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  • 1. Abbott, Anne L.
    et al.
    Adelman, Mark A.
    Alexandrov, Andrei V.
    Barber, P. Alan
    Barnett, Henry J. M.
    Beard, Jonathan
    Bell, Peter
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Blacker, David
    Bonati, Leo H.
    Brown, Martin M.
    Buckley, Clifford J.
    Cambria, Richard P.
    Castaldo, John E.
    Comerota, Anthony J.
    Connolly, E. Sander, Jr.
    Dalman, Ronald L.
    Davies, Alun H.
    Eckstein, Hans-Henning
    Faruqi, Rishad
    Feasby, Thomas E.
    Fraedrich, Gustav
    Gloviczki, Peter
    Hankey, Graeme J.
    Harbaugh, Robert E.
    Heldenberg, Eitan
    Hennerici, Michael G.
    Hill, Michael D.
    Kleinig, Timothy J.
    Mikhailidis, Dimitri P.
    Moore, Wesley S.
    Naylor, Ross
    Nicolaides, Andrew
    Paraskevas, Kosmas I.
    Pelz, David M.
    Prichard, James W.
    Purdie, Grant
    Ricco, Jean-Baptiste
    Ringleb, Peter A.
    Riles, Thomas
    Rothwell, Peter M.
    Sandercock, Peter
    Sillesen, Henrik
    Spence, J. David
    Spinelli, Francesco
    Sturm, Jonathon
    Tan, Aaron
    Thapar, Ankur
    Veith, Frank J.
    Wijeratne, Tissa
    Zhou, Wei
    Why Calls for More Routine Carotid Stenting Are Currently Inappropriate An International, Multispecialty, Expert Review and Position Statement2013In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 44, no 4, p. 1186-1190Article in journal (Refereed)
  • 2. Ahmed, Niaz
    et al.
    Näsman, Per
    KTH, Superseded Departments, Infrastructure.
    Wahlgren, Nils Gunnar
    Effect of intravenous nimodipine on blood pressure and outcome after acute stroke2000In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 31, no 6, p. 1250-1255Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-The Intravenous Nimodipine West European Stroke Trial (INWEST) found a correlation between nimodipine-induced reduction in blood pressure (BP) and an unfavorable outcome in acute stroke. We sought to confirm this correlation with and without adjustment for prognostic variables and to investigate outcome in subgroups with increasing levels of BP reduction. Methods-Patients with a clinical diagnosis of ischemic stroke (within 24 hours) were consecutively allocated to receive placebo (n=100), 1 mg/h (low-dose) nimodipine (n=101), or 2 mg/h (high-dose) nimodipine (n=94). The correlation between average BP change during the first 2 days and the outcome at day 21 was analysed. Results-Two hundred sixty-five patients were included in this analysis (n=92, 93, and 80 for placebo, low dose, and high dose. respectively). Nimodipine treatment resulted in a statistically significant reduction in systolic BP (SBP) and diastolic BP (DBP) from baseline compared with placebo during the first few days. In multivariate analysis, a significant correlation between DBP reduction and worsening of the neurological score was round for the high-close group (beta=0.49, P=0.048). Patients with a DBP reduction of greater than or equal to 20% in the high-dose group had a significantly increased adjusted OR for the compound outcome variable death or dependency (Barthel Index <60) (n/N=25/26, OR 10.16, 95% CI 1.02 to 101.74) and death alone (n/N=9/26, OR 4.3361 95% CI 1.131 16.619) compared with all placebo patients (n/N=62/92 and 14/92. respectively). There was no correlation between SEP change and outcome. Conclusions-DBP, but not SEP, reduction was associated with neurological worsening after the intravenous administration of high-dose nimodipine after acute stroke. For low-dose nimodipine, the results were not conclusive. These results do not confirm or exclude a neuroprotective property of nimodipine.

  • 3. Aho, Leena
    et al.
    Jolkkonen, Jukka
    Alafuzoff, Irina
    Kuopio University, Finland.
    Beta-amyloid aggregation in human brains with cerebrovascular lesions.2006In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 37, no 12, p. 2940-5Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: The present study assessed beta-amyloid (Abeta) protein aggregates in postmortem human brains in subjects who had experienced stroke to examine the proposed association between ischemic stress and the accumulation of Abeta reported in rodents.

    METHODS: A sample of 484 postmortem brains from nondemented subjects, lacking isocortical neurodegenerative pathology with verified cerebrovascular lesions, and 57 age-matched controls were assessed with respect to Abeta, Abeta40, and Abeta42 aggregates in the cortex and thalamus by immunohistochemical techniques.

    RESULTS: The load of Abeta aggregates did not display a significant association with cerebrovascular lesions. The load of Abeta, Abeta40, and Abeta42 aggregates increased with age, and there was a tendency toward higher odds ratios for Abeta aggregates, though not statistically significant, in subjects with acute cerebrovascular lesions. In the oldest subjects with cerebrovascular lesions and with both thalamic and cortical Abeta aggregates, the load of thalamic Abeta42 was significantly higher than the load of Abeta40.

    CONCLUSIONS: Our findings indicate that cerebrovascular disease does not influence the load of Abeta, whereas a shift of aggregation from the Abeta40 to the Abeta42 residue is noted in the thalamus but only in aged subjects. It is impossible, however, to state whether this result is attributable to increased Abeta production, its insufficient elimination, or other susceptibility factors.

  • 4.
    Alafuzoff, Irina
    Department of Neuroscience and Neurology, University of Kuopio Finland .
    Cerebral amyloid angiopathy, hemorrhages and superficial siderosis.2008In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 39, no 10, p. 2699-700Article in journal (Refereed)
  • 5.
    Appelros, Peter
    Örebro University, Department of Clinical Medicine.
    Heart failure and stroke2006In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 37, no 7, p. 1637-1637Article in journal (Refereed)
  • 6.
    Appelros, Peter
    et al.
    Örebro University Hospital. Department of Neurology, Örebro University Hospital, Örebro, Sweden.
    Farahmand, Bahman
    Epi-consultants (Formerly Karolinska Institute), Alzheimer Disease Research Center, Stockholm, Sweden.
    Terént, Andreas
    Department of Medical Sciences,Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden.
    Åsberg, Signild
    Department of Medical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden.
    To Treat or Not to Treat: Anticoagulants as Secondary Preventives to the Oldest Old With Atrial Fibrillation.2017In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 48, no 6, p. 1617-1623Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Anticoagulant treatment is effective for preventing recurrent ischemic strokes in patients who have atrial fibrillation. This benefit is paid by a small increase of hemorrhages. Anticoagulant-related hemorrhages seem to increase with age, but there are few studies showing whether the benefits of treatment persist in old age.

    METHODS: For this observational study, 4 different registers were used, among them Riksstroke, the Swedish Stroke Register. Patients who have had a recent ischemic stroke, were 80 to 100 years of age, and had atrial fibrillation, were included from 2006 through 2013. The patients were stratified into 3 age groups: 80 to 84, 85 to 89, and ≥90 years of age. Information on stroke severity, risk factors, drugs, and comorbidities was gathered from the registers. The patients were followed with respect to ischemic or hemorrhagic stroke, other hemorrhages, or death.

    RESULTS: Of all 23 356 patients with atrial fibrillation, 6361 (27%) used anticoagulants after an ischemic stroke. Anticoagulant treatment was associated with less recurrent ischemic stroke in all age groups. Hemorrhages increased most in the ≥90-year age group, but this did not offset the overall beneficial effect of the anticoagulant. Apart from age, no other cardiovascular risk factor or comorbidity was identified that influenced the risk of anticoagulant-associated hemorrhage. Drugs other than anticoagulants did not influence the incidence of major hemorrhage.

    CONCLUSIONS: Given the patient characteristics in this study, there is room for more patients to be treated with anticoagulants, without hemorrhages to prevail. In nonagenarians, hemorrhages increased somewhat more, but this did not affect the overall outcome in this age stratum.

  • 7.
    Appelros, Peter
    et al.
    Örebro Univ Hosp.
    Farahmand, Bahman
    Alzheimer Dis Res Ctr, Epiconsultant Formerly Karolinska Inst, Stockholm, Sweden..
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology.
    Åsberg, Signild
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology.
    To Treat or Not to Treat: Anticoagulants as Secondary Preventives to the Oldest Old With Atrial Fibrillation2017In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 48, no 6, p. 1617-1622Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Anticoagulant treatment is effective for preventing recurrent ischemic strokes in patients who have atrial fibrillation. This benefit is paid by a small increase of hemorrhages. Anticoagulant-related hemorrhages seem to increase with age, but there are few studies showing whether the benefits of treatment persist in old age.

    Methods-For this observational study, 4 different registers were used, among them Riksstroke, the Swedish Stroke Register. Patients who have had a recent ischemic stroke, were 80 to 100 years of age, and had atrial fibrillation, were included from 2006 through 2013. The patients were stratified into 3 age groups: 80 to 84, 85 to 89, and ?90 years of age. Information on stroke severity, risk factors, drugs, and comorbidities was gathered from the registers. The patients were followed with respect to ischemic or hemorrhagic stroke, other hemorrhages, or death.

    Results-Of all 23 356 patients with atrial fibrillation, 6361 (27%) used anticoagulants after an ischemic stroke. Anticoagulant treatment was associated with less recurrent ischemic stroke in all age groups. Hemorrhages increased most in the >= 90-year age group, but this did not offset the overall beneficial effect of the anticoagulant. Apart from age, no other cardiovascular risk factor or comorbidity was identified that influenced the risk of anticoagulant-associated hemorrhage. Drugs other than anticoagulants did not influence the incidence of major hemorrhage.

    Conclusions-Given the patient characteristics in this study, there is room for more patients to be treated with anticoagulants, without hemorrhages to prevail. In nonagenarians, hemorrhages increased somewhat more, but this did not affect the overall outcome in this age stratum.

  • 8. Appelros, Peter
    et al.
    Stegmayr, Birgitta
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Internal Medicine.
    Sex differences in stroke epidemiology: a systematic review2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 4, p. 1082-1090Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Epidemiological studies, mainly based on Western European surveys, have shown that stroke is more common in men than in women. In recent years, sex-specific data on stroke incidence, prevalence, subtypes, severity and case-fatality have become available from other parts of the world. The purpose of this article is to give a worldwide review on sex differences in stroke epidemiology. METHODS: We searched PubMed, tables-of-contents, review articles, and reference lists for community-based studies including information on sex differences. In some areas, such as secular trends, ischemic subtypes and stroke severity, noncommunity-based studies were also reviewed. Male/female ratios were calculated. RESULTS: We found 98 articles that contained relevant sex-specific information, including 59 incidence studies from 19 countries and 5 continents. The mean age at first-ever stroke was 68.6 years among men, and 72.9 years among women. Male stroke incidence rate was 33% higher and stroke prevalence was 41% higher than the female, with large variations between age bands and between populations. The incidence rates of brain infarction and intracerebral hemorrhage were higher among men, whereas the rate of subarachnoidal hemorrhage was higher among women, although this difference was not statistically significant. Stroke tended to be more severe in women, with a 1-month case fatality of 24.7% compared with 19.7% for men. CONCLUSIONS: Worldwide, stroke is more common among men, but women are more severely ill. The mismatch between the sexes is larger than previously described.

  • 9. Appelros, Peter
    et al.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terént, Andreas
    Sex differences in stroke epidemiology: a systematic review2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 4, p. 1082-1090Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Epidemiological studies, mainly based on Western European surveys, have shown that stroke is more common in men than in women. In recent years, sex-specific data on stroke incidence, prevalence, subtypes, severity and case-fatality have become available from other parts of the world. The purpose of this article is to give a worldwide review on sex differences in stroke epidemiology. METHODS: We searched PubMed, tables-of-contents, review articles, and reference lists for community-based studies including information on sex differences. In some areas, such as secular trends, ischemic subtypes and stroke severity, noncommunity-based studies were also reviewed. Male/female ratios were calculated. RESULTS: We found 98 articles that contained relevant sex-specific information, including 59 incidence studies from 19 countries and 5 continents. The mean age at first-ever stroke was 68.6 years among men, and 72.9 years among women. Male stroke incidence rate was 33% higher and stroke prevalence was 41% higher than the female, with large variations between age bands and between populations. The incidence rates of brain infarction and intracerebral hemorrhage were higher among men, whereas the rate of subarachnoidal hemorrhage was higher among women, although this difference was not statistically significant. Stroke tended to be more severe in women, with a 1-month case fatality of 24.7% compared with 19.7% for men. CONCLUSIONS: Worldwide, stroke is more common among men, but women are more severely ill. The mismatch between the sexes is larger than previously described.

  • 10.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stroke in the uninsured2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 6, p. 1950-1951Article in journal (Refereed)
  • 11.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Persson, Olle
    Umeå University, Faculty of Social Sciences, Department of Sociology.
    Country comparisons of human stroke research since 2001: a bibliometric study2012In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 43, no 3, p. 830-837Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: This is the first bibliometric comparison between countries of the development of stroke research over time.

    METHODS: Clinical and epidemiological articles on stroke published 2001 to mid-2011 were identified in Science Citation Index Expanded. Article fractions, citation fractions, h-index, and international collaboration were calculated using the BibExcel software and adjusted for population size and gross domestic product.

    RESULTS: The United States dominated with 28.7% of the sum of article fractions and 36.2% of the sum of citation fractions. The United States, Japan, the United Kingdom, and Germany together accounted for 52.1% of articles and 61.0% of citations. When adjusted for population size or gross domestic product, several small European countries, together with Israel and Taiwan, ranked the highest. Per population, there was a negative association (r=0.60) between burden of stroke (disability-adjusted life-years lost) and number of articles per population. In China, South Korea, and Singapore, the annual growth of stroke articles was more than twice the worldwide average. Whereas multinational collaboration was common within Europe and North America, it was relatively uncommon between Asian countries.

    CONCLUSIONS: The Big 4 in scientific literature on stroke, as to both number of articles and citations, are the United States, Japan, the United Kingdom, and Germany. Many small European countries have, in relation to their size, a high scientific production. Several countries with rapidly expanding economies have very fast growth of scientific production on stroke. Our results emphasize the need for stroke research in countries with a high population burden of stroke and they highlight the role of multinational collaboration.

  • 12.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Department of Statistics.
    Effects of Extending the Time Window of Thrombolysis to 4.5 Hours: Observations in the Swedish Stroke Register (Riks-Stroke)2011In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 42, no 9, p. 2492-2497Article in journal (Refereed)
    Abstract [en]

    Background and Purpose: The European Cooperative Acute Stroke Study (ECASS) III trial and Safe Implementation of Thrombolysis in Stroke–International Stroke Thrombolysis Register (SITS-ISTR) data were published in 2008. Riks-Stroke, the Swedish Stroke Register, was used to explore how thrombolysis in the 3- to 4.5-hour window has been spread in different hospitals and patient groups and what effects this has had on treatment within 3 hours.

    Methods: All 76 hospitals in Sweden admitting patients with acute stroke participate in Riks-Stroke. During the study period, January 2003 to June 2010, 92 150 18- to 80-year-old patients were hospitalized for acute ischemic stroke.

    Results: After the publication of the ECASS III results in the third quarter of 2008, thrombolysis in the 3- to 4.5-hour window increased from 0.5% before publication to 2.1% in 2010. Thrombolysis in the 3- to 4.5-hour window spread somewhat faster in men than women (P=0.04) but at a similar rate in different age groups. The use of thrombolysis within 3 hours after onset of symptoms increased successively from 0.9% in 2003 to 6.6% in late 2008 and then it stabilized at 6%. The median time from arrival to the hospital to start of treatment remained unchanged at 66 to 69 minutes before and after 2008 (P=0.06).

    Conclusions: Since the end of 2008, there has been a rapid nationwide dissemination of thrombolysis in the 3- to 4.5-hour window, whereas rates in the <3-hour window have leveled off. The extended time window has not affected door-to-needle time.

  • 13. Asplund, Kjell
    et al.
    Jonsson, Fredrik
    Eriksson, Marie
    Stegmayr, Birgitta
    Appelros, Peter
    Norrving, Bo
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Internal Medicine.
    Asberg, Kerstin Hulter
    Patient dissatisfaction with acute stroke care2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 12, p. 3851-3856Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. METHODS: All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104,876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. RESULTS: The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). CONCLUSIONS: Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.

  • 14.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    National Board of Health and Welfare, Stockholm, Sweden; Department of Neurology .
    Appelros, Peter
    University Hospital. Örebro, Sweden; Department of Neurology .
    Norrving, Bo
    University Hospital, Lund, Sweden; Department of Medicine.
    Terént, Andreas
    Akademiska University Hospital, Uppsala, Sweden; Department of Medicine.
    Åsberg, Kerstin Hulter
    Enköping Hospital, Enköping, Sweden.
    Patient dissatisfaction with acute stroke care2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 12, p. 3851-3856Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. METHODS: All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104 876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. RESULTS: The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). CONCLUSIONS: Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.

  • 15.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Karvanen, Juha
    Giampaoli, Simona
    Jousilahti, Pekka
    Niemelä, Matti
    Broda, Grazyna
    Cesana, Giancarlo
    Dallongeville, Jean
    Ducimetriere, Pierre
    Evans, Alun
    Ferrières, Jean
    Haas, Bernadette
    Jorgensen, Torben
    Tamosiunas, Abdonas
    Vanuzzo, Diego
    Wiklund, Per-Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Yarnell, John
    Kuulasmaa, Kari
    Kulathinal, Sangita
    Relative risks for stroke by age, sex, and population based on follow-up of 18 European populations in the MORGAM Project2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 7, p. 2319-2326Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Within the framework of the MOnica Risk, Genetics, Archiving and Monograph (MORGAM) Project, the variations in impact of classical risk factors of stroke by population, sex, and age were analyzed. METHODS: Follow-up data were collected in 43 cohorts in 18 populations in 8 European countries surveyed for cardiovascular risk factors. In 93 695 persons aged 19 to 77 years and free of major cardiovascular disease at baseline, total observation years were 1 234 252 and the number of stroke events analyzed was 3142. Hazard ratios were calculated by Cox regression analyses. RESULTS: Each year of age increased the risk of stroke (fatal and nonfatal together) by 9% (95% CI, 9% to 10%) in men and by 10% (9% to 10%) in women. A 10-mm Hg increase in systolic blood pressure involved a similar increase in risk in men (28%; 24% to 32%) and women (25%; 20% to 29%). Smoking conferred a similar excess risk in women (104%; 78% to 133%) and in men (82%; 66% to 100%). The effect of increasing body mass index was very modest. Higher high-density lipoprotein cholesterol levels decreased the risk of stroke more in women (hazard ratio per mmol/L 0.58; 0.49 to 0.68) than in men (0.80; 0.69 to 0.92). The impact of the individual risk factors differed somewhat between countries/regions with high blood pressure being particularly important in central Europe (Poland and Lithuania). CONCLUSIONS: Age, sex, and region-specific estimates of relative risks for stroke conferred by classical risk factors in various regions of Europe are provided. From a public health perspective, an important lesson is that smoking confers a high risk for stroke across Europe.

  • 16.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Sukhova, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Diagnostic procedures, treatments, and outcomes in stroke patients admitted to different types of hospitals2015In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 46, no 3, p. 806-812Article in journal (Refereed)
    Abstract [en]

    Background and Purpose: In many countries, including Sweden, initiatives have been taken to reduce between-hospital differences in the quality of stroke services. We have explored to what extent hospital type (university, specialized nonuniversity, or community hospital) influences hospital performance. Methods: Riksstroke collects clinical data during hospital stay (national coverage 94%). Follow-up data at 3 months were collected using administrative registers and a questionnaire completed by surviving patients (response rate 88%). Structural data were collected from a questionnaire completed by hospital staff (response rate 100%). Multivariate analyses with adjustment for clustering were used to test differences between types of hospitals. Results: The proportion of patients admitted directly to a stroke unit was highest in community hospitals and lowest in university hospitals. Magnetic resonance, carotid imaging, and thrombectomy were more frequently performed in university hospitals, and the door-to-needle time for thrombolysis was shorter. Secondary prevention with antihypertensive drugs was used less often, and outpatient follow-up was less frequent in university hospitals. Fewer patients in community hospitals were dissatisfied with their rehabilitation. After adjusting for possible confounders, poor outcome (dead or activities of daily living dependency 3 months after stroke) was not significantly different between the 3 types of hospital. Conclusions: In a setting with national stroke guidelines, stroke units in all hospitals, and measurement of hospital performance and benchmarking, outcome (after case-mix adjustment) is similar in university, specialized nonuniversity, and community hospitals. There seems to be fewer barriers to organizing well-functioning stroke services in community hospitals compared with university hospitals.

  • 17.
    Bergh, Cecilia
    et al.
    Örebro University, School of Medical Sciences.
    Udumyan, Ruzan
    Örebro University, School of Medical Sciences.
    Appelros, Peter
    Department of Neurology, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Fall, Katja
    Örebro University, School of Medical Sciences.
    Montgomery, Scott
    Örebro University, School of Medical Sciences. Clinical Epidemiology Unit, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology and Public Health, University College London, London, United Kingdom.
    Determinants in adolescence of stroke-related hospital stay duration in men: a national cohort study2016In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 47, no 9, p. 2416-2418Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Physical and psychological characteristics in adolescence are associated with subsequent stroke risk. Our aim is to investigate their relevance to length of hospital stay and risk of second stroke.

    Methods: Swedish men born between 1952 and 1956 (n=237 879) were followed from 1987 to 2010 using information from population-based national registers. Stress resilience, body mass index, cognitive function, physical fitness, and blood pressure were measured at compulsory military conscription examinations in late adolescence. Joint Cox proportional hazards models estimated the associations of these characteristics with long compared with short duration of stroke-related hospital stay and with second stroke compared with first.

    Results: Some 3000 men were diagnosed with nonfatal stroke between ages 31 and 58 years. Low stress resilience, underweight, and higher systolic blood pressure (per 1-mm Hg increase) during adolescence were associated with longer hospital stay (compared with shorter) in ischemic stroke, with adjusted relative hazard ratios (and 95% confidence intervals) of 1.46 (1.08-1.89), 1.41 (1.04-1.91), and 1.01 (1.00-1.02), respectively. Elevated systolic and diastolic blood pressures during adolescence were associated with longer hospital stay in men with intracerebral hemorrhage: 1.01 (1.00-1.03) and 1.02 (1.00-1.04), respectively. Among both stroke types, obesity in adolescence conferred an increased risk of second stroke: 2.06 (1.21-3.45).

    Conclusions: Some characteristics relevant to length of stroke-related hospital stay and risk of second stroke are already present in adolescence. Early lifestyle influences are of importance not only to stroke risk by middle age but also to recurrence and use of healthcare resources among stroke survivors.

