bluuebunny/crossref_metadata_2025 huggingface dataset:
Qualitative Comparison of the Reliability of Health Status Assessments With the EuroQol and SF-36 Questionnaires After Stroke
Authors: Dorman Paul , Slattery Jim , Farrell Barbara , Dennis Martin , Sandercock Peter
Published: June 2011

Background and Purpose
—The reliability of the EuroQol and SF-36 questionnaires after stroke is not known. We therefore aimed to assess and compare the test-retest reliability of both instruments in a group of stroke patients.

Methods
—A total of 2253 patients with stroke entered by United Kingdom hospitals in the International Stroke Trial were randomized to follow up with either the EuroQol or the SF-36 instruments. For both instruments, we randomly selected one third of respondents and asked them to complete another, identical questionnaire. We assessed test-retest reliability using agreement statistics: unweighted κ statistics for the categorical domains of the EuroQol and intraclass correlation coefficients for the EuroQol visual analog scale, utility scores, and SF-36.

Results
—For the five categorical domains of the EuroQol, reproducibility was generally good (κ ranged from 0.63 to 0.80). The reproducibility of the domains of the SF-36 was qualitatively similar for all the domains except mental health (intraclass correlation coefficient=.28). However, the 95% confidence intervals for the difference in scores between test and retest were substantial. For both instruments, reproducibility was better when the patient completed the questionnaires than when a proxy did.

Conclusions
—Both the EuroQol and SF-36 have acceptable and qualitatively similar test-retest reliability. Therefore, either instrument might function effectively as a discriminatory measure for assessing health-related quality-of-life outcomes in groups of patients after stroke. However, our data do not support the use of either instrument for serial assessments in individual patients unless very large differences over time are expected.
Comparison of Near-Infrared Spectroscopy and Somatosensory Evoked Potentials for the Detection of Cerebral Ischemia During Carotid Endarterectomy
Authors: Beese Ulrich , Langer Harald , Lang Werner , Dinkel Michael
Published: June 2011

Background and Purpose
—We sought to assess the clinical value of regional cerebral saturation (rS
o
2
) obtained by means of the cerebral oximeter INVOS 3100A (Somanetics) in comparison to monitoring of somatosensory evoked potentials (SEP) for the reliable detection of severe cerebral ischemia requiring shunt placement in the individual patient undergoing carotid surgery under general anesthesia.

Methods
—In 317 patients undergoing reconstructive surgery on the internal carotid artery, simultaneous recordings of SEP and rS
o
2
were obtained throughout the operation.

Results
—All 287 patients with preserved cortical SEP remained neurologically intact. Shunt placement was performed in 27 patients (9%) after flattening of cortical SEP during cross-clamping of the internal carotid artery. A stable rS
o
2
value just before cross-clamping and the lowest value after cross-clamping were registered, and the decrease was calculated. A statistically significant (
P
<0.01) decrease of rS
o
2
after cross-clamping could be found in patients without (64.9±8.3% to 60.9±9.9%) as well as in patients with consecutive loss of cortical SEP (65.8±9.1% to 56.1±13.4%). The difference of the decrease of rS
o
2
in both groups was highly significant (6.9±9.0% versus 15.6±14.0%;
P
<0.001). However, substantial interindividual variability of rS
o
2
and derived change of rS
o
2
did not allow the definition of a threshold value indicating need of shunt placement.

Conclusions
—The reliability of SEP for the detection of clamp-related hypoperfusion has been reaffirmed. As long as rS
o
2
threshold values indicating critical cerebral ischemia are not defined, therapeutic interventions based on monitoring with the cerebral oximeter INVOS 3100A are not justified.
Predicting the Effect of Carotid Artery Occlusion During Carotid Endarterectomy
Authors: Doblar Dennis D. , Plyushcheva Nataliya V. , Jordan William , McDowell Holt
Published: June 2011

Background and Purpose
—We correlated the mean transcranial Doppler blood flow velocity (FVm) during carotid endarterectomy with the functional collateral pathway(s) documented by angiography.

Methods
—Three patient groups were established: group 1 was dependent on the anterior communicating artery, group 2 on the anterior communicating artery and ipsilateral posterior communicating artery, and group 3 on the ipsilateral posterior communicating artery. Continuous middle cerebral artery FVm and electroencephalographic monitoring were performed in 45 patients during carotid endarterectomy.

Results
—Clamped FVm was lowest in group 3 at 17±9 cm/s versus 36±16 and 33±11 cm/s for groups 1 and 2 (
P
<0.01). FVm values in groups 1 and 2 were similar. There was significant cerebral arterial vasodilation in group 3 patients on the basis of a pulsatility index of 0.38±0.15. The maximum FVm after clamp release was similar among the 3 groups. Normalized blood flow velocity 1 minute before release of the clamp was increased from the minimum flow velocity after clamping only in group 1 and 2 patients.

Conclusions
—The ipsilateral posterior communicating artery is a minor collateral pathway during acute carotid occlusion that contributes little to the collateral flow if there is a functional anterior communicating artery. Collateral flow through the middle cerebral artery is not recruited during occlusion in group 3 patients. The reperfusion FVm transient is independent of the primary collateral pathway. Documentation of functional collateral pathways on the basis of Doppler or angiographic examination may be advantageous in future studies since it can provide the basis for comparison among studies.
Effects of Acupuncture Treatment on Daily Life Activities and Quality of Life
Authors: Gosman-Hedström Gunilla , Claesson Lisbet , Klingenstierna Ulrika , Carlsson Jane , Olausson Bengt , Frizell Martin , Fagerberg Björn , Blomstrand Christian
Published: June 2011

Background and Purpose
—A number of studies have indicated that acupuncture might improve the functional recovery of stroke patients. These studies vary in inclusion criteria, sample size, and evaluation methods. The present study was designed to investigate whether electroacupuncture treatment favorably affects stroke patients’ ability to perform daily life activities, their health-related quality of life, and their use of health care and social services.

Methods
—One hundred four consecutive patients >40 years of age admitted to hospital because of an acute stroke were randomized to 3 groups: deep, superficial, and no acupuncture treatment. The acupuncture treatment given by 4 physiotherapists started 4 to 10 days after randomization and was given twice a week for 10 weeks. All patients underwent conventional stroke rehabilitation as well. Two occupational therapists, blinded regarding the patients’ allocation, evaluated the treatment effects. The assessments were performed 4 times during the first year after randomization by means of interviews and observations.

Results
—There were no differences between the groups with reference to changes in the neurological score and the Barthel and Sunnaas activities of daily living index scores after 3 and 12 months. Regarding the Nottingham Health Profile, the no acupuncture group had somewhat fewer mobility problems. No differences in health care and social services were found between the groups.

Conclusions
—The present study does not give support to the previous studies, which indicates that acupuncture treatment may have a beneficial effect on acute stroke patients’ ability to perform daily life activities, their health-related quality of life, and their use of health care and social services.
A Longitudinal Prospective Study of Soluble Adhesion Molecules in Acute Stroke
Authors: Bitsch A. , Klene W. , Murtada L. , Prange H. , Rieckmann P.
Published: June 2011

Background and Purpose
—Activation of endothelial cells is a consequence of cerebral ischemia and leads to the expression of adhesion molecules such as intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), and E-selectin, which can be released into the blood. This study aimed to define the kinetics of soluble adhesion molecule serum levels after cerebral ischemia and their correlation with the extent of neurological deficits, clinical outcome, and infarct volume as measured on CT scans.

Methods
—Plasma levels of soluble (s) ICAM-1, sVCAM-1, and sE-selectin were repeatedly determined by ELISA in 38 patients during a period of 14 days after acute cerebral ischemia.

Results
—Soluble adhesion molecule levels demonstrated considerable variability. Overall, concentrations revealed characteristic and significant changes after completed strokes but not after transient ischemic attacks. In patients with completed stroke (n=26) but not in patients with transient ischemic attacks (n=12), sICAM-1 peaked within 24 hours (
P
=0.04), sVCAM-1 reached a maximum after 5 days (
P
=0.02), and sE-selectin levels decreased after 5 days (
P
=0.002). There was no clear-cut correlation of soluble adhesion molecule levels with infarct volume or clinical disability. The initial increase of sE-selectin levels was higher in more disabled patients (
P
=0.02). sICAM-1 levels were higher in patients with signs of infection (n=9;
P
=0.03).

Conclusions
—As a result of large interindividual variability influenced by ischemia-independent factors, soluble adhesion molecules are not reliable candidates as surrogate markers in acute cerebral ischemia. The characteristic profile of individual soluble adhesion molecules after completed stroke supports prior hypotheses of their involvement in the pathogenesis of acute cerebral ischemia, but this needs to be clarified in detail.
Cerebrovascular Ischemic Events With High Positive Anticardiolipin Antibodies
Authors: Verro Piero , Levine Steven R. , Tietjen Gretchen E.
Published: June 2011

Background and Purpose
—The aim of our study was to characterize the patient profile and prognostic value associated with high positive IgG (>100 GPL) anticardiolipin antibodies (aCL).

Methods
—We studied the clinical, laboratory, radiological, and prospective historical features of ischemic cerebrovascular disease in patients with >100 GPL titers. From our neurology department, 27 consecutive patients were prospectively identified and followed up (mean follow-up time, 34 months).

Results
—The mean age of our cohort was 41 years. Lupuslike illness occurred in 3; 23 had primary antiphospholipid syndrome, including 3 who met criteria for Sneddon’s syndrome; 1 patient had progressive systemic sclerosis. Cerebral infarcts occurred in 74% and were recurrent in 37%. Systemic ischemic events, most commonly deep vein thrombosis, occurred in 37%. Tobacco use was documented in 85%, hyperlipidemia in 74%, hypertension in 44%, and diabetes mellitus in 7% of patients. A prominent headache history was present in 67%. Lupus anticoagulant (LA) was present in 72%, approximately one half had positive antinuclear antibodies and thrombocytopenia, and one quarter had a false-positive VDRL. We compared mean GPL levels in patients testing positive for specific laboratory features of antiphospholipid syndrome with those testing negative for these parameters. Only the LA(+) group had a significantly higher mean GPL than the LA(-) group (
P
=0.006). Brain imaging showed nonlacunar infarcts in 73% and lacunes in 12%. Of 19 cerebral angiograms, 5 (26%) showed large-vessel occlusive disease and 6 (32%) branch obstruction. Echocardiograms were abnormal in 75%: thickened left-sided valves in 33% and vegetations in 12%. Recurrent cerebrovascular ischemic events were observed in 96%, with transient events (mean rate, 25%/y) occurring 5 times more frequently than strokes (mean rate, 5%/y). Using a standardized disability scale blinded to aCL titer, neurological impairment was severe in 7%, moderate in 30%, and mild or nonexistent in 63%, and unrelated to mean GPL value (
P
=0.567). Titers fluctuated greatly for individual patients, and most did not consistently test as highly positive. An analysis of fluctuation in symptom severity with concurrent GPL values did not show a statistically significant correlation. Compared with historical controls having a wide range of positive titers, the presence of high IgG aCL titers did not confer a worse prognosis for disability and recurrent ischemic events.

Conclusions
—Our data suggest that cerebrovascular events associated with high positive GPL are frequently multiple and minor (with no disability-titer correlation), present in relatively young patients, and often associated with tobacco abuse, hyperlipidemia, LA, systemic ischemic events, and occult cardiac disease.
Analysis of Canadian Population With Potential Geographic Access to Intravenous Thrombolysis for Acute Ischemic Stroke
Authors: Scott Phillip A. , Temovsky Chris J. , Lawrence Kate , Gudaitis Edward , Lowell Mark J.
Published: June 2011

Background and Purpose
—We sought to identify the Canadian population with potential access to intravenous tissue plasminogen activator within 3 hours of onset of acute ischemic stroke.

Methods
—Assuming that 60 minutes is needed for stroke recognition, emergency room evaluation, and administration of tissue plasminogen activator, 120 minutes remain for transport, using a 3-hour treatment window. Ambulance databases were analyzed for transport times of 60, 90, and 120 minutes and were found to correspond to transport distances of 32, 64, and 105 kilometers (20, 40, and 65 miles), respectively. Using Geographical Information System (GIS) software, these radii were overlaid on thematic maps of Canadian hospitals identified as having a third- or fourth-generation CT and with a neurologist and an emergency physician on staff. Analysis was then performed on complete Canadian census data from 1991 and the interim 1996 census count.

Results
—67.3%, 78.2%, and 85.3% of the total Canadian population were within 32, 64, and 105 kilometers, respectively, of an identified hospital. For individuals ≥65 years of age, 64.4%, 77.0%, and 85.7% were within the respective radii. Complete analysis by age, ethnic origin, and gender are detailed.

Conclusions
—In the model described, a substantial percentage of the Canadian population has geographic access to a hospital potentially capable of delivering intravenous thrombolysis for acute ischemic stroke. GIS analysis can identify both population groups and rural areas with limited access to thrombolytic stroke treatment. A coordinated emergency medical service response for stroke is advocated to maximize coverage, as a 60-minute delay in emergency room arrival eliminated 5.1 million people from potential treatment.
Frequency and Clinical Determinants of Poststroke Depression
Authors: Pohjasvaara Tarja , Leppävuori Antero , Siira Irina , Vataja Risto , Kaste Markku , Erkinjuntti Timo
Published: June 2011

Background and Purpose
—Previous studies have shown a large variation concerning the frequency of poststroke depression. This variation is caused by differences in patient populations, psychiatric assessment methods, and diagnostic criteria. In this study, we evaluated the frequency and clinical correlates of poststroke depression in a large well-defined stroke cohort.

Methods
—We studied a consecutive series of 486 patients with ischemic stroke aged from 55 to 85 years. Of these, 277 patients underwent a comprehensive psychiatric evaluation, including the Present State Examination, from 3 to 4 months after ischemic stroke. The criteria of the
Diagnostic and Statistical Manual of Mental Disorders
, edition 3, revised (DSM-III-R), were used for the diagnosis of depressive disorders.

Results
—The frequency of any depressive disorder was 40.1% (n=111). Major depression was diagnosed in 26.0% (n=72) and minor depression in 14.1% (n=39). Major depression with no other explanatory factor besides stroke was diagnosed in 18.0% (n=49) of the patients. Comparing depressed and nondepressed patients, we found no statistically significant difference in sex, age, education, stroke type, stroke localization, stroke syndrome, history of previous cerebrovascular disease, or frequency of DSM-III-R dementia. According to the multiple logistic regression model, dependency in daily life correlated with the diagnosis of depression (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1 to 3.1) and with the diagnosis of major depression (OR, 2.9; 95% CI, 1.6 to 5.5). A history of previous depressive episodes also correlated with the diagnosis of depression (OR, 2.3; 95% CI, 1.3 to 4.4) and with the diagnosis of major depression (OR, 2.9; 95% CI, 1.6 to 5.5), whereas solely stroke-related major depression correlated only weakly with stroke severity as measured on the Scandinavian Stroke Scale (OR, 1.1; 95% CI, 1.0 to 1.1).

Conclusions
—Clinically significant depression is frequent after ischemic stroke. We emphasize the importance of the psychiatric examination of poststroke patients, especially those with a significant disability and with a history of prior depressive episodes.
Grading of Cerebral Dynamic Autoregulation From Spontaneous Fluctuations in Arterial Blood Pressure
Authors: Panerai Ronney B. , White Richard P. , Markus Hugh S. , Evans David H.
Published: June 2011

Background and Purpose
—Assessment of cerebral autoregulation has been traditionally performed with static changes in arterial blood pressure. Newer dynamic methods require the induction of sudden drops in arterial blood pressure with the sudden release of bilateral thigh cuffs. An alternative method is proposed, based on the spontaneous variability of arterial blood pressure that does not require its manipulation. We compared this method with the established thigh cuff method in patients with carotid artery stenosis.

Methods
—Cerebral blood flow velocity (determined by transcranial Doppler) and arterial blood pressure (determined by noninvasive servo-controlled plethysmograph) were recorded in 20 patients with carotid artery stenosis and 18 age-matched controls. At rest, grading of dynamic autoregulation was estimated from the impulse response of the blood pressure–velocity dynamic relationship. This was compared with the autoregulatory index (ARI) provided by the thigh cuff method and with the degree of stenosis. The critical closing pressure was derived from the fitted models and was also correlated with degree of stenosis.

