bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of Surgical Revascularization on Outcome of Patients With Pediatric Moyamoya Disease
Authors: Ishikawa Tatsuya , Houkin Kiyohiro , Kamiyama Hiroyasu , Abe Hiroshi
Published: June 2011

Background and Purpose
We reviewed surgically treated patients with pediatric moyamoya disease and examined whether vasoreconstructive surgeries reduced the risk of recurrent ischemic attacks and changed overall outcomes in terms of the patients’ performance and intellectual status.

Methods
Sixty-four hemispheric sides in 34 pediatric moyamoya disease patients who received surgical treatment were examined. We performed superficial temporal artery to middle cerebral artery (STA-MCA) bypass and encephalo-duro-arterio-myo-synangiosis (EDAMS) on 48 sides (combined group) and indirect bypass surgery such as EDAMS on 16 sides (indirect group). These 34 patients were observed postoperatively from 1 to 14 years (mean±SD, 6.6±3.8 years) and were examined for the incidence of recurrent ischemic attack. Of the 34 patients, 23 were followed up for >5 postoperative years, and their overall outcomes in terms of their performance and intellectual status were determined.

Results
Perioperative ischemic events (≤2 weeks after surgery) occurred in 5 surgeries (31%) of the indirect group and in 6 (13%) of the combined group (
P
=NS). The incidence of postoperative ischemic events (>2 weeks after surgery) was significantly reduced in the combined group (10%) compared with the indirect group (56%;
P
<.01). Of the 23 patients observed >5 years, 7 patients (30%) were mentally retarded and regarded as having a fair outcome.

Conclusions
Combined surgery (STA-MCA bypass with EDAMS) for pediatric moyamoya disease was effective in reducing the risk of postoperative ischemic attacks compared with indirect surgery. Surgical revascularization may be effective in preventing intellectual deterioration and improving overall outcome.
Effect of Pco
2
Changes Induced by Head-Upright Tilt on Transcranial Doppler Recordings
Authors: Cencetti Simone , Bandinelli Gabriele , Lagi Alfonso
Published: June 2011

Background and Purpose
Transcranial Doppler (TCD) monitoring of mean blood flow velocity (mV) during head-upright tilt can allow testing of cerebral autoregulation. Nonetheless, head-upright tilt can induce changes in the ventilation-perfusion relationship and/or respiratory activity that might influence TCD data.

Methods
Forty-eight healthy volunteers underwent monitoring of mV and end-tidal CO
2
in the horizontal position and during head-upright tilt.

Results
Both mV and end-tidal CO
2
significantly decreased in orthostasis (
P
<.01). Linear regression analysis showed a significant linkage between end-tidal CO
2
and mV changes (
r
=.83,
P
<.01).

Conclusions
Changes in ventilation-perfusion ratio and in the respiratory pattern induced by head-upright tilt can significantly influence TCD data by determining a P
co
2
decrease.
Doppler Microembolic Signals in Children With Prosthetic Cardiac Valves
Authors: Georgiadis D. , Preiss M. , Lindner A. , Gybels Y. , Zierz S. , Zerkowski H. R.
Published: June 2011

Background and Purpose
The aim of this study was the evaluation of the prevalence and counts of Doppler microembolic signals (MES) in children with prosthetic cardiac valves and their comparison to those obtained in corresponding adult patients.

Patients and Methods
Nine children and 43 adults with ATS valves implanted in the aortic position were monitored over both middle cerebral arteries with transcranial Doppler ultrasound. MES were identified on-line according to standard criteria. Heart rate and rhythm, valve type, size and duration, patients’ height, International Normalized Ratio, and prevalence of neurological complications were obtained from all study participants.

Results
MES prevalence and counts were significantly higher in children compared with adult patients (100% versus 25.5% and 58 [18.5 to 115.5] versus 5.5 [2 to 10.5], median, 95% CI, respectively). No corresponding differences in valve size or duration of valve implant were evident, but children had faster heart rates and were significantly smaller compared with adults. A positive correlation between patients’ size, heart rate, and MES counts was noted.

Conclusions
MES counts in children with mechanical prosthetic valves are significantly higher compared with those in corresponding adults. We hypothesize that this is due to (1) the shorter distance between aortic valve and middle cerebral artery, since cavitation bubbles have a short life span and are bound to dissolve with time, and (2) the faster heart rate in children, resulting in a higher number of valve closures per minute.
Effects of the Allosteric Modification of Hemoglobin on Brain Oxygen and Infarct Size in a Feline Model of Stroke
Authors: Watson Joe C. , Doppenberg Egon M. R. , Bullock M. Ross , Zauner Alois , Rice Melody R. , Abraham Donald , Young Harold F.
Published: June 2011

Background and Purpose
Cerebral ischemia and stroke are leading causes of morbidity and mortality. An approach to protecting the brain during ischemia is to try to increase the delivery of oxygen via the residual blood flow through and around ischemic tissue. To test this hypothesis, we used a novel oxygen delivery agent, RSR-13 (2-[4-[[(3,5-dimethylanilino)-carbonyl]-methyl]phenoxy]-2-methylpropionic acid). Intravenous administration of RSR-13 increases oxygen delivery through allosteric modification of the hemoglobin molecule, resulting in a shift in the hemoglobin/oxygen dissociation curve in favor of oxygen delivery.

Methods
We studied RSR-13 in a feline model of permanent middle cerebral artery occlusion to assess its effects on cerebral oxygenation and infarct size. A randomized, blinded study of RSR-13 (n=6) versus 0.45% saline (n=12) was conducted, after an RSR-13 dose-escalation study (n=4). Drug was administered as a preocclusion bolus followed by a continuous infusion for the duration of the experiment (5 hours). Brain oxygen was measured continuously with the use of a Clark oxygen electrode. Infarct size was measured at 5 hours after occlusion with computer-assisted volumetric analysis.