  • 18.
    Bergström, Lisa
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Soderstrom, Lars
    Ögren, Joachim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Laurell, Katarina
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    One-Year Incidence, Time Trends, and Predictors of Recurrent Ischemic Stroke in Sweden From 1998 to 2010 An Observational Study2017In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 48, no 8, p. 2046-Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Recent data on the incidence, time trends, and predictors of recurrent ischemic stroke are limited for unselected patient populations. Methods-Data for ischemic stroke patients were obtained from The Swedish Stroke Register (Riksstroke) between 1998 and 2009 and merged with The Swedish National Inpatient Register. A reference group of patients was created by Statistics Sweden. The ischemic stroke patient cohort was divided into 4 time periods. Recurrent ischemic stroke within 1 year was recorded until 2010. Kaplan-Meier and Cox regression analyses were performed to study time trends and predictors of ischemic stroke recurrence. Results-Of 196 765 patients with ischemic stroke, 11.3% had a recurrent ischemic stroke within 1 year. The Kaplan-Meier estimates of the 1-year cumulative incidence of recurrent ischemic stroke decreased from 15.0% in 1998 to 2001 to 12.0% in 2007 to 2010 in the stroke patient cohort while the cumulative incidence of ischemic stroke decreased from 0.7% to 0.4% in the reference population. Age > 75 years, prior ischemic stroke or myocardial infarction, atrial fibrillation without warfarin treatment, diabetes mellitus, and treatment with beta-blockers or diuretics were associated with a higher risk while warfarin treatment for atrial fibrillation, lipid-lowering medication, and antithrombotic treatment (acetylsalicylic acid, dipyridamole) were associated with a reduced risk of recurrent ischemic stroke. Conclusions-The risk of recurrent ischemic stroke decreased from 1998 to 2010. Well-known risk factors for stroke were associated with a higher risk of ischemic stroke recurrence; whereas, secondary preventive medication was associated with a reduced risk, emphasizing the importance of secondary preventive treatment.

  • 19.
    Bernspång, Birgitta
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eriksson, Sture
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Fugl-Meyer, Axel R.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
    Motor and perceptual impairments in acute stroke patients: effects on self-care ability1987In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 18, no 6, p. 1081-1086Article in journal (Refereed)
    Abstract [en]

    The relative importance of motor, perceptual, and some cognitive functions for self-care ability was analyzed in a representative sample of 109 subjects within 2 weeks of acute stroke. Forty-nine patients (45%) were dependent or partly dependent in self-care. Profound motor dysfunction was present in 39%, low-order perceptual deficits in 10%, high-order perceptual deficits in 60%, and disorientation in time and space in 13% of the patients. There was a significant covariation between motor function and self-care ability and between low-order perception and orientation function. Low-order and high-order perception covaried only weakly. Discriminant analyses showed that the actual level of self-care proficiency could be correctly predicted in 70% of the cases by the 4 indexes of motor function, low-order perception, high-order perception, and orientation. The dominating predictor was motor function, and the next highest was high-order perception. When a program for early training is designed with the aim to alleviate long-term self-care disability after stroke, correct assessment of motor and perceptual functions in the individual stroke patient is essential.

  • 20.
    Brammås, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jakobsson, Stina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Ulvenstam, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Internal Medicine, Section of Cardiology, Östersund Hospital, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mortality After Ischemic Stroke in Patients With Acute Myocardial Infarction Predictors and Trends Over Time in Sweden2013In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 44, no 11, p. 3050-3055Article in journal (Refereed)
    Abstract [en]

    Background and Purpose Acute myocardial infarction (AMI) increases the risk of ischemic stroke, and mortality among these patients is high. Here, we aimed to estimate the 1-year mortality reliably after AMI complicated by ischemic stroke. We also aimed to identify trends over time for mortality during 1998-2008, as well as factors that predicted increased or decreased mortality. Methods Data for 173 233 unselected patients with AMI were collected from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions registry for 1998-2008. Specifically, we analyzed 1-year follow-up and mortality data for patients with AMI with and without ischemic stroke. Kaplan-Meyer analysis was used to analyze mortality trends over time, and Cox regression analysis was used to identify uni- and multivariate predictors of mortality. Results The 1-year mortality was 36.5% for AMI complicated by ischemic stroke and 18.3% for AMI without stroke. Mortality decreased over time in patients with and without ischemic stroke. The absolute decreases in mortality were 9.4% and 7.5%, respectively. Reperfusion and secondary preventive therapies were associated with a decreased mortality rate. Conclusions Mortality after AMI complicated by an ischemic stroke is very high but decreased from 1998 to 2008. The increased use of evidence-based therapies explains the improved prognosis.

  • 21.
    Bravi, Luca
    et al.
    IFOM, the FIRC Institute of Molecular Oncology Foundation.
    Malinverno, Matteo
    IFOM, the FIRC Institute of Molecular Oncology Foundation.
    Pisati, Federica
    Rudini, Noemi
    Cuttano, Roberto
    Pallini, Roberto
    Martini, Maurizio
    Larocca, Luigi Maria
    Locatelli, Marco
    Levi, Vincenzo
    Bertani, Giulio Andrea
    Dejana, Elisabetta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology.
    Lampugnani, Maria Grazia
    Endothelial Cells Lining Sporadic Cerebral Cavernous Malformation Cavernomas Undergo Endothelial-to-Mesenchymal Transition2016In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 47, no 3, p. 886-890Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Cerebral cavernous malformation (CCM) is characterized by multiple lumen vascular malformations in the central nervous system that can cause neurological symptoms and brain hemorrhages. About 20% of CCM patients have an inherited form of the disease with ubiquitous loss-of-function mutation in any one of 3 genes CCM1, CCM2, and CCM3. The rest of patients develop sporadic vascular lesions histologically similar to those of the inherited form and likely mediated by a biallelic acquired mutation of CCM genes in the brain vasculature. However, the molecular phenotypic features of endothelial cells in CCM lesions in sporadic patients are still poorly described. This information is crucial for a targeted therapy.

    METHODS: We used immunofluorescence microscopy and immunohistochemistry to analyze the expression of endothelial-to-mesenchymal transition markers in the cavernoma of sporadic CCM patients in parallel with human familial cavernoma as a reference control.

    RESULTS: We report here that endothelial cells, a cell type critically involved in CCM development, undergo endothelial-to-mesenchymal transition in the lesions of sporadic patients. This switch in endothelial phenotype has been described only in genetic CCM patients and in murine models of the disease. In addition, TGF-β/p-Smad- and β-catenin-dependent signaling pathways seem activated in sporadic cavernomas as in familial ones.

    CONCLUSIONS: Our findings support the use of common therapeutic strategies for both sporadic and genetic CCM malformations.

  • 22. Cadilhac, Dominique A.
    et al.
    Amatya, Bhasker
    Lalor, Erin
    Rudd, Anthony
    Lindsay, Patrice
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Is There Evidence That Performance Measurement in Stroke Has Influenced Health Policy and Changes to Health Systems?2012In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 43, no 12, p. 3413-3420Article, review/survey (Refereed)
  • 23.
    Carlberg, B
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hägg, E
    Factors influencing admission blood pressure levels in patients with acute stroke.1991In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 22, no 4, p. 527-30Article in journal (Refereed)
    Abstract [en]

    In clinical practice, patients with acute stroke often have high blood pressure. The aim of this study was to investigate factors correlated with blood pressure elevation in 843 consecutive stroke patients on hospital admission to a nonintensive stroke unit. Using a multivariate analysis model, we analyzed the influence on admission blood pressure of sex, age, previous hypertension, cardiac failure, diabetes, type of stroke, impaired consciousness, and latency between onset of symptoms and admission. Previous hypertension was the strongest predictor (p less than 0.001) of elevated blood pressure on admission, followed by the presence of intracerebral hemorrhage (p less than 0.001). The latency between onset of symptoms and admission showed no correlation with blood pressure levels at hospitalization. Previously, high blood pressure levels on hospital admission have been shown to decline within a few days in hospital. We therefore hypothesize that mental stress on hospital admission may be a major factor in the blood pressure elevation seen in acute stroke.

  • 24.
    Carlberg, B
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hägg, E
    The prognostic value of admission blood pressure in patients with acute stroke.1993In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 24, no 9, p. 1372-5Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Patients with acute stroke are often found to have high blood pressures at hospital admission. Previous studies have shown variable results regarding the prognostic value of high blood pressure in acute stroke. The aim of this study was to investigate the prognostic value of admission blood pressure in a population-based sample of patients with acute stroke.

    METHODS: Eighty-five patients with intracerebral hemorrhage and 831 with ischemic disease were included in the study. The relations between admission blood pressure and 30-day mortality were studied by logistic regression analyses.

    RESULTS: High blood pressure in patients with impaired consciousness on hospital admission was significantly related to 30-day mortality in patients with intracerebral hemorrhage (P = .037) and in patients with ischemic disease (P < .0001). In patients without impaired consciousness, high blood pressure at time of admission was not related to increased mortality at 30 days.

    CONCLUSIONS: High admission blood pressure in alert stroke patients was not related to increased mortality. Stroke patients with impaired consciousness showed higher mortality rates with increasing blood pressure. However, this does not provide a basis for recommending antihypertensive therapy for such patients.

  • 25. Chroinin, Danielle Ni
    et al.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asberg, Signild
    Callaly, Elizabeth
    Cuadrado-Godia, Elisa
    Diez-Tejedor, Exuperio
    Di Napoli, Mario
    Engelter, Stefan T.
    Furie, Karen L.
    Giannopoulos, Sotirios
    Gotto, Antonio M., Jr.
    Hannon, Niamh
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Kapral, Moira K.
    Marti-Fabregas, Joan
    Martinez-Sanchez, Patricia
    Milionis, Haralampos J.
    Montaner, Joan
    Muscari, Antonio
    Pikija, Slaven
    Probstfield, Jeffrey
    Rost, Natalia S.
    Thrift, Amanda G.
    Vemmos, Konstantinos
    Kelly, Peter J.
    Statin Therapy and Outcome After Ischemic Stroke: Systematic Review and Meta-Analysis of Observational Studies and Randomized Trials2013In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 44, no 2, p. 448-456Article, review/survey (Refereed)
    Abstract [en]

    Background and Purpose-Although experimental data suggest that statin therapy may improve neurological outcome after acute cerebral ischemia, the results from clinical studies are conflicting. We performed a systematic review and meta-analysis investigating the relationship between statin therapy and outcome after ischemic stroke. Methods-The primary analysis investigated statin therapy at stroke onset (prestroke statin use) and good functional outcome (modified Rankin score 0 to 2) and death. Secondary analyses included the following: (1) acute poststroke statin therapy (<= 72 hours after stroke), and (2) thrombolysis-treated patients. Results-The primary analysis included 113 148 subjects (27 studies). Among observational studies, statin treatment at stroke onset was associated with good functional outcome at 90 days (pooled odds ratio [OR], 1.41; 95% confidence interval [CI], 1.29-1.56; P<0.001), but not 1 year (OR, 1.12; 95% CI, 0.9-1.4; P=0.31), and with reduced fatality at 90 days (pooled OR, 0.71; 95% CI, 0.62-0.82; P<0.001) and 1 year (OR, 0.80;95% CI, 0.67-0.95; P=0.01). In the single randomized controlled trial reporting 90-day functional outcome, statin treatment was associated with good outcome (OR, 1.5; 95% CI, 1.0-2.24; P=0.05). No reduction in fatality was observed on meta-analysis of data from 3 randomized controlled trials (P=0.9). In studies restricted to of thrombolysis-treated patients, an association between statins and increased fatality at 90 days was observed (pooled OR, 1.25; 95% CI, 1.02-1.52; P=0.03, 3 studies, 4339 patients). However, this association was no longer present after adjusting for age and stroke severity in the largest study (adjusted OR, 1.14; 95% CI, 0.90-1.44; 4012 patients). Conclusion-In the largest meta-analysis to date, statin therapy at stroke onset was associated with improved outcome, a finding not observed in studies restricted to thrombolysis-treated patients. Randomized trials of statin therapy in acute ischemic stroke are needed.

