bluuebunny/crossref_metadata_2025 huggingface dataset:
Cuyahoga County Operation Stroke Speed of Emergency Department Evaluation and Compliance With National Institutes of Neurological Disorders and Stroke Time Targets
Authors: Katzan Irene L. , Graber Thomas W. , Furlan Anthony J. , Sundararajan Sophia , Sila Cathy A. , Houser Gary , Landis Dennis M.
Published: April 2003

Background and Purpose—

Although the National Institutes of Neurological Disorders and Stroke (NINDS) has established time targets for the evaluation of acute stroke patients, little is known about how often these targets are met in the community. To track compliance with NINDS guidelines, Cuyahoga County Operation Stroke implemented a countywide data collection process that provides comparative reporting of hospital performance.

Methods—

Data on the emergency department evaluation of stroke patients have been retrospectively collected since January 2000 by hospitals participating in Cuyahoga County Operation Stroke. All hospitals used a 1-page form that includes NINDS time target information.

Results—

Median time to emergency department arrival for the 1003 patients in this cohort was 115 minutes; 382 patients (38%) arrived in <3 hours; 506 (50%) arrived in <6 hours. After arrival, median time to physician contact was 12 minutes, time to CT was 65 minutes, and time to imaging results was 105 minutes. Earlier arrival intervals after symptom onset were independently associated with shorter evaluation times. All time targets were met in patients receiving intravenous tissue plasminogen activator.

Conclusions—

A countywide data collection system for acute stroke evaluation is feasible. In the Cleveland metropolitan area, time to physician contact is close to the recommended NINDS target. Time to CT and time to imaging results are substantially longer than recommended. However, there was wide variation between hospitals. The association between time to arrival, speed of evaluation, and administration of intravenous tissue plasminogen activator suggests that community physicians selectively accelerate the evaluation and management of potential thrombolysis candidates.
Spontaneous Recanalization of Internal Carotid Artery Occlusion
Authors: Nguyen-Huynh Mai N. , Lev Michael H. , Rordorf Guy
Published: April 2003

Background and Purpose—

Spontaneous recanalization of an acutely occluded internal carotid artery (ICA) is an important phenomenon, the natural history and incidence of which have been incompletely studied. Although conventional catheter arteriography remains the gold standard for distinguishing total arterial occlusion from hairline residual lumen, CT angiography (CTA) is able to make this distinction noninvasively and more sensitively than either unenhanced MR angiography or ultrasound. The purpose of this report is to raise awareness of spontaneous recanalization and to demonstrate the possible use of CTA in following up cases of ICA occlusion.

Methods—

We describe here 2 cases of acute cervical ICA occlusion seen on CTAs done at our institution.

Results—

Follow-up CTAs in both cases showed spontaneous recanalization of the ICA requiring ipsilateral carotid endarterectomy within 1 month of the initial presentation.

Conclusions—

CTA, an accurate, rapid, and less invasive modality than conventional catheter arteriography, can be used to serially monitor anticoagulated patients with new-onset ICA occlusion for potential spontaneous vascular recanalization. The ability to conveniently assess ICA patency not only may influence management of individual patients but also could help us better establish the true incidence of spontaneous carotid recanalization in future studies.
Patterns of Cortical Oxygen Saturation Changes During CO
2
Reactivity Testing in the Vicinity of Cerebral Arteriovenous Malformations
Authors: Schaller Carlo , Schramm Johannes , Haun Dorothee , Meyer Bernhard
Published: April 2003

Background and Purpose—

The aim of this study was to test the hypothesis that patterns of cerebrovascular reactivity (CVR) in the vicinity of cerebral arteriovenous malformations (AVMs) before and after resection are not specific for this disease.

Methods—

With a microspectrophotometer, cortical oxygen saturation (S
o
2
) was measured under steady-state conditions (Pa
co
2
, 33 mm Hg) before and after removal of 22 AVMs and in 30 control subjects before and after transsylvian amygdalohippocampectomy. Intraoperative vasoreactivity tests were performed by induced changes of end-tidal CO
2
(25, 45, and 25 mm Hg) with simultaneous recording of local S
o
2
in all patients. CVR patterns were established by linear regression analysis (
P
<0.05) to define parallel (positive) versus inverse (negative) behavior, and reactivity indexes were calculated to define their degree.

Results—

Cortical oxygenation under steady-state conditions increased significantly (
P
<0.05) from preoperative to postoperative levels equally in both groups (preoperative AVM, 54.8±10.4%S
o
2
; postoperative AVM, 73.1±10.1%S
o
2
; preoperative control, 52.7±9.1%S
o
2
; postoperative control, 73.6±8.9%S
o
2
). The rate of inverse CVR patterns increased significantly (
P
<0.05) from before to after resection without showing statistically significant differences between groups.

Conclusions—

Local CVR patterns on presumably normal human cortex of control subjects are heterogeneous, including inverse behavior, and are similar to those of AVM patients before surgery. After surgery, cortical hyperemia is present in both groups, and a significant increase in inverse reactivity patterns interpreted as microvascular steal is noted. An AVM-specific CVR pattern could not convincingly be proved.
Cervical Sympathetic Block to Reverse Delayed Ischemic Neurological Deficits After Aneurysmal Subarachnoid Hemorrhage
Authors: Treggiari Miriam M. , Romand Jacques-André , Martin Jean-Baptiste , Reverdin Alain , Rüfenacht Daniel A. , de Tribolet Nicolas
Published: April 2003

Background and Purpose—

The purpose of the present study was to evaluate the feasibility and safety of a locoregional cervical sympathetic block to improve cerebral perfusion in patients suffering from cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

Methods—

Nine consecutive patients with symptoms of delayed ischemic deficits, induced by angiographically confirmed cerebral vasospasm, were treated with the injection of locoregional anesthesia to block the ascending cervical sympathetic chain at the level of the superior cervical ganglion. Neurological status was recorded before and after the procedure, and cerebral angiography was performed before and after the procedure.

