Neuroepidemiology
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BACKGROUND AND RELEVANCE: Intracranial atherosclerosis is responsible for 70,000 ischemic strokes each year in the USA. Noninvasive testing such as transcranial Doppler ultrasound (TCD) and magnetic resonance angiography (MRA) to identify intracranial atherosclerosis is in widespread use, but has not been rigorously validated against the gold standard, catheter angiography. The recently NIH-funded Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial will compare warfarin with aspirin for stroke prevention in patients with intracranial atherosclerosis. WASID requires performance of angiography along with TCD and MRA, providing an opportunity to critically evaluate these noninvasive tests. ⋯ Central readings will be used to validate the cutpoints and to develop measures of negative predictive value, and inter- and intra-observer variability. Sensitivity and specificity will be determined after adjustment for verification bias and employed in receiver-operator characteristic analyses. SONIA will use these techniques to develop TCD and MRA cutpoints that minimize the clinical consequences of test errors occurring in the noninvasive evaluation of patients with suspected intracranial atherosclerosis.
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Racial differences in stroke mortality are widely recognized, but it is unclear whether or not these differences are due mainly to blacks having a greater stroke incidence or higher case fatality rates compared to those of whites. ⋯ Differences between blacks and whites in terms of stroke mortality are more likely due to differences in stroke incidence rather than case fatality. These data imply that greater attention should be given to primary/secondary prevention and that additional research is needed to understand the reasons for these patterns.
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The purpose of the present prospective observational study was to assess whether or not the presence of anticardiolipin antibodies (aCL) in unselected first ischemic stroke patients is associated with adverse outcome. Consecutive patients (n = 300; mean age 64 years; 48% males) presenting with a first acute ischemic stroke were evaluated for IgG aCL and were systematically followed up. During a median follow-up of 21 months, 58 patients (19%) died. ⋯ Rates of malignancy detected during follow-up were higher among patients with aCL >20 GPL (19 vs. 5%, p = 0.007) and >40 GPL (27 vs. 6%, p = 0.01). The excess mortality associated with elevated aCL was eliminated after adjustment for age, cardiovascular risk factors and malignancy. These results demonstrate that aCL above 20-40 GPL among consecutive ischemic stroke patients is a marker of increased mortality during follow-up, but older age and higher rates of cardiovascular risk factors and malignancy detected during follow-up account for the higher mortality.
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Current guidelines emphasize the need for early stroke care. However, significant delays occur during both the prehospital and in-hospital phases of care, making many patients ineligible for stroke therapies. The purpose of this study was to systematically review and summarize the existing scientific literature reporting prehospital and in-hospital stroke delay times in order to assist future delivery of effective interventions to reduce delay time and to raise several key issues which future studies should consider. ⋯ Definitions and methodologies differed across studies, making direct comparisons difficult. This review suggests that the majority of stroke patients are unlikely to arrive at the emergency department and receive a diagnostic evaluation in under 3 h. Further studies of stroke delay and corresponding interventions are needed, with careful attention to definitions and methodologies.
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Since the 1970s, the care of critically ill neurologic and neurosurgical patients has emerged as a developing subspecialty. Management of these patients involves an enormous amount of data generation and analysis. Review of the history of neuroepidemiology and neurocritical care demonstrates the inevitability of their present unwiedly burden of information. ⋯ Several investigators have initiated information management projects including automation of beside clinical documentation, development of systems for remote access to information and patient registries to study the natural history and outcome of specific neurological conditions. These are steps toward the development of integrated systems to aid in patient monitoring, data management, continuous quality improvement and the generation of hypotheses for further clinical investigation. Improvements in information management technology will allow increased efficiency in an era where information generation continues to increase exponentially.