[Thrombolysis in stroke?].
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Cerebrovascular Disorders↗
Biomedical subjects
T S Olsen
Publications and source records attributed to T S Olsen.
What determines good recovery in patients with the most severe strokes? The Copenhagen Stroke Study.
BACKGROUND AND PURPOSE: Even patients with the most severe strokes sometimes experience a remarkably good recovery. We evaluated possible predictors of a good outcome to search for new therapeutic strategies. METHODS: We included the 223 patients (19%) with the most severe strokes (Scandinavian Stroke Scale score <15 points) from the 1197 unselected patients in the Copenhagen Stroke Study. Of these, 139 (62%) died in the hospital and were excluded. The 26 survivors (31%) with a good functional outcome (Barthel Index >/=50 points) were compared with the 58 survivors (69%) with a poor functional outcome (Barthel Index <50 points). The predictive value of the following factors was examined in a multivariate logistic regression model: age; sex; a spouse; work; home care before stroke; initial stroke severity; blood pressure, blood glucose, and body temperature on admission; stroke subtype; neurological impairment 1 week after onset; diabetes; hypertension; atrial fibrillation; ischemic heart disease; previous stroke; and other disabling disease. RESULTS: Decreasing age (odds ratio [OR], 0.50 per 10-year decrease; 95% CI, 0.25 to 0.99; P=0.04), a spouse (OR, 3.1; 95% CI, 1.1 to 8. 8; P=0.03), decreasing body temperature on admission (OR, 1.8 per 1 degrees C decrease; 95% CI, 1.1 to 3.1; P=0.01), and neurological recovery after 1 week (OR, 3.2 per 10-point increase in Scandinavian Stroke Scale score; 95% CI, 1.1 to 7.8; P=0.01) were all independent predictors of good functional outcome. CONCLUSIONS: Patients with the most severe strokes who achieve a good functional outcome are generally characterized by younger age, the presence of a spouse at home, and early neurological recovery. Body temperature was a strong predictor of good functional outcome and the only potentially modifiable factor. We suggest that a randomized controlled trial be undertaken to evaluate whether active reduction of body temperature can improve the generally poor prognosis of patients with the most severe strokes.
Demography↗
Treatment and rehabilitation on a stroke unit improves 5-year survival. A community-based study.
BACKGROUND AND PURPOSE: We have previously reported a marked reduction in mortality up to 1 year after treatment and rehabilitation on a stroke unit versus on general neurological and medical wards in unselected stroke patients. In the present study we wanted to test the hypothesis that this mortality-reducing effect is not temporary but is long lasting. METHODS: We performed a community-based comparison of outcome in 1241 stroke patients from 2 adjacent communities in Copenhagen: in one (Frederiksberg), treatment and rehabilitation were provided on general neurological and medical wards, and in the other (Bispebjerg), treatment and rehabilitation were provided on a single large stroke unit. RESULTS: The 2 stroke populations were comparable regarding age, sex, initial stroke severity, lesion diameter on CT, and stroke subtype (hemorrhage/infarct), but patients treated on the stroke unit had a higher frequency of comorbidity and lower incomes. One-year mortality was 39% (general wards) versus 32% (stroke unit) (P=0.01). This difference was still present 5 years after stroke (71% versus 64%; P=0.02). In a multiple logistic regression model of 5-year mortality, treatment on a stroke unit reduced the relative risk of death by 40% (odds ratio, 0.60; 95% CI, 0.42 to 0.85; P<0.01), independent of age, sex, stroke severity, and comorbidity. CONCLUSIONS: The mortality-reducing effect of treatment and rehabilitation on a dedicated stroke unit is long lasting rather than temporary. Stroke unit treatment reduced the relative risk of death within 5 years after stroke by 40% in an unselected, community-based stroke population. These results emphasize the need for organization of treatment and rehabilitation of unselected stroke patients on dedicated stroke units.
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Epidemiology of stroke-related disability.
This article describes basic characteristics and primary outcomes of unselected patients with stroke. These patients were part of the Copenhagen Stroke Study, a prospective, consecutive, and community-based study of 1197 acute stroke patients. The setting and care was multidisciplinary and all treatment was performed within the dedicated stroke unit. Neurologic impairment was measured at admission, weekly throughout the hospital stay, and again at the 6-month follow up. Basic activities of daily living, as measured by the Barthel Index, were assessed within the first week of admission, weekly throughout the hospital stay, and again after 6 months. Upon completion of the in-hospital rehabilitation, which averaged 37 days, two-thirds of surviving patients were discharged to their homes, with another 15% being discharged to a nursing home. Only 4% of the patients with very severe strokes reached independent function, as compared with 13% of patients with severe stroke, 37% of patients with moderate stroke, and 68% of patients with mild stroke.
