysis, patients with cancer were excluded. Results Data for 952 patients with CVT were included, 22% of whom had anaemia at admission. Patients with anaemia more often had a history of cancer (17% vs. 7%, P < 0.001) than patients without anaemia. Poor clinical outcome (21% vs. 11%, P < 0.001) and mortality (11% vs. 6%, P = 0.07) were more common amongst patients with anaemia. After adjustment, anaemia at admission increased the risk of poor outcome [adjusted odds ratio (aOR) 2.4, 95% confidence interval (CI) 1.5–3.7, model 1]. Model 2 revealed comparable results (aOR 1.9, 95% CI 1.2–3.2), as did the sensitivity analysis excluding patients with cancer (aOR 2.3, 95% CI 1.3–3.8, model 1). Conclusion The risk of poor clinical outcome is doubled in CVT patients presenting with anaemia at admission.
Collapse
Affiliation(s)
- S M Silvis
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Reinstra
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Hiltunen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - E Lindgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M Mansour
- Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | - M Ghiasian
- Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | - K Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - S M Zuurbier
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A E Groot
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M A Barboza
- Neurosciences Department, Hospital Dr R.A. Calderón Guardia, CCSS, San José, Costa Rica
| | - A Arauz
- National Institute of Neurology and Neurosurgery Manuel Velasco Suarez, Mexico City, Mexico
| | - J Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - T Tatlisumak
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
18
|
Mustanoja S, Putaala J, Koivunen R, Surakka I, Tatlisumak T. Blood pressure levels in the acute phase after intracerebral hemorrhage are associated with mortality in young adults. Eur J Neurol 2018; 25:1034-1040. [DOI: 10.1111/ene.13662] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/28/2018] [Indexed: 01/18/2023]
Affiliation(s)
- S. Mustanoja
- Department of Neurology Helsinki University Hospital and Clinical Neurosciences University of Helsinki Helsinki Finland
| | - J. Putaala
- Department of Neurology Helsinki University Hospital and Clinical Neurosciences University of Helsinki Helsinki Finland
| | - R.‐J. Koivunen
- Department of Neurology Helsinki University Hospital and Clinical Neurosciences University of Helsinki Helsinki Finland
- Department of Anesthesiology Päijät‐Häme Central Hospital Lahti Finland
| | - I. Surakka
- Molecular Medicine Finland (FIMM) University of Helsinki Helsinki Finland
| | - T. Tatlisumak
- Department of Neurology Helsinki University Hospital and Clinical Neurosciences University of Helsinki Helsinki Finland
- Department of Clinical Neurosciences Institute of Neuroscience and Physiology Sahlgrenska Academy at University of GothenburgGothenburg Sweden
- Department of Neurology Sahlgrenska University Hospital Gothenburg Sweden
| |
Collapse
|
19
|
Virkkala J, Martinez-Majander N, Pakarinen S, Niemelä M, Putaala J, Müller K, Korja M. 1038 Sleep Disruption Experienced by Surgically Treated Brain Aneurysm Patients. Sleep 2018. [DOI: 10.1093/sleep/zsy061.1037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J Virkkala
- Finnish Institute of Occupational Health, Helsinki, FINL
| | | | - S Pakarinen
- Finnish Institute of Occupational Health, Helsinki, FINL
| | - M Niemelä
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, FINL
| | - J Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, FINL
| | - K Müller
- Digital Health Lab, Nokia Technologies, Espoo, FINL
- Department of Neurology, Helsinki University Hospital, Helsinki, FINL
| | - M Korja
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, FINL
| |
Collapse
|
20
|
Liebkind R, Gordin D, Strbian D, Meretoja A, Thorn LM, Hägg-Holmberg S, Forsblom C, Tatlisumak T, Groop PH, Putaala J. Diabetes and intracerebral hemorrhage: baseline characteristics and mortality. Eur J Neurol 2018; 25:825-832. [PMID: 29443444 DOI: 10.1111/ene.13603] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/06/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Acknowledging the conflicting evidence for diabetes as a predictor of short- and long-term mortality following an intracerebral hemorrhage (ICH), we compared baseline characteristics and 30-day and long-term mortality between patients with and without diabetes after an ICH, paying special attention to differences between type 1 (T1D) and type 2 (T2D) diabetes. METHODS Patients with a first-ever ICH were followed for a median of 2.3 years. Adjusting for demographics, comorbidities and documented ICH characteristics increasing mortality after ICH, logistic regression analysis assessed factors associated with case fatality and 1-year survival among the 30-day survivors. Diabetes was compared with patients without diabetes in separate models as (i) any diabetes and (ii) T1D or T2D. RESULTS Of our 969 patients, 813 (83.9%) had no diabetes, 41 (4.2%) had T1D and 115 (11.9%) had T2D. Compared with patients without diabetes, those with diabetes were younger, more often men and more frequently had hypertension, coronary heart disease and chronic kidney disease, with similar ICH characteristics. Patients with T1D were younger, more often had chronic kidney disease and brainstem ICH, and less often had atrial fibrillation and lobar ICH, than did patients with T2D. Diabetes had no impact on case fatality. Any diabetes (odds ratio, 2.57; 1.19-5.52), T1D (odds ratio, 7.04; 1.14-43.48) and T2D (odds ratio, 2.32; 1.04-5.17) were independently associated with 1-year mortality. CONCLUSIONS Patients with ICH with diabetes exhibited a distinct pattern of comorbidities and disease characteristics with specific differences between T1D and T2D. Despite their younger age, T1D seems to carry a substantially higher likelihood of long-term mortality after an ICH than does T2D.
