bluuebunny/crossref_metadata_2025 huggingface dataset:
Predictors of Cerebrovascular Events and Death Among Patients With Valvular Heart Disease
Authors: Petty George W. , Khandheria Bijoy K. , Whisnant Jack P. , Sicks JoRean D. , O’Fallon W. Michael , Wiebers David O.
Published: June 2011

Background and Purpose
—There is little population-based information on cerebrovascular events and survival among valvular heart disease patients. We used the Kaplan-Meier product-limit method and the Cox proportional hazards model to determine rates and predictors of cerebrovascular events and death among valve disease patients.

Methods
—This population-based historical cohort study in Olmsted County, Minnesota, reviewed residents with a first echocardiographic diagnosis of mitral stenosis (n=19), mitral regurgitation (n=528), aortic stenosis (n=140), and aortic regurgitation (n=106) between 1985 and 1992.

Results
—During 2694 person-years of follow-up, 98 patients developed cerebrovascular events and 356 died. Compared with expected numbers, these observations are significantly elevated, with standardized morbidity ratio of 3.2 (95% CI, 2.6 to 3.8) and 2.5 (95% CI, 2.2 to 2.7), respectively. Independent predictors of cerebrovascular events were age, atrial fibrillation, and severe aortic stenosis. The risk ratio of severe aortic stenosis was 3.5 (95% CI, 1.4 to 8.6), with atrial fibrillation conferring greater risk at younger age. Predictors of death were age, sex, cerebrovascular events, ischemic heart disease, and congestive heart failure, the greatest risk being among those with both congestive heart failure and cerebrovascular events (risk ratio=8.8; 95% CI, 5.8 to 13.4). Valve disease type and severity were not independent determinants of death.

Conclusions
—The risk of cerebrovascular events and death among patients with valve disease remains high. Age, atrial fibrillation, and severe aortic stenosis are independent predictors of cerebrovascular events, and age, sex, cerebrovascular events, congestive heart failure, and ischemic heart disease are independent predictors of death in these patients.
99m
Tc Annexin V Imaging of Neonatal Hypoxic Brain Injury
Authors: D’Arceuil Helen , Rhine William , de Crespigny Alex , Yenari Midori , Tait John F. , Strauss William H. , Engelhorn Tobias , Kastrup Andreas , Moseley Michael , Blankenberg Francis G.
Published: June 2011

Background and Purpose:
—Delayed cell loss in neonates after cerebral hypoxic-ischemic injury (HII) is believed to be a major cause of cerebral palsy. In this study, we used radiolabeled annexin V, a marker of delayed cell loss (apoptosis), to image neonatal rabbits suffering from HII.

Methods
—Twenty-two neonatal New Zealand White rabbits had ligation of the right common carotid artery with reduction of inspired oxygen concentration to induce HII. Experimental animals (n=17) were exposed to hypoxia until an ipsilateral hemispheric decrease in the average diffusion coefficient occurred. After reversal of hypoxia and normalization of average diffusion coefficient values, experimental animals were injected with
99m
Tc annexin V. Radionuclide images were recorded 2 hours later.

Results
—Experimental animals showed no MR evidence of blood-brain barrier breakdown or perfusion abnormalities after hypoxia. Annexin images demonstrated multifocal brain uptake in both hemispheres of experimental but not control animals. Histology of the brains from experimental animals demonstrated scattered pyknotic cortical and hippocampal neurons with cytoplasmic vacuolization of glial cells without evidence of apoptotic nuclei by terminal deoxynucleotidyl transferase–mediated dUTP nick end-labeling (TUNEL) staining. Double staining with markers of cell type and exogenous annexin V revealed that annexin V was localized in the cytoplasm of scattered neurons and astrocytes in experimental and, less commonly, control brains in the presence of an intact blood-brain barrier.

Conclusions
—Apoptosis may develop after HII even in brains that appear normal on diffusion-weighted and perfusion MR. These data suggest a role of radiolabeled annexin V screening of neonates at risk for the development of cerebral palsy.
Failure to Demonstrate Peri-Infarct Depolarizations by Repetitive MR Diffusion Imaging in Acute Human Stroke
Authors: Back Tobias , Hirsch Jochen G. , Szabo Kristina , Gass Achim
Published: June 2011

Background and Purpose
—Peri-infarct depolarizations (PIDs) have been demonstrated with diffusion-weighted MRI (DWI) in experimental stroke and are regarded as an important mechanism of ischemic injury. We tested the hypothesis that PIDs are of relevance for the early enlargement of human brain infarcts.

Methods
—Ten stroke patients were investigated by repetitive imaging of the apparent diffusion coefficient (ADC) in the acute phase (7 patients) or subacute phase (3 patients) of developing cortical infarction. In each patient, 20 ADC maps were obtained from serially measured echo-planar DWI (interval of 45 seconds). Data analysis focused on the potential spatial and temporal ADC changes, including structured qualitative analysis, calculation of subtraction images, serial analysis of regions of interest positioned in the infarct core and border, and calculation of hemispheric lesion areas, depending on various ADC thresholds ranging between 0 and 800 μm
2
/s.

Results
—Data analysis was unable to disclose any time-dependent changes in ADC that would resemble PID. In ischemic regions, the ADC reduction significantly progressed from the infarct border (555±96 μm
2
/s) to the infarct core (431±104 μm
2
/s,
P
<0.01).

