European Academy of Neurology and European Stroke Organization consensus statement and practical guidance for pre­hospital management of stroke

Background and purpose The reduction of delay between onset and hospital arrival and adequate pre­hospital care of persons with acute stroke are important for improving the chances of a favourable outcome. The objective is to recommend evidence­based practices for the management of patients with suspected stroke in the pre­hospital setting. Methods The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to define the key clinical questions. An expert panel then reviewed the literature, established the quality of the evidence, and made recommendations. Results Despite very low quality of evidence educational campaigns to increase the awareness of immediately calling emergency medical services are strongly recommended. Moderate quality evidence was found to support strong recommendations for the training of emergency medical personnel in recognizing the symptoms of a stroke and in implementation of a pre­hospital 'code stroke' including highest priority dispatch, pre­hospital notification and rapid transfer to the closest 'stroke­ready' centre. Insufficient evidence was found to recommend a pre­hospital stroke scale to predict large vessel occlusion. Despite the very low quality of evidence, restoring normoxia in patients with hypoxia is recommended, and blood pressure lowering drugs and treating hyperglycaemia with insulin should be avoided. There is insufficient evidence to recommend the routine use of mobile stroke units delivering intravenous thrombolysis at the scene. Because only feasibility studies have been reported, no recommendations can be provided for pre­hospital telemedicine during ambulance transport. Conclusions These guidelines inform on the contemporary approach to patients with suspected stroke in the pre­hospital setting. Further studies, preferably randomized controlled trials, are required to examine the impact of particular interventions on quality parameters and outcome.

Clinical outcome of cardioembolic stroke treated by intravenous thrombolysis.

INTRODUCTION: Cardioembolic stroke (CS) in patients without thrombolytic treatment is associated with a worse clinical outcome and higher mortality compared to other types of stroke. The aim of this study was to determine the clinical outcome of CS in patients treated by intravenous thrombolysis (IVT). MATERIAL AND METHODOLOGY: Data of patients from the SITS-EAST register (Safe Implementation of Treatments in Stroke) were analyzed in patients who received IVT treatment from 2000 to April 2014. The effect of the stroke etiology according to ICD-10 classification on outcome was analyzed using a univariate and multivariate analysis. The outcomes were assessed as follows: excellent clinical outcome (modified Rankin scale (mRS) 0-1) at 3 months, the rate of symptomatic intracranial hemorrhage (sICH), mortality, and improvement at 24 hours after IVT. RESULTS: Data of 13 772 patients were analyzed. CS represented 30% of all strokes. The mean age of patients with CS, atherothrombotic stroke, lacunar stroke, and other stroke was 70.8, 66.7, 66.2, and 63.3 years, respectively (P < .001). Severity of stroke on admission by median NIHSS score was 13 points in patients with CS, 12 points - in atherothrombotic stroke, 7 points - in lacunar stroke, and 10 points-in other stroke types (P < .001). No difference in mortality was detected among atherothrombotic and CS; however, atherothrombotic strokes had higher odds of sICH [OR = 1.63 (95% CI: 1.07-2.47), P = .023], lower odds of early improvement [OR = 0.79 (95% CI: 0.72-0.86), P < .001], and excellent clinical outcome [OR = 0.77 (95% CI: 0.67-0.87), P < .001] compared with CS. CONCLUSIONS: Cardioembolic strokes are not associated with increased mortality. Patients with CS are less likely to have sICH and have better outcome after IVT.

European Academy of Neurology and European Stroke Organization consensus statement and practical guidance for pre-hospital management of stroke.

BACKGROUND AND PURPOSE: The reduction of delay between onset and hospital arrival and adequate pre-hospital care of persons with acute stroke are important for improving the chances of a favourable outcome. The objective is to recommend evidence-based practices for the management of patients with suspected stroke in the pre-hospital setting. METHODS: The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to define the key clinical questions. An expert panel then reviewed the literature, established the quality of the evidence, and made recommendations. RESULTS: Despite very low quality of evidence educational campaigns to increase the awareness of immediately calling emergency medical services are strongly recommended. Moderate quality evidence was found to support strong recommendations for the training of emergency medical personnel in recognizing the symptoms of a stroke and in implementation of a pre-hospital 'code stroke' including highest priority dispatch, pre-hospital notification and rapid transfer to the closest 'stroke-ready' centre. Insufficient evidence was found to recommend a pre-hospital stroke scale to predict large vessel occlusion. Despite the very low quality of evidence, restoring normoxia in patients with hypoxia is recommended, and blood pressure lowering drugs and treating hyperglycaemia with insulin should be avoided. There is insufficient evidence to recommend the routine use of mobile stroke units delivering intravenous thrombolysis at the scene. Because only feasibility studies have been reported, no recommendations can be provided for pre-hospital telemedicine during ambulance transport. CONCLUSIONS: These guidelines inform on the contemporary approach to patients with suspected stroke in the pre-hospital setting. Further studies, preferably randomized controlled trials, are required to examine the impact of particular interventions on quality parameters and outcome.

Intravenous thrombolysis for patients with in-hospital stroke onset: propensity-matched analysis from the Safe Implementation of Treatments in Stroke-East registry.

BACKGROUND AND PURPOSE: Recent cross-sectional study data suggest that intravenous thrombolysis (IVT) in patients with in-hospital stroke (IHS) onset is associated with unfavorable functional outcomes at hospital discharge and in-hospital mortality compared to patients with out-of-hospital stroke (OHS) onset treated with IVT. We sought to compare outcomes between IVT-treated patients with IHS and OHS by analysing propensity-score-matched data from the Safe Implementation of Treatments in Stroke-East registry. METHODS: We compared the following outcomes for all propensity-score-matched patients: (i) symptomatic intracranial hemorrhage defined with the safe implementation of thrombolysis in stroke-monitoring study criteria, (ii) favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-1 at 3 months, (iii) functional independence defined as an mRS score of 0-2 at 3 months and (iv) 3-month mortality. RESULTS: Out of a total of 19 077 IVT-treated patients with acute ischaemic stroke, 196 patients with IHS were matched to 5124 patients with OHS, with no differences in all baseline characteristics (P > 0.1). Patients with IHS had longer door-to-needle [90 (interquartile range, IQR, 60-140) vs. 65 (IQR, 47-95) min, P < 0.001] and door-to-imaging [40 (IQR, 20-90) vs. 24 (IQR, 15-35) min, P < 0.001] times compared with patients with OHS. No differences were detected in the rates of symptomatic intracranial hemorrhage (1.6% vs. 1.9%, P = 0.756), favorable functional outcome (46.4% vs. 42.3%, P = 0.257), functional independence (60.7% vs. 60.0%, P = 0.447) and mortality (14.3% vs. 15.1%, P = 0.764). The distribution of 3-month mRS scores was similar in the two groups (P = 0.273). CONCLUSIONS: Our findings underline the safety and efficacy of IVT for IHS. They also underscore the potential of reducing in-hospital delays for timely tissue plasminogen activator delivery in patients with IHS.

Brain activation in the chronic phase of traumatic spinal cord injury.

STUDY DESIGN: Cross-sectional clinical study. OBJECTIVES: Plastic changes within cortical areas occur after traumatic spinal cord injury (TSCI). The aim of the study was to assess cortical activation in the chronic phase of TSCI using functional magnetic resonance imaging (fMRI). SETTING: Tartu University Hospital, Tartu, Estonia. METHODS: Ten right-handed patients with paraplegia and 18 healthy controls were studied by fMRI. Individuals performed simple flexion/extension of the right hand fingers and the right ankle during fMRI. The activation volumes, maximum t values (T max) and centres of gravity (COG) were calculated. RESULTS: The mean time since trauma was 1848±1046 days (range 388-4459). During hand movements, the volume of activation (VOA) in the contralateral primary motor cortex was significantly larger among the TSCI patients who did not recover compared with the controls (4112 vs 2777, P=0.02). The VOA did not enlarge during the ankle movements (2420 vs 1114, P=0.08). There was a significant relationship between the VOA in Brodmann area 4 (BA4) and American Spinal Injury Association motor score during hand movements (r=-0.67, P=0.03). A positive correlation was found during hand movements in the VOA of BA4 and time since injury (r=0.62, P=0.05). CONCLUSIONS: We found increased cortical activation in the chronic phase of thoraco-lumbar TSCI that may be caused by increased use of upper limbs.

