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Background and Purpose — Body temperature is considered crucial in the management of acute stroke patients. Recently hypothermia applied as a therapy for stroke has been demonstrated to be feasible and safe in acute stroke patients. In the present study, we investigated the predictive role of admission body temperature to the long-term mortality in stroke patients. Methods — We studied 390 patients with acute stroke admitted within 6 hours from stroke onset. Admission clinical characteristics (age, sex, admission stroke severity, admission blood glucose, cardiovascular risk factor profile, and stroke subtype) were recorded for patients with hypothermia (body temperature ≤37°C) versus patients with hyperthermia (body temperature >37°C). Univariately the mortality rates for all patients were studied by Kaplan-Meier statistics. To find independent predictors of long-term mortality for all patients, Cox proportional-hazards models were built. We included all clinical characteristics and body temperature as a continuous variable. Results — Patients with hyperthermia had more severe strokes and more frequently diabetes, whereas no difference was found for the other clinical characteristics. For all patients mortality rate at 60 months after stroke was higher for patients with hyperthermia (73 per 100 cases versus 59 per 10 cases, P =0.001). When body temperature was studied in a multivariate Cox proportional-hazards model, a 1°C increase of admission body temperature independently predicted a 30% relative increase (95% CI, 4% to 57%) in long-term mortality risk. For 3-month survivors we found no association between body temperature and long-term survival when studied in a multivariate Cox proportional hazard model (hazards ratio, 1.11 per 1°C; 95% CI, 0.82 to 1.52). Conclusion — Low body temperature on admission is considered to be an independent predictor of good short-term outcome. The present study suggests that admission body temperature seems to be a major determinant even for long-term mortality after stroke. Hypothermic therapy in the early stage in which body temperature is kept low for a longer period after ictus could be a long-lasting neuroprotective measure.

Background and purpose— Educating the youth about stroke is a promising approach for spreading stroke knowledge. The aim of this study was to verify communication of stroke knowledge to parents by educating junior high school students about stroke. Methods— We enrolled 1127 junior high school students (age, 13–15 years) and their parents in the Tochigi prefecture, Japan. All students received a stroke lesson, watched an animated cartoon, and read the related Manga comic as educational aids. The students took back home the Manga and discussed what they learned with their parents. Questionnaires on stroke knowledge were given to all at baseline and immediately after the lesson. Results— A total of 1125 students and 915 parents answered the questionnaires. In the students, the frequency of correct answers increased significantly for all questions on stroke symptoms except for headache, and for all questions on risk factors after the lesson. In the parents, the correct answer rates increased for stroke symptoms except for headache and numbness in one side of the body, and for all questions on risk factors except for hypertension. Ninety-one percent of students and 92.7% of parents correctly understood the Face, Arm, Speech, and Time (FAST) mnemonic after the lesson. Conclusions— Improvement of stroke knowledge immediately after the stroke lesson was observed in parents as well as their children, which indicated that our teaching materials using the Manga was effective in delivering the stroke knowledge to parents through their children.

Background and Purpose: School-based interventions of stroke enlightenment are not only beneficial for students but also expected to deliver stroke message effectively to their parents. We produced stroke teaching materials using FAST mnemonic. The aim of this study is to verify the effectiveness of stroke education project (the Tochigi project) for delivering stroke message to their parents through their children, using our teaching materials of stroke enlightenment. Methods: Subjects were guardians of 1,125 students (13-15 y.o.) in 9 public junior high schools in Tochigi prefecture, Japan. All students received a 20-minute stroke lesson by their teacher using the FAST mnemonic, and then watched a 10-minute animated cartoon and read the comic book. At the close of the lesson, the teacher asked the students to take back the comic book and talk about stroke with their guardians while showing the comic book. Questionnaires on stroke knowledge were examined for all the guardians before and immediately after the conversation about stroke with their children. Results: There were 915 guardians (81.3%, 94%; parents) participated in the present study. Correct answer rates for the questions of headache (81.1 vs. 72.8%, p Conclusions: Our teaching materials of stroke enlightenment for junior high school students would be promising means of delivering the stroke message effectively to their guardians.

