摘要:

In clinical trials stroke is reported as a major morbid outcome, but the impact of stroke on patients is not directly assessed. This study examines patient preferences for different outcomes of stroke, including death.MethodsWe presented patients with written case scenarios of stroke outcomes. The scenarios represented four categories of stroke severity (mild, moderate, severe, and fatal), and for nonfatal strokes the scenarios described motor, language, and cognitive deficits. Patients reported values for each of the 10 stroke scenarios using a rank-and-scale method over a 100-point range, with 100 representing perfect health and 0 corresponding to the worst possible health state.ResultsOne hundred seventeen of 209 consecutive patients at risk for stroke participated in this study. Severe strokes were uniformly rated as having low preference weights (mean±SD [median]: 3±4 [1] for disabling hemiplegia, 8±9 [5] for confusion, and 15 ±14 [10] for global aphasia), and severe motor impairment (a disabling hemiplegia) was rated as significantly worse than death. Even mild deficits resulted in substantial loss to patients (54±21 [55] for dysarthria and 53±21 [50] for mild anomia).ConclusionsStrokes may result in a wide variety of poststroke consequences for patients. Severe strokes may be viewed by patients as tantamount to or worse than death. Even mild strokes may cause significant declines in patient preferences for health states. These data are useful in interpreting studies that report stroke and death, in designing new studies that measure stroke in at-risk populations, and in helping patients reach treatment decisions about therapies designed to prevent strokes.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

We sought to establish the pattern of blood pressure (BP) change after hospitalization for acute hemispheric stroke.MethodsIn 292 patients from the Leicester teaching hospitals with acute hemispheric stroke within the previous 24 hours (139 men; median age, 75 years [range, 42 to 98 years]), we prospectively studied BP changes between admission, 24 hours, 1 week, and 4 to 6 weeks. Changes were assessed in relation to the main stroke risk factors, stroke type and severity, and antihypertensive drug treatment. All subjects were followed up for 1 week, with 117 subjects followed up for 4 to 6 weeks. Changes were assessed by repeated-measures ANOVA, and Student'sttests were used to compare group pairs.ResultsSystolic and diastolic BP fell by 12 mm Hg (95% confidence interval [CI], 8 to 15 mm Hg) and 7 mm Hg (95% CI, 5 to 9 mm Hg), respectively, in the first 24 hours and 22 mm Hg (95%CI, 18 to 25 mm Hg) and 12 mm Hg (95% CI, 10 to 14 mm Hg), respectively, during the first week (all changes significant atP<.01) but no further thereafter. In those patients receiving no antihypertensive medication before or after stroke, the pattern of change was similar to that of the whole group. Previously diagnosed hypertensive subjects (n=106) had higher initial BP values than did normotensive subjects, although by 1 week the levels were not significantly different. Patients with cerebral hemorrhage confirmed by computed tomography (n=20) had higher systolic BP, but not diastolic BP, throughout the first week than those with cerebral infarction (n=89). The severity of stroke, age, and previous stroke history did not appear to alter the BP pattern. Stroke patients who were moderate to heavy alcohol consumers had lower convalescent systolic BP levels than lighter drinkers or abstainers.ConclusionsWe have demonstrated a marked fall in systolic and diastolic BP levels during the first 7 days after acute hemispheric stroke, with little change thereafter. Higher initial systolic BP values were found in patients with cerebral hemorrhage compared with those with cerebral infarct. Moderate to heavy alcohol consumption before stroke was associated with a greater systolic BP decline in the first week after the event compared with stroke patients who were light drinkers or abstainers.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

