Multidomain intervention for the prevention of cognitive decline after stroke - a pooled patient-level data analysis.

BACKGROUND AND PURPOSE: The aim of this pooled patient-level data analysis was to test if multidomain interventions, addressing several modifiable vascular risk factors simultaneously, are more effective than usual post-stroke care for the prevention of cognitive decline after stroke. METHODS: This pooled patient-level data analysis included two randomized controlled trials using a multidomain approach to target vascular risk factors in stroke patients and cognition as primary outcome. Changes from baseline to 12 months in the trail making test (TMT)-A, TMT-B and 10-words test were analysed using stepwise backward linear mixed models with study as random factor. Two analyses were based on the intention-to-treat (ITT) principle using different imputation approaches and one was based on complete cases. RESULTS: Data from 322 patients (157 assigned to multidomain intervention and 165 to standard care) were analysed. Differences between randomization groups for TMT-A scores were found in one ITT model (P = 0.014) and approached significance in the second ITT model (P = 0.087) and for complete cases (P = 0.091). No significant intervention effects were found for any of the other cognitive variables. CONCLUSION: We found indications that multidomain interventions compared with standard care can improve the scores in TMT-A at 1 year after stroke but not those for TMT-B or the 10-words test. These results have to be interpreted with caution due to the small number of patients.

Disabling neurological syndromes: prevalence amongst hospitalized neurological patients.

Neurological patient populations are usually described by diagnosis or in terms of functional disability measures but rarely by their clinical syndromes. A point-prevalence study was conducted assessing 349 neurological inpatients to determine the frequency and co-occurrence of disabling neurological syndromes, considering a wider spectrum including pain, emotional, neuropsychological, vegetative and sensorimotor syndromes. Of the study patients, 61% (n = 224) had sensorimotor syndromes, 53% (n = 185) had neuropsychological disorders, 40% (n = 139) of the patients suffered from pain, emotional disorders were found in 36% (n = 122) and vegetative disorders in 33% (n = 113). Although frequency varied by neurological diagnosis, these disabling conditions were found across all inpatient groups of diagnosis. Similarly, disorders outside the motor domains grouped according to their Barthel Index showed a striking frequency in patients considered as activities of daily living independent, reflecting a wider spectrum of disability that functional measures are not able to capture. Of the study population, 68% (n = 237) suffered from co-occurring disorders from different categories (pain, emotional, neuropsychological, vegetative and sensorimotor syndromes). There is a high prevalence and co-occurrence of disabling syndromes in neurological inpatients. These proportions reflect the neurological workload in a patient population and should be considered in future rehabilitation research and allocation of resources.

Dyslipidemia, elevated LDL cholesterol and reduced nocturnal blood pressure dipping denote lacunar strokes occurring during nighttime.

Previous studies have shown a peak occurrence of ischemic stroke in the morning but no consistent finding has been attributed to this. Focused on lacunar strokes we performed a prospective study with a detailed diagnostic protocol including parameters of recent infection, indicators of sleep apnea and cerebral vasoreactivity (CVR), aimed at defining differences in risk profiles between diurnal and nocturnal strokes. Consecutively we included 33 nocturnal and 54 diurnal strokes. Baseline characteristics, known risk factors, stroke severity and topology were not different between groups. The mean low-density lipoprotein (LDL) cholesterol level was significantly higher amongst patients with nocturnal strokes (133.3 +/- 35.2 mg/dl vs. 115.5 +/- 39.8 mg/dl; P = 0.04), as well as the proportion of patients with any dyslipidemia (94% vs. 77.8%; P = 0.047). Twenty-four-hour blood pressure recordings showed a reduced nocturnal decrease of blood pressure in subjects with strokes that occurred between 10 pm and 6 am in comparison with those whose strokes occurred between 6 am and 2 pm (5.0 +/- 7.3% vs. 11.0 +/- 6.7%; P = 0.049). No significant differences were found for parameters of recent infection (including seroreactivity against Chlamydia pneumoniae and cytomegalovirus), CVR, indicators of sleep apnea and the degree of white matter disease assessed by magnetic resonance tomography. Dyslipidemia, especially elevated LDL cholesterol is more prevalent in nocturnal lacunar strokes especially when combined with a reduced nocturnal dipping of blood pressure. This risk factor profile can be regarded as an additional target for stroke prevention.

[Time delays in admission to a Stroke Unit and emergency treatment of patients with ischemic stroke]. / Zeitliche Verzögerungen bei der Zuweisung und Akutbehandlung von ischämischen Insulten an einer Stroke Unit.

