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Background: New national clinical guidelines are now available on advance care planning (ACP). Confidence in communication is important for implementation of the guidelines. This study aims to identify healthcare personnel's self-perceived confidence in communication about future medical care and patients' wishes at the end of life., Material and Method: Healthcare personnel in twelve geriatric units in South-Eastern Norway Regional Health Authority responded to an online questionnaire survey in autumn 2022. The four response alternatives for self-reported confidence - 'unconfident', 'fairly confident', 'very confident' and 'extremely confident'- are combined into two categories: 'limited confidence' ('unconfident' and 'fairly confident') and 'high confidence' ('very confident' and 'extremely confident')., Results: We received responses from 289 of the 470 (61.5 %) invited, with an average age of 37.8 ± 11.3 years, of whom 217 out of 289 (75 %) had more than five years of professional experience. Of the doctors, 15 out of 67 (22 %) reported limited confidence in communication about 'future deterioration of the patient's health condition', 20 out of 67 (30 %) about 'life-sustaining treatment' and 13 out of 67 (19 %) about 'preferences towards the end of life'. For other healthcare personnel, the corresponding responses were 119 out of 222 (54 %), 140 out of 222 (63 %) and 109 out of 222 (49 %)., Interpretation: Self-assessed confidence in communication about future deterioration, future medical care and the patient's own wishes at the end of life varies, and such confidence is limited among many health personnel in geriatric units. Measures appear to be needed to increase confidence in the communication and implementation of ACP in the Norwegian health service.

Background: American and European guidelines define hypertension differently and are sex agnostic. Our aim was to assess the impact of different hypertension thresholds at the age of 40 on 30-year stroke risk and to examine sex differences., Methods: We included 2608 stroke-free individuals from the Akershus Cardiac Examination 1950 Study, a Norwegian regional study conducted in 2012-2015 of the 1950 birth cohort, who had previously participated in the Age 40 Program, a nationwide health examination study conducted in 1990-1993. We categorised participants by systolic blood pressure (SBP) at age 40 (<120 mm Hg (reference), 120-129 mm Hg, 130-139 mm Hg and ≥140 mm Hg) and compared stroke risk using Cox proportional hazard regressions adjusted for age, sex, smoking, cholesterol, physical activity, obesity and education. Fatal and non-fatal strokes were obtained from the Norwegian Cardiovascular Disease Registry from 1 January 2012 to 31 December 2020, in addition to self-reported strokes., Results: The mean age was 40.1±0.3 years (50.4% women) and mean SBP was 128.3±13.5 mm Hg (mean±SD). Stroke occurred in 115 (4.4%) individuals (32 (28%) women and 83 (72%) men) during 29.4±2.9 years of follow-up. SBP between 130 and 139 mm Hg was not associated with stroke (adjusted HR 1.71, 95% CI 0.87 to 3.36) while SBP ≥140 mm Hg was associated with increased stroke risk (adjusted HR 3.11, 95% CI 1.62 to 6.00). The adjusted HR of stroke was 4.32 (95% CI 1.66 to 11.26) for women and 2.66 (95% CI 1.03 to 6.89) for men, with non-significant sex interactions., Conclusions: SBP ≥140 mm Hg was significantly associated with 30-year stroke risk in both sexes. A small subgroup of women had SBP ≥140 mm Hg and systolic hypertension was a strong risk factor for stroke in these women., Trial Registration Number: NCT01555411., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Early diagnosis and triage of patients with ischemic stroke is essential for rapid reperfusion therapy. The prehospital delay may be substantial and patients from rural districts often arrive at their local hospital too late for disability-preventing thrombolytic therapy due to prolonged transport times., Methods: Hallingdal District Medical Centre (HDMC) is located in a rural area of Norway and is equipped with a computed tomography (CT) scanner. We established emergency pathways of CT imaging and thrombolytic treatment of patients with acute ischemic stroke at HDMC. During office hours these pathways were managed by a radiographer and a general physician supported by videoconference from the Primary Stroke Centre. Outside office hours we remotely controlled the CT exam and supported telestroke guided paramedics handling and examining the patients. With a primary aim of demonstrating the feasibility of this de novo concept we enrolled patients in the period 2017-2021 into a comparative cohort observational study. We compared patients treated at HDMC (the Rural CT group) to patients from two other rural regions in Norway with similar distances to their local hospital but without access to a rural CT scanner (the Reference group)., Results: A total of 86 patients were included in the Rural CT group (mean age 74, 52% male, 43% stroke mimics), and 69 patients were included in the Reference group (mean age 70, 42% male, 28% stroke mimics). Median time from onset of symptoms to completed CT examination was 93 min in the Rural CT group as compared to 240 min in the Reference group ( p  < 0.05). In patients receiving intravenous thrombolysis time from onset of symptoms to treatment was median 124 min in the Rural CT group and 213 min in the Reference group, p  < 0.05. The frequency of thrombolysis for ischemic stroke did not significantly differ between the two groups., Conclusion: Combining prehospital rural CT examination with telestroke guided diagnosis and thrombolytic treatment by paramedics may facilitate earlier initiation of thrombolysis for patients with ischemic stroke., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: We aimed to explore the predictive value of pre-stroke frailty index (FI) on functional dependency and mortality 3 years after stroke., Methods: Based on the Rockwood 36-item FI score, we calculated the pre-stroke FI from medical conditions recorded at baseline in the multicenter prospective Nor-COAST study 2015-2017. Participants with a FI score and a modified Rankin scale (mRS) 0-6 3 years post-stroke were included in this study. We used logistic regression analysis with unfavorable mRS (over 2 vs. 0-2) at 3 years, or dead within 3 years, as dependent variable, and frailty and pre-stroke mRS, one at a time, and simultaneously, as predictors. The analyses were carried out unadjusted and adjusted for the following variables one at a time: Age, sex, years of education, stroke severity at admission, infections treated with antibiotics and stroke progression. We report odds ratio (OR) per 0.10 increase in FI., Results: At baseline, the 609 included patients had mean age 72.8 (standard deviation [SD] 11.8), 261 (43%) were females, and had a FI mean score of 0.16 (SD 0.12), range 0-0.69. During 3 years, 138 (23%) had died. Both the FI, and pre-stroke mRS, were strong predictors for unfavorable mRS (OR 4.1 and 2.7) and dead within 3 years (OR 2.2 and 1.7). Only adjusting for age affected the result. The OR for pre-stroke mRS decreased relatively more than the OR for FI when entered as predictors simultaneously., Conclusions: FI is a stronger predictor than premorbid mRS for prognostication after stroke., (© 2024 S. Karger AG, Basel.)