  • 26.
    Chróinín, Danielle Ní
    et al.
    Natl Univ Ireland Univ Coll Dublin, Neurovasc Unit Appl Translat Res & Therapeut, Mater Univ Hosp, Dublin Acad Med Ctr, Dublin, Ireland.
    Asplund, Kjell
    Umeå Univ Hosp, Dept Med, Umeå, Sweden.
    Åsberg, Signild
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Epidemiology.
    Callaly, Elizabeth
    Natl Univ Ireland Univ Coll Dublin, Neurovasc Unit Appl Translat Res & Therapeut, Mater Univ Hosp, Dublin Acad Med Ctr, Dublin, Ireland.
    Cuadrado-Godia, Elisa
    Hosp del Mar IMIM, Dept Neurol, Barcelona, Spain.
    Diez-Tejedor, Exuperio
    Univ Autonoma Madrid, Dept Neurol, La Paz Univ Hosp, Madrid, Spain; Univ Autonoma Madrid, Stroke Ctr, La Paz Univ Hosp, Madrid, Spain.
    Di Napoli, Mario
    San Camillo deLellis Gen Hosp, Neurol Serv, Rieti, Italy; Ctr Cardiovasc Med & Cerebrovasc Dis Prevent, SMDN, Laquila, Italy .
    Engelter, Stefan T.
    Univ Basel Hosp, Dept Neurol, Basel, Switzerland.
    Furie, Karen L.
    Massachusetts Gen Hosp, J Philip Kistler Stroke Res Ctr, Ctr Human Genet Res, Boston, MA USA.
    Giannopoulos, Sotirios
    Univ Ioannina, Sch Med, Ioannina, Greece.
    Gotto, Antonio M., Jr.
    Weill Cornell Med Coll, New York, NY USA.
    Hannon, Niamh
    Natl Univ Ireland Univ Coll Dublin, Neurovasc Unit Appl Translat Res & Therapeut, Mater Univ Hosp, Dublin Acad Med Ctr, Dublin, Ireland.
    Jonsson, Fredrik
    Umeå Univ Hosp, Dept Med, Umeå, Sweden.
    Kapral, Moira K.
    Toronto Gen Hosp, Inst Clin Evaluat Sci, Toronto, ON, Canada.
    Martí-Fàbregas, Joan
    Hosp Santa Creu & Sant Pau, Barcelona, Spain.
    Martínez-Sánchez, Patricia
    Univ Autonoma Madrid, Dept Neurol, La Paz Univ Hosp, Madrid, Spain; Univ Autonoma Madrid, Stroke Ctr, La Paz Univ Hosp, Madrid, Spain.
    Milionis, Haralampos J.
    Univ Ioannina, Sch Med, Ioannina, Greece.
    Montaner, Joan
    Autonomous Univ Barcelona, Hosp Vall dHebron, Barcelona, Spain; Autonomous Univ Barcelona, Vall dHebron Res Inst VHIR, Barcelona, Spain.
    Muscari, Antonio
    Univ Bologna, S Orsola Malpighi Hosp, Bologna, Italy.
    Pikija, Slaven
    Gen Hosp Varazdin, Varazhdin, Croatia.
    Probstfield, Jeffrey
    Univ Washington, Dept Med, Seattle, WA USA; Univ Washington, Dept Epidemiol, Seattle, WA USA.
    Rost, Natalia S.
    Massachusetts Gen Hosp, J Philip Kistler Stroke Res Ctr, Ctr Human Genet Res, Boston, MA USA.
    Thrift, Amanda G.
    Monash Univ, Monash Med Ctr, Stroke & Ageing Res Ctr, Dept Med, Clayton, Vic, Australia; Natl Stroke Res Inst, Heidelberg, Vic, Australia.
    Vemmos, Konstantinos
    Univ Athens, Dept Therapeut, Alexandra Hosp, Athens, Greece.
    Kelly, Peter J.
    Natl Univ Ireland Univ Coll Dublin, Neurovasc Unit Appl Translat Res & Therapeut, Mater Univ Hosp, Dublin Acad Med Ctr, Dublin, Ireland.
    Statin Therapy and Outcome After Ischemic Stroke: Systematic Review and Meta-Analysis of Observational Studies and Randomized Trials2013In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 44, no 2, p. 448-456Article, review/survey (Refereed)
    Abstract [en]

    Background and Purpose: Although experimental data suggest that statin therapy may improve neurological outcome after acute cerebral ischemia, the results from clinical studies are conflicting. We performed a systematic review and meta-analysis investigating the relationship between statin therapy and outcome after ischemic stroke.

    Methods: The primary analysis investigated statin therapy at stroke onset (prestroke statin use) and good functional outcome (modified Rankin score 0 to 2) and death. Secondary analyses included the following: (1) acute poststroke statin therapy (≤72 hours after stroke), and (2) thrombolysis-treated patients.

    Results: The primary analysis included 113 148 subjects (27 studies). Among observational studies, statin treatment at stroke onset was associated with good functional outcome at 90 days (pooled odds ratio [OR], 1.41; 95% confidence interval [CI], 1.29–1.56; P<0.001), but not 1 year (OR, 1.12; 95% CI, 0.9–1.4; P=0.31), and with reduced fatality at 90 days (pooled OR, 0.71; 95% CI, 0.62–0.82; P<0.001) and 1 year (OR, 0.80; 95% CI, 0.67–0.95; P=0.01). In the single randomized controlled trial reporting 90-day functional outcome, statin treatment was associated with good outcome (OR, 1.5; 95% CI, 1.0–2.24; P=0.05). No reduction in fatality was observed on meta-analysis of data from 3 randomized controlled trials (P=0.9). In studies restricted to of thrombolysis-treated patients, an association between statins and increased fatality at 90 days was observed (pooled OR, 1.25; 95% CI, 1.02–1.52; P=0.03, 3 studies, 4339 patients). However, this association was no longer present after adjusting for age and stroke severity in the largest study (adjusted OR, 1.14; 95% CI, 0.90–1.44; 4012 patients).

    Conclusion: In the largest meta-analysis to date, statin therapy at stroke onset was associated with improved outcome, a finding not observed in studies restricted to thrombolysis-treated patients. Randomized trials of statin therapy in acute ischemic stroke are needed.

  • 27. Dennis, Martin
    et al.
    Forbes, John
    Graham, Catriona
    Hackett, Maree L
    Hankey, Graeme J
    House, Allan
    Lewis, Steff
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience.
    Sandercock, Peter
    Mead, Gillian
    Fluoxetine and Fractures After Stroke: Exploratory Analyses From the FOCUS Trial2019In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 50, no 11, p. 3280-3282Article in journal (Refereed)
    Abstract [en]

    Background and Purpose- The FOCUS trial (Fluoxetine or Control Under Supervision) showed that fluoxetine did not improve modified Rankin Scale scores (mRS) but increased the risk of fractures. We aimed to describe the fractures, their impact on mRS and factors associated with fracture risk. Methods- A United Kingdom, multicenter, parallel-group, randomized, placebo-controlled trial. Patients ≥18 years with a clinical stroke and persisting deficit assessed 2 to 15 days after onset were eligible. Consenting patients were allocated fluoxetine 20 mg or matching placebo for 6 months. The primary outcome was the mRS at 6 months and secondary outcomes included fractures. Results- Sixty-five of 3127 (2.1%) patients had 67 fractures within 6 months of randomization; 43 assigned fluoxetine and 22 placebo. Fifty-nine (90.8%) had fallen and 26 (40%) had fractured their neck of femur. The effect of fluoxetine on mRS (common odds ratio =0.951) was not significantly altered by excluding fracture patients (common odds ratio =0.961). Cox proportional hazards modeling showed that only age >70 year (hazard ratio =1.97; 95% CI, 1.13-3.45; P=0.017), female sex (hazard ratio =2.13; 95% CI, 1.29-3.51; P=0.003), and fluoxetine (hazard ratio =2.00; 95% CI, 1.20-3.34; P=0.008) were independently associated with fractures. Conclusions- Most fractures resulted from falls. Although many fractures were serious, and likely to impair patients' function, the increased fracture risk did not explain the lack of observed effect of fluoxetine on mRS. Only increasing age, female sex, and fluoxetine were independent predictors of fractures. Clinical Trial Registration- URL: http://www.controlled-trials.com. Unique identifier: ISRCTN83290762.

  • 28. Di Castelnuovo, Augusto
    et al.
    Veronesi, Giovanni
    Costanzo, Simona
    Zeller, Tanja
    Schnabel, Renate B.
    de Curtis, Amalia
    Salomaa, Veikko
    Borchini, Rossana
    Ferrario, Marco
    Giampaoli, Simona
    Kee, Frank
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Niiranen, Teemu
    Kuulasmaa, Kari
    de Gaetano, Giovanni
    Donati, Maria Benedetta
    Blankenberg, Stefan
    Iacoviello, Licia
    NT-proBNP (N-Terminal Pro-B-Type Natriuretic Peptide) and the Risk of Stroke Results From the BiomarCaRE Consortium2019In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 50, no 3, p. 610-617Article in journal (Refereed)
    Abstract [en]

    Background and Purpose: NT-proBNP (N-terminal pro-B-type natriuretic peptide) is a risk factor for atrial fibrillation and a marker of cardiac function used in the detection of heart failure. Given the link between cardiac dysfunction and stroke, NT-proBNP is a candidate marker of stroke risk. Our aim was to evaluate the association of NT-proBNP with stroke and to determine the predictive value beyond a panel of established risk factors. Methods: Based on the Biomarkers for Cardiovascular Risk Assessment in Europe-Consortium, we analyzed data of 58 173 participants (50% men; mean age 52 y) free of stroke from 6 community-based cohorts. NT-proBNP measurements were performed in the central Biomarkers for Cardiovascular Risk Assessment in Europe laboratory. The outcomes considered were total stroke and subtypes of stroke (ischemic/hemorrhagic). Results: During a median follow-up time of 7.9 years, we observed 1550 stroke events (1176 ischemic). Increasing quarters of the NT-proBNP distribution were associated with increasing risk of stroke (P for trend < 0.0001; multivariable Cox regression analysis adjusted for risk factors and cardiac diseases). Individuals in the highest NT-proBNP quarter (NTproBNP > 82.2 pg/mL) had 2-fold (95% CI, 75%-151%) greater risk of stroke than individuals in the lowest quarter (NTproBNP < 20.4 pg/mL). The association remained unchanged when adjusted for interim coronary events during followup, and though it was somewhat heterogeneous across cohorts, it was highly homogenous according to cardiovascular risk profile or subtypes of stroke. The addition of NT-proBNP to a reference model increased the C-index discrimination measure by 0.006 (P=0.0005), yielded a categorical net reclassification improvement of 2.0% in events and 1.4% in nonevents and an integrated discrimination improvement of 0.007. Conclusions: In European individuals free of stroke, levels of NT-proBNP are positively associated with risk of ischemic and hemorrhagic stroke, independently from several other risk factors and conditions. The addition of NT-proBNP to variables of established risk scores improves prediction of stroke, with a medium effect size.

  • 29. Ellekjaer, Hanne
    et al.
    Holmen, Jostein
    Krüger, Oystein
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Internal Medicine.
    Identification of incident stroke in Norway: hospital discharge data compared with a population-based stroke register1999In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 30, no 1, p. 56-60Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: The validity of hospital discharge diagnoses is essential in improving stroke surveillance and estimating healthcare costs of stroke. The aim of this study was to assess sensitivity, positive predictive value, and accuracy of discharge diagnoses compared with a stroke register. METHODS: A record linkage was made between a population-based stroke register and the discharge records of the hospital serving the population of the stroke register (n=70 000). The stroke register (including patients aged 15 and older and with no upper age limit), applied here as a "gold standard," was used to estimate sensitivity, positive predictive value, and accuracy of the discharge diagnoses classification. The length of stay in hospital by stroke patients was measured. RESULTS: Identifying cerebrovascular diseases by hospital discharge diagnoses (International Classification of Diseases, 9th Revision [ICD-9], codes 430 to 438.9, first admission) lead to a substantial overestimation of stroke in the target population. Restricting the retrieval to acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436) gave an incidence estimate closer to the "true" incidence rate in the stroke register. Selecting ICD-9 codes 430 to 438 of cerebrovascular diseases gave the highest sensitivity (86%). The highest positive predictive value (68%) was achieved by selecting acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436), at the expense of a lower sensitivity (81%). Accuracy of ICD codes 430 to 438.9 (n=678) revealed the highest proportion of incident strokes identified by the acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436). Seventy-four percent of hospital discharge diagnoses classified as first-ever stroke kept the original diagnosis. Only 4.6% of the discharge diagnoses were classified as nonstroke diagnoses after validation. The estimation of length of stay in the hospital was improved by selection of acute stroke diagnoses from hospital discharge data (ICD-9 codes 430, 431, 434, and 436), which gave the same estimate of length of stay, a median of 8 days (2.5 percentile=0 and 97.5 percentile=56), compared with a median of 8 days (2.5 percentile=0 and 97.5 percentile=51) based on the stroke register. CONCLUSIONS: Hospital discharge data may overestimate stroke incidence and underestimate the length of stay in the hospital, unless selection routines of hospital discharge diagnoses are restricted to acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436). If supplemented by a validation procedure, including estimates of sensitivity, positive predictive value, and accuracy, hospital discharge data may provide valid information on hospital-based stroke incidence and lead to better allocation of health resources. Distinguishing subtypes of stroke from hospital discharge diagnoses should not be performed unless coding practices are improved.

  • 30. Eriksson, M.
    et al.
    Appelros, P.
    Norrving, B.
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Stegmayr, B.
    Assessment of functional outcome in a national quality register for acute stroke: Can simple self-reported items be transformed into the modified Rankin Scale?2007In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 38, no 4, p. 1384-1386Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE - To enable self-reporting of functional outcome in quality registers, the corresponding questions have to be easy to interpret. In scientific research, the modified Rankin Scale (mRS) is a standard assessment method. Such methods, with an outsider observer, are not feasible to use in quality registers. For several aspects, eg, comparisons between outcome in clinical studies and observational studies, we determined to see whether the functional outcome, as assessed in a quality register, can be transformed into mRS grades. METHODS - The agreement between self-reported functional outcome (including dependency, living situation, mobility, dressing and toileting) and mRS were analyzed using 555 stroke patients registered in Riks-Stroke, the Swedish quality register for acute stroke, during a 5-month period in 4 hospitals. The self-reported outcome and the mRS grades were concurrently assessed by a telephone interview performed by an experienced nurse 3 months after stroke. RESULTS - A translation using 5 of the questions from Riks-Stroke classified 76% of the patients to the correct mRS grade. The correlation between Riks-Stroke and mRS was 0.821 and Cohen's κ (weighted) was 0.853. CONCLUSION - The study shows that self-reported functional outcome can be transformed into mRS grades with a high precision, making the translation useful for future comparative purposes in stroke outcome studies.

  • 31. Eriksson, Marie
    et al.
    Glader, Eva-Lotta
    Norrving, Bo
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Stegmayr, Birgitta
    Sex differences in stroke care and outcome in the Swedish national quality register for stroke care2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 3, p. 909-14Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Previous reports concerning sex-related differences in stroke management and outcome are inconsistent and are sometimes difficult to interpret. We used data from a national stroke register to further explore possible differences between men and women in baseline characteristics, stroke treatment, and outcome. METHODS: This study included 24633 stroke events registered in Riks-Stroke, the Swedish national quality register for stroke care, during 2006. Information on background variables and treatment was collected during the hospital stay. After 3 months, the patients' living situation and outcome were assessed. RESULTS: Women were older than men when they had their stroke (mean age, 78.4 versus 73.6 years; P<0.001). On admission to the hospital, women were more often unconscious. Among conscious patients, there was no sex-related difference in the use of stroke unit care. Men and women had equal probability to receive thrombolysis and oral anticoagulants. Women were more likely to develop deep venous thromboses and fractures, whereas men were more likely to develop pneumonia during their hospital stay. Women had a lower 3-month survival, a difference that was associated with higher age and impaired level of consciousness on admission. Women were less often living at home at the 3-month follow-up. However, the difference in residency was not present in patients <85 years who were living at home without community support before the stroke. CONCLUSIONS: Reported sex differences in stroke care and outcome were mainly explained by the women's higher age and lower level of consciousness on admission.

  • 32.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
    Norrving, Bo
    the Department of Neurology, Lund University Hospital, Lund, Sweden.
    Terént, Andreas
    the Department of Medical Sciences, Uppsala University Hospital, Uppsala.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Sex differences in stroke care and outcome in the Swedish national quality register for stroke care2009In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 40, no 3, p. 909-914Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Previous reports concerning sex-related differences in stroke management and outcome are inconsistent and are sometimes difficult to interpret. We used data from a national stroke register to further explore possible differences between men and women in baseline characteristics, stroke treatment, and outcome.

    Methods: This study included 24633 stroke events registered in Riks-Stroke, the Swedish national quality register for stroke care, during 2006. Information on background variables and treatment was collected during the hospital stay. After 3 months, the patients' living situation and outcome were assessed.

    Results: Women were older than men when they had their stroke (mean age, 78.4 versus 73.6 years; P<0.001). On admission to the hospital, women were more often unconscious. Among conscious patients, there was no sex-related difference in the use of stroke unit care. Men and women had equal probability to receive thrombolysis and oral anticoagulants. Women were more likely to develop deep venous thromboses and fractures, whereas men were more likely to develop pneumonia during their hospital stay. Women had a lower 3-month survival, a difference that was associated with higher age and impaired level of consciousness on admission. Women were less often living at home at the 3-month follow-up. However, the difference in residency was not present in patients <85 years who were living at home without community support before the stroke.

    Conclusions: Reported sex differences in stroke care and outcome were mainly explained by the women's higher age and lower level of consciousness on admission.

  • 33.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jonsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Appelros, Peter
    Asberg, Kerstin Hulter
    Norrving, Bo
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terént, Andreas
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Dissemination of thrombolysis for acute ischemic stroke across a nation: experiences from the Swedish stroke register, 2003 to 20082010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 6, p. 1115-22Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: We used Riks-Stroke, the Swedish Stroke Register, to explore how thrombolysis has been disseminated in Swedish hospitals since it was approved in 2003. METHODS: All 78 hospitals in Sweden admitting patients with acute stroke participate in Riks-Stroke. Between 2003 and 2008, 72 033 adult patients were hospitalized for acute ischemic stroke. We analyzed thrombolysis use by region, patient characteristics, and stroke service settings. RESULTS: Nationwide, the use of thrombolysis increased from 0.9% in 2003 to 6.6% in 2008. There were marked regional differences in the dissemination of thrombolysis, but these gaps narrowed over time. Nonuniversity hospitals reached treatment levels similar to university settings, although with a 2- to 3-year delay. Symptomatic intracranial hemorrhage remained at the 3% to 9% level without an apparent time trend during dissemination. Independent predictors of higher thrombolysis use included younger age, male sex, not living alone, and no history of stroke or diabetes. In 2008, patients admitted to a stroke unit were 5 times more likely to receive thrombolysis than those admitted to general wards. CONCLUSIONS: Nationwide implementation of thrombolysis has been slow but has accelerated mainly due to increased access outside university hospitals. The increased use has been achieved safely, but access has been unequal.

  • 34. Eriksson, Marie
    et al.
    Jonsson, Fredrik
    Appelros, Peter
    Åsberg, Kerstin Hulter
    Norrving, Bo
    Stegmayr, Birgitta
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Internal Medicine.
    Asplund, Kjell
    Dissemination of thrombolysis for acute ischemic stroke across a nation: experiences from the Swedish stroke register, 2003 to 20082010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 6, p. 1115-1122Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: We used Riks-Stroke, the Swedish Stroke Register, to explore how thrombolysis has been disseminated in Swedish hospitals since it was approved in 2003. METHODS: All 78 hospitals in Sweden admitting patients with acute stroke participate in Riks-Stroke. Between 2003 and 2008, 72 033 adult patients were hospitalized for acute ischemic stroke. We analyzed thrombolysis use by region, patient characteristics, and stroke service settings. RESULTS: Nationwide, the use of thrombolysis increased from 0.9% in 2003 to 6.6% in 2008. There were marked regional differences in the dissemination of thrombolysis, but these gaps narrowed over time. Nonuniversity hospitals reached treatment levels similar to university settings, although with a 2- to 3-year delay. Symptomatic intracranial hemorrhage remained at the 3% to 9% level without an apparent time trend during dissemination. Independent predictors of higher thrombolysis use included younger age, male sex, not living alone, and no history of stroke or diabetes. In 2008, patients admitted to a stroke unit were 5 times more likely to receive thrombolysis than those admitted to general wards. CONCLUSIONS: Nationwide implementation of thrombolysis has been slow but has accelerated mainly due to increased access outside university hospitals. The increased use has been achieved safely, but access has been unequal.

  • 35.
    Eriksson, Marie
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stecksén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norrving, Bo
    Appelros, Peter
    Hulter Åsberg, Kerstin
    Stegmayr, Birgitta
    The National Board of Health and Welfare, Stockholm, Sweden.
    Terént, Andreas
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Discarding heparins as treatment for progressive stroke in Sweden 2001 to 20082010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 11, p. 2552-2558Article in journal (Refereed)
    Abstract [en]

    There is no immediate, stepwise effect of new scientific information and national guidelines on clinical practice. Rather, the phasing out of heparin has followed a linear course over several years, with less variation between hospitals. We speculate that open comparisons between hospitals in a national stroke register may have helped to reduce the variations in clinical practice.

