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Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial
Olive Lennon, Catherine Blake
BMC Neurology , 2009, DOI: 10.1186/1471-2377-9-9
Abstract: A single blind randomised controlled trial is proposed to examine a primary care cardiac rehabilitation programme for adults post transient ischemic attack (TIA) and stroke in effecting a positive change in the primary outcome measures of cardiac risk scores derived from Blood Pressure, lipid profile, smoking and diabetic status and lifestyle factors of habitual smoking, exercise and healthy eating participation. Secondary outcomes of interest include health related quality of life as measured by the Hospital Anxiety and Depression Scale, the Stroke Specific Quality of Life scale and WONCA COOP Functional Health Status charts and cardiovascular fitness as measured by a sub-maximal fitness test.A total of 144 patients, over 18 years of age with confirmed diagnosis of ischaemic stroke or TIA, will be recruited from Dublin community stroke services and two tertiary T.I.A clinics. Exclusion criteria will include oxygen dependence, unstable cardiac conditions, uncontrolled diabetes, major medical conditions, claudication, febrile illness, pregnancy or cognitive impairment. Participants will be block-statified, randomly allocated to one of two groups using a pre-prepared computer generated randomisation schedule. Both groups will receive a two hour education class on risk reduction post stroke. The intervention group will receive a 10 week programme of supervised aerobic exercises (twice weekly) and individually tailored brief intervention lifestyle counselling. Both groups will be tested on week one and week ten of the programme. Follow-up at 1 year will assess longer term benefits. Analysis will test for significant changes in the key variables indicated.Application of the Cardiac Rehabilitation paradigm to patients with ischaemic stroke or TIA has not been explored despite the obvious overlap in aetiology. It is hoped the anticipated improvement in vascular risk factors and fitness resulting from such a programme will enhance health and social gain in this population.C
Determining the Feasibility of Ambulance-Based Randomised Controlled Trials in Patients with Ultra-Acute Stroke: Study Protocol for the “Rapid Intervention with GTN in Hypertensive Stroke Trial” (RIGHT, ISRCTN66434824)  [PDF]
Sandeep Ankolekar,Gillian Sare,Chamila Geeganage,Michael Fuller,Lynn Stokes,Nikola Sprigg,Ruth Parry,A. Niroshan Siriwardena,Philip M. W. Bath
Stroke Research and Treatment , 2012, DOI: 10.1155/2012/385753
Abstract: Background. Time from acute stroke to enrolment in clinical trials needs to be reduced to improve the chances of finding effective treatments. No completed randomised controlled trials of ambulance-based treatment for acute stroke have been reported in the UK, and the practicalities of recruiting, consenting, and treating patients are unknown. Methods. RIGHT is an ambulance based, single-blind, randomised controlled trial with blinded-outcome assessment. The trial will assess feasibility of using ambulance services to deliver ultra-acute stroke treatments; a secondary aim is to assess the effect of glyceryl trinitrate (GTN) on haemodynamic variables and functional outcomes. Initial consent, randomisation, and treatment are performed by paramedics prior to hospitalisation. Patients with ultra-acute stroke (≤4 hours of onset) are randomised to transdermal GTN (5?mg/24 hours) or gauze dressing daily for 7 days. The primary outcome is systolic blood pressure at 2 hours. Secondary outcomes include feasibility, haemodynamics, dependency, and other functional outcomes. A nested qualitative study is included. Trial Status. The trial has all relevant ethics and regulatory approvals and recruitment started on February 15, 2010. The trial stopped recruitment in December 2011 after 41 patients were recruited. Trial Registration. The trial registration number is ISRCTN66434824 and EudraCT number is 2007-004766-40. 1. Background Finding acute interventions which reduce early brain damage and improve outcome after acute stroke is of major importance and has proved challenging. Irreversible brain damage starts in the first minutes to hours after a stroke [1] and acute stroke treatments can be highly time dependent; outcomes after stroke thrombolysis are better when treatment is given early [2]. Ambulance administration of emergency treatment is standard in acute medical emergencies such as acute myocardial infarction and asthma; thrombolysis for MI was given 45 minutes earlier if administered in an ambulance than at hospital [3]. Treatments for acute ischaemic stroke (AIS) are not routinely administered prior to hospital since current therapies reduce haemostasis (e.g., aspirin and alteplase) and need neuroimaging to exclude primary intracerebral haemorrhage (PICH). However, other potential treatments for acute stroke such as neuroprotection and management of physiological disturbances (e.g., high blood pressure [BP], hyperglycaemia and pyrexia) do not necessarily need prior neuroimaging and could be delivered before hospitalisation. As benefits of such interventions
