[Rational cardiologic diagnosis after cerebral ischemic event]. / Rationelle kardiologische Diagnostik nach zerebralem ischämischen Ereignis.

Stroke continues to be a serious socioeconomic problem in the industrialized countries. The three disease processes responsible for most ischemic cerebrovascular events (CVE) are large-vessel and small-vessel atherothrombotic disease and, in up to 20-30% of cases, cardiac embolism. Data from the literature show that life expectancy after CVE is mainly dependent on the coexistence of cardiac disease. It is the responsibility of the cardiologist to exclude or identify the source of cardiac embolism and to initiate adequate treatment for the prevention of recurrences, as well as to diagnose, and treat any concomitant cardiac disease which may be present. We propose a cost-effective algorithmic approach to help the cardiologist in the diagnosis and treatment of patients with transient ischemic attacks and ischemic stroke.

Treatment of embolic stroke as a medical emergency. Implications in a managed care environment.

Encouraging innovations should be a concern of the providers/gatekeepers of health-care if lower health-care costs are to become a reality. Controlled prices and improper incentives will dramatically slow innovation in American medicine. For the vertically integrated health-care system providing capitated coverage, the aggressive treatment of stroke is a sound financial decision.

Cost-effectiveness of emergency intraarterial intracerebral thrombolysis: a pilot study.

PURPOSE: To assess the clinical efficacy and cost-effectiveness of emergency thrombolysis as a treatment strategy for thromboembolic intracerebral events. METHODS: Thirty-four patients with symptoms suggestive of middle cerebral artery occlusion were included. Eight of these patients were treated with intraarterial urokinase. Effectiveness was determined by comparing the admission National Institutes of Health stroke score to the 24-hour National Institutes of Health stroke score. The cost and length of stay of both populations were derived and used as measures of direct cost. The likelihood of admission to extended care facilities and estimated length cost of admission was used as a measure of indirect cost. RESULTS: The control population became slightly worse, with a change in National Institutes of Health score of -0.5, whereas the treated population improved slightly, with a change in National Institutes of Health score of +5.12. Analysis of the direct costs data between the two populations revealed a slight increased mean for the treated population ($15,202) as compared with the control population ($13,478). The unpaired t test, however, revealed no significant cost difference between the two groups. By reducing the number of completed strokes by one third or by decreasing the severity by the same factor (as shown in our study), the likelihood of admission to an extended nursing facility also is decreased. The cost saving per patient from extended care facilities is approximately $3435. CONCLUSION: The emergency application of intraarterial thrombolysis with urokinase results in a statistically significant positive change in National Institutes of Health score by at least five points. A statistically significant benefit is realized through the use of intraarterial urokinase. A statistically insignificant additional cost is shown by this study. This insignificant cost is more than offset by the saved nursing home costs.