The frequency of alcohol consumption is associated with the stroke mortality

OBJECTIVES

The purpose of this study was to examine the association between the frequency of alcohol consumption and stroke mortality among eastern Finnish men.

MATERIAL AND METHODS

This study is a population-based sample of men with an average follow-up of 20.2 years. A total of 2609 men with no history of stroke at baseline participated in the study. During the follow-up, 66 deaths from stroke occurred.

RESULTS

After adjustment for systolic blood pressure, smoking, BMI, diabetes, and socioeconomic status, the relative risk (RR) among men who consumed alcohol <0.5 times per week was 0.70 (95% CI, 0.30-1.66; P = 0.419) compared with nondrinkers. Respective RR was 1.08 (95% CI, 0.51-2.27; P = 0.846) for men with alcohol consumption of 0.5-2.5 times per week and 2.44 (95% CI, 1.11-5.40; P = 0.027) for men who consumed alcohol >2.5 times per week after adjustment for risk factors. When the total amount of alcohol consumption (g/week) was taken into account with other covariates, RR was 0.71 (95% CI, 0.30-1.68; P = 0.437) for men with alcohol consumption <0.5 times per week and 1.16 (95% CI, 0.54-2.50; P = 0.704) among men who consumed alcohol 0.5-2.5 times per week. Among men who consumed alcohol >2.5 times per week compared with nondrinkers, RR was 3.03 (95% CI, 1.19-7.72; P = 0.020).

CONCLUSIONS

This study shows a strong association between the frequency of alcohol consumption and stroke mortality, independent of total amount of alcohol consumption. The risk of stroke death was the highest among men who consumed alcohol >2.5 times per week.

Hangover and the risk of stroke in middle-aged men

OBJECTIVES

The aim of this study was to examine the association between hangover and the risk of stroke.

MATERIAL AND METHODS

A population-based sample of men with an average follow-up of 15.7 years. 2466 men with no history of stroke at baseline participated. Two hundred and six strokes occurred, of which 167 were ischemic strokes.

RESULTS

The age-adjusted, relative risk (RR) for any stroke among men with ≥1 hangover per year was 2.33-fold (95% confidence interval (CI), 1.19-4.56; P = 0.013) relative to men without hangover, and 2.99-fold (95% CI, 1.52-5.86; P = 0.001) for ischemic stroke, respectively. After adjustment for age, smoking, high density lipoprotein (HDL)-cholesterol, LDL-cholesterol, BMI, SBP, myocardial ischemia during exercise, symptomatic coronary heart disease (CHD) and CHD in family, C-reactive protein, diabetes, and total alcohol consumption, the RR for any stroke was 1.94-fold (95% CI, 0.95-3.96; P = 0.070) and 2.58-fold (95% CI, 1.24-5.36; P = 0.011) for ischemic stroke among men with hangovers. Additional adjustment of atrial fibrillation and cardiac failure and risk was 2.45-fold (95% CI, 1.18-5.12; P = 0.017) for ischemic strokes.

CONCLUSION

This study shows that at least one hangover a year is related to an increased risk of ischemic stroke in men.

Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review

OBJECTIVES

Antiplatelet therapy (APT) promotes bleeding; therefore, APT might worsen outcome in patients with intracerebral hemorrhage (ICH). We performed a systematic review and meta-analysis to address the hypothesis that pre-ICH APT use is associated with mortality and poor functional outcome following ICH.

METHODS

The Medline and Embase databases were searched in February 2008 using relevant key words, limited to human studies in the English language. Cohort studies of consecutive patients with ICH reporting mortality or functional outcome according to pre-ICH APT use were identified. Of 2,873 studies screened, 10 were judged to meet inclusion criteria by consensus of 2 authors. Additionally, we solicited unpublished data from all authors of cohort studies with >100 patients published within the last 10 years, and received data from 15 more studies. Univariate and multivariable-adjusted odds ratios (ORs) for mortality and poor functional outcome were abstracted as available and pooled using a random effects model.

RESULTS

We obtained mortality data from 25 cohorts (15 unpublished) and functional outcome data from 21 cohorts (14 unpublished). Pre-ICH APT users had increased mortality in both univariate (OR 1.41, 95% confidence interval [CI] 1.21 to 1.64) and multivariable-adjusted (OR 1.27, 95% CI 1.10 to 1.47) pooled analyses. By contrast, the pooled OR for poor functional outcome was no longer significant when using multivariable-adjusted estimates (univariate OR 1.29, 95% CI 1.09 to 1.53; multivariable-adjusted OR 1.10, 95% CI 0.93 to 1.29).

CONCLUSIONS

In cohort studies, APT use at the time of ICH compared to no APT use was independently associated with increased mortality but not with poor functional outcome.

Modelling the Burden of Stroke in Finland until 2030

Background

It is well known that increasing age is the strongest risk factor of stroke. Therefore, it has been a common belief in many countries including Finland that the numbers of stroke patients will increase considerably during the next two decades because the population is rapidly ageing.

Methods

The FINMONICA and FINSTROKE registers operated in Finland in the Kuopio area and city of Turku from 1983 to 1997. The results showed that the incidence, mortality and case fatality of stroke declined significantly during that period. Importantly, it was established that the trends in incidence and mortality were also declining among the elderly (>74 years). We used these results to create a model for the entire country. The model was based on the trends present in these registers from Turku and Kuopio area and age-specific population projections up to the year 2030 that were obtained from Statistics Finland.

Results

In the year 2000, the number of new first stroke cases was estimated to be 11500. If the declining trend were to level off totally after the year 2000, the number of new strokes would be 20100 in the year 2030 due to the ageing of the population. It would be 12100 if the trend continued as favourable as during the years 1983–1997.

Conclusions

Ageing of the population will not inevitably increase the burden of stroke in Finland if the present declining trends are maintained, but the annual number of cases will almost double if the incidence remains at the level of the year 2000.

Exercise workload, cardiovascular risk factor evaluation and the risk of stroke in middle-aged men

OBJECTIVE

We investigated the prognostic significance of risk scores and exercise workload with respect to stroke. Background. There are no data on exercise workload combined with European Systematic Coronary Risk Evaluation (SCORE) in the prediction of stroke.

