uu.seUppsala University Publications
Change search
Refine search result
1 - 36 of 36
CiteExportLink to result list
Permanent link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Rows per page
  • 5
  • 10
  • 20
  • 50
  • 100
  • 250
Sort
  • Standard (Relevance)
  • Author A-Ö
  • Author Ö-A
  • Title A-Ö
  • Title Ö-A
  • Publication type A-Ö
  • Publication type Ö-A
  • Issued (Oldest first)
  • Issued (Newest first)
  • Created (Oldest first)
  • Created (Newest first)
  • Last updated (Oldest first)
  • Last updated (Newest first)
  • Disputation date (earliest first)
  • Disputation date (latest first)
  • Standard (Relevance)
  • Author A-Ö
  • Author Ö-A
  • Title A-Ö
  • Title Ö-A
  • Publication type A-Ö
  • Publication type Ö-A
  • Issued (Oldest first)
  • Issued (Newest first)
  • Created (Oldest first)
  • Created (Newest first)
  • Last updated (Oldest first)
  • Last updated (Newest first)
  • Disputation date (earliest first)
  • Disputation date (latest first)
Select
The maximal number of hits you can export is 250. When you want to export more records please use the Create feeds function.
  • 1. Ahmed, Niaz
    et al.
    Audebert, Heinrich
    Turc, Guillaume
    Cordonnier, Charlotte
    Christensen, Hanne
    Sacco, Simona
    Sandset, Else Charlotte
    Ntaios, George
    Charidimou, Andreas
    Toni, Danilo
    Pristipino, Christian
    Köhrmann, Martin
    Kuramatsu, Joji B
    Thomalla, Götz
    Mikulik, Robert
    Ford, Gary A
    Martí-Fàbregas, Joan
    Fischer, Urs
    Thoren, Magnus
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Landtblom: Neurology.
    Rinkel, Gabriel Je
    van der Worp, H Bart
    Matusevicius, Marius
    Tsivgoulis, Georgios
    Milionis, Haralampos
    Rubiera, Marta
    Hart, Robert
    Moreira, Tiago
    Lantz, Maria
    Sjöstrand, Christina
    Andersen, Grethe
    Schellinger, Peter
    Kostulas, Konstantinos
    Sunnerhagen, Katharina Stibrant
    Keselman, Boris
    Korompoki, Eleni
    Purrucker, Jan
    Khatri, Pooja
    Whiteley, William
    Berge, Eivind
    Mazya, Michael
    Dippel, Diederik Wj
    Mustanoja, Satu
    Rasmussen, Mads
    Söderqvist, Åsa Kuntze
    Escudero-Martínez, Irene
    Steiner, Thorsten
    Consensus statements and recommendations from the ESO-Karolinska Stroke Update Conference, Stockholm 11-13 November 2018.2019In: European Stroke Journal, ISSN 2396-9873, E-ISSN 2396-9881, Vol. 4, no 4, p. 307-317Article in journal (Refereed)
    Abstract [en]

    The purpose of the European Stroke Organisation-Karolinska Stroke Update Conference is to provide updates on recent stroke therapy research and to give an opportunity for the participants to discuss how these results may be implemented into clinical routine. The meeting started 22 years ago as Karolinska Stroke Update, but since 2014 it is a joint conference with European Stroke Organisation. Importantly, it provides a platform for discussion on the European Stroke Organisation guidelines process and on recommendations to the European Stroke Organisation guidelines committee on specific topics. By this, it adds a direct influence from stroke professionals otherwise not involved in committees and work groups on the guideline procedure. The discussions at the conference may also inspire new guidelines when motivated. The topics raised at the meeting are selected by the scientific programme committee mainly based on recent important scientific publications. This year's European Stroke Organisation-Karolinska Stroke Update Meeting was held in Stockholm on 11-13 November 2018. There were 11 scientific sessions discussed in the meeting including two short sessions. Each session except the short sessions produced a consensus statement (Full version with background, issues, conclusions and references are published as web-material and at www.eso-karolinska.org and http://eso-stroke.org) and recommendations which were prepared by a writing committee consisting of session chair(s), scientific secretary and speakers. These statements were presented to the 250 participants of the meeting. In the open meeting, general participants commented on the consensus statement and recommendations and the final document were adjusted based on the discussion from the general participants Recommendations (grade of evidence) were graded according to the 1998 Karolinska Stroke Update meeting with regard to the strength of evidence. Grade A Evidence: Strong support from randomised controlled trials and statistical reviews (at least one randomised controlled trial plus one statistical review). Grade B Evidence: Support from randomised controlled trials and statistical reviews (one randomised controlled trial or one statistical review). Grade C Evidence: No reasonable support from randomised controlled trials, recommendations based on small randomised and/or non-randomised controlled trials evidence.

  • 2. Berge, Eivind
    et al.
    Cohen, Geoffrey
    Roaldsen, Melinda B
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology. Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
    Isaksson, Eva
    Rudberg, Ann-Sofie
    Slot, Karsten Bruins
    Forbes, John
    Smith, Joel
    Drever, Jonathan
    Wardlaw, Joanna M
    Lindley, Richard I
    Sandercock, Peter A G
    Whiteley, William N
    Effects of alteplase on survival after ischaemic stroke (IST-3): 3 year follow-up of a randomised, controlled, open-label trial2016In: Lancet Neurology, ISSN 1474-4422, E-ISSN 1474-4465, Vol. 15, no 10, p. 1028-34, article id S1474-4422(16)30139-9Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The effect of alteplase on patient survival after ischaemic stroke is the subject of debate. We report the effect of intravenous alteplase on long-term survival after ischaemic stroke of participants in the Third International Stroke Trial (IST-3).

    METHODS: In IST-3, done at 156 hospitals in 12 countries (Australia, Europe, and the UK), participants (aged >18 years) were randomly assigned with a telephone voice-activated or web-based system in a 1:1 ratio to treatment with intravenous 0·9 mg/kg alteplase plus standard care or standard care alone within 6 h of ischaemic stroke. We followed up participants in the UK and Scandinavia (Sweden and Norway) for survival up to 3 years after randomisation using data from national registries and compared survival in the two groups with proportional hazards survival analysis, adjusting for key prognostic variables. IST-3 is registered with the ISRCTN registry, number ISRCTN25765518.

    FINDINGS: Between May 5, 2000, and July 27, 2011, 3035 participants were enrolled in IST-3. Of these, 1948 (64%) of 3035 participants were scheduled for analysis of 3 year survival, and 1946 (>99%) of these were included in the analysis (967 [50%] in the alteplase plus standard care group and 979 [50%] in the standard care alone group). By 3 years after randomisation, 453 (47%) of 967 participants in the alteplase plus standard care group and 494 (50%) of 979 in the standard care alone group had died (risk difference 3·6% [95% CI -0·8 to 8·1]). Participants allocated to alteplase had a significantly higher hazard of death during the first 7 days (99 [10%] of 967 died in the alteplase plus standard care group vs 65 [7%] of 979 in the standard care alone group; hazard ratio 1·52 [95% CI 1·11-2·08]; p=0·004) and a significantly lower hazard of death between 8 days and 3 years (354 [41%] of 868 vs 429 [47%] of 914; 0·78 [0·68-0·90]; p=0·007).

    INTERPRETATION: Alteplase treatment within 6 h after ischaemic stroke was associated with a small, non-significant reduction in risk of death at 3 years, but among individuals who survived the acute phase, treatment was associated with a significant increase in long-term survival. These results are reassuring for clinicians who have expressed concerns about the effect of alteplase on survival.

    FUNDING: Heart and Stroke Scotland, UK Medical Research Council, Health Foundation UK, Stroke Association UK, Research Council of Norway, AFA Insurance, Swedish Heart Lung Fund, Foundation of Marianne and Marcus Wallenberg, Polish Ministry of Science and Education, Australian Heart Foundation, Australian National Health and Medical Research Council, Swiss National Research Foundation, Swiss Heart Foundation, Assessorato alla Sanita (Regione dell'Umbria), and Danube University.

  • 3.
    Blomberg, Hans
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Toss, Henrik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Gedeborg, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Johansson, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Agreement between ambulance nurses and physicians in assessing stroke patients2013In: Acta Neurologica Scandinavica, ISSN 0001-6314, E-ISSN 1600-0404, Vol. 129, no 1, p. 49-55Article in journal (Refereed)
    Abstract [en]

    Objectives: If an ambulance nurse could bypass the emergency department (ED) and bring suspected stroke patients directly to a CT scanner, time to thrombolysis could be shortened. This study evaluates the level of agreement between ambulance nurses and emergency physicians in assessing the need for a CT scan, and interventions and monitoring beforehand, in patients with suspected stroke and/or a lowered level of consciousness.

    Materials and Methods: From October 2008 to June 2009 we compared the ambulance nurses’ and ED physicians’ judgement of 200 patients with stroke symptoms . Both groups answered identical questions on patients’ need for a CT scan, and interventions and monitoring beforehand.  

