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A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Iterim Chair and Neurologist-in-Chief, Director, Division of Stroke & Critical Care Neurology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY. Dr. Fink reports no financial relationship to this field of study.
These reports originally appeared in the February issue of Neurology Alert. At that time it was peer reviewed by M. Flint Beal, MD, Anne Parrish Titzel Professor, Department of Neurology and Neuroscience, Weill Cornell Medical Center, New York, NY. Dr. Beal reports no financial relationship to this field of study.
Risk of Stroke and CV Death from NSAIDs
Source: Trelle 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; 95% CI, 1.00-11.6), followed by diclofenac. Naproxen was associated with the lowest risk of stroke (RR, 1.76; 95% 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.
Do Patients with Isolated Vertigo Have a Higher Risk for Stroke?
Source: Lee CC, et al. Risk of stroke in patients hospitalized for isolated vertigo. Stroke 2011;42:48-52.
In a study from taiwan, all patients hospitalized with a principal diagnosis of vertigo (n = 3021) 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 significantly higher rates of hypertension, diabetes, coronary disease, and hyperlipiemia, 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, 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 to 2008, and analyzed outcomes based on stroke type, using a multivariate logistic regression. Good outcome was defined as modified Rankin Scale ≤ 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 (NIHSS) score, lower mortality, and no episodes of intracranial hemorrhage. Common vascular risk factors hypertension, diabetes, hypercholesterolemia, and transient ischemic attacks were equally distributed across all stroke subtypes. After adjustment for baseline NIHSS, glucose level, and hyperdense artery sign, patients with SVD still had better outcomes.