Conclusions
—By using an MRI protocol with high temporal resolution and elaborated postprocessing, we were unable to demonstrate a pattern of diffusion changes that would be indicative of PID in human stroke. Experimental infarction and human stroke may differ in the detectability of PID.
Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke
Authors: Chapman Kristine M. , Woolfenden Andrew R. , Graeb Douglas , Johnston Dean C. C. , Beckman Jeff , Schulzer Michael , Teal Phil A.
Published: June 2011

Background and Purpose
—In the United States, tissue plasminogen activator (tPA) was approved for treatment of acute ischemic stroke in 1996. Its use has only recently been approved in Canada. We sought to evaluate the safety, feasibility, and efficacy of treatment in a Canadian hospital setting.

Methods
—A combined retrospective and prospective review is presented of 46 consecutive patients treated with intravenous tPA at our hospital with a treatment protocol similar to that of the National Institute of Neurological Disorders and Stroke (NINDS) trial.

Results
—Symptomatic intracranial hemorrhage at 36 hours occurred in 1 patient (2.2%). The median time to treat was 165 minutes, with a median “door-to-needle” time of 84 minutes. Compared with patients presenting initially at our hospital, patients transferred from another institution for tPA therapy were treated closer to the 3-hour time window (mean 173 versus 148 minutes,
P
<0.001) but had a shorter door-to-needle time (43 versus 102 minutes,
P
<0.001). For every 10 minutes closer to the 3-hour time window that any patient arrived at the hospital, 7 minutes was saved in the door-to-needle time (correlation coefficient 0.9,
P
<0.001). Patient outcome did not differ from that in the NINDS trial (
P
>0.75).

Conclusions
—Our safety and patient outcome data compare favorably with NINDS and Phase IV data. Although a 3-hour treatment window was feasible, the median door-to-needle time lengthened as more treatment time was available and the door-to-needle time was beyond recommended standards. This review has prompted changes in our community to improve treatment efficiency.
Comparison of Different Clinical Criteria (DSM-III, ADDTC, ICD-10, NINDS-AIREN, DSM-IV) for the Diagnosis of Vascular Dementia
Authors: Pohjasvaara T. , Mäntylä R. , Ylikoski R. , Kaste M. , Erkinjuntti T.
Published: June 2011

Background and Purpose
—The criteria for vascular dementia (VaD) include definition of the cognitive syndrome and the vascular cause. Different criteria for dementia identify different frequencies and clusters of patients. In addition, variation in defining the cause and etiology may have an effect. We compared different clinical criteria for VaD in series of patients with poststroke dementia.

Methods
—The study group comprised 107 patients fulfilling the
Diagnostic and Statistical Manual of Mental Disorders, Third Edition
(DSM-III) definition for dementia from a cohort of consecutive patients with ischemic stroke who completed a comprehensive neuropsychological test battery and MRI. The mean age (SD) of the patients was 71.4 (7.6) years. The definitions of vascular cause of VaD were those of the DSM-III (1980), Alzheimer’s Disease Diagnostic and Treatment Centers (ADDTC; 1992),
International Statistical
Classification of Diseases, 10th Revision
(ICD-10; 1992), National Institute of Neurological Disorders and Stroke–Association Internationale pour la Recherche et l’Enseignement en Neurosciences (NINDS-AIREN; 1993), and
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV; 1994).

Results
—The number of cases that could be classified as VaD according to the different criteria varied considerably: 36.4% (n=39) by DSM-III, 86.9% (n=93) by ADDTC, 32.7% (n=35) by NINDS-AIREN, 36.4% (n=39) by ICD-10, and 91.6% (n=98) by DSM-IV criteria. The concordance between DSM-III/ICD-10 was perfect (100%; κ=1.0), between ICD-10/NINDS-AIREN and ADDTC/DSM-IV good to moderate (85.0% and 87.3%; κ=0.87 and 0.37, respectively), but otherwise poor between the other criteria. Only 31 patients fulfilled all the criteria for VaD applied. Major discriminating factors between the criteria were requirement of (1) focal neurological signs, (2) unequal distribution of deficits in higher cortical functions, and (3) evidence of relevant CVD based on brain imaging findings.

Conclusions
—Current criteria of VaD identify different frequencies and clusters of patients and are not interchangeable. Optimally, prospective studies with clinicopathological correlation could identify new criteria. Meanwhile, focus on more homogeneous subtypes (eg, small-vessel subcortical VaD) and detailed neuroimaging criteria could improve the diagnostics.
Magnetic Resonance Techniques for the Identification of Patients With Symptomatic Carotid Artery Occlusion at High Risk of Cerebral Ischemic Events
Authors: Klijn Catharina J. M. , Kappelle L. Jaap , van der Grond Jeroen , Algra Ale , Tulleken Cornelis A. F. , van Gijn Jan
Published: June 2011

Background and Purpose
—We sought to assess whether MRI, MR angiography, or
1
H MR spectroscopy can be used to identify patients with symptomatic carotid artery occlusion (CAO) who are at high risk of recurrent ipsilateral cerebral ischemic events.

Methods
—In 115 consecutive patients with transient or moderately disabling symptoms of cerebral or retinal ischemia and ipsilateral CAO, we studied the prognostic value of (1) presence of a border-zone infarct; (2) quantitative flow in the middle cerebral artery (MCA) ipsilateral to the CAO; and (3) metabolic ratios in the centrum semiovale ipsilateral to the CAO.