Collapse
Affiliation(s)
- R Liebkind
- Department of Neurology and Neurosciences, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - D Gordin
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.,Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.,Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - D Strbian
- Department of Neurology and Neurosciences, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - A Meretoja
- Department of Neurology and Neurosciences, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - L M Thorn
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.,Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - S Hägg-Holmberg
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.,Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - C Forsblom
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.,Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - T Tatlisumak
- Department of Neurology and Neurosciences, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Department of Clinical Neurosciences, Sahlgrenska Academy at the University of Gothenburg and Department of Neurology, Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P-H Groop
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.,Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.,Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - J Putaala
- Department of Neurology and Neurosciences, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| |
Collapse
|
21
|
Martinez‐Majander N, Aarnio K, Pirinen J, Lumikari T, Nieminen T, Lehto M, Sinisalo J, Kaste M, Tatlisumak T, Putaala J. Embolic strokes of undetermined source in young adults: baseline characteristics and long‐term outcome. Eur J Neurol 2018; 25:535-541. [DOI: 10.1111/ene.13540] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/01/2017] [Indexed: 11/28/2022]
Affiliation(s)
- N. Martinez‐Majander
- Clinical Neurosciences, Neurology University of Helsinki HelsinkiFinland
- Department of Neurology Helsinki University Hospital HelsinkiFinland
| | - K. Aarnio
- Clinical Neurosciences, Neurology University of Helsinki HelsinkiFinland
- Department of Neurology Helsinki University Hospital HelsinkiFinland
| | - J. Pirinen
- Clinical Neurosciences, Neurology University of Helsinki HelsinkiFinland
- Department of Neurology Helsinki University Hospital HelsinkiFinland
- Department of Cardiology, Heart and Lung Center Helsinki University Hospital and University of Helsinki HelsinkiFinland
- Department of Clinical Physiology and Nuclear Medicine HUS Medical Imaging Center Helsinki University Hospital and University of Helsinki HelsinkiFinland
| | - T. Lumikari
- Clinical Neurosciences, Neurology University of Helsinki HelsinkiFinland
- Department of Neurology Helsinki University Hospital HelsinkiFinland
| | - T. Nieminen
- Internal Medicine University of Helsinki Helsinki University Hospital and South Karelia Central Hospital HelsinkiFinland
| | - M. Lehto
- Department of Cardiology, Heart and Lung Center Helsinki University Hospital and University of Helsinki HelsinkiFinland
| | - J. Sinisalo
- Department of Cardiology, Heart and Lung Center Helsinki University Hospital and University of Helsinki HelsinkiFinland
| | - M. Kaste
- Clinical Neurosciences, Neurology University of Helsinki HelsinkiFinland
- Department of Neurology Helsinki University Hospital HelsinkiFinland
| | - T. Tatlisumak
- Clinical Neurosciences, Neurology University of Helsinki HelsinkiFinland
- Department of Neurology Helsinki University Hospital HelsinkiFinland
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy at University of Gothenburg GothenburgSweden
- Department of Neurology Sahlgrenska University Hospital Gothenburg Sweden
| | - J. Putaala
- Clinical Neurosciences, Neurology University of Helsinki HelsinkiFinland
- Department of Neurology Helsinki University Hospital HelsinkiFinland
| |
Collapse
|
22
|
Sykora M, Putaala J, Meretoja A, Tatlisumak T, Strbian D. Beta-blocker therapy is not associated with mortality after intracerebral hemorrhage. Acta Neurol Scand 2018; 137:105-108. [PMID: 28869294 DOI: 10.1111/ane.12817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Beta-blocker therapy has been suggested to have neuroprotective properties in the setting of acute stroke; however, the evidence is weak and contradictory. We aimed to examine the effects of pre-admission therapy with beta-blockers (BB) on the mortality following spontaneous intracerebral hemorrhage (ICH). METHODS Retrospective analysis of the Helsinki ICH Study database. RESULTS A total of 1013 patients with ICH were included in the analysis. Patients taking BB were significantly older, had a higher premorbid mRS score, had more DNR orders, and more comorbidities as atrial fibrillation, hypertension, diabetes mellitus, ischemic heart disease, and heart failure. After adjustment for age, pre-existing comorbidities, and prior use of antithrombotic and antihypertensive medications, no differences in in-hospital mortality (OR 1.1, 95% CI 0.8-1.7), 12-month mortality (OR 1.3, 95% CI 0.9-1.9), and 3-month mortality (OR 1.2, 95% CI 0.8-1.7) emerged. CONCLUSION Pre-admission use of BB was not associated with mortality after ICH.
Collapse
Affiliation(s)
- M. Sykora
- Department of Neurology; St. John's Hospital; Medical faculty; Sigmund Freud University Vienna; Wien Austria
| | - J. Putaala
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - A. Meretoja
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
- Department of Medicine at the Royal Melbourne Hospital; University of Melbourne; Parkville VIC Australia
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
- Department of Clinical Neurosciences/Neurology; Institute of Neuroscience and Physiology; Sahlgrenska Academy at University of Gothenburg and Sahlgrenska University Hospital; Gothenburg Sweden
| | - D. Strbian
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| |
Collapse
|
23
|
Silvis SM, Hiltunen S, Lindgren E, Jood K, Zuurbier SM, Middeldorp S, Putaala J, Cannegieter SC, Tatlisumak T, Coutinho JM. Cancer and risk of cerebral venous thrombosis: a case-control study. J Thromb Haemost 2018; 16:90-95. [PMID: 29125690 DOI: 10.1111/jth.13903] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Indexed: 12/21/2022]
Abstract
Essentials The risk of cerebral venous thrombosis (CVT) in patients with cancer is not known. We performed a case-control study including 594 patients with CVT and 6278 controls. History of cancer increased the risk of CVT approximately 5-fold. The association was strongest with hematological cancer in the first year after diagnosis. SUMMARY Background Cancer is an established risk factor for leg vein thrombosis and pulmonary embolism. Controlled studies assessing the risk of cerebral venous thrombosis (CVT) in patients with cancer have not been performed. Objective To assess whether cancer is a risk factor for CVT. Patients/Methods This was a case-control study. We assessed consecutive adult patients with CVT from three academic hospitals from 1987 to 2015, and control subjects from the Dutch MEGA study (Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis). We adjusted for age, sex and oral contraceptive use, and stratified for type of cancer and time since diagnosis of cancer. Results We included 594 cases and 6278 controls. In total, 53 cases (8.9%) and 160 controls (2.5%) had a history of cancer. Cases were younger (median 42 vs. 48 years), more often female (68% vs. 54%) and more often used oral contraceptives (55% vs. 23%) than controls. The risk of CVT was increased in patients with cancer compared with those without cancer (adjusted odds ratio [aOR], 4.86; 95% confidence interval [CI], 3.46-6.81). Patients with a hematological type of cancer had a higher risk of CVT (aOR, 25.14; 95% CI, 11.64-54.30) than those with a solid type of cancer (aOR, 3.07; 95% CI, 2.03-4.65). The association was strongest in the first year after diagnosis of cancer (hematological aOR, 85.57; 95% CI, 19.70-371.69; solid aOR, 10.50; 95% CI, 5.40-20.42). Conclusions Our study indicates that cancer is a strong risk factor for CVT, particularly within the first year of diagnosis and in patients with a hematological type of cancer.
Collapse
Affiliation(s)
- S M Silvis
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | - S Hiltunen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - E Lindgren
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - K Jood
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - S M Zuurbier
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | - S Middeldorp
- Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - J Putaala
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - S C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Amsterdam, the Netherlands
| | - T Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J M Coutinho
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| |
Collapse
|
24
|
Gensicke H, Frih AA, Strbian D, Zini A, Pezzini A, Padjen V, Haueter M, Seiffge DJ, Mäkitie L, Traenka C, Poli L, Martinez-Majander N, Putaala J, Bonati LH, Sibolt G, Giovannini G, Curtze S, Beslac-Bumbasirevic L, Vandelli L, Lyrer PA, Nederkoorn PJ, Tatlisumak T, Engelter ST. Prognostic significance of proteinuria in stroke patients treated with intravenous thrombolysis. Eur J Neurol 2016; 24:262-269. [DOI: 10.1111/ene.13179] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/16/2016] [Indexed: 11/27/2022]
Affiliation(s)
- H. Gensicke
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - A. A. Frih
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - D. Strbian
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - A. Zini
- Stroke Unit; Department of Neuroscience; Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena; Modena Italy
| | - A. Pezzini
- Department of Clinical and Experimental Sciences; Neurology Clinic; University of Brescia; Modena Italy
| | - V. Padjen
- Neurology Clinic; Clinical Centre of Serbia; Beograd Serbia
| | - M. Haueter
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
- Neurorehabilitation Unit; Felix Platter Hospital; University of Basel and University Center for Medicine of Aging; Basel Switzerland
| | - D. J. Seiffge
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - L. Mäkitie
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - C. Traenka
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - L. Poli
- Department of Clinical and Experimental Sciences; Neurology Clinic; University of Brescia; Modena Italy
