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Stroke Alert: A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Interim Chair and Neurologist-in-Chief, Director, Division of Stroke & Critical Care Neurology, Weill Cornell Medical College and New York Presbyterian Hospital
Risk of Stroke and Cardiovascular Death from Non-Steroidal Anti-Inflammatory Medications (NSAIDs)
Source: Trelle S, Reichenbach S, Wandel S, et. al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: Network meta-analysis. BMJ 2011;342:c7086. doi:10.1136/bmj.c7086
The authors reviewed all large-scale, randomized controlled clinical trials comparing any NSAIDs or placebo, and performed a meta-analysis looking at the rates of myocardial infarction, stroke, death from cardiovascular cause, and death from any cause. They reviewed 31 trials in 116,429 patients with more than 115,000 patient years of follow-up. Patients were allocated to naproxen, ibuprofen, diclofenac, celecoxib, etoricoxib, rofecoxib, lumiracoxib, or placebo.
Compared with placebo, rofecoxib was associated with the highest risk of myocardial infarction (rate ratio [RR] = 2.12, 95% confidence interval [CI] 1.26 – 3.56). Ibuprofen was associated with the highest risk of stroke (RR = 3.36, CI 1.00 – 11.6), followed by diclofenac. Naproxen was associated with the lowest risk of stroke (RR = 1.76, CI 0.91 – 3.33) and its use was not associated with an increased risk of cardiovascular death. It appears that the entire class of NSAIDs is associated with an increased risk of cardiovascular events, and alternatives should be considered in the management of pain.
Cervical Artery Abnormalities are Common in Children with Stroke
Source: Ganesan V, Cox TC, Gunny R. Abnormalities of cervical arteries in children with arterial ischemic stroke. Neurology 2011;76:166-171.
Ischemic stroke is rare in children, and etiologies have been varied. The authors reviewed all cases admitted to their hospital in London from 2002-2009, and performed time-of-flight MR imaging of the cervical and intracranial arteries, in addition to MR imaging of the brain, with special attention to infarct presence and location, nature of the arterial disease, risk factors, antecedent trauma, and the presence of cervical arterial disease.
Sixty children (31 boys, median age 5 years 3 months) were included. Fifty children had anterior circulation infarcts only, and nine had posterior circulation infarcts. Cervical arterial abnormalities were found in 15/60 (25%) and intracranial abnormalities were identified in 26. Cervical arterial disease was characterized as definite arterial dissection in 2 cases, probable dissection in 7, nonspecific occlusive arteriopathy in 5, and migrated cardiac occlusive device in 1. In a logistic regression analysis, the presence of posterior circulation infarct predicted the presence of a cervical arterial abnormality (P = 0.04). A history of antecedent trauma was not predictive. The cervical vessels should be imaged in all children with acute ischemic stroke.
Do Patients with Isolated Vertigo Have a Higher Risk for Stroke?
Source: Lee, CC, Su YC, Ho HC, et.al. Risk of stroke in patients hospitalized for isolated vertigo. A four-year follow-up study. Stroke 2011;42:48-52.
In a study from taiwan, all patients hospitalized with a principal diagnosis of vertigo (n = 3,021) were compared to an age- and sex-matched control group of patients hospitalized for appendectomy, and the two cohorts were followed for 4 years to ascertain cardiovascular risk factors and subsequent stroke.
During the 4-year follow-up period, 185 (6.1%) patients from the study group were admitted with stroke, and 58(1.9%) from the control group had a stroke. The vertigo group had statistically-significant higher rates of hypertension, diabetes, coronary disease, and hyperlipidemia, and the risk of stroke was determined by the presence of these risk factors, plus age > 55 years and male sex. The patients were divided into three groups, based on risk factors, and the 4-year cumulative risks for stroke were 1.9 (no risk factors), 7.7 (1-2 risk factors) and 14 (3 or more risk factors). Vertigo may be a clinical symptom of vertebrobasilar disease and cardiovascular risk factors should be identified and treated, to prevent future stroke. Isolated vertigo, without these risk factors, is rarely associated with any type of stroke.
Stroke-Type May Determine Outcome After Treatment with Thrombolysis
Source: Mustanoja S, Meretoja A, Putaala J, et.al. Outcome by stroke etiology in patients receiving thrombolytic treatment. Descriptive subtype analysis. Stroke 2011;42:102-106.
In a population-based study from helsinki, finland, investigators looked at outcomes after intravenous thrombolysis from a single hospital from 1995–2008, and analyzed outcomes based on stroke-type, using a multivariate logistic regression. Good outcome was defined as modified Rankin Scale less than or equal to 2. Stroke classification was based on the TOAST trial.
Of 957 ischemic stroke patients treated with intravenous thrombolysis, 41% (389) had cardioembolism, 23% (217) had large-artery atherosclerosis, and 11% (101) had small-vessel disease (SVD). A good outcome was more common with SVD than with any other subtype. Patients with SVD were more often male, had a lower baseline NIH Stroke Scale score, lower mortality, and had no episodes of intracranial hemorrhage. Common vascular risk factorshypertension, diabetes, hypercholesterolemia, and transient ischemic attackswere equally distributed across all stroke subtypes. After adjustment for baseline NIHSS, glucose level, and hyperdense artery sign, patients with SVD still had better outcomes.