Oral Sessions Wednesday, 25 May 2011

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Background: Incidence of subarachnoid haemorrhage (SAH) is higher in women ...... Imam Reza Medical Center is a tertiary university hospital which ...... presence of RVLM vascular compression was evaluated using time-of-flight 3D MRI.
Oral Sessions

Wednesday, 25 May 2011

Cerebrovasc Dis 2011;31(suppl 2):1–322

1 Meta-analysis and reviews APHASIA REHABILITATION – A COCHRANE SYSTEMATIC REVIEW UPDATE OF THE EVIDENCE FOR SPEECH AND LANGUAGE THERAPY (SLT) COMPARED WITH NO SLT

M.C. Brady1, H. Kelly2, P. Enderby3 1 NMAHP Research Unit, Glasgow Caledonian University, Glasgow, United Kingdom; 2NMAHP Research Unit, University of Stirling; Dept of Speech and Hearing Sciences, Queen Margaret University, Edinburgh, United Kingdom; 3 School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom Background: Each year more than 1 million Europeans experience a stroke. A third acquire aphasia, a language impairment affecting the expression and understanding of speech, reading and writing. The original Cochrane Review of SLT for aphasia after stroke (Greener et al., 1999) reviewed 12 trials but a lack of available data meant that the evidence was inconclusive. In this review update we identified and synthesised current evidence from 30 trials that compared SLT with a) no SLT, b) social support and stimulation, and c) different approaches to SLT. Here we report the evidence from (a). Methods: We searched the Cochrane Stroke Group Trials Register, MEDLINE and CINAHL, hand searched key journals, screened reference lists of relevant articles and contacted researchers to identify other published, unpublished and ongoing randomised controlled trials (RCTs) that compared SLT with no SLT. Two review authors independently extracted the data and assessed the quality of included trials. We sought missing data from trialists. Results: We included 14 randomised SLT versus no SLT comparisons (n = 1064). Approaches evaluated included “conventional”, computer-mediated, group, functional, intensive, operant training and volunteer-facilitated SLT. Outcomes measured included functional communication, receptive and expressive language, severity of impairment, psychosocial impact, number of drop-outs, compliance with allocated intervention and economic outcomes. A meta-analysis of four comparisons found that participants that received SLT had better receptive language scores than those that did not have SLT (MD 8.04, 95% CI [1.55, 14.52]) P = 0.02. We found no other evidence of between-group differences, though we noticed a promising consistency in the direction of the Results which favoured the provision of SLT. Conclusion: More data are required to inform this comparison. Improved design and reporting of trials in this field will further contribute to the evidence for SLT for aphasia following stroke.

2 Meta-analysis and reviews GROWING INTEREST IN STROKE REHABILITATION IN CHINA: A SYSTEMATIC REVIEW OF 30 RANDOMIZED CONTROLLED REHABILITATION TRIALS

W.W. Zhang1, S. Speare2, L. Churilov1, M. Thuy2, J. Bernhardt3 National Stroke Research Institute (part of Florey Neuroscience Institutes), University of Melbourne, Melbourne, Australia; 2National Stroke Research Institute (part of Florey Neuroscience Institutes), Melbourne, Australia; 3 National Stroke Research Institute (part of Florey Neuroscience Institutes), La Trobe University, Melbourne, Australia

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Background: Rehabilitation is not standard in stroke care in China. However, growing interest in the efficacy of rehabilitation is evident. Aims: To systematically review randomized controlled trials (RCTs) comparing rehabilitation versus no rehabilitation after stroke in China. Methods: We searched 24 databases including Wanfangdata (China) MEDLINE, EMBASE, CENTRAL and Cochrane Stroke Group Register. The primary outcome of interest: Activities of daily living (Barthel Index (BI)), secondary outcome: Disability (Fugl-Meyer Score (FMS)). Random-effect meta-analysis was performed.

