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At least 19 recordsLinked to original sources
PubMed2006

Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline.

BACKGROUND AND PURPOSE: This guideline provides an overview of the evidence on various established and potential stroke risk factors and provides recommendations for the reduction of stroke risk. METHODS: Writing group members were nominated by the committee chair on the basis of each writer's previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statement Oversight Committee. The writers used systematic literature reviews (covering the time period since the last review published in 2001 up to January 2005), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations based on standard American Heart Association criteria. All members of the writing group had numerous opportunities to comment in writing on the recommendations and approved the final version of this document. The guideline underwent extensive peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS: Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to their potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic factors. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, migraine headache, hyperhomocysteinemia, elevated lipoprotein(a), elevated lipoprotein-associated phospholipase, hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed. CONCLUSIONS: Extensive evidence is available identifying a variety of specific factors that increase the risk of a first stroke and providing strategies for reducing that risk.

Brain Ischemia↗
PubMed2000

Organised inpatient (stroke unit) care for stroke.

BACKGROUND: Specially organised stroke units can be a ward or team that exclusively manages stroke patients (a dedicated stroke unit) or a ward or team that provides a generic disability service (a mixed assessment or rehabilitation unit). OBJECTIVES: The objective of this review was to assess the effect of care in a stroke unit compared with conventional care of patients following a stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register, reference lists of articles and contacted researchers in the field. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing organised inpatient stroke unit care with conventional care. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility and trial quality. The principal reviewer conducted a structured interview with the coordinators of unpublished trials. MAIN RESULTS: Twenty trials were included. Stroke unit care showed a reduction in the odds of death recorded at final follow-up (median one year). The odds ratio was 0.83, 95% confidence interval 0.71 to 0.97. The odds of death or institutionalised care were lower (0.76, 95% confidence interval 0.65 to 0.90) as were death or dependency at final review (odds ratio 0.75, 95% confidence interval 0.65 to 0.87). Subgroup analyses showed that the observed benefits were independent of patient age, sex, stroke severity, and types of stroke unit organisation. There was no indication that organised stroke unit care resulted in increased hospital stay, although there was heterogeneity between the trials. REVIEWER'S CONCLUSIONS: Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The apparent benefits are not restricted to any particular sub-group of patients or model of stroke unit care. No systematic increase was observed in the length of inpatient stay.

Hospital Units↗
PubMed2002

Recommendations for improving the quality of care through stroke centers and systems: an examination of stroke center identification options: multidisciplinary consensus recommendations from the Advisory Working Group on Stroke Center Identification Options of the American Stroke Association.

BACKGROUND AND PURPOSE: The American Stroke Association (ASA) assembled a multidisciplinary group of experts to develop recommendations regarding the potential effectiveness of establishing an identification program for stroke centers and systems. "Identification" refers to the full spectrum of models for assessing and recognizing standards of quality care (self-assessment, verification, certification, and accreditation). A primary consideration is whether stroke center identification might improve patient outcomes. METHODS: In February 2001, ASA, with the support of the Stroke Council's Executive Committee, decided to embark on an evaluation of the potential impact of stroke center identification. HealthPolicy R&D was selected to prepare a comprehensive report. The investigators reported on models outside the area of stroke, ongoing initiatives within the stroke community (such as Operation Stroke), and state and federal activities designed to improve care for stroke patients. The investigators also conducted interviews with thought leaders in the stroke community, representing a diverse sampling of specialties and affiliations. In October 2001, the Advisory Working Group on Stroke Center Identification developed its consensus recommendations. This group included recognized experts in neurology, emergency medicine, emergency medical services, neurological surgery, neurointensive care, vascular disease, and stroke program planning. RESULTS: There are a variety of existing identification programs, generally falling within 1 of 4 categories (self-assessment, verification, certification, and accreditation) along a continuum with respect to intensity and scope of review and consumption of resources. Ten programs were evaluated, including Peer Review Organizations, trauma centers, and new efforts by the National Committee on Quality Assurance and the Joint Commission on the Accreditation of Healthcare Organizations to identify providers and disease management programs. The largest body of literature on clinical outcomes associated with identification programs involves trauma centers. Most studies support that trauma centers and systems lead to improved mortality rates and patient outcomes. The Advisory Working Group felt that comparison to the trauma model was most relevant given the need for urgent evaluation and treatment of stroke. The literature in other areas generally supports the positive impact of identification programs, although patient outcomes data have less often been published. In the leadership interviews, participants generally expressed strong support for pursuing some form of voluntary identification program, although concerns were raised that this effort could meet with some resistance. CONCLUSIONS: Identification of stroke centers and stroke systems competencies is in the best interest of stroke patients in the United States, and ASA should support the development and implementation of such processes. The purpose of a stroke center/systems identification program is to increase the capacity for all hospitals to treat stroke patients according to standards of care, recognizing that levels of involvement will vary according to the resources of hospitals and systems.

