Risk factors and outcome of subtypes of ischemic stroke. Data from a multicenter multinational hospital-based registry. The European Community Stroke Project

https://doi.org/10.1016/j.jns.2006.01.016Get rights and content

Abstract

Background

Information on determinants and prognosis of ischemic stroke subtypes is scarce. We aimed at evaluating risk factors, pathogenesis, treatment and outcome of different ischemic stroke subtypes.

Methods

In a European Concerted Action involving seven countries, ischemic stroke subtypes defined according to the Oxfordshire Community Stroke Project (OCSP) were evaluated for demographics, baseline risk factors, resource use, 3-month survival, disability (Barthel Index) and handicap (Rankin Scale).

Results

During the 12-month study period, cerebral infarction was diagnosed in 2740 patients with first-in-a-lifetime stroke (mean age 70.5 ± 12.4 years, 53.4% males). OCSP classification was achieved in 2472 (90.2%). Of these, 26.7% were total anterior circulation infarctions (TACI), 29.9% partial anterior circulation infarctions (PACI), 16.7% posterior circulation infarctions (POCI) and 26.7% lacunar infarctions (LACI). In multivariate analysis, atrial fibrillation was predictive of TACI (odds ratio [OR], 1.61; 95% CI, 1.28–2.03), hypertension (OR, 1.38; 95% CI, 1.16–1.65) and myocardial infarction (OR, 1.42; 95% CI, 1.08–1.86) predictive of PACI, hypertension (OR, 1.25; 95% CI, 1.04–1.50) predictive of LACI. A negative association was observed between TACI and hypertension (OR, 0.51; 95% CI, 0.42–0.61). Discharge home was 50% less probable in TACI and PACI than in LACI patients. As compared to LACI, TACI significantly increased the risk of 3-month death (OR, 5.73; 95% CI, 3.91–8.41), disability (OR, 3.27; 95% CI, 2.30–4.66) and handicap (OR, 2.71; 95% CI, 1.91–3.85).

Conclusions

Ischemic stroke subtypes have different risk factors profile, with consequences on pathogenesis and prognosis. Information on determinants of the clinical syndromes may impact on prevention and acute-phase interventions.

Introduction

Stroke is a highly heterogeneous disorder with distinct subtypes, each presenting specific clinical and epidemiological aspects [1]. In developed countries, cerebral infarction represents the most common type of stroke and may be further differentiated in subtypes. Subtype characterization of ischemic stroke may improve knowledge of risk factors and pathogenesis, with a positive impact on prevention, acute-phase treatment and, possibly, outcome [2].

The Oxfordshire Community Stroke Project (OCSP) classification defined four clinically identifiable subgroups of cerebral infarction: total anterior circulation infarction (TACI), partial anterior circulation infarction (PACI), posterior circulation infarction (POCI) and lacunar infarction (LACI) [3]. This classification showed a moderate to good interobserver reliability [4], [5], could predict size and site of infarction seen on computed tomography or magnetic resonance imaging in about 75% of cases [6], and was proposed for clinical–epidemiological purposes, but little is known about possible determinants and prognosis of the single subtypes.

The objective of the present study was to evaluate differences in risk factors, resource use and 3-month outcome of different ischemic stroke subtypes, defined according to the OCSP classification, in a large European setting of patients hospitalized for acute stroke.

Section snippets

Patients and methods

A European Union Concerted Action was initiated to establish the relationships between resource use, costs and outcome of packages of care for stroke in Europe. The specific objectives have been outlined previously [7]. The study was prospective and involved 12 centers (22 hospitals) in 7 countries: England, France, Germany, Hungary, Italy, Portugal and Spain. The hospitals were chosen because they contained staff interested in stroke research. They provide general acute care to the local

Results

During the 12-month study period, cerebral infarction was diagnosed in 2740 patients with first-in-a-lifetime stroke (mean age 70.5 ± 12.4 years, range 13.7–100.4). Overall, 1463 patients were males (53.4%, mean age 68.2 ± 11.9 years) and 1277 females (46.6%, mean age 73.1 ± 12.4 years). A definition of OCSP subtypes was achieved in 2472 (90.2%) of the 2740 events diagnosed as ischemic strokes. A total of 659 events (26.7%) were TACI, 740 (29.9%) PACI, 413 (16.7%) POCI and 660 (26.7%) LACI.

Table 1

Discussion

This study evaluated differences in risk factors, management and outcome of subtypes of ischemic stroke, defined according to the OCSP classification, in a large sample of European patients. There were differences in baseline living conditions, risk factor profile and stroke outcome. Different subtypes required different use of in-hospital rehabilitation services and diagnostic tools. Also, separate patterns were observed for in-hospital stay, 28-day case-fatality rate and 3-month mortality.

Acknowledgments

This study was supported by European Union BIOMED I Program. The authors thank Ms. Maria Elena Della Santa for her support in preparing the manuscript.

References (31)

  • J. Bamford et al.

    Classification and natural history of clinically identifiable subtypes of cerebral infarction

    Lancet

    (1991)
  • L.J. Beilin et al.

    Lifestyle and hypertension

    Am J Hypertens

    (1999)
  • C.L. Sudlow et al.

    Comparable studies of the incidence of stroke and its pathological types. Results from an international collaboration

    Stroke

    (1997)
  • G.W. Petty et al.

    Ischemic stroke subtypes. A population-based study of incidence and risk factors

    Stroke

    (1999)
  • R.I. Lindley et al.

    Interobserver reliability of a clinical classification of acute cerebral infarction

    Stroke

    (1993)
  • L. Aerdean et al.

    Validation of the Oxfordshire Community Stroke Project syndrome diagnosis derived from a standard symptom list in acute stroke

    J Neurol Sci

    (2004)
  • G.E. Mead et al.

    How well does the Oxfordshire Community Stroke Project classification predict the site and size of the infarct on brain imaging?

    J Neurol Neurosurg Psychiatry

    (2000)
  • R. Beech et al.

    Hospital services for stroke care. A European perspective

    Stroke

    (1996)
  • S. Hatano

    Experience from a multicentre stroke register: a preliminary report

    Bull WHO

    (1976)
  • J. Rankin

    Cerebral vascular accidents in patients over the age of 60: II. Prognosis

    Scott Med J

    (1957)
  • F.I. Mahoney et al.

    Functional evaluation: the Barthel Index

    Md State Med J

    (1965)
  • S. Ricci et al.

    SEPIVAC: a community-based study of stroke incidence in Umbria, Italy

    J Neurol Neurosurg Psychiatry

    (1991)
  • C.S. Anderson et al.

    Validation of a clinical classification for subtypes of acute cerebral infarction

    J Neurol Neurosurg Psychiatry

    (1994)
  • B. Johansson et al.

    Increased stroke incidence in Lund-Orup, Sweden, between 1983–1985 and 1993–1995

    Stroke

    (2000)
  • H.M. Dewey et al.

    Incidence and outcome of subtypes of ischaemic stroke: initial results from the North East Melbourne Stroke Incidence Study (NEMESIS)

    Cerebrovasc Dis

    (2003)
  • Cited by (117)

    • Differences in Ischemic Anterior and Posterior Circulation Strokes: A Clinico-Radiological and Outcome Analysis

      2019, Journal of Stroke and Cerebrovascular Diseases
      Citation Excerpt :

      About 20% of the cerebral blood flow is directed to the posterior circulation (PC), explaining the approximate 20% rate of PC strokes observed in several case series.1-5 Current data comparing PC and AC strokes with regards to clinical, etiological, radiological, and outcome factors are scarce and multivariate analyses were not applied6,7-9 or are limited to large PC-only case series.2,10,11 The arterial anatomy and the site of obstruction in PC and AC strokes show notable differences.10,12

    View all citing articles on Scopus
    View full text