Showing papers in "Stroke in 1993"
TL;DR: The TOAST stroke subtype classification system is easy to use and has good interobserver agreement and should allow investigators to report responses to treatment among important subgroups of patients with ischemic stroke.
Abstract: The etiology of ischemic stroke affects prognosis, outcome, and management. Trials of therapies for patients with acute stroke should include measurements of responses as influenced by subtype of ischemic stroke. A system for categorization of subtypes of ischemic stroke mainly based on etiology has been developed for the Trial of Org 10172 in Acute Stroke Treatment (TOAST). A classification of subtypes was prepared using clinical features and the results of ancillary diagnostic studies. "Possible" and "probable" diagnoses can be made based on the physician9s certainty of diagnosis. The usefulness and interrater agreement of the classification were tested by two neurologists who had not participated in the writing of the criteria. The neurologists independently used the TOAST classification system in their bedside evaluation of 20 patients, first based only on clinical features and then after reviewing the results of diagnostic tests. The TOAST classification denotes five subtypes of ischemic stroke: 1) large-artery atherosclerosis, 2) cardioembolism, 3) small-vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology. Using this rating system, interphysician agreement was very high. The two physicians disagreed in only one patient. They were both able to reach a specific etiologic diagnosis in 11 patients, whereas the cause of stroke was not determined in nine. The TOAST stroke subtype classification system is easy to use and has good interobserver agreement. This system should allow investigators to report responses to treatment among important subgroups of patients with ischemic stroke. Clinical trials testing treatments for acute ischemic stroke should include similar methods to diagnose subtypes of stroke.
9,913 citations
TL;DR: Volume of intracerebral hemorrhage, in combination with the initial Glasgow Coma Scale score, is a powerful and easy-to-use predictor of 30-day mortality and morbidity in patients with spontaneous intrACEre cerebral hemorrhage.
Abstract: The aim of this study was to determine the 30-day mortality and morbidity of intracerebral hemorrhage in a large metropolitan population and to determine the most important predictors of 30-day outcome.We reviewed the medical records and computed tomographic films for all cases of spontaneous intracerebral hemorrhage in Greater Cincinnati during 1988. Independent predictors of 30-day mortality were determined using univariate and multivariate statistical analyses.The 30-day mortality for the 188 cases of intracerebral hemorrhage was 44%, with half of deaths occurring within the first 2 days of onset. Volume of intracerebral hemorrhage was the strongest predictor of 30-day mortality for all locations of intracerebral hemorrhage. Using three categories of parenchymal hemorrhage volume (0 to 29 cm3, 30 to 60 cm3, and 61 cm3 or more), calculated by a quick and easy-to-use ellipsoid method, and two categories of the Glasgow Coma Scale (9 or more and 8 or less), 30-day mortality was predicted correctly with a s...
1,553 citations
TL;DR: This study confirms that the Chedoke-McMaster Stroke Assessment can be used with confidence as both a clinical and a research tool that can discriminate among subjects and evaluate patient outcomes.
Abstract: The Chedoke-McMaster Stroke Assessment measures the physical impairments and disabilities that impact on the lives of individuals with stroke. This measure has three overall purposes: 1) to stage motor recovery to classify individuals in terms of clinical characteristics, 2) to predict rehabilitation outcomes, and 3) to measure clinically important change in physical function. This study was carried out to evaluate the ability of this measure to yield reliable and valid results.Thirty-two subjects from a stroke rehabilitation treatment unit were assessed by research and treating physical therapists using multiple measures on multiple occasions. The measure's three purposes dictated the study objectives and design.Intrarater, interrater, and test-retest reliabilities of the impairment and disability inventories were estimated. Reliability coefficients for the total scores ranged from 0.97 to 0.99. Construct and concurrent validities were studied by examining the correlations between this and other measures...
823 citations
TL;DR: The distribution of carotid atherosclerosis in the general population was described by race-sex strata, in which 759 to 4952 individuals were imaged depending on strata and location in thecarotid system.
