Risk factors and prognosis of young stroke. The FUTURE study: A prospective cohort study. Study rationale and protocol

Contains fulltext : 98322.pdf (postprint version ) (Open Access)BACKGROUND: Young stroke can have devastating consequences with respect to quality of life, the ability to work, plan or run a family, and participate in social life. Better insight into risk factors and the long-term prognosis is extremely important, especially in young stroke patients with a life expectancy of decades. To date, detailed information on risk factors and the long-term prognosis in young stroke patients, and more specific risk of mortality or recurrent vascular events, remains scarce. METHODS/DESIGN: The FUTURE study is a prospective cohort study on risk factors and prognosis of young ischemic and hemorrhagic stroke among 1006 patients, aged 18-50 years, included in our study database between 1-1-1980 and 1-11-2010. Follow-up visits at our research centre take place from the end of 2009 until the end of 2011. Control subjects will be recruited among the patients' spouses, relatives or social environment. Information on mortality and incident vascular events will be retrieved via structured questionnaires. In addition, participants are invited to the research centre to undergo an extensive sub study including MRI. DISCUSSION: The FUTURE study has the potential to make an important contribution to increase the knowledge on risk factors and long-term prognosis in young stroke patients. Our study differs from previous studies by having a maximal follow-up of more than 30 years, including not only TIA and ischemic stroke but also hemorrhagic stroke, the addition of healthy controls and prospectively collect data during an extensive follow-up visit. Completion of the FUTURE study may provide better information for treating physicians and patients with respect to the prognosis of young stroke.8 p

Increased risk of ischemic stroke after radiotherapy on the neck in patients younger than 60 years

PURPOSE: To estimate the risk of ischemic stroke in patients irradiated for head and neck tumors. PATIENTS AND METHODS: The incidence of ischemic stroke was determined in 367 patients with head and neck tumors (162 larynx carcinomas, 114 pleomorphic adenomas, and 91 parotid carcinomas) who had been treated with local radiotherapy (RT) at an age younger than 60 years. Relative risk (RR) of ischemic stroke was determined by comparison with population rates from a stroke-incidence register, adjusted for sex and age. Other risk factors for stroke (hypertension, smoking, hypercholesterolemia, diabetes mellitus [DM]) were registered. The median follow-up time after RT was 7.7 years (3,011 person-years of follow-up). RESULTS: Fourteen cases of stroke occurred (expected, 2.5; RR, 5.6; 95% confidence interval [CI], 3.1 to 9.4): eight in patients with laryngeal carcinoma (expected,1.56; RR, 5.1; 95% CI, 2.2 to 10.1), four in pleomorphic adenoma patients (expected, 0.71; RR, 5.7; 95% CI, 1.5 to 14.5), and two in parotid carcinoma patients (expected, 0.24; RR, 8.5, 95% CI, 1.0 to 30.6). Five of six strokes in patients irradiated for a parotid tumor occurred at the ipsilateral side. Analysis of other risk factors for cerebrovascular disease showed hypertension and DM to cause an increase of the RR after RT. After more than 10 years' follow-up, the RR was 10.1 (95% CI, 4.4 to 20.0). The 15-year cumulative risk of stroke after RT on the neck was 12.0% (95% CI, 6.5% to 21.4%). CONCLUSION: This is the first study to demonstrate an increased risk of stroke after RT on the neck. During medical follow-up, preventive measures should be taken to reduce the impact of the risk factors for cerebrovascular disease, to decrease stroke in these patient

Magnetic resonance imaging of the carotid artery in long-term head and neck cancer survivors treated with radiotherapy

<div><p></p><p><b><i>Background.</i></b> In head and neck cancer (HNC) patients, long-term treatment-related complications include radiotherapy (RT)-induced carotid vasculopathy and stroke. The current study investigated the magnetic resonance imaging (MRI) characteristics of the carotid wall in long-term HNC survivors treated with RT.</p><p><b><i>Methods.</i></b> MRI of the carotid arteries was performed within a prospective cohort of 42 HNC patients on average 7 years after RT. Two independent radiologists assessed maximal vessel wall thickness of common and internal carotid arteries. In case of wall thickening (≥ 2 mm) the MRI signals as well as length of the thickened segment were assessed.</p><p><b><i>Results.</i></b> Mean (SD) age of the 42 patients at baseline was 53 (13) years and mean (SD) follow-up time after RT was 6.8 (1.3) years. In total 62% were men and 60% had one or more cerebrovascular risk factors. Mean (SD) dose of RT on the common carotid arteries and internal carotid arteries was 57 Gy (11) and 61 Gy (10), respectively. Wall thickening was observed in 58% of irradiated versus 27% of non-irradiated common carotid arteries and 24% of irradiated versus 6% of non-irradiated internal carotid arteries (p < 0.05). Mean (SD) thickness of the irradiated and non-irradiated common carotid arteries was 2.5 (0.9) and 2 (0.7) mm (p = 0.02). Mean thickness of the irradiated and non-irradiated internal carotid arteries was 1.8 (0.8) and 1.5 mm (0.3) (n.s.). Mean length of the thickened vessel wall was 48 mm versus 36 mm in the irradiated versus non-irradiated common carotid arteries (p = 0.03) and 20 mm versus 15 mm in the irradiated versus non-irradiated internal carotid arteries (n.s.). No significant differences were observed for signal intensities of the vessel walls.</p><p><b><i>Conclusions.</i></b> Our study showed significantly more vessel wall thickening in irradiated versus non-irradiated carotid arteries years after RT for HNC, while no differences in signal intensities were observed.</p></div

