Meeting NewsPerspective

Survival rates after ischemic stroke improved from 1991 to 2015

Reem Waziry

Survival after a first ischemic stroke has improved from 1991 to 2015, according to data presented in a late-breaking science session at the International Stroke Conference.

The study also found that survival rates for hemorrhagic stroke did not improve during this time.

“Stroke unit care has a positive impact on case fatality and 1-year mortality,” Reem Waziry, MD, MPH, PhD, research fellow in the department of epidemiology at Harvard T.H. Chan School of Public Health, said during the presentation. “There are several factors that could have contributed to the observed favorable trends in survival following ischemic stroke in our study and the observed decline in mortality after any stroke in other settings. First, the introduction of stroke units providing timely acute medical management and dedicated rehabilitation. Second, the availability of high-quality evidence and guidelines on best practices in the acute phase, particularly on postacute stroke management in recent years. Third, the improved control of risk factors and timely counseling after stroke.”

Researchers analyzed data from the Rotterdam Study between 1991 and 2015 of 162 patients (median age at stroke, 80 years; 59% women) with first-ever hemorrhagic stroke and 988 patients (median age at stroke, 78 years; 56% women) with ischemic stroke.

Follow-up was conducted until the date of death, date of last contact during follow-up or January 2016, whichever came first. The findings were simultaneously published in Stroke.

There were 144 deaths in patients with hemorrhagic stroke during 386 person-years. In those with ischemic stroke, 711 deaths occurred during 4,897 person-years.

Mortality rates in the hemorrhagic stroke group were similar from 1991 (25 per 100 person-years) to 2015 (30 per 100 person-years). In contrast, these rates in the ischemic stroke group declined from 29 per 100 person-years in 1991 to 11 per 100 person-years in 2015.

Compared with 1991 to 1998, mortality rates for hemorrhagic stroke from 2008 to 2015 remained unchanged (HR = 0.98; 95% CI, 0.61-1.57). Favorable trends were observed when these two periods were compared for ischemic stroke (HR = 0.71; 95% CI, 0.56-0.9).

“Alongside the long follow-up duration and state-of-the-art clinical examinations, a key strength of our study includes the unselected sample of participants who were followed up prospectively, thus avoiding common biases related to institution or patient selection,” Waziry and colleagues wrote in Stroke. “These factors all together provide a close reflection of the current disease burden in the population.” – by Darlene Dobkowski

References:

Waziry R, et al. LB14. Presented at: International Stroke Conference; Feb. 19-21, 2020; Los Angeles.

Waziry R, et al. Stroke. 2020;doi:10.1161/STROKEAHA.119.027198.

Disclosures: The authors report no relevant financial disclosures.

Reem Waziry

Survival after a first ischemic stroke has improved from 1991 to 2015, according to data presented in a late-breaking science session at the International Stroke Conference.

The study also found that survival rates for hemorrhagic stroke did not improve during this time.

“Stroke unit care has a positive impact on case fatality and 1-year mortality,” Reem Waziry, MD, MPH, PhD, research fellow in the department of epidemiology at Harvard T.H. Chan School of Public Health, said during the presentation. “There are several factors that could have contributed to the observed favorable trends in survival following ischemic stroke in our study and the observed decline in mortality after any stroke in other settings. First, the introduction of stroke units providing timely acute medical management and dedicated rehabilitation. Second, the availability of high-quality evidence and guidelines on best practices in the acute phase, particularly on postacute stroke management in recent years. Third, the improved control of risk factors and timely counseling after stroke.”

Researchers analyzed data from the Rotterdam Study between 1991 and 2015 of 162 patients (median age at stroke, 80 years; 59% women) with first-ever hemorrhagic stroke and 988 patients (median age at stroke, 78 years; 56% women) with ischemic stroke.

Follow-up was conducted until the date of death, date of last contact during follow-up or January 2016, whichever came first. The findings were simultaneously published in Stroke.

There were 144 deaths in patients with hemorrhagic stroke during 386 person-years. In those with ischemic stroke, 711 deaths occurred during 4,897 person-years.

Mortality rates in the hemorrhagic stroke group were similar from 1991 (25 per 100 person-years) to 2015 (30 per 100 person-years). In contrast, these rates in the ischemic stroke group declined from 29 per 100 person-years in 1991 to 11 per 100 person-years in 2015.

Compared with 1991 to 1998, mortality rates for hemorrhagic stroke from 2008 to 2015 remained unchanged (HR = 0.98; 95% CI, 0.61-1.57). Favorable trends were observed when these two periods were compared for ischemic stroke (HR = 0.71; 95% CI, 0.56-0.9).

“Alongside the long follow-up duration and state-of-the-art clinical examinations, a key strength of our study includes the unselected sample of participants who were followed up prospectively, thus avoiding common biases related to institution or patient selection,” Waziry and colleagues wrote in Stroke. “These factors all together provide a close reflection of the current disease burden in the population.” – by Darlene Dobkowski

References:

Waziry R, et al. LB14. Presented at: International Stroke Conference; Feb. 19-21, 2020; Los Angeles.

Waziry R, et al. Stroke. 2020;doi:10.1161/STROKEAHA.119.027198.

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Philip B. Gorelick

    Philip B. Gorelick

    Hemorrhagic stroke may manifest as any one of several subtypes (intraparenchymal hemorrhage, subarachnoid hemorrhage, intraventricular hemorrhage) and is viewed as the most lethal type of stroke. There is limited long-term data on mortality over time for hemorrhagic stroke. In this study, ischemic and hemorrhagic stroke survival was compared over time in the Netherlands. As one might expect, ischemic stroke survival improved over the 25-year comparative time period, whereas hemorrhagic stroke survival did not in a carefully done and systematic data collection project carried out by the Rotterdam investigators.

    Similar to cardiac disorders, stroke has benefited from organization of medical care efforts. For example, there has been a proliferation of stroke units, especially, in developed areas of the world, administration of acute thrombolytic therapy for ischemic types of stroke, and development and utilization of thrombectomy devices for large artery occlusive stroke, all means to improve ischemic stroke functional outcomes and, possibly, enhance survival. Therefore, and predictably, one might expect ischemic stroke survival to improve over a 25-year comparative time period based on these substantial advances in the field.

    On the other hand, although guidance recommendations support the need to place hemorrhagic stroke patients in neuroscience ICUs to monitor and treat them, the explosion of advances to acutely treat hemorrhagic strokes have lagged behind those of ischemic stroke, though substantial efforts via a number of innovative clinical trials to improve outcomes in hemorrhagic stroke have been tried but without significant and life-changing success.

    Clinical researchers will need to be innovative and create new ways to approach hemorrhagic stroke and test new paradigms. For example, new approaches to stunting hematoma growth and managing BP variability might prove to be opportunities to make a dent in the persistent survival disadvantage associated with brain hemorrhage.

    • Philip B. Gorelick, MD, MPH
    • Chief Medical Officer
      Thorek Memorial Hospital, Chicago
      Adjunct Professor of Neurology (Stroke and Neurocritical Care)
      Northwestern University Feinberg School of Medicine

    Disclosures: Gorelick reports no relevant financial disclosures.

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