The prevalence of depression after stroke was comparable with that reported from other studies, and considerably less than that reported from in-patient and rehabilitation units.

Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28-item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM-III criteria. The GHQ-28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ-28 having an overall superiority. The performance of all 3 scales for screening post-stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.

In a population based register of stroke (n = 536) compiled in Perth, Western Australia during an 18 month period in 1989-90, 60 cases (11%) of primary intracerebral haemorrhage were identified among 56 persons (52% men). The mean age of these patients was 68 (range 23-93) and 46 (77%) events were first ever strokes. The crude annual incidence was 35 per 100 000, with a peak in the eighth decade, and a male predominance. Deep and lobar haemorrhages each accounted for almost one third of all cases. The clinical presentations included sudden coma (12%), headache (8%), seizures (8%), and pure sensory-motor stroke (3%). Primary intracerebral haemorrhage was the first presentation of leukaemia in two cases (both fatal) and it followed an alcoholic binge in four cases. 55% had a history of hypertension. 16 (27%) patients, half of whom had a history of hypertension, were taking antiplatelet agents, and one patient was taking warfarin. There were only two confirmed cases of amyloid angiopathy. The overall 28 day case fatality was 35%, but this varied from 100% for haemorrhages in the brainstem to 22% for those in the basal ganglionic or thalamic region. Other predictors of early death were intraventricular extension of blood, volume of haematoma, mass effect, and coma and severe paresis at onset. Although based on small numbers, these data confirm the heterogeneous nature of primary intracerebral haemorrhage, but they also suggest a different clinical spectrum of this type of stroke in the community compared with the experience of specialist neurological units. (7 Neurol Neurosurg Psychiatry 1994;57:936-940) For many years medical thinking about the aetiology of primary intracerebral haemorrhage (PICH) has been dominated by the influence of chronic hypertension and a characteristic vasculopathy of the penetrating branches of major cerebral arteries called lipohyalinosis.' Since the advent of CT, however, there has been a reappraisal of the pathogenesis for this uncommon but most lethal subtype of stroke.23 This instrument has given clinicians the ability to distinguish PICH from cerebral infarction accurately, rather than relying on correlation of the symptoms and signs with the findings at necropsy in the subset of patients for whom such data become available. Moreover, it is now possible to diagnose small, peripheral (lobar) PICHs that might have been misdiagnosed as cerebral infarction in the pre-CT era.4 Although hypertension remains the prominent risk factor for PICH,5 the frequency of massive ganglionic PICH seems to have diminished over

BackgroundThe prevalence of anxiety disorders in 294 patients who survived to four months in the Perth Community Stroke Study (Perth, Australia), and a follow-up of these patients at 12 months, are presented.MethodDiagnoses are described both in the usual DSM hierarchic format and by a non-hierarchic approach. Adoption of the hierarchic approach alone greatly underestimates the prevalence of anxiety disorders.ResultsMost cases were of agoraphobia, and the remainder were generalised anxiety disorder. The prevalence of anxiety disorders alone was 5% in men and 19% in women; in community controls, it was 5% in men and 8% in women. Adopting a non-hierarchic approach to diagnosis gave a prevalence of 12% in men and 28% in women. When those who showed evidence of anxiety disorder before stroke were subtracted, the latter prevalence was 9% in men and 20% in women.ConclusionOne-third of the men and half of the women with post-stroke anxiety disorders showed evidence of either depression or an anxiety disorder at the time of the stroke. At 12 month follow-up of 49 patients with agoraphobia by a non-hierarchic approach, 51 % had recovered, and equal proportions of the remainder had died or still had agoraphobia. The only major difference in outcome between those with anxiety disorder alone and those with comorbid depression was the greater mortality in the latter.

SummaryRadiographs and medical and surgical records of 51 patients following spinal injury have been reviewed. All the patients had been paraplegic for 20 years or more at the time of the survey. The reason for the survey was to assess the incidence of degenerative change of the hips, sacroiliac and shoulder joints in patients following spinal injury. Our review indicates that the number of para plegic patients who develop degeneration of hip and sacroiliac joint changes is less significant than has been previously reported. Analysis of our figures has revealed certain important associations which predispose these patients to joint degeneration. The associations (anatomical level of injury, urinary tract infec tions, and the level of the patients' activity) with joint degeneration are de scribed.

ObjectiveTo determine the incidence and case fatality of seven distinct subtypes of stroke in Perth, Western Australia. Design and settingA population‐based descriptive epidemiological study. SubjectsAll residents of a geographically defined segment of the Perth metropolitan area (estimated population 138 708 persons) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, Inclusive. Main outcome measuresThe following subtypes of stroke were classified according to standard clinical, radiological and pathological criteria: types of cerebral infarction, namely, large artery (thrombotic) occlusive infarction (LAOI), cerebral embolic infarction (EMBI), lacunar infarction (LACI) and boundary zone infarction (BZI); primary intracerebral haemorrhage (PICH); subarachnoid haemorrhage (SAH); and stroke of undetermined cause. ResultsOver the 18‐month study period 538 stroke events were registered, of which 86% (95% confidence interval, 83%–89%) had a defined “pathological” diagnosis on the basis of computed tomographic scanning, magnetic resonance imaging or necropsy. Cerebral infarction accounted for 71% of cases (95% CI, 68%–75%), PICH 11% (95% CI, 9%–14%) and SAH 4% (95% CI, 2%–5%). The 382 cases of cerebral infarction included LAOI (in approximately 71%), EMBI (15%), LACI (10%) and BZI (5%). While the incidence of all subtypes of stroke Increased with age, there were age and sex differences in their proportional frequency, management and prognosis: patients with PICH, SAH and EMBI were more likely to be admitted to hospital, and these conditions carried the highest early case fatality. Over all, the 28‐day case fatality was 24% (95% CI, 20%–28%), but varied from 0 for LACI and BZI, to 37% (95% CI, 15%–59%) for SAH and 35% (CI, 23%–47%) for PICH. ConclusionsIn this study, we found considerable differences In incidence rates, the effect of age and sex on incidence rates, and prognosis for the different subtypes of stroke. Hospital‐based studies are likely to be selectively biased by emphasising strokes that are severe and require admission to hospital. These data have important implications in the design and evaluation of clinical trials of therapy for stroke.

ObjectiveTo determine the age and sex specific incidence, and case fatality of stroke in Perth, Western Australia. Design and settingA population‐based descriptive epidemiological study. SubjectsAll residents of a geographically defined segment of the Perth metropolitan area (population 138 708) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, Inclusive. Main outcome measuresDefinite acute “first‐ever‐in‐a‐lifetime” (first‐ever) and recurrent stroke classified according to standard definitions and criteria. ResultsDuring the 18‐month study period, 536 stroke events occurred among 492 patients, 69% of which were first‐ever strokes. The crude annual event rate for all strokes was 258 (95% confidence interval 231–285) per 100 000, and the overall case fatality at 28 days was 24% (95% CI, 20%–28%). The crude annual incidence for first‐ever strokes was 178 (95% CI, 156–200) per 100 000; 189 (95% CI, 157–221) per 100 000 in males and 166 (95% CI, 136–196) per 100 000 in females. The corresponding rates, age‐adjusted to the “world” population, were 132 (95% CI, 109–155) for males and 77 (95% CI, 60–94) for females. ConclusionsIn contrast to mortality rates for Ischaemic heart disease, the incidence of stroke in Australia appears little different from that for several other Western countries. For both mates and females the incidence of stroke rises exponentially with increasing age. Although the sex‐dependent difference in the risk of stroke is greatest in middle age, males are at greater risk of stroke even among the most elderly. To determine the incidence of stroke accurately, population‐based studies of stroke need exhaustive and overlapping sources of case ascertainment. If only cases admitted to hospital had been used, we would have underestimated the rate of stroke among the most elderly by almost 40%. We estimate that approximately 37 000 people, about 50% of whom are over the age of 75, suffer a stroke each year in Australia.

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