OBJECTIVE:Information on the nature and relative frequency of diagnoses made in referrals to neurology outpatient clinics is an important guide to priorities in services, teaching and research. Previous studies of this topic have been limited by being of only single centres or lacking in detail. We aimed to describe the neurological diagnoses made in a large series of referrals to neurology outpatient clinics. METHOD:Newly referred outpatients attending neurology clinics in all the NHS neurological centres in Scotland, UK were recruited over a period of 15 months. The assessing neurologists recorded the initial diagnosis they made. An additional rating of the degree to which the neurologist considered the patient's symptoms to be explained by disease was used to categorise those diagnoses that simply described a symptom such as 'fatigue'. RESULTS:Three thousand seven hundred and eighty-one patients participated (91% of those eligible). The commonest categories of diagnosis made were: headache (19%), functional and psychological symptoms (16%), epilepsy (14%), peripheral nerve disorders (11%), miscellaneous neurological disorders (10%), demyelination (7%), spinal disorders (6%), Parkinson's disease/movement disorders (6%), and syncope (4%). Detailed breakdowns of each category are provided. CONCLUSIONS:Headache, functional/psychological disorders and epilepsy are the most common diagnoses in new patient referral to neurological services. This information should be used to shape priorities for services, teaching and research.

Background. Patients whose symptoms are 'unexplained by disease' often have a poor symptomatic outcome after specialist consultation, but we know little about which patient factors predict this. We therefore aimed to determine predictors of poor subjective outcome for new neurology out-patients with symptoms unexplained by disease 1 year after the initial consultation.Method. The Scottish Neurological Symptom Study was a 1-year prospective cohort study of patients referred to secondary care National Health Service neurology clinics in Scotland (UK). Patients were included if the neurologist rated their symptoms as 'not at all' or only 'somewhat explained' by organic disease. Patient-rated change in health was rated on a five-point Clinical Global Improvement (CGI) scale ('much better' to 'much worse') 1 year later.Results. The 12-month outcome data were available on 716 of 1144 patients (63%). Poor outcome on the CGI ('unchanged', 'worse' or 'much worse') was reported by 482 (67%) out of 716 patients. The only strong independent baseline predictors were patients' beliefs [expectation of non-recovery (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.40-2.96), non-attribution of symptoms to psychological factors (OR 2.22, 95% CI 1.51-3.26)] and the receipt of illness-related financial benefits (OR 2.30, 95% CI 1.37-3.86). Together, these factors predicted 13% of the variance in outcome.Conclusions. Of the patients, two-thirds had a poor outcome at 1 year. Illness beliefs and financial benefits are more useful in predicting poor outcome than the number of symptoms, disability and distress.

Health outcomes and costs are both important when deciding whether general (GA) or local (LA) anaesthesia should be used during carotid endarterectomy. The aim of this study was to assess the cost‐effectiveness of carotid endarterectomy under LA or GA in patients with symptomatic or asymptomatic carotid stenosis for whom surgery was advised.

Objective: ESCT and NASCET established the role of CEA in appropriate patients but reported a 5-7% 30-day stroke/death risk.Strategies reducing this would be important.The GALA Trial was conceived following analysis of non-randomised and randomised studies suggesting a 50% risk reduction for LA CEA.Method: A total of 3526 patients (symptomatic or asymptomatic disease) were randomised to GA or LA (95 centres, 24 countries).Primary outcome events were stroke, myocardial infarction or death (randomisation -30 days post-surgery).The data were analysed by intention-to-treat analysis.Results: Events occurred (99•9% follow-up) in 84/1752 (4•8%) GA and 80/1771 (4•5%) LA patients (not significant: three events prevented per 1000 LA patients [95% CI -11, +17]; risk ratio 0•94 [95% CI 0•70, 1•27]).There were no differences for individual outcome events: stroke 70 (4•0%) GA versus 66 (3•7%) LA (three prevented per 1000 LA patients [95% CI -10 to +16]); death 26 (1•5%) GA versus 19 (1•1%) LA (four prevented per 1000 [95% CI -3 to +12]); myocardial infarction LA 9 (0•5%) versus GA 4 (0•2%) (three more per 1000 LA patients [95% CI -2 to +8]).In patients with contralateral carotid occlusion (pre-defined sub-group), outcome events occurred in 15/150 (10%) GA versus 8/160 (5%) LA, p = 0•098.Further 1-year survival data indicate fewer subsequent events (stroke, death, MI) in LA patients (p = 0•094).Conclusion: These data show that CEA outcomes have improved by up to a third since earlier trials and that both LA and GA are safe.For patients with contralateral carotid occlusion, LA might offer a benefit and trends suggesting improved 1-year survival following LA surgery require further analysis.Change in practice from heparin to aspirin prophylaxis significantly reduced the thrombosis rate in renal paediatric recipients in a single centre

This chapter contains section titled: Introduction Planning and developing a stroke service Comprehensive stroke service General principles when discussing a comprehensive stroke service Interventions to improve access to early specialist assessment and treatment Organized inpatient (stroke unit) care Transfer from hospital to community Continuing rehabilitation and reintegration back to normal life Longer-term follow-up and chronic disease management Generic issues in stroke service delivery Planning, developing and maintaining a stroke service Evaluating and monitoring stroke services Stroke guidelines Integrated care pathways Impact of a comprehensive stroke service Cost-effectiveness of stroke services

This chapter contains section titled: General principles Treatable causes of poor clinical condition on admission and their management General care Prevention of rebleeding Prevention of delayed cerebral ischaemia Management of rebleeding Management of delayed cerebral ischaemia Management of acute hydrocephalus Management of systemic complications Late sequelae and complications

This chapter contains section titled: General approach to preventing recurrent stroke and other serious vascular events Prognosis and prediction of future vascular events Pharmacological blood pressure reduction Pharmacological cholesterol reduction Antiplatelet drugs Anticoagulants Lifestyle modification Dietary supplements: B vitamins and antioxidants Management of diabetes mellitus and glucose intolerance Treatment of specific underlying causes Endarterectomy for symptomatic carotid stenosis Endarterectomy for asymptomatic carotid stenosis Carotid angioplasty and stenting Carotid endarterectomy before, during or after coronary artery surgery? Extra-to-intracranial bypass surgery Surgery and angioplasty for vertebrobasilar ischaemia Other surgical procedures Putting secondary prevention into practice

This chapter contains section titled: Introduction Airway, breathing and circulation Reduced level of consciousness Severe stroke vs apparently severe stroke Worsening after a stroke Coexisting medical problems High and low blood pressure after stroke Epileptic seizures Headache, nausea and vomiting Hiccups Immobility and poor positioning Fever and infection Venous thromboembolism Urinary incontinence and retention Faecal incontinence and constipation Pressure ulcers Swallowing problems Metabolic disturbances Nutritional problems Spasticity and contractures Limb weakness, poor truncal control and unsteady gait Sensory impairment Pain (excluding headache) Painful shoulder Swollen and cold limbs Falls and fractures Visual problems Visuospatial dysfunction Cognitive dysfunction Communication difficulties Psychological problems Dependency in activities of daily living Social difficulties Carer problems

Carotid endarterectomy (CEA) is of benefit for stroke prevention in the presence of severe carotid stenosis, provided surgical morbidity and mortality are acceptably low. To assess the current performance of CEA in the UK, an interim analysis of 30-day postoperative outcome data, blinded to anaesthetic allocation, from the first 1,001 UK patients randomised in the GALA Trial (multicentre randomised trial of general versus local anaesthesia for CEA) took place and the time from last symptomatic event to surgery was recorded. The 30-day risk of stroke was 5.3%, myocardial infarction (MI) 0.4%, death 1.7%, and stroke, MI or death 6.4%. Median delay between symptoms and surgery was 82 days. These risks are similar to those reported in the large randomised trials of CEA, but current delays to surgery are excessive and must have substantially reduced the benefit of endarterectomy.

Background and Purpose— Eligibility criteria determine the external validity (generalizability) of the results of randomized controlled trials. To increase the number of outcome events, and hence statistical power, some recent stroke prevention trials have required additional vascular risk factors for eligibility. Methods— To assess the merits of additional eligibility criteria in stroke prevention trials, we analyzed data from 3 trials and 1 hospital-referred series of patients with a transient ischemic attack or minor ischemic stroke. Patients were stratified according to 2 sets of additional risk factors similar to those used in recent trials (MATCH, SPORTIF and PRoFESS); risk of stroke, myocardial infarction, or vascular death was calculated in relation to the number of risk factors. Results— Although the observed risk during follow-up did increase with the number of risk factors present ( P <0.01 for both sets), the risks in patients with ≥1 risk factors were not substantially greater than those in all patients. Consequently, although the proportions of patients with no risk factors in the 4 cohorts differed substantially between the 2 sets of eligibility criteria (21% to 28% versus 56% to 73%), in neither case could their exclusion be justified on statistical grounds. Conclusions— The degree of patient selection introduced by use of additional vascular risk factors as eligibility criteria for trials can differ substantially between apparently similar sets of risk factors. Given that the potential for additional eligibility criteria to undermine generalizability and prolong recruitment outweighs any benefits in terms of statistical power, the exclusion of patients with no risk factors is difficult to justify.

We developed a model identifying patients with previous cerebral ischaemia at increased risk of intracerebral haemorrhage (ICH). Based on data from eight cohorts, 107 ICHs were found to have occurred among 12 648 patients. Multivariate Cox regression analysis identified the following predictors: age (> or = 60 years, hazard ratio (HR) 2.07), blood glucose level (> or = 7 mmol/l, HR 0.33), systolic blood pressure (> or = 140 mm Hg, HR 2.17), and antihypertensive drugs (HR 1.53). The highest risk quartile was associated with five times more ICHs than the lowest quartile.