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Stroke subtype and mortality. a follow-up study in 998 patients with a first cerebral infarct
Gosse de Jong1, Lisette van Raak, Fons Kessels
1Department of Neurology, Isala Clinics-Weezenlanden, Postbus 10500, 8000 GM Zwolle, The Netherlands.
Insights
Mortality after a first cerebral infarct varies significantly by stroke subtype, with cardioembolic stroke patients facing the highest risk and lacunar stroke patients the lowest. However, lacunar stroke is not mild, as a quarter die within two years.
Area of Science:
- Neurology
- Cardiology
- Public Health
Background:
- Cerebral infarct (stroke) is a leading cause of mortality and disability worldwide.
- Understanding mortality patterns across different ischemic stroke subtypes is crucial for targeted interventions.
- Previous studies have not fully elucidated long-term survival differences between lacunar, cardioembolic, and atherothrombotic stroke subtypes.
Purpose of the Study:
- To investigate mortality rates following a first-ever cerebral infarct.
- To compare mortality across ischemic stroke subtypes: lacunar, cardioembolic, and atherothrombotic.
- To identify prognostic variables influencing mortality after stroke.
Main Methods:
- A hospital-based prospective registry of first-ever cerebral infarct patients was utilized.
- Standardized methods and CT scans ensured high case ascertainment for first and recurrent strokes.
- Statistical analyses included logistic regression for 30-day and 1-year mortality, and Cox proportional hazard modeling for long-term survival, alongside Kaplan-Meier curves and log-rank tests.
Main Results:
- Overall 30-day case fatality was 10%, 1-year mortality was 15%, and 36% died by the end of follow-up (mean 691 days).
- Mortality was lowest in lacunar stroke (2%, 12%, 14% at 30 days, 1 year, and end of follow-up, respectively), intermediate in atherothrombotic stroke, and highest in cardioembolic stroke (23%, 22%, 21%).
- Diabetes mellitus, age, and initial stroke severity predicted 30-day fatality, while only diabetes and age predicted later mortality. Recurrent stroke and heart failure were significant causes of death.
Conclusions:
- Prognosis after a first cerebral infarct differs significantly by stroke subtype, with cardioembolic stroke carrying the grimmest outlook.
- Lacunar stroke, despite lower initial mortality, has a substantial long-term fatality rate, underscoring it is not a mild condition.
- Improving long-term survival may involve therapies reducing stroke recurrence and enhancing heart failure management.
Abstract:
The aim of this article was to study mortality following a first-ever cerebral infarct, accounting for ischemic stroke subtypes (lacunar, cardioembolic, atherothrombotic) and relevant prognostic variables. This study was done from s a hospital-based prospective registry of all patients with a first cerebral infarct, with a high case ascertainment of first and recurrent stroke by CT. We used a cross-sectional follow-up, using standardized methods. Analyses were performed using crude comparison of mortality data and death causes between stroke subtypes. We analyzed 30-day case fatality and 1-year mortality in 30-day survivors by means of logistic regression analysis, and mortality in 1-year survivors by means of Cox proportional hazard modeling. We also constructed Kaplan-Meier survival curves, and used log-rank testing for differences between stroke subtypes. Thirty-day case fatality was 10%, 1-year mortality 15%, and after 1-year mortality 16%. Mean follow-up was 691, SD 521 days. At the end of follow-up 36% of all patients had died. Mortality was at all three time points lowest in lacunar stroke (2, 12, and 14%, respectively), intermediate in atherothrombotic stroke (10, 16, and 15%, respectively), and highest in cardioembolic stroke (23, 22, and 21%, respectively). Death related to recurrent stroke was similar in all three stroke subtypes (13-16%). Although 30-day case fatality rate was low in lacunar stroke, a quarter of lacunar stroke patients had died at the end of follow-up. Diabetes mellitus, age, stroke subtype, and initial stroke severity were independent predictors of 30-day case fatality, but only diabetes and age were consistent independent predictors for later mortality. Recurrent stroke and heart failure were important death causes. Prognosis for (future) death following a first cerebral infarct differs between stroke subtypes; lacunar stroke patients have the lowest mortality. However, lacunar stroke cannot be regarded as a mild stroke type, as after 2 years more than a quarter of such stroke patients had died. Cardioembolic stroke patients have the grimmest prognosis: more than half of them had died within 1.5 years. Better prognosis for long-term survival following stroke may be achieved by therapies which lower the risk of stroke recurrence, provide better treatment of heart failure, or both.