Biomedical subjects

A Algra

Publications and source records attributed to A Algra.

At least 37 records · Page 2Linked to original sources

PubMed2005

Corticosteroid use and risk of aneurysmal subarachnoid haemorrhage.

OBJECTIVES: Corticosteroids can induce hypertension and inhibit collagen synthesis in the blood vessel wall. Deficiencies in collagen have been found in intracranial aneurysms. Therefore use of corticosteroids could be a risk factor for intracranial aneurysms and aneurysmal subarachnoid haemorrhage (SAH). We investigated the relationship between the systemic use of corticosteroids in the past and the occurrence of aneurysmal SAH. METHODS: We compared the systemic use of corticosteroids (oral or intravenous) in the past between a consecutive series of 1158 patients with aneurysmal SAH and a control group consisting of 1019 patients diagnosed with a primary central nervous system (CNS) tumour. We discriminated between definite use of corticosteroids defined as use mentioned in the medical record and possible use defined as note in the medical record of a disease that may be treated with corticosteroids. We calculated odds ratios (OR) with corresponding 95% confidence intervals (CI) and adjusted for age and sex by means of logistic regression analyses. RESULTS: Twenty (1.7%, 95% CI 1.1-2.7) of the SAH patients and eight (0.8%, 95% CI 0.3-1.5) of the controls had used systemic corticosteroids (OR: 2.22; 95% CI 0.97-5.05; p-value 0.058; adjusted OR 2.23; 95 % CI 0.97-5.15; p-value 0.059). For definite plus possible use the OR was 1.67 (95% CI 1.09-2.54; p-value 0.016) and the adjusted OR 1.52 (95% CI 0.99-2.33; p-value 0.055). CONCLUSIONS: Patients with aneurysmal SAH more often have used systemic corticosteroids in the past than controls. This may suggest that the use of corticosteroids is a risk factor for aneurysmal SAH.

Adrenal Cortex Hormones↗

PubMed2005

Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage.

BACKGROUND: Patients who have had an aneurysmal subarachnoid haemorrhage (SAH) are at very high risk of rebleeding if the aneurysm is not treated. The standard treatment for several decades has been surgical clipping of the neck of the aneurysm. In recent years, an alternative, the introduction of detachable coils to occlude the aneurysm, has become more common. OBJECTIVES: To compare the effects of endovascular coiling versus neurosurgical clipping in patients with aneurysmal subarachnoid haemorrhage. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched in February 2005). In addition we searched MEDLINE (1966 to January 2004) and EMBASE (1980 to January 2004), and contacted trialists. SELECTION CRITERIA: We included randomised trials in which endovascular coiling of aneurysms was compared with neurosurgical clipping in patients with SAH who have proven aneurysm. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information. MAIN RESULTS: We identified three randomised trials: two published and one unpublished. The trials included a total of 2272 patients (range per trial: 20 to 2143 patients). Most of the patients were in good clinical condition and had an aneurysm on the anterior circulation. After one year of follow up, the relative risk (RR) of poor outcome for coiling versus clipping was 0.76 (95% confidence interval (CI) 0.67 to 0.88). The absolute risk reduction was 7% (95% CI 4% to 11%). In the worst-case scenario analysis for poor outcome overall, the relative risk for coiling versus clipping was 0.81 (95% CI 0.70 to 0.92) and the absolute risk reduction was 6% (95% CI 2% to 10%). For patients with anterior circulation aneurysm the relative risk of poor outcome was 0.78 (95% CI 0.68 to 0.90) and the absolute risk decrease was 7% (95% CI 3% to 10%). For those with a posterior circulation aneurysm the relative risk was 0.41 (95% CI 0.19 to 0.92) and the absolute decrease in risk 27% (95% CI 6% to 48%). AUTHORS' CONCLUSIONS: The evidence comes mainly from one large trial. For patients in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation we have firm evidence that, if the aneurysm is considered suitable for both surgical clipping and endovascular treatment, coiling is associated with a better outcome.

Aneurysm, Ruptured↗

PubMed2005

Cognitive and functional outcome after intravenous recombinant tissue plasminogen activator treatment in patients with a first symptomatic brain infarct.

OBJECTIVE: To examine whether intravenous recombinant tissue plasminogen activator (rt-PA) treatment given in the acute phase of ischaemic stroke has a favourable effect on cognitive and functional outcome at six months post-stroke. METHODS: The present study included 92 patients with a first-ever symptomatic infarct, of whom 25 (27%) were subjected to rt-PA treatment in the first three hours post-stroke. Multivariate logistic regression analyses adjusted for stroke severity, education, age, and sex were performed to examine whether rt-PA treatment influenced cognitive outcome (assessed with a neuropsychological examination covering 7 cognitive domains), basic ADL independence (modified Barthel Index > or = 19), and instrumental ADL independence (Frenchay Activities Index > or = 15) after six months. RESULTS: The adjusted odds ratio for intact cognition was 1.0 (95% CI 0.2 to 4.3), that for basic ADL outcome 13.5 (95 % CI 1.4 to 129.4) and for instrumental ADL 7.1 (95 % CI 1.2 to 42.2). CONCLUSION: Our findings suggest that rt-PA treatment is associated with a favourable basic and instrumental ADL outcome, but not with a beneficial cognitive outcome after 6 months.

Activities of Daily Living↗

PubMed2005

Outcome after occlusion of infrainguinal bypasses in the Dutch BOA Study: comparison of amputation rate in venous and prosthetic grafts.

OBJECTIVE: To compare the consequences of occlusion of infrainguinal venous and prosthetic grafts. METHODS: In total, 2690 patients were included in the Dutch BOA study, a multicenter randomised trial that compared the effectiveness of oral anticoagulants with aspirin in the prevention of infrainguinal bypass graft occlusion. Two thousand four hundred and four patients received a femoropopliteal or femorodistal bypass with a venous (64%) or prosthetic (36%) graft. The incidence of occlusion and amputation was calculated according to graft material and the incidence of amputation after occlusion was compared with Cox regression to adjust for differences in prognostic factors. RESULTS: The indication for operation was claudication in 51%, rest pain in 20% and tissue loss in 28% of patients. The mean follow up was 21 months. After venous bypass grafting 171 (15%) femoropopliteal and 96 (24%) femorodistal grafts occluded. After prosthetic bypass grafting 234 (30%) femoropopliteal and 25 (38%) femorodistal grafts occluded. Patients with occlusions in the venous group had more severe ischemia, less runoff vessels and were older than the patients with prosthetic grafts. In the venous occlusion group 54 (20%) amputations were performed compared to 42 (16%) in the prosthetic occlusion group; crude hazard ratio 1.17 (95% CI 0.78-1.75). After adjustment for above mentioned differences in patient characteristics the hazard ratio was 0.86 (95% CI 0.56-1.32). CONCLUSION: The need for amputation after occlusion is not influenced by graft material in infrainguinal bypass surgery.

Aged↗

PubMed2005

The risk of rebleeding after external lumbar drainage in patients with untreated ruptured cerebral aneurysms.

BACKGROUND: Does continuous external lumbar CSF drainage before aneurysm repair in patients with aneurysmal subarachnoid hemorrhage increase the risk of rebleeding? METHOD: The study population, consisting of 18 patients treated by External Lumbar Drainage (ELD) after SAH before aneurysm repair, was compared with an independent control group of 324 SAH patients treated in another clinic. Control patients were selected for not being treated for the ruptured aneurysm yet and not having undergone any form of CSF drainage during the exposure time in the case patients. We calculated hazard ratios with the Cox regression model, adjusted for age and clinical condition on admission and hydrocephalus. FINDINGS: The cox regression analysis shows a non-adjusted hazard ratio of 2.1 (95% CI 0.8 to 5.3) in the model with 5 rebleedings in 18 patients. Adjustment for age, clinical condition on admission and hydrocephalus did not alter the hazard ratio estimate importantly in either analyses. CONCLUSIONS: An increased risk of rebleeding by external lumbar drainage in the acute phase after aneurysmal SAH could not be confirmed, but the data are too imprecise to rule out an increased risk. The potential benefits of early drainage should be weighed against the risks if the aneurysm is not occluded before or early after the start of drainage.

