bluuebunny/crossref_metadata_2025 huggingface dataset:
A Prediction Model for Functional Recovery in Stroke
Authors: Stineman Margaret G. , Maislin Greg , Fiedler Roger C. , Granger Carl V.
Published: June 2011

Background and Purpose
Stroke-related physical disability can diminish quality of daily living, place care burden on families, and increase need for long-term institutionalization. We developed a prognostic index for use in research and with potential for adaptation to clinical practice that establishes the likelihood of an individual achieving a specific stage of functional recovery after stroke rehabilitation.

Methods
We constructed the index using logistic regression based on 3760 patient records from 96 rehabilitation facilities in 31 states. The stage, as measured by the Functional Independence Measure, includes achievement of the following: independence in eating, grooming, and dressing the upper body; continence in bowel and bladder; and transfer between a bed and chair with supervision only.

Results
This stage was achieved by 26.1% of patients functioning below it at rehabilitation admission. Disability onset of less than 60 days was associated with more than a 3-fold increase in the likelihood of achieving the stage (adjusted odds ratio, 3.5; 95% confidence interval, 2.0 to 6.0). Each eight-point increase in an eight-item activities of daily living score, measured at admission to rehabilitation, increased the odds 2.5-fold (95% confidence interval, 2.3 to 2.8). For those living alone or employed before the stroke, the odds of achieving the stage increased by factors of 1.3 and 2.2, respectively. The index showed minimal shrinkage on cross validation. The achievement of this profile of function is important because 95.3% of stroke patients who achieved or exceeded it were discharged home, as opposed to only 66.8% of those who did not achieve it.

Conclusions
The index can be used to establish prognoses for individual stroke patients at admission to rehabilitation with regard to achieving this stage. Achievement of the stage is associated with a high likelihood of discharge to home.
Intravenous Basic Fibroblast Growth Factor Decreases Brain Injury Resulting From Focal Ischemia in Cats
Authors: Bethel Ameil , Kirsch Jeffrey R. , Koehler Raymond C. , Finklestein Seth P. , Traystman Richard J.
Published: June 2011

Background and Purpose
We tested the hypothesis that intravenous administration of basic fibroblast growth factor (bFGF) during 4 hours of permanent focal ischemia would affect acute brain injury.

Methods
Halothane-anesthetized cats underwent left middle cerebral artery (MCA) occlusion for 4 hours. Control cats received diluent (n=14). Experimental cats were treated with bFGF at a rate of 5 (n=13), 50 (n=13), or 250 μg/kg per hour (n=9) intravenously beginning 60 minutes after initiation of ischemia and continuing until the end of the protocol.

Results
As measured by the microsphere method, blood flow to ipsilateral caudate nucleus and ipsilateral inferior temporal cortex was decreased similarly during ischemia, before drug administration, in all groups. Likewise, there was no difference in blood flow to ipsilateral caudate nucleus or inferior temporal cortex as a result of bFGF administration during MCA occlusion. Triphenyltetrazolium-determined injury volume of the ipsilateral cerebral cortex (control, 40±7%; bFGF 5 μg/kg per hour, 22±5%; bFGF 50 μg/kg per hour, 26±7%; bFGF 255 μg/kg per hour, 23±6% of ipsilateral cerebral cortex; mean±SEM) was less in cats treated with bFGF. There was no difference among groups in injury volume to caudate nucleus (control, 29±8%; bFGF 5 μg/kg per hour, 29±8%; bFGF 50 μg/kg per hour, 21±7%; bFGF 250 μg/kg per hour, 32±7% of ipsilateral caudate nucleus). Somatosensory evoked potential amplitude decreased similarly (to <20% of baseline amplitude in all groups) during MCA occlusion and was not altered by bFGF administration.

Conclusions
These data indicate that systemic administration of bFGF ameliorates acute injury in the cerebral cortex without increasing blood flow during focal ischemia in cats. Because bFGF afforded protection when administered after the onset of ischemia, bFGF may provide its beneficial effect by limiting progression of injury in ischemic border regions.
Intravitreal Injection of Ganglioside GM1 After Ischemia Reduces Retinal Damage in Rats
Authors: Mohand-Said Saddek , Weber Michel , Hicks David , Dreyfus Henri , Sahel José Alain
Published: June 2011

Background and Purpose
Gangliosides are normal components of cell membranes and contribute to structural rigidity and membrane function. They have been shown to protect against various insults in the brain. We have shown previously that GM1 administered intraperitoneally before the induction of retinal ischemia provides a protective effect. This study evaluates the protective effect of GM1 administered intravitreally after ischemia on retinal lesions.

Methods
We induced retinal ischemia unilaterally in Long-Evans rats by increasing intraocular pressure to 160 mm Hg for 60 minutes. GM1 (20 μL · 10
−5
mol/L) or saline (20 μL) was injected into the vitreous 15 minutes after ischemia, and the postischemic survival time was either 8 or 15 days. The degree of retinal damage was assessed by histopathological study.

Results
Retinal ischemia led to reductions in thickness and cell number, principally in the inner retinal layers (39% to 80%) and to a lesser extent in the outer retinal layers (26% to 45%). Postischemic treatment with intravitreally injected GM1 conferred significant protection against retinal ischemic damage after both 8 and 15 days of survival time. After 8 days of reperfusion, the ischemia-induced loss in overall retinal thickness was reduced by 15% and those of the inner nuclear and plexiform layers by 44% and 17%, respectively. Ischemic-induced ganglion cell and inner nuclear cell density losses were reduced by 37% and 27%, respectively. After 15 days of reperfusion, approximately the same statistically significant differences could be observed in comparison with the 15-day saline-injected group.

