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Introduction and objectives Potassium derangements are frequent among patients with chronic cardiovascular conditions. Studies on the associations between potassium derangements and clinical outcomes have yielded mixed findings, and the implications for health care expenditure are unknown. We assessed the population-based associations between hyperkalemia, hypokalemia and clinical outcomes and health care costs, in patients with chronic heart failure, chronic kidney disease, diabetes mellitus, hypertension, and ischemic heart disease. Methods Population-based, longitudinal study including up to 36 269 patients from a health care area with at least one of the above-mentioned conditions. We used administrative, hospital and primary care databases. Participants were followed up between 2015 and 2017, were aged ≥ 55 years and had at least 1 potassium measurement. Four analytic designs were used to evaluate prevalent and incident cases and the use of renin-angiotensin-aldosterone system inhibitors. Results Hyperkalemia was twice as frequent as hypokalemia. On multivariable-adjusted analyses, hyperkalemia was robustly and significantly associated with an increased risk of all-cause death (HR from Cox regression models ranging from 1.31–1.68) and with an increased odds of a yearly health care expenditure > 85th percentile (OR, 1.21–1.29). Associations were even stronger in hypokalemic patients (HR for all-cause death, 1.92–2.60; OR for health care expenditure > percentile 85th, 1.81–1.85). Conclusions Experimental studies are needed to confirm whether the prevention of potassium derangements reduces mortality and health care expenditure in these chronic conditions. Until then, our findings provide observational evidence on the potential importance of maintaining normal potassium levels.

Resumen Introduccion y objetivos Las alteraciones de la potasemia son frecuentes en las enfermedades cardiovasculares cronicas. El objetivo del estudio es evaluar las asociaciones de la hiperpotasemia y la hipopotasemia con eventos clinicos y costes sanitarios en pacientes con insuficiencia cardiaca, enfermedad renal cronica, diabetes mellitus, hipertension y cardiopatia isquemica. Metodos Estudio longitudinal que incluyo a 36.269 pacientes de un Area de Salud que tuvieran al menos una de las afecciones mencionadas. Se utilizaron bases de datos administrativas, hospitalarias y de atencion primaria. Se siguio a los participantes entre 2015 y 2017; estos tenian 55 o mas anos y al menos 1 medicion de potasio. Se utilizaron 4 disenos analiticos para evaluar la prevalencia y la incidencia y el uso de inhibidores del sistema renina-angiotensina-aldosterona. Resultados La hiperpotasemia fue 2 veces mas frecuente que la hipopotasemia. En los analisis ajustados, la hiperpotasemia se asocio de manera significativa con un mayor riesgo de muerte por todas las causas (HR de los modelos de regresion de Cox entre 1,31 y 1,68) y con un aumento de las probabilidades de que los gastos anuales de atencion sanitaria superen el 85% (OR entre 1,21 y 1,29). Las asociaciones fueron aun mayores en los pacientes hipopotasemicos (HR para la muerte por todas las causas, 1,92-2,60; OR para los gastos de atencion sanitaria > percentil 85, 1,81-1,85). Conclusiones Se necesitarian estudios experimentales para confirmar si la prevencion de los trastornos del potasio reduce la mortalidad y los gastos sanitarios en estas enfermedades cronicas. Hasta entonces, nuestros hallazgos proporcionan conclusiones observacionales sobre la importancia de mantener normales las concentraciones de potasio.

Background The aims of the present analysis are to estimate the prevalence of five key chronic cardiovascular, metabolic and renal conditions at the population level, the prevalence of renin-angiotensin-aldosterone system inhibitor (RAASI) medication use and the magnitude of potassium (K+) derangements among RAASI users. Methods and Results We used data from more than 375,000 individuals, 55 years of age or older, included in the population-based healthcare database of the Catalan Institute of Health between 2015 and 2017. The conditions of interest were chronic heart failure (CHF), chronic kidney disease (CKD), diabetes mellitus, ischemic heart disease and hypertension. RAASI medications included angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists (MRAs) and renin inhibitors. Hyperkalemia was defined as K+ levels >5.0 mEq/L and hypokalemia as K+

Background Accurate risk adjustment is crucial for healthcare management and benchmarking. Purpose We aimed to compare the performance of classic comorbidity functions (Charlson's and Elixhauser's), of the All Patients Refined Diagnosis Related Groups (APR-DRG), and of the Queralt Indices, a family of novel, comprehensive comorbidity indices for the prediction of key clinical outcomes in hospitalized patients. Material and Methods We conducted an observational, retrospective cohort study using administrative healthcare data from 156,459 hospital discharges in Catalonia (Spain) during 2018. Study outcomes were in-hospital death, long hospital stay, and intensive care unit (ICU) stay. We evaluated the performance of the following indices: Charlson's and Elixhauser's functions, Queralt's Index for secondary hospital discharge diagnoses (Queralt DxS), the overall Queralt's Index, which includes pre-existing comorbidities, in-hospital complications, and principal discharge diagnosis (Queralt Dx), and the APR-DRG. Discriminative ability was evaluated using the area under the curve (AUC), and measures of goodness of fit were also computed. Subgroup analyses were conducted by principal discharge diagnosis, by age, and type of admission. Results Queralt DxS provided relevant risk adjustment information in a larger number of patients compared to Charlson's and Elixhauser's functions, and outperformed both for the prediction of the 3 study outcomes. Queralt Dx also outperformed Charlson's and Elixhauser's indices, and yielded superior predictive ability and goodness of fit compared to APR-DRG (AUC for in-hospital death 0.95 for Queralt Dx, 0.77-0.93 for all other indices; for ICU stay 0.84 for Queralt Dx, 0.73-0.83 for all other indices). The performance of Queralt DxS was at least as good as that of the APR-DRG in most principal discharge diagnosis subgroups. Conclusion Our findings suggest that risk adjustment should go beyond pre-existing comorbidities and include principal discharge diagnoses and in-hospital complications. Validation of comprehensive risk adjustment tools such as the Queralt indices in other settings is needed.

Resumen: Introducción: Los grupos de morbilidad ajustados (GMA) y los clinical risk groups (CRG) son herramientas de estratificación poblacional basada en la morbilidad que permiten clasificar a los pacientes en categorías mutuamente excluyentes. Objetivo: Comparar la estratificación, según niveles de complejidad, proporcionada por los GMA con la de los CRG y con la realizada ad-hoc por los evaluadores. Diseño: Muestra aleatoria por estratos de riesgo de morbilidad. Emplazamiento: Cataluña. Participantes: Cuarenta médicos de atención primaria emparejados 2 a 2. Intervenciones: Cada pareja de evaluadores tuvo que validar 25 historias. Mediciones principales: Se evaluó la concordancia entre evaluadores, y entre los evaluadores y los resultados obtenidos por los 2 agrupadores de morbilidad con el índice kappa, la sensibilidad, la especificidad, el valor predictivo positivo y el negativo. Resultados: La concordancia entre evaluadores se situó alrededor del valor kappa 0,75 (valor medio = 0,67), entre los GMA y los evaluadores fue similar (valor medio = 0,63), y más elevada que para los CRG (valor medio = 0,35). Los profesionales otorgaron una puntuación de 7,5 a la bondad de ambos agrupadores, aunque para los estratos de mayor complejidad, según asignación de los profesionales, los GMA obtuvieron mejores puntuaciones que los CRG. Los profesionales prefirieron mayoritariamente los GMA frente a los CRG. Estas diferencias se incrementaron con el aumento de la complejidad de los pacientes según el criterio clínico.Globalmente, se encontró menos de un 2% de errores graves de clasificación proporcionada por ambos agrupadores. Conclusión: Los profesionales consideraron que ambos agrupadores clasificaban adecuadamente a la población, aunque los GMA tienen un mejor comportamiento en los estratos que los profesionales identifican como de mayor complejidad. Además, en la mayoría de los casos, los evaluadores clínicos prefirieron los GMA. Abstract: Introduction: Adjusted Morbidity Groups (GMAs) and the Clinical Risk Groups (CRGs) are population morbidity based stratification tools which classify patients into mutually exclusive categories. Objetive: To compare the stratification provided by the GMAs, CRGs and that carried out by the evaluators according to the levels of complexity. Design: Random sample stratified by morbidity risk. Location: Catalonia. Participants: Forty paired general practitioners in the primary care, matched pairs. Interventions: Each pair of evaluators had to review 25 clinical records. Main outputs: The concordance by evaluators, and between the evaluators and the results obtained by the 2 morbidity tools were evaluated according to the kappa index, sensitivity, specificity, and positive and negative predicted values. Results: The concordance between general practitioners pairs was around the kappa value 0.75 (mean value = 0.67), between the GMA and the evaluators was similar (mean value = 0.63), and higher than for the CRG (mean value = 0.35). The general practitioners gave a score of 7.5 over 10 to both tools, although for the most complex strata, according to the professionals’ assignment, the GMA obtained better scores than the CRGs. The professionals preferred the GMAs over the CRGs. These differences increased with the complexity level of the patients according to clinical criteria.Overall, less than 2% of serious classification errors were found by both groupers. Conclusion: The evaluators considered that both grouping systems classified the studied population satisfactorily, although the GMAs showed a better performance for more complex strata. In addition, the clinical raters preferred the GMAs in most cases. Palabras clave: Agrupador de morbilidad, Multimorbilidad, Validación clínica, Keywords: Morbidity grouper, Multimorbidity, Clinical Validation

