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Abstract

This study reviews available data on stroke epidemiology in Italy. Data were identified through Medline/PubMed, Embase, and from reference lists, related articles, and citation lists of each of the retrieved papers. Nineteen papers were considered, referring to selected stroke-registers performed in seven different geographical areas: Acquaviva-Casamassima county, Aeolian Islands, Aosta district, Belluno district, L'Aquila district, Trasimeno area, and Vibo Valentia district. Registers covered a total population of 2 262 940 people, with a hospitalization rate from 82% to 98%. The mean age at stroke onset was 74·6 ± 1·1 years, 72·3 years in men and 76·6 years in women. Among all strokes: 67·3–82·6% were classified ischemic 9·9–19·6% as primary intracerebral hemorrhage 1·6–4·0% as sub-arachnoid hemorrhage, and 1·2–17·7% as undetermined. Annual incidence rates standardized to the Italian population ranged from 175/1 00 000 to 360/1 00 000 in men and from 130/1 00 000 to 273/1 00 000 in women. Thirty-day case-fatality rates for all strokes ranged from 18·1% to 33·0% while one-year case-fatality rates ranged from 37·9% to 40·2%. Data from selected Italian registers on stroke incidence and case-fatality indicate the great burden of the disease on our national healthcare system. The continuous implementation of preventive strategies, either population-based or addressed to the single patient at a high risk of stroke, is important to reduce the burden of the disease.

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... This issue is quite relevant, considering that stroke represents a major clinical burden in Italy, as well as in other high-income countries, with an annual incidence rate standardized to the Italian population of at least 175/1.000.000 in men and 130/1.000.000 in women, with some differences across regions [3,4]. Besides, the incidence is expected to rise in the next few years due to the ageing population, so that an increasing amount of people are expected to seek help for stroke symptoms. ...
... According to several reports [1,2,[4][5][6][7][8][9][10], stroke symptom knowledge and the intention to call the Emergency service are not associated. It should be noted that the American Heart Association advises that calling 911 should be the first and only response to suspected stroke symptoms, because the use of emergency medical services (EMS) is associated with earlier presentation to the hospital and greater rate of recombinant tPA use [5,[11][12][13]. ...
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Assessing the level of public stroke awareness is a prerequisite for development of community educational campaigns aimed at reducing prehospital delay of stroke patients. The Stroke Action Test (STAT) is a validated instrument specifically developed in the United States with the objective to assess the public's readiness to respond to stroke. Our purpose was to perform the cross-cultural adaptation of the original version of STAT to be applied to the Italian population. The process of cross-cultural adaptation has been performed according to guidelines, intended for questionnaires of self-report health status measures, following five steps: forward translation, synthesis, back translation, approval by an Expert Committee and test of the pre-final version. For this last step, 31 adults were asked to rate each item in terms of adequacy of content, clarity of wording and usefulness, according to a 3-point scale. The final version has been administered to a sample of 202 volunteers to assess its acceptability and reliability in terms of the internal consistency. The pre-final version of the STAT was developed taking into accounts few and minimal discrepancies between the two back translations and the original version of the instrument. Most items were judged as adequate, easy to understand and useful, according to the frequency of high scores (>50 %) given by the adaptation sample. As for further testing of the adapted final version, completeness of item response was very good. Distribution of scores ranged from 0 to 100 %, without any floor or ceiling effect, with a percentage of the lowest scoring of 1.5 % for the 28-item test and 2.5 % for the 21-item test and a percentage of the highest scoring of 1 % for both tests. Internal consistency was high for both the 28-item and 21-item tests (Cronbach alpha = 0.85 and 0.84, respectively). The process used to perform the cross-cultural adaptation of the questionnaire was successful. The Italian version of STAT demonstrated good acceptability and psychometric properties and is now available to assess stroke awareness in Italian people.
... By 2020, assuming stable incidence rates, 195,000 new stroke cases per year are expected because of age. 3 Annual stroke incidence rates, standardized to the Italian population, range from 175 of 100,000 to 360 of 100,000 in men and from 130 of 100,000 to 273 of 100,000 in women; 30-day mortality for all strokes ranges from 18.1% to 33.0% and 1-year mortality rates from 37.9% to 40.2%. 6 This epidemic and economic burden has, over the years, fostered joint action by scientific societies and public institutions to promote health policies and facilitate risk factor control and stroke prevention campaigns. [7][8][9] Secondary stroke prevention includes conventional lifestyle and pharmacologic approaches as well as more specific interventions such as anticoagulation for prevention of cardioembolic stroke due to atrial fibrillation. ...
... 6 Three registers reported data valuable for examining stroke incidence trends. 6 The L'Aquila register, the largest one including over 4000 patients, based on a 5-year data set, showed a mean rise in annual stroke incidence of 4.28% mainly due to the higher incidence in women, particularly those aged 851 years. Disparities between our results and epidemiologic data on stroke incidence from Italian registers might be variously explained. ...
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To describe the incidence of ischemic stroke, short-term mortality, recurrences, and prescription patterns. Data from administrative health databases of the Lombardy Region from 2002 to 2010 (about 4 million people) were analyzed for stroke incidence and recurrence, mortality, and drug prescriptions after an ischemic stroke. A total of 43,352 patients with a first hospital admission for ischemic stroke were identified. During 8 years, stroke incidence decreased from 3.2 of 1000 to 2.4 of 1000 (P < .001) in people aged 65-74 years, from 7.1 of 1000 to 5.3 of 1000 (P < .001) at ages 75-84 years and from 11.9 of 1000 to 9.4 of 1000 (P < .001) at age 85 years or older. Stroke recurrences dropped by 30% (from 10.0% to 7.0%, P < .001) and 30-day mortality rate also decreased. Prescription trends showed linear increase in antiplatelets and lipid-lowering drugs, respectively, from 60.2% to 65.0% (P < .001) and from 19.1% to 34.6% (P < .001), whereas antihypertensive prescriptions did not change appreciably. Anticoagulant prescription increased in patients with atrial fibrillation, from 64.8% to 72.1% in the 65-74 years age group, (P = .004) and from 40.2% to 53.7% in the 75-84 years age group (P < .001); less than 20% of the 85 years or older age group were treated with anticoagulants (P < .0001). Stroke incidence, recurrence, and 30-day mortality decreased from 2002 to 2010 concomitant with an increase in prescriptions of secondary stroke prevention drugs. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.
... These patients are characterized by a high degree of comorbidity, predisposing them to a greater risk of cardio-and cerebrovascular events [15,16]. Indeed, the incidence rate of ischemic or hemorrhagic stroke is higher in our OA cohort (with NSAIDs use as inclusion criteria) than what is known in the general population (11.0 vs. 1.2-1.7 per 1000 person-years for all cerebrovascular events; 3.9 vs. 0.4-0.7 per 1000 person-years for hemorrhagic stroke, and 7.0 vs. 1.2-2.5 per 1000 person-years for ischemic stroke [41,42]). As such, for patients with OA treated with NSAIDs, the excess risk of cerebrovascular events that we calculated for diclofenac and ketoprofen appears particularly relevant in terms of public health. ...
... Finally, given that cases have not been formally validated, they might be prone to some misclassification. However, the overall incidence rate of cerebrovascular events is greater than what is known in the general population, which is expected in a cohort of NSAIDs users who suffer from OA [41]. In addition, when we restricted the analysis to cases identified using a more strict definition, the results do not change. ...
Article
Recent studies show that the risk of cardiovascular adverse events for certain traditional non-steroidal anti-inflammatory drugs (NSAIDs) is similar to that of rofecoxib. While these results are focused on ischemic cardiomyopathy, there is little evidence concerning the risk of ischemic stroke/transient ischemic attack and hemorrhagic stroke. Additionally, there is no information on nimesulide and ketoprofen, the most frequently prescribed NSAIDs in Italy, along with diclofenac. This study aims to determine whether the use of NSAIDs is associated with an increased risk of cerebrovascular events in Italy. We performed a case-control analysis nested in a cohort of patients with osteoarthritis between 2002 and 2011 who were newly treated with NSAIDs. The patients were followed until December 31, 2012. Conditional logistic regression was used to estimate odds ratios (ORs) with 95 % confidence intervals (95 % CI) of cerebrovascular events (index date) associated with current (until 30 days before the index date), recent (31-365 days) and past (>365 days) use of NSAIDs. Within a cohort of 29,722 patients, 1566 cases (1546 matched with controls) were identified (incidence rate = 11.0/1000 person-years). The overall rate of cerebrovascular event was not elevated with current NSAIDs overall when compared with past use. Among individual NSAIDs, diclofenac and ketoprofen were the molecules significantly associated with an increased rate of cerebrovascular events (OR = 1.53; 95 % CI 1.04-2.24; OR = 1.62; 95 % CI 1.02-2.58, respectively). The most frequent event was hemorrhagic stroke following the use of ketoprofen (OR = 2.09; 95 % CI 1.05-4.15). Diclofenac and ketoprofen seemed to increase the risk of cerebrovascular events. These findings might influence the choice of NSAIDs according to patient characteristics.
... The most recent literature on the field stresses on the role of inflammatory molecules as biomarkers in stroke. Stroke, which can be simply considered as an injury occurring in brain when blood flow is cut off, may be of ischemic or hemorrhagic nature and each year about 800,000 people experience a new or recurrent stroke, being the fifth leading cause of death in the United States and about a third in Italy [15][16][17][18]. This circumstance suggests that searching for new emerging biomarkers for either stroke predictivity, diagnosis, or prognosis has come in the spotlight and is asking for new insights and data from experimental research [19,20]. ...
... ↑ Prognostic value to be reviewed [1,15,16] Interleukin-33 (IL-33) ...
Article
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Since the increasing update of the biomolecular scientific literature, biomarkers in stroke have reached an outstanding and remarkable revision in the very recent years. Besides the diagnostic and prognostic role of some inflammatory markers, many further molecules and biological factors have been added to the list, including tissue derived cytokines, growth factor-like molecules, hormones, and microRNAs. The literatures on brain derived growth factor and other neuroimmune mediators, bone-skeletal muscle biomarkers, cellular and immunity biomarkers, and the role of microRNAs in stroke recovery were reviewed. To date, biomarkers represent a possible challenge in the diagnostic and prognostic evaluation of stroke onset, pathogenesis, and recovery. Many molecules are still under investigation and may become promising and encouraging biomarkers. Experimental and clinical research should increase this list and promote new discoveries in this field, to improve stroke diagnosis and treatment.
... Furthermore, since the STROKOVID network, unlike other studies [4,8], includes all centers designated as hubs for the management of acute stroke in a given geographical area, we can assume that all acute strokes that occurred in Lombardy during the study period were included in the present analysis, which makes any further selection bias very unlikely. In addition, as the general characteristics of our cohort of non-infected patients reflect those of other hospital series of ischemic stroke patients [38,39], we presume that our study population is a representative sample of Italian patients with acute ischemic stroke. Second, it is possible that the non-systematic ascertainment of AF in our patients may have resulted in misclassification, especially for asymptomatic paroxysms. ...
Article
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Objective To characterize patients with acute ischemic stroke related to SARS-CoV-2 infection and assess the classification performance of clinical and laboratory parameters in predicting in-hospital outcome of these patients. Methods In the setting of the STROKOVID study including patients with acute ischemic stroke consecutively admitted to the ten hub hospitals in Lombardy, Italy, between March 8 and April 30, 2020, we compared clinical features of patients with confirmed infection and non-infected patients by logistic regression models and survival analysis. Then, we trained and tested a random forest (RF) binary classifier for the prediction of in-hospital death among patients with COVID-19. Results Among 1013 patients, 160 (15.8%) had SARS-CoV-2 infection. Male sex (OR 1.53; 95% CI 1.06–2.27) and atrial fibrillation (OR 1.60; 95% CI 1.05–2.43) were independently associated with COVID-19 status. Patients with COVID-19 had increased stroke severity at admission [median NIHSS score, 9 (25th to75th percentile, 13) vs 6 (25th to75th percentile, 9)] and increased risk of in-hospital death (38.1% deaths vs 7.2%; HR 3.30; 95% CI 2.17–5.02). The RF model based on six clinical and laboratory parameters exhibited high cross-validated classification accuracy (0.86) and precision (0.87), good recall (0.72) and F1-score (0.79) in predicting in-hospital death. Conclusions Ischemic strokes in COVID-19 patients have distinctive risk factor profile and etiology, increased clinical severity and higher in-hospital mortality rate compared to non-COVID-19 patients. A simple model based on clinical and routine laboratory parameters may be useful in identifying ischemic stroke patients with SARS-CoV-2 infection who are unlikely to survive the acute phase.
... In the last decade, specific task-related training at different intensity for stroke survivors were developed and the best mode is still unclear (8)(9)(10). The intensity of the training could be an important component in exercise prescription for stroke survivors. ...