Conclusions
GM1 protects the rat retina from pressure-induced ischemic injury when given intravitreally after the insult. The protection provided by GM1 after initiation of retinal damage could be of therapeutic interest.
Response to Hypercapnia in Moyamoya Disease
Authors: Kuwabara Yasuo , Ichiya Yuichi , Sasaki Masayuki , Yoshida Tsuyoshi , Masuda Kouji , Matsushima Toshio , Fukui Masashi
Published: June 2011

Background and Purpose
We have previously reported that cerebral blood flow decreased and oxygen extraction fraction and cerebral blood volume increased in pediatric patients with moyamoya disease, whereas these values did not change significantly in adult patients. In this study, we measured the cerebrovascular response to hypercapnia using
15
O H
2
O positron emission tomography (PET) in each group of patients. These data were also compared with the oxygen extraction fraction and transit time (cerebral blood volume/cerebral blood flow) measured by
15
O PET.

Methods
The subjects consisted of 20 patients with moyamoya disease (7 pediatric and 13 adult patients). Cerebral blood flow was measured by the
15
O H
2
O bolus injection method at the resting state and during the inhalation of 5% CO
2
. Cerebrovascular CO
2
response was estimated as the percentage change of cerebral blood flow per 1 mm Hg change of Pa
co
2
. Oxygen extraction fraction and transit time were measured by the
15
O steady-state method.

Results
Cerebrovascular response to hypercapnia severely decreased over the cerebral cortices in both pediatric and adult patients with moyamoya disease when compared with those of normal control subjects, and there was no significant difference between pediatric and adult patients. A significant correlation was observed between the CO
2
response and transit time, whereas no significant correlation was seen between the CO
2
response and oxygen extraction fraction.

Conclusions
Our study revealed that the cerebral hemodynamic reserve capacity decreased to an equal degree in both pediatric and adult patients with moyamoya disease. This finding may thus help to explain the occurrence of transient ischemic attack in adult patients.
Task-Related Training Improves Performance of Seated Reaching Tasks After Stroke
Authors: Dean Catherine M. , Shepherd Roberta B.
Published: June 2011

Background and Purpose
After stroke, the ability to balance in sitting is critical to independence. Although impairments in sitting balance are common, little is known about the effectiveness of rehabilitation strategies designed to improve it. The purpose of this randomized placebo-controlled study was to evaluate the effect of a 2-week task-related training program aimed at increasing distance reached and the contribution of the affected lower leg to support and balance.

Methods
Twenty subjects at least 1 year after stroke were randomized into an experimental or control group. The experimental group participated in a standardized training program involving practice of reaching beyond arm’s length. The control group received sham training involving completion of cognitive-manipulative tasks within arm’s length. Performance of reaching in sitting was measured before and after training using electromyography, videotaping, and two force plates. Variables tested were movement time, distance reached, vertical ground reaction forces through the feet, and muscle activity. Subjects were also tested on sit-to-stand, walking, and cognitive tasks. Nineteen subjects completed the study.

Results
After training, experimental subjects were able to reach faster and further, increase load through the affected foot, and increase activation of affected leg muscles compared with the control group (
P
<.01). The experimental group also improved in sit-to-stand. The control group did not improve in reaching or sit-to-stand. Neither group improved in walking.

Conclusions
This study provides strong evidence of the efficacy of task-related motor training in improving the ability to balance during seated reaching activities after stroke.
Ethnic Differences in Stroke Incidence and Case Fatality in Auckland, New Zealand
Authors: Bonita Ruth , Broad Joanna B. , Beaglehole Robert
Published: June 2011

Background and Purpose
This study compares stroke incidence, 28-day case fatality, and hospital management for Maori, Pacific Islands people (“Pacific people”), and others (mostly Europeans) living in Auckland, New Zealand.

Methods
Data come from the Auckland Stroke Study, a population-based study that registered all stroke events occurring among Auckland residents aged 15 years or more during a 1-year period ending February 29, 1992.

Results
During the study year, 1803 stroke events were registered, including 82 (4.5%) in Maori, 113 (6.3%) in Pacific people, 1572 (87.2%) in Europeans, and 36 (2.0%) in others of Indian or Chinese origin. The mean±SD age of stroke patients was 55.0±16.0 years in Maori, 59.7±14.9 years in Pacific people, and 73.3±12.1 years in Europeans. Maori and Pacific people have significantly higher estimated relative risks of stroke compared with Europeans (OR, 1.34; 95% confidence interval [CI], 1.05 to 1.67 in Maori; and OR, 1.63; 95% CI, 1.33 to 1.98 in Pacific people). Maori and Pacific people also have higher estimated relative risks of death within 28 days of stroke compared with Europeans, especially men.

Conclusions
This study indicates that there are important differences in stroke incidence rates and case fatality among the major ethnic groups in Auckland. The reasons for the higher incidence rates in Maori and Pacific people may be related to levels of risk factors, but this requires further investigation. Ongoing monitoring of stroke incidence and outcome should include separate reporting by ethnicity.
Cognitive Deficits in Peripheral Vascular Disease
Authors: Phillips Natalie A. , Mate-Kole C. Charles
Published: June 2011

Background and Purpose
Evidence indicates that peripheral vascular disease (PVD) and cerebrovascular disease (CVD) coexist and therefore reflect a generalized pattern of atherosclerotic disease in an individual. Given the known deleterious effects of CVD on cognitive function, it was hypothesized that patients with PVD may have impaired cerebral function due to concomitant but clinically unrecognized CVD. The purpose of this study was to determine whether neuropsychological tests would reveal this potential dysfunction.

