台大医院脑中风中心

脑中风中心或卒中单元可明显降低卒中患者的死亡率、提高功能恢复、降低住院天数,对于急性卒中患者的监护可提供显著的疗效。台大医院于2002年11月成立卒中中心,提供卒中患者的跨科整合医疗、推展急性卒中团队、卒中的重症治疗、提升血栓溶解与其他特殊治疗、卒中处置的标准作业流程及临床路径、民众及医疗人员卒中继续教育、建立卒中患者登录库、早期康复治疗、卒中患者长期预后随访等,以建构卒中由预防、治疗、监护至长期护理转介及随访的全程规划。     

Essen评分在TIA、缺血性小卒中与大卒中 患者中预测效度的比较

目的 比较Essen卒中风险分层量表（Essen Stroke Risk Score,ESRS）预测短暂性脑缺血发作（transient
ischemic attack,TIA）、缺血性小卒中和缺血性大卒中患者的卒中复发和联合血管事件发生的效度。
方法 以前瞻性、多中心中国国家卒中登记研究（China National Stroke Registry,CNSR）中连续录入
的11 384例完成1年随访的TIA、非心房颤动性缺血性卒中的住院患者为研究人群,小卒中定义为入院
时缺血性卒中患者的美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale,NIHSS）
评分≤3分,大卒中定义为NIHSS评分＞3分。采用曲线下面积（area under the curve,AUC）评价ESRS对
TIA、缺血性小卒中和大卒中患者进行卒中复发和联合血管事件复发风险的分层能力,预测卒中复发
和联合血管事件发生的效度。
结果 本研究有1061例TIA,3254例小卒中,7069例大卒中患者。在TIA患者中,ESRS预测卒中复发
AUC=0.57,预测联合血管事件AUC=0.56;小卒中患者中,ESRS预测卒中复发的AUC=0.58,预测联合
血管事件AUC=0.59;大卒中患者中,ESRS预测卒中复发的AUC=0.60,预测联合血管事件AUC=0.60。
结论 ESRS评分对大卒中的卒中复发/联合血管事件发生的预测效度最高,其次是对小卒中,在TIA
中预测效度最低,但是三组人群中差异无显著性。     

Clinical study of 222 patients with pure motor stroke

The objective was to assess the frequency of pure motor stroke caused by different stroke subtypes and to compare demographic, clinical, neuroimaging, and outcome data of pure motor stroke with those of patients with other lacunar stroke as well as with those of patients with non-lacunar stroke. Data from 2000 patients with acute stroke (n=1761) or transient ischaemic attack (n=239) admitted consecutively to the department of neurology of an acute care 350 bed teaching hospital were prospectively collected in the Sagrat Cor Hospital of Barcelona stroke registry over a 10 year period. For the purpose of the study 222 (12.7%) patients with pure motor stroke were selected. The other study groups included 218 (12.3%) patients with other lacunar strokes and 1321 (75%) patients with non-lacunar stroke. In relation to stroke subtype, lacunar infarcts were found in 189 (85%) patients, whereas ischaemic lacunar syndromes not due to lacunar infarcts occurred in 23 (10.4%) patients (atherothrombotic stroke in 12, cardioembolic stroke in seven, infarction of undetermined origin in three, and infarction of unusual aetiology in one) and haemorrhagic lacunar syndromes in 10 (4.5%). Patients with pure motor stroke showed a better outcome than patients with non-lacunar stroke with a significantly lower number of complications and in hospital mortality rate, shorter duration of hospital stay, and a higher number of symptom free patients at hospital discharge. After multivariate analysis, hypertension, diabetes, obesity, hyperlipidaemia, non-sudden stroke onset, internal capsule involvement, and pons topography seemed to be independent factors of pure motor stroke in patients with acute stroke. In conclusion, about one of every 10 patients with acute stroke had a pure motor stroke. Pure motor stroke was caused by a lacunar infarct in 85% of patients and by other stroke subtypes in 15%. Several clinical features are more frequent in patients with pure motor stroke than in patients with non-lacunar stroke.     

院内缺血性卒中的诊疗现状与挑战

院内卒中是指因其他疾病住院的患者在住院期间发生的急性卒中,其中最常见的类型是缺血性卒中.与社区卒中相比,院内缺血性卒中的危险因素和发病机制更为复杂,除了栓塞、低灌注、高凝状态,医源性因素也是重要的致病原因之一.院内缺血性卒中患者的不良功能预后和死亡率均较社区患者显著增高,研究提示基础疾病较多、围手术期栓塞所致脑梗死范围...     

Japan stroke scales and its application for stroke]

There are many stroke scales currently available for estimating the severity and outcome of stroke. However, none of the stroke scales have been able to objectively quantify the severity of stroke. The Japan Stroke Society formed a subcommittee to task force the development of an innovative, quantifiable stroke scale. Conjoint analysis was utilized to compile this data. Finally, they developed a novel, and quantifiable Japan Stroke for the acute phase of stroke (JSS) (Stroke 32: 1800-1807, 2001). In addition to standard JSS, the Japan Stroke Scale Motor Function and Japan Stroke scale--Higher Cortical Function were finalized. These stroke scales are all parametric stroke scales. We utilize the stroke scales to monitor stroke patients, to start clinical pathway on patients with lacunas infarction after deciding whether severity of stroke is suitable for the clinical pathway by JSS. We use the JSS for the clinical studies of stroke patients. Furthermore, the JSS was utilized in the phase 2 trial of a new treatment in stroke patients which had significant statistical power. The scales were also introduced to the stroke databank. Therefore, these scales are useful to monitoring the neurological damage of stroke patients in the acute and chronic phase and to estimating the severity of stroke symptoms and predicting stroke outcome in clinical studies. They also have a potential to prove the efficacy of treatments through parametric analysis.     

Sensitivity and Specificity of an Adult Stroke Screening Tool in Childhood Ischemic Stroke

BackgroundThere are frequent delays in the diagnosis of acute pediatric ischemic stroke. A screening tool that could increase the suspicion of acute ischemic stroke could aid early recognition and might improve initial care. An earlier study reported that children with acute ischemic stroke have signs that can be recognized with two adult stroke scales. We tested the hypothesis that an adult stroke scale could distinguish children with acute ischemic stroke from children with acute focal neurological deficits not due to stroke.MethodsWe retrospectively applied an adult stroke scale to the recorded examinations of 53 children with acute symptomatic acute ischemic stroke and 53 age-matched control subjects who presented with focal neurological deficits. We examined the sensitivity and specificity of the stroke scale and the occurrence of acute seizures as predictors of stroke status.ResultsThe total stroke scale did not differentiate children with acute ischemic stroke from those who had acute deficits from nonstroke causes; however, the presence of arm weakness was significantly associated with stroke cases. Acute seizures were significantly associated with stroke cases.ConclusionsAn adult stroke scale is not sensitive or specific to distinguish children with acute ischemic stroke from those with nonstroke focal neurological deficits. The development of a pediatric acute ischemic stroke screening tool should include arm weakness and perhaps acute seizures as core elements. Such a scale must account for the limitations of language in young or intellectually disabled children.     

Características de las unidades de ictus y equipos de ictus en España en el año 2018. Proyecto Pre2Ictus

IntroductionThe aim of this work is to describe the characteristics of stroke units and stroke teams in Spain.MethodWe performed a cross-sectional study based on an ad hoc questionnaire designed by 5 experts and addressed to neurologists leading stroke units/teams that had been operational for ≥ 1 year.ResultsThe survey was completed by 43 stroke units (61% of units in Spain) and 14 stroke teams. The mean (SD) number of neurologists assigned to each unit/team is 4±3. 98% of stroke units (and 38% of stroke teams) have a neurologist on-call available 24hours, 365 days. 98% of stroke units (79% of stroke teams) have specialised nurse, 95% of units (71% of stroke teams) auxiliary personnel, 86% of units (71% of stroke teams) social worker, 81% of stroke units (71% of stroke teams) have a rehabilitation physician and 81% of stroke units (86% of stroke teams) a physiotherapist. Most stroke units (80%) have 4-6 beds with continuous non-invasive monitoring. The mean number of unmonitored beds is 14 (8) for stroke units and 12 (7) for stroke teams. The mean duration of non-invasive monitoring is 3 (1) days. All stroke units and 86% of stroke teams have intravenous thrombolysis available, and 81% of stroke units and 21% of stroke teams are able to perform mechanical thrombectomy, whereas the remaining centres have referral pathways in place. Telestroke systems are available at 44% of stroke units, providing support to a mean of 4 (3) centres. Activity is recorded in clinical registries by 77% of stroke units and 50% of stroke teams, but less than 75% of data is completed in 25% of cases.ConclusionsMost stroke units/teams comply with the current recommendations. The systematic use of clinical registries should be improved to further improve patient care.     

Stroke incidence and prevalence in Europe: a review of available data

Reliable data on stroke incidence and prevalence are essential for calculating the burden of stroke and the planning of prevention and treatment of stroke patients. In the current study we have reviewed the published data from EU countries, Iceland, Norway, and Switzerland, and provide WHO estimates for stroke incidence and prevalence in these countries. Studies on stroke epidemiology published in peer-reviewed journals during the past 10 years were identified using Medline/PubMed searches, and reviewed using the structure of WHO's stroke component of the WHO InfoBase. WHO estimates for stroke incidence and prevalence for each country were calculated from routine mortality statistics. Rates from studies that met the 'ideal' criteria were compared with WHO's estimates. Forty-four incidence studies and 12 prevalence studies were identified. There were several methodological differences that hampered comparisons of data. WHO stroke estimates were in good agreement with results from 'ideal' stroke population studies. According to the WHO estimates the number of stroke events in these selected countries is likely to increase from 1.1 million per year in 2000 to more than 1.5 million per year in 2025 solely because of the demographic changes. Until better and more stroke studies are available, the WHO stroke estimates may provide the best data for understanding the stroke burden in countries where no stroke data currently exists. A standardized protocol for stroke surveillance is recommended.     

卒中领域护士的卒中专科护士培训需求分析

目的 分析我国卒中领域护士的卒中专科护士培训需求,为开展卒中专科护士培训及建立专科护士培养体系提供参考依据.方法 选取全国20余省市的2630名卒中领域护士为研究对象,进行网络问卷调查,统计护士对开展卒中专科护士培训的需求及影响因素.结果 2531名(96.2％)的护士认为有必要开展卒中专科护士资格认证.护理管理者(O...     

Stroke knowledge among stroke support group members

BACKGROUND AND PURPOSE: Community stroke education is needed to improve early stroke recognition and reduce delays in the referral of stroke patients. In some regions, stroke support groups are important promoters of regional stroke education. However, there are no data about the level of stroke knowledge among support group members that support this promotional role. METHODS: We performed a cross-sectional questionnaire survey among 11 German stroke support groups. The questionnaire asked for stroke knowledge and sociodemographic and medical data. Stroke knowledge was excellent if a participant knew (1) at least 2 stroke symptoms (good symptom knowledge) and (2) at least 2 stroke risk factors (good risk factor knowledge), as well as knowing (3) that immediate hospital admission or an emergency call is necessary in case of stroke (good action knowledge). RESULTS: A total of 133 members (96.2%) of 11 stroke support groups took part in the study. Mean age was 65.3 years (SD 11.2 years). Fifty-four percent of subjects were female, 72.8% were retired, and 69.8% were stroke patients. Of the participants, 80.3% had good symptom knowledge, 64.7% had good risk factor knowledge, and 79.7% had good action knowledge. Stroke knowledge was excellent in 44.0% of subjects. Logistic regression analysis showed that age <70 years and not having had a stroke were significant predictors for excellent stroke knowledge. CONCLUSIONS: Overall, members of stroke support groups are well informed about all aspects of modern stroke care. Because of their knowledge and personal experience, support groups should be viewed as important partners in community stroke education.     

Clinical Characteristics of Driving-related Stroke Occurring as a Recurrent Stroke

Background: Although the number of seemingly healthy subjects who suffer a minor stroke increases, there are no data on how frequently they sustain another stroke while driving. Methods: A single-center, retrospective study was conducted to clarify the clinical characteristics of driving-related stroke occurring as a recurrent stroke by analyzing data prospectively acquired between January 2009 and June 2019 on 3452 acute stroke patients. Results: One hundred-thirty five patients (85 ischemic stroke [IS] and 50 hemorrhagic stroke [HS]) had suffered a driving-related stroke. Of them, 22 (16%) had suffered a prior stroke (recurrent stroke group), while 113 had never suffered a stroke before (first-time stroke group). While the use of anti-thrombotics was significantly more common in the RS group, other variables including the frequency of road traffic accidents, did not differ significantly. The first stroke–recurrent stroke interval ranged from 0.2 to 18 years. The stroke type at the time of recurrence was IS in the majority of patients with prior IS. When compared to 432 patients with recurrent IS unrelated to driving, patients with recurrent IS related to driving (n = 16) had significantly higher frequency of lacunar strokes (56% vs 27%, P = .02) and lower frequency of cardioembolic strokes (6% vs 29%, P = .04). Conclusion: The current finding that 16% of patients who presented with driving-related stroke had previously suffered a stroke indicates that drivers with a prior stroke may be at increased risk for recurrent stroke while driving, and prolonged follow-up be necessary for minor stroke patients who resume driving.     

The Copenhagen Stroke Study experience.

The Copenhagen Stroke (COST) Study was a prospective, consecutive, community-based study of 1,197 patients with acute stroke who underwent acute stroke care and rehabilitation in a stroke unit setting. This article reviews the results of this study with respect to (1) the effect of organized stroke care and rehabilitation, (2) neurological outcome and functional outcome of stroke in relation to initial stroke severity and functional disability, (3) recovery of upper-extremity function and walking, (4) time course of neurological and functional recovery relative to initial stroke severity, (5) mechanisms of stroke recovery, and (6) the effect on stroke recovery of various demographic, medical, and pathophysiological factors, such as stroke in progression, spontaneous reperfusion age, diabetes, blood glucose on admission, stroke type (hemorrhage/infarction), silent infarction, and leuco-araiosis.     

脑卒中患者急性期血糖水平与病情严重程度的关系

目的探讨脑卒中患者急性期血糖水平与病情严重程度的关系。方法采用前瞻性队列研究的方法检测2005-02～2008-02所有入院病程<24h的340例脑卒中患者(其中出血性卒中153例,缺血性卒中187例)的空腹血糖水平。采用斯勘的纳维亚卒中评分(SSS)量表评价患者入院时神经功能缺损程度。按卒中类型和空腹血糖水平分组,比较各组间指标差异。结果出血性卒中组空腹血糖水平及SSS评分高于缺血性卒中组(P<0.05);血糖升高组SSS评分高于正常血糖组(P<0.01)。结论急性脑卒中患者血糖越高,病情越重,其中出血性卒中更显著。对急性脑卒中患者检测血糖有利于病情的判断。     

Recurrent Ischemic Stroke – A Systematic Review and Meta-Analysis

ObjectivesRecurrent stroke remains a challenge though secondary prevention is initiated immediately post-stroke. Stroke subtype may determine the risk of recurrent stroke and require specific preventive measures. We aimed to identify subtype-specific stroke recurrence and associated risk factors over time.Methods and materialsA systematic review was performed using PubMed and Embase for studies including adults >18 years, first-ever ischemic stroke in population-based observational studies or registries, documented TOAST-criteria and minimum 1-year follow-up. Meta-analysis on stroke recurrence rate was performed. Final search: November 2019.ResultsThe search retrieved 26 studies (between 1997 and 2019). Stroke recurrence rate ranged from 5.7% to 51.3%. Recurrent stroke was most frequent in large artery atherosclerosis (LAA) and cardioembolic (CE) stroke with recurrent stroke similar to index stroke subtype. We identified a lower recurrence rate for small vessel occlusion (SVO) stroke with recurrence frequently of another stroke subtype. Based on a meta-analysis the summary proportion recurrence rate of recurrent stroke in studies using TOAST-criteria = 0.12 and = 0.14 in studies using TOAST-like criteria. Hypertension, diabetes mellitus, atrial fibrillation previous transient ischemic attack, and high stroke severity were independent risk factors for recurrence.ConclusionStroke recurrence rates seem unchanged over time despite the use of secondary prevention. The highest recurrence rate is in LAA and CE stroke eliciting same subtype recurrent stroke. A lower recurrence rate is seen with SVO stroke with a more diverse recurrence pattern. Extensive workup is important in all stroke subtypes - including SVO stroke. Future research needs to identify better preventive treatment and improve compliance to risk factor prevention to reduce stroke recurrence.     

Evaluation of single nucleotide polymorphisms in the phosphodiesterase 4D gene (PDE4D) and their association with ischaemic stroke in a large German cohort

Genetic fine mapping of the first locus identified for genetically complex forms of stroke, STRK1 (which has been mapped to chromosome 5q12 in Icelandic families), has identified the phosphodiesterase 4D gene (PDE4D) gene as a good candidate gene. Association analysis of single nucleotide polymorphisms (SNPs) in the PDE4D gene in an Icelandic stroke cohort demonstrated genetic association between six SNPs in the 5' region of PDE4D and ischaemic stroke. The present study aimed to test whether the same six SNPs in PDE4D were also associated with stroke in a large stroke cohort from northern Germany (stroke patients with acute completed ischaemic stroke: n = 1181; population based controls: n = 1569). None of the six SNPs showed significant association with ischaemic stroke in the whole stroke sample before and after adjustment for conventional stroke risk factors (age, sex, hypertension, diabetes, and hypercholesterolaemia). Haplotype analysis did also not reveal any significant association. Marginally positive statistical measures of association in the subgroup with cardioembolic stroke did not remain significant after correction for multiple testing. In conclusion, this study was unable to demonstrate an association between the six SNPs which had showed significant single marker association with stroke in the Icelandic stroke cohort and ischaemic stroke in a large German cohort.     

Training and experience in stroke units

The social and sanitary benefits provided by stroke units can not be achieved without an adequate training and learning process. This dynamic process consists of the progressive acquisition of: a) a greater degree of expertise in stroke management by the stroke team; b) better coordination between the stroke team, extrahospitalary emergency medical systems, and other in-hospital professionals involved in stroke assistance, and c) more human and technological resources dedicated to improve attention to stroke patients. The higher degree of experience in a stroke unit will have an effect: a) improving (time and quality) the diagnostic process in acute stroke patients; b) increasing the proportion of patients treated with thrombolysis; c) reducing extra and intrahospitalary latencies to stroke treatment, and d) improving stroke outcome in terms of reducing mortality and increasing functional independence. Finally, comprehensive stroke centers will achieve a higher degree of organizational complexity that will permit a global assessment of the most advanced aspects in stroke management, including education and research.     

Family history of stroke and death or vascular events within one year after ischemic stroke

ABSTRACT

Background and aims: The association between family history of stroke and clinical outcomes after ischemic stroke remains unclear.

Methods: A total of 3878 acute ischemic stroke patients from CATIS were included. The participants with ischemic stroke were divided into groups according to types of family history of stroke, stroke onset age and stroke subtypes. The primary outcome was a composite outcome of death and vascular events within 1 year after stroke. Multivariable Cox proportional hazard models were used to analyze the association between family history of stroke and other variables and clinical outcomes.

Results: Among 3878 ischemic stroke patients, 708 (18.26%) had a history of stroke in their first-degree relatives and 399 experienced a composite outcome (172 patients died and 227 experienced vascular events) within 1 year after stroke. Overall family history was not associated with the primary outcome (HR, 1.08; 95% CI, 0.37–3.19). However, the patients with maternal stroke history (HR, 1.87; 95% CI, 1.31–2.97), stroke onset age<55 years with family history (HR, 2.02; 95% CI, 1.08–3.80) and thrombotic stroke in the patients with family history (HR, 1.46; 95% CI, 1.00–2.12) were associated with primary outcome, death and vascular events, respectively.

Conclusion: This study suggests that maternal stroke history, age<55 years at stroke onset and thrombotic stroke in the patients with a family history are associated with poor outcomes after stroke. Further studies from other samples are needed to replicate our findings due to a reason for excluding some severe stroke patients in this study.     

Long-term outcome after ischaemic stroke/transient ischaemic attack

During the first 30 days after a stroke, the case fatality is about 25% and the major cause of death is the index stroke and its sequelae. The most consistent predictor of 30-day mortality after stroke is stroke severity. Other predictors include increasing age, a history of previous stroke, cardiac failure, and a high blood glucose concentration and white blood cell count. Other less common, but important, causes of early mortality are recurrent ischaemic stroke and a coronary event. The risk of a recurrent cerebrovascular event is highest in the first month (4%) and year (12%) after a stroke and transient ischaemic attack (TIA), probably reflecting the presence of active, unstable atherosclerotic plaque. Thereafter, the risk of a recurrent cerebrovascular event falls to about 5% per year, similar to the risk of a coronary event. During years 1-5 after a TIA and ischaemic stroke, cardiovascular disease increasingly becomes the major cause of death, reflecting the generalized nature of atherothrombosis, the most common cause of the index stroke. The most robust predictor of death within 1-5 years after stroke is increasing age, closely followed by cardiac failure. Additional baseline predictors of longer-term mortality include a history of previous symptomatic atherothrombosis (TIA, ischaemic stroke, peripheral arterial disease, and early-onset ischaemic heart disease), risk factors for atherothrombosis (smoking), other heart diseases (cardiac failure, atrial fibrillation) and increasing stroke severity. Lacunar syndromes can be predictive of relative longevity. At 5 years after stroke, survival is about 40%, and about half of survivors are disabled and dependent. The most robust predictors of disability at 5 years after stroke are increasing age, stroke severity, and recurrent stroke. The most powerful predictor of early recurrent stroke (within 30 days after stroke) is an atherosclerotic ischaemic stroke caused by large-artery atherosclerosis with >50% stenosis, whereas the strongest predictor of stroke recurrence over 5 years is diabetes. Other predictors of recurrent stroke include increasing age, previous TIA, atrial fibrillation, high alcohol consumption, haemorrhagic index stroke, and hypertension at discharge. The clinical implication of these findings is that strategies for optimizing long-term outcome after TIA and stroke should be directed toward reducing the high risk of recurrent stroke and coronary events by removing/recanalizing the symptomatic atherosclerotic plaque, controlling the underlying causal vascular risk factors, and administering long-term, effective antiplatelet therapy.     

Awareness of stroke risk in chagasic stroke patients

BACKGROUND: Reduction in stroke risk may depend on the general population's knowledge of stroke. In South America, chagasic myocardiopathy is independently associated with ischemic stroke. OBJECTIVE: The aim of this study was to evaluate awareness of Chagas' disease (CD) as a stroke risk factor and to determine the frequency of stroke patients that are diagnosed as having CD after stroke. METHODS: Eighty CD stroke patients and 140 non-chagasic stroke patients (53.2% males; mean age 60 years), consecutively admitted to the hospital during 2005 were interviewed with a questionnaire. Demographic variables included age, sex, ethnicity, education, previous history of stroke, vascular risk factors, social background information and several questions regarding awareness of CD as a stroke risk factor. A logistic regression model was developed to identify social variables that could predict the risk of CD stroke. RESULTS: The diagnosis of CD was established after stroke in 42.5% of CD stroke patients. Most respondents (95%) were not aware of stroke risk in CD. Chagasic patients had the lowest rate of awareness about stroke risk (2.5 vs 7.1%), although they had the greatest knowledge about the kissing bug vector (83.7 vs 62.1%; p<0.001). The main social variables associated with CD stroke were: having family members with Chagas' disease (p<0.0001; odds ratio 10.1; 95% CI 3.6-16.1) and a past history of living in a mud-brick house during childhood (p<0.001; odds ratio 8.9; 95% CI: 4.1-24.6). CONCLUSION: Awareness about CD as a risk factor of stroke is low. Educational campaigns about risk of stroke in CD patients are encouraged.