Stroke. 2009;40:e481-e482
Published online before print May 14, 2009,
doi: 10.1161/STROKEAHA.108.546234
(Stroke. 2009;40:e481.)
© 2009 American Heart Association, Inc.
Temperature-Lowering Therapy for Acute Stroke
Heleen M. Den Hertog;
H. Bart van der Worp;
Mei-Chiun Tseng
Diederik W.J. Dippel
From the Department of Neurology (H.M.D.H., D.W.J.D.), Erasmus Medical Center, Rotterdam, The Netherlands; the Department of Neurology (H.B.v.d.W.), Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, The Netherlands; and the Department of Business Management (M.-C.T.), National Sun Yat-Sen University, Kaohsiung, Taiwan.
Correspondence to Heleen den Hertog, Department of Neurology, Erasmus MC University Medical Center, Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands. E-mail m.denhertog{at}erasmusmc.nl
Graeme J. Hankey MD, FRCP Section Editor:
Key Words: stroke • body temperature • temperature-lowering therapy • clinical outcome
 |
Introduction
|
|---|
Body temperatures above 37.5°C have been observed in 4%
to 25% of patients within the first 24 to 36 hours after stroke
onset and are associated with poor long-term outcome. In the
observational Copenhagen Stroke study, a 1°C increase in
body temperature measured within 12 hours after stroke onset
doubled the odds of poor outcome.
In animal models of focal cerebral ischemia, cooling reduces infarct volume. Hypothermia is successfully used in cardiac surgery and has been associated with a more favorable neurological outcome in patients who were resuscitated after cardiac arrest.
These observations suggest that reduction of body temperature and prevention of fever may improve functional outcome after stroke. However, the potentially beneficial effects of temperature-lowering therapy might be offset by side effects such as infections, cardiac arrhythmias, hemorrhagic transformation of infarcts, and deep venous thrombosis.
|
Objectives
|
|---|
The aim of this review was to assess the relation between interventions
to reduce body or brain temperature and functional outcome or
death in patients with acute stroke, and to determine whether
there is any clear evidence that temperature reduction of any
kind is beneficial, or whether the intervention is sufficiently
promising to merit further trials.
|
Search Strategy
|
|---|
We updated the 1999 Cochrane review "Cooling Therapy for Acute
Stroke." Relevant trials were identified in the Specialized
Register of Controlled Trials (last search, December 2007).
Additional searches were performed in MEDLINE and EMBASE (January
1998 to December 2007). We scanned references and contacted
authors of included trials.
|
Selection Criteria
|
|---|
We considered all completed randomized or nonrandomized controlled
clinical trials, published or unpublished, where pharmacological
or physical strategies to reduce body or brain temperature were
applied in patients with acute ischemic stroke or intracerebral
hemorrhage and the effect on clinical outcome was reported.
|
Data Collection and Analysis
|
|---|
Two reviewers independently selected trials for inclusion. Thereafter,
2 of 3 reviewers assessed the methodological quality of each
identified trial and extracted the data. Outcome measures were
death or dependency (modified Rankin Scale score >2) and
death at the end of follow-up, and adverse effects.
|
Main Results
|
|---|
Five pharmacological temperature reduction trials and 3 physical
temperature reduction trials involving a total of 423 patients
were included. We found no statistically significant effect
of pharmacological or physical temperature-lowering therapy
in reducing the risk of death or dependency (OR 0.9, 95% CI
0.6 to 1.4) or death (OR 0.9, 95% CI 0.5 to 1.5). Both interventions
were associated with a nonsignificant increase in the occurrence
of infections (OR 1.5, 95% CI 0.8 to 2.6).
|
Implications for Practice and Future Research
|
|---|
There is currently no evidence from randomized trials to support
routine use of physical or pharmacological strategies to reduce
temperature in patients with acute stroke.
Large randomized clinical trails are needed to study the safety, optimal duration, and the effectiveness of both physical and pharmacological temperature reduction in patients with acute stroke. Note: The full text, data tables, analyses, results and reference list of this article are available in the Cochrane Library.1
View larger version (27K):
[in this window]
[in a new window]
|
Figure. Effect of temperature-lowering therapy on death or dependency (score on the modified Rankin Scale >2) at final follow up. *Two intervention groups; the number of patients with poor outcome and the total number of patients in the control group were divided by 2, to avoid multiple comparisons using the same subset of patients.
|
|
|
Acknowledgments
|
|---|
Disclosures
None.
Received December 24, 2008;
accepted January 12, 2009.
|
Reference
|
|---|
1. Heleen M.den Hertog, H. Bartvan der Worp, Mei-ChiunTseng, DiederikW.J. Dippel. Cooling therapy for acute stroke.
The Cochrane Database Syst Rev. 2009; CD001247.
Top
Introduction
Objectives