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PubMedDate not supplied

The Italian hemodilution trial in acute stroke. Italian Acute Stroke Study Group.

The Italian Acute Stroke Study is a prospective, multicenter, randomized, clinical trial to evaluate hemodilution in acute stroke. Thirty-one centers will recruit 1,200 patients with a recent (less than 12 hours) hemispheric acute stroke. Randomization is performed centrally, and patients are stratified by center and severity of neurologic deficit. Hemodilution is achieved by venesection and infusion of the same amount of dextran 40. Otherwise, both treated and control groups receive the standard treatment provided by each center within agreed guidelines. At 6 months after stroke, one member of the Clinical Coordinating Center, blind as to treatment allocation, collects data on mortality and disability by telephone. We expect to terminate the randomization on December 31, 1986, and the follow-up evaluation on June 30, 1987. The aim of the study is to evaluate whether mortality and disability are significantly reduced in the group treated with hemodilution compared with the control group.

Acute Disease↗
PubMed2000

Aspirin or heparin in acute stroke.

Acute stroke treatment using aspirin and/or heparin was studied in the International Stroke Trial (IST) and Chinese Acute Stroke Trial (CAST) which randomised over 40,000 patients altogether. Combining the results demonstrated that aspirin (150-300 mg) given within 48 h of the onset of stroke produced a small but significant improvement in outcome (death or dependency) 4 weeks to 6 months after stroke of about 1 patient per 100 treated. There was a significant reduction in recurrent ischaemic stroke of similar degree, which was not associated with significant increase in cerebral haemorrhage. Therefore, aspirin should be used as early secondary prevention against recurrent stroke, after excluding cerebral haemorrhage by scanning the patient. Heparin does not improve clinical outcome after stroke even in patients in atrial fibrillation. It decreased recurrent ischaemic stroke significantly in IST, but at the cost of a significant increase in cerebral haemorrhage. Low molecular weight heparins and heparinoids have not proved any more beneficial. Therefore, heparin does not appear to be a useful routine therapy in acute stroke. The use of heparin should, therefore, be limited to patients at high risk of deep vein thrombosis or early recurrence.

Acute Disease↗
PubMed2001

Non-neurological variables and mortality of acute stroke.

Acute stroke is associated with high mortality. While this is the direct consequence of the neurological injury, stroke patients develop a number of physiological abnormalities and complications in the acute phase. Extensive research has produced a plethora of information about these non-neurological variables. Different patients have different abnormalities. Some of these variables have severe adverse effects on mortality, both acute and long term. Some of the variables are pre-existing, while others are non-modifiable. The body responds to cerebral tissue injury in a way that seems to lead to further damage to the brain and other vital systems, and patients usually have more than one variable needing attention. Acute stroke presents as a multisystem disease on the verge of multisystem failure. Although there is lack of evidence of the benefits of correcting the deranged variables, it makes clinical sense that non-neurological variables should be identified, monitored and managed, with the aim of improving the outcome of acute stroke patients.

Acute Disease↗
PubMed2005

Xenon CT cerebral blood flow in acute stroke.

Acute stroke therapy is evolving rapidly as research moves toward extending the time window for treatment so that more patients can benefit. As physiology-based imaging increasingly is used in patient selection, it is becoming evident that rigid time windows are not applicable to individual patients. Xenon CT has an important role in acute stroke therapeutic intervention as a quantitative, reproducible, rapid, and safe modality, which can provide valuable physiologic data that can optimize patient triage and aid in management.

Blood Flow Velocity↗
PubMed2003

The quality of acute stroke units on a nation-wide level: the Austrian Stroke Registry for acute stroke units.

