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Liang HH, Liu HY, Kosik RO, Chan WP, Chien LN. Association between repeat imaging and readmission in patients with acute ischaemic stroke: a 16-year nationwide population-based study. Br J Radiol 2024; 97:1343-1350. [PMID: 38640490 PMCID: PMC11186559 DOI: 10.1093/bjr/tqae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 12/04/2023] [Accepted: 04/15/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES This study aims to evaluate such usage patterns and identify factors that may contribute to the need for repeat imaging in acute ischaemic stroke patients and determine the association between repeat imaging and readmission in Taiwan. METHODS We searched and analysed data from the Taiwan National Health Insurance Research Database for patients admitted for acute ischaemic stroke between 2002 and 2017. Cases where repeat brain imaging during the initial hospital admission occurred and where patients were readmitted within 30 days following discharge were documented. RESULTS Of a total of 195 016 patients with new onset ischaemic stroke, 51 798 (26.6%) underwent repeat imaging during their initial admission. Factors associated with repeat brain imaging included younger age, longer hospital stay, use of recombinant tissue plasminogen activator (rt-PA) therapy (odds ratio = 2.10 [95% CI, 1.98-2.22]), more recent year of diagnosis, higher National Institutes of Health Stroke Scale (NIHSS) score, and admission to a hospital offering a higher level of care. Repeat imaging was also associated with an increased risk of ischaemic stroke and all types of stroke readmission. CONCLUSIONS Repeat brain imaging of patients with stroke has increased in recent years, and it is associated with certain factors including age, length of stay, use of rt-PA, hospital level of care, and NIHSS score. It is also associated with increased readmission. ADVANCES IN KNOWLEDGE Knowledge of the associations of repeat imaging may help clinicians use repeat imaging more carefully and efficaciously.
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Affiliation(s)
- Han-Hsuan Liang
- Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Hung-Yi Liu
- Health Data Analytical and Statistical Center, Office of Data Science, Taipei Medical University, New Taipei City 235, Taiwan
| | - Russell Oliver Kosik
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Wing P Chan
- Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
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The Potential Impact of Neuroimaging and Translational Research on the Clinical Management of Lacunar Stroke. Int J Mol Sci 2022; 23:ijms23031497. [PMID: 35163423 PMCID: PMC8835925 DOI: 10.3390/ijms23031497] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 12/21/2022] Open
Abstract
Lacunar infarcts represent one of the most frequent subtypes of ischemic strokes and may represent the first recognizable manifestation of a progressive disease of the small perforating arteries, capillaries, and venules of the brain, defined as cerebral small vessel disease. The pathophysiological mechanisms leading to a perforating artery occlusion are multiple and still not completely defined, due to spatial resolution issues in neuroimaging, sparsity of pathological studies, and lack of valid experimental models. Recent advances in the endovascular treatment of large vessel occlusion may have diverted attention from the management of patients with small vessel occlusions, often excluded from clinical trials of acute therapy and secondary prevention. However, patients with a lacunar stroke benefit from early diagnosis, reperfusion therapy, and secondary prevention measures. In addition, there are new developments in the knowledge of this entity that suggest potential benefits of thrombolysis in an extended time window in selected patients, as well as novel therapeutic approaches targeting different pathophysiological mechanisms involved in small vessel disease. This review offers a comprehensive update in lacunar stroke pathophysiology and clinical perspective for managing lacunar strokes, in light of the latest insights from imaging and translational studies.
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Arba F, Mair G, Phillips S, Sandercock P, Wardlaw JM. Improving Clinical Detection of Acute Lacunar Stroke: Analysis From the IST-3. Stroke 2020; 51:1411-1418. [PMID: 32268853 PMCID: PMC7185055 DOI: 10.1161/strokeaha.119.028402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Supplemental Digital Content is available in the text. We aim to identify factors associated with imaging-confirmed lacunar strokes and improve their rapid clinical identification early after symptom onset using data from the IST-3 (Third International Stroke Trial).
