Quality-of-Life Problems Linger Long Term Even After Successful Stroke Treatment

Daniel M. Keller, PhD

November 11, 2016

HYDERABAD, India — Years after successful reperfusion for acute ischemic stroke, problems may linger, even for patients who have very good functional outcomes as assessed by National Institutes of Health Stroke Scale (NIHSS) scores, a study from the University of Gothenberg, Sweden, shows.

"According to the NIH Stroke Scale very few problems remained," Katharina Sunnerhagen, MD, PhD, professor and chair of rehabilitation medicine, said during a poster tour here at the World Stroke Congress (WSC) 2016. "But according to the perception of the patients, there were still lots of remaining problems."

One of the predominant problems that patients reported was a lack of follow-up, both in the acute setting and from primary healthcare providers. She said patients essentially said, "There were angels in the hospital, but then there was nothing."

Reperfusion treatment has become common for ischemic stroke, and near-term outcomes are often well documented, but long-term outcomes and consequences after these therapies have been uncertain, the researchers note.

"Here we go even further down the line from an acute stroke. This is a 5- and 6-year follow-up," Dr Sunnerhagen said.

In an 18-month period during 2009 to -2010, 75 patients received thrombectomy or thrombolysis at Sahlgrenska Hospital for their first-time stroke. The investigators sent out questionnaires about 5 years later. Follow-up home visits were done 6 years after stroke; these visits involved interviews, clinical examinations, and additional questionnaires.

Many Problems Linger

Fifty-four of the patients were alive at long-term follow-up, 31 (57%) answered the survey, and 16 agreed to a home visit. Overall, reperfusion rates had been quite good, and so were most functional outcomes. Of 4 patients who had been treated with thrombectomy, 6 years later their NIHSS scores were 0, 0, 1, and 3, respectively. For the 12 patients treated with thrombolysis, 9 had an NIHSS score of 0 to 2 and 1 each scored 3, 7, and 10.

Nonetheless, the stroke impact scale showed problems in all of its domains, with emotion being the predominant one. The EuroQol Quality of Life scale revealed that 33% of the respondents experienced moderate problems with mobility, 50% had pain or discomfort, and 43% had signs of depression, even though most (56%) were independent in activities of daily living and there were large improvements in the NIHSS scores at follow-up. Cognitive impairment affected 38%.

Patients' expectations appeared to define what they saw as a problem, Dr Sunnerhagen said. She related that a patient "complained he could not jump the way he used to do when he played volleyball." So even though he had no apparent motor deficits on clinical exam, he still reported a diminished quality of life.

She said as patients get better, many expect that they should achieve even more function, and that can color how they view their quality of life. "The whole conclusion is that there is definitely room for improvement of follow-up with patients with reperfusion after stroke," she said.

Poster walk moderator Sunil Gajre, MBBS, MD, DM, head of his own clinic in Jalgaon, Maharashtra, India, asked Dr Sunnerhagen what sorts of improvements she would suggest. She said she is working with the Swedish government to develop guidelines in stroke, and a panel just reached a consensus agreement for follow-up after stroke treatment "at least for the first year and then depending on the needs of the patient and individualizing for follow-up because there is not enough knowledge about the long-term consequences of stroke."

She said that one of the long-term problems is suicide if people are living with the residual effects of stroke, "so we need to treat these patients as patients even though they are 'fixed' by the acute treatment."

Dr Gajre noted that in India stroke patients come for follow-up at 10 days, 1 month, and 3 months after hospital discharge. Patients present their symptoms to the treating neurologist, who then can guide them to seek the appropriate therapy. He asked whether that kind of system would be beneficial in Sweden.

Dr Sunnerhagen said it is already being done, "but life is more than 3 months. It's a long life, hopefully."

In response to a question from Medscape Medical News about whether all the problems seen at 6-year follow up are attributable to the stroke, she replied, "I would say the majority of the disabilities and complaints are related to the stroke, but they do have other comorbidities," she said.

Furthermore, they are 6 years older, so that needs to be considered, she added. "So you have to have a wider scope when you follow patients over time, not just focus on one thing."

Dr Gajre asked whether patients had progressive stroke disease. She said there were no new strokes, and patients who died within the 5- to 6-year period died of other causes, including heart attack, cancer, and car accidents. "So the secondary prevention in this group worked very well as far as the stroke" was concerned, Dr Sunnerhagen said.

There was no commercial funding for the study. Dr Sunnerhagen and Dr Gajre have disclosed no relevant financial relationships.

World Stroke Congress (WSC) 2017. Abstract 187. Presented October 28, 2016.

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