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Importance: Approximately 10% to 15% of ischemic strokes are associated with cancer; cancer-associated stroke, particularly when cryptogenic, is associated with high rates of recurrent stroke and major bleeding. Limited data exist on the safety and efficacy of different antithrombotic strategies in patients with cancer and cryptogenic stroke. Objective: To compare apixaban vs aspirin for the prevention of adverse clinical outcomes in patients with history of cancer and cryptogenic stroke. Design, Setting, and Participants: Post hoc analysis of data from 1015 patients with a recent cryptogenic stroke and biomarker evidence of atrial cardiopathy in the Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke (ARCADIA) trial, a multicenter, randomized, double-blind clinical trial conducted from 2018 to 2023 at 185 stroke centers in North America. Data analysis was performed from October 15, 2023, to May 23, 2024. Exposures: Oral apixaban, 5 mg (or 2.5 mg if criteria met), twice daily vs oral aspirin, 81 mg, once daily. Subgroups of patients with and without cancer at baseline were examined. Main Outcomes and Measures: The primary outcome for this post hoc analysis was a composite of major ischemic or major hemorrhagic events. Major ischemic events were recurrent ischemic stroke, myocardial infarction, systemic embolism, and symptomatic deep vein thrombosis or pulmonary embolism. Major hemorrhagic events included symptomatic intracranial hemorrhage and any major extracranial hemorrhage. Results: Among 1015 participants (median [IQR] age, 68 [60-76] years; 551 [54.3%] female), 137 (13.5%) had a history of cancer. The median (IQR) follow-up was 1.5 (0.6-2.5) years for patients with history of cancer and 1.5 (0.6-3.0) years for those without history of cancer. Participants with history of cancer, compared with those without history of cancer, had a higher risk of major ischemic or major hemorrhagic events (hazard ratio [HR], 1.73; 95% CI, 1.10-2.71). Among those with history of cancer, 8 of 61 participants (13.1%) randomized to apixaban and 16 of 76 participants (21.1%) randomized to aspirin had a major ischemic or major hemorrhagic event; however, the risk was not significantly different between groups (HR, 0.61; 95% CI, 0.26-1.43). Comparing participants randomized to apixaban vs aspirin among those with cancer, events included recurrent stroke (5 [8.2%] vs 9 [11.8%]), major ischemic events (7 [11.5%] vs 14 [18.4%]), and major hemorrhagic events (1 [1.6%] vs 2 [2.6%]). Conclusions and Relevance: Among participants in the ARCADIA trial with history of cancer, the risk of major ischemic and hemorrhagic events did not differ significantly with apixaban compared with aspirin. Trial Registration: ClinicalTrials.gov Identifier: NCT03192215.
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Aspirina , Inhibidores del Factor Xa , Accidente Cerebrovascular Isquémico , Neoplasias , Pirazoles , Piridonas , Humanos , Piridonas/uso terapéutico , Piridonas/efectos adversos , Masculino , Femenino , Aspirina/uso terapéutico , Aspirina/efectos adversos , Neoplasias/complicaciones , Neoplasias/tratamiento farmacológico , Pirazoles/uso terapéutico , Pirazoles/efectos adversos , Anciano , Persona de Mediana Edad , Método Doble Ciego , Accidente Cerebrovascular Isquémico/prevención & control , Accidente Cerebrovascular Isquémico/etiología , Accidente Cerebrovascular Isquémico/epidemiología , Inhibidores del Factor Xa/uso terapéutico , Inhibidores del Factor Xa/efectos adversos , Fibrinolíticos/uso terapéutico , Fibrinolíticos/efectos adversos , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Hemorragia/inducido químicamenteRESUMEN
Background and purpose: Telestroke has grown significantly since its implementation. Despite growing utilization, there is a paucity of data regarding the diagnostic accuracy of telestroke to distinguish between stroke and its mimics. We aimed to evaluate diagnostic accuracy of telestroke consultations and explore the characteristics of misdiagnosed patients with a focus on stroke mimics. Methods: We conducted a retrospective study of all the consultations in our Ochsner Health's TeleStroke program seen between April 2015 and April 2016. Consultations were classified into one of three diagnostic categories: stroke/transient ischemic attack, mimic, and uncertain. Initial telestroke diagnosis was compared with the final diagnosis post review of all emergency department and hospital data. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) for diagnosis of stroke/TIA versus mimic were calculated. Area under receiver-operating characteristic curve (AUC) analysis to predict true stroke was performed. Bivariate analysis based on the diagnostic categories examined association with sex, age, NIHSS, stroke risk factors, tPA given, bleeding after tPA, symptom onset to last known normal, symptom onset to consult, timing in the day, and consult duration. Logistic regression was performed as indicated by bivariate analysis. Results: Eight hundred and seventy-four telestroke evaluations were included in our analysis. Accurate diagnosis through teleneurological consultation was seen in 85% of which 532 were strokes (true positives) and 170 were mimics (true negatives). Sensitivity, specificity, PPV, NPV were 97.8, 82.5, 93.7 and 93.4%, respectively. LR+ and LR- were 5.6 and 0.03. AUC (95% CI) was 0.9016 (0.8749-0.9283). Stroke mimics were more common with younger age and female gender and in those with less vascular risk factors. LR revealed OR (95% CI) of misdiagnosis for female gender of 1.9 (1.3-2.9). Lower age and lower NIHSS score were other predictors of misdiagnosis. Conclusion: We report high diagnostic accuracy of the Ochsner Telestroke Program in discriminating stroke/TIA and stroke mimics, with slight tendency towards over diagnosis of stroke. Female gender, younger age and lower NIHSS score were associated with misdiagnosis.
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BACKGROUND: The coronavirus disease of 2019 (COVID-19), which is caused by infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has recently been designated a pandemic by the World Health Organization, affecting 2.7 million individuals globally as of April 25, 2020, with more than 187,000 deaths. An increasing body of evidence has supported central nervous system involvement. METHODS: We conducted a review of the reported data for studies concerning COVID-19 pathophysiology, neurological manifestations, and neuroscience provider recommendations and guidelines. RESULTS: Central nervous system manifestations range from vague nonfocal complaints to severe neurological impairment associated with encephalitis. It is unclear whether the neurological dysfunction results from direct viral injury or systemic disease. The virus could affect brainstem pathways that lead to indirect respiratory dysfunction, in addition to direct pulmonary injury. Necessary adaptations in patient management, triage, and diagnosis are evolving in light of the ongoing scientific and clinical findings. CONCLUSIONS: The present review has consolidated the current body of data regarding the neurological impact of coronaviruses, discussed the reported neurological manifestations of COVID-19, and highlighted the recommendations for patient management. Specific recommendations pertaining to clinical practice for neurologists and neurosurgeons have also been provided.
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Betacoronavirus , Infecciones por Coronavirus/complicaciones , Infecciones por Coronavirus/diagnóstico , Enfermedades del Sistema Nervioso/diagnóstico , Enfermedades del Sistema Nervioso/etiología , Neurociencias/tendencias , Neumonía Viral/complicaciones , Neumonía Viral/diagnóstico , Adulto , Anciano , COVID-19 , Infecciones por Coronavirus/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/terapia , Pandemias , Neumonía Viral/terapia , SARS-CoV-2RESUMEN
Nearly 800,000 strokes occur in the United States each year, and stroke is the leading cause of preventable permanent disability. Timely recognition and treatment are imperative to reduce stroke-related morbidity and mortality. Given the evidence supporting intravenous thrombolysis and mechanical thrombectomy for ischemic stroke, stroke symptoms must be rapidly identified and mimics quickly excluded prior to therapeutic decisions. Intravenous tissue plasminogen activator is recommended for all qualified patients and patients with presentations suggesting large vessel occlusion should be evaluated for mechanical thrombectomy. Time to treatment is the most important prognostic factor for clinical outcome, highlighting the importance of reliable and efficient local and regional systems of care.
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Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Trombectomía , Terapia Trombolítica/métodos , Tiempo de Tratamiento , Activador de Tejido Plasminógeno/administración & dosificación , Triaje , Algoritmos , Vías Clínicas , Técnicas de Apoyo para la Decisión , Prestación Integrada de Atención de Salud , Diagnóstico Precoz , Humanos , Infusiones Intravenosas , Valor Predictivo de las Pruebas , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
United States (US) and worldwide telestroke programs frequently focus only on emergency room hyper-acute stroke management. This article describes a comprehensive, telemedicine-enabled, stroke care delivery system that combines "drip and ship" and "drip and keep" models with a comprehensive stroke center primary hub at Ochsner Medical Center in New Orleans, advanced stroke-capable regional hubs, and geographically-aligned, "stroke-ready" spokes. The primary hub provides vascular neurology expertise via telemedicine and monitors care for patients remaining at regional hubs and spokes using a multidisciplinary team approach. By 2014, primary hub telestroke consults grew to ≈1000/year with 16 min average door to consult initiation and 20 min to completion, and 29% of ischemic stroke patients received recombinant tissue-type plasminogen activator (rtPA), increasing 275%. Most patients remained in hospitals close to home, but neurointensive care and interventional procedures were common reasons for primary hub transfer. Given the time sensitivity and expert consultation needed for complex acute stroke care delivery paradigms, telestroke programs are effective for fulfilling unmet care needs. Combining drip and ship and drip and keep management allows more patients to stay "local," limiting primary hub transfer unless more advanced services are required. Post admission telestroke management at spokes increases personnel efficiency and can positively impact stroke outcomes.
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Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Telemedicina/métodos , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Servicio de Urgencia en Hospital , HumanosRESUMEN
OBJECTIVE: To evaluate the safety and tolerability of dalfampridine extended release (D-ER) in participants with chronic post-ischemic stroke deficits, and to assess for potential drug activity on sensorimotor function. METHODS: Using a double-blind, placebo-controlled, cross-over design, participants were randomized to placebo/D-ER or D-ER/placebo sequences and given D-ER 10 mg or placebo twice daily. Key inclusion criteria were: ischemic stroke ≥ 6 months, Fugl-Meyer Assessment lower extremity motor score ≤ 28, ability to complete Timed 25-Foot Walk (T25FW). The primary outcome was safety and tolerability. The key exploratory measure was walking speed (T25FW). Other assessments were: Box and Block, and Grip and Pinch tests; Functional Independence Measure. Full-crossover data were analyzed using mixed-effects model. RESULTS: A total of 83 participants were randomized: 70 completed and 13 discontinued the study. Adverse events were consistent with previous D-ER trials; no new safety signals were observed. Four participants experienced serious adverse events: 3 seizures (1 placebo, 2 D-ER), 1 was secondary to intentional overdose. Most common treatment-emergent adverse events were: dizziness, nausea, arthralgia and fatigue. Mixed-effects analysis showed an effect for D-ER vs. placebo in improving walking speed (0.21 vs. 0.10 ft/s; p = 0.027). CONCLUSIONS: D-ER was generally well tolerated in participants with chronic stroke deficits. Potential drug activity on lower extremity sensorimotor function, with an improvement in walking speed, was seen.
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4-Aminopiridina/uso terapéutico , Bloqueadores de los Canales de Potasio/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , 4-Aminopiridina/administración & dosificación , 4-Aminopiridina/farmacología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Estudios Cruzados , Método Doble Ciego , Retroalimentación Sensorial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Bloqueadores de los Canales de Potasio/administración & dosificación , Bloqueadores de los Canales de Potasio/farmacología , Adulto JovenRESUMEN
BACKGROUND: Lipid management is less aggressive in blacks than whites and women than men. PURPOSE: To examine whether differences in lipid management for race-sex groups compared to white men are due to factors influencing health services utilization or physician prescribing patterns. METHODS: Because coronary heart disease (CHD) risk influences physician prescribing, Adult Treatment Panel III CHD risk categories were constructed using baseline data from REasons for Geographic And Racial Differences in Stroke study participants (recruited 2003-2007). Prevalence, awareness, treatment, and control of hyperlipidemia were examined for race-sex groups across CHD risk categories. Multivariable models conducted in 2013 estimated prevalence ratios adjusted for predisposing, enabling, and need factors influencing health services utilization. RESULTS: The analytic sample included 7,809 WM; 7,712 white women; 4,096 black men; and 6,594 black women. Except in the lowest risk group, black men were less aware of hyperlipidemia than others. A higher percentage of white men in the highest risk group was treated (83.2%) and controlled (72.8%) than others (treatment, 68.6%-72.1%; control, 52.2%-65.5%), with black women treated and controlled the least. These differences remained significant after adjustment for predisposing, enabling, and need factors. Stratified analyses demonstrated that treatment and control were lower for other race-sex groups relative to white men only in the highest risk category. CONCLUSIONS: Hyperlipidemia was more aggressively treated and controlled among white men compared with white women, black men, and especially black women among those at highest risk for CHD. These differences were not attributable to factors influencing health services utilization.
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Hiperlipidemias/tratamiento farmacológico , Hiperlipidemias/etnología , Accidente Cerebrovascular/etnología , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Geografía , Humanos , Masculino , Persona de Mediana Edad , Factores SexualesRESUMEN
BACKGROUND/AIMS: There are racial and geographic disparities in stroke mortality, with higher rates among African Americans (AAs) and those living in the southeastern US ('stroke belt'). Racial and geographic differences in dyslipidemia prevalence, awareness, treatment and control may, in part, account for the observed disparities in stroke mortality. METHODS: Reasons for Geographic and Racial Differences in Stroke (REGARDS) is a national observational study of community-dwelling black and white participants aged 45 and older, with oversampling from the stroke belt. As of January 15, 2007, 26,122 participants were enrolled and a fasting lipid panel was available of 21,068. Awareness, treatment and control of dyslipidemia were estimated overall and compared across race-sex-region strata. RESULTS: There were 55% of the participants with dyslipidemia and no racial differences in prevalence. Adjusting for demographic and established stroke risk factors, AAs had a lower prevalence (OR 0.74; 95% CI: 0.66, 0.77) and were less likely to be aware (0.69; 0.61, 0.78), treated (0.77; 0.67, 0.89) and controlled (0.67; 0.58, 0.77) than whites. There was lower control outside of the stroke belt (0.87; 0.76, 0.99). CONCLUSION: Racial, but not geographic, differences in dyslipidemia management may play a role in the excess stroke burden in the Southeast.
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Dislipidemias/epidemiología , Conocimientos, Actitudes y Práctica en Salud , Disparidades en Atención de Salud , Accidente Cerebrovascular/epidemiología , Negro o Afroamericano , Anciano , Anciano de 80 o más Años , Concienciación , Dislipidemias/prevención & control , Dislipidemias/terapia , Disparidades en el Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Factores de Riesgo , Accidente Cerebrovascular/prevención & control , Estados Unidos/epidemiología , Población BlancaRESUMEN
BACKGROUND AND PURPOSE: Noncoronary forms of atherosclerosis (including transient ischemic attacks or stroke of carotid origin or >50% stenosis of the carotid artery) are associated with a 10-year vascular risk of >20% and are considered as a coronary heart disease (CHD) -risk equivalent from the standpoint of lipid management. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial included patients with stroke or transient ischemic attack and no known CHD regardless of the presence of carotid atherosclerosis. We evaluated the risk of developing clinically recognized CHD in SPARCL patients. METHODS: A total of 4731 patients (mean age, 63 years) was randomized to 80 mg/day atorvastatin placebo. The rates of major coronary event, any CHD event, and any revascularization procedure were evaluated. RESULTS: After 4.9 years of follow-up, the risks of a major coronary event and of any CHD end point in the placebo group were 5.1% and 8.6%, respectively. The rate of outcome of stroke decreased over time, whereas the major coronary event rate was stable. Relative to those having a large vessel-related stroke at baseline, those having a transient ischemic attack, hemorrhagic stroke, small vessel stroke, or a stroke of unknown cause had similar absolute rates for a first major coronary event and for any CHD event; transient ischemic attack, small vessel, and unknown cause groups had lower absolute revascularization procedure rates. Major coronary event, any CHD event, and any revascularization procedure rates were similarly reduced in all baseline stroke subtypes in the atorvastatin arm compared with placebo with no heterogeneity between groups. CONCLUSIONS: CHD risk can be substantially reduced by atorvastatin therapy in patients with recent stroke or transient ischemic attack regardless of stroke subtype.
