Tage Strand

A non-intensive stroke unit reduces functional disability and the need for long-term hospitalization.

In a prospective controlled trial we compared the clinical outcome for unselected acute stroke patients in a non-intensive stroke unit (n = 110) and in general medical wards (n = 183). The patients were comparable in age, marital state and functional impairment on admission. Case fatality rates over the first year after the stroke were similar in the two groups. By three months after the stroke, 15% of the survivors initially admitted to the stroke unit and 39% of those admitted to general medical wards remained hospitalized (p less than 0.001). The corresponding figures by one year after the cerebrovascular accident were 12% and 28%, respectively (p less than 0.05). A greater proportion of surviving stroke unit patients was independent in walking (0.10 greater than p greater than 0.05), personal hygiene (p less than 0.05) and dressing (p less than 0.001). Essential features of the stroke unit are team work headed by a stroke nurse, staff, patient and family education and very early onset of rehabilitation. We conclude that this strategy improves functional outcome and reduces the need for long-term hospital care.

Evaluation of long-term outcome and safety after hemodilution therapy in acute ischemic stroke.

Background and Purpose In a previous single-center, randomized controlled trial including 102 patients treated in a stroke unit, we showed that rapid, modest hemodilution improved short-term clinical outcome in ischemic stroke patients. I now evaluate the long-term outcome and potential risks of this combined venesection/dextran 40 therapy in the same 52 treated and 50 control patients. Methods Mortality, need for institutional care, and recurrent strokes were registered during 1 year following inclusion in the trial, and a final evaluation of functional outcome was performed at 12 months after the stroke. Cerebrospinal fluid was analyzed for protein content and hemorrhagic admixture at two occasions during the acute phase. Results Thirty-six hemodiluted and 30 control patients survived the first year following the stroke (difference not significant). One year after the stroke, persistent neurological deficits were less frequent among the hemodiluted patients and a larger proportion of hemodiluted survivors was independent in walking (92% versus 73%, p<0.05). Two hemodiluted patients (6%) and nine control patients (30%) were totally dependent in the activities of daily living (p<0.05). Three hemodiluted patients (8%) and eight control patients (27%) remained hospitalized 1 year after the stroke (p<0.05). With the possible exception of patients with a medical history of congestive heart failure, subset analyses revealed a tendency toward improved outcome for hemodiluted patients in all clinically important subgroups compared with the controls. When analyzing cerebrospinal fluid, signs of blood–brain barrier breakdown and hemorrhagic admixture to the cerebrospinal fluid during the acute phase were less frequent in the hemodiluted subjects. Conclusions These results suggest that, when applied in a stroke unit, the combination of venesection and dextran 40 administration is a clinically safe, therapeutic regimen in the treatment of acute cerebralinfarction that improves long-term clinical outcome.

Release of superoxide dismutase into cerebrospinal fluid as a marker of brain lesion in acute cerebral infarction.

Evaluation of biochemical patterns in cerebrospinal fluid may add diagnostic and prognostic information. We tested to determine whether the concentration of superoxide dismutase in cerebrospinal fluid is a marker of brain tissue damage in acute ischemic stroke. Methods We investigated 36 acute ischemic stroke patients for cerebrospinal fluid activity of the enzyme superoxide dismutase on two occasions shortly after symptom onset (average, day 1 and day 4). Results In 75% of the patients, the first of two lumbar punctures revealed the maximal superoxide dismutase value. The amount in the cerebrospinal fluid was significantly correlated with the size of infarction on computed tomographic scan (p<0.001 by analysis of variance) and to functional impairment and stroke-related mortality during initial hospital stay (p<0.002). The correlation of initial superoxide dismutase concentration with the need for long-term institutional care and mortality at 3 months after the stroke was also significant (p<0.03). Conclusions We conclude that superoxide dismutase in cerebrospinal fluid is a marker of an acute brain lesion and has some value as a prognostic predictor. This small enzyme leaks rapidly from ischemically injured cells.

CLINICAL PROFILES OF CEREBROVASCULAR DISORDERS IN A POPULATION-BASED PATIENT SAMPLE

Clinical features of different types of stroke were investigated in a sample of 409 patients representative of all cases admitted for acute stroke, except subarachnoidal hemorrhages, within a well defined population. A specific cerebrovascular diagnosis was obtained by detailed clinical investigation, including CT scan. In people greater than 50 years old, men/women risk for stroke was estimated to be 1.40:1. The risk was higher in men up to the age of 80; above this age similar risk for the two genders was observed. Eleven per cent had intracerebral hemorrhage, 13% TIA, 51% non-embolic and 25% embolic brain infarction. In all diagnostic categories there were similar proportions of patients who had a history of hypertension and previous stroke, neither did hemoglobin and hematocrit levels differ between the different stroke disorders. TIA preceded intracerebral hemorrhage in 11% and brain infarction in 15-20%. As opposed to patients with ischemic lesions, subjects with intracerebral hemorrhage had higher systolic blood pressure levels and more severe symptoms on admission to hospital. Ischemic stroke was associated with male predominance, different ischemic manifestations of heart diseases and diabetes.

Anticoagulant treatment at a specialized outpatient anticoagulant therapy unit, a descriptive study

BackgroundThe indications for continuous oral anticoagulant treatment, the target interval and the procedures for withdrawing treatment have changed in the last 10 years.MethodsPatients on continuous oral anticoagulant treatment at the Outpatient Anticoagulant Clinic at Umeå University Hospital in 2002 were included in a descriptive study (n = 900). 263 of those had a mechanical heart valve prosthesis. Only patient records for patients with other indications than mechanical heart valve prosthesis were examined. 582 of those records were found. In the 55 remaining patients some clinical information was retrieved from the computerised warfarin dosage database. These latter, more unsure clinical data, are presented separately. Anticoagulant treatment was discontinued if lack of proper indication or presence of too high risk for hemorrhagic complications were found.ResultsThe prevalence of continuous oral anticoagulant treatment in the uptake area was 0.65%. The most common target interval was INR 2.1–3.0, but patients with a mechanical heart valve prosthesis were often treated more aggressively, i.e. with a higher INR target interval. Of the patients on continuous treatment, 26.6% of the INR values were outside 2.0–3.0. The most common reasons for oral anticoagulant treatment were atrial fibrillation or mechanical heart valve prosthesis, in contrast to earlier findings in studies of our population in 1987 and 1990. We found 90 patients (10.0%) without proper indication for oral anticoagulant treatment or too high risk, and their treatment was discontinued.ConclusionIn patients on oral anticoagulant therapy, re-evaluation of indications and risks resulted in a substantial number of treatment withdrawals. There have been major changes in treatment indications during the last decade, possibly due to rapid development of knowledge in the field of thrombosis risk factors. Treatment should be re-considered once a year.