Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

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Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Guidelines for the Primary Prevention of Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

The Unified Parkinson's Disease Rating Scale (UPDRS) is the main outcome measure in clinical trials of Parkinson's disease (PD). The minimal change that represents a clinically meaningful improvement is unknown. The objective of this study was to determine the minimal change on the UPDRS that represents a clinically meaningful improvement in early PD after 6 months of treatment. Data from two independent randomized treatment trials over 6 months involving 603 patients with de novo PD were analyzed to determine the minimal clinically important change (MCIC), referred to the status before treatment, for the UPDRS motor, activities of daily living (ADL), and total scores. An anchor-based method using ratings on a seven-point global clinical improvement was used. A change of five points on the UPDRS motor part was found to be the most appropriate cutoff score for all Hoehn and Yahr stages I to III, and a change of eight points for the UDPRS total score. For the UDPRS ADL score, an MCIC of two points for Hoehn and Yahr stages I/I.5 and II and of three points for Hoehn and Yahr stage II.5/III was the most appropriate cutoff score. These data give the first estimate for cutoffs defining clinically important changes in UPDRS ADL and motor scores. Further studies using larger databases from more diverse study populations are encouraged to better define and solidify the MCIC for the UPDRS.

Minimal clinically important change on the unified Parkinson's disease rating scale.

Post-stroke depression (PSD) is a frequent problem in stroke rehabilitation. Several studies have evaluated association between the lesion location and the risk of depression. Different conclusions and contradictory findings have been published. The aim of the present study was to perform a systematic meta-analysis to evaluate the relationship between PSD and lesion location. We researched PubMed, ISI Web of Science, EMBASE, and systematically reviewed available publications reporting investigations on stroke location and risk of PSD. Subgroup analyses were performed according to the time since stroke onset to assessment for PSD or the source of patients. Odds ratios (ORs) and 95 % confidence intervals (CIs) were used for pooled analyses. Heterogeneity was assessed with Cochran's Q test and I (2) test. Begg's funnel plot and Egger's test were used to examine the publication bias. A total of 43 studies involving 5,507 patients suffering from stroke were included in this meta-analysis. The pooled OR with 95 % CI for the overall association of stroke location and depression risk was 0.99 (0.88-1.11). Subgroups analyses highlighted that only studies with subacute post-stroke group (1-6 months) showed a statistical association between right hemisphere stroke and risk of depression (OR = 0.79, 95 % CI 0.66-0.93). This systematic review offered no support for the hypothesis that lesion of the left hemisphere was associated with an increased risk of depression after stroke. We only find significant association between right hemisphere stroke and incidence of depression for studies within subacute post-stroke phase.

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Post-stroke depression and lesion location: a systematic review

Objective: To assess stroke prevalence and stroke risk factors in Thailand. Material and Method: Thai Epidemiologic Stroke (TES) Study is an ongoing, community based cohort study that has been conducted in five geographic regions of Thailand. Baseline health status survey was started in 2004 and enrollment continued until the end of 2006. All participants who were suspicious of being stroke victims were verified. In this analysis, baseline data of 19,997 participants aged 45 to 80 years were identified and analyzed as a cross-sectional analysis. Results: Three hundred and seventy six subjects were proved to have a stroke thus resulting the crude prevalence of stroke to be 1.88% (95% CI, 1.69 to 2.07). Age standardization to Segi world standard population was 1.81% (95% CI, 1.62 to 1.99). Crude prevalence among adults aged > 65 years was 2.70% (95% CI, 2.28 to 3.11). Stroke prevalence differed among five geographic regions of the country (Bangkok 3.34%, Central region 2.41%, Southern 2.29%, Northern 1.46% and Northeastern 1.09%). Using multiple logistic regression analysis, factors associated with higher stroke prevalence were male gender (p < 0.001), occupational class (p < 0.001), geographic region (p < 0.001), hypertension (p < 0.001), diabetes mellitus (p = 0.002) and hypercholesterolemia (p = 0.026). Conclusion: Stroke prevalence in Thailand from TES study is higher than previous studies, but it is lower than developed countries, probably due to high case fatality rate in Thai population. Geographic variation in stroke prevalence is found more in Bangkok, Central and Southern regions. Longitudinal follow-up of TES cohort study will provide further information on risk factors and incidence of stroke. Keywords: Prevalence of stroke, Stroke risk factors, Geographic gradient, Epidemiology of stroke, Thailand

Prevalence of stroke and stroke risk factors in Thailand: Thai Epidemiologic Stroke (TES) Study.

Objectives: To determine efficacy and tolerability of aspirin plus dipyridamole (combination) versus aspirin alone in acute intervention treatment after acute ischemic stoke among Thai patients. Material and Method: This pilot study enrolled ischemic stroke patients within 48 hours and randomized to aspirin 300 mg/d or combination (aspirin 300 mg/d+ standard release dipyridamole 75 mg thrice a day) and followed up for 6 months. End points were recurrent ischemic stroke, transient ischemic attack and vascular death. Side effects were recorded. National Institutes of Health Stroke Scale was assessed at entry and at 6 months period for determining neurological functions. Results: Of 38 patients, mean age was 64.3 years. Male and female were 52.6% and 47.4% respectively. There were 18 patients in the aspirin group and 20 patients in the combination group. No patient developed end point events or no significant adverse event in both groups. The combination group showed more improvement in neurological function than the aspirin group (p-value 0.009). Conclusion: This pilot study showed equal efficacy and tolerability of the combination group and aspirin alone in acute intervention treatment for prevention of recurrent stroke or vascular death within 6 months.

Comparison between aspirin combined with dipyridamole versus aspirin alone within 48 hours after ischemic stroke event for prevention of recurrent stroke and improvement of neurological function: a preliminary study.

The present study was a prospective controlled study and enrolled the patients whounderwent Lumbar Puncture (LP) from Phramongkutklao Hospital, Thailand. The background characteris-tics were recorded. Standard LP method was done. The patients were randomized to 6 hour-supine recumbenceand < 1hour- (early ambulation) groups. Prevalence and characteristics of PDPH were compared.

Comparison of prevalence of post-dural puncture headache between six hour- supine recumbence and early ambulation after lumbar puncture in thai patients: A randomized controlled study.

Objective : To measure the changes of mean platelet volume (MPV) after using four antiplatelet drugs in acute non-cardioembolic ischemic stroke patients and assess the association of antiplatelets and MPV and stroke outcome. Material and Method : Ischemic stroke survivors with National Institute of Health Stroke Scale (NIHSS) ≤8 were randomly allocated into four groups, receiving aspirin, clopidogrel, combined aspirin and dipyridamole, and cilostazol. The change of MPV, NIHSS, and modified Rankin Scale (mRS) were recorded at baseline and week 4 in all studied groups. MPV was measured using the standard automated blood test for complete blood count. Results : Twenty-one subjects were included in this study. They comprised of five cases in each antiplatelet group, except for aspirin, which had six subjects. Male was 57%, and hypertension was the most common risk factor (61.9%). Most of participants (76%) had small vessel disease. At 4-week, MPV was reduced and NIHSS, mRS were improved in every studied group. Clopidogrel significantly reduced NIHSS score (p = 0.003), and it produced the greatest reduction in MPV compared to others. Conclusion : Every type of antiplatelets included in this study reduced MPV, NIHSS, and mRS in acute non-cardioembolic stroke patients. Clopidogrel improved NIHSS the most. Keywords : Mean platelet volume (MPV), Stroke, Antiplatelet drugs

The Changes in Mean Platelet Volume after Using of Antiplatelet Drugs in Acute Ischemic Stroke: A Randomized Controlled Trial.

Melioidosis which is infection with Burkholderia pseudomallei, is an important cause of sepsis in India, southeast Asia and northern Australia. Mortality is high and treatment is problematic. Neurological melioidosis is unusual but meningoencephalitis, encephalomyelitis and brain microabscess can occur. Dural sinus thrombosis is not an uncommon cerebrovascular disorder with various etiologies. Hypercoagulable state, pregnancy, dehydration, certain blood dyscrasia and contraceptive pills are common causes however meningitis and local head & neck infections may lead to this condition. Dural sinus thrombosis complicating septicemic melioidosis has never been reported. The authors report a 42-year-old Thai man suffering from septicemic melioidosis with dural sinus thrombosis. He had high fever, headache, left hemiparesis, focal seizure and increased intracranial pressure. Diabetes and mild alcoholic cirrhosis were diagnosed in this admission. CT scan, MRI brain and MRV revealed superior saggital sinus thrombosis with complicating venous infarction over right posterior parietal lobe. Hemoculture demonstrated Burkholderia pseudomallei and CSF was acellular. Investigations for causes of dural sinus thrombosis were all negative. This patient gradually improved after treatment with ceftazidime, antiepileptic drug and heparin without clinical recurrence. Neuromelioidosis is a rare syndrome that may present as brain abscess, encephalitis or meningoencephalitis. The authors report dural sinus thrombosis associated with septicemic melioidosis. The authors’ hypothesis of venous thrombosis in the presented case is sepsis induced hypercoagulable state. Physicians should be aware of cerebral venous thrombosis in case of suspicious melioidosis with neurological involvement. Prompt treatment with intravenous heparin and antibiotic is potentially effective. Keywords: Dural sinus thrombosis, Melioidosis, Neuromelioidosis, Venous infarction

Jithanorm Suwantamee

Papers

Prevalence of stroke and stroke risk factors in Thailand: Thai Epidemiologic Stroke (TES) Study.

Comparison between aspirin combined with dipyridamole versus aspirin alone within 48 hours after ischemic stroke event for prevention of recurrent stroke and improvement of neurological function: a preliminary study.

Comparison of prevalence of post-dural puncture headache between six hour- supine recumbence and early ambulation after lumbar puncture in thai patients: A randomized controlled study.

The Changes in Mean Platelet Volume after Using of Antiplatelet Drugs in Acute Ischemic Stroke: A Randomized Controlled Trial.

Dural sinus thrombosis in melioidosis: the first case report.