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Colesterol/sangre , Enfermedad Coronaria/sangre , Ataque Isquémico Transitorio/sangre , Ataque Isquémico Transitorio/prevención & control , Accidente Cerebrovascular/sangre , Accidente Cerebrovascular/prevención & control , Atorvastatina , Enfermedad Coronaria/tratamiento farmacológico , Enfermedad Coronaria/etiología , Método Doble Ciego , Femenino , Estudios de Seguimiento , Ácidos Heptanoicos/uso terapéutico , Humanos , Ataque Isquémico Transitorio/complicaciones , Masculino , Pirroles/uso terapéutico , Accidente Cerebrovascular/complicacionesRESUMEN
Hypothermia is a potent neuroprotectant and induced hypothermia holds great promise as a therapy for acute neuronal injury. Thermoregulatory responses, most notably shivering, present major obstacles to therapeutic temperature management. A review of thermoregulatory physiology and strategies aimed at controlling physiologic responses to hypothermia is presented.
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Regulación de la Temperatura Corporal/fisiología , Hipotermia/prevención & control , Tiritona/fisiología , Agonistas alfa-Adrenérgicos/farmacología , Analgésicos Opioides/farmacología , Anestésicos/farmacología , Humanos , Relajación Muscular/fisiología , Antagonistas de la Serotonina/farmacología , Agonistas de Receptores de Serotonina/farmacología , Inhibidores Selectivos de la Recaptación de Serotonina/farmacología , Tiritona/efectos de los fármacosRESUMEN
OBJECTIVE: To determine whether the addition of patient education to routine medical management improves the clinical status of migraine patients and reduces their utilization of healthcare resources. BACKGROUND: Optimal migraine management typically requires effective patient education. Such education often is difficult to accomplish in the busy clinic setting. METHODS: One hundred consecutive patients with migraine presenting to an university-based headache clinic were randomized to receive or not receive a standardized course of didactic instruction regarding migraine biogenesis and management. The course consisted of 3 classes taught by lay migraineurs who themselves previously had undergone intensive training. All patients were evaluated initially and at 1, 3, and 6 months by a neurologist blinded as to the results of randomization. Clinical variables examined included headache frequency/severity, migraine disability assessment (MIDAS) scores, patient compliance, presence versus absence of analgesic use/overuse, and headache-related unscheduled visits or phone calls. Comparisons were made between baseline findings and findings at the 6-month follow-up visit, with the change in mean MIDAS score serving as the primary outcome variable. RESULTS: At 6 months the group randomized to receive intensive education exhibited a significantly greater reduction in mean MIDAS score than the group randomized to routine medical management only (24 vs. 14 points; P < .05). Those patients also experienced a reduction in mean headache days per month and a greater reduction in functionally incapacitating headache days per month, exhibited less analgesic overuse and need for abortive therapy, were more compliant with prophylactic therapy prescribed, and made fewer headache-related calls to the clinic or unscheduled visits. CONCLUSION: Intensive education of migraine patients by trained lay instructors may convey significant benefit to those patients and reduce their utilization of healthcare resources.
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Trastornos Migrañosos/psicología , Trastornos Migrañosos/terapia , Educación del Paciente como Asunto/métodos , Grupo Paritario , Adolescente , Adulto , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Analgésicos/uso terapéutico , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Cooperación del Paciente , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: Induced hypothermia holds promise as an effective neuroprotective strategy following cerebral ischemia. The effect of mild hypothermia on cerebral hemodynamics is not well known. The authors investigated the influence of brain temperature on middle cerebral artery (MCA) mean flow velocity (MCA FV) and pulsatility index (MCA PI) in nonintubated, healthy volunteers undergoing mild induced hypothermia. METHODS: Mild hypothermia (target tympanic membrane temperature [T tym] degrees C) was induced in subjects using the Arctic Sun Temperature Management System (Medivance, Inc, Louisville, CO). MCA FV and MCA PI were recorded bilaterally with a 2 MHz pulsed probe every 30 minutes via the transtemporal window. RESULTS: Eighteen subjects (8 males, 10 females) 32 +/- 8 years of age were studied. Multivariate analysis indicated that MCA FV increased with increasing change in temperature (baseline tympanic temperature-tympanic temperature [DeltaT tym]) (P< .001), heart rate (HR) (P< .001), end-tidal CO 2(P= .025), arterial oxygen saturation (O2%) (P= .001), and with decreasing mean arterial blood pressure (P= .004). Multivariate analysis also indicated that ln(MCA PI) (natural logarithm of MCA PI) decreased with decreasing T tym(P< .001) and increasing HR (P< .001). CONCLUSIONS: Mild induced hypothermia is associated with an increase in MCA FV and a decrease in MCA PI. The increase in MCA FV may be partially due to microcirculatory vasodilation.
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Velocidad del Flujo Sanguíneo , Circulación Cerebrovascular , Hipotermia Inducida , Arteria Cerebral Media/diagnóstico por imagen , Ultrasonografía Doppler Transcraneal , Adulto , Presión Sanguínea , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Oxígeno/sangre , Flujo PulsátilRESUMEN
OBJECTIVE: To identify variables predictive of a negative response to prophylactic therapy with topiramate in patients with chronic migraine. BACKGROUND: While certain of the newer antiepileptic drugs (AEDs) have emerged as promising or definitely effective therapies for migraine prevention, we continue to lack biologic or clinical variables predictive of treatment response to these or other widely used prophylactic therapies. METHODS: A consecutive series of 170 patients with IHS-defined migraine who were experiencing 15 or more days of headache per month were treated with topiramate according to a uniform dosing protocol. Variables examined for their potential value in predicting treatment response included age, gender, prior experience with prophylactic therapy, prior experience with divalproex sodium specifically, headache frequency and, if present, duration of chronic daily headache (CDH). A positive treatment response was defined as a 50% or greater reduction in headache days during the second treatment month relative to the patient's pretopiramate baseline. Only patients who completed the treatment phase and achieved the 50 mg BID target dose were analyzed (efficacy analysis). Each variable prospectively selected was evaluated in regards to treatment outcome via a paired t-test, and a multiple regression analysis of all variables subsequently was performed. RESULTS: A total of 116 patients completed at least 60 days of treatment and consequently were available for analysis. In the efficacy analysis, 45 (38.8%) of the 116 responded positively to topiramate. Neither age nor gender influenced treatment response. Those patients with CDH of more than 6 months duration, patients who previously had tried and failed more than three prophylactic agents and patients who previously had failed to respond to divalproex sodium were more likely to be nonresponders, but after multiple regression analysis the only statistically significant predictor of a negative treatment response was CDH of more than 6 months duration (P<.001). CONCLUSIONS: Patients with chronic migraine who are treated with topiramate may respond positively at a rate approaching that reported from placebo-controlled trials involving topiramate or other AEDs administered to less severely afflicted migraineurs. Our analysis suggests that patients with chronic migraine least likely to respond to topiramate would be those with extensive and negative previous experience with prophylactic therapy, previous failure to respond to divalproex sodium, CDH, and, most notably, CDH of more than 6 months duration.
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Fructosa/análogos & derivados , Trastornos Migrañosos/prevención & control , Adolescente , Adulto , Enfermedad Crónica , Femenino , Fructosa/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Análisis de Regresión , Topiramato , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: Therapeutic hypothermia shows promise as a treatment for acute stroke. Surface cooling techniques are being developed but, although noninvasive, they typically achieve slower cooling rates than endovascular methods. We assessed the hypothesis that the addition of intravenous MgSO4 to an antishivering pharmacological regimen increases the cooling rate when using a surface cooling technique. METHODS: Twenty-two healthy volunteers were studied. Hypothermia was induced using a surface technique with a target tympanic temperature (Ttym) of 34.5 degrees C (target range 34 to 35 degrees C). Subjects received 1 of the following pharmacological regimens: (1) meperidine monotherapy (n=5); (2) meperidine plus buspirone, 30 to 60 mg PO administered at the time of initiation of cooling (n=4); (3) meperidine and ondansetron, 8 to 16 mg IV administered as an 8 mg bolus at the time of initiation of cooling with an optional second dose after 4 hours as needed for nausea (n=5); or (4) meperidine, ondansetron, and MgSO4, 4 to 6 g IV bolus followed by 1 to 3 g per hour infusion (n=8). Thermal comfort was evaluated with a 100-mm-long visual analog scale. RESULTS: More subjects who received MgSO4 were vasodilated during hypothermia induction (7 of 8 [88%] versus 4 of 14 [29%]; P=0.024). MgSO4 (coefficient -17.265; P=0.039), weight (1.838, 0.001), and the initial 2-hour meperidine dose (0.726, 0.003) were found to significantly impact the time to achieve Ttym of 35 degrees C. Subjects who received MgSO(4) had significantly higher mean comfort scores than those who did not (48+/-15 versus 38+/-12; P<0.001). CONCLUSIONS: Administration of intravenous MgSO(4) increases the cooling rate and comfort when using a surface cooling technique.