Abstract: B-mode ultrasound is a widely used technique for the clinical and epidemiological assessment of carotid atherosclerosis. This article provides a description of the distribution of carotid atherosclerosis in the general population.Intimal-medial arterial wall thickness was measured by B-mode real-time ultrasound as an index of atherosclerotic involvement in the extracranial carotid arteries as part of the population-based Atherosclerosis Risk in Communities (ARIC) study. The distribution was described by race-sex strata, in which 759 to 4952 individuals were imaged depending on strata and location in the carotid system.Median wall thickness ranged between 0.5 and 1 mm at all ages; fewer than 5% of ARIC participants had values exceeding 2 mm. Individuals tended to have a larger wall thickness in the carotid bifurcation than in the common carotid artery. Internal carotid artery values were more variable, with higher proportions of both large and small wall thicknesses than in the common carotid. The proporti...
747 citations
TL;DR: New protein synthesis appears to contribute to ischemic cell death in which endonucleolytic DNA degradation is apparent and may open unique therapeutic approaches for the preservation of neurons in stroke.
Abstract: Cells die by one of two mechanisms, necrosis or programmed cell death. Necrosis has been implicated in stroke and occurs when the cytoplasmic membrane is compromised. Programmed cell death requires protein synthesis and often involves endonucleolytic cleavage of the cellular DNA. We assessed the potential contribution of programmed cell death to ischemia-induced neuronal death.Cycloheximide (protein synthesis inhibitor; 1 mg/kg per 24 hours) or vehicle (1 mL/kg per 24 hours) was continuously infused into the right cerebral ventricle of spontaneously hypertensive rats. Neocortical focal ischemia was produced by tandem occlusion of the right common carotid artery and the ipsilateral middle cerebral artery. After 24 hours the brain was stained with 2% 2,3,5-triphenyltetrazolium and the ischemic zone quantitated. Protein synthesis was determined by [3H]methionine incorporation into acid-precipitated protein. DNA integrity was determined in isolated DNA by gel electrophoresis and in whole cells by flow cytomet...
719 citations
TL;DR: Traditional direct measurement of infarct volume is associated with an overestimation of infArct volume during the development of brain edema in the first 3 days after ischemia, which can be reduced with indirect measurement, which is based on noninfarcted cortex volume.
Abstract: Infarct volume is one of the common indexes for assessing the extent of ischemic brain injury following focal cerebral ischemia. Accuracy in the measurement of infarct volume is compounded by postischemic brain edema that may increase brain volume in the infarcted region. We evaluated the effect of brain edema on infarct volume determined by triphenyltetrazolium chloride and hematoxylin and eosin stains in a focal cerebral ischemia model in rats.In a middle cerebral artery occlusion model in rats, infarction is confined to the cerebral cortex. The infarct was delineated by triphenyltetrazolium chloride stain and, in selected samples, by hematoxylin and eosin stain. We determined infarct size at different times after the ischemic insult (6 hours to 7 days) in relation to the evolution of brain edema by the direct measurement of infarct volume. Indirect measurement to reduce the effect of edema on infarct volume was also conducted in the same brain samples.Direct measurement showed that infarct volume fluct...
702 citations
TL;DR: Evidence is provided of a differentiation of factors likely to be implicated in the development of depression after stroke based on the period of time since the stroke event.
Abstract: BACKGROUND AND PURPOSE: This prospective study was designed to examine the contributions of neurobiological, functional, and psychosocial factors to major depression after stroke. In addition, the ...
681 citations
TL;DR: Predictably, older patients had a worse absolute survival but, relative to the general population, stroke also increased the relative risk of dying in younger patients, which highlights the importance of long-term secondary prevention of vascular events in stroke patients.
Abstract: There have been relatively few community-based studies of long-term prognosis after acute stroke. This study aimed to provide precise estimates of the absolute and relative risks of dying in an unselected cohort of patients with a first-ever stroke.
Six hundred seventy-five patients were registered by a community-based stroke register (the Oxfordshire Community Stroke Project) and prospectively followed up for up to 6.5 years. Their relative risk of death was calculated using age- and sex-specific mortality rates for Oxfordshire.
During the first 30 days, 129 (19%) patients died. Patients who survived at least 30 days after a first-ever stroke thereafter had an average annual risk of death of 9.1%, 2.3-fold the risk in people from the general population. Although the absolute (about 15%) and relative (about threefold) risks of death were highest in these 30-day survivors over the first year after the stroke, they were at increased risk of dying over the next few years (range of relative risk for individual years, 1.1-2.9). Predictably, older patients had a worse absolute survival but, relative to the general population, stroke also increased the relative risk of dying in younger patients. During the first 30 days stroke accounts for most deaths; after this time nonstroke cardiovascular disease becomes increasingly important and is the most common cause of death after the first year.
These data highlight the importance of long-term secondary prevention of vascular events in stroke patients, targeted as much at the cardiovascular as at the cerebrovascular circulation.
585 citations
TL;DR: This study shows that atrial septal aneurysm and patent foramen ovale are both significantly associated with cryptogenic stroke and that their association has a marked synergistic effect.
Abstract: Background and Purpose: An association between atrial septal aneurysm and embolic events has been suggested. Atrial septal aneurysm has been shown to be associated with patent foramen ovale and,.in some reports, with mitral valve prolapse. These two latter cardiac disorder; have been identified as potential risk factors for ischemic stroke. The aim of this prospective study was to assess the role of atrial septal aneurysm as an independent risk factor for stroke, especially for cryptogenic stroke. Methods: We studied the prevalence of atrial septal aneurysm, patent foramen ovale, and mitral valve prolapse in 100 consecutive patients lo-mm excursion, the stroke odds were approximately 8 times the stroke odds of a patient with atrial septal aneurysm of lo-mm excursion are associated with a higher risk of stroke. (Stroke. 1993;24:1865-1873.) KEY WORDS aneurysm echocardiography foramen ovale, patent mitral valve prolapse o young adults
561 citations
TL;DR: Cerebral venous thrombosis associated with pregnancy and puerperium has a more acute onset and a better prognosis than thromBosis due to other causes and these findings might be helpful in the diagnostic and therapeutic strategies for patients with cerebral venousThrombotic disease.
Abstract: Cerebral venous thrombosis is characterized by its clinical pleomorphism and pathogenetic variability We studied 67 patients with cerebral venous thrombosis associated with pregnancy and puerperium and compared them with 46 other cases unrelated to obstetric causes to disclose differences in their clinical presentation, neuroradiological findings, clinical course, and prognosisIn this retrospective study, we analyzed the clinical, laboratory, and neuroimaging findings of 113 patients collected consecutively at our institute The diagnosis of cerebral venous thrombosis was confirmed by angiography, magnetic resonance imaging, or neuropathological studyPatients with cerebral venous thrombosis associated with pregnancy and puerperium were younger (average age, 26 versus 36 years), and in most, the onset of symptoms was acute (82% versus 54%; P = 003) The evolution of symptoms reached a plateau within 10 days in 70% of patients with thrombosis from obstetric causes, compared with only 45% in those from o
391 citations
TL;DR: It is demonstrated that apathy is a frequent finding among patients with acute stroke lesions and may coexist with important emotional and cognitive poststroke disturbances.
Abstract: Although apathy has been reported to constitute a frequent sequela of stroke lesions, there have been no prospective studies on the frequency and correlates of apathy after stroke lesions. In the present study, we examined the frequency and correlates of apathy in a consecutive series of 80 patients with cerebrovascular lesions.We included patients within the first 10 days after a stroke lesion. Patients were examined with a comprehensive neuropsychiatric battery that included the Apathy Scale.Eighteen patients (22.5%) showed apathy, nine of whom were also depressed. On the other hand, 18 patients (22.5%) showed depression in the absence of apathy. Although depression and apathy may exist independent of one another, major depression (but not minor depression) was associated with an increased frequency of apathy. Apathy was also significantly associated with older age, cognitive impairments, and deficits in activities of daily living. Finally, apathy was significantly associated with lesions in the posteri...
TL;DR: The Frenchay Activities Index is a useful stroke-specific instrument to assess functional status and could be improved by deleting two items and by creating two subscale scores: domestic and outdoors activities.
Abstract: Assessment of functional status in stroke patients is of major importance in both clinical practice and outcome studies The Frenchay Activities Index has been developed specifically for measuring disability and handicap in stroke patients The purpose of the study was to evaluate the metric properties of this instrument and to obtain normal values in a group of unselected elderly subjectsThe Frenchay Activities Index was tested in a group of stroke patients and a group of unselected subjects aged 65 or older The functional status of the stroke patients was measured 26 weeks after stroke Their prestroke status was registered retrospectively Reliability and validity of the instrument were assessedThe mean scores in the prestroke, poststroke, and control group demonstrated differences in functional status The reliability of unweighted scores (range of Cronbach's alpha-coefficients, 078 to 087) was sufficient The construct validity was supported by meaningful correlations between the Frenchay Activi
TL;DR: High levels of social support were associated with faster and more extensive recovery of functional status after stroke, suggesting that social support may be an important prognostic factor in recovery from stroke.
