ACUTE STROKE - PROGNOSIS AND A PREDICTION OF THE EFFECT OF MEDICAL-TREATMENT ON OUTCOME AND HEALTH-CARE UTILIZATION - THE COPENHAGEN STROKESTUDY

Medical treatment of acute stroke with tissue plasminogen activator (t PA) was recently approved in the United States, and neuroprotective ag ents are being developed. Should all patients with stroke, regardless of severity, receive such treatment? In the Copenhagen Stroke Study we studied the prognosis of stroke in 1,351 unselected patients from a w ell-defined catchment area treated in a community-based stroke unit fr om the time of acute admission to death or the end of rehabilitation. Outcome measures were mortality, discharge rates to the patients' own home or to a nursing home, length of hospital stay, and neurologic and functional outcomes. Prognosis was stratified according to initial st roke severity measured by the Scandinavian Neurological Stroke Scale ( SSS) on admission. We estimated the effect of medical treatment on pro gnosis and health care utilization by assuming a medically induced dec rease in initial stroke severity by 5 and 10 points in the initial SSS score. This mild and moderate decrease in initial stroke severity cor responded to an overall improvement in outcome and an overall cost red uction through shorter hospital stays. This was also true in patients with both mild and moderate stroke. However, in patients with severe s troke, survival increases expenses because of an increased discharge r ate to a nursing home and an increase in the cost of acute care and re habilitation. Future medical stroke trials should therefore focus on t he effect and cost of treatment, especially in patients with severe st roke, and search for factors predictive of good clinical outcome in th is group.