Early neurological deterioration in acute stroke.
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Brain Damage, Chronic↗
Biomedical subjects
P Langhorne
Publications and source records attributed to P Langhorne.
Occupational therapy for patients with problems in activities of daily living after stroke.
BACKGROUND: Occupational therapy aims to help people reach their maximum level of function and independence in all aspects of daily life. OBJECTIVES: To determine whether occupational therapy focused specifically on personal activities of daily living improves recovery for patients following stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched January 2006). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006), CINAHL (1983 to March 2006), PsycLIT (1974 to March 2006), AMED (1985 to March 2006), Wilson Social Sciences Abstracts (1984 to March 2006) and the following Web of Science databases: Science Citation Index (1945 to March 2006), Social Science Citation Index (1956 to March 2006) and Arts and Humanities Citation Index (1975 to March 2006). In an effort to identify further published, unpublished and ongoing trials we searched The Occupational Therapy Research Index and Dissertation Abstracts register, scanned reference lists of relevant articles, contacted authors and researchers and handsearched relevant journals. SELECTION CRITERIA: We identified randomised controlled trials of an occupational therapy intervention (compared to usual care or no care) where stroke patients practiced personal activities of daily living, or performance in activities of daily living was the focus of the occupational therapy intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials and extracted data for pre-specified outcomes. The primary outcomes were the proportion of patients who had deteriorated or were dependent in personal activities of daily living and performance in personal activities of daily living at the end of follow up. MAIN RESULTS: We identified 64 potentially eligible trials and included 10 studies (1348 participants). Occupational therapy interventions reduced the odds of a poor outcome (Peto odds ratio 0.67 (95% confidence interval (CI) 0.51 to 0.87; P = 0.003). and increased personal activity of daily living scores (standardised mean difference 0.18 (95% CI 0.04 to 0.32; P = 0.01). For every 11 (95% CI 7 to 30) patients receiving an occupational therapy intervention to facilitate personal activities of daily living, one patient was spared a poor outcome. AUTHORS' CONCLUSIONS: Patients who receive occupational therapy interventions are less likely to deteriorate and are more likely to be independent in their ability to perform personal activities of daily living. However, the exact nature of the occupational therapy intervention to achieve maximum benefit needs to be defined.
Activities of Daily Living↗
Electrostimulation for promoting recovery of movement or functional ability after stroke.
BACKGROUND: Electrostimulation might improve motor recovery after stroke by providing neuromuscular re-training. OBJECTIVES: To find if electrostimulation improved functional motor ability, and the ability to undertake activities of daily living. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), CINAHL (1982 to January 2004), AMED - Allied and Complementary Medicine Database (1985 to January 2004), Physiotherapy Evidence Database (PEDro), REHABDATA and the ISI Science Citation Index (1981 to 2003). We placed a request on the PHYSIO e-mail discussion list and contacted authors of relevant studies to elicit any unpublished or ongoing studies, searched the reference lists of included trials and contacted trialists. SELECTION CRITERIA: Randomised controlled trials of electrostimulation delivered to the peripheral neuromuscular system which was designed to improve voluntary movement control, functional motor ability and activities of daily living. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS: Of the 2077 references identified, 24 trials were included in this review. For electrostimulation compared with no treatment this review found that electrostimulation improved some aspects of functional motor ability and some aspects of motor impairment and normality of movement. In addition, there was a significant difference in favour of no treatment compared with electrostimulation for an aspect of functional motor ability. For electrostimulation compared with placebo this review found that electrostimulation improved an aspect of functional motor ability. For electrostimulation compared with conventional physical therapy this review found that electrostimulation improved an aspect of motor impairment. There were no statistically significant differences between electrostimulation and control treatment for all other outcomes. However, these results need to be interpreted with reference to the following: (1) the majority of analyses only contained one trial; (2) variation was found between included trials in time after stroke, level of functional deficit, and dose of electrostimulation; and (3) the possibility of selection and detection bias in the majority of included trials. AUTHORS' CONCLUSIONS: At present, there are insufficient robust data to inform clinical use of electrostimulation for neuromuscular re-training. Research is needed to address specific questions about the type of electrostimulation that might be most effective, in what dose and at what time after stroke.
