Journal of Stroke & Cerebrovascular Diseases - Articles in Press

Relationship of Obesity to Recanalization After Hyperacute Recombinant Tissue-Plasminogen Activator Infusion Therapy in Patients With Middle Cerebral Artery Occlusion - Corrected Proof

2012-01-30

Background: This was a retrospective analysis of factors related to recanalization after hyperacute recombinant tissue-plasminogen activator (rt-PA) infusion therapy in patients with middle cerebral artery occlusion.Methods: Of the 50 patients (39 males and 11 females; mean age 70 ± 11 years) with cerebral infarction who were able to undergo diffusion-weighted magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of the head within 24 hours of starting rt-PA infusion therapy while hospitalized at our center between April 2007 and October 2010, 23 patients (18 males and 5 females; mean age 71 ± 9.4 years) with hyperacute cerebral infarction with findings of obstruction in the proximal segment of the middle cerebral artery (MCA-M1) served as subjects.Results: Of the 23 patients with MCA occlusion, 13 (57%) were recanalized. Analysis of factors related to recanalization revealed a significant difference (P = .019) for obesity (body mass index >25 kg/m2), with significantly more obese patients in the nonrecanalized group than in the recanalized group. The study revealed no significant differences in other factors between the 2 groups.Conclusions: The results suggest that obesity may be involved in recanalization after hyperacute rt-PA infusion therapy in patients with MCA occlusion.

C-Reactive Protein is a Predictor of Early Neurologic Deterioration in Acute Ischemic Stroke - Corrected Proof

2012-01-27

Although the association between elevated C-reactive protein (CRP) level and long-term outcome after ischemic stroke is well known, the association between CRP and early neurologic deterioration (END) has not yet been thoroughly studied. We investigated the impact of CRP on END in patients with acute ischemic stroke. From a prospectively collected, multicenter stroke registry, 428 patients with acute ischemic stroke diagnosed within 24 hours of onset were enrolled in the study. Patients with hemorrhagic stroke, transient ischemic attack, and thrombolysis were excluded. END was defined as a >2-point increase in the National Institutes of Health Stroke Scale score within a 72-hour period. Data considered potentially associated with CRP level and the END were collected. END was observed in 47 patients. CRP level, time before arrival at the hospital, age, female sex, hematocrit, high-density lipoprotein (HDL) cholesterol level, hemoglobin A1c level, and internal carotid artery occlusion were significantly associated with END. On logistic regression analysis, CRP level, internal carotid artery occlusion, and HDL cholesterol proved to be independent variables. Our data suggest that CRP level at admission is significantly associated with END in acute ischemic stroke. HDL cholesterol and internal carotid artery occlusion are also associated with END.

Rotational Vertigo Associated with Putaminal Infarction - Corrected Proof

2012-01-24

A 57-year-old man was admitted because of left hemiparesis. A magnetic resonance imaging scan of the brain revealed a recent infarct from the dorsal side of the right putamen to the corona radiata. Three hours after onset, he complained of rotational vertigo. Truncal ataxia was also found on standing a few days later, which persisted until the chronic phase. Repeat magnetic resonance imaging scans on days 2 and 11 revealed no additional lesions. The present case indicates that rotational vertigo might result from a small, supratentorial, subcortical lesion.

Ischemic Stroke After Low-voltage Electric Injury in a Diabetic and Coagulopathic Woman - Corrected Proof

Wei-Hsi Chen, Chi Chui, Chun-Chung Lui, Hsin-Ling Yin — 2012-01-24

Electric injury is a common physical injury in daily life. Because of the low resistance of vascular tissue, vascular injury and thrombosis are frequently found in cases of high-voltage electric injury but are rarely reported in low-voltage conditions. We present the case of a diabetic woman who suffered symptomatic brainstem stroke after a short duration of 60 Hz/110V alternate current electric contact with a home washer socket. A stroke risk factor survey did not reveal remarkable cardiac or vascular abnormality, except increased glycohemoglobin levels and decreased protein C activity. In contrast to a direct and adequate energy transfer in high-voltage electric injury, a pre-existing vasculohemostatic deficit, such as coagulopathy, has been proposed to provide a predisposition to thrombosis in low-voltage electric injury. Nevertheless, the findings in this patient remind the possibility of physical triggering factor for stroke occurrence in our environment as new technology and product generates rapidly enough for understanding their safety and biologic effect.

von Willebrand Factor Genetic Variant Associated with Hematoma Expansion After Intracerebral Hemorrhage - Corrected Proof

2012-01-16

Background: Hematoma expansion, the leading cause of neurologic deterioration after intracerebral hemorrhage (ICH), remains one of the few modifiable risk factors for poor outcome. In the present study, we explored whether common genetic variants within the hemostasis pathway were related to hematoma expansion during the acute period after ICH.Methods: Patients with spontaneous ICH who were admitted to the institutional Neuro-ICU between 2009 and 2011 were enrolled in the study, and clinical data were collected prