bluuebunny/crossref_metadata_2025 huggingface dataset:
Prothrombin Gene G
20210
→A Transition Is a Risk Factor for Cerebral Venous Thrombosis
Authors: Reuner Karl H. , Ruf Andreas , Grau Armin , Rickmann Henning , Stolz Erwin , Jüttler Eric , Druschky Karl-F. , Patscheke Heinrich
Published: June 2011

Background and Purpose
—It has been recently reported that a G→A transition at nucleotide position 20210 in the 3′-untranslated region of the prothrombin gene is associated with elevated plasma prothrombin levels and an increased risk of deep venous thrombosis. To date, it is unknown whether this polymorphism also represents a risk factor for cerebral venous thrombosis (CVT).

Methods
—Venous blood samples were collected from 45 patients with CVT and from 354 healthy blood donors as controls. A second control group consisted of 131 subjects with acute ischemic stroke or transient ischemic attack (TIA). Genomic DNA was isolated from peripheral blood leukocytes. Amplification of DNA was performed by polymerase chain reaction (PCR). The G→A transition at nucleotide position 20210 of the prothrombin gene was detected by allele-specific restriction digestion.

Results
—The G
20210
→A transition in the prothrombin gene was found in a heterozygous form in 4 of 45 patients with CVT (8.9%) and in 8 of 354 healthy control subjects (2.3%). This difference was statistically significant (
P
=0.010). The G
20210
→A transition increased the relative risk for CVT approximately 5-fold (age-adjusted odds ratio 5.7; 95% CI 1.5 to 21.5). In contrast, in the group of patients with acute cerebral ischemia, only 3 of 131 subjects (2.3%) were heterozygous for the G
20210
→A transition, which corresponded to the prevalence in the group of healthy blood donors.

Conclusions
—The recently described G
20210
→A transition in the 3′-untranslated region of the prothrombin gene is an inherited risk factor for CVT but obviously not for acute ischemic stroke or TIA.
Recurrent Primary Cerebral Hemorrhage
Authors: González-Duarte Alejandra , Cantú Carlos , Ruíz-Sandoval Jose Luis , Barinagarrementeria Fernando
Published: June 2011

Background and Purpose
—The frequency of recurrent primary cerebral hemorrhage (RPCH), mainly in cases related to hypertension, has been considered low. This study investigated the frequency, mechanisms, and prognosis of RPCH.

Methods
—We evaluated 359 patients with neuroimaging evidence of cerebral hemorrhage and selected 22 with RPCH.

Results
—Five patients (23%) were older than 70 years at the first cerebral hemorrhage. Mean ages at the first and second hemorrhages were 60 and 63 years, respectively. Risk factors included hypertension (86%), diabetes (27%), and tobacco and alcohol use (each 14%). Hypocholesterolemia was demonstrated in 35% of the patients. The most common pattern of recurrent bleeding was ganglionic-ganglionic, mainly related to hypertension. Overall mortality was 32%. Forty-one percent and 27% of patients, respectively, had incapacitating and nonincapacitating sequelae; 2 of the latter had RPCH with a lobar location. Ganglionic-ganglionic hemorrhage was associated with a poor prognosis; otherwise, this pattern was uncommon in patients with nonincapacitating sequelae. Analysis of the control of risk factors, primarily hypertension after the first cerebral hemorrhage, disclosed that 56% of patients did not gain subsequent control.

Conclusions
—Rebleeding after a first primary intracerebral hemorrhage is not uncommon. The main topographic pattern of bleeding, ganglionic-ganglionic, is likely the result of hypertension; the less common lobar-lobar pattern probably results from amyloid angiopathy.
Blood Pressure Control and Recurrence of Hypertensive Brain Hemorrhage
Authors: Arakawa Shuji , Saku Yoshisuke , Ibayashi Setsuro , Nagao Tetsuhiko , Fujishima Masatoshi
Published: June 2011

Background and Purpose
—Recent studies have demonstrated that recurrence of hypertensive brain hemorrhage (HBH) is not uncommon. However, risk factors for the recurrence of HBH have not been evaluated systematically.

Methods
—We analyzed 74 patients with HBH who were admitted to our clinic and followed up as outpatients for a mean of 2.8 years. Blood pressure (BP) and other clinical features were compared between the groups of patients with and without rebleeding. We determined the recurrence rate of HBH in relation to BP.

Results
—Diastolic BP was significantly higher in the recurrence group than in the nonrecurrence group (88±8 versus 82±7 mm Hg;
P
=0.04). Systolic BP and other clinical variables were not different between the groups. The recurrence rate was 10.0% per patient-year in patients with diastolic BP >90 mm Hg and <1.5% in those with lower diastolic BP (
P
<0.001). No patients with diastolic BP <70 mm Hg experienced rebleeding.

Conclusions
—Higher diastolic BP was related to an increased rate of rebleeding. Diastolic BP >90 mm Hg may be regarded as a factor predictive of the recurrence of HBH.
Blood Pressure and Functional Recovery in Acute Ischemic Stroke
Authors: Chamorro A. , Vila N. , Ascaso C. , Elices E. , Schonewille W. , Blanc R.
Published: June 2011

Background and Purpose
—The relevance of elevated blood pressure in acute ischemic stroke and its most appropriate management are unresolved. We aimed to evaluate the rate of functional recovery with relation to early blood pressure management in patients with ischemic stroke.

