Pain is a common complication after stroke and is associated with the presence of depression, cognitive dysfunction, and impaired quality of life. It remains underdiagnosed and undertreated, despite ...evidence that effective treatment of pain may improve function and quality of life.
We provide an overview of the means for clinical assessment and risk factors for the development of post-stroke pain, then review the newest available literature regarding the commonest post-stroke pain syndromes, including central post-stroke pain, complex regional pain syndrome, musculoskeletal pain including shoulder subluxation, spasticity-related pain, and post-stroke headache, as well as the available epidemiology and current treatment options. Key Messages: In the best interests of optimizing quality of life and function after stroke, clinicians should be aware of pain as a common complication after stroke, identify those patients at highest risk, directly inquire as to the presence and characteristics of pain, and should be aware of the options for treatment for the various pain syndromes.
Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, ...resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely to seek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as “atypical,” can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.
Définis comme un préjugé favorable ou défavorable, les biais que l’on retrouve tant chez le dispensateur de soins, le patient ou dans la société en général influencent le diagnostic et le traitement de la maladie cardiovasculaire, d’où les écarts liés au sexe et au genre dans les statistiques. Faute de reconnaître les particularités et les facteurs de risque de la maladie cardiovasculaire chez la femme, le dispensateur de soins pourrait ne pas évaluer ni traiter adéquatement des patientes. Qui plus est, il y a eu moins de recherches sur des traitements ciblant des phénotypes courants chez les femmes, comme la coronaropathie non obstructive et l’insuffisance cardiaque à fraction d’éjection préservée, un autre facteur de sous-traitement chez les femmes. Par ailleurs, les femmes sont moins susceptibles de recourir à des soins médicaux d’urgence, peut-être en raison des attentes sociétales qui les amènent à faire passer les besoins d’autrui avant les leurs, ce qui contribue à retarder le diagnostic. Les femmes sont aussi moins susceptibles de discuter des facteurs de risque de coronaropathie que les hommes, en partie parce qu’elles sont moins enclines à se considérer comme à risque de maladie cardiaque. Les dispensateurs de soins pourraient avoir une interprétation biaisée d’un grand nombre de symptômes, certains étant qualifiés d’atypiques, et exclure le diagnostic de maladie cardiovasculaire. De plus, ils pourraient éviter d’aborder certains traitements avec leurs patientes, comme la thrombolyse dans les cas d’accident vasculaire cérébral et le traitement de resynchronisation cardiaque dans les cas d’insuffi-sance cardiaque, parce qu’ils présument, à tort, que les femmes ne souhaitent pas avoir recours à des traitements jugés plus invasifs. Pour éviter les biais, les organisations devraient chercher à accroître la visibilité et la présence des femmes dans la recherche, la promotion de la santé, les initiatives cliniques et les travaux de pointe. D’autres recherches sont nécessaires pour trouver des interventions efficaces afin d’éliminer les biais liés au sexe et au genre, et de réduire les écarts dans les résultats cardiovasculaires.
Prognosis following cerebral venous thrombosis (CVT) is more favorable than other stroke types, but longer-term literature is limited, and trends over time are under-explored.
Using administrative ...data, we examined factors associated with mortality in the inpatient setting, at 30 days and at one year following hospital discharge among a large consecutive cohort of Canadian patients with CVT.
CVT patients from British Columbia (BC), Canada from 2000 to 2017 were identified using ICD diagnosis codes from the BC subset of the Canadian Institute for Health Information's Discharge Abstract Database. Logistic regression was used to investigate factors associated with inpatient mortality and survival analysis with Cox regression was used to explore factors associated with mortality at 30 days and one year.
Of 554 incident CVT patients identified, 508 (92 %) survived their index admission. Older age (OR 1.04, 95 % CI 1.03-1.06, p < 0.01) and the presence of seizures (OR 2.31, 95 % CI 1.08-4.94, p = 0.03) or intracranial bleeding (OR 2.28, 95 % CI 1.08-4.85, p = 0.03) were associated with increased odds of inpatient mortality. Mortality after hospital discharge was 3.0 % at 30 days and 9.4 % at one year. Older age (HR 1.05, 95 % CI 1.02-1.08, p < 0.01 at 30 days; HR 1.05, 95 % CI 1.04-1.07, p < 0.01 at 1 year) and having recent or active malignancy (HR 4.17, 95 % CI 1.51-11.52, p < 0.01 at 30 days; HR 4.60, 95 % CI 2.60-8.11, p < 0.01 at 1 year) were significantly associated with higher risks of mortality at 30 days and one year after discharge. There were decreases in inpatient mortality over the study period, but this was offset by higher mortality within 30 days after discharge in the later study epochs.
Among patients discharged with a diagnosis of CVT, one-year mortality was high at 9.4 %. Older age and a history of cancer were associated with higher mortality after discharge.
The association between atrial fibrillation and stroke is firmly established, and anticoagulation reduces stroke risk in patients with atrial fibrillation. However, the role of anticoagulation in ...very brief durations of atrial fibrillation (subclinical atrial fibrillation) is an area of controversy.
Stroke risk increases alongside burden of atrial fibrillation. Ongoing trials will clarify if 24 h or less of atrial fibrillation on extended monitoring necessitates lifelong anticoagulation. Trials examining empiric anticoagulation for individuals with ESUS did not demonstrate benefit over antiplatelet agents. However, hypothesis-generating sub-analyses suggest that certain at-risk groups may benefit. Atrial cardiopathy is associated with subclinical atrial fibrillation and research examining anticoagulation after ESUS in this population is underway.
Stroke risk increases alongside burden of ectopic atrial activity. However, this risk may in part be because of prothrombotic dysfunction associated with atrial cardiopathy in addition to the arrhythmia itself. The minimal amount of subclinical atrial fibrillation to warrant anticoagulation for stroke prevention, and how this may be modified by the total duration of monitoring, will be clarified by the results of ongoing clinical trials. Currently research will also help identify whether a select group of ESUS patients who have structural and electrophysiological markers of atrial cardiopathy warrant anticoagulation for secondary prevention.
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