Background: The shift towards milder strokes and studies suggesting that stroke symptoms vary by age and sex may challenge the Face-Arm-Speech Time (FAST) coverage. We aimed to study the proportion of stroke cases admitted with FAST symptoms, sex and age differences in FAST presentation and explore any additional advantage of including new item(s) from the National Institute of Health Stroke Scale (NIHSS) to the FAST algorithm., Methods: This registry-based study included patients admitted with acute stroke to Sahlgrenska University Hospital (November 2014 to June 2019) with NIHSS items at admission. FAST symptoms were extracted from the NIHSS at admission, and sex and age differences were explored using descriptive statistics., Results: Of 5022 patients, 46% were women. Median NIHSS at admission for women was (2 (8-0) and for men 2 (7-0)). In total, 2972 (59%) had at least one FAST symptom, with no sex difference (p=0.22). No sex or age differences were found in FAST coverage when stratifying for stroke severity. 52% suffered mild strokes, whereas 30% had FAST symptoms. The most frequent focal NIHSS items not included in FAST were sensory (29%) and visual field (25%) and adding these or both in modified FAST algorithms led to a slight increase in strokes captured by the algorithms (59%-67%), without providing enhanced prognostic information., Conclusions: 60% had at least one FAST symptom at admission, only 30% in mild strokes, with no sex or age difference. Adding new items from the NIHSS to the FAST algorithm led only to a slight increase in strokes captured., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The bulk of the current knowledge on atrial fibrillation (AF)-associated stroke risk and benefit of oral anticoagulation derives from studies on patients with clinically diagnosed AF. Subclinical AF (SCAF), defined as AF discovered during the interrogation of prolonged heart monitoring, is often asymptomatic and short-lasting, is associated with increased stroke risk compared with sinus rhythm, and may progress to clinical AF. Despite the extensive screening for and treatment of SCAF, especially in secondary stroke prevention, the net benefit of this practice is not established. Recent studies of SCAF have provided new insights: (1) SCAF is extremely common and may sometimes indicate physiological findings, (2) the stroke risk associated with SCAF is lower than that of clinically detected AF, and (3) any benefit on stroke risk may be countered by increased bleeding risk (no net benefit). How should we interpret the latest knowledge in the setting of poststroke AF screening and prevention?, Competing Interests: Disclosures Dr Andrade has received support from Medtronic, Abbott Canada, Biosense Webster, and Boston Scientific Corporation. Dr Diederichsen has received consultant fees from Bristol-Meyers Squibb/Pfizer and Cortrium, speaker fees from Bristol-Meyers Squibb/Pfizer and Bayer, and is employed by Vital Beats. Dr Sandset has received support from Bayer, Boston Scientific Corporation, Bristol-Myers Squibb, and Daiichi Sankyo Company.

Objectives: Hypertension in midlife is a risk factor for cognitive impairment. Still, the ideal midlife blood pressure (BP) remains unknown. We examined associations between different systolic blood pressure (SBP) levels at the age of 40-43 years and change in SBP over a 25-year period with cognitive function at age 62-65 years., Methods: We included 2424 individuals born in 1950 who had participated both in the Age 40 Program (1990-1993) and the Akershus Cardiac Examination (ACE) 1950 Study (2012-2015). The exposure was SBP at age 40-43 years and the outcome was cognitive function at age 62-65 years, assessed with Montreal Cognitive Assessment, Delayed recall trial from the Consortium to Establish a Registry for Alzheimer's Disease Word List Memory Task, and Trail Making Test part B (TMT B)., Results: Participants were 40.1 ± 0.3 years old with mean SPB 128 ± 13 mmHg at the Age 40 Program, and 63.9 ± 0.6 years old with mean SPB 138 ± 18 at the ACE 1950 Study. Adjusted linear regressions showed no associations between SBP and subsequent cognitive function. In logistic regressions, individuals with SBP ≥140 mmHg, compared to individuals with SBP <120 mmHg (odds ratio 2.29, 95% confidence interval 1.28-4.10, P-value 0.005) had increased risk of an abnormal TMT B-score. Change in SBP during the 25-year follow-up was not associated with cognitive function., Conclusions: SBP ≥140 mmHg at age 40-43 was associated with reduced capacity on TMT B, a domain specific cognitive test sensitive to vascular impairment. No other associations were found between SBP, or change in SBP, and cognitive function., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Guri Hagberg,1,2 Brynjar Fure,3 Else Charlotte Sandset,4 Bente Thommessen,5 Håkon Ihle-Hansen,1,2 Anne Rita Øksengård,1 Ståle Nygård,6 Torgeir B Wyller,2,7 Hege Ihle-Hansen1,7 1Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway; 2Institute of Clinical Medicine, University of Oslo, Oslo, Norway; 3Department of Internal Medicine, Karlstad Central Hospital and Institute of Public Health, University of Tromsoe, Tromsoe, Norway; 4Department of Neurology, Oslo University Hospital, Oslo, Norway; 5Department of Neurology, Akershus University Hospital, Lørenskog, Norway; 6Department of Informatics, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway; 7Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway Background: Stroke and coronary heart disease share the same risk factors, and a multifactorial intervention after stroke may potentially result in the same reduction in cardiovascular mortality as seen after coronary events. We aimed to evaluate the effect on survival 7 years after a 1-year multifactorial risk factor intervention, and identify clinical predictors for long-term survival in a hospital-based cohort of patients with first-ever stroke or transient ischemic attack (TIA). Materials and methods: We performed a secondary analysis of a randomized controlled trial including patients between February 2007 and July 2008 comparing an intensive risk factor intervention vs usual care the first year poststroke to prevent cognitive impairment. From February 2014 to July 2016, all patients were invited to a follow-up. For patients dying throughout the follow-up period, date of death was obtained from the medical record. Examination at baseline and 1-year follow-up included extensive assessment of vascular risk factors and cognitive assessments. Results: A total of 195 patients were randomized. Mean (SD) age was 71.6 (12.5) years, 53.3% were male, mean (SD) body mass index (BMI) was 25.6 (4.1) kg/m². During follow-up, 35 patients in the intervention group and 41 in the control group died. Kaplan–Meier survival estimates show no significant difference in intention-to-treat (ITT) population or complete case (CC) population (log-rank P=0.29 vs log-rank P=0.07). In multivariable Cox proportional hazards regression analyses, lower age and higher BMI was independently associated with long-term survival, adjusted HR (95% CI) 1.08 (1.05–1.11) per year and 0.91 (0.85–0.97) per kg/m². Conclusion: In this post hoc analysis, we found no significant effect on survival after 7 years of a multifactorial risk factor program given during the first year after first-ever stroke or TIA. Higher BMI was an independent predictor for long-term survival in this cohort. Keywords: RCT, stroke, cardiovascular risk, risk factor management, secondary prevention

