Publications by authors named "Karoliina Aarnio"

18 Publications

  • Page 1 of 1

Hemicraniectomy for Dominant vs Nondominant Middle Cerebral Artery Infarction: A Systematic Review and Meta-Analysis.

J Stroke Cerebrovasc Dis 2021 Nov 15;30(11):106102. Epub 2021 Sep 15.

Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00290, Finland.

Objectives: Decompressive hemicraniectomy decreases mortality and severe disability from space-occupying middle cerebral artery infarction in selected patients. However, attitudes towards hemicraniectomy for dominant-hemispheric stroke have been hesitant. This systematic review and meta-analysis examines the association of stroke laterality with outcome after hemicraniectomy.

Materials And Methods: We performed a systematic literature search up to 6th February 2020 to retrieve original articles about hemicraniectomy for space-occupying middle cerebral artery infarction that reported outcome in relation to laterality. The primary outcome was severe disability (modified Rankin Scale 4‒6 or 5‒6 or Glasgow Outcome Scale 1‒3) or death. A two-stage combined individual patient and aggregate data meta-analysis evaluated the association between dominant-lateralized stroke and (a) short-term (≤ 3 months) and (b) long-term (> 3 months) outcome. We performed sensitivity analyses excluding studies with sheer mortality outcome, second-look strokectomy, low quality, or small sample size, and comparing populations from North America/Europe vs Asia/South America.

Results: The analysis included 51 studies (46 observational studies, one nonrandomized trial, and four randomized controlled trials) comprising 2361 patients. We found no association between dominant laterality and unfavorable short-term (OR 1.00, 95% CI 0.69‒1.45) or long-term (OR 1.01, 95% CI 0.76‒1.33) outcome. The results were unchanged in all sensitivity analyses. The grade of evidence was very low for short-term and low for long-term outcome.

Conclusions: This meta-analysis suggests that patients with dominant-hemispheric stroke have equal outcome after hemicraniectomy compared to patients with nondominant stroke. Despite the shortcomings of the available evidence, our results do not support withholding hemicraniectomy based on stroke laterality.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106102DOI Listing
November 2021

Initiation of antidepressants in young adults after ischemic stroke: a registry-based follow-up study.

J Neurol 2021 Jun 24. Epub 2021 Jun 24.

Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00029, Helsinki, Finland.

Objective: Data on post-stroke use of antidepressants in young individuals are scarce. We examined pattern and factors associated with initiating post-stroke antidepressants (PSAD) after ischemic stroke (IS) in young adults.

Methods: Helsinki Young Stroke Registry includes patients aged 15-49 years with first-ever IS, 1994-2007. Data on prescriptions, hospitalizations and death came from nationwide registers. We defined time of initiating PSAD as time of the first filled prescription for antidepressants within 1 year from IS. We assessed factors associated with initiating PSAD with multivariable Cox regression models, allowing for time-varying effects when appropriate.

Results: We followed 888 patients, of which 206 (23.2%) initiated PSAD. Higher hazard of starting PSAD within the first 100 days appeared among patients with mild versus no limb paresis 2.53 (95% confidence interval 1.48-4.31) and during later follow-up among those with silent infarcts (2.04; 1.27-3.28), prior use of antidepressants (2.09; 1.26-3.46) and moderate versus mild stroke (2.06; 1.18-3.58). The relative difference in the hazard rate for moderate-severe limb paresis persisted both within the first 100 days (3.84, 2.12-6.97) and during later follow-up (4.54; 2.51-8.23). The hazard rate was higher throughout the follow-up among smokers (1.48; 1.11-1.97) as well as lower (1.78; 1.25-2.54) and upper white-collar workers (2.00; 1.24-3.23) compared to blue-collar workers.

Conclusion: One-fourth of young adults started PSADs within 1 year from IS. We identified several specific clinical characteristics associated with PSAD initiation, highlighting their utility in assessing the risk of post-stroke depression during follow-up.
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http://dx.doi.org/10.1007/s00415-021-10678-4DOI Listing
June 2021

Stroke in Pregnancy and Puerperium: Validated Incidence Trends With Risk Factor Analysis in Finland 1987-2016.

Neurology 2021 05 7;96(21):e2564-e2575. Epub 2021 Apr 7.