The Professional Medical Journal , 2007,
Abstract: Objective: To determine the frequency of carotid atherosclerosis inischaemic stroke patients in our population using color Doppler ultrasound. Design: Observational. Place and Durationof study: This study was conducted in Medical Unit II of Jinnah Postgraduate Medical Centre, Karachi from Oct 2002to Feb 2003. Subjects and Methods: All the patients admitted in our ward during this duration with CT scan proof ofstroke were included in the study. Risk factors in all these patients were stratified. Complete history and examinationwas done and carotid Doppler ultrasound was performed on all patients with ischaemic stroke according to the studyprotocol. Results: A total of 100 patients were included in this study following the above-mentioned protocol over aperiod of five months. 66% of these were having cerebral infarction. Hypertension (72%), diabetes (35%), smoking(29%) and obesity (20%) were the common risk factors in these patients. The frequency of significant carotidatherosclerosis in acute ischaemic stroke patients was 21%. Conclusion: Doppler ultrasound is non-invasive, safe andcost-effective modality for evaluation of carotid vessels. In symptomatic and high-risk group, it should be used as firstdiagnostic modality for management or selecting patients for further investigation.
Management of Ischaemic Stroke: The Role of the Neurosurgeon
B Ogungbo, D Okor, FI Ojini
West African Journal of Medicine , 2010,
Abstract: BACKGROUND: Neurosurgeons are often not involved in the management of patients with stroke in Nigeria. OBJECTIVE: To discuss the role of neurosurgeons in the management of ischaemic stroke. METHODS: We looked at the contributions that a neurosurgeon may be able to make in the care of the patient with an ischaemic stroke. The emphasis was on preventive and curative interventions in the surgical armamentarium of the neurosurgeon that could be of benefit to the patient. RESULTS: We presented some scenarios in patients with ischemic stroke that may require the assistance of a neurosurgeon. The article explored the role of preventive and definitive surgery in reducing morbidity and mortality in ischaemic stroke patients. CONCLUSION: There is a role for the neurosurgeon in the management of patients with ischaemic stroke. It is important that patients who might benefit from neurosurgical intervention are referred early for neurosurgical evaluation.
Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care
Kate Fletcher, Jonathan Mant, Richard McManus, Sarah Campbell, Jonathan Betts, Clare Taylor, Satnam Virdee, Sue Jowett, Una Martin, Sheila Greenfield, Gary Ford, Nick Freemantle, FD Richard Hobbs
BMC Cardiovascular Disorders , 2010, DOI: 10.1186/1471-2261-10-37
Abstract: This is a randomised controlled trial (RCT) in patients with a past history of stroke or TIA. Patients will be randomised to two groups and will either have their blood pressure (BP) lowered intensively to a target of 130 mmHg systolic, (or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg) compared to a standard group where the BP will be reduced to a target of 140 mmHg systolic. Patients will be managed by their practice at 1-3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practices. The following exclusion criteria will be applied: systolic BP <125 mmHg at baseline, 3 or more anti-hypertensive agents, orthostatic hypotension, diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness.The primary outcome will be change in systolic BP over twelve months. Secondary outcomes include quality of life, adverse events and cardiovascular events.In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals understanding and views of BP management.The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care, and help determine whether or not further research is required before recommending such targets for this population.ISRCTN29062286Stroke is the third largest cause of death in England, and the single largest cause of adult disability[1]. A National Audit Office report (2005) highlighted the high cost of stroke to the NHS: about £2.8 billion per year in direct care costs, and an additional £1.8 billion per year cost to the wider economy due to lost productivity and disability [2]. Recent estimates suggest that between 30-45% of strokes are recurrent events, [3] so more effective secondary prevention
