bluuebunny/crossref_metadata_2025 huggingface dataset:
Parental History of Cardiovascular Disease and Risk of Stroke
Authors: Jousilahti Pekka , Rastenyte Daiva , Tuomilehto Jaakko , Sarti Cinzia , Vartiainen Erkki
Published: June 2011

Background and Purpose
Studies on risk factors for stroke have been less intensive than those for coronary disease. Only a few studies have addressed the question of the role of heredity in the occurrence of stroke. We analyzed whether a positive parental history of cardiovascular disease predicts the risk of stroke independently from other risk factors and whether the role of parental history varies by age and stroke subtypes.

Methods
This study was a prospective follow-up of 14 371 middle-aged men and women. A positive parental history of cardiovascular disease was defined as either stroke or coronary disease before the age of 60 years. The end point of the follow-up was an incident case of stroke. Multivariate analyses were performed with the Cox proportional hazards model.

Results
The risk ratio of stroke after multifactorial adjustment (age, smoking, blood pressure, cholesterol, diabetes, and education) associated with a positive parental history of stroke was 1.89 (
P
=.004) in men and 1.80 (
P
=.007) in women. The association between parental history of stroke and the risk of stroke was stronger among subjects aged 25 to 49 years than among older subjects. Parental history of coronary disease was not associated with the risk of stroke in men, but in women it had a borderline significant association with the risk of ischemic stroke.

Conclusions
A positive parental history of stroke predicted the risk of stroke independently from the other risk factors.
Trunk Control Test as an Early Predictor of Stroke Rehabilitation Outcome
Authors: Franchignoni F. P. , Tesio L. , Ricupero C. , Martino M. T.
Published: June 2011

Background and Purpose
The aim of this study was to investigate the construct and predictive validity of the Trunk Control Test (TCT) in postacute stroke patients by comparing TCT scores at admission and discharge with the Functional Independence Measure (FIM) scores.

Methods
Forty-nine patients participated in the study. The TCT examines four movements: rolling from a supine position to the weak side (T1) and to the strong side (T2), sitting up from a lying-down position (T3), and sitting balance (T4). The FIM is an 18-item scale (13 motor [motFIM] and 5 cognitive [cognFIM]) used to determine the level of dependence of patients in daily life.

Results
Thirty-six patients (73%) increased their TCT overall score at discharge. The TCT item-total correlations were high, both at admission and discharge (
P
<.0001). The individual TCT items were intercorrelated. Furthermore, the homogeneity of the TCT was confirmed by a high Cronbach’s index. High correlations were found between admission and discharge scores in the different tests (TCT, FIM, and motFIM;
P
<.0001) and between TCT at admission and FIM (
P
<.0001) and motFIM (
P
<.0001) at admission. TCT at admission alone explained 71% of the variance in motFIM at discharge.

Conclusions
The TCT showed a good sensitivity to change in assessing recovery of stroke patients. The high item-total correlation and Cronbach’s α value of the TCT suggest that there is one homogeneous construct underlying the item list. The TCT construct validity was confirmed by the correlation between this test and the FIM scores. TCT at admission predicted motFIM at discharge even better than motFIM at admission alone. Possibly, the TCT captures basic motor skills that foreshadow the recovery of more complex behavioral skills described by the FIM.
99m
Tc-HMPAO Brain SPECT Imaging in a Case of Repeated Syncopal Episodes Associated With Smoking
Authors: Fukuda Hitoshi , Kitani Mitsuhiro , Omodani Hiroki
Published: June 2011

Background
We report here a rare case of repeated syncopal episodes associated with smoking and findings of
99m
Tc–hexamethylpropyleneamine oxime (HMPAO) brain single-photon emission CT (SPECT) imaging.

Case Description
A 77-year-old man had four syncopal episodes during a half-month period. All four occurred when he stood up and walked immediately after smoking a cigarette, and syncope did not occur after cessation of smoking. Although upright testing revealed orthostatic hypotension, the patient did not complain of fainting on standing alone. Compared with brain SPECT in the supine position, perfusion was decreased in the posterior circulation structures after the subject smoked a cigarette or chewed nicotine gum.

Conclusions
The combination of cerebral vasoconstriction due to smoking and orthostatic hypotension probably decreased cerebral blood flow in this patient, resulting in syncope.
Severe Pathological Crying After Left Anterior Choroidal Artery Infarct
Authors: Derex Laurent , Ostrowsky Karine , Nighoghossian Norbert , Trouillas Paul
Published: June 2011

Background
There is increasing evidence that serotonergic neurotransmission may be damaged in poststroke pathological crying. A correlation between the clinical severity of pathological crying and the size of stroke-induced serotonergic pathway lesions is commonly accepted. We present a case of severe pathological crying after a limited left anterior choroidal artery territory infarction.

Case Description
A right-handed 55-year-old man who was a heavy smoker was admitted to the hospital after a right hemiplegia of sudden onset. Clinical examination revealed a right global hemiplegia including the face and a right hemihypoesthesia. Cerebral CT scan and MRI showed an infarct in the retrolenticular part of the posterior limb of the left internal capsule extending upward into the posterior paraventricular corona radiata region. Transesophageal echocardiography revealed an atrial septal aneurysm of 15-mm excursion without associated patent foramen ovale. From the first day of admission, the patient exhibited very frequent and intense fits of pathological crying. Their persistence led to initiation of treatment with the selective serotonin reuptake inhibitor paroxetine on day 30. Complete and immediate resolution of pathological crying occurred 24 hours after onset of therapy. Follow-up examination at day 90 confirmed the absence of relapse of pathological crying.