Accreditation↗
PubMed2000

[Calculation of costs of stroke, cost effectiveness of stroke units and secondary prevention in patients after a stroke, as recommended by revised CBO practice guideline 'Stroke'].

OBJECTIVE: Economic analyses have been part of the revision of the Dutch multi-disciplinary stroke guidelines. We evaluated the recommendations on stroke units and prevention of stroke recurrencies in terms of medical costs and health effects among stroke patients. DESIGN: Cost calculation. METHOD: Mathematical modelling of medical costs per patient and costs per life year gained without severe stroke (Rankin score (> 3)), by age and sex for each guideline. RESULTS: Lifetime costs of stroke depended on age and sex and vary between 84,000 and 292,000 Dutch guilders (HFL). The cost-effectiveness of stroke units decreases with age and varies between HFL 37,000 and HFL 60,200 with a large uncertainty range. Four of seven options in secondary prevention were cost-effective by previously established criteria (< HFL 40,000 per year gained without severe disease). Acetylsalicylic acid remained the drug of choice for monotherapy with dipyridamol as a second choice in patients without atrial fibrillation. Clopidogrel was not cost-effective at the current cost level. Anticoagulation after stroke in case of atrial fibrillation was cost-effective. CONCLUSIONS: Given a short hospital stay stroke units can be as affective as other hospital interventions. Acetylsalicylic acid is the most cost effective monotherapy for secondary prevention.

Age Factors↗
PubMed2006

Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline.

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for the implementation of guidelines and their use in high-risk populations.

Adult↗
PubMed2006

Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline.

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for the implementation of guidelines and their use in high-risk populations.

American Heart Association↗
PubMed2002

[Treatment of ischemic stroke in 14 neurologic stroke units. An evaluation of the stroke databank of the German Stroke Aid Foundation].

This study compares the treatment characteristics of 3,740 patients with acute ischemic stroke in 14 established German stroke units. Follow-up after 3 months in surviving patients additionally assessed functional outcome and risk factor modification. The median age was 68 years and 41.9% were women. Twenty-six percent of all patients were admitted within 3 h after the event, and 4.2% received systemic thrombolysis. The median length of stay of all patients in the stroke unit was 3 days. Thereafter, 63% were transferred to another ward in the documenting clinic. The mean length of stay in the documenting hospital was 12 days. In seven hospitals with a follow-up rate of > 80%, mortality amounted to 10.5%, and 56.2% of the patients regained functional independence. This study demonstrates the relatively favorable prognosis of patients in German stroke units as well as the low standardization of diagnostic work-up and treatment strategies.

Aged↗
PubMed2000

Indications for early aspirin use in acute ischemic stroke : A combined analysis of 40 000 randomized patients from the chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups.

