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Stress reactions and ischemic CVAs after the September 11, 2001 terrorist attacks

      To the Editor:—After the tragic events of September 11 in New York, many stress reactions have been reported. In particular, a study conducted by the University of California reported that after terrorist attacks, the 44% of adults who were not present at those events developed substantial symptoms of stress.
      • Schuster M.A.
      • Stein B.D.
      • Jaycox L.H.
      • et al.
      A National survey of stress reactions after the September 11, 2001, terrorist attacks.
      Furthermore, severe psychologic trauma and related stress can alter mental and physical healthness,
      • DeVries A.C.
      • Joh H.D.
      • Bernard O.
      • et al.
      Social stress exacerbates stroke outcome by suppressing Bcl-2 expression.
      ,
      • Stalnikowicz R.
      • Tsafrir A.
      Acute psychosocial stress and cardiovascular events.
      and the recent Caerphilly Study showed that psychologic distress has been associated with fatal ischemic strokes.
      • May M.
      • McCarron P.
      • Stansfeld S.
      • et al.
      Does psychological distress predict the risk of ischemic stroke and transient ischemic attack?.
      We evaluate, from our register of acute cerebrovascular accidents, whether this circumstance led to an increase in ischemic cerebrovascular events.
      Since 1998 at Fatebenefratelli Hospital, in Milan, Italy, we have registered every patient arriving at the ED because of an acute cerebrovascular event. Between 1998 and December 31, 2001, we registered 1528 patients with an ischemic stroke. From this register we tabulate every case of ischemic stroke in the period between September 11 and October 7 (the day of the first U.S. attack on Afghanistan). We compare the relevant data during the interval September 11 and October 7 since 1998. We also calculate the number of registered patients born before 1940 as subjects who have already been through a war experience. Data are analyzed by the Student t test and chi-squared test. A P value lower than .05 is considered significant.
      In the considered period (September 11-October 7), the percentage of the registered cases was higher in 2001 than in other years (Table 1). There were more females with an acute cerebrovascular accident and mean and median age were higher in 2001. In the 2001 cohort, there was a higher percentage of subjects born before 1940 in the considered period than the annual percentage for 2001. This difference was higher in 2001 than in the other years (Table 2). Only in 2001, the median age of the considered period was higher than median age of cases registered in the year. None of the data were statistically significant.
      TABLE 1Distribution of Data for Every Year
      1998199920002001
      No. of patients37332936
      Percent per year6.78.97.79.5
      Male (%)18 (48.6)17 (51.5)14 (48.3)12 (33.3)
      Female (%)19 (51.4)16 (48.5)15 (51.7)24 (66.7)
      Mean age (± SD)
      Data in considered period (September 11-October 7).
      73 ± 1079 ± 1172 ± 1479 ± 10
      Median age
      Data in considered period (September 11-October 7).
      75777581
      Mean age/year (± SD)76 ± 1276 ± 1275 ± 1274 ± 14
      Median age/year78787777
      Abbreviation: SD, standard deviation.
      Data in considered period (September 11-October 7).
      TABLE 2Percentage of Subjects Born Before 1940
      1998199920002001
      Annual percentage92.190.790.685.4
      Period
      Period = September 11–October 7.
      percentage
      89.290.986.291.7
      Δ percentage (period
      Period = September 11–October 7.
      — year)
      −2.9+0.2−4.4+6.3
      Period = September 11–October 7.
      The relationship between stressful life events and onset of disease is well documented.
      • DeVries A.C.
      • Joh H.D.
      • Bernard O.
      • et al.
      Social stress exacerbates stroke outcome by suppressing Bcl-2 expression.
      ,
      • Stalnikowicz R.
      • Tsafrir A.
      Acute psychosocial stress and cardiovascular events.
      ,
      • Boden-Albala B.
      • Sacco R.L.
      Lifestyle factors and stroke risk exercise, alchool, diet, obesity, smoking, drug use, and stress.
      The brain mediates and integrates all the cognitive activities, the emotional experiences, and finally the behaviours.
      • Carota A.
      • Staub F.
      • Bogousslavsky J.
      Emotions, behaviours and mood changes in stroke.
      Devries et al. demonstrated that stressful experience significantly compromises an endogenous molecular mechanism of neuroprotection in an injured brain.
      • DeVries A.C.
      • Joh H.D.
      • Bernard O.
      • et al.
      Social stress exacerbates stroke outcome by suppressing Bcl-2 expression.
      In this way, stress could play a role as cofactor in increasing the stroke risk. Our data show that in the period between September 11 and October 7, the percentage of stroke was higher than during the same period in other years. As a result of the chronobiologic rhythm, the onset of ischemic stroke is more common in September, in fact, an increase in ischemic events in the autumnal months has been already reported,
      • Villa A.
      • Paese S.
      • Bonacina M.
      • Meroni L.
      • Omboni E.
      Chronobiological risk in onset of acute cerebrovascular diseases.
      but the percentage of events in September 2001 was higher than in other years in any case. In addition, mean age in the considered period was higher and there were more patients born before 1940.
      We believe that those who have already experienced a war could be more susceptible to events that recall these experiences.
      Our data represent a relatively limited number of a local register and thus do not constitute an epidemiologic study. However, they could suggest that even in our reality, which seems far from New York, such a dramatic event can provoke psychologic stress that can contribute to the precipitation of a cerebrovascular event.

      References

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        • Stein B.D.
        • Jaycox L.H.
        • et al.
        A National survey of stress reactions after the September 11, 2001, terrorist attacks.
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        • Joh H.D.
        • Bernard O.
        • et al.
        Social stress exacerbates stroke outcome by suppressing Bcl-2 expression.
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        • Tsafrir A.
        Acute psychosocial stress and cardiovascular events.
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        • McCarron P.
        • Stansfeld S.
        • et al.
        Does psychological distress predict the risk of ischemic stroke and transient ischemic attack?.
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        • Sacco R.L.
        Lifestyle factors and stroke risk.
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        Emotions, behaviours and mood changes in stroke.
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        • Paese S.
        • Bonacina M.
        • Meroni L.
        • Omboni E.
        Chronobiological risk in onset of acute cerebrovascular diseases.
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