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Affiliation(s)
- Francesco Arba
- From the Stroke Unit, AOU Careggi, Florence, Italy (F.A.)
| | - Grant Mair
- Division of Neuroimaging Sciences, Brain Research Imaging Centre, University of Edinburgh, United Kingdom (G.M., J.M.W.).,Brain Research Imaging Centre, SINAPSE Collaboration, United Kingdom (G.M., J.M.W.).,Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, United Kingdom (G.M., P.S., J.M.W.)
| | - Stephen Phillips
- Division of Neurology, Department of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada (S.P.)
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, United Kingdom (G.M., P.S., J.M.W.)
| | - Joanna M Wardlaw
- Division of Neuroimaging Sciences, Brain Research Imaging Centre, University of Edinburgh, United Kingdom (G.M., J.M.W.).,Brain Research Imaging Centre, SINAPSE Collaboration, United Kingdom (G.M., J.M.W.).,Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, United Kingdom (G.M., P.S., J.M.W.)
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Arboix A, Massons J, García-Eroles L, Grau-Olivares M, Targa C, Comes E, Oliveres M. [Trends in risk factors, clinical characteristics and prognosis in primary intracerebral haemorrhage (1986-2004)]. Med Clin (Barc) 2013; 142:1-6. [PMID: 23768852 DOI: 10.1016/j.medcli.2013.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 03/06/2013] [Accepted: 03/07/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Cardiovascular risk factors, clinical features and early outcome of first-ever primary intracerebral haemorrhage (PIH) from 1986 to 2004 using the Sagrat Cor Hospital of Barcelona Stroke Registry were assessed, and compared with data from patients with first-ever ischemic stroke. PATIENTS AND METHODS The study population consisted of 380 patients with PIH and 2,082 patients with ischemic stroke. Secular trends for the periods 1986-1992, 1993-1998 and 1999-2004 were analyzed. RESULTS Age increased significantly (P<.001) throughout the 3 study periods and there was a significant increase in the percentage of patients with atrial fibrillation, chronic obstructive pulmonary disease (COPD) and lobar topography. The use of brain magnetic resonance imaging (MRI) also increased significantly throughout the study periods. In comparison with ischemic stroke in-hospital death was more frequent (28,2 vs. 12%) and lacunar syndrome (9,5 vs. 31,4%) and symptom-free patients at discharge were less frequent in the intracerebral haemorrhage group (6,1 vs. 18,3%). CONCLUSIONS Significant changes over a 19-year period included an increase in the patient's age, frequency of COPD and atrial fibrillation and use of MRI imaging studies. PIH is a severe subtype of stroke with a higher risk of early death and lower asymptomatic frequency at discharge than ischemic cerebral infarct.
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Affiliation(s)
- Adrià Arboix
- Unidad de Enfermedades Vasculares Cerebrales, Servicio de Neurología, Capio-Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Barcelona, España.
