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October 31, 2017; 89 (18) ArticleOpen Access

Thrombolysis in acute ischemic stroke in patients with dementia

A Swedish registry study

Eva Zupanic, Mia von Euler, Ingemar Kåreholt, Beatriz Contreras Escamez, Johan Fastbom, Bo Norrving, Dorota Religa, Milica G. Kramberger, Bengt Winblad, Kristina Johnell, Maria Eriksdotter, Sara Garcia-Ptacek
First published October 6, 2017, DOI: https://doi.org/10.1212/WNL.0000000000004598
Eva Zupanic
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Mia von Euler
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Ingemar Kåreholt
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Beatriz Contreras Escamez
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Johan Fastbom
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Bo Norrving
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Dorota Religa
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Milica G. Kramberger
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Bengt Winblad
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Kristina Johnell
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Maria Eriksdotter
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Sara Garcia-Ptacek
From the Karolinska Institutet (E.Z., D.R., B.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Huddinge, Sweden; Department of Neurology (E.Z., M.G.K.), University Medical Centre, Ljubljana, Slovenia; Karolinska Institutet (M.v.E.), Department of Clinical Science and Education, Södersjukhuset, and Department of Medicine, Solna; Karolinska University Hospital (M.v.E.), Department of Clinical Pharmacology; Karolinska Institutet and Stockholm University (I.K., J.F., K.J.), Aging Research Center, Stockholm, Sweden; Jönköping University (I.K.), Institute of Gerontology, School of Health and Welfare, Aging Research Network–Jönköping; Karolinska Institutet (B.C.E., M.E., S.G.-P.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden; Department of Geriatrics (B.C.E.), Hospital Universitario de Getafe, Madrid, Spain; Lund University (B.N.), Skane University Hospital, Department of Clinical Sciences Lund, Neurology; Karolinska University Hospital, Department of Geriatric Medicine (D.R., M.E., S.G.-P.); and Södersjukhuset (S.G.-P.), Department of Internal Medicine, Section for Neurology, Stockholm, Sweden.
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Citation
Thrombolysis in acute ischemic stroke in patients with dementia
A Swedish registry study
Eva Zupanic, Mia von Euler, Ingemar Kåreholt, Beatriz Contreras Escamez, Johan Fastbom, Bo Norrving, Dorota Religa, Milica G. Kramberger, Bengt Winblad, Kristina Johnell, Maria Eriksdotter, Sara Garcia-Ptacek
Neurology Oct 2017, 89 (18) 1860-1868; DOI: 10.1212/WNL.0000000000004598

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This article has a correction. Please see:

  • Thrombolysis in Acute Ischemic Stroke in Patients With Dementia - July 20, 2021
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Abstract

Objective: To compare access to intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) and its outcomes in patients with and without dementia.

Methods: This was a longitudinal cohort study of the Swedish dementia and stroke registries. Patients with preexisting dementia who had AIS from 2010 to 2014 (n = 1,356) were compared with matched patients without dementia (n = 6,755). We examined access to thrombolysis and its outcomes at 3 months (death, residency, and modified Rankin Scale [mRS] score). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with logistic and ordinal logistic regression.

Results: The median age at stroke onset was 83 years in both groups. IVT was administered to 94 (7.0%) patients with dementia and 639 (9.5%) patients without dementia. The OR of receiving IVT was 0.68 (95% CI 0.54–0.86) for patients with dementia. When the analysis was repeated exclusively among patients independent in everyday activities, dementia status was no longer significant (OR 0.79, 95% CI 0.60–1.06). However, differences persisted in patients ≤80 years of age (OR 0.58, 95% CI 0.36–0.94). In patients who received thrombolysis, the incidence of symptomatic intracerebral hemorrhage (sICH; 7.4% vs 7.3%) and death at 3 months (22.0% vs 18.8%) did not differ significantly between the 2 groups. However, mRS score and accommodation status were worse among patients with dementia after 3 months in adjusted analyses (both p < 0.001). Unfavorable outcomes with an mRS score of 5 to 6 were doubled in patients with dementia (56.1% vs 28.1%).

Conclusions: Younger patients with dementia and AIS are less likely to receive IVT. Among patients receiving thrombolysis, there are no differences in sICH or death, although patients with dementia have worse accommodation and functional outcomes at 3 months.

GLOSSARY

ADL=
activities of daily living;
AIS=
acute ischemic stroke;
ATC=
Anatomical Therapeutic Chemical;
CI=
confidence interval;
ICD-10=
International Classification of Diseases, 10th revision;
IVT=
intravenous thrombolysis;
MMSE=
Mini-Mental State Examination;
mRS=
modified Rankin Scale;
NIHSS=
NIH Stroke Scale;
OR=
odds ratio;
Riksstroke=
Swedish national quality registry for acute vascular diseases of the brain;
RLS=
Reaction Level Scale;
sICH=
symptomatic intracranial hemorrhage;
SveDem=
Swedish Dementia Registry

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. The Article Processing Charge was funded by Swedish Research Council and Johanniterorden i Sverige/Swedish Order of Saint John.

  • Received March 29, 2017.
  • Accepted in final form August 11, 2017.
  • Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology

This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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