Types of stroke and outcomes following stroke

Despite advances in management, strokes generally show a poor prognosis including a high case fatality rate

Ischaemic strokes account for about 80% of cases in Europe, although this varies from 55% to 90% depending on the study. Intracerebral and subarachnoid haemorrhages account for 10–25% and 0.5–5% of strokes respectively.Numerous well-established factors contribute to the risk of developing a stroke including hypertension, dyslipidaemia, carotid stenosis and AF.7 Nevertheless, cryptogenic strokes and TIAs, those with an unknown aetiology, account for between 25% and 39% of strokes.8

Ischaemic strokes interrupt the cerebral blood supply, causing areas of cell death in the brain.9 The reduction in cerebral blood can fall beneath the threshold for brain function, generally 25–50% of the perfusion before the stroke. These areas generally recover if blood flow returns. A further decrease to about 20% or less of the flow before the stroke can lead to irreversible tissue damage, which is generally closer to the area of reduced blood supply. The penumbra refers to the range between these thresholds. The infarction develops from the core of ischaemia propagating a wave of irreversible tissue damage that spreads through the penumbra reaching areas less severely affected by the reduced blood flow.10 

In ischaemic stroke, the necrotic core can arise in three ways:9

  • small vessel disease, which may be non-atherosclerotic or atherosclerotic, arises from blockages in the small cerebral perforating arteries
  • large vessel disease results from occlusions or emboli released by the rupture of atherosclerotic plaques in the carotid artery or another large blood vessel
  • cardioembolic stroke arises typically from emboli that travel from the heart to the cerebral arteries

AF may cause up to half of cardioembolic strokes.11

Outcomes following stroke

Case fatality rates after a stroke

Case fatality rates after a stroke increase from about 15% at 1 month, to 25% at 1 year and 50% at 5 years. Following intracerebral haemorrhage, case fatality rates increase from 55% at 1 year to 70% after 5 years.7

Despite advances in management – such as tissue plasminogen activator, which, when used promptly, reduces the propagation of the ischaemic penumbra – strokes generally show a poor prognosis (Table 1), including a high case fatality rate. About 40% of people who survive are disabled, defined as a modified Rankin Scale score of 3–5, 1 month and 5 years after the stroke.7

Table 1. Outcomes of stroke in Europe.3

Stroke outcomes

Recurrent strokes are also common, underscoring the importance of secondary prevention with oral anticoagulants. Following an ischaemic stroke or TIA, the risk of recurrence is about 10% at 1 week and 18% at 3 months. Rapid assessment and treatment reduces the risk of recurrence by 80%. Longer term, the recurrence risk is about 10%, 25% and 40% after 1, 5 and 10 years respectively. The likelihood of recurrence is especially high among people with symptomatic atherosclerotic disease, vascular risk factors, an active source of thrombosis (such as AF), or who discontinued antiplatelet and antihypertensive drugs.7

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