Results
The drug treatment group had consistently higher mean brain oxygen tension than controls (33±5 and 27±6 mm Hg, respectively) and significantly smaller infarcts (21±9% versus 33±9%, respectively;
P
<.008). We observed an inverse relationship between the dose response of RSR-13 (the shift in the hemoglobin/oxygen dissociation curve) and infarct size.

Conclusions
These results are evidence that allosteric hemoglobin modification is protective to the brain after acute focal ischemia, providing a new opportunity for neuroprotection and raising the possibility of enhancing the protective effect of thrombolysis and ion channel blockade.
Cerebrospinal Fluid Tissue Factor and Thrombin-Antithrombin III Complex as Indicators of Tissue Injury After Subarachnoid Hemorrhage
Authors: Hirashima Yutaka , Nakamura Shin , Suzuki Michiyasu , Kurimoto Masanori , Endo Shunro , Ogawa Akira , Takaku Akira
Published: June 2011

Background and Purpose
No marker that reflects and predicts brain injury due to subarachnoid hemorrhage (SAH) and cerebral vasospasm has been reported. We hypothesized that membrane-bound tissue factor (mTF) and thrombin–antithrombin III complex (TAT) in the cerebrospinal fluid (CSF) of patients with SAH become markers indicating brain injury. To evaluate the hypothesis, we correlated levels of mTF and TAT in the CSF of patients with SAH with clinical severity, the degree of SAH, and outcome.

Methods
We assayed CSF mTF, TAT and myelin basic protein (MBP) in patients with SAH at intervals that included days 0 to 4 and days 5 to 9 after ictus. Classification of clinical severity of disease on admission was based on Hunt and Hess grade, degree of SAH on CT on Fisher’s grading, and outcome 3 months after SAH on the Glasgow Outcome Scale.

Results
In the interval from days 0 to 4, mTF and TAT correlated with Hunt and Hess and Fisher grades, and occurrence of cerebral infarction due to vasospasm. Only mTF correlated significantly in this period with outcome. TAT, mTF, and MBP all correlated significantly with each other. From days 5 to 9, only mTF correlated with cerebral infarction, infarction volume, MBP levels, and outcome.

Conclusions
Both mTF and TAT reflected brain injury from SAH and predicted vasospasm, though mTF was more sensitive and a better predictor of outcome. Unlike mTF, TAT did not correlate with vasospasm during the interval when it most commonly occurs, which raised doubt about thrombin activation as a cause.
Transfer Function Analysis of Cerebral Autoregulation Dynamics in Autonomic Failure Patients
Authors: Blaber Andrew P. , Bondar Roberta L. , Stein Flo , Dunphy Paul T. , Moradshahi Peyman , Kassam Mahmood S. , Freeman R.
Published: June 2011

Background and Purpose
Autonomic nervous system diseases affect systemic blood pressure regulation. Patients with autonomic nervous system diseases have consistently larger drops in blood pressure associated with standing than the normal population. Autonomic dysfunction and/or these changes in blood pressure may affect dynamic cerebral autoregulation.

Methods
Heart rate, mean blood flow velocity (MBFV) of the middle cerebral artery via transcranial Doppler ultrasound, mean arterial blood pressure adjusted to brain level (MABP
brain
) via Finapres, and end tidal CO
2
were measured continuously during graded tilt (after 5 minutes in supine position as baseline, −10°, +10°, +30°, +60°, −10°, and supine recovery) in autonomic failure patients and their age- and sex-matched control subjects. The dynamic response of MBFV to spontaneous variations in MABP
brain
was investigated by cross-spectral analysis. The transfer gain and phase relationships between MBFV and MABP
brain
were determined from the final 256 beats of each 5-minute–tilt segment. The transfer gain was normalized to mean MABP
brain
and MBFV and then converted to decibels (dB).

Results
MBFV variation (0.03 to 0.14 Hz) preceded MABP
brain
by similar phase angles in patients and control subjects and in all tilt conditions (patients: 31±5°; control subjects: 30±5°; mean±SEM). Patients had a higher supine gain than control subjects (
P
<.05). Both patients and control subjects showed a significant decrease in gain with tilt and by 60° the patients were not different from the control subjects (supine to 60°: patients=5.23±0.77 to −1.65±0.89 dB; control subjects=1.74±0.82 to −1.80±0.62 dB).

Conclusions
These data indicate an altered, yet present, autoregulatory response with autonomic failure.
Plasma Insulin-like Growth Factor I and IGF Binding Protein 3 Levels in Patients With Acute Cerebral Ischemic Injury
Authors: Schwab Stefan , Spranger Matthias , Krempien Sebastian , Hacke Werner , Bettendorf Markus
Published: June 2011

Background and Purpose
The insulin-like growth factors (IGF) are synthesized in the brain and are involved in fetal brain development. An increased expression of IGF-I and IGF-II occurs in cerebral regions with neuronal damage after experimental hypoxic injury. Furthermore, the expression of mRNAs coding for IGF-I and the binding proteins IGFBP-2 and IGFBP-3 is augmented in response to unilateral ischemia in animal models. The secretory dynamics of IGF-I in human cerebral ischemia have not yet been investigated.

Methods
Plasma IGF-I and IGFBP-3 were measured sequentially in 20 patients with acute ischemic stroke (within 24 hours and 3, 5, and 10 days thereafter). For analysis the patients were assigned to three groups according to the diameter of the infarct area as measured on CT scan: small (<1.5 cm), moderate (≥1.5 cm and ≤5 cm), and large (>5 cm). Eight age-matched patients with nonvascular, neurological illnesses served as controls.

