July 1999 - Volume 4 - Issue 1 A Publication for Members of Medical Outcomes Trust Survival and recurrence after first cerebral infarction: Results from the Stroke Prevention PORT.
Petty GW, Brown RD, Whisnant JP, et al. Neurology 1998 Jan; 50:208-216.
Within the first year proceeding a cerebral event, 27 percent of those affected are at risk of death, while just over ten percent are at risk for another stroke. The strongest predictors of death after first cerebral infarction are congestive heart failure and ischemic heart disease. The Stroke Prevention PORT sought to determine independent predictors of and temporal trends in survival and recurrent stroke among 1,111 residents of Rochester, MN, who had a first stroke between 1975 and 1989. Stroke as a cause of death subsequent to first stroke declined over the study period, however, deaths due to events such as pneumonia or pulmonary embolism increased. While stroke may become less lethal over time, survivors, the disabled in particular, appear more apt to succumb to other non-neurologic conditions.
Quality of life after stroke.
King RB. Stroke 1996 Sept; 27(9):1467-72
The purposes of this study were to examine overall and domain-specific quality of life in long-term stroke survivors and to identify variables that predict quality of life after stroke. The study used a cross-sectional, descriptive correlational design. Subjects were 86 stroke survivors who were interviewed one to three years after stroke. Quality of life was measured with the use of an instrument that assesses satisfaction and importance for four domains (health and functioning, socioeconomic, family, and psychological-spiritual). Independent variables were age, social class, aphasia, functional status, motor impairment, depression, comorbidity, and perceived social support. Multiple regression analysis was used to predict quality of life. Thirty percent of subjects scored in the depressed range. The mean overall quality of life score was relatively high and was comparable to that of a normative population. Quality of life was highest for the family domain and lowest for health and functioning. Depression, perceived social support, and functional status predicted quality of life (adjusted R2 = .38) and contributed to prediction of quality of life. Social support and three additional variables, social class, age, and cardiovascular disease, predicted socioeconomic quality of life.
Many chronic problems in CVA patients at home.
Hochstenbach JB, Donders AR, Mulder T, Van Limbeek J, Schoonderwaldt H. Ned Tijdschr Geneeskd 1996 Jun 1; 140(22):1182-86 .
A cross sectional study designed to find out what the late implications of a stroke were for patients and relatives and whether specific requests for help existed. Patients who had sustained a cerebrovascular accident (CVA) in the last five years were asked, using the Sickness Impact Profile (SIP), about their subjective functioning and the effect of the CVA on daily life. They were also asked about the degree to which they experienced their complaints as a problem, and whether they needed help. In this study 165 patients and their close relatives filled out the SIP. Stroke had a very high impact on everyday functioning as indicated by a total SIP score of 20. The results further showed that psychosocial problems arise independently of the degree of physical problems, that these problems were chronic, and that psychosocial problems hindered 52 percent of the patients often to always. The physical problems hindered 60 percent of them often to always. A third of the patients wanted help for their physical problems, a quarter for their psychosocial problems.
Delay in neurological attention and stroke outcome; Cerebrovascular Diseases Study Group of the Spanish Society of Neurology.
Dvalos A, Castillo J, Martinez-Vila E. Stroke 1995 Dec; 26(12):2233-37
Despite efforts to reduce the delay between stroke onset and new interventional treatments, no studies have analyzed the repercussions of early neurological attention on the clinical outcome of stroke patients. In this study, data were obtained from 721 patients admitted consecutively for a transient ischemic attack or stroke to the neurology departments of 18 Spanish hospitals that followed the same diagnostic and therapeutic guidelines in the acute phase. Factors assessed were age, sex, Canadian Stroke Scale score on admission, previous Barthel Index, and delay before attention by the first physician, by emergency services, by a neurologist, and before hospitalization. Patients' outcomes were classified as good (Barthel Index > 60) or poor (Barthel Index < or = 60 or in-hospital death) depending on patient's functional capacity on discharge. Patients in worse neurological condition on admission presented earlier to the first physician, emergency department, and neurologist. The mortality rate was not significantly modified by early or late presentation at the different medical stages, but early neurological attention in acute stroke is related to better functional outcome and shorter hospitalization.
The importance of brain infarct size and location in predicting outcome after stroke.
Beloosesky Y, Streifler JY, Burstin A, Grinblat J. Age and Ageing 1995 Nov; 24(6):515-18.