Results—

No complications occurred in this short series. The procedure appeared to be simple and safe. Horner’s signs appeared within 12±0.1 minutes and lasted for an average of 6.3±4 hours. In all patients, improved cerebral perfusion was detected at the confirmatory angiography but without change in vessel caliber. One patient died of the complications of the initial hemorrhage, and 2 died of the consequences of the severe vasospasm despite maximal medical treatment. In all the other cases, the neurological status promptly returned to normal within 48 hours after the locoregional treatment.

Conclusions—

Patients with mild to moderate symptoms seem to benefit greatly from transient ipsilateral cervical sympathetic block. This simple technique may be helpful when used as an adjunct to the standard therapy to improve cerebral perfusion.
Internal Carotid Artery Angle of Origin
Authors: Sitzer Matthias , Puac Damir , Buehler Alexandra , Steckel Donata A. , von Kegler Stephan , Markus Hugh S. , Steinmetz Helmuth
Published: April 2003

Background and Purpose—

Established “systemic” vascular risk factors do not fully explain the occurrence of atherosclerosis at the carotid bifurcation. Local anatomic and hemodynamic factors may also influence the initiation of the atherosclerotic process. We determined whether the angle of internal carotid artery (ICA) origin is a risk factor for early atherosclerosis.

Methods—

In 1300 individuals from a normal population aged 40 to 70 years, we measured both carotid intima-media thickness (IMT) at 3 arterial sites (common carotid artery; carotid bifurcation; ICA bulb) and the presence of any atherosclerotic plaque within the ICA bulb bilaterally by means of high-resolution ultrasound. A standardized transverse insonation was used to determine the angle of ICA origin, expressed as the angle of rotation relative to the external carotid artery.

Results—

This angle was positively associated with ICA bulb IMT but not with IMT at other sites. After we controlled for age, sex, and other cardiovascular risk factors, a dorsal/dorsomedial ICA origin (angle ≥60°) conferred an odds ratio for having an ICA bulb IMT in the highest quartile of 2.99 (95% CI, 1.86 to 4.83) on the left and 2.01 (95% CI, 1.31 to 3.09) on the right side (both
P
<0.001). A similar relationship was found for plaque; odds ratios on multivariate analysis were 3.67 (95% CI, 1.49 to 9.03) on the left and 2.07 (95% CI, 1.10 to 4.83) on the right side (both
P
=0.035).

Conclusions—

This study suggests that the angle of ICA origin may be an independent risk factor for early atherosclerotic changes at the ICA bulb. This new hypothesis should be tested in prospective studies.
Detection of Diffusion-Weighted MRI Abnormalities in Patients With Transient Ischemic Attack
Authors: Crisostomo Ralph A. , Garcia Madelleine M. , Tong David C.
Published: April 2003

Background and Purpose—

Although diffusion-weighted MRI (DWI) has demonstrated clear superiority over other conventional imaging modalities in the detection of hyperacute cerebral ischemia, its value in the evaluation of patients with transient symptoms has received only limited attention. We assessed the utility of DWI in patients with transient ischemic attack (TIA) to further evaluate the usefulness of this technique in these individuals.

Methods—

A retrospective analysis was performed on all patients entered in the Stanford Stroke Center database during 1997–2001 who were clinically diagnosed with a TIA and who had also undergone a DWI scan ≤3 days after symptom onset. The relationship between DWI-detected findings and patients’ clinical presentation was then analyzed.

Results—

Seventy-five patients experiencing 78 TIAs who also underwent DWI within 3 days of symptom onset were identified. DWI-detected abnormalities were present in 16 of 78 cases (21%). Patients with positive DWI scans were 9.6 times more likely to have had symptom duration ≥1 hour, 16 times more likely to have had motor deficits, and 25 times more likely to have had aphasia than patients with negative DWI scans. The combination of all 3 symptoms was 100% specific for an abnormality on DWI. In 7 of 16 cases (44%), a DWI abnormality was present on both DWI and conventional imaging (T2-weighted imaging or fluid-attenuated inversion recovery [FLAIR]). In all of these cases the DWI clarified the extent or acuity of the lesion (n=7) or identified additional lesions not detected by conventional imaging (n=9).

Conclusions—

In TIA patients, symptom duration ≥1 hour, motor deficits, and aphasia were each independently correlated with detecting an abnormality with DWI. DWI was also helpful in differentiating between chronic versus acute lesions. These data may be of value in identifying those TIA patients for whom MRI evaluation with DWI is of greatest clinical utility.
William Feinberg Lecture 2002
Authors: Bogousslavsky J.
Published: April 2003

While emotional outcome is a critical factor influencing early evolution and late prognosis after stroke, few relevant studies have been performed on this subject. However, mood changes, modified judgment, and emotional reactions may also dramatically alter recruitment into clinical trials; for instance, up to one third of patients with acute stroke may have altered time perception, inappropriate self-evaluation of their condition, and attentional or memory dysfunction, with a subsequent increase in referral-to-hospital delays. In addition, the value of the “informed” consenting process may be questionable in the setting of urgent randomization into an acute stroke clinical trial. Data from ongoing studies suggest that behavior and emotional reactions in acute stroke patients may be classified into a few broad categories, with considerable overlap. Correlations between mood changes and the type, location, and severity of stroke may provide useful information for improving patient management, including the prediction of functional evolution and late prognosis. While depressive reactions have been widely studied in the recovery-rehabilitation phase after stroke, significant depression is uncommon shortly after stroke. On the other hand, related, though different, emotional behavioral changes may be more frequent; these have often been confused with depression and include catastrophic reaction, emotionalism, and athymhormia. Late depression is the most common mood alteration during the first year after stroke and has specific characteristics that differentiate it from classic endogenous and reactive depression, thus emphasizing the critical role of brain damage in the pathogenesis of poststroke depression. Early recognition and management of mood disorders after stroke are critical for the functional improvement of individual patients. However, little is known about specific indications for different antidepressant drugs in poststroke depression and related disorders. Ongoing research has identified a “new” emotional-behavioral disorder, poststroke fatigue, which is clearly distinct from depression in most instances. It is especially disabling and frustrating in that it typically involves patients with total or near-total neurological recovery, who should have been able to go back to their previous activities but who become severely disabled because of early and persisting exhaustion. Preliminary neuropsychological and MR and PET imaging studies suggest that disruption of subtle mechanisms underlying attention, in the absence of significant cognitive and mood alterations, may be responsible. Research projects are now being launched to better delineate poststroke fatigue and its management.
Abnormal Expression of Matrix Metalloproteinases and Tissue Inhibitors of Metalloproteinases in Brain Arteriovenous Malformations
Authors: Hashimoto Tomoki , Wen Gen , Lawton Michael T. , Boudreau Nancy J. , Bollen Andrew W. , Yang Guo-Yuan , Barbaro Nicholas M. , Higashida Randall T. , Dowd Christopher F. , Halbach Van V. , Young William L.
Published: April 2003

Background and Purpose—

Excessive degradation of the vascular matrix by matrix metalloproteinases (MMPs) can lead to structural instability of vessels. In this study we examined the expression of MMPs and tissue inhibitors of metalloproteinases (TIMPs) in brain arteriovenous malformations (BAVMs).

Methods—

We performed gelatin zymography for MMPs and Western blot for MMP-9, MMP-2, TIMP-1, TIMP-2, TIMP-3, and TIMP-4. MMP-9 expression was localized by immunohistochemistry.

Results—

We analyzed 37 BAVM specimens and 9 control brain specimens from epilepsy surgery. Thirty-two BAVM patients had embolization treatment before resection. Eighteen BAVM patients had a history of hemorrhage from BAVMs. Neither MMP-2 nor TIMP-2 was detected in BAVMs or control brain specimens. Compared with control brain samples, BAVM samples had higher levels of total MMP-9, active MMP-9, pro-MMP-9, TIMP-1, and TIMP-3. TIMP-4 levels were higher in the control brain than in BAVM specimens. MMP-9 was localized to the endothelial cell/peri–endothelial cell layer and infiltrating neutrophils of BAVMs. BAVMs with venous stenosis ≥50% had higher expression of MMP-9 than BAVMs with venous stenosis <50%. There was no apparent association between total MMP-9, pro-MMP-9, or active MMP-9 levels and (1) feeding artery pressure, (2) pattern of draining vein (exclusively deep venous drainage versus any superficial drainage), and (3) BAVM size.

Conclusions—

We found increased levels of MMP-9 and TIMPs in BAVMs. Abnormal balance of MMP-9 and TIMPs may contribute to vascular instability of BAVMs.
Intensity of Aphasia Therapy, Impact on Recovery
Authors: Bhogal Sanjit K. , Teasell Robert , Speechley Mark
Published: April 2003

Background—

It has been speculated that the conflicting results demonstrated across poststroke aphasia therapy studies might be related to differences in intensity of therapy provided across studies. The aim of this study is to investigate the relationship between intensity of aphasia therapy and aphasia recovery.

Methods—

A MEDLINE literature search was conducted to retrieve clinical trials investigating aphasia therapy after stroke. Changes in mean scores from each study were recorded. Intensity of therapy was recorded in terms of length of therapy, hours of therapy provided per week, and total hours of therapy provided. Pearson correlation was used to assess the relationship between changes in mean scores of outcome measures and intensity of therapy.

Results—

Studies that demonstrated a significant treatment effect provided 8.8 hours of therapy per week for 11.2 weeks versus the negative studies that only provided ≈2 hours per week for 22.9 weeks. On average, positive studies provided a total of 98.4 hours of therapy, whereas negative studies provided 43.6 hours of therapy. Total length of therapy time was found to be inversely correlated with hours of therapy provided per week (
P
=0.003) and total hours of therapy provided (
P
=0.001). Total length of therapy was significantly inversely correlated with mean change in Porch Index of Communicative Abilities (PICA) scores (
P
=0.0001). The number of hours of therapy provided in a week was significantly correlated to greater improvement on the PICA (
P
=0.001) and the Token Test (
P
=0.027). Total number of hours of therapy was significantly correlated with greater improvement on the PICA (
P
<0.001) and the Token Test (
P
<0.001).

Conclusions—

Intense therapy over a short amount of time can improve outcomes of speech and language therapy for stroke patients with aphasia.
Self-Reported Stress and Risk of Stroke
Authors: Truelsen Thomas , Nielsen Naja , Boysen Gudrun , Grønbæk Morten
Published: April 2003

Background and Purpose—

Lay people often mention stress as one of the most important risk factors for stroke. Stress might trigger a cerebrovascular event directly or could be associated with higher levels of blood pressure or an unfavorable lifestyle. To examine these possibilities, we analyzed the association between self-reported stress frequency and intensity and risk of stroke.