Activities of Daily Living↗
Stroke. Neurologic and functional recovery the Copenhagen Stroke Study.
Neurologic and functional recovery is dependent on a large variety of factors such as initial stroke severity, body temperature and blood glucose in the acute phase of stroke, stroke in progression, and treatment and rehabilitation on a dedicated stroke unit. The most important factor for recovery remains the initial severity of the stroke. In unselected patients 19% of the strokes are very severe, 14% are severe, 26% are moderate, and 41% are mild. In survivors, neurologic impairment after completed rehabilitation is still severe or very severe in 11%, moderate in 11%, mild in 47%, and 31% have achieved normal neurologic function. The ability to perform basic activities of daily living initially is reduced in three out of four patients with stroke. Most often affected is the ability to transfer, dress, and walk. After completed rehabilitation the group with moderate and severe disability is reduced from 50% to 25%, and the group with mild or no disability is increased from 50% to 75%. The prognosis of patients with mild or moderate stroke generally is excellent. Patients with severe stroke have a very variable recovery. Although the prognosis of patients with the most severe stroke is generally poor, one third of the survivors in this group are able to be discharged back to their own homes with no or only mild disability, if rehabilitated on a dedicated stroke unit. Functional recovery generally was completed within 3 months of stroke onset. Patients with mild stroke, however, recover within 2 months, patients with moderate stroke within 3 months, patients with severe stroke within 4 months, and patients with the most severe strokes have their functional recovery within 5 months from onset. Functional recovery is preceded by neurologic recovery by a mean of 2 weeks.
Activities of Daily Living↗
[Seizures in acute apoplexy. Predisposing factors and significance for prognosis].
The aim of the study was to determine the relationships between seizures during the early phase of stroke (early seizures, ES) and stroke outcome, and to identify predictors of ES. The study was prospective, consecutive and community-based, and included 1197 patients with acute stroke. We determined the number and type of seizures, initial stroke severity, infarct size, mortality, and outcome in survivors. Stroke severity was measured on admission, weekly, and at discharge using the Scandinavian Stroke Scale (SSS). Multiple logistic and linear regression outcome analyses included relevant confounders and potential predictors. Fifty patients (4.2%) had seizures within 14 days of the stroke. In the multivariate analyses, only initial stroke severity was related to ES. For each 10-point increase in stroke severity (SSS score), the relative risk of ES increased by a factor of 1.65 (95% confidence interval, 1.4 to 1.9) (p < 0.0001). ES did not influence the risk of death during hospital stay (p = 0.56). In survivors, ES was related to a better outcome, equivalent to an improvement in SSS score of 5.7 points (SE [b] = 1.8; p = 0.002). The decisive factor of ES was initial stroke severity. ES per se was not related to mortality. Surprisingly, in survivors, ES predicted a better outcome. We explain this finding by a relatively larger ischaemic penumbra in patients who have ES after a stroke.
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["CADASIL"--a newly discovered hereditary cerebrovascular disease].
CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leucoencephalopathy) is a newly discovered inherited cerebrovascular disease characterized clinically by recurrent stroke-like incidents, dementia and often pseudobulbar palsy. Neuroimaging reveals intensive subcortical changes and pathologically one finds apparently systemic changes concerning the vessels such as thickening of the vessel wall, loss of smooth muscle cells and patches of granular material of unknown origin. The disease is not associated with atherosclerosis and vascular risk factors are missing or few. The CADASIL-locus maps to chromosome 19, but the gene has not yet been identified. Treatment and pathogenesis are unknown. In a Danish stroke population (The Copenhagen Stroke Study) no CADASIL-suspected cases were found among patients < or = 55 years, indicating a rare disease as far as Denmark is concerned.
Cerebral Arterial Diseases↗
[Pattern of admissions of patients with apoplexy. Time connection between symptom onset and admission and relation to medical and social factors. The Copenhagen Stroke Study].
The purpose of the study was to study admission delay in patients with stroke, and to analyze the influence of demographic, medical, and pathophysiological factors on admission delay. The study was prospective and consecutive and included 1197 unselected patients admitted with acute stroke from a well-defined catchment area in Copenhagen. Only 35% were admitted within the first six hours from stroke onset, and 50% of the patients were admitted later than 14 hours from stroke onset. Living alone (OR 1.75, 95% CI 1.3 to 2.3) and retired working status (OR 1.6, 95% CI 1.01 to 1.54) delayed admission. A well-functioning social network thus seems important to early admission. The milder the stroke, the higher was the risk of delayed admission (OR 1.25 per 10 points increase in stroke severity (Scandinavian Neurological Stroke Scale on admission), 95% CI 1.06 to 2.54. Other factors such as age, sex, diabetes, hypertension, ischaemic heart disease, other comorbidity, previous stroke, headache, aphasia, apraxia, anosognosia, neglect, lowered consciousness, mental status, and type of stroke had no independent influence on admission time. However, a history of TIA increased the chance of early admission by odds 1.64 (95% CI 1.01 to 2.54), indicating that an increase in public awareness and knowledge may reduce delay and save precious time.
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[Aphasia in acute apoplexy. Incidence, background factors and course].
Knowledge of the frequency and remission of aphasia is essential for the rehabilitation of stroke patients. Information on its determinants provides insight on brain organization of language. Therefore, a community based sample of 881 unselected, acute stroke patients was studied prospectively and consecutively. Assessment of aphasia was done on admission, weekly during hospital stay, and again at a six-month follow-up using the aphasia score of the Scandinavian Stroke Scale. Thirty-eight percent had aphasia at the time of admission, while at discharge it was 18%. Sex was not a significant determinant of aphasia in stroke, and no sex difference was found in the anterior-posterior distribution of lesions causing aphasia. There was, however, a higher rate of women with aphasia with right-sided lesions. The remission curve was steep: stationary language function in 95% was reached within two weeks in those with initial mild aphasia, within six weeks with moderate, and within ten weeks with severe aphasia. Initial severity of aphasia was the only clinically relevant predictor of aphasia outcome in multiple linear regression analysis. Sex, handedness, and side of stroke lesion were not independent outcome predictors, and the influence of age was minimal.
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Comprehensive assessment of activities of daily living in stroke. The Copenhagen Stroke Study.
OBJECTIVE: To assess activities of daily living (ADL) in stroke in a comprehensive way. The Barthel Index (BI) is widely used in stroke research, but is limited because it measures basic ADL functions only. This study sought to determine whether the Frenchay Activities Index (FAI) is a good choice for supplementary assessment of higher order ADL functions. DESIGN: Prospective and consecutive. SETTING: Follow-up investigation 6 months after stroke of patients who were admitted to, and completed rehabilitation at, a stroke unit. PATIENTS: 437 patients with strokes. MAIN OUTCOME MEASURES: Factor analysis of the BI, FAI, and the Scandinavian Neurological Stroke Scale (SSS); distribution characteristics of a comprehensive, combined ADL scale. RESULTS: Five factors were found. One factor comprised all items from the BI and all the motor items from the SSS, but no items from the FAI. The FAI loaded on three other factors. Finally, orientation and speech from the SSS loaded on a separate factor. A combined score consisting of the BI total score and a simple transformation of the FAI total score had a much improved distribution without strong ceiling or floor effects. CONCLUSIONS: The FAI supplements the BI with minimal overlap in content. A combined total score has a distribution that makes it very usable for research in stroke outcome and stroke rehabilitation effect.
Activities of Daily Living↗
Prevalence and risk factors of incontinence after stroke. The Copenhagen Stroke Study.
BACKGROUND AND PURPOSE: The purpose of this study was to investigate in a community-based population the prevalence of both urinary (UI) and fecal (FI) incontinence and to analyze risk factors by means of multivariate analysis. METHODS: Included were 935 acute stroke patients admitted consecutively during 19 months. We evaluated UI and FI using subscores of the Barthel Index during the hospital stay and at 6-month follow-up. RESULTS: On admission, the proportions of patients with full UI, partial UI, and no UI were 36%, 11%, and 53%, respectively (8%, 11%, and 81% at 6-month follow-up). The proportions of patients, with full FI, partial FI, and no FI on admission were 34%, 6%, and 60%, respectively (5%, 4%, and 91% at 6-month follow-up). By multivariate analysis, significant risk factors for UI and FI were age, severity of stroke, diabetes, and comorbidity of other disabling diseases. CONCLUSIONS: On admission in the acute state, almost half of an unselected stroke population have UI and/or FI. The proportion declines to one fifth (UI) and one tenth (FI) of the surviving patients at 6 months. Increasing age, stroke severity, diabetes, and other disabling diseases increase the risk of UI as well as FI.
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Acute stroke care and rehabilitation: an analysis of the direct cost and its clinical and social determinants. The Copenhagen Stroke Study.
