Stroke

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REVIEW our Selected Stroke Articles in 2006. Stay informed and updated!

Stroke

NIH - Medical Encyclopedia: Stroke

"The goal is to get the person to the emergency room immediately, determine if he or she is having a bleeding stroke or a stroke from a blood clot, and start therapy -- all within 3 hours of when the stroke began."

Highlighted Article

Transient Ischemic Attack: A Dangerous Harbinger and an Opportunity to Intervene. (Semin Neurol. 2005)

"Transient ischemic attack (TIA) and ischemic stroke are both characterized by sudden onset of neurological symptoms due to focal cerebral ischemia, but they are distinguished by the duration of neurological symptoms, with TIA traditionally defined by resolution of symptoms within 24 hours and stroke reserved for symptoms of longer duration. ... The short-term risk of ischemic stroke after TIA is very high ..."

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Stroke

Daily Treatment Report

Cognitive Therapy-CBT-Psychotherapy

Device Therapy

Stroke treatment: Carotid and intracranial stents

Lifesaving Stroke Device

Drug Side-Effects and Interactions

Myocardial infarction following t-PA for acute stroke. (Can J Neurol Sci. 2007)

Hemorrhage After Thrombolytic Therapy for Stroke. The Clinically Relevant Number Needed to Harm (Stroke 2007) "Conclusions--Most patients who experience SICH have severe baseline infarcts and already are destined for poor outcomes. For every 100 patients treated with tPA, approximately 1 will experience a severely disabled or fatal final outcome as a result of tPA-related SICH."

Risk Factors of Symptomatic Intracerebral Hemorrhage After tPA Therapy for Acute Stroke (Stroke. 2007) "Studies evaluating predictors of tPA-associated symptomatic intracerebral hemorrhage (SICH) have typically focused on clinical and CT-based variables. MRI-based variables have generally not been included in predictive models, and little is known about the influence of reperfusion on SICH risk. … Conclusion— Patients with large baseline DWI lesion volumes who achieve early reperfusion appear to be at greatest risk of SICH after tPA therapy."

Symptomatic Intracerebral Hemorrhage following Thrombolytic Therapy for Acute Ischemic Stroke: A Review of the Risk Factors. (Cerebrovasc Dis. 2007) "Summary of Review: Twelve studies met inclusion criteria for the systematic review. Extent of hypoattenuated brain parenchyma on pretreatment CT and elevated serum glucose or history of diabetes were independent risk factors for thrombolysis-associated SICH in six of the twelve studies. Symptom severity was an independent risk factor in three of the studies and advanced age, increased time to treatment, high systolic blood pressure, low platelets, history of congestive heart failure and low plasminogen activator inhibitor levels were found to be independent risk factors for SICH in a single study. Although these data should not alter the current guidelines for the use of rt-PA in acute stroke, they may help develop future strategies aimed at reducing the rate of thrombolysis-associated SICH."

The increasing incidence of anticoagulant-associated intracerebral hemorrhage. (Neurology. 2007) "CONCLUSIONS: The incidence of anticoagulant-associated intracerebral hemorrhage quintupled in our population during the 1990s. The majority of this change can be explained by increasing warfarin use. Anticoagulant-associated intracerebral hemorrhage now occurs at a frequency comparable to subarachnoid hemorrhage."

Efficacy and Safety of Anticoagulant Treatment in Acute Cardioembolic Stroke. A Meta-Analysis of Randomized Controlled Trials. (Stroke. 2007) "CONCLUSIONS: Our findings indicate that in patients with acute cardioembolic stroke, early anticoagulation is associated with a nonsignificant reduction in recurrence of ischemic stroke, no substantial reduction in death and disability, and an increased intracranial bleeding."

Drugs

[Antithrombotic therapy in ischemic stroke and transient ischemic attack.] (Ugeskr Laeger. 2007)

Minocycline May Improve Stroke Outcomes Out to 24 Hours "Minocycline is a semisynthetic, second-generation derivative of tetracycline and has been shown to have a "clear beneficial protective effect" in animal models of multiple sclerosis, Parkinson's disease, Huntington's disease, and amyotrophic lateral sclerosis, as well as in stroke models, the authors write. The proposed mechanism of benefit is thought to relate not to its antibiotic action but to its anti-inflammatory effects, a reduction in microglial activation, matrix metalloproteinase reduction, nitric oxide production, or inhibition of apoptotic cell death, they note."