Methods
—Four hundred eighty-one consecutive ischemic stroke patients were admitted to the Neurology Service within 20.9±10.5 hours of symptoms onset as part of the Barcelona Downtown Stroke Registry, including 235 patients who received oral antihypertensive agents within <24 hours after stroke onset. Demographic, clinical (Mathew scale), and CT scan findings were collected prospectively. Mean arterial pressure (MAP) was recorded before hospital arrival and at 7
am
on days 1, 2, and 7 of hospitalization. The primary end point was complete functional recovery at day 7 defined as a score of 0 to 1 on the modified Rankin scale.

Results
—Two hundred fifty-two patients achieved complete recovery on day 7. Using logistic regression, independent predictors of complete recovery included mild impairment at stroke presentation, lack of history of hypertension, and absence of brain edema on CT scan. Also, a 20% to 30% drop in MAP on day 2 after stroke onset almost tripled the odds of full recovery (odds ratio, 2.9; 95% CI, 1.3 to 6.3). MAP tended to normalize after stroke in all subjects, more rapidly if hypotensive agents were administered. Brain edema was also less frequent in patients with a greater drop in blood pressure. Despite the fact that a drop in MAP >30% from baseline was observed in 49 patients, this preceded worsening stroke in only 4 patients. Conversely, worsening stroke occurred in 51 patients despite stable blood pressure.

Conclusions
—These results suggest that complete recovery in ischemic stroke is facilitated by a moderate blood pressure reduction when brain edema develops, most likely as the result of a more adequate cerebral perfusion pressure. Conversely, stroke worsening due to pharmacological hypoperfusion is exceptional.
Circadian Variation in Acute Ischemic Stroke
Authors: Lago Aida , Geffner Daniel , Tembl José , Landete Lamberto , Valero Caridad , Baquero Miguel
Published: June 2011

Background and Purpose
—We investigated circadian rhythm in ischemic stroke onset and its subtypes, differentiating between first-ever stroke and recurrent stroke.

Methods
—A consecutive series of 1223 patients with ischemic stroke was admitted at 2 reference hospitals; the time of onset of symptoms was obtained, differentiating between onset while asleep and awake. We compared circadian rhythm between stroke types and between first-ever and recurrent stroke.

Results
—The onset time was known in 914 patients; 25.6% experienced onset on awakening [higher incidence in thrombotic and lacunar stroke (28.9% and 28.4%, respectively) than in embolic stroke (18.8%)]. For all stroke subtypes, there was a significant diurnal variation, with a morning peak between 6
am
and noon; after redistributing the hour of onset of patients awakening with stroke, the morning peak was minimal in all types of stroke. There were no differences in circadian rhythm between patients with first-ever and recurrent stroke.

Conclusions
—Only hospitalized patients were studied. There is a circadian rhythm in all types of stroke, with higher frequency during the day and lower frequency in the last hours in the evening. The highest incidence in the early hours of the morning can be overestimated, due to patients who awaken with stroke. There is no difference in circadian rhythm between first-ever stroke and recurrent stroke.
Papaverine Hydrochloride and Experimental Hemorrhagic Cerebral Arterial Spasm
Authors: Kuwayama Akio , Zervas Nicholas T. , Shintani Akira , Pickren Kenneth S.
Published: June 2011

Chronic hemorrhagic spasm of the basilar artery was produced in beagle dogs by introducing blood into the cisterna magna. Spasm was evaluated by means of vertebral angiography. Papaverine hydrochloride was administered intravenously, intracisternally as well as intra-arterially. The intracisternal route was the more effective in combating spasm but the effect was transitory. The results suggest that the treatment of spasm by chemical means in subarachnoid hemorrhage using agents currently available would require continuous topical application.
Cranial Arteritis With Liver Involvement
Authors: MANN DONALD C. , TOOLE JAMES F.
Published: June 2011

An elderly man with cranial nerve palsies was found to have cranial arteritis. Laboratory studies established concurrent liver disease which improved with treatment. The liver and brain stem pathology is discussed.
Monocytes and Basophilic Granulocytes in the Cranial Circulation of Patients With Organic Brain Disorders
Authors: Thonnard-Neumann Ernst , Thonnard Costanza
Published: June 2011

In 30 patients with organic brain disorders, blood samples from both ear lobes were examined for their white cell contents. In nine of them, blood from the external and internal jugular veins also was examined. The total white cell, neutrophil, and eosinophil counts did not show any difference when the two sides of the head were compared; nor was there any difference in the average-of-sides values of these cells in cranial blood samples when compared with blood from a finger puncture, or when compared with ear lobe blood from ten healthy control subjects.

Basophil values were lower in blood from the internal jugular veins than in blood from the external jugular veins, and basophils in ear lobe blood were at an intermediate level.

In patients with one-sided cerebral lesions, fewer basophils were found on the focal side even when the lesions were remote in time. Monocyte levels were higher on the focal side during the first two months after a cerebrovascular attack.

Patients with bilateral brain lesions had fewer basophils in ear lobe samples than normal controls but showed no side-related difference.

A single intravenous injection of 5,000 units of heparin caused an existing bias in basophil and monocyte values between focal and opposite side to disappear and produced an increase in the cranial level of these cells. The side-related differences did not reappear for an average of three weeks.