Results
Plasma IGF-I and IGFBP-3 plasma concentrations after acute cerebral ischemia were strikingly lower than those in control subjects and healthy individuals reported in the literature. Plasma IGF-I levels in patients with large infarcts were significantly statistically lower than those in control subjects (
P
<.05), and plasma IGFBP-3 levels were significantly lower than those in control subjects on days 5 and 10.

Conclusions
IGF-I and IGFBP-3 plasma levels are decreased in patients after cerebral ischemia. After acute ischemic stroke, increased demand for growth factors, altered tissue distribution, and accelerated metabolic clearance rate or central inhibition of the somatotrophic axis may contribute to these low plasma concentrations. Growth factors such as IGF-I and IGFBP-3 may play an important role in the pathophysiology of acute cerebral ischemia, and growth factors may have a considerable effect on future therapeutic regimens.
Does Pulse Oximetry Reliably Detect Aspiration in Dysphagic Stroke Patients?
Authors: Collins M. J. , Bakheit A. M. O.
Published: June 2011

Background and Purpose
The aim of the present study was to examine the value of pulse oximetry in the diagnosis of aspiration by comparing it with the gold standard, videofluoroscopy, by use of a prospective, controlled, single-blind study design.

Methods
Pulse oximetry was performed simultaneously with videofluoroscopy in 54 consecutive dysphagic stroke patients. Oxygen saturation measurements were taken before the videofluoroscopic examination (baseline), on swallowing and continuously for 2 minutes after swallowing, and 10 minutes later.

Results
Pulse oximetry reliably predicted aspiration or lack of it in 81.5% of cases. The predictive value of the test was low in patients aged ≥65 years and possibly those with chronic lung disease. One smoker also had a false-negative pulse oximetry result, ie, normal oxygen saturation despite radiological evidence of aspiration.

Conclusions
Pulse oximetry is a reliable method of diagnosis of aspiration in most dysphagic patients. However, careful interpretation of pulse oximetry data is necessary in older subjects, possibly those with chronic pulmonary disease, and smokers. The method is noninvasive, simple, and quick, and can be used routinely in the clinical assessment of dysphagic patients.
Functional Hyperemia in the Brain
Authors: Harder David R. , Alkayed Nabil J. , Lange Andrew R. , Gebremedhin Debebe , Roman Richard J.
Published: June 2011

Background
—Cerebral blood flow is tightly coupled to neuronal metabolic activity, a phenomenon referred to as functional hyperemia. The mechanisms underlying functional hyperemia in the brain have been extensively studied, but the link between neuronal activation and nutritive blood flow has yet to be defined. Recent investigations by our laboratory and others have identified a potential role for astrocytes as an intermediary cell type in this process.

Summary of Review
—This short review will develop the hypothesis that cytochrome P450 epoxygenase activity in astrocytes catalyzes formation of epoxyeicosatrienoic acids (EETs), which act as potent dilators of cerebral vessels and are released in response to glutamate receptor activation within astrocytes. Neuronal activity stimulates release of arachidonic acid from the phospholipid pool of astrocytic membranes. We provide evidence that the arachidonic acid released on stimulation of glutamate receptors within astrocytes is metabolized by cytochrome P450 2C11 cDNA enzymes into EETs.

Conclusions
—The EETs thus formed will be released and activate K
+
channels, increase outward K
+
current, and hyperpolarize the plasma membrane. The resulting membrane hyperpolarization inhibits voltage-gated Ca
2+
channels and leads to arteriolar dilation, thereby increasing regional nutritive blood flow in response to neuronal activity.
PROACT: A Phase II Randomized Trial of Recombinant Pro-Urokinase by Direct Arterial Delivery in Acute Middle Cerebral Artery Stroke
Authors: del Zoppo Gregory J. , Higashida Randall T. , Furlan Anthony J. , Pessin Michael S. , Rowley Howard A. , Gent Michael
Published: June 2011

Background and Purpose
—To test the safety and recanalization efficacy of intra-arterial local delivery of plasminogen activators in acute ischemic stroke, a randomized trial of recombinant pro-urokinase (rpro-UK) versus placebo was undertaken in patients with angiographically documented proximal middle cerebral artery occlusion.

Methods
—After exclusion of intracranial hemorrhage by CT scan, patients with abrupt onset of symptoms of focal ischemia likely to receive treatment within 6 hours who satisfied all clinical eligibility criteria underwent carotid angiography. Patients displaying Thrombolysis in Acute Myocardial Infarction grade 0 or 1 occlusion of the M1 or M2 middle cerebral artery were randomized 2:1 to receive rpro-UK (6 mg) or placebo over 120 minutes into the proximal thrombus face. All patients received intravenous heparin. Recanalization efficacy was assessed at the end of the 2-hour infusion, and intracerebral hemorrhage causing neurological deterioration was assessed at 24 hours.

Results
—Of 105 patients who underwent angiography, 59 were excluded from randomization. Among the 46 patients randomized, 40 were treated with rpro-UK (n=26) or placebo (n=14) a median of 5.5 hours from symptom onset. Recanalization was significantly associated with rpro-UK (2
P
=.017). Hemorrhagic transformation causing neurological deterioration within 24 hours of treatment occurred in 15.4% of the rpro-UK–treated patients and 7.1% of the placebo-treated patients (2
P
=.64). Both recanalization and hemorrhage frequencies were influenced by heparin dose.