The shortage of recently approved vaccines against the severe acute respiratory syndrome coronavirus (SARS-CoV-2) has highlighted the need for evidence-based tools to prioritize healthcare resources for people at higher risk of severe coronavirus disease 2019 (COVID-19). Current evidence indicates that age is far from accurate in identifying the risk of severe illness; furthermore, the count of individual risk factors has limited applicability to population-based “stratify-and-shield” strategies. We developed a COVID-19 risk stratification system that allows allocating people into four mutually-exclusive risk categories based on multivariate models for hospital admissions, transfer to intensive care unit (ICU), and mortality among the general population. The model was developed using clinical, hospital, and epidemiological data from the entire population of Catalonia (North-East Spain; 7.5 million people) and validated using an independent dataset of 218,329 individuals with PCR-confirmed COVID-19, who were infected after developing the model. This showed high discrimination capacity, with an area under the curve of the receiving operating characteristics of 0.85 (95% CI 0.85–0.85) for hospital admissions, 0.86 (0.86–0.97) for ICU transfers, and 0.96 (0.96–0.96) for deaths. Our results provide clinicians and policymakers with an evidence-based tool for prioritizing COVID-19 healthcare resources other population groups aside from those with higher exposure to SARS-CoV-2 and frontline workers.

espanolAntecedentes: hay poca informacion sobre las caracteristicas clinicas tempranas del accidente cerebrovascular cardioembolico antes de los examenes complementarios. Objetivo: El objetivo de este estudio fue identificar los factores de riesgo, las caracteristicas clinicas y los resultados tempranos del accidente cerebrovascular cardioembolico. Metodos: estudio retrospectivo basado en datos recopilados prospectivamente disponibles de un registro de accidentes cerebrovasculares de un centro medico universitario en un hospital. Se seleccionaron pacientes consecutivos diagnosticados de infarto cardioembolico y se compararon con los diagnosticados de ictus aterotrombotico. Los predictores de infarto cardioembolico se evaluaron mediante analisis multivariante. Resultados:De una cohorte de 4597 pacientes consecutivos, estudiamos 956 pacientes diagnosticados de infarto cardioembolico (80 anos [desviacion estandar (DE) 9,14]; 63% mujeres) y 945 con infarto aterotrombotico (77,01 anos [DE 9,75]; 49,8% mujeres). El analisis comparativo univariado informo que la edad avanzada (≥ 85 anos), el sexo femenino, la fibrilacion auricular (FA), la cardiopatia isquemica y la insuficiencia cardiaca congestiva fueron significativamente mas frecuentes en el grupo cardioembolico, mientras que la hipertension, la diabetes, la enfermedad vascular periferica, el tabaquismo, la hiperlipidemia y el ataque isquemico transitorio previo fueron significativos en el grupo aterotrombotico. En el modelo de regresion logistica, FA (razon de posibilidades [OR] 15,75, intervalo de confianza [IC] del 95%: 12,14-20,42), cardiopatia isquemica (OR 3,12, IC del 95%: 2,16-4,5), sexo femenino (OR 1,56, IC del 95%: 1,22-2,00), Conclusiones: El posible ictus cardioembolico requiere una evaluacion integral, ya que una clasificacion e identificacion precoces a traves de predictores mejoraria el manejo efectivo. (REV INVEST CLIN. 2021; 73 (1): 23-30) EnglishBackground: There is little information about the early clinical features of cardioembolic stroke before complementary examinations. Objective: The aim of this study was to identify risk factors, clinical features, and early outcomes of cardioembolic stroke. Methods: Retrospective study based on prospectively collected data available from a university medical center hospital-based stroke registry. Consecutive patients diagnosed with cardioembolic infarction were selected and compared to those diagnosed with an atherothrombotic stroke. Predictors of cardioembolic infarction were assessed by multivariate analysis. Results: From a cohort of 4597 consecutive patients, we studied 956 patients diagnosed with cardioembolic infarction (80 years [standard deviation (SD) 9.14]; 63% women) and 945 with atherothrombotic infarction (77.01 years [SD 9.75]; 49.8% women). The univariate comparative analysis reported that advanced age (≥ 85 years), female gender, atrial fibrillation (AF), ischemic heart disease, and congestive heart failure were significantly more frequent in the cardioembolic group, whereas hypertension, diabetes, peripheral vascular disease, heavy smoking, hyperlipidemia, and previous transient ischemic attack were significant in the atherothrombotic group. In the logistic regression model, AF (odds ratio [OR] 15.75, 95% confidence interval [CI]: 12.14-20.42), ischemic heart disease (OR 3.12, 95% CI: 2.16-4.5), female gender (OR 1.56, 95% CI: 1.22-2.00), and sudden-onset (OR 1.97, 95% CI: 1.54-2.51), were independent significant predictors of cardioembolic stroke. Conclusions: Potential cardioembolic stroke requires a comprehensive evaluation, since early classification and identification through predictors would improve effective management. (REV INVEST CLIN. 2021;73(1):23-30)

BackgroundMultimorbidity measures are useful for resource planning, patient selection and prioritization, and factor adjustment in clinical practice, research, and benchmarking. We aimed to compare the explanatory performance of the adjusted morbidity group (GMA) index in predicting relevant healthcare outcomes with that of other quantitative measures of multimorbidity.MethodsThe performance of multimorbidity measures was retrospectively assessed on anonymized records of the entire adult population of Catalonia (North-East Spain). Five quantitative measures of multimorbidity were added to a baseline model based on age, gender, and socioeconomic status: the Charlson index score, the count of chronic diseases according to three different proposals (i.e., the QOF, HCUP, and Karolinska institute), and the multimorbidity index score of the GMA tool. Outcomes included all-cause death, total and non-scheduled hospitalization, primary care and ER visits, medication use, admission to a skilled nursing facility for intermediate care, and high expenditure (time frame 2017). The analysis was performed on 10 subpopulations: all adults (i.e., aged > 17 years), people aged > 64 years, people aged > 64 years and institutionalized in a nursing home for long-term care, and people with specific diagnoses (e.g., ischemic heart disease, cirrhosis, dementia, diabetes mellitus, heart failure, chronic kidney disease, and chronic obstructive pulmonary disease). The explanatory performance was assessed using the area under the receiving operating curves (AUC-ROC) (main analysis) and three additional statistics (secondary analysis).ResultsThe adult population included 6,224,316 individuals. The addition of any of the multimorbidity measures to the baseline model increased the explanatory performance for all outcomes and subpopulations. All measurements performed better in the general adult population. The GMA index had higher performance and consistency across subpopulations than the rest of multimorbidity measures. The Charlson index stood out on explaining mortality, whereas measures based on exhaustive definitions of chronic diagnostic (e.g., HCUP and GMA) performed better than those using predefined lists of diagnostics (e.g., QOF or the Karolinska proposal).ConclusionsThe addition of multimorbidity measures to models for explaining healthcare outcomes increase the performance. The GMA index has high performance in explaining relevant healthcare outcomes and may be useful for clinical practice, resource planning, and public health research.