Adult↗

PubMed2005

Corticosteroids for aneurysmal subarachnoid haemorrhage and primary intracerebral haemorrhage.

BACKGROUND: Corticosteroids, particularly dexamethasone, are commonly used for treatments in patients with subarachnoid haemorrhage (SAH) and primary intracerebral haemorrhage (PICH) despite the lack of evidence. OBJECTIVES: This review aimed: (1) to determine whether corticosteroid therapy reduces the proportion of patients who die or have a poor outcome at one to six months after the onset of SAH or PICH; (2) to determine whether corticosteroid therapy reduces the frequency of delayed cerebral ischaemia (DCI) in patients with SAH; (3) to determine the frequency of adverse effects of corticosteroid therapy in patients with SAH or PICH within six months of the onset of the event. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched November 2003). In addition, we searched MEDLINE (1966 to March 2004) and EMBASE (1980 to March 2004), and searched reference lists of relevant studies identified. We also made an attempt to identify any relevant ongoing and published or unpublished studies by contacting trialists and pharmaceutical companies. SELECTION CRITERIA: We sought to identify all randomised or quasi-randomised clinical trials of corticosteroid therapy, in patients with SAH or PICH, that have a placebo or standard strategy arm as control. Patients of any age and either gender with clinically (bed-side) diagnosed PICH and cerebrospinal fluid documented SAH were included in the analysis. The data were analysed both separately and combined for computed tomography (CT)/magnetic resonance imaging (MRI)/autopsy/angiography verified patients. DATA COLLECTION AND ANALYSIS: Data extracted from eligible clinical trials included: (1) death and poor outcome (death, severe disability, or vegetative state) within the first one to six months of the event onset (primary outcomes); (2) development of delayed cerebral ischaemia (as defined by the trialists) in patients with SAH; and (3) adverse effects of the treatment during the scheduled treatment or follow-up period (secondary outcomes). A pooled estimate of the effect size was computed, and the test for heterogeneity between trial results was carried out using The Cochrane Collaboration's Review Manager software, RevMan 4.2. Intention-to-treat analysis was carried out whenever possible. MAIN RESULTS: Eight trials that fulfilled the eligibility criteria were identified, with a total of 256 randomised patients in three SAH trials, and 206 patients in five PICH trials. The studies differed substantially with regard to the study populations and drugs, and methodological quality. The number of patients allocated to either hydrocortisone or fludrocortisone acetate treatment in patients with SAH, or to dexamethasone treatment in patients with PICH, was too small to make any definitive conclusions (confidence intervals were wide for any of the outcome estimates). AUTHORS' CONCLUSIONS: Overall, there is no evidence of a beneficial or adverse effect of corticosteroids in patients with either SAH or PICH. Confidence intervals are wide and include clinically significant effects in both directions.

Adrenal Cortex Hormones↗

PubMed2005

Follow-up screening after subarachnoid haemorrhage: frequency and determinants of new aneurysms and enlargement of existing aneurysms.