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Results: 62 papers were identified, 95% published since 2000. 32 papers were excluded because they were not-RCTs or the authors failed to report BI and/or FMS data or data were missing. This left 30 included trials with a total of 4,574 patients, 931 patients with haemorrhagic stroke (20.4%) and 2,525 were males (55.2%). The rehabilitation interventions were mixed but all included additional exercise therapy. Control patients had no or limited rehabilitation. The weighted average effect of rehabilitation on primary outcome was a 20.03 points (95%CI: 16.9-23.2) improvement on BI Scale and 17.34 points (95%CI, 12.60-22.08) improvement on FMS. Patients who received rehabilitation showed marked improvements in BI (Standardized Mean Difference (SMD): 1.16, 95%CI: 0.96-1.35) and FMS (SMD: 1.54, 95%CI: 1.03-2.04) compared to controls. Reporting quality was often low however, with randomization method and time to start of rehabilitation unclear. Reasons for loss to follow up were frequently not stated. Conclusions: Recent interest in stroke rehabilitation in China has resulted in a large number of trials on the topic. Although reporting quality of many RCTs was low, there is evidence of overwhelmingly positive Results of rehabilitation after stroke.

3 Meta-analysis and reviews META-ANALYSIS OF INSULIN USE FOR POST-STROKE HYPERGLYCEMIA

N.J.J. MacDougall, K.W. Muir University of Glasgow, Glasgow, United Kingdom Background: Post-stroke hyperglycemia (PSH) is associated with poor clinical outcomes. Clinical guidelines advocate insulin for PSH, but no clinical benefit has been evident in several clinical trials, and there is a risk of hypoglycaemia. Methods: Systematic review of papers identified from databases and reference lists was undertaken. Data from randomised controlled trials (RCTs) that reported mortality or functional outcome were extracted. Favourable functional outcome was defined as modified Rankin score (mRS) ≤2 or favourable extended Glasgow Outcome Scores (eGOS). A DerSimonian-Laird random effects model was used to generate odds ratios and 95% confidence intervals. Results: We identified 16 studies (2459 patients) including 1 large RCT of 933 patients, 9 pilot RCTs of between 10 and 116 patients and 6 cohort studies, one of which included 851 patients. One study involved a mixed population of neuroscience ITU patients with a subset of 15 stroke patients. One paper used the control group from another paper by the same group. 1421 patients were in RCTs while 1038 were in cohort studies. Minimum glucose levels for study inclusion varied from 5.6-9.4mmol/L. Mean onset to treatment time ranged from 9.1h to 20.8h. Glucose targets varied from 3.8-11.1mmol/L. Treatment Duration varied from 24h to 5 days. Eight RCTs reported mortality data and seven reported functional outcome. Insulin infusions had a neutral effect on mortality (OR 1.1, 95% CI 0.9 to 1.5, p = 0.29, n = 1236) and on good functional outcome (OR 1.03, 95% CI 0.7 to 1.5, p = 0.88, n = 1217). Incidence of hypoglycaemia varied from 8%-80%. Definitions of hypoglycemia varied from 150 (OR 4.9; 95%CI: 2.5-9.7; p24 (OR 2.6; 95%CI: 1.5-4.7; p50 (OR: 0.4; 95%CI: 0.2-0.7; p=0.005), psychical SF12 score >50 (OR: 0.5; 95%CI: 0.3-0.8 p=0.008), GHQ28 score >8 (OR: 1.3; 95%CI: 0.7-2.4; p=0.34). Conclusion: Psycho-physical stress related to vital events, Type A behaviour and low QoL were associated with a higher risk of stroke compared to healthy individuals. Conversely, levels of anxiety and distress did not appear significantly associated with ictus.

844 Acute stroke: clinical patterns and practise including nursing DETECTION, WORK-UP AND MANAGEMENT OF ACUTE ISCHEMIC STROKE PATIENTS APPROPRIATE FOR THROMBOLYSIS BY EXTENDED NURSING SERVICE IN RAMBAM HEALTH CARE CAMPUS

