The predictive value of casual blood pressure (BP) levels following acute stroke on outcome is currently unclear. This may in part reflect the observer bias and variability of casual recordings, which are reduced with 24-hour recordings. We therefore proposed to assess the prognostic significance of 24-hour compared to casual BP in predicting 30-day mortality, dependency and neurological outcome. A total of 136 consecutive patients were assessed within 24 h of ictus by one observer, with casual and 24-hour BP recording, and National Institutes of Health Stroke Scale and Modified Rankin Scale scores. Repeat assessments were made at 7 and 30 days. Admission casual and 24-hour systolic BP (SBP) and diastolic BP levels were significantly higher in patients with poor outcome at 1 month following acute stroke, whether expressed in terms of mortality, dependency or neurological deterioration, on single-variable logistic regression analysis. However, of these variables, only admission 24-hour (not casual) SBP remained a significant outcome predictor in a multiple model containing factors with an established association with poor prognosis. The odds ratio for outcome of death or dependency associated with each 10-mm-Hg increase in 24-hour SBP at admission was 1.88 (95% confidence interval: 1.27-2.78). For an outcome of death or high dependency, the model had a specificity of 75% and sensitivity of 76% when tested by the jackknife technique. Therefore, increasing 24-hour BP levels following acute stroke predict poor outcome. Whether BP should be reduced pharmacologically in the acute stroke period now warrants a suitable prospective intervention trial.

Cerebrovascular dysautoregulation is well recognised following acute stroke, and thus blood pressure (BP) changes may have important effects on cerebral blood flow. Whilst absolute BP levels have been shown to influence outcome in some studies, the importance of short-term BP variability has not been addressed. We assessed beat-to-beat BP and pulse interval variability non-invasively using the Finapres device in 32 patients with CT-diagnosed acute cerebral infarction compared to a control group matched with respect to age and sex. Systolic BP variability was assessed as the standard deviation (SD) of all measurements and as the root mean squared of successive differences (RMS; which removes the portion of variability related to the underlying BP level). Systolic BP variability (taken as either the SD or the RMS) was significantly greater in acute stroke patients than controls. This difference is unlikely to reflect impaired cardiac baroreceptor sensitivity in acute stroke patients as no differences were observed in pulse interval variability compared to controls, but may be related to alterations in peripheral vascular resistance mediated by centrally induced changes in sympathetic nervous system activity. The prognostic significance of increased BP variability and the implications for BP management in acute stroke require further evaluation.

No abstract

Admission to an acute stroke unit is decided on the basis of clinical and computed tomographic data collected in emergency, leading to a risk of misdiagnosis. The aim of this study was to evaluate the rate of misdiagnoses in an acute stroke unit. This study was conducted over a 1-year period in consecutive patients, who were initially examined in the emergency department and underwent a non-contrast computed tomographic scan, an electrocardiogram (ECG) and routine biological tests. Then they were referred to the acute stroke unit, where they were re-examined by a board-certified in-house neurologist and underwent continuous ECG recording, ultrasonography and echocardiography within 24 h and other tests if necessary. Of 1,250 patients admitted to the acute stroke unit, 1,071 (85.7%) had a definite neurovascular disorder (ischemic stroke, transient ischemic attacks, intracerebral hemorrhage, cerebral venous thrombosis, subarachnoid hemorrhage and spinal stroke). 66 (5.3%) had a possible neurovascular disorder (migraine aura, post-stroke epileptic seizure, isolated acute vertigo and acute hypertensive encephalopathy), and 113 (9 %) had a non-vascular disorder, the final diagnosis was a neurological disorder in 96 of them. Therefore, misdiagnoses occur in one tenth of patients and usually consist of other neurological disorders. Therefore, neurologists should be involved in the management of stroke patients at the acute stage and should remain general neurologidts even if they are overspecialized ''strokologists.''

No abstract