Intracranial aneurysms have long been considered a once in a lifetime event. Nevertheless, patients who survive after subarachnoid haemorrhage (SAH) may be at risk for new aneurysms. In a cohort of patients with clipped aneurysms, we studied the yield of screening in the years after the SAH and we tried to identify risk factors for formation of new aneurysms as well as for enlargement of aneurysms that were already present at the time of the SAH. We screened 610 patients who had been admitted between 1985 and 2001 for SAH by means of CT-angiography. Risk factors were evaluated by Cox regression analyses. With screening we detected 129 aneurysms in 96 (16%) patients, after a mean interval of 8.9 years. Of these, 24 (19%) were located at the site of the previously ruptured and clipped aneurysm and 105 (81%) at a site remote from the clip site. Of the aneurysms at a remote site 59 could be compared with the initial (CT)-angiogram. Of these, 19 were truly de novo (32%) and 40 (68%) were already visible in retrospect. Of the 53 aneurysms that were followed over time 13 (25%) had enlarged. Risk factors for aneurysm formation and growth were presence of multiple aneurysms at time of SAH (HR 3.2, 95% CI 1.2-8.6), current smoking (HR 3.8, 95% CI 1.5-9.4) and hypertension (HR 2.3, 95% CI 1.1-4.9). These results suggest that intracranial aneurysms should not be considered as a single event in a lifetime but rather as a continuous process. Patients with a previous SAH have a substantial risk for new aneurysm formation and enlargement of untreated aneurysms. Screening these patients might be beneficial, especially in patients with multiple aneurysms, hypertension and a history of smoking. The risks and benefits of screening, however, should be carefully weighed, for example, in a decision model.

Adult↗

PubMed2005

Timing of aneurysm surgery in subarachnoid haemorrhage--an observational study in The Netherlands.

BACKGROUND: There is still lack of evidence on the optimal timing of surgery in patients with aneurysmal subarachnoid haemorrhage. Only one randomised clinical trial has been done, which showed no difference between early and late surgery. Other studies were observational in nature and most had methodological drawbacks that preclude clinically meaningful conclusions. We performed a retrospective observational study on the timing of aneurysm surgery in The Netherlands over a two-year period. METHOD: In eight hospitals we identified 1,500 patients with an aneurysmal subarachnoid haemorrhage. They were subjected to predefined inclusion criteria. We included all patients who were admitted and were conscious at any one time between admission and the end of the third day after the haemorrhage. We categorised the clinical condition on admission according the World Federation of Neurological Surgeons (WFNS) grading scale. Early aneurysm surgery was defined as operation performed within three days after onset of subarachnoid haemorrhage; intermediate surgery as performed on days four to seven, and late surgery as performed after day seven. Outcome was classified as the proportion of patients with poor outcome (death or dependent) two to four months after onset of subarachnoid haemorrhage. We calculated crude odds ratios with late surgery as reference. We distinguished between management results (reconstructed intention to treat analysis) and surgical results (on treatment analysis). The results were adjusted for the major prognosticators for outcome after subarachnoid haemorrhage. FINDINGS: We included 411 patients. There were 276 patients in the early surgery group, 36 in the intermediate surgery group and 99 in the late surgery group. On admission 78% were in good neurological condition (WFNS I-III). MANAGEMENT RESULTS: Overall, 93 patients (34%) operated on early had a poor outcome, 13 (36%) of those with intermediate surgery and 37 (37%) in the late surgery group had a poor outcome. For patients in good clinical condition on admission and planned for early surgery the adjusted odds ratio (OR) was 1.3 (95% CI 0.5 to 3.0). The adjusted OR for patients admitted in poor neurologicalcondition (WFNS IV-V) and planned for early surgery was 0.1 (95% CI 0.0 to 0.6). SURGICAL RESULTS: For patients in good clinical condition on admission who underwent early operation the adjusted OR was 1.1 (95% CI 0.4 to 3.2); it was 0.2 (95% CI 0.0 to 0.9) for patients admitted in poor clinical condition. CONCLUSIONS: In this observational study we found no significant difference in outcome between early and late operation for patients in good clinical condition on admission. For patients in poor clinical condition on admission outcome was significantly better after early surgery. The optimal timing of surgery is not yet settled. Ideally, evidence on this issue should come from a randomised clinical trial. However, such a trial or even a prospective study are unlikely to be ever performed because of the rapid development of endovascular coiling.

Adolescent↗

PubMed2005

Non-adherence to aspirin or oral anticoagulants in secondary prevention after ischaemic stroke.

