Stroke has a
greater effect on women than men because women have more
events and are less likely to recover. Age-specific stroke rates are
higher in men, but, because of their longer life expectancy and much
higher incidence at older ages, women have more stroke events than
men. This review article (Lancet Neurology 2008; 7:915-926)
discusses the functional outcomes and quality of life after stroke.
This is consistently poorer in women, despite adjustment for
baseline differences in age, prestroke function, and comorbidities.
This article comprehensively reviews the epidemiology, clinical
presentation, medical care, and outcomes of stroke in women.
Early correct
diagnosis of cerebellar infarction is crucial to help prevent
treatable but potentially fatal complications, such as brainstem
compression and obstructive hydrocephalus.
In this review article Edlow JA et al (Lancet
Neurology 2008; 7:951-964) discusses the diagnosis and the
management plan for patients with signs and symptoms of
cerebellar infarction. It focuses on differential diagnosis of
the disease which is broad, and includes many common and benign
causes. The authors review the clinical presentation of
cerebellar infarction, from diagnosis and misdiagnosis to
patients' monitoring, treatment, and potential complications
This review of
articles and research papers ( Lancet Neurology 2008; 7:425-435)
regarding the subject of childhood stroke is useful to both stroke
physicians and pediatricians. Amlie-Lefond C et al, mentioned that
stroke is increasingly recognised as a cause of childhood disability
and lifelong morbidity.
Diagnosis of stroke in children is often delayed owing to low
clinical suspicion and the need to exclude the frequent mimics of
stroke in childhood. Outcomes are related to presentation,
associated illnesses, the underlying cause, size, and location of
the infarct, and stroke subtype, but more than a half of the
children who have had a stroke will have long-term neurological
sequelae. Furthermore, estimates of recurrence rates range from
6–19% in the first few years. Arteriopathy—including arterial
dissection and other progressive and non-progressive arteriopathies—might
account for up to 80% of childhood stroke in otherwise healthy
children. Because children with cerebrovascular abnormalities are at
the highest risk of recurrence (66% at 5 years), understanding of
the nature and course of these arteriopathies is crucial to the
development of secondary stroke prevention strategies.
The author of this study stated that
the female population carries a higher stroke burden than the male
population, both because females have a longer life expectancy and
because most stroke deaths occur in women (Nat Clin Pract Neurol.
2008 Jan;4(1):22-33).
Differences between the sexes in relation to stroke are increasingly
being recognized; for example, among stroke survivors, women tend to
have worse outcomes than men, as indicated by more-severe disability
and an increased likelihood of institutionalization in women.
Women and men with stroke also differ in their risk factor profiles,
and they respond differently to primary-prevention and acute stroke
treatment. Women experience variations in endogenous estrogens
throughout their life cycle and might also be exposed to exogenous
estrogens, both of which markedly affect the brain.
An understanding of the effects of endogenous and exogenous
estrogens on cerebral hemodynamics could guide research into
explaining how hormone therapy increases the risk of stroke in
postmenopausal women.
This Review summarizes the sex differences related to stroke, and
the effect of endogenous and exogenous hormones on the
cerebrovasculature of the female brain. It also proposes potential
research approaches, the results of which could fill in gaps in our
knowledge regarding the mechanism of action of estrogen in the
brain.
Stroke is one of the most feared
complications of surgery. To provide adequate preventive and
therapeutic measures, physicians need to be knowledgeable about the
risk factors for stroke during the perioperative period. In this
article, the author review the pathophysiology of perioperative
stroke and provide recommendations for the stratification of risk
and the management of risk factors (New England J of Med 2007,356;
706-713).
Atrial fibrillation (AF) is a common
arrhythmia that is associated with substantial morbidity and
mortality, particularly due to stroke and thromboembolism.
