To investigate the safety and efficacy of stroke thrombolysis in a local hospital.
Historical cohort study.
A tertiary hospital in Hong Kong.
The outcome of acute ischaemic stroke patients treated ...with intravenous tissue plasminogen activator between October 2008 and May 2011 was compared to those admitted during the same period who were thrombolysis-eligible, but treated conservatively due to unavailability of the thrombolysis service after-hours.
Intravenous tissue plasminogen activator.
Primary outcome was functional independence (modified Rankin Scale score of 2 or below) at 3 months. Safety outcomes were symptomatic intracranial haemorrhage and 3-month mortality. Secondary outcomes were hospital length of stay, direct home discharge, and nursing home discharge.
A total of 48 thrombolysis and 63 non-thrombolysis patients were identified. Fifty-two percent of the thrombolysis group achieved functional independence compared to 24% of non-thrombolysis group (P=0.003), without significant increase in mortality (15% vs 13%, P=0.51) or symptomatic intracranial haemorrhage (4% vs 2%, P=0.58). Twenty-nine percent of the thrombolysis group patients were discharged home directly, versus 6% of non-thrombolysis group (P<0.001). Mean length of stay was shorter for the thrombolysis group (25 vs 35 days; P=0.034). A similar percentage from each group was discharged to nursing homes.
Implementation of the stroke thrombolysis service in Hong Kong appeared safe and efficacious. Patients who received thrombolysis had better outcomes compared to non-thrombolysis cohort. Further studies are needed to investigate the economics of stroke thrombolysis in Hong Kong, which may help to improve funding for provision of this service.
To assess time management of stroke thrombolysis triage and functional outcomes in patients receiving recombinant tissue plasminogen activator for hyperacute stroke, and identify bottlenecks in ...delivery of the treatment.
Prospective study.
A university teaching hospital in Hong Kong.
Patients with suspected hyperacute stroke referred to the stroke thrombolysis team during October 2008 to September 2009.
Time performance records including door-to-stroke team, door-to-needle, and onset-to-thrombolysis times. Functional outcomes by modified Rankin Scale score at 3 months, and thrombolysis-related complications including haemorrhagic transformations and mortality.
During the 12-month period, 95 thrombolysis calls were received; recombinant tissue plasminogen activator was given intravenously to 17 (18%) of the patients and intra-arterially to 11 (12%). The mean (standard deviation) door-to-stroke team and the door-to-needle times for intravenous recombinant tissue plasminogen activator patients were 33 (25) and 80 (25) minutes, respectively; both were about 20 minutes longer than that recommended by the National Institute of Neurological Disorders and Stroke. The mean National Institute of Health Stroke Scale score for patients received intravenous recombinant tissue plasminogen activator was 16 (standard deviation, 7). The mean (standard deviation) onset-to-treatment time was 144 (42) minutes. Nine (53%) patients who received intravenous recombinant tissue plasminogen activator achieved favourable outcomes at 3 months, with a modified Rankin Scale score of 0 to 1. Symptomatic haemorrhage and mortality occurred in one (6%) patient.
A dedicated stroke triage pathway is essential to ensure efficient and safe delivery of thrombolysis therapy. Improvements in door-to-stroke team time through integration with emergency medicine staff and neuroradiologists may improve thrombolysis eligibility.
Background
Adjudication of endpoints is a standard procedure in cardiovascular clinical trials. However, several studies indicate that the benefit of adjudication in estimating treatment effect may ...be limited.
Aims
This post hoc analysis of SOCRATES (NCT01994720) compared the treatment effects and investigated the agreement of clinical event assessment by site investigators and independent adjudicators.
Methods
SOCRATES compared ticagrelor and aspirin in 13,199 patients with acute minor stroke or high-risk transient ischemic attack. The primary endpoint was stroke, myocardial infarction, or death. Stroke was the major component of the primary endpoint and a secondary endpoint. The endpoints were adjudicated by a blinded independent committee. We compared the treatment effect on the primary endpoint and stroke alone based on the investigators' and adjudicators' assessments, and investigated the agreement rate on the stroke endpoint and major hemorrhages.
Results
The hazard ratios (95% confidence interval) for ticagrelor versus aspirin therapy for the primary endpoint were 0.89 (0.78–1.01) when calculated on adjudicator-assessed events and 0.88 (0.78–1.00) for investigator-assessed events. The hazard ratios (95% confidence intervals) for stroke were 0.86 (0.75–0.99) based on the adjudicators' diagnoses and 0.85 (0.75–0.97) based on the investigators' diagnoses. The overall agreement between adjudicator- and investigator-diagnosed stroke was 91%, and for major hemorrhages was 88%.
Conclusions
In SOCRATES, there was no clinically meaningful difference in the estimated treatment effect, on either the primary endpoint or stroke, by using investigator- or adjudicator-assessed events. Double-blind treatment outcome studies with stroke endpoints may not benefit from adjudication.
Trial Registration
ClinicalTrials.gov Identifier: NCT01994720.
This paper aimed to assess the usefulness and safety of video-EEG (video-electroencephalography) monitoring in patients with refractory epilepsy. We analysed the video-EEG recordings of consecutive ...patients over a 3-year period from 2002 to 2005. The pre-admission diagnosis, demographic information, number of ictal episodes, adverse events, and final diagnosis were recorded in all patients. The diagnostic labels before and after monitoring were compared in order to assess whether it had led to a change in diagnosis and management. Of the 100 patients who underwent video-EEG, 227 clinical events were recorded in 62 cases. The most common events were complex partial seizures followed by non-epileptic attacks. Video-EEG allowed a diagnosis to be made in 81 patients and the diagnosis at discharge was altered in 19 cases. Major injuries and status epilepticus did not occur during monitoring. In our experience video-EEG is safe and provides important clinical information in over 80% of patients.
Abstract only BACKGROUND The prevalence, characteristics and outcomes of stroke patients with intracranial large artery atherosclerosis have not been clearly established by large multicenter ...prospective study. METHODS In this prospective multicenter study, we evaluated 2864 consecutive patients (mean age, 62 years) who experienced an acute cerebral ischemia, including ischemic stroke or transient ischemic attack (TIA), within 7 days of symptom onset in 22 hospitals in China. All patients underwent magnetic resonance angiography (MRA), with measurement of diameter of the main intracranial arteries. Intracranial large artery atherosclerosis was defined as at least 50% diameter reduction on MRA. RESULTS The prevalence of intracranial stenosis was 46.6% (1,335 patients, including 261 patients with co-existing extracranial carotid stenosis). Patients with intracranial stenosis had more severe stroke at admission and stayed longer in hospitals than those without intracranial stenosis (median NIHSS 3 vs 5, ; median length of stay 14 vs 16 days respectively, both p<.0001). In hospital treatment included antithrombotics (96%), statins (76%), and antihypertensives (51%). After 12 months, recurrent stroke occurred in 3.34% of patients with no stenosis, 3.82% for 50-69% stenosis, 5.16% for 70-99% stenosis and 7.40% for 100% occlusion. Apart from the degree of arterial stenosis, age, family history of stroke, prior history of cerebral ischemia or heart disease and no prior use of antithrombotic drug were independent risk factors for recurrent stroke. The recurrent rate of each group of patients categorized by degree of stenosis and number of risk factor is shown in the Figure . The highest rate of recurrence was observed in patients with 100% occlusion with the presence of 3 additional risk factors. CONCLUSION Intracranial large artery stenosis is the commonest vascular lesion in patients with cerebrovascular disease in China. Recurrent stroke rates remains high in patients with severe stenosis and other risk factors despite prevalent use of medical treatment such as antiplatelet, antihypertensive and statin therapies.
Subclavian steal syndrome Lee, David H F; Leung, Thomas W; Yu, Simon C H ...
Hong Kong medical journal = Xianggang yi xue za zhi
15, Številka:
4
Journal Article
Currently, when stroke patients are offered thrombolytic therapy, their ischaemic stroke subtypes are usually unknown. Given the risk of haemorrhage that accompanies thrombolytic therapy, unselective ...(or undiscriminating) use of recombinant tissue plasminogen activator in patients without large-artery thromboemboli is potentially hazardous. Advances in computed tomography techniques have enabled the stroke pathophysiology to be quickly delineated by multimodal computed tomography without compromise in time for recombinant tissue plasminogen activator administration. Through description of the investigation of a typical stroke patient, we report how this technique is feasible in a regional hospital and may guide judicious use of recombinant tissue plasminogen activator.
Background and Aim
A pre-specified country analysis of subjects from the Philippines in the CHInese Medicine NeuroAiD Efficacy on Stroke recovery (CHIMES) Study showed significantly improved ...functional and neurological outcomes on MLC601 at month (M) 3. We aimed to assess these effects on long-term functional recovery in the Filipino cohort.
Methods
The CHIMES-E (extension) Study evaluated subjects who completed three months of randomized placebo-controlled treatment in CHIMES up to two years. Blinding of treatment allocation was maintained and all subjects received standard stroke care and rehabilitation. Modified Rankin Score (mRS) and Barthel Index (BI) were assessed in-person at M3 and by telephone at M6, M12, M18, M24. Odds ratios (OR) with corresponding 95% confidence intervals (CI) for functional recovery using ordinal analysis of mRS and for achieving functional independence (mRS 0-1 or BI ≥ 95) at each time point were calculated, adjusting for age, sex, baseline National Institute of Health Stroke Scale (NIHSS), onset-to-treatment time (OTT) and pre-stroke mRS.
Results
The 378 subjects (MLC601 192, placebo 186) included in CHIMES-E from the Philippines (mean age 60.2 ± 11.1) had more women (p < 0.001), worse baseline NIHSS (p < 0.001) and longer onset to treatment time (p = 0.002) compared to other countries. Baseline characteristics were similar between treatment groups. The treatment effect of MLC601 seen at M3 peaked at M6 with OR for mRS shift of 1.53 (95% CI 1.05–2.22), mRS dichotomy 0–1 of 1.77 (95% CI 1.10–2.83), and BI ≥ 95 of 1.87 (95% CI 1.16–3.02). The beneficial effect persisted up to M24.
Conclusion
The beneficial effect of MLC601 seen at M3 in the Filipino cohort is durable up to two years after stroke.
OBJECTIVE To evaluate the clinical utility of mesial frontal semiology. DESIGN Retrospective case series. SETTING Tertiary epilepsy referral center. PATIENTS Part 1 of the study involved 152 patients ...who underwent frontal lobe surgery. Part 2 involved 253 patients who underwent non–frontal lobe surgery. MAIN OUTCOME MEASURES Inclusion criteria for both parts of the study were seizure localization by analysis of resection margins (mesial frontal, lateral frontal, orbitofrontal, nonfrontal) or intracranial exploration and an Engel class I outcome. In part 1, 84 patients had their habitual seizures analyzed by video encephalography using a semiology checklist of 47 items during the early phase (electrographic onset to 10 seconds) and late phase (rest of episode). Localization semiology was analyzed by χ2 test with Bonferroni correction and cluster analysis when occurrence exceeded 10% in at least 1 region. In part 2, 144 patients had their habitual seizures screened with mesial frontal semiology from the first part of study during the early phase only. RESULTS In part 1 of the study, the statistically significant localizing semiology for the mesial frontal region in the early phase was ictal body turning along the horizontal axis (57% of patients), crawling (57% of patients), restlessness (64.3% of patients), facial expressions of anxiety (42.9% of patients) and fear (35.7% of patients), grimacing produced by bilateral facial contraction (42.9% of patients), barking (32.1% of patients), head shaking (25% of patients), and pelvic raising (25% of patients) (all P < .001). In the late phase, recurrent utterance (21.4% of patients) was the additional statistically significant item (P < .002). In part 2 of the study, ictal body turning along the horizontal axis gave a 55.2% positive predictive value, which improved to 85.7% when clustered with restlessness, facial expressions of anxiety and fear, and barking. CONCLUSIONS Ictal body turning along the horizontal body axis and semiology with physiological movement are not only prevalent semiology items of mesial frontal lobe epilepsy but they distinguish mesial frontal from lateral frontal and orbitofrontal seizures.Arch Neurol. 2008;65(1):71-77-->
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