bluuebunny/crossref_metadata_2025 huggingface dataset:
High-Speed Rotational Atherectomy in the Treatment of Bifurcation-Type Coronary Lesions
Authors: Nageh Thuraia , Kulkarni Nitin M. , Thomas Martyn R.
Published: April 2003

Background: Bifurcational coronary lesions present a major interventional challenge. The differential cutting mechanism of high-speed rotational atherectomy (HSRA) may provide a favourable technique of treating this complex lesion subtype. Methods: We evaluated the use of HSRA (32 lesions) compared to balloon angioplasty (BA) (118 lesions), with provisional stenting in both groups, in a non-randomised, retrospective study of 150 bifurcation-type lesions. Results: The HSRA/stent group had a high primary success rate of 97%, an acceptably low in-hospital event rate of 9% and an overall major adverse cardiac event (MACE) rate at a mean follow-up period of 15 ± 3.4 months of 22.5% with a target lesion revascularisation (TLR) rate of 18.7%. Procedural success in the BA/stent group was 81% with an in-hospital event rate of 14.4%, and the overall MACE rate at follow-up was 27.5% with a TLR rate of 23%. We achieved a greater acute gain in minimal luminal diameter and a lesser percentage of residual stenosis after intervention in the HSRA/stent group compared to the BA/stent group (p < 0.01). Outcome at follow-up favoured the HSRA/stent group, although the difference did not reach statistical significance. Conclusion: HSRA with provisional stenting provided a safe and effective means of treating bifurcation lesions.
Different Effects of Calcium Antagonist and Beta-Blocker Therapy on Left-Ventricular Diastolic Function in Ischemic Heart Disease
Authors: Hassager Christian , Thygesen Kristian , Grande Peer , Fischer Hansen Jørgen , Mickley Hans , Gustafsson Ida , Skagen Knud , Steensgaard-Hansen Frank
Published: April 2003

Objective: To compare the effect of a calcium antagonist and a beta-blocker on left-ventricular diastolic function in patients with ischemic heart disease. Methods: 138 patients with chronic stable angina pectoris were randomized in a multicenter, double-blind trial to treatment with either mibefradil or atenolol for 6 weeks (50 mg once daily for 2 weeks followed by 100 mg once daily for 4 weeks). The ratio between early (E) and late (A) diastolic mitral flow velocities (E/A), the E wave deceleration time (DT) and the left ventricular isovolumetric relaxation time (IRT) were measured by Doppler echocardiography as parameters of left-ventricular diastolic function initially, after 4 and after 6 weeks of treatment. Results: Mibefradil did not change the E/A ratio significantly (+4%, NS), while atenolol treatment resulted in a significant increase in the E/A ratio (+20%, p < 0.001). Mibefradil treatment, on the other hand, resulted in a significant decrease (–8%, p < 0.001) in IRT, while atenolol treatment did not change IRT. Neither mibefradil nor atenolol treatment changed DT significantly. Conclusions: Both mibefradil and atenolol treatment significantly improves echocardiographic indices of left-ventricular diastolic function in patients with chronic stable angina. However, they affect different parameters and thus apparently act through different mechanisms.
Diuretic Therapy and Resistance in Congestive Heart Failure
Authors: Ellison David H.
Published: April 2003

Treatment of congestive heart failure has changed dramatically during the past 20 years, but diuretic drugs remain an essential component. Diuretics are essential despite the fact that these drugs stimulate the renin-angiotensin-aldosterone (RAA) axis and lead to adaptive responses that may be counterproductive. In this paper, new diuretic drugs and new uses of older drugs are discussed. These approaches emphasize low-dose combination therapy and may prove superior to traditional approaches that rely exclusively on loop diuretics. Such approaches aim to prevent adverse compensatory processes that appear to result from chronic diuretic treatment. These include acute and chronic increases in plasma renin activity and stimulation of the sympathetic nervous system, both of which increase afterload and may tend to increase mortality. They also include adaptive changes in nephron structure and function resulting from diuretic-induced increases in distal sodium load and diuretic-induced neurohormonal stimulation. These adaptations blunt the effectiveness of diuretic therapy. Diuretic strategies that rely on combinations of diuretics are emphasized as a method to prevent resistance. If diuretic resistance does develop, higher-dose combination regimens, continuous diuretic infusions and mechanical ultrafiltration can be used to overcome diuretic adaptations and restore diuretic efficacy. The goal of reducing the extracellular fluid volume with the least stimulation of the RAA axis and minimal changes in nephron architecture can be achieved in many patients.
Ultrafiltration in Diuretic-Resistant Volume Overload in Nephrotic Syndrome and Patients with Ascites due to Chronic Liver Disease
Authors: Davenport Andrew
Published: April 2003

Patients with nephrotic syndrome and those with cirrhosis are predisposed to salt and water retention due to reduced renal sodium excretion. Despite the prescription of low-sodium diets and diuretics, some patients develop refractory oedema. When other medical treatments have been ineffective, isolated ultrafiltration and hemofiltration have been successfully used to treat refractory nephrotic patients. Following fluid removal, patients become responsive to diuretics. In cirrhotic patients, re-infusion of ascites and paracentesis with albumin infusion have been reported to be equally effective in managing ascites refractory to diuretic and other standard therapies. Although isolated ultrafiltration has not been successful in controlling ascitic fluid, hemofiltration has been shown to be beneficial, whereas standard intermittent hemodialysis has been reported to be ineffective.
Hemodynamic Response to Fluid Withdrawal in Overhydrated Patients Treated with Intermittent Ultrafiltration and Slow Continuous Ultrafiltration: Role of Blood Volume Monitoring
Authors: Ronco Claudio , Bellomo Rinaldo , Ricci Zaccaria
Published: April 2003

