Browsing by Subject "stroke"

Backround Returning to work (RTW) is an essential part of stroke patients’ wellbeing. According to previous literature, severity of stroke is the most consistent predictor of RTW. However, the role of neuropsychological rehabilitation and cognitive deficits in the context of RTW is less clear. Closer examination of the predictors of RTW could enable the identification of stroke patients who are in a greater risk of unsuccessful RTW. Analyzing the connections between rehabilitation and RTW could help to provide better treatment. We studied whether RTW could be predicted by acute cognitive deficits, duration and different elements of neuropsychological rehabilitation. Methods Participants were 79 stroke patients (33% women) who had received outpatient neuropsychological rehabilitation. Prior to stroke, all patients had been either full or part time working or studying. Patients were neuropsychologically assessed in the acute phase. Logistic regression was used to assess variables associated with RTW. Results Of the patients, 49% had returned to work. Deficits in attention and processing speed predicted poorer likelihood to RTW. Fewer outpatient visits and more straightforward content of the rehabilitation were associated with RTW, possibly due to lesser stroke severity. Finally, most of the aspects of neuropsychological rehabilitation were associated with RTW. Conclusions According to this study, RTW of stroke patients can partly be predicted by acute cognitive performance. Results regarding attention and processing speed are in congruence with previous research. Additional research is needed to clarify the relations of cognitive performance and neurorehabilitation to RTW.

Background and purpose: Cognitive impairment is a common and well-known consequence of supratentorial infarct, but its prevalence and severity after infratentorial infarct is unclear. We compared the frequency and prognostic value of domain-specific cognitive deficits after supratentorial and infratentorial infarct. Methods: In a consecutive cohort of first-ever stroke patients (N=244) admitted to Helsinki University Hospital, 37 patients had an infratentorial infarct. Patients were assessed by a neuropsychologist 3 months post-stroke in 9 cognitive domains, and functional disability was assessed at 15 months. Frequencies of cognitive deficits were compared using the Pearson chi-square test. The association between cognitive deficits and functional disability at the 15-month follow-up was analysed using logistic regression. Results: There was no significant difference between the frequency of cognitive deficits in patients with infratentorial vs supratentorial infarct. Altogether 73% of patients with infratentorial infarct and 82.1% of patients with supratentorial infarct had impairment in at least one cognitive domain, and 42.3% in the infratentorial group and 47.3% in the supratentorial group had deficits in 3 or more cognitive domains. In the infratentorial group, only visuoconstructional and spatial functions showed at least a convincing trend of association with functional disability at 15 months (OR 9.0, 95%CI 1.3-62.5, p=0.027). In the supratentorial group, both executive functions and attention (OR 2,9, 95%CI 1.5-5.8, p=0.002) and visuoconstructional and spatial functions (OR 2.9, 95%CI 1.5-5.7, p=0.001) showed this association. Conclusion: Cognitive deficits are as common in infratentorial as in supratentorial infarct, and it is important to recognize them to meet the needs of rehabilitation.

Intracerebral blödning under graviditet eller puerperium (pICH) är en av de främsta orsakerna till mödradödlighet. Trots det är den tillgängliga epidemiologiska informationen gällande etiologin och utfall för pICH bristfällig. Därmed utförde vi en retrospektiv, riksomfattande studie och en kapslad fall-kontrollstudie med etiologin i fokus. Vi identifierade patienter som drabbats av pICH under tidsperioden 1987–2016 i Finland från Registret över födda barn och Registret över sjukhusutskrivningar. Klinisk information samlades från patientjournaler. För varje fall valdes tre matchade kontroller med en graviditet utan stroke. Vi använde SMASH-U klassifikationssystemet för att klassificera fallen enligt etiologi. Totalt identifierades 49 fall av pICH, varav hälften drabbades under graviditet och hälften under peripartum eller puerperium. Majoriteten av patienterna (35,4%) hade en systemisk sjukdom som etiologi. Preeklampsi, eklampsi och HELLP-syndrom var de mest förekommande systemiska sjukdomarna. En kärlmissbildning var etiologin för 31,3% och för 31,3% förblev etiologin oklar. En patient hade kronisk hypertension som etiologi. Viktigaste riskfaktorn var hypertensiva tillstånd under graviditet, som diagnostiserades hos 31%. Patienterna med systemisk sjukdom hade sämst prognos. Mödradödligheten var 12,5%. Enligt vår kännedom är vår studie den första riksomfattande studien gällande etiologin för pICH i Europa. pICH kopplas till hög dödlighet och har allvarliga konsekvenser även för patienter i Finland. Därmed är tidig identifiering och vård av hypertensiva tillstånd under graviditet viktigt för att förebygga denna allvarliga graviditetskomplikation.