METHODS

Exercise workload was measured by exercise test with an electrically braked cycle ergometer performed at baseline. The study is based on a random population-based sample of 1639 men (42-60 years) without history of type 2 diabetes or atherosclerotic cardiovascular disease including coronary heart disease, stroke or claudication.

RESULTS

During an average follow-up of 16 years, a total of 97 strokes occurred, of which 71 were ischaemic strokes. Independent predictors for all strokes were European SCORE [for 1% increment, relative risk (RR): 1.12, 95% CI: 1.02 to 1.22, P=0.017), maximal workload (for 20 W increment, RR: 0.87, 95% CI: 0.80 to 0.95, P=0.003) and body mass index (for 5 kg m(-2) increment, RR: 1.08, 95% CI: 1.03 to 1.14, P=0.004), when adjusted for serum HDL, alcohol consumption, C-reactive protein, family history of coronary heart disease, exercise-induced ST changes and the use of medications for hypertension, dyslipidaemia or aspirin. The risk was 2.54-fold (95% CI: 1.27-5.09, P=0.008) for any strokes and 4.43-fold (95% CI 1.69-11.78, P=0.003) for ischaemic strokes amongst men with exercise capacity less than 162 W when compared with those with high exercise capacity over 230 W, after adjustment for risk factors.

CONCLUSIONS

Low exercise workload predicts an especially high risk for stroke in the presence of high risk SCORE.

Epileptogenesis after cortical photothrombotic brain lesion in rats

We investigated epileptogenesis after cortical photothrombotic stroke induced with Rose Bengal dye in adult Sprague-Dawley rats. To detect spontaneous seizures, video-electroencephalograms were recorded at 2, 4, 6, 8, and 10 months for 7-14 days (24 h/day). At the end, spatial and emotional learning and memory were assessed using the Morris water-maze and fear-conditioning test, respectively, and the brains were processed for histologic analysis. Seizures were detected in 18% of rats that received photothrombosis. The average seizure frequency was 0.39 seizures per recording day and mean seizure duration was 117 s. Over 60% of seizures occurred during the dark hours. Rats with photothrombotic lesions were impaired in the water-maze (P<0.05) but not in the fear-conditioning test as compared with controls. Histology revealed that lesion depth varied from cortical layers I to VI in photothrombotic rats with epilepsy. Epileptic rats had light mossy fiber sprouting in the inner molecular layer of the dentate gyrus both ipsilateral and contralateral to the lesion. This study extends the current understanding of epileptogenesis and functional impairment after cortical lesions induced by photothrombosis. Our observations support the hypothesis that photothrombotic stroke in rats is a useful animal model for investigating the mechanisms of post-stroke epileptogenesis.

Assessing the outcome of stroke: a comparison between MRI and clinical stroke scales

OBJECTIVES

To assess the correlation of diffusion-weighted (DWI) and perfusion-weighted imaging (PWI) findings with the severity of acute neurologic deficit and their ability to predict short and long-term clinical outcomes of stroke. The ability of DWI and PWI to predict the outcome was compared with the ability of clinical stroke scales to predict the outcome.

METHODS

Forty-eight patients with acute stroke underwent diffusion DWI and PWI on the first and eighth day after the ictus. Clinical and functional scales were carried out before each scan and 3 months after the stroke.

RESULTS

The volumes of both the DWI and the PWI lesions correlated well with the acute neurologic deficit and the final outcome. The first day PWI (r = 0.64) and the National Institutes of Health Stroke Scale (NIHSS) scores (r = 0.70) correlated well with the final outcome. However, in logistic regression analysis, only the NIHSS score at the acute stage was the only independent predictor of the long-term clinical outcome.

CONCLUSION

While the PWI and DWI lesion volumes correlated well with the outcome of the stroke, the imaging measurements did not improve the prognostic power over plain clinical stroke scale scores.

Cardiac Power During Exercise and the Risk of Stroke in Men

Background and Purpose— Low maximal oxygen uptake (VO 2max ) has been shown to predict the risk of stroke. However, VO 2max does not take into account the differences in cardiac afterload between subjects. The aim of this study was to examine the relationship of exercise cardiac power (ECP), defined as a ratio of VO 2max with peak systolic blood pressure (SBP) during exercise, with the risk for stroke.

Methods— Population-based cohort study with an average follow-up of 12 years from eastern Finland. A total of 1761 men with no history of stroke or coronary heart disease at baseline participated. Among these men, 91 strokes occurred, of which 69 were attributable to ischemic causes.

Results— The relative risk of any stroke in men with low ECP (<10.3 mL/mm Hg) was 2.7 (95% CI, 1.2 to 6.0; P =0.01; P =0.02 for the trend across the quartiles), and the relative risk for ischemic stroke was 2.7 (95% CI, 1.1 to 7.0; P =0.03; P =0.04 for trend across the quartiles) compared with men having high ECP (>14.3 mL/mm Hg) during exercise after adjusting for age, examination year, cigarette smoking, alcohol consumption, body mass index, diabetes, serum total cholesterol level, energy expenditure of physical activity, exercise-induced myocardial ischemia, and the use of antihypertensive medication. After further adjustment for resting SBP, results were statistically nonsignificant.

Conclusions— Low ECP provides noninvasive and easily available measure for stroke risk. One of the most potential explanations for the association between ECP and the increased risk of stroke is an elevated afterload and peripheral resistance indicated by elevated SBP.

Association of exercise-induced, silent ST-segment depression with the risk of stroke and cardiovascular diseases in men

BACKGROUND AND PURPOSE

There are few if any data on the prognostic importance of silent myocardial ischemia during exercise with regard to the risk of stroke and cardiovascular diseases (CVDs) among asymptomatic men. In this prospective study, we investigated the relation of silent myocardial ischemia and the risk of stroke and CVD death in men with and without conventional risk factors.

METHODS

The study sample included 1726 middle-aged men with no history of stroke, coronary heart disease, or atrial fibrillation at baseline. Silent myocardial ischemia was defined as a horizontal or downsloping ST-segment depression (>or=1 mm) during exercise electrocardiography. A total of 86 CVD-related deaths and 78 strokes occurred during an average follow-up of 10 years.

