ISSN:1015-9770    

DOI:10.1159/000108168

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

In a prospective study of 128 patients with acute ischemic stroke less than 24 h from onset, we explored new predictive factors for early neurological deterioration (a decrease in Canadian Stroke Scale score during the first 48 h of ≧ 1 point). A computed tomographic scan was performed before inclusion and repeated between days 4 and 7. Independent factors predictive of progression were identified by logistic regression analysis. There was worsening during the first 48 h in 33.6% of the patients. Body temperature (p < 0.0001) and plasma fibrinogen (p = 0.003) were independently related to progressing stroke. For each 1 °C increase in body temperature, the relative risk of progression rose by 9.2 (95% CI, 4–21). The percentage of correct classifications was 83%. Thus, hyperthermia and plasma fibrinogen levels within the first 24 h of acute ischemic stroke are related to early neurological worse

ISSN:1015-9770    

DOI:10.1159/000108169

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

In many young stroke patients the cause of stroke remains unclear. Enhanced red blood cell aggregation is considered a factor related to the pathogenesis of stroke in elderly patients, in whom enhanced red blood cell aggregation is correlated with increased fibrinogen. We determined red blood cell aggregation, fibrinogen concentration, hematocrit value and erythrocyte sedimentation rate in 18 stroke patients ≤ 50 years of age in the early phase and in 40 stroke patients ≤ 50 years in the late phase, and compared the values with those in young control persons. We also determined these variables in stroke patients ≤ 60 years of age in the early and in the late phases and in elderly controls. In young stroke patients we found an enhanced red blood cell aggregation compared with young controls (p < 0.00005), both in the early and in the late phases, whereas fibrinogen was normal. Red blood cell aggregation was significantly associated with stroke after adjusting for fibrinogen, hematocrit and erythrocyte sedimentation rate [adjusted odds ratio 16.20; 95% confidence interval (CI) 2.80–93.61]. Red blood cell aggregation was higher in elderly patients than in elderly controls (p < 0.05). In elderly patients fibrinogen was associated with stroke (crude odds ratio 12.92; 95% CI 2.54–65.82), whereas after adjusting for red blood cell aggregation, fibrinogen, hematocrit and erythrocyte sedimentation rate only erythrocyte sedimentation rate showed a significant association with stroke (odds ratio 26.37; 95% CI 1.93–359.74). In conclusion, enhanced red blood cell aggregation independently relates to stroke in young people, which may suggest that enhanced red blood cell aggregation contributes to stroke cause, whereas in elderly patients any such effect is probably related to confounding by raised

ISSN:1015-9770    

DOI:10.1159/000108170

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Background: Comparisons of outcome between stroke units are important but difficult to undertake because of differences in patient composition and operational environments. This prospective study describes the use of standardised assessments to compare stroke rehabilitation units. Methods: The study was undertaken in 186 patients admitted to two stroke units (unit A: n = 110; unit B: n = 76) over 1 year. Patients were managed according to existing practices on each unit. Data were collected on the structure, process of rehabilitation and outcome on both units. Results: The age, gender, pre-morbid function and social support characteristics of patients were comparable between the two units. Data for the whole patient group did not show significant differences for mortality or institutionalisation. Median discharge Barthel Index was higher (16 vs. 14; p < 0.02) for patients managed on unit B who also showed a longer median length of stay (59 days vs. 37 days; p < 0.001). As outcome may have been influenced by the greater proportion of mild strokes on unit B (36 vs. 7%), data for the ''middle group'' of patients (unit A: n = 68; unit B: n = 48) were compared. This comparison showed no significant difference in mortality (4 vs. 8%), institutionalisation (25 vs. 17%) or median discharge Barthel Index (14 vs. 15). Patients on unit B stayed significantly longer (73 vs. 37 days) even in this group. Conclusions: Non-randomised comparisons between mainstream stroke rehabilitation units are facilitated by standardised assessments and may help identify potentially effective practices suitable for further investigation. The study also highlighted the need for extreme caution in interpreting non-randomised studies, even when standardised measures are used.

