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Sato M, Yamahata H, Yasuda M, Hiwatari T, Yonenaga M, Ishimaru K, Miyanohara O, Shimozuru T, Yoshimoto K. Treatment of rotational/positional vertebral artery occlusion due to degenerative changes in the cervical vertebrae: A case report and review of the literature. J Orthop Sci 2023; 28:1614-1619. [PMID: 35078705 DOI: 10.1016/j.jos.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/21/2021] [Accepted: 12/23/2021] [Indexed: 02/09/2023]
Affiliation(s)
- Masanori Sato
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan.
| | - Hitoshi Yamahata
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Muneyoshi Yasuda
- Division of Neurosurgery, Ichinomiyanishi Hospital, Ichinomiya,1 Kaimeihira, Ichinomiya-shi, Aichi, 494-0001, Japan
| | - Takaaki Hiwatari
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Masanori Yonenaga
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Koichi Ishimaru
- Division of Neurosurgery, Kushikino Neurosurgical Center, 5391-3, Seifuku, Ichikikushikino-shi, Kagoshima, 896-0078, Japan
| | - Osamu Miyanohara
- Division of Neurosurgery, Kushikino Neurosurgical Center, 5391-3, Seifuku, Ichikikushikino-shi, Kagoshima, 896-0078, Japan
| | - Tetsuro Shimozuru
- Division of Neurosurgery, Kushikino Neurosurgical Center, 5391-3, Seifuku, Ichikikushikino-shi, Kagoshima, 896-0078, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
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2
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Pelletier J, Koyfman A, Long B. Pearls for the Emergency Clinician: Posterior Circulation Stroke. J Emerg Med 2023; 65:e414-e426. [PMID: 37806810 DOI: 10.1016/j.jemermed.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity. OBJECTIVE OF THE REVIEW This review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence. DISCUSSION PC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors. Neurologic examination for focal neurologic deficit, dysmetria, dysarthria, ataxia, and truncal ataxia is essential, as is the differentiation of acute vestibular syndrome vs. spontaneous episodic vestibular syndrome vs. triggered episodic vestibular syndrome. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful for identifying dizziness presentations concerning for stroke when performed by those with appropriate training. However, it should only be used in patients with continuous dizziness who have ongoing nystagmus. Contrast tomography (CT), CT angiography, and CT perfusion have limited sensitivity for identifying PC strokes, and although magnetic resonance imaging is the gold standard, it may miss some PC strokes early in their course. Thrombolysis is recommended in patients presenting within the appropriate time window for thrombolytic therapy, and although some data suggest endovascular therapy for basilar artery and posterior cerebral artery infarcts is beneficial, its applicability for all PC strokes remains to be determined. CONCLUSIONS An understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, Texas
| | - Brit Long
- San Antonio Uniformed Services Health Education Consortium, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.
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Palmisciano P, Hoz SS, Algburi HA, Ventre G, Street S, Agyeman N, Robinson MW, Smith MS, Shirani P, Grossman AW, Prestigiacomo CJ. Percutaneous transluminal angioplasty and/or stenting for the treatment of basilar artery stenosis: a systematic review and meta-analysis. Neuroradiology 2023; 65:985-1000. [PMID: 36881121 DOI: 10.1007/s00234-023-03124-x] [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: 10/09/2022] [Accepted: 01/14/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE Basilar artery stenosis (BAS) carries high morbidity and mortality, with variable outcomes after endovascular treatments. We systematically reviewed the literature on percutaneous transluminal angioplasty and/or stenting (PTAS) for BAS. METHODS PubMed, EMBASE, Web-of-Science, Scopus, and Cochrane were searched upon the PRISMA guidelines to include prospective/retrospective cohort studies describing PTAS for BAS. Pooled rates of intervention-related complications and outcomes were analyzed with random-effect model meta-analyses. RESULTS We included 25 retrospective cohort studies comprising 1016 patients. All patients were symptomatic, presenting with transient ischemic attack or ischemic stroke. BAS frequently involved the middle basilar artery (51.4%), mostly classified as Mori-B (57.4%). PTAS for BAS was indicated in severe (≥ 50-70%), symptomatic BAS refractory to dual antiplatelet therapy. Patients underwent angioplasty (95.5%) and/or stenting (92.2%), preferably using Wingspan or Apollo stents. Median baseline BAS was 81% (range, 53-99%), while median post-intervention BAS was 13% (0-75%). Actuarial rates of successful intervention and "good" final outcome were 100% (95% CI: 100-100%) and 89% (95% CI: 85-93%). Intervention-related recurrent ischemic stroke occurred in 85 patients (8.3%) with actuarial rates of 5% (95% CI: 4-7%), differentiated into perforator (5.4%), in-stent (2.6%), and embolic (0.4%). Actuarial rates of intervention-related dissection, restenosis, and death were 0% (95% CI: 0-0%), 1% (95% CI: 0-1%), and 0% (95% CI: 0-2%). CONCLUSION Elective PTAS appears to be safe and effective in selected patients with medically refractory, severe, symptomatic, and non-acute BAS. Different stent types and angioplasty-assisted procedures should be considered based on specific clinico-radiological characteristics of the lesions. Future randomized controlled trials are required to corroborate these findings.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45229, USA
| | - Samer S Hoz
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45229, USA
| | | | - Giancarlo Ventre
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Seth Street
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nana Agyeman
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael W Robinson
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45229, USA
| | - Matthew S Smith
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Peyman Shirani
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron W Grossman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45229, USA.
