Panayiotis Mitsias

Factors determining headache at onset of acute ischemic stroke

Headache is a frequent accompaniment of acute ischaemic stroke. The predisposing factors and underlying mechanisms are currently incompletely defined. We analysed prospectively collected data relevant to headache occurring at ischaemic stroke onset in consecutive patients included in the Henry Ford Hospital Stroke Data Bank. Patients with headache (HA+) and without headache (HA–) were compared for demographic factors, medical history, medications, examination findings, laboratory findings, and stroke localization and subtype. Group comparisons for categorical data were performed with χ2 test, and for continuous variables with two-sample t-tests. Stepwise logistic regression analysis, including all variables with P < 0.25, was used to define the independent predictors of onset headache. Three hundred and seventy-five patients had complete headache and clinical datasets and were included in the analysis (HA+, N = 118; HA–, N = 257). Multivariate analysis revealed that the independent predictors of HA+ were: infarct in the distribution of the posterior circulation [P = 0.0076, odds ratio (OR) 2.15, 95% confidence interval (CI) 1.23, 3.77], absence of history of hypertension (P = 0.0106, OR 0.48, 95% CI 0.27, 0.84), and treatment with warfarin at the time of the index stroke (P = 0.0135, OR 4.89, 95% CI 1.39, 17.21). The occurrence of headache at onset of ischaemic stroke is determined by posterior circulation distribution of the ischaemic event, absence of history of hypertension and treatment with warfarin at the time of the index stroke. These results suggest that preserved elasticity and maintenance of the intracranial vasculature in a relaxed state, in combination with coagulation system derangements, and activation of dense perivascular afferent nerves, play a role in the pathogenesis of onset headache.

The Mannheim Declaration of Stroke in Eastern Europe

Accessible online at: www.karger.com/ced Stroke is the most devastating cause of morbidity and mortality in the Eastern European countries. In this region, stroke is more frequent and the victims are younger than in Western Europe. Moreover, the incidence of stroke is significantly higher in social classes with low income, which represents a higher percentage of the Eastern European populations. Stroke is still one of the most important contributors to the mortality gap between East and West. The socioeconomic impact of stroke further weakens the economic development of these societies. The frequency of stroke is partly dependent on modifiable risk factors. In Eastern Europe, relatively more high-risk patients (hypertension + diabetes + smoking) live in worse environmental conditions compared with Western individuals. The positive tendency of decreasing mortality and morbidity could not be seen in the majority of Eastern countries, therefore urgent and efficient steps should be done to improve the situation. To avoid death and permanent disability caused by stroke in Eastern Europe, a specialised action plan has been established. This action plan is based on the Helsingborg Declaration and the 10-Point Action Plan to Tackle Stroke summarised by the European Parliament in June, 2003. The governments of these countries should elaborate a countryspecific programme based on the following elements. 1 Highlight the link between stroke and risk factors to physicians, emergency medical personnel, other health care professionals and the general public by facilitating education programmes. Recognition of symptoms of stroke is the cornerstone of successful stroke management. 2 Health care budgets should be allocated considering stroke prevention and therapy as a priority. 3 In specialised stroke units, widespread application of diagnostic interventions, pharmacological and surgical treatments should be available for all patients with stroke. The prevention and treatment of stroke should be based on the principle of evidence-based medicine. There is a pressing need for further randomised and placebo-controlled trials. 4 Stroke patients should receive an individual, patient-centred rehabilitation treatment carried out by an interdisciplinary team and involving the family. 5 Ensure the timely prevention of stroke by adequately treated modifiable risk factors such as hypertension, diabetes, hyperlipidaemia and atrial fibrillation by helping physicians making their treatment decisions using swiftly adoptable guidelines. 6 Because stroke is an emergency and efficient therapy is possible only in a limited time window, simplify the transport of acute stroke patients from their home to the stroke units and try to shorten the stroke-to-needle time. 7 Persuade people of the importance of changing their lifestyle including smoking, heavy alcohol and calorie intake, lack of physical activity, mental and emotional stress, which are very common, but also modifiable risk factors of stroke in Eastern Europe. 8 Encourage active and establish new patients’ associations. Patient groups play an important role in health policy and are able to coordinate actions to promote better rehabilitation and social support for people with stroke and their families. 9 Set realistic, time-based targets for stroke management and produce population-based monitoring systems covering incidence, prevalence, mortality and disability to provide an Eastern European picture of stroke management. 10 Foundation of an East and West European Stroke Forum to share all information between Western and Eastern European stroke professionals by identifying and disseminating the best practices in stroke prevention and treatment.

Ischemic stroke management in the critical care unit: The first 24 hours

process. Until recently, most patients with acute ischemic stroke were managed in the general wards, with random, nonstandardized monitoring, and similarly random treatment of complications. Admission to a critical care unit was reserved for only the small number of patients with depressed levels of consciousness who were unable to protect their airways or those with significant cardiovascular comorbidity. Nonetheless, it is clear that neurological or medical complications place the life of the acute stroke patient in danger, prolong hospitalization, and delay or prevent rehabilitation. Consequently, we are witnessing a shift toward more standardized intensive neurological monitoring and prompt intervention when neurological deterioration or systemic complications occur. The question of whether full-scale critical care management of stroke patients improves the outcome is still debatable. With todays standards, however, a significant proportion of hospitalized stroke patients, perhaps 10%, will require some form of critical care treatment for various reasons. 2 These include large cerebral hemispheric infarctions, large cerebellar infarctions, acute basilar or vertebral artery occlusions, and stroke associated with systemic complications, such as pulmonary or cardiac dysfunction. In addition, aggressive approaches to acute ischemic stroke, such as intravenous or intraarterial thrombolytic therap~ necessitate monitoring and treatment in an intensive care unit environment.