| | - Joan Massons
- Unidad de Enfermedades Vasculares Cerebrales, Servicio de Neurología, Capio-Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Barcelona, España
| | - Luís García-Eroles
- Unidad de Organización y Sistema de Información, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Marta Grau-Olivares
- Unidad de Enfermedades Vasculares Cerebrales, Servicio de Neurología, Capio-Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Barcelona, España
| | - Cecília Targa
- Unidad de Enfermedades Vasculares Cerebrales, Servicio de Neurología, Capio-Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Barcelona, España
| | - Emili Comes
- Unidad de Enfermedades Vasculares Cerebrales, Servicio de Neurología, Capio-Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Barcelona, España
| | - Montserrat Oliveres
- Unidad de Enfermedades Vasculares Cerebrales, Servicio de Neurología, Capio-Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Barcelona, España
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Shobha N, Fang J, Hill MD. Do Lacunar Strokes Benefit from Thrombolysis? Evidence from the Registry of the Canadian Stroke Network. Int J Stroke 2012; 8 Suppl A100:45-9. [DOI: 10.1111/j.1747-4949.2012.00932.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Lacunar infarcts constitute up to 25% of all ischaemic strokes. As acute intracranial vascular imaging has become widely available with computed tomographic angiography, thrombolysis of lacunar strokes has become contentious because an intracranial vascular lesion cannot be visualized. We studied the effect of thrombolysis on lacunar strokes compared to other clinical ischaemic stroke sub-types. Methods Ischaemic stroke patients from phase 3 of the Registry of the Canadian Stroke Network data (July 2003–March 2008) were included. Lacunar stroke was defined as a lacunar syndrome supported by computed tomography brain showing a subcortical hypodense lesion with a diameter <20 mm. Clinical syndromes were used to define other stroke sub-types. The outcomes were mortality at 90 days, modified Rankin Scale score 0–2 at discharge, occurrence of intracranial haemorrhage as a complication of stroke in-hospital, and discharge disposition to home. Results A total of 11 503 patients of ischaemic stroke were included from the Registry of the Canadian Stroke Network 3 between July 2003 and March 2008. Lacunar strokes formed 19·1% of the total strokes. The total number of patients who received tissue plasminogen activator was 1630 (14·2%). A significant association was found between tissue plasminogen activator treatment and outcomes after controlling Oxfordshire Community Stroke Project types – for modified Rankin Scale at discharge and discharge to home, but not for mortality. A thrombolysis-by-Oxfordshire Community Stroke Project stroke sub-type interaction was observed due to lack of benefit among the posterior circulation stroke sub-types. Patients with lacunar strokes, partial anterior circulation stroke, and total anterior circulation strokes all benefited approximately equally from thrombolysis. Conclusions Thrombolysis is associated with clinically improved outcome among patients with lacunar stroke syndromes.
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Affiliation(s)
- Nandavar Shobha
- Bangalore Neuro Centre, Vagus Superspeciality hospital, Bhagwan Mahaveer Jain hospital, Vikram Hospital, Bangalore, India
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Michael D. Hill
- Departments of Clinical Neurosciences, Medicine, Radiology and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Calgary, AB Canada
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Arboix A, Massons J, García-Eroles L, Targa C, Comes E, Parra O. Clinical predictors of lacunar syndrome not due to lacunar infarction. BMC Neurol 2010; 10:31. [PMID: 20482763 PMCID: PMC2877662 DOI: 10.1186/1471-2377-10-31] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 05/18/2010] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Lacunar syndrome not due to lacunar infarct is poorly characterised. This single centre, retrospective study was conducted to describe the clinical characteristics of patients with lacunar syndrome not due to lacunar infarct and to identify clinical predictors of this variant of lacunar stroke. METHODS A total of 146 patients with lacunar syndrome not due to lacunar infarction were included in the "Sagrat Cor Hospital of Barcelona Stroke Registry" during a period of 19 years (1986-2004). Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The characteristics of these 146 patients with lacunar syndrome not due to lacunar infarct were compared with those of the 733 patients with lacunar infarction. RESULTS Lacunar syndrome not due to lacunar infarct accounted for 16.6% (146/879) of all cases of lacunar stroke. Subtypes of lacunar syndromes included pure motor stroke in 63 patients, sensorimotor stroke in 51, pure sensory stroke in 14, atypical lacunar syndrome in 9, ataxic hemiparesis in 5 and dysarthria-clumsy hand in 4. Valvular heart disease, atrial fibrillation, sudden onset, limb weakness and sensory symptoms were significantly more frequent among patients with lacunar syndrome not due to lacunar infarct than in those with lacunar infarction, whereas diabetes was less frequent. In the multivariate analysis, atrial fibrillation (OR = 4.62), sensorimotor stroke (OR = 4.05), limb weakness (OR = 2.09), sudden onset (OR = 2.06) and age (OR = 0.96) were independent predictors of lacunar syndrome not due to lacunar infarct. CONCLUSIONS Although lacunar syndromes are highly suggestive of small deep cerebral infarctions, lacunar syndromes not due to lacunar infarcts are found in 16.6% of cases. The presence of sensorimotor stroke, limb weakness and sudden onset in a patient with atrial fibrillation should alert the clinician to the possibility of a lacunar syndrome not due to a lacunar infarct.