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Mortality after total anterior circulation stroke: a 25-year observational study. Neurol Sci 2022:1-7. [PMID: 35722755 DOI: 10.1017/cjn.2022.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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5
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Wilseck ZM, Chaudhary N, Gemmete JJ. Commentary: Neuroendovascular Management of Acute Ischemic Basilar Strokes: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E348-E349. [PMID: 34245159 DOI: 10.1093/ons/opab251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/02/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Zachary M Wilseck
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Otorhinolaryngology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Otorhinolaryngology, University of Michigan, Ann Arbor, Michigan, USA
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Strilciuc S, Grad DA, Radu C, Chira D, Stan A, Ungureanu M, Gheorghe A, Muresanu FD. The economic burden of stroke: a systematic review of cost of illness studies. J Med Life 2021; 14:606-619. [PMID: 35027963 PMCID: PMC8742896 DOI: 10.25122/jml-2021-0361] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/23/2021] [Indexed: 01/02/2023] Open
Abstract
Stroke is one of the leading causes of morbidity and mortality worldwide. As the number of stroke cases is rising from one year to another, policymakers require data on the amount spent on stroke to enforce better financing policies for prevention, hospital care, outpatient rehabilitation services and social services. We aimed to systematically assess the economic burden of stroke at global level. Cost of stroke studies were retrieved from five databases. We retrieved the average cost per patient, where specified, or estimated it using a top-down approach. Resulting costs were grouped in two main categories: per patient per year and per patient lifetime. We extracted information from forty-six cost of illness studies. Per patient per year costs are larger in high income countries and in studies conducted from the payer perspective. The highest average per patient per year cost by country was reported in the United States ($59,900), followed by Sweden ($52,725) and Spain ($41,950). The highest per patient lifetime costs were reported in Australia ($232,100) for all identified definitions of stroke. Existing literature regarding the economic burden of stroke is concentrated in high-income settings, with very few studies conducted in South America and Africa. Published manuscripts on this topic highlight substantial methodological heterogeneity, rendering comparisons difficult or impossible, even within the same country or among studies with similar costing perspectives.
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Affiliation(s)
- Stefan Strilciuc
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Diana Alecsandra Grad
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Constantin Radu
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Diana Chira
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Adina Stan
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Marius Ungureanu
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
- Center for Health Workforce Research and Policy, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Adrian Gheorghe
- Department of Infectious Disease Epidemiology, Global Health and Development Group, Imperial College London, London, United Kingdom
| | - Fior-Dafin Muresanu
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
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Acute basilar artery occlusion (BAO): a pictorial review of multimodal imaging findings. Emerg Radiol 2021; 28:1205-1212. [PMID: 34231114 DOI: 10.1007/s10140-021-01965-8] [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: 05/05/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
Acute basilar artery occlusion (BAO) is an uncommon cause of stroke; however, it constitutes a serious medical emergency and is associated with elevated mortality rates as well as unfavorable functional outcomes. This is especially true when it is not rapidly diagnosed, and the initiation of reperfusion therapies is delayed. Its etiology is mainly embolic or atherosclerotic, and it often presents with non-specific signs and symptoms (e.g., vertigo, cephalalgia, reduced consciousness, or hemiparesis) that can simulate an anterior circulation stroke. Therefore, obtaining imaging studies that include computed tomography (CT), computed tomography angiography (CTA), and diffusion-weighted magnetic resonance imaging (DWI MRI) as part of the diagnostic approach is crucial to make an accurate diagnosis. The main pillar of acute BAO treatment is early recanalization using intravenous thrombolysis, mechanical thrombectomy, or bridging therapy, in which both methods are used. This pictorial essay illustrates the essential role that multimodal imaging plays in the prompt diagnosis, management, and overall outcome of patients with acute BAO.
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8
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Multimodal CT pc-ASPECTS in infratentorial stroke: diagnostic and prognostic value. Neurol Sci 2021; 42:4231-4240. [PMID: 33590432 DOI: 10.1007/s10072-021-05072-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Diagnosis of posterior circulation stroke may be challenged. National Institutes of Health Stroke Scale (NIHSS) and brain imaging (non-contrast brain computed tomography-CT) are used for diagnosis; evaluation on posterior circulation stroke remains a limit of NIHSS, and the value of non-contrast CT (NCCT) is limited due to artifacts caused by the bones of the base of the skull. We tested the validity and prognostic value of posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) in patients with posterior circulation stroke. METHODS Pc-ASPECTS allots the posterior circulation 10 points. We studied 50 patients with posterior circulation stroke. We applied pc-ASPECTS to NCCT, CT angiography, and CT Perfusion. We evaluated the correlation of pc-ASPECT with outcome parameters for stroke. RESULTS Out of 50 patients, CTP showed abnormalities in 34 cases. The pc-ASPECT score calculated on brain CT and on the brain CT + angio CT had a sensibility of 24%, calculated on brain CT, angio CT and CTPerfusion gain a sensibility of 72%. Pc-ASPECT MTT resulted to be the more reliable parameter: outcome given by NIHSS score at discharge, mRS at discharge, and at 3 months was more severe in patients with Pc-ASPECT MTT alteration. Outcome given by NIHSS score at discharge and mRS at discharge and 1 at 3 months was more severe in patients with higher NIHSS score at admission. CONCLUSION We evaluated the usefulness of pc-ASPECTS on CTP in predicting functional outcome in acute posterior circulation stroke that appears to be a powerful marker for predicting functional outcome.
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Posterior circulation ischaemic stroke-a review part I: anatomy, aetiology and clinical presentations. Neurol Sci 2019; 40:1995-2006. [PMID: 31222544 DOI: 10.1007/s10072-019-03977-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 06/10/2019] [Indexed: 02/07/2023]
Abstract
Posterior circulation ischaemia is a clinicopathological condition with complex symptomatology associated with an infarction within the vertebrobasilar arterial system. Posterior circulation strokes account for about 20-25% of all ischemic strokes and remain a significant cause of patient disability and mortality. Diagnosis can be challenging because presenting symptoms are often non-focal and because there is a substantial overlap in symptoms and signs of ischaemia in the anterior circulation. Despite better imaging techniques, diagnosis and treatment of life-threatening conditions, such as basilar artery occlusions, are often delayed. Therefore, early detection of symptoms and causes of posterior circulation ischaemia is essential for choosing the most appropriate therapy. In this review, we summarise the anatomy, aetiology, typical presentations and characteristic findings of common strokes resulting from disease in the vertebrobasilar arterial system.
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10
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Posterior circulation ischemic stroke-a review part II: imaging and acute treatment. Neurol Sci 2019; 40:2007-2015. [PMID: 31127426 DOI: 10.1007/s10072-019-03936-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 05/09/2019] [Indexed: 01/01/2023]
Abstract
Posterior circulation strokes affect the vertebrobasilar arterial system, account for about 20-25% of all ischemic strokes, and are a significant cause of patient disability and mortality. Diagnosis can be challenging; clinical presentation and common pitfalls facing posterior circulation stroke have been discussed elsewhere. In the first part of the review, we focus on the imaging, discussing the information that can be gathered through a correct selection and interpretation of different possible studies helping to achieve an early diagnosis and to select the best medical treatment. In the second part of the review, we will discuss the best therapeutic treatments available at the moment for posterior circulation ischemia.
