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Chauhan, Anjali, Hope Moser, and Louise D. McCullough. "Sex differences in ischaemic stroke: potential cellular mechanisms." Clinical Science 131, no. 7 (March 17, 2017): 533–52. http://dx.doi.org/10.1042/cs20160841.
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Stroke remains a leading cause of mortality and disability worldwide. More women than men have strokes each year, in part because women live longer. Women have poorer functional outcomes, are more likely to need nursing home care and have higher rates of recurrent stroke compared with men. Despite continued advancements in primary prevention, innovative acute therapies and ongoing developments in neurorehabilitation, stroke incidence and mortality continue to increase due to the aging of the U.S. population. Sex chromosomes (XX compared with XY), sex hormones (oestrogen and androgen), epigenetic regulation and environmental factors all contribute to sex differences. Ischaemic sensitivity varies over the lifespan, with females having an “ischaemia resistant” phenotype that wanes after menopause, which has recently been modelled in the laboratory. Pharmacological therapies for acute ischaemic stroke are limited. The only pharmacological treatment for stroke approved by the Food and Drug Administration (FDA) is tissue plasminogen activator (tPA), which must be used within hours of stroke onset and has a number of contraindications. Pre-clinical studies have identified a number of potentially efficacious neuroprotective agents; however, nothing has been effectively translated into therapy in clinical practice. This may be due, in part, to the overwhelming use of young male rodents in pre-clinical research, as well as lack of sex-specific design and analysis in clinical trials. The review will summarize the current clinical evidence for sex differences in ischaemic stroke, and will discuss sex differences in the cellular mechanisms of acute ischaemic injury, highlighting cell death and immune/inflammatory pathways that may contribute to these clinical differences.
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Lake, Evelyn M. R., Paolo Bazzigaluppi, and Bojana Stefanovic. "Functional magnetic resonance imaging in chronic ischaemic stroke." Philosophical Transactions of the Royal Society B: Biological Sciences 371, no. 1705 (October 5, 2016): 20150353. http://dx.doi.org/10.1098/rstb.2015.0353.
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Ischaemic stroke is the leading cause of adult disability worldwide. Effective rehabilitation is hindered by uncertainty surrounding the underlying mechanisms that govern long-term ischaemic injury progression. Despite its potential as a sensitive non-invasive in vivo marker of brain function that may aid in the development of new treatments, blood oxygenation level-dependent (BOLD) functional magnetic resonance imaging (fMRI) has found limited application in the clinical research on chronic stage stroke progression. Stroke affects each of the physiological parameters underlying the BOLD contrast, markedly complicating the interpretation of BOLD fMRI data. This review summarizes current progress on application of BOLD fMRI in the chronic stage of ischaemic injury progression and discusses means by which more information may be gained from such BOLD fMRI measurements. Concomitant measurements of vascular reactivity, neuronal activity and metabolism in preclinical models of stroke are reviewed along with illustrative examples of post-ischaemic evolution in neuronal, glial and vascular function. The realization of the BOLD fMRI potential to propel stroke research is predicated on the carefully designed preclinical research establishing an ischaemia-specific quantitative model of BOLD signal contrast to provide the framework for interpretation of fMRI findings in clinical populations. This article is part of the themed issue ‘Interpreting BOLD: a dialogue between cognitive and cellular neuroscience’.
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Moxon, Joseph V., Alexandra F. Trollope, Brittany Dewdney, Catherine de Hollander, Domenico R. Nastasi, Jane M. Maguire, and Jonathan Golledge. "The effect of angiopoietin-1 upregulation on the outcome of acute ischaemic stroke in rodent models: A meta-analysis." Journal of Cerebral Blood Flow & Metabolism 39, no. 12 (October 4, 2019): 2343–54. http://dx.doi.org/10.1177/0271678x19876876.
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Clinical studies report that low circulating angiopoietin-1 concentration at presentation predicts worse outcomes after ischaemic stroke. Upregulating angiopoietin-1 may therefore have therapeutic benefit for ischaemic stroke. This systematic review assessed whether upregulating angiopoietin-1 improved outcomes in rodent models of ischaemic stroke. Random-effects models quantified the effect of angiopoietin-1 upregulation on stroke severity in terms of the size of cerebral infarction and the extent of blood–brain barrier permeability. Eleven studies utilising rat and mouse models of ischaemic stroke fulfilled the inclusion criteria. Meta-analyses demonstrated that angiopoietin-1 upregulation significantly reduced cerebral infarction size (standardised mean difference: –3.02; 95% confidence intervals: –4.41, –1.63; p < 0.001; n = 171 animals) and improved blood–brain barrier integrity (standardized mean difference: –2.02; 95% confidence intervals: –3.27, –0.77; p = 0.002; n = 129 animals). Subgroup analyses demonstrated that angiopoietin-1 upregulation improved outcomes in models of transient, not permanent cerebral ischaemia. Six studies assessed the effect of angiopoietin-1 upregulation on neurological function; however, inter-study heterogeneity prevented meta-analysis. In conclusion, published rodent data suggest that angiopoietin-1 upregulation improves outcome following temporary cerebral ischaemia by reducing cerebral infarction size and improving blood–brain barrier integrity. Additional research is required to examine the effect of angiopoietin-1 upregulation on neurological function during stroke recovery and investigate the benefit and risks in patients.
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Liu, Yan, Bo Yin, and Yanping Cong. "The Probability of Ischaemic Stroke Prediction with a Multi-Neural-Network Model." Sensors 20, no. 17 (September 3, 2020): 4995. http://dx.doi.org/10.3390/s20174995.
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As is known, cerebral stroke has become one of the main diseases endangering people’s health; ischaemic strokes accounts for approximately 85% of cerebral strokes. According to research, early prediction and prevention can effectively reduce the incidence rate of the disease. However, it is difficult to predict the ischaemic stroke because the data related to the disease are multi-modal. To achieve high accuracy of prediction and combine the stroke risk predictors obtained by previous researchers, a method for predicting the probability of stroke occurrence based on a multi-model fusion convolutional neural network structure is proposed. In such a way, the accuracy of ischaemic stroke prediction is improved by processing multi-modal data through multiple end-to-end neural networks. In this method, the feature extraction of structured data (age, gender, history of hypertension, etc.) and streaming data (heart rate, blood pressure, etc.) based on a convolutional neural network is first realized. A neural network model for feature fusion is then constructed to realize the feature fusion of structured data and streaming data. Finally, a predictive model for predicting the probability of stroke is obtained by training. As shown in the experimental results, the accuracy of ischaemic stroke prediction reached 98.53%. Such a high prediction accuracy will be helpful for preventing the occurrence of stroke.
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Fraser, Justin F. "Standardisation of research strategies in acute ischaemic stroke." Lancet Neurology 15, no. 8 (July 2016): 784–85. http://dx.doi.org/10.1016/s1474-4422(16)30080-1.
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Appleton, Jason P., Randeep Mullhi, and Naginder Singh. "Initial management of acute ischaemic stroke." British Journal of Hospital Medicine 82, no. 1 (January 2, 2021): 1–9. http://dx.doi.org/10.12968/hmed.2020.0193.
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The management of acute ischaemic stroke has been revolutionised by effective reperfusion therapies including thrombolysis and mechanical thrombectomy. In particular, mechanical thrombectomy has heralded a new era in stroke medicine. There have also been developments to improve clinical outcomes for patients who have had an acute ischaemic stroke but are not eligible for this procedure. This article presents an update on the initial management of acute ischaemic stroke, including reperfusion therapies, periprocedural considerations and ongoing research for potential improvements in the care of these patients.
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Jia, Jia, Jie Li, and Jian Cheng. "H2S-based therapies for ischaemic stroke: opportunities and challenges." Stroke and Vascular Neurology 4, no. 2 (June 2019): 63–66. http://dx.doi.org/10.1136/svn-2018-000194.
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Stroke is a cerebrovascular disease displaying high mortality and morbidity. Despite extensive efforts, only very few therapies are available for stroke patients as yet. Hydrogen sulfide (H2S) is thought to be a signalling molecule that is endogenously produced and plays functional roles in the central nervous system. Currently, numerous studies show that H2S impacts stroke outcomes in animal and cellular models. Here, we review the recent research regarding the effects of endogenously produced H2S as well as exogenous H2S donors on stroke pathology, focusing on the potential of H2S-based therapies in treating ischaemic stroke. We also discuss the several issues that hinder the clinical translation of H2S-based therapies from the bench. Taken together, we think that H2S-based therapies are promising strategies for treating cerebral ischaemia if we successfully address these issues.
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Kirkham, Fenella, Guillaume Sébire, Maja Steinlin, and Ronald Sträter. "Arterial ischaemic stroke in children." Thrombosis and Haemostasis 92, no. 10 (2004): 697–706. http://dx.doi.org/10.1160/th04-04-0209.
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SummaryConditions associated with arterial ischaemic stroke in children include a great variety of diseases and triggers such as congenital heart malformations, sickle cell disease, infections and vasculopathies, although up to 50% are cryptogenic. An abnormal vascular status can be demonstrated by vascular imaging in up to 80% of children with ischaemic stroke, and case control studies demonstrate an association between ischaemic stroke in children and hereditary prothrombotic risk factors and infections such as Varicella. Conventional risk factors such as hypertension and dyslipidaemia may also play a role, and most children have several potential triggers rather than one single cause. This review focuses on clinical presentations, imaging methods, stroke subtypes, underlying conditions including prothrombotic risk factors, outcome and recurrence. Although data from randomised controlled trials, on which clinical practice might be based, are sparse, therapeutic approaches and future research directions are discussed.