Methods—

Data from the second examination, 1981 to 1983, of participants in the Copenhagen City Heart Study were analyzed with Cox regression after a mean of 13 years of follow-up. A total of 5604 men and 6970 women were included, and 929 first-ever strokes occurred, of which 207 (22%) were fatal within 28 days after onset of symptoms. The stress frequency categories were never/hardly ever, monthly, weekly, or daily. The stress intensity categories were never/hardly ever, light, moderate, or high.

Results—

Subjects with high stress intensity had almost a doubled risk of fatal stroke compared with subjects who were not stressed (relative risk [RR], 1.89; 95% CI, 1.11 to 3.21). Weekly stress was associated with an RR of 1.49 (95% CI, 1.00 to 2.23). There was no significant effect of stress in analyses of nonfatal strokes. Subjects who reported to be stressed often were more likely to have an adverse risk factor profile.

Conclusions—

Self-reported high stress intensity and weekly stress were associated with a higher risk of fatal stroke compared with no stress. However, there were no significant trends, and the present data do not provide strong evidence that self-reported stress is an independent risk factor for stroke.
Synergistic Effect of −174 G/C Polymorphism of the Interleukin-6 Gene Promoter and 469 E/K Polymorphism of the Intercellular Adhesion Molecule-1 Gene in Italian Patients With History of Ischemic Stroke
Authors: Pola Roberto , Flex Andrea , Gaetani Eleonora , Flore Roberto , Serricchio Michele , Pola Paolo
Published: April 2003

Background and Purpose—

Interleukin-6 (IL-6) and intercellular adhesion molecule-1 (ICAM-1) are involved in the pathogenetic mechanisms responsible for several ischemic cardiovascular disorders, including cerebral ischemia. IL-6 and ICAM-1 plasma levels and/or function may be genetically influenced. We sought to evaluate distribution and reciprocal interaction of IL-6 G/C gene promoter polymorphism and ICAM-1 E/K gene polymorphism in Italian patients with history of ischemic stroke.

Methods—

One hundred nineteen patients with history of ischemic stroke and 133 age- and sex-matched controls were studied. IL-6 and ICAM-1 genotypes were evaluated by polymerase chain reaction and restriction enzyme analysis.

Results—

The
GG
genotype of −174 IL-6 G/C gene polymorphism was significantly associated with history of ischemic stroke at both univariate (
P
<0.0001) and multivariate analysis (odds ratio [OR], 8.6;
P
<0.0001). Additionally, the
EE
genotype of ICAM-1 E/K gene polymorphism was significantly more common in the group of patients with history of ischemic stroke (
P
=0.003) and was an independent variable associated with stroke history (OR, 4.0;
P
=0.002). Interestingly, a further increased risk of stroke was found in subjects who concomitantly carry the IL-6
GG
and ICAM-1
EE
genotypes (IL-6
GG
/ICAM-1
EE
double-homozygous subjects) (OR, 10.1;
P
=0.004).

Conclusions—

There is a synergistic effect of IL-6 G/C and ICAM-1 E/K gene polymorphisms in patients with stroke history. Reciprocal interactions between genotypes may contribute in determining the risk profile for cardiovascular diseases and may merit further investigation as potential therapeutic targets.
Monitoring of Cerebral Vasodilatory Capacity With Transcranial Doppler Carbon Dioxide Inhalation in Patients With Severe Carotid Artery Disease
Authors: Marshall Randolph S. , Rundek Tanja , Sproule Douglas M. , Fitzsimmons Brian-Fred M. , Schwartz Shauna , Lazar Ronald M.
Published: April 2003

Background and Purpose—

Cerebral vasodilatory capacity (CVC) testing with transcranial Doppler has been shown to be useful in the assessment of stroke risk in patients with symptomatic and asymptomatic internal carotid artery (ICA) stenosis and occlusion, but whether hemodynamic status improves, deteriorates, or remains the same over time is uncertain.

Methods—

Thirty-five patients with ≥80% carotid artery stenosis or complete occlusion underwent CVC testing at baseline and 6 months later. CVC was assessed by measuring the increase in ipsilateral middle cerebral artery mean flow velocity in response to 5% inhaled CO
2
. Continuous tracings of left and right middle cerebral artery flow velocity, heart rate, respiratory rate, and P
co
2
were recorded and then analyzed offline. One-way analysis of variance was used to compare baseline CVC in symptomatic and asymptomatic patients with control subjects. A paired
t
test was used to compare CVC before and after revascularization. Also, χ
2
analysis was used to compare rates of cerebrovascular events in patients with low compared with normal CVC over the 6-month period and in 14 patients whose ICAs were revascularized.

Results—

Patients with high-grade stenosis or occlusion of the ICA who had ICA disease had an average CVC of 2.4±1.9%/mm Hg P
co
2
; control subjects averaged 4.2±1.1%/mm Hg P
co
2
. (
P
=0.01). In the revascularization group, CVC increased from an average of 1.4±1.7%/mm Hg P
co
2
at baseline to an average of 2.8±1.0%/mm Hg P
co
2
after revascularization, significantly different from the spontaneous change in the natural history group over 6 months (
P
=0.003). Over the 6-month follow-up period, in the natural history group and in the treatment group after revascularization, 4 ischemic events occurred, all in patients with abnormal CVCs; abnormal CVC was associated with ischemic events (Fisher’s exact test,
P
=0.03).