Conclusions
We conclude that poststroke pathological crying in our patient may have been due to unilateral disruption of the capsular ascending projections of the serotonergic brain stem raphe nuclei. A small left-sided capsular lesion may have led to severe pathological crying. This disabling condition may be reversible with selective serotonin reuptake inhibitor therapy.
Cerebrovascular Reactivity in Comatose Patients Resuscitated From a Cardiac Arrest
Authors: Buunk Gerba , van der Hoeven Johannes G. , Meinders Arend E.
Published: June 2011

Background and Purpose
Cerebral blood flow after cardiac arrest is reduced during the delayed hypoperfusion phase, while cerebral metabolic rate of oxygen returns to baseline values. Hypocapnia can induce cerebral ischemia in neurosurgical patients who already have reduced cerebral blood flow. The purpose of the present study was to determine whether comatose patients resuscitated from a cardiac arrest have a normal cerebrovascular reactivity to changes in Paco
2
and whether hypocapnia causes cerebral ischemia.

Methods
We measured mean flow velocity (MFV) and pulsatility index (PI) in the middle cerebral artery, jugular bulb oxygen saturation (Sjb
o
2
), and arterial-jugular lactate difference (AJLD) during normo-, hypo-, and hyperventilation in 10 comatose patients resuscitated from a cardiac arrest. The first measurements were made within 6 hours after cardiac arrest and repeated 6, 12, and 24 hours later.

Results
During hypoventilation we observed a significant decrease in PI and an increase in MFV and Sjb
o
2
. During hyperventilation PI and MFV did not change, but Sjb
o
2
showed a significant decrease. This was accompanied by an increase in AJLD, suggesting cerebral ischemia. In four patients the Sjb
o
2
decreased below the ischemic threshold of 55%.

Conclusions
The cerebrovascular reactivity to changes in arterial carbon dioxide tension is preserved in comatose patients resuscitated from a cardiac arrest. Hyperventilation may induce cerebral ischemia in the postresuscitation period.
Variable Agreement Between Visual Rating Scales for White Matter Hyperintensities on MRI
Authors: Mäntylä Riitta , Erkinjuntti Timo , Salonen Oili , Aronen Hannu J. , Peltonen Teemu , Pohjasvaara Tarja , Standertskjöld-Nordenstam Carl-Gustaf
Published: June 2011

Background and Purpose
Previous reports on the frequency, extent, and clinical correlates of white matter hyperintensities (WMHIs) have been contradictory. The purpose of this study was to test whether part of this variation could be explained by the different properties of the visual WMHI rating scales used.

Methods
The periventricular (PVHIs) and deep white matter (DWMHIs) hyperintensities of 395 poststroke patients were systematically analyzed and transformed to correspond to 13 different rating scales. The scales were compared with the use of Goodman-Kruskal measures of association. The relative frequencies, means, and medians of PVHI and DWMHI grades as well as Spearman rank correlations between WMHI grade and hypertension were calculated.

Results
At best more than 80% of the patients received an equivalent WMHI grade by different scales, but at worst the corresponding values were only 0.4% for PVHI and 18% for DWMHI. At best different scales categorized patients similarly in regard to WMHI grade, but at worst the corresponding values were 8% for PVHI and 57% for DWMHI ratings. The distribution of WMHI grades also varied, and when the effect of age on WMHI was assessed, some of the scales had a ceiling effect and some had a floor effect. Only 1 of the 7 PVHI, 5 of the 9 DWMHI, and 1 of the 3 combined rating scales showed a significant correlation with arterial hypertension, a putative risk factor for WMHIs.

Conclusions
Some of the inconsistencies in previous studies of WMHIs are due to differences in visual rating scales. Our findings may warrant international debate regarding harmonization of WMHI ratings.
Cardiac Baroreceptor Sensitivity Is Impaired After Acute Stroke
Authors: Robinson Thompson G. , James Martin , Youde Jane , Panerai Ronney , Potter John
Published: June 2011

Background and Purpose
The blood pressure (BP) fall and increased BP variability after acute stroke have been previously described. The underlying pathophysiological mechanisms producing these findings are unclear but may include abnormalities of cardiac baroreceptor reflex arc and/or changes in sympathetic nervous system activity. To date, evidence of impaired cardiac baroreceptor sensitivity (BRS) after stroke is limited to patients with chronic disease as determined by invasive methodology. Therefore, it was proposed to assess cardiac BRS and sympathovagal balance with the use of novel noninvasive techniques after acute stroke.

Methods
Thirty-seven acute stroke patients underwent simultaneous surface electrocardiographic and noninvasive beat-to-beat BP recording. Cardiac BRS was assessed by power spectral analysis techniques, and sympathovagal balance was determined from the ratio of the low- to high-frequency powers for pulse interval variability. The responses were compared with a control group matched for age, sex, and BP.

Results
Median cardiac BRS was significantly lower in stroke patients than in control subjects (high-frequency α-index, 4.89 versus 6.50 ms/mm Hg;
P
=.007; combined α-index, 4.65 versus 5.46 ms/mm Hg;
P
=.02). Median normalized high- but not low-frequency power of systolic BP variability was significantly greater in stroke patients (11.0 versus 6.7 normalized units;
P
<.001), probably reflecting differences in the mechanical effects of respiration on BP in stroke patients. No significant differences were observed in the power spectrum of pulse interval variability between stroke patients and control subjects. Patients with right hemisphere strokes, however, had a significant reduction in median high-frequency pulse interval power compared with patients with left hemisphere strokes (8 versus 20 normalized units;
P
=.03), which may reflect a change in sympathovagal balance in favor of increased sympathetic tone in this group.

Conclusions
The impairment of cardiac BRS may be important in explaining the increased BP variability after stroke. There was no significant difference in surrogate measures of sympathovagal activity between acute stroke patients and control subjects, but right hemisphere stroke patients had a significant alteration in the sympathovagal balance of pulse interval variability compared with left hemisphere stroke patients. This sympathetic predominance in right hemisphere strokes may be important in the development of cardiac arrhythmias after stroke. The prognostic implications of these findings need to be further explored.
Epidemiology and Etiology of Ischemic Stroke in Young Adults Aged 18 to 44 Years in Northern Sweden
Authors: Kristensen Bo , Malm Jan , Carlberg Bo , Stegmayr Birgitta , Backman Christer , Fagerlund Markku , Olsson Tommy
Published: June 2011

Background and Purpose
The aim of this study was to conduct a population-based epidemiological survey among young adults aged 18 to 44 years in Northern Sweden and furthermore to gain further insight into the etiology of ischemic stroke in this age group.

Methods
Two studies were done. In the first part, epidemiological data were collected to calculate incidence and mortality from 1991 through 1994. This was based on the World Health Organization Northern Sweden MONICA register of acute stroke events. Eighty-eight first-ever ischemic stroke patients were identified during that period. In the second part, 107 consecutive patients aged 18 to 44 years with ischemic stroke referred to a university hospital were studied prospectively during a 5-year period and were extensively evaluated according to a standardized protocol. On the basis of modified Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria, the patients were classified into eight subtypes of ischemic stroke.

Results
The average population-based annual incidence rate for ischemic stroke (cases per 100 000 per year) was 11.3 (95% confidence interval, 6.7 to 16.1). The case-fatality rate was 5.7%. According to the modified TOAST criteria, a probable cause of ischemic stroke was identified in 36% and remained unexplained in 21% of cases. Spontaneous cervical arterial dissection was the leading probable etiology (13%). Patent foramen ovale or atrial septal aneurysm was a possible cause of stroke in 28% of cases. The percentages of ischemic stroke attributed to IgG anticardiolipin antibodies (4.7%), atherothrombotic vasculopathy (3.7%), oral contraceptive use (7%), and migraine (1%) were lower than reported in recent clinical series.

Conclusions
The incidence rate for ischemic stroke was higher than previously reported from most countries in Western Europe. The higher incidence was not explained by a higher prevalence of premature atherosclerotic vasculopathy. Without the additional diagnostic information derived from advanced cardiac imaging, the proportion of indeterminate cases would have constituted 37% of the patients.
Bone Changes and Carotid Atherosclerosis in Postmenopausal Women
Authors: Uyama Osamu , Yoshimoto Yoshio , Yamamoto Yukiko , Kawai Abi
Published: June 2011

Background and Purpose
Because of increased life expectancy, most postmenopausal women today suffer from osteoporosis and atherosclerotic diseases, which are currently considered unrelated diseases. Our study was aimed at analyzing relations between bone mineral density (BMD) and ultrasonographic assessment of carotid wall characteristics.

Methods
The relation of carotid atherosclerosis to BMD was examined in 30 postmenopausal women aged 67 to 85 years. High-resolution B-mode ultrasonography was performed, and the severity of carotid atherosclerosis was determined by plaque score. BMD was measured by dual-energy x-ray absorptiometry.

Results
The correlation of plaque score with low total BMD was
r
=.549 (
P
<.002). Multiple linear regression analysis indicated significant correlation of plaque score with total cholesterol level and low total BMD.

Conclusions
Our results suggest a relation between carotid atherosclerosis, one of the major causes of ischemic cerebrovascular diseases, and osteoporosis.
Motor Behavior in Stroke Patients With Isolated Medial Frontal Ischemic Infarction
Authors: Chamorro Angel , Marshall Randolph S. , Valls-Solé Josep , Tolosa Eduardo , Mohr J. P.
Published: June 2011

Background and Purpose
Current interpretation of hemiparesis in anterior cerebral artery infarction holds that whereas leg weakness correlates with destruction of the corticospinal tract at the paracentral lobe, faciobrachial symptoms indicate extension of the infarct to the upper lateral convexity or to subcortical structures, where the corticospinal tract subserving the arm would be interrupted. We analyzed the motor behavior in eight patients with purely medial hemispheric infarctions who had face, arm, and leg involvement.

Methods
In addition to careful clinical testing, we performed neuroimaging or pathological studies to exclude the involvement of the primary motor cortex or subcortical structures. Motor function was further tested in three patients by studying the reaction time to an auditory stimulus and by stimulating the motor cortex and the cervical and lumbar spine with a magnetic stimulator.

Results
All patients had signs of motor neglect, such as lack of spontaneous movement in the upper limb, unilateral reaction to pain stimuli, clumsy voluntary movements, or motor impairment on bimanual tasks. Electrophysiologically, we found absent or poor voluntary activity in both upper and lower limbs contralateral to the infarction. However, whereas cortical stimulation showed absent responses in the lower limb, it disclosed normal latencies in the upper limb, indicating that the corticospinal tract to paretic muscles of the upper limb was intact.

