Executive Dysfunction Related to Binge Drinking in Ischemic Stroke.

BACKGROUND: Recent evidence has shown that cognitive dysfunction is associated with a history of binge drinking in adolescents who do not have an alcohol use disorder. Most previous studies with adults, however, have failed to show a link between cognitive dysfunction and subdiagnostic binge drinking, nor have any studies investigated the additive cognitive effect of binge drinking to ischemic stroke. OBJECTIVE: To examine whether a pattern of cognitive dysfunction, especially executive and memory dysfunction, in patients with a first-ever ischemic stroke is associated with a history of subdiagnostic binge drinking. METHODS: We studied 206 first-ever ischemic stroke patients (18-65 years) and 50 healthy, demographically comparable adults-both groups with no alcohol use disorder. After exclusion by matching, 189 patients and 39 healthy participants were included in our study (228 participants). The binge-drinking group included 76 participants; the non-binge-drinking group included 152. A multivariate analysis of covariance was used to compare nine cognitive functions between the two groups, with age, education, and stroke severity used as covariates. RESULTS: Binge drinking had a significant negative effect on executive functions (P<0.001). The non-binge-drinking group outperformed the binge-drinking group on the Stroop Test (P=0.001), Trail Making Test (P=0.002), and a phonemic fluency test (P=0.005). The Binge×Stroke Severity interaction (P=0.037) indicated that a history of binge drinking increased the negative effect of stroke on executive functions. CONCLUSIONS: Subdiagnostic binge drinking may exacerbate the adverse effects of ischemic stroke on executive dysfunction.

Domain-Specific Cognitive Recovery after First-Ever Stroke: A 2-Year Follow-Up.

OBJECTIVES: The aim of this work was to study the change in different cognitive domains after stroke during a 2-year follow-up. METHOD: We evaluated both neuropsychologically and neurologically a consecutive cohort of working-age patients with a first-ever stroke at baseline (within the first weeks), 6 months, and 2 years after stroke-onset. A total of 153 patients participated in all examinations and were compared to 50 healthy controls. RESULTS: Forty-nine percent of the patients were cognitively impaired at baseline, 41% at 6 months, and 39% at 2-year follow-up. We analyzed seven cognitive domains (impairment rates at baseline and 2-year follow-up): psychomotor speed (34%; 23%), executive functions (27%; 17%), visual memory (21%; 4%), visuospatial function (20%; 14%), verbal memory (18%; 12%), basic language processing (baseline 11%; 6 months 5%), and reasoning (2 years 14%). The patients who were cognitively impaired at baseline improved more within 6 months, than either the controls or cognitively intact patients in all cognitive domains (all p<.05). Later on, between 6 months and 2 years, the domain-specific change scores did not differ between patients who were cognitively intact and impaired at 6 months. Also, the cognitive status (intact or impaired) remained the same in 90% of patients between 6-month and 2-year follow-ups. At 2 years, half of the patients, who were categorized cognitively impaired, were rated as well-recovered according to neurological evaluation. CONCLUSIONS: Most of the cognitive improvement took place within 6 months. Long-lasting cognitive impairment was common even after good neurological recovery. An early neuropsychological examination is essential in evaluating cognitive dysfunction and need for rehabilitation. (JINS, 2018, 24, 117-127).

Cerebral white matter lesions and post-thrombolytic remote parenchymal hemorrhage.

