The Epidemiology of Intracerebral Haemorrahge. Risk factors and prognosis

Abstract The present thesis explored the epidemiology of intracerebral haemorrhage (ICH), i.e., factors associated to incidence and prognosis. In the population of Malmö (Malmö 1990 cohort), it was shown that immigrants from China/Vietnam and the Former Soviet Union had higher risk of ICH than citizens born in Sweden. Although hypertension is a well-known risk factor for stroke, the relation between blood pressure (BP) levels and stroke subtypes is less clear. In the Malmö Diet and Cancer cohort increasing BP was strongly associated with higher incidence of cerebral infarction, as measured by the crude and standardised incidence rates. However, in terms of relative risks (RR), the risk was highest for primary ICH (PICH), especially for nonlobar PICH. The results of previous studies have indicated differences in pathology and genetics between PICH subtypes by bleeding location. In the Malmö Preventive Project cohort, systolic BP and smoking were found to be associated with increased risk of lobar PICH. Systolic BP, psychiatric morbidity and diabetes were found to be associated with nonlobar PICH.. Of 474 patients with PICH (Malmö Stroke Registry), 26% died within 28 days and 49% within three years. Male sex predicted 28-day and 3-year mortality, largely explained by high 28-day mortality in male patients older than 75 years. It conclusion, the incidence of ICH varies by country of birth. The impact of high BP, in terms of RR, is highest for nonlobar PICH. Smoking is associated with lobar PICH, and diabetes with nonlobar PICH. Female PICH patients have better survival than men

Perceived Unmet Rehabilitation Needs 1 Year After Stroke: An Observational Study From the Swedish Stroke Register.

Met care demands are key aspects in poststroke quality of care. This study aimed to identify baseline predictors and 12-month factors that were associated with perceived unmet rehabilitation needs 1 year poststroke

Doctor’s follow-up after stroke in the south of Sweden : An observational study from the Swedish stroke register (Riksstroke)

Introduction: Information on follow-up practices after stroke in clinical routine are sparse. We studied the probability of doctor’s follow-up within 90, 120, 180, and 365 days after hospital discharge, and how patient characteristics were associated with the probability of follow-up, in a large unselected stroke cohort. Patients and methods: Data on patients living in southern Sweden, hospitalized with acute ischemic stroke or intracerebral hemorrhage 1 January 2008 to 31 December 2010, were obtained from the Swedish stroke register (Riksstroke) and merged with administrative data on doctor’s visits during the year following stroke. Results: Complete data were registered in 8164 patients. The cumulative probability of a doctor’s follow-up was 76.3% within 90 days, 83.6% within 120 days, 88.7% within 180 days, and 93.1% within 365 days. Using Cox regression calculating hazard ratios (HR), factors associated with 90-day follow-up were: female sex HR = 1.066 (95%CI: 1.014–1.121), age: ages 65–74 HR = 0.928 (95%CI: 0.863–0.999), ages 75–84 HR = 0.943 (95%CI: 0.880–1.011), ages 85 + HR = 0.836 (95%CI: 0.774–0.904), pre-stroke dependency in activities of daily living (ADL): HR = 0.902 (95%CI = 0.819–0.994), prior stroke HR = 0.902 (95%CI: 0.764–0.872), and severe stroke HR = 0.506 (95%CI: 0.407–0.629). In patients discharged to assisted living, the following factors were associated with lower follow-up probability: living alone pre-stroke HR = 0.836 (95%CI: 0.736–0.949), and pre-stroke dependency HR = 0.887 (95%CI: 0.775–0.991). Discussion: This study was based on hospital administrative data of post-stroke doctor’s visits, but may be confounded by attendance for other conditions than stroke. Conclusions: One in four stroke patients was not followed up within three months after hospital discharge. Vulnerable patients with high age, pre-stroke ADL dependency, and prior stroke were less likely to receive doctor’s follow-up

Incidence of Stroke and Stroke Subtypes in Malmo, Sweden, 1990-2000. Marked Differences Between Groups Defined by Birth Country.