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11
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Attention Deficits in Stroke Patients: The Role of Lesion Characteristics, Time from Stroke, and Concomitant Neuropsychological Deficits. Behav Neurol 2019; 2019:7835710. [PMID: 31263512 PMCID: PMC6556322 DOI: 10.1155/2019/7835710] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 04/08/2019] [Indexed: 01/08/2023] Open
Abstract
Attention impairments are frequent in stroke patients with important consequences on the rehabilitation outcomes and quality of life. The aim of the study was to perform a comprehensive assessment of selective and intensive attention processes in a large population of brain-damaged patients, evaluating the influence of the side and site of the brain lesion, the time from stroke, and the concomitant presence of aphasia or neglect. We assessed 204 patients with a first unilateral brain lesion and 42 healthy individuals with three subtests of the Test of Attentional Performance (TAP): Alertness, Go-No Go, and Divided Attention. 44.4% of patients had an impairment in both intensive and selective aspects of attention, 5.6% had deficits only in the intensive component, and 31.8% had deficits only in selective tasks. More than 80% of the patients fell below the cut-off point on at least one task. Patients with a right hemispheric lesion (RHL) were more impaired than patients with a left hemispheric lesion (LHL) especially in tonic and phasic alertness. Patients with total anterior infarcts (TACI) presented the worst profile compared to other stroke subtypes, with a difference between total and lacunar subtypes in the Alertness test, independent of the presence of warning. Patients in the chronic phase had shorter RTs than acute patients only in the Alertness test. In patients with LHL, the presence of aphasia was associated with a greater deficit in selective attention. In patients with RHL, the presence of unilateral neglect was associated with impaired alertness and selective attention. Attention deficits are common after a unilateral first stroke. In keeping with the hierarchical organization of attention functions, results confirm the important role of the right hemisphere for the intensive components of attention, also highlighting the involvement of left hemisphere functioning for the selective aspects, possibly indicating a role of its linguistic functions.
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12
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Atzema CL, Grewal K, Lu H, Kapral MK, Kulkarni G, Austin PC. Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol 2015; 79:32-41. [DOI: 10.1002/ana.24521] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 09/08/2015] [Accepted: 09/10/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Clare L. Atzema
- Division of Emergency Medicine, Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- the Institute of Health Policy; Management and Evaluation at the University of Toronto; Toronto Ontario Canada
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Keerat Grewal
- Division of Emergency Medicine, Department of Medicine; University of Toronto; Toronto Ontario Canada
| | - Hong Lu
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Moira K. Kapral
- University Health Network; Toronto Ontario Canada
- the Institute of Health Policy; Management and Evaluation at the University of Toronto; Toronto Ontario Canada
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Girish Kulkarni
- University Health Network; Toronto Ontario Canada
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Peter C. Austin
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- the Institute of Health Policy; Management and Evaluation at the University of Toronto; Toronto Ontario Canada
- the Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
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Abstract
In acute stroke, the major factor for recovery is the early use of thrombolysis aimed at arterial recanalization and reperfusion of ischemic brain tissue. Subsequently, neurorehabilitative training critically improves clinical recovery due to augmention of postlesional plasticity. Neuroimaging and electrophysiology studies have revealed that the location and volume of the stroke lesion, the affection of nerve fiber tracts, as well as functional and structural changes in the perilesional tissue and in large-scale bihemispheric networks are relevant biomarkers of post-stroke recovery. However, associated disorders, such as mood disorders, epilepsy, and neurodegenerative diseases, may induce secondary cerebral changes or aggravate the functional deficits and, thereby, compromise the potential for recovery.
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Affiliation(s)
- Rüdiger J Seitz
- Department of Neurology, Centre of Neurology and Neuropsychiatry, LVR-Klinikum Düsseldorf, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Biomedical Research Centre, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Florey Institute of Neuroscience and Mental Health, University of Melbourne , Parkville, VIC , Australia
| | - Geoffrey A Donnan
- Florey Institute of Neuroscience and Mental Health, University of Melbourne , Parkville, VIC , Australia
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Comparison of provision of stroke care in younger and older patients: findings from the South london stroke register. Stroke Res Treat 2012; 2012:319581. [PMID: 22593833 PMCID: PMC3347760 DOI: 10.1155/2012/319581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 01/30/2012] [Accepted: 02/11/2012] [Indexed: 12/26/2022] Open
Abstract
Background. Evidence-based stroke care should be available to all patients. However, evidence exists of inequalities according to age. This study compared access to care for younger adults to that for over 65s. Methods. Using population-based data from 4229 patients with first-ever stroke between 1995 and 2010, associations between age and 21 care indicators were investigated using multivariable logistic regression. Results. Age was not associated with stroke unit admission for ischaemic stroke (P = 0.666). Younger PICH patients were least likely to be admitted to stroke units (P = 0.001), instead treated on neurosurgical or ICU wards. Younger age was also associated with admission to neurosurgery or ICU after SAH (P = 0.006), increased occupational or physiotherapy at 1 year (P = 0.043), and contact with a GP 3 months after stroke (P < 0.001). Conclusion. Younger patients have equal or greater access to evidence-based care. However, there is a need to ensure that services meet the needs of this group.
