Hemicraniectomy for Dominant vs Nondominant Middle Cerebral Artery Infarction : A Systematic Review and Meta- Analysis

Objectives: Decompressive hemicraniectomy decreases mortality and severe disabil-ity from space-occupying middle cerebral artery infarction in selected patients. However, attitudes towards hemicraniectomy for dominant-hemispheric stroke have been hesitant. This systematic review and meta-analysis examines the associa-tion of stroke laterality with outcome after hemicraniectomy. Materials and methods: We performed a systematic literature search up to 6th February 2020 to retrieve original articles about hemicraniectomy for space-occupying middle cere-bral artery infarction that reported outcome in relation to laterality. The primary outcome was severe disability (modified Rankin Scale 4-6 or 5-6 or Glasgow Out -come Scale 1-3) or death. A two-stage combined individual patient and aggregate data meta-analysis evaluated the association between dominant-lateralized stroke and (a) short-term ( 3 months) outcome. We per -formed sensitivity analyses excluding studies with sheer mortality outcome, sec -ond-look strokectomy, low quality, or small sample size, and comparing populations from North America/Europe vs Asia/South America. Results: The analysis included 51 studies (46 observational studies, one nonrandomized trial, and four randomized controlled trials) comprising 2361 patients. We found no asso-ciation between dominant laterality and unfavorable short-term (OR 1.00, 95% CI 0.69-1.45) or long-term (OR 1.01, 95% CI 0.76-1.33) outcome. The results were unchanged in all sensitivity analyses. The grade of evidence was very low for short -term and low for long-term outcome. Conclusions: This meta-analysis suggests that patients with dominant-hemispheric stroke have equal outcome after hemicraniec-tomy compared to patients with nondominant stroke. Despite the shortcomings of the available evidence, our results do not support withholding hemicraniectomy based on stroke laterality.Peer reviewe

Initiation of antidepressants in young adults after ischemic stroke: a registry-based follow-up study

cited By 0Objective Data on post-stroke use of antidepressants in young individuals are scarce. We examined pattern and factors associated with initiating post-stroke antidepressants (PSAD) after ischemic stroke (IS) in young adults. Methods Helsinki Young Stroke Registry includes patients aged 15-49 years with first-ever IS, 1994-2007. Data on prescriptions, hospitalizations and death came from nationwide registers. We defined time of initiating PSAD as time of the first filled prescription for antidepressants within 1 year from IS. We assessed factors associated with initiating PSAD with multivariable Cox regression models, allowing for time-varying effects when appropriate. Results We followed 888 patients, of which 206 (23.2%) initiated PSAD. Higher hazard of starting PSAD within the first 100 days appeared among patients with mild versus no limb paresis 2.53 (95% confidence interval 1.48-4.31) and during later follow-up among those with silent infarcts (2.04; 1.27-3.28), prior use of antidepressants (2.09; 1.26-3.46) and moderate versus mild stroke (2.06; 1.18-3.58). The relative difference in the hazard rate for moderate-severe limb paresis persisted both within the first 100 days (3.84, 2.12-6.97) and during later follow-up (4.54; 2.51-8.23). The hazard rate was higher throughout the follow-up among smokers (1.48; 1.11-1.97) as well as lower (1.78; 1.25-2.54) and upper white-collar workers (2.00; 1.24-3.23) compared to blue-collar workers. Conclusion One-fourth of young adults started PSADs within 1 year from IS. We identified several specific clinical characteristics associated with PSAD initiation, highlighting their utility in assessing the risk of post-stroke depression during follow-up.Peer reviewe

Association of post-stroke-initiated antidepressants with long-term outcomes in young adults with ischaemic stroke

