Quality of Life After Intravenous Thrombolysis for Acute Ischemic Stroke: Results From the AcT Randomized Controlled Trial.

BACKGROUND: Recent evidence from thrombolysis trials indicates the noninferiority of intravenous tenecteplase to intravenous alteplase with respect to good functional outcomes in patients with acute stroke. We examined whether the health-related quality of life (HRQOL) of patients with acute stroke differs by the type of thrombolysis treatment received. In addition, we examined the association between the modified Rankin Scale score 0 to 1 and HRQOL and patient-reported return to prebaseline stroke functioning at 90 days. METHODS: Data were from all patients included in the AcT trial (Alteplase Compared to Tenecteplase), a pragmatic, registry-linked randomized trial comparing tenecteplase with alteplase. HRQOL at 90-day post-randomization was assessed using the 5-item EuroQOL questionnaire (EQ5D), which consists of 5 items and a visual analog scale (VAS). EQ5D index values were estimated from the EQ5D items using the time tradeoff approach based on Canadian norms. Tobit regression and quantile regression models were used to evaluate the adjusted effect of tenecteplase versus alteplase treatment on the EQ5D index values and VAS score, respectively. The association between return to prebaseline stroke functioning and the modified Rankin Scale score 0 to 1 and HRQOL was quantified using correlation coefficient (r) with 95% CI. RESULTS: Of 1577 included in the intention-to-treat analysis patients, 1503 (95.3%) had complete data on the EQ5D. Of this, 769 (51.2%) were administered tenecteplase and 717 (47.7%) were female. The mean EQ5D VAS score and EQ5D index values were not significantly higher for those who received intravenous tenecteplase compared with those who received intravenous alteplase (P=0.10). Older age (P<0.01), more severe stroke assessed using the National Institutes of Health Stroke Scale (P<0.01), and longer stroke onset-to-needle time (P=0.004) were associated with lower EQ5D index and VAS scores. There was a strong association (r, 0.85 [95% CI, 0.81-0.89]) between patient-reported return to prebaseline functioning and modified Rankin Scale score 0 to 1 Similarly, there was a moderate association between return to prebaseline functioning and EQ5D index (r, 0.45 [95% CI, 0.40-0.49]) and EQ5D VAS scores (r, 0.42 [95% CI, 0.37-0.46]). CONCLUSIONS: Although there is no differential effect of thrombolysis type on patient-reported global HRQOL and EQ 5D-5L index values in patients with acute stroke, sex- and age-related differences in HRQOL were noted in this study. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249.

Calculation of Prognostic Scores, Using Delayed Imaging, Outperforms Baseline Assessments in Acute Intracerebral Hemorrhage.

Background and Purpose- Patients with intracerebral hemorrhage (ICH) are often subject to rapid deterioration due to hematoma expansion. Current prognostic scores are largely based on the assessment of baseline radiographic characteristics and do not account for subsequent changes. We propose that calculation of prognostic scores using delayed imaging will have better predictive values for long-term mortality compared with baseline assessments. Methods- We analyzed prospectively collected data from the multicenter PREDICT study (Prediction of Hematoma Growth and Outcome in Patients With Intracerebral Hemorrhage Using the CT-Angiography Spot Sign). We calculated the ICH Score, Functional Outcome in Patients With Primary Intracerebral Hemorrhage (FUNC) Score, and modified ICH Score using imaging data at initial presentation and at 24 hours. The primary outcome was mortality at 90 days. We generated receiver operating characteristic curves for all 3 scores, both at baseline and at 24 hours, and assessed predictive accuracy for 90-day mortality with their respective area under the curve. Competing curves were assessed with nonparametric methods. Results- The analysis included 280 patients, with a 90-day mortality rate of 25.4%. All 3 prognostic scores calculated using 24-hour imaging were more predictive of mortality as compared with baseline: the area under the curve was 0.82 at 24 hours (95% CI, 0.76-0.87) compared with 0.78 at baseline (95% CI, 0.72-0.84) for ICH Score, 0.84 at 24 hours (95% CI, 0.79-0.89) compared with 0.76 at baseline (95% CI, 0.70-0.83) for FUNC, and 0.82 at 24 hours (95% CI, 0.76-0.88) compared with 0.74 at baseline (95% CI, 0.67-0.81) for modified ICH Score. Conclusions- Calculation of the ICH Score, FUNC Score, and modified ICH Score using 24-hour imaging demonstrated better prognostic value in predicting 90-day mortality compared with those calculated at presentation.

Do Intracerebral Hemorrhage Nonexpanders Actually Expand Into the Ventricular Space?

BACKGROUND AND PURPOSE: The computed tomographic angiography spot sign as a predictor of hematoma expansion is limited by its modest sensitivity and positive predictive value. It is possible that hematoma expansion in spot-positive patients is missed because of decompression of intracerebral hemorrhage (ICH) into the ventricular space. We hypothesized that revising hematoma expansion definitions to include intraventricular hemorrhage (IVH) expansion will improve the predictive performance of the spot sign. Our objectives were to determine the proportion of ICH nonexpanders who actually have IVH expansion, determine the proportion of false-positive spot signs that have IVH expansion, and compare the known predictive performance of the spot sign to a revised definition incorporating IVH expansion. METHODS: We analyzed patients from the multicenter PREDICT ICH spot sign study. We defined hematoma expansion as ≥6 mL or ≥33% ICH expansion or >2 mL IVH expansion and compared spot sign performance using this revised definition with the conventional 6 mL/33% definition using receiver operating curve analysis. RESULTS: Of 311 patients, 213 did not meet the 6-mL/33% expansion definition (nonexpanders). Only 13 of 213 (6.1%) nonexpanders had ≥2 mL IVH expansion. Of the false-positive spot signs, 4 of 40 (10%) had >2 mL ventricular expansion. The area under the curve for spot sign to predict significant ICH expansion was 0.65 (95% confidence interval, 0.58-0.72), which was no different than when IVH expansion was added to the definition (area under the curve, 0.66; 95% confidence interval, 0.58-0.71). CONCLUSIONS: Although IVH expansion does indeed occur in a minority of ICH nonexpanders, its inclusion into a revised hematoma expansion definition does not alter the predictive performance of the spot sign.

Best practice interprofessional stroke care collaboration and simulation: The student perspective.

Interprofessional practice (IPP) is the accepted standard of care for clients following a stroke. A brief, embedded and evidence-based IPP team simulation was designed to address stroke care knowledge and IPP competencies for students within limited curriculum space. Each team was required to construct a collaborative care plan for their patient during the simulation and submit the care plan for evaluation of best practice stroke care knowledge and implementation with evidence of interprofessional collaboration (IPC). A total of 302 students (274 on-site, 28 by distance technology) representing four professions comprised of 55 teams took part in this experience. Post-simulation, voluntary and anonymous programme evaluations were completed using the standardised interprofessional collaborative competency assessment scale (ICCAS) and open-ended free-text responses to five questions. There was a significant improvement for all pre-post ratings on the ICCAS regardless of profession or previous interprofessional experience. Additionally, the open-ended responses indicated perceived changes to role clarification, communication, and teamwork. The combined interpretation of the programme evaluation results supports interprofessional team simulation as an effective and efficient learning experience for students regardless of previous interprofessional experience, and demonstrated positive changes in stroke best-practice knowledge and IPC competencies.

Dysmetropsia and Cotard's syndrome due to migrainous infarction - or not?

INTRODUCTION: Migrainous infarction accounts for 12.8% of ischemic strokes of unusual etiology. CASE REPORT: A 59-year-old woman with longstanding migraine with aura experienced what appeared to be migrainous infarction characterized by dysmetropsia and transient Cotard's syndrome. Imaging demonstrated right temporal-parietal-occipital changes with apparent cortical laminar necrosis. CONCLUSION: The spectrum of the pathophysiology of migrainous infarction has not been established; however, cortical spreading depression may explain the appearance of imaging findings that do not obey a vascular territory.

Fatigue impact scale demonstrates greater fatigue in younger stroke survivors.

BACKGROUND: Fatigue affects 33-77% of stroke survivors. There is no consensus concerning risk factors for fatigue post-stroke, perhaps reflecting the multifaceted nature of fatigue. We characterized post-stroke fatigue using the Fatigue Impact Scale (FIS), a validated questionnaire capturing physical, cognitive, and psychosocial aspects of fatigue. METHODS: The Stroke Outcomes Study (SOS) prospectively enrolled ischemic stroke patients from 2001-2002. Measures collected included basic demographics, pre-morbid function (Oxford Handicap Scale, OHS), stroke severity (Stroke Severity Scale, SSS), stroke subtype (Oxfordshire Community Stroke Project Classification, OCSP), and discharge function (OHS; Barthel Index, BI). An interview was performed at 12 months evaluating function (BI; Modified Rankin Score, mRS), quality of life (Reintegration into Normal living Scale, RNL), depression (Geriatric Depression Scale, GDS), and fatigue (FIS). RESULTS: We enrolled 522 ischemic stroke patients and 228 (57.6%) survivors completed one-year follow-up. In total, 36.8% endorsed fatigue (59.5% rated one of worst post-stroke symptoms). Linear regression demonstrated younger age was associated with increased fatigue frequency (ß=-0.20;p=0.01), duration (ß=-0.22;p<0.01), and disability (ß=-0.24;p<0.01). Younger patients were more likely to describe fatigue as one of the worst symptoms post-stroke (ß=-0.24;p=0.001). Younger patients experienced greater impact on cognitive (ß=-0.27;p<0.05) and psychosocial (ß=-0.27;p<0.05) function due to fatigue. Fatigue was correlated with depressive symptoms and diminished quality of life. Fatigue occurred without depression as 49.0% of respondents with fatigue as one of their worst symptoms did not have an elevated GDS. CONCLUSIONS: Age was the only consistent predictor of fatigue severity at one year. Younger participants experienced increased cognitive and psychosocial fatigue.

Surviving Long Enough to Die? An Analysis of Incomplete Assessments for Medical Assistance in Dying.

Background: Medical assistance in dying (MAiD) was legalized in Canada on June 17, 2016, yet many who request MAiD do not complete the assessment process and instead experience a natural death. This analysis of patients who made a formal request for MAiD aims to clarify timelines and factors associated with completion of the MAiD assessment process, and factors associated with completion or noncompletion of MAiD once eligible. Materials and Methods: This retrospective cohort study included all patients in Nova Scotia who requested MAiD between January 1, 2018 and December 31, 2018, were deceased at the time of analysis, did not withdraw their request, and were not formally deemed ineligible for the procedure (n = 218). Descriptive statistics, Kaplan-Meier curves, and logistic regression were used in data analysis. Results: Of 218 patients, 48 did not complete the MAiD assessment process. Of the 170 patients who completed the assessment process and were deemed eligible for MAiD, 79.4% (n = 135) completed the procedure. Those with an incomplete assessment had a median survival from request to death of 8.0 days (interquartile range [IQR] = 11.5), whereas for those deemed eligible, median survival from request to determination of MAiD eligibility was also 8.0 days (IQR = 16.0). Interpretation: Proximity to natural death and poor performance status at the time of MAiD request may drive incomplete MAiD assessments. The majority of patients deemed eligible for MAiD complete the procedure, and as such, patients who did not complete the MAiD assessment process may not have experienced their preferred mode of death.

Program of Rehabilitative Exercise and Education to Avert Vascular Events After Non-Disabling Stroke or Transient Ischemic Attack (PREVENT Trial): A Randomized Controlled Trial.

BACKGROUND: Non-disabling stroke (NDS) and transient ischemic attack (TIA) herald the possibility of future, more debilitating vascular events. Evidence is conflicting about potency of exercise and education in reducing risk factors for second stroke. METHODS: Three-site, single-blinded, randomized controlled trial with 184 participants <3 months of NDS or TIA (mean age, 65 years; 66% male) randomized to usual care (UC) or UC + 12-week program of exercise and education (PREVENT). Primary (resting systolic blood pressure) and secondary outcomes (diastolic blood pressure [DBPrest], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], total cholesterol [TC], TC/HDL, triglycerides, fasting glucose, and body mass index) were assessed at baseline, post-intervention, and 6- and 12-month follow-up. Peak oxygen consumption (VO2peak) was measured at baseline, post-intervention, 12-month assessments. RESULTS: Significant between-group differences at post-intervention favored PREVENT group over UC: DBPrest (mean difference [MD]: -3.2 mmHg, 95% confidence interval [CI]: -6.3, -.2, P = .04) and LDL-C (MD: -.31 mmol/L, 95% CI: -.42, -.20, P = .02). Trends of improvement in PREVENT group were noted in several variables between baseline and 6-month follow-up but not sustained at 12-month follow-up. Of note, VO2 peak did not change over time in either group. CONCLUSION: Impact of PREVENT on vascular risk factor reduction was more modest than anticipated, possibly because several outcome variables approximated normative values at baseline and training intensity may have been sub-optimal. Further investigation is warranted to determine when exercise and education programs are viable adjuncts to pharmaceutical management for reduction of risk factors for second stroke.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: #NCT00885456.

A Retrospective Review of Medically Assisted Deaths in Nova Scotia: What Do We Know and Where Should We Go?

Background: Since legalization of medical assistance in dying (MAiD) in Canada on June 17, 2016, there has been limited information regarding how outcomes of those requesting MAiD relates to comorbidity, social circumstances, geographic location, and access to care. This study aims to identify characteristics associated with the completion of MAiD, once requested, with specialist palliative care (SPC) as the primary exposure of interest. Methods: This retrospective cohort study consists of all patients in Nova Scotia who requested MAiD between June 17, 2016 and December 31, 2018 and were deceased at the time of analysis (n = 383). Descriptive statistics and logistic regression were performed. Results: A smaller proportion of patients who completed MAiD were seen in consultation by SPC (69.4% vs. 81.1%, p = 0.01). SPC was associated with decreased odds of completing MAiD (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.36-0.96, p = 0.04), as was cohabitation (OR 0.64, 95% CI 0.41-0.99, p = 0.05) and Charlson comorbidity index >6 (OR 0.64, 95% CI 0.41-0.99, p = 0.05). Interpretation: SPC consultation was associated with significantly reduced likelihood of MAiD completion. Contributing factors may include differences in access to SPC services, those completing MAiD being more likely to decline a consultation with SPC, or the impact of SPC upon patient preferences and access to MAiD. While the interface between SPC and MAiD is in its early stages, our findings are supportive of a more integrated approach to coordination of SPC and MAiD services.

How is the medical assistance in dying (MAID) process carried out in Nova Scotia, Canada? A qualitative process model flowchart study.

OBJECTIVES: The aims of this study are: (1) to create a flowchart process model of how medical assistance in dying (MAID) occurs in Nova Scotia (NS), Canada and (2) to detail how NS healthcare professionals are involved in each stage of MAID. The research questions are: how is the MAID process carried out and which professionals are involved at which points? and which roles and activities do professionals carry out during MAID? DESIGN: Qualitative process model flowchart study with semistructured interviews. SETTING: Primary and secondary care in NS, Canada. PARTICIPANTS: Thirty-two interviewees self-selected to participate (12 physicians, 3 nurse practitioners (NP), 6 nurses, 6 pharmacists and 5 healthcare administrators and advocates). Participants were included if they conduct assessments, provide MAID, fill prescriptions, insert the intravenous lines, organise care and so on. RESULTS: The flowchart process model details five stages of how MAID occurs in NS: (1) starting the MAID process, (2) MAID assessments, (3) MAID preparation (hospital in-patient, hospital outpatient, non-hospital), (4) day of MAID and (5) post-MAID (hospital in-patient and outpatient, non-hospital, after leaving setting). Nineteen points where the process could stop or be delayed were identified. MAID differs slightly by location and multiple professionals from different organisations are involved at different points. Some physicians and NP provide MAID for free as they cannot be reimbursed or find it too difficult to be reimbursed. CONCLUSIONS: Our study adds knowledge about the MAID activities and roles of NS professionals, which are not documented in the international literature. Clinicians and pharmacists spend significant additional time to participate, raising questions about MAID's sustainability and uncompensated costs. The process model flowchart identifies where MAID can stop or be delayed, signalling where resources, training and relationship-building may need to occur. Knowing where potential delays can occur can help clinicians, administrators and policymakers in other jurisdictions improve MAID.

Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack (PREVENT Trial): a multi-centred, randomised controlled trial.

BACKGROUND: Despite lack of outward signs, most individuals after non-disabling stroke (NDS) and transient ischemic attack (TIA) have significant cardiovascular and cerebrovascular disease and are at high risk of a major stroke, hospitalization for other vascular events, or death. Most have multiple modifiable risk factors (e.g., hypertension, physical inactivity, hyperlipidaemia, diabetes, tobacco consumption, psychological stress). In addition, accelerated rates of depression, cognitive decline, and poor quality of sleep have been reported following TIA, which correlate with poor functional outcomes and reduced quality of life. Thus, NSD and TIA are important warning signs that should not be overlooked. The challenge is not unlike that facing other 'silent' conditions - to identify a model of care that is effective in changing people's current behaviors in order to avert further morbidity. METHODS/DESIGN: A single blind, randomized controlled trial will be conducted at two sites to compare the effectiveness of a program of rehabilitative exercise and education versus usual care in modifying vascular risk factors in adults after NDS/TIA. 250 adults within 90 days of being diagnosed with NDS/TIA will be randomly allocated to a 12-week program of exercise and education (PREVENT) or to an outpatient clinic assessment and discussion of secondary prevention recommendations with return clinic visits as indicated (USUAL CARE). Primary outcome measures will include blood pressure, waist circumference, 12-hour fasting lipid profile, and 12-hour fasting glucose/hemoglobin A1c. Secondary measures will include exercise capacity, walking endurance, physical activity, cognitive function, depression, goal attainment and health-related quality of life. Outcome assessment will be conducted at baseline, post-intervention, and 6- and 12-month follow-ups. Direct health care costs incurred over one year by PREVENT versus USUAL CARE participants will also be compared. Ethical approval for the trial has been obtained from the relevant Human Research Ethics Boards. DISCUSSION: Whether timely delivery of an adapted cardiac rehabilitation model is effective in attaining and maintaining vascular risk reduction targets in adults after NDS/TIA is not yet known. We anticipate that the findings of this trial will make a meaningful contribution to the knowledge base regarding secondary stroke prevention.

People With Lived Experience at the Centre of Canadian Stroke Best Practice Recommendations: A Model for Guideline Developers.

Actively engaging people with lived experience (PWLE) in stroke-related clinical practice guideline development has not been effectively implemented. This pilot project evaluated the feasibility, perceived value, and effectiveness of the Community Consultation and Review Panel (CCRP), a new model to engage PWLE in the writing and review of Canadian Stroke Best Practice Recommendations. Responses to a standardized evaluation tool indicated that participants perceived the CCRP as valued, impactful, effective, and beneficial to stroke care. This project successfully demonstrated that values, experiences, and recommendations of PWLE can be effectively incorporated into guideline content and is applicable to all guideline development processes.

Stroke outcome in those over 80: a multicenter cohort study across Canada.

BACKGROUND AND PURPOSE: The prevalence of stroke in elderly patients has been increasing in recent years. However, limited information is available about the burden of stroke in individuals over 80. We sought to evaluate differences in clinical outcomes in Canadians over 80 years old hospitalized for an acute ischemic stroke. METHODS: The authors conducted a multicenter cohort study including all hospital admissions for ischemic stroke identified from the Canadian Hospital Morbidity and Mortality Database from April 2003 to March 2004. The Hospital Morbidity and Mortality Database contains a national database that contains patient-level sociodemographic, diagnostic, procedural, and administrative information from across Canada. Multivariable analysis was performed using logistic regression. The primary outcome was 7-day case fatality and fatality at discharge. Secondary end points included intensive care unit admissions, medical complications, gender differences, length of hospital stay, and discharge disposition. RESULTS: We analyzed 26,676 patients with ischemic stroke admitted to 606 hospitals across Canada. Mean age (SD) was 74+/-13 years. Overall, 10,171 (38%) were aged 80 years or older. Case fatality at discharge was 5.7% (age < 59), 8.6% (age 60 to 69), 13.4% (age 70 to 79), and 24.2% (age > or = 80; P<0.001). Patients aged 80 and over were less likely to be admitted to the intensive care unit (7.7% versus 15.3%; P<0.001) and discharged to their prestroke residence (47.2% for those over 80 versus 61.6% for patients younger than 80; P<0.001). Median length of stay was longer in those over 80 (10 days versus 7 days; P<0.0001). In the multivariable analysis for the older group, admission to the intensive care unit, low socioeconomic status, and admission to a nonacademic institution were associated with increased fatality after adjusting for covariates. CONCLUSIONS: Aging of the population is a growing reality in Western societies and this translates into an increasing demand on healthcare systems. In our study, patients with stroke over 80 had higher risk-adjusted fatality, longer hospitalization, and were less likely to be discharged to their original place of residence. Strategies need to be implemented to facilitate equal access to specialized stroke care for the elderly.

Medication persistence rates and factors associated with persistence in patients following stroke: a cohort study.

BACKGROUND: Medication nonadherence can be as high as 50% and results in suboptimal patient outcomes. Stroke patients in particular can benefit from pharmacotherapy for thrombosis, hypertension, and dyslipidemia but are at high risk for medication nonpersistence. METHODS: Patients who were admitted to the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, with stroke between January 1, 2001 and December 31, 2002 were analyzed. Data collected were pre-stroke function, stroke subtype, stroke severity, patient outcomes, and medication use at discharge, and six and 12 months post discharge. Medication persistence at six and 12 months and the factors associated with nonpersistence at six months were examined using multivariable stepwise logistic regression. RESULTS: At discharge, 420 patients (mean age 68.2 years, 55.7% male) were prescribed an average of 6.4 medications and mean prescription drug cost was $167 monthly. Antihypertensive (91%) and antithrombotic (96%) drug use at discharge were frequent, antilipidemic (73%) and antihyperglycemic (25%) drug use were less common. Self-reported persistence at six and 12 months after stroke was high (> 90%) for all categories. In the multivariable model of medication nonpersistence at six months, people aged 65 to 79 years were less likely to be nonpersistent with antihypertensive medications than people aged 80 years or more (Odds ratio (OR) 0.11, 95% Confidence Interval (CI) 0.03-0.39). Monthly drug costs of < $90 or $90-199.99 were associated with greater nonpersistence, compared to monthly drug costs > or =$200 (OR 6.74, 95% CI 1.32-34.46 for < $90; OR 5.25, 95% CI 1.14-24.25 for $90-199.99). For the antithrombotic drug category, people aged 65 to 79 years were less likely to be nonpersistent than people aged 80 years or more (OR 0.23, 95% CI 0.06-0.81), and people who were disabled before admission were more likely to be nonpersistent than those not disabled (OR 7.01, 95% CI 1.66-29.58). CONCLUSION: Patients reported high medication persistence rates six and 12 months after stroke. Identification of factors associated with nonpersistence (such as older age and prior disability) will help predict which patients are at higher risk for discontinuing their medications.

Diagnostic accuracy of neurological problems in the emergency department.

BACKGROUND: Previous studies describe significant rates of misdiagnosis of stroke, seizure and other neurological problems, but there are few studies examining diagnostic accuracy of all emergency referrals to a neurology service. This information could be useful in focusing the neurological education of physicians who assess and refer patients with neurological complaints in emergency departments. METHODS: All neurological consultations in the emergency department at a tertiary-care teaching hospital were recorded for six months. The initial diagnosis of the requesting physician was recorded for each patient. This was compared to the initial diagnosis of the consulting neurologist and to the final diagnosis, as determined by retrospective chart review. RESULTS: Over a six-month period, 493 neurological consultations were requested. The initial diagnosis of the requesting physician agreed with the final diagnosis in 60.4% (298/493) of cases, and disagreed or was uncertain in 35.7% of cases (19.1% and 16.6% respectively). In 3.9% of cases, the initial diagnosis of both the referring physician and the neurologist disagreed with the final diagnosis. Common misdiagnoses included neurocardiogenic syncope, peripheral vertigo, primary headache and psychogenic syndromes. Often, these were initially diagnosed as stroke or seizure. CONCLUSIONS: Our data indicate that misdiagnosis or diagnostic uncertainty occurred in over one-third of all neurological consultations in the emergency department setting. Benign neurological conditions, such as migraine, syncope and peripheral vertigo are frequently mislabeled as seizure or stroke. Educational strategies that emphasize emergent evaluation of these common conditions could improve diagnostic accuracy, and may result in better patient care.

Antiplatelet therapy for acute ischaemic stroke.

BACKGROUND: In patients with acute ischaemic stroke, platelets become activated. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and reduce the risk of early recurrent ischaemic stroke. This might reduce the risk of early death and improve long-term outcome in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage. OBJECTIVES: To assess the efficacy and safety of antiplatelet therapy in acute ischaemic stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched June 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2007), MEDLINE (June 1998 to May 2007), and EMBASE (June 1998 to May 2007). In 1998, for a previous version of this review, we searched the register of the Antiplatelet Trialists' Collaboration, MedStrategy and contacted relevant drug companies. SELECTION CRITERIA: Randomised trials comparing antiplatelet therapy (started within 14 days of the stroke) with control in patients with definite or presumed ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the inclusion criteria and assessed trial quality, and for the included trials, extracted and cross-checked the data. MAIN RESULTS: Twelve trials involving 43,041 participants were included. Two trials testing aspirin 160 mg to 300 mg once daily started within 48 hours of onset contributed 94% of the data. The maximum follow up was six months. With treatment, there was a significant decrease in death or dependency at the end of follow up (odds ratio 0.95, 95% confidence interval 0.91 to 0.99). For every 1000 patients treated with aspirin, 13 patients will avoid death or dependency (number needed to treat to benefit: 79). Antiplatelet therapy was associated with a small but definite excess of symptomatic intracranial haemorrhages, but this was more than offset by the reduction of recurrent ischaemic strokes and pulmonary embolus. AUTHORS' CONCLUSIONS: Antiplatelet therapy with aspirin 160 mg to 300 mg daily, given orally (or by nasogastric tube or per rectum in patients who cannot swallow), and started within 48 hours of onset of presumed ischaemic stroke reduces the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications and improves long-term outcome.

Clinical diagnosis of lacunar stroke in the first 6 hours after symptom onset: analysis of data from the glycine antagonist in neuroprotection (GAIN) Americas trial.

BACKGROUND AND PURPOSE: Although the pathophysiological heterogeneity of stroke may be highly relevant to the development of acute-phase therapies, discriminating between ischemic stroke subtypes soon after onset remains a challenge. We conducted a study of the accuracy of a clinical diagnosis of lacunar stroke in the first 6 hours after symptom onset. METHODS: We analyzed data from 1367 patients in the Glycine Antagonist In Neuroprotection (GAIN) Americas trial. The Trial of ORG10172 in Acute Stroke Treatment (TOAST) category "small vessel (lacunar)" disease at day 7 or at hospital discharge was used as the reference standard to determine the accuracy of a diagnosis of a lacunar stroke made within 6 hours of symptom onset using the Oxfordshire Community Stroke Project (OCSP) classification "LACS." Outcome was analyzed by comparing the proportions of patients classified as "LACS" at baseline or "small vessel (lacunar)" at 7 days who were dead or dependent at 3 months. RESULTS: The positive predictive value of an OCSP diagnosis of a lacunar stroke was 76% (95% CI: 69% to 81%; sensitivity 64% [95% CI: 58% to 70%]; specificity 96% [95% CI: 95% to 97%]; negative predictive value 93% [95% CI: 92% to 94%]; accuracy 91% [95% CI: 89% to 92%]). The 3-month outcomes of patients classified as either OCSP "LACS" within 6 hours of onset or TOAST "small vessel (lacunar)" at 7 days were not significantly different. CONCLUSIONS: An OCSP LACS diagnosis made within 6 hours of stroke onset is reasonably predictive of a final diagnosis of "small vessel (lacunar)" disease made using TOAST criteria and has a similar relationship to outcome at 3 months.