OBJECTIVE: Parenchymal hematoma (PH) following intravenous thrombolysis (IVT) in ischemic stroke can occur either within the ischemic area (iPH) or as a remote PH (rPH). The latter could be, at least partly, related to cerebral amyloid angiopathy, which belongs to the continuum of cerebral small vessel disease. We hypothesized that cerebral white matter lesions (WMLs)-an imaging surrogate of small vessel disease-are associated with a higher rate of rPH. METHODS: We analyzed 2,485 consecutive patients treated with IVT at the Helsinki University Hospital. Blennow rating scale of 5 to 6 points on baseline computed tomographic head scans was considered as severe WMLs. An rPH was defined as hemorrhage that-contrary to iPH-appears in brain regions without visible ischemic damage and is clinically not related to the symptomatic acute lesion site. The associations between severe WMLs and pure rPH versus no PH, pure iPH versus no PH, and pure rPH versus pure iPH were studied in multivariate logistic regression models. RESULTS: rPHs were mostly (74%) located in lobar regions. After adjustments, the presence of severe WMLs was associated with pure rPH (odds ratio [OR] = 6.79, 95% confidence interval [CI] = 2.57-17.94) but not with pure iPH (OR = 1.45, 95% CI = 0.83-2.53) when compared to patients with no PH. In direct comparison of pure rPH with pure iPH, severe cerebral WMLs were further associated with higher iPH rates (OR = 3.60, 95% CI = 1.06-12.19). INTERPRETATION: Severe cerebral WMLs were associated with post-thrombolytic rPH but not with iPH within the ischemic area. Ann Neurol 2016;80:593-599.

Acute-Phase Blood Pressure Levels Correlate With a High Risk of Recurrent Strokes in Young-Onset Ischemic Stroke.

BACKGROUND AND PURPOSE: High blood pressure (BP) in acute stroke has been associated with a poor outcome; however, this has not been evaluated in young adults. METHODS: The relationship between BP and long-term outcome was assessed in 1004 consecutive young, first-ever ischemic stroke patients aged 15 to 49 years enrolled in the Helsinki Young Stroke Registry. BP parameters included systolic (SBP) and diastolic BP, pulse pressure, and mean arterial pressure at admission and 24 hours. The primary outcome measure was recurrent stroke in the long-term follow-up. Adjusted for demographics and preexisting comorbidities, Cox regression models were used to assess independent BP parameters associated with outcome. RESULTS: Of our patients (63% male), 393 patients (39%) had prestroke hypertension and 358 (36%) used antihypertensive treatment. The median follow-up period was 8.9 years (interquartile range 5.7-13.2). Patients with a recurrent stroke (n=142, 14%) had significantly higher admission SBP, diastolic BP, pulse pressure, and mean arterial pressure (P<0.001) and 24-h SBP, diastolic BP, and mean arterial pressure compared with patients without the recurrent stroke. Patients with SBP ≥160 mm Hg compared with those with SBP <160 mm Hg had significantly more recurrent strokes (hazard ratio 3.3 [95% confidence interval, 2.05-4.55]; P<0.001) occurring earlier (13.9 years [13.0-14.6] versus 16.2 [15.8-16.6]; P<0.001) within the follow-up period. In multivariable analyses, higher admission SBP, diastolic BP, pulse pressure, and mean arterial pressure were independently associated with the risk of recurrent stroke, while the 24-hour BP levels were not. CONCLUSIONS: In young ischemic stroke patients, high acute phase BP levels are independently associated with a high risk of recurrent strokes.

Executive Impairment Is Associated with Impaired Memory Performance in Working-Aged Stroke Patients.

OBJECTIVES: Executive dysfunction is associated with impaired memory performance, but controversies remain about which aspects of memory are involved and how general intelligence influences these connections. We aimed to clarify these connections in stroke patients by comparing various memory measures in patients with and without executive impairment. METHODS: Our consecutive cohort included patients with a first-ever ischemic stroke. Neuropsychological assessments were completed 6 months and 2 years after stroke. We classified patients as executively impaired, when at least two of five executive measures were defective at 6 months. At both 6 months and 2 years, we compared list learning of unrelated words, story recall, and recall of geometric figures in patients with and without executive impairment, while controlling for general intelligence. RESULTS: Patients with executive impairment (n=66; 37%) performed worse in list learning (p=.001; partial η2=.058) and immediate recall of a logical passage (p=.010; partial η2=.037) 6 months after stroke compared to executively intact patients (n=113). At the end of the 2-year follow-up period, the patients who were executively impaired at 6 months (n=53; 37%) still performed worse than executively intact patients (n=92) in list learning (p<.001; partial η2=.096), and additionally in delayed recall of the list (p=.006; partial η2=.052) and immediate recall of geometric figures (p=.007; partial η2=.050). CONCLUSIONS: In our working-aged stroke patients, executive impairment was common. Executive impairment was associated with memory tasks that provided less inherent structure and required the use of active memory strategies. Clinicians should remember this role of executive dysfunction when interpreting memory performance.

Cerebral computed tomography-graded white matter lesions are associated with worse outcome after thrombolysis in patients with stroke.

BACKGROUND AND PURPOSE: Compared with other stroke causes, small-vessel disease is associated with better 3-month outcomes in patients with acute ischemic stroke treated with intravenous thrombolysis. Another question is the impact of coexisting cerebral white matter lesions (WMLs; a surrogate marker of small-vessel disease) on outcome, which was addressed in the current study. METHODS: We analyzed 2485 consecutive intravenous thrombolysis-treated patients at the Helsinki University Central Hospital, 2001 to 2014. WMLs were scored according to 4 previously published computed tomographic visual rating scales from all baseline head scans. The inter-rater agreement was calculated. The primary outcome measure was shift analysis, and the secondary examined all possible binary cutoffs in the modified Rankin Scale at 3 months. The associations of modified Rankin Scale with nominal, ordinal, and continuous variables were analyzed in univariate and adjusted in multivariate binary and ordinal regression (shift analysis) models. RESULTS: In univariate and multivariate regression analyses, all 4 tested visual WML rating scales (as continuous variables, or dichotomized at different cutoff points) were associated with worse outcome at all binary levels and in shift analyses of the modified Rankin Scale. After adjusting for confounders, the statistically strongest association in shift analyses remained for the Blennow scale dichotomized at >3 points, reflecting at least moderate WMLs (odds ratio, 1.90; 95% confidence interval, 1.48-2.44). CONCLUSIONS: WMLs on admission computed tomographic scan are independently associated with worse outcome in intravenous thrombolysis-treated patients with stroke.

White Matter Lesions Double the Risk of Post-Thrombolytic Intracerebral Hemorrhage.

BACKGROUND AND PURPOSE: Cerebral white matter lesions (WMLs), a surrogate for small-vessel disease, are common in patients with stroke and may be related to an increased intracranial bleeding risk after intravenous thrombolysis in acute ischemic stroke. We aimed to investigate the risk of symptomatic intracerebral hemorrhage (sICH) in the presence of WMLs in a large cohort of ischemic stroke patients treated with intravenous thrombolysis. METHODS: We included 2485 consecutive patients treated with intravenous thrombolysis at the Helsinki University Central Hospital. WMLs were scored according to 4 previously published computed tomography visual rating scales from all baseline head scans. A sICH was classified according to the European Cooperative Acute Stroke Study II criteria. The associations of sICH with nominal, ordinal, and continuous variables were analyzed in a univariate binary regression model and adjusted in multivariate binary regression models. RESULTS: In univariate and multivariate regression analyses, all 4 tested visual WML rating scales (as continuous variables or dichotomized at different cutoff points) were associated with increased risk of sICH. In binary analyses, WML doubled the bleeding risk: the odds ratios of all 4 visual rating scales ranged from 2.22 (95% confidence interval, 1.49-3.30) to 2.70 (1.87-3.90) in univariable and from 2.00 (1.26-3.16) to 2.62 (1.71-4.02) in multivariable analyses. The multivariable-adjusted odds ratio for the association of high load of WMLs with remote parenchymal hemorrhage was 4.11 (2.38-7.10). CONCLUSIONS: WMLs visible on computed tomography are associated with a more than doubled risk of sICH in patients treated with intravenous thrombolysis for acute ischemic stroke.

Cortical Excitability Measured with nTMS and MEG during Stroke Recovery.

