COMPARISON OF HOSPITALIZED ACUTE STROKE PATIENTS' CHARACTERISTICS USING TWO LARGE CENTRAL-EASTERN EUROPEAN DATABASES.

OBJECTIVES: Stroke is the third leading cause of death in the European region. In spite of a decreasing trend, stroke related mortality remains higher in Hungary and Romania when compared to the EU average. This might be due to higher incidence, increased severity or even less effective care. METHODS: In this study we used two large, hospital based databases from Targu Mures (Romania) and Debrecen (Hungary) to compare not only the demographic characteristics of stroke patients from these countries but also the risk factors, as well as stroke severity and short term outcome. RESULTS: The gender related distribution of patients was similar to those found in the European Survey, whereas the mean age of patients at stroke onset was similar in the two countries but lower by four years. Although the length of hospital stay was significantly different in the two countries it was still much shorter (about half) than in most reports from western European countries. The overall fatality rate in both databases, regardless of gender was comparable to averages from Europe and other countries. In both countries we found a high number of risk factors, frequently overlapping. The prevalence of risk factors (hypertension, smoking, hyperlipidaemia) was higher than those reported in other countries, which can explain the high ratio of recurring stroke.

Prestroke alcohol consumption and smoking are not associated with stroke severity, disability at discharge, and case fatality.

BACKGROUND: Heavy alcohol consumption and smoking are known risk factors for stroke, but their influence on stroke severity and outcome may also be important. We tested if alcohol consumption and smoking relate to initial stroke severity, disability at discharge from hospital, and outcome at 30 days and at 1 year in 1049 patients of the Mures-Uzhgorod-Debrecen database. METHODS: Initial stroke severity was scored by the National Institutes of Health Stroke Scale. Case fatality and the modified outcome scale of the First International Stroke Trial were used to assess outcome. We used multiple regression analysis. RESULTS: Before their stroke, 24.5% were smokers and 24.7% admitted regular alcohol consumption. Neither smoking nor alcohol consumption status was associated with initial stroke severity. Case fatalities at discharge, at 30 days, and at 1 year were 12.2%, 16.9%, and 28.3%, respectively. Initial stroke severity, hemorrhagic subtype, and age in men over 60 years were strong predictors of outcome. We did not find significant difference among alcohol consumers and nonconsumers in 30-day and in 1-year case fatality in all stroke patients and in ischemic stroke patients. In hemorrhagic stroke, there was a nonsignificant tendency for higher case fatality among alcohol consumers (39.5% versus 26.4%, P > .2, at 30 days and 48.8% versus 35.8%, P > .2, at 1 year). Smoking did not influence significantly the outcome at 30 days and at 1 year. CONCLUSION: Despite being risk factors, prestroke smoking and alcohol consumption do not have a significant influence on stroke severity and on short- and long-term outcome.

Demographic and geographic vascular risk factor differences in European young adults with ischemic stroke: the 15 cities young stroke study.

BACKGROUND AND PURPOSE: We compared among young patients with ischemic stroke the distribution of vascular risk factors among sex, age groups, and 3 distinct geographic regions in Europe. METHODS: We included patients with first-ever ischemic stroke aged 15 to 49 years from existing hospital- or population-based prospective or consecutive young stroke registries involving 15 cities in 12 countries. Geographic regions were defined as northern (Finland, Norway), central (Austria, Belgium, France, Germany, Hungary, The Netherlands, Switzerland), and southern (Greece, Italy, Turkey) Europe. Hierarchical regression models were used for comparisons. RESULTS: In the study cohort (n=3944), the 3 most frequent risk factors were current smoking (48.7%), dyslipidemia (45.8%), and hypertension (35.9%). Compared with central (n=1868; median age, 43 years) and northern (n=1330; median age, 44 years) European patients, southern Europeans (n=746; median age, 41 years) were younger. No sex difference emerged between the regions, male:female ratio being 0.7 in those aged <34 years and reaching 1.7 in those aged 45 to 49 years. After accounting for confounders, no risk-factor differences emerged at the region level. Compared with females, males were older and they more frequently had dyslipidemia or coronary heart disease, or were smokers, irrespective of region. In both sexes, prevalence of family history of stroke, dyslipidemia, smoking, hypertension, diabetes mellitus, coronary heart disease, peripheral arterial disease, and atrial fibrillation positively correlated with age across all regions. CONCLUSIONS: Primary preventive strategies for ischemic stroke in young adults-having high rate of modifiable risk factors-should be targeted according to sex and age at continental level.

Mannitol use in acute stroke: case fatality at 30 days and 1 year.