  • 36. Eriksson, Marie
    et al.
    Stecksén, Anna
    Glader, Eva-Lotta
    Norrving, Bo
    Appelros, Peter
    Åsberg, Kerstin Hulter
    Stegmayr, Birgitta
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Asplund, Kjell
    Discarding Heparins as Treatment for Progressive Stroke in Sweden 2001 to 20082010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 11, p. 2552-2558Article in journal (Refereed)
    Abstract [en]

    Background and Purpose - High-dose heparin has been used extensively to treat patients with progressive ischemic stroke, but the scientific support is poor and the current stroke guidelines advise against its use. We studied how heparin treatment for progressive stroke has been discarded in Sweden. Methods - All 78 hospitals in Sweden that admit acute stroke patients participate in Riks-Stroke, the Swedish Stroke Register. During 2001 to 2008, information on the use of high-dose heparin was available for 155 344 patients with acute ischemic stroke. The determinants as to region, patient characteristics, and stroke service settings were analyzed. Results - Use of heparin for progressive stroke declined from 7.5% (2001) to 1.6% (2008) of all patients with ischemic stroke. The marked regional differences present in 2001 were reduced over time. The use of heparin declined at a similar rate in all types of hospital settings, in stroke units vs nonstroke units, and in neurological vs medical wards. Independent predictors of use of heparin included younger age, first-ever stroke, independence in activities of daily living before stroke, atrial fibrillation, no aspirin treatment, and lowered consciousness on admission. Conclusions - There is no immediate, stepwise effect of new scientific information and national guidelines on clinical practice. Rather, the phasing out of heparin has followed a linear course over several years, with less variation between hospitals. We speculate that open comparisons between hospitals in a national stroke register may have helped to reduce the variations in clinical practice.

  • 37.
    Falkstedt, Daniel
    et al.
    Stockholm University, Faculty of Social Sciences, Centre for Social Research on Alcohol and Drugs (SoRAD). Karolinska Institutet, Sweden; University of Strasbourg, France; Stockholm County Council, Sweden.
    Wolff, Valerie
    Stockholm University, Faculty of Social Sciences, Centre for Social Research on Alcohol and Drugs (SoRAD). Karolinska Institutet, Sweden; University of Strasbourg, France; Stockholm County Council, Sweden.
    Allebeck, Peter
    Stockholm University, Faculty of Social Sciences, Centre for Social Research on Alcohol and Drugs (SoRAD). Karolinska Institutet, Sweden; University of Strasbourg, France; Stockholm County Council, Sweden.
    Hemmingsson, Tomas
    Stockholm University, Faculty of Social Sciences, Centre for Social Research on Alcohol and Drugs (SoRAD). Karolinska Institutet, Sweden; University of Strasbourg, France; Stockholm County Council, Sweden.
    Danielsson, Anna-Karin
    Stockholm University, Faculty of Social Sciences, Centre for Social Research on Alcohol and Drugs (SoRAD). Karolinska Institutet, Sweden; University of Strasbourg, France; Stockholm County Council, Sweden.
    Cannabis, Tobacco, Alcohol Use, and the Risk of Early Stroke: A Population-Based Cohort Study of 45000 Swedish Men2017In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 48, no 2, p. 265-270Article in journal (Refereed)
    Abstract [en]

    Background and Purpose - Current knowledge on cannabis use in relation to stroke is based almost exclusively on clinical reports. By using a population-based cohort, we aimed to find out whether there was an association between cannabis use and early-onset stroke, when accounting for the use of tobacco and alcohol.

    Methods - The cohort comprises 49321 Swedish men, born between 1949 and 1951, who were conscripted into compulsory military service between the ages of 18 and 20. All men answered 2 detailed questionnaires at conscription and were subject to examinations of physical aptitude, psychological functioning, and medical status. Information on stroke events up to approximate to 60 years of age was obtained from national databases; this includes strokes experienced before 45 years of age.

    Results - No associations between cannabis use in young adulthood and strokes experienced 45 years of age or beyond were found in multivariable models: cannabis use >50 times, hazard ratios=0.93 (95% confidence interval [CI], 0.34-2.57) and 0.95 (95% CI, 0.59-1.53). Although an almost doubled risk of ischemic stroke was observed in those with cannabis use >50 times, this risk was attenuated when adjusted for tobacco usage: hazards ratio=1.47 (95% CI, 0.83-2.56). Smoking 20 cigarettes per day was clearly associated both with strokes before 45 years of age, hazards ratio=5.04 (95% CI, 2.80-9.06), and with strokes throughout the follow-up, hazards ratio=2.15 (95% CI, 1.61-2.88).

    Conclusions - We found no evident association between cannabis use in young adulthood and stroke, including strokes before 45 years of age. Tobacco smoking, however, showed a clear, dose-response shaped association with stroke.

  • 38. Feigin, Valery L.
    et al.
    Parmar, Priya G.
    Barker-Collo, Suzanne
    Bennett, Derrick A.
    Anderson, Craig S.
    Thrift, Amanda G.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Rothwell, Peter M.
    Giroud, Maurice
    Bejot, Yannick
    Carvil, Phillip
    Krishnamurthi, Rita
    Kasabov, Nikola
    Geomagnetic Storms Can Trigger Stroke Evidence From 6 Large Population-Based Studies in Europe and Australasia2014In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 45, no 6, p. 1639-1645Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Although the research linking cardiovascular disorders to geomagnetic activity is accumulating, robust evidence for the impact of geomagnetic activity on stroke occurrence is limited and controversial. Methods-We used a time-stratified case-crossover study design to analyze individual participant and daily geomagnetic activity (as measured by Ap Index) data from several large population-based stroke incidence studies (with information on 11 453 patients with stroke collected during 16 031 764 person-years of observation) in New Zealand, Australia, United Kingdom, France, and Sweden conducted between 1981 and 2004. Hazard ratios and corresponding 95% confidence intervals (CIs) were calculated. Results-Overall, geomagnetic storms (Ap Index 60+) were associated with 19% increase in the risk of stroke occurrence (95% CI, 11%-27%). The triggering effect of geomagnetic storms was most evident across the combined group of all strokes in those aged <65 years, increasing stroke risk by >50%: moderate geomagnetic storms (60-99 Ap Index) were associated with a 27% (95% CI, 8%-48%) increased risk of stroke occurrence, strong geomagnetic storms (100-149 Ap Index) with a 52% (95% CI, 19%-92%) increased risk, and severe/extreme geomagnetic storms (Ap Index 150+) with a 52% (95% CI, 19%-94%) increased risk (test for trend, P<2x10(-16)). Conclusions-Geomagnetic storms are associated with increased risk of stroke and should be considered along with other established risk factors. Our findings provide a framework to advance stroke prevention through future investigation of the contribution of geomagnetic factors to the risk of stroke occurrence and pathogenesis.

  • 39. Fiskesund, Roland
    et al.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Vikström, Max
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    de Faire, Ulf
    Frostegård, Johan
    Low levels of antibodies against phosphorylcholine predict development of stroke in a population-based study from northern Sweden2010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 4, p. 607-612Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Natural immunoglobulin M antibodies specific for phosphorylcholine (anti-PC) have been implicated in atherosclerosis. We have shown previously that high levels of anti-PC predict a slower progression of atherosclerosis in humans and that low levels of anti-PC are associated with higher risk for cardiovascular disease. Here we determine the association between anti-PC and the incidence of stroke. METHODS: Using a nested case control study design, we examined 227 incident cases (125 men and 102 women) of first-time stroke and 455 age- and sex-matched controls identified during a 13-year time period (1985 to 1999) within the population-based cohorts of the Västerbotten Intervention Project (VIP) and the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) project in Northern Sweden. Odds ratios of stroke with 95% CIs with adjustments for age, gender, smoking, serum cholesterol, diabetes, body mass index, and blood pressure were determined. Anti-PC levels were measured using ELISA. RESULTS: A significant association between low levels of anti-PC at baseline and incident stroke was seen for the whole group of anti-PC levels below the 30th percentile (multivariately adjusted odds ratio, 1.62; CI, 1.11 to 2.35). Analyses of gender-specific associations indicated fairly strong associations for females, especially at the lowest 30th percentile (multivariately adjusted odds ratio, 2.65; CI, 1.41 to 4.95). No associations were noted for men. CONCLUSION: Low anti-PC is a novel independent risk marker for development of stroke. Measurements of anti-PC could be used to identify immunodeficient subjects at an increased risk for stroke. The possibility that such subjects might be targets for novel modes of treatment such as immunotherapies deserves further investigation.

  • 40.
    Fragata, Isabel
    et al.
    Ctr Hosp Lisboa Cent, Dept Neuroradiol, Rua Jose Antonio Serrano, P-1150099 Lisbon, Portugal..
    Alves, Marta
    Ctr Hosp Lisboa Cent, Ctr Invest, Lisbon, Portugal..
    Papoila, Ana Lusia
    Ctr Hosp Lisboa Cent, Ctr Invest, Lisbon, Portugal.;Ctr Hosp Lisboa Cent, Unidade Cerebrovasc, Lisbon, Portugal.;NOVA Med Sch, Fac Ciencias Med, Lisbon, Portugal..
    Nunes, Ana Paiva
    Ferreira, Patricia
    Ctr Hosp Lisboa Cent, Unidade Cerebrovasc, Lisbon, Portugal..
    Canto-Moreira, Nuno
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Canhao, Patricia
    Ctr Hosp Lisboa Norte, Dept Neurol, Lisbon, Portugal.;Univ Lisbon, Fac Med, Inst Med Mol, Lisbon, Portugal..
    Early Prediction of Delayed Ischemia and Functional Outcome in Acute Subarachnoid Hemorrhage: Role of Diffusion Tensor Imaging2017In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 48, no 8, p. 2091-2097Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Diffusion tensor imaging (DTI) parameters are markers of cerebral lesion in some diseases. In patients with acute subarachnoid hemorrhage (SAH), we investigated whether DTI parameters measured at < 72 hours might be associated with delayed cerebral ischemia (DCI) and with poor functional outcome at 3 months (modified Rankin Scale score =3).

    Methods-DTI was performed in a prospective cohort of 60 patients with nontraumatic SAH at < 72 hours. Association of fractional anisotropy and apparent diffusion coefficient values at < 72 hours with the occurrence of DCI and outcome at 3 months was evaluated with logistic regression models, adjusting for known predictors of prognosis.

    Results-At < 72 hours after SAH, fractional anisotropy values at the cerebellum were associated with DCI occurrence (78% less odds of DCI for each 0.1 increase in fractional anisotropy; P=0.019). Early apparent diffusion coefficient values were not associated with DCI. After adjusting for confounding variables, an increase of 10 U in apparent diffusion coefficient at the frontal centrum semiovale corresponded to 15% increased odds of poor outcome (P=0.061).

    Conclusions-DTI parameters at < 72 hours post-SAH are independently associated with the occurrence of DCI and functional outcome. These preliminary results suggest the role of DTI parameters as surrogate markers of prognosis in nontraumatic SAH.

  • 41. Fransson, Eleonor I.
    et al.
    Nyberg, Solja T.
    Heikkila, Katriina
    Alfredsson, Lars
    Bjorner, Jakob B.
    Borritz, Marianne
    Burr, Hermann
    Dragano, Nico
    Geuskens, Goedele A.
    Goldberg, Marcel
    Hamer, Mark
    Hooftman, Wendela E.
    Houtman, Irene L.
    Joensuu, Matti
    Jokela, Markus
    Knutsson, Anders
    Koskenvuo, Markku
    Koskinen, Aki
    Kumari, Meena
    Leineweber, Constanze
    Lunau, Thorsten
    Madsen, Ida E. H.
    Hanson, Linda L. Magnusson
    Nielsen, Martin L.
    Nordin, Maria
    Oksanen, Tuula
    Pentti, Jaana
    Pejtersen, Jan H.
    Rugulies, Reiner
    Salo, Paula
    Shipley, Martin J.
    Steptoe, Andrew
    Suominen, Sakari B.
    Theorell, Toeres
    Toppinen-Tanner, Salla
    Vahtera, Jussi
    Virtanen, Marianna
    Vaananen, Ari
    Westerholm, Peter J. M.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Occupational and Environmental Medicine.
    Westerlund, Hugo
    Zins, Marie
    Britton, Annie
    Brunner, Eric J.
    Singh-Manoux, Archana
    Batty, G. David
    Kivimaki, Mika
    Job Strain and the Risk of Stroke An Individual-Participant Data Meta-Analysis2015In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 46, no 2, p. 557-559Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Psychosocial stress at work has been proposed to be a risk factor for cardiovascular disease. However, its role as a risk factor for stroke is uncertain. Methods-We conducted an individual-participant-data meta-analysis of 196 380 males and females from 14 European cohort studies to investigate the association between job strain, a measure of work-related stress, and incident stroke. Results-In 1.8 million person-years at risk (mean follow-up 9.2 years), 2023 first-time stroke events were recorded. The age-and sex-adjusted hazard ratio for job strain relative to no job strain was 1.24 (95% confidence interval, 1.05; 1.47) for ischemic stroke, 1.01 (95% confidence interval, 0.75; 1.36) for hemorrhagic stroke, and 1.09 (95% confidence interval, 0.94; 1.26) for overall stroke. The association with ischemic stroke was robust to further adjustment for socioeconomic status. Conclusion-Job strain may be associated with an increased risk of ischemic stroke, but further research is needed to determine whether interventions targeting job strain would reduce stroke risk beyond existing preventive strategies.

