Recovery, Functional Status, and Health-Related Quality of Life Status up to 4 Years after First-Ever Stroke Onset: A Population-Based Study.

BACKGROUND: Stroke is a leading cause of acquired disability in adults worldwide, and the burden of stroke is projected to increase. Current long-term stroke outcome data including functional status, activity, and participation limitations as well as information on health-related quality of life (HRQoL) are vital for future rehabilitation and resource planning of stroke survivors. METHODS: First-ever stroke survivors from a population-based cohort with ischemic stroke or intracerebral hemorrhage were followed up 3-4 years after stroke onset via clinic appointments, home visits, or telephone. Ischemic stroke was stratified by clinical syndrome (Oxfordshire Community Stroke Project classification) and pathogenetic mechanism (TOAST classification). We assessed the participants' functional status and independence with the modified Rankin Scale (mRS) and Barthel Index (BI) and their HRQoL across several domains (Short Form Questionnaire-36, EuroQoL-5D, and Stroke Impact Scale (SIS)). We used logistic and linear regression analyses to analyze potential baseline predictors of 3-4-year outcome. RESULTS: Four hundred individuals were included; 151 died before clinical follow-up and 47 (12%) were lost to detailed follow-up. Two hundred and two individuals (median age: 72, IQR: 65-79; 40% female) were followed up after a median of 3.2 years (IQR: 3.1-3.5). Nineteen individuals (9%) had a recurrent stroke during the 3-4-year follow-up period. Among the 202 follow-up attendees, 147 (73%) had favorable functional outcome (mRS ≤2) and 134 (69%) of the 195 respondents reported good-excellent HRQoL according to SF-36. Age (HR: 1.03; 95% CI: 1.00-1.05), initial stroke severity (HR: 1.16; 95% CI: 1.10-1.22; p < 0.001), living with in-home care or in care facility at baseline (HR: 8.77; 95% CI: 2.98-25.64), and recurrent stroke (HR: 3.58; 95% CI: 1.47-8.77) were predictors of poor functional outcome (mRS>2). Poor functional outcome/death was less common among IS due to Other Causes and Small Artery Occlusion than other pathogenetic mechanisms (20% and 33% vs. 56-68%; p < 0.01). SIS respondents with poor functional outcomes (n = 32) reported worst outcome in the hand domain of SIS (median: 28/100; IQR: 0-73). CONCLUSIONS: Most 3-4-year stroke survivors have favorable functional outcomes and are independent in ADL in a population-based cohort. Despite its relative rarity, recurrent stroke was a predictor of poor functional outcome, emphasizing the need of adequate secondary prevention.

Survival, causes of death and recurrence up to 3 years after stroke: A population-based study.

BACKGROUND AND PURPOSE: Up-to-date population-based information about long-term survival, causes of death and recurrence after stroke is needed. METHODS: Four hundred consecutive individuals in a population-based cohort of first-ever stroke between 2015 and 2016 in Lund, Sweden, were followed up to 3 years regarding (i) survival (Swedish Population Register); (ii) causes of death (Swedish Causes of Death Register); and (iii) stroke recurrence (interview and medical chart review). Index and recurrent ischaemic stroke cases were classified using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) and Oxfordshire Community Stroke Project; and comorbidities were classified using the Charlson Comorbidity Index. Cox regression was used to determine predictors for 3-year mortality. Survival rates were compared with three local studies over a 30-year timespan. RESULTS: Amongst 400 first-ever stroke patients, 265 (66%) survived 3 years post-stroke. Age (hazard ratio [HR] 1.09; 95% confidence interval [CI] 1.06-1.11), stroke severity (HR 1.11; 95% CI 1.08-1.13) and comorbidities (HR 1.36; 95% CI 1.22-1.53) were independently related to 3-year mortality. Amongst index ischaemic stroke patients, survival was lowest amongst those with cardio-aortic embolism (51/91; 56%). Cerebrovascular disease (54/135; 40%) and ischaemic heart disease (25/135; 19%) were the most common causes of death. Within 3 years, 30 (8%) had recurrent stroke. Amongst patients with index ischaemic stroke, 16/29 (55%) had a different TOAST pathogenetic mechanism or hemorrhagic stroke upon recurrence. Stroke survival improved between 1983-1985 and 2015-2016 (p = 0.002), but no significant change was observed between 2001-2002 and 2015-2016 (p = 0.48). CONCLUSIONS: Stroke survival rates are relatively high, but their improvement over recent decades may be slowing down, possibly due to the composition of the first-ever stroke population. The common occurrence of changed pathogenetic mechanisms between first-ever and recurrent stroke highlights the value of reassessment in recurrent stroke.

Completeness of case ascertainment in Swedish hospital-based stroke registers.

BACKGROUND: There is a worldwide development toward using data from hospital-based stroke registers to estimate epidemiological trends. However, incomplete case ascertainment may cause selection bias. We examined the completeness of case ascertainment and selection bias in two hospital-based Swedish stroke registers. METHODS: First-ever stroke cases between March 2015 and February 2016 in the catchment area of Skåne University Hospital, Lund, Sweden, were included from multiple overlapping sources: two hospital-based stroke registers, Riksstroke-Lund and Lund Stroke Register (LSR); local outpatient and inpatient registers; primary care registers; and autopsy registers. The resulting population-based cohort was used as reference to assess completeness of case ascertainment and patient characteristics in Riksstroke-Lund and LSR. RESULTS: In total, 400 stroke patients were identified. Riksstroke-Lund detected 328 (82%) patients, whereas LSR detected 363 (91%). Patients undetected by hospital-based registers had higher 28-day case fatality than those detected (44% vs 9%; P = .001). Patients only detected in primary care (n = 11) more often lived in healthcare facilities compared with those detected by hospital-based registers (57% vs 7%; P = .001). Patients not detected by Riksstroke-Lund, but detected by population-based sources, had less severe strokes (median NIHSS 3 vs 5; P = .013). CONCLUSIONS: Some first-ever stroke patients, such as those with high early case fatality and those with mild stroke, may go undetected with hospital-based screening used in clinical stroke registers. This can result in selection bias due to not identifying specific groups of patients including some with high early case fatality and those living in healthcare facilities.