BACKGROUND AND PURPOSE: Long-term daily aspirin is of benefit in the years after ischemic stroke, and 2 large randomized trials (the Chinese Acute Stroke Trial [CAST] and the International Stroke Trial [IST]), with 20 000 patients in each, have shown that starting daily aspirin promptly in patients with suspected acute ischemic stroke also reduces the immediate risk of further stroke or death in hospital and the overall risk of death or dependency. However, some uncertainty remains about the effects of early aspirin in particular categories of patient with acute stroke. METHODS: To assess the balance of benefits and risks of aspirin in particular categories of patient with acute stroke (eg, the elderly, those without a CT scan, or those with atrial fibrillation), a prospectively planned meta-analysis is presented of the data from 40 000 individual patients from both trials on events that occurred in the hospital during the scheduled treatment period (4 weeks in CAST, 2 weeks in IST), with 10 characteristics used to define 28 subgroups. This represents 99% of the worldwide evidence from randomized trials. RESULTS: There was a highly significant reduction of 7 per 1000 (SD 1) in recurrent ischemic stroke (320 [1.6%] aspirin versus 457 [2. 3%] control, 2P<0.000001) and a less clearly significant reduction of 4 (SD 2) per 1000 in death without further stroke (5.0% versus 5. 4%, 2P=0.05). Against these benefits, there was an increase of 2 (SD 1) per 1000 in hemorrhagic stroke or hemorrhagic transformation of the original infarct (1.0% versus 0.8%, 2P=0.07) and no apparent effect on further stroke of unknown cause (0.9% versus 0.9%). In total, therefore, there was a net decrease of 9 (SD 3) per 1000 in the overall risk of further stroke or death in hospital (8.2% versus 9.1%, 2P=0.001). For the reduction of one third in recurrent ischemic stroke, subgroup-specific analyses found no significant heterogeneity of the proportional benefit of aspirin (chi(2)(18)=20. 9, NS), even though the overall treatment effect (chi(2)(1)=24.8, 2P<0.000001) was sufficiently large for such subgroup analyses to be statistically informative. The absolute risk among control patients was similar in all 28 subgroups, so the absolute reduction of approximately 7 per 1000 in recurrent ischemic stroke does not differ substantially with respect to age, sex, level of consciousness, atrial fibrillation, CT findings, blood pressure, stroke subtype, or concomitant heparin use. There was no good evidence that the apparent decrease of approximately 4 per 1000 in death without further stroke was reversed in any subgroup or that in any subgroup the increase in hemorrhagic stroke was much larger than the overall average of approximately 2 per 1000. Finally, there was no significant heterogeneity between the reductions in the composite outcome of any further stroke or death (chi(2)(18)=16.5, NS). Among the 9000 patients (22%) randomized without a prior CT scan, aspirin appeared to be of net benefit with no unusual excess of hemorrhagic stroke; moreover, even among the 800 (2%) who had inadvertently been randomized after a hemorrhagic stroke, there was no evidence of net hazard (further stroke or death, 63 aspirin versus 67 control). CONCLUSIONS: Early aspirin is of benefit for a wide range of patients, and its prompt use should be routinely considered for all patients with suspected acute ischemic stroke, mainly to reduce the risk of early recurrence.

Acute Disease↗
PubMed2002

Randomized controlled study of stroke unit care versus stroke team care in different stroke subtypes.