Impact of fatal cases on the epidemiology of traumatic spinal cord injury in Estonia.

BACKGROUND AND PURPOSE: Most epidemiological studies on traumatic spinal cord injury (TSCI) have not included patients who die before hospitalization. The aim of the research was to study the incidence of TSCI by including the individuals who die at the scene of the accident in addition to data retrieved from all hospitals in Estonia. METHODS: Medical records of patients with TSCI from all hospitals in Estonia from 2005 to 2007 were studied. With collaboration from the Estonian Forensic Science Institute the data of the victims of TSCI who died before hospitalization were included. RESULTS: From 2005 to 2007, 391 TSCI cases were identified: 183 patients were found retrospectively from medical records and 208 cases were detected from autopsy reports. Fifty-three per cent of patients died before hospitalization. The annual incidence rate was 97.0 per million population (95% confidence interval 87.4-106.6). The mean age at injury was 44.4 ± 18.7 years. Motor vehicle accidents were the leading cause of TSCI amongst the individuals who died before hospitalization (75%). Falls accounted for the highest number of TSCIs (43%) amongst the patients who reached hospital. CONCLUSIONS: Our study shows that, when the cases that die at the scene of the accident are included, the incidence of TSCI in Estonia rises from 39.7 to 97.0 per million population.

Health-related quality of life in patients with traumatic spinal cord injury in Estonia.

OBJECTIVES: To describe health-related quality of life (HRQoL) in persons with traumatic spinal cord injury (TSCI) and to assess factors that affect HRQoL. STUDY DESIGN: Cross-sectional. METHODS: Eighty Estonian-speaking TSCI patients from the Estonian TSCI database were included in the study. The RAND-36 questionnaire, the Life Orientation Test, the Emotional State Questionnaire and the Brief Social Support Questionnaire were used. RESULTS: There were 66 men and 14 women; the mean age was 38.9±14.8 years. The mean time that had elapsed since injury was 4.2 years. According to the RAND-36 scales, the lowest scores were given for physical health-related domains, followed by the energy/fatigue and the general health domains. The regression analysis adjusted to age and gender revealed that age, employment and category of the American Spinal Injury Association (ASIA) Impairment Scale during the acute phase of injury were significant factors in predicting physical functioning (P<0.001). Age, depression and general anxiety were significant predictors of emotional well-being (P<0.001). Age and depression were independently associated with general health (P<0.001). CONCLUSION: As expected, physical functioning and physical role limitation were the most pronounced deficits in HRQoL. Compared with data from other countries, all scores for the RAND-36 scales are lower in Estonian TSCI patients. The HRQoL following TSCI is affected by severity of injury, depression, age and employment status.

Benefit of thrombolysis for stroke is maintained around the clock: results from the SITS-EAST Registry.

BACKGROUND AND PURPOSE: The outcome of thrombolysis for early morning and sleep time strokes may be worse because of uncertainty of stroke onset time or differences in logistics. The aim of the study was to analyze if stroke outcome after intravenous thrombolysis differs depending on time of day when the stroke occurs. METHODS: The data collected in the Safe Implementation of Treatments in Stroke - Eastern Europe (SITS-EAST) Registry between September 2000 and December 2011 were used. Strokes were categorized as night-time 00:00-07:59, day-time 08:00-15:59 and evening-time 16:00-23:59 and were compared in terms of several outcome measures. All results were adjusted for baseline differences. RESULTS: A total of 8878 patients were enrolled: 18% had night-time, 54% day-time and 28% evening-time strokes. Onset-to-treatment time in patients with night-time strokes was 10 min longer than in day-time and evening-time strokes (P < 0.001). Symptomatic intracerebral hemorrhage by ECASS II definition occurred in 5.6%, 5.6% and 5.3% (adjusted P = 0.41) of the night-time, day-time and evening-time stroke patients, respectively; by SITS definition it occurred in 2.5%, 1.9% and 1.3% (adjusted P = 0.013) and by NINDS definition in 7.8%, 7.6% and 7.5% (adjusted P = 0.74). Patients with night-time, day-time and evening-time strokes achieved modified Rankin Scale score 0-1 in 33%, 31%, 31% (adjusted P = 0.34) and 0-2 in 52%, 51%, 50% (adjusted P = 0.23), and 13%, 15%, 16% respectively of patients died (adjusted P = 0.17) by 3 months. CONCLUSIONS: The time when stroke occurs (day versus evening versus night) does not affect the outcome after thrombolysis despite the fact that patients with night-time strokes have worse time management.

Brain activation in the acute phase of traumatic spinal cord injury.

STUDY DESIGN: Prospective clinical study. BACKGROUND: The aim of the study was to investigate cortical reorganisation after traumatic spinal cord injury (TSCI) using functional magnetic resonance imaging (fMRI). SETTING: Tartu University Hospital, Tartu, Estonia. METHODS: We studied six right-handed tetraplegic TSCI patients at 1, 3 and 12 months after the injury and 12 age- and gender-matched healthy controls. Individuals performed simple test-rest cycles of flexion/extension of the right-hand fingers and flexion/extension of the right ankle during fMRI. The volumes of activation (VOA), maximum t-values, centres of gravity (COG) and weighted laterality indexes were calculated. RESULTS: There was no recovery of neurologic function in three patients and, according to the American Spinal Injury Association (ASIA) Impairment Scale the remaining three recovered. A positive correlation between the VOA in the primary motor cortex and the ASIA impairment scale (1 month: r=0.82, P=0.002; 3 Month: r=0.63, P=0.03; 12 Month: r=0.23, P=0.52) was found. The study also revealed a pattern of cortical activation that was increased among the patients who recovered (in Brodmann area 4 (BA 4), P=0.06; BA 1-2-3-5, P=0.08; BA 6, P=0.05). During the hand task there was an expansion of COG laterally, anteriorly and inferiorly among the patients who recovered. During the hand movement the cortical activation was less lateralised among the patients compared with the controls (P<0.05). CONCLUSION: Our study has found broadening of cortical activation and shift of COG during the first year after TSCI, depending on the recovery.

Traumatic spinal cord injury in two European countries: why the differences?

BACKGROUND AND PURPOSE: The aim of the study was to compare the incidence, causes, severity and mortality of traumatic spinal cord injury (TSCI) in Western Norway and Estonia from 1997 to 2001. METHODS: The patients were identified from hospital records. All patients were followed until death or 14 October 2011. Analysed data included demographic data, causes of injury, neurological level, American Spinal Injury Association Impairment Scale and mortality. RESULTS: A total of 71 patients in Western Norway and 244 in Estonia were included. The standardized incidence rate per million was 24.9 (CI 95%, 19.4-31.7) for Western Norway and 37.4 (CI 95%, 32.8-42.5) for Estonia. Falls was the most frequent cause of TSCI in both countries. The incidence of TSCI was highest among men in their 20s in Estonia and men in their 70s in Western Norway. The median survival time among the deceased was 4.0 (95% CI, 1.50-6.50) years in Norway and 2.8 (95% CI, 1.54-4.04) in Estonia. The mean standardized mortality ratio (SMR) was 5.00 (95% CI, 4.00-6.20) in Estonia and 1.89 (95% CI, 1.23-2.77) in Western Norway. CONCLUSION: Although the two cohorts had similar demographic, injury and clinical characteristics, the age profile of the victims was different. The incidence rate was 1.5 times higher and SMR was 2.7 times higher in Estonia. Probable explanations for the different outcomes of the two European countries are socioeconomic differences, lower physical activity level, lower life expectancy and insufficient injury prevention programmes in Estonia.

Functional MRI of the cortical sensorimotor system in patients with hereditary spastic paraplegia.

OBJECTIVES: The study aimed to use functional magnetic resonance imaging to ascertain changes in sensorimotor system function in patients with hereditary spastic paraplegia and to correlate it with severity of spasticity and paresis. SETTING: Tartu University Hospital, Tartu, Estonia. METHODS: Nine patients with autosomal-dominant pure HSP and 14 age- and sex-matched healthy controls were investigated with a 1.5T fMRI scanner during flexion/extension of the right-hand fingers and right ankle. Images were analysed with a general linear model and Statistical Parametrical Mapping software. Highest Z-scores were identified from probability maps, and weighted laterality indices were calculated using combined bootstrap/histogram analysis; these were correlated with clinical severity of spasticity and paresis. RESULTS: During hand movements, clusters located in contralateral primary sensorimotor and premotor areas activated in both controls and patients. Bilateral activation occurred in the supplementary motor area, parietal operculum and cerebellum (predominantly ipsilateral). During the ankle task, bilateral activation was noted in the primary sensorimotor area, supplementary motor area and cerebellum. Activation clusters in HSP patients were smaller than those in controls in the sensorimotor area, especially during the ankle task, and more pronounced ipsilaterally in cerebellum both during hand and ankle motor tasks. Spasticity was significantly associated with contralateral activation in the sensory area and correlated negatively with the highest Z-scores in Brodmann areas 1-2-3 and 4. CONCLUSION: Our results suggest changes in cortical sensorimotor network function in patients with HSP compared with healthy subjects. Lower activation in patients might reflect damage to the corticospinal tract, be influenced by compensatory mechanisms, and/or be a reflection of neurorehabilitation.

Long-term survival of young stroke patients: a population-based study of two stroke registries from tartu, estonia.

The aim of this paper was to evaluate the long-term survival of young stroke patients in Estonia, analyse time trends of survival, and compare the results with other studies. We have used 2 population-based first-ever stroke registry data (1991-1993 and 2001-2003) to analyse the 1-, 5-, and 7-year outcome of young stroke patients by the Kaplan-Meier method of analysis. From the group of 1206 patients, 129 (11%) were aged under 55 years. The overall survival rate at 1, 5, and 7 years was 0.70 (95% CI 0.62-0.78), 0.63 (95% CI 0.55-0.72), and 0.61 (95% CI 0.53-0.70), respectively. The survival was significantly worse for patients with intracerebral haemorrhage (P < 0.01) and for those aged from 45 to 54 years compared to the younger age group from 0 to 44 years (P = 0.03). For patients with ischemic stroke, aged from 15 to 44 years, the 1-, 5-, and 7-year survival rate was 0.89 (95% CI 0.79-1.00), 0.75 (95% CI 0.61-0.93), and 0.75 (0.61-0.93), respectively. There was no difference in overall survival between the two studied periods. We report a low long-term survival rate among young stroke patients in Estonia. Increasing age and hemorrhagic stroke subtype were associated with lower survival. We have previously shown a worse outcome for 1-year survival compared to other studies and currently this trend continues for 5- and 7-year survival rates. In fact, these are the lowest survival rates for the combined and separate stroke subtypes reported so far.

High incidence of traumatic spinal cord injury in Estonia.

STUDY DESIGN: Retrospective population-based cohort study. OBJECTIVES: To provide national data on epidemiology of traumatic spinal cord injury (TSCI) among the population of Estonia from 1997 to 2007. SETTING: All Estonian hospitals. METHODS: Medical records of patients with TSCI from all regional, central, general and rehabilitation hospitals in Estonia were retrospectively reviewed. Epidemiological characteristics, etiology, neurological level and severity of injury, concomitant injuries were analyzed. RESULTS: A total of 595 patients with TSCI from 1 January 1997 to 31 December 2007 were identified. The male to female ratio was 5.5:1. The mean age at injury was 39.0 years. The crude incidence rate was 39.7 (95% confidence interval: 36.6-43.0) per million population. The most frequent cause of TSCI was falls (41%), followed by traffic accidents (29%). Alcohol consumption preceded 43% of injuries. The lesion level was cervical in 59.4%, thoracic in 18.3% and lumbar/sacral in 22.3%. CONCLUSION: Compared to recent studies from Europe, where the incidence of TSCI is between 15 and 30 per million population, the incidence of TSCI in Estonia is among the highest. The rates are significantly higher in men compared with women and especially among the youngest men. The leading cause of TSCI is falls. A significant proportion of injuries are related to alcohol consumption before trauma in Estonia.

