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This article brings an update of the Recommendations for Stroke Management, first published in this journal in 2001. The Recommendations are consistent with the Recommendations of three European societies represented Iri the European Stroke Initiative: the European Stroke Council, the European Neurological Society, and the European federation of Ne...
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... Ανεπαρκής βρέθηκε να είναι η αναγνώριση συμπτωμάτων των ΑΕΕ, καθώς και η κατάλληλη ανταπόκριση από το κοινό [33] . [37] . ...
... Οι κατευθυντήριες οδηγίες δίνονται από την Ευρωπαϊκή-Κροατική Εταιρεία ΑΕΕ και την Κροατική Εταιρεία Νευροαγγειακών Διαταραχών [37] . ...
Το βιβλίο Οι επιπτώσεις του Εγκεφαλικού Επεισοδίου στην Ευρώπη (The Burden of Stroke in Europe) είναι μια μελέτη που πραγματοποίησαν ερευνητές στο King's College του Λονδίνου, η οποία παρουσιάζει μια εις βάθος ανάλυση σχετικά με την ευαισθητοποίηση, την πληροφόρηση και την πρόληψη αυτής της επείγουσας κατάστασης ανάγκης. Εξετάζει τους τρόπους περίθαλψης, αποκατάστασης, υποστήριξης και κοινωνικής ενσωμάτωσης και γενικότερα τη ζωή των Ευρωπαίων πολιτών που ήρθαν αντιμέτωποι με ένα εγκεφαλικό επεισόδιο. Η μελέτη, που ανατέθηκε στους ερευνητές στο Λονδίνο από την Μ.Κ.Ο. Stroke Alliance for Europe (S.A.F.E.), εξέτασε μητρώα, έγγραφα και πληροφορίες από 35 ευρωπαϊκές χώρες, συμπεριλαμβανομένης της Ελλάδας, επισημαίνοντας σημαντικές διαφορές μεταξύ των διαφορετικών μοντέλων περίθαλψης και ανισότητες στην προσφορά και στην πρόσβαση σε θεραπείες. Η έκθεση υπογραμμίζει ανησυχητικά επιδημιολογικά δεδομένα: Το αγγειακό εγκεφαλικό επεισόδιο είναι μία από τις πρώτες αιτίες θανάτου στην Ευρώπη, η δεύτερη αιτία της ενσυνείδητης νοητικής ανεπάρκειας των ενηλίκων και η πρώτη αιτία μακροχρόνιας αναπηρίας. Παρά τις προσπάθειες που καταβάλλουν οι ευρωπαϊκές χώρες για την αντιμετώπιση αυτής της ανθρωπιστικής καταστροφής, αναμένεται αύξηση κατά περίπου 30% των νέων περιπτώσεων τα επόμενα χρόνια, κυρίως λόγω της γήρανσης του πληθυσμού. Η μελέτη που πραγματοποιήθηκε από το King's College London έδειξε ότι είναι δυνατό να βελτιωθεί σημαντικά το ποσοστό επιβίωσης μετά από ένα εγκεφαλικό επεισόδιο, μέσω της καθιέρωσης μονάδων για το εγκεφαλικό επεισόδιο και της θεραπείας με θρομβόλυση. Ωστόσο, παρά τη συμπερίληψη αυτών των δομών στις ευρωπαϊκές και εθνικές κατευθυντήριες γραμμές, εκτιμάται ότι μόνο το 30% των ασθενών με αγγειακό εγκεφαλικό επεισόδιο λαμβάνουν την κατάλληλη μέριμνα. Επομένως, η πρόληψη και η σωστή θεραπεία εγκεφαλικού επεισοδίου πρέπει να είναι απόλυτη προτεραιότητα των ευρωπαϊκών χωρών Επομένως, στοχεύοντας στη βελτίωση των πρακτικών πρόληψης και θεραπείας του εγκεφαλικού επεισοδίου στην Ελλάδα, το Πανεπιστήμιο Μακεδονίας σε συνεργασία με το Κέντρο Αποθεραπείας-Αποκατάστασης «η Αναγέννηση», καθώς και με άλλους ερευνητές, επιχειρεί την προώθηση της ελληνικής εκδοχής της έκθεσης αξιοποιώντας αυτή την πολύτιμη ευκαιρία για ενημέρωση και ανταλλαγή πληροφοριών όχι μόνο με τον ελληνικό πληθυσμό, αλλά και με ενδιαφερόμενους από το χώρο της πολιτικής και με επαγγελματίες που συμμετέχουν στο σχεδιασμό και την οργάνωση των υπηρεσιών υγείας.