BACKGROUND AND PURPOSE: The benefits of stroke unit management may vary according to stroke subtype. A post hoc analysis of the influence of stroke subtype on stroke unit effectiveness was undertaken by using prospective data collected in a randomized controlled trial. METHODS: Two hundred sixty-seven patients with moderately severe ischemic stroke (164 with large-vessel infarcts and 103 with lacunar infarcts) were randomly allocated to treatment in stroke units or in general medical wards with specialist stroke team support. Mortality, institutionalization, neurological, functional, and quality-of-life scores and resource use were assessed at 3 and again at 12 months after stroke onset. An intention-to-treat analysis was undertaken, and logistic regression was used to evaluate the independent effect of stroke unit intervention. RESULTS: Stroke team-supported management was associated with higher mortality (odds ratio [OR] 4.9, 95% CI 1.3 to 18.6) and higher mortality or institutionalization (OR 2.9, 95% CI 1.1 to 7.4) at 3 months (OR 3.6, 95% CI 1.5 to 8.7) and at 1 year (OR 2.8, 95% CI 1.3 to 6.2) in patients with large-vessel infarcts. In contrast, there were no significant differences in outcome in patients with lacunar strokes managed in the stroke unit or by the stroke team. In patients with lacunar strokes, stroke unit care was associated with a longer length of hospital stay (18 versus 13.5 days for stroke unit care versus stroke team care, respectively; P<0.01) and significantly greater use of therapy. CONCLUSIONS: Stroke units improve the outcome in patients with large-vessel infarcts but not in those with lacunar syndromes. For lacunar strokes, stroke unit management may be associated with higher initial health costs for equivalent benefit.

Aged↗
PubMed2003

Cause of stroke recurrence is multifactorial: patterns, risk factors, and outcomes of stroke recurrence in the South London Stroke Register.

BACKGROUND AND PURPOSE: This article examines stroke recurrence and whether the subtype of the initial stroke influences the risk and subtypes of further strokes. The proportion of recurrences attributable to conventional risk factors is quantified. METHODS: From January 1995 to August 2000, all first-in-a-lifetime strokes (n=1626) were identified and prospectively followed up in a defined multiethnic inner city population of 234 533. Twelve overlapping referral sources and face-to-face follow-up at 3 months and 1 and 3 years were used to attain complete registration of stroke recurrence. Index and recurrent stroke were classified according to the Oxford Community Stroke Project classification. RESULTS: In 2744 person-years of follow-up, 153 recurrences were observed. At 5 years, the cumulative risk of first stroke recurrence was 16.6% (95% CI, 13.5 to 20.4), and the combined risk of death or stroke recurrence was 65.3% (95% CI, 61.9 to 68.6). Ethnicity and subtype of index stroke were not associated with stroke recurrence. A change in subtype between index and recurrent stroke occurred in 45.5% (95% CI, 35.8 to 55.2) of cases and was most frequent among index lacunar strokes and primary intracerebral hemorrhages. In multivariable analyses, diabetes mellitus and atrial fibrillation were associated with both stroke recurrence and recurrence-free survival. In the stroke population, 9.1% (95% CI, -2.0 to 20.2) of recurrences were attributable to diabetes and 4.9% (95% CI, -7.3 to 17.2) to atrial fibrillation during the first year after the index stroke. CONCLUSIONS: The cause of stroke recurrence is multifactorial, and the subtypes of index and recurrent strokes are often not identical. Most recurrences remain unexplained by conventional risk factors.

Aged↗
PubMed1999

Does the National Institutes of Health Stroke Scale favor left hemisphere strokes? NINDS t-PA Stroke Study Group.