Conclusions
Our findings suggest that faciobrachial symptoms in purely medial hemispheric infarctions in the anterior cerebral artery territory reflect motor neglect caused not by involvement of primary motor pathways but by damage to medial premotor areas.
Brain Single-Photon Emission CT With HMPAO and Safety of Thrombolytic Therapy in Acute Ischemic Stroke
Authors: Alexandrov Andrei V. , Masdeu Joseph C. , Devous Michael D. , Black Sandra E. , Grotta James C.
Published: June 2011

Background
To reliably identify patients at risk for symptomatic hemorrhagic transformation (SHT), future trials of thrombolysis for acute ischemic stroke might use a vascular imaging protocol applicable to a multicenter setting. The goal of this commentary is to address the safety of intravenous thrombolysis with the recombinant tissue plasminogen activator (rTPA) and potential solutions offered by single-photon emission CT (SPECT) as a noninvasive brain perfusion imaging modality.

Summary of Review
Even if patients with severe stroke, extensive ischemic changes on CT scan, advanced age, and high blood pressure are excluded from thrombolytic therapy, this cannot completely guarantee the safety of using rTPA. Brain SPECT scanning with hexamethylpropyleneamine oxime (HMPAO) may help to screen out patients at risk if performed in addition to clinical and CT tests. The knowledge of pretreatment severity, extent, and location of ischemia might identify good versus poor responders to rTPA therapy. HMPAO-SPECT is widely available and feasible to perform without delaying rTPA therapy. Rigorous quality control and use of reproducible visual and semiquantitative methods of interpreting SPECT are necessary for implementation of SPECT technology in multicenter clinical trials.

Conclusions
The major obstacle to general acceptance of thrombolytic therapies and rTPA in particular is the fear of symptomatic hemorrhagic transformation, and because HMPAO-SPECT might reliably identify patients at high risk of symptomatic hemorrhagic transformation, the clinical value of HMPAO-SPECT in patient selection for thrombolysis during the first hours of acute ischemic stroke should be determined through a prospective clinical trial.
Pilot Study of Functional MRI to Assess Cerebral Activation of Motor Function After Poststroke Hemiparesis
Authors: Cao Y. , D’Olhaberriague L. , Vikingstad E. M. , Levine S. R. , Welch K. M. A.
Published: June 2011

Background and Purpose
—Studies of cerebral activation of motor function after ischemic stroke may enhance our understanding of the underlying mechanisms of motor functional recovery, including the role of the noninfarcted hemisphere.

Methods
—Eight right-handed recovering hemiparetic or hemiplegic patients were studied using functional MRI. Results were evaluated for each patient to consider individual variability in original functional organization, neuroanatomy, infarct size and extent, treatment, age, and sex. The results were also pooled as a group for comparison with a control group of eight right-handed normal subjects.

Results
—In six of eight stroke patients, extended activation in ipsilateral sensorimotor cortex was observed during paretic hand movements. Bilateral activation of the primary sensorimotor cortex was recorded in three of these six patients; ipsilateral activation alone was recorded in the remaining three patients. Only two patients had mild synkinesia. Furthermore, in two male patients, the paretic hand movements activated extended areas of ipsilateral premotor and dorsolateral prefrontal cortex, when compared with normal subjects. In two patients with left frontal infarction, profound activation in the right supramarginal gyrus and in the right premotor cortex was observed during the ipsilateral paretic hand movements.

Conclusions
—Synkinesia alone cannot explain the extent of ipsilateral activation in primary sensorimotor cortex. The explanation offered for our findings is that preexisting uncrossed motor neural pathways may be accessed or recruited to compensate for damage to the crossed motor pathways after ischemic stroke.
Frequency of Cerebral Arteritis in Subarachnoid Cysticercosis
Authors: Barinagarrementeria Fernando , Cantú Carlos
Published: June 2011

Background and Purpose
—Subarachnoid cysticercosis is a well-recognized cause of cerebral infarction. However, few patients with this infection develop cerebral infarction, and the reason for this is not known. The aim of this study was to determine the frequency of cerebral arteritis in these patients.

Methods
—Using cerebral arteriography, we studied 28 patients with subarachnoid cysticercosis admitted to our hospital from July 1993 to February 1996. All patients underwent MRI to detect the presence of basal arachnoiditis. We analyzed demographic data, time to cysticercosis since the first symptom onset, mode of onset, stroke syndromes, neuroimaging features of cysticercosis and cerebral infarction, and arteriographic findings for each patient.

Results
—Of the 28 patients (mean age, 37 years), 15 patients had angiographic evidence of cerebral arteritis (53%); 12 of the 15 had a stroke syndrome (
P
=.02). Eight of the 15 patients (53%) with cerebral arteritis had evidence of cerebral infarction on MRI, whereas only one patient without cerebral arteritis had cerebral infarction (
P
=.05). The most commonly involved vessels were the middle cerebral artery and the posterior cerebral artery.

