Stroke is the third most common cause of death in most developed countries. It is a worldwide problem; about 4.5 million people die from stroke each year. Stroke can occur at any age, but half of all strokes occur in people aged over 70 years. About 80% of all acute strokes are ischaemic, usually resulting from thrombotic or embolic occlusion of a cerebral artery. The remainder are caused either by intracerebral or subarachnoid haemorrhage.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of specialised care in people with acute stroke? What are the effects of medical treatment in people with acute ischaemic stroke? What are the effects of decompressive hemicraniectomy in acute ischaemic stroke? What are the effects of surgical evacuation for intracerebral haematomas? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 44 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acute reduction in blood pressure, aspirin, evacuation (early surgical evacuation, or conservative treatment), decompressive hemicraniectomy, neuroprotective agents (calcium channel blockers, citicoline, gamma-aminobutyric acid agonists, glycine antagonists, lubeluzole, magnesium, N-methyl-D-aspartate antagonists), specialised stroke care, systemic anticoagulation (heparinoids, low or specific thrombin inhibitors, low molecular weight heparin, oral anticoagulants, unfractionated heparin), and thrombolysis.
Stroke is characterised by rapidly developing clinical symptoms and signs of focal, and at times global, loss of cerebral function lasting over 24 hours or leading to death, with no apparent cause other than that of vascular origin.
Ischaemic stroke (which accounts for about 80% of all acute strokes) is caused by vascular insufficiency (such as cerebrovascular thromboembolism) rather than haemorrhage.It is the third most common cause of death in most developing countries, with about 4.5 million people worldwide dying from stroke each year.About 10% of all people with acute ischaemic strokes will die within 30 days of onset, and, of those who survive the acute event, about 50% will still experience some level of disability after 6 months.
Specialised stroke rehabilitation seems more effective than conventional care at reducing death and dependency after 1 year.
Aspirin effectively reduces death or dependency at 6 months when given within 48 hours of ischaemic stroke.
Aspirin has a similar effectiveness as anticoagulants (unfractionated or low molecular weight heparin), but a lower risk of intra- and extracranial haemorrhage.
Thrombolysis (given within 3 hours of symptom onset) reduces death or dependency at 6 months in people with confirmed ischaemic stroke, but increases the risk of symptomatic haemorrhage.
The reduction in death or dependency may not apply to streptokinase treatment.
While there does seem to be a direct link between blood pressure and risk of recurrent stroke, acute blood pressure lowering in acute ischaemic stroke may actually lead to increased cerebral ischaemia.
Neuroprotective drugs do not seem to significantly reduce the risk of poor outcome (including death) or to improve outcome in people with ischaemic stroke.
In young people with malignant middle cerebral artery (MCA) infarction, decompressive hemicraniectomy is an effective life-saving treatment.
In people with primary supratentorial haematomas, surgical evacuation may be more effective at reducing death or dependency.
We found no evidence examining the effects of evacuation in people with infratentorial haematoma whose consciousness level is declining.