Twenty-Year Time Trends in Long-Term Case-Fatality and Recurrence Rates After Ischemic Stroke Stratified by Etiology

Background and Purpose: Data on long-term survival and recurrence after stroke are lacking. We investigated time trends in ischemic stroke case-fatality and recurrence rates over 20-years stratified by etiological subtype according to the Trial of ORG 10172 in Acute Stroke Treatment classification within a population-based stroke register in Germany. Methods: Data was collected within the Erlangen Stroke Project, a prospective, population-based stroke register covering a source population of 105 164 inhabitants (2010). Case fatality and recurrence rates for 3 months, 1 year, and 5 years were estimated with Kaplan-Meier estimates. Sex-specific time trends for case-fatality and recurrence rates were estimated with Cox regression. We adjusted for age, sex, and year of event and stratified for etiological subtypes. A sensitivity analysis with competing risk analysis for time trends in recurrence were performed. Results: Between 1996 and 2015, 3346 patients with first ischemic stroke were included; age-standardized incidence per 100 000 was 75.8 in women and 131.6 in men (2015). Overall, 5-year survival probabilities were 50.4% (95% CI, 47.9–53.1) in women and 59.2% (95% CI, 56.4–62.0) in men; 5-year survival was highest in patients with first stroke due to small-artery occlusion (women, 71.8% [95% CI, 67.1–76.9]; men, 75.9% [95% CI, 71.3–80.9]) and lowest in cardioembolic stroke (women, 35.7% [95% CI, 31.0–41.1]; men, 47.8% [95% CI, 42.2–54.3]). Five-year recurrence rates were 20.1% (95% CI, 17.5–22.6) in women and 20.1% (95% CI, 17.5–22.7) in men; 5-year recurrence rate was lowest in women in stroke due to small artery occlusion 16.0% (95% CI, 11.7–20.1) and in men in large-artery atherosclerosis 16.6% (95% CI, 8.7–23.9); highest risk of recurrence was observed in undefined strokes (women, 22.3% [95% CI, 17.8–26.6]; men, 21.4% [95% CI, 16.7–25.9]). Cox regression revealed improvements in case-fatality rates over time with differences in stroke causes. No time trends in recurrence rates were observed. Conclusions: Long-term survival and recurrence varied substantially by first stroke cause. Survival probabilities improved over the past 2 decades; no major trends in stroke recurrence rates were observed.

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Impacts of treatments on recurrence and 28-year survival of ischemic stroke patients

Scientific Reports ◽

10.1038/s41598-021-94757-6 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Ting-Ann Wang ◽

Tzy-Haw Wu ◽

Shin-Liang Pan ◽

Hsiu-Hsi Chen ◽

Sherry Yueh-Hsia Chiu

Keyword(s):

Ischemic Stroke ◽

Cerebrovascular Disease ◽

Cox Regression ◽

Controlled Trial ◽

Stroke Recurrence ◽

Long Term Effects ◽

Stroke Patients ◽

Double Blind ◽

Term Survival

AbstractAspirin and nicametate are well-established therapies for preventing recurrence and mortality from stroke in patients diagnosed as ischemic stroke. However, their respective effects on the recurrence, making allowance for the duration of recurrence and death without the occurrence of recurrence, and long-term survival have not been well elucidated. We aimed to evaluate long-term effect of two kinds of treatment on cerebrovascular death among ischemic stroke patients with or without the recurrence of stroke. Data used in this study were derived from the cohort based on a multicenter randomized double-blind controlled trial during 1992 to 1995 with the enrollment of a total of 466 patients with first-time non-cardioembolic ischemic stroke who were randomly allocated to receive aspirin (n = 222) or nicametate (n = 244). The trial cohort was followed up over time to ascertain the date of recurrence within trial period and death until Sep of 2019. The time-dependent Cox regression model was used to estimate the long-term effects of two treatments on death from cerebrovascular disease with and without recurrence. A total of 49 patients experienced stroke recurrence and 89 cerebrovascular deaths was confirmed. Patients treated with nicametate were more likely, but non statistically significantly, to have recurrence (aHR: 1.73, 95% CI 0.96–3.13) as compared with those treated by aspirin. Nicametate reduced the risk of cerebrovascular death about 37% (aHR: 0.63, 95% CI 0.41–0.97) compared with aspirin. The aspirin group had a lower recurrence rate than the nicametate group even with recurrence after 1–2 years of follow-up of first stroke but the latter had significantly reduced death from cerebrovascular disease for nicametate group, which requires more research to verify.

