This Article Abstract Full Text (PDF) All Versions of this Article: 34/1/122    most recent 01.STR.0000047852.05842.3Cv1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Appelros, P. Articles by Viitanen, M. Search for Related Content PubMed PubMed Citation Articles by Appelros, P. Articles by Viitanen, M. Pubmed/NCBI databases Medline Plus Health Information Stroke Related Collections Health policy and outcome research Acute Cerebral Hemorrhage Acute Cerebral Infarction Risk Factors for Stroke Epidemiology

(Stroke. 2003;34:122.)
© 2003 American Heart Association, Inc.

Original Contributions

Poor Outcome After First-Ever Stroke

Predictors for Death, Dependency, and Recurrent Stroke Within the First Year

From the Departments of Neurology and Geriatrics, Örebro University Hospital, Örebro (P.A.), and the Department of Neurotec, Division of Geriatric Medicine, Karolinska Institutet, Stockholm (P.A., I.N., M.V.), Sweden.

Correspondence to Dr Peter Appelros, Department of Neurology, Örebro University Hospital, SE-701 85 Örebro, Sweden. E-mail peter.appelros{at}orebroll.se

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose— The purpose of this study was to define predictors of poor outcome after a first-ever stroke. We studied risk factors and stroke severity at baseline in relationship to death, dependency, and stroke recurrence within a year after the event.

Methods— The study included a community-based cohort of first-ever stroke patients. Subarachnoid hemorrhage was not included. All patients (n=377) were subjected to investigations regarding risk factors. Stroke severity was evaluated with the National Institutes of Health Stroke Scale, and dependency was defined according to the modified Rankin Scale. Multivariate regression models were used to analyze predictors of survival, dependency, and stroke recurrence. The following independent variables were used: age, sex, cohabitation status, cigarette smoking, dementia, hypertension, ischemic heart disease, heart failure, atrial fibrillation, diabetes mellitus, transitory ischemic attack, peripheral atherosclerosis, and stroke severity.

Results— The 1-year mortality was 33%. After 1 year, 37% of the survivors were dependent; 9% of survivors had a recurrent stroke within a year. Dementia, age, stroke severity, and atrial fibrillation were associated with death within a year. Dependency was associated with age, stroke severity, and heart failure. Stroke recurrence was predicted by age and dementia.

Conclusions— In addition to age and stroke severity, heart diseases and dementia before the stroke seem to have an impact on mortality and recurrence after 1 year. Finding and, when possible, treating these prestroke conditions may affect stroke morbidity and mortality favorably.

Key Words: atrial fibrillation • cognitive disorders • heart failure, congestive • prognosis • stroke

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
In the last decades, in Sweden, as well as in many other Western countries, stroke seems to have become a less severe disease.¹ The reasons for this are not clear, but it has been suggested that a reduction in the population level of blood pressure, diminished smoking, reduced intake of saturated fats, and better stroke care in dedicated units may contribute.^1,2 One way of affecting stroke morbidity and mortality might be to further reduce the impact of factors that increase stroke severity. Several authors have studied prognostic factors for long-time survival after stroke,^3–13 stroke recurrence,^3,11,14–17 and functional outcome or dependency.^4,13,18–23 Although few of these studies used population-based materials, it is well established that old age and severe impairment after stroke predict poor outcome. Few studies have considered the impact of prestroke dementia, which is now recognized as a risk factor for stroke.^24,25 Dementia after stroke is also known to have a negative impact on long-term survival.²⁶ We have previously shown that heart failure, atrial fibrillation, and dementia are associated with more severe strokes.²⁷ The purpose of this article is to demonstrate the impact of prestroke risk factors on the outcome of patients who survived the acute phase of a stroke. We designed the present study to compare 3 different domains of poor stroke outcome, with special attention given to whether risk factors other than age and stroke severity play a role.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
All cases of first-ever stroke were registered in Örebro, Sweden, during a 12-month period, from February 1, 1999, through January 31, 2000. The study population was 123 503. The World Health Organization (WHO) definition of stroke was used.²⁸ Cases were found inside and outside the hospital. Multiple overlapping sources and "hot pursuit" techniques were used in the process of case ascertainment to fulfill the requirements of an "ideal" stroke incidence study.²⁹ Patients with subarachnoid hemorrhage (n=11) were not included in the present study because of their different etiologies and prognoses. Case ascertainment and the definition of stroke types have been discussed in detail.³⁰

A year after the stroke event, each patient was offered a free follow-up consultation. Optional to the patient, the investigator either saw the patient at the consulting room or visited the patient at a house call. A single doctor (P.A.) evaluated 99% of the patients at baseline and all patients at 1 year.

Stroke severity at baseline was assessed with the National Institutes of Health Stroke Scale (NIHSS).³¹ The assessment was performed within 24 to 48 hours after the event, except if a patient’s general health was rapidly declining; in this case, the assessment was performed within the first 24 hours. At the follow-up after 1 year, dependency was assessed with the modified Rankin Scale (MRS).³² Functionally dependent was defined as an MRS score of 3, 4, or 5.³³ The MONICA criterion for stroke recurrence³⁴ was adapted: "every stroke event must have its apparent onset... more than 28 days from any preceding stroke event." At the follow-up, the incidence of new stroke events was verified in 1 of 3 ways. First, some stroke events could be verified directly by the study doctor at the time of the new stroke. Second, clear documentation in medical records of new focal signs that had lasted >24 hours was accepted. Third, some patients did not seek medical help when they had their second stroke but told the study doctor and showed signs of it at the 1-year follow-up visit. If a patient died within the year of follow-up, the cause of death was researched in hospital or primary care medical records.

Strokes were divided into the following main types according to the WHO criteria: brain infarction (BI), intracerebral hemorrhage (ICH), and stroke of undetermined pathological type (UND). Risk factors were evaluated at the time of stroke diagnosis. A structured interview was done to map the relevant medical history of each patient. When appropriate, the next of kin was interviewed. Previous hospital medical records and, when relevant, primary care records were reviewed. Assessment of prestroke dementia was based on interviews with the patient and a knowledgeable informant. We required the presence of memory impairment and deficits in at least 1 other cognitive ability. The presence of prestroke dementia was established if these disabilities were severe enough to interfere with everyday activities for at least 6 months or if there had been a confirmed diagnosis of dementia according to medical records. First-hand information was gained from a relative in 75% of patients. This relative was most often the patient’s spouse, son, or daughter. The diagnosis of dementia was based entirely on clinical grounds, and both etiological main groups of dementia—vascular and primary degenerative—were included. For a comprehensive definition of risk factors, we refer to our previous article.²⁷ Population statistics were used to ascertain whether a patient was still alive 1 year after the stroke event.

Statistical Analysis
The Kaplan-Meier method was used to estimate the probability of survival 1 year after the stroke event. Assuming binomial distribution, CIs for proportions were calculated with STATA, version 7.0. Cox’s regression and multiple logistic regression were used to calculate which factors contributed to each outcome. We used SPSS, version 11.0.

The regression analyses were performed as follows. All variables except age and stroke severity were dichotomized. The 13 explanatory variables were first tested 1 by 1 against the dependent variable for the presence of a significant association (P<0.05). Variables for which no significant association was found were removed from the model. Thereafter, the remaining variables were cross tabulated to assess for multicollinearity. In no cases were 2 variables correlated at >0.25 with each other, which was acceptable for the subsequent analysis. The regression analysis was then performed. Finally, the logistic regression models were examined for goodness of fit. Deviance values were calculated to analyze how well the model fit each case. The relative influence of individual observations was analyzed by Cook’s influence statistic. In all cases, it was concluded that the model fit was adequate, and experimental removal of outliers did not violate the model.

Ethics
Before entering the study, patients were asked orally for consent and received written information. When a patient’s ability to communicate was restricted, consent was obtained from the next of kin. The Human Ethics Committee of the Örebro County Council and the local Data Inspection Board approved the study.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Three hundred seventy-seven patients were found to have had a first-ever stroke in Örebro during the study period. Nineteen were included retrospectively when the hospital discharge records and death certificates were scrutinized. Two hundred nine patients (55%) were female, and 168 were male. The overall 28-day case fatality was 18.3% (95% CI, 14.7 to 22.5). The baseline characteristics of the study population are given in Table 1. A CT of the brain was performed at baseline in 84% of the patients. At the 1-year follow-up, 6 patients denied consent to take part in the consultation visit but agreed to answer questions in a telephone interview.

One-Year Mortality
After 1 year, 124 patients had died. The overall 1-year probability of death was 0.33 (95% CI, 0.28 to 0.38). The survival probability for different stroke subtypes was as follows: ICH, 0.36 (95% CI, 0.22 to 0.52); nonlacunar type of BI, 0.29 (95% CI, 0.23 to 0.36); lacunar type of BI, 0.06 (95% CI, 0.02 to 0.14); and UND, 0.78 (95% CI, 0.65 to 0.88). No significant differences were seen between men and women. Ninety-seven deaths (78%) were stroke related. Other causes of death were heart disease (n=9), malignant tumor (n=7), infection (n=6), and other disease (n=5).

Functional Outcome
At baseline, the median NIHSS score for all 377 patients was 6 (interquartile range, 3 to 12). The mean value was 9.2, which indicates a positive skewness. For survivors, the median score was 1.0 after 1 year (interquartile range, 0 to 3; mean value, 2.2). No patient with a baseline NIHSS score of 30 survived the first year. These patients often had lowered consciousness at the time of admission.

The frequency of different MRS scores at 1 year was as follows: 42 (16%) scored 0, 58 (23%) scored 1, 60 (24%) scored 2, 40 (16%) scored 3, 25 (10%) scored 4, and 28 (11%) scored 5.

Stroke Recurrence
Of the 310 survivors, 27 had a new stroke within the year of follow-up. The overall 1-year probability of recurrence was 0.09 (95% CI, 0.06 to 0.12). The probabilities for different stroke subtypes were as follows: ICH, 0.09 (95% CI, 0.02 to 0.23); nonlacunar type of BI, 0.10 (95% CI, 0.05 to 0.14); lacunar type of BI, 0.03 (95% CI, 0.003 to 0.09); and UND, 0.29 (95% CI, 0.11 to 0.46). No significant differences were seen between men and women. Half of the patients (n=13) did not seek medical help for their recurrent stroke, which was recorded in the follow-up examination.

Risk of Death
To evaluate which risk factors were independent predictors of death within 1 year, Cox’s proportional-hazards regression analysis was used. The following explanatory variables were included: (1) age, (2) sex, (3) living alone, (4) cigarette smoking, (5) dementia, (6) hypertension, (7) ischemic heart disease, (8) heart failure, (9) atrial fibrillation, (10) diabetes mellitus, (11) previous transitory ischemic attack (TIA), (12) peripheral atherosclerosis, and (13) stroke severity as measured with the NIHSS. Because of obvious covariation between dementia and items 1b and 1c in the NIHSS (questions and commands), these items were excluded from this calculation.

The results of both the univariate analysis and the final Cox’s model (with 95% CIs and probability values) are shown in Table 2. Hypertension, diabetes, ischemic heart disease, and TIA variables were removed from the model because of a lack of significant association. The following variables were identified as the best predictors of death within 1 year: stroke severity, age, atrial fibrillation, and dementia. Because of the heavy impact of stroke severity on mortality, the model was also tried without stroke severity as an explanatory variable. Then, heart failure, in addition to age, atrial fibrillation, and dementia, was significant.

To further validate the model, age was divided into 4 categories (<72, 72 to 77, 78 to 84, >84 years), and stroke severity was dichotomized into mild stroke (NIHSS score <6) and severe stroke (NIHSS score 6). Obviously, this changed the numerical values of the hazard ratios, but it did not change which predictors were significant.

Cox’s regression was also performed on different stroke subtypes. Stroke severity, atrial fibrillation, and dementia were significant in patients with both BI and ICH, whereas age and heart failure were significant only in patients with BI. Although differences between sexes were small, the impact of age seemed somewhat larger on women, whereas atrial fibrillation and dementia had a larger impact on men.

Risk of Dependency
Logistic regression was used to determine the risk of dependency, defined as an MRS score 3, 1 year after a first-ever stroke in 253 survivors. The explanatory variables listed above were used. The results of both the univariate and the multivariate analysis (with 95% CIs and probability values) are shown in Table 2. Sex, hypertension, diabetes, ischemic heart disease, TIA, and peripheral atherosclerosis were not included in the multivariate model because of a lack of significant association in the univariate model. The following combination was identified as the best predictor of dependency after 1 year: stroke severity, age, heart failure, and dementia.

In a logistic regression model performed for BI only, diabetes mellitus, in addition to age and stroke severity, was a significant predictor of dependency. When logistic regression was performed on the sexes separately, heart failure was a significant predictor only in men, whereas age and stroke severity were significant in both sexes.

