Risk of stroke in women using levonorgestrel-releasing intra-uterine device (IUD) for contraception

Background: The commonly used combined hormonal contraceptives with progestins and ethinylestradiol are associated with an increased risk of ischemic stroke (IS). Progestin-only preparations, including levonorgestrel-releasing intra-uterine devices (LG-IUD), are not associated with an increased risk, and in smaller studies, the risk is even reduced. The risk of intracerebral hemorrhage (ICH) has never been investigated. We studied the risk of IS and ICH in women using LG-IUDs compared to women not using hormonal contraceptives. Methods: In this Danish historical cohort study (2004-2021) we followed non-pregnant women (18-49 years) registering incident IS and ICH in relation to use of LG-IUD/non-use of hormonal contraceptives utilizing Danish high-quality registries with nation-wide coverage. Poisson regression models adjusting for age, ethnicity, education, calendar-year, and medication use for risk factors were applied. Results: A total of 1,681,611 non-pregnant women contributed 11,971,745 person-years (py) of observation. Mean age at inclusion was 30.0 years; mean length of follow-up was 7.1 years; 2916 women (24.4 per 100,000 py) had IS; 367 (3.1 per 100,000 py) had ICH. Of these 364,784 were users of LG-IUD contributing 1,720,311 py to the investigation; mean age at start of usage was 34.6 years. Non-users of hormonal contraceptives contributed 10,251,434 py; mean age at inclusion was 30.0 years. Incidence rate of IS/ICH among LG-IUD users was 19.2/3.0 and among non-users it was 25.2/3.1 per 100,000 py. After adjustment incidence rate ratio for IS was 0.78 (CI: 0.70; 0.88), and for ICH it was 0.94 (CI: 0.69; 1.28). Conclusions:Use of LG-IUD was associated with a 22% lower incidence rate of IS without raising incidence rate of ICH. The finding raises the question of whether levonorgestrel, in addition to its contraceptive properties, could have the potential to prevent IS.

Absolute risk of ischemic and hemorrhagic stroke in Danish women using oral contraceptives

OBJECTIVE

Uncertainty exists for the absolute risk of ischemic and hemorrhagic stroke in users of oral contraceptives (OCs). Estimates greatly vary between countries. In Denmark, absolute risk of ischemic stroke (IS) is estimated to be 21 per 100,000 person-years. Risk of cerebral hemorrhage (CH) is unknown. Using the Danish Stroke Registry, we investigated absolute risk of IS and CH in users of OC.

MATERIAL AND METHODS

For the Danish female population aged 15-49 years during 2003-2011, we obtained information on hospital admission for IS and CH and current use of OC from Danish nationwide registries. We defined current use of OC as redeeming at least two OC prescriptions within the previous year.

RESULTS

The Danish female population years 2003-2011 consisted mean of 1,246,142 women per year. Of these, 29.6% were OC users. In the study period, OC users had 291 IS and 14 CH. Absolute risk of IS in OC users was 8.8 per 100,000 person-years and of CH it was 0.4 per 100,000 person-years.

CONCLUSIONS

In OC users, absolute risk of IS was 8.8 per 100,000 person-years. This is more than half that of the risk previously assumed in Denmark. Risk of CH in OC users was very low and 0.4 per 100,000 person-years.

Types of occult cancer in stroke and the relation to smoking

OBJECTIVES

Stroke is associated with a higher risk of occult cancer. We studied the types of occult cancer most often associated with stroke.

MATERIALS AND METHODS

All patients with incident stroke in Denmark 2003-2015 were identified through the Danish Stroke Registry (n = 85 893) and matched 1:10 on age and sex to the Danish background population without history of stroke (n = 858 740). Linking data to the Danish Cancer Registry, we determined the prevalence of occult cancer in stroke defined as the event of previously unknown cancer during a one-year follow-up in the stroke and the background population. We stratified cancers into the 15 most common cancers and into cancers related to and not related to smoking.

RESULTS

Prevalence (per 1000 person-years; stroke/background population) of smoking-related occult cancers (lung, colon, bladder rectum, pancreas, kidney, stomach, and head and neck) was 13.3/8.1 (P < .01) and of cancers not related to smoking (prostate, breast, melanoma, non-Hodgkin lymphoma, ovary, endometrial) it was 6.6/6.2 (P > .05). Among men with stroke prostate (5.8), lung (5.7), and colon cancers (2.9) were most frequent; among women, it was lung (4.7), breast(3.5), and colon cancer(2.8). Among men in the background population, prostate(5.4), lung (3.0), and colon cancers (2.1) were most frequent. Among women, it was breast (3.7), lung(2.1), and colon cancers (1.9).

CONCLUSION

Stroke patients' increased risk of occult cancer was predominantly for smoking-related cancers while there was no higher risk for the most frequent cancers unrelated to smoking, that is, prostate and breast cancers. Lung cancer is the dominant type of occult cancer in stroke.

Occult primary brain cancers manifesting in the aftermath of ischaemic and haemorrhagic stroke

Introduction

Symptoms of occult brain cancer may mimic stroke. Misdiagnosis may lead to improper treatment and delayed diagnosis. We characterised strokes associated with occult primary brain cancer and determined risk that ischaemic and haemorrhagic strokes are associated with occult primary brain cancer.

Patients and methods

All patients with incident stroke in Denmark 2003-2015 were identified through the Danish Stroke Registry (n = 85,893) and matched 1:10 on age and sex to the Danish background population without a stroke history (n = 858,740). This cohort was linked to the Danish Cancer Registry and prevalence of occult primary brain cancer defined as the event of previously unknown primary brain cancer during a one-year follow-up was estimated. We used Cox regression models to study risk of occult primary brain cancer in comparison to the background population.

Results

Of 77,484 patients with ischaemic strokes, 39 (1 in 2000) were associated with primary brain cancer; of 8409 with haemorrhagic strokes, it was 126 (1 in 66). In the background cohort, 205 (1 in 4000) had occult primary brain cancer. The multivariate stroke risk factor analysis showed that patients with occult primary brain cancer differed significantly from those without occult primary brain cancer indicating they might have stroke mimics rather than true strokes.Discussion and conclusions: Strokes associated with occult primary brain cancer tend to be stroke mimics rather than true strokes. Primary brain cancer is rare in patients with ischaemic stroke (1 in 2000); risk that misdiagnosis results in maltreatment is, therefore, very low. Occult primary brain cancers are mainly found among patients with haemorrhagic stroke; they are not uncommon (1 in 66) and should always be kept in mind.

Prevalence and risk of occult cancer in stroke

OBJECTIVES

Cancer is associated with higher risk of stroke. Whether this translates into higher risk of cancer in stroke of an extent calling for cancer screening in stroke is unclear. We investigated prevalence and risk of occult cancer in stroke compared to the background population without history of stroke.

MATERIALS AND METHODS

All patients >40 years of age with incident stroke in Denmark 2003-2015 were identified through the Danish Stroke Registry (n = 85 893) and matched 1:10 on age and sex to the Danish background population without history of stroke (n = 858 740). Linking data to the Danish Cancer Registry, we determined prevalence of occult cancer in stroke defined as the event of previously unknown cancer during a 1-year follow-up in the stroke and in the background population. Cox regression models were used to study risk in comparison to the background population.

RESULTS

Prevalence (per 1000) of occult cancer in the stroke/background cohorts was 25.0/15.8 in women and 29.8/20.4 in men. Prevalence was dependent on age and sex. Highest among stroke patients aged 70-80 years (35.6 in women, 42.4 in men); lowest in patients aged 40-50 years (8.3 in women, 6.8 in men). Stroke was associated with an overall 54% higher risk of occult cancer but risk increased significantly with smoking, hazard ratio (HR) 1.47, age HR 1.27 per 10 years, male sex HR 1.25, and diabetes HR 1.25.

CONCLUSIONS

Prevalence and risk of occult cancer in stroke is considerable and calls for attention when designing the stroke investigation program.

Risk of Ischemic and Hemorrhagic Strokes in Occult and Manifest Cancers

BACKGROUND AND PURPOSE

Manifest cancer is associated with increased risk of stroke. The risk of stroke in people with occult cancer in comparison to the risk in the background population without cancer has not been investigated. Smoking is a risk factor for both cancer and stroke, but the role of smoking for the risk of stroke in cancer has not been investigated.

METHODS

We identified all incident cases of cancer in Denmark 2003 to 2012 (n=264.376) from the Danish Cancer Registry. Each person with cancer was matched by age, sex, and income with 10 randomly selected persons without cancer at index date (n=2.571.260). Linking data to the Danish Stroke Registry, we studied risk of ischemic/hemorrhagic stroke the year before (occult cancer) and after cancer diagnosis was established in the Danish Stroke Registry (manifest cancer) and stratified into the 15 most common cancer types related (lung, colon, bladder, rectum, pancreas, kidney, stomach, and head and neck cancer) and unrelated (non-Hodgkin lymphoma, breast, prostate, melanoma, central nervous system, ovary and endometrial) to smoking.

RESULTS

Risk of ischemic/hemorrhagic stroke was increased for both occult (relative risk, 1.75/2.00) and manifest cancers (relative risk, 1.30/1.41). For occult cancer, risk of ischemic stroke was increased for all of the smoking-related cancers, but among cancers unrelated to smoking, only lymphoma, central nervous system, and endometrial cancer were associated with increased risk of stroke; breast, prostate, melanoma, and ovarian cancers were not. For occult cancer, risk of hemorrhagic stroke was generally increased for smoking-related cancers while not for cancers unrelated to smoking. For manifest cancer, risk of ischemic and hemorrhagic stroke was generally increased for cancers related to smoking while not for cancers unrelated to smoking.

CONCLUSIONS

Cancer, occult and manifest, is associated with increased risks for stroke. The increased risk is linked mainly to cancers related to smoking.

Risk of Stroke in Migraineurs Using Triptans. Associations with Age, Sex, Stroke Severity and Subtype

BACKGROUND

Identifying migraineurs by triptan utilization we studied risk for stroke in migraineurs compared to the general population.

METHODS

A cohort study including all citizens 25-80years of age in Denmark 2003-2011 was conducted. All persons prescribed triptans, and all those hospitalized for a first stroke were identified in the Danish Registries. Information on stroke severity/subtype and cardiovascular risk factors was available for stroke patients.

FINDINGS

Of the 49,711 patients hospitalized for a first stroke, 1084 were migraineurs using triptans. Adjusting for age, sex, income, and educational level, risk for stroke was higher among migraineurs in respect to all strokes (RR 1.07; CI 1.01-1.14) and ischemic strokes (RR 1.07; CI 1.00-1.14). Risk for hemorrhagic stroke was increased but only in women (RR 1.41; CI 1.11-1.79). Risk was for mild strokes (RR 1.31; CI 1.16-1.48) while risk for severe strokes was lower among migraineurs (RR 0.77; CI 0.65-0.91). Risk was age-related; highest among women 25-45years (RR≈1.7). Risk was unrelated to numbers of dispensations.

INTERPRETATION

Migraineurs identified by triptan utilization had higher risk for stroke. Strokes were minor and cardiovascular risk factors were less prevalent pointing to a migraine-specific etiology of stroke different from that of thromboembolism.

Symptoms and side effects in chronic non-cancer pain patients: clinical implications and development of new assessment tools

OBJECTIVE

To improve a 41-item screening tool evaluated in our previous study by making it more simple and convenient to patients and at the same time maintain the level of information and the sensitivity.

METHODS

In a prospective, two-period questionnaire study, patients suffering from chronic pain of non-cancer origin for more than 6 months, were asked to fill in two questionnaires: QSSE-41 or QSSE-33 and SF-36. The first part of the study (QSSE-41) included an age- and sex-matched control group.

RESULTS

A total of 67 patients were included in QSSE-41 and 60 patients in QSSE-33. In QSSE-41, the mean number of symptoms reported by the patient group (12.3) was significantly higher than those reported by the controls (6.8) (P < 0.001). Out of the total number of symptoms, 40.3% were reported to be side effects caused by analgesics, and out of those 61.3% were reported as acceptable and 38.7% as unacceptable side effects. In the QSSE-33, the mean number of symptoms reported by the patient group was 13.6. Out of the total number of symptoms, 46.3% were reported to be side effects caused by analgesics, and out of those 56.4% were reported as acceptable and 43.6% as unacceptable side effects.

CONCLUSIONS

This new and shorter screening tool QSSE-33 may substitute the original QSSE-41 and in clinical use, contribute substantially to a more comprehensive and detailed understanding of symptoms/side effects and may consequently lead to improved therapies.

The obesity paradox in stroke: lower mortality and lower risk of readmission for recurrent stroke in obese stroke patients

BACKGROUND

Although associated with excess mortality and morbidity, obesity is associated with lower mortality after stroke. The association between obesity and risk of recurrent stroke is unclear.

AIMS

The study aims to investigate the association in stroke patients between body mass index and risk of death and readmission for recurrent stroke.

METHODS

An administrative Danish quality-control registry designed to collect a predefined dataset on all hospitalized stroke patients in Denmark 2000–2010 includes 45 615 acute first-ever stroke patients with information on body mass index in 29 326. Data include age, gender, civil status, stroke severity, computed tomography, and cardiovascular risk factors. Patients were followed up to 9·8 years (median 2·6 years). We used Cox regression models to compare risk of death and readmission for recurrent stroke in the four body mass index groups: underweight (body mass index < 18·5), normal weight (body mass index 18·5–24·9), overweight (body mass index 25·0–29·9), obese (body mass index ≥ 30·0).

RESULTS

Mean age 72·3 years, 48% women. Mean body mass index 23·0. Within follow-up, 7902 (26·9%) patients had died; 2437 (8·3%) were readmitted because of recurrent stroke. Mortality was significantly lower in overweight (hazard ratio 0·72; confidence interval 0·68–0·78) and obese (hazard ratio 0·80; confidence interval 0·73–0·88) patients while significantly higher in underweight patients (hazard ratio 1·66; confidence interval 1·49–1·84) compared with normal weight patients. Risk of readmission for recurrent stroke was significantly lower in obese than in normal weight patients (hazard ratio 0·84; confidence interval 0·72–0·92).

CONCLUSIONS

Obesity was not only associated with reduced mortality relative to normal weight patients. Compared with normal weight, risk of readmission for recurrent stroke was also lower in obese stroke patients.

Sex Disparities in Stroke: Women Have More Severe Strokes but Better Survival Than Men

BACKGROUND

Uncertainty remains about whether stroke affects men and women similarly. We studied differences between men and women with regard to stroke severity and survival.

METHODS AND RESULTS

We used the Danish Stroke Registry, with information on all hospital admissions for stroke in Denmark between 2003 and 2012 (N=79 617), and the Danish Register of Causes of Death. Information was available on age, sex, marital status, stroke severity, stroke subtype, socioeconomic status, and cardiovascular risk profile. We studied only deaths due to the index stroke, with the assumption that death reported on death certificates as due to stroke was related to the index stroke if death occurred within the first week or month after stroke. Multivariate Cox regression analysis and multiple imputation were applied. Stroke was the cause of death for 4373 and 5512 of the 79 617 patients within 1 week (5.5%) or 1 month (6.9%), respectively. After the age of 60 years, women had more severe strokes than men. Up to ages in the mid-60s, no difference in the risk of death from stroke was seen between the 2 sexes. For people aged >65 years, however, the risk gradually became greater in men than in women and significantly so (>15%) from the mid-70s (adjusted for age, marital status, stroke severity, stroke subtype, socioeconomic status, and cardiovascular risk factors). Results were essentially the same when analyzing deaths within 1 week, 1 month and ischemic and hemorrhagic stroke separately.

CONCLUSIONS

Stroke affects women and men differently. Elderly women were affected more severely than elderly men but were more likely to survive.

Socioeconomic position and incidence of ischemic stroke in Denmark 2003-2012. A nationwide hospital-based study

BACKGROUND

A greater burden of stroke risk factors in general is associated with a higher risk for stroke among people of lower than those of higher socioeconomic position. The relative impact of individual stroke risk factors is still unclear.

METHODS AND RESULTS

We studied the relations between socioeconomic position, measured as household income and length of education, and all hospital admissions for a first ischemic stroke among 54 048 people over the age of 40 years in Denmark in 2003-2012 in comparison with the general Danish population (23.5 million person-years). We also studied the cardiovascular risk factor profile associated with socioeconomic position in stroke patients. Relative risks for stroke were estimated in log-linear Poisson regression models. The risk for hospitalization for a first ischemic stroke was almost doubled for people in the lowest income group, and the risk of those of working age (<65 years) was increased by 36% among people with the shortest education. Diabetes, obesity, smoking, and high alcohol consumption in particular and, to a lesser extent, previous myocardial infarction or intermittent arterial claudication were significantly overrepresented among stroke patients with lower socioeconomic position. Atrial fibrillation and hypertension were not.

CONCLUSIONS

In Denmark, there is a strong relation between low socioeconomic position and risk for hospitalization for stroke. Lifestyle, as indicated by smoking, obesity, and alcohol consumption, and diabetes appears to increase the risk for stroke in people with lower socioeconomic position.

Early case-fatality rates in elderly stroke patients do not increase when age increases

AIM

We studied the association between age and survival after stroke. We particularly focused on deaths that could be attributed to the stroke lesion itself; that is, early death in severe stroke.

METHODS

A registry of all hospitalized stroke patients in Denmark included 93897 patients with information on stroke severity (Scandinavian Stroke Scale [SSS] 0-58), computed tomography, cardiovascular risk, age, sex and fatality within 1 month. Using regression models, we constructed age trajectories of 3-days, 1-week, and 1-month case-fatality rates unadjusted and adjusted for stroke severity, sex, and cardiovascular risk factors for patients with SSS <25 and SSS ≥ 25.

RESULTS

The 3-days, 1-week, and 1-month case-fatality were 3.6%, 5.8% and 10.3%, respectively. Age-trajectories (SSS <25): 3-days case-fatality rates increased to the age of 75 years. Case-fatality rates then declined (unadjusted model) or leveled off (adjusted model) as age increased. One-week case-fatality increased to the age of 85 years. Case-fatality then leveled off (unadjusted model) or continued to rise (adjusted model) as age increased. One-month case-fatality rates increased throughout the entire lifespan. Age-trajectories (SSS ≥ 25): the leveling off phenomenon was still present for 3-days case-fatality; however, it was less pronounced.

CONCLUSIONS

Very early stroke case-fatality rates increasing to the age of 75-85 years subsequently leveled off or even declined with increasing age. Advanced age per se should not be seen as a disadvantage in terms of surviving stroke in the very acute phase.

Body mass index and stroke: overweight and obesity less often associated with stroke recurrence

BACKGROUND

Although obesity is associated with excess mortality and morbidity, mortality is lower in obese than in normal weight stroke patients (the obesity paradox). Studies now indicate that obesity is not associated with increased risk of recurrent stroke in the years after first stroke. We studied the association between body mass index (BMI) and stroke patient's risk of having a history of previous stroke (recurrent stroke).

METHODS

A registry designed to collect data on all hospitalized stroke patients in Denmark 2000-2010 includes 61,872 acute stroke patients with information on BMI in 38,506. Data include age, sex, civil status, stroke severity (Scandinavian Stroke Scale), computed tomography, and cardiovascular risk factors. There were 28,382 patients with complete covariate information. We used multiple logistic regression models on this data set to compare the risk of stroke being recurrent in the 4 BMI groups: underweight (BMI<18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), and obese (BMI≥30.0).

RESULTS

Of the patients with complete covariate information, 22,811 (80.1%) had first-ever stroke; in 5571 patients (19.6%), stroke was recurrent. Multiple logistic regression analysis adjusting for age, stroke severity, sex, BMI, civil status, and cardiovascular risk factors showed that being obese and overweight in comparison with normal weight was associated with a significantly lower risk of stroke being recurrent (obese: odds ratio [OR]=.90, confidence interval [CI] .82-.98; overweight: OR=.89, CI .83-.96). Being underweight was associated with a significantly higher risk of stroke being recurrent (OR=1.23; CI 1.06-1.43).

CONCLUSIONS

The obesity paradox in stroke can be extended to include also stroke recurrence. Obese and overweight stroke patients had experienced less previous strokes than normal weight stroke patients.

Ischemic stroke and n-3 fatty acids

The content of fatty acids in subcutaneous adipose tissue was measured to determine whether differences of fatty acids correlate with presence or absence of cerebral infarction in individual patients. Adipose tissue microbiopsies was sampled from 10 patients with computed tomography (CT) verified cerebral infarction and 10 matched control subjects, and assayed for content of fatty acids by gas-liquid chromatographic analysis. There were no differences in levels of n-3 fatty acids of marine origin. Patients with cerebral infarction had statistically significant lower levels of the essential fatty acids linoleic acid (mean+/-SE, 8.9+/-0.4 v 10.7+/-0.5%) (P<.05) and linolenic acid (0.80+/-0.05 v 1.00+/-0.06%) (P<.05) and high levels of palmitoleic acid (8.5+/-0.6% v 5.7+/-0.4%) (P<.005) indicative of increased lipid synthesis de novo, which might explain the depressed levels of fatty acids primarily supplied by the diet. Although significant differences in levels of essential fatty acids were found, no judgment could be made regarding a causal relationship between essential fatty acids and cerebral infarction. The present study does not support the hypothesis of an association between dietary fatty acids (e.g., fish consumption) and ischemic stroke.

Costs of secondary prevention of stroke by carotid endarterectomy

BACKGROUND

We estimated the costs to the Danish National Health Service of preventing stroke due to carotid artery stenosis by carotid endarterectomy (CEA), including costs of identifying patients, Doppler ultrasound (DUS) examination and CEA.

METHODS

Estimations are based on patients with stroke, transient ischemic attacks (TIA) or amaurosis fugax referred for carotid DUS in the municipality of Frederiksberg, Denmark (127,184 residents), within an 18-month period in 2008-2009.

RESULTS

In total, 372 patients with stroke (n = 194), TIA (n = 157) or amaurosis fugax (n = 21) were referred for DUS. We identified 12 patients with 50-70% stenosis and 20 patients with >70% stenosis. Six had CEA, all of whom had stenosis >70%. Waiting time from symptom to CEA was a median of 38 days. Costs of preventing 1 recurrent stroke in the study period [number needed to treat (NNT) = 13] was in the range of EUR 207,675-333,918. If CEA had been performed within 2 weeks after onset of symptoms (NNT = 4), costs would be in the range of EUR 63,900-102,744.

CONCLUSION

Costs of preventing stroke by CEA were high. Substantial reductions of costs (by about 2/3) can be achieved if CEA is performed <2 weeks after the ischemic event.

Explaining poorer stroke outcomes in women: women surviving 3 months have more severe strokes than men despite a lower 3-month case fatality

BACKGROUND

Women who survive stroke are more disabled and more often institutionalized than men.

OBJECTIVE

We explore this phenomenon by studying case fatality and stroke severity in stroke survivors separately for men and women.

METHODS

A Danish stroke registry (2000-2007) contains information about 26,818 patients with first-ever ischemic stroke, including stroke severity (Scandinavian Stroke Scale, 0 worst to 58 best), computed tomography scan, cardiovascular risk factors, and death 3 months after stroke. We modeled stroke severity by generalized additive linear model and 3-month case fatality with logistic model adjusting for age and cardiovascular risk factors.

RESULTS

Male to female ratio was 51.5% to 48.5%. Mean age was 68.8 (SD 12.6) years in men; 73.7 (13.8) years in women. Stroke was more severe in women (mean [SD] Scandinavian Stroke Scale, 42.2 [16.0]) than in men (mean [SD] Scandinavian Stroke Scale, 45.6 [14.2]) also after adjustment for age and cardiovascular risk factors; significant in patients older than 75 years. In survivors at 3 months, stroke was more severe in women than men, given same age and cardiovascular risk factor profile; significant in patients older than 75 years. More women (11.9%) had died within 3 months than men (8.6%). However, adjusting for age, stroke severity, and risk factor profile, 3-month case fatality was lower in women than men; significant in patients older than 78 years.

CONCLUSIONS

Although 3-month case fatality was lower in women than men, strokes were more severe among survivors at 3 months in women than in men. In addition, strokes were more severe in women. Our data help elucidate why women survive stroke better but have poorer functional outcomes that require more care than men.

Predictors of early and late case-fatality in a nationwide Danish study of 26,818 patients with first-ever ischemic stroke

BACKGROUND AND PURPOSE

Predictors of early case-fatality (3-day, 7-day, and 30-day) in first-ever ischemic stroke were identified and compared with predictors of late case-fatality (90-day and 1-year).

METHODS

A registry designed to register hospitalized patients with stroke in Denmark 2000 to 2007 holds 26,818 patients with first-ever ischemic stroke with information on stroke severity (Scandinavian Stroke Scale), CT scan, cardiovascular risk factors, marital status, and fatality within 1 year. Multiple logistic regression was used in identifying predictors.

RESULTS

Mean age was 71.2 years; 48.5% were women; mean Scandinavian Stroke Scale score was 43.9. Early case-fatality showed stroke severity and age were significant predictors of 3-day, 7-day, and 30-day case-fatality (nonlinear effect). In addition, atrial fibrillation (OR, 1.56) predicted 30-day case-fatality. For late case-fatality, significant predictors of 90-day and 1-year case-fatality were age, stroke severity (nonlinear effect), atrial fibrillation (OR, 1.37 and 1.57), and diabetes (OR, 1.35 and 1.33), respectively. Male gender (OR, 1.28), previous myocardial infarction (OR, 1.40), and smoking (OR, 1.21) were also associated with 1-year case-fatality. Alcohol consumption, hypertension, intermittent arterial claudication, and marital state had no influence. All case-fatality rates accelerated with increasing age, but 3-day and 7-day case-fatality rates tended to level off or decline at the highest ages.

CONCLUSIONS

Age and stroke severity were the only significant predictors of fatality within the first poststroke week; they were associated with late case-fatality as well. Cardiovascular risk factors were associated with late case-fatality; with the exception of atrial fibrillation, they were not significantly associated with early case-fatality rates.

Female survival advantage relates to male inferiority rather than female superiority: A hypothesis based on the impact of age and stroke severity on 1-week to 1-year case fatality in 40,155 men and women

BACKGROUND

It is generally believed that differences in age, stroke characteristics, and cardiovascular risk factors account for observed sex-specific differences in stroke survival.

OBJECTIVES

We aimed to study female stroke survival advantage before and after the average age of menopause, and whether female survival advantage applies only to patients for whom stroke is the most likely cause of death.

METHODS

The Danish National Indicator Project, a registry designed to list all hospitalized stroke patients in Denmark beginning in March 2001, had 40,155 registered patients as of February 2007. All registered patients had undergone evaluation including stroke severity (as measured by the Scandinavian Stroke Scale [SSS], using a total score of 0-58, in which lower scores indicate more severe strokes), computed tomography, and cardiovascular risk factors. Patients were followed from admission until death or censoring. Case fatality (stratified by 1 week, 1 month, 3 months, and 1 year) in men and women was correlated with age and stroke severity. Adjustment for cardiovascular risk factors was performed by means of multivariate regression analysis.

RESULTS

A total of 20,854 (51.9%) men and 19,301 (48.1%) women were registered. Women were significantly older than men at the time of stroke (74.5 vs 69.7 years, respectively; P < 0.001) and had signficantly more severe strokes, as expressed by the mean SSS score (39.6 vs 43.3; P < 0.001). Stratification of 1-week to 1-year case fatality according to age and stroke severity indicated that women survived significantly better than men from the mid-fifties onward, when controlling for age, stroke severity, and cardiovascular risk factor profile. The observed female survival advantage increased with age. The female survival advantage was seen in patients with severe as well as mild strokes, but not in those younger than age 50 years.

CONCLUSIONS

Our findings dispute the effects of female sex hormones as the underlying cause of female survival superiority over men. Instead, we propose the hypothesis that the progressive deficiency of male sex hormones (testosterone), beginning in men in middle age, is the underlying cause of the gap in survival rates between men and women. Accordingly, the female survival advantage is rooted in male inferiority rather than innate female superiority.

Age- and gender-specific prevalence of cardiovascular risk factors in 40,102 patients with first-ever ischemic stroke: a Nationwide Danish Study

BACKGROUND AND PURPOSE

We describe the prevalence of cardiovascular risk factors at stroke onset in men and women of all ages.

METHODS

A registry started in 2001, designed to register all hospitalized stroke patients in Denmark, now holds 40,102 patients with first-ever ischemic stroke. Patients underwent evaluation including stroke severity (Scandinavian Stroke Scale), CT, and cardiovascular risk factors: hypertension, atrial fibrillation, diabetes mellitus, intermittent arterial claudication, previous myocardial infarction, body mass index, smoking, and alcohol consumption. We estimated the independent effect of gender and age on prevalence of cardiovascular risk factors and calculated age and gender-specific prevalence rates for each risk factor.

RESULTS

The register contained 47.9% women and 52.1% men. Men had more often diabetes mellitus, previous myocardial infarction, intermittent arterial claudication, and over the limit alcohol consumption. Women had more often hypertension and obesity. Atrial fibrillation and smoking were equally frequent in both genders. Age stratification revealed that the lifestyle cardiovascular risk factors smoking, alcohol, and obesity were more common in the younger patients with stroke (< 60 years), whereas prevalence of hypertension, diabetes mellitus, myocardial infarction, intermittent arterial claudication, and, in men, also atrial fibrillation decreases in the elderly (> 70 to 80 years), the decrease being generally more pronounced in men than in women.

CONCLUSIONS

Cardiovascular risk factors were generally more prevalent in men. Lifestyle cardiovascular risk factors were more common in the young. Prevalence of hypertension, diabetes mellitus, coronary heart disease, and, in men, also atrial fibrillation go down after the age of 70 to 80 years.

One-month to 10-year survival in the Copenhagen stroke study: interactions between stroke severity and other prognostic indicators

We studied the association of stroke severity with survival from 1 month to 10 years after stroke and explored how stroke severity interacts with other prognostic indicators with time. The study is based on 999 stroke patients from the community-based Copenhagen Stroke Study (mean age, 74.3±11.0 years; 56% women; mean Scandinavian Stroke Scale [SSS], 38.0±17.4). Evaluation included stroke severity (based on the SSS), computed tomography scan, and a cardiovascular risk profile. Using logistic regression models, we examined the relevance of the SSS on mortality at 1 month and 1, 5, and 10 years. We analyzed the proportion of the variation explained by the models and bias of risk factors estimates with and without the SSS in the model. Mortality rate was 16.6% at 1 month, 31.5% at 1 year, 60.2% at 5 years, and 81.3% at 10 years. In models including the SSS, 22.4%, 20.9%, 32.8%, and 39.5% of the variance was explained for the endpoints of 1 month, 1 year, 5 years, and 10 years, respectively. When SSS was left out of the model, the corresponding values were 6.9%, 13.3%, 29.0%, and 35.1%. Factors significantly associated with survival were SSS at 1 month; SSS, age, diabetes, and stroke type at 1 year; SSS, age, sex, previous stroke, other complicating diseases, diabetes, smoking, and atrial fibrillation at 5 years; and SSS, age, sex, other complicating diseases, and diabetes at 10 years. Our data suggest that stroke severity is significantly associated with short-term and long-term survival. It is the all-important predictor of short-term survival, whereas it is of less importance in predicting long-term survival.

