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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Over the past decade there has been an increasing use of thrombolytic agents in the treatment of coronary artery disease, pulmonary embolism, and thromboembolic strokes. The use of thrombolytic agents has been most successful in treating acute myocardial infarction. When treatment with intravenous streptokinase or tissue plasminogen activator (tPA) is initiated within the first 3 to 4 hours from the onset of symptoms, the rate of reperfusion ranges from 60% to 90%, as compared to a rate of 13% to 21% for placebo control. Both streptokinase and tPA have been extensively studied as therapies for acute myocardial infarction, and in general, a higher initial rate of reperfusion is achieved in tPA-treated patients than in streptokinase-treated patients, although the final arterial patency rate may not be different in the two groups due to a higher rate of reocclusion in the tPA-treated population. Furthermore, time dependency for efficacy from the onset of symptoms to the initiation of treatment is less for tPA than for streptokinase. However, the role of thrombolytic agents in the treatment of thromboembolic strokes is more experimental than clinical at the present time. Of all agents, tPA is the most promising and the most extensively studied. This paper will review the experimental data on the use of tPA in acute thromboembolic strokes as well as the existing clinical data on stroke reperfusion.
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PMID:The efficacy and safety of tissue plasminogen activator in acute ischemic strokes. 162 47

In the past twenty years autopsies are performed much less frequently in the elderly than in younger patients. The clinical diagnostic error rate documented by autopsy studies ranges from 6% to 68%. We analyzed the clinical and autopsy records of 214 patients who died from 1 January 1986 to 31 December 1989 at our Institute to determine the accuracy of clinical cause of death with respect to the pathologic cause of death. The most common cause of death were bronchopneumonia (25.2%) followed by gastroenteric and lung cancer (20%), cerebrovascular accident (15.8%), myocardial infarction (8%) and pulmonary embolism (7.4%). Pulmonary embolism was correctly classified only in 25% of patients. The most accurately diagnosed condition were neoplastic diseases (88%) and cerebrovascular accident (84.8%) while bronchopneumonia were correctly diagnosed antemortem in 72.2% of the patients studied. Our data suggest that advances in diagnostic technology have not reduced the value of the autopsy and that a goal-directed autopsy remains a vital component in the assurance of good medical care.
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PMID:[An autopsy study of patients who died at the Medical Clinic of the University of Siena from 1986 to 1989]. 162 9

A consensus conference on stroke was held on March 22, 1991. Subjects on which consensus was reached were: There are different kinds of cerebral haemorrhage and infarction, which can be differentiated by computerized tomography, and this can have practical consequences. At clinical examination special attention should be paid to cognitive impairment. Angiography is indicated only if carotid surgery or unusual causes are considered. CSF examination and EEG are performed only on special indications. Cardiological consultation is necessary in young patients, or if clinical signs of cardiogenic embolism are present. Coumarin derivatives are prescribed in some of these cardiac causes of stroke, to prevent recurrence. There is as yet no effective medical treatment for cerebral infarction. In lobar and cerebellar haemorrhage surgical treatment may be indicated. In the acute phase of stroke it is always important to prevent aspiration pneumonia, pulmonary embolism and decubitus, and to care for muscles and joints. Advantages and disadvantages of gastric tube and indwelling catheter should be weighed. Treatment of hypertension after the acute phase is indicated to prevent recurrent stroke. After TIA and minor stroke, aspirin is prescribed, which reduces the risk of cerebral and myocardial infarction by 30%. Carotid endarterectomy in symptomatic patients with carotid stenosis of 70% or more, reduces the number of fatal or disabling strokes by 50%, if perioperative complications are less than 4%. Rehabilitation after stroke reduces disability and improves the adaptation of both the patient and his environment. The patient should be stimulated and supported; good information, including the family, is essential. Supplying aids and taking special measures should be done on individual basis, after a period of training.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Consensus cerebrovascular accident]. 174 34