Results
—The 2 ARIs were significantly correlated (
r
=0.76) and reduced in subjects with carotid stenosis (baseline ARI, 3.65±3.11 versus 6.68±1.88,
P
<0.0001; thigh cuff ARI, 3.78±2.32 versus 6.35±1.06,
P
<10
−5
). The critical closing pressure (relative to mean arterial blood pressure) was also significantly reduced (−0.24±1.06 versus 0.50±0.31,
P
<0.0001) and correlated with the thigh cuff ARI (
r
=0.68). Both the baseline ARI and critical closing pressure were correlated with degree of stenosis (
P
<10
−6
).

Conclusions
—Grading of dynamic autoregulation with the use of undisturbed recordings of arterial blood pressure and cerebral blood flow velocity might provide a safer technique for assessment of patients in whom a sudden drop of arterial blood pressure is not desirable, such as patients with heart or autonomic failure.
Transcranial Doppler Detection of Microemboli During Percutaneous Transluminal Coronary Angioplasty
Authors: Bladin Christopher F. , Bingham Linda , Grigg Leeanne , Yapanis Anthony G. , Gerraty Richard , Davis Stephen M.
Published: June 2011

Background and Purpose
—The use of percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease is now commonplace. The occurrence of microemboli during invasive procedures such as cardiac angiography and bypass surgery is well documented, although neurological complications are relatively uncommon. To date, no investigation has been undertaken of the frequency or nature of microemboli occurring during PTCA or of the correlation with aortic atheroma.

Methods
—Twenty patients having elective PTCA underwent examination by transcranial Doppler ultrasonography (TCD) to detect left middle cerebral artery microemboli occurring during the procedure. Blinded off-line analysis correlated microembolic signal counts on TCD with the components of each stage of the PTCA. Patients later underwent transesophageal (TEE) echocardiography, with measurements made of the thickness of the intima and atheroma in the ascending and descending thoracic aortic arch by cardiologists blinded to the TCD results.

Results
—A total of 973 microembolic signals were detected (mean±SD, 48.7±36.7 per patient); 196 (20%) occurred on movement of the PTCA catheter and wire around the aortic arch, 84 (9%) with other PTCA catheter–associated movements, and 679 (70%) in association with injection of solutions (eg, saline and contrast). Mean signal counts during contrast injection were significantly greater than during the other 3 phases (
P
<0.001). No neurological events occurred in the study. Although not statistically significant, there was a trend toward greater microembolic signal counts with the number of times the catheter was passed around the aortic arch and the amount of arch atheroma detected by transesophageal echocardiography.

Conclusions
—Microemboli detected on TCD are a common occurrence during PTCA but are largely asymptomatic. The majority of microembolic signals are most probably gaseous in origin and do not appear to be related to the extent of aortic atheroma or to clinical events.
Timing for Fever-Related Brain Damage in Acute Ischemic Stroke
Authors: Castillo José , Dávalos Antoni , Marrugat Jaume , Noya Manuel
Published: June 2011

Background and Purpose
—The association between hyperthermia and early neurological deterioration, increased morbidity, and mortality in acute ischemic stroke is well known. However, the timing at which the cerebral lesion may be aggravated by high temperature has not been firmly established. The aim of this study was to determine the prognostic value of body temperature measured at different times after onset of stroke.

Methods
—Axillary temperature was recorded every 2 hours for 72 hours in 260 patients with a hemispheric cerebral infarction of <24 hours’ duration. A potential infectious focus was examined in all patients with hyperthermia (temperature >37.5°C in any of the assessments). Stroke severity was quantified with the Canadian Stroke Scale on admission. The relationship between the highest temperature recorded in each 6-hour interval from stroke onset and stroke outcome (Canadian Stroke Scale and Barthel Index at 3 months) or infarct volume was evaluated by correlation analyses. The importance of the time at which hyperthermia was first detected was assessed by logistic regression analysis.

Results
—During the first 72 hours, 158 patients (60.8%) had hyperthermia, and in 57.6% of them an infectious cause was identified. Mortality rate at 3 months was 1% in normothermic patients and 15.8% in hyperthermic patients (
P
<0.001). The correlation coefficients between the final infarct volume, Canadian Stroke Scale and Barthel Index scores at 3 months, and each temperature recording decreased progressively over time from symptom onset. Hyperthermia initiated within the first 24 hours from stroke onset, but not afterward, was independently related to larger infarct volume (odds ratio [OR]=3.23, 95% CI=1.63 to 6.43;
P
<0.001) and higher neurological deficit (OR=3.06, 95% CI=1.70 to 5.53;
P
<0.001) and dependency (OR=3.41, 95% CI=1.69 to 6.88;
P
=0.002) at 3 months. The infectious origin of hyperthermia was not associated with poorer outcome or greater infarct volume.

Conclusions
—The relationship between brain damage and high temperature is greater the earlier the increase in temperature occurs. However, only body temperature within the first 24 hours from stroke onset is associated with poor outcome and large cerebral infarcts.
Moderate Hypothermia in the Treatment of Patients With Severe Middle Cerebral Artery Infarction
Authors: Schwab S. , Schwarz S. , Spranger M. , Keller E. , Bertram M. , Hacke W.
Published: June 2011

Background and Purpose
—Animal research and clinical studies in head trauma patients suggest that moderate hypothermia may improve outcome by attenuating the deleterious metabolic processes in neuronal injury. Clinical studies on moderate hypothermia in the treatment of acute ischemic stroke patients are still lacking.