Objectives: In this study we aimed to explore EMCC triage of suspected and confirmed stroke patients to gain more knowledge about the initial phase of the acute stroke response chain. Accurate dispatch at the Emergency Medical Communication Center (EMCC) is crucial for optimal resource utilization in the prehospital service, and early identification of acute stroke is known to improve patient outcome., Materials and Methods: We conducted a descriptive retrospective study based on data from the Emergency Department and EMCC records at a comprehensive stroke center in Oslo, Norway, during a six-month period (2019-2020). Patients dispatched with EMCC stroke criteria and/or discharged with a stroke diagnosis were included. We identified EMCC true positive, false positive and false negative stroke patients and estimated EMCC stroke sensitivity and positive predictive value (PPV). Furthermore, we analyzed prehospital time intervals and identified patient destinations to gain knowledge on ambulance services assessments., Results: We included 1298 patients. EMCC stroke sensitivity was 77% (95% CI: 72 - 82%), and PPV was 16% (95% CI: 14 - 18%). EMCC false negative stroke patients experienced an increased median prehospital delay of 11 min (p < 0.001). Upon arrival at the scene, 68% of the EMCC false negative patients were identified as suspected stroke cases by the ambulance services. Similarly, 68% of the false positive stroke patients were either referred to a GP, out-of-hours GP acute clinic, local hospitals or left at the scene by the ambulance services, indicating that no obvious stroke symptoms were identified by ambulance personnel upon arrival at the scene., Conclusions: This study reveals a high EMCC stroke sensitivity and an extensive number of false positive stroke dispatches. By comparing the assessments made by both the EMCC and the ambulance service, we have identified specific patient groups that should be the focus for future research efforts aimed at improving the sensitivity and specificity of stroke recognition in the EMCC., (© 2024. The Author(s).)

Background We aimed to explore the predictive value of the carotid plaque score, compared with the Systematic Coronary Risk Evaluation 2 (SCORE2) risk prediction algorithm, on incident ischemic stroke and major adverse cardiovascular events and establish a prognostic cutoff of the carotid plaque score. Methods and Results In the prospective ACE 1950 (Akershus Cardiac Examination 1950 study), carotid plaque score was calculated with ultrasonography at inclusion in 2012 to 2015. The largest plaque diameter in each extracranial segment of the carotid artery on both sides was scored from 0 to 3 points. The sum of points in all segments provided the carotid plaque score. The cohort was followed up by linkage to national registries for incident ischemic stroke and major adverse cardiovascular events (nonfatal ischemic stroke, nonfatal myocardial infarction, and cardiovascular death) throughout 2020. Carotid plaque score was available in 3650 (98.5%) participants, with mean±SD age of 63.9±0.64 years at inclusion. Only 462 (12.7%) participants were free of plaque, and and 970 (26.6%) had a carotid plaque score of >3. Carotid plaque score predicted ischemic stroke (hazard ratio [HR], 1.25 [95% CI, 1.15-1.36]) and major adverse cardiovascular events (HR, 1.21 [95% CI, 1.14-1.27]) after adjustment for SCORE2 and provided strong incremental prognostic information to SCORE2. The best cutoff value of carotid plaque score for ischemic stroke was >3, with positive predictive value of 2.5% and negative predictive value of 99.3%. Conclusions The carotid plaque score is a strong predictor of ischemic stroke and major adverse cardiovascular events, and it provides incremental prognostic information to SCORE2 for risk prediction. A cutoff score of >3 seems to be suitable to discriminate high-risk subjects. Registration Information clinicaltrials.gov. Identifier: NCT01555411.

Purpose: We aimed to identify whether health care professionals (HCP) examine their patient and next-of-kin preferences, and to study whether medical decisions follow these preferences., Method: A cross-sectional web-based survey was conducted with multidisciplinary HCP from 12 geriatric wards in the South-Eastern Norway Regional Health Authority., Results: Of the 289 HCPs responding (response rate 61%), mean age 37.8 years (SD 11.3), 235 (81.3%) women, 12.4 (SD 9.6) years of experience and 67 (23.2%) medical doctors, only half report clarifying patients' preferences. The majority reported that they did not inform, involve and treat in line with such preferences. However, 53% believe that HCP, patients and next-of-kin should make clinical decisions together., Discussion: Our findings indicate a lack of engagement in conversation and inclusion of patient preferences when providing health interventions in geriatric wards. Measures for change of culture are needed., (© 2024. The Author(s).)

Background: Post-stroke neurocognitive disorder, though common, is often overlooked by clinicians. Moreover, although the Montreal Cognitive Assessment (MoCA) has proven to be a valid screening test for neurocognitive disorder, even more time saving tests would be preferred. In our study, we aimed to determine the diagnostic accuracy of the Clock Drawing Test (CDT) for post-stroke neurocognitive disorder and the association between the CDT and MoCA., Methods: This study is part of the Norwegian Cognitive Impairment After Stroke study, a multicentre prospective cohort study following patients admitted with acute stroke. At the three-month follow-up, patients were classified with normal cognition, mild neurocognitive disorder, or major neurocognitive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Any neurocognitive disorder compromised both mild- and major neurocognitive disorder. The CDT at the three-month assessment was given scores ranging from 0 to 5. Patients able to complete the CDT and whose cognitive status could be classified were included in analyses. The CDT diagnostic accuracy for post-stroke neurocognitive disorder was identified using receiver operating characteristic curves, sensitivity, specificity, positive predictive value, and negative predictive value. The association between the MoCA and CDT was analysed with Spearman's rho., Results: Of 554 participants, 238 (43.0%) were women. Mean (SD) age was 71.5 (11.8) years, while mean (SD) National Institutes of Health Stroke Scale score was 2.6 (3.7). The area under the receiver operating characteristic curve of the CDT for major neurocognitive disorder and any neurocognitive disorder was 0.73 (95% CI, 0.68-0.79) and 0.68 (95% CI, 0.63-0.72), respectively. A CDT cutoff of < 5 yielded 68% sensitivity and 60% specificity for any neurocognitive disorder and 78% sensitivity and 53% specificity for major neurocognitive disorder. Spearman's correlation coefficient between scores on the MoCA and CDT was 0.50 (95% CI, 0.44-0.57, p < .001)., Conclusions: The CDT is not accurate enough to diagnose post-stroke neurocognitive disorder but shows acceptable accuracy in identifying major neurocognitive disorder. Performance on the CDT was associated with performance on MoCA; however, the CDT is inferior to MoCA in identifying post-stroke neurocognitive disorder., Trial Registration: ClinicalTrials.gov (NCT02650531). Retrospectively registered January 8, 2016., (© 2024. The Author(s).)