Coronavirus SARS-CoV-2; COVID-19; 2019-nCoV; Digital health; eHealth; Telemedicine; Public health Coronavirus SARS-CoV-2; COVID-19; 2019-nCoV; Salud digital; eSalud; Telemedicina; Salud pública Coronavirus SARS-CoV-2; COVID-19; 2019-nCoV; Salut digital; eSalut; Telemedicina; Salut pública Digital health technologies offer significant opportunities to reshape current health care systems. From the adoption of electronic medical records to mobile health apps and other disruptive technologies, digital health solutions have promised a better quality of care at a more sustainable cost. However, the widescale adoption of these solutions is lagging behind. The most adverse scenarios often provide an opportunity to develop and test the capacity of digital health technologies to increase the efficiency of health care systems. Catalonia (Northeast Spain) is one of the most advanced regions in terms of digital health adoption across Europe. The region has a long tradition of health information exchange in the public health care sector and is currently implementin an ambitious digital health strategy. In this viewpoint, we discuss the crucial role digital health solutions play during the coronavirus disease (COVID-19) pandemic to support public health policies. We also report on the strategies currently deployed at scale during the outbreak in Catalonia

Background and objective To assess the clinical features and incidence rate of stroke in young adults (less than 55 years of age). Methods Hospital-based descriptive study of 280 young inpatients consecutively admitted for stroke over a period of 24 years. We conducted a comparison with the remaining 4,312 patients admitted for stroke. Results Stroke in young adults represented 6.1% of all strokes, 5.7% of transient ischaemic attacks, 5.8% of cerebral infarctions and 8.4% of brain haemorrhages. However, reported minimal frequency of cardioembolic (2.1%) and atherothrombotic (3.4%) infarctions, accounted for 5.9% of lacunar and for 10.7% of essential infarctions and showed a maximum frequency in those infarctions of unusual aetiology (36%). Factors independently associated with stroke in young adults were cigarette smoking (OR 4.23; 95% CI 3.02–5.93; P = .000), unusual aetiology (OR 4.97; 95% CI 3.15–7.84; P = .000), headache (OR 4.57; 95% CI 2.59–8.07; P = .000), alcohol abuse (OR 3.93; 95% CI 2.46–6.29; P = .000), oral contraceptives (OR 14.07; 95% CI 2.37–83.40; P = .004), atrial fibrillation (OR 0.15; 95% CI 0.08–0.28; P = .000), arterial hypertension (OR 0.43; 95% CI 0.33–0.57; P = .000), COPD (OR 0.20; 95% CI 0.09–0.44; P = .000), atherothrombotic infarction (OR 0.51; 95% CI 0.34–0.77; P = .001), female sex (OR 0.71; 95% CI 0.52–0.97; P = .029), diabetes mellitus (OR 0.66; 95% CI 0.46–0.98; P = .030), ischaemic heart disease (OR 0.56; 95% CI 0.33–0.95; P = .032) and intermittent claudication (OR 0.48; 95% CI 0.24–0.94; P = .033). Conclusions Stroke in young adults is infrequent (6.1% of the total), but represents the highest frequency of cerebral infarcts of unusual aetiology (36%). We conclude that stroke in younger patients presents its own and differentiated clinical profile.

Resumen Fundamento y objetivo Analizar los rasgos clinicos y la frecuencia de presentacion de los ictus en adultos jovenes (55 o menos anos de edad). Metodos Estudio hospitalario de 280 pacientes jovenes consecutivos ingresados por presentar un ictus durante un periodo de 24 anos. Se efectua una comparacion con los 4.312 pacientes restantes ingresados con ictus. Resultados Los ictus en adultos jovenes representan el 6,1% del total de los ictus, el 5,7% de los ataques isquemicos transitorios, el 5,8% de los infartos cerebrales y el 8,4% de las hemorragias cerebrales. Su frecuencia fue minima en los infartos cardioembolicos (2,1%) y en los aterotromboticos (3,4%). Se observo en el 5,9% de los lacunares y en el 10,7% de los infartos esenciales, y su frecuencia fue maxima en los infartos de causa inhabitual (36%). Las variables asociadas a los ictus jovenes de forma independiente fueron el tabaquismo (OR 4,23; IC del 95% 3,02-5,93; p = 0,000), la etiologia inhabitual (OR 4,97; IC del 95% 3,15-7,84; p = 0,000), la cefalea (OR 4,57; IC del 95% 2,59-8,07; p = 0,000), el abuso de alcohol (OR 3,93; IC del 95% 2,46-6,29; p = 0,000), los anovulatorios (OR 14,07; IC del 95% 2,37-83,40; p = 0,004), la fibrilacion auricular (OR 0,15; IC del 95% 0,08-0,28; p = 0,000), la hipertension arterial (OR 0,43; IC del 95% 0,33-0,57; p = 0,000), la EPOC (OR 0,20; IC del 95% 0,09-0,44; p = 0,000), el infarto aterotrombotico (OR 0,51; IC del 95% 0,34-0,77; p = 0,001), el sexo femenino (OR 0,71; IC del 95% 0,52-0,97; p = 0,029), la diabetes mellitus (OR 0,66; IC del 95% 0,46-0,98; p = 0,030), la cardiopatia isquemica (OR 0,56; IC del 95% 0,33-0,95; p = 0,032) y la claudicacion intermitente (OR 0,48; IC del 95% 0,24-0,94; p = 0,033). Conclusiones Los ictus en adultos jovenes son infrecuentes (6,1% del total), pero representan el 36% de los infartos de causa inhabitual. Las ictus en adultos jovenes presentan un perfil clinico propio y diferenciado.

Acute lacunar stroke in subjects under 55 years of age has been poorly characterized.We assessed the clinical features of lacunar stroke in 51 patients aged ≤55 years (84.5% men, mean standard deviation [SD] age 49.8 [5.2] years) collected from a prospective hospital-based stroke registry in Barcelona, Catalonia, Spain.This subset of young lacunar stroke patients accounted for only 5.2% of all lacunar strokes, 1.2% of all ischemic strokes, and 1.1% of all acute strokes included in the registry over a 24-year period. In the multivariate analysis, factors independently associated with acute lacunar stroke in patients aged ≤55 years were alcohol consumption (60 g/day) (odds ratio [OR] = 6.67), heavy smoking (20 cigarettes/day) (OR = 3.02), obesity (OR = 2.81), essential etiology (OR = 2.73), and headache at stroke onset (OR = 2.45).Characterization of the clinical profile of acute lacunar stroke in younger patients contributes to a better knowledge of the full clinical expression of this ischemic stroke subtype.

Resumen Objetivo Comparar el rendimiento referente a la bondad de ajuste y el poder explicativo de 2 agrupadores de morbilidad en el ámbito de la atención primaria (AP): los grupos de morbilidad ajustados (GMA) y los clinical risk groups (CRG). Diseño Estudio transversal. Emplazamiento Ámbito de la AP del Instituto Catalán de la Salud (ICS), Cataluña, España. Participantes Población asignada a centros de AP del ICS para el año 2014. Mediciones principales Se analizan 3 indicadores de interés, como son el ingreso urgente, el número de visitas y el gasto en farmacia. Se aplica un análisis estratificado por centros ajustando modelos lineales generalizados a partir de las variables edad, sexo y agrupador de morbilidad para explicar cada una de las 3 variables de interés. Las medidas estadísticas para analizar el rendimiento de los distintos modelos aplicados son el índice de Akaike, el índice de Bayes y la seudovariabilidad explicada mediante cambio de deviance. Resultados Los resultados muestran que en el ámbito de la AP del ICS el poder explicativo de los GMA es superior al ofrecido por los CRG, especialmente para el caso de las visitas y el gasto en farmacia. Conclusiones El rendimiento de los GMA en el ámbito de la AP del ICS es superior al mostrado por los CRG.

