Risk of Stroke in Women Using Levonorgestrel-Releasing Intrauterine Device 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 intrauterine devices (LG-IUDs), 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 with women not using hormonal contraceptives. METHODS: In this Danish historical cohort study (2004-2021), we followed nonpregnant women (18-49 years) registering incident IS and ICH in relation to use of LG-IUDs/nonuse of hormonal contraceptives utilizing Danish high-quality registries with nationwide 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 nonpregnant 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. Nonusers of hormonal contraceptives contributed 10 251 434 py; mean age at inclusion was 30.0 years. The incidence rate of IS/ICH among LG-IUD users was 19.2/3.0 and among nonusers, 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: The use of LG-IUD was associated with a 22% lower incidence rate of IS without raising the 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 lung cancer manifesting within the first year after stroke.

BACKGROUND: Lung cancer and stroke share smoking as a major cause of disease. We investigated prevalence and risk of occult lung cancer with manifestation during the first year after stroke. 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 a history of stroke (n=858,740). Linking data to the Danish Cancer Registry we determined prevalence of occult primary lung cancer defined as the event of previously unknown lung cancer during a one-year follow-up in the stroke and the background population. Cox regression models with adjustments for demographics, co-morbidities and stroke risk factors were used to study risk compared to the background population. RESULTS: Prevalence (per 1000 person-years) of occult lung cancer in the stroke cohort was 5.3; in the background cohort 2.6. Prevalence separately for current smokers (n=26,055) was 9.6; ex-smokers (n=20,035) 6.5; never-smokers (n=27,268) 1.4. Risk of occult lung cancer (adjusted) was increased HR 1.95 in the stroke population. In the stroke population adjusting for stroke risk factors age (HR 1.24 per 10 years) and smoking (HR 7.1 in current smokers; HR 1.6 in ex-smokers) were the only significant risk factors for occult lung cancer. CONCLUSIONS: Occult lung cancer is rarely found in stroke patients who have never smoked. It is not uncommon in smokers in whom 1% of current smokers had occult lung cancer that became manifest within the first year after stroke.

Social Inequality by Income in Short- and Long-Term Cause-Specific Mortality after Stroke.

GOALS: It is unclear whether social inequality exists for mortality after stroke. Results of studies on the relation between socioeconomic position (SEP) and mortality after stroke have been inconsistent and inconclusive. MATERIAL AND METHODS: We studied the association between SEP expressed by income and the risk of death after stroke by merging data on incident stroke from Danish registries with nationwide coverage. We identified all incident cases of stroke hospitalized in Denmark 2003-2012 (n = 60503). Patients were followed up to 9 years after stroke (median 2.6 years). Adjusting for age and sex we studied all-cause death and cause-specific death by stroke, cardiac disease, cancer, and other diseases certified by death records and stratified by income. RESULTS: Of the patients 20,953 (34.6%) had died within follow-up: Death by stroke 8018 (13.2%); cardiac disease 4250 (7.0%); cancer 3060 (5.0%); other diseases 5625 (9.2%). Long-term mortality rates were inversely related to income for all causes of death. The difference in mortality between the lowest and the highest income group at 5 years after stroke was 15.5% (relative) and 5.7% (absolute). Differences in short-term mortality (1-month to 1-year) between income groups were small and clinically insignificant. CONCLUSIONS: Social inequality in mortality after stroke expressed by income was pronounced for long-term mortality while not for short-term mortality. It seems that social inequality is expressed in a greater risk among stroke patients with low income for the advent of new diseases subsequently leading to death rather than in their ability to survive the incident stroke.

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.

Socioeconomic position and survival after stroke in Denmark 2003 to 2012: nationwide hospital-based study.

BACKGROUND AND PURPOSE: The risk for stroke is higher in low-income groups. It is not clear whether these groups also have a higher risk for death after a stroke. METHODS: We studied survival in relation to income and level of education in all patients aged >40 years admitted to hospital for stroke in Denmark in 2003 to 2012. All Danish hospitals report data to the Danish Stroke Register for all patients admitted for acute stroke, including age, sex, stroke severity, subtype, and a cardiovascular risk profile. Information on income and education was obtained from Statistics Denmark; deaths from all causes from the Civil Registration Registry. RESULTS: Information on education and disposable income was available for 56 581 Danes hospitalized for stroke during the 9.5-year study period. Median length of follow-up was 3.1 years. For the entire follow-up period, there was a significant, stepwise, independent relation between income and risk for death after stroke, which was 30% higher for the lowest than for the highest quintile income group (relative risk, 0.70, 95% confidence interval, 0.65-0.74). People aged <65 years with basic education had a slightly higher risk for death than those with the longest (relative risk, 1.15; 95% confidence interval, 1.02-1.30). Death within 1 month was not associated with income or education. CONCLUSIONS: The survival of patients with low income was reduced by 30% as compared with those with high income. Education had only a modest effect and only in patients aged <65 years. The impact of socioeconomic position was on late but not on early poststroke death.