ISSN:1015-9770    

DOI:10.1159/000108171

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Many studies have addressed prognostic factors in patients with intracerebral haemorrhage on early outcome, but thesis paucity of data on prognostic factors for functional outcome in the long term. We studied prognostic factors for long-term outcome in a consecutive series of 155 patients admitted to the university department of Neurology in Utrecht. After a mean period of follow-up of 54 months, 89 (57%) patients had died; 49 (32%) were independent. Multivariate analysis identified three characteristics to be independently related with independence in the long run: lobar location of the haematoma (odds ratio [OR] 5.8; 95% confidence interval [CI] 2.3–15), age younger than 60 years (OR 9.1; 95% CI 3.7–25) and haematoma size less than 40 cm3 (OR 6.3; 95% CI 2.2–17). We conclude that besides young age and a medium-sized haematoma also a lobar rather than deep location of the haematoma relates to better outcome in the long

ISSN:1015-9770    

DOI:10.1159/000108172

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Objective: Ischemic cerebral stroke should be treated as early as possible to improve therapeutic effects and decrease disability rate. This study was performed to investigate the time of presentation of acute stroke and the time of establishment of definite diagnosis. Method: Four hospitals of different types in the Beijing area participated. Eight hundred and thirty-three patients were observed prospectively. The time from symptom onset of acute stroke to hospital arrival and the time of CT scanning were recorded. Results: Five hundred and ninety-one (70.9%) were ischemic stroke patients and 242 (29.1%) were hemorrhagic stroke patients. In Beijing Hospital the time of presentation of acute stroke was shortest among the four hospitals. The rates of patients who arrived at hospital within 3 and 6 h after acute stroke were higher for Beijing Hospital than for the other three hospitals, accounting for 42.5 and 58.8%, respectively. The time of presentation after acute ischemic stroke was longer than that after hemorrhagic stroke in all four hospitals. CT scanning was conducted most timely in Beijing Hospital. The rates of CT scanning within 3 and 6 h also were higher in Beijing Hospital, accounting for 23.5 and 40.0%, respectively. Conclusion: In the Beijing area, even in a large hospital at the city center, only half of the patients with, ischemic stroke arrived at hospital within 6 h after stroke onset. The patients who were examined with CT scan within 6 h were less than half. It is suggested that for early treatment of ischemic stroke a great deal of work, such as public and professional education in the community, should be done.

ISSN:1015-9770    

DOI:10.1159/000108173

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Stroke due to basilar artery occlusion has a high mortality and morbidity. Intra-arterial thrombolysis has been reported to improve survival and outcome status. Our aim was to assess the safety and efficacy of intra-arterial urokinase in a consecutive series of patients with clinically severe brainstem ischaemic stroke and major vertebrobasilar vessel occlusion. Incremental doses of urokinase were administered until clot lysis was achieved, or until a limit of 1,000,000 U. Patients were then anticoagulated with heparin and warfarin, and 6-month functional status was measured by the Barthel index. Sixteen patients, aged 22–73 (median 60), were treated 5–31 (median 15) h following symptom onset. Thirteen of the 16 patients (82%) had initial complete or partial recanalisation. Complete occlusion of the basilar artery was present in 13, and recanalisation was achieved in 10 of these (77%), although 2 re-occluded. Four of 5 patients with persistent occlusion died, compared with only 1 death in 8 patients with sustained recanalisation (p = 0.02, Fisher''s exact test, one-tailed). Intra-arterial urokinase can recanalise basilar artery occlusion, with significant reduction in mortality at 6 months. A prospective randomised, controlled trial is necessary to confirm the benefit of this ther

ISSN:1015-9770    

DOI:10.1159/000108174

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

We present the methodology and data indicating the feasibility of a five-study collaborative stroke trial. The core study, the Warfarin-Aspirin Recurrent Stroke Study (WARSS), is a prospective, randomized, double-blind multicenter trial comparing warfarin and aspirin in preventing the recurrence of ischemic stroke. The WARSS primary endpoint is the earlier of death or symptomatic ischemic stroke recurrence. The primary null hypothesis is that, over 2 years, warfarin therapy will not differ in frequency of death or ischemic stroke recurrence compared with platelet antiaggregant therapy (aspirin). The target sample size is 1,920. Four related studies use the WARSS data. The Antiphospholipid Antibodies and Stroke Study (APASS) investigates the significance of antiphospholipid antibodies in ischemic stroke; the Patent Foramen Ovale in Cryptogenic Stroke Study (PICSS) assesses the risk of stroke recurrence or systemic embolization in medically treated cryptogenic stroke patients with and without patent foramen ovale; and the Hemostatic System Activation Study (HAS) studies the F1 + 2 fractions of prothrombin in a subgroup of patients to allow comparison between the international normalized ratio (INR) and the evidence of prothrombin split products activity. The Genes in Stroke Study (GENESIS) investigates whether the double deletion genotype of the angiotensin converting enzyme is a risk factor for stroke. Features of the collaboration are cost savings in research arising from the use of a common data base; standardization through use of one central laboratory for processing of INR values, and double blinding by fabrication of INR values for aspirin patients. WARSS randomization began June 22, 1993. Cumulative patient recruitment through June 1, 1996 exceeds 1,400 at 50 sites.