We assessed gender differences and women-specific secular trends in stroke.Data from 2318 women and 2274 men with first-ever stroke collected from the Sagrat Cor Hospital Stroke Registry of Barcelona between 1986 and 2009 were analyzed.Patient's age increased significantly from a mean of 74.5 years in 1986-1992 to 81.2 years in 2004-2009 (P0.001). Patients aged ≥ 85 years increased from 18.5% to 38.5% (P = 0.0001) as were patients with hypertension, atrial fibrillation, and cardioembolic stroke. The in-hospital death decreased from 17.6% to 11% (P = 0.02), median length of hospital from 14 to 9 days (P = 0.0001) and prolonged hospital stay (12 days) from 59.7% to 33.7% (P = 0.0001). Lacunar infarction was more frequent in men (21.5% vs. 16.2%, P = 0.0003) and cardioembolic infarction in women (26% vs. 15.6%, P = 0.0001). Acute stroke in women continues to be a severe disease with high risk of death in the immediate post-stroke phase (13.5%) and low probability of early full neurological recovery (13.9% vs. 11.8%, P = 0.029).Women differ from men in the distribution of risk factors and stroke subtype, stroke severity, and outcome. An increase in the patient's age, hypertension, atrial fibrillation and cardioembolic infarction, as well as a decrease mortality and length of hospitalization over a 24-year period was recorded.

A B S T R A C T Background and objectives: Cardiovascular risk factors, clinical features and early outcome of first-ever primary intracerebral haemorrhage (PIH) from 1986 to 2004 using the Sagrat Cor Hospital of Barcelona Stroke Registry were assessed, and compared with data from patients with first-ever ischemic stroke. Patients and methods: The study population consisted of 380 patients with PIH and 2,082 patients with ischemic stroke. Secular trends for the periods 1986-1992, 1993-1998 and 1999-2004 were analyzed. Results: Age increased significantly (P < .001) throughout the 3 study periods and there was a significant increase in the percentage of patients with atrial fibrillation, chronic obstructive pulmonary disease (COPD) and lobar topography. The use of brain magnetic resonance imaging (MRI) also increased significantly throughout the study periods. In comparison with ischemic stroke in-hospital death was more frequent (28,2 vs. 12%) and lacunar syndrome (9,5 vs. 31,4%) and symptom-free patients at discharge were less frequent in the intracerebral haemorrhage group (6,1 vs. 18,3%).

There are few studies analyzing features of ischemic stroke subtypes in women. We assessed gender differences in lacunar stroke subtype based on data collected from a prospective stroke registry in Barcelona, Spain. Lacunar ischemic stroke was diagnosed in 310 (8.1 %) women and 423 (11.1 %) men of a total of 3,808 consecutive stroke patients included in a prospective hospital-based stroke registry, in Barcelona, Catalonia (Spain), over a period of 19 years. Independent factors for lacunar stroke in women were assessed by multivariate analysis. Women accounted for 42 % of all lacunar stroke patients (n = 733) in the registry and 11.4 % of all patients with ischemic stroke (n = 2,704). Very old age (85 years or older) was found in 20.3 % in women versus 11.1 % in men (P0.0001). In the logistic regression analysis, obesity [odds ratio (OR) = 4.24], prolonged hospital stay (12 days) (OR = 1.59), arterial hypertension (OR = 1.50), and age (OR = 1.06) were significant variables independently associated with lacunar stoke in women, whereas peripheral vascular disease (OR = 0.51), chronic obstructive pulmonary disease (OR = 0.46), renal dysfunction (OR = 0.13), and heavy smoking (OR = 0.04) were independent variables for lacunar stroke in men. Women with lacunar stroke were remarkably older and presented with obesity and hypertension more frequently than did men. Lacunar stroke severity was similar in men and women. These findings in lacunar stroke patients could be explained by differences in gender for ischemic stroke in general.

Resumen Fundamento y objetivo Analizar las caracteristicas demograficas, pronosticas y el perfil clinico relacionado con las hemorragias intracerebrales no traumaticas recurrentes (HCR). Pacientes y metodo Estudio hospitalario descriptivo de 28 pacientes consecutivos ingresados durante un periodo de 19 anos por presentar HCR. Se efectua una comparacion con 380 pacientes con una primera hemorragia intracerebral no traumatica. Resultados Las HCR representan el 6,8% del total de hemorragias intracerebrales primarias. Las HCR fueron mayoritariamente lobulares (67,9%). Otras topografias incluyen: el talamo (10,7%), la region capsuloganglionar (7,1%), la zona intraventricular (3,6%) y la topografia multiple (10,7%). Aunque las HCR tienen mal pronostico evolutivo, este no es peor en comparacion con el de las primeras hemorragias cerebrales primarias, tanto por su elevada mortalidad hospitalaria (17,9 frente al 28,2%), como por su baja frecuencia de ausencia de limitacion al alta hospitalaria (3,6 frente al 6,1%). El perfil clinico significativamente asociado con las HCR fue: presencia de valvulopatia (odds ratio [OR] 5,32; intervalo de confianza del 95% [IC 95%] 1,45-19,47), la topografia lobular (OR 3,53; IC 95% 1,53-8,13) y la presencia de nauseas y vomitos (OR 2,43; IC 95% 1,06-5,52). Conclusiones Las HCR constituyen menos de una decima parte de las hemorragias intracerebrales no traumaticas ingresadas en el Servicio de Neurologia, siendo mas frecuentes las localizadas en los lobulos cerebrales. Aunque su pronostico es grave, este no es peor -durante su fase aguda- que el de las primeras hemorragias intracerebrales. Las HCR presentan un perfil clinico propio y diferenciado.

Purpose. Primary hemorrhage in the ventricular system without a recognizable parenchymal component is very rare. This single-center retrospective study aimed to further characterize the clinical characteristics and early outcome of this stroke subtype. Methods. All patients with primary intraventricular hemorrhage included in a prospective hospital-based stroke registry over a 19-year period were assessed. A standardized protocol with 161 items, including demographics, risk factors, clinical data, neuroimaging findings, and outcome, was used for data collection. A comparison was made between the groups of primary intraventricular hemorrhage and subcortical intracerebral hemorrhage. Predictors of primary intraventricular hemorrhage were identified by logistic regression analysis. Results. There were 12 patients with primary intraventricular hemorrhage (0.31% of all cases of stroke included in the database) and 133 in the cohort of subcortical hemorrhage. Very old age (≥85 years) (odds ratio (OR) 9.89), atrial fibrillation (OR 8.92), headache (OR 6.89), and altered consciousness (OR 4.36) were independent predictors of intraventricular hemorrhage. The overall in-hospital mortality rate was 41.7% (5/12) but increased to 60% (3/5) in patients aged 85 years or older. Conclusion. Although primary intraventricular hemorrhage is uncommon, it is a severe clinical condition with a high early mortality. The prognosis is particularly poor in very old patients.