The findings with regard to the role of monocytes as precursors of cerebral macrophages and of basophils as carriers of heparin are discussed, and the examination of ear lobe blood is proposed as a noninvasive and simple method for hematological studies of cerebral disorders.
II. Stroke Rehabilitation
Authors: Peszczynski Mieczyslaw , Benson D. Frank , Collins Joyce M. , Darley Frederic L. , Diller Leonard , Greenhouse Arnold H. , Katzen Faye P. , Lake Lorraine F. , Rothberg June S. , Waggoner Raymond W.
Published: June 2011

Rehabilitation offers means by which persons disabled after a stroke can be returned to patterns of daily living as close to normal as possible. Often simple and readily available restorative techniques suffice, but sophisticated methods and facilities may be needed in many cases. Certain complex problems require specialized attention by persons with detailed knowledge and specific training. Among these are rehabilitation of language and the management of incontinence, sensory loss, pain, spasticity, and psychosocial problems. High-quality rehabilitation is best delivered by a closely cooperating team, including the family physician, medical specialists, nurses, allied health professionals (physical therapist, occupational therapist, social worker, dietitian, rehabilitation counselor, speech therapist, psychologist), the patient's family, and also the patient. To accomplish these ends, hospitals, rehabilitation centers, extended care facilities, and nursing homes should give specific attention to the special needs of stroke patients. Careful discharge planning and follow-up are necessary in all cases. The home environment and the family attitudes may require considerable revision to meet the patient's individual needs. The family physician can offer many rehabilitation services in his office, and additional education in medical school and on a postgraduate level will belp him to reach his full potential in aiding both the acutely ill and the chronically disabled stroke patient.
Cerebral Blood Flow, Metabolism and Mean Arterial Pressure Changes Following Unilateral Internal Carotid Endarterectomy: Cerebral Ischemia and Elevated Systemic Arterial Pressure
Authors: JONES F. HAVEN , DYKEN MARK L. , KING ROBERT
Published: June 2011

Cerebral blood flow and metabolism studies were performed on 13 patients before and after unilateral carotid endarterectomy for severe atheromatous occlusive disease. Mean brachial arterial pressure was monitored during these studies. Postoperative studies compared to a control group revealed a rise in cerebral blood flow and a fall in mean arterial pressure and cerebral vascular resistance. The clinically recorded blood pressure in the study group compared to closely matched control patients with cerebral vascular disease showed a similar but not significant difference. Ten patients studied following ligation of a common carotid artery had a small but significant increase in mean systemic arterial pressure. These results suggest a relationship between systemic arterial pressure and cerebral ischemia. Some possibilities for this relationship are discussed.
Cerebral Vasospasm With Infarction
Authors: SIMEONE FREDERICK A. , TREPPER PETER
Published: June 2011

A case of intense unilateral cerebral vasospasm with appropriate neurological deficit following rupture of a posterior communicating aneurysm was followed with serial angiography. Associated with the initially intense spasm was subsequent regional hyperperfusion with early venous filling which disappeared as signs of focal cerebral atrophy ensued. These angiographical findings can explain previous reported autopsy demonstrations of focal infarction in the distribution of aneurysm-bearing cerebral vessels. Laboratory cerebral blood flow studies in conjunction with experimental subarachnoid hemorrhage indicate that constriction of major cerebral arteries to less than one-half of their normal caliber is associated with reduction in regional cerebral blood flow to infarction levels.
Cerebral Hemispheric "Counter-Steal" Phenomenon During Hyperventilation in Cerebrovascular Diseases
Authors: PISTOLESE G. RAIMONDO , FARAGLIA VITTORIO , AGNOLI ALESSANDRO , PRENCIPE MASSIMILIANO , PASTORE ENRICA , SPARTERA CARLO , FIORANI PAOLO
Published: June 2011

Use of hyperventilation (HV) was recently suggested for the treatment of acute cerebrovascular insufficiency. There is indeed no general agreement on the effectiveness of hyperventilation even though clinical and experimental findings could support its value in clinical use.

During carotid surgery, hyperventilation was used in order to attenuate cerebral ischemia effects during carotid clamping, and a counter-steal phenomenon affecting a whole cerebral hemisphere was demonstrated.

This suggests the role that hyperventilation may play in the treatment of cerebral ischemia.
About Three Old Men: An Inquiry Into How Cerebral Arteriosclerosis Has Altered World Politics
Authors: FRIEDLANDER WALTER J.
Published: June 2011

In the recent past three men were disabled by cerebral arteriosclerosis: Wilson, Hindenburg and Lenin. The illness of these particular people altered the course of history. The thesis is offered that this was so not just because these individuals were ill but because of the specific qualities of their disease, cerebral arteriosclerosis.
Arteriographically Visualized Extravasation in Hypertensive Intracerebral Hemorrhage
Authors: MIZUKAMI MASAHIRO , Araki Goro , Mihara Hiroshi , TOMITA TAKASHI , Fujinaga Ryozo
Published: June 2011

Seven cases are reported in which extravasation of contrast medium from the lateral lenticulostriate artery was observed on cerebral angiography performed in the early stage of hypertensive intracerebral hemorrhage.

