Varicella-zoster virus vasculopathy in a patient with multiple sclerosis receiving natalizumab.

We present a case of a woman in her 30s with relapsing-remitting multiple sclerosis, treated with natalizumab, who developed ophthalmic varicella zoster virus (VZV) infection, with subsequent vasculopathy causing cerebral ischaemic lesions. She was treated with acyclovir, prednisolone and acetylsalicylic acid and fully recovered. VZV vasculopathy is associated with stroke and immunomodulating treatments may increase the risks of these adverse events. To date, nine VZV-related vasculopathy cases in patients treated with natalizumab have been reported in English literature and are summarised in this paper. Although rare, VZV intracerebral vasculopathy is an important differential diagnosis in patients with unexplained new-onset neurological symptoms after a herpes zoster infection. Treatment guidelines for VZV vasculopathy and for continuing treatment of multiple sclerosis after such an event are currently not established.

[TIA - immediate acute care and treatment decrease the risk of stroke substantially]. / TIA ­ akut handläggning och behandling minskar strokerisk.

TIA is defined as an episode of neurological deficit with sudden onset, caused by focal cerebral or retinal ischemia lasting less than 24 hours. A tissue-based definition has been proposed but its application has been challenging, in part as its use requires magnetic resonance imaging. In most cases the diagnosis is solely based on history as provided by the patient. The diagnosis can therefore be challenging, and interobserver agreement between physicians is only fair. The importance of a TIA is its subsequent substantial risk of stroke, especially within the first weeks. Immediate acute care and treatment has been shown to decrease the risk of stroke substantially and is therefore crucial. Diagnostic procedures include imaging of the brain and neck vessels, ECG and cardiac rhythm monitoring, and blood pressure measuring. Treatment decisions are based on the diagnostic findings and include antithrombotic therapy, statins, blood pressure lowering medications, and carotid surgery if indicated.

Diverging Trends in the Incidence of Spontaneous Intracerebral Hemorrhage in Sweden 2010-2019: An Observational Study from the Swedish Stroke Register (Riksstroke).

INTRODUCTION: Although ischemic stroke incidence has decreased in Sweden over the past decade, trends in spontaneous intracerebral hemorrhage (ICH) incidence are less well delineated. In this time period, there has been a dramatic increase in use of oral anticoagulants (OAC). The aim of our study was to investigate incidence trends in spontaneous first-ever ICH in Sweden between 2010 and 2019, with a focus on non-OAC-associated and OAC-associated ICH. METHODS: We included patients (≥18 years) with first-ever ICH registered in the hospital-based Swedish Stroke Register (Riksstroke) 2010-2019. Data were stratified by non-OAC and OAC ICH and analyzed for 2010-2012, 2013-2016, and 2017-2019. Incidence rates are shown as crude and age-specific per 100,000 person-years. RESULTS: Between 2010 and 2019, 22,289 patients with first-ever ICH were registered; 18,325 (82.2%) patients with non-OAC ICH and 3,964 (17.8%) patients with OAC ICH. Annual crude incidence (per 100,000) of all first-ever ICH decreased by 10% from 29.5 (95% CI 28.8-30.3) to 26.7 (95% CI 26.0-27.3) between 2010-2012 and 2017-2019. The crude incidence rate of non-OAC ICH decreased by 20% from 25.7 (95% CI 25.0-26.3) to 20.7 (95% CI 20.1-21.2), whereas OAC ICH increased by 56% from 3.86 (95% CI 3.61-4.12) to 6.01 (95% CI 5.70-6.32). The proportion of OAC ICH of all first-ever ICH increased between 2010-2012 and 2017-2019 from 13.1% to 22.5% (p < 0.001). Proportional changes were largest in the age group ≥85 years with a decrease in non-OAC ICH by 32% from 155 (95% CI 146-164) to 106 (95% CI 98.6-113) and an increase in OAC ICH by 155% from 25.7 (95% CI 22.1-29.4) to 65.5 (95% CI 59.9-71.2). CONCLUSION: Incidence of first-ever ICH in Sweden decreased by 10% between 2010 and 2019. We found diverging trends with a 20% decrease in non-OAC-associated ICH and a 56% increase in OAC-associated ICH. Further research on ICH epidemiology, analyzing non-OAC and OAC-associated ICH separately, is needed to follow up these diverging trends including underlying risk factors.

Epidemiology of First and Recurrent Ischemic Stroke in Sweden 2010-2019: A Riksstroke Study.