Risk of Having a Recurrent Stroke
Cox’s regression was used to evaluate which risk factors could predict a recurrent stroke within a year from the first stroke. The results are shown in Table 2. In the first step, all variables except age, ischemic heart disease, and dementia were removed because of a lack of significant association. Age and dementia were identified as the best predictors of recurrence.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
This community-based stroke study has shown that prestroke dementia has an impact on outcome 1 year after stroke in terms of mortality and recurrence. Furthermore, atrial fibrillation affects mortality, and heart failure is associated with dependency after 1 year. Although our study is small compared with some longitudinal or multicenter studies, it has the advantage of a complete case ascertainment, including even cases managed outside the hospital, and a single investigator who evaluated patients at both baseline and the 1-year follow-up.

We have previously shown that prestroke dementia is a risk factor for initial stroke severity and for 28-day case fatality.²⁷ Others have shown that dementia after stroke increases the risk of long-term stroke recurrence³⁵ and shortens long-time survival²⁶ and that patients with cognitive impairment have an increased risk of a first stroke.^24,25 From the present study, it is also evident that prestroke dementia is a risk factor for death and stroke recurrence within 1 year. To the best of our knowledge, this has not been shown before. The common denominator between stroke and dementia may be apolipoprotein E 4, which is linked to both sporadic and late-onset Alzheimer’s disease,³⁶ as well as dementia with stroke.³⁷ Patients expressing this apolipoprotein may be more vulnerable to a vascular insult.³⁸ This has been discussed in more detail elsewhere.²⁷ Because patients with dementia are at an elevated risk of having a first stroke,^24,25 they may well be susceptible to a second stroke. However, it was not possible to show that prestroke dementia had any influence on dependency, although there was a tendency in that direction.

Atrial fibrillation is perhaps the most well-recognized cardiac risk factor. Atrial fibrillation increases stroke severity and early mortality,^27,39 as well as late mortality, as this and other studies^9–13 have shown. Atrial fibrillation is also associated with increased risk for a second ischemic stroke.¹⁶ The latter was not shown in the present study, which may be explained by the fact that 38% of the patients were on warfarin after the stroke compared with only 7% before. Also, the number of patients with recurrent stroke in this study was small, which negatively affects precision.

The negative impact of heart failure on late mortality^3,6,10–12 is well documented. Prestroke heart failure is associated with more severe strokes,²⁷ but the impact of heart failure on 1-year mortality in the present study was significant only in univariate analysis and when stroke severity was excluded from the multivariate analysis. The reason that heart failure is associated with more severe strokes remains unclear, although it may predispose to cardiac embolism, which gives rise to larger infarcts.⁴⁰ Recently, it has been shown that the administration of an angiotensin-converting enzyme inhibitor (ramipril) to patients at high risk of cardiovascular events reduces the relative risk of stroke by 32%.⁴¹ There are also proposals for 2 studies comparing warfarin and antiplatelet agents in patients with low ejection fraction.⁴⁰ The relationship between heart failure and stroke is certainly interesting because it may open new possibilities for prophylactic treatment. A more aggressive attitude toward investigation and treatment of heart diseases may already have had a part in lowering stroke mortality and morbidity in Western countries. Ryglewicz and coworkers⁴² found that ischemic strokes were more severe in Poland than in the United States. They also found that cardiac diseases (coronary disease, myocardial infarction, atrial fibrillation, and heart failure) were more frequent in Poland than in the United States, while the prevalence of hypertension, smoking, and diabetes mellitus was similar in the both countries.

Within a community-based study design, we have confirmed that age and stroke severity are risk factors for mortality and dependency within the first year after a first-ever stroke. We have also shown that ischemic heart disease, heart failure, and atrial fibrillation have adverse influence on long-term prognosis in different ways. The adverse effect of prestroke dementia on stroke severity and short-term survival²⁷ continues to influence long-term survival. It seems that effective treatment of heart diseases, especially atrial fibrillation and heart failure, before and after a stroke may improve outcome. Further studies are needed to confirm the impact of dementia on stroke outcome, and the causal connection remains to be explored.

	Acknowledgments

 
This study was supported by grants from the Research Funds of Örebro County Council. We thank Professor Åke Seiger for commenting on the manuscript and Anders Magnusson, BSc, for statistical advice.

