Estimación de la prevalencia de riesgo de síndrome de apneas obstructivas del sueño en funcionarios de una Institución de Salud según el cuestionario STOP-Bang / Estimation of the prevalence of risk of obstructive sleep apnea syndrome in workers of a health institution according to the stop-bang questionnaire

INTRODUCCIÓN: En Chile, se estima que 8,5% de los adultos tiene riesgo elevado de síndrome de apnea e hipopnea obstructiva del sueño (SAHOS). OBJETIVO: Estimar el riesgo de SAHOS en funcionarios de la salud. MATERIAL Y MÉTODO: Se consignaron los datos clínicos, antropométricos, presión arterial, cuestionarios STOP-Bang (CSB), índice de Flemons y escalas de Epworth y de Thornton en trabajadores de Clínica Dávila, Santiago, Chile. RESULTADOS: Se evaluaron 1.332 funcionarios, 77,1% mujeres, circunferencia de cuello: 35,7 ± 3,7 cm (26-54), circunferencia de cintura: 89,3 ± 3,7 cm, e índice de masa corporal: 27,5 ± 4,5 (17,5-49,4) kg/m2; 42% tenía sobrepeso y 26% obesidad. El Cuestionario SB los clasificó en tres categorías: Riesgo alto (RA): 43 funcionarios (3,2%), 50 ± 10,5 años; riesgo moderado: 215 (16,1%), 45,6 ± 11,4 años y riesgo bajo: 1.074 (80,6%), 36,2 ± 10,6 años. En hombres, la edad y los puntajes de los cuestionarios de sueño fueron diferentes en las tres categorías de riesgo (p = 0,003 y 0,001). En mujeres, los puntajes de los cuestionarios fueron distintos en los tres grupos de riesgo, no hubo diferencias en la escala de Epworth (p = 0,274), ni en la edad (p = 0,08). La escala Mallampati no permitió predecir el riesgo de SAHOS en ambos sexos. CONCLUSIONES: El cuestionario SB identificó a 9,8% de los hombres con riesgo alto de SAHOS. En los hombres, la edad, cuestionario SB, Flemons, Epworth y Thornton, fueron diferentes en las tres categorías de riesgo de SAHOS. En las mujeres, la edad y escala de Epworth fueron similares en las tres categorías de riesgo.

INTRODUCTION: In Chile, it is estimated that 8.5% of adults are at high risk of Obstructive Sleep Apnea (OSA). OBJECTIVE: To estimate the risk of OSA in health workers. MATERIAL AND METHOD: clinical and anthropometric data, blood pressure, STOP-Bang (CSB) questionnaires, Flemons index and Epworth and Thornton scales were assessed in workers from Clínica Dávila, Santiago, Chile. RESULTS: 1,332 workers were evaluated, 77.1% women, neck circumference: 35.7 ± 3.7 cm (26-54), waist circumference: 89.3 ± 3.7 cm, and body mass index: 27.5 ± 4.5 (17.5-49.4) kg/m2; 42% were overweight and 26% obese. The SB Questionnaire classified them into three risk categories: High risk (HR): 43 workers (3.2%), 50 ± 10.5 years-old; moderate risk: 215 (16.1%), 45.6 ± 11.4 years-old and low risk: 1,074 (80.6%), 36.2 ± 10.6 years-old. In men, age and sleep questionnaire scores were different in the three risk categories (p = 0.003 and 0.001). In women, the sleep questionnaire scores were different in the three risk groups, there were no differences in the Epworth scale (p = 0.274), nor in age (p = 0.08). The Mallampati scale did not allow predict OSA risk in both sexes. CONCLUSIONS: The SB questionnaire identified 9.8% of the men with high risk of OSA. In men, age, SB questionnaire, Flemons index, Epworth and Thornton scale, were different in the three OSA risk categories. In women, the age and Epworth scale were similar in the different risk categories.

Spontaneous limb movements and posturing secondary to acute basilar artery occlusion: a potentially devastating seizure mimic.

Basilar artery occlusion is a devastating but treatable form of ischaemic stroke with high morbidity and mortality rates. The diagnosis is often challenging due to considerable heterogeneity of clinical signs and symptoms. We report a case of an acute basilar artery occlusion presenting with decreased level of consciousness associated with rhythmic tonic movements of the four extremities, mimicking seizure activity. The patient was treated with intravenous thrombolysis and subsequently gained good recovery. Awareness of this entity is required to recognise this potentially treatable, but otherwise devastating seizure mimic.

Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial.

BACKGROUND: Lowering of blood pressure prevents stroke but optimum target levels to prevent recurrent stroke are unknown. We investigated the effects of different blood-pressure targets on the rate of recurrent stroke in patients with recent lacunar stroke. METHODS: In this randomised open-label trial, eligible patients lived in North America, Latin America, and Spain and had recent, MRI-defined symptomatic lacunar infarctions. Patients were recruited between March, 2003, and April, 2011, and randomly assigned, according to a two-by-two multifactorial design, to a systolic-blood-pressure target of 130-149 mm Hg or less than 130 mm Hg. The primary endpoint was reduction in all stroke (including ischaemic strokes and intracranial haemorrhages). Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT 00059306. FINDINGS: 3020 enrolled patients, 1519 in the higher-target group and 1501 in the lower-target group, were followed up for a mean of 3·7 (SD 2·0) years. Mean age was 63 (SD 11) years. After 1 year, mean systolic blood pressure was 138 mm Hg (95% CI 137-139) in the higher-target group and 127 mm Hg (95% CI 126-128) in the lower-target group. Non-significant rate reductions were seen for all stroke (hazard ratio 0·81, 95% CI 0·64-1·03, p=0·08), disabling or fatal stroke (0·81, 0·53-1·23, p=0·32), and the composite outcome of myocardial infarction or vascular death (0·84, 0·68-1·04, p=0·32) with the lower target. The rate of intracerebral haemorrhage was reduced significantly (0·37, 0·15-0·95, p=0·03). Treatment-related serious adverse events were infrequent. INTERPRETATION: Although the reduction in stroke was not significant, our results support that in patients with recent lacunar stroke, the use of a systolic-blood-pressure target of less than 130 mm Hg is likely to be beneficial. FUNDING: National Institutes of Health-National Institute of Neurological Disorders and Stroke (NIH-NINDS).

Cerebral microbleeds: histopathological correlation of neuroimaging.

BACKGROUND: In recent years, there has been a growing interest in cerebral microbleeds (CMBs) and their role in cerebrovascular disease. A few studies have investigated the histopathological correlation between CMBs and neuroimaging findings. We conducted a systematic review in an attempt to characterize the pathological and radiological correlation. METHODS: A systematic literature search was conducted for studies in which CMBs were characterized histopathologically and correlated with MRI findings. RESULTS: Five studies met the inclusion criteria, with a total of 18 patients. Hemosiderin deposition was reported in 42 CMBs (49%), while 16 CMBs (19%) were described as old hematomas which stained for iron, 13 (15%) had no associated specific pathology, 11 (13%) contained intact erythrocytes, 1 (1%) was due to vascular pseudocalcification, 1 (1%) was a microaneurysm and 1 (1%) was a distended dissected vessel. Lipofibrohyalinosis was the most prominent associated vascular finding. Amyloid angiopathy was present primarily in patients with dementia. CONCLUSIONS: Although histopathological associations have been observed using MRI in patients with CMBs, the findings have yet to be validated and further research is warranted.

The Levels of Inflammatory Markers in the Treatment of Stroke study (LIMITS): inflammatory biomarkers as risk predictors after lacunar stroke.

BACKGROUND: Inflammation is increasingly recognised as playing a central role in atherosclerosis, and peripheral blood markers of inflammation have been associated with incident and recurrent cardiac events. The relationship of these potentially modifiable risk markers to prognosis after ischaemic stroke is less clear. The Levels of Inflammatory Markers in the Treatment of Stroke (LIMITS) study will address hypotheses related to the role of inflammatory markers in secondary stroke prevention in an efficient manner using the well-established framework of the Secondary Prevention of Small Subcortical Strokes (SPS3) trial (NCT00059306). METHODS: SPS3 is an ongoing Phase III multicentre secondary prevention trial focused on preventing recurrent stroke in patients with small vessel ischaemic stroke, or lacunes. In SPS3, patients are assigned in a factorial design to aspirin vs. aspirin plus clopidogrel, and to usual vs. aggressive blood pressure targets. The purpose of LIMITS is to determine whether serum levels of inflammatory markers - including high-sensitivity C-reactive protein, serum amyloid A, CD40 ligand, and monocyte chemoattractant protein-1 - predict recurrent stroke and other vascular events among lacunar stroke patients. The project will also determine whether these markers predict which people will respond best to dual antiplatelet therapy with clopidogrel and aspirin, as well the relationship to cognitive function. ANALYSIS: plan Multivariable Cox proportional hazard regression modeling will be used to estimate hazard ratios for the effect of marker levels on risk of recurrent stroke and other outcomes after adjusting for additional potential risk factors, including age, gender, ethnicity, treatment arm, and traditional stroke risk factors. Interactions between marker levels and treatment assignment for both arms of the SPS3 study will be assessed. Observations will be censored at the time of last follow-up visit. CONCLUSIONS: LIMITS represents an efficient approach to the identification of novel inflammatory biomarkers for use in risk prediction and treatment selection in patients with small vessel disease.

