Acute Stroke

Full Title: Acute Stroke: Evaluation and Treatment

July 2005

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Structured Abstract

Objectives: Researchers addressed the following key questions:

1. What interventions in acute stroke (<24 hours from onset) are effective in reducing morbidity and mortality?
2. How does safety and effectiveness of these interventions vary by timing in relation to onset of symptoms?
3. What is the evidence that specific systems of care improve outcomes of acute stroke?

Data Sources: Investigators searched MEDLINE®, EMBASE, and CINAHL® as well as the Stroke Trials Directory, the Cochrane Stroke Group Registry, and conference proceedings from the 28th International Stroke Conference 2003 and the American Academy of Neurology Annual Meeting. The Effective Practices and Organization of Care (EPOC) registry was searched by the Cochrane review group.

Review Methods: Two reviewers assessed all evidence search results; they also screened all studies by reviewing the bibliographic records, and when meeting inclusion criteria, the subsequent full-text of the record. Two reviewers independently abstracted the contents of each included study using an electronic Data Abstraction form developed especially for this review.

Results: Currently, available data do not support a role for surgery in the treatment of acute intracerebral hemorrhage. Results, however, do not preclude benefit from surgery which involves modalities other than those studied in the acute trials (e.g., minimally invasive technologies) or treatment of hemispheric hematoma at very early timeframes. Further, the available literature did not comment on cerebellar hematoma and thus this analysis does not apply to infratentorial hemorrhage.

Intravenous (IV) thrombolysis with tissue plasminogen activator (tPA) is effective and efficacious for acute ischemic stroke within 3 hours of symptom onset. The effectiveness is strongly linked to time since onset of symptoms with shorter times demonstrating significantly better outcomes. Patient level meta-analysis suggests that treatment may be effective up to 270 minutes with treatment increasing the odds of death beyond 270 minutes. Further work is needed to define the risks and benefits outside the 3-hour window prior to advocating widespread use in these patients.

Conclusions: Further studies are required to determine whether the use of antihypertensive agents for acute intracerebral hemorrhage (ICH) and glucose management for acute ischemic stroke is of benefit (or results in harm). Intra-arterial therapy remains an option for a subgroup of patients with large vessel occlusions principally in the middle cerebral artery distribution. Ultrasound for enhancement of thrombolysis in the setting of middle cerebral artery (MCA) occlusion has suggested efficacy in two studies, and a definitive trial to demonstrate the benefit and risks is required. Computerized axial tomography (CT) and magnetic resonance imaging (MRI) imaging for patient selection and prediction of outcome in thrombolysis has yet to be prospectively evaluated. As CT is widely available, this system deserves further exploration. Diffusion-weighted MRI (DWI) lesions correlate with the presence of infarcts in small cohorts of patients and time to peak measures on early scans may correlate with recanalization after IV tPA treatment. These findings require reproduction and further evaluation. Because of a lack of independent evaluation, it is unclear whether community education programs regarding the symptoms of stroke are effective in improving patient outcomes.

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Acute Stroke: Evaluation and Treatment

• Summary (Publication No. 05-E023-1).
• Evidence Report (Publication No. 05-E023-2): (PDF File, 1.5 MB) Plugin Software Help.

Evidence-based Practice Center: University of Ottawa
Topic Nominator and Funder: American Association of Health Plans

Current as of July 2005