Fluid overload may occur in patients with congestive heart failure, especially when there is associated acute renal failure. When the pharmacological approach is not sufficient to maintain the patient’s fluid balance, extracorporeal therapies must be instituted. However, since the ultrafiltration rate may be faster than fluid refilling from the interstitial space, remarkable changes in the circulating blood volume may occur. This may finally result in further worsening of peripheral perfusion due to a significant drop in cardiac output. In order to prevent a fall in the circulating blood volume, slow continuous ultrafiltration (SCUF) should be employed instead of acute intermittent ultrafiltration (UF). To further improve the tolerance to extracorporeal ultrafiltration, the session can be driven by the relative blood volume change monitored on-line with adequate sensors and devices. We utilized one of these systems (Crit-Line, Hemametrics, USA) to compare the relative changes in blood volume during UF and SCUF in 22 patients with fluid overload. Variations in blood pressure were significantly greater with UF than with SCUF even in the presence of similar levels of fluid removal. The variations in blood pressure were paralleled by variations in blood volume, which were greater with UF than with SCUF. In conclusion, extracorporeal ultrafiltration can be used to control the fluid balance in congestive heart failure, but it is advisable to prescribe low ultrafiltration rates over an extended period of time. The use of on-line blood volume monitors can be of further help in improving tolerance and the hemodynamic response.
Autoantibodies to Cardiolipin and Beta-2-Glycoprotein-I in Coronary Artery Disease Patients with and without Hypertension
Authors: Sherer Yaniv , Tenenbaum Alexander , Praprotnik Sonja , Shemesh Joseph , Blank Miri , Fisman Enrique Z. , Motro Michael , Shoenfeld Yehuda
Published: April 2003

Background: Autoantibodies to cardiolipin (aCL) and β2-glycoprotein-I (β2GPI) are considered proatherogenic. Elevated levels of both antibodies have been reported in hypertension. Nonetheless, there are no data regarding an association between these autoantibodies and hypertension in coronary artery disease. Methods: The levels of aCL and anti-β2GPI antibodies were measured in patients having coronary artery disease with (n = 82) or without (n = 36) hypertension, in association with other major risk factors for coronary artery disease. Results: The levels of aCL and anti-β2GPI antibodies were (OD at 405 nm) 0.23 ± 0.14 and 0.22 ± 0.12 in the normal blood pressure group, as opposed to 0.24 ± 0.12 and 0.20 ± 0.12 in the hypertensive group, respectively (p = 0.67; 0.42). No significant difference in either antibody levels was found between hypertensive patients with normal and abnormal blood pressure measurements. The presence of additional risk factors did not affect antibody levels in normotensive patients. However, in the hypertensive group, the presence of smoking was associated with significantly decreased anti-β2GPI antibody levels, whereas no change was found in aCL. Further, patients who had hypertension, smoking and hypercholesterolemia, had significantly decreased anti-β2GPI antibody levels compared with patients without any of these risk factors (0.13 ± 0.04 versus 0.23 ± 0.13, respectively; p = 0.02). Conclusion: Hypertension is not associated with modification of aCL and anti-β2GPI antibody levels in coronary artery disease patients. However, there are elevated anti-β2GPI antibody levels in patients without conventional risk factors compared with patients with these risk factors.
Gender Gap in Coronary Artery Disease: Comparison of the Extent, Severity and Risk Factors in Men and Women Aged 45–65 Years
Authors: Hochner-Celnikier D. , Manor O. , Gotzman O. , Lotan H. , Chajek-Shaul T.
Published: April 2003

This retrospective study aimed to characterize coronary artery disease (CAD) and its risk factors among relatively young women, as compared to men in a similar age group. Confirmed cases of CAD were compared regarding their medical background, performance and outcome of coronary artery procedures, physical profile and lifestyle information. The study population included 179 women and 270 men aged 45–65 years who were hospitalized during the study period 1990–1995 in the Hadassah Medical Centers. Significantly more women presented with histories of prior myocardial infarction and a higher number of vessels occluded by 80% or more and required percutaneous transluminal coronary angioplasty for 3 or more arteries, and the women had a higher incidence of risk factors such as diabetes, hypertension and hypercholesterolemia than their male counterparts.
Prognosis of Caries Increment with Past Caries Experience Variables
Authors: van Palenstein Helderman W.H. , van’t Hof M.A. , van Loveren C.
Published: April 2003

This study aimed to select past caries experience variables as caries predictors and to compare their prognostic accuracy with the variables used in a method of caries prognosis developed in a Swiss child population. The data used for the analyses originated from an 8–year longitudinal study starting in 1980 on caries of 7.5–year–old Dutch children. Stepwise logistic regression analyses provided predictor variables. The newly introduced variables D23fi, D123fi and D23pifi were interchangeable and the most powerful caries predictors. For the sake of uniformity and ease of application, D23fi (number of fissures of the permanent first molar with non–cavitated or cavitated caries lesions) was chosen as the first variable in the logistic regression equations. The gain in accuracy of the second and third predictor variables (number of sound primary molars and the number of buccal and lingual smooth surfaces of the permanent first molar with non–cavitated or cavitated caries) in the regression equations was limited. The D1 condition of surfaces could be omitted from the prediction models. The present forced three–predictor–regression equations for 7.5–, 9.5– and 11.5–year–old children were evaluated to assess their prognostic performance by using the area under the ROC curve as a measure of prognostic quality. For the present regression equations, the area under the ROC curve was 81–87%, which was higher compared to the Swiss regression equations for caries prognosis.
Early Childhood Caries: Analysis of Psychosocial and Biological Factors in a High–Risk Population
Authors: Quiñonez R.B. , Keels M.A. , Vann Jr. W.F. , McIver F.T. , Heller K. , Whitt J.K.
Published: April 2003

