Several hospital-based studies suggest a circadian rhythm for stroke, with a peak of onset in the morning. To verify whether these results could be confirmed in a community-based study, we used data from the SEPIVAC, a community-based stroke register in Umbria, Italy. Cerebral infarctions (48%), primary intracerebral hemorrhages (54%), subarachnoid hemorrhages (53%) and ''not known'' strokes (51%) were all more common between 6 a.m. and noon, and this peak was still present when strokes recognized on awakening were evenly redistributed over the sleep period. Looking at the subgroups of cerebral infarction, lacunar syndromes were more common during sleep. Cerebral infarctions were more frequent during winter, and primary intracerebral hemorrhages during autumn.

The SEPIVAC study is a communitybased epidemiological survey of incidence and outcome of acute cerebrovascular disease in the Sixth Local Health Unit, Umbria, Italy (population 49 218). The study was carried out from 1 September 1986 to 31 August 1989. There were 375 patients who were registered with a first ever stroke, with a crude rate of 2-54 (95% confidence limits 2-29-2-81) per 1000 per year; the rate adjusted to the European population is 1 55 (CL 1-36-1-77). The age adjusted relative risk for males is 1-35 (CL 1-101-66). Up to 15% of the patients were not admitted to hospital during the acute phase of their disease. At least 286 (76-3%, CL 72-80 6) of the cases were due to cerebral ischaemia; in 56 of these (19-6%, CL 15-24-2) a clinical diagnosis of lacunar ischaemia was made. The 30 day case fatality rate was 20-3% (CL 16-2-24-3); between one and six months 7-5% (CL 5-10-6) of patients died.

An improvement in patient arrival time to stroke unit (SU) is recommended, since earlier stroke management seems to improve 'per se' functional outcome. The objective of this study was to determine if early admission influences the outcome, reduces disability and mortality at discharge and three months later independent of tlirombolytic treatment. Consecutive acute stroke patients admitted to SU between January 1st 2000 and December 31st 2003 were studied in order to analyze the actual role of acute management independent specific pharmacological treatment, we excluded subjects who underwent rt-PA. 35.8% of 2,041 consecutive stroke patients arrived within 3 hours; 62.4% within 6 hours; 37.6% arrived later. Approximately 80% of the <6 hour patients presented a National Institutes of Health Stroke Scale (NIHSS) >4 and modified Rankin Scale (mRS) score >2 in comparison with 60% of the >6 hour patients. In hospital (8.7%) and three-month (7.3%) mortality in <3 hour patients were not significantly different from what observed in >3 hour patients (6.8% and 6.1% respectively) while functional outcome after three months was better in <3 hour patients (NIHSS: 34.6 vs 15.2; mRS: 32.9% vs 16.8%). Old age, history of TIA, cardioembolic etiology, severity of neurological deficit and hemorrhagic stroke type all led to earlier arrival time. Admission within 3 hours 'per se' improves outcome and reduced disability at three months.

The SEPIVAC study is a community-based epidemiological survey of incidence and outcome of transient ischaemic attacks (TIAs) and strokes in the territory of the 6th Local Health Unit, Umbria, Italy, where 49,218 people live, from 1 September 1986 to 31 August 1989. All cases were registered with the study either by notification from general practitioners (GPs) or by a check of hospital admission within the study area and in the two hospitals of Perugia. There were 94 incident cases of TIAs (45 males, 49 females), thus giving a crude rate of 0.64 per 1000 per year [95% conficence intervals (CI) 0.52/0.78]. The rate adjusted to the European population is 0.42 (CI 0.33/0.54). Mean age was 69.4 years, and females were significantly older than males. The weighted relative risk for males was 1.19 (CI 0.79/1.79). Thirty-one patients were treated at home by their GPs. Females had hypertension more frequently than males, whereas males smoked more frequently; we did not find any other statistically significant difference in the distribution of risk factors. Twelve patients out of 58 who had CT had an infarct, and 29 out of 54 submitted to Doppler ultrasonography had carotid stenosis. At 1 month, 4 patients had suffered an ischaemic stroke, 1 of whom died. At 6 months, 3 further strokes and 2 further deaths (1 due to myocardial infarction) had occurred.

The SEPIVAC study (Italian initials for "epidemiologic study of incidence of acute cerebrovascular disease") is a community-based epidemiologic survey of incidence and outcome of cerebrovascular disease in the territory of the 6th Local Health Unit, Umbria, Italy, where 49,101 people live. All cases were registered with the study either by notification from general practitioners or by check of hospital admission within the study area and in the two hospitals of Perugia. Death certificates were looked at as well. Patients were registered with the study when the clinical picture fulfilled the definition of stroke and transient ischemic attack (TLA) adopted for this study. Patients were followed up at approximately 30 days and 6 months. During the Arst year of the study (September 1, 1986 to August 31, 1987), 189 cases were registered: 108 suffered a "first ever in a lifetime" stroke, 30 a recurrent stroke, and 51 a "first ever in a lifetime" transient ischemic attack. Sixty-one percent of patients (71% of first strokes) had a computed tomography scan. For our study, the crude annual incidence rate of first stroke was 2.2 per 1,000 (confidence intervals 1.81-2.66); the standardized rate to the European population was 1.36 (confidence intervals 1.06-1.74). At least 83% of first strokes were due to cerebral ischemia; in 26 cases a clinical diagnosis of lacunar ischemia was made. The 30-day case fatality rate was 21%; 25% of our patients had recovered completely or almost completely after 1 month. (Stroke 1989;20:853-857)