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Kermode-Scott, Barbara. "Research suggests thrombolysis is effective for acute ischaemic stroke." BMJ 330, no. 7501 (May 19, 2005): 1167.2. http://dx.doi.org/10.1136/bmj.330.7501.1167-a.
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Kang, Eugene Yu-Chuan, Yun-Hsuan Lin, Nan-Kai Wang, Ling Yeung, Caesar Luo, Wei-Chi Wu, Chi-Chin Sun, Je-Ho Kang, Ming-Jui Hung, and Tien-Hsing Chen. "Aspirin use in central retinal arterial occlusion to prevent ischaemic stroke: a retrospective cohort study in Taiwan." BMJ Open 9, no. 2 (February 2019): e025455. http://dx.doi.org/10.1136/bmjopen-2018-025455.
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ObjectiveTo understand the efficacy of aspirin use for preventing ischaemic stroke after central retinal artery occlusion (CRAO).DesignThe retrospective cohort study was conducted using the National Health Insurance Research Database from 1998 to 2013.SettingA population-based study.ParticipantsA total of 9437 participants with newly diagnosed CRAO were identified. Participants who had a previous stroke and/or retinal vascular occlusion, were aged <20 years and used aspirin 3 months before the event were excluded. There were 3778 eligible participants matched by propensity score, and they were divided into aspirin (n=434) and aspirin-naive (n=1736) groups after the matching.MethodsCox proportional hazard models and cumulative survival curves were used to assess ischaemic stroke in the study groups, along with log-rank tests to compare group differences.Main outcome measuresIncidence of ischaemic stroke in the aspirin and aspirin-naive groups 1 year after CRAO.ResultsOf the 3778 patients with newly diagnosed CRAO, 151 (4%) had a subsequent ischaemic stroke within 1 year. The risk was especially high during the first week of the CRAO. No difference between the aspirin and aspirin-naive groups was found in risk of ischaemic stroke, haemorrhagic stroke, gastrointestinal bleeding, major bleeding, acute coronary syndrome, retinal vein occlusion, new-onset glaucoma, undergoing panretinal photocoagulation or all-cause mortality. Risk factors for ischaemic stroke within 1 year of CRAO included male gender (p=0.031; HR=1.46) and age (p=0.032; HR=1.14).ConclusionsAspirin use after a CRAO showed no benefit on attenuating the risk of ischaemic stroke. The risk of ischaemic stroke was increased after CRAO especially during the first week. Male gender and age were risk factors for ischaemic stroke after CRAO.
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Damiza-Detmer, Agnieszka, Izabela Damiza, and Małgorzata Pawełczyk. "Wake-up stroke – diagnosis, management and treatment." Aktualności Neurologiczne 20, no. 2 (October 30, 2020): 66–70. http://dx.doi.org/10.15557/an.2020.0009.
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Wake-up stroke is defined as ischaemic stroke with unknown time of symptom onset, when patients go to sleep normal and awaken with neurological symptoms. This type of stoke accounts for about 20% (14–24%) of all ischaemic strokes. The high incidence of wake-up stroke may be associated with diurnal variability of heart rate and blood pressure, coagulation processes, as well as episodes of atrial fibrillation, which are more common in the morning. The risk of wake-up stroke increases during REM sleep. Individuals with obstructive sleep apnoea account for the majority of patients with wake-up stroke. Until recently, wake-up stroke was considered a contraindication for reperfusion treatment due to the unknown time of onset and a potential risk of intracranial bleeding. The latest research has shown that wake-up stroke occurs shortly before awakening. Therefore, these patients could be qualified for reperfusion treatment, which would improve their clinical status.
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Camen, Stephan, Francisco M. Ojeda, Teemu Niiranen, Francesco Gianfagna, Julie K. Vishram-Nielsen, Simona Costanzo, Stefan Söderberg, et al. "Temporal relations between atrial fibrillation and ischaemic stroke and their prognostic impact on mortality." EP Europace 22, no. 4 (November 18, 2019): 522–29. http://dx.doi.org/10.1093/europace/euz312.
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Abstract Aims Limited evidence is available on the temporal relationship between atrial fibrillation (AF) and ischaemic stroke and their impact on mortality in the community. We sought to understand the temporal relationship of AF and ischaemic stroke and to determine the sequence of disease onset in relation to mortality. Methods and results Across five prospective community cohorts of the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) project we assessed baseline cardiovascular risk factors in 100 132 individuals, median age 46.1 (25th–75th percentile 35.8–57.5) years, 48.4% men. We followed them for incident ischaemic stroke and AF and determined the relation of subsequent disease diagnosis with overall mortality. Over a median follow-up of 16.1 years, N = 4555 individuals were diagnosed solely with AF, N = 2269 had an ischaemic stroke but no AF diagnosed, and N = 898 developed both, ischaemic stroke and AF. Temporal relationships showed a clustering of diagnosis of both diseases within the years around the diagnosis of the other disease. In multivariable-adjusted Cox regression analyses with time-dependent covariates subsequent diagnosis of AF after ischaemic stroke was associated with increased mortality [hazard ratio (HR) 4.05, 95% confidence interval (CI) 2.17–7.54; P < 0.001] which was also apparent when ischaemic stroke followed after the diagnosis of AF (HR 3.08, 95% CI 1.90–5.00; P < 0.001). Conclusion The temporal relations of ischaemic stroke and AF appear to be bidirectional. Ischaemic stroke may precede detection of AF by years. The subsequent diagnosis of both diseases significantly increases mortality risk. Future research needs to investigate the common underlying systemic disease processes.
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Wang, Andrew, Abel N. Kho, and Dustin D. French. "Association of the Robert Wood Johnson Foundations’ social determinants of health and Medicare hospitalisations for ischaemic strokes: a cross-sectional data analysis." Open Heart 7, no. 1 (January 2020): e001189. http://dx.doi.org/10.1136/openhrt-2019-001189.
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ObjectiveSocial determinants of health (SDH) have previously demonstrated to be important risk factors in determining health outcomes. To document whether the SDH are associated with hospitalisations for ischaemic stroke.MethodsThis cross-sectional study examines data from fiscal year 2015. Patients from the national Medicare 100% Inpatient Limited Dataset were linked with SDH measures from the Robert Wood Johnson Foundation (RWJF) County Health Rankings. Medicare patients were included in the study group if they had either an admitting or primary diagnosis of ischaemic stroke. Counties without RWJF data were excluded from the study. Ischaemic strokes were compared with all other hospitalisations associated with characteristics of the SDH measures and benchmarked to above or below their respective national median. Estimates were performed with nested logistic regression.ResultsApproximately 256 766 Medicare patients had ischaemic stroke hospitalisations compared with all other Medicare patients (n=6 386 180) without ischaemic stroke hospitalisations while 30 853 patients were excluded due to residence in US territories. Significant factors included air pollution exceeding the national median (OR 1.06; 95% CI 1.05 to 1.07), per cent of children in single parent households exceeding the national median, (OR 1.02; 95% CI 1.01 to 1.03), violent crime rates exceeding the national median, (OR 1.02; 95% CI 1.01 to 1.03) and per cent smoking exceeding the national median, (OR 1.02; 95% CI 1.01 to 1.03).ConclusionsWhen cross-sectional SDH are benchmarked to national median for ischaemic stroke hospitalisations and compared with all-cause hospitalisations, the effects remain significant. Further research on the longitudinal effects of the SDH and cardiovascular health, particularly disease-specific outcomes, is needed.
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Etherton, Mark R., Khawja A. Siddiqui, and Lee H. Schwamm. "Prestroke selective serotonin reuptake inhibitor use and functional outcomes after ischaemic stroke." Stroke and Vascular Neurology 3, no. 1 (January 13, 2018): 9–16. http://dx.doi.org/10.1136/svn-2017-000119.
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BackgroundSelective serotonin reuptake inhibitors (SSRIs) have been implicated in contributing to recovery after acute ischaemic stroke. In particular, poststroke initiation of an SSRI has been demonstrated to improve motor recovery. The role of prestroke SSRI use on functional outcomes and stroke recovery is less clear. We aimed to examine the effect of prestroke SSRI use on metrics of hospitalisation and functional recovery.MethodsWe included 4968 consecutive patients from January 2006 to June 2015 in our local Get With The Guidelines-Stroke registry in whom a preadmission drug list could be extracted from an administrative research data registry. Univariate and multivariate analyses were performed to identify predictors of functional outcomes.ResultsOn univariate analysis, among 4698 ischaemic strokes (740 SSRI users and 3948 non-users), SSRI use before acute ischaemic stroke did not impact the National Institutes of Health Stroke Scale (NIHSS) admission score, length of stay or rate of symptomatic haemorrhage. Patients using SSRIs prior to their stroke were more likely to present with weakness (57% vs 47.3%; P<0.001) and have hospitalisations complicated by pneumonia (7.6% vs 5.7%; P<0.001). Moreover, prestroke SSRI use was associated with a negative impact on ambulatory status at discharge and discharge to home. On multivariate regression analysis, SSRI use was associated with lower likelihood of discharge to home (adjusted OR 0.79, 95% CI 0.62 to 0.997, P<0.05).ConclusionsSSRI use preceding an acute ischaemic stroke is associated with lower rates of discharge to home despite no significant increase in length of stay or NIHSS score.
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Rachmawati, Mayori, Paulus Sugianto, and Rr Indrayuni Lukitra Wardhani. "LDL Level in Ischaemic Stroke Patients at Dr. Soetomo General Hospital Surabaya." Biomolecular and Health Science Journal 2, no. 1 (June 30, 2019): 41. http://dx.doi.org/10.20473/bhsj.v2i1.12743.
