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

The indications for thrombolytic therapy in acute myocardial infarction, pulmonary embolism, deep venous thrombosis and ischemic stroke are reviewed on the basis of a risk-benefit analysis. There is strong evidence that thrombolysis benefits the majority of patients with acute myocardial infarction. Nevertheless, the overall proportion of patients actually receiving this therapy is disappointingly low (10-30%). Efforts are mainly required in minimizing delays in initiating thrombolysis (patient, doctor, in-hospital) and in providing thrombolytic therapy to an extended proportion of qualifying patients. This implies that many traditional but inappropriate exclusion criteria (e.g. age, presentation 6 to 12 hours after onset of symptoms, hypertension, reinfarction, brief cardiopulmonary resuscitation) are unfounded. Depending on duration of symptoms, infarct localization and age, we favor a differentiated thrombolytic regimen with rt-PA or streptokinase. In contrast to acute myocardial infarction, the risk-benefit ratio for the other thrombotic disorders discussed favours thrombolytic therapy only in a minority of carefully selected patients.
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PMID:[Possibilities and limitations of thrombolysis. Benefits and risk in acute myocardial infarct, lung embolism, pelvic and leg vein thrombosis as well as cerebrovascular accidents]. 817 7

Thromboembolism is a common problem in neurosurgery and neurology patients. Within this diverse population are subpopulations of patients with varying degrees of thromboembolic risk: low, moderate, and high. Patients at substantial risk for deep vein thrombosis and pulmonary embolism include those with spinal cord injury, brain tumor, subarachnoid hemorrhage, head trauma, stroke, and patients undergoing a neurosurgical operation. There are prophylactic strategies that can be applied to these various risk groups that will dramatically reduce the incidence of thromboembolism. The risk of pulmonary embolism or fatal pulmonary embolism typically exceeds the risk of severe or fatal bleeding from adequate prophylaxis, and these techniques should be applied on a routine basis. To adequately care for patients with deep venous thrombosis and pulmonary embolism, the physician requires a thorough understanding of the methods of diagnosis, the pharmacokinetics of heparin and warfarin, and a knowledge of their role in the treatment strategies that have proven efficacy and safety. In addition, an awareness of the low molecular weight heparins and heparinoids is becoming essential. These new agents have a potentially promising role in both the prophylaxis and treatment of patients with neurological disease. The principles concerning the prophylaxis, diagnosis, and clinical management of venous thromboembolic disease in neurosurgery and neurology patients are dealt with in this review.
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PMID:Venous thromboembolism in neurosurgery and neurology patients: a review. 817 90

After decades of focus on the effects of cocaine abuse on the central nervous system (CNS), the cardiovascular toxicity of cocaine is just beginning to be appreciated. The most common cardiovascular pathologies associated with cocaine use include: cardiomyopathy, left ventricular dysfunction, myocarditis, arrhythmia, hypertension, myocardial infarction, stroke, arterial thrombosis, deep vein thrombosis, and gastrointestinal, renal, and skeletal muscle ischemia. This article reviews the above pathologies with speculations on the mechanisms by which cocaine produces cardiovascular tissue damage.
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PMID:Cardiovascular and thrombosis pathology associated with cocaine use. 829 12

Primary antiphospholipid syndrome (PAPS) is an autoimmune disorder manifested by recurrent thrombosis in the venous and arterial system. We report a group of seven patients with lower limb ischaemia associated with PAPS. Four were male patients and three were females, with a mean age of 37 years. All had a previous deep vein thrombosis and the majority, five out of seven, had a prior cerebrovascular accident (CVA). Prolonged activated thromboplastin time was demonstrated in all our patients and PAPS was established by positive thromboplastin titration index, circulating anticoagulant index and increased anticardiolipin levels. Symptoms included claudication in three, rest pain in four and gangrene in five patients. Angiography demonstrated thrombosis of various segments of the arterial tree including: aorta, iliac, femoral and popliteal arteries. Two patients were treated conservatively and one by percutaneous transluminal angioplasty (PTA) of the distal aorta. A total of eleven vascular surgical procedures were performed in four patients resulting in early postoperative thrombosis (2h-30 days) in 10 cases. Only one graft remained patent, when full heparinisation (1000 units/h) was used perioperatively. We conclude that PAPS patients are at high risk for graft thrombosis and should only be operated upon on full anticoagulation, starting at operation and proceeding indefinitely.
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PMID:Lower limb ischaemia in primary antiphospholipid syndrome. 835 98

Despite being the most common benign intracardiac tumour with an excellent prognosis after surgical excision the incidence of atrial myxoma (except at autopsy) is unknown. We reviewed all patients admitted to the National Cardiac Surgery Unit (n = 26) with an atrial myxoma over a fifteen year period (1977-1991) to compile national incidence data and assess pre-operative diagnosis, management, surgical technique, and outcome. Preoperative symptoms were: congestive cardiac failure (12 patients), embolism (8 patients), constitutional (3 patients), asymptomatic (2 patients) and tachyarrhythmia (1 patient). The diagnosis was confirmed by 2D echocardiography alone in thirteen patients and by a combination of echocardiography and angiography in thirteen patients. At operation the site of the tumour was left atrial in 24 patients and bi-atrial in two patients. All cases were confirmed by histology. All patients made a good post-operative recovery, although one patient survived a pulmonary embolus and one patient developed a deep venous thrombosis. There has been one late death (five months after surgery) from a cerebrovascular accident. Serial echocardiography has revealed one recurrence to date (8 years after surgery). The surgical incidence of these tumours in the Republic of Ireland over the study period was 0.5 atrial myxomas/million population/year. Although rare atrial myxomas are the most important cardiac tumours to diagnose as the results from surgery are excellent.
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PMID:Atrial myxoma: national incidence, diagnosis and surgical management. 840 60

A formal statistical overview of all truly randomised trials was undertaken to determine whether antithrombotic therapy is effective and safe in the early treatment of patients with acute stroke. There were 15 completed randomised controlled trials of the value of early antithrombotic treatment in patients with acute stroke. The regimes tested in acute presumed or confirmed ischaemic stroke were: heparin, 10 trials with 1047 patients: oral anticoagulants, one trial with 51 patients: antiplatelet therapy, three trials with 103 patients. Heparin was tested in one trial with 46 patients with acute haemorrhagic stroke. Outcome measures were deep venous thrombosis (confirmed by I125 scanning or venography), pulmonary embolism, death from all causes, haemorrhagic transformation of cerebral infarction, level of disability in survivors. In patients with acute ischaemic stroke, allocation to heparin was associated with a highly significant 81% (SD 8, 2p < 0.00001) reduction in deep venous thrombosis detected by I125 fibrinogen scanning or venogram. Only three trials systematically identified pulmonary emboli, which occurred in 6/106 (5.7%) allocated control vs 3/132 (2.3%) allocated heparin, a non-significant 58% reduction (SD 45.7, 2p > 0.1). There were relatively few deaths in the trials in patients with presumed ischaemic stroke: 94/485 (19.4%) among patients allocated to the control group vs 79/497 (15.9%) among patients who were allocated heparin. The observed 18% (SD 16) reduction in the odds of death was not statistically significant. The least biased estimated of the effect of treatment on haemorrhagic transformation of the cerebral infarct (HTI) comes from trials where all patients were scanned at the end of treatment, irrespective of clinical deterioration; using this analysis, haemorrhagic transformation occurred in 7/102 (6.9%) control vs 8/106 (7.5%) treated, a non-significant 12% increase (SD 56, 2p > 0.1). These data cannot exclude the possibility that heparin substantially increases the risks of HTI. No data on disability in survivors could be obtained. Early heparin treatment might be associated with substantial reductions in deep venous thrombosis (and probably also pulmonary embolism) and possibly a one fifth reduction in mortality (equivalent to the avoidance of 20-40 early deaths per thousand patients treated.) However, the data were wholly inadequate on safety, particularly on the risk of haemorrhagic transformation of the infarct and on the hazards of heparin therapy in patients with known intracerebral haemorrhage. The trials of oral anticoagulants (15 deaths among 57 patients) and antiplatelet therapy (two deaths among 103 patients) were too small to be informative. Much larger randomized trials-comparing aspirin, heparin and the combination of both drugs against control-in patients with acute ischaemic stroke are justified (and several are now planned or underway).
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PMID:Antithrombotic therapy in acute ischaemic stroke: an overview of the completed randomised trials. 812 24

Pregnancy and oral contraceptives (OCs) reduce the levels of the natural anticoagulant protein S and about 50% and 20%. respectively. Original work on the link between OCs and development of deep vein thrombosis and pulmonary embolism do not necessarily confirm an association, today since it included cohort studies of women using high estrogen OCs. Also, physicians tended to actively diagnose thrombophlebitis in women they knew were using OCs. Objective diagnostic measures, e.g., venography, were not used in the cohort studies. Decreased estrogen content of current OCs and a case control study design show the likelihood of thrombotic complications of OS use has decreased significantly. Women who have experienced an episode of venous thrombosis and are not on oral anticoagulation therapy should not use OCs, because as many of 30% experience a second episode. Women with a strong family history of thromboembolism and those with antiphospholipid antibodies who have experienced a thrombotic event should also not use OCs. Current or past use of low estrogen Ocs does not significantly increase the risk of myocardial infarction, but smoking does. Physicians doe not know, however, whether women who use an OC with at the most 30 mcg estrogen and who smoke are at greater risk than those who smoke but do not use OCs. Just one study suggests a possible association between OC use and mitral valve prolapse leading to a cerebrovascular accident. The likelihood of developing calf vein clots in women who use low-dose OCs appears to be reduced, if they use sequential compression stockings and subcutaneous low molecular weight heparin following surgery. Since OCs decrease the chance of serious bleeding during ovulation and of heavy menstrual flow, oral anticoagulation is not a contraindication to OC use. The risk of OC-associated thromboembolism is considerably lower than that of pregnancy-associated thromboembolism.
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PMID:Contraceptive choices in women with coagulation disorders. 851 43