OBJECTIVE: Stroke alters cortical excitability both in the lesioned and in the nonlesioned hemisphere. Stroke recovery has been studied using transcranial magnetic stimulation (TMS). Spontaneous brain oscillations and somatosensory evoked fields (SEFs) measured by magnetoencephalography (MEG) are modified in stroke patients during recovery. METHODS: We recorded SEFs and spontaneous MEG activity and motor threshold (MT) short intracortical inhibition (SICI) and intracortical facilitation (ICF) with navigated TMS (nTMS) at one and three months after first-ever hemispheric ischemic strokes. Changes of MEG and nTMS parameters attributed to gamma-aminobutyrate and glutamate transmission were compared. RESULTS: ICF correlated with the strength and extent of SEF source areas depicted by MEG at three months. The nTMS MT and event-related desynchronization (ERD) of beta-band MEG activity and SICI and the beta-band MEG event-related synchronization (ERS) were correlated, but less strongly. CONCLUSIONS: This first report using sequential nTMS and MEG in stroke recovery found intra- and interhemispheric correlations of nTMS and MEG estimates of cortical excitability. ICF and SEF parameters, MT and the ERD of the lesioned hemisphere, and SICI and ERS of the nonlesioned hemisphere were correlated. Covarying excitability in the lesioned and nonlesioned hemispheres emphasizes the importance of the hemispheric balance of the excitability of the sensorimotor system.

Use of Stroke-Related Income Supplements and Predictors of Use in a Working-Aged Finnish Ischemic Stroke Cohort.

BACKGROUND: Compared with the direct costs, the indirect costs of stroke may be larger contributors to the socioeconomic burden of stroke, and the need to better understand the indirect costs of stroke is well established. We investigated the indirect costs of stroke according to a novel outcome, the use of stroke-related income supplements, in a Finnish cohort of working-aged patients. METHODS: Consecutive patients (n = 230) who experienced a first-ever ischemic stroke were recruited. Demographic, clinical, and cognitive function data (which were measured using clinical neuropsychological assessments) were collected at baseline and at 6-month and 2-year follow-ups. Data on the use of income supplements within the first 3 years of the stroke were retrieved from national insurance registry files and used to construct survival models. RESULTS: Stroke patients used a mean of 11 months of stroke-related income supplements; this use was associated with atrial fibrillation, cognitive impairment, prestroke income supplement use, higher National Institutes of Health Stroke Scale scores, lower Barthel Index scores, and increased lesion sizes. In multivariate survival models, atrial fibrillation and cognitive impairment were the factors most strongly associated with the use of stroke-related income supplements. CONCLUSIONS: Using stroke-related income supplement data to quantify poststroke productivity losses allowed a working-aged cohort to be investigated without inclusion restrictions based on occupational status or other factors; the use of these data as an outcome emphasized the well-known detrimental effects of atrial fibrillation and cognitive impairment on stroke outcome. The results support stroke-related income supplement use as a complementary outcome for understanding stroke-related productivity losses.

Mild hypothermia after intravenous thrombolysis in patients with acute stroke: a randomized controlled trial.

BACKGROUND AND PURPOSE: Hypothermia improves outcome in resuscitated patients and newborns with hypoxic brain injury. We studied the safety and feasibility of mild hypothermia in awake patients with stroke after intravenous thrombolysis. METHODS: Patients were randomized 1:1 to mild hypothermia (35°C) or to standard stroke unit care within 6 hours of symptom onset. Hypothermia was induced with a surface-cooling device and cold saline infusions. Active cooling was restrained gradually after 12 hours at <35.5°C. The primary outcome measure was the number of patients with <36°C body temperature for >80% of the 12-hour cooling period. RESULTS: We included 36 patients with a median of National Institutes of Health Stroke Scale score of 9 one hour after thrombolysis. Fifteen of 18 (83%) patients achieved the primary end point. Sixteen (89%) patients reached <35.5°C in a median time of 10 hours (range, 7-16 hours) from symptom onset, spent 10.5 hours (1-17 hours) in hypothermia, and were back to normothermia in 23 hours (15-29 hours). Few serious adverse events were more common in the hypothermia group. At 3 months, 7 patients (39%) in both groups had good outcome (modified Ranking Scale, 0-2), whereas poor outcome (modified Ranking Scale, 4-6) was twice as common in the normothermia group (44% versus 22%). CONCLUSIONS: Mild hypothermia with a surface-cooling device in an acute stroke unit is safe and feasible in thrombolyzed, spontaneously breathing patients with stroke, despite the adverse events. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00987922.