Atrial fibrillation is the most common sustained cardiac arythmia. It has been estimated that there will be 14 to 17 million atrial fibrillation patients in Europe by the year 2030. In Finland, there are over 50 000 atrial fibrillation patients. The prevalence of atrial fibrillation increases by age. In addition to age, people who have hearth failure, high blood pressure, coronary artery disease, valvular hearth disease, diabetes mellitus, chronic kidney disease or who suffer from obesity have increased prevalence. Atrial fibrillation is usually not a life threatening condition. However, people who suffer from atrial fibrillation have a greater risk of the stroke compared with people who have normal sinus rhythm. Warfarin has been the standard treatment for preventing the stroke in atrial fibrillation patients. However, there are many inconveniences in warfarin therapy such as food and drug interactions and frequent laboratory visits. Therefore, new oral anticoagulants have been introduced to prevent the stroke in non-valvular atrial fibrillation. These new drugs apixaban, dabigatran, edoxaban and rivaroxaban are more expensive than warfarin. Many people suffer from atrial fibrillation and the number of atrial fibrillation patients is increasing. Due to the expected increase in the number of atrial fibrillation patients in future the costs of the new drugs have led to a concern for their impact on the health care budget. The knowledge of the cost-effectiveness of the new anticoagulants is important for decision making. In this Master's thesis, the cost-effectiveness of rivaroxaban was compared with warfarin for stroke prevention in non-valvular atrial fibrillation. Systematic literature review was used as the study method and 363 studies were screened and 23 of them filled the inclusion criteria. One was a previously published systematic review and 22 were cost-utility studies. All of the cost-utility studies had used decision analytic modelling. The studies were conducted in 13 different countries. In the cost-utility studies included in this systematic review there was a great variability in the cost-effectiveness of rivaroxaban compared with warfarin. Rivaroxaban was cost-effective in more than half of the studies, for example in Belgium, Italy, Norway and Singapore. However, in China, Thailand and Slovenia the cost-effectiveness could not be established. Contradictory cost-effectiveness results were obtained in studies conducted in Germany, Canada and USA. The incremental cost-effectiveness ratio varied from 2580 € to 174915 € per quality adjusted life years (QALY) gained with warfarin over all the 22 cost-utility studies. In studies conducted in Europe the incremental cost effectiveness ratio varied from 4188 € 139163 €/QALY gained. In studies where rivaroxaban, apixaban, dabigatran and warfarin were compared together using an indirect comparison or a network meta-analysis it seemed that rivaroxaban was not the optimal treatment. The most common adverse effect of anticoagulation treatment is bleeding. This complication was included in all the cost-utility studies. However, there was only some uniformity of the bleeding events reported. In most cost-utility studies the acute care cost of intracranial hemorrhages was reported and in many studies, also the long term costs. The cost-utility studies included in this systematic review were quite heterogeneous. Because they were done in different countries their health care settings, treatment options and costs were different. There were also differences in cost-effective models. Modell structure, settings, data and assumptions were different. Due to the heterogeneous nature of the studies, no unambiguous answer could be reached to the question concerning the cost-effectiveness of rivaroxaban compared with warfarin. The quality assessment of the cost-utility studies revealed that some quality criteria were not met. Transferability of the results from one country to the other seemed to be poor. The strength of this master's thesis is the comprehensive literature search concerning the cost-effectiveness of rivaroxaban compared with warfarin. Also, the reporting of methods and results are transparent. There are also limitations in this study. One person was conducting the literature search, data extraction and quality assessment. This might have increased the risk for subjective interpretations and errors.

The immune system is crucial in the central nervous system (CNS), protecting sensitive tissues, promoting regeneration, and maintaining homeostasis. It is involved in CNS-disorders, such as neurodegenerative diseases and neurological insults related to stroke. Critical myeloid leukocytes in the CNS are microglia, divided into pro-inflammatory M1 and anti-inflammatory M2 phenotypes. This polarization achieves modulation of the inflammatory response by amplifying or dampening it. Therefore, microglia are widely investigated in CNS-disorders. β2-integrins are adhesion proteins that mediate inflammation. They are expressed explicitly on leukocytes, including microglia. Important processes, such as phagocytosis and cell motility, are regulated by β2-integrins. They also relay downstream signals, altering inflammation in many settings, although their effects on microglial properties and stroke are currently poorly understood. We here aimed to investigate the role of β2-integrins in stroke-related injury and microglia polarization in vivo using knock-in (KI) mice, which lack functional β2-integrins. Our results show that in a mouse model of haemorrhagic stroke, the functional outcome was less severe in β2-integrin KI versus wild-type (WT) mice (P = 0.0147), suggesting that β2-integrins are involved in stroke pathophysiology. Furthermore, by using flow cytometry we observed significantly lower frequencies of M1 microglia in the KI mouse brain (P = 0.0096). Therefore, our findings reveal neuroprotective aspects by inhibiting β2-integrins in neuroinflammation. Investigating microglial properties mediated by β2-integrins could contribute to the understanding of neuroinflammatory events, leading to the development of therapies for poorly treated CNS-disorders. Our results suggest that β2-integrins should be further explored as molecular targets for novel stroke treatments.