The Management of Stroke Patients by Neurologists: Common Questions and New Observations

ABSTRACT

Tools and strategies available for stroke prevention and management have grown impressively during the past decade. Caring for the acute stroke patient has become a priority for emergency medical systems, enhanced by the advances in neuroimaging techniques and acute administration of thrombolytic agents. Light continues to be shed on the pathophysiology of cerebral ischemia and the atherosclerotic process enriching the armamentarium of the clinician in secondary stroke prevention. In spite of major therapeutic developments over the last decade there remains a high level of uncertainty and many recurrent questions pertaining to patient management. Frequent questions of referring physicians that have been posed to this stroke specialist serve as the format for discussing some of the most recent developments in acute stroke care and stroke prevention.

KEYWORDS

Acute stroke therapy - thrombolytic therapy - secondary stroke prevention

REFERENCES

• 1 The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke.  N Engl J Med . 1995;  333 1581-1587
• 2 Diener H, Cunha L, Forbes C. European Stroke Prevention Study 2. Dipyridamole and acetylsalycilic acid in the secondary prevention of stroke.  J Neurol Sci . 1996;  143 1-13
• 3 CAPRIE Steering Committee. A randomised blinded trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE).  Lancet . 1996;  348 1329-1339
• 4 Gorelick P B, Sacco R L, Smith D B. Prevention of first stroke. A review of guidelines and multidisciplinary consensus statement from the National Stroke Association.  JAMA . 1999;  281 112-1120
• 5 The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients.  New Engl J Med . 2000;  342 145-153
• 6 PROGRESS Collaborative Group. Lancet .  2001;  358 1033-1041
• 7 Morgenstern L B, Staub L, Chan W. Improving delivery of acute stroke therapy: the TLL Temple Foundation Stroke Project.  Stroke . 2002;  160-166
• 8 Lopez-Yunez A M, Bruno A, Williams L S. Protocol violations are associated with increased risk of ICH in community-based rt-PA use.  Stroke . 2001;  32 12-16
• 8a Albers G W, Bates V E, Clark W M, Bell R, Verro P, Hamilton S A. Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study.  JAMA . 2000;  283 1189-1191
• 9 Grotta J C, Burgin W S, El-Mitwalli A. Intravenous tissue-type plasminogen activator therapy for ischemic stroke: Houston experience 1996 to 2000.  Arch Neurol . 2001;  58 2009-2013
• 10 Marler J R, Tilley B C, Lu M. Early stroke treatment associated with better outcomes: the NINDS rt-PA stroke study.  Neurology . 2000;  55 1649-1655
• 11 Demchuk A M, Morgenstern L B, Krieger D W. Serum glucose level and diabetes predict tissue plasminogen activator-related intracerebral hemorrhage in acute ischemic stroke.  Stroke . 2000;  30 34-39
• 12 Patel S C, Levine S R, Tilley B C. Lack of clinical significance of early ischemic changes on computed tomography in acute stroke.  JAMA . 2001;  286 2830-2838
• 13 Alenxandrov A V, Demchuk A M, Felberg R A. High rate of complete recanalization and dramatic clinical recovery during tPA infusion when continuously monitored with 2-MHz trans-cranial Doppler monitoring.  Stroke . 2000;  31 610-614
• 14 Furlan A, Higashida R, Wechsler L. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in acute cerebral thromboembolism.  JAMA . 1999;  282 2003-2011
• 15 Kase C S, Furlan A J, Wechsler L R. Cerebral hemorrhage after intra-arterial thrombolysis for ischemic stroke: the PROACT II trial.  Neurology . 2001;  57 1603-1610
• 16 Suarez J I, Sunshine J L, Tarr R. Predictors of clinical improvement, angiographic recanalization, and intracranial hemorrhage after intra-arterial thrombolysis for acute ischemic stroke.  Stroke . 1999;  30 2094-2100
• 17 Wijdicks E F, Nichols D A, Thielen K R. Intra-arterial thrombolysis in acute basilar artery thromboembolism: the initial Mayo Clinic experience.  Mayo Clin Proc . 1997;  72 1005-1013
• 18 Sliwka U, Mull M, Stelzer A. Long-term follow-up of patients after intraarterial thrombolytic therapy of acute vertebrobasilar artery occlusion.  Cerebrovasc Dis . 2001;  12 214-219
• 19 Brandt T, von Kummer R, Muller-Kuppers M, Hacke W. Stroke thrombolytic therapy of acute basilar artery occlusion: variables affecting recanalization and outcome.  Stroke . 1996;  27 875-881
• 20 Archer C R, Horenstein S. Basilar artery occlusion: clinical and radiological correlation.  Stroke . 1977;  8 383-390
• 21 Chalela J A, Katzan I, Liebeskind D S. Safety of intra-arterial thrombolysis in the postoperative period.  Stroke . 2001;  32 1365-1369
• 22 Suarez J I, Zaidat O O, Sunshine J L. Endovascular administration after intravenous infusion of thrombolytic agents for the treatment of patients with acute ischemic strokes.  Neurosurgery . 2002;  50 251-260
• 23 International Stroke Trial Collaborative Group. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19,435 patients with acute ischemic stroke.  Lancet . 1997;  349 1569-1581
• 24 The Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial.  JAMA . 1998;  279 1304-1306
• 25 Hommel M. Fraxiparin in ischemic stroke study.  Cerebrovasc Dis . 1998;  8 19A-23A
• 26 Antiplatelet Trialists' Collaboration. Collaborative overview of randomized trials of antiplatelet therapy. I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients.  Br Med J . 1994;  308 81-106
• 27 Hacke W. From CURE to MATCH: ADP receptor antagonists as the treatment of choice for high-risk atherothrombotic patients.  Cerebrovasc Dis . 2002;  13 22-26
• 28 Callahan A. Cerebrovascular disease and statins: a potential addition to the therapeutic armamentarium for stroke prevention.  Am J Cardiol . 2001;  88 33J-37J
• 29 Crisby M, Nordin-Fredriksson G, Shah P K. Pravastatin treatment increases collagen content and decreases lipid content, inflammation, metalloproteinases, and cell death in human carotid plaques: implications for plaque stabilization.  Circulation . 2001;  103 926-933
• 30 Boushey C J, Beresford A A, Omenn G S. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease.  JAMA . 1995;  274 1049-1057
• 31 Mohr J P, Thompson J L, Lazar R M. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke.  N Engl J Med . 2001;  345 1493-1495
• 32 Bogousslavsky J, Garazi S, Jeanrenaud X. Stroke recurrence in patients with patent foramen ovale: the Lausanne Study. Lausanne Stroke with Paradoxal Embolism Study Group.  Neurology . 1996;  46 1301-1305
• 33 Mas J L, Arquizan C, Lamy C. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both.  N Engl J Med . 2001;  345 1740-1746
• 34 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis.  N Engl J Med . 1991;  325 445-453
• 35 Naylor A R, Bolia A, Abbott R J. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial.  J Vasc Surg . 2000;  31 622-624
• 36 Albers G. Carotid endarterectomy versus stent: a randomized trial. Oral presentation, International Stroke Conference, Fort Lauderdale, FL, February 2001
• 37 Roubin G S, New G, Iyer S S. Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis.  Circulation . 2001;  103 532-537
• 38 Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial.  Lancet   2001;  357 1729-1737
• 39 Brooks W H, McClure R R, Jones M R. Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital.  J Am Coll Cardiol . 2001;  38 1589-1595
• 40 Zhu C Z, Norris J W. A therapeutic window for carotid endarterectomy in patients with asymptomatic carotid stenosis.  Can J Surg . 1991;  34 437-440
• 41 Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis.  JAMA . 1995;  273 1421-1427
• 42 Warach S. New imaging strategies for patient selection for thrombolytic and neuroprotective therapies.  Neurology . 2001;  S48-52