Background and Purpose —The beneficial effects of treatment and rehabilitation of patients with acute stroke in a dedicated stroke unit (SU) are well established. We wanted to examine if these effects are limited to certain groups of patients or if they apply to all patients independent of age, sex, comorbidity, and initial stroke severity. Methods —This was a community-based study of outcome in 1241 consecutive stroke patients from 2 communities in Copenhagen: In one (Frederiksberg), treatment and rehabilitation were given in general neurological and medical wards (GW), and in the other (Bispebjerg) in one single large SU. Outcome measures were initial, 1-year, and 5-year mortality rates, a poor outcome (initial death or discharge to a nursing home), and length of hospital stay (LOHS). Multivariate regression analyses were used to examine the independent effect of SU treatment on the various subgroups. Results —The relative risks of initial death, poor outcome, and 1-year and 5-year mortality rates were reduced by 40% on average in patients treated in the SU compared with the GW. A beneficial effect of SU treatment was observed regardless of the patient’s age, sex, comorbidity, and initial stroke severity. Those who benefited most appeared to be the patients with the most severe strokes (poor outcome: OR 0.17; 95% CI 0.05 to 0.58). Those who benefited least were patients with mild or moderate strokes (poor outcome: OR 0.66; 95% CI 0.41 to 0.98) and patients Conclusions —A beneficial effect of treatment in a SU is achieved in completely unselected patients independent of their age, sex, comorbidity, and stroke severity. Those who had the most severe strokes appeared to benefit most. All patients with acute stroke should therefore have access to treatment and rehabilitation in a dedicated SU.

Background Atrial fibrillation (AF) is a common arrhythmia and a major risk factor for stroke. Many physicians remain reluctant to provide stroke prevention by anticoagulant therapy especially for elderly individuals with AF. Using multivariate regression analyses, we studied the characteristics and the prognosis of stroke in patients with AF. Methods The study is part of the Copenhagen Stroke Study, a prospective, community-based study of 1197 patients with acute stroke treated on a stroke unit from the time of acute admission to the end of rehabilitation. Initial stroke severity was measured by the Scandinavian Neurological Stroke Scale (SSS). Neurological and functional outcomes were evaluated by the SSS and the Barthel Index. Results AF was diagnosed in 18% of the patients. AF increased steeply with age in the stroke population, from 2% in patients P Conclusions Stroke in patients with AF is generally more severe and outcome markedly poorer than in patients with sinus rhythm. This accentuates the importance of anticoagulant treatment of individuals with AF. A lower blood pressure in the acute stage of stroke may contribute to the increased stroke severity in patients with AF.

Although diabetes is a strong risk factor for stroke, it is still unsettled whether stroke is different in patients with and without diabetes. This is true for stroke type, stroke severity, the prognosis, and the relation between admission glucose levels and stroke severity/mortality. This community-based study included 1135 acute stroke patients (233 [20%] had diabetes). All patients were evaluated until the end of rehabilitation by weekly assessment of neurological deficits (Scandinavian Stroke Scale) and functional disabilities (Barthel Index). A computed tomographic scan was performed in 83%. The diabetic stroke patient was 3.2 years younger than the nondiabetic stroke patient (P < .001) and had hypertension more frequently (48% versus 30%, P < .0001). Intracerebral hemorrhages were six times less frequent in diabetic patients (P = .002). Initial stroke severity, lesion size, and site were comparable between the two groups. However, mortality was higher in diabetic patients (24% versus 17%, P = .03), and diabetes independently increased the relative death risk by 1.8 (95% confidence interval [CI], 1.04 to 3.19). Outcome was comparable in surviving patients with and without diabetes, but patients with diabetes recovered more slowly. Mortality increased with increasing glucose levels on admission in nondiabetic patients independent of stroke severity (odds ratio, 1.2 per 1 mmol/L; CI, 1.01 to 1.42; P = .04). This was not the case in diabetic patients. Diabetes influences stroke in several aspects: in age, in subtype, in speed of recovery, and in mortality. Increased glucose levels on admission independently increase mortality from stroke in nondiabetic but not in diabetic patients. The effect of reducing high admission glucose levels in nondiabetic stroke patients should be examined in future trials.