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Fang XH, Wang WH, Zhang XQ, Liu HJ, Zhang HM, Qin XM, Wang ZC, Ji XM, Li LM. Incidence and survival of symptomatic lacunar infarction in a Beijing population: a 6-year prospective study. Eur J Neurol 2012; 19:1114-20. [DOI: 10.1111/j.1468-1331.2012.03709.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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English CK, Thoirs KA, Fisher L, McLennan H, Bernhardt J. Ultrasound is a reliable measure of muscle thickness in acute stroke patients, for some, but not all anatomical sites: a study of the intra-rater reliability of muscle thickness measures in acute stroke patients. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:368-376. [PMID: 22266233 DOI: 10.1016/j.ultrasmedbio.2011.12.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 11/23/2011] [Accepted: 12/08/2011] [Indexed: 05/31/2023]
Abstract
This prospective, blinded study investigates the test retest reliability of measures of muscle thickness made by one sonographer across two cohort groups (n = 29) of people hospitalised with acute stroke. Reliability was assessed in cohort one (n = 14) for measurements made bilaterally at the anterior and posterior upper arms, the anterior and posterior thighs (total of eight measurements) and in cohort two (n = 15), for measurements made bilaterally at the lateral forearms, the anterior abdominal wall and the anterior and lower legs (total of eight measurements). Reliability estimates varied between measurement sites; intraclass correlation coefficients (ICCs) ranged from -0.26 (lateral forearm, paretic side) to 0.95 (anterior thigh, nonparetic side), percent mean differences ranged from 0.42% (posterior upper arm, nonparetic side) to 14.68% (anterior lower limb, nonparetic side) and method error ranged from 1.08 (abdomen, nonparetic side) to 9.69 mm (posterior lower limb, nonparetic side). Only four measurement sites (anterior upper arm, posterior upper arm, abdomen and anterior thigh) were within the acceptable ranges (ICC 0.60 to 1.00, mean percent difference range 0%-5% and method error range 0-5 mm) and considered reliable to use for measures of muscle thickness in people hospitalised with acute stroke.
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Affiliation(s)
- Coralie K English
- International Centre for Allied Health Evidence, School of Health Sciences, University of South Australia, Adelaide, South Australia
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Barker-Collo S, Starkey N, Lawes CM, Feigin V, Senior H, Parag V. Neuropsychological Profiles of 5-Year Ischemic Stroke Survivors by Oxfordshire Stroke Classification and Hemisphere of Lesion. Stroke 2012; 43:50-5. [DOI: 10.1161/strokeaha.111.627182] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Although the neuropsychological literature typically examines stroke outcomes by hemisphere of lesion, the medical literature provides classifications more closely linked to circulatory distribution impacted by stroke. This article examined profiles of cognitive function by hemisphere and by Oxfordshire Community Stroke Project stroke classification.
Methods—
This study included a sample of 315 5-year ischemic stroke survivors. Assessment included tests of verbal memory, visual memory, word finding/verbal fluency, abstract visual reasoning, executive functioning, and speed of processing.
Results—
The sample produced scores within 1 standard deviation of the normative mean on tests of abstract visual reasoning, verbal memory, and visual recall. Impaired performances were observed for executive function and processing speed. Profile analysis revealed no significant differences in overall cognitive performance or in the profile of performance across measures by hemisphere of lesion. However, groups defined by Oxfordshire Community Stroke Project categories produced significantly different cognitive profiles. Post hoc analyses indicate those with posterior stroke performed best overall on all tests except the Stroop Dots trial, whereas those with total anterior stroke produced significantly worse scores on tasks requiring visual abstract reasoning (Block Design, Rey Figure Copy), word finding (Boston Naming Test), and processing speed (Stroop Dots, Trails A).
Conclusions—
Oxfordshire Community Stroke Project stroke subtypes identified significant differences between groups, suggesting this classification system is of greater use than hemisphere of lesion in predicting poststroke cognitive outcomes.
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Affiliation(s)
- Suzanne Barker-Collo
- From the Department of Psychology (S.B.C.), Faculty of Sciences, University of Auckland, Auckland, New Zealand; School of Psychology (N.S.), Faculty of Arts and Social Sciences, University of Waikato, Hamilton, New Zealand; Clinical Trials Research Unit (C.M.M.L.), Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand; National Institute for Stroke and Applied Neurosciences (V.F.), School of Rehabilitation and Occupation Studies, AUT University, Auckland, New
| | - Nicola Starkey
- From the Department of Psychology (S.B.C.), Faculty of Sciences, University of Auckland, Auckland, New Zealand; School of Psychology (N.S.), Faculty of Arts and Social Sciences, University of Waikato, Hamilton, New Zealand; Clinical Trials Research Unit (C.M.M.L.), Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand; National Institute for Stroke and Applied Neurosciences (V.F.), School of Rehabilitation and Occupation Studies, AUT University, Auckland, New
| | - Carlene M.M. Lawes
- From the Department of Psychology (S.B.C.), Faculty of Sciences, University of Auckland, Auckland, New Zealand; School of Psychology (N.S.), Faculty of Arts and Social Sciences, University of Waikato, Hamilton, New Zealand; Clinical Trials Research Unit (C.M.M.L.), Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand; National Institute for Stroke and Applied Neurosciences (V.F.), School of Rehabilitation and Occupation Studies, AUT University, Auckland, New
| | - Valery Feigin
- From the Department of Psychology (S.B.C.), Faculty of Sciences, University of Auckland, Auckland, New Zealand; School of Psychology (N.S.), Faculty of Arts and Social Sciences, University of Waikato, Hamilton, New Zealand; Clinical Trials Research Unit (C.M.M.L.), Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand; National Institute for Stroke and Applied Neurosciences (V.F.), School of Rehabilitation and Occupation Studies, AUT University, Auckland, New
| | - Hugh Senior
- From the Department of Psychology (S.B.C.), Faculty of Sciences, University of Auckland, Auckland, New Zealand; School of Psychology (N.S.), Faculty of Arts and Social Sciences, University of Waikato, Hamilton, New Zealand; Clinical Trials Research Unit (C.M.M.L.), Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand; National Institute for Stroke and Applied Neurosciences (V.F.), School of Rehabilitation and Occupation Studies, AUT University, Auckland, New
| | - Varsha Parag
- From the Department of Psychology (S.B.C.), Faculty of Sciences, University of Auckland, Auckland, New Zealand; School of Psychology (N.S.), Faculty of Arts and Social Sciences, University of Waikato, Hamilton, New Zealand; Clinical Trials Research Unit (C.M.M.L.), Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand; National Institute for Stroke and Applied Neurosciences (V.F.), School of Rehabilitation and Occupation Studies, AUT University, Auckland, New
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Luker JA, Bernhardt J, Grimmer-Somers KA. Demographic and stroke-related factors as predictors of quality of acute stroke care provided by allied health professionals. J Multidiscip Healthc 2011; 4:247-59. [PMID: 21847347 PMCID: PMC3155855 DOI: 10.2147/jmdh.s22569] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Indexed: 11/25/2022] Open
Abstract
Background: We recently indicated that patient age on its own is not a determinant of quality of allied health care received after an acute stroke. It has not been tested whether other non-age variables influence care decisions made by allied health professionals. This paper explores demographic and stroke-related variables that are putatively associated with the quality of care provided to acute stroke patients by allied health professionals. Methods: Data were retrospectively audited from 300 acute stroke patient records regarding allied health care. Compliance with each of 20 indicators of allied health care quality was established. The influence of various demographic and stroke-related variables on each performance indicator was examined. We undertook a series of analyses using univariate logistic regression models to establish the influence of these variables on care quality. Results: Patient age had a significant correlation with only one process indicator (early mobilization). Seven variables, including stroke severity and level of dependence, were associated with patient age. The majority of these age proxies had significant associations with process indicator compliance. Correlations between non-age variables, in particular stroke severity and comorbidity, suggest the potential for complex confounding relationships between non-age variables and quality of allied health care. Conclusion: Compliance with individual indicators of allied health care was significantly associated with variables other than patient age, and included stroke severity, previous independence, comorbidities, day of admission, stroke unit admission, and length of stay. The inter-relationships between these non-age variables suggest that their influence on quality of care is complex.
