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temporary phenomenon or low body temperature on admission provides long-lasting improvements remains unknown.
Recently, there have been a few small studies of the
feasibility and safety of hypothermic therapy in patients with
acute stroke,9,10 and this seems to be possible and well
tolerated even in awake stroke patients.11 At least 1 randomized clinical trial of hypothermia in acute stroke patients has
been launched recently by a Danish research team. Furthermore, it is a widely accepted practice to avoid hyperthermia
in the early stages after acute stroke.12
In this study, we sought to evaluate whether body temperature on admission is an independent predictor of long-term
prognosis after stroke. The purpose of the study was 2-fold, as
follows: (1) to determine the relation between admission
Received November 23, 2001; final revision received March 12, 2002; accepted April 2, 2002.
From the Departments of Neurology, University Hospital Gentofte (L.P.K., H.S.J., J.A.R., U.J.W., J.H., T.S.O.), Hellerup, and Bispebjerg Hospital
(J.R., H.N.), Copenhagen, Denmark.
Correspondence to Dr Lars Peter Kammersgaard, Department of Neurology, University Hospital Gentofte, Niels Andersensvej 65, DK-2900 Hellerup,
Denmark. E-mail kammersgaard@dadlnet.dk
2002 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
DOI: 10.1161/01.STR.0000019910.90280.F1
1759
1760
Stroke
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TABLE 1.
Number of patients
37C
179 (45.9%)
P Value
211 (54.1%)
Age, years, SD
73.511.6
74.711.0
0.29
Sex female/male
88/179 (49.2%)
108/103 (51.2%)
0.75
36.516.8
30.218.2
0.001
Cerebral hemorrhage
14/125 (10.0%)
19/134 (12.4%)
0.63
Unclassified
40/139 (22.3%)
58/153 (27.3%)
0.58
43/129 (25.0%)
52/145 (26.4%)
0.81
Hypertension
67/106 (38.7%)
60/138 (30.3%)
0.10
Atrial fibrillation
31/146 (17.5%)
46/163 (22.0%)
0.31
Diabetes
25/151 (14.2%)
46/156 (22.8%)
0.04
Intermittent claudication
17/149 (10.2%)
26/161 (13.9%)
0.32
Smoking
76/81 (48.4%)
67/97 (40.9%)
0.18
48/148 (30.8%)
53/115 (31.5%)
0.91
Previous stroke
40/136 (22.7%)
55/143 (27.8%)
0.29
Preexisting disability
34/143 (19.2%)
41/159 (20.5%)
0.80
0.16
7.52.5
7.93.4
144/35 (80.4%)
132/79 (62.5%)
0.001
72/107 (40.2%)
55/156 (26.1%)
0.006
Test statistics were the Student t test for continuous variables and the 2 test for comparison of
dichotomized variables.
Methods
We included all patients with acute stroke (onset within 6 hours)
admitted consecutively, during a 25-month period from 1991 to
1993, to the stroke unit at Bispebjerg Hospital (Copenhagen,
Denmark). The study is prospective and community-based, as has
previously been described in detail.13 Hospital care is free, and a very
high proportion (88%) of the stroke patients in the area were
admitted to this hospital serving a well-defined catchment area of
nearly 240 000 inhabitants in the city of Copenhagen.14 No selection
of patients was performed with regard to age, severity of stroke, or
medical condition before admission. All treatment, rehabilitation,
and diagnostic procedures were performed within the stroke unit.
Patients were not discharged until the rehabilitation team decided
that no further in-hospital improvement could be expected. Therefore, no referral to other departments or hospitals for further
rehabilitation was necessary.
Stroke was defined according to the World Health Organization
criteria.15 The study does not include patients with transient ischemic
attacks or subarachnoid hemorrhage.
The Scandinavian Stroke Scale (SSS) was used to assess stroke
severity.16 The SSS evaluates level of consciousness; eye movement;
power in arm, hand, and leg; orientation; aphasia; facial paresis; and
gait on a total score from 0 (worst) to 58 (best).17 The score was
recorded on admission, weekly during hospital stay, and at discharge
by the same neurologist (H.S.J.). The long-term follow-up data on
mortality and date of death were obtained from the Danish Central
Registry of Persons where date of death for all residents in Denmark
are recorded through a unique 10-digit identification code containing
information on birth date. Another experienced neurologist (L.P.K.)
who was blinded to data obtained on admission prospectively
recorded the follow-up data. Follow-up was performed during the
year 1999 with December 29, 1999, as censoring date.
Results
In Table 1, the basic clinical characteristics are given stratified in 2 groups according to admission body temperature.
Hypothermia was present in 45.9% of the 390 patients
included. Patients who were hyperthermic on admission had
Kammersgaard et al
1761
fibrillation (HR, 0.63; 95% CI, 0.41 to 0.95), and hypertension (HR, 0.67; 95% CI, 0.48 to 0.94) were independent
predictors of survival 3 months after onset.
Discussion
Cox Regression Analysis (Final Model) for All Patients (n294): Overall 2 <0.0001
Variable
Covariate
Coeff (b)
SE (b)
Hazards Ratio
95% CI
Survival
0.23
0.11
0.03
1.30
1.041.57
0.04
0.02
0.09
1.04
0.981.09
0.03
0.004
0.0001
1.32
1.201.43
0.05
0.009
0.0001
1.69
1.432.00
Atrial fibrillation
0.41
0.17
0.01
0.66
0.480.93
Hypertension
0.12
0.16
0.23
0.89
0.631.12
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TABLE 3. Cox Regression Analysis (Final Model) for Patients Surviving 3 Months After Stroke Onset
(n234): Overall 2 <0.0001
Variable
Survival
Covariate
Coeff (b)
SE (b)
Hazards Ratio
95% CI
0.821.52
0.11
0.16
0.50
1.11
0.04
0.04
0.34
1.04
0.961.12
0.02
0.006
0.005
1.18
1.011.32
0.06
0.01
0.0001
1.85
1.512.26
Atrial fibrillation
0.47
0.21
0.03
0.63
0.410.95
Hypertension
0.40
0.18
0.02
0.67
0.480.94
rons are at risk of degenerating if reperfusion is not established within a reasonable time. If temperature is decreased in
the penumbra, a subsequent slowing down of the neurodegenerative processes may result. This means that the time
window for reperfusion to be established will be widened,
and more neurons in the penumbra will be able to survive and
regain their function.
The present study suggests that the neuroprotective effect
of low body temperature go beyond the first few weeks after
stroke onset. We speculate that a slowing down of the
degenerative processes in the penumbra resulting in smaller
brain lesions causes the long-lasting effect of decreased body
temperature. The current results may suggest that if hypothermia proves to be an efficient therapy in acute stroke
patients, this is likely to have long-lasting implications for
mortality. Trials on hypothermia applied deliberately in acute
stroke patients are warranted.
References
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