    Results: There was a poor agreement between ambulance nurses and ED physicians in judging the need for a CT scan: κ = 0.22 (95% confidence interval (CI): 0.06–0.37). The nurses’ ability to select the same patients as the physician for a CT scan had a sensitivity of 84% (95% CI: 77–89) and a specificity of 37% (95% CI: 23–53). Agreement concerning the need for interventions and monitoring was also low: κ = 0.32 (95% CI: 0.18–0.47). In 18% of cases, the nurses considered interventions before a CT scan unnecessary when the physicians’ deemed them necessary.

    Conclusions: Additional tools to support ambulance nurses decisions appear to be required before suspected stroke patients can be taken directly to a CT scanner.

     

     

  • 4.
    Dennis, Martin
    et al.
    Univ Edinburgh, Ctr Clin Brain Sci, Edinburgh EH16 4SB, Midlothian, Scotland.
    Forbes, John
    Univ Limerick, Hlth Res Inst, Limerick, Ireland.
    Graham, Catriona
    Univ Edinburgh, Edinburgh Clin Res Facil, Edinburgh, Midlothian, Scotland.
    Hackett, Maree
    Univ New South Wales, George Inst Global Hlth, Kensington, NSW, Australia;Univ Cent Lancashire, Fac Hlth & Wellbeing, Preston, Lancs, England.
    Hankey, Graeme J.
    Univ Western Australia, Med Sch, Perth, WA, Australia.
    House, Allan
    Univ Leeds, Inst Hlth Sci, Leeds, W Yorkshire, England.
    Lewis, Stephanie
    Univ Edinburgh, Edinburgh Clin Trials Unit, Edinburgh, Midlothian, Scotland.
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology. Karolinska Inst, Dept Clin Neurosci, Solna, Sweden.
    Sandercock, Peter
    Univ Edinburgh, Ctr Clin Brain Sci, Edinburgh EH16 4SB, Midlothian, Scotland.
    Mead, Gillian
    Univ Edinburgh, Ctr Clin Brain Sci, Edinburgh EH16 4SB, Midlothian, Scotland.
    Anderson, Rosemary
    Buchanan, David
    Deary, Ann
    Drever, Jonathan
    Fraser, Ruth
    Innes, Karen
    McGill, Connor
    McGrath, Aileen
    Perry, David
    Walker, Pauli
    Williams, Carol
    Chun, Yvonne
    Dinsmore, Lynn
    Maschauer, Emma
    Fraser, Greig
    Lawrence, Katherine
    Shaw, Alison
    Barugh, Amanda
    Mikhail, Shadia
    Blair, Gordon
    Hoeritzauer, Ingrid
    Scott, Maggie
    Lewis, Steff
    Williamson, Judith
    Murray, Veronica
    French, Ray
    Stott, David
    Burgess, David
    Emberson, Jonathan
    Ellis, Graham
    Tyrrell, Pippa
    Brady, Marian
    MacLeod, Malcolm
    Milligan, Hazel
    Sullivan, Frank
    van Wijck, Frederike
    Watkins, Caroline
    Anderson, Craig
    Morales, D.
    Langhorne, Peter
    Reid, Fiona
    Rodgers, Helen
    Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial2019In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 393, no 10168, p. 265-274Article in journal (Refereed)
    Abstract [en]

    Background Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.

    Methods FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.

    Findings Between Sept 10,2012, and March 31,2017,3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99.3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0.951 [95% CI 0.839-1.079]; p=0.439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13.43%] patients vs 269 [17.21%]; difference 3.78% [95% CI 1.26-6.30]; p=0.0033), but they had more bone fractures (45 [2.88%] vs 23 [1.47%]; difference 1.41% [95% CI 0.38-2.43]; p=0.0070). There were no significant differences in any other event at 6 or 12 months.

    Interpretation Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.

  • 5. Dennis, Martin
    et al.
    Forbes, John
    Graham, Catriona
    Hackett, Maree L
    Hankey, Graeme J
    House, Allan
    Lewis, Steff
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience.
    Sandercock, Peter
    Mead, Gillian
    Fluoxetine and Fractures After Stroke: Exploratory Analyses From the FOCUS Trial2019In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 50, no 11, p. 3280-3282Article in journal (Refereed)
    Abstract [en]

    Background and Purpose- The FOCUS trial (Fluoxetine or Control Under Supervision) showed that fluoxetine did not improve modified Rankin Scale scores (mRS) but increased the risk of fractures. We aimed to describe the fractures, their impact on mRS and factors associated with fracture risk. Methods- A United Kingdom, multicenter, parallel-group, randomized, placebo-controlled trial. Patients ≥18 years with a clinical stroke and persisting deficit assessed 2 to 15 days after onset were eligible. Consenting patients were allocated fluoxetine 20 mg or matching placebo for 6 months. The primary outcome was the mRS at 6 months and secondary outcomes included fractures. Results- Sixty-five of 3127 (2.1%) patients had 67 fractures within 6 months of randomization; 43 assigned fluoxetine and 22 placebo. Fifty-nine (90.8%) had fallen and 26 (40%) had fractured their neck of femur. The effect of fluoxetine on mRS (common odds ratio =0.951) was not significantly altered by excluding fracture patients (common odds ratio =0.961). Cox proportional hazards modeling showed that only age >70 year (hazard ratio =1.97; 95% CI, 1.13-3.45; P=0.017), female sex (hazard ratio =2.13; 95% CI, 1.29-3.51; P=0.003), and fluoxetine (hazard ratio =2.00; 95% CI, 1.20-3.34; P=0.008) were independently associated with fractures. Conclusions- Most fractures resulted from falls. Although many fractures were serious, and likely to impair patients' function, the increased fracture risk did not explain the lack of observed effect of fluoxetine on mRS. Only increasing age, female sex, and fluoxetine were independent predictors of fractures. Clinical Trial Registration- URL: http://www.controlled-trials.com. Unique identifier: ISRCTN83290762.

  • 6. Hedlund, Fredrik
    et al.
    Leighs, Andrew
    Barber, P Alan
    Lundström, E
    Uppsala University, Disciplinary Domain of Science and Technology, Mathematics and Computer Science, Department of Information Technology, Automatic control. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Landtblom: Neurology.
    Wu, Teddy Y
    Ranta, Annemarei
    Trends in stroke reperfusion treatment and outcomes in New Zealand.2019In: Internal medicine journal (Print), ISSN 1444-0903, E-ISSN 1445-5994Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) can help reverse stroke symptoms in selected patients but are both time sensitive interventions.

    AIMS: To report current stroke reperfusion rates and quality measures as well as trends over time in New Zealand.

    METHOD: Since 2015 New Zealand treatment centers have been mandated to prospectively enter all IVT and EVT patients into a low cost National Stroke Register. Data was cleaned and missing data added where possible through contact with individual hospitals. Main outcomes include treatment delays, vital status at day seven and complications.

    RESULTS: In 2018, there were 719 of 7173 (10.0%) patients with ischemic stroke or stroke unspecified treated with intravenous IVT, up from 389 of 5963 (6.5%) patients in 2015 (p < 0.001), with no change in day seven mortality (p = 0.63) or sICH rate (p = 0.22). Median (interquartile range (IQR)) door-to-needle times decreased from 65 (47-89) minutes in 2017 to 59 (40-84) minutes in 2018 (p = 0.022), and patients treated within 60 min increased from 40% to 51% (p < 0.001). In 2018, there were 243 (3.4%) patients treated with EVT up from 134/6859 (1.9%) in 2017 (p < 0.0001), with no change in seven mortality (p = 0.39) or sICH (p = 0.78). There was no significant change in onset-to-needle (p = 0.21), arrival-to-groin (p = 0.28) or onset-to-reperfusion time (p = 0.32).

    CONCLUSION: Stroke reperfusion rates in New Zealand are continuously rising with no associated increase in complications. More patients are being treated faster upon hospital arrival but there remains room for further improvement in reducing onset to treatment delays. This article is protected by copyright. All rights reserved.

  • 7.
    Isaksson, Eva
    et al.
    Karolinska Inst, Dept Clin Neurosci, Neurol, Nobels Vag 6, SE-17176 Stockholm, Sweden.
    Wester, Per
    Danderyd Hosp, Karolinska Inst, Dept Clin Sci, SE-18288 Stockholm, Sweden;Umea Univ, Dept Publ Hlth & Clin Med, S-90187 Umea, Sweden.
    Laska, Ann Charlotte
    Danderyd Hosp, Karolinska Inst, Dept Clin Sci, SE-18288 Stockholm, Sweden.
    Nasman, Per
    KTH Royal Inst Technol, Ctr Safety Res, SE-10044 Stockholm, Sweden.
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Landtblom: Neurology.
    Identifying important barriers to recruitment of patients in randomised clinical studies using a questionnaire for study personnel2019In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 20, no 1, article id 618Article in journal (Refereed)
    Abstract [en]

    Background:

    Many randomised controlled trials (RCT) fail to meet their recruitment goals. Study personnel play a key role in recruitment. The aim of this study was to identify successful strategies that study personnel consider to be important in patient recruitment to RCT.

