Download 22. European Stroke Conference

22. European Stroke Conference
9 Epidemiology of stroke
15:50 - 16:00
Ethnic and age disparities in incidence of stroke over time: analysis from the South London Stroke Register over 16 years
Y. Wang1, A.G. Rudd2, C.D.A. Wolfe3
Division of Health and Social Care Research, King’s College London, London, UNITED
KINGDOM1,Division of Health and Social Care Research, King’s College London, London,
UNITED KINGDOM2, Division of Health and Social Care Research, King’s College London,
London, UNITED KINGDOM3
Objectives: To investigate ethnic and age disparities in stroke incidence over time from an inner-city population-based stroke register.
Methods: Trends in stroke incidence and prior-to-stroke risk factors were investigated with the
South London Stroke Register (SLSR), a population-based register, covering a multiethnic population of 271,817 inhabitants in South London with 63% white, 28% black, and 9% of other
ethnic group. Age-, ethnicity- and sex- specific incidence rates with 95% confidence intervals
were calculated assuming a Poisson distribution and their trends over time tested by the Cochran-Armitage test.
Results: 4251 patients with first-ever stroke were registered between 1995 and 2010. Total
stroke incidence reduced by 34.4% over the 16-year period from 202.6 to 132.9 per 100,000
population (p<0.0001). Similar declines in stroke incidence were observed in men (228.2 to
143.6) and women (177.9 to 121.4), white (190.6 to 126.2) and black (264.1 to 148.2), and patients aged over 55 years (658.4 to 419.5) (all significant with p<0.0001), but not in patients
aged under 55 years (24 to 20.7, not significant with p>0.05). The mean age at stroke decreased
significantly from 71.6 years in 1995-1998 to 69.4 years in 2007-2010 (p=0.0002). The proportion of all strokes aged < 55 years increased from 10% in 1995 to 20.4% in 2010. The reduction
in prevalence of prior-to-stroke risk factors was mostly seen in white patients over 55 years,
while an increase in diabetes was observed in younger black patients aged under 55 years.
Conclusions: Total stroke incidence decreased over a 16-year time period. However, this was
not seen in younger age groups. Stroke risk increased in younger age and black groups. The
advances in risk factor reduction observed in white groups over age 55 years failed to be transferred to younger age groups for both black and white.
144
© 2013 S. Karger AG, Basel
14:30-16:00 Oral Session Room 9,10
Rehabilitation and reorganisation after stroke B
Chairs: S.C. Cramer, USA and A. Leff, UK
10 Rehabilitation and reorganisation after stroke B
14:30 - 14:40
Cognitive determinants of return to work after a stroke
M. Hommel1, B. Naegele2, S. Miguel3, A. Jaillard4
University Hospital, Grenoble, FRANCE1,University Hospital, Grenoble, FRANCE2, University Hospital, Grenoble, FRANCE3, University Hospital, Grenoble, FRANCE4
Background
Despite the known relation to age, about 20% of strokes occur at vocational age and they have
a major individual and societal impact. As work market requires higher professional skills associated with higher cognitive capabilities, we studied the cognitive determinants of return to
work (RTW).
Methods
We prospectively included patients in a subacute infarcts cohort (N=156) and in a confirmatory chronic stroke cohort (N=62). The patients were non demented (MMSE&#8805;23). We
collected demographic including previous occupation, social and familial, imaging, and diagnostic data. Using a comprehensive neuropsychological battery of tests, we assessed cognition
within the first month in the first cohort and after 6±3 months in the confirmatory. General and
instrumental functions, memory, executive functions and working memory were the cognitive
domains explored. RTW was assessed at the 1 year follow-up visit in all the patients. We used
confirmatory factor analysis to estimate the cognitive domains and logistic regressions for testing the predictors of return to work.
Results
Age, previous occupation, stroke severity, and depression were associated with RTW in univariate comparisons. Tests from each cognitive domain were predictive of RTW after correction
for multiple comparisons. All cognitive domains but memory were predictive of RTW. In multivariate analysis, age (0.01), depression (0.01) and working memory (< 0.000) were the predictors of RTW in both cohorts. The cognitive domain working memory was the best predictor
of RTW overall, and carries more information than a fast global cognitive evaluation such as
MMSE when considering RTW.
Conclusion
Cognition was the main factor of RTW after stroke. Working memory was the best marker of
cognitive deficits when considering RTW. It suggests focusing rehabilitation trials on working
memory deficits.
Scientific Programme
London, United Kingdom 2013
2 Behavioral disorders and post-stroke dementia
3 Behavioral disorders and post-stroke dementia
8:40 - 8:50
8:50 - 9:00
Long-term risk of dementia after TIA and stroke: current estimates from a large population-based study
S.T. Pendlebury1, P-J. Chen2, Z. Mehta3, P.M Rothwell4
for the Oxford Vascular Study
Long-term effects of secondary prevention on cognitive function in stroke patients
A. Douiri1, C. McKevitt2, E.S. Emmett3, A.G. Rudd4, C.D.A. Wolfe5
Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Oxford, UNITED KINGDOM1,Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Oxford, UNITED KINGDOM2, Stroke Prevention Research Unit, Nuffield
Department of Clinical Neurosciences, Oxford, UNITED KINGDOM3, Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, Oxford, UNITED KINGDOM4
NIHR-BRC and King’s Colleg London, London, UNITED KINGDOM1,King’s Colleg
London, London, UNITED KINGDOM2, King’s Colleg London, London, UNITED KINGDOM3, King’s Colleg London, London, UNITED KINGDOM4, NIHR-BRC and King’s Colleg
London, London, UNITED KINGDOM5
Background
Limited long-term follow-up data exist on the impact of secondary prevention drug therapies
on cognitive function in patients after first ever stroke. The aim of this study is to determine the
BACKGROUND: Previous studies have shown that risk of dementia early after stroke is high effect of secondary prevention on cognitive function after stroke.
and is associated with stroke-related factors, such as lesion size and number. Late post-stroke
Methods
dementia may be more related to vascular risk factors and non-lesional pathology. Incidence
Data were collected between 1995 and 2011 (n=4413) from the community-based South Lonof late post-event dementia might therefore follow a similar trajectory after TIA. We therefore
don Stroke Register covering an inner-city multi-ethnic source population of 271,817 inhabiexamined rates of dementia after all TIA and stroke in a large population-based study with fol- tants. Patients were assessed for cognition using Abbreviated Mental Test or Mini Metal State
low-up to 5 years.
Examination at 3 months and annually thereafter. A longitudinal analysis was used to investiMETHODS: In a population-based study of all TIA and stroke (Oxford Vascular Study), pagate the relationship between the cognitive function and post-stroke secondary prevention thertients recruited from 2002-2007 had functional and cognitive assessment at baseline and 1, 6,
apy over time. The analyses were adjusted for age, sex, ethnicity, socioeconomic status, case12 months, 2 and 5 years (up to 2012), including the mini-mental-state-examination (MMSE)
mix, stroke sub-type, and time-dependent variables, vascular risk factors, disability and stroke
and Montreal Cognitive assessment (MoCA). To identify dementia occurring between folrecurrence.
low-up visits, or in patients missing visits, all primary care and hospital medical records were
Results
also hand-searched. Dementia was defined as MMSE<24 with associated functional impairMean age was 70 (SD:15) years, 2,181 (49%) were female and 1137 (26%) died within the first
ment not solely caused by stroke, and/or a clinical diagnosis of dementia.
3 months. In multivariate longitudinal analysis, post-stroke cognitive impairment was signifiRESULTS: In 1247 patients (mean age 75+13 years, 47% male, 32% TIA), 94 (8%) had precantly reduced in association with anticoagulants (relative risk RR: 0.8, 95%CI [0.69-0.87]),
stroke dementia, 190 (16%) of the remainder developed new post-stroke dementia within one
lipid-lowering (RR: 0.9, 95%CI [0.78-0.94]), antiplatelets (RR: 0.9, 95%CI [0.77-0.96] in dual
year and 341 (30%) by 5 years. One-year incidence of dementia was lowest in TIA without
therapies) and antihypertensives (RR: 0.9, 95%CI [0.81-0.98] in combination therapies). Borprior stroke (8.4%, 5.3-11.4), intermediate after first ever stroke (17.9%, 14.8-21.1) and highderline significant associations were noted between post-stroke cognitive impairment and treatest after recurrent stroke (26.1%, 17.8-34.3). Rates had increased to 15.6% (11.5-19.7), 30.5% ments with antihypertensive or antiplatelet monotherapy. Atrial fibrillation was independently
(26.4-34.6) and 44.3% (33.8-54.8) respectively by 5 years.
associated with an increased risk of cognitive impairment (RR: 1.13, 95% CI [1.01-1.27]).
CONCLUSIONS: Early risk of dementia was higher after stroke than TIA, in keeping with the Conclusions
hypothesis of a lesional effect. However, subsequent incidence of new dementia was also lower Optimal medication therapy management after stroke was associated with reduced risk of cogafter TIA, suggesting differences in susceptibility and/or underlying cerebral pathology, which nitive impairment after stroke. Secondary prevention drugs do not have any major effect on
require further research.
cognitive function in atrial fibrillation stroke patients.
Cerebrovasc Dis 2013; 35 (suppl 3)1-854
187
London, United Kingdom 2013
6 Behavioral disorders and post-stroke dementia
7 Behavioral disorders and post-stroke dementia
9:20 - 9:30
9:30 - 9:40
Post-stroke depression: Prospective longitudinal study reveals the predictive value of
measuring depressive symptoms within the first weeks after stroke
K. Werheid1, Anna Lewin2, M. Joebges3
Health Related Quality of Life (HRQoL) One Year after Stroke in Persistently Anxious
Patients
S. Ayis1, L. Ayerbe2, A.G. Rudd3, C.D.A. Wolfe4
Humboldt University, Dept. of Psychology, Clinical Gerontopsychology, Berlin, GERKing’s College London, London, UNITED KINGDOM1,King’s College London, London,
MANY1,Humboldt University, Dept. of Psychology, Clinical Gerontopsychology, Berlin, GER- UNITED KINGDOM2, King’s College London, London, UNITED KINGDOM3, King’s ColMANY2, Brandenburg Klinik, Bernau, GERMANY3
lege London, London, UNITED KINGDOM4
Background: Depression is the most frequent mental disorder after stroke, associated with prolonged recovery, reduced quality of life, and increased mortality. While it is well-established
that post-stroke depression (PSD) usually evolves within the first year after stroke, it is still
unclear whether postacute depressive symptoms within the first weeks after stroke are predictive for later depression, and whether they are associated with other known psychosocial risk
factors such as self-perceived social support, living conditions, and self-efficacy. Our prospective longitudinal study investigates the trajectories of stroke patients by recurrent assessment of
these factors.
Methods: Depressive symptoms measured by the Geriatric Depression Scale as well as renowned demographic, stroke-related and psychosocial risk factors were examined in 96 stroke
patients treated in a neurological rehabilitation clinic. Baseline assessment within 6 weeks after stroke was followed up by telephone interviews 6 months later. Linear regression analysis
was performed to investigate the predictive value of factors measured at baseline on depressive
symptoms after 6 months.
Results: As expected, prevalence of depressive disorders significantly increased from baseline
(35%) to 6-months follow-up (44%). Regression analysis revealed baseline depressiveness and
younger age as significant predictors for depressive symptoms at follow-up. Further, the influence of perceived social support at baseline on depressive symptoms at follow-up was fully
mediated by depressive symptoms at baseline.
Conclusions: Our main result was that depressive symptoms measured within the first 6 weeks
after stroke reliably predicted depression 6 months after stroke. This finding confirms the importance of early depression screening for identifying patients at risk for PSD, which offers the
possibility to initiate preventive interventions.
Background: Evidence on Health Related Quality of Life (HRQoL) of stroke patients is not
consistent and often conflicting. We examined the physical and mental well–being one year after stroke, and the associations of these with persistent anxiety.
Methods: Data from 4022 patients registered in the South London Stroke Register (SLSR)
between 1st January 1995 and 31st December 2009 were used. Outcomes: the physical component summary (PCS) and the mental component summary (MCS) of SF-12. Anxiety was defined by 4 categories: no anxiety, anxiety at 3 months, anxiety at one year, and anxiety at both
times (persistent). Anxiety was defined by a score > 7, using the anxiety subscale (maximum
score 21) of the Hospital Anxiety and Depression (HAD) Scale. Linear regression methods
were used to investigate the associations between the outcomes and anxiety, adjusting for, age,
gender, subtypes and severity (the verbal components of Glasgow coma scale (GCS), arm power, ability to walk, incontinence) and SF-12 components at 3 months.