Purpose: This study aims to identify clinical predictors of prolonged hospital stay after acute stroke based on data collected from a prospective hospital-based acute stroke registry. Methods: All patients with first-ever ischemic stroke and primary intracerebral hemorrhage included in the Sagrat Cor Hospital of Barcelona stroke database over a 17-year period were assessed. Prolonged hospital stay was defined as hospitalization for longer than 12 days after admission. Demographic data, cardiovascular risk factors, clinical factors, neuroimaging findings, and outcome were compared in patients hospitalized for more or less than 12 days. Logistic regression analysis was used to assess the independent influence of statistically significant variables in the bivariate analysis and duration of hospitalization. Results: Of a total of 3112 acute stroke patients included in the study, prolonged hospital stay was recorded in 1536 (49.4%). Male sex (OR = 1.16), limb weakness (OR = 1.79), vascular complications (OR = 2.68), urinary complications (OR = 2.56), and infectious complications (OR = 1.78) were independently associated with longer stay, whereas symptom free at discharge (OR = 0.45) and lacunar infarction (OR = 0.43) were inversely associated with prolonged hospitalization. Conclusion: In-hospital medical complications (vascular, urinary, and infectious) are relevant factors influencing duration of hospitalization after acute stroke. Therefore, prevention of potentially modifiable risk factors for medical complications is an important aspect of the early management of patients with stroke.

Background: Cardiovascular risk factors, clinical features and early outcome of first-ever cerebral lacunar infarcts from 1986 to 2004, using the Sagrat Cor Hospital of Barcelona Stroke Registry, were assessed and compared with data from patients with nonlacunar infarction. Methods: The study population consisted of 566 patients with lacunar infarct and 1,516 patients with nonlacunar infarct. Secular trends for the periods 1986–1992, 1993–1998 and 1999–2004 were analyzed. Results: Age and the percentage of very old patients (≧85 years old) increased significantly (p < 0.001) throughout the time period. There was a significant decrease in the percentage of patients with hypertension, but the percentage of patients with chronic obstructive pulmonary disease increased. The use of brain magnetic resonance imaging (MRI) also increased significantly. The median length of hospital stay decreased significantly. Conclusions: Significant changes over a 19-year period included an increase in the patients’ age, frequency of very old patients (≧85 years old) and use of MRI studies, whereas the frequency of hypertension and length of hospital stay decreased.

Background: Prospective stroke registries allow analyzing important aspects of the natural history of acute cerebrovascular events. Using the Sagrat Cor Hospital of Barcelona Stroke Registry, we aimed to determine trends in risk factors, stroke subtypes, prognosis and in-hospital mortality over 19 years in hospitalized stroke patients. Methods: The study population consisted of 2,416 first-ever stroke patients (ischemic stroke, n = 2,028; intracerebral hemorrhage, n = 334) included in the stroke registry up to December 31, 2004. Temporal trends in stroke patient characteristics for the periods 1986–1992, 1993–1998 and 1999–2004 were assessed. Results: Age was significantly different among the analyzed periods (p < 0.001), showing an increment in older patients throughout time. Hypertension (p = 0.001), diabetes (p = 0.004), ischemic heart disease (p = 0.002) and atrial fibrillation increased (p = 0.000) as opposed to heavy smoking (p = 0.000) and history of TIA (p = 0.025). The mortality rate and the length of hospital stay decreased (p = 0.001), whereas transfer to convalescent/rehabilitation units increased (p = 0.001). Conclusions: An improvement in acute-stroke management and possibly evolution of cerebrovascular risk factors is reflected by changes in the risk factors and outcome of first-ever stroke patients admitted to a stroke unit over a 19-year time span.

Objective.—To assess whether the infarction topography influenced upon the incidence of headache and the likelihood of neurological recovery in lacunar infarction. Background.—The relationship between topography of infarction and the incidence of headache as well as the influence of headache on neurological outcome in patients with lacunar stroke are still unclear. Methods.—In a cohort of 387 patients with neuroimaging-proven acute lacunar infarction collected from a prospective hospital-based stroke registry over a 12-year period, 43 patients (11.1%) presented with headache within a 72-hour interval of stroke onset. Results.—Headache was more common in deep brain gray matter or brainstem lacunar infarction than in supratentorial white matter lacunar infarction (14.9% vs 8%, P < .033), but lacunar infarctions in the supratentorial white matter had less frequently absence of limitation at discharge (15.1% vs 25.1%, P < .013). In deep brain gray matter or brainstem lacunar infarction, early neurological recovery decreased from 26.2% to 19.2% when headache was present at stroke onset. In the multivariate analysis, dysarthria-clumsy hand and absence of headache in deep brain gray matter or brainstem lacunar infarction were independent predictors of favorable outcome. Conclusions.—In patients with lacunar infarction, headache at stroke onset was more common in deep brain gray matter or brainstem topographies than in supratentorial white matter lesions. In deep brain gray matter or brainstem lacunar infarctions, early neurological recovery was less likely when headache was present.

This study assessed gender differences in diabetic patients with ischemic stroke with respect to vascular risk factors, clinical features and early outcome. Ischemic stroke was diagnosed in 261 diabetic women and 300 diabetic men of 2,446 ischemic stroke patients included in a prospective stroke registry over 17 years. Mean +/- SD age was 77.5 +/- 8.3 years in women and 71.8 +/- 9.7 years in men (p < 0.021). Risk factors for stroke including hypertension, atrial fibrillation, congestive heart failure and valvular heart disease were significantly more common in women. Cardioembolic infarction occurred in 29.5% of women and 15.3% of men (p < 0.001), and lacunar stroke in 40.3% of men and 29.9% of women (p < 0.006). In-hospital mortality was 14.9% in diabetic women, and 8.3% in diabetic men (p < 0.02). After multivariate analysis, congestive heart failure (OR = 4.59), frontal lobe involvement (OR = 2.67), hypertension (OR = 1.62) and age were independent variables for ischemic stroke in diabetic women. Diabetic women had a poor prognosis, which may be due to differences in age, comorbidity and stroke subtype distribution.

Objective We report a clinical description of pure sensory stroke based on data collected from a prospective acute stroke registry. Methods From 2500 acute stroke patients included in a hospital-based prospective stroke registry over a 12-year period, 99 were identified as having pure sensory stroke. Results Pure sensory stroke accounted for 4.7% of all acute stroke patients, 5.4% of acute ischemic stroke, and 17.4% of lacunar syndromes. Complete hemisensory syndrome was present in 80 patients and incomplete hemisensory syndrome in 19 (cheiro-oral syndrome 12, cheiro-oral-pedal 6, isolated oral syndrome 1). The lacunar hypothesis was fulfilled in 88% of patients. Atherothrombotic infarction occurred in 8 patients, intracerebral hemorrhage in 3, and stroke of undetermined cause in 1. Hemorrhagic pure sensory stroke was diagnosed in 1% of all cases of hemorrhagic stroke (n = 270) in the database. Outcome was good (in-hospital mortality 0%, symptom-free at discharge 41.5%). After multivariate analysis, absence of disability at discharge, hypertension, diabetes, hyperlipidemia, and thalamic (56.5%) and corona radiata (4%) locations were clinical and topographic variables significantly associated with pure sensory stroke. Conclusions Pure sensory stroke is an infrequent cerebrovascular syndrome, in which the lacunar hypothesis is supported. Most patients had thalamic lacunar infarction. Incomplete hemisensory syndromes were also caused by a lacunar infarct in 84% of patients. Hemorrhagic pure sensory stroke accounted only for 3% of the cases. The prognosis is good with striking similarity to other lacunar strokes. There are important differences between pure sensory stroke and nonlacunar strokes.

The objectives of the study were to assess differential features between capsular stroke of ischemic and hemorrhagic origin, and to compare capsular strokes with all other (non-capsular) strokes. Data of 148 patients with isolated capsular stroke were collected from a prospective hospital-based stroke registry in which 2000 consecutive acute stroke patients were included. Isolated capsular stroke accounted for 8.4% of strokes included in the registry (8.4% of ischemic strokes and 10.5% of intracerebral hemorrhages). Capsular stroke of hemorrhagic origin (n = 24) was more severe than ischemic capsular stroke (n = 124) as determined by a significantly higher in-hospital mortality, length of stay, and lower number of patients free of functional deficit at discharge. After multivariate analysis, limb weakness, sudden onset, and sensory symptoms were independently associated with capsular hemorrhage, whereas pure motor hemiparesis appeared to be associated with capsular infarction. In summary, one of each 12 patients with acute ischemic stroke and one of each 10 patients with acute intracerebral hemorrhage had an isolated capsular stroke. Lacunar syndrome was the most frequent clinical presentation being more common (particularly pure motor hemiparesis) in ischemic than in hemorrhagic capsular stroke. Capsular hemorrhage and capsular infarction showed identical risk factor profiles suggesting the same underlying vascular pathology for both conditions.