Abstract: The purpose of this study is to examine the impact of social support on outcome after first stroke in a prospective cohort study. Although modest evidence exists for the importance of several psychosocial factors, studies have failed to use widely recognized measures of outcome and social support, have failed to control for time since onset, and have not used longitudinal techniques.Forty-six surviving patients were followed for 6 months after stroke. Recovery was measured using repeated measures of functional status as indicated by the Barthel Index of activities of daily living. Perceived social support was measured at 1, 3, and 6 months after onset. Repeated-measures multivariate analysis of variance was used to analyze changes in functional status.Significant differences were found across levels of social support in trajectories of functional status (p = 0.002). A significant three-way interaction between stroke severity, social support, and outcome was also found (p = 0.012). Patients with more sever...
TL;DR: Higher levels of erythrocyte mean corpuscular volume in patients with subarachnoid hemorrhage than in control subjects supported the notion of different smoking and drinking habits.
Abstract: Aneurysmal subarachnoid hemorrhage is a serious disease despite recent improvements in medical and surgical treatment. Hence, identification of modifiable risk factors for subarachnoid hemorrhage is important.
We compared the smoking and drinking habits of 278 consecutive patients with aneurysmal subarachnoid hemorrhage, aged 15-60 years (145 men and 133 women) with those of 314 hospitalized control patients (164 men and 150 women) who did not differ in regard to age, day of onset of symptoms, and acuteness of disease onset.
Multiple logistic regression analysis showed that recent alcohol intake and smoking, but not hypertension, were significant independent risk factors for hemorrhage. After adjustment for age, hypertension, and smoking status, men who had consumed 1-40, 41-120, or > 120 g of alcohol within the 24 hours preceding the onset of illness had a relative risk of hemorrhage of 0.3 (95% confidence interval [CI], 0.1-0.8), 2.5 (95% CI, 1.1-5.5), and 4.5 (95% CI, 1.5-12.9), respectively, compared with men who had consumed 0 g. Women who had consumed 1-40 or > 40 g of alcohol had a risk of hemorrhage of 0.4 (95% CI, 0.2-0.8) and 6.4 (95% CI, 2.3-17.9), respectively, compared with women without use of alcohol. Heavily smoking (> 20 cigarettes per day) men and currently smoking women had adjusted relative risks of hemorrhage of 7.3 (95% CI, 3.8-14.3) and 2.1 (95% CI, 1.2-3.6), respectively, compared with men who had never smoked and with women who were not current smokers. Higher levels of erythrocyte mean corpuscular volume in patients with subarachnoid hemorrhage than in control subjects supported the notion of different smoking and drinking habits.
Recent heavy alcohol intake and current smoking seem to be independent risk factors for aneurysmal subarachnoid hemorrhage.
TL;DR: Brain interleukin-1 beta mRNA is elevated acutely after permanent focal ischemia and especially in hypertensive rats, suggesting that this potent proinflammatory and procoagulant cytokine might have a role in brain damage following ischemIA.
Abstract: Interleukin-1 beta is a proinflammatory cytokine produced by blood-borne and resident brain inflammatory cells. The present study was conducted to determine if interleukin-1 beta mRNA was produced in the brain of rats subjected to permanent focal ischemia.
Rat interleukin-1 beta cDNA, synthesized from stimulated rat peritoneal macrophage RNA by reverse transcription and polymerase chain reaction and cloned in plasmid Bluescript KS+, was used to evaluate the expression of interleukin-1 beta mRNA in cerebral cortex from spontaneously hypertensive rats and normotensive rats subjected to permanent middle cerebral artery occlusion. Interleukin-1 beta mRNA was quantified by Northern blot analysis and compared with rat macrophage RNA standard. To correct for gel loading, blots were also analyzed with cyclophilin cDNA, which encodes an abundant, conserved protein that was unchanged by the experimental conditions.