... We retrospectively reviewed the medical data of thrombolysed patients from SITS registry in the period of 7 years (11/2005-11/2012) All patients were screened by a neurologist to determine eligibility for intravenous thrombolytic therapy according to strict European Stroke Organization (ESO) protocol, and Croatian recommendations for stroke management [6,7]. ...
A decade ago, stroke was the first leading cause of morbidity and mortality in Croatia. Nowadays, we record reduction in stroke incidence, as well as stroke consequences-invalidity and mortality. These are due to long-term planned actions in the field of public health as well as actions performed by professional organizations. Today, we can be satisfied with improvement in that field, but there are still things we can improve, at the first place improvement of the emergency medicine network due to Croatian-specific topographical characteristics to reduce onset-to-door time. In this paper, we evaluated results from 11 Croatian hospitals in the period 11/2005-11/2012. To find out about the past and present state in applying thrombolytic therapy in Croatia and to plan further actions in light of new studies and efforts in Europe and in the world, all with the aim of improvement in stroke prevention and acute treatment resulting in reduction of stroke morbidity, mortality and symptomatic intracerebral hemorrhage as well as better functional outcome. Our results have shown that we improved stroke treatment in the last decade, but further actions should be performed to raise public stroke awareness and to improve emergency medicine network as well as in hospital protocols.
... We analyzed 7 neurology guidelines that were available at the web-site of the Croatian Physicians' Assembly in 2012 [10]. Six were developed by Croatian authors and one was adapted (translated) from the European Federation of Neurological Societies (EFNS) guideline: 1) Consensus opinion on diagnosing brain death -Guidelines for use of confirmatory tests [13]; 2) Recommendations for neuropathic pain treatment [14]; 3) Recommendations for stroke management 2006 update [15]; 4) Evidence based guidelines for treatment of primary headaches [16]; 5) Guidelines for preoperative diagnostic evaluation of patients with pharmacoresistant epilepsy [17], 6) Epilepsytherapeutic guidelines [18], 7) EFNS guidelines on pharmacological treatment of neuropathic pain [19]. ...
... The criteria for selecting the evidence was described only in the EFNS guidelines [19]. Methods for formulating recommendations were described in EFNS guidelines on pharmacological treatment of neuropathic pain [19] and in Recommendations for stroke management 2006 update [15]. We found no evidence of external review prior to the publication for any of the evaluated guidelines. ...
... In 3 out of 7 assessed guidelines, recommendations were partially based on evidence from Cochrane systematic reviews: EFNS guidelines on pharmacological treatment of neuropathic pain [19]; Recommendations for neuropathic pain treatment [14]; and Recommendations for stroke management 2006 update [15]. The key conclusions made by prior studies were confirmed in updated versions of the reviews and one update provided new information on effectiveness of another antidepressant -venlafaxine [22]. ...
Clinical practice guidelines are systematically created documents that summarize knowledge and assist in delivering high-quality medicine by identifying evidence that supports best clinical care. They are produced not only by international professional groups but also by local professionals to address locally-relevant clinical practice. We evaluated the methodological rigour and transparency of guideline development in neurology formulated by professionals in a local medical community.
We analyzed clinical guidelines in neurology publicly available at the web-site of the Physicians' Assembly in Croatia in 2012: 6 guidelines developed by Croatian authors and 1 adapted from the European Federation of Neurological Societies. The quality was assessed by 2 independent evaluators using the AGREE II instrument. We also conducted a search of the Cochrane Library to identify potential changes in recommendation from Cochrane systematic reviews included in guideline preparation.
The methodological quality of the guidelines greatly varied across different domains. "Scope and Purpose" and "Clarity of Presentation" domains received high scores (100% [95% confidence interval (CI) 98.5-100] and 97% [77.9-100], respectively), the lowest scores were in "Stakeholder Involvement" (19% [15.5-34.6]) and "Editorial Independence" (0% [0-19.2]). Conclusions of 3 guidelines based on Cochrane systematic reviews were confirmed in updated versions and one update provided new information on the effectiveness of another antidepressant. Two Cochrane reviews used in guidelines were withdrawn and split into new reviews and their findings are now considered to be out of date.
Neurological guidelines used in Croatia differ in structure and their methodological quality. We recommend to national societies and professional groups to develop a more systematic and rigorous approach to the development of the guidelines, timely inclusion of best evidences and an effort to involve target users and patients in the guideline development procedures.
... Patients with diabetes are at 1.5-3 times the risk of stroke compared with general population and associated mortality and morbidity is greater than in those without this underlying condition. Even patients with metabolic syndrome component have a 1.5-fold increased risk of stroke [1,2]. This is primarily due to increased proatherogenic risk factorsabnormal plasma lipid profiles, hypertension, and hyperglycemia. ...
The aim of the study was to evaluate correlation of breath holding index (BHI) as functional parameter for intracranial subclinical atherosclerotic changes – we have shown in our previous works and arterial stiffness (AS – functional parameter for extracranial subclinical atherosclerotic changes) in diabetic patients with well and poor controlled glucose blood values in correlation with healthy population.Patients and methodsWe included 60 volunteers divided into 3 aged standardized groups – healthy volunteers, patients with well controlled diabetes and patients with poor controlled diabetes. We excluded individuals with moderate and severe carotid stenosis.ResultsThere was decreasing trend in BHI values and increasing trend in AS values in diabetic patients, especially with poor regulated blood glucose values (r = −0.14 and 1.42; p < 0.05).Conclusion
These results show that decline in BHI as parameter for intracranial microvessel dysfunction is in good correlation with increase of AS as functional parameter of extracranial vascular aging in diabetic patients.
... After a stroke, specific pattern of cortical reorganization has been described (1). During the past few years, three principles for remodeling motor cortex; forced use of the affected limb (2, 3,), constraining the unaffected limb (5), and massed practice (6), showed very promising results (7,8,9,10) But the question remains: What's the most effective way to reach restoration of the whole body movement? ...
... A. Short-term feedback interfaces 1. EEG NEUROFEEDBACK Electroencephalogram (EEG) is produced by synchronous postsynaptic potentials from cortical neurons, recorded at the scalp. The raw EEG signal is amplified, digitized, plotted, and filtered to isolate narrow frequency bands (defined in Hz) that reflect specific brain sources and functions (10). ...
Every year, 15 million people worldwide suffer a stroke, when the blood supply to the brain is blocked orwhen a blood vessel in the brain bursts. After a stroke, specific pattern of cortical reorganization has been described (1). During the past few years, three principles for remodeling motor cortex; forced use of the affected limb (2, 3,), constraining the unaffected limb (5), and massed practice (6), showed very promising results (7, 8, 9, 10) But the question remains:What's the most effectiveway to reach restoration of the whole body movement? Advances in clinical neurology, embodied cognitive neuroscience and computer technology have made possible the emergence of a new set of neurorehabilitation tools, helping physiatrists and neurologist to find evidence- based answers in the formof clinical trials. Interface here are define as a point of interaction helping communication between the patient and his own body, using feedback and feedforward signals.