Objective We examined the association between initiation of antidepressants within the first year after ischaemic stroke (IS) in young adults and long-term fatal and non-fatal cardiovascular events, as well as all-cause mortality. Patients and methods The Helsinki Young Stroke Registry (HYSR) includes patients aged 15-49 years with their first-ever IS occurring 1994-2007. From nationwide registers, we obtained data on prescriptions (1993-2011) and outcomes of interest (1994-2011). Time of initiating post-stroke antidepressants (PSADs) was defined as time of the first filled prescription for antidepressants within the first year from IS. To account for non-random assignment of PSADs, we performed propensity score matching and studied the relationship between PSAD initiation and outcomes using Cox regression models with time-varying coefficients. Results Of all patients (n = 888), 206 (23.2%) initiated PSADs within the first year, of which 203 (98.5%) could be matched to 406 non-initiators. In this matched sample of 609 patients, the median follow-up time was 8.1 (interquartile range [IQR] 5.0-12.6) years and 169 (28.9%) patients had any cardiovascular events, 95 (15.8%) had recurrent ischaemic or haemorrhagic strokes and 106 (17.4%) died. Adjusted for sociodemographics and cardiovascular comorbidities, PSAD initiation was associated with recurrent ischaemic or haemorrhagic stroke 5-10 years after IS (hazard ratio [HR] 3.07, 95% confidence interval [CI] 1.32-7.12). No association emerged between PSAD initiation and other outcomes. Conclusions In young adults, PSAD initiation within the first year after IS was associated with a heightened hazard of recurrent ischaemic or haemorrhagic stroke in the long term. Future studies are needed to verify the results and to further study the nature of this finding. KEY MESSAGES Initiation of post-stroke antidepressants (PSADs) within the first year after ischaemic stroke (IS) was associated with a heightened hazard of recurrent ischaemic or haemorrhagic stroke in the long term. Patients starting antidepressants after IS should be followed up more closely in case of recurrent events. Future studies are needed to verify the results and to further study the nature of this finding.Peer reviewe

Aivoverenkiertohäiriöiden ennuste nuorilla aikuisilla

Aivoverenkiertohäiriöt ovat yleistymässä alle 50-vuotiailla. Nuoret ja keski-ikäiset aivoverenkiertohäiriöpotilaat toipuvat yleensä paremmin kuin iäkkäät. Akuuttivaiheen hoito, kuten aivoinfarktin liuotushoito, mekaaninen aivovaltimon veritulpan poisto ja hoito aivohalvausyksikössä, parantavat ennustetta. Toipumiseen ja kuolleisuuteen vaikuttavat mm. häiriön syy, akuuttivaiheen oirekuva, diabetes, tupakointi ja infektiot. Noin puolet aivoverenkiertohäiriön sairastaneista palaa työelämään. Tavalliset riskitekijät ovat nuorillakin potilailla tavallisia, ja ne vaativat seurantaa ja sitoutumista pitkäaikaiseen lääkehoitoon. Pitkäaikaisseurannassa joka kymmenennelle iskeemisen aivoverenkiertohäiriön sairastaneista ja jopa joka neljännelle aivoverenvuotopotilaista kehittyy epilepsia.Peer reviewe

Use of antihypertensive medication after ischemic stroke in young adults and its association with long-term outcome

Background: Knowledge on the use of secondary preventive medication in young adults is limited. Methods: We included 936 first-ever ischemic stroke 30-day survivors aged 15-49, enrolled in the Helsinki Young Stroke Registry, 1994-2007. Follow-up data until 2012 came from Finnish Care Register, Statistics Finland, and Social Insurance Institution of Finland. Usage thresholds were defined as non-users, low (prescription coverage 80%). Adjusted Cox regression allowed assessing the association of usage with all-cause mortality and recurrent vascular events. Results: Of our patients, 40.5% were non-users, 7.8% had low usage, 11.8% intermediate usage and 40.0% high usage. Median follow-up was 8.3 years. Compared to non-users, risk of mortality and recurrent stroke or TIA was lower for patients with low-intermediate (HR 0.40, 95% CI 0.22-0.65; HR 0.31, 95% CI 0.18-0.53) and high usage (HR 0.25, 95% CI 0.15-0.42; HR 0.30, 95% CI 0.19-0.46), after adjustment for confounders. Conclusions: Use of antihypertensives was suboptimal in one-third of patients in whom antihypertensives were initially prescribed. Users were at lower risk of mortality and recurrent stroke or TIA compared to non-users.Key Messages The use of antihypertensive medication is suboptimal in one-third of patients in whom antihypertensive medication was initially prescribed after ischemic stroke at young age. The risk of mortality and recurrent stroke or TIA is lower for users of antihypertensive medication after ischemic stroke at young age compared to non-users, after adjustment for relevant confounders including pre-existing hypertension and prior use of antihypertensive medication. Specific guidelines on antihypertensive medication use after ischemic stroke at young age are lacking. However, our results may motivate doctors and patients in gaining better usage of antihypertensive medication, since better usage was associated with more favorable outcome in this study.Peer reviewe