Results: 55% of patients were not anxious, 15% anxious at three months, 13% at one year and
17% were anxious at the two times. A dose response association between MCS and the 4 categories of anxiety was found. Adjustments reduced the effect of anxiety at three month only
but the dose response relationship was maintained. The average adjusted mean MCS for the
none-anxious patients was: 39.5 (95% CI: 28.6, 50.4), and the MCS for the other groups differ
from that by, 2.6 (-1.2, 6.4); -8.7(-12.4, -5.0); -12.1 (-16.3, -7.8) for the anxious at 3 months,
one year and anxious at the two occasions, p-values were, 0.08, <.01 and <.001, respectively.
The PCS for the none-anxious were much lower than that for the general population and no association with anxiety was found after adjustment for PCS at 3 month.
Conclusion: HRQoL is associated with anxiety. Highest risk of reduced mental health one year
after stroke was associated with persistent anxiety.
Cerebrovasc Dis 2013; 35 (suppl 3)1-854
189
London, United Kingdom 2013
66 Stroke prognosis
Socioeconomic Deprivation and Survival after Stroke: Findings from the Prospective South
London Stroke Register of 1995-2011
R. Chen1, C.J. McKevitt2, A.G. Rudd3, C.D.A. Wolfe4
King’s College London, London, UNITED KINGDOM , King’s College London, London,
UNITED KINGDOM2, King’s College London, London, UNITED KINGDOM3, King’s College
London, London, UNITED KINGDOM4
1
Background Associations between socioeconomic deprivation (SED) and survival after stroke are
inconsistent, and the long-term impact of SED on survival is unclear. The impact is not entirely
known for black and minority ethnic people living in high income countries.
Methods We analysed data from 4398 patients (3103 Whites, 932 Blacks, 253 Asians) with first-ever stroke, collected by a population-based stroke register in South London, UK from 1995 to 2011.
SED was measured using the Carstairs deprivation index (the higher score, the more deprived) and
analysed in its sextitles for all patients, and then in the quartitle within each of 3 ethnic groups. The
impact of SED on mortality was examined in multivariate Cox regression models.
Results During 17 years follow up 2,754 patients died. Patients with the 6th versus 1st sextile of
Carstairs score had a significant increase in 3-month mortality (Table 1), and in 17-year mortality
(adjusted hazard ratio (HR) 1.16, 95%CI 1.01-1.32). The increased HR was significant in white patients only. However, the data for the 4th versus 1st quartile of Carstairs score showed that while the
HR increased not significantly in Whites (eg, 1.13, 0.93-1.36 for 3-month mortality), Blacks with
SED had a significant increase in 3-month and 1-year mortality but not in >2 years follow up, and
Asians had similar patterns of increased HRs with borderline significance (Table 2). Asians in the
3rd versus all 1st and 2nd tertile of Carstairs score had a multivariate adjusted HR of 1.80 (1.013.21) for 2-year mortality. Further adjustment for hospital care attenuated the HRs in Blacks and
Asians, but did not substantially change in those for Whites (Table 1).
Conclusions Stroke survival inequalities may exist in England. The Blacks and Asians had shortterm impact of SED on survival, which was stronger than Whites, while Whites had both short and
long term impacts. Further efforts are required to achieve equality in survival among stroke patients.
Table 1. Number* and adjusted HR† of mortality among stroke patients across 6 groups of the Carstairs score: SLSR of 1995-2011
Duration of follow up
3 months
5 years
different SED
Death (%)
HR† (95%CI)
Death (%)
HR† (95%CI)
Sextile SED
S-1
S-2
181 (24.4)
178 (24.9)
S-3
189 (25.9)
S-4
204 (28.0)
S-5
184 (25.0)
S-6 #
198 (27.8)
1.00
1.14 (0.93-1.41)
0.99 (0.80-1.22)
1.18 (0.96-1.45)
1.01 (0.82-1.24)
1.29 (1.05-1.58)
363 (50.1)
364 (51.9)
376 (52.4)
382 (53.9)
377 (52.2)
348 (50.5)
1.00
1.10 (0.95-1.28)
1.00 (0.86-1.16)
1.13 (0.98-1.31)
1.10 (0.95-1.28)
1.14 (0.99-1.33)
* the number of patients at the follow up time were derived from those who were actually followed
up to the time, including deaths.
†
adjusted for age, sex, ethnicity, years of stroke occurring, location of hospital admission, living
conditions before stroke, cardiovascular risk factors score, type of stroke, Glasgow coma, speech
deficit and motor deficit.
# corresponding HRs for 3-month and 5-year mortality in Whites were 1.37 (1.08-1.73) and 1.21
(1.02-1.44), and in the groups of Blacks and Asians 1.32 (0.79-2.21) and 1.00 (0.72-1.40)
Table 2. Number* and adjusted HR† of mortality among stroke patients across 4 groups of the
Carstairs score within each ethnicity: SLSR of 1995-2011
Duration of follow up
Patient with
different SED
Black
Quartile SED
Q-1
Q-2
Death (%)
31 (13.2)
35 (15.6)
Q-3
39 (17.0)
Q-4
41 (18.1)
Asian
Quartile SED
Q-1
Q-2
14 (21.9)
8 (12.3)
Q-3
13 (21.3)
Q-4
10 (16.1)
3 months
HR† (95%CI)
Death (%)
1.00
1.19 (0.69-2.06)
1.40 (0.84-2.32)
45 (19.7)
46 (21.1)
1.76 (1.06-2.94)
50 (24.2)
1.00
0.93 (0.31-2.81)
1.75 (0.65-4.76)
17 (26.6)
11 (17.7)
1.33 (0.43-4.09)
51 (23.3)
15 (24.6)
15 (24.6)
1 year
HR† (95%CI)
1.00
1.16 (0.74-1.83)
1.39 (0.91-2.13)
1.54 (1.00-2.37)
1.00
0.91 (0.35-2.31)
1.50 (0.63-3.58)
1.80 (0.72-4.48)
* the number of patients at the follow up time were derived from those who were actually followed
up to the time, including deaths.
†
adjusted for age, sex, ethnicity, years of stroke occurring, location of hospital admission, living
conditions before stroke, cardiovascular risk factors score, type of stroke, Glasgow coma, speech
deficit and motor deficit.
Poster Session Red
Cerebrovasc Dis 2013; 35 (suppl 3)1-854
313
22. European Stroke Conference
70 Stroke prognosis
A patient-specific predicting tool for functional recovery after stroke
J.J. Grace1, A. Douiri2, A.G. Rudd3, C. McKevitt4, C.A. Wolfe5
King’s College London, London, UNITED KINGDOM1, King’s College London, London,
UNITED KINGDOM2, King’s College London, London, UNITED KINGDOM3, King’s College
London, London, UNITED KINGDOM4, King’s College London, London, UNITED KINGDOM5
Objectives: Existing prognostic models of stroke recovery are rare. This study aimed to develop and
validate a patient-specific model for predicting functional recovery up to 1 year post-stroke.
Methods: Data were from 495 patients recruited from the population-based South London Stroke
Register. Functional assessments were performed using the Barthel Index (BI) at 1, 2, 3, 4, 6, 8, 12,
26 and 52 weeks after stroke. Multilevel growth models were used to predict BI trajectories, recovery curves, allowing for day-to-day and between-patient variation. Cross-validation procedures were
used for selecting strong predictors of BI model parameters. The predictive performance of the recovery curves was validated using 10-fold internal cross-validation. The model was also validated
for classification accuracy of poor BI (<8) outcomes at 3 and 12 months using 2 external samples
totaling 1830 stroke patients.
Results: Mean age was 71 years, 51% were females and 24% died within the first year. Age, gender, NIH Stroke Scale, Glasgow Coma Scale and stroke subtype were identified as independent
predictors of BI. Accuracy of the recovery curves model were satisfactory, with a root mean square
deviation less than 2.3 BI points at 3 and 12 months. The model was highly effective at classifying
patients as likely to have poor outcome or not at 3 and 12 months, which is a clinically useful distinction.
Conclusions: The model predicts functional recovery over time after stroke and could potentially
aid clinicians in early identification of and intervention with patients at risk of poorer than expected
functional outcome.
316
© 2013 S. Karger AG, Basel
71 Stroke prognosis
Hemostatic factors as predictors of recurrent vascular events up to 12 years after ischemic
stroke: the Sahlgrenska Academy Study on Ischemic Stroke Outcome
C. Jern1, A. Pedersén2, P. Redfors3, L. Lundberg4, E. Hanson5, C. Blomstrand6, A. Rosengren7, K.
Jood8
Institute of Neuroscience and Physiology, the Sahlgrenska Academy at Gothenburg University,
Goteborg, SWEDEN1, Institute of Neuroscience and Physiology, Goteborg, SWEDEN2, Institute
of Neuroscience and Physiology, Goteborg, SWEDEN3, Institute of Neuroscience and Physiology,
Goteborg, SWEDEN4, Institute of Neuroscience and Physiology, Goteborg, SWEDEN5, Institute of
Neuroscience and Physiology, Goteborg, SWEDEN6, Institute of Medicine, Goteborg, SWEDEN7,
Institute of Neuroscience and Physiology, Goteborg, SWEDEN8
Background: The hemostatic factors tissue plasminogen activator (tPA), von Willebrand factor
(vWF) and fibrinogen are known from prospective studies to predict vascular events. Here, we investigate the relations between tPA antigen, vWF and fibrinogen levels and the risk of vascular
events in a population of young and middle-aged ischemic stroke sufferers.
Methods: As part of the Sahlgrenska Academy Study on Ischemic Stroke Outcome, 600 consecutive
patients with ischemic stroke (IS) before 70 years of age were prospectively followed. Blood was
drawn in the acute and the convalescent phase (3 months) after index stroke. Vascular deaths, recurrent stroke, and coronary events were registered through national registers and medical records.
Hazard ratios (HR) for associations between plasma levels and recurrent vascular events were calculated using Cox Regression models.
Results: Patients were followed up to 12 years with a mean follow-up time of 8.5 (SD 1.6) years. No
patient was lost to follow-up. We registered 75 vascular deaths, 119 recurrent strokes, and 53 coronary events. In univariate analyses both acute and convalescent levels of all three hemostatic factors
showed significant associations with vascular death. The same was true when analyzing all events
combined (n=184), except for the acute levels of vWF. No significant associations were observed
with recurrent stroke. In multivariate analyses, adjusting for vascular risk factors and hsCRP, the
association for convalescent plasma levels of tPA antigen and vascular death was retained, HR per 1
SD increase 1.40 (95% CI 1.05-1.88, p=0.02).
Conclusion: In young and middle-aged ischemic stroke sufferers, the convalescent plasma level of
tPA is an independent predictor of long-term risk of vascular death. Levels of tPA, vWF and fibrinogen are associated with an increased risk of the combined outcome of fatal and non-fatal vascular
events. However, these associations are not independent of vascular risk factors.
Scientific Programme
London, United Kingdom 2013
85 Stroke prognosis
Comparison of functional outcomes and predictors between ischaemic and haemorrhagic
stroke: The South London Stroke Register (SLSR)
A. Bhalla1, Y. Wang2, A. Rudd3, C.D.A. Wolfe4
86 Stroke prognosis
Long-term prognosis of stroke in young adults: the PORTYSTROKE study
M. Viana-Baptista1, T.P. Melo2, M. Carvalho3, V.T. Cruz4, C. Fernandes5, F.A. Silva6, C. Ferreira7, G. Lopes8, A. Leitão9, A.A.N. Pinto10, R. Guerreiro11, J.P. Gabriel12, S. Calado13, M. Rodrigues14,
J.M. Ferro15
Division of Health and Social Care Research, King’s College, London, UNITED KINGDOM1, PORTYSTROKE Investigators
Division of Health and Social Care Research, King’s College, London, UNITED KINGDOM2, Divi- Department of Neurology, CEDOC - Faculdade de Ciências Médicas da Universidade Nova de
sion of Health and Social Care Research, King’s College, London, UNITED KINGDOM3, Division Lisboa; Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, PORTUGAL1, Deof Health and Social Care Research, King’s College, London, UNITED KINGDOM4
partment of Neurology, Hospital de Santa Maria, Lisbon, PORTUGAL2, Department of Neurology,
Hospital de São João, Porto, PORTUGAL3, Department of Neurology, Hospital de São Sebastião,
Background: Few population based studies describing comparative functional outcome between
Santa Maria da Feira, PORTUGAL4, Department of Neurology, Hospital Garcia de Orta, Almada,
ischaemic stroke (IS) and haemorrhagic stroke (HS) in the short and long term are available. Knowl- PORTUGAL5, Department of Neurology, Hospitais da Universidade de Coimbra, Coimbra, PORedge of the natural history and factors associated with poor outcome are important in providing
TUGAL6, Department of Neurology, Hospital de São Marcos, Braga, PORTUGAL7, Department of
prognostic information and subsequent resource allocation.