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Analgésicos/uso terapéutico , Hipotermia Inducida , Sulfato de Magnesio/uso terapéutico , Adulto , Temperatura Corporal/efectos de los fármacos , Buspirona/uso terapéutico , Femenino , Humanos , Hipotermia Inducida/métodos , Infusiones Intravenosas , Masculino , Meperidina/uso terapéutico , Persona de Mediana Edad , Ondansetrón/uso terapéutico , Serotoninérgicos/uso terapéuticoRESUMEN
INTRODUCTION: Mild induced hypothermia holds promise as an effective neuroprotective strategy following acute stroke and cardiac arrest. Dependable noninvasive measurements of brain temperature are imperative for the investigation and clinical application of therapeutic hypothermia. Although the tympanic membrane temperature correlates best with brain temperature, it is a cumbersome location to record from continuously in the clinical setting. Data are lacking regarding the relationship between rectal and tympanic temperatures in nonintubated humans undergoing induced hypothermia via surface cooling. METHODS: We induced mild hypothermia in healthy volunteers using a novel surface cooling method (Arctic Sun Temperature Management System, Medivance, Inc., Louisville, CO). Core temperatures were recorded at the tympanic membrane (Ttym) and rectum (Trec). The gradient was defined as (Ttym-Trec). Controlled hypothermia was maintained for up to 300 minutes with a target Ttym of 34 degrees C to 35 degrees C; subjects were then actively rewarmed to a target Ttym of 36 degrees C over 1.5 to 3 hours. RESULTS: Twenty-two volunteers (10 males and 12 females) 31 +/- 8 years of age were studied. Subjects showed a triphasic temperature response: induction, maintenance, and rewarming. The mean gradient at baseline was -0.1 +/- 0.3 degrees C and the maximum gradient increased to -0.6 +/- 0.4 degrees C at 105 minutes. During maintenance of hypothermia (from 150 to 300 minutes), the mean gradient was -0.3 +/- 0.5 degrees C (95% confidence limits, -1.2 degrees C to 0.6 degrees C). CONCLUSIONS: : Our data suggest that Ttym and Trec are not related during the induction of hypothermia via surface cooling but correlate during the maintenance phase, with a -0.3 degrees C gradient. These findings support the use of rectal temperature as a measure of tympanic and, therefore, brain temperature during maintenance of induced hypothermia in nonintubated humans.
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Temperatura Corporal/fisiología , Hipotermia Inducida , Recto/fisiología , Membrana Timpánica/fisiología , Acetaminofén/farmacología , Adulto , Analgésicos no Narcóticos/farmacología , Analgésicos Opioides/farmacología , Femenino , Humanos , Masculino , Meperidina/farmacología , Recalentamiento , TiritonaRESUMEN
Stroke is the third leading cause of death and a leading cause of disability in the United States, with a particularly high burden on the residents of the southeastern states, a region dubbed the "Stroke Belt." These five states - Alabama, Arkansas, Louisiana, Mississippi, and Tennessee - have formed the Delta States Stroke Consortium to direct efforts to reduce this burden. The consortium is proposing an approach to identify domains where interventions may be instituted and an array of activities that can be implemented in each of the domains. Specific domains include 1) risk factor prevention and control; 2) identification of stroke signs and symptoms and encouragement of appropriate responses; 3) transportation, Emergency Medical Services care, and acute care; 4) secondary prevention; and 5) recovery and rehabilitation management. The array of activities includes 1) education of lay public; 2) education of health professionals; 3) general advocacy and legislative actions; 4) modification of the general environment; and 5) modification of the health care environment. The Delta States Stroke Consortium members propose that together these domains and activities define a structure to guide interventions to reduce the public health burden of stroke in this region.