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Introduction: Stroke is one of the top killers amongst the non-infectious diseases. Ischemic stroke dominates the rate by 87.0% amongst all type of strokes. One of the risk factors for stroke ischemic stroke is atherosclerosis which caused by lipid build-up in the arteries.Methods: This research is a retrospective study on secondary data. Admitted Ischaemic stroke patients. Lipid profile, and Barthel Index were collected from medical record and presented descriptively.Results: Of the 248 patients, 144 (58.1%) were men, mean age was 59.33. 61.7% ischemic stroke patients have their LDL level elevated, 59.7% HDL decreased, 39.1% total cholesterol elevated, and 33.9% TG elevated. This study also observe the dependency based on Barthel Index of the admitted stroke patients. 75% percents amongst subjects were categorized as “total dependece” are having their LDL level elevated.Conclusion: Most of stroke patients have elevated LDL and HDL while the TG and total cholesterol are mostly optimized. Stroke patients whose admitted with “total dependence” most likely to have elevated LDL in this study.
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Rehni, Ashish K., Inderbir Singh, Nirmal Singh, and Manoj Kumar. "Stem Cells: Implications in Experimental Ischaemic Stroke Therapy." Stem Cell Reviews 4, no. 3 (May 31, 2008): 227–33. http://dx.doi.org/10.1007/s12015-008-9025-1.
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Lucaci, Paul, Marius Neculaes, and Danisia Haba. "The Contribution of Imaging and Functional Diagnosis to the Rehabilitation of Patients with Stroke." Revista de Chimie 70, no. 8 (September 15, 2019): 2847–50. http://dx.doi.org/10.37358/rc.19.8.7440.
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The research conducted is based on the clinical evaluation through magnetic resonance and on functional testing using the stabilometric platform, of a sample of 23 subjects with a stroke ischemic localised in the area of the middle cerebral artery. With the help of magnetic resonance, the structural changes of the ischaemic focus were determined. At the same time, the evolution in time of the ischaemia and the alteration at the level of the ischaemic area were monitored. By using the stabilometric platform GPS 400, the distribution of the load at the level of the lower limbs was analysed, as well as barycentre variations. The results obtained after conducting the study highlight the high possibility of the functional re-education of the subjects when brain lesions do not extend and no complications arise, elements underlined by imaging exploration using magnetic resonance.
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Evans, Nicholas R., Jasmine Wall, Benjaman To, Stephen J. Wallis, Roman Romero-Ortuno, and Elizabeth A. Warburton. "Clinical frailty independently predicts early mortality after ischaemic stroke." Age and Ageing 49, no. 4 (January 17, 2020): 588–91. http://dx.doi.org/10.1093/ageing/afaa004.
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Abstract Background Clinical frailty is an important syndrome for clinical care and research, independently predicting mortality and rates of institutionalisation in a range of medical conditions. However, there has been little research into the role of frailty in stroke. Objective This study investigates the effect of frailty on 28-day mortality following ischaemic stroke and outcomes following stroke thrombolysis. Methods Frailty was measured using the Clinical Frailty Scale (CFS) for all ischaemic stroke admissions aged ≥75 years. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). 28-day mortality and clinical outcomes were collected retrospectively. Analysis included both dichotomised measures of frailty (non-frail: CFS 1–4, frail: 5–8) and CFS as a continuous ordinal scale. Results In 433 individuals with ischaemic stroke, 28-day mortality was higher in frail versus non-frail individuals (39 (16.7%) versus 10 (5%), P < 0.01). On multivariable analysis, a one-point increase in CFS was independently associated with 28-day mortality (OR 1.03 (1.01–1.05)). In 63 thrombolysed individuals, median NIHSS reduced significantly in non-frail individuals (12.5 (interquartile range (IQR) 9.25) to 5 (IQR 10.5), P < 0.01) but not in frail individuals (15 (IQR 11.5) to 16 (IQR 16.5), P = 0.23). On multivariable analysis, a one-point increase in CFS was independently associated with a one-point reduction in post-thrombolysis NIHSS improvement (coefficient 1.07, P = 0.03). Conclusion Clinical frailty is independently associated with 28-day mortality after ischaemic stroke and appears independently associated with attenuated improvement in NIHSS following stroke thrombolysis. Further research is needed to elucidate the underlying mechanisms and how frailty may be utilised in clinical decision-making.
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Zlokovic, Berislav, John Griffin, and Laurent Mosnier. "Cytoprotective-selective activated protein C therapy for ischaemic stroke." Thrombosis and Haemostasis 112, no. 11 (2014): 883–92. http://dx.doi.org/10.1160/th14-05-0448.
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SummaryDespite years of research and efforts to translate stroke research to clinical therapy, ischaemic stroke remains a major cause of death, disability, and diminished quality of life. Primary and secondary preventive measures combined with improved quality of care have made significant progress. However, no novel drug for ischaemic stroke therapy has been approved in the past decade. Numerous studies have shown beneficial effects of activated protein C (APC) in rodent stroke models. In addition to its natural anticoagulant functions, APC conveys multiple direct cytoprotective effects on many different cell types that involve multiple receptors including protease activated receptor (PAR) 1, PAR3, and the endothelial protein C receptor (EPCR). Application of molecular engineered APC variants with altered selectivity profiles to rodent stroke models demonstrated that the beneficial effects of APC primarily require its cytoprotective activities but not its anticoagulant activities. Extensive basic, preclinical, and clinical research provided a compelling rationale based on strong evidence for translation of APC therapy that has led to the clinical development of the cytoprotectiveselective APC variant, 3K3A-APC, for ischaemic stroke. Recent identification of non-canonical PAR1 and PAR3 activation by APC that give rise to novel tethered-ligands capable of inducing biased cytoprotective signalling as opposed to the canonical signalling provides a mechanistic explanation for how APC-mediated PAR activation can selectively induce cytoprotective signalling pathways. Collectively, these paradigm-shifting discoveries provide detailed insights into the receptor targets and the molecular mechanisms for neuroprotection by cytoprotective-selective 3K3A-APC, which is currently a biologic drug in clinical trials for ischaemic stroke.
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Mcneill, A. "How Accurate are Primary Care Referral Letters for Presumed Acute Stroke?" Scottish Medical Journal 53, no. 4 (November 2008): 11–12. http://dx.doi.org/10.1258/rsmsmj.53.4.11.
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The introduction of thrombolysis for the treatment of acute ischaemic stroke has increased the importance of prompt and accurate diagnosis. Research has shown a high rate of misdiagnosis of acute stroke in the community by paramedics and primary care doctors (PCDs). In this study, referral letters for presumed acute stroke or Transient Ischaemic Attack (TIA) were audited to assess the diagnostic accuracy of PCDs and the quality of the referral letters. In 30 % of cases, the diagnosis of stroke was correct. Important stroke mimics included sepsis, delirium and functional disorders. PCDs may benefit from a stroke recognition tool to increase diagnostic accuracy.
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Dawson, Jesse, Niall Broomfield, Krishna Dani, David A. Dickie, Alex Doney, Kirsten Forbes, Graeme Houston, et al. "Xanthine oxidase inhibition for the improvement of long-term outcomes following ischaemic stroke and transient ischaemic attack (XILO-FIST) – Protocol for a randomised double blind placebo-controlled clinical trial." European Stroke Journal 3, no. 3 (April 18, 2018): 281–90. http://dx.doi.org/10.1177/2396987318771426.
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Background Allopurinol, a xanthine oxidase inhibitor, reduced progression of carotid-intima media thickness and lowered blood pressure in a small clinical trial in people with ischaemic stroke. Xanthine oxidase inhibition for improvement of long-term outcomes following ischaemic stroke and transient ischaemic attack (XILO-FIST) aims to assess the effect of allopurinol treatment on white matter hyperintensity progression and blood pressure after stroke. This paper describes the XILO-FIST protocol. Methods XILO-FIST is a multicentre randomised double-blind, placebo-controlled, parallel group clinical trial funded by the British Heart Foundation and the Stroke Association. The trial has been adopted by the Scottish Stroke Research Network and the UK Clinical Research Network. The trial is registered in clinicaltrials.gov (registration number NCT02122718). XILO-FIST will randomise 464 participants, aged greater than 50 years, with ischaemic stroke within the past month, on a 1:1 basis, to two years treatment with allopurinol 300 mg twice daily or placebo. Participants will undergo brain magnetic resonance imaging, cognitive assessment, ambulatory blood pressure monitoring and blood sampling at baseline and after two years treatment. The primary outcome will be white matter hyperintensity progression, measured using the Rotterdam progression scale. Secondary outcomes will include change in white matter hyperintensity volume, mean day-time systolic blood pressure and measures of cognitive function. Up to 100 will undergo additional cardiac magnetic resonance imaging in a sub-study of left ventricular mass. Discussion If white matter hyperintensity progression is reduced, allopurinol could be an effective preventative treatment for patients with ischaemic stroke and clinical endpoint studies would be needed. If allopurinol reduces blood pressure after stroke, then it could be used to help patients reach blood pressure targets.
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Macrae, I. Mhairi, and Stuart M. Allan. "Stroke: The past, present and future." Brain and Neuroscience Advances 2 (January 2018): 239821281881068. http://dx.doi.org/10.1177/2398212818810689.
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Since the inception of the British Neuroscience Association, there have been major advances in our knowledge of the mechanistic basis for stroke-induced brain damage. Identification of the ischaemic cascade led to the development of hundreds of new drugs, many showing efficacy in preclinical (animal-based) studies. None of these drugs has yet translated to a successful stroke treatment, current therapy being limited to thrombolysis/thrombectomy. However, this translational failure has led to significant improvements in the quality of animal-based stroke research, with the refinement of rodent models, introduction of new technologies (e.g. transgenics, in vivo brain imaging) and improvements in study design (e.g. STAIR, ARRIVE and IMPROVE guidelines). This has run in parallel with advances in clinical diagnostic imaging for detection of ischaemic versus haemorrhagic stroke, differentiating penumbra from ischaemic core, and improved clinical trial design. These preclinical and clinical advances represent the foundation for successful translation from the bench to the bedside in the near future.
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Chen, Mu-Hong, Tai-Long Pan, Cheng-Ta Li, Wei-Chen Lin, Ying-Sheue Chen, Ying-Chiao Lee, Shih-Jen Tsai, et al. "Risk of stroke among patients with post-traumatic stress disorder: nationwide longitudinal study." British Journal of Psychiatry 206, no. 4 (April 2015): 302–7. http://dx.doi.org/10.1192/bjp.bp.113.143610.
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BackgroundPrevious evidence has shown positive associations between post-traumatic stress disorder (PTSD) and hypertension, dyslipidaemia and diabetes mellitus, which are all risk factors for stroke, but the role of PTSD in the subsequent development of stroke is still unknown.AimsTo investigate the temporal association between PTSD and the development of stroke.MethodIdentified from the Taiwan National Health Insurance Research Database, 5217 individuals aged 18 years, with PTSD but with no history of stroke, and 20 868 age- and gender-matched controls were enrolled between 2002 and 2009, and followed up until the end of 2011 to identify the development of stroke.ResultsIndividuals with PTSD had an increased risk of developing any stroke (hazard ratio (HR) 3.37, 95% CI 2.44–4.67) and ischaemic stroke (HR = 3.47, 95% CI 2.23–5.39) after adjusting for demographic data and medical comorbidities. Sensitivity tests showed consistent findings (any stroke HR = 3.02, 95% CI 2.13–4.28; ischaemic stroke HR = 2.89, 95% CI 1.79–4.66) after excluding the first year of observation.ConclusionsIndividuals with PTSD have an increased risk of developing any stroke and ischaemic stroke. Further studies are required to investigate the underlying mechanisms.
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Wu, Simiao, Ruozhen Yuan, Yao Xiong, Shihong Zhang, Bo Wu, and Ming Liu. "Clinical features, management and outcomes of severe ischaemic stroke in tertiary hospitals in China: protocol for a prospective multicentre registry-based observational study." BMJ Open 8, no. 10 (October 2018): e024900. http://dx.doi.org/10.1136/bmjopen-2018-024900.
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IntroductionSevere ischaemic stroke is a devastating condition with high mortality and morbidity; however, there is insufficient evidence on its management. The aim of this study is to investigate causes, risk factors, clinical course, management and outcomes of severe ischaemic stroke in a real-world setting in tertiary hospitals in China.Methods and analysisThis is a prospective, multicentre, registry-based observational study. We will recruit 2500 patients with acute ischaemic stroke from nine tertiary hospitals in Western China. Patients with acute ischaemic stroke admitted to the Department of Neurology within 30 days of stroke onset will be included. Patients will be visited within 24 hours after admission, on day 3, day 7 and at discharge, to collect data on their clinical state, blood biomarkers and brain imaging. Severe stroke is defined as severe neurological deficits (National Institute of Health Stroke Scale (NIHSS) ≥15 or in coma) on admission or clinical worsening (NIHSS increased by ≥4 scores) during hospitalisation. Patients will be followed up by structured telephone interviews at 3 months and 1 year after stroke onset. In-hospital outcomes include symptomatic haemorrhagic transformation and brain oedema by day 7 of admission, and survival status (death or survival) by discharge; follow-up outcomes will include survival status and functional outcome (assessed by modified Rankin Scale) at 3 months and 1 year. The current study will improve our knowledge about the development of severe ischaemic stroke at acute phase and factors influencing its outcomes, which will eventually facilitate optimisation of individualised interventions for its prevention and treatment.Ethics and disseminationEthics approval is obtained from The Biomedical Research Ethics Committee of West China Hospital, Sichuan University (Reference No. 2017(130)). We will present our findings at the national and international conferences and peer-reviewed journals in stroke and neurology.Trial registration numberNCT03222024; Pre-results.
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Wang, C. X., A. Stroink, J. M. Casto, and K. Kattner. "Hyperthermia Exacerbates Ischaemic Brain Injury." International Journal of Stroke 4, no. 4 (August 2009): 274–84. http://dx.doi.org/10.1111/j.1747-4949.2009.00317.x.
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Hyperthermia frequently occurs in stroke patients. Hyperthermia negatively correlates with clinical outcome and adversely effects treatment regiments otherwise successful under normothermic conditions. Preclinical studies also demonstrate that hyperthermia converts salvageable penumbra to ischaemic infarct. The present article reviews the knowledge accumulated from both clinical and preclinical studies about hyperthermia and ischaemic brain injury, examines current treatment strategies and discusses future research directions.
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Best, Jonathan Gordon, Robert Bell, Mohammed Haque, Arvind Chandratheva, and David John Werring. "Atrial fibrillation and stroke: a practical guide." Practical Neurology 19, no. 3 (March 2, 2019): 208–24. http://dx.doi.org/10.1136/practneurol-2018-002089.
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Neurologists and stroke physicians will be familiar with atrial fibrillation as a major cause of ischaemic stroke, and the role of anticoagulation in preventing cardioembolic stroke. However, making decisions about anticoagulation for individual patients remains a difficult area of clinical practice, balancing the serious risk of ischaemic stroke against that of major bleeding, particularly intracranial haemorrhage. Atrial fibrillation management requires interdisciplinary collaboration with colleagues in cardiology and haematology. Recent advances, especially the now-widespread availability of direct oral anticoagulants, have brought opportunities to improve stroke care while posing new challenges. This article gives an overview of the contemporary diagnosis and management of atrial fibrillation, and the associated evidence base. Where there is uncertainty, we describe our own approach to these areas, while highlighting ongoing research that will likely guide future practice.
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Selvik, Henriette Aurora, Anna Therese Bjerkreim, Lars Thomassen, Ulrike Waje-Andreassen, Halvor Naess, and Christopher Elnan Kvistad. "When to Screen Ischaemic Stroke Patients for Cancer." Cerebrovascular Diseases 45, no. 1-2 (2018): 42–47. http://dx.doi.org/10.1159/000484668.
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Background and Purpose: Ischemic stroke can be the first manifestation of cancer and it is therefore important to ascertain which stroke patients should be considered for cancer-diagnostic investigations. We aimed to determine the frequency of active cancer in patients with acute ischemic stroke and to compare clinical findings in stroke patients with active cancer to ischemic stroke patients with no history of cancer. Finally, we aimed to develop a predictive and feasible score for clinical use to uncover underlying malignancy. Methods: All ischemic stroke patients admitted to the stroke unit in the Department of Neurology, Haukeland University Hospital were consecutively included in the Norwegian Stroke Research Registry (NORSTROKE). Stroke etiology was determined by the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Data on cancer diagnoses was obtained from patients’ medical records and the Cancer Registry of Norway. Active cancer was defined as cancer diagnosis, metastasis of known cancer, recurrent cancer or receiving cancer treatment, all within 12 months before or after the index stroke. Based on variables independently associated with active cancer, a predictive score was developed using the area under the receiver operating characteristic (AUC-ROC) curves. Bayes’ theorem was used to calculate post-test probabilities of active cancer. Results: Of the 1,646 ischemic stroke patients included, 82 (5.0%) had active cancer. Increased D-dimer (OR = 1.1, 95% CI: 1.1–1.2, p = <0.001), lower Hb (OR = 0.6, 95% CI: 0.5–0.7, p = <0.001), smoking (OR = 2.2, 95% CI: 1.2–4.3, p = 0.02) and suffering a stroke of undetermined etiology (OR = 1.9, 95% CI: 1.1–3.3, p = 0.03) were factors independently associated with active cancer. These were included in the final predictive score which gave an AUC of 0.73 (95% CI: 0.65–0.81) in patients younger than 75 years of age. Assuming the prevalence of cancer to be 5%, the score shows that if a patient fulfills all 3 score points, the probability of active cancer is 53%. Conclusions: Active cancer was found in 5% of our ischemic stroke patients. We found that a clinical score comprising elevated D-dimer ≥3 mg/L, lower Hb ≤12.0 g/dL and previous or current smoking is feasible for predicting active cancer in ischemic stroke patients.
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McGreevy, Cora, Alan Moore, Ciaran Donegan, and David JP Williams. "Stroke thrombolysis in the very elderly." Reviews in Clinical Gerontology 20, no. 4 (September 20, 2010): 261–67. http://dx.doi.org/10.1017/s0959259810000298.
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SummaryAcute ischaemic stroke is common in older people and is associated with a higher morbidity and mortality compared with younger patients. Intravenous thrombolysis with recombinant tissue plasminogen activator (r-tPA) has become the mainstay of treatment and is the only evidence-based specific treatment for acute ischaemic stroke. However, little data are available on the safety of thrombolysis in the over-80 years age group due to under-representation of this group in trials and the upper age limit for licensing of the drug. In this review, we look at the pathophysiology of stroke and recent advances in neuroimaging techniques. We also look at the evidence base for use of thrombolysis in stroke and in particular analyse the trials that include the very elderly as subjects. Finally, issues around ongoing trials and future research are discussed.
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Zhang, Jing, Ping Zhu, Bingqing Liu, Qiang Yao, Ke Yan, Qianwen Zheng, Yawen Li, et al. "Time to recurrence after first-ever ischaemic stroke within 3 years and its risk factors in Chinese population: a prospective cohort study." BMJ Open 9, no. 12 (December 2019): e032087. http://dx.doi.org/10.1136/bmjopen-2019-032087.
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ObjectiveThis study aimed to estimate the time of recurrent ischaemic stroke events among the first 3 years of follow-up after hospitalisation discharge.Study designA prospective cohort study.SettingThe research was conducted in the Department of Neurology at a tertiary hospital, Chengdu of China, from January 2010 to June 2016.Outcome measuresWe estimated the restricted mean survival time (RMST) of ischaemic stroke recurrence for the first 3 years after discharge. Basic sociodemographic characteristics and major potential risk factors for recurrence were collected using a semistructured questionnaire. Regression analysis of RMST was used to identify risk factors of recurrent stroke.ParticipantsPatients hospitalised with first-ever ischaemic stroke were eligible for this study. Patients with severe cognitive impairment were excluded.ResultsWe included 641 surviving patients who were followed up for 3 years. Stroke recurrence occurred in 115 patients, including 16 patients who died of stroke recurrence. The cumulative risk of stroke recurrence rate was 11.51% (9.20%–14.35%) at 1 year, 16.76% (13.96%–20.05%) at 2 years and 20.07% (17.00%–23.61%) at 3 years. Modified Rankin Scale (mRS) score ≥3 thus resulted in the recurrence time loss, which was 0.22 months (p=0.008) at 6 months, 0.61 months (p=0.004) at 1 year, 1.49 months (p=0.007) at 2 years and 2.46 months (p=0.008) at 3 years. It is similar with the effects of drug adherence after stroke. The recurrence time of patients ≥75 years at 3 years was 2.02 months (p=0.220) less than that of those aged <55 years.ConclusionIn China, the time of first recurrence varies among different patients with ischaemic stroke. The mRS and the level of drug adherence after stroke are important risk factors of stroke recurrence.
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Hayreh, Sohan Singh. "Controversies on neuroprotection therapy in non-arteritic anterior ischaemic optic neuropathy." British Journal of Ophthalmology 104, no. 2 (September 5, 2019): 153–56. http://dx.doi.org/10.1136/bjophthalmol-2019-314656.
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ObjectiveThere has long been a great interest in neuroprotection therapy for ischaemic stroke and various types of optic neuropathies. In view of that, I reviewed the literature on the role of neuroprotection for non-arteritic anterior ischaemic optic neuropathy (NA-AION).MethodsThe review is based on a PubMed search of literature about the use of neuroprotectors in stroke and optic neuropathies and about current clinical trials of RPh201 and QPI-1007 in NA-AION.ResultsSeveral neuroprotection agents for ischaemic stroke and various types of optic neuropathies have been evaluated extensively in experimental studies in animals and benefits claimed. However, translation of therapeutic strategies for neuroprotection from experimental research to humans has invariably been fraught with failure. Two currently ongoing studies dealing with neuroprotection by RPh201 and QPI-1007 in NA-AION may have limitations in their rationale and study designs.ConclusionsUnfortunately, in spite of all the experimental and clinical research on neuroprotection agents in NA-AION so far, we have no scientifically proven evidence of neuroprotection agents showing any benefit in the human clinical studies so far.
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Suo, Yue, Jing Jing, Xia Meng, Zixiao Li, Yuesong Pan, Yong Jiang, Xiaomeng Yang, et al. "Inconsistent centralised versus non-centralised ischaemic stroke aetiology." Stroke and Vascular Neurology 5, no. 4 (November 5, 2020): 337–47. http://dx.doi.org/10.1136/svn-2020-000576.
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Background and purposeThe Trial of Org 10 172 in Acute Stroke Treatment (TOAST) system is the most widely used aetiological categorisation system in clinical practice and research. Limited studies have validated the accuracy of routine aetiological diagnosis of patients with ischaemic stroke according to the TOAST criteria when the reported subtype is assumed to be correct. We investigated the agreement between centralised and non-centralised (site-reported, at discharge) stroke subtypes in the Third China National Stroke Registry (CNSR-III), and analysed the influence of classification consistency on evaluation during hospitalisation and for secondary prevention strategy.MethodsAll patients with ischaemic stroke from the CNSR-III study with complete diffusion-weighted imaging data were included. We used multivariable Cox proportional-hazard regression models to evaluate the factors associated with consistency between centralised and non-centralised stroke subtypes. Sensitivity analyses were conducted of the subgroup of patients with complete information.ResultsThis study included 12 180 patients (mean age, 62.3 years; and women, 31.4%). Agreement between centralised and non-centralised subtype was the highest for the large-artery atherosclerosis subtype stroke (77.4% of centralised patients), followed by the small-vessel occlusion subtype (40.6% of centralised patients). Agreements for cardioembolism and stroke of other determined aetiology subtypes were 38.7% and 12.2%, respectively. Patient-level and hospital-level factors were associated with the inconsistency between centralised/non-centralised aetiological subtyping. This inconsistency was related to differences in secondary prevention strategies. Only 15.3% of the newly diagnosed patients with cardioembolism underwent centralised subtyping with indications to receive oral anticoagulants at discharge. In comparison, 51.3% of the consistent cardioembolism group and 42.0% of the centrally reassigned cardioembolism group with anticoagulation indications were prescribed oral anticoagulants.ConclusionsSubstantial inconsistency exists between centralised and non-centralised subtyping in China. Inaccurate aetiological subtyping could lead to inadequate secondary prevention, especially in patients with cardioembolic stroke.
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Liu, Liping, Jing Ding, Xinyi Leng, Yuehua Pu, Li-An Huang, Anding Xu, Ka Sing Lawrence Wong, Xin Wang, and Yongjun Wang. "Guidelines for evaluation and management of cerebral collateral circulation in ischaemic stroke 2017." Stroke and Vascular Neurology 3, no. 3 (May 30, 2018): 117–30. http://dx.doi.org/10.1136/svn-2017-000135.
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Collateral circulation plays a vital role in sustaining blood flow to the ischaemic areas in acute, subacute or chronic phases after an ischaemic stroke or transient ischaemic attack. Good collateral circulation has shown protective effects towards a favourable functional outcome and a lower risk of recurrence in stroke attributed to different aetiologies or undergoing medical or endovascular treatment. Over the past decade, the importance of collateral circulation has attracted more attention and is becoming a hot spot for research. However, the diversity in imaging methods and criteria to evaluate collateral circulation has hindered comparisons of findings from different cohorts and further studies in exploring the clinical relevance of collateral circulation and possible methods to enhance collateral flow. The statement is aimed to update currently available evidence and provide evidence-based recommendations regarding grading methods for collateral circulation, its significance in patients with stroke and methods under investigation to improve collateral flow.
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Bath, Philip M., Lisa J. Woodhouse, Jason P. Appleton, Maia Beridze, Hanne Christensen, Robert A. Dineen, Katie Flaherty, et al. "Triple versus guideline antiplatelet therapy to prevent recurrence after acute ischaemic stroke or transient ischaemic attack: the TARDIS RCT." Health Technology Assessment 22, no. 48 (August 2018): 1–76. http://dx.doi.org/10.3310/hta22480.
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BackgroundTwo antiplatelet agents are better than one for preventing recurrent stroke after acute ischaemic stroke or transient ischaemic attack (TIA). Therefore, intensive treatment with three agents might be better still, providing it does not cause undue bleeding.ObjectiveTo compare the safety and efficacy of intensive therapy with guideline antiplatelet therapy for acute ischaemic stroke and TIA.DesignInternational prospective randomised open-label blinded end-point parallel-group superiority clinical trial.SettingAcute hospitals at 106 sites in four countries.ParticipantsPatients > 50 years of age with acute non-cardioembolic ischaemic stroke or TIA within 48 hours of ictus (stroke).InterventionsParticipants were allocated at random by computer to 1 month of intensive (combined aspirin, clopidogrel and dipyridamole) or guideline (combined aspirin and dipyridamole, or clopidogrel alone) antiplatelet agents, and followed for 90 days.Main outcome measuresThe primary outcome was the incidence and severity of any recurrent stroke (ischaemic, haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days by blinded telephone follow-up. Analysis using ordinal logistic regression was by intention to treat. Other outcomes included bleeding and its severity, death, myocardial infarction (MI), disability, mood, cognition and quality of life.ResultsThe trial was stopped early on the recommendation of the Data Monitoring Committee after recruitment of 3096 participants (intensive,n = 1556; guideline,n = 1540) from 106 hospitals in four countries between April 2009 and March 2016. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy in 3070 (99.2%) participants with data [93 vs. 105 stroke/TIA events; adjusted common odds ratio 0.90, 95% confidence interval (CI) 0.67 to 1.20;p = 0.47]. Major (encompassing fatal) bleeding was increased with intensive as compared with guideline therapy [39 vs. 17 participants; adjusted hazard ratio (aHR) 2.23, 95% CI 1.25 to 3.96;p = 0.006]. There were no differences between the treatment groups in all-cause mortality, or the composite of death, stroke, MI and major bleeding (aHR 1.02, 95% CI 0.77 to 1.35;p = 0.88).LimitationsPatients and investigators were not blinded to treatment. The comparator group comprised two guideline strategies because of changes in national guidelines during the trial. The trial was stopped early, thereby reducing its statistical power.ConclusionsThe use of three antiplatelet agents is associated with increased bleeding without any significant reduction in recurrence of stroke or TIA.Future workThe safety and efficacy of dual antiplatelet therapy (combined aspirin and clopidogrel) versus aspirin remains to be defined. Further research is required on identifying individual patient response to antiplatelets, and the relationship between response and the subsequent risks of vascular recurrent events and bleeding complications.Trial registrationCurrent Controlled Trials ISRCTN47823388.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 22, No. 48. See the NIHR Journal Library website for further project information. The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) vanguard phase was funded by the British Heart Foundation (grant PG/08/083/25779, from 1 April 2009 to 30 September 2012) and indirect funding was provided by the Stroke Association through its funding of the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK. There was no commercial support for the trial and antiplatelet drugs were sourced locally at each site. The trial was sponsored by the University of Nottingham.