From Neurology (L.K., K.R., K.A., A.K., A.S., P.I.), Obstetrics and Gynecology (M.T.), and Medical and Clinical Genetics (H.L.), University of Helsinki and Helsinki University Hospital; Obstetrics and Gynecology (L.K.), University of Helsinki and Hyvinkää Hospital, Helsinki University Hospital, Hyvinkää/Helsinki; Institute for Molecular Medicine Finland (H.L.), Helsinki Institute of Life Science, University of Helsinki; Department of Obstetrics and Gynecology (H.L.), Tampere University Hospital; Faculty of Medicine and Health Technology (H.L.), Tampere University; Department of Information Services (M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; and Department of Neurobiology (M.G.), Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.

Objective: To investigate whether previously reported increasing incidence of pregnancy-associated stroke (PAS) is observed in chart-validated register data in Finland. In an exploratory analysis, we studied risk factors for PAS.

Methods: We performed a retrospective population-based cohort study and nested case-control study in Finland from 1987 to 2016. The Medical Birth Register (MBR) was linked to the Hospital Discharge Register to identify women with incident stroke (ischemic stroke, cerebral venous thrombosis, intracerebral or subarachnoid hemorrhage) during pregnancy or puerperium. Cases were verified from patient records. Incidence of PAS over the study period in 5-year age groups and pregnancy/postpartum period was calculated per number of deliveries. Three matched controls were selected for each case from MBR to compare risk factors.

Results: After chart review, 29.6% (257 of 868) of cases were PAS. The incidence of PAS was 14.5 (95% confidence interval [CI] 12.8-16.3) per 100,000 deliveries. Incidence increased from 11.1 to 25.2 per 100,000 deliveries from 1987 to 1991 to 2012 to 2016 ( < 0.0001). Incidence increased by age from 9.8 to 29.9 per 100,000 deliveries from 20 to 24 years to >40 years of age ( < 0.0001). During the early postpartum period, incidence was 5-fold greater compared to the first trimester. Maternal mortality was 6.6%. In the multivariable-adjusted model, smoking beyond 12 gestational weeks (odds ratio [OR] 1.8, 95% CI 1.2-2.7), migraine (OR 16.3, 95% CI 5.3-49.8), and hypertensive disorders of pregnancy (OR 4.0, 95% CI 2.5-6.3) were the most important risk factors for PAS.

Conclusion: PAS incidence is increasing, stressing the importance of careful pregnancy surveillance and risk factor management, particularly in older expectant mothers and extending to puerperium.

Classification Of Evidence: This study provides Class III evidence that smoking beyond 12 gestational weeks, migraine, and hypertensive disorders of pregnancy are associated with an increased risk of PAS.
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http://dx.doi.org/10.1212/WNL.0000000000011990DOI Listing
May 2021

Global Outcome Assessment Life-long after stroke in young adults initiative-the GOAL initiative: study protocol and rationale of a multicentre retrospective individual patient data meta-analysis.

BMJ Open 2019 11 14;9(11):e031144. Epub 2019 Nov 14.

Neurology Department, University of Maryland School of Medicine, Baltimore, Maryland, USA.

Introduction: Worldwide, 2 million patients aged 18-50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis and optimal secondary prevention in young stroke patients are limited. This limits evidence-based treatment and hampers the provision of appropriate information regarding the causes of stroke, risk factors and prognosis of young stroke patients.

Methods And Analysis: The Global Outcome Assessment Life-long after stroke in young adults (GOAL) initiative aims to perform a global individual patient data meta-analysis with existing data from young stroke cohorts worldwide. All patients aged 18-50 years with ischaemic stroke or intracerebral haemorrhage will be included. Outcomes will be the distribution of stroke aetiology and (vascular) risk factors, functional outcome after stroke, risk of recurrent vascular events and death and finally the use of secondary prevention. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and climate of residence.

Ethics And Dissemination: Ethical approval for the GOAL study has already been obtained from the Medical Review Ethics Committee region Arnhem-Nijmegen. Additionally and when necessary, approval will also be obtained from national or local institutional review boards in the participating centres. When needed, a standardised data transfer agreement will be provided for participating centres. We plan dissemination of our results in peer-reviewed international scientific journals and through conference presentations. We expect that the results of this unique study will lead to better understanding of worldwide differences in risk factors, causes and outcome of young stroke patients.
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http://dx.doi.org/10.1136/bmjopen-2019-031144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887075PMC
November 2019

Use of Statins After Ischemic Stroke in Young Adults and Its Association With Long-Term Outcome.