BACKGROUND AND PURPOSE: The National Institutes of Health Stroke Scale (NIHSS) is a valid, reproducible scale that measures neurological deficit. Of 42 possible points, 7 points are directly related to measurement of language compared with only 2 points related to neglect. METHODS: We examined the placebo arm of the NINDS t-PA stroke trial to test the hypothesis that the total volume of cerebral infarction in patients with right hemisphere strokes would be greater than the volume of cerebral infarction in patients with left hemisphere strokes who have similar NIHSS scores. The volume of stroke was determined by computerized image analysis of CT films and CT images stored on computer tape and optical disks. Cube-root transformation of lesion volume was performed for each CT. Transformed lesion volume was analyzed in a logistic regression model to predict volume of stroke by NIHSS score for each hemisphere. Spearman rank correlation was used to determine the relation between the NIHSS score and lesion volume. RESULTS: The volume for right hemisphere stroke was statistically greater than the volume for left hemisphere strokes, adjusting for the baseline NIHSS (P<0. 001). For each 5-point category of the NIHSS score <20, the median volume of right hemisphere strokes was approximately double the median volume of left hemisphere strokes. For example, for patients with a left hemisphere stroke and a 24-hour NIHSS score of 16 to 20, the median volume of cerebral infarction was 48 mL (interquartile range 14 to 111 mL) as compared with 133 mL (interquartile range 81 to 208 mL) for patients with a right hemisphere stroke (P<0.001). The median volume of a right hemisphere stroke was roughly equal to the median volume of a left hemisphere stroke in the next highest 5-point category of the NIHSS. The Spearman rank correlation between the 24-hour NIHSS score and 3-month lesion volume was 0.72 for patients with left hemisphere stroke and 0.71 for patients with right hemisphere stroke. CONCLUSIONS: For a given NIHSS score, the median volume of right hemisphere strokes is consistently larger than the median volume of left hemisphere strokes. The clinical implications of our finding need further exploration.

Brain↗
PubMed2005

Recombinant tissue plasminogen activator for minor strokes: the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study experience.

STUDY OBJECTIVE: Acute ischemic stroke patients eligible for tissue plasminogen activator and with less severe neurologic deficits, although still generally benefiting from therapy, may have a different risk-benefit profile than all eligible acute stroke patients. We address whether patients with a minor stroke should receive tissue plasminogen activator, analyze minor stroke syndromes in the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study, and define what constitutes a "minor stroke." METHODS: The NINDS rt-PA Stroke Study included 624 patients with acute ischemic stroke within 180 minutes of symptom onset within a randomized, double-blind, placebo-controlled trial. To explore the relationship among stroke severity, thrombolytic therapy, and stroke outcome, we defined minor strokes (5 specified definitions) based on the standardized data available at treatment decision, including National Institutes of Health Stroke Scale score. We studied prespecified clinical outcomes, including 3-month favorable outcome (global statistic) defined from a set of standardized clinical scales, dichotomized clinical outcome at 3 months (good=modified Rankin Scale < or =2, bad=modified Rankin Scale >2), and risk of symptomatic intracerebral hemorrhage. RESULTS: For each of the 5 definitions of minor stroke, adjusted odds ratios for treatment benefit were consistently 2.0 with the lower 95% confidence limit, ranging from 1.4 to 1.5, and the upper 95% confidence limit, ranging from 2.7 to 2.9. There were less frequent "bad" outcomes (modified Rankin Scale >2) after therapy with tissue plasminogen activator than placebo. Symptomatic intracerebral hemorrhage within 36 hours of treatment had a frequency in the tissue plasminogen activator-treated subjects, ranging from 0% to 4%, depending on minor stroke definition. CONCLUSION: Recognizing the limitations of post hoc subgroup analyses, we could not detect a difference in the beneficial effects of tissue plasminogen activator in patients with minor stroke syndromes compared to the overall treatment effects in the entire cohort. Our data suggest that the risk-benefit ratio for using tissue plasminogen activator in minor-stroke patients favors treatment in eligible patients.

Confidence Intervals↗
PubMed2003

Management of acute ischaemic stroke: new guidelines from the American Stroke Association and European Stroke Initiative.

