bluuebunny/crossref_metadata_2025 huggingface dataset:
Safety of Intra-Arterial Thrombolysis in the Postoperative Period
Authors: Chalela Julio A. , Katzan Irene , Liebeskind David S. , Rasmussen Peter , Zaidat Osama , Suarez Jose I. , Chiu David , Klucznick Richard P. , Jauch Edward , Cucchiara Brett L. , Saver Jeffrey , Kasner Scott E.
Published: June 2011

Background and Purpose
—Limited systemic fibrinolysis and reduced dosage are features of intra-arterial thrombolyis (IAT) that may be advantageous in the treatment of postoperative strokes. However, IAT may increase the risk of surgical bleeding. We sought to determine the safety of postoperative IAT.

Methods
—This was a retrospective case series from 6 university hospitals. All cases of IAT within 2 weeks of surgery were identified. Demographics, stroke mechanism, stroke severity, imaging and angiographic findings, time between surgery and lysis, thrombolytic agent used, surgical site bleeding, intracranial bleeding, and mortality rates were determined. Death or complications directly related to IAT were determined.

Results
—Thirty-six patients (median age, 71.5 years; range, 45 to 85) were identified. Median time from surgery to stroke was 21.5 hours (range, 1 to 120). Open heart surgery was done in 18 (50%), carotid endarterectomy in 6 (17%), craniotomy in 3 (8%), ophthalmologic–ear, nose and throat surgery in 2 (6%), urologic-gynecologic surgery in 4 (11%), orthopedic surgery in 2 (6%), and plastic surgery in 1 (3%). The stroke causes were cardioembolism in 24 (67%), large-vessel atherosclerosis in 4 (11%), dissection in 3 (8%), postendarterectomy occlusion in 4 (11%), and radiation arteriopathy in 1 (3%). Median time to angiogram was 2.5 hours (0.1 to 5.5). Occlusion sites were M1 in 19 (53%), M2 in 9 (25%), internal carotid artery in 5 (14%), basilar artery in 2 (6%), and posterior communicating artery in 1 (3%). Thrombolysis was completed at a median of 4.5 hours (range, 1 to 8.0). Tissue plasminogen activator was used in 19 (53%) and urokinase in 17 (47%). Nine (26%) patients died. Surgical site bleeding occurred in 9 (25%) cases (minor in 6, major in 3). The major surgical bleeds were 2 post–craniotomy intracranial hemorrhages and 1 hemopericardium after coronary artery bypass grafting; all were fatal. Six deaths were non-IAT related: 3 caused by cerebral edema and 3 by systemic causes. Major bleeding complications were significantly more common among patients with craniotomy (
P
<0.02).

Conclusions
—Postoperative IAT carries a risk of bleeding in up to 25% of patients but is usually minor surgical site bleeding. Avoiding IAT in intracranial surgery patients may reduce complications. Mortality rate in this series was similar to that reported in prior IAT trials. IAT remains a viable therapeutic option for postoperative strokes.
Possible Effect of DRGs on the Classification of Stroke
Authors: Derby Carol A. , Lapane Kate L. , Feldman Henry A. , Carleton Richard A.
Published: June 2011

Background and Purpose
—Accurate data on the distribution of stroke subtypes are essential for understanding the forces driving recent morbidity and mortality trends. The introduction of diagnosis-related groups (DRGs) in the 1980s may have affected the distribution of stroke subtypes as defined by
International Classification of Diseases, Ninth Revision
(ICD-9), discharge diagnosis codes.

Methods
—The Pawtucket Heart Health Program cardiovascular surveillance data were used to examine trends in stroke classification for 1980 to 1991 in relation to the introduction of DRGs in 2 communities in Massachusetts and Rhode Island, where DRGs were implemented 2 years apart. Included were all hospital discharges for residents aged 35 to 74 with a primary ICD-9 diagnosis of 431 to 432, 434, or 436 to 437 (N=1386 in Rhode Island, N=1839 in Massachusetts).

Results
—In each state, concurrently with the introduction of DRGs, the proportion of strokes classified as cerebral occlusion (ICD-9 434.0 to 434.9) increased, and the proportion classified as acute but ill-defined (ICD-9 436.0 to 436.9) decreased. Before DRGs, 30.0% of strokes in Rhode Island and 26.6% in Massachusetts were classified as cerebral occlusion, whereas 51.8% in Rhode Island and 51.7% in Massachusetts were classified as acute ill defined. After DRGs were instituted, the proportions of cerebral occlusion and acute, ill-defined stroke, respectively, were 70.9% and 8.5% in Rhode Island and 74.1% and 7.7% in Massachusetts (χ
2
, all
P
<0.001). The proportions of strokes classified as intracerebral hemorrhage or transient cerebral ischemia remained constant.

Conclusions
—The implementation of DRGs may have influenced coding of strokes to the ICD-9. Findings highlight the limitations of hospital discharge data for evaluating stroke subtypes and demonstrate the need for community-based surveillance for monitoring specific trends in stroke.
Sex Differences in Carotid Bifurcation Anatomy and the Distribution of Atherosclerotic Plaque
Authors: Schulz Ursula G.R. , Rothwell Peter M.
Published: June 2011

Background and Purpose
—Plaque formation at arterial bifurcations depends on vessel anatomy, particularly the relative sizes of the branches, and the ratio of the outflow to inflow area. The facts that carotid plaque is more common in men and that carotid bruits in the absence of stenosis are more frequent in women raise the possibility that there are sex differences in carotid bifurcation anatomy. We studied 5395 angiograms from the European Carotid Surgery Trial.

Methods
—To minimize secondary changes we excluded angiograms with ≥50% stenosis and also studied vessels with no disease. We measured arterial diameters at disease-free points and calculated the following ratios: internal/common (ICA/CCA); external/common (ECA/CCA); internal/external (ICA/ECA) carotid arteries; carotid bulb/CCA; and outflow/inflow area. We related these to sex and also studied the distribution of plaque in the whole trial population.

Results
—Among 2930 angiograms with <50% stenosis, the mean ICA/CCA ratio, ICA/ECA ratio, and outflow/inflow area ratio were larger in women than in men (all
P
<0.0001). The findings were similar in 622 bifurcations without atheroma. There were also differences in the distribution of plaque, with men more likely to have the maximum stenosis distal to the carotid bulb (odds ratio, 2.29; 95% CI, 1.33 to 4.01;
P
=0.001) and women more likely to have stenosis of the ECA (odds ratio, 1.54; 95% CI, 1.30 to 1.85;
P
<0.0001).

Conclusions
—Sex differences in carotid bifurcation anatomy are not limited to absolute vessel size. In addition, the outflow to inflow area ratio is bigger in women, and relative to the CCA and ECA, women have larger ICAs than men. Irrespective of whether these differences are congenital or acquired, they may partly explain the sex differences that we found in the distribution of plaque and the sex differences in the prevalence of carotid atheroma in the general population.
Is Patent Foramen Ovale a Family Trait?
Authors: Arquizan Caroline , Coste Joël , Touboul Pierre-Jean , Mas Jean-Louis
Published: June 2011

Background and Purpose
—Patent foramen ovale (PFO) is a frequent finding in young patients with stroke. The aim of this study was to assess whether PFO is a family trait.

Methods
—Sixty-two consecutive patients younger than 60 years of age with ischemic stroke and 62 age and gender-matched control siblings were examined by means of contrast transcranial Doppler (TCD) of the middle cerebral artery, using a standardized protocol. The reliability of TCD examination in our laboratory was assessed against transesophageal echocardiography (TEE). All TCD recordings were reviewed by a blinded experienced observer from another center. Disagreements between readers were resolved by unblinded consensus review.

Results
—Siblings of patients with PFO had a significantly higher prevalence of PFO than had siblings of patients without PFO (61.5% versus 30.6%; OR 3.64 [1.3 to 10.5];
P
=0.015). The κ statistics indicated that agreement of pairs (patients/control siblings) was not due to chance. The strength of the association was sex dependent. In women pairs, prevalence of a PFO was 76.5% in siblings of patients with PFO and 25% in siblings of patients without PFO, giving an OR of 9.8 (95% CI 2 to 47.9;
P
<0.01). In contrast, in men, no significant difference was observed in the prevalence of PFO between siblings of patients with or without PFO (respectively 33.3% and 35%), giving an OR of 0.9 (95% CI 0.2 to 4.9;
P
=0.9).

Conclusions
—This study suggests that, in women, PFO is a family trait.
Neuroprotective Effect of σ
1
-Receptor Ligand 4-Phenyl-1-(4-Phenylbutyl) Piperidine (PPBP) Is Linked to Reduced Neuronal Nitric Oxide Production
Authors: Goyagi Toru , Goto Shozo , Bhardwaj Anish , Dawson Valina L. , Hurn Patricia D. , Kirsch Jeffrey R.
Published: June 2011

Background and Purpose
—The potent σ
1
-receptor ligand 4-phenyl-1-(4-phenylbutyl) piperidine (PPBP) provides neuroprotection in experimental stroke. We tested the hypothesis that PPBP attenuates striatal tissue damage after middle cerebral artery occlusion (MCAO) by a mechanism involving reduction of ischemia-evoked nitric oxide (NO) production. Furthermore, we determined whether the agent fails to protect ischemic brain when neuronal nitric oxide synthase (nNOS) is genetically deleted or pharmacologically inhibited (selective nNOS inhibitor, 7-nitroindazole [7-NI]).

Methods
—Halothane-anesthetized adult male Wistar rats were subjected to 2 hours of MCAO by the intraluminal filament occlusion technique. All physiological variables were controlled during the ischemic insult. In vivo striatal NO production was estimated via microdialysis by quantification of local, labeled citrulline recovery after labeled arginine infusion. In a second series of experiments, nNOS null mutants (nNOSKOs) and the genetically matched wild-type (WT) strain were treated with 90 minutes of MCAO. Brains were harvested at 22 hours of reperfusion for measurement of infarction volume by triphenyltetrazolium chloride histology.

Results
—PPBP attenuated infarction volume at 22 hours of reperfusion in cerebral cortex and striatum and markedly attenuated NO production in ischemic and nonischemic striatum during occlusion and early reperfusion. Treatment with 7-NI mimicked the effects of PPBP. In WT mice, infarction volume was robustly decreased by both PPBP and 7-NI, but the efficacy of PPBP was not altered by pharmacological nNOS inhibition in combined therapy. In contrast, PPBP did not decrease infarction volume in nNOSKO mice.

Conclusions
—These data suggest that the mechanism of neuroprotection of PPBP in vivo is through attenuation of nNOS activity and ischemia-evoked NO production. Neuroprotective effects of PPBP are lost when nNOS is not present or is inhibited; therefore, PPBP likely acts upstream from NO generation and its subsequent neurotoxicity.
Negative Attitudes Among Short-Term Stroke Survivors Predict Worse Long-Term Survival
Authors: Lewis S.C. , Dennis M.S. , O’Rourke S.J. , Sharpe M.
Published: June 2011

Background and Purpose
—Patients respond to serious illness in different ways. We wished to determine whether different attitudes toward illness are associated with survival after stroke.