Methods
Neuropsychological test scores (n=25) were compared across three groups: (1) 29 PVD patients (13 amputees, 16 nonamputees), (2) 29 age- and education-matched patients with atherothrombotic brain infarcts (ie, CVD), and (3) 30 age- and education-matched control subjects.

Results
PVD patients performed significantly worse (
P
<.002) than control subjects on eight neuropsychological measures of executive function, attention, and visuospatial function. The pattern and, in certain instances, the magnitude of impairment was highly similar between PVD and CVD subjects. Regression analyses revealed that PVD severity and ischemic heart disease were significant negative predictors of test performance. Depression and atherosclerotic risk factors did not explain neuropsychological deficits after the effects of PVD and ischemic heart disease were considered.

Conclusions
PVD patients exhibit neuropsychological deficits that suggest the presence of mild vascular-related brain dysfunction. Patients with multiple manifestations of generalized atherosclerosis (ie, severe PVD, ischemic heart disease) appear to be particularly at risk. Clinicians should be alert to these potential deficits and to the possibility of further vascular-related cognitive decline.
Polymorphisms of the Factor VII Gene and Circulating FVII:C Levels in Relation to Acute Cerebrovascular Disease and Poststroke Mortality
Authors: Heywood Daniella M. , Carter Angela M. , Catto Andrew J. , Bamford John M. , Grant Peter J.
Published: June 2011

Background and Purpose
FVII:C has been shown to be an independent risk factor for myocardial infarction and is related to environmental and genetic factors. This study sought to investigate FVII:C levels and factor VII (FVII) gene polymorphisms in relation to stroke and disease outcome.

Methods
To examine the association of FVII:C and the
Msp
I and promoter insertion polymorphisms of the FVII gene in acute stroke, 317 patients and 198 age-matched control subjects were studied.

Results
FVII:C levels were significantly lower in patients at onset than 3 months later (119% versus 135%, respectively;
P
<.0005). Levels were significantly lower in patients at onset than in control subjects (124% [95% confidence interval, 120% to 129%] versus 141% [95% confidence interval, 135% to 148%], respectively;
P
<.0005) but were not significantly different at 3 months (135% [95% confidence interval, 128% to 141%] versus 141% [95% confidence interval, 135% to 148%], respectively). We found no difference in genotype distribution for either polymorphism between patients and control subjects, no difference in FVII:C level or genotype distribution between pathological types of stroke, and no relationship with poststroke mortality. Both polymorphisms were significantly associated with FVII:C levels in patients and control subjects. In a multiple regression model for patients,
Msp
I genotype, cholesterol, and smoking remained as independent predictors of FVII:C levels, accounting for 32% of interindividual variation.

Conclusions
These results suggest that neither FVII:C levels nor FVII gene polymorphisms are associated with cerebrovascular disease. There were no genotype-specific correlations of environmental factors with FVII:C, but there was evidence of an acute-phase or consumptive fall in FVII:C levels at the time of stroke, whereas levels increased to those similar for healthy age-matched control subjects by 3 months, when the acute phase had presumably subsided.
Gene Transfer to Cerebral Blood Vessels After Subarachnoid Hemorrhage
Authors: Muhonen Michael G. , Ooboshi Hiroaki , Welsh Michael J. , Davidson Beverly L. , Heistad Donald D.
Published: June 2011

Background and Purpose
Vasospasm remains a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. One step toward gene therapy to prevent spasm of cerebral vessels is to determine whether subarachnoid blood prevents transgene expression.

Methods
Vasospasm was induced in mongrel dogs using the double-hemorrhage intracranial-injection model. Diameter of the basilar artery was assessed by angiography, and profound vasospasm (>50% decrease in diameter) was demonstrated at 4 and 7 days. Recombinant adenovirus expressing nuclear-targeted β-galactosidase (reporter gene) under the control of the cytomegalovirus promoter was injected into the cisterna magna at the same time as (n=9) or 2 days after (n=4) injection of blood for induction of vasospasm. Brains were removed and examined histochemically for expression of nuclear β-galactosidase.

Results
At 2 to 7 days, β-galactosidase was expressed in leptomeninges over the brain stem, cortex, cerebral arteries, in small vessels in the cerebrum and brain stem, and in the ependymal lining of the ventricles. Transgene expression was observed in adventitia of blood vessels but not in vascular muscle or endothelium. Transgene expression was observed after simultaneous injection of virus and blood or when virus was injected 2 days after blood.

Conclusions
The findings indicate that intracisternal injection of recombinant adenovirus can be used for gene transfer to cerebral blood vessels and overlying meninges, even in the presence of cisternal blood. We speculate that transfer of genes using recombinant viral vectors that encode for enzymes with vasodilator function to cerebral blood vessels and perivascular tissues may be useful for prevention or treatment of cerebral vasospasm after subarachnoid hemorrhage.
Indobufen Versus Warfarin in the Secondary Prevention of Major Vascular Events in Nonrheumatic Atrial Fibrillation
Authors: Morocutti Cristoforo , Amabile Giuseppe , Fattapposta Francesco , Nicolosi Alfredo , Matteoli Sergio , Trappolini Massimo , Cataldo Gabriella , Milanesi Geremia , Lavezzari Maurizio , Pamparana Franco , Coccheri Sergio
Published: June 2011

Background and Purpose
The results of a large prospective randomized trial have shown the efficacy of oral anticoagulation in the secondary prevention of major vascular events in patients with nonrheumatic atrial fibrillation (NRAF); less well established is the role of antiplatelet agents. The present study compared the effects of indobufen, a reversible inhibitor of platelet cyclooxygenase, with those of warfarin in this setting.

Methods
A total of 916 patients with NRAF and a recent (≤15 days) cerebral ischemic episode were admitted to this multicenter, randomized study, during which they were treated with either indobufen (100 or 200 mg BID) or warfarin (to obtain an international normalized ratio of 2.0 to 3.5) for 12 months. The two groups (462 on indobufen and 454 on warfarin) were well balanced in terms of their main baseline characteristics. The primary outcome of the study was the combined incidence of nonfatal stroke (including intracerebral bleeding), pulmonary or systemic embolism, nonfatal myocardial infarction, and vascular death.

Results
At the end of follow-up, the incidence of primary outcome events was 10.6% in the indobufen group (95% confidence interval, 7.7% to 13.5%) and 9.0% in the warfarin group (95% confidence interval, 6.3% to 11.8%), with no statistically significant difference between treatments. The frequency of noncerebral major bleeding complications was low: only four cases (0.9%) of gastrointestinal bleeding were observed, all of them in the warfarin group.

Conclusions
We conclude that, within the limitations of its design, this study may help the medical community in devising appropriate antithrombotic strategies for NRAF patients for whom oral anticoagulants are contraindicated or do not represent a feasible approach to treatment.
Cerebral Infarcts Related to Isolated Middle Cerebral Artery Stenosis
Authors: Lyrer P. A. , Engelter S. , Radü E. W. , Steck A. J.
Published: June 2011

Background and Purpose
The clinical presentation of middle cerebral artery (MCA) stenosis, a rarely diagnosed condition, is not well known. The aim of this study was to analyze the stroke patterns of patients with isolated MCA stenosis.

Methods
Twenty-two patients with cerebral infarcts due to isolated MCA stenosis were analyzed with respect to their clinical syndrome, and cerebral lesions were assessed by neuroimaging. MCA stenosis was diagnosed by transcranial Doppler sonography (TCD) in 16, by TCD and digital subtraction angiography (DSA) in 4, and by DSA alone in 2 patients.

Results
Ten patients (45.5%) had lacunar syndromes, suggesting small-vessel disease, and 12 patients (55.5%) showed signs and symptoms of cortical dysfunction. Cerebral CT or MRI showed no lesion in 2 patients, small deep infarcts in 10, large striatocapsular infarcts in 2, combined piomedullary and striatocapsular infarcts in 4, piomedullary branch infarcts in 3, and MCA trunk infarct in 1.

Conclusions
The results suggest an association between MCA stenosis and (1) lacunar infarcts and (2) the occurrence of piomedullary MCA branch infarcts alone or in combination with subcortical infarcts. The clinical syndromes and the radiological findings correspond in most cases.
Diffusion-Weighted Imaging Discriminates Between Cytotoxic and Vasogenic Edema in a Patient With Eclampsia
Authors: Schaefer Pamela W. , Buonanno Ferdinand S. , Gonzalez R. Gilberto , Schwamm Lee H.
Published: June 2011

Background
The pathophysiology of eclampsia remains unclear. While the majority of patients develop reversible T2 hyperintense signal abnormalities on MR scans and reversible neurological deficits, some patients do develop infarctions (permanent T2 hyperintense abnormalities) and permanent neurological impairment. Routine MRI cannot prospectively differentiate between these two patient groups. Echo-planar diffusion-weighted imaging, however, is a new technique that clearly differentiates between cytotoxic and vasogenic edema.

Case Description
A 30-year-old woman developed symptoms consistent with eclampsia 24 hours after delivering premature twins. An MRI demonstrated extensive, diffuse T2 hyperintense signal abnormalities involving subcortical white matter and adjacent gray matter with a posterior predominance, consistent with either infarction or hypertensive ischemic encephalopathy. Diffusion-weighted images demonstrated increased diffusion, consistent with vasogenic edema and hypertensive ischemic encephalopathy.

Conclusions
Unlike routine MRI, diffusion-weighted imaging reliably differentiates between vasogenic edema and cytotoxic edema. Consequently, in eclamptic patients diffusion-weighted imaging can afford clear differentiation between hypertensive ischemic encephalopathy and infarction, two very different entities with very different treatment protocols. Diffusion-weighted imaging should be performed in all eclamptic patients and should greatly affect their management.
Internal and External Carotid Contributions to Near-Infrared Spectroscopy During Carotid Endarterectomy
Authors: Lam Joseph M.K. , Smielewski Peter , Al-Rawi Pippa , Griffiths Paul , Pickard John D. , Kirkpatrick Peter J.
Published: June 2011

Background and Purpose
The internal carotid (ICA) and external carotid (ECA) contributions to changing concentrations of oxyhemoglobin (Hb
o
2
) and deoxyhemoglobin (Hb) during carotid endarterectomy were assessed with the use of near-infrared spectroscopy (NIRS).

Methods
NIRS optodes were placed on the forehead with an interoptode distance of 6 cm, and laser-Doppler flowmetry (LDF) was used to monitor the change in skin blood flow between the optodes. Hb, Hb
o
2
, LDF, arterial blood pressure, and middle cerebral artery flow velocity were recorded continuously. The ECA was clamped 2 minutes before the ICA was clamped. Suitable multimodal recordings were achieved in 44 patients.