This article represents the update of ‘European Stroke Initiative Recommendations for Stroke Management’, first published in this Journal in 2000. The recommendations are endorsed by the 3 European societies which are represented in the European Stroke Initiative: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies.

Objectives– To describe the influence of the site of the bleeding on clinical spectrum and early outcome of patients with acute spontaneous intracerebral hemorrhage (ICH). Material and methods– ICH was diagnosed in 229 (11%) of 2000 consecutive stroke patients included in a prospective stroke registry over a 10-year period. Frequency of demographic variables, risk factors, clinical events, neuroimaging data, and early outcome (until hospital discharge) according to different sites of bleeding was assessed. Each topography of the bleeding (independent variable) was compared with the remaining ICH cases by means of logistic regression analysis. Results– In the multivariate analysis, sensory deficit was significantly associated with ICH in the thalamus; lacunar syndrome and hypertension with ICH in the internal capsule-basal ganglia; seizures, non-sudden stroke onset, and hypertension with lobar ICH; ataxia and sensory deficit with ICH in the cerebellum; cranial nerve palsy with ICH in the brainstem; and limb weakness, diabetes, and altered consciousness with multiple topographic involvement. The overall in-hospital mortality rate was 31%, but this varied from 65% for multiple topographic involvement, 44% for intraventricular ICH, and 40% for ICH in the brainstem to 16% for ICH in the internal capsule-basal ganglia. Conclusion– These data show the heterogeneous clinical profile of ICH, but they also suggest a difference in the clinical spectrum and in-hospital mortality according to the site of bleeding.

In 2,000 consecutive stroke patients collected in a prospective hospital-based stroke registry over a 10-year period, we assessed whether stroke in men and women was different in respect to vascular risk factors, clinical features and natural history. The frequency of the different variable in men and women was analyzed by means of univariate analysis and logistic regression models. Women accounted for 48% of the study population (n = 967) and were older than men (mean age 75 vs. 69 years, p < 0.001). In the age group of 85 years or older, stroke was more frequent in women than in men (69.8 vs. 30.2%, p < 0.001). Women showed a higher frequency of cardioembolic infarction and a lower occurrence of lacunar infarction and stroke of undetermined cause than men. In-hospital mortality (17.4 vs. 13.3%) and length of hospital stay (19.6 vs. 16.7 days) was significantly higher (p < 0.001) in women than in men. In the model based on demographic variables and cardiovascular risk factors, obesity, heart failure, atrial fibrillation and age were significant predictors of stroke in women, while intermittent claudication, ischemic heart disease, chronic obstructive pulmonary disease, cigarette smoking and alcohol abuse were predictors in male sex. Hypertension and limb weakness were predictors for stroke in women, and absence of neurological deficit at hospital discharge, lacunar syndrome and ataxia were predictors in men in the models based on all variables. Women differ from men in the distribution of risk factors and stroke subtype, stroke severity and outcome. Differences in stroke pathology and/or differences in functional anatomy or plasticity of the brain between sexes may account for these findings.

To assess changing trends in clinical characteristics and early outcome of patients with acute cardioembolic stroke (ACS) over a 19-year period.Data of 575 patients with first-ever ACS included in the Sagrat Cor Hospital of Barcelona Stroke Registry were analyzed. Changing trends for 1986-1992, 1993-1998, and 1999-2004 periods were compared.A statistically significant increase (P0.001) in the age of patients (74.6 years in 1986-1992 vs. 81.4 years in 1999-2004) and the percentage of patients older than 85 years of age (16% vs. 38.2%) was observed. Patients with hypertension increased from 40.5 to 60.8% (P = 0.001) as were patients with diabetes, chronic bronchitis, and obesity (P = NS). The median length of hospital stay decreased from 18 to 12 days (P = 0.031) and prolonged hospital stay (12 days) from 18.3 to 13.1 (P = 0.033). In-hospital death rate remained around 20%.ACS continues to be a severe ischemic stroke subtype with high risk of in-hospital death. The lack of improvement in the early prognosis over a 19-year period may be explained by an increase in the prevalence of major cardiovascular risk factors and progressive aging of the population.

Background Ischemic stroke caused by infarction in the territory of the posterior cerebral artery (PCA) has not been studied as extensively as infarctions in other vascular territories. This single centre, retrospective clinical study was conducted a) to describe salient characteristics of stroke patients with PCA infarction, b) to compare data of these patients with those with ischaemic stroke due to middle cerebral artery (MCA) and anterior cerebral artery (ACA) infarctions, and c) to identify predictors of PCA stroke. Findings A total of 232 patients with PCA stroke were included in the "Sagrat Cor Hospital of Barcelona Stroke Registry" during a period of 19 years (1986-2004). Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The characteristics of these 232 patients with PCA stroke were compared with those of the 1355 patients with MCA infarctions and 51 patients with ACA infarctions included in the registry. Infarctions of the PCA accounted for 6.8% of all cases of stroke (n = 3808) and 9.6% of cerebral infarctions (n = 2704). Lacunar infarction was the most frequent stroke subtype (34.5%) followed by atherothrombotic infarction (29.3%) and cardioembolic infarction (21.6%). In-hospital mortality was 3.9% (n = 9). Forty-five patients (19.4%) were symptom-free at hospital discharge. Hemianopia (odds ratio [OR] = 6.43), lacunar stroke subtype (OR = 2.18), symptom-free at discharge (OR = 1.92), limb weakness (OR = 0.10), speech disorders (OR = 0.33) and cardioembolism (OR = 0.65) were independent variables of PCA stroke in comparison with MCA infarction, whereas sensory deficit (OR = 2.36), limb weakness (OR = 0.11) and cardioembolism as stroke mechanism (OR = 0.43) were independent variables associated with PCA stroke in comparison with ACA infarction. Conclusions Lacunar stroke is the main subtype of infarction occurring in the PCA territory. Several clinical features are more frequent in stroke patients with PCA infarction than in patients with ischaemic stroke due to infarction in the MCA and ACA territories. In-hospital mortality in patients with PCA territory is low.

Background Lacunar syndrome not due to lacunar infarct is poorly characterised. This single centre, retrospective study was conducted to describe the clinical characteristics of patients with lacunar syndrome not due to lacunar infarct and to identify clinical predictors of this variant of lacunar stroke. Methods A total of 146 patients with lacunar syndrome not due to lacunar infarction were included in the "Sagrat Cor Hospital of Barcelona Stroke Registry" during a period of 19 years (1986-2004). Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The characteristics of these 146 patients with lacunar syndrome not due to lacunar infarct were compared with those of the 733 patients with lacunar infarction. Results Lacunar syndrome not due to lacunar infarct accounted for 16.6% (146/879) of all cases of lacunar stroke. Subtypes of lacunar syndromes included pure motor stroke in 63 patients, sensorimotor stroke in 51, pure sensory stroke in 14, atypical lacunar syndrome in 9, ataxic hemiparesis in 5 and dysarthria-clumsy hand in 4. Valvular heart disease, atrial fibrillation, sudden onset, limb weakness and sensory symptoms were significantly more frequent among patients with lacunar syndrome not due to lacunar infarct than in those with lacunar infarction, whereas diabetes was less frequent. In the multivariate analysis, atrial fibrillation (OR = 4.62), sensorimotor stroke (OR = 4.05), limb weakness (OR = 2.09), sudden onset (OR = 2.06) and age (OR = 0.96) were independent predictors of lacunar syndrome not due to lacunar infarct. Conclusions Although lacunar syndromes are highly suggestive of small deep cerebral infarctions, lacunar syndromes not due to lacunar infarcts are found in 16.6% of cases. The presence of sensorimotor stroke, limb weakness and sudden onset in a patient with atrial fibrillation should alert the clinician to the possibility of a lacunar syndrome not due to a lacunar infarct.

