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Focused Readings: Acute Stroke
Cod. A19052007
there was an article in Journal Watch website concerning the advancement on stroke. here is the main article and 2 other articles cited inside.
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Focused Readings: Acute Stroke
Recent studies address advances in acute stroke care.
Few areas in emergency medicine have changed as rapidly, or with as much controversy, as the care of acute stroke. Systemic fibrinolysis, once vilified as dangerous and unproven, has emerged as the standard of care for a highly select patient population, with proven outcome benefit. Imaging modalities have evolved, but the clear superiority of magnetic resonance imaging is often negated by lack of access to this imaging study. Here, we present several recent studies of acute stroke. They address the incidence of acute stroke, validation of a score (ABCD2) to help identify patients at high risk, the role of imaging in the decision to administer systemic lytic therapy, functional outcomes at stroke centers, and performance of systemic lytic therapy in "real life."
The bottom line? Emergency departments should have a tightly organized system of care for acute stroke patients, with access to prompt imaging and protocols for administration of acute lytic therapy.
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ARTICLE 1
Declining Risk and Incidence of Clinical Stroke
Age-adjusted incidence of first stroke has decreased during the past 50 years.
Stroke is the third leading cause of death and the number-one etiology of long-term neurologic disability in the U.S. Researchers prospectively examined the Framingham Study cohorts during three intervals (19501977, 19781989, and 19902004) to ascertain trends in stroke incidence, severity, 30-day mortality, and risk. The authors defined clinical stroke as "rapidly developing signs of focal neurologic disturbance of presumed vascular etiology, lasting more than 24 hours."
The age-adjusted incidence of first stroke per 1000 person-years decreased in each of the three intervals both in men (7.6, 6.2, and 5.3, respectively) and in women (6.2, 5.8, and 5.1). The 10-year risk at age 65 decreased significantly in men (from 19.5% to 14.5%) but not in women (from 18.0% to 16.1%). Similarly, 30-day mortality decreased significantly in men (from 23% to 14%) but not in women (from 21% to 20%). Assessment of risk factors at age 65 demonstrated significant reductions in mean systolic blood pressure, total cholesterol, prevalence of hypertension, and prevalence of current smoking as well as an increase in the proportion of persons receiving antihypertensive treatment. However, the prevalence of atrial fibrillation in men and the mean body-mass index in both sexes increased. Overall, the Framingham Stroke Risk Profile, a validated instrument, improved significantly for both men and women. The proportion of strokes that were moderate or severe did not change significantly in men or women.
Comment: The good news is that the annual incidence of clinical stroke has declined during the past 50-plus years for men and women, as has the 10-year risk for stroke for people aged 65. The bad news is that stroke severity has not declined and that 30-day mortality has dropped only in men. The latter finding could be due to older age at stroke onset and greater stroke severity in women. The need for primary prevention continues.
John A. Marx, MD, FAAEM, FACEP
Published in Journal Watch Emergency Medicine February 2, 2007
Citation(s):
Carandang R et al. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. JAMA 2006 Dec 27; 296:2939-46.
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ARTICLE 2
Whos at Risk for Stroke After TIA?
A risk-stratification system is effective for determining a patient's risk for stroke within 2 days.
From 4% to 20% of patients with transient ischemic attacks (TIAs) progress to stroke within 90 days, half within the first 48 hours. How do we identify patients at greatest risk? Researchers first validated two recently developed prognostic scores the California score (designed to predict stroke within 90 days) and the ABCD score (designed to predict stroke within 7 days; see Journal Watch Emergency Medicine Aug 23 2005) and then combined the two systems and validated the resulting new score, termed ABCD2 (designed to predict stroke within 2 days).
The scores were derived in two groups of patients (totaling 1916) and validated in four groups of patients (totaling 2893) from emergency departments, clinics, and population-based cohorts in California and Oxford, England.
The ABCD2 score assigns 0 to 7 points based on Age (≥60 years, 1 point), Blood pressure at presentation (≥140/90 mm Hg, 1 point), Clinical features (unilateral weakness, 2 points; speech disturbance without weakness, 1 point), Duration of symptoms (≥60 minutes, 2 points; 1059 minutes, 1 point), and Diabetes (1 point).
Strokes occurred in 3.9% of patients within 2 days, 5.5% within 7 days, 7.5% within 30 days, and 9.2% within 90 days. When applied to the validation groups, the ABCD2 score stratified 21% of patients as high risk (score, 67), 45% as moderate risk (score, 45), and 34% as low risk (score, 03). The 2-day risks for stroke in the high-, moderate-, and low-risk groups were 8.1%, 4.1%, and 1.0%, respectively.
An editorialist suggests that the ABCD2 system is the best available method for determining which patients are at short-term risk for stroke after TIA but notes that the score should be used as an adjunct to, rather than a replacement for, clinical judgment and data from other sources, such as imaging.
Comment: TIAs are like angina of the brain, and symptoms lasting longer than 1 hour are highly likely to represent stroke (see Journal Watch Emergency Medicine Mar 12 2003). The ABCD2 prediction score helps us to risk-stratify patients. Patients with a score of less than 4 might be suitable for discharge on aspirin therapy with close follow-up, but most patients with new-onset TIA should be admitted to a hospital.
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine February 23, 2007
Citation(s):
Johnston SC et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007 Jan 27; 369:283-92.
Medline abstract (Free)
Kernan WN. Stroke after transient ischaemic attack: Dealing in futures. Lancet 2007 Jan 27; 369:251-2.
Medline abstract (Free)
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