Results
—Presence of a border-zone infarct and the rate of flow in the MCA did not have a significant relationship with recurrence of cerebral ischemic events. Patients with a low
N
-acetyl aspartate (NAA)/choline ratio had an annual risk of recurrent, ipsilateral, cerebral ischemic events of 16.0% (95% CI, 9.5 to 27.0), whereas this risk was 4.2% (95% CI, 2.2 to 8.0) in those with a normal NAA/choline ratio (hazard ratio, 0.43; 95% CI, 0.19 to 1.00). Patients who on entry had had only retinal symptoms had on average a higher NAA/choline ratio (mean difference, 0.25; 95% CI, 0.13 to 0.37) and a lower risk of recurrent cerebral ischemic events (odds ratio, 0.0; 95% CI, 0.0 to 0.6) than those with cerebral ischemic symptoms.

Conclusions
—NAA/choline ratio measured by
1
H MRS, but not the presence of a border-zone infarct or the amount of flow in the MCA, can identify patients with symptomatic CAO who are at risk of future ipsilateral cerebral ischemic events.
Preoperative MRA Flow Quantification in CEA Patients
Authors: Rutgers D. R. , Blankensteijn J. D. , van der Grond J.
Published: June 2011

Background and Purpose
—We sought to investigate whether preoperative volume flow in the internal carotid arteries (ICAs), the basilar artery (BA), and the middle cerebral arteries (MCAs) and collateral flow via the circle of Willis differ between patients who do and patients who do not develop cerebral ischemia during clamping of the carotid artery in carotid endarterectomy (CEA).

Methods
—Quantitative volume flow in the ICAs, BA, and MCAs and directional flow in the circle of Willis were measured preoperatively with 2-dimensional phase-contrast MR angiography in 86 CEA patients. During the operation, electroencephalographic (EEG) recordings were obtained that were monitored by a clinical neurophysiologist. Reference volume flow values were assessed in 24 control subjects.

Results
—In patients with an ICA stenosis without contralateral ICA occlusion (n=62), of whom 16% developed ischemic EEG changes during clamping, preoperative flow in the clamped ICA was significantly higher in patients with cerebral ischemia than in patients without (mean, 278 versus 160 mL/min;
P
<0.05). Flow in the contralateral ICA (156 versus 273 mL/min;
P
<0.01), flow in the BA (116 versus 165 mL/min;
P
<0.05), and presence of collateral flow via the circle of Willis to the clamped ICA (0% versus 37%;
P
<0.05) were significantly lower. MCA flow did not differ significantly between groups. Additionally, in patients with an ICA stenosis and a contralateral ICA occlusion (n=24), of whom 42% developed cerebral ischemia, preoperative flow in the clamped ICA was significantly higher in patients with cerebral ischemia than in patients without (309 versus 239 mL/min;
P
<0.05). BA flow, MCA flow, and presence of willisian collateral flow (0% versus 14%) did not differ significantly between groups.

Conclusions
—Preoperative volume flow in the clamped ICA is significantly higher in CEA patients with ischemic EEG changes during clamping than in CEA patients without such changes. The latter patients probably have better developed collateral pathways preoperatively.
Postischemic Cerebrovascular E-Selectin Expression Mediates Tissue Injury in Murine Stroke
Authors: Huang Judy , Choudhri Tanvir F. , Winfree Christopher J. , McTaggart Ryan A. , Kiss Szilard , Mocco J. , Kim Louis J. , Protopsaltis Themistocles S. , Zhang Yuan , Pinsky David J. , Connolly E. Sander
Published: June 2011

Background and Purpose
—Although the deleterious role of several proinflammatory mediators, including P-selectin, in reperfused stroke is well established, the role of E-selectin has not been fully characterized.

Methods
—E-selectin mRNA expression was studied at 4, 10, and 24 hours after reperfusion with reverse transcription and polymerase chain reaction in mice (n=18) subjected to transient intraluminal middle cerebral artery occlusion (MCAO). Mice received intravenous injection with anti–E-selectin monoclonal antibody (10, 35, or 50 μg), nonimmune IgG, or vehicle immediately before MCAO and 90 minutes later (n=85). Others received anti–E-selectin antibody 3 or 6 hours after MCAO (n=32). Myeloperoxidase activity was measured in sham-operated mice and after 10 hours of reperfusion in saline-, nonimmune IgG–, or anti–E-selectin IgG–treated cohorts (n=17). Serial cerebral blood flow was measured with laser-Doppler flowmetry, and outcomes were assessed by neurological deficits and infarct volumes with the use of planimetric analysis of triphenyltetrazolium chloride–stained sections.

Results
—Upregulated E-selectin expression occurred in the ischemic cerebral vasculature within 4 hours of reperfusion and persisted for 24 hours. Anti–E-selectin antibody increased ischemic cortical cerebral blood flow up to 2.6-fold (
P
<0.05). In addition to dose-dependent reductions in neurological deficits (
P
<0.05), mortality, and infarct volumes (
P
<0.01 for 35 and 50 μg), anti–E-selectin treatment reduced cerebral neutrophil accumulation (
P
<0.05) and was neuroprotective even if delayed until 3 hours after ischemia (
P
<0.05).

Conclusions
—These findings establish a functional role for E-selectin in the pathogenesis of tissue injury after cerebral ischemia and reperfusion and suggest that E-selectin blockade may be clinically useful in the treatment of reperfused stroke.
Restricted Dissociated Sensory Loss in a Patient With a Lateral Medullary Syndrome
Authors: Cerrato Paolo , Imperiale Daniele , Bergui Mauro , Giraudo Marco , Baima Chiara , Grasso Maria , Lopiano Leonardo , Bergamasco Bruno
Published: June 2011

Background
—Various sensory syndromes in lateral medullary infarctions are described. A small variation in the location of a lesion may lead to very different clinical features, owing to the complex anatomy of the medulla oblongata. MRI may identify the location and extent of the ischemic lesions, allowing a clear clinical-anatomical correlation.