Methods
—Three hundred seventy-two stroke patients were identified and medically assessed as part of a randomized trial to evaluate a stroke family care worker. They had all survived 6 months from randomization. A research psychologist visited each patient and administered the Mental Adjustment to Stroke Scale (a self-rated attitude scale based on the Mental Adjustment to Cancer Scale). Disability and dependence (Barthel Index, modified Rankin Scale) and mood (Hospital Anxiety and Depression Scale, General Health Questionnaire 30) were also assessed. Patients were followed up in 1998 (3 to 5 years after the initial stroke) to establish their survival. We modeled the relationship between Mental Adjustment to Stroke scores and survival, adjusting for other factors associated with stroke survival.

Results
—Eighty-two patients (22%) died within 3 years. After adjustment for other significant factors, fatalism and helplessness/hopelessness were both associated with decreased survival (
P
=0.03 and 0.04, respectively), but fighting spirit, anxious preoccupation, and denial/avoidance were not. Mood was not associated with survival.

Conclusions
—Patients’ attitudes toward their illness seem to be associated with survival after stroke. Patients who feel that there is nothing they can do to help themselves 6 months after a stroke have a shorter survival. These findings need to be confirmed and any causal relationship between attitude and survival further explored in a randomized controlled trial to “improve” the attitude of stroke patients toward their illness.
Threshold Duration of Ischemia for Myogenic Tone in Middle Cerebral Arteries
Authors: Cipolla Marilyn J. , Lessov Nikola , Hammer Erica S. , Curry Amy B.
Published: June 2011

Background and Purpose
—We investigated the effect of different periods of ischemia on the myogenic tone of middle cerebral arteries (MCAs) and tested the hypothesis that ischemia disrupts the actin cytoskeleton in vascular smooth muscle.

Methods
—The MCA occlusion model was used in male Wistar rats (n=27) to induce different periods of ischemia (15, 30, and 120 minutes) with 24 hours of reperfusion. Successful occlusion was determined by laser-Doppler flowmetry. MCAs were then studied in vitro with a specialized arteriograph system that allowed control of transmural pressure and measurement of lumen diameter. After equilibration for 1 hour at transmural pressure of 75 mm Hg, lumen diameter was measured, and the amount of spontaneous myogenic tone was determined. Arteries were then fixed with 10% formalin while still pressurized in the arteriograph bath and stained for filamentous (F-) actin with fluorescently labeled phalloidin, a specific probe for F-actin. The amount of F-actin was quantified by confocal microscopy.

Results
—The amount of tone was similar between control and 15 minutes of ischemia (27.0±2.0% and 25.3±1.7%, respectively;
P
>0.05) but was significantly diminished after 30 and 120 minutes (11.7±2.0% and 8.5±2.0%, respectively;
P
<0.01 versus control). F-actin content also decreased at the longer ischemic periods and correlated significantly with vascular tone (
P
=0.04) such that the lesser the tone, the lesser was the F-actin content. Fluorescence intensity for control and 15, 30, and 120 minutes of ischemia was (×10
7
) 3.21±0.25, 2.54±0.32 (
P
>0.05), 2.32±0.15 (
P
<0.01), and 2.22±0.16 (
P
<0.01), respectively.

Conclusions
—These results demonstrate that ischemia disrupts the actin cytoskeleton in smooth muscle and diminishes vascular tone of MCAs in a threshold-dependent manner. This effect likely exacerbates brain tissue damage during stroke, including infarction and edema formation.
Race-Ethnic Disparities in the Impact of Stroke Risk Factors
Authors: Sacco Ralph L. , Boden-Albala Bernadette , Abel Gregory , Lin I-Feng , Elkind Mitchell , Hauser W. Allen , Paik Myunghee C. , Shea Steven
Published: June 2011

Background and Purpose

—

Stroke risk factors have been determined in large part through epidemiological studies in white cohorts; as a result, race-ethnic disparities in stroke incidence and mortality rates remained unexplained. The aim in the present study was to compare the prevalence, OR, and etiological fraction (EF) of stroke risk factors among white, blacks, and Caribbean Hispanics living in the same urban community of northern Manhattan.

Methods

—

In this population-based incident case-control study, cases (n=688) of first ischemic stroke were prospectively matched 1:2 by age, sex, and race-ethnicity with community controls (n=1156). Risk factors were determined through in-person assessment. Conditional logistic regression was used to calculate adjusted ORs in each race-ethnic group. Prevalence and multivariate EFs were determined in each race-ethnic group.

Results

—

Hypertension was an independent risk factor for whites (OR 1.8, EF 25%), blacks (OR 2.0, EF 37%), and Caribbean Hispanics (OR 2.1, EF 32%), but greater prevalence led to elevated EFs among blacks and Caribbean Hispanics. Greater prevalence rates of diabetes increased stroke risk in blacks (OR 1.8, EF 14%) and Caribbean Hispanics (OR 2.1
P
<0.05, EF 10%) compared with whites (OR 1.0, EF 0%), whereas atrial fibrillation had a greater prevalence and EF for whites (OR 4.4, EF 20%) compared with blacks (OR 1.7, EF 3%) and Caribbean Hispanics (OR 3.0, EF 2%). Coronary artery disease was most important for whites (OR 1.3, EF 16%), followed by Caribbean Hispanics (OR 1.5, EF 6%) and then blacks (OR 1.1, EF 2%). Prevalence of physical inactivity was greater in Caribbean Hispanics, but an elevated EF was found in all groups.

Conclusions

—

The prevalence, OR, and EF for stroke risk factors vary by race-ethnicity. These differences are crucial to the etiology of stroke, as well as to the design and implementation of stroke prevention programs.
Effect of Hemiparetic Stroke on Pulse Oximetry Readings on the Affected Side
Authors: Roffe Christine , Sills Sheila , Wilde Kathryn , Crome Peter
Published: June 2011

Background and Purpose

—

Hypoxia is common after stroke, and monitoring by pulse oximetry is suggested in the acute phase. Physical changes on the affected side or intravenous infusions may affect oximeter readings. This study was designed to test whether pulse oximetry recordings are the same on the affected and nonaffected sides in stroke patients.