Article
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Background: Stroke is a major cause of death and long-term disability across the globe. Previous studies have demonstrated the trainability of stroke survivors and documented beneficial effects of aerobic exercises on cardiovascular fitness and gait ability. Aim: The main aim of this study was to compare the effects of a high-intensity treadmill training (HITT) against low-intensity treadmill training (LITT) on gait ability, quality of life, cardiorespiratory fitness and cost of walking in chronic stroke subjects. Design: Randomized, controlled pilot study. Setting: Patients were recruited among Neurorehabilitation Unit outpatient. Population: The sample was composed of 16 subjects suffering from chronic stroke. Methods: Subjects were enrolled and randomly allocated either in the HITT (n=8) or in the LITT (n=8). Both groups performed 3-month training, 3 times per week. Subjects were evaluated before starting the training and after the end of the training by mean of clinical scales (Six Minute Walk Test, Ten Meter Walk Test, Health Survey Questionnaire SF-36, Stroke Impact Scale) and instrumental tests (Gait analysis, V02peak and Walking Energy Cost). Results: Fifteen subjects completed the study and no dropouts were observed. One patient in the LITT refused to initiate the training. The HITT group produced greater improvements than LITT group on the Six Minute Walk Test (HITT: 644 meters, LITT: 6 meters; p=0.005) and Ten Meter Walk Test performances (HITT: -1,7 seconds, LITT: 0,6 seconds; p=0.007), stride length (HITT: 3,3 centimetres, LITT: 0,4 centimetres, p=0.003), step length non-paretic side (HITT: 0,5 centimetres, LITT: 2,4 centimetres, p=0.008), step length paretic side (HITT: 1,8 centimetres, LITT: 0,7 centimetres, p=0.004), cadence (HITT: 1,6 step/minute, LITT: 0,6 step/minute, p=0.021) and symmetry ratio (HITT: 0,04, LITT: 0,01, p=0.004), V02peak (HITT: 4,6 ml/kg/min, LITT: 0,87 ml/kg/min; p=0.015) and Walking Energy Cost at 100% of self-selected speed (HITT: -30,8 ml/kg*km, LITT: -20,5 ml/kg*km; p=0.021). Significant changes were found on Six Minute Walk Test (p=0.012) and Ten Meter Walk Test (p=0.042) performances, spatio-temporal gait parameters (stride length p=0.011, step length paretic side p=0.012, cadence p=0.037 and symmetry ratio p=0.012), VO2peak (p=0.025) and cost of walking at 100% of self-selected speed (p=0.018) in the HITT group. In the LITT no significant results were observed. Conclusion: HITT could be considered a feasible training and led to improvement in gait ability and enhanced VO2peak and reduction in cost of walking compared to LITT. Clinical rehabilitation impact: Chronic stroke survivors should be encouraged to engage regular aerobic treadmill training at medium/high intensity. HITT is safe and feasible and has positive effects on gait ability, cardiovascular fitness and cost of walking in subjects with stroke in chronic phase.
... being ischemic strokes. 4 Patients with stroke may suffer several types of pain, including articular pain, musculoskeletal pain, painful spasticity, headache, and neuropathic central post-stroke pain (CPSP). Central post-stroke pain is one of a group of chronic pain conditions that are termed central neuropathic pain, because pain is due to a lesion or a disease affecting the central somatosensory system. ...
Article
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Central post-stroke pain (CPSP) is still an underestimated complication of stroke, resulting in impaired quality of life and, in addition to the functional and cognitive consequences of stroke, the presence of CPSP may be associated with mood disorders, such as depression, anxiety, and sleep disturbances. This type of pain may also impair activities of daily living and further worsen quality of life, negatively influencing the rehabilitation process. The prevalence of CSPS in the literature is highly variable (1%-12%) according to different studies, and this variability could be influenced by selection criteria and the different ethnic populations being investigated. With this scenario in mind, we performed a population-based study to assess the prevalence of CPSP and its main features in a homogeneous health district (Rimini, Italy), including five hospitals for a total population of 329,970 inhabitants. From 2008 to 2010, we selected 1,494 post-stroke patients and were able to interview 660 patients, 66 (11%) of whom reported pain with related tactile and thermal hyperesthesia, accompanied by needle puncture, tingling, swelling, and pressure sensations. Patients reported motor impairment and disability, which influenced their working ability, rehabilitation, and social life. Despite this severe pain state, there was a high percentage of patients who did not receive adequate treatment for pain.
... The relevance of looking for an effective and safe acute stroke treatment to elderly patients is beyond question. Stroke is very common in the elderly; in fact, about 35 % of all strokes occur in subjects over 80 years of age [3,4], and with aging of the population, the number of elderly subjects having strokes will increase worldwide. However, elderly patients were excluded or underrepresented in the randomized-controlled trials of i.v. ...
... Nonetheless, in our opinion, at the present state of our knowledge, the use of anticoagulants should be avoided in most if not in all subjects with ICH in the presence of a cardiac source of embolism, since patients would be exposed to the deadliest and least treatable type of stroke event. Actually, even in subjects who do not use anticoagulants, ICH is the deadliest form of stroke with a 30-day case-fatality-rate close to 50 % [9,10] while for ischemic stroke associated with atrial fibrillation, the 30-day case-fatality rate is equal to approximately 30 % [11]. In anticoagulant users, compared with non-users, hematoma volume is higher, and there is also an increased rate of early hematoma expansion [12]. ...
Article
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Oral anticoagulant therapy is an effective treatment for stroke prevention in patients with atrial fibrillation and other forms of cardiac sources of embolism. However, vitamin K antagonists (VKAs) and novel direct oral anticoagulants (NOACs), such as direct thrombin inhibitors or direct factor Xa inhibitors, are associated with an increased bleeding risk, including intracerebral hemorrhage (ICH). In the absence of a previous history of ICH, reduction in the risk of thromboembolic events outweighs the increased risk of ICH. In subjects with previous ICH, the equilibrium changes and the risk/benefit ratio is unpredictable since those subjects were excluded from clinical trials on the prevention of thromboembolic events with oral anticoagulants. Even in the absence of reliable research data, it is widely accepted that anticoagulants should not be resumed in the acute stroke phase for the risk of hematoma expansion and early re-bleeding [1]. At variance, long-term prophylaxis is concerned ...
... The association between migraine and HS is still unanswered, because of several issues. ICH and SAH are rarer than ischemic stroke in high-income countries [16], and very large populations are needed to assess the association between HS and migraine. Electronic datasets, offering the opportunity to compute huge networks of data, could help in overcoming that problem. ...
... Many literature data [1][2][3][4][5][6][7] showed that stroke unit (SU) care is associated with long-term reductions in death, disability, and institutionalized long-term care in ischemic stroke (IS) patients. American Heart Association/American Stroke Association Guidelines 8 recommend that patients with an acute stroke should be hospitalized in a comprehensive and specialized SU with dedicated beds and staff. ...
Article
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The purpose of our study is to investigate whether stroke unit (SU) care and the utilization of Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria may contribute to reduce death and disability in hospitalized patients after a first-ever ischemic stroke (IS). Data included in the present study were derived from our previous study on the incidence and outcome of cerebrovascular diseases in the district of Udine, performed from April 1, 2007, to March 31, 2009. We identified 429 hospitalized first-ever IS cases, 297 of 429 (69.2%) patients were admitted to a dedicated SU and 132 of 429 (30.8%) to a general medical ward. According to the TOAST criteria, 101 of 132 first-ever ISs (76.5%) admitted to general medical wards were of undetermined (UND) etiology, whereas in only 105 of 297 (35.4%) patients admitted to the SU, the diagnosis remained UND. Multivariable analysis after propensity score matching showed that compared with general medical wards, SU care was associated with a reduced probability of being dead or highly disabled (P = .025) at the end of follow-up. Moreover, patients with an UND diagnosis had a worse 6-month case fatality (P < .0001) and also higher risk of being dead or highly disabled (P < .0001). Our study provides real-world evidence that accurate etiologic subtype classification of ISs according to TOAST criteria and SU care as opposed to general medical ward management are associated with reduction of the proportion of poor outcomes in first-ever IS patients. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.
... In Italy, the epidemiology of stroke is similar to that of other high-income countries, with ischemic stroke accounting for about 80% of total cases (5). ...
Article
The consequences of stroke must be assessed not only in terms of incidence and mortality rates, but also in terms of disability, which may persist long after the acute phase. Thrombolysis, if timely administered, can effectively reduce post-stroke disability. The economic model presented herein aims to evaluate, in eligible patients, the effects of alteplase on post-stroke disability and related costs over three-years. The economic analysis was developed on the basis of four key components: clinical outcomes from international trials, economic consequences extracted from cost of illness studies, regulatory data from national and international agencies, and national epidemiological data. A population-level model estimated the difference in disability costs between patients treated with standard care versus those receiving thrombolytic therapy within 4×5 h of acute ischemic stroke. The analysis covered 36 months from discharge. Reduced costs related to post-stroke disability were observed in treated patients compared with those receiving standard care (control). The overall savings were €2330×15 per average patient: €1445×81 during the first 18 months, €362×25 between 18 and 24 months, and €522×09 in the 24-36 months period. The overall savings on 3174 Italian treated patients in 2013 were €7 395 907 over three-years. Our study reveals that performing thrombolytic therapy in eligible patients improves economic outcomes compared with patients receiving standard care. This model is useful for decision makers, both within and outside of the Italian national context, as a tool to assess the cost-effectiveness of thrombolysis in both short- and long-term period. © 2015 World Stroke Organization.
... Nevertheless, it did not estimate the long-term case fatality. 1,2 One-year case-fatality studies conducted elsewhere in the world reported a rate of 34.3% in Iran, 8 27.9% in China, 9 37.9% to 40.2% in Italy, 10 25.1% in Brazil, 11 and 29.0% in Mexico. 12 The case-fatality studies conducted in SSA on stroke have produced rather disparate results. ...
Article
Background: The burden of stroke is high in sub-Saharan Africa; however, few data are available on long-term mortality. Objective: To estimate over one-month stroke case fatality in sub-Saharan Africa. Methods: A systematic review and meta-analysis were performed according to meta-analysis of observational studies in epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO protocol: CRD42020192439), on five electronic databases (PubMed, Science direct, AJOL, EMBASE, and Web of Sciences). We searched all studies on stroke case fatality over one month in sub-Saharan Africa published between 1st January 2000 and 31st December 2019. Results: We included 91 studies with a total of 34,362 stroke cases. The one-month pooled stroke case-fatality rate was 24.1% [95% CI: 21.5-27.0] and 33.2% [95% CI: 23.6-44.5] at one year. At three and five years, the case-fatality rates were respectively 40.1% [95% CI: 20.8-63.0] and 39.4% [95% CI: 14.3-71.5] with high heterogeneity. Hemorrhagic stroke was associated with a higher risk of mortality at one month, but ischemic stroke increased the risk of mortality over six months. Diabetes was associated with poor prognosis at 6 and 12 months with odds ratios of 1.64 [95% CI: 1.22-2.20] and 1.85 [1.25-2.75], respectively. Conclusion: The stroke case fatality over one month was very high, compared to case fatalities reported in Western countries and can be explained by a weak healthcare systems and vascular risk factors.
... Stroke, also called 'brain attack', is a major public health problem, representing the third leading cause of death and the main cause of disability (Sacco et al, 2011). The risk of stroke is influenced by a number of factors. ...
Article
Stroke (brain attack), is a serious global public health problem and the main cause of many forms of disability. The majority of stroke survivors are mostly left with motor (muscle movement or mobility) impairments. Although remarkable developments have been made in drug treatment, post-stroke care continues to rely on rehabilitation interventions mostly. On the other hand, the presence of post-stroke depression has been associated with decreases in functional recovery, social activity and cognition. Therefore, this project aims to improve the quality of people’s lives after a stroke by introducing sailing as outdoor mobility rehabilitation. It is intended to increase the patients’ motivation and engagement in the rehabilitation process by a more enjoyable and relaxing intervention than the existing ones especially for long term periods. The project, based on a haptic system installed on the deck of NYTEC 28 sailing boat, aim to monitoring rehab process development in post-stroke during normal sailing activity.
... This result supports the use of scores per each factor as well as per a combined score of the 15-items in both versions of the MS. Test-retest reliability of the MS factors and total scale was assessed with examination of ICCs (Sacco, Stracci, Cerone, Ricci, & Carolei, 2011; Table 4 reports the dyadic statistics of the MS and its four factors for matched patient-caregiver samples (n = 163). With the exception of love factor, all factors and the total scale's scores were significantly higher in patients. ...
Article
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Purpose: The Mutuality Scale (MS) is composed of four theoretically derived factors (love, shared pleasurable activities, shared values, and reciprocity), but this structure has never been confirmed. Also, research involving the patient's perspective on the MS is limited. In this study, we tested the factorial structure of the MS and its reliability in stroke patients and caregivers. Design and method: Cross-sectional, with a follow-up after 15 days for test-retest reliability. A total of 248 stroke patients and 163 stroke caregivers completed the MS. Stroke patients and their caregivers were enrolled in 10 rehabilitation hospitals across Italy. MS factorial structure was analyzed using confirmatory factor analysis; internal consistency reliability was evaluated with Cronbach's α and model-based internal consistency index; test-retest reliability was evaluated with intraclass correlation coefficient. Results: Confirmatory factor analysis supported the four-factor structure of MS in its patient and caregiver version (CFI = 0.94; RMSEA = 0.06, for both). Cronbach's αs and model-based internal consistency index were >0.90 and intraclass correlations ranged between 0.66 and 0.93 in MS patient and caregiver version. Implication: This study tested the theoretical dimensions of the MS in stroke patients and their caregivers. From a scientific and clinical point of view, an assessment of stroke patient and caregiver mutuality would allow dyadic approaches to data analysis and care that account for the nonindependence between the stroke patient and the caregiver.
... To the best of our knowledge, this is the first study to provide data on the prevalence of ICAS in an Italian ischemic stroke population. Previous population-or hospital-based studies on stroke epidemiology in Italy provided no data on the prevalence of ICAS among Italian patients with cerebrovascular disease [23]. This study fills this gap and consistently with many reports [1,2,8], it demonstrates that besides carotid and/or vertebral arteries, the intracranial vessels should not be ignored as a potential site of atherosclerosis causing stroke syndromes. ...