Background: Treatment with intravenous thrombolysis for acute ischemic stroke is contraindicated with intake of apixaban/rivaroxaban in the last 48 hours. Recent European Stroke Organization guidelines suggest that thrombolysis can be considered if anti-factor Xa activity (AFXa) is <0.5 × 10 3 IU/L with low-molecular-weight (LMWH) or unfractionated heparin (UFH) calibrated assays. Some centers also use apixaban/rivaroxaban-calibrated AFXa assays to identify patients with low drug concentrations., Objectives: To prospectively evaluate the first year of implementation of drug-calibrated AFXa assays at our center with 2500 yearly admittances with suspected stroke., Methods: Samples were analyzed on Sysmex CS-5100 instruments with Innovance anti-Xa reagents. Thrombolysis could be considered with drug concentrations <25 μg/L. Patients were registered in an institutionally approved quality register. Outcomes included (1) the number of patients receiving thrombolysis after drug measurement, (2) turn-around time for drug concentration measurements, and (3) sensitivity of LMWH/UFH AFXa to apixaban and rivaroxaban., Results: Apixaban or rivaroxaban was measured in 148 samples, and 4 patients who previously would have been ineligible for thrombolysis were treated with thrombolysis. In total, thrombolysis was administered in 123 patient episodes in the study period. The median turn-around time for the drug measurements was 38 minutes. Apixaban concentrations of 25 μg/L and 50 μg/L corresponded to LMWH/UFH AFXa of 0.13 and 0.27 × 10 3 IU/L, respectively. There were too few rivaroxaban results for regression analysis., Conclusion: Implementation of apixaban and rivaroxaban measurements led to a small increase in the number of patients receiving thrombolysis. Excluding significant concentrations of apixaban or rivaroxaban using LMWH/UFH AFXa may be feasible., (© 2024 The Authors.)

Objectives: We aimed to study how the individual items of the National Institutes of Health Stroke Scale (NIHSS) at admission predict functional independence 3 months post-stroke in patients with first-ever stroke., Setting: This registry-based study used data from two Swedish stroke registers (Riksstroke, the mandatory national quality register for stroke care in Sweden, and Väststroke, a local quality stroke register in Gothenburg)., Participants: This study included patients with first-ever acute stroke admitted from November 2014 to August 2018, with available NIHSS at admission and modified Rankin Scale (mRS) at 3-month follow-up., Primary Outcome: The primary outcome variable was mRS≤1 (defined as an excellent outcome) at 3-month follow-up., Results: We included 1471 patients, mean age was 72 (± 14.5) years, 48% were female, and 66% had mild strokes (NIHSS≤3). In adjusted binary logistic regression analysis, the NIHSS items impaired right motor arm and leg, and impairment in visual field, reduced the odds of an excellent outcome at 3 months ((OR 0.60 (95% CI 0.37 to 0.98), OR 0.60 (95% CI 0.37 to 0.97), and OR 0.65 (95% CI 0.45 to 0.94)). When exploring the effect size of associations between NIHSS items and mRS≤1 p, orientation, language and right leg motor had the largest yet small association., Conclusions: Stroke patients with scores on the NIHSS items right motor symptoms or visual field at admission are less likely to have an excellent outcome at 3 months. Clinicians should consider the NIHSS items affected, not only the total NIHSS score, both in treatment guidance and prognostics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To assess how physical activity levels changed in a stroke cohort during the COVID-19 (SARS-CoV-2) pandemic, and how these changes were associated with quality of life (QoL)., Methods: Between March and July 2021, 150 patients with stroke already included in the Life after Stroke (LAST-long) trial in Norway were invited to participate in this cross-sectional survey. Participants were asked to complete a questionnaire assessing changes in physical activity and self-reported health following the pandemic. Univariate and multivariate logistic regression analyses were used to explore the association between physical activity, loneliness, mental health, social activity and QoL., Results: In all, 118 (79%) participants completed the questionnaire. A total of 80 (68%) reported less physical activity, 46 (39%) felt lonelier, and 43 (37%) reported worse mental health, while 50 (42%) reported reduced QoL compared with before the lockdown. In the univariate analyses less physical activity, feeling lonelier and changes in mental health were associated with reduced QoL. In the multivariate analysis only less physical activity odds ratio (OR) = 4.04 (95% confidence interval (95% CI) 1.44-11.34, p = 0.008) was significantly associated with reduced QoL., Conclusion: More than two-thirds of patients with stroke reported reduced physical activity during the COVID-19 pandemic, and less physical activity was strongly associated with reduced QoL.

Background and Purpose: There are currently no biomarkers to select cryptogenic stroke (CS) patients for monitoring with insertable cardiac monitors (ICMs), the most effective tool for diagnosing atrial fibrillation (AF) in CS. The purpose of this study was to assess clinically available biomarkers as predictors of AF., Methods: Eligible CS and cryptogenic transient ischaemic attack patients underwent 12-month monitoring with ICMs, clinical follow-up and biomarker sampling. Levels of cardiac and thromboembolic biomarkers, taken within 14 days from symptom onset, were compared between patients diagnosed with AF (n = 74) during monitoring and those without AF (n = 185). Receiver operating characteristic curves were created. Biomarkers reaching area under the receiver operating characteristic curve ≥ 0.7 were dichotomized by finding optimal cut-off values and were used in logistic regression establishing their predictive value for increased risk of AF in unadjusted and adjusted models., Results: B-type natriuretic peptide (BNP), N-terminal pro-brain natriuretic peptide (NT-proBNP), creatine kinase, D-dimer and high-sensitivity cardiac troponin I and T were significantly higher in the AF than non-AF group. BNP and NT-proBNP reached the predefined area under the curve level, 0.755 and 0.725 respectively. Optimal cut-off values were 33.5 ng/l for BNP and 87 ng/l for NT-proBNP. Regression analysis showed that NT-proBNP was a predictor of AF in both unadjusted (odds ratio 7.72, 95% confidence interval 3.16-18.87) and age- and sex-adjusted models (odds ratio 4.82, 95% confidence interval 1.79-12.96)., Conclusion: Several clinically established biomarkers were associated with AF. NT-proBNP performed best as AF predictor and could be used for selecting patients for long-term monitoring with ICMs., (© 2023 European Academy of Neurology.)