Methods

—

Oxygen saturation (Sp
o
2
) and heart rate (HR) were assessed simultaneously in the left and right hands in patients with hemiparetic stroke over a 3-hour period with 2 Minolta Pulsox-3i oximeters attached to the index fingers.

Results

—

Fifteen patients (53% men; 67% left hemiparesis; mean age, 73 years [SD, 7.5 years]) were recruited. HR and Sp
o
2
(12 measurements per minute) were monitored. The maximum difference between simultaneous left and right arm readings was 2% Sp
o
2
. HR fluctuated more, but no affected/nonaffected side pattern was seen. Means for each patient of HR and Sp
o
2
for the affected and nonaffected sides were compared by
t
tests. Mean Sp
o
2
was 96% (SD, 1%) on both sides. Mean HR was 81 bpm (SD, 11 bpm) on the affected side and 80 bpm (SD, 10 bpm) on the nonaffected side. There was no significant difference between the 2 sides for either parameter (n=15;
P
=0.86 for Sp
o
2
and
P
=0.91 for HR).

Conclusions

—

Oximeters can be attached to either the affected or nonaffected side in hemiparetic stroke.
Treatment With Tissue Plasminogen Activator and Inpatient Mortality Rates for Patients With Ischemic Stroke Treated in Community Hospitals
Authors: Reed Shelby D. , Cramer Steven C. , Blough David K. , Meyer Kerry , Jarvik Jeffrey G.
Published: June 2011

Background and Purpose

—

Most analyses of intravenous tissue plasminogen activator (IV tPA) use for acute stroke in routine practice have been limited by sample size and generally restricted to patients treated in large academic medical facilities. In the present study, we sought to estimate among community hospitals the use of IV tPA and to identify factors associated with the use of IV tPA and inpatient mortality.

Methods

—

We evaluated a retrospective cohort of 23 058 patients with ischemic stroke from 137 community hospitals.

Results

—

Three hundred sixty-two (1.6%) patients were treated with IV tPA, and 9.9% of those patients died during the hospitalization period. In 35.0% of the hospitals, no patients were treated with IV tPA, whereas 14.6% of hospitals treated ≈3.0% with IV tPA. After control for multiple factors, younger patients, more severely ill patients (OR 2.02, 95% CI 1.36 to 3.01), and patients treated in rural hospitals (OR 1.80, 95% CI 0.99 to 3.26) were more likely to receive IV tPA, whereas black patients were less likely (OR 0.54, 95% CI 0.31 to 0.95). There also was a trend showing that women were less likely to receive IV tPA (OR 0.84, 95% CI 0.69 to 1.03). Factors associated with an increased odds of inpatient mortality included receipt of IV tPA among men (OR 2.81, 95% CI 1.72 to 4.58) and increased age. Black patients were 27% less likely to die during hospitalization (95% CI 0.60 to 0.90).

Conclusions

—

In this large, retrospective evaluation of community hospital practice, the use IV tPA and inpatient mortality rates among IV tPA–treated patients were consistent with those of other studies. The likelihood of receiving IV tPA varies by race, age, disease severity, and possibly gender. These factors may influence mortality rates.
Endovascular Treatment of Symptomatic Carotid Stenosis Using Stent Placement
Authors: Dietz Andreas , Berkefeld Joachim , Theron Jacques G. , Schmitz-Rixen Thomas , Zanella Friedhelm E. , Turowski Bernd , Steinmetz Helmuth , Sitzer Matthias
Published: June 2011

Background and Purpose

—

Carotid endarterectomy (CEA) is not necessarily beneficial in all patients with symptomatic high-grade (≥70%) internal carotid artery (ICA) stenosis. Independent risk factors modulate both the individual stroke risk under medical treatment and the combined stroke and death risk after CEA. Endovascular stenting of symptomatic ICA stenosis may be an alternative to CEA in patients with a balanced surgical risk/benefit ratio.

Methods

—

We included 43 patients (71% men; median age, 67 years) with a recently symptomatic ICA stenosis with ≥70% luminal narrowing in whom the individual sum of medical and surgical risk factors suggested a balanced surgical risk/benefit ratio (risk-modeling appraisal derived from the European Carotid Surgery Trial). After stenting of the stenosed ICA with distal balloon protection, the mean±SD follow-up, including clinical and ultrasonographic examinations, was 20±11.8 months, with a median number of examinations of 5 per patient.

Results

—

Recanalization of ICA stenoses was technically successful in 40 of 43 procedures (93%). Within the 30-day postinterventional period 1 death occurred (2.5%), and the combined stroke and death rate within follow-up was 5%. Except for 1 asymptomatic ICA occlusion, no restenosis ≥70% occurred during follow-up.

Conclusions

—

ICA stenting in symptomatic patients with a balanced surgical risk/benefit ratio is technically feasible, with a low periprocedural risk of stroke or death. Furthermore, the risk of future stroke and rate of significant restenosis during long-term follow-up appears to be low, suggesting that ICA stenting may be useful in carotid revascularization and stroke prevention.
Nimodipine Increases Fibrinolytic Activity in Patients With Aneurysmal Subarachnoid Hemorrhage
Authors: Roos Y.B.W.E.M. , Levi M. , Carroll T.A. , Beenen L.F.M. , Vermeulen M.
Published: June 2011

Background and Purpose

—

The purpose of this study was first, to investigate which factor in the fibrinolytic cascade is responsible for the recently observed increase of fibrinolytic activity in patients with aneurysmal subarachnoid hemorrhage (SAH), and second, the cause of this increase.

