1
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Sagaro GG, Amenta F. Choline-Containing Phospholipids in Stroke Treatment: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12082875. [PMID: 37109211 PMCID: PMC10143951 DOI: 10.3390/jcm12082875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/14/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Globally, stroke is the second leading cause of death and disability. In different studies conducted previously, the choline-containing phospholipids citicoline and choline alphoscerate have been proposed as adjuvants in the treatment of acute strokes. A systematic review was conducted to provide updated information on the effects of citicoline and choline alphoscerate in patients with acute and hemorrhagic strokes. METHODS PubMed/Medline, Scopus, and Web of Science were searched to identify relevant materials. Data were pooled, and odds ratios (OR) were reported for binary outcomes. Using mean differences (MD), we evaluated continuous outcomes. RESULTS A total of 1460 studies were reviewed; 15 studies with 8357 subjects met the eligibility criteria and were included in the analysis. In our study, citicoline treatment did not result in improved neurological function (NIHSS < 1, OR = 1.05; 95% confidence interval (CI): 0.87-1.27) or functional recovery (mRS < 1, OR = 1.36; 95% CI: 0.99-1.87) in patients with acute stroke. Choline alphoscerate improved neurological function and functional recovery in stroke patients based on the Mathew's scale and the Mini-Mental State Examination (MMSE). CONCLUSION Citicoline did not improve the neurological or functional outcomes in acute stroke patients. In contrast, choline alphoscerate improved neurological function and functional recovery and reduced dependency in stroke patients.
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Affiliation(s)
- Getu Gamo Sagaro
- Clinical Research, Telemedicine and Telepharmacy Center, School of Medicinal and Health Products Sciences, University of Camerino, 62032 Camerino, Italy
| | - Francesco Amenta
- Clinical Research, Telemedicine and Telepharmacy Center, School of Medicinal and Health Products Sciences, University of Camerino, 62032 Camerino, Italy
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2
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Adams HP. Clinical Scales to Assess Patients With Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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3
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Glycerol Infusion Versus Mannitol for Cerebral Edema: A Systematic Review and Meta-analysis. Clin Ther 2021; 43:637-649. [PMID: 33581877 DOI: 10.1016/j.clinthera.2021.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/01/2020] [Accepted: 01/07/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE For the treatment of cerebral edema, the use of glycerol, an osmotic agent, as well as mannitol, is popular in Asia. However, the relative therapeutic benefit of glycerol remains unknown. The goal of this study was to investigate the comparative efficacy and safety of glycerol infusion versus mannitol infusion for cerebral edema. METHODS A systematic search was performed in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, and Scopus for all eligible articles published before July 2020, with no restrictions on language. Two reviewers independently screened the articles, extracted data, and carefully assessed the quality of the evidence. FINDINGS Eight studies (6 clinical, 2 animal) were ultimately included in the qualitative analysis, and five were included in the quantitative analysis. Pooled analyses revealed nonsignificant differences in the successful control of cerebral edema (relative risk [RR], 0.97; 95% CI, 0.81-1.15). The combination therapy with glycerol led to a favorable trend in neurologic improvements. Regarding safety, glycerol was associated with a significantly lower risk of acute kidney injury (RR, 0.27; 95% CI, 0.11-0.69) and electrolyte disturbances (RR, 0.20; 95% CI, 0.06-0.64), as well as a lower possibility of rebound effects. No hemolysis was observed at the final follow-up. IMPLICATIONS Although the data are limited, compared with mannitol, glycerol shows a similar level of effectiveness, a more favorable safety profile, and promising neurologic improvement in individuals with cerebral edema. Additional research is needed to confirm these findings. PROSPERO CRD42020187702.
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4
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Iijima K, Oshima T, Kawakami R, Nemoto T. Optical clearing of living brains with MAGICAL to extend i n vivo imaging. iScience 2021; 24:101888. [PMID: 33364578 PMCID: PMC7750414 DOI: 10.1016/j.isci.2020.101888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/02/2020] [Accepted: 11/26/2020] [Indexed: 12/16/2022] Open
Abstract
To understand brain functions, it is important to observe directly how multiple neural circuits are performing in living brains. However, due to tissue opaqueness, observable depth and spatiotemporal resolution are severely degraded in vivo. Here, we propose an optical brain clearing method for in vivo fluorescence microscopy, termed MAGICAL (magical additive glycerol improves clear alive luminance). MAGICAL enabled two-photon microscopy to capture vivid images with fast speed, at cortical layer V and hippocampal CA1 in vivo. Moreover, MAGICAL promoted conventional confocal microscopy to visualize finer neuronal structures including synaptic boutons and spines in unprecedented deep regions, without intensive illumination leading to phototoxic effects. Fluorescence emission spectrum transmissive analysis showed that MAGICAL improved in vivo transmittance of shorter wavelength light, which is vulnerable to optical scattering, thus unsuited for in vivo microscopy. These results suggest that MAGICAL would transparentize living brains via scattering reduction. Oral glycerol administration (MAGICAL) enhances fluorescent signals in living brains MAGICAL achieves in vivo optical clearing for living brains via scattering reduction MAGICAL enables in vivo microscopy to observe brains faster, deeper, and more finely
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Affiliation(s)
- Kouichirou Iijima
- Research Institute for Electronic Science, Hokkaido University, N20W10, Kita-ku, Sapporo, Hokkaido 001-0020, Japan
| | - Takuto Oshima
- Graduate School of Information Science and Technology, Hokkaido University, N14W9, Kita-ku, Sapporo, Hokkaido 060-0814, Japan
| | - Ryosuke Kawakami
- Research Institute for Electronic Science, Hokkaido University, N20W10, Kita-ku, Sapporo, Hokkaido 001-0020, Japan.,Graduate School of Information Science and Technology, Hokkaido University, N14W9, Kita-ku, Sapporo, Hokkaido 060-0814, Japan
| | - Tomomi Nemoto
- Research Institute for Electronic Science, Hokkaido University, N20W10, Kita-ku, Sapporo, Hokkaido 001-0020, Japan.,Graduate School of Information Science and Technology, Hokkaido University, N14W9, Kita-ku, Sapporo, Hokkaido 060-0814, Japan.,Division of Biophotonics, National Institute for Physiological Sciences, National Institutes of Natural Sciences, Higashiyama 5-1, Myodaiji, Okazaki 444-0865, Aichi, Japan.,Biophotonics Research Group, Research Center on Life and Living Systems (ExCELLS), National Institutes of Natural Sciences, Higashiyama 5-1, Myodaiji, Okazaki, Aichi 444-8787, Japan.,School of Life Science, The Graduate University for Advanced Studies (SOKENDAI), Higashiyama 5-1, Myodaiji, Okazaki, Aichi 444-8787, Japan
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5
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Chong PZ, Ng HY, Tai JT, Lee SWH. Efficacy and Safety of Ginkgo biloba in Patients with Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2020; 48:513-534. [PMID: 32349519 DOI: 10.1142/s0192415x20500263] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Ginkgo biloba and its extract have been suggested to have a neuroprotective role in patients with acute ischemic stroke. We aimed to examine the efficacy and safety of Ginkgo biloba use in patients with acute ischemic stroke. We searched seven databases for randomized controlled studies examining the use of Ginkgo biloba in patients with acute ischemic stroke. Relevant studies were retrieved, screened, and data were extracted independently by two reviewers. Random effects meta-analyses were performed to evaluate the efficacy and safety outcomes of Ginkgo biloba. We subsequently assessed the certainty of evidence using the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology. We found 12 randomized controlled studies enrolling 1466 patients. Pooled results suggest that Ginkgo biloba use was associated with an improvement in neurological function among individuals with AIS with a reduction of 2.87 points on the National Institute of Health Stroke Scale score (95% CI: -4.01--1.74, p<0.001). Ginkgo biloba use was also associated with an improvement in activities of daily living and functional outcome (Mean Difference: 9.52; 4.66-14.33, p<0.001). Subgroup analysis suggest that the impact was larger when using an injectable formulation of Ginkgo biloba compared to the oral formulation. There was no apparent impact of Ginkgo biloba use on all-cause mortality (Risk ratio (RR): 1.21; 0.29-5.09, p=0.80) or cerebrovascular bleeding (RR: 0.82; 0.43-1.57, p=0.55). There was limited evidence on to support the use of gingko biloba in terms of improving quality of life and other stroke events. As such, more studies are needed before it can be recommended for routine use in improving neurological and cognitive function in patients with acute ischemic stroke.