Activities of Daily Living↗
Thrombophilia in pregnancy: a systematic review.
Growing evidence suggests that thrombophilia is associated with venous thromboembolism (VTE) and adverse pregnancy outcomes. However, methodological limitations have made it difficult to obtain a clear overview of the overall risks. We conducted a systematic review to determine the risk of VTE and adverse pregnancy outcomes associated with thrombophilia in pregnancy. The effectiveness of prophylactic interventions during pregnancy was also evaluated. Major electronic databases were searched, relevant data abstracted and study quality assessed by two independent reviewers. Odds ratios (ORs) stratified by thrombophilia type were calculated for each outcome. A total of 79 studies were included in our review. The risks for individual thrombophilic defects were determined for VTE (ORs, 0.74-34.40); early pregnancy loss (ORs, 1.40-6.25); late pregnancy loss (ORs, 1.31-20.09); pre-eclampsia (ORs, 1.37-3.49); placental abruption (ORs, 1.42-7.71) and intrauterine growth restriction (ORs, 1.24-2.92). Low-dose aspirin plus heparin was the most effective in preventing pregnancy loss in thrombophilic women (OR, 1.62). Our findings confirm that women with thrombophilia are at risk of developing VTE and complications in pregnancy. However, despite the increase in relative risk, the absolute risk of VTE and adverse outcomes remains low. There is also a lack of controlled trials of antithrombotic intervention to prevent pregnancy complications. Thus, at present, universal screening for thrombophilia in pregnancy cannot be justified clinically.
Female↗
Screening for thrombophilia in high-risk situations: systematic review and cost-effectiveness analysis. The Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) study.
OBJECTIVES: To assess the risk of clinical complications associated with thrombophilia in three high-risk patient groups: women using oral oestrogen preparations, women during pregnancy and patients undergoing major orthopaedic surgery. To assess the effectiveness of prophylactic treatments in preventing venous thromboembolism (VTE) and adverse pregnancy outcomes in women with thrombophilia during pregnancy and VTE in patients with thrombophilia, undergoing major orthopaedic surgery. To evaluate the relative cost-effectiveness of universal and selective VTE history-based screening for thrombophilia compared with no screening in the three high-risk patient groups. DATA SOURCES: Electronic databases including MEDLINE, EMBASE, and four other major databases were searched up to June 2003. REVIEW METHODS: In order to assess the risk of clinical complications associated with thrombophilia, a systematic review of the literature on VTE and thrombophilia in women using oral oestrogen preparations and patients undergoing major orthopaedic surgery; and studies of VTE and adverse obstetric complications in women with thrombophilia during pregnancy was carried out. Meta-analysis was used to calculate pooled odds ratios (ORs) associated with individual clinical outcomes, stratified by thrombophilia type and were calculated for each patient group. To assess the effectiveness of prophylaxis, a systematic review was carried out on the use of prophylaxis in the prevention of VTE and pregnancy loss in pregnant women with thrombophilic defects and the use of thromboprophylaxis in the prevention of VTE in patients with thrombophilia undergoing major elective orthopaedic surgery. Relevant data were summarised according to the patient groups and stratified according to the types of prophylaxis. A narrative summary was provided; where appropriate, meta-analysis was conducted. An incremental cost-effectiveness analysis was then carried out, from the perspective of the NHS in the UK. A decision analytical model was developed to simulate the clinical consequences of four thrombophilia screening scenarios. Results from the meta-analyses, information from the literature and results of two Delphi studies of clinical management of VTE and adverse pregnancy complications were incorporated into the model. Only direct health service costs were measured and unit costs for all healthcare resources used were obtained from routinely collected data and the literature. Cost-effectiveness was expressed as incremental cost-effectiveness ratios (ICERs); an estimate of the cost per adverse clinical