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Effects of long-term anti-seizure medication monotherapy on all-cause death in patients with post-stroke epilepsy: a nationwide population-based study in Taiwan

BMC Neurology ◽

10.1186/s12883-021-02241-5 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Chia-Yu Hsu ◽

Chun-Yu Cheng ◽

Jiann-Der Lee ◽

Meng Lee ◽

Bruce Ovbiagele

Keyword(s):

Valproic Acid ◽

Ischemic Stroke ◽

Cox Regression ◽

Population Based ◽

Primary Diagnosis ◽

Research Database ◽

Post Stroke ◽

Risk Of Death ◽

Index Stroke

Abstract Objective We aim to compare the effect of long-term anti-seizure medication (ASM) monotherapy on the risk of death and new ischemic stroke in patients with post-stroke epilepsy (PSE). Patients and methods We identified all hospitalized patients (≥ 20 years) with a primary diagnosis of ischemic or hemorrhagic stroke from 2001 to 2012 using the National Health Insurance Research Database in Taiwan. The PSE cohort were defined as the stroke patients (1) who had no epilepsy and no ASMs use before the index stroke, and (2) who had epilepsy and ASMs use after 14 days from the stroke onset. The patients with PSE receiving ASM monotherapy were enrolled and were categorized into phenytoin, valproic acid, carbamazepine, and new ASM groups. We employed the Cox regression model to estimate the unadjusted and adjusted hazard ratios (HRs) with 95 % confidence intervals (CIs) of death and new ischemic stroke within 5 years across all groups, using the new ASM group as the reference. Results Of 6962 patients with PSE using ASM monotherapy, 3917 (56 %) were on phenytoin, 1623 (23 %) on valproic acid, 457 (7 %) on carbamazepine, and 965 (14 %) on new ASMs. After adjusting for confounders, compared with new ASM users, phenytoin users had a higher risk of death in 5 years (HR: 1.64; 95 % CI: 1.06–2.55). On the other hand, all ASM groups showed a similar risk of new ischemic stroke in 5 years. Conclusions Among patients with PSE on first-line monotherapy, compared to new ASMs, use of phenytoin was associated with a higher risk of death in 5 years.

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Association of masseter area and radiodensity with three-month survival after proximal anterior circulation occlusion

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-015837 ◽

2020 ◽

Vol 13 (1) ◽

pp. 25-29 ◽

Cited By ~ 1

Author(s):

Iisa Lindström ◽

Sara Protto ◽

Niina Khan ◽

Jussi Hernesniemi ◽

Niko Sillanpää ◽

...

Keyword(s):

Regression Analysis ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cox Regression ◽

Multivariable Logistic Regression Analysis ◽

Anterior Circulation ◽

Term Survival ◽

Cox Regression Analysis ◽

Kaplan Meier

BackgroundMasseter area (MA), a surrogate for sarcopenia, appears to be useful when estimating postoperative survival, but there is lack of consensus regarding the potential predictive value of sarcopenia in acute ischemic stroke (AIS) patients. We hypothesized that MA and density (MD) evaluated from pre-interventional CT angiography scans predict postinterventional survival in patients undergoing mechanical thrombectomy (MT).Materials and methods312 patients treated with MT for acute occlusions of the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (M1-MCA) between 2013 and 2018. Median follow-up was 27.4 months (range 0–70.4). Binary logistic (alive at 3 months, OR <1) and Cox regression analyses were used to study the effect of MA and MD averages (MAavg and MDavg) on survival.ResultsIn Kaplan–Meier analysis, there was a significant inverse relationship with both MDavg and MAavg and mortality (MDavg P<0.001, MAavg P=0.002). Long-term mortality was 19.6% (n=61) and 3-month mortality 12.2% (n=38). In multivariable logistic regression analysis at 3 months, per 1-SD increase MDavg (OR 0.61, 95% CI 0.41 to 0.92, P=0.018:) and MAavg (OR 0.57, 95% CI 0.35 to 0.91, P=0.019) were the independent predictors associated with lower mortality. In Cox regression analysis, MDavg and MAavg were not associated with long-term survival.ConclusionsIn acute ischemic stroke patients, MDavg and MAavg are independent predictors of 3-month survival after MT of the ICA or M1-MCA. A 1-SD increase in MDavg and MAavg was associated with a 39%–43% decrease in the probability of death during the first 3 months after MT.