Case Description
—We describe a man with an ischemic lesion in the right portion of the lower medulla that presented a contralateral impairment of spinothalamic sensory modalities and an ipsilateral impairment of lemniscal modalities with a restricted distribution (left forearm and hand, right hand and fingers, respectively). The restricted and dissociated sensory abnormalities represent the only permanent neurological consequence of that lesion.

Conclusions
—The atypical sensory syndrome may be explained by the involvement of the medial portion of spinothalamic tract and the lateral portion of archiform fibers at the level of the lemniscal decussation.
Risk Factors for Multiple Intracranial Aneurysms
Authors: Juvela Seppo
Published: June 2011

Background and Purpose
—The presence of multiple intracranial aneurysms may be a sign of significant risk factors for aneurysm formation that differ from those factors that increase risk for aneurysm rupture. Only 2 studies concern independent risk factors for multiple aneurysms, and the results are in part controversial. This study was designed to identify independent risk factors for multiple intracranial aneurysms in patients with subarachnoid hemorrhage.

Methods
—Of 266 patients with aneurysmal subarachnoid hemorrhage (139 men and 127 women, aged 15 to 60 years), 80 (30%) had multiple intracranial aneurysms. The prevalence of several health-related habits, previous diseases, and medications of these patients were compared by multiple logistic regression between those with single and those with multiple aneurysms.

Results
—On the basis of multivariate statistics, only regular cigarette smoking at any time was a significant risk factor for the presence of multiple aneurysms. The odds ratio (OR) of smoking for multiple aneurysms was 2.10 (95% CI, 1.06 to 4.13) after adjustment for age and sex. After additional adjustment for hypertension, the risk was 2.06 (95% CI, 1.04 to 4.07). Of other variables, only age (OR, 1.02 per year; 95% CI, 1.00 to 1.05;
P
=0.09) and female sex (OR, 1.60; 95% CI, 0.90 to 2.85;
P
=0.11) showed a tendency to increase the risk for multiple aneurysms after adjustment for smoking. On the other hand, patients with hypertension had significantly (
P
=0.029) more aneurysms (1.61±1.04) than did those without (1.37±0.68), although they did not more frequently have multiple aneurysms.

Conclusions
—Cigarette smoking and possibly also age and female sex seem to be risk factors for multiple intracranial aneurysms in patients of working age who have suffered a subarachnoid hemorrhage. Patients with hypertension seem to have more aneurysms than those without.
Influence of Admission Body Temperature on Stroke Mortality
Authors: Wang Yang , Lim Lynette L.-Y. , Levi Christopher , Heller Richard F. , Fisher Janet
Published: June 2011

Background and Purpose
—The influence of body temperature on stroke outcome remains uncertain. The aim of this study was to investigate the prognostic role of admission body temperature on short-term and long-term mortality in a retrospective cohort study of patients with acute stroke.

Methods
—A retrospective cohort of 509 patients with acute stroke, admitted to a tertiary hospital between July 1, 1995, and June 30, 1997, was studied. The relationship between admission body temperature and mortality both in-hospital and at 1-year mortality was evaluated. Body temperature on admission was classified as hypothermia (≤36.5°C), normothermia (>36.5°C and ≤37.5°C), and hyperthermia (>37.5°C). Logistic regression and proportional hazards function analysis were performed after adjustment for clinical predictors of stroke outcome.

Results
—In ischemic stoke, mortality was lower among patients with hypothermia and higher among patients with hyperthermia. The odds ratio for in-hospital mortality in hypothermic versus normothermic patients was 0.1 (95% CI, 0.02 to 0.5). The relative risk for 1-year mortality of hyperthermic versus normothermic patients was 3.4 (95% CI, 1.6 to 7.3). A similar but nonsignificant trend for in-hospital mortality was seen among patients with hemorrhagic stroke.

Conclusions
—An association between admission body temperature and stroke mortality was noted independent of clinical variables of stroke severity. Hyperthermia was associated with an increase in 1-year mortality. Hypothermia was associated with a reduction in in-hospital mortality.
Recovery of Ipsilateral Dexterity After Stroke
Authors: Sunderland Alan
Published: June 2011

Background and Purpose
—Previous work indicated that patients within 1 month of parietal or posterior frontal damage are often abnormally slow or clumsy when using the ipsilateral hand for dexterity tasks. This article reports a 6-month follow-up study to assess recovery and the impact on functional outcome.

Methods
—Twenty-four patients (80%) were available for follow-up. They used the ipsilateral hand on a dexterity test that simulated everyday hand function. Weakness and ideomotor apraxia were also assessed. Performance was compared with that of healthy age-matched control subjects using the same hand. Rating scales for self-care and dexterity in everyday life were completed by patients and carers.

Results
—Significant recovery had occurred on all measures, but patients with left hemisphere damage remained impaired on the dexterity test, with 7 patients (58%) scoring below the normal range. Five of these were apraxic. Reports of everyday functioning did not reflect this impairment, but there were inconsistencies in these reports, which raised doubts as to their accuracy.

Conclusions
—Ipsilateral dexterity shows recovery during the first 6 months, but there may be persistent impairment related to apraxia after left hemisphere stroke. It appears that the impact of this on functional outcome is typically small compared with the large effect of severity of contralateral paresis. It may be a significant factor in some cases, however, and direct observation of everyday functioning would be needed to clarify more subtle effects on outcome.
Who Benefits From Treatment and Rehabilitation in a Stroke Unit?
Authors: Jørgensen Henrik Stig , Kammersgaard Lars Peter , Houth Jakob , Nakayama Hirofumi , Raaschou Hans Otto , Larsen Kim , Hübbe Per , Olsen Tom Skyhøj
Published: June 2011

Background and Purpose
—The beneficial effects of treatment and rehabilitation of patients with acute stroke in a dedicated stroke unit (SU) are well established. We wanted to examine if these effects are limited to certain groups of patients or if they apply to all patients independent of age, sex, comorbidity, and initial stroke severity.