Temporal Trends of Stroke Epidemiology in Southern Sweden: A Population-Based Study on Stroke Incidence and Early Case-Fatality.

BACKGROUND: Up-to-date epidemiological stroke studies are important for healthcare planning and evaluating prevention strategies. This population-based study investigates temporal trends in stroke incidence and case-fatality in southern Sweden. METHODS: First-ever stroke cases in the local catchment area of Skåne University Hospital in Lund, Sweden, between March, 2015 and February, 2016, were included from several sources, including 2 prospective hospital-based registers, retrospective screening of primary care visits, and autopsy registers. Stroke incidence and 28-day case-fatality rates were compared with data from this area obtained through similar methodology between March, 2001 and February, 2002. RESULTS: Altogether, 456 and 413 first-ever stroke patients were identified during the earlier and later time periods respectively. The age- and sex-standardized stroke incidence rates decreased from 246 (95% CI 224-270) to 165 (95% CI 149-182) per 100,000 people. However, incidence remained unaltered among those <65 years. Early case-fatality decreased from 14 to 11% (p = 0.165). -Conclusion: First-ever stroke incidence in southern Sweden has decreased with 33% since the beginning of this millenni-um. Incidence rates have decreased among the elderly but remain unchanged among younger age groups. Our findings warrant further studies on trends in risk factor profiles and effects of prevention strategies, and heightened focus on stroke in the young.

Attitudes to Stem Cell Therapy Among Ischemic Stroke Survivors in the Lund Stroke Recovery Study.

Preclinical studies suggest that stem cell therapy (SCT) may improve poststroke recovery, and clinical trials investigating safety are ongoing. However, knowledge about patients' attitudes to SCT in stroke is limited. We evaluated the knowledge and attitudes to this therapeutic approach as well as possible factors influencing this among stroke patients potentially suitable for SCT. Consecutive first-ever acute ischemic stroke patients aged 20-75 years with NIH stroke scale scores 1-18 were included. Exclusion criteria were severe comorbidities or infratentorial stroke. Clinical follow-up after 3-5 years assessed severity of residual stroke symptoms, cognitive function, functional status, patient-reported outcome, and comorbidity, and after receiving standardized information, the participants also completed an eight-item questionnaire on knowledge and attitudes about SCT. The relationships between clinical variables and positive attitude to SCT were assessed with logistic regression analyses. Of 108 patients included at baseline, 84 participated at follow-up and completed the questionnaire. In total, 12% had prior knowledge of SCT. When informed, 63% were positive toward it and 36% reported willingness to participate in SCT trials. Only 5%-8% expressed ethical considerations regarding different stem cell sources. Positive attitudes to SCT were associated with male gender (OR: 3.74; 95% CI: 1.45-9.61; P < 0.01) and better patient-reported outcome (OR: 1.02; 95% CI: 1.00-1.04; P < 0.05). In conclusion, stroke patients had limited prior knowledge of SCT, yet attitudes were positive among the majority after receiving standardized and neutral information. Gender and degree of stroke recovery may influence attitudes to SCT, indicating a need for targeted information to improve knowledge about SCT.

Spontaneous Recovery of Upper Extremity Motor Impairment After Ischemic Stroke: Implications for Stem Cell-Based Therapeutic Approaches.

Preclinical studies suggest that stem cell therapy (SCT) may improve sensorimotor recovery after stroke. Upper extremity motor impairment (UEMI) is common after stroke, often entailing substantial disability. To evaluate the feasibility of post-stroke UEMI as a target for SCT, we examined a selected sample of stroke patients potentially suitable for SCT, aiming to assess the frequency and recovery of UEMI, as well as its relation to activity limitations and participation restrictions. Patients aged 20-75 years with first-ever ischemic stroke, and National Institutes of Health Stroke Scale (NIHSS) scores 1-18, underwent brain diffusion-weighted MRI within 4 days of stroke onset (n = 108). Survivors were followed up after 3-5 years, including assessment with NIHSS, Fugl-Meyer assessment of upper extremity (FMA-UE), modified Rankin Scale (mRS), and Stroke Impact Scale (SIS). UEMI was defined as NIHSS arm/hand score ≥1. UEMI recovery was evaluated with change in NIHSS arm/hand scores between baseline and follow-up. Of 97 survivors, 84 were available to follow-up. Among 76 subjects (of 84) without recurrent stroke, 41 had UEMI at baseline of which 10 had residual UEMI at follow-up. The FMA-UE showed moderate-severe impairment in seven of 10 survivors with residual UEMI. UEMI was correlated to mRS (r s = 0.49, p < 0.001) and the SIS social participation domain (r s = -0.38, p = 0.001). Nearly 25% of the subjects with UEMI at baseline had residual impairment after 3-5 years, whereas about 75% showed complete recovery. Most of the subjects with residual UEMI had moderate-severe impairment, which correlated strongly to dependency in daily activities and social participation restrictions. Our findings suggest that SCT targeting post-stroke UEMI may be clinically valuable with significant meaningful benefits for patients but also emphasize the need of early prognostication to detect patients that will have residual impairment in order to optimize patient selection for SCT.