Interleukin-1 beta mRNA produced in the ischemic zone was significantly increased from 6 hours to 120 hours, with a maximum of 211 +/- 24% of interleukin-1 beta reference standard, ie, 0.2 ng stimulated rat macrophage RNA, mRNA compared with the level in nonischemic cortices (4 +/- 2%) at 12 hours after ischemia (P < .01; n = 6). Interleukin-1 beta mRNA at 12 hours after ischemia was markedly elevated in hypertensive rats over levels found in two normotensive rat strains. Neurological deficits were also apparent only in the hypertensive rats.
Brain interleukin-1 beta mRNA is elevated acutely after permanent focal ischemia and especially in hypertensive rats. These data suggest that this potent proinflammatory and procoagulant cytokine might have a role in brain damage following ischemia.
TL;DR: The purpose of this review is to outline the meaning of the concept, describe important methodological issues and methods of assessment, review existing quality of life measures, and discuss criteria for selecting an appropriate instrument.
Abstract: Little attention has been focused on quality of life in stroke outcome research. The purpose of this review is to outline the meaning of the concept, describe important methodological issues and methods of assessment, review existing quality of life measures, and discuss criteria for selecting an appropriate instrument.The following 10 quality of life instruments were reviewed: COOP Charts; Euroqol; Frenchay Activities Index; Karnofsky Performance Status Scale; McMaster Health Index Questionnaire; Medical Outcomes Study 20-Item Short-Form Health Survey; Nottingham Health Profile; Quality of Life Index; Quality of Well-being Scale; and the Sickness Impact Profile. They were evaluated in terms of length, time needed to complete, content, scoring, and psychometric characteristics.Emphasis should be placed on further psychometric evaluation of existing quality of life measures rather than on generating new instruments. There is particular need for supplementary data on the responsiveness of the instruments to...
TL;DR: In this article, a 40-year-old woman experienced her first grand mal seizure in 1971. From 1983 on she suffered recurrent strokes, seizures, and psychiatric disturbances with depressions, manic episodes, and dementia.
Abstract: We recently described an autosomal dominant syndrome characterized mainly by recurrent strokes and neuroimaging evidence of leukoencephalopathy. We now report the pathological findings in one of the affected subjects.A 40-year-old woman experienced her first grand mal seizure in 1971. From 1983 on she suffered recurrent strokes, seizures, and psychiatric disturbances with depressions, manic episodes, and dementia. In 1988, after her fourth stroke, she became tetraplegic with a severe pseudobulbar palsy, and she died in 1990. Pathological examination disclosed a recent capsulolenticular hematoma, multiple small deep infarcts, a diffuse myelin loss and pallor of the hemispheric white matter, and a widespread vasculopathy of the small arteries penetrating the white matter. The arterial wall was markedly thickened with an extensive nonamyloid eosinophilic deposit in the media and reduplication of the internal elastic lamella.The underlying lesion of this hereditary disorder is located in the small arteries an...
TL;DR: Transesophageal echocardiography is more sensitive than transcranial Doppler examination in detecting a patent foramen ovale, but only in cases of minimal right-to-left shunts, the clinical relevance of which remains to be established.
Abstract: The prevalence of a patent foramen ovale has been shown to be increased in patients with ischemic stroke. Transesophageal echocardiography, transthoracic echocardiography, and transcranial Doppler examination with contrast injection can all be used to search for a patent foramen ovale. We compared the accuracy of these techniques for identifying a patent foramen ovale in 49 patients with acute ischemic stroke or transient ischemic attack.Transcranial Doppler examination of the right middle cerebral artery was performed during simultaneous transthoracic echocardiography with aerated saline injection, and again during transesophageal echocardiography; the latter was adopted as the "gold standard" for assessing the sensitivity of the other two tests.Contrast transesophageal echocardiography detected a patent foramen ovale in 19 of 49 patients (39%), during normal respiration in 15 of them and during Valsalva maneuver in 4. Transcranial Doppler correctly identified 13 patients with a patent foramen ovale and ...
TL;DR: This study provides incidence rates for spontaneous cervical internal carotid artery dissections for the first time, and indicates an increased awareness of the disorder among physicians since 1987.