BACKGROUND: The effectiveness of medication is influenced by treatment adherence. After TIA or minor disabling stroke patients usually are advised to take antithrombotic medication. Stroke patients are an interesting group of patients with respect to adherence, since cardiovascular risk factors and stroke may (indirectly) negatively influence brain function, which can affect adherence. We investigated determinants of non-adherence in patients who used aspirin or oral anticoagulation after cerebral ischaemia of arterial origin. METHODS: Data of patients prospectively followed in two clinical trials (the Dutch TIA Trial and the Stroke Prevention In Reversible Ischaemia Trial) were analysed with Cox proportional hazards modelling. RESULTS: In the two trials 3796 patients were treated with aspirin. During a mean follow-up of 2.1 years, 689 patients (18%) prematurely stopped treatment, 305 (8 %) did so without a clear medical reason (non-adherence). Age >or= 65 years and the use of 300 instead of 30 mg of aspirin were independently associated with non-adherence. Diastolic blood pressure of >or= 90 mmHg and dizziness were associated with better adherence. Of 651 patients on oral anticoagulation, 143 patients (22 %) stopped after a mean follow-up of 1.0 year, 66 (10 %) did so because of nonadherence. No statistically significant determinants for non-adherence were identified. CONCLUSION: As found in the literature on nonadherence in general, age of >or= 65 years and a higher dose of aspirin (300 mg versus 30 mg) were independently associated with non-adherence with aspirin treatment that was prescribed for secondary prevention after cerebral ischaemia of arterial origin. Older patients may require extra encouragement to continue antithrombotic treatment. Lower doses of aspirin may improve treatment adherence.

Age Factors↗

PubMed2005

Risk of major haemorrhage in patients after infrainguinal venous bypass surgery: therapeutic consequences? The Dutch BOA (Bypass Oral Anticoagulants or Aspirin) Study.

OBJECTIVES: The beneficial effect of oral anticoagulants after infrainguinal venous bypass surgery is compromised by bleeding complications. We developed a model to identify patients, treated with anticoagulation, at risk of major haemorrhage and estimated whether this complication could have been prevented if patients had received aspirin. DESIGN: Randomised clinical trial. METHODS: Data of patients who participated in the Dutch Bypass Oral Anticoagulation or Aspirin Study were reanalysed using Cox regression. After infrainguinal bypass surgery these patients were randomised to oral anticoagulants (n = 1326) or aspirin (n = 1324). RESULTS: Predictors of major haemorrhage for patients on oral anticoagulants were increased systolic blood pressure (> or = 140 mmHg, hazard ratio [HR] 1.62), age > or = 75 years (HR 2.77) and diabetes mellitus (HR 1.60). If the 345 patients in the highest risk quartile had received aspirin, major haemorrhages would have been reduced from 46 to 22, with no major changes in ischemic events and graft occlusions. In the subgroup with venous bypasses major haemorrhages would have been reduced from 27 to 13, at the cost of seven more ischemic events (mostly fatal) and 17 more graft occlusions. CONCLUSIONS: Treating patients at highest risk of major haemorrhage with aspirin instead of oral anticoagulants would have resulted in a reduction of non-fatal haemorrhages, but for venous bypasses this reduction was outweighed by an increase in ischemic events and graft occlusions. We still recommend treatment with oral anticoagulants after peripheral venous bypass surgery.

Administration, Oral↗

PubMed2005

Magnesium sulfate in aneurysmal subarachnoid hemorrhage: a randomized controlled trial.

BACKGROUND AND PURPOSE: Magnesium reverses cerebral vasospasm and reduces infarct volume after experimental subarachnoid hemorrhage (SAH) in rats. We aimed to assess whether magnesium reduces the frequency of delayed cerebral ischemia (DCI) in patients with aneurysmal SAH. METHODS: Patients were randomized within 4 days after SAH. Magnesium sulfate therapy consisted of a continuous intravenous dose of 64 mmol/L per day, to be started within 4 days after SAH and continued until 14 days after occlusion of the aneurysm. The primary outcome DCI (defined as the occurrence of a new hypodense lesion on computed tomography compatible with clinical features of DCI) was analyzed according to the "on-treatment" principle. For the secondary outcome measures "poor outcome" (Rankin >3) and "excellent outcome" (Rankin 0), we used the "intention-to-treat" principle. RESULTS: A total of 283 patients were randomized. Magnesium treatment reduced the risk of DCI by 34% (hazard ratio, 0.66; 95% CI, 0.38 to 1.14). After 3 months, the risk reduction for poor outcome was 23% (risk ratio, 0.77; 95% CI, 0.54 to 1.09). At that time, 18 patients in the treatment group and 6 in the placebo group had an excellent outcome (risk ratio, 3.4; 95% CI, 1.3 to 8.9). CONCLUSIONS: This study suggests that magnesium reduces DCI and subsequent poor outcome, but the results are not yet definitive. A next step should be a phase III trial to confirm the beneficial effect of magnesium therapy, with poor outcome as primary outcome.

Brain Ischemia↗

PubMed2005

The prognostic value of domain-specific cognitive abilities in acute first-ever stroke.

OBJECTIVE: To evaluate the prognostic value of domain-specific cognitive abilities in acute stroke with respect to long-term cognitive and functional outcome in addition to neurologic and demographic predictors. METHODS: The authors evaluated 168 patients within the first 3 weeks after first-ever stroke. The prevalence of neuropsychological impairment was calculated vs 75 matched healthy controls. The authors also recorded demographic data, vascular risk factors, lesion characteristics, and clinical factors at admission. Independent predictor variables associated with long-term cognitive impairment (assessed with a follow-up neuropsychological examination) and functional impairment (assessed with the modified Barthel Index and the Frenchay Activities Index) were identified with stepwise multiple logistic regression. Areas under receiver operator characteristic curves were used to compare the predictive value of three models, i.e., a standard medical model, a purely cognitive model, and a model consisting of both medical and cognitive predictors. RESULTS: Thirty-one percent of patients showed long-term cognitive impairment. Basic and instrumental ADL disturbances remained present in 19% and 24% of patients. Domain-specific cognitive functioning predicted cognitive and functional outcome better than any other variable. Moreover, the prediction of instrumental ADL functioning improved when cognitive predictors were added to the standard medical model (p < 0.05). Impairments in abstract reasoning and executive functioning were independent predictors of long-term cognitive impairment. Inattention and perceptual disorders were more important in predicting long-term functional impairment. CONCLUSION: Domain-specific cognitive abilities in the early phase of stroke are excellent independent predictors of long-term cognitive and functional outcome.

Acute Disease↗

PubMed2005

Calcium antagonists for aneurysmal subarachnoid haemorrhage.

BACKGROUND: Secondary ischaemia is a frequent cause of poor outcome in patients with subarachnoid haemorrhage (SAH). Its pathogenesis has not been elucidated yet, but may be related to vasospasm. Experimental studies have indicated that calcium antagonists can prevent or reverse vasospasm and have neuroprotective properties. Several types of calcium antagonists have been studied in several clinical trials. OBJECTIVES: To determine whether calcium antagonists improve outcome in patients with aneurysmal SAH. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (September 2003). In addition, we searched MEDLINE (1966 to October 2003) and EMBASE (1980 to October 2003), handsearched two Russian journals (1990 to 2003) and contacted trialists and pharmaceutical companies (in 1995 and 1996) to identify further studies. SELECTION CRITERIA: All unconfounded, truly randomised controlled trials comparing any calcium antagonist with control. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information. MAIN RESULTS: We analysed 12 trials totalling 2844 patients with SAH (1396 in the treatment group and 1448 in the control group). The drugs analysed were: nimodipine (eight trials, 1574 patients), nicardipine (two trials, 954 patients), AT877 (one trial, 276 patients) and magnesium (one trial, 40 patients). Overall, calcium antagonists reduced the risk of poor outcome: relative risk (RR) 0.82 (95% confidence interval (CI) 0.72 to 0.93); the absolute risk reduction was 5.1%, the corresponding number of patients needed to treat to prevent a single poor outcome event was 20. For oral nimodipine alone the RR was 0.70 (0.58 to 0.84). The RR of death on treatment with calcium antagonists was 0.90 (95% CI 0.76 to 1.07), that of clinical signs of secondary ischaemia 0.67 (95% CI 0.60 to 0.76), and that of CT or MR confirmed infarction 0.80 (95% CI 0.71 to 0.89). AUTHORS' CONCLUSIONS: Calcium antagonists reduce the risk of poor outcome and secondary ischaemia after aneurysmal SAH. The results for 'poor outcome' depend largely on a single large trial with oral nimodipine; the evidence for nicardipine, AT877 and magnesium is inconclusive. The evidence for nimodipine is not beyond every doubt, but given the potential benefits and modest risks of this treatment, against the background of a devastating natural history, oral nimodipine (60 mg every 4 hours) is currently indicated in patients with aneurysmal SAH. Intravenous administration of calcium antagonists cannot be recommended for routine practice on the basis of the present evidence.

Calcium Channel Blockers↗

PubMed2005

Prothrombotic conditions, oral contraceptives, and the risk of ischemic stroke.

BACKGROUND: The role of inherited prothrombotic conditions, including factor V Leiden (FV G1691A), prothrombin G20210A, and the methylenetetrahydrofolate reductase (MTHFR) C677T genotype, in the pathogenesis of ischemic stroke is not well established. The effects of these factors may be potentiated by the use of oral contraceptives, analogous to observations in venous thrombosis. METHODS: Patients (n = 193) were women aged 20-49 years with ischemic stroke. Controls (n = 767) were women without arterial thrombosis stratified for age, calendar year of the index event, and residence. The relative risk of ischemic stroke was estimated with unconditional logistic regression, adjusted for stratification variables. FINDINGS: Factor V Leiden and MTHFR 677TT were more common in patients than in controls [odds ratio (OR): 1.8; 95% confidence interval (CI): 0.9-3.6 respectively OR: 1.5; 95% CI: 0.9-2.6]. The frequency of prothrombin G20210A was similar in cases and controls. Carriers of FV Leiden using oral contraceptives had a 11.2-fold (95% CI: 4.3-29.0) higher risk of ischemic stroke than women without either risk factor. Women with MTHFR 677TT using oral contraceptives had a 5.4-fold (95% CI: 2.4-12.0) higher risk than women without these risk factors. INTERPRETATION: These data suggest that carriers of FV Leiden or MTHFR 677TT who use oral contraceptives have an increased risk of ischemic stroke. When these findings are confirmed, a cost-effectiveness analysis should indicate whether ischemic stroke could be prevented with genetic testing before the start of oral contraceptives.

Adult↗

PubMed2005

Neurodevelopmental treatment after stroke: a comparative study.

BACKGROUND: Neurodevelopmental treatment (NDT) is a rehabilitation approach increasingly used in the care of stroke patients, although no evidence has been provided for its efficacy. OBJECTIVE: To investigate the effects of NDT on the functional status and quality of life (QoL) of patients with stroke during one year after stroke onset. METHODS: 324 consecutive patients with stroke from 12 Dutch hospitals were included in a prospective, non-randomised, parallel group study. In the experimental group (n = 223), nurses and physiotherapists from six neurological wards used the NDT approach, while conventional treatment was used in six control wards (n = 101). Functional status was assessed by the Barthel index. Primary outcome was "poor outcome", defined as Barthel index <12 or death after one year. QoL was assessed with the 30 item version of the sickness impact profile (SA-SIP30) and the visual analogue scale. RESULTS: At 12 months, 59 patients (27%) in the NDT group and 24 (24%) in the non-NDT group had poor outcome (corresponding adjusted odds ratio = 1.7 (95% confidence interval, 0.8 to 3.5)). At discharge the adjusted odds ratio was 0.8 (0.4 to 1.5) and after six months it was 1.6 (0.8 to 3.2). Adjusted mean differences in the two QoL measures showed no significant differences between the study groups at six or 12 months after stroke onset. CONCLUSIONS: The NDT approach was not found effective in the care of stroke patients in the hospital setting. Health care professionals need to reconsider the use of this approach.

Aged↗

PubMed2005

Applicability and relevance of models that predict short term outcome after intracerebral haemorrhage.