Article
There are currently no data available on the prevalence of symptomatic intracranial atherosclerosis (ICAS) in Italy. The aim of this prospective, multicenter, hospital-based, transcranial ultrasound study was to establish the prevalence of ICAS among patients hospitalized with acute ischemic stroke. At 11 stroke centers across Italy, patients consecutively admitted for their first ever acute ischemic stroke were assessed prospectively over a 24-month period either with transcranial color-coded Doppler sonography (TCCS) or transcranial Doppler (TCD) according to validated criteria. ICAS was diagnosed when there was an evidence of a cerebral infarction in the territory of a ≥50 % stenosis detected by TCCS/TCD and confirmed by magnetic resonance angiography or computed tomography angiography. A total of 1134 patients were enrolled, 665 of them (58.6 %) men, with a mean age of 71.2 ± 13.3 years. ICAS was recorded in 99 patients (8.7 % of the whole sample, 8.9 % among Caucasians), most commonly located in the anterior circulation (63 of 99, 5.5 %). After adjusting for potential confounders, multivariate analysis identified carotid/vertebral ≥50 % stenosis [odds ratio (OR) 2.59, 95 % (confidence interval) CI 1.77–6.33; P = 0.02] and hypercholesterolemia (OR 1.38, 95 % CI 1.02–1.89; P = 0.02) as being independently associated with ICAS. ICAS is a surprisingly relevant cause of ischemic stroke in Italy, identified in almost 9 % of first-ever stroke patients. It is more prevalent in the anterior circulation and independently associated with hemodynamically significant cervical vessel atherosclerosis and hypercholesterolemia. These findings support the systematic use of transcranial ultrasound to identify ICAS in patients presenting with acute ischemic stroke and in cases with ≥50 % cervical vessel stenoses.
... On the other hand, one may argue that an ICH is usually associated with more severe clinical presentation and worse outcome compared with an atrial fibrillation-related ischemic stroke, with approximately 50% case fatality rate at 1 month in the former and 30% in the latter case [7,8]. Therefore, even if the risks of recurrent ICH and ischemic stroke were to be comparable during the follow-up of a patient with an anticoagulantrelated ICH, the overall clinical outcome might be poorer in patients who suffer an recurrent ICH compared with patients who suffer an ischemic stroke; in this context, someone may prefer to risk a (possibly milder) ischemic stroke by not restarting anticoagulants rather than a (possibly more severe) recurrent ICH recurrence by restarting anticoagulants. ...
Article
Purpose of review: A significant proportion of stroke patients is treated with anticoagulants for secondary stroke prevention. Often, in such patients, stroke physicians are required to make difficult clinical decisions when confronted with the dilemma to choose between the risk of thromboembolism and the risk of bleeding. This article focuses on three common anticoagulant-related situations, where the stroke physician needs to find the delicate balance between the two risks. Recent findings: Three typical case vignettes are presented and the associated dilemmas are discussed: a patient with an anticoagulant-related intracranial hemorrhage: would you restart anticoagulation?, an anticoagulated patient with a previous stroke because of atrial fibrillation is scheduled for an elective polyp removal: how would you handle anticoagulation perioperatively?, and a patient presents with an ischemic stroke because of atrial fibrillation: how soon would you start anticoagulation for secondary stroke prevention? The article summarizes the related literature and discusses the pros and cons of each choice. Summary: The available evidence is limited; we need to individualize our approach according to the specific characteristics of our patients, and share the decision process with our patients and their proxies, taking strongly into consideration their values and preferences.
... According to a recent study, in 2010 stroke represents the second cause of death and the third cause of reduced disability-adjusted life-years worldwide, 1 being a leading cause of adult disability in Western countries. 2,3 Ischemic stroke may be due to small vessel occlusion, large artery atherosclerosis, cardioembolism, or other less common causes (e.g., dissection, hypercoagulable disorders, vasospasm, drug abuse). It is noteworthy that some conditions (e.g., hematocrit levels) may act as risk factors for ischemic stroke, facilitating its occurrence and influencing its prognosis. ...
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Although in the last few years emerging conventional and unconventional radiological and laboratory techniques have shed light on different pathophysiologic causes of stroke, nowadays almost 25% of ischemic strokes results of undetermined etiology. Different diagnostic criteria have been developed to define cryptogenic stroke and to establish its prevalence in stroke units. Different studies tried to unravel mechanisms of cryptogenic stroke and to evaluate adequate primary and secondary preventive measures, but standardized diagnostic and therapeutic strategies are still missing. In this review we report the most relevant updated notions in cryptogenic stroke providing an overview of the definition, the recommendations for diagnostic evaluation and the updated treatment strategies for secondary prevention.
... Except for very few studies [9][10][11][12], population-based investigations of stroke incidence have largely been confined to pathological subtypes [6,[13][14][15][16]. A more complex pattern of trends by IS aetiologies could have been masked, and characterising these trends can guide future prevention and therapeutic priorities. ...
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Background As the average life expectancy increases, more people are predicted to have strokes. Recent studies have shown an increasing incidence in certain types of cerebral infarction. We aimed to estimate time trends in incidence, prior risk factors, and use of preventive treatments for ischaemic stroke (IS) aetiological subtypes and to ascertain any demographic disparities. Methods and findings Population-based data from the South London Stroke Register (SLSR) between 2000 and 2015 were studied. IS was classified, based on the underlying mechanism, into large-artery atherosclerosis (LAA), cardio-embolism (CE), small-vessel occlusion (SVO), other determined aetiologies (OTH), and undetermined aetiologies (UND). After calculation of age-, sex-, and ethnicity-specific incidence rates by subtype for the 16-year period, we analysed trends using Cochran-Armitage tests, Poisson regression models, and locally estimated scatterplot smoothers (loess). A total of 3,088 patients with first IS were registered. Between 2000–2003 and 2012–2015, the age-adjusted incidence of IS decreased by 43% from 137.3 to 78.4/100,000/year (incidence rate ratio [IRR] 0.57, 95% CI 0.5–0.64). Significant declines were observed in all subtypes, particularly in SVO (37.4–18; p < 0.0001) and less in CE (39.3–25; p < 0.0001). Reductions were recorded in males and females, younger (<55 years old) and older (≥55 years old) individuals, and white and black ethnic groups, though not significantly in the latter (144.6–116.2; p = 0.31 for IS). A 4-fold increase in prior-to-stroke use of statins was found (adjusted odds ratio [OR] 4.39, 95% CI 3.29–5.86), and despite the increasing prevalence of hypertension (OR 1.54, 95% CI 1.21–1.96) and atrial fibrillation (OR 1.7, 95% CI 1.22–2.36), preventive use of antihypertensive and antiplatelet drugs was declining. A smaller number of participants in certain subgroup-specific analyses (e.g., black ethnicity and LAA subtype) could have limited the power to identify significant trends. Conclusions The incidence of ISs has been declining since 2000 in all age groups but to a lesser extent in the black population. The reported changes in medication use are unlikely to fully explain the reduction in stroke incidence; however, innovative prevention strategies and better management of risk factors may contribute further reduction.
... Nevertheless, it did not estimate the long-term case fatality. 1,2 One-year case-fatality studies conducted elsewhere in the world reported a rate of 34.3% in Iran, 8 27.9% in China, 9 37.9% to 40.2% in Italy, 10 25.1% in Brazil, 11 and 29.0% in Mexico. 12 The case-fatality studies conducted in SSA on stroke have produced rather disparate results. ...
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Background: The burden of stroke is high in sub-Saharan Africa (SSA), but few data are available on its long-term mortality. Objective: To estimate over one-month stroke case-fatality in sub-Saharan Africa Methods: Systematic review and meta-analysis was performed according to Meta-analysis of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO protocol: CRD42020192439), on five electronic databases (PubMed, Science direct, AJOL, EMBASE and Web of Sciences). We searched all studies on stroke mortality case-fatality over one-month in SSA published between 1st January 2000 and 31 December 2019. Results: We included 91 studies with 34,362 stroke cases. The one-month pooled stroke case-fatality rate was 24.1% [95%CI: 21.5-27.0] and 33.2% [95%CI: 23.6-44.5] at 1-year. At 3 and 5-years the case-fatality rates were respectively 40.1% [95% CI: 20.8-63.0] and 39.4% [95%CI: 14.3-71.5] with high heterogeneity. Hemorrhagic stroke was associated with a higher risk of mortality at one month, but ischemic stroke increased the risk of mortality over 6 months. Diabetes was associated with poor prognosis at 6 and 12 months with odds ratios of 1.64 [95% CI: 1.22-2.20] and 1.85 [1.25-2.75] respectively. Conclusion: The stroke case-fatality over one-month was very high compared to other reported in Western countries and can be explained by the weak healthcare systems and vascular risk factors despite the high heterogeneity in this review.
... Only 25% of patients who survive an ischemic stroke recover fully, while the majority become disabled and in a substantial proportion of these their disability is so severe that they are no longer selfsufficient and need to be managed in a chronic care setting [8]. ...
... In Europe, we expect an increase of about 32% of incidence in the next twenty years, mainly due to the aging of the population [2]. Epidemiological data of stroke in Italy are in line with those of other high-income countries [3]. ...
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Background Validation of administrative databases for cerebrovascular diseases is crucial for epidemiological, outcome, and health services research. The aim of this study was to validate ICD-9 codes for hemorrhagic or ischemic stroke in administrative databases, to use them for a comprehensive assessment of the burden of disease in terms of major outcomes, such as mortality, hospital readmissions, and use of healthcare resources. Methods We considered the hospital discharge abstract database of the Umbria Region (890,000 residents). Source population was represented by patients aged >18 discharged from hospital with a diagnosis of hemorrhagic or ischemic stroke between 2012 and 2014 using ICD-9-CM codes in primary position. We randomly selected and reviewed medical charts of cases and non-cases from hospitals. For case ascertainment we considered symptoms and instrumental tests reported in the medical charts. Diagnostic accuracy measures were computed using 2x2 tables. Results We reviewed 767 medical charts for cases and 78 charts for non-cases. Diagnostic accuracy measures were: subarachnoid hemorrhage: sensitivity (SE) 100% (95% CI: 97%-100%), specificity (SP) 96% (90–99), positive predictive value (PPV) 98% (93–100), negative predictive value (NPV) 100% (95–100); intracerebral hemorrhage: SE 100% (97–100), SP 98% (91–100), PPV 98% (94–100), NPV 100% (95–100); other and unspecified intracranial hemorrhage: SE 100% (97–100), SP 96% (90–99), PPV 98% (93–100), NPV 100% (95–100); ischemic stroke due to occlusion and stenosis of precerebral arteries: SE 99% (94–100), SP 66 (57–75), PPV 70% (61–77), NPV 99% (93–100); occlusion of cerebral arteries: SE 100% (97–100), SP 87% (78–93), PPV 91% (84–95), NPV 100% (95–100); acute, but ill-defined, cerebrovascular disease: SE 100% (97–100), SP 78% (69–86), PPV % 83 (75–89), NPV 100% (95–100). Conclusions Case ascertainment for both ischemic and hemorrhagic stroke showed good or high levels of accuracy within the regional healthcare databases in Umbria. This database can confidently be employed for epidemiological, outcome, and health services research related to any type of stroke.
... Stroke incidence in Italy ranges from 1.8/1.000 to 4.5/ 1.000 new cases per year, with a prevalence of 6.5/100, similarly to other high-income countries [4]. Incidence of stroke increases with age and is higher in men than in women (mean age at onset 75 years in men and 76.6 years in women), with a peak of incidence in subjects older than 85 [5][6][7]. About 40% of all people who experience a stroke develop aphasia, more frequently in case of a cardioembolic stroke and more frequently if thrombolysis is performed [8]. ...
Article
Aphasia is one of the most devastating symptoms in stroke survivors and severely affects patients’ communication, quality of life, and social interactions. Several factors are critical to the prediction of aphasia recovery, including acute stroke management and subsequent language rehabilitation. A comprehensive assessment of language skills with appropriate instruments in different phases of post stroke months and years is needed in patients, in order to monitor their language improvement and to guide speech therapies over time. Beyond spontaneous recovery, the effects of speech and language therapy in terms of time and dosage of administration during the course of post stroke aphasia are still under investigation. Data point to its efficacy either in the early or in the chronic (> 6 months) post stroke phase, with greater effects if intensive treatments are provided. Tailored interventions for single patients’ aphasia characteristics are recommended, with different levels of evidence for specific techniques. Ongoing trials and meta-analyses will be useful in order to change the allocation of rehabilitation resources for patients with aphasia.
... Ο ιδιωτικός τομέας υπάρχει σε μικρό ποσοστό στην οξεία φάση και είναι πιο σημαντικός στα εξωτερικά ιατρεία και στην αποκατάσταση [9,17] . [141] . ...
