Predicting outcome of IV thrombolysis–treated ischemic stroke patients: the DRAGON score

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Objective: To develop a functional outcome prediction score, based on immediate pretreatment parameters, in ischemic stroke patients receiving IV alteplase.
Methods: The derivation cohort consists of 1,319 ischemic stroke patients treated with IV alteplase at the Helsinki University Central Hospital, Helsinki, Finland. We evaluated the predictive value of parameters associated with the 3-month outcome and developed the score according to the magnitude of logistic regression coefficients. We assessed accuracy of the model with bootstrapping. External validation was performed in a cohort of 330 patients treated at the University Hospital Basel, Basel, Switzerland. We assessed the score performance with area under the receiver operating characteristic curve (AUC-ROC).
Results: The DRAGON score (0–10 points) consists of (hyper)Dense cerebral artery sign/early infarct signs on admission CT scan (both = 2, either = 1, none = 0), prestroke modified Rankin Scale (mRS) score >1 (yes = 1), Age (≥80 years = 2, 65–79 years = 1, <65 years = 0), Glucose level at baseline (>8 mmol/L [>144 mg/dL] = 1), Onset-to-treatment time (>90 minutes = 1), and baseline National Institutes of Health Stroke Scale score (>15 = 3, 10–15 = 2, 5–9 = 1, 0–4 = 0). AUC-ROC was 0.84 (0.80–0.87) in the derivation cohort and 0.80 (0.74–0.86) in the validation cohort. Proportions of patients with good outcome (mRS score 0–2) were 96%, 88%, 74%, and 0% for 0–1, 2, 3, and 8–10 points, respectively. Proportions of patients with miserable outcome (mRS score 5–6) were 0%, 2%, 5%, 70%, and 100% for 0–1, 2, 3, 8, and 9–10 points, respectively. External validation showed similar results.
Conclusions: The DRAGON score is valid at our site and was reliable externally. It can support clinical decision-making, especially when invasive add-on strategies are considered. The score was not studied in patients with basilar artery occlusion. Further external validation is warranted.

 

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D. Strbian, MD, PhD, A. Meretoja, MD, PhD, MSc (Stroke Med), F.J. Ahlhelm, MD, PhD, J. Pitkäniemi, PhD (Stat), P. Lyrer, MD, M. Kaste, MD, PhD, S. Engelter, MD and T. Tatlisumak, MD, PhD

From the Department of Neurology (D.S., A.M., M.K., T.T.), Helsinki University Central Hospital, Helsinki, Finland; Departments of Diagnostic and Interventional Neuroradiology (F.J.A.) and Neurology (P.L., S.E.), University Hospital Basel, Basel, Switzerland; and Department of Public Health (J.P.), University of Helsinki, Helsinki, Finland.

TCC na fase aguda do AVC – site para treinamento

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Já está disponível o site – www.aspectsinstroke.com – desenvolvido pelo Calgary Stroke Team no Canadá para treinamento de interpretação de Tomografia Computadorizada do Crânio (TCC) no contexto da fase aguda do Acidente Vascular Cerebral Isquêmico (AVCi).

Trata-se de excelente ferramenta baseada no escore ASPECTS aplicável sobretudo nas doenças isquêmicas em território de artéria cerebral média.

O site roda em qualquer browser mas fica bem mais funcional no Internet Explorer. Além de discutir o papel da TCC na fase aguda do AVCi, explica e exemplifica o escore ASPECTS e traz casos para treinamento. Muito bom.

The Treatment of Super-Refractory Status Epilepticus

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Super-refractory status epilepticus is defined as status epilepticus that continues or recurs 24 h or more after the onset of anaesthetic therapy, including those cases where status epilepticus recurs on the reduction or withdrawal of anaesthesia. It is an uncommon but important clinical problem with high mortality and morbidity rates. This article reviews the treatment approaches. There are no controlled or randomized studies, and so therapy has to be based on clinical reports and opinion. The published world literature on the following treatments was critically evaluated: anaesthetic agents, anti-epileptic drugs, magnesium infusion, pyridoxine, steroids and immunotherapy, ketogenic diet, hypothermia, emergency resective neurosurgery and multiple subpial transection, transcranial magnetic stimulation, vagal nerve stimulation, deep brain stimulation, electroconvulsive therapy, drainage of the cerebrospinal fluid and other older drug therapies. The importance of treating the identifying cause is stressed. A protocol and flowchart for managing super-refractory status epilepticus is suggested. In view of the small number of published reports, there is an urgent need for the establishment of a database of outcomes of individual therapies.

NIH STROKE SCALE (booklet)

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Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort). >>> NIHSS Booklet >>>

Assessment of Current Diagnostic Criteria for Guillain-Barré Syndrome

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Diagnostic criteria for Guillain-Barré syndrome (GBS) were devised in 1978 at the request of the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS, now NINDS). The basis for issuing diagnostic criteria related to the swine flu vaccine incident of 1976-1977, which is reviewed in more detail elsewhere in the proceedings of this symposium. At the previous conference on Guillain-Barré syndrome in 1981, clarification of these diagnostic criteria was offered. In the intervening eight years it has become apparent that further comments and elaboration on the diagnostic criteria first stated in 1978 are in order. The reader should recognize that the suggestions made are solely the opinions of the authors and are not officially sanctioned by the NINDS or any neurological societies. The definition of GBS and criteria for diagnosis are reproduced below as they were first published in the Annals of Neurology in 1978. These are followed by a series of comments and suggested modifications.  >>> leia o artigo >>>