Methods
—This was a community-based study of outcome in 1241 consecutive stroke patients from 2 communities in Copenhagen: In one (Frederiksberg), treatment and rehabilitation were given in general neurological and medical wards (GW), and in the other (Bispebjerg) in one single large SU. Outcome measures were initial, 1-year, and 5-year mortality rates, a poor outcome (initial death or discharge to a nursing home), and length of hospital stay (LOHS). Multivariate regression analyses were used to examine the independent effect of SU treatment on the various subgroups.

Results
—The relative risks of initial death, poor outcome, and 1-year and 5-year mortality rates were reduced by 40% on average in patients treated in the SU compared with the GW. A beneficial effect of SU treatment was observed regardless of the patient’s age, sex, comorbidity, and initial stroke severity. Those who benefited most appeared to be the patients with the most severe strokes (poor outcome: OR 0.17; 95% CI 0.05 to 0.58). Those who benefited least were patients with mild or moderate strokes (poor outcome: OR 0.66; 95% CI 0.41 to 0.98) and patients <75 years of age (poor outcome: OR 0.66; 95% CI 0.36 to 1.19). LOHS was reduced by 2 to 3 weeks in all who had their treatment in the SU except in patients with the most severe strokes. LOHS in these patients was similar to LOHS in the GW.

Conclusions
—A beneficial effect of treatment in a SU is achieved in completely unselected patients independent of their age, sex, comorbidity, and stroke severity. Those who had the most severe strokes appeared to benefit most. All patients with acute stroke should therefore have access to treatment and rehabilitation in a dedicated SU.
Increased Stroke Incidence in Lund-Orup, Sweden, Between 1983 to 1985 and 1993 to 1995
Authors: Johansson Björn , Norrving Bo , Lindgren Arne
Published: June 2011

Background and Purpose
—Some studies suggest that the incidence of stroke may continue to change. We examined recent temporal trends in a defined geographical area of southern Sweden.

Methods
—Medical records at the University Hospital of Lund (hospital district population 224 126 in 1993) were retrospectively screened for possible first-ever strokes during 1993 to 1995. Included patients were classified into pathological subtypes (cerebral infarction, intracerebral hemorrhage, subarachnoid hemorrhage, and undetermined pathological type) and according to the Oxfordshire Community Stroke Project (OCSP) classification system. Stroke patients from a previous study from 1983 to 1985 in the same area were reevaluated with the same criteria. Epidemiological data for the 2 time periods were compared.

Results
—There were 998 patients with first-ever stroke in 1983 to 1985 and 1318 in 1993 to 1995. The total incidence rate per 100 000 person-years (age-adjusted to the European population) increased from 134 (95% confidence limits [CL] 126 to 143) to 158 (95% CL 149 to 168). The incidence rate for patients <75 years of age increased from 94 (95% CL 85 to 103) in 1983 to 1985 to 117 (95% CL 108 to 127) in 1993 to 1995, whereas the incidence rate for patients ≥75 years was stable. The age-adjusted incidence rates for the OCSP subtypes lacunar and posterior circulation syndromes increased significantly, by 30% and 55%, respectively.

Conclusions
—A marked increase in the incidence of first-ever stroke was observed, surprisingly mainly confined to people <75 years of age. The underlying causes of this increase must be explored in future studies.
Increased Platelet Sensitivity to Collagen in Individuals Resistant to Low-Dose Aspirin
Authors: Kawasaki Tomio , Ozeki Yasushi , Igawa Takehiro , Kambayashi Jun-ichi
Published: June 2011

Background and Purpose
—The purpose of this study was to assess individual differences in the pharmacological effects of acetylsalicylic acid (ASA) on bleeding time as measured by in vitro platelet aggregation and to examine the consistency of responses over time.

Methods
—We measured template IIR bleeding time and platelet aggregation in 8 healthy male volunteers before and 2 hours after ingestion of 324 mg of ASA. An individual was considered a nonresponder if his post-ASA bleeding time was not 2 SDs above his baseline bleeding time, where SD was estimated from the baseline bleeding times of the 8 volunteers. The same experiment was done after a 30-month interval.

Results
—Five volunteers were identified as ASA responders, and 3 were identified as nonresponders. Bleeding time before and after ingestion of ASA was 408±121 seconds (mean±SD) and 720±225 seconds, respectively, in ASA responders and 330±30 seconds and 330±52 seconds, respectively, in ASA nonresponders. The mean ED
50
for collagen-induced platelet aggregation, that is, the mean concentration of collagen that caused a response at 50% of maximum, was 0.91 μg/mL (95% CI, 0.73 to 1.14) in ASA responders and 0.48 μg/mL (95% CI, 0.38 to 0.60) in nonresponders. When optimum concentrations of collagen, ie, concentrations that yielded 90% maximum aggregation, were used as stimuli, the mean IC
50
for ASA, that is, the mean concentration that yielded 50% inhibition, was 322.5 μmol/L (95% CI, 264.8 to 392.6) in ASA responders and 336.1 μmol/L (95% CI, 261.0 to 432.8) in nonresponders. The variability in individual responsiveness in the second experiment remained consistent with that in the first experiment.