Effect of Aspirin on Lipoprotein(a) in Patients With Ischemic Stroke. (J Stroke Cerebrovasc Dis. 2007) "Results of our study confirm that aspirin lowers the increased Lp(a) levels in patients with ischemic stroke."

Continued Statin Use Boosts Post-Stroke Outcomes " Hospitalized stroke patients who stop taking their cholesterol-lowering statin drugs -- even for a short time -- may increase their long-term risk of death and disability, researchers report. The Spanish study found that withdrawing statins -- which include drugs like Crestor, Pravachol and Zocor -- in the first three days after a stroke raised a patient's risk of either dying or becoming physically dependant three months later by nearly fivefold, compared with patients who continued their statin regimen. "

Long-Term Outcome as Function of Blood Pressure in Acute Ischemic Stroke and Effects of Thrombolysis. (Cerebrovasc Dis. 2007)

Calcium antagonists for aneurysmal subarachnoid haemorrhage. (Cochrane Database Syst Rev. 2007)

Mannitol for acute stroke. (Cochrane Database Syst Rev. 2007)

The efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of venous thromboembolism after acute ischaemic stroke (PREVAIL Study): an open-label randomised comparison (The Lancet 2007) "Our results suggest that for patients with acute ischaemic stroke, enoxaparin is preferable to unfractionated heparin for venous thromboembolism prophylaxis in view of its better clinical benefits to risk ratio and convenience of once daily administration."

Naftidrofuryl for acute stroke. (Cochrane Database Syst Rev. 2007) "AUTHORS' CONCLUSIONS: There is not enough evidence to support the use of naftidrofuryl in the treatment of acute ischaemic or haemorrhagic stroke."

Men benefit more than women from tPA stroke treatment "Men are more likely than women to benefit from the use of tissue plasminogen activator within three hours after stroke, according to a study published in the March 13 issue of Neurology. The study involved 333 people who were treated with tPA. It found that men were more than three times as likely as women to achieve functional independence at three months after tPA treatment, despite the fact that fewer men than women survived three months after treatment."

[Effective acute stroke treatment beyond approval limitations: intravenous thrombolysis within an extended time window (3 - 6 h) and in old patients (aged 80 or older).] (Fortschr Neurol Psychiatr. 2007) "To summarize, we recommend experienced stroke centres to treat acute stroke patients with thrombolysis up to 6 hours using MRI criteria for patient selection, and to treat also patients aged 80 years or older"

Speed of tPA-Induced Clot Lysis Predicts DWI Lesion Evolution in Acute Stroke (Stroke. 2007) "Conclusions— The speed of tPA-induced clot lysis predicts DWI lesion evolution and clinical outcome. Unlike sudden and stepwise patterns, slow recanalization is associated with greater DWI lesion growth and poorer short- and long-term outcomes."

Symptomatic intracranial haemorrhage after intra-arterial thrombolysis in acute ischaemic stroke: assessment of 294 patients treated with urokinase. (J Neurol Neurosurg Psychiatry. 2007) " CONCLUSIONS: With regard to the whole spectrum of cerebral vessel occlusions, an incidence of <5% sICH after IAT is distinctly low. This result underlines the important role of IAT in the treatment of acute stroke."

Reduced Poststroke Mortality in Patients With Stroke and Atrial Fibrillation Treated With Anticoagulants (Stroke. 2007) "Conclusions— Our data suggest that anticoagulation treatment reduces poststroke mortality in patients with ischemic stroke and AF."

Thrombolytic Therapy for Acute Ischemic Stroke in Octogenarians: MRI Selection Improves Safety but Does not Improve Efficacy Outcomes. (J Neurol Neurosurg Psychiatry. 2007) "The overall rate of haemorrhage and improved efficacy outcomes was not statistically different in the two age groups and no significant difference was observed concerning the efficacy outcomes in MRI versus CT-patients."