Seizure versus syncope

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One of the most common but difficult management problems in medicine is that of patients who present with a paroxysmal loss of consciousness. All too often the underlying diagnosis remains elusive. This has a cost both in terms of mortality and ongoing morbidity and in terms of the financial burden associated with hospitalisation and repeated investigations. We describe a practical approach to this clinical dilemma, which is rooted in adherence to basic principles of history talcing and examination, formulation of a reasonable differential diagnosis, followed by an intelligent use of specific investigations and selection of an appropriate treatment. We also discuss the effect of sudden unexpected deadi in epilepsy and sudden cardiac dead». Despite a careful and thorough approach to the patient with a “seizure versus syncope” problem, many will require repeated assessment before a diagnosis is made. >>> leia o artigo >>>

The diagnosis of dementia due to Alzheimer’s disease

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The National Institute on Aging and the Alzheimer’s Association charged a workgroup with the task of revising the 1984 criteria for Alzheimer’s disease (AD) dementia. The workgroup sought to ensure that the revised criteria would be flexible enough to be used by both general healthcare providers without access to neuropsychological testing, advanced imaging, and cerebrospinal fluid measures, and specialized investigators involved in research or in clinical trial studies who would have these tools available. We present criteria for all-cause dementia and for AD dementia. We retained the general framework of probable AD dementia from the 1984 criteria. On the basis of the past 27 years of experience, we made several changes in the clinical criteria for the diagnosis. We also retained the term possible AD dementia, but redefined it in a manner more focused than before. Bio-marker evidence was also integrated into the diagnostic formulations for probable and possible AD dementia for use in research settings. The core clinical criteria for AD dementia will continue to be the cornerstone of the diagnosis in clinical practice, but biomarker evidence is expected to enhance the pathophysiological specificity of the diagnosis of AD dementia. Much work lies ahead for validating the biomarker diagnosis of AD dementia. >>> leia o artigo >>>

The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist

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The rule of 4 is a simple method developed to help ‘students of neurology’ to remember the anatomy of the brainstem and thus the features of the various brainstem vascular syndromes. As medical students, we are taught detailed anatomy of the brainstem containing a bewildering number of structures with curious names such as superior colliculi, inferior olives, various cranial nerve nuclei and the median longitudinal fasciculus. In reality when we do a neurological examination we test for only a few of these structures. The rule of 4 recognizes this and only describes the parts of the brainstem that we actually examine when doing a neurological examination. The blood supply of the brainstem is such that there are paramedian branches and long circumferential branches (the anterior inferior cerebellar artery (AICA), the posterior inferior cerebellar artery (PICA) and the superior cerebellar artery (SCA). Occlusion of the paramedian branches results in medial (or paramedian) brainstem syndromes and occlusion of the circumferential branches results in lateral brainstem syndromes. Occasionally lateral brainstem syndromes are seen in unilateral vertebral occlusion. This paper describes a simple technique to aid in the understanding of brainstem vascular syndromes.  >>> Leia o artigo

Manuseio crítico de pacientes com hemorragia subaracnóide

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Subarachnoid hemorrhage (SAH) is an acute cerebrovascular event which can have devastating effects on the central nervous system as well as a profound impact on several other organs. SAH patients are routinely admitted to an intensive care unit and are cared for by a multidisciplinary team. A lack of high quality data has led to numerous approaches to management and limited guidance on choosing among them. Existing guidelines emphasize risk factors, prevention, natural history, and prevention of rebleeding, but provide limited discussion of the complex critical care issues involved in the care of SAH patients. The Neurocritical Care Society organized an international, multidisciplinary consensus conference on the critical care management ofSAHto address this need. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. A jury of four experienced neurointensivists was selected for their experience in clinical investigations and development of practice guidelines. Recommendations were developed based on literature review using the GRADE system, discussion integrating the literature with the collective experience of the participants and critical review by an impartial jury. Recommendations were developed using the GRADE system. Emphasis was placed on the principle that recommendations should be based not only on the quality of the data but also tradeoffs and translation into practice. Strong consideration was given to providing guidance and recommendations for all issues faced in the daily management of SAH patients, even in the absence of high quality data.        >>> Leia o artigo

Hemorragia cerebral

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Introdução: A hemorragia cerebral intraparenquimatosa é com frequência um dos aspectos mais esquecidos da doença vascular cerebral. Objetivo: Rever a hemorragia intracerebral em diversos aspectos desde a sua epidemiologia e etiologia, assim como a patogenia, clínica, diagnóstico e prognóstico. Métodos. Realizamos uma revisão rigorosa da literatura existente, com especial atenção à publicada nos últimos anos. Foram analisadas as tendências atuais no tratamento médico e cirúrgico da hemorragia intraparenquimatosa e à luz destes dados depreende-se algumas ideias que podem resultar úteis para o seu tratamento. Conclusões: É evidente que existem nestes momentos lacunas importantes no tratamento de vários aspectos da hemorragia cerebral e que deve ser este um campo em que no futuro abundem estudos terapêuticos que venham resolver as grandes incertezas que existe no tratamento desta patologia. [REV NEUROL 2002; 35: 1056-66]  >>> Leia o artigo