Conclusions
—ASA resistance may be caused by an increased sensitivity of platelets to collagen. A platelet aggregation study specific for collagen dose response may be useful for strict selection of ASA responders for low-dose ASA therapy and for identifying ASA nonresponders for high-dose ASA therapy.
Decreased Severity of Brain Infarct Can in Part Explain the Decreasing Case Fatality Rate of Stroke
Authors: Numminen Heikki , Kaste Markku , Aho Kari , Waltimo Olli , Kotila Mervi
Published: June 2011

Background and Purpose
—Case fatality rates for stroke has declined in most Western industrialized countries during recent decades. One possible explanation for this is a decrease in the severity of stroke symptoms. We therefore sought evidence for a change in stroke severity and its relationship with case fatality rates.

Methods
—We compared the severity of symptoms among first-ever stroke patients in 2 population-based prospective stroke registers maintained during 1972 to 1973 and 1989 to 1991 in Finland. Patients who were evaluated by study assistants or the investigator during the first week after the onset of symptoms were included in the study, and their severity of symptoms was assessed with the use of comparable scales modified from the Scandinavian Stroke Scale.

Results
—A total of 244 and 594 patients were registered, and a portion of them (155 [63.5%] and 360 [60.6%]) were included in the analyses in the registers for Espoo-Kauniainen from 1972 to 1973 and for 4 separate districts in Finland from 1989 to 1991, respectively. The death rates during the first week among those who were not included did not differ between the registers. The severity of symptoms decreased significantly between the registers in both patients with brain infarct or intracerebral hemorrhage but not in those with subarachnoid hemorrhage. The severity of symptoms was an independent factor of case fatality at 1 month.

Conclusions
—The severity of symptoms of brain infarcts has decreased and can in part explain the decreased case fatality rate of stroke in Finland. However, the change in patients with intracerebral hemorrhage may be overestimated due to undiagnosed intracerebral hemorrhages in the first register resulting from the lack of brain CT.
Objective Measurement of Functional Upper-Extremity Movement Using Accelerometer Recordings Transformed With a Threshold Filter
Authors: Uswatte Gitendra , Miltner Wolfgang H. R. , Foo Benjamin , Varma Maneesh , Moran Scott , Taub Edward
Published: June 2011

Background and Purpose
—The consensus is that the most important outcome for rehabilitation is functional activity in the life situation. Constraint-Induced Movement Therapy, a new treatment that transfers in-clinic gains to the life situation, demands objective measurement of real-world movement. However, direct, objective, and accurate measures of arm use in the real world are not available. Previous attempts to use accelerometry to measure extremity movement have failed because of unacceptable variability. This problem has been addressed here by use of a threshold filter.

Methods
—Nine stroke patients and 1 healthy individual wearing accelerometers were videotaped while they carried out their usual activities at home or in the clinic; the duration of their arm, torso, and ambulatory movements was judged by 2 observation teams. In addition, 11 college students performed 5 standardized activities of daily living for varying durations in the laboratory. The accelerometer data were transformed; the raw value recorded for a given epoch was set to a constant if it exceeded a low threshold.

Results
—The threshold-filtered recordings measured the duration of movement accurately and with very little variability. Correlations between the threshold-filtered recordings and the observer ratings of the duration of arm, torso, and ambulatory movements were 0.93, 0.93 and 0.99, respectively; the corresponding correlations for the raw values were −0.17, 0.34, and 0.85.

Conclusions
—These results present initial evidence for the validity of threshold-filtered accelerometer recordings for objectively measuring the amount of real-world upper-extremity movement as an index of treatment outcome for rehabilitation patients.
Carotid and Transcranial Color-Coded Duplex Sonography in Different Types of Carotid-Cavernous Fistula
Authors: Chen Yu-Wei , Jeng Jiann-Shing , Liu Hon-Man , Hwang Bao-Show , Lin Win-Hwan , Yip Ping-Keung
Published: June 2011

Background and Purpose
—Patients with carotid-cavernous fistula (CCF) may undergo direct or indirect shunting. Ultrasonography has value that is complementary to angiography in the assessment and follow-up of these patients. The aim of this study was to characterize findings provided by carotid duplex sonography (CDS) and transcranial color-coded duplex sonography (TCCD) in patients with different types of CCF.

Methods
—CDS and TCCD were independently performed by technologists and neurologists. Digital subtraction or MR angiography was interpreted by a neuroradiologist. Ultrasonographic studies were categorized into 4 types: I, direct shunting only; II, direct shunting with a carotid aneurysm; III, indirect shunting only; and IV, mixed (direct and indirect) shunting. In addition to carotid and intracranial flow velocities, volume, and pulsatility, other direct and indirect ultrasound signs of shunting were evaluated. The direct sign of CCF was a mosaic flash detected by TCCD. Alteration of hemodynamic parameters on CDS and demonstration of draining veins with the use of TCCD were considered indirect signs.

Results
—Fifteen patients (8 men, 7 women) were included in the study. According to angiographic results, patients in ultrasonographic classification types I (n=7) and II (n=3) corresponded to type A of Barrow’s classification. Patients with type III (n=8) were Barrow’s type C. Type IV (n=1) had a combination of Barrow’s types A and C. On ultrasound, both direct and indirect signs were seen in types I, II, and IV CCF. The presence of a 2-colored oval mass divided by a zone of separation without turbulence differentiated type I from type II CCF. All patients with type III CCF had indirect signs, and only 1 patient had direct signs on TCCD. Abnormal TCCD findings were most commonly seen through the transorbital window (100%), followed by the transtemporal window (63%) and transforaminal window (40%).