Nuoren aivoinfarktipotilaan erityispiirteet

English summaryPeer reviewe

Global Outcome Assessment Life-long after stroke in young adults initiative-the GOAL initiative : study protocol and rationale of a multicentre retrospective individual patient data meta-analysis

Introduction Worldwide, 2 million patients aged 18-50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis and optimal secondary prevention in young stroke patients are limited. This limits evidence-based treatment and hampers the provision of appropriate information regarding the causes of stroke, risk factors and prognosis of young stroke patients. Methods and analysis The Global Outcome Assessment Life-long after stroke in young adults (GOAL) initiative aims to perform a global individual patient data meta-analysis with existing data from young stroke cohorts worldwide. All patients aged 18-50 years with ischaemic stroke or intracerebral haemorrhage will be included. Outcomes will be the distribution of stroke aetiology and (vascular) risk factors, functional outcome after stroke, risk of recurrent vascular events and death and finally the use of secondary prevention. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and climate of residence.Peer reviewe

Long-term outcome of young adults with ischemic stroke

Ischemic stroke (IS) is one of the most common causes of death and disability worldwide. Around 10% of ISs affect young adults less than 50 years of age. Incidence of IS in young adults is approximately 10-20/100 000 people per year in the developed countries. Young patients typically have many years of active life ahead, and have families and work to take care of. Therefore, their long-term outcomes after IS are of paramount importance, but remains understudied. The aim of this thesis was to investigate the outcome of these young patients; regarding their cancer diagnoses and long-term risk of death, future cardiovascular events, and return to work, as well as to study factors, such as the etiology of index IS, that are associated with poor outcome. Also, we wanted to investigate whether the incidence of pregnancy- and delivery-related complications before and after IS were different from stroke-free matched controls. Helsinki Young Stroke Registry (HYSR) includes 1008 consecutive first-ever IS patients aged 15-49 years, treated 1994 to 2007 at the Department of Neurology, Helsinki University Hospital. We obtained outcome data for these patients from several national registries, including Hospital Discharge Registry (HDR) and Medical Birth Registry (MBR) from the National Institute of Health and Welfare (THL), Death Registry from Statistics Finland, and Earnings and Accrual registry from the Finnish Centre for Pensions. The unique personal identification number that exists for all people residing in Finland allowed the linkage of patients from HYSR to the follow-up data. The outcome events were verified from patient records whenever feasible. A total of 3.9% of young IS patients had cancer diagnosed before or during hospitalization for IS, with a median time of 4.9 years from cancer diagnosis to IS. Similarly, 3.8% of patients had cancer diagnosed after IS until the end of 2011, with a median time of 6.7 years from IS to cancer diagnosis. We found no cancers in the youngest patients aged <30 years at IS onset. The largest single groups of cancers were lung and respiratory tract cancers. Especially active cancer without any other cause of IS, melanoma, and lung/respiratory tract cancers were significantly associated with death, when adjusted for known confounders. Limiting to those young patients who survived over 30 days from the index event, a total of 152 (15.7%) patients died during a median follow-up of 10.1 years. We found a 35.7% cumulative 15-year risk for composite vascular events and a 11.1% risk for vascular death, accordingly. Adjusted for age