bluuebunny/crossref_metadata_2025 huggingface dataset:
Neuromuscular Stimulation for Upper Extremity Motor and Functional Recovery in Acute Hemiplegia
Authors: Chae John , Bethoux Francois , Bohinc Theresa , Dobos Loreen , Davis Tina , Friedl Amy
Published: June 2011

Background and Purpose
—The purpose of this study was to assess the efficacy of neuromuscular stimulation in enhancing the upper extremity motor and functional recovery of acute stroke survivors.

Methods
—Forty-six stroke survivors admitted to an inpatient rehabilitation unit were randomly assigned to receive either neuromuscular stimulation or placebo. Twenty-eight subjects completed the study. The treatment group received surface neuromuscular stimulation to produce wrist and finger extension exercises. The control group received placebo stimulation over the paretic forearm. All subjects were treated 1 hour per day, for a total of 15 sessions. Outcomes were assessed in a blinded manner with the upper extremity component of the Fugl-Meyer Motor Assessment and the self-care component of the Functional Independence Measure at pretreatment, after treatment, and at 4 and 12 weeks after treatment.

Results
—The treatment subjects and control subjects had comparable baseline characteristics. Parametric analyses revealed significantly greater gains in Fugl-Meyer scores for the treatment group after treatment (13.1 versus 6.5;
P
=0.05), at 4 weeks after treatment (17.9 versus 9.7;
P
=0.05), and at 12 weeks after treatment (20.6 versus 11.2;
P
=0.06). Functional Independence Measure scores were not different between groups at any of the time periods (
P
>0.10).

Conclusions
—Data suggest that neuromuscular stimulation enhances the upper extremity motor recovery of acute stroke survivors. However, the sample size in this study was too small to detect any significant effect of neuromuscular stimulation on self-care function.
Detecting Psychiatric Morbidity After Stroke
Authors: O’Rourke Suzanne , MacHale Siobhan , Signorini David , Dennis Martin
Published: June 2011

Background and Purpose
—Mood disorders are common after stroke and may impede physical, functional, and cognitive recovery, making early identification and treatment of potential importance. We aimed to compare the accuracy of the General Health Questionnaire (GHQ-30) and the Hospital Anxiety and Depression (HAD) Scale in detecting psychiatric morbidity after stroke and to determine the most suitable cutoff points for different purposes.

Methods
—One hundred five hospital-referred stroke patients completed both the GHQ-30 and HAD Scale 6 months after onset before a blinded psychiatric assessment in which the Schedule for Affective Disorders and Schizophrenia with some supplementary questions was used to determine a DSM-IV (
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition)
diagnosis. Measures were compared in terms of sensitivity, specificity, and receiver operating characteristic curves.

Results
—No significant differences were found between the GHQ-30 and the HAD Scale in identifying those patients with any DSM-IV diagnosis (
P
=0.95), grouped depression (
P
=0.56), or anxiety (
P
=0.25) disorders. The previously recommended cutoff points for identifying “cases” for the GHQ (4/5) and for the HAD Scale (8/9 and 11/12) were found to be suboptimal in this population.

Conclusions
—The GHQ-30 and HAD scale exhibited similar levels of sensitivity and specificity. Data are presented, taking into account the “cost” of false-positives and negatives, to allow a choice of cutoff points suitable for differing situations.
Neuropsychometric Changes in Patients After Carotid Endarterectomy
Authors: Heyer Eric J. , Adams David C. , Solomon Robert A. , Todd George J. , Quest Donald O. , McMahon Donald J. , Steneck Susan D. , Choudhri Tanvir F. , Connolly E. Sander
Published: June 2011

Background and Purpose
—One hundred twelve patients undergoing elective carotid endarterectomy for symptomatic and asymptomatic carotid artery stenosis were enrolled in a prospective study to evaluate the incidence of change in postoperative cerebral function.

Methods
—Patients were evaluated preoperatively and postoperatively before hospital discharge and at follow-up 1 and 5 months later with a battery of neuropsychometric tests. The results were analyzed by both event-rate and group-rate analyses. For event-rate analysis, change was defined as either a decline or improvement in postoperative neuropsychometric performance by 25% or more compared with a preoperative baseline.

Results
—Approximately 80% of patients showed decline in one or more test scores, and 60% had one or more improved test scores at the first follow-up examination. The percentage of declined test scores decreased and the percentage of improved test scores increased with subsequent follow-up examinations. Group-rate analysis was similar for group performance on individual tests. However, a decline in performance was seen most commonly on verbal memory tests, and improved performance was seen most commonly on executive and motor tests.

Conclusions
—Neuropsychometric evaluation of patients undergoing carotid endarterectomy for significant carotid artery stenosis demonstrates both declines and improvements in neuropsychometric performance. The test changes that showed decreased performance may be associated with ischemia from global hypoperfusion or embolic phenomena, and the improvement seen may be related to increased cerebral blood flow from removal of stenosis.
Temporal Variability of Asymptomatic Embolization in Carotid Artery Stenosis and Optimal Recording Protocols
Authors: Molloy Jane , Khan Naheed , Markus Hugh S.
Published: June 2011

Background and Purpose
—Although asymptomatic embolization can be detected in patients with carotid artery stenosis, its temporal variability is unclear. An understanding of this is important in designing optimal recording protocols for future prospective studies of the predictive value of embolic signals (ES). We determined the effect of repeating and extending recording times in patients with symptomatic and asymptomatic carotid stenosis.