Background: Whether the SARS-CoV-2 mRNA vaccines may cause a transient increased stroke risk is uncertain., Methods: In a registry-based cohort of all adult residents at December 27, 2020, in Norway, we linked individual-level data on COVID-19 vaccination, positive SARS-CoV-2 test, hospital admissions, cause of death, health care worker status, and nursing home resident status extracted from the Emergency Preparedness Register for COVID-19 in Norway. The cohort was followed for incident intracerebral bleeding, ischemic stroke, and subarachnoid hemorrhage within the first 28 days after the first/second or third dose of mRNA vaccination until January 24, 2022. Stroke risk after vaccination relative to time not exposed to vaccination was assessed by Cox proportional hazard ratio, adjusted for age, sex, risk groups, health care personnel, and nursing home resident., Results: The cohort included 4 139 888 people, 49.8% women, and 6.7% were ≥80 years of age. During the first 28 days after an mRNA vaccine, 2104 people experienced a stroke (82% ischemic stroke, 13% intracerebral hemorrhage, and 5% subarachnoid hemorrhage). Adjusted hazard ratios (95% CI) after the first/second and after the third mRNA vaccine doses were 0.92 (0.85-1.00) and 0.89 (0.73-1.08) for ischemic stroke, 0.81 (0.67-0.98) and 1.05 (0.64-1.71) for intracerebral hemorrhage, and 0.64 (0.46-0.87) and 1.12 (0.57-2.19) for subarachnoid hemorrhage, respectively., Conclusions: We did not find increased risk of stroke during the first 28 days after an mRNA SARS-CoV-2 vaccine.

Introduction: Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians., Patients and Methods: Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection., Results: ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p  < 0.001), had higher pre-stroke CHA₂DS₂-VASc score (median 3 vs 2; p  < 0.001) and admission NIHSS (median 2 vs 1; p  = 0.001); and more often hypertension ( p  = 0.045) and dyslipidaemia ( p  = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%., Discussion and Conclusions: ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: DA has received honoraria from Actelion, Amgen, AstraZeneca, BMS/Pfizer, Bayer, Boehringer-Ingelheim, MSD, Novartis, Roche Diagnostics, Sanofi and Vifor Pharma; and research grants from BMS/Pfizer, Bayer, Roche Diagnostics and Medtronic. AHA has received travel support and honoraria for advice or lecturing from Bayer, Boehringer Ingelheim, BMS, Allergan, Teva, Sanofi-Genzyme, Novartis, Roche and Teva; and research grant from Boehringer Ingelheim. BRT and ATL have received travel funding from Medtronic., (© The Author(s) 2022.)

Hege Ihle-Hansen,1 Bente Thommessen,2 Morten W Fagerland,3 Anne R Øksengård,4 Torgeir B Wyller,5 Knut Engedal,6 Brynjar Fure7 1Department of Internal Medicine, Vestre Viken Hospital Trust, Bærum Hospital, Bærum, Norway; 2Department of Neurology, Akershus University Hospital, Lørenskog, Norway; 3Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Norway; 4Department of Internal medicine, Vestre Viken Hospital Trust, Bærum Hospital, Bærum, Norway; 5Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway; 6Norwegian Centre for Dementia Research, Oslo University Hospital, Oslo, Norway; 7Norwegian Knowledge Centre for the Health Services, Oslo, Norway Background: Treatment of hypertension post-stroke preserves cognition through prevention of recurrent stroke, but it is not clear whether it prevents cognitive decline through other mechanisms. We aimed to describe changes in blood pressure from baseline to 1 year post-stroke and to evaluate the association between achieved blood pressure targets and cognitive function, mild cognitive impairment (MCI), and dementia.Methods: We included patients with first-ever stroke, and defined achieved blood pressure goals as systolic blood pressure (SBP) in the categories ≤125 mmHg, ≤140 mmHg, and ≤160 mmHg, SBP reduction of ≥10 mmHg, and diastolic blood pressure (DBP) reduction of ≥5 mmHg. The main outcome variables were cognitive assessments 1 year post stroke. Secondary outcomes were diagnoses of MCI or dementia.Results: Forty-one of 166 patients (25%) reached SBP ≤125 mmHg after 1 year, 92/166 (55%) reached SBP ≤140 mmHg, and 150/166 (90%) reached SBP ≤160 mmHg. SBP was reduced by ≥10 mmHg in 44/150 (29%) and DBP by ≥5 mmHg in 57/150 (38%). We did not find any statistically significant associations between cognitive test performances and different blood pressure goals (P=0.070–1.0). Nor was there any significant association between achieved goal blood pressure or blood pressure reduction after 1 year and the diagnoses of MCI or dementia (P=0.32–0.56).Conclusion: Treatment of hypertension is important for primary and secondary prevention of stroke. Showing a potential beneficial effect of blood pressure control on cognitive function, however, probably needs longer follow-up. Keywords: cognitive impairment, hypertension, cerebrovascular disease, risk factor management, secondary prevention