D. Rozenfeld, A. Reznik, A. Baruch, A. Salama, Y. Safran Rambam Health Care Campus, Haifa, Israel

Background: Emergent and immediate assessment of acute ischemic stroke patients is extremely important in the achievement of the best Results in the treatment and outcome of stroke. This is especially imperative in patients treated with either intra-arterial (IA) or intravenous (IV) thrombolysis. For the better identification of patients appropriate for thrombolysis two nurses and stroke coordinator were defined as nursing stroke team in neurology department and ER in 2009. Also, it was considered that such reinforcing will increase the number of diagnostic tests such as CT angiography (CTA) and CT perfusion of brain performed in ER and through the hospitalization. Patients and Methods: All patients diagnosed as acute ischemic stroke in Emergency Room (ER) in 2009-2010 were included in the study. The number of IV treatments was 25 in 2009 versus 26 patients in 2010 (NS). However, the number of IA treatments increased from 8 in 2009 to 14 in 2010. Also, the number of the imaging procedures increased significantly - totally 510 exams of CTA of carotid, CTA of brain and CT perfusion in 2009 versus 706 in 2010 (p6 months) stroke (PwS) and age-matched healthy controls (HC) were recruited for an observational, cross-sectional study. Thoracic, lumbar, sacral and total spinal inclination were measured with the standardized SpinalMouse® while standing upright, flexed forward and extended backward. Clinical measures included the Trunk Impairment Scale (TIS), Barthel Index (BI) and Stroke Impact Scale (SIS). Results: We assessed 16 PwS and 17 HC. When standing upright, PwS had significantly greater forward spinal inclination (p=0.006) in comparison with HC. When flexed forward, PwS demonstrated less anterior sacral inclination (p=.017) and less total spinal inclination (p=0.023). When extended backward, PwS showed less posterior sacral inclination (p=0.016) and less total spinal inclination (p=.004). All these variables correlated significantly with the TIS. Total spinal inclination in the upright and extended backward position as well as sacral inclination in the extended backward position correlated also significantly with the Barthel Index (r=0.55 to -0.65). Conclusion: Total spinal inclination is impaired in the chronic phase after stroke and related to deficits at impairment and activity level. Furthermore, we observed decreased sacral movement when bending forward and backward which was also related to independence after stroke and could become a specific target of rehabilitation.

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MIRROR THERAPY FOR IMPROVING MOTOR FUNCTION AFTER STROKE - A SYSTEMATIC REVIEW CARRIED OUT USING COCHRANE METHODOLOGY

Poster Session Nurses/AHP's and Poster Session Red Cerebrovasc Dis 2011;31(suppl 2):1–322

850 Stroke care problems IRANIAN EXPERTS’ EXPERIENCE OF REHABILITATION SERVICES FOR STROKE SURVIVORS

A. Dalvandi1, S.L. Ekman1, S.S.B. Maddah2, H.R. Khankeh2, K. Heikkilä1 Karolinska Institutet, Stockholm, Sweden; 2University of Social Sciences & Rehabilitation Sciences, Tehran, Iran 1

Background/Aim: Stroke is a global burden that can cause significant health care problems. Stroke sufferers and their family caregivers experience that the rehabilitation care in Iran needs to be developed. In order to understand the broader picture of stroke rehabilitation, even the experiences of stroke rehabilitation experts is needed. The aim of this study was to explore the experiences of Iranian rehabilitation experts about rehabilitation services in community for stroke survivors and their points of view on how to develop these services. Method: A qualitative research using grounded theory approach with purposive and theoretical sampling was used. Data were gathered through two focus group Discussions and four individual interviews with ten Iranian rehabilitation experts. Constant comparative analysis method was used. Findings: Non-integrated rehabilitation service emerged as core concept of the study. The explored concepts were identified as “deficiently allocated budget”, “inadequate social insurance”, “lack of availability of rehabilitative care”, “public views”, “lack of consistency of care”, “split services and professional separation”, “need for changing policymakers attitudes”, “needs for re-defining rehabilitation in health care system”, “needs for establishing a registration system”, “needs for providing information and skills” and “needs for seeing family as a whole”. Conclusion: The experts experienced that the rehabilitation services are not profoundly integrated within the health system in Iran and refinements need to be done. Adequate budgets for implicating discharge plan should be allocated to make opportunities for rehabilitation team working. These efforts could bring opportunities for stroke survivors and their family caregivers to gain knowledge and skills and to participate in rehabilitation teams and also to help reduce their problems.