Methods
—In 20 asymptomatic and 20 symptomatic subjects with >60% carotid stenosis, we used transcranial Doppler ultrasound to record for ES in the ipsilateral middle cerebral artery. Three 1-hour recordings were performed on three separate days, and on one occasion (not necessarily the first) the recording was extended to 2 hours. The recordings were saved onto digital tape for subsequent blinded analysis.

Results
—Marked temporal variability was seen in symptomatic patients in whom the cumulative proportion of subjects with ES increased from 10 (50%) after a single hour of recording to 12 (60%) and 15 (75%) after two and three recordings, respectively. Extending the recording to 2 hours increased the yield of ES-positive patients from 6 (30%) to 8 (40%). In symptomatic patients there was excellent agreement between whether patients were positive for ES during each of two consecutive 1-hour recordings (κ=0.78,
P
=0.0003) but poor agreement between the results of two single-hour recordings performed on different days (κ=0.22,
P
=0.27). In asymptomatic patients, 4 (20%) were ES positive during the first hour; this increased to 5 (25%) after the recording was repeated once, with no further increase after the third recording. Extending the recording to 2 hours increased the yield from 3 (15%) to 7 (35%). In contrast to symptomatic stenoses, in patients with asymptomatic stenoses there was fair agreement between whether patients were ES positive on two consecutive 1-hour recordings (κ=0.49,
P
=0.01) or two single-hour recordings performed on different days (κ=0.48,
P
=0.02). Symptomatic subjects were more likely to have ES (when all 1-hour recordings were considered, 24/60 versus 10/60;
P
=0.0046). ES in symptomatic subjects had a higher relative intensity increase than in asymptomatic subjects (
P
=0.01).

Conclusions
—The temporal variability of ES needs to be taken into account in the design of optimal recording protocols and comparisons of results from different studies. Extending the duration of recording beyond an hour in symptomatic stenoses is of less value, but repeating the recording on a different day will often identify additional subjects with ES. In intervention studies in symptomatic patients, the time since last symptoms must be considered. In asymptomatic stenosis, extending the duration of recording beyond an hour will increase the proportion of patients positive for ES.
A Comparison of Four Methods for Distinguishing Doppler Signals From Gaseous and Particulate Emboli
Authors: Smith Julia L. , Evans David H. , Bell Peter R. F. , Naylor A. Ross
Published: June 2011

Background and Purpose
—Many reports in the medical literature have proposed methods of differentiating between gaseous and particulate emboli detected with the use of transcranial Doppler ultrasound. The purpose of this study was to compare the previously published methods with our own sample volume length (SVL) parameter to assess the accuracy of each method in classifying emboli.

Methods
—A pure source of gaseous and particulate emboli was obtained from in vitro and in vivo studies, respectively, and recorded onto digital audiotape for off-line analysis. In total, 100 gaseous emboli and 215 particulate emboli were analyzed to measure four embolic parameters, namely, embolic duration, embolic velocity, relative signal intensity increase (measured embolic power [MEP]), and SVL of the embolic signal (=Duration×Velocity). Receiver operator characteristic analysis was used to assess the optimum threshold for each parameter to differentiate between particulate and gaseous emboli, and levels of sensitivity and specificity were calculated.

Results
—Embolic duration and velocity produced the poorest levels of sensitivity and specificity compared with the MEP and SVL parameters. The optimum thresholds for embolic duration and velocity were 35 ms and 1 m/s, respectively, which produced a sensitivity (specificity) of 85.1% (87%) and 87% (67%), respectively. The optimum MEP and SVL thresholds were 30 dB and 12.8 mm, respectively, which produced a sensitivity (specificity) of 86.5% (95%) and 93% (97%), respectively. The SVL and MEP parameters were compared statistically (χ
2
) at chosen specificity values of 90%, 95%, 97%, 99%, and 100%, which showed that the SVL sensitivities were statistically greater than MEP sensitivities (
P
<0.01).

Conclusions
—SVL is the best parameter for differentiating between gaseous and particulate emboli but needs to be calculated with the use of a high-temporal-resolution spectral analyzer to measure embolic duration and velocity.
Cerebral Microembolism in Patients With Retinal Ischemia
Authors: Wijman Christine A. C. , Babikian Viken L. , Matjucha Ippolit C. A. , Koleini Behrooz , Hyde Charles , Winter Michael R. , Pochay Val E.
Published: June 2011

Background and Purpose
—We investigated the frequency of cerebral microembolism detected by transcranial Doppler ultrasonography in patients with clinical evidence of retinal ischemia, including transient monocular blindness, central and branch retinal artery infarction, and ischemic oculopathy, and assessed its correlation with carotid artery stenosis.

Methods
—Records of 331 consecutive patients examined during a 47-month period at the Neurovascular Laboratory were reviewed. Of the original 453 intracranial arteries, 186 middle cerebral arteries (MCAs) satisfied qualifying criteria that excluded patients with cardiac embolic sources. Forty-five MCAs ipsilateral to the symptomatic eye constituted the study group. The control group consisted of 141 asymptomatic MCAs. Microembolus detection studies were performed on transcranial Doppler instruments equipped with special software, and the degree of carotid artery stenosis was measured by cerebral or MR angiography or by color duplex studies.

Results
—Microembolism was detected in 40.0% of study MCAs and 9.2% of controls (
P
<0.001). In the study group, microembolic signals were detected in 61.9% of MCAs tested within a week of symptom onset and 20.8% of those tested afterward (
P
<0.001). Severe (≥70%) carotid stenosis or occlusion was more frequent in the study group (
P
<0.001). Microembolic signals were detected in 25.3% and 11.2%, respectively, of MCAs distal to carotid arteries with 70% to 100% and 0% to 69% stenosis (
P
=0.013).

