Biomedical subjects

W Pasteur

Publications and source records attributed to W Pasteur.

4 recordsLinked to original sources

PubMed1998

Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinical trial.

OBJECTIVE: To perform a single-center pilot investigation of early hematoma removal in patients with intracerebral hemorrhage (ICH). BACKGROUND: Considerable debate remains regarding the utility of surgical clot evacuation for ICH. METHODS: This was a prospective trial of open craniotomy within 12 hours of ICH symptom onset versus best medical therapy. Patients were eligible if they had a nontraumatic ICH >9 mL with significant neurologic impairment and were prepared for surgery within 12 hours of symptom onset. The study included a prospective registry of patients and a randomized trial. RESULTS: The registry group included 34 medical and seven surgical patients. The surgical group had larger hemorrhages (median, 96 mL) and a lower Glasgow Coma Scale (GCS) score (median, 10) compared with the medical group (33 mL; GCS score, 13). Six-month mortality was less in the medical group (36%) compared with the surgical group (54%). In the randomized series, median ICH volumes were similar in the surgical group (n = 17; 49 mL) compared with the medical group (n = 17; 44 mL). Median GCS score was also similar (medical, 10; surgical, 11). Mortality was lower in the surgical group (6%) compared with the medical group (24%) at 1 month, but similar at 6 months (surgical group, 17%; medical group, 24%). CONCLUSION: A trial of early surgery for ICH is feasible. This study represents the largest prospective, randomized series of surgery for ICH. A modest early mortality benefit for surgery is possible, but long-term benefit for surgery was not established in this single-center pilot investigation.

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PubMed1995

Current emergency department management of stroke in Houston, Texas.

BACKGROUND AND PURPOSE: This study describes emergency department (ED) management of stroke in Houston, Tex, in 1992 to identify delays and deficiencies in recognition and management of stroke patients in various hospital subtypes and to quantitate the impact of a rapid response stroke team. METHODS: ED logs of eight hospitals were retrospectively screened, and 112 patients with suspected acute stroke onset within 6 hours were identified. EDs were divided into four groups based on hospital size (175 to 979 beds), acuity, number of stroke admissions (50/y to 210/y), and availability of neurological consultations. The intervals from stroke onset to triage, examination by a physician, neurological evaluation, computed tomography (CT) and other tests, vital signs, and treatments were recorded. RESULTS: The average time from stroke to ED arrival was 115 minutes, and times from ED arrival to examination by a physician and CT scan were 28 and 100 minutes, respectively, with little variability among hospital groups except that the public hospital was slower. Neurological examinations were poorly documented in community and public hospitals. The presence of a stroke team shortened the time to examination by a physician and to CT by 13 and 63 minutes, respectively, and increased the number of patients admitted to the intensive care unit. Blood pressure was excessively lowered in 31% of hypertensive patients, and hypotonic dextrose intravenous fluids were given to 69% of all patients. CONCLUSIONS: Transport, initial evaluation, and ED care of acute stroke patients are currently slow and often inexpert in all types of hospitals. A stroke team can speed initial ED management.

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PubMed1995

Elective intubation for neurologic deterioration after stroke.

OBJECTIVE: To provide data to guide physicians and family when deciding whether a patient should be electively intubated after ischemic stroke. DESIGN: Chart review and patient interview. Clinical course, neurologic outcome, and financial and psychosocial effect of the decision to intubate were determined. SETTING: Neurology/Neurosurgery critical care unit. PATIENTS: Of our last 250 acute carotid territory ischemic stroke cases, we found 20 patients (8%) who were electively intubated, after CT and neurologic assessment, for neurologic deterioration. INTERVENTIONS: All patients received standard medical therapy. RESULTS: Intubation occurred 3 hours to 7 days (mean, 41 hours) after the onset of symptoms; six of 20 patients required intubation within the first 6 hours. Once clinical deterioration began, 10 of 20 patients required intubation within 1 hour. Six of 20 patients were discharged alive; two subsequently died, one is mostly dependent, two became mostly independent (one of these had a hemicraniectomy and is still improving, and the other died of an intercurrent illness 4 years after her stroke), and one is totally independent. The four "good" outcome survivors were distinguished by higher Glasgow Coma Scale scores (9.2 versus 5.9), and extubation was usually possible within 72 hours. For nonsurvivors, mean hospitalization after intubation was 6.4 days. In survivors, the monthly uninsured cost was $0 to $2,000, and caregivers experienced moderate stress. The same decision would be repeated by 76% of caregivers; 53% of caregivers would want intubation for themselves. CONCLUSIONS: Satisfactory outcome is possible in the 8% of ischemic stroke patients requiring elective intubation. Possible predictors of good outcome include less severe depression of consciousness at the time of intubation, extubation within 3 days, and hemicraniectomy. In retrospect, most families would repeat the decision to intubate. Further study in more patients of the cost/benefit of cerebral resuscitation after stroke is greatly needed.

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PubMed1994

Early presentation of hemispheric intracerebral hemorrhage: prediction of outcome and guidelines for treatment allocation.

Criteria for selecting patients for possible surgery in the management of intracerebral hemorrhage (ICH) are needed to plan a prospective therapeutic evaluation of surgical intervention. This study specifically addressed patients seen in the emergency room within a few hours of the ictus, many of whom were still awake, to identify and subsequently exclude from surgical procedure those expected to recover completely and those expected to die regardless of treatment. We retrospectively studied 75 patients evaluated at a mean time of 3 hours and 37 minutes after hemispheric ICH to determine factors that would predict both good and poor outcomes at the time of discharge. Eighty percent of our patients presented within 6 hours of symptom onset. These patients were younger and had more severe lesions than did those presenting later, yet most were still awake (mean admission Glasgow Coma Scale [GCS] score = 11.0). Using multivariate regression, we created two models. The first model predicts independent outcome, ie, Rankin 0 to 2, of all patients with a GCS score greater than 9 on admission who do not undergo surgery. The significant factors in this model were hemorrhage diameter, intraventricular extension, and age. The second model predicts poor outcome, ie, Rankin 5 and death, of all patients. GCS score, hemorrhage volume, age, and gender were the important factors in this model. We conclude that ICH patients presenting early to the emergency room have more severe lesions radiologically, although their initial clinical status may not be different from those seen late. Our models should identify and thus exclude those with very good and very poor prognoses from future randomized surgical trials.

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