Pulmonary embolism secondary to deep vein thrombosis is a frequent cause of death in stroke patients. In a multicentre study of deep vein thrombosis prophylaxis, 112 patients with cerebral infarction and leg paresis were given aspirin 300 mg three times a day (t.d.s.) alone or with dipyridamole 100 mg t.d.s. To screen for deep vein thrombosis liquid crystal thermography of the legs was performed daily for 15 days on all patients. Those patients with positive thermography underwent immediate X-ray venography of the appropriate limb as the definitive investigation for venous thrombosis. Twenty-two patients had positive thermograms, of whom 16 had confirmed deep vein thrombosis as demonstrated by X-ray venography. Only 8 of the 22 had clinical signs of deep vein thrombosis and 2 of those had a negative venogram. Of the 14 patients with positive thermography but negative clinical signs 10 had positive venograms. Difference in the incidence of deep vein thrombosis in the two treatment groups was not demonstrated. It is concluded that occult deep venous thrombosis is common after ischaemic stroke and it can occur without clinical signs. Liquid crystal thermography is a simple, rapid and cheap screening test that will allow the detection of clinically unrecognized thrombosis.
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PMID:Liquid crystal thermography as a screening test for deep vein thrombosis in patients with cerebral infarction. 175 94

Selected secondary diagnoses (e.g. pulmonary embolism) may provide an efficient and inexpensive source of data for quality assurance (QA) monitoring if their absence at admission were known. In June 1990 we modified our hospital abstracting methods to classify each diagnosis into categories: (1) present on admission, (2) acquired during hospitalization, or (3) uncertain. Our experience has confirmed the identification and elimination from QA reports of the majority of pre-existing secondary diagnoses. Examples of secondary diagnosis codes acquired or uncertain were acute myocardial infarction 48%, pneumonias 25%, pulmonary emoboli 54% and cerebral vascular accident/hemorrhage 35%. Abstracting time has increased less than 2 min per discharge. A reabstraction study showed 87% agreement (kappa = 0.733, p less than 0.001) between initial collection and blinded reabstraction. The separation of secondary diagnoses into preexisting or acquired can: (1) be reliably undertaken by discharge abstracters; (2) be efficient in adding minimal time; and (3) enhance the validity and usefulness of data and increase physician acceptance.
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PMID:Acquired conditions: an improvement to hospital discharge abstracts. 179 Mar 24

In a rehabilitation setting, pulmonary embolism is a relatively frequent and life-threatening complication. Deciding when a patient may be experiencing this condition is difficult, however, because of frequent deficits in patient communication skills (eg, aphasia and cognitive deficits) and the multisystem illnesses affecting many rehabilitation patients. We reviewed the charts of 30 rehabilitation patients transferred emergently during the years 1986 to 1988 with a diagnosis of pulmonary embolism, which was subsequently documented by ventilation-perfusion scanning. The average age of the 30 patients was 65; 63% were women and 20 (67%) had an admitting diagnosis of stroke. The most common new-onset clinical findings in the 24 hours before discharge were unusual facial skin color changes (pale, flushed, or cyanotic) (57%), chest or upper back pain (47%), tachycardia (heart rate more than 100 bpm) (40%), hypoxemia (arterial oxygen saturation less than or equal to 90%) (40%), and fever less than 101F (37%). In 63% of the patients, either anxiety, restlessness, diaphoresis, or dyspnea was also noted in the 24 hours before discharge. The data suggest that careful physician and nursing scrutiny may identify clinical signs characteristic of pulmonary embolism, and that the de novo appearance of these constellations of findings may help to select candidates for ventilation-perfusion scanning.
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PMID:Clinical findings associated with pulmonary embolism in a rehabilitation setting. 185 63

Medical complications may account for 30% or more of the deaths resulting from acute ischemic stroke in the elderly. In descending order of frequency, the most deadly complications are bacterial pneumonia, pulmonary embolism, myocardial infarction, and sepsis without pneumonia (often in the setting of a urinary tract infection or a necrotic decubitus). Normal aging is associated with declining pulmonary and cardiovascular functions as well as declining immunocompetence and physical barriers to infection. The neurological effects of acute ischemic brain injury compound these susceptibilities. Accordingly, a high degree of vigilance is emphasized in the diagnostic and therapeutic guidelines provided for care of the lungs, the heart, the urinary tract, and the skin. Guidelines are also provided for management of blood pressure during the first hours and days following stroke onset. Treatment should be withheld unless specific medical indications are identified. When antihypertensive agents are administered, the appropriate dose may be lower than usually recommended (e.g. labetalol) in order to minimize abrupt drops in blood pressure that may result in further injury to potentially viable ischemic brain tissue.
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PMID:Prevention and management of medical complications of the hospitalized elderly stroke patient. 186 5

Though pulmonary embolism (PE) has been thought to be rare, the incidence seems to be increasing recently. During the past 10 years the authors have encountered 5 cases of PE among stroke patients. There were 2 males and 3 females, aged 51 to 71 years (mean age; 63 years). The mean time between admission and onset of PE was 23 days. As to the primary disease to be treated, 5 patients had subarachnoid hemorrhage and one had intracerebral hemorrhage. Generally, PE tends to be overlooked or misdiagnosed because of the fact that stroke patients are often in a state of unconsciousness. In our series, only one patient complained of dyspnea and the other 4 patients due to unexplained sudden tachycardia, tachypnea and hypoxemia were suspected to have PE. Deep venous thrombosis known as the risk factor leading to PE was presented in 3 patients. Especially in one patient, femoral venous catheterization was considered as a risk factor possibly leading to deep venous thrombosis. Regarding the diagnosis of PE, the roles of electrocardiogram and of chest x-ray film were small. In 3 patients, the elevation of the diaphragm was the only abnormal finding on chest X-ray. On the other hand, the lung scintigram with 99mTc-MAA was a useful method for definitive diagnosis of PE. In 3 patients, filling defects were demonstrated on the lung perfusion scintigrams. Consequently, we emphasize that PE must be kept in mind when tachycardia, tachypnea and hypoxemia appear suddenly. Prompt diagnosis and treatment are required.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Pulmonary embolism complicated with stroke: analysis of 5 cases]. 189 17

The effect of LMW heparin (Kabi 2165, Fragmin) was compared with placebo for the prevention of DVT in 103 patients with acute ischemic stroke using a prospective, double-blind, randomized trial design. Treatment was started within 72 hours, and LMW heparin was administered subcutaneously once daily according to body weight classes, which corresponded to about 55 to 65 Factor-Xa inhibitory U/kg, for 14 days, or until discharge from the hospital, if earlier. All patients underwent thrombosis surveillance with unilateral venography of the paretic limb. Evaluation of venography could be performed in 42 of 52 patients randomized to LMW heparin and in 50 of 51 patients randomized to placebo. The frequency of DVT was 15 of 42 patients or 36% (95% confidence interval 22 to 52%) in the LMW heparin group and 17 of 50 patients or 34% (21 to 49%) in the placebo group. The frequency of proximal thrombi was 5 of 42 (12%) and 8 of 50 (16%), respectively. There was one fatal pulmonary embolism in the placebo group. The mortality rate (28 days follow-up) was 5 of 52 in the LMW heparin group and 1 of 51 in the placebo group (p = 0.24). None of the deaths was related to treatment. No major hemorrhagic complications were observed. The mean Factor Xa inhibitory activity levels at peak concentration were 0.34 U/ml on day 2 and 0.42 U/ml on day 12 (p = 0.02). We conclude that LMW heparin in the dose range studied did not provide efficient prophylaxis against DVT in patients with acute ischemic stroke.
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PMID:A double-blind and randomized placebo-controlled trial of low molecular weight heparin once daily to prevent deep-vein thrombosis in acute ischemic stroke. 196 1

Thrombolytic therapy has been used fairly extensively in the management of acute proximal deep-vein thrombophlebitis of the extremities, acute pulmonary embolism, and acute peripheral arterial thrombosis and embolism in addition to acute thrombotic coronary events. In the presence of acceptable indications and a favorable benefit to risk ratio, this form of therapy, when successful, has served as a useful adjunct in the management of these disorders. In deep-vein thrombophlebitis, lysis of the thrombus before permanent pathological changes (eg, organization, scarring) have occurred can prevent venous valvular dysfunction and postural venous hypertension and its complications, especially the postphlebitic syndrome. In the more severe forms of acute pulmonary embolism, thrombolytic therapy, when applied early after symptom onset, decreases morbidity and is likely to prevent a chronic increase in pulmonary vascular resistance and persistent pulmonary hypertension. In peripheral arterial thrombo-occlusive events, early restoration of flow through thrombolysis has been shown to limit ischemic damage and serve as a useful supplement to angioplasty or surgery. Thrombolytic therapy has been used less extensively in acute strokes. Here the danger of reperfusion causing bleeding into a softened area of brain undergoing infarction has slowed its evaluation for this disorder; its application to stroke remains experimental.
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PMID:Thrombolytic therapy for noncoronary diseases. 200 69


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