Conclusions
—In patients without cardiac embolic sources, cerebral microembolism is frequently present on the side of retinal ischemia, particularly during the week after onset of symptoms. It is often associated with severe stenosis or occlusion of the ipsilateral carotid artery.
Reproducibility of Functional Transcranial Doppler Sonography in Determining Hemispheric Language Lateralization
Authors: Knecht S. , Deppe M. , Ringelstein E.-B. , Wirtz M. , Lohmann H. , Dräger B. , Huber T. , Henningsen H.
Published: June 2011

Background and Purpose
—Since functional transcranial Doppler ultrasonography (fTCD) allows convenient and fully automated quantification of language lateralization, it seems ideal for longitudinal studies of perfusion changes during deterioration as well as recovery of language functions. However, during serial examinations, the technical, stochastic, and physiological variabilities of cerebral blood flow velocities (CBFV) have to be considered. Therefore, before fTCD is accepted as a tool for evaluation of changes in lateralization in the diseased state, its reliability in healthy subjects needs to be determined.

Methods
—We performed fTCD during a word generation task based on a previously validated technique with automated calculation of the averaged CBFV differences in the middle cerebral arteries providing an index of lateralization (LI).

Results
—(1) The accuracy of the LI as assessed by the confidence interval was better than 1% of the mean hemispheric difference. (2) On repeated examination, LIs obtained from 10 subjects showed a high test-retest reproducibility (Pearson product moment correlation coefficient
r
=0.95,
P
<0.0001). (3) On 10 repeated assessments of LI in the same subject, no practice effects were detected.

Conclusions
—Functional TCD is a suitable and very robust tool for the longitudinal quantitative measurement of cerebral language lateralization.
Evidence For Genetic Variance in White Matter Hyperintensity Volume in Normal Elderly Male Twins
Authors: Carmelli Dorit , DeCarli Charles , Swan Gary E. , Jack Lisa M. , Reed Terry , Wolf Philip A. , Miller Bruce L.
Published: June 2011

Background and Purpose
—White matter hyperintensities (WMHs), as detected by MRI, are common among the elderly and are frequently interpreted as representing a subclinical form of ischemic brain damage. We used volumetric MR techniques to investigate the contribution of genes and the environment to measures of brain morphology in a sample of community dwelling elderly male twins.

Methods
—Brain MR (1.5 T) scans were obtained from 74 monozygotic (MZ) and 71 dizygotic (DZ), white, male, World War II veteran twins born in the United States and age 68 to 79 when scanned. MR quantification used a previously published semiautomated segmentation algorithm to segment brain images into total brain, cerebrospinal fluid (CSF), and WMH volumes. Twin pair covariances were computed for each measure, and structural equation genetic models were fitted to these data.

Results
—Total cranial, brain parenchyma, CSF, and WMH volumes were highly correlated in MZ pairs, and correlations in MZ pairs were significantly greater than those in DZ pairs. Structural equation modeling indicated heritabilities of 91%, 92%, and 73%, respectively, for total cranial, brain parenchyma, and WMH volumes. Correction for age and head size reduced the heritability of brain parenchyma to 62% (95% confidence interval, 56% to 68%) and the heritability of WMH volume to 71% (95% confidence interval, 66% to 76%). Proband concordance rates for large amounts of WMH were 61% in MZ pairs and 38% in DZ pairs, compared with a prevalence of 15% in the entire sample.

Conclusions
—This study is the first to quantify the relative contribution of genetic and individual environmental influences to measures of brain morphology in the elderly.
Quantitative Assessment of Mirror Movements After Stroke
Authors: Nelles Gereon , Cramer Steven C. , Schaechter Judith D. , Kaplan Jill D. , Finklestein Seth P.
Published: June 2011

Background and Purpose
—Mirror movements (MM) are involuntary synchronous movements of one limb during voluntary unilateral movements of the opposite limb. We measured MM in stroke and control subjects and evaluated whether MM after stroke are related to motor function.

Methods
—Twenty-three patients and 16 control subjects were studied. A computerized dynamometer was used during two squeezing tasks to measure intended movements from the active hand as well as MM from the opposite hand. Motor deficits were measured with the arm motor component of the Fugl-Meyer scale.

Results
—During paretic hand squeezing, MM in the unaffected hand were detected in 70% (repetitive squeeze) to 78% (sustained squeeze) of stroke patients. For both tasks, this was significantly (
P
<0.05) greater than the incidence of MM in the paretic hand or in either hand of control subjects (17% to 44%), except when compared with the incidence of MM in the dominant hand of control subjects (56%;
P
=0.17). The incidence of MM in the paretic hand was not significantly different from that seen in either hand of control subjects. Patients with MM in the unaffected hand had significantly greater motor deficit than patients without MM. Patients with MM in the paretic hand had significantly better motor function than patients without MM.

Conclusions
—Simultaneously recording motor performances of both hands provides precise information to characterize MM. MM in the unaffected hand and in the paretic hand are associated with different degrees of motor deficit after stroke. Evaluation of MM may be useful for studying mechanisms of stroke recovery.
Transoral Carotid Ultrasonography
Authors: Yasaka Masahiro , Kimura Kazumi , Otsubo Ryoichi , Isa Katsunori , Wada Kuniyasu , Nagatsuka Kazuyuki , Minematsu Kazuo , Yamaguchi Takenori
Published: June 2011

Background and Purpose
—We attempted ultrasonographic evaluation of the distal extracranial internal carotid artery (ICA) using the transoral method (transoral carotid ultrasonography [TOCU]).

Methods
—The subjects consisted of five healthy volunteers and seven stroke patients. Examinations were performed with a color Doppler flow imaging system equipped with convex array transducers (7 or 9.5 MHz), originally designed for transrectal use. After local anesthesia of the pharynx, we inserted a probe covered with thin gum transorally, touching the tip to the pharyngeal posterolateral wall. We then attempted to detect the ICA and measure flow velocity of the distal extracranial ICA using principal images obtained by TOCU.

Results
—TOCU was successfully performed in all subjects without any difficulty. In the healthy volunteers, the ICA was identified at a depth of 2.2±0.6 cm and visualized as a vertical linear vessel 2.9±0.3 cm in length and bent slightly backward. The diameter and mean flow velocity of the distal extracranial ICA were 4.7±0.2 mm and 50±7 cm/s, respectively. In the stroke patients, some remarkable findings were obtained, including a narrow ICA with low flow velocity in a patient with possible ICA dissection, a lucent echo without flow signal in a patient with acute cardioembolic ICA occlusion, and decreased ICA flow velocity in a patient with ipsilateral MCA stenosis.

Conclusions
—These preliminary data demonstrate the potential applicability of TOCU to the evaluation of flow in the far distal extracranial ICA. TOCU definitely warrants further investigation in patients with carotid artery disease.
Frequency of the 20210 G→A Mutation in the 3′-Untranslated Region of the Prothrombin Gene in 35 Cases of Cerebral Venous Thrombosis
Authors: Biousse V. , Conard J. , Brouzes C. , Horellou M. H. , Ameri A. , Bousser M. G.
Published: June 2011

Background and Purpose
—A novel sequence variation in the 3′-untranslated region of the prothrombin (factor II) gene (nucleotide 20210 G→A) has been recently described as a risk factor for deep vein thrombosis and pulmonary embolism. It is found in ≈1% to 4% of healthy subjects. We studied the frequency of this factor II variant in patients with cerebral venous thrombosis.

Methods
—The 20210A allele of the prothrombin gene was studied after DNA extraction, polymerase chain reaction amplification, and
Hin
dIII digestion in 35 patients with magnetic resonance imaging or angiographically confirmed cerebral venous thrombosis (23 women and 12 men, aged 11 to 71 years).

Results
—Two patients (5.7%) had the 20210A allele of the prothrombin gene. Both had other risk factors for thrombosis (use of oral contraceptives and of intrathecal steroids).

Conclusions
—The 20210A allele of the prothrombin gene in association with other prothrombic factors may increase the risk of cerebral venous thrombosis, but case-control studies will be necessary to clarify these associations.
Hypertension and Its Treatment in the NINDS rt-PA Stroke Trial
Authors: Brott Thomas , Lu Mei , Kothari Rashmi , Fagan Susan C. , Frankel Michael , Grotta James C. , Broderick Joseph , Kwiatkowski Thomas , Lewandowski Christopher , Haley E. Clarke , Marler John R. , Tilley Barbara C.
Published: June 2011

Background and Purpose
—We examined the frequency, course, and treatment of hypertension in the NINDS rt-PA Stroke Trial.

Methods
—Blood pressure (BP) was measured at the time of admission, at randomization, and then 36 times during the first 24 hours after randomization. Patients with a systolic BP of >185 mm Hg and a diastolic BP of >110 mm Hg at admission were defined as hypertensive before randomization, and those with a systolic BP of >180 mm Hg or a diastolic BP of >105 mm Hg within the first 24 hours after randomization were defined as hypertensive after randomization. Standardized clinical assessments were conducted at 24 hours and at 3 months. Post hoc analyses were conducted to evaluate the association of antihypertensive therapy with clinical outcomes.

Results
—Of the 624 patients, 121(19%) had hypertension on admission and 372 (60%) had hypertension in the 24 hours after randomization. The use of antihypertensive therapy before randomization (tPA 9%, placebo 9%) and after randomization (tPA 24%, placebo 29%) was similar between placebo- and tPA-treated patients. No adverse effects of prerandomization antihypertensive therapy on 3-month favorable outcome were detected for either the placebo- or tPA-treated groups. For placebo patients with hypertension in the 24 hours after randomization, clinical outcome measures were similar for those patients who did and did not receive antihypertensive therapy after randomization (
P
≥0.26); antihypertensive therapy was not associated with declines in BP (
P
=0.44) or with abrupt declines (
P
=0.14). Those tPA patients who were hypertensive after randomization and received antihypertensive therapy were less likely to have a favorable outcome at 3 months (
P
<0.01) than those who were hypertensive and did not receive antihypertensive therapy.

Conclusions
—The frequency of hypertension and the use of antihypertensive therapy were similar between the tPA and placebo groups in the NINDS rt-PA Stroke Trial. In the placebo group, antihypertensive therapy was not associated with less favorable outcomes at 3 months; postrandomization antihypertensive therapy was associated with less favorable outcomes for the tPA patients who were hypertensive. However, because of the nonrandomized use of antihypertensive therapy and the many post hoc comparisons leading to type 1 errors, the significance of this observation is unclear. Careful attention to BP and gentle management remain warranted for stroke patients treated with tPA.
Diurnal Blood Pressure Change Varies With Stroke Subtype in the Acute Phase
Authors: Dawson Suzanne L. , Evans Steve N. , Manktelow Bradley N. , Fotherby Martin D. , Robinson Thompson G. , Potter John F.
Published: June 2011

Background and Purpose
—It is unclear whether acute stroke is associated with a loss of the normal diurnal blood pressure (BP) change and whether stroke type influences this. Some of this confusion results from the use of fixed time definitions of day and night, which can be overcome by the use of cumulative sums analysis (cusums).