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Affiliation(s)
- Adrià Arboix
- Unit of Cerebrovascular Diseases, Service of Neurology, Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Barcelona, Spain.
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7
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Brazzelli M, Sandercock PA, Chappell FM, Celani MG, Righetti E, Arestis N, Wardlaw JM, Deeks JJ. Magnetic resonance imaging versus computed tomography for detection of acute vascular lesions in patients presenting with stroke symptoms. Cochrane Database Syst Rev 2009:CD007424. [PMID: 19821415 DOI: 10.1002/14651858.cd007424.pub2] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is increasingly used for the diagnosis of acute ischaemic stroke but its sensitivity for the early detection of intracerebral haemorrhage has been debated. Computed tomography (CT) is extensively used in the clinical management of acute stroke, especially for the rapid exclusion of intracerebral haemorrhage. OBJECTIVES To compare the diagnostic accuracy of diffusion-weighted MRI (DWI) and CT for acute ischaemic stroke, and to estimate the diagnostic accuracy of MRI for acute haemorrhagic stroke. SEARCH STRATEGY We searched MEDLINE and EMBASE (January 1995 to March 2009) and perused bibliographies of relevant studies for additional references. SELECTION CRITERIA We selected studies that either compared DWI and CT in the same patients for detection of ischaemic stroke or examined the utility of MRI for detection of haemorrhagic stroke, had imaging performed within 12 hours of stroke onset, and presented sufficient data to allow construction of contingency tables. DATA COLLECTION AND ANALYSIS Three authors independently extracted data on study characteristics and measures of accuracy. We assessed data on ischaemic stroke using random-effects and fixed-effect meta-analyses. MAIN RESULTS Eight studies with a total of 308 participants met our inclusion criteria. Seven studies contributed to the assessment of ischaemic stroke and two studies to the assessment of haemorrhagic stroke. The spectrum of patients was relatively narrow in all studies, sample sizes were small, there was substantial incorporation bias, and blinding procedures were often incomplete. Amongst the patients subsequently confirmed to have acute ischaemic stroke (161/226), the summary estimates for DWI were: sensitivity 0.99 (95% CI 0.23 to 1.00), specificity 0.92 (95% CI 0.83 to 0.97). The summary estimates for CT were: sensitivity 0.39 (95% CI 0.16 to 0.69), specificity 1.00 (95% CI 0.94 to 1.00). The two studies on haemorrhagic stroke reported high estimates for diffusion-weighted and gradient-echo sequences but had inconsistent reference standards. We did not calculate overall estimates for these two studies. We were not able to assess practicality or cost-effectiveness issues. AUTHORS' CONCLUSIONS DWI appears to be more sensitive than CT for the early detection of ischaemic stroke in highly selected patients. However, the variability in the quality of included studies and the presence of spectrum and incorporation biases render the reliability and generalisability of observed results questionable. Further well-designed studies without methodological biases, in more representative patient samples, with practicality and cost estimates are now needed to determine which patients should undergo MRI and which CT in suspected acute stroke.