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Urimubenshi, Gerard, Peter Langhorne, Dominique A. Cadilhac, Jeanne N. Kagwiza, and Olivia Wu. "Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis." European Stroke Journal 2, no. 4 (October 5, 2017): 287–307. http://dx.doi.org/10.1177/2396987317735426.
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Purpose Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes. Method We sought publications of recent (January 2000–May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up. Findings We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72–0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66–0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50–0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43–0.64), lipid management (odds ratio 0.52; 0.38–0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67–0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43–0.78) and stroke unit admission (odds ratio 0.83; 0.77–0.89). Adherence with several key performance indicators appeared to have an additive benefit. Discussion Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke. Conclusion Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.
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Kaur, Inderjeet, Ashok Khurana, Jasmine Kaur Sachdev, and Gurinder Mohan. "Evaluation of serum uric acid in acute ischaemic stroke." International Journal of Advances in Medicine 4, no. 1 (January 23, 2017): 60. http://dx.doi.org/10.18203/2349-3933.ijam20170036.
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Background: The role of serum uric acid as a risk factor for acute ischaemic stroke is controversial and there is little information about it. Present study was done to estimate serum uric acid levels in patients of acute ischaemic stroke and to assess its risk factor potential.Methods: It was a prospective case control study carried out in the department of Medicine at Sri Guru Ramdas Institute of Medical Sciences and Research, Vallah, Sri Amritsar, Punjab, India from January 2015 to July 2016. 50 cases of acute ischaemic stroke were enrolled and were compared with same number of age and sex matched healthy controls. Serum uric acid levels were measured in cases (within 24 hours of stroke evolution). Glasgow coma scale (GCS) score was calculated for cases at time of admission. The results were statistically analysed.Results: Mean serum uric acid level in cases was 6.15±1.91mg/dl whereas it was 5.1±1.4 mg/dl in controls. The difference of serum uric acid levels between cases and controls was statistically significant (p = 0.0054). Patients with poor GCS had higher mean serum uric acid levels as compared to patients with mild or moderate GCS score which was statistically significant(p = 0.0426).Conclusions: Serum uric acid can be used as a marker for increased risk of stroke. Furthermore, serum uric acid can also be used for risk stratification after stroke.
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Wan Zain, Wan Mohd Saifuhisam, Julia Omar, Tuan Salwani Tuan Ismail, and Noor Azlin Azraini Che Soh. "Acute Ischaemic Stroke With Hyperprolactinemia:A Case Report." Journal of the Endocrine Society 5, Supplement_1 (May 1, 2021): A570. http://dx.doi.org/10.1210/jendso/bvab048.1162.
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Abstract Background: Macroincidentalomas were reported in 0.2% of patient underwent imaging (CT scans) for central nervous symptoms (1). In acute ischaemic stroke with hyperprolactinemia, the diagnosis of a double pathology of ischemic stroke and sellar tumour especially prolactinoma need to be considered. Hyperprolactinemia itself may be considered as a risk factor for ischemic stroke due to its thrombogenic effect (3). Clinical Case: A 47-year old man underlying hypertension and diabetes mellitus for 5 years presented with sudden onset of right sided body weakness associated with facial asymmetry and aphasia. No history of fever or trauma. Asymptomatic of hyperprolactinemia previously. On general examinations Glasgow Coma Scale 11/15 Eye 4 Verbal 1 Motor 6, blood pressure was unstable with readings of systolic 244mmHg and diastolic 142mmHg. Neurological examinations showed expressive aphasia, right hemianopia, right facial nerve palsy and absence of gag reflex. Cerebellar signs were negative. Motor function examinations of right upper and lower limbs showed hypertonia, reduce power of 2/5, normal reflexes and up going plantar response. Sensory functions of right upper and lower limbs were reduced. Clinically diagnosed as stroke with hypertensive emergency. CT brain showed multiple hypodensities due to recent infarct and incidental finding of an aggressive sellar mass. MRI brain showed left Middle Cerebral Artery territory infarct and an aggressive sphenoid sinus mass with suprasellar and bilateral cavernous sinus extension possibility of a macroadenoma. Serum prolactin level showed markedly hyperprolactinemia (21146 ng/ml, n 4.04 – 15.2 ng/ml) which level of 500ng/ml or greater is diagnostic of a macroprolactinoma (2). FSH level (0.929 IU/L, n 1.5-12.4 IU/L) and LH level (1.11 IU/L, n 1.7-8.6 IU/L) were low in this patient due to suppression of GnRH secretion from hypothalamus by prolactin. Testosterone level (0.15 nmol/L, n 8.64-29.0 nmol/L) was low secondary to low LH. Serum cortisol, growth hormone and TSH were normal. Platelet count and coagulation profiles were normal. The patient was treated conservatively in ward for acute ischaemic stroke and later was started on dopamine agonist cabergoline for hyperprolactinemia. Conclusion: This is a case report of acute ischaemic stroke with markedly hyperprolactinemia secondary to incidentaloma macroprolactinoma. Reference: (1)Freda PU, Beckers AM, Katznelson L, et al. Pituitary incidentaloma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96 (4): 894-904.(2)Abha Majumdar and Nisha Sharma Mangal. Hyperprolactinemia. J Hum Reprod Sci. 2013 Jul-Sep; 6(3): 168–175.(3)Sankalp Kumar Tripathi, Pallavi Kamble, M.G. Muddeshwar. Serum Prolactin Level in Patients of Ischemic stroke. International Journal of Contemporary Medical Research 2016; 3(12): 3459-3460.
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Wu, Victor Chien-Chia, Michael Wu, Victor Aboyans, Shang-Hung Chang, Shao-Wei Chen, Mien-Cheng Chen, Chun-Li Wang, I.-Chang Hsieh, Pao-Hsien Chu, and Yu-Shen Lin. "Female sex as a risk factor for ischaemic stroke varies with age in patients with atrial fibrillation." Heart 106, no. 7 (September 26, 2019): 534–40. http://dx.doi.org/10.1136/heartjnl-2019-315065.
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ObjectivesFemale sex is an inconsistent ischaemic stroke risk factor in patients with atrial fibrillation (AF). We hypothesised that the ischaemic stroke risk varies with age among women compared with men.MethodsWe retrieved the patients with newly diagnosed AF during 2001–2013 from Taiwan’s National Health Insurance Research Database. Patients with missing information, age <20 years, history of valvular heart disease and surgery, rheumatic heart disease, hyperthyroidism or anticoagulation and/or antiplatelet use were excluded. Propensity score matching (PSM) included patient comorbidities, medications and index date stratified by age and sex groups. Primary outcome was defined as ischaemic stroke at follow-up.ResultsAfter exclusion criteria, 87 369 men and 71 853 women remained for analysis (aged 73.1±14.4 years). After 1:1 PSM, we included 59 583 men (aged 73.5±13.7 years) and 59 583 women (aged 73.4±13.8 years) for analysis. We also stratified patients by age. The ischaemic stroke risk varied with age in women compared with men: lower in the ≤55 years (subdistribution HR (SHR)=0.75, 95% CI 0.62 to 0.90) and 56–65 years (SHR=0.87, 95% CI 0.78 to 0.98) groups, neutral in the 66–75 years group (SHR=1.01, 95% CI 0.94 to 1.08) and adverse in the >75 years group (SHR=1.14, 95% CI 1.09 to 1.19).ConclusionsThe female/male ischaemic stroke risk ratio varied with age. Only women aged >75 years had a higher risk, whereas women aged <65 years had a lower risk compared with men. These findings challenge the ‘sex category’ component of the CHA2DS2-VASc score, used to make decision regarding anticoagulation treatment in AF patients.
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Reiff, Tilman, Christoph Gumbinger, Sibu Mundiyanapurath, and Peter A. Ringleb. "Update on Extracranial Carotid Stenosis." European Neurological Review 11, no. 1 (2016): 18. http://dx.doi.org/10.17925/enr.2016.11.01.18.
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Carotid stenosis is a risk factor of ischaemic stroke and has an increasing prevalence with age. Stroke risk under optimised medical therapy, as well as recommendations of carotid artery endarterectomy/stenting, as therapy in high risk carotid stenosis, are discussed in consideration of recent research results.
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deVeber, G. "Paediatric stroke." Hämostaseologie 29, no. 01 (2009): 88–90. http://dx.doi.org/10.1055/s-0037-1616948.
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SummaryThe past decade has seen a dramatic increase in pediatric stroke research. However few studies have addressed anti-thrombotic safety or effectiveness. Three paediatric stroke guidelines combining research data with expert consensus have been published in the past five years. For most patients treatment recommendations are consistent. Newborns with arterial ischaemic stroke (AIS) rarely require antithrombotic treatment given their extremely low risk of recurrence. In children with AIS a substantial recurrence risk means that antithrombotic treatment is required unless contraindicated. Anticoagulation (heparins, warfarin) is recommended for possible or established dissection and cardiogenic embolism. Antiplatelet treatment is recommended for other children with AIS. For neonatal cerebral sinovenous thrombosis (CSVT) most centers provide initial anticoagulation in the absence of haemorrhagic contra indications, and otherwise, monitor for propagation. Children with CSVT, even with haemorrhagic infarction, more consistently receive anticoagulation, as in adults. While more studies are necessary, current treatment guidelines offer an interim option for guiding the treatment of paediatric stroke.