BACKGROUND: Ischaemic stroke is an important cause of death and dependency in industrialised countries; it has a high incidence (affecting up to 0.2% of the population each year) and is commonly lethal or disabling. One in six patients die in the first month after ischaemic stroke, and half of survivors are permanently disabled despite best efforts to rehabilitate them and to prevent complications, recurrent stroke, and other serious vascular events. Optimisation of the early, and ongoing, management of patients with acute ischaemic stroke is pivotal to the reduction of both case fatality and long-term disability. RECENT DEVELOPMENTS: Guidelines for the early management of patients with ischaemic stroke have recently been published by the Stroke Council of the American Stroke Association (ASA; Adams and co-workers, Stroke 2003; 34: 1056-83) and the European Stroke Initiative (EUSI; European Stroke Initiative Executive Committee and Writing Committee, Cerebrovasc Dis 2003; 16: 311-38). Although transatlantic differences might create different interpretations, priorities, and views, the guidelines are remarkably similar, even regarding controversial issues. We believe this is not only because both groups have had the opportunity to discuss many of the controversial issues at international meetings, but also because both groups have endorsed the concept of evidence-based medicine and have based their recommendations on similar classifications of the levels of evidence for the effectiveness of interventions. This is a triumph for evidence-based medicine and a major step towards unification of acute stroke management worldwide. WHERE NEXT?: There are three main challenges in stroke management. To increase the body of reliable evidence from large randomised controlled trials (RCTs) of the safety, effectiveness, and cost of promising treatments (eg, thrombolysis, antithrombotic therapy, neuroprotection, and interventional recanalisation, alone and in combination) in a wide range of patients around the world. To facilitate the widespread development of stroke units, delivery of organised stroke care, and emergency transport of patients with stroke to appropriate stroke centres. And finally, to improve the uptake of effective therapies into clinical practice (eg, by widely disseminating the ASA and EUSI guidelines).

Acute Disease↗
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

Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. Stroke Unit Trialists' Collaboration.

OBJECTIVES: To define the characteristics and determine the effectiveness of organised inpatient (stroke unit) care compared with conventional care in reducing death, dependency, and the requirement for long term institutional care after stroke. DESIGN: Systematic review of all randomised trials which compared organised inpatient stroke care with the contemporary conventional care. Specialist stroke unit interventions were defined as either a ward or team exclusively managing stroke (dedicated stroke unit) or a ward or team specialising in the management of disabling illnesses, which include stroke (mixed assessment/rehabilitation unit). Conventional care was usually provided in a general medical ward. SETTING: 19 trials (of which three had two treatment arms). 12 trials randomised a total of 2060 patients to a dedicated stroke unit or a general medical ward, six trials (647 patients) compared a mixed assessment/rehabilitation unit with a general medical ward, and four trials (542 patients) compared a dedicated stroke unit with a mixed assessment/rehabilitation unit. MAIN OUTCOME MEASURES: Death, institutionalisation, and dependency. RESULTS: Organised inpatient (stroke unit) care, when compared with conventional care, was best characterised by coordinated multidisciplinary rehabilitation, programmes of education and training in stroke, and specialisation of medical and nursing staff. The stroke unit care was usually housed in a geographically discrete ward. Stroke unit care was associated with a long term (median one year follow up) reduction of death (odds ratio 0.83, 95% confidence interval 0.69 to 0.98; P < 0.05) and of the combined poor outcomes of death or dependency (0.69, 0.59 to 0.82; P < 0.0001) and death or institutionalisation (0.75, 0.65 to 0.87; P < 0.0001). Beneficial effects were independent of patients' age, sex, or stroke severity and of variations in stroke unit organisation. Length of stay in a hospital or institution was reduced by 8% (95% confidence interval 3% to 13%) compared with conventional care but there was considerable heterogeneity of results. CONCLUSIONS: Organised stroke unit care resulted in long term reductions in death, dependency, and the need for institutional care. The observed benefits were not restricted to any particular subgroup of patients or model of stroke unit care. No systematic increase in the use of resources (in terms of length of stay) was apparent.

Cerebrovascular Disorders↗
PubMed2004

Ten-year risk of first recurrent stroke and disability after first-ever stroke in the Perth Community Stroke Study.