| | - N. Martinez-Majander
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - J. Putaala
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - L. H. Bonati
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - G. Sibolt
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - G. Giovannini
- Stroke Unit; Department of Neuroscience; Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena; Modena Italy
| | - S. Curtze
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | | | - L. Vandelli
- Stroke Unit; Department of Neuroscience; Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena; Modena Italy
| | - P. A. Lyrer
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
| | - P. J. Nederkoorn
- Department of Neurology; Academic Medical Center Amsterdam; The Netherlands
| | - T. Tatlisumak
- Clinical Neurosciences; Neurology; University of Helsinki, and Department of Neurology; Helsinki University Hospital; Helsinki Finland
- Institute of Neuroscience and Physiology; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
- Department of Neurology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - S. T. Engelter
- Stroke Center and Neurology; University Hospital Basel; Basel Switzerland
- Neurorehabilitation Unit; Felix Platter Hospital; University of Basel and University Center for Medicine of Aging; Basel Switzerland
| | | |
Collapse
|
25
|
Curtze S, Sibolt G, Melkas S, Mustanoja S, Haapaniemi E, Putaala J, Sairanen T, Tiainen M, Tatlisumak T, Strbian D. Symptomatic post-thrombolytic intracerebral hemorrhage is not related to the cause of stroke. Eur J Neurol 2016; 23:1700-1704. [DOI: 10.1111/ene.13128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 08/09/2016] [Indexed: 11/30/2022]
Affiliation(s)
- S. Curtze
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - G. Sibolt
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - S. Melkas
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - S. Mustanoja
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - E. Haapaniemi
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - J. Putaala
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - T. Sairanen
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - M. Tiainen
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| | - T. Tatlisumak
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
- Institute of Neuroscience and Physiology; Salhgrenska Academy at University of Gothenburg; Gothenburg
- Department of Neurology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - D. Strbian
- Clinical Neurosciences; Neurology; University of Helsinki; Helsinki
- Department of Neurology; Helsinki University Hospital; Helsinki Finland
| |
Collapse
|
26
|
Tanislav C, Grittner U, Fazekas F, Thijs V, Tatlisumak T, Huber R, von Sarnowski B, Putaala J, Schmidt R, Kropp P, Norrving B, Martus P, Gramsch C, Giese AK, Rolfs A, Enzinger C. Frequency and predictors of acute ischaemic lesions on brain magnetic resonance imaging in young patients with a clinical diagnosis of transient ischaemic attack. Eur J Neurol 2016; 23:1174-82. [PMID: 27105904 DOI: 10.1111/ene.13012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 03/01/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Acute lesions in patients with transient ischaemic attack (TIA) are important as they are associated with increased risk for recurrence. Characteristics associated with acute lesions in young TIA patients were therefore investigated. METHODS The sifap1 study prospectively recruited a multinational European cohort (n = 5023) of patients aged 18-55 years with acute cerebrovascular event. The detection of acute ischaemic lesions was based on diffusion-weighted imaging (DWI). The frequency of DWI lesions was assessed in 829 TIA patients who met the criteria of symptom duration <24 h and their association with demographic, clinical and imaging variables was analysed. RESULTS The median age was 46 years (interquartile range 40-51 years); 45% of the patients were female. In 121 patients (15%) ≥1 acute DWI lesion was detected. In 92 patients, DWI lesions were found in the anterior circulation, mostly located in cortical-subcortical areas (n = 63). Factors associated with DWI lesions in multiple regression analysis were left hemispheric presenting symptoms [odds ratio (OR) 1.92, 95% confidence interval (CI) 1.27-2.91], dysarthria (OR 2.17, 95% CI 1.38-3.43) and old brain infarctions on MRI (territories of the middle and posterior cerebral artery: OR 2.43, 95% CI 1.42-4.15; OR 2.41, 95% CI 1.02-5.69, respectively). CONCLUSIONS In young patients with a clinical TIA 15% demonstrated acute DWI lesions on brain MRI, with an event pattern highly suggestive of an embolic origin. Except for the association with previous infarctions there was no clear clinical predictor for acute ischaemic lesions, which indicates the need to obtain MRI in young individuals with TIA.
Collapse
Affiliation(s)
- C Tanislav
- Department of Neurology, Justus Liebig University, Giessen, Germany
| | - U Grittner
- Department for Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - F Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - V Thijs
- Clinical and Experimental Neurology, Leuven, Belgium
| | - T Tatlisumak
- Institute of Neuroscience and Physiology and Department of Neurology, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.,Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - R Huber
- Department of Neurology, Klinikum Friedrichshafen, Friedrichshafen, Germany
| | - B von Sarnowski
- Department of Neurology, University of Greifswald, Greifswald, Germany
| | - J Putaala
- Institute of Neuroscience and Physiology and Department of Neurology, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - R Schmidt
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - P Kropp
- Institute of Medical Psychology and Medical Sociology, University of Rostock, Rostock, Germany
| | - B Norrving
- Department of Clinical Neuroscience, Lund University Hospital, Lund, Sweden
| | - P Martus
- Department for Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - C Gramsch
- Department of Neurology, Justus Liebig University, Giessen, Germany
| | - A K Giese
- Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany
| | - A Rolfs
- Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany
| | - C Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria
| |
Collapse
|
27
|
Koivunen RJ, Harno H, Tatlisumak T, Putaala J. Depression, anxiety, and cognitive functioning after intracerebral hemorrhage. Acta Neurol Scand 2015; 132:179-84. [PMID: 25639837 DOI: 10.1111/ane.12367] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Post-stroke depression (PSD) is an important complication of stroke. We studied long-term PSD after intracerebral hemorrhage (ICH) at young age, as well as anxiety, and cognitive functioning of the survivors. METHODS We gathered clinical and imaging data of 336 young ICH patients between age 16 and 49 treated in the Helsinki University Central Hospital. After a median follow-up of 9.7 (7.0-12.0) years, we interviewed 130 survivors with structural questionnaires including Beck Depression Inventory II (BDI-II), Hospital Anxiety and Depression Scale (HADS), Pain Anxiety Symptoms Scale (PASS), Brief Pain Inventory (BPI), and Montreal Cognitive Assessment (MoCA). Univariate and multivariate analysis was performed to identify factors associated with PSD (BDI-II score >13). Degree of disability was measured by modified Rankin Scale score (mRS). RESULTS PSD was present among 30 (23.1%) and anxiety among 52 (40.0%) patients (HADS score >6). Higher degree of disability was associated with symptoms of depression (higher BDI-II scores, P = 0.001), emotional distress (higher HADS scores, P = 0.004), and pain (higher PASS scores, P = 0.008, and higher BPI scores, P = 0.003). The only baseline factor identified to associate with PSD was hydrocephalus (P = 0.014). Median PASS score was 9 (IQR 0-25), median BPI score was 5 (0-23), and median MoCA score was 26 (22-28) hinting to normal or mild cognitive dysfunction. Antidepressants were used by 9.2%. CONCLUSIONS One of four survivors of ICH at young age suffers long-term PSD. Higher degree of disability predicted occurrence of PSD. Treatment of depression appears as an unmet need in young ICH survivors.
Collapse
Affiliation(s)
- R.-J. Koivunen
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - H. Harno
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - J. Putaala
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| |
Collapse
|
28
|
Koivunen RJ, Tatlisumak T, Satopää J, Niemelä M, Putaala J. Intracerebral hemorrhage at young age: long-term prognosis. Eur J Neurol 2015; 22:1029-37. [PMID: 25850522 DOI: 10.1111/ene.12704] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 02/06/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) is a devastating disorder associated with dismal outcomes. The long-term mortality and functional outcome of ICH in young patients was studied - areas so far poorly investigated. METHODS A follow-up study was performed on a cohort of patients. Clinical and imaging data on ICH patients aged 16-49 were retrospectively obtained and linked with a nationwide cause-of-death register. The modified Rankin Scale (mRS) was evaluated for 30-day survivors at a visit 9.7 (7.0-12.0) years after ICH onset. Independent factors associated with mortality and unfavorable functional outcome (mRS 2-5) were sought by multivariate analysis. RESULTS Amongst the 268 1-month survivors, 1-year survival was 98.1% [95% confidence interval (CI) 96.2%-100%], 5-year survival 93.2% (89.3%-97.1%) and 10-year survival 88.8% (84.9%-92.7%). After adjustment for age and intraventricular hematoma extension, male sex [odds ratio (OR) 3.36, 95% CI 1.28-8.80] and diabetes (OR 2.64, 1.01-6.89) were associated with increased mortality. Unfavorable functional outcome emerged in 49%. After adjustment for confounders, age (OR 1.09 per 1 year, 95% CI 1.03-1.15), initial stroke severity (1.17 per one National Institutes of Health Stroke Scale score point, 1.08-1.27) and intraventricular hemorrhage (3.26, 1.11-9.55) were associated with unfavorable functional outcome. CONCLUSIONS Of every 10 survivors of acute phase ICH at a young age, one died within 10 years after onset, male sex and diabetes being associated with increased mortality. Half the survivors did not achieve a favorable functional outcome, which was predicted by increasing age, initial stroke severity and intraventricular hemorrhage.
Collapse
Affiliation(s)
- R-J Koivunen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - T Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - J Satopää
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - M Niemelä
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - J Putaala
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| |
Collapse
|
29
|
Koivunen RJ, Satopää J, Meretoja A, Strbian D, Haapaniemi E, Niemelä M, Tatlisumak T, Putaala J. Incidence, risk factors, etiology, severity and short-term outcome of non-traumatic intracerebral hemorrhage in young adults. Eur J Neurol 2014; 22:123-32. [PMID: 25142530 DOI: 10.1111/ene.12543] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/23/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) is a common and severe form of stroke but is scarcely studied in young adults. Our aim was to study risk factors, clinical presentation and early mortality of ICH in the young and compare these features with older patients. METHODS All consecutive patients aged between 16 and 49 diagnosed with a first-ever ICH at the Departments of Neurology or Neurosurgery of the Helsinki University Central Hospital between January 2000 and March 2010 (n = 336) were analyzed retrospectively. Comparisons were performed amongst demographic subgroups and with patients over 49 years of age enrolled between January 2005 and March 2010 (n = 921). RESULTS In the young patients, median age was 42 years (interquartile range 34-47), 59.5% were male, and annual incidence was 4.9 (95% confidence interval 4.5-5.3) per 100 000. The most prevalent risk factors were hypertension (29.8%) and smoking (22.3%). Compared with older patients hypertensive microangiopathy was less common (25.0% vs. 34.3%, P = 0.002) and structural lesions more common (25.0% vs. 4.9%, P < 0.001) assumed etiologies of ICH. The cause remained elusive in 32.1% of all young patients and in 22.5% of those who underwent magnetic resonance imaging and any angiography (n = 89, P = 0.023). Three-month mortality rate was lower in young patients compared with older ones (17.0% vs. 32.7%, P < 0.001). Hematoma volumes were similar across all ages (P = 0.324) and independently predicted mortality in older patients but not in the young. CONCLUSIONS Intracerebral hemorrhage (ICH) in the young appears less fatal and has a different spectrum of causes and factors associated with short-term mortality than for the elderly.
Collapse
Affiliation(s)
- R-J Koivunen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Curtze S, Strbian D, Meretoja A, Putaala J, Eriksson H, Haapaniemi E, Mustanoja S, Sairanen T, Satopää J, Silvennoinen H, Niemelä M, Kaste M, Tatlisumak T. Higher baseline international normalized ratio value correlates with higher mortality in intracerebral hemorrhage during warfarin use. Eur J Neurol 2014; 21:616-22. [DOI: 10.1111/ene.12352] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 12/11/2013] [Indexed: 11/29/2022]
Affiliation(s)
- S. Curtze
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - D. Strbian
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - A. Meretoja
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
- Department of Medicine and the Florey Institute; University of Melbourne; Melbourne Victoria Australia
| | - J. Putaala
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - H. Eriksson
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - E. Haapaniemi
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - S. Mustanoja
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - T. Sairanen
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - J. Satopää
- Department of Neurosurgery; Helsinki University Central Hospital; Helsinki Finland
| | - H. Silvennoinen
- Department of Radiology; Helsinki University Central Hospital; Helsinki Finland
| | - M. Niemelä
- Department of Neurosurgery; Helsinki University Central Hospital; Helsinki Finland
| | - M. Kaste
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| |
Collapse
|
31
|
Sairanen T, Koivisto A, Koivusalo AM, Rantanen K, Mustanoja S, Meretoja A, Putaala J, Strbian D, Kaste M, Isoniemi H, Tatlisumak T. Lost potential of kidney and liver donors amongst deceased intracerebral hemorrhage patients. Eur J Neurol 2013; 21:153-9. [DOI: 10.1111/ene.12288] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 09/23/2013] [Indexed: 12/21/2022]
Affiliation(s)
- T. Sairanen
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - A. Koivisto
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
- Faculty of Medicine; University of Helsinki; Helsinki Finland
| | - A.-M. Koivusalo
- Intensive Care Unit; Helsinki University Central Hospital; Helsinki Finland
| | - K. Rantanen
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - S. Mustanoja
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - A. Meretoja
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
- Departments of Neurology, Medicine, and the Florey; Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
| | - J. Putaala
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - D. Strbian
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - M. Kaste
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - H. Isoniemi
- Transplantation and Liver Surgery Clinic; Helsinki University Central Hospital; Helsinki Finland
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| |
Collapse
|
32
|
Putaala J, Lehto M, Meretoja A, Silvennoinen K, Curtze S, Kääriäinen J, Koivunen RJ, Kaste M, Tatlisumak T, Strbian D. In-Hospital Cardiac Complications after Intracerebral Hemorrhage. Int J Stroke 2013; 9:741-6. [DOI: 10.1111/ijs.12180] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and purpose Data on cardiac complications and their precipitants after intracerebral hemorrhage are scarce. We examined the frequency and risk factors for serious in-hospital cardiac events in a large cohort of consecutive intracerebral hemorrhage patients. Methods A retrospective chart review of 1013 consecutive patients with nontraumatic intracerebral hemorrhage treated at the Helsinki University Central Hospital (2005–2010). We excluded patients with intraparenchymal hematoma related to sub-arachnoid hemorrhage or intracerebral hemorrhage because of fibrinolytic therapies for acute ischemic stroke or myocardial infarction. Serious in-hospital cardiac event was defined as any of in-hospital poststroke acute myocardial infarction, ventricular fibrillation or tachycardia, moderate to serious acute heart failure, or cardiac death. Results Among the 948 patients included, ≥1 serious in-hospital cardiac event occurred in 39 (4·1%) patients after a median delay of two-days from stroke onset (acute myocardial infarction in three patients, ventricular fibrillation or tachycardia in three patients, acute heart failure in 36 patients, and cardiac death in three patients). Hospital stay was longer in patients with serious in-hospital cardiac event than in those without (median 12, interquartile range 7–19 vs. 8, 3–14; P = 0·001), with no difference in in-hospital mortality (23·1% vs. 24·3%; P = 0·86). In multivariable logistic regression analysis adjusted for age, gender, and diabetes, atrial fibrillation during hospitalization (odds ratio 6·68 for new-onset atrial fibrillation, 95% confidence interval 2·11–21·18; 4·46 for old atrial fibrillation, 2·08–9·56), and history of myocardial infarction (3·20, 1·18–8·66) were independently associated with serious in-hospital cardiac events. Conclusions After intracerebral hemorrhage, 4% of patients suffer an acute serious cardiac complication. Those with history of myocardial infarction or in-hospital atrial fibrillation are at greater risk for such events.
Collapse
Affiliation(s)
- J. Putaala
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - M. Lehto
- Department of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - A. Meretoja
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
- Melbourne Brain Centre at the Royal Melbourne Hospital, Department of Medicine, University of Melbourne, Florey Neuroscience Institutes, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - K. Silvennoinen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - S. Curtze
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - J. Kääriäinen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - R.-J. Koivunen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - M. Kaste
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - T. Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - D. Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| |
Collapse
|
33
|
Yesilot Barlas N, Putaala J, Waje-Andreassen U, Vassilopoulou S, Nardi K, Odier C, Hofgart G, Engelter S, Burow A, Mihalka L, Kloss M, Ferrari J, Lemmens R, Coban O, Haapaniemi E, Maaijwee N, Rutten-Jacobs L, Bersano A, Cereda C, Baron P, Borellini L, Valcarenghi C, Thomassen L, Grau AJ, Palm F, Urbanek C, Tuncay R, Durukan Tolvanen A, van Dijk EJ, de Leeuw FE, Thijs V, Greisenegger S, Vemmos K, Lichy C, Bereczki D, Csiba L, Michel P, Leys D, Spengos K, Naess H, Tatlisumak T, Bahar SZ. Etiology of first-ever ischaemic stroke in European young adults: the 15 cities young stroke study. Eur J Neurol 2013; 20:1431-9. [PMID: 23837733 DOI: 10.1111/ene.12228] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 06/05/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Risk factors for IS in young adults differ between genders and evolve with age, but data on the age- and gender-specific differences by stroke etiology are scare. These features were compared based on individual patient data from 15 European stroke centers. METHODS Stroke etiology was reported in detail for 3331 patients aged 15-49 years with first-ever IS according to Trial of Org in Acute Stroke Treatment (TOAST) criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-vessel occlusion (SVO), other determined etiology, or undetermined etiology. CE was categorized into low- and high-risk sources. Other determined group was divided into dissection and other non-dissection causes. Comparisons were done using logistic regression, adjusting for age, gender, and center heterogeneity. RESULTS Etiology remained undetermined in 39.6%. Other determined etiology was found in 21.6%, CE in 17.3%, SVO in 12.2%, and LAA in 9.3%. Other determined etiology was more common in females and younger patients, with cervical artery dissection being the single most common etiology (12.8%). CE was more common in younger patients. Within CE, the most frequent high-risk sources were atrial fibrillation/flutter (15.1%) and cardiomyopathy (11.5%). LAA, high-risk sources of CE, and SVO were more common in males. LAA and SVO showed an increasing frequency with age. No significant etiologic distribution differences were found amongst southern, central, or northern Europe. CONCLUSIONS The etiology of IS in young adults has clear gender-specific patterns that change with age. A notable portion of these patients remains without an evident stroke mechanism according to TOAST criteria.
Collapse
Affiliation(s)
- N Yesilot Barlas
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Roivainen R, Haapaniemi E, Putaala J, Kaste M, Tatlisumak T. Young adult ischaemic stroke related acute symptomatic and late seizures: risk factors. Eur J Neurol 2013; 20:1247-55. [PMID: 23581284 DOI: 10.1111/ene.12157] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 02/28/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE After first-ever ischaemic stroke, to assess the risk and baseline factors associated with acute symptomatic seizure (ASS) (occurring within 7 days) and late post-stroke seizure (LPS) (>7 days). METHODS All consecutive patients aged 15-49 with first-ever ischaemic stroke between 1994 and 2007 treated at the Helsinki University Central Hospital were included, using Cox proportional hazard models to identify factors associated with seizures. Adjustment was for age, gender, vascular risk factors, admission hyperglycemia (>6.1 mm) and hyponatremia (<137 mm), use of psychiatric medication, stroke severity (NIH Stroke Scale) and anatomical (Bamford criteria) and etiological (Trial of Org in Acute Stroke Treatment) stroke subtype. RESULTS ASSs emerged in 35 (3.5%) patients. LPSs (n = 102) occurred at a cumulative rate of 6.1% at 1 year, 9.5% at 5 years and 11.5% at 10 years. In multivariate analysis, anxiolytic use at time of index stroke (hazard ratio 13.43, 95% confidence interval 3.91-46.14), moderate stroke severity (3.95, 1.86-8.41), cortical involvement (3.69, 1.66-8.18) and hyponatremia (3.26, 1.41-7.57) were independently associated with ASSs. Risk factors for LPSs were total anterior circulation infarct (15.94, 7.62-33.33), partial anterior circulation infarct (3.48, 1.52-7.93), history of ASS (3.94, 2.07-7.48), antidepressant use at the time of LPS (3.88, 2.46-6.11), hemorrhagic infarct (1.94, 1.19-3.15), male gender (1.79, 1.10-2.92) and hyperglycemia (1.62, 1.05-2.51). CONCLUSIONS In young ischaemic stroke patients, the magnitude of seizure risk and the major risk factors were similar to older ischaemic stroke patients but risk factors for ASSs and LPSs differed.
Collapse
Affiliation(s)
- R Roivainen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.
| | | | | | | | | |
Collapse
|
35
|
von Sarnowski B, Schminke U, Tatlisumak T, Putaala J, Grittner U, Kaps M, Tobin WO, Kinsella JA, McCabe DJH, Hennerici MG, Fazekas F, Norrving B, Kessler C, Rolfs A. Prevalence of stenoses and occlusions of brain-supplying arteries in young stroke patients. Neurology 2013; 80:1287-94. [DOI: 10.1212/wnl.0b013e31828ab2ed] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
36
|
Rolfs A, Fazekas F, Grittner U, Dichgans M, Martus P, Holzhausen M, Böttcher T, Heuschmann PU, Tatlisumak T, Tanislav C, Jungehulsing GJ, Giese AK, Putaala J, Huber R, Bodechtel U, Lichy C, Enzinger C, Schmidt R, Hennerici MG, Kaps M, Kessler C, Lackner K, Paschke E, Meyer W, Mascher H, Riess O, Kolodny E, Norrving B, Rolfs A, Ginsberg M, Hennerici MG, Kessler C, Kolodny E, Martus P, Norrving B, Ringelstein EB, Rothwell PM, Venables G, Bornstein N, deDeyn P, Dichgans M, Fazekas F, Markus H, Rieß O, Biedermann C, Böttcher T, Brüderlein K, Burmeister J, Federow I, König F, Makowei G, Niemann D, Rolfs A, Rösner S, Zielke S, Grittner U, Martus P, Holzhausen M, Fazekas F, Enzinger C, Schmidt R, Ropele S, Windisch M, Sterner E, Bodamer O, Fellgiebel A, Hillen U, Jonas L, Kampmann C, Kropp P, Lackner K, Laue M, Mascher H, Meyer W, Paschke E, Weidemann F, Berrouschot J, Stoll A, Rokicha A, Sternitzky C, Thomä M, DeDeyn PP, Sheorajpanday R, De Brabander I, Yperzeele L, Brouns R, Oschmann P, Pott M, Schultes K, Schultze C, Hirsekorn J, Jungehulsing GJ, Villringer A, Schmidt W, Liman T, Nowe T, Ebinger M, Wille A, Loui H, Objartel A, übelacker A, Mette R, Jegzentis K, Nabavi DG, Crome O, Bahr D, Ebke M, Platte B, Kleinen C, Mermolja Gunther K, Heide W, Pape O, Hanssen JR, Stangenberg D, Klingelhofer J, Schmidt B, Schwarz S, Schwarze J, Frandlih L, Iwanow J, Steinbach I, Krieger D, Boysen G, Leth Jeppesen L, Petersen A, Reichmann H, Becker U, Dzialkowski I, Hentschel H, Lautenschlager C, Hanso H, Gahn G, Ziemssen T, Fleischer K, Sehr B, McCabe DJH, Tobin O, Kinsella J, Murphy RP, Jander S, Hartung HP, Siebler M, Bottcher C, Kohne A, Platzen J, Brosig TC, Rothhammer V, Henseler C, Neumann-Haefelin T, Singer OC, Ermis U, dos Santos IMRM, Schuhmann C, van de Loo S, Kaps M, Allendorfer J, Tanislav C, Brandtner M, Muir K, Dani K, MacDougall N, Smith W, Rowe A, Welch A, Fazekas F, Schrotter G, Krenn U, Horner S, Pendl B, Pluta-Fuerst A, Trummer U, Kessler C, Chatzopoulos M, v Sarnowski B, Schminke U, Link T, Khaw A, Nieber E, Zierz S, Muller T, Wegener N, Wartenberg K, Gaul C, Richter D, Rosenkranz M, Krützelmann AC, Hoppe J, Choe CU, Narr S, Magnus TU, Thomalla G, Leypoldt F, Otto D, Lichy C, Hacke W, Barrows RJ, Tatlisumak T, Putaala J, Curtze S, Metso M, Willeit J, Furtner M, Spiegel M, Knoflach MH, Prantl B, Witte OW, Brämer D, Günther A, Prell T, Herzau C, Aurich K, Deuschl G, Wodarg F, Zimmermann P, Eschenfelder CC, Levsen M, Weber JR, Marecek SM, Schneider D, Michalski D, Kloppig W, Küppers-Tiedt L, Schneider M, Schulz A, Matzen P, Weise C, Hobohm C, Meier H, Langos R, Urban D, Gerhardt I, Thijs V, Lemmens R, Marcelis E, Hulsbosch C, Aichner F, Haring HP, Bach E, Machado Candido J, e Silva AA, Lourenco M, de Sousa AIM, Derex L, Cho TH, Díez-Tejedor E, Fuentes B, Martínez-Sanchez P, Pérez-Guevara MI, Hamer H, Metz A, Hallenberger K, Müller P, Baron P, Bersano A, Gattinoni M, Vella N, Mallia M, Jauss M, Adam L, Heidler F, Gube C, Kiszka M, Dichgans M, Karpinska A, Mewald Y, Straub V, Dörr A, Zollver A, Ringelstein EB, Schilling M, Borchert A, Preuth N, Duning T, Kuhlenbäumer G, Schulte D, Rothwell PM, Marquardt L, Schlachetzki F, Boy S, Mädl J, Ertl GM, Fehm NPR, Stadler C, Benecke R, Dudesek A, Kolbaske S, Lardurner G, Sulzer C, Zerbs A, Lilek S, Walleczek AM, Sinadinowska D, Janelidze M, Beridze M, Lobjanidze N, Dzagnidze A, Melms A, Horber K, Fink I, Liske B, Ludolph AC, Huber R, Knauer K, Hendrich C, Raubold S, Czlonkowska A, Baranowska A, Blazejewska-Hyzorek B, Lang W, Kristoferitsch W, Ferrari J, Ulrich E, Flamm-Horak A, Lischka-Lindner A, Schreiber W, Demarin V, Tranjec Z, Bosner-Puretic M, Jurašić MJ, Basic Kes V, Budisic M, Kopacevic L. Acute Cerebrovascular Disease in the Young. Stroke 2013; 44:340-9. [PMID: 23306324 DOI: 10.1161/strokeaha.112.663708] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.
Methods—
Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.
Results—
Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).
Conclusions—
Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.
Clinical Trial Registration Information—
URL:
http://www.clinicaltrials.gov
.Unique identifier: NCT00414583
Collapse
Affiliation(s)
- Arndt Rolfs
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Franz Fazekas
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Ulrike Grittner
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Martin Dichgans
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Peter Martus
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Martin Holzhausen
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Tobias Böttcher
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Peter U. Heuschmann
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Turgut Tatlisumak
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Christian Tanislav
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Gerhard J. Jungehulsing
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Anne-Katrin Giese
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Jukaa Putaala
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Roman Huber
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Ulf Bodechtel
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Christoph Lichy
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Christian Enzinger
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Reinhold Schmidt
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Michael G. Hennerici
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Manfred Kaps
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Christof Kessler
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Karl Lackner
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Eduard Paschke
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Wolfgang Meyer
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Hermann Mascher
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Olaf Riess
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Edwin Kolodny
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - Bo Norrving
- From the Albrecht-Kossel-Institute for Neuroregeneration, University of Rostock, Rostock, Germany (A.R., T.B., A.K.G.); Department of Neurology, University of Graz, Graz, Austria (F.F., C.E., R.S.); Institute for Biostatistics and Clinical Epidemiology, Charite-University Medicine, Berlin, Germany (U.G., P.M., M.H.); Institute for Stroke and Dementia Research and Department of Neurology, Ludwig-Maximillians University, Munich, Germany (M.D.); Center for Stroke Research Berlin,
| | - A Rolfs
- University of Rostock, Rostock, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - I Federow
- University of Rostock, Rostock, Germany
| | - F König
- University of Rostock, Rostock, Germany
| | - G Makowei
- University of Rostock, Rostock, Germany
| | - D Niemann
- University of Rostock, Rostock, Germany
| | - A Rolfs
- University of Rostock, Rostock, Germany
| | - S Rösner
- University of Rostock, Rostock, Germany
| | - S Zielke
- University of Rostock, Rostock, Germany
| | - U Grittner
- Department of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany
| | - P Martus
- Department of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany
| | - M Holzhausen
- Department of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany
| | - F Fazekas
- Dept of Neurology, Medical University of Graz, Graz, Austria
| | - C Enzinger
- Dept of Neurology, Medical University of Graz, Graz, Austria
| | - R Schmidt
- Dept of Neurology, Medical University of Graz, Graz, Austria
| | - S Ropele
- Dept of Neurology, Medical University of Graz, Graz, Austria
| | | | | | | | | | - U Hillen
- (Essen, Germany) immunohistochemistry
| | - L Jonas
- (Rostock, Germany) electron-microscopy
| | | | - P Kropp
- (Rostock, Germany) headache and pain
| | | | - M Laue
- (Rostock, Germany) electron-microscopy
| | | | - W Meyer
- (London) epidemiology and neuropsychiatry
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - W Schmidt
- Berlin – Charite/Germany, University
| | - T Liman
- Berlin – Charite/Germany, University
| | - T Nowe
- Berlin – Charite/Germany, University
| | - M Ebinger
- Berlin – Charite/Germany, University
| | - A Wille
- Berlin – Charite/Germany, University
| | - H Loui
- Berlin – Charite/Germany, University
| | | | | | - R Mette
- Berlin – Charite/Germany, University
| | | | | | | | - D Bahr
- Berlin – Neukolln/Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - G Gahn
- Dresden/Germany, University
| | | | | | - B Sehr
- Dresden/Germany, University
| | | | | | | | | | | | | | | | | | - A Kohne
- Dusseldorf/Germany, University
| | | | | | | | | | | | - OC Singer
- Frankfurt am Main/Germany, University
| | - U Ermis
- Frankfurt am Main/Germany, University
| | | | | | | | - M Kaps
- Giessen/Germany, University
| | | | | | | | - K Muir
- Glasgow/United Kingdom, University
| | - K Dani
- Glasgow/United Kingdom, University
| | | | - W Smith
- Glasgow/United Kingdom, University
| | - A Rowe
- Glasgow/United Kingdom, University
| | - A Welch
- Glasgow/United Kingdom, University
| | | | | | - U Krenn
- Graz/Austria, Medical University
| | - S Horner
- Graz/Austria, Medical University
| | - B Pendl
- Graz/Austria, Medical University
| | | | | | | | | | | | | | - T Link
- Greifswald/Germany, University
| | - A Khaw
- Greifswald/Germany, University
| | | | | | | | | | | | - C Gaul
- Halle/Germany, University
| | | | | | | | | | | | - S Narr
- Hamburg/Germany, University
| | | | | | | | - D Otto
- Hamburg/Germany, University
| | - C Lichy
- Heidelberg/Germany, University
| | - W Hacke
- Heidelberg/Germany, University
| | | | | | | | | | - M Metso
- Helsinki/Finland, University
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - A Metz
- Marburg/Germany, University
| | | | | | | | | | | | | | | | - M Jauss
- Muhlhausen/Thuringen/Germany
| | - L Adam
- Muhlhausen/Thuringen/Germany
| | | | - C Gube
- Muhlhausen/Thuringen/Germany
| | | | | | | | | | | | - A Dörr
- Munich/Germany, University
| | | | | | | | | | | | | | | | | | | | | | | | - S Boy
- Regensburg/Germany, University
| | - J Mädl
- Regensburg/Germany, University
| | - GM Ertl
- Regensburg/Germany, University
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - A Melms
- Tubingen/Germany, University
| | | | - I Fink
- Tubingen/Germany, University
| | - B Liske
- Tubingen/Germany, University
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Putaala J, Strbian D, Mustanoja S, Haapaniemi E, Kaste M, Tatlisumak T. Functional outcome in young adult ischemic stroke: impact of lipoproteins. Acta Neurol Scand 2013; 127:61-9. [PMID: 22616937 DOI: 10.1111/j.1600-0404.2012.01683.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2012] [Indexed: 12/19/2022]
Abstract
AIM To determine the functional outcome in a cohort of young adults with ischemic stroke patients, focusing on components of lipid profile. METHODS In our registry including consecutive patients with first-ever ischemic stroke aged 15-49 from 1994 to 2007, we analyzed predictors of 3-month functional outcome (modified Rankin Scale, mRS). Infarct size fell into small, medium, large posterior, or large anterior. Stroke severity was assessed with NIH Stroke Scale (NIHSS). Serum lipids were measured within 72 h after admission. Binary, multinomial ordinal, and Poisson regressions allowed revealing factors associated with size of infarct, stroke severity, and unfavorable outcome or death (mRS, 2-6) or mRS as an ordinal measure. RESULTS In the 968 patients included (mean age, 41.3 ± 7.6; 62.6% men; 49.5% with mRS 0-1), factors associated with unfavorable outcome after multivariable analysis were increasing age (odds ratio, 1.03 per year; 95% confidence interval, 1.01-1.05), higher NIHSS score (1.23 per point, 1.17-1.29), large anterior (4.37, 2.26-8.42) or posterior (1.73, 1.05-2.85) infarcts, bilateral lesions (2.28, 1.30-3.98), internal carotid artery dissection (ICAD) (3.65, 1.41-9.47), and inversely high-density lipoprotein (HDL) levels (0.58 per unit increase, 0.38-0.86). Increasing HDL associated with smaller infarct size (0.71, 0.51-0.98). Both higher total and HDL cholesterol associated with lower NIHSS score (0.96, 0.93-0.98 for total cholesterol and 0.82, 0.75-0.88 for HDL) and lower 3-month mRS (0.87, 0.78-0.97 for total cholesterol and 0.65, 0.47-0.90 for HDL). CONCLUSION In addition to known prognosticators, ICAD and lower HDL levels were independently associated with adverse clinical outcomes in our young adult stroke cohort.
Collapse
Affiliation(s)
- J. Putaala
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - D. Strbian
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - S. Mustanoja
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - E. Haapaniemi
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - M. Kaste
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| |
Collapse
|
38
|
Mustanoja S, Putaala J, Haapaniemi E, Strbian D, Kaste M, Tatlisumak T. Multiple brain infarcts in young adults: clues for etiologic diagnosis and prognostic impact. Eur J Neurol 2012; 20:216-22. [DOI: 10.1111/j.1468-1331.2012.03872.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 08/17/2012] [Indexed: 11/30/2022]
Affiliation(s)
- S. Mustanoja
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - J. Putaala
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - E. Haapaniemi
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - D. Strbian
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - M. Kaste
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Central Hospital; Helsinki; Finland
| |
Collapse
|
39
|
Affiliation(s)
- A. Meretoja
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
- Florey Neuroscience Institutes; Melbourne Brain Centre at the Royal Melbourne Hospital; Department of Medicine, University of Melbourne; Melbourne Australia
- Department of Neurology; The Royal Melbourne Hospital; Melbourne Australia
| | - D. Strbian
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - J. Putaala
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - M. Kaste
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | | |
Collapse
|
40
|
Toni D, Ahmed N, Anzini A, Lorenzano S, Brozman M, Kaste M, Mikulik R, Putaala J, Wahlgren N. Intravenous thrombolysis in young stroke patients: results from the SITS-ISTR. Neurology 2012; 78:880-7. [PMID: 22402853 DOI: 10.1212/wnl.0b013e31824d966b] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess safety and efficacy of thrombolysis in 18- to 50-year-old patients compared to those aged 51 to 80 years recorded in the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). METHODS A total of 27,671 patients aged 18-80 years treated with IV alteplase within 4.5 hours of symptom onset were enrolled in SITS-ISTR between 2002 and 2010. Main outcome measures were symptomatic intracerebral hemorrhage (SICH; deterioration of ≥4 points on the NIH Stroke Scale [NIHSS] within 24 hours and type 2 parenchymal hematoma), mortality, and functional independence (modified Rankin Scale [mRS] 0-2) at 3 months. RESULTS In the 3,246 (11.7%) patients aged 18-50, SICH occurred in 0.6% vs 1.9% in those aged 51-80 (adjusted odds ratio [aOR] 0.53; 95% confidence interval [CI] 0.31-0.90, p = 0.02). Three-month mortality was 4.9% and 14.4%, respectively (aOR 0.49; 95% CI 0.40-0.60, p < 0.001) and functional independence was 72.1% vs 54.5%, respectively (aOR 1.61; 95% CI 1.43-1.80, p < 0.0001). In multivariable analysis in young patients, baseline systolic blood pressure (SBP) was the only independent factor associated with SICH (p = 0.04). Baseline NIHSS, baseline glucose, and signs of infarction in baseline imaging scan were associated with higher mortality and poorer functional outcome. Male gender, mRS before stroke, and atrial fibrillation (AF) were associated with higher mortality, and age, SBP, and previous stroke were associated with mRS. CONCLUSIONS Treatment with IV alteplase is safe in young ischemic stroke patients and they benefit more compared to older patients. We found several factors associated with SICH, mortality, and functional outcome. These can be used to help in the selection of young ischemic stroke patients for thrombolysis. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that younger patients (18-50 years) with ischemic stroke symptoms treated with IV alteplase have lower morbidity and mortality compared to older patients (51-80 years).
Collapse
Affiliation(s)
- D Toni
- Department of Neurology and Psychiatry, La Sapienza University of Rome, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Melkas S, Sibolt G, Oksala N, Putaala J, Pohjasvaara T, Kaste M, Karhunen P, Erkinjuntti T. Extensive White Matter Changes Predict Stroke Recurrence up to 5 Years after a First-Ever Ischemic Stroke. Cerebrovasc Dis 2012; 34:191-8. [DOI: 10.1159/000341404] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 06/25/2012] [Indexed: 11/19/2022] Open
|
42
|
Mascitelli L, Goldstein MR, Putaala J, Haapaniemi E, Kaste M, Tatlisumak T. Statins after ischemic stroke of undetermined etiology in young adults. Neurology 2011; 77:1931; discussion 1931. [DOI: 10.1212/wnl.0b013e31823c1560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
43
|
|
44
|
Putaala J, Haapaniemi E, Kurkinen M, Salonen O, Kaste M, Tatlisumak T. Silent brain infarcts, leukoaraiosis, and long-term prognosis in young ischemic stroke patients. Neurology 2011; 76:1742-9. [PMID: 21576692 DOI: 10.1212/wnl.0b013e31821a44ad] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate prognostic relevance of silent brain infarcts (SBIs) and leukoaraiosis (LA) in young patients with ischemic stroke. METHODS This observational cohort study included consecutive MRI-scanned patients aged 15 to 49 with first-ever ischemic stroke treated at Helsinki University Central Hospital (1994-2007) with long-term follow-up data available. Outcome measures were 1) nonfatal or fatal ischemic stroke, 2) composite vascular endpoint, and 3) death from any cause. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) and Bamford criteria allowed for stroke subtyping. Number of SBIs was categorized into none, single, or multiple. LA fell into groups of none, mild, or moderate to severe (validated visual rating scale). RESULTS The 655 patients (mean age 40.0 ± 8.0 years) included were followed for a mean 8.7 ± 3.8 years (survivors). Of the 86 (13.1%) patients with SBIs, 46 had single and 40 had multiple SBIs. In the 50 (7.6%) patients with LA, these changes were mild in 21 and moderate to severe in 29. In Cox regression analysis, multiple SBIs independently raised the risk for recurrent ischemic stroke (odds ratio 2.48; 95% confidence interval 1.24-4.94) adjusted for age, gender, risk factors, stroke etiology, and LA. After further adjustment for initial stroke severity, TOAST and Bamford subgroups, and presence of SBIs, moderate to severe LA increased the risk for death (3.43; 1.58-7.42). Neither SBIs nor LA associated with the composite vascular endpoint. CONCLUSIONS MRI-defined SBIs and LA are prognostically valuable in young adults after their first-ever ischemic stroke.