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Το βιβλίο Οι επιπτώσεις του Εγκεφαλικού Επεισοδίου στην Ευρώπη (The Burden of Stroke in Europe) είναι μια μελέτη που πραγματοποίησαν ερευνητές στο King's College του Λονδίνου, η οποία παρουσιάζει μια εις βάθος ανάλυση σχετικά με την ευαισθητοποίηση, την πληροφόρηση και την πρόληψη αυτής της επείγουσας κατάστασης ανάγκης. Εξετάζει τους τρόπους περίθαλψης, αποκατάστασης, υποστήριξης και κοινωνικής ενσωμάτωσης και γενικότερα τη ζωή των Ευρωπαίων πολιτών που ήρθαν αντιμέτωποι με ένα εγκεφαλικό επεισόδιο. Η μελέτη, που ανατέθηκε στους ερευνητές στο Λονδίνο από την Μ.Κ.Ο. Stroke Alliance for Europe (S.A.F.E.), εξέτασε μητρώα, έγγραφα και πληροφορίες από 35 ευρωπαϊκές χώρες, συμπεριλαμβανομένης της Ελλάδας, επισημαίνοντας σημαντικές διαφορές μεταξύ των διαφορετικών μοντέλων περίθαλψης και ανισότητες στην προσφορά και στην πρόσβαση σε θεραπείες. Η έκθεση υπογραμμίζει ανησυχητικά επιδημιολογικά δεδομένα: Το αγγειακό εγκεφαλικό επεισόδιο είναι μία από τις πρώτες αιτίες θανάτου στην Ευρώπη, η δεύτερη αιτία της ενσυνείδητης νοητικής ανεπάρκειας των ενηλίκων και η πρώτη αιτία μακροχρόνιας αναπηρίας. Παρά τις προσπάθειες που καταβάλλουν οι ευρωπαϊκές χώρες για την αντιμετώπιση αυτής της ανθρωπιστικής καταστροφής, αναμένεται αύξηση κατά περίπου 30% των νέων περιπτώσεων τα επόμενα χρόνια, κυρίως λόγω της γήρανσης του πληθυσμού. Η μελέτη που πραγματοποιήθηκε από το King's College London έδειξε ότι είναι δυνατό να βελτιωθεί σημαντικά το ποσοστό επιβίωσης μετά από ένα εγκεφαλικό επεισόδιο, μέσω της καθιέρωσης μονάδων για το εγκεφαλικό επεισόδιο και της θεραπείας με θρομβόλυση. Ωστόσο, παρά τη συμπερίληψη αυτών των δομών στις ευρωπαϊκές και εθνικές κατευθυντήριες γραμμές, εκτιμάται ότι μόνο το 30% των ασθενών με αγγειακό εγκεφαλικό επεισόδιο λαμβάνουν την κατάλληλη μέριμνα. Επομένως, η πρόληψη και η σωστή θεραπεία εγκεφαλικού επεισοδίου πρέπει να είναι απόλυτη προτεραιότητα των ευρωπαϊκών χωρών Επομένως, στοχεύοντας στη βελτίωση των πρακτικών πρόληψης και θεραπείας του εγκεφαλικού επεισοδίου στην Ελλάδα, το Πανεπιστήμιο Μακεδονίας σε συνεργασία με το Κέντρο Αποθεραπείας-Αποκατάστασης «η Αναγέννηση», καθώς και με άλλους ερευνητές, επιχειρεί την προώθηση της ελληνικής εκδοχής της έκθεσης αξιοποιώντας αυτή την πολύτιμη ευκαιρία για ενημέρωση και ανταλλαγή πληροφοριών όχι μόνο με τον ελληνικό πληθυσμό, αλλά και με ενδιαφερόμενους από το χώρο της πολιτικής και με επαγγελματίες που συμμετέχουν στο σχεδιασμό και την οργάνωση των υπηρεσιών υγείας.
... Likewise, the 1-year case fatality varied from 39.1 on the Aeolian Island [12] to 40.2 in Vibo Valentia [11]. In our population, the 30-day and 1-year mortality rates were the lowest reported in Italy [13,14]. Despite this, it could be easy to hypothesise that these differences may be due to an improved global health; however, we must consider that this is the first study to be conducted on this area in 30 years and to compare the results from different geographical areas could lead to unreliable conclusions. ...
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Background: The incidence of stroke in high-income countries has been on the decline; however, few epidemiological surveys have been conducted in recent years to specifically estimate the incidence along with outcome of stroke, in Italy. This study aimed to examine the incidence and case fatality rates of stroke in an elderly Italian population. Methods: A cohort of 2200 people > 65 years was randomly stratified from the total elderly population of Bagheria, Italy. A 9-year prospective population-based study was performed (19,800 person/years). Results: We identified 112 first-ever strokes, 53 females and 59 males: 82 (73.1%) ischemic, 13(11.6%) intracerebral haemorrhages, 6 (5.35%) subarachnoid haemorrhages, while 11(9.8%) were classified as undetermined strokes. The crude overall annual incidence was 5.65 per 1000 (95%CI: 4.61 to 6.70) for first-ever stroke. The overall crude incidence rates were 4.74 per 1000 (5.08 for males and 4.46 for females) for ischemic stroke, 0.65 (0.99 for males and 0.37 for females) for intracerebral haemorrhage, and 0.03 for subarachnoid haemorrhage. The incidence rate for first-ever stroke was 5.4 per 1000 (95% CI: 5.36 to 5.45) after adjustment for the 2015 World population and 5.56 (95% CI: 5.52 to 5.61), compared to the 2015 European population. Overall case fatality rates for first-ever stroke was 8.19% at 28 days and 24.1% at 1 year. Conclusion: Our study shows that in the elderly population investigated, stroke incidence and case fatality rates resulted being lower, compared to those from Italian and most European populations. Similar to previous studies, these rates increased linearly with age and were higher in males.
Article
Objective: This study was performed to assess the incidence, treatment and outcome of non-traumatic Subarachnoid Haemorrhage (SAH) in an island which does not offer a neurovascular service and to determine whether such limitation is associated with a poor outcome. Method: Data of adult patients with a diagnosis of non-traumatic SAH was analysed retrospectively over a two-year period from January 01, 2009 to December 31, 2010. Results: The incidence of SAH in Malta is 3.16 cases per 100 000 population per year. An underlying aneurysm was found in 50% of all cases investigated with angiography. These patients were transported to the United Kingdom for definitve management and the outcome of all these patients at 6 months was excellent. (modified Rankin Scale of 0 or 1). Conclusions: With the incidence of non-traumatic SAH being in the low range, setting up an interventional neuroradiology service in our country to treat aneurysmal SAH would not have the required numbers to maintain expertise and would probably translate into worse clinical outcomes. Despite having geographical and logistic limitations, our standards of care and survival rates are not below those of other international centres. Outcomes for patients with low initial Hunt and Hess scores have not been adversely affected by the lack of a local neurovascular service.
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Stroke is one of the most important causes of mortality and morbidity worldwide and, for a long time, was the leading cause of death in developed countries. Atherothrombotic carotid stenosis is one of the most important etiologies behind this event. If properly recognized and treated, lives can be saved, as well as long-term disabilities prevented. With population aging and improvements in surgical and clinical care, patients with several comorbidities will be referred for revascularization procedures more frequently, posing a challenge for physicians. The purpose of this review is to provide internists and clinicians with information based on several studies so they can offer to their patients, the best evidence-based care, indicating appropriate medical therapy, as well as referral to a vascular surgeon, or what contraindicates endarterectomy or angioplasty, depending on individual characteristics.
Article
Early recognition of stroke symptoms and activation of emergency medical service (EMS) positively affects prognosis after a stroke. To assess stroke awareness among stroke patients and medical personnel in the catchment area of Verona Hospital and how it affects stroke care, we prospectively studied timing of acute stroke care in relation to patients' characteristics. Patients admitted to Medical Departments of Verona University Hospital between January 1st and December 31st 2009 with a diagnosis of TIA or stroke were enrolled. Outcome measures were: time between (i) symptoms onset and hospital arrival, (ii) hospital arrival and brain CT scan, blood examination, ECG and neurological evaluation. The following patient/event characteristics were also collected: means of hospital arrival, sex, age, degree of disability, type of event (first or recurrent) and acute-phase treatment. Of 578 patients providing complete information, 60 % arrived to the emergency department with the EMS (EMS+ group), while 40 % arrived on their own (EMS-). EMS+ group was older than EMS- (mean age 76.2, SD 13.2, vs. 72.3, SD 13, respectively), displayed more severe symptoms (mRS 4 vs. 2) and shorter time interval between symptoms onset and hospital arrival, hospital arrival and CT scan, ECG, laboratory tests and neurological evaluation (p < 0.0001); 22 % of the EMS+ patients were stroke recurrences versus 29 % of the EMS- (p = 0.058); 85 % of thrombolised patients were EMS+. We conclude that there is a lack of awareness of stroke symptoms and risks of recurrence even among patients who already had a stroke and among medical personnel.
Intracerebral hemorrhage (ICH) remains a life-threatening disease that carries significant morbidity and mortality despite recent diagnostic and management advances. Various conditions are associated with increased risk of intracerebral hemorrhage. Understanding the etiology of these conditions and their pathophysiological contribution to ICH will likely lead to better therapeutic and preventative measures and improve the morbidity and mortality associated with intracerebral hemorrhage. We will review the current literature regarding important etiologies/risk factors of intracerebral hemorrhage.
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Cell transplantation is a 'hype and hope' in the current scenario. It is in the early stage of development with promises to restore function in chronic diseases. Mesenchymal stem cell (MSC) transplantation in stroke patients has shown significant improvement by reducing clinical and functional deficits. They are feasible and multipotent and have homing characteristics. This study evaluates the safety, feasibility and efficacy of autologous MSC transplantation in patients with chronic stroke using clinical scores and functional imaging (blood oxygen level-dependent and diffusion tensor imaging techniques). Twelve chronic stroke patients were recruited; inclusion criteria were stroke lasting 3 months to 1 year, motor strength of hand muscles of at least 2, and NIHSS of 4-15, and patients had to be conscious and able to comprehend. Fugl Meyer (FM), modified Barthel index (mBI), MRC, Ashworth tone grade scale scores and functional imaging scans were assessed at baseline, and after 8 and 24 weeks. Bone marrow was aspirated under aseptic conditions and expansion of MSC took 3 weeks with animal serum-free media (Stem Pro SFM). Six patients were administered a mean of 50-60 × 10(6) cells i.v. followed by 8 weeks of physiotherapy. Six patients served as controls. This was a non-randomized experimental controlled trial. Clinical and radiological scanning was normal for the stem cell group patients. There was no mortality or cell-related adverse reaction. The laboratory tests on days 1, 3, 5 and 7 were also normal in the MSC group till the last follow-up. The FM and mBI showed a modest increase in the stem cell group compared to controls. There was an increased number of cluster activation of Brodmann areas BA 4 and BA 6 after stem cell infusion compared to controls, indicating neural plasticity. MSC therapy aiming to restore function in stroke is safe and feasible. Further randomized controlled trials are needed to evaluate its efficacy.
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Introduction: Stroke is the third largest cause of mortality in India after heart attack and cancer. The stroke mortality rates are declining or stabilising in developed countries but there is concern over the emerging epidemic of stroke in India. Study of topographical distribution, seasonal and temporal variations in occurrence of ischemic stroke provides insight into factors that trigger onset of stroke which might lead to more rational treatment.Objective: To assess and categorize anatomical distribution of ischemic strokes, seasonal and diurnal variations in occurrence of stroke.Method: A retrospective analysis of MRI data of patients of Jabalpur Diagnostic Center, Jabalpur M.P. India who were enrolled during 1st January 2010 to 31st December 2010 was performed. The Demographic and medical history from the patients who met WHO criteria for stroke and had undergone MRI were collected and analyzed. We examined MRI data to find out early and late signs of IS and determine topography (cerebral arterial territory). Study subjects were categorized into three groups: young (65 years). Season was categorized as: winter (December–February); summer (March–May); monsoon (June–August); and post monsoon (September-November). Time of onset of ischemic stroke was defined as the time when neurological symptoms were first noticed. It was divided into four subgroups: night (00:00–05:59 hours), morning (06:00-11:59), noon (12:00-17:59) and evening (18:00-23:59). Association between topographical distribution, season, and time of stroke onset were derived.Result: A total of 216 subjects were included (59.3% males and 40.7% females) with median age observed at 58 years (range: 20-80 years). Middle cerebral arterial territory (MCA) was the most commonly affected (38.9%) followed by posterior cerebral artery (PCA) 13%, brainstem 13%, anterior cerebral artery (ACA) lesion in 11.1%, multiple vessel territory 9.3%, small vessel infarcts in 8.4% and cerebellum 6.5%. The rate of occurrence of stroke (33.3%) was highest in morning (0600–1159 hours) irrespective of gender or age of the patient. Summer season recorded significantly higher frequency of IS with 35.2% (P
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Estimation of cost burden of a disease condition is a very important part of health care policy making worldwide. Till now, such documents are lacking especially on non-communicable diseases in the health policy making process in Nigeria. This article therefore attempts to report the results of a prospective cross-sectional study on the cost burden of a cerebrovascular accident condition (stroke) in Nigeria. It estimates the direct health care cost for a minimum period of 12weeks and maximum of 36weeks for post stroke hemiplegia. It was a collaborative cross-sectional study amongst centers situated in urban and sub-urban environments in Southern Nigeria. It involved a hospital of an Oil and Gas Company in Port Harcourt, Nigeria, two Government tertiary hospitals in Port Harcourt and Benin-City, all in South-South Nigeria, the industrial hub of the country. A Private Specialist hospital in Lagos, South-West Nigeria, the corporate hub of the country was also included. Patients diagnosed and admitted for management for cerebrovascular accident (stroke) in the above named health facilities formed the subjects of this study. Medical records (case files) of two hundred and forty (240) stroke patients managed within the last six years (2005- 2011) were randomly selected from the medical record departments of the study centers. Files of the patients who were admitted during acute care period (without discharge against medical advice) and were followed on out-patient basis without default within the study period were purposively utilized. The files were then assessed for the various investigations and treatment interventions of acute and long term care and the costs thereof. Ethical approval to access patients' case files was sought and granted by the Research Ethics Committee of the different study centers. The results revealed that it requires an average of N95,100: 00 ($600 ) and N767,900: 00 ($4860)in a government and a private hospital, respectively to access care within the first 36weeks of post stroke affectation in Nigeria. The outcome of this study suggests that managing stroke constitutes a huge direct cost burden unaffordable by an average Nigerian stroke sufferer. The implication is that lack of means for rehabilitative care may result in disability adjusted life years which further compounds burdens in terms of indirect cost on the sufferers' and care givers' productivity. It is therefore recommended that awareness of this disorder is created by policy makers and implementers where it does not exist and increased where it does with health promotion and preventive measures.
Article
Background and purpose: Prognostic risk factors of haemorrhagic stroke are not yet fully identified. This study investigated clinical factors leading to poor outcome at three months in patients with intracerebral haemorrhage (ICH) in order to better understand the role of clinical features in prognostic evaluation. Subjects and methods: This was a prospective cohort study on patients having ICH admitted to two Italian hospitals (the Stroke Units at "Ospedale Santa Maria della Misericordia", Perugia and "Ospedale C. Poma", Mantua) between January 1, 2006 and June 30, 2010. Results: A total of 470 consecutive ICH patients (mean age 73.89±13.02 years) were included and of these, 241 (51.1%) were males. At three months, 293 (62.3%) patients had poor outcome including 133 (27.6%) deaths. The resulting significant predictors of poor outcome from univariate analysis included: age, NIH Stroke Scale Score (NIHSSS) at admission, hyperglycaemia and the presence of atrial fibrillation (AF). These variables were confirmed in logistic regression analyses as being independent predictors of disability: age (OR 1.04 95% CI, 1.02-1.07, p=0.0001), AF (OR 3.18 95% CI, 1.12-9.05 p=0.03) and NIHSSS (OR 1.38 95% CI, 1.28-1.48, p=0.0001), while elderly age (OR 1.10 95% CI, 1.06-1.14, p≤0.0001) and high NIHSSS (OR 1.25 95% CI, 1.19-1.31, p≤0.0001) resulted being independent predictors of mortality. Conclusions: This study found that severity of ICH, elderly age and AF were independent predictors of poor outcome in ICH patients at three months. Thereby, this highlights the importance of understanding the roles of clinical features in ICH prognostic evaluation.