... Croatian Stroke Society [50] Not included Recommend early mobilisation unless intracerebral hypertension is present, to help prevent complications including aspiration pneumonia, DVT, & ulcers (IV). ...
Physical inactivity contributes to accelerated bone loss after stroke, leading to heightened fracture risk, increased mortality, and reduced independence. This paper sought to summarise the evidence for the use of physical activity to protect bone in healthy adults and adults with stroke, and to identify international recommendations regarding any means of bone protection after stroke, in order to guide rehabilitation practice and future research. A search was undertaken, which identified 12 systematic reviews of controlled trials which investigated the effect of physical activity on bone outcomes in adults. Nine reviews included healthy adults and three included adults with stroke. Twenty-five current international stroke management guidelines were identified. High-impact loading exercise appears to have a site-specific effect on the microarchitecture of healthy postmenopausal women, and physical activity has a small effect on enhancing or maintaining bone mineral density in chronic stroke patients. It is not known whether this translates to reduce fracture risk. Most guidelines included recommendations for early mobilisation after stroke and falls prevention. Two recommendations were identified which advocated exercise for the prevention bone loss after stroke, but supporting evidence was limited. Research is required to determine whether targeted physical activity can protect bone from early after stroke, and whether this can reduce fracture risk.
... Citicoline showed a robust neuroprotective effect in preclinical studies, but a mild neuroprotective effect in clinical trials, which was recognized by ESO [12], but not recommended by the neurological professional societies [12,36,37]. We are waiting for the results of the International Citicoline Trial on Acute Stroke (ICTUS), in which patients are still being recruited [15,51,52]. ...
Neuroprotection is a therapeutic strategy that attempts to save neurons from irreversible injury by modifying the effects of the ischemic cascade or facilitating reperfusion. Although numerous agents have shown neuroprotective effect in preclinical trials, their translation to clinical trials failed to show any meaningful effect. The Stroke Therapy Academic Industry Roundtable (STAIR) guidelines were made for performing research on neuroprotective agents in pre-clinical and clinical trials. Although the STAIR guidelines have been available for more than ten years, we still do not have any adequate neuroprotective agents. Reasons for unsuccessful translation from preclinical to clinical research can be considered along stages of drug development: 1) preclinical, 2) transitional and 3) clinical. By extending the therapeutic window for application of intravenous thrombolysis in acute stroke patients to 4.5 hours, as well as increasing the use intra-arterial thrombolysis and development of mechanical devices for thrombectomy in 6 hour period we may be able to achieve some degree of neuroprotection in acute stroke. Future therapy is likely to add to the current thrombolytic therapy with potential neuroprotective drugs or procedures.
... The aim of the study was to follow the evolution of cognitive impairment in different clinical phases of stroke, the confirmation and recording of impairment, and the possibility of starting an early therapeutic and rehabilitation procedure 17,18 . ...
Cognitive abilities have great impact on rehabilitation program in stroke patients. Therefore, fast and practical psychometric assessment as an indicator of individual rehabilitation program is of great importance. The aim of this study was to analyze and compare motor and cognitive impairment in stroke patients in acute, subacute and chronic phase of the disease, taking age, sex, education, stroke risk factors, lateralization and type of stroke in consideration. The study included 50 stroke patients, 33 male and 17 female. Ischemic stroke was diagnosed in 78% and hemorrhagic stroke in 22% of patients. Hypertension was the leading stroke risk factor in 82% of patients. Cognitive impairment in acute, subacute and chronic phase of the disease was noticed in 12% of stroke patients with ischemia in the left brain hemisphere, mMMSE average score 31 and SKT score 19, IQ under 90. Better motor recovery in acute and subacute phase of stroke was followed by better cognitive status. All cognitively impaired stroke patients had low level of education, some had accomplished elementary education and others had not, all much below the dementia risk age of 75 years. Exclusion of patients with severe stroke from the study led to overestimation of the results. Finally, a coherent algorithm for somatic and cognitive stroke assessment in stroke patients poses itself as an imperative as a guideline for plastic, individualized and appropriate rehabilitation.