Collapse
Affiliation(s)
- J Putaala
- Department of Neurology, Helsinki University Central Hospital, Haartmaninkatu 4, FIN-00290, Helsinki, Finland.
| | | | | | | | | | | |
Collapse
|
45
|
Strbian D, Sairanen T, Meretoja A, Pitkaniemi J, Putaala J, Salonen O, Silvennoinen H, Kaste M, Tatlisumak T. Patient outcomes from symptomatic intracerebral hemorrhage after stroke thrombolysis. Neurology 2011; 77:341-8. [DOI: 10.1212/wnl.0b013e3182267b8c] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
46
|
Putaala J, Liebkind R, Gordin D, Thorn LM, Haapaniemi E, Forsblom C, Groop PH, Kaste M, Tatlisumak T. Diabetes mellitus and ischemic stroke in the young: Clinical features and long-term prognosis. Neurology 2011; 76:1831-7. [DOI: 10.1212/wnl.0b013e31821cccc2] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
47
|
Melkas S, Putaala J, Oksala NKJ, Pohjasvaara T, Oksala A, Kaste M, Karhunen PJ, Erkinjuntti T. Small-vessel disease relates to poor poststroke survival in a 12-year follow-up. Neurology 2011; 76:734-9. [PMID: 21339501 DOI: 10.1212/wnl.0b013e31820db666] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We sought to compare ultra-long-term poststroke survival in small-vessel disease (SVD) vs non-SVD subtype of stroke. METHODS We followed patients hospitalized with acute ischemic stroke (age 55-85) for 12 years. The diagnosis of SVD was based on the criteria of Trial of Org 10172 in Acute Stroke Treatment. A detailed medical history regarding the relevant risk factors was obtained. Stroke severity was assessed with the modified Rankin Scale (mRS) at 3 months. Influence of the SVD subtype of stroke was analyzed using Kaplan-Meier log-rank analysis with endpoint all-cause death, and Cox regression proportional hazards model was constructed for multivariate analysis. The association between SVD and causes of death (cardiac, brain-related, all other) was analyzed using Kaplan-Meier log-rank analysis. RESULTS Of the 486 patients, stroke etiology was SVD in 63 patients (13.0%). Median survival was 4.3 years for SVD and 7.9 years for non-SVD (p ≤ 0.001). In the stepwise Cox regression analysis adjusted for relevant confounders, independent predictors of death were SVD (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.06-2.41), advanced age (HR 1.07, 95% CI 1.05-1.09), stroke severity (mRS 3-5 vs 1-2; HR 2.02, 95% CI 1.58-2.58), smoking (HR 1.44, 95% CI 1.10-1.88), and cardiac failure (HR 1.53, 95% CI 1.14-2.06). SVD was associated with cardiac cause of death (p = 0.021). CONCLUSIONS In this well-characterized ischemic stroke cohort of patients aged 55-85 years with a 12-year follow-up, acute index stroke attributable to SVD was associated with poorer long-term survival and higher risk for cardiac death than other stroke subtypes.
Collapse
Affiliation(s)
- S Melkas
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Laurell K, Artto V, Bendtsen L, Hagen K, Kallela M, Meyer EL, Putaala J, Tronvik E, Zwart JA, Linde M. Migrainous infarction: a Nordic multicenter study. Eur J Neurol 2011; 18:1220-6. [PMID: 21414105 DOI: 10.1111/j.1468-1331.2011.03364.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Migrainous infarction (MI), i.e., an ischemic stroke developing during an attack of migraine with aura is rare and the knowledge of its clinical characteristics is limited. Previous case series using the International Classification of Headache Disorders (ICHD) included <10 cases which make conclusions less valid. This study aimed to describe characteristics and outcome of MI in a larger sample. METHODS We analyzed demographic data, risk factors, migraine medication, stroke localization, symptoms, and outcome in a sample of 33 patients with MI according to second edition of the ICHD criteria collected from seven Nordic headache clinics. RESULTS Amongst 33 patients with MI, there were 20 (61%) women and 13 (39%) men with the median age for stroke of 39 (range 19-76) years. Traditional risk factors for stroke were rare compared with Scandinavian young ischemic stroke populations. During the acute phase, 12 (36%) patients used ergotamines or triptans. Stroke was located in the posterior circulation in 27 (82%) patients and cerebellum was involved in 7 (21%). Except in two patients with brainstem infarctions, the outcome was favorable with total recovery or limited residual symptoms. CONCLUSIONS The prevalence of traditional risk factors was low and the infarctions were predominantly located in posterior circulation territory, supporting theories of migraine specific mechanisms. The outcome was in general favorable.
Collapse
Affiliation(s)
- K Laurell
- Department of Neuroscience, Neurology, Uppsala University Hospital, Uppsala, Sweden. mail:
| | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
|
50
|
Artto V, Metso TM, Metso AJ, Putaala J, Haapaniemi E, Wessman M, Färkkilä M, Kallela M, Tatlisumak T. Migraine with aura is a risk factor for cervical artery dissection: a case-control study. Cerebrovasc Dis 2010; 30:36-40. [PMID: 20431287 DOI: 10.1159/000313608] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 01/29/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cervical artery dissection (CAD) is the most common single etiology for stroke in young adults. Migraine, especially with aura (MA), is a known risk factor for ischemic stroke. The association between CAD and migraine was suggested based on a few small studies, but there are no large-scale case-control data, and the mechanisms are not yet clear. METHODS We compared the lifetime prevalence of migraine and migraine characteristics in 313 CAD patients with 313 healthy age- and sex-matched controls. We also analyzed clinical and radiological characteristics of CAD with respect to migraine subtypes to investigate whether clear phenotypical associations can be found that might help in the search for a possible shared genetic background for migraine and CAD. RESULTS Migraine was clearly more common in CAD patients than in controls (36 vs. 23%; OR 2.15; 95% CI 1.48-3.14), and the association was also highly significant for MA (23 vs. 12%; OR 2.41; 95% CI 1.53-3.80). Percentages of reported migraine history and MA of CAD patients vs. controls compared separately for both sexes were as follows: for women, migraine 54 vs. 35% (OR 2.30; 95% CI 1.28-4.13), MA 35 vs. 18% (OR 2.79; 95% CI 1.40-5.59); for men, migraine 27 vs. 16% (OR 2.02; 95% CI 1.23-3.31), MA 16 vs. 10% (OR 2.21; 95% CI 1.19-4.11). Over 60% of the CAD patients with still active migraine at the time of dissection reported later alleviation of migraine activity. CONCLUSION Our observations suggest that patients with CAD are a significant link between ischemic stroke and migraine. This connection may represent a common pathophysiological or genetic background, or both. Migraine activity appears to be alleviated by CAD.
Collapse
Affiliation(s)
- V Artto
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.
| | | | | | | | | | | | | | | | | |
Collapse
|