Stroke Update » Stroke

Long term Statin treatment

amer — Fri, 09 Dec 2011 18:53:15 +0000

Practicing evidence based medicine means that you initiate statin treatment for the patients with cardiovascular diseases or TIA/Stroke if the level of the total cholesterol is >3.5 mmol/L. The clinical question arise all the time about the duration of the treatment with statin itself and if there is any side effect of this treatment. We might have the answer today from the trial that was published in The Lancet (The Lancet, 378; 9808:2013-2020).

Assessing the long- term efficacy and safety of Lowering LDL cholesterol, the authors of the Heart Protection Study (HPS) allocated 40 mg once a day simvastatin or placebo for 20 536 patients of vascular and non- vascular outcomes. Major vascular event was the primary outcome measure of the trial. A mean total duration of 11 years was yielded from the post-trial follow-up of surviving patients.

It was reported today that during the in-trial period, allocation to simvastatin yielded a proportional decrease in major vascular events of 23%. The trialists concluded that more prolonged LDL- lowering statin treatment produces larger absolute reductions in vascular events. The benefit of this treatment persists after stopping it for at least 5 years without any evidence of adverse reaction to the simvastatin.

The implications of such trials are significant on prevention strategies of stroke and cardiovascular diseases as hyperlipidemia is one of the established risk factors for cardiovascular diseases and stroke.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61125-2/abstract

How to prevent 1 million strokes in 5 years?

amer — Fri, 23 Sep 2011 06:48:44 +0000

The US Department of Health and Human Services is palnning to prevent 1 millioon heart attacks and strokes by 2017. The focus of the new startegy is on the ( ABCS) or the aspirin, blood pressure, choelsterol and smoking. The epidemiological studies showed that currently only 46% of people in the USA at increased risk of cardiovascular disease are taking aspirin, only 46% of people with hypertension have adequately controlled blood pressure, 33% of people with high cholesterol have adequately controlled hyperlipidaemia, and only 23% of people who are trying to quit smoking get help to do so. The use of the mutidisciplinary team approach and the medical education facilities is part of the new startegy. The Lancet Journal which published the news today ( 23rd September 2011) did not mention the exact cost of the new initiative.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61490-6/fulltext

Strength Training in Stroke patients

amer — Tue, 29 Dec 2009 23:24:48 +0000

Two occupational therapists from University of British Columbia in Vancouver/Canada have performed a meta-analysis of randomized controlledtrials related to the subject of strength training for the arm weakness following a stroke. This type of training is considered in rehabilitation as an important intervention with the potential to improvefunction

Electronic databases were searched from 1950 throughApril 2009. Strength training articles were assessed accordingto outcomes: strength, upper-limb function, and activities ofdaily living.

The reported results which were published recently (Stroke; 2010;41:136) showed that from the 650 trials identified, 13 were includedin the review, totalling 517 individuals. A positive outcomefor strength training was found for grip strength and upper-limb function. No treatmenteffect was found for strength training on measures of activitiesof daily living. A significant effect for strength trainingon upper-limb function was found for studies including subjectswith moderate and mild upper-limb motor impairment. No trials reported adverse effects.

The authors concluded that there is evidence that strength trainingcan improve upper-limb strength and function without increasingtone or pain in individuals with stroke.

Incidence of Stroke in Iran

amer — Tue, 29 Dec 2009 22:57:49 +0000

A team of Physicians from Mashhad university of Medical Science in Iran and from Monash University in Melbourne in Australia has published in January issue of Stroke the first epidemiological study about the incidence of Stroke in Iran (Stroke; 2010;41). The published results are based on the evidences from the Mashhad Stroke Incidence Study or MSIS.

The authors stated that during a 12-month period (2006–2007), theyprospectively ascertained all strokes occurring in a populationof 450 229. Multiple overlapping sources were used to identifypeople with stroke.

The results showed that a total of 624 first-ever strokes occurred duringthe study period, 98.4% undergoing imaging. Despite a relativelylow crude annual incidence rate of first-ever stroke FES per 100 000 residents, rates adjusted tothe European population aged 45 to 84 years were higher thanin most other countries.

The study confirmed that age-specificstroke incidence was higher in younger patients in Mashhad/Iran than is typicallyseen in Western countries. Comparison of age-specific incidencerates between regions revealed that stroke in Mashhad occursapproximately 1 decade earlier than in Western countries.

This useful study concluded that the incidence of stroke in Iran is considerably greaterthan in most Western countries, with stroke occurring at youngerages. Ischaemic stroke incidence was also considerably greaterthan reported in other regions. This conclusion will have a significant implication on prevention strategies of cardiovascular diseases in general and stroke in particular in that part of the world.

Falls following stroke: What are the risk factors?

amer — Wed, 05 Aug 2009 21:32:03 +0000

From Institute of Psychiatry and Neurology in Poland, two authors were aiming to assess the incidence and circumstances of falls among stroke patients in a rehabilitation ward, the frequency of fall-related fractures, the relationship between falls and rehabilitation outcomes, and risk factors for falls.
The results of the study which was a prospective one and published recently (Clinical Rehabilitation 2009 Feb; 23(2):176-88) showed that in total 1155 patients (56% men; mean age 61.5 +/- 14.3 years) admitted to the neurological rehabilitation ward after a stroke. Median time since stroke onset was 36.5 (68) days.
A total of 252 falls were recorded for 189 (16.3%) patients and 45 patients experienced 108 repeated falls. The incidence rate for falls was 7.6/1000 patient-days. Most patients fell while being transferred (33.9%) and while seated (21.5%), and 1.2% of falls resulted in fractures (n = 3). Increased risk of both first and multiple falls was strongly associated with initial Barthel score below 15 and time since stroke onset >/=12 weeks. First falls were significantly associated with visuo-spatial neglect. Repeated falls were related to age greater than 65 years.

The study concluded that patients with severe stroke-related disability in the early period after stroke are prone to falls during rehabilitation. Multiple falls are most frequent in patients over 65 years of age.

Chinese Medicine for stroke patients

amer — Sat, 01 Aug 2009 16:04:58 +0000

There are many centers worldwide practicing Chinese medicine for different diseases. It makes the stroke patient wonders whether this type of medicine is useful for functional recovery post stroke?
This review which was published recently (stroke 2009;40: 2797) by the a team from Tianjin University of Traditional Chinese in china and a team from Italy mentioned that its objective was to evaluate whether complex Traditional Chinese Medicine (cTCM) improves poststroke motor recovery.
The review define the cTCM as it included at least acupuncture and Chinese herbal medicine.
After selection of 11 234 articles, 34 RCTs and quasi-RCTs were included. All these trials were conducted in China and published on Chinese journals. All trials but one reported results in favor of cTCM treatments suggesting a strong publication bias. Because of the significant clinical and methodological heterogeneity, no meta-analysis was performed and thus no cumulative result was obtained pooling data of RCTs.
What appears from this systematic review is that scant data are available to evaluate efficacy of cTCM for poststroke motor dysfunction. Most of the primary studies available for this review were inadequately designed trials characterized by unknown dropout rates and definitional vagueness in outcomes measures. The authors mentioned that the key to lead to evidence-based practices is establishing a consensus on standardized relevant outcome measures and then designing and conducting appropriate Randomised controlled Trials that adopt those standards.

Stroke Care: a practical manual

amer — Sun, 26 Jul 2009 18:01:27 +0000

This is a well written book from Oxford University Press which was published in 2005 in its first edition. In their preface the authors mentioned that the book is written for people who look after stroke patients, in particular, doctors and nurses working in hospitals. In spite of being intended for the physicians, the book is valuable for the public as well. It includes information about stroke and its definition and signs and symptoms with a focus on stroke in young adults. That is consistent with the fact that almost 10% of stroke occur in people under 50 years of age. The other chapters in the book are: what to do in the first few days?, the first two weeks , subarachnoid haemorrhage, neuroimaging in stroke, making difficult decisions, terminal care, rehabilitation, discharge, preventing stroks and other vascular events and outcomes and prognosis. The book might need to be udated in the near future in view of the new evidences and the guidlines in stroke care that were published since 2005.

Graduated compression stockings and risk of venous thrombosis following Stroke: CLOTS TRIAL1

amer — Sat, 18 Jul 2009 20:18:30 +0000

Stroke care teams all over the world were looking with interest to the results of Clots Trial 1. It has been reported in medical literature that graduated compression stockings GCS might help in reducing the risk of the deep venous thrombosis (DVT) and the risk of pulmonary embolism (PE) in surgical patients. This notion led to the hypothesis that this type of stockings might be useful in reducing the risk of DVT and PE in ischaemic stroke patients.
In this outcome-blinded, randomised controlled trial (The lancet 2009;373: 9679; 1958-1965), 2518 patients who were admitted to hospital within 1 week of an acute stroke and who were immobile were enrolled from 64 centres in the UK, Italy, and Australia. Patients were allocated via a central randomisation system to routine care plus thigh-length GCS (n=1256) or to routine care plus avoidance of GCS (n=1262).
A technician who was blinded to treatment allocation undertook compression Doppler ultrasound of both legs at about 7—10 days and, when practical, again at 25—30 days after enrolment. The primary outcome was the occurrence of symptomatic or asymptomatic DVT in the popliteal or femoral veins. Analyses were by intention to treat.
All patients were included in the analyses. The primary outcome occurred in 126 (10•0%) patients allocated to thigh-length GCS and in 133 (10•5%) allocated to avoid GCS, resulting in a non-significant absolute reduction in risk of 0•5%. Skin breaks, ulcers, blisters, and skin necrosis were significantly more common in patients allocated to GCS than in those allocated to avoid their use.
The study concluded that The data from Clots Trial 1 do not lend support to the use of thigh-length GCS in patients admitted to hospital with acute stroke. The time is right now to revise the national guidelines for stroke on the basis of these results.

Ultra-early Doppler Sonography in Acute Ischaemic Stroke

amer — Tue, 14 Jul 2009 21:24:52 +0000

In the hyperacute stage of the cerebrovascular accident, cerebrovascular ultrasound can be used to determine the vascular pathology, but the significance of very early findings on ultrasound is unclear. The present study (Lancet Neurology 2006; 5:835-840) aimed to assess the prognostic value of doppler ultrasonography within the first hours after stroke for functional outcome.
In a prospective multicentre design, patients with clinical signs of ischaemic anterior-circulation stroke were examined by doppler ultrasonography of the intracranial and extracranial arteries. Patients were separated into three groups according to the findings: normal middle-cerebral artery (MCA); branch occlusions; or a main-stem occlusion. The primary endpoint was functional outcome at 3 months.
The study identified 361 patients with moderate to severe clinical deficits (National Institutes of Health Stroke Scale score 5–25). Of these, 121 (34%) had a normal MCA, 176 (48%) had branch occlusions, 7 (2%) had severe MCA stenosis, and 57 (16%) had a main-stem occlusion. 50 of the 57 (88%) patients with main-stem occlusion were dead or dependent 3 months after stroke. An occlusion of the main stem of the MCA within 6 h after stroke was an independent predictor for poor outcome (p=0•0006). 50% of patients with ultrasonographic diagnosis of branch occlusions and 63% with normal MCA had a good outcome. Combination of CT scan without early signs of infarction and a normal MCA resulted in a predictive value of 71% for a good functional outcome.
The study concluded that cerebrovascular ultrasonography provides additional functional prognostic information in the hyperacute stage of ischaemic stroke. The technique is practical in a well-resourced unit, can be used to identify patients with high risk for poor functional outcome, and thus would be an appropriate investigation for future trials.

Strokeupdate at the 8th Welsh Stroke Conference/ June 09

amer — Thu, 25 Jun 2009 19:22:10 +0000

On 19th of June 2009, hundreds of doctors and allied health professionals were gathering in River Front in Newport City in Wales for the 8th Welsh Stroke Conference. Strokeupdate was at the conference and participated in the programme of the meeting.
The conference started with a lecture form Professor Steve Dunnett from Cardiff University. The professor was speaking about his experience with Parkinson’s disease patients and the benefit of stem cells transplantation in cases of stroke. Dr. Michel from Lausanne was speaking about the art of treating acute stroke. He summarised his experience in dealing with prevention and treatment of ischaemic and haemorrhaic stroke patients. The third speaker in the conference was D. Mark Bayley from Toronto, Canada. He presented his views about the translation of stroke rehabilitation evidence into practice. He spoke about the experiences of the Canadian stroke network. Mark mentioned some details about the SCORE project of 2003 and the benefit of integrating the severely stroke patients in the community and the feasibility of this process. He mentioned that it is vital to identify the barriers against implementing the guidelines for care for stroke patients.
Dr. Damaian Jenkinson was speaking about the improving stroke services and the role of clinical networks in UK. The last speaker in the first session of the conference was Professor Jonathan Mant from Cambridge University. He spoke about the subject of the role of primary care in developing stroke services. The afternoon sessions were mainly about stroke rehabilitation and one of the main risk factor for stroke the Hypertension problem and the recent developments in its management. Professor Anthony Ward was speaking in the first parallel session about the use of botulinum toxin in stroke rehabilitation- current evidence. The results of EXITE trial were presented in the conference by Professor Steven Wolf from Emory University in Atlanta.