Low awareness of transient ischemic attacks and risk factors of stroke in a Swiss urban community

BACKGROUND AND PURPOSE: Time delays from stroke onset to arrival at the hospital are the main obstacles for widespread use of thrombolysis. In order to decrease the delays, educational campaigns try to inform the general public how to act optimally in case of stroke. To determine the content of such a campaign, we assessed the stroke knowledge in our population. METHODS: The stroke knowledge was studied by means of a closed-ended questionnaire. 422 randomly chosen inhabitants of Bern, Switzerland, were interviewed. RESULTS: The knowledge of stroke warning signs (WS) was classified as good in 64.7%. A good knowledge of stroke risk factors (RF) was noted in 6.4%. 4.2% knew both the WS and the RF of stroke indicating a very good global knowledge of stroke. Only 8.3% recognized TIA as symptoms of stroke resolving within 24 hours, and only 2.8% identified TIA as a disease requiring immediate medical help. In multivariate analysis being a woman, advancing age, and having an afflicted relative were associated with a good knowledge of WS (p = 0.048, p < 0.001 and p = 0.043). Good knowledge of RF was related to university education (p < 0.001). The good knowledge of TIA did not depend on age, sex, level of education or having an afflicted relative. CONCLUSIONS: The study brings to light relevant deficits of stroke knowledge in our population. A small number of participants could recognize TIA as stroke related symptoms resolving completely within 24 hours. Only a third of the surveyed persons would seek immediate medical help in case of TIA. The information obtained will be used in the development of future educational campaigns.

Neuro-imaging of cerebral ischemic stroke

Major progress has recently been made in the neuro-imaging of stroke as a result of improvements in imaging hardware and software. Imaging may be based on either magnetic resonance imaging (MRI) or computed tomography (CT) techniques. Imaging should provide information on the entire vascular cervical and intracranial network, from the aortic arch to the circle of Willis. Equally, it should also give information on the viability of brain tissue and brain hemodynamics. CT has the advantage in the detection of acute hemorrhage whereas MRI offers more accurate pathophysiological information in the follow-up of patients.

Pain management and the effect of guidelines in neonatal units in Austria, Germany and Switzerland

BACKGROUND: Painful invasive procedures are frequently performed on preterm infants admitted to a neonatal intensive care unit (NICU). The aim of the present study was to investigate current pain management in Austrian, German and Swiss NICU and to identify factors associated with improved pain management in preterm infants. METHODS: A questionnaire was sent to all Austrian, German and Swiss pediatric hospitals with an NICU (n = 370). Pain assessment and documentation, use of analgesics for 13 painful procedures, presence of written guidelines for pain management and the use of 12 analgesics and sedatives were examined. RESULTS: A total of 225 units responded (61%). Pain assessment and documentation and frequent analgesic therapy for painful procedures were performed more often in units using written guidelines for pain management and in those treating >50 preterm infants at <32 weeks of gestation per year. This was also the case for the use of opioid analgesics and sucrose solution. Non-opioid analgesics were used more often in smaller units and in units with written guidelines. There was a broad variation in dosage of analgesics and sedatives within all groups. CONCLUSION: Pain assessment, documentation of pain and analgesic therapy are more frequently performed in NICU with written guidelines for pain management and in larger units with more than 50 preterm infants at <32 weeks of gestation per year.

Symptomatic intracranial haemorrhage after intra-arterial thrombolysis in acute ischaemic stroke: assessment of 294 patients treated with urokinase

BACKGROUND: The PROACT II trial showed that intra-arterial thrombolysis (IAT) is effective for treatment of acute ischaemic stroke attributable to M1 and M2 segment occlusions. Incidence of symptomatic intracranial haemorrhage (sICH) was 10%. OBJECTIVE: To evaluate the risk and predictors of sICH after IAT by using urokinase in a large number of patients presenting with the whole spectrum of cerebral vessel occlusions. METHODS: 294 patients with stroke treated with intra-arterial urokinase were retrospectively analysed. The risk of sICH as well as bleeding characteristics were assessed. Demographic and radiological data, time to treatment, urokinase dose, recanalisation rates, stroke aetiology and severity were analysed for predictors. RESULTS: sICH occurred in 14 of 294 (4.8%) patients. The median National Institute of Health Stroke Scale score of all patients was 15. All but one sICH were located in the infarcted brain tissue, and no sICH occurred in patients with peripheral vessel occlusions (M3 or M4 segments of the middle cerebral artery). Poor collaterals (p = 0.001), early signs of ischaemia on computed tomography (p = 0.003), higher urokinase dose (p = 0.019), lower recanalisation rate (p = 0.02) and higher diastolic blood pressure on admission (p = 0.04) were found to be correlated with sICH on univariate analysis. On multivariate analysis, poor collaterals (p = 0.004), urokinase dose (p = 0.021) and early signs on computed tomography (p = 0.026) remained predictors of sICH. CONCLUSIONS: With regard to the whole spectrum of cerebral vessel occlusions, an incidence of <5% sICH after IAT is distinctly low. This result underlines the important role of IAT in the treatment of acute stroke.