BACKGROUND AND PURPOSE: Limited information exists on the long-term prognosis after first-ever stroke. We aimed to determine the absolute frequency of first recurrent stroke and disability and the relative frequency of recurrent stroke over 10 years after first-ever stroke in Perth, Western Australia. METHODS: For a 12-month period beginning February 1989, all individuals with suspected acute stroke or transient ischemic attack who lived in a geographically defined and representative region of Perth were registered prospectively. Patients with a definite first-ever stroke were followed up 10 years after the index event. RESULTS: Over 10 years of follow-up, the cumulative risk of a first recurrent stroke was 43% (95% confidence interval [CI], 34 to 51). After the first year after first-ever stroke, the average annual risk of recurrent stroke was approximately 4%. Case fatality at 30 days after first recurrent stroke was 41%, which was significantly greater than the case fatality at 30 days after first-ever stroke (22%) (P=0.003). For 30-day survivors of first-ever stroke, the 10-year cumulative risk of death or new institutionalization was 79% (95% CI, 73 to 85) and of death or new disability was 87% (95% CI, 81 to 92). CONCLUSIONS: Over 10 years of follow-up, the risk of first recurrent stroke is 6 times greater than the risk of first-ever stroke in the general population of the same age and sex, almost one half of survivors remain disabled, and one seventh require institutional care. Effective strategies for prevention of stroke need to be implemented early, monitored frequently, and maintained long term after first-ever stroke.

Adult↗
PubMed2001

Risk of early death and recurrent stroke and effect of heparin in 3169 patients with acute ischemic stroke and atrial fibrillation in the International Stroke Trial.

BACKGROUND AND PURPOSE: We sought to investigate the apparently high risk of early death after an ischemic stroke among patients with atrial fibrillation (AF), identify the main factors associated with early death, and assess the effect of treatment with different doses of subcutaneous unfractionated heparin (UFH) given within 48 hours. METHODS: We studied the occurrence of major clinical events within 14 days among 18 451 patients from the International Stroke Trial, first for all treatment groups combined. Then, among patients with AF, we examined the effects of treatment with subcutaneous UFH started within 48 hours and continued until 14 days after stroke onset. RESULTS: A total of 3169 patients (17%) had AF. Seven hundred eighty-four patients were allocated to UFH 12 500 IU SC BID, 773 to UFH 5000 IU SC BID, and 1612 to no heparin. Within each of these groups, half of the patients were randomly assigned to aspirin 300 mg once daily. Compared with patients without AF, patients with AF were more likely to be female (56% versus 45%), to be old (mean age, 78 versus 71 years), to have an infarct on prerandomization CT (57% versus 47%), and to have impaired consciousness (37% versus 20%). The initial ischemic stroke type was more often a large-artery infarct (36% versus 21%). A lacunar stroke syndrome was less common (13% versus 26%). Death within 14 days was more common in patients with AF (17% versus 8%) and more often attributed to neurological damage from the initial stroke (10% versus 4%). The frequency of recurrent ischemic or undefined stroke was not significantly different (3.9% versus 3.3%). The proportion of AF patients with further events within 14 days allocated to UFH 12 500 IU (n=784), UFH 5000 IU (n=773), and to no-heparin (n=1612) groups were as follows: ischemic stroke, 2.3%, 3.4%, 4.9% (P=0.001); hemorrhagic stroke, 2.8%, 1.3%, 0.4% (P<0.0001); and any stroke or death, 18.8%, 19.4% and 20.7% (P=0.3), respectively. No effect of heparin on the proportion of patients dead or dependent at 6 months was apparent. CONCLUSIONS: Acute ischemic stroke patients with AF have a higher risk of early death, which can be explained by older age and larger infarcts but not by a higher risk of early recurrent ischemic stroke, although slightly more patients with AF died from a fatal recurrent stroke of ischemic or unknown type (1.3% versus 0.9%). In patients with AF the absolute risk of early recurrent stroke is low, and there is no net advantage to treatment with heparin. These data do not support the widespread use of intensive heparin regimens in the acute phase of ischemic stroke associated with AF.

Acute Disease↗