Results
When the ECA was clamped, 76% of patients showed a fall in Hb
o
2
and 65% an increase in Hb. When corrected for changes in arterial blood pressure, an accompanying fall in cutaneous LDF predicted the fall in Hb
o
2
with high sensitivity (100%) and specificity (100%). Among those with no NIRS changes during ECA clamping, 56% had severe ECA stenosis or occlusion; none of these showed an accompanying fall in LDF. In contrast, when the ICA was clamped, substantial additional changes in NIRS occurred in 55% of cases, all of which were associated with a fall in flow velocity, but none with a change in LDF. Patients with a constant flow velocity after ICA clamping also showed no change in NIRS.

Conclusions
Both the ECA and ICA vascular territories contribute to NIRS changes during carotid endarterectomy. The external carotid contribution to NIRS can be monitored with cutaneous LDF.
Race-Ethnicity and Determinants of Carotid Atherosclerosis in a Multiethnic Population
Authors: Sacco Ralph L. , Roberts J. Kirk , Boden-Albala Bernadette , Gu Qiong , Lin I-Feng , Kargman Douglas E. , Berglund Lars , Hauser W. Allen , Shea Steven , Paik Myunghee C.
Published: June 2011

Background and Purpose
Risk factors for carotid atherosclerosis have been studied in white populations but infrequently in multiethnic cohorts. The aim of this study was to determine the importance of race-ethnicity and other factors associated with carotid atherosclerosis in a mixed population of Hispanics, blacks, and whites.

Methods
As part of the Northern Manhattan Stroke Study, 526 stroke-free community residents (aged ≥40 years; 41% men, 59% women; 46% Hispanic, 31% black, 23% white) were recruited through random-digit dialing and had vascular risk factor evaluations. Maximum internal carotid artery plaque thickness (MICPT) was measured with B-mode ultrasound. The frequency distribution of MICPT was examined in the three race-ethnic groups, and multivariate regression was performed to identify factors that were independently associated with MICPT.

Results
Mean MICPT in the entire sample was 1.5±1.4 mm, increased directly with age, and was greater in whites and blacks than Hispanics. Other independent determinants of MICPT included smoking, glucose, LDL cholesterol, and hypertension. After we controlled for these covariates, Hispanic (versus non-Hispanic) race-ethnicity was still an independent determinant of less carotid plaque. There was a significant interaction between race-ethnicity and LDL cholesterol, with a greater effect of increasing LDL cholesterol among Hispanics.

Conclusions
Atherosclerotic risk factors were predictive of MICPT in this mixed-ethnic cohort. Hispanics had significantly less carotid plaque after adjustment for other known risk factors, but they also had a greater impact of increasing LDL cholesterol.
Evaluation of Social Status as a Contributing Factor to the Stroke Belt Region of the United States
Authors: Howard George , Anderson Roger , Johnson Norman J. , Sorlie Paul , Russell Gregory , Howard Virginia J.
Published: June 2011

Background and Purpose
The southeastern United States has stroke mortality rates above the national average. The causes for this excess mortality are unknown; however, lower socioeconomic status (SES) is a risk factor for stroke, and the lower SES in the Southeast is a potential cause. In this report we assess the proportion of the excess stroke mortality attributable to SES.

Methods
The more than 400 000 participants in the National Longitudinal Mortality Study were categorized into three regions: the coastal plain region of North Carolina, South Carolina, and Georgia (“stroke buckle”); the remainder of these states plus five other southern states (“stroke belt”); and the remainder of the United States. The stroke mortality rates were calculated with and without adjustment for SES, and the proportion of the excess mortality attributable to SES was estimated.

Results
In persons between the ages of 35 and 54 years, stroke mortality in the stroke buckle is estimated to be more than twice that of the rest of the nation and 1.7 times greater for ages 55 to 74 years. For persons in the stroke belt, the stroke mortality was 1.3 times greater than that in the rest of the nation for the ages of 35 to 54 and 55 to 74 years. Less than 16% of this excess stroke morality was attributable to SES.

Conclusions
SES does not appear to be a major contributor to the excess mortality in the southeastern United States. Of additional concern is the stroke buckle region, which was shown to have stroke mortality rates substantially greater than those in the traditionally recognized stroke belt.
Stroke, Statins, and Cholesterol
Authors: Blauw Gerard J. , Lagaay A. Margot , Smelt Augustinus H. M. , Westendorp Rudi G. J.
Published: June 2011

Background and Purpose
To estimate the effect of 3-hydroxy-3-methylglutaryl–coenzyme A (HMG-CoA) reductase inhibitors (“statins”) on stroke risk, we combined the data of the randomized, placebo-controlled, double-blind trials with HMG-CoA reductase inhibitors published so far.

Methods
The studies were identified using the Medline CD+ and Current Contents databases from January 1980 through May 1996, inclusive. All studies were evaluated on the use of a placebo control, monotherapy, and double blindness. When the type of stroke or the occurrence of clinical events or adverse effects were incompletely or not reported, the investigators were contacted personally. For each trial, the number of strokes in the treatment arm was compared with the number of strokes expected on all observations under the assumption that drug treatment had no effect.

Results
A total of 462 strokes among 20 438 participants in 13 trials could be analyzed. A total of 181 strokes were observed in patients randomized to treatment with an HMG-CoA reductase inhibitor and 261 strokes in patients randomized to placebo. A lower than expected number of strokes was observed in the treatment groups of all but one trial (
P
=.001). Treatment with an HMG-CoA reductase inhibitor led to an overall risk reduction of 31% (odds ratio, 0.69; 95% confidence interval, 0.57 to 0.83).

