Clinical Practice Guidelines

2021 ◽  
Vol 3 (1) ◽  
pp. 1-155
Author(s):  
Malaysian Society of Neurosciences
Keyword(s):  
Emergency Department ◽  
Clinical Practice ◽  
Hospital Care ◽  
Elderly Population ◽  
Mechanical Thrombectomy ◽  
Rapid Development ◽  
Reperfusion Therapy ◽  
Current Evidence ◽  
Older Person ◽  
Stroke Patients

The 1st Clinical Practice Guideline (CPG) on the management of ischaemic stroke was published in 2006 and the second edition was published in 2012. Since then, there was a rapid development in the management of acute stroke, mainly with the improvement and advancement of reperfusion therapy, encompassing both medical thrombolysis and mechanical thrombectomy. Furthermore, the importance of timely intervention, especially in the emergency department, had significantly improved the outcome in stroke patients. Therefore, this current CPG emphasizes the hyperacute management and has introduced new chapters, for example, emergency medical services. With the growing numbers of elderly population in Malaysia, we have also included a new chapter on stroke in the older person. This 3rd edition was developed to provide a clear and concise approach based on current evidence with the focus being on the efforts to reduce time and improve pre-hospital care. We have summarised and adapted relevant clinical trials data and published literatures to our local practice.

How to use C-reactive protein

2018 ◽  
Vol 104 (3) ◽  
pp. 150-153
Author(s):  
Emma M Dyer ◽  
Thomas Waterfield ◽  
Hannah Baynes
Keyword(s):  
Emergency Department ◽  
Clinical Practice ◽  
Antibiotic Therapy ◽  
Inflammatory Markers ◽  
Biochemical Test ◽  
Current Evidence ◽  
C Reactive Protein ◽  
Paediatric Emergency Department ◽  
Reactive Protein ◽  
Paediatric Emergency

A 3-month-old baby is brought to the paediatric emergency department by their parents because of a fever. You decide to check their inflammatory markers. Their C-reactive protein (CRP) level comes back as 20 mg/L. Does this affect whether or not you start antibiotic therapy? Does it influence your decision to admit or discharge the patient? CRP is a commonly used biochemical test and yet its use is constantly debated and challenged. We look at the current evidence and suggest the best way to use this test in clinical practice.

Abstract MP6: Thrombolysis for Acute Wake-Up And Unclear Onset Strokes With Alteplase at 0.6mg /kg in Clinical Practice: THAWS2 Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Sohei Yoshimura ◽  
Masatoshi Koga ◽  
Takashi Okada ◽  
Manabu Inoue ◽  
Kaori Miwa ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Mechanical Thrombectomy ◽  
Randomized Control Trials ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Acute Hospitalization ◽  
Multicenter Observational Study ◽  
Intravenous Alteplase ◽  
Randomized Control

Background and Purpose: IV alteplase at 0.6 mg/kg for acute wake-up and unclear onset strokes was recommended in Japanese stroke guidelines in March 2019. We determined the safety and effectiveness of this newly recommended thrombolysis in clinical practice. Methods: This is a multicenter observational study, enrolling acute ischemic stroke patients with a time last-known-well >4.5 h who have a mismatch between DWI and FLAIR treated with intravenous alteplase. The safety outcomes are intracranial hemorrhage (ICH) with neurological deterioration within 36 h after thrombolysis, all cause deaths within 90 days, and adverse events. The efficacy outcomes are functionally independence defined as a mRS score of 0-1 at 90 days, and NIHSS change at 24h from baseline. Results: Between 2019 March and 2020 March, 63 patients (33 females; age, 74±11y; premorbid functionally independence, 50 (82%); median NIHSS on admission, 11) were enrolled at 14 hospitals. Of them, 40 patients (63%) recognized stroke symptoms at wake-up time, and median time between last-known-well and admission was 6.5 h. Baseline MRA showed any vessel occlusion in 52 patients (88%). IV alteplase was disrupted in one patient. Two patients (3%) had symptomatic ICH (≥4 increase in NIHSS) within 36 h. NIHSS change was -5.1±8.1. Twenty-one patients (36%) had functionally independence at discharge and there was no death during acute hospitalization. Of the overall 63 patients, 22 also underwent mechanical thrombectomy (36%, 72±9y, median NIHSS 16), showing no symptomatic ICH, mean NIHSS change of -8.9±7.5, and 8 patients (42%) had functionally independence at discharge. Conclusions: In clinical practice, IV alteplase for wake-up and unclear onset stroke patients with DWI-FLAIR mismatch seemed to be safe and effective compared with previous randomized control trials. Mechanical thrombectomy could be combined with alteplase safely and effectively.

Histologic features of acute thrombi retrieved from stroke patients during mechanical reperfusion therapy

2016 ◽  
Vol 11 (9) ◽  
pp. 1036-1044 ◽  
Author(s):  
Seong Hwan Ahn ◽  
Ran Hong ◽  
In Sung Choo ◽  
Ji Hoe Heo ◽  
Hyo Suk Nam ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Red Blood Cells ◽  
Blood Cells ◽  
Mechanical Thrombectomy ◽  
Reperfusion Therapy ◽  
Stroke Patients ◽  
Stroke Treatment ◽  
Stroke Subtypes ◽  
The Rich ◽  
Undetermined Etiology

Background The histologic features of thrombus may differ according to the stroke subtypes. However, in acute reperfusion therapy, fibrin-specific thrombolytics are used based on the assumption that all thrombi are alike. Aims The histologic characteristics of thrombi were compared between patients with different stroke etiologies. Methods Between April 2010 and March 2012, we analyzed thrombi retrieved from acute stroke patients during mechanical thrombectomy. All thrombi were analyzed using component-specific stains such as Martius scarlet blue for fibrins and immunostaining with CD42b antibody for platelets. The stroke subtypes were determined based on the Trial of ORG 10172 in Acute Stroke Treatment classification. Results Among 36 patients, 22 were diagnosed with cardioembolism, 8 with atherothrombosis, and 6 with undetermined etiology. In arteriogenic thrombi, red blood cells were most abundant (56.9 ± 12.2%), and the platelets covered the fibrin layers or were localized at the edge or periphery of the thrombus. In cardiogenic thrombi, fibrin was most abundant (39.5 ± 13.5%), and platelets were clustered within the rich fibrin. Red blood cells proportion was greater in arteriogenic thrombi than in cardiogenic thrombi ( p < 0.001), whereas fibrin proportion was greater in cardiogenic thrombi than in arteriogenic thrombi ( p = 0.003). Of six patients with undetermined etiology, the thrombi in five showed histologic features and composition similar to that of cardiogenic thrombi. Conclusions Acute thrombi showed different histologic features according to the stroke etiology. The distribution of platelets and proportion of red blood cells and fibrin were major distinguishing factors between stroke subtypes.

scholarly journals Incidence and Association of Reperfusion Therapies With Poststroke Seizures

Stroke ◽  
2020 ◽  
Vol 51 (9) ◽  
pp. 2715-2723 ◽  
Author(s):  
Alain Lekoubou ◽  
Jonah Fox ◽  
Paddy Ssentongo
Keyword(s):  
Primary Outcome ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Reperfusion Therapy ◽  
Incidence Rates ◽  
Tissue Type ◽  
Cochrane Library ◽  
Stroke Patients ◽  
Type Plasminogen Activator

Background and Purpose: We performed a systematic review and meta-analysis to assess the incidence and risk of seizures following acute stroke reperfusion therapy (intravenous thrombolysis [IVT] with r-tPA [recombinant tissue-type plasminogen activator], mechanical thrombectomy or both). Methods: We searched major databases (MEDLINE, SCOPUS, and Cochrane Library) for articles published between 1995 and October 28, 2019. The primary outcome was the overall and treatment specific pooled incidence of poststroke seizures (PSS) following acute reperfusion therapy. We also computed the pooled incidence of early poststroke seizures and late poststroke seizures separately for all studies. We derived the risk of PSS associated with IVT in the pooled cohort of patients who received only IVT. The small number of studies (<3) that reported on the risk of PSS associated with mechanical thrombectomy alone or in combination with IVT did not allow us to compute an estimate of the risk of seizures associated with this therapy. Results: We identified 13 753 patients with stroke, of which 592 had seizures. The pooled incidence of PSS was 5.9 % (95% CI, 4.2%–8.2%). PSS incidence rates among patients with stroke treated with IVT, mechanical thrombectomy, and both were respectively 6.1% (95% CI, 3.6%–10.2%), 5.9% (95% CI, 4.1%–8.4%), and 5.8 % (95% CI, 3.0%–10.9%). The incidence of late PSS was 6.7% (95% CI, 4.01%–11.02%) and that of early PSS was 3.14% (95% CI, 2.05%–4.76%). The pooled odds ratio for the association between IVT and PSS was 1.24 (95% CI, 0.75–2.05). Conclusions: The findings of this meta-analysis suggest that about one in 15 ischemic stroke patients treated with IVT, mechanical thrombectomy, or both develop seizures independently of the specific reperfusion treatment that they received.

Memantine for the treatment of ischemic stroke: experimental benefits and clinical lack of studies

2019 ◽  
Vol 30 (2) ◽  
pp. 203-220 ◽  
Author(s):  
Seyed Mohammad Seyedsaadat ◽  
David F. Kallmes
Keyword(s):  
Ischemic Stroke ◽  
Functional Recovery ◽  
Glutamate Release ◽  
Reperfusion Therapy ◽  
Current Evidence ◽  
Future Research ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Critical Determinant ◽  
Intravenous Tissue Plasminogen Activator

AbstractStroke is an important cause of mortality and disability worldwide. Immediately after stroke onset, the ischemic cascade initiates and deleteriously affects neural cells. Time to reperfusion therapy is a critical determinant of functional recovery in stroke patients. Although recent trials have shown the significant efficacy of endovascular thrombectomy, either alone or with intravenous tissue plasminogen activator, in improving the functional outcomes of stroke patients with large vessel occlusion, hours can pass before patients receive reperfusion therapy. Moreover, many patients do not meet the eligibility criteria to receive reperfusion treatments. Therefore, an adjunct and alternative agent that can protect ischemic neuronal tissue during the hyperacute phase until reperfusion therapy can be administered may prevent further brain damage and enhance functional recovery. Memantine is a US Food and Drug Administration approved drug for the treatment of Alzheimer’s disease. Memantine blocks overstimulated N-methyl-d-aspartate receptors and prevents neurotoxicity caused by massive glutamate release. Preclinical studies show that memantine decreases infarction volume and improves neurologic outcomes. However, few clinical studies have evaluated the safety and efficacy of memantine in stroke patients. This review article summarizes the current evidence for the role of memantine in the treatment of ischemic stroke and highlights areas for future research.

Psychotherapy and the older person

2017 ◽  
Vol 25 (3) ◽  
pp. 225-226 ◽  
Author(s):  
Neil Raveen Jeyasingam
Keyword(s):  
Older Adults ◽  
Clinical Practice ◽  
Older Adult ◽  
Current Evidence ◽  
Older Person

Objective: This article aims to provide a brief overview of the current evidence for psychotherapeutic approaches in older adults, together with clinical practice notes for interventions. Conclusion: There are a range of appropriate psychotherapeutic options for the older adult that merit further study, and further opportunities for enhancing clinical practice.

scholarly journals Which Imaging Approach Should Be Used for Stroke of Unknown Time of Onset?

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 373-380
Author(s):  
Claus Z. Simonsen ◽  
Thabele M. Leslie-Mazwi ◽  
Götz Thomalla
Keyword(s):  
Clinical Practice ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Imaging Biomarkers ◽  
Acute Stroke Care ◽  
Vessel Occlusion ◽  
Imaging Approach ◽  
Different Populations

Reperfusion therapy with intravenous thrombolysis or mechanical thrombectomy is effective in improving outcome for ischemic stroke but remains underused. Patients presenting with stroke of unknown onset are a common clinical scenario and a common reason for not offering reperfusion therapy. Recent studies have demonstrated the efficacy of reperfusion therapy in stroke of unknown time of onset, when guided by advanced brain imaging. However, translation into clinical practice is challenged by variability in the available data. Comparison between studies is difficult because of use of different imaging modalities (magnetic resonance imaging or computed tomography), different imaging paradigms (imaging biomarkers of lesion age versus imaging biomarkers of tissue viability), and different populations studied (ie, both patients with large vessel occlusion or those with less severe strokes). Physicians involved in acute stroke care are faced with the key question of which imaging approach they should use to guide reperfusion treatment for stroke with unknown time of onset. In this review, we provide an overview of the available evidence for selecting and treating patients with strokes of unknown onset, based on the underlying imaging concepts. The perspective provided is from the viewpoint of the clinician seeing these patients acutely, to provide pragmatic recommendations for clinical practice.

scholarly journals Sex-Specific Cut-Offs for High-Sensitivity Cardiac Troponin: Is Less More?

2019 ◽  
Vol 2019 ◽  
pp. 1-12 ◽  
Author(s):  
Giulio Francesco Romiti ◽  
Roberto Cangemi ◽  
Filippo Toriello ◽  
Eleonora Ruscio ◽  
Susanna Sciomer ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Clinical Practice ◽  
Cardiac Troponin ◽  
Diagnostic Performance ◽  
High Sensitivity ◽  
Current Evidence ◽  
Simplified Approach ◽  
Coronary Syndrome

Management of patients presenting to the Emergency Department with chest pain is continuously evolving. In the setting of acute coronary syndrome, the availability of high-sensitivity cardiac troponin assays (hs-cTn) has allowed for the development of algorithms aimed at rapidly assessing the risk of an ongoing myocardial infarction. However, concerns were raised about the massive application of such a simplified approach to heterogeneous real-world populations. As a result, there is a potential risk of underdiagnosis in several clusters of patients, including women, for whom a lower threshold for hs-cTn was suggested to be more appropriate. Implementation in clinical practice of sex-tailored cut-off values for hs-cTn represents a hot topic due to the need to reduce inequality and improve diagnostic performance in females. The aim of this review is to summarize current evidence on sex-specific cut-off values of hs-cTn and their application and usefulness in clinical practice. We also offer an extensive overview of thresholds reported in literature and of the mechanisms underlying such differences among sexes, suggesting possible explanations about debated issues.

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