We advance the theory that continuous bleeding from the ruptured artery with mechanical destruction and displacement of cerebral tissue is the cause of massive hematoma formation, and discuss the possibility of surgical treatment of the acute stage of hypertensive intracerebral hemorrhage.
Hyperventilation and Cerebral Blood Flow
Authors: Raichle Marcus E. , PLUM F.
Published: June 2011

Hypocapnic-hyperventilation has a profound, but probably temporary, effect on CBF, producing approximately a 2% decline in CBF for each 1 torr decline in P

co
co2

. This effect appears to be mediated through changes in perivascular pH of the cerebral resistance vessels acting directly on the vessel wall. At low P

co
co2

the vasoconstrictor effect of short-term hypocapnic-hyperventilation is attenuated by resultant cerebral hypoxia. During prolonged hyperventilation CBF returns toward normal as the pH in the CSF is restored.

Short-term hypocapnic-hyperventilation can be lifesaving in the treatment of acute intracranial hypertension. On the other hand,
prolonged
hyperventilation has not been convincingly shown to benefit patients, whether with severe head injury or cerebral infarction, or during carotid endarterectomy without bypass.
Spreading Depression–Induced Gene Expression Is Regulated by Plasma Glucose
Authors: Koistinaho Jari , Pasonen Sanna , Yrjänheikki Juha , Chan Pak H.
Published: June 2011

Background and Purpose
—Plasma glucose and spreading depression (SD) are both determinants of brain ischemia. The purpose of this study was to examine whether plasma glucose affects SD-induced gene expression in the cortex.

Methods
—SD was induced by topical application of KCl. Hyperglycemia and hypoglycemia were induced by intraperitoneal injection of glucose and insulin, respectively. The expression of c-
fos
, cyclooxygenase-2 (COX-2), protein kinase C-δ (PKCδ), and heme oxygenase-1 (HO-1) was determined by in situ hybridization.

Results
—SD alone induced expression of c-
fos
(by 340%), COX-2 (210%), HO-1 (470%), and PKCδ (410%). Hypoglycemia (2.4±0.9 mmol/L) alone did not induce gene expression, and hyperglycemia (22.1±3.7 mmol/L) alone induced only c-
fos
by 42%. When hypoglycemia was induced 30 minutes before SD, c-
fos
induction was enhanced by 145%, but the induction of HO-1 and PKCδ was reduced to 43% and 64%, respectively. When hyperglycemia was induced 30 minutes before SD, c-
fos
induction was enhanced by 388% and COX-2 expression by 53%, whereas the induction of PKCδ and HO-1 was reduced to 54% and 51%, respectively. The frequency, amplitude, and duration of direct current potentials were unaltered in hyperglycemic SD animals, whereas in hypoglycemic animals the duration was increased by 47%.

Conclusions
—While SD induces expression of several genes, the availability of glucose regulates the extent of the gene induction. The effect of glucose is different on early-response genes (c-
fos
and COX-2) compared with late-response genes. Plasma glucose may contribute to neuronal damage partially by regulating gene expression.
Neuroprotection for Acute Stroke
Authors: Muir Keith W. , Grosset Donald G.
Published: June 2011

Background
—With the exception of the National Institutes of Neurological Disorders and Stroke trial of recombinant tissue plasminogen activator, clinical trials in stroke have failed to show improved outcome. If further negative results such as those of recent large neuroprotective trials are to be avoided, trial methodology must be reevaluated.

Summary
—Because there is little evidence from animal focal ischemia models for protection of white matter, glia, or subcortical neurons, the logical target population for initial clinical trials is patients with middle cerebral artery stroke involving cerebral cortex. Clinical differentiation of moderate to large middle cerebral stroke from lacunar stroke is possible with the Oxfordshire Community Stroke Project classification but less readily achieved by numerical stroke scales. Several imaging techniques can further distinguish middle cerebral stroke patients with a “penumbra” potentially amenable to intervention from those without a penumbra, in whom outcome appears already determined. The window for intervention may be better defined by imaging than by time alone. Shortened follow-up periods may reduce variation in outcome attributable to differences in provision of rehabilitation or secondary preventative treatments among centers, and imaging may provide useful surrogate end points.

Conclusions
—Clinical trials restricted to patients with large middle cerebral stroke accompanied by radiological evidence of a penumbra should be an essential component of drug development. Slower recruitment may be offset by extended time windows and requirements for fewer patients. Imaging may define surrogate evidence of biological effect prior to embarking on a phase 3 program.
Postoperative Outcome of 37 Patients With Lobar Intracerebral Hemorrhage Related to Cerebral Amyloid Angiopathy
Authors: Izumihara Akifumi , Ishihara Tokuhiro , Iwamoto Naoki , Yamashita Katsuhiro , Ito Haruhide
Published: June 2011

Background and Purpose
—Several recent studies have suggested that neurosurgical procedures are not contraindicated in patients with cerebral amyloid angiopathy (CAA). The purpose of this study was to elucidate the clinical factors influencing the outcome of patients with CAA-related intracerebral hemorrhage (ICH) treated surgically.

Methods
—A total of 50 neurosurgical procedures (42 intracerebral hematoma evacuations, 4 ventriculoperitoneal shunts, 3 ventricular drainages, and 1 brain biopsy) were performed in 37 patients with CAA-related ICH. To ascertain the clinical factors that may influence their postoperative outcome, their clinical data (demographics, medical history, recurrent lobar hemorrhage, radiographic characteristics, multiple lobar hemorrhage, surgical details, and postoperative hemorrhage) were examined retrospectively and subjected to multivariate analysis.