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Time Trends in Incidence and Case Fatality of Ischemic Stroke

Stroke ◽

10.1161/strokeaha.114.008387 ◽

2015 ◽

Vol 46 (5) ◽

pp. 1173-1179 ◽

Cited By ~ 23

Author(s):

Anne Merete Vangen-Lønne ◽

Tom Wilsgaard ◽

Stein Harald Johnsen ◽

Maria Carlsson ◽

Ellisiv B. Mathiesen

Keyword(s):

Ischemic Stroke ◽

Time Trends ◽

Age Groups ◽

Case Fatality ◽

Population Based ◽

Industrialized Countries ◽

Stroke Incidence ◽

Fractional Polynomial ◽

Adjusted Incidence ◽

Age And Sex

Background and Purpose— Ischemic stroke incidence has declined in industrialized countries the last decades, with possible exception for the youngest age groups. We estimated age- and sex-specific trends in incidence and case fatality of first-ever ischemic stroke between 1977 and 2010 in a Norwegian municipality. Methods— Age-adjusted time trends in incidence from 1977 to 2010 were estimated by fractional polynomial and Poisson regression, and case fatality by logistic regression in 36 575 participants of the population-based Tromsø Study. Results— There were 1214 first-ever ischemic strokes within a total follow-up time of 611 176 person-years. The overall age- and sex-adjusted incidence decreased by 24% in 1995 to 2010. In women aged 30 to 49 years, the incidence increased significantly from 1980 to 2010. In men aged 30 to 49 years, there was a nonsignificant, rising trend from 1977 to 2010. Men aged 50 to 64 years had similar incidence in 2010 compared with 1989. From the mid-1990s to 2010, the incidence declined significantly in women aged 50 to 74 years and in men aged 65 to 74 years, but remained stable in those aged ≥75 years. Case fatality decreased significantly in men aged 30 to 84 years from 1995 to 2010, whereas there was no significant change in women. Conclusions— Age-adjusted incidence of first-ever ischemic stroke increased in young women, declined in women aged 50 to 74 years and men aged 65 to 74 years and remained stable among the oldest. Case fatality declined in men aged 30 to 84 years, but not in women.

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Effects of long-term Antiepileptic Drug Monotherapy on All-cause Death in Patients with Post-Stroke Epilepsy: A Nationwide Population-based Study

10.21203/rs.3.rs-126429/v1 ◽

2020 ◽

Author(s):

Chia-Yu Hsu ◽

Chun-Yu Cheng ◽

Jiann-Der Lee ◽

Meng Lee ◽

Bruce Ovbiagele

Keyword(s):

