RESUMEN
BACKGROUND AND PURPOSE: Inhospital placement of patients with mild (National Institutes of Health Stroke Scale [NIHSS] score <8) or moderate (NIHSS 8 through 16) acute strokes is variable. We assessed the outcome of such patients based on intensive care unit (ICU) versus general ward placement. METHODS: We reviewed 138 consecutive patients admitted within 24 hours of stroke onset to 2 physically adjacent hospitals with different admitting practices. Outcome measures included complication rates, discharge Rankin scale score, hospital discharge placement, costs, and length of stay (LOS). RESULTS: Hospital A, a 626-bed university-affiliated hospital, admitted 43% of mild and moderate strokes (MMS) to an ICU (26% of mild, 74% of moderate), whereas hospital B, a 618-bed community facility, admitted 18% of MMS to an ICU (3% of mild, 45% of moderate; P<0.004). There were no significant differences in outcomes between the 2 hospitals. Analysis of only patients admitted to hospital A, and of all patients, demonstrated that mild stroke patients admitted to the general ward had fewer complications and more favorable discharge Rankin scale scores than similar patients admitted to an ICU. There was no statistically significant difference in LOS, but total room costs for a patient admitted first to the ICU averaged $15 270 versus $3638 for admission directly to the ward. CONCLUSIONS: While limited by the retrospective nature of our study, routinely admitting acute MMS patients to an ICU provides no cost or outcomes benefits.
Asunto(s)
Unidades de Cuidados Intensivos/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Habitaciones de Pacientes/estadística & datos numéricos , Triaje/estadística & datos numéricos , Distribución por Edad , Anciano , Demografía , Femenino , Hospitales Comunitarios/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos/economía , Unidades de Cuidados Intensivos/normas , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud/economía , Admisión del Paciente/economía , Habitaciones de Pacientes/economía , Habitaciones de Pacientes/normas , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Distribución por Sexo , Triaje/economía , Estados UnidosRESUMEN
Although outcomes from coronary artery bypass grafting (CABG) surgery have improved in general, there has been little or no improvement in the incidence of postoperative stroke or neurologic dysfunction. Several studies have identified factors that increase the CABG patient's risk for developing a stroke and neurologic complications. It is important to identify those patients at increased risk and differentiate among stroke, delirium, and seizures. Post-CABG patients need to be monitored for neurological dysfunction with appropriate assessments. Neurologic complications must be appropriately managed to optimize patient recovery.
Asunto(s)
Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/enfermería , Puente de Arteria Coronaria/efectos adversos , Delirio/etiología , Delirio/enfermería , Convulsiones/etiología , Convulsiones/enfermería , Trastornos Cerebrovasculares/diagnóstico , Delirio/diagnóstico , Diagnóstico Diferencial , Humanos , Incidencia , Examen Neurológico , Evaluación en Enfermería , Cuidados Posoperatorios , Factores de Riesgo , Convulsiones/diagnósticoRESUMEN
BACKGROUND AND PURPOSE: We report the clinical features and longitudinal outcome of the largest cohort of patients with moyamoya disease described from a single institution in the western hemisphere. Moyamoya disease in Asia usually presents with ischemic stroke in children and intracranial hemorrhage in adults. METHODS: Our study population included all patients with moyamoya disease evaluated at a university hospital in Houston, Texas from 1985 through 1995 (n = 35). We used Kaplan-Meier methods to estimate individual and hemispheric stroke risk by treatment status (medical versus surgical). Predictors of neurological outcome were assessed. RESULTS: The ethnic background of our patients was representative of the general population in Texas. The mean age at diagnosis was 32 years (range, 6 to 59 years). Ischemic stroke or transient ischemic attack was the predominant initial symptom in both adults and children. Of the 6 patients with intracranial hemorrhage, 5 had an intraventricular site of hemorrhage. The crude stroke recurrence rate was 10.3% per year in 116 patient-years of follow-up. Twenty patients underwent surgical revascularization, the most common procedure being encephaloduroarteriosynangiosis. The 5-year risk of ipsilateral stroke after synangiosis was 15%, compared with 20% for medical treatment and 22% overall for surgery. CONCLUSIONS: Our observations indicate that moyamoya disease may have a different clinical expression in the United States than in Asia, and may demonstrate a trend toward a lower stroke recurrence rate and better functional outcome after synangiosis.
Asunto(s)
Enfermedad de Moyamoya/fisiopatología , Adolescente , Adulto , Isquemia Encefálica/etiología , Hemorragia Cerebral/etiología , Revascularización Cerebral , Trastornos Cerebrovasculares/etiología , Niño , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Ataque Isquémico Transitorio/etiología , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Enfermedad de Moyamoya/complicaciones , Enfermedad de Moyamoya/cirugía , Recurrencia , Análisis de Supervivencia , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND AND PURPOSE: The feasibility, safety, and efficacy of intravenous tissue plasminogen activator (t-PA) for patients with acute ischemic stroke in clinical practice need to be assessed. METHODS: We initiated a prospective open-label study at a university hospital and two community hospitals in Houston, Tex, immediately after the publication of the National Institute of Neurological Disorders and Stroke (NINDS) t-PA study. A total of 30 patients, age 32 to 90 years, were treated with 0.9 mg/kg of intravenous t-PA (maximum dose, 90 mg) within 3 hours of acute ischemic stroke between December 1995 and December 1996. RESULTS: Six percent (6%) of all patients hospitalized with ischemic stroke received intravenous t-PA at the university hospital and 1.1% at the community hospitals. The rates of total, symptomatic, and fatal intracerebral hemorrhage were 10%, 7%, and 3%. Thirty-seven percent (37%) of patients recovered to fully independent function. The average time from stroke onset to emergency department arrival was 57 minutes; emergency department arrival to computed tomography scan 41 minutes; and computed tomography scan to administration of treatment 59 minutes. CONCLUSIONS: When treatment guidelines are carefully followed in an urban hospital setting, intravenous t-PA for acute ischemic stroke is feasible and shows safety and efficacy comparable to the results of the NINDS study.
Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Activadores Plasminogénicos/uso terapéutico , Activador de Tejido Plasminógeno/uso terapéutico , Actividades Cotidianas , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico por imagen , Causas de Muerte , Hemorragia Cerebral/etiología , Trastornos Cerebrovasculares/diagnóstico por imagen , Trastornos Cerebrovasculares/tratamiento farmacológico , Protocolos Clínicos , Servicio de Urgencia en Hospital , Estudios de Factibilidad , Femenino , Hospitales Urbanos , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Activadores Plasminogénicos/administración & dosificación , Activadores Plasminogénicos/efectos adversos , Vigilancia de Productos Comercializados , Estudios Prospectivos , Seguridad , Factores de Tiempo , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/efectos adversos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: Dissection of the carotid and vertebral arteries is most accurately diagnosed with conventional angiography. MR techniques are sensitive for detecting the abnormalities associated with dissection but may lack specificity. We hypothesized that MR may be useful for serial monitoring of dissection and may therefore guide therapy. METHODS: All patients with angiographically proven carotid and/or vertebral artery dissection from July 1994 to June 1996 were followed for a median duration of 10.5 months. Of these 29 patients (44 vessels), 18 were concurrently evaluated with MR, and a target group of 9 patients (17 vessels) was prospectively followed with MR at 3-month intervals. RESULTS: In the 18 patients with both imaging studies at baseline, angiography revealed 30 dissected vessels while MR detected 27 (90%). In the target group of 9 patients, initial MR identified 15 of the 17 dissections diagnosed with angiography. Serial MR revealed complete healing in 5 vessels, improvement in 6 vessels, no change in 4 vessels, and worsening in 2 vessels. The radiographic features most likely to resolve were stenosis and mural hematoma, while occlusion and luminal irregularity tended to persist. Late ischemic events occurred in 2 patients, both with persistent MR evidence of dissection, one while subtherapeutic on warfarin therapy and the other occurring 1 week after warfarin was discontinued. CONCLUSIONS: MR is a reliable noninvasive method for following the vascular response to treatment and may guide the course of a clinical trial comparing medical therapies for carotid and vertebral artery dissection.
Asunto(s)
Disección Aórtica/diagnóstico , Arterias Carótidas/fisiopatología , Aneurisma Intracraneal/diagnóstico , Angiografía por Resonancia Magnética , Arteria Vertebral/fisiopatología , Cicatrización de Heridas/fisiología , Adolescente , Adulto , Disección Aórtica/fisiopatología , Anticoagulantes/uso terapéutico , Angiografía Cerebral , Niño , Femenino , Humanos , Aneurisma Intracraneal/fisiopatología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Warfarina/uso terapéuticoRESUMEN
Ischemic stroke remains a significant problem in the United States. Complex intracellular metabolic events occur leading to cell death. A search for treatments to prevent this ischemic process continues. Thrombolytic agents, recently developed and tested, may lessen the disabling effects of stroke.
Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Trastornos Cerebrovasculares/tratamiento farmacológico , Fibrinolíticos/uso terapéutico , Activadores Plasminogénicos/uso terapéutico , Proteínas Recombinantes/uso terapéutico , Activador de Tejido Plasminógeno/uso terapéutico , Isquemia Encefálica/complicaciones , Isquemia Encefálica/metabolismo , Trastornos Cerebrovasculares/complicaciones , Trastornos Cerebrovasculares/metabolismo , Personas con Discapacidad , Humanos , Activadores Plasminogénicos/farmacología , Proteínas Recombinantes/farmacología , Activador de Tejido Plasminógeno/farmacología , Resultado del TratamientoRESUMEN
Stroke is a leading cause of death and disability among Americans. The recent US Food and Drug Administration approval of recombinant tissue plasminogen activator (rt-PA, Activase) for the treatment of acute ischemic stroke offers the first proven therapy to reverse or ameliorate stroke symptoms. rt-PA is thought to restore circulation in the patient with acute ischemic stroke by dissolving an occluding thrombus or embolus. A basic understanding of cerebral circulation and the mechanism by which stroke compromises brain tissue is fundamental to appreciating this new therapy. The importance of prompt stroke diagnosis and treatment cannot be underestimated.
Asunto(s)
Trastornos Cerebrovasculares/tratamiento farmacológico , Trastornos Cerebrovasculares/fisiopatología , Activadores Plasminogénicos/uso terapéutico , Proteínas Recombinantes/uso terapéutico , Activador de Tejido Plasminógeno/uso terapéutico , Enfermedad Aguda , Circulación Cerebrovascular/efectos de los fármacos , Trastornos Cerebrovasculares/clasificación , Trastornos Cerebrovasculares/etiología , Humanos , Activadores Plasminogénicos/farmacología , Proteínas Recombinantes/farmacología , Activador de Tejido Plasminógeno/farmacologíaRESUMEN
With the approval of rt-PA therapy for ischemic stroke, stroke care has acutely transitioned from focusing on rehabilitative services to emergency services. This treatment, which must be initiated within the first three hours after the onset of stroke symptoms, requires reorganization of current management approaches. Developing a Code Stroke Team facilitates this process and helps to identify potential thrombolysis candidates. A pathway to deliver rapid care begins with 911 notification and transport, emergency department triage and procedures, and moves through the initiation of thrombolytic therapy. We call this pathway "Code Stroke".
Asunto(s)
Trastornos Cerebrovasculares/diagnóstico , Trastornos Cerebrovasculares/tratamiento farmacológico , Vías Clínicas , Tratamiento de Urgencia/métodos , Grupo de Atención al Paciente/organización & administración , Activadores Plasminogénicos/uso terapéutico , Proteínas Recombinantes/uso terapéutico , Activador de Tejido Plasminógeno/uso terapéutico , Triaje/métodos , Contraindicaciones , Humanos , Selección de Paciente , Factores de TiempoRESUMEN
Treatment with tissue plasminogen activator (rt-PA) for acute stroke requires intensive care of the patient. The risk of thrombolytic therapy and the need for rapid interventions make it clear that the nursing role during this time is crucial. Nurses should be familiar with safe dosage and administration of rt-PA for stroke, which is clearly different than administration of rt-PA for myocardial infarction. Furthermore, thrombolytic stroke treatment must be accompanied by intensive neurological monitoring to observe for complications. Intracerebral hemorrhage is usually accompanied by an acute change in neurological status and vital sign instability. Intensive monitoring of neurologic condition, vital signs, cardiac status and other standard critical care practices must be initiated immediately to optimize patient outcome.
Asunto(s)
Trastornos Cerebrovasculares/tratamiento farmacológico , Trastornos Cerebrovasculares/enfermería , Cuidados Críticos/métodos , Activadores Plasminogénicos/uso terapéutico , Proteínas Recombinantes/uso terapéutico , Activador de Tejido Plasminógeno/uso terapéutico , Algoritmos , Vías Clínicas , Árboles de Decisión , Monitoreo de Drogas/enfermería , Humanos , Examen Neurológico/enfermería , Evaluación en EnfermeríaRESUMEN
In the National Institutes of Neurologic Disorders and Stroke (NINDS) recombinant tissue plasminogen activator (rt-PA) stroke trial, the primary adverse events monitored were intracranial hemorrhage (ICH), systemic bleeding, death and new stroke. Nurses caring for the study patients noted these adverse events and other complications. In addition to what is known about acute ischemic stroke (AIS), the NINDS trial provides further information for optimal care of this specific group of patients. The complications found in this trial require expert nursing care to monitor, prevent and intervene, making clinical decisions relevant to the patients needs. The critical decision-making process must be grounded in knowledge of acute stroke physiology and thrombolysis.
Asunto(s)
Trastornos Cerebrovasculares/tratamiento farmacológico , Trastornos Cerebrovasculares/enfermería , Monitoreo de Drogas/enfermería , Activadores Plasminogénicos/efectos adversos , Proteínas Recombinantes/efectos adversos , Activador de Tejido Plasminógeno/efectos adversos , Enfermedad Aguda , Algoritmos , Vías Clínicas , Humanos , Examen Neurológico/enfermería , Evaluación en EnfermeríaRESUMEN
Patients delay in responding to stroke as an emergency in part because they have deficient information about the disease and treatment. Healthcare providers may also have a lack of information about stroke assessment and management, which could attribute to delays in patient care. In order to provide early, rapid stroke treatment in eligible persons, the public and the healthcare community must be informed. Information on stroke risk, symptoms and treatment should be provided to those likely to experience stroke, the general public and the emergency and medical communities who may witness and intervene when stroke occurs. Programs developed at the eight centers of the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA stroke trial provide a sampling of approaches that increase awareness in these groups. Lessons learned include: 1. Program planning should start with a community needs assessment. 2. A variety of strategies can be applied to meet the community needs and resources. 3. Educational principles and models should be utilized in planning effective programs. 4. The message must be simple: "Stroke is an emergency. Time is brain".
Asunto(s)
Trastornos Cerebrovasculares/diagnóstico , Trastornos Cerebrovasculares/terapia , Tratamiento de Urgencia , Personal de Salud/educación , Educación del Paciente como Asunto/organización & administración , Trastornos Cerebrovasculares/etiología , Conocimientos, Actitudes y Práctica en Salud , Humanos , National Institutes of Health (U.S.) , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Factores de Riesgo , Estados UnidosRESUMEN
BACKGROUND: There are no reports describing patients' perception of having a stroke and then dramatically recovering. SUMMARY OF REPORT: We interviewed 24 patients randomized at our center to intravenous tissue plasminogen activator or placebo in an ongoing multicenter blinded prospective study. These patients demonstrated at least 50% improvement or an absolute improvement of 5 points on the National Institutes of Health Stroke Scale during the first 24 hours after treatment, with 7 patients returning completely to normal. Twelve of 24 of the strokes involved the right middle cerebral artery, 2 of 24 the right posterior cerebral artery, 8 of 24 the left middle cerebral artery, and 2 of 24 the basilar artery territory. CT scans at 24 hours or 1 week showed infarction in 19 of 24. Most patients (19 of 24) could clearly recall the exact circumstances involving the onset of their stroke, but only 12 of 24 were aware of the magnitude of their neurological deficit (7 of 14 right hemisphere and 4 of 8 left hemisphere patients). Only 6 of 24 were aware of their improvement when it occurred (3 of 14 right hemisphere and 2 of 8 left hemisphere patients). Five of 24 remembered positive phenomena such as warmth or tingling during their recovery, and only 2 patients demonstrated euphoria. Most patients seemed peculiarly unaware or blasé about their deficit and improvement. CONCLUSIONS: Most patients with acute stroke are not aware of the severity of their problem, and recovering patients do not remember important events during the next 24 hours. This occurs with either right or left hemisphere lesions and may have a significant impact on early stroke recognition.
Asunto(s)
Trastornos Cerebrovasculares/tratamiento farmacológico , Trastornos Cerebrovasculares/psicología , Activador de Tejido Plasminógeno/uso terapéutico , Concienciación , Arteria Basilar , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/fisiopatología , Arterias Cerebrales , Infarto Cerebral/diagnóstico por imagen , Infarto Cerebral/fisiopatología , Trastornos Cerebrovasculares/diagnóstico por imagen , Trastornos Cerebrovasculares/fisiopatología , Emociones , Estudios de Seguimiento , Humanos , Inyecciones Intravenosas , Recuerdo Mental , Placebos , Estudios Prospectivos , Sensación , Método Simple Ciego , Activador de Tejido Plasminógeno/administración & dosificación , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND AND PURPOSE: This study describes emergency department (ED) management of stroke in Houston, Tex, in 1992 to identify delays and deficiencies in recognition and management of stroke patients in various hospital subtypes and to quantitate the impact of a rapid response stroke team. METHODS: ED logs of eight hospitals were retrospectively screened, and 112 patients with suspected acute stroke onset within 6 hours were identified. EDs were divided into four groups based on hospital size (175 to 979 beds), acuity, number of stroke admissions (50/y to 210/y), and availability of neurological consultations. The intervals from stroke onset to triage, examination by a physician, neurological evaluation, computed tomography (CT) and other tests, vital signs, and treatments were recorded. RESULTS: The average time from stroke to ED arrival was 115 minutes, and times from ED arrival to examination by a physician and CT scan were 28 and 100 minutes, respectively, with little variability among hospital groups except that the public hospital was slower. Neurological examinations were poorly documented in community and public hospitals. The presence of a stroke team shortened the time to examination by a physician and to CT by 13 and 63 minutes, respectively, and increased the number of patients admitted to the intensive care unit. Blood pressure was excessively lowered in 31% of hypertensive patients, and hypotonic dextrose intravenous fluids were given to 69% of all patients. CONCLUSIONS: Transport, initial evaluation, and ED care of acute stroke patients are currently slow and often inexpert in all types of hospitals. A stroke team can speed initial ED management.
Asunto(s)
Trastornos Cerebrovasculares/tratamiento farmacológico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Terapia Trombolítica , Adulto , Anciano , Anciano de 80 o más Años , Trastornos Cerebrovasculares/diagnóstico , Trastornos Cerebrovasculares/diagnóstico por imagen , Cuidados Críticos/estadística & datos numéricos , Servicio de Urgencia en Hospital/organización & administración , Femenino , Tamaño de las Instituciones de Salud , Capacidad de Camas en Hospitales , Humanos , Masculino , Registros Médicos/estadística & datos numéricos , Persona de Mediana Edad , Examen Neurológico/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Grupo de Atención al Paciente , Derivación y Consulta/estadística & datos numéricos , Estudios Retrospectivos , Texas/epidemiología , Factores de Tiempo , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Triaje/estadística & datos numéricosRESUMEN
The author performed a pilot study of nicardipine (NC), a Ca(+)+ channel blocker, to study its dosing, toxicity, and possible efficacy for hemispheric cerebral infarction within 12 hours (mean 6.9 hr) of onset to determine the advisability of proceeding with a multi-centered controlled trial. NC was administered IV (3 to 7 mg/hr) X 72 hours by titrating dose to mean arterial blood pressure (MABP not less than 10% of baseline), then orally X 30 days. Forty-three patients have been entered; mean age 63 (range 34-89), 25 male and 18 female. Only 3 had CT evidence of infarct on entry. Results have shown improvement in a 100-point (pt) graded exam (40 pts at entry, 68 pts at 3 months). Of 20 patients completing 3 months' evaluation, 17 improved and none worsened. Sixteen out of 20 were at home and 8 had minimal or no impairment. Mean Barthel's index was 72. Mean maximal serum NC level was 75 ng/mL. MABP decreased from 103 (entry) to 83 (72 hours). A larger controlled study is warranted to determine the efficacy of NC for acute cerebral infarct.
Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Nicardipino/uso terapéutico , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Presión Sanguínea/efectos de los fármacos , Presión Sanguínea/fisiología , Isquemia Encefálica/mortalidad , Isquemia Encefálica/fisiopatología , Relación Dosis-Respuesta a Droga , Evaluación de Medicamentos , Femenino , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Nicardipino/efectos adversos , Nicardipino/sangre , Proyectos PilotoRESUMEN
We followed 19 men and 19 women with asymptomatic carotid stenosis up to 30 months to determine whether hematologic or lipid abnormalities could identify those individuals developing progressing carotid atherosclerosis (defined as an increase in mean percent stenosis greater than or equal to 19% or an increase in a single region of greater than or equal to 23%) on B-mode carotid ultrasonography performed at 2- to 6-month intervals. Our patients demonstrated increased beta-thromboglobulin, platelet factor 4, and fibrinogen compared with age-matched controls. Eight patients developed progression of carotid stenosis, and this group had higher baseline low-density lipoprotein (LDL) and fibrinogen than the 30 nonprogressing patients. Multiple regression analyses of age, sex, smoking, coronary artery disease, peripheral vascular disease, diabetes, hypertension, and baseline high-density lipoprotein (HDL), HDL2, HDL3, LDL, beta-thromboglobulin, platelet factor 4, and fibrinogen identified coronary artery disease and elevated LDL and fibrinogen as the only independent variables significantly associated with the progressing group. We conclude that, in patients with carotid atherosclerosis, a combination of coronary artery disease and elevated LDL and fibrinogen will predict with 88% accuracy whether the patient will have progressing carotid stenosis.