No abstract

Although these results reflect high standards of acute stroke care and improvements regarding early admission, thrombolytic therapy, and several secondary preventive measures, there is still the potential for further improvement regarding thrombolysis, use of oral anticoagulation and statins, and admission to stroke units, for example.

Background: The risk of stroke after cardiac and carotid surgery is well established. In contrast, stroke risk in association with non-cardiac and non-carotid surgery and its time course are insufficiently known. We investigated the prevalence of recent and planned surgery among patients with stroke and transient ischemic attack (TIA), time dependency of stroke risk, stroke etiology, and interruption of antithrombotic medication in association with surgery. Methods: Data on type and date of surgery and similar interventions within the last year or planned for the next 2 weeks were anonymously collected together with demographic data, vascular risk factors, stroke severity, handicap before stroke and stroke etiology within a state-wide, mandatory, hospital-based acute stroke care quality monitoring project (Rhineland-Palatinate, Germany) for 1 year (2010). Results: Non-carotid and non-cardiothoracic surgery was reported as performed within 1 year before the index event or as planned for the next 2 weeks thereafter in 532 out of 12,120 patients with ischemic stroke/TIA (4.4%). Compared to 91-365 days before stroke/TIA as reference period, risk of cerebral ischemia (per day analysis) was increased for surgery within 61-90 days before ischemia (rate ratio 2.0, 95% CI 1.5-2.8) and continuously increased along shorter intervals between stroke and surgery (31-60 days: rate ratio 3.6, 95% CI 2.9-4.5; 15-30 days: rate ratio 8.2, 95% CI 6.7-10.1; 8-14 days: rate ratio 13.2, 95% CI 10.3-16.8; 4-7 days: rate ratio 16.5, 95% CI 12.2-22.1) peaking at an interval of 1-3 days before ischemia (rate ratio 34.0, 95% CI 26.9-42.8). On the day of surgery, rate ratio was 14.8 (95% CI 7.8-27.9) and for planned surgery it was 2.7 (95% CI 1.8-4.0). Results were similar for first-ever and for recurrent ischemic stroke. Perioperative stroke/TIA was positively associated with atrial fibrillation and cardioembolic stroke etiology, higher mortality, more severe neurological deficits at discharge, and longer hospital stay; and it was inversely associated with microangiopathic etiology and discharge at home. In 34.5% of patients with recent/planned surgery, prior antithrombotic or anticoagulant medication had been interrupted. Conclusions: Recent or planned surgery imposes a considerable short-term stroke risk particularly by cardioembolism with cessation of medication as an important contributor. Stroke after surgery is associated with poor outcome and high mortality. Better strategies to reduce the burden of perioperative stroke are urgently required.

The mother was a 29 year old primigravida. The girl was born at 35 weeks' gestation by emergency caesarean section due to breech presentation and maternal haemorrhage. The pregnancy had been uncomplicated except for an upper respiratory tract infection with fever in the last four weeks. The amniotic fluid was stained with meconium. The umbilical cord arterial pH was 7-29 and venous pH was 7 31. Apgar scores were 5, 9, and 9 at 1, 5, and 10 minutes. The infant was intubated due to increasing respiratory distress. The chest radiograph showed a totally opaque left lung, presumably due to atelectasis. Clinical findingsThe birth weight was 1820 g (10th centile) and the head circumference was 30 5 cm (lOth-SOth centile). The infant made no spontaneous movements, there was pronounced spasticity with leg abduction, exaggerated tendon reflexes, and absent suck and swallow (fig 1)

Cardioembolic mechanisms cause 15 to 20% of all strokes and may account for the high incidence of neurological dysfunction associated with cardiopulmonary bypass. Accurate identification of high-risk subjects and/or surgical techniques would allow more effective testing and implementation of preventive or therapeutic measures to help reduce morbidity and mortality. This article reports on validity and reliability testing of a new emboli detection device that allows continuous monitoring of the common carotid artery. The instrument appears to be capable of detecting accurately particles of 193 mu or less in diameter and is highly reliable both within and between observers. In preliminary clinical use, the instrument also detected embolic signals in all patients monitored during cardiopulmonary bypass, while none were detected in healthy control subjects. These results establish the validity and reliability of a new emboli detection device and suggest its potential application to emboli detection monitoring during cardiopulmonary bypass.