Asymmetric oro-facial angioedema following alteplase for acute ischaemic stroke.

We present a patient with asymmetric oro-facial angioedema following thrombolysis for acute ischaemic stroke with serial photographs of this phenomenon. We discuss the mechanism for the development of asymmetric oro-facial oedema following thrombolysis and suggest a management plan.

Not all patients with atrial fibrillation-associated ischemic stroke can be started on anticoagulant therapy.

BACKGROUND AND PURPOSE: Ischemic stroke patients in atrial fibrillation (AF) have a 10% to 20% risk of recurrent stroke. Warfarin reduces this risk by two thirds. However, warfarin is underutilized in this patient group. We performed a prospective study to determine the reasons why warfarin is not started in these patients. METHODS: All patients with AF-associated ischemic stroke over a 12-month period were identified. Demographic and other data, including whether warfarin was commenced or recommended at discharge, and if not why not, were recorded. RESULTS: Ninety-three of 412 (23%) ischemic stroke patients had paroxysmal or permanent AF. Of these patients, 17 (18%) died, 48 (52%) were discharged home, and 28 (30%) were discharged to institutional care. Only 13 of 64 (20%) patients with known AF were taking warfarin at stroke onset. Warfarin was started (or recommended) in 35 of 76 (46%) survivors. Of those not commenced on warfarin, 32 (78%) were dependent (P<0.001) and 23 (56%) were discharged to institutional care (P<0.001). Warfarin was not started because of severe disability and frailty in 13 (32%), risk of falls in 12 (30%), and limited life expectancy in 4 (10%). CONCLUSIONS: In this cohort of patients with AF, warfarin was primarily underutilized before stroke onset, and it was too late to use anticoagulation, in approximately half, once a stroke had occurred. The decision to start or continue anticoagulation requires clinical judgment and should be made on a case by case basis after a complete risk benefit assessment.

Changes in stroke care at Auckland Hospital between 1996 and 2001.

AIMS: In 1996, we performed a descriptive audit of stroke care in Auckland Hospital. Since then, a mobile stroke team has been established. We have repeated the 1996 audit to assess changes in stroke management. METHODS: From 1 June to 30 September 2001, information was prospectively recorded for all patients with stroke. RESULTS: There were 177 strokes in 175 patients (92 men, mean age 70.9, standard deviation [SD] 14.9 years). Ninety-seven percent of patients had cerebral imaging (median 4.5 hours; interquartile range [IQR] 2.7-11.6). Acute aspirin was given to 78% of patients in 2001 and 40% in 1996 (p <0.001). Twenty-four percent of patients were kept 'nil by mouth' for at least 24 hours (46% in 1996, p <0.001). At discharge, 73% of patients were taking antiplatelet or anticoagulant therapy (61% in 1996, p <0.001). Only 50% of the patients with elevated discharge blood pressures were taking antihypertensives. There had been a reduction in the mean length of hospital stay to 16 days (21 days in 1996) but no significant change in mortality (14% compared with 17% in 1996). CONCLUSION: A stroke service may increase the attention to the 'processes' of stroke care and use of therapies, which are shown to be of benefit in randomised controlled trials.