Ischaemic stroke : new frontiers.  [cached]
Prabhakar S,Das C
Neurology India , 1999,
Abstract: Lot of advancement has taken place, not only in the management but also in the pathophysiology and imaging modalities in patients of stroke. Indolent chronic infections, particularly those due to H. pylori, have been identified as one of the risk factors. The mechanism of inflammation in inducing a precoagulant state has also been worked out. SPECT studies have detected ischaemic areas before appearance of CT abnormalities. CT angiography identifies abnormalities in the ′circle of willis′ in posterior circulation strokes much better, and helps weigh the risk versus benefit of thrombolysis. With experiance in use of r-TPA, the list of contra indications and precautions has become longer than its indications. Newer drugs like lubeluzole and edselen have also been recommended. Various other drugs e.g. aptiganel hydrochloride, MDL 28170, ′basic fibroblast growth factor′ and ′superoxide dismutase′ are at an experimental stage. The concept of a ′stroke cocktail′ may be in vogue soon. Controversies still exit regarding the exact indication of prophylactic anticoagulant and the ′international normalized ratio′ (INR) to be achieved. Guidelines have been laid down for the approach to patients with asymptomatic carotid artery stenosis. However, the paramount message in stroke care is dissipation of the concept of ′brain attack′, amongst the primary care medical and para-medical personnel.
Comparative evaluation of treatment with low-dose aspirin plus dipyridamole versus aspirin only in patients with acute ischaemic stroke
Arnarsdottir Lola,Hjalmarsson Clara,Bokemark Lena,Andersson Bj?rn
BMC Neurology , 2012, DOI: 10.1186/1471-2377-12-67
Abstract: Background Previous studies have suggested that pre-stroke treatment with low-dose aspirin (A) could reduce the severity of acute ischaemic stroke, but less is known on the effect of pre-stroke treatment with a combination of aspirin and dipyridamole (A + D) and post-stroke effects of these drugs. The aim of the present study was to evaluate the effect of this drug combination on acute and long-term prognosis of ischaemic stroke. Methods Patients without atrial fibrillation admitted to the stroke unit with acute ischaemic stroke (n = 554) or TIA (n = 108) were studied during acute hospital care and up to 12 months after discharge from hospital. Results Prior to acute stroke 62 patients were treated with A + D while 247 patients were treated with A only. No beneficial effects of the combination A + D compared to A only were noted on stroke severity and/or acute in-hospital mortality. However, survival analysis by Cox-proportional hazard model demonstrated lower 12-months all-cause mortality in patients discharged with A + D (n = 275) compared with patients on A only (HR, 0.52; CI, 0.32-0.86; p = 0.011; n = 262) after adjusting for age, baseline NIHSS, previous stroke, previous myocardial infarction and type 2 diabetes. We also noted a tendency towards lower all-cause mortality at 3 months with use of A + D, but this was not statistically significant (p = 0.12). Conclusions Pre-stroke treatment with a combination of low-dose A + D does not reduce the severity of acute stroke, nor does it reduce the acute in-hospital mortality. However, treatment with A + D at discharge from hospital is seemingly associated with lower long-term mortality compared with A only, contrary to the results from previous randomised studies. However, our results must be interpreted with extreme caution considering the non-randomised study design.
Role of Citicoline in Ischaemic Stroke  [PDF]
S.K Gupta,Anupriya Gupta, Deeraj Gondhotra, Ajay Gupta, Shruti Gupta
JK Science : Journal of Medical Education & Research , 2008,
Abstract: Stroke or cerebrovascular accident is the thirdcommonest cause of death and the leading cause of longtermdisability in the world. Citicoline is a neuroprotectiveagent that serves as a choline donor and intermediate inthe biosynthesis of phospholipids. Citicoline reducesischaemic injury in the CNS by preserving membranephospholipids, chiefly phosphatidylcholine. Citicoline isfound to be a drug of choice due to its proven safety andefficacy in patients with stroke.However, the clinicalexperience will help to establish its clinical supermacy inthe coming times.