RESULTS

Men with silent ischemia during exercise had a 3.5-fold increased risk of CVD death and a 2.2-fold increased risk of stroke compared with men without silent ischemia, after adjusting for conventional risk factors. Silent ischemia during exercise was associated with a 3.8-fold (95% confidence interval [CI], 1.5 to 9.5) increased risk for CVD in smokers, a 3.9-fold (95% CI, 2.1 to 7.3) increased risk in hypercholesterolemic subjects, a 3.6-fold (95% CI, 1.9 to 6.8) increased risk in the hypertensives, and 3.8-fold (95% CI, 2.0 to 7.1) increased risk in overweight men. The respective relative risks for stroke were 3.8 (95% CI, 1.1 to 12.5), 3.5 (95% CI, 1.7 to 7.4), 3.4 (95% CI, 1.6 to 7.1), and 2.9 (95% CI, 1.4 to 6.1).

CONCLUSIONS

Exercise-induced silent myocardial ischemia is an important indicator of increased risk of stroke and CVD in men with other risk factors, such as smoking, hypercholesterolemia, hypertension, and being overweight.

Cutaneous electrical stimulation may enhance sensorimotor recovery in chronic stroke

OBJECTIVE

To investigate whether cutaneous electrical stimulation has a role in the enhancement of sensorimotor function in chronic stroke.

SUBJECTS AND SETTING

Fifty-nine patients with chronic stroke received cutaneous stimulation during their three-week-long inpatient rehabilitation. Thirty-two received active treatment in the paretic hand and eight received no-current placebo treatment in the paretic hand. Nineteen patients received active stimulation of the paretic foot. None received stimulation in both upper and lower limbs.

INTERVENTION

Cutaneous stimulation was delivered twice daily via a special glove/sock electrode.

MAIN OUTCOME MEASURES

Modified Motor Assessment Scale, 10-metre walking test, paretic limb function, limb skin sensation and somatosensory evoked potentials (SEP) were performed before and after the treatment.

RESULTS

Modified Motor Assessment Scale (p < 0.001), 10-metre walking test (p < 0.05), paretic hand function (p < 0.01), upper limb skin sensation (p < 0.01) and SEP normality classification of paretic upper limb (p < 0.01) and paretic lower limb (p < 0.5) improved significantly in the treatment group (n = 51) after three weeks of stimulation. When active hand treatment and placebo hand treatment were compared, a significant improvement in the sensory and motor function was observed only in the actively treated group.

CONCLUSIONS

Cutaneous stimulation had positive effects in the motor performance, limb sensation and the configuration of SEP of the paretic limb in chronic stroke patients.

Plasma vitamin C modifies the association between hypertension and risk of stroke

BACKGROUND AND PURPOSE

There are no prospective studies to determine whether plasma vitamin C modifies the risk of stroke among hypertensive and overweight individuals. We sought to examine whether plasma vitamin C modifies the association between overweight and hypertension and the risk of stroke in middle-aged men from eastern Finland.

METHODS

We conducted a 10.4-year prospective population-based cohort study of 2419 randomly selected middle-aged men (42 to 60 years) with no history of stroke at baseline examination. A total of 120 men developed a stroke, of which 96 were ischemic and 24 hemorrhagic strokes.

RESULTS

Men with the lowest levels of plasma vitamin C (<28.4 micromol/L, lowest quarter) had a 2.4-fold (95% CI, 1.4 to 4.3; P=0.002) risk of any stroke compared with men with highest levels of plasma vitamin C (>64.96 micromol/L, highest quarter) after adjustment for age and examination months. An additional adjustment for body mass index, systolic blood pressure, smoking, alcohol consumption, serum total cholesterol, diabetes, and exercise-induced myocardial ischemia attenuated the association marginally (relative risk, 2.1; 95% CI, 1.2 to 3.8; P=0.01). Adjustment for prevalent coronary heart disease and atrial fibrillation did not attenuate the association any further. Furthermore, hypertensive men with the lowest vitamin C levels (<28.4 micromol/L) had a 2.6-fold risk (95% CI, 1.52 to 4.48; P<0.001), and overweight men (> or =25 kg/m2) with low plasma vitamin C had a 2.7-fold risk (95% CI, 1.48 to 4.90; P=0.001) for any stroke after adjustment for age, examination months, and other risk factors.

CONCLUSIONS

Low plasma vitamin C was associated with increased risk of stroke, especially among hypertensive and overweight men.

Selegiline treatment facilitates recovery after stroke

OBJECTIVE

Selegiline (L-deprenyl) is a selective monoamine oxidase B (MAO-B) inhibitor used in the treatment of Parkinson's disease. In addition, it is thought to rescue neurons with a loss of target-derived trophic support. Several mechanisms have been proposed to explain these phenomena, such as the production of neurotrophic actions through astrocyte activation, reduction of free radical production, or the presence of antiapoptotic properties. The aim of this study was to investigate whether the systemic administration of selegiline facilitates recovery after a cerebral infarction in humans.

METHODS

This phase II study was randomized, double-blind, and placebo controlled. Selegiline, 5 mg, or matched placebo was given twice a day for 3 months. The drug therapy was started within 48 h after a hemispheric infarction in the territory of middle cerebral artery. There were 24 patients recruited. Twenty patients were followed up to 3 months or until their death, and they represent the efficacy analysis group. The primary efficacy parameters were Scandinavian Stroke Scale (SSS), Barthel Index (BI), and Fugl-Meyer Scale (FMS). Secondary parameters were Zung Self-Rating Depression Scale (ZDS) and 15-Dimensional Measure of Health Related Quality of Life test (15-D).

RESULTS

SSS improved statistically significantly from the baseline when compared with placebo (p = 0.019). The results were parallel among the other two primary efficacy variables (BI and FMS), showing a positive trend for selegiline, although they did not reach statistical significance. Similarly, in the analysis of the secondary efficacy variables, both the 15-D test and ZDS supported this positive trend in favor of selegiline, although no statistically significant differences between groups were found (p = 0.06 in 15-D test).

CONCLUSIONS

Selegiline seems to be beneficial after a cerebral infarction. This benefit may be due to the enhancement of the recovery process.

Differential effect of the alpha2-adrenoceptor antagonist, atipamezole, in limb-placing task and skilled forepaw use following experimental stroke

PURPOSE

Tbc present study compared tbc effect of chronic administration of the selective alpha2-adrenoceptor antagonist, atipamezole, on performance in behavioral tests that differ in motoric complexity in two experimental stroke models.

METHODS

Transient occlusion (120 min) of the middle cerebral artery (MCA) using the intraluminal method was used to produce corticostriatal infarcts and permanent occlusion of distal MCA by electrocoagulation was used to produce cortical infarcts. Chronic atipamezole treatment (1 mg/kg, s.c., once per day) was started 2 days after ischemia induction and continued until the end of the experiment, 35 days after ischemia induction. Behavioral performance of the operated rats was assessed 30 min after drug administration using the limb-placing test and Montoya's staircase test.

RESULTS

Atipamezole facilitated spontaneous recovery in the limb-placing task particularly in rats subjected to transient MCA occlusion. The analysis of retrieved pellets in Montoya's staircase test suggests that there is no recovery (Time effect, P > 0.05) in the use of the impaired forelimb (contralateral-to-lesion) following transient MCA occlusion, whereas there was some recovery following permanent MCA occlusion (Time effect, P < 0.001). The impairment was bilateral in rats subjected to transient MCA occlusion. Atipamezole treatment did not affect the use of the impaired forelimb to retrieve pellets following transient MCA occlusion, but there was a tendency to facilitate impaired forelimb use following permanent MCA occlusion (Time*Treatment interaction, P = 0.086).

CONCLUSION

Transient occlusion of the MCA produced a severe, long lasting, and bilateral deficit in skilled forelimb use. Permanent occlusion of the distal MCA was associated with less severe impairment, which was alleviated to some extent by administration of atipamezole. This is in contrast to spontaneous recovery and recovery-enhancing effects of atipamezole in the limb-placing test, particularly in the transient MCA occlusion model.

The EUROSTROKE cohorts: a short description and data analytical approach

This paper describes the design and methodology of the participating cohorts in the EUROSTROKE project. Information is given about the cohort sampling, its size, the follow up procedures and event classification. Information is also given about the measurement of the cardiovascular and cerebrovascular risk factors in each of the cohorts separately. The cohorts described are the Caerphilly study in Cardiff, United Kingdom; the Kuopio Ischaemic Heart disease study in Kuopio, Finland; the Portugal study in Coimbra, Portugal; the EPIC cohort in Athens, Greece; the Ilsa study from Firenze, Italy; the Rotterdam Study in Rotterdam, the Netherlands, and the Novosibirsk cohort in Novosibirsk, Russia.

Level of fibrinogen and risk of fatal and non-fatal stroke. EUROSTROKE: a collaborative study among research centres in Europe

BACKGROUND

It is well established that raised levels of fibrinogen increase the risk of coronary heart disease. For stroke, however, data are much more limited and restricted to overall stroke. This study investigated the association between fibrinogen and fatal, non-fatal, haemorrhagic and ischaemic stroke in three European cohorts participating in EUROSTROKE.

METHODS

EUROSTROKE is a collaborative project among ongoing European cohort studies on incidence and risk factors of stroke. EUROSTROKE is designed as a nested case-control study. For each stroke case, two controls were sampled. Strokes were classified according to MONICA criteria or reviewed by a panel of four neurologists. Recently, data on stroke and fibrinogen became available from cohorts in Cardiff (79 cases/194 controls), Kuopio (74/124), and Rotterdam (62/203). Results were adjusted for age, sex, smoking, and systolic blood pressure.

RESULTS

The risk of stroke gradually increased with increasing fibrinogen levels: the odds ratios per quartile increase were 1.08 (95% CI 0.63 to 1.84), 1.91 (1.12 to 3.26) and 2.78 (1.64 to 4.72), respectively. This association was similar for ischaemic (n=138) and haemorrhagic stroke (n=25). Associations between fibrinogen and stroke were similar across strata of smoking, diabetes mellitus, previous myocardial infarction, and HDL cholesterol. The odds ratio, however, tended to increase with increasing systolic blood pressure: from 1.21 among those with a systolic pressure <120 mm Hg to 1.99 among subjects with a systolic pressure of 160 mm Hg or above.

CONCLUSION

This analysis of the EUROSTROKE project indicates that fibrinogen is a powerful predictor of stroke. Results did not disclose a differential in this relation of fibrinogen and fatal or non-fatal stroke, or with type of stroke (ischaemic or haemorrhagic).

Gamma-glutamyltransferase and risk of stroke: the EUROSTROKE project

BACKGROUND

Alcohol consumption has been implicated in the aetiology of stroke. As data on alcohol consumption obtained by questionnaire are susceptible to misclassification, this study evaluated the association between gamma-glutamyltransferase (gamma-GT), as a marker for alcohol consumption, and fatal, non-fatal, haemorrhagic and ischaemic stroke in three European cohort studies, participating in EUROSTROKE.

METHODS

EUROSTROKE is a collaborative project among ongoing European cohort studies on incidence and risk factors of stroke. EUROSTROKE is designed as a nested case-control study. For each stroke case, two controls were sampled. Strokes were classified according to MONICA criteria or reviewed by a panel of four neurologists. At present, data on stroke and gamma-GT were available from cohorts in Cardiff (57 cases), Kuopio (66 cases), and Rotterdam (108 cases).

RESULTS

An increase in gamma-GT of one standard deviation (28.7 IU/ml) was associated with an age and sex adjusted 26% (95% CI 5 to 53) increase in risk of stroke. Adjustment for confounding variables such as drug use, history of myocardial infarction, total cholesterol, and diabetes mellitus did not materially attenuate the association. The risk of haemorrhagic stroke increased linearly with increase in gamma-GT. The association for cerebral infarction was not graded: the risk increased beyond the first quartile, and remained increased. The association of gamma-GT with stroke was significantly stronger among subjects without diabetes mellitus compared with subjects with diabetes mellitus (no association observed).

CONCLUSION

This EUROSTROKE analysis showed that an increased gamma-GT, as a marker of alcohol consumption, is associated with increased risk of stroke, in particular haemorrhagic stroke.

Left ventricular hypertrophy and risk of fatal and non-fatal stroke. EUROSTROKE: a collaborative study among research centres in Europe

BACKGROUND

This study investigated the association between electrocardiographically assessed left ventricular hypertrophy (LVH) and fatal, non-fatal, haemorrhagic and ischaemic stroke in four European cohorts participating in EUROSTROKE.

METHODS

EUROSTROKE is a collaborative project among ongoing European cohort studies to investigate differences in incidence of, and risk factors for, stroke between countries. EUROSTROKE is designed as a nested case-control study. For each stroke case, two controls were sampled. Strokes were classified according to MONICA criteria or reviewed by a panel of four neurologists. LVH was assessed according to the Minnesota code or the automated diagnostic MEANS classification system. For this analysis, data on LVH and stroke were available from cohorts in Cardiff (84 cases/200 controls), Kuopio (60/116), Rotterdam (114/334), and Novosibirsk (62/168). Results are adjusted for age and sex.

RESULTS

LVH was associated with a twofold increased risk of stroke (odds ratio 2.1 (95% CI 1.3 to 3.5). The risk was particularly pronounced for fatal stroke (4.0 (95% CI 2.1 to 7.9)), whereas the risk was non-significantly increased for non-fatal stroke (1.5 (95% CI 0.8 to 2.7)). The increased risk was more pronounced in smokers: for total stroke 3.5 (95% CI 1.5 to 8.1) versus 1.6 (95% CI 0.8 to 3.1) in non-smokers. Adjustment for systolic blood pressure and body mass index attenuated the associations. LVH was not preferentially associated with a particular type of stroke, although the association with cerebral infarction was stronger.

CONCLUSION

This analysis of the EUROSTROKE project indicates that LVH assessed by electrocardiogram is a predictor of stroke. The association seems to be stronger for fatal stroke than for non-fatal stroke and is more pronounced in smokers.

Prediction of stroke in the general population in Europe (EUROSTROKE): Is there a role for fibrinogen and electrocardiography?

BACKGROUND

To decide whether a person with certain characteristics should be given any kind of intervention to prevent a cardiovascular event, it would be helpful to classify subjects in low, medium and high risk categories. The study evaluated which well known cerebrovascular and cardiovascular correlates, in particular fibrinogen level and ECG characteristics, are able to predict the occurrence of stroke in men of the general population using data from three European cohorts participating in EUROSTROKE.

METHODS

EUROSTROKE is a collaborative project among ongoing European population based cohort studies and designed as a prospective nested case-control study. For each stroke case two controls were sampled. Strokes were classified according to MONICA criteria or reviewed by a panel of four neurologists. Complete data were available of 698 men (219 stroke events) from cohorts in Cardiff (84 cases/200 controls), Kuopio (74/148) and Rotterdam (61/131). Multivariable logistic regression modeling was used to evaluate which information from history, physical examination (for example, blood pressure), blood lipids, and fibrinogen and ECG measurements independently contributed to the prediction of stroke. The area under receiver operating characteristic curve (ROC area) was used to estimate the predictive ability of models.

RESULTS

Independent predictors from medical history and physical examination were age, stroke history, medically treated hypertension, smoking, diabetes mellitus and diastolic blood pressure. The ROC area of this model was 0.69. After validating and transforming this model to an easy applicable rule, 40% of all future stroke cases could be predicted. Adding pulse rate, body mass index, blood lipids, fibrinogen level and ECG parameters did not improve the classification of subjects in low, medium and high risk. Results were similar when fibrinogen was dichotomised at the upper tertile or quintile.

CONCLUSION

In the general male population the future occurrence of stroke may be predicted using easy obtainable information from medical history and physical examination. Measurement of pulse rate, body mass index, blood lipids, fibrinogen level and ECG characteristics do not contribute to the risk stratification of stroke and have no value in the screening for stroke in the general male population.

Total and HDL cholesterol and risk of stroke. EUROSTROKE: a collaborative study among research centres in Europe

BACKGROUND

Controversy remains on the relation between serum lipids levels and stroke risk. This paper investigated the association of total and HDL cholesterol level to fatal and non-fatal, and haemorrhagic and ischaemic stroke in four European cohorts participating in EUROSTROKE.

METHODS

EUROSTROKE is a collaborative project among ongoing European cohort studies on incidence and risk factors of stroke. EUROSTROKE is designed as a nested case-control study. For each stroke case, two controls were sampled. Strokes were classified according to MONICA criteria or reviewed by a panel of four neurologists. At present, data on stroke and risk factors were available from cohorts in Cardiff (84 cases), Kuopio (74 cases), Rotterdam (157 cases), and Novosibirsk (79 cases).

RESULTS

Pooled analyses showed no significant association between total cholesterol and risk of stroke (odds ratio for increase of 1 mmol/l in cholesterol of 0.98 (95% CI 0.88 to 1.09)). Analyses for haemorrhagic stroke and cerebral infarction revealed odds ratios of 0.80 (95% CI 0.61 to 1.05) and 1.06 (95% CI 0.94 to 1.19), respectively. The association of HDL cholesterol to stroke was different in men compared with women. In men, there was a general trend towards a lower risk of stroke with an increase in HDL (odds ratio per 1 mmol/l increase in HDL cholesterol 0.68 (95% CI 0.40 to 1.16)). In women, however, an increase in HDL was associated with a significant increased risk of non-fatal stroke and of cerebral infarction (odds ratios of 2.46 (95% 0.1.20 to 5.04) and 2.52 (95% CI 1.15 to 5.50), respectively. The difference between men and women in the association of HDL with stroke seemed to differ mainly in smokers and never smokers, but not among ex smokers.

CONCLUSION

This analysis of the EUROSTROKE project could not disclose an association of total cholesterol with fatal, non-fatal, haemorrhagic or ischaemic stroke. HDL cholesterol however, seemed to be related to stroke differently in men than in women.

Effects of supporting community-living demented patients and their caregivers: a randomized trial

OBJECTIVES

To determine whether community care of demented patients can be prolonged by means of a 2-year support program based on nurse case management.

DESIGN

Randomized controlled intervention study with 2-year follow-up.

SETTING

Demented patients entitled to payments from the Social Insurance Institution for community care, in five municipalities in eastern Finland.

PARTICIPANTS

One hundred demented patients, age 65 and older, living at home with the primary support of informal caregivers, allocated at random to the intervention (n = 53) or control group (n = 47).

INTERVENTION

Intervention patients and their caregivers were provided with a 2-year intervention program of systematic, comprehensive support by a dementia family care coordinator.

MEASUREMENTS

Time to institutionalization (period in community care) from enrollment of patients in the study to their placement in long-term institutional care.

RESULTS

During the first months, the rate of institutionalization was significantly lower in the intervention group than in the control group (P = .042), but the benefit of the intervention decreased with time (P = .028). Estimated probability of staying in community care up to 6, 12, and 24 months was 0.98, 0.92, and 0.63 in the intervention group and 0.91, 0.81, and 0.68 in the control group, respectively. Results also suggest that the intervention used in the study might be especially beneficial to patients with severe dementia and those with problems threatening the continuity of community care.

CONCLUSIONS

The placement of demented patients in long-term institutional care can be deferred with the support of a dementia family care coordinator. However, by the end of the 2-year intervention, the number of patients institutionalized was similar in the intervention and control group. It seems to be beneficial to direct this type of intensive support at severely demented patients and their caregivers. On the basis of our experiences, we suggest that intervention by a dementia family care coordinator should be targeted especially at patients with problems threatening the continuity of community care.

Effects of dexmedetomidine after transient and permanent occlusion of the middle cerebral artery in the rat

Increased sympathetic tone is a consequence of cerebral ischemia. Although the role of catecholamines in ischemic damage is still unclear, in some experimental ischemia models alpha2-adrenergic agonism has proved to be neuroprotective. In the present work we have compared the effects of transient and permanent middle cerebral artery occlusion (MCAO) on the infarct volume, and, also, examined whether a selective alpha2-adrenergic receptor agonist, dexmedetomidine (9 microg/kg or 15 microg/kg i.v.), is able to reduce ischemic damage after transient or permanent MCAO in rats. Permanent MCAO led to a significantly larger infarct volume than transient occlusion (p < 0.05). The rats receiving the higher dose of dexmedetomidine were detectected to have smaller (statistically non-significant) infarct volume in the cortex (30.9%) and in the striatum (20.3%) after transient occlusion. Additionally, dexmedetomidine caused significant variations in the physiological parameters.

Socioeconomic inequalities in the incidence, mortality and prognosis of subarachnoid hemorrhage: the FINMONICA Stroke Register

Low socioeconomic status (SES) is associated with increased mortality from stroke, but usually no distinction is made between stroke subtypes. We analyzed the relationship of SES with mortality and morbidity of subarachnoid hemorrhage (SAH). In the FINMONICA Stroke Register, 956 consecutive SAH events were recorded during 1983-1992 in patients aged 25-74 years. We used taxable income stratified into three categories, low, middle, and high, as an indicator of SES. The age-standardized incidence of SAH among men and women aged 25-44 years was approximately three times higher in the low-income group than in the high-income group. In older individuals, differences between the income groups were less pronounced. Among survivors of the acute stage, a poorer prognosis was observed in patients with low income than in those with high income. In conclusion, there is a clear excess mortality and morbidity of SAH in young individuals with low income, particularly among men.

Systolic blood pressure response to exercise stress test and risk of stroke

BACKGROUND AND PURPOSE

Systolic blood pressure (SBP) during exercise has been found to predict a future diagnosis of hypertension, coronary heart disease, and cardiovascular disease death. No studies have been conducted to show a relationship between SBP during exercise test and stroke. The aim of the present study was to study the associations between SBP rise, percent maximum SBP at 2 minutes after exercise, and the risk of stroke in a population-based sample of men with no prior coronary heart disease.

METHODS

SBP was measured every 2 minutes during and after the exercise test. The subjects were a population-based sample of 1026 men without clinical coronary heart disease, antihypertensive medication, or prior stroke at baseline. During an average follow-up of 10.4 years, there were 46 cases of stroke (38 ischemic strokes).

RESULTS

Men with SBP rise >19.7 mm Hg per minute of exercise duration had a 2.3-fold increased risk of any stroke and a 2.3-fold increased risk of ischemic stroke compared with men whose SBP rise was <16.1 mm Hg/min. Similarly, percent maximum SBP at 2 minutes after exercise (SBP at 2 minutes' recovery divided by maximum SBP) was associated (highest tertile) with a 4.6-fold increased risk of any stroke and a 5.2-fold increased risk of ischemic stroke.

CONCLUSIONS

SBP rise during exercise and percent maximum SBP at 2 minutes after exercise were directly and independently associated with the risk of all stroke and ischemic stroke. Exercise SBP testing may be recommended as an additional tool in the prediction of future stroke.

Socioeconomic differences in the incidence, mortality and prognosis of intracerebral hemorrhage in Finnish Adult Population. The FINMONICA Stroke Register

We examined the association of socioeconomic status (SES) with the incidence, mortality and case fatality of intracerebral hemorrhage (ICH). During 1982-1992, 909 ICH events were registered among persons aged 25-74 years. Taxable income was used as an indicator of SES. It was stratified into three categories: low, middle and high. The age-standardized incidence and mortality of ICH were significantly higher in the low- than in the high-income group in both genders. Among men aged 25-59 years, the adjusted odds ratio (OR) of ICH death within 1 year after the onset of the event was twice as high in the low-income group as in the high-income group (OR = 2.12, 95% confidence interval 1.02-4.40). In conclusion, marked socioeconomic differences were found in the incidence and mortality of ICH, in particular among working aged men.

Diffusion and perfusion MR imaging in acute ischemic stroke: a comparison to SPECT

Diffusion (DWI) and perfusion (PWI) magnetic resonance imaging are relatively new methods of clinical imaging that probably can detect infarcted (DWI) and hypoperfused but still salvageable tissue (PWI) in acute human stroke. Forty-six acute stroke patients were imaged within 24 h of ictus, on the second day and after a week. SPECT was also performed on 23 patients in the acute phase (first or second day). On the first day, mean volume of hypoperfused tissue was significantly greater (P<0.001) than the infarcted tissue. The initial hypoperfusion volume correlated significantly with the final infarct size (P<0.001). The initial perfusion-diffusion mismatch correlated significantly with the infarct growth (P< or =0.001). The hypoperfusion volumes measured from PWI and SPECT correlated significantly (P<0.001). In conclusion, combined DWI and PWI is a powerful tool in evaluating the hemodynamics of acute ischemic stroke and can predict the infarct growth during 1 week.

Socioeconomic status and ischemic stroke: The FINMONICA Stroke Register

BACKGROUND AND PURPOSE

It has been shown that low socioeconomic status is associated with death from stroke. More-detailed data have, however, remained scanty. The purpose of the present study was to examine the association of socioeconomic status with ischemic stroke. Besides mortality, we analyzed the incidence, case-fatality ratio, and prognosis of ischemic stroke events.

METHODS

Our population-based study included 6903 first stroke events registered by the FINMONICA Stroke Register in 3 areas of Finland during 1983 to 1992. Indicators of socioeconomic status, such as taxable income and education, were obtained by record linkage of the stroke register data with files of Statistics Finland.

RESULTS

Incidence, case-fatality ratio, and mortality rates for ischemic stroke were all inversely related to income. Furthermore, 28 days after the onset of symptoms, a greater proportion of patients with low income than of those with high income was still in institutionalized care and/or in need of help for their activities of daily living. Population-attributable risk of the incidence of first ischemic stroke due to low socioeconomic status was 36% for both sexes. For the death from first ischemic stroke, it was 56% for both sexes.

CONCLUSIONS

Persons with low socioeconomic status have considerable excess rates of morbidity and mortality from ischemic stroke in Finland. A reduction in this excess could markedly decrease the burden of ischemic stroke to the society and thus constitute an important public health improvement.

Stress-induced blood pressure reactivity and incident stroke in middle-aged men

BACKGROUND AND PURPOSE

Exaggerated blood pressure reactivity to stress is associated with atherosclerosis and hypertension, which are known stroke risk factors, but its relation to stroke is unknown. Previous work also indicates that the association between reactivity and cardiovascular diseases may be influenced by socioeconomic status.

METHODS

The impact of blood pressure reactivity and socioeconomic status on incident stroke was examined in 2303 men (mean age, 52.8+/-5.1 years) from a population-based, longitudinal study of risk factors for ischemic heart disease in eastern FINLAND: Reactivity was calculated as the difference between blood pressure measured during the anticipatory phase of an exercise tolerance test (before exercise) and resting blood pressure, measured 1 week earlier. Mean systolic reactivity was 20 mm Hg (+/-15.9), and mean diastolic reactivity was 8.6 mm Hg (+/-8.5). Socioeconomic status was assessed as years of education. One hundred thirteen incident strokes (90 ischemic) occurred in 11.2 (+/-1.6) years of follow-up.

RESULTS

Men with exaggerated systolic reactivity (>/=20 mm Hg) had 72% greater risk of any stroke (relative hazard ratio [RH], 1.72; 95% CI, 1.17 to 2.54) and 87% greater risk of ischemic stroke (RH, 1.87; 95% CI, 1.20 to 2.89) relative to less reactive men. Moreover, men who were high reactors and poorly educated were nearly 3 times more likely to suffer a stroke than better educated, less reactive men (RH, 2.90; 95% CI, 1.66 to 5.08). Adjustment for stroke risk factors had little impact on these associations. Diastolic reactivity was unrelated to stroke risk.

CONCLUSIONS

Excessive sympathetic reactivity to stress may be etiologically important in stroke, especially ischemic strokes, and low socioeconomic status confers added risk.

Low serum lycopene concentration is associated with an excess incidence of acute coronary events and stroke: the Kuopio Ischaemic Heart Disease Risk Factor Study

A number of epidemiological studies have shown an association between beta-carotene and the risk of cardiovascular diseases, whereas only a few studies are available concerning the association of lycopene with the risk of coronary events, and no studies have been undertaken concerning lycopene and stroke. Thus, we tested the hypothesis that low serum levels of lycopene are associated with increased risk of acute coronary events and stroke in middle-aged men previously free of CHD and stroke. The subjects were 725 men aged 46-64 years examined in 1991-3 in the Kuopio Ischaemic Heart Disease Risk Factor Study. Forty-one men had either a fatal or a non-fatal acute coronary event or a stroke by December 1997. In a Cox' proportional hazard's model adjusting for examination years, age, systolic blood pressure and three nutritional factors (serum folate, beta-carotene and plasma vitamin C), men in the lowest quarter of serum lycopene levels (< or =0.07 micromol/l) had a 3.3-fold (95 % CI 1.7, 6.4, risk of acute coronary events or stroke compared with the others. Our study suggests that a low serum level of lycopene is associated with an increased risk of atherosclerotic vascular events in middle-aged men previously free of CHD and stroke.

An alpha(2)-adrenergic antagonist, atipamezole, facilitates behavioral recovery after focal cerebral ischemia in rats

Previous studies suggest that enhanced noradrenergic neurotransmission promotes functional recovery following cerebral lesions. The present study investigated whether systemic administration of an alpha(2)-adrenergic antagonist, atipamezole, facilitates recovery following transient focal cerebral ischemia in rats. The effect of atipamezole therapy on recovery from ischemia was compared with the effect of enriched-environment housing in rats. Ischemia was induced by occlusion of the right middle cerebral artery (MCA) for 120 min using the intraluminal filament model. Daily atipamezole treatment (1 mg/kg, subcutaneously) was started on day 2 after ischemia induction and drug administration stopped after 10 days. Another group of rats was housed in an enriched environment from day 2 following ischemia induction until the end of the experiment. Several different behavioral tests were used to measure functional recovery during the 26 days following the induction of focal cerebral ischemia. There was improved performance in the limb-placing test from the beginning of atipamezole treatment to day 8, and in wheel-running in the foot-slip test on days 2 and 4. Enriched-environment housing facilitated recovery in the foot-slip test in a later phase of the test period (days 8 to 10). Discovery of a hidden platform in a water-maze task was also facilitated in rats housed in the enriched environment, but this was probably due to the increased swimming speed of these rats. The present data suggest that the alpha(2)-adrenergic antagonist, atipamezole, facilitates sensorimotor recovery after focal ischemia, but has no effect on subsequent water-maze tests assessing spatial learning and memory, when assessed 11 days after the cessation of drug administration.

Systematic intervention for supporting community care of elderly people after a delirium episode

OBJECTIVE

To investigate the effects of a systematic intervention with a case manager concept and rehabilitation periods compared to standard aftercare in elderly community-dwelling patients discharged from the hospital after a delirium episode.

DESIGN

Before/after intervention cohort study with 3-year follow-up.

SETTINGS

Acute geriatric wards of a city hospital and a private rehabilitation center.

SUBJECTS AND METHODS

The intervention group consisted of 51 community-dwelling people over 65 years of age without severe underlying disorders, who were consequently admitted as emergency cases to the hospital because of a delirious state or who were delirious immediately after admission. The intervention included continuous support and counseling by a nurse specialist and rehabilitation periods at a rehabilitation center. The control group consisted of 51 age- and gender-matched patients admitted to the same hospital for delirium fulfilling the same inclusion and exclusion criteria during preceding years. The main outcome measures were duration of community care, the use of long-term institutional care, the use of short-term hospitalizations during the follow-up, and the death of the patients.

RESULTS

Delirium even in the healthy community-dwelling subjects indicated a poor prognosis. After 3 years, 18 patients (35%) from the intervention group and 9 patients (18%) from the controls were in community care. The mean duration of community care was 671 days in the intervention group and 503 days in the control group, p = .025. A reduction of 19 years was achieved in the cumulative time spent in long-term institutionalized care. The use of short-duration hospitalization was similar in both groups.

CONCLUSION

The institutionalization of elderly patients after a delirious state could be delayed using rehabilitation periods and systematic intervention with the case manager concept.

Enriched-environment housing increases neuronal Fos-staining in the dentate gyrus after a water maze spatial learning task

The present study examined whether housing in an enriched environment affects hippocampal function in responding to the challenge of a spatial water maze task in naive rats and following transient global ischemia. The enriched-environment housing was used for 11 days and was instituted the day after the induction of 20-min ischemia. Thereafter, the rats were tested in the water maze. The function of hippocampal neurons was assessed by Fos-immunostaining in ischemic and sham-operated rats 3 h after water maze testing. Rats housed in an enriched environment had an increased number of Fos-positive neurons per section in the granule cell layer of the dentate gyrus compared to rats housed individually in standard cages. This increase was observed in both ischemic and sham-operated rats. The experimental groups showed no differences in the number of Fos-positive cells in different hippocampal areas when the rats were placed in the enriched environment for the same period without the learning task. These results suggest that the number of neurons responding with altered gene expression in the dentate gyrus is increased in rats housed in an enriched environment following training in a water maze task. The altered gene expression is also preserved in ischemic rats.

The neuroprotective effects of (-)deprenyl in the gerbil hippocampus following transient global ischemia

(-)Deprenyl (selegeline) is a monoamine oxidase B (MAO-B) inhibitor, but it also exerts several effects independent of MAO-B inhibition. For example, it has been shown to improve neuronal survival in different neurodegenerative models. In the present study, we have tested whether (-)deprenyl attenuates the neuronal damage in the hippocampus that is induced in a model of transient global ischemia in gerbils. (-)Deprenyl was administered 1) at a low daily dose starting two weeks before occlusion, 2) at a single high dose administered 3h after occlusion, or 3) at a low daily dose for one or two weeks after occlusion. A nonsignificant trend of reduced neuronal damage in the hippocampal CA1 area was seen in all experimental groups treated with (-)deprenyl, regardless of the timing of treatment. The results together with previous evidence suggest that (-)deprenyl may protect CA1 neurons from ischemia-induced delayed death by several possible mechanisms, including the suppression of oxidative stress and apoptotic processes.

Selegiline combined with enriched-environment housing attenuates spatial learning deficits following focal cerebral ischemia in rats

Selegiline (l-deprenyl) is an irreversible monoamine oxidase B (MAO-B) inhibitor that is suggested to have neuroprotective and neuronal rescuing properties. The present study investigated whether systemic administration of selegiline facilitates behavioral recovery after transient focal cerebral ischemia in rats using a combination of different behavioral tests (limb placing, foot slip, water maze, and Montoya's staircase test) to measure the outcome of recovery. Selegiline (0.5 mg/kg, SC) or 0.9% NaCl was administered once a day, beginning on the second day after induction of ischemia and continuing for 30 days. Selegiline administration combined with enriched-environment housing attenuated ischemia-induced spatial learning deficits in a water-maze task and enhanced performance of both the contralateral affected and ipsilateral nonaffected forelimbs in a staircase test. Selegiline administration alone was not beneficial in any of the tests. Subsequent histologic examination revealed that the infarct volumes were not different between the experimental ischemic groups. Thus, these results suggest that selegiline combined with enriched-environment housing reduces behavioral and cognitive deficits without affecting infarct size.

Delirium in elderly people without severe predisposing disorders: etiology and 1-year prognosis after discharge

BACKGROUND

The etiologic factors of delirium have been frequently studied in hospitalized elderly patients who usually have an underlying disorder, i.e., hip fracture or dementia predisposing to delirium. The etiologic factors of delirium and prognosis in healthy elderly remain unstudied. The aim of our study was to detect the primary and additional etiologic factors contributing to delirium among community-dwelling healthy elderly people without predisposing disorders to delirium and to evaluate 1-year prognosis after discharge to home.

METHOD

The study subjects consisted of 51 community-dwelling people over 65 years of age, without severe underlying disorders predisposing to delirium, admitted consecutively to the hospital because of a delirious state. The diagnosis of delirium was based on the DSM-III-R criteria. After discharge to home, the subjects were followed up for 1 year.

RESULTS

The most important primary causes of delirium were infections in 22 cases (43%) and cerebrovascular attacks in 13 cases (25%). After the 1-year follow-up period, 10 patients (20%) had been taken into long-term care and 5 patients (10%) had died.

DISCUSSION

The plausible etiologic factor of delirium was detected in all cases. Among healthy elderly people, infections and cerebrovascular attacks were the most important etiologic factors for delirium. After discharge to home, 30% of the patients had to be taken into long-term care or had died within 1 year of the delirium.

MAO-B inhibition by a single dose of l-deprenyl or lazabemide does not prevent neuronal damage following focal cerebral ischaemia in rats

The present study investigated the effect of postischaemic infusion of an irreversible monoamine oxidase B (MAO-B) inhibitor, l-deprenyl, an equipotent dose of a reversible MAO-B inhibitor, lazabemide, or 0.9% NaCl on infarct volumes following focal cerebral ischaemia in rats. The drug doses (0.3 mg/kg) were selected to induce selective MAO-B inhibition (45-55%), but not MAO-A inhibition. The infarct volumes in the cortex or in the striatum did not differ between the experimental groups 72 hr after transient occlusion of the middle cerebral artery, which suggests that during ischaemia/reperfusion, suppressed oxidative stress by partial MAO-B inhibition or MAO-B independent mechanisms such as induction of trophic factors, does not protect against ischaemia/reperfusion damage.