Predictors of early mortality in young adults after intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Patient and radiological characteristics of intracerebral hemorrhage (ICH), surgical treatment, and outcome after ICH are interrelated. Our purpose was to define whether these characteristics or surgical treatment correlate with mortality among young adults. METHODS: We retrospectively reviewed clinical and imaging data of all first-ever nontraumatic patients with ICH between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 and linked these data with national causes of death registry. A logistic regression analysis of factors associated with 3-month mortality and a propensity score comparison between patients treated conservatively and operatively was performed. RESULTS: Among the 325 eligible patients (59.4% men), factors associated with 3-month mortality included higher National Institutes of Health Stroke Scale score, infratentorial location, hydrocephalus, herniation, and multiple hemorrhages. Adjusted for these factors, as well as demographics, ICH volume, and the underlying cause, surgical evacuation was associated with lower 3-month mortality (odds ratio, 0.06; 95% confidence interval, 0.02-0.21). In propensity score-matched analysis, 3-month case fatality rates were 3-fold in those treated conservatively (27.5% versus 7.8%; P<0.001). CONCLUSIONS: The predictors of short-term case fatality are alike in young and elderly patients with ICH. However, initial hematoma evacuation was associated with lower 3-month case fatality in our young patients with ICH.

The CAVE score for predicting late seizures after intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Seizures are a common complication of intracerebral hemorrhage (ICH). We developed a novel tool to quantify this risk in individual patients. METHODS: Retrospective analysis of the observational Helsinki ICH Study (n=993; median follow-up, 2.7 years) and the Lille Prognosis of InTra-Cerebral Hemorrhage (n=325; 2.2 years) cohorts of consecutive ICH patients admitted between 2004 and 2010. Helsinki ICH Study patients' province-wide electronic records were evaluated for early seizures occurring within 7 days of ICH and among 7-day survivors (n=764) for late seizures (LSs) occurring >7 days from ICH. A Cox regression model estimating risk of LSs was used to derive a prognostic score, validated in the Prognosis of InTra-Cerebral Hemorrhage cohort. RESULTS: Of the Helsinki ICH Study patients, 109 (11.0%) had early seizures within 7 days of ICH. Among the 7-day survivors, 70 (9.2%) patients developed LSs. The cumulative risk of LSs was 7.1%, 10.0%, 10.2%, 11.0%, and 11.8% at 1 to 5 years after ICH, respectively. We created the CAVE score (0-4 points) to estimate the risk of LSs, with 1 point for each of cortical involvement, age<65 years, volume>10 mL, and early seizures within 7 days of ICH. The risk of LSs was 0.6%, 3.6%, 9.8%, 34.8%, and 46.2% for CAVE scores 0 to 4, respectively. The c-statistic was 0.81 (0.76-0.86) and 0.69 (0.59-0.78) in the validation cohort. CONCLUSIONS: One in 10 patients will develop seizures after ICH. The risk of this adverse outcome can be estimated by a simple score based on baseline variables.

The cognitive burden of stroke emerges even with an intact NIH Stroke Scale Score: a cohort study.

BACKGROUND: We aim to facilitate recognition of the cognitive burden of stroke by describing the parallels between cognitive deficits and the National Institutes of Health Stroke Scale (NIHSS), a widely used measure of stroke severity. METHODS: A consecutive cohort of 223 working-age patients with an acute first-ever ischaemic stroke was assessed neuropsychologically within the first weeks after stroke and at a 6-months follow-up visit and compared with 50 healthy demographic controls. The NIHSS was administered at the time of hospital admittance and upon discharge from the acute care unit. The associations between total NIHSS scores and domain-specific cognitive deficits were analysed correlatively and with a binary logistic regression. RESULTS: Of the NIHSS measurements (admittance median=3, range 0-24; discharge median=1, range 0-13), the total score at the time of discharge had systematically stronger correlations with cognitive impairment. Adjusted for demographics, the NIHSS discharge score stably predicted every cognitive deficit with ORs ranging from 1.4 (95% CI 1.2 to 1.6) for episodic memory to 1.9 (95% CI 1.5 to 2.3) for motor skills. The specificities of the models ranged from 89.5-97.7%, but the sensitivities were as low as 11.6-47.9%. Cognitive deficits were found in 41% of patients with intact NIHSS scores and in all patients with NIHSS scores ≥4, a finding that could not be accounted for by confounding factors. CONCLUSIONS: Cognitive deficits were common even in patients with the lowest NIHSS scores. Thus, low NIHSS scores are not effective indicators of good cognitive outcomes after stroke.

Executive and memory dysfunction related to binge drinking in stroke survivors during a 9-year follow-up.

Background: Ischemic stroke and heavy alcohol consumption are both known risk factors for cognitive impairment. The issue gains importance because the prevalence of stroke and binge drinking have both increased among working-aged adults. Alarmingly, a recent cross-sectional study suggests the additive negative effects of binge drinking and comorbid brain disease on cognition. However, the long-term cognitive prognosis of the additive effects of stroke and binge drinking on adults remains unknown. Methods: In this prospective, two-center cohort study, we recruited consecutive 18-65-year-old patients with first-ever ischemic stroke along with demographically matched stroke-free controls. Patients participated in neuropsychological assessment at 6 months, 2 years, and 9 years after stroke, and in neurological assessment at acute care and at 9-year follow-up. Controls participated in a similar follow-up procedure. We examined the association between binge drinking, follow-up time, and long-term cognitive outcomes using repeated-measures analysis of variance. Results: We included 85 patients who had had their first-ever and only ischemic stroke (mean age 53 years at the incident stroke). Patients were divided into binge-drinking (n = 22) and non-binge-drinking groups (n = 63) based on the shortened version of the Alcohol Use Disorders Identification Test. Follow-up data in healthy controls (n = 31) was used to normalize the patients' test scores for effects of age, sex, and education. We compared cognitive changes between binge-drinking and non-binge-drinking patients over a 9-year follow-up. Non-binge-drinking patients outperformed binge-drinking patients across all follow-up points on most of the executive function tests and in one memory test: binge drinking had a significant main effect both on executive function (the phonemic fluency task, p = 0.002; the Trail Making Test, p = 0.013) and memory (the list learning task, p = 0.002). Conclusion: Binge drinking was associated with executive and memory dysfunction at three time points over a decade after a first-ever ischemic stroke. Subdiagnostic binge drinking might increase the adverse effects of a first-ever ischemic stroke on executive function and memory, evident over a decade poststroke.

Association of prestroke statin use and lipid levels with outcome of intracerebral hemorrhage.

BACKGROUND AND PURPOSE: It is unclear whether blood lipid profiles and statin use before intracerebral hemorrhage (ICH) are associated with its outcome. METHODS: The Helsinki ICH Study, a single-center observational registry of consecutive ICH patients, was used to study the associations between premorbid statin use, baseline lipid levels, and clinical outcome. RESULTS: The registry includes 964 ICH patients. Statin users (n=187; 19%) were significantly older, had more frequent comorbidities and medication, lower lipid levels, and higher admission Glasgow Coma Scale compared with nonusers. Modified Rankin Scale at discharge or mortality did not differ between statin users and nonusers. Compared with survivors, significantly lower total cholesterol and low-density lipoprotein cholesterol levels were observed in patients who died in hospital (median, 4.1 mmol/L [interquartile range, 3.6-4.4] versus 4.5 [3.8-5.1]; P<0.01; 1.9 mmol/L [1.4-2.5] versus 2.4 [1.8-3.0]; P<0.001, respectively), at 3 or 12 months. After adjusting for known ICH prognostic factors based on univariate analysis that is, age, National Institutes of Health Stroke Scale, Glasgow Coma Scale, ICH volume, and intraventricular location, lower low-density lipoprotein levels were independently associated with in-hospital mortality (odds ratio, 0.54 [95% confidence interval, 0.31-0.93]; P=0.028). CONCLUSIONS: Premorbid statin use did not affect the outcome of ICH, but lower low-density lipoprotein levels were associated with higher in-hospital mortality.