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Affiliation(s)
- Phui Zee Chong
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 47500 Selangor, Malaysia
| | - Huey Ying Ng
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 47500 Selangor, Malaysia
| | - Jing Tong Tai
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 47500 Selangor, Malaysia
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 47500 Selangor, Malaysia.,School of Pharmacy, Taylor's University Lakeside Campus, Jalan Taylor's, 47500 Selangor, Malaysia
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6
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Abstract
BACKGROUND The sudden loss of blood supply in ischemic stroke is associated with an increase of calcium ions within neurons. Inhibiting this increase could protect neurons and might reduce neurological impairment, disability, and handicap after stroke. OBJECTIVES To assess the effects of calcium antagonists for reducing the risk of death or dependency after acute ischemic stroke. We investigated the influence of different drugs, dosages, routes of administration, time intervals after stroke, and trial design on the outcomes. SEARCH METHODS The evidence is current to 6 February 2018. We searched the Cochrane Stroke Group Trials Register (6 February 2018), Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 2), MEDLINE Ovid (1950 to 6 February 2018), Embase Ovid (1980 to 6 February 2018), and four Chinese databases (6 February 2018): Chinese Biological Medicine Database (CBM-disc), China National Knowledge Infrastructure (CNKI), Chinese Scientific Periodical Database of VIP information, and Wanfang Data. We also searched the following trials registers: ClinicalTrials.gov, EU Clinical Trials Register, Stroke Trials Registry, ISRCTN registry, WHO International Clinical Trials Registry Platform, and Chinese Clinical Trial Registry, and we contacted trialists and researchers. SELECTION CRITERIA Randomized controlled trials comparing a calcium antagonist versus control in people with acute ischemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. We used death or dependency at the end of long-term follow-up (at least three months) in activities of daily living as the primary outcome. We used standard Cochrane methodological procedures. MAIN RESULTS We included 34 trials involving 7731 participants. All the participants were in the acute stage of ischemic stroke, and their age ranged from 18 to 85 years, with the average age ranging from 52.3 to 74.6 years across different trials. There were more men than women in most trials. Twenty-six trials tested nimodipine, and three trials assessed flunarizine. One trial each used isradipine, nicardipine, PY108-608, fasudil, and lifarizine. More than half of these trials followed participants for at least three months. Calcium antagonists showed no effects on the primary outcome (risk ratio (RR) 1.05; 95% confidence interval (CI) 0.98 to 1.13; 22 trials; 22 studies; 6684 participants; moderate-quality evidence) or on death at the end of follow-up (RR 1.07, 95% CI 0.98 to 1.17; 31 trials; 7483 participants; moderate-quality evidence). Thirteen trials reported adverse events, finding no significant differences between groups. Most trials did not report the allocation process or how they managed missing data, so we considered these at high risk of selection and attrition bias. Most trials reported double-blind methods but did not state who was blinded, and none of the trial protocols were available. AUTHORS' CONCLUSIONS We found no evidence to support the use of calcium antagonists in people with acute ischemic stroke.
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Affiliation(s)
- Jing Zhang
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyNo. 45, Changchun StreetBeijingBeijingChina100053
| | - Jia Liu
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyNo. 45, Changchun StreetBeijingBeijingChina100053
| | - Dan Li
- Henan Provincial People's Hospital of Zhengzhou UniversityDepartment of NeurologyZhengzhouChina
| | - Canfei Zhang
- The First Affiliated Hospital of Henan University of Science and TechnologyDepartment of NeurologyNo. 24, Jinghua RoadLuoyangHenan ProvinceChina471003
| | - Ming Liu
- West China Hospital, Sichuan UniversityDepartment of NeurologyNo. 37, Guo Xue XiangChengduSichuanChina610041
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7
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Wall ECB, Ajdukiewicz KMB, Bergman H, Heyderman RS, Garner P. Osmotic therapies added to antibiotics for acute bacterial meningitis. Cochrane Database Syst Rev 2018; 2:CD008806. [PMID: 29405037 PMCID: PMC5815491 DOI: 10.1002/14651858.cd008806.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Every day children and adults die from acute community-acquired bacterial meningitis, particularly in low-income countries, and survivors risk deafness, epilepsy and neurological disabilities. Osmotic therapies may attract extra-vascular fluid and reduce cerebral oedema, and thus reduce death and improve neurological outcomes.This is an update of a Cochrane Review first published in 2013. OBJECTIVES To evaluate the effects of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults on mortality, deafness and neurological disability. SEARCH METHODS We searched CENTRAL (2017, Issue 1), MEDLINE (1950 to 17 February 2017), Embase (1974 to 17 February 2017), CINAHL (1981 to 17 February 2017), LILACS (1982 to 17 February 2017) and registers of ongoing clinical trials (ClinicalTrials.com, WHO ICTRP) (21 February 2017). We also searched conference abstracts and contacted researchers in the field (up to 12 December 2015). SELECTION CRITERIA Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results and selected trials for inclusion. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included five trials with 1451 participants. Four trials evaluated glycerol against placebo, and one evaluated glycerol against 50% dextrose; in addition three trials evaluated dexamethasone and one trial evaluated acetaminophen (paracetamol) in a factorial design. Stratified analysis shows no effect modification with steroids; we present aggregate effect estimates.Compared to placebo, glycerol probably has little or no effect on death in people with bacterial meningitis (RR 1.08, 95% CI 0.90 to 1.30; 5 studies, 1272 participants; moderate-certainty evidence), but may reduce neurological disability (RR 0.73, 95% CI 0.53 to 1.00; 5 studies, 1270 participants; low-certainty evidence).Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30; 4 studies, 1090 participants; low-certainty evidence).Glycerol may reduce the risk of subsequent deafness (RR 0.64, 95% CI 0.44 to 0.93; 5 studies, 922 participants; low to moderate-certainty evidence).Glycerol probably has little or no effect on gastrointestinal bleeding (RR 0.93, 95% CI 0.39 to 2.19; 3 studies, 607 participants; moderate-certainty evidence). The evidence on nausea, vomiting and diarrhoea is uncertain (RR 1.09, 95% CI 0.81 to 1.47; 2 studies, 851 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Glycerol was the only osmotic therapy evaluated, and data from trials to date have not demonstrated an effect on death. Glycerol may reduce neurological deficiency and deafness.
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Affiliation(s)
- Emma CB Wall
- University College LondonDivision of Infection and ImmunityGower StreetLondonUKWC1E 6BT
| | - Katherine MB Ajdukiewicz
- Pennine Acute Hospitals NHS TrustDepartment of Infectious DiseasesNorth Manchester General HospitalDelaunays Road, CrumpsallManchesterUKMB 5RB
| | - Hanna Bergman
- CochraneCochrane ResponseSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Robert S Heyderman
- University of Malawi College of MedicineMalawi‐Liverpool‐Wellcome Clinical Research ProgrammeP. O Box 30096BlantyreChichiriMalawi
| | - Paul Garner
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
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8
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9
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Vaziri S, Mansouri F, Sayad B, Ghadiri K, Torkashvand E, Rezaei M, Najafi F, Azizi M. Meta-analysis of studies comparing adjuvant dexamethasone to glycerol to improve clinical outcome of bacterial meningitis. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:22. [PMID: 27904568 PMCID: PMC5122109 DOI: 10.4103/1735-1995.179890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/08/2015] [Accepted: 02/09/2016] [Indexed: 01/27/2023]
Abstract
Background: Neurological complications are a problematic factor in acute bacterial meningitis; hence, its prevention is the key to ensure the success of meningitis treatment. Glycerol and dexamethasone are both applied in this regard. Oral glycerol is an appropriate alternative instead of intravenous dexamethasone because it does not have problems related to intravenous injection, the high cost, and drug complications. The main objective of this study was to compare the efficacy of adjuvant dexamethasone versus glycerol in order to improve the clinical outcome of bacterial meningitis. Materials and Methods: We conducted a search on the available resources including PubMed, Ovid, Elsevier, Cochrane, and another search engines such as Google till 2014. All clinical trials that were performed in the field of comparing the effectiveness of the two drugs and met the inclusion criteria were gathered and after extraction the relative risk (RR) values, the pooled RR was calculated. The main outcome was neurological complications. Meta-analysis of the data was performed in Stata version 11.2 using both fixed and random effect models, weighting each study by inverse of variance. Results: In 5 comparative studies (1,340 patients), the rate of neurological complications of glycerol compared to that of dexamethasone was 1.02 [95% confidence interval (CI), 0.98 compared to 1.12]. The rate of neurological complications of dexamethasone compared to dexamethasone + glycerol was 1 (95% CI, 0.97 compared to 1.03), dexamethasone compared to placebo was 0.99 (95% CI, 0.97 compared to 1.03), glycerol compared to glycerol + dexamethasone was 0.98 (95% CI, 0.94 compared to 1.02), and glycerol compared to placebo was 0.97 (95% CI, 0.94 compared to 1.01). In these studies, no difference was reported between dexamethasone and glycerol in terms of reducing neurological complications. Conclusion: Although there were some weak evidences for the nonstatistical significant effect of glycerol in the prevention of neurologic complication after meningitis, there was no difference between glycerol and dexamethasone.
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Affiliation(s)
- Siavash Vaziri
- Department of Infectious and Tropical Disease, School of Medicine, Kermanshah, Iran
| | - Fiezollah Mansouri
- Department of Infectious and Tropical Disease, School of Medicine, Kermanshah, Iran
| | - Babak Sayad
- Department of Infectious and Tropical Disease, School of Medicine, Kermanshah, Iran
| | - Keyghobad Ghadiri
- Department of Infectious and Tropical Disease, School of Medicine, Kermanshah, Iran
| | - Elham Torkashvand
- Department of Infectious and Tropical Disease, School of Medicine, Kermanshah, Iran
| | - Mansour Rezaei
- Department of Biostatistics and Epidemiology, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Farid Najafi
- Department of Biostatistics and Epidemiology, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohsen Azizi
- Department of Medical Microbiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
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10
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Sun Z, Yue Y, Leung C, Chan M, Gelb A. Clinical diagnostic tools for screening of perioperative stroke in general surgery: a systematic review. Br J Anaesth 2016; 116:328-38. [DOI: 10.1093/bja/aev452] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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12
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Van Hooff RJ, De Smedt A, De Raedt S, Moens M, Mariën P, Paquier P, De Keyser J, Brouns R. Unassisted Assessment of Stroke Severity Using Telemedicine. Stroke 2013; 44:1249-55. [DOI: 10.1161/strokeaha.111.680868] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Quantification of stroke severity through telemedicine consultation is challenging and relies on professional support at the patient’s bedside. We aimed to develop a novel scale for assessing stroke severity through telemedicine without assistance from a third party (Unassisted TeleStroke Scale [UTSS]).