INTRODUCTION: Ischemic stroke incidence appears to have decreased during the last decades, but most studies focus on the first-ever events and epidemiological data on recurrent stroke are scarce. The aim of our study was to investigate trends in incidence, risk factors, and medication in patients with first-ever and recurrent ischemic stroke between 2010 and 2019 in Sweden. METHODS: We included patients (≥18 years old) with ischemic stroke registered in the hospital-based Swedish Stroke Register (Riksstroke) 2010-2019. The coverage of Riksstroke was consistently high (about 90%) during this period. Data were stratified by first-ever and recurrent ischemic stroke in three different time periods (2010-2012, 2013-2016, and 2017-2019) and shown as crude and age-specific incidence rates per 100,000 person-years. Statistics Sweden provided census data on the Swedish population in different age groups. RESULTS: During the study period, 201,316 cases of ischemic stroke were registered in Riksstroke, including 153,865 (76.4%) cases of first-ever ischemic stroke and 46,248 (23.0%) cases of recurrent ischemic stroke (0.6% of cases unclassified). The crude incidence of first-ever ischemic stroke decreased by 17% from 216 (95% CI 214-218) to 179 (95% CI 177-181) between 2010-2012 and 2017-2019, whereas recurrent ischemic stroke decreased by 33% from 72 (95% CI 71-73) to 48 (95% CI 47-49). Between these time periods, diminishing ischemic stroke incidence was seen in all age groups with highest decline noted in those aged 75-84 years (928 [95% CI 914-943] to 698 [95% CI 686-709]; -25% in first-ever ischemic stroke and 361 [95% CI 351-370] to 219 [95% CI 213-226]; -39% in recurrent ischemic stroke) and ≥85 years (1,674 [95% CI 1,645-1,703] to 1,295 [95% CI 1,270-1,320]; -23% in first-ever ischemic stroke and 683 [95% CI 664-702] to 423 [95% CI 409-437]; -38% in recurrent ischemic stroke). Treatment with anticoagulants in patients with atrial fibrillation and lipid-lowering drugs increased considerably in patients with first-ever and recurrent ischemic stroke both at admission and discharge during the study period. CONCLUSION: Whereas both first-ever and recurrent ischemic stroke rates declined in Sweden between 2010 and 2019, the proportional decline was almost double for recurrent ischemic stroke than for first-ever ischemic stroke and most pronounced in the elderly. Increased use of secondary preventive drugs, in particular anticoagulants in atrial fibrillation, appears to have contributed, but further studies on precise causes for the decline in recurrent ischemic stroke are needed.

Atrial Fibrillation in Transient Ischemic Attack Versus Ischemic Stroke: A Swedish Stroke Register (Riksstroke) Study.

BACKGROUND AND PURPOSE: Compared with ischemic stroke (IS), the association of atrial fibrillation (AF) with transient ischemic attack (TIA) is less well established. We aimed to assess the proportion of AF in patients with TIA, and these patients' characteristics and secondary preventive treatment in comparison to patients with IS. METHODS: Hospital-based data on TIA and IS events, registered from July 2011 to June 2013, were obtained from the Swedish Stroke Register (Riksstroke). A time-based TIA definition (duration of symptoms <24 hours) was applied. AF was registered as present when previously known or diagnosed at the time of assessment. RESULTS: AF was present in 2779 of 14 980 (18.6%) patients with TIA and 13 258 of 44 173 (30.0%) patients with IS. The proportion of AF increased with age, reaching 32.9% in TIA and 46.6% in IS patients ≥85 years. Both in TIA and IS, age, hypertension, a history of stroke, and TIA, and being a nonsmoker were associated with the presence of AF. In contrast to IS, AF was less common in female than in male patients with TIA. At discharge, 64.2% of TIA and 50.0% of IS patients with AF were treated with oral anticoagulants. Proportions of AF patients treated with oral anticoagulants decreased substantially with increasing age. CONCLUSIONS: AF is highly prevalent not only in IS but also in TIA patients, with proportions steeply increasing with age. In both TIA and IS, a substantial proportion of patients with AF were discharged without anticoagulant therapy.

Validation of Diagnoses of Transient Ischemic Attack in the Swedish Stroke Register (Riksstroke) TIA-Module.