Conclusions—

In a timeframe pertinent to clinical decision making and clinical trial outcomes, cerebral hemodynamic status may not be constant. A higher ischemic risk may be present in patients with severe carotid artery disease whose CVC is poor at baseline, becomes poor over 6 months, or fails to normalize after revascularization.
Absence of Linkage of Familial Intracranial Aneurysms to 7q11 in Highly Aggregated Japanese Families
Authors: Yamada Shigeki , Utsunomiya Maki , Inoue Kayoko , Nozaki Kazuhiko , Miyamoto Susumu , Hashimoto Nobuo , Takenaka Katsunobu , Yoshinaga Takeo , Koizumi Akio
Published: April 2003

Background and Purpose—

We sought to test the linkage of familial intracranial aneurysms (FIAs) to the
ELN
(elastin) locus in chromosome 7q11 reported previously.

Methods—

Intracranial aneurysm (IA) probands were searched from patient records or neurosurgeons’ recalls in collaborating hospitals. Members of the participating probands’ families who had unknown affection status were screened by MR angiography and diagnosed by digital subtraction angiography. Inclusion criteria of families for genetic analyses were as follows: at least 3 alive affected members or 2 alive affected members with at least 1 unaffected member (≥60 years). Linkage to the
ELN
locus was tested with the use of GENEHUNTER by parametric and nonparametric methods. To exclude false-negatives in the linkage analysis, the lowest 5% limits of logarithms of the odds (LOD) and nonparametric LOD (NPL) scores for individual families and for the total set of families were simulated on assumption that the
ELN
locus is linked to FIAs.

Results—

Questionnaires were sent to 885 patients, and 563 responded. Seventy-nine probands were positive for family history. One hundred thirty-four family members of unknown affection status were screened. A total of 14 families with 64 members met the criteria. Linkage to the
ELN
locus was discarded in 11 families and was inconclusive for 3 families. The total LOD and total NPL scores for 14 families were −8.04 and −0.643, respectively. Our conclusion did not change even when the values of penetrance were changed or only affected members were analyzed.

Conclusions—

The majority of aggregated IA Japanese families may not have a genetic linkage to chromosome 7q11.
Secondary Prevention of Stroke in Italy
Authors: Filippi Alessandro , Bignamini Angelo Antonio , Sessa Emiliano , Samani Fabio , Mazzaglia Giampiero
Published: April 2003

Background—

Hypertension control and antiplatelet or oral anticoagulant drugs are the basis for secondary prevention of cerebrovascular events. Family physicians (FPs) are usually involved in both aspects of prevention, but no research has been carried out in Italy to evaluate the behavior of FPs in this field of prevention.

Methods—

Data concerning 318 Italian FPs and 465 061 patients were extracted from the Health Search Database. Patients with coded diagnoses of stroke and transient ischemic attack (TIA) were selected. Demographic records and information regarding presence of concurrent disease and medical records were also obtained. Logistic regression analyses were carried out to assess whether conditions exist that make appropriate control of blood pressure (BP) and prescription of antiplatelet or anticoagulant drugs more likely.

Results—

We selected 2555 patients with diagnosis of stroke and 2755 with TIA. Among all of the subjects, 32.6% had no BP recorded. Among the remaining subjects, 58.7% reported uncontrolled BP. Isolated systolic hypertension has been shown in 68.8% of patients with uncontrolled BP. Antiplatelet and anticoagulant drugs were prescribed in 72% of these cases. Factors that made the prescription significantly more unlikely were diagnosis of TIA (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.41 to 0.54), total invalidity (OR, 0.66; 95% CI 0.56 to 0.78), and time from event of 5 years or more (OR, 0.81; 95% CI, 0.70 to 0.94).

Conclusions—

Italian FPs could improve secondary prevention of cerebrovascular accidents. The primary target of intervention should be the control of systolic BP, and the group of patients with unacceptably high BP should be given priority. All of these patients should have been prescribed antiplatelet drugs or anticoagulant agents, except in cases of extremely short life expectancy or substantial contraindications.
Apolipoprotein E Gene Polymorphisms Are Associated With Carotid Plaque Formation but Not With Intima-Media Wall Thickening
Authors: Beilby John P. , Hunt Clive C.J. , Palmer Lyle J. , Chapman Caroline M.L. , Burley Jodi P. , McQuillan Brendan M. , Thompson Peter L. , Hung Joseph
Published: April 2003

Background and Purpose—

Several studies have investigated the role of apolipoprotein E (apoE) polymorphisms on carotid intima-media thickness (IMT) with conflicting results. The objective of this study was to use a large, community-based population to investigate associations between apoE gene polymorphisms and cardiovascular disease–associated phenotypes: IMT, carotid artery plaque, and low- (LDL-C) and high-density lipoprotein cholesterol (HDL-C).

Methods—

ApoE genotypes were determined in 1109 randomly selected community subjects with an equal man-to-woman ratio and equal numbers in each age decile who were 27 to 77 years of age and had bilateral carotid B-mode ultrasound and cardiovascular risk factor measurements.

Results—

Multivariate analyses, stratified by sex, demonstrated an association between apoE genotypes and LDL-C levels in men (
P
=0.03) and women (
P
<0.001). A significant linear trend in increasing LDL-C (β=0.33 per unit change in genotype; SE=0.07;
P
<0.001) levels with increasing number of ε4 alleles across the ε3/ε3, ε3/ε4, or ε4/ε4 genotypes was observed in women but not in men. The associations were independent of age, diastolic blood pressure, and history of diabetes mellitus. Multivariate analyses found a log-additive trend in risk of developing carotid plaque with increasing numbers of ε4 alleles across the ε3/ε3, ε3/ε4, and ε4/ε4 genotypes (odds ratio [OR], 1.72 per unit change in genotype; 95% CI, 1.05 to 2.80;
P
=0.03) in men. There was no association between plaque frequency and the ε4 allele in women. However, the ε2/ε3 genotype was shown to be associated with a lower OR (OR, 0.40; 95% CI, 0.17 to 0.91;
P
=0.03) for carotid plaques relative to the ε3/ε3 genotype in women. The associations were independent of age and standard vascular risk factors. There were no significant independent associations between apoE genotypes and IMT in either men or women.