and sex, patients whose index IS were caused by large-artery atherosclerosis (LAA), had the highest hazard ratio (HR) for recurrent strokes, 2.7, compared with patients with IS of undetermined etiology. Similarly, patients whose index strokes were caused by high-risk sources of cardioembolism (CEH) had the highest HR, 3.7, for any subsequent cardiovascular events. On the contrary, patients whose ISs were caused by vertebral artery dissection (VAD) had the lowest HR, 0.3, for future cardiovascular events, again adjusted for age and sex. Overall, the cumulative 15-year risks were 9 times greater for arterial (33.7%) than for venous events (3.9%). In addition, patients with a cardiovascular disease or hemorrhagic stroke diagnosed before the index event had 4 times higher long-term incidence rate for any cardiovascular event (113.0/1000 person-years) than patients without such history (28.1/1000 person-years). There were 207 singleton pregnancies for 124 mothers before IS and 68 pregnancies for 45 mothers after IS. A total of 17 mothers had pregnancies both before and after IS. No deaths occurred during pregnancy or puerperium. Mothers with a history of IS seemed to have had more assisted reproductive technologies (ART), induced abortions, miscarriages, and cesarean sections at first pregnancy after IS compared with matched controls in the descriptive analyses, without statistical testing applied. Mothers with an impending IS in the future had a slightly increased risk for pregnancy- and delivery-related complications adjusted for socioeconomic status and maternal smoking, compared with matched control mothers, although only being borderline in statistical significance. Mothers who had experienced IS had more hospitalizations during subsequent pregnancies than their matched controls, with an adjusted incidence rate ratio of 1.85. When restricting to patients with mild to moderate IS and who were working within one year before IS, as many as 37.6% of patients were not working at one year, 42.0% at two years, the number increasing up to 46.9% at five years from IS. Large anterior strokes, strokes caused by LAA, CEH, and rare causes other than dissection, compared with undetermined etiology, moderate to severe aphasia compared with no aphasia, mild and moderate to severe limb paresis compared with no paresis, and moderate to severe visual field deficit compared with no deficit, were associated with a patient not working at one year after IS, when adjusted for age, sex, socioeconomic status, and National Institutes of Health Stroke Scale (NIHSS) score at admission. In conclusion, despite their young age, IS affected many life aspects, specifically the morbidity, mortality, and return to work, and as such has a major impact for the patient, also during the long-term follow-up. The worst prognosis regarding their long-term risk of vascular death, future cardiovascular events, and return to work seems to be for those individuals with an etiology of LAA and CEH underlying their index ISs.Valtimotukoksen aiheuttama aivoverenkierron häiriö eli aivoinfarkti on yksi yleisimpiä kuoleman ja toimintakyvyn laskun aiheuttajia maailmanlaajuisesti. Alle 50-vuotiaiden nuorten aikuisten aivoinfarktien osuus kattaa noin 10 % kaikista aivoinfarktitapauksista. Nuorilla aikuisilla on usein paljon menetettävää uran ja perhe-elämän sekä tulevien elinvuosien osalta. Tämän väitöskirjatutkimuksen tavoitteena oli tutkia nuorten aivoinfarktipotilaiden pitkäaikaisennustetta, käsittäen heidän syöpäsairastavuutta, uusivia sydän- ja verisuonitapahtumia, sydän- ja verisuonitautikuolleisuutta, lisääntymisterveyttä sekä työhön paluuta. Helsinki Young Stroke Registry koostuu vuosina 1994-2007 Meilahden sairaalan Neurologian klinikassa hoidetuista 1008:sta 15-49-vuotiaasta aivoinfarktipotilaasta. Haimme seurantatietoja näistä potilaista Terveyden ja Hyvinvoinnin laitoksen