Results
—Twenty patients (54%) had a good outcome, and only 4 (11%) died. Parietal hematomas, advanced age (≥75 years), and intraventricular hemorrhages had significant adverse influence on the postoperative outcome. Clinically significant postoperative hemorrhage requiring evacuation occurred after 2 (5%) of 42 intracerebral hematoma evacuations. Postoperative hemorrhage did not have significant adverse influence on the outcome.

Conclusions
—Neurosurgery can be performed relatively safely in patients with CAA-related ICH, and their postoperative outcome is better than that reported previously. Surgical treatment should be considered for such patients aged <75 years without a parietal hematoma and intraventricular hemorrhage.
Factors Associated With Delayed Admission to Hospital and In-Hospital Delays> in Acute Stroke and TIA
Authors: Wester Per , Rådberg Johan , Lundgren Bo , Peltonen Markku
Published: June 2011

Background and Purpose
—Early admission to hospital followed by correct diagnosis with minimum delay is a prerequisite for successful intervention in acute stroke. This study aimed at clarifying in detail the factors related to these delays.

Methods
—This was a prospective, multicenter, consecutive study that explored factors influencing the time from stroke or transient ischemic attack (TIA) onset until patient arrival at the emergency department, stroke unit, and CT laboratory. Within 3 days of hospital admission, the patients and/or their relatives were interviewed by use of a standardized structured protocol, and the patients’ neurological deficits were assessed. No information about this study was given to the public or to the staff.

Results
—Patients (n=329) were studied at 15 Swedish academic or community-based hospitals: 252 subjects with brain infarct, 18 with intracerebral hemorrhage, and 59 with TIA. Among stroke and TIA patients, the median times from onset to hospital admission, stroke unit, and CT scan laboratory were 4.8 and 4.0 hours, 8.8 and 7.5 hours, and 22.0 and 17.5 hours, respectively. From multivariate ANOVA with logarithmically transformed time for increasing delay to hospital admission as the dependent variable, a profile of significant risk factors was obtained. This included patients with a brain infarct, gradual onset, mild neurological symptoms, patients who were alone and did not contact anybody when symptoms occurred, patients who lived in a large catchment area, those who did not use ambulance transportation, and those who visited a primary care site. These factors explained 45.3% of the variance in delayed hospital admission. The median time from arrival at the emergency department to arrival at the stroke unit or CT scan laboratory (whichever occurred first) was 2.6 and 2.7 hours in the stroke and TIA groups, respectively. A large catchment area, moderate to mild neurological deficit, and waiting for the physician at the emergency department were all significantly related to in-hospital delay.

Conclusions
—Increased public awareness of the need to seek medical or other attention promptly after stroke onset, to use an ambulance with direct transportation to the acute-care hospital, and to have more effective in-hospital organization will be required for effective acute treatment options to be available to stroke patients.
Identification of Incident Stroke in Norway
Authors: Ellekjær Hanne , Holmen Jostein , Krüger Øystein , Terent Andreas
Published: June 2011

Background and Purpose
—The validity of hospital discharge diagnoses is essential in improving stroke surveillance and estimating healthcare costs of stroke. The aim of this study was to assess sensitivity, positive predictive value, and accuracy of discharge diagnoses compared with a stroke register.

Methods
—A record linkage was made between a population-based stroke register and the discharge records of the hospital serving the population of the stroke register (n=70 000). The stroke register (including patients aged 15 and older and with no upper age limit), applied here as a “gold standard,” was used to estimate sensitivity, positive predictive value, and accuracy of the discharge diagnoses classification. The length of stay in hospital by stroke patients was measured.

Results
—Identifying cerebrovascular diseases by hospital discharge diagnoses (
International Classification of Diseases, 9th Revision
[ICD-9], codes 430 to 438.9, first admission) lead to a substantial overestimation of stroke in the target population. Restricting the retrieval to acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436) gave an incidence estimate closer to the “true” incidence rate in the stroke register. Selecting ICD-9 codes 430 to 438 of cerebrovascular diseases gave the highest sensitivity (86%). The highest positive predictive value (68%) was achieved by selecting acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436), at the expense of a lower sensitivity (81%). Accuracy of ICD codes 430 to 438.9 (n=678) revealed the highest proportion of incident strokes identified by the acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436). Seventy-four percent of hospital discharge diagnoses classified as first-ever stroke kept the original diagnosis. Only 4.6% of the discharge diagnoses were classified as nonstroke diagnoses after validation. The estimation of length of stay in the hospital was improved by selection of acute stroke diagnoses from hospital discharge data (ICD-9 codes 430, 431, 434, and 436), which gave the same estimate of length of stay, a median of 8 days (2.5 percentile=0 and 97.5 percentile=56), compared with a median of 8 days (2.5 percentile=0 and 97.5 percentile=51) based on the stroke register.

Conclusions
—Hospital discharge data may overestimate stroke incidence and underestimate the length of stay in the hospital, unless selection routines of hospital discharge diagnoses are restricted to acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436). If supplemented by a validation procedure, including estimates of sensitivity, positive predictive value, and accuracy, hospital discharge data may provide valid information on hospital-based stroke incidence and lead to better allocation of health resources. Distinguishing subtypes of stroke from hospital discharge diagnoses should not be performed unless coding practices are improved.
Carotid Plaque Characterization by Duplex Scanning
Authors: Arnold J. A. C. , Modaresi K. B. , Thomas N. , Taylor P. R. , Padayachee T. S.
Published: June 2011

Background and Purpose
—Clinical studies currently in progress are using subjective methods to characterize plaque morphology from ultrasound images. However, there are few studies on the intraobserver and interobserver variability of these classifications. This study was designed to assess these variables.