Aim: To assess the feasibility of delirium screening with the screening tool 4AT conducted by stroke unit nurses., Design: Observational., Methods: Patients with confirmed acute stroke admitted to the stroke unit at Baerum Hospital, Norway, from March to October 2020, were consecutively recruited. Nurses performed delirium screening using the rapid screening tool 4AT within 24 h of admission, at discharge and when delirium was suspected, and filled out a questionnaire assessing their experiences with the delirium screening. A geriatrician validated the delirium diagnosis., Results: In all, 62 patients were included, mean age 73.3 years. 4AT was performed according to protocol in 49 (79.0%) and 39 (62.9%) patients at admission and discharge respectively. Lack of time (40%) was reported as the most common reason for not performing delirium screening. The nurses reported that the felt competent to carry out the 4AT screening, and did not experience it as significant extra workload. Five patients (8%) were diagnosed with delirium. Delirium screening performed by stroke unit nurses seemed feasible and the nurses experienced that 4AT was a useful tool for this purpose., (© 2023 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Background: Timely treatment of acute stroke depends on early identification and triage. Improved methods for recognition of stroke in the prehospital setting are needed. We aimed to assess whether use of the National Institutes of Health Stroke Scale (NIHSS) by paramedics in the ambulance could improve communication with the hospital, augment triage, and enhance diagnostic accuracy of acute stroke., Methods: The Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) was a stepped-wedge, single-blind, cluster-randomised controlled trial. Patients with suspected acute stroke, who were evaluated by paramedics from five ambulance stations in Oslo, Norway, were eligible for inclusion. The five ambulance stations (defined as clusters) all initially managed patients according to a standard stroke protocol (control group), with randomised sequential crossover of each station to the intervention group. The intervention consisted of supervised training on NIHSS scoring, a mobile application to aid scoring, and standardised communication with stroke physicians. Random allocation was done via a simple lottery draw by administrators at Oslo University Hospital, who were independent of the research team. Allocation concealment was not possible due to the nature of the intervention. The primary outcome was the positive predictive value (PPV) for prehospital identification of patients with a final discharge diagnosis of acute stroke, analysed by intention to treat. Prespecified secondary safety outcomes were median prehospital on-scene time and median door-to-needle time. This trial is registered with ClinicalTrials.gov, NCT04137874, and is completed., Findings: Between June 3, 2019, and July 1, 2021, 935 patients were evaluated by paramedics for suspected acute stroke. 134 patients met exclusion criteria or did not consent to participate. The primary analysis included 447 patients in the intervention group and 354 in the control group. There was no difference in PPV for prehospital identification of patients with a final discharge diagnosis of acute stroke between the intervention group (48·1%, 95% CI 43·4-52·8) and control group (45·8%, 40·5-51·1), with an estimated percentage points difference between groups of 2·3 (95% CI -4·6 to 9·3; p=0·51). Median prehospital on-scene time increased by 5 min in the intervention group (29 min [IQR 23-36] vs 24 min [19-31]; p<0·0001), whereas median door-to-needle time was similar between groups (26 min [21-36] vs 27 min [20-36]; p=0·90). No prehospital deaths were reported in either group., Interpretation: The intervention did not improve diagnostic accuracy in patients with suspected stroke. A general increase in prehospital time during the pandemic and the identification of smaller strokes that require more deliberation are possible explanations for the increased on-scene time. The ParaNASPP model is to be implemented in Norway from 2023, and will provide real-life data for further research., Funding: Norwegian Air Ambulance Foundation and Oslo University Hospital., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background and Purpose: Pulsatility index (PI) in the middle cerebral artery (MCA) is considered a measure of peripheral vascular resistance. Several established cardiovascular risk factors are common for both MCA PI and carotid atherosclerosis. Accordingly, in the present study we hypothesized an association between ultrasound-derived indices of carotid atherosclerosis and MCA PI., Methods: All residents in Akershus County, born in 1950, were invited to a cardiovascular examination, The Akershus Cardiac Examination (ACE) 1950 Study (2012-2015). A thorough ultrasound examination was performed to assess indices of atherosclerosis in the carotid arteries, and PI in the MCAs. In all, 3154 (85.1%) had adequate transcranial and carotid data. Associations between indices of carotid atherosclerosis and MCA PI were assessed by regression analyses adjusted for established cardiovascular risk factors., Results: Mean age was 64 (standard deviation [SD]: .6) years, and 1,357 (43%) were women. Mean MCA PI was .97 (SD: .17). Participants in the upper quartile of MCA PI had higher pulse pressure, more frequently hypertension, diabetes mellitus, and a history of coronary artery disease. Both carotid plaque score (B .007 [95% CI: .003-.010]) and carotid intimamedia thickness (B .173 [95% CI: .120-.226]) were significantly associated with MCA PI in adjusted analysis. The model R 2 was .055., Conclusion: In a population-based sample of middle-aged adults, ultrasound-derived indices of carotid atherosclerosis were independently associated with MCA PI. However, the overall explained variance of MCA PI was low, suggesting other factors than atherosclerosis and cardiovascular risk factors to play an important role for MCA PI., (© 2019 The Authors. Journal of Neuroimaging published by Wiley Periodicals, Inc. on behalf of American Society of Neuroimaging.)

Background: Waves of infection have formed the pattern of the COVID-19 pandemic. A wave dominated by the delta variant of the SARS-CoV-2 virus in autumn 2021 was superseded by the omicron variant over the course of a few weeks around Christmas. We describe how this transition affected the population of patients admitted to a Norwegian local hospital with COVID-19., Material and Method: All patients admitted to Bærum Hospital with confirmed SARS-CoV-2 virus were included in a quality study which aimed to describe patient characteristics and clinical course. We present patients admitted in the periods 28 June 2021-31 December 2021 and 1 January 2022-12 June 2022, described here as the delta wave and the omicron wave., Results: The SARS-CoV-2-virus was confirmed in a total of 144 patients who were admitted during the delta wave, and in 261 patients during the omicron wave, where 14/144 (10 %) and 89/261 (34 %) were admitted for reasons other than COVID-19. Patients with COVID-19 during the delta wave were younger on average (59 vs. 69 years) and had a lower Charlson comorbidity index score (2.6 vs. 4.9) and a lower Clinical Frailty Scale score (2.8 vs. 3.7) than patients in the omicron wave. Among 302/405 patients admitted with COVID-19 as the principal diagnosis, 88/130 (68 %) patients had respiratory failure during the delta wave and 59/172 (34 %) during the omicron wave, with a median number of 8 bed days (interquartile range 5-15) and 5 (interquartile range 3-8)., Interpretation: The transition from the wave of infection that was dominated by the delta variant of the SARS-CoV-2 virus to the wave dominated by the omicron variant had a considerable effect on the characteristics and clinical course of patients admitted to hospital with SARS-CoV-2 infection.

Introduction: Multimodal interventions have emerged as new approaches to provide more targeted intervention to reduce functional decline after stroke. Still, the evidence is contradictory. The main objective of the Life After Stroke (LAST)-long trial is to investigate if monthly meetings with a stroke coordinator who offers a multimodal approach to long-term follow-up can prevent functional decline after stroke., Methods and Analysis: LAST-long is a pragmatic single-blinded, parallel-group randomised controlled trial recruiting participants living in six different municipalities, admitted to four hospitals in Norway. The patients are screened for inclusion and recruited into the trial 3 months after stroke. A total of 300 patients fulfilling the inclusion criteria will be randomised to an intervention group receiving monthly follow-up by a community-based stroke coordinator who identifies the participants' individual risk profile and sets up an action plan based on individual goals, or to a control group receiving standard care. All participants undergo blinded assessments at 6-month, 12-month and 18-month follow-up. Modified Rankin Scale at 18 months is primary outcome. Secondary outcomes are results of blood tests, blood pressure, adherence to secondary prophylaxis, measures of activities of daily living, cognitive function, physical function, physical activity, patient reported outcome measures, caregiver's burden, the use and costs of health services, safety measures and measures of adherence to the intervention. Mixed models will be used to evaluate differences between the intervention and control group for all endpoints across the four time points, with treatment group, time as categorical covariates and their interaction as fixed effects, and patient as random effect., Ethics and Dissemination: This trial was approved by the Regional Committee of Medical and Health Research Ethics, REC no. 2018/1809. The main results will be published in international peer-reviewed open access scientific journals and to policy-makers and end users in relevant channels., Trial Registration Number: ClincalTrials.gov Identifier: NCT03859063, registered on 1 March 2019., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Even mild strokes may affect the patients' everyday life by impairing cognitive and emotional functions. Our aim was to study predictors of such impairments one year after first-ever mild stroke. We included cognitively healthy patients ≤ 70 years with acute mild stroke. Vascular risk factors, sociodemographic factors and stroke classifications were recorded. At one-year post-stroke, different domains related to cognitive and emotional function were assessed with validated instruments. Logistic regression analyses were performed to identify predictors of cognitive and emotional outcome. Of 117 patient assessed at follow-up, only 21 patients (18%) scored within the reference range on all cognitive and emotional assessments. Younger age, multiple infarcts, and being outside working life at stroke onset were independent predictors of cognitive impairments (psychomotor speed, attention, executive and visuospatial function, memory). Female gender and a higher National Institutes of Health Stroke Scale (NIHSS) score at discharge were significantly associated with emotional impairments (anxiety, depressive symptoms, fatigue, apathy, emotional lability) after one year, but these associations were only seen in the unadjusted models. In conclusion, patients in working age may profit from a follow-up during the post-stroke period, with extra focus on cognitive and emotional functions.