Management Of Ischaemic Stroke – Recent Advances
SA Ogun
Nigerian Journal of Clinical Practice , 2002,
Abstract: There is a better understanding of the natural course of stroke as well as its pathogenesis. This has led to the philosophy of “watch and intervene from ischaemie damage. Thrombolytic therapy given within 3 hours of ictus has been effective but this is not feasible in Africa because of time delay and lack of neuro-imaging facilities in most centers. Contemporary management of stroke is divided into 4 phases; acute, early subacute, late subacute and long term. Acute phase involves early assessment and supportive care from the onset of stroke to the 7th day. These include adequate fluid therapy (not haemodilution) of isotonic or hypertonic infusion to improve cerebral blood flow and reduce cerebral oedema; insulin therapy for hyperglycaemia as well as use of free radical scavengers. Hypertension is the commonest predisposing factor for stroke, but the weight of available evidence does not support its treatment in the first 10 days of stroke onset. However, for extra cerebral complications with blood pressure above 220/120, oral antihypertensive agents could be beneficial. Combination of thrombolytics, agents to protect against the effects of ischaemia and ant-oedema measures are likely to be required. Possible agents that might halt the ischaemic process before infarction becomes inevitable include NMDA receptor blockers, ion channel blockers, free radical scavengers, caspace and xanthine oxidase inhibitors. During the early subacute phase, from the 2nd to the 4th week, prevention of pulmonary embolism with subcutaneous heparin, treatment of pneumonia with antibiotics and early physiotherapy are important. During the late phase, physical and psychological rehabilitation and prevention of stroke recurrence by modifying the risk factors are essential. For effective management of stroke (“brain attack”), stroke units are now in vogue in developed nations. Stroke management in our nation should be reprioritized as a time dependent urgent medical emergency just as is currently stressed for major trauma and acute myocardial infarction (heart attack). Efforts should equally be made to set up stroke units and strengthen primary prevention. KEY WORDS: stroke, management. Nigerian Journal of Clinical Practice Vol.5(2) 2002: 130-138
Update on the third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke and baseline features of the 3035 patients recruited
Peter Sandercock, Richard Lindley, Joanna Wardlaw, Martin Dennis, Karen Innes, Geoff Cohen, Will Whiteley, David Perry, Vera Soosay, David Buchanan, Graham Venables, Anna Czlonkowska, Adam Kobayashi, Eivind Berge, Karsten Slot, Veronica Murray, Andre Peeters, Graeme J Hankey, Karl Matz, Michael Brainin, Stefano Ricci, Teresa A Cantisani, Gordon Gubitz, Stephen J Phillips, Arauz Antonio, Manuel Correia, Phillippe Lyrer, Ingrid Kane, Erik Lundstrom, the IST-3 collaborative group
Trials , 2011, DOI: 10.1186/1745-6215-12-252
Abstract: International, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rtPA in acute ischaemic stroke. Suitable patients had to be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracranial haemorrhage and stroke mimics.The initial pilot phase was double blind and then, on 01/08/2003, changed to an open design. Recruitment began on 05/05/2000 and closed on 31/07/2011, by which time 3035 patients had been included, only 61 (2%) of whom met the criteria for the 2003 European approval for thrombolysis. 1617 patients were aged over 80 years at trial entry. The analysis plan will be finalised, without reference to the unblinded data, and published before the trial data are unblinded in early 2012. The main trial results will be presented at the European Stroke Conference in Lisbon in May 2012 with the aim to publish simultaneously in a peer-reviewed journal. The trial result will be presented in the context of an updated Cochrane systematic review. We also intend to include the trial data in an individual patient data meta-analysis of all the relevant randomised trials.The data from the trial will: improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of iv rtPA in acute ischaemic stroke; provide: new evidence on the balance of risk and benefit of intravenous rtPA among types of patients who do not clearly meet the terms of the current EU approval; and, provide the first large-scale randomised evidence on effects in patients over 80, an age group which had largely been excluded from previous acute stroke trials.ISRCTN25765518Planning for the third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke with intravenous recombinant tissue plasminogen activator (rtPA) began in 1998. At its outset in 2000, the trial was planned as a pragmatic trial which sought to improve the external validi
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