BACKGROUND AND PURPOSE: Stroke represents a major economic challenge to society. The direct cost of stroke is largely determined by the duration of hospital stay, but internationally applicable estimates of the direct cost of acute stroke care and rehabilitation on cost-efficient stroke units are not available. Information regarding social and medical factors influencing the length of hospital stay (LOHS) and thereby cost is needed to direct cost-reducing efforts. METHODS: We determined the direct cost of stroke in the prospective, consecutive, and community-based stroke population of the Copenhagen Stroke Study by measuring the total LOHS in the 1197 acute stroke patients included in the study. All patients had all their acute care and rehabilitation on a dedicated stroke unit. Neurological impairment was measured by the Scandinavian Stroke Scale. Local nonmedical factors affecting the LOHS, such as waiting time for discharge to a nursing home after completed rehabilitation, were accounted for in the analysis. The influence of social and medical factors on the LOHS was analyzed in a multiple linear regression model. RESULTS: The average LOHS was 27.1 days (SD, 44.1; range, 1 to 193), corresponding to a direct cost of $12.150 per patient including all acute care and rehabilitation. The LOHS increased with increasing stroke severity (6 days per 10-point increase in severity; P < .0001) and single marital status (3.4 days; P = .02). Death reduced LOHS (22.0 days; P < .0001). Age, sex, diabetes, hypertension, claudication, ischemic heart disease, atrial fibrillation, former stroke, other disabling comorbidity, smoking, daily alcohol consumption, and the type of stroke (hemorrhage/infarct) had no independent influence on LOHS. CONCLUSIONS: Acute care and rehabilitation of unselected patients on a dedicated stroke unit takes on average 4 weeks. In general, comorbidity such as diabetes or heart disease does not increase LOHS. Efforts to reduce costs should therefore aim at reducing initial stroke severity or improving the rate of recovery.
Acute Disease↗
Seizures in acute stroke: predictors and prognostic significance. The Copenhagen Stroke Study.
BACKGROUND: Despite the common occurrence of seizures during the early phase of stroke (ES), the effect of ES on prognosis is not known. We determined the relationships between ES and stroke outcome and identified predictors of ES. METHODS: In this community-based study, we prospectively and consecutively studied 1197 patients with acute stroke. We determined the number and type of seizures, initial stroke severity, infarct size, mortality, and outcome in survivors. Stroke severity was measured on admission, weekly, and at discharge using the Scandinavian Stroke Scale (SSS). Multiple logistic and linear regression outcome analyses included relevant confounders and potential predictors, including age, gender, stroke severity on admission, atrial fibrillation, ischemic heart disease, diabetes, blood glucose level on admission, claudication, and hypertension. RESULTS: Fifty patients (4.2%) had seizures within 14 days of the stroke. In the multivariate analyses, only initial stroke severity was related to ES; stroke type and lesion localization were not related. For each 10-point increase in stroke severity (SSS score), the relative risk of ES increased by a factor of 1.65 (95% confidence interval, 1.4 to 1.9) (P < .0001). ES did not influence the risk of death during hospital stay (P = .56). In survivors, ES was related to a better outcome, equivalent to an increased SSS score of 5.7 points (SE [b] = 1.8; P = .002). CONCLUSIONS: The decisive factor of ES was initial stroke severity. ES per se was not related to mortality. Surprisingly, in survivors, ES predicted a better outcome. We explain this finding by a relatively larger ischemic penumbra in patients who have an ES after a stroke.
Acute Disease↗
Stroke recurrence: predictors, severity, and prognosis. The Copenhagen Stroke Study.
We compared stroke severity, risk factors, and prognosis in patients with recurrent versus first-ever stroke. In the Copenhagen Stroke Study, we prospectively studied 1,138 unselected patients with acute stroke. Stroke was recurrent in 265 (23%) despite most of these patients being given prophylactic treatment prior to recurrence. Only 12% of patients with atrial fibrillation were receiving anticoagulant treatment prior to recurrence. In multivariate analysis, recurrence was more frequently associated with a history of TIA, atrial fibrillation, male gender, and hypertension, but not with age, daily alcohol consumption, smoking, diabetes, ischemic heart disease, serum cholesterol, or hematocrit. Mortality was almost doubled compared with patients with a first-ever stroke. In survivors, however, both neurologic and functional outcomes and the speed of recovery were, in general, similar in the two groups. Despite similar neurologic impairments, patients with recurrence contralateral to their first stroke had markedly more severe functional disability after completed rehabilitation than patients with ipsilateral recurrence, implying that the ability to compensate functionally is decreased in patients with contralateral recurrence. Our findings emphasize the importance of consistent anticoagulant treatment for stroke patients with atrial fibrillation and close blood pressure control in stroke patients with hypertension. Other prophylactic measures are needed in patients in whom ASA fails to prevent recurrence. Patients with recurrent stroke have a markedly higher mortality than patients with a first-ever stroke, but those who survive recover as well and as fast as patients with a first-ever stroke. However, if recurrence is contralateral to the first stroke, functional recovery is poorer.