Methods

—

Fibrinolytic activity and the main regulators of endogenous fibrinolytic activity, tissue plasminogen activator, and plasminogen activator inhibitor 1 (PAI-1) were measured in patients treated with and without nimodipine.

Results

—

In patients with aneurysmal SAH, fibrinolytic activity significantly increases from 2.7 IU/mL on admission to 4.2 IU/mL in week 3 (
P
<0.01, paired-sample
t
test), caused by a 1.6-fold decrease in plasma levels of PAI-1. The results also show that increased fibrinolytic activity is seen only in patients treated with nimodipine and that plasminogen activity and PAI-1 returned to baseline levels after treatment with nimodipine had been discontinued.

Conclusions

—

The mechanism of increased fibrinolytic activity in patients with aneurysmal SAH is a decrease in the level of PAI-1, which is most likely caused by treatment with nimodipine.
Natural History of Stroke in Rochester, Minnesota, 1955 Through 1969: An Extension of a Previous Study, 1945 Through 1954
Authors: MATSUMOTO NOBUTERU , WHISNANT JACK P. , KURLAND LEONARD T. , OKAZAKI HARUO
Published: June 2011

This study has attempted to identify all patients in the population of Rochester, Minnesota, who had stroke during the period 1955 through 1969, and to determine the course and survival of patients who have had stroke. Cerebral infarction from all causes, including embolic infarction, accounted for 79% of all strokes. Intracerebral hemorrhage accounted for 10% of the cases, and subarachnoid hemorrhage accounted for 6%. The average annual incidence rate for the 15 years of the study was 164 per 100,000 population per year. The rates for all strokes and for cerebral infarction were significantly higher for men than for women, except in the youngest age group. After the end of an earlier study, 1945 through 1954, the average annual incidence rate for all strokes decreased in each succeeding five-year interval and reached 141 during the period 1965 through 1969. The decrease in rates is apparent for all strokes and for cerebral infarction, and is more apparent for women than for men. The prevalence rate on January 1, 1960, and January 1, 1965, of about 700 per 100,000 population was higher than the rate for January 1, 1970, reflecting decreasing incidence rates. A study of the functioning capacity of survivors of stroke after six months indicates that only 4% required total care and nearly 30% were functioning normally. Fifty-four percent had some neurological deficit that may have been benefited by rehabilitative care. Aphasia was an important residual incapacity in 10%. The first-year recurrence rate of stroke was 10%, and the five-year recurrence rate was 20%. Among patients with stroke who died, 38% died of the initial stroke, 10% of a subsequent stroke, and 18% of heart disease. During the 25-year period, 1945 through 1969, there has been a trend toward gradually increasing survival for cerebral infarction in this community.
Anatomy of the Middle Cerebral Artery: The Temporal Branches
Authors: DELONG W. BRADFORD
Published: June 2011

Nineteen out of 23 middle cerebral arterial specimens had as the first major branch of the middle cerebral artery a sizable anterior temporal artery; a trunk forming the anterior and middle temporal branches; a trunk forming the anterior, middle, and posterior temporal arteries; or a trunk forming temporal and angular arterial branches.

Patients harboring middle cerebral stenoses or occlusions who have correlating cerebral ischemic symptoms may be considered as candidates for microsurgical cerebral revascularization. However, if such patients undergo intracranial surgery, the superficial temporal artery should probably be joined to a supra-Sylvian arterial branch, rather than to a temporal arterial branch, in order to avoid delivering the new blood supply proximal to the stenotic or occluded segment.
Left Atrial Myxoma as a Neurological Problem: A Case Report and Review
Authors: STEINMETZ EDWARD F. , CALANCHINI PHILIP R. , AGUILAR MARY JANE
Published: June 2011

A puzzling neurological illness in a patient with a clinically normal heart was explained at autopsy by cerebral embolization from a left atrial myxoma (LAM). Constitutional symptoms associated with LAM were present. Cerebral angiography revealed aneurysms and focal areas of abnormal blushing. Cerebral and cardiac pathology is presented.

The surgical follow-up of seven other cases is reported to determine the "curability" of such tumors.

We believe that echocardiography should be performed in any case of suspected cerebral embolization even though cardiac symptoms and signs may be absent.
A Simplified Technique for Cannulation of the Jugular Bulb
Authors: GRIFFITHS D. P. G. , GREENBAUM R.
Published: June 2011

A method of jugular bulb cannulation is discussed which is quick and easy to perform, ensures accurate placement of the catheter tip and causes minimal discomfort to the patient. Advantages of this technique are discussed.
Hypertension and Risk of Stroke in an Elderly Population
Authors: SHEKELLE RICHARD B. , OSTFILD ADRIAN M. , KLAWANS HAROLD L.
Published: June 2011

The contribution of hypertension to risk of all strokes and of nonembolic brain infarction in elderly black and white men and women is examined.

The results of the Chicago Stroke Study show that hypertension is significantly associated with increased risk of nonembolic brain infarction, as well as all stroke, in this population of elderly black and white men and women. It is possible that 25% or more of the total incidence of stroke in persons 65 to 74 years of age may be attributable to hypertension.
The Effect of Graded Hypocapnia and Hypercapnia on Regional Cerebral Blood Flow and Cerebral Vessel Caliber in the Rhesus Monkey: Study of Cerebral Hemodynamics Following Subarachnoid Hemorrhage and Traumatic Internal Carotid Spasm
Authors: PETRUK K. C. , WEIR B. K. , OVERTON T. R. , MARRIOTT M. R. , GRACE M. G.
Published: June 2011

Correlative cerebral blood flow (CBF) and vessel diameter studies were performed during graded Paco, change in control monkeys and in monkeys subjected to subarachnoid hemorrhage and internal carotid artery spasm.

