Stroke; a journal of cerebral circulation
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Multicenter Study
Agreement on disease-specific criteria for do-not-resuscitate orders in acute stroke. Members of the Canadian and Western New York Stroke Consortiums.
The do-not-resuscitate (DNR) order is a mechanism of withholding cardiopulmonary resuscitation (CPR). The lack of DNR guidelines specific for acute stroke may result in many stroke patients receiving unnecessary and futile resuscitation and ventilator-assisted breathing. ⋯ Disease-specific criteria for DNR orders were developed to supplement general DNR policies for patients with hemispheric brain infarction and intracerebral hemorrhage during the first 2 weeks of stroke. A significant agreement was reached by a panel of physicians that patients with acute stroke should not be resuscitated if these disease-specific criteria are met.
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Multicenter Study Clinical Trial
Current emergency department management of stroke in Houston, Texas.
This study describes emergency department (ED) management of stroke in Houston, Tex, in 1992 to identify delays and deficiencies in recognition and management of stroke patients in various hospital subtypes and to quantitate the impact of a rapid response stroke team. ⋯ Transport, initial evaluation, and ED care of acute stroke patients are currently slow and often inexpert in all types of hospitals. A stroke team can speed initial ED management.
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Multicenter Study Clinical Trial
Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms.
Randomized clinical trials have shown that carotid endarterectomy decreases the risk of subsequent stroke in patients with high-grade carotid stenosis and ipsilateral transient ischemic attack or minor stroke. The benefit of surgery is highly dependent on surgical risk. We previously found that patients with ipsilateral hemispheric symptoms were at greater risk of carotid endarterectomy complications compared with those who were asymptomatic or had nonipsilateral symptoms. The goals of the present study were (1) to identify preoperative clinical factors that may increase the risk of complications after carotid endarterectomy in patients with ipsilateral hemispheric symptoms and (2) to develop a risk index based on this patient-level data. ⋯ Certain preoperative clinical variables may place patients with ipsilateral symptoms at greater risk of perioperative complications after carotid endarterectomy. Prospective validation of a simple risk index would provide an additional method for assessing preoperative risk in endarterectomy candidates.
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Randomized Controlled Trial Multicenter Study Clinical Trial
Pilot randomized trial of tissue plasminogen activator in acute ischemic stroke. The TPA Bridging Study Group.
Early thrombolytic therapy with recombinant tissue-type plasminogen activator is a theoretically attractive approach to the treatment of acute focal cerebral ischemia. In preparation for a larger multicenter trial, three centers piloted a protocol for a randomized, double-blind, placebo-controlled trial of intravenous recombinant tissue-type plasminogen activator begun within 3 hours of the onset of symptoms of acute stroke to test its feasibility and to explore trends. ⋯ A randomized, double-blind, placebo-controlled trial of recombinant tissue-type plasminogen activator very early in acute stroke is feasible. Preliminary observations suggest that recombinant tissue-type plasminogen activator treatment within 90 minutes may be associated with early neurological improvement. Larger studies are needed so that the potentially serious short-term risks of this treatment can be assessed in relation to meaningful long-term benefit.
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We reviewed 212 consecutive episodes of infective endocarditis in 203 patients at six hospitals between 1978 and 1986 and found that 21% were complicated by stroke. Of 133 episodes involving native mitral and/or aortic valves, brain ischemia occurred in 19%, brain hemorrhage in 7%, and non-central nervous system emboli in 11%; vegetations were identified in 56% of 113 adequate echocardiograms and did not correlate with risk of embolism. In native-valve endocarditis, most (74%) ischemic strokes had occurred by the time of presentation and an additional 13% occurred less than or equal to 48 hours after diagnosis; the incidence of brain ischemia was 13% on presentation, 3% during the first 48 hours of hospitalization, and 2%-5% during the remainder of the acute course. ⋯ Only 9% of ischemic infarcts were large (all in patients with Staphylococcus aureus infection), while 8% were small and subcortical. Brain hemorrhage occurred primarily at the time of presentation, particularly in intravenous drug abusers, and was associated with uncontrolled S. aureus infection with pyogenic arteritis. Ischemic and hemorrhagic stroke continue to be frequent and important in patients with infective endocarditis and are clustered during uncontrolled infection.(ABSTRACT TRUNCATED AT 250 WORDS)