Prognosis of transient ischemic attacks in the Oxfordshire Community Stroke Project

In a community-based study of approximately 105,000 people, 184 presented with a transient ischemic attack during the 5 years between 1981 and 1986; we believe these persons represent almost all new cases of transient ischemic attack going to a doctor during that period. During a mean follow-up of 3.7 years 49 patients died, 45 had a first-ever stroke, and 17 had a myocardial infarction. Cardiac disease accounted for 17 (35%) deaths, while stroke was the cause of death in 15 patients (31%). The average actuarial risk of death was approximately 6.3%/yr, slightly greater than that expected for similar people without transient ischemic attacks (risk ratio [observed divided by expected] = 1.4). The actuarial risk of stroke was 11.6% during the first year after a transient ischemic attack and approximately 5.9%/yr over the first 5 years. Patients who suffered a transient ischemic attack had a 13-fold excess risk of stroke during the first year and a sevenfold excess risk over the first 7 years compared with people without transient ischemic attacks. The actuarial risk of death, stroke, or myocardial infarction over the first 5 years after a transient ischemic attack was approximately 8.4%/yr. The prognosis in this community-based cohort was better than that in previous reports. The high early risk of stroke means that investigation and treatment of new cases should commence as soon as possible.     

A systematic review of barriers to delivery of thrombolysis for acute stroke

BACKGROUND AND PURPOSE: Barriers within the patient pathway can prevent early administration of thrombolytic therapy in patients admitted with acute stroke. This systematic review aimed to identify such barriers that have been reported in the medical literature. METHODS: We searched MEDLINE and EMBASE for prospective and retrospective observational studies that assessed the nature of barriers to delivery of thrombolysis for acute stroke. RESULTS: We identified 54 eligible studies (including a total of 39030 patients). The reported barriers included: (i). the patient or family did not recognise symptoms of stroke or seek urgent help, (ii). the general practitioner (rather than an ambulance) was called first, (iii). the paramedics and emergency department staff triaged stroke as non-urgent, (iv). delays in neuroimaging, (v). inefficient process of in-hospital emergency stroke care, (vi). difficulties in obtaining consent for thrombolysis, and (vii). physicians' uncertainty about administering thrombolysis. CONCLUSIONS: We identified important pre-hospital and in-hospital barriers that should be overcome if thrombolysis is to be administered to stroke patients efficiently and equitably.