Neurology, Hospital de Santo António, Porto, PORTUGAL8, Department of Neurology, Centro HosMethods: Data were collected within the population based SLSR between 1995 and 2011. Baseline
pitalar de Coimbra, Coimbra, PORTUGAL9,
data were collection of socio-demographic factors, case mix, risk factors prior to stroke and acute
Department of Neurology, Hospital Fernando Fonseca, Amadora, PORTUGAL10, Department of
stroke processes with outcomes at 7 days, 3 months, 1, 5 and 10 years post stroke. Logistic regresNeurology, Hospital de São Bernardo, Setúbal, PORTUGAL11, Department of Neurology, Hospital
sion was used to determine factors associated with poor outcome (dead and dependency: Barthel In- de São Pedro, Vila Real, PORTUGAL12, Department of Neurology, Hospital Egas Moniz, Lisbon,
dex <15). Linear regression was used to estimate variation in recovery pattern by subtype.
PORTUGAL13, Department of Neurology, Hospital Garcia de Orta, Almada, PORTUGAL14, DepartResults: Baseline clinical impairments for stroke were more severe in HS. Patients with IS were
ment of Neurology, Hospital de Santa Maria, Lisbon, PORTUGAL15
more likely to undergo brain imaging (P=0.01), swallow test (P<0.001) and stroke unit care
(P<0.001) than HS. In patients with HS, age and incontinence were associated with poor outcome
Background: There is limited information about long-term prognosis of stroke in young adults. We
at 1, 5 and 10 years whereas age, incontinence, failed swallow, atrial fibrillation and diabetes were
performed a five-year follow-up assessment of patients included in the PORTYSTROKE study, a
associated with poor outcome in IS. Patients with HS were more likely to have poorer outcomes at 3 nationwide multicentre survey of Fabry disease and CADASIL in consecutive young (18-55 years)
months (OR: 2.24, CI: 1.8 to 2.8), 1 year (OR: 2.1, CI 1.67 to 2.56) but not at 5 year (OR: 1.09, CI: Portuguese patients with first-ever stroke, between November 2006 and October 2007.
0.85 to 1.22) or 10 years (OR: 0.88, CI: 0.39 to 2.39), however the rate of functional recovery from
Methods: Follow-up assessments were performed by questionnaires, either on outpatient consultaday 7 day to 3months was significantly greater for HS: regression co-efficient: 2.1, (CI: 1.3 to 2.9),
tion or by telephone interview, and review of medical records. Data about risk factors, etiology of
(P<0.0001).
stroke, recurrent stroke (RS), non-cerebral vascular events (NCVE), and deaths were collected, as
Conclusion: Patients with HS have poorer outcomes compared with IS up to 5 years post stroke.
well as clinical features of Fabry disease and CADASIL.
However the rate of recovery up to 3 months was significantly greater with HS. Identification of fac- Results: From the 493 patients included (364 ischemic stroke, 115 with hemorrhagic stroke and
tors associated with poor outcome may be used for clinical predictions.
14 cerebral venous thrombosis) 4.1% were lost to follow-up. Information was obtained on outpatient consultation in 26.8% and by telephone interview in 73.1% of patients. Overall, there were 76
events. Death occurred in 32 (6.8%), RS in 36 (7.6%) and NCVE in 35 (7.4%) patients among the
study population. Among patients with mutations of the GLA gene (n=12) there were no deaths,
no RS, and no NCVE, (p=0.351, p=0.320, and p=0.327, respectively), and among patients with alterations of the NOTCH3 gene (n=8) death occurred in 1 (12.5%), RS in 2 (25%), and NCVE in 1
(12.5%), (p=0.524, p=0.070, p=0.586, respectively).
Conclusion: The risk of death or recurrent vascular events in young patients with stroke is considerable. The prognostic significance of GLA gene mutations and NOTCH3 gene alterations identified
in this setting remains to be further elucidated.
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London, United Kingdom 2013
344 Vascular surgery and neurosurgery
Vasospasm of proximal internal carotid artery causing acute ischemic stroke after transcranial
removal of a pituitary adenoma
W. Joo1
The Catholic University of Korea, ST. Mary’s Hospital, Seoul, SOUTH KOREA
1
Introduction
Cerebral vasospasm is well known to occur after various events that cause subarachnoid hemorrhage, such as aneurysmal hemorrhage and neurotrauma. Vasospasm after resection of skull base tumors is rare. We present a patient with vasospasm of cervical, petrous and cavernous ICA proximal
to pituitary tumor.
Case presentation
A 45-year-old man presented with right visual disturbance and ocular pain for 3 months. MRI
demonstrated suprasellar and right cavernous mass impinging on the right optic nerve with encasement of right ICA. MRA showed no abnormality. We performed optic nerve decompression by removing the suprasellar mass. No vasospasm was evident at the time of closure. On third postoperative day, he suddenly developed left arm weakness. MRA and diffusion MRI showed spasm of right
proximal ICA and high signal intensity in right frontal area respectively. Active hypertensive hypervolemic hemodilution therapy was initiated immediately. On the postoperative 14th day, follow up
MRA revealed complete resolution of arterial spasm.
Discussion
Several hypotheses may be suggested explaining the occurrence of vasospasm after pituitary surgery: blood spillage into the basal cistern, direct damage to blood vessels, hypothalamic dysfunction
and vasoactive material released from the tumor. Among the hypotheses, imbalance of vascular tone
is attractive to us. Increased cerebral vasoreactivity to vasoactive substance liberated from tumor
may be reliable in causing the vasospasm suffered by this patient.
Conclusion
Although vasospasm associated with tumor resection is infrequent complication, one must take it
into consideration if there is any delayed deterioration in a patient who has undergone cranial base
tumor surgery. If vasospasm was confirmed by angiography or MRA, aggressive and prompt management is a key element for improving patient’s outcome.
Management and economics (PO 345 - 376)
345 Management and economics
The association between 7 day consultant ward rounds and mortality risk in stroke patients
admitted at the weekend
B.D. Bray1, S. Ayis2, J. Campbell3, A. Hoffman4, P. Tyrrell5, C.D.A. Wolfe6, A.G. Rudd7
on behalf of the Intercollegiate Stroke Working Party Group
King’s College London, London, UNITED KINGDOM1, King’s College London, London,
UNITED KINGDOM2, Royal College of Physician’s London, London, UNITED KINGDOM3, Royal College of Physician’s London, London, UNITED KINGDOM4, Salford Royal Foundation Trust,
Manchester, UNITED KINGDOM5, King’s College London, London, UNITED KINGDOM6, Guy’s
and St Thomas’ Foundation Trust, London, UNITED KINGDOM7
Background
Observational studies have demonstrated higher post stroke mortality following weekend admission.
7 days a week consultant ward rounds have been proposed as a solution to this, although evidence is
lacking that this can reduce the “weekend effect”. We aimed to estimate the relationship between 7
day consultant ward rounds, weekend admission and 30 day mortality in stroke patients.
Methods
Patient level data were extracted from the Stroke Improvement National Audit Programme (SINAP)
of patients admitted with stroke to a participating hospital in England from June 2011-Sep 2012.
These were linked with data from the 2012 Sentinel Audit of the characteristics of stroke services.
Mortality data were obtained from national mortality records. Multivariable Cox regression was
used to estimate hazard ratios for 30 day mortality, adjusting for patient level prognostic variables
(stroke type, age, pre stroke independence, reduced consciousness, hypoxia, dysphasia, hemianopia, arm weakness, leg weakness), stroke service variables (stroke unit type, nurse: patient ratio and
thrombolysis provision)and clustering effects.
Results
Of 46 757 patients with stroke admitted to 106 participating hospitals in England, 11 890 (25.6%)
were admitted on a weekend. 26 270 patients were admitted to a hospital (n=44) reporting 7 day
consultant ward rounds. Crude 30 day mortality was 12.6% for weekday and 14.5% for weekend admissions. After adjustment for patient and stroke service variables, patients admitted at the weekend
were observed to have higher mortality if they were admitted to a hospital without 7 day consultant
ward rounds (HR 1.13, 95% CI 1.01-1.26, p=0.028) but not following admission to a hospital with 7
day consultant rounds (HR 1.04, 95% CI 0.94-1.14, p=0.47).
Conclusion
Observational data suggest that 7 day per week ward rounds by a consultant may mitigate the effect
of weekend admission on post stroke mortality.
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London, United Kingdom 2013
348 Management and economics
Burden of stroke in a large county in Sweden
Sickness cost and potential development
J. Ferraz-Nunes1
University West, Goteborg, SWEDEN1
Objective: To estimate the economic burden of stroke in a large county with 1.5 million inhabitants
in West Sweden and discuss the potential for improvement given different conditions.
Materials and methods: Estimation of the economic burden of stroke was done from a societal perspective with an incidence approach. Data were collected from clinical registries and 3 074 patients
were included. In the cost calculations both direct and indirect costs were estimated and were based
on costs for 12 months after a first-ever stroke. Estimation of the value of informal care was based
on interviews.
Results: The present value of total excess costs arising from stroke was €69 million during the first
12 months after the first-ever stroke for a population of 1.5 million. Men consumed more acute care
in hospitals, while women consumed more rehabilitation and long-term care provided by municipalities. Younger patients brought a significantly higher burden on the society compared to older
patients, due to the loss of productivity and the increased use of resources in health care. The impact
of increased inputs in specific activities like secondary prevention and rehabilitation may give rise to
increased cost efficient at the margin, but the effect in total cost should not decrease.
Conclusions: The results of this cost of illness study are consistent with previous studies, although
we have improved the cost calculation process in a number of fields. For the scientific analysis it is
of importance to clearly state details in the population such as age and medical status. The result of
this study can be used for further development of the methods for economic analyses as well as for
analysis of improvements and investments in health care.
349 Management and economics
Trends in the cost-effectiveness of Stroke Care
E. Urbina-Valdespino1, O. Saka2, C.D.A. Wolfe3, T. Rudd4, A. McGuire5, J. Maervoet6
Deloitte, Diegem, BELGIUM1, King’s College London, London, UNITED KINGDOM2, King’s
College London, London, UNITED KINGDOM3, King’s College London, London, UNITED
KINGDOM4, London School of Economics, London, UNITED KINGDOM5, Deloitte, Diegem,
BELGIUM6
Background
Stroke services in many European countries have been subject to changes in the recent years especially with the emergence of stroke units. Yet no study has evaluated the year on year economics of
stroke care provision for the purpose of investigating the state of efficiency gains. For this study we
have developed a discrete event simulation model to assess the annual average and incremental costs
and quality adjusted life years (QALYs) of stroke services between 2006-2011. Incremental cost effectiveness ratios (ICER) comparing each year with the year before were calculated.
Methods
Data from the South London Stroke Register from 2006 to 2011 were used to populate the health
economic model. The parameters included in the analysis were calculated by using cox regression
and multivariate regression methods and used as input for the model. The model simulated the
stroke care delivery from stroke onset with10-year follow up. Organised Care Index (OCI) was used
to assess the improvements in the provision of stroke services and measurement of QALYs. Year-onyear average and incremental cost effectiveness was calculated in order to assess the progression.
Results
OCI index scores have constantly improved since 2006 with a higher proportion of patients having
access to better organised stroke care. The average total costs per patient decreased from £30,745
to £27,086 and quality adjusted life years improved from 2.18 to 3.07 from 2006 till 2011 (p-value
for trend < 0.001) indicating a drop in average cost per QALY. Economic evaluation results suggest
dominant or very favourable ICER ratios when each year is compared with the year before.
Conclusion
The reconfigurations to stroke care have provided better value for money over time with constant
efficiency gains in stroke services. The use of real world evidence studies such as SLSR is crucial to
evaluate the trends and provide guidance to policy makers.
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22. European Stroke Conference
Trends in the Cost-effectiveness of stroke care - Tables
Table 1.
Results per 2006
year
QALY
Costs
Average
length of
stay (days)
Deaths
Table
2. Year
on Year
ICER
ΔQALY
Δcosts
ICER
470
2007
2.2
2.2
2008
2009
2.2
2010
2.4
2011
2.7
£30,745 £28,939 £28,408 £28,635
£26,933
3.1
P-value for
trend
<0.001
28
27
24
19
18 <0.001
161
164
165
154
142
123 <0.001
2007 vs 2006
2008 vs 2007
0
-£1,807
£0
Cost-effective
0
-£531
£0
Cost-effective
2009 vs 2008
0.2
£ 227
£1,137
Cost-effective
© 2013 S. Karger AG, Basel
King’s College London, London, UNITED KINGDOM1, Royal College of Physician’s London,
London, UNITED KINGDOM2, St George’s Hospital, London, UNITED KINGDOM3, Royal Devon & Exeter Hospital, Exeter, UNITED KINGDOM4, Salford Royal Foundation Trust, Manchester, UNITED KINGDOM5, King’s College London, London, UNITED KINGDOM6, Guy’s and St
Thomas’ Foundation Trust7
£27,086 <0.001
29
2010 vs 2009
0.3
-£1,702
2010 Dominates
350 Management and economics
Door-to-needle times of tPA administration in acute stroke: the relationship with hospital volume of thrombolysis activity
B.D. Bray1, J. Campbell2, G.C. Cloud3, M.A. James4, P. Tyrrell5, C.D.A. Wolfe6, A.G. Rudd7
2011 vs 2010
0.4
£153
£383
Cost-effective
Background Short door-to-needle times of thrombolytic (tPA) therapy in acute stroke is central to
its effectiveness.Experience from other conditions suggests that high volume hospitals may achieve
better outcomes. We aimed to identify if there was a relationship between the number of patients
treated with tPA by hospitals and the door-to-needle times achieved in patients with acute stroke.