The influences that link social factors and caries development are not well understood, although mediation by stress has been suggested. The association between caregiver stress and early childhood caries (ECC), in particular, remains unclear. The purpose of this study was to examine the relationships between parenting stress and ECC while controlling for behavioral and biological factors in a high–risk population. One hundred and fifty healthy children aged 18–36 months were examined in a cross–sectional study design. Parental interviews were conducted to obtain demographic, oral health behavior and parenting stress data. Clinical data included parent and child bacterial measures, fingernail fluoride analyses, caries prevalence and presence of child enamel hypoplasia. Bivariate analyses revealed that parenting stress predicted caries. Multivariate analyses demonstrated that a combination of psychosocial, behavioral, temporal and biological variables predicted ECC outcomes. Total parenting stress did not contribute independently to the best prediction model. Our findings suggest the need for the development of a multidimensional stress model that considers the parent–child dyad to elucidate further the link between psychosocial factors and ECC.
The Predominant Microflora of Nursing Caries Lesions
Authors: Marchant S. , Brailsford S.R. , Twomey A.C. , Roberts G.J. , Beighton D.
Published: April 2003

The predominant microflora recovered from infected dentine of 52 carious teeth from 14 children with nursing caries was determined using both selective and non–selective media for the isolation of specific genera and acidified media (pH 5.2) to isolate the predominant aciduric microorganisms, and compared with the microflora of sound enamel surfaces in caries–free children. Streptococcus mutans formed a significantly greater proportion of the lesion flora while Streptococcus oralis, Streptococcus sanguis and Streptococcus gordonii formed a significantly greater proportion of the plaque flora from sound tooth surfaces. The proportions of Actinomyces naeslundii and Actinomyces odontolyticus were significantly greater in the plaque samples than in the lesion samples. Actinomyces israelii formed 18.2% of the flora from the lesions, but was not isolated from the plaque samples. The proportions of Candida albicans, Lactobacillus spp. and Veillonella spp. were also significantly greater in the carious dentine than in the plaque samples. The most frequently isolated lactobacilli were Lactobacillus casei, Lactobacillus fermentum and Lactobacillus rhamnosus. The predominant aciduric flora was S. oralis, S. mutans and A. israelii and these taxa were also isolated from a similar proportion of the lesions at pH 7.0. Strains of S. mutans, L. casei, L. fermentum and L. rhamnosus isolated from individual carious teeth were genotyped using PCR–based methods. Each species was genotypically heterogeneous and different genotypes were recovered from different carious teeth in the same child. These data indicate that the microflora of lesions in the same child is microbiologically diverse and support a non–specific aetiology for nursing caries in which the physiological characteristics of the infecting flora, not its composition, is the major determinant underlying the disease process.
The Value of a Baseline Caries Risk Assessment Model in the Primary Dentition for the Prediction of Caries Incidence in the Permanent Dentition
Authors: Vanobbergen J. , Martens L. , Lesaffre E. , Bogaerts K. , Declerck D.
Published: April 2003

To establish a reliable screening method for caries prediction and to identify predominant risk factors, this study tested whether a cross–sectional caries risk model assessed at age 7 could be used to predict future caries onset in the permanent first molars at age 10 in 3,303 children born in 1989. As prediction variables, assessing the believed risk, baseline data at age 7 on oral health status, oral hygiene level, oral health behaviour and sociodemographic factors were used. The real risk, based on data collected for the first permanent molars during the follow–up, was assessed by different approaches. Cumulative incidence during the 3–year observation period was 31.6%, ranging from 22.4% in the believed low–risk group to 43.2% in the believed high–risk group. A stepwise logistic regression analysis was performed with net caries increment as outcome measure, adjusted for the real time at risk, using eruption times. Baseline dmfs and occlusal and buccal plaque indices were highly significant for having a high caries increment in permanent first molars with respective odds ratios of 1.07, 1.43 and 1.35. Brushing less than once a day and the daily use of sugar–containing drinks between meals were confirmed as risk factors (OR 2.43 and 1.25, respectively). The logistic regression analysis provided a sensitivity of 59–66% and a specificity of 65.7–72.8%, which indicates that the risk marker did not have an important predictive power. None of the socio–demographic and behavioural variables had enough predictive power at community level to be useful for identifying caries susceptible children. Even the power of dmfs at baseline must be considered modest.
Community-Based Education Improves Stroke Knowledge
Authors: Becker Kyra J. , Fruin Michael S. , Gooding Tracey D. , Tirschwell David L. , Love Pamela J. , Mankowski Tina M.
Published: April 2003

Background and Purpose: Despite advances in stroke therapy, the public remains uninformed about stroke, and few stroke patients present to the hospital in time to receive treatment. Health education campaigns can increase community awareness and may decrease time to hospital presentation among stroke patients. Methods: We conducted a community-based education campaign utilizing television and newspapers to inform the residents of King County, Wash., USA, about stroke and the need to call 911. The effectiveness of the campaign was assessed, using a pretest-posttest design, through telephone interviews with residents of King County. Results: Prior to the education campaign, 59.6% of persons in King County could name a risk factor for stroke, but only 45.2% knew that the brain was the organ of injury. And while 68.2% of persons stated that they would call 911 in the event of stroke, only 38.6% could name a symptom of stroke. The knowledge deficit was greatest among Asian-Americans, men, the less educated and low-income residents. There was a significant increase in stroke knowledge following the education campaign; respondents were 52% (p = 0.005) more likely to know a risk factor for stroke and 35% (p = 0.032) more likely to know a symptom of stroke after the campaign. Conclusions: Baseline knowledge about stroke among the public is poor, but can be increased through public education campaigns.
Comparison of MRI Perfusion Imaging and Single Photon Emission Computed Tomography in Chronic Stroke
Authors: Barber P.A. , Consolo H.K. , Yang Q. , Darby D.G. , Desmond P.M. , Lichtenstein M. , Tress B.M. , Davis S.M.
Published: April 2003

There have been few direct comparisons between MR perfusion-weighted imaging (PWI) and established perfusion imaging techniques, and none in chronic stroke. We therefore studied 17 chronic hemispheric infarction patients (mean, 90 days) and compared hypoperfusion volumes determined from PWI maps of relative cerebral blood flow (rCBF) and volume (rCBV), and mean transit time (rMTT) with those measured with 99Tc-HMPAO single photon emission computed tomography (SPECT). Comparisons were also made between infarct size (T2-WI) and clinical scales. Correlations were found between lesion location and volume in all three PWI hemodynamic parameter maps with clinical state and lesions on SPECT and T2-WI. In 3 patients, rCBF and rCBV lesions extended well beyond the borders of moderate-sized infarctions. We conclude that in chronic stroke, PWI can delineate regions of abnormal perfusion that reflect the degree of functional impairment and structural damage. The finding of peri-infarct hypoperfusion suggests that PWI may have the potential to provide a rapid and non-invasive template against which interventional strategies aimed at promoting functional recovery may be investigated.
Scattered Brain Infarct Pattern on Diffusion-Weighted Magnetic Resonance Imaging in Patients with Acute Ischemic Stroke
Authors: Koennecke Hans-Christian , Bernarding Johannes , Braun Jürgen , Faulstich Andreas , Hofmeister Chris , Nohr Roland , Leistner Stefanie , Marx Peter
Published: April 2003

Background and Purpose: Infarct patterns on brain imaging contribute to the etiologic classification of ischemic stroke. However, the association of specific subtypes of infarcts and etiologic mechanisms is often weak, and acute lesions are frequently missed on initial computed tomography (CT). Diffusion-weighted imaging (DWI) is superior in visualizing acute ischemic lesions as compared to CT and conventional magnetic resonance imaging (MRI). In our prospective study, we addressed the question whether a distinct pattern of infarction on DWI is associated with infarct etiology and clinical outcome. Methods: Sixty-two patients with clinical signs of acute ischemic stroke and negative acute CT upon admission underwent DWI within 10 days after the ictus. Neurological status was documented using the NIH stroke scale. A scattered lesion pattern was defined by at least 2 separate hyperintense DWI lesions within the territory of one of the major cerebral arteries. Ischemic lesions were defined as acute if the region was demarcated strongly hyperintense in all DW images, and if the apparent diffusion coefficient was below normal. Results: In 32 patients, DWI revealed a scattered lesion pattern, while in 30 patients a single acute lesion was detected. In patients with scattered lesions, potential arterial or cardiac embolic sources were detected in 26 patients (81.3%), as compared to 5 patients (16.6%) in the group with single lesions (χ2 test, p < 0.0001). The neurological status of patients with scattered lesions improved significantly more than among patients with single lesions (Mann-Whitney test, p < 0.0003). Conclusion: A scattered lesion pattern on DWI in patients with acute brain infarction and negative initial CT scan is associated with an embolic etiology and may indicate a favorable clinical outcome.
Can We Predict Poor Outcome at Presentation in Patients with Lobar Hemorrhage?
Authors: Flemming Kelly D. , Wijdicks Eelco F.M. , Li Hongzhi
Published: April 2003

Objective: Supratentorial lobar hemorrhage can be devastating. Outcome prediction at presentation is important in triage and management decisions as well as appropriate resource utilization. We performed a decision tree analysis combining clinical and CT scan features to predict poor and hopeless outcome at initial presentation in patients with lobar hemorrhage. Methods: We analyzed 81 patients with spontaneous lobar hemorrhage presenting within 48 hours of initial neurologic symptoms. In the first analysis, poor outcome was defined as Glasgow outcome score (GOS) of 1 (death), 2 (vegetative state) or 3 (dependence) at discharge. A second analysis was based on worst possible outcome (GOS 1–2). Binary recursive partitioning was fitted in a model, and odds ratios with 95% confidence intervals (CI) were calculated. Results: Lobes involved were temporal (36%), parietal (33%), frontal (25%) and occipital (6%). Seventy-three percent of patients presented less than 17 h after initial ictus. The probability of poor outcome was 97% (CI 85–100%) in patients with hemorrhage greater than 40 cm3. In the subset of patients with a volume less than 40 cm3, time interval from ictus to presentation (<17 h) together with a Glasgow coma score (GCS) less than or equal to 13 predicted poor outcome. Eighty-five percent (CI 42–99%) of those presenting early with GCS less than or equal to 13 had a poor outcome. In the second analysis, all patients with GCS less than or equal to 12 and septum pellucidum shift >6 mm had GOS of 1 or 2 (CI 72–100%). Conclusion: Poor outcome in patients with lobar hemorrhage is associated with a hemorrhage size of more than 40 cm3, GCS less than or equal to 13, but also dependent on time interval between ictus and presentation. This is consistent with prior studies demonstrating deterioration from enlargement may occur when patients present early on. Stupor and septum pellucidum shift greater than 6 mm on CT scan at presentation predict a hopeless outcome in conservatively treated patients. Ninety-one percent of patients were treated medically, thus these outcomes are largely a reflection of the natural history of spontaneous lobar hemorrhage. These signs may influence triage and management decisions.
Intracranial Hemorrhage and Oral Anticoagulant Treatment
Authors: Neau J.-Ph. , Couderq C. , Ingrand P. , Blanchon P. , Gil R.
Published: April 2003

Objective: To detect risk factors for intracranial hemorrhage (ICH) in patients with long-term oral anticoagulant and to identify clinical or radiological data specific of anticoagulant-related ICH. Methods and Patients: Three groups of patients were included. Group 1 represents patients who were admitted because of anticoagulant-related ICH between January 1984 and February 1996. All patients underwent CT scan. Clinical data, anticoagulation parameters, location and volume of the ICH, treatment and the 30-days in-hospital mortality were analyzed. Group 2 consisted of patients selected at random among all patients with spontaneous ICH admitted to our department during the same period of time. Patients without ICH, but regularly taking oral anticoagulants constituted group 3. Results: Seventy-nine patients with anticoagulant-related ICH were compared to 127 patients with spontaneous ICH. The volume of supratentorial ICH was greater in group 1 of patients and was correlated with a worse prognosis. Comparison of group 1 with group 3 (212 controls) demonstrated that length of anticoagulation, prothrombin time or excessive anticoagulation, prior cerebral infarct and use of acénocoumarol, but not age or indication of anticoagulant, were significant risk factors for ICH in multivariate analysis. Conclusions: The results emphasize that anticoagulant-related ICH are not clinically different from spontaneous ICH except for volume of bleeding, and that frequent and careful coagulation monitoring is needed, especially during the first year in order to decrease the risk of ICH.
Correlation of Aphasia and/or Neglect with Cortical Infarction in a Subpopulation of RANTTAS
Authors: Worrall Bradford Burke , Farace Elana , Hillis Argye E. , Hutson R. Kent , Wityk Robert , Saver Jeffrey L. , Johnston Karen C. , Haley E. Clarke
Published: April 2003

Classically in neurology, aphasia and neglect were accepted as reliable markers of cortical lesions. The actual prognostic values of aphasia and neglect have yet to be formally tested. This analysis sought to determine the predictive accuracy of aphasia and/or neglect in acute stroke for cortical infarction. Data from the RANTTAS investigation of tirilazad mesylate in stroke patients were reanalyzed, comparing acute National Institutes of Health Stroke Scale (NIHSS) measures of aphasia and neglect to lesion location on day 7–10 CT scans. Correlations between the presence of aphasia and/or neglect and the presence of a cortical lesion were only in the moderate range, and positive predictive values were far from perfect, as would be expected. ‘Subcortical’ aphasia or neglect was more likely in large, subcortical lesions. Aphasia and neglect, as determined in the acute setting by the NIHSS, are only moderately associated with cortical infarct identified on follow-up CT scans. If selective neuroprotection is envisioned for acute stroke patients, more accurate markers of cortical infarction may be needed.
4G/5G Polymorphism of the Plasminogen Activator Inhibitor-1 Gene and Insertion/Deletion Polymorphism of the Tissue-Type Plasminogen Activator Gene in Atherothrombotic Stroke
Authors: Bang Cha-Ok , Park Hyung-Kook , Ahn Moo-Young , Shin Hyun-Kil , Hwang Kyu-Yoon , Hong Sae-Yong
Published: April 2003

Background and Purpose: Decreased fibrinolytic capacity due to increased plasminogen activator inhibitor-1 (PAI-1) activity and decreased tissue-type plasminogen activator (t-PA) activity has been associated with hypertension or atherothrombotic disorders. The aims of this study were to observe associations of the genetic polymorphism for PAI-1 and t-PA with hypertension and atherothrombotic stroke, and to elucidate whether impaired fibrinolytic activity in atherothrombotic stroke was related to atherothrombosis per se or to other risk factors such as hypertension. Methods: Patients with atherothrombotic stroke (n = 60), hypertension (n = 100), and control subjects (n = 100) were enrolled. We genotyped all subjects for 4G/5G polymorphism in the promoter region of the PAI-1 gene and the Alu-repeat insertion/deletion (I/D) polymorphism in intron h of the t-PA gene by polymerase chain reaction and endonuclease digestion. Results: The frequency of the 4G/4G genotype of PAI-1 was significanlty higher in the atherothombotic stroke patients than the control subjects (41.7 versus 21%; p = 0.005), but not in the hypertensive subjects. There was a significant association between 4G/4G genotype of PAI-1 and atherothrombotic stroke (adjusted odds ratio = 3.11, 95% confidence interval 1.18–8.15), adjusting for age, sex, total cholesterol, low-density lipoprotein, triglyceride, and body mass index. However, the number of the I/I genotype of t-PA in the atherothrombotic stroke or hypertensive patients was virtually identical to the control subjects. Conclusion: Our results suggest that the 4G/4G genotype of the PAI-1 gene is significantly associated with an increased risk of atherothrombotic stroke. This finding also supports that impaired fibrinolytic activity in atherothrombotic stroke is related to atherothrombosis per se, but not to hypertension, one of the most important risk factors of atherothrombotic stroke.
Determinants of Social Outcome Measured by the Frenchay Activities Index at One Year after Stroke Onset
Authors: Young John , Bogle Susan , Forster Anne
Published: April 2003

We report an investigation to identify patient factors which influence social outcome measured by the Frenchay Activities Index at 12 months after a disabling stroke. Using data from a previous randomised trial a logistic regression model identified gait speed, prestroke Frenchay Activities Index, the Abbreviated Mental Test score, sensory neglect, chronic obstructive airways disease and left hemiplegia as significantly associated with 12-month social outcome scores. The model correctly predicted the social outcome for 78% of the study population and, when tested on a second data set, correctly predicted 76% of cases. These patient factors provide insight into social activity recovery after stroke and could be considered as stratification factors in future community stroke randomised trials.
Systematic Review of Prognostic Models in Patients with Acute Stroke
Authors: Counsell Carl , Dennis Martin
Published: April 2003

Prognostic models in stroke may be useful in clinical practice and research. We systematically reviewed the methodology and results of studies that have identified independent predictors of survival, independence in activities of daily living, and getting home in patients with acute stroke. Eligible studies (published in full in English) included at least 100 patients in whom at least 3 predictor variables were assessed within 30 days of stroke onset and who were followed up for at least 30 days. We recorded 25 indicators of the validity and practicality of each model and identified variables that were consistent independent predictors of each outcome. Eighty-three separate prognostic models were found but most had potentially serious deficiencies in internal and statistical validity, many had limited generalisability, and none had been adequately validated. Only 4 studies met 8 simple quality criteria. Over 150 different predictor variables have been analysed but most were assessed in only 1 or 2 models. None of the existing prognostic models have been sufficiently well developed and validated to be useful in either clinical practice or research. Better quality models must be produced to enable, for example, adequate case-mix correction when comparing outcome among different groups of stroke patients.
Microembolic Signal Detection in Patients with Symptomatic and Asymptomatic Lone Atrial Fibrillation
Authors: Kumral Emre , Balkır Kaan , Uzuner Nevzat , Evyapan Dilek , Nalbantgil Sanem
Published: April 2003

Background and Purpose: There are few data on the occurrence of microembolic signals (MES) in patients with lone atrial fibrillation (LAF). The aim of this work was to systematically study the frequency of MES in patients with symptomatic and asymptomatic LAF and to compare it with that of nonvalvular atrial fibrillation (NVAF). Methods: 37 consecutive acute stroke patients with LAF, 10 asymptomatic patients with LAF and 100 age-matched healthy controls were studied. Another 92 stroke patients with known NVAF were included in the study to compare patients with LAF regarding the presence of MES. Both middle cerebral arteries were monitored by transcranial Doppler ultrasound for at least 30 min at admission and after 1 week in symptomatic and asymptomatic patients with LAF. All patients with LAF were followed up for a mean duration of 18 months, and recurrent strokes were registered. Results: MES was detected in 11 (29%) symptomatic patients with LAF but only in 1 asymptomatic patient with LAF (χ2 = 11.3; p = 0.0008) and in no control subjects (χ2 = 106; p = 0.00001). There was no difference in the frequency of MES-positive patients and the number of MES between subjects with symptomatic LAF and known NVAF (29% in both groups; mean count, 16 ± 4 vs. 17 ± 6; p = 0.73). In patients with symptomatic LAF and NVAF who underwent anticoagulant therapy, there was no difference in the frequency of MES after 1 week of hospitalization (χ2 = 1.53; p = 0.2). During a mean follow-up period of 18 months, 1 patient with symptomatic LAF and MES had a recurrent ischemic event 1 year after the first stroke and none of those with asymptomatic LAF had any events. Conclusion: Our study suggests that asymptomatic and paroxysmal LAF with a lower frequency of MES is a benign disorder compared to chronic and symptomatic LAF with a higher frequency of MES. Further studies need to justify whether MES has a predictive value in patients with chronic LAF who are prone to ischemic stroke.
Anticoagulant (Fluindione)-Aspirin Combination in Patients with High-Risk Atrial Fibrillation
Authors: Lechat Philippe , Lardoux Hervé , Mallet Alain , Sanchez Paola , Derumeaux Genevieve , Lecompte Thomas , Maillard Luc , Mas Jean-Louis , Mentre France , Pousset Françoise , Lacomblez Lucette , Pisica George , Solbes-Latourette Solange , Raynaud Philippe , Chaumet-Riffaud Philippe
Published: April 2003