Blood glucose in acute stroke

Blood glucose is often elevated in acute stroke, and higher admission glucose levels are associated with larger lesions, greater mortality and poorer functional outcome. In patients treated with thrombolysis, hyperglycemia is associated with an increased risk of hemorrhagic transformation of infarcts. For a number of years, tight glycemic control has been regarded as beneficial in critically illness, but recent research has been unable to support this notion. The only completed randomized study on glucose-lowering therapy in stroke has failed to demonstrate effect, and concerns relating to the risk of inducing potentially harmful hypoglycemia has been raised. Still, basic and observational research is overwhelmingly in support of a causal relationship between blood glucose and stroke outcome and further research on glucose-lowering therapy in acute stroke is highly warranted.

Cytomegalovirus pneumonia after treatment with melphalan and prednisone. Report of a case

A patient with multiple myeloma had pancytopenia after treatment with melphalan and prednisone and died of an interstitial pneumonia. Post-mortem examinations showed cytomegalic cells in the lungs. Lung tissue showed a high titer of cytomegalovirus. Only when other causes have been ruled out by microbiologic, serologic, and histologic examinations should melphalan be believed to cause respiratory illness.

[Gender differences in stroke mortality rate]

A registry of hospitalized stroke patients in Denmark included 39,484 patients; 48% women, 52% men. Median time from stroke to admission was 1 day; median follow-up 1.5 years. A multivariate survival analysis showed that although time-dependent, the female/male stroke mortality rate generally favoured women from first day post-stroke, reflecting a female survival advantage. The analysis also showed that women who survive stroke live longer than men.

Poststroke epilepsy in the Copenhagen stroke study: incidence and predictors

Poststroke epilepsy (PSE) is a feared complication after stroke and is reported in 3% to 5% of stroke survivors. In this study we sought to identify incidence and predictors of PSE in an unselected stroke population with a follow-up period of 7 years. The study was community-based and comprises a cohort of 1197 consecutively and prospectively admitted patients with stroke. Patients were followed up for 7 years. We defined PSE as recurrent epileptic seizures with onset after stroke and requiring antiepileptic prophylaxis. PSE was related to clinical factors (age, sex, onset stroke severity, lesion size on computed tomography scans, stroke subtype, localization, stroke risk factor profile, and early seizures) in univariate analyses. Independent predictors of PSE were identified through multiple logistic regression analyses. Overall, 38 patients (3.2%) developed PSE. Univariately, PSE was associated with younger age, intracerebral hemorrhage, and larger lesions. PSE was less frequently associated with atrial fibrillation and ischemic heart disease. In the final multiple regression model for the dependent variable PSE, independent predictors were younger age (odds ratio [OR] 1.7/10 years; 95% confidence interval [CI] 1.3-2.1), onset stroke severity (OR 1.3-/10-point decrease; 95% CI 1.0-1.6), lesion size (OR 1.2-/10-mm enlargement; 95% CI 1.0-1.3), intracerebral hemorrhage (OR 3.3; 95% CI 1.3-8.6), and early seizures (OR 4.5; 95% CI 1.3-16.0). We conclude that PSE occurs in about 3% of all patients with stroke within 7 years after stroke. Age, intracerebral hemorrhage, lesion size, increasing stroke severity, and early seizures are independent predictors of PSE.

Sex-related time-dependent variations in post-stroke survival--evidence of a female stroke survival advantage

BACKGROUND

Women live longer than men, yet most studies show that gender has no influence on survival after stroke.

METHODS

A registry was started in 2001, with the aim of registering all hospitalized stroke patients in Denmark, and it now holds 39,484 patients of which 48% are female. We studied the influence of gender on post-stroke mortality, from the time of admission through the subsequent years until death or censoring (mean follow-up time: 538 days). All patients underwent an evaluation including stroke severity, computed tomography and cardiovascular risk factors. Independent predictors of death were identified by means of a survival model based on 22,222 individuals with a complete data set.

RESULTS

Females were older and had severer stroke. Interestingly, the risk of death between genders was time dependent. The female/male stroke mortality rate favoured women from the first day of stroke and remained so during the first month suggesting a female survival advantage. Throughout the second month the rate reversed in favour of men suggesting that women in that period are paying a 'toll' for their initial survival advantage. Hereafter, the rate steadily decreased, and after 4 months women continued to have the same low risk as in the first week.

CONCLUSIONS

Our study suggests a female superiority in stroke survival competence.

Early infection and prognosis after acute stroke: the Copenhagen Stroke Study

BACKGROUND AND PURPOSE

Infection is a frequent complication in the early course of acute stroke and may adversely affect stroke outcome. In the present study, we investigate early infection developing in patients within 3 days of admission to the hospital and its independent relation to recovery and stroke outcome. In addition, we identify predictors for early infections, infection subtypes, and their relation to initial stroke severity.

METHODS

In the community-based Copenhagen Stroke Study, 1,156 unselected patients were examined for early infection. Stroke severity was assessed with the Scandinavian Stroke Scale (SSS) on admission and at discharge. Multiple logistic and linear regression analyses were used to determine independent relations to early infection. Relevant stroke risk factors, admission stroke severity, and body temperature were included in the analysis.