In the control series CBF increased linearly between Pa

CO
CO2

values of 30 mm Hg and 60 mm Hg. An increase in Pa

CO
CO2

from 40 mm Hg to 62 mm Hg produced a mean CBF increase of 74% while a reduction of Pa

CO
CO2

to 25 mm Hg resulted in a decrease of 40%. Cerebral gray matter was more responsive to Pa

CO
CO2

change than white matter. Caliber of the larger capacitance vessels did not provide an adequate index of the status of cerebral circulation.

In the experimental series both SAH and traumatic internal carotid artery spasm caused a decreased hemodynamic responsiveness to Pa

CO
CO2

. However, when Pa

CO
CO2

was raised to 60 to 65 mm Hg, marked increases in cerebral perfusion occurred (breakthrough phenomenon). In general, a poor correlation between CBF and vessel diameter studies was found in the postinsult period.

The studies indicated: (1) SAH caused an increase in cerebrovascular resistance and a decrease in CBF, (2) hemodynamic responses to Pa

CO
CO2

change, although diminished, were not abolished in the acute period after SAH, (3) hypercapnia (Pa

CO
CO2

> 60 mm Hg) significantly increased cerebral perfusion whether or not vasospasm was alleviated, and (4) the small distal cerebral vessels were more reactive to Pa

CO
CO2

change and were more intimately associated with regulation of cerebral perfusion.
The Effect of Acute Stroke on Cardiac Functions as Observed in an Intensive Stroke Care Unit
Authors: LAVY SYLVAN , YAAR ISRAEL , MELAMED ELDAD , STERN SHLOMO
Published: June 2011

Fifty-two stroke patients, 43 with cerebral ischemia and nine with cerebral hemorrhage, underwent continuous cardiac monitoring in an Intensive Stroke Care Unit shortly after the onset of the acute cerebrovascular accident. In the group of patients with no evidence of pre-existing heart disease, eight of 18 with cerebral ischemia and five of seven with hemorrhage developed ECG abnormalities. Additional ECG changes were noted in 21 of 25 patients with cerebral ischemia and two of two with hemorrhage who were known to have previous heart disease. Both disturbances in rhythm and conduction and "ischemic" ST-T alterations were detected and the frequency of the former exceeded that of the latter. The ECG alterations were transient in 32 patients and permanent in four. New electrocardiographical abnormalities in patients without evidence of heart disease prior to the stroke were associated with poorer prognosis. The pathogenetic mechanisms leading to the appearance of cardiac abnormalities in stroke patients are considered.
Stroke in the Young: A Four-Year Study, 1968 to 1972
Authors: JANAKI S. , BARUAH J. K. , JAYARAM S. R. , SAXENA V. K. , SHARMA S. R. , GULATI M. S.
Published: June 2011

Twenty-six patients under 20 years of age having cerebrovascular disease were studied from 1968 to 1972. Common risk factors such as hypertension, diabetes mellitus, hyperlipidemia and heart disease were not present. Angiographical study showed a variety of abnormalities. No consistent defect was present.

There was a high incidence of pyrexia and convulsions in the early stages of stroke and it appears possible that some form of arteritis might have been important in the production of the cerebral infarction.
Increased Platelet Aggregates in Patients With Transient Ischemic Attacks
Authors: WU KENNETH K. , HOAK JOHN C.
Published: June 2011

In order to evaluate the pathogenetic importance of platelet aggregates in cerebrovascular disease, a platelet count ratio method was used to study 66 patients with transient ischemic attacks (TIAs). Thirty normal subjects and 22 patients without thromboembolic disorders were also included as controls. The mean platelet aggregate ratio of the TIA group was 0.75 ± 0.03 SEM which was significantly lower than that of normal subjects (0.90 ± 0.02) or patient controls (0.88 ± 0.01) (P < 0.01). Seventeen patients with TIA were then treated with aspirin (1,200 mg) and dipyridamole (200 mg) daily. The platelet aggregate ratios were normalized in 13 patients. Of four patients who did not respond to this regimen, one did respond to sulfinpyrazone. When sulfinpyrazone was discontinued, recurrence of symptoms was preceded by an increase in platelet aggregates. These findings suggest that platelet aggregates may play an important role in the pathogenesis of cerebrovascular insufficiency. The determination of platelet aggregates appears useful in selecting patients for antiplatelet therapy.
Cerebrospinal Fluid in Cerebral Hemorrhage and Infarction
Authors: LEE MYOUNG C. , HEANEY LOIS M. , JACOBSON RONALD L. , KLASSEN ARTHUR C.
Published: June 2011

Cerebrospinal fluid (CSF) abnormalities were correlated with pathological diagnoses in 61 patients with autopsy-verified intracerebral hemorrhage or cerebral infarction. Lumbar punctures were performed within one week of onset of symptoms. The CSF color and red blood cell counts were the most useful CSF parameters in differentiating between intracerebral hemorrhage and cerebral infarction. In 75% of the patients with intracerebral hemorrhage, the CSF was either grossly bloody or xanthochromic; in 25%, the CSF was clear. In patients with cerebral infarction, the CSF was never grossly bloody; in two patients with hemorrhagic infarction, the CSF was xanthochromic. The CSF pressure, protein values and leukocyte counts were less useful in differentiating intracerebral hemorrhage from cerebral infarction. Cases with hemorrhagic infarction could not be separated from those with ischemic infarction on the basis of CSF analysis. In clear CSF, the polymorphonuclear neutrophilic leukocyte (PNL) counts were never greater than 20 per cubic millimeter. In xanthochromic or cloudy CSF, leukocyte counts, especially PNLs, were frequently elevated, occasionally to high levels.
Determinants of Response of Pial Arteries to Norepinephrine and Sympathetic Nerve Stimulation
Authors: WEI ENOCH P. , RAPER A. JARRELL , KONTOS HERMES A. , PATTERSON JOHN L.
Published: June 2011