The Ross operation has been performed for more than 25 years and its popularity has increased dramatically in recent years. We developed an interest in this procedure through a combination of a basic dissatisfaction with a device that requires life-long anticoagulation and the belief that a vital, autologous tissue valve with normal valve morphology and hemodynamics would prove to be superior to the mechanical valve, and that these advantages would outweigh the potential drawbacks related to the operation's technical difficulty and the risk of autograft or homograft dysfunction. From December 1992 to November 1994 40 Ross operations as total root replacements in a diverse group of patients between 5 and 72 years of age (median 32) were performed at Rigshospitalet. Seventeen (43%) of the patients had undergone at least one previous open heart operation. Eleven patients (28%) required surgery because of ongoing or previous endocarditis, and of these, nine had aortic annular destruction and cavity/pseudoaneurysm formation and five had prosthetic valve endocarditis. Three patients (8%) were operated because of mechanical valve dysfunction. One patient was treated for an ascending aortic aneurysm and aortic insufficiency. The remaining 25 patients were operated because of congenital or acquired aortic insufficiency, stenosis, or both. Ten patients (25%) underwent concomitant procedures. No mortality or serious complications occurred. Morbidity was limited to one case each of total atrioventricular (A-V) block, sternal pseudarthrosis, minor stroke, and deep vein thrombosis. Thirty-five patients had no or trivial, two patients mild, and three patients moderate autograft valve insufficiency during a median follow-up of 8 months (range 0-23 months). Two patients had pulmonary stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:The Ross operation: results of early experience including treatment for endocarditis. 851 18

Alteplase is the product of recombinant DNA technology and is chemically identical to endogenous tissue-type plasminogen activator: Plasminogen is converted to plasmin by alteplase, and fibrinolysis of blood thrombi is subsequently stimulated. Alteplase is now firmly established as a treatment of choice in the management of acute myocardial infarction. The efficacy of intravenous alteplase in the treatment of pulmonary thromboembolism has also been established and appears to be similar to that of streptokinase and urokinase in this indication and in arterial thrombotic occlusion. However, its use in this latter indication and in other vascular disorders has not been as extensively documented. Although trials demonstrating the efficacy of intravenous alteplase in patients with deep vein thrombosis and intra-arterial alteplase in patients with arterial thrombotic occlusion exist, reliable data on the efficacy of the fibrinolytic in ischaemic stroke and intracranial haemorrhage are scarce. Little clinical benefit is apparent in patients with unstable angina, although careful use may be warranted in those with definite pretreatment coronary thrombi. Of concern, there is a suggestion that general use of alteplase in patients with unstable angina may be associated with increased incidence of myocardial infarction. The incidence of major haemorrhage associated with alteplase therapy increases with increasing dose and appears to be similar to that seen with other fibrinolytic agents. Thus, further well-designed studies of the use of alteplase in ischaemic stroke and cerebral haemorrhage are required. However, a small subset of patients with unstable angina and definite pretreatment coronary thrombi may benefit from alteplase therapy. Further, preliminary data suggest efficacy in the therapy of deep vein thrombosis and arterial thrombotic occlusion, and alteplase has a proven place in the fibrinolytic treatment of pulmonary thromboembolism.
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PMID:Alteplase. A reappraisal of its pharmacology and therapeutic use in vascular disorders other than acute myocardial infarction. 852 60

A hospital-based, case-control study of the association between current usage of oral contraceptives and first-time cases of acute myocardial infarction, stroke, or a venous thromboembolic event (deep vein thrombosis or pulmonary embolus) was carried out in 17 countries from four regions (Africa, Asia, Europe, and Latin America). A total of 3792 cases and 10,281 hospitalised controls matched for age were recruited during a 4-year period, ending in June 1993. The study was designed to have sufficient power to detect a relative risk of 2 for developing each of the three study diseases, associated with current oral contraceptive use in each of the four regions, with the exception of acute myocardial infarction (for which all non-European regions were to be combined) and for venous thromboembolic events in Asia, where these disorders are rare. This report describes the background, pilot study, methods, and the analyses carried out to validate the methods used in the study.
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PMID:A multinational case-control study of cardiovascular disease and steroid hormone contraceptives. Description and validation of methods. World Health Organization Collaborative Study of Cardiovascular and Steroid Hormone Contraception. 854 65


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