Symptomatic intracranial hemorrhage after stroke thrombolysis: the SEDAN score.

OBJECTIVE: A study was undertaken to develop a score for assessing risk for symptomatic intracranial hemorrhage (sICH) in ischemic stroke patients treated with intravenous (IV) thrombolysis. METHODS: The derivation cohort comprised 974 ischemic stroke patients treated (1995-2008) with IV thrombolysis at the Helsinki University Central Hospital. The predictive value of parameters associated with sICH (European Cooperative Acute Stroke Study II) was evaluated, and we developed our score according to the magnitude of logistic regression coefficients. We calculated absolute risks and likelihood ratios of sICH per increasing score points. The score was validated in 828 patients from 3 Swiss cohorts (Lausanne, Basel, and Geneva). Performance of the score was tested with area under a receiver operating characteristic curve (AUC-ROC). RESULTS: Our SEDAN score (0 to 6 points) comprises baseline blood Sugar (glucose; 8.1-12.0 mmol/l [145-216 mg/dl] = 1; >12.0 mmol/l [>216 mg/dl] = 2), Early infarct signs (yes = 1) and (hyper)Dense cerebral artery sign (yes = 1) on admission computed tomography scan, Age (>75 years = 1), and NIH Stroke Scale on admission (≥10 = 1). Absolute risk for sICH in the derivation cohort was: 1.4%, 2.9%, 8.5%, 12.2%, 21.7%, and 33.3% for 0, 1, 2, 3, 4, and 5 score points, respectively. In the validation cohort, absolute risks were similar (1.0%, 3.5%, 5.1%, 9.2%, 16.9%, and 27.8%, respectively). AUC-ROC was 0.77 (0.71-0.83; p < 0.001). INTERPRETATION: Our SEDAN score reliably assessed risk for sICH in IV thrombolysis-treated patients with anterior- and posterior circulation ischemic stroke, and it can support clinical decision making in high-risk patients. External validation of the score supports its generalization.

The severity of cognitive deficits predicts return to work after a first-ever ischaemic stroke.

BACKGROUND: The inability of stroke patients to return to work contributes disproportionately to the socioeconomic impact of stroke and is best predicted by the severity of stroke. However, the role of cognitive deficits in stroke severity has not been scrutinised. We studied whether the initial cognitive severity of stroke, compared with other influential factors, predicts the inability to return to work after stroke. METHODS: Consecutive patients aged 18--65 with a first-ever ischaemic stroke, working full time previously, were assessed neuropsychologically within the first weeks after stroke and at the 6-month follow-up. Similarly, 50 healthy demographic controls were assessed twice. The cognitive severity of stroke was operationalised as the number of initial cognitive deficits. Cognitive severity as a predictor of the inability to return to work was compared with demographic, occupational, neurological, radiological and functional data, vascular risk factors and mood state. RESULTS: The mean age of the 140 patients assessed both initially and at follow-up was 52 years. They had a mean of 13 years of education and 59% were men. At 6 months, only 41% of the patients had returned to work despite the relatively minor neurological and functional impairments of the cohort. In our model, the number of early cognitive deficits (OR=2.252, CI 1.294 to 3.918) was the only significant predictor of the inability to return to work. CONCLUSIONS: The initial cognitive severity of stroke predicts the later inability to return to work. The benefits of neuropsychological assessments within the first weeks after stroke are emphasised.

SMASH-U: a proposal for etiologic classification of intracerebral hemorrhage.