BACKGROUND AND OBJECTIVE: This observational study describes the time delays involved in the emergency treatment of acute strokes admitted for treatment in the acute stroke unit of the Landesnervenklinik Gugging, Austria. The aim was to define avoidable delays in the prehospital and intrahospital phase. PATIENTS AND METHODS: 261 stroke patients were included consecutively within the one-year study period (September 1996 until September 1997). Minute-by-minute reconstruction of events starting from the first symptoms to the first therapeutic application within the stroke unit was performed for every stroke patient by a neurologist during or immediately after treatment. RESULTS: Time delays are predominantly in the prehospital phase. Only 20.5% are admitted within 120 minutes after noticing first symptoms. Public registration time was 42 +/- 212 minutes. In the intrahospital phase, the mean door-to-drug-time was 50 +/- 28 minutes (including CT). In 25% of the patients, adequate treatment of acute stroke was started within 35 minutes after the patient's arriving at the hospital. In 92% cerebral computed tomography was performed before treatment was started. CONCLUSIONS: This study shows the necessity for continuing efforts to increase public awareness for immediate hospitalisation after stroke in order to achieve a higher rate of urgent and direct admission to a stroke unit.

[Stroke prevention with a high risk strategy of treating hypertension in patients after a transient ischemic attack]. / Schlaganfallprävention mittels einer Hochrisikostrategie der Hypertoniebehandlung bei Patienten nach einer transienten ischämischen Attacke.

High-risk strategies represent important preventive measures that focus on individuals with a defined high risk of suffering a chronic disease. They are valuable in addition to measures of prevention within the general population. One example for a high-risk approach for stroke prevention is the treatment of hypertension in individuals that have previously suffered a transient ischemic attack (TIA). Data from the Klosterneuburg Stroke Data Bank and other sources enable an estimate of 2000 TIAs occurring in Austria each year, half of them being hypertensives that are mostly not treated or not sufficiently treated for their hypertension. A high-risk programme that implies forced and effective treatment of hypertension would prevent some 400 strokes or 3% of 16,000 first-ever strokes per year. Costs for preventing one stroke by means of Betablocker agents would amount to ATS 3500 and by ACE-inhibitor agents ATS 11,500, respectively. In addition to general preventive measures, such a programme would have an important impact on stroke incidence and public health.

[Modification of risk factors after cerebral infarct: results of the Klosterneuburg Stroke Databank]. / Modifikation von Risikofaktoren nach zerebralem Insult: Ergebnisse der Klosterneuburger Schlaganfall-Datenbank.

A number of studies have shown that reduction of elevated blood pressure and other major risk factors are essential for the primary prevention of stroke. In contrast, only sparce data exist as to the reduction of risk factors in secondary prevention although many patients are only ready to modify their lifestyle after having suffered a stroke. This study reports the results of the one-year follow-up examinations from the Klosterneuburg Stroke Data Bank, a prospective, hospital-based registry. Out of 870 stroke survivors (97.4% follow-up rate) registered between 1988 and 1994 575 patients (69%) had been hypertensive before their index stroke. Out of these, 112 hypertensives (19.7% of all hypertensives) had not received antihypertensive treatment before their index stroke. Compared to all other hypertensive stroke patients they were significantly younger (p = 0.01), more often regular drinkers (p = 0.01), and regular smokers (p = 0.007). They showed significantly less heart diseases (p = 0.03) as well as prior strokes (p = 0.006). 12 months after the index-stroke the rate of untreated hypertension in this group fell to 6.0% (34 patients). In the latter group there were more frequent prior strokes compared to those hypertensives who started regular treatment after their index stroke (p = 0.003). Out of 221 smokers only 115 (52%) had quit smoking within one year after the index-stroke and 110 out of 270 (40.7%) stroke patients that had had regular alcohol intake had stopped drinking. 42 out of 118 (36%) patients who had been regular drinkers and smokers continued to drink and smoke. Regular intake of aspirin was noted more often in those patients who also had regular blood pressure checks (p = 0.009) and regular antihypertensive treatment (p = 0.001). It is concluded that there is insufficient modification of risk factors after stroke and controlled interventional studies in secondary stroke prevention are an important issue.

Silent brain infarcts and transient ischemic attacks. A three-year study of first-ever ischemic stroke patients: the Klosterneuburg Stroke Data Bank.

BACKGROUND AND PURPOSE: We undertook to study the clinical relevance of silent strokes and history of transient ischemic attacks (TIAs) and their individual and combined effects on outcome variables of neurological and epidemiological interest in first-ever stroke patients. METHODS: We performed univariate and multivariate analyses of data prospectively collected in the Klosterneuburg Stroke Data Bank, a hospital-based registry in Austria that includes a 3-year follow-up program. RESULTS: Of 728 patients (mean age, 68 +/- 10 years) with a first-ever ischemic stroke, 110 (15%) had had a previous TIA, and 66/618 (11%) patients did not have a history of TIA but showed evidence of silent brain infarct on CT. Outcome variables of neurological interest were not significantly different between groups, including time between stroke and study entry, activities of daily living status at first presentation, median time of hospitalization, 30-day mortality, or 3-year mortality. Univariate analyses of epidemiologically important risk factors showed either history of TIA or evidence of silent infarct to be more frequently associated with hypertension (P = .007). Cox models of survival showed that neither history of TIA nor evidence of silent infarct were significantly associated with an increase in 3-year mortality. CONCLUSIONS: Over a period of 3 years, neither history of TIA nor evidence of silent infarct diagnosed at the time of the presenting major stroke in first-ever ischemic stroke patients exert an important influence on neurological or epidemiological outcome variables.