Methods
—Moderate hypothermia was induced in 25 patients with severe ischemic stroke in the middle cerebral artery (MCA) territory for therapy of postischemic brain edema. Hypothermia was induced within 14±7 hours after stroke onset and achieved by external cooling with cooling blankets, cold infusions, and cold washing. Patients were kept at 33°C body-core temperature for 48 to 72 hours, and intracranial pressure (ICP), cerebral perfusion pressure, and brain temperature were monitored continuously. Outcome at 4 weeks and 3 months after the stroke was analyzed with the Scandinavian Stroke Scale (SSS) and Barthel index. The side effects of induced moderate hypothermia were analyzed.

Results
—Fourteen patients survived the hemispheric stroke (56%). Neurological outcome according to the SSS score was 29 (range, 25 to 37) 4 weeks after stroke and 38 (range 28 to 48) 3 months after stroke. During hypothermia, elevated ICP values could be significantly reduced. Herniation caused by a secondary rise in ICP after rewarming was the cause of death in all remaining patients. The most frequent complication of moderate hypothermia was pneumonia in 10 of the 25 patients (40%). Other severe side effects of hypothermia could not be detected.

Conclusions
—Moderate hypothermia in the treatment of severe cerebral ischemia is not associated with severe side effects. Moderate hypothermia can help to control critically elevated ICP values in severe space-occupying edema after MCA stroke and may improve clinical outcome in these patients.
Risk of Recurrent Subarachnoid Hemorrhage After Complete Obliteration of Cerebral Aneurysms
Authors: Tsutsumi K. , Ueki K. , Usui M. , Kwak S. , Kirino T.
Published: June 2011

Background and Purpose
—The neck clipping of cerebral aneurysms is a well-established treatment for subarachnoid hemorrhage (SAH) caused by aneurysmal rupture. However, it is still unclear how great a risk of recurrence patients with a successfully treated aneurysm carry over a long-term period.

Methods
—Of 425 patients with SAH surgically treated in Aizu Chuou Hospital from 1976 to 1994, 220 cases meeting the following criteria were studied: (1) all aneurysms detected by 3- or 4-vessel cerebral angiography were clipped, (2) complete obliteration of aneurysm(s) was confirmed by postoperative angiography, and (3) the patient survived >3 years. All patients were traced until January 1998 for recurrent SAH or death. The mean follow-up period was 9.9 (range, 3 to 21) years.

Results
—Six patients (2.7%) had recurrent SAH, each with an interval ranging from 3 to 17 years (mean, 11 years) since the original treatment. In addition, 2 patients were found to have regrowth of the originally operated aneurysms. The cumulative recurrence rate of SAH, calculated using the Kaplan-Meier method, was 2.2% at 10 years and 9.0% at 20 years after the original treatment.

Conclusions
—The recurrence rate was considerably higher than the previously reported risk of SAH in the normal population, and the rate increased with time. These data indicate that patients with ruptured cerebral aneurysms still carry higher risks for SAH in a long-term period, even after complete obliteration of the aneurysm, and that periodic examination to detect recurrent aneurysms may be indicated for such patients.
MR Imaging in Pretruncal Nonaneurysmal Subarachnoid Hemorrhage
Authors: Wijdicks Eelco F. M. , Schievink Wouter I. , Miller Gary M.
Published: June 2011

Background and Purpose
—The cause of pretruncal (perimesencephalic) nonaneurysmal subarachnoid hemorrhage is not known. MRI of the brain or spine is often performed to exclude any other vascular abnormalities. Its diagnostic value is not known.

Methods
—We used MR imaging of the brain with routine sequences, gadolinium enhancement, and additional thin T1-weighted axial sections following a triple dose of contrast.

Results
—We performed MR imaging of the brain in 18 patients with a pretruncal nonaneurysmal subarachnoid hemorrhage. The focal nature of the subarachnoid hemorrhage exclusively in front of the brain stem was confirmed in 14 patients studied within 7 days of the ictus. No vascular abnormalities were found in 17 cases, including 14 patients with gadolinium enhancement. An incidental capillary telangiectasia was found in 1 patient. Fluid-attenuated inverse recovery MR additionally documented blood in the sulci due to cerebrospinal fluid recirculation of blood. Five patients underwent MR imaging of the spine, and no arteriovenous malformations were found.

Conclusions
—MR imaging did not reveal a source of pretruncal subarachnoid hemorrhage. The cost of MR imaging probably outweighs the benefit in the evaluation of this variant of subarachnoid hemorrhage.
Correlates of Subjective Well-being in Stroke Patients
Authors: Wyller Torgeir Bruun , Holmen Jostein , Laake Petter , Laake Knut
Published: June 2011

Background and Purpose
—Data on survival and functioning after stroke needs to be supplemented by measures emphasizing the patients’ subjective perception. We studied (1) subjective well-being (SWB) as a latent variable in a common-factor model with four items, (2) the reliability of these four items, and (3) variables related to SWB in stroke patients.

Methods
—Data on all stroke patients (n=1417) and a random subsample of stroke-free individuals of similar age (n=1439) were collected from the Nord-Trøndelag Health Survey, a cross-sectional study of 74 977 persons. Based on a two-sample factor analysis model, scores of SWB were calculated, and variables explaining SWB were studied in a regression model.

Results
—Four items were a priori believed to measure SWB as a latent variable (“satisfaction,” “strength,” “calmness,” and “cheerfulness”). This was confirmed by factor analysis. The reliability of these items (the proportion of the variance of the items that can be explained by the common factor) was between .42 and .53. Regression analyses showed a significant effect of having had a stroke, gender (lower SWB in men), age (increasing SWB with increasing age), perceived general health, nervousness, loneliness, sleep problems, social support, and use of analgesics. There was no statistical interaction between these variables and having had a stroke.

Conclusions
—Higher SWB after stroke relates to female gender, older age, good general and mental health, and a firm social network.
Prevalence of Apolipoprotein E Alleles in Healthy Subjects and Survivors of Ischemic Stroke
Authors: Margaglione Maurizio , Seripa Davide , Gravina Carolina , Grandone Elvira , Vecchione Gennaro , Cappucci Giuseppe , Merla Giuseppe , Papa Sara , Postiglione Alfredo , Di Minno Giovanni , Fazio Vito M.
Published: June 2011

Background and Purpose
—The ε4 allele of the apolipoprotein E (apoE) has been related to the occurrence of myocardial infarction, but its association with ischemic stroke is controversial. We have evaluated the relation between apoE alleles and the occurrence of cerebrovascular ischemia.

Methods
—The apoE ε genotypes of 100 patients with a documented history of ischemic stroke without clinically apparent dementia (stroke+) and 108 subjects without such history (stroke−) were determined. The relative frequency of the apoE alleles and genotypes was estimated in 398 healthy subjects aged <40 years from the same ethnic background.

Results
—The frequency of the apoE ε4 allele in stroke+ (0.18 [95% CI, 0.12 to 0.25]) was higher than in stroke− (0.07 [95% CI, 0.03 to 0.12];
P
<.001) or in healthy subjects (0.09 [95% CI, 0.07 to 0.12];
P
<.001). Carriers of the ε4 allele differed between stroke+ (0.30 [95% CI, 0.19 to 0.42]) and stroke− (0.12 [95% CI, 0.5 to 0.22];
P
=.004) or healthy subjects (0.16 [95% CI; 0.12 to 0.22];
P
=.015). Accordingly, ε3/ε3 homozygotes were less frequent in stroke+ (0.59 [95% CI, 0.45 to 0.71]) than in stroke− (0.72 [95% CI, 0.59 to 0.82];
P
=.063) or in healthy subjects (0.73 [95% CI, 0.67 to 0.78];
P
=.01). In a multiple logistic regression analysis, age (
P
<.03), positive family history (
P
<.04) and apoE (
P
<.002) independently contributed to a stroke history, with ε4 carriers exhibiting a higher estimated risk (odds ratio, 5.05).

Conclusions
—Our data show an association between apoE gene and a personal history of ischemic stroke and support the possibility that the apoE gene is a susceptibility locus for the risk of cerebrovascular ischemic disease.
Calcium and Magnesium in Drinking Water and Risk of Death From Cerebrovascular Disease
Authors: Yang Chun-Yuh
Published: June 2011

Background and Purpose
—Many studies have demonstrated a negative association between mortality from cardiovascular or cerebrovascular diseases and water hardness. This report examines whether calcium and magnesium in drinking water are protective against cerebrovascular disease.

Methods
—All eligible cerebrovascular deaths (17 133 cases) of Taiwan residents from 1989 through 1993 were compared with deaths from other causes (17 133 controls), and the levels of calcium and magnesium in drinking water of these residents were determined. Data on calcium and magnesium levels in drinking water throughout Taiwan were obtained from the Taiwan Water Supply Corporation. The control group consisted of people who died from other causes, and the controls were pair matched to the cases by sex, year of birth, and year of death.

Results
—The adjusted odds ratios (95% confidence interval) were 0.75 (0.65 to 0.85) for the group with water magnesium levels between 7.4 and 13.4 mg/L and 0.60 (0.52 to 0.70) for the group with magnesium levels of 13.5 mg/L or more. After adjustment for magnesium levels in drinking water, there was no difference between the groups with different levels of calcium.

Conclusions
—The results of the present study show that there is a significant protective effect of magnesium intake from drinking water on the risk of cerebrovascular disease. This is an important finding for the Taiwan water industry and human health.
Potential of Carotid Ultrasonography in the Diagnosis of Coronary Artery Disease
Authors: Nowak Jacek , Nilsson Tage , Sylvén Christer , Jogestrand Tomas
Published: June 2011

Background and Purpose
—Carotid artery atherosclerosis has been shown to correlate with coronary artery disease (CAD). This study evaluates the capacity of duplex ultrasonography of the carotid arteries as a tool in the diagnosis of CAD in comparison with exercise stress test and variance ECG.

Methods
—Carotid ultrasonography, exercise stress test, and variance ECG were performed in 184 symptomatic patients evaluated with coronary angiography. The diagnostic capacity of the studied noninvasive methods was assessed by use of receiver operating characteristic (ROC) curves constructed by successive consideration of several cut points, such as (1) the presence of unilateral/bilateral plaques and (2) cross-sectional common carotid artery (CCA) intima-media (IM) area from 10 to 30 mm
2
for ultrasonography; (1) ST depression ≥0.1 mV and ≥0.2 mV with and (2) without chest pain for exercise test; and electrical variability index from 50 to 100 for variance ECG.

Results
—Coronary angiography revealed the presence of CAD (≥50% luminal stenosis in 1 or more major epicardial arteries) in 147 patients (80%). Identification of carotid plaques on one or both sides and calculation of the left-sided (but not right-sided) CCA IM area provided a significant discrimination (
P
<.001 and
P
<.01, respectively) of patients with CAD. The discriminating capacity of the ultrasound procedures was equal to that of variance ECG and exercise test with ST depression criterion only but somewhat lower than that of exercise test with the combined chest pain and ST depression criterion (
P
<.05). However, at the chosen cut points, carotid plaque identification offered higher sensitivity than exercise test with either criterion (
P
<.01 and
P
<.001, respectively).