Background: Inflammation is proposed to be involved in the pathogenesis of poststroke cognitive impairment. The aim of this study was to investigate associations between concentrations of systemic inflammatory biomarkers after ischemic stroke and poststroke cognitive impairment., Methods: The Nor-COAST study (Norwegian Cognitive Impairment After Stroke) is a prospective observational multicenter cohort study, including patients hospitalized with acute stroke between 2015 and 2017. Inflammatory biomarkers, including the TCC (terminal C5b-9 complement complex) and 20 cytokines, were analyzed in plasma, collected at baseline, 3-, and 18 months poststroke, using ELISA and a multiplex assay. Global cognitive outcome was assessed with the Montreal Cognitive Assessment (MoCA) scale. We investigated the associations between plasma inflammatory biomarkers at baseline and MoCA score at 3-, 18-, and 36-month follow-ups; the associations between inflammatory biomarkers at 3 months and MoCA score at 18- and 36-month follow-ups; and the association between these biomarkers at 18 months and MoCA score at 36-month follow-up. We used mixed linear regression adjusted for age and sex., Results: We included 455 survivors of ischemic stroke. Higher concentrations of 7 baseline biomarkers were significantly associated with lower MoCA score at 36 months; TCC, IL (interleukin)-6, and MIP (macrophage inflammatory protein)-1α were associated with MoCA at 3, 18, and 36 months ( P <0.01). No biomarker at 3 months was significantly associated with MoCA score at either 18 or 36 months, whereas higher concentrations of 3 biomarkers at 18 months were associated with lower MoCA score at 36 months ( P <0.01). TCC at baseline and IL-6 and MIP-1α measured both at baseline and 18 months were particularly strongly associated with MoCA ( P <0.01)., Conclusions: Higher concentrations of plasma inflammatory biomarkers were associated with lower MoCA scores up to 36 months poststroke. This was most pronounced for inflammatory biomarkers measured in the acute phase following stroke., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT02650531.

Background: The National Early Warning Score 2 (NEWS2) is a scoring tool predictive of poor outcome in hospitalised patients. Older patients with COVID-19 have increased risk of poor outcome, but it is not known if frailty may impact the predictive performance of NEWS2. We aimed to investigate the impact of frailty on the performance of NEWS2 to predict in-hospital mortality in patients hospitalised due to COVID-19., Methods: We included all patients admitted to a non-university Norwegian hospital due to COVID-19 from 9 March 2020 until 31 December 2021. NEWS2 was scored based on the first vital signs recorded upon hospital admission. Frailty was defined as a Clinical Frailty Scale score ≥ 4. The performance of a NEWS2 score ≥ 5 to predict in-hospital mortality was assessed with sensitivity, specificity and area under the receiver operating characteristic curve (AUROC) according to frailty status., Results: Out of 412 patients, 70 were aged ≥ 65 years and with frailty. They presented less frequently with respiratory symptoms, and more often with acute functional decline or new-onset confusion. In-hospital mortality was 6% in patients without frailty, and 26% in patients with frailty. NEWS2 predicted in-hospital mortality with a sensitivity of 86%, 95% confidence interval (CI) 64%-97% and AUROC 0.73, 95% CI 0.65-0.81 in patients without frailty. In older patients with frailty, sensitivity was 61%, 95% CI 36%-83% and AUROC 0.61, 95% CI 0.48-0.75., Conclusion: A single NEWS2 score at hospital admission performed poorly to predict in-hospital mortality in patients with frailty and COVID-19 and should be used with caution in this patient group. Graphical abstract summing up study design, results and conclusion., (© 2023. The Author(s).)

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide. With better pre- and inhospital treatment, including cardiopulmonary resuscitation (CPR) as an integrated part of public education and more public-access defibrillators available, OHCA survival has increased over the last decade. There are concerns, after successful resuscitation, of cerebral hypoxia and degrees of potential acquired brain injury with resulting poor cognitive functioning. Cognitive function is not routinely assessed in OHCA survivors, and there is a lack of consensus on screening methods for cognitive changes. This narrative mini-review, explores available evidence on hypoxic brain injury and long-term cognitive function in cardiac arrest survivors and highlights remaining knowledge deficits., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Hagberg, Ihle-Hansen, Sandset, Jacobsen, Wimmer and Ihle-Hansen.)

Background: A high intake of linoleic acid (LA), the major dietary polyunsaturated fatty acid (PUFA), has previously been associated with reduced cardiovascular (CV) morbidity and mortality in observational studies. However, recent secondary analyses from clinical trials of LA-rich diet suggest harmful effects of LA on CV health., Methods: A total of 3706 participants, all born in 1950, were included in this cross-sectional study. We investigated associations between plasma phospholipid levels of LA and CV risk factors in a Norwegian general population, characterized by a relative low LA and high marine n-3 PUFA intake. The main statistical approach was multivariable linear regression., Results: Plasma phospholipid LA levels ranged from 11.4 to 32.0 wt%, with a median level of 20.8 wt% (interquartile range 16.8-24.8 wt%). High plasma LA levels were associated with lower serum low-density lipoprotein cholesterol levels (standardized regression coefficient [Std. β-coeff.] -0.04, p = 0.02), serum triglycerides (Std. β-coeff. -0.10, p < 0.001), fasting plasma glucose (Std. β-coeff. -0.10, p < 0.001), body mass index (Std. β-coeff. -0.13, p < 0.001), systolic and diastolic blood pressure (Std. β-coeff. -0.04, p = 0.03 and Std. β-coeff. -0.02, p = 0.02, respectively) and estimated glomerular filtration rate (Std. β-coeff. -0.09, p < 0.001). We found no association between plasma LA levels and high-density lipoprotein cholesterol levels, glycated hemoglobin, carotid intima-media thickness, or C-reactive protein., Conclusion: High plasma LA levels were favorably associated with several CV risk factors in this study of a Norwegian general population.