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It has been recognised for some time that many disorders such as vascular malformations, hypertension, collagen vascular diseases, tumours, eclampsia, central nervous system infection, bacterial endocarditis and blood dyscrasias can cause non-traumatic intracerebral haemorrhage in young adults. Factor XIII deficiency is a rare cause of intracranial bleed. The impressive clinical signs with bleeding starting in the neonatal period (prolonged bleeding from the umbilical cord), followed by severe, life-threatening episodes of intracranial haemorrhage should raise the clinical suspicion of factor XIII deficiency. Tests for factor XIII deficiency in high index clinical suspicious cases despite negative coagulative screening tests are essential for diagnosis. The diagnosis of factor XIII deficiency is difficult but has important therapeutic consequences. We are reporting here the clinical outcome of a young woman with intracranial bleed due to factor XIII deficiency. The patient was managed successfully with fresh frozen plasma transfusion and supportive treatments. The prophylactic substitution therapy of factor XIII (recombinant factor XIII, cryoprecipitate and fresh frozen plasma) enables patients to live normal lives, free from catastrophic bleeding episodes.
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Background: Stroke incidence in high-income countries is reported to decrease, and new data on stroke incidence and outcome are needed to design stroke services and to ameliorate stroke management. Methods: This study is part of a two-year prospective community-based registry of all cerebrovascular events in the district of Udine (153,312 inhabitants), Friuli-Venezia Giulia region, northeast of Italy, between 1 April 2007 and 31 March 2009. Overlapping sources for case finding were used, combining hot and cold pursuit. Results: We identified 784 stroke cases, 640 (81.6%) incident. The crude overall annual incidence rate per 100,000 residents was 256 (95% confidence interval 241-271) for all strokes and 209 (95% confidence interval 195-223) for first-ever strokes. Incidence rate for first-ever strokes was 181 (95% confidence interval 155-211) after adjustment to the 2007 Italian population and 104 (95% confidence interval 88-122) compared with the European standard population. Incidence rates for first-ever strokes was 215 (196-235) for women, 202 (183-223) for men. Crude annual incidence rates per 100,000 population were 167 (153-178) for ischemic stroke, 31 (26-37) for intracerebral hemorrhage, 8.1 (5.7-11.4) for sub-arachnoid hemorrhage, and 4.6 (2.8-7.1) for undetermined stroke. Overall case fatality rates for first-ever stroke were 20.6% at 28 days and 30.2% at 180 days. Conclusions: Our study shows incidence rates higher than previously reported in our region but not supporting the view of higher incidence rates in Northern than in Southern Italy. Results contribute to time-trends analysis on epidemiology, useful for dimensioning services in Italy and show the persistence of a gap between the outcome of stroke in Italy and that of the best performing European countries, urging to adopt better stroke management plans.
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Up to now, the possibility of neurosurgical approach remains one of the main key points in acute management of non traumatic intracranial haemorrhage. The aims of neurosurgical evacuation are represented by stopping bleeding, reducing haematoma enlargement, endocranial hypertension and mass effect, and improving cerebral perfusion. In the acute phase of intracranial bleeding, neurosurgeons are called to take critical decisions about the indication or exclusion of surgical approach and this kind of choices can be very difficult. Only a minority of patients suffering from intraparenchimal bleeding undergo urgent surgical evacuation. This decision is based on the presence or the absence of mass effect, occlusion of liquoral flow associated to impairment of vigilance, sites of hematoma surgically accessible and good performance status. In patients suffering for subarachnoid haemorrhage, mainly due to rupture of aneurisms or artero-venous malformations, the percentage of surgery increases together with the possibility of the elective approach.
Article
We determined incidence and intra-hospital mortality rate of stroke in Molise, Italy, to provide information for planning regional healthcare facilities and to ameliorate stroke management in this region. This study is part of the "Rete Molisana dell’Ictus Cerebrale (REMOLIC)” study, a population-based Cerebrovascular Registry in Molise, from 2009 to 2013, with a cold pursuit approach. The crude annual incidence rates for total stroke per 100,000 inhabitants, notified by hospital discharge records, were 198 for 2009, 185 for 2010, 169 for 2011, and 176 for both 2012 and 2013. There was a significant decrease in risk in the years 2011–2013 [RR2011 vs. 2009: 0.85 (0.76–0.98), RR2012 vs. 2009: 0.89 (0.79–0.99), RR2013 vs. 2009: 0.89 (0.79–0.99)] as compared with 2009. For the year 2010, after adjustment to the Italian, European, and world populations, the overall incidence rates were 165, 134, and 67 per 100,000/year, respectively. Similar trends were found when men and women were analyzed separately. In the average, 20.8 % of subjects admitted for a cerebrovascular accident died during the hospitalization, among these 93.5 % in the first 28 days. The duration of hospital stay was constant in the years (2009–2012), except during 2013, where there was a significant decrease in the average (p < 0.001). Our study shows incidence rates decreasing from 2009 to 2013, while mortality rates were stable during the same years. This study underlines the need to plan better stroke management in Italy, in order to obtain outcomes more similar to those of the best performing countries.
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Introduction: Previous research has reported impaired hand function on the “unaffected” ipsilateral side after stroke, but its incidence, origins, and impact on rehabilitation remain unclear. Ipsilateral side deficits are usually not given much importance in stroke rehabilitation. The objective of this study is to evaluate the ipsilateral upper extremity muscle strength and grip strength and compare it with normal individuals. Materials and Methods: A comparative study was done by convenient sampling of 50 subjects of ischemic stroke of 1 month duration and 60 normal subjects matched with age, sex and hand dominance with the stroke subjects were taken for the study. Ipsilateral upper extremity muscle strength and grip strength of stroke subjects and corresponding normal were assessed using Hand Dynamometer and Manual Muscle Testing. Results: There was significant difference between the ipsilateral upper extremity muscle strength and grip strength of stroke subjects and that of normal (p< 0.05) independent of the side of lesion. Conclusion: The ipsilateral upper limb which is considered normal is also affected after stroke not only in dexterity of hand as stated earlier by other researchers but also in the muscle strength as well as in the grip strength regardless of the side of involvement. Key words: Stroke, Ipsilateral Upper Extremity, Manual Muscle Testing, Hand Dynamometer.
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Quality monitoring has great relevance in stroke care. The Project "How to guarantee adherence to effective interventions in stroke care" aimed to estimate adherence to acute-phase guidelines in stroke care in Italy. A prospective observational study was performed in 27 hospitals of 13 Italian Regions. Adherence to 15 process indicators was evaluated, comparing also stroke units (SU) with conventional wards. An overall score of care, defined as the sum of achieved indicators, was calculated. A multilevel hierarchical model described performance at patient, hospital and regional level. Overall, 484 consecutive stroke patients (mean age, 73.4 years; 52.7 % males) were included. Total score ranged from 2 to 15 (mean 8.5 ± 2.4). SU patients were more often evaluated with the National Institutes of Health Stroke Scale (NIHSS) within 24 h, had more frequently an assessment of pre- and post-stroke disability, and a CT scan the same or the day after admission. Regional-hospital- and patient-level variability explained, respectively, 25, 34, and 41 % of total score variance. In multivariate models, patients >80 years vs. younger showed a change in total score of -0.45 (95 % CI -0.79 to -0.12), and those with NIHSS ≥14 vs. ≤5 of -0.92 (95 % CI -1.53 to -0.30). A negative change means a worse adjusted average adherence to process indicators. SU admission increased total score of 1.55 (95 % CI 0.52-2.58). Our data confirm the need of quality monitoring in stroke care. Although SU patients showed a better adherence to quality indicators, overall compliance was unsatisfactory.
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There is a growing body of literature about the efficacy in neurorehabilitation of the devices providing rhythmic auditory stimulations or visual-auditory stimulations, such as videogames, for guiding the patients' movements. Despite being presented as tools able to motivate patients, their efficacy was not been proven yet, probably due to the limited knowledge about the factors influencing the capability of patients to move the upper limbs following an external stimulus. In this study, we used a marker less system based on two infrared sensors to assess the kinematics of up and down in-phase and anti-phase bilateral hand oscillations synchronized or not with an external stimulus. A group of stroke survivors, one of age-matched healthy subjects and one of young healthy subjects were tested in three conditions: no stimulus, auditory stimulus, and video-auditory stimulus. Our results showed significant negative effects of visual-auditory stimulus in the frequency of movements (p = 0.001), and of auditory stimulus in their fluidity (p = 0.013). These results are conceivably related to the attentional overload required during the execution of bilateral movements driven by an external stimulus. However, a positive effect of external stimulus was found in increasing the range of movements of the less functional hand in all subjects (p = 0.023). These findings highlight as the type of stimulus may play a crucial role in the patient's performance with respect to movements that are not-externally driven.
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Background and purpose: The incidence and case-fatality rate (CFR) of primary intracerebral hemorrhage (PICH) over two decades were assessed in a prospective population-based study. Methods: Cases of incident first-ever PICH were recorded over a 2-year period (2011-2012) from multiple sources in the district of L'Aquila, central Italy. Included patients were followed up to 1 year after the event to ascertain CFRs. Current data were compared with those previously collected from 1994 through 1998. Results: In all, 115 patients (52 men; 45.2%) with a first-ever PICH were included. Mean age ± SD was 77.4 ± 11.8 years. The hemorrhage was lobar in 43 (37.4%) patients, deep in 56 (48.7%), in the posterior fossa in 11 (9.6%) and intraventricular or multiple localized in five (4.3%). Crude annual incidence rate was 19.3 per 100 000 and 14.8 per 100 000 when standardized to the 2011 European population, indicating a 48% reduction comparing data of 2011-2012 to those of 1994-1998 (incidence rate ratio 0.52; 95% confidence interval 0.43-0.64; P < 0.001). In 2011-2012, the 7-day CFR was 27.8%, the 30-day CFR was 42.6% and the 1-year CFR was 52.2%; the 1-year standardized mortality ratio was 0.81 (95% confidence interval 0.63-1.04) compared with 1994-1998. Conclusions: The annual incidence rate of PICH was lower than that found two decades before and close to the rates recently found in other western countries. Data also indicated a non-significant trend towards a decrease in mortality, which nonetheless remained high, pointing to the need for more appropriate treatments in order to reduce PICH severity and mortality.
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Up to now, the possibility of neurosurgical approach remains one of the main key points in acute management of non traumatic intracranial haemorrhage. The aims of neurosurgical evacuation are represented by stopping bleeding, reducing haematoma enlargement, endocranial hypertension and mass effect, and improving cerebral perfusion. In the acute phase of intracranial bleeding, neurosurgeons are called to take critical decisions about the indication or exclusion of surgical approach and this kind of choices can be very difficult. Only a minority of patients suffering from intraparenchimal bleeding undergo urgent surgical evacuation. This decision is based on the presence or the absence of mass effect, occlusion of liquoral flow associated to impairment of vigilance, sites of hematoma surgically accessible and good performance status. In patients suffering for subarachnoid haemorrhage, mainly due to rupture of aneurisms or artero-venous malformations, the percentage of surgery increases together with the possibility of the elective approach.
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Aphasia is the partial or complete loss of language skills in its production and/or comprehension processes, resulting from an acquired brain injury or degenerative condition. When a person is confronted by the challenges of aphasia, their quality of life can be undermined through simultaneous neurological, psychological and psycho-social difficulties. Aphasia risks reducing the influence which a person can exercise on what was once a two-way interaction. In the eyes of others, it is probable that people with aphasia will be found to be of unsound mind, instead of being perceived as interlocutors with expressive abilities and a brain which still thinks. Communication can be understood as a “joint activity of actor and partner, who consciously and intentionally cooperate to build together the meaning of their interaction”. The agents of the interaction are together and to the same extent actively engaged in the construction of a shared meaning. What happens when a person totally or partially loses the possibility of being considered by the other as an active subject in the linguistic communicative interaction? Which consequences does the compromising of the linguistic activity involve in the other aspects of life? Even after the conclusion of functional rehabilitation programs, these people may find themselves faced with a radical change in their identity, which seems to promise limited future expectations in the social and physical activities, as a consequence established by the disability. The characteristics of aphasia are also unique when compared with other forms of impairment and disability. It is hardly recognizable and very different both from person to person and from moment to moment, even in the same person because it depends on the levels of stress and fatigue. Persons with aphasia who do not report visible physical damages seem to find themselves at a crossroads in different public situations. The choice of a person with aphasia is between withdrawing from relationships “because aphasia is a difficult problem to explain” or risking and exposing himself, often perceiving his condition as a fault: “Excuse me, but I am aphasic.
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Today neurological diseases such as stroke represent one of the leading cause of long-term disability. Many research efforts have been focused on designing new and effective rehabilitation strategies. In particular, robotic treatment for upper limb stroke rehabilitation has received significant attention due to its ability to provide high-intensity and repetitive movement therapy with less effort than traditional methods. In addition, the development of non-invasive brain stimulation techniques such as transcranial Direct Current Stimulation (tDCS) has also demonstrated the capability of modulating brain excitability thus increasing motor performance. The combination of these two methods is expected to enhance functional and motor recovery after stroke; to this purpose, the current trends in this research field are presented and discussed through an in-depth analysis of the state-of-the-art. The heterogeneity and the restricted number of collected studies make difficult to perform a systematic review. However, the literature analysis of the published data seems to demonstrate that the association of tDCS with robotic training has the same clinical gain derived from robotic therapy alone. Future studies should investigate combined approach tailored to the individual patient's characteristics, critically evaluating the brain areas to be targeted and the induced functional changes.