Conclusions
—The frequency of cerebral arteritis in subarachnoid cysticercosis is higher than previously reported, and middle-size vessel involvement is a common finding, even in those patients without clinical evidence of cerebral ischemia.
Proteinuria Precedes Cerebral Edema in Stroke-Prone Rats
Authors: Blezer Erwin L. A. , Schurink Merel , Nicolay Klaas , Bär P. R. Dop , Jansen Gerard H. , Koomans Hein A. , Joles Jaap A.
Published: June 2011

Background and Purpose
—Stroke-prone spontaneously hypertensive rats (SHRSP) subjected to high sodium intake develop severe hypertension, cerebral edema, and proteinuria, culminating in organ damage and early death. MRI, which can be applied serially, provides the unique opportunity to study temporal and quantitative relations between these changes and whether diminution of sodium intake can attenuate established cerebral edema.

Methods
—SHRSP were subjected to 1% NaCl in drinking water. Cerebral MRI, proteinuria and systolic blood pressure (SBP) were measured serially. After detection of cerebral edema (T2-weighted MRI), 6 rats were killed for histology, to confirm the diagnosis of cerebral edema. The others were followed up for 7 more days while salt loading was continued (n=10, group 1) or after sodium intake was normalized (n=7, group 2).

Results
—SHRSP invariably developed cerebral edema in 30 days (range, 8 to 54 days). At this point neurological signs were absent in 16 of 23 rats. SBP rose until 1 week before detection of cerebral edema, and then stabilized at approximately 265 mm Hg. Proteinuria invariably preceded cerebral edema, with a concentration exceeding 40 mg/d predicting development of cerebral edema in 9 days (range, 3 to 15 days). There was linear correlation (
R
=.62,
P
<.0001) between proteinuria and cerebral edema (pixels with an intensity above a defined threshold). Rats in group 1 showed an increase in cerebral edema (from 5.8±1.1% to 12.5±2.8%;
P
<.05), and proteinuria remained high (from 305±44 to 338±29 mg/d); and 2 died spontaneously. Rats in group 2 showed no significant change in edema (from 4.9±0.5% to 6.9±1.3%) but a marked fall in proteinuria (from 294±24 to 119±10 mg/d;
P
<.05), both significantly different from group 1 (
P
<.05); all survived. SBP remained unaltered in both groups.

Conclusions
—Our data establish MRI as a sensitive method for detection of cerebral edema, often prior to neurological signs, in SHRSP. Proteinuria predicts cerebral edema, and these two variables, both obtained noninvasively, are quantitatively related. Moreover, in SHRSP normalizing sodium intake after salt loading attenuates development of cerebral edema and reduces proteinuria.
A Glycine Site Antagonist, ZD9379, Reduces Number of Spreading Depressions and Infarct Size in Rats With Permanent Middle Cerebral Artery Occlusion
Authors: Tatlisumak Turgut , Takano Kentaro , Meiler Michael R. , Fisher Marc
Published: June 2011

Background and Purpose
—Spreading depressions (SDs) occur in experimental focal ischemia and contribute to lesion evolution.
N
-Methyl-
d
-aspartate (NMDA) antagonists inhibit SDs and reduce infarct size. The glycine site on the NMDA receptor complex offers a therapeutic target for acute focal ischemia, potentially devoid of many side effects associated with competitive and noncompetitive NMDA antagonists. We evaluated the effect of the glycine antagonist ZD9379 on SDs and brain infarction.

Methods
—Male Sprague-Dawley rats (n=18) weighing 290 to 340 g undergoing permanent middle cerebral artery occlusion (MCAO) were randomly and blindly assigned to receive drug or placebo: group 1 (pre-MCAO treatment group; n=5), a 5-mg/kg bolus of ZD9379 over 5 minutes followed by 5 mg/kg per hour drug infusion for 4 hours beginning 30 minutes before MCAO; group 2 (post-MCAO treatment group; n=7), a 5-mg/kg bolus of ZD9379 30 minutes after MCAO followed by 5 mg/kg per hour drug infusion for 4 hours; and group 3 (control group; n=6), vehicle for 5 hours beginning 30 minutes before MCAO. SDs were monitored electrophysiologically for 4.5 hours after MCAO by continuous recording of cortical DC potentials and electrocorticogram. Infarct volume was measured 24 hours after MCAO by 2,3,5-triphenyltetrazolium chloride staining.

Results
—Corrected infarct volume was 90±72 mm
3
(mean±standard deviation) in group 1, 105±46 mm
3
in group 2, and 226±40 mm
3
in group 3 (
P
<.001). The corresponding numbers of SDs in the three groups were 8.2±5.8, 8.1±2.5, and 16.0±5.1, respectively (
P
<.01). When all animals (n=18) were analyzed, infarct volumes and the number of SDs were significantly correlated (
r
=.68,
P
=.002).

Conclusions
—This study demonstrated that ZD9379 initiated before or after MCAO significantly reduced the number of SDs and infarct volume in a permanent focal ischemia model, implying that ZD9379 is neuroprotective and its neuroprotective effect may be related to inhibiting ischemia-related SDs.
Transient Increase of Manganese–Superoxide Dismutase in Remote Brain Areas After Focal Photothrombotic Cortical Lesion
Authors: Bidmon Hans-J. , Kato Kanefusa , Schleicher Axel , Witte Otto W. , Zilles Karl
Published: June 2011

Background and Purpose
—Free radicals including superoxide are responsible for postlesional cytotoxicity. In contrast to the constitutive CuZn–superoxide dismutases (SODs), manganese–superoxide dismutase (Mn–SOD) is inducible and has the potential to protect neurons by its superoxide dismutating activity. Therefore, we studied the presence and the regional changes in Mn–SOD within the brain after focal cortical ischemia.