Methods—
Stroke severity was assessed in 45 patients with suspicion of acute stroke by bedside examination using the National Institutes of Health Stroke Scale (NIHSS) and by teleconsultation using the UTSS. Scale reliability was evaluated by intrarater and interrater variability, internal consistency, and rater agreement. Concurrent and predictive validity were tested by relating the UTSS with the NIHSS and long-term outcome (modified Rankin Scale and mortality at 6 months). Clinimetric analysis of the UTSS was obtained via the Rasch model.
Results—
The mean examination time for the UTSS was 3.1 minutes (SD, 1.1) versus 8.5 minutes for the NIHSS (SD, 2.6;
P
<0.001). Both UTSS and NIHSS showed excellent intrarater variability (
r
=0.97 and 0.98;
P
<0.001) and interrater variability (
r
=0.96 and 0.98;
P
<0.001), as well as excellent internal consistency and rater agreement. The UTSS correlated strongly with the NIHSS and was identified as an independent predictor of stroke outcome in logistic regression analysis. Rasch analysis indicated that the UTSS represents a unidimensional scale of stroke severity.
Conclusions—
The UTSS is a rapid, reliable, and valid tool for unassisted assessment of stroke severity through telemedicine.
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Affiliation(s)
- Robbert-Jan Van Hooff
- From the Department of Neurology (R.-J.V.H., A.D.S., S.D.R., J.D.K., R.B.), and Department of Neurosurgery (M.M.), Universitair Ziekenhuis Brussel, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Neurology and Memory Clinic, ZNA Middelheim Hospital, Antwerp, Belgium (P.M.); Department of Neurology and Neuropsychology, University Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium (P.P.); Department of Clinical and Experimental
| | - Ann De Smedt
- From the Department of Neurology (R.-J.V.H., A.D.S., S.D.R., J.D.K., R.B.), and Department of Neurosurgery (M.M.), Universitair Ziekenhuis Brussel, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Neurology and Memory Clinic, ZNA Middelheim Hospital, Antwerp, Belgium (P.M.); Department of Neurology and Neuropsychology, University Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium (P.P.); Department of Clinical and Experimental
| | - Sylvie De Raedt
- From the Department of Neurology (R.-J.V.H., A.D.S., S.D.R., J.D.K., R.B.), and Department of Neurosurgery (M.M.), Universitair Ziekenhuis Brussel, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Neurology and Memory Clinic, ZNA Middelheim Hospital, Antwerp, Belgium (P.M.); Department of Neurology and Neuropsychology, University Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium (P.P.); Department of Clinical and Experimental
| | - Maarten Moens
- From the Department of Neurology (R.-J.V.H., A.D.S., S.D.R., J.D.K., R.B.), and Department of Neurosurgery (M.M.), Universitair Ziekenhuis Brussel, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Neurology and Memory Clinic, ZNA Middelheim Hospital, Antwerp, Belgium (P.M.); Department of Neurology and Neuropsychology, University Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium (P.P.); Department of Clinical and Experimental
| | - Peter Mariën
- From the Department of Neurology (R.-J.V.H., A.D.S., S.D.R., J.D.K., R.B.), and Department of Neurosurgery (M.M.), Universitair Ziekenhuis Brussel, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Neurology and Memory Clinic, ZNA Middelheim Hospital, Antwerp, Belgium (P.M.); Department of Neurology and Neuropsychology, University Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium (P.P.); Department of Clinical and Experimental
| | - Philippe Paquier
- From the Department of Neurology (R.-J.V.H., A.D.S., S.D.R., J.D.K., R.B.), and Department of Neurosurgery (M.M.), Universitair Ziekenhuis Brussel, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Neurology and Memory Clinic, ZNA Middelheim Hospital, Antwerp, Belgium (P.M.); Department of Neurology and Neuropsychology, University Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium (P.P.); Department of Clinical and Experimental
| | - Jacques De Keyser
- From the Department of Neurology (R.-J.V.H., A.D.S., S.D.R., J.D.K., R.B.), and Department of Neurosurgery (M.M.), Universitair Ziekenhuis Brussel, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Neurology and Memory Clinic, ZNA Middelheim Hospital, Antwerp, Belgium (P.M.); Department of Neurology and Neuropsychology, University Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium (P.P.); Department of Clinical and Experimental
| | - Raf Brouns
- From the Department of Neurology (R.-J.V.H., A.D.S., S.D.R., J.D.K., R.B.), and Department of Neurosurgery (M.M.), Universitair Ziekenhuis Brussel, Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Neurology and Memory Clinic, ZNA Middelheim Hospital, Antwerp, Belgium (P.M.); Department of Neurology and Neuropsychology, University Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium (P.P.); Department of Clinical and Experimental
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Wall ECB, Ajdukiewicz KMB, Heyderman RS, Garner P. Osmotic therapies added to antibiotics for acute bacterial meningitis. Cochrane Database Syst Rev 2013; 3:CD008806. [PMID: 23543568 PMCID: PMC3996551 DOI: 10.1002/14651858.cd008806.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Every day children and adults throughout the world die from acute community-acquired bacterial meningitis, particularly in low-income countries. Survivors are at risk of deafness, epilepsy and neurological disabilities. Osmotic therapies have been proposed as an adjunct to improve mortality and morbidity from bacterial meningitis. The theory is that they will attract extra-vascular fluid by osmosis and thus reduce cerebral oedema by moving excess water from the brain into the blood. The intention is to thus reduce death and improve neurological outcomes. OBJECTIVES To evaluate the effects on mortality, deafness and neurological disability of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults. SEARCH METHODS We searched CENTRAL 2012, Issue 11, MEDLINE (1950 to November week 3, 2012), EMBASE (1974 to November 2012), CINAHL (1981 to November 2012), LILACS (1982 to November 2012) and registers of ongoing clinical trials (April 2012). We also searched conference abstracts and contacted researchers in the field. SELECTION CRITERIA Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results and selected trials for inclusion. We collected data from each study for mortality, deafness, seizures and neurological disabilities. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not. MAIN RESULTS Four trials were included comprising 1091 participants. All compared glycerol (a water-soluble sugar alcohol) with a control; in three trials this was a placebo, and in one a small amount of 50% dextrose. Three trials included comparators of dexamethasone alone or in combination with glycerol. As dexamethasone appeared to have no modifying effect, we aggregated results across arms where both treatment and control groups received corticosteroids and where both treatment and control groups did not.Compared to placebo, glycerol may have little or no effect on death in people with bacterial meningitis (RR 1.09, 95% confidence interval (CI) 0.89 to 1.33, 1091 participants, four trials, low-quality evidence); or on death and neurological disability combined (RR 1.04, 95% CI 0.86 to 1.25).Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30, 909 participants, three trials, low-quality evidence).Glycerol may reduce the risk of subsequent deafness (RR 0.60, 95% CI 0.38 to 0.93, 741 participants, four trials, low-quality evidence). AUTHORS' CONCLUSIONS The only osmotic diuretic to have undergone randomised evaluation is glycerol. Data from trials to date have not demonstrated benefit on death, but it may reduce deafness. Osmotic diuretics, including glycerol, should not be given to adults and children with bacterial meningitis unless as part of carefully conducted randomised controlled trial.
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Affiliation(s)
- Emma C B Wall
- International Health Group, Liverpool School of Tropical Medicine, Liverpool, UK.
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Abstract
BACKGROUND The sudden loss of blood supply in ischemic stroke is associated with the increase of calcium ions within neurons. Inhibiting this increase could protect neurons and hence might reduce neurological impairment, disability and handicap after stroke. OBJECTIVES To determine whether calcium antagonists reduce the risk of death or dependency after acute ischemic stroke. To investigate the influence of different drugs, dosages, routes of administration, time intervals after stroke and trial design on the risk of a primary outcome. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (January 2012), MEDLINE (1950 to December 2011), EMBASE (1980 to December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2011 issue 4) and four Chinese databases (December 2011): Chinese Biological Medicine Database (CBM-disc), China National Knowledge Infrastructure (CNKI), Chinese scientific periodical database of VIP information and Wanfang Data. We also contacted trialists and researchers. SELECTION CRITERIA All truly randomized trials comparing a calcium antagonist with control in patients with acute ischemic stroke. DATA COLLECTION AND ANALYSIS Two authors assessed all trials and extracted the data. We used death or dependency at the end of long-term follow-up (at least three months) in activities of daily living as the primary outcome. Analyses were, if possible, intention-to-treat. MAIN RESULTS We included 34 trials including 7731 patients. There was no effect of calcium antagonists on the primary outcome (risk ratio (RR) 1.05; 95% confidence interval (CI) 0.98 to 1.13), or on death at the end of follow-up (RR 1.07, 95% CI 0.98 to 1.17). Comparisons of different doses of nimodipine suggested that the highest doses were associated with poorer outcome. AUTHORS' CONCLUSIONS No evidence is available using calcium antagonists in patients with acute ischemic stroke is effective.
