Stroke; a journal of cerebral circulation
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Multicenter Study Clinical Trial
Guideline compliance improves stroke outcome: a preliminary study in 4 districts in the Italian region of Lombardia.
Guidelines for medical practice in stroke have been proposed in different countries, but their impact on stroke outcome has not been verified to date. The aim of this study was to evaluate the impact of the American Heart Association guidelines for acute stroke and for transient ischemic attack on first-ever stroke patients. ⋯ This study demonstrates an association between adherence to guidelines and stroke outcome, and it can be viewed as a study that prepares the way for a randomized controlled trial in this area. It also emphasizes the need to develop personnel and structures devoted to stroke care because an evidence-based clinical approach could significantly reduce the risk of death.
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The use of recombinant tissue plasminogen activator (rtPA) within 3 hours after onset of an ischemic stroke is an established therapy. Because the use of intravenous rtPA beyond a time window of 3 hours after stroke onset is still a matter of debate, we sought to review the evidence for the use of thrombolytic therapy in a time window up to 6 hours after onset of symptoms of ischemic stroke. ⋯ Consequently, from our point of view it appears unjustified to limit thrombolytic therapy to 3 hours. Because of lack of approvals for 3 to 6 hours, thrombolytic therapy within this time window should be done only as part of an institutional protocol after extensive information is obtained from the patient and the patient's relatives. Better methods for patient selection are required; in particular, newer MRI techniques, such as diffusion- and perfusion-weighted imaging, can play a key role. The aim is to qualify and individualize the time window according to the findings in each patient's imaging results rather than to use a strictly time-defined therapeutic window.
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Comparative Study Clinical Trial
Modified National Institutes of Health Stroke Scale for use in stroke clinical trials: prospective reliability and validity.
To prospectively evaluate the reliability and validity of this previously developed stroke scale in an independently collected cohort. The National Institutes of Health Stroke Scale (NIHSS) has been criticized for its complexity and variability. Prior formal clinimetric analyses were used to obtain a modified version of NIHSS (mNIHSS), which retrospectively demonstrated improved reliability and validity. We sought to prospectively measure the reliability and validity of the mNIHSS. ⋯ This prospective study found high reliability and continued validity by using a previously developed mNIHSS. Items found to have low kappa values were consistent with the previously derived retrospective mNIHSS. The resulting mNIHSS scale has much higher kappa values. The mNIHSS showed improved agreement between examiners and was also easier to administer, having fewer and simpler items. Further prospective evaluation should assess whether the mNIHSS could be used in lieu of the NIHSS.
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Comparative Study Clinical Trial
Early dramatic recovery during intravenous tissue plasminogen activator infusion: clinical pattern and outcome in acute middle cerebral artery stroke.
Acute-stroke patients receiving standard intravenous tissue plasminogen activator (tPA) have been noted to experience early dramatic recoveries. The prevalence, clinical characteristics, and outcome of patients experiencing dramatic recovery is not well described. ⋯ Early dramatic recovery in acute MCA stroke patients treated with intravenous tPA is relatively frequent. The benefit of dramatic recovery is maintained at 24 hours and over the long term. TCD monitoring suggests that dramatic recovery is a result of early restoration of MCA flow during the tPA infusion. The consistent pattern of early clinical recovery may help explain the mechanisms by which thrombolysis improves outcome and could suggest targets for enhancing the therapeutic effect of intravenous tPA.
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Case Reports Clinical Trial
Acute basilar artery occlusion treated with combined intravenous Abciximab and intra-arterial tissue plasminogen activator: report of 3 cases.
Acute vertebrobasilar occlusion remains a disease with a high mortality even after treatment by local intra-arterial fibrinolysis. Adjunctive treatment with platelet glycoprotein IIb/IIIa receptor inhibitors such as abciximab may facilitate recanalization and improve the neurological outcome. Results after treatment of 3 patients by combined intravenous abciximab and local intra-arterial tissue plasminogen activator (tPA) are reported. ⋯ The combination of glycoprotein IIb/IIIa receptor inhibitor with local intra-arterial tPA might be a promising therapy for patients with acute vertebrobasilar occlusion. Further studies are necessary to define the clinical benefit and the bleeding rate of this new pharmacological approach.