We investigated the changes of circadian blood pressure patterns after thromboembolic and hemodynamic brain infarction and evaluated the relation between circadian blood pressure variation, infarct location, and activation of the autonomic nervous system after thromboembolic stroke.MethodsRepeated 24-hour blood pressure measurements were performed in 45 patients with proven first-ever brain infarctions of different origins. Evaluation of serum norepinephrine concentration, prolongation of the QT interval, and degree of cardiac arrhythmias were used to determine the extent of sympathetic activation after thromboembolic stroke.ResultsWhereas circadian blood pressure variation was significantly increased after hemodynamic infarction compared with a control group (diastolic, −25.2±4.5% versus −13.8±6.5%;P<.005), a clearly reduced variation was observed after thromboembolic infarction (diastolic, −5.2±6.9%). Blood pressure variation was positively related to serum norepinephrine concentration (r=.79;P<01) after thromboembolic infarction. Patients with involvement of the insular cortex showed a nocturnal rise of blood pressure significantly more frequently (66.7% versus 11.8%;p<.005) and had higher norepinephrine levels (540±110 pg/mL versus 290±178 pg/mL;P<.01) than patients without insular cortex infarction, indicating increased sympathetic activity. This was associated with a significantly more frequent occurrence of QT prolongation and cardiac arrhythmias.ConclusionsThe observed differences in circadian blood pressure patterns may (1) help to distinguish the pathophysiological basis of the stroke, (2) help to explain worsening in some cases of hemodynamic stroke, (3) confirm the importance of the insular cortex for sympathetic activation, and (4) identify subgroups of patients with increased risk of myocardial infarction and arrhythmia.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Incidence, case-fatality rate at 28 days, and severity of acute stroke were recorded for 7 years in a large population-based stroke register to understand the reasons for the decline in stroke mortality in northern Sweden.MethodsWithin the framework of the World Health Organization MONICA Project, acute stroke was monitored in people aged 35 to 74 years in northern Sweden from 1985 through 1991 (target population in 1985, 238 948).ResultsThe annual incidence of stroke decreased by an average of 2.3%/y in men aged 35 to 64 years (P=.074) and increased significantly by 1.1%/y in men aged 65 to 74 years (p=.041). No significant changes in incidence occurred in either age group in women. The 28-day case-fatality rate in first-ever strokes (both sexes together) declined from 21.9% to 15.4% in patients aged 65 to 74 yean (P=.02). Among survivors, the proportion with extensive motor deficits (at any time during the first 28 days) declined in patients younger than 65 years as well as in those older than 65 years (p=.007 andp=.019, respectively). In patients aged 35 to 64 years, the proportion with aphasia/dysphasia also decreased significantly (P=.032), but no such trend was seen in those aged 65 to 74 years.ConclusionsA shift toward higher ages has been noted in the occurrence of first-ever strokes in men, while incidence has remained unchanged in women. During the 7 years of observation, stroke has become a less severe disease.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Ensuring the reliability and validity of outcome measures used in clinical trials is essential to the success of the trial. The Trial of Org 10172 in Acute Stroke Treatment (TOAST) is a multicenter clinical trial that is recruiting patients with acute ischemic stroke seen at medical centers across the United States.MethodsThis paper describes an approach to train physicians to use three clinical measures: the National Institutes of Health (NIH) Stroke Scale, a supplemental motor examination, and the Glasgow Outcome Scale. The program included education, certification, remediation when needed, monitoring, and reliability assessment. The goal was to ensure that interrater assessments were as equivalent to one another as possible.ResultsOf the first 95 clinicians who began the certification process, 75 passed during the first evaluation. Eighteen of the other physicians were able to complete the process after remediation. The intraclass correlations of both the NIH Stroke Scale and supplemental motor examination exceeded 0.95. The K values for the Glasgow Outcome Scale were 0.61 and 0.62 for the first and second ratings of the videotape, respectively.ConclusionsOur experience suggests that a program that includes educational and certification processes can be performed as part of the design of a multicenter clinical trial. The method of providing educational and testing videotapes to each site so that physicians can be trained and certified is an effective, inexpensive, and practical approach for enhancing and certifying the expertise of the large number of physicians involved in a multicenter study.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

The incidence of stroke among inpatients is not known. The aim of our study was to investigate the incidence of stroke not preceded by evident iatrogenic factors such as surgical or medical procedures in a cohort of inpatients in a large Italian general hospital.MethodsFrom January 1, 1992, to December 31, 1992, we evaluated patients referred to our neurology department with a suspected diagnosis of stroke that occurred during hospitalization. Patients presenting with stroke as a complication of iatrogenic causes were excluded. We calculated the incidence rate of first-ever stroke in our cohort (crude and among patients aged older than 50 years), thereafter adjusting these rates for age to the general population of the city district of Bologna (Italy).ResultsIn 1992, 22 inpatients had a first-ever stroke with no evidence of iatrogenic factors. The crude stroke incidence rate was 11.08/1000 per year (95% confidence interval, 6.95 to 16.73). The age-adjusted rate was 5.46 (95% confidence interval, 3.42 to 8.24).ConclusionsThe incidence rate of first-ever stroke among hospitalized patients is higher than those reported in community-based studies. Higher frequency of coronary artery disease among our patients could explain our findings. Further studies are needed to identify possible predisposing factors (individual or environmental) for stroke among inpatients.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