    Methods:

    We constructed a questionnaire based on the literature, discussions with colleagues and our own experience as trialists. The survey was named "What is Important for Making a Study Successful questionnaire" (WIMSS-q). Our target group was the study personnel in the ongoing EFFECTS study. The questionnaire was sent out electronically to all physicians and nurses (n = 148). Success factors and barriers were divided according to patient, centre and study level, respectively.

    Results:

    Responses were received from 94% of the study personnel (139/148). The five most important factors at centre level for enhancing recruitment were that the research question was important (97%), a simple procedure for providing information and gaining consent (92%), a highly engaged local principal investigator and research nurse (both 87%), and that study-related follow-ups are practically feasible and possible to coordinate with the clinical follow-up (87%). The most significant barrier at the local centre was lack of time and resources devoted to research (72%). Important patient-related barriers were fear of side effects (35%) and language problems (30%).

    Conclusions:

    For recruitment in an RCT to be successful, the research question must be relevant, and the protocol must be simple and easy to implement in the daily routine.

  • 8. Kong, Wan-Yee
    et al.
    Tan, Benjamin Y Q
    Ngiam, Nicholas J H
    Tan, Deborah Y C
    Yuan, Christine H
    Holmin, Staffan
    Andersson, Tommy
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Teoh, Hock Luen
    Chan, Bernard P L
    Rathakrishnan, Rahul
    Ting, Eric Y S
    Sharma, Vijay K
    Yeo, Leonard L L
    Validation of Serial Alberta Stroke Program Early CT Score as an Outcome Predictor in Thrombolyzed Stroke Patients.2017In: Journal of Stroke & Cerebrovascular Diseases, ISSN 1052-3057, E-ISSN 1532-8511, Vol. 26, no 10, p. 2264-2271, article id S1052-3057(17)30227-6Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The Alberta Stroke Program Early CT Score (ASPECTS) on baseline imaging is an established predictor of functional outcome in anterior circulation acute ischemic stroke (AIS). We studied ASPECTS before intravenous thrombolysis (IVT) and at 24 hours to assess its prognostic value.

    METHODS: Data for consecutive anterior circulation AIS patients treated with IVT from 2006 to 2013 were extracted from a prospectively managed registry at our tertiary center. Pre-thrombolysis and 24-hour ASPECTS were evaluated by 2 independent neuroradiologists. Outcome measures included symptomatic intracranial hemorrhage (SICH), modified Rankin Scale (mRS) at 90 days, and mortality. Unfavorable functional outcome was defined by mRS >1. Dramatic ASPECTS progression (DAP) was defined as deterioration in ASPECTS by 6 points or more.

    RESULTS: Of 554 AIS patients thrombolyzed during the study period, 400 suffered from anterior circulation infarction. The median age was 65 years (interquartile range (IQR): 59-70) and the median National Institutes of Health Stroke Scale score was 18 points (IQR: 12-22). Compared with the pre-IVT ASPECTS (area under the curve [AUC] = .64, 95% confidence interval [CI]: .54-.65, P = .001), ASPECTS on the 24-hour CT scan (AUC = .78, 95% CI: .73-.82, P < .001), and change in ASPECTS (AUC = .69, 95% CI: .64-.74, P < .001) were better predictors of unfavorable functional outcome at 3 months. DAP, noted in 34 (14.4%) patients with good baseline ASPECTS (8-10 points), was significantly associated with unfavorable functional outcome (odds ratio [OR]: 9.91, 95% CI: 3.37-29.19, P ≤ .001), mortality (OR: 21.99, 95% CI: 7.98-60.58, P < .001), and SICH (OR: 8.57, 95% CI: 2.87-25.59, P < .001).

    CONCLUSION: Compared with the pre-thrombolysis score, ASPECTS measured at 24 hours as well as serial change in ASPECTS is a better predictor of 3-month functional outcome.

  • 9.
    Laurell, Katarina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Migrainous Infarction: Aspects on Risk Factors and Therapy2012In: Current Pain and Headache Reports, ISSN 1531-3433, E-ISSN 1534-3081, Vol. 16, no 3, p. 255-260Article, review/survey (Refereed)
    Abstract [en]

    Migraine and stroke are related in more than one way. Migraine with aura is a risk factor for ischemic stroke in women under age 45 years, particularly when combined with other risk factors such as smoking and oral contraceptives. Further, individuals with migraine with aura seem to have more white matter lesions and ischemic infarctions than control patients. Migraine has been correlated to cervical artery dissection, the symptoms of which can mimic migraine. Correspondingly, migraine with aura sometimes is mistaken for stroke. Migrainous infarction is a rare but specific type of ischemic stroke developing during an attack of migraine with aura. It is important to recognize this unusual complication of migraine because the management probably is important. In this review, we will discuss the present knowledge of migrainous infarction, the clinical picture, possible mechanisms, and potential prevention and treatment.

  • 10. Legg, Lynn A
    et al.
    Tilney, Russel
    Hsieh, Cheng-Fang
    Wu, Simiao
    Lundström, E
    Uppsala University, Disciplinary Domain of Science and Technology, Mathematics and Computer Science, Department of Information Technology, Automatic control. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Landtblom: Neurology.
    Rudberg, Ann-Sofie
    Kutlubaev, Mansur A
    Dennis, Martin
    Soleimani, Babak
    Barugh, Amanda
    Hackett, Maree L
    Hankey, Graeme J
    Mead, Gillian E
    Selective serotonin reuptake inhibitors (SSRIs) for stroke recovery.2019In: Cochrane Database of Systematic Reviews, ISSN 1469-493X, E-ISSN 1469-493X, Vol. 2019, no 11Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Stroke is a major cause of adult disability. Selective serotonin reuptake inhibitors (SSRIs) have been used for many years to manage depression and other mood disorders after stroke. The 2012 Cochrane Review of SSRIs for stroke recovery demonstrated positive effects on recovery, even in people who were not depressed at randomisation. A large trial of fluoxetine for stroke recovery (fluoxetine versus placebo under supervision) has recently been published, and it is now appropriate to update the evidence.

    OBJECTIVES: To determine if SSRIs are more effective than placebo or usual care at improving outcomes in people less than 12 months post-stroke, and to determine whether treatment with SSRIs is associated with adverse effects.

    SEARCH METHODS: For this update, we searched the Cochrane Stroke Group Trials Register (last searched 16 July 2018), the Cochrane Controlled Trials Register (CENTRAL, Issue 7 of 12, July 2018), MEDLINE (1946 to July 2018), Embase (1974 to July 2018), CINAHL (1982 July 2018), PsycINFO (1985 to July 2018), AMED (1985 to July 2018), and PsycBITE March 2012 to July 2018). We also searched grey literature and clinical trials registers.

    SELECTION CRITERIA: We included randomised controlled trials (RCTs) that recruited ischaemic or haemorrhagic stroke survivors at any time within the first year. The intervention was any SSRI, given at any dose, for any period, and for any indication. We excluded drugs with mixed pharmacological effects. The comparator was usual care or placebo. To be included, trials had to collect data on at least one of our primary (disability score or independence) or secondary outcomes (impairments, depression, anxiety, quality of life, fatigue, healthcare cost, death, adverse events and leaving the trial early).

    DATA COLLECTION AND ANALYSIS: We extracted data on demographics, type of stroke, time since stroke, our primary and secondary outcomes, and sources of bias. Two review authors independently extracted data from each trial. We used standardised mean differences (SMDs) to estimate treatment effects for continuous variables, and risk ratios (RRs) for dichotomous effects, with their 95% confidence intervals (CIs). We assessed risks of bias and applied GRADE criteria.

    MAIN RESULTS: We identified a total of 63 eligible trials recruiting 9168 participants, most of which provided data only at end of treatment and not at follow-up. There was a wide age range. About half the trials required participants to have depression to enter the trial. The duration, drug, and dose varied between trials. Only three of the included trials were at low risk of bias across the key 'Risk of bias' domains. A meta-analysis of these three trials found little or no effect of SSRI on either disability score: SMD -0.01 (95% CI -0.09 to 0.06; P = 0.75; 2 studies, 2829 participants; moderate-quality evidence) or independence: RR 1.00 (95% CI 0.91 to 1.09; P = 0.99; 3 studies, 3249 participants; moderate-quality evidence). We downgraded both these outcomes for imprecision. SSRIs reduced the average depression score (SMD 0.11 lower, 0.19 lower to 0.04 lower; 2 trials, 2861 participants; moderate-quality evidence), but there was a higher observed number of gastrointestinal side effects among participants treated with SSRIs compared to placebo (RR 2.19, 95% CI 1.00 to 4.76; P = 0.05; 2 studies, 148 participants; moderate-quality evidence), with no evidence of heterogeneity (I2 = 0%). For seizures there was no evidence of a substantial difference. When we included all trials in a sensitivity analysis, irrespective of risk of bias, SSRIs appeared to reduce disability scores but not dependence. One large trial (FOCUS) dominated the results. We identified several ongoing trials, including two large trials that together will recruit more than 3000 participants.

    AUTHORS' CONCLUSIONS: We found no reliable evidence that SSRIs should be used routinely to promote recovery after stroke. Meta-analysis of the trials at low risk of bias indicate that SSRIs do not improve recovery from stroke. We identified potential improvements in disability only in the analyses which included trials at high risk of bias. A further meta-analysis of large ongoing trials will be required to determine the generalisability of these findings.

  • 11.
    Lundström, E
    Karolinska institutet, Solna, Sweden.
    EFFECTS: en randomiserad kontrollerad studie av fluoxetine efter stroke2016In: Neurologi i Sverige, no 2, p. 47-51Article in journal (Other (popular science, discussion, etc.))
  • 12.
    Lundström, E
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Medicinsk behandling av cervical dissektion2017In: Neurologi i Sverige, E-ISSN 2002-9004, no 2, p. 58-62Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Dissektion av hjärnans arteriella kärl är en vanlig orsak till stroke hos unga personer. Denna artikel av Erik Lundström, docent och sektionsöverläkare i neurologi, Karolinska Universitetssjukhuset, Solna, fokuserar på frågor som rör den medicinska behandlingen av halskärlsdissektion.

    Dissektion av hjärnans arteriella kärl är den vanligaste kända orsaken till stroke hos yngre individer.1 Medelåldern är 45 år med en viss övervikt av män.2 Hälften av alla individer har haft någon form av trauma mot halsen. Patienter med cervikal artärdissektion har oftare högre blodtryck men samtidigt lägre förekomst av hyperkolesterolemi än matchade friska kontroller. Migrän – särskilt med aura – och hyperhomocystemi har identifierats som riskfaktorer. Anamnes på nyligen genomgången infektion ökar risken och detta kan delvis förklara den säsongsvariation som förekommer. Populationsbaserade studier uppskattar incidensen av cervikal dissektion till ungefär 3 per 100 000 individer och år varav hälften drabbas av en stroke eller TIA.3 I Sverige skulle det innebära att 300 individer varje år får cervikal dissektion och att 150 drabbas av stroke eller TIA. Dissektionen kan vara extrakraniell, dvs förekomma i arteria carotis interna eller arteria vertebralis fram till dess inträde i kraniet, eller intrakraniell, dvs förekomma i ett kärl inne i hjärnan. Det är erkänt svårt att ställa diagnosen intrakraniell dissektion och jag har inte hittat några bra uppgifter på hur stor andel just den delen utgör av det totala antalet dissektioner. Denna artikel fokuserar på medicinsk behandling av cervikal dissektion och tar upp några vanliga frågor som jag får som stroke-profilerad neurolog: ”Törs vi ge intravenös trombolys vid en dissektion? Ska vi ge acetylsalicylsyra eller warfarin som sekundärprofylax? Hur lång tid ska vi behandla?” Råden anknyter till de nyligen publicerade rekommendationerna från Karolinska Stroke Update, november 20164 där undertecknad var sekreterare i avsnittet om halskärlsdissektion. De nationella riktlinjerna för stroke kommer att presenteras under 2017, men jag har ingen förhandsinformation om vad de kommer att ge för rekommendationer inom detta område.

  • 13.
    Lundström, E
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Trombektomi vid ischemisk stroke: ett paradigmskifte inom akut strokebehandling2015In: Neurologi i Sverige, Vol. 2015, no 4, p. 14-20Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Trombektomi är en endovaskulär metod där man med kateter mekaniskt avlägsnar en propp i hjärnan. Mycket talar för att trombektomi är det viktigaste som har hänt inom stroke de senaste 20 åren, ett paradigmskifte inom akut strokebehandling. I denna översiktsartikel sammanfattar Erik Lundström, sektionsöverläkare vid Neurologkliniken, Karolinska Universitetssjukhuset, Solna, bevisläget för trombektomi vid ischemisk stroke

  • 14.
    Lundström, E
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Trombektomi är möjlig upp till 24 timmar efter stroke: Om man väljer rätt patient2018In: Neurologi i Sverige, no 2, p. 50-53Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    År 2015 publicerades den epokgörande studien MR CLEAN1 som visade att trombektomi vid stroke i den främre cirkulationen fungerade inom upp till 6 timmar. Därefter har ytterligare studier bekräftat resultatet. En metaanalys av fem studier har visat att trombektomi inom 6 timmar av patienter med ocklusion av de stora kärlen i den främre cirkulationen är en högeffektiv behandling. Trombektomi innebär att dubbelt så många patienter kan få ett oberoende liv jämfört med de som enbart får trombolys. Sammantaget har detta inneburit att trombektomi inom 6 timmar har fått den högsta prioriteringen i de svenska strokeriktlinjerna. Under senaste året har det tillkommit ytterligare två trombektomistudier – DAWN och DEFUSE 3 – med ett utökat tidsfönster. De har visat att det i utvalda fall skulle kunna fungera att behandla upp till 24 timmar efter insjuknandet. Erik Lundström, överläkare vid Neurologen, Akademiska sjukhuset, Uppsala, kommenterar i denna artikel dessa två artiklar och gör en personlig tolkning av vad det kan ha för betydelse för strokevården i Sverige.

  • 15.
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Hur ska alla i Sverige få tillgång till trombektomi vid stroke?2019In: Neurologi i Sverige, ISSN 2000-8538, no 2, p. 46-49Article in journal (Other (popular science, discussion, etc.))
  • 16.
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Rehabilitation Medicine.
    Spasticity after first-ever stroke2009Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The prevalence of spasticity after first-ever stroke is approximately 20%, but there are no data on the prevalence of disabling spasticity.The reported prevalence of pain after stroke varies between 19% and 74%, whether pain is associated with spasticity is not known. Until now, there is no health economic analysis of patients with spasticity after stroke.

    Methods: Two groups of patients were studied.

    Cohort I was a cross-sectional survey. A representative sample of 140 patients was investigated 1 year after their first-ever stroke. Spasticity was defined as ≥ 1 score on the modified Ashworth scale, disabling spasticity was defined as spasticity having such an impact that intervention, e.g. intensive physiotherapy, orthoses or pharmacological treatment, should be offered. Pain was assesed with the Visual Analogue Scale. All direct costs during one year were identified and converted into Purchasing Power Parities US dollar (PPP$).

    Cohort II was a prospective cohort study. Forty-nine patients were examined at day 2–10, at one month, and at six months after their first-ever stroke. Assessment and definitions were similar as for cohort I.

    Results: Spasticity occurs within 1 month and disabling spasticity occur within 6 months.

    After one year, the prevalence of spasticity was 17% and that of  disabling spasticity 4%. Disabling spasticity was more frequent in the upper extremity. There was an independent effect of severe upper extremity paresis (OR 22, CI 3.9–125) and age below 65 years (OR 9.5, CI 1.5–60).

    The prevalence of stroke-related pain was 21% after one year. Stroke-related pain was associated with paresis (OR 3.1, 95% CI 1.2–7.7), sensory disturbance (OR 3.1, 95% CI 1.1–8.9) and depression (OR 4.1, 95% CI 1.4–13), but not with spasticity as an independent variable.

    The majority of the direct costs for one year (78%) were associated with hospitalization, whereas 20% was associated with municipality services. Only 1% of all direct costs were related to primary health care and 1% to medication. The mean (median, inter-quartile range) direct cost for stroke patients with spasticity was PPP$ 84 195 (72 116, 53 707) compared to PPP$ 21 842 (12 385, 17 484) for stroke patients without spasticity (P < 0.001).

    List of papers
    1. Prevalence of disabling spasticity 1 year after first-ever stroke
    Open this publication in new window or tab >>Prevalence of disabling spasticity 1 year after first-ever stroke
    2008 (English)In: European Journal of Neurology, ISSN 1351-5101, E-ISSN 1468-1331, Vol. 15, no 6, p. 533-9Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVE: To estimate the prevalence of disabling spasticity (DS) 1 year after first-ever stroke. DESIGN: Cross-sectional survey 1 year after first-ever stroke. METHODS: Patients above 18 years from one county with first-ever stroke were identified by use of the national stroke registry. A representative sample of 163 patients was created and 140 of these were followed up. Assessments of motor function and ability with the modified Ashworth Scale, the modified Rankin Scale (mRS), the Barthel Index (BI) and clinical evaluation were performed in order to identify patients with spasticity-related disability. RESULTS: The observed prevalence of any spasticity was 17% and of DS 4%. Patients with DS scored significantly worse than those with no DS on the mRS (P = 0.009) and the BI (P = 0.005). DS was more frequent in the upper extremity, correlated positively with other indices of motor impairment and inversely with age. There was an independent effect of severe upper extremity paresis (OR 22, CI 3.9-125) and age below 65 years (OR 9.5, CI 1.5-60). CONCLUSIONS: The prevalence of DS after first-ever stroke is low but corresponds to a large number of patients and deserves further attention with regards to prevention and treatment.