Prestroke physical activity is associated with severity and long-term outcome from first-ever stroke.

OBJECTIVE: To determine whether prestroke level of physical activity influenced stroke severity and long-term outcome. METHODS: Patients included into the present analyses represent a subset of patients with first-ever stroke enrolled into the ExStroke Pilot Trial. Patients with ischemic stroke were randomized in the ExStroke Pilot Trial to an intervention of repeated instructions and encouragement to increase the level of physical activity or to a control group. Prestroke level of physical activity was assessed retrospectively by interview using the Physical Activity Scale for the Elderly (PASE) questionnaire. The PASE questionnaire quantifies the amount of physical activity done during a 7-day period. In this prospectively collected patient population initial stroke severity was measured using the Scandinavian Stroke Scale and long-term outcome was assessed after 2 years using the modified Rankin Scale. Statistical analyses were done using ordinal logistic regression. RESULTS: Data from 265 patients were included with a mean (SD) age of 68.2 (12.2) years. Confirming univariable analyses, multivariable analyses showed that patients with physical activity in the top quartile more likely presented with a less severe stroke, OR 2.54 (95% CI 1.30-4.95), and had a decreased likelihood of poor outcome, OR 0.46 (95% CI 0.22-0.96), compared to patients in the lowest quartile. CONCLUSIONS: In the present study physical activity prior to stroke was associated with a less severe stroke and better long-term outcome.

One-year outcome after first-ever stroke according to stroke subtype, severity, risk factors and pre-stroke treatment. A population-based study from Tartu, Estonia.

The aim of the current study was to evaluate the outcome at 1 year following a first-ever stroke based on a population-based registry from 2001 to 2003 in Tartu, Estonia. The outcome of first-ever stroke was assessed in 433 patients by stroke risk factors, demographic data and stroke severity at onset using the Barthel Index (BI) score and the modified Rankin Score (mRS) at seventh day, 6 months and 1 year. Female sex, older age, blood glucose value >10 mmol/l on admission and more severe stroke on admission were the best predictors of dependency 1 year following the first-ever stroke. At 1 year, the percentage of functionally dependent patients was 20% and the survival rate was 56%. The use of antihypertensive/antithrombotic medication prior to stroke did not significantly affect the outcome. The survival rate of stroke patients in Tartu is lower compared with other studied populations. The outcome of stroke was mainly determined by the initial severity of stroke and by elevated blood glucose value on admission. Patients with untreated hypertension had more severe stroke and trend for unfavourable outcome compared with those who were on treatment.

The Third Stroke Registry in Tartu, Estonia, from 2001 to 2003.

OBJECTIVES: The main goal of the Third Stroke Registry in Tartu was to determine the incidence and 28-day case-fatality of first-ever stroke in an Estonian population. SUBJECTS AND METHODS: Stroke registry was conducted from 1 December 2001 to 30 November 2003. RESULTS: The registry included 451 patients. The incidence rate of first-ever stroke age-standardized to the European population was 188/100,000. Among younger patients, the rates for men dominated. The incidence among men aged 0-44 years was 18/100,000, for women 9/100,000. In the age group 45-54 years, the corresponding rates were 143/100,000 and 98/100,000 respectively. The overall 28-day case-fatality rate was 26%. CONCLUSIONS: The total stroke incidence in Tartu is comparable with other European studies, but the rates for younger patients are higher. This may be associated with lower quality of life, less attention to public health, high prevalence and/or poor control of stroke risk factors. The 28-day case-fatality is somewhat higher than in other European centres.