Conclusions
—Intra-arterial local rpro-UK infusion was associated with superior recanalization in acute thrombotic/thromboembolic stroke compared with placebo. In this regimen, heparin dose influenced hemorrhage frequency and recanalization. Although symptomatic hemorrhage remains a concern, this study suggests that recanalization is enhanced with rpro-UK and heparin.
Carotid Endarterectomy Among Medicare Beneficiaries
Authors: Karp Herbert R. , Flanders W. Dana , Shipp Clanton C. , Taylor Brenda , Martin Debra
Published: June 2011

Background and Purpose
—We sought to examine the appropriateness and the surgical outcomes of carotid endarterectomy (CE) in unselected community hospitals to identify opportunities for improvement.

Methods
—We performed a retrospective review of all CEs performed on Medicare beneficiaries in Georgia in 1993 (n=1945). Conclusions regarding appropriateness were based on current guidelines as interpreted by a physician reviewer and were supported by the aggregate results of structured, blinded overreading by clinicians with relevant expertise. Adverse outcomes were confirmed and rated as to severity by a physician. Outcomes were correlated with demography, vascular anatomic findings, comorbidity, surgical techniques, and hospital characteristics.

Results
—The majority of the patients (51%) were asymptomatic at presentation. CEs were performed appropriately in 96.1% of the cases in accordance with current guidelines. There was no significant difference in the rate of appropriateness between the symptomatic (96%) and the asymptomatic patients (96.4%). Survival without stroke or myocardial infarction (MI) was 94.3%. The 30-day mortality was 1.9%; moderate to severe strokes occurred in 1.8%, stroke-related death in 0.7%, MI in 1.1%, and MI-related death in 0.5%. Those hospitals performing <10 CEs in the observed year had a statistically significant higher morbidity and mortality as well as an increase in less severe complications such as hematomas, wound dehiscence, wound infection, and pneumonia than did hospitals with higher volume of CEs.. Older patients and women had statistically significantly higher morbidity and mortality. Patients with a Charlson Severity Index score of ≥1 had a risk for adverse outcomes 3.4 times higher than patients with a score of 0 after adjustment for age and sex.

Conclusions
—The great majority of CEs performed in Georgia on Medicare patients were appropriate, according to current guidelines. Slightly more than half of the patients were asymptomatic as defined in the Asymptomatic Carotid Atherosclerosis Study. In hospitals performing <CEs in the index year, we noted higher morbidity and mortality, as well as an increase in less severe complications. This relationship between the volume of surgery and outcome was confirmed in the analysis of the 30-day mortality for all Medicare cases (n=10 569) performed in Georgia from 1991 to 1995. This was the most important opportunity for improvement identified in this study. In view of the increased use of CE, it is important to continue to monitor the patterns of practice for this procedure to improve outcomes.
Stroke Risk Management
Authors: Kalra L. , Perez I. , Melbourn A.
Published: June 2011

Background
—Research shows that identification and control of risk factors reduces ischemic stroke. The impact of this evidence and health initiatives on mainstream practice remains unknown.

Methods
—The purpose of this observational study was to investigate prior management of risk factors (hypertension, atrial fibrillation, previous stroke/transient ischemic attacks) in patients with acute cerebral infarction. Data were collected on the frequency of known risk factors before the incident stroke and their management compared with predefined criteria for appropriateness. The proportion of patients receiving treatment for risk factors before the acute episode was studied over 3 years.

Results
—One thousand seventy-four patients (median age, 76 years; 60% women) were included in the study over 3 years. The proportion of patients with known hypertension (41% to 46%), diabetes (12% to 13%), previous stroke or transient ischemic attack (TIA) (21% to 31%), and atrial fibrillation (16% to 21%) remained stable. Overall, approximately 45% patients with atrial fibrillation, 60% patients with hypertension, and 70% with cerebrovascular disease were being actively managed. Time trends analysis showed a significant increase in the proportion of patients being treated for risk due to known cerebrovascular disease (59% to 85%), atrial fibrillation (18% to 59%), ischemic heart disease (35% to 72%), and carotid disease (13% to 85%) between the first and third year. The proportion of patients receiving treatment for hypertension remained unchanged. Patients with preexisting symptomatic vascular disease were more likely to receive appropriate risk management compared with asymptomatic patients (72% versus 46%,
P
<.001).

Conclusions
—Although a significant number of ischemic events remain potentially preventable, there appears to be a positive trend in improved control of stroke risk.
Noninvasive Determination of Language Lateralization by Functional Transcranial Doppler Sonography
Authors: Knecht S. , Deppe M. , Ebner A. , Henningsen H. , Huber T. , Jokeit H. , Ringelstein E.-B.
Published: June 2011

Background and Purpose
—Functional transcranial Doppler ultrasonography (fTCD) can assess event-related changes in cerebral blood flow velocities and, by comparison between sides, can provide a measure of hemispheric perfusional lateralization. It is easily applicable, insensitive to movement artifacts, and can be used in patients with less than perfect cooperation. In the present study we investigated the validity of fTCD in determining the hemispheric dominance for language by direct comparison of fTCD with intracarotid amobarbital anesthesia (Wada test).

Methods
—fTCD and the Wada test were performed in 19 patients evaluated for epilepsy surgery. By the Wada test, 13 patients were classified as left-hemisphere dominant and 6 as right-hemisphere dominant for language. fTCD was based on the continuous bilateral measurements of blood flow velocities in the middle cerebral arteries and event-related averaging during a cued word generation task previously shown to activate lateralized language areas in normal adults.

Results
—In 4 patients fTCD assessment was not possible because of lack of an acoustic temporal bone window. In the remaining 15 candidates, determination of language dominance was concordant with the Wada test in every case. Moreover, the correlation of the lateralization measures from both procedures was highly significant (
r
=.92,
P
<.0001).

Conclusions
—This strong correlation validates fTCD as a noninvasive and practical tool for the determination of language lateralization that can be applied for clinical and investigative purposes.
Cerebral Hematocrit Decreases With Hemodynamic Compromise in Carotid Artery Occlusion
Authors: Yamauchi Hiroshi , Fukuyama Hidenao , Nagahama Yasuhiro , Katsumi Yukinori , Okazawa Hidehiko
Published: June 2011

Background and Purpose
—This study investigated whether in patients with internal carotid artery occlusion the regional cerebral hematocrit correlates with cerebral hemodynamics or metabolic state and, if so, how the regional cerebral hematocrit changes in the hemodynamically compromised region.

Methods
—We used positron emission tomography to study seven patients with unilateral internal carotid artery occlusion and no cortical infarction in the chronic stage. The distributions of red blood cell and plasma volumes were assessed using oxygen-15–labeled carbon monoxide and copper-62–labeled human serum albumin-dithiosemicarbazone tracers, respectively. The calculated hematocrit value was compared with the hemodynamic and metabolic parameters measured with the oxygen-15 steady-state technique.

Results
—In the cerebral cortex, the value of the cerebral hematocrit varied but was correlated with the hemodynamic and metabolic status. Stepwise regression analysis revealed that the large vessel hematocrit, the cerebral metabolic rate of oxygen, and the cerebral blood flow or the oxygen extraction fraction accounted for a significant proportion of variance of the cerebral hematocrit. The oxygen extraction fraction and the cerebral metabolic rate of oxygen negatively correlated with the cerebral hematocrit, whereas the cerebral blood flow correlated positively: patients with reduced blood supply relative to metabolic demand (decreased blood flow with increased oxygen extraction fraction) showed low hematocrit values.

Conclusions
—In carotid artery occlusion in the chronic stage, regional cerebral hematocrit may vary according to cerebral hemodynamics and metabolic status. Regional cerebral hematocrit may decrease with hemodynamic compromise unless oxygen metabolism concomitantly decreases.
Selective Intra-Arterial Fibrinolysis of Acute Central Retinal Artery Occlusion
Authors: Weber Johannes , Remonda Luca , Mattle Heinrich P. , Koerner Ursula , Baumgartner Ralf W. , Sturzenegger Matthias , Ozdoba Christoph , Koerner Fritz , Schroth Gerhard
Published: June 2011

Background and Purpose
—Occlusion of the central retinal artery (CRAO) causes a sudden decrease of monocular vision. Because early restoration of blood flow may improve outcome, we attempted to treat CRAO with selective intra-arterial fibrinolysis.

Methods
—Intra-arterial fibrinolysis was performed within 6 hours after symptom onset in 17 patients with thromboembolic CRAO. Symptoms were painless, acute and severe decrease of vision. Urokinase (100 000 to 900 000 IU) was given through a microcatheter into the ophthalmic artery over 10 to 90 minutes. For comparison, the history and visual outcome of 15 control patients who did not receive fibrinolytics were evaluated. In both groups some of the patients underwent paracentesis and/or received carboanhydrase inhibitors.

Results
—Patients who underwent fibrinolysis fared better than control patients (
P
=0.01). Three patients (17.6%) recovered completely after fibrinolysis and regained visual acuity of 20/20 (n=2) to 25/20 (n=1). Two additional patients (11.8%) showed a marked improvement to a visual acuity of 20/30. In 6 patients (35.3%) vision improved slightly. They were able to count fingers, detect hand movements, or perceive light. In 6 patients (35.3%), fibrinolytic treatment was without effect. Among control patients, 1 patient (6.7%) showed partial, 4 patients (26.7%) minimal, and 10 (66.7%) no improvement of vision.

Conclusions
—A complete or marked improvement of visual acuity was achieved in one third of intra-arterial fibrinolysis patients but in none of the control patients. Intra-arterial fibrinolysis seems to have the potential to “lighten” the spontaneously poor outcome of CRAO.
Incidence of Transient Ischemic Attack in Rochester, Minnesota, 1985–1989
Authors: Brown Robert D. , Petty George W. , O’Fallon W. Michael , Wiebers David O. , Whisnant Jack P.
Published: June 2011

Background and Purpose
—There is scant information available on the incidence of transient ischemic attack (TIA) in a defined population. This study defines incidence rates of first TIA and subtypes of TIA during 1985–1989 and compares the incidence to that obtained from a 1960–1972 cohort study.

Methods
—Medical records of all residents of Rochester with potential diagnosis of TIA during 1985–1989 were screened to determine whether the case met the criteria for TIA. All available data were used to determine the vascular distribution of the TIA. Average annual age- and sex-adjusted incidence rates were calculated for 1985–1989, and results were compared with incidence rates determined in a Rochester-based 1960–1972 cohort study.

Results
—Two hundred two cases of first TIA or amaurosis fugax occurred among Rochester residents during 1985–1989. The age- and sex-adjusted incidence rate for any TIA was 68/100 000 population. Incidence of amaurosis fugax was 13/100 000; anterior circulation (cerebral) TIA, 38/100 000; and vertebrobasilar distribution TIA, 14/100 000. Rates were similar to those determined from a 1960–1972 cohort study.