BACKGROUND AND PURPOSE: The purpose of this study was to provide a simple and practical clinical classification for the etiology of intracerebral hemorrhage (ICH). METHODS: We performed a retrospective chart review of consecutive patients with ICH treated at the Helsinki University Central Hospital, January 2005 to March 2010 (n=1013). We classified ICH etiology by predefined criteria as structural vascular lesions (S), medication (M), amyloid angiopathy (A), systemic disease (S), hypertension (H), or undetermined (U). Clinical and radiological features and mortality by SMASH-U (Structural lesion, Medication, Amyloid angiopathy, Systemic/other disease, Hypertension, Undetermined) etiology were analyzed. RESULTS: Structural lesions, namely cavernomas and arteriovenous malformations, caused 5% of the ICH, anticoagulation 14%, and systemic disease 5% (23 liver cirrhosis, 8 thrombocytopenia, and 17 various rare conditions). Amyloid angiopathy (20%) and hypertensive angiopathy (35%) were common, but etiology remained undetermined in 21%. Interrater agreement in classifying cases was high (κ, 0.89; 95% CI, 0.82-0.96). Patients with structural lesions had the smallest hemorrhages (median volume, 2.8 mL) and best prognosis (3-month mortality 4%), whereas anticoagulation-related ICHs were largest (13.4 mL) and most often fatal (54%). Overall, median ICH survival was 5½ years, varying strongly by etiology (P<0.001). After adjustment for baseline characteristics, patients with structural lesions had the lowest 3-month mortality rates (OR, 0.06; 95% CI, 0.01-0.37) and those with anticoagulation (OR, 1.9; 1.0-3.6) or other systemic cause (OR, 4.0; 1.6-10.1) the highest. CONCLUSIONS: In our patients, performing the SMASH-U classification was feasible and interrater agreement excellent. A plausible etiology was determined in most patients but remained elusive in one in 5. In this series, SMASH-U based etiology was strongly associated with survival.

Activation in parietal operculum parallels motor recovery in stroke.

Motor recovery after stroke requires continuous interaction of motor and somatosensory systems. Integration of somatosensory feedback with motor programs is needed for the automatic adjustment of the speed, range, and strength of the movement. We recorded somatosensory evoked fields (SEFs) to tactile finger stimulation with whole-scalp magnetoencephalography in 23 acute stroke patients at 1 week, 1 month, and 3 months after stroke to investigate how deficits in the somatosensory cortical network affect motor recovery. SEFs were generated in the contralateral primary somatosensory cortex (SI) and in the bilateral parietal opercula (PO) in controls and patients. In the patients, SI amplitude or latency did not correlate with any of the functional outcome measures used. In contrast, the contralateral PO (cPO) amplitude to the affected hand stimuli correlated significantly with hand function in the acute phase and during recovery; the weaker the PO activation, the clumsier the hand was. At 1 and 3 months, enhancement of the cPO activation paralleled the improvement of the hand function. Whole-scalp magnetoencephalography measurements revealed that dysfunction of somatosensory cortical areas distant from the ischemic lesion may affect the motor recovery. Activation strength of the PO paralleled motor recovery after stroke, suggesting that the PO area is an important hub in mediating modulatory afferent input to motor cortex.

Probing modifications of cortical excitability during stroke recovery with navigated transcranial magnetic stimulation.

OBJECTIVE: To follow cortical excitability changes during recovery from stroke with navigated transcranial magnetic stimulation (nTMS), in particular, to characterize changes of short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF), to correlate them with recovery of upper extremity function, and to detect possible shifts of cortical hand representations. METHODS: Single and paired pulse nTMS were delivered to the hemisphere with infarction and to the hemisphere without infarction in 14 first-ever stroke patients at 1 (T1) and 3 months (T2) after stroke. Electromyographic responses to nTMS stimulation were recorded from the first dorsal interosseus muscles. nTMS was used to ensure an accurate coil repositioning in repeated measurements. Hand function recovery was clinically evaluated using the Action Research Arm Test (ARAT) and 9-hole peg test (9-HPT). RESULTS: SICI and ICF were modulated in both hemispheres during recovery. Inhibition in the hemisphere without infarction correlated significantly with the affected hand performance at T2; stronger disinhibition (poor inhibition) was associated with worse hand performance. Location of hand muscle representations was shifted in 3 well-recovered patients out of 14 patients at T2. CONCLUSIONS: In line with earlier studies, disinhibition in the hemisphere without infarction may be related to poor recovery of the affected hand. Usage of the affected hand during stroke recovery seems to influence these cortical excitability changes. nTMS is a valuable tool for tracking muscle cortical representation changes during brain reorganization.