The considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative study.

BACKGROUND: Treatment decision-making by family members on behalf of patients with major stroke can be challenging because of the shock of the diagnosis and lack of knowledge of the patient's treatment preferences. We aimed to understand how, and why, family members made certain treatment decisions, and explored their information and support needs. METHOD: Semi-structured interviews with family members (n = 24) of patients with major stroke, within 2 weeks of hospital admission. Data were analysed thematically. RESULTS: Families' approach to treatment decision-making lay on a spectrum according to the patient's state of health pre-stroke (i.e. patient's prior experience of illness and functional status) and any views expressed about treatment preferences in the event of life-threatening illness. Support and information needs varied according to where they were on this spectrum. At one extreme, family members described deciding not to initiate life-extending treatments from the outset because of the patients' deteriorating health and preferences expressed pre-stroke. Information from doctors about poor prognosis was merely used to confirm this decision. In the middle of the spectrum were family members of patients who had been moderately independent pre-stroke. They described the initial shock of the diagnosis and how they had initially wanted all treatments to continue. However, once they overcame their shock, and had gathered relevant information, including information about poor prognosis from doctors, they decided that life-extending treatments were no longer appropriate. Many reported this process to be upsetting and expressed a need for psychological support. At the other end of the spectrum were family members of previously independent patients whose preferences pre-stroke had not been known. Family members described feeling extremely distressed at such an unexpected situation and wanting all treatments to continue. They described needing psychological support and hope that the patient would survive. CONCLUSION: The knowledge that family members' treatment decision-making approaches lay on a spectrum depending on the patient's state of health and stated preferences pre-stroke may allow doctors to better prepare for discussions regarding the patient's prognosis. This may enable doctors to provide information and support that is tailored towards family members' needs.

The differential diagnosis of suspected stroke: a systematic review.

BACKGROUND: We aimed to determine the proportion of patients who had suffered a stroke and compare this to those patients with suspected stroke, and the range of differential diagnosis for suspected stroke. METHODS: We searched for prospective studies of suspected stroke in electronic databases and our personal files. We undertook a meta-analysis of these studies, aimed at determining the proportions of patients with confirmed stroke in different settings. RESULTS: We identified 29 studies involving 8,839 patients: 13 studies were from emergency departments, five from stroke units or transient ischaemic attack (TIA) clinics, three from primary care, three from ambulance services and five were unspecified. About three-quarters (74% [95% confidence interval (CI): 66 to 83%]) of patients had a diagnosis of stroke, though there was significant heterogeneity in this estimate. The five most frequent non-stroke diagnoses were seizure, syncope, sepsis, migraine and brain tumours. CONCLUSION: Patients who had not had a stroke accounted for a significant proportion of people referred to stroke services. Expertise in the differential diagnoses of stroke is needed in order to manage the patients at the point of referral.

Identifying blood biomarkers to improve the diagnosis of stroke.

Blood biomarkers are useful for the management of many diseases and could be useful for doctors caring for stroke patients, if they accurately predicted a diagnosis or recurrence of stroke. In a series of studies, we systematically reviewed the blood biomarker literature in stroke, determined the performance of existing blood biomarkers for the diagnosis of stroke and examined the value of markers of inflammation to predict recurrent stroke and myocardial infarction.

CSF opening pressure: reference interval and the effect of body mass index.

We prospectively recorded CSF opening pressure in 242 adults who had a lumbar puncture with concomitant measurement of weight and height. The 95% reference interval for lumbar CSF opening pressure was 10 to 25 cm CSF. Body mass index had a small but clinically insignificant influence on CSF opening pressure.

Spontaneous intracranial hypotension causing confusion and coma: a headache for the neurologist and the neurosurgeon.

Spontaneous intracranial hypotension presenting with confusion and coma has rarely been reported. A case is presented and the clinical features of spontaneous intracranial hypotension are discussed.

A parent's experience of a special care baby unit.

Parents of a preterm baby usually experience considerable stress and need sympathetic understanding and support. The technology and procedures that are routine to SCBU staff are strange and worrying to parents. Parents' feelings are often complex and may include temporary anger towards staff as well as gratitude.

Juxtasellar hyperostosis of non-meningiomatous origin.

Seven patients are described who had juxtasellar hyperostosis with visual disturbance secondary to non-meningiomatous lesions. Two had chromophobe adenomas, one craniopharyngioma, one carcinoma of the sphenoid sinus, one a thrombosed aneurysm of the intracavernous portion of the internal carotid artery, one epidermoidoma of the orbit, and one chondroblastoma of the anterior clinoid process. The diagnosis of meningioma was entertained initially on the basis of hyperostosis plus visual impairment. Careful evaluation of hyperostosis is essential for correct diagnosis of meningioma, according to our experience. Suprasellar meningiomas almost invariably produce irregular hyperostosis of the planum sphenoidale, often associated with serration and blistering. Sphenoid meningioma, when it is sclerotic, always shows thickening or expansion of the sphenoid wings. Therefore, in the absence of typical meningiomatous hyperostosis, one can readily differentiate non-meningiomatous hyperostosis from true meningioma.

Angiographic findings in recurrent meningioma.

Of 147 patients who underwent radical surgery for intracranial meningioma, 25 (17%) had symptomatic recurrence requiring further surgery. Correlation between histological and angiographic findings of recurrent meningioma was poor. Following extirpation of feeding meningeal vessels in convexity meningiomas, the principal blood supply was usually from the anterior, middle, and/or posterior cerebral arteries. The angiographic appearance was that of a "tree-root" or "sunburst" pattern, indicating neoplastic invasion of the pia mater and/or underlying brain tissue. Polytomography, selective cerebral angiography, and radionuclide imaging of the brain are often necessary to detect early recurrent meningiomas. Computed tomography appears to be an innocuous and accurate method of diagnosing recurrent tumor, especially when the bone is not involved.