Stroke 2019 12 8;50(12):3385-3392. Epub 2019 Nov 8.

Clinical Neurosciences, Neurology (K.A., N.M.-M., M.K., T.T., J.P.), University of Helsinki, Finland.

Background and Purpose- Knowledge of the use of secondary preventive medication in young adults is limited. We studied the use of statins and its association with subsequent vascular events in young adults with ischemic stroke-a patient group with a known low burden of atherosclerosis. Methods- The study population included 935 first-ever 30-day ischemic stroke survivors aged 15 to 49 years from the Helsinki Young Stroke Registry, 1994 to 2007. Follow-up data until 2012 were obtained from the Social Insurance Institution of Finland (Drug Prescription Register), the Finnish Care Register, and Statistics Finland. The association of the use of statins (defined as at least 2 purchases) with all-cause mortality, recurrent stroke, and other recurrent vascular events was assessed through adjusted Cox regression analyses. We further compared propensity score-matched statin users with nonusers. Results- Of our 935 patients, 46.8% used statins at some point during follow-up. Higher age, dyslipidemia, heavy alcohol use, and hypertension were significantly associated with purchasing statins. Statin users exhibited lower risk of all-cause mortality (hazard ratio, 0.38 [95% CI, 0.25-0.58]) and recurrent stroke (hazard ratio, 0.29 [95% CI, 0.19-0.44]) than nonusers, after adjustment for dyslipidemia, stroke subtype, and other confounders. These results remained unchanged after propensity score-matched comparison. Conclusions- Less than half of young ischemic stroke patients used statins; use was affected by age and risk factor profile. Statin use was independently associated with lower risk of all-cause mortality and recurrent stroke.
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http://dx.doi.org/10.1161/STROKEAHA.119.026992DOI Listing
December 2019

Risk Factors for Early-Onset Ischemic Stroke: A Case-Control Study.

J Am Heart Assoc 2018 11;7(21):e009774

1 Clinical Neurosciences University of Helsinki and Department of Neurology, Helsinki University Hospital Helsinki Finland.

Background Recent studies have shown an increasing prevalence of vascular risk factors in young adults with ischemic stroke ( IS ). However, the strength of the association between all vascular risk factors and early-onset IS has not been fully established. Methods and Results We compared 961 patients with a first-ever IS at 25 to 49 years to 1403 frequency-matched stroke-free controls from a population-based cohort study ( FINRISK ). Assessed risk factors included an active malignancy, atrial fibrillation, cardiovascular disease, current smoking status, a family history of stroke, high low-density lipoprotein cholesterol, high triglycerides, low high-density lipoprotein cholesterol, hypertension, and type 1 and type 2 diabetes mellitus. We performed subgroup analyses based on age, sex, and IS etiology. In a fully adjusted multivariable logistic regression analysis, significant risk factors for IS consisted of atrial fibrillation (odds ratio [OR], 10.43; 95% confidence interval [ CI ], 2.33-46.77], cardiovascular disease (OR, 8.01; 95% CI , 3.09-20.78), type 1 diabetes mellitus (OR, 6.72; 95% CI , 3.15-14.33), type 2 diabetes mellitus (OR, 2.31; 95% CI , 1.35-3.95), low high-density lipoprotein cholesterol (OR, 1.81; 95% CI , 1.37-2.40), current smoking status (OR, 1.81; 95% CI , 1.50-2.17), hypertension (OR, 1.43; 95% CI , 1.17-1.75), and a family history of stroke (OR, 1.37; 95% CI , 1.04-1.82). High low-density lipoprotein cholesterol exhibited an inverse association with IS . In the subgroup analyses, the most consistent associations appeared for current smoking status and type 1 diabetes mellitus. Conclusions Our study establishes the associations between 11 vascular risk factors and early-onset IS , among which atrial fibrillation, cardiovascular disease, and both type 1 and 2 diabetes mellitus in particular showed strong associations.
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http://dx.doi.org/10.1161/JAHA.118.009774DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404210PMC
November 2018

Use of antihypertensive medication after ischemic stroke in young adults and its association with long-term outcome.

Ann Med 2019 02 14;51(1):68-77. Epub 2019 Feb 14.

b Department of Neurology, Clinical Neurosciences , University of Helsinki , Helsinki , Finland.

Background: Knowledge on the use of secondary preventive medication in young adults is limited.

Methods: We included 936 first-ever ischemic stroke 30-day survivors aged 15-49, enrolled in the Helsinki Young Stroke Registry, 1994-2007. Follow-up data until 2012 came from Finnish Care Register, Statistics Finland, and Social Insurance Institution of Finland. Usage thresholds were defined as non-users, low (prescription coverage <30%), intermediate (30-80%) and high users (>80%). Adjusted Cox regression allowed assessing the association of usage with all-cause mortality and recurrent vascular events.

Results: Of our patients, 40.5% were non-users, 7.8% had low usage, 11.8% intermediate usage and 40.0% high usage. Median follow-up was 8.3 years. Compared to non-users, risk of mortality and recurrent stroke or TIA was lower for patients with low-intermediate (HR 0.40, 95% CI 0.22-0.65; HR 0.31, 95% CI 0.18-0.53) and high usage (HR 0.25, 95% CI 0.15-0.42; HR 0.30, 95% CI 0.19-0.46), after adjustment for confounders.

Conclusions: Use of antihypertensives was suboptimal in one-third of patients in whom antihypertensives were initially prescribed. Users were at lower risk of mortality and recurrent stroke or TIA compared to non-users. Key Messages The use of antihypertensive medication is suboptimal in one-third of patients in whom antihypertensive medication was initially prescribed after ischemic stroke at young age. The risk of mortality and recurrent stroke or TIA is lower for users of antihypertensive medication after ischemic stroke at young age compared to non-users, after adjustment for relevant confounders including pre-existing hypertension and prior use of antihypertensive medication. Specific guidelines on antihypertensive medication use after ischemic stroke at young age are lacking. However, our results may motivate doctors and patients in gaining better usage of antihypertensive medication, since better usage was associated with more favorable outcome in this study.
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http://dx.doi.org/10.1080/07853890.2018.1564358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857461PMC
February 2019

Return to work after ischemic stroke in young adults: A registry-based follow-up study.

Neurology 2018 11 12;91(20):e1909-e1917. Epub 2018 Oct 12.

From Clinical Neurosciences (K.A., J.B., L.T., E.H., M.K., T.T., J.P.), Neurology, University of Helsinki and Department of Neurology, Helsinki University Hospital; Department of Neurology (J.R.-P.), Helsinki University Hospital, Finland; Department of Neurology (J.R.-P.), La Paz University Hospital, Madrid, Spain; Center for Stroke Research Berlin (B.S., J.H.), Institute of Biometry and Clinical Epidemiology (J.H.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin Germany; Berlin Institute of Health (BIH) (J.H.), Berlin, Germany. Clinical Research Unit (CRU) (J.H.), Berlin Institute of Health (BIH), Berlin, Germany; Department of Clinical Neuroscience (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden.

Objective: We aimed to investigate the proportion of young patients not returning to work (NRTW) at 1 year after ischemic stroke (IS) and during follow-up, and clinical factors associated with NRTW.

Methods: Patients from the Helsinki Young Stroke Registry with an IS occurring in the years 1994-2007, who were at paid employment within 1 year before IS, and with NIH Stroke Scale score ≤15 points at hospital discharge, were included. Data on periods of payment came from the Finnish Centre for Pensions, and death data from Statistics Finland. Multivariate logistic regression analyses assessed factors associated with NRTW 1 year after IS, and lasagna plots visualized the proportion of patients returning to work over time.

Results: We included a total of 769 patients, of whom 289 (37.6%) were not working at 1 year, 323 (42.0%) at 2 years, and 361 (46.9%) at 5 years from IS. When adjusted for age, sex, socioeconomic status, and NIH Stroke Scale score at admission, factors associated with NRTW at 1 year after IS were large anterior strokes, strokes caused by large artery atherosclerosis, high-risk sources of cardioembolism, and rare causes other than dissection compared with undetermined cause, moderate to severe aphasia vs no aphasia, mild and moderate to severe limb paresis vs no paresis, and moderate to severe visual field deficit vs no deficit.

Conclusions: NRTW is a frequent adverse outcome after IS in young adults with mild to moderate IS. Clinical variables available during acute hospitalization may allow prediction of NRTW.
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http://dx.doi.org/10.1212/WNL.0000000000006510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260196PMC
November 2018

Outcome of pregnancies and deliveries before and after ischaemic stroke.

Eur Stroke J 2017 Dec 28;2(4):346-355. Epub 2017 Jul 28.

Clinical Neurosciences, Neurology, University of Helsinki, Finland.

Introduction: Limited data exist on the outcome of pregnancies and deliveries in women with ischaemic stroke. We investigated the incidence of pregnancy- and delivery-related complications in women with ischaemic stroke before and after pregnancy compared with stroke-free matched controls.

Patients And Methods: Of our 1008 consecutive patients aged 15-49 years with first-ever ischaemic stroke, 1994-2007, we included women with pregnancy data before or after stroke recorded in the Medical Birth Register (MBR) ( = 152), and for them searched stroke-free controls matched by age, parity, year of birth, residential area and multiplicity ( = 608). Data on hospital admissions and deaths (1987-2014) came from national health registries. Poisson regression mixed models allowed comparison of the incidence of complications.

Results: A total of 124 stroke mothers had 207 singleton pregnancies before and 45 mothers 68 pregnancies after stroke. The incidence rate ratio (IRR) for the composite outcome of pregnancy and delivery complications adjusted for socioeconomic status and maternal smoking was 1.43 (95% confidence interval [CI] 1.00-2.03,  = 0.05) for pre-stroke mothers, and 1.09 (95% CI 0.66-1.78) for post-stroke mothers, compared with matched controls. Similarly, the adjusted IRR for post-stroke hospital admission during pregnancy was 1.85 (95% CI 1.03-3.31). The IRR for perinatal death of the child was 3.43 (95% CI 0.57-20.53) before and 8.88 (95% CI 0.81-97.95) after stroke.

Discussion And Conclusions: Compared with stroke-free mothers, we found a higher incidence of pregnancy- and delivery-related complications in mothers with ischaemic stroke. Larger studies are needed to verify our results.
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http://dx.doi.org/10.1177/2396987317723795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453190PMC
December 2017

Twelve-lead electrocardiogram and mortality in young adults after ischaemic stroke.

Eur Stroke J 2017 Mar 1;2(1):77-86. Epub 2017 Mar 1.

Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.

Introduction: Ischaemic stroke at young age carries an increased risk for mortality in comparison to the general population, but factors associated with mortality have been poorly studied. We studied the role of electrocardiogram in mortality risk stratification in young stroke patients.

Patients And Methods: The Helsinki Young Stroke Registry encompasses 1008 patients aged <50 years with ischaemic stroke. We included 690 patients for this electrocardiogram substudy. Our endpoints were all-cause and cardiovascular mortality. Cox regression models - adjusted for clinical and demographic characteristics - were used to identify the electrocardiogram parameters associated with these endpoints.

Results: At a mean follow-up of 8.8 years, cumulative all-cause and cardiovascular mortality were 16.1 and 9.1%, respectively. Factors associated with both endpoints included diabetes (type 1 for all-cause, type 2 for cardiovascular mortality), heavy drinking, malignancy, as well as stroke severity and aetiology. Of the electrocardiogram parameters, higher heart rate (hazard ratio 1.35 per 10/min, 95% confidence interval 1.21-1.49), a shorter P-wave (hazard ratio 0.78 per 10 ms decrement, 0.64-0.92) and longer QTc interval (1.09 per 10 ms, 1.03-1.16) were associated with increased all-cause mortality. Only a higher heart rate (1.42 per 10/min, 1.24-1.60) was associated with death from cardiovascular causes.

Conclusions: A higher heart rate during the subacute phase after stroke is associated with an elevated risk of all-cause and cardiovascular mortality in young adults. A longer QTc interval is associated only with higher all-cause mortality. P-wave characteristics and their possible association with mortality need further studies.
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http://dx.doi.org/10.1177/2396987316684706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453181PMC
March 2017

Sex Differences and Functional Outcome After Intravenous Thrombolysis.

Stroke 2017 03 31;48(3):699-703. Epub 2017 Jan 31.

From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S.); University Lille, Inserm, CHU Lille, U1171-Degenerative and Vascular Cognitive Disorders, France (D.L., A.H.); Department of Neurology, Clinical Centre of Serbia, Beograd (V.P.); Department of Neurology, Kantonsspital St. Gallen, Switzerland (G.K.); Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Italy (A.P.); Department of Neurology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Switzerland (P.M., O.B.); and Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Italy (A.Z.).

