Stroke following percutaneous coronary intervention : type-specific incidence, outcomes and determinants seen by the British Cardiovascular Intervention Society 2007-12

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Prior antithrombotic therapy, particularly anticoagulant is associated with unfavorable outcomes in primary spontaneous intracerebral hemorrhage patients receiving craniotomy: A nationwide population-based cohort study.

OBJECTIVE: The impact of antithrombotic agents on primary intracerebral hemorrhage (ICH) patients remains controversial, especially with patients that require emergent craniotomy. This study was to evaluate clinical outcomes in operated ICH patients with and without prior antithrombotic agents. METHODS: This is a retrospective cohort study. Between January 2001 to December 2013, all ICH patients that received emergent craniotomy and is present in Taiwan's National Health Insurance Research Database were screened, and divided into prior antiplatelet therapy, anticoagulant therapy and non-antithrombotic therapy according to patient's healthcare claims data within 3 months of index admission. The primary endpoints included in-hospital mortality and complication, and short-term outcome. RESULTS: Of 18,872 eligible patients, 16,251 (87.1%) patients did not receive any antithrombotic therapy, 2,267 patients had antiplatelet therapy and 354 patients had anticoagulation therapy. After propensity score matching, significantly higher amount of blood transfusion and number of craniectomy was identified in the patients with prior antithrombotic treatment compared with non-antithrombotic therapy. In comparison with the non-antithrombotic treatment cohort, patients under prior anticoagulant treatment had significantly higher in-hospital mortality rate (Odds ratio, 2.12; 95% confidence interval, 1.45-3.10). Furthermore, during the 6-month follow-up period, prior anticoagulant therapy was independently associated with a greater risk of all-cause mortality rates (P = 0.001). Interestingly, the in-hospital and 6-month all-cause mortality of patients with prior antiplatelet treatment was not significantly different to patients with non-antithrombotic treatment. CONCLUSION: These findings suggested an increased risk of in-hospital mortality and poor short-term outcome among operated ICH patients with prior antithrombotic therapy, particularly anticoagulant therapy, but not with antiplatelet therapy

Epidemiology and Etiology of Young Stroke

Introduction. Stroke in people under 45 years of age is less frequent than in older populations but has a major impact on the individual and society. In this article we provide an overview of the epidemiology and etiology of young stroke. Methods. This paper is based on a review of population-based studies on stroke incidence that have included subgroup analyses for patients under 45 years of age, as well as smaller community-based studies and case-series specifically examining the incidence of stroke in the young. Trends are discussed along with the relative frequencies of various etiologies. Discussion. Stroke in the young requires a different approach to investigation and management than stroke in the elderly given differences in the relative frequencies of possible underlying causes. It remains the case, however, that atherosclerosis contributes to a large proportion of stroke in young patients, thus, conventional risk factors must be targeted aggressively

A study of factors associated with strokes in young adults in Hospital Universiti Sains Malaysia,Kelantan

Background Stroke in young adults causes morbidity and it is responsible for significant socioeconomic losses worldwide. There are limited data regarding the incidence and prevalence of strokes in Malaysia. A prospective, hospital-based study concluded that large vessel atherosclerosis and small vessel occlusion are the most common types of strokes. Diabetes, hypertension and chronic renal disease were found to be significant risk factors for young ischaemic stroke. The objective of this study was to determine the association between risk factors and ischaemic strokes in young adults. Information regarding the factors associated with ischaemic stroke in young adults in a local setting would improve our quality of care and it might provide ways to reduce the incidence of such strokes. Methodology This is a retrospective cohort study of 166 young adult patients which 99 of suffered an ischaemic stroke, and 67 of which suffered a non ischaemic stroke. The variables included in this study were hypertension, diabetes mellitus, dyslipidemia, smoking, alcohol intake, ischaemic heart disease, valvular heart disease, atrial fibrillation and previous ischaemic stroke. Data were assessed using simple logistic regression analysis to look for associations with ischaemic strokes and large artery atherosclerosis. Any factors with a P value ≤ 0.25 were included in the multiple logistic regression analysis and P value ≤ 0.05 were considered to be significant. Result The mean/±SD age for ischaemic stroke patients was 38.6 (±4.96). Hypertension was found to be associated with young ischaemic stroke (OR=1.85, 95% CI: 3. 10, 12.98, p<0.001) and diabetes mellitus was associated with large artery atherosclerosis in young ischaemic stroke patients. (OR=1.63, 95%CI: 1. 86, 13.94, p=0.002). Conclusion This study showed that hypertension is significantly associated with ischaemic stroke and that diabetes mellitus was associated with large artery atherosclerosis in young adults. Optimal management of hypertension and diabetes mellitus in young patients is recommended to reduce the risk of stroke and to prevent significant morbidity and mortality in these patients