Received May 29, 2002; revision received July 10, 2002; accepted August 16, 2002.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 
1. Stegmayr B, Asplund K. Exploring the declining case fatality in acute stroke: population-based observations in the northern Sweden MONICA Project. J Intern Med. 1996; 240: 143–149.[CrossRef][Medline] [Order article via Infotrieve]

2. Numminen H, Kaste M, Aho K, Waltimo O, Kotila M. Decreased severity of brain infarct can in part explain the decreasing case fatality rate of stroke. Stroke. 2000; 31: 651–655.[Abstract/Free Full Text]

3. Sacco RL, Wolf PA, Kannel WB, McNamara PM. Survival and recurrence following stroke: the Framingham study. Stroke. 1982; 13: 290–295.[Abstract/Free Full Text]

4. Sheikh K, Brennan PJ, Meade TW, Smith DS, Goldenberg E. Predictors of mortality and disability in stroke. J Epidemiol Community Health. 1983; 37: 70–74.[Abstract/Free Full Text]

5. Howard G, Walker MD, Becker C, Coull B, Feibel J, McLeroy K, Toole JF, Yatsu F, Community hospital-based stroke programs: North Carolina, Oregon, and New York, III: factors influencing survival after stroke: proportional hazards analysis of 4219 patients. Stroke. 1986; 17: 294–299.[Abstract/Free Full Text]

6. Viitanen M, Eriksson S, Asplund K, Wester PO, Winblad B. Determinants of long-term mortality after stroke. Acta Med Scand. 1987; 221: 349–356.[Medline] [Order article via Infotrieve]

7. Chambers BR, Norris JW, Shurvell BL, Hachinski VC. Prognosis of acute stroke. Neurology. 1987; 37: 221–225.[Abstract/Free Full Text]

8. Westling B, Norrving B, Thorngren M. Survival following stroke: a prospective population-based study of 438 hospitalized cases with prediction according to subtype, severity and age. Acta Neurol Scand. 1990; 81: 457–463.[Medline] [Order article via Infotrieve]

9. Anderson CS, Jamrozik KD, Broadhurst RJ, Stewart-Wynne EG. Predicting survival for 1 year among different subtypes of stroke: results from the Perth Community Stroke Study. Stroke. 1994; 25: 1935–1944.[Abstract]

10. Friedman P. Predictors of survival after cerebral infarction: importance of cardiac factors. Aust N Z J Med. 1994; 24: 51–54.[Medline] [Order article via Infotrieve]

11. Petty GW, Brown RD, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO. Survival and recurrence after first cerebral infarction: a population-based study in Rochester, Minnesota, 1975 through 1989. Neurology. 1998; 50: 208–216.[Abstract/Free Full Text]

12. Loor HI, Groenier KH, Limburg M, Schuling J, Meyboom-de Jong B. Risks and causes of death in a community-based stroke population: 1 month and 3 years after stroke. Neuroepidemiology. 1999; 18: 75–84.[CrossRef][Medline] [Order article via Infotrieve]

13. Vemmos KN, Bots ML, Tsibouris PK, Zis VP, Takis CE, Grobbee DE, Stamatelopoulos S. Prognosis of stroke in the south of Greece: 1 year mortality, functional outcome and its determinants: the Arcadia Stroke Registry. J Neurol Neurosurg Psychiatry. 2000; 69: 595–600.[Abstract/Free Full Text]

14. Viitanen M, Eriksson S, Asplund K. Risk of recurrent stroke, myocardial infarction and epilepsy during long-term follow-up after stroke. Eur Neurol. 1988; 28: 227–231.[Medline] [Order article via Infotrieve]

15. Burn J, Dennis M, Bamford J, Sandercock P, Wade D, Warlow C. Long-term risk of recurrent stroke after a first-ever stroke: the Oxfordshire Community Stroke Project. Stroke. 1994; 25: 333–337.[Abstract]

16. Lai SM, Alter M, Friday G, Sobel E. A multifactorial analysis of risk factors for recurrence of ischemic stroke. Stroke. 1994; 25: 958–962.[Abstract]

17. Hankey GJ, Jamrozik K, Broadhurst RJ, Forbes S, Burvill PW, Anderson CS, Stewart-Wynne EG. Long-term risk of first recurrent stroke in the Perth Community Stroke Study. Stroke. 1998; 29: 2491–2500.[Abstract/Free Full Text]

18. Kelly-Hayes M, Wolf PA, Kannel WB, Sytkowski P, D’Agostino RB, Gresham GE. Factors influencing survival and need for institutionalization following stroke: the Framingham study. Arch Phys Med Rehabil. 1988; 69: 415–418.[Medline] [Order article via Infotrieve]

19. Burn J, Sandercock P. Predicting the outcome of acute stroke. J Neurol Neurosurg Psychiatry. 1993; 56: 576.[Free Full Text]

20. Anderson CS, Jamrozik KD, Stewart-Wynne EG. Patterns of acute hospital care, rehabilitation, and discharge disposition after acute stroke: the Perth Community Stroke Study 1989–1990. Cerebrovasc Dis. 1994; 4: 344–353.