Conclusions
—The incidence rate of TIA is 41% that of stroke incidence. TIA incidence in Rochester, Minn, is higher than has been previously reported for other sites throughout the world. Although comparison with prior time periods is difficult because of ascertainment issues, it appears that there has been no significant change in TIA incidence since the decade of the 1960s or earlier. This suggests that the most common mechanism for TIA (atherosclerosis) has not changed in prevalence, nor have risk factors leading to this mechanism.
Optimal Depth and Duration of Mild Hypothermia in a Focal Model of Transient Cerebral Ischemia
Authors: Maier Carolina M. , Ahern Kristine vB. , Cheng Ming L. , Lee Jong Eun , Yenari Midori A. , Steinberg Gary K.
Published: June 2011

Background and Purpose
—Mild hypothermia is possibly the single most effective method of cerebroprotection developed to date. However, many questions regarding mild hypothermia remain to be addressed before its potential implementation in the treatment of human stroke. Here we report the results of 2 studies designed to determine the optimal depth and duration of mild hypothermia in focal stroke and its effects on infarct size, neurological outcome, programmed cell death, and inflammation.

Methods
—Rats underwent a 2-hour occlusion of the left middle cerebral artery. In the first study (I) animals were kept (intraischemically) at either 37°C (n=8), 33°C (n=8), or 30°C (n=8). Study II consisted of 4 groups: (1) controls (37°C, n=10), (2) 30 minutes of hypothermia started at ischemic onset (33°C, n=9), (3)1 hour (33°C, n=8), and (4) 2 hours (33°C, n=8). Brain temperature was measured by a thermocouple probe placed in the contralateral cortex. After suture removal, all animals were rewarmed and reperfused for 22 hours (I) or 70 hours (II).

Results
—Mild hypothermia to 33°C or 30°C was neuroprotective (17±7% and 27±6%, respectively) relative to controls (53±8%,
P
<0.02), but 33°C was better tolerated and recovery from anesthesia was faster. The neurological score of hypothermic animals was significantly better than that of controls (I & II) at both 24 and 72 hours postischemia except for the 30-minute group (II), which showed no improvement. In Study II, 2 hours of hypothermia reduced injury by 59%, 1 hour reduced injury by 84% whereas 30 minutes did not reduce injury. Normalized for infarct size, 2 hours of mild hypothermia decreased neutrophil accumulation by 57% whereas both 1 hour and 30 minutes had no effect. At 72 hours, 1 and 2 hours of mild hypothermia decreased transferase dUTP nick-end labeling (TUNEL) staining by 78% and 99%, respectively, and 30 minutes of hypothermia had no effect.

Conclusions
—Intraischemic mild hypothermia must be maintained for 1 to 2 hours to obtain optimal neuroprotection against ischemic cell death due to necrosis and apoptosis.
Quality of Full and Final Publications Reporting Acute Stroke Trials
Authors: Bath Fiona J. , Owen Victoria E. , Bath Philip M. W.
Published: June 2011

Background and Purpose
—Several studies have shown that the quality of reporting of trials throughout medicine is variable and often poor. We report on the quality of the final reports of randomized controlled trials (RCTs) of drug therapies assessed in acute stroke.

Methods
—English-language reports published up to the end of 1996 relating to completed RCTs in acute stroke were identified from electronic searches of the Cochrane Stroke Review Group database of stroke trials and the Cochrane Controlled Trials Register (CD-ROM issue 1, 1997, of the Cochrane Library). Report quality was assessed with the 33 criteria of the CONSORT statement and 53 additional factors relevant to acute stroke or trials in general. Trial quality was also assessed with a 7-point scale.

Results
—Up to 1996, 114 RCTs were published which involved 20 536 patients (median, 80; range, 16 to 1267 per trial); 39 (35.5%) of these were published in
Stroke.
The median total report quality was 40/86 (range, 15 to 61) for all criteria and 19/33 (range, 9 to 29) for the CONSORT criteria alone. Although adequate information was given in the introduction and discussion sections of most reports, insufficient details were given on methods, assignment of patients to treatment groups, statistical analyses, the prevalence of risk factors, and assessment of outcomes. Report quality has improved between 1956 and 1996 (Spearman correlation coefficient [
r
s
], 0.575; 95% confidence interval [CI], 0.439 to 0.685) and was superior in large trials (
r
s
=0.434; 95% CI, 0.274 to 0.571). Although report quality was related to trial quality (
r
s
=0.675; 95% CI, 0.563 to 0.763), it was not related to journal impact factor (
r
s
=0.170; 95% CI, −0.015 to 0.344). Trials with a positive outcome tended to be less well reported than those with a neutral or negative outcome (
r
s
=−0.192; 95% CI, −0.351 to −0.011).

Conclusions
—The overall quality of study reports for parallel group RCTs in acute stroke is poor but appears to be improving with time and in parallel with an increase in trial size. Reports often lack detailed information on the methods of randomization, concealment of allocation, and statistical analysis, all factors which can, if undertaken poorly, affect trial results and validity. It is vital that future trials are adequately reported; we believe that authors should follow the CONSORT guidelines and that referees and editors should ensure this happens.
A Prospective Community-Based Study of Stroke in Germany—The Erlangen Stroke Project (ESPro)
Authors: Kolominsky-Rabas Peter L. , Sarti Cinzia , Heuschmann Peter Ulrich , Graf Christian , Siemonsen Sven , Neundoerfer Bernhard , Katalinic Alexandar , Lang Erich , Gassmann Karl-Günther , von Stockert Theodor Ritter
Published: June 2011

Background and Purpose
—In Germany, basic data on stroke morbidity are lacking. If a population-based register in former East Germany is excluded, only routine mortality statistics have thus far provided information on epidemiology of stroke. Therefore, a population-based register of stroke was set up in Southern Germany to determine incidence and case fatality in a defined German population.