    Keywords
    disability, prevalence, spasticity, stroke
    National Category
    Medical and Health Sciences
    Research subject
    Neurology
    Identifiers
    urn:nbn:se:uu:diva-103569 (URN)10.1111/j.1468-1331.2008.02114.x (DOI)000255702200007 ()18355307 (PubMedID)
    Available from: 2009-05-20 Created: 2009-05-20 Last updated: 2018-04-15
    2. Risk factors for stroke-related pain 1 year after first-ever stroke
    Open this publication in new window or tab >>Risk factors for stroke-related pain 1 year after first-ever stroke
    2009 (English)In: European Journal of Neurology, ISSN 1351-5101, E-ISSN 1468-1331, Vol. 16, no 2, p. 188-193Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVE:

    To estimate the prevalence of stroke-related pain and to explore its relation to spasticity.

    DESIGN:

    Cross-sectional survey.

    PATIENTS AND METHODS:

    One hundred and forty patients were examined at 1 year after first-ever stroke. Pain was assessed by a structured interview and categorized as stroke-related or not, pain intensity by use of the visual analogue scale (VAS), spasticity by use of the modified Ashworth scale, stroke severity and the presence of specific neurological impairments by use of the National Institute of Health Stroke Scale (NIHSS), and depression by use of the Montgomery-Asberg Depression Scale.

    RESULTS:

    Pain was reported by 68 patients (49%) with a mean VAS of 42 (95% CI 36-47). In 29 patients (21%), pain was categorized as stroke-related pain. Univariate analyses demonstrated correlations between stroke-related pain and total NIHSS score, paresis, sensory disturbance, depression and spasticity respectively. A multiple regression analysis demonstrated an independent association of stroke-related pain with paresis (OR = 3.1, 95% CI 1.2-7.7), sensory disturbance (OR = 3.1, 95% CI 1.1-8.9) and depression (OR = 4.1, 95% CI 1.4-13).

    CONCLUSIONS:

    The estimated prevalence of stroke-related pain was 21%. Stroke-related pain was associated with sensorimotor impairments and depression, but not with spasticity as an independent variable.

    Keywords
    depression, pain, prevalence, sensorimotor impairment, spasticity, stroke, stroke-related pain
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-103416 (URN)10.1111/j.1468-1331.2008.02378.x (DOI)000262468900016 ()19138338 (PubMedID)
    Available from: 2009-05-19 Created: 2009-05-19 Last updated: 2017-12-13Bibliographically approved
    3. Four-fold increase in direct costs of stroke-survivors with spas-ticity compared to stroke-survivors without spasticity: the first year after the event
    Open this publication in new window or tab >>Four-fold increase in direct costs of stroke-survivors with spas-ticity compared to stroke-survivors without spasticity: the first year after the event
    2010 (English)In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 2, p. 319-324Article in journal (Refereed) Published
    Abstract [en]

    Background and Purpose:

    The prevalence of spasticity after first-ever stroke is approximately 20%, but there are no health economic studies on costs associated with spasticity after stroke. The objective of our study was to estimate direct costs of stroke with spasticity for patients surviving up to one year after the stroke event in comparison to costs of stroke without spastic-ity.

    Methods:

    A representative sample of first-ever stroke patients hospitalized at Uppsala University Hospital was eligible for our cross-sectional survey. All direct costs during one year were identified for each patient, includ-ing costs for hospitalization (acute and rehabilitation), primary health care, medication, and costs for municipality services. The Swedish currency (SEK) was converted into Purchasing Power Parities US dollar (PPP$).

    Results:

    Median age (inter-quartile range) was 73 years (18), and the proportion of women was 48%. The majority of the direct costs (78%) were associated with hospitalization, whereas 20% was associated with municipality services during one year after first-ever stroke. Only 1% of all direct costs were related to primary health care and 1% to medication. The level of costs for stroke patients was correlated with the presence of spasticity, as measured with modified Ashworth Scale (rs = 0.524), and with the degree of disability, as measured with modified Rankin Scale (rs = 0.624). The mean (median, inter-quartile range) direct cost for stroke patients with spasticity was PPP$ 84 195 (72 116, 53 707) compared to PPP$ 21 842 (12 385, 17 484) for stroke patients without spasticity (P < 0.001).

    Conclusions:

    Direct costs for stroke patients with spasticity are four times higher than direct costs for non-spasticity stroke patients during the first year after the event.

    Keywords
    stroke, spasticity, cost of illness, medical economics
    National Category
    Neurology
    Research subject
    Neurology
    Identifiers
    urn:nbn:se:uu:diva-107135 (URN)10.1161/STROKEAHA.109.558619 (DOI)000273951600022 ()
    Available from: 2009-07-20 Created: 2009-07-18 Last updated: 2017-12-13Bibliographically approved
    4. Time-course and determinants of spasticity during the first six months following first-ever stroke
    Open this publication in new window or tab >>Time-course and determinants of spasticity during the first six months following first-ever stroke
    2010 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 42, no 4, p. 296-301Article in journal (Refereed) Published
    Abstract [en]

    Purpose:

    To explore the occurrence of and risk factors for spasticity until six months after first-ever stroke.

    Methods:

    Forty-nine patients were examined at day 2-10, at one month, and at six months. The Modified Ashworth Scale (MAS) was used to assess resistance to passive movements. A comprehensive clinical examination was performed to identify other positive signs of the upper motor neuron syndrome, in accordance with a broader definition of spasticity, and to evaluate if spasticity was disabling. Neurological impairments were determined by use of the National Institutes of Health Stroke Scale and global disability by use of the modified Rankin Scale.

    Results:

    Spasticity was present in two patients (4%) at day 2-10, in 13 patients (27%) at one month, and in 11 patients (23%) at six months. Severe paresis at day 2-10 was associated with a 10-fold higher risk for spasticity at one month (OR=10, 95% CI 2-48). Disabling spasticity was present  in one patient at one month and in 6 patients (13%) at six months.

    Conclusions:

    Spasticity according to MAS usually occurs within one month and disabling spasticity later in a subgroup. Severe paresis of the arm is a risk factor for spasticity.

    Keywords
    stroke, spasticity, incidence, prevalence, prediction
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-107136 (URN)10.2340/16501977-0509 (DOI)000277827500002 ()20461330 (PubMedID)
    Available from: 2009-07-20 Created: 2009-07-18 Last updated: 2017-12-13Bibliographically approved
  • 17.
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience.
    Update On The Effects Trial Of Fluoxetine For Stroke Recovery: An Investigator-Led Randomised Controlled Study In Sweden2019In: European Stroke Journal, ISSN 2396-9873, E-ISSN 2396-9881, Vol. 4, no 1 suppl., article id AS36-014Article in journal (Refereed)
    Abstract [en]

    Background and Aims: Animal studies and several small human studies suggest that fluoxetine improves neurological recovery after stroke. In contrast, the most recent and largest fluoxetine study for stroke recovery (FOCUS trial, N = 3,127) was neutral. This abstract presents un update on EFFECTS, a trial of fluoxetine for stroke recovery.

    Methods: In this investigator-led, multicentre, parallel group, randomised, placebo-controlled trial, we enrolled non-depressed stroke patients aged 18 years or older between 2-5 days after stroke. Inclusion required a clinical diagnosis of stroke (ischaemic or intracere- bral haemorrhage) with persisting focal neurological deficits. Patients were randomly assigned to fluoxetine 20 mg once daily or placebo cap- sules for 6 months.

    The primary outcome is functional status, measured with the modified Rankin scale at the 6-month follow-up, using ordinal logistic regression. Results: Recruitment began on 20 October 2014. Half of the 1,500 patients were recruited from 20% of the centres. The results will be available within one year.

    Conclusions: The data from the trial will improve the external validity and precision of the estimates of the efficacy and safety of fluoxetine in ischaemic and haemorrhagic stroke. Trial registration number: EudraCT 2011-006130-16. Registered on 8 August 2014.

    ISRCTN, ISRCTN13020412. Registered on 19 December 2014. ClinicalTrials.gov: NCT02683213, retrospectively registered on 2 February 2016

  • 18.
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Landtblom: Neurology.
    Återinsättning av trombocythämmare RESTART ger oss (nästan) hela svaret2019In: Neurologi i sverige, , p. 2Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Återinsättning av trombocythämmare efter en spontan intrakraniell blödning ökar inte risken för en ny blödning jämfört med att avstå. Tvärtom. Återinsättning verkar till och med minska risken för framtida blödningar. Det är det oväntade resultatet av RESTART-studien som pre-senterades på den europeiska strokekongressen ESOC i Milano, maj 2019. I denna artikel sammanfattas RESTART av Erik Lundström, överläkare vid Akademiska sjukhuset. Pågåen-de studier (RESTART-Fr och STATICH) kommer sannolikt att kunna ge oss ett definitivt svar på denna viktiga kliniska fråga.