851 Stroke care problems ETHICAL PROBLEMS IN STROKE CARE DUE TO SUDDEN AND UNEXPECTED DEATH BY ACUTE STROKE - A STROKE UNIT TEAM APPROACH

Å. Rejnö, E. Danielson, L. Berg Institute of Health and Care Sciences, The Sahlgrenska Academy at Gothenburg University, Goteborg, Sweden

When people die suddenly and unexpectedly caused by acute stroke ethical issues often come to the fore and staff at stroke units have to deal with ethical problems in care. We aimed at describing stroke teams’ staffs’ experiences of ethical problems in care and how the teams managed the situation when caring for patients faced with sudden and unexpected death from stroke. Data were collected through four focus group interviews with nineteen team members, enrolled nurses, registered nurses and physicians in stroke-unit teams. The result show three themes: To give information when conditions are unstable; To decide on care when the situation is changing and To support when uncertainty prevails. To give information was experienced as central and related to several ethical problems since the situation was experienced as unstable. Difficulties in making ethical decisions for example about treatment, nutrition and drip for those patients suffering from severe stroke were experienced because of the changing and uncertain situation. In striving to support next-of-kin in the changing and uncertain situation the teams said they felt the patients slipped into the Background and the focus moved

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to the next-of-kin and questioned who’s needs that should guide the care, the next of kin’s or the patients. Mutual trust, both within the stroke team and with next-of-kin, emerged as the core and was seen as a way of handling ethical problems when giving care with the patient’s best at heart. Issues experienced as ethically problematic require reflection and cooperation with next-of-kin and other team members. A mutual exchange of information forms the basis for decisions that need to be made when uncertainty prevails. Through trust, a relationship can be constructed that enables the stroketeam members to support the next-of-kin. It is a challenge for the stroke-teams to create mutuality, which is the basis of trust, when conditions are changing.

852 Stroke care problems FORMEL DIALOG MEETINGS WITH THE CHILDREN OF PARENTS WITH ACUTE STROKE

L.K. Christiansen Stroke Unit, Neurological Department, Aalborg Hospital, Aalborg, Denmark

Background: Children of parents with stroke express themselves as forgotten and kept away in connection to the illness of their parents. At the same time the healthy parent is often going through a psychological crisis and may be unaware of how to react toward the children. In the Stroke Unit of Aalborg Hospital, Denmark, we decided to concentrate on these children by organizing formal dialog meetings with the participation of children between 6 and 18 years, nurses, social workers, and neurological psychologists. Parents were allowed to participate, but the children and their interests were in focus. Aim: To describe our experiences with dialog meetings with children of parents with stroke. Method: A qualitative semi structured interview was completed with the participation of nurses, a social worker, and a neurological psychologist. The interview dealt with the reaction of the children, how to make the children open up for a talk, which remedies were needed, the reaction of the parents, the wishes of the children and which information the children were given. Results: The poster shows our experiences with these dialog meetings.

853 Stroke care problems THE PREVALENCE OF MOOD DISORDERS AMONG STROKE PATIENTS ADMITTED INTO A REHABILITATION CENTER IN SINGAPORE

X.H. Sam, L.P. Aaron Ang, S.E. Goh, W.M. Nicholas Chew Tan Tock Seng Hospital, Singapore, Singapore

To study the prevalence of mood disorders among stroke patients who were transferred to a rehabilitation center from acute hospitals. A total of 214 stroke patients were admitted into Tan Tock Seng Rehabilitation Center from acute hospitals over a period of six months. Patients with apparent cognitive or hearing impairment, aphasia, dysphasia, Abbreviated Mental Test (AMT) score 2, only a third of patients with AF received oral anticoagulation before stroke.