This study was undertaken to elucidate whether and how age influences stroke outcome. This prospective and community-based study comprised 515 consecutive acute stroke patients. Computed tomographic scan was performed in 79% of patients. Activities of daily living (ADL) and neurological status were assessed weekly during hospital stay using the Barthel Index (BI) and the Scandinavian Stroke Scale (SSS), respectively. Information regarding social condition and comorbidity before stroke was also registered. A multiple regression model was used to analyze the independent influence of age on stroke outcome. Age was not related to the type of stroke lesion or infarct size. However, age independently influenced initial BI (-4 points per 10 years, P < .01), initial SSS (-2 points per 10 years, P = .01), and discharge BI (-3 points per 10 years, P < .01). No independent influence of age was found regarding mortality within 3 months, discharge SSS, length of hospital stay, and discharge placement. ADL improvement was influenced independently by age (-3 points per 10 years, P < .01), whereas age had no influence on neurological improvement or on speed of recovery. Age independently influences stroke outcome selectively in ADL-related aspects (BI) but not in neurological aspects (SSS), suggesting a poorer compensatory ability in elderly stroke patients. Therefore, rehabilitation of elderly stroke patients should be focused more on ADL and compensation rather than on the recovery of neurological status, and age itself should not be a selection criterion for rehabilitation.

Background and Purpose —Even patients with the most severe strokes sometimes experience a remarkably good recovery. We evaluated possible predictors of a good outcome to search for new therapeutic strategies. Methods —We included the 223 patients (19%) with the most severe strokes (Scandinavian Stroke Scale score Results —Decreasing age (odds ratio [OR], 0.50 per 10-year decrease; 95% CI, 0.25 to 0.99; P =0.04), a spouse (OR, 3.1; 95% CI, 1.1 to 8.8; P =0.03), decreasing body temperature on admission (OR, 1.8 per 1°C decrease; 95% CI, 1.1 to 3.1; P =0.01), and neurological recovery after 1 week (OR, 3.2 per 10-point increase in Scandinavian Stroke Scale score; 95% CI, 1.1 to 7.8; P =0.01) were all independent predictors of good functional outcome. Conclusions —Patients with the most severe strokes who achieve a good functional outcome are generally characterized by younger age, the presence of a spouse at home, and early neurological recovery. Body temperature was a strong predictor of good functional outcome and the only potentially modifiable factor. We suggest that a randomized controlled trial be undertaken to evaluate whether active reduction of body temperature can improve the generally poor prognosis of patients with the most severe strokes.

Background and Purpose —We have previously reported a marked reduction in mortality up to 1 year after treatment and rehabilitation on a stroke unit versus on general neurological and medical wards in unselected stroke patients. In the present study we wanted to test the hypothesis that this mortality-reducing effect is not temporary but is long lasting. Methods —We performed a community-based comparison of outcome in 1241 stroke patients from 2 adjacent communities in Copenhagen: in one (Frederiksberg), treatment and rehabilitation were provided on general neurological and medical wards, and in the other (Bispebjerg), treatment and rehabilitation were provided on a single large stroke unit. Results —The 2 stroke populations were comparable regarding age, sex, initial stroke severity, lesion diameter on CT, and stroke subtype (hemorrhage/infarct), but patients treated on the stroke unit had a higher frequency of comorbidity and lower incomes. One-year mortality was 39% (general wards) versus 32% (stroke unit) ( P =0.01). This difference was still present 5 years after stroke (71% versus 64%; P =0.02). In a multiple logistic regression model of 5-year mortality, treatment on a stroke unit reduced the relative risk of death by 40% (odds ratio, 0.60; 95% CI, 0.42 to 0.85; P Conclusions —The mortality-reducing effect of treatment and rehabilitation on a dedicated stroke unit is long lasting rather than temporary. Stroke unit treatment reduced the relative risk of death within 5 years after stroke by 40% in an unselected, community-based stroke population. These results emphasize the need for organization of treatment and rehabilitation of unselected stroke patients on dedicated stroke units.

Background Despite the common occurrence of seizures during the early phase of stroke (ES), the effect of ES on prognosis is not known. We determined the relationships between ES and stroke outcome and identified predictors of ES. Methods In this community-based study, we prospectively and consecutively studied 1197 patients with acute stroke. We determined the number and type of seizures, initial stroke severity, infarct size, mortality, and outcome in survivors. Stroke severity was measured on admission, weekly, and at discharge using the Scandinavian Stroke Scale (SSS). Multiple logistic and linear regression outcome analyses included relevant confounders and potential predictors, including age, gender, stroke severity on admission, atrial fibrillation, ischemic heart disease, diabetes, blood glucose level on admission, claudication, and hypertension. Results Fifty patients (4.2%) had seizures within 14 days of the stroke. In the multivariate analyses, only initial stroke severity was related to ES; stroke type and lesion localization were not related. For each 10-point increase in stroke severity (SSS score), the relative risk of ES increased by a factor of 1.65 (95% confidence interval, 1.4 to 1.9) ( P P =.56). In survivors, ES was related to a better outcome, equivalent to an increased SSS score of 5.7 points (SE [b]=1.8; P =.002). Conclusions The decisive factor of ES was initial stroke severity. ES per se was not related to mortality. Surprisingly, in survivors, ES predicted a better outcome. We explain this finding by a relatively larger ischemic penumbra in patients who have an ES after a stroke.