Conclusions
The combined data suggest that treatment with HMG-CoA reductase inhibitors prevents stroke in middle-aged persons. Because stroke is especially common in older age, these data reinforce the need for clinical trials to evaluate the effect of HMG-CoA reductase inhibitors in preventing stroke in the elderly.
Apolipoprotein E Polymorphism and Silent Microangiopathy-Related Cerebral Damage
Authors: Schmidt R. , Schmidt H. , Fazekas F. , Schumacher M. , Niederkorn K. , Kapeller P. , Weinrauch V. , Kostner G. M.
Published: June 2011

Background and Purpose
Microangiopathy-related cerebral damage (MARCD) includes white matter abnormalities and lacunar infarctions and represents a common MRI observation in subjects above 50 years of age. The risk factors of such brain abnormalities are not fully determined. The goal of this study was to determine whether the genetic heterogeneity of apolipoprotein E (apoE) contributes to the occurrence of MARCD.

Methods
Brain MRI (1.5 T) was performed in 280 individuals (ages 50 to 75 years) without neuropsychiatric disease randomly selected from the official register of residents of the city of Graz, Austria. All study participants underwent apoE genotyping, carotid Doppler sonography, electrocardiography, echocardiography, and a complete blood chemistry panel. MARCD was defined as evidence of early confluent and confluent white matter hyperintensities or lacunes. Carotid atherosclerosis was graded on a five-point scale ranging from not present (0) to complete occlusion (5).

Results
MARCD occurred in 61 individuals (21%). The distribution of apoE genotypes differed significantly between subjects with and without MARCD (
P
=.036). Subjects with such findings more commonly had the ε2/ε3 genotype (24.6% versus 10%) at similar frequencies of genotypes containing the ε4 allele. The ε2/ε3 genotype was associated with lower levels of total cholesterol (
P
=.0009), LDL cholesterol (
P
=.00001), and apolipoprotein B (
P
=.00001). Also, there was a nonsignificant trend toward less cardiac disease. Other major vascular risk factors and carotid abnormalities were similar among the various genotypes. Multiple logistic regression analysis created a model of significant MARCD predictors, including age (odds ratio [OR], 1.1 per year), hypertension (OR, 3.4), and the apoE ε2/ε3 genotype (OR, 3.0).

Conclusions
These data suggest an association between the apoE ε2/ε3 genotype and MARCD despite favorable effects on the lipid profile and cardiac disease.
Implementation of a Stroke Code System in Mobile, Alabama
Authors: Zweifler Richard M. , Drinkard Renay , Cunningham Sarah , Brody Mark L. , Rothrock John F.
Published: June 2011

Background and Purpose
There is now therapy of proven benefit for acute ischemic stroke. Successful interventional therapy for stroke patients requires implementation of a system that facilitates rapid triage and diagnostic evaluation.

Methods
We initiated a 24-hour, 7-day-per-week stroke code system at the University of South Alabama Hospitals and prospectively collected data from the first 100 patients whose clinical presentations triggered this system.

Results
Seventy-eight patients (78%) had acute ischemic stroke. Of the remaining 22, 9 had evidence of intracerebral hemorrhage. The most common nonstroke diagnosis was seizure (n=5). Forty-eight of the 87 stroke patients (55%) presented within 6 hours of stroke onset (40/78=51% of the ischemic stroke patients), and 35 of the 87 (40%) presented within 3 hours of onset (28/78=36% of the ischemic stroke patients). Thirty-one (31% of the group overall; 40% of the ischemic stroke patients) were eligible for acute therapy. Twenty-five of these eligible patients were entered into a treatment study, 4 declined participation, and 2 were treated with open-label tissue plasminogen activator.

Conclusions
Implementation of a stroke code system may result in a high yield of patients with acute stroke and relatively few “stroke mimickers.” A significant proportion of all cases generated will be eligible for acute treatment under current experimental protocols or with tissue plasminogen activator, but the majority will not.
Xenon Contrast CT-CBF Measurements in High-Intensity Foci on T2-Weighted MR Images in Centrum Semiovale of Asymptomatic Individuals
Authors: Miyazawa Nobuhiko , Satoh Takashi , Hashizume Kazuhiro , Fukamachi Akira
Published: June 2011

Background and Purpose
White matter lesions (WMLs) on T2-weighted MR images occurring in the centrum semiovale of normal individuals are a subject of great clinical interest. We therefore investigated regional cerebral blood flow (rCBF) of the centrum semiovale among neurologically normal individuals.

Methods
One hundred thirty-five neurologically normal subjects were divided into four grades of WML on the basis of their MR images. rCBF values in the centrum semiovale were measured by xenon contrast CT methods.

Results
Advanced age and associated hypertension were significant risk factors for higher grade WMLs. Centrum semiovale rCBF values on the left side were 24.27±2.60 mL·100 g
−1
·min
−1
in grade 0, 23.52±2.78 in grade I, 19.35±2.81 in grade II, 15.82±2.05 in grade III, and 11.31±2.56 in grade IV. Differences were significant between grades (
P
<.005 between grade 0 and grades II, III, and IV; between grade II and grades III and IV; and between grades III and IV). Patients with hypertension had lower rCBF values than those without in grades 0, I, II, and III, with significant difference in grade I (
P
<.005). Age-matched studies between patients 61 to 70 years old confirmed a significant difference between WML grades.