Methods
—The Erlangen Stroke Project (ESPro) is a prospective community-based study among the 101 450 residents of the city of Erlangen, Bavaria, Germany. Standard definitions and overlapping case-finding methods were used to identify all cases of first-ever stroke in all age-groups, occurring in the 2 years of registration (April 1, 1994, to March 31, 1996). All identified cases of first-ever strokes were followed up at 3 and 12 months from onset.

Results
—During 2 years of registration, 354 first-ever-in-a-lifetime strokes (FELS) were registered. The diagnosis and stroke type were confirmed by CT scan in 95% of cases. Fifty-one percent of all FELS occurred in the age group ≥75 years of age. The crude annual incidence rate was 1.74 per 1000 (1.47 for men and 2.01 for women). After age-adjustment to the European population, the incidence rate was 1.34 per 1000 (1.48 for men and 1.25 for women). The annual crude incidence rate of cerebral infarction was 1.37/1000, intracerebral hemorrhage 0.24/1000, subarachnoid hemorrhage 0.06/1000, and unspecified stroke 0.08/1000. Overall case fatality at 28 days was 19.4%, at 3 months it was 28.5%, and at 1 year 37.3%.

Conclusions
—The first prospective community-based stroke register including all age groups in Germany revealed incidence rates of stroke similar to those reported from other population-based studies in western industrialized countries, but lower than that observed in former East Germany.
Spontaneous Reperfusion After Ischemic Stroke Is Associated With Improved Outcome
Authors: Barber P. Alan , Davis Stephen M. , Infeld Bernard , Baird Alison E. , Donnan Geoffrey A. , Jolley Damien , Lichtenstein Meir
Published: June 2011

Background and Purpose
—The rationale behind thrombolytic therapy in acute ischemic stroke is penumbral salvage by rapid restoration of cerebral blood flow. The relationship, however, between early reperfusion (potentially composed of both nutritional and nonnutritional components) and outcome remains unclear.

Methods
—To establish the relationship between reperfusion parameters and outcome variables (Canadian Neurological Scale, Barthel Index, outcome CT scans), we used
99
Tc–hexamethylpropyleneamine oxime (
99
Tc-HMPAO) single-photon emission CT (SPECT) to examine 41 acute ischemic stroke patients. All patients had at least 2 SPECT studies (24 with 3 studies), and none had been treated with thrombolytic or other acute investigational drugs.

Results
—A total of 106 studies were performed. Mean time to acute study was 9.2 hours; that for subacute study was 42 hours and for outcome study was 150 days. Hypoperfusion (HP) volumes at each of the 3 time points correlated with outcome clinical state and final infarct size. Both early reperfusion (61% of patients) and nutritional reperfusion alone (56%), which is early reperfusion maintained at outcome, were associated with improvement in clinical state and better functional outcome. Early HP volume change (acute minus subacute HP volume) and total HP volume change (acute minus outcome HP volume) also correlated with clinical improvement and better outcome.

Conclusions
—This study establishes the benefit of spontaneous reperfusion after ischemic stroke and emphasizes the prognostic value of HP deficit volumes.
99
Tc-HMPAO SPECT may be used to screen patients and group them according to perfusion deficit in acute stroke trials, thereby decreasing patient numbers required to show drug effect.
Risk of Harboring an Unruptured Intracranial Aneurysm
Authors: Ronkainen Antti , Miettinen Heikki , Karkola Kari , Papinaho Sari , Vanninen Ritva , Puranen Matti , Hernesniemi Juha
Published: June 2011

Background and Purpose
—The purpose of the present study was to calculate the prevalence and relative risk of unruptured incidental intracranial aneurysms (IAs) among families with IA case(s) compared with the general population in one geographically defined area in East Finland and to identify the risk group that could benefit most from screening for IAs. We compared these results with our earlier study results of familial IA (FIA) cases, with two or more known IA cases in the same family.

Methods
—The study groups were collected from the catchment area of the University Hospital of Kuopio in East Finland. The inclusion criteria were age 30 to 70 years and unruptured incidental IAs ≥3 mm. Patients with previous subarachnoid hemorrhage or in whom a ruptured IA was found to be the cause of death were excluded from all study groups. During routine forensic autopsies the circle of Willis was studied for IAs to estimate the number of IAs in the general population. In the families with one known IA case and in FIA families, MR angiography was used as a preliminary screening method for IAs, followed by intra-arterial angiography to verify suspected IAs. Study populations were age and sex adjusted for the statistical calculations.

Results
—The relative risk for IAs among first-degree relatives in FIA families was 4.2 (95% confidence interval, 2.2 to 8.0) and among first-degree relatives in families with only one affected family member was 1.8 (95% confidence interval, 0.7 to 4.8) compared with the general population in East Finland.

Conclusions
—First-degree relatives in FIA families constitute a high-risk group for incidental IAs, and this group would benefit from screening studies for IAs. Screening for IAs in families with only one affected member or in the general population is not recommended.
Increased Oxygen Extraction Fraction Is Associated With Prior Ischemic Events in Patients With Carotid Occlusion
Authors: Derdeyn Colin P. , Yundt Kent D. , Videen Tom O. , Carpenter David A. , Grubb Robert L. , Powers William J.
Published: June 2011

Background and Purpose
—The purpose of our study was to investigate the relationship between misery perfusion (increased oxygen extraction fraction, OEF) and baseline risk factors in patients with carotid occlusion.

Methods
—One-hundred seventeen patients with atherosclerotic carotid occlusion were studied prospectively by clinical evaluation, laboratory testing, and positron emission tomography (PET). PET measurements of cerebral blood flow (CBF), cerebral blood volume (CBV), and OEF were made on enrollment in the study. Increased ipsilateral OEF was identified by comparison with 18 normal control subjects. Twenty-five baseline clinical, epidemiological, and arteriographic risk factors were assessed on study entry. Student
t
tests, χ
2
tests, and Fisher exact tests with Bonferroni correction were used to assess statistical significance (
P
<.05).

