Goals of care changes after acute ischaemic stroke: decision frequency and predictors.

OBJECTIVES: Little is known about the factors leading to a change in goals of care (CGC) in patients with an acute ischaemic stroke (AIS). Our aim was to analyse the proportion and outcome of such patients and identify medical predictors of a CGC during acute hospitalisation. METHODS: We retrospectively reviewed all patients who had an AIS over a 13-year period from the prospectively constructed Acute Stroke Registry and Analysis of Lausanne. We compared patients with a CGC during the acute hospital phase to all other patients and identified associated clinical and radiological variables using logistic regression analysis. RESULTS: A CGC decision was taken in 440/4264 (10.3%) consecutive patients who had an AIS. The most powerful acute phase predictors of a CGC were transit through the intensive care unit, older age, pre-existing disability, higher stroke severity and initial decreased level of consciousness. Adding subacute phase variables, we also identified active oncological disease, fever and poor recanalisation as predictors. 76.6% of the CGC patients died in the stroke unit and 1.0% of other patients, and 30.5% of patients with a CGC received a palliative care consultation. At 12 months, 93.6% of patients with CGC had died, compared with 10.1% of non-CGC patients. CONCLUSIONS: Over three-quarters of AIS patients with CGC died in hospital, but less than a third received a palliative care consultation. The identified clinical and radiological predictors of a CGC may allow physicians to initiate timely the decision-making process for a possible CGC.

[CME - Transient Global Amnesia]. / CME - Transiente globale Amnesie.

Transient global amnesia (TGA) is a neurological condition which is still a diagnostic challenge for clinicians. Diagnostic clues are an acute onset of a disturbance of memory, a lack of other focal neurological deficits, and repetitive questioning of the patients about time and circumstances. Although the signs and symptoms are quite typical, making the diagnosis of TGA might still be challenging, depending on the patient's characteristics. Taking a precise history from the patient and his/her next of kin is seminal. This article discusses the typical clinical presentation, pathophysiological hypotheses, the diagnostic clues and the most important differential diagnoses.