Conclusions
WMLs in centrum semiovale are associated with greater age, hypertension, and reduced rCBF values.
Acute Stroke Care and Rehabilitation: An Analysis of the Direct Cost and Its Clinical and Social Determinants
Authors: Jørgensen Henrik Stig , Nakayama Hirofumi , Raaschou Hans Otto , Olsen Tom Skyhøj
Published: June 2011

Background and Purpose
Stroke represents a major economic challenge to society. The direct cost of stroke is largely determined by the duration of hospital stay, but internationally applicable estimates of the direct cost of acute stroke care and rehabilitation on cost-efficient stroke units are not available. Information regarding social and medical factors influencing the length of hospital stay (LOHS) and thereby cost is needed to direct cost-reducing efforts.

Methods
We determined the direct cost of stroke in the prospective, consecutive, and community-based stroke population of the Copenhagen Stroke Study by measuring the total LOHS in the 1197 acute stroke patients included in the study. All patients had all their acute care and rehabilitation on a dedicated stroke unit. Neurological impairment was measured by the Scandinavian Stroke Scale. Local nonmedical factors affecting the LOHS, such as waiting time for discharge to a nursing home after completed rehabilitation, were accounted for in the analysis. The influence of social and medical factors on the LOHS was analyzed in a multiple linear regression model.

Results
The average LOHS was 27.1 days (SD, 44.1; range, 1 to 193), corresponding to a direct cost of $12.150 per patient including all acute care and rehabilitation. The LOHS increased with increasing stroke severity (6 days per 10-point increase in severity;
P
<.0001) and single marital status (3.4 days;
P
=.02). Death reduced LOHS (22.0 days;
P
<.0001). Age, sex, diabetes, hypertension, claudication, ischemic heart disease, atrial fibrillation, former stroke, other disabling comorbidity, smoking, daily alcohol consumption, and the type of stroke (hemorrhage/infarct) had no independent influence on LOHS.

Conclusions
Acute care and rehabilitation of unselected patients on a dedicated stroke unit takes on average 4 weeks. In general, comorbidity such as diabetes or heart disease does not increase LOHS. Efforts to reduce costs should therefore aim at reducing initial stroke severity or improving the rate of recovery.
Stroke Recurrence in Diabetics
Authors: Alter Milton , Lai Sue-Min , Friday Gary , Singh Vineeta , Kumar V. Mangesh , Sobel Eugene
Published: June 2011

Background and Purpose
Patients with diabetes are at increased risk of stroke. Risk might be reduced if blood glucose level were controlled.

Methods
In a population-based study, we enrolled 621 patients within a month of an initial ischemic stroke and followed them regularly twice annually; 198 were diabetic. We monitored blood glucose level in 142 (72%) using glycosylated hemoglobin (HbA
lc
). Recurrent stroke frequency was determined by history, examination, and medical records. Cox proportional hazards models were used to examine the relationship between risk of recurrent stroke and HbA
lc
level. The models included interaction with time-dependent HbA
lc
level and history of diabetes, selected medical comorbidities, age, and sex. HbA
lc
level was analyzed as both a continuous and a dichotomous variable (ie, controlled versus uncontrolled); “controlled” was defined with different cut points.

Results
All but 17 patients (12%) whose blood glucose was monitored were well controlled (HbA
lc
<8%). HbA
lc
level was not associated with increased risk of stroke recurrence (hazard ratio [HR], 0.87 per 1% increment in HbA
lc
; 95% confidence interval [CI], 0.623 to 1.219), nor was there a trend toward increased risk of recurrent stroke as the cut point defining “controlled” increased: with HbA
lc
at <6%, the HR for the uncontrolled group was 0.51 (95% CI, 0.176 to 1.503); at <7%, it was 0.43 (95% CI, 0.089 to 1.923); and at <8%, it was also 0.43 (95% CI, 0.057 to 3.317).

Conclusions
Among diabetic patients with an initial stroke, no association between HbA
lc
level over time and risk of stroke recurrence was found. However, most patients in this cohort were well controlled, and any adverse effect of poor control could not be adequately tested.
Perspectives of Stroke in Persons Living in Seoul, South Korea
Authors: Kim Jong S. , Yoon Sung S.
Published: June 2011

Background and Purpose
The aim of the present study was to investigate the perspectives of stroke in persons who live in Seoul, South Korea, a country which is unique in that the social and political status of traditional (herbal) medicine is equal to that of western (modern) medicine.

Methods
We randomly selected 1000 persons living in Seoul, South Korea, and performed open-ended telephone interviews regarding stroke risk factors, symptoms, and the choice of treatment for stroke. We also asked whether the subjects would prefer to visit western-medicine doctors or traditional-medicine doctors if they developed stroke.

Results
Twenty-nine percent of the interviewees responded correctly that the most important risk factor for stroke is hypertension. However, other major factors, such as cigarette smoking, diabetes mellitus, and heart disease, were greatly underappreciated, while less important risk factors such as hyperlipidemia/obesity, stress, and exposure to coldness were overappreciated. Also, although 65% of the subjects correctly identified paresis as the most important symptom of stroke, tremor was indicated incorrectly as an important symptom of stroke. Regarding the choice of treatment, only 46% responded that visiting a hospital is the most important method of treatment, whereas a significant percentage of the subjects responded that they would prefer herbal medicine and other traditional methods of treatment. Generally, the older and less educated the subjects, the more they prefer to depend on traditional medicine.