Feline pial arteries larger than 100 µ in diameter constricted in response to cervical sympathetic nerve stimulation or in response to topical application of norepinephrine. Smaller pial arteries were unresponsive to norepinephrine. This unresponsiveness persisted when norepinephrine was dissolved in CSF with high calcium ion concentration, or in CSF with both high calcium ion and zero magnesium ion concentration, or when it was dissolved in the acid fluid used by Wahl et al. and applied by constant infusion or by intermittent application. Comparison of the responses of the larger pial vessels to norepinephrine and to sympathetic nerve stimulation suggests that maximal activation of sympathetic nerves achieves a concentration of released norepinephrine equal to 5.9 x 10
-4
M. The constriction of the larger pial vessels in response to sympathetic nerve stimulation could account for modest reductions in cerebral blood flow.
Surgical treatment of primary intracerebral hemorrhage- Part 1: new angiographical classification.
Authors: Mizukami M , Kin H , Araki G , Mihara H , Yoshida Y
Published: June 2011

A new angiographical classification of primary intracerebral hemorrhage is presented. We have clarified the predilection sites of intracerebral hemorrhage and the advancing direction of the hematoma by studying autopsy cases. Furthermore, we tried to detect the presence or absence of destruction of the internal capsule and ventricular rupture by means of angiography. Our classification, introducing the idea of dynamic changes of hematoma advancement from localized to advanced type, can be applied to clinical practice. This classification, along with the patient's level of consciousness, it felt to be the most important indication for operation.
Heterogeneities of regional cerebral blood flow during hypoxia-ischemia in the rat.
Authors: Ginsberg M D , Medoff R , Reivich M
Published: June 2011

The distribution of regional cerebral blood flow (rCBF) within the cerebral hemispheres of rats was investigated following an hypoxic-ischemic insult consisting of a 30-minute exposure to 6.5% to 7% inspired oxygen coupled with unilateral ligation of the common carotid artery and maintenance of normal blood pressure (modified Levine preparation). rCBF was estimated by means of an autoradiographic method employing 14C-antipyrine. Mean arterial PO2 values of 26.8 to 27.5 mm Hg were attained during the insult period. rCBF rose above control values in all structures of the hemisphere contralateral to carotid artery ligation. Structures of the hemisphere ipsilateral to arterial ligation exhibited rCBF values less than those of the opposite side. However, the degree to which carotid artery occlusion reduced the rCBF of a structure relative to that of the opposite hemisphere varied greatly from region to region, with the greatest decrements occurring in the lateral cerebral cortex and the caudoputamen. Previous studies in this model have shown that these regions of the hemisphere ipsilateral to carotid artery occlusion are zones of frequent histological injury. These data suggest that inhomogeneities of rCBF may in part determine the phenomenon of "selective vulnerability" of the nervous system to hypoxia-ischemia.
Epidemiology of cerebrovascular disease in Tartu, Estonia, USSR, 1970 through 1973.
Authors: Zupping R , Roose M
Published: June 2011

This study was undertaken to establish the incidence and mortality for various types of cerebrovascular disease in the population of Tartu. All medical records for this population were reviewed for the period 1970 through 1973, and those with a diagnosis of brain infarction, transient ischemic attacks, cerebral hemorrhage or subarachnoid hemorrhage were identified. Only the first stroke was considered when determining incidence. A total of 786 cases were included in the study. Without cases of transient ischemic attacks, the number was 667 (e.g., cases of stroke). Cerebral infarction accounted for 80% of all strokes, cerebral hemorrhage for 13.5% and subarachnoid hemorrhage for 6.5%. The incidence rate for stroke was higher for men than for women and significantly increased in each older age group. The rate for all persons was 184 per 100,000 population per year. The incidence of transient ischemic attacks was 33 per 100,000 population per year. The mortality rate for stroke for this population was 98/100,000 per year. The data on incidence of stroke and its type, its dependence on age and sex, and mortality rate are close to the corresponding data reported from other countries.
Total and regional cerebral blood flow during stimulation of carotid baroreceptors.
Authors: Heistad D D , Marcus M L
Published: June 2011

The concept that reflex control of cerebral vessels is unimportant has been challenged by recent studies which suggest that carotid baroreceptors have an important role in regulation of cerebral blood flow (CBF). In this study we have tested the hypothesis that arterial baroreceptors contribute to regulation of total or regional CBF. CBF was measured in anesthetized dogs with 15 mu microspheres. Stimulation of carotid baroreceptors, by raising carotid sinus pressure, did not alter or redistribute cerebral flow. Responses to baroreceptor stimulation were intact, as manifested by vasodilation in skeletal muscle. CBF decreased during systemic hypocapnia and increased during hypercapnia, which indicates that failure of cerebral flow to change during baroreceptor stimulation was not due to unresponsiveness of cerebral vessels. During hypercapnia, baroreceptor stimulation also failed to alter CBF. In other studies CBF was measured during increases in systemic arterial pressure, before and after denervation of arterial baroreceptors. Increases in arterial pressure did not increase CBF either before or after denervation of baroreceptors. We conclude that baroreceptor stimulation does not alter total or regional CBF and that baroreceptors do not regulate cerebral flow during systemic hypertension.
Comparison of Local Blood Flow and Oxygen Availability at the Same Locus in the Ischemic Gerbil Brain
Authors: KELLY ROGER A. , HALSEY JAMES H.
Published: June 2011