Background: A combination of low-dose aspirin with anticoagulants may provide better protection against thromboembolic events compared to anticoagulants alone in high-risk patients with atrial fibrillation. Objective: Evaluation of the preventive efficacy against nonfatal thromboembolic events and vascular deaths of the combination of the oral anticoagulant fluindione and aspirin (100 mg) in patients with high-risk atrial fibrillation. Methods: A multicenter, placebo-controlled, double-blind, randomized trial was conducted at 49 investigating centers in France. Atrial fibrillation patients with a previous thromboembolic event or older than 65 years and with either a history of hypertension, a recent episode of heart failure or decreased left ventricular function were included in the study. Patients were treated with fluindione plus placebo (i.e. anticoagulant alone) or fluindione plus aspirin (i.e. combination therapy), with an international normalized ratio target of between 2 and 2.6. The combined primary endpoint was stroke (ischemic or hemorrhagic), myocardial infarction, systemic arterial emboli or vascular death. The secondary endpoint was the incidence of hemorrhagic complications. Results: The 157 participants (average age 74 years; 52% women; 42% with paroxysmal atrial fibrillation) were followed for an average of 0.84 years. Three nonfatal thromboembolic events were observed (1 in the anticoagulation group, 2 in the combination group) and 6 patients died (3 in the anticoagulation group, 3 in the combination group), none of them from a thromboembolic complication. However, 3 deaths were secondary to severe hemorrhagic complications (1 in the anticoagulation group, 2 in the combination group). Nonfatal hemorrhagic complications occurred more often in the combination group (n = 10, 13.1%) compared to the anticoagulation group (n = 1, 1.2%) (p = 0.003). Conclusion: The combination of aspirin with anticoagulant is associated with increased bleeding in elderly atrial fibrillation patients. The effect on thromboembolism and the overall balance of benefit to risk could not be accurately assessed in this study due to the limited number of ischemic events.
A Double-Blind Placebo-Controlled Study of the Effects of Amphetamine and Physiotherapy after Stroke
Authors: Sonde Lars , Nordström Maria , Nilsson Carl-Gustav , Lökk Johan , Viitanen Matti
Published: April 2003

Major therapeutic advances in the rehabilitation of subacute stroke are lacking. One promising approach is treatment with amphetamine in combination with physiotherapy so as to promote motor function. In a randomized, double-blind, placebo-controlled clinical trial, the effect of 10 sessions with 10 mg of amphetamine combined with physiotherapy during a 5-week period was investigated in 39 geriatric patients who had been admitted to a stroke rehabilitation unit. Motor function (Fugl-Meyer motor performance score) and activities of daily living (ADL; Barthel’s index) were assessed at baseline and at the end of treatment. All patients improved significantly over the intervention period. Amphetamine-treated patients did not show any increase in motor function or ADL as compared to the control group. Rehabilitation with amphetamine at this dosage and interval, combined with physiotherapy, did not promote motor recovery or functional capacity in patients suffering from stroke.
Cure of a Direct Carotid Cavernous Fistula by Endovascular Stent Deployment
Authors: Weber Werner , Henkes Hans , Berg-Dammer Elisabeth , Esser Joachim , Kühne Dietmar
Published: April 2003

A 53-year-old woman underwent surgical thrombendarterectomy for treatment of artherosclerotic stenoses of her left internal carotid artery (ICA). A Fogarty catheter was used during this operation. The postoperative course was complicated by the development of a sixth cranial nerve palsy, protrusio, chemosis and ciliar injection of both eyes. Digital subtraction angiography showed a direct fistula between the cavernous segment of the left ICA and the cavernous sinus, with early and retrograde opacification of both superior ophthalmic veins. Endovascular occlusion of the fistula was achieved with preservation of the ICA by stent deployment over the rupture site of the ICA, as two detachable balloons could not obliterate the fistula while preserving the ICA patent. Follow-up angiography 7 months after the endovascular treatment confirmed persisting occlusion of the fistula with a patent ICA. Highly flexible porous coronary stents can easily be introduced into tortuous vessels, including the distal ICA. The haemodynamic effects achieved by stent deployment together with two balloons detached in the cavernous sinus may be sufficient to interrupt a direct carotid cavernous fistula.
Subcortical Dementia Associated with Striking Enlargement of the Virchow-Robin Spaces and Transneural Degeneration of the Left Mammillo-Thalamic Tract
Authors: Uggetti Carla , Egitto Maria Grazia , Pichiecchio Anna , Sinforiani Elena , Bevilacqua Maria Stella , Cavallini Anna , Micieli Giuseppe
Published: April 2003

We report a case of subcortical dementia in a 68-year-old woman. MR examination of the patient’s brain revealed two types of alterations as a possible cause of the dementia, both anomalous in respect of their entity and incidence: the first was a striking enlargement of the Virchow-Robin spaces, and the second an anterograde transneural degeneration of the left mammillo-thalamic tract and mammillary body secondary to a lacunar infarction of the ipsilateral anterior thalamus.
Significance of Early CT Signs in Acute Stroke
Authors: Jaillard Assia , Hommel Marc , Baird Alison E. , Linfante Italo , Llinas Rafael H. , Caplan Louis R. , Edelman Robert R. , Warach Steven
Published: April 2003