Confirmation of tPA Treatment Effect by Baseline Severity-Adjusted End Point Reanalysis of the NINDS-tPA Stroke Trials (Stroke. 2007) "Conclusion— Baseline-adjusted severity end point reanalysis of the NINDS Stroke tPA trials confirms a beneficial treatment effect of intravenous tPA."

Reduced Poststroke Mortality in Patients With Stroke and Atrial Fibrillation Treated With Anticoagulants (Stroke. 2007) "Conclusions— Our data suggest that anticoagulation treatment reduces poststroke mortality in patients with ischemic stroke and AF."

Efficacy and Safety of Anticoagulant Treatment in Acute Cardioembolic Stroke (Stroke. 2007) " Conclusions— Our findings indicate that in patients with acute cardioembolic stroke, early anticoagulation is associated with a nonsignificant reduction in recurrence of ischemic stroke, no substantial reduction in death and disability, and an increased intracranial bleeding."

Intra-Arterial Thrombolysis for Acute Stroke in Patients 80 and Older: A Comparison of Results in Patients Younger than 80 Years (American Journal of Neuroradiology 2007) "CONCLUSIONS: Intra-arterial fibrinolysis in the elderly can be accomplished with recanalization rates and hemorrhage rates equal to that in younger patients. Although mortality rates are higher and good functional outcomes are lower than in younger persons, nondisabling outcomes may be achieved in a quarter of patients. These findings suggest that the investigation and use of intra-arterial thrombolytic treatment in very elderly patients should not be avoided but pursued judiciously."

Recanalization after thrombolysis in stroke patients (NEUROLOGY 2007) "Conclusions: We found a high rate of vessel recanalization after IV thrombolysis occlusion. However, recanalization was infrequent in patients with diabetes and extracranial carotid occlusion. Information on recanalization was a powerful, early predictor for clinical outcome."

Acute Stroke Management in the Elderly (Cerebrovascular Diseases 2007) "Conclusions: Early treatment with rtPA in patients >80 years appears to be both safe and efficacious. Treated patients showed improvements both acutely (a decrease in NIHSS at 72 h) and chronically, as shown by a sustained improvement in the Barthel Index. A large number of elderly patients were excluded from rtPA treatment despite arriving within the time frame of treatment for reasons not considered as traditional exclusion criteria. Older patients with AIS can be treated safely with thrombolytic therapy in a community setting. This therapy should not be withheld on the basis of age."

Exercise

General Information

Poststroke depression: importance of its detection and treatment. (Cerebrovasc Dis. 2007)

Need For Speed: Two New Studies On Stroke "No matter what kind of stroke or mini-strokes patients have, the best course of action in all cases is to call 911, so that an ambulance or other emergency medical team can arrive and transport the patient to the hospital. Driving to the hospital oneself, or being driven by a friend or loved one, is less ideal because of delays that can occur en route or upon arrival at the hospital. Even at major hospitals with dedicated 24-hour stroke teams, such as U-M, it can take an hour or more to use diagnostic tests to assess what type of stroke a patient is having and to start tPA treatment. At smaller hospitals, it can be more than an hour -- and intra-arterial tPA, which can be given up to six hours after the start of a stroke, may not be available. So, a person experiencing a stroke really needs to get to a hospital within two hours of the start of a stroke to have the best chance of receiving tPA ... "

Atrial fibrillation as an independent predictor for no early recanalization after IV-t-PA in acute ischemic stroke. (J Neurol Sci. 2007)

[Hypertension and stroke.] (Ugeskr Laeger. 2007)

[Stroke - an emergency.] (Ugeskr Laeger. 2007)

[Intracerebral haemorrhage.] (Ugeskr Laeger. 2007)

Treating mini-strokes rapidly cuts later risk "Treating patients quickly for mini-strokes could dramatically cut the risk of a major stroke later, report two studies that could change standard treatment and potentially save millions of people from stroke’s damaging effects. In research published Tuesday, British and French doctors found that patients treated within 24 hours of having a mini-stroke cut their chances by 80 percent of having a more serious stroke in the next three months. … In the U.K., most patients who have small strokes are referred by their doctors to specialist clinics. Many wait several weeks before being treated. In the United States too, many people are sent home within a day if their symptoms seem to resolve. … Doctors increasingly say that small strokes should be seen as warning signals for a more dangerous stroke later on, in the same way that chest pain can be a red flag for an imminent heart attack."