Carotid endarterectomy--an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

OBJECTIVE: To assess the efficacy of carotid endarterectomy for stroke prevention in asymptomatic and symptomatic patients with internal carotid artery stenosis. Additional clinical scenarios, such as use of endarterectomy combined with cardiac surgery, are also reviewed. METHODS: The authors selected nine important clinical questions. A systematic search was performed for articles from 1990 (the year of the last statement) until 2001. Additional articles from 2002 through 2004 were included using prespecified criteria. Two reviewers also screened for other relevant articles from 2002 to 2004. Case reports, review articles, technical studies, and single surgeon case series were excluded. RESULTS: For several questions, high quality randomized clinical trials had been completed. Carotid endarterectomy reduces the stroke risk compared to medical therapy alone for patients with 70 to 99% symptomatic stenosis (16% absolute risk reduction at 5 years). There is a smaller benefit for patients with 50 to 69% symptomatic stenosis (absolute risk reduction 4.6% at 5 years). There is a small benefit for asymptomatic patients with 60 to 99% stenosis if the perioperative complication rate is low. Aspirin in a dose of 81 to 325 mg per day is preferred vs higher doses (650 to 1,300 mg per day) in patients undergoing endarterectomy. CONCLUSIONS: Evidence supports carotid endarterectomy for severe (70 to 99%) symptomatic stenosis (Level A). Endarterectomy is moderately useful for symptomatic patients with 50 to 69% stenosis (Level B) and not indicated for symptomatic patients with <50% stenosis (Level A). For asymptomatic patients with 60 to 99% stenosis, the benefit/risk ratio is smaller compared to symptomatic patients and individual decisions must be made. Endarterectomy can reduce the future stroke rate if the perioperative stroke/death rate is kept low (<3%) (Level A). Low dose aspirin (81 to 325 mg) is preferred for patients before and after carotid endarterectomy to reduce the rate of stroke, myocardial infarction, and death (Level A).

[Stroke of unusual origin]. / Ictus de origen poco habitual.

INTRODUCTION: Stroke of unusual origin is a heterogeneous syndrome with a number of different aetiologies. Most patients who are affected are young adults and it is often the first manifestation of a systemic disease. DEVELOPMENT: This type of stroke accounts for less than 10% of all ischemic strokes. Among its multiple aetiologies, cardioembolic and haematological diseases with a tendency toward hypocoagulability and dissections of the cervico encephalic arteries are the most common. The prognosis depends on the underlying aetiology but generally speaking this kind of stroke has a better prognosis than that of other types. CONCLUSIONS: Stroke of unusual origin is relatively rare, but nevertheless it deserves special attention since it affects young people above all, although its prognosis and treatment vary according to the aetiology. Exhaustive research needs to be conducted on these patients to establish the aetiological diagnosis and an early treatment

Ictus de origen poco habitual / Stroke of unusual origin

Introducción. El ictus de origen poco habitual es un síndrome heterogéneo con múltiples etiologías. La mayoría de los pacientes afectados son adultos jóvenes, y con frecuencia es la primera manifestación de una enfermedad sistémica. Desarrollo. Este tipo de ictus representa menos del 10 per cent de los ictus isquémicos. Dentro de las múltiples etiologías, las enfermedades cardioembólicas, hematológicas con tendencia a la hipercoagulabilidad y las disecciones de arterias cervicocefálicas son las más comunes. El pronóstico depende de la etiología subyacente, pero en general este tipo de ictus tiene un mejor pronóstico que el de otras clases. Conclusiones. El ictus de origen poco habitual es relativamente poco común, sin embargo, merece especial atención ya que afecta sobre todo a los jóvenes, si bien su pronóstico y tratamiento varían de acuerdo a la etiología. Es necesario investigar exhaustivamente a estos pacientes para establecer el diagnóstico etiológico y el tratamiento precoz (AU)

Prognosis after transient monocular blindness associated with carotid-artery stenosis.

