S. Suravaram

Statins in Ischemic Stroke: Just Low-Density Lipoprotein Lowering or More?

BACKGROUND Statins have been shown to improve the functional outcome of patients after an ischemic stroke. We hypothesized that daily statin intake improves functional outcome after an acute ischemic stroke in patients with low-density lipoprotein (LDL) less than or equal to 100 mg/dL. METHODS This was a prospective cohort study during a 22-month period of patients presenting with an acute ischemic stroke and lipid profiles measured. The functional disability was determined using modified Rankin scale score (0-2 good outcome, 3-6 bad outcome) at discharge. Chi-square test for binary data and nonparametric tests for nonnormally distributed variables were used for analysis. RESULTS Of 508 patients, 207 presented with an LDL of 100 mg/dL or less and were included in the analysis. There was no significant difference in admission stroke severity (National Institutes of Health Stroke Scale [NIHSS]; P = .18), age (P = .31), and sex (P = .06) between those taking statins and not taking statins. Patients with LDL less than or equal to 100 mg/dL and taking statins (n = 100) were significantly more likely to have a good functional outcome (odds ratio 1.91; 95% confidence interval 1.05-3.47) when compared with those not on the medication. After adjusting for age, sex, and NIHSS, statin intake still predicted a better functional outcome (P < .0001). CONCLUSION Daily statin intake appears to result in a better functional outcome after an ischemic stroke in patients with ideal LDL levels (<or=100 mg/dL) before and after adjusting for age and stroke severity. Pleiotropic effects of statins may play a role in this.

An Assessment of the Incremental Value of the ABCD2 Score in the Emergency Department Evaluation of Transient Ischemic Attack

STUDY OBJECTIVE We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack. METHODS This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days. RESULTS The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days. CONCLUSION The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification.

Knowledge of signs, treatment and need for urgent management in patients presenting with an acute ischaemic stroke or transient ischaemic attack: A prospective study

Objective: To assess stroke awareness among patients presenting to the emergency department with an acute ischaemic stroke or transient ischaemic attack (TIA). Methods: A consecutive cohort of patients presenting with a cerebrovascular event was prospectively enrolled over a 15-month period and questionnaires were administered. If the patient was unable to respond to the questions or answer the questionnaire, it was administered to the primary caregiver. Comprehension of having a cerebrovascular event, reason for delay in presentation, mode of arrival and knowledge of treatment modalities were determined. Results: Only 42% of 400 patients thought they were having a stroke or TIA. The median time to presentation was 3.4 h. Delayed presentation was almost equal in men and women. When asked about onset, 19.4% thought that a stroke came on gradually and only 51.9% thought immediate presentation was crucial. 20.8% of patients had heard of thrombolysis. Conclusion: Community knowledge of ischaemic stroke needs to be enhanced so that individuals present earlier, leading to timely management.

Testicular torsion–a common surgical emergency

Testicular torsion, or rotation of the testes with twisting of the spermatic cord, is a common surgical emergency. Incidence follows a bimodal peak, highest around puberty, with a smaller peak in infancy. Differential diagnoses include scrotal edema, epididymitis, hernia, tumor, varicocele, hydrocele and trauma. This condition warrants strong clinical suspicion, early diagnosis and expeditious surgical management. Int J Emerg Med (2008) 1:147 DOI 10.1007/s12245-008-0003-9