Methods Data were extracted from the Stroke Improvement National Audit Programme (SINAP) of
patients with acute ischaemic stroke admitted to a participating hospital in England from Jan 2011Aug 2012. Data were linked with the national admissions dataset for England (Hospital Episode
Statistics) and only patients from hospitals with >80% case ascertainment in SINAP were included
in the analysis. Hospitals were categorised by the annualised number of patients treated with tPA:
<50, 50-99 and ≥100 per annum. Median door-to-needle times were compared using Kruskall-Wallis tests. Results Of 44 942 patients admitted with acute stroke to 83 hospitals, 4478 (9.1%) received
tPA. Median door-to-needle times were significantly shorter in patients admitted to hospitals treating≥100 patients per year (41 mins IQR 30-60) compared to those admitted to hospitals treating
50-99 patients (72 mins IQR 51-98) or <50 (73 mins IQR 53-102); time difference 32 minutes ,
p=0.0001. A similar result was found after categorising hospitals into quintiles of thrombolysis volume, with hospitals in the top quintile of thrombolysis activity achieving a median door-to-needle
time of 40 mins (IQR 29-58) compared to 78 mins in the lowest quintile (IQR 60-103); time difference 38 mins, p<0.0001. Conclusions Hospitals treating high volumes of patients with tPA achieved
clinically and statistically significant shorter door-to-needle times in this large observational dataset.
These findings may have important implications for the planning of stroke services.
Scientific Programme
London, United Kingdom 2013
351 Management and economics
Producing a patient accessible audit report for stroke survivors and carers
S.J. Kavanagh1, J.T. Campbell2, A.M. Hoffman3, D. McDonnell4, I.K. Morris5, C.J. McKevitt6, A.
Bowen7, G. Pearl8, A.G. Rudd9
On behalf of the Intercollegiate Stroke Working Party and Speakeasy
Royal College of Physicians, London, UNITED KINGDOM1, Royal College of Physicians, London, UNITED KINGDOM2, Royal College of Physicians, London, UNITED KINGDOM3, Royal College of Physicians, London, UNITED KINGDOM4, Royal College of Physicians, London,
UNITED KINGDOM5, King’s College London, London, UNITED KINGDOM6, University of
Manchester, Manchester, UNITED KINGDOM7, Speakeasy, Bury, UNITED KINGDOM8, Guy’s
and St Thomas’ NHS Foundation Trust, London, UNITED KINGDOM9
Background
The Royal College of Physicians’ (RCP) Stroke Programme has run the National Sentinel Stroke
snapshot audit since 1998 and the continuous stroke register SINAP since 2010. Reports with
named hospital results are produced for hospitals, national health departments and the general public. In 2007, the need for a patient friendly report was identified to make complex, clinically-focused audit results more accessible to stroke survivors and carers and raise awareness of the quality
of stroke care and services in England, Wales and Northern Ireland.
Methods
The implementation group, including patients, determined requirements and planned the work.
Stroke survivors with aphasia, identified as integral project stakeholders, were consulted through
regular meetings about which aspects to include, optimal ways of presenting complex national and
regional data, and the report structure and layout. The stroke programme’s multi-disciplinary steering group, additional patient groups and the national stroke charity iteratively revised the report.
Results
Patient versions of audit reports have been produced by the RCP Stroke Programme since 2008.
Key results are made accessible electronically and in hard copy to stroke survivors with communication and cognitive impairments through charts and graphs, symbols, and colour-coded point maps
and results are updated every 3 months. They are downloaded extensively, disseminated to hospitals, at national stroke conferences, and via patient groups. Feedback indicates the usefulness of
these reports for stroke survivors and carers, clinical teams, chief executives and members of parliament in instigating improvements in stroke care.
Conclusion
Stroke survivors have a powerful voice. Audit reports tailored to their needs are effective to increase knowledge and drive change. Involvement of patient groups is key to transforming complex
data into information understood and used by stroke survivors and carers.
Poster Session Red
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London, United Kingdom 2013
365 Management and economics
Early supported discharge and length of stay in contemporary stroke care
S.J. Kavanagh1, M. Roughton2, J.T. Campbell3, B. Bray4, A.M. Hoffman5, G,C. Cloud6, P. Tyrrell7,
A.G. Rudd8
On behalf of the Intercollegiate Stroke Working Party
Royal College of Physicians, London, UNITED KINGDOM , Royal College of Physicians, London, UNITED KINGDOM2, Royal Collegeof Physicians, London, UNITED KINGDOM3, Royal College of Physicians, London, UNITED KINGDOM4, Royal College of Physicians, London,
UNITED KINGDOM5, St George’s Healthcare NHS Trust, London, UNITED KINGDOM6, University of Manchester, Manchester, UNITED KINGDOM7, Guy’s and St Thomas’ NHS Foundation
Trust, London, UNITED KINGDOM8
1
Background
Previous studies demonstrated that Early Supported Discharge (ESD) for stroke reduced length
of stay and improved patient outcomes. However, changes in acute stroke care over recent years
and falling length of stay may mean that the benefit of ESD in current stroke practice may be less
marked. We aimed to describe the provision, use and effect on length of stay of ESD in a national
cohort of contemporary stroke patients
Methods
Data were obtained by the National Sentinel Stroke Audit 2010 of all 200 hospitals in England,
Wales and Northern Ireland treating patients with acute stroke . Data were collected on the organisation and staffing of services and the process of care received by consecutive admissions over a three
month period.
Results
In 2010, 88 (44 %) hospitals reported having an ESD team, an increase of 7% from 2009. Of
11 353 patients admitted with stroke, 1 158 (10.2%) received ESD. A greater proportion of patients
receiving ESD were treated for >90% of their admission on a stroke unit (72.6% versus 67.9%,
p <0.001). Median length of stay was 1 day lower in stroke units with an ESD team (9 days, IQR
4-24), compared to those without an ESD team (10 days, 4-29), p<0.001.
Conclusions
The number of stroke units with an ESD has increased in England, Wales and Northern Ireland. Despite the large reductions in length of stay in recent years, ESD care is still associated with significantly reduced length of stay in units with ESD provision and remains an important component of
stroke care.
366 Management and economics
From acute care to a primary care-led post stroke service for patients residing at home: Doing
away with ‘blanket-referrals’!
N.A. Aziz1, A.F. Abdul Aziz2, M.F. Ali3, B.S. Saperi4, S.M. Aljunid5
Department of Family Medicine, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, MALAYSIA1, United Nations University IIGH & Department of Family Medicine,
Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MALAYSIA2, Department of
Family Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MALAYSIA3,
Department of Health Information, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MALAYSIA4, United Nations University IIGH; International Centre for Casemix & Clinical
Coding, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MALAYSIA5
Introduction
Delivery of post stroke care has been mostly fragmented in developing countries. Lack of access to
limited specialised stroke care pose greater problems after discharge from tertiary care. ‘Blanket referrals’ at discharge generally contain generic instructions to manage stroke risk factors (i.e. hypertension, diabetes mellitus) per se, neglecting long-term care plans and goals for post stroke patients.
To empower a primary care coordinated post stroke service, a transfer of care discharge protocol
was derived among Specialist Stroke Care providers.
Method An expert panel discussion conducted among Specialist Stroke Care Providers, was represented, by Family Physicians, Neurologists, Rehabilitation Physicians and therapists, and Nurse
Managers from both Ministry of Health and Acadaemia. Solutions to identified transfer of care issues were discussed. Variances in practice were resolved by consensus, using the modified Delphi
technique.
Results Transfer of care problems from Specialist Stroke service to primary care occurred mainly at
discharge, while at community level, patients diagnosed at primary care during subacute or longterm phase were managed with minimal Specialist support. ‘Young stroke’ patients aged <40 years
, with concurrent cardiovascular disease, chronic renal failure and carotid artery stenosis >50%
should not be managed at primary care. Patients were best transferred to primary care at six months
or more after stroke, regardless of stroke type or severity. Essential information during transfer of
care included details of acute stroke management, stroke risk factor(s) screening, rehabilitation status (i.e. functional status at discharge) and goals. Treatment targets for risk factor(s) management
were as per local clinical practice guidelines.
Conclusion
The transfer of care checklist consolidated relevant information necessary to guide the primary care
team to optimise post stroke care in areas lacking access to Specialist Stroke services.
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London, United Kingdom 2013
420 Behavioral disorders and post-stroke dementia
Natural history and predictors of anxiety after stroke
L. Ayerbe1, S. Ayis2, S.L. Crichton3, C.D.A. Wolfe4, A.G. Rudd5
Division of Health and Social Care Research. King’s College London, London, UNITED
KINGDOM1, Division of Health and Social Care Research. King’s College London, London,
UNITED KINGDOM2, Division of Health and Social Care Research. King’s College London, London, UNITED KINGDOM3, Division of Health and Social Care Research. King’s College London,
London, UNITED KINGDOM4, Division of Health and Social Care Research. King’s College London, London, UNITED KINGDOM5
Background: Evidence on the long term natural history and predictors of anxiety after stroke is limited.
Methods: Data on first ever strokes collected from the population-based South London Stroke Register. 4022 patients were registered between January 1995 and December 2009. Baseline data included sociodemographics, previous history of depression, stroke severity (Glasgow coma score,
urine incontinence and paresis) and disability measures (Barthel Index). Patients were followed up
three months and then at one, three and five years after stroke. Follow up included assessments for
anxiety (Hospital Anxiety and Depression Scale. Anxiety subscale scores >7 = anxiety). Multivariable regression models were used to identify predictors of anxiety.
Results: Prevalence of anxiety three months after stroke was 34.1% (31.3-36.9). 53% of the patients
with anxiety at three months remained anxious at one year. Female gender was associated with higher risk of persistent anxiety OR: 2.2 (1.3-3.8) while age over 65 and independence in activities of
daily living were associated with lower risk of persistent anxiety.
Female gender was associated with anxiety at three months, one and three years after stroke OR:
1.7 (1.3-2.2), 2.2 (1.7-2.2), 1.7 (1.3-2.2) respectively. Paresis was associated with anxiety at all time
points: OR: 1.6 (1.2-2.3), 2.0 (1.4-2.7), 1.3 (1.0-1.8), 1.5 (1.1-2.2). Depression before stroke was
associated with anxiety at one, three and five years after stroke: OR: 2.2 (1.4-3.6), 1.7 (1.0-3.0), 2.2
(1.0-4.5). Age over 65 was associated with lower risk of anxiety at three months, one, three and five
years. Independence for activities of daily living seven days after stroke was also associated with
lower risk of anxiety at three months, one and three years after stroke.
Conclusion: Female patients, those aged under 65 years, and those with severe strokes, have a higher risk of anxiety after stroke. Interventions for anxiety targeting these groups should be developed.
421 Behavioral disorders and post-stroke dementia
Balance and gait measures as predictors of cognitive function following stroke
E. Ben Assayag1, S. Shenhar-Tsarfaty2, E. Kliper3, H. Hallevi4, L. Shopin5, N.M. Bornstein6, A.D.
Korczyn7, N. Giladi8, A. Mike9, A. Mirelman10, A. Weiss11, J.M. Hausdorff12
Tel Aviv Sourasky Medical Center, Tel Aviv, ISRAEL1, Tel Aviv Sourasky Medical Center, Tel
Aviv, ISRAEL2, Tel Aviv Sourasky Medical Center, Tel Aviv, ISRAEL3, Tel Aviv Sourasky Medical Center, Tel Aviv, ISRAEL4, Tel Aviv Sourasky Medical Center, Tel Aviv, ISRAEL5, Tel Aviv
Sourasky Medical Center, Tel Aviv, ISRAEL6, Tel Aviv University, Tel Aviv, ISRAEL7, Tel Aviv
Sourasky Medical Center, Tel Aviv, ISRAEL8, Tel Aviv Sourasky Medical Center, Tel Aviv, ISRAEL9,Tel Aviv Sourasky Medical Center, Tel Aviv, ISRAEL10, Tel Aviv Sourasky Medical Center,
Tel Aviv, ISRAEL11, Tel Aviv Sourasky Medical Center, Tel Aviv, ISRAEL12
Introduction: Stroke survivors are at increased risk for developing cognitive impairment. Associations between physical function and cognitive decline in older adults have been well established,
while motor function changes and decline in physical performance may precede the onset of cognitive impairment.
Aims:
We sought to test whether quantitative balance and gait parameters can predict long-term cognitive
outcome following ischemic stroke.
Methods: The TABASCO (Tel-Aviv Brain Acute Stroke Cohort) is a prospective study of first-ever
mild-moderate ischemic stroke patients who were cognitively intact at baseline. Quantitative gait
and balance parameters and cognitive tests were obtained at admission, 6, 12 and 24 months later.
Results:
Data were obtained from 319 consecutive patients (mean age: 67.2±10.2).
Sixty two participants (19.4%) were found to have cognitively declined during follow-up of 2 years
post-stroke. Although the declined and intact groups did not differ in their neurological deficit 6
months after the index event, those who have declined were found to have prolonged timed up and
go (TUG) test time (p=0.003) and lower Berg balance scale (BBS) (p<0.001) 6 month post-stroke.
Multivariate regression showed that TUG and BBS at 6 months were significant predictors of cognitive decline (p=0.002 and p=0.021, respectively).
Conclusions:
Our results show that quantitative movement parameters (poor balance and prolonged TUG test) are
significant predictors for cognitive status 2 years after stroke.
Early detection of patients who are prone to develop cognitive decline using simple quantitative
movement parameters may aid in adapting rehabilitation strategies to delay the onset of cognitive
decline and dementia.
Poster Session Red
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509
22. European Stroke Conference
472 Experimental studies
Health Related Quality of Life Trends among Stroke Survivors: Analysis from the Prospective
South London Stroke Register 1995-2011
A. Sheldenkar1, A. Douiri2, A.G. Rudd3, C.D.A. Wolfe4, R. Chen5
473 Experimental studies
Homing of mesenchymal stem cells in rat brain after MCAO induced stroke monitored by 9.4
T MRI
S. Grudzenski1, A. Lemke2, P. Heiler3, A. Alonso4, K. Bieback5, L. Schad6, M. Fatar7
Kings College London, London, UNITED KINGDOM1, Kings College London, London, UNITED KINGDOM2, Kings College London, London, UNITED KINGDOM3, Kings College London,
London, UNITED KINGDOM4, Kings College London, London, UNITED KINGDOM5
Dept. of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim,
GERMANY1, Dept. of Computer Assisted Clinical Medicine, UniversitätsMedizin Mannheim,
University of Heidelberg, Mannheim, GERMANY2, Dept. of Computer Assisted Clinical Medicine, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim, GERMANY3, Dept. of
Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim, GERMANY4,
Insitute of Transfusion Medicine and Immunology, UniversitätsMedizin Mannheim, University of
Heidelberg, Mannheim, GERMANY5, Dept. of Computer Assisted Clinical Medicine, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim, GERMANY6, Dept. of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim, GERMANY7
Background: There has been a global rise in stroke prevalence and hence potentially on longer term
outcomes after stroke, including health related quality of life (HRQOL). This study investigated
long-term trends in mental and physical HRQOL among stroke survivors as evidence on this topic is lacking. Methods: Data were obtained from the South London Stroke Register between 1995
and 2011. Using the Short Form-12 Health Survey (SF-12), trends in self-reported HRQOL were
assessed over 17 years at 3 months and 1 year after stroke using linear regression models and adjusting for socio-demographics, risk factors, case-mix and processes of care. Stratified analyses by functional impairment level were also performed using Barthel Index at 3 months and 1 year after stroke
respectively. Results: Overall mental HRQOL trends remained relatively unchanged over 17 years
3 months after stroke (β= -0.16, 95% CI=0.75 to 0.43, p=0.59), although perceived mental HRQOL
scores improved from 1995-2007 and fell in 2008-2011. Similar results were found 1 year after
stroke. Physical HRQOL showed significant worsening trends at 3 months post-stroke (β=-0.62,
-1.10 to -0.13, p=0.01), however this decline was not found at 1 year after stroke. Stratifying by
functional impairment, physical HRQOL scores worsened overtime in stroke survivors with no/mild
functional impairment but remained stable in those with severe functional impairment. No trends
were found in mental HRQOL by functional impairment. Similar results were found at 1 year after
stroke. Conclusion: Overall mental HRQOL has remained fairly stable overtime for stroke survivors, however physical HRQOL has worsened. The decline in physical HRQOL was seen in stroke
survivors with no/mild functional impairment, which has been found in general population trends;
but not in those with severe functional impairment which remained unchanged. This requires further
investigation.
538
© 2013 S. Karger AG, Basel
Background: Mesenchymal stem cells (MSCs) are considered as new therapy method after stroke
but still few is known about the influence of administered cell numbers, infarct size or occlusion
time on cell homing. Aim of this study was therefore to analyse these parameters by in vivo MRI
and post-mortem histology in an animal model of stroke.
Methods: Human MSCs were labeled with very small superparamagnetic iron oxide particles
(VSOPs) and injected post reperfusion via the internal carotid artery into 33 male Wistar rats that
underwent middle cerebral artery occlusion (MCAO) by a nylon thread for 45 or 90 min. Groups
were saline without (n=14; 45 min n=5; 90 min n=9) or with 1 Mio (n=6; 45 min n=3; 90 min n=3)
or 300.000 MSCs (n=13; 45 min n=6; 90 min n=7). 48h post MCAO infarct size and MSC localisation was measured by 9.4 T MRI. Histology 14d post stroke included evaluation of MSC number,
localisation and viability by analysis of VSOP fluorescence, iron uptake, human nuclei and fibronectin.
Results: MSCs visualized as hypo-intensive dots in T2* images (fig.1) and in histology were mainly
located in the affected hemisphere (>95%). Cell membranes were still intact. The 1 Mio MSC group
had larger infarct sizes compared to the 300.000 and control group (314.5+/-186.3 vs. 154.1+/-109.7
vs. 112.8+/-104.4 mm³, p<0.05). Parenchymal MSC numbers after 45 and 90 min MCAO were
72.9+/-27.9x10³ vs. 96.8+/-109.6x10³ in the 1 Mio MSC group and 44.2+/-29.0x10³ vs. 34.5+/22.3x10³ in the 300.000 MSC group. MSC numbers correlate to infarct size after 45 min MCAO
(R²=0.94 for 1 Mio; R²=0.6 for 300.000 MSCs).
Conclusion: MSCs remain in the affected hemisphere vital up to 14d after MCAO. Larger infarct
sizes in the 1 Mio MSC group can’t yet be explained but could be due to additional vessel occlusions by cell clusters. Parenchymal MSC numbers depend more on injected cell numbers than on
occlusion time and correlate with infarct size as a possible consequence of blood-brain-barrier opening.
Scientific Programme
22. European Stroke Conference
E-Poster Terminal 2
28 Large clinical trials (RCTs)
Development and testing of bespoke image data management system for large multicentre
randomised clinical trials
J.A. Adil-Smith1, D. Buchanan2, M. MacLeod3, B. Colam4, R. von Kummer5, J.M. Wardlaw6
EuroHYP-1 Consortium
University of Edinburgh, Edinburgh, UNITED KINGDOM1, University of Edinburgh, Edinburgh, UNITED KINGDOM2, University of Edinburgh, Edinburgh, UNITED KINGDOM3, University of Edinburgh, Edinburgh, UNITED KINGDOM4, Technischen Universität Dresden, Dresden,
GERMANY5, University of Edinburgh, Edinburgh, UNITED KINGDOM6
Introduction: The IST3 Image Management System was developed during a period of major changes in image data formats (from film to digital) and quantity (from axial scan of 20 images to volume
scan of 300+ images). It also responded to challenges unique to large multi-centre international trials, e.g. differences in data quality; approaches to anonymisation and data security; handling many
patients’ scan files (6576 scans by end of trial). We tested this system prior to using it to manage the
imaging component of a new trial, EuroHYP-1, to identify any points for refinement and potential
improvements in efficiency.
Methods: We selected 50 anonymised patient files from the IST3 image archive and put them into
PACS. A new entry was made for each “patient” in the scan Housekeeping database, including details of each imaging study in the patient file. Each scan sequence was checked for validity/quality
against criteria based on the EuroHYP-1 Image Acquisition Guidelines. The results of each check
were entered into the Housekeeping database. Notes were kept of: details which could not be recorded in the database; suggestions for changes to database or system.
Results: We identified several changes required to the housekeeping system, including: sub-categorisation of “on hold” status; grading of artefacts according to severity; ability to breakdown image
attributes and select studies for future end uses, e.g. by slice thickness, anatomy coverage, suitability
for volume analysis.
Conclusion: Testing the Image Management System identified some scope for improvement. The
Housekeeping database has been modified to collect additional key data (e.g. detailed image characteristics), and to optimise ease of use and interrogation. However the main functions were robust
and efficient for the current era of medical imaging in clinical trials.
564
© 2013 S. Karger AG, Basel
29 Large clinical trials (RCTs)
Training caregivers after stroke: process evaluation of the implementation of the London
Stroke Caregiver Training Course (LSCTC) in a pragmatic cluster randomised controlled trial.
D.J. Clarke1, R. Hawkins2, E.S. Sadler3, G. Harding4, A. Forster5, C. McKevitt6, M. Godfrey7, J.
Dickerson8, A.J Farrin9, L. Kalra10, D. Smithard11
Academic Unit of Elderly Care and Rehabilitation , University of Leeds, Leeds, UNITED
KINGDOM1, Leeds Institute of Health Sciences, University of Leeds, Leeds, UNITED KINGDOM2, Department of Primary Care and Public Health Sciences, King’s College London, London,
UNITED KINGDOM3, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter,
UNITED KINGDOM4, Academic Unit of Elderly Care and Rehabilitation , University of Leeds,
Leeds, UNITED KINGDOM5, Department of Primary Care and Public Health Sciences, King’s
College London, London, UNITED KINGDOM6, Leeds Institute of Health Sciences, University of
Leeds, Leeds, UNITED KINGDOM7, Academic Unit of Elderly Care and Rehabilitation , University of Leeds, Leeds, UNITED KINGDOM8, Clinical Trials Research Unit, University of Leeds,
Leeds, UNITED KINGDOM9,
Department of Stroke Medicine Guy’s, King’s & St Thomas’ School of Medicine, Kings College
London, London, UNITED KINGDOM10, Department of Stroke Medicine Guy’s, King’s & St
Thomas’ School of Medicine, Kings College London, London, UNITED KINGDOM11
Background: Most long-term care to stroke survivors is provided by family carers who receive little
preparation for this often challenging role. The pragmatic multicentre cluster randomised controlled
trial (Training Caregivers after Stroke (TRACS) sought to determine whether the London Stroke
Caregiver Training Course (LSCTC), a structured competency based in-patient caregiver training
programme, improved patients’ functional independence and reduced caregiver burden when delivered as part of routine stroke unit care.
Methods: To assist in interpretation of the TRACS trial results and to understand the contexts in
which the LSCTC was implemented, a process evaluation was undertaken in parallel to the trial.
Results: Over 1200 hours of observation were undertaken in six intervention and four control stroke
units. Interviews were conducted with staff (n=53), patients and caregivers (n=37 pairs); documentary analysis was undertaken.
In most intervention units senior therapists engaged with and delivered components of the LSCTC.
However, cascade training did not reach all staff or lead to multidisciplinary team (MDT) wide understanding and engagement with the LSCTC. Caregivers had limited opportunities to make sense
of and participate in developing knowledge and skills as part of the LSCTC.
Conclusions: Delivery of structured caregiver training programmes is unlikely to be practical in
stroke units with short inpatient stays. Early supported discharge schemes potentially offer a more
sustained opportunity to introduce caregiver training consistent with the LSCTC. In the TRACS trial
contextual factors including pressures for service improvement and staff perceptions of the necessity
for and the work required in caregiver training significantly influenced implementation of the caregiver training intervention. Implementation of complex interventions such as the LSCTC requires
prior and parallel exploration of factors which may facilitate or hinder their implementation.
Scientific Programme
22. European Stroke Conference
508 Epidemiology of stroke
Incidence of perioperative stroke, cardiovascular events and bleeding complications related to
dental procedure in patients receiving antithrombotic therapy
J. Kessava1, Y. Nilanon2
Faculty of medicine , siriraj hospital, Bangkok, THAILAND1, faculty of medicine , siriraj hospital, Bangkok, THAILAND2
Background
Antiplatelet and/or anticoagulant given for primary or secondary prevention of cardiovascular disease,stroke and other thromboembolic event is frequently withdrawn prior to dental procedures to
reduce bleeding complications. This may expose patients to increased morbidity and mortality from
thromboembolic event . Aim of the study was to collect data of thromboembolic events because of
periprocedural antiplatelet and/or anticoagulant withdrawal in many dental procedure and bleeding
risks with the continuation of antiplatelet and/or anticoagulant
Methods and Results
This was a prospective, cohort study of patients given antiplatelet and/or anticoagulant more than
1 month in dentistry department of siriraj hospital from august 2011 to September 2012 . Patients
were followed up for 1 week for thromboembolism and bleeding in both drug withdrawal and drug
continuation group 1010 patients were enrolled. No patients had an episode of thromboembolism,
There were 6 episodes of minor bleeding. And 1 episode of major bleeding .Major bleeding occurred with warfarin withdrawal , minor bleeding occurred with drug continuation ( 4 for warfarin
alone ,1 for aspirin and clopidogrel and 1 for aspirin plus warfarin ) . There was no death in this
study .
Conclusion : There was no thromboembolic event in both drug continuation and drug withdrawal
group . Antiplatelet and anticoagulant was not increase perioperative bleeding in the study population significantly .This study may change practical guideline in management of dental procedure in
special population in Thailand
614
© 2013 S. Karger AG, Basel
509 Epidemiology of stroke
Variations in indicators for quality of acute stroke care in 7 European regions: the European
Implementation Score (EIS) Collaboration
S. Wiedmann1, S. Abilleira2, M. Dennis3, P. Hermanek4, M. Niewada5, B. Norrving6, A. Rudd7, V.
Thijs8, Wolfe9, P.U. Heuschmann10
on behalf of the European Implementation Score (EIS) collaboration
University of Würzburg, Würzburg, GERMANY1, Stroke Programme/ Catalan Agency for
Health Information, Assessment and Quality, Barcelona, SPAIN2, Western General Hospital, Edinburgh, UNITED KINGDOM3, Bavarian Permanent Working Party for Quality Assurance, Munich,
GERMANY4, Warsaw Medical University, Warsaw, POLAND5, Lund University, Lund, SWEDEN6,
King’s College London, London, UNITED KINGDOM7, University of Leuven, Leuven, BELGIUM8, King’s College London, London, UNITED KINGDOM9,University of Würzburg, Würzburg, GERMANY10
Background: Several countries or regions in Europe have established audits for measuring quality of acute hospital stroke care on a regional or national level. The aim of the present study was to
compare variations in indicators of quality of care that were collected in a comparable way within a
number of these audits.
Methods: Adherence to indicators of quality of care was compared between seven national or regional stroke audits (Flanders-Belgium, Germany, Poland, Scotland, Catalonia-Spain, Sweden, England/Wales/Northern-Ireland) collaborating within the European Union FP7 funded project “The
European Implementation Score (EIS)”. Indicators of quality of care of acute care hospitals were
defined a priori by a European consensus group within the EIS project. Compliance with quality
indicators was estimated for those measures that could be calculated in at least six of the seven participating audits. Overall means were calculated as arithmetic means of country means and p-values
were adjusted for age and sex by logistic regression modelling.
Results: From 2007 and/or 2008 individual data from more than 400,000 patients were documented
in the participating audits. Thrombolytic therapy was delivered in 5% (1 to 10%; p<0.001) of ischemic stroke patients. Dysphagia screening was performed in 73% (48 to 95%; p<0.001) of stroke
patients. 34% of ischemic stroke patients with atrial fibrillation have been prescribed anticoagulants
(18 to 58%; p<0.001). Antiplatelet therapy was prescribed in 71% (58 to 78%; p<0.001) of ischemic
stroke patients. 4% of ischemic stroke patients were dead at 7 days (4 to 7%; p<0.001).
Conclusion: Adherence to a common set of a priori selected indicators for quality of care varied
across participating audits. These variations might be caused by variations in case mix or patient selection across participating hospitals and countries or by real differences in quality of care provided.
Scientific Programme
22. European Stroke Conference
523 Epidemiology of stroke
Variation in stroke outcome across geographical regions: data from the ‘Efficacy of Nitric Oxide in Stroke’ (ENOS) trial
P.M.W Bath1, A Houlton2, K Krishnan3, S Ellender4, T Payne5, N Sprigg6
University of Nottingham, Division of Stroke, Nottingham, UNITED KINGDOM1, University
of Nottingham, Division of Stroke, Nottingham, UNITED KINGDOM2, University of Nottingham,
Division of Stroke, Nottingham, UNITED KINGDOM3, University of Nottingham, Division of
Stroke, Nottingham, UNITED KINGDOM4, University of Nottingham, Division of Stroke, Nottingham, UNITED KINGDOM5, University of Nottingham, Division of Stroke, Nottingham, UNITED
KINGDOM6
Background: Stroke outcomes have shown previously to vary widely around the world. We assess
whether such variation continues to be present.
Methods: Data from the on-going ENOS trial were assessed, these including 3556 participants recruited from 7 geographical regions (Africa, north America, south Asia, south-east Asia, Australasia,
Europe and UK). Functional outcome (modified Rankin Scale, mRS >2) and mortality at day 90
were compared across regions relative to the UK using logistic regression with adjustment for baseline clinical covariates alone (age, sex, pre-stroke mRS, diabetes, IHD, AF, hypertension, systolic
BP, severity, stroke type, TACS syndrome, time to randomisation, year of randomisation), and then
in combination with treatment factors (admission to acute stroke unit, alteplase, physiotherapy, occupational therapy, speech/language therapy, antithrombotic, lipid lowering, antihypertensive).
Results: 69% of patients came from the UK. In unadjusted analysis, mRS varied significantly by region (p=<0.0001) with the best outcome in SE Asia. Similarly, death rates varied significantly with
the lowest rate also in SE Asia. Functional outcome was better in all regions, except N America,
relative to the UK when adjusted for clinical +/- treatment factors. Death varied between the regions
when adjusted for clinical +/- treatment factors.
Conclusion: Variation in outcome after stroke continues to be present, even after adjustment for clinical and treatment factors. However, the discrepancy between findings for functional outcome and
death suggest that interpretation of the meaning of mRS scores may still vary geographically.
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© 2013 S. Karger AG, Basel
524 Epidemiology of stroke
Variations in stroke care and outcome up to One Year After Stroke in Six European Populations: The European Register of Stroke (EROS) Investigators
S. Ayis1, C. McKevitt2, I. Wellwood3, A. Bhalla4, A.G. Rudd5, A. Di Carlo6, Y. Bejot7, D. Ryglewicz8, D. Rastenyte9, P. Langhorne10, M. Dennis11, B. Coker12, C.D.A. Wolfe13
King’s College London, London, UNITED KINGDOM1, King’s College London, London,
UNITED KINGDOM2, Center for Stroke Research Berlin, Berlin, GERMANY3, King’s College
London, London, UNITED KINGDOM4, King’s College London, London, UNITED KINGDOM5,
Institute of Neurosciences, Italian National Research Council, Florence, ITALY6, University of Burgundy, University Hospital of Dijon, Dijon, FRANCE7, Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, POLAND8, Institute of Cardiology, Kaunas University of Medicine,
Kaunas, LITHUANIA9,Academic Section of Geriatric Medicine, University of Glasgow, Glasgow,
UNITED KINGDOM10, Division of Clinical Neurosciences, Western General Hospital,, Edinburgh,
UNITED KINGDOM11, King’s College London, London, UNITED KINGDOM12, King’s College
London, London, UNITED KINGDOM13, , London14
Background: Although there are reports of variations in the processes of stroke care and outcomes
internationally, appropriate adjustment for confounding factors to improve the interpretation of these
variations is rarely achieved. We aim to investigate variations in post-acute stroke care and to explore the associations of these with Activities of Daily Living (ADL) and health-related quality of
life (HRQoL) at 3 and 12 months after stroke.
Methods: Data were obtained from six population stroke registers: France; Lithuania; UK; Spain;
Poland, and Italy between 2004 and 2006. We examined the Organised Care Index (OCI) for acute
care and post discharge access to general practitioner (GP), hospital doctor, community nurse and
therapists. Outcomes: the physical component summary (PCS) and the mental component summary (MCS) of SF-12, and ADL dependency. Mixed effect regression models were used to investigate
variations and multivariable relations.
Results: We studied 1388 one year stroke survivors; mean age 69.1 (SD: 13.1) and 52.6% were females. Wide variations in case-mix, processes of care, and outcomes were found. Access to highest
OCI level vary widely, range (26% - 63.4%). Overall 38.5% have some ADL dependency; 11.2%
were seen by physiotherapist (PT), range (0.4% - 34.8); 54.3% were seen by a GP, range (40.8% 80.2%) at one year after stroke. Mean predicted PCS range was (37.3(se: 0.4) to 43.6 (se: 0.9)), and
MCS (39.0 (se, 0.5) to 52.9 (se, 0.5)) after adjustments for case mix, socio- demographic factors,
post- acute care, OCI and interactions. PCS predictors were age, arm power, ability to walk, and incontinence, while MCS predictors were the verbal components of Glasgow Coma Scale (GCS) and
incontinence.
Conclusions: Wide variations in ADL dependency and HRQoL were identified but not fully explained by adjustments for severity, and care. Wide variations in pre and post discharge care were
found and populations with very low access to care were identified.
Scientific Programme
22. European Stroke Conference
535 Epidemiology of stroke
Trends in Activities of Daily Living (ADL) among Stroke Survivors: Analysis from the South
London Stroke Register 1995-2011
K. Chattopadhyay1, A. Douiri2, A. Sheldenkar3, A.G. Rudd4, C.D.A. Wolfe5, R Chen6
Division of Health and Social Care Research, King’s College London, London, UNITED
KINGDOM1, Division of Health and Social Care Research, King’s College London, London,
UNITED KINGDOM2, Division of Health and Social Care Research, King’s College London,
London, UNITED KINGDOM3, Division of Health & Social Care Research, King’s College London;Department of Elderly Care, St Thomas’ Hospital, Guy’s&StThomas’ NHS Foundation Trust,
London, UNITED KINGDOM4, Division of Health and Social Care Research, King’s College London; NIHR Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust, London,
UNITED KINGDOM5, Division of Health and Social Care Research, King’s College London, London, UNITED KINGDOM6
536 Epidemiology of stroke
Epidemiology of stroke in Stavropol region of the Russian Federation
M. D. Bogatiryova1, O.A. Кlochihina, L.V. Stakhovskay3
The Russian National Research Medical University named after N.I. Pirogov, Moscow, RUSSIAN FEDERATION1, The Russian National Research Medical University named after N.I. Pirogov, Moscow, RUSSIAN FEDERATION2, The Russian National Research Medical University
named after N.I. Pirogov, Moscow, RUSSIAN FEDERATION3
Cerebrovascular diseases is an actual medical and social problem in Stavropol region.
Background and purposes: Since 2007 the program “Improvement of medical health care for cerebrovascular disease patients” has been introduced and has been working in Stavropol region. The
aim of the work was to show results of the feasible program.
Methods: The stroke research was held by the method Stroke Register in according to the program
“Improvement of medical health care for cerebrovascular disease patients” in Stavropol region in
Background National and international acute stroke care guidelines came into effect during the last
2009-2010. This research was held in industrial district of the city Stavropol with the population of
decade to improve outcomes after stroke but their impact on activities of daily living (ADL) im182407 citizens. Epidemiological stroke parameters were counted in accordance with clinical diagprovement over time is not known. To the best of knowledge, no study has examined post-stroke
nosis of neurologists.
ADL trends over time.
Results: Incidence of stroke was 4.31 per 1 000 population in 2010. It is higher than in 2009 (3.14
Methods Data from the South London Stroke Register were analysed from 1995 to 2011. At 3
per 1000). Probably, the increase of incidence of stroke rate is connected with the stroke diagnosis
months and 1 year post-stroke, basic and instrumental ADL were measured using Barthel Index
improvement. Incidence of stroke rate was higher for men (4.43 per 1000) then for women
(poor outcome score<15) and Frenchay Activities Index (poor outcome score<=15), respectively.
(4.10 per 1 000) in 2010. High stroke incidence parameters were registered for men and women oldTrends in poor ADL over time were examined using logistic regression analyses, after adjusting for er aged groups. Among patients older than 70 stroke incidence index was 24.49 per 1000 in 2009
socio-demographics, pre-stroke risk factors, stroke subtype, stroke severity and processes of acute
and 25.61 per 1000 in 2010. It should be noted that Stavropol region differs from other Russian Fedstroke care. We also examined these trends in different socio-economic groups.
eration’s regions by the most of the population older than 70.
Results At 3 months post-stroke, the prevalence of poor basic ADL reduced significantly from
Despite of sickness rate increase, decrease of stroke mortality rate among men and women is no33.4% in 1995-1998 to 25.1% in 2008-2011 (trend p<0.001) and poor instrumental ADL declined
ticed. Mortality rate was 1.93 per 1000 in 2009; 1.86 per 1000 in 2010.
significantly from 59.8% to 53.1% (trend p=0.005). The corresponding figures at 1 year were: from The stroke mortality rate for women was higher (2.05 per 1000) than for men ( 1.45 per 1000) in
27.8% to 24.3% (trend p=0.001) and from 51.6% to 42.8% (trend p=0.004). At 3 months, significant 2010.
reduction in poor ADL was observed over time in the first (least deprived) and second Index of Mul- Conclusion: Results of the study “Stroke Register” in Stavropol region are suggested to make a contiple Deprivation (IMD) tertiles (trend p=0.006 and 0.001, respectively in poor basic ADL; 0.019
clusion that some positive changes have happened in the regard to stroke mortality. It may be assoand 0.047, respectively in poor instrumental ADL). At 1 year, poor basic ADL declined significantly ciated with effective implementation of the program “Improvement of medical health care for cereover time in the first and third IMD tertiles (trend p=0.002 and 0.043, respectively), whereas poor
brovascular disease patients”.
instrumental ADL reduced significantly only in the first IMD tertile (trend p=0.05).
Conclusion ADL has improved over time among stroke survivors. This may reflect the effectiveness
of acute stroke care (stroke unit care and rehabilitation). Disparities in ADL improvement still exist
in different socio-economic groups and health inequality needs to be tackled.
628
© 2013 S. Karger AG, Basel
Scientific Programme
London, United Kingdom 2013
561 Acute stroke: emergency management, stroke units and complications
The association between time to stroke unit admission and receipt of multidisciplinary stroke
care
J.T. Campbell1, L Paley2, M Roughton3, B Bray4, S Kavanagh5, M James6, G Cloud7, P Tyrrell8,
A.G. Rudd9
Royal College of Physicians, London, UNITED KINGDOM1, Royal College of Physicians, London, UNITED KINGDOM2, Royal College of Physicians, London, UNITED KINGDOM3, King’s
College London, London, UNITED KINGDOM4, Royal College of Physicians, London, UNITED
KINGDOM5, Royal Devon and Exeter NHS Foundation Trust, Exeter, UNITED KINGDOM6, St
George’s Healthcare NHS Trust, London, UNITED KINGDOM7, University of Manchester, Manchester, UNITED KINGDOM8, Guy’s and St Thomas’ NHS Foundation Trust, London, UNITED
KINGDOM9
Background: There is a large body of evidence demonstrating the effectiveness of stroke unit care.
Intercollegiate Stroke Working Party guidelines in the United Kingdom recommend admission to
stroke unit within 4 hours of hospital admission. We aimed to identify if delays in stroke unit admission beyond 4 hours were associated with the probability of receiving comprehensive multidisciplinary specialist stroke care.
Methods: Data were extracted from the Stroke Improvement National Audit Programme (SINAP) of
adults with acute stroke admitted to a participating hospital in England from January 2011-September 2012. Compliance with stroke specific care bundles in the first 72 hours of admission was compared for patients admitted to a stroke unit within 4 hours, 4-24 hours and 24-72 hours.
Results: Of 54 531 adults admitted with acute stroke to 110 hospitals, 36 112 (66%) were admitted to a stroke unit within 4 hours, 14 233 (26%) between 4 and 24 hours and 4186 (8%) between
24 and 72 hours after hospital admission. Patients admitted within four hours were more likely to
receive a care bundle comprising nursing and therapist assessments within 24 hours and 72 hours
(65%) compared to those admitted 4-24 hours (56%) or those admitted 24-72 hours (24%), Chi2
p<0.0001. A similar association was observed for patients receiving a care bundle comprising nutrition screening and formal swallow assessments within 72 hours (92%, 87%, 77% respectively),
Chi2 p<0.0001.
Conclusions: Patients experiencing delays in stroke unit admission longer than 4 hours of arrival in
hospital are less likely to receive specialist multidisciplinary stroke care in the first 3 days of admission. Ensuring that more patients are admitted quickly to stroke units may increase the proportion
receiving specialist multidisciplinary stroke care.
562 Acute stroke: emergency management, stroke units and complications
Estimated weight of patients in emergency: Reliable for thrombolysis?
S. Deltour1, Y. L’Hermitte2, G. Mutlu3, S. Crozier4, A. Leger5, C. Zavanone6, Y. Samson7
Stroke Unit, HOSPITAL PITIE SALPETRIERE, Paris, FRANCE1, SAMU 77/SMUR/Unit
Care, Hôpital Marc Jacquet,, Melun, FRANCE2, Stroke Unit, HOSPITAL PITIE SALPETRIERE,
PARIS, FRANCE3, Stroke Unit, HOSPITAL PITIE SALPETRIERE, Paris, FRANCE4, Stroke Unit,
HOSPITAL PITIE SALPETRIERE, Paris, FRANCE5, Stroke Unit, HOSPITAL PITIE SALPETRIERE, Paris, FRANCE6, Stroke Unit, HOSPITAL PITIE SALPETRIERE, Paris, FRANCE7, Stroke
Unit, HOSPITAL PITIE SALPETRIERE8
Introduction:
Before thrombolysis, knowledge of the patient’s weight is required (Tissue Plasminogen Activator :0.9 mg / kg). Neurovascular units have equipment to weigh deficient patients, but emergency
services remain largely unequipped (expensive and bulky hardware). Currently, tele-thrombolysis
develops in the emergency services. Therefore, we investigated whether the estimated weight of the
patients was sufficient.
Method:
For each patient with suspected stroke and potential “candidate” to thrombolysis, weight estimation was performed by averaging estimates made by five members (at least) of the healthcare team:
Team EMS, firefighters, manipulators, radiologists , nurse-aides, nurses and neurologists (external,
internal, senior). Different values were collected on a form. We then asked the patient to give us his
weight. There is no answer, the reason was clear: “Unable to answer” or “do not know”. Finally,
weighing the patient was performed and compared to the estimate. A subgroup analysis was able to
identify the best “assessor”.
Results:
Between September 2011 and September 2012, we collected 60 evaluation forms (50% female,
mean age 63 years, median weight 72Kg). Of patients able to respond (48 or 80%), 31 patients
(52%) knew their weight. The error of the estimate (estimated weight difference compared to the
actual weight of the patient) was on average 4.5 kg (equivalent to an error of 4.1 mg rTpa) with differences of up to 25 kg, obese patients or very thin are the most difficult to assess. The estimation of
the nurse-aides appear more reliable with standard deviation nevertheless amounted to 8.9.
Conclusion:
These results are insufficient to conclude formally. However to weight “standard”, the evaluation is
relatively reliable and especially if it is done by the nurse-aides.
Poster Session Blue Cerebrovasc Dis 2013; 35 (suppl 3)1-854
641
London, United Kingdom 2013
678 Acute stroke: clinical patterns and practice
Concurrent validity of two nutrition screening tools in acute stroke patients
V.C. Aubrey1, F. Gomes2, C.E. Weekes3
King’s Collage London, London, UNITED KINGDOM1, King’s Collage London, London,
UNITED KINGDOM2, Guy’s and St Thomas’ NHS foundation trust, London, UNITED KINGDOM3
679 Acute stroke: clinical patterns and practice
Variation in care between patients with thrombolysed ischaemic stroke, non-thrombolysed
ischaemic stroke and haemorrhagic stroke
L. Paley1, J.T. Campbell2, B. Bray3, S. Kavanagh4, A.M. Hoffman5, M. James6, G. Cloud7, P. Tyrrell8, A.G. Rudd9
Royal College of Physicians, London, UNITED KINGDOM1, Royal College of Physicians, London, UNITED KINGDOM2, King’s College London, London, UNITED KINGDOM3, Royal ColIntroduction There is a continued high prevalence and lack of recognition of malnutrition in hospilege of Physicians, London, UNITED KINGDOM4, Royal College of Physicians, London, UNITED
tals. Nutrition screening tools (NSTs) are used to identify those at risk of malnutrition who may ben- KINGDOM5, Royal Devon and Exeter NHS Foundation Trust, Exeter, UNITED KINGDOM6, St
efit from intervention. This study was used to assess the concurrent validity of two NSTs in stroke
George’s Healthcare NHS Trust, London, UNITED KINGDOM7, University of Manchester, Manpatients. Method Patients admitted to St Thomas’ Hospital with acute stroke were assessed using
chester, UNITED KINGDOM8, Guy’s and St Thomas’ NHS Foundation Trust, London, UNITED
two NSTs; MUST (Elia, 2003) and Guy’s & St Thomas’ (GST) (Weekes et al 2004) if they were in
KINGDOM9
hospital more than 3 days. Both tools include three variables (BMI, weight loss and nil by mouth
over 5 days). MUST requires calculation of % weight loss whereas the GST simply requires a record Background: Over recent years many stroke services have developed fast track services for stroke
of weight loss with no requirement to calculate % change. An extra variable (decreased appetite) is
thrombolysis. Focusing care pathways around thrombolysis may exclude other groups of patients
included in GST. Both tools assign patients to one of three categories (low, medium or high risk of
who might also benefit from rapid access to specialist stroke care. We aimed to identity if patients
malnutrition). Agreement between the methods was tested using the Kappa statistic, a chance corwith ischaemic stroke who did not receive thrombolysis (tPA) or those who had a haemorrhagic
rected measure of agreement where k > 0.6 represents good agreement (Landis & Koch 1977). Sta- stroke received the same process of care as patients treated with thrombolysis.
tistical tests were conducted using SPSS (v 18). Results NSTs were completed for all subjects using Methods: Data were extracted from the Stroke Improvement National Audit Programme (SINAP)
GST (n = 158) and 154 (97 %) using MUST due to missing information for % weight loss. Data
of adults with acute stroke admitted to a participating hospital in England from January 2011-Sepwere analysed on 154 patients; 77 males (50%); mean age 72.3 (SD 13.9) years; BMI 25.7 (SD 6.1) tember 2012. Achievement of the processes of care in the first 72 hours of admission were compared
kg/m2; NIHSS score 10.2 (SD 6.4). There was complete agreement between the tools in 132 paacross three groups: ischaemic stroke treated with tPA, ischaemic stroke not treated with tPA and
tients (85.7%) and chance corrected agreement between the tools was good (= 0.746, SE 0.046) (see haemorrhagic stroke.
Table 1). Although agreement between the tools was good, the GST classified more patients in the
Results: Of 58 459 adults admitted with acute stroke to 110 hospitals, 6333 (10.8%) had a haemhigher risk categories. Conclusion This study suggests good concurrent validity between the MUST orrhagic stroke, 5683 (9.7%) had ischaemic stroke treated with tPA and 46 443 (79.4%) had ischand GST screening tools. Completion of MUST was not possible in a small proportion of cases.
aemic stroke not treated with tPA. A greater proportion of patients treated with tPA were admitted
Agreement between these tools suggests either MUST or GST can be used to assess nutritional risk to a stroke unit within 4 hours of hospital arrival (86%) compared to those with ischaemic stroke
status in acute stroke patients. Elia M (2003) BAPEN Landis JR & Koch GG (1977) Biometrics 33: not treated with tPA (59%) or haemorrhagic stroke (53%), Chi2 p<0.0001. A similar pattern was
159-74 Weekes CE et al (2004) Clinical Nutrition, 23:1104-12
observed for being seen by a stroke consultant within 24 hours (97%, 82%, 78% respectively, Chi2
p<0.0001). Overall, patients treated with tPA had higher achievement of 11 of the 12 key indicators
Table 1: Concurrent validity of two NSTs
of care quality reported in SINAP.
GST
Conclusions: Patients treated with tPA are both more likely to receive timely specialist stroke care
Medium
Low
High
than patients not receiving tPA or those with haemorrhagic stroke. Providing the most timely care
Low
72
10
2
should be possible for all patients admitted with stroke and may improve outcomes in patients not
MUST
Medium
4
2
4
treated with tPA.