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Affiliation(s)
- Jing Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Zsuga J, Gesztelyi R, Kemeny-Beke A, Fekete K, Mihalka L, Adrienn SM, Kardos L, Csiba L, Bereczki D. Different effect of hyperglycemia on stroke outcome in non-diabetic and diabetic patients--a cohort study. Neurol Res 2012; 34:72-9. [PMID: 22196865 DOI: 10.1179/1743132811y.0000000062] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Relationship between hyperglycemia and stroke outcome is unclear, partly due to the small sample size in most studies, and partly due to lack of consensus concerning the cutoff level for hyperglycemia. METHODS In a cohort study, we investigated whether on-admission hyperglycemia is an independent predictor for 30-day case fatality by analyzing data of 2496 consecutive computed tomography (CT) verified acute ischemic stroke patients (2077 non-diabetic and 419 diabetic) included in the prospective, hospital-based Debrecen Stroke Database. Instead of using an arbitrary cutoff level for hyperglycemia, quartiles of on-admission glucose level were used for Kaplan-Meier survival curves and Cox proportional hazard modeling. RESULTS The four quartiles of serum glucose level were in the range as follows: <5.2 mmol/l, 5.201-6.1 mmol/l, 6.101-7.5 mmol/l, and >7.501 mmol/l (n = 664, 618, 597, and 617, respectively). Among all 2496 participants, the adjusted hazard ratios for death increased with each quartile of admission glucose 1.96 [95% confidence interval (CI): 1.07-3.60; P = 0.03], 1.56 (95% CI: 0.83-2.94; P = 0.17), and 3.04 (95% CI: 1.70-5.44; P < 0.0001) for the second, third, and fourth quartiles, respectively). Upon stratification with respect to diabetes, we found similarly high risk for poor outcome among non-diabetic patients, while the risk was considerably lower among diabetic patients. DISCUSSION These data suggest that even mild elevation of on-admission glucose levels is an independent predictor of 30-day case fatality. So, we propose that the ideal target blood glucose level is lower for non-diabetic than diabetic patients.
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Affiliation(s)
- Judit Zsuga
- Department of Ophthalmology, Faculty of Medicine, University of Debrecen, Hungary
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16
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Chamorro A, Vila N, Blanc R, Saiz A, Ascaso C, Deulofeu R. The prognostic value of the acute-phase response in stroke recurrence. Eur J Neurol 2011. [DOI: 10.1111/j.1468-1331.1997.tb00389.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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17
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Adams HP. Clinical Scales to Assess Patients with Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Wall ECB, Ajdukiewicz KMB, Heyderman RS, Garner P. Osmotic therapies as adjuncts to antibiotics for acute bacterial meningitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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19
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Dokumentation, Messung und Qualitätsmanagement. NeuroRehabilitation 2010. [DOI: 10.1007/978-3-642-12915-5_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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20
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Bereczki D, Mihálka L, Fekete I, Valikovics A, Csépány T, Fülesdi B, Bajkó Z, Szekeres C, Fekete K, Csiba L. The Debrecen Stroke Database: demographic characteristics, risk factors, stroke severity and outcome in 8088 consecutive hospitalised patients with acute cerebrovascular disease. Int J Stroke 2009; 4:335-9. [PMID: 19765120 DOI: 10.1111/j.1747-4949.2009.00332.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND High stroke mortality in central-eastern European countries might be due to higher stroke incidence, more severe strokes or less effective acute care than in countries with lower mortality rate. Hospital databases usually yield more detailed information on risk factors, stroke severity and short-term outcome than population-based registries. PATIENTS AND METHODS The Debrecen Stroke Database, data of 8088 consecutively hospitalised patients with acute cerebrovascular disease in a single stroke centre in East Hungary between October 1994 and December 2006, is analysed. Risk factors were recorded and stroke severity on admission was scored by the Mathew stroke scale. The modified Glasgow outcome scale was used to describe patient condition at discharge. RESULTS Mean age was 68+/-13 years, 11.4% had haemorrhagic stroke. The rate of hypertension on admission was 79% in men, and 84% in women, 40.3% of men and 19.8% of women were smokers, and 34% of all patients had a previous cerebrovascular disease in their history. Case fatality was 14.9%, and 43% had some disability at discharge. Outcome at discharge was worse with higher age, higher glucose, higher blood pressure, higher white cell count and erythrocyte sedimentation rate and more severe clinical signs on admission. In multivariate analysis admission blood pressure lost its significance in predicting outcome. CONCLUSIONS In this large Hungarian stroke unit database hypertension on admission, smoking and previous cerebrovascular disease were more frequent than in most western databases. These findings indicate major opportunities for more efficient stroke prevention in this and probably other eastern European countries.
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Affiliation(s)
- D Bereczki
- Department of Neurology, Health Science and Medical Center, University of Debrecen, Debrecen, Hungary.
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21
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Tomassoni D, Lanari A, Silvestrelli G, Traini E, Amenta F. Nimodipine and Its Use in Cerebrovascular Disease: Evidence from Recent Preclinical and Controlled Clinical Studies. Clin Exp Hypertens 2009; 30:744-66. [DOI: 10.1080/10641960802580232] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Mellbring G, Strand T, Eriksson S. Venous thromboembolism after cerebral infarction and the prophylactic effect of dextran 40. ACTA MEDICA SCANDINAVICA 2009; 220:425-9. [PMID: 2433901 DOI: 10.1111/j.0954-6820.1986.tb02791.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In a prospective study of the incidence of deep vein thrombosis (DVT) after stroke, and the prophylactic effect of dextran, 50 patients, admitted with a diagnosis of cerebral infarction with paresis of the lower extremity within the first 48 hours, were randomly allocated to treatment or non-treatment groups. The treatment group received 500 ml of dextran 40 on admission and on days 1 and 2, and 250 ml on days 4 and 6. Venesection was performed on admission and if necessary on day 1. The control group received no dextran or venesection. DVT was diagnosed with the 125I-fibrinogen test during the first ten days. The incidence of DVT was 54% in the treatment group and 50% in the control group. There were no statistically significant differences between the groups regarding number of DVTs needing treatment, number of positive scanning points or number of days for scan to become positive. Lethal pulmonary emboli occurred in one treated and in three control patients, respectively. Age and progress of neurologic symptoms predisposed for the development of DVT. The high incidence of DVT in stroke patients indicates the need for prophylactic routines.
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Adams HP, Lyden P. Assessment of a patient with stroke neurological examination and clinical rating scales. HANDBOOK OF CLINICAL NEUROLOGY 2009; 94:971-1009. [PMID: 18793885 DOI: 10.1016/s0072-9752(08)94048-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Harold P Adams
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
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Zsuga J, Gesztelyi R, Juhasz B, Kemeny-Beke A, Fekete I, Csiba L, Bereczki D. Prior transient ischemic attack is independently associated with lesser in-hospital case fatality in acute stroke. Psychiatry Clin Neurosci 2008; 62:705-12. [PMID: 19068008 DOI: 10.1111/j.1440-1819.2008.01874.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM Ischemic preconditioning has been well established in healthy human hearts, but limited information is available about its occurrence or its integrity in the brain. The aim of the present study was therefore to investigate whether a prior cerebral ischemic episode (stroke or transient ischemic attack [TIA]) is able to confer protection against ischemic stroke, reflected by in-hospital case fatality. METHODS A total of 2874 acute stroke patients included in the prospective, hospital-based Debrecen Stroke Database were studied, of whom 673 had previous stroke and 195 had prior TIA. RESULTS Following adjustment for active confounders, TIA but not stroke in the history was associated with decreased odds for in-hospital case fatality (odds ratio, 0.53; 95% confidence interval: 0.29-0.98; P = 0.041). The fitness of the final multiple regression model was good (Hosmer-Lemeshow goodness-of-fit chi(2) statistic (P = 0.328). CONCLUSION TIA may have an ischemic preconditioning effect in the human brain.
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Affiliation(s)
- Judit Zsuga
- Department of Neurology, University of Debrecen, Hungary.
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26
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Bhalla A, Hargroves D. Does early medical intervention have a role in the management of intracerebral haemorrhage? Int J Clin Pract 2008; 62:633-41. [PMID: 18205794 DOI: 10.1111/j.1742-1241.2007.01691.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION An increasing amount of research is now being directed towards the medical treatment of patients who have suffered an intracerebral haemorrhage (ICH). Despite this, no routine drug treatment to date has been shown to be unequivocally effective in unselected patients. TREATMENTS/DISCUSSION Approaches to treatment are based upon our understanding of the pathophysiological sequelae following ICH. Strategies to reduce haematoma growth, subsequent oedema formation and perihaematoma ischaemia are key targets for further research. Whether these therapies become valuable tools for the future is as yet unclear. Until then, the mainstay of the medical management of ICH remains individualised care. CONCLUSIONS There is now a pressing need for large prospective randomised controlled trials to determine the effectiveness of pharmacological therapies for this condition.
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Affiliation(s)
- A Bhalla
- St Helier Stroke Service, Epsom and St Helier University Hospitals NHS Trust, Surrey, UK.
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27
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Bessenyei M, Fekete I, Csiba L, Bereczki D. Characteristics of 4 stroke scales for the detection of changes in clinical signs in the acute phase of stroke. J Stroke Cerebrovasc Dis 2007; 10:70-8. [PMID: 17903803 DOI: 10.1053/jscd.2001.24655] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2000] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES Detection of minor changes in clinical signs of stroke may be of interest when evaluating treatment interventions. This study analyzes the internal structure of four frequently used stroke scales and compares them for their sensitivity to detect changes in neurologic signs in the first week after acute stroke. METHODS A cohort of 77 hospitalized acute stroke patients was scored by the Mathew, the National Institutes of Health (NIH), the Scandinavian, and the Orgogozo scales within 48 hours of hospital admission and again 7 days later. RESULTS Scores on different scales correlated well with each other (range of absolute value of Spearman R, .82-.91; P <.001 in all comparisons). Scales reflected significant changes from entry to reexamination: P = .0013 for the Scandinavian scale (P = .004 for prognostic and P = .009 for long-term items, respectively); P = .00009 for the Orgogozo scale; P = .000007 for the Mathew scale; and P < .000001 for the NIH scale. This difference in sensitivity coincided with the number of factors extracted by principal component analysis: higher sensitivity of a scale was associated with a larger number of factors. Initial scores differed significantly among patients who were discharged, patients who died, and patients who remained hospitalized 7 days after the first examination (Kruskal-Wallis ANOVA, P < .01 for all scales). CONCLUSIONS There are considerable differences in the internal structure of the different scales as reflected by the different number of factors extracted from the scale items. The application of the NIH scale is recommended for the most sensitive detection of changes in stroke signs.
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Affiliation(s)
- M Bessenyei
- Department of Neurology, Health Science and Medical Center, University of Debrecen, Hungary
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28
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Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM. Guidelines for the Early Management of Adults With Ischemic Stroke. Circulation 2007; 115:e478-534. [PMID: 17515473 DOI: 10.1161/circulationaha.107.181486] [Citation(s) in RCA: 657] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose—
Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.
Methods—
Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.
Results—
Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.
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Gur AY, Lampl Y, Gross B, Royter V, Shopin L, Bornstein NM. A new scale for assessing patients with vertebrobasilar stroke—the Israeli Vertebrobasilar Stroke Scale (IVBSS): Inter-rater reliability and concurrent validity. Clin Neurol Neurosurg 2007; 109:317-22. [PMID: 17254701 DOI: 10.1016/j.clineuro.2006.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2006] [Revised: 11/15/2006] [Accepted: 12/19/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Most of existing stroke scoring systems have limited ability to evaluate patients with cerebrovascular events in the vertebrobasilar territory. We devised a new scale, the Israeli Vertebrobasilar Stroke Scale (IVBSS) in order to directly and more accurately assess clinical deficits of patients with vertebrobasilar stroke. The present study measured the reliability and validity of the IVBSS. PATIENTS AND METHODS Forty-three patients (mean age+/-S.D., 70.9+/-8.8 years, 27 males) with vertebrobasilar stroke were evaluated with the IVBSS (11 items), the NIH Stroke Scale (NIHSS) and the disability modified Rankin Scale (mRS) by independent examiners. Interobserver agreement was rated by weighted kappa statistics for each item and the total IVBSS score. Validity was examined with Spearman rank coefficients to compare the IVBSS with NIHSS and mRS. RESULTS Excellent reliability was demonstrated between the examiners for almost each item and the total score of the IVBSS (kappa>0.75). The total IVBSS score was strongly associated with NIHSS and mRS results (r=0.80 and 0.76, respectively; P<0.0002). CONCLUSIONS The IVBSS is a valid instrument that allows the assessment of patients with vertebrobasilar stroke with high reliability. Further observations are warranted to determine the predictive value of the IVBSS for stroke outcome.
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Affiliation(s)
- Alexander Y Gur
- Department of Neurology, Tel Aviv Sourasky Medical Center (TASMC), Tel Aviv, Israel.
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30
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Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007; 38:1655-711. [PMID: 17431204 DOI: 10.1161/strokeaha.107.181486] [Citation(s) in RCA: 1511] [Impact Index Per Article: 88.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included. METHODS Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years. RESULTS Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.
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Kerenyi L, Mihalka L, Csiba L, Bacso H, Bereczki D. Role of hyperlipidemia in atherosclerotic plaque formation in the internal carotid artery. JOURNAL OF CLINICAL ULTRASOUND : JCU 2006; 34:283-8. [PMID: 16788960 DOI: 10.1002/jcu.20233] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
PURPOSE The role of hyperlipidemia in atherosclerotic changes of the carotid artery is controversial. The aims of this retrospective study were to assess (1) the relationship between total serum cholesterol and triglyceride and the grade of internal carotid artery stenosis and (2) whether total serum cholesterol and triglyceride levels are independent risk factors for internal carotid artery atherosclerosis. METHODS The files of 1,934 acute ischemic stroke patients were investigated retrospectively. The atherosclerotic involvement of the internal carotid artery was assessed via duplex sonography as percent of stenosis and was graded as follows: group 1, no plaque; group 2, <30% stenosis; group 3, 30-99% stenosis; and group 4, occlusion. RESULTS The mean age of the patients was 66.9 +/- 12.8 years. Patients without any plaque had significantly lower cholesterol levels compared with those with any degree of internal carotid artery stenosis. Univariate analysis revealed that age (p < 0.001), sex (p < 0.001), hypertension (p < 0.05), cholesterol (p < 0.01), triglycerides(p < 0.05), and smoking (p < 0.001) were significant contributors to atherosclerosis. In the ordinal logistic regression model, age (p < 0.001), sex (p < 0.001), smoking(p < 0.001), and cholesterol (p < 0.05) remained independent predictors of internal carotid artery atherosclerosis. CONCLUSIONS Total serum cholesterol level seems to be an independent risk factor of atherosclerosis in the carotid artery.
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Affiliation(s)
- Levente Kerenyi
- Department of Neurology, University of Debrecen, Medical and Health Science Center, Hungary
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Abstract
BACKGROUND Ginkgo biloba extract is widely used in the treatment of acute ischaemic stroke in China. We aimed to assess the evidence from randomised controlled trials and quasi-randomised controlled trials on the use of Ginkgo biloba extract in acute ischaemic stroke. OBJECTIVES The primary objective was to determine whether Ginkgo biloba extract improves functional outcome without causing undue harm in patients with acute ischaemic stroke. Secondary objectives were to assess the effect of Ginkgo biloba extract on neurological impairment and quality of life. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched October 2004), the Trials Register of the Cochrane Complementary Medicine Field (last searched October 2004) and the Chinese Stroke Trials Register (last searched June 2004). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to August 2004), EMBASE (1980 to June 2004), AMED (1985 to May 2002) and the China Biological Medicine Database (CBM-disc, 1979 to August 2004). We searched relevant clinical trials and research registers and contacted pharmaceutical companies and researchers in an effort to identify further published and unpublished studies. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled clinical trials comparing Ginkgo biloba extract with placebo or open control (no placebo) in patients with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS Fourteen trials were identified, of which 10 trials (792 patients) were included. Four trials are awaiting assessment. In the 10 included trials follow up was performed at 14 to 35 days after stroke. In all studies neurological outcome was assessed but none of them reported on disability (activities of daily living function) or quality of life. Only three trials reported adverse events. In nine trials, all of them assessed to be of inferior quality, significant improvement in neurological deficit at the end of the treatment was used as the outcome measure. When analysing these trials together, Ginkgo biloba extract was associated with a significant increase in the number of improved patients (Peto odds ratio (OR) 2.66; 95% confidence interval (CI) 1.79 to 3.94). One placebo-controlled trial, assessed to be of good quality, reported neurological outcome as a continuous variable. It failed to show an improvement of neurological deficit at the end of treatment (weighted mean difference (fixed) 0.81; 95% CI -8.9 to 10.52). No deaths or major adverse events were reported during the follow-up period. AUTHORS' CONCLUSIONS There was no convincing evidence from trials of sufficient methodological quality to support the routine use of Ginkgo biloba extract to promote recovery after stroke. High-quality and large-scale randomised controlled trials are needed to test its efficacy.
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Affiliation(s)
- X Zeng
- Sichuan Provincial Hospital, Department of Neurology, Chengdu, China 610072.
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Krainik A, Hund-Georgiadis M, Zysset S, von Cramon DY. Regional impairment of cerebrovascular reactivity and BOLD signal in adults after stroke. Stroke 2005; 36:1146-52. [PMID: 15879326 DOI: 10.1161/01.str.0000166178.40973.a7] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Comparative studies across populations using functional magnetic resonance imaging (fMRI) rely on a similar relationship between blood oxygen level-dependent (BOLD) signal and neural activity. However, in elderly and patients with cerebrovascular disease, impaired cerebrovascular dynamics and neurovascular coupling may explain differences in BOLD contrast across populations and brain regions. The purpose of the study was to determine whether poststroke patients have regional heterogeneities of cerebrovascular reactivity (CVR) and their potential influence on voxel-wise motor-related BOLD signal. METHODS Using fMRI, 8 fully recovered patients from stroke in the frontal lobe without cortical lesion in the regions of interest located in the primary sensorimotor cortex (SMC), supplementary motor area (SMA), and cerebellum (CRB) were compared with 8 healthy subjects. Motor-related BOLD signal changes (%SC) were evaluated during simple unimanual and bimanual tasks, and CVR was evaluated during hyperventilation (HV). Analyses were performed using Lipsia software in SMC, SMA, and CRB. RESULTS In controls, amplitudes of BOLD signal were symmetrical in all regions of interest during all motor tasks and HV. In patients, %SC was decreased in SMC and SMA of the lesioned hemisphere despite their apparent anatomical integrity for all tasks. Impaired CVR was a predictor of impaired motor-related BOLD response in the SMC during contralateral movements (beta=-1.87; R=-0.75; P=0.03). CONCLUSIONS These preliminary findings suggest that CVR heterogeneities may account for task-related BOLD signal changes in patients after stroke.
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Affiliation(s)
- Alexandre Krainik
- Max-Plack Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.
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Moretti R, Torre P, Antonello RM, Cattaruzza T, Cazzato G. Olanzapine as a possible treatment of behavioral symptoms in vascular dementia: risks of cerebrovascular events. J Neurol 2005; 252:1186-93. [PMID: 15809822 DOI: 10.1007/s00415-005-0830-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2004] [Revised: 01/27/2005] [Accepted: 02/02/2005] [Indexed: 12/27/2022]
Abstract
Behavioral problems produce excess disability, potentially devastating in cognitively impaired patients. These behavioral symptoms can be a major cause of stress, anxiety and concern for caregivers. While psychotropic drugs are frequently used to control these symptoms, they have the potential for significant side effects, which include sedation, disinhibition, depression, falls, incontinence, parkinsonism and akathisia. We followed up (for 12 months) a group of 346 consecutive outpatients, with a diagnosis of subcortical vascular dementia or multi-infarctual dementia. Patients eligible for this open-label study were required to have behavioral problems (BPSD). Patients were divided into two groups, Group A received olanzapine 2.5-7.5 mg/day while Group B received typical antipsychotics. Patients in both groups were allowed to continue any previous therapy. Patients in both groups were significantly improved in their BPSD. Our patients had a host of medical conditions and received numerous concomitant medications. Given the potential complications associated with these therapeutic agents, these patients tolerated olanzapine quite well. On examination of consequences of adverse events, particularly somnolence, postural instability, and postural hypotension, it appeared that cerebrovascular events were not present. Moreover, no anticholinergic effect was recorded. These findings suggest that olanzapine could be a safe and effective treatment even for elderly population in suitable doses and receiving the adequate follow-up.
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Affiliation(s)
- Rita Moretti
- Dip. di Medicina Clinica e Neurologia, UCO di Neurologia, Università degli Studi di Trieste, Ospedale di Cattinara, 34149 Trieste, Italy.
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Alexandrova M, Bochev P, Markova V, Bechev B, Popova M, Danovska M, Simeonova V. Dynamics of free radical processes in acute ischemic stroke: influence on neurological status and outcome. J Clin Neurosci 2004; 11:501-6. [PMID: 15177393 DOI: 10.1016/j.jocn.2003.10.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2003] [Accepted: 10/06/2003] [Indexed: 11/28/2022]
Abstract
The dynamics of free radical processes during the acute stage of ischemic stroke and their relationship with the clinical status of patients were studied. An enhanced extracellular generation of reactive oxygen species (ROS) by peripheral phagocytes was observed in severe stroke patients during the whole acute stage. This generation correlated positively with the size of infarct, the severity of neurological deficit and handicap and correlated negatively with the improvement of the neurological status of patients. An increase in the activity of two enzymes from the antioxidant defense mechanism, catalase and glutathione peroxidase, was registered during the whole acute phase of stroke, regardless of its severity. The concentration of lipid peroxidation products increased over time. Blood concentration of thiobarbituric acid-reactive material (TBARM) correlated positively with the size of infarct, the severity of neurological deficit and handicap. In conclusion, extracellular ROS generation by phagocytes and blood TBARM concentration could be used as indicators for stroke outcome.
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Abstract
BACKGROUND Brain oedema is a major cause of early death after stroke. A 10% solution of glycerol is a hyperosmolar agent that is claimed to reduce brain oedema. OBJECTIVES To determine whether intravenous (I.V.) glycerol treatment in acute stroke, either ischaemic or haemorrhagic, influences death rates and functional outcome in the short or long term, and whether the treatment is safe. SEARCH STRATEGY The Cochrane Stroke Group trials register was searched (January 2003), and some trialists were personally contacted. SELECTION CRITERIA All completed, randomised and quasi-randomised, controlled, published and unpublished comparisons, evaluating clinical outcome in which I.V. glycerol treatment was initiated within the first days after stroke onset. DATA COLLECTION AND ANALYSIS Two reviewers independently applied the inclusion criteria, assessed the trial quality and extracted data and this was checked with all co-reviewers. Death from all causes, functional outcome, and adverse effects were analysed. MAIN RESULTS Eleven completed, randomised trials comparing I.V. glycerol and control were considered. Analysis of death during the scheduled treatment period for acute ischaemic and/or haemorrhagic stroke was possible in 10 trials where 482 glycerol treated patients were compared with 463 control patients. Glycerol was associated with a non-significant reduction in the odds of death within the scheduled treatment period (Odds Ratio (OR) 0.78, 95% Confidence Intervals (CI) 0.58 to 1.06). Among patients with definite or probable ischaemic stroke, glycerol was associated with a significant reduction in the odds of death during the scheduled treatment period (OR 0.65, 95% CI 0.44 to 0.97). However, at the end of the scheduled follow up period, there was no significant difference in the odds of death (OR 0.98, 95% CI 0.73 to 1.31). Functional outcome was reported in only two studies but there were non-significantly more patients who had a good outcome at the end of scheduled follow up (OR 0.73, 95% CI 0.37 to 1.42). Haemolysis seems to be the only relevant adverse effect of glycerol treatment. REVIEWERS' CONCLUSIONS This systematic review suggests a favourable effect of glycerol treatment on short term survival in patients with probable or definite ischaemic stroke but the confidence intervals were wide and the magnitude of the treatment effect may be only minimal. Due to the relatively small number of patients, and that the trials were performed in the pre-CT era, the results must be interpreted cautiously. The lack of evidence of benefit in long term survival does not support the routine or selective use of glycerol treatment in patients with acute stroke.
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Affiliation(s)
- Enrico Righetti
- USL 2Servizio di Neurologia e Ictus Via Cestellini PerugiaItaly06087
| | | | - Teresa Anna Cantisani
- Azienda Ospedaliera PerugiaNeurofisiopatologiaS. Andrea Delle FratteSan SistoPerugiaUMBRIAItaly06156
| | - Roberto Sterzi
- Azienda Ospedaliera Sant'AnnaDirettore UO NeurologiaVia Napoleona, 50ComoItaly22100
| | - Gudrun Boysen
- Bispebjerg HospitalDepartment of Neurology, University of CopenhagenBispebjerg Bakke 23DK 2400 Copenhagen NVDenmark
| | - Stefano Ricci
- USL 2Servizio di Neurologia e IctusVia Cestellini PerugiaItaly06087
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Ohtsuru I, Eto F, Wada N, Saotome I, Furuichi T. New reliable and valid motor assessment scale for stroke patients: Hemiplegic motor behavior tests. Geriatr Gerontol Int 2003. [DOI: 10.1046/j.1444-1586.2001.00010.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Weinberger J, Frishman WH, Terashita D. Drug therapy of neurovascular disease. Cardiol Rev 2003; 11:122-46. [PMID: 12705843 DOI: 10.1097/01.crd.0000053459.09918.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Recent advances in the prevention and pharmacotherapy of cerebrovascular disease have provided more favorable clinical outcomes. For the treatment of an acute ischemic stroke, the early use of thrombolytic agents can reduce the degree of brain damage while improving functional outcomes. However, trials evaluating various classes of other neuroprotective agents have not shown benefit to date. For the prevention of second stroke, the use of antiplatelet drugs, HMG-CoA reductase inhibitors, and angiotensin-converting enzyme inhibitors with a diuretic have shown benefit in reducing new events. In patients with underlying heart disease or atrial fibrillation, warfarin appears to be the drug of choice in preventing stroke. Early treatment of hemorrhagic stroke with calcium channel blockers can improve the functional outcome. Innovative therapies are now available for the treatment of migraine and vascular dementia. Primary prevention of stroke remains the optimal therapeutic strategy and includes treatment of systemic hypertension and hypercholesterolemia.
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Affiliation(s)
- Jesse Weinberger
- Department of Neurology, Mt. Sinai Medical Center, New York, New York, USA.
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Adams HP, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ. Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003; 34:1056-83. [PMID: 12677087 DOI: 10.1161/01.str.0000064841.47697.22] [Citation(s) in RCA: 647] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Szatmári S, Pascu I, Mihálka L, Mulesa SV, Fekete I, Fülesdi B, Csiba L, Zselyuk G, Szász J, Gebefügi J, Nicolescu S, Văsieşiu D, Smolanka VI, Bereczki D. The Mureş-Uzhgorod-Debrecen study: a comparison of hospital stroke services in Central-Eastern Europe. Eur J Neurol 2002; 9:293-6. [PMID: 11985638 DOI: 10.1046/j.1468-1331.2002.00402.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Stroke mortality is extremely high in Central-Eastern European countries. The high rate of risk factors and differences in health care services might be among the factors resulting in high stroke morbidity and mortality in this region. As only few prospectively collected information are available from this region, we decided to evaluate some characteristics of stroke services in neurological departments of a Romanian, a Ukrainian and a Hungarian city in the framework of the Mureş-Uzhgorod-Debrecen comparative epidemiological study. We registered demographic data, the absence or presence of the most important risk factors, and clinical signs on admission and at discharge. We recorded the application of various diagnostic methods, stroke treatment and recommendations for secondary prevention. Follow-up is planned after 30 days and after 1 year. The paper summarizes the methodology of this prospective epidemiological study of stroke patients hospitalized in neurological departments in Târgu Mureş, Uzhgorod and Debrecen, three Central-Eastern European cities in Romania, Ukraine and Hungary, respectively.
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Affiliation(s)
- S Szatmári
- Department of Neurology, University of Medicine and Pharmacy, Târgu Mures, Romania, Hungary
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Chamorro A, Obach V, Cervera A, Revilla M, Deulofeu R, Aponte JH. Prognostic significance of uric acid serum concentration in patients with acute ischemic stroke. Stroke 2002; 33:1048-52. [PMID: 11935059 DOI: 10.1161/hs0402.105927] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We sought to assess in 881 consecutive patients with acute ischemic stroke the clinical relevance in regard to functional outcome of the natural antioxidant uric acid measured at hospital admission. METHODS Patients had serum uric acid (mg/dL) measured by standard procedures 18.2+/-15.5 hours from clinical onset. At hospital discharge (11.0+/-6.0 days), neurological impairment was classified as moderate/severe (Mathew score < or =75; n=304) or mild/absent (Mathew score >75; n=577). Demographics, atherosclerotic risk factors, history of organ disease, baseline neurological score, stroke subtype, infarction size, renal function, aspirin use before stroke, stroke therapy, diuretic use, and laboratory markers, including erythrocyte sedimentation rate, were analyzed in both outcome groups with the use of backward logistic regression. RESULTS Increased uric acid values were found in men, hypertensives, alcohol drinkers, and patients with coronary, pulmonary, or renal diseases. Diabetic patients had lower uric acid levels on admission. Uric acid was directly associated with hematocrit (P=0.001), sodium (P=0.001), creatinine (P=0.001), and triglycerides (P=0.001) and inversely related with nonfasting glucose (P=0.001) levels. Neurological impairment on admission (P=0.001) and final infarction size on CT/MRI (P=0.01) were also inversely associated with uric acid. A logistic regression adjusted for confounders confirmed the following independent (odds ratio, 95% CI) good outcome predictors: age (0.97, 0.96 to 0.99), Mathew score on admission (1.14, 1.12 to 1.17), erythrocyte sedimentation rate (0.98, 0.97 to 0.99), infarction volume (0.98, 0.98 to 0.99), and uric acid (1.12, 1.00 to 1.25). CONCLUSIONS In patients with acute ischemic stroke, there is a 12% increase in the odds of good clinical outcome for each milligram per deciliter increase of serum uric acid. This finding reinforces the relevance of oxidative damage in ischemic stroke.
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Affiliation(s)
- Angel Chamorro
- Neurology Service and Institut d'Investigació Biomédica August Pi i Sunyer, Hospital Clínic, Barcelona, Spain.
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Abstract
The reduction of blood flow to parts of the brain is the cause of ischemic stroke leading to functional deficits and, if prolonged, to irreversible neurological and morphological defects. The fast reperfusion, therefore is the most important therapeutic strategy and was proven to be effective in clinical trials. Steps to intervene with secondary biochemical, molecular, or inflammatory disturbances were not successful so far. Since direct therapeutic interventions are limited, the general management of the stroke victim is of utmost importance--and was shown to be most successful in dedicated stroke units. Acute therapeutic interventions in ischemic stroke can only be successful as long as tissue in the area of the ischemic compromise is still viable. The area of irreversible damage can be identified and distinguished from the penumbral zone, i.e., tissue with impaired function but preserved morphology by functional imaging modalities, like positron emission tomography (PET) or perfusion-(PW) and diffusion-weighted (DW) magnetic resonance imaging (MRI). In such studies it was demonstrated that a large portion of the final infarct is irreversibly affected in the first few hours in many patients. A considerable tissue volume is viable but critically hypoperfused; a smaller portion of the final infarct is sufficiently perfused and in this area secondary and delayed biochemical and molecular mechanisms contribute to the damage. Based on this concept the improvement of perfusion within the time window of opportunity must be the primary goal in treatment of ischemic stroke, and neuroprotective and other strategies can only play a supportive and additive role. That this is the case can be seen from the results of many controlled therapeutic trials, in which up to now only thrombolytic therapy with a 3 h time window for systemic and a 6 h time window for intraarterial application proved its efficacy, whereas all trials with neuroprotective, anti-inflammatory or anti-apoptotic strategies failed. Since the direct treatment strategies are limited the acute management of stroke victims is of utmost importance: This can be achieved optimally in dedicated stroke units in which the outcome was significantly improved over the regular care. It is still to be investigated if invasive strategies--e.g., craniectomy and hypothermia--or the combination of reperfusion and neuroprotective therapy can improve the outcome after ischemic stroke.
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Affiliation(s)
- W D Heiss
- Max-Planck-Institut für neurologische Forschung and Neurologische Universitätsklinik, Köln, Federal Republic of Germany.
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Gotoh F, Terayama Y, Amano T. Development of a novel, weighted, quantifiable stroke scale: Japan stroke scale. Stroke 2001; 32:1800-7. [PMID: 11486108 DOI: 10.1161/01.str.32.8.1800] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Several stroke scales are available for estimation of the severity of stroke, but none of them provides information regarding the relative weights of the observed variables. To define an integrated severity of stroke, we developed a quantifiable stroke scale with weighted variables that apply conjoint analysis to calculate the relative weight of each item. METHODS We selected 10 variables (consciousness, language, neglect, hemianopsia, gaze, pupillary abnormality, facial palsy, plantar reflex, sensation, and weakness) based on the multivariate analysis of the Keio Stroke Patient Database Battery. The variables were categorized and evaluated for their distribution and sensitivity. The categorizations were then modified and rechecked. The procedure was repeated until the appropriate categorization was obtained from 198 patients. A temporary stroke scale without weight was then formulated, and the reliability of the scale was examined and revised with 80 new stroke patients. As a next step, 150 neurologists were asked to rank a set of 27 virtual patients, each with a different combination of variables, according to severity. From these rankings, conjoint analysis was used to derive utility scores (weights) for each factor level. RESULTS The relative weights of each of the factors were as follows: consciousness 49.8%, language 9.9%, weakness of lower extremity 7.3%, pupillary abnormality 6.8%, gaze palsy 5.6%, weakness of arm 4.3%, weakness of hand 3.7%, neglect 3.7%, facial palsy 2.4%, plantar reflex 2.2%, hemianopsia 2.2%, and sensory impairment 2.1%. The total score for a patient could be calculated from the sum of the scores for each of the variables ranging from -0.38 to 27.86. Scoring of 100 patients with acute stroke was carried out, and the changes in scores were followed for validation. Longitudinal clinical monitoring of the patients correlated well with the scores in each patient. The interrater and intrarater reliabilities of the scale were excellent (weighted kappa 0.83; Cronbach's alpha 0.998). CONCLUSIONS The Japan Stroke Scale is a parametric stroke scale that provides a quantitative measure of the severity of stroke. Each of the variables of the scale has a relative weight according to the severity of stroke. Reliability and responsiveness were proved to be excellent. The present data revealed a potentiality for the Japan Stroke Scale to be a universally accepted and reliable standardized system from the clinimetrical point of view.
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Affiliation(s)
- F Gotoh
- Department of Neurology, School of Medicine, Keio University, Tokyo, Japan.
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Lyden PD, Lu M, Levine SR, Brott TG, Broderick J. A modified National Institutes of Health Stroke Scale for use in stroke clinical trials: preliminary reliability and validity. Stroke 2001; 32:1310-7. [PMID: 11387492 DOI: 10.1161/01.str.32.6.1310] [Citation(s) in RCA: 189] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE The National Institutes of Health Stroke Scale (NIHSS) is accepted widely for measuring acute stroke deficits in clinical trials, but it contains items that exhibit poor reliability or do not contribute meaningful information. To improve the scale for use in clinical research, we used formal clinimetric analyses to derive a modified version, the mNIHSS. We then sought to demonstrate the validity and reliability of the new mNIHSS. METHODS The mNIHSS was derived from our prior clinimetric studies of the NIHSS by deleting poorly reproducible or redundant items (level of consciousness, face weakness, ataxia, dysarthria) and collapsing the sensory item into 2 responses. Reliability of the mNIHSS was assessed with the certification data originally collected to assess the reliability of investigators in the National Institute of Neurological Disorders and Stroke (NINDS) rtPA (recombinant tissue plasminogen activator) Stroke TRIAL Validity of the mNIHSS was assessed with the outcome results of the NINDS rtPA Stroke Trial: RESULTS Reliability was improved with the mNIHSS: the number of scale items with poor kappa coefficients on either of the certification tapes decreased from 8 (20%) to 3 (14%) with the mNIHSS. With the use of factor analysis, the structure underlying the mNIHSS was found identical to the original scale. On serial use of the scale, goodness of fit coefficients were higher with the mNIHSS. With data from part I of the trial data, the proportion of patients who improved >/=4 points within 24 hours after treatment was statistically significantly increased by tPA (odds ratio, 1.3; 95% confidence limits, 1.0, 1.8; P=0.05). Likewise, the odds ratio for complete/nearly complete resolution of stroke symptoms 3 months after treatment was 1.7 (95% confidence limits, 1.2, 2.6) with the mNIHSS. Other outcomes showed the same agreement when the mNIHSS was compared with the original scale. The mNIHSS showed good responsiveness, ie, was useful in differentiating patients likely to hemorrhage or have a good outcome after stroke. CONCLUSIONS The mNIHSS appears to be identical clinimetrically to the original NIHSS when the same data are used for validation and reliability. Power appears to be greater with the mNIHSS with the use of 24-hour end points, suggesting the need for fewer patients in trials designed to detect treatment effects comparable to rtPA. The mNIHSS contains fewer items and might be simpler to use in clinical research trials. Prospective analysis of reliability and validity, with the use of an independently collected cohort, must be obtained before the mNIHSS is used in a research setting.
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Affiliation(s)
- P D Lyden
- Department of Neurosciences, University of California at San Diego School of Medicine, USA.