Methods
—Ninety-eight stroke patients had 24-hour BP monitoring (Spacelabs 90207) performed within 48 hours of ictus. Three subgroups were identified: cortical infarct, n=50; subcortical infarct, n=29; and primary intracerebral hemorrhage [PICH], n=19. An age-matched control group of 74 subjects was also studied. Diurnal change was assessed by both day-night differences (absolute and percentage) and cusums (cusums plot height [CPH] and circadian alteration magnitude [CDCAM]); ANCOVA was used to compare groups.

Results
—Compared with control subjects, cortical infarct and PICH subgroups had significantly reduced mean diurnal systolic changes using day-night differences (absolute, –12 and –17 mm Hg; percentage, –10 and –12, respectively;
P
<0.0001) and cusums (CDCAM, –6.96 and –8.6 mm Hg; CPH, –32.05 and –46.04 mm Hg, respectively;
P
<0.005), only the subcortical infarct subgroup demonstrated reduced percentage differences (–4.4%,
P
<0.02). Mean diastolic differences were significantly reduced in all stroke subgroups(CPH, –24.84, –17.31, and –36.92 mm Hg; absolute, –8.26, –4.04, and –11.44 mm Hg; percentage, –10.65, –5.81, and –15.23%, for cortical infarct, subcortical infarct, and PICH subgroups, respectively;
P
<0.05), except for CDCAM, which was not reduced in subcortical infarcts (–4.78 and –7.70 mm Hg for cortical infarct and PICH subgroups, respectively;
P
<0.001).

Conclusions
—Diurnal BP change was reduced in the 3 stroke subgroups studied, especially in patients with cortical infarcts and PICH. This may reflect damage to the central modulation of autonomic BP control. The implications in terms of prognosis and therapy in the acute period require further study.
Long-Term Hemodynamic Effects of Carotid Endarterectomy
Authors: Kluytmans Manon , van der Grond Jeroen , Eikelboom Bert C. , Viergever Max A.
Published: June 2011

Background and Purpose
—The presence and importance of hemodynamic factors to the beneficial effect of carotid endarterectomy (CEA) in patients with severe stenosis of the internal carotid artery (ICA) is unclear. The purpose of this study was to investigate possible hemodynamic changes caused by a severe ICA stenosis and the subsequent changes after CEA.

Methods
—Hemodynamic parameters were acquired with dynamic susceptibility contrast MRI. Regional cerebral blood volume (rCBV), mean transit time (MTT), time of appearance, and time to peak were determined in 19 patients with severe stenosis (>70%) of the ICA before and after CEA and in 33 control subjects. Four patients had an occlusion of the contralateral ICA. Corresponding T2-weighted MRI and inversion recovery MRI scans were used for segmentation of gray and white matter regions.

Results
—In the hemisphere ipsilateral to the stenosed ICA, no significant differences were found for the rCBV or MTT between patients and control subjects. Also, no significant alterations in these two parameters were observed after CEA. In the hemisphere contralateral to the stenosed ICA, hemodynamic changes were observed only in patients with an ICA occlusion contralateral to the stenosed ICA. In these patients, rCBV, MTT, time of appearance, and time to peak were all increased in the contralateral hemisphere. After CEA, all hemodynamic parameters fell in the normal range.

Conclusions
—Although CEA does improve the cerebral circulation in patients with a severe stenosis and a contralateral ICA occlusion, the hemodynamic effects of CEA in patients with severe stenosis without a contralateral ICA occlusion are negligible.
Microvasculopathy Is Associated With the Number of Cerebrovascular Lesions in Hereditary Cerebral Hemorrhage With Amyloidosis, Dutch Type
Authors: Natté Remco , Vinters Harry V. , Maat-Schieman Marion L. C. , Bornebroek Marjolijn , Haan Joost , Roos Raymund A. C. , van Duinen Sjoerd G.
Published: June 2011

Background and Purpose
—Microvascular changes such as microaneurysms and fibrinoid necrosis have been found in the presence of cerebral amyloid angiopathy (CAA). These CAA-associated microvasculopathies (CAA-AM) may contribute to the development of CAA-associated hemorrhages and/or infarcts, hereafter referred to as “cerebrovascular lesions.” Hereditary cerebral hemorrhage with amyloidosis, Dutch type (HCHWA-D) is an autosomal dominant form of CAA, in which the amyloid angiopathy is pathologically and biochemically similar to sporadic CAA associated with aging and Alzheimer disease. To determine the significance of CAA-AM for CAA-associated cerebrovascular complications, we investigated the association between CAA-AM and cerebrovascular lesions in HCHWA-D patients.

Methods
—In a previous autopsy study we semiquantitatively scored CAA-AM in 29 HCHWA-D patients. In the present study we reviewed clinical charts and autopsy protocols of these same patients. We investigated whether CAA-AM was associated with age at death, number of cerebrovascular lesions, duration of clinical illness, hypertension, and atherosclerosis.

Results
—An association was found between CAA-AM and the number of cerebrovascular lesions (
P
=0.009). The presence of microaneurysmal degeneration was most strongly associated with the number of cerebrovascular lesions (
P
<0.001). In addition, we found an association between atherosclerosis and the CAA-AM score (
P
=0.047). Hypertension was not associated with CAA-AM.