21. Fiorelli M, Alperovitch A, Argentino C, Sacchetti ML, Toni D, Sette G, Cavalletti C, Gori MC, Fieschi C. Prediction of long-term outcome in the early hours following acute ischemic stroke: Italian Acute Stroke Study Group. Arch Neurol. 1995; 52: 250–255.[Abstract/Free Full Text]

22. Hénon H, Godefroy O, Leys D, Mounier-Vehier F, Lucas C, Rondepierre P, Duhamel A, Pruvo JP. Early predictors of death and disability after acute cerebral ischemic event. Stroke. 1995; 26: 392–398.[Abstract/Free Full Text]

23. Harwood RH, Gompertz P, Pound P, Ebrahim S. Determinants of handicap 1 and 3 years after a stroke. Disabil Rehabil. 1997; 19: 205–211.[Medline] [Order article via Infotrieve]

24. Ferrucci L, Guralnik JM, Salive ME, Pahor M, Corti MC, Baroni A, Havlik RJ. Cognitive impairment and risk of stroke in the older population. J Am Geriatr Soc. 1996; 44: 237–241.[Medline] [Order article via Infotrieve]

25. Zhu L, Fratiglioni L, Guo Z, Winblad B, Viitanen M. Incidence of stroke in relation to cognitive function and dementia in the Kungsholmen Project. Neurology. 2000; 54: 2103–2107.[Abstract/Free Full Text]

26. Tatemichi TK, Paik M, Bagiella E, Desmond DW, Pirro M, Hanzawa LK. Dementia after stroke is a predictor of long-term survival. Stroke. 1994; 25: 1915–1919.[Abstract]

27. Appelros P, Nydevik I, Seiger Å, Terént A. Predictors of severe stroke: influence of preexisting dementia and cardiac disorders. Stroke. 2002; 33: 2357–2362.[Abstract/Free Full Text]

28. Aho K, Harmsen P, Hatano S, Marquardsen J, Smirnov VE, Strasser T. Cerebrovascular disease in the community: results of a WHO collaborative study. Bull World Health Org. 1980; 58: 113–130.[Medline] [Order article via Infotrieve]

29. Sudlow CL, Warlow CP. Comparing stroke incidence worldwide: what makes studies comparable? Stroke. 1996; 27: 550–558.[Abstract/Free Full Text]

30. Appelros P, Nydevik I, Seiger Å, Terént A. High incidence rates of stroke in Örebro, Sweden: further support for regional incidence differences within Scandinavia. Cerebrovasc Dis. 2002; 14: 161–168.[Medline] [Order article via Infotrieve]

31. Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH stroke scale. Arch Neurol. 1989; 46: 660–662.[Abstract/Free Full Text]

32. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988; 19: 604–607.[Abstract/Free Full Text]

33. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project, 1981–86, 2: incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1990; 53: 16–22.[Abstract/Free Full Text]

34. Asplund K, Tuomilehto J, Stegmayr B, Wester PO, Tunstall-Pedoe H. Diagnostic criteria and quality control of the registration of stroke events in the MONICA project. Acta Med Scand Suppl. 1988; 728: 26–39.[Medline] [Order article via Infotrieve]

35. Moroney JT, Bagiella E, Tatemichi TK, Paik MC, Stern Y, Desmond DW. Dementia after stroke increases the risk of long-term stroke recurrence. Neurology. 1997; 48: 1317–1325.[Abstract]

36. Saunders AM, Strittmatter WJ, Schmechel D, George-Hyslop PH, Pericak-Vance MA, Joo SH, Rosi BL, Gusella JF, Crapper-MacLachlan DR, Alberts MJ, Hulette C, Crain B, Goldgaber D, Roses AD. Association of apolipoprotein E allele 4 with late-onset familial and sporadic Alzheimer’s disease. Neurology. 1993; 43: 1467–1472.[Abstract/Free Full Text]

