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CVA

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Cerebrovascular accident

(CT scan)

Treatment

Thrombolysis

  • only the NIH rt-PA study has shown improved outcome on an intention to treat analysis. Patients with cerebral infarction were given rt-PA within 3h of onset of symptoms. Morbidity at 3 months was reduced although mortality was unchanged.
  • ECASS showed decreased morbidity (1 grade difference in the 6 grade Rankin score) at 90 days but only after post hoc analysis with exclusion of protocol deviations. Patients given rt-PA within 6 h of ischaemic stroke. No change in mortality
  • 3 randomised trials of IV streptokinase were overwhelmingly negative. All were terminated early due to unacceptable rates of ICH with mortality in treatment group twice that in control groups

Neuroprotection

  • meta-analysis of effect of nimodipine suggests that outcome is improved if it is started within 12 h but worsened if started between 24 and 48 h
  • ganglioside GM1: no benefit in Sygen Acute Stroke Study. Slightly reduced morbidity in Early Stroke Trial. Reports of severe G-B syndrome as a complication of treatment
  • probably no indication for the use of steroids
  • benefit of hyperventilation is unproven
  • no positive effects of barbiturates have been proven
  • lubeluzole improved functional outcome if given within 6h of ischaemic stroke in US but not European study. Third trial is currently in progress. Lubelazole is a Na-channel blocker that may inhibit glutamate release from ischaemic neurons and thus decrease post-synaptic excitotonicitiy. May also ¯ post-synaptic NO synthetase activity and thus ¯ intracellular ischaemic damage.

Anticoagulation

  • Limited evidence that LMW heparin may beneficial following thrombotic stroke

Prevention

  • aspirin reduces incidence and severity of stokes in patients with TIAs. Optimum dose has yet to be determined. No effect on mortality has been demonstrated. May be increased risk of moderate-severe haemorrhagic stroke. Efficacy of dipyridamole or sulphinpyrazone unproven
  • carotid end-arterectomy indicated for patients with carotid artery stenosis and TIAs. Also if perioperative mortality and morbidity <3% carotid end-arterectomy reduces 5 year risk of ipsilateral stroke in good-risk patients with asymptomatic carotid stenoses of ³ 60%
  • emergency carotid end-arterectomy may be indicated in:
  • crescendo TIAs
  • first few hours of an abrupt severe neurological deficit
  • first 48 h of a complete carotid occlusion
  • patients with recent onset mild to moderate neurological deficits with normal conscious level and normal CT

Further reading

Lees KR. Does neuroprotection improve stroke outcome? Lancet, 1998; 351:1447-8

http://ips1.lwwonline.com/servlet/GetFileServlet?J=1800&I=2&A=2&U=1&T=1

© Charles Gomersall December 1999


©Charles Gomersall, February, 2015 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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