Purpose A clinical pathway for patients with acute ischemic stroke was implemented in 2014 by one Italian teaching hospital multidisciplinary team. The objective was to determine whether this clinical pathway had a positive effect on patient management by comparing performance data. Design/methodology/approach Volume, process and outcome indicators were analysed in a pre-post retrospective observational study. Patients’ (admitted in 2013 and 2015) medical records with International Classification of Diseases, ICD-9 code 433.x (precerebral artery occlusion and stenosis), 434.x (cerebral artery occlusion), and 435.x (transient cerebral ischemia) and registered correctly according to hospital guidelines were included. Findings An increase context-sensitive in-patient numbers with more severe cerebrovascular events and an increase in patient transfers from the Stroke to Neurology Unit within three days (70%, p=0.25) were noted. Clinical pathway implementation led to an increase in patient flow from the Emergency Department (ED) to dedicated specialized wards such as the Stroke and Neurology Unit (SaNU) (23.7%, p<0.001). Results revealed no statistically significant decrease in readmission rates within 30 days (5.7%, p=0.85) and no statistically significant differences in 30-day mortality. Research limitations/implications The pre-post retrospective observational study design was considered suitable to evaluate likely changes in patient flow after clinical pathway implementation, even though this design comes with limitations, describing only associations between exposure and outcome. Originality/value Clinical pathway implementation showed an overall positive effect on patient management and service efficiency owing to the standardized application in time-dependent protocols and multidisciplinary/integrated care implementation, which improved all phases in acute ischemic stroke care.
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Stroke as a cause of long-term disability is a growing public health burden. Therefore, focusing on prevention is important. The most prominent aim of this strategy is to treat modifiable risk factors, such as arterial hypertension, the leading modifiable contributor to stroke. Thus, efforts to adequately reduce Blood Pressure (BP) among hypertensives are mandatory. In this respect, although safety and benefits of BP control related to long-term outcome have been largely demonstrated, there are open questions that remain to be addressed, such as optimal timing to initiate BP reduction and BP goals to be targeted. Moreover, evidence on antihypertensive treatment during the acute phase of stroke or BP management in specific categories (i.e. patients with carotid stenosis and post-acute stroke) remain controversial. This review provides a critical update on the current knowledge concerning BP management and stroke pathophysiology in patients who are either at risk for stroke or who experienced stroke.
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Antiplatelets, antihypertensives, and statins might reduce the severity of the event or improve outcome in patients who, despite prior medical treatment, have a stroke. We evaluated, in patients who had an ischemic stroke, the effect, on stroke severity and outcome, of prior treatment with antiplatelets, antihypertensives, and statins, used either alone or in a three-drug combination. Stroke in Italy and Related Impact on Outcome (SIRIO) was a prospective, nationwide, multicenter, hospital-based, observational study that included patients aged.18 years with acute ischemic stroke. We studied 2,529 acute ischemic stroke patients from the SIRIO population: 887 were antiplatelet users, 1,497 antihypertensive users, 231 statin users, and 138 three-drug combination users prior to the index event. The adjusted logistic regression analysis showed an association between prior treatment with statins and good functional outcome at discharge, while prior treatment with antiplatelets, antihypertensives or the three-drug combination did not influence severity or outcome. The absolute probability of a good functional outcome was 46.3% (95% CI: 40.3%-53.2%) in statin users and 36.7% (95% CI: 34.7%-38.7%) in non-users of statins; the absolute risk difference was 9.6% (95% CI: 2.9%-16.4%; p=0.004). Prior treatment with antiplatelets, antihypertensives, or the three-drug combination did not influence stroke severity or outcome, while prior treatment with statins did not influence stroke severity but was associated with a better functional outcome.
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Background and Purpose: Data on stroke morbidity are lacking in southern Italy, an area with about 20 million inhabitants and a mean income lower than the rest of the country. Therefore a population-based stroke register was established to determine incidence and case fatality in the Province of Vibo Valentia, Calabria. Methods: The survey was conducted among the 179,186 residents. Standard definitions and multiple case-finding procedures were employed. All identified cases of first-ever stroke were followed at 28 days, 3 and 12 months. The registration started on January 1, 1996, and ended on December 31, 1996. Results: A total of 321 first-ever-in-a-lifetime strokes were identified. The crude annual incidence rate was 1.79 (95&percnt; CI 1.60–1.99) per 1,000 inhabitants. Rates age-standardized to the 1996 Italian population and to the standard European population were, respectively, 1.99 (95&percnt; CI 1.79–2.20) and 1.36 (95&percnt; CI 1.19–1.53) per 1,000 inhabitants. A subtype diagnosis was reached in 96&percnt; of patients. The crude annual incidence rates per 1,000 inhabitants were 1.31 for cerebral infarction, 0.35 for intracerebral hemorrhage, 0.06 for subarachnoid hemorrhage, and 0.07 for unspecified stroke. Overall case fatality was 23.7&percnt; at 28 days, 27.4&percnt; at 3 months and 40.2&percnt; at 12 months. Conclusions: This is the first prospective population-based stroke register established in southern Italy. Incidence and case fatality were comparable to those previously reported in northern and central Italy and other industrialized countries. Our estimates are useful for developing management services and allocating resources.
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Few studies have evaluated the relationship between fruit and vegetable intake and cardiovascular disease. To examine the associations between fruit and vegetable intake and ischemic stroke. Prospective cohort studies, including 75 596 women aged 34 to 59 years in the Nurses' Health Study with 14 years of follow-up (1980-1994), and 38683 men aged 40 to 75 years in the Health Professionals' Follow-up Study with 8 years of follow-up (1986-1994). All individuals were free of cardiovascular disease, cancer, and diabetes at baseline. Incidence of ischemic stroke by quintile of fruit and vegetable intake. A total of 366 women and 204 men had an ischemic stroke. After controlling for standard cardiovascular risk factors, persons in the highest quintile of fruit and vegetable intake (median of 5.1 servings per day among men and 5.8 servings per day among women) had a relative risk (RR) of 0.69 (95% confidence interval [CI], 0.52-0.92) compared with those in the lowest quintile. An increment of 1 serving per day of fruits or vegetables was associated with a 6% lower risk of ischemic stroke (RR, 0.94; 95 % CI, 0.90-0.99; P =.01, test for trend). Cruciferous vegetables (RR, 0.68 for an increment of 1 serving per day; 95% CI, 0.49-0.94), green leafy vegetables (RR, 0.79; 95% CI, 0.62-0.99), citrus fruit including juice (RR, 0.81; 95% CI, 0.68-0.96), and citrus fruit juice (RR, 0.75; 95% CI, 0.61-0.93) contributed most to the apparent protective effect of total fruits and vegetables. Legumes or potatoes were not associated with lower ischemic stroke risk. The multivariate pooled RR for total stroke was 0.96 (95% CI, 0.93-1.00) for each increment of 2 servings per day. These data support a protective relationship between consumption of fruit and vegetables-particularly cruciferous and green leafy vegetables and citrus fruit and juice-and ischemic stroke risk.
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This systematic review of population-based studies of the incidence and early (21 days to 1 month) case fatality of stroke is based on studies published from 1970 to 2008. Stroke incidence (incident strokes only) and case fatality from 21 days to 1 month post-stroke were analysed by four decades of study, two country income groups (high-income countries and low to middle income countries, in accordance with the World Bank's country classification) and, when possible, by stroke pathological type: ischaemic stroke, primary intracerebral haemorrhage, and subarachnoid haemorrhage. This Review shows a divergent, statistically significant trend in stroke incidence rates over the past four decades, with a 42% decrease in stroke incidence in high-income countries and a greater than 100% increase in stroke incidence in low to middle income countries. In 2000-08, the overall stroke incidence rates in low to middle income countries have, for the first time, exceeded the level of stroke incidence seen in high-income countries, by 20%. The time to decide whether or not stroke is an issue that should be on the governmental agenda in low to middle income countries has now passed. Now is the time for action.
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The SEPIVAC study is a community-based epidemiological survey of incidence and outcome of acute cerebrovascular disease in the Sixth Local Health Unit, Umbria, Italy (population 49,218). The study was carried out from 1 September 1986 to 31 August 1989. There were 375 patients who were registered with a first ever stroke, with a crude rate of 2.54 (95% confidence limits 2.29-2.81) per 1000 per year; the rate adjusted to the European population is 1.55 (CL 1.36-1.77). The age adjusted relative risk for males is 1.35 (CL 1.10-1.66). Up to 15% of the patients were not admitted to hospital during the acute phase of their disease. At least 286 (76.3%, CL 72-80.6) of the cases were due to cerebral ischaemia; in 56 of these (19.6%, CL 15-24.2) a clinical diagnosis of lacunar ischaemia was made. The 30 day case fatality rate was 20.3% (CL 16.2-24.3); between one and six months 7.5% (CL 5-10.6) of patients died.
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Data on stroke morbidity are lacking in southern Italy, an area with about 20 million inhabitants and a mean income lower than the rest of the country. Therefore a population-based stroke register was established to determine incidence and case fatality in the Province of Vibo Valentia, Calabria. The survey was conducted among the 179186 residents. Standard definitions and multiple case-finding procedures were employed. All identified cases of first-ever stroke were followed at 28 days, 3 and 12 months. The registration started on January 1, 1996, and ended on December 31, 1996. A total of 321 first-ever-in-a-lifetime strokes were identified. The crude annual incidence rate was 1.79 (95% CI 1.60-1.99) per 1000 inhabitants. Rates age-standardized to the 1996 Italian population and to the standard European population were, respectively, 1.99 (95% CI 1.79-2.20) and 1.36 (95% CI 1.19-1.53) per 1000 inhabitants. A subtype diagnosis was reached in 96% of patients. The crude annual incidence rates per 1000 inhabitants were 1.31 for cerebral infarction, 0.35 for intracerebral hemorrhage, 0.06 for subarachnoid hemorrhage, and 0.07 for unspecified stroke. Overall case fatality was 23.7% at 28 days, 27.4% at 3 months and 40.2% at 12 months. This is the first prospective population-based stroke register established in southern Italy. Incidence and case fatality were comparable to those previously reported in northern and central Italy and other industrialized countries. Our estimates are useful for developing management services and allocating resources.
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Higher proportions of hemorrhagic stroke and lacunar infarction were reported in rural Japan compared with those in Western countries. We examined the relative proportions of stroke subtypes in an urban Japanese city where westernized lifestyles are more common than in rural areas. Stroke registration was performed in 1992, 1997, and 2002 for residents > or =40 years of age who were admitted with acute strokes to all of the 10 hospitals with > or =90 beds in Yao City, Osaka, Japan. Strokes were classified as intraparenchymal hemorrhage, subarachnoid hemorrhage, or ischemic strokes (embolic infarction, large-artery occlusive infarction, lacunar infarction, and unclassified thrombotic infarction) by criteria using computed tomography or MRI. A total of 650 first-ever strokes were registered. The age-adjusted proportion of each stroke subtype was not significantly different among the 3 study periods in both men and women. Throughout the 3 periods, intraparenchymal hemorrhage, subarachnoid hemorrhage, and ischemic stroke accounted for 26%, 7%, and 65% in men, respectively. In women, the respective proportions were 29%, 21%, and 44%. The proportion of each subtype for total ischemic strokes was as follows: 51% to 61% lacunar infarction, 25% to 26% large-artery occlusive infarction, and 11% to 17% embolic infarction. Our study showed that hemorrhagic stroke represented a large proportion of all strokes, especially among women, and lacunar infarction was the most common subtype of ischemic stroke among both men and women in Yao City, which differed from findings in Western countries.
Article
Introduction: Stroke is the second leading cause of death worldwide and the third in most Western countries. Stroke also represents the leading cause of adult disability maintaining a relevant economic burden in terms of health care costs and lost productivity. Methods: The L'Aquila registry was aimed to evaluate stroke incidence, risk factors, comorbidities, mortality, and recurrences in a well-defined and stable population and to compare local data with regional, national, and international data in order to formulate guidelines for patients at risk of stroke and to improve the organization of health services and of medical care. All patients living in the L'Aquila district with a first-ever stroke in a 5-year period were included in the prospective registry. The registry complies with established criteria for stroke incidence studies. Results: From January 1994 up to December 1998, 4,353 patients (2,049 men and 2,304 women: mean age 74.8±11.4 years) with a first-ever stroke were included in the registry. Eighty-eight percent of the patients had neuroimaging studies of the brain. The occurrence of subarachnoid hemorrhage, intracerebral hemorrhage, cerebral infarction, and ill-defined events was 2.7%, 13.5%, 82.6%, and 1.2%, respectively. Crude annual incidence of first-ever stroke was 2.93/1,000 (95% confidence interval [CI], 2.90-2.96) and 2.34/1,000 after standardization to the 1996 European population. The incidence increased with age and was 24.89/1,000 in patients aged over 85 years of age. Annual incidence rates progressively increased from 2.75/1,000 in 1994 up to 3.19 in 1998 with a mean increase of 1.76% per year. The increase was particularly evident for ischemic stroke and more pronounced for women aged over 85 years of age (8.52% per year; P=0.0213). The 30-day case-fatality rate was 25.9% (95% CI, 24.6-27.2). The 1-year case-fatality rate was 37.9% (95% CI, 36.5-39.4). Case-fatality rates were higher for intracerebral hemorrhage than for cerebral infarction at 30 days (48.1% vs 21.2%) and at 1 year (57.7% vs 33.8%). Conclusions: So far, the L'Aquila registry is the largest population-based stroke registry, covering the full spectrum of the disease. We found a high stroke incidence, and an icreasing stroke incidence trend, especially in the older age subgroups, suggesting that rather than declining, stroke is only postponed until later in life.
