Lichtman JH, Krumholz HM, Wang Y, Radford MJ, Brass LM.
Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, USA. Judith.Lichtman@yale.edu
Circulation. 2002 Mar 5;105(9):E9079-80.

BACKGROUND: Stroke is an important outcome after acute myocardial infarction. Studies that have examined this relationship have largely excluded older patients, even though half of stroke admissions occur among patients 75 years of age and older. METHODS AND RESULTS: Among 111 023 medicare patients discharged with a principal diagnosis of acute myocardial infarction during an 8-month period in 1994 to 1995, we identified hospital admissions for ischemic stroke within 6 months of discharge. The rate of admission was 2.5% within 6 months. Independent predictors of ischemic stroke were age greater-than-or-equal 75 years, black race, no aspirin at discharge, frailty, prior stroke, atrial fibrillation, diabetes, hypertension, and history of peripheral vascular disease. To identify individuals at increased risk for stroke, a risk stratification score was constructed from identified factors. The 6-month stroke admission rate for patients with a score of 4 or higher (approximately 20% of the total sample) was approximately 4%. CONCLUSIONS: The risk of stroke after myocardial infarction is substantial, with about 1 in 40 patients suffering an ischemic stroke within 6 months of discharge. Simple clinical factors can predict the risk of stroke and, based on these factors, we identified 20% of older patients who have a 1 in 25 chance of being hospitalized for a stroke within 6 months of discharge.

Source: PubMed

Experience with a questionnaire administered by emergency medical service for pre-hospital identification of patients with acute stroke.

Neurol Sci 2001 Oct;22(5):357-61
Camerlingo M, Casto L, Censori B, Ferraro B, Gazzaniga G, Partziguian T, Signore M, Panagia C, Fascendini A, Cesana B M, Mamoli A.
Department of Neurology, Ospedali Riuniti, Bergamo, Italy.

We prospectively verified whether an ad-hoc questionnaire administered by phone supports pre-hospital suspicion of stroke in order to reduce the time before care is given. From June 1996 to May 1997, physicians of the Emergency Medical Service in the area of Bergamo, Italy asked all people calling for a patient with symptoms and signs suggesting a cerebral vascular injury to immediately answer some questions on common symptoms and signs of stroke. The medical records of the patients hospitalized at Ospedali Riuniti of Bergamo were reviewed at the end of the study by a single neurologist, skilled in stroke management and blinded to the questionnaires. Sensitivity and specificity, in addition to positive and negative predictive values, of single questions versus final diagnosis were assessed. Logistic regression analysis was also performed to identify those questions useful to suspect strokes. We collected 143 valid questionnaires, related to 63 men and 80 women, aged 34-99 years (mean, 71.8 years). The question concerning headache had the lowest sensitivity and specificity, respectively 57.1% and 36.5%, and the question concerning leg palsy had the highest sensitivity and specificity, respectively 82.0% and 52.4%. Multivariate analysis identified questions on facial and leg palsy as independent predictors of a final diagnosis of stroke. A few questions on motor deficits proposed by emergency medical service operators may be useful in the pre-hospital identification of stroke patients. Concordance of any questions versus final diagnosis of stroke was, however, far to be satisfying. Thus, our experience supports the need for an educational program to improve the efficiency of a pre-hospital diagnosis of stroke.

Source: PubMed

Acute cerebral infarction-diagnosis of subgroups

Salvesen R.
Nevrologisk avdeling Nordland Sentralsykehus 8092 Bodo. rolf.salvesen@c2i.net
Tidsskr Nor Laegeforen 2002 Jan 20;122(2):183-5

BACKGROUND: Subclassification of cerebral infarcts is crucial in order to optimise and differentiate therapy. If we are to apply specific treatment modalities early while neurological deficits are still reversible, we need a fast diagnosis that reliably predicts etiology. MATERIAL AND METHODS: The early clinical classification into Oxford subgroups is presented with an assessment of their predictive value in relation to aetiology (TOAST classification). RESULTS: The various Oxford subgroups correlate well to the topography of the infarction demonstrated by neuroradiology, to the vascular aetiology as demonstrated by ultrasound techniques, and to the "aetiologic" subgroup as determined by a full diagnostic work-up. However, the correlation is not sufficient to guide potentially specific treatments of subgroups if the treatment in question has serious side effects (e.g. thrombolysis). However, if the clinical diagnosis is supplemented with diffusion-weighted MRI and perhaps MR angiography, the predictive value of the diagnosis is extremely high. INTERPRETATION: Very early clinical diagnosis of cerebral infarction must be supplemented with diffusion-weighted MRI to make the diagnostic precision sufficiently high to guide the application of specific treatments with potentially serious side effects.

Source: PubMed