Results
—Of 117 patients, 44 had increased OEF distal to the occluded carotid and 73 had normal OEFs. Thirty-nine of the 81 patients with prior ipsilateral ischemic symptoms had high OEFs (42%), whereas only 5 of the 31 asymptomatic patients had high OEFs (16%,
P
<.001) All of the other baseline risk factors were similar between the two groups of patients.

Conclusions
—Investigations of the relationship between hemodynamic factors and stroke risk must take into account the lower frequency of hemodynamic abnormalities in asymptomatic patients.
Intellectual Decline After Stroke
Authors: Kase C. S. , Wolf P. A. , Kelly-Hayes M. , Kannel W. B. , Beiser A. , D’Agostino R. B.
Published: June 2011

Background and Purpose
—The causes and characteristics of cognitive decline after stroke are poorly defined, because most studies have relied on the diagnosis of dementia after stroke, without measurement of prestroke cognitive function.

Methods
—The Mini-Mental State Examination (MMSE) was used to assess the cognitive performance of 74 subjects from the Framingham Study cohort who had suffered a stroke during a 13-year period. We compared their poststroke cognitive performance with the prestroke MMSE scores collected during their biennial examinations, and their prestroke/poststroke changes in MMSE score were then compared with those of 74 control subjects matched for age and sex. Cases and controls underwent testing for symptoms of depression using the Center for Epidemiologic Studies of Depression (CES-D) scale, and these findings were correlated with their cognitive performance. Changes in cognitive performance in the cases were correlated with the CT-documented characteristics of the stroke.

Results
—The cases had a significantly lower mean±SE MMSE score at prestroke baseline (27.28±0.34) than did the control subjects (28.08±0.21), a difference that became more pronounced (23.57±0.92 versus 28.31±0.25;
P
<.001) after stroke. The poststroke decline in cognitive function in the cases was correlated only with a large, left-sided stroke on CT. The CES-D scores were significantly higher in the cases, but nondepressed cases had significantly lower MMSE scores than nondepressed controls.

Conclusions
—Stroke is followed by a significant decline in cognitive performance when prestroke and poststroke measurements are compared. Although depression is more frequent in the stroke patients, their intellectual decline appears to be independent from the presence of depression.
Factor XIII Val 34 Leu
Authors: Catto Andrew J , Kohler Hans P , Bannan Sally , Stickland Max , Carter Angela , Grant Peter J
Published: June 2011

Background and Purpose
—A common G-to-T point mutation (Val 34 Leu) in exon 2 of the α-subunit of the factor XIII is strongly negatively associated with the development of myocardial infarction. This result suggests that factor XIII Val 34 Leu is interfering with the formation of cross-linked fibrin. The role of factor XIII Val 34 Leu in the pathogenesis of cerebral infarction and primary intracerebral hemorrhage is unknown.

Methods
—Six hundred twelve patients with acute stroke, defined by World Health Organization criteria and cranial CT, and 436 age-matched control subjects free of cerebrovascular disease were genotyped for the factor XIII Val 34 Leu mutation. Venous blood was drawn for the determination of hemostatic variables and lipids. Factor XIII genotype was determined through a single-stranded conformational polymorphism technique and plasminogen activator inhibitor (PAI)-1 4G/5G promoter genotype by allele-specific polymerase chain reaction.

Results
—The mutation was more frequent in patients with primary intracerebral hemorrhage (n=62) (54.8%;
P
=.05) than in control subjects (41.7%) or in patients with cerebral infarction (n=529) (46.5%;
P
=.22). There was no relationship between PAI-1 levels and the PAI-1 4G/5G genotype.

Conclusions
—There was a slightly higher incidence of factor XIII Val 34 Leu in patients with PICH. This may be related to impaired cross-linking of fibrin and/or coagulation proteins.
Anticardiolipin Antibody Aggravates Cerebral Vasospasm After Subarachnoid Hemorrhage in Rabbits
Authors: Nomura Hiroaki , Hirashima Yutaka , Endo Shunro , Takaku Akira
Published: June 2011

Background and Purpose
—We previously reported that patients with antiphospholipid antibodies (aPLs) frequently demonstrate cerebral infarction due to cerebral vasospasm after subarachnoid hemorrhage (SAH). To examine the participation of aPLs in the pathogenesis of vasospasm after SAH, we studied the relationships of aPLs and SAH in an animal model.

Methods
—SAH was produced in 34 rabbits that received two subarachnoid injections of autologous arterial blood. The animals were divided into four experimental groups: SAH was induced in group A (n=9), intracutaneous injection of cardiolipin (CL) was performed before the induction of SAH in group B (n=5), intravenous injection of CL was performed before SAH in group C (n=12), and cyclosporin A was infused intravenously after the intravenous injection of CL and induction of SAH in group D (n=8). Enzyme-linked immunosorbent assay identifying the titer of IgG CL antibodies, neurological evaluation, cerebral angiography, and histological examination were performed in all four groups.

Results
—A significant elevation of anti-CL antibodies, aggravation of neurological deficit, and reduction of caliber of the basilar artery were observed in rabbits that received the intravenous immunization of CL (group C). The administration of cyclosporin A reduced the titer of anti-CL antibody, aggravation of neurological deficit, constriction of basilar artery, and the incidence of cerebral infarction (group D).

Conclusions
—Anti-CL antibodies may therefore be involved in the deterioration of cerebral vasospasm after SAH.