ISSN:1015-9770    

DOI:10.1159/000108175

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

The concept of critical care in stroke is a controversial issue. The question of whether full-scale critical care management of stroke improves patient outcome is still open and probably depends on the definition adopted for critical care. At a second meeting of the European Ad Hoc Consensus Group, the following recommendations for optimal critical care management of stroke patients were made. Emergency Stroke Care: Public and professional education programmes and an active policy should be implemented to reduce the time from stroke symptom onset to initiation of therapy, in order to optimize care for all patients and allow selection of a maximum number of patients eligible for specific acute therapy. The prehospital care services should be made full partners in acute stroke care. As in any other medical emergency, urgent evaluation is paramount; evaluation, by the family physician could result in unnecessary delays. It is essential that a stroke patient be urgently referred by theflrst examining physician to the hospital best equipped to provide the most appropriate acute stroke care. Certain subgroups of patients, including those with large hemispheric infarctions, basilar or vertebral artery occlusion, coma, lower cranial nerve palsy, or systemic complications, e.g. aspiration or concomitant myocardial infarction, may benefit from intensive care if they are identified rapidly. Multi-hospital networks following standard protocols may enlarge the catchment area for stroke units and ensure consistency and continuity of stroke care. Rapid response systems should be developed in individual hospitals to shorten in-hospital treatment delays. Diagnostic delays should be avoided by ensuring that the necessary personnel and equipment are available at all times. A neurologist in attendance or on call should be an integral member of any emergency department that admits acute stroke patients. Intensive Stroke Care: Organized stroke care can reduce mortality and improve functional outcome in acute stroke patients. New techniques for treating stroke subtypes with a poor prognosis require intensive care unit (ICU) facilities and can reduce mortality. The essential elements of stroke intensive care consist of 24-hour availability of third- or fourth-generation computed tomography scanning, Doppler ultrasonography, a neurologist, a neurosurgeon, a neuroradiologist, monitoring (including invasive monitoring) and laboratory services, and optional ventilation capacity. A written protocol, supported by explicit checklists, is necessary to ensure that patient care is standardized. The use of such a protocol can significantly improve outcome and reduce the incidence of complications, the length of hospital stay, and costs. The issues that must be addressed in a protocol for acute stroke care include support of vital functions, detailed diagnostic studies, prevention of deterioration and complications, use of specific acute therapies for appropriate patients, risk factor correction, early and late rehabilitation, and secondary prevention. Specific Problems of Stroke Intensive Care: All patients with moderate to severe acute stroke should be monitored carefully with respect to general and cerebral functions. ECG, oxygen saturation, blood pressure and temperature should ideally be monitored continuously during the first 24 h. Other functions, including blood glucose levels, should be monitored intermittently but frequently. Stroke patients considered at risk of cardiac complications and possible cardiac arrest should be cardiac-monitored preferably for 2–3 days. Routine intracranial pressure (ICP) monitoring should not be performed. Elevation of the head and upper body, combined with osmotherapy and mild hyperventilation if indicated, is recommended as basic treatment for oedema and mass effect in acute ischaemic stroke. Hypertension should not be routinely treated in the acute phase of stroke. Antihypertensive agents may be used with caution, however, in patients with markedly elevated blood pressure at 2 consecutive measurements [systolic blood pressure >220 mm Hg, or mean arterial blood pressure (MABP) > 140 mm Hg]. As a general guide, MABP should be lowered by decrements no larger than 15 mm Hg. Antihypertensive agents should be chosen appropriately to avoid increases in cerebrovascular blood volume or ICP. An antipyretic and/or an antibiotic should be given immediately for raised temperature, possibly with a cooling blanket, and subcutaneous or intravenous insulin should be used for markedly elevated blood glucose levels. Prophylaxis against deep vein thrombosis and pulmonary embolism is indicated in all acute stroke patients, but anticoagulation should be avoided in those with large intracranial haemorrhage and in selected neurosurgical patients. Physiotherapy as well as speech and occupational therapy should be started as early as possible. The Need for Neurological Intensive Care: Neurological ICUs can improve the survival and outcome of those acute stroke patients who require intensive care. Aggressive approaches to acute stroke therapy, e.g. hypervolaemic-hypertensive therapy, ventricular drainage, decompressive surgery, or experimental use of thrombolytic agents, require management in a specialized neurological ICU. About 10% of hospitalized acute stroke patients require ICU care, which is best provided by staff with specialized training in neurological care. The minimum requirements for optimal neurological intensive care are a 24-hour neurologist or neurointensivist shift service, 1 nurse per patient in attendance at all times, and facilities for advanced haemodynamic, neurological and ICP monitorin

ISSN:1015-9770    

DOI:10.1159/000108176

出版商:S. Karger AG    

年代:1997

数据来源: Karger

ISSN:1015-9770    

DOI:10.1159/000108177

出版商:S. Karger AG    

年代:1997

数据来源: Karger