OBJECTIVES: Several models for prediction of short term outcome after intracerebral haemorrhage (ICH) have been published, however, these are rarely used in clinical practice for treatment decisions. This study was conducted to identify current models for prediction of short term outcome after ICH and to evaluate their clinical applicability and relevance in treatment decisions. METHODS: MEDLINE was searched from 1966 to June 2003 and studies were included if they met predefined criteria. Regression coefficients of multivariate models were extracted. Two neurologists independently evaluated the models for applicability in clinical practice. To assess clinical relevance and accuracy of each model, in a validation series of 122 patients the proportion with a >or=95% probability of death or poor outcome and the actual 30 day case fatality in these patients were calculated. Receiver operator characteristic (ROC) curves were computed for assessment of discriminatory power. RESULTS: A total of 18 prognostic models were identified, of which 14 appeared easy to apply. In the validation series, the proportion of patients with a >or=95% probability of death or poor outcome ranged from 0% to 43% (median 23%). The 30 day case fatality in these patients ranged from 75% to 100% (median 93%). The area under the ROC curves ranged from 0.81 to 0.90. CONCLUSIONS: Most models are easy to apply and can generate a high probability of death or poor outcome. However, only a small proportion of patients have such a high probability, and 30 day case fatality is not always correctly predicted. Therefore, current models have limited relevance in triage, but can be used to estimate the chances of survival of individual patients.

Adolescent↗

PubMed2005

Outcome in patients with basilar artery occlusion treated conventionally.

BACKGROUND: Most data on the outcome of basilar artery occlusion are from recent case series of patients treated with intra-arterial thrombolysis. The limited knowledge on the outcome after a conventional treatment approach comes from a few small case series of highly selected patients. OBJECTIVE: To provide more data on the outcome of conventional treatment. METHODS: Data were analysed on patients from three centres with symptomatic basilar artery occlusion treated conventionally. Conventional therapy was defined as treatment with antiplatelets, anticoagulation, or both. RESULTS: Data were available on 82 patients. The case fatality was 40%. Among survivors, 65% remained dependent (Rankin score 4-5). Patients younger than 60 years (odds ratio = 3.1 (95% confidence interval, 1.0 to 9.5)) and those with a minor stroke (OR = 3.1 (1.0 to 9.6)) were more likely to have a good outcome (Rankin score 0-3). Patients with a progressive stroke were less likely to have a good outcome (OR = 0.3 (0.08 to 1.2)) than patients with a maximum deficit at onset or fluctuating symptoms at presentation. CONCLUSIONS: Conventional treatment of symptomatic basilar artery occlusion is associated with a poor outcome in almost 80% of patients, which emphasises the importance of the search for a more effective treatment approach.

Age Factors↗

PubMed2005

Visual inspection versus spectrophotometry in detecting bilirubin in cerebrospinal fluid.

OBJECTIVES: To compare the diagnostic accuracy of visual inspection and spectrophotometry for identifying the presence of bilirubin in the cerebrospinal fluid (CSF). METHODS: Clinicians and students assessed CSF specimens with seven degrees of extinction between 0.00 and 0.09 at 450-460 nm as "yellow," "doubtful," or "colourless" after random presentation under standard conditions. The assessments were compared with spectrophotometry, with 0.05 being taken as the cut off level for the presence of bilirubin. Results were compared between the two groups and explored by means of receiver operating characteristic (ROC) curves. RESULTS: All 51 clinicians and 50 of 51 students scored the tubes with extinction of 0.06 or higher as "yellow" or "doubtful." Tubes without any bilirubin were scored as "yellow" by three of the students only. The ROC curves confirmed that the diagnostic properties of the visual inspection versus spectrophotometry were slightly better for the clinicians than for the students. CONCLUSIONS: If CSF is considered colourless, the extinction of bilirubin is too low to be compatible with a diagnosis of recent subarachnoid haemorrhage. If CSF is not considered colourless, spectrophotometry should be carried out to determine the level of extinction of bilirubin.

Bilirubin↗