Concepts for stroke units that cover the acute phase vary. Therefore, the network of acute stroke units that is being set up in Austria in a uniform way is of general interest. This nationwide network has been established in accordance to evidence-based recommendations and prespecified criteria for available resources. The location for such a unit follows a maximum of 90-min isochrones (transport time) to the hospital. The quality of the network is currently documented and the results are reported. A nationwide stroke registry was prospectively performed on 15 stroke units that were already functional in this network. The aim was to document the quality performance of Austrian stroke units, focusing on rapid admissions, ready availability of investigations and therapies performed. Outcome measures were Barthel scale, Rankin score and percentages of complications. Between August 1998 and December 2000, 2,313 patients with ischemic stroke or with primary intracerebral hemorrhage admitted to an Austrian stroke unit within 24 h after onset of symptoms were prospectively included. Forty-three percent of the patients had a moderate or severe stroke. Fifty-seven percent of all patients were admitted to the stroke unit within 3 h after the onset of symptoms. Twenty-seven percent of these patients were brought in by ambulance accompanied by an emergency physician. Two percent of patients were admitted by helicopter. Fifty-four percent of patients had their first brain imaging within 30 min after admission, another 26% within 3 h. Intravenous thrombolysis was performed in 4.1% of patients. The overall stroke-unit mortality was about 6.8% and mortality at 3 months was 12.9%. The outcome at 3 months showed a modified Rankin Scale score of 0 or 1 in 47% of patients, denoting none or mild impairment. This network of acute stroke units is highly efficient in terms of rapid admissions, short intrahospital delays, as well as rapid use of readily available investigations. Stroke units seem to be well accepted by the general public and the medical community because our data show that all types of strokes are treated in Austrian stroke units, including severe strokes. The total number of concurrently treated acute strokes in other institutions across Austria is not known and no formal comparison with other systems of hospitalized care was undertaken, therefore further research is necessary.

Adolescent↗
PubMed1997

Current management of acute stroke.

Acute stroke is an emergency clinical situation that is relatively frequently encountered by general practitioners. Recent studies in the management of cerebral ischaemia have determined that the time to definitive treatment is an important factor. Thus, the actions of the medical professional who has initial contact with the patient may significantly affect the outcome of the patient with stroke.

Acute Disease↗
PubMed2006

[Imaging of acute stroke].

Acute stroke patients represent an important diagnostic and therapeutic challenge. Patients with brain damage in the ischemic, but not yet infarcted, phase have the greatest potential for recovery. Here we review the most commonly employed diagnostic tools that are currently used before stroke therapy. While computed tomography is pertinent to differentiate ischemic from hemorrhagic stroke, this technique cannot be used as an etiological screening too. The ischemic origin of symptoms can be confirmed with magnetic resonance imaging which also contributes to for therapeutic decision making, prognosis assessment and etiological screening.

Acute Disease↗
PubMedDate not supplied

The Canadian Neurological Scale: a preliminary study in acute stroke.

Acute central nervous system dysfunction resulting in coma can be measured simply and reliably by the Glasgow scale. However, when the injury does not impair consciousness and the patient has aphasia, no comparable scale exists. A complementary scale to assess conscious and aphasic patients is proposed. Preliminary validation has been carried out in acute stroke patients, who commonly suffer neurological deficits without loss of consciousness. A simple standardized scale aids in the monitoring of neurological status, and may help in the assessment of prognosis and therapy.

Acute Disease↗
PubMed2002

Management of acute stroke.

Acute stroke is a medical emergency. The outcome is influenced by the rapidity and quality of initial care, which is best delivered by specialists with appropriate facilities, including 24 h access to computed tomography. Stroke management requires attention to simple details and has been summarised in clinical guidelines. General measures include control of blood glucose concentration, temperature, fluid balance, and oxygenation. Blood-pressure management is a matter for continuing research. Aspirin should be started early in ischaemic stroke, but heparin has doubtful value; antiembolism stockings may be preferable. Thrombolysis has a substantial benefit in selected circumstances, and trials continue to examine a wider role. Neuroprotection remains experimental, though magnesium is potentially of interest. Early neurosurgery has a role limited to decompression of lesions in the posterior fossa but is under trial for large hemispheric infarcts and moderate intracerebral bleeds.

Animals↗
PubMed1999

Subjective experience and behavior in acute stroke: the Lausanne Emotion in Acute Stroke Study.

OBJECTIVE: To assess subjective experience in acute stroke and to correlate it with stroke features, acute emotional behavior, and impact on seeking of medical care. METHODS: The authors studied patients with acute first-ever stroke prospectively. During the first 4 days they rated subjective experience (happiness, sadness, irascibility, and fear); behavioral reactions, using a specifically designed scale; and mood (Hamilton anxiety and depression). Fifty-three patients (30 men, 23 women; age, 60 +/- 19 years) completed the 3-month follow-up. RESULTS: Seventeen patients failed to seek medical care spontaneously. Sixteen patients presented behavioral reactions of overt sadness, 20 presented indifference, 12 presented aggressiveness, 20 presented disinhibition, and 16 presented denial. Eight patients were anosognosic and 12 were anosodiaphoric. Twenty-four patients expressed happiness, 20 expressed sadness, 7 expressed anger, and 11 expressed fear. Ten patients with aphasia could be interviewed, but four required delayed questioning. Denial reactions and anosognosia were independent. Acute denial reactions were not dependent on the side of stroke, but were more frequent after deep lesions (p < 0.010). Patients with a denial reaction had a tendency to present less subjective experience of fear (p < 0.078) and a higher occurrence of delayed depression (p < 0.02). Intergroup comparison of all measures showed that lack of seeking care was related to reactions of indifference (p < 0.007), a tendency toward a less subjective experience of fear (p < 0.078), poor recall of the acute event (p < 0.001), decreased nosognosia (p < 0.001), and right-side lesions (p < 0.035). CONCLUSIONS: Patients with acute behavioral denial had a decreased occurrence of subjective experience of fear and a more frequent occurrence of delayed depression. These denial reactions were independent of anosognosia. A subjective experience of fear was related to appropriate care seeking. An impaired subjective experience of fear may contribute, as with anosognosia, to an increased delay in consultation. All other emotional reactions were dissociated from the patients' subjective experience.

Acute Disease↗
PubMed1993

The experiences of an acute stroke unit--implications for multicentre acute stroke trials.

The suitability of 200 consecutive patients admitted to a newly established acute stroke unit was assessed for participation in two multicentre trials currently in their pilot phase: the International Stroke Trial of aspirin and heparin, and the Multicentre Acute Stroke Trial of streptokinase versus placebo. Of the 200 patients (74 men, 126 women, mean age 71 years), 96% had cerebral CT, and 94% had a final diagnosis of cerebrovascular disease. Overall, 50% of patients presented within 6 hours and 70% within 12 hours of the onset of ictus. A total of 113 patients (56.5%) were potentially eligible for trial treatment with aspirin/heparin. Only 9 patients (4.5%) were eligible for streptokinase treatment: 50% were excluded because they presented after 6 hours; 23% had a previous stroke with clinical sequelae and 23% had severe systemic illness. Forty eight per cent of patients had more than one exclusion criterion. The potentially high enrollment rates in trials of antithrombotic agents contrast with the restricted recruitment for trials of streptokinase, emphasising the need for multiple centres to achieve useful study enrollment.

Adult↗
PubMed2005

The effect of weekends and holidays on stroke outcome in acute stroke units.

BACKGROUND AND PURPOSE: In almost all acute stroke units in Japan, staffing level is lower on weekends and holidays and rehabilitative services are provided only on weekdays. We sought to investigate the effects of low-volume care early after stroke resulting from weekends and holidays on the outcome of stroke. METHODS: Patients with completed stroke within 72 h of onset were prospectively registered by 10 acute stroke units in Japan. Main outcome measures were favorable outcomes as indicated by a score of 0-1 on the modified Rankin scale (mRS01) on their 21st hospital day and at discharge and case fatality during the hospital stay. Cox proportional hazardsmodels were used to identify the effects of weekday admission and a weekday ratio (a number of weekdays / total length of hospital stay, or 21 days if hospitalization was longer than 21 days) on the main outcome measures. RESULTS: In a total of 1,134 patients, Cox proportional hazards regression analyses demonstrated that the weekday admission was significantly associated with mRS01 at discharge (hazard ratio, HR: 1.385, 95% CI: 1.087-1.764) and case fatality (HR: 0.477, 95% CI: 0.285-0.798). In 858 patients with rehabilitative therapy, the weekday ratio was significantly associated with mRS01 at discharge (p = 0.014). Compared with the lowest tertile of weekday ratio (<66.6%), the highest tertile (>71.4%) was significantly positively associated with mRS01 at discharge (HR: 1.524, 95% CI: 1.053-2.206; p < 0.026). CONCLUSIONS: Weekday admission was an independent negative predictor of case fatality and a positive predictor of favorable outcome (mRS01) at discharge from acute stroke units. In patients with rehabilitative therapy, a reduction in the weekday ratio was also associated with unfavorable outcome, probably due to a reduction in multidisciplinary care.

Acute Disease↗
PubMed2006

Acute autonomic dysfunction contralateral to acute strokes: a prospective study of 100 consecutive cases.

Complex painful reflex syndrome is sometimes described in the chronic phase of stroke. Acute autonomic dysfunction (AAD), which is occasionally present in cases of acute stroke, has not been studied prospectively. The aim of the study was to investigate AAD on the hemibody contralateral to the lesion in the acute phase of stroke. One hundred consecutive patients (median age +/- interquartile range, 74 +/- 21; range 19-93; 51 women: 80 +/- 17 and 49 men: 70 +/- 17 years) in the acute phase of stroke were studied prospectively. Changes in skin temperature or coloration, diaphoresis, pain, or edema were noted in the first 3 days post-stroke. Associations between AAD and topography (cortical pre- and/or post-central, insular, corona radiata, basal ganglia, internal capsule, thalamus, and brainstem), age, gender, ischemic or hemorrhagic etiology, or the presence of sensorimotor deficits or ataxia were examined using the chi-squared or Fisher's exact test and logistic regression analysis. AAD was found in 71% of the patients and showed a significant positive association with the presence of a lesion in the post-central cortex (P = 0.037), internal capsule (P = 0.005), basal ganglia (P = 0.002), or insula (P = 0.011) and a negative association with the presence of a lesion in the brainstem (P = 0.004). Multivariate logistic regression analysis including all studied topographic variables showed that only brainstem lesions were significantly associated with a decreased risk of developing AAD (odds ratio = 0.08, 95% confidence interval: 0.01-0.69, P = 0.022). AAD was not associated with age, gender, the ischemic or hemorrhagic nature of the lesion, the side of lesion, hypertonic or hypotonic paresis, or hyperreflexia or hyporeflexia. AAD was found in association with sensory deficits (P = 0.001) and contralateral hyperkinesia (P = 0.004). Acute AAD is significantly more likely to occur in the presence of hemispheric lesions involving sensory pathways from the cortex to the internal capsule and insula and is significantly less prevalent in the presence of brainstem lesions.

Acute Disease↗
PubMed2006

The relationship between homocysteine, cognition and stroke subtypes in acute stroke.

BACKGROUND: Elevations in plasma homocysteine (Hcy) have been associated with an increased risk of stroke and dementia. The mechanisms underlying these associations remain poorly understood. OBJECTIVES: This study examines the relationships between Hcy, cognition, and stroke subtype. We hypothesize that: 1) Hcy levels are inversely related to cognition, 2) Hcy levels are unrelated to stroke subtype, and 3) stroke subtype affects cognition. METHODS: We studied 169 consenting patients admitted for acute stroke during a 4 month period. Blood was drawn for Hcy levels and the Mini-Mental State Examination (MMSE) was administered within 9 days of admission. The Oxfordshire Community Stroke Project Classification was used to characterize stroke subtypes. Correlation between Hcy and MMSE scores was examined as was the relationships between Hcy and stroke subtype, and between stroke subtypes and MMSE scores. RESULTS: A significant inverse correlation between Hcy levels and MMSE scores was demonstrated (r=-0.243, p=0.001). MMSE scores also differed according to the type of stroke, with Total or Partial Anterior Circulation Infarcts (TACI/PACI) scoring lowest (F=8.77, df=2, p<0.001). Hcy levels did not differ between the various stroke subtypes (F=0.21, df=2, p=0.81). Multivariate linear regression analysis showed that age, education, and stroke subtype, but not Hcy, were independent predictors of acute MMSE scores. CONCLUSIONS: In this study sample, there was an inverse relationship between Hcy and cognition in acute stroke patients. However, Hcy was not an independent predictor for cognition in acute stroke after other factors such as stroke subtype and patient age were taken into account. These results suggest that during the acute stage of stroke, stroke subtype is a more important factor in determining cognition than Hcy levels.

Acute Disease↗
PubMed1997

[Treatment of acute stroke on the stroke unit. Initial experiences with an acute stroke unit in Germany].

We studied the effects of stroke unit care in an acute Neurology department on the outcome and the length of hospital stay in acute stroke patients. After an emergency evaluation on admission including CCT, ultrasound studies and ECG the patients were treated on a specialist stroke unit for an average 3.9 days. For 48 +/- 24 h monitoring of blood pressure, ECG, pO2 and transcranial Doppler sonography was instituted. Stroke unit treatment reduced the length of hospital stay from an average 15.8 days in the time period before institution of the stroke unit to 12.9 days. This effect was especially marked in patients with acute occlusion of major intracranial arteries (before stroke unit treatment: n = 33; hospital stay 22.5 days; after stroke unit treatment: n = 54; hospital stay 13.9 days). Clinical deterioration in acute ischemic stroke was related to reduction of cerebral blood flow velocities due to blood pressure changes or space occupying effects. Monitoring on the stroke unit allowed immediate treatment of systemic hypotension, cerebral edema or cardiac arrhythmias. Transcranial Doppler sonography revealed HITS in 6/55 acute stroke patients without new clinical symptoms. Monitoring on the stroke unit improved the specific care for acute stroke patients. The length of hospital stay was reduced after stroke unit care.

Acute Disease↗
PubMed2000

Interventions for deliberately altering blood pressure in acute stroke.

BACKGROUND: It is unclear whether hypertension should be treated after acute stroke, and some have hypothesised that blood pressure should be increased to improve cerebral perfusion. OBJECTIVES: The objective of this review was to assess the effect of lowering or elevating blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register, the Ottawa Stroke Trials Registry (1994), Medline (from 1965), Embase (from 1981), ISI, and existing review articles. We contacted researchers in the field and pharmaceutical companies. SELECTION CRITERIA: Randomised trials of interventions that aimed to alter blood pressure in patients within two weeks of acute ischaemic or haemorrhagic stroke. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied the inclusion criteria and assessed trial quality. Two reviewers extracted the data. MAIN RESULTS: Three trials involving 133 people were included. The trials tested the following vasodilators: nimodipine (66 people), nicardipine (five people), captopril (three people) and clonidine (two people). Oral calcium channel blockers (nimodipine, nicardipine) reduced systolic blood pressure (weighted mean difference 10.9mmHg, 95% confidence interval 2.0 to 19.7), diastolic blood pressure (weighted mean difference 9.5mmHg, 95% confidence interval 4.0 to 15.1) and heart rate (weighted mean difference 4.7 beats per minute, 95% confidence interval 0.2 to 9.2) at 48 hours. The greatest fall in blood pressure over the first 24 hours was shown in patients given the highest dose of nimodipine. The relationship between change in blood pressure and clinical outcome was not clear. There was not enough information to assess the effect of drugs other than calcium channel blockers. No studies of interventions to raise blood pressure were found. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the effect of altering blood pressure after acute stroke. Although oral calcium channel blockers appear to reduce blood pressure following acute stroke, the balance of benefit and risk remains unclear.

Blood Pressure↗
PubMed2004

Pharmacologic agents in stroke prevention, acute stroke therapy, and interventional procedures.

Pharmaceutical agents have moved far beyond just the aspirin and heparin that were the mainstays of stroke and interventional therapy as recently as 10 to 15 years ago. Our understanding of the mechanisms of thrombus formation and vascular response to damage as well as our armamentarium has tremendously improved in the past decade. Direct thrombin inhibitors, powerful antiplatelet agents, new fibrinolytic agents, and statins now allow far greater manipulation of the intraprocedural and postprocedural clot cascade and atherogenesis. It is mandatory that current-day interventionists understand the correct and appropriate use of these agents to achieve the desired outcomes of therapy.

Acute Disease↗