Medical treatment of acute ischaemic stroke

Stroke Lesion Outcome Prediction Based on MRI Imaging Combined With Clinical Information

In developed countries, the second leading cause of death is stroke, which has the ischemic stroke as the most common type. The preferred diagnosis procedure involves the acquisition of multi-modal Magnetic Resonance Imaging. Besides detecting and locating the stroke lesion, Magnetic Resonance Imaging captures blood flow dynamics that guides the physician in evaluating the risks and benefits of the reperfusion procedure. However, the decision process is an intricate task due to the variability of lesion size, shape, and location, as well as the complexity of the underlying cerebral hemodynamic process. Therefore, an automatic method that predicts the stroke lesion outcome, at a 3-month follow-up, would provide an important support to the physicians' decision process. In this work, we propose an automatic deep learning-based method for stroke lesion outcome prediction. Our main contribution resides in the combination of multi-modal Magnetic Resonance Imaging maps with non-imaging clinical meta-data: the thrombolysis in cerebral infarction scale, which categorizes the success of recanalization, achieved through mechanical thrombectomy. In our proposal, this clinical information is considered at two levels. First, at a population level by embedding the clinical information in a custom loss function used during training of our deep learning architecture. Second, at a patient-level through an extra input channel of the neural network used at testing time for a given patient case. By merging imaging with non-imaging clinical information, we aim to obtain a model aware of the principal and collateral blood flow dynamics for cases where there is no perfusion beyond the point of occlusion and for cases where the perfusion is complete after the occlusion point.

Interventions for deliberately altering blood pressure in acute stroke

BACKGROUND

It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008.

OBJECTIVES

To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014).

SELECTION CRITERIA

Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross-checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available.

MAIN RESULTS

We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha-2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide-like diuretics, and target-driven blood pressure lowering. One trial tested phenylephrine.At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) -8 mmHg, 95% confidence interval (CI) -17 to 1) and diastolic blood pressure (DBP, MD -3 mmHg, 95% CI -9 to 2), sublingual ACEIs reduced SBP (MD -12.00 mm Hg, 95% CI -26 to 2) and DBP (MD -2, 95%CI -10 to 6), oral ARA reduced SBP (MD -1 mm Hg, 95% CI -3 to 2) and DBP (MD -1 mm Hg, 95% CI -3 to 1), oral beta blockers reduced SBP (MD -14 mm Hg; 95% CI -27 to -1) and DBP (MD -1 mm Hg, 95% CI -9 to 7), intravenous (iv) beta blockers reduced SBP (MD -5 mm Hg, 95% CI -18 to 8) and DBP (-5 mm Hg, 95% CI -13 to 3), oral CCBs reduced SBP (MD -13 mmHg, 95% CI -43 to 17) and DBP (MD -6 mmHg, 95% CI -14 to 2), iv CCBs reduced SBP (MD -32 mmHg, 95% CI -65 to 1) and DBP (MD -13, 95% CI -31 to 6), NO donors reduced SBP (MD -12 mmHg, 95% CI -19 to -5) and DBP (MD -3, 95% CI -4 to -2) while phenylephrine, non-significantly increased SBP (MD 21 mmHg, 95% CI -13 to 55) and DBP (MD 1 mmHg, 95% CI -15 to 16).Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre-stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD -3.2, 95% CI -5.8, -0.6).

AUTHORS' CONCLUSIONS

There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure-lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial.

Vasoactive drugs for acute stroke

BACKGROUND

It is unclear whether blood pressure (BP) should be altered actively during the acute phase of stroke.

OBJECTIVES

To assess the effect of lowering or elevating BP in people with acute stroke, and the effect of different vasoactive drugs on BP in acute stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched June 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2009), MEDLINE (1966 to October 2009), EMBASE (1980 to October 2009), and Science Citation Index (1981 to October 2009).

SELECTION CRITERIA

Randomised trials of interventions that would be expected, on pharmacological grounds, to alter BP in patients within one week of the onset of acute stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the trial inclusion criteria, assessed trial quality, and extracted data.

MAIN RESULTS

We identified 131 trials involving in excess of 18,000 patients; a further 13 trials are ongoing. We obtained data for 43 trials (7649 patients). Among BP-lowering trials, beta receptor antagonists lowered BP (early systolic BP (SBP) mean difference (MD) -6.1 mmHg, 95% CI -11.4 to -0.9; late SBP MD -4.9 mmHg, 95% CI -10.2 to 0.4; late diastolic BP (DBP) MD -4.5 mmHg, 95% CI -7.8 to -1.2). Oral calcium channel blockers (CCB) lowered BP (late SBP MD -3.2 mmHg, 95% CI -5.4 to -1.1; early DBP MD -2.5, 95% CI -5.6 to 0.7; late DBP MD -2.1, 95% CI -3.5 to -0.7). Nitric oxide donors lowered BP (early SBP MD -10.3 mmHg, 95% CI -17.6 to -3.0). Prostacyclin lowered BP (late SBP MD, -7.7 mmHg, 95% CI -15.6 to 0.2; late DBP MD -3.9 mmHg, 95% CI -8.1 to 0.4). Among BP-increasing trials, diaspirin cross-linked haemoglobin (DCLHb) increased BP (early SBP MD 15.3 mmHg, 95% CI 4.0 to 26.6; late SBP MD 15.9 mmHg, 95% CI 1.8 to 30.0). None of the drug classes significantly altered outcome apart from DCLHb which increased combined death or dependency (odds ratio (OR) 5.41, 95% CI 1.87 to 15.64).

