Stroke management

Despite being listed in the official recommendation and guidelines for stroke management by the American Stroke Association, the American Heart Association, the American Academy of Neurology, and the American College of Chest Physi-... 

European stroke initiative recommendations for stroke management— update 2003. Cerebrovasc Diseases 2003 16 311-337. 

Although MRI is promising in that it provides specific information which could improve treatment in ischemic stroke, there is no scientific proof that it actually does improve patients clinical outcome. Consequently, based on current knowledge, the recommendation to base acute stroke management solely on MRI means a big investment without a guaranteed return in the form of reduced health care costs. 

Stroke is a heterogeneous disease and acute stroke management includes more than just the initial diagnosis. Acute stroke management should be in the hands of neurologists and neuroradiologists. If such a stroke service is not established, the patient should be referred to the next stroke center. If this is too far away, other options include neurological advice via telemedicine or telephone consultation. 

A major clinical role of CTA in acute ischemic stroke management remains the exclusion of unnecessary lA thrombolytic therapy in patients presenting with acute embolic stroke, but who do not have large... 

MRA of neck vessels is important in stroke management because extracranial atherosclerosis causes an estimated 20-30% of strokes. The NASCET trial demonstrated that carotid endarterectomy improves survival in symptomatic patients with carotid stenosis of 70-99% [35]. The Asymptomatic Carotid Atherosclerosis Study also suggested that asymptomatic patients with a stenosis of 60% could benefit from endarterectomy [36]. Since then, multiple studies have evaluated the ability of contrast-enhanced and noncontrast MRA to distinguish between nonsurgical (<70%) and surgical stenoses (70-99%). 

Ready availability of imaging is crucial for the proper management of acute stroke. The noncontrast, head CT is the minimal imaging study necessary for proper stroke management. The immediate availability of more... 

Aboderin I, Venables G (1996) Stroke management in Europe. Pan European Consensus Meeting on Stroke Management. J Intern Med 240 173-180... 

It was stressed that physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. While some have... 

Haematologic Intravenous administration of recombinant tissue plasminogen activator (rtPA), also known as alteplase, is a common component of ischaemic stroke management, but its use is associated with intracranial haemorrhage in 6.4% of patients. A 51-year-old woman who had received IV rtPA for acute left middle cerebral artery thromboembolism later presented with subarachnoid haemorrhage from an acutely ruptured anterior communicating artery aneurysm. The patient xmderwent mechanical thromboembolectomy of the left middle cerebral artery occlusion with recanalization followed by coil embolization of the aneurysm, but she did not improve neurologjcally and ultimately died (32). ... 

Expert opinion is a source, frequently elicited by survey, that is used to obtain information where no or few data are available. For example, in our experience with a multicountry evaluation of health care resource utilization in atrial fibrillation, very few country-specific published data were available on this subject. Thus the decision-analytic model was supplemented with data from a physician expert panel survey to determine initial management approach (rate control vs. cardioversion) first-, second-, and third-line agents doses and durations of therapy type and frequency of studies that would be performed to initiate and monitor therapy type and frequency of adverse events, by body system and the resources used to manage them place of treatment and adverse consequences of lack of atrial fibrillation control and cost of these consequences, for example, stroke, congestive heart failure. This method may also be used in testing the robustness of the analysis [30]. 

The effectiveness of catheter-based intra-arterial therapy to remove residual thrombus after IV rt-PA treatment is being tested in the Interventional Management of Stroke study (IMS-Ill). This study will randomize patients to 0.6 mg/kg IV rt-PA, followed by angiography with additional intra-arterial therapy as indicated, or IV full-dose rt-PA (0.9 mg/kg). A nonrandomized safety study suggested that intraarterial therapy, after 0.6 mg/kg IV rt-PA, could be accomphshed with acceptable rates of sICH. ° ... 

Adams HP, Jr., Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ. Guidelines fortbe early management of patients with ischemic stroke A scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003 34 1056-1083. 

IMS Study Investigators. Combined intravenous and intra-arterial recanalization for acute ischemic stroke the Interventional Management of Stroke study. Stroke. 2004 35 904-911. 

The Interventional Management of Stroke (IMS I) Study was a multicenter, open-labeled, single-arm pilot study in which 80 patients (median NIHSS 18) were enrolled to receive IV rt-PA (0.6 mg/kg, 60 mg maximum, 15% of the dose as a bolus with the remainder administered over 30 minutes) within 3 hours of stroke onset (median time to initiation 140 minutes). " Additional rt-PA was subsequently administered via a microcatheter at the site of the thrombus in 62 of the 80 patients, up to a total dose of 22 mg over 2 hours of infusion or until complete recanalization. Primary comparisons were with similar subsets of the placebo and rt-PA-treated subjects from the NINDS rt-PA Stroke Trial. The 3-month mortality in IMS I subjects (16%) was numerically lower but not statistically different than the mortality of the placebo (24%) or rt-PA-treated subjects (21%) in the NINDS rt-PA Stroke Trial. The rate of symptomatic ICH (6.3%) in IMS I subjects was similar to that of the rt-PA-treated subjects (6.6%) but higher than the rate in the... 

Furlan A, Higashida R. Intra-arterial thrombolysis in acute ischemic Stroke. In Mohr JP, Choi DW, Grotta JC, et al., eds. Stroke Pathophysiology, Diagnosis, and Management. 4th ed. Philadelphia, PA Churchill Livingstone 2004 p. 943-951. 

Lewandowski CA, Frankel M, Tomsick TA, Broderick J, Frey J, Clark W, Starkman S, Grotta J, Spilker J, Khoury J, Brott T. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke Emergency Management of Stroke (EMS) Bridging Trial. Stroke 1999 30 2598-2605. 

Buchan A, Gates P, Pelz D, Barnett HJ. Intraluminal thrombus in the cerebral circulation. Implications for surgical management. Stroke 1988 19 681-687. 

Jensen MB, St. Louis EK. Management of acute cerebellar stroke. Arch Neurol 2005 62 537-544. 

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. 

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