7 Epidemiology of stroke DIFFERENCES IN STROKE SUBTYPE BETWEEN FIRST-EVER AND RECURRENT STROKE: THE SOUTH LONDON STROKE REGISTER (SLSR)

K.M. Mohan1, A.P. Grieve1, A.G. Rudd2, P.U. Heuschmann3, P.L. KolominskyRabas4, C.D.A. Wolfe1 1 King’s College London, London, United Kingdom; 2Guys’s and St. Thomas NHS Foundation Trust, London, United Kingdom; 3Charité Universitaetsmedizin Berlin, Berlin, Germany; 4University of ErlangenNurnberg, Erlangen, Germany Background: Data reporting long-term patterns of cumulative risk of stroke recurrence between different aetiological and pathological stroke subtypes are lacking. Furthermore, information regarding transition in subtype of first and recurrent stroke is not widely available. Methods: Data were collected from the SLSR, a population-based stroke register in South London. Patients were followed up for a maximum of 12 years. KaplanMeier estimates were performed to assess cumulative risk of stroke recurrence and this was stratified using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) and Oxford Community Project Classification (OCSP) classifications. Initial and recurrent stroke subtypes were cross-tabulated to calculate transition probabilities. Results: Between 1995 and 2009, 4023 patients with first-ever stroke were included in the SLSR. Mean follow-up period was 3.0 years. In 11981.7 person-years of follow up, 394 recurrent strokes were documented. The overall cumulative risk of stroke recurrence was 6.7% at 1 year, 15.1% at 5 years, 21.5% at 10 years and 23.5% at 12 years after first stroke. Between 1999 and 2009, the cumulative risk of stroke recurrence 1 year post stroke ranged from 4.0% in the small vessel occlusion (SVO) group to 6.5% in the large artery occlusion (LAA) group. These Results were lower than 1 year recurrence rates for both intracerebral (PICH) and sub-arachnoid (SAH) haemorrhages which were 8.6% and 8.8%. Transition in aetiological subtype between initial and recurrent stroke was seen in 51.0% at 1 year, increasing to 61.9% 10 years after first stroke. Discussion: The cumulative risk of stroke recurrence is wide-ranging between aetiological and pathological subtypes. Further research is needed to identify predictors for increased risk of recurrence amongst different stroke subtypes and to investigate whether implementation of intensified secondary prevention strategies in high risk patients can reduce the long-term risk of stroke recurrence.

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differently using the 2 schemes. In particular, given the higher level of evidence required in particular in the cardioembolic stroke category, we hypothesised an increase in those coded as undetermined stroke by ASCO criteria. Methods: We recorded all stroke presentations in those ≤55 years over an 18 month period. All cases-notes were reviewed and stroke subtype by TOAST and ASCO recorded. ASCO grading was grouped by level 1 (ASCO1) and level 2 (ASCO2) evidence for comparison with TOAST. Proportion of cases classified as undetermined by TOAST and ASCO was compared (using McNemar’s test). Results: 316 cases ≤55 years (145 inpatient, 171 outpatient) presented to the stroke service in the time period. Of these, there were 124 confirmed strokes (107 infarcts and 14 haemorrhages); 29 TIAs, 157 mimics and 9 with incomplete data were excluded. By TOAST criteria, there were 6%, 11%, 28%, 22% and 34% of large artery atherosclerosis, small vessel occlusion, cardiac embolism, other determined cause and undetermined cause respectively. Considering the same groups, there were 6%, 9%, 11%, 22% and 52% by ASCO1 and 6%, 16%, 16%, 22% and 41% by ASCO2 (Figure). The proportion of cases classified as undetermined by ASCO1 was significantly greater than by TOAST (52.3% v 33.6%; p=0.0002). For those with a cardiac cause of stroke by TOAST criteria, the majority had a PFO (60.0%), which were not coded as cardioembolic by ASCO1 criteria.

LONG TERM SURVIVAL: PREDICTORS AND TRENDS IN THE SOUTH LONDON STROKE REGISTER FROM 1995 TO 2009

Y. Wang, C.D.A. Wolfe, A.G. Rudd King’s College London, Division of Health and Social Care Research; Guy’s & St. Thomas’ NHS Foundation Trust and King’s College London, NIHR cBRC;, London, United Kingdom Aim: To estimate survival up to 15 years after a first-ever stroke and the influence of year of stroke, sociodemographic, case-mix, stroke subtype and acute stroke care factors on survival. Methods: Population based stroke register registering first in a lifetime strokes between 1995 and 2009. Baseline data collected on sociodemographic factors, subtype, case mix, risk factors prior to stroke, and acute stroke care variables. Survival curves were estimated with Kaplan-Meier Methods and multivariate survival analyses were undertaken using Cox Proportional-hazards models. Results: Among 4037 patients with a first-ever stroke between 1st January 1995 and 31st December 2009, 2514 (62.3%) have died (all causes) by 31st May 2010. Survival gradually improved over this 15-year period as shown in Kaplan-Meier curves for patients registering in each consecutive 3-year period (P-value18 years, with a diagnosis of AIS and ARDS. Definitions were based on ICD9CM codes. Adjusted incidence rates for the U.S census were calculated and multivariate logistic regression models were then fitted to assess for the impact of ARDS on hospital mortality. Results: Over the 15-year period, we identified 5,451,998 admissions that corresponded to a primary diagnosis of AIS of which 209,291 had ARDS for a cumulative incidence of 4%. The adjusted rate of AIS increased from 132/100,000 in 1994 to 142/100,000 in 2008 and the adjusted rate of ARDS after AIS increased from 4.7/100,000 in 1994 to 5.7/100,000 in 2008. ARDS was more common among old (OR 0.9; 95%CI 0.9-0.98), men (OR 1.2; 95%CI 1.2-1.21), blacks (OR 1.2; 95%CI 1.1-1.2), urban-academic centers (OR 1.4; 95%CI 1.3-1.5); and in sepsis (OR 8.0; 95%CI 7.6-8.4), cardiovascular dysf. (OR 3.5; 95%CI 3.3-3.7), renal dysf. (OR 2.3; 95%CI, 2.2-2.4), hepatic dysf. (OR 2.9; 95%CI 2.4-3.4), hematological dysf. (OR 1.9; 95%CI, 1.8-2.1), and thrombolysis (OR 3.8; 95%CI, 3.6-4.0). The total hospital mortality after AIS fell from 9% in 1994 to 5% in 2008. Mortality was highest among ARDS (adjusted (a) OR 17; 95%CI 16-18), old (aOR 1.03; 95%CI 1.03-1.03), whites (OR 1.2; 95%CI 1.1-1.2), sepsis (aOR 3.4; 95%CI 3.2-3.6); and thrombolysis (aOR 1.6 95%CI 1.4-1.7). A differential effect of ARDS on hospital mortality was found in those that received thrombolytics (aOR 0.5; 95%CI 0.4-0.6). Conclusion: Our analysis demonstrates an increase in the incidence of AIS in the U.S. Despite a decline in overall AIS related mortality, ARDS increased the risk of in-hospital death but those that received thrombolytics were more likely to survive.

11 Epidemiology of stroke THE STROKE EPIDEMIOLOGY IN SIX REGIONS OF RUSSIA

O.A. Klochihina, V.I. Skvortsova, L.V. Stachovskay National Association of Fight against Stroke, Moscow, Russian Federation Background: The aim of the work is to study rates of incidence, attack, mortality and fatality cases from stroke in Russia, in order to organize treatment and acute stroke prevention. Material and Methods: The research was executed with the Register method according to the uniform criteria of Methodological Instruction Russian National Association of Fight against Stroke. Study of epidemiological stroke indexes was conducted in open population of men and women older than 25 years in six regions of Russia, the number of residents was 981 207, among them: men were 435 678 and women - 545 529. Those regions were the Republic of Bashkiria, Ivanovo region, Irkutsk region, the Republic of Karelia, Stavropol region, Sverdlovsk region. The number of stroke cases registered for 1 year was 3 411; 1 572 stroke cases and 1 839 stroke cases, among men and women, in accordance. Results: According to the European standard, standardized stroke attack rate in 6 regions for 1-year study period (2009) was 3.48 per 1 000 population: 3.61 per 1 000 for men and 3.37 per 1 000 for women. Incidence of first stroke was 2,65 per 1 000 population: 2.69 per 1 000 for men and 2.62 per 1000 for women. Incidence of recurrent stroke was 0,85 per 1 000 population: 0.91 per 1 000 for men and 0.75 per 1 000 for women. Non-fatal incidence first stroke (not finished with case fatality in a period within 28 days from the onset of the stroke) was 1.86 cases per 1 000 population. Non-fatal incidence recurrent stroke was 0.54 cases per 1 000 population. A stroke case mortality rate within 28-days period of the stroke was 0.91 per 1 000 population: 0.82 - among men, 0.99 - among women.

20th European Stroke Conference

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8 Epidemiology of stroke

Conclusions: Epidemiological study of stroke in the open population of Russia demonstrates the high rate of incidence, attack and case fatality and shows the necessity of further investigation of stroke risk factors.

12 Epidemiology of stroke DIFFERENTIAL PROPENSITY OF MAJOR HAEMORRHAGIC EVENTS IN PATIENTS WITH DIFFERENT TYPES OF ARTERIAL DISEASES

S. Achterberg1, F.L.J. Visseren2, L.J. Kappelle1, D.M.O. Pruissen1, Y. van der Graaf3, A. Algra4, the SMART Study Group 1 Department of Neurology, Utrecht Stroke Center, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands; 2 Departement of Vascular Medicine University Medical Center Utrecht, Utrecht, The Netherlands; 3Julius Center for Health Sciences and Primary Care University Medical Center Utrecht, Utrecht, The Netherlands; 4Department of Neurology, Rudolf Magnus Institute of Neuroscience and Julius Center for Health Sciences and Primary Care University Medical Center, Utrecht, The Netherlands Aims: Atherosclerosis is the most frequent cause of coronary artery disease (CAD), cerebrovascular disease (CVD) or peripheral arterial obstructive disease (PAOD). We previously found that patients with CVD or PAOD had a two times higher risk of major haemorrhagic complications than patients with CAD. We investigated whether this difference was attributable to baseline risk factors or genetic variants involved in haemostasis. Methods and Results: We included 2622 consecutive patients from a single university hospital who presented with non-disabling CAD, CVD or PAOD. All patients were followed for the occurrence of major haemorrhagic complications during a mean of 6.6 years. Major haemorrhagic events included intracranial haemorrhagic, fatal haemorrhagic event and any haemorrhagic complication requiring hospitalisation, irrespective of interventions. Major haemorrhagic complications occurred in 122 patients (annual event rate 0.77%). Patients with CVD or PAOD had more haemorrhagic complications than patients with CAD (HR: 2.05 (95%CI: 1.39-3.01). Hypertension, diabetes, renal failure and use of oral anticoagulants or antiplatelet therapy did not explain the difference (HR adjusted for all characteristics 1.74; 95%CI 1.14-2.61). Additional adjustment for genetic variants did not further change the HR. Conclusion: Patients with CVD or PAOD are at higher risk for major haemorrhagic events than patients with CAD. This difference could not be explained by known risk factors, use of antithrombotic agents or genetic variants involved in haemostasis. Further research to find the reason for this difference and possible differences in pathogenesis is warranted.

13 Epidemiology of stroke NATIONAL TRENDS IN STROKE ADMISSIONS, DENMARK 1997-2009

M.N. Demant1, T. Truelsen2 1 Department of Cardiology, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark; 2Department of Neurology, Copenhagen University Hospital, Herlev, Copenhagen, Denmark Background: The aim of this nationwide register study is to analyze trends of incidence in hospitalized stroke events in Denmark from 1997-2009 and to provide projections on the number of stroke patients in Denmark in 2030. Methods: Data from the Danish National Patient Register were used to identify all first-ever hospitalized stroke events in Denmark from 1997-2009. Persons aged 25 years and above were included. Incidence rates were calculated for all major stroke sub-types. Poisson regression analyses adjusting for age in 1-year intervals were used to examine trends in age-, gender- and subtype stratified IRs. Results: During the observation period of 5.44*107 person years-at-risk (PY) a total of 88,153 and 88,254 stroke events were registered in men and women, respectively. For all ages the total absolute unadjusted incidence rate (IR) in 1997 was 3.21/1000 PY (95% CI 3.15-3.26) and increased in 2009 to 3.73/1000 PY (95% CI 3.67-3.79). Incidence rate ratio adjusted for age in the time period 2007-2009 was statistically significant increased compared with the time period 1997-2000 in most 10-years age groups, see tables 1 and 2.

Table 1. Stroke incidence rate ratios for men for all types of stroke for 4 time periods (1997-2000 reference) All types, 1997-2000 2001-2003 p-value 2004-2006 p-value 2007-2009 p-value men