BACKGROUND: Transient monocular blindness associated with internal-carotid-artery stenosis is a risk factor for stroke. The effect of carotid endarterectomy in patients who present with transient monocular blindness has not been determined. METHODS: We compared the risk of stroke among patients presenting with transient monocular blindness with the risk among patients presenting with hemispheric transient ischemic attack. The effect of endarterectomy was assessed in patients with transient monocular blindness. The analyses were based on data from the North American Symptomatic Carotid Endarterectomy Trial. RESULTS: A total of 198 medically treated patients with transient monocular blindness had a three-year risk of ipsilateral stroke that was approximately half of that among 417 medically treated patients with hemispheric transient ischemic attack (adjusted hazard ratio, 0.53; 95 percent confidence interval, 0.30 to 0.94). Six factors were associated with a higher risk of stroke in patients with monocular blindness--an age of 75 years or more, male sex, a history of hemispheric transient ischemic attack or stroke, a history of intermittent claudication, stenosis of 80 to 94 percent of the luminal diameter, and the absence of collateral circulation. The three-year risk of stroke with medical treatment for patients with zero or one risk factor was 1.8 percent, with two risk factors 12.3 percent, and with three or more risk factors 24.2 percent (P=0.003). The three-year absolute reduction in the risk of stroke associated with endarterectomy was -2.2 percent (i.e., a 2.2 percent increase in risk) among patients with zero or one risk factor, 4.9 percent among those with two risk factors, and 14.3 percent among those with three or more risk factors (P=0.23 by a test for interaction). CONCLUSIONS: Among patients with internal-carotidartery stenosis, the prognosis was better for those presenting with transient monocular blindness than for those presenting with hemispheric transient ischemic attack. Among patients with transient monocular blindness, carotid endarterectomy may be beneficial when other risk factors for stroke are also present.

Recurrent brain hemorrhage is more frequent than ischemic stroke after intracranial hemorrhage.

OBJECTIVE: To characterize the rates of recurrent intracranial hemorrhage (ICH), ischemic stroke, and death in survivors of primary ICH. METHODS: Systematic review of studies reporting recurrent stroke in survivors of primary ICH, identified at index ICH and followed forward. Studies were identified by computerized search of the literature and review of reference lists. RESULTS: Ten studies published between 1982 and 2000 reporting 1,880 survivors of ICH, followed for a total of 6,326 patient-years (mean follow-up, 3.4 patient-years), were included. The aggregate rate of all stroke from five studies was 4.3% per patient-year (95% CI, 3.5% to 5.4%). The rate in the three population-based studies was higher than in the two hospital-based studies, 6.2% versus 4.0% per patient-year (p = 0.04). About three fourths of recurrent strokes were ICH. Considering all 10 studies, a total of 147 patients had a recurrent ICH, an aggregate rate of 2.3% per patient-year (95% CI, 1.9% to 2.7%). Based on data from four studies, patients with a primary lobar ICH had a higher rate of recurrent ICH than those with a deep, hemispheric ICH (4.4% versus 2.1% per patient-year; p = 0.002). The aggregate rates of subsequent ischemic stroke and mortality were 1.1% per patient-year (95% CI, 0.8% to 1.7%) and 8.8% per patient-year (95% CI, 5.2% to 11.0%). CONCLUSIONS: Recurrent stroke among survivors of primary ICH occurs at a rate of about 4% per patient-year, and most are recurrent ICH. Survivors of ICH have a higher risk of recurrent ICH than of ischemic stroke, and this has implications for the use of antithrombotic agents in these patients.

Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks.