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Affiliation(s)
- Julie A Luker
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, South Australia
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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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Varona JF. Long-term prognosis of ischemic stroke in young adults. Stroke Res Treat 2010; 2011:879817. [PMID: 21197408 PMCID: PMC3010699 DOI: 10.4061/2011/879817] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 10/07/2010] [Accepted: 11/08/2010] [Indexed: 11/20/2022] Open
Abstract
There is limited information about long-term prognosis of ischemic stroke in young adults. Giving the potentially negative impact in physical, social, and emotional aspects of an ischemic stroke in young people, providing early accurate long-term prognostic information is very important in this clinical setting. Moreover, detection of factors associated with bad outcomes (death, recurrence, moderate-to-severe disability) help physicians in optimizing secondary prevention strategies. The present paper reviews the most relevant published information concerning long-term prognosis and predictors of unfavorable outcomes of ischemic stroke affecting young adults. As a summary, we can conclude that, in the long term, stroke in the young adult increases slightly the risk of mortality, implies higher risk of future cardiovascular events, and determines functional limitations in a significant percentage of patients. Nevertheless, in every individual case the prognosis has to be considered depending on several factors (stroke subtype, initial severity, cardiovascular risk factors) that determine the long-term outcomes.
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Affiliation(s)
- Jose F Varona
- Department of Internal Medicine, University Hospital "Madrid Montepríncipe", CEU-San Pablo University School of Medicine and Institute of Applied Molecular Medicine (IMMA), Avenida Montepríncipe 25, Boadilla del Monte, 28660 Madrid, Spain
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Seitz RJ, Donnan GA. Role of neuroimaging in promoting long-term recovery from ischemic stroke. J Magn Reson Imaging 2010; 32:756-72. [PMID: 20882606 DOI: 10.1002/jmri.22315] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Rüdiger J Seitz
- Department of Neurology, University Hospital Düsseldorf, and Biomedical Research Centre, Heinrich-Heine-University Düsseldorf, Germany.
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Middleton S, Levi C, Ward J, Grimshaw J, Griffiths R, D'Este C, Dale S, Quinn C, Evans M, Cadilhac D, McElduff P. Death, dependency and health status 90 days following hospital admission for acute stroke in NSW. Intern Med J 2010; 41:736-43. [DOI: 10.1111/j.1445-5994.2010.02330.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practise time without increasing staffing. OBJECTIVES To examine the effectiveness and safety of CCT on mobility in adults with stroke. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched October 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2009), MEDLINE (1950 to November 2008), EMBASE (1980 to November 2008), CINAHL (1982 to November 2008) and 14 other electronic databases (to November 2008). We also searched proceedings from relevant conferences, reference lists and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers. SELECTION CRITERIA Randomised or quasi-randomised controlled trials including people over 18 years old diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed methodological quality and extracted data. MAIN RESULTS We included six trials involving 292 participants. Participants were long-term stroke survivors living in the community or receiving inpatient rehabilitation. All could walk 10 metres with or without assistance. Four studies measured walking capacity and three measured gait speed, demonstrating that CCT was superior to the comparison intervention (Six Minute Walk Test: mean difference (MD), fixed 76.57 metres, 95% confidence interval (CI) 38.44 to 114.70, P < 0.0001; gait speed: MD, fixed 0.12 m/s, 95% CI 0.00 to 0.24, P = 004). Two studies measured balance, showing a superior effect in favour of CCT (Step Test: MD, fixed 3.00 steps, 95% CI 0.08 to 5.91, P = 0.04; activities-specific balance and confidence: MD, fixed 7.76, 95% CI 0.66 to 14.87, P = 0.03). Studies also measured other balance items showing no difference in effect. Length of stay (two studies) showed a significant effect in favour of CCT (MD, fixed -19.73 days, 95% CI -35.43 to -4.04, P = 0.01). Only two studies measured adverse events (falls during therapy): all were minor. AUTHORS' CONCLUSIONS CCT is safe and effective in improving mobility for people after moderate stroke and may reduce inpatient length of stay. Further research is required, investigating quality of life, participation and cost-benefits, that compares CCT to standard care and that also investigates the differential effects of stroke severity, latency and age.
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Affiliation(s)
- Coralie English
- University of South Australia (City East)Centre for Allied Health EvidenceNorth TerraceAdelaideAustralia5000
| | - Susan L Hillier
- University of South Australia (City East)Centre for Allied Health EvidenceNorth TerraceAdelaideAustralia5000
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Bertram MY, Lim SS, Barendregt JJ, Vos T. Assessing the cost-effectiveness of drug and lifestyle intervention following opportunistic screening for pre-diabetes in primary care. Diabetologia 2010; 53:875-81. [PMID: 20135088 DOI: 10.1007/s00125-010-1661-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 12/16/2009] [Indexed: 10/19/2022]
Abstract
AIMS/HYPOTHESIS This study aims to evaluate the cost-effectiveness of a screening programme for pre-diabetes, which was followed up by treatment with pharmaceutical interventions (acarbose, metformin, orlistat) or lifestyle interventions (diet, exercise, diet and exercise) in order to prevent or slow the onset of diabetes in those at high risk. METHODS To approximate the experience of individuals with pre-diabetes in the Australian population, we used a microsimulation approach, following patient progression through diabetes, cardiovascular disease and renal failure. The model compares costs and disability-adjusted life years lived in people identified through an opportunistic screening programme for each intervention compared with a 'do nothing' scenario, which is representative of current practice. It is assumed that the effect of a lifestyle change will decay by 10% per year, while the effect of a pharmaceutical intervention remains constant throughout use. RESULTS The most cost-effective intervention options are diet and exercise combined, with a cost-effectiveness ratio of AUD 22,500 per disability-adjusted life year (DALY) averted, and metformin with a cost-effectiveness ratio of AUD 21,500 per DALY averted. The incremental addition of one intervention to the other is not cost-effective. CONCLUSIONS/INTERPRETATION Screening for pre-diabetes followed by diet and exercise, or metformin treatment is cost-effective and should be considered for incorporation into current practice. The number of dietitians and exercise physiologists needed to deliver such lifestyle change interventions will need to be increased to appropriately support the intervention.