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.

Cause-specific mortality after stroke: relation to age, sex, stroke severity, and risk factors in a 10-year follow-up study.

We investigated cause-specific mortality in relation to age, sex, stroke severity, and cardiovascular risk factor profile in the Copenhagen Stroke Study cohort with 10 years of follow-up. In a Copenhagen community, all patients admitted to the hospital with stroke during 1992-1993 (n = 988) were registered on admission. Evaluation included stroke severity, computed tomography scan, and a cardiovascular risk profile. Cause of death within 10 years according to death certificate information was classified as stroke, heart/arterial disease, or nonvascular disease. Competing-risks analyses were performed by cause-specific Cox regression after multiple imputation of missing data, assuming that values were missing at random. Death was due to stroke in 310 patients (31%), to heart/arterial disease in 209 patients (21%), and to nonvascular diseases in 289 patients (29%); 180 patients were still alive after 10 years (18%). Stroke was the dominant cause of death during first year, with an absolute risk of 20.2% versus 5.2% for heart/arterial disease and 6.5% for nonvascular disease. The subsequent absolute risk of death per year was 2.8% for stroke, 4.5% for heart/arterial disease, and 5.2% for nonvascular disease. Death after stroke was associated with older age, male sex, greater stroke severity, and diabetes regardless of the cause of death. Previous stroke and hemorrhagic stroke were associated with death by stroke, ischemic heart disease was associated with death by heart/arterial disease and atrial fibrillation was associated with death by cardiovascular disease (stroke or heart/arterial disease). Hypertension, smoking, and alcohol consumption were not associated with cause-specific death.

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.

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.

Age trajectories of stroke case fatality: leveling off at the highest ages.

BACKGROUND: Mortality rates level off at older ages. Age trajectories of stroke case-fatality rates were studied with the aim of investigating prevalence of this phenomenon, specifically in case-fatality rates at older ages. METHODS: A registry of all hospitalized stroke patients in Denmark included 40,155 patients with evaluations of stroke severity, computed tomography, and cardiovascular risk factors. Data on mortality were used to construct age trajectories of 3-day, 1-week, 1-month, and 1-year case-fatality rates in men and women. RESULTS: Of the 40,155 patients, 19,301 (48%) were women (mean age, 74.5 years) and 20,854 (52%) were men (mean age, 69.7 years). In both women and men, 3-day case-fatality rates leveled off, beginning in the patients' mid-70s. In women, 1-week case-fatality rates leveled off further in their early 80s, whereas in men, 1-week case-fatality rates accelerated with age. One-month and 1-year case-fatality rates accelerated with age for both sexes. CONCLUSIONS: It is an apparent paradox that case-fatality rates in the acute state of stroke level off at the highest ages. Heterogeneity, innate or acquired, in regard to survival capacity may explain the phenomenon.

Association between short-term exposure to ultrafine particles and hospital admissions for stroke in Copenhagen, Denmark.

AIMS: The relevance of ultrafine particles (UFPs, particles <0.1 microm diameter), the smallest fraction of ambient particulate matter, on stroke morbidity has not been documented. We studied the effects of short-term changes in exposure to these particles on stroke, separately for ischaemic and haemorrhagic strokes, mild and severe strokes, and ischaemic strokes with (likely embolic) and without (likely thrombotic) atrial fibrillation (AF). METHODS AND RESULTS: We used a time-stratified case-crossover design to study the association between short-term exposure to UFPs, particulate matter <10 microm in diameter (PM(10)), nitrogen oxides (NO(x)) and carbon monoxide (CO) (measured at single background station) and hospital admissions for stroke in Copenhagen (2003-2006). Of 7485 stroke admissions, 6798 were ischaemic and 687 haemorrhagic, 3485 mild, and 2248 severe. Of the ischaemic stroke cases, 1204 had AF and 5273 did not. We found significant positive association with exposure to UFPs, NO(x) and CO, and ischaemic strokes, and UFPs and NO(x) and mild strokes, 4 days before admission. The strongest associations were with UFPs. Exposure to UFPs lead to a 21% increase in hospital admissions (per interquartile range of 5-day averages; 95% confidence interval 4-41%) for mild ischaemic stroke of without AF (likely thrombotic origin). CONCLUSION: Our results indicate possible effects of traffic-related air pollution, mainly UFPs, on hospital admissions for ischaemic stroke, especially for mild ischaemic stroke of likely thrombotic origin (without AF). These are novel findings regarding the relevance of UFPs and the heterogeneous effect of air pollution on the severity and origin of stroke, and need confirmation by other data.