Oxygen availability (O
2
a) and local cerebral blood flow (CBF) as H
2
clearance were measured at the same point, taking advantage of the sensitivity of the platinized platinum electrode to both H
2
and O
2
in gerbils following ischemia made by transient bilateral carotid artery ligations. Both O
2
a and CBF were zero during carotid ligation. During postischemic reperfusion there was a qualitative correlation between the two, with a tendency for the O
2
a recovery to be less than that of CBF in the first hour and greater in the second hour. These differences in the time course of O
2
a and cerebral blood flow may be accounted for by altered oxygen consumption in relation to tissue perfusion, or by altered oxygen sensitivity of the electrode. The results demonstrated the feasibility of making oxygen and flow measurements at the same point in tissue.
Reversibility of the chronic post-stroke state.
Authors: Holbach K H , Wassmann H W , Hohelüchter K L
Published: June 2011

Forty patients with cerebral infarction associated with occlusion of the internal carotid artery (ICA) or the middle cerebral artery (MCA) were treated with hyperbaric oxygenation (HO). EEG analyses were performed regularly in order to assess the course of the cerebral lesion. Patients in an early post-stroke stage (III B) and patients in a chronic post-stroke stage (IV) had the changes in EEG analysis and neurological distributed evenly between these two groups.
Noninavasive angiography for the diagnosis of carotid artery disease using Doppler ultrasound (carotid artery Doppler).
Authors: Keller H , Meier W , Yonekawa Y , Kumpe D
Published: June 2011

To detect stenosis in the carotid artery with a bidirectional continuous-wave Doppler ultrasound device, the following noninvasive procedure, applied on 800 patients and compared with 249 angiograms of 186 patients, has proved to be about 90% reliable. Measurements of flow signals were taken over the terminal branches of the ophthalmic artery (supratrochlear and supraorbital arteries) and averaged. Compression of superficial temporal and facial arteries revealed flow direction and common carotid artery compression revealed the supplying blood vessel and the effectiveness of the circle of Willis. Measurements over the common carotid arteries were used to evaluate peripheral resistance. A set of eight criteria was used; the diagnostic value of each criterion was calculated by comparing 138 pathological Doppler findings in 123 patients with the angiograms. If reverse flow direction in supratrochlear or supraorbital artery was used alone, only 43% correct diagnoses would have resulted. A more severe stenosis is not necessarily correlated with a more weighted criterion; a subset of criteria is less efficient than the combination of all criteria. Application during 32 extracranial endarterectomies on 28 patients informed the surgeon immediately about the hemodynamic effect of the surgical intervention. Rethrombosis was diagnosed in two patients by postoperative Doppler examination.
The reliability of clinical predictors of extracranial artery disease.
Authors: Lemak N A , Fields W S
Published: June 2011

The records of 628 patients admitted to the Joint Study of Extracranial Arterial Occlusion with transient symptoms of carotid system ischemic disease were examined to determine the accuracy of predicting disease of the extracranial internal carotid artery on the basis of clinical information alone. A patient with a history of episodes of amaurosis fugax is more likely to have a lesion of the internal carotid artery on the same side than if he were having only transient cerebral ischemic attacks. In patients with transient symptoms and a carotid bruit on the appropriate side, the incidence of an angiographically normal carotid artery was 15%. In those patients with transient symptoms and no palpable pulsation in the cervical region on the appropirate side, the incidence of an angiographically normal carotid artery was zero.
Prognosis of patients with middle cerebral artery occlusion.
Authors: Kaste M , Waltimo O
Published: June 2011

The long-term prognosis of 78 stroke patients with occlusion of the middle cerebral artery (MCA) or its branches is described. The mean age of the patients was 44 years. The mortality rate in the acute phase was 5%. The acute and total mortality rates of men were higher than those of women (p less than 0.05). Life-table analysis gave 94% probability for one year's survival, 84% for three years' survival, and 78% for five years' survival. Subsequent strokes were twice as common as cardiovascular events as the cause of death. Seventy-two percent of the survivors became fully independent in activities of daily living (ADL) , 27% required assistance, 1% was totally disabled, and 43% returned to work. Left-sided occlusion was overrepresented in those who died (p less than 0.00(1) and those who returned to work (p less than 0.05), and right-sided occlusion was overrepresented in those who required assistance in ADL (p less than 0.05).
Cerebrovascular CO2 reactivity in normotensive and hypertensive man.
Authors: Tominaga S , Strandgaard S , Uemura K , Ito K , Kutsuzawa T
Published: June 2011

Cerebrovascular reactivity to CO2 inhalation and voluntary hyperventilation was studied in seven normotensive subjects and nine hypertensive patients without clinical or angiographical signs of arteriosclerosis. Cerebral blood flow (CBF) was measured by the intracarotid 133Xe clearance method and calculated as the initial slope index. Three to five CBF measurements were made in each patient in the PaCO2 range of 20 to 55 mm Hg. No difference was observed in reactivity between hypertensive and normotensive patients, either during CO2 inhalation or during hyperventilation. The shape of the CBF:PaCO2 curve suggested a decrease in reactivity below a PaCO2 of 30 to 35 mm Hg in both groups. Above a PaCO2 of 35 mm Hg, exponential regression analysis yielded a mean reactivity of 6 +/- 2%, whereas below a PaCO2 of 30 mm Hg it was about 2%. The rise in CBF during CO2 inhalation was not influenced by the intravenous infusion of a small dose of trimethaphan which blocked the concomitant rise in blood pressure.
Intracranial fibromuscular dysplasia: report of two cases, one with autopsy verification.
Authors: Rinaldi I , Harris W O , Kopp J E , Legier J
Published: June 2011

We report two patients with fibromuscular dysplasia (FMD) involving intracranial arteries. In the first patient the diagnosis was made at autopsy. Both patients were symptomatic from this disease and, in addition, displayed unusual hormonal abnormalities which may well have contributed to the genesis or evolution of FMD.