Methods
—Focal cortical photothrombotic lesions were produced in the hindlimb region of rat brains. Animals were anesthetized and transcardially perfused with Zamboni’s fixative. Mn–SOD was immunohistochemically localized using an antiserum against rat-Mn–SOD. Changes in Mn–SOD immunoreactivity were quantified by image analysis.

Results
—Focal photothrombosis caused a perilesional increase in Mn–SOD after 24 hours, followed by a further significant increase at 48 hours in perilesional cortex, ipsilateral corpus callosum, hippocampus, and thalamus, as well as in a homotopic cortical area within the nonlesioned hemisphere. At day 2, Mn–SOD was present in neurons and astrocytes. Up to day 7, Mn–SOD increased in the entire ipsilateral and contralateral cortex but remained higher elevated in the ipsilateral hippocampus and thalamus. Thereafter, Mn–SOD decreased globally but remained elevated in some cortical neurons up to day 60.

Conclusions
—The early transient increase of Mn–SOD in distinct brain regions, which are functionally connected via afferents and efferents, suggests that these regions are affected by the injury. It suggests that Mn–SOD protects the cells in these regions from superoxide-induced damage and therefore may limit the retrograde and anterograde spread of neurotoxicity.
Risk Factors for Ischemic Stroke in a Russian Community
Authors: Feigin Valery L. , Wiebers David O. , Nikitin Yury P. , O’Fallon W. Michael , Whisnant Jack P.
Published: June 2011

Background and Purpose
—This study was conducted to determine the risk factors for ischemic stroke in a defined Russian population.

Methods
—Our data are based on a population-based case-control study of 237 patients with first-ever ischemic stroke and 237 age- and sex-matched controls. Logistic regression methods for matched pairs were used to estimate the relative risk for the variables studied.

Results
—In a multivariate analysis, hypertension, left ventricular hypertrophy on electrocardiography, ischemic heart disease, mitral valve disease, current cigarette smoking, and high body mass index were significant and independent risk factors for ischemic stroke in this Russian community.

Conclusions
—The significant risk factors for ischemic stroke in Novosibirsk are similar to those from other populations and cohorts. This study, the first of stroke risk factors in Russia, has implications for clinical practice and the planning of stroke prevention in the population.
Blood Flow of the Middle Cerebral Artery With Sleep-Disordered Breathing
Authors: Netzer Nikolaus , Werner Peter , Jochums Isabel , Lehmann Manfred , Strohl Kingman P.
Published: June 2011

Background and Purpose
—Epidemiological data link heavy snoring to an increased risk for stroke, an association often ascribed to hypertension and/or sleep apnea. The aim of this study was to determine whether obstructive hypopneas, central apneas, or obstructive apneas during sleep alter blood flow of the middle cerebral artery (MCA).

Methods
—Doppler sonography of the MCA was performed in conjunction with nightly polysomnography in 11 men and one woman.

Results
—A significant decline in blood flow occurred in 76% (169/223) of obstructive hypopneas and in 80% (98/123) of obstructive apneas, compared with only 14% (13/96) of central apneas (
P
≤.0001). While duration of events was not significantly different, MCA blood flow reductions were associated only with the duration of the obstructive hypopneas (
P
≤.01) and not with the duration of central (
P
=.17) or obstructive (
P
=.07) apneas. The magnitude of fall in arterial oxygen saturation from baseline correlated with a reduced blood flow with obstructive hypopneas but not with obstructive or central apneas.

Conclusions
—With obstructive hypopneas and obstructive apneas, MCA blood flow is more often decreased in comparison to central apneas. MCA blood flow reductions occur with longer obstructive hypopneas and with those hypopneas with greater falls in oxygen saturation. These observations indicate pathophysiology relevant to an increased risk for stroke in heavy snorers and patients with obstructive hypopneas and apneas.
Changing Practice and Costs of Carotid Endarterectomy in Toronto, Canada
Authors: Smurawska L. T. , Bowyer B. , Rowed D. , Maggisano R. , Oh P. , Norris J. W.
Published: June 2011

Background and Purpose
—During our annual audits of carotid endarterectomy (CEA) in Toronto metropolitan hospitals, we have been aware of major changes in the practice of this operation in recent years. To evaluate the effect of changing practice on costs of carotid endarterectomy, we have therefore compared the effects of changes in length of stay, complication rates, and other variables on cost during the last 3 years for which we have complete data.

Methods
—We evaluated 757 consecutive patients, of whom 600 had CEA procedures in 3 teaching hospitals, and 190 procedures in 2 community hospitals in metropolitan Toronto. We estimated costs using a specially designed computer program, Transitional System Incorporated, including surgical complications, in patients admitted between January 1994 and December 1996.

Results
—There was a significant decrease in length of stay in both groups of hospitals, mainly due to preoperative outpatient evaluation but also due to lower complication rates, which probably reflect an increase in asymptomatic surgery in both hospital groups. Costs fell from approximately $8000 per procedure to $5000 in asymptomatic patients and from approximately $10 000 to $7000 in symptomatic patients (Can $).

Conclusions
—Major changes in the management of patients undergoing CEA have resulted in a significant decrease in both length of hospital stay and utilization of postoperative intensive care. At the same time, complication rates have significantly fallen, although our mortality and morbidity figures remain slightly higher than those from published multicenter trials. Future changes in surgical practice in Canada, including noninvasive carotid imaging, should produce even lower costs within the next few years.
Recurrent Carotid Stenosis
Authors: Moore Wesley S. , Kempczinski Richard F. , Nelson J. J. , Toole James F.
Published: June 2011

Background and Purpose
—We sought to determine the incidence of recurrent carotid stenosis in patients in the Asymptomatic Carotid Atherosclerosis Study (ACAS) who had undergone carotid endarterectomy and were prospectively followed with Doppler ultrasound for up to 5 years.

Methods
—The ACAS database was interrogated to determine the rate of recurrent carotid stenosis (≥60%) based up angiogram-validated Doppler data, with a 90% and a 95% positive predictive value, as well as information concerning the technologists’ interpretation of percent stenosis. These 3 parameters are reported for each of 3 time intervals: within 3 months of operation (residual disease), between 3 and 18 months (early restenoses), and between 18 and 60 months (late restenosis).

Results
—Of the 825 patients randomized to the surgical arm of the study, 720 actually underwent carotid endarterectomy, and 645 had complete ultrasound data. The aggregate incidence of residual and recurrent carotid stenosis for all time intervals ranged from 12.7% to 20.4%, depending on the positive predictive value confidence level desired. Residual disease occurred in 4.1% to 6.5%; true, early restenosis was found in 7.6% to 11.4%; and late restenosis occurred in 1.9% to 4.9%. None of the traditional risk factors showed a statistically significant effect on recurrent stenosis. The use of patch angioplasty closure reduced overall risk of restenosis from 21.2% to 7.1%, from 16.7% to 4.6%, and from 27.4% to 8.2%, depending on the PPV confidence level desired (
P
<0.001). Of the 136 patients judged to have recurrent stenosis, only 8 (5.9%) underwent reoperation (only 1 for symptoms). There was no correlation between late stroke and recurrent stenosis.

Conclusions
—Carotid endarterectomy is a durable procedure with a low rate of true restenosis, particularly when patch angioplasty is used to close the arteriotomy.
Physical Activity and Stroke Incidence
Authors: Lee I-Min , Paffenbarger Ralph S.
Published: June 2011

Background and Purpose
—Physiologically, it appears plausible for physical activity to decrease stroke risk; however, epidemiological studies have produced mixed findings. Furthermore, few studies have examined specific kinds and intensities of activities. The purpose of this study was to examine the association between physical activity, including its various components (walking, climbing stairs, participation in sports and recreational activities), and stroke risk.

Methods
—This was a prospective cohort study of 11 130 Harvard University alumni (mean age, 58 years) without cardiovascular disease and cancer at baseline. Men reported their walking, stair climbing, and participation in sports or recreation on baseline questionnaires in 1977. Stroke occurrence was assessed with another questionnaire in 1988. Death certificates were obtained for decedents through 1990 to determine strokes not previously reported (total strokes=378). We used Cox proportional hazards regression to estimate the relative risks and 95% CIs for stroke occurrence associated with physical activity.

Results
—After adjustment for age, smoking, alcohol intake, and early parental death, the relative risks of stroke associated with <1000, 1000 to 1999, 2000 to 2999, 3000 to 3999, and ≥4000 kcal/wk of energy expenditure at baseline were 1.00 (referent), 0.76 (95% CI, 0.59 to 0.98), 0.54 (0.38 to 0.76), 0.78 (0.53 to 1.15), and 0.82 (0.58 to 1.14), respectively;
P
=0.05 for linear trend. Walking ≥20 km/wk was associated with significantly lower risk, independent of other physical activity components. Climbing stairs and activities of at least moderate intensity (≥4.5 METs, or multiples of resting metabolic rate) each showed U-shaped relations to stroke risk, with the risk being significantly lower at the nadir of the curve. Light intensity activities (<4.5 METs), however, were unrelated to stroke risk.

Conclusions
—Physical activity is associated with decreased stroke risk in men. A decreased risk was observed at energy expenditures of 1000 to 1999 kcal/wk, with further risk decrement seen at 2000 to 2999 kcal/wk but not beyond. Confirmation of the U-shaped relation observed in these data requires similar observations in other populations.
North Carolina Stroke Prevention and Treatment Facilities Survey
Authors: Goldstein Larry B. , Hey Lloyd A. , Laney Ronnie
Published: June 2011

Background and Purpose
—North Carolina is situated in the “stroke belt” region of the United States, an area of the country with a particularly high incidence of cerebrovascular disease. The North Carolina Stroke Prevention and Treatment Facilities Survey was carried out to determine the availabilities of a variety of stroke prevention and treatment services throughout the state. The purpose of the present study was to determine how widely recombinant tissue-type plasminogen activator (rtPA) has been adopted for the treatment of patients with acute ischemic stroke and to determine the characteristics of the medical facilities in the state offering this therapy.

Methods
—A single-page survey was mailed to the medical center directors of each inpatient medical facility in North Carolina. Data collected included questions related to the availability of selected basic and advanced diagnostic tests and procedures, stroke prevention and treatment programs and services (community stroke awareness program, acute stroke identification program, acute stroke team, stroke rtPA protocol, stroke care map, neurologist), and facilities (Stroke Acute Care Unit or equivalent).

Results
—Responses were obtained from all 125 inpatient medical facilities in North Carolina. rtPA stroke protocols were adopted in 54 facilities located in 46 of the state’s 100 counties. Seventy-four percent of the state’s population resides in counties with hospitals providing rtPA treatment. Compared with facilities not offering rtPA, those with rtPA protocols more commonly sponsored stroke community awareness programs (41% versus 17%,
P
=0.003) and more frequently had an organized stroke team (31% versus 8%,
P
=0.001), used stroke care maps (56% versus 17%,
P
<0.001), had rapid stroke identification programs (33% versus 6%,
P
<0.001), or had a Stroke Acute Care Unit or its equivalent (33% versus 7%,
P
<0.001). Neurologists were available in 78% of the facilities offering rtPA compared with 38% in facilities without rtPA protocols (
P
<0.001).

Conclusions
—These data show that this new therapy for ischemic stroke is potentially available to a high proportion of the state’s citizens based on their county of residence. However, other services that may improve outcomes and reduce stroke-related costs (eg, stroke teams, stroke units, care maps) are not being widely used, even in centers providing treatment with rtPA. The simple methodology used in this study is potentially applicable in other states and permits targeting of selected centers for development of stroke treatment capabilities.
Dichotomized Efficacy End Points and Global End-Point Analysis Applied to the ECASS Intention-to-Treat Data Set
Authors: Hacke Werner , Bluhmki Erich , Steiner Thorsten , Tatlisumak Turgut , Mahagne Marie-Helene , Sacchetti Marisa-Luisa , Meier Dieter
Published: June 2011

Background and Purpose
—It is not yet known which end points are the most suitable for evaluation of the effects of acute stroke intervention. The European Cooperative Acute Stroke Study (ECASS) I study used 2 primary end points. The study was powered to detect a 15% improvement of the median of each primary end point. The study failed to show this effect and was negative in the intention-to-treat analysis. The National Institute of Neurological Disorders and Stroke (NINDS) study used 4 dichotomized end points and applied a global end-point analysis. This study was positive and led to FDA approval of thrombolytic therapy for acute ischemic stroke. This study was undertaken to answer the question of whether a different statistical design may have shown a positive results of the ECASS I trial.

Methods
—We performed a retrospective analysis of the ECASS I intention-to-treat data set (615 randomized and treated patients, rtPA treatment versus placebo) and post hoc application of the NINDS trial statistical methodology (global end-point analysis). The scores of the modified Rankin Scale (mRS), Barthel Index (BI), and the National Institutes of Health Stroke Scale (NIHSS) were dichotomized according to the criteria used in the NINDS trial. Favorable outcome was defined as a score of 0 or 1 on mRS, a score of 95 or 100 on BI, and a score of 0 or 1 on NIHSS.

Results
—The number of patients reaching favorable outcome were higher in all 3 end points in the rtPA-treated group. The effect sizes were 8% for mRS, 6% for BI, and 14% for NIHSS, respectively. The differences are statistically significant for the mRS (
P
=0.044; odds ratio [OR], 1.4; 95% confidence interval [CI], 1.0 to 2.0) and the NIHSS (
P
=0.001; OR, 1.9; 95% CI, 1.4 to 2.8), while for the BI significance was missed (
P
=0.102; OR, 1.3; 95% CI, 0.9 to 1.8). The global end-point statistics, however, shows a significant increase (
P
=0.008; OR, 1.5; 95% CI, 1.1 to 2.0) of favorable outcome in the rtPA-treated patient group.

Conclusions
—Using the global end-point analysis, ECASS is positive in the intention-to-treat analysis. This may indicate that the time window for thrombolysis may be as long as 6 hours. Looking at the 3 dichotomized end points, the effect sizes for 2 end points, mRS and BI, are smaller in the ECASS 6-hour intention-to-treat population compared with the NINDS trial, whereas the effect size for the NIHSS is larger. While in the NINDS trial all 3 end points reveal statistically significant results, in ECASS only 2 of the 3 corresponding end points, mRS and NIHSS, were statistically significant. This finding underlines an important difference of a global end-point approach: it may show a positive overall result although one of the end points is not positive.
Incidence and Determinants of Poststroke Dementia as Defined by an Informant Interview Method in a Hospital-Based Stroke Registry
Authors: Inzitari Domenico , Di Carlo Antonio , Pracucci Giovanni , Lamassa Maria , Vanni Paola , Romanelli Marco , Spolveri Stefano , Adriani Paolo , Meucci Ilaria , Landini Giancarlo , Ghetti Augusto
Published: June 2011

Background and Purpose
—Inconsistent information about incidence and determinants of poststroke dementia might be related to patient attrition, partly because of nonapplicability of formal neuropsychological testing to a large proportion of patients registered in a definite setting.

Methods
—Using a proxy-informant interview based on ICD-10 criteria, we determined dementia at stroke onset and 1 year after stroke in the 339 patients who survived, were available for follow-up, and were not demented at stroke onset of 635 patients entered over a 1-year period in a stroke registry taken at 2 community hospitals in Florence, Italy.

Results
—Of the 339 patients, 57 (16.8%) proved to have poststroke dementia. These patients were older, more frequently female, and more often (multivariate odds ratio, 2.35; 95% CI, 1.21 to 4.58) had atrial fibrillation than those without dementia. Aphasia and the clinical features expressing the severity of the stroke event in the acute phase predicted poststroke dementia.

Conclusions
—In a hospital-based nonselected series of stroke survivors, despite the use of a method with low sensitivity for defining dementia, our study confirms that dementia is a frequent sequela of stroke and is mainly predicted by stroke severity. Certain determinants could be controlled in the prestroke phase, thus reducing its risk.