Tailored interventions to improve hypertension management after stroke or TIA--phase II (TIMS II).

BACKGROUND: Reduction of blood pressure (BP) after stroke or TIA decreases stroke recurrence and is a major goal ofsecondary Stroke Prevention Clinics (SPCs). Health care providers need effective screening processes to identify those clients at highest risk of not achieving BP targets and those clients at highest risk ofnon-adherence to medication. METHODS: This multicentred, randomized controlled study used a screening process to identify SPC patients with psychosocial/cognitive deficits (e.g., lack of confidence in the utility of medications, poor memory, mild cognitive impairment) who were experiencing difficulty managing their BP to target values and evaluated whether a model of nurse-led case management program (monthly telephone calls, motivational interviewingfor lifestyle change, plus home BP monitoring and use ofdosettes for medication administration) would improve BP measures and adherence to medications. RESULTS: Both intervention (n=29) and usual care groups (n=27) showed a trend-for'reduced BP at six months (Median ql-q3, Systolic BR p=0.46; Diastolic BR p=0.37). Diabetic patients, irrespective of the group to which they were randomized, were less likely to meet Best Practice Guideline targets than those without diabetes (Chi Square test, p=0.0001). CONCLUSION: Stroke and TIA patients with diabetes may require additional resources and support in order to reach BP target values.

Association between time-to-presentation and clinical outcome in patients with subarachnoid hemorrhage: an observational study.

BACKGROUND: Headache is the most common presenting symptom of subarachnoid hemorrhage (SAH), ranging from mild headache to the "worst headache of my life". As headache is often non-specific, patients may not seek immediate medical attention, though prompt medical and surgical management is expected to improve clinical outcomes. In this study, we explore the independent association between duration from onset of symptoms to presentation at an emergency department (ED) and clinical outcomes after SAH. METHODS: Participants with a primary diagnosis of nontraumatic SAH were identified from consecutive patients at 11 regional stroke centres participating in the Registry of the Canadian Stroke Network (RCSN, 2003-2005). Hunt and Hess score (H+H), and modified Rankin Scale (mRS) at discharge were collected on SAH cases by trained nurse-abstractors. For analysis, patients were categorized into patients with mild-moderate dependency (mRS 0-3) and those with severe dependence or death (mRS 4-6) at hospital discharge. Multivariable regression analyses were used to determine the association between 'time to presentation' and clinical outcomes, independent of comorbidities. RESULTS: Of 721 SAH patients included in the RCSN, 642 (89.0%) had the interval between 'time last seen normal' and time of ED presentation recorded. Mean duration from symptom onset to ED arrival was 27.04 hours (+/- 2.02). One hundred and sixty-six patients (25.9%) presented to the ED more than 24 hours after onset of symptoms. On multivariable analysis, there was no association between time to presentation and severe disability or death at hospital discharge (OR 1.0 [95% CI 0.95-1.01]); 30-day mortality (OR 1.0 [95% CI 0.91-1.02]; or six-month mortality (OR 1.0 [95% CI 1.0-1.02]). Increasing H+H score and age were significantly associated with increased odds of death and severe dependence at hospital discharge. CONCLUSIONS: In this observational study, duration from symptom onset to hospital presentation was not independently associated with death or severe disability at hospital discharge following SAH. Age and H+H score were independent predictors of clinical outcome after non-traumatic SAH.

Risk factors for posterior compared to anterior ischemic stroke: an observational study of the Registry of the Canadian Stroke Network.

BACKGROUND: Traditional vascular risk factors appear to exert varying magnitudes of risk for different major vascular events. For example, hypercholesterolemia is a much stronger risk factor for myocardial infarction than ischemic stroke. Limited evidence also suggests that vascular risk factors may exert differing magnitudes of risk for ischemic stroke within different cerebral arterial territories. We sought to determine the association between traditional vascular risk factors and the location of ischemic stroke (posterior versus anterior). METHODS: Consecutive patients with acute ischemic stroke who were admitted to 11 regional stroke centers within the Registry of the Canadian Stroke Network were included in the study sample. The Oxfordshire Community Stroke Project classification was used to distinguish posterior from anterior circulation ischemic stroke. Multivariable logistic regression was applied to determine the association between risk factors (age, gender, diabetes mellitus, hypercholesterolemia, hypertension, atrial fibrillation and smoking history) and posterior (compared to anterior) circulation ischemic stroke. RESULTS: In total, 8,489 patients with acute ischemic stroke were included. On multivariable analysis, diabetes mellitus (OR = 1.14; 95% CI = 1.02-1.27) was associated with an increased odds of posterior circulation ischemic stroke, whereas age (OR = 0.86; 95% CI = 0.83-0.90), female sex (OR = 0.84; 95% CI = 0.76-0.93), atrial fibrillation (OR = 0.83; 95% CI = 0.74-0.94) and pulmonary edema (OR = 0.74; 95% CI = 0.62-0.88) were related to a reduced odds of posterior compared with anterior circulation ischemic stroke. CONCLUSIONS: Some traditional vascular risk factors for ischemic stroke appear to exert different magnitudes of risk for posterior compared to anterior circulation ischemic stroke.

Gastrointestinal bleeding after acute ischemic stroke.

OBJECTIVE: Recent studies report that major bleeding is associated with a significant increase in mortality after acute coronary syndrome. Major bleeding has also been reported to be common after ischemic stroke, most often gastrointestinal, but its association with clinical outcome is less certain. We sought to describe the incidence, risk factors, and association with clinical outcomes of gastrointestinal bleeding following acute ischemic stroke. METHODS: Consecutive patients with acute ischemic stroke, who were admitted to 11 Ontario hospitals, were identified from the Registry of the Canadian Stroke Network (2003-2006). Stroke severity was measured using the Canadian Neurological Scale. Dependence was measured with the modified Rankin Scale (mRS), and categorized into strokes with no or mild-moderate dependency (mRS 0-3) and those with severe dependence or death (mRS 4-6). Multivariable logistic regression was used to determine the association between gastrointestinal bleeding and clinical outcome (death or severe dependence at hospital discharge and 6-month mortality), independent of comorbidities and in-hospital medical complications. RESULTS: In total, 6,853 patients with acute ischemic stroke were included. One hundred (1.5%) patients experienced gastrointestinal hemorrhage during hospitalization, of which 36 (0.5%) required blood transfusion. On multivariable analyses, previous history of peptic ulcer disease, cancer, and stroke severity were independent predictors of gastrointestinal bleeding. Gastrointestinal hemorrhage was independently associated with death or severe dependence at discharge (OR 3.3; 95% CI 1.9-5.8) and mortality at 6 months (HR 1.5; 95% CI 1.1-2.0). CONCLUSIONS: Gastrointestinal hemorrhage is relatively uncommon after acute ischemic stroke but is associated with increased odds of death and severe dependence.

Neural network modeling accurately predicts the functional outcome of stroke survivors with moderate disabilities.

OBJECTIVE: To predict the place of discharge or discharge Functional Independence Measure (FIM) score for stroke survivors with moderate disability using neural network modeling. Our previous work demonstrated that the FIM predicts the level of recovery for stroke survivors with either severe or mild disabilities. DESIGN: Neural network analysis. SETTING: Tertiary care rehabilitation program. PATIENTS: One hundred forty-seven consecutive stroke survivors admitted for rehabilitation with admission FIM scores between 37 and 96 were used as the training and internal test set. Seventeen other randomly selected stroke survivors were used as the external test set. INTERVENTION: A neural network model was developed using a small set of clinical variables and the admission FIM score. MAIN OUTCOME MEASURE: Neural network model predicting place of discharge or discharge FIM score. RESULTS: A working and accurate model was developed to predict the discharge FIM score. The model was able to predict the 17 external test cases with an accuracy = 88%, sensitivity = 83%, specificity = 91%, positive predictive value = 83%, and negative predictive value = 91%. CONCLUSION: Neural network modeling is useful in the prediction of functional recovery and helps in discharge planning and allocation of rehabilitation resources.

The functional independence measure: its use to identify rehabilitation needs in stroke survivors.

To explore the potential of the Functional Independence Measure (FIM) as a prognostic indicator of outcome in stroke survivors, 113 consecutive patients were observed from admission until discharge. Patients received assessment and treatment by a multidisciplinary team in a regional tertiary care stroke-specific rehabilitation program. The FIM, Chedoke-McMaster Stroke Assessment, and discharge location were used as the main outcome measures. The results suggested that; (1) impairment variables alone are insufficient as prognostic indicators of outcome; (2) the absolute admission FIM score, not the change in the FIM score, is the best predictor of outcome disability and place of discharge; and (3) subgroups of stroke survivors with differing rehabilitation needs can be identified. The FIM allows us to classify stroke survivors according to their needs; therefore, attention should be redirected to the development of prognostic indicators for groups of stroke survivors.

Venous thromboembolism in patients undergoing rehabilitation for stroke.

OBJECTIVE: To determine the incidence of venous thromboembolism during rehabilitation for stroke and to identify factors that alter its risk. DESIGN: Cohort. SETTING: Tertiary care stroke rehabilitation program. PATIENTS: 102 consecutive patients undergoing rehabilitation for stroke. INTERVENTIONS: Impedance plethysmography (IPG) as routine screening and in patients with symptoms of deep venous thrombosis (DVT). MAIN OUTCOME MEASURES: DVT, pulmonary embolism (PE), death from PE. RESULTS: Venous thromboembolism was documented in 11 patients (11%) an average of 60 days after stroke onset (range 14-138 days); 2 patients (2%) died from PE. DVT was found on routine IPG screening in six patients and verified by IPG in two clinically symptomatic patients. The odds of developing venous thromboembolism was 17.6 (95% confidence interval: 2.2-143.5) in patients who were bedridden or wheelchair-bound at the time of admission. CONCLUSIONS: The incidence of venous thromboembolism is high and greatest in bedridden or wheelchair-bound patients undergoing stroke rehabilitation; randomized trials evaluating the safety and efficacy of screening and/or prophylaxis in such patients are required.

Antithrombotic treatment of cerebrovascular disease.

The most common type of cerebrovascular disease is ischaemia or infarction from atherothrombosis or cardiac embolism. Antithrombotic treatment with an antiplatelet agent or anticoagulant assumes a prior clinical classification into categories of transient ischaemic attack (TIA) or minor stroke, acute partial stable stroke, stroke-in-progression, and completed stroke. Aspirin reduces the risk of stroke, myocardial infarction, and death after TIA or minor stroke secondary to atherothrombosis. Aspirin is effective in both sexes at a dose of 300 or 1200 mg/day. Ticlopidine (500 mg/day), a new antiplatelet agent, is more effective than aspirin in preventing stroke and death in patients with TIA or minor stroke. Ticlopidine (500 mg/day) is effective in preventing recurrent stroke, myocardial infarction, or vascular death in patients with completed stroke. Aspirin has not been directly shown to be effective after completed stroke. No clear evidence exists for the use of anticoagulants in atherothrombotic cerebral vascular disease in patients presenting with TIA or minor stroke, acute partial stable stroke, stroke-in-progression, or completed stroke. Anticoagulation for rheumatic valvular heart disease is effective in preventing recurrent embolism. Long-term anticoagulation of patients with mechanical prosthetic valves protects against initial embolism and prevents recurrent embolism. The addition of aspirin (500-1000 mg/day) to warfarin reduces the rate of cerebral embolism from mechanical prosthetic heart valves but is associated with increased bleeding. The addition of dipyridamole (400 mg/day) to warfarin may be more effective than aspirin in reducing the rate of cerebral embolism from mechanical prosthetic heart valves and has fewer bleeding side-effects. Anticoagulation during the hospital phase of myocardial infarction reduces the incidence of systemic embolism/stroke. Long-term anticoagulation of patients after the hospital phase of myocardial infarction reduces the incidence of systemic embolism/stroke, recurrent myocardial infarction and death. Prophylactic anticoagulant treatment of patients with non-valvular atrial fibrillation reduces the incidence of embolism, but the optimal duration of treatment is not known. Immediate anticoagulation of patients with completed cardioembolic stroke is safe and effective in preventing recurrent embolism.

A double-blind, randomized trial of PY108-068 in acute ischemic cerebral infarction.

A double-blind, randomized, pilot trial of the calcium channel antagonist PY108-068 was completed in patients with acute ischemic cerebral infarction. Nine treated patients received PY108-068 orally (150 mg/day in divided doses) and 10 control patients received placebo within 48 hours of stroke onset for 21 days. The mean age of the treated patients (four men, five women) was 63.7 years and of the control patients (seven men, three women) 64.4 years. Most infarctions were in the territory of the middle cerebral artery. One treated patient died of sudden cardiac death on Day 12; one control patient died of cerebral herniation. Two treated patients had episodes of clinically insignificant hypotension during Day 1 of treatment. Two control patients had myocardial infarctions during the trial. The mean Toronto Stroke Scale scores at stroke onset were 67 and 90 and at Week 12 were 22.5 and 34.7 in the treated and control groups, respectively. There was parallel improvement in the two groups, with no significant difference between groups (p = 0.12). The mean Barthel Index functional scores at stroke onset were 32.8 and 33 and at Week 12 were 90 and 78.8 in the treated and control groups, respectively. There was a trend in favor of the treated group, but differences between groups did not reach significance. In this pilot trial, PY108-068 was found to be safe but not effective in patients with acute ischemic cerebral infarction.

Transient ischemic attacks and normal cerebral angiograms: a follow-up study.

To determine the outcome of patients with carotid transient ischemic attacks (TIAs) and normal cerebral angiograms, we assessed 68 patients (40 men, 28 women) aged 24-72 (mean 53.5) years for recurrent TIAs and strokes and for the development of cardiac disease over 2-6 (mean 4.4) years. All but one patient had a follow-up interview in early 1987; that patient had died of an unrelated cause (lung cancer) 18 months after the presenting TIA. The diagnosis was changed at the follow-up interview in three patients (multiple sclerosis, meningioma, migraine). Among the 64 remaining patients, at admission cranial computed tomography had shown cerebral infarction in 11 of 64, two-dimensional echocardiography had been abnormal in nine of 61, Holter monitoring had been abnormal in eight of 45, and twelve-lead electrocardiography had been abnormal in three of 64. Two patients had abnormalities on both echocardiography and Holter monitoring. At the follow-up interview of the 64 remaining patients, TIAs had recurred in nine and three had developed a completed stroke; cardiac disease (angina in seven, myocardial infarction in four) was noted in 11 patients. Findings from cardiac investigations on admission in the nine patients with recurrent TIAs had been abnormal in six and normal in three; all three patients who developed a stroke had had abnormal cardiac findings. Overall, further neurologic or cardiac events occurred in 12 of 46 patients (26%) with normal and in 10 of 18 patients (55.5%) with abnormal findings on admission (p less than 0.01). In the presence of normal angiograms, extensive cardiac investigations may help predict the outcome of patients with TIAs.

Wernicke's encephalopathy after gastroplasty for morbid obesity.

A young woman developed Wernicke's encephalopathy after gastroplasty for morbid obesity. Her clinical presentation of nystagmus and ocular gaze palsies, ataxia, and a sensorimotor neuropathy is described. A small number of previously described patients are compared with respect to clinical features, response to treatment, and investigative procedures.