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Affiliation(s)
- M Y Bertram
- Centre for Burden of Disease and Cost-Effectiveness, School of Population Health, The University of Queensland, Herston Rd, Herston, Queensland 4006, Australia.
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English C, Hillier SL. Circuit class therapy for improving mobility after stroke. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Piechowski-Jóźwiak B, Bogousslavsky J. Posterior circulation strokes. HANDBOOK OF CLINICAL NEUROLOGY 2009; 93:537-558. [PMID: 18804667 DOI: 10.1016/s0072-9752(08)93026-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Azarpazhooh MR, Nicol MB, Donnan GA, Dewey HM, Sturm JW, Macdonell RAL, Pearce DC, Thrift AG. Patterns of Stroke Recurrence According to Subtype of First Stroke Event: The North East Melbourne Stroke Incidence Study (NEMESIS). Int J Stroke 2008; 3:158-64. [DOI: 10.1111/j.1747-4949.2008.00204.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Specific information about the nature of recurrent events that occur after each subtype of index stroke may be useful for refining preventive therapies. We aimed to determine whether stroke recurrence rates, the pattern of subtype recurrence, and prescription of secondary prevention agents differed according to initial stroke subtype. Methods Multiple overlapping sources were used to recruit all first-ever stroke patients from a geographically defined region of Melbourne, Australia over a 3-year period from 1996 to 1999. Potential stroke recurrences (fatal and nonfatal) occurring within 2 years of the initial event were identified following patient interview and follow up of death records. Subjects were classified into the different Oxfordshire groups and the type of first-ever stroke was compared with recurrent stroke events. Results One thousand, three hundred and sixteen first-ever strokes were registered during the 3-year period (mean age 74·4 years). A total of 103 first recurrent stroke events (fatal and nonfatal) occurred among those with a first-ever ischemic stroke or intracerebral hemorrhage (ICH) during the 2-year follow-up period. The recurrent stroke subtype was different to the index stroke subtype in most (78%) patients. People with partial anterior circulation infarct had the greatest proportion of recurrences (13%), with a third of these being the more severe total anterior circulation infarct subgroup. The relative risk of ICH after an index lacunar infarct (LACI) compared with an index non-LACI was 4·06 (95% CI 1·10–14·97, P=0·038). Prescription of secondary prevention agents was greater at 2 years after stroke than at hospital discharge, and was similar between ischemic stroke subtypes. Conclusion Approximately 9% of people with first-ever stroke suffered a recurrent event, despite many being prescribed secondary prevention agents. This has implications for the uptake of current preventive strategies and the development of new strategies. The possibility that ICH is greater among index LACI cases needs to be confirmed.
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Affiliation(s)
- Mahmoud Reza Azarpazhooh
- National Stroke Research Institute, Austin Health, Heidelberg, Victoria, Australia
- Neurology Department, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Marcus B. Nicol
- National Stroke Research Institute, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey A. Donnan
- National Stroke Research Institute, Austin Health, Heidelberg, Victoria, Australia
- Neurology Department, Austin Health, Melbourne, Victoria, Australia
| | - Helen M. Dewey
- National Stroke Research Institute, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Neurology Department, Austin Health, Melbourne, Victoria, Australia
| | - Jonathan W. Sturm
- National Stroke Research Institute, Austin Health, Heidelberg, Victoria, Australia
| | - Richard A. L. Macdonell
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Neurology Department, Austin Health, Melbourne, Victoria, Australia
| | - Dora C. Pearce
- National Stroke Research Institute, Austin Health, Heidelberg, Victoria, Australia
| | - Amanda G. Thrift
- National Stroke Research Institute, Austin Health, Heidelberg, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Baker Heart Research Institute, Melbourne, Victoria, Australia
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Slot KB, Berge E, Dorman P, Lewis S, Dennis M, Sandercock P. Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies. BMJ 2008; 336:376-9. [PMID: 18230644 PMCID: PMC2244762 DOI: 10.1136/bmj.39456.688333.be] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To estimate the impact on long term survival of functional status at six months after ischaemic stroke. DESIGN Prospective cohort study. Settings Three cohorts: Oxfordshire community stroke project, Lothian stroke register, and the first international stroke trial (in the United Kingdom). PARTICIPANTS 7710 patients with ischaemic stroke registered between 1981 and 2000 and followed up for a maximum of 19 years. MAIN OUTCOME MEASURES Functional status at six months after stroke assessed with modified Rankin scale or "two simple questions." Mortality during follow-up. Survival analysis with Kaplan-Meier curves, log rank test, and Cox's regression model. RESULTS In a combined analysis of all three cohorts, among patients who survived to assessment six months after the index stroke, the subsequent median length of survival among those independent in daily living and those dependent was 9.7 years (95% confidence interval 8.9 to 10.6) and 6.0 years (5.7 to 6.4), respectively. In a combined analysis of the Oxfordshire and Lothian cohorts, subsequent median survival fell progressively from 12.9 years (10.0 to 15.9) for patients with a Rankin score of 0-1 at six months after the stroke to 2.5 years (1.4 to 3.5) for patients with a Rankin score of 5. All previously stated differences in median survival were significant (log rank test P<0.001). The influence of functional outcome on survival remained significant (P<0.05) in each cohort after adjustment for relevant covariates (such as age, presence of atrial fibrillation, visible infarct on computed tomography, subtype of stroke) in a Cox's regression model. CONCLUSION Functional status six months after an ischaemic stroke is associated with long term survival. Early interventions that reduce dependency at six months might have positive effects on long term survival.
