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 AND OBJECTIVE

A growing body of evidence supports that inflammatory mechanisms are involved in secondary brain injury after intracerebral hemorrhage (ICH) which has implications on the morbidity and mortality of stroke patients. Neutrophil-to-lymphocyte ratio (NLR) is a comprehensive index marker of inflammation and immune status of a patient. The prognostic value of NLR in predicting in-hospital mortality and functional outcome of patients with spontaneous intracerebral hemorrhage will be assessed in this study.

METHODS

We retrospectively selected 151 hemorrhagic stroke patients, and demographic and clinical characteristics were collected and computed for NLR. Receiver operating characteristic analysis using Youden’s index was utilized to determine the NLR cut-off value with the best sensitivity and specificity. The association of NLR with the inhospital mortality and functional outcome was assessed using Logistic regression analysis. Pearson Product Model Correlation was employed to evaluate the correlation of NLR with ICH volume.

RESULTS

Admission NLR >7 showed a significant association (p = <0.001 OR 7.99) with in-hospital mortality with a sensitivity of 70.83% and specificity of 72.82%. Furthermore, computed NLR of more than 6.4 showed significant association (p = 0.040 OR 2.92) with poor functional outcome. However, our study revealed that admission NLR showed a low level of correlation (r=0.2968, p=0.002) with the volume of ICH.

CONCLUSION

This study demonstrated that ICH patients with an elevated NLR is associated with increased inhospital mortality and poor functional outcome and that NLR can be used to predict clinical outcome among patients with spontaneous ICH.

Cerebral Hemorrhage ; Intracerebral Hemorrhage ; Hospital Mortality ; In-hospital Mortality

OBJECTIVES

This study aims to describe the demographic factors, clinical and laboratory features and outcomes of adult cryptococcal meningitis and possibly to identify demographic as well as CSF parameters affecting mortality in adult Filipinos with cryptococcal meningitis.

STUDY DESIGN

Retrospective case review

RESULTS

A total of 61 patients were admitted with a diagnosis of cryptococcal meningitis from 1993 to 2005, 60% of which were males (male to female ratio 1.5:1). Ages ranged from 18 to 73 years, with 11 (18%) patients having underlying co-morbidities. The most common presenting complaint was headache (76%) followed by nausea and vomiting (72%) and fever (52%). All patients had lumbar puncture. Of the 18 patients with available complete CSF profiles, all had an elevated opening pressure on initial lumbar tap (mean: 396mmH₂0), 83% had elevated total protein (mean: 120mg/dl), 61% showed hypoglycorrhachia, 83% had CSF WBC count greater than 20 cells/mm³, 70% had a positive India ink test, and 89% had a CSF CALAS titer of at least 1 :8. The mortality rate was 49% and the most common cause of death was found to be brain herniation. Forty nine percent of the patients received treatment, 40% of whom died. The relationship between age, sex, CSF findings and mortality were analyzed using Chi square test or Fisher's exact test. Only the CSF CALAS titer was found to be predictive of subsequent outcome (p=0.0019).

CONCLUSION

Most Filipinos admitted at UP-PGH with cryptococcal meningitis were males, with a mean age of 54 years old. Only 11 patients were found to be immu11ocompromised. The most common presenting complaint was headache, whereas the most common sign was nuchal rigidity. All patients have elevated opening pressure, abnormal CSF profiles, positive India ink and elevated CALAS titers. The mortality rate was found to be 49%. Only a CALAS titer greater than 1 :32 was found to be predictive of outcome.

Human ; Adult: 25-44 Yrs Old ; Meningitis ; Prognostic Factors ; Prognosis

BACKGROUND: Surgical management of patients with thalamic hemorrhage lacks evidence of benefit
GENERAL OBJECTIVE: To compare the outcomes of patients with thalamic hemorrhage managed surgically and non-surgically, and to determine the predictors of mortality
SPECIFIC OBJECTIVES: To describe baseline demographic and clinical characteristics of patients with thalamic hemorrhage, determine which are predictors of mortality, and to compare the mortality rate of those managed surgically and non-surgically
METHODOLOGY: Data from patients with thalamic hemorrhage admitted within July 1, 2000 to June 30, 2003 were recorded. Univariate and multivariate analyses were done using SPSS for Windows v9.0. P0.05 was considered significant.
RESULTS AND CONCLUSIONS: Among 119 patients, average age was 58 years, predominantly males (68.3 percent), hypertensive (90.8 percent) and had IVE (79 percent). Obstructive hydrocephalus was present in 43.7 percent. Most common sign and symptom was hemiparesis. Prognostic factors significantly associated with mortality were GCS 12 (p30 cc (p=0.023), presence of obstructive hydrocephalus (p=0.003), hypertension (p=0.005) and ischemic heart disease (0.009). Patients in the surgical arm had a higher mortality rate (65 percent vs 37 percent), but surgery was not shown to be a significant predictor of mortality (p=0.23). The poorer outcome in surgical patients may be secondary to their having lower GCS scores, bigger hematoma sizes and greater frequency of hydrocephalus.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Multivariate Analysis ; Arm ; Hydrocephalus ; Hypertension ; Coronary Artery Disease ; Cerebral Hemorrhage ; Hematoma ; Paresis ; Demography ; Prognosis