Methods
—Grading of plaque morphology from ultrasound images, stored both digitally and to hard copy, was performed by 2 classification schemes. Interobserver agreement was determined by 4 observers. Within-observer agreement was performed at intervals for up to 6 months. Accuracy of the 2 methods was determined by comparison with histology.

Results
—Within- and between-observer agreement was moderate to good for full-color digital image analyses, with pooled κ values of κ
p
=0.49±0.10 and κ
p
=0.62±0.07 for the 2-category method and κ
p
=0.53±0.06 and κ
p
=0.52±0.05 for the 4-category method, respectively. Hard copy data analyses gave lower κ values. The more experienced observers produced higher within-observer agreements and higher correlation with histology.

Conclusions
—Reproducible grading of ultrasound images is not consistently achievable among experienced observers, and within-observer agreement may vary with time. The current subjective ultrasound characterization of carotid plaque morphology used in clinical trials may be associated with unacceptable levels of reproducibility in some centers. Variability between observers may be reduced by using the simpler 2-category grading of plaque morphology to interrogate full-color digitally stored images. Observer agreement should be audited regularly.
Assessment of Intracranial Venous Hemodynamics in Normal Individuals and Patients With Cerebral Venous Thrombosis
Authors: Stolz Erwin , Kaps Manfred , Dorndorf Wolfgang
Published: June 2011

Background and Purpose
—Despite ongoing improvements in noninvasive imaging techniques, transcranial color-coded duplex sonography (TCCS) has so far been used only on a limited basis in patients with cerebral venous thrombosis. We evaluated the diagnostic value of both noncontrast and contrast-enhanced TCCS by comparing normal volunteers and patients with acute cerebral venous thrombosis.

Methods
—In 75 healthy volunteers (aged 45.8±17.4 years), normal values for the deep cerebral veins (DCVs) and the posterior fossa sinuses were established by transtemporal insonation. Eight patients with cerebral venous thrombosis were assessed by TCCS, through which the hemodynamics of the DCVs were measured, and the patients were followed-up over a period of between 33 and 387 days after examination. MR angiography served as the “gold standard” technique for confirming the venous status in all 8 patients.

Results
—No side differences in flow velocities were detected in the paired venous structures in normal volunteers. As indirect signs of (and diagnostic criteria for) cerebral venous thrombosis, pathologically increased flow velocities or significant side differences in the DCVs were registered in 5 of the 8 patients; the other patients showed nonsignificant increases in flow velocity which decreased over time. During follow-up, the status of the posterior fossa sinuses could be diagnosed correctly in seven patients after contrast enhancement when these results were compared with those of venous MR angiography. In 1 patient, a partial recanalization was mistakenly diagnosed as an occlusion.

Conclusions
—TCCS allows a reliable evaluation of the major DCVs and posterior fossa sinuses. The anterior and mid portions of the superior sagittal sinus and cortical veins cannot be assessed. Increased venous blood flow velocity can be used as an indirect criterion for indicating a cerebral venous thrombosis. Clinical recovery coincided with decreases in blood flow velocity in the series of patients investigated in this study.
Assessment of ≥50% and <50% Intracranial Stenoses by Transcranial Color-Coded Duplex Sonography
Authors: Baumgartner Ralf W. , Mattle Heinrich P. , Schroth Gerhard
Published: June 2011

Background and Purpose
—A favorable risk-benefit ratio for warfarin compared with aspirin has been reported for the prevention of major vascular events in symptomatic ≥50% intracranial stenoses. Transcranial color-coded duplex sonography (TCCS) criteria providing an accurate detection of ≥50% and <50% stenoses of the anterior, middle, and posterior cerebral arteries and basilar and vertebral arteries were evaluated retrospectively with angiography used as the standard of reference.

Methods
—Prospectively collected TCCS, extracranial color-coded duplex sonography, and intra-arterial digital subtraction angiography data of 310 patients were reviewed. The patients had angiography for confirmation of symptomatic extracranial ≥70% carotid stenoses, symptomatic stenoses (peak systolic velocity higher than the corresponding mean value +2 SDs of 104 normal subjects), and occlusions of the middle cerebral or basilar artery previously assessed by ultrasound. The sonographer was not aware of angiographic findings.

Results
—TCCS would have detected all 31 of ≥50% intracranial stenoses with 1 false-positive and 35 of 38 <50% stenoses with 3 false-positives. One of 69 stenoses (1%) and 280 of 2741 normal arteries (10%) were missed because of inadequate insonation windows. The corresponding peak systolic velocity cutoffs for ≥50%/<50% stenoses were ≥155/≥120 cm/s (anterior cerebral artery), ≥220/≥155 cm/s (middle cerebral artery), ≥145/≥100 cm/s (posterior cerebral artery), ≥140/≥100 cm/s (basilar artery), and ≥120/≥90 cm/s (vertebral artery).