37. Slooter AJ, Tang MX, van Duijn CM, Stern Y, Ott A, Bell K, Breteler MM, Van Broeckhoven C, Tatemichi TK, Tycko B, Hofman A, Mayeux R. Apolipoprotein E 4 and the risk of dementia with stroke: a population-based investigation. JAMA. 1997; 277: 818–821.[Abstract/Free Full Text]

38. Sabo T, Lomnitski L, Nyska A, Beni S, Maronpot RR, Shohami E, Roses AD, Michaelson DM. Susceptibility of transgenic mice expressing human apolipoprotein E to closed head injury: the allele E3 is neuroprotective whereas E4 increases fatalities. Neuroscience. 2000; 101: 879–884.[CrossRef][Medline] [Order article via Infotrieve]

39. Lin HJ, Wolf PA, Kelly-Hayes M, Beiser AS, Kase CS, Benjamin EJ, D’Agostino RB. Stroke severity in atrial fibrillation: the Framingham study. Stroke. 1996; 27: 1760–1764.[Abstract/Free Full Text]

40. Pullicino PM, Halperin JL, Thompson JL. Stroke in patients with heart failure and reduced left ventricular ejection fraction. Neurology. 2000; 54: 288–294.[Abstract/Free Full Text]

41. Bosch J, Yusuf S, Pogue J, Sleight P, Lonn E, Rangoonwala B, Davies R, Östergren J, Probstfield J. Use of ramipril in preventing stroke: double blind randomised trial. BMJ. 2002; 324: 699–703.[Abstract/Free Full Text]

42. Ryglewicz D, Hier DB, Wiszniewska M, Cichy S, Lechowicz W, Czlonkowska A. Ischemic strokes are more severe in Poland than in the United States. Neurology. 2000; 54: 513–515.[Abstract/Free Full Text]

This article has been cited by other articles:

				B. Hallstrom, A.-C. Jonsson, C. Nerbrand, B. Norrving, and A. Lindgren Stroke Incidence and Survival in the Beginning of the 21st Century in Southern Sweden: Comparisons With the Late 20th Century and Projections Into the Future Stroke, January 1, 2008; 39(1): 10 - 15. [Abstract] [Full Text] [PDF]

				A. Ois, E. Cuadrado-Godia, J. Jimenez-Conde, M. Gomis, A. Rodriguez-Campello, J. E. Martinez-Rodriguez, E. Munteis, and J. Roquer Early Arterial Study in the Prediction of Mortality After Acute Ischemic Stroke Stroke, July 1, 2007; 38(7): 2085 - 2089. [Abstract] [Full Text] [PDF]

				G. J. Hankey, J. Spiesser, Z. Hakimi, G. Bego, P. Carita, and S. Gabriel Rate, degree, and predictors of recovery from disability following ischemic stroke Neurology, May 8, 2007; 68(19): 1583 - 1587. [Abstract] [Full Text] [PDF]

				M. Saqqur, K. Uchino, A. M. Demchuk, C. A. Molina, Z. Garami, S. Calleja, N. Akhtar, F. O. Orouk, A. Salam, A. Shuaib, et al. Site of Arterial Occlusion Identified by Transcranial Doppler Predicts the Response to Intravenous Thrombolysis for Stroke Stroke, March 1, 2007; 38(3): 948 - 954. [Abstract] [Full Text] [PDF]

				J. L. Banks and C. A. Marotta Outcomes Validity and Reliability of the Modified Rankin Scale: Implications for Stroke Clinical Trials: A Literature Review and Synthesis Stroke, March 1, 2007; 38(3): 1091 - 1096. [Abstract] [Full Text] [PDF]

				D. G. Smithard, N. C. Smeeton, and C. D. A. Wolfe Long-term outcome after stroke: does dysphagia matter? Age Ageing, January 1, 2007; 36(1): 90 - 94. [Abstract] [Full Text] [PDF]

				J. F. Meschia, L. D. Case, B. B. Worrall, R. D. Brown Jr, T. G. Brott, M. Frankel, S. Silliman, S. S. Rich, and for the Ischemic Stroke Genetics Study Group Family history of stroke and severity of neurologic deficit after stroke Neurology, October 24, 2006; 67(8): 1396 - 1402. [Abstract] [Full Text] [PDF]

				S. L. Paul, J. W. Sturm, H. M. Dewey, G. A. Donnan, R. A.L. Macdonell, and A. G. Thrift Long-Term Outcome in the North East Melbourne Stroke Incidence Study: Predictors of Quality of Life at 5 Years After Stroke Stroke, October 1, 2005; 36(10): 2082 - 2086. [Abstract] [Full Text] [PDF]