... All patients were screened by a neurologist to determine eligibility for systemic thrombolytic therapy according to strict European Stroke Organization (ESO) protocol, and Croatian guidelines [4,5]. ...
The aims of this paper are: 1) to present the data of systemic thrombolysis for ischemic stroke in five Croatian centers from July 2008 till January 2010; 2) to compare the results between centers and; 3) to compare data with previously published results from 2006 to 2008 period from our center, and with the data from SITS (Safe Implementation of Treatments in Stroke).
We retrospectively reviewed the medical data of thrombolysed patients in following hospitals: University Hospital Center Zagreb (91 patients), University Hospital Split (25 patients), University Hospital Osijek (22 patients), General Hospital Varaždin (21 patient), and General Hospital Zadar (7 patients).
The "time to door" for all centers was 79.71±38.63 min, the "door to needle" period was 64.39±24.18 min. Systolic and diastolic blood pressures at admission were 158.65±27.72 and 90.18±15.03 mm Hg, respectively. Systolic and diastolic blood pressures measured immediately prior to administering rt-PA were 152.19±23.17 and 85.40±15.27 mm Hg, respectively. Initial median NIHSS score was 12, median NIHSS 2h post thrombolysis was 8, and 7th day after rt-PA treatment 4. Intracerebral hemorrhages or secondary hemorrhagic transformations occurred in 21 (12.65%) patients, among which nine were symptomatic. In a 4.5h time window total of 17 patients were thrombolysed. We did not find any differences in outcome between this group and group of patients thrombolysed in the 3h time-window. The group of patients older than 80 years had a worse outcome.
According to our data, treatment with rt-PA is safe, feasible and effective for stroke patients in both university as well as regional hospitals having stroke units established. Organization of stroke units in regional hospitals, as well as systematic education of public health workers and neurologists, leads to the possibility for each patient to reach the nearest stroke unit and gets the thrombolytic therapy in the therapeutic time window.
... The diagnosis of acute ischemic stroke was set based on clinical signs and symptoms of a sudden focal or global disorder of brain functions caused by an ischemic event and based on CT results.2 The CT excluded the existence of cerebral hemorrhage and other possible causes of a brain damage (eg, a tumor) that can imitate the clinical picture of ischemic stroke. ...
... Many risk factors have been found for the appearance of a stroke and new factors are continually recognized.12 The awareness that atherosclerosis is partially an inflammatory disease has lead to the acceptance of inflammation and its markers as new and significant risk factors for the development of cardiovascular and cerebrovascular diseases. ...
The expression of soluble adhesion molecules inter-cellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1), besides activation of endothelial cells and transendothelial migration of leukocytes, play an important role in inflammation and progression of ischemic injury after acute stroke. The aim of this study was to determine serum levels of soluble ICAM-1 and VCAM-1 in patients with acute ischemic stroke and controls and correlate them according to etiological subtypes (thromboembolic or lacunar stroke), stroke severity and disability after acute stroke.
Hospital-based prospective study of acute stroke patients hospitalized between December 2008 and September 2009 at the University Hospital Sestre Milosrdnice in Zagreb, Croatia.
We enrolled 110 patients with acute ischemic stroke and 93 healthy individuals as controls. Serum concentrations of VCAM-1 and ICAM-1 were determined by means of quantitative sandwich enzyme immunoassay. Patients were classified according to etiological subtype, clinical severity of stroke and disability after stroke.
There was no significant difference between levels of soluble adhesion molecules VCAM-1 and ICAM-1 in patients and in controls. Levels of VCAM-1 were significantly higher in patients with thromboembolic stroke than in controls. There was no significant correlation between levels of soluble adhesion molecules VCAM-1 and ICAM-1 and stroke severity and disability. There was marked biological interindividual variability in all patient groups.
This study confirms the role of adhesion molecule VCAM-1 in the pathogenesis of acute thromboembolic stroke.