Conclusions
—TCCS may reliably assess ≥50% and <50% basal cerebral artery narrowing and prove useful for noninvasive management of patients with symptomatic intracranial stenoses.
Risk Factors and 20-Year Stroke Mortality in Men and Women in the Renfrew/Paisley Study in Scotland
Authors: Hart Carole L. , Hole David J. , Smith George Davey
Published: June 2011

Background and Purpose
—The aim of this study was to relate risk factors in middle-aged men and women to stroke mortality over a long follow-up period.

Methods
—In the early to mid 1970s, 7052 men and 8354 women from the Renfrew/Paisley prospective cohort study in Scotland were screened when aged 45 to 64 years. Risk factors measured included blood pressure, blood cholesterol and glucose, respiratory function, cardiothoracic ratio, smoking habit, height, body mass index, age, preexisting coronary heart disease, and diabetes. These were related to stroke mortality over 20 years of follow-up.

Results
—Women’s stroke mortality rates were similar to men’s, unlike coronary heart disease mortality, in which case women’s rates were lower than men’s. Diastolic and systolic blood pressure, smoking, cardiothoracic ratio, preexisting coronary heart disease, and diabetes were positively related to stroke mortality for men and women, while adjusted forced expiratory volume in 1 second and height were negatively related. Cholesterol and body mass index were not related to stroke mortality. Glucose in nondiabetics was positively related to stroke mortality for women but not men, and there was evidence of a threshold effect at the highest levels of glucose. Former smokers had mortality rates that were similar to those of never-smokers. In sex-specific multivariate models, most variables retained a statistically significant association with stroke mortality, illustrating the multifactorial etiology of stroke.

Conclusions
—Overall, findings for women were similar to those for men. Control of risk factors for reduction of stroke mortality should be targeted at men and women in a similar fashion, particularly with reference to smoking cessation and blood pressure control.
Identification of Major Ischemic Change
Authors: Barber P. A. , Darby D. G. , Desmond P. M. , Gerraty R. P. , Yang Q. , Li T. , Jolley D. , Donnan G. A. , Tress B. M. , Davis S. M.
Published: June 2011

Background and Purpose
—Thrombolytic therapy is not recommended in patients with CT changes of recent major infarction, which has been defined as reduced attenuation or cerebral edema involving >33% of the middle cerebral artery territory (European Cooperative Acute Stroke Study [ECASS] criteria). Diffusion-weighted imaging (DWI) is more sensitive than CT in detecting acute ischemia, and the combination of DWI, MR perfusion imaging, and MR angiography provides additional information from a single examination. We sought to determine whether DWI could identify the presence and extent of major ischemia as well as CT in hyperacute stroke patients.

Methods
—Seventeen suspected hemispheric stroke patients were studied with both CT and DWI within 6 hours of symptom onset. None received thrombolytic therapy. The scans were examined separately by 2 neuroradiologists in a blinded fashion for ischemic change and cerebral edema, graded as normal, <33%, or >33% of the MCA territory. Final diagnosis of stroke was determined with the use of standard clinical criteria and T2-weighted imaging at day 90.

Results
—Sixteen of 17 patients had a final diagnosis of stroke. Acute ischemic changes were seen in all 16 on DWI (100% sensitivity) and in 12 of 16 on CT (75% sensitivity). DWI identified all 6 patients with major ischemia on CT, with excellent agreement between the 2 imaging techniques (κ=0.88). One patient eligible for thrombolysis on the ECASS CT criteria had major ischemia on DWI.

Conclusions
—DWI is more sensitive than CT in the identification of acute ischemia and can visualize major ischemia more easily than CT.
Diffusion-Weighted MRI in Acute Lacunar Syndromes
Authors: Schonewille Wouter J. , Tuhrim Stanley , Singer Michael B. , Atlas Scott W.
Published: June 2011

Background and Purpose
—Clinical-radiological correlation studies in lacunar syndromes have been handicapped by the low sensitivity of CT and standard MRI for acute small-vessel infarction and their difficulty in differentiating between acute and chronic lesions.

Methods
—We prospectively studied 43 patients presenting with a classic lacunar syndrome using diffusion-weighted MRI, a technique with a high sensitivity and specificity for acute small-vessel infarction.

Results
—All patients were scanned within 6 days of stroke onset. An acute infarction was identified in all patients. Pure motor stroke was associated with lesions in the posterior limb of the internal capsule (PLIC), pons, corona radiata, and medial medulla; ataxic hemipareses with lesions in the PLIC, corona radiata, pons, and insular cortex; sensorimotor stroke with lesions in the PLIC and lateral medulla; dysarthria–clumsy hand syndrome with lesions in the PLIC and caudate nucleus; and pure sensory stroke with a lesion in the thalamus. Supratentorial lesions extended into neighboring anatomic structures in 48% of the patients.

Conclusions
—Lacunar syndromes can be caused by lesions in a variety of locations, and specific locations can cause a variety of lacunar syndromes. Extension of lesions into neighboring structures in patients with lacunar syndromes appears to be more frequent than previously described in studies using CT and standard MRI.
Frequency and Determinants of Postprocedural Hemodynamic Instability After Carotid Angioplasty and Stenting
Authors: Qureshi Adnan I. , Luft Andreas R. , Sharma Mudit , Janardhan Vallabh , Lopes Demetrius K. , Khan Jehanzeb , Guterman Lee R. , Hopkins L. Nelson
Published: June 2011

Background and Purpose
—Hemodynamic instability can occur acutely after carotid angioplasty and stent placement (CAS). We performed this study to determine the frequency of hemodynamic instability in a series of patients who underwent CAS and to analyze factors associated with development of postprocedural hemodynamic events.