There is no acute therapy proven to be of benefit for ischemic stroke. Ancrod is a potentially effective therapy because of the advantageous consequences of fibrinogen lowering.MethodsWe studied the safety and efficacy of ancrod in patients with acute ischemic stroke administered within 6 hours of stroke onset. In a doubleblind, randomized, placebocontrolled trial 64 patients received intravenous ancrod and 68 received placebo for 7 days. Neurological outcome, disability, and brain infarct volume were measured.ResultsThere was no significant difference in overall mean scores on the Scandinavian Stroke Scale. No increase in bleeding occurred in the ancrod-treated patients. The target reduction of plasma fibrinogen levels of less than 100 mg/dL was achieved in only 15 (23%) of 64 ancrod-treated patients. Those patients with ancrod-induced 6-hour fibrinogen levels 130 mg/dL or less had a marginally significantly better neurological outcome on the Scandinavian Stroke Scale, mortality, and Barthel Index than ancrod-treated patients with higher fibrinogen levels.ConclusionsAncrod appears safe and potentially effective when administered to patients within 6 hours of onset of ischemic stroke.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Prostaglandins are believed to play an important role in maintenance of cerebral blood flow and possibly in the vasodilatory response to carbon dioxide. Therefore, the nonsteroidal anti-inflammatory drugs and aspirin, which inhibit cyclooxygenase, might be expected to reduce cerebral blood flow and the response to hypercapnia. This could induce cerebral ischemia in patients with a hemodynamically critical circulation. It would also interfere with the measurement of cerebrovascular reserve using carbon dioxide.MethodsThe effect of a single dose of indomethacin and of two other cyclooxygenase inhibitors (aspirin and sulindac) on the cerebral circulation was measured using transcranial Doppler ultrasonography of the middle cerebral artery. Seven normal adults were studied in each drug group. Resting blood flow velocity and the responses to hypercapnia and to hyperventilation were measured.ResultsIndomethacin resulted in a fall in basal middle cerebral artery flow velocity from a mean of 48.9 cm/s to 34.0 cm/s (p<.002). It also reduced the vasoconstrictor response to hypocapnia (induced by hyperventilation) from 37.5% to 20.7% (P<.003). There was a nonsignificant reduction in the vasodilatory response to 8% carbon dioxide (mean: predrug, 87.7%; postdrug, 61.0%), with marked intersubject variability. In contrast, basal middle cerebral artery velocity and vasoconstrictor and vasodilatory responses to changes in carbon dioxide were unchanged after aspirin or sulindac administration.ConclusionsThe lack of effect of aspirin on basal cerebral blood flow velocity and on vasodilatory reserve is reassuring; aspirin will not reduce cerebral blood flow or the response to a reduced perfusion pressure in patients with critically impaired cerebral hemodynamics. However, indomethacin should be avoided in such patients.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Vasomotor changes occur in the arm after hemiplegic stroke. Previous studies have provided conflicting results, with most showing an increase in skin temperature of the hemiplegic arm. However, a number of patients complain of distressing coldness of the hemiplegic arm.MethodsEleven patients with symptomatic coldness and 10 patients with hemiplegia but no coldness were recruited. The severity of the symptom of coldness was compared by questionnaire with other common symptoms after stroke. A thermographic camera was used to record the finger skin temperature response to cold stress. Blood flow to both hands was also measured simultaneously by means of two plethysmographs. In all patients there were no symptoms in the unaffected arm, and this was used as a control.ResultsThe symptom of coldness rated highly compared with other symptoms. In the symptomatic group the finger temperature on the hemiplegic side was lower at rest (median difference at rest, 0.65°C;P<.0001) and at all times after cold stress. In the asymptomatic group the fingers on the hemiplegic side were colder at rest and after initial cooling (median temperature difference, 0.2°C) but at no other time. Hand blood flow on the hemiplegic side was also decreased in the symptomatic group by 35%. This was not seen in the asymptomatic group.ConclusionsColdness of the hand may be a severe and distressing symptom in some patients after hemiplegia. Symptomatic patients have lower finger skin temperatures at rest and after standard cold stress. These symptomatic patients also had reduced blood flow to the hemiplegic hand.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Transcranial Doppler measurements of blood flow velocity permit an assessment of variations in intracraniaJ hemodynamics in response to acute arterial pressure variations. The purpose of this study was to scan healthy volunteers and patients with autonomic failure for differences in cerebral hemodynamic patterns under an acute hypotensive stimulus.MethodsWe used transcranial Doppler monitoring of blood flow velocity in the middle cerebral artery and noninvasive monitoring of arterial blood pressure and heart rate before, during, and after acute arterial hypotension induced by reactive hyperemia of the lower limbs.ResultsAfter maximum hypotension, the mean blood flow velocity was higher in the healthy volunteers than in the patients. In the healthy subjects mean velocity rose significantly (P<.01) higher than arterial blood pressure after 30 seconds and 60 seconds; in the patients mean velocity and arterial pressure moved in parallel fashion. The diastolic blood flow velocity increased more in the control group than in the patients during the early stages of the test; furthermore, only in the healthy volunteers did it increase significantly more than arterial pressure after 30 seconds and 60 seconds. Regarding the pulsatility index, the differences between the two groups were similar to the diastolic velocity results.Conclusions(1) Monitoring of mean blood flow velocity showed the ability to mantain an adequate cerebral blood flow in healthy subjects; this mechanism was not efficient in the patients with autonomic failure. (2) Diastolic velocity and pulsatility index values clearly showed that only in healthy subjects were cerebral hemodynamics relatively independent of pressure values.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID