Interobserver agreement for the assessment of handicap in stroke patients was investigated in a group of 10 senior neurologists and 24 residents from two centers. One hundred patients were separately interviewed by two physicians in different combinations. The degree of handicap was recorded by each observer on the modified Rankin scale, which has six grades (0-5). The agreement rates were corrected for chance (kappa statistics). Both physicians agreed on the degree of handicap in 65 patients; they differed by one grade in 32 patients and by two grades in 3 patients. Kappa for all pairwise observations was 0.56; the value for weighted kappa (with quadratic disagreement weights) was 0.91. Our results confirm the value of the modified Rankin scale in the assessment of handicap in stroke patients; nevertheless, further improvements are possible.

Interobserver agreement for the assessment of handicap in stroke patients.

In 1994, a panel appointed by the Stroke Council of the American Heart Association authored guidelines for the management of patients with acute ischemic stroke.1 After the approval of the use of intravenous recombinant tissue plasminogen activator (rtPA) for treatment of acute ischemic stroke by the Food and Drug Administration, the guidelines were supplemented by a series of recommendations 2 years later.2 Several promising interventions for the treatment of acute ischemic stroke have subsequently been tested in clinical trials, and other components of acute management have been evaluated since the previous guidelines were published. These new data have prompted the present revision of the prior guideline statement.

The goal of these guidelines is to provide updated recommendations that can be used by primary care physicians, emergency medicine physicians, neurologists, and other physicians who provide acute stroke care from admission to an emergency department through the first 24 to 48 hours of hospitalization by addressing the diagnosis and emergent treatment of the acute ischemic stroke in addition to the management of its acute and subacute neurological and medical complications.

Several groups have now written statements about management of stroke.3–7 These statements also include recommendations about public educational programs, the organization of stroke resources, and other aspects of patient management. For example, the Brain Attack Coalition published recommendations for organizing stroke services in a community, and the recommendations of the American Heart Association Emergency Cardiovascular Care Committee provide an outline for emergency medical services.6 The current panel elected not to duplicate these recent efforts.

Therapies to prevent recurrent stroke, also a component of acute management, are similar to prophylactic medical or surgical therapies used for patients with transient ischemic attacks and other high-risk patients. The reader is referred to relevant recent statements for additional information.8,9 

In developing …

https://www.pennstatehershey.org/c/document_library/get_file?folderId=115233&name=DLFE-2413.pdf

Guidelines for the Early Management of Patients With Ischemic Stroke A Scientific Statement From the Stroke Council of the American Stroke Association

On presente les objectifs et le protocole general de l'essai, les centres participants, l'inclusion des patients, les taux de l'hematocrite, les criteres d'inclinaison et exclusion, la cotation et la stratification, le protocole du traitement, l'evaluation du traitement, l'ethique, la taille de l'echantillon de malade, le controle de la qualite et le programme

Multicenter trial of hemodilution in ischemic stroke--background and study protocol. Scandinavian Stroke Study Group.

This article serves as an update of “Guidelines for the Early Management of Patients With Ischemic Stroke,” published in Stroke in 2003 (http://stroke.ahajournals.org/cgi/content/full/34/4/1056). This update is intended to reflect advances in the field since the publication of the full guidelines. See Tables 1 and 2⇓, reprinted in this article from the 2003 document, for explanations of grade (strength of recommendation). 

View this table:

TABLE 1. Levels of Evidence 



View this table:

TABLE 2. Quality of Evidence Ratings for Radiological Diagnostic Tests 



CT remains the most widely used neuroimaging technique for the evaluation of patients with suspected acute ischemic stroke. Quantitative CT-based scoring systems (eg, the Alberta Stroke Program Early CT Score [ASPECTS]) are useful for identifying patients who are unlikely to recover fully despite thrombolytic therapy.1 Substantial agreement between the ASPECTS rating performed in real time and the score obtained later by an expert can be achieved when used by an experienced reader, but correlations are not perfect (weighted κ 0.69, 95% CI 0.59 to 0.79).2 This scoring system has not been assessed in general clinical practice and is limited to use in patients with infarctions suspected to be in the distribution of the middle cerebral artery. In addition, advances in CT technology, including the development of CT angiography and perfusion studies, may affect future recommendations about the use of CT in the evaluation of patients with suspected stroke.

MRI techniques also are used widely in the assessment of patients with suspected stroke or transient ischemic attack (TIA). For example, a retrospective analysis of patients having diffusion-weighted MRI studies within 3 days of TIA demonstrated relevant abnormalities in 21% of cases.3 Changes in ≈44% of cases are detected by T2-weighted or fluid attenuation inversion recovery MRI studies.

A scientific statement authored by a panel of the American Heart Association focused on …

Guidelines for the Early Management of Patients With Ischemic Stroke 2005 Guidelines Update A Scientific Statement From the Stroke Council of the American Heart Association/American Stroke Association

✓ From a larger series of autopsies with subarachnoid hemorrhage (SAH), 20 cases were selected for the known complication of cerebral vasospasm. Evidence for vasospasm was radiological and pathological in 17 cases and pathological alone in three. A systematic histological examination of the large arteries in places known formerly to have been in spasm showed that, in the 12 early cases (death before 3 weeks), there were relevant changes in all the layers of the arterial wall, the most significant being evidence of necrosis in the tunica media. In the eight late cases (death after 3 weeks), in addition to the sequelae of the earlier acute changes, there was marked concentric intimal thickening by subendothelial fibrosis, again located in the segments of arteries formerly in spasm. Changes were also found in the small arteries, capillaries, and veins, both in the early and late cases but these changes, although striking, were thought to be caused by the ischemia due to the vasospasm; similar changes were al...

Cerebral artery spasm: A histological study at necropsy of the blood vessels in cases of subarachnoid hemorrhage

A blind controlled trial of dextran 40 in ischaemic stroke is reported. In the treated group mortality in the acute stage in patients with severe strokes was significantly reduced but survivors were severely disabled and six months later no significant benefit could be detected. In less severe strokes no effect of treatment was found. It is concluded that the action of dextran 40 in reducing acute mortality probably lay in preventing or reversing cerebral swelling but no evidence of the expected action in reducing the area of infarction following improved blood flow was found. The importance of extending assessment beyond the two weeks customary in therapeutic trials in stroke is emphasized.

W. B. Matthews

Papers

A blind controlled trial of dextran 40 in the treatment of ischæmic stroke