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Affiliation(s)
- Miriam Brazzelli
- Division of Clinical Neurosciences, University of Edinburgh, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh, UK, EH4 2XU
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8
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Chung SP, Chung HS, Ryu S, Rhu S, Kim SW, Yoo IS, Kim J, Song CJ. Emergency department experience of primary diffusion weighted magnetic resonance imaging for the patient with lacunar syndrome. Emerg Med J 2007; 23:675-8. [PMID: 16921077 PMCID: PMC2564205 DOI: 10.1136/emj.2006.035402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the usefulness of a particular magnetic resonance imaging technique known as primary diffusion weighted imaging (DWI) for patients with lacunar syndrome in the emergency department (ED). METHODS Patients with one of five classic lacunar syndromes underwent DWI as primary imaging modality. The DWI findings were classified into groups: (a) having a lesion with high signal intensity, (b) having a lesion with mixed signal intensity, and (c) unremarkable. The final clinical diagnoses were extracted from the patients' medical records, and used as a reference standard. RESULTS Of 151 DWI images, 120 (79%) were interpreted as high signal lesions, 21 (14%) as mixed signal lesions, and 10 (7%) as unremarkable. All patients with high signal lesions or unremarkable findings were diagnosed with ischaemic stroke. The patients with mixed signal lesions were diagnosed with haemorrhagic stroke with an exception of one ischaemic stroke. CONCLUSION Primary DWI is a feasible and useful neuroimaging tool for patients with lacunar syndrome in the ED.
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Affiliation(s)
- S P Chung
- Department of Emergency Medicine, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea Seoul, Republic of Korea.
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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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10
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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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Rossmeisl JH, Rohleder JJ, Pickett JP, Duncan R, Herring IP. Presumed and confirmed striatocapsular brain infarctions in six dogs. Vet Ophthalmol 2007; 10:23-36. [PMID: 17204125 DOI: 10.1111/j.1463-5224.2007.00487.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the clinical and diagnostic features of the canine sensorimotor syndrome caused by striatocapsular brain infarctions (SCI). ANIMALS STUDIED Six dogs with diagnostic imaging or postmortem evidence of SCI. PROCEDURES Medical records of dogs with SCI were retrospectively reviewed and the signalment, history, clinical signs, antemortem clinicopathologic test results, diagnostic imaging findings, case outcomes, and pathologic findings recorded. RESULTS All dogs had an acute onset of nonprogressive homonymous visual field deficits and contralateral general proprioceptive (GP) deficits. Contralateral hemiparesis and facial hypalgesia were noted in 5/6 dogs. CT scans were normal in 2/4 dogs, and revealed poorly defined hypoattenuating lesions in the subcortical white matter in two dogs. MRI exams were performed in 5/6 dogs and revealed unilateral, variably sized, striatocapsular lesions consistent with nonhemorrhagic infarctions. Diagnostic imaging (6/6) and postmortem examinations (2/6) suggested that SCI resulted from lesions in the vascular territories of the rostral choriodal (6/6) and lenticulostriate arteries (2/6). Diseases predisposing to infarction were not identified in 5/6 dogs. Improvements in mentation, behavior, proprioceptive deficits, and hemiparesis were seen in surviving dogs, but persistent, symptomatic sensory deficits were noted during the follow-up period. CONCLUSIONS SCI should be considered as a differential diagnosis for dogs with acute onset, nonprogressive homonymous hemianopia, contralateral GP deficits or hemiparesis, and facial hypalgesia. MRI is the preferred modality for the antemortem imaging diagnosis of SCI. Although partial recovery occurred in all surviving dogs, visual and facial sensory disturbances persisted.
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Affiliation(s)
- John H Rossmeisl
- Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA.
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Abstract
Small vessel disease is a common cause of cerebrovascular disease. It is responsible for ischemic and hemorrhagic strokes, cognitive decline, and asymptomatic disease. Millions of Americans are affected by silent strokes and white matter abnormalities. Lacunar stroke is the most common manifestation. Despite its importance, small vessel strokes remain understudied. There is a need for research focused on this prevalent stroke subtype to define optimal interventions to prevent stroke recurrence and cognitive impairment.