Asunto(s)
Accidente Cerebrovascular/prevención & control , Adulto , Centers for Disease Control and Prevention, U.S./economía , Niño , Defensa del Consumidor , Costo de Enfermedad , Diagnóstico Precoz , Servicios Médicos de Urgencia , Financiación Gubernamental , Primeros Auxilios , Educación en Salud , Personal de Salud/educación , Humanos , Salud Pública , Administración en Salud Pública/economía , Recurrencia , Factores de Riesgo , Sudeste de Estados Unidos/epidemiología , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia , Rehabilitación de Accidente Cerebrovascular , Estados UnidosRESUMEN
Stroke ranks as the third leading cause of death and the most common cause of permanent disability in adults. Timely recognition and treatment is imperative to reduce stroke-related morbidity and mortality. Patients with acute ischemic stroke should be evaluated for administration of intravenous tissue plasminogen activator (t-PA); those who do not qualify for t-PA should receive aspirin therapy in the absence of a contraindication. In all stroke patients, intravenous hydration with normal saline should be administered, hypoxia should be corrected with supplemental oxygen, and hyperglycemia and fever should be treated aggressively. Blood pressure management should be individualized on the basis of stroke pathophysiology and specific treatment plan (e.g., planned thrombolysis) following published guidelines. Evaluation of stroke etiology should be undertaken, and the results should be used to guide secondary stroke prevention efforts.
Asunto(s)
Antihipertensivos/uso terapéutico , Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Algoritmos , Presión Sanguínea , Contraindicaciones , Diagnóstico Diferencial , Humanos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Estados Unidos/epidemiologíaRESUMEN
Mild induced hypothermia holds promise as an effective therapy for acute ischemic stroke. We developed a novel strategy to rapidly induce and maintain mild hypothermia in unanesthetized, non-intubated subjects as a model for the treatment of acute stroke patients. We induced and maintained mild hypothermia (tympanic membrane temperature 34 degrees C-35 degrees C) for over 5 hours in 10 healthy volunteers. All subjects received 1000 mg of acetaminophen orally and meperidine intravenously for comfort and suppression of shivering. In phase 1, subjects (n=5) were cooled using Arctic Sun Energy Transfer Pads (Medivance, Inc., Louisville, CO) with manual temperature control. In phase 2, subjects (n=5) were cooled using the Arctic Sun Energy Transfer Pads connected to the Arctic Sun Model 200 Temperature control module (Medivance, Inc.). Core temperatures were measured at the tympanic membrane and rectum. All subjects reached the target tympanic temperature range. The mean time to reach a tympanic temperature of 35 degrees C was 90+/-53 minutes (1.4 degrees C/hour) in phase 2. The most common side effect was nausea, observed in 30% of subjects. There was no statistically significant change in heart rate, blood oxygenation, or diastolic blood pressure compared with baseline; systolic blood pressure was significantly elevated for the 180 minute time point only (140+/-20 mm Hg v 122+/-13 mm Hg; P = .042). We developed a method to rapidly and comfortably induce and maintain mild hypothermia in unanesthetized, non-intubated humans. Further study to optimize the pharmacologic inhibition of thermoregulation and to assess tolerability over longer durations is warranted.
RESUMEN
Brain ischaemia leads to a cascade of biochemical events, many of which ultimately cause cell membrane injury. Therefore, measures aimed at protecting neuronal membranes could be useful treatment strategies following stroke. Citicoline (cytidine-5-diphosphocholine; CDP-choline) is a naturally occurring nucleotide derivative that may reduce central nervous system (CNS) ischaemic injury by stabilizing cell membranes and reducing free radical generation. Several animal models of ischaemic stroke or hypoxia have shown beneficial effects of citicoline treatment. Randomized clinical stroke treatment trials performed outside of the United States (US) have shown promising results but several recent US trials have failed to support the use of citicoline following middle cerebral artery (MCA) stroke. It remains possible that more specific subgroups of patients may benefit from this well tolerated therapy, but these subgroups have yet to be determined. In addition, there remains the possibility that efficacy may be seen when citicoline is administered in combination with other neuroprotectants with complementary mechanisms of action.