Fifty-six consecutive elderly ( > or = 65 years) patients, admitted for acute stroke to a geriatric department were included in the study and underwent CT scanning. Functional status was graded according to the modified Rankin scale. Three patients had primary intra-cerebral hemorrhage, 22 deep hemispheric infarct, 17 had anterior circulation cortical infarcts, five had posterior circulation infarcts and in nine the CT scan was normal. Stroke risk factors were equally distributed among the different CT scan groups, and all three larger groups had similar rates of non-neurological major complications including death (41%). However, independence in ADL (Rankin 0-2) was observed in 72% of deep infarct survivors, but only 15% of the cortical infarct group (p = 0.00018). For the normal scan group, functional recovery was intermediate. In the cortical infarct group patients with an infarct of > or = 50 mm mean diameter (five cases) should worse functional recovery than did eight patients with small infarcts. The mean difference between pre- and post-stroke Rankin score (DR) was 3.4 for the larger infarct patients and 1.9 for the smaller infarct group (p = 0.027). Pearson correlation revealed a direct relationship between the infarction size and DR (p = 0.039). Such a relationship was not observed for the deep hemispheric group.
Unified Neurological Stroke Scale is valid in ischemic and hemorrhagic stroke.
Edwards DF, Chen YW, Diringer MN. Stroke 1995 Oct; 26(10):1852-58 .
The growing interest in testing new therapeutic agents for acute brain injury has lead to increased use of stroke scales. The reliability and validity of these measures need to be examined more completely. We used structural equation modeling, a technique that merges the analytic procedures of factor analysis and multiple regression, to examine the reliability and construct validity of the Middle Cerebral Artery Neurological Scale and the Scandinavian Neurological Stroke Scale used together as the Unified Neurological Stroke Scale. We also analyzed the predictive validity, sensitivity, and specificity of the scales in predicting mortality and functional outcome. Prospectively, 84 consecutive patients admitted to a neurology/neurosurgery intensive care unit with intracerebral hemorrhage (n = 30), subarachnoid hemorrhage (n = 15), ischemic stroke (n = 15), and traumatic brain injury (n = 24) were studied. Patients were evaluated within 24 hours of admission and at 48-hour intervals until intensive care unit discharge. A total of 386 assessments were obtained. The Functional Independence Measure was administered by telephone 3 months after hospital discharge. High levels of reliability and construct validity were observed for the majority of the Unified Stroke Scale items. Facial palsy and eye movement items had the lowest reliability and validity. In total, the Unified Stroke Scale demonstrates reliability and construct and predictive validity, and its use is supported in ischemic and hemorrhagic stroke.
Cognitive status as a predictor of right hemisphere stroke outcomes.
Sisson RA. J Neurosci Nurs 1995 June; 27(3):152-56.
The care of stroke patients continues to present a challenge to health care professionals. There is evidence that the quality of life following a stroke is related to functional status and also emotional, behavioral and cognitive abilities. The purpose of this study was to examine the relationship between emotional, behavioral and cognitive status and functional activity status of stroke survivors. The sample of 15 right hemisphere stroke patients was seen at four time periods after the stroke and they were assessed using the Neurobehavioral Rating Scale (NRS) and the Barthel Functional Index (BFI). The most frequently occurring mental status changes at six months were somatic concern, memory deficit, depressive mood and mental fatigue. There was a correlation between cognitive ability and functional ability. Although there was improvement over time in the scores of the NRS and BFI, there remained sufficient cognitive impairment to affect functional ability. Findings indicated the need for nurses to assess mental status when planning rehabilitation to establish realistic goals.
Quality of life after stroke: impact of stroke type and lesion location.
De Haan RJ, Limburg M, Van der Meulen JH, Jacobs HM, Aaronson NK. Stroke 1995 Mar; 26(3):402-08.
Being that little attention has been focused on the relationship between neurological lesions and quality of life (QL) in stroke research, this study sought to analyze the impact of stroke types and lesion locations on QL. The study sample was composed of 441 stroke patients. Lesion locations and stroke types were divided into 194 left-sided and 173 right-sided lesions, 61 infratentorial strokes (55 infarctions and 6 hemorrhages), and 335 supratentorial strokes (204 [sub]cortical infarctions, 82 lacunar infarctions, and 49 hemorrhages). Six-months after stroke, QL was assessed with the Sickness Impact Profile. Age-adjusted QL scores were expressed in standard scores. Although patients with left-sided lesions had more speech pathology (P < .001), there was slightly more QL deterioration in patients with right-sided lesions. Patients with infratentorial strokes reported better overall functioning than patients with supratentorial strokes (P = .02). There was no difference in QL between supratentorial (sub)cortical infarcts and hemorrhages. Lesion locations and stroke types did not affect patients' emotional distress. Severely impaired QL patterns were related significantly to older age (P < .001), comorbidity (P = .02), stroke severity (P < .001), and supratentorial lesions (P = .02). In conclusion, there is only a weak relationship between lesion laterality and QL. Survivors of hemorrhagic strokes do not evidence more QL impairment than survivors of ischemic strokes.