Showing papers in "Stroke in 1986"

Rat middle cerebral artery occlusion: evaluation of the model and development of a neurologic examination.

Abstract: We have examined the incidence and size of infarction after occlusion of different portions of the rat middle cerebral artery (MCA) in order to define the reliability and predictability of this model of brain ischemia. We developed a neurologic examination and have correlated changes in neurologic status with the size and location of areas of infarction. The MCA was surgically occluded at different sites in six groups of normal rats. After 24 hr, rats were evaluated for the extent of neurologic deficits and graded as having severe, moderate, or no deficit using a new examination developed for this model. After rats were sacrificed the incidence of infarction was determined at histologic examination. In a subset of rats, the size of the area of infarction was measured as a percent of the area of a standard coronal section. Focal (1-2 mm) occlusion of the MCA at its origin, at the olfactory tract, or lateral to the inferior cerebral vein produced infarction in 13%, 67%, and 0% of rats, respectively (N = 38) and produced variable neurologic deficits. However, more extensive (3 or 6 mm) occlusion of the MCA beginning proximal to the olfactory tract--thus isolating lenticulostriate end-arteries from the proximal and distal supply--produced infarctions of uniform size, location, and with severe neurologic deficit (Grade 2) in 100% of rats (N = 17). Neurologic deficit correlated significantly with the size of the infarcted area (Grade 2, N = 17, 28 +/- 5% infarction; Grade 1, N = 5, 19 +/- 5%; Grade 0, N = 3, 10 +/- 2%; p less than 0.05). We have characterized precise anatomical sites of the MCA that when surgically occluded reliably produce uniform cerebral infarction in rats, and have developed a neurologic grading system that can be used to evaluate the effects of cerebral ischemia rapidly and accurately. The model will be useful for experimental assessment of new therapies for irreversible cerebral ischemia.

Evaluation of 2,3,5-triphenyltetrazolium chloride as a stain for detection and quantification of experimental cerebral infarction in rats.

Abstract: We have evaluated the use of 2,3,5-triphenyltetrazolium chloride (TTC) as an histopathologic stain for identification of infarcted rat brain tissue. The middle cerebral artery (MCA) of 35 normal adult rats was occluded surgically. At various times after surgical occlusion, rats were sacrificed and brain slices were obtained and stained with TTC or hematoxolin and eosin (H & E); the size of the area of infarcted tissue stained by each method was quantified. In rats sacrificed 24 hr after occlusion of the MCA, the size of the area of infarction was 21 +/- 2% of the coronal section for TTC, and 21 +/- 2% for H & E (mean +/- S.D., N = 13). The size of areas of infarction determined by either staining method was not significantly different in area by the paired test, and a significant correlation between sizes determined by each method was found by linear regression analysis (r = 0.91, slope = 0.89, and the y intercept = 4.4%). Staining with TTC is a rapid, convenient, inexpensive, and reliable method for the detection and quantification of cerebral infarction in rats 24 hr after the onset of ischemia.

Transcranial Doppler measurement of middle cerebral artery blood flow velocity: a validation study.

Abstract: Measurement of intracranial arterial blood flow velocity is a new technique with potentially a number of very useful applications. This study validates the technique by comparing it to cerebral blood flow (CBF) measured using intravenous Xenon133 and extracranial clearance recording. We have measured the middle cerebral artery (MCA) blood flow velocity in 17 symptomatic patients with the EME TC 264 transcranial Doppler velocimeter and compared these measurements to the ipsilateral hemispheric cerebral blood flow measured with an intravenous Xenon133 technique (Novo Cerebrograph 10A). Measurements were made at rest and during hypercapnia. The absolute measurement of MCA velocity and hemispheric CBF showed a poor correlation (r = 0.424, p less than 0.01) due to wide between-patient variations at rest but the blood flow response to hypercapnia, expressed as a reactivity index, showed a good correlation (r = 0.849, p less than 0.001). Thus changes in MCA velocity reliably correlate with changes in cerebral blood flow but the absolute velocity cannot be used as an indicator of CBF.

Incidental subcortical lesions identified on magnetic resonance imaging in the elderly. I. Correlation with age and cerebrovascular risk factors.

Abstract: Patchy subcortical foci of increased signal intensity are frequently identified on magnetic resonance imaging (MRI) in the elderly. The incidence and clinical correlates of these lesions remain unknown. In this report, 240 consecutive MRI scans performed over a 6-month period were reviewed (excluding patients with recent brain trauma or known demyelinating disease). Subcortical incidental lesions (ILs) were identified, which could not be accounted for by the patient's current clinical diagnosis, neurological status, or CT scan. The ILs were graded according to size, multiplicity, and location. The incidence and severity of ILs increased with advancing age (p less than 0.0005). Among patients over 50 years of age, the incidence and severity of ILs were correlated with a previous history of history of ischemic cerebrovascular disease (p less than 0.05) and with hypertension (p less than 0.05). Multivariable regression analysis identified age, prior brain ischemia, and hypertension as the major predictors of ILs in the elderly. Diabetes, coronary artery diseases, and sex did not play a significant role. With the exception of cerebrovascular disease, there was no association between ILs and any particular clinical entity, including dementia. It is concluded that subcortical parenchymal lesions are frequent incidental findings on MRI in the elderly, and may represent an index of chronic cerebrovascular diseases in such patients.

A model of focal ischemic stroke in the rat: reproducible extensive cortical infarction.

Abstract: In the search for a more reproducible focal ischemic stroke model in the rat, we systematically interrupted blood flow to the right middle cerebral artery territory by ligating the right middle cerebral artery, and the right and left common carotid arteries in succession. Using a laser-Doppler flowmeter, we found that the relative surface blood flow in cerebral cortex supplied by the right middle cerebral artery decreased to 62, 48, and 18% of baseline respectively after successive ligation of the right middle cerebral artery, and the right and left common carotid arteries. A focal infarct in the cerebral cortex supplied by the right middle cerebral artery was consistently noted after ligation of the right middle cerebral and the right common carotid arteries and temporary clip occlusion of the left common carotid artery for 60 min. The surface areas of infarction measured 100 +/- 6 mm2 and the maximal cross-sectional area of infarction was 10.4 +/- 1.1 mm2 (N = 10). The mortality rate was 7% (N = 70). The characteristic changes of ischemic necrosis were limited to the cortex with sparing of subcortical structures. No motor deficits occurred. Occlusion of the right middle cerebral artery alone or together with the right common carotid artery did not consistently cause gross infarction and the maximal cross-sectional area of infarction was smaller (the right middle cerebral artery, 1.7 +/- 0.8 mm2, N = 10; the right middle cerebral artery plus the right common carotid artery, 4.8 +/- 1.9 mm2, N = 10). Permanent ligation of the right middle cerebral artery and both common carotid arteries had a high mortality (60% in 3 days, N = 10).(ABSTRACT TRUNCATED AT 250 WORDS)

Incidental subcortical lesions identified on magnetic resonance imaging in the elderly. II. Postmortem pathological correlations.

Abstract: The pathological correlates of subcortical lesions noted on magnetic resonance imaging (MRI) in the elderly are not known. Postmortem in vitro proton MRI was performed on the brains of seven consecutive elderly patients dying of nonneurologic causes. Scans were done in the fresh and fixed states with the specimen immersed in saline and formaldehyde respectively. A 1.5 Tesla superconductive system was used with a multiple spin-echo protocol generating T2 weighted images. Subcortical MRI lesions were localized in three dimensions and identified at brain cutting. In addition, pathological correlations were obtained from an eighth patient who underwent MRI eleven days before death. Histological examinations were performed in a blinded fashion, including control areas from the same brains. Subcortical MRI lesions were found to be associated with arteriosclerosis, dilated perivascular spaces, and vascular ectasia (p less than 0.05). These histological changes were characteristic of "etat crible" which, like subcortical MRI lesions, is associated with age and hypertension. Shrinkage (or atrophy) of the brain parenchyma around ectatic blood vessels would result in an extensive network of tunnels filled with extracellular water. The proton MRI signal from such areas of the brain would be increased. Gliosis and small areas of infarction occasionally coexisted with "etat crible," but these were not present in all areas with MRI lesions and could not be distinguished by MRI signal alone. In conclusion, clinical and pathological correlations lend support to the uniform hypothesis that MRI provides a nonspecific index of brain parenchymal alterations caused by aging and chronic cerebrovascular disease.

Prediction of function after stroke: a critical review.

Abstract: A review of 33 studies identifies the factors of prior stroke, older age, urinary and bowel incontinence, and visuo-spatial deficits as adverse prognostic indicators of function. No relationship is shown between sex, hemisphere of stroke, and functional outcome. Functional admission score is a strong predictor of discharge functional status, but its relationship with improvement in function is unclear. Findings regarding the prognostic value of severity of paralysis and onset-admission delay are ambiguous. Comparison among studies is hindered by differences in patient samples, timing of assessments, criteria by which outcome is measured and measuring instrument used. Future studies should measure function at set times post-stroke, use functional scales whose reliability and validity is well established, and be conducted in several treatment centres to ensure that the sample is representative of the population to which the predictor measure is to be applied.

Race, sex and occlusive cerebrovascular disease: a review.

Abstract: IDEALLY, treatment of a patient with cerebral ischemia should be guided by knowledge of the nature, location, and severity of the occlusive disease within the extracranial and intracranial vessels.' To plan efficient evaluation of the individual patient, the responsible clinician must be familiar with the relative probability of finding occlusive lesions at various sites within the vascular tree since individual imaging and non-invasive tests have different capabilities with regard to various vascular loci. A growing body of data suggests that there are important differences in the distribution of occlusive vascular disease in Blacks and Whites and in men and women. This review summarizes the presently available data.

Polymorphonuclear leukocyte accumulation in brain regions with low blood flow during the early postischemic period.

Abstract: In an anesthetized canine model in which ischemia was induced by incremental air embolism, 16 animals were exposed to 1 hr of ischemia and monitored for 10 min (n = 4), 60 min (n = 6), or 240 min (n = 6). Fourteen animals were observed for corresponding periods without being subjected to ischemia 70 min (n = 4), 120 min (n = 4), or 300 min (n = 6). Autologous granulocytes were labeled with 111In and reinfused just before ischemia. At the conclusion of each experiment, a 14C-iodoantipyrine autoradiographic blood flow study was performed. Granulocyte accumulation measured by gamma scintigraphy (cpm/gm) occurred in the injured hemisphere of ischemic animals at 60 min in anterior brain segments and at 240 min in anterior, middle, and posterior segments. By means of a double-label autoradiography technique, clustering of punctate granulocyte images was detected in regions of low flow or heterogeneous flow in half of the animals at both 60 min and 240 min postischemia. Granulocyte clustering did not occur in the autoradiograms of nonischemic animals. The results implicate granulocyte participation in the acute phase of ischemic brain injury and signal a convergence of hemostatic and inflammatory processes during the immediate postischemic period.

Post-stroke depression: relationships to functional impairment, coping strategies, and rehabilitation outcome.

Abstract: This study examined the phenomenon of post-stroke depression and evaluated its impact on rehabilitation outcome. Sixty-four patients presenting to a rehabilitation program within weeks of first stroke were evaluated for depression through self-report measures and staff ratings. Patients also rated the particular coping strategies which they used in dealing with their illness and hospital stay. Physical and occupational therapists provided measures of functional impairment at admission and discharge. A high (47%) prevalence of depression was found in this population, with no overall differences observed between patients with right or left hemisphere lesions. Depressed patients, in comparison to non-depressed, evidenced greater functional impairment at both admission and discharge. However, both groups showed similar gains over the course of rehabilitation. Coping strategies employed by depressed patients appeared to reflect a lower level of participation in the rehabilitation process. A subgroup of patients evaluated 6 weeks after discharge revealed that depression was associated with a worsening on one measure of functional status. These findings indicate that depression is a frequent companion of stroke, that it is associated with degree of functional impairment, and that it may exert a negative impact on the rehabilitation process and outcome.

The Canadian Neurological Scale: a preliminary study in acute stroke.

Abstract: Acute central nervous system dysfunction resulting in coma can be measured simply and reliably by the Glasgow scale. However, when the injury does not impair consciousness and the patient has aphasia, no comparable scale exists. A complementary scale to assess conscious and aphasic patients is proposed. Preliminary validation has been carried out in acute stroke patients, who commonly suffer neurological deficits without loss of consciousness. A simple standardized scale aids in the monitoring of neurological status, and may help in the assessment of prognosis and therapy.

Hypertension as a risk factor for spontaneous intracerebral hemorrhage.

Abstract: To better define the etiologic importance of hypertension for spontaneous intracerebral hemorrhage, hospital records were studied for all patients sustaining intracerebral hemorrhage during 1982 in the Cincinnati metropolitan area. Hypertension pre-dating the hemorrhage was present in 45% (69 of 154), as determined by history. A more inclusive definition of hypertension, combining those with a positive history with those found to have left ventricular hypertrophy by electrocardiogram or cardiomegaly by chest radiography, applied in 56% (87 of 154). The cases were compared to controls with and without hypertension derived from the NHANES II study of blood pressure (n = 16,204) to determine relative risk. For the presence of hypertension by history, the relative risk of intracerebral hemorrhage was 3.9 (95% confidence interval, 2.7 to 5.7). For the inclusive definition of hypertension, the relative risk was 5.4 (3.7 to 7.9). Relative risk was also determined for hypertension in blacks (= 4.4), age greater than 70 (= 7), prior cerebral infarction (= 22), and diabetes (= 3). We conclude that the term "hypertensive hemorrhage" should be used very selectively, particularly in whites, and propose that hypertension be viewed as one of several important risk factors for spontaneous intracerebral hemorrhage.

Lipoprotein(a) as a strong indicator for cerebrovascular disease.

Abstract: To evaluate the role of lipoprotein(a) (Lp(a] in patients with cerebrovascular disease (CVD), lipid parameters were compared with a control group (CO). Additionally, the Lp(a) serum levels were investigated in a coronary artery disease (CAD) group. The CO was made up of 37 healthy persons (age: 54.5 +/- 7.7, 26 males and 11 females), the CVD group included 46 patients with sustained transient ischemic attack (TIA) prolonged reversible ischemic neurologic deficits (PRIND) and cerebral infarction (CI) (age: 53.6 +/- 9.7, 32 males and 14 females), and the CAD group was made up of 28 survivors of myocardial infarctions (age: 52.5 +/- 8.1, 18 males and 10 females). The median values of Lp(a) in CVD were significantly higher than in the CO (p less than 0.01) and did not differ significantly from the CAD. Total TC, HDL-C, TG, LDL-C and the ratio of LDL-C/HDL-C did not show any significant difference between the control and cerebrovascular disease group. For quantification of the vascular lesions of the carotid system, a Duplex Doppler score system was used. The score correlated with Lp(a) in patients between 40 to 65 years of age (r = 0.34, p less than 0.01). Thus, we conclude that Lp(a) is not only a risk factor for CAD but also for CVD.

Blood pressure course in patients with acute stroke and matched controls.

Abstract: The natural course of blood pressure (BP) was studied after emergency hospitalization in 209 consecutive stroke patients and as many age and sex matched controls. Histories of hypertension were more common among patients than controls (46% vs 26%). On admission 69% of the stroke group and 36% of the controls had BP greater than or equal to 170/100 mm Hg. In the first four days there was a spontaneous BP decline, which was greater the higher the initial values. During the whole hospitalization though, stroke patients with previous hypertension had the highest BP levels and previously normotensive controls the lowest. Even if WHO as well as the Joint Committee for Stroke have recommended cautious antihypertensive therapy in stroke patients with extreme hypertension, such therapy is not evaluated. If this is to be done, the present findings have to be taken into consideration. Stroke controls, matched according to the initial BP level, will thus be required.

Prediction of function after stroke: a critical review.

Abstract: A review of 33 studies identifies the factors of prior stroke, older age, urinary and bowel incontinence, and visuo-spatial deficits as adverse prognostic indicators of function. No relationship is shown between sex, hemisphere of stroke, and functional outcome. Functional admission score is a strong predictor of discharge functional status, but its relationship with improvement in function is unclear. Findings regarding the prognostic value of severity of paralysis and onset-admission delay are ambiguous. Comparison among studies is hindered by differences in patient samples, timing of assessments, criteria by which outcome is measured and measuring instrument used. Future studies should measure function at set times post-stroke, use functional scales whose reliability and validity is well established, and be conducted in several treatment centres to ensure that the sample is representative of the population to which the predictor measure is to be applied.

Hemorrhagic cerebral infarction--a prospective study.

Abstract: In 65 cases of ischemic cerebral infarction, CT scans and quantitative assessments of the neurological disturbances were undertaken at specific intervals during the 4 week period after stroke. Forty-three patients underwent lumbar puncture to determine the serum/CSF albumin ratio. The etiology of the infarction was evaluated on the basis of angiographic, ultrasonic and cardiologic findings. A hemorrhagic transformation of the infarction occurred in 28 patients, eleven within the first week, and 15 within the second. Risks of hemorrhage were correlated with a severe neurological deficit, disturbance of consciousness, large infarction with a mass effect, enhancement of contrast medium in CT (especially if occurring early), involvement of the cortex, and distinct blood/CSF barrier disturbances. Cardiac embolism was a frequent etiology in patients with secondary hemorrhagic infarction, especially when transformation occurred within the first week after stroke. In addition to a heterogeneous pattern of hemorrhage, frank hematoma predominated in those infarcts which underwent early transformation, while those transforming late often showed less hyperdense cortical hemorrhagic changes. Deterioration evident on clinical evaluation was caused by the hemorrhagic transformation in three cases, in each instance within the first week after stroke.

Locked-in syndrome: a review of 139 cases.

Abstract: Etiology, clinical manifestations and outcome were reviewed in 139 cases of "locked-in syndrome." Six cases were reported from our center and the remaining 133 cases were taken from a review of the literature. The results of this review emphasized the necessity for a comprehensive program of pulmonary management in this population. Furthermore, an effective system of communication for the patient is considered essential in the management of the "locked-in" state. Reported mortality in the cases reviewed was 60%. Overall, the prognosis for survival and recovery was found to be better in the group of patients whose syndrome was nonvascular in origin than those with a vascular etiology. Functional recovery was generally good in those patients with a vascular etiology who survived beyond 4 months while recovery occurred earlier and more completely in the nonvascular group. Thus, a program of intensive rehabilitation should be considered early in both groups in order to assist each patient in attaining the highest level of function possible as recovery progresses.

Evaluation of the cerebral vasodilatory capacity by the acetazolamide test before EC-IC bypass surgery in patients with occlusion of the internal carotid artery.

Abstract: Cerebral blood flow (CBF) was measured by xenon-133 inhalation tomography in 18 patients with cerebrovascular disease before and 4 months after extracranial-intracranial bypass surgery. Only patients who showed a reduced CBF in areas that were intact on the CT scan and relevant to the clinical and angiographical findings were operated. The majority of the patients had suffered a minor stroke with or without subsequent transient ischemic attacks. They were studied at least 6 weeks following the stroke. All patients had an occlusion of the relevant internal carotid artery. To identify preoperatively the patients with a compromised collateral circulation and hence reduced CBF due to reduced perfusion pressure, a cerebral vasodilatory stress test was performed using acetazolamide (Diamox). In normal subjects, Diamox has been shown to increase tomographic CBF without change of the flow distribution. In the present series 9 patients showed a significant redistribution of flow in favor of the non-occluded side ("positive" Diamox test). Two of these 9 patients showed even a paradoxical decrease in focal CBF preoperatively, i.e., a "steal" effect. These 2 patients were the only patients who improved in focal CBF after shunting. The remaining 9 patients all showed uniform flow responses ("negative" Diamox test), and none of these increased in focal CBF postoperatively. The finding of an unchanged flow map postoperatively confirmed that the low flow areas were not due to restricted flow via collateral pathways. However, an increase in the regional vasodilatory capacity was observed postoperatively in the majority of patients.

Embolic complications in paroxysmal atrial fibrillation.

Abstract: The incidence of embolic complications among 426 patients with initial paroxysmal atrial fibrillation (PAF) was analysed. A distinct clustering of emboli was seen at the time of onset of PAF. After transition to chronic atrial fibrillation (CAF), which developed in 141 patients (33.1%), the incidence of emboli was seen to rise to a new level several times higher than the incidence level for patients with PAF. Also in this group a distinct clustering of emboli was seen during the first year after transition to CAF. On this background it is suggested that patients with PAF may benefit from treatment with anti-arrhythmic agents in order to prevent the development of CAF and that anticoagulants for stroke prevention seems especially desirable in atrial fibrillation (AF) of recent onset.

Rehabilitation for stroke: a review.

Abstract: Survivors of stroke are often left with severe mental and physical disabilities, which create a major social and economic burden. Many investigators have attempted to assess the role of rehabilitation in reducing such disability. Few controlled studies provide accurate assessment and documentation of benefit. Because of the presence of multiple variables and inadequate measures of outcome, it is difficult to design studies evaluating the effectiveness of rehabilitation for stroke. It is unclear how early rehabilitation should begin and what aspects of rehabilitation are important. Intensive rehabilitation is an expensive and limited resource; thus, the ability to identify the subgroup of patients with stroke who are likely to benefit is a critical issue. Although preliminary guidelines for the selection of patients who are appropriate for rehabilitation are given, no uniform criteria reliably differentiate patients who need rehabilitation from those who will recover spontaneously or do poorly. Controlled studies in the practice of rehabilitation for stroke will provide much useful information for patient management.

Reduction in regional cerebral metabolic rate of oxygen during human aging.

Abstract: To investigate changes in cerebral circulation and oxygen metabolism during aging, regional cerebral blood flow (rCBF), regional oxygen extraction fraction (rOEF), regional cerebral metabolic rate of oxygen (rCMRO2) and regional cerebral blood volume (rCBV) were measured using the 15O labelled gas inhalation technique and a multi-slice positron emission tomograph (PET) in 22 healthy volunteers, aged from 26 to 64 years old. The measurements were performed with subjects at rest, without sensory deprivation. The values of rCBF, rOEF, rCMRO2 and rCBV in more than 40 anatomical structures of the brain were evaluated by studying a large series of scans in each region of interest after the functional PET image had been anatomically identified using x-ray computed tomographic images corresponding to the PET. In mean gray values, only CMRO2 showed significant reduction with age. rCMRO2 significantly decreased with age only in the supratentrium, and much more in the left hemisphere. Especially remarkable was rCMRO2 reduction in the left caudate region. Both CBF and OEF were variable and less age-dependent. It was concluded that CMRO2 could be reflecting healthy brain aging most properly.

Progress review: hypoglycemic brain damage.

Abstract: The central question to be addressed in this review can be stated as "How does hypoglycemia kill neurons?" Initial research on hypoglycemic brain damage in the 1930s was aimed at demonstrating the existence of any brain damage whatsoever due to insulin. Recent results indicate that uncomplicated hypoglycemia is capable of killing neurons in the brain. However, the mechanism does not appear to be simply glucose starvation of the neuron resulting in neuronal breakdown. Rather than such an "internal catabolic death" current evidence suggests that in hypoglycemia, neurons are killed from without, i.e. from the extracellular space. Around the time the EEG becomes isoelectric, an endogenous neurotoxin is produced, and is released by the brain into tissue and cerebrospinal fluid. The distribution of necrotic neurons is unlike that in ischemia, being related to white matter and cerebrospinal fluid pathways. The toxin acts by first disrupting dendritic trees, sparing intermediate axons, indicating it to be an excitotoxin. Exact mechanisms of excitotoxic neuronal necrosis are not yet clear, but neuronal death involves hyperexcitation, and culminates in cell membrane rupture. Endogenous excitotoxins produced during hypoglycemia may explain the tendency toward seizure activity often seen clinically. The recent research results on which these findings are based are reviewed, and clinical implications are discussed.

Cigarette smoking, hypertension and the risk of subarachnoid hemorrhage: a population-based case-control study.

Abstract: A case-control analysis is used to examine the relation of cigarette smoking, hypertension and the risk of subarachnoid hemorrhage in men and women aged 35-64 years. 45 men and 70 women with subarachnoid hemorrhage were identified as part of a large community based study of stroke, and the controls, 1017 men and 569 women, came from a survey of cardiovascular risk factors conducted in the same community. Cigarette smokers, after adjusting for age, had a significantly increased risk of subarachnoid hemorrhage compared with nonsmokers with relative risks of 3.0 for men and 4.7 for women. The strength of the risk increased with the amount smoked. The association remained significant for each sex after adjusting for hypertension. Those who both smoked and had a history of hypertension had an increased risk of subarachnoid hemorrhage of almost 15 fold compared to those who neither smoked nor had been treated for hypertension. The estimated population attributable risk of subarachnoid hemorrhage associated with cigarette smoking (43%) was greater than that of hypertension (28%) in this population.

Screening for depression in stroke patients: the reliability and validity of the Center for Epidemiologic Studies Depression Scale.

Abstract: This study examined the inter-observer reliability and validity of the Center for Epidemiologic Studies Depression Scale (CES-D) as a measure of depressive symptomatology in stroke patients, and its utility as a screening tool for depression in this population. The CES-D Scale is a brief questionnaire originally designed for use in community surveys. Twenty-seven non-aphasic patients enrolled in the Stroke Data Bank at the University of Maryland were interviewed by a research nurse using the CES-D. On the same day, each patient was independently evaluated by a research assistant using a psychiatric battery for depression and measures of cognitive, physical, and social functioning. Forty-one percent (11/27) of the patients were depressed according to clinical criteria for major or minor depression. With a cutpoint corresponding to the upper (most severe) 20% in community surveys, the CES-D Scale picked up 73% (8/11) of the depressed patients. In this sample no nondepressed patient scored over 16 on the CES-D (no false positives). The CES-D Scale scores correlated significantly with the other depression measures (r = .57 to r = .82, p less than .002) and did not correlate with the measures of cognitive, physical, or social functioning. Based on 24 patients who received a CES-D Scale score from both the nurse and the research assistant, inter-rater reliability was high (r = .76, p less than .001). Thus, the CES-D was found to be reliable and valid as a screening tool for assessing depression in stroke patients.

Locked-in syndrome: a review of 139 cases.

Abstract: Etiology, clinical manifestations and outcome were reviewed in 139 cases of "locked-in syndrome." Six cases were reported from our center and the remaining 133 cases were taken from a review of the literature. The results of this review emphasized the necessity for a comprehensive program of pulmonary management in this population. Furthermore, an effective system of communication for the patient is considered essential in the management of the "locked-in" state. Reported mortality in the cases reviewed was 60%. Overall, the prognosis for survival and recovery was found to be better in the group of patients whose syndrome was nonvascular in origin than those with a vascular etiology. Functional recovery was generally good in those patients with a vascular etiology who survived beyond 4 months while recovery occurred earlier and more completely in the nonvascular group. Thus, a program of intensive rehabilitation should be considered early in both groups in order to assist each patient in attaining the hig...

Atherosclerotic disease of the middle cerebral artery.

Abstract: Three hundred and fifty-two patients with atherosclerotic middle cerebral artery stenosis (MCAS, 53%) or occlusion (MCAO, 47%) have been systematically studied. The study involved all patients entered into the EC/IC Bypass Study with isolated MCA disease or a tandem lesion predominating in the MCA ipsilateral to the ischemic events (18 patients with a tandem lesion of greater magnitude in the internal carotid artery were not included). The Asian patients represented 58% of all Asians entered into the EC/IC Bypass Study, whereas the white patients represented 18% of all whites and the black patients 34% of all blacks. Isolated TIAs were less frequent in MCAO (12%) than in MCAS (34%). Warning TIAs before a stroke occurred in one third of the cases. Presentation with stroke or isolated TIA was not influenced by sex, age, level of MCA obstruction, collateral circulation nor associated carotid disease. In MCAS, no major difference in presentation was found between severe and moderate stenosis. Pure motor hemiparesis occurred in 15% and pure sensory stroke in 2% of the patients with stroke and 30% of the MCA territory infarcts were small and limited to the lenticulocapsular area, confirming that so-called lacunar infarcts may be due to large vessel disease. During follow-up (42 months) of 164 medically-treated patients, further cerebrovascular events (TIA and stroke) occurred in 11.7% of the patients per year. In MCAO the stroke rate was 10.1% per patient-year and the ipsilateral infarct rate was 7.1% per patient-year. In MCAS, the stroke rate was 9.5% per patient-year and the ipsilateral stroke rate was 7.8% per patient-year.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombolytic therapy in stroke: possibilities and hazards.

Abstract: 35. Wessler S, Gitel SN: Warfarin: From bedside to bench. New Engl J Med 311: 645-652, 1984 36. HullR, HirshJ, Jay R.etah Different intensities of oral anticoagulant therapy in the treatment of proximal-vein thrombosis. New Engl J Med 307: 1676-1681, 1982 37. Barron KD, Fergusson G: Intracranial hemorrhage as a complication of anticoagulant therapy. Neurology 9: 447-455, 1959 38. Iizuka J: Intracranial and inlraspinal haematomas associated with anticoagulant therapy. Neurochirurgia 1: 15-25, 1972 39. Snyder M, Renaudin J: Intracranial hemorrhage associated with anticoagulation therapy. Surg Neurol 7: 31-34, 1977 40. Delaney P, Estes M: Intracranial hemorrhage with amphetamine use. Neurology 30: 1125-1128, 1980 41. Harrington H, Heller HA, Dawson D, Caplan L, Rumbaugh C: Intracerebral hemorrhage and oral amphetamine. Arch Neurol 40: 503-507, 1983 42. Salanova V, Taubner R: Intracerebral haemorrhage and vasculitis secondary to amphetamine use. Postgrad Med J 60:429-430, 1984 43. Citron BP, Halpern M, McCarron M, et al: Necrotizing angiitis associated with drug abuse. New Engl J Med 283: 1003-1011, 1970 44. Lukes SA: Intracerebral hemorrhage from an arteriovenous malformation after amphetamine injection. Arch Neurol 40: 60—61, 1983 45. Maticlc H, Anderson D, Brumlik J: Cerebral vasculitis associated with oral amphetamine overdose. Arch Neurol 40: 253-254, 1983 46. Fallis RJ, Fisher M: Cerebral vasculitis and hemorrhage associated with phenylpropanolamine. Neurology 35: 405—407, 1985 47. Kikta DG, Devereaux MW, Chandar K: Intracranial hemorrhages due to phenylpropanolamine. Stroke 16: 510-512, 1985 48. Stoessl AJ, Young GB, Feasby TE: Intracerebral haemorrhage and angiographic beading following ingestion of catecholaminergics. Stroke 16: 734-736, 1985 49. Caplan LR, Hier DB, Banks G: Stroke and drug abuse. Current Concepts of Cerebrovascular Disease/Stroke 17: 9-14, 1982 50. Caplan LR, Thomas C, Banks G: Central nervous system complications of addiction to \"T's and blues\". Neurology 32: 623-628, 1982

Lipoprotein(a) as a strong indicator for cerebrovascular disease.

Abstract: To evaluate the role of lipoprotein(a) (Lp(a] in patients with cerebrovascular disease (CVD), lipid parameters were compared with a control group (CO). Additionally, the Lp(a) serum levels were investigated in a coronary artery disease (CAD) group. The CO was made up of 37 healthy persons (age: 54.5 +/- 7.7, 26 males and 11 females), the CVD group included 46 patients with sustained transient ischemic attack (TIA) prolonged reversible ischemic neurologic deficits (PRIND) and cerebral infarction (CI) (age: 53.6 +/- 9.7, 32 males and 14 females), and the CAD group was made up of 28 survivors of myocardial infarctions (age: 52.5 +/- 8.1, 18 males and 10 females). The median values of Lp(a) in CVD were significantly higher than in the CO (p less than 0.01) and did not differ significantly from the CAD. Total TC, HDL-C, TG, LDL-C and the ratio of LDL-C/HDL-C did not show any significant difference between the control and cerebrovascular disease group. For quantification of the vascular lesions of the carotid s...

Long-term cerebral outcome after open-heart surgery. A five-year neuropsychological follow-up study.

Abstract: A prospective 5 years' neuropsychological, neurological, cardiological and electroencephalographical follow-up study was carried out in 44 patients who had undergone open-heart surgery for valve replacement. A distinct interrelationship was found between the clinical outcome immediately after operation and the neuropsychological long-term course despite the rapid recovery of occasional clinical disorders related to operative procedures. In fact, the psychometric performance scores of those who did not develop clinical signs of cerebral dysfunction induced in operation showed a significant difference only years after operation. Similarly, the harmful effects of long perfusion time (extracorporeal circulation) in operation were reflected in the long-term neuropsychological performance. Some evidence seemed to suggest that the correction of the prolonged circulatory disorder might possibly afford real enhancement of higher cerebral functions. The long-term results not only emphasize the importance of a careful clinical evaluation but also emphasize the necessity of considering the subclinical level of events both before and after operation when assessing the overall outcome and cerebral safety of cardiac surgery patients.

Multicenter retrospective review of results and complications of carotid endarterectomy in 1981.

Abstract: A multicenter retrospective audit of carotid endarterectomies performed during 1981 was completed with 46 institutions contributing 3,328 cases. Overall, there was a 2.5% risk of transient neurological dysfunction following surgery and a 6% risk of stroke or death. The intra-institutional combined major morbidity and mortality varied from 21% to 0. Those institutions with greater than 700 beds had a statistically lower incidence of stroke or death than did other institutions. The incidence of stroke or death postoperatively was significantly lower for patients who were operated on for amaurosis fugax or for unspecified reasons. Those patients who were operated on for a progressing stroke had a higher incidence of stroke but this group was at greatest risk for stroke without surgery. The incidence of postoperative stroke or death was related to the type of arterial repair; vein patch grafting was statistically better than both fabric patch grafting and primary closure. When all patients who were not monitored during surgery were compared to all patients who had electroencephalographic (EEG) monitoring, there was found to be a significant statistical difference in favor of the EEG group. Endarterectomy combined with coronary artery bypass or simultaneous bilateral endarterectomies had a statistically significant higher incidence of stroke or death than did unilateral carotid endarterectomy.