Conclusions
—If only indirect ultrasonographic signs of CCF are present, TCCD can be used to predict an indirect CCF type on the basis of the origin of the fistula. With direct communication between carotid artery and cavernous sinus, both direct and indirect ultrasonographic signs can be found. The combination of CDS/TCCD may provide a noninvasive and reliable way to classify patients with CCF.
Renal Artery Lesions in Patients With Moyamoya Disease
Authors: Yamada Ichiro , Himeno Yoshiro , Matsushima Yoshiharu , Shibuya Hitoshi
Published: June 2011

Background and Purpose
—Renal artery lesions in moyamoya disease have been described sporadically in several case reports. The purpose of this study is to evaluate the angiographic findings of renal artery lesions in moyamoya disease and to determine the prevalence of renal artery lesions in patients with moyamoya disease.

Methods
—Eighty-six consecutive patients with idiopathic moyamoya disease were prospectively examined with both cerebral angiography and abdominal aortography. The findings of abdominal aortography were reviewed for the presence and appearance of renal artery lesions and compared with the clinical data and cerebral angiographic findings.

Results
—Of 86 patients with idiopathic moyamoya disease, 7 patients (8%) were found to have renal artery lesions. Six patients (7%) had stenosis in the renal artery, and 1 patient (1%) had a small saccular aneurysm in the renal artery. Two patients (2%) with a marked renal artery stenosis presented with renovascular hypertension, which resulted in an intraventricular hemorrhage in 1 patient. Furthermore, the renal artery stenosis in the 2 patients with renovascular hypertension was successfully treated with percutaneous transluminal angioplasty. There was no significant correlation between the presence of renal artery lesions and cerebral angiographic findings.

Conclusions
—Seven (8%) of 86 patients with moyamoya disease showed renal artery lesions, including 6 stenoses (7%) and 1 aneurysm (1%). Renal artery lesions are a clinically relevant systemic manifestation in patients with moyamoya disease.
The rtPA (Alteplase) 0- to 6-Hour Acute Stroke Trial, Part A (A0276g)
Authors: Clark Wayne M. , Albers Gregory W. , Madden Kenneth P. , Hamilton Scott
Published: June 2011

Background and Purpose
—The Thrombolytic Therapy in Acute Ischemic Stroke Study, which started in August of 1991, was designed to assess the efficacy and safety of intravenous rtPA (alteplase) in patients with acute (0 to 6 hours) ischemic stroke. In October 1993 enrollment was halted because of Safety Committee (DMSB) concerns. In December 1993 the time window was changed to 0 to 5 hours, and it was decided to restart enrollment as a separate study (part B). We report here the results of the original study (part A), focusing on evaluating the safety and efficacy of rtPA given between 0 and 6 hours after stroke onset.

Methods
—This investigation was a phase II, placebo-controlled, double-blind, randomized study utilizing 0.9 mg/kg IV rtPA or placebo over 1 hour, which was conducted at university and community sites in North America. Except for time to treatment, enrollment criteria were very similar to those of the NINDS rtPA stroke study. Primary efficacy end points were the number of patients with a decrease of 4 or more points on the National Institutes of Health Stroke Scale (NIHSS) at 24 hours and day 30, along with infarct volume at day 30. Secondary end points included mortality and functional recoveries on the Barthel Index and Modified Rankin scale at days 30 and 90.

Results
—A total of 142 patients were enrolled at 42 sites in North America, including 22 <3 hours (15%) and 46 between 5 and 6 hours (32%). The groups were well matched on baseline characteristics, including NIHSS (mean of 13 for both). For the primary end points, a higher percentage of rtPA patients had a 4-point improvement at 24 hours (placebo 21%, rtPA 40%;
P
=0.02); however, this early effect was reversed by 30 days, with more placebo patients having a 4-point improvement (75%) than patients treated with rtPA (60%,
P
=0.05). Treatment with rtPA significantly increased the rate of symptomatic intracerebral hemorrhage within 10 days (11% versus 0%,
P
<0.01) and mortality at 90 days (23% versus 7%,
P
<0.01).

Conclusions
—This study found no significant rtPA benefit on any of the planned efficacy end points at 30 and 90 days in patients treated between 0 and 6 hours after stroke onset. These negative results apply to patients treated after 3 hours, because only 15% of the patients were enrolled before 3 hours. The risk of symptomatic intracerebral hemorrhage was increased with rtPA treatment, particularly in patients treated between 5 and 6 hours after onset. These results do not support the use of intravenous rtPA for stroke treatment >3 hours after onset.
Optimal Intensity of Warfarin Therapy for Secondary Prevention of Stroke in Patients with Nonvalvular Atrial Fibrillation
Authors: Yamaguchi Takenori
Published: June 2011

Background and Purpose
—The optimal intensity of warfarin therapy for secondary prevention of stroke in nonvalvular atrial fibrillation (NVAF) remains unclear. We studied the efficacy and safety of conventional- and low-intensity warfarin therapy in a prospective, randomized, multicenter trial.

Methods
—The study population consisted of patients with NVAF (<80 years old) who had a stroke or transient ischemic attack. The patients were randomly allocated into a conventional-intensity group (international normalized ratio [INR] 2.2 to 3.5) and a low-intensity group (INR 1.5 to 2.1). They were carefully monitored, and the annual rate of recurrent ischemic stroke and major hemorrhagic complications were compared between the groups.