Background and Purpose: Sex differences in acute ischemic stroke is of increasing interest in the era of precision medicine. We aimed to explore sex disparities in baseline characteristics, management and outcomes in patients treated with intravenous thrombolysis included in the Norwegian Tenecteplase trial (NOR-TEST)., Methods: NOR-TEST was an open-label, randomized, blinded endpoint trial, performed from 2012 to 2016, comparing treatment with tenecteplase to treatment with alteplase within 4.5 h after acute ischemic stroke symptom onset. Sex differences at baseline, treatment and outcomes were compared using multivariable logistic regression models. Heterogeneity in treatment was evaluated by including an interaction term in the model., Results: Of 1100 patients enrolled, 40% were women, and in patients aged >80 years, the proportion of women was greater than men (19% vs. 14%; p = 0.02). Women had a lower burden of cardiovascular risk factors, such as diabetes mellitus (11% vs. 15%; p = 0.05) and a higher mean high-density lipoprotein cholesterol level (1.7 ± 0.6 mmol/L vs. 1.3 ± 0.4 mmol/L; p < 0.001), and a higher proportion of women had never smoked (45% vs. 33%; p < 0.001) compared with men. While there was no sex difference in time from onset of symptoms to admission, door to needle time or in-hospital workup, women were admitted with more severe stroke (National Institutes of Health Stroke Scale [NIHSS] score 6.2 ± 5.6 vs. 5.3 ± 5.1; p = 0.01). Stroke mimic diagnosis was more common in women (21% vs. 15%; p = 0.01). There were no significant sex differences in clinical outcome, measured by the NIHSS, the modified Rankin Scale, intracranial hemorrhage and mortality., Conclusion: Women were underrepresented in number in NOR-TEST. The included women had a lower cardiovascular risk factor burden and more severe strokes., (© 2021 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Introduction: Transcranial Doppler (TCD) sonography is a noninvasive tool for measuring cerebrovascular hemodynamics. Studies have reported alterations in cerebrovascular hemodynamics in normal aging, mild cognitive impairment (MCI), and dementia, as well as in different etiologies of dementia. This systematic review and meta-analysis was designed to investigate the relationship between cerebral blood velocity (CBv) and pulsatility index (PI) in the middle cerebral artery (MCA) in persons with MCI and dementia., Methods: A systematic literature search was conducted in Pubmed, Embase, Cochrane Library, Epistemonikos, PsychINFO, and CINAHL. The search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After screening of 33,439 articles, 86 were reviewed in full-text, and 35 fulfilled the inclusion criteria., Results: CBv was significantly lower and PI significantly higher in MCA in vascular dementia (VaD) and Alzheimer's disease (AD) compared to cognitively normal (CN) older persons. Also, CBv was lower in MCI compared to CN. There were no significant differences in CBv in MCA in AD compared with VaD, although PI was higher in VaD compared to AD., Conclusion: Alterations in cerebrovascular hemodynamics are seen in AD, VaD, and MCI. While PI was slightly higher in VaD compared to AD, the reduction in CBv appears to be equally pronounced across neurodegenerative and vascular etiologies of dementia., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Background: Studies regarding adequacy of secondary stroke prevention are limited. We report medication adherence, risk factor control and factors influencing vascular risk profile following ischaemic stroke. Methods: A total of 664 home‐dwelling participants in the Norwegian Cognitive Impairment After Stroke study, a multicenter observational study, were evaluated 3 and 18 months poststroke. We assessed medication adherence by self‐reporting (4‐item Morisky Medication Adherence Scale) and medication persistence (defined as continuation of medication(s) prescribed at discharge), achievement of guideline‐defined targets of blood pressure (BP) (<140/90 mmHg), low‐density lipoprotein cholesterol (LDL‐C) (<2.0 mmol L−1) and haemoglobin A1c (HbA1c) (≤53 mmol mol−1) and determinants of risk factor control. Results: At discharge, 97% were prescribed antithrombotics, 88% lipid‐lowering drugs, 68% antihypertensives and 12% antidiabetic drugs. Persistence of users declined to 99%, 88%, 93% and 95%, respectively, at 18 months. After 3 and 18 months, 80% and 73% reported high adherence. After 3 and 18 months, 40.7% and 47.0% gained BP control, 48.4% and 44.6% achieved LDL‐C control, and 69.2% and 69.5% of diabetic patients achieved HbA1c control. Advanced age was associated with increased LDL‐C control (OR 1.03, 95% CI 1.01 to 1.06) and reduced BP control (OR 0.98, 0.96 to 0.99). Women had poorer LDL‐C control (OR 0.60, 0.37 to 0.98). Polypharmacy was associated with increased LDL‐C control (OR 1.29, 1.18 to 1.41) and reduced HbA1c control (OR 0.76, 0.60 to 0.98). Conclusion: Risk factor control is suboptimal despite high medication persistence and adherence. Improved understanding of this complex clinical setting is needed for optimization of secondary preventive strategies. [ABSTRACT FROM AUTHOR]

Anticoagulant drugs are effective in preventing and treating blood clots, but they also increase the risk of intracerebral haemorrhage. When intracerebral haemorrhage occurs, rapid reversal of the anticoagulant effect is recommended. However, reversal treatment must be selected on the basis of the anticoagulants' various mechanisms of action, and a specific antidote is preferred where available.

Objectives: We aimed to assess longitudinal changes in MRI measures of brain atrophy and white matter lesions in stroke and transient ischemic attack (TIA) survivors, and explore whether carotid stenosis predicts progression of these changes, assessed by visual rating scales., Materials and Methods: All patients with a first-ever stroke or TIA admitted to Bærum Hospital, Norway, in 2007/2008, were invited in the acute phase and followed for seven years. Carotid ultrasound was performed during the hospital stay. Carotid stenosis was defined as ≥50% narrowing of lumen. MRI was performed one and seven years after the index event and analyzed according to the visual rating scales Fazekas scale (0-3), Medial Temporal Lobe Atrophy (MTLA) (0-4) score, and Global Cortical Atrophy (GCA) scale (0-3). Patients with MRI scans at both time points were included in this sub-study., Results: Of 227 patients recruited, 76 had both MRI examinations. Mean age 73.9±10.6, 41% women, and 9% had ≥50% carotid stenosis. Mean Fazekas scale was 1.7±0.9 and 1.8±1.0, mean MTLA score 1.0 ±1.0 and 1.7±1.0, and mean GCA scale score 1.4±0.7 and 1.4±0.6 after one and seven years, respectively. 71% retained the same Fazekas scale score, while 21% showed progression. Deterioration in GCA scale was seen in 20% and increasing MTLA score in 57%. Carotid stenosis was not associated with progression on Fazekas score, MTLA score or GCA scale., Conclusions: Three out of five showed progression on the MTLA score. Carotid stenosis was not associated with longitudinal change of visual rating scales., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)