AUTHORS' CONCLUSIONS

There is not enough evidence to evaluate reliably the effect of altering BP on outcome after acute stroke. However, treatment with DCLHb was associated with poor clinical outcomes. Beta receptor antagonists, CCBs, nitric oxide, and prostacyclin each lowered BP during the acute phase of stroke. In contrast, DCLHb increased BP.

Interventions for deliberately altering blood pressure in acute stroke

BACKGROUND

It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001.

OBJECTIVES

To assess the effect of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched July 2007), the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2 2008), MEDLINE, EMBASE and other databases, reference lists of relevant publications and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials of interventions that aimed to alter blood pressure in patients within one week of acute ischaemic or haemorrhagic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data.

MAIN RESULTS

Twelve trials involving 1153 participants were included (603 participants were assigned active therapy and 550 participants received placebo/control). The trials tested angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), clonidine, glyceryl trinitrate (GTN), thiazide diuretic and mixed antihypertensive therapy. One trial tested phenylephrine. At 24 hours after randomisation ACEIs reduced systolic blood pressure (SBP, mean difference, MD -6 mmHg, 95% confidence interval, CI -22 to 10) and diastolic blood pressure (DBP, MD -5 mmHg, 95% CI -18 to 7), ARA reduced SBP (MD -3, 95% CI -7 to 2) and DBP (MD -3, 95% CI -6 to 0.4), iv CCBs reduced SBP (MD -32 mmHg, 95% CI -65 to 1) and DBP (MD -13 mmHg, 95% CI -31 to 6), oral CCBs reduced SBP (MD -13 mmHg, 95% , CI -43 to 17) and DBP (MD -6 mmHg, 95% CI -14 to 2), GTN reduced SBP (MD -10 mmHg, 95% CI -18 to -3) and DBP (MD -1 mmHg, 95% CI -5 to 3) while phenylephrine, non-significantly increased SBP (MD 21 mmHg, 95% CI -13 to 55) and DBP (MD 1 mmHg, 95% CI -15 to 16). Functional outcome and death were not altered by any of the drugs.

AUTHORS' CONCLUSIONS

There is insufficient evidence to evaluate the effect of altering blood pressure on outcome during the acute phase of stroke. In patients with acute stroke, CCBs, ACEI, ARA and GTN each lower blood pressure while phenylephrine probably increases blood pressure.

Naftidrofuryl for acute stroke

BACKGROUND

Stroke is the third most common cause of death and the most common cause of disability in the western world. The development of drugs to limit the effects of brain damage caused by stroke continues but no routine effective treatment has yet been identified. Naftidrofuryl has been reported to be beneficial in the treatment of acute stroke in some studies, but it is unclear whether all of the evidence supports these findings.

OBJECTIVES

To assess the effects of naftidrofuryl in the acute phase of stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched November 2006); the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects (The Cochrane Library Issue 2, 2006); MEDLINE (1966 to July 2006); EMBASE (1980 to July 2006); Science Citation Index (1981 to July 2006); National Research Register (July 2006); LILACS Database (1982 to July 2006); metaRegister of Controlled Trials (mRCT) (July 2006); SUMsearch (July 2006). To identify further published, unpublished and ongoing studies we searched reference lists, handsearched conference proceedings and contacted pharmaceutical companies and authors of relevant articles.

SELECTION CRITERIA

We included patients with acute ischaemic or haemorrhagic stroke clinically diagnosed by a medical practitioner with or without a computerised tomography (CT) scan.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion, assessed trial quality, and extracted data using data extraction forms or, if available, re-analysed individual patient data.

MAIN RESULTS

Six trials involving 1274 participants were included. We found no significant benefits of naftidrofuryl compared with placebo in reducing the risks of mortality (pooled odds ratio (OR) 1.03, 95% confidence interval (CI) 0.78 to 1.36, six studies) or combined death or dependency/disability (pooled OR 0.94, 95% CI 0.70 to 1.16, three studies). Pooled results showed naftidrofuryl had no significant effect on systolic, diastolic or mean arterial blood pressure. No trials reported the effects of naftidrofuryl on the risk of early death or deterioration, quality of life, stroke recurrence, or discharge site. However, we found a trend towards an increase in risk of minor adverse events in patients taking naftidrofuryl (OR 1.99, 95% CI 0.96 to 4.11, P = 0.06).

AUTHORS' CONCLUSIONS

There is not enough evidence to support the use of naftidrofuryl in the treatment of acute ischaemic or haemorrhagic stroke.

Neuroprotection by Brazilian Green Propolis against In vitro and In vivo Ischemic Neuronal Damage

We examined whether Brazilian green propolis, a widely used folk medicine, has a neuroprotective function in vitro and/or in vivo. In vitro, propolis significantly inhibited neurotoxicity induced in neuronally differentiated PC12 cell cultures by either 24 h hydrogen peroxide (H₂O₂) exposure or 48 h serum deprivation. Regarding the possible underlying mechanism, propolis protected against oxidative stress (lipid peroxidation) in mouse forebrain homogenates and scavenged free radicals [induced by diphenyl-p-picrylhydrazyl (DPPH). In mice in vivo, propolis [30 or 100 mg/kg; intraperitoneally administered four times (at 2 days, 1 day and 60 min before, and at 4 h after induction of focal cerebral ischemia by permanent middle cerebral artery occlusion)] reduced brain infarction at 24 h after the occlusion. Thus, a propolis-induced inhibition of oxidative stress may be partly responsible for its neuroprotective function against in vitro cell death and in vivo focal cerebral ischemia.

[Focal cerebral ischaemia induced by middle cerebral artery occlusion and the neuroprotective effect of ketoprofen in rats]

Cerebral ischaemia is eventualy observed during neurosurgical procedures and in several clinical entities that may cause severe neurological deficits and even death. Because it is a severe and complex problem, several studies have been done aiming to elucidate the mechanisms of the ischemic phenomenon and aiming to abolish or to diminish its effects, using drugs that protect the neurons from ischaemia-induced damage. Several neurotransmitters play a role in cerebral ischaemia with emphasis to glutamate by its high concentration in the central nervous system. The purpose of this study was to evaluate the effect of focal cerebral ischaemia in the rat through the dosage of the glutamate and morphological findings, and to evaluate a possible protective effect of the ketoprofen to ischemic neurons. Thirty-six rats Wistar were divided into four groups. The first was a control group, the second a sham group and the animals of the third and fourth groups were submitted to induced cerebral ischaemia through selective obstruction of the midlle cerebral artery during 15, 30 and 45 minutes. Animals of the fourth group were previously treated with ketoprofen 15 minutes before the ischaemia. The ischaemia was evaluated through the histopathological examination and through dosage of the extracellular glutamate in vitro. The histopathological examination showed that there was no difference between the animals of the control and of the sham groups. In the animals submitted to ischemia histopathological alterations appeared at 30 minutes and become more intense at 45 minutes of ischaemia. The main findings were interstitial edema, chromatinic disorganization, vacuolization and nuclear desintegration. The animals treated with ketoprofen showed similar alterations, but they were less intense. Decrease in the dosage of glutamate in the parietal cortex of the animals submitted to ischaemia started at 30 minutes and became more intense at 45 minutes of ischaemia and was similar for animals previously treated or not with ketoprofen, indicating that this drug seems not to interfere with the metabolism of the glutamate at the synapses. The morphological findings in the parietal cortex of the animals submitted to ischaemia, previously treated or not with ketoprofen, suggest that this drug has a neuroprotective effect.

Vasoactive drugs for acute stroke

BACKGROUND

It is unclear whether blood pressure should be managed after acute stroke and if so whether it is best to reduce or increase blood pressure.

OBJECTIVES

The objective of this review was to assess the effect of lowering or elevating blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.

SEARCH STRATEGY

We searched the Cochrane Library (1999 Issue 1) using the CDSR and the CCTR databases, MEDLINE (from 1966), EMBASE (from 1980), BIDS ISI (Science Citation Index from 1981), and existing review articles. We contacted researchers in the field and pharmaceutical companies.

SELECTION CRITERIA

Randomised trials of interventions that would be expected, on pharmacological grounds, to alter blood pressure in patients within two weeks of the onset of acute ischaemic or haemorrhagic stroke.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the trial inclusion criteria, assessed trial quality, and extracted the data.

MAIN RESULTS

Sixty five trials were identified involving in excess of 11,500 patients; a further 5 trials are ongoing. Data were obtained for 32 trials (5,368 patients). Significant imbalances in baseline blood pressure were present across trials of intravenous calcium channel blockers and prostacyclin. Major imbalances in baseline blood pressure between treatment and control groups have made the interpretation of these results difficult. Intravenous calcium channel blockers (CCBs) and oral CCBs significantly lowered late blood pressure as compared to controls. (systolic/diastolic BP): iv CCBs -8.2/-6.7 mm Hg (95% CI -12.6 to -3.8)/ (95% CI -9.2 to -4.3); oral CCBs -3.2/-2.1 mm Hg (95% CI -5.0 to -1.3)/ (95% CI -3.0 to -1.0). Beta blockers significantly lowered late diastolic blood pressure but not significantly late systolic blood pressure; -5.0/-4.5 mm Hg (95% CI -10.2 to 0.4)/(95% CI -7.8 to -1.15). Angiotensin converting enzyme inhibitors and prostacyclin non-significantly reduced late BP as compared to the controls by -5.4/-3.0 mm Hg (95% CI -16.5 to 5.8)/(95% CI -11.1 to 5.0) and -7.4/-3.9 mmHg (95% CI -15.6 to 0.2)/(95% CI -8.1 to 0.4) respectively. Magnesium, naftidrofuryl and piracetam had no significant effect on blood pressure. Oral CCBs and beta blockers each significantly reduced late heart rate (beats per minute (bpm)): CCBs -2.8 bpm (95%CI -3.9 to -1.7); beta blockers -9.3 bpm (95% CI -12.0 to -6.6). Prostacyclin significantly increased late heart rate by +5.6 bpm (95% CI 0.8 to 10.4). None of the drug classes significantly altered outcome apart from beta blockers and streptokinase which increased early case fatality (odds ratio 1.77, 95%CI, 1.05 to 3.00) and 2.27 (95% CI 1.4 to 3.67).

REVIEWER'S CONCLUSIONS

There is not enough evidence reliably to evaluate the effect of altering blood pressure on outcome after acute stroke. CCBs, beta blockers, and probably ACE-inhibitors, prostacyclin and nitric oxide, each lowered BP during the acute phase of stroke. In contrast, magnesium, naftidrofuryl and piracetam had little or no effect on BP.

Interventions for deliberately altering blood pressure in acute stroke

BACKGROUND

It is unclear whether hypertension should be treated after acute stroke, and some have hypothesised that blood pressure should be increased to improve cerebral perfusion.

OBJECTIVES

The objective of this review was to assess the effect of lowering or elevating blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register, the Ottawa Stroke Trials Registry (1994), Medline (from 1965), Embase (from 1981), ISI, and existing review articles. We contacted researchers in the field and pharmaceutical companies.

SELECTION CRITERIA

Randomised trials of interventions that aimed to alter blood pressure in patients within two weeks of acute ischaemic or haemorrhagic stroke.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria and assessed trial quality. Two reviewers extracted the data.

MAIN RESULTS

Three trials involving 133 people were included. The trials tested the following vasodilators: nimodipine (66 people), nicardipine (five people), captopril (three people) and clonidine (two people). Oral calcium channel blockers (nimodipine, nicardipine) reduced systolic blood pressure (weighted mean difference 10.9mmHg, 95% confidence interval 2.0 to 19.7), diastolic blood pressure (weighted mean difference 9.5mmHg, 95% confidence interval 4.0 to 15.1) and heart rate (weighted mean difference 4.7 beats per minute, 95% confidence interval 0.2 to 9.2) at 48 hours. The greatest fall in blood pressure over the first 24 hours was shown in patients given the highest dose of nimodipine. The relationship between change in blood pressure and clinical outcome was not clear. There was not enough information to assess the effect of drugs other than calcium channel blockers. No studies of interventions to raise blood pressure were found.

REVIEWER'S CONCLUSIONS

There is not enough evidence to evaluate the effect of altering blood pressure after acute stroke. Although oral calcium channel blockers appear to reduce blood pressure following acute stroke, the balance of benefit and risk remains unclear.

Vinpocetine for acute ischaemic stroke

BACKGROUND

Vasoactive and neuroprotective drugs are used to treat stroke in some countries.

OBJECTIVES

The objective of this review was to assess the effect of vinpocetine in acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched: August 1999) and Medline. We contacted researchers in the field and drug companies.

SELECTION CRITERIA

Unconfounded randomised trials of vinpocetine compared with placebo, or any other reference treatment, in people with acute stroke. Trials were included if treatment started no later than 14 days after stroke onset.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria. One reviewer extracted the data that was then checked by the second reviewer. Trial quality was assessed.

MAIN RESULTS

One trial involving 40 patients was included. Data for 33 patients were reported. No deaths occurred in the trial and no significant difference in dependency was shown between the treatment and placebo groups. No adverse effects were reported.

REVIEWER'S CONCLUSIONS

There is not enough evidence to evaluate the effect of vinpocetine on survival or dependency of patients with acute stroke.

Neuroprotection in acute ischaemic stroke. II: Clinical potential

In the 4 years since our first article, there has been considerable progress in our understanding of the pathophysiology of acute ischaemic stroke, and the results of well-conducted trials have at last begun to change everyday clinical practice. The timing of the various processes of the ischaemic cascade and the potential time windows for different interventions are better understood. Furthermore, the importance of maintaining cerebral perfusion and optimizing systemic physiological and biochemical factors in order to prevent neurological deterioration ('progressing stroke') is increasingly being realized. Numerous antithrombotic and neuroprotective drugs have been evaluated in clinical trials, and while none has shown unequivocal benefits on its own, prospects for successful intervention are still good. This will probably involve different combinations of treatments targeted on different pathophysiological stroke types, so that the management of acute stroke will offer a considerable challenge to the stroke physicians of the future.

Superselective Intra-Arterial Thrombolysis for Acute Cardioembolic Stroke in a Child with Idiopathic Dilated Cardiomyopathy

We describe a case of cardioembolic dominant hemisphere internal carotid artery occlusion in a child with idiopathic dilated cardiomyopathy. The patient was subjected to superselective local intra-arterial thrombolysis using recombinant tissue plasminogen activator (Alteplase; Actilyse®). In presence of good collateral flow local intra-arterial thrombolysis prevented a major dominant hemisphere ischaemic stroke, although post-interventional computed tomographic scans disclosed haemorrhagic conversion in the left corpus striatum. Forty eight months after ischaemic stroke and thrombolysis the patient is ambulatory with a moderate neurologic deficit.

Economic consequences of early inpatient discharge to community-based rehabilitation for stroke in an inner-London teaching hospital

BACKGROUND AND PURPOSE

In an inner-London teaching hospital, a randomized trial of "conventional" care versus early discharge to community-based therapy found no significant differences in clinical outcomes between patient groups. This report examines the economic consequences of the alternative strategies.

METHODS

One hundred sixty-seven patients received the early discharge package, and 164 received conventional care. Patient utilization of health and social services was recorded over a 12-month period, and cost was determined using data from provider departments and other published sources.

RESULTS

Inpatient stay after randomization was 12 days (intervention group) versus 18 days (controls) (P=0.0001). Average units of therapy per patient were as follows: physiotherapy, 22.4 (early discharge) versus 15.0 (conventional) (P=0.0006); occupational therapy, 29.0 versus 23.8 (P=0.002); speech therapy, 13. 7 versus 5.8 (P=0.0001). The early discharge group had more annual hospital physician contacts (P=0.015) and general practitioner clinic visits (P=0.019) but fewer incidences of day hospital attendance (P=0.04). Other differences in utilization were nonsignificant. Average annual costs per patient were pound sterling 6800 (early discharge) and pound sterling 7432 (conventional). The early discharge group had lower inpatient costs per patient (pound sterling 4862 [71% of total cost] versus pound sterling 6343 [85%] for controls) but higher non-inpatient costs (pound sterling 1938 [29%] versus pound sterling 1089 [15%]). Further analysis demonstrated that early discharge is unlikely to lead to financial savings; its main benefit is to release capacity for an expansion in stroke caseload.

CONCLUSIONS

Overall results of this trial indicate that early discharge to community rehabilitation for stroke is cost-effective. It may provide a means of addressing the predicted increase in need for stroke care within existing hospital capacity.

Recent advances in the acute management of ischaemic stroke

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Quality of full and final publications reporting acute stroke trials: a systematic review

BACKGROUND AND PURPOSE

Several studies have shown that the quality of reporting of trials throughout medicine is variable and often poor. We report on the quality of the final reports of randomized controlled trials (RCTs) of drug therapies assessed in acute stroke.

METHODS

English-language reports published up to the end of 1996 relating to completed RCTs in acute stroke were identified from electronic searches of the Cochrane Stroke Review Group database of stroke trials and the Cochrane Controlled Trials Register (CD-ROM issue 1, 1997, of the Cochrane Library). Report quality was assessed with the 33 criteria of the CONSORT statement and 53 additional factors relevant to acute stroke or trials in general. Trial quality was also assessed with a 7-point scale.

RESULTS

Up to 1996, 114 RCTs were published which involved 20 536 patients (median, 80; range, 16 to 1267 per trial); 39 (35.5%) of these were published in Stroke. The median total report quality was 40/86 (range, 15 to 61) for all criteria and 19/33 (range, 9 to 29) for the CONSORT criteria alone. Although adequate information was given in the introduction and discussion sections of most reports, insufficient details were given on methods, assignment of patients to treatment groups, statistical analyses, the prevalence of risk factors, and assessment of outcomes. Report quality has improved between 1956 and 1996 (Spearman correlation coefficient [rs], 0.575; 95% confidence interval [CI], 0. 439 to 0.685) and was superior in large trials (rs=0.434; 95% CI, 0. 274 to 0.571). Although report quality was related to trial quality (rs=0.675; 95% CI, 0.563 to 0.763), it was not related to journal impact factor (rs=0.170; 95% CI, -0.015 to 0.344). Trials with a positive outcome tended to be less well reported than those with a neutral or negative outcome (rs=-0.192; 95% CI, -0.351 to -0.011).

CONCLUSIONS

The overall quality of study reports for parallel group RCTs in acute stroke is poor but appears to be improving with time and in parallel with an increase in trial size. Reports often lack detailed information on the methods of randomization, concealment of allocation, and statistical analysis, all factors which can, if undertaken poorly, affect trial results and validity. It is vital that future trials are adequately reported; we believe that authors should follow the CONSORT guidelines and that referees and editors should ensure this happens.

Stroke units versus general medical wards, I: twelve- and eighteen-month survival: a randomized, controlled trial

BACKGROUND AND PURPOSE

The long-term effect on survival of treatment in stroke units is still under debate. The hypothesis that a stroke unit with short length of stay increases 1-year and 18-month survival rates was tested in this study.

METHODS

A quasi-randomized, controlled study was undertaken among 802 patients > or =60 years old admitted to the Central Hospital of Akershus in Norway with a diagnosis of stroke between January 1, 1993, and February 1, 1995. All patients with onset of symptoms <24 hours before admittance were included and enrolled and were followed until death or to the end of the observation 18 months after stroke. Patients were allocated to a stroke unit (n=364) or a general medical ward (n=438).

RESULTS

Case fatality within the first 10 days was 8.2% among patients in the stroke unit and 15.1% among patients in the general medical ward (P=.0019). One-year survival among patients treated in the stroke unit was 70.6% and in the general medical wards 64.6% (P=.026); 18-month survival rates were 65.1% and 58.0%, respectively (P=.021). Among patients with cerebral hemorrhage, 10-day case fatality was 24.5% and 51.6% (P=.004) in favor of the stroke unit.

CONCLUSIONS

Stroke units increase survival rates among stroke patients compared with general medical wards. The effect on survival occurs early after the stroke and sustains during at least 18 months of observation.

How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke Unit Trialists Collaboration

BACKGROUND AND PURPOSE

We sought to clarify the way in which organized inpatient (stroke unit) care can produce reductions in case fatality and in the need for institutional care after stroke.

METHODS

We performed a secondary analysis of a collaborative systematic review of all randomized trials that compared organized inpatient (stroke unit) care with contemporary conventional care. Nineteen trials were included, of which 18 (3246 patients) could provide outcome data on death, place of residence, and final functional outcome. Data were less complete (but always available for at least 12 trials; 1611 patients) for subgroup analyses examining timing and cause of death and outcomes in patients with different levels of severity of initial stroke.

RESULTS

The reduction in case fatality of patients managed in a stroke unit setting developed between 1 and 4 weeks after the index stroke. The reduction in the odds of death was evident across all causes of death and most marked for those deaths considered to be secondary to immobility. However, data were insufficient to permit a firm conclusion. The relative increase in the number of patients discharged home from stroke units as opposed to conventional care was largely attributable to an increase in the number of patients returning home physically independent. Across the range of stroke severity, stroke unit care was associated with nonsignificant increases in the number of patients regaining independence.

CONCLUSIONS

Within the limitations of the available data, we conclude that organized inpatient stroke unit care probably benefits a wide range of stroke patients in a variety of different ways, ie, reducing death from secondary complications of stroke and reducing the need for institutional care through a reduction in disability.

Hospital management of acute ischemic stroke in China

OBJECTIVE

Hospital management of acute ischemic stroke varies greatly within and between different countries. This study assesses the current practices and opinions of doctors in China routinely involved in the treatment of stroke, and compares them with those of British doctors.

METHODS

Questionnaires about the usual management of acute ischemic stroke were sent to 247 Chinese hospitals (mostly urban) collaborating in an acute stroke trial, seeking responses from five doctors (one consultant, two registrars, and two house officers) in each. After one mailing, 1,095 doctors (89%) responded.

RESULTS

Sixty-nine percent of the hospitals had computed tomography scanners, and 88% of the doctors in those hospitals reported that they would routinely scan acute stroke patients (78% usually within 24 hours of admission and 22% only later). Sixty-two percent of doctors reported average hospital stays of 2 to 4 weeks, whereas 36% reported longer average stays. Treatments reported to be used routinely within the first 48 hours of acute ischemic stroke included glycerol or mannitol (69% of doctors), Chinese herb products (66%), calcium antagonists (54%), and aspirin (53%); for each of these treatments, over 70% of all doctors believed it produced definite benefit. Reported routine use of dextran (44%), snake venom (32%), "photo-therapy" (22%), and steroids (19%) was also moderately common, and about half of all doctors believed each was beneficial. In contrast, routine use of thrombolytic agents (4%) or anticoagulants (1%) was uncommon. Only one third of the doctors reported active treatment of hypertension immediately after admission.

CONCLUSIONS

Comparison with a similar survey in Britain showed reported use of most treatments for acute ischemic stroke was more extensive in China, but that within both countries there was wide variation. The substantial variations in clinical practice both within and between China, the United Kingdom and other countries reflect, at least in part, the substantial uncertainty about the effectiveness of many of the possible treatments for acute ischemic stroke. Large-scale randomized evidence is needed to confirm or refute the efficacy of these and newer treatments for acute stroke.

Effects of Lamotrigine on brain nitrite and cGMP levels during focal cerebral ischemia in rats

Glutamate receptor antagonists are protective in animal models of focal cerebral ischemia. Lamotrigine (3,5-diamino-6-[2,3-dichlorophenyl]-1,2, 4-triazine) is an anticonvulsant drug that blocks voltage-gated sodium channels and inhibits the ischemia-induced release of glutamate. Experiments in primary neuronal cultures implicate nitric oxide (NO) as a mediator of glutamatergic neurotoxicity acting via N-Methyl-D-Aspartate (NMDA) receptors. The effect of glutamate release inhibitor, Lamotrigine upon NO and cGMP production has been examined in focal cerebral ischemia in rats. Focal cerebral ischemia was produced by the permanent occlusion of right middle cerebral artery (MCA) in urethane anesthetized rats. A number of indicators of brain NO production (nitrite, cGMP) were determined in ipsilateral and contralateral cerebral cortex and cerebellum after 0, 10, 60 min of focal cerebral ischemia. The same parameters were measured in rats treated with Lamotrigine (20 mg/kg, i.p.) 30 min before or just after the occlusion of the right MCA.

Hospital services for stroke care. A European Perspective. European Study of Stroke Care

BACKGROUND AND PURPOSE

Stroke is a common cause of mortality and morbidity in Europe and a major consumer of healthcare costs. However, outcomes from stroke vary significantly across Europe, raising the issue of the extent to which the delivery of care varies across Europe.

METHODS

A multicenter, multinational study collected data on hospital admission for stroke. These included patient baseline characteristics, clinical status, and use of inpatient services.

RESULTS

Initial results examined inpatient services in nine hospitals in six countries. Statistically significant differences existed between hospitals in key processes of care, most notably in the areas of (1) mean length of stay (11 to 39 days) and median length of stay (8 to 21 days), (2) percentage of admissions receiving brain imaging (30% to 98%) and neurosurgery (0% to 31%), and (3) percentage of admissions with an identified "need" who received physiotherapy (44% to 90%) and occupational (0% to 65%) and speech (0% to 59%) therapy. Although there were significant hospital differences (P < .001) in the case mix of admissions in terms of level of consciousness, presence of incontinence, prestroke Rankin Scale score, and age, these did not explain the differences in care across sites.

CONCLUSIONS

There is geographic inequity across Europe in the care a stroke patient can expect to receive. Ongoing analysis will examine the link between European variations in service use and outcomes, in terms of mortality, handicap, and functional ability, as a means of indicating which patterns of care are the most effective.

Considerations in the design of clinical trials of neuroprotective therapy in acute stroke

Any therapeutic trial of a new treatment for stroke must provide sufficient reliable evidence to convince clinicians and healthcare purchasers of its merits. Clinicians are most likely to be convinced by large independent studies that provide clear evidence of benefit. If the trial is really to alter healthcare delivery, it should also confirm that the treatment is cost-effective enough to satisfy the increasingly critical demands of the healthcare purchasers. Although some of the current trials will be able to detect large benefits, reliable detection of the moderate benefits that seem more plausible with neuroprotection will need to wait until completion of trials that are perhaps an order of magnitude larger. If tens of thousands of patients are to be recruited into trials of neuroprotective therapy, it is essential that the trials have simple practicable designs that allow participation not only by interested university hospitals but also busy general hospitals with few research resources.

Study design of the International Stroke Trial (IST), baseline data, and outcome in 984 randomised patients in the pilot study

BACKGROUND AND PURPOSE

To test the design and feasibility of a very large randomised controlled trial assessing the efficacy and safety of antithrombotic therapy started within 48 hours of symptom onset in patients with suspected acute ischaemic stroke.

DESIGN

Randomised controlled multicentre open study, with a 3 x 2 factorial design, allocating patients to: medium dose subcutaneous heparin (12,500 units twice per day), versus low dose subcutaneous heparin (5000 units twice per day) versus no heparin; and aspirin (300 mg daily) versus no aspirin. Treatment was given for two weeks or until discharge from hospital if sooner.

RESULTS

984 patients were randomised. CT was performed in 924 (94%) (before randomisation in 622/984 (63%). Within 14 days: 97 patients had died (10%), 30 (3.0%) had a fatal or non-fatal recurrent ischaemic stroke, nine (0.9%) had fatal or non-fatal recurrent stroke due to intracranial haemorrhage, and eight (0.8%) had a fatal or non-fatal pulmonary embolus. At six months, vital status was known for 975 patients (99%), of whom 210 (22%) were dead, 373 (38%) were alive but dependent, and 225 (23%) were independent but not fully recovered.

CONCLUSIONS

The trial procedures proved practicable and a wide variety of patients were recruited. Sample size calculation based on the event rates confirmed that reliable evidence on the balance of risk and benefit of early antithrombotic therapy might require a study with more than 20,000 patients. Recruitment rates in the pilot study indicated that if about 200 hospitals participated, recruitment could be completed by 1997.

The assessment of acute stroke in general medical wards

In order to assess the completeness of clinical clerking, a retrospective study was made of the medical notes of 194 patients admitted with acute stroke over a 1-year period. The noting of clinical features associated with disease severity and prognosis, such as level of consciousness, proprioception, neglect, mental test score and continence was assessed. These features were rarely noted. Factors likely to influence placement following recovery were also poorly reported. In order to allow an accurate guide to stroke severity and prognosis these factors must be noted. An alternative form of clinical clerking is suggested in order to improve patient management.

Vascular holism: the epidemiology of vascular disease

This article reviews the distinguishing features of epidemiology and clinical medicine and their interdependence in clinical epidemiology as applied to vascular disease. Selected literature is reviewed to emphasize the principles of clinical epidemiology for five vascular disorders: abdominal aortic aneurysms, lower extremity peripheral arterial occlusive disease, cerebrovascular disease, deep vein thrombosis and pulmonary embolism, and varicose veins. These vascular disorders are prevalent and pose significant risks for death and disability. Many have risk factors that can be controlled. All can be treated by vascular surgery, but outcomes including functional health and well-being may fall short of that which is implied in our traditional surgical literature. Appropriate allocation of resources to detect and treat vascular disease demands that clinicians not only assume responsibility for the care of individual patients but also develop a working knowledge of the clinical epidemiology of vascular health and disease and its management within populations.

Management of transient ischaemic attacks and stroke

The management of stroke and transient ischaemic attacks (TIAs) has changed greatly in the last two decades. The importance of good blood pressure control is the hallmark of stroke prevention. Large multicentre trials have proven beyond doubt the value of aspirin in TIAs, warfarin in patients with atrial fibrillation and embolic cerebrovascular symptoms, and carotid endarterectomy in patients with carotid TIAs. There seems little doubt that patients managed in acute stroke units are more likely to be independent at six months than those managed in a general medical ward. This article emphasizes the importance of basing clinical management on simple history taking and examination and appropriate investigation. This, combined with knowledge of the natural history risk of TIA and stroke and the results of randomised trials, allows individuals to be managed in the most appropriate manner. This review is designed to be a practical guide, useful in the day to day management of patients with cerebrovascular disease.

Early intrathecal production of interleukin-6 predicts the size of brain lesion in stroke

BACKGROUND AND PURPOSE

We have previously demonstrated that stroke influences systemic immune responses. The aim of the present study was to investigate patterns of local inflammatory response as a consequence of acute stroke.

METHODS

Thirty stroke patients were studied prospectively on days 0 to 3, 7 to 9, 21 to 26, and after day 90 with clinical evaluations, radiological assessments, and analysis of serum and cerebrospinal fluid cytokine levels.

RESULTS

Significantly increased levels of interleukin-6 (IL-6) in cerebrospinal fluid (P < .001) were observed in virtually all patients studied compared with healthy control subjects. This increase was observed during the whole observation period but was significantly more pronounced within the first days after stroke onset, with a peak level on days 2 and 3. This initial increase was significantly correlated (r = .65, P = .002) with the volume of infarct measured by MRI 2 to 3 months later. Serum levels of IL-6 in stroke patients were significantly lower than cerebrospinal fluid levels of IL-6 (P = .013) and did not display any significant correlation to the size of the brain lesion. Also, increase in intrathecal but not systemic production of IL-1 beta was observed early during the stroke. Only minor increases of cerebrospinal fluid interferon-gamma levels were observed in two patients.

CONCLUSIONS

Our study demonstrates an intrathecal production of IL-6 and IL-1 beta in patients with stroke, supporting the notion of localized inflammatory response to acute brain lesion. In addition, the significant correlation between early intrathecal production of IL-6 and the subsequent size of the brain lesion can be used as a prognostic tool, predicting the size of the brain damage before it is possible to accurately visualize it with radiological methods.

Stroke care in Europe. Can we learn lessons from the different ways stroke is managed in different countries?

Stroke is a major health care problem in the European Union and consumes significant resources. The mortality rates from stroke and treatment strategies vary significantly between member states. Only by comparison between centres in different member states with differing health care delivery can the effect of these varying approaches to the management of stroke on outcome be assessed. Conducting a study on a European wide basis in centres which are known to differ in terms of treatment strategies and outcomes allows an immediate analysis of the effectiveness, resource requirements and cost of different methods of managing stroke patients. This paper addresses the current burden of stroke and strategies for its management. An outline of a European Union project, assessing how stroke is managed in different countries, is provided with the aim of indicating a strategy for discovering and promoting more cost-effective services for stroke care in the future.

Incidence of stroke among inpatients in a large Italian hospital

BACKGROUND AND PURPOSE

The incidence of stroke among inpatients is not known. The aim of our study was to investigate the incidence of stroke not preceded by evident iatrogenic factors such as surgical or medical procedures in a cohort of inpatients in a large Italian general hospital.

METHODS

From January 1, 1992, to December 31, 1992, we evaluated patients referred to our neurology department with a suspected diagnosis of stroke that occurred during hospitalization. Patients presenting with stroke as a complication of iatrogenic causes were excluded. We calculated the incidence rate of first-ever stroke in our cohort (crude and among patients aged older than 50 years), thereafter adjusting these rates for age to the general population of the city district of Bologna (Italy).

