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PubMed2003

Admitting acute ischemic stroke patients to a stroke care monitoring unit versus a conventional stroke unit: a randomized pilot study.

BACKGROUND AND PURPOSE: Pathophysiological considerations and observational studies indicate that elevated body temperature, hypoxia, hypotension, and cardiac arrhythmias in the acute phase of ischemic stroke may aggravate brain damage and worsen outcome. METHODS: Both units were organized with the same standard care and multidisciplinary approach to nursing and rehabilitation. A blinded observer assessed functional outcome at 3 months with the modified Rankin scale (mRS) and Barthel Index (BI). End points were (1) poor outcome, defined as either mRS > or =4 or BI <60 or the need for institutional care and (2) mortality. RESULTS: Fifty-four patients meeting the inclusion criteria were randomized. The groups were well matched for baseline characteristics, stroke subtype, stroke severity, vascular risk factors, and prognostic factors. Poor outcome was seen in 7 (25.9%) patients in the SCMU group and in 13 (48.1%) in the SU group (P=0.16). Mortality was lower in the SCMU group than in the SU group (1 [3.7%] vs 7 [25.9%]; odds ratio, 0.11 [95% CI, 0.02 to 0.96], P=0.05). CONCLUSIONS: This pilot study suggests that admission of acute stroke patients to an SCMU may reduce mortality and poor outcome. A larger trial is required to confirm these findings.

Aged↗
PubMed2000

Language performance in three groups of children with sickle cell disease: those with stroke, without stroke, and at risk for stroke.

Language performance was assessed in three groups of children (16 boys and 14 girls) with sickle cell disease: those with stroke, without stroke, and at risk for stroke. Scores of the three groups did not differ significantly on language comprehension, language expression, spatial orientation, or on overall combined performance scores. Such results have positive medical implications.

Adolescent↗
PubMed1975

Experimental studies on the pathogenesis and prophylaxis of stroke in stroke-prone spontaneously hypertensive rats (SHR). (2) Prophylactic effect of moderate control of blood pressure on stroke.

The offspring of male stroke-prone SHR, 80 in total, were divided into treated and nontreated groups at the age of 30 to 45 days. The former groups were treated with alpha-methyl dopa (2 g/l in the drinking water), or L-dopa (2 g/l) with or without peripheral decarboxylase inhibitor (MK-486, 1-3 g/l) or apresoline (0.08 g/l) thereafter till they died a natural death during 1 and a half year observation period. So far as hypertension was controlled under about 210 mmHg, no stroke was observed, while nontreated group developed cerebrovascular lesions spontaneously in about 80 per cent. This study experimentally confirmed the importance of blood pressure control for the prevention of stroke.

Animals↗
PubMedDate not supplied

A brief descriptive analysis of stroke features in a population of patients from a large urban hospital in Richmond, Virginia, a city within the 'stroke belt'.

PURPOSE: To provide a descriptive analysis of the stroke features in a population of patients from a large urban hospital within the 'stroke belt', with the intention of stimulating interest in creating similar comprehensive databases across the country; the differential population features that may contribute to the increased incidence of ischemic and hemorrhagic stroke within the 'stroke belt' can thus be better studied and understood. BACKGROUND: Strokes account for approximately 5-10% of all deaths in the western world. Within a geographically nondescript region in the Southern United States known as the 'stroke belt', however, the incidence of stroke is 1.5-2 times greater than in other regions of the country. Despite the relatively high incidence of stroke within the 'stroke belt', very little information is available regarding the differential population features that distinguish stroke patients within this region from those in other parts of the country. DESIGN/METHODS: During the period September 1, 1995 to August 31, 1998, data for 506 patients meeting criteria for stroke as outlined in the National Survey of Stroke were entered into the 'Adult Brain Attack Database' at the Medical College of Virginia Hospitals of Virginia Commonwealth University. The data were analyzed using descriptive statistics. RESULTS: Of the 506 patients entered into the database 281 experienced their first stroke during the data collection period. Of these individuals, 60.5% (n = 170) were female (mean age 60.6). The mean age in men presenting with new stroke (n = 111) was 62.5. African-Americans represented the predominant ethnic group making up 63.3% (n = 178) of all first stroke patients. The three most common risk factors among deceased ischemic stroke patients (3.2%; n = 9) included hypertension (58.3%), alcohol abuse (41.6%) and cigarette smoking (33.3%). Among ischemic stroke survivors, the three most common risk factors included hypertension (53.6%), prior neurovascular disease (36.2%) and cigarette smoking (28.0%). Risk factors among hemorrhagic stroke patients included hypertension (42.0%), cigarette smoking (26.3%) and alcohol abuse (21.1%). The most common complication associated with stroke across all subtypes was hypertension with an overall prevalence of 9.3%. The use of antiplatelet and antihypertensive therapy at discharge among stroke patients in whom such data was recorded was 58.8% (179/289) and 48.9% (132/270), respectively. DISCUSSION: Future studies comparing data from the Richmond, Va. stroke database with data from other regions of the country outside the 'stroke belt' may allow for differentiation of the population features that contribute to the increased prevalence of stroke within the 'stroke belt'.

Adult↗
PubMed2006

A protocol for investigation of the effects of outdoor air pollution on stroke incidence, phenotypes and survival using the South London Stroke Register.

Stroke is a major cause of death and disability. About 5.3 million people die every year from stroke worldwide with over 9 million people surviving at any one time after suffering a stroke. About 1 in 4 men and 1 in 5 women aged 45 years will suffer a stroke if they live to their 85th year. It is estimated that by 2023 there will be an absolute increase in the number of people experiencing a first ever stroke of about 30% compared with 1983. In the UK, stroke is the third commonest cause of death and the most common cause of adult physical disability and consumes 5% of the health and social services budget. Stroke is assuming strategic public health importance because of increased awareness in society, an ageing population and emerging new treatments. It is an NHS health service and research priority, being identified as a target in Our Healthier Nation and the NSF for Older People for prevention and risk factor control and in the NHS Plan as a disease requiring intermediate care planning and reduction in inequalities of care. Whilst a number of risk factors for stroke are well known (e.g. increasing age, ethnicity, socioeconomic deprivation, hypertension), the potential importance of outdoor air pollution as a modifiable risk factor is much less well recognised. This is because studies to date are inconclusive or have methodological limitations. In Sheffield, we estimated that 11% of stroke deaths may be linked to current levels of outdoor air pollution and this high figure is explained by the fact that so many people are exposed to air pollution.We plan to study the effects of outdoor air pollution on stroke using a series of epidemiological (i.e. population based) studies. The purpose of this project is: to examine if short term increases in pollution can trigger a stroke in susceptible individuals, to investigate if the occurrence of stroke is higher amongst people living in more polluted areas (which would be explained by a combination of exposure to short term increases and longer term exposure to higher pollution levels), and to see if people living in more polluted areas have reduced survival following their stroke. We will use geographical information systems, robust statistical methods and powerful grid computing facilities to link and analyse the data. The datasets we will use are the South London Stroke Register database, daily monitored pollution data from national monitoring networks and modelled pollution data for London from the Greater London Authority. The South London Stroke Register records information on all patients who suffer a stroke ("incident" cases) living within a defined area. This stroke incidence dataset offers major advantages over previous studies examining the effects of pollution on hospital admissions and mortality, as not all patients with stroke are admitted or die and there may be a delay between the onset of stroke and admission or death. In addition, it contains other useful information, particularly the type of stroke people have suffered. Air pollution is a potentially modifiable risk factor for stroke. This study will provide robust population level evidence regarding the effects of outdoor air pollution on stroke. If it confirms the link, it will suggest to policy-makers at national and international levels that targeting policy interventions at high pollution areas may be a feasible option for stroke prevention.

Adult↗
PubMed2002

[Japan stroke scales and its application for stroke].

There are many stroke scales currently available for estimating the severity and outcome of stroke. However, none of the stroke scales have been able to objectively quantify the severity of stroke. The Japan Stroke Society formed a subcommittee to task force the development of an innovative, quantifiable stroke scale. Conjoint analysis was utilized to compile this data. Finally, they developed a novel, and quantifiable Japan Stroke for the acute phase of stroke (JSS) (Stroke 32: 1800-1807, 2001). In addition to standard JSS, the Japan Stroke Scale Motor Function and Japan Stroke scale--Higher Cortical Function were finalized. These stroke scales are all parametric stroke scales. We utilize the stroke scales to monitor stroke patients, to start clinical pathway on patients with lacunas infarction after deciding whether severity of stroke is suitable for the clinical pathway by JSS. We use the JSS for the clinical studies of stroke patients. Furthermore, the JSS was utilized in the phase 2 trial of a new treatment in stroke patients which had significant statistical power. The scales were also introduced to the stroke databank. Therefore, these scales are useful to monitoring the neurological damage of stroke patients in the acute and chronic phase and to estimating the severity of stroke symptoms and predicting stroke outcome in clinical studies. They also have a potential to prove the efficacy of treatments through parametric analysis.

Humans↗
PubMed1998

North Carolina stroke prevention and treatment facilities survey: rtPA therapy for acute stroke.

BACKGROUND AND PURPOSE: North Carolina is situated in the "stroke belt" region of the United States, an area of the country with a particularly high incidence of cerebrovascular disease. The North Carolina Stroke Prevention and Treatment Facilities Survey was carried out to determine the availabilities of a variety of stroke prevention and treatment services throughout the state. The purpose of the present study was to determine how widely recombinant tissue-type plasminogen activator (rtPA) has been adopted for the treatment of patients with acute ischemic stroke and to determine the characteristics of the medical facilities in the state offering this therapy. METHODS: A single-page survey was mailed to the medical center directors of each inpatient medical facility in North Carolina. Data collected included questions related to the availability of selected basic and advanced diagnostic tests and procedures, stroke prevention and treatment programs and services (community stroke awareness program, acute stroke identification program, acute stroke team, stroke rtPA protocol, stroke care map, neurologist), and facilities (Stroke Acute Care Unit or equivalent). RESULTS: Responses were obtained from all 125 inpatient medical facilities in North Carolina. rtPA stroke protocols were adopted in 54 facilities located in 46 of the state's 100 counties. Seventy-four percent of the state's population resides in counties with hospitals providing rtPA treatment. Compared with facilities not offering rtPA, those with rtPA protocols more commonly sponsored stroke community awareness programs (41% versus 17%, P=0.003) and more frequently had an organized stroke team (31% versus 8%, P=0. 001), used stroke care maps (56% versus 17%, P<0.001), had rapid stroke identification programs (33% versus 6%, P<0.001), or had a Stroke Acute Care Unit or its equivalent (33% versus 7%, P<0.001). Neurologists were available in 78% of the facilities offering rtPA compared with 38% in facilities without rtPA protocols (P<0.001). CONCLUSIONS: These data show that this new therapy for ischemic stroke is potentially available to a high proportion of the state's citizens based on their county of residence. However, other services that may improve outcomes and reduce stroke-related costs (eg, stroke teams, stroke units, care maps) are not being widely used, even in centers providing treatment with rtPA. The simple methodology used in this study is potentially applicable in other states and permits targeting of selected centers for development of stroke treatment capabilities.

Acute Disease↗
PubMed2006

Single-vessel versus multivessel territory acute ischemic stroke: value of transesophageal echocardiography in the differentiation of embolic stroke.

OBJECTIVES: We sought to assess the presence of potential aortic or cardiac sources of embolism in patients presenting with acute ischemic stroke in one or more vascular territories. BACKGROUND: In patients with acute ischemic stroke, involvement of multiple vascular territories has been used to implicate a cardiac or aortic source of embolus. It remains unclear whether patients with multivessel stroke have a higher frequency of cardiac or aortic embolic sources on transesophageal echocardiography (TEE) compared with patients with single-territory stroke. METHODS: We identified 210 patients with acute ischemic stroke documented by neuroimaging undergoing TEE for identification of a potential embolic source. Patients were divided into 3 groups (lacunar stroke, nonlacunar stroke/single-vessel involvement, nonlacunar stroke/multivessel involvement) and the frequency of potential embolic sources on TEE was compared. RESULTS: Of the 210 patients, 121 (58%) were male and the mean age was 61 years. In all, 139 patients (66%) were classified as having single-vessel stroke, 47 (22%) as having multivessel stroke, and 24 (11%) as having lacunar stroke. On TEE, 87 patients (41%) had at least one potential source of embolism. Patients with multivessel strokes had fewer potential embolic sources on TEE than patients with single-vessel or lacunar strokes (26% vs 46% and 46%, respectively; P = .043). CONCLUSIONS: In patients with acute ischemic stroke, the incidence of a potential cardiac or aortic source of embolism is high, regardless of the vascular distribution of the stroke. TEE may be a useful tool to assess the source of stroke in single-vessel, multivessel, and lacunar territory stroke distribution. We aimed to assess the presence of potential aortic or cardiac sources of embolism in patients presenting with acute ischemic stroke in one or more vascular territories. A total of 210 patients with acute ischemic stroke were divided into 3 groups (lacunar stroke, nonlacunar stroke/single-vessel involvement, nonlacunar stroke/multivessel involvement) and the frequency of potential embolic sources on transesophageal echocardiography was compared. Patients with multivessel strokes had fewer potential embolic sources on transesophageal echocardiography than patients with single-vessel or lacunar strokes, but the frequency of a potential cardiac or aortic source of embolism was high, regardless of the vascular distribution of stroke.

Brain Ischemia↗
PubMed2006

The roles of exercise-induced immune system disturbances in the pathology of heat stroke : the dual pathway model of heat stroke.

Heat stroke is a life-threatening condition that can be fatal if not appropriately managed. Although heat stroke has been recognised as a medical condition for centuries, a universally accepted definition of heat stroke is lacking and the pathology of heat stroke is not fully understood. Information derived from autopsy reports and the clinical presentation of patients with heat stroke indicates that hyperthermia, septicaemia, central nervous system impairment and cardiovascular failure play important roles in the pathology of heat stroke. The current models of heat stroke advocate that heat stroke is triggered by hyperthermia but is driven by endotoxaemia. Endotoxaemia triggers the systemic inflammatory response, which can lead to systemic coagulation and haemorrhage, necrosis, cell death and multi-organ failure. However, the current heat stroke models cannot fully explain the discrepancies in high core temperature (Tc) as a trigger of heat stroke within and between individuals. Research on the concept of critical Tc as a limitation to endurance exercise implies that a high Tc may function as a signal to trigger the protective mechanisms against heat stroke. Athletes undergoing a period of intense training are subjected to a variety of immune and gastrointestinal (GI) disturbances. The immune disturbances include the suppression of immune cells and their functions, suppression of cell-mediated immunity, translocation of lipopolysaccharide (LPS), suppression of anti-LPS antibodies, increased macrophage activity due to muscle tissue damage, and increased concentration of circulating inflammatory and pyrogenic cytokines. Common symptoms of exercise-induced GI disturbances include diarrhoea, vomiting, gastrointestinal bleeding, and cramps, which may increase gut-related LPS translocation. This article discusses the current evidence that supports the argument that these exercise-induced immune and GI disturbances may contribute to the development of endotoxaemia and heat stroke. When endotoxaemia can be tolerated or prevented, continuing exercise and heat exposure will elevate Tc to a higher level (>42 degrees C), where heat stroke may occur through the direct thermal effects of heat on organ tissues and cells. We also discuss the evidence suggesting that heat stroke may occur through endotoxaemia (heat sepsis), the primary pathway of heat stroke, or hyperthermia, the secondary pathway of heat stroke. The existence of these two pathways of heat stroke and the contribution of exercise-induced immune and GI disturbances in the primary pathway of heat stroke are illustrated in the dual pathway model of heat stroke. This model of heat stroke suggests that prolonged intense exercise suppresses anti-LPS mechanisms, and promotes inflammatory and pyrogenic activities in the pathway of heat stroke.

Adult↗
PubMed1997

Stroke patients' knowledge of stroke. Influence on time to presentation.

BACKGROUND AND PURPOSE: New treatments for acute stroke will likely have to be given soon after stroke onset. Little is known about stroke patients' general knowledge about stroke, their interpretation of stroke symptoms, and how these factors influence the timing of their decision to seek medical attention. METHODS: We interviewed consecutive stroke patients within 72 hours of stroke onset to define factors influencing time of arrival to the emergency department. Data recorded included demographic information, method of transportation, type of stroke symptoms, the patient's interpretation of the symptoms, previous stroke, and knowledge of stroke warning signs. Stroke severity was measured with the Barthel Index. Early arrival was defined as within 3 hours of awareness of symptoms. RESULTS: Sixty-seven patients were interviewed; 96% had an ischemic stroke and 4% a cerebral hemorrhage. Although 38% of patients professed to know the warning signs of stroke, only 25% correctly interpreted their symptoms. Patients with prior stroke were more likely to correctly interpret their symptoms (45% versus 16%; P = .03) but were not more likely to present early (19% versus 39%; P = .35). Eighty-six percent of patients presenting more than 3 hours after stroke onset thought that their symptoms were not serious. The 24% (n = 16) of early arrivals were more likely to arrive by ambulance (81% versus 38%; P = .003) and had more severe stroke (Barthel Index score of 49 versus 72; P = .01) than late arrivals. Arrival by ambulance was independently associated with early arrival (odds ratio, 5.55; 95% confidence interval, 1.37 to 22.6). CONCLUSIONS: Approximately one quarter of stroke patients correctly interpret their symptoms as representing a stroke. This knowledge is not associated with early presentation to the emergency department. Ambulance transport is independently associated with early arrival at the emergency department. Even when patients know that they are having a stroke, most present late because they perceive their symptoms as "not serious." Widespread public education of stroke-prone individuals may increase the proportion of patients eligible for new acute stroke treatments.

Aged↗
PubMed1998

Long-term risk of first recurrent stroke in the Perth Community Stroke Study.

BACKGROUND AND PURPOSE: Few community-based studies have examined the long-term risk of recurrent stroke after an acute first-ever stroke. This study aimed to determine the absolute and relative risks of a first recurrent stroke over the first 5 years after a first-ever stroke and the predictors of such recurrence in a population-based series of people with first-ever stroke in Perth, Western Australia. METHODS: Between February 1989 and August 1990, all people with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event. RESULTS: Three hundred seventy patients with a first-ever stroke were registered, of whom 351 survived >2 days. Data were available for 98% of the cohort at 5 years, by which time 199 patients (58%) had died and 52 (15%) had experienced a recurrent stroke, 12 (23%) of which were fatal within 28 days. The 5-year cumulative risk of first recurrent stroke was 22.5% (95% confidence limits [CL], 16.8%, 28.1%). The risk of recurrent stroke was greatest in the first 6 months after stroke, at 8.8% (95% CL, 5.4%, 12.1%). After adjustment for age and sex, the prognostic factors for recurrent stroke were advanced, but not extreme, age (75 to 84 years) (hazard ratio [HR], 2.6; 95% CL, 1.1, 6.2), hemorrhagic index stroke (HR, 2.1; 95% CL, 0.98, 4.4), and diabetes mellitus (HR, 2.1; 95% CL, 0.95, 4.4). CONCLUSIONS: Approximately 1 in 6 survivors (15%) of a first-ever stroke experience a recurrent stroke over the next 5 years, of which 25% are fatal within 28 days. The pathological subtype of the recurrent stroke is the same as that of the index stroke in 88% of cases. The predictors of first recurrent stroke in this study were advanced age, hemorrhagic index stroke, and diabetes mellitus, but numbers of recurrent events were modest. Because the risk of recurrent stroke is highest (8.8%) in the first 6 months after stroke, strategies for secondary prevention should be initiated as soon as possible after the index event.

Age Factors↗
PubMed2000

Antiplatelet therapy for acute ischaemic stroke.

BACKGROUND: In patients with acute ischaemic stroke, platelets become activated. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and reduce the risk of early recurrent ischaemic stroke. This might reduce the risk of early death and improve long-term outcome in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage. OBJECTIVES: The aim of this review is to assess the net result of antiplatelet therapy in acute ischaemic stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register (most recent date of search March 1999), the register of trials held by the Antiplatelet Trialists' Collaboration, and MedStrategy (1995). We also contacted relevant pharmaceutical companies. SELECTION CRITERIA: Randomised trials comparing antiplatelet therapy started within 14 days of the stroke with control in patients with definite or presumed ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied the inclusion criteria and assessed trial quality, and for the included trials, extracted and cross-checked the data. MAIN RESULTS: Eight trials involving 41,325 patients were included. Two trials testing aspirin 160 to 300 mg once daily started within 48 hours of onset contributed 98% of the data. The maximum follow-up was six months. With treatment, there was a significant decrease in death or dependency at the end of follow-up (OR = 0.94; 95% CI 0.91 - 0.98). In absolute terms, 13 more patients were alive and independent at the end of follow-up for every 1000 patients treated. Furthermore, treatment increased the odds of making a complete recovery from the stroke (OR = 1.06; 95% CI 1.01 - 1.11). In absolute terms, 10 patients made a complete recovery for every 1000 patients treated. Antiplatelet therapy was associated with a small but definite excess of 2 symptomatic intracranial haemorrhages for every 1000 patients treated, but this was more than offset by a reduction of 7 recurrent ischaemic strokes for every 1000 patients treated. REVIEWER'S CONCLUSIONS: Antiplatelet therapy with aspirin 160 to 300 mg daily, given orally (or per rectum in patients who cannot swallow), and started within 48 hours of onset of presumed ischaemic stroke reduces the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications and improves long-term outcome.

Brain Ischemia↗
PubMed2000

Thrombolysis for acute ischaemic stroke.

BACKGROUND: The majority of strokes are due to blockage of an artery in the brain by a blood clot. Clot dissolving (or thrombolytic) drugs may reduce brain damage from the stroke, but may also cause serious bleeding in the brain. Thrombolytic therapy has now been evaluated in several randomised trials in acute ischaemic stroke. OBJECTIVES: The objective of this review was to assess the safety and efficacy of thrombolytic agents in patients with acute ischaemic stroke. SEARCH STRATEGY: Cochrane Stroke Review Group search strategy plus ongoing contact with researchers and pharmaceutical companies. Last search conducted March 1999. SELECTION CRITERIA: Randomised trials of any thrombolytic agent compared with control in patients with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS: One reviewer applied the inclusion criteria and extracted the data. Trial quality was assessed. The extracted data were verified by the principal investigators of all major trials. MAIN RESULTS: Seventeen trials including 5216 patients were included. Fifteen trials were double-blind. The trials tested urokinase, streptokinase, recombinant tissue plasminogen activator or recombinant pro-urokinase. Two trials used intra-arterial administration but the rest used the intravenous route. About 50% of the data come from trials testing intravenous tissue Plasminogen Activator. Thrombolytic therapy significantly increased the odds of death within the first ten days (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.48 to 2.32). The main cause of the increase in deaths was fatal intracranial haemorrhage following thrombolysis (OR 4.15, 95% CI 2.96 to 5.84). Symptomatic intracranial haemorrhage is also increased following thrombolysis (OR 3.53, 95% CI 2.79 to 4.45). Thrombolytic therapy also increased the odds of death at the end of follow-up (OR 1.31, 95% CI 1.13 to 1. 52). Despite this, thrombolytic therapy, administered up to six hours after ischaemic stroke, significantly reduced the proportion of patients who were dead or dependent (modified Rankin 3 to 6) at the end of follow-up (OR 0.83, 95% CI 0.73 to 0.94). For patients treated within three hours of stroke, thrombolytic therapy appeared more effective in reducing death or dependency (OR 0.58, 95% CI 0.46 to 0.74) with less adverse effect on death (OR 1.11, 95% CI 0.84 to 1.47). There was heterogeneity between the trials that could have been due to : thrombolytic drug used, variation in the concomitant use of aspirin and heparin, severity of the stroke, and time to treatment. Trials testing intravenous recombinant tissue Plasminogen Activator suggest that it may be associated with slightly less hazard and more benefit when given up to six hours after stroke - death within the first ten days OR 1.24, 95% CI 0.85 to 1.81, death at the end of follow-up OR 1.16, 95% CI 0.94 to 1.44, dead or dependent at the end of follow-up OR 0.79, 95% CI 0.68 to 0.92. One trial that tested thrombolysis plus aspirin showed an increase in deaths of patients given both drugs in combination compared with thrombolysis alone. REVIEWER'S CONCLUSIONS: Thrombolytic therapy increases deaths within the first seven to ten days, and deaths at final follow-up. Thrombolytic therapy also significantly increases symptomatic and fatal intracranial haemorrhage. These risks are offset by a reduction in disability in survivors, so that there is, overall, a significant net reduction in the proportion of patients dead or dependent in activities of daily living. The data from trials using intravenous recombinant tissue Plasminogen Activator, from which there is the most evidence on thrombolytic therapy so far, suggest that it may be associated with less hazard and more benefit. There was heterogeneity between the trials and the optimum criteria to identify the patients most likely to benefit and least likely to be harmed, the agent, dose, and route of administration, are not clear. (ABSTRACT TRUNCATED)

Brain Ischemia↗
PubMed2000

Stroke therapy clinical guideline. South African Medical Association-- Neurological Association of South Africa Stroke Working Group.

OBJECTIVE: To describe the prevention, management and rehabilitation of stroke in South Africa as provided by a range of caregivers. OPTIONS: Emphasis should predominantly be on finding the cause, preventing, and treating stroke in the transient and mild stroke group. Moderate stroke patients require maximal rehabilitation and secondary prevention. Severe disabling stroke patients require home and community care. OUTCOMES: The most effective use of resources (personnel and facilities) in relation to the different types of stroke. These should be used to decrease stroke incidence, increase stroke awareness, improve acute stroke therapy, and improve access to rehabilitation. EVIDENCE: Based on international reports and research. Meta-analyses were used when the topic warranted such specific literature review. Stroke consensus has been achieved internationally and widely reported. A wide range of South African reviewers from various health fields, including representatives of local and national health groups, were consulted. Evidence-based documents were considered and incorporated. VALUES: As far as possible, cultural and economic preferences were given major emphasis. The aim of the guideline is to optimise stroke care from the point of view of individual patients, health practitioners, reimbursing agencies and society as a whole. Where possible, best-practice stroke care of international standard has been used in this document. However, at no stage has the Working Group deviated from the unique set of South African stroke problems, namely differing risk and preventive factors, multi-cultural, genetic and traditional practices and the problems of cost saving from best-practice funding for stroke care. BENEFITS, HARMS, COSTS: It is difficult to assess the local situation without prospective research. However, stroke causes the following in South Africa: between 8% and 10% of all reported deaths 7.5% of deaths in the workforce (25-64 years of age) age-standardised mortality rate of 125-175/100,000. More can be done to improve the cost-effectiveness of available resources by increasing education of health care professionals and patients. RECOMMENDATIONS: Assess and treat all cerebral vascular events within 6 hours if possible; categorize the stoke into mild, moderate or severe; transient ischaemic attack (TIA), minor or reversible stroke should be intensively investigated to find the cause and this should be treated vigorously; all risk factors should be treated; moderate strokes require active rehabilitation; secondary prevention is required to prevent another stroke; when vegetative symptoms persist after 7 days, therapy should be supportive. VALIDATION: This guideline is similar to others produced in other countries but with reference to South Africa, and has been developed in collaboration with the Neurological Association of South Africa. The initial document was developed in 1997 with a multidisciplinary group with special interest in the management of stroke. In July 1998 a nationally representative stroke consensus meeting was held and the document was widely scrutinised. The guideline is endorsed by the South African Medical Association.

Algorithms↗
PubMed2006

The effect of diabetes and stroke at baseline and during follow-up on stroke mortality.

AIMS/HYPOTHESIS: The aim of this study was to compare the magnitude of the effect of diabetes and stroke at baseline and during follow-up on risk of stroke mortality. MATERIALS AND METHODS: Study cohorts included 25,155 Finnish men and 26,423 women aged 25-74 years. Data on diabetes and stroke history at baseline, their incidence during follow-up, and stroke death were obtained from national registers. RESULTS: During a mean follow-up of 18.9 years, 838 stroke deaths were recorded. In the baseline study, hazard ratios (HRs) for stroke mortality were 5.26 for men with prior diabetes only, 4.76 for men with prior stroke only, and 13.4 for men with both prior diabetes and stroke compared with men without diabetes and stroke at baseline and during follow-up. In women, the corresponding hazard ratios were 7.29, 5.27 and 5.52, respectively. When only diabetes and stroke status during the follow-up were considered, the hazard ratios for stroke mortality were 1.41 for men and 1.56 for women with incident diabetes only, 5.62 for men and 5.58 for women with incident stroke only, and 5.59 for men and 4.48 for women with both incident diabetes and stroke compared with men and women without diabetes and stroke at baseline and during follow-up. CONCLUSIONS/INTERPRETATION: Diabetes and stroke, present either at baseline or during follow-up, markedly increase the risk of stroke death. Prior stroke at baseline carries a similar risk of stroke mortality as prior diabetes. There is a greater risk of stroke mortality associated with incident stroke during follow-up than with incident diabetes.

Adult↗