Baseline characteristics of patients.

<p>Abbreviations: TIA, transient ischemic attack; SD, standard deviation; NIHSS, National Institute of Health Stroke Scale; IQR, interquartile range; TOAST, Trial of Org 10172 in Acute Stroke Treatment.</p><p>Data are given as number (percentage) or otherwise stated</p>*<p>Scores range from 0 to 42 with higher scores on the scale indicating worse stroke severity. 0.5% of NIHSS was missing.</p>†<p>Smoking was defined as smoking at least 1 cigarette a day in the year prior to the event. 1.9% of data on smoking was missing.</p>‡<p>Excess alcohol consumption was defined as consuming more than 200 grams of pure alcohol per week</p>§<p>First degree family member. 0.9% of data on family history of diabetes was missing.</p

Presence of baseline factors in patients with incident diabetes or impaired fasting glucose at follow-up.

<p>Abbreviations: IFG, impaired fasting glucose; TIA, transient ischemic attack; SD, standard deviation; NIHSS, National Institute of Health Stroke Scale; IQR, interquartile range; TOAST, Trial of Org 10172 in Acute Stroke Treatment.</p><p>Data are given as number (percentage) or otherwise stated</p>*<p><i>p</i> values refer to a comparison between patients with incident diabetes and patients with no IFG or diabetes</p>†<p><i>p</i> values refer to a comparison between patients with IFG and patients with no IFG or diabetes</p>‡<p>Scores range from 0 to 42 with higher scores on the scale indicating worse stroke severity. 0.4% of NIHSS was missing.</p>§<p>Smoking was defined as smoking at least 1 cigarette a day in the year prior to the event. 2.9% of data on smoking was missing.</p>||<p>Excess alcohol consumption was defined as consuming more than 200 grams of pure alcohol per week</p>¶<p>First degree family member. 1.0% of data on family history of diabetes was missing.</p

Comparisons between hemispheric stroke patients with normal ipsilateral hippocampal volume and high versus low ipsilateral hippocampal MD.

<p>Data are presented as number or adjusted mean (±SEM).</p><p>^aComparison between left-hemispheric stroke patients with low left hippocampal MD versus high left hippocampal MD.</p><p>^bComparison between right-hemispheric stroke patients with low right hippocampal MD versus high right hippocampal MD. For the analyses on hippocampal volume we adjusted for age, sex, and follow-up duration. For the analyses on ipsilateral hippocampal MD we additionally adjusted for ipsilateral hippocampal volume. For the analyses on immediate and delayed verbal recall we adjusted for age, sex, education, follow-up duration, and ipsilateral hippocampal volume.</p><p>MD = Mean Diffusivity.</p><p>Comparisons between hemispheric stroke patients with normal ipsilateral hippocampal volume and high versus low ipsilateral hippocampal MD.</p

Lesion probability maps in patients with left-hemispheric stroke, right-hemispheric stroke, and infratentorial stroke.

<p>The color overlay created on top of the Montreal Neurologic Institute (MNI) standard brain template shows the probability of each voxel containing a lesion in each patient group. The color bar denotes the probability range.</p

Demographic and clinical characteristics of ischemic stroke patients and controls.

<p>Data are expressed as mean (SD), number (%), or median (Q1–Q3).</p><p>NIHSS = National Institutes of Health Stroke Scale</p><p>mRS = modified Rankin Scale.</p><p>HADS = Hospital Anxiety and Depression Scale</p><p>CIS-20R = Checklist Individual Strength.</p><p>TOAST = Trial of Org 10172 in Acute Stroke Treatment.</p><p>Missing data in patients: education = 0.7%, NIHSS at admission = 1.4%</p><p>HADS-depressive symptoms = 0.7%, CIS-20R = 0.7%.</p><p>^aStroke could be located in more than one region in a patient.</p><p>^bGroup comparisons between the three groups of patients (left/right/infratentorial stroke).</p><p>Demographic and clinical characteristics of ischemic stroke patients and controls.</p