Conclusions—

Our data suggest that polymorphisms in the apoE gene are significantly associated with LDL-C levels and increased risk of carotid plaque formation in men but not IMT in either men or women.
Prognostication of Recovery in Patients With Acute Ischemic Stroke Through the Use of Brain SPECT With Technetium-99m—Labeled Metronidazole
Authors: Song Ho-Chun , Bom Hee-Seung , Cho Ki Hyun , Kim Byeong Chae , Seo Jeong-Jin , Kim Chang-Guhn , Yang David J. , Kim E. Edmund
Published: April 2003

Background and Purpose—

We hypothesized that technetium-99m-ethylene dicysteine-metronidazole (
99m
Tc-EC-MN) localizes to brain tissue that is hypoxic but viable. This study prospectively evaluated the relationship between neurological outcome and uptake of
99m
Tc-EC-MN in peri-infarcted regions of the brain.

Methods—

Eight patients with acute ischemic stroke in the territory of the left middle cerebral artery underwent
99m
Tc-EC-MN and
99m
Tc-ethyl cysteinate dimer (ECD) brain SPECTs on the same day during the subacute stage (10.3±2.5 days). The infarct volumes from
99m
Tc-ECD images (IV
ECD
), infarct volumes from diffusion-weighted MRI images (IV
DW
), and hypoxic volume (HV) from
99m
Tc-EC-MN images were calculated. The net infarct volume (NIV
ECD
) was defined as IV
ECD
minus HV. The National Institutes of Health Stroke Scale scores were measured on admission and days 1, 3, 7, and 30.

Results—

IV
ECD
was greater than IV
DW
. The lesion-to-normal count-density ratios of
99m
Tc-EC-MN ranged from 1.80 to 5.96. HV was 60.2±65.2 cm
3
, and the mean percent HV was 24.5±28.1% of IV
ECD
. NIV
ECD
was 162.6±133.4 cm
3
and was significantly smaller than IV
ECD
. NIV
ECD
was significantly correlated with National Institutes of Health Stroke Scale score at 1 month and was a significant predictor of neurological deficit at 1 month.

Conclusions—

99m
Tc-EC-MN brain SPECT can detect hypoxic tissue after acute ischemic stroke and, in combination with
99m
Tc-ECD brain SPECT, is useful in predicting neurological outcome in ischemic stroke patients.
Thrombin-Activable Fibrinolysis Inhibitor Levels in the Acute Phase of Ischemic Stroke
Authors: Montaner Joan , Ribó Marc , Monasterio Jasone , Molina Carlos A. , Alvarez-Sabín José
Published: April 2003

Background and Purpose—

Thrombin-activable fibrinolysis inhibitor (TAFI) is a recently identified fibrinolysis inhibitor in plasma. The purpose of this work was to study TAFI levels in the acute phase of ischemic stroke and their relationship with stroke evolution.

Methods—

In 30 consecutive ischemic stroke patients, TAFI plasma levels were measured by means of enzyme-linked immunosorbent assay (percentage of the pooled reference kit expressed as mean±SD) and compared with the values obtained in 30 healthy control subjects. All samples were drawn within the first 24 hours after symptom onset (mean, 4.6 hours) and before any treatment was started.

Results—

TAFI plasma concentration was significantly higher (
P
<0.001) in stroke patients (158.4±53.2%) than in healthy control subjects (105.6±30.2%). The highest TAFI levels were found in cases of neurological deterioration (worsening, 198.1±63.0%; stability, 130.5±39.3%; improvement, 173.9±52.0%;
P
=0.057).

Conclusions—

High levels of TAFI are found in the acute phase of ischemic stroke.
Feasibility of Radioactive Embolization of Intracranial Aneurysms Using
32
P-Implanted Coils
Authors: Raymond Jean , Leblanc Philippe , Lambert Anick , Georganos Stavros A. , Guilbert François , Janicki Christian , Roorda Sjoerd
Published: April 2003

Background and Purpose—

Beta radiation can prevent recanalization after embolization. Our goal was to assess the feasibility of endovascular treatment of intracranial aneurysms using coils of a predetermined activity of
32
P per centimeter.

Methods—

We studied the total length of coils deployed into 357 intracranial aneurysms. Aneurysmal volumes were estimated using 3 mathematical models. We simulated that coils were implanted with 0.26 μCi/cm of
32
P, calculated resulting volumetric activities, and compared them with “effective” levels derived from experimental data and “safe” levels prescribed for the clinical use of
32
P in cystic craniopharyngiomas.

Results—

Effective activities would have been reached in 92% to 98% of lesions had the coils been radioactive at the time of treatment.

Conclusion—

Radioactive coil embolization of aneurysms is feasible in most patients.
Comparison of Triflusal and Aspirin for Prevention of Vascular Events in Patients After Cerebral Infarction
Authors: Matías-Guiu Jordi , Ferro José M. , Alvarez-Sabín José , Torres Ferran , Jiménez M. Dolores , Lago Aida , Melo Teresa
Published: April 2003

Background and Purpose—

The efficacy of the antiplatelet agent triflusal for prevention of vascular events after stroke has been reported in a pilot study. However, there is a need to confirm those results in a larger study.