RESULTS

Of the subjects studied, 19.4% developed early infection. In women, 68% of the early infections were urinary tract infections, and in men, 49% of the early infections were pneumonias. Independent predictors of early infection were advanced age (OR per 10 years, 1.24; 95% CI, 1.02-1.64), female gender (OR, 2.0; 95% CI, 1.3-3.0), and decreased SSS score on admission (OR per 10 points, 0.69; 95% CI, 0.62-0.78). The presence of early infection prolonged hospital stay by a mean of 9.3 days (P < .0001) but not death during hospital stay (P = .78), stroke severity at discharge (P = .32), or rate of discharge to nursing home (P = .17).

CONCLUSION

Advanced age, female gender, and increased stroke severity independently predict development of early infection. The present study indicates that early infection does not influence outcome in acute stroke patients per se, but it delays patient discharge from the hospital.

[Lower mortality in patients with stroke and atrial fibrillation who received anticoagulation treatment]

A registry of hospitalized stroke patients in Denmark included 1,909 patients with stroke and atrial fibrillation (AF) without contraindications to anticoagulation (AC) treatment. AC instituted in 60.2% was significantly associated to age and stroke severity. In a Cox Proportional Hazard regression model the risk of death was doubled in patients who had no AC treatment (HR =1.91, 95% CI=1.44 to 2.52). The study indicates under-use of AC in elderly stroke patients with AF, leading to increased mortality.

[Rehabilitation of stroke patients]

The introduction of stroke units is the only well-documented cause of reduced stroke mortality during the latest decades. Factors affecting rehabilitation outcome in terms of activities of daily living includes hemiplegia, urinary and fecal incontinence, cognitive deficits and anosognosia. Physiotherapy, speech therapy and cognitive rehabilitation are indicated whenever the relevant symptoms are present, although there is insufficient knowledge of the relative efficiency of competing methods.

Higher total serum cholesterol levels are associated with less severe strokes and lower all-cause mortality: ten-year follow-up of ischemic strokes in the Copenhagen Stroke Study

BACKGROUND AND PURPOSE

Evidence of a causal relation between serum cholesterol and stroke is inconsistent. We investigated the relation between total serum cholesterol and both stroke severity and poststroke mortality to test the hypothesis that hypercholesterolemia is primarily associated with minor stroke.

METHODS

In the study, 652 unselected patients with ischemic stroke arrived at the hospital within 24 hours of stroke onset. A measure of total serum cholesterol was obtained in 513 (79%) within the 24-hour time window. Stroke severity was measured with the Scandinavian Stroke Scale (0=worst, 58=best); a full cardiovascular risk profile was established for all. Death within 10 years after stroke onset was obtained from the Danish Registry of Persons.

RESULTS

Mean+/-SD age of the 513 patients was 75+/-10 years, 54% were women, and the mean+/-SD Scandinavian Stroke Scale score was 39+/-17. Serum cholesterol was inversely and almost linearly related to stroke severity: an increase of 1 mmol/L in total serum cholesterol resulted in an increase in the Scandinavian Stroke Scale score of 1.32 (95% CI, 0.28 to 2.36, P=0.013), meaning that higher cholesterol levels are associated with less severe strokes. A survival analysis revealed an inverse linear relation between serum cholesterol and mortality, meaning that an increase of 1 mmol/L in cholesterol results in a hazard ratio of 0.89 (95% CI, 0.82 to 0.97, P=0.01).

CONCLUSIONS

The results of our study support the hypothesis that a higher cholesterol level favors development of minor strokes. Because of selection, therefore, major strokes are more often seen in patients with lower cholesterol levels. Poststroke mortality, therefore, is inversely related to cholesterol.

Reduced Poststroke Mortality in Patients With Stroke and Atrial Fibrillation Treated With Anticoagulants

BACKGROUND AND PURPOSE

The preventive effect of anticoagulation in patients with stroke and atrial fibrillation (AF) is documented only in trials of minor stroke. Although anticoagulation reduced stroke recurrence, those trials did not demonstrate an influence of anticoagulation on survival.

METHODS

A nationwide registry that was started in 2001 with the aim of registering all hospitalized stroke patients in Denmark now includes 24 791 patients. We studied the survival of patients with ischemic stroke and AF with respect to anticoagulation treatment. All underwent an evaluation for stroke severity (according to the Scandinavian Stroke Scale), computed tomography scan, and an evaluation for cardiovascular risk factors. Follow-up duration was 4 years (mean, 1.2 years).

RESULTS

Of all patients, 22 179 (89.4%) experienced an ischemic stroke. In total, 3670 (16.5%) had AF, and 1909 had no contraindication to anticoagulation treatment. Anticoagulation treatment was initiated in 1149 of these patients (60.2%) but omitted in 760 (39.8%) despite no contraindication to such treatment. Of the patients so treated, 18.9% died during follow-up versus 45.2% without treatment. Patients who received treatment were younger (76.7+/-9.5 versus 80.7+/-9.0 years, P<0.0001) and had less severe strokes (Scandinavian Stroke Scale score, 42.0+/-15.0 versus 33.6+/-18.2, P<0.0001). A Cox proportional-hazards model was built to study the effect of anticoagulation on survival in patients without contraindications to treatment while controlling for stroke severity, sex, and cardiovascular risk factors. Patients without anticoagulation treatment were at greater risk of dying (hazard ratio=1.91, 95% CI=1.44 to 2.52) compared with patients who received anticoagulation treatment.

CONCLUSIONS

Our data suggest that anticoagulation treatment reduces poststroke mortality in patients with ischemic stroke and AF.