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PubMed2001

Ischemic stroke outcome: racial differences in the trial of danaparoid in acute stroke (TOAST).

OBJECTIVE: To determine racial differences in baseline stroke risk factors and other measures in the Trial of ORG 10172 in Acute Stroke Therapy (TOAST). Differences in these factors could influence response to acute stroke therapy and overall stroke outcome. METHODS: The authors compared baseline demographic, medical, stroke, physical examination, CT, laboratory, and neurologic factors among 292 African-American and 801 white patients who enrolled in the TOAST study. TOAST compared danaparoid (ORG 10172) with placebo among acute ischemic stroke patients who were treated within 24 hours of stroke onset. RESULTS: African-Americans were younger and more frequently had hypertension, diabetes mellitus, congestive heart failure, and prior strokes. In addition, African-Americans had higher mean diastolic blood pressure, more lacunar strokes, and more severe prestroke disability. There were no significant differences between African-Americans and white patients in outcomes at 7 days, overall number of adverse experiences, or occurrence of serious bleeds or hemorrhagic transformations. However, there was a trend toward a higher rate of favorable outcomes in white patients at 7 days. There was no significant difference in very favorable outcome at 3 months between African-American and white patients, but significantly more white patients had favorable outcome at 3 months. CONCLUSION: Although African-Americans possess a number of factors that should predict higher rates of poor stroke outcome after acute therapy, they have the capacity to respond similarly to white patients after acute stroke therapy. Perhaps younger age and presence of lacunar infarction are stronger predictors of good outcomes than was appreciated previously.

Anticoagulants↗

PubMed2002

Innovative strategies in the management of acute stroke.

Advances in acute stroke therapy are rapidly changing our approach to management of patients with ischemic stroke. Intravenous tissue-plasminogen activator (tPA) was the first treatment demonstrated in a randomized controlled trial to improve outcome if given within the first 3 hours of stroke onset. Subsequent trials failed to extend the time window for intravenous therapy beyond 3 hours. Intra-arterial thrombolysis provides an alternative approach, with several advantages over intravenous therapy. The major drawback is the additional time needed for the interventional procedure, and the equipment and personnel requirements. New strategies aimed at reducing the total time from stroke onset to recanalization of occluded arteries include a combined intravenous/ intra-arterial delivery of thrombolysis and mechanical devices. For the millions of stroke survivors, investigations are now underway into the possibility of improvement of function through neuronal transplantation.

Fibrinolytic Agents↗

PubMed2002

Innovative Strategies in the Management of Acute Stroke.

Advances in acute stroke therapy are rapidly changing our approach to the management of patients with ischemic stroke. Intravenous tissue plasminogen activator was the first treatment demonstrated in a randomized controlled trial to improve outcome if given within the first 3 hours of stroke onset. Subsequent trials failed to extend the time window for intravenous therapy beyond 3 hours. Intra- arterial thrombolysis provides an alternative approach, with several advantages over intravenous therapy. The major drawback is the additional time needed for the interventional procedure, and the equipment and personnel requirements. New strategies aimed at reducing the total time from stroke onset to recanalization of occluded arteries include a combined intravenous/intra-arterial delivery of thrombolysis and mechanical devices. For the millions of stroke survivors, investigations are now underway into the possibility of improvement of function through neuronal transplantation.

Journal Article↗

PubMed1999

Limitations of clinical diagnosis in acute stroke.

Trials in acute stroke have recruited on the basis of clinical diagnosis. Using MRI we have shown that clinical diagnosis is more limited than previously appreciated, thus trials may have been underpowered or confounded.

Clinical Trials as Topic↗

PubMed1994

Frequency and characteristics of early seizures in Chinese acute stroke.

We retrospectively studied 1200 hospitalized acute strokes of all etiologies between July 1990 and August 1992. Ninety-six % of all strokes underwent computed tomography of the head. Fifty-eight percent of the 1200 strokes were brain infarction, 32% brain hemorrhage, 6% subarachnoid hemorrhage and 4% were other stroke subtypes. Thirty (2.5%) of all strokes suffered from early seizures. The incidences of early seizures were 2.8% in brain hemorrhage, 2.3% in brain infarction, 2.7% in subarachnoid hemorrhage and 2% in other stroke subtypes. Early seizures were documented in 6% of the patients with carotid territory cortical infarctions and 12% of the patients with lobar hemorrhage, whereas only 0.6% of the patients without carotid territory cortical infarctions and 0.6% of the patients without lobar hemorrhage were affected. Sixty-six percent of 30 early seizures were partial seizures, 24% generalized and status epilepticus were seen only in 10%. In conclusion, we found the early seizure incidence was 2.5% in Chinese patients hospitalized with acute strokes. There was no correlation between seizure occurrence and stroke subtypes. Early seizure developed significantly higher in acute stroke patients with lesions of the cortex than those patients without cortical involvement. The partial seizures were the most frequent type occurring in 66% of all acute stroke patients with early seizures.

Acute Disease↗

PubMed2001

A study of factors delaying hospital arrival of patients with acute stroke.

Thrombolytic therapy for acute ischaemic stroke has recently become available in India but its success depends on initiating the treatment in the narrow therapeutic time window. There is commonly a delay of several hours before patients with acute stroke seek medical attention. A prospective study was conducted to assess the factors influencing this delay in admission of acute stroke cases. 110 cases (71 males, 39 females) of acute stroke that arrived within 72 hours at our hospital casualty were recruited. A standardized structured questionnaire was given to patients or their attendants. The median time to casualty arrival was 7.66 hours with 25% cases arriving within 3 hours and 49 % cases within 6 hours. Distance from hospital, contact with a local doctor and low threat perception of symptoms of stroke were independent factors associated with delay in arrival. Living in city, presence of family history and older age were associated with early arrival. There was no correlation with patients' or attendants' sex, educational status, history of previous stroke or transient ischaemic attack, subtype or severity of stroke, time of stroke and availability of transport. Adequate measures need to be taken to improve the public awareness of stroke and the role of local doctors.

Acute Disease↗

PubMed2004

Myocardial injury in acute stroke: a troponin I study.

INTRODUCTION: Acute cerebrovascular insults can induce a variety of cardiac changes. We sought to describe the findings in a cohort of patients who had an acute stroke in whom Troponin I (TI) was sampled to determine the presence of associated myocardial damage. MATERIALS AND METHODS: This is a retrospective case series study. The investigators identified all patients who had an acute stroke in whom TI had been sampled. Demographics, stroke severity as determined by National Institutes of Health Stroke Scale (NIHSS), stroke location, electrocardiogram (EKG) results, echocardiography results, and cardiology evaluation were obtained from the stroke database or the medical records. Logistic regression analysis was performed to determine the clinical and paraclinical variables associated with TI elevation. RESULTS: During a 14-month period, 191 patients were studied, but TI levels were available in only 160 (84%) of the 191 patients. The sample was composed of 89 (55%) men and 71 (45%) women, with a median age of 76 years. Elevated TI occurred in 10 (6%) of the 160 patients. EKG changes suggestive of cardiac ischemia occurred in 2 of the 10 patients with high TI who had a stroke. In the remainder patients' TI elevations occurred in the absence of EKG or echocardiographic abnormalities. High NIHSS but no other variable was associated with TI elevation (p=.02). Ventricular arrhythmias, congestive heart failure, post-infarct pericarditis, and sudden death did not occur. CONCLUSION: In this limited sample, elevated TI occurred in 6% of the patients with acute stroke and was associated with severe stroke. Although in some patients who have acute stroke, TI elevation may represent coronary ischemia, in others it may reflect neurogenic-induced cardiac injury.

Adult↗

PubMed2006

Intermittent oro-esophageal tube feeding in acute stroke patients -- a pilot study.

OBJECTIVE: Acute stroke patients with dysphagia are usually fed by nasogastric tube. However, this method sometimes causes pneumonia or diarrhea. We investigated the use of a new feeding procedure called intermittent oro-esophageal (IOE) tube feeding in acute stroke patients with severe dysphagia. MATERIALS AND METHODS: The IOE method was used in 13 acute stroke patients (68 +/- 14 years old; 12 had a brainstem infarction), who were alert, but had severe dysphagia and a weak pharyngeal reflex. IOE tube feeding was carried out as follows. A feeding tube was passed orally into the lower portion of the esophagus, food supplements were administered through the tube at a rate of approximately 50 ml/min, and the tube was removed after finishing the supplement infusion. RESULTS: We found that the IOE method had the following advantages: (i) IOE feeding took approximately 15 min; (ii) potentially reduced a risk of complications such as pneumonia and diarrhea; and (iii) oral tube insertion stimulated the oral cavity and pharynx, which may improve the swallowing function. However, the IOE feeding method should not be used in patients who: (i) could not understand the IOE procedure; (ii) had an esophageal hiatal hernia or incomplete peristalsis of the esophagus, as such patients are at risk of having the supplement reflux into the oral cavity. CONCLUSION: The IOE feeding method may be one of the alternatives to continuous nasogastric tube feeding in acute stroke patients with severe dysphagia, who are alert.

Acute Disease↗

PubMed2004

Validation of the Oxfordshire Community Stroke Project syndrome diagnosis derived from a standard symptom list in acute stroke.

BACKGROUND: The Oxfordshire Community Stroke Project (OCSP) classification allows distinction of stroke subtypes with different prognosis. OCSP classification inferred from clinical signs filled out on patient entry forms has been used to facilitate subgroup analysis in clinical trials. However, such procedure has not been validated against clinical diagnosis. In preparation for an acute stroke trial, we set out to perform such a validation. METHODS: An OCSP syndrome diagnosis of 194 acute stroke patients in four hospitals was made within 24 h using a standard list with neurological signs, to be filled out by a stroke physician or neurological resident on duty. This was compared with OCSP diagnosis within 2 days of stroke onset by a (blinded) stroke neurologist ("gold standard"). RESULTS: The proportion of the OCSP syndromes was quite similar between standard list and clinical judgement. Sensitivity, specificity, positive and negative predictive values were respectively: LACS: 0.76, 0.88, 0.72, 0.90; TACS: 0.63, 0.93, 0.62, 0.88; PACS: 0.62, 0.76, 0.63, 0.75; POCS: 0.50, 0.98, 0.60, 0.97. Kappa for agreement was 0.63 (LACS), 0.37 (PACS), 0.50 (TACS). Neuro-imaging falsified stroke subtype diagnosis in 40 cases (20.6%) diagnosed using the standard list, and 42 (21.6%) diagnosed by stroke neurologists. CONCLUSION: A standard list-derived stroke syndrome diagnosis may be used as a clinical test to make an OCSP syndrome diagnosis in acute stroke. The use of such list in acute stroke trials may facilitate uniformity in early stroke subtype diagnosis. However, to increase such uniformity, ancillary methods such as acute MRI should be evaluated.

Aged↗

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↗

PubMed2003

HandiStroke: a handheld tool for the emergent evaluation of acute stroke patients.

BACKGROUND: The management of acute stroke is time-sensitive. Clinical decision making requires data not only from laboratory testing and neuroimaging, but also from a detailed history and neurologic examination. The neurologic examination provides baseline information and assists in differentiating acute stroke from its mimickers. There is a need for tools to facilitate the evaluation and decision making in the acute stroke patient to make the correct diagnosis and, when indicated, to properly administer intravenous thrombolytic therapy. OBJECTIVES: The goals of this project were to create a standardized, handheld software program to aid physicians in their evaluation of patients presenting to the emergency department (ED) with acute ischemic stroke, and to create an educational tool with which residents and other health care professionals can gain a level of proficiency in treating these patients. RESULTS: A comprehensive handheld tool was created that incorporates a National Institutes of Health Stroke Scale (NIHSS) calculator, inclusion criteria, absolute contraindications, and relative warnings for thrombolytic use (i.e., recombinant tissue plasminogen activator), and a weight-based dosing calculator that flows in a logical and clinically relevant format. Additionally, the program includes reference materials and guidelines for clinical management to further assist the clinician. CONCLUSIONS: Applications of this program include reformatting for use as a data-gathering tool in future clinical studies investigating the treatment of stroke patients, increasing the use and documentation of the NIHSS within the ED in acute ischemic stroke patients, and improving protocol adherence for rt-PA use.

Emergency Service, Hospital↗

PubMed1997

Emergency imaging of the acute stroke patient.

Patients presenting with suspected acute stroke require rapid diagnosis and treatment. Neuroimaging is critical in determining acute-stroke type and thus appropriate management. A review of various neuroimaging techniques and their role in the evaluation of both acute ischemic stroke and acute hemorrhagic stroke is provided.

Acute Disease↗

PubMed1999

Aetiology of fever in patients with acute stroke.

OBJECTIVE: Fever in patients with acute stroke is usually related to infectious complications. In some cases, a focus of infection cannot be identified, fever does not respond to empirical antibiotic treatment and is thought to be due to the central nervous system lesion. The aim of this study was to determine the frequency and origin of fever in patients with acute stroke and the characteristics associated with the presence of fever. DESIGN: A retrospective study of 36 months' duration. SETTING: The study was carried out at 'Alexandra' Hospital, a tertiary care teaching centre in Athens, Greece. SUBJECTS: A total of 330 patients hospitalized for acute stroke from June 1992 until July 1994. RESULTS: In 37.6% of 330 patients, fever was noted; 22.7% had a documented infection and 14.8% had fever without a documented infection. In univariate analysis, older age was associated with the presence of fever (P = 0.001). The development of fever was associated with intracerebral haemorrhage versus ischaemic infarct (P < 0.001) and with the presence of mass effect (P < 0.001), transtentorial herniation (P < 0.001), intraventricular blood (P < 0. 001), and larger size of ischaemic infarct (P = 0.0001) and of haemorrhage (P = 0.0002). Patients with fever had lower scores on admission on the Glasgow Coma Scale (P = 0.0001) and the Scandinavian Stroke Scale (P = 0.0001). The development of fever was associated with prior use of an invasive technique (P < 0.001) and more specifically with urinary catheterization (P < 0.001), but not with the presence of risk factors for infection. Patients with fever had a worse outcome assessed by the Modified Rankin Scale (P = 0. 0001) and the Barthel Index (P = 0.0001). In multivariate analysis, age, Scandinavian Stroke Scale score and mass effect were found to be significantly associated with fever (P = 0.035, P = 0.0001 and P = 0.0004, respectively). Patients with fever without documented infection had an earlier onset of fever than those with infection (P = 0.0061). In a logistic regression analysis, the only factor predictive of fever without documented infection versus infection was earlier onset of fever (P = 0.029). CONCLUSION: Patients with acute stroke who develop fever are older, suffer severe stroke, their fever is associated with the use of invasive techniques, and they have a poor outcome. In patients with fever without a focus of infection, the only characteristic that is different from patients with known infection is earlier onset of fever.

Acute Disease↗

PubMed1988

Investigational use of tPA in acute stroke.

Significant current interest has focused on the possible value of fibrin-selective thrombolytic agents in acute stroke. Acute thrombosis contributes to carotid and vertebrobasilar arterial occlusions in the majority of acute stroke patients. Hence, fibrin(ogen)olytic agents may produce arterial recanalization and clinical benefit in thrombotic stroke. There are, however, unique features of cerebral tissue that suggest caution with the use of fibrin-selective agents in cerebral ischemia. The specific vascular anatomy and collateral flow suggest that salvage of the "ischemic penumbra" following vascular recanalization in focal ischemia is more likely to be successful than attempts in global ischemia. Recanalization may be associated with reperfusion injury and, more importantly, the risk of hemorrhagic transformation. There is little concrete information regarding the relative contribution of either event to post-thrombolysis cerebral injury. Early studies with exogenous fibrinolytic agents (urokinase, streptokinase) in completed stroke were regarded as inconclusive, demonstrating only an increased risk of intracerebral hemorrhage. Subsequent pilot studies in carotid and in vertebrobasilar territory thrombotic stroke have demonstrated that recanalization can result when exogenous agents are infused just proximal to the cerebral artery occlusion by interventional neuroradiological techniques. This experience and the advent of fibrin-selective agents (tissue plasminogen activator [tPA] and single-chain urokinase plasminogen activator) have led to the development of a multicenter prospective safety/dose-ranging study of tPA in acute (less than eight hours from symptom onset) thrombotic stroke. Following initial clinical assessment, computed tomography scan, and angiography, each patient with a documented cerebral artery occlusion appropriate to the clinical syndrome receives a preassigned intravenous dose of tPA over 60 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebral Hemorrhage↗

PubMed2000

Cooling therapy for acute stroke.

BACKGROUND: Recent studies in acute stroke patients have shown an association between body temperature and prognosis. OBJECTIVES: Our objective was to assess the effects of cooling when applied to patients with acute ischaemic stroke or primary intracerebral haemorrhage. SEARCH STRATEGY: We searched the Cochrane Stroke Group's trial register (last searched in March 1999), plus MEDLINE searched up to November 1998 and EMBASE searched from January 1980 to November 1998. We contacted investigators, pharmaceutical companies and manufacturers of cooling equipment in this field. SELECTION CRITERIA: All completed randomised controlled trials or controlled clinical trials, published or unpublished, where cooling therapy (therapy given by physical devices or antipyretic drugs primarily to lower body temperature independently of basal temperature at the beginning of treatment) was applied up to two weeks of an acute ischaemic stroke or primary intracerebral haemorrhage. DATA COLLECTION AND ANALYSIS: Two reviewers independently searched for relevant trials. MAIN RESULTS: No randomised trials or controlled trials were identified; one placebo-controlled trial of metamizol is currently underway. REVIEWER'S CONCLUSIONS: There is currently no evidence from randomised trials to support the routine use of physical or chemical cooling therapy in acute stroke. Since experimental studies showed a neuroprotective effect of hypothermia in cerebral ischaemia, and hypothermia appears to improve the outcome in patients with severe closed head injury, trials with cooling therapy in acute stroke are warranted.

Humans↗

PubMed2001

Use of anti-ICAM-1 therapy in ischemic stroke: results of the Enlimomab Acute Stroke Trial.

BACKGROUND: There has been recent interest in the possible role of reperfusion-induced inflammation with neuronal injury after stroke. Enlimomab, a murine intercellular adhesion molecule-1 (ICAM-1) antibody, reduces leukocyte adhesion and infarct size in experimental stroke studies. The purpose of the current clinical trial was to evaluate the use of enlimomab after ischemic stroke. METHODS: A total of 625 patients with ischemic stroke were randomized to receive either enlimomab (n = 317) or placebo (n = 308) within 6 hours of stroke onset. Treatment was given over 5 days. Patients were evaluated at baseline and on days 5 and 90 after initiation of treatment; long-term assessments were carried out after 6 and 12 months. The primary efficacy endpoint was the response to therapy at 90 days on the Modified Rankin Scale; other endpoints included Barthel Index (BI) and NIH Stroke Scale and survival. RESULTS: At day 90, the Modified Rankin Scale score was worse in patients treated with enlimomab than with placebo (p = 0.004). Fewer patients had symptom-free recovery on enlimomab than placebo (p = 0.004), and more died (22.2 versus 16.2%). The negative effect of enlimomab was apparent on days 5, 30, and 90 of treatment (p = 0.005). There were significantly more adverse events with enlimomab treatment than placebo, primarily infections and fever. Patients experiencing fever were more likely to have a poor outcome or die. CONCLUSIONS: The authors conclude that anti-ICAM therapy with enlimomab is not an effective treatment for ischemic stroke in the model studied and, indeed, may significantly worsen stroke outcome.

Acute Disease↗

PubMed1997

Early management and outcome of acute stroke in Auckland.

BACKGROUND: Studies of acute stroke management in stroke units and tertiary referral hospitals may not accurately reflect practice within the population. Reliable information on the management of stroke within a population is sparse. AIMS: To compare clinical practice in acute stroke management in Auckland with guidelines for the management and treatment of stroke in other countries; to provide a baseline measure against which future changes in management can be evaluated. METHODS: All new stroke events in Auckland residents in 12 months were traced through multiple case finding sources. For each patient, a record of investigations and treatment during the first week of hospital admission was kept. RESULTS: One thousand eight hundred and three stroke events (including subarachnoid haemorrhages) occurred in 1761 patients in one year. Twenty-seven per cent of all events were managed outside hospital and 73% of the stroke events were treated in an acute hospital. Of the 1242 stroke events admitted to an acute hospital in the first week, only 6% were managed on the neurology and neurosurgery ward, 83% were managed by a general physician or geriatrician and 42% had computed tomography (CT). Of 376 validated ischaemic strokes, 44% were treated with aspirin and 12% with intravenous heparin. Of the 690 unspecified strokes (no CT or autopsy), 38% received aspirin and 0.5% heparin. The 28 day in-hospital case fatality for all stroke events admitted to an acute hospital during the first week was 25%. CONCLUSIONS: In Auckland, management of acute stroke differed from clinical guidelines in the high proportion of patients managed in the community, the low rate of neurological consultation, and the low frequency of CT scanning. Despite these deficiencies in management, the 28 day hospital case fatality in Auckland was similar to other comparable studies which had a high proportion of cases evaluated by a neurologist and CT.

Adolescent↗

PubMed2002

Improving delivery of acute stroke therapy: The TLL Temple Foundation Stroke Project.

BACKGROUND AND PURPOSE: Only a small minority of acute stroke patients receive approved acute stroke therapy. We performed a community and professional behavioral intervention project to increase the proportion of stroke patients treated with approved acute stroke therapy. METHODS: This study used a quasi-experimental design. Intervention and comparison communities were compared at baseline and during educational intervention. The communities were based in 5 nonurban East Texas counties. The multilevel intervention worked with hospitals and community physicians while changing the stroke identification skills, outcome expectations, and social norms of community residents. The primary goal was to increase the proportion of patients treated with intravenous recombinant tissue plasminogen activator (rTPA) from 1% to 6% of all cerebrovascular events in the intervention community. RESULTS: We prospectively evaluated 1733 patients and validated 1189 cerebrovascular events. Intravenous rTPA treatment increased from 1.38% to 5.75% among all cerebrovascular event patients in the intervention community (P=0.01) compared with a change from 0.49% to 0.55% in the comparison community (P=1.00). Among the ischemic stroke patients, an increase from 2.21% to 8.65% was noted in the intervention community (P=0.02). The comparison group did not appreciably change (0.71% to 0.86%, P=1.00). Of eligible intravenous rTPA candidates, treatment increased in the intervention community from 14% to 52% (P=0.003) and was unchanged in the comparison community (7% to 6%, P=1.00). CONCLUSIONS: An aggressive, multilevel stroke educational intervention program can increase delivery of acute stroke therapy. This may have important public health implications for reducing disability on a national level.

Acute Disease↗