Methods—

We performed a randomized, double-blind, multicenter study to test the efficacy of triflusal (600 mg/d) versus aspirin (325 mg/d) for prevention of vascular events in patients with stroke or transient ischemic attack (Triflusal versus Aspirin in Cerebral Infarction Prevention [TACIP]). We assessed a combined end point (incidence of nonfatal ischemic stroke, nonfatal acute myocardial infarction, or vascular death) as well as the incidence of these events separately and the incidence of major hemorrhage.

Results—

Of 2113 patients, 1058 received triflusal and 1055 aspirin. The mean follow-up period was 30.1 months. The incidence of combined end point (13.1% for triflusal, 12.4% for aspirin) as well the survival analysis (hazard ratio [HR] for triflusal versus aspirin, 1.09; 95% CI, 0.85 to 1.38) showed no differences between groups. The incidence of nonfatal stroke (HR, 1.09; 95% CI, 0.82 to 1.44), nonfatal acute myocardial infarction (HR, 0.95; 95% CI, 0.46 to 1.98,) and vascular death (HR, 1.22; 95% CI, 0.75 to 1.96) was also similar. A significantly higher incidence of major hemorrhages in the aspirin group was recorded (HR, 0.48; 95% CI, 0.28 to 0.82). The overall incidence of hemorrhage was significantly lower in the triflusal group (16.7% versus 25.2%) (odds ratio, 0.76; 95% CI, 0.67 to 0.86;
P
<0.001).

Conclusions—

This study failed to show significantly superior efficacy of triflusal over aspirin in the long-term prevention of vascular events after stroke, but triflusal was associated with a significantly lower rate of hemorrhagic complications.
Recommendations for the Relationship Between Sponsors and Investigators in the Design and Conduct of Clinical Stroke Trials
Authors: Donnan Geoffrey A. , Davis Stephen M. , Kaste Markku
Published: April 2003

Background—

As increasing numbers of clinical trials are being conducted worldwide, there has been concern about the relationship between the sponsors and investigators. Both parties need benchmarks or recommendations to act as a reference point when trials are initiated and conducted. These recommendations are designed to fulfill this role.

Summary of Comment—

A series of meetings of the International Trial Subcommittee of the International Stroke Liaison Committee, American Stroke Association, were conducted to review a series of draft recommendations that were then modified on the basis of the experience of the committee in the conduct of clinical trials. Consensus was reached on all points of the final document. The recommendations represent the opinions of the authors and do not necessarily reflect the views of the American Stroke Association. The document contains sensible recommendations concerning required sponsor company qualities, trial management structure, protocol development, trial conduct, data management, blinding, data analyses, publication, remuneration, and conflict of interest issues.

Conclusions—

The recommendations should provide a simple and practical benchmark for both investigators and sponsors in the conduct of clinical trials. Although designed for trials involving therapies for stroke, the framework allows generalization to other disciplines.
Veterans Administration Acute Stroke (VASt) Study
Authors: Goldstein Larry B. , Matchar David B. , Hoff-Lindquist Jennifer , Samsa Gregory P. , Horner Ronnie D.
Published: April 2003

Background and Purpose—

Race/ethnic-based disparities in the utilization of health-related services have been reported. Data collected as part of the Veterans Administration Acute Stroke Study (VASt) were analyzed to determine whether similar differences were present in patients admitted to Veterans Administration (VA) hospitals with acute ischemic stroke.

Methods—

VASt prospectively identified stroke patients admitted to 9 geographically separated VA hospitals between April 1995 and March 1997. Demographic characteristics and all inpatient diagnostic tests/procedures were recorded. Frequencies were compared with χ
2
tests.

Results—

Of 1073 enrolled patients, 775 (white, n=520; nonwhite, n=255, including 226 blacks and 28 Hispanic-Americans) with ischemic stroke were admitted from home. Mean ages (71.0±0.6 versus 71.9±0.4 years;
P
=0.25) and Trial of ORG 10172 in Acute Stroke Treatment (TOAST) stroke types (atherothrombotic, 12.9% versus 13.3%; cardioembolic, 16.5% versus 18.0%; lacunar, 26.4% versus 27.1%; other, 1.4% versus 2.0%; unclassified, 42.9% versus 39.6%;
P
=0.89) for whites versus nonwhites were similar. There were no race/ethnic-based differences in the utilization of brain CT (91.0% versus 92.2%;
P
=0.58), MRI (36.2% versus 41.6%;
P
=0.14), transthoracic (52.5% versus 53.7%;
P
=0.75) or transesophageal echocardiography (10.2% versus 10.6%;
P
=0.86), 24-hour ECG (3.3% versus 1.6%;
P
=0.17), carotid ultrasound (64.0% versus 62.0%;
P
=0.57), carotid endarterectomy (1.5% versus 0.8%;
P
=0.38), rehabilitation evaluations (71.0% versus 76.5%;
P
=0.11), speech therapy (9.6% versus 12.6%;
P
=0.21), recreational therapy (3.1% versus 2.0%;
P
=0.37), or occupational therapy (16.0% versus 19.6%;
P
=0.20) for whites versus nonwhites, respectively. Angiography was performed less frequently (3.1% versus 8.5%;
P
=0.01) and ECG more frequently (81.6% versus 73.5%;
P
=0.01) in nonwhites. The proportions of patients discharged functionally independent were also similar (52% of whites and 50% of nonwhites had discharge Rankin Scale scores of 0, 1, or 2;
P
=0.63).