complication prevented, comparing screening with no screening, were calculated for each patient group. RESULTS: In the review of risk of clinical complications, 81 studies were included, nine for oral oestrogen preparations, 72 for pregnancy and eight for orthopaedic surgery. For oral contraceptive use, significant associations of the risk of VTE were found in women with factor V Leiden (FVL); deficiencies of antithrombin, protein C, or protein S, elevated levels of factor VIIIc; and FVL and prothrombin G20210A. For hormone replacement therapy (HRT), a significant association was found in women with FVL. The highest risk in pregnancy was found for FVL and VTE, in particular, homozygous carriers of this mutation are 34 times more likely to develop VTE in pregnancy than non-carriers. Significant risks for individual thrombophilic defects were also established for early, recurrent and late pregnancy loss; preeclampsia; placental abruption; and intrauterine growth restriction. Significant associations were found between FVL and high factor VIIIc and postoperative VTE following elective hip or knee replacement surgery. Prothrombin G20210A was significantly associated with postoperative pulmonary embolism. However, antithrombin deficiency, MTHFR and hyperhomocysteinaemia were not associated with increased risk of postoperative VTE. In the review of the effectiveness of prophylaxis, based on available data from eight studies, low-dose aspirin and heparin was found to be the most effective in preventing pregnancy loss in thrombophilic women during pregnancy, while aspirin alone was the most effective in preventing minor bleeding. All the studies on thrombophilia and major elective orthopaedic surgery included in the review of risk complications were also used in the review of the effectiveness of thromboprophylaxis. However, there were insufficient data to determine the relative effectiveness of different thromboprophylaxis in preventing VTE in this patient group. For the cost-effectiveness analysis, of all the patient groups evaluated, universal screening of women prior to prescribing HRT was the most cost-effective (ICER pound6824). In contrast, universal screening of women prior to prescribing combined oral contraceptives was the least cost-effective strategy (ICER pound202,402). Selective thrombophilia screening based on previous personal and/or family history of VTE was more cost-effective than universal screening in all the patient groups evaluated. CONCLUSIONS: Thrombophilia is associated with increased risks of VTE in women taking oral oestrogen preparations and patients undergoing major elective orthopaedic surgery, and of VTE and adverse pregnancy outcomes in women with thrombophilia during pregnancy. There is considerable difference in the magnitude of the risks among different patient groups with different thrombophilic defects. In women who are on combined oral contraceptives, the OR of VTE among those who are carriers of the FVL mutation was 15.62 (95% confidence interval 8.66 to 28.15). However, in view of the prevalence of thrombophilia and the low prevalence of VTE in non-users of combined oral contraceptives, the absolute risk remains low. Significant risks for VTE and adverse pregnancy outcomes have been established with individual thrombophilic defects. Thrombophilic defects including FVL, high plasma factor VIIIc levels and prothrombin G20210A are associated with the occurrence of postoperative VTE in elective hip or knee replacement therapy. These associations are observed in patients who were given preoperative thromboprophylaxis and are, therefore, of clinical significance. Universal thrombophilia screening in women prior to prescribing oral oestrogen preparations, in women during pregnancy and in patients undergoing major orthopaedic surgery is not supported by current evidence. The findings from this study show that selective screening based on prior VTE history is more cost-effective than universal screening. Large prospective studies should be undertaken to refine the risks and establish the associations of thrombophilias with VTE among hormone users and in patients undergoing orthopaedic surgery. The relative value of a thrombophilia screening programme to other healthcare programmes needs to be established.
Cost-Benefit Analysis↗
Speech and language therapy for dysarthria due to non-progressive brain damage.
BACKGROUND: Dysarthria is a common sequel of non-progressive brain damage (typically stroke and traumatic brain damage). Impairment-based therapy and a wide variety of compensatory management strategies are undertaken by speech and language therapists with this patient population. OBJECTIVES: To determine the efficacy of speech and language therapy interventions for adults with dysarthria following non-progressive brain damage. SEARCH STRATEGY: We searched the trials registers of the following Cochrane Groups: Stroke, Injuries, Movement Disorders and Infectious Diseases. We also searched the trials register of the Cochrane Rehabilitation and Related Therapies Field. The trials registers were last searched in September 2004. The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2004), MEDLINE (1966 to September 2004), EMBASE (1980 to September 2004), CINAHL (1983 to September 2004), PsycINFO (1974 to October 2004), and Linguistics and Language Behavior Abstracts (1983 to December 2004) were searched electronically. We handsearched the International Journal of Language and Communication Disorders (1966 to 2005, Issue 1) and selected conference proceedings, and scanned the reference lists of relevant articles. We approached colleagues and speech and language therapy training institutions to identify other possible published and unpublished studies. SELECTION CRITERIA: Unconfounded randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS: One author assessed trial quality. Two co-authors were available to examine any potential trials for possible inclusion in the review. MAIN RESULTS: No trials of the required standard were identified. AUTHORS' CONCLUSIONS: There is no evidence of the quality required by this review to support or refute the effectiveness of speech and language therapy interventions for dysarthria following non-progressive brain damage. Despite the recent commencement of a RCT of optimised speech and language therapy for communication difficulties after stroke, there continues to be an urgent need for good quality research in this area.
Adult↗
Is stroke unit care portable? A systematic review of the clinical trials.
BACKGROUND: It is not known if mobile stroke teams can achieve the good results seen in trials of geographically discrete stroke wards (stroke units). OBJECTIVE: To establish the effectiveness of mobile stroke teams. DESIGN: Systematic review of controlled clinical trials that compared peripatetic systems of organised stroke care (stroke team care) with alternative hospital services. METHODS: Systematic review and meta-analysis (using Cochrane Collaboration methodology and involving the primary trialists). Clinical outcomes included death, dependency, the need for institutional care and measures of the process of care such as the delivery of key investigations and treatments. RESULTS: Six clinical trials (1,085 patients) were identified; five (781 patients) compared some form of stroke team care with conventional care in general medical wards and one (304 patients) compared team care with a comprehensive stroke unit. Compared with care in general wards, stroke team care improved some aspects of the process of care, but clinical outcomes were similar. Compared with a comprehensive stroke unit, stroke team patients were significantly less likely to survive (P <0.001), return home (P < 0.001) or regain independence (P < 0.0001). Most aspects of the process of care were also poorer than in the stroke unit. CONCLUSIONS: Care from a mobile stroke team had no major impact on death, dependency or the need for institutional care.
Controlled Clinical Trials as Topic↗
Early recurrence of cerebrovascular events after transient ischaemic attack.
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Humans↗
Individual patient data meta-analysis of randomized controlled trials of community occupational therapy for stroke patients.
BACKGROUND AND PURPOSE: Trials of occupational therapy for stroke patients living in the community have varied in their findings. It is unclear why these discrepancies have occurred. METHODS: Trials were identified from searches of the Cochrane Library and other sources. The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) score at the end of intervention. Secondary outcome measures included the Barthel Index or the Rivermead ADL (Personal ADL), General Health Questionnaire (GHQ), Nottingham Leisure Questionnaire (NLQ), and death. Data were analyzed using linear or logistic regression with a random effect for trial and adjustment for age, gender, baseline dependency, and method of follow-up. Subgroup analyses compared any occupational therapy intervention with control. RESULTS: We included 8 single-blind randomized controlled trials incorporating 1143 patients. Occupational therapy was associated with higher NEADL scores at the end of intervention (weighted mean difference [WMD], 1.30 points, 95% confidence intervals [CI], 0.47 to 2.13) and higher leisure scores at the end of intervention (WMD, 1.51 points; 95% CI, 0.24 to 2.79). Occupational therapy emphasizing activities of daily living (ADL) was associated with improved end of intervention NEADL (WMD, 1.61 points; 95% CI, 0.72 to 2.49) and personal activities of daily living (odds ratio [OR], 0.65; 95% CI, 0.46 to 0.91), but not NLQ. Leisure-based occupational therapy improved end of intervention NLQ (WMD, 1.96 points; 95% CI, 0.27 to 3.66) but not NEADL or PADL. CONCLUSIONS: Community occupational therapy significantly improved personal and extended activities of daily living and leisure activity in patients with stroke. Better outcomes were found with targeted interventions.
Activities of Daily Living↗
Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials.
BACKGROUND: Stroke-unit care can be valuable for stroke patients in hospital, but effectiveness of outpatient care is less certain. We aimed to assess the effects of therapy-based rehabilitation services targeted at stroke patients resident in the community within 1 year of stroke onset or discharge from hospital. METHODS: We did a systematic review of randomised trials of outpatient services, including physiotherapy, occupational therapy, and multidisciplinary teams. We used Cochrane collaboration methodology. FINDINGS: We identified a heterogeneous group of 14 trials (1617 patients). Therapy-based rehabilitation services for stroke patients living at home reduced the odds of deteriorating in personal activities of daily living (odds ratio 0.72 [95% CI 0.57-0.92], p=0.009) and increased ability of patients to do personal activities of daily living (standardised mean difference 0.14 [95% CI 0.02-0.25], p=0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, seven (95% CI 2-11) would not deteriorate. INTERPRETATION: Therapy-based rehabilitation services targeted at selected patients resident in the community after stroke improve ability to undertake personal activities of daily living and reduce risk of deterioration in ability. These findings should be considered in future service planning.
Activities of Daily Living↗
Poor outcome in primary intracerebral haemorrhage: results of a matched comparison.
BACKGROUND: Primary intracerebral haemorrhage (PICH) is associated with a poorer outcome than cerebral infarction. This study aimed to determine whether this is explained by the clinical severity of stroke. METHODS: An observational study of outcome in consecutive admissions with acute PICH and ischaemic stroke was undertaken. A nested case-control analysis, matched on a 1:2 basis for age, pre-stroke disability, early neurological impairment (Scandinavian Stroke Scale; SSS), and Oxfordshire Community Stroke Project classification was then performed. Follow up was at 30 days and at hospital discharge. RESULTS: Overall, 679 subjects were included in the analysis. Of these, 53 (8%) had PICH; this group had more severe initial neurological impairment (day 3 SSS 28 v 45 points, p<0.001) and a higher prevalence of total anterior circulation strokes (55% v 21%, p<0.001) than did the group admitted with ischaemic strokes. Outcomes were poorer in the PICH group, with 36% inpatient mortality and 68% of survivors having a day 30 modified Rankin Scale (MRS) of at least 3 (compared with 13% and 52%, respectively, in the ischaemic stroke group). Following matching for baseline clinical characteristics, the PICH group had a higher mortality, but this was not statistically significant; the day 30 MRS and institutionalisation rates in survivors were similar in the matched haemorrhage and infarct groups. CONCLUSIONS: Compared with ischaemic stroke, PICH is associated with higher mortality and increased disability in survivors. The severity of clinical stroke is a major contributor to these poor outcomes; baseline characteristics, however, do not fully explain outcome differences.
Aged↗
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke.
BACKGROUND: There are a number of different approaches to physiotherapy treatment following stroke. Central to these are approaches based on 'neurophysiological' principles, 'motor learning' principles and 'orthopaedic' principles. OBJECTIVES: To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles. SEARCH STRATEGY: This review drew on the search strategy developed by the Stroke Group as a whole. Relevant trials were identified in the Stroke Group Trials Register of Controlled Trials which was last searched in May 2001. We also searched the Cochrane Controlled Trials Register (Cochrane Library, Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999) and CINAHL (1982-1999) and contacted experts and researchers with an interest in stroke. SELECTION CRITERIA: Studies - randomised or quasi-randomised controlled trials. Participants - adults with a clinical diagnosis of stroke. Interventions - physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function. Outcomes - measures of disability, motor impairment or participation. DATA COLLECTION AND ANALYSIS: Two independent reviewers categorised the identified trials according to the inclusion/exclusion criteria, documented the methodological quality and extracted the data. MAIN RESULTS: Eleven trials were included in the review, three of which were included in two comparisons. Four trials compared a neurophysiological approach with another approach; four trials compared a motor learning approach with another approach; four studies compared a mixed approach with another approach; two trials reported comparisons of sub-groups of the same approach. A large number of heterogeneous outcome measures were used, limiting the comparison of trial results. No one type of approach had a significantly better outcome than any other type of approach. REVIEWER'S CONCLUSIONS: There is insufficient evidence to conclude that any one physiotherapy treatment approach is more effective than another in promoting the recovery of postural control or lower limb function.
Adult↗
Evidence behind stroke rehabilitation.
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Evidence-Based Medicine↗
A systematic review of exercise trials post stroke.
OBJECTIVE: To perform a systematic review of exercise trials post stroke. DESIGN: A systematic review of controlled clinical trials. SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, Amed, Sports Discus, Cochrane controlled trials register and PEDro were searched for relevant trials. INCLUSION CRITERIA: Studies--randomized or quasi-randomized controlled clinical trials. Participants--Adults of any age with a clinical diagnosis of stroke. Interventions--Any cardiovascular exercise intervention aimed at improving cardiovascular fitness and/or function. OUTCOMES: Impairment: gait speed, strength, endurance, balance, flexibility, tonus and exercise capacity. Disability: global dependency, functional independence. Extended activities of daily living. Quality of life. Death. DATA COLLECTION AND ANALYSIS: Two independent reviewers categorized selected trials, documented the methodological quality and extracted the relevant data. Comparisons of cardiovascular exercise interventions versus no cardiovascular intervention were made. Statistical comparisons were carried out using a random effects model to calculate standardized mean differences. RESULTS: We identified three eligible trials. Small numbers and heterogeneous outcomes limited the analyses and comparisons. Based on the limited data available, we found that cardiovascular exercise post stroke was no better than no exercise with respect to disability, impairment, extended activities of daily living, quality of life and death. CONCLUSION: Insufficient evidence was identified to establish if cardiovascular exercise has a positive effect on disability, impairment, extended activities of daily living, quality of life and case fatality post stroke.
Activities of Daily Living↗
Intensity of rehabilitation: some answers and more questions?
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Activities of Daily Living↗
Systematic reviews in rehabilitation for stroke: issues and approaches to addressing them.
OBJECTIVES: To describe the problems encountered when undertaking systematic reviews of rehabilitation and to give advice to reviewers about ways of addressing these issues. BACKGROUND: Evidence-based practice has become established as a way of linking clinical practice with research evidence. The most robust evidence is usually considered to be that from randomized controlled trials, and from systematic reviews of these trials. However, most reviews have focused on drug and surgical interventions, and few reviews have been produced in the field of rehabilitation. This may be due to the unique difficulties that are posed by reviews in this area. EXPERIENCE OF SYSTEMATIC REVIEWS IN APHASIA: We describe the challenges that occurred when carrying out systematic reviews of speech and language therapy for aphasia following stroke, and of ways to deliver rehabilitation services to people who have suffered a stroke. Issues arose at all stages of the reviews and included: using expertise; planning the review; defining the health care problem, patients, outcomes and interventions of interest; searching for, interpreting and synthesizing the results of the studies identified; and deriving implications from the review. Suggestions made to address these challenges include: developing a suitable team of reviewers; using inclusive and broad criteria for inclusion of trials to a review; developing appropriate search strategies; and using caution in arriving at conclusions. It is important to be explicit about decisions made during the review process concerning how to handle the challenges. Practical advice about carrying out reviews in the field of stroke rehabilitation is likely to be helpful to reviewers of other rehabilitative interventions. There are likely to be relatively few studies available for such reviews, and limitations in drawing specific practical conclusions. Such undertakings are, however, useful in setting the agenda for further research.
Humans↗
Revisiting the Cochrane Collaboration. Meeting the challenge of Archie Cochrane--and facing up to some new ones.
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Databases, Bibliographic↗
Taking acute stroke care seriously. In the absence of evidence we should manage acute stroke as a medical emergency.
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Acute Disease↗