Biopolitics, space and hospital reconfiguration

Major service change in healthcare – whereby the distribution of services is reconfigured at a local or regional level - is often a contested, political and poorly understood set of processes. This paper contributes to the theoretical understanding of major service change by demonstrating the utility of interpreting health service reconfiguration as a biopolitical intervention. Such an approach orients the analytical focus towards an exploration of the spatial and the population – crucial factors in major service change. Drawing on a qualitative study from 2011–12 of major service change in the English NHS combining documentary analyses of historically relevant policy papers and contemporary policy documentation (n = 125) with semi-structured interviews (n = 20) we highlight how a particular ‘geography of stroke’ in London was created building upon multiple types of knowledge: medical, epidemiological, economic, demographic, managerial and organisational. These informed particular spatial practices of government providing legitimation for the significant political upheaval that accompanies NHS service reconfiguration by problematizing existing variation in outcomes and making these visible. We suggest that major service change may be analysed as a ‘practice of security’ – a way of redefining a case, conceiving of risks and dangers, and averting potential crises in the interests of the population.</p

Cerebral Bypass Surgery: Level of Evidence and Grade of Recommendation

BACKGROUND AND AIMS Cerebral bypasses are categorized according to function (flow augmentation or flow preservation) and to characteristics: direct, indirect or combined bypass, extra-to-intracranial or intra-to-intracranial bypass, and high-, moderate- or low-capacity bypass. We critically summarize the current state of evidence and grades of recommendation for cerebral bypass surgery. METHODS The current indications for cerebral bypass are discussed depending on the function of the bypass (flow preservation or augmentation) and analyzed according to level of evidence criteria. RESULTS Flow-preservation bypass plays an important role in managing complex intracranial aneurysms (level of evidence 4; grade of recommendation C). Flow-preservation bypass is currently only very rarely indicated in the treatment of cerebral tumors involving major cerebral arteries (level of evidence 5; grade of recommendation D). The trend has evolved in favor of partial resection and radiotherapy. To preserve the flow, the bypass is always a direct bypass.Flow-augmentation bypass is currently recommended for Moyamoya patients with ischemic symptoms and compromised hemodynamics (level of evidence 4; grade of recommendation C) and patients with hemorrhagic onset (level of evidence 1B; grade of recommendation A). Flow-augmentation bypass is currently not recommended for patients with recently symptomatic carotid artery occlusion, even in the setting of compromised cerebral hemodynamics (level of evidence 1A; grade of recommendation A), but may be considered in patients with hemodynamic failure and recurrent medically refractory symptoms as a final resort (level of evidence 5; grade of recommendation D). CONCLUSIONS The results of recent randomized clinical trials narrow the indication for cerebral bypass in the setting of ischemic cerebrovascular disease. However, cerebral bypass is still very useful for managing complex intracranial aneurysms (not amenable to selective clipping or endovascular therapies) and is the only treatment option for managing symptomatic patients with Moyamoya vasculopathy and impaired brain hemodynamics

Surgical Treatment of Moyamoya Disease

Moyamoya disease is a rare cerebrovascular disease most prevalent in East Asian Countries. Thanks to the new diagnostic capabilities, the number of cases discovered has been rising steadily in the latest years, including many asymptomatic patients. But asymptomatic from the clinical point of view does not necessarily mean that there are no subjacent problems and that there will be no disease progression. Indeed, many patients harbour cognitive decline long before they start with clinical or even radiological manifestations. The only effective treatment is surgical revascularization, with all its possibilities: direct, indirect, and combined. While direct techniques are more useful in adult moyamoya patients, children seem to benefit most from indirect techniques. Additionally, indirect or combined procedures can be used as salvage procedures in case of unsatisfactory outcomes. Thus, many surgeons posit that surgical treatment should be considered in moyamoya patients, even if asymptomatic, particularly in the paediatric age group

Modelling the UK burden of cardiovascular disease to 2020

This new research report demonstrates the scale of the burden of cardiovascular disease (CVD) - shown to be large, costly, and increasing. Whilst mortality from CVD has fallen, an increasing population over the next decade will create further demands on services as the actual numbers of people living with CVD climb higher.<br /