Variability in outcome and resource use in intensive care units

OBJECTIVE: To examine variability in outcome and resource use between ICUs. Secondary aims: to assess whether outcome and resource use are related to ICU structure and process, to explore factors associated with efficient resource use. DESIGN AND SETTING: Cohort study, based on the SAPS 3 database in 275 ICUs worldwide. PATIENTS: 16,560 adults. MEASUREMENTS AND RESULTS: Outcome was defined by standardized mortality rate (SMR). Standardized resource use (SRU) was calculated based on length of stay in the ICU, adjusted for severity of acute illness. Each unit was assigned to one of four groups: "most efficient" (SMR and SRU < median); "least efficient" (SMR, SRU > median); "overachieving" (low SMR, high SRU), "underachieving" (high SMR, low SRU). Univariate analysis and stepwise logistic regression were used to test for factors separating "most" from "least efficient" units. Overall median SMR was 1.00 (IQR 0.77-1.28) and SRU 1.07 (0.76-1.58). There were 91 "most efficient", 91 "least efficient", 47 "overachieving", and 46 "underachieving" ICUs. Number of physicians, of full-time specialists, and of nurses per bed, clinical rounds, availability of physicians, presence of emergency department, and geographical region were significant in univariate analysis. In multivariate analysis only interprofessional rounds, emergency department, and geographical region entered the model as significant. CONCLUSIONS: Despite considerable variability in outcome and resource use only few factors of ICU structure and process were associated with efficient use of ICU. This suggests that other confounding factors play an important role.

"Death may come on like a stroke of lightening ..." : Phenomenological and morphological aspects of fatalities caused by manure gas

Due to the decomposition of biological material, hydrogen sulphide (H(2)S) is produced. In low concentrations, the well-known smell of "rotten eggs" is associated with H(2)S. In higher concentrations, H(2)S is an odourless and colourless gas that may cause rapid loss of consciousness, neurological and respiratory depression and imminent death-"... like a stroke of lightening". Hydrogen sulphide poisoning is an un-common incident that is often associated with colleague fatalities. In this study, 4 fatal accidents with 10 deceased victims are reported and the morphological and phenomenological aspects are presented. In these cases, the morphological findings, namely, discolouration of the livores, pulmonary pathologies and sub-mucosal or sub-serosal congestion bleeding were found in nearly all cases. Also the impending threat for colleagues, first aid helpers and professional rescue teams is demonstrated. The suspicion of a fatal H(2)S intoxication should be based on a precise scene analysis with respect to the possibility of life-threatening H(2)S intoxication for the helpers, the typical scent of rotten eggs, which may be noted on the corpses and the abovementioned morphological findings. The diagnosis should be confirmed by a qualitative and, if possible, quantitative analysis of H(2)S.

Mechanical thromboembolectomy for acute ischemic stroke: comparison of the catch thrombectomy device and the Merci Retriever in vivo

BACKGROUND AND PURPOSE: The purpose of the study was to compare efficacy and potential complications of 2 commercially available devices for mechanical thromboembolectomy. METHODS: Devices were tested in an established animal model allowing the use of routine angiography catheters and thrombectomy devices. Radio-opaque thrombi were used for visualization of thrombus-device interaction during angiography. The Merci Retrieval System and the Catch Thromboembolectomy System were assessed each in 10 vessel occlusions. For every occluded vessel up to 5 retrieval attempts were performed. RESULTS: Sufficient recanalization was achieved with the Merci Retriever in 90% of occlusions, and with the Catch device recanalization was achieved in 70% of occlusions. Recanalization at the first attempt occurred significantly more often with the Merci Retriever compared to the Catch device (OR, 21; 95% CI, 1.78-248.11). Consequently, significantly more attempts (P=0.02) had to be performed with the Catch device; therefore, time to recanalization was longer. Thrombus fragmentations during retrieval were caused more often by the Catch device compared to the Merci Retriever (OR, 15.6; 95% CI, 1.73-140.84), resulting in a higher distal embolization rate. During retrieval both devices lost thrombotic material at the tip of the guide catheter, which was then aspirated in most cases. CONCLUSIONS: Both distal devices are effective for thromboembolectomy. To avoid loss of thrombotic material and distal embolization, the use of large luminal balloon guide catheters and aspiration during retrieval seems to be mandatory. The design of the Merci Retriever appears to be more efficient during thrombus mobilization and retrieval with less fragmentation compared to the Catch Thromboembolectomy System.