Background Data from different studies suggest a favourable association between pretreatment with statins or hypercholesterolemia and outcome after ischaemic stroke. We examined whether there were differences in in-hospital mortality according to the presence or absence of statin therapy in a large population of first-ever ischaemic stroke patients and assessed the influence of statins upon early death and spontaneous neurological recovery. Methods In 2,082 consecutive patients with first-ever ischaemic stroke collected from a prospective hospital-based stroke registry during a period of 19 years (1986-2004), statin use or hypercholesterolemia before stroke was documented in 381 patients. On the other hand, favourable outcome defined as grades 0-2 in the modified Rankin scale was recorded in 382 patients. Results Early outcome was better in the presence of statin therapy or hypercholesterolemia (cholesterol levels were not measured) with significant differences between the groups with and without pretreatment with statins in in-hospital mortality (6% vs 13.3%, P = 0.001) and symptom-free (22% vs 17.5%, P = 0.025) and severe functional limitation (6.6% vs 11.5%, P = 0.002) at hospital discharge, as well as lower rates of infectious respiratory complications during hospitalization. In the logistic regression model, statin therapy was the only variable inversely associated with in-hospital death (odds ratio 0.57) and directly associated with favourable outcome (odds ratio 1.32). Conclusions Use of statins or hypercholesterolemia before first-ever ischaemic stroke was associated with better early outcome with a reduced mortality during hospitalization and neurological disability at hospital discharge. However, statin therapy may increase the risk of intracerebral haemorrhage, particularly in the setting of thrombolysis.

Background Little is known about clinical features and prognosis of patients with ischaemic stroke caused by infarction in the territory of the anterior cerebral artery (ACA). This single centre, retrospective study was conducted with the following objectives: a) to describe the clinical characteristics and short-term outcome of stroke patients with ACA infarction as compared with that of patients with ischaemic stroke due to middle cerebral artery (MCA) and posterior cerebral artery (PCA) infarctions, and b) to identify predictors of ACA stroke. Methods Fifty-one patients with ACA stroke were included in the "Sagrat Cor Hospital of Barcelona Stroke Registry" during a period of 19 years (1986–2004). Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The characteristics of these 51 patients with ACA stroke were compared with those of the 1355 patients with MCA infarctions and 232 patients with PCA infarctions included in the registry. Results Infarctions of the ACA accounted for 1.3% of all cases of stroke (n = 3808) and 1.8% of cerebral infarctions (n = 2704). Stroke subtypes included cardioembolic infarction in 45.1% of patients, atherothrombotic infarction in 29.4%, lacunar infarct in 11.8%, infarct of unknown cause in 11.8% and infarction of unusual aetiology in 2%. In-hospital mortality was 7.8% (n = 4). Only 5 (9.8%) patients were symptom-free at hospital discharge. Speech disturbances (odds ratio [OR] = 0.48) and altered consciousness (OR = 0.31) were independent variables of ACA stroke in comparison with MCA infarction, whereas limb weakness (OR = 9.11), cardioembolism as stroke mechanism (OR = 2.49) and sensory deficit (OR = 0.35) were independent variables associated with ACA stroke in comparison with PCA infarction. Conclusion Cardioembolism is the main cause of brain infarction in the territory of the ACA. Several clinical features are more frequent in stroke patients with ACA infarction than in patients with ischaemic stroke due to infarction in the MCA and PCA territories.

The purpose was to examine the occurrence of sleep-related breathing disorders (SRBD) and variables related to SRBD in patients with acute lacunar stroke. In 68 consecutive patients with radiologically proven lacunes, respiratory polygraphy within the first 48 h of stroke onset was performed. SRBDs were classified according to mutually exclusive cutoff values of the apnea/hypopnea index (AHI) as mild (AHI ≥ 10), moderate (AHI ≥ 20), and severe (AHI ≥ 30). Variables independently associated with SRBDs were assessed by logistic regression analysis. The mean (standard deviation) AHI was 21.9 (17.4). A total of 69.1% of patients showed AHI ≥ 10, 44.1% AHI ≥ 20, and 25% AHI ≥ 30. Cheyne-Stokes respiration (CSR) was present in 20.6% of patients. Smoking (20 cigarettes/day) or location of lacunes in the internal capsule or the pons was significantly more frequent in the AHI ≥ 10 group than in the remaining AHI groups (80.9% vs. 57.1%, P = 0.041). AHI ≥ 20 and AHI ≥ 30 occurred more frequently in smokers or in capsular or pontine lacunes than in the remaining patients (20% vs. 2.6%, P = 0.053; 29.4% vs. 3.9%, P = 0.01, respectively). In the multivariate analysis, smoking or capsular or pontine topographies were associated with AHI ≥ 10 [odds ratio (OR) = 3.17, 95% confidence interval (CI) 1.02–9.79; P = 0.045]. Lacunes in the internal capsule or the pons in smokers were associated with AHI ≥ 20 (OR = 9.25, 95% CI 1.05–81.70; P = 0.045). Smoking (OR = 19.64, 95% CI 1.68–229.85; P = 0.010) and body mass index (OR = 1.68, 95% CI 1.13–2.50; P = 0.010) were associated with AHI ≥ 30. Smoker patients with capsular or pontine acute lacunar stroke should be screened for SRDB.

Objective.—To describe the characteristics of headache related to lacunar stroke based on data collected from a prospective hospital-based stroke registry over a 12-year period. Demographics, clinical variables, and prognostic features of lacunar stroke in patients with and without headache are compared. Background.—Stroke-related headache has been largely investigated, but there is little clinical data on headache in individualized stroke subtypes. Methods.—The cohort of 484 patients with lacunar infarction was selected. Forty-five (9.3%) presented headache within a 72-hour interval of stroke onset. Predictors of lacunar infarction with headache were assessed by logistic regression analysis. Results.—The intensity of headache was mild in severity and poorly localized (diffuse or bilateral headache). Tension-type headache was present in 36 patients (80%) and 9 patients (20%) presented nausea or vomiting while experiencing mild pulsating pain. The frequency of headache was 17% in patients with atypical lacunar syndrome, 12% in dysarthria-clumsy hand, 11.5% in pure sensory stroke, 9.4% in sensorimotor stroke, and 7.1% in pure motor hemiparesis. When patients with lacunar infarction with and without headache were compared, female sex, diabetes mellitus, nausea and vomiting, and mesencephalic topography were significantly more frequent and dysarthria and frequency of symptom free at discharge were less frequent in the headache group. In the multivariate analysis, mesencephalic topography (odds ratio [OR] 16.62), nausea and vomiting (OR 13.27), sex female (OR 2.29), diabetes mellitus (OR 1.96), and age (OR 0.95) were predictors of lacunar infarction with headache. Conclusions.—Headache at the onset of a lacunar infarction is uncommon. Mesencephalic topography, nausea and vomiting, female sex, diabetes, and age were independent variables significantly associated with lacunar infarction with headache. These findings contribute to knowledge of stroke-related headache in patients with lacunes. Ke yw ords: acute stroke, cerebrovascular disease, headache, lacunar infarct, pain, vascular headache

Objectives To define a cardiovascular risk factor profile in very old patients with ischemic stroke. Patients and methods Data from a prospective hospital-based stroke registry was collected. Demographic characteristics and cardiovascular risk factors in individuals aged 85 years or older with ischemic stroke (n = 303) were compared with patients under 85 years (n = 1537). Results The study population accounted for 16.5% of all cases of ischemic stroke. The mean (S.D.) age was 88.2 (2.8) years (70% women). Hypertension occurred in 44.9% of patients, atrial fibrillation in 42.6%, diabetes in 16.2%, and congestive heart failure in 15.5%. The most frequent stroke subtypes were cardioembolic (36%) and atherothrombotic (31.4%) infarction. Congestive heart failure (odds ratio [OR] = 3.62), chronic renal disease (OR = 2.54), female sex (OR = 2.27), previous cerebrovascular disease (OR = 1.71), and atrial fibrillation (OR = 1.38) were significantly associated with ischemic stroke, whereas diabetes (OR = 0.68), hypertension (OR = 0.61), hyperlipidemia (OR = 0.45), and heavy smoking (OR = 0.21) occurred more frequently in patients under 85 years. Conclusion Adequate treatment of potentially modifiable risk factors, including congestive heart failure, chronic renal disease, and atrial fibrillation may contribute to prevent ischemic stroke in very old people.