Long term outcome after poliomyelitis in different health and social conditions.

OBJECTIVE: To examine and compare the long term outcome after polio in an east European and a west European country with different access to rehabilitation and with different medical and social conditions. DESIGN AND SETTING: The patients who were acutely hospitalised for polio 1950-54 in the University Hospital in Bergen, Norway and 1958 in the University Hospital in Tartu, Estonia received the mailed questionnaire in the period between January 1998 and December 1998. PATIENTS: Patient files concerning 334 patients hospitalised in Tartu and 243 patients hospitalised in Bergen were obtained; of these 128 Estonian and 148 Norwegian patients were re-examined. MAIN RESULTS: Despite more pronounced disability in the acute stage, significantly more Norwegian patients were working full time and part time in 1998 (p<0.0001) and also through the period 1958-1998. In both countries, 30% of patients had manual work and 18% changed profession during their career. Low income (below 50% of national average) was reported by 73% of Estonian and 35% of Norwegian patients (p<0.0001). Except for the odds ratio for muscular pain of 1.89 (95%CI =1.14 to 3.14) for Norwegian patients, new symptoms indicating late progression did not differ. Norwegian patients were more independent with significantly less need for assistance in housekeeping (p=0.02), whereas the use of orthopaedic devices did not differ. CONCLUSIONS: The long term outcome after polio is different in eastern and western Europe. Access to continuous rehabilitation seems to maintain physical independence in polio patients, improves their ability to earn their own income, and lessens the need for disability pensions.

Registry of first-ever stroke in Tartu, Estonia, 1991 through 1993: outcome of stroke.

OBJECTIVES: To provide information about the functional ability of the survivors of first-ever stroke in Estonia. PATIENTS AND METHODS: A population based epidemiological study 1991 through 1993 in Tartu. Herewith the data for 1991 and 1993 are presented. A total of 519 persons were registered; 82% of them were admitted (mean length 14 days), 66% were discharged home. RESULTS: During 6 months 41% of the patients died, the remaining 305 patients were interviewed about their living conditions, and functional ability using the Barthel ADL Index. Although 58% of patients responded to the questionnaire, no significant differences in several factors between the respondents and non-respondents were found. Thirty-eight percent of the patients were totally independent in ADL. CONCLUSION: The case-fatality rate at 6 months was high in Estonia and the proportion of totally independent patients 6 months after stroke is slightly lower compared to other studies. The short length of hospital treatment was possibly compensated by sufficient support by relatives after discharge.

Changed incidence and case-fatality rates of first-ever stroke between 1970 and 1993 in Tartu, Estonia.

BACKGROUND AND PURPOSE: The incidence of stroke has stabilized or increased in several developed countries recently, but few data about the trends are available from Eastern Europe. The study was designed to evaluate the possible changes of stroke incidence in Estonia. METHODS: A population-based stroke registry was conducted in Tartu during 1991 through 1993 (mean population, 110,631) to compare it with the study of 1970 through 1973 (population, 90,459). The majority of stroke patients were recorded prospectively, and most were hospitalized and evaluated by a neurologist. All available medical records were reviewed. Only first-ever stroke cases were registered. RESULTS: A total of 667 patients in 1970 through 1973 and 829 patients in 1991 through 1993 were recorded. The total annual incidence per 100,000 rose from 221 to 250 (P = .0173). The total rate for men increased nonsignificantly from 183 to 209 and for women from 258 to 284. Significant increases were observed for men aged 50 to 59 years and for women aged 50 to 69 years; for persons over 70 years, the rates slightly declined. The case-fatality rate at 1 month declined significantly, from 49% to 30%. CONCLUSIONS: A remarkable increase in the incidence and decline in the case-fatality rate of first-ever stroke was observed in Tartu, Estonia. The increase of incidence for those younger than 70 years could be due to the increased prevalence of risk factors. The decline in case fatality could theoretically be related to better management of secondary complications.