Abstract: Cervical internal carotid artery dissections are diagnosed with an increasing frequency, but reliable epidemiologic data are not available. The aim of this study was to determine the incidence rate of spontaneous cervical internal carotid artery dissection in a defined population.Using the medical record linkage system used for epidemiologic studies in Rochester, Minn, all patients diagnosed with spontaneous cervical ICA dissection for 1987 through 1992 were identified.A total of 10 patients with spontaneous cervical internal carotid artery dissection (6 women and 4 men; mean age, 44 years) were identified. For the period 1987 through 1992, the average annual incidence rate for all ages was 2.6 per 100,000 (95% confidence intervals, 0.9 to 4.2).This study, for the first time, provides incidence rates for spontaneous cervical internal carotid artery dissections. No diagnoses were made before 1987, probably reflecting an increased awareness of the disorder among physicians.
TL;DR: These results suggest that a sharp transient increase in the activity of nitric oxide synthase occurs during the first hour of cerebral ischemia, which leads to a burst in nitrics oxide production and activation of guanylate cyclase.
Abstract: Nitric oxide has been implicated as a mediator of glutamate excitotoxicity in primary neuronal cultures.A number of indicators of brain nitric oxide production (nitric and cyclic guanosine monophosphate [cGMP] concentrations and nitric oxide synthase activity) were examined after bilateral carotid ligation and right middle cerebral artery occlusion in adult rats.Brain nitrite was significantly increased in the right versus left cortex 5, 10, and 20 minutes after middle cerebral artery occlusion (P < .05), with a return to baseline at 60 minutes. There were no significant changes in cerebellar concentrations. Cortical levels of cGMP were increased at 10, 20, and 60 minutes after occlusion, with significant right-to-left differences (P < .05). Cerebellar concentrations of cGMP were also increased but without significant side-to-side differences. Nitric oxide synthase activity increased approximately 10-fold from baseline 10 minutes after occlusion in the right cortex but decreased markedly by 60 minutes fro...
TL;DR: The impact of impairments on functional outcomes seems to be underestimated by the stroke scale weights, which give empirical support to the hierarchical structure of the International Classification of Impairments, Disabilities and Handicaps.
Abstract: Recently much debate has arisen on the appropriateness of assessing stroke outcomes with stroke impairment scales Our purpose was to study the relationship between long-term impairments and functional outcomes in terms of disability, handicap, and quality of lifeWe studied 87 patients who had a stroke 6 months earlier Impairments were scored on five stroke scales: the Orgogozo Scale, the National Institutes of Health scale, the Canadian Neurological Scale, the Mathew scale, and the Scandinavian Stroke Scale Disability was assessed with the Barthel Index, handicap with the Rankin scale, and quality of life with the Sickness Impact Profile The linear relationship between stroke scales and functional scales was assessed with correlation coefficients We used regression analyses to explain functional healthThe stroke scales were highly related to one another (range, r = -85 to 92) The correlation between stroke scales and functional scales was < 70 and decreased from Barthel (mean r2 = 475%) to Ran
TL;DR: Analysis of maximum amplitude of the Doppler signal may provide information on the type of embolic material, however, it may be difficult to determine whether a given signal is associated with a large platelet embolus or a small atheroma emboli.
Abstract: The detection of circulating particulate cerebral emboli using transcranial Doppler ultrasonography has been recently reported. It has been suggested that this method might allow discrimination between different embolic materials; this would be very useful for selecting specific pharmacological treatment in individual patients. This study was designed to identify those parameters of the Doppler signal that might prove useful in discriminating between different types and sizes of particulate cerebral emboli.
An extracorporeal circuit filled with a saline/Tween solution and driven by a peristaltic pump was used. The tubing was placed in a skull in the position of the middle cerebral artery. Using transcranial Doppler ultrasound, flow was insonated via the transtemporal window. The following embolic materials of measured sizes (range of maximum dimension, 0.5-5.0 mm) were introduced into the circuit: thrombus (n = 20), platelet-rich aggregates (n = 15), atheromatous material (n = 20), and fat (n = 20). The Doppler signal was recorded during the passage of each embolus. Off-line analysis was performed to measure the maximum amplitude and duration of the signal.
For all embolic materials there was a highly significant relation between embolus size and maximum amplitude of the Doppler signal. The closest correlation was obtained when the logarithm of maximum amplitude was used (for thrombi, r = 0.74; for platelet, r = 0.87; for atheroma, r = 0.46; and for fat, r = 0.68). The slope of the regression line differed for the different embolic materials and was significantly steeper for platelets than for atheroma (p 2 mm) there was little further increase in maximum amplitude with increases in embolus size. For all embolic materials there was a highly significant linear relation between embolus size and duration of the high-amplitude (> 150 dB) signal (for thrombi, r = 0.75; for platelet, r = 0.90; for atheroma, r = 0.77; and for fat, r = 0.86).
Platelet emboli result in lower-amplitude signals, and therefore analysis of maximum amplitude may provide information on the type of embolic material. However, it may be difficult to determine whether a given signal is associated with a large platelet embolus or a small atheroma embolus. Duration of the high-amplitude signal will allow accurate estimation of the size of emboli, particularly where the emboli are all of the same material.
TL;DR: It is suggested that parental history of stroke may be a risk factor for stroke as more stroke or transient ischemic attack events develop among the Offspring Study members.
Abstract: Family history is perceived to be an important risk factor for stroke despite conflicting published data. We examined patterns of familial aggregation of stroke among three generations using data from the Framingham Study.Cox proportional hazards analyses, adjusting for known stroke risk factors, were used to examine familial concordance in three groups: (1) members of the original Framingham cohort using reported parental stroke death; (2) members of the Framingham Offspring Study and their parents (members of the original Framingham Study); and (3) sibships within the original Framingham cohort.We found no association between stroke or transient ischemic attack among original cohort members and their reported parental stroke death (n = 4933; relative risk [RR] = 1.07). Using verified cases of parental stroke or transient ischemic attack, the Offspring analyses revealed that both paternal (n = 1762; RR = 2.4; 95% confidence interval [CI], 0.96 to 6.03) and maternal (n = 2074; RR = 1.4; 95% CI, 0.60 to 3....
TL;DR: An active treatment policy of subarachnoid hemorrhage including early surgery only marginally improves survival, but the quality of life of the survivors is significantly better.
Abstract: Population-based patient materials have not been used earlier in assessing the effects of neurosurgical treatment on survival and functional outcome of subarachnoid hemorrhage. Moreover, the proportion of all subarachnoid hemorrhage patients who might be candidates for neurosurgical treatment has not been estimated.We compared the survival and functional outcome of two population-based patient materials from Central Finland in 1976 through 1978 (n = 146) and 1980 through 1987 (n = 351). The most important basic characteristics of both materials were similar. In the 1970s, only patients aged < 60 years with carotid territory aneurysms were operated on after an interval of 2 weeks from the bleeding. In the 1980s, early surgery was attempted, and the other exclusion criteria were abandoned. Allocation to medical or surgical treatment was not randomized.During the 1970s, only 14% of the patients had surgical treatment, with a median delay of 15 days after the bleeding; in the 1980s, the corresponding figures ...
TL;DR: Cerebellar infarcts in the posterior inferior cerebellar artery and superior cerebellary artery distribution have distinct differences in clinical presentation, course, and prognosis, which should help in the selection of appropriate monitoring and treatment strategies.
Abstract: Cerebellar infarction displays different clinical features, depending on the vascular territory involved. We studied patients with infarcts in the territories of the posterior inferior cerebellar artery or the superior cerebellar artery to compare their clinical presentation, course, and prognosis.We retrospectively analyzed the clinical features, laboratory data, and imaging studies of 66 patients with cerebellar infarction collected consecutively at five institutions. All the cerebellar infarcts were documented on computed tomographic scan or magnetic resonance imaging.Two distinct profiles emerged, depending on the vascular territory involved. In 36 patients with posterior inferior cerebellar artery territory infarcts, a triad of vertigo, headache, and gait imbalance predominated at stroke onset. Computed tomography showed severe cerebellar mass effect in 11 cases (30%), with associated hydrocephalus in seven. In these seven patients (19%), postinfarct swelling led to brain stem compression that result...
TL;DR: Under normothermic ischemic conditions, hyperglycemia significantly worsens the degree of acute blood-brain barrier breakdown compared with normoglycemia and postischemic blood- brain barrier disruption may play an important role in the pathogenesis of increased brain damage associated with systemic hyperglyCEmia.
Abstract: Clinical and experimental data indicate that hyperglycemia can aggravate the consequences of stroke and cerebral ischemia. The purpose of this study was to examine the effects of moderate hyperglyc...
TL;DR: The findings suggest that half of presenile-onset major depression and the majority of senile-ONSet major depressed might be organic depression related to silent cerebral infarction.