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.

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.

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.

Hemorrhagic and ischemic strokes compared: stroke severity, mortality, and risk factors.

BACKGROUND AND PURPOSE: Stroke patients with hemorrhagic (HS) and ischemic strokes were compared with regard to stroke severity, mortality, and cardiovascular risk factors. METHODS: A registry started in 2001, with the aim of registering all hospitalized stroke patients in Denmark, now holds information for 39,484 patients. The patients underwent an evaluation including stroke severity (Scandinavian Stroke Scale), CT, and cardiovascular risk factors. They were followed-up from admission until death or censoring in 2007. Independent predictors of death were identified by means of a survival model based on 25,123 individuals with a complete data set. RESULTS: Of the patients 3993 (10.1%) had HS. Stroke severity was almost linearly related to the probability of having HS (2% in patients with the mildest stroke and 30% in those with the most severe strokes). Factors favoring ischemic strokes vs HS were diabetes, atrial fibrillation, previous myocardial infarction, previous stroke, and intermittent arterial claudication. Smoking and alcohol consumption favored HS, whereas age, sex, and hypertension did not herald stroke type. Compared with ischemic strokes, HS was associated with an overall higher mortality risk (HR, 1.564; 95% CI, 1.441-1.696). The increased risk was, however, time-dependent; initially, risk was 4-fold, after 1 week it was 2.5-fold, and after 3 weeks it was 1.5-fold. After 3 months stroke type did not correlate to mortality. CONCLUSIONS: Strokes are generally more severe in patients with HS. Within the first 3 months after stroke, HS is associated with a considerable increase of mortality, which is specifically associated with the hemorrhagic nature of the lesion.

The female stroke survival advantage: relation to age.

BACKGROUND: Age-related hormonal factors are thought to be related to the gender gap in longevity. Testing the hypothesis that survival is best in young premenopausal women we studied the effect of age on 1-week mortality in stroke patients. METHODS: A registry was started in 2001 with the aim of registering all hospitalized patients in Denmark. The patients' risk factors, stroke severity and CT scan were evaluated. A total of 25,607 patients (63%) gave complete information on all risk factors and were used in the analysis. Independent predictors of survival were identified by means of multiple logistic regression. RESULTS: The probability of death within 1 week adjusted for stroke severity, stroke type and risk factors was highly age-dependent in both men and women. Up to the age of 50 years, the 1-week female/male mortality rates paralleled being slightly (15%) but insignificantly better in women. While mortality increased almost linearly in women over the entire age range, it increased steeply in men from the age of 50 and at the age of 80 years survival was 80% better in women. CONCLUSION: The female stroke survival advantage applies to all ages. It increases with age due to a steeply increase of mortality in middle-aged and elderly men.

Body mass index and poststroke mortality.

BACKGROUND: Obesity is an established cardiovascular risk factor. We studied the association between body mass index (BMI) and all-cause mortality after stroke. METHODS: A registry started in 2001 with the aim to register all hospitalized stroke patients in Denmark now includes 21,884 patients in whom BMI was recorded. There are five BMI groups: underweight (BMI < 18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), obese (BMI 30.0-34.9) and severely obese (BMI > or = 35). All patients underwent an evaluation including stroke severity, computed tomography, and cardiovascular risk factors. Survival was followed up to 5 years after stroke (median 1.5 years). Independent predictors of death were identified by means of a survival model based on 13,242 individuals with a complete data set. RESULTS: Compared to normal-weight patients, mortality was lower in overweight [hazard rate (HR) 0.73, 95% CI 0.66-0.81], obese (HR 0.84, 95% CI 0.73-0.98) and severely obese stroke patients (HR 0.84, 95% CI 0.64-1.10), while mortality was higher in underweight patients (HR 1.63, 95% CI 1.41-1.90). CONCLUSIONS: Poststroke mortality is inversely related to BMI: overweight and obese stroke patients have a lower poststroke mortality rate than normal-weight and underweight patients.

Reduced poststroke mortality in patients with stroke and atrial fibrillation treated with anticoagulants: results from a Danish quality-control registry of 22,179 patients with ischemic stroke.

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.