BACKGROUND AND PURPOSE: Mannitol is used worldwide to treat acute stroke, although its efficacy and safety have not been proven by randomized trials. METHODS: In a tricenter, prospective study, we analyzed the 30-day and 1-year case fatality with respect to mannitol treatment status in 805 patients consecutively admitted within 72 hours of stroke onset. Confounding factors were compared between treated and nontreated patients. RESULTS: Two thirds of the patients received intravenous mannitol as part of their routine treatment (mean dose, 47+/-22 g/d; mean duration, 6+/-3 days). The case fatality was 25% versus 16% (P=0.006) at 30 days and 38% versus 25% (P<0.001) at 1 year in the-mannitol treated and nontreated groups, respectively. Mannitol treatment effect was adjusted for age, stroke severity, fever in the first 3 days, and aspirin treatment (for ischemic strokes) in logistic regression models. Depending on the factors entered into the model, either no effect or harm could be attributed to mannitol. When the analysis was restricted to those admitted within 24 hours (n=568), case fatality differed significantly only at 1 year (35% in treated and 26% in nontreated patients, P=0.044). Although the prognostic scores of the Scandinavian Neurological Stroke Scale were similar in treated and nontreated patients, both in ischemic and hemorrhagic strokes, the patient groups differed in several factors that might also have influenced survival. CONCLUSIONS: Based on the results of this study, no recommendations can be made on the use of mannitol in acute stroke, and properly randomized, controlled trials should be performed to come to a final conclusion.

Different effect of hyperglycemia on stroke outcome in non-diabetic and diabetic patients--a cohort study.

OBJECTIVES: Relationship between hyperglycemia and stroke outcome is unclear, partly due to the small sample size in most studies, and partly due to lack of consensus concerning the cutoff level for hyperglycemia. METHODS: In a cohort study, we investigated whether on-admission hyperglycemia is an independent predictor for 30-day case fatality by analyzing data of 2496 consecutive computed tomography (CT) verified acute ischemic stroke patients (2077 non-diabetic and 419 diabetic) included in the prospective, hospital-based Debrecen Stroke Database. Instead of using an arbitrary cutoff level for hyperglycemia, quartiles of on-admission glucose level were used for Kaplan-Meier survival curves and Cox proportional hazard modeling. RESULTS: The four quartiles of serum glucose level were in the range as follows: <5.2 mmol/l, 5.201-6.1 mmol/l, 6.101-7.5 mmol/l, and >7.501 mmol/l (n = 664, 618, 597, and 617, respectively). Among all 2496 participants, the adjusted hazard ratios for death increased with each quartile of admission glucose 1.96 [95% confidence interval (CI): 1.07-3.60; P = 0.03], 1.56 (95% CI: 0.83-2.94; P = 0.17), and 3.04 (95% CI: 1.70-5.44; P < 0.0001) for the second, third, and fourth quartiles, respectively). Upon stratification with respect to diabetes, we found similarly high risk for poor outcome among non-diabetic patients, while the risk was considerably lower among diabetic patients. DISCUSSION: These data suggest that even mild elevation of on-admission glucose levels is an independent predictor of 30-day case fatality. So, we propose that the ideal target blood glucose level is lower for non-diabetic than diabetic patients.

Role of hyperlipidemia in atherosclerotic plaque formation in the internal carotid artery.

PURPOSE: The role of hyperlipidemia in atherosclerotic changes of the carotid artery is controversial. The aims of this retrospective study were to assess (1) the relationship between total serum cholesterol and triglyceride and the grade of internal carotid artery stenosis and (2) whether total serum cholesterol and triglyceride levels are independent risk factors for internal carotid artery atherosclerosis. METHODS: The files of 1,934 acute ischemic stroke patients were investigated retrospectively. The atherosclerotic involvement of the internal carotid artery was assessed via duplex sonography as percent of stenosis and was graded as follows: group 1, no plaque; group 2, <30% stenosis; group 3, 30-99% stenosis; and group 4, occlusion. RESULTS: The mean age of the patients was 66.9 +/- 12.8 years. Patients without any plaque had significantly lower cholesterol levels compared with those with any degree of internal carotid artery stenosis. Univariate analysis revealed that age (p < 0.001), sex (p < 0.001), hypertension (p < 0.05), cholesterol (p < 0.01), triglycerides(p < 0.05), and smoking (p < 0.001) were significant contributors to atherosclerosis. In the ordinal logistic regression model, age (p < 0.001), sex (p < 0.001), smoking(p < 0.001), and cholesterol (p < 0.05) remained independent predictors of internal carotid artery atherosclerosis. CONCLUSIONS: Total serum cholesterol level seems to be an independent risk factor of atherosclerosis in the carotid artery.