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Affiliation(s)
- Oscar Benavente
- Department of Medicine, Division of Neurology, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
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13
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Rabinstein AA, Chirinos JA, Fernandez FR, Zambrano JP. Is TEE useful in patients with small subcortical strokes? Eur J Neurol 2006; 13:522-7. [PMID: 16722979 DOI: 10.1111/j.1468-1331.2006.01283.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although the role of transesophageal echocardiography (TEE) in the investigation of stroke mechanism is well established, the value of this test in patients with lacunar presentation is unclear. Review of 214 patients with acute cerebral ischemia referred for TEE to exclude cardioaortic sources of embolism after non-diagnostic basic work-up including carotid ultrasound and transthoracic echocardiography. TEE was considered positive when it showed large or complex aortic arch plaques, left atrial thrombus, mitral or aortic valve vegetations, or patent foramen ovale with atrial septal aneurysm. Multivariate regression analysis was performed to assess the value of lacunar syndrome and radiological small subcortical infarctions in predicting TEE result. Predictive values and likelihood ratios for these variables were calculated. Fifty-two patients (24%) had positive TEE. The most common embolic source was large or complex aortic plaques in 19% of patients. Neither clinical presentation with lacunar syndrome nor the presence of small subcortical infarction on CT scan predicted a negative TEE result on univariate or multivariate analysis. However, the combination of lacunar syndrome with radiological small subcortical infarction was uniformly associated with negative TEE (P=0.01; negative predictive value 100%). The combination of lacunar syndrome with small subcortical radiological infarct predicts the absence of cardioaortic sources of embolism on TEE in patients with acute cerebral ischemia.
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Affiliation(s)
- A A Rabinstein
- Department of Neurology, Cerebrovascular Division, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, FL 33101, USA.
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14
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Immink RV, van Montfrans GA, Stam J, Karemaker JM, Diamant M, van Lieshout JJ. Dynamic Cerebral Autoregulation in Acute Lacunar and Middle Cerebral Artery Territory Ischemic Stroke. Stroke 2005; 36:2595-600. [PMID: 16254228 DOI: 10.1161/01.str.0000189624.06836.03] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We addressed whether dynamic cerebral autoregulation (dCA) is affected in middle cerebral artery (MCA) territory (MCAS) and lacunar ischemic stroke (LS).
Methods—
Blood pressure (MAP) and MCA velocity (V) were measured in 10 patients with large MCAS (National Institutes of Health Stroke score, 17±2; mean±SEM), in 10 with LS (score, 9±1), and in 10 reference subjects. dCA was evaluated in time (delay of the MCA V
mean
counter-regulation during changes in MAP) and frequency domains (cross-spectral MCA V
mean
-to-MAP phase lead).
Results—
In reference subjects, latencies for MAP increments (5.3±0.5 seconds) and decrements (5.6±0.5 seconds) were comparable, and low frequency MCA V
mean
-to-MAP phase lead was 56±5 and 59±5° (left and right hemisphere). In MCAS, these latencies were 4.6±0.7 and 5.6±0.5 seconds in the nonischemic hemisphere and not detectable in the ischemic hemisphere. In the unaffected hemisphere, phase lead was 61±6° versus 26±6° on the ischemic side (
P
<0.05). In LS, no latency and smaller phase lead bilaterally (32±6 and 33±5°) conformed to globally impaired dCA.
Conclusions—
In large MCAS infarcts, dynamic cerebral autoregulation was impaired in the affected hemisphere. In LS, dynamic cerebral autoregulation was impaired bilaterally, a finding consistent with the hypothesis of bilateral small vessel disease in patients with lacunar infarcts.
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Affiliation(s)
- Rogier V Immink
- Cardiovascular Research Institute Amsterdam, Department of Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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15
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Abstract
Stroke is the most common life-threatening neurologic disease and the leading cause of serious long-term disability. The advent of new treatment options for selected patients suffering ischemic stroke (such as systemic administration of tissue plasminogen activator or catheter-guided intra-arterial thrombolysis), the structural reorganization of patient care facilities into stroke units, and interdisciplinary cerebrovascular centers have broadened the scope of possible therapeutic interventions in the acute and post-acute phase after cerebral ischemia. This review summarizes currently available and recommended treatment modalities for acute ischemic stroke from an interdisciplinary perspective, including medical, neurointerventional, and neurosurgical therapies.
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Affiliation(s)
- C Stapf
- The Neurological Institute, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, New York 10032, USA
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