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Affiliation(s)
- Karsten Bruins Slot
- Department of Internal Medicine, Ullevaal University Hospital, NO-0407 Oslo, Norway.
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Di Carlo A, Lamassa M, Baldereschi M, Pracucci G, Consoli D, Wolfe CDA, Giroud M, Rudd A, Burger I, Ghetti A, Inzitari D. Risk factors and outcome of subtypes of ischemic stroke. Data from a multicenter multinational hospital-based registry. The European Community Stroke Project. J Neurol Sci 2006; 244:143-50. [PMID: 16530226 DOI: 10.1016/j.jns.2006.01.016] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Revised: 11/21/2005] [Accepted: 01/20/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND Information on determinants and prognosis of ischemic stroke subtypes is scarce. We aimed at evaluating risk factors, pathogenesis, treatment and outcome of different ischemic stroke subtypes. METHODS In a European Concerted Action involving seven countries, ischemic stroke subtypes defined according to the Oxfordshire Community Stroke Project (OCSP) were evaluated for demographics, baseline risk factors, resource use, 3-month survival, disability (Barthel Index) and handicap (Rankin Scale). RESULTS During the 12-month study period, cerebral infarction was diagnosed in 2740 patients with first-in-a-lifetime stroke (mean age 70.5+/-12.4 years, 53.4% males). OCSP classification was achieved in 2472 (90.2%). Of these, 26.7% were total anterior circulation infarctions (TACI), 29.9% partial anterior circulation infarctions (PACI), 16.7% posterior circulation infarctions (POCI) and 26.7% lacunar infarctions (LACI). In multivariate analysis, atrial fibrillation was predictive of TACI (odds ratio [OR], 1.61; 95% CI, 1.28-2.03), hypertension (OR, 1.38; 95% CI, 1.16-1.65) and myocardial infarction (OR, 1.42; 95% CI, 1.08-1.86) predictive of PACI, hypertension (OR, 1.25; 95% CI, 1.04-1.50) predictive of LACI. A negative association was observed between TACI and hypertension (OR, 0.51; 95% CI, 0.42-0.61). Discharge home was 50% less probable in TACI and PACI than in LACI patients. As compared to LACI, TACI significantly increased the risk of 3-month death (OR, 5.73; 95% CI, 3.91-8.41), disability (OR, 3.27; 95% CI, 2.30-4.66) and handicap (OR, 2.71; 95% CI, 1.91-3.85). CONCLUSIONS Ischemic stroke subtypes have different risk factors profile, with consequences on pathogenesis and prognosis. Information on determinants of the clinical syndromes may impact on prevention and acute-phase interventions.
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Affiliation(s)
- Antonio Di Carlo
- Institute of Neurosciences, ILSA Study, Italian National Research Council, Viale Morgagni 46/48, 50134 Florence, Italy.
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Slivka AP, Notestine MA, Li J, Christoforidis GA. Clinical Predictors of Cerebrovascular Occlusion for Patients Presenting With Acute Stroke. J Stroke Cerebrovasc Dis 2006; 15:30-3. [PMID: 17904044 DOI: 10.1016/j.jstrokecerebrovasdis.2005.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Accepted: 08/05/2005] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE We sought to determine clinical predictors of vascular occlusion in patients with stroke. METHODS From November 1994 to December 1999, 88 patients who were thrombolytic candidates and seen within 6 hours of stroke symptom onset had cerebral angiography. The Oxford Community Stroke Project clinical classification system, admission National Institutes of Health Stroke Scale score, and time from symptom onset until angiography were used to predict vascular occlusion. RESULTS In all, 79% of patients with total anterior circulation infarctions and 73% with partial anterior circulation infarctions had vascular occlusions, whereas only 29% with lacunar infarcts had occlusion. Strokes were more severe in patients with occlusion than in those without occlusion. Time to angiography was also associated with vascular occlusion. CONCLUSIONS Clinical classification of stroke, stroke scales, and time to angiography are useful screening tools to predict cerebral occlusion in acute stroke patients.
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Affiliation(s)
- Andrew P Slivka
- Department of Neurology, Ohio State University Medical Center, Columbus, Ohio, USA
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Toyoda K, Fujii K, Fujimi S, Kumai Y, Tsuchimochi H, Ibayashi S, Iida M. Stroke in Patients on Maintenance Hemodialysis: A 22-Year Single-Center Study. Am J Kidney Dis 2005; 45:1058-66. [PMID: 15957135 DOI: 10.1053/j.ajkd.2005.02.028] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Few studies have reported the detailed clinical features of stroke in patients with end-stage renal disease. We examined the frequency of the subtypes, mechanism, and outcome of stroke in patients receiving hemodialysis (HD). METHODS We studied 151 consecutive patients who developed an acute stroke among the maintenance HD population in our kidney center during 22 years, divided into the initial 17-year (n = 61) and the more recent 5-year (n = 90) groups. For purposes of comparison, we also studied 1,017 stroke patients with normal renal function. RESULTS Stroke patients receiving HD were younger (age, 64 +/- 10 versus 67 +/- 13 years; P < 0.02) and more frequently had hypertension (87% versus 43%; P < 0.0001) and diabetes (53% versus 23%; P < 0.0001) compared with stroke patients with normal renal function. In the initial HD group, brain hemorrhage was the major subtype of stroke (52%), whereas in the more recent group, brain infarction (BI) replaced hemorrhage as the leading subtype (68%; P < 0.005). In patients with BI, large-artery atherosclerosis was more prevalent in the more recent group than in the initial HD group (33% versus 12%; P < 0.05). A vertebrobasilar territory infarct was more prevalent for HD patients than for those with normal renal function (48% versus 33%; P < 0.05). BI (especially large-artery atherosclerosis and cardioembolism) occurred more frequently during or less than 30 minutes after the dialysis procedure (34%) than brain hemorrhage (19%; P < 0.05). Receiving HD was an independent indicator for poor functional outcome and mortality after stroke. CONCLUSION In our maintenance HD population, stroke showed several unique characteristics compared with the control population, including a predominance of vertebrobasilar arterial territory infarcts. The dialysis procedure itself seems to be associated more frequently with ischemic rather than hemorrhagic strokes.