Background and Purpose Stroke represents a major economic challenge to society. The direct cost of stroke is largely determined by the duration of hospital stay, but internationally applicable estimates of the direct cost of acute stroke care and rehabilitation on cost-efficient stroke units are not available. Information regarding social and medical factors influencing the length of hospital stay (LOHS) and thereby cost is needed to direct cost-reducing efforts. Methods We determined the direct cost of stroke in the prospective, consecutive, and community-based stroke population of the Copenhagen Stroke Study by measuring the total LOHS in the 1197 acute stroke patients included in the study. All patients had all their acute care and rehabilitation on a dedicated stroke unit. Neurological impairment was measured by the Scandinavian Stroke Scale. Local nonmedical factors affecting the LOHS, such as waiting time for discharge to a nursing home after completed rehabilitation, were accounted for in the analysis. The influence of social and medical factors on the LOHS was analyzed in a multiple linear regression model. Results The average LOHS was 27.1 days (SD, 44.1; range, 1 to 193), corresponding to a direct cost of $12.150 per patient including all acute care and rehabilitation. The LOHS increased with increasing stroke severity (6 days per 10-point increase in severity; P P =.02). Death reduced LOHS (22.0 days; P Conclusions Acute care and rehabilitation of unselected patients on a dedicated stroke unit takes on average 4 weeks. In general, comorbidity such as diabetes or heart disease does not increase LOHS. Efforts to reduce costs should therefore aim at reducing initial stroke severity or improving the rate of recovery.

Background and Purpose The purpose of this study was to investigate in a community-based population the prevalence of both urinary (UI) and fecal (FI) incontinence and to analyze risk factors by means of multivariate analysis. Methods Included were 935 acute stroke patients admitted consecutively during 19 months. We evaluated UI and FI using subscores of the Barthel Index during the hospital stay and at 6-month follow-up. Results On admission, the proportions of patients with full UI, partial UI, and no UI were 36%, 11%, and 53%, respectively (8%, 11%, and 81% at 6-month follow-up). The proportions of patients with full FI, partial FI, and no FI on admission were 34%, 6%, and 60%, respectively (5%, 4%, and 91% at 6-month follow-up). By multivariate analysis, significant risk factors for UI and FI were age, severity of stroke, diabetes, and comorbidity of other disabling diseases. Conclusions On admission in the acute state, almost half of an unselected stroke population have UI and/or FI. The proportion declines to one fifth (UI) and one tenth (FI) of the surviving patients at 6 months. Increasing age, stroke severity, diabetes, and other disabling diseases increase the risk of UI as well as FI.

Background and Purpose Treatment of stroke patients in specialized stroke units has become more frequent, yet the effect of this treatment has not been determined. Methods In a community-based, prospective, and consecutive study of 1241 unselected acute stroke patients, we compared outcome of stroke treatment between two neighboring communities within Greater Copenhagen: the Bispebjerg community, where all acute stroke patients are treated and rehabilitated on a stroke unit, and Frederiksberg community, where all acute stroke patients are treated and rehabilitated on general neurological and medical wards. Except for the different organization of stroke treatment, the two communities and the two patient groups were comparable. Specifically, age, sex, marital status, prestroke residence, and stroke severity were not statistically different between patients treated on the stroke unit and those treated on the general neurological and medical wards. Multivariate regression analyses were used to estimate the independent influence of stroke unit treatment on outcome. Results Stroke unit treatment significantly reduced in-hospital mortality (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.34 to 0.74; P P P =.002), 1-year mortality (OR, 0.59; CI, 0.42 to 0.84; P =.003), and discharge rate to a nursing home (OR, 0.61; CI, 0.38 to 0.98; P =.04). Discharge rate to the patient’s own home was significantly increased (OR, 1.90; CI, 1.30 to 2.70; P P Conclusions Treatment of unselected acute stroke patients on a stroke care unit saved lives, reduced the length of hospital stay, reduced the frequency of discharge to a nursing home, and potentially reduced cost.