Conclusions—

Aside from cerebral angiography and ECG, there were no race/ethnic-based disparities in the utilization of a variety of stroke-related procedures and services. The difference in the use of angiography is unlikely to be related to a difference in screening for carotid endarterectomy because there was no difference in the frequency of carotid ultrasonography. The reason ECG was obtained more frequently in nonwhites is uncertain.
Increasing Stroke Incidence and Decreasing Case Fatality, 1989–1998
Authors: Pessah-Rasmussen Hélène , Engström Gunnar , Jerntorp Ingela , Janzon Lars
Published: April 2003

Background and Purpose—

Although the incidence of and mortality from myocardial infarction (MI) have declined in most industrialized countries, incidence studies of stroke have shown less consistent trends. This study examines time trends in the incidence of stroke and case fatality rates in relation to socioeconomic circumstances and history of MI.

Methods—

Stroke incidence in the city of Malmö, Sweden (250 000 citizens), has been continuously monitored since 1989. All patients 50 to 79 years of age who experienced a first-ever stroke between 1989 and 1998 were included.

Results—

We included 3621 patients (1969 men, 1652 women). The age-standardized incidence was 647 per 100 000 persons-years for men and 400 per 100 000 persons-years for women. The annual increase—3.1% in men (
P
<0.05) and 2.9% in women (
P
<0.05)—was more pronounced in the younger age groups and was lowest in areas with poor socioeconomic circumstances. We found that 13% of the men and 6% of the women had a history of MI; this proportion was stable over the study period. The average case fatality rates in 1989 to 1998 were 10% for men and 9.3% for women. Rates remained stable for men but declined significantly in women (odds ratio per year, 0.895; 95% confidence interval, 0.84 to 0.95).

Conclusions—

In this urban population, stroke incidence increased between 1989 and 1998. The rate of increase tended to be lower in residential areas with least favorable socioeconomic circumstances. The proportion with a history of MI remained unchanged during the study period. There has been significant improvement in the case fatality rate in women but not in men.
Emergency Calls in Acute Stroke
Authors: Handschu René , Poppe Reinhard , Rauß Joachim , Neundörfer Bernhard , Erbguth Frank
Published: April 2003

Background and Purpose—

In the last 10 years, stroke has become a medical emergency. Subsequently, early recognition of stroke symptoms and rapid activation of the medical system are essential. We sought to investigate what witnesses or victims of an acute stroke syndrome recognize and report in the actual situation.

Methods—

We analyzed the recordings of all patients admitted to our stroke unit via the Emergency Medical System (EMS) dispatch center in Nuremberg within 1 year. With a structured evaluation form, the calls were screened for symptoms reported and for any diagnosis or other facts mentioned spontaneously or in response to a question by the dispatcher. We also evaluated data about EMS response and patient condition on admission.

Results—

Of 482 patients treated in our stroke unit, 141 calls were evaluated. Main symptoms reported included speech problems (25.5%), motor deficits (21.9%), and disturbances of consciousness (14.8%). In many cases, a fall (21.2%) was presented as the main problem. Sensory deficits (7.8%) and vertigo (5.6%) were rarely mentioned. In 28 calls (19.8%), stroke was mentioned as a possible cause of the acute health problems. The dispatcher suspected a stroke in 51.7% of all cases.

Conclusions—

This is one of the first studies to investigate emergency calls in acute stroke. We found that motor deficits and speech problems were the most dramatic symptoms that led to activation of the EMS. Other symptoms were less frequently reported, or atypical descriptions were given. Educational efforts are needed to improve recognition of atypical stroke symptoms by stroke victims and EMS professionals.
Stereotactic Treatment of Intracerebral Hematoma by Means of a Plasminogen Activator
Authors: Teernstra O.P.M. , Evers S.M.A.A. , Lodder J. , Leffers P. , Franke C.L. , Blaauw G.
Published: April 2003

Background and Purpose—Treatment of intracerebral hematoma (ICH) is controversial. An advantage of neurosurgical intervention over conservative treatment of ICH has not been established. Recent reports suggest a favorable effect of stereotactic blood clot removal after liquefaction by means of a plasminogen activator. The SICHPA trial was aimed at investigating the efficacy of this treatment.

Methods—A stereotactically placed catheter was used to instill urokinase to liquefy and drain the ICH in 6-hour intervals over 48 hours. From 1996 to 1999, 13 centers entered 71 patients into the study. Patients were randomized into a surgical group (n=36) and a nonsurgical group (n=35). Admission criteria were the following: age >45 years, spontaneous supratentorial ICH, Glasgow Eye Motor score ranging from 2 to 10, ICH volume >10 cm3, and treatment within 72 hours. The primary end point was death at 6 months. As secondary end points, ICH volume reduction and overall outcome measured by the modified Rankin scale were chosen. The trial was prematurely stopped as a result of slow patient accrual.

Results—Seventy patients were analyzed. Overall mortality at day 180 after stroke was 57%; this included 20 of 36 patients (56%) in the surgical group and 20 of 34 patients (59%) in the nonsurgical group. A significant ICH volume reduction was achieved by the intervention (10% to 20%,P<0.05). Logistic regression analysis indicated the possibility of efficacy for surgical treatment (odds ratio, 0.23; 95% confidence interval, 0.05 to 1.20;P=0.08). The odds ratio of mortality combined with modified Rankin scale score 5 at 180 days was also not statistically significant (odds ratio, 0.52; 95% confidence interval, 1.2 to 2.3;P=0.38).

Conclusions—Stereotactic aspiration can be performed safely and in a relatively uniform manner; it leads to a modest reduction of 18 mL of hematoma reduction over 7 days when compared with control, which has a 7-mL reduction, and therefore may improve prognosis.