Cerebrovascular diseases
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Cerebrovascular diseases · Jan 2014
ReviewPrehospital stroke care: limitations of current interventions and focus on new developments.
The global burden of stroke is immense, both in medical and economic terms. With the aging population and the ongoing industrialization of the third world, stroke prevalence is expected to increase and will have a major effect on national health expenditures. Currently, the medical treatment for acute ischemic stroke is limited to intravenous recombinant tissue plasminogen activator (IV r-tPA), but its time dependency leads to low utilization rates in routine clinical practice. Prehospital delay contributes significantly to delayed or missed treatment opportunities in acute stroke. State-of-the-art acute stroke care, starting in the prehospital phase, could thereby reduce the disease burden and its enormous financial costs. ⋯ The first part of this review focuses on current education measures for the general public, the emergency medical services (EMS) dispatchers and paramedics. Although much has been expected of these measures to improve stroke care, no major effects on prehospital delay or missed treatment opportunities have been demonstrated over the years. Most interventional studies showed little or no effect on the onset-to-door time, IV r-tPA utilization rates or outcome, except for prenotification of the receiving hospital by the EMS. No data are currently available on the cost-effectiveness of these commonly used measures. In the second part, we discuss new developments for the improvement of prehospital stroke diagnosis and treatment which could open new perspectives in the nearby future. These include the implementation of prehospital telestroke and the deployment of mobile stroke units. These approaches may improve patient care and could serve as a platform for prehospital clinical trials. Other opportunities include the implementation of noninvasive diagnostics (like transcranial ultrasound and blood-borne biomarkers) and the reevaluation of neuroprotective strategies in the prehospital phase. Key Messages: Timely initiation of treatment can effectively reduce the medical and economic burden of stroke and should begin with optimal prehospital stroke care. For this, prehospital telemedicine is a particularly attractive approach because it is a scalable solution that has the potential to rapidly optimize acute stroke care at limited cost.
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Cerebrovascular diseases · Jan 2014
ReviewTime is Penumbra: imaging, selection and outcome. The Johann jacob wepfer award 2014.
The foundation of modern therapy for ischaemic stroke involves reperfusion of the ischaemic penumbra and salvage of threatened but potentially viable brain tissue. Work on imaging of the penumbra and clinical trials using penumbral evaluation or selection have been a major focus of our collaborative work over several decades. We review the original description of the ischaemic penumbra, its measurement using a variety of imaging techniques, the duration of the penumbra and its potential salvage up to 48 h after stroke onset. ⋯ Major reperfusion times were associated with reduced growth of the ischaemic core and improved clinical outcomes. Our current trial programme involves the application of penumbral imaging to attempt to extend the time window for intravenous tPA and treat wake-up strokes, to test the benefits of endovascular therapy in patients who have already received tPA but still have both substantial penumbra and an occluded vessel, and, finally, to use penumbral imaging to define a responder population in a phase III trial testing intravenous tenecteplase versus tPA within the current 4.5-hour time window. We believe that confirmation of these trial hypotheses will substantiate the role of multimodal imaging of the penumbra as a routine part of acute stroke management.
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Cerebrovascular diseases · Jan 2014
Multicenter StudyThe serum level of brain natriuretic peptide increases in severe subarachnoid hemorrhage thereby reflecting an increase in both cardiac preload and afterload.
The increase of serum brain natriuretic peptide (sBNP) is well known in patients with severe subarachnoid hemorrhage (SAH). However, the pathophysiology between the clinical severity of SAH and the sBNP secretion is still not clear. The aim of this study is thus to clarify the cardiovascular pathophysiological mechanisms of sBNP secretion in severe SAH patients. ⋯ In severe SAH patients, sBNP elevation was significantly associated with the increase of both cardiac preload and afterload. sBNP may be a good severity biomarker in SAH patients, reflecting the systemic impact it makes on cardiovascular preload and afterload.
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Cerebrovascular diseases · Jan 2014
ReviewThrombolysis in acute stroke patients with cerebral small vessel disease.
Thrombolytic treatment is of proven benefit in acute ischemic stroke. The term cerebral small vessel disease (SVD) refers to a group of pathological processes affecting the small arteries, arterioles, venules and capillaries of the brain, and encompasses both ischemic and hemorrhagic lesions. Lacunar stroke, an expression of SVD, is associated with an unfavorable long-term prognosis for an increased risk of death, recurrent stroke and cognitive dysfunction. Nonetheless, the efficacy and safety of intravenous thrombolysis in patients with lacunar stroke has been debated for two main reasons. First, among all ischemic stroke subtypes, lacunar strokes have been considered the most benign. Second, the efficacy of a pharmacological reperfusion has been questioned given the absence of a clear demonstration of thrombosis. Intracerebral hemorrhage (ICH) remains the most devastating and unpredictable complication related to thrombolysis, and neuroimaging evidence of SVD is nowadays recognized as one of the risk factors for thrombolysis-related ICH. ⋯ The studies herein reviewed show that thrombolysis is an effective treatment in acute lacunar stroke, and that the presence of cerebral SVD increases the risk of ICH during thrombolysis but does not represent an absolute exclusion criterion. In the future, it can be assumed that the use of MRI on a routine basis might lead to a better quantitative definition of SVD and its correlates, permitting a step forward in thrombolysis decision making.
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Cerebrovascular diseases · Jan 2014
Functional status three months after the first ischemic stroke is associated with long-term outcome: data from a community-based cohort.
The impact of public health interventions to reduce disability after stroke may be underestimated if only the modest effects on short-term disability are measured. We estimated the impact of differences in short-term functional outcome on long-term functional outcome. ⋯ In patients with ischemic stroke who survive to 3 months, a three grade simplified mRS summarizes the patient risk profile and stroke characteristics. These data confirm that modest differences in the functional status at 3 months are associated with significant differences in survival and functional status over 7 years follow-up and have implications for health care planning and the health economic assessment of treatments for acute stroke.