  • 19.
    Lundström, Erik
    et al.
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Neuroscience.
    Andersson, Per
    Gustavsson, Lisbeth
    Terent, Andreas
    Department of Medical Sciences.
    "Rädda hjärnan" - nätverk i Uppsala län för trombolys vid slaganfall=[Save the brain-network in the county of Uppsala for throbolytic therapy in stroke]2004In: Lakartidningen, ISSN 0023-7205, Vol. 101, no 8, p. 678-82Article in journal (Refereed)
  • 20.
    Lundström, Erik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience.
    Dennis, M.
    University of Edinburgh, Centre for Clinical Brain Sciences, Edinburgh, United Kingdom.
    Mead, G.
    University of Edinburgh, Centre for Clinical Brain Sciences, Edinburgh, United Kingdom.
    The Effects Of Fluoxetine On Fracture Risk After Stroke: Further Analyses From The Focus Trial2019Conference paper (Other academic)
    Abstract [en]

    Background and Aims: The FOCUS trial showed that 20mg of fluoxetine daily, for six months, started 2–15 days post stroke had no effect on the modified Rankin scale (mRS), reduced the risk of new depression (Risk difference 3.8%) but increased the risk of bone fractures (Risk difference 1.4%). Further analyses aimed to explore the factors associated with bone fractures.

    Methods: Sixty five of the 3127 (2.1%) patients enrolled had a fracture within six months of randomisation. Of these 59 (90.8%) resulted from a fall and 26 (40%) affected the neck of femur. Cox proportional hazards modelling of the risk of fracture showed that only age ≤70yr (Hazard Ratio = 0.51 (95%CI 0.29-0.89; p = 0.017), female sex (HR = 2.13 (1.29-3.51; p = 0.003) and fluoxetine treatment (HR = 2.00 (1.20-3.34; p = 0.008) were independent predictors. Stroke pathology, severity, type of deficit, prior fractures, other medication affecting blood pressure, bone density and balance had no significant effect. Furthermore, removing patients with a fracture from the primary analysis did not significantly alter the effect on mRS (Common odds ratio 0.951 with fractures, 0.961 without).

    Results: Only increasing age, female sex and fluoxetine were independent predictors of fracture risk. Most fractures resulted from falls. Although many of the fractures were serious, and are likely to have impaired patients’ function, the increased fracture risk did not explain the lack of observed effect of fluoxetine on mRS.

    Conclusions: A future individual patient data meta-analysis including the patients from the ongoing AFFINITY and EFFECTS trials may clarify the mechanism of fractures due to fluoxetine.

    Trial registration number: ISRCTN registry, number ISRCTN83290762.

  • 21.
    Lundström, Erik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Rehabilitation Medicine.
    Smits, Anja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Borg, Jörgen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Rehabilitation Medicine.
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Four-fold increase in direct costs of stroke-survivors with spas-ticity compared to stroke-survivors without spasticity: the first year after the event2010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 2, p. 319-324Article in journal (Refereed)
    Abstract [en]

    Background and Purpose:

    The prevalence of spasticity after first-ever stroke is approximately 20%, but there are no health economic studies on costs associated with spasticity after stroke. The objective of our study was to estimate direct costs of stroke with spasticity for patients surviving up to one year after the stroke event in comparison to costs of stroke without spastic-ity.

    Methods:

    A representative sample of first-ever stroke patients hospitalized at Uppsala University Hospital was eligible for our cross-sectional survey. All direct costs during one year were identified for each patient, includ-ing costs for hospitalization (acute and rehabilitation), primary health care, medication, and costs for municipality services. The Swedish currency (SEK) was converted into Purchasing Power Parities US dollar (PPP$).

    Results:

    Median age (inter-quartile range) was 73 years (18), and the proportion of women was 48%. The majority of the direct costs (78%) were associated with hospitalization, whereas 20% was associated with municipality services during one year after first-ever stroke. Only 1% of all direct costs were related to primary health care and 1% to medication. The level of costs for stroke patients was correlated with the presence of spasticity, as measured with modified Ashworth Scale (rs = 0.524), and with the degree of disability, as measured with modified Rankin Scale (rs = 0.624). The mean (median, inter-quartile range) direct cost for stroke patients with spasticity was PPP$ 84 195 (72 116, 53 707) compared to PPP$ 21 842 (12 385, 17 484) for stroke patients without spasticity (P < 0.001).

    Conclusions:

    Direct costs for stroke patients with spasticity are four times higher than direct costs for non-spasticity stroke patients during the first year after the event.

  • 22.
    Lundström, Erik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Smits, Anja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Borg, Jörgen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Rehabilitation Medicine.
    Risk factors for stroke-related pain 1 year after first-ever stroke2009In: European Journal of Neurology, ISSN 1351-5101, E-ISSN 1468-1331, Vol. 16, no 2, p. 188-193Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE:

    To estimate the prevalence of stroke-related pain and to explore its relation to spasticity.

    DESIGN:

    Cross-sectional survey.

    PATIENTS AND METHODS:

    One hundred and forty patients were examined at 1 year after first-ever stroke. Pain was assessed by a structured interview and categorized as stroke-related or not, pain intensity by use of the visual analogue scale (VAS), spasticity by use of the modified Ashworth scale, stroke severity and the presence of specific neurological impairments by use of the National Institute of Health Stroke Scale (NIHSS), and depression by use of the Montgomery-Asberg Depression Scale.

    RESULTS:

    Pain was reported by 68 patients (49%) with a mean VAS of 42 (95% CI 36-47). In 29 patients (21%), pain was categorized as stroke-related pain. Univariate analyses demonstrated correlations between stroke-related pain and total NIHSS score, paresis, sensory disturbance, depression and spasticity respectively. A multiple regression analysis demonstrated an independent association of stroke-related pain with paresis (OR = 3.1, 95% CI 1.2-7.7), sensory disturbance (OR = 3.1, 95% CI 1.1-8.9) and depression (OR = 4.1, 95% CI 1.4-13).

    CONCLUSIONS:

    The estimated prevalence of stroke-related pain was 21%. Stroke-related pain was associated with sensorimotor impairments and depression, but not with spasticity as an independent variable.

  • 23.
    Lundström, Erik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Smits, Anja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Terént, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Borg, Jörgen
    Time-course and determinants of spasticity during the first six months following first-ever stroke2010In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 42, no 4, p. 296-301Article in journal (Refereed)
    Abstract [en]

    Purpose:

    To explore the occurrence of and risk factors for spasticity until six months after first-ever stroke.

    Methods:

    Forty-nine patients were examined at day 2-10, at one month, and at six months. The Modified Ashworth Scale (MAS) was used to assess resistance to passive movements. A comprehensive clinical examination was performed to identify other positive signs of the upper motor neuron syndrome, in accordance with a broader definition of spasticity, and to evaluate if spasticity was disabling. Neurological impairments were determined by use of the National Institutes of Health Stroke Scale and global disability by use of the modified Rankin Scale.

    Results:

    Spasticity was present in two patients (4%) at day 2-10, in 13 patients (27%) at one month, and in 11 patients (23%) at six months. Severe paresis at day 2-10 was associated with a 10-fold higher risk for spasticity at one month (OR=10, 95% CI 2-48). Disabling spasticity was present  in one patient at one month and in 6 patients (13%) at six months.

    Conclusions:

    Spasticity according to MAS usually occurs within one month and disabling spasticity later in a subgroup. Severe paresis of the arm is a risk factor for spasticity.

  • 24.
    Lundström, Erik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Zini, Andrea
    Wahlgren, Nils
    Ahmed, Niaz
    How common is isolated dysphasia among patients with stroke treated with intravenous thrombolysis, and what is their outcome? Results from the SITS-ISTR.2015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 11, article id e009109Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To describe the frequency and outcome of isolated dysphasia among patients treated with intravenous thrombolysis (IVT).

    DESIGN: Patients registered in the SITS International Stroke Thrombolysis Register (SITS-ISTR).

    PARTICIPANTS: Patients with stroke (N=58,293) treated with IVT between December 2002 and December 2012.

    SETTING: A multinational, prospective, observational monitoring register.

    MAIN OUTCOME MEASURES: Isolated dysphasia and modified Rankin Scale (mRS).

    METHODS: We identified patients presenting with isolated dysphasia by reviewing items within the baseline National Institutes of Health Stroke Scale (NIHSS). We performed descriptive statistics for baseline and demographic data, and reported patients' characteristics, radiological data and changes in their NIHSS score within 7 days and mRS score at 3 months. We also reported corresponding data from the general SITS-ISTR cohort.