Occlusion length is a crucial determinant of efficiency and complication rate in thrombectomy for acute ischemic stroke

BACKGROUND AND PURPOSE: Although mechanical thrombectomy (MT) has an encouragingly high recanalization rate in treating stroke, it is associated with severe complications of which the underlying factors have yet to be identified. Because MT is a mechanical approach, the mechanical properties of the thrombus might be crucial for its success. The present study assesses the effect of thrombus length on the in vivo effectiveness and complication rate of MT. MATERIALS AND METHODS: Angiography and embolization of 21 cranial vessels with radiopaque whole-blood thrombi 10, 20, and 40 mm in length (7 occlusions each) were performed in 7 swine. MT was carried out using a distal snarelike device (BCR Roadsaver) with proximal balloon occlusion. A total of 61 retrievals were attempted. RESULTS: In the group of 10-mm occlusions, 77.8% of the attempts achieved complete recanalisation. For longer occlusions, the success rates decreased significantly to 20% of attempts for 20-mm occlusions (odds ratio [OR], 14; 95% confidence interval [CI], 2.2-89.2) and 11.1% for 40-mm occlusions (OR, 28; 95% CI, 3.9-202.2; P < .005). The low success rates were largely due to complications associated with thrombus compaction during retrieval. Similarly, the rate of thromboembolic events increased from 0% in 10-mm occlusions to 14.8% in 40-mm occlusions. CONCLUSIONS: MT using a distal device proved to be a fast, effective, and safe procedure for recanalizing short (10-mm) occlusions in the animal model. However, occlusion length emerged as a crucial determinant for MT with a significant decrease in recanalization success per attempt and increased complication rates. These findings suggest limitations of MT in the clinical application.

Quality of life in stroke survivors after local intra-arterial thrombolysis

Background: We aimed to assess quality of life (QOL) and its predictors in stroke survivors after local intra-arterial thrombolysis (IAT) as well as to measure QOL according to the site of pretreatment vessel occlusion. Methods: From January 2000 to April 2004, 175 consecutive patients underwent IAT for acute ischemic stroke. Clinical and radiological data were collected prospectively. We contacted 135 stroke survivors after a mean of 923 (+/-431) days, 132 responded. QOL, assessed with EuroQol (EQ-5D), and functional abilities, measured with the modified Rankin Scale (mRS) and the Barthel Index, were compared, and predictors of QOL were analyzed. Results: Measured with EQ-5D, 56% of the patients reported a good QOL (EQ-5D Index >/=70). Low mRS and high Barthel Index scores at follow-up were associated with better overall QOL (Kendall's tau >0.5). Nevertheless, 25% of the functionally independent patients (mRS 0-2) indicated a markedly impaired QOL (EQ-5D Index <70) and 10% of disabled patients indicated good QOL. QOL was significantly lower in patients with occlusion of the internal carotid artery compared to patients with occlusion of the basilar artery or the M1, M2 or M3/4 segment of the middle cerebral artery (EQ-5D Index: p = 0.005). A high National Institute of Health Stroke Scale score on admission and occlusion of the internal carotid artery were independent predictors of impaired QOL (p < 0.05). Conclusion: More than half of the stroke survivors treated with IAT reported a good QOL, mostly survivors with mild disabilities. QOL assessment gives information that is not provided by traditional outcome scores. Our results support guidelines to measure QOL in stroke research. Copyright (c) 2008 S. Karger AG, Basel.

Age-dependent differences in demographics, risk factors, co-morbidity, etiology, management, and clinical outcome of acute ischemic stroke

BACKGROUND : Comparisons between younger and older stroke patients including comorbidities are limited. METHODS : Prospective data of consecutive patients with first ever acute ischemic stroke were compared between younger ( 45 years). RESULTS : Among 1004 patients, 137 (14 %) were