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Abstract
OBJECTIVE To evaluate the relationship between high initial blood pressure and functional outcome in patients with acute stroke. DESIGN An observational study based on the data from the Intravenous Nimodipine West European Stroke Trial (INWEST). INWEST was a placebo-controlled randomized study terminated prematurely; subsequent analysis found a correlation between diastolic BP (DBP) reduction caused by high-dose nimodipine and unfavourable outcome. Subjects. Of the 295 patients with acute ischaemic stroke (within 24 h) recruited in the INWEST, 265 were included in this analysis [n = 92 for placebo, n = 93 for low-dose nimodipine (1-mg h(-1)) and n=80 for high-dose nimodipine (2-mg h(-1))]. Definition. Initial BP was defined as BP at the time of randomization. Normal initial BP (NIBP)=systolic BP (SBP) 120-160 and DBP 60-90 mmHg (n=126). Four alternatives were defined as high initial BP (HIBP): (1) >160/90 (n=126), (2) >170/95 (n=106), (3) >180/100 (n=63), (4) >190/105 (n=45). Main outcome measures. Combined death or dependency (DD) (Barthel index < 60) at 21 days. RESULTS In multiple logistic regression analyses, the odds ratio [OR] for DD at day 21 was significantly higher in patients with any definition of HIBP than with NIBP. For all patients, OR and 95% confidence intervals [CI] for 160/90 versus NIBP=3.1, 1.3-7.3, respectively; for 170/95=3.3, 1.4-8.1; for 180/100=7.0, 2.1-22.8; for 190/105=3.7, 1.1-12.4. For only placebo patients, OR and 95% CI for 160/90=4.8, 1.2-19.3; for 170/95=4.4, 1.1-17.8; for 180/100=12.7, 2.2-74.7; for 190/105=5.6, 1.1-30.0. The outcome was similar at 24 weeks but did not reach statistical significance for the placebo patients. CONCLUSION Patients with HIBP had a poor functional outcome after acute stroke.
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Affiliation(s)
- N Ahmed
- Department of Neurology, Stroke Research Unit, Karolinska Hospital, Sweden.
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Abstract
BACKGROUND AND PURPOSE Stroke is a common disease, and many trials with calcium antagonists as possible neuroprotective agents have been conducted. The aim of this review is to determine whether calcium antagonists reduce the risk of death or dependency after acute ischemic stroke. METHODS Acute stroke trials were identified with help of the Cochrane Collaboration Stroke Group and personal contacts. All randomized trials (published and unpublished) investigating a calcium antagonist (acting on voltage-sensitive calcium channels) were included. Poor outcome, defined as death or dependency in activities of daily living, was used as main outcome. Analyses were, if possible, "intention-to-treat"; pooled relative risks with 95% CIs were calculated. RESULTS Forty-seven trials were identified, of which 29 were included (7665 patients). No effect of calcium antagonists on poor outcome at the end of follow-up (relative risk, 1.04; 95% CI, 0.98 to 1.09) or on death at end of follow-up (relative risk, 1.07; 95% CI, 0.98 to 1.17) was found. Sensitivity analyses on route of administration and time interval between stroke and start of treatment showed no effect on outcome. In subgroups of unpublished and methodologically sound trials, a statistically significant negative effect for calcium antagonists was found. This contrasts with results of published trials and trials of moderate or poor methodological quality. CONCLUSIONS The presented evidence rules out a clinically important effect of calcium antagonists after ischemic stroke. The large amount of data leads to narrow CIs with no significant heterogeneity, and the overall results are therefore likely to be statistically robust.
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Affiliation(s)
- J Horn
- Department of Neurology, Academic Medical Center, University of Amsterdam (Netherlands).
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Lampl Y, Gilad R, Geva D, Eshel Y, Sadeh M. Intravenous administration of magnesium sulfate in acute stroke: a randomized double-blind study. Clin Neuropharmacol 2001; 24:11-5. [PMID: 11290876 DOI: 10.1097/00002826-200101000-00003] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A randomized, placebo-controlled, double-blind study was performed as a pilot study to examine the benefit of the administration of magnesium sulfate given intravenously as a protective substance during the first 24 hours following a stroke. Patients who had cortical infarction in the middle cerebral artery territory with moderate to severe neurologic deficits lasting for more than 15 minutes with onset less than 24 hours were included. The patients were treated with magnesium sulfate or placebo for 5 days and examined by a blinded investigator. Patients had follow-up for 30 days. The primary efficacy variable was the proportion of patients reaching mild to moderate neurologic deficit on the Orgogozo scale (80 points) and relative functional independence on the Barthel index (60 points). Orgogozo scale and Mathew scale values were obtained on admission and days 2, 4, 8, and 30 after stroke. Barthel activities of daily living index and Rankin disability score were obtained on day 30. Forty-one patients (22 given treatment and 19 given placebo) demonstrated significant beneficial effects on the Orgogozo scale (84 +/- 11 vs. 64 +/- 10, p < 0.0001) and (83 +/- 14 vs. 70 +/- 15, p < 0.009), respectively. At the end of 1-month follow-up, the Barthel ADL index was nonsignificantly higher and the Rankin disability score was marginally significantly lower in the magnesium-treated group (84 +/- 26 vs. 71.8 +/- 26, p < 0.143) than in control subjects (2.3 +/- 1.1 vs. 3 +/- 1.3, p < 0.077). Intravenous magnesium sulfate had significant positive effect on the outcome in patients with acute stroke. Further studies on a larger scale are needed to confirm these findings.
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Affiliation(s)
- Y Lampl
- Department of Neurology, Edith Wolfson Medical Center, Holon, Israel
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Chamorro A, Obach V, Vila N, Revilla M, Cervera A, Ascaso C. Comparison of the acute-phase response in patients with ischemic stroke treated with high-dose heparin or aspirin. J Neurol Sci 2000; 178:17-22. [PMID: 11018244 DOI: 10.1016/s0022-510x(00)00345-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Experimental studies have suggested that unfractionated heparin (UH) has antiinflammatory properties. It is unknown whether UH also has these properties in patients with acute ischemic stroke. Within 12-24 h of treatment onset we measured the acute-phase response as reflected by the erythrocyte sedimentation rate (ESR) and total number of leukocytes (x10(9)/l) in 706 consecutive patients with acute ischemic stroke treated with full-dose UH (n=450), or 300 mg/day aspirin (n=256). Clinical outcome (Mathew scale) at hospital discharge and the effect of factors such as treatment (UH and aspirin), and acute phase response were assessed using multivariate analyses adjusted for baseline confounders and incident complications. Separate models were created for patients with lacunar and nonlacunar stroke. Whereas there were not differences at baseline between the two treatment groups, total leukocyte counts (8. 0+/-4.1 vs. 8.6+/-3.2, P<0.01) and ESR (21.7+/-20.9 vs. 25.2+/-22.9, P<0.05) were statistically significantly lower in patients treated with UH. This effect of UH was more accentuated in patients with nonlacunar stroke. Overall, leukocytes (7.2+/-2.3 vs. 8.4+/-4.0, P<0. 01), and ESR (15.7+/-17.2 vs. 24.3+/-22.2, P=0.0001) were lower in patients with complete early recovery and this effect was restricted to patients with nonlacunar stroke. Whereas baseline impairment, symptomatic bleeding and stroke recurrence were independent negative outcome predictors, the use of UH was positively associated with early recovery in all patients. This study shows that full-dose UH reduces the acute-phase reaction that follows ischemic stroke more effectively than aspirin. The prognostic implications of such effect seem more notable in patients with nonlacunar stroke.
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Affiliation(s)
- A Chamorro
- Stroke Unit, Neurology Service-IDIBAPS. Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain.
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Vila N, Reverter JC, Yagüe J, Chamorro A. Interaction between interleukin-6 and the natural anticoagulant system in acute stroke. J Interferon Cytokine Res 2000; 20:325-9. [PMID: 10762081 DOI: 10.1089/107999000312478] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Inflammatory reactions mediated by cytokines are involved in the pathogenesis of acute stroke. Decrease in circulating levels of protein C (PC) and protein S (PS) induced by inflammatory cytokines has been postulated as a potential mechanism for a procoagulant tendency during acute stroke. The procoagulant state associated with impairments in natural anticoagulants may induce microvascular obstruction leading to a tissue perfusion reduction that worsens cerebral ischemia. Interleukin-6 (IL-6) regulate the synthesis of C4b-binding protein (C4BP), an acute-phase protein that also regulates PS plasma levels. We measured IL-6, C4BP, erythrocyte sedimentation rate (ESR), total and free PS and PC in 44 patients with acute ischemic stroke to determine if IL-6 decreases circulating levels of natural anticoagulants through the C4BP pathway and if these acute changes in natural anticoagulants may have clinical implications. Patients with higher levels of IL-6 had more severe neurologic deficits on admission, greater infarct size, higher levels of acute-phase reactants, and lower levels of free PS. IL-6 was significantly correlated with C4BP, ESR, and free PS levels. PC levels were also lower in the group of patients with greater IL-6, but differences were not statistically significant. No correlations were found between C4BP and natural anticoagulants. Severe neurologic deficit, greater infarct volume, atrial fibrillation, increased levels of inflammatory parameters (ESR and IL-6), and reduced levels of free PS were associated with disabling stroke at 3 months, but only neurologic severity and ESR remained as independent predictors of stroke disability on multiple regression analysis. Inflammatory reactions mediated by IL-6 during the acute phase of stroke influence the modulation of free PS. However, variations in free PS levels do not have implications for clinical outcome in stroke patients. The link between proinflammatory cytokines and free PS in the acute phase of stroke is not related to the C4BP pathway.
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Affiliation(s)
- N Vila
- Service of Neurology, Hospital Clínic i Provincial, Barcelona, Spain.
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