INTRODUCTION

Stroke is the leading cause of disability worldwide and remains a major cause of death among Filipinos. Despite being the most common neurological disease, wide variations in management persist among clinicians. This CPG aims to provide evidence-based recommendations for the diagnosis and management of acute stroke.

METHODS

A systematic synthesis of evidence was conducted to address the diagnosis and management of both acute hemorrhagic and ischemic stroke. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was followed. The process included: (1) generation of critical questions and outcomes (2) retrieval of current and relevant evidence, (3) synthesis and appraisal of the evidence base, (4) formulation of draft recommendations, (5) deliberation by a multi-sectoral stakeholder panel on feasibility, values and preferences to assess the strength of recommendations and (6) planning for dissemination, implementation, impact evaluation and updating.

RESULTS

Sixteen clinical questions were addressed leading to 21 recommendations. Most were strong recommendations supported by moderate to high certainty of evidence. The recommendations span the spectrum of acute stroke care, including early diagnosis with imaging, admission to stroke units, reperfusion therapies, surgical options, prevention of complications and the role of adjunctive treatments.

CONCLUSION

The recommendations in this CPG are intended to guide clinicians and other stakeholders in the diagnosis and management of acute stroke. They are meant to supplement, not replace, the sound clinical judgment of healthcare providers.

Ischemic Stroke ; Cerebral Hemorrhage ; Hemorrhage ; Hemorrhagic Stroke

INTRODUCTION

Stroke is the leading cause of disability worldwide and remains a major cause of death among Filipinos. Despite being the most common neurological disease, wide variations in management persist among clinicians. This CPG aims to provide evidence-based recommendations for the diagnosis and management of acute stroke.

METHODS

A systematic synthesis of evidence was conducted to address the diagnosis and management of both acute hemorrhagic and ischemic stroke. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was followed. The process included: (1) generation of critical questions and outcomes (2) retrieval of current and relevant evidence, (3) synthesis and appraisal of the evidence base, (4) formulation of draft recommendations, (5) deliberation by a multi-sectoral stakeholder panel on feasibility, values and preferences to assess the strength of recommendations and (6) planning for dissemination, implementation, impact evaluation and updating.

RESULTS

Sixteen clinical questions were addressed leading to 21 recommendations. Most were strong recommendations supported by moderate to high certainty of evidence. The recommendations span the spectrum of acute stroke care, including early diagnosis with imaging, admission to stroke units, reperfusion therapies, surgical options, prevention of complications and the role of adjunctive treatments.

CONCLUSION

The recommendations in this CPG are intended to guide clinicians and other stakeholders in the diagnosis and management of acute stroke. They are meant to supplement, not replace, the sound clinical judgment of healthcare providers.

Ischemic Stroke ; Cerebral Hemorrhage ; Hemorrhage ; Hemorrhagic Stroke

BACKGROUND: Hemorrhagic stroke (HS) is associated with significant disability and mortality. However, the relationship between meteorological factors and hemorrhagic stroke, as well as the potential moderating role of these factors, remains unclear. METHODS: Daily data on HS, air pollution, and meteorological conditions were collected from January 2015 to December 2021 in Ganzhou to analyze the relationship between meteorological factors and HS admissions. This analysis employed a time-stratified case-crossover design in conjunction with a distributional lag nonlinear model. Additionally, a bivariate response surface modelling was utilized to further investigate the interaction between meteorological factors and particulate matter. The study also stratified the analyses by gender and age. To investigate the potential impact of extreme weather conditions on HS, this study defined the 97.5th percentile as representing extremely high weather conditions, while the 2.5th percentile was classified as extremely low. RESULTS: In single-day lags, the risk of admissions for HS was significantly associated with extremely low temperature (lag 1-2 and lag 13-14), extremely low humidity (lag 1 and lag 9-12), and extremely high precipitation (lag 2-7). Females exhibited greater susceptibility to extremely low temperature than males within the single-day lag pattern in the subcomponent layer, with a maximum relative risk (RR) that was 7% higher. In the cumulative lag analysis, the risk of HS admissions was significantly associated with extremely high temperature (lag 0-8∼lag 0-14), extremely low humidity (lag 0-2∼lag 0-14), and extremely high precipitation (lag 0-4∼lag 0-14). Within the cumulative lag day structure of the subcomponent layer, both extremely low and extremely high temperature had a more pronounced effect on females and aged ≥65 years. The risk of HS admissions was positively associated with extremely high barometric pressure in the female subgroups (lag 0-1 and lag 0-2). The highest number of HS admissions occurred when high PM_2.5 concentrations coexisted with low precipitation. CONCLUSIONS Meteorological factors were significantly associated with the risk of hospital admissions for HS. Individuals who were female and aged ≥65 years were found to be more susceptible to these meteorological influences. Additionally, an interaction was observed between airborne particulate matter and meteorological factors. These findings contributed new evidence to the association between meteorological factors and HS.
China/epidemiology* ; Humans ; Female ; Male ; Aged ; Middle Aged ; Cross-Over Studies ; Hospitalization/statistics & numerical data* ; Adult ; Hemorrhagic Stroke/etiology* ; Meteorological Concepts ; Weather ; Particulate Matter/analysis* ; Air Pollution/adverse effects* ; Environmental Exposure/adverse effects* ; Aged, 80 and over ; Young Adult

Objective: To describe the prevalence of alcohol consumption and the burden of hemorrhagic stroke and hypertensive heart disease attributed to alcohol consumption in adults aged ≥20 years in 31 provinces in China from 2005 to 2018. Methods: Data from several national representative surveys was used to estimate provincial alcohol exposure level of adults aged ≥20 years from 2005 to 2018 by using kriging interpolation and locally weighted regression methods. Global disease burden research method and data, and China's death cause surveillance data were used to calculate the population attributable fraction (PAF) of hemorrhagic stroke and hypertensive heart disease and the deaths due to alcohol consumption in men and women aged ≥20 years in 31 provinces in China. China census data of 2010 were used to calculate the attributable standardized mortality rate. Results: In 2005 and 2018, the prevalence of alcohol consumption was 58.7% (95%CI: 57.8%-59.5%) and 58.4% (95%CI: 57.6%-59.3%), respectively, in men and 17.0% (95%CI: 16.6%-17.4%) and 18.7% (95%CI:18.1%-19.3%), respectively, in women. The daily alcohol intake was 24.6 (95%CI: 23.8-25.3) g and 27.7 (95%CI: 26.8-28.7) g, respectively, in men and 6.3 (95%CI: 6.0-6.5) g and 5.3 (95%CI: 5.0-5.6) g, respectively, in women. Alcohol exposure level was higher in the provinces in central and eastern China than in western provinces. The lowest exposure level was found in northwestern provinces. From 2005 to 2018, the PAF of hemorrhagic stroke death due to alcohol consumption increased from 5.5% to 6.8%, the attributable deaths increased from 50 200 to 59 100, while the PAF of hypertensive heart disease death due to alcohol consumption increased from 7.0% to 7.7%, the attributable deaths increased from 15 200 to 29 300. The PAF of hypertensive heart disease and hemorrhagic stroke was higher in men than in women, and in central and eastern provinces than in western provinces. In 2018, the standardized mortality rates of hemorrhagic stroke and hypertensive heart disease attributed to alcohol consumption were 4.58/100 000 and 2.11/100 000, respectively. Conclusions: The prevalence of alcohol consumption in men and daily alcohol intake of drinkers were relatively high in China, especially in eastern provinces. Alcohol exposure level was lower in women than in men. Regional measures should be taken to reduce the alcohol intakes in men and current drinkers in order to reduce the health problems caused by alcohol consumption.
Adult ; Male ; Humans ; Female ; Hemorrhagic Stroke ; Hypertension/epidemiology* ; Alcohol Drinking/epidemiology* ; Heart Diseases/epidemiology* ; China/epidemiology*