Article
The SEPIVAC study is a community-based epidemiological survey of incidence and outcome of transient ischaemic attacks (TIAs) and strokes in the territory of the 6th Local Health Unit, Umbria, Italy, where 49218 people live, from 1 September 1986 to 31 August 1989. All cases were registered with the study either by notification from general practitioners (GPs) or by a check of hospital admission within the study area and in the two hospitals of Perugia. There were 94 incident cases of TIAs (45 males, 49 females), thus giving a crude rate of 0.64 per 1000 per year [95% conficence intervals (CI) 0.52/0.78]. The rate adjusted to the European population is 0.42 (CI 0.33/0.54). Mean age was 69.4 years, and females were significantly older than males. The weighted relative risk for males was 1.19 (CI 0.79/1.79). Thirty-one patients were treated at home by their GPs. Females had hypertension more frequently than males, whereas males smoked more frequently; we did not find any other statistically significant difference in the distribution of risk factors. Twelve patients out of 58 who had CT had an infarct, and 29 out of 54 submitted to Doppler ultrasonography had carotid stenosis. At 1 month, 4 patients had suffered an ischaemic stroke, 1 of whom died. At 6 months, 3 further strokes and 2 further deaths (1 due to myocardial infarction) had occurred.
Article
If the pace of increase in life expectancy in developed countries over the past two centuries continues through the 21st century, most babies born since 2000 in France, Germany, Italy, the UK, the USA, Canada, Japan, and other countries with long life expectancies will celebrate their 100th birthdays. Although trends differ between countries, populations of nearly all such countries are ageing as a result of low fertility, low immigration, and long lives. A key question is: are increases in life expectancy accompanied by a concurrent postponement of functional limitations and disability? The answer is still open, but research suggests that ageing processes are modifiable and that people are living longer without severe disability. This finding, together with technological and medical development and redistribution of work, will be important for our chances to meet the challenges of ageing populations.
Article
To evaluate incidence, case fatalities and prognosis of subarachnoid hemorrhage (SAH). Subjects and Prospective population-based registry (1994-1998) including patients with a first-ever stroke followed up to 10 years. In a 5-year period we included 118 patients (55 men and 63 women; mean age +/- SD 60.7 +/- 15.9 years) with an SAH. The crude annual incidence rate was 7.93 cases per 100,000 inhabitants (95% CI 6.46-9.63), 7.60 per 100,000 when standardized to the 2006 European population and 5.27 per 100,000 when standardized to the 2005 world population. The 7-day case-fatality rate was 16.1% (95% CI 9.5-22.7), 30-day case-fatality rate was 34.7% (95% CI 21.2-43.3), and 1-year case-fatality rate was 44.9% (95% CI 35.9-53.9). At the end of the 1-year follow-up, 53 patients (44.9%) had a good recovery [modified Rankin scale (mRS) 0-2] and 12 (10.2%) had a severe disability (mRS 3-5). The 10-year survival rate was 46.4% (95% CI 36.0-57.8). In our district, the SAH incidence rate was similar to what is reported in most European countries. Since more than half of the patients with SAH remained severely disabled or died, results from our population-based study strongly support the notion that the most appropriate treatments should be made available for all patients in comprehensive centers and the call for an urgent implementation of telemedicine in the rural areas of our district.
Article
The purpose of this study was to evaluate the incidence and prognosis of intracerebral hemorrhage. We analyzed data referring to our prospective population-based registry, including patients with a first-ever stroke followed up to 10 years. In a 5-year period, we included 549 patients (247 men and 302 women; mean age+/-SD, 73.6+/-12.5 years) with an intracerebral hemorrhage. The crude annual incidence rate was 36.9 per 100000 (95% CI, 33.8 to 40.0), 32.9 per 100000 when standardized to the 2006 European population, and 15.9 per 100000 when standardized to the world population. The case-fatality rate was 34.6% (95% CI, 30.6 to 38.6) at 7 days; it increased to 50.3% (95% CI, 46.1 to 54.5) at 30 days and to 59.0% (95% CI, 54.9 to 63.1) at 1 year. Diabetes mellitus and posterior fossa hemorrhage were associated with an increased risk of 7- and 30-day mortality, whereas older age was associated with an increased risk of 30-day mortality only. At the Kaplan-Meier analysis, the 10-year survival rate was 24.1% (95% CI, 20.1 to 28.1). Intracerebral hemorrhage is characterized by a severe prognosis, mostly in the short term. Because of the high proportion of fatal events that occurs early after the stroke, it is mandatory to identify and apply specific therapeutic strategies for patients with intracerebral hemorrhage.
Article
Although a lower incidence of stroke has been observed in the Mediterranean area compared to other European countries, this is based on only a few studies. We sought to determine the incidence and 28-day case-fatality of stroke through a population-based stroke register in a rural area in Southern Italy, characterized by a stroke unit in the referral hospital. We established a multisource prospective population-based register in a well defined geographic area of 38 735 inhabitants in Puglia, Southern Italy. We identified all subjects in the study area with a first-ever stroke between January 1, 2001 and December 31, 2002. We identified 127 first-ever strokes (77 males, 50 females) during the two-year study period. Hospitalization was 95%: 92 cases (72.4%) were cerebral infarction, 24 (18.9%) intracerebral hemorrhage, 3 (2.4%) subarachnoid hemorrhage, and 8 (6.3%) were unclassifiable strokes. The overall crude annual incidence was 1.6 per 1000 (95%CI: 1.4 to 1.9), 2.0 for males (95% CI:1.6 to 2.5), and 1.3 for females (95% CI:0.9 to 1.6). The incidence rates standardized to the 2001 European and world populations were respectively 1.5 (2.0 for males and 1.3 for females) and 0.8 (0.9 for males and 0.6 for females). Incidence rates progressively increased with age in both sexes, reaching their peak at 85 years or more (21.4/1000 overall, 35.0 for men and 13.4 for women). The 28-day case-fatality was 18.1%. Our study supports previous findings of lower incidence of stroke in the Mediterranean area, whereas the case-fatality in our study was lower than in previous studies from Italy. Further studies are needed to determine the role of prompt referral and stroke units on prognosis in population-based setting.
Article
We sought to determine the incidence rate, risk factors, and prognosis of stroke in Valle d'Aosta, Italy, to provide information for planning regional health-care facilities. We undertook a prospective study of all new cases of stroke in the geographically defined population of 114,325 residents of Valle d'Aosta in northern Italy. In the first year of the study (January 1-December 31, 1989), 254 cases of first stroke were registered. The crude annual incidence rate was 2.23/1,000, 1.98/1,000 for men and 2.46/1,000 for women. After adjustment to the 1988 Italian population, the incidence rate for first stroke was 2.15/1,000 per year, 2.48/1,000 per year for men and 1.99/1,000 per year for women. The pathological diagnosis was cerebral infarction in 67%, intracranial hemorrhage in 15%, and unknown in 18%. The overall 30-day case-fatality rate was 31%. In survivors, Barthel Index Score recorded at 30 days from stroke onset showed that 100 patients (62%) were dependent in activities of daily living. Our results do not differ significantly from those reported in Umbria, the only similar study performed in Italy, and support non-Italian data as to risk factors in stroke.
Article
The SEPIVAC study (Italian initials for "epidemiologic study of incidence of acute cerebrovascular disease") is a community-based epidemiologic survey of incidence and outcome of cerebrovascular disease in the territory of the 6th Local Health Unit, Umbria, Italy, where 49,101 people live. All cases were registered with the study either by notification from general practitioners or by check of hospital admission within the study area and in the two hospitals of Perugia. Death certificates were looked at as well. Patients were registered with the study when the clinical picture fulfilled the definition of stroke and transient ischemic attack (TIA) adopted for this study. Patients were followed up at approximately 30 days and 6 months. During the first year of the study (September 1, 1986 to August 31, 1987), 189 cases were registered: 108 suffered a "first ever in a lifetime" stroke, 30 a recurrent stroke, and 51 a "first ever in a lifetime" transient ischemic attack. Sixty-one percent of patients (71% of first strokes) had a computed tomography scan. For our study, the crude annual incidence rate of first stroke was 2.2 per 1,000 (confidence intervals 1.81-2.66); the standardized rate to the European population was 1.36 (confidence intervals 1.06-1.74). At least 83% of first strokes were due to cerebral ischemia; in 26 cases a clinical diagnosis of lacunar ischemia was made. The 30-day case fatality rate was 21%; 25% of our patients had recovered completely or almost completely after 1 month.
Article
We sought to register the incidence rate, risk factors, and case-fatality rate of all the new cases of first-ever-in-a-lifetime stroke in the province of Beluno, Italy. This study aimed to provide an epidemiological survey of cerebrovascular disease that could supply investigative objectives and support information for regional healthcare facilities planning. We undertook a prospective population-based study in the territory of the 1st, 2nd, 3rd, and 4th local health units in the province of Belluno, an area located in northeast Italy (population, 211 389). In the first year of the study (June 1, 1992, to May 31, 1993), 474 cases of first-ever stroke were registered. The crude annual incidence rate was 2.24/1000 (2.01/1000 for men and 2.45/1000 for women). After adjustment to the European population, the incidence rate for first stroke was 1.70/1000 per year. The pathological diagnosis was confirmed by a CT scan in 89.5% of cases. Cerebral infarction accounted for 319 cases, while 93 patients suffered a primary intracerebral hemorrhage, 12 patients a subarachnoid hemorrhage, and 50 patients a stroke of unknown origin. The overall 30-day case-fatality rate was 33%, and the mortality within the first week from stroke onset was 23%. The recurrence rate after 1 month was 1.9%. After 1 month, 46% of our patients were functionally independent in activities of daily living. Our first-year results confirm the fairly high risk for stroke in central and northern Italy and support European findings regarding risk factors for stroke.
Article
Comparing stroke rates in different parts of the world and at different points in time may increase our understanding of the disease. Comparisons are only meaningful if they are based on studies that use similar definitions, methods, and data presentation. We discuss the criteria that make such studies comparable, drawing on the experiences of recent studies performed around the world. If only those studies that fulfill the proposed criteria for comparison are considered, comparable data do not exist for vast areas of the world, including Africa, Asia, and South America. The importance of complete, community-based case ascertainment, including strokes managed outside the hospital, is emphasized. An approach for measuring and comparing the incidence of the pathological types of stroke (cerebral infarction, primary intracerebral hemorrhage, and subarachnoid hemorrhage) and subtypes of cerebral infarction is suggested. The "ideal" stroke incidence study does not exist, but studies closely approaching it will reveal the most reliable and comparable results. There is a need for further studies to fill the gaps in our knowledge of the worldwide incidence of stroke, particularly for developing countries.
Article
Comparing stroke rates in different parts of the world may increase our understanding of both etiology and prevention. However, comparisons are meaningful only if studies use standard definitions and methods, with comparably presented data. We compared the incidence of stroke and its pathological types (cerebral infarction, primary intracerebral hemorrhage, and subarachnoid hemorrhage) in recent studies from around the world. Studies with a midyear of 1984 or later, fulfilling standard criteria for a comparable, community-based study, provided original data for comparative analyses. By mid-1995, data were available from 11 studies in Europe, Russia, Australasia, and the United States, comprising approximately 3.5 million person-years and 5575 incident strokes. Age- and sex-standardized annual incidence rates for subjects aged 45 to 84 years were similar (between approximately 300/100,000) and 500/100,000) in most places but were significantly lower in Dijon, France (238/100,000), and higher in Novosibirsk, Russia (627/100,000). In subjects aged 75 to 84 years, however, Novosibirsk no longer ranked higher than the other studies. The distribution of pathological types, when these were reliably distinguished, did not differ significantly between studies. The similarities in stroke incidence and pathological types are perhaps not surprising given that all the populations were westernized and mainly white. The higher rates in Novosibirsk, disappearing in the elderly, and the lower rates in Dijon have several potential explanations. These include methodological artifact and different patterns of population risk factors. Further work is needed to explore these possibilities and to extend our knowledge of stroke incidence to other parts of the world, especially developing countries.
Article
Changes in stroke incidence are likely to occur as a consequence of aging of the population, but evidence for this hypothesis is lacking. A prospective community-based registry of first-ever strokes (1994 to 1998) classified according to the International Classification of Diseases, 9th Revision (ICD-9) was established in the L'Aquila district, central Italy, with a total population of 297,838 (1991 census). Patients were identified by active monitoring of multiple sources, including general practitioners. In 1994, 819 patients (398 men and 421 women; mean +/- SD age, 74.8 +/- 11.3 years) suffered from a first-ever stroke. Eighty-nine percent of the patients had neuroimaging studies of the brain and were reclassified with the recent Application of the International Classification of Diseases to Neurology (ICD-10 NA). The occurrence of subarachnoid hemorrhage, intracerebral hemorrhage, cerebral infarction, and ill-defined events was 2.9%, 14.9%, 80.2%, and 2.0%, respectively. Crude annual incidence of first-ever stroke was 2.75/1000 (95% confidence interval [CI], 2.57 to 2.94) and 24.23/1000 (95% CI, 21.65 to 27.10) in patients older than 80 years. Incidence rates were higher in men and steeply increased with age. The standardized rate was 2.37/1000 for the Italian and 2.28/1000 for the European population. The 30-day case-fatality rate was 25.6% (95% CI, 22.8% to 28.7%). The occurrence of death, disability, and full recovery at 1 year was 36.9%, 38.9%, and 24.2%, respectively. No differences were found in stroke incidence and case-fatality according to income and urban or rural residences. In our population-based study, we found a high stroke incidence notably in the older age subgroups, suggesting that rather than declining, stroke is only being postponed until later in life.
