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Background and Purpose-Significant bone mineral density (BMD) reduction occurs in stroke patients on the hemiplegic side compared with the intact side. To elucidate the pathogenesis of hip fractures in this population, we measured serum markers of bone metabolism and BMD in the stroke patients within 1 year (early group) and between 1 and 2 years after onset of hemiplegia (long-term group). Methods-Sera were collected from 51 patients from the early group and 93 patients from the long-term group. All patients had hemiplegia. Sera were assayed for pyridinoline cross-linked carboxy-terminal telopeptide of type I collagen (ICTP; a bone resorption marker) and bone Gla protein (a bone formation marker). The z score of BMD was determined in both second metacarpals. Results-Serum ICTP concentrations (ng/mL) were higher in the early group (15.4Ϯ4.1) than in the long-term group (6.7Ϯ4.4). Bone Gla protein was normal or low in both groups. Multiple regression analysis identified Barthel Index, degree of hemiplegia, and illness duration as independent determinants of ICTP in the early group, whereas Barthel Index, degree of hemiplegia, and serum calcium were determinants of ICTP in the long-term group. There were statistically significant correlations between the z score of the hemiplegic side and age, Barthel Index, degree of hemiplegia, illness duration, 25-hydroxyvitamin D (25-OHD), and ICTP in the early group and between the z score and degree of hemiplegia and 25-OHD level in the long-term group. Conclusions-The pathogenesis of reduced BMD differed between the early and long-term stroke groups. These results suggest that in the early group, increased bone resorption caused by immobilization was responsible for osteopenia on the hemiplegic side, whereas the degree of hemiplegia and 25-OHD level were the determinants of osteopenia in the long-term group. (Stroke. 1998;29:1373-1377.)

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Background and Purpose-Risk of hip fracture after stroke is 2 to 4 times that in a reference population. Osteomalacia is present in some patients with hip fractures in the absence of stroke, while disabled elderly stroke patients occasionally have severe deficiency in serum concentrations of 25-hydroxyvitamin D (25-OHD) (Յ5 ng/mL). To determine the effects of vitamin D status on hip fracture risk, we prospectively studied a cohort of patients with hemiplegia after stroke who were aged at least 65 years. Methods-We compared baseline serum indices of bone metabolism, bone mineral density, and hip fracture occurrence in stroke patients with serum 25-OHD Յ25 nmol/L (Յ10 ng/mL; deficient group, nϭ88) with findings in patients from the same cohort who had 25-OHD levels 26 to 50 nmol/L (10 to 20 ng/mL; insufficient group, nϭ76) or Ն51 nmol/L (Ն21 ng/mL; sufficient group, nϭ72). Results-Over a 2-year follow-up interval, hip fractures on the paretic side occurred in 7 patients in the deficient group and 1 patient in the insufficient group (PϽ0.05; hazard ratioϭ6.5), while no hip fractures occurred in the sufficient group. The 7 hip fracture patients in the deficient group had an osteomalacic 25-OHD level of Ͻ5 ng/mL. Higher age and severe immobilization were noted in the deficient group. Serum 25-OHD levels correlated positively with age, Barthel Index, and serum parathyroid hormone. Conclusions-Elderly disabled stroke patients with serum 25-OHD concentrations Յ12 nmol/L (Յ5 ng/mL) have an increased risk of hip fracture. Immobilization and advanced age cause severe 25-OHD deficiency and consequent reduction of BMD.