Results
—We enrolled 115 patients (mean age 66.7±6.5 years) into the study. Fifty-five and 60 patients were allocated into the conventional- and low-intensity groups, respectively. The trial was stopped after a follow-up of 658±423 days, when major hemorrhagic complications occurred in 6 patients of the conventional-intensity group and the frequency (6.6% per year) was significantly higher than that in the low-intensity group (0% per year,
P
=0.01, Fisher’s exact test). All of the 6 patients with major bleeding were elderly (mean age 74 years), and their mean INR before the major hemorrhage was 2.8. The annual rate of ischemic stroke was low in both groups (1.1% per year in the conventional-intensity group and 1.7% per year in the low-intensity groups) and did not differ significantly.

Conclusions
—For secondary prevention of stroke in persons with NVAF, especially in old patients, the low-intensity warfarin (INR 1.5 to 2.1) treatment seems to be safer than the conventional-intensity (INR 2.2 to 3.5) treatment.
Stereotactic Computed Tomographic–Guided Aspiration and Thrombolysis of Intracerebral Hematoma
Authors: Montes Jose M. , Wong John H. , Fayad Pierre B. , Awad Issam A.
Published: June 2011

Background and Purpose
—We review preliminary experience with patients harboring intracerebral hematoma (ICH) treated by stereotactic computed tomographic (CT) guided thrombolysis and aspiration and assess procedure feasibility and safety.

Methods—
Twelve patients with supratentorial ICH ≥25 mL without suspected underlying structural etiology or coagulopathy and an initial Glasgow Coma Scale (GCS) score of ≥5 were treated. A catheter was directed stereotactically or manually into the ICH through a burr hole under CT guidance. Hematoma aspiration was followed by instillation of urokinase (5 000 to 10 000 IU). This was repeated every 6 to 8 hours at bedside, with interval CT imaging, until the ICH volume diminished to <25 mL, less than half of its initial volume, or after a maximum of 10 aspirations/instillations.

Results
—Mean age was 69 years (range 55 to 82 years). Median initial GCS was 12 (range 5 to 14). There were 7 ganglionic and 5 lobar ICH, and baseline hematoma size ranged 29 to 70 mL (mean 46 mL). Final ICH volume ranged from 14 to 51 mL (mean 21 mL), with ICH volume reduction by an average of 57% (range 38% to 70%). One patient (8.3%) suffered hematoma expansion during the procedure. At 6 months after the procedure, 3 patients (25%) had achieved a good recovery (Glasgow Outcome Scale [GOS] score of 5), 5 patients (42%) were dependent (GOS 3), and 1 (8.3%) remained vegetative (GOS 2). Three patients (25%) died in hospital (1 from cardiac arrhythmia and 2 from respiratory failure).

Conclusions
—CT-guided thrombolysis and aspiration appears safe and effective in the reduction of ICH volume. Further studies are needed to assess optimal thrombolytic dosage and must include controlled comparisons of mortality, disability outcome, time until convalescence, and cost of care in treated and untreated patients.
Predictors of Death and Vascular Events in the Elderly
Authors: Jamrozik Konrad , Broadhurst Robyn J. , Forbes Susanne , Hankey Graeme J. , Anderson Craig S.
Published: June 2011

Background and Purpose
—The goal of the present study was to identify risk factors for vascular disease in the elderly.

Methods
—We conducted a prospective study of control subjects from a population-based study of stroke in Perth, Western Australia, that was completed in 1989 to 1990 and used record linkage and a survey of survivors to identify deaths and nonfatal vascular events. Data validated through reference to medical records were analyzed with the use of Cox proportional hazards models.

Results
—Follow-up for the 931 subjects was 88% complete. By June 24, 1994, 198 (24%) of the subjects had died (96 from vascular disease), and there had been 45 nonfatal strokes or myocardial infarctions. The hazard ratio for diabetes exceeded 2.0 for all end points, whereas the consumption of meat >4 times weekly was associated with a reduction in risk of ≤30%. In most models, female sex and consumption of alcohol were associated with reduced risks, whereas previous myocardial infarction was linked to an increase in risk.

Conclusions
—There are only limited associations between lifestyle and major vascular illness in old age. Effective health promotion activities in early and middle life may be the key to a longer and healthier old age.
Prevalence and Impact of Urinary Symptoms Among Community-Dwelling Stroke Survivors
Authors: Brittain K. R. , Perry S. I. , Peet S. M. , Shaw C. , Dallosso H. , Assassa R. P. , Williams K. , Jagger C. , Potter J. F. , Castleden C. M.
Published: June 2011

Background and Purpose
—To establish prevalence of urinary symptoms among community-dwelling stroke survivors and how these symptoms affected lives of these survivors compared with a nonstroke population.

Methods
—The present study was a community-based postal survey in Leicestershire community, UK (that excluded institutional settings), that was designed to track stroke, urinary, and bowel symptoms and the effect of such symptoms on relationships, social life, daily activities, and overall quality of life. Subjects included 14 600 people who were living in the community and ≤40 years of age, randomly selected from the Leicestershire Health Authority Register.

Results
—A 70% response rate was achieved with the return of 10 226 questionnaires. Prevalence of reported stroke was 4% (n=423). Prevalence of urinary symptoms was 34% (n=3197). Overall, stroke survivors had a higher prevalence of symptoms than the nonstroke population (64% to 32%, respectively). These symptoms were reported to have more of an effect on the lives of the stroke survivors compared with the nonstroke population even when adjusted for age and sex differences. This reported impact was not related to the stroke per se but to the severity of the urinary symptoms.

Conclusions
—These data show a high prevalence of urinary symptoms among community-dwelling stroke survivors. These symptoms were reported to have considerable impact on the lives of stroke survivors, which needs to be taken into account in future research and clinical practice.