  • 42.
    Fransson, Eleonor I.
    et al.
    Department of Natural Science and Biomedicine, School of Health Sciences, Jönköping University, Box 1026, Jönköping, Sweden.
    Nyberg, Solja T.
    Finnish Institute of Occupational Health, Tampere, Finland.
    Heikkila, Katriina
    Finnish Institute of Occupational Health, Tampere, Finland.
    Alfredsson, Lars
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden .
    Bjorner, Jakob B.
    National Research Centre for the Working Environment, Copenhagen, Denmark.
    Borritz, Marianne
    Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark .
    Burr, Hermann
    Federal Institute for Occupational Safety and Health (BAuA), Berlin, Germany .
    Dragano, Nico
    Institute for Medical Sociology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany .
    Geuskens, Goedele A.
    Netherlands Organisation for Applied Scientific Research (TNO), Hoofddorp, Netherlands .
    Goldberg, Marcel
    Versailles-Saint Quentin University, Versailles, France .
    Hamer, Mark
    Department of Epidemiology and Public Health, University College London, London, United Kingdom.
    Hooftman, Wendela E.
    Netherlands Organisation for Applied Scientific Research (TNO), Hoofddorp, Netherlands .
    Houtman, Irene L.
    Netherlands Organisation for Applied Scientific Research (TNO), Hoofddorp, Netherlands .
    Joensuu, Matti
    Finnish Institute of Occupational Health, Helsinki, Finland .
    Jokela, Markus
    Institute of Behavioural Sciences, University of Helsinki, Helsinki, Finland .
    Knutsson, Anders
    Mid Sweden University, Faculty of Human Sciences, Department of Health Sciences.
    Koskenvuo, Markku
    Department of Public Health, University of Helsinki, Helsinki, Finland.
    Koskinen, Aki
    Finnish Institute of Occupational Health, Helsinki, Finland.
    Kumari, Meena
    Department of Epidemiology and Public Health, University College London, London, United Kingdom .
    Leineweber, Constanze
    Stress Research Institute, Stockholm University, Stockholm, Sweden.
    Lunau, Thorsten
    Institute for Medical Sociology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany .
    Madsen, Ida E. H.
    National Research Centre for the Working Environment, Copenhagen, Denmark .
    Hanson, Linda L. Magnusson
    Stress Research Institute, Stockholm University, Stockholm, Sweden.
    Nielsen, Martin L.
    Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark .
    Nordin, Maria
    Department of Psychology, Umeå University, Umeå, Sweden .
    Oksanen, Tuula
    Finnish Institute of Occupational Health, Turku, Finland .
    Pentti, Jaana
    Finnish Institute of Occupational Health, Turku, Finland .
    Pejtersen, Jan H.
    Danish National Centre for Social Research, Copenhagen, Denmark.
    Rugulies, Reiner
    Department of Public Health, Department of Psychology, University of Copenhagen, Copenhagen, Denmark .
    Salo, Paula
    Finnish Institute of Occupational Health, Turku, Finland .
    Shipley, Martin J.
    Department of Epidemiology and Public Health, University College London, London, United Kingdom .
    Steptoe, Andrew
    Department of Epidemiology and Public Health, University College London, London, United Kingdom .
    Suominen, Sakari B.
    Folkhälsan Research Centre, Helsinki, Finland .
    Theorell, Toeres
    Stress Research Institute, Stockholm University, Stockholm, Sweden .
    Toppinen-Tanner, Salla
    Finnish Institute of Occupational Health, Helsinki, Finland .
    Vahtera, Jussi
    Finnish Institute of Occupational Health, Turku, Finland .
    Virtanen, Marianna
    Finnish Institute of Occupational Health, Helsinki, Finland .
    Vaananen, Ari
    Finnish Institute of Occupational Health, Helsinki, Finland .
    Westerholm, Peter J. M.
    Department of Medical Sciences, Occupational and Environmental Medicine, Uppsala University, Uppsala, Sweden .
    Westerlund, Hugo
    Stress Research Institute, Stockholm University, Stockholm, Sweden .
    Zins, Marie
    Department of Natural Science and Biomedicine, School of Health Sciences, Jönköping University, Box 1026, Jönköping, Sweden .
    Britton, Annie
    Department of Epidemiology and Public Health, University College London, London, United Kingdom .
    Brunner, Eric J.
    Department of Epidemiology and Public Health, University College London, London, United Kingdom .
    Singh-Manoux, Archana
    Department of Epidemiology and Public Health, University College London, London, United Kingdom .
    Batty, G. David
    Department of Epidemiology and Public Health, University College London, London, United Kingdom .
    Kivimaki, Mika
    Department of Epidemiology and Public Health, University College London, London, United Kingdom .
    Job Strain and the Risk of Stroke An Individual-Participant Data Meta-Analysis2015In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 46, no 2, p. 557-559Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Psychosocial stress at work has been proposed to be a risk factor for cardiovascular disease. However, its role as a risk factor for stroke is uncertain. Methods-We conducted an individual-participant-data meta-analysis of 196 380 males and females from 14 European cohort studies to investigate the association between job strain, a measure of work-related stress, and incident stroke. Results-In 1.8 million person-years at risk (mean follow-up 9.2 years), 2023 first-time stroke events were recorded. The age-and sex-adjusted hazard ratio for job strain relative to no job strain was 1.24 (95% confidence interval, 1.05; 1.47) for ischemic stroke, 1.01 (95% confidence interval, 0.75; 1.36) for hemorrhagic stroke, and 1.09 (95% confidence interval, 0.94; 1.26) for overall stroke. The association with ischemic stroke was robust to further adjustment for socioeconomic status. Conclusion-Job strain may be associated with an increased risk of ischemic stroke, but further research is needed to determine whether interventions targeting job strain would reduce stroke risk beyond existing preventive strategies.

  • 43. Fransson, Eleonor I.
    et al.
    Nyberg, Solja T.
    Heikkila, Katriina
    Alfredsson, Lars
    Bjorner, Jakob B.
    Borritz, Marianne
    Burr, Hermann
    Dragano, Nico
    Geuskens, Goedele A.
    Goldberg, Marcel
    Hamer, Mark
    Hooftman, Wendela E.
    Houtman, Irene L.
    Joensuu, Matti
    Jokela, Markus
    Knutsson, Anders
    Koskenvuo, Markku
    Koskinen, Aki
    Kumari, Meena
    Leineweber, Constanze
    Lunau, Thorsten
    Madsen, Ida E. H.
    Hanson, Linda L. Magnusson
    Nielsen, Martin L.
    Nordin, Maria
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Oksanen, Tuula
    Pentti, Jaana
    Pejtersen, Jan H.
    Rugulies, Reiner
    Salo, Paula
    Shipley, Martin J.
    Steptoe, Andrew
    Suominen, Sakari B.
    Theorell, Toeres
    Toppinen-Tanner, Salla
    Vahtera, Jussi
    Virtanen, Marianna
    Vaananen, Ari
    Westerholm, Peter J. M.
    Westerlund, Hugo
    Zins, Marie
    Britton, Annie
    Brunner, Eric J.
    Singh-Manoux, Archana
    Batty, G. David
    Kivimaki, Mika
    Job Strain and the Risk of Stroke An Individual-Participant Data Meta-Analysis2015In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 46, no 2, p. 557-559Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Psychosocial stress at work has been proposed to be a risk factor for cardiovascular disease. However, its role as a risk factor for stroke is uncertain. Methods-We conducted an individual-participant-data meta-analysis of 196 380 males and females from 14 European cohort studies to investigate the association between job strain, a measure of work-related stress, and incident stroke. Results-In 1.8 million person-years at risk (mean follow-up 9.2 years), 2023 first-time stroke events were recorded. The age-and sex-adjusted hazard ratio for job strain relative to no job strain was 1.24 (95% confidence interval, 1.05; 1.47) for ischemic stroke, 1.01 (95% confidence interval, 0.75; 1.36) for hemorrhagic stroke, and 1.09 (95% confidence interval, 0.94; 1.26) for overall stroke. The association with ischemic stroke was robust to further adjustment for socioeconomic status. Conclusion-Job strain may be associated with an increased risk of ischemic stroke, but further research is needed to determine whether interventions targeting job strain would reduce stroke risk beyond existing preventive strategies.

  • 44.
    Fransson, Eleonor I
    et al.
    Jönköping University, School of Health and Welfare, HHJ, Dep. of Natural Science and Biomedicine. Jönköping University, School of Health and Welfare, HHJ. ADULT.
    Nyberg, Solja T
    Heikkilä, Katriina
    Alfredsson, Lars
    Bjorner, Jakob B
    Borritz, Marianne
    Burr, Hermann
    Dragano, Nico
    Geuskens, Goedele A
    Goldberg, Marcel
    Hamer, Mark
    Hooftman, Wendela E
    Houtman, Irene L
    Joensuu, Matti
    Jokela, Markus
    Knutsson, Anders
    Koskenvuo, Markku
    Koskinen, Aki
    Kumari, Meena
    Leineweber, Constanze
    Lunau, Thorsten
    Madsen, Ida E H
    Hanson, Linda L Magnusson
    Nielsen, Martin L
    Nordin, Maria
    Oksanen, Tuula
    Pentti, Jaana
    Pejtersen, Jan H
    Rugulies, Reiner
    Salo, Paula
    Shipley, Martin J
    Steptoe, Andrew
    Suominen, Sakari B
    Theorell, Töres
    Toppinen-Tanner, Salla
    Vahtera, Jussi
    Virtanen, Marianna
    Väänänen, Ari
    Westerholm, Peter J M
    Westerlund, Hugo
    Zins, Marie
    Britton, Annie
    Brunner, Eric J
    Singh-Manoux, Archana
    Batty, G David
    Kivimäki, Mika
    Job Strain and the Risk of Stroke: An Individual-Participant Data Meta-Analysis2015In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 46, no 2, p. 557-559Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Psychosocial stress at work has been proposed to be a risk factor for cardiovascular disease. However, its role as a risk factor for stroke is uncertain.

    METHODS: We conducted an individual-participant-data meta-analysis of 196 380 males and females from 14 European cohort studies to investigate the association between job strain, a measure of work-related stress, and incident stroke.

