The 25th edition of the European Stroke Conference took place in springtime Venice. Numerous research projects from different European countries were presented. Some interesting studies and innovative approaches are presented below.
From the United Kingdom comes a meta-analysis that addresses an exciting and relevant question: How do prevalence rates for stroke differ in countries with different levels of income? And what are the reasons for possible differences?
Stroke is also a relevant health issue in emerging markets
It is mainly infectious diseases that determine morbidity rates in low- and middle-income countries, while high-income Western countries struggle with diabetes, obesity, hypertension, physical inactivity and, as a result, stroke. Nevertheless, strokes are increasingly becoming a relevant health issue in lower-income countries, especially as economic strength increases over the years and people age and move less. Medical care often lags behind social development: the loss of Disability Adjusted Life Years (DALY) for stroke in these countries is in some cases seven times higher than in high-income countries.
For their analysis, the researchers accessed community-based studies from several large databases such as MEDLINE, EMBASE, Web of Sciences, SCOPUS, etc., to obtain an up-to-date inventory of stroke survivor prevalence rates. 101 studies were included in the meta-analysis. Overall, stroke prevalence increased steadily in low- and middle-income countries across all geographic regions, but most strongly in Latin America and the Caribbean (annual increase of 17%), followed by East Asia and the Pacific region (13.3%), and finally sub-Saharan Africa (12%). The lowest-income states experienced the largest increase in annual prevalence rates (14.3%), while prevalence in low- to middle-income states increased at a slightly slower rate (6%).
The authors stated that while higher-income countries continue to account for the majority of stroke prevalence. Low-income regions, however, have seen the steepest growth over the past 30 years, and they are likely to overtake the other states in the future – with major socioeconomic consequences. The researchers see reasons for the trend primarily in poorer control of risk factors (e.g., undetected or uncontrolled hypertension). Moreover, when stroke does occur, care for patients in lower-income countries is poorer, which in turn leads to increased morbidity.
Long-term follow-up: spasticity after stroke.
Spasticity after stroke, defined as various forms of muscle hyperactivity, is a complication that can be highly distressing and limiting for the patient and those around them. Two German investigators from a neurological clinic in Hamburg presented data from 149 patients with stroke and paresis of >24 hours’ duration, who after 4-6 months (time point 1) and 16-26 months (time 2) Have been evaluated for increased muscle tone, spasm, paresis, and pain. The scales used were:
- Modified Ashworth Scale (MAS)
- Spasm Frequency Scale (SFS)
- Medical Research Council Scale (MRCS)
- Global Pain Scale (GPS).
A total of 97 subjects could be followed up over the entire period (26 had died, 26 could not be recalled). In 64%, the paresis had regressed at the first time of examination, 36% were still paralyzed (affected: arms in 2%, legs in 1%, both extremities in 33%). Muscle hyperactivity was found in 29% overall. Increased muscle tone was found in 28% (3% arm, 4% leg, 21% both), and this was associated with pain in 13% (9% of patients had a GPS score above 50). Spasms occurred in 16% of patients. Action-induced dystonia was found in only 2%. Treatment most commonly included rehabilitation (65%), physical therapy (32%), psychotropics (26%), occupational therapy (21%), analgesics (16%), and spasmolytics (5%).
By the second time point in the study, these characteristics had hardly changed. 35% were still paralyzed. 33% showed muscle hyperactivity, 32% increased muscle tone (still associated with pain in 13%), 13% spasms, and 3% action-induced dystonia. The number of patients with MAS of at least 2 in the arms or legs increased from the first time point in each case (from 12% to 14% and from 11% to 21%, respectively), but the differences were not significant. Therapies were physical therapy (25%), occupational therapy (17%), psychotropics (13%), analgesics (9%), and spasmolytics (7%).
The authors also consider the data to indicate that spasmolytic therapy is inadequate. Alternative approaches, e.g. with botulinum toxin, would also rarely be used.
When do strokes occur and what are their cognitive effects?
The Montreal Cognitive Assessment (MoCA) and the Mini Mental State Examination (MMSE) are routine tests used to elicit cognition. Both were used in a single-center study presented at the congress to measure cognitive impairment in 100 hospitalized patients 24-48 hours after stroke. On the NIHS acute stroke assessment scale, the mean score was 15. The localization of the stroke was in the middle cerebral artery in all patients.
Affected individuals scored an average of 21.6 on the MoCA (normal >26) and 23.75 on the MMSE (normal >27). The differences compared with the normal population were significant. Thus, 24-48 hours after stroke, both tests showed relevant impairment of cognitive function. The authors also considered the MoCA to be the more appropriate test (the scores of the two tests were significantly different from each other).
The same researchers presented another study that looked at the preferred time of onset of a stroke. It is important to describe the conditions and circumstances of a stroke as precisely as possible in order to better understand their possible dependence on the circadian rhythm. Indeed, relevant differences in event timing were found in the 301 ischemic stroke patients studied. Two peaks over the entire 24 hours were evident: 8% experienced stroke at 09:00, and another 8% at 19:00. Compared with the next most frequent time point (16:00, 6.6%), the differences were significant in each case.
Source: 25th European Stroke Conference, April 13-15, 2016, Venice.
CARDIOVASC 2016; 15(3): 38-39