Valproic Acid ◽

Ischemic Stroke ◽

Antiepileptic Drug ◽

Cox Regression ◽

Population Based ◽

Primary Diagnosis ◽

Research Database ◽

Post Stroke ◽

Risk Of Death

Abstract Objective We aim to compare the effect of long-term antiepileptic drug (AED) monotherapy on the risk of death and recurrent ischemic stroke in patients with post-stroke epilepsy (PSE). Patients and Methods We identified all hospitalized patients (≥20 years) with a primary diagnosis of ischemic or hemorrhagic stroke from 2001 to 2012 using the National Health Insurance Research Database in Taiwan. The PSE cohorts were defined as the stroke patients (1) who had no epilepsy and no AEDs use before the index stroke, and (2) who had epilepsy and AEDs use after 14 days from the stroke onset. The PSE patients receiving AED monotherapy were enrolled and were categorized into phenytoin, valproic acid, carbamazepine, and new AED groups. We employed the Cox regression model to estimate the unadjusted and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of death and recurrent ischemic stroke within 5 years across all groups, using the new AED group as the reference. Results Of 6962 PSE patients using AED monotherapy, 3917 (56%) were on phenytoin, 1623 (23%) on valproic acid, 457 (7%) on carbamazepine, and 965 (14%) on new AEDs. After adjusting for confounders, compared with new AED users, phenytoin users had a higher risk of death in 5 years (HR: 1.64; 95% CI: 1.06-2.55). On the other hand, all AED groups showed a similar risk of recurrent ischemic stroke. Conclusion Among PSE patients on first-line monotherapy, compared to new AEDs, use of phenytoin was associated with a higher risk of death in 5 years.

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O45 THE ASSOCIATION OF PERIOPERATIVE QUALITY-OF-CARE PARAMETERS (TEXTBOOK OUTCOME) WITH LONG TERM OUTCOME AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Diseases of the Esophagus ◽

10.1093/dote/doz092.45 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

M C Kalff ◽

I Vesseur ◽

W Eshuis ◽

D Heineman ◽

F Daams ◽

...

Keyword(s):

Overall Survival ◽

Esophageal Cancer ◽

Cox Regression ◽

Neoadjuvant Treatment ◽

Recurrence Rates ◽

Term Survival ◽

Long Term Outcome ◽

Asa Score

Abstract Aim The objectives of this study were to confirm the association of textbook outcome (TO) and overall long-term survival after esophagectomy for esophageal cancer, to investigate the relationship of TO and recurrence rates and to identify clinicopathological predictors for not achieving TO. Background & Methods Despite current improvements in the multimodal treatment of esophageal cancer, surgery remains the key component. Therefore, it is essential to optimize the surgical procedure and to pursue the highest surgical quality. TO is a composite measure of ten perioperative parameters reflecting the quality of surgical care concerning esophagectomy. All patients with esophageal cancer who underwent a transthoracic or transhiatal esophagectomy with curative intent in two tertiary referral centers in The Netherlands between 2007-2016 were included. Patients with a carcinoma in situ, patients undergoing salvage or emergency procedure and patients that applied for opt-out were excluded. Clinicopathological predictors for not achieving TO were identified using univariate and multivariate logistic regression. Survival was compared using Kaplan-Meier life-table estimates and cox regression. Results In total, 1057 patients were included. Over time, the percentage of patients who achieved TO increased from 28.9% in 2007 to 37.5% in 2016. BMI under 18.5, ASA score above one and age above 65 years were associated with a worse TO rate (OR 2.72 [1.02-7.24], ASA 2 OR 1.57 [1.13-2.17] and ASA 3+4 OR 2.33 [1.56-3.48], OR 1.387 [1.06-1.81], respectively), whereas neoadjuvant treatment predicted a better TO rate (OR 0.58 [0.41-0.81]). The median overall survival was 53 months (95% CI 42 – 63) for patients with TO and 35 months (95% CI 29 – 41) for patients without TO; resulting in an overall survival benefit of 18 months (HR 0.759, 95% CI 0.636 – 0.906, P = 0.002). The recurrence rates between TO and no-TO differed, but was not statistically significant (47.1% vs 42.8%, P = 0.177). Conclusion BMI less than 18.5, ASA-score higher than one and age older than 65 were characteristics associated with not achieving TO. Neoadjuvant therapy was associated with a better TO rate. Achieved TO resulted in a better overall five-year survival indicating the importance of pursuing TO.

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Long-term outcome of prolonged critical illness: A multicentered study in North Brisbane, Australia

PLoS ONE ◽

10.1371/journal.pone.0249840 ◽

2021 ◽

Vol 16 (4) ◽

pp. e0249840

Author(s):

Kevin B. Laupland ◽

Mahesh Ramanan ◽

Kiran Shekar ◽

Felicity Edwards ◽

Pierre Clement ◽

...