Background and Purpose This study was undertaken to determine factors of importance for the development of leukoaraiosis and to evaluate whether leukoaraiosis influences stroke outcome. Methods The study was prospective and consecutive and included 1084 unselected patients with acute stroke and transient ischemic attack admitted from the community of Bispebjerg (Copenhagen, Denmark) during a 25-month period from September 1, 1991, to September 30, 1993. All patients were treated in a stroke unit from the time of acute admission to completion of rehabilitation. Daily alcohol consumption and other putative risk factors were registered on admission, and patients were evaluated weekly to death or time of completed rehabilitation by means of neurological (Scandinavian Stroke Scale) and functional (Barthel Index) scores. Leukoaraiosis was diagnosed on computed tomographic scan. Multivariate analyses were applied to test relations independent of other influencing factors. Results Leukoaraiosis was present in 15% of the patients. Age was the only factor that significantly increased the risk of leukoaraiosis (odds ratio [OR] per 10-year increase, 2.4; 95% confidence interval [CI], 1.8 to 3.1), whereas the presence of atrial fibrillation was adversely related to leukoaraiosis (OR, 0.26; 95% CI, 0.13 to 0.52). Moderate daily alcohol consumption (1 to 5 drinks) reduced the risk of leukoaraiosis (OR, 0.50; 95% CI, 0.28 to 0.87), whereas heavy daily alcohol consumption (>5 drinks) tended to increase the risk (OR, 1.3; 95% CI, 0.5 to 3.3). Leukoaraiosis was not related to the presence of hypertension, diabetes, ischemic heart disease, atrial fibrillation, intermittent claudication, smoking, or sex. The presence of leukoaraiosis had no influence on neurological outcome ( P =.20), functional outcome ( P =.47), length of hospital stay ( P =.75), or mortality ( P =.31). Conclusions Moderate daily alcohol intake seems associated with a decreased risk of leukoaraiosis in stroke patients. The relation between alcohol intake and leukoaraiosis may even be U-shaped, like the relation between alcohol intake and coronary heart disease, alcohol intake and mortality, and alcohol intake and stroke. The presence of leukoaraiosis does not seem to influence the rehabilitation process or outcome of stroke.

Our objective was to study age-specific prevalence, computed tomographic (CT) characteristics, risk factors, and the prognostic influence on stroke outcome of silent infarction in acute stroke patients. The study was prospective and community-based and included 801 acute stroke patients, of whom 587 had first-ever stroke. A CT scan was performed in 500 (85%) of the 587 patients with first-ever stroke. CT was reviewed blindly, and infarcts were classified according to patient history as silent or symptomatic. Patients were evaluated initially with the Mini-Mental State Examination (MMSE) and weekly with both the Scandinavian Stroke Scale (SSS) and the Barthel Index (BI) from the onset of stroke to completion of rehabilitation. CT characteristics, risk factors, and stroke outcome were compared in stroke patients with and without silent infarction. The prevalence of silent infarction in patients with first-ever stroke and recurrent strokes was similar, at 29% (group aged 0 to 54 years, 16%; 55 to 64 years, 22%; 65 to 74 years, 30%; 75 years or older, 33%). Silent infarcts were small and subcortical. Independent risk factors were increasing age (odds ratio [OR], 1.95 per 25 years; confidence interval [CI], 1.19 to 3.15), hypertension (OR, 1.75; CI, 1.13 to 2.70), claudication (OR, 1.74; CI, 1.01 to 3.00), and male sex (OR, 1.72; CI, 1.12 to 2.64); other stroke risk factors such as atrial fibrillation and former transient ischemic attack were not independent risk factors. Patients with and without silent infarction did not differ in frequency of prestroke home care (P = .2). MMSE (P = .56), initial BI (P = .62) and SSS score (P = .08), BI (P = .85) and SSS score (P = .75) after completion of rehabilitation, or in the speed of recovery (P = .85). Length of hospital stay, mortality rate, and discharge rate to nursing home also did not differ between the two groups. This community-based study shows that silent infarction in stroke patients is more related to certain stroke risk factors than others and that silent infarction does not seem to influence the prognosis of stroke.