Abstract: There have been few studies of the incidence of silent cerebral infarction detected by magnetic resonance imaging in patients with presenile or senile major depression.We examined silent cerebral infarction in patients with presenile and senile major depression who were diagnosed at Hiroshima Prefectural Hospital. The diagnostic criteria of the American Psychiatric Association (DSM-III-R) were used. Patients with stroke or focal neurological symptoms were excluded.Silent cerebral infarction was observed in 51.4% of the patients with presenile-onset presenile depression, and the incidence was significantly higher than in patients with juvenile-onset presenile depression (P < .01). Among the patients with senile major depression, silent cerebral infarction was observed in 65.9% of those with presenile-onset depression and in 93.7% of those with senile-onset depression.Our findings suggest that half of presenile-onset major depression and the majority of senile-onset major depression might be organic depress...
TL;DR: The prognosis and management of patients in whom no aneurysm is found on the initial angiogram depends on the pattern of hemorrhage on theInitial CT scan.
Abstract: In 15% to 20% of patients with a spontaneous subarachnoid hemorrhage, no aneurysm is found on the first angiogram. This review emphasizes that this group of patients is in fact heterogeneous and describes the clinical features, pattern of hemorrhage on early computed tomographic (CT) scan, prognosis, and proposed management in the several and distinct subsets of these patients.Patients in whom no aneurysm is revealed on the initial angiogram can be subdivided mainly according to the pattern of hemorrhage on an early CT scan. In two thirds of these patients the CT scan shows a perimesencephalic pattern of hemorrhage (ie, blood confined to the cisterns around the midbrain); these patients invariably have a good prognosis, which obviates the need for a second angiogram. Patients with diffuse or anteriorly located blood on CT scan are at risk of rebleeding. In most of these patients the source of hemorrhage is an occult aneurysm, but intracranial artery dissections, dural arteriovenous malformations, mycotic ...
TL;DR: The ability of aspirin and the dose required to inhibit platelet aggregation may depend upon the individual, and how the inhibition of Platelet aggregation relates to stroke prevention remains unclear.
Abstract: The purpose of this study was to assess the biological effect of aspirin as measured by the inhibition of platelet aggregation in patients taking aspirin for stroke prevention and in patients with acute stroke.We administered increasing doses of aspirin (325, 650, 975, and 1,300 mg daily) to 113 patients for stroke prevention and measured the inhibition of platelet aggregation in these patients and in 33 patients with acute stroke taking aspirin before stroke onset.Eighty-five patients on or = 650 mg aspirin had complete inhibition of platelet aggregation. Increase of the dose by 325 mg in nine of the 22 patients with partial inhibition of platelet aggregation produced complete inhibition in five patients at 650 mg and in one at 975 mg. At 1,300 mg, three patients still had only partial inhibition of platelet aggregation (aspirin resistance). Of the 33 inpatients with acute stroke, 24 had platelet aggregation studies done before further administration of aspirin. Of these, 19 had c...
TL;DR: The hypothesis that paradoxical embolism is the primary mechanism of stroke in patients with a patent foramen ovale is not supported.
Abstract: Background and Purpose: A patent foramen ovale has been reported to be significantly more frequent in young stroke patients than in matched control subjects, and paradoxical embolism has been suggested as the main mechanism of stroke in-this situation. The present study was designed to test this hypothesis. Methods: Sixty-eight consecutive patients under 55 years of age presenting with an ischemic stroke had an extensive workup, including transesophageal echocardiography with contrast. We compared the prevalence of criteria for the diagnosis of paradoxical embolism in patients with and without a patent foramen ovale. Results: A patent foramen ovale was found in 32 patients (47%). A Valsalva-provoking activity was present at stroke onset in six patients with a patent foramen ovale and in eight patients with no patent foramen ovale (X(sup 2)=0.1, nonsignificant). Clinical/radiological features suggestive of an embolic mechanism were not more frequent in patients with a patent foramen ovale. Clinical evidence of deep vein thrombosis was present in one patient with a patent foramen ovale and in none of the others. No occult venous thrombosis was found in a subgroup of patients with a patent foramen ovale and no definite cause for stroke who underwent venography (n=13). Conclusions. Our results do not support the hypothesis that paradoxical embolism is the primary mechanism of stroke in patients with a patent foramen ovale. (Stroke 1993;24:31-34) KEY WORDS e cerebral ischemia e embolism foramen ovale, patent