Conclusions
These data show that perspectives of stroke are heavily influenced by the presence of traditional medicine in Korea, especially in older and less educated persons. This perspective significantly deviates from the scientific concept regarding the etiology, symptoms, and treatment of stroke. Current science-based health education is urgently needed in this country.
DNA Scission After Focal Brain Ischemia
Authors: Tagaya Masafumi , Liu Kai-Feng , Copeland Brian , Seiffert Dietmar , Engler Robert , Garcia Julio H. , del Zoppo Gregory J.
Published: June 2011

Background and Purpose
Species- and model-dependent differences in cell response to focal brain ischemia may underlie differences in adhesion receptor expression. The aim of this study was to quantitatively evaluate the spatial and temporal distribution of dUTP incorporation into damaged DNA, as an indicator of ischemic injury, in the corpus striatum.

Methods
Cerebral ischemia was produced in 16 nonhuman primates and 19 rats by occluding the middle cerebral artery (MCA:O) with reperfusion for various periods. In situ dUTP was incorporated into cells with DNA damage by terminal deoxynucleotidyl transferase (TdT), DNA polymerase I, or the Klenow fragment of DNA polymerase. Dual immunolabeling experiments with immunoprobes against neuronal, vascular, or glial marker proteins were performed.

Results
Significant topographical differences in dUTP between the two species were seen. In both models the TdT and polymerase I regions changed characteristically during focal ischemia. The number and density of dUTP-labeled cells increased with time from MCA:O and were dramatically different between the species (2
P
<.001). By 2 hours of ischemia, the density of dUTP label was 48.8±10.3 cells/mm
2
in the primate and 2.4±0.8 cells/mm
2
in the rat (2
P
<.05), but these values became nearly identical by 24 hours of reperfusion. In the primate, 80.0±6.6% of labeled cells displayed microtubule-associated protein-2 antigen (at 2-hour MCA:O), while 1.8±0.5% were associated with microvessels at 24 hours of reperfusion.

Conclusions
In situ detection of DNA damage, accomplished by three methods, reveals distinct temporal, topographical, and density differences in ischemic injury to cells in the primate and the rat corpus striatum as a result of MCA:O.
Ruptured Dissecting Aneurysm as a Cause of Subarachnoid Hemorrhage of Unverified Etiology
Authors: Nakatomi Hirofumi , Nagata Kazuya , Kawamoto Shunsuke , Shiokawa Yoshiaki
Published: June 2011

Background and Purpose
The clinical features of “aneurysmal” subarachnoid hemorrhage (SAH) of angiographically unverified etiology were reviewed to clarify the incidence and natural history of dissecting aneurysms as the hemorrhagic source of SAH.

Methods
We reviewed 30 patients with SAH of unverified etiology in whom initial CT scan showed a diffuse or anteriorly distributed subarachnoid blood clot. Ten of the patients had stenotic or occlusive lesions (SOCL) on initial angiography, and these were the main focus of this study.

Results
Among the 10 patients with SOCL on initial angiography, the lesions were located on the anterior circulation in 6 and on the posterior circulation in 4. Ruptured dissecting aneurysms were confirmed by exploratory surgery or autopsy in 6 patients. Subsequent rupture occurred in 6 of the 10 patients (60%), and all 6 of these patients died as a result.

Conclusions
The incidence (6/30) of dissecting aneurysms as the cause of SAH of unverified etiology was unexpectedly high, especially when initial angiography disclosed SOCL (6/10). The moribund patients with SOCL showed a high rate of rebleeding, and the untreated recurrent hemorrhages were fatal. Further MRI study is indicated for these patients to demonstrate the intramural hematoma. Compared with the devastating mortality caused by the subsequent ruptures, the extent of surgical morbidity was minor. Surgical intervention could therefore be justified when the following neuroradiological findings are present: (1) SOCL evident on angiography, (2) distribution of SAH on CT compatible with the location of the SOCL, and (3) intramural hematoma on MRI in the same region as the SOCL.
Continuous Intraoperative Monitoring of Middle Cerebral Artery Blood Flow Velocities and Electroencephalography During Carotid Endarterectomy
Authors: Arnold Marcel , Sturzenegger Matthias , Schäffler Leonard , Seiler Rolf W.
Published: June 2011

Background and Purpose
Intraoperative monitoring of brain function may influence the outcome of carotid endarterectomy (CEA).

Methods
We performed transcranial Doppler (TCD) monitoring of middle cerebral artery blood flow velocities (VMCAs) and eight-channel electroencephalographic (EEG) recording simultaneously in 82 patients undergoing CEA. Thiopental narcosis limited EEG interpretation in 11 patients, thus allowing direct comparison of both methods in 71 patients.

Results
There was a significant correlation between VMCA decrease and the frequency of EEG changes after carotid clamping (
P
<.001). Eight patients (11%) showed a VMCA decrease exceeding 60%, accompanied by EEG changes in 7 patients. Altogether, 16 patients (22%) showed severe or moderate EEG changes. Stenosis or occlusion of the contralateral carotid artery led to an increase of abnormal findings with both monitoring methods, which was, however, significant only for TCD (
P
<.05). Four patients (4.8%) suffered intraoperative transient ischemic attacks. In 3 of these patients, there were no abnormal findings with either of the methods. The events were thus unpredictable and probably of embolic origin. The fourth patient showed VMCA decrease to 0 and severe EEG changes. Nine patients had severe or moderate EEG changes without significant VMCA decrease and without complications. EEG monitoring alone in these would have led to unnecessary use of a shunt with the increased risk of embolism.

Conclusion
EEG and TCD monitoring are complementary techniques. Their results showed a good overall correlation but with marked differences in the individual patient. TCD monitoring alone was sensitive enough to prevent ischemic intraoperative complications. EEG findings are of limited value when barbiturates are used.