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Acute stroke: prognosis and a prediction of the effect of medical treatment on outcome and health care utilization. The Copenhagen Stroke Study.
Medical treatment of acute stroke with tissue plasminogen activator (tPA) was recently approved in the United States, and neuroprotective agents are being developed. Should all patients with stroke, regardless of severity, receive such treatment? In the Copenhagen Stroke Study we studied the prognosis of stroke in 1,351 unselected patients from a well-defined catchment area treated in a community-based stroke unit from the time of acute admission to death or the end of rehabilitation. Outcome measures were mortality, discharge rates to the patients' own home or to a nursing home, length of hospital stay, and neurological and functional outcomes. Prognosis was stratified according to initial stroke severity measured by the Scandinavian Neurological Stroke Scale (SSS) on admission. We estimated the effect of medical treatment on prognosis and health care utilization by assuming a medically induced decrease in initial stroke severity by 5 and 10 points in the initial SSS score. This mild and moderate decrease in initial stroke severity corresponded to an overall improvement in outcome and an overall cost reduction through shorter hospital stays. This was also true in patients with both mild and moderate stroke. However, in patients with severe stroke, survival increases expenses because of an increased discharge rate to a nursing home and an increase in the cost of acute care and rehabilitation. Future medical stroke trials should therefore focus on the effect and cost of treatment, especially in patients with severe stroke, and search for factors predictive of good clinical outcome in this group.
Activities of Daily Living↗
[Apoplexy units--reduced mortality, need for nursing homes, length of stay and cost savings].
Treatment of stroke patients on specialised stroke units has become more frequent, yet the effect of this treatment has not been determined. In this prospective, community-based study of 1241 unselected acute stroke patients we compared outcome between patients geographically randomised to treatment on a stroke unit or a general neurological/medical ward, from the time of acute admission to the end of rehabilitation. Baseline characteristics were comparable between the two treatment groups regarding age, sex, marital status, prestroke residence, and stroke severity. The patients treated on the stroke unit had higher comorbidity with regard to hypertension and diabetes. Multivariate linear and logistic regression analyses were applied to estimate the independent influence of stroke unit treatment on outcome. Stroke unit treatment significantly reduced in-hospital mortality (OR 0.50), case-fatality rate (OR 0.45), 6-month mortality (OR 0.57), 1-year mortality (0.59, and discharge rate to a nursing home (OR 0.61). The relative chance of being discharged to own home was almost doubled (OR 1.9), and the length of hospital stay reduced by 30% in patients treated on the stroke unit, P < 0.001. Treatment of unselected stroke patients on a stroke unit saves lives, nursing homes, and cost.
Cerebrovascular Disorders↗
Body temperature and outcome in stroke patients.
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Body Temperature↗
Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome.
BACKGROUND: In laboratory animals, cerebral ischaemia is worsened by hyperthermia and improved by hypothermia. Whether these observations apply to human beings with stroke is unknown. We therefore examined the relation between body temperature on admission with acute stroke and various indices of stroke severity and outcome. METHODS: In a prospective and consecutive study 390 stroke patients were admitted to hospital within 6 h after stroke (median 2.4 h). We determined body temperature on admission, initial stroke severity, infarct size, mortality, and outcome in survivors. Stroke severity was measured on admission, weekly, and at discharge on the Scandinavian Stroke Scale (SSS). Infarct size was determined by computed tomography. Multiple logistic and linear regression outcome analyses included relevant confounders and potential predictors such as age, gender, stroke severity on admission, body temperature, infections, leucocytosis, diabetes, hypertension, atrial fibrillation, ischaemic heart disease, smoking previous stroke, and comorbidity. FINDINGS: Mortality was lower and outcome better in patients with mild hypothermia on admission; both were worse in patients with hyperthermia. Body temperature was independently related to initial stroke severity (p < 0.009), infarct size (p < 0.0001), mortality (p < 0.02), and outcome in survivors (SSS at discharge) (p < 0.003). For each 1 degrees C increase in body temperature the relative risk of poor outcome (death or SSS score on discharge < 30 points) rose by 2.2 (95% CI 1.4-3.5) (p < 0.002). INTERPRETATION: We have shown that, in acute human stroke, an association exists between body temperature and initial stroke severity, infarct size, mortality, and outcome. Only intervention trials of hypothermic treatment can prove whether this relation is causal.
Acute Disease↗