High
0
2
58
Poster Session Blue Cerebrovasc Dis 2013; 35 (suppl 3)1-854
705
22. European Stroke Conference
754 Stroke prevention
Utility of a Novel Predicting Bleeding Risk Score (HAS-BLED) to Assess Risk of Bleeding in
New Oral Anticoagulation Therapy for Secondary Stroke Prevention
T. Kanzawa1, K. Suzuki2, T. Horikoshi3, B. Mihara4
755 Stroke prevention
Developing a psychologically-informed, community based walking intervention for stroke survivors
A.J. Wright1, E.A. Walker2, D.P. French3, C. McKevitt4, I. Wellwood5, C.D.A. Wolfe6
Department of Stroke Medicine,Institute of Brain and Blood Vessels,Mihara Memorial Hospital, Isesaki, JAPAN1, Department of Stroke Medicine,Institute of Brain and Blood Vessels,Mihara
Memorial Hospital, Isesaki, JAPAN2, Department of Stroke Medicine,Institute of Brain and Blood
Vesse, Isesaki, JAPAN3, Department of Neurology,Institute of Brain and Blood Vessels,Mihara Memorial Hospital, Isesaki, JAPAN4
King’s College London, London, UNITED KINGDOM1, King’s College London, London,
UNITED KINGDOM2, University of Manchester, Manchester, UNITED KINGDOM3, King’s College London, London, UNITED KINGDOM4, Charité - Universitätsmedizin Berlin, Berlin, GERMANY5, King’s College London and NIHR Biomedical Research Centre at Guy’s and St Thomas’
NHS Foundation Trust and King’s College London, London, UNITED KINGDOM6
Background and purpose: A new oral anticoagulant:dabigatran (DE) has been available for stroke
prevention in patients with AF (atrial fibrillation). However, it has been reported that patients including the elderly and those with renal impairment have a greater risk of severe bleeding and are needed to balance the risk of stroke against hemorrhagic events. HAS-BLED score is useful in assessing
bleeding risk for anticoagulated patients with warfarin and has not studied in DE. The aim of our
study is to evaluate the clinical utility of HAS-BLED score in patients on DE for secondary stroke
prevention. Methods: In our single stroke center database from Mar. 2011 to Jan. 2013, 230 consecutive patients treated with DE were retrospectively studied. A new bleeding risk score termed HASBLED (Hypertension[>160mmHg], Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly[>65 years], Drugs/alcohol concomitantly)
was calculated. In cases of a high risk for bleeding (HAS-BLED>3), patients were treated to lower
the HAS-BLED score by lowering blood pressure(BP) and avoiding the abuse of Drugs/alcohol in
cooperation with the dietitian, the nurse, and the pharmacist. Results: We included 230 patients who
had 65% male, median age:73 (66-80), a mean body weight:59±12, rates of previous TIA/stroke:
82.3%, average CHADS2 score:3.5±0.9, and average CCr:68±28. In 12(4.8%) patients, all of whom
are >65 years, DE was discontinued due to CCr<30. The median of HAS-BLED score was 2(1-5).
The rate of high bleeding risk (HAS-BLED score>3) was 30.6% at base line and after the intervention for a bleeding risk profile significantly decreased to 17.4% (median:2, range:1-4, p<0.05).
During follow-up (Median:345 days, IQR:210-532) there was a one patient (0.4%) who suffered a
major bleeding event (lower digest tract and not Life-threatening) and 6(2.1%) ischemic stroke or
systemic embolism. Conclusion: Our findings suggest the clinical utility of the simple HAS-BLED
score not only for predicting the bleeding, but also improving the safety in new oral anticoagulated
patients with the management of a risk profile.
Background: Many stroke survivors who are able to walk do not walk enough to benefit their health
and wellbeing. However, walking is an acceptable form of physical activity to older adults that facilitates social participation. We plan to adapt an existing psychologically-informed walking intervention for stroke survivors who can walk outdoors. Thus, we aimed to identify the key views about
walking for this group and the intervention’s feasibility.
Methods: Semi-structured interviews with a purposive sample of 14 South London Stroke Register
participants, 3mo-3yr post-stroke, who could walk outdoors. The interview topic guide explored participants’ beliefs about walking and the acceptability/feasibility of pedometers and action planning.
Results: Stroke survivors valued walking’s potential to increase health, fitness, and their ability to
travel to desired places, but were worried walking more might increase pain from comorbid conditions. Participants’ families were the largest social influence on walking. Increasing walking was
easier in good weather, in good health and using walking aids. Less active participants were unsure
about pedometers, while more active participants were positive about them, saying they quantified
walking and gave an impetus for improvement. However, two more active participants felt pedometers were only suitable for the less active or those with recent strokes. Regarding planning, participants felt that plans should be tailored to the person and their local urban environment.
Conclusion: Stroke survivors’ perceived benefits of, and social influences upon, walking were similar to those reported for older adults in general. Planning seemed acceptable to most participants.
However, the rationale for use of pedometers should be presented carefully to motivate adherence.
Successfully adapting the intervention will also require sensitivity to participants’ local neighbourhoods and comorbid health issues.
744
© 2013 S. Karger AG, Basel
Scientific Programme
22. European Stroke Conference
808 Rehabilitation and reorganisation after stroke
Patients’ and health professionals’ views of self-management: systematic review and narrative
synthesis
E.A. Sadler1, C.D.A. Wolfe2, C. McKevitt3
King’s College London, London, UNITED KINGDOM1, King’s College London and NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UNITED KINGDOM2, King’s College London and NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UNITED
KINGDOM3
Background
Self-management (SM) interventions teach individuals strategies to manage the long term consequences of health conditions, and are proposed as one way to meet stroke survivors’ long term
needs. However, there is mixed evidence that such interventions work. This may be due to differences in patients’ and health professionals’ (HP) views regarding SM, but this has not been confirmed
through a systematic review. This study aimed to review patients and HP views of SM after stroke
and other long term conditions (LTC).
Table 1. Spearman correlations between glycaemia level (mg/dL) and USN by LBT
Methods
Line Bisection Test
We systematically reviewed the literature for qualitative studies of patients and HP views of SM af% Mean of
% Mean of deter stroke and other LTC. Relevant databases were searched from inception to 05/12. Inclusion criabsolute devi- Number of deviations
viations to the
% Mean of deviteria: English language, peer reviewed publications. Data from papers was extracted using a matrix
ation
to the right
right
ations to the left
to record purpose, methods, results and quality criteria. Two authors analysed themes using narrative
r
0.02
-0.35
-0.35
0.35
synthesis.
p
0.950
0.133
0.133
0.133
Results
n
26
26
26
26
r – Spearman correlation value; p – value associated to Spearman correlation; n – number of individ- 91 papers were included. HP viewed SM as involving psychological strategies to help people to
cope with their LTC. Patients also saw SM as involving psychological strategies, but emphasised
uals
the importance of personal choice and control to their SM. All HP saw SM as something that could
be taught, but noted they lacked training in how to do so. Therapists and nurses also emphasised the
importance of collaborative relationships to help patients acquire SM skills. Patients agreed collaborative relationships were important, but they also noted barriers to successful SM, including lack of
social support, poor relationships with HP and coping with co-morbid conditions.
Conclusion
HP and patients shared an understanding of SM as involving psychological strategies to cope with
LTC. HP did not note the same barriers to SM as patients did. Interventions to promote SM should
help patients exercise choice and control over managing their LTC. HP should acknowledge patients’ barriers to SM and support them to overcome these.
772
© 2013 S. Karger AG, Basel
Scientific Programme
London, United Kingdom 2013
814 Rehabilitation and reorganisation after stroke
Stroke patients’ and physiotherapists’ views of self-management after stroke
E.A. Sadler1, C.D.A. Wolfe2, C. McKevitt3
King’s College London, London, UNITED KINGDOM1, King’s College London and NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UNITED KINGDOM2, King’s College London and NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UNITED
KINGDOM3
Background
Self-management (SM) interventions teach individuals strategies to manage the long term consequences of health conditions, and are proposed as one way to meet stroke patients’ long term needs.
However, there is mixed evidence that such interventions work. This may be due to differences in
patients’ and health professionals’ (HP) views regarding SM, but little empirical work has been done
in this area. This study aimed to investigate how stroke patients and physiotherapists view SM management after stroke.
Methods
We conducted one-to-one in-depth interviews with 13 participants from the South London Stroke
Register admitted to a stroke unit in London, UK, and 12 physiotherapists involved in their care.
Topics focused on the role of SM after stroke and factors facilitating or hindering this. Interviews
were analysed thematically.
Results
Stroke patients viewed SM as regaining their independence to carry out pre-stroke daily activities.
Factors identified as facilitating SM included: psychological attributes, such as motivation and willingness to take responsibility, trust in the physiotherapist to guide recovery, and a supportive, motivating relationship with the therapist. Physiotherapists viewed SM as patients’ ability to take an active role in their rehabilitation and recovery. They felt that similar psychological attributes facilitated
SM, as did the skill and experience of the physiotherapist. They also noted barriers to SM including,
cognitive impairments and a lack of training on how to support stroke patients in learning SM skills.
Conclusion
Physiotherapists and stroke patients agreed SM involved psychological resources to take an active
role in rehabilitation and recovery after stroke. The patient/therapist relationship provided a context
for learning SM skills. Interventions to promote SM should focus on the nature of the patient/therapist relationship, adapt approaches for patients with cognitive impairments and provide training for
physiotherapists.
Poster Session Blue Cerebrovasc Dis 2013; 35 (suppl 3)1-854
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London, United Kingdom 2013
905 Meta-analysis and reviews
906 Meta-analysis and reviews
Association between asymptomatic carotid stenosis and cognitive function: a systematic review Adjusting after stroke: A systematic review and synthesis of qualitative studies
X.L. Chang1, H.Q. Zhou2, C.Y. Lei3, B. W4, Y.C. Chen5, Z.L. Hao6, W. Dong7, M. Liu8
S. Sarre1, C. Redlich2, A. Tinker3, E. Sadler4, A. Bhalla5, C. McKevitt6
Department of Neurology, West China Hospital, Sichuan University, Chengdu, CHINA1, Department of Neurology, West China Hospital, Sichuan University, Chengdu, CHINA2, Department of
Neurology, West China Hospital, Sichuan University, Chengdu, CHINA3, Department of Neurology,
West China Hospital, Sichuan University, Chengdu, CHINA4, Department of Neurology, West China
Hospital, Sichuan University, Chengdu, CHINA5, Department of Neurology, West China Hospital,
Sichuan University, Chengdu, CHINA6, Department of Neurology, West China Hospital, Sichuan
University, Chengdu, CHINA7, Department of Neurology, West China Hospital, Sichuan University,
Chengdu, CHINA8, Chengdu,CHINA9
King’s College London, London, UNITED KINGDOM1, University of Brighton, Brighton,
UNITED KINGDOM2, King’s College London, London, UNITED KINGDOM3, King’s College
London, London, UNITED KINGDOM4, Guy’s & St Thomas’ NHS Foundation Trust, London,
UNITED KINGDOM5, King’s College London, London, UNITED KINGDOM6
Background: There is evidence of variation in longer-term mental health and wellbeing after stroke,
which is not completely explained by severity or level and type of disability. The way people adjust
to the consequences of stroke may be a factor. Stroke survivors’ own views on adjusting after stroke
have been captured in qualitative studies. A systematic review and synthesis of such studies was
Background: Asymptomatic carotid stenosis (CS), defined as that patients have carotid stenosis
conducted, in order to understand adjustment and the barriers and facilitators to it.
without a past history and current clinical evidence of any prior cerebrovascular event, have tradiMethods: Qualitative studies drawing on stroke survivor’s accounts of their recovery and adjusttionally been considered clinically silent. It is less clear whether an asymptomatic CS itself is an in- ment, published in peer reviewed journals from 1990 – 2011 were searched for in databases CIdependent risk factor for a cognitive impairment.
NAHL, SSCI, Medline, ASSIA and Psychinfo, and by hand-searching relevant systematic reviews.
Methods: We conducted a systematic review of the literature using the Cochrane Library, MEDPapers were quality assessed for credibility and contribution using published criteria. Findings from
LINE, EMBASE and the China National Knowledge Infrastructure database. We also searched the
included studies were systematically extracted using a data matrix, and synthesised thematically.
reference lists of relevant studies and review articles. Two reviewers used a standardised form to
Results: Forty of 692 studies were included. Reported impacts of stroke were on physical functioncollect data and assess eligibility. The quality of study was assessed by the Newcastle–Ottawa Scale. ing, relationships and sense of self, with interactions between these domains. Adjustment to these
Results: A total of ten studies comprising 763 participants in the CS group and 6308 in the non-CS
changes had practical and psychosocial elements. It was not a linear process, but often marked by
group were included. All studies but one support the association between asymptomatic CS and cog- set-backs and new challenges over time. Participants identified personal characteristics such as denition impairment. When examining the concomitant factors of asymptomatic carotid stenosis and
termination as key to adjustment, but also employed practical and mental strategies. Their accounts
cognition in seven eligible studies, age (two studies) and reduced cerebrovascular reactivity (two
suggest that relationships (including relationships with health care professionals) and structural facstudies) showed positive results associated with cognitive impairment.
tors (such as access to health services, employment possibilities and welfare systems) influenced efConclusions: These results suggest that rather than being clinically silent, asymptomatic carotid ste- forts to adjust after stroke.
nosis may be associated with cognitive function impairment, which need to be further investigated
Conclusions: Processes of adjustment draw on resources found at the personal, inter-personal and
with high-quality studies.
structural levels. Adjustment usually continues long after discharge from services. Some stroke survivors may benefit from more explicit professional support to develop strategies for adjustment in
the long term.
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