Background To compare the characteristics and prognostic features of ischemic stroke in patients with diabetes and without diabetes, and to determine the independent predictors of in-hospital mortality in people with diabetes and ischemic stroke. Methods Diabetes was diagnosed in 393 (21.3%) of 1,840 consecutive patients with cerebral infarction included in a prospective stroke registry over a 12-year period. Demographic characteristics, cardiovascular risk factors, clinical events, stroke subtypes, neuroimaging data, and outcome in ischemic stroke patients with and without diabetes were compared. Predictors of in-hospital mortality in diabetic patients with ischemic stroke were assessed by multivariate analysis. Results People with diabetes compared to people without diabetes presented more frequently atherothrombotic stroke (41.2% vs 27%) and lacunar infarction (35.1% vs 23.9%) (P < 0.01). The in-hospital mortality in ischemic stroke patients with diabetes was 12.5% and 14.6% in those without (P = NS). Ischemic heart disease, hyperlipidemia, subacute onset, 85 years old or more, atherothrombotic and lacunar infarcts, and thalamic topography were independently associated with ischemic stroke in patients with diabetes, whereas predictors of in-hospital mortality included the patient's age, decreased consciousness, chronic nephropathy, congestive heart failure and atrial fibrillation Conclusion Ischemic stroke in people with diabetes showed a different clinical pattern from those without diabetes, with atherothrombotic stroke and lacunar infarcts being more frequent. Clinical factors indicative of the severity of ischemic stroke available at onset have a predominant influence upon in-hospital mortality and may help clinicians to assess prognosis more accurately.

Nine of 2000 consecutive stroke patients included in the Sagrat Cor Hospital of Barcelona Stroke Registry over a 10-year period fulfilled the strictly defined International Headache Society criteria for migrainous stroke and in whom other causes of stroke were ruled out. They accounted for 13% of all first-ever ischaemic stroke of unusual cause. Migrainous stroke was more common in women (67%) and in patients aged ≤ 45 years (78%) compared to the remaining ischaemic strokes of unusual cause. No patient died during hospital stay and 67% were symptom-free at discharge. In the multivariate analysis, nausea or vomiting (odds ratio (OR) 8.40, 95% confidence interval (CI) 1.49-47.21) and age (OR 0.95, 95% CI 0.91-0.99) were predictors of migrainous stroke. Migrainous stroke is a rare entity. Vascular risk factors are uncommon and the prognosis is generally good. Patients with migrainous stroke present some different clinical features from other ischaemic strokes of unusual aetiology.

We studied the influence of very early seizures (within 48 h of stroke onset) on in-hospital mortality in a cohort of 452 consecutive patients with atherothrombotic infarction. These patients were selected from 2,000 consecutive acute stroke patients registered in a prospective hospital-based stroke registry in Barcelona, Spain. A comparison of data between the nonseizure (n = 442) and seizure (n = 10) groups was made. Predictors of very early seizures were assessed by multivariate analysis. The in-hospital mortality rate was significantly higher in atherothrombotic stroke patients with very early seizures than in those without seizures (70 vs. 19.5%, p < 0.001). Independent predictors of in-hospital mortality included very early seizures, congestive heart failure, atrial fibrillation, 85 years of age or older, altered consciousness, dizziness, parietal and pons involvement, and respiratory and cardiac complications. After multivariate analysis, atherothrombotic infarction of occipital topography and decreased consciousness appeared to be independent predictors of atherothrombotic stroke with very early seizures. Very early seizures constitute an important risk factor for in-hospital mortality after atherothrombotic stroke.

A total of 17 patients with lacunar syndromes due to intracerebral hemorrhage or hemorrhagic lacunar stroke (pure motor hemiparesis 9, sensorimotor stroke 5, pure sensory stroke 3) are reported. Data from these patients were obtained from consecutive stroke patients included in the prospective Hospital Sagrat Cor-Aliança Stroke Registry. Hemorrhagic lacunar stroke accounted for 3.8% of all cases of lacunar syndrome (n = 439) and 7.4% of all cases of intracerebral hemorrhage (n = 229) entered in the database. Demographic, anamnestic, clinical and neuroimaging variables in patients with hemorrhagic lacunar stroke, non-lacunar intracerebral hemorrhage and non-hemorrhagic lacunar stroke were compared. Predictors of hemorrhagic lacunar stroke were assessed by logistic regression analysis. Hypertension, cigarette smoking and involvement of the internal capsule were significantly more frequent in patients with hemorrhagic lacunar stroke than in those with non-lacunar intracerebral hemorrhage, whereas nausea and vomiting, altered consciousness, speech disturbances, hemianopia, and ventricular hemorrhage were significantly less frequent. As compared with non-hemorrhagic lacunar stroke, patients with hemorrhagic lacunar stroke were more likely to have hypertension, sudden stroke onset (minutes), head injury, headache, and basal ganglia involvement and less likely to have diabetes, gradual stroke onset (hours), and dysarthria. After multivariate analysis, only headache (OR 10.14), sudden onset (OR 9.89), and dysarthria (OR 0.10) were independent predictors of hemorrhagic lacunar stroke. Accordingly, the presence of headache and sudden onset of symptoms and absence of dysarthria may be useful signs for distinguishing hemorrhagic lacunar stroke from other causes of lacunar stroke.

To investigate the prevalence and behavior of sleep-related breathing disorders (SRBDs) associated with a first-ever stroke or transient ischemic attack (TIA), we prospectively studied 161 consecutive patients admitted to our stroke unit. Complete neurological assessment was performed to determine parenchymatous and vascular localization of the neurological lesion. Stroke subtype was categorized as TIA, ischemic (IS), or hemorrhagic (HS). A portable respiratory recording (PRR) study was performed within 48-72 h after admission (acute phase), and subsequently after 3 mo (stable phase). During the acute phase, 116 patients (71.4%) had an apnea-hypopnea index (AHI) > 10 events/h and 45 (28%) had an AHI > 30. No relationships were found between sleep-related respiratory events and the topographical parenchymatous location of the neurological lesion or vascular involvement. Cheyne-Stokes breathing (CSB) was observed in 42 cases (26.1%). There were no significant differences in SRBD according to the stroke subtype except for the central apnea index (CAI). During the stable phase a second PRR was performed in 86 patients: 53 of 86 had an AHI > 10 and 17 of 86 had an AHI > 30. The AHI and CAI were significantly lower than those in the acute phase (16.9 +/- 13.8 versus 22.4 +/- 17.3 and 3.3 +/- 7.6 versus 6.2 +/- 10.2, respectively) (p < 0.05) while the obstructive apnea index (OAI) remained unchanged. CSB was observed in 6 of 86 patients. The prevalence of SRBD in patients with first-ever stroke or TIA is higher than expected from the available epidemiological data in our country. No correlation was found between neurological location and the presence or type of SRBD. Obstructive events seem to be a condition prior to the neurological disease whereas central events and CSB could be its consequence.