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

Thrombolysis increases case fatality but reduces the proportion of disabled survivors in recent trials in acute ischaemic stroke, although some trials show much higher mortality rates than others. One possible explanation for the different outcomes between trials is that the treatment effect with thrombolysis varies with baseline prognostic factors such as stroke severity. We examined the interaction between baseline risk and thrombolysis on outcome using individual patient data from the Multicentre Acute Stroke Trial-Italy (MAST-I). A multiple logistic regression of the MAST-I data was performed to identify which factors, identifiable at randomisation, most strongly predict a poor functional outcome. We then stratified the patients into those with severe strokes and those with mild strokes and examined the effect of thrombolysis on (a) case fatality and (b) dependency at 6 months after the stroke in the 157 patients who received streptokinase alone and the 156 controls. Streptokinase was found to cause an absolute increase of about 3% in case fatality in both "severe" and "mild" strokes; however, there was a 12% reduction in the number of dead or dependent "mild" strokes but a 6% increase in "severe" strokes. The number of patients was small, and therefore neither finding was statistically significant. In this exploratory analysis, the hazard with streptokinase appears similar in "severe" and "mild" strokes, but the benefit may be greater in "mild" strokes. Thrombolysis may be more effective in patients with "mild" strokes, but more information is required to confirm this hypothesis.
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PMID:The influence of baseline prognostic variables on outcome after thrombolysis. MAST-Italy Collaborative Group. 1063 38

Acute stroke is a neurologic emergency which should be preferentially treated in a Stroke Unit. The applications of general therapeutic measures in these units decreases the mortality or dependence in 29% of the cases. Thrombolytic treatment with rt-PA in the first 3 hours of cerebral ischemia reduces the risk of mortality or dependence at 3 months by 51%. This treatment should be used in centers with an adequate organization and experience in the management of stroke. Careful patient selection allows a favorable conscious risk/benefit when rt-PA is used in clinical practice. In the last decade numerous neuroprotector drugs have been developed which, despite decreasing the volume of the infarction in animal models, have not currently achieved a reduction in the mortality and morbidity of cerebral infarction in clinical trials. Ebselen, citicoline, piracetam and clomethiazol have shown beneficial effects in preliminary studies or in some subgroups of patients, but their use based on evidence is not recommendable. Anticoagulants and antiplatelet drugs have not been shown to be effective in the acute phase of cerebral infarction. The neuroprotector effect of unfractionated heparin and glycoprotein IIb IIIa antagonists is still under study. Clopidogrel and the association of aspirin and dipiridamol are new alternatives to aspirin in the secondary prevention of cerebral infarction. Both options provide a lower risk of recurrence, and clopidogrel also shows better tolerance. The preventive effect of low intensity anticoagulation and statins is being analyzed in clinical studies.
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PMID:[New treatments in cerebrovascular diseases]. 1065 7

81 patients with ischemic stroke were studied in order to assess the pathogenesis, the accuracy of the pathogenetic diagnosis and the relationship between pathogenesis and infarct site. The pathogenetic mechanisms were grouped according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) system. TOAST system settles five pathogenetic diagnosis: 1) Large artery atherosclerosis (LM); 2) Cardioembolism (CE); 3) Small artery occlusion (SAO); 4) Other etiologies (SOE); 5) Undetermined pathogenesis. As regards the site, the patients were divided into the following groups: Posterior Circulation Infarcts (POCI) 8.6%, Total Anterior Circulation Infarcts (TACI) 19.8%, Partial Anterior Circulation Infarcts (PACI) 29.6%, Lacunar Anterior Circulation Infarcts (LACI) 30.9%, Multiple Site Infarcts 11.1%. A probable or certain diagnosis was issued only in 33.3%. The diagnosis was not complete in 22.2%. That was due either to the severe clinical status or the patient and his relatives' refusal. Most of the incomplete diagnosis occurred in TACI patients. The undetermined pathogenesis due to absent clues occurred in 18.5%. CE often brought about TACI, whereas LM was likely to provoke PACI. SOE, like systemic hypotension, brought about Multiple Site Infarcts. Unfortunately assessing the pathogenetic diagnosis is still a controversial issue and TOAST method itself is not satisfactory as an overall classification system.
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PMID:[The probability of assessing the pathogenesis of ischemic stroke. Study of 81 patients]. 1074 48

To assess the efficacy and safety of thrombolytic therapy in acute ischaemic stroke, randomised clinical trials have been undertaken. Their results suggest that further research should be attempted to identify patients for whom the benefit/risk ratio of thrombolysis is beneficial. The Thrombolysis in Acute Stroke Pooling Project (TAS-PP) group will pool individual patient data from recent studies and meta-analyse these. A Steering Committee drafted the protocol and defined access rules to the common file. The objectives are to assess the efficacy of thrombolysis to reduce death or severe disability, to identify predictors of death and haemorrhagic transformation, and to identify subgroups with a better response to treatment, using logistic regression, survival curve comparison (log rank test), multivariate modelling (with treatment, baseline characteristics, delay from symptom to treatment as covariates). This project will help defining subpopulations that are more likely to benefit from this treatment, which cannot be achieved using tabulated data, and designing future trials. Copyright 1999 Harcourt Publishers Ltd.
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PMID:Thrombolysis in Acute Stroke Pooling Project: a meta-analysis on individual patient data. 1083 65

Graded compression stockings are commonly used to prevent deep-vein thrombosis (DVT) after stroke, but their efficacy in this setting has not been evaluated. Extrapolation of effectiveness from trials in patients undergoing elective surgery may be inappropriate. We undertook a randomized, controlled trial, with blinded data review, in a University hospital Acute Stroke Unit. Patients were allocated to graded compression stockings or to standard care alone. DVT incidence was determined at baseline and at day 7+/-2 by colour-flow Doppler ultrasound. Ninety-eight patients with acute, immobilizing stroke were randomized; 97 had full outcome data. One patient had clinically manifest DVT, and no patient had pulmonary thromboembolism. DVT was detected in 7/65 patients allocated stockings, and 7/32 controls (odds ratio 0.43, 95% CI 0.14-1.36); DVT involving femoral veins was detected in 3/65 and 2/32. In the first week after stroke, radiologically-detected DVT remains common, but is usually clinically silent. Proximal DVT is less common. Graded compression stockings produced a reduction in DVT incidence comparable to that in other patient groups, but the reduction was not statistically significant, and the magnitude of effect size requires confirmation. There is greater doubt over efficacy in early prevention of proximal DVT.
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PMID:Randomized trial of graded compression stockings for prevention of deep-vein thrombosis after acute stroke. 1087 85

Acute stroke is associated with a high morbidity and mortality: up to 24% of patients may not survive their hospital admission. Stroke unit care has been shown in a meta-analysis to reduce this morbidity and mortality. We present a three-year audit of the first acute stroke service in an Irish teaching hospital. The audit was carried out prospectively on 193 patients admitted to the acute stroke service, from July 1996 to end of June 1999. Details regarding patients, type and severity of stroke, length of stay and outcome were collected prospectively on a standard pro-forma. We observed a reduction in mortality from 19% to 15% to 9%, and an increasing percentage of patients discharged home from 55% to 64% to 68%, in year 1, year 2 and year 3 respectively. A trend towards a greater number of patients, younger age and improved outcome with lower mortality was observed from year to year, without significant change in length of stay. This study confirms the value to patients of organised stroke care in terms of reduction in mortality and morbidity without increasing length of stay or disability. We suggest that every acute hospital should have organised stroke care.
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PMID:An acute stroke service: potential to improve patient outcome without increasing length of stay. 1096 55

Acute stroke treatment using aspirin and/or heparin was studied in the International Stroke Trial (IST) and Chinese Acute Stroke Trial (CAST) which randomised over 40,000 patients altogether. Combining the results demonstrated that aspirin (150-300 mg) given within 48 h of the onset of stroke produced a small but significant improvement in outcome (death or dependency) 4 weeks to 6 months after stroke of about 1 patient per 100 treated. There was a significant reduction in recurrent ischaemic stroke of similar degree, which was not associated with significant increase in cerebral haemorrhage. Therefore, aspirin should be used as early secondary prevention against recurrent stroke, after excluding cerebral haemorrhage by scanning the patient. Heparin does not improve clinical outcome after stroke even in patients in atrial fibrillation. It decreased recurrent ischaemic stroke significantly in IST, but at the cost of a significant increase in cerebral haemorrhage. Low molecular weight heparins and heparinoids have not proved any more beneficial. Therefore, heparin does not appear to be a useful routine therapy in acute stroke. The use of heparin should, therefore, be limited to patients at high risk of deep vein thrombosis or early recurrence.
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PMID:Aspirin or heparin in acute stroke. 1109 90

Both anticoagulants and antiplatelet agents have been advocated, used and studied for the treatment of acute ischemic stroke. Randomized trials of unfractionated heparin, low-molecular-weight heparin and heparinoids have failed to show an overall benefit to these agents largely because the benefits in reducing thromboembolic events are offset by the increased risk of bleeding complications. The International Stroke Trial, the Trial of ORG 10172 Acute Stroke Treatment and studies of fraxaripine all failed to show an overall benefit to anticoagulation in the patients studied. Aspirin has been shown to offer a modest benefit when studied in patients treated within 48 h of stroke onset. Ancrod is an antithrombotic agent that acts by reducing circulating fibrinogen levels. Patients treated within 3 h of stroke symptom onset had a better functional outcome at 90 days compared to placebo-treated patients with both the benefits and the risk of intracerebral bleeding related to the fibrinogen lowering achieved. Abciximab is a blocker of the platelet GPIIb/IIIa receptor. A dose finding safety study suggests that in doses up to that typically given in patients with acute coronary occlusion syndromes, there is no increased risk of symptomatic intracerebral bleeding and suggestions of potential benefits on neurological outcome.
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PMID:Antithrombotic therapy in the acute phase: new approaches. 1124

The publication of the positive results of the National Institute of Neurological Disorders and Stroke (NINDS) trial of alteplase (a recombinant tissue plasminogen activator; rt-PA) for acute stroke patients in 1995 and its approval by the US Food and Drug Administration as well as the American Academy of Neurology and American Heart Association increased the interest and attention of the medical community in acute stroke treatment. However, the implication of this NINDS Stroke Study and other thrombolytic trials in clinical practice remains controversial and debated. Furthermore, the recent publication of the results from the European Cooperative Acute Stroke Study II (ECASS II) and Alteplase Thrombolysis of Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) studies will feed the controversy, since the results of these two studies are disappointing and do not confirm the positive results of the NINDS Stroke Study as expected by clinicians managing patients with acute stroke. The Standard Treatment with Alteplase to Reverse Stroke (STARS) and Cleveland studies, which involved a large number of community hospitals to assess the safety profile and the benefit of rt-PA thrombolysis for acute stroke patients in clinical practice, have shown controversial results. Consequently, the issue arises of which is the more reasonable position concerning thrombolysis by alteplase, which seems to work but has not been proven yet beyond reasonable doubt? The recent publication of the results from the Prolyse in Acute Cerebral Thromboembolism (PROACT II) study has shown that intra-arterial thrombolysis with prourokinase is a benefit treatment in stroke patients with a proven middle cerebral artery occlusion within 6 h of stroke onset. Numerous trials devoted to neuroprotection against acute ischemic stroke have been prematurely stopped because of safety concerns or poor risk-benefit ratios, but some new neuroprotective drugs seem promising and are being tested in ongoing studies. The third issue under study concerns the use of antithrombotic drugs in the acute phase of stroke, particularly the new potent platelet glycoprotein IIb/IIIa antagonists such as abciximab. In this paper, we have reviewed selected recent clinical trials focusing on recent advances in acute stroke therapy.
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PMID:Recent progress in drug treatment for acute ischemic stroke. 1124 3

Low fibrinolytic activity may increase the risk of thrombosis. Plasminogen activator inhibitor-1 (PAI-1) is an inhibitor of the fibrinolytic system. We examined the PAI-1 levels in patients with ischemic stroke. Plasma levels of PAI-1 were measured using enzyme-linked immunosorbent assay (ELISA) in 55 consecutive patients (age 60.2 +/- 11.4, 40 males and 15 females) with ischemic stroke. The PAI-1 assessments as well as neurological examinations using validated stroke scales were conducted at admission and 1 week, 1 month, and 3 months after stroke. Sex- and age-matched controls (+/- 4 years) underwent plasma PAI-1 measurement once. Etiology of the stroke was classified using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. All pertinent stroke risk factors were recorded. All patients were contacted 3 years after stroke for recurrent vascular thrombotic disease. The plasma PAI-1 levels were 17.2 +/- 7.8 IU at admission, 11.2 +/- 9.2 IU at 1 week, 14.4 +/- 7.9 IU at 1 month, and 17.8 +/- 7.8 IU at 3 months among patients and 11.8 +/- 9.5 IU among controls (p values are < .002, .7, .12, and < .0005, respectively). As a rule, the neurological scores did not show a correlation to the PAI-1 levels. Presence of diabetes, hypertension, obesity, smoking, anticoagulant treatment, and sleep apnea did not affect the PAI-1 levels at any time point. Females had slightly higher PAI-1 levels. Age was a strong determinant for PAI-1 levels being higher in younger patients at every sampling time point (p values .02, .02, .02, and .03 respectively). The etiology of the ischemic stroke did not have an impact on PAI-1 levels. In 16 patients recurrent thrombosis had occurred. The high PAI-1 levels at admittance may reflect either an acute phase response or a chronic state. Normalized levels at 1 week and 1 month may be due to hospital diet, antithrombotic medication, weight loss, active physical therapy, and better care for diabetes. PAI-1 levels at 3 months after stroke did not predict recurrent thrombosis.
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PMID:Plasminogen activator inhibitor-1 in patients with ischemic stroke. 1145 24


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