Long-term aspects of stroke : survival, health-related quality of life and costs

Sammanfattning: Stroke, a disease that affects millions of people globally every year, is an emergency situation requiring fast and immediate action in hospital. Acute stroke treatments have rapidly improved and been developed over the recent decades and stroke mortality is decreasing. However, many patients suffer from long-term health deficits, making stroke a condition with a vast spectrum of decreased functional outcomes with associated healthcare and ensuing societal costs. This thesis focuses on the impact of acute stroke in life after stroke. Thrombolysis given as an acute treatment to ischemic stroke has well documented effect on improved functional outcome, but long-term survival after thrombolysis has been poorly investigated. We performed a three-year follow up on patients with ischemic stroke and did not find a significant difference in survival between patients receiving thrombolysis compared to those receiving standard of care (Study I). However, among those who survived the first seven days after the stroke, patients who received thrombolysis did have a significantly better survival compared to those who received standard of care. Long-term deficits after stroke includes hemiparesis, depression, decreased cognition, communication deficits, and post-stroke fatigue, symptoms affecting health-related quality of life. With an increasing number of stroke-survivors the impact on patients and society are immense. We performed an investigation which showed that health-related quality of life and survival is associated with stroke related functional outcome (Study II). The study also showed that survival decreased and costs to healthcare increased with decreasing functional outcome after stroke. Further we investigated the impact of disability level on health-related quality of life over time and found that patients with the lower functional outcome after stroke subsequently decrease in health-related quality of life, whereas stroke survivors with a better functional outcome after stroke increased in health-related quality of life over time (Study III). Studies II-III demonstrated that patients perceive life differently, depending on severity of their functional deficit, with many stroke patients suffering from low health-related quality of life. The diversity in needs from individual patients challenges healthcare provision when deciding on interventions required in order to improve health-related quality of life after stroke. Research on improving the life after stroke is likely to have the best impact if addressing areas directed by the patients. Therefore, we asked a large group of patients what research areas they prioritized in life after stroke (Study IV). We found that most stroke patients prioritize more research on balance and walking difficulties. The second most prioritized area was post-stroke fatigue, and that was in particular evident among younger stroke patients. Together these results display the high need for both rehabilitation and further research to improve the quality of life and survival after stroke, and at the same time decrease the burden to healthcare and society.