Conclusions
—Carotid ultrasonography is a useful diagnostic method that is comparable to exercise test and variance ECG for detection of CAD in a high-prevalence population.
Nitric Oxide Synthase Inhibition in Humans Reduces Cerebral Blood Flow but Not the Hyperemic Response to Hypercapnia
Authors: White Richard P. , Deane Colin , Vallance Patrick , Markus Hugh S.
Published: June 2011

Background and Purpose
—Animal studies suggest that nitric oxide (NO) is important in basal cerebral blood flow (CBF) regulation and that it may mediate the vasodilatory response to carbon dioxide. We investigated its role in the human circulation using the NO synthase inhibitor
N
G
-monomethyl-
l
-arginine (L-NMMA).

Methods
—L-NMMA was administered as an intravenous bolus at three doses (1, 3, and 10 mg/kg). CBF was assessed by color velocity ultrasonic imaging of internal and common carotid artery volume flow (ICA flow and CCA flow) and transcranial Doppler ultrasound measurement of middle cerebral artery flow velocity (MCAν). The pressor effect of L-NMMA was controlled for by comparison with noradrenaline titrated to effect an equivalent blood pressure elevation.

Results
—L-NMMA produced a dose-dependent reduction in basal mean±SD CCA flow from 415.2±51.9 to 294±56.2 mL/min (at 10 mg/kg) and ICA flow from 268.8±59.4 to 226.2±72.6 mL/min (
P
<.005 and
P
<.05, respectively, comparing areas under the dose-response curve). This was reversed by
l
-arginine. Mean±SD systemic blood pressure rose from 85.2±6.4 to 100.8±9.6 mm Hg (
P
<.01). There was no significant reduction in MCAν. There was no significant change in the CBF response to either 6% or 8% carbon dioxide after L-NMMA. Noradrenaline produced a lesser fall in basal CCA flow (12.0%) but had a similar effect on the hypercapnic response.

Conclusions
—Basal NO release is important in controlling human CBF, but intravenously administered L-NMMA does not inhibit the hypercapnic hyperemic response in humans. The discrepancy between CBF and MCAν after L-NMMA administration is consistent with MCA vasoconstriction. Neuronal NO synthase inhibition may be protective in stroke. However, our results suggest that nonselective NO synthase inhibitors such as L-NMMA should be used with caution because they reduce CBF.
Increased Serum Levels of the S-100 Protein Are Associated With Hypoxic Brain Damage After Cardiac Arrest
Authors: Rosén H. , Rosengren L. , Herlitz J. , Blomstrand C.
Published: June 2011

Background and Purpose
Patients resuscitated from cardiac arrest have a high early mortality rate. Prognostic evaluation based on clinical observations is uncertain and would benefit from the use of biochemical markers of hypoxic brain damage. The astroglial protein S-100 is an established biochemical marker of central nervous system injury. The purpose of the present study was to validate the use of serum determinations of S-100 with regard to outcome after cardiac arrest.

Methods
Levels of serum S-100 were measured with a radioimmunoassay in 41 patients the first 3 days after out-of-hospital cardiac arrest. The main outcome variable was fatal outcome within 14 days.

Results
S-100 levels were increased after cardiac arrest compared with controls with the highest levels observed the first day. S-100 levels day 1 and 2 correlated to the degree of coma as well as to the time of anoxia. Seventeen patients died within 14 days after the cardiac arrest. The deceased patients had increased S-100 levels on days 1 through 3 compared with survivors. All patients (100%) with an S-100 level of ≥0.2 on day 2 after the cardiac arrest died within 14 days, and 89% of the patients with levels below this limit value survived (positive and negative predictive values). The corresponding predictive values on day 1 were 71% and 85%, respectively.

Conclusions
The present study shows that hypoxic brain damage after cardiac arrest can be estimated by measurement of serum S-100 concentrations. The method can be used in early prognostic evaluation of short-term outcome after cardiac arrest.
Role of Tyrosine Kinase in Serotonin-Induced Constriction of the Basilar Artery In Vivo
Authors: Kitazono Takanari , Ibayashi Setsuro , Nagao Tetsuhiko , Kagiyama Tomoko , Kitayama Jiro , Fujishima Masatoshi
Published: June 2011

Background and Purpose
—Serotonin is one of the most potent constrictors of cerebral blood vessels and is implicated in several pathological conditions, including migraine and cerebral ischemia. Recent evidence has suggested that tyrosine kinase is involved in vasocontractile responses. The objective of this study was to test the hypothesis that activation of tyrosine kinase contributes to serotonin-induced constriction of the basilar artery in vivo.

Methods
—Using a cranial window in anesthetized Sprague-Dawley rats, we examined effects of inhibitors of tyrosine kinase and tyrosine phosphatase on constrictor responses of the basilar artery to serotonin in vivo.

Results
—Serotonin (10
−8
, 10
−7
, and 10
−6
mol/L) produced constriction of the basilar artery by 12±2%, 27±2%, and 37±3%, respectively. Genistein (3×10
−6
mol/L), an inhibitor of tyrosine kinase, did not affect baseline diameter of the basilar artery but attenuated serotonin-induced vasoconstriction (
P
<.05 versus control responses). Daidzein, an inactive analogue of genistein, did not affect serotonin-induced constriction of the basilar artery. Tyrphostin 47 (10
−5
mol/L), another inhibitor of tyrosine kinase, also attenuated serotonin-induced vasoconstriction, and tyrphostin 63, an inactive analogue of tyrphostin 47, did not affect the vasoconstriction. Sodium orthovanadate (10
−5
mol/L), an inhibitor of tyrosine phosphatase, enhanced serotonin-induced vasoconstriction. Phorbol 12,13-dibutyrate, a direct activator of protein kinase C, also caused constriction of the basilar artery, which was not affected by genistein or sodium orthovanadate.