Keyword(s):

Critical Illness ◽

Cox Regression ◽

Case Fatality ◽

Severity Of Illness ◽

Term Survival ◽

Long Term Outcome ◽

Icu Stay ◽

Lengths Of Stay ◽

One Year

Background Although critical illness is usually of high acuity and short duration, some patients require prolonged management in intensive care units (ICU) and suffer long-term morbidity and mortality. Objective To describe the long-term survival and examine determinants of death among patients with prolonged ICU admission. Methods A retrospective cohort of adult Queensland residents admitted to ICUs for 14 days or longer in North Brisbane, Australia was assembled. Comorbid illnesses were classified using the Charlson definitions and all cause case fatality established using statewide vital statistics. Results During the study a total of 28,742 adult Queensland residents had first admissions to participating ICUs of which 1,157 (4.0%) had prolonged admissions for two weeks or longer. Patients with prolonged admissions included 645 (55.8%), 243 (21.0%), and 269 (23.3%) with ICU lengths of stay lasting 14–20, 21–27, and ≥28 days, respectively. Although the severity of illness at admission did not vary, pre-existing comorbid illnesses including myocardial infarction, congestive heart failure, kidney disease, and peptic ulcer disease were more frequent whereas cancer, cerebrovascular accidents, and plegia were less frequently observed among patients with increasing ICU lengths of stay lasting 14–20, 21–27, and ≥28 days. The ICU, hospital, 90-day, and one-year all cause case-fatality rates were 12.7%, 18.5%, 20.2%, and 24.9%, respectively, and were not different according to duration of ICU stay. The median duration of observation was 1,037 (interquartile range, 214–1888) days. Although comorbidity, age, and admitting diagnosis were significant, neither ICU duration of stay nor severity of illness at admission were associated with overall survival outcome in a multivariable Cox regression model. Conclusions Most patients with prolonged stays in our ICUs are alive at one year post-admission. Older age and previous comorbidities, but not severity of illness or duration of ICU stay, are associated with adverse long-term mortality outcome.

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Nomograms Predicting Long-Term Overall Survival and Cancer-Specific Survival in Metastatic Hepatocellular Carcinoma Patients: A SEER Population-Based Study

10.21203/rs.3.rs-37178/v1 ◽

2020 ◽

Author(s):

Chi Cui ◽

Yaru Duan ◽

Rui Li ◽

Hua Ye ◽

Peng Wang ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Overall Survival ◽

Cox Regression ◽

Training Group ◽

Population Based ◽

Validation Group ◽

Cancer Specific Survival ◽

Term Survival ◽

Metastatic Hepatocellular Carcinoma

Abstract Background: This study aims to evaluate the clinicopathological characteristics of metastatic hepatocellular carcinoma (HCC) patients and develop nomograms to predict their long-term overall survival (OS) and cancer-specific survival (CSS). Methods: Information on metastatic HCC from 2010 to 2015 was retrieved from the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute. The metastatic HCC patients were divided into a long-term survival (LTS) group and a short-term survival (STS) group with 1 year selected as the cut-off value. Then, we compared the demographic and clinicopathological features between the two groups. Next, all patients were randomly divided into a training group and validation group at a 7:3 ratio. Univariate and multivariate Cox regression analyses were used to identify potential predictors for OS and CSS in the training group, and nomograms of OS and CSS were established. These predictive models were further validated in the validation group. Results: A total of 2163 patients were included in the current study according to the inclusion and exclusion criteria. Patients with characteristics including lower T stage and N stage; treatment with surgery, radiation or chemotherapy; no lung metastasis; and AFP negative status showed better survival. The concordance index (C-index) of the OS nomogram was 0.72 based on 9 variables. The C-index of the CSS nomogram was 0.71 based on 8 variables.Conclusions: These nomograms may help clinicians make better treatment recommendations for metastatic HCC patients.

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Long-Term Trends in Stroke Management and Burden Among Low-Income Women in a Rural Area From China (1992–2019): A Prospective Population-Based Study

Frontiers in Neurology ◽

10.3389/fneur.2021.720962 ◽

2021 ◽

Vol 12 ◽

Author(s):

Xiaobing Tian ◽

Jie Liu ◽

Changshen Yu ◽

Yabing Hou ◽

Changqing Zhan ◽

...