Article
The objective of this study was to evaluate temporal changes of stroke in an Italian community by comparing the present incidence rates with those reported in the same area for 1989. The two studies were conducted by the same research group and met almost all the criteria proposed for an "ideal" stroke incidence study. The annual incidence rate per 1000 inhabitants increased (p < 0.01) by 29%, from 2.23 (95% CL, 1.96-2.50) in 1989 to 2.89 (95% CL, 2.58-3.20) in 1997. No statistically significant change was found when these rates were adjusted to the 1991 Italian population. The overall incidence rate was 2.40 (95% CL, 2.14-2.66) in 1989 and 2.65 (95% CL, 2.39-2.91) in 1997. The thirty-day case fatality rate declined dramatically (p < 0.001) from 31% (95% CL, 26-36) to 20% (95% CL, 16-24) between 1989 and 1997. Ageing of the population and better identification of cases could explain the high incidence rate, whereas the decrease of fatality rate may be due to a general improvement in acute care and inclusion of milder cases.
Article
Stroke type in the young may influence the outcome and may have a dramatic impact on the quality of life in survivors. This study aimed to evaluate the incidence and prognosis of first-ever stroke in the young and to make comparisons with older patients within a well-defined population. All first-ever strokes occurring in the L'Aquila district, central Italy, were traced by active monitoring of inpatient and outpatient health services. Incidence rates were standardized to the 1996 European population according to the direct method. Long-term survival was estimated by the Kaplan-Meier method; outcome in survivors was evaluated by the modified Rankin scale. Of 4353 patients who had a first-ever stroke, 89 patients <45 years of age (55 men and 34 women) (2%) were identified in a 5-year period. Mean age+/-SD was 36.1+/-8.1 years. Twenty patients (22.5%) had a subarachnoid hemorrhage, 18 (20.2%) an intracerebral hemorrhage, and 51 (57.3%) a cerebral infarction. The corresponding proportions in patients >45 years of age were 2.4%, 13.3%, and 83.1%. Neuroimaging studies of the brain detected 14 intracranial aneurysms and 6 arteriovenous malformations in 20 of 38 patients (52.6%) with either subarachnoid (n=17) or intracerebral (n=3) hemorrhage. The crude annual incidence rate was 10.18/100,000 (95% CI, 8.14 to 12.57) and 10.23/100,000 when standardized to the 1996 European population. The 30-day case-fatality rate was 11.2% (95% CI, 6.2 to 19.4). Patients with subarachnoid hemorrhage had the highest proportion of good recovery (60%), patients with intracerebral hemorrhage had the highest mortality (44%), and patients with cerebral infarction had the highest proportion of severe disability (47%). Stroke patients <45 years of age showed a disproportionate cumulative high prevalence (42.7%) of subarachnoid and intracerebral hemorrhage with respect to older patients (15.7%), mainly (52.6%) due to aneurysms and arteriovenous malformations. Therefore, screening procedures and preventive strategies in the young should also be addressed to subjects at risk of subarachnoid and intracerebral hemorrhage.
Article
In the Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events (CAPRIE) trial, clopidogrel showed a statistically significant superiority over aspirin in the prevention of ischaemic stroke, myocardial infarction and vascular death in patients with symptomatic atherosclerosis. More recently, post-hoc analysis of the data also showed that repeat hospitalization for ischaemic or bleeding events was decreased with clopidogrel compared with aspirin. Complementary analyses show that the benefit of clopidogrel over aspirin is amplified in a large population at very high risk of further atherothrombotic events (diabetics, patients with high cholesterol, and patients with previous manifestations of atherothrombosis). A potential clinically useful advantage of clopidogrel is its low propensity for adverse interaction with angiotensin-converting enzyme (ACE) inhibitors, contrary to what may be seen with aspirin, as observed in a post-hoc CAPRIE analysis. The putative aspirin-ACE inhibitor interaction is being tested prospectively in the Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trial - a randomized comparison of warfarin, clopidogrel and aspirin in patients with chronic heart failure. The good gastrointestinal tolerance of clopidogrel seen in CAPRIE has been further demonstrated in a study in healthy volunteers where there was a markedly lower gastroduodenal erosion score after 8 days' administration of clopidogrel 75 mg/day compared with aspirin 325 mg/day (p < 0.001). Following the positive findings obtained with clopidogrel plus aspirin in the Clopidogrel Aspirin Stent International Cooperative Study (CLASSICS) trial, other studies of clopidogrel plus aspirin have been initiated or are planned. These include Management of Atherothrombosis with Clopidogrel in High-risk patients (MATCH), a randomized comparison of clopidogrel plus aspirin versus clopidogrel in high-risk patients with recent stroke or transient ischaemic attack.
Article
To compare stroke incidence rates among comparable registries and to make correlations with aging of the resident populations. This correlation study included all comparable stroke registries maintained in industrialized countries (Italy, France, United Kingdom, Denmark, Norway, United States, and Australia). Eleven community-based stroke registries with similar high proportions of radiologically confirmed diagnoses based on standard definitions were identified. Incidence rates of first-ever stroke from the prospective L'Aquila registry and from the other registries were compared after age and sex standardization to the 1996 European population. The rates were then correlated with the proportion of individuals aged 65 and over in the corresponding resident populations by means of the Poisson regression analysis. In the L'Aquila registry, the crude annual incidence of first-ever stroke was 281/100,000 (95% confidence interval 271-293) based on 2,515 patients included during a 3-year period. The rate standardized to the European population was 249/100,000. Standardized incidence ratios indicated a significant excess of first-ever strokes in the L'Aquila registry up to 51% with respect to most of the compared studies. A significant correlation was also found between crude (p < 0.0001) and standardized (p = 0.0012) stroke incidence rates and proportions of individuals aged 65 and over in the different populations. The L'Aquila experience suggests that any further aging of a population will increase the stroke occurrence for both the reasons of a direct and predictable effect of the growing proportion of elderly individuals within that population and a disproportionately increased stroke risk in the older age groups.
Article
This overview of population-based studies of incidence, prevalence, mortality, and case-fatality of stroke was based on studies from 1990. Incidence (first stroke in an individual's lifetime) and prevalence were computed by age, sex, and stroke type. Age-standardised incidence and prevalence with the corresponding 95% CI were plotted for each study to facilitate comparisons. The review shows that the burden of stroke is high and is likely to increase in future decades as a result of demographic and epidemiological transitions in populations. The main features of stroke epidemiology include modest geographical variation in incidence, prevalence, and case-fatality among the--predominantly white--populations studied so far, and a stabilisation or reversal in the declining secular trends in the pre-1990s rates, especially in older people. However, further research that uses the best possible methods to study the incidence, risk factors, and outcome of stroke are urgently needed in other populations of the world, especially in less developed countries where the risk of stroke is high, lifestyles are changing rapidly, and population restructuring is occurring.
Article
To evaluate the contribution of subjects 80 years old or older to the burden of ischemic stroke as compared with subjects younger than 80 years. All first-ever ischemic strokes occurring in a 5-year period (1994 to 1998) in the population-based L'Aquila registry were traced. Incidence, total health care utilization, disability, and mortality were assessed in patients 80 years old or older, and differences with those younger than 80 years were assessed by univariate and survival analyses. One thousand three hundred sixteen of 3,594 first-ever ischemic strokes (36.6%) occurred in patients 80 years old or older, accounting on average for one-third of health care utilization. The crude annual incidence rate was 21.54 per 1,000 (95% CI 20.42 to 22.72). At the 1-year follow-up, 27.7% of patients had mild or no disability, 20.7% had severe disability, and 51.6% had died. With respect to patients under 80 years of age, older patients showed a higher proportion of women (61.3 vs 47.7%), atrial fibrillation (30.2 vs 20.7%), coronary heart disease (31.0 vs 23.4%), and peripheral arterial disease (14.6 vs 10.8%) and a lower proportion of cigarette smoking (15.3 vs 29.2%) and hypercholesterolemia (20.4 vs 29.4%). Thirty-day (34.6 vs 13.4%) and 1-year (51.6 vs 22.3%) mortality were higher in patients 80 years old or older than in those younger than 80, mostly in the presence of atrial fibrillation (hazard ratio [HR] was 1.39 for 30-day mortality and 1.37 for 1-year mortality) and diabetes mellitus (HR was 1.39 for 30-day mortality and 1.31 for 1-year mortality). The burden of ischemic stroke is high in subjects 80 years old or older, contributing about one-third of health care utilization and 59.8% of deaths within 30 days.
Article
Results from observational studies on fish consumption and risk of stroke are inconsistent. We quantitatively assessed the relationship between fish intake and incidence of stroke using a meta-analysis of cohort studies. We searched the Medline and Embase databases (1966 through October 2003) and identified 9 independent cohorts (from 8 studies) that provided a relative risk (RR) and corresponding 95% CI for total or any type of stroke in relation to fish consumption. Pooled RR and 95% CI of stroke were estimated by variance-based meta-analysis. Compared with those who never consumed fish or ate fish less than once per month, the pooled RRs for total stroke were 0.91 (95% CI, 0.79 to 1.06) for individuals with fish intake 1 to 3 times per month, 0.87 (95% CI, 0.77 to 0.98) for once per week, 0.82 (95% CI, 0.72 to 0.94) for 2 to 4 times per week, and 0.69 (95% CI, 0.54 to 0.88) for > or =5 times per week (P for trend=0.06). In stratified analyses of 3 large cohort studies with data on stroke subtypes, the pooled RRs across 5 categories of fish intake were 1.0, 0.69 (95% CI, 0.48 to 0.99), 0.68 (95% CI, 0.52 to 0.88), 0.66 (95% CI, 0.51 to 0.87), and 0.65 (95% CI, 0.46 to 0.93) for ischemic stroke (P for trend=0.24); and 1.0, 1.47 (95% CI, 0.81 to 2.69), 1.21 (95% CI, 0.78 to 1.85), 0.89 (95% CI, 0.56 to 1.40), and 0.80 (95% CI, 0.44 to 1.47) for hemorrhagic stroke (P for trend=0.31). These results suggest that intake of fish is inversely related to risk of stroke, particularly ischemic stroke. Fish consumption as seldom as 1 to 3 times per month may protect against the incidence of ischemic stroke.
Article
Background: The incidence of stroke is predicted to rise because of the rapidly ageing population. However, over the past two decades, findings of randomised trials have identified several interventions that are effective in prevention of stroke. Reliable data on time-trends in stroke incidence, major risk factors, and use of preventive treatments in an ageing population are required to ascertain whether implementation of preventive strategies can offset the predicted rise in stroke incidence. We aimed to obtain these data. Methods: We ascertained changes in incidence of transient ischaemic attack and stroke, risk factors, and premorbid use of preventive treatments from 1981-84 (Oxford Community Stroke Project; OCSP) to 2002-04 (Oxford Vascular Study; OXVASC). Findings: Of 476 patients with transient ischaemic attacks or strokes in OXVASC, 262 strokes and 93 transient ischaemic attacks were incident events. Despite more complete case-ascertainment than in OCSP, age-adjusted and sex-adjusted incidence of first-ever stroke fell by 29% (relative incidence 0.71, 95% CI 0.61-0.83, p=0.0002). Incidence declined by more than 50% for primary intracerebral haemorrhage (0.47, 0.27-0.83, p=0.01) but was unchanged for subarachnoid haemorrhage (0.83, 0.44-1.57, p=0.57). Thus, although 28% more incident strokes (366 vs 286) were expected in OXVASC due to demographic change alone (33% increase in those aged 75 or older), the observed number fell (262 vs 286). Major reductions were recorded in mortality rates for incident stroke (0.63, 0.44-0.90, p=0.02) and in incidence of disabling or fatal stroke (0.60, 0.50-0.73, p<0.0001), but no change was seen in case-fatality due to incident stroke (17.2% vs 17.8%; age and sex adjusted relative risk 0.85, 95% CI 0.57-1.28, p=0.45). Comparison of premorbid risk factors revealed substantial reductions in the proportion of smokers, mean total cholesterol, and mean systolic and diastolic blood pressures and major increases in premorbid treatment with antiplatelet, lipid-lowering, and blood pressure lowering drugs (all p<0.0001). Interpretation: The age-specific incidence of major stroke in Oxfordshire has fallen by 40% over the past 20 years in association with increased use of preventive treatments and major reductions in premorbid risk factors.
Article
Atrial fibrillation (AF) is a major risk factor for ischemic stroke and its prevalence increases steeply with age. Population-based data on its influence on stroke outcome are scarce. We evaluated the prevalence of AF and its influence on prognosis in patients with a first-ever ischemic stroke from a population-based registry. The presence of AF at stroke onset and during the acute phase was confirmed by a standard electrocardiogram in 869 (24.6%) of 3530 patients with ischemic stroke. With respect to patients without the arrhythmia, those with AF were more frequently women, aged 80 years and older, with coronary heart disease and peripheral arterial disease. The presence of AF was associated with high 30-day (32.5%; 95% CI, 29.3 to 35.6) and 1-year case-fatality rates (49.5%; 95% CI, 46.2 to 52.8), with a higher stroke recurrence rate within the first year of follow-up (6.6% versus 4.4%; P=0.046) and with the worst survival after an average follow-up of 45.2 months (P<0.0001). At the multivariate Cox regression analysis, AF was an independent predictor of 30-day and 1-year mortality. Approximately 17% of all deaths were attributable to the presence of AF. We found a high prevalence of AF in patients with a first-ever ischemic stroke, especially among elderly women. The overall contribution of AF to stroke mortality was relevant, suggesting that together with new strategies to prevent the development of the arrhythmia more appropriate treatments are needed, mostly in elderly women.
Article
Not many data on stroke epidemiology come from studies on islands. This is the first report on a Mediterranean archipelago population. Using recommended criteria, from July 1, 1999, to June 30, 2002, information was collected on first-ever stroke and 30-day case fatality in Aeolian island residents (13,431). The overall crude incidence rate was 154 of 100,000 (95% CI, 118 to 197; 128 in men and 180 in women) or 180, 154, and 87, if adjusted to the Italian, European, and world populations, respectively. The 30-day case fatality rate was 24.2% (95% CI, 14.22 to 36.75). Besides