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At least 127 records · Page 7Linked to original sources

PubMed2000

Activation of emergency medical services for acute stroke in a nonurban population: the T.L.L. Temple Foundation Stroke Project.

BACKGROUND AND PURPOSE: Activating emergency medical services (EMS) is the most important factor in reducing delay times to hospital arrival for stroke patients. Determining who calls 911 for stroke would allow more efficient targeting of public health initiatives. METHODS: The T.L.L. Temple Foundation Stroke Project is an acute stroke surveillance and intervention project in nonurban East Texas. Prospective case ascertainment allowed chart abstraction and structured interviews for all hospitalized stroke patients to determine if EMS was activated, and if so, by whom. RESULTS: Of 429 validated strokes, 38.0% activated EMS by calling 911. Logistic regression analysis comparing those who called 911 with those who did not activate EMS found that individuals who were employed were 81% less likely to have EMS activated (OR 0.19, 95% CI 0.04 to 0.63). Of the 163 cases in which 911 was called, the person activating EMS was: self (patient), 4.3%; family member of significant other, 60. 1%; paid caregiver, 18.4%; and coworker or other, 12.9%. Significant associations between the variables age group (P=0.02), insurance status (P=0.007), and living alone (P=0.05) with who called 911 was found on chi(2) analysis. CONCLUSIONS: Educational efforts directed at patients themselves at risk for stroke may be of low yield. To increase the use of time dependent acute stroke therapy, interventions may wish to concentrate on family, caregivers, and coworkers of high-risk patients. Large employers may be good targets to increase utilization of EMS services for acute stroke.

Acute Disease↗

PubMed2005

A study of the workload and effectiveness of a comprehensive acute stroke service.

OBJECTIVE: To study the workload of and use of acute intervention within an established acute stroke service, the Calgary Stroke Programme (CSP). METHODS: Prospective record of all acute referrals, diagnoses, and management decisions over a 4 month period. RESULTS: The CSP received 572 referrals (median: 32 per week), 88% of which were made between 7 am and midnight. Of the 427 patients seen in person, 29% had not had an acute stroke or transient ischaemic attack (TIA). Fifty percent of patients with suspected acute stroke were referred within 3 h of symptom onset and 11% with acute ischaemic stroke (equating to 35% of those referred within 3 h of onset and seen in person) were treated with thrombolysis. CONCLUSION: Centralisation of services facilitates the rapid referral of, and use of acute interventions in, patients with acute stroke and TIA. Centralised services are likely to be busy (although less so at night), to attract large numbers of patients with disorders that mimic stroke and TIA, and yet still likely to treat only the minority of acute strokes using thrombolysis. These observations may help those planning similar services and underline the need to develop more widely applicable treatments for acute stroke.

Acute Disease↗

PubMed2001

Blood pressure response to glucose potassium insulin therapy in patients with acute stroke with mild to moderate hyperglycaemia.

Insulin is neuroprotective in animal stroke models but its effects in acute stroke in humans are unknown. The Glucose Insulin in Stroke Trial (GIST-UK) is a randomised controlled trial investigating the benefits of maintaining euglycaemia in hyperglycaemic patients with acute stroke. Data are reported from a GIST-UK substudy which sought to determine the influence of glucose potassium insulin (GKI) infusion on blood pressure in acute stroke. All adult patients admitted to hospital with acute stroke with hyperglycaemia (plasma glucose 6.1-17 mmol/l) were potentially eligible. Randomised patients received either a GKI infusion (500 ml 10% glucose, 20 mmol potassium chloride, 16 units of insulin) or control therapy with 154 mmol/l (0.9%) saline at 100 ml/h for 24 hours. BM test strip glucose monitoring was performed 2 hourly, blood pressure monitoring 4 hourly, and plasma glucose sampling 8 hourly. Insulin concentration in the GKI infusate was altered according to test strip values to maintain test strip values between 4-7 mmol/l in the GKI group. Neurological impairment was determined using the European stroke scale (ESS). 145 patients were studied (73 GKI, 72 control). Mean systolic blood pressure was significantly lower during GKI infusion between 4 hours and 24 hours except at 8 hours. Median total ESS scores improved significantly between admission and day 7 in the GKI group (p<0.001) although there was no significant difference in total ESS score between groups at day 7. The significant reduction of systolic blood pressure in acute stroke associated with GKI therapy was not associated with neurological deterioration and may have been beneficial.

Adult↗

PubMed2000

Depression and other determinants of values placed on current health state by stroke patients: evidence from the VA Acute Stroke (VASt) study.

BACKGROUND AND PURPOSE: This prospective study examined the determinants of the utility (value) placed on health status among a sample of patients with acute ischemic and intracerebral hemorrhagic stroke. METHODS: Data were from the VA Acute Stroke (VASt) study, a nationwide prospective cohort of 1073 acute stroke patients admitted at any of 9 Department of Veterans Affairs Medical Center sites between April 1, 1995, and March 31, 1997. The primary outcome was the patient's health status utility as measured by the time-tradeoff method. Data were obtained by telephone interviews at 1, 6, and 12 months and by medical record review. General linear mixed modeling was used to assess the effects of social, psychological, and physical factors on patients' valuations of their current health state. The analysis was confined to the 327 patients who were able to provide self-reports at >/=2 time points. RESULTS: Patients' valuations of their health state status over the initial 12 months after stroke were very stable over time, with only a slight improvement at 6 months, followed by a slight decline at 12 months. In adjusted analyses, living alone, being institutionalized, decreased physical function, and depression were independently associated with lower levels of patient health status utility over time. CONCLUSIONS: Stroke patient health status utilities are relatively stable during the initial year after stroke. In addition to physical function, psychological health and social environment are important determinants of patient health status utility. These factors need to be considered when conducting stroke decision analyses if more accurate conclusions are to be drawn regarding preferred patterns of care.

Acute Disease↗

PubMed2005

Comparison of the National Institutes of Health Stroke Scale with disability outcome measures in acute stroke trials.

BACKGROUND AND PURPOSE: Acute stroke trials typically use disability scales as their primary end point. Neurologic impairment scales such as the National Institutes of Health Stroke Scale (NIHSS) are possibly more sensitive to change in patient status. We aimed to compare a range of potential NIHSS end points with modified Rankin Scale (mRS) and Barthel Index (BI) end points. METHODS: We simulated a total of 6000 clinical trials, each with 1400 patients. We estimated statistical power for a range of NIHSS end points, including prognosis-adjusted and fixed dichotomized end points. These end points were compared with the BI and mRS dichotomized at 95 and 1, respectively. RESULTS: The most powerful fixed end point was the NIHSS dichotomized at 1. For prognosis-adjusted outcome, we found greatest power if we defined success as achieving a score of < or =1 or improvement by at least 11 points from baseline. We are more likely to achieve a statistically significant result by using this prognosis-adjusted end point instead of NIHSS < or =1 (odds ratio, 2.8; 95% confidence interval [CI], 2.5 to 3.2). Use of the optimal NIHSS prognosis-adjusted end point rather than BI > or =95 could justify a reduction in sample size of approximately 68% (95% CI, 67% to 69%) without loss of statistical power. CONCLUSIONS: The NIHSS neurologic scale appears more sensitive than the BI or mRS, allowing smaller sample sizes or greater statistical power. The use of an NIHSS prognosis-adjusted end point could allow therapeutic effects from drugs to be more easily identified.

Clinical Trials as Topic↗

PubMed2006

Immediate catheter-directed reperfusion for acute stroke occurring during diagnostic cardiac catheterization.

Acute stroke is a rare but the most dreaded complication of cardiac catheterization. We report a case about the management of an acute stroke that occurred during a diagnostic cardiac catheterization procedure. Immediate catheter-based intraarterial thrombolysis with adjunctive balloon angioplasty of the left middle cerebral artery was carried out. The patient recovered markedly within the first 2 hr and was discharged without neurological sequelae after 3 days. A clinical pathway for acute stroke management in the catheterization laboratory is discussed.

Adult↗

PubMed1993

The prognostic value of admission blood pressure in patients with acute stroke.

BACKGROUND AND PURPOSE: Patients with acute stroke are often found to have high blood pressures at hospital admission. Previous studies have shown variable results regarding the prognostic value of high blood pressure in acute stroke. The aim of this study was to investigate the prognostic value of admission blood pressure in a population-based sample of patients with acute stroke. METHODS: Eighty-five patients with intracerebral hemorrhage and 831 with ischemic disease were included in the study. The relations between admission blood pressure and 30-day mortality were studied by logistic regression analyses. RESULTS: High blood pressure in patients with impaired consciousness on hospital admission was significantly related to 30-day mortality in patients with intracerebral hemorrhage (P = .037) and in patients with ischemic disease (P < .0001). In patients without impaired consciousness, high blood pressure at time of admission was not related to increased mortality at 30 days. CONCLUSIONS: High admission blood pressure in alert stroke patients was not related to increased mortality. Stroke patients with impaired consciousness showed higher mortality rates with increasing blood pressure. However, this does not provide a basis for recommending antihypertensive therapy for such patients.