Background And Purpose: Women have a worse outcome after stroke compared with men, although in intravenous thrombolysis (IVT)-treated patients, women seem to benefit more. Besides sex differences, age has also a possible effect on functional outcome. The interaction of sex on the functional outcome in IVT-treated patients in relation to age remains complex. The purpose of this study was to compare outcome after IVT between women and men with regard to age in a large multicenter European cohort reflecting daily clinical practice of acute stroke care.

Methods: Data were obtained from IVT registries of 12 European tertiary hospitals. The primary outcome was poor functional outcome, defined as a modified Rankin scale score of 3 to 6 at 3 months. We stratified outcome by age in decades. Safety measures were symptomatic intracranial hemorrhage and mortality at 3 months.

Results: In this cohort, 9495 patients were treated with IVT, and 4170 (43.9%) were women with a mean age of 71.9 years. After adjustments for baseline differences, female sex remained associated with poor functional outcome (odds ratio, 1.15; 95% confidence interval, 1.02-1.31). There was no association between sex and functional outcome when data were stratified by age. Symptomatic intracranial hemorrhage rate was similar in both sexes (adjusted odds ratio, 0.93; 95% confidence interval, 0.73-1.19), whereas mortality was lower among women (adjusted odds ratio, 0.83; 95% confidence interval, 0.70-0.99).

Conclusions: In this large cohort of IVT-treated patients, women more often had poor functional outcome compared with men. This difference was not dependent on age.
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http://dx.doi.org/10.1161/STROKEAHA.116.014739DOI Listing
March 2017

Are 12-lead ECG findings associated with the risk of cardiovascular events after ischemic stroke in young adults?

Ann Med 2016 11 29;48(7):532-540. Epub 2016 Sep 29.

a Department of Cardiology , Heart and Lung Center, Helsinki University Hospital , Helsinki , Finland.

Introduction: Ischemic stroke (IS) in a young patient is a disaster and recurrent cardiovascular events could add further impairment. Identifying patients with high risk of such events is therefore important. The prognostic relevance of ECG for this population is unknown.

Materials And Methods: A total of 690 IS patients aged 15-49 years were included. A 12-lead ECG was obtained 1-14 d after the onset of stroke. We adjusted for demographic factors, comorbidities, and stroke characteristics, Cox regression models were used to identify independent ECG parameters associated with long-term risks of (1) any cardiovascular event, (2) cardiac events, and (3) recurrent stroke.

Results: Median follow-up time was 8.8 years. About 26.4% of patients experienced a cardiovascular event, 14.5% had cardiac events, and 14.6% recurrent strokes. ECG parameters associated with recurrent cardiovascular events were bundle branch blocks, P-terminal force, left ventricular hypertrophy, and a broader QRS complex. Furthermore, more leftward P-wave axis, prolonged QTc, and P-wave duration >120 ms were associated with increased risks of cardiac events. No ECG parameters were independently associated with recurrent stroke.

Conclusion: A 12-lead ECG can be used for risk prediction of cardiovascular events but not for recurrent stroke in young IS patients. KEY MESSAGES ECG is an easy, inexpensive, and useful tool for identifying young ischemic stroke patients with a high risk for recurrent cardiovascular events and it has a statistically significant association with these events even after adjusting for confounding factors. Bundle branch blocks, P-terminal force, broader QRS complex, LVH according to Cornell voltage duration criteria, more leftward P-wave axis, prolonged QTc, and P-wave duration >120 ms are predictors for future cardiovascular or cardiac events in these patients. No ECG parameters were independently associated with recurrent stroke.
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http://dx.doi.org/10.1080/07853890.2016.1202443DOI Listing
November 2016

Acute-Phase Blood Pressure Levels Correlate With a High Risk of Recurrent Strokes in Young-Onset Ischemic Stroke.

Stroke 2016 06 5;47(6):1593-8. Epub 2016 May 5.

From the Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland (S.M., J. Putaala, L.T., K.A., J. Pirinen, T.T.); Abdominal Center Nephrology, Helsinki University Hospital, Folkhälsan Institute of Genetics at Folkhälsan Research Center, and Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland (D.G.); Department of Clinical Physiology and Nuclear Medicine, HUS Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland (J. Pirinen, I.S.); Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland (J. Pirinen, J.S., M.L.); and Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).

Background And Purpose: High blood pressure (BP) in acute stroke has been associated with a poor outcome; however, this has not been evaluated in young adults.