Brain Ischemia ; Cardiomyopathy, Hypertrophic/diagnostic imaging* ; Hemorrhagic Stroke ; Humans ; Moyamoya Disease/diagnostic imaging* ; Stroke/etiology*

Patients with hereditary hemorrhagic telangiectasia (HHT) are at risk of developing pulmonary arteriovenous malformations (pAVMs). Paradoxical embolism may occur through pAVMs or patent foramen ovale (PFO) and lead to cerebral infarction. We present a case of cerebral infarction with both pAVM associated with HHT and PFO. Evidence of a right-to-left shunt can suggest other treatment options for stroke prevention, and patients without evidence of conventional stroke etiologies require a thorough evaluation.
Arteriovenous Malformations ; Cerebral Infarction ; Embolism, Paradoxical ; Foramen Ovale, Patent* ; Humans ; Infarction, Posterior Cerebral Artery* ; Posterior Cerebral Artery* ; Stroke ; Telangiectasia, Hereditary Hemorrhagic*

Patients with hereditary hemorrhagic telangiectasia (HHT) are at risk of developing pulmonary arteriovenous malformations (pAVMs). Paradoxical embolism may occur through pAVMs or patent foramen ovale (PFO) and lead to cerebral infarction. We present a case of cerebral infarction with both pAVM associated with HHT and PFO. Evidence of a right-to-left shunt can suggest other treatment options for stroke prevention, and patients without evidence of conventional stroke etiologies require a thorough evaluation.
Arteriovenous Malformations ; Cerebral Infarction ; Embolism, Paradoxical ; Foramen Ovale, Patent* ; Humans ; Infarction, Posterior Cerebral Artery* ; Posterior Cerebral Artery* ; Stroke ; Telangiectasia, Hereditary Hemorrhagic*

BACKGROUND

Identification of the type of stroke upon presentation at the emergency room is paramount. The initiation of prompt treatment may pay dividends in the eventual outcome of strokes. This is a retrospective study. The aim of this paper is to determine if there is a correlation berween an elevared blood pressure and rhe occurrence of either an ischemic infarcr or a hemorrhagic infarct. It aims to determine if a systolic blood pressure of >160 mm Hg or a diastolic blood pressme of >110 mmHg may be correlated to an incidence of hemorrhagic strokes.

METHODS

A series of 273 consecutive patients hospitalized in our institution berween January 2006 and December 2006 with a diagnosis of stroke were reviewed from the stroke database of our institution. Analysis was carried out using the SPSS software package (version 10.0.1; SPSS Inc., Chicago, Illinois, USA).

RESULTS

There was no correlation among the key variables: a) none berween type of stroke and presence of severe systolic HTN, p > .05 (exact value = .075), b) none berween rype of stroke and presence of severe diastolic HTN, p > .05 (exact value= .240), and c) none between type of stroke and age (young-middle versus older), p > .05 (exact value= .088).

CONCLUSION

The study was not able to establish a correlation between elevated hypertension and stroke type. There was no significant correlation between either systolic hypertension or diastolic hypertension in the occurrence of intracerebral hemorrhage.

Human ; Stroke ; Ischemic Stroke ; Hemorrhagic Stroke ; Hypertension

PURPOSE: Although hypothermia has been used in many clinical situations, such as post cardiopulmonary resuscitation, stroke, traumatic brain injury, septic shock, and hemorrhagic shock, the mechanism by which it works has not been clearly elucidated. We aimed to evaluate the effect of hypothermia on the plasma nitric oxide (NO) concentration, lung iNOS expression, and histologic changes in intestinal ischemia-reperfusion (IR). METHOD: Male Sprague-Dawley rats were randomly divided into the hypothermia group (HT, n=8, 27~30 degrees C) and the normothermia group (NT, n=8, 36~37 degrees C). They underwent 30 min of intestinal ischemia by clamping the superior mesenteric artery, which was followed by 1.5 h of reperfusion. They were then sacrificed. The acute lung injury (ALI) score, the plasma NO concentration, and lung iNOS gene expression were measured. RESULTS: Compared with the HT group, the NT group showed severe infiltrations of inflammatrory cells, alveolar hemorrhages, and interstitial hypertrophies in lung tissues. There were significant differences in the ALI scores between the NT and the HT groups (8.7 +/- 1.5/HPF in NT vs 5.8 +/- 1.2/HPF in HT, p=0.008). Although the plasma NO concentration was slightly lower in the HT group, there was no significant difference between the two groups (0.80 +/- 0.24 micromol/L in NT vs 0.75 +/- 0.30 micromol/L in HT, p=0.917). Lung iNOS gene expression was stronger in the NT group than in the HT group. The band density of the expression of iNOS in lung tissues was significantly increased in the NT group compared to the HT group (5.54 +/- 2.75 in NT vs 0.08 +/- 0.52 in HT, p=0.002). CONCLUSIONS: This study showed that hypothermia in intestinal IR reduces inflammatory responses, ALI scores, and iNOS gene expression in lung tissues. There was no significant effect of hypothermia on the plasma NO concentration.
Acute Lung Injury ; Brain Injuries ; Cardiopulmonary Resuscitation ; Constriction ; Gene Expression* ; Hemorrhage ; Humans ; Hypertrophy ; Hypothermia* ; Ischemia ; Lung* ; Male ; Mesenteric Artery, Superior ; Nitric Oxide ; Nitric Oxide Synthase Type II* ; Plasma ; Rats, Sprague-Dawley ; Reperfusion ; Reperfusion Injury* ; Shock, Hemorrhagic ; Shock, Septic ; Stroke

OBJECTIVETo assess the significance of stroke volume variation (SVV) and intrathoracic blood volume index (ITBI) on the responsiveness to volume loading in mechanically ventilated canine with hemorrhagic shock.

METHODSHemorrhagic shock canine model was established with the modified Wiggers' method. The heart rate (HR), mean artery pressure (MAP), central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), intrathoracic blood volume index (ITBI) and stroke volume variation (SVV) were investigated by Swan-Ganz catheter or PiCCO monitor. Graded volume loading (VL) was performed. Successive responsive VLs were performed (increase in SV > 5% after VL) until continuous change in SV < 5% (unresponsive) was reached.

RESULTSFourteen canines were studied and a total of 134 VLs were performed. In 94 VLs, an increase in SV of more than 5% was reached. In the other 40 VLs, increase in SV was less than 5%. The change of HR, MAP, ITBI, SVV in responsive were more than those of unresponsive after VL. The change of CVP, PAWP in responsive were less than those of unresponsive. Significant correlation was found between DeltaSV after VL and the baseline values of ITBI, SVV. No correlation was found between DeltaSV and HR, MAP, CVP, PAWP. Significant correlations were also found between DeltaSV and DeltaCVP, DeltaPAWP, DeltaITBI, DeltaSVV after fluid loading. No correlation was found between DeltaSV and DeltaHR, DeltaMAP. By using receiver operating characteristic analysis, the area under the curve were 0.872 for SVV and 0.689 for ITBI, more than those of HR, MAP, CVP, PAWP statistically. As SVV value of 9.5% or more will predict an increase in the SV of at least 5% in response to a VL with a sensitivity of 92.6% and a specificity of 82.5%.

CONCLUSIONSSVV and ITBI were more useful indicators than CVP and PAWP on the assessment of responsiveness to volume loading. SVV as a functional preload parameter and for on-line monitoring may help to improve the hemodynamic management.

Animals ; Blood Volume ; physiology ; Blood Volume Determination ; methods ; Dogs ; Female ; Male ; Shock, Hemorrhagic ; diagnosis ; physiopathology ; Stroke Volume ; physiology