Conclusions
—Our findings support previous reports suggesting an important role of secondary microvascular degenerative changes in CAA-associated cerebrovascular lesions and suggest an aggravating effect of systemic atherosclerosis, but not hypertension, on the evolution of CAA-AM. These findings may be of relevance to understanding cerebrovascular complications of sporadic or Alzheimer disease–associated CAA.
Accuracy of ICD-9-CM Coding for the Identification of Patients With Acute Ischemic Stroke
Authors: Goldstein Larry B.
Published: June 2011

Background and Purpose
—Discharge ICD-9-CM (
International Classification of Diseases, 9th Revision, Clinical Modification
) codes have been used to identify patients with acute stroke for epidemiological, quality of care, and cost studies. The aim of this study was to determine if the accuracy of the primary ICD-9-CM codes for ischemic stroke is improved by modifier codes and how specific codes reflect stroke subtype diagnoses.

Methods
—Available hospital charts for all patients discharged from a single hospital between May 1995 and June 1997 with ICD-9-CM codes 433 (occlusion and stenosis of precerebral arteries), 434 (occlusion of cerebral arteries), or 436 (acute but ill-defined cerebrovascular disease) listed in the first position were reviewed. The primary discharge diagnosis was verified, and a presumed stroke subtype was assigned on the basis of information provided in the medical record.

Results
—Charts were available for 175 of the 198 identified patients (88%). Of these, 61% had an acute ischemic stroke (code 433, 4%; 434, 82%; 436, 79%) with the remaining patients having other conditions. Of the 130 patients with a modifier code indicating cerebral infarction, 79% had an acute stroke; of the 45 patients with a modifier code indicating an absence of cerebral infarction, 7% had acute stroke (sensitivity, 0.97; specificity, 0.60). The codes with the highest proportions of ischemic stroke cases were 434.11 (embolic occlusion of cerebral arteries with infarction, 85%), 434.91 (unspecified occlusion of precerebral arteries with infarction, 82%), and 436 (79%), with a combined sensitivity of 0.81 and specificity of 0.90. On review, 73% of patients with code 434.11 had embolic strokes, and 47% of those with code 436 had an identified stroke cause. Of patients with code 434.91, 39% had stroke of uncertain cause, 25% “lacunar,” 17% atherothrombosis, and 15% embolism.

Conclusions
—Despite the use of modifier codes, 15% to 20% of patients with the indicated primary ICD-9-CM codes have conditions other than acute ischemic stroke. Although the proportion of patients with acute stroke increased from 61% to 79% with the use of modifier codes, the inclusion of modifier codes did not have an appreciable effect on the accuracy of the coding if patients with code 433 are excluded. Assignment of presumed ischemic stroke subtype is particularly inaccurate.
Positioning of Stroke Patients
Authors: Jones Anne , Carr Elizabeth K. , Newham Dianne J. , Wilson-Barnett Jenifer
Published: June 2011

Background and Purpose
—There is agreement, although little evidence, that consistently positioning stroke patients in allegedly reflex-inhibiting positions is therapeutic and will enhance functional recovery. The nursing staff, therefore, needs to know and implement these postures and understand their potential underlying value. We examined nurses’ knowledge of and practice in positioning stroke patients before and after a formal teaching intervention.

Methods
—In a quasi-experimental study, 38 stroke patients and 59 nursing staff members (44 trained nurses and 15 healthcare assistants) from 6 wards were studied. The wards were randomly allocated to experimental or control status. Patients were assessed on entry into the study by use of a range of measures to establish group equivalence. Nineteen aspects of their position were documented at intervals throughout their stay with a previously developed observational tool. One thousand sets of observations of patient position were made. Using 2 questionnaires, the nurses’ knowledge of the terminology used to denote posture and of issues relating to the moving and positioning of stroke patients was assessed before, immediately after, and 3 months after a package of formal teaching was implemented on the experimental wards. Nurse knowledge and patient position were used as the main outcome measures.

Results
—Immediately after teaching, nurses in the experimental group scored significantly higher than those in the control group on the terminology questionnaire (
P
<0.05) and the moving and positioning questionnaire (
P
<0.001). Three months later, the experimental group scored higher on the latter questionnaire only (
P
<0.005). The positioning of patients in the experimental group was improved overall after the teaching (
P
<0.0005), and improvements to specific parts of the body were noted.

Conclusions
—It was possible to effect a degree of change in the nurses’ knowledge of and practice in the positioning of stroke patients. However, the quality of patient positioning remained variable. More effective ways of improving positioning need to be developed. Only then can the effects of recommended positioning be evaluated.
Studies of Acute Ischemic Stroke With Proton Magnetic Resonance Spectroscopy
Authors: Wardlaw Joanna M. , Marshall Ian , Wild Jim , Dennis Martin S. , Cannon Jim , Lewis Stephanie C.
Published: June 2011

Background and Purpose
—Proton magnetic resonance spectroscopy (MRS) can be used to study metabolite abnormalities in the brains of stroke patients. We have used it to examine the relations between the metabolites in the infarct (
N
-acetylaspartate [NAA] and lactate) and the time lapse from stroke to MRS, the presenting neurological deficit, infarct size and swelling (on MRI), blood flow to the infarct (estimated by transcranial Doppler ultrasound), and clinical outcome.

Methods
—Patients with symptoms of a moderate to large cortical infarct underwent serial proton MRS (Siemens 1.5 Magnetom) within 4 days, from 5 to 10, and from 11 to 35 days after the stroke. A long echo time PRESS single voxel or chemical shift imaging acquisition was used. Transcranial Doppler ultrasound was performed daily in the first week and twice per week thereafter until the final MRS. Clinical features and baseline demographic data were collected independently by a stroke physician and 6-month outcome by postal questionnaire.

Results
—Fifty patients underwent at least 1 MRS examination. Reduced NAA in the infarct within the first 4 days was related to the clinical stroke syndrome, more extensive infarction, more severely reduced blood supply to the infarct, and the presence of lactate. The presence of lactate was related to large infarcts and reduced NAA. Swelling in the infarct was most closely associated with large infarcts and reduced blood supply but not reduced NAA or the presence of lactate. Clinical outcome was most closely related to the extent of the infarct (more than to the clinical syndrome)−the larger the infarct the worse the outcome−but not to the metabolite concentrations alone.

Conclusions
—The reduction in NAA (but not the presence of lactate) in a visible infarct was related to the reduction in blood flow to the infarct, which in turn was related to infarct extent and clinical outcome.
Inflammation in High-Grade Carotid Stenosis
Authors: Jander Sebastian , Sitzer Matthias , Schumann René , Schroeter Michael , Siebler Mario , Steinmetz Helmuth , Stoll Guido
Published: June 2011

Background and Purpose
—Inflammatory mechanisms have been implicated in the pathogenesis of atherosclerosis. In this study, we investigated whether the extent of inflammatory infiltration in high-grade stenoses of the internal carotid artery (ICA) correlates to clinical features of plaque destabilization.

Methods
—Endarterectomy specimens from 37 consecutive patients undergoing surgery for high-grade ICA stenosis were stained immunocytochemically for macrophages (CD68) and T cells (CD3). The staining was quantified by planimetry of immunostained areas (CD68) or counting individual cells (CD3). Clinical evidence of plaque instability was provided by the preoperative assessment of recent ischemic symptoms attributable to the stenosis and of the occurrence of cerebral microembolism in transcranial Doppler ultrasound monitoring of the ipsilateral middle cerebral artery.

Results
—The percentage of macrophage-rich areas and number of T cells per mm
2
section area were larger in recently symptomatic patients than in asymptomatic patients (macrophages: 18±10% versus 11±4%,
P
=0.005; T cells: 71.2±34.4 versus 40.5±31.4 mm
2
,
P
=0.005). The presence of microembolism was associated with an increase in macrophage-rich areas (
P
=0.011). Macrophage (19±10% versus 9±3%,
P
=0.0009) and T cell (71.5±39.0 versus 46.4±22 mm
2
,
P
=0.045) infiltration were more pronounced in predominantly atheromatous than in fibrous plaques, but did not correlate significantly to the presence of surface ulceration or luminal thrombosis.

Conclusions
—Our data suggest a role of plaque-infiltrating macrophages and T cells in the clinical destabilization of high-grade ICA stenoses. Inflammatory mechanisms may be a therapeutic target in patients with symptomatic ICA disease.
Estrogen-Mediated Neuroprotection After Experimental Stroke in Male Rats
Authors: Toung Thomas J. K. , Traystman Richard J. , Hurn Patricia D.
Published: June 2011

Background and Purpose
—We have previously shown that 17β-estradiol reduces infarction volume in female rats. The present study determined whether single injection or chronic implantation of estrogen confers neuroprotection in male animals with middle cerebral artery occlusion (MCAO) and whether there is an interaction with endogenous testosterone.

Methods
—Male Wistar rats were treated with 2 hours of reversible MCAO. In protocol 1, acute versus chronic estrogen administration was examined in groups receiving the following: Premarin (USP) 1 mg/kg IV, immediately before MCAO (Acute, n=13, plasma estradiol=171±51 pg/mL); 7 days of 25 μg (E25, n=10, 10±3 pg/mL) or 100 μg 17β-estradiol (E100, n=12, 69±20 pg/mL) by subcutaneous implant; or saline (SAL, n=21, 3±1 pg/mL). Laser-Doppler flowmetry was used to monitor the ipsilateral parietal cortex throughout the ischemic period and early reperfusion. At 22 hours of reperfusion, infarction volume was determined by 0 2,3,5-triphenyltetrazolium chloride staining and image analysis. In protocol 2, rats were castrated to deplete endogenous testosterone and then treated with estradiol implants: castration only (CAST, n=13, estradiol=5±2 pg/mL), sham-operated (SHAM, n=10, 4±2 pg/mL), estradiol implant 25 μg (CAST+E25, n=16, 7±2 pg/mL) or 100 μg (CAST+E100, n=14, 77±14 pg/mL).

Results
—Cortical infarct volumes were reduced in all estrogen-treated groups: Acute (21±4% of ipsilateral cortex), E25 (12±5%), and E100 (12±3%) relative to SAL (38±5%). Caudate infarction was similarly decreased: Acute (39±7% of ipsilateral striatum), E25 (25±7%), and E100 (34±6%) relative to SAL (63±4%). Castration did not alter ischemic outcome; cortical and caudate infarction (percentage of respective ipsilateral regions) were 37±5% and 59±5% in CAST and 39±7% and 57±5% in SHAM, respectively. Estrogen replacement reduced infarction volume in castrated animals in cortex (19±4% in CAST+E25 and 12±4% in CAST+E100) and in caudate (42±6% in CAST+25 and 20±7% in CAST+100). Laser-Doppler flowmetry results during ischemia and reperfusion was not different among groups.

Conclusions
—Both acute and chronic 17β-estradiol treatments protect male brain in experimental stroke. Testosterone availability does not alter estradiol-mediated tissue salvage after MCAO.
Enalapril Prevents Imminent and Reduces Manifest Cerebral Edema in Stroke-Prone Hypertensive Rats
Authors: Blezer Erwin L. A. , Nicolay Klaas , Bär P. R. Dop , Goldschmeding Roel , Jansen Gerard H. , Koomans Hein A. , Joles Jaap A.
Published: June 2011

Background and Purpose
—Stroke-prone spontaneously hypertensive rats (SHRSP), subjected to high NaCl intake, show severe hypertension, organ damage, and early death. Preventive treatment with an angiotensin-converting enzyme (ACE) inhibitor is known to reduce mortality. Previously we found that proteinuria always precedes cerebral edema in SHRSP. Hence, in this study ACE inhibition was started later, ie, directly after manifestation of either proteinuria or cerebral edema.

Methods
—SHRSP were subjected to 1% NaCl intake. Group 1 served as a control. In group 2 early-onset treatment with the ACE inhibitor enalapril was initiated after proteinuria was >40 mg/d. In group 3 late-onset ACE inhibition was started after the first observation of cerebral edema with T2-weighted MRI. Cerebral edema was expressed as the percentage of pixels with an intensity above a defined threshold.

Results
—In controls median survival was 54 days (range, 32 to 80 days) after start of salt loading. The terminal level of cerebral edema was 19.0±3.0%. Under early-onset enalapril, median survival increased to 320 days (range, 134 to 368 days;
P
<0.01 versus group 1). Cerebral edema was prevented in all but 1 rat. Systolic blood pressure was slightly and transiently reduced at day 14. Proteinuria was markedly reduced (52±7 versus 190±46 mg/d in group 1 at day 7;
P
<0.05). Under late-onset enalapril, median survival was 264 days (range, 154 to 319 days;
P
<0.01 versus group 1). Cerebral edema decreased to baseline levels (9.6±2.9 at day 0 to 3.4±0.5% at day 3; (
P
<0.05). Ultimately cerebral edema reoccurred in 6 of the 8 rats. SBP decreased slightly at day 7 only. Proteinuria decreased from 283±27 at day 0 to 116±22 mg/d at day 7 (
P
<0.05). Complete remission of the original locus of cerebral edema was confirmed histologically.

Conclusions
—In SHRSP with proteinuria, treatment with an ACE inhibitor both prevented the development of cerebral edema and reduced manifest cerebral edema and proteinuria. Survival was markedly prolonged. These findings support the use of ACE inhibition for treatment in hypertensive encephalopathy.
Normoxic Ventilation After Cardiac Arrest Reduces Oxidation of Brain Lipids and Improves Neurological Outcome
Authors: Liu Yuanbin , Rosenthal Robert E. , Haywood Yolanda , Miljkovic-Lolic Milena , Vanderhoek Jack Y. , Fiskum Gary
Published: June 2011

Background and Purpose
—Increasing evidence that oxidative stress contributes to delayed neuronal death after global cerebral ischemia has led to reconsideration of the prolonged use of 100% ventilatory O
2
following resuscitation from cardiac arrest. This study determined the temporal course of oxidation of brain fatty acyl groups in a clinically relevant canine model of cardiac arrest and resuscitation and tested the hypothesis that postischemic ventilation with 21% inspired O
2,
rather than 100% O
2,
results in reduced levels of oxidized brain lipids and decreased neurological impairment.

Methods
—Neurological deficit scoring and high performance liquid chromatography measurement of fatty acyl lipid oxidation were used in an established canine model using 10 minutes of cardiac arrest followed by resuscitation with different ventilatory oxygenation protocols and restoration of spontaneous circulation for 30 minutes to 24 hours.

Results
—Significant increases in frontal cortex lipid oxidation occurred after 10 minutes of cardiac arrest alone with no reperfusion and after reperfusion for 30 minutes, 2 hours, and 24 hours (relative total 235-nm absorbing peak areas=7.1±0.7 SE, 17.3±2.7, 14.2±3.2, 16.1±1.0, and 14.0±0.8, respectively; n=4,
P
<0.05). The predominant oxidized lipids were identified by gas chromatography/mass spectrometry as 13- and 9-hydroxyoctadecadienoic acids (13- and 9-HODE). Animals ventilated on 21% to 30% O
2
versus 100% O
2
for the first hour after resuscitation exhibited significantly lower levels of total and specific oxidized lipids in the frontal cortex (1.7±0.1 versus 3.12±0.78 μg 13-HODE/g wet wt cortex., n=4 to 6,
P
<0.05) and lower neurological deficit scores (45.1±3.6 versus 58.3±3.8, n=9,
P
<0.05).

Conclusions
—With a clinically relevant canine model of 10 minutes of cardiac arrest, resuscitation with 21% versus 100% inspired O
2
resulted in lower levels of oxidized brain lipids and improved neurological outcome measured after 24 hours of reperfusion. This study casts further doubt on the appropriateness of present guidelines that recommend the indiscriminate use of 100% ventilatory O
2
for undefined periods during and after resuscitation from cardiac arrest.
Dural-Pial Arteriovenous Malformation After Sinus Thrombosis
Authors: Ozawa Tatsuya , Miyasaka Yoshio , Tanaka Ryusui , Kurata Akira , Fujii Kiyotaka
Published: June 2011

Background
—We report an unusual case of acquired dural-pial arteriovenous malformation (AVM) following sinus thrombosis.

Case Description
—Initial angiography performed in a 39-year-old man showed thrombosis of the superior sagittal sinus (SSS) and the right transverse sinus (TS) but no vascular malformations. Follow-up angiography 29 months later revealed recanalization of the SSS and the TS, retrograde cortical venous drainage which suggested that thrombosis of the sinuses probably propagated into the adjacent parietal cortical veins, and development of a dural-pial AVM at or near the site of thrombi in more than one cortical vein. Complete surgical excision of the lesion was accomplished without neurological deterioration.

Conclusions
—The present case suggests the possibility that the pial AVM is not only a congenital condition but also may develop as an acquired lesion.