Hoitoilmoitus-rekisteristä ja Syntyneiden lasten rekisteristä, Tilastokeskuksen Kuolinsyyrekisteristä ja Eläketurvakeskuksen Ansaintarekisteristä. Tutkimuksemme osoitti, että 4 % nuorista aivoinfarktipotilaistamme oli diagnosoitu syöpä ennen aivoinfarktiin sairastumista tai sairastumisen yhteydessä. Mediaaniaika syöpädiagnoosista aivoinfarktin diagnoosiin oli 5 vuotta. Kaikkiaan 4 %:lla nuorista aivoinfarktipotilaista diagnosoitiin syöpäsairaus vuoden 2011 loppuun mennessä. Mediaaniaika aivoinfarktista syöpädiagnoosiin oli 7 vuotta. Aktiivinen syöpäsairaus, melanooma ja keuhko/hengitystiesyövät olivat erityisesti yhteydessä suurentuneeseen kuoleman riskiin nuorilla aivoinfarktipotilailla. Kaiken kaikkiaan 152 (16 %) ensimmäisestä aivoinfarktistaan selvinnyttä nuorta aivoinfarktipotilasta kuoli mediaani 10 vuoden seurannassa. Kumulatiivinen 15 vuoden riski uusivaan sydän- tai verisuonitapahtumaan oli 36 % ja riski kuolla vastaavaan tapahtumaan 11 %. Niillä aivoinfarktipotilailla, joilla ensimmäisen aivoinfarktin taustalla oli suuren suonen valtimonkovettumatauti, oli suurin riski saada uusiva aivohalvaus. Vastaavasti niillä aivoinfarktipotilailla, joilla ensimmäisen aivoinfarktin taustalla oli suuren riskin sydänperäinen syy, kuten eteisvärinä, oli suurin riski saada mikä tahansa sydän- tai verisuonitapahtuma seurantajakson aikana. Yhteensä 124:llä nuorella naispotilaalla oli 207 yksisikiöraskautta ennen aivoinfarktia ja 45 äidillä 68 raskautta aivoinfarktin jälkeen 1987-2014 välisenä aikana. Raskauden tai synnytyksen aikana ei havaittu yhtäkään kuolemantapausta. Nuorilla aivoinfarktin sairastaneilla äideillä oli sattunut kuitenkin hieman enemmän raskaus- ja synnytyskomplikaatioita ennen aivoinfarktia kuin verrokkiäideillä, joskin tulos jäi tilastollisesti raja-arvoiseksi. Aivoinfarktin jo sairastaneilla äideillä oli enemmän raskauden aikaisia sairaalassaoloja kuin verrokkiäideillä. Nuorista lievän tai keskivaikean aivoinfarktin sairastaneista potilaista 38 % ei ollut työelämässä vuoden, 42 % 2 vuoden ja peräti 47 % 5 vuoden kuluttua aivoinfarktiin sairastumisesta. Potilaat, joilla oli kookas aivojen etuosan infarkti, suurten suonten valtimonkovettumatauti, suuren riskin sydänperäinen syy tai harvinaisia aiheuttajia aivoinfarktin taustalla taikka keskivaikea- tai vaikea-asteinen kielellinen häiriö, käden tai jalan motorinen halvaus tai keskivaikea- tai vaikea-asteinen näkökenttäpuutos sairaalasta kotiutuessa, oli lisääntynyt riski olla työelämän ulkopuolella vuoden kuluessa aivoinfarktista. Yhteenvetona siis aivoinfarkti saattaa vaikuttaa nuoren elämään monella tavalla. Huonoin ennuste uusintatapahtumien ja sydän- ja verisuonitautikuolleisuuden sekä työhön paluun osalta vaikuttaisi olevan niillä potilailla, joiden aivoinfarktin taustalla on suuren suonen valtimonkovettumatauti tai suuren riskin sydänperäinen syy. Etenkin harvinaisempien ennustemuuttujien, kuten raskauskomplikaatioiden, osalta tarvitaan vielä lisää tutkimuksia aiheesta lisänäytön saamiseksi

Raskauteen liittyvät aivoverenkiertohäiriöt

Aivoverenkiertohäiriö on harvinainen mutta vakava raskauskomplikaatio, johon liittyy huomattavaa kuolleisuutta ja pitkäaikaissairastavuutta. Raskausajan aivoverenkiertohäiriöt ovat lisääntyneet viime vuosikymmenten aikana paitsi maailmanlaajuisesti myös Suomessa, kun ikääntyvien odottajien verisuoniriskitekijät yleistyvät. Keskeisin yksittäinen hoidettava riskitekijä on kohonnut verenpaine. Raskaudenaikaisten aivoverenkiertohäiriöiden hoidossa voidaan yleensä soveltaa normaaleja hoitomuotoja niin, että lääkkeiden ja säteilyä aiheuttavien kuvantamismenetelmien mahdolliset sikiövaikutukset kuitenkin huomioidaan. Aivoverenkiertohäiriön sairastaneiden naisten raskauksia on syytä seurata äitiyspoliklinikassa, ja sekundaaripreventio on suunniteltava huolella. Naisten pitkäaikaisennusteesta ei ole juuri tutkimustietoa.publishedVersionPeer reviewe