Background and Purpose-The proportion of immigrants has increased in Sweden markedly during the last decades, as in many other Western countries. Incidence of stroke has increased during this period. However, it is primarily unknown whether incidence of stroke and stroke subtypes in Sweden is related to country of birth. Methods-Incidence of first-ever stroke was followed during 10 years in a cohort consisting of all 40- to 89-year-old inhabitants in the city of Malmo, Sweden (n=118134). Immigrants from 12 different countries were compared with native-born Swedes. Results-Adjusted for age, sex, marital status, and socioeconomic indicators, the incidence of stroke ( all subtypes) was significantly higher among immigrants from former Yugoslavia (relative risk [RR], 1.31; 95% CI, 1.1 to 1.6) and Hungary (RR, 1.33; CI, 1.02 to 1.7). A significantly increased incidence of intracerebral hemorrhage was observed in immigrants from Peoples Republic of China or Vietnam (RR, 4.2; CI, 1.7 to 10.4) and the former Soviet Union ( RR, 2.7; CI, 1.01 to 7.3). Immigrants from Finland had a significantly higher incidence of subarachnoid hemorrhage (RR, 2.8; CI, 1.1 to 6.8). A significantly lower incidence of stroke was observed in the group from Romania (RR, 0.14; CI, 0.04 to 0.6). Immigrants from Denmark, Norway, Germany, Chile, Czechoslovakia, and Poland had approximately the same risk as citizens born in Sweden. Conclusions-In this urban population from Sweden, there are substantial differences in stroke incidence and stroke subtypes between immigrants from different countries. To what extent this could be accounted for by exposure to biological risk factors remains to be explored

Lung Function as a Risk Factor for Subarachnoid Hemorrhage: A Prospective Cohort Study.

BACKGROUND AND PURPOSE: The etiology of subarachnoid hemorrhage (SAH) is poorly understood. Reduced lung function, expressed as low forced expiratory volume in 1 second (FEV(1)) and low forced vital capacity (FVC), is a predictor of cardiovascular disease, but whether reduced lung function is a risk factor for SAH is not known. The association between lung function and incidence of SAH was investigated in a prospective cohort study. METHODS: Between 1974 and 1992, 20 534 men and 7237 women (mean age, 44 years) were examined in a health screening program including spirometry. The incidence of SAH was studied during a mean follow-up of 26 years in relation to age- and height-standardized FEV(1), FVC, and FEV(1)/FVC. RESULTS: One hundred forty-five subjects had a SAH (18.3 per 100 000 person-years in men and 26.5 per 100 000 person-years in women). The hazard ratio for SAH in the lowest compared to the highest quartile of FEV(1) and FEV(1)/FVC was 2.24 (95% CI, 1.32-3.81; P for trend=0.014) and 1.92 (95% CI, 1.14-3.23; P for trend=0.003), respectively, after adjustment for several confounding factors including smoking and hypertension. The results persisted when analysis was restricted to nonsmokers. FVC showed no significant association with incidence of SAH. CONCLUSIONS: Baseline lung function, expressed as low FEV(1) or FEV(1)/FVC, is a risk factor for SAH, independently of smoking

Leukocyte count and incidence of subarachnoid haemorrhage: a prospective cohort study

Subarachnoid haemorrhage (SAH) is a devastating disease, in the majority of cases caused by a rupture of an arterial intracranial aneurysm. The effect of systemic low-grade inflammation on incidence of SAH is not known. The purpose of this study was to evaluate the relationship between leukocyte count, a marker of systemic inflammation, and incidence of SAH in a large cohort study

Changes in Functional Outcome Over the First Year After Stroke: An Observational Study From the Swedish Stroke Register.

Large longitudinal studies on stroke outcome are scarce. The aim of this study was to analyze predictors and changes in functional outcome during the first year poststroke

Swirl sign in intracerebral haemorrhage: definition, prevalence, reliability and prognostic value

Background: Swirl sign has previously been described in epidural hematomas as areas of low attenuation, radiolucency or irregular density. The aims of this study were to describe swirl sign in ICH, study its prevalence, study the reliability of the subjective evaluation on computed tomography (CT), and to explore its prognostic value. Methods: CTs of 203 patients with ICH were retrospectively evaluated for the presence of swirl sign. Association between swirl sign and different clinical and radiological variables was studied. Results: Inter-and intraobserver agreement with regard to the occurrence of swirl sign was substantial (kappa 0.80) and almost perfect (kappa 0.87), respectively. Swirl sign was found in 30% of the study population. 61% of patients with swirl sign were dead at one month compared with 21% of those with no swirl sign (p < 0.001). Only 19% of patients with swirl sign exhibited favorable outcome at three months compared with 53% of those with no swirl sign (p < 0.001). Patients with swirl sign exhibited larger ICHs with average ICH-volume 52 +/- 50 ml (median 42 ml) compared with 15 +/- 25 ml (median 6) in patients whose CT did not show swirl sign (p < 0.001). Swirl sign was independent predictor of death at one month (p = 0.03; adjusted odds ratio 2.6, 95% CI 1.1 - 6), and functional outcome at three months (p = 0.045; adjusted odds ratio 2.6, 95% CI 1.02 - 6.5). Conclusions: As swirl sign showed to be an ominous sign, we recommend identification of this sign in cases of ICHs