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Stroke: Evidence For Our Role in Prevention…Or Not

There are nearly 795,000 stroke cases in the U.S yearly and nearly a quarter of are patients under the age of 65. Recent research found that nationwide, hospitalization rates for ischemic strokes increased over 30% among people ages 15 to 44 in the last 10 years. And then THERE IS THE TREND that Americans are becoming fatter, more frequently hypertensive, and more often acquiring diabetes with the consequential atherosclerotic changes they develop at an earlier age. Lastly, data shows an increase in strokes during pregnancy and in the post-partum period.

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In adults, minor acute infections are considered a risk factor for stroke. However the issue had not been adequately explored in pediatrics. Now, according to Nancy Hills, PhD, of the U.C. San Francisco reporting at the ASAs International Stroke Conference, acute infection appears to be associated with an increased likelihood of ischemic stroke in children who were at least 29 days old. This retrospective cohort study found an increased risk if the individual had had an outpatient visit for acute infection within the previous 30 days, and especially within two days of the stroke. (N = 126 pediatric ischemic strokes, study population of 2.5 million, 1993- 2007). A prospective study to verify these findings — The Vascular Effects of Infection in Pediatrics (VIPS) trial — will likely to be published within two years.

So what’s bubbling up in the literature that may be good news? Dr. D. Manawadu from the King’s College Hospital in London presented data at the ASA in New Orleans suggesting that it may be safe to give rTPA to people who wake up with stroke symptoms. Almost 25 percent of strokes have their onset during sleep. The investigators used a stroke registry comparing 326 patients treated with rTPA within 4.5 hours of symptoms to 68 “wake-up” stroke patients. In the study, the death rates, risk of ICH and recovery rates after three months were similar in both groups of stroke patients. “Administering rTPA to ‘wake-up’ stroke patients matched for clinical and imaging features as those treated within current guidelines appears feasible and safe.” It could make sense that our technology has finally improved to the point that it can finally begin to tell us something the patient can’t about when they started having problems. Future studies will likely tell us more.

The bottom line still remains, the earlier the treatment is started the better. So, what can we do for these people? Foremost, we have to tell the general population that it is time to take better care of themselves! (maybe not by telling them, “you’re a fat unconditioned slob”, take it from me). We also need to start teaching our patients at all ages about stroke signs and symptoms. They need to be familiar with the following: sudden unilateral numbness or weakness in the face, arm or leg; sudden difficulty speaking or understanding speech, trouble seeing or walking, a sudden onset-severe headache. And finally, the general public needs to understand TIAs are a warning of imminent stroke.

References: Hills N, et al “Timing of infection and risk of arterial ischemic stroke in children” ASA 2012; Abstract 39.
Source: Feb. 1, 2012, presentation, American Stroke Association meeting, New Orleans, LA

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