    RESULTS: In 1.8 million person-years at risk (mean follow-up 9.2 years), 2023 first-time stroke events were recorded. The age- and sex-adjusted hazard ratio for job strain relative to no job strain was 1.24 (95% confidence interval, 1.05;1.47) for ischemic stroke, 1.01 (95% confidence interval, 0.75;1.36) for hemorrhagic stroke, and 1.09 (95% confidence interval, 0.94;1.26) for overall stroke. The association with ischemic stroke was robust to further adjustment for socioeconomic status.

    CONCLUSION: Job strain may be associated with an increased risk of ischemic stroke, but further research is needed to determine whether interventions targeting job strain would reduce stroke risk beyond existing preventive strategies.

  • 45.
    Fransson, Eleonor I.
    et al.
    Stockholm University, Faculty of Social Sciences, Stress Research Institute. Karolinska Institutet, Sweden; Jönköping University, Sweden.
    Nyberg, Solja T.
    Heikkilä, Katriina
    Alfredsson, Lars
    Bjorner, Jakob B.
    Borritz, Marianne
    Burr, Hermann
    Dragano, Nico
    Geuskens, Goedele A.
    Goldberg, Marcel
    Hamer, Mark
    Hooftman, Wendela E.
    Houtman, Irene L
    Joensuu, Matti
    Jokela, Markus
    Knutsson, Anders
    Koskenvuo, Markku
    Koskinen, Aki
    Kumari, Meena
    Leineweber, Constanze
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Lunau, Thorsten
    Madsen, Ida E. H.
    Magnusson Hanson, Linda
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Nielsen, Martin L.
    Nordin, Maria
    Oksanen, Tuula
    Pentti, Jaana
    Pejtersen, Jan H.
    Rugulies, Reiner
    Salo, Paula
    Shipley, Martin J.
    Steptoe, Andrew
    Suominen, Sakari B.
    Theorell, Töres
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Toppinen-Tanner, Salla
    Vahtera, Jussi
    Virtanen, Marianna
    Väänänen, Ari
    Westerholm, Peter J. M.
    Westerlund, Hugo
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Zins, Marie
    Britton, Annie
    Brunner, Eric J.
    Singh-Manoux, Archana
    Batty, G. David
    Kivimäki, Mika
    Job strain and the risk of stroke: an individual-participant data meta-analysis2015In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 46, no 2, p. 557-559Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Psychosocial stress at work has been proposed to be a risk factor for cardiovascular disease. However, its role as a risk factor for stroke is uncertain.

    METHODS: We conducted an individual-participant-data meta-analysis of 196 380 males and females from 14 European cohort studies to investigate the association between job strain, a measure of work-related stress, and incident stroke.

    RESULTS: In 1.8 million person-years at risk (mean follow-up 9.2 years), 2023 first-time stroke events were recorded. The age- and sex-adjusted hazard ratio for job strain relative to no job strain was 1.24 (95% confidence interval, 1.05;1.47) for ischemic stroke, 1.01 (95% confidence interval, 0.75;1.36) for hemorrhagic stroke, and 1.09 (95% confidence interval, 0.94;1.26) for overall stroke. The association with ischemic stroke was robust to further adjustment for socioeconomic status.

    CONCLUSION: Job strain may be associated with an increased risk of ischemic stroke, but further research is needed to determine whether interventions targeting job strain would reduce stroke risk beyond existing preventive strategies.

  • 46. Friberg, Leif
    et al.
    Rosenqvist, Marten
    Lindgren, Arne
    Terent, Andreas
    Norrving, Bo
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    High prevalence of atrial fibrillation among patients with ischemic stroke2014In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 45, no 9, p. 2599-+Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Atrial fibrillation (AF) is a common cause of devastating but potentially preventable stroke. Estimates of the prevalence of AF among patients with stroke vary considerably because of difficulties in detection of intermittent, silent AF. Better recognition of AF in this patient group may help to identify and offer protection to individuals at risk. Our aim was to determine the nationwide prevalence of AF among patients with ischemic stroke, as well as their use of oral anticoagulation. Methods-Cross-sectional study of unselected patients in cross-linked nationwide Swedish health registers. All 94 083 patients with a diagnosis of ischemic stroke in the nationwide stroke register Riks-Stroke between 2005 and 2010 were studied. Information about previously diagnosed AF, and comorbidity, was obtained from the nationwide Patient Register and cross-referenced with the national Drug Register containing data on all dispensed pharmacological prescriptions in Sweden. Results-Combination of data from Riks-Stroke and from the Patient Register showed that 31 428 (33.4%) patients with ischemic stroke had previously known, or newly diagnosed, AF. Of those, only 16.2% had received warfarin in a pharmacy within 6 months before stroke onset. After hospital discharge, only 35.0% of the survivors received warfarin within the first 3 months after discharge. The likelihood for underlying AF was strongly correlated to the CHA(2)DS(2)-VASC score, which is a point based scheme for assessment of stroke risk in AF but which also predicts likelihood of AF. In this scheme points are given for age, previous stroke or transient ischemic attack, hypertension, heart failure, diabetes, vascular disease and female sex. Conclusions-Access to nationwide register data shows that AF is more common among patients with ischemic stroke than those previously reported. Few patients with stroke and AF had anticoagulant treatment before the event, and few got it after the event. CHA(2)DS(2)-VASc could be a useful monitoring tool to intensify efforts to diagnose AF among patients with cryptogenic stroke.

  • 47. Friberg, Leif
    et al.
    Rosenqvist, Marten
    Lindgren, Arne
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology.
    Norrving, Bo
    Asplund, Kjell
    High Prevalence of Atrial Fibrillation Among Patients With Ischemic Stroke2014In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 45, no 9, p. 2599-+Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Atrial fibrillation (AF) is a common cause of devastating but potentially preventable stroke. Estimates of the prevalence of AF among patients with stroke vary considerably because of difficulties in detection of intermittent, silent AF. Better recognition of AF in this patient group may help to identify and offer protection to individuals at risk. Our aim was to determine the nationwide prevalence of AF among patients with ischemic stroke, as well as their use of oral anticoagulation. Methods-Cross-sectional study of unselected patients in cross-linked nationwide Swedish health registers. All 94 083 patients with a diagnosis of ischemic stroke in the nationwide stroke register Riks-Stroke between 2005 and 2010 were studied. Information about previously diagnosed AF, and comorbidity, was obtained from the nationwide Patient Register and cross-referenced with the national Drug Register containing data on all dispensed pharmacological prescriptions in Sweden. Results-Combination of data from Riks-Stroke and from the Patient Register showed that 31 428 (33.4%) patients with ischemic stroke had previously known, or newly diagnosed, AF. Of those, only 16.2% had received warfarin in a pharmacy within 6 months before stroke onset. After hospital discharge, only 35.0% of the survivors received warfarin within the first 3 months after discharge. The likelihood for underlying AF was strongly correlated to the CHA(2)DS(2)-VASC score, which is a point based scheme for assessment of stroke risk in AF but which also predicts likelihood of AF. In this scheme points are given for age, previous stroke or transient ischemic attack, hypertension, heart failure, diabetes, vascular disease and female sex. Conclusions-Access to nationwide register data shows that AF is more common among patients with ischemic stroke than those previously reported. Few patients with stroke and AF had anticoagulant treatment before the event, and few got it after the event. CHA(2)DS(2)-VASc could be a useful monitoring tool to intensify efforts to diagnose AF among patients with cryptogenic stroke.

  • 48.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Sjölander, Maria
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology.
    Eriksson, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lundberg, Michael
    Persistent use of secondary preventive drugs declines rapidly during the first 2 years after stroke.2010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 2, p. 397-401Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: To prevent new cardiovascular events after stroke, prescribed preventive drugs should be used continuously. This study measures persistent use of preventive drugs after stroke and identifies factors associated with persistence.

    METHODS: A 1-year cohort (21,077 survivors) from Riks-Stroke, the Swedish Stroke Register, was linked to the Swedish Prescribed Drug Register.

    RESULTS: The proportion of patients who were persistent users of drugs prescribed at discharge from hospital declined progressively over the first 2 years to reach 74.2% for antihypertensive drugs, 56.1% for statins, 63.7% for antiplatelet drugs, and 45.0% for warfarin. For most drugs, advanced age, comorbidity, good self-perceived health, absence of low mood, acute treatment in a stroke unit, and institutional living at follow-up were independently associated with persistent medication use.

    CONCLUSIONS: Persistent secondary prevention treatment declines rapidly during the first 2 years after stroke, particularly for statins and warfarin. Effective interventions to improve persistent secondary prevention after stroke need to be developed.

  • 49.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Asplund, Kjell
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Poststroke Fatigue: A 2-Year Follow-Up Study of Stroke Patients in Sweden2002In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 33, p. 1327-1333Article in journal (Refereed)
    Abstract [en]

    Background and Purpose Fatigue is common among stroke patients. This study determined the prevalence of fatigue among long-term survivors after stroke and what impact fatigue had on various aspects of daily life and on survival.

    Methods— This study was based on Riks-Stroke, a hospital-based national register for quality assessment of acute stroke events in Sweden. During the first 6 months of 1997, 8194 patients were registered in Riks-Stroke, and 5189 were still alive 2 years after the stroke. They were followed up by a mail questionnaire, to which 4023 (79%) responded. Patients who reported that they always felt depressed were excluded.

    Results— To the question, “Do you feel tired?” 366 (10.0%) of the patients answered that they always felt tired, and an additional 1070 (29.2%) were often tired. Patients who always felt tired were on average older than the rest of the study population (74.5 versus 71.5 years, P<0.001); therefore, all subsequent analyses were age adjusted. Fatigue was an independent predictor for having to move into an institutional setting after stroke. Fatigue was also an independent predictor for being dependent in primary activities of daily living functions. Three years after stroke, patients with fatigue also had a higher case fatality rate.

    Conclusions— Fatigue is frequent and often severe, even late after stroke. It is associated with profound deterioration of several aspects of everyday life and with higher case fatality, but it usually receives little attention by healthcare professionals. Intervention studies are needed.

  • 50.
    Glader, Eva-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Johansson, Lennart
    National Board of Health and Welfare, Stockholm, Sweden.
    Hulter-Åsberg, Kerstin
    Department of Medicine, Enköping Hospital, Enköping, Sweden.
    Wester, P.-O.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Differences in Long-Term Outcome Between Patients Treated in Stroke Units and in General Wards: A 2-Year Follow-Up of Stroke Patients in Sweden2001In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 32, p. 2124-2130Article in journal (Refereed)
    Abstract [en]

    Background and Purpose— The long-term beneficial effects of stroke unit care have been proved in several randomized trials. However, there is a question of large-scale applicability in routine clinical practice of interventions used by dedicated investigators in small randomized trials. The objective of this study was to compare, 21/2 years after stroke, patients who had been treated in stroke units and those treated in general wards in routine clinical practice.

    Methods— This is a prospective cohort study based on 8194 patients who were included, during the first 6 months in 1997, in Riks-Stroke, the Swedish National Register for quality assessment of acute stroke. Two years after the event, 5189 patients were still alive and 5104 were followed up with a postal questionnaire to which 4038 responded.

    Results— Among the group of patients who were independent in activities of daily living (ADL) functions before the stroke, patients who were treated in stroke units were less often dependent in ADL functions, after adjustment for case mix (OR, 0.79; CI, 0.66 to 0.94). If they also lived at home before the stroke, then they had a lower case-fatality rate 2 years after the stroke (OR, 0.81; CI, 0.72 to 0.92).

    Conclusions— Long-term beneficial effects of treatment in stroke units were shown for patients who were independent in ADL functions before the stroke. No benefits were shown for patients who were dependent on help for primary ADL before the stroke. Further studies on this group of patients with more detailed outcome measures are needed.

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