				M S Mouradian, A Senthilselvan, G Jickling, J A McCombe, D J Emery, N Dean, and A Shuaib Intravenous rt-PA for acute stroke: comparing its effectiveness in younger and older patients J. Neurol. Neurosurg. Psychiatry, September 1, 2005; 76(9): 1234 - 1237. [Abstract] [Full Text] [PDF]

				R. G. Holloway, C. G. Benesch, W. S. Burgin, and J. B. Zentner Prognosis and Decision Making in Severe Stroke JAMA, August 10, 2005; 294(6): 725 - 733. [Abstract] [Full Text] [PDF]

				F. Colivicchi, A. Bassi, M. Santini, and C. Caltagirone Prognostic Implications of Right-Sided Insular Damage, Cardiac Autonomic Derangement, and Arrhythmias After Acute Ischemic Stroke Stroke, August 1, 2005; 36(8): 1710 - 1715. [Abstract] [Full Text] [PDF]

				P. S.J. Miller, M. F. Drummond, L. K. Langkilde, J. J.V. McMurray, and M. Ogren Economic factors associated with antithrombotic treatments for stroke prevention in patients with atrial fibrillation Eur. Heart J. Suppl., May 1, 2005; 7(suppl_C): C41 - C54. [Abstract] [Full Text] [PDF]

				P. S.J. Miller, F. L. Andersson, and L. Kalra Are Cost Benefits of Anticoagulation for Stroke Prevention in Atrial Fibrillation Underestimated? Stroke, February 1, 2005; 36(2): 360 - 366. [Abstract] [Full Text] [PDF]

				T. Etgen, H. Baum, K. Sander, and D. Sander Cardiac Troponins and N-Terminal Pro-Brain Natriuretic Peptide in Acute Ischemic Stroke Do Not Relate to Clinical Prognosis Stroke, February 1, 2005; 36(2): 270 - 275. [Abstract] [Full Text] [PDF]

				J Ellul, P Talelli, G Terzis, A Chrysanthopoulou, G Gioldasis, and T Papapetropoulos Is the common carotid artery intima-media thickness associated with functional outcome after acute ischaemic stroke? J. Neurol. Neurosurg. Psychiatry, August 1, 2004; 75(8): 1197 - 1199. [Abstract] [Full Text] [PDF]

				B. Jiang, W.-z. Wang, S.-p. Wu, X.-l. Du, and Q.-j. Bao Effects of Urban Community Intervention on 3-Year Survival and Recurrence After First-Ever Stroke Stroke, June 1, 2004; 35(6): 1242 - 1247. [Abstract] [Full Text] [PDF]

				B.A. Schaer, M.J. Zellweger, T.A. Cron, C.A. Kaiser, and S. Osswald Value of Routine Holter Monitoring for the Detection of Paroxysmal Atrial Fibrillation in Patients With Cerebral Ischemic Events Stroke, March 1, 2004; 35 (3): e68 - e70. [Abstract] [Full Text] [PDF]

				E.-L. Glader, B. Stegmayr, B. Norrving, A. Terent, K. Hulter-Asberg, P.-O. Wester, and K. Asplund Sex Differences in Management and Outcome After Stroke: A Swedish National Perspective Stroke, August 1, 2003; 34(8): 1970 - 1975. [Abstract] [Full Text] [PDF]

				J. C. Sharma, P. Appelros, I. Nydevik, and M. Viitanen Poor Outcome After First-Ever Stroke * Response Stroke, August 1, 2003; 34 (8): e104 - e104. [Full Text] [PDF]

				OTHER ARTICLES NOTED (24 Jan 03 to 18 Apr 03) Evid. Based Nurs., July 1, 2003; 6(3): e1 - 12. [Full Text] [PDF]

This Article Abstract Full Text (PDF) All Versions of this Article: 34/1/122    most recent 01.STR.0000047852.05842.3Cv1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Appelros, P. Articles by Viitanen, M. Search for Related Content PubMed PubMed Citation Articles by Appelros, P. Articles by Viitanen, M. Pubmed/NCBI databases Medline Plus Health Information Stroke Related Collections Health policy and outcome research Acute Cerebral Hemorrhage Acute Cerebral Infarction Risk Factors for Stroke Epidemiology