    RESULTS: We found isolated dysphasia at baseline in 1.14% (663/58,293) of all patients treated with IVT patients. Patients with isolated dysphasia had a longer onset to treatment time, lower proportion of visible infarctions on admission imaging scan and atrial fibrillation, and were less often classified as having large vessels causing strokes, in comparison with the rest of the SITS-ISTR. Symptomatic intracerebral haemorrhage occurred in 2.3% of patients per SITS-MOST definition and fatal outcome in 5.5%. At 7 days, 50% of patients with isolated dysphasia recovered completely and at 3 months, 86.3% patients were functionally independent (mRS score 0-2), 71.7% had an excellent outcome (mRS score 0-1) and 45.5% had an mRS score of 0.

    CONCLUSIONS: A low proportion of patients with isolated dysphasia are treated with IVT. Half of these patients were fully recovered at 7 days.

  • 25. Mead, Gillian E
    et al.
    Dennis, Martin
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Murray, Veronica
    Hackett, Maree
    Hankey, Graeme J
    Letter by Mead et al Regarding Article, "Selective Serotonin Reuptake Inhibitors for Stroke: More Trials are Needed"2013In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 44, no 4, p. E40-E41Article in journal (Other academic)
  • 26. Mead, Gillian E
    et al.
    Legg, Lynn
    Tilney, Russel
    Hsieh, Cheng Fang
    Wu, Simiao
    Lundström, E
    Uppsala University, Disciplinary Domain of Science and Technology, Mathematics and Computer Science, Department of Information Technology, Automatic control. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Landtblom: Neurology.
    Rudberg, Ann Sofie
    Kutlubaev, Mansur
    Dennis, Martin S
    Soleimani, Babak
    Barugh, Amanda
    Hackett, Maree L
    Hankey, Graeme J
    Fluoxetine for stroke recovery: Meta-analysis of randomized controlled trials.2019In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, article id 1747493019879655Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To determine whether fluoxetine, at any dose, given within the first year after stroke to patients who did not have to have mood disorders at randomization reduced disability, dependency, neurological deficits and fatigue; improved motor function, mood, and cognition at the end of treatment and follow-up, with the same number or fewer adverse effects.

    METHODS: Searches (from 2012) in July 2018 included databases, trials registers, reference lists, and contact with experts. Co-primary outcomes were dependence and disability. Dichotomous data were synthesized using risk ratios (RR) and continuous data using standardized mean differences (SMD). Quality was appraised using Cochrane risk of bias methods. Sensitivity analyses explored influence of study quality.

    RESULTS: The searches identified 3414 references of which 499 full texts were assessed for eligibility. Six new completed RCTs (n = 3710) were eligible, and were added to the seven trials identified in a 2012 Cochrane review (total: 13 trials, n = 4145). There was no difference in the proportion independent (3 trials, n = 3249, 36.6% fluoxetine vs. 36.7% control; RR 1.00, 95% confidence interval 0.91 to 1.09, p = 0.99, I2 = 78%) nor in disability (7 trials n = 3404, SMD 0.05, -0.02 to 0.12 p = 0.15, I2 = 81%) at end of treatment. Fluoxetine was associated with better neurological scores and less depression. Among the four (n = 3283) high-quality RCTs, the only difference between groups was lower depression scores with fluoxetine.

    CONCLUSION: This class I evidence demonstrates that fluoxetine does not reduce disability and dependency after stroke but improves depression.

  • 27. Mead, Gillian
    et al.
    Hackett, Maree L
    Lundström, E
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology. Karolinska Univ Hosp, Dept Neurol, Solna, Sweden.
    Murray, Veronica
    Hankey, Graeme J
    Dennis, Martin
    The FOCUS, AFFINITY and EFFECTS trials studying the effect(s) of fluoxetine in patients with a recent stroke: a study protocol for three multicentre randomised controlled trials.2015In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 16, article id 369Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Several small trials have suggested that fluoxetine improves neurological recovery from stroke. FOCUS, AFFINITY and EFFECTS are a family of investigator-led, multicentre, parallel group, randomised, placebo-controlled trials that aim to determine whether routine administration of fluoxetine (20 mg daily) for 6 months after acute stroke improves patients' functional outcome.

    METHODS/DESIGN: The three trial investigator teams have collaboratively developed a core protocol. Minor variations have been tailored to the national setting in the UK (FOCUS), Australia and New Zealand (AFFINITY) and Sweden (EFFECTS). Each trial is run and funded independently and will report its own results. A prospectively planned individual patient data meta-analysis of all three trials will subsequently provide the most precise estimate of the overall effect of fluoxetine after stroke and establish whether any effects differ between trials and subgroups of patients. The trials include patients ≥18 years old with a clinical diagnosis of stroke, persisting focal neurological deficits at randomisation between 2 and 15 days after stroke onset. Patients are randomised centrally via web-based randomisation systems using a common minimisation algorithm. Patients are allocated fluoxetine 20 mg once daily or matching placebo capsules for 6 months. Our primary outcome measure is the modified Rankin scale (mRS) at 6 months. Secondary outcomes include the Stroke Impact Scale, EuroQol (EQ5D-5 L), the vitality subscale of the Short-Form 36, diagnosis of depression, adherence to medication, adverse events and resource use. Outcomes are collected at 6 and 12 months. The methods of collecting these data are tailored to the national setting. If FOCUS, AFFINITY and EFFECTS combined enrol 6000 participants as planned, they would have 90 % power (alpha 5 %) to detect a common odds ratio of 1.16, equivalent to a 3.7 % absolute difference in percentage with mRS 0-2 (44.0 % to 47.7 %). This is based on an ordinal analysis of mRS adjusted for baseline variables included in the minimisation algorithm.

    DISCUSSION: If fluoxetine is safe and effective in promoting functional recovery, it could be rapidly, widely and affordably implemented in routine clinical practice and reduce the burden of disability due to stroke.

    TRIAL REGISTRATION:

    FOCUS: ISRCTN83290762 (23/05/2012), AFFINITY: ACTRN12611000774921 (22/07/2011).

    EFFECTS: ISRCTN13020412 (19/12/2014).

  • 28. Roaldsen, M. B.
    et al.
    Soyland, M. -H
    Jusufovic, M.
    Tveiten, A.
    Lundström, E
    Uppsala University, Disciplinary Domain of Science and Technology, Mathematics and Computer Science, Department of Information Technology, Automatic control. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Landtblom: Neurology.
    Petersson, J.
    Putaala, J.
    Korv, J.
    Christensen, H. K.
    Jatuzis, D.
    Engelter, S.
    de Marchis, G. M.
    Werring, D.
    Robinson, T.
    Mathiesen, E.
    Berge, E.
    TWIST tenecteplase in wake-up ischaemic stroke trial2019In: European Journal of Neurology, ISSN 1351-5101, E-ISSN 1468-1331, Vol. 26, no 1, SIArticle in journal (Refereed)
  • 29.
    Ronne-Engström, Elisabeth
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
    Enblad, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
    Lundström, E
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Outcome After Spontaneous Subarachnoid Hemorrhage Measured With the EQ-5D2011In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 42, no 11, p. 3284-3286Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: The EQ-5D measures quality of life based on self-reported health status in 5 dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. In this study, the EQ-5D was evaluated as an outcome measure for patients with subarachnoid hemorrhage.

    METHODS: The EQ-5D was completed in 710 patients 9 months after subarachnoid hemorrhage. Relevant demographic and clinical factors were evaluated as predictors of the 5 outcome dimensions in a series of linear regression models.

    RESULTS: Worse health status in mobility, self-care, and usual activities was predicted by increasing age and by a more severe disease as indicated by the presence of an aneurysm, worse clinical condition at admission, or more blood on the CT scan. Younger age and female gender predicted worse health status regarding anxiety/depression. '

    CONCLUSIONS: The evaluation of the EQ-5D reveals age-related differences in the nature of the challenges faced by these patients.

  • 30.
    Ronne-Engström, Elisabeth
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
    Enblad, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Health-related quality of life at median 12 months after aneurysmal subarachnoid hemorrhage, measured with EuroQoL-5D2013In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 155, no 4, p. 587-593Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    A measurement of quality of life (QoL) should cover the important aspects of daily life and be easy to perform. Ease of performance is especially important for patients with spontaneous subarachnoid haemorrhage (SAH), since fatigue and cognitive disabilities are known sequeles. EuroQoL (EQ-5D) is a preference-based instrument measuring QoL, based on self-reported health status in five dimensions: Mobility, Self-Care, Usual Activities, Pain/Discomfort and Anxiety/Depression. In the present study EuroQoL was used in patients with aneurysmal SAH (aSAH) in comparison with a Swedish reference population. We also determined the extent to which demographic characteristics and clinical parameters predicted outcome.

    METHODS:

    Seven hundred fifty-five patients with aSAH were studied after a median 12 months. The proportion of patients in the best QoL category for each dimension was compared with the corresponding proportion in an age matched reference population. Disease severity was measured using the World Federation of Neurosurgical Societies' SAH grading system and the Fisher scale. The extent to which demographic and clinical factors predicted outcome was evaluated using linear regression.