BACKGROUND: In 2010, the Swedish Stroke Register (Riksstroke; RS) established a module for transient ischemic attacks (RS-TIA). We report a diagnostic validation study of patients included in RS-TIA. METHODS: During the first year, 7,825 patients were registered at 59 out of 74 Swedish hospitals. A time-based TIA definition was applied. A sample of 180 patients (30 patients each from 6 hospitals), with a similar distribution of age and sex as in RS-TIA, was prepared. Two independent observers assessed medical records for quality of documentation and assigned a diagnosis of likely, possible, unlikely TIA or ischemic stroke, according to prespecified criteria. RESULTS: The 2 observers agreed in 77% of cases that the event was a likely or possible TIA, in 3% that the event was an ischemic stroke, and in 2% that the event was an unlikely TIA. The observers disagreed in 8% of patients on TIA vs. ischemic stroke, and in 11% on a vascular vs. non-vascular cause. Quality of documentation was fair. CONCLUSIONS: There was interobserver agreement on diagnosis of TIA in the majority of patients included in RS-TIA. Diagnostic accuracy may be further improved by more systematic documentation of symptoms and signs.

Combined clinical and radiological prognostic model in acute ischemic stroke.

We sought to propose and test the validity ofa comprehensive prognostic model in middle cerebral artery-stroke treated with intravenous thrombolysis. A total of 127 consecutive patients (aged 70 +/- 12 years; 54% males) were included in this retrospective study. Variables included in our prognostic model were: NIHSS on admission (1-3 points), occurrence of hyperdense middle cerebral artery sign and early ischemic signs on baseline CT (1 point each), NIHSS at 24 hours (0-3 points), posttreatment hemorrhage (1 point), and infarct volume (0-4 points). The score range was 1-13, with higher values suggest unfavorable prognosis. Our prognostic score was correlated with the modified Rankin scale (mRS) at 3 months after stroke [correlation coefficient of 0.62, P < 0.001] and can thus help early prediction of the functional outcome. Logistic regression showed that NIHSS at 24 hours and EICs on baseline CT were independent predictor of our prognostic score (adjusted odds ratio of 4.1 and 5). Adopting a cut-off value of prognostic score < or = 3 for favorable prognosis and > or = 7for unfavorable prognosis helped to predict the need for institutionalization and the functional outcome with higher accuracy and predictive values compared with using scores only based on NIHSS.

Transient ischemic attack with deceptive presentation.

A patient with an initial diagnosis of TIA presented with a deceptive course of events and unfavorable outcome. Only a non-enhanced brain CT was performed initially. Hemodynamic studies were done later on and revealed internal carotid artery (ICA) dissection on CT-angiography and evidence of irreversible ischemic changes on perfusion studies indicating that the ischemic process presumably was ongoing since the initial ischemic episode. Efforts to define patients with TIA with risk of developing major stroke are ongoing. We hereby exhort for more effort to include hemodynamic studies as early as possible in the radiological work-up of TIA.

Stroke incidence, recurrence, and case-fatality in relation to socioeconomic position: a population-based study of middle-aged Swedish men and women.

BACKGROUND AND PURPOSE: Low socioeconomic status is associated with increased incidence of stroke. This study investigated stroke incidence, recurrence, and case-fatality after stroke among middle-aged Swedish men and women and whether this association differs by gender or stroke subtype. METHODS: A total of 69 625 (49% men) citizens, aged 40 to 65 years, living in the city of Malmö in 1990 were studied in relation to total annual income and occupation class, ie, 2 indicators of socioeconomic status. Incidence of first-ever stroke, stroke recurrence, and case-fatality (death within 28 days or 1 year after stroke) were studied over 10 years of follow-up. RESULTS: During the follow-up, a total of 1648 subjects developed a first-ever stroke of whom 275 also experienced a recurrent stroke. By using Cox regression model with covariate adjustments, the incidence of stroke was significantly increased (relative risk: 1.75, 95% CI:1.36 to 2.25) in women who were in the lowest quartile of income compared with the women being in the highest quartile. Corresponding relative risk in men was 1.29 (1.06 to 1.58). Both in men and women, income was significantly associated with ischemic, but not hemorrhagic, subtypes of stroke. Similar relationships were observed between occupation level and incidence of stroke. In addition, low income was associated with higher 28-day and 1-year fatality rates in men (relative risk: 3.13, 1.35 to 7.24 and 2.17, 1.18 to 4.00, respectively), but not in women. In contrast, recurrence of stroke was inversely associated with income only in women. CONCLUSIONS: Incidence of stroke, stroke recurrence, and case-fatality increased with decreasing socioeconomic status; however, this relationship differed by gender and subtype of events.