RESULTS

In 1992, 22 inpatients had a first-ever stroke with no evidence of iatrogenic factors. The crude stroke incidence rate was 11.08/1000 per year (95% confidence interval, 6.95 to 16.73). The age-adjusted rate was 5.46 (95% confidence interval 3.42 to 8.24).

CONCLUSIONS

The incidence rate of first-ever stroke among hospitalized patients is higher than those reported in community-based studies. Higher frequency of coronary artery disease among our patients could explain our findings. Further studies are needed to identify possible predisposing factors (individual or environmental) for stroke among inpatients.

Stroke study group. Preliminary results. Early intensive care improves functional outcome

Early and intensive care seems to positively affect outcome in stroke patients. A standardized protocol, costly adjusted to our reality and suitable for application by non-specialist at Emergency Room, proved effective, reflecting in diagnosis reliability, reducing time for beginning therapy, leading to low mortality rates and better functional outcomes at discharge.

[Treatment of cerebral ischemia in its acute phase and prospectives]

At the acute stage of cerebral ischemia, the "therapeutic window" probably does not last more than 6-12 hours. Despite similar treatments, patients admitted in stroke specialist units are more likely to survive and to have a good functional outcome than patients treated in general wards. In most cases acute arterial hypertension should not be treated. Thrombolytic agents given within 6 hours after onset, are now under evaluation in several clinical trials. There is no scientific evidence to support the use of anti-coagulation as a curative treatment of acute cerebral ischemia; however, clinical trials remain necessary, especially in progressing stroke. Neuroprotective drugs protect neurons against the consequences of hypoxia in animals: most clinical trials with oral nimodipine led to negative results but the meta-analysis suggests that patients receiving nimodipine within 12 hours after stroke onset might have a lower mortality rate and a better functional outcome. Other clinical trials with neuroprotective drugs are currently running: anti-NMDA drugs, chlomethiazol, tirilazad, ganglioside GM 1, etc Most therapeutic agents are now under evaluation. An early admission of patients with acute stroke is required to evaluate therapeutics agents which probably cannot be effective if started more than 6-12 hours after stroke onset.

Pilot study of low-molecular-weight heparin in the treatment of acute ischemic stroke

BACKGROUND

Our purpose was to assess the feasibility and risk of performing a double-blind placebo-controlled study of low-molecular-weight heparin in the treatment of acute ischemic stroke.

SUMMARY OF REPORT

Fifty-five patients were treated within 48 hours of stroke onset. Pretreatment computed tomography was performed to rule out cerebral hemorrhage. Fraxiparine (6000 IU per day) was given subcutaneously for 7 days. No adverse reaction was encountered during the treatment period. At 3 months, 26 patients were independent, 21 moderately disabled, 4 severely disabled, and 4 dead.

CONCLUSIONS

It would be safe and practical to conduct a clinical trial on the use of Fraxiparine in the treatment of acute ischemic stroke.

Evaluation times for patients with in-hospital strokes

BACKGROUND

Each year at least 35,000 people suffer a stroke while hospitalized, but little is known about the clinical characteristics of such patients or how rapidly they are identified and evaluated. With a recent emphasis on the very early treatment of stroke, in-hospital stroke patients may be candidates for some early interventions.

METHODS

This was a retrospective study using the stroke registries at two academic medical centers. Data were collected about the clinical characteristics of patients with an in-hospital stroke and who recognized the stroke. Detailed time data were analyzed to determine the time of stroke recognition, medical evaluation, and neurological evaluation. These specific time epochs were analyzed to determine which were responsible for any delays in stroke identification and assessment. Data were analyzed using nonparametric methods, including the Wilcoxon rank sum and Kruskal-Wallis procedure.

RESULTS

Sixty-three patients were identified with in-hospital strokes and adequate time data. In-hospital stroke patients were recognized most frequently by nurses (63%) and by the patient (16%). Patients on a cardiology service and general surgery service accounted for 48% of all in-hospital strokes. The mean and median times from stroke recognition to a neurology evaluation were 14.5 and 2.5 hours, respectively. Total delays differed significantly with service and locale (P = .004). Patients on the Duke neurology service were evaluated significantly sooner (median delay, 0.5 hour) than patients on the Duke medical (median delay, 5.8 hours) or Duke surgical (median delay, 20.5 hours; P < .01 by Wilcoxon rank sum) services. Patients on the Yale surgical service were evaluated significantly sooner than patients on the Duke medical (P = .0006) or surgical (P = .0001) services. The time between physician notification and calling for a neurology evaluation accounted for > 60% of the total time delay for patients not on a neurology service.

CONCLUSIONS

A substantial number of in-hospital stroke patients experience a long delay between symptom recognition and a neurological evaluation. While medical personnel are usually notified very soon after an in-hospital stroke is recognized, such patients often do not receive a rapid neurological evaluation. Additional education of hospital staff may reduce these time delays.

Do stroke units save lives?

Management of stroke patients in specialist stroke units hastens recovery but is not believed to influence mortality. We did a statistical overview of randomised controlled trials reported between 1962 and 1993 in which the management of stroke patients in a specialist unit was compared with that in general wards. We identified 10 trials, 8 of which used a strict randomisation procedure. 1586 stroke patients were included; 766 were allocated to a stroke unit and 820 to general wards. The odds ratio (stroke unit vs general wards) for mortality within the first 4 months (median follow-up 3 months) after the stroke was 0.72 (95% CI 0.56-0.92), consistent with a reduction in mortality of 28% (2p < 0.01). This reduction persisted (odds ratio 0.79, 95% CI 0.63-0.99, 2p < 0.05) when calculated for mortality during the first 12 months. The findings were not significantly altered if the analysis was limited to studies that used a formal randomisation procedure. We conclude that management of stroke patients in a stroke unit is associated with a sustained reduction in mortality.