Clinical review: Imaging in ischaemic stroke - implications for acute management. (Crit Care. 2007)

Hospital volume and stroke outcome (NEUROLOGY 2007) "Conclusions: High annual hospital volume was consistently associated with lower stroke mortality. Our study encourages further research to determine whether this is due to differences in case mix, more organized care in high-volume facilities, or differences in the performance or in the processes of care among facilities."

Advances in the Care of Patients With Intracerebral Hemorrhage (Mayo Clin Proc. 2007)

Thrombolytic Therapy for Acute Ischemic Stroke: The Likelihood of Being Helped Versus Harmed

The management of blood pressure after stroke. (Neurologist. 2007)

The headache over warfarin in British neurosurgical intensive care units: a national survey of current practice. (Intensive Care Med. 2007)

Combining Multiple Approaches for the Secondary Prevention of Vascular Events After Stroke (Stroke. 2007) ”Results— The combination of 5 proven strategies applied to survivors of an initial stroke or transient ischemic attack—dietary modification, exercise, aspirin, a statin, and an antihypertensive agent—could result in a cumulative relative risk reduction of 80%."

NYT Feature Looks at Lost Opportunities in Stroke Care "Among the missed opportunities discussed is the underuse of tissue plasminogen activator (tPA). "Many hospitals say they cannot afford to have neurologists on call to diagnose strokes and cannot afford to have [magnetic resonance imaging] MRI scanners, the most accurate way to diagnose strokes, for the emergency room," Ms. Kolata notes. Although more than 10 years have passed since it was shown to be effective, only 3% to 4% of patients receive tPA. "I label this a national tragedy or a national embarrassment," Mark J. Alberts, MD, a neurologist from the Feinberg School of Medicine at Northwestern University, in Chicago, Illinois, tells Ms. Kolata."

[Stroke - a study of clinical management and prognosis.] (Tidsskr Nor Laegeforen. 2007)

Management and Outcome of Patients with Transient Ischemic Attack Admitted to a Stroke Unit. (Cerebrovasc Dis. 2007)

Prehospital and Hospital Delays After Stroke Onset --- United States, 2005--2006 (MMWR 2007) "Editorial Note: For ischemic stroke patients to benefit from intravenous t-PA therapy, under current guidelines therapy should begin as soon as possible after diagnosis and determination of eligibility and within 3 hours of symptom onset (3). The findings described in this report indicate that fewer than half of the patients arrived at the ED within 2 hours of symptom onset, whereas nearly two-thirds of those who arrived at the ED within 2 hours of onset received brain imaging within 1 hour of ED arrival. … Patients arriving by ambulance had significantly shorter wait times for brain imaging. Consistent with previous reports (6), approximately half of the patients in the registry population arrived by ambulance. Arriving by ambulance might expedite triage decisions in the ED and lead to shorter delays before brain imaging. Both shorter prehospital and hospital delays will increase the proportion of patients with ischemic stroke who can receive brain imaging, t-PA therapy, and early secondary prevention therapies and reduce their risk for severe disability from stroke."

Combining Multiple Approaches for the Secondary Prevention of Vascular Events After Stroke. A Quantitative Modeling Study. (Stroke. 2007)

Secondary Prevention of Stroke and Transient Ischemic Attack (Circulation. 2007) "Conclusion— Because the vast majority of patients with ischemic stroke have recurrent stroke or transient ischemic attack, rather than myocardial infarction, as their next event, antiplatelet therapies for these patients should be administered according to what has been shown to be efficacious for secondary stroke protection rather than for myocardial protection. Combination therapies, which provide optimal platelet inhibition as well as vascular protection, may offer the best strategy for secondary stroke protection."

Current management of transient ischemic attack. (Am J Cardiovasc Drugs. 2007) "In general, aspirin is the first line of treatment to prevent further stroke. Other antiplatelet agents such as clopidogrel alone or in combination with aspirin and the combination aspirin/extended-release dipyridamole may be administered. Endarterectomy or carotid stenting is of great benefit to patients with TIA secondary to stenosis in the extracranial carotid artery."

Weekends: A Dangerous Time for Having a Stroke? (Stroke. 2007) "CONCLUSIONS: Stroke patients admitted on weekends had a higher risk-adjusted mortality than did patients admitted on weekdays. Disparities in resources, expertise, and healthcare providers working during weekends may explain the observed differences in weekend mortality."

Stroke care demands radical approach "Around 10% to 15% of patients in the developed world die following acute stroke, 30% to 60% survive with long-term disabilities, and 20% to 25% require a hospital stay. … The current standard of practice is to send patients for thrombolytic therapy within three hours of symptom onset. Once this time window has passed, treatments such as intravenous tissue plasminogen activator are not generally considered. … Results from recent clinical trials show that the time window for treating stroke could be extended, possibly up to nine hours. These same trials have also validated the concept of an ischemic penumbra, that is, an area of potentially salvageable tissue surrounding infarcted, dead brain. … An increasing number of stroke patients are being treated with endovascular methods rather than thrombolytic therapy, said Dr. Michael Forsting, chair of radiology and neuroradiology at the University of Essen in Germany. He recommends that mechanical recanalization be included in any endovascular repertoire, owing to its ability to dramatically reduce the risk of hemorrhagic transformation and true intracerebral hemorrhage. "

The Impact of Recanalization on Ischemic Stroke Outcome (Stroke. 2007) "Conclusions— Formal meta-analysis confirms a strong correlation between recanalization and outcome in acute ischemic stroke. Recanalization is strongly associated with improved functional outcomes and reduced mortality. These findings suggest that recanalization is an appropriate biomarker of therapeutic activity in early phase trials of thrombolytic treatment in acute ischemic stroke."

Prevention of deep venous thrombosis and pulmonary embolism following stroke: a systematic review of published articles. (Eur J Neurol. 2007)

Monitoring and imaging the clot during systemic thrombolysis in stroke patients. (Expert Rev Cardiovasc Ther. 2007)

Stroke and the statistics of the aspirin/clopidogrel secondary prevention trials. (Curr Opin Neurol. 2007) " SUMMARY: Even after four large randomized trials we still do not know the optimal treatment for secondary prevention of stroke."

Analysis of the reasons for exclusion from tPA therapy after early arrival in acute stroke patients (Clinical Neurology and Neurosurgery 2007)

Guidelines

NGC - Alteplase for the treatment of acute ischaemic stroke. (2007)

Guidelines Updated for Treatment of Spontaneous Intracerebral Hemorrhage in Adults

NGC - 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. (2007)

Guidelines for the Early Management of Adults With Ischemic Stroke (Stroke. 2007)

NGC - Guidelines for the management of spontaneous intracerebral hemorrhage in adults. 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. (2007)

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. (Stroke 2007)

Immunotherapy

Internet Sites

Treatment Information

DrugBank (drug structure)

FDA - MedWatch (Drug Alerts)

Drug-Food-Supplement Information

Drug Information Online

Drug Interaction Checker

DrugDigest (drug interactions)

FDA - Drug Interactions: What You Should Know

NIH - Botanical Dietary Supplements: Background Information

NIH - Drug, Supplements, and Herbal Information

NIH - Herbal Supplements: Consider Safety, Too

NIH - Medicines

NIH - Vitamin and Mineral Supplement Fact Sheets

Nutrition

Other

Other Treatments

A review of oxygen therapy in ischemic stroke. (Neurol Res. 2007)

Therapeutic hypothermia in acute ischemic stroke. (xpert Rev Neurother. 2007)

Experimental

Radiotherapy

Supplements-Vitamins-CAM

Surgery

Surgical treatment of intracerebral haemorrhage. (Current Opinion in Critical Care 2007)

Transplantation

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