Keyword(s):

Low Income ◽

Chinese Women ◽

Case Fatality ◽

Population Based ◽

Stroke Recurrence ◽

Stroke Management ◽

Recurrence Rates ◽

Long Term Trends ◽

Low Income Women

Although an increasing number of studies are considering sex-related differences in stroke burden, the trends in stroke burden and management among women in China, especially among low-income women, remain unclear. This study evaluated the long-term trends in stroke management and burden among low-income Chinese women during the period between 1992 and 2019. Stroke burden was assessed using the age-adjusted incidence of first-ever stroke, whereas stroke management was assessed using the rates of neuroimaging diagnoses, hospitalizations, case fatalities, and stroke recurrence. Stroke burden and management were analyzed during four study periods: 1992–1998, 1999–2004, 2005–2012, and 2013–2019. During the 193,385 person-years of surveillance in this study, 597 female stroke patients were identified. The stroke incidences per 100,000 person-years were 88.1 cases during 1992–1998, 145.4 cases during 1999–2004, 264.3 cases during 2005–2012, and 309.8 cases during 2013–2019 (P < 0.001). Between 1992 and 2019, the incidence of stroke significantly increased (6.4% annually) as did the incidence of ischemic stroke (7.8% annually; both, P < 0.001). The rates of neuroimaging diagnoses and hospitalizations significantly increased during the four periods, while the case fatality rates and 1-year recurrence rates decreased significantly for both overall strokes and ischemic strokes, especially among patients ≥45 years old (all, P < 0.001). Among low-income women in China, stroke management is gradually improving, despite the increasing stroke burden. Thus, improved healthcare coverage is needed to further reduce the stroke burden among low-income Chinese women.

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Trimethylamine N-Oxide and Stroke Recurrence Depends on Ischemic Stroke Subtypes

Stroke ◽

10.1161/strokeaha.120.031443 ◽

2021 ◽

Author(s):

Jie Xu ◽

Aichun Cheng ◽

Bo Song ◽

Mingming Zhao ◽

Jing Xue ◽

...

Keyword(s):

Ischemic Stroke ◽

Cox Regression ◽

Meta Analysis ◽

Artery Occlusion ◽

Hazard Ratio ◽

Stroke Recurrence ◽

Large Artery ◽

Small Artery ◽

Increased Risk ◽

Small Artery Occlusion

Background and Purpose: Trimethylamine N-oxide (TMAO) has been recognized as a risk factor for cardiovascular disease. However, the role of TMAO in ischemic stroke remains unclear. As we know, ischemic stroke is a heterogeneous disease with variable pathogenesis. Hence, we aimed to investigate the association between TMAO and stroke recurrence according to etiology subtypes. Methods: A total of 10 756 ischemic stroke/transient ischemic attack patients from the Third China National Stroke Registry were enrolled, and 1-year follow-up data for stroke recurrence were analyzed. TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria was used to classify the etiology subtypes. Plasma TMAO levels were quantified by liquid chromatography–mass spectrometry. The association between TMAO and stroke outcomes was analyzed using Cox regression models. We also conducted a meta-analysis on the association of TMAO levels and stroke risk. Results: Elevated TMAO level was independently associated with the risk of stroke recurrence (Q4 versus Q1: adjusted hazard ratio, 1.37 [95% CI, 1.15–1.64]) in multivariate Cox regression model. After stratification by TOAST subtypes, there was a significant association between TMAO and stroke recurrence in small artery occlusion subtype (adjusted hazard ratio, 1.43 [95% CI, 1.03–2.00]) but not in the others subtype (large-artery atherosclerosis, 1.19 [0.95–1.48]; cardioembolism, 1.54 [0.95–2.48]; others, 1.19 [0.98–1.44]). The meta-analysis reported on stroke recurrence for the highest versus lowest TMAO levels with a pooled hazard ratio of 1.66 (95% CI, 0.91–3.01) and similarly found an increased risk of stroke recurrence. Conclusions: Elevated TMAO level is associated with increased risk of stroke recurrence in patients with small artery occlusion subtype, but this association seems to be attenuated in large-artery atherosclerosis, cardioembolism, and others subtypes.

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