Objective: To study the pathophysiology of early CT signs. Background: Early CT signs, due to an increase in tissue water content, are commonly attributed to cytotoxic edema and development of irreversible injury. This may have important implications for thrombolysis. Methods: In patients with acute ischemic stroke in the middle cerebral artery territory, the areas of early CT signs and diffusion weighted imaging (DWI) hypersignal were independently assessed and drawn on a standardized atlas. Then, patients were classified into three groups (early CT signs larger than, similar to or smaller than DWI hypersignal) and compared with perfusion weighted imaging (PWI). Results: Of 16 patients, CT scanning was performed with a median time of 3 h after onset and early CT scan signs were recorded in 10/16 patients (62.5%). DWI signal hyperintensity was present in 15/16 (94%) patients. In 7/16 (43%) patients, the area with early CT scan signs was larger than the DWI lesion (‘CT-larger group’). Only in 2/16 (12%) patients were the areas matching (‘matching group’). In 7/16 (43%) the DWI lesion was larger than the early CT scan signs area (‘DWI-larger group’). When compared with PWI, the areas of early CT signs were larger than DWI hypersignal and were matching with PWI abnormalities (rMTT) in 2 cases, suggesting that they may represent a reversible process. Conclusions: Early CT signs might have a potential dual fate: infarction or reversibility. Other techniques of recognizing reversible ischemic damage, such as DWI-PWI, are needed to improve acute stroke diagnosis and management.
Transoesophageal Echocardiography in Patients without Arterial and Major Cardiac Sources of Embolism: Difference between Stroke Subtypes
Authors: Cerrato P. , Imperiale D. , Priano L. , Mangiardi L. , Morello M. , Marson A.M. , Carrà F. , Barberis G. , Bergamasco B.
Published: April 2003

We studied the records of 175 consecutive patients referred to our neurologic ward between January 1994 and February 2000 with a diagnosis of ischaemic cerebrovascular disease (ICVD) (stroke or transient ischaemic attack – TIA) who underwent transoesophageal echocardiography (TEE). We excluded patients with large vessel disease, high-risk embolic cardiopathies and other rare causes of stroke. According to clinical and neuroimaging findings, patients were divided into two groups. The lacunar (LAC) group (69/175 (39.4%)) and the nonlacunar (N-LAC) one (106/175 (60.6%)). The control population consisted of 78 consecutive patients, referred to the echocardiography laboratory for TEE without history of ICVD and known heart disorders. Patent foramen ovale (PFO) frequency was significantly higher in case patients than in control subjects (55/175 (31.4%) vs. 13/78 (16.6%); p = 0.02). Among case patients, PFO was more prevalent in the N-LAC group than in the LAC one (43/106 (40.6%) vs. 12/69 (17.4%); p = 0.0005). A large degree of shunt occurred in 53.5% of N-LAC patients and in 16.7% of LAC ones (p = 0.04). Atrial septal aneurysm (ASA) was detected in 12% of case patients and 1.3% of control subjects (p = 0.003) and was more frequent in the N-LAC group than in the LAC one (16 vs. 5.8%; p = 0.05). Mitral prolapse (MP) was present in 6/175 (3.4%) ICVD patients (vs. 1/78 among controls) in most cases associated with myxomatous valve redundancy. Aortic arch atheromas (AA) were detected in 12% of ICVD patients and in 10.2% of controls. The frequency was 9.4% in N-LAC and 15.9 in LAC. No complicated AA (plaque thickness >4 mm, ulcerated atheroma, superimposed thrombus) were detected. After multivariate analysis, PFO (OR = 3.8; 95% CI = 2.7–7.9) and ASA (OR = 8.01; 95% CI = 3.0–16.1) appeared to be independent predictors of ICVD. PFO (OR = 2.24; 95% CI = 1.24–4.92) was also independently associated with N-LAC stroke subtype and its importance was even higher in younger patients. Our study provides further evidence that TEE is a helpful diagnostic tool in stroke patients without arterial and major cardiac sources of embolism. However, its utility differs according to type and localization of the ischaemic lesion being more relevant in patient with N-LAC infarctions.
Extensive Cerebral Venous Thrombosis Associated with Moderate Hyperhomocyst(e)inemia and Successfully Treated with Thrombolysis
Authors: Chaves Claudia , Voetsch Barbara , Loscalzo Joseph , Caplan Louis , Chavali Ram
Published: April 2003

Cerebral venous thrombosis (CVT) is a relatively rare condition caused by multiple etiologies, usually secondary to hypercoagulable states. The optimal treatment is controversial, especially in the presence of hemorrhagic infarcts. We describe an unusual patient with extensive CVT associated with moderate hyperhomocyst(e)inemia who was aggressively treated with chemical and mechanical thrombolysis with an excellent outcome.
Differential Expression of Proteoglycan Epitopes and Growth Characteristics of Intervertebral Disc Cells Grown in Alginate Bead Culture
Authors: Melrose James , Smith Susan , Ghosh Peter , Taylor Thomas K.F.
Published: April 2003

This study assessed the growth characteristics and proteoglycan (PG) production in vitro of cells isolated from various zones; annulus fibrosus (AF), the transitional zone (TZ, an opalescent region situated between the AF and nucleus pulposus, NP) and the NP of the ovine intervertebral disc. The isolated cells were subsequently cultured in calcium alginate microspheres. Cellular metabolic activity was assessed over the 10 days of culture by the bioreduction of a tetrazolium dye substrate to a coloured formazan chromophore which could be measured colorimetrically at 490 nm. These data were correlated with the DNA content of beads measured using the fluorescent dye Hoechst 33258. Viable and non-viable cells in alginate beads were also assessed histochemically using the fluorescent dyes 5-chloromethylfluorescein diacetate and ethidium homodimer-1. PGs synthesised in culture were examined immunohistologically using monoclonal antibodies to defined glycosaminoglycan side chain PG epitopes. The results obtained clearly showed that AF and TZ cells differed from NP cells in the measured indices of cellular metabolism and in the extent of matrix deposition. In contrast to cells from the NP the cells from the AF and TZ were more metabolically active and programmed more to cellular proliferation than to matrix production.