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Affiliation(s)
- Kazunori Toyoda
- Stroke Center, Department of Neurosurgery, Fukuoka Red Cross Hospital, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Varona JF, Bermejo F, Guerra JM, Molina JA. Long-term prognosis of ischemic stroke in young adults. Study of 272 cases. J Neurol 2005; 251:1507-14. [PMID: 15645352 DOI: 10.1007/s00415-004-0583-0] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2004] [Revised: 06/08/2004] [Accepted: 06/14/2004] [Indexed: 12/11/2022]
Abstract
BACKGROUND There have been few studies of the long-term prognosis of young adults with ischemic stroke. The present study aimed to evaluate the long-term clinical outcome in a large series of young adults with ischemic stroke admitted to a tertiary medical center over the last 27 years, and to identify possible predictors for mortality, stroke recurrence and poor functional recovery. METHODS We retrospectively reviewed 272 young adults (15-45 years) with a first-ever ischemic stroke admitted to the Neurology Department of University Hospital "12 de Octubre" between 1974 and 2001. Follow-up assessments were performed by review of medical records and telephone interviews. RESULTS Nine patients (3%) died as the result of their initial stroke and follow-up information about the status of 23 (8%) patients was not available. The remaining 240 patients (89%) were followed. Two hundred and ten of them (88%) were alive with a mean follow-up of 12.3 years and 30 (12%) died during follow-up. The average annual mortality rate was 1.4%, being notably higher during the first (4.9%) than in the subsequent years (0.9%) after the initial stroke. Ninety per cent of the followed patients were independent and 53% returned to work, although adjustments were necessary for 23% of them. The annual stroke recurrence rate during the first year was 3.6% dropping to 1.7% in subsequent years. Age over 35 years, male gender, the presence of cardiovascular risk factors and large-artery atherosclerosis in the carotid territory were predictors of negative long-term outcome after the initial stroke. CONCLUSIONS The long-term prognosis for the ischemic stroke in the young is better than in the elderly, but the risk of mortality in young adults with ischemic stroke is much higher than in the general population of the same age. A bad prognosis is associated with an atherosclerotic risk profile, with a higher mortality and recurrent stroke rates and poorer functional recovery. The main functional limitation in the young survivors of their initial ischemic stroke occurs in work activity, since most patients are independent but almost half of them do not return to work.
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Affiliation(s)
- J F Varona
- Department of Internal Medicine, University Hospital 12 de Octubre, Avda. Andalucía, km 5.4, 28041-Madrid, Spain.
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Qureshi AI, Kirmani JF, Sayed MA, Siddiqui AM, Safdar A, Pande RU, Ahmed S, Ferguson R, Hershey LA, Qazi KJ. Buffalo Metropolitan Area and Erie County Stroke Study: Rationale, Design, and Methods. Neuroepidemiology 2004; 23:289-98. [PMID: 15297796 DOI: 10.1159/000080095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The primary objective of this study was to define the incidence, disability, and death associated with stroke in the Buffalo metropolitan area and Erie County. This area has the highest stroke rate in New York State and therefore represents an ideal site to develop a successful model for prevention and management of stroke. DESIGN A cross-sectional design to study all new and recurrent strokes that occurred in the calendar year 2000 in the geographical location of Buffalo metropolitan area and Erie County. PATIENTS AND DATA COLLECTED: A retrospective review of an estimated 5,000 patients with new stroke will be performed at regional hospitals and the coroner's office to determine the stroke subtypes, cerebrovascular risk factors, diagnostic investigations, treatment provided, and outcome. The total population residing in Buffalo in the year 2000 is available through the recent census. The study will also evaluate the quality of care provided for stroke patients including effectiveness of primary and secondary stroke prevention measures within this geographical region. CONCLUSIONS We believe that this information will assist in allocation of resources and implementation of steps to improve stroke prevention and treatment.
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Affiliation(s)
- Adnan I Qureshi
- Department of Neurology, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA.
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Dewey HM, Thrift AG, Mihalopoulos C, Carter R, Macdonell RAL, McNeil JJ, Donnan GA. Lifetime cost of stroke subtypes in Australia: findings from the North East Melbourne Stroke Incidence Study (NEMESIS). Stroke 2003; 34:2502-7. [PMID: 12970517 DOI: 10.1161/01.str.0000091395.85357.09] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Little is known about any variations in resource use and costs of care between stroke subtypes, especially nonhospital costs. The purpose of this study was to describe the patterns of resource use and to estimate the first-year and lifetime costs for stroke subtypes. METHODS A cost-of-illness model was used to estimate the total first-year costs and lifetime costs of stroke subtypes for all strokes (subarachnoid hemorrhages excluded) that occurred in Australia during 1997. For each subtype, average cost per case during the first year and the present value of average cost per case over a lifetime were calculated. Resource use data obtained in the North East Melbourne Stroke Incidence Study (NEMESIS) were used. RESULTS The present value of total lifetime costs for all strokes was Aus 1.3 billion dollars (US 985 million dollars). Total lifetime costs were greatest for ischemic stroke (72%; Aus 936.8 million dollars; US 709.7 million dollars), followed by intracerebral hemorrhage (26%; Aus 334.5 million dollars; US 253.4 million dollars) and unclassified stroke (2%; Aus 30 million dollars; US 22.7 million dollars). The average cost per case during the first year was greatest for total anterior circulation infarction (Aus 28 266 dollars). Over a lifetime, the present value of average costs was greatest for intracerebral hemorrhage (Aus 73 542 dollars), followed by total anterior circulation infarction (Aus 53 020 dollars), partial anterior circulation infarction (Aus 50 692 dollars), posterior circulation infarction (Aus 37 270 dollars), lacunar infarction (Aus 34 470 dollars), and unclassified stroke (Aus 12 031 dollars). CONCLUSIONS First-year and lifetime costs vary considerably between stroke subtypes. Variation in average length of total hospital stay is the main explanation for differences in first-year costs.
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Affiliation(s)
- Helen M Dewey
- National Stroke Research Institute, Level 1, Neurosciences Bldg, Repatriation Campus, Austin & Repatriation Medical Centre, 300 Waterdale Rd, Heidelberg Heights, Victoria 3081, Australia. au
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