Aged↗

PubMed2006

Reduction in IV t-PA door to needle times using an Acute Stroke Triage Pathway.

OBJECTIVE: To determine the effectiveness of an Acute Stroke Triage Pathway in reducing door to needle times in acute stroke treatment with IV t-PA. BACKGROUND: A previous study at our tertiary referral centre, examining IV t-PA door to needle times, was completed in 2000. The median door to needle time was beyond the recommended National Institute for Neurological Disorders and Stroke (NINDS) standard of 60 minutes. In November 2001, an Acute Stroke Triage Pathway was introduced in the emergency room (ER) to address this issue. The goal of this pathway was to rapidly identify patients eligible for treatment for IV t-PA, so that CT scans and lab studies could be arranged immediately upon ER arrival. Our hypothesis was that the Triage Pathway would shorten door to CT and door to needle times. DESIGN/METHODS: Using retrospective data, pre (n=87) and post (n=47) triage pathway times were compared. The door to CT time was reduced by 11 minutes (p=0.015) and door to needle time was reduced by 18 minutes (p=0.0036) in a subgroup of patients that presented directly to our hospital. CONCLUSIONS: These results indicate that the Acute Stroke Triage Pathway is effective in reducing Door to CT and Door to Needle Times in patients presenting directly to our ER. However, a majority of treatment times were still beyond NINDS recommendations. Stroke Centers require periodic review of their efficiency to ensure that target times are being obtained and may benefit from the use of an Acute Stroke Triage Pathway.

Acute Disease↗

PubMed2003

Recommendations for advancing development of acute stroke therapies: Stroke Therapy Academic Industry Roundtable 3.

BACKGROUND: The development of acute stroke therapy has proven to be a daunting task, with a few successful and many unsuccessful trials. New strategies need to be considered to enhance the chances for success in future trials. SUMMARY OF REVIEW: The third Stroke Therapy Academic Industry Roundtable (STAIR) conference focused on issues related to increasing the percentage of acute stroke patients who might be included in acute stroke therapy trials and ultimately treated with drugs proven to be effective. A second focus was directed at the need for implementing multimodality stroke trials and potential ways to organize such trials in the near future. Finally, concepts for organizing and implementing acute stroke trials that incorporate current, state of the art trial methodology were discussed. CONCLUSIONS: It is hoped that these suggestions will enhance future stroke trials and the development of effective, new acute stroke treatments that are maximally effective and utilized.

Clinical Trials as Topic↗

PubMed2003

Acute Stroke Therapy by Inhibition of Neutrophils (ASTIN): an adaptive dose-response study of UK-279,276 in acute ischemic stroke.

BACKGROUND AND PURPOSE: UK-279,276 (neutrophil inhibitory factor) reduced infarct volume in a rat middle cerebral artery occlusion reperfusion model. ASTIN (Acute Stroke Therapy by Inhibition of Neutrophils) was an adaptive phase 2 dose-response-finding, proof-of-concept study to establish whether UK-279,276 improves recovery in acute ischemic stroke. The prime objective was to determine the dose that gave a clinically relevant effect in patients. METHODS: A Bayesian sequential design with real-time efficacy data capture and continuous reassessment of the dose response allowed double-blind, randomized, adaptive allocation to 1 of 15 doses (dose range, 10 to 120 mg) or placebo and early termination for efficacy or futility. The primary end point was change from baseline to day 90 on the Scandinavian Stroke Scale (DeltaSSS), adjusted for baseline SSS, aiming for a 3-point additional mean recovery above placebo. RESULTS: Nine hundred sixty-six acute stroke patients (887 ischemic, 204 cotreated with intravenous tissue plasminogen activator; mean baseline SSS score, 28; range, 10 to 40) were treated within 6 hours of symptom onset. Mean DeltaSSS was approximately +17 points of improvement on SSS for the overall evaluable population. There was no treatment effect for UK-279,276 (posterior probability of futility, 0.89). The trial was stopped early for futility. Post hoc analysis indicated a mean 1.6-point additional improvement on DeltaSSS in the tissue plasminogen activator-treated subset (credible interval=0.5, 2.6). UK-279,276 was generally well tolerated, with no increased incidence of infections. CONCLUSIONS: UK-279,276 did not improve recovery in acute ischemic stroke patients but was devoid of serious side effects. The adaptive design facilitated early termination for futility.

Acute Disease↗

PubMed2000

Influence of raised plasma osmolality on clinical outcome after acute stroke.

BACKGROUND AND PURPOSE: Abnormal physiological parameters after acute stroke may induce early neurological deterioration. Studies of the effect of dehydration on stroke outcome are limited. We examined the association of raised plasma osmolality on stroke outcome at 3 months and the change of plasma osmolality with hydration during the first week after stroke. METHODS: Acute stroke patients had their plasma osmolality measured at admission and at days 1, 3, and 7. Maximum plasma osmolality and the area under curve (AUC) were also calculated during the first week. Patients were stratified according to how they were hydrated: orally, intravenously, or both. Outcome included survival at 3 months after stroke. Logistic regression was performed to examine the association between raised plasma osmolality (>296 mOsm/kg) and survival, adjusting for stroke severity. Linear regression was performed to examine the pattern of plasma osmolality across hydration groups. RESULTS: One hundred sixty-seven patients were included. Mean admission (300 mOsm/kg, SD 11.4), maximum (308.1 mOsm/kg, SD 17.1), and AUC (298.3 mOsm/kg, SD 11.7) plasma osmolality were significantly higher in those who died compared with survivors (293.1 mOsm/kg [SD 8.2], 297.7 mOsm/kg [SD 8. 7], and 291.7 mOsm/kg [SD 8.1], respectively; P:<0.0001). Admission plasma osmolality >296 mOsm/kg was significantly associated with mortality (OR 2.4, 95% CI 1.0 to 5.9). In patients hydrated intravenously, there was no significant fall in plasma osmolality compared with patients hydrated orally (P:=0.68). CONCLUSIONS: Raised plasma osmolality on admission is associated with stroke mortality, after correcting for case mix. Correction of dehydration after stroke requires a more systematic approach. Trials are required to determine whether correcting dehydration after stroke improves outcome.

Acute Disease↗

PubMed1997

Mass effect and death from severe acute stroke.

BACKGROUND: In severe acute stroke, the degree of midline cerebral displacement is related to level of consciousness but not to survival. Early identification of patients at high risk of death from mass effect would assist patient management decisions. METHODS: We measured lesion volume, horizontal pineal displacement (PD), and horizontal septum pellucidum displacement (SD) on axial CT of consecutive patients with severe (Canadian Neurological Scale score < or = 5) acute hemispheric stroke. We correlated CT measurements with the probability of 14-day survival. RESULTS: Forty-six (39%) of 118 patients died within 14 days and 72 (61%) died within 1 year following stroke. Crude risk factors for 14-day mortality were as follows: lesion volume > or = 400 ml, SD > or = 9 mm, PD > or = 4 mm, intraventricular hemorrhage, and coma on admission. Only SD (p = 0.001) and coma on admission (p = 0.019) remained significant in multivariate analysis, but PD was highly correlated with SD (r = 0.82). PD of > or = 4 mm on a scan performed within 48 hours of stroke onset identified patients with a low probability of 14-day survival (0.16; CI 0 to 0.32) with a specificity of 89% and a sensitivity of 46%. CONCLUSIONS: The degree of horizontal midline cerebral displacement correlates with the likelihood of death following stroke. Patients with > or = 4 mm PD on CT performed within 48 hours of stroke onset are at high risk for early death.

Acute Disease↗

PubMed2000

Doubts, fears and misconceptions. What is the future of thrombolysis in acute stroke?

Alteplase for acute ischemic stroke may be the first stroke intervention to have a significant public health impact. In February 1999, this therapy was conditionally licensed in Canada for acute ischemic stroke within three hours of symptom onset. However, considerable controversy exists regarding its safety, its wider applicability outside clinical trials, and its ultimate availability. In this article we review the thrombolytic literature, attempt to answer many of the concerns, provide new guidelines for its use, and cite the need for more information about whom we should and should not be treating with this therapy.

Brain Ischemia↗

PubMed1995

Acute stroke in South Ayrshire: comparative study of pre and post stroke units.

In September 1993 arrangements for managing acute stroke victims in South Ayrshire changed with the opening of a six bedded Acute Stroke Unit and a fifteen bedded Rehabilitation Stroke Unit. Previously all such patients were managed within general medical wards with a few being managed in geriatric assessment and rehabilitation facilities. This study compares the management and outcome from acute stroke before and after the establishment of these new Units. Fifty-eight patients' medical, nursing and paramedical records were studied for the period of investigation in 1992 and 68 for the same period in 1993. There was no significant difference in the age of the patients admitted or in the degree of neurological or functional impairment at the time of admission. There was a reduction in mortality from 37.9% in 1992 to 22.0% in 1993. This was not accomplished by an increase in the number of survivors requiring long term institutional care and there was no significant difference in the degree neurological or functional impairment at the time of discharge. A variety of specific management issues were also addressed by the study and in all areas there were improvements in the quality of care received by this group of patients in 1993. This study supports the view that management of acute stroke victims in specifically designated Stroke Units has a beneficial effect on outcome and quality of care.

Activities of Daily Living↗

PubMed2004

[Early recognition of speech and speech-associated disorders after acute stroke].

In the course of increasing demands in acute stroke care in stroke units, criteria for efficient speech diagnosis, which can be applied in the first hours of acute stroke are necessary. In this study we investigated early recognition of speech and speech-associated disorders in acute stroke, and compared the neurologists' clinical diagnoses at admission with the results of a test battery (KAP--Kurze Aphasieprüfung). 90 of 104 consecutively recruited patients could be tested within the first three days. 53.8% (n = 49/N = 91) of the patients presented with language disorders in the clinical neurological examination at admission compared to 63.7% (n = 58/N = 91) that were found to have language disorders according to KAP. Syndrome classification in the group of aphasias showed a frequent occurrence of global aphasia, unclassified aphasia, anomic aphasia and agraphia. Speech apraxia and alexia were always accompanied by aphasia. A large amount of patients are affected by a variety of speech disorders. This study could show that a portion of these disorders could not be diagnosed in the acute situation without using a standardized test battery. Therefore clinical examination should be supplemented by standardized tests in routine diagnosis of speech disorders in acute stroke units in order to treat every patient adequately as soon as possible.

Acute Disease↗

PubMed2002

[The merits of comprehensive therapy for acute stroke].

OBJECTIVE: To evaluate the advantages of comprehensive therapy for acute stroke in a stroke unit. METHODS: The data of 207 acute stroke patients treated in a stroke unit in Australia (group A) were compared with those of 326 acute stroke patients treated in our neurological ward (group B). They were diagnosed by CT or MRI and found to have hemiplegia in 48 hours. RESULTS: There were significant differences between group A and group B in mortality within 14 days (5.3% vs 10.4%), rate of non-cerebral causes of death (27.3% vs 64.7%) and rate of infection (17.9% vs 47.9%), P < 0.01. Moreover the scores of Europe Stroke Scale at 21 days and Modified Rankin Scale at 90 days were significantly different between the two groups (P < 0.01). CONCLUSION: Prognosis of acute stroke patients managed by comprehensive therapy in stroke unit was superior to that treated conventionally in neurological ward.

Aged↗

PubMed2003

New magnetic resonance imaging and computed tomography techniques for imaging of acute stroke.

With continued advances in acute stroke therapy, the ability to accurately assess the physiologic status of ischemic brain tissue and related vascular lesions has become increasingly important. In this review, evidence regarding the use of new magnetic resonance imaging and computed tomography techniques to guide thrombolytic therapy, diagnose stroke subtype, and detect acute hemorrhage are discussed in order to provide a clearer picture of the status of these neuroimaging techniques in the assessment of acute ischemic stroke patients.

Animals↗

PubMed2001

[Myocardial injury in acute stroke assessed by troponin I].

BACKGROUND: Acute ischaemic or haemorrhagic cerebrovascular events may produce myocardial damage. Cardiac troponin I is an indicator of cardiac cell injury with very high sensitivity and specificity. MATERIAL AND METHODS: We measured troponin I in 149 acute stroke patients admitted to the stroke unit of Trondheim University Hospital, Norway, in January to June 1999. RESULTS: 40 patients (27%) had troponin I values at 0.4 microgram/l or higher, indicating myocardial injury. 10 patients (6.7%) had troponin I values above 2.0 micrograms/l. Similarly, the mean value of CK-MB vas higher in the patients with myocardial injury, and these patients had more often ECG findings suggesting myocardial ischaemia. Patients with myocardial injury had a higher rate of previous TIA and heart failure. ECG showed atrial fibrillation in 13 of 39 patients with myocardial damage. Patients with detectable levels of troponin I had more embolic brain infarctions than thrombotic brain infarctions. Patients with myocardial injury did more often have abnormal values of CRP. 9 of 10 patients with troponin I-values above 2.0 micrograms/l had abnormal CRP values. No differences in glycosylated haemoglobin, cholesterol, heart rate, blood pressure or body temperature were found. Patients with the highest troponin I values had lower systolic blood pressure, and a higher heart rate, but these differences were not statistically significant. Patients with troponin I values above 2.0 micrograms/l had lower functional and neurological scores at admittance. Patients with myocardial injury were more often discharged to nursing homes. INTERPRETATION: Many patients with an acute stroke have at the same time a myocardial injury, determined by elevated troponin I values.

Activities of Daily Living↗