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Robak, Tadeusz, Joanna Góra-Tybor, Krzysztof Tybor, Krzysztof Jamroziak, Paweł Robak, Radzisław Kordek, Piotr Rieske, Agata Majos, and Halina Urbańska-Ryś. "Richter's Syndrome in the Brain First Manifested as an Ischaemic Stroke." Leukemia & Lymphoma 45, no. 6 (June 2004): 1261–67. http://dx.doi.org/10.1080/10428190310001638823.
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Zhang, Haojie, Zixiao Li, Yunyi Dai, Enhui Guo, Changqing Zhang, and Yongjun Wang. "Ischaemic stroke etiological classification system: the agreement analysis of CISS, SPARKLE and TOAST." Stroke and Vascular Neurology 4, no. 3 (June 2, 2019): 123–28. http://dx.doi.org/10.1136/svn-2018-000226.
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Background and purposeThe ideal stroke classification system needs to have validity, high reliability and applicability among different stroke research settings. The Chinese Ischemic Stroke Subclassification (CISS) and the Subtypes of Ischemic Stroke Classification System (SPARKLE) have emerged recently but have not been tested using agreement analysis. As a result, the objective of this study is to investigate the level of agreement among stroke subtype classifications using CISS, SPARKLE and Trial of Org 10172 in Acute Stroke Treatment (TOAST). We also analyse the inter-rater reliability of CISS.MethodsThe data include 623 inpatients who have had an ischaemic stroke, accrued from Beijing Tiantan Hospital between 1 October 2015 and 19 April 2016. According to the diagnostic standards of the three subtype classification systems, 299 inpatients who satisfied the requirements of our study were independently classified with etiological subtypes, and we compared the three subclassifications.ResultsThere was substantial overall agreement among the three classification systems: CISS versus SPARKLE (kappa value=0.684, p<0.001), CISS versus TOAST (kappa value=0.615, p<0.001) and SPARKLE versus TOAST (kappa value=0.675, p<0.001). The inter-rater reliability of CISS was excellent (kappa value=0.857, p<0.001). Furthermore, among the three subtype classification systems, the variance analysis results of the etiological subtypes were not uniform.ConclusionThere were generally substantial agreements among three ischaemic stroke etiological classification systems. CISS is a valid and reliable classification system, with which different stroke research centres can apply and compare data.
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Gupta, Navnika, and Sanjay Pandey. "Post-Thalamic Stroke Movement Disorders: A Systematic Review." European Neurology 79, no. 5-6 (2018): 303–14. http://dx.doi.org/10.1159/000490070.
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Background: After a stroke, movement disorders are rare manifestations mainly affecting the deep structures of the brain like the basal ganglia (44%) and thalamus (37%), although there have been case studies of movement disorders in strokes affecting the cerebral cortex also. Summary: This review aims to delineate the various movement disorders seen in association with thalamic strokes and tries to identify the location of the nuclei affected in each of the described movement disorders. Cases were identified through a search of PubMed database using different search terms related to post-thalamic stroke movement disorders and a secondary search of references of identified articles. We reviewed 2,520 research articles and only 86 papers met the inclusion criteria. Cases were included if they met criteria for post-thalamic stroke movement disorders. Case-cohort studies were also reviewed and will be discussed further. Key Messages: The most common post-stroke abnormal movement disorder reported in our review was dystonia followed by hemiataxia. There was a higher association between ischaemic stroke and movement disorder. Acute onset movement disorders were more common than delayed. The posterolateral thalamus was most commonly involved in post-thalamic stroke movement disorders.
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Buchtele, Nina, Michael Schwameis, James Gilbert, Christian Schörgenhofer, and Bernd Jilma. "Targeting von Willebrand Factor in Ischaemic Stroke: Focus on Clinical Evidence." Thrombosis and Haemostasis 118, no. 06 (May 30, 2018): 959–78. http://dx.doi.org/10.1055/s-0038-1648251.
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AbstractDespite great efforts in stroke research, disability and recurrence rates in ischaemic stroke remain unacceptably high. To address this issue, one potential target for novel therapeutics is the glycoprotein von Willebrand factor (vWF), which increases in thrombogenicity especially under high shear rates as it bridges between vascular sub-endothelial collagen and platelets. The rationale for vWF as a potential target in stroke comes from four bodies of evidence. (1) Animal models which recapitulate the pathogenesis of stroke and validate the concept of targeting vWF for stroke prevention and the use of the vWF cleavage enzyme ADAMTS13 in acute stroke treatment. (2) Extensive epidemiologic data establishing the prognostic role of vWF in the clinical setting showing that high vWF levels are associated with an increased risk of first stroke, stroke recurrence or stroke-associated mortality. As such, vWF levels may be a suitable marker for further risk stratification to potentially fine-tune current risk prediction models which are mainly based on clinical and imaging data. (3) Genetic studies showing an association between vWF levels and stroke risk on genomic levels. Finally, (4) studies of patients with primary disorders of excess or deficiency of function in the vWF axis (e.g. thrombotic thrombocytopenic purpura and von Willebrand disease, respectively) which demonstrate the crucial role of vWF in atherothrombosis. Therapeutic inhibition of VWF by novel agents appears particularly promising for secondary prevention of stroke recurrence in specific sub-groups of patients such as those suffering from large artery atherosclerosis, as designated according to the TOAST classification.
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Hildick-Smith, David, Ulf Landmesser, A. John Camm, Hans-Christoph Diener, Vince Paul, Boris Schmidt, Magnus Settergren, Emmanuel Teiger, Jens Erik Nielsen-Kudsk, and Claudio Tondo. "Left atrial appendage occlusion with the Amplatzer™ Amulet™ device: full results of the prospective global observational study." European Heart Journal 41, no. 30 (April 3, 2020): 2894–901. http://dx.doi.org/10.1093/eurheartj/ehaa169.
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Abstract Aims To evaluate the safety and efficacy of left atrial appendage occlusion (LAAO) with the Amplatzer™ Amulet™ occluder. Methods and results Patients with atrial fibrillation eligible for LAAO were recruited to a prospective global study. Implant procedures were undertaken with echocardiographic guidance. Transoesophageal echocardiography (TOE) was undertaken 1–3 months post-LAAO. Implant and follow-up TOEs were evaluated by a CoreLab. The primary endpoint was a composite of ischaemic stroke and cardiovascular death at 2 years. Serious adverse events were adjudicated by an independent clinical events committee. A total of 1088 patients were enrolled, aged 75.2 ± 8.5 years; 64.5% were male. CHA2DS2-VASc and HAS-BLED scores were 4.2 ± 1.6 and 3.3 ± 1.1, respectively. A total of 71.7% had prior major bleeding, and 82.8% had contraindications to oral anticoagulants. Implant success was 99.1%. Major adverse events (≤7 days post-procedure) occurred in 4.0%, including death (0.3%), stroke (0.4%), major vascular (1.3%), and device embolization (0.2%). A total of 80.2% of patients were discharged on antiplatelet therapy alone. Peridevice flow was <3 mm in 98.4% at follow-up TOE. Device-related thrombus (DRT) was seen in 1.6% of cases. Cardiovascular death or ischaemic stroke occurred in 8.7% of patients at 2 years. The ischaemic stroke rate was 2.2%/year—a 67% reduction compared to the CHA2DS2-VASc predicted rate. Major bleeding (Bleeding Academic Research Consortium type ≥ 3) occurred at rates of 10.1%/year (year 1) and 4.0%/year (year 2). Conclusion Following LAAO with the Amplatzer Amulet device, the ischaemic stroke rate was reduced by 67% compared to the predicted risk. Closure was complete in 98.4% of cases and DRT seen in only 1.6%.
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Li, Ce, Tingting Zhang, Kewei Yu, Hongyu Xie, Yulong Bai, Li Zhang, Yi Wu, and Nianhong Wang. "Neuroprotective Effect of Electroacupuncture and Upregulation of Hypoxia-Inducible Factor-1α during Acute Ischaemic Stroke in Rats." Acupuncture in Medicine 35, no. 5 (October 2017): 360–65. http://dx.doi.org/10.1136/acupmed-2016-011148.
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Background Acupuncture is a traditional method that has been widely used in various fields of medicine with therapeutic effect. However, evidence of effectiveness to support the application of electroacupuncture (EA) during the process of ischaemia is scarce. Objectives To investigate dynamic changes in hypoxia-inducible factor (HIF)-1α expression as well as its association with neurological status in rats subjected to acute ischaemic stroke and EA intervention. Methods Forty adult male rats were randomly divided into three groups that received sham surgery (Control group, n=10) or underwent middle cerebral artery occlusion and EA (MCAO+EA group, n=15) or minimal acupuncture as a control treatment (MCAO+MA group, n=15). The rats in the MCAO+EA and MCAO+MA groups received EA or acupuncture without any electrical current, respectively, during 90 min of ischaemia. Rats in the Control group received the same surgical procedure but without MCAO. EA involved electrical stimulation of needles inserted into the quadriceps at 50 Hz frequency and 3 mA current intensity. Neurological status was evaluated on postoperative day 1, and cerebral infarction volume (IV) and HIF-1α expression 24 hours later. Results Neurological scores were improved and cerebral IV was decreased in the MCAO+EA group compared to the MCAO+MA group (both p<0.05). Moreover, HIF-1α expression was higher in the MCAO+EA group versus the MCAO+MA group (p<0.05). Conclusions EA enhanced recovery of neurological function, decreased cerebral IV and increased HIF-1α expression in ischaemic rats. Further research is needed to determine whether EA is effective for stroke treatment through the stimulation of muscle contraction.
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Williams, A., M. Sittampalam, N. Barua, and A. Mohd Nor. "Case Series of Post-Thrombolysis Patients Undergoing Hemicraniectomy for Malignant Anterior Circulation Ischaemic Stroke." Cardiovascular Psychiatry and Neurology 2011 (April 18, 2011): 1–4. http://dx.doi.org/10.1155/2011/254569.
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While ischaemic stroke remains a leading cause of death and disability, there have been recent advancements in treatment modalities including thrombolysis and decompressive hemicraniectomy. A retrospective review of patients treated in our NHS teaching hospital, in Plymouth (UK), over a 2 year period identified 17 thrombolysed patients, of whom two had undergone subsequent decompressive hemicraniectomy. These were non-dominant hemisphere strokes in young patients, aged 51 and 57. Initial NIHSS scores were 16 and 17, and they received thrombolysis at 2 hrs 42 min and 5 hrs 10 min post onset of symptoms respectively. CT imaging demonstrated cerebral swelling with significant midline shift in both cases, and decompressive hemicraniectomy was undertaken at 29 hrs 8 min and 27 hrs 30 min post-thrombolysis. We found no significant intra-operative complications attributable to prior use of thrombolytics. Both patients have had acceptable psychological and physical outcomes, with Barthel Index scores of 40 and 25, and MMSE scores of 29/30 and 27/30. We conclude that the use of thrombolytic therapy does not contra-indicate subsequent decompressive hemicraniectomy in well selected patients with non-dominant hemisphere strokes. More research in this field is required to elucidate factors which would facilitate recognition of stroke patients who will benefit most from aggressive medical and neurosurgical intervention.
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Venema, Esmee, Martijne H. C. Duvekot, Hester F. Lingsma, Anouk D. Rozeman, Walid Moudrous, Frederique H. Vermeij, Marileen Biekart, et al. "Prehospital triage of patients with suspected stroke symptoms (PRESTO): protocol of a prospective observational study." BMJ Open 9, no. 7 (July 2019): e028810. http://dx.doi.org/10.1136/bmjopen-2018-028810.
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IntroductionThe efficacy of both intravenous treatment (IVT) and endovascular treatment (EVT) for patients with acute ischaemic stroke strongly declines over time. Only a subset of patients with ischaemic stroke caused by an intracranial large vessel occlusion (LVO) in the anterior circulation can benefit from EVT. Several prehospital stroke scales were developed to identify patients that are likely to have an LVO, which could allow for direct transportation of EVT eligible patients to an endovascular-capable centre without delaying IVT for the other patients. We aim to prospectively validate these prehospital stroke scales simultaneously to assess their accuracy in predicting LVO in the prehospital setting.Methods and analysisPrehospital triage of patients with suspected stroke symptoms (PRESTO) is a prospective multicentre observational cohort study in the southwest of the Netherlands including adult patients with suspected stroke in the ambulance. The paramedic will assess a combination of items from five prehospital stroke scales, without changing the normal workflow. Primary outcome is the clinical diagnosis of an acute ischaemic stroke with an intracranial LVO in the anterior circulation. Additional hospital data concerning the diagnosis and provided treatment will be collected by chart review. Logistic regression analysis will be performed, and performance of the prehospital stroke scales will be expressed as sensitivity, specificity and area under the receiver operator curve.Ethics and disseminationThe Institutional Review Board of the Erasmus MC University Medical Centre has reviewed the study protocol and confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) is not applicable. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. The best performing scale, or the simplest scale in case of clinical equipoise, will be integrated in a decision model with other clinical characteristics and real-life driving times to improve prehospital triage of suspected stroke patients.Trial registration numberNTR7595.
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Harshfield, Eric L., Matthew C. Sims, Matthew Traylor, Willem H. Ouwehand, and Hugh S. Markus. "The role of haematological traits in risk of ischaemic stroke and its subtypes." Brain 143, no. 1 (November 22, 2019): 210–21. http://dx.doi.org/10.1093/brain/awz362.
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Abstract Thrombosis and platelet activation play a central role in stroke pathogenesis, and antiplatelet and anticoagulant therapies are central to stroke prevention. However, whether haematological traits contribute equally to all ischaemic stroke subtypes is uncertain. Furthermore, identification of associations with new traits may offer novel treatment opportunities. The aim of this research was to ascertain causal relationships between a wide range of haematological traits and ischaemic stroke and its subtypes. We obtained summary statistics from 27 published genome-wide association studies of haematological traits involving over 375 000 individuals, and genetic associations with stroke from the MEGASTROKE Consortium (n = 67 000 stroke cases). Using two-sample Mendelian randomization we analysed the association of genetically elevated levels of 36 blood cell traits (platelets, mature/immature red cells, and myeloid/lymphoid/compound white cells) and 49 haemostasis traits (including clotting cascade factors and markers of platelet function) with risk of developing ischaemic (AIS), cardioembolic (CES), large artery (LAS), and small vessel stroke (SVS). Several factors on the intrinsic clotting pathway were significantly associated (P < 3.85 × 10−4) with CES and LAS, but not with SVS (e.g. reduced factor VIII activity with AIS/CES/LAS; raised factor VIII antigen with AIS/CES; and increased factor XI activity with AIS/CES). On the common pathway, increased gamma (γ′) fibrinogen was significantly associated with AIS/CES. Furthermore, elevated plateletcrit was significantly associated with AIS/CES, eosinophil percentage of white cells with LAS, and thrombin-activatable fibrinolysis inhibitor activation peptide antigen with AIS. We also conducted a follow-up analysis in UK Biobank, which showed that amongst individuals with atrial fibrillation, those with genetically lower levels of factor XI are at reduced risk of AIS compared to those with normal levels of factor XI. These results implicate components of the intrinsic and common pathways of the clotting cascade, as well as several other haematological traits, in the pathogenesis of CES and possibly LAS, but not SVS. The lack of associations with SVS suggests thrombosis may be less important for this stroke subtype. Plateletcrit and factor XI are potentially tractable new targets for secondary prevention of ischaemic stroke, while factor VIII and γ′ fibrinogen require further population-based studies to ascertain their possible aetiological roles.
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Joo, Heesoo, Guijing Wang, and Mary G. George. "A literature review of cost-effectiveness of intravenous recombinant tissue plasminogen activator for treating acute ischaemic stroke." Stroke and Vascular Neurology 2, no. 2 (April 28, 2017): 73–83. http://dx.doi.org/10.1136/svn-2016-000063.
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BackgroundIntravenous recombinant tissue plasminogen activator (IV rtPA) is recommended treatment for patients with acute ischaemic stroke, but the cost-effectiveness of IV rtPA within different time windows after the onset of acute ischaemic stroke is not well reviewed.AimsTo conduct a literature review of the cost-effectiveness studies about IV rtPA by treatment times.Summary of reviewA literature search was conducted using MEDLINE, EMBASE, CINAHL and Cochrane Library, with the keywords acute ischemic stroke, tissue plasminogen activator, cost, economic benefit, saving and incremental cost-effectiveness analysis. The review is limited to original research articles published during 1995–2016 in English-language peer-reviewed journals. We found 16 studies meeting our criteria for this review. Nine of them were cost-effectiveness studies of IV rtPA treatment within 0–3 hours after stroke onset, 2 studies within 3–4.5 hours, 3 studies within 0–4.5 hours and 2 studies within 0–6 hours. IV rtPA is a cost-saving or a cost-effectiveness strategy from most of the study results. Only one study showed incremental cost-effectiveness ratio of IV rtPA within 1 year was marginally above US$50 000 per quality-adjusted life year threshold. IV rtPA within 0–3 hours after stroke led to cost savings for lifetime or 30 years and IV rtPA within 3–4.5 hours after stroke increased costs but still was cost-effective.ConclusionsThe literature generally showed that IV rtPA was a dominant or a cost-effective strategy compared with traditional treatment for patients with acute ischaemic stroke without IV rtPA. The findings from the literature lacked generalisability because of limited data and various assumptions.
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Wang, Yongjun, Zixiao Li, Yilong Wang, Xingquan Zhao, Liping Liu, Xin Yang, Caiyun Wang, et al. "Chinese Stroke Center Alliance: a national effort to improve healthcare quality for acute stroke and transient ischaemic attack: rationale, design and preliminary findings." Stroke and Vascular Neurology 3, no. 4 (September 8, 2018): 256–62. http://dx.doi.org/10.1136/svn-2018-000154.
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BackgroundIn June 2015, the Chinese Stroke Association (CSA) initiated the Chinese Stroke Center Alliance (CSCA) to establish the national hospital-based stroke care quality assessment and improvement platform. This article outlines its objectives, operational structure, patient population, quality improvement (QI) intervention tools, data elements, data collection methodology and current patient and hospital data.MethodsThe CSCA is a national, hospital-based, multicentre, voluntary, multifaceted intervention and continuous QI initiative. This multifaceted intervention includes stroke centre development, written care protocols, workshops and a monitoring/feedback system of evidence-based performance measures. The data coordinating centre of the CSCA resides at the China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital.ResultsAs of July 2017, 1576 hospitals in China have contributed detailed clinical information to serve as a benchmark for the stroke care quality of 433 264 patients with acute stroke/transient ischaemic attacks (TIA), including 352 572 (81.38%) acute ischaemic stroke, 30 362 (7.01%) TIA, 42 080 (9.71%) spontaneous intracranial haemorrhage, 5505 (1.27%) subarachnoid haemorrhage and 2745 (0.63%) not specified stroke.ConclusionThe CSCA programme is designed to establish a continuous national stroke registry and help healthcare providers develop stroke centres and treat patients in a consistent manner in accordance with accepted national guidelines and, ultimately, improve patient outcomes. It supports the CSA mission to reduce stroke burden in China.