Conclusions
—These results suggest that serotonin-induced constriction of the basilar artery is mediated, at least in part, by activation of tyrosine kinase in vivo.
Stroke and Incontinence
Authors: Brittain K. R. , Peet S. M. , Castleden C. M.
Published: June 2011

Background
—Urinary incontinence in the acute stage of stroke is seen as a predictor of death, severe disability, and an important factor on hospital discharge destination. Therefore, it is an important measure of stroke severity that not only affects the lives of stroke survivors but also those of caregivers.

Summary of Review
—A number of studies have linked the presence of bladder dysfunction in stroke survivors to various neurological lesions in areas thought to be primarily involved in micturition. However, neurological deficits may affect management of bladder control secondarily by apraxia or aphasia, for example, and a significant number of strokes occur in individuals already experiencing incontinence.

Conclusions
—Despite incontinence being such an important prognostic feature, there are many gaps in our knowledge of the relationship of stroke and incontinence, particularly fecal incontinence. There are almost no studies on the influence of achieving continence on outcome or how this might be brought about. This article reviews the literature on this important topic and highlights deficiencies in our knowledge and areas of future research.
Thrombolysis-Related Intracranial Hemorrhage
Authors: Gebel James M. , Sila Cathy A. , Sloan Michael A. , Granger Christopher B. , Mahaffey Kenneth W. , Weisenberger Joseph , Green Cindy L. , White Harvey D. , Gore Joel M. , Weaver W. Douglas , Califf Robert M. , Topol Eric J.
Published: June 2011

Background and Purpose
—Intracranial hemorrhage (ICH) is a serious complication of thrombolytic therapy. We systematically reviewed the radiographic features of 244 cases of symptomatic ICH complicating thrombolysis for acute myocardial infarction in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial, correlated these observations with clinical data, and speculated on hemorrhage pathogenesis.

Methods
—CT scans from 244 patients suffering symptomatic ICH were systematically reviewed for selected radiographic features, including ICH type, location, hematoma characteristics, mass effect features, hydrocephalus, and preexisting lesions. Hematoma volume was estimated by computer-assisted volumetric analysis. Data from this analysis were correlated with clinical data including hypertension, anticoagulation, age, thrombolytic regimen, and ICH timing.

Results
—Most hemorrhages were large (median [25th, 75th percentile] volume, 72 mL [39, 118]), solitary (66%), lobar (77%), confluent (80%), and intraparenchymal (82%) with a blood/fluid level (82%) and little edema (median [25th, 75th percentile] volume, 9 mL [5, 16]). Hydrocephalus (
P
<.001), any one mass effect feature (
P
<.001), intraventricular hemorrhage (
P
=.022), mottled hematoma appearance (
P
=.050), and hematoma blood/fluid level (
P
<.001) were associated with higher hemorrhage volume in the radiographic analysis, as were older age (
P
=.005), treatment with combined streptokinase and tissue plasminogen activator (
P
=.034), and hemorrhage onset 8 to13 hours after treatment (
P
=.008) in the clinical analysis. Subdural hemorrhage was a high-volume subgroup whose risk increased with antecedent trauma (
P
=.026) or syncope (
P
=.006). Deep intraparenchymal hemorrhage was associated with hypertension (
P
=.016), and multifocal ICH occurred significantly earlier after treatment (
P
=.002).

Conclusions
—Although the majority of postthrombolytic ICH are large, solitary, and supratentorial, the spectrum is diverse. Features of mass effect reflected the large volumes, and hematoma characteristics of mottling and blood/fluid levels were frequent. Thrombolysis-related coagulopathy and age appear to be the most important identifiable factors in the genesis of postthrombolytic ICH, but the hemorrhage subtype seen may reflect an interaction with other factors such as hypertension, ICH timing, antecedent head trauma, and syncope.
Prevalence of Extracranial Carotid and Vertebral Artery Disease in Chinese Patients With Coronary Artery Disease
Authors: Chen Wai Hong , Ho David Sai Wah , Ho Shu Leong , Cheung Raymond Tak Fai , Cheng Stephen Wing Keung
Published: June 2011

Background and Purpose
—Chinese have been reported to have an extremely low prevalence rate of carotid and vertebral artery disease in comparison with whites. Previous studies, however, have been limited to general hospital stroke admission or postmortem series and were prone to selection bias. Extracranial cerebrovascular disease (ECCVD) is associated with coronary artery disease (CAD) in whites. Data associating ECCVD with CAD in Chinese patients are not available.

Methods
—We studied 153 consecutive Chinese patients with angiographically documented CAD. Duplex ultrasonography was performed to identify any underlying extracranial carotid and vertebral artery disease. Patient demographics; vascular risk factors; history of myocardial infarction, transient ischemic attack (TIA) or stroke; concomitant peripheral vascular disease (PVD); degree of left ventricular dysfunction; and extent and severity of CAD were also noted and analyzed.

Results
—Significant (≥50%) stenosis of one or more of the extracranial cerebral arteries was found in 32 patients (21%). The internal and external carotid arteries were involved in 17 of 153 patients (11%) and 19 of 153 patients (12%), respectively. The vertebral artery was involved in 9 of 153 patients (6%) and the common carotid artery in 3 of 153 (2%). Diabetes mellitus, hypertension, a history of TIA or stroke, and PVD were significantly associated with the presence of ECCVD.

Conclusions
—Significant ECCVD is not uncommon in Chinese patients with CAD, and the prevalence is comparable with that reported in white populations. Patients with a history of diabetes, hypertension, TIA, stroke, and PVD are more likely to have concomitant ECCVD.