Stroke major ischemic

Cerebrovascular Carotid spasm Compromise of ECA ostium Hyperfusion syndrome Contrast encephalopathy Transient symptomatic cerebral ischemia Global Focal Carotid dissection Carotid perforation Hyperperfusion syndrome Acute stent thrombosis Major ischemic stroke Cerebral hemorrhage... 

Aspirin CAST Aspirin versus placebo within 48 hours of major ischemic stroke... 

There are fundamental questions about the role interventional treatments should play in dealing with major ischemic stroke. While the incidence of acute ischemic stroke (AIS) is well documented, there is scant literature regarding the total number of cases treated endo-vascularly or the number of potential cases amenable to... 

O Connor RE, McGraw P, Edelsohn L. Thrombolytic therapy for acute ischemic stroke why the majority of patients remain ineligible for treatment. Ann Emerg Med 1999 33 9-14. 

Stroke is the leading cause of major long-term disability in adults and the third leading cause of death in the United States. On average, a new stroke occurs every 45 seconds. Thrombolytic therapy with intravenous recombinant tissue-plasminogen activator (IV rt-PA) is the most effective treatment for acute ischemic stroke. In this chapter, we review the rationale for thrombolysis in acute ischemic stroke, clinical evidence supporting the use of thrombolytics, and the application of thrombolysis in practice. 

The authors concluded that campaigns to educate patients to seek treatment sooner should be major components of system-wide interventions to increase the rate of thrombolysis for acute ischemic stroke. There is some evidence that public education may help to increase the rate of rt-PA utilization by encouraging earlier presentation when stroke symptoms occur. ... 

OR 1.81, 95% Cl 1.46-2.24), most of which were related to symptomatic intracranial hemorrhage (OR 3.37, 95% Cl 2.68. 22). In addition, a pooled analysis of six major randomized placebo-controlled IV rt-PA stroke trials (Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) I and II, European Cooperative Acute Stroke Study (ECASS) I and II, and NINDS I and II), including 2775 patients who were treated with IV rt-PA or placebo within 360 minutes of stroke onset, confirmed the beneht up to 3 hours and suggested a potential beneht beyond 3 hours for some patients. The pattern of a decreasing chance of a favorable 3-month outcome as the time interval from stroke onset to start of treatment increased was consistent with the findings of the original NINDS study. ... 

No direct comparison trials have been reported between the different thrombolytic agents in acute ischemic stroke. In a retrospective review of the results for acute stroke lAT performed at our center, we have found significantly higher rates of recanalization and good clinical outcome in the era in which lA UK was used versus the era in which UK was not available and lAT with rt-PA was the primary treatment. Conversely, in another retrospective study, Eckert et al. found no major difference between the recanalization rates of UK and rt-PA. 

The timing of CEA after ischemic stroke has been a controversial issue. In 1969, the Joint Study of Extracranial Arterial Occlusion reported 42% mortality after CEA in patients with neurological deficits of less than 2 weeks duration, compared with 5% mortality in patients with more than 2 weeks of symptoms. Early evidence also demonstrated an increased risk of intracerebral hemorrhage after early CEA in patients with acute stroke. This led to the conclusion that most complications occurred with early surgical intervention, and resulted in a traditional 4-6 week delay for CEA after an acute stroke. In retrospect, however, there were major problems with patient selection in these earlier reports. Many of the patients... 

Cl 0.08-0.96) and symptomatic pulmonary embolism (PE) (OR 0.34, 95% Cl 0.17-0.69), but an increase in major extracranial hemorrhage when compared to placebo (OR 2.17, 95% Cl 1.10. 28). Nonsignificant reductions in combined death and disability, as well as increases in case fatality and sICH were also observed. The authors concluded that insufficient evidence existed to support the routine use of LMWH in the management of patients with ischemic stroke. 

Overall no evidence was found to support the claim that anticoagulants offer a net advantage over aspirin in patients with acute ischemic stroke. There was evidence, however, to suggest that combination anticoagulant and aspirin therapy was associated with a small increase in the number of deaths at the end of follow-up, equivalent to 20 more deaths per 1000 patients treated. This adverse effect can probably be attributed partly to the 10 extra sICHs, and the 5 extra major extracranial hemorrhages per 1000 patients treated with combination anticoagulant/ aspirin therapy. 

The abciximab in Acute Ischemic Stroke trial was a randomized, placebo-controlled dose-escalation study to examine the safety of abciximab in acute stroke. It randomized 74 patients within 24 hours of stroke onset to receive one of four doses of abciximab (by bolus with or without additional infusion, 54 patients) or placebo (20 patients). The median baseline National Institute of Health Stroke Scale (NIHSS) score was 15. The rates of asymptomatic ICH were 19% in the intervention group compared to 5% in the placebo group p = 0.07). Most (9 of 11) of the asymptomatic ICH patients had more severe stroke (NIHSS >14). No cases of symptomatic ICH or major systemic bleeding occurred. There was a trend toward a lower rate of stroke recurrence (2% vs. 5%) and a higher rate of functional recovery at 3 months in the group treated with abciximab than with placebo. 

Although several approaches to stroke classification have been described, the most common mechanism-based classification in current use is the system described by the TOAST investigators." This classification describes five major subtypes of ischemic stroke based on the results of neuroimaging and other medical investigations, namely (1) LAA, (2) cardioembolism, (3) small-vessel occlusion, (4) stroke of other determined etiology, and (5) stroke of undetermined etiology. Inter-rater reliability of the TOAST scheme has been reported as moderate-to-substantial K 0.5-0.7). 

Carotid artery disease is one of the major causes of ischemic stroke. The predominant mechanisms by which it causes stroke are (a) arterial embolism from atherosclerotic plaques (b) hemodynamic changes, leading to watershed infarcts and (c) distal propagation of thrombus originating from acute carotid occlusion. ... 

Fewer than half of all patients with acute stroke are seen in the emergency department (ED) within 3 hours of symptom onset." Patients in remote locations or in hospitals without available stroke expertise may have even more limited access to thrombolysis. In a study of non-urban East Texas communities in the United States, only 1.4% of patients with ischemic stroke received IV rt-PA, versus 14.7% at a university hospital in Houston, the nearest major city. Other studies have linked racial, ethnic, geographic, or socioeconomic differences to low rates of rt-PA utilization," suggesting that populations most underserved by stroke expertise may have the lowest rates of rt-PA delivery. 

Age >40 yr, previous venous thromboembolism, chronic heart failure, acute respiratory failure, recent major surgery (within 2 wk), confined air/ground travel (>6 h duration within 1 wk of admission), inflammatory bowel disease, myocardial infarction, nephrotic syndrome, and ischemic stroke... 

Moderate Major or minor surgery, age 40-60 years, and no clinical risk factors Major surgery, age less than 40 years, and no clinical risk factors Minor surgery, with clinical risk factor(s) Acutely ill (e.g., myocardial infarction, ischemic stroke, heart failure exacerbation), and no clinical risk factors 10-20 1-2 I o UFH 5000 units SC every 12 hours Dalteparin 2500 units SC every 24 hours Enoxaparin 40 mg SC every 24 hours Tinzaparin 3500 units SC every 24 hours IPC Graduated compression stockings... 

A major goal in the long-term treatment of ischemic stroke involves the prevention of a recurrent stroke through the reduction and modification of risk factors. 

Assessment of risk factors for ischemic stroke as well as for hemorrhagic stroke is an important component of the diagnosis and treatment of patients. A major goal in the long-term treatment of ischemic stroke involves the prevention of a recurrent stroke through the reduction and modification of risk factors. The major focus of primary prevention (prevention of the first stroke) is also reduction and modification of risk factors. Risk factors for ischemic stroke can be divided into modifiable and non-modifiable factors. Every patient should have risk factors assessed and treated, if possible, as management of risk factors can decrease the occurrence and/or recurrence of stroke.4... 

Major surgery, age >60 years, and no clinical risk factors Major surgery, age 40-60 years, with clinical risk factor(s) Acutely ill (e.g., Ml, ischemic stroke, CHF exacerbation), with risk factor(s)... 

More than 50% of patients with cerebral embolism have atrial fibrillation. In the majority of these patients, the underlying cardiac disease is nonvalvular. The risk of ischemic stroke and atrial fibrillation increases with age, reaching a cumulative risk of 35% during a patient s lifetime. Combined results from several randomized trials show that warfarin reduces the risk of stroke in patients with nonrheumatic atrial fibrillation by 68% (to 1.4% per year), with an excess incidence of major hemorrhage (including intracranial) of only 0.3% per year. 

The results showed that patients treated with clopidogrel had an annual 5,32% risk of ischemic stroke, Ml, or vascular death compared with 5,83% with aspirin (RRR = 8.7% in favor of clopidogrel, P = 0,045). There were no major differences in terms of safety. 

Thus, PI is a particularly important tool in DWI negative vascular events and non-ischemic strokelike episodes and may, indeed, clarify the underlying pathology. The majority of patients with DWI negative scans can be classified correctly based on PI as suffering from a cerebrovascular event or from a stroke mimic. Negative DWI and PI studies should intensify the search for non-ischemic conditions. However, in the majority of stroke patients DWI will reveal the clinically relevant lesion and has now become the centerpiece of integrated stroke MRI examinations. 

Barber PA, Darby DG, Desmond PM, Gerraty RP, Yang Q, Li T, Jolley D, Donnan GA, Tress BM, Davis SM (1999) Identification of major ischemic change. Diffusion-weighted imaging versus computed tomography. Stroke 30 2059-2065... 

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