Entries Tagged as 'Cerebrovasc Dis'
Acute hyperglycemia and early hemorrhagic transformation in ischemic stroke.
Cerebrovasc Dis. 2009;28(2):119-23
Authors: Paciaroni M, Agnelli G, Caso V, Corea F, Ageno W, Alberti A, Lanari A, Micheli S, Bertolani L, Venti M, Palmerini F, Billeci AM, Comi G, Previdi P, Silvestrelli G
BACKGROUND: Hyperglycemia has been claimed to be associated with hemorrhagic transformation (HT) in patients with acute ischemic stroke treated with thrombolysis. The aim of this study was to assess whether the admission blood glucose level is related to HT in a prospective study in consecutive patients with acute ischemic stroke. METHODS: Consecutive patients admitted for ischemic stroke to 4 Italian hospitals were included in this prospective cohort study. RESULTS: Among 1,125 consecutive patients included in the analysis, 98 (8.7%) had HT: 62 (5.5%) had hemorrhagic infarction (HI) and 36 (3.2%) parenchymal hematoma (PH). A blood glucose level >110 mg/dl was found in 42.4% of the patients, a level between 110 and 149 mg/dl in 25.2%, and a level >150 mg/dl in 17.2%. At 3 months, 7 patients were lost at follow-up, 326 patients (29.2%) were disabled (modified Rankin score > or = 3) and 129 died (11.5%). PH was associated with an increased risk of death or disability (OR 15.29, 95% CI 2.35-99.35). However, this was not the case for HT overall and HI. At logistic regression analysis, PH was predicted by high levels of admission blood glucose (OR 1.01, 95% CI 1.00-1.01 for 1 added mg/dl). The rate of PH was 2.1% in patients with <110 mg/dl, 3.6% in patients with a level between 110 and 149 mg/dl and 6.4% in patients with a level >150 mg/dl. The curve estimation regression model showed a significant linear increase in the risk of PH related to an increase in blood glucose levels (R(2) = 0.007, p = 0.007). CONCLUSIONS: Hyperglycemia during acute ischemic stroke predisposes to PH, which in turn determines a non-favorable outcome at 3 months. This relationship seems to be linear.
PMID: 19506370 [PubMed - indexed for MEDLINE]
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Old and new anticoagulant agents for the prevention and treatment of patients with ischemic stroke.
Cerebrovasc Dis. 2009;27 Suppl 1:111-9
Authors: Martí-Fàbregas J, Mateo J
Vitamin K antagonists are the only oral anticoagulants available and are considered as well-established treatment to prevent a first stroke or a recurrent stroke in patients with atrial fibrillation. The difficulties in the routine management of these patients cause an underuse of vitamin K antagonists. For long-term use, there is a need for safer and more effective oral anticoagulants that do not require routine monitoring of coagulation. Recently, new drugs have been developed and there are a number of clinical trials for the primary and secondary prevention of stroke in atrial fibrillation. The new anticoagulants that are being investigated target factor Xa or thrombin. The factor Xa inhibitors include indirect inhibitors such as idraparinux and biotinylated idraparinux that inhibit factor Xa by potentiating antithrombin. Also being investigated are apixaban and rivaroxaban, orally active agents that inhibit factor Xa directly. Direct thrombin inhibitors include ximelagatran and dabigatran etexilate. Although ximelagatran was withdrawn early because of liver toxicity, it provided convincing evidence that new oral anticoagulants have the potential to replace warfarin. However, even if these new drugs prove superior to dose-adjusted warfarin, their benefits must be substantial (retaining high efficacy with added safety and convenience) to offset their increased cost.
PMID: 19342840 [PubMed - indexed for MEDLINE]
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High blood pressure in acute ischaemic stroke–broadening therapeutic horizons.
Cerebrovasc Dis. 2009;27 Suppl 1:156-61
Authors: Sare GM, Geeganage C, Bath PM
High blood pressure (BP) is present in 80% of patients with acute ischaemic stroke and is independently associated with poor outcome. Although this epidemiology suggests that BP should be lowered acutely, concerns about dysfunctional cerebral autoregulation suggest otherwise. Several small randomised trials have assessed cerebral blood flow with various antihypertensive classes and agents in acute ischaemic stroke. Overall, these studies showed no change in cerebral perfusion, although the numbers of studies and patients are limited and there are methodological problems with some trials. There are no large published randomised trials assessing outcome with BP lowering in acute stroke. Calcium channel blockers did not alter outcome after ischaemic stroke (29 trials, 7,665 patients). However, some trials, especially those testing intravenous calcium channel blockers (INWEST) or oral beta-receptor antagonists (BEST) reported real or potential hazard. In contrast, oral candesartan reduced combined vascular events in 339 patients with ischaemic stroke (ACCESS) although it had no effect on disability. The CHHIPS trial found that death was reduced in patients randomised to active treatment (labetalol, lisinopril) as compared with placebo. Two larger trials reported that glucose-potassium-insulin therapy (GIST) or magnesium (IMAGES) lowered BP but had no effect on functional outcome. The INTERACT pilot trial studied patients with intracerebral haemorrhage and found that an intensive BP-lowering regime non-significantly reduced haematoma expansion. There are four large ongoing trials examining whether to continue or stop pre-stroke antihypertensive therapy (COSSACS, ENOS) or lower BP in acute stroke (ENOS, SCAST) or haemorrhage (INTERACT 2).
PMID: 19342846 [PubMed - indexed for MEDLINE]
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Hyperglycaemia in acute stroke–to treat or not to treat.
Cerebrovasc Dis. 2009;27 Suppl 1:148-55
Authors: Quinn TJ, Lees KR
Diabetes is common amongst patients with stroke and is associated with poorer outcome. Post-stroke hyperglycaemia is also recognised in up to half of the patients, and is independently associated with adverse sequelae: both increased mortality and poorer functional outcomes. Neither the aetiology nor the pathophysiology of such hyperglycaemia is fully understood. Both direct neurological toxicity and systemic consequences are postulated to occur. A distinction between occult diabetes and non-diabetic hyperglycaemia seems important as prognosis and effect of intervention differ in these two groups. The optimal management of the milder forms of hyperglycaemia associated with acute stroke is unknown. Randomised trial data remain limited but presently offer no strong support for aggressive intervention in stroke, though in other critical illness settings tight control of blood sugar appears beneficial. Studies based in coronary care and high dependency units have shown a possible beneficial effect of insulin, but evidence for intervention in acute stroke is at best limited. However, if glucose management is to be undertaken, this should be instituted while there is still salvageable tissue and the glucose reduction must be substantial. Intravenous insulin may be more effective than glucose-potassium-insulin infusion. Both interventions carry a risk of hypoglycaemia and any proposed intervention must balance safety, convenience and glycaemic control. Until further trial data are available, consensus guidelines may be followed, which are generally conservative for blood glucose levels below 10 mM (180 mg/dl).
PMID: 19342845 [PubMed - indexed for MEDLINE]
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Misdiagnosis of transient ischemic attacks in the emergency room.
Cerebrovasc Dis. 2008;26(6):630-5
Authors: Prabhakaran S, Silver AJ, Warrior L, McClenathan B, Lee VH
BACKGROUND: To determine a pattern of symptoms and/or risk factors that distinguishes transient ischemic attack (TIA) from nonischemic causes of transient neurologic attacks (NI-TNA). METHODS: We reviewed demographic, clinical, and hospital data on 100 consecutive patients with transient focal neurologic episode(s) lasting less than 24 h and in whom the initial diagnosis was TIA. After inpatient evaluation and review, final diagnoses were made by two stroke neurologists. Using stepwise multivariable logistic regression, we estimated odds ratios (OR) for independent predictors of NI-TNA. p < 0.05 was considered significant. RESULTS: Of the 100 patients, 40 were confirmed to have TIA and 60 NI-TNA. Compared to TIA patients, those with NI-TNA were less likely to be male and white but more likely to have a history of prior unexplained TNA, gradual symptom onset, associated nonspecific symptoms, longer symptom duration, and delayed presentation. Other variables were similar between the two groups. In a multivariable logistic regression model, gradual symptom onset (adjusted OR 6.7, p = 0.002), prior history of unexplained transient neurologic attack (adjusted OR 10.6, p = 0.031), and presence of nonspecific symptoms (adjusted OR 4.2, p = 0.008) were independent predictors of the final diagnosis of NI-TNA. CONCLUSIONS: Distinguishing TIA from nonischemic causes is difficult in the emergency room, with 60% of suspected TIA patients having nonischemic causes on inpatient evaluation. We found 3 clinical features that may be useful in the emergency room triage of transient neurologic attacks. Further study is needed to develop tools that can accurately diagnose TIA.
PMID: 18984948 [PubMed - indexed for MEDLINE]
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Clopidogrel and aspirin versus aspirin alone for the prevention of stroke in patients with a history of atrial fibrillation: subgroup analysis of the CHARISMA randomized trial.
Cerebrovasc Dis. 2008;25(4):344-7
Authors: Hart RG, Bhatt DL, Hacke W, Fox KA, Hankey GJ, Berger PB, Hu T, Topol EJ,
BACKGROUND: Aspirin offers modest reduction in stroke in patients with atrial fibrillation. Whether combination of aspirin with clopidogrel offers additional protection is unclear. METHODS: Post-hoc subgroup analysis of 593 participants with a history of atrial fibrillation in the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) randomized trial testing clopidogrel 75 mg per day plus aspirin (75-162 mg per day) vs. aspirin alone in patients with stable cardiovascular disease or multiple cardiovascular risk factors. RESULTS: Mean patient age was 70 years, 78% were men, and hypertension, heart failure and diabetes were present in 78, 20 and 44%, respectively. During a median follow-up of 2.3 years, stroke (ischemic and hemorrhagic) occurred in 15 of 298 assigned to clopidogrel plus aspirin and in 14 of 285 given aspirin alone (hazard ratio, HR, 1.03, 95% CI 0.49-2.1). There was no difference in all-cause mortality (HR 1.1, 95% CI 0.6-1.9) or in the composite of stroke, myocardial infarction, or vascular death (HR = 1.2, 95% CI 0.7-2.0). Severe/fatal extracranial hemorrhage occurred in 6 patients with combination vs. 3 with aspirin alone. CONCLUSIONS: This post-hoc subgroup analysis does not support the use of this combination over aspirin alone in patients with a history of atrial fibrillation pending results of ongoing larger randomized trials.
PMID: 18303254 [PubMed - indexed for MEDLINE]
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