Methods
—We reviewed medical records and angiograms in a series of 51 patients (mean age 68.3±8.9 years) who underwent CAS for symptomatic (n=29) or asymptomatic (n=22) carotid artery stenosis. Any episodes of hypotension (systolic blood pressure <90 mm Hg), hypertension (systolic blood pressure >160 mm Hg), or bradycardia (heart rate <60 bpm) that occurred in the acute postprocedural period were recorded. The effect of demographic, clinical, intraprocedural, and angiographic factors on subsequent development of hemodynamic instability was analyzed by logistic regression.

Results
—The frequency of postprocedural hemodynamic complications in our patient series was as follows: hypotension, 22.4%; hypertension, 38.8%; and bradycardia, 27.5%. Intraprocedural hypotension (odds ratio [OR] 14.6,
P
=0.024) and history of myocardial infarction (OR 14.1,
P
=0.04) independently predicted postprocedural hypotension. Postprocedural hypertension was predicted by intraprocedural hypertension (OR 7.6,
P
=0.01) and previous ipsilateral carotid endarterectomy (OR 7.6,
P
=0.02). Postprocedural bradycardia was associated with intraprocedural hypotension (OR 74,
P
=0.001) and intraprocedural bradycardia (OR 12,
P
=0.008). All events had resolved at the conclusion of the intensive care unit monitoring period (mean 25.7 hours, range 18 to 43 hours).

Conclusions
—Postprocedural hemodynamic instability is frequent after CAS and supports the need for monitoring in settings suited to expeditious management of cardiovascular emergencies. Patients who have evidence of hemodynamic instability during the procedure are at highest risk.
Predictors of Clinical Improvement, Angiographic Recanalization, and Intracranial Hemorrhage After Intra-Arterial Thrombolysis for Acute Ischemic Stroke
Authors: Suarez J. I. , Sunshine J. L. , Tarr R. , Zaidat O. , Selman W. R. , Kernich C. , Landis D. M. D.
Published: June 2011

Background and Purpose
—We sought to evaluate predictors of clinical outcome, angiographic success, and adverse effects after intra-arterial administration of urokinase for acute ischemic stroke.

Methods
—We designed a Brain Attack program at University Hospitals of Cleveland for diagnosis and treatment of patients presenting within 6 hours of onset of neurological deficit. Patients with ischemia referable to the carotid circulation were treated with intra-arterial urokinase. Angiographic recanalization was assessed at the end of medication infusion. Intracerebral hemorrhage was investigated immediately after and 24 hours after treatment. Stroke severity was determined, followed by long-term outcome.

Results
—Fifty-four patients were treated. There was improvement of ≥4 points on the National Institutes of Health Stroke Scale from presentation to 24 hours after onset in 43% of the treated patients, and this was related to the severity of the initial deficit. Forty-eight percent of patients had a Barthel Index score of 95 to 100 at 90 days, and total mortality was 24%. Cranial CT scans revealed intracerebral hemorrhage in 17% of patients in the first 24 hours, and these patients had more severe deficits at presentation. Eighty-seven percent of patients received intravenous heparin after thrombolysis, and 9% of them developed a hemorrhage into infarction. Angiographic recanalization was the rule in complete occlusions of the horizontal portion of the middle cerebral artery, but distal carotid occlusions responded less well to thrombolysis.

Conclusions
—The intra-arterial route for thrombolysis allows for greater diagnostic precision and achievement of a higher concentration of the thrombolytic agent in the vicinity of the clot. Disadvantages of this therapy lie in the cost and delay. Severity of stroke and site of angiographic occlusion may be important predictors of successful treatment.
Effects of Spontaneous Recanalization on Functional and Electrophysiological Recovery in Acute Ischemic Stroke
Authors: Vang Chu , Dunbabin David , Kilpatrick David
Published: June 2011

Background and Purpose
—Transcranial Doppler ultrasound (TCD) studies have shown that spontaneous recanalization results in a better clinical improvement after the onset of stroke. However, its effect on electrophysiological recovery is still unknown. The aim of this study was to determine the effects of spontaneous recanalization on the change in central motor conduction time (CMCT) in acute ischemic stroke.

Methods
—Seventeen healthy subjects and 38 consecutive patients with a first acute ischemic stroke involving the middle cerebral artery territory were included. TCD was used to detect spontaneous recanalization. Transcranial magnetic stimulation was used to determine the change in CMCT on days 1 and 14. Improvement of the CMCT at day 14 was indicated if it decreased in comparison with previous data recorded at day 1 or when a nonrecordable motor response at day 1 reappeared at day 14. No CMCT improvement was indicated when there was no recordable motor response at day 1 and day 14 or the CMCT at day 14 worsened, becoming absent or more delayed. The Pearson χ
2
test was used to assess the statistical significance of the results in this study.

Results
—Spontaneous recanalization was observed in 62% of the patients: 24% before 24 hours and 38% after this period. No recanalization was observed in 14 patients. The CMCT improved in 87% of the patients who had recanalized before 24 hours and 62% in the recanalized after 24 hours group (
P
=0.005). In contrast, CMCT improved in only 17% of the patients in the non-recanalized group

Conclusions
—These data show that spontaneous recanalization results in a better recovery of the central motor pathway leading to a better CMCT improvement in acute ischemic stroke.