Anticoagulant therapy reduces the risk of stroke, and the greatest
benefit is seen in patients at highest absolute risk. Aspirin is a
less effective alternative, and any benefit of aspirin might be due
to its favourable effects on arterial thrombosis caused by vascular
disease. However, anticoagulant therapy remains underused,
particularly in the elderly, who probably have the most to gain from
stroke prevention owing to their high absolute risk. The underuse of
anticoagulation might also be related to uncertain risk of
thromboembolism in individual patients and a perceived
overestimation of the benefit and underestimation of risk of
bleeding with warfarin in clinical trials. In this Review, the
authors summarise the data for and against warfarin and aspirin
therapies and discuss the clinical assessments and risk
stratifications that guide the use of antithrombotic therapy for
stroke prevention in patients with AF. Possible barriers to the
uptake of anticoagulation therapy are also discussed (Lancet
Neurology 2007; 6:981-993).
Brain microbleeds (BMBs) are seen as
small, homogeneous, round foci of low signal intensity on magnetic
resonance imaging gradient echo (GRE) sequences. BMBs might only be
a biomarker for microangiopathy, or alternatively BMBs might provide
useful diagnostic and prognostic information, potentially with
therapeutic implications for the treatment of stroke. Because of the
rapid expansion in recent BMB research, the authors systematically
reviewed and critically appraised the published literature according
to QUADAS, STARD and Cochrane principles (Brain 2007
130(8):1988-2003).
The selection criteria were met by 54 studies of 53 case series
involving 9073 participants, 4432 of whom were people with
cerebrovascular diseases. There were significant biases in many of
the studies. By pooling data from similar studies, the authors found that the
prevalence of BMBs was 5% in healthy adults, 34% in people with
ischaemic stroke, and 60% in people with non-traumatic intracerebral
haemorrhage (ICH). In the studies where a distinction could be made,
BMBs were more prevalent among recurrent strokes than first-ever
strokes: they affected 23% with first-ever ischaemic stroke but 44%
with recurrent ischaemic stroke, and 52% with first-ever ICH but 83%
with recurrent ICH.
By pooling data that could be extracted from similar studies, it
appears that BMBs are associated with hypertension and diabetes
mellitus in otherwise healthy adults, and that they are associated
with hypertension in adults with cerebrovascular diseases. The
association with hypertension was robust in sensitivity analyses.
There is a pressing need for better designed studies to assess the
diagnostic utility of BMBs, disentangle the many likely influences
on their occurrence, and determine their prognostic utility and
whether they should influence treatment. The reviewers conclude by
proposing criteria for ideal study design and reporting.
The objective of this study (Age and
Ageing 2007 36(3):247-255) is to determine whether access to
high-quality stroke care is affected by the age or gender of the
patient or by weekend admission. Data were collected as part of the National Sentinel Audit of stroke
in 2004, both on the organisation of in-patient stroke care and the
process of care to hospitals managing stroke patients. The study mentioned that two hundred and forty-six hospitals from
England, Wales and Northern Ireland took part in the 2004 National
Stroke Audit, a response rate of 100%. These sites audited the care
of 8,718 patients. The results showed that overall standards of care for cases of
stroke in England, Wales and Northern Ireland are low. Older
patients are less likely to be treated in a stroke unit than younger
patients. Seventy-one per cent of patients under 65 years were
scanned within 24 h compared to 51% aged over 85 years. Older
patients were also less likely than younger ones to receive
secondary prevention and some aspects of rehabilitation, especially
around higher functioning. Standards were consistently better for
patients of all ages managed in stroke units compared to general
wards. At weekends, patients were less likely to be admitted
directly to a stroke unit and brain imaging was performed less often
for older (85 + years) patients (weekday 56%, weekend 40%). There
was little evidence of differences in standards of care between
males and females. The study concluded that there is clear evidence of an age effect on
the delivery of stroke care in England, Wales, and Northern Ireland,
with older patients being less likely to receive care in line with
current clinical guidelines. Quality of acute care is also less good
for patients admitted at weekends. No systematic evidence for sexism
was identified.
The mismatch between perfusion and diffusion
lesions on magnetic resonance perfusion-weighted imaging (PWI)/diffusion-weighted
imaging (DWI) may help identify patients for thrombolysis. Evidence
underlying this hypothesis was assessed in this review article ( Journal of
Neurology, Neurosurgery, and Psychiatry 2007;78:485-491) All papers describing magnetic resonance PWI/DWI findings in patients with
acute ischaemic stroke, and their functional and/or radiological outcome at
1 month, with or without thrombolysis were systematically reviewed. 11 papers fulfilled the inclusion criteria. Among these, there were 5
different mismatch definitions and at least 7 different PWI methods. Only 3
papers including 61 patients with and 18 without mismatch provided data on
mismatch, outcome and influence of thrombolysis. Mismatch (v no mismatch)
without thrombolysis was associated with a non-significant twofold increase
in the odds of infarct expansion, which did not change with thrombolysis.
Half of the patients without mismatch also had infarct growth (with or
without thrombolysis). No data were available on functional outcome. Standardised definitions of mismatch and perfusion are needed. Infarct
growth may occur even in the absence of mismatch. The reviewers concluded
that currently, data available on mismatch are too limited to guide
thrombolysis in routine practice. More data are needed from studies
including patients with and without mismatch, and randomised treatment
allocation, to determine the role of mismatch.
Unilateral
spatial neglect causes difficulty attending to one side of space. Various
rehabilitation strategies have been used but evidence of their benefit is
lacking. The objectives of this review is to determine the persisting
effects of cognitive rehabilitation specifically aimed at spatial neglect
following stroke, as measured on impairment and disability level outcome
assessments and on destination on discharge from hospital (Cochrane Database Syst Rev. 2007 Apr 18).
Bowen A. and Lincoln N. searched the Cochrane Stroke Group Trials Register
(last searched 4 July 2005), MEDLINE (1966 to July 2005), EMBASE (1980 to
July 2005), CINAHL (1983 to July 2005), PsycINFO (1974 to July 2005), UK
National Research Register (July 2005). They handsearched relevant journals,
screened reference lists, and tracked citations using SCISEARCH.
The reviewers included randomised controlled trials of cognitive
rehabilitation specifically aimed at spatial neglect. They excluded studies
of general stroke rehabilitation and studies with mixed patient groups,
unless more than 75% of their sample were stroke patients or separate stroke
data were available.
This review showed that cognitive rehabilitation did improve performance on
some, but not all, standardised neglect tests. The number of cancellation
errors made was reduced and the ability to find the midpoint of a line
improved immediately and persisted at follow up. These effects appeared
likely to generalise from the samples studied to the target population, but
were based on a small number of studies. The authors concluded that several
types of neglect specific approaches are now described but there is
insufficient evidence to support or refute their effectiveness at reducing
disability and improving independence. They can alter test performance and
warrant further investigation in high quality randomised controlled trials.
Saccular
intracranial aneurysms, abnormal focal outpouchings of cerebral arteries,
cause substantial rates of morbidity and mortality. Recently, major changes
have occurred in the way doctors think about and treat this disease.
Previous concepts about the natural history, particularly the risk of
rupture of certain aneurysms, have been challenged.
This review article ( NEJM 2006; 355: 928-939) is discussing Cerebral
aneurysms in relation to:
Epidemiology and Pathophysiology
Natural History and Risk of Rupture
Medical Diagnosis and Management of Subarachnoid Haemorrhage
Clinical Presentation and Diagnosis
Imaging Methods and Options
Clinical Approach to Imaging
Acute Effects of Subarachnoid Hemorrhage
Medical Therapy
Treatment Options
Comparison of Clipping and Coiling
Risks of Clipping
Risks of Inserting Detachable Coils
Relative Risks of Coiling and Clipping
The main burden of
stroke to individuals and to societies is as a leading cause for
disability—about 40% of stroke survivors are left with some degree of
functional impairment. Reducing this burden requires optimising stroke
prevention and improving acute care, but rehabilitation is equally
essential. This clinical review (BMJ 2007; 334:86-90 ) discussed important issues
related to stroke rehabilitation such as: What is stroke recovery?,
Immediate rehabilitation, What is a stroke unit?, What sort of therapy,
How much therapy, What can we do for the carers, Resettlement at home
and Rehabilitation when the patients gets home. The review concluded
that the strongest evidence for effective stroke rehabilitation relates
to better outcomes associated with specialist, coordinated,
multidisciplinary teams, both during early inpatient recovery and for
resettlement at home.
As ocular and visual
problems are common in patients with stroke, it is important that their
implications are understood.
This article (Age and Ageing 2006 35(6):560-565) aims at providing a
broad overview of the literature relating to visual problems in stroke
patients, looking particularly at the impact on, and the potential for,
recovery and rehabilitation. The online database PubMed was searched for literature relating to
visual and ocular problems in stroke. The resulting abstracts and
articles were then reviewed to extract clinically relevant information.
Findings are summarised and discussed. The authors concluded that visual problems in stroke are associated with
problems with activities of daily living (ADL), falls and
rehabilitation. Because many visual problems are easily corrected or
improve with intervention, there may be a role for formal screening for
visual problems in stroke patients in a rehabilitation setting. The
orthoptist has an important role to play in stroke rehabilitation, and
links between the stroke and orthoptic departments should be established
in all units.
Elderly stroke patients
were excluded or underrepresented in the randomised controlled trials of
intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA)
applied within 3 h. Cohort studies comparing intravenous rtPA in stroke
patients of 80 versus <80 years of age were limited by small sample
sizes and yielded conflicting results. The authors of this review (Age
and Ageing 2006 35(6):572-580) performed a systematic review across all
such studies. A systematic literature search (PubMed; Science Citation Index) was
performed to retrieve all eligible studies. Two reviewers independently
extracted data on ‘death’, ‘favourable 3-month outcome (modified Rankin
Scale 1)’ and ‘symptomatic intracranial haemorrhage (sICH)’. Across
studies, weighted odds ratios (ORs) with 95% confidence intervals (95%
CI) were calculated. Six studies were included [n = 2,244 patients; 477 (21%) aged 80 years].
Significant differences in baseline characteristics to the disadvantage
of older patients were present in all studies. Compared with younger
patients, older patients had a 3.09-time higher 3-month mortality and
were less likely to regain a ‘favourable outcome’. The likelihood for
‘sICH’ was similar in both age groups. The article concluded that intravenous rtPA-treated stroke patients of
80 years of age have a less favourable outcome than younger ones.
Imbalances in predictive baseline variables to the disadvantage of the
older patients may contribute to this finding. Compared with the younger
cohort, rtPA-treated stroke patients aged 80 years do not seem
exceedingly prone to sICH. Thus, there is scope for benefit from
thrombolysis for the older age group. Hence, to obtain reliable evidence
on the balance of risk and benefit of intravenous rtPA for stroke
patients aged 80 years, it is safe and reasonable to include such
patients in randomised placebo-controlled trials.
Thrombolytic therapy has
led to a higher proportion of patients presenting to hospital early, and
this, with parallel developments in imaging technology, has greatly
improved the understanding of acute stroke pathophysiology.
Additionally, MRI, including diffusion-weighted imaging (DWI) and
gradient echo, or T2*, imaging is important in understanding basic
structural information—such as distinguishing acute ischaemia from
haemorrhage. It has also greatly increased sensitivity in the diagnosis
of acute cerebral ischaemia. The pathophysiology of the ischaemic
penumbra can now be assessed with CT or MRI-based perfusion imaging
techniques, which are widely available and clinically applicable.
Pathophysiological information from CT or MRI increasingly helps
clinical trial design, may allow targeted therapy in individual
patients, and may extend the time scale for reperfusion therapy (Lancet
Neurology 2006; 5:755-768)
This
article reviews the literature regarding the prevalence, aetiology, and
clinical symptoms of various visual deficits including those that are
age related and those that are a result of neurological damage to the
brain, such as in traumatic brain injury or stroke ( Top Stroke Rehabil.
2006 Summer;13(3):12-21).
It discusses treatment options provided by an occupational therapist,
along with other members of the rehabilitation team, to educate the
patient and family members regarding vision loss, to accommodate for
visual loss, and to optimize independence with activities of daily
living. This article also briefly reviews the literature and discusses
possibilities for individuals who identify computer access and return to
driving as goal areas.
Stroke is the third
leading cause of death and a foremost cause of serious, long-term
disability in the United States. As cardiovascular and metabolic disease
incidence rises with age, older people are more likely to experience
strokes. Age is the single most important risk factor for stroke. For
each successive 10 years after age 55, the stroke rate more than doubles
in both men and women. However, stroke is not an inevitable consequence
of aging. By identifying and modifying risk factors in older people,
nurses can partner with other providers to reduce the incidence,
morbidity, and mortality associated with stroke in older adults. Control
of hypertension, resolution of dyslipidemia, management of diabetes
mellitus, anticoagulation for atrial fibrillation, promotion of exercise
and healthy diet, and cessation of cigarette smoking are of particular
importance in older adults. Recognition of stroke symptoms, access to
emergency evaluation and treatments, and participation in comprehensive
rehabilitation may determine stroke outcomes in aging. This article (J
Cardiovasc Nurs. 2006 Sep-Oct;21(5 Suppl 1):S21-6) presents stroke risk
factors and primary and secondary prevention in the context of aging,
with special considerations in the identification and management of
acute stroke, recovery, and rehabilitation for older adults who survive
stroke.
February 2008
treatable but potentially fatal complications, such as brainstem
compression and obstructive hydrocephalus.
been used but evidence of their benefit is
lacking. The objectives of this review is to determine the persisting
effects of cognitive rehabilitation specifically aimed at spatial neglect
following stroke, as measured on impairment and disability level outcome
assessments and on destination on discharge from hospital (Cochrane Database Syst Rev. 2007 Apr 18).
and mortality. Recently, major changes
have occurred in the way doctors think about and treat this disease.
Previous concepts about the natural history, particularly the risk of
rupture of certain aneurysms, have been challenged.
with recombinant tissue plasminogen activator (rtPA)
applied within 3 h. Cohort studies comparing intravenous rtPA in stroke
patients of 80 versus <80 years of age were limited by small sample
sizes and yielded conflicting results. The authors of this review (Age
and Ageing 2006 35(6):572-580) performed a systematic review across all
such studies.
imaging technology, has greatly
improved the understanding of acute stroke pathophysiology.
Additionally, MRI, including diffusion-weighted imaging (DWI) and
gradient echo, or T2*, imaging is important in understanding basic
structural information—such as distinguishing acute ischaemia from
haemorrhage. It has also greatly increased sensitivity in the diagnosis
of acute cerebral ischaemia. The pathophysiology of the ischaemic
penumbra can now be assessed with CT or MRI-based perfusion imaging
techniques, which are widely available and clinically applicable.
Pathophysiological information from CT or MRI increasingly helps
clinical trial design, may allow targeted therapy in individual
patients, and may extend the time scale for reperfusion therapy (Lancet
Neurology 2006; 5:755-768) 
metabolic disease
incidence rises with age, older people are more likely to experience
strokes. Age is the single most important risk factor for stroke. For
each successive 10 years after age 55, the stroke rate more than doubles
in both men and women. However, stroke is not an inevitable consequence
of aging. By identifying and modifying risk factors in older people,
nurses can partner with other providers to reduce the incidence,
morbidity, and mortality associated with stroke in older adults. Control
of hypertension, resolution of dyslipidemia, management of diabetes
mellitus, anticoagulation for atrial fibrillation, promotion of exercise
and healthy diet, and cessation of cigarette smoking are of particular
importance in older adults. Recognition of stroke symptoms, access to
emergency evaluation and treatments, and participation in comprehensive
rehabilitation may determine stroke outcomes in aging. This article (J
Cardiovasc Nurs. 2006 Sep-Oct;21(5 Suppl 1):S21-6) presents stroke risk
factors and primary and secondary prevention in the context of aging,
with special considerations in the identification and management of
acute stroke, recovery, and rehabilitation for older adults who survive
stroke.