Methods: The relationship between BP and long-term outcome was assessed in 1004 consecutive young, first-ever ischemic stroke patients aged 15 to 49 years enrolled in the Helsinki Young Stroke Registry. BP parameters included systolic (SBP) and diastolic BP, pulse pressure, and mean arterial pressure at admission and 24 hours. The primary outcome measure was recurrent stroke in the long-term follow-up. Adjusted for demographics and preexisting comorbidities, Cox regression models were used to assess independent BP parameters associated with outcome.

Results: Of our patients (63% male), 393 patients (39%) had prestroke hypertension and 358 (36%) used antihypertensive treatment. The median follow-up period was 8.9 years (interquartile range 5.7-13.2). Patients with a recurrent stroke (n=142, 14%) had significantly higher admission SBP, diastolic BP, pulse pressure, and mean arterial pressure (P<0.001) and 24-h SBP, diastolic BP, and mean arterial pressure compared with patients without the recurrent stroke. Patients with SBP ≥160 mm Hg compared with those with SBP <160 mm Hg had significantly more recurrent strokes (hazard ratio 3.3 [95% confidence interval, 2.05-4.55]; P<0.001) occurring earlier (13.9 years [13.0-14.6] versus 16.2 [15.8-16.6]; P<0.001) within the follow-up period. In multivariable analyses, higher admission SBP, diastolic BP, pulse pressure, and mean arterial pressure were independently associated with the risk of recurrent stroke, while the 24-hour BP levels were not.

Conclusions: In young ischemic stroke patients, high acute phase BP levels are independently associated with a high risk of recurrent strokes.
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http://dx.doi.org/10.1161/STROKEAHA.116.012944DOI Listing
June 2016

Cardiovascular events after ischemic stroke in young adults: A prospective follow-up study.

Neurology 2016 05 20;86(20):1872-9. Epub 2016 Apr 20.

From Clinical Neurosciences (K.A., E.H., M.K., T.T., J. Putaala), Neurology, University of Helsinki; Department of Neurology (K.A., E.H., M.K., T.T., J. Putaala), Helsinki University Central Hospital, Finland; Center for Stroke Research Berlin (CSB) (B.S., A.-H.N.), Charité Universitätsmedizin Berlin, Germany; Department of Cardiology (J. Pirinen, J.S., M.L.), Heart and Lung Center, Helsinki University Hospital, Finland; Institute of Neurosciences and Physiology (T.T.), Sahlgrenska Academy, University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden.

Objectives: To study the long-term risk of recurrent cardiac, arterial, and venous events in young stroke patients, and whether these risks differed between etiologic subgroups.

Methods: The study population comprised 970 patients aged 15-49 years from the Helsinki Young Stroke Registry (HYSR) who had an ischemic stroke in 1994-2007. We obtained follow-up data until 2012 from the Finnish Care Register and Statistics Finland. Cumulative 15-year risks were analyzed with life tables, whereas relative risks and corresponding confidence intervals (CI) were based on hazard ratios (HR) from Cox regression analyses.

Results: There were 283 (29.2%) patients with a cardiovascular event during the median follow-up of 10.1 years (range 0.1-18.0). Cumulative 15-year risk for venous events was 3.9%. Cumulative 15-year incidence rate for composite vascular events was 34.0 (95% CI 30.1-38.2) per 1,000 person-years. When adjusted for age and sex, patients with an index stroke caused by high-risk sources of cardioembolism had the highest HR for any subsequent cardiovascular events (3.7; 95% CI 2.6-5.4), whereas the large-artery atherosclerosis group had the highest HR (2.7; 95% CI 1.6-4.6) for recurrent stroke compared with patients with stroke of undetermined etiology.

Conclusions: The risk for future cardiovascular events after ischemic stroke in young adults remains high for years after the index stroke, in particular when the index stroke is caused by high-risk sources of cardioembolism or large-artery atherosclerosis.
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http://dx.doi.org/10.1212/WNL.0000000000002689DOI Listing
May 2016

Cancer in young adults with ischemic stroke.

Stroke 2015 Jun 28;46(6):1601-6. Epub 2015 Apr 28.

From the Clinical Neurosciences, Department of Neurology, University of Helsinki and Helsinki University Central Hospital, Finland (K.A., E.H., S.M., M.K., T.T., J.P.); Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland (H.J.); and Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).

Background And Purpose: Cancer is a risk factor for ischemic stroke. Little is known about cancer among young adults with ischemic stroke. We studied the frequency of cancer and its association with long-term risk of death among young patients with first-ever ischemic stroke.

Methods: 1002 patients aged 15 to 49 years, registered in the Helsinki Young Stroke Registry, and with a median follow-up of 10.0 years (interquartile range 6.5-13.8) after stroke were included. Historical and follow-up data were derived from the Finnish Care Register and Statistics Finland. Survival between groups was compared with the Kaplan-Meier life-table method, and Cox proportional hazard models were used to identify factors associated with mortality.

Results: One or more cancer diagnosis was made in 77 (7.7%) patients, of whom 39 (3.9%) had cancer diagnosed prestroke. During the poststroke follow-up, 41 (53.2%) of the cancer patients died. Median time from prestroke cancer to stroke was 4.9 (1.0-9.5) years and from stroke to poststroke cancer was 6.7 (2.7-10.9) years. Poststroke cancer was associated with age>40 years, heavy drinking, and cigarette smoking. The cumulative mortality was significantly higher among the cancer patients (68.6%, 95% confidence interval 52.0%-85.3%) compared with patients without cancer (19.7%, 95% confidence interval 16.3%-23.2%). Active cancer at index stroke, melanoma, and lung/respiratory tract cancer had the strongest independent association with death during the follow-up when adjusted for known poststroke mortality prognosticators.

Conclusions: Cancer, and especially active cancer and no other apparent cause for stroke, is associated with unfavorable survival among young stroke patients.
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http://dx.doi.org/10.1161/STROKEAHA.115.008694DOI Listing
June 2015

Response to letter regarding article, "long-term mortality after first-ever and recurrent stroke in young adults".

Stroke 2014 Dec 16;45(12):e302. Epub 2014 Oct 16.

Department of Neurology, Helsinki University Central Hospital and Division of Neurosciences, Helsinki University, Finland.

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http://dx.doi.org/10.1161/STROKEAHA.114.007341DOI Listing
December 2014

Young patient with isolated tongue deviation.

Stroke 2014 Nov 11;45(11):e226-8. Epub 2014 Sep 11.

From the Department of Neurology (K.A., M.L., D.S.) and Helsinki Medical Imaging Center (J.M.), Helsinki University Central Hospital, Helsinki, Finland; and Department of Neurology, Stroke Unit University Hospitals of Cleveland/Case Medical Center, OH (S.S.).

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http://dx.doi.org/10.1161/STROKEAHA.114.006701DOI Listing
November 2014

Long-term mortality after first-ever and recurrent stroke in young adults.

Stroke 2014 Sep 24;45(9):2670-6. Epub 2014 Jul 24.

From the Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.

Background And Purpose: Mortality after first-ever stroke, and particularly after recurrent stroke, and predictors of long-term mortality among young and middle-aged stroke patients are not well-known. We assessed 17-year risk of mortality with focus on the effect of recurrence on the risk of death of young and middle-aged patients with stroke.

Methods: Mortality and recurrent stroke rate of 970 consecutive 30-day survivors of first-ever ischemic stroke aged 15 to 49 years (1994-2007) were studied. Prospective follow-up data came from the Finnish Care Register for Health Care and Statistics Finland. Mean follow-up was 10.2±4.3 years. We compared survival between clinical subgroups and identified factors associated with mortality. Standardized mortality ratio was calculated for demographic and pathogenetic subgroups using mortality data of the general population matched with age, sex, calendar year, and geographical area.

Results: At the end of follow-up, 152 (15.7%) patients had died (cumulative risk, 23.0%; 95% confidence interval, 19.1%-26.9%) and 132 (13.6%) had experienced a recurrent stroke. After adjusting for baseline characteristics, recurrent stroke was statistically the most important risk factor for mortality after first-ever ischemic stroke (hazard ratio, 16.68; 95% confidence interval, 2.33-119.56; P=0.005). Observed mortality was 7-fold higher than the expected mortality (standardized mortality ratio, 6.94; 95% confidence interval, 5.84-8.04) and particularly high among patients who experienced a recurrent stroke (standardized mortality ratio, 14.43; 95% confidence interval, 10.11-18.74).

Conclusions: The high mortality rates and the striking impact of recurrent stroke on the risk of death should lead to development of more robust primary and secondary prevention strategies for young patients with stroke.
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http://dx.doi.org/10.1161/STROKEAHA.114.005648DOI Listing
September 2014
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