BACKGROUND: Atrial fibrillation (AF) carries an increased risk of stroke; antiplatelet agents are proven effective for stroke prevention in other settings. OBJECTIVES: The objective of this review was to determine the efficacy and safety of antiplatelet therapy for prevention of stroke in patients with chronic non-valvular AF. SEARCH STRATEGY: We searched the Cochrane Stroke Group Specialised Register of Trials, MEDLINE database (June 1999), and the database of the Antithrombotic Trialists Collaboration, as well as reference lists of relevant articles. SELECTION CRITERIA: All randomized trials comparing antiplatelet therapies to placebo in patients with non-valvular AF and no history of transient ischemic attack (TIA) or stroke. DATA COLLECTION AND ANALYSIS: Trials for inclusion were independently selected by two reviewers who also extracted each outcome and double-checked the data. The Peto method was used for combining odds ratios. All analysis were, as far as possible, "intention-to-treat". Since the published results of two trials included 3-8% of participants with prior stroke or TIA, unpublished results excluding these participants were obtained from the Atrial Fibrillation Investigators. MAIN RESULTS: Among 1680 participants without prior stroke/TIA, randomized to aspirin (N = 838) or placebo in two trials, aspirin was associated with nonsignificantly lower risks of ischemic stroke (OR = 0.71, CI 95% 0. 46 - 1.10), all stroke (OR = 0.70, CI 95% 0.45 - 1.08) all disabling/fatal stroke (OR =0.88, CI 95% 0.48 - 1.58) and the constellation of stroke, MI or vascular death (OR = 0.76, CI 95% 0. 54 - 1.05 ). Considering all randomized participants including those with prior stroke or TIA, reductions in these events by aspirin were consistently smaller and marginally statistically significant: ischemic stroke (OR = 0.77, CI 95% 0.60-1.00), all stroke (OR = 0.76, CI 95% 0.61 - 0.93), all disabling/fatal stroke (OR = 0.87, CI 95% 0.64 - 1.19) and the combined outcome (OR = 0.79, CI 95% 0.64 - 0. 99). No increase in major hemorrhage was seen, but the number of hemorrhagic events was small. REVIEWER'S CONCLUSIONS: Considering all randomized data, aspirin modestly (by about 20%) reduces stroke and major vascular events in nonvalvular AF. For primary prevention among AF patients with an average stroke rate of 4.5%/year, about 10 strokes would be prevented yearly for every 1000 given aspirin.

Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks.

BACKGROUND: Non-valvular atrial fibrillation (AF) is associated with an increased risk of stroke. OBJECTIVES: The objective of this review was to characterize the efficacy and safety of oral anticoagulation (OAC) with vitamin K antagonists for the primary prevention of stroke in patients with chronic AF. SEARCH STRATEGY: We searched the Cochrane Stroke Group Specialised Register of Trials (June 1999), MEDLINE database, and the database of the Antithrombotic Trialists Collaboration, as well as reference lists of relevant articles. SELECTION CRITERIA: All randomized controlled trials comparing the value of OAC versus control in patients with non-valvular chronic atrial fibrillation and no history of transient ischemic attack (TIA) or stroke. DATA COLLECTION AND ANALYSIS: Trials for inclusion were independently selected by two reviewers who also extracted each outcome and double-checked the data. The Peto method was used for combining odds ratios. All analysis were, as far as possible, "intention-to-treat". Since the published results of four trials included 3-8% of participants with prior stroke or TIA, unpublished results excluding these participants were obtained from the Atrial Fibrillation Investigators. MAIN RESULTS: Of 2313 participants without prior cerebral ischemia from five trials, about half (n = 1154) were randomized to adjusted-dose OAC with an estimated mean INRs ranging between 2.0-2.6 during 1.5 years/participant average follow-up. Participant features and study quality were similar between trials. OAC was associated with large, highly statistically significant reductions in ischemic stroke (OR = 0.34, 95% CI 0.23 - 0.52), all stroke (OR = 0.39, 95% CI 0.26 - 0. 59), all disabling or fatal stroke (OR = 0.47, 95% CI 0.28 - 0.80), and the combined endpoint of all stroke, MI or vascular death (OR = 0.56, 95% CI 0.42 - 0.76). The observed rates of intracranial and extracranial hemorrhage not significantly increased by OAC therapy, but confidence intervals were wide. REVIEWER'S CONCLUSIONS: Adjusted-dose OAC (achieved INRs between 2-3) reduces stroke as well as disabling/fatal stroke for patients with nonvalvular AF, and these benefits were not substantially offset by increased bleeding among participants in randomized clinical trials. Limitations include relatively short follow-up and imprecise estimates of bleeding risks from these selected participants. For primary prevention in AF patients who have an average stroke rate of 4%/year, about 25 strokes and about 12 disabling fatal strokes would be prevented yearly for every 1000 given OAC.

Aspirin for the primary prevention of stroke and other major vascular events: meta-analysis and hypotheses.

BACKGROUND: Aspirin therapy reduces stroke by about 25% for persons with atherosclerotic vascular disease, but the effect in those without clinically apparent vascular disease is distinctly different. OBJECTIVE: To define the effect of aspirin use on stroke and other major vascular events when given for primary prevention to persons without clinically recognized vascular disease. DATA SOURCES AND EXTRACTION: Systematic review of randomized clinical trials and large prospective observational cohort studies examining the relation between aspirin use and stroke in persons at low intrinsic risk. Studies were identified by a computerized search of the English-language literature. DATA SYNTHESIS: Five randomized trials of primary prevention included 52 251 participants randomized to aspirin doses ranging from 75 to 650 mg/d; the mean overall stroke rate was 0.3% per year during an average follow-up of 4.6 years. Meta-analysis revealed no significant effect on stroke (relative risk = 1.08; 95% confidence interval, 0.95-1.24) contrasting with a decrease in myocardial infarction (relative risk = 0.74; 95% confidence interval, 0.68-0.82). The lack of reduction of stroke by aspirin for primary prevention was incompatible with its protective effect against stroke in patients with manifest vascular disease (P = .001). Intracranial hemorrhage was increased by the regular use of aspirin (relative risk = 1.35; P = .03), similarly for both primary and secondary prevention. In 4 large observational studies, self-selected use of aspirin was consistently associated with higher rates of stroke. CONCLUSIONS: The effect of aspirin therapy on stroke differs between individuals based on the presence or absence of overt vascular disease, in contrast with the consistent reduction in myocardial infarction by aspirin therapy observed in all populations. We hypothesize that the effect of aspirin therapy on stroke for persons with major risk factors for vascular disease may be intermediate between a substantial decrease for those with manifest vascular disease and a possible small increase for healthy persons due to accentuated intracranial hemorrhage. When aspirin is given for primary prevention of vascular events, available data support using 75 to 81 mg/d.

Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis.

PURPOSE: To characterize the efficacy and safety of anticoagulants and antiplatelet agents for prevention of stroke in patients with atrial fibrillation. DATA SOURCES: Randomized trials identified by using the search strategy developed by the Cochrane Collaboration Stroke Review Group. STUDY SELECTION: All published randomized trials testing antithrombotic agents to prevent stroke in patients with atrial fibrillation. DATA EXTRACTION: Data on interventions, number of participants, duration of exposure and occurrence of all stroke (ischemic and hemorrhagic), major extracranial bleeding, and death were extracted independently by two investigators. DATA SYNTHESIS: Sixteen trials included a total of 9874 participants (mean follow-up, 1.7 years). Adjusted-dose warfarin (six trials, 2900 participants) reduced stroke by 62% (95% CI, 48% to 72%); absolute risk reductions were 2.7% per year for primary prevention and 8.4% per year for secondary prevention. Major extracranial bleeding was increased by warfarin therapy (absolute risk increase, 0.3% per year). Aspirin (six trials, 3119 participants) reduced stroke by 22% (CI, 2% to 38%); absolute risk reductions were 1.5% per year for primary prevention and 2.5% per year for secondary prevention. Adjusted-dose warfarin (five trials, 2837 participants) was more efficacious than aspirin (relative risk reduction, 36% [CI, 14% to 52%]). Other randomized comparisons yielded inconclusive results. CONCLUSIONS: Adjusted-dose warfarin and aspirin reduce stroke in patients with atrial fibrillation, and warfarin is substantially more efficacious than aspirin. The benefit of antithrombotic therapy was not offset by the occurrence of major hemorrhage among participants in randomized trials. Judicious use of antithrombotic therapy, tailored according to the inherent risk for stroke, importantly reduces stroke in patients with atrial fibrillation.

Increased risk of intracranial hemorrhage when aspirin is combined with warfarin: A meta-analysis and hypothesis.

BACKGROUND: Oral anticoagulation with vitamin K antagonists increases the risk of intracranial hemorrhage; whether addition of aspirin to oral anticoagulation augments this risk is unclear. METHODS: Meta-analysis of randomized clinical trials in which aspirin was added to oral anticoagulants. RESULTS: Six randomized clinical trials were identified, including a total of 3,874 participants. Use of aspirin with oral anticoagulants was associated with more than double the frequency of intracranial hemorrhage (relative risk = 2.4, 95% CI = 1.2-4.8, p = 0.02). CONCLUSION: We hypothesize that aspirin when added to oral vitamin K antagonists may increase the risk of intracranial hemorrhage, but this observation requires confirmation. The magnitude of this effect is uncertain, and the clinical importance is likely different for different patient populations.

Stroke: part I. A clinical update on prevention.

Clinical trials conducted during the past five years have yielded important results that have allowed us to refine our approach to stroke prevention. Treatment of isolated systolic hypertension prevents stroke and is generally well tolerated. New antiplatelet agents (clopidogrel and the combination of aspirin plus high-dose dipyridamole) have been shown to be effective in reducing vascular events in survivors of ischemic stroke, although aspirin remains the mainstay of antiplatelet therapy for stroke prevention. Several clinical trials support the benefit of lipid-lowering agents ("statins") in reducing stroke. Warfarin reduces stroke for high-risk patients with atrial fibrillation. Carotid endarterectomy is highly beneficial in reducing stroke for symptomatic patients with severe carotid stenosis (greater than 70 percent), but the benefit is less for symptomatic patients with a moderate degree of stenosis (50 to 69 percent) and for patients with asymptomatic carotid disease of any severity.

Stroke: part II. Management of acute ischemic stroke.

Optimal treatment of the patient who has sustained an acute ischemic stroke requires rapid assessment and early intervention. The leisurely approach to acute stroke management sometimes taken in the past should be replaced by an approach that treats stroke as a true medical emergency. Thrombolysis with tissue plasminogen activator has been labeled for the treatment of acute ischemic stroke, but it must be given within three hours of stroke onset. However, fibrinolytic therapy can be given safely to only a fraction of patients with acute stroke, and more broadly applicable therapies are needed. Recent evidence does not support the routine use of heparin in patients with acute stroke, and early use of aspirin offers only modest benefit. Neuroprotective therapies designed to interfere with cytotoxic events initiated by ischemia are undergoing clinical trials that should be completed within the next year. At present, only tissue plasminogen activator has been labeled for acute stroke treatment; however, other agents are on the horizon, and much can be done supportively to improve neurologic outcome. Because of the unique susceptibility of neurons to ischemia, minutes count. Thus, hospitals providing care for patients with acute stroke should organize clinical protocols and pathways for effective implementation of therapies.

Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis.

OBJECTIVE: To assess the value of carotid endarterectomy for prevention of stroke in patients with asymptomatic carotid stenosis. DESIGN: Systematic review and meta-analysis of randomised controlled trials in patients with asymptomatic carotid stenosis in which subjects were allocated to carotid endarterectomy or to medical treatment alone. SUBJECTS: Five trials enrolled 2440 patients with stenosis >/ 50%. MAIN OUTCOME MEASURES: Stroke ipsilateral to the stenosis, all strokes, and perioperative complications (stroke or death). RESULTS: In patients who underwent carotid endarterectomy (n=1215) there was a significant reduction in the odds of ipsilateral stroke plus perioperative stroke or death (odds ratio 0.62; 95% confidence interval 0.44 to 0.86), corresponding to a 2% absolute risk reduction over about 3.1 years. The prevalence of stroke in any location was also reduced (0.68; 0.51 to 0.9) in patients undergoing carotid endarterectomy. During the immediate postoperative period there was an increased prevalence of stroke or death among such patients (4.51; 2.36 to 8.64). CONCLUSION: Carotid endarterectomy in patients with asymptomatic carotid stenosis unequivocally reduces the incidence of ipsilateral stroke, though the absolute benefit is relatively small. Given the modest benefit of surgery for unselected patients with asymptomatic carotid artery stenosis carotid endarterectomy cannot be routinely recommended for these patients pending reliable identification of high risk subgroups, and medical management is a sensible alternative for most patients.

Clobazam in partial status epilepticus.

Clobazam is the first and only 1,5-benzodiazepine to be used in the management of epilepsy. The use and effectiveness of oral clobazam in patients with status epilepticus has only been previously described in one study of 16 cases, seven of whom were in complex partial status. We have used clobazam in four patients with EEG-proven partial status epilepticus refractory to standard antiepileptic drugs. In all cases, except one, the seizure activity was controlled within 2 hr of administering clobazam. Our four patients responded promptly to an oral loading of clobazam which was approximately twice the usual daily maintenance dose. The drug was well tolerated and no adverse effects were seen. Clobazam's effectiveness as a first-line agent remains to be studied. Further controlled studies are recommended.