An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

Despite the global impact and advances in understanding the pathophysiology of cerebrovascular diseases, the term "stroke" is not consistently defined in clinical practice, in clinical research, or in assessments of the public health. The classic definition is mainly clinical and does not account for advances in science and technology. The Stroke Council of the American Heart Association/American Stroke Association convened a writing group to develop an expert consensus document for an updated definition of stroke for the 21st century. Central nervous system infarction is defined as brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury. Central nervous system infarction occurs over a clinical spectrum: Ischemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, while silent infarction by definition causes no known symptoms. Stroke also broadly includes intracerebral hemorrhage and subarachnoid hemorrhage. The updated definition of stroke incorporates clinical and tissue criteria and can be incorporated into practice, research, and assessments of the public health.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

BACKGROUND AND PURPOSE: The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS: Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS: The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS: Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

BACKGROUND: Stroke is a major cause of disability and death. The Brain Attack Coalition has proposed establishment of primary and comprehensive stroke centers to provide appropriate care to stroke patients who require basic and more advanced interventions, respectively. Primary stroke centers have been designated by The Joint Commission since 2003, as well as by various states. The designation of comprehensive stroke centers (CSCs) is now being considered. To assist in this process, we propose a set of metrics and related data that CSCs should track to monitor the quality of care that they provide and to facilitate quality improvement. METHODS AND RESULTS: We analyzed available guideline statements, reviews, and other literature to identify the major features that distinguish CSCs from primary stroke centers, drafted a set of metrics and related data elements to measure the key components of these aspects of stroke care, and then revised these through an iterative process to reach a consensus. We propose a set of metrics and related data elements that cover the major aspects of specialized care for patients with ischemic cerebrovascular disease and nontraumatic subarachnoid and intracerebral hemorrhages at CSCs. CONCLUSIONS: The metrics that we propose are intended to provide a framework for standardized data collection at CSCs to facilitate local quality improvement efforts and to allow for analysis of pooled data from different CSCs that may lead to development of national performance standards for CSCs in the future.

Intracranial angioplasty and stenting: long-term results from a single center.

BACKGROUND AND PURPOSE: Large-vessel intracranial atherosclerotic stenosis carries a proved stroke risk of 8%-22% per year with "best medical therapy." The long-term clinical neurologic and angiographic outcomes of angioplasty and/or stent placement for intracranial atherosclerosis in a consecutive series of patients are presented. METHODS: The demographics, procedural details, procedural outcome, and long-term neurologic follow-up in 60 consecutive patients with 71 lesions, undergoing a total of 84 procedures, were analyzed. RESULTS: Angioplasty alone was performed in 62 procedures; 22 procedures involved stent placement. The periprocedural stroke+death rate was 4.8%. The overall complication-free success rate was 90.5%. Restenosis occurred in 23 lesions at a mean of 4.6 months; 13 were re-treated without complication. There were 4 strokes and 4 non-neurologic deaths during 224 patient-years of follow-up. The annualized stroke rate was 1.8%, and the annualized stroke+all-cause death rate was 3.0%. CONCLUSIONS: The stroke and death rates in this consecutive series of patients with severe intracranial atherosclerotic stenosis treated with optimal endovascular therapy are considerably less than those associated with the natural history of intracranial atherosclerosis treated with maximal medical therapy. Intracranial angioplasty with conditional stent placement is technically feasible and clinically effective with a substantial reduction in long-term stroke and death.

Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition.

BACKGROUND AND PURPOSE: To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease. SUMMARY OF REVIEW: A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors. CONCLUSIONS: There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.

Pharmacologic agents in stroke prevention, acute stroke therapy, and interventional procedures.

Pharmaceutical agents have moved far beyond just the aspirin and heparin that were the mainstays of stroke and interventional therapy as recently as 10 to 15 years ago. Our understanding of the mechanisms of thrombus formation and vascular response to damage as well as our armamentarium has tremendously improved in the past decade. Direct thrombin inhibitors, powerful antiplatelet agents, new fibrinolytic agents, and statins now allow far greater manipulation of the intraprocedural and postprocedural clot cascade and atherogenesis. It is mandatory that current-day interventionists understand the correct and appropriate use of these agents to achieve the desired outcomes of therapy.

Training, competency, and credentialing standards for carotid stenting.

Appropriate and adequate training is the hallmark of modern medical care. The foundation of medical education in the United States is accredited medical schools combined with formal residencies and fellowship training programs. This concept has been officially recognized by the Accreditation Council of Graduate Medical Education, the Federal Licensing Examination, all state medical boards, the federal government, and all medical professions and societies. Appropriate medical education is of utmost importance for procedures and therapies that offer the greatest risk to patients. There is little doubt that any procedure that has "stroke" as a defined potential risk would qualify as one that should require formal, adequate, and officially provided education. Hospitals and accrediting authorities such as the Joint Commission on Accreditation of Healthcare Organizations are obligated to ensure adequate standards of patient care in the United States.

Transcatheter interventions for the treatment of peripheral atherosclerotic lesions: part II.

Transcatheter endovascular procedures are increasingly used to treat symptomatic peripheral atherosclerosis. This second part of a two-part review assesses the existing supportive evidence for the application of recently introduced transcatheter treatments for lesions that cause cerebrovascular ischemia and stroke. Studies were identified via MEDLINE (January 1993 through April 1999) and reference lists of identified articles. When multicenter prospective randomized trials or other high-quality studies were unavailable, studies with at least 50 patients per treated group and a minimum follow-up duration of 6 months were included. For each application, the authors assessed the quality of evidence (efficacy, safety, and, where available, cost-effectiveness) and made recommendations with appropriate caveats. Although recommendations based on proven efficacy and cost-effectiveness cannot be made in general, the use of transcatheter therapies can be supported in specific circumstances based on expected reduction in procedure-related morbidity and/or mortality. It is hoped that the identification of deficiencies in the literature will inform and inspire critically needed research in this area.

Current status of carotid bifurcation angioplasty and stenting based on a consensus of opinion leaders.

OBJECTIVE: Carotid bifurcation angioplasty and stenting (CBAS) has generated controversy and widely divergent opinions about its current therapeutic role. To resolve differences and establish a unified view of CBAS' present role, a consensus conference of 17 experts, world opinion leaders from five countries, was held on November 21, 1999. METHODS: These 17 participants had previously answered 18 key questions on current CBAS issues. At the conference these 18 questions and participants' answers were discussed and in some cases modified to determine points of agreement (consensus), near consensus, (prevailing opinion), or divided opinion (disagreement). RESULTS: Conference discussion added two modified questions, placing a total of 20 key questions before the participants, representing four specialties (interventional radiology, seven; vascular surgery, six; interventional cardiology, three; neurosurgery, one). It is interesting that consensus was reached on the answers to 11 (55%) of 20 of the questions, and near consensus was reached on answers to 6 (30%) of 20 of the questions. Only with the answers to three (15%) of the questions was there persisting controversy. Moreover, both these differences and areas of agreement crossed specialty lines. Consensus Conclusions: CBAS should not currently undergo widespread practice, which should await results of randomized trials. CBAS is currently appropriate treatment for patients at high risk in experienced centers. CBAS is not generally appropriate for patients at low risk. Neurorescue skills should be available if CBAS is performed. When cerebral protection devices are available, they should be used for CBAS. Adequate stents and technology for performing CBAS currently exist. There were divergent opinions regarding the proportions of patients presently acceptable for CBAS treatment (<5% to 100%, mean 44%) and best treated by CBAS (<3% to 100%, mean 34%). These and other consensus conclusions will help physicians in all specialties deal with CBAS in a rational way rather than by being guided by unsubstantiated claims.

Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results.

OBJECT: A retrospective analysis of a 9-year experience with balloon angioplasty for intracranial atherosclerotic stenosis was undertaken with the goals of illustrating development of a safe technique for treatment of intracranial atherosclerotic disease and reporting the immediate results in this series of patients. METHODS: Three distinct periods are defined, based on the technique used. In the early period, in which eight patients were treated, the angioplasty balloon size approximated the vessel size, but was always smaller. Angioplasty was moderately rapid and brief (15-30 seconds). Clinical improvement occurred in seven (87.5%) of eight patients, dissection without consequence occurred in four (50%) of eight, and residual stenosis greater than 50% was found in three (37.5%) of eight. No neurological complications occurred. In the middle period, in which 12 patients were treated, the balloon size approximated the vessel size, but oversizing by up to 0.25 mm was permitted. Angioplasty was extremely rapid and brief. Angiographically visible dissection occurred in nine (75%) of 12 patients, necessitating urokinase infusion in five (41.7%) of 12 and producing abrupt occlusion in one (8.3%) of 12, resulting in death. Occlusion secondary to the recrossing of the lesion occurred in one (8.3%) of 12, resulting in stroke. Good outcome was eventually achieved in 10 (83.3%) of 12. In the current period, in which 50 patients have been treated, the balloon is always undersized and inflation is extremely slow (several minutes). Dissection occurred in seven (14%) of 50 patients, necessitating fibrinolysis in two of 50 (4%, both uneventful) and producing no abrupt occlusion or stroke. Residual stenosis greater than 50% occurred in eight (16%) of 50, with no stenosis greater than 70%. Late restenosis occurred in four (9%) of 44 and successful repeated angioplasty was performed in all four. One guidewire vessel perforation occurred (2%), resulting in the patient's death. Good angiographic and short-term clinical outcome was achieved in the other 49 patients (98%). CONCLUSIONS: Extremely slow balloon inflation combined with balloon undersizing results in decreased intimal damage, decreased acute platelet/thrombus deposition, and decreased acute closure. This technique sometimes yields suboptimal angiographic results but achieves the clinical goal safely. Intracranial angioplasty can be safely performed using this technique and modern equipment.