    RESULTS:

    Aneurysmal SAH patients generally had a worse QoL compared with the reference population, in all five dimensions of EQ-5D. In the patient population, disease severity predicted worse outcome in all five dimensions. Female gender and surgery as treatment method (in the case of anterior aneurysms) predicted worse outcome in Usual Activities and Anxiety/Depression.

    CONCLUSION:

    The nature of the sequeles after SAH depends on severity of disease, gender and treatment method. These factors should be more emphasised in planning rehabilitation.

  • 31. Rudberg, Ann-Sofie
    et al.
    Berge, Eivind
    Gustafsson, Anders
    Näsman, Per
    Lundström, Erik
    Long-term health-related quality of life, survival and costs by different levels of functional outcome six months after stroke2018In: European Stroke Journal, ISSN 2396-9873, E-ISSN 2396-9881Article in journal (Refereed)
  • 32. Sandercock, P
    et al.
    Lindley, R
    Wardlaw, J
    Dennis, M
    Innes, K
    Cohen, G
    Whiteley, W
    Perry, D
    Soosay, V
    Buchanan, D
    Venables, G
    Czionkowska, A
    Kobayashi, A
    Berge, E
    Bruins Slot, K
    Murray, V
    Peeters, A
    Hankey, GJ
    Matz, K
    Brainin, M
    Ricci, S
    Cantisani, TA
    Gubitz, G
    Phillips, J
    Arauz, A
    Correia, M
    Lyrer, P
    Kane, I
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Update on the third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke and baseline features of the 3035 patients recruited2011In: Trials, ISSN 1745-6215, Vol. 12, p. 252-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Intravenous recombinant tissue plasminogen activator (rtPA) is approved in Europe for use in patients with acute ischaemic stroke who meet strictly defined criteria. IST-3 sought to improve the external validity and prediction of the estimates of the overall treatment effects (efficacy and safety) of rtPA in acute ischaemic stroke, and to determine whether a wider range of patients might benefit.

    DESIGN:

    International, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rtPA in acute ischaemic stroke. Suitable patients had to be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracranial haemorrhage and stroke mimics.

    RESULTS:

    The initial pilot phase was double blind and then, on 01/08/2003, changed to an open design. Recruitment began on 05/05/2000 and closed on 31/07/2011, by which time 3035 patients had been included, only 61 (2%) of whom met the criteria for the 2003 European approval for thrombolysis. 1617 patients were aged over 80 years at trial entry. The analysis plan will be finalised, without reference to the unblinded data, and published before the trial data are unblinded in early 2012. The main trial results will be presented at the European Stroke Conference in Lisbon in May 2012 with the aim to publish simultaneously in a peer-reviewed journal. The trial result will be presented in the context of an updated Cochrane systematic review. We also intend to include the trial data in an individual patient data meta-analysis of all the relevant randomised trials.

    CONCLUSION:

    The data from the trial will: improve the external validity and prediction of the estimates of the overall treatment effects (efficacy and safety) of iv rtPA in acute ischaemic stroke; provide: new evidence on the balance of risk and benefit of intravenous rtPA among types of patients who do not clearly meet the terms of the current EU approval; and, provide the first large-scale randomised evidence on effects in patients over 80, an age group which had largely been excluded from previous acute stroke trials. Trial registration ISRCTN25765518.

  • 33. Yeo, Leonard L L
    et al.
    Andersson, Tommy
    Yee, Kong Wan
    Tan, Benjamin Y Q
    Paliwal, Prakash
    Gopinathan, Anil
    Nadarajah, Mahendran
    Ting, Eric
    Teoh, Hock L
    Cherian, Robin
    Lundström, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
    Tay, Edgar L W
    Sharma, Vijay K
    Synchronous cardiocerebral infarction in the era of endovascular therapy: which to treat first?2017In: Journal of Thrombosis and Thrombolysis, ISSN 0929-5305, E-ISSN 1573-742X, Vol. 44, no 1, p. 104-111Article in journal (Refereed)
    Abstract [en]

    A cardiocerebral ischemic attack (CCI) or a concurrent acute ischemic stroke (AIS) and myocardial infarction (AMI) is a severe event with no clear recommendations for ideal management because of the rarity of the scenario. The narrow time window for treatment and complexity of the treatment decision puts immense pressure on the treating physician. We evaluated this challenging situation at our tertiary center. Using our prospective stroke database out of a total of 555 patients with acute ischemic stroke between 2009 and 2014, we identified five consecutive cases with CCI (incidence 0.009%). Demography, risk factor characteristics, vascular occlusions and treatment approach were recorded. Good functional outcome was defined by the modified Rankin scale (mRS) score of 0-2 points. Out of five patients, AIS was treated with endovascular treatment in three cases, while two were treated with intravenous thrombolysis only. One out of three patients had embolectomy of the brain performed prior to the coronary intervention, while the other two patients underwent coronary intervention first. One patient developed sudden cardiac arrest on day-2 and passed away. CCI is an uncommon and devastating clinical scenario, further research is needed for the ideal management strategy that provides the best outcomes. However, the rarity of the disease does not lend itself to the conduct of a trial easily. We have proposed a considered treatment algorithm based on the current literature and our experience.

  • 34. Yeo, Leonard L L
    et al.
    Holmin, Staffan
    Andersson, Tommy
    Lundström, Erik
    Karolinska institutet, Solna, Sweden.
    Gopinathan, Anil
    Lim, Er Luen
    Leong, Benjamin S H
    Kuan, Win Sen
    Ting, Eric
    Tan, Benjamin Y Q
    Eide, Sterling Ellis
    Tay, Edgar L K
    Nongated Cardiac Computed Tomographic Angiograms for Detection of Embolic Sources in Acute Ischemic Stroke2017In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 48, no 5, p. 1256-1261Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: axis coverage of a non-ECG-gated computed tomographic angiogram performed in the primary evaluation of acute stroke without increasing the contrast dose.

    METHODS: Twenty consecutive patients with acute ischemic stroke within the 4.5 hours of symptom onset were prospectively recruited. We increased the longitudinal coverage to the domes of the diaphragm to include the heart. Contrast administration (Omnipaque 350) remained unchanged (injected at 3-4 mL/s; total 60-80 mL, triggered by bolus tracking). Images of the heart and aorta, reconstructed at 5 mm slice thickness in 3 orthogonal planes, were read by a radiologist and cardiologist, findings conveyed to the treating neurologist, and correlated with the transthoracic or transesophageal echocardiogram performed within the next 24 hours.

    RESULTS: Of 20 patients studied, 3 (15%) had abnormal findings: a left ventricular thrombus, a Stanford type A aortic dissection, and a thrombus of the left atrial appendage. Both thrombi were confirmed by transesophageal echocardiography, and anticoagulation was started urgently the following day. None of the patients developed contrast-induced nephropathy on follow-up. The radiation dose was slightly increased from a mean of 4.26 mSV (range, 3.88-4.70 mSV) to 5.17 (range, 3.95 to 6.25 mSV).

    CONCLUSIONS: Including the heart and ascending aorta in a routine non-ECG-gated computed tomographic angiogram enhances an existing imaging modality, with no increased incidence of contrast-induced nephropathy and minimal increase in radiation dose. This may help in the detection of high-risk cardiac and aortic sources of embolism in acute stroke patients.

  • 35.
    Zetterberg, Lena
    et al.
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Neuroscience. Teknisk-naturvetenskapliga vetenskapsområdet, Mathematics and Computer Science, Department of Information Technology, Automatic control. Enheten för sjukgymnastik.
    Aquilonius, S-M
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Neuroscience. Teknisk-naturvetenskapliga vetenskapsområdet, Mathematics and Computer Science, Department of Information Technology, Automatic control.
    Lindmark, Birgitta
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Neuroscience. Teknisk-naturvetenskapliga vetenskapsområdet, Mathematics and Computer Science, Department of Information Technology, Automatic control. Enheten för sjukgymnastik.
    Lundström, E
    Teknisk-naturvetenskapliga vetenskapsområdet, Mathematics and Computer Science, Department of Information Technology, Automatic control.
    Stokes, V
    Teknisk-naturvetenskapliga vetenskapsområdet, Mathematics and Computer Science, Department of Information Technology, Automatic control.
    Färnstrand, C
    Halvorsen, K
    Objective assessment in cervical dystonia.2004In: Proceedings from ESMAC 13th Annual Meeting of European Society of Movement Analysis of Adult and Children in Warsaw, Poland, 23-25 September 2004., 2004Conference paper (Other scientific)
  • 36.
    Zetterberg, Lena
    et al.
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Neuroscience. sjukgym.
    Halvorsen, K
    Färnstrand, Catarina
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Neuroscience. neurofysiologi.
    Lundström, Erik
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Neuroscience. neurologi.
    Lindmark, Birgitta
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Neuroscience. sjukgym.
    Aquilonius, S-M
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Neuroscience. neurologi.
    Objective assessment of cervical dystonia: a pilot study2005In: Acta Neurol Scand, Vol. 112, p. 248-253Article in journal (Refereed)
1 - 36 of 36
CiteExportLink to result list
Permanent link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf