Treatment of stroke in older patients. A state of the art review

The treatment of stroke in older patients is the rule rather than the exception in most parts of the world. Thus, an understanding of the effects of aging on pharmacological aspects of treatment, recovery and rehabilitation is very important. A considerable amount of work has now been completed looking for therapeutic interventions that might ameliorate the effects of stroke disease. Sadly, none has yet proved to be effective, but much is still awaited. In contrast, recent work has clarified the place of treatment in stroke prevention, particularly in hypertension and atrial fibrillation, which should help reduce the burden of stroke disease. In addition, it is now clear that well organised stroke care can dramatically reduce mortality and disability. The state of art in stroke treatment is now encapsulated in the multidisciplinary stroke unit and well coordinated hospital and community care.

Factors affecting changes in blood pressure after acute stroke

BACKGROUND AND PURPOSE

We sought to establish the pattern of blood pressure (BP) change after hospitalization for acute hemispheric stroke.

METHODS

In 292 patients from the Leicester teaching hospitals with acute hemispheric stroke within the previous 24 hours (139 men; median age, 75 years [range, 42 to 98 years]), we prospectively studied BP changes between admission, 24 hours, 1 week, and 4 to 6 weeks. Changes were assessed in relation to the main stroke risk factors, stroke type and severity, and antihypertensive drug treatment. All subjects were followed up for 1 week, with 117 subjects followed up for 4 to 6 weeks. Changes were assessed by repeated-measures ANOVA, and Student's t tests were used to compare group pairs.

RESULTS

Systolic and diastolic BP fell by 12 mm Hg (95% confidence interval [CI], 8 to 15 mm Hg) and 7 mm Hg (95% CI, 5 to 9 mm Hg), respectively, in the first 24 hours and 22 mm Hg (95% CI, 18 to 25 mm Hg) and 12 mm Hg (95% CI, 10 to 14 mm Hg), respectively, during the first week (all changes significant at P < .01) but no further thereafter. In those patients receiving no antihypertensive medication before or after stroke, the pattern of change was similar to that of the whole group. Previously diagnosed hypertensive subjects (n = 106) had higher initial BP values than did normotensive subjects, although by 1 week the levels were not significantly different. Patients with cerebral hemorrhage confirmed by computed tomography (n = 20) had higher systolic BP, but not diastolic BP, throughout the first week than those with cerebral infarction (n = 89). The severity of stroke, age, and previous stroke history did not appear to alter the BP pattern. Stroke patients who were moderate to heavy alcohol consumers had lower convalescent systolic BP levels than lighter drinkers or abstainers.

CONCLUSIONS

We have demonstrated a marked fall in systolic and diastolic BP levels during the first 7 days after acute hemispheric stroke, with little change thereafter. Higher initial systolic BP values were found in patients with cerebral hemorrhage compared with those with cerebral infarct. Moderate to heavy alcohol consumption before stroke was associated with a greater systolic BP decline in the first week after the event compared with stroke patients who were light drinkers or abstainers.

Continuous infusion bleomycin in AIDS-related Kaposi's sarcoma

PURPOSE

To determine the toxicity, response, and survival rate of 72-hour continuous infusion bleomycin administered to patients with AIDS-related Kaposi's sarcoma.

PATIENTS AND METHODS

Seventeen patients with biopsy-proven and measurable-disease AIDS-related Kaposi's sarcoma were treated with a continuous infusion of bleomycin at a dose of 20 mg/m2/d for 3 days every 3 weeks. All patients were evaluated for toxicity, response, and survival using the National Cancer Institute common toxicity criteria, and both the Eastern Cooperative Oncology Group (ECOG) and AIDS Clinical Trials Group (ACTG) response criteria. Fourteen of 17 patients (82%) enrolled had at least two on-study poor-risk factors by ACTG staging criteria.

RESULTS

A total of 59 cycles of therapy were administered. Only one cycle (2%) was complicated by an absolute neutrophil count less than 500, and there were no episodes of febrile neutropenia. Fifty-four percent of cycles were associated with fever during the infusion, and five cycles (8%) were complicated by grade 3 rash. There were no other clinically significant (> or = grade 3) toxicities. There were seven partial remissions (41%) by ECOG criteria (95% confidence interval, 18% to 64%) and 11 partial remissions (65%) by ACTG criteria (95% confidence interval, 42% to 88%). Three of five (60%) previously treated patients had a partial remission with this schedule of bleomycin. The median survival duration was 7 months, with a range of 2.5 to 25 months.

CONCLUSION

This continuous infusion schedule of bleomycin is active in patients with advanced-stage AIDS-related Kaposi's sarcoma and has acceptable toxicity. This regimen should be further evaluated in patients with earlier stage Kaposi's sarcoma and as salvage therapy.

The changes in blood pressure after acute stroke: abolishing the 'white coat effect' with 24-h ambulatory monitoring

OBJECTIVES

To assess the changes in 24-h and casual blood pressure (BP) levels following hospitalization for acute stroke.

DESIGN

Prospective study of patients admitted with acute hemispheric stroke and hospitalized controls using casual and 24-h BP monitoring.

SETTING

Medical wards in a large teaching hospital.

SUBJECTS

Thirty-three patients (median age 77 years, 17 male) and 21 control subjects admitted non-acutely.

INTERVENTIONS

All subjects underwent 24-h BP monitoring within 24 h of stroke onset (patients) or admission (controls) and again at 1 week. Casual BPs were recorded over the same period.

MAIN OUTCOME MEASURES

The change in BP over the first week in each group. Eleven stroke subjects had 24-h BP monitoring repeated at 6 months.

RESULTS

In the stroke group, 24-h systolic BP (SBP) fell by 7 mmHg (95% CI, 0 to 14 mmHg; P < 0.05) and diastolic BP (DBP) by 3 mmHg (95% CI, 0 to 6 mmHg; P < 0.02) over the first week. Mean 24-h BP levels in the control group did not change during this period. However, casual BP recordings fell in both stroke (18/12 mmHg) and control (19/9 mmHg) groups. Stroke subjects followed to 6 months showed no further change in 24-h BP (day 7: 137 +/- 17/79 +/- 13 mmHg; month 6: 138 +/- 16/78 +/- 11 mmHg).

CONCLUSIONS

Although there was a large fall in causal BPs seen in both groups there was only a small, but a significant fall in mean 24-h BP over the first week following hemispheric stroke that was not seen in control subjects. Although the 'white coat effect' and admission to hospital play an important part in the high casual BP observed in the days following acute stroke they are unlikely to be the sole factors.

Cerebellar manifestations of prostatic carcinoma

We present two patients known to have prostate cancer who presented with acute cerebellar signs. The neurological deficit of the first patient was due to a paraneoplastic cerebellar manifestation and progressed, despite evidence of response of the primary prostate tumour to hormonal manipulation. The second case, resulting from a solitary cerebellar metastasis, was amenable to surgical intervention and subsequent hormonal manipulation. This latter patient has experienced no recurrent neurological signs after a period of 7 years follow-up. This is the first report of a paraneoplastic cerebellar deficit and, to our knowledge, only the sixth case of parenchymatous cerebellar metastasis of prostatic origin to appear in the literature.

Predictors of osteopenia in premenopausal women with anorexia nervosa

The study retrospectively evaluated risk factors for osteopenia in anorexia nervosa (AN) patients. Sixty-nine outpatient, female anorexia nervosa patients (age range 20-40 years, mean 27.5) at varying stages of recovery, and 31 controls had lumbar spine trabecular bone density assessed with single energy computed tomography (CT) scans. An investigator-based, semistructured interview assessed weight and menstrual histories from age 10. Current exercise and dietary calcium levels were categorized and lifetime durations in categories were estimated for each subject. Bone density was significantly lower in the patient group (mean 120 mg/cm3) than in the controls (mean 148 mg/cm3, P less than 0.001). Bone density correlated significantly with duration of illness, amenorrhea, and weight histories but not with measures of dietary calcium or exercise histories. The most important predictor of bone loss on stepwise multiple regression analysis was duration of AN (23% of variance, P less than 0.001), and duration of an inadequate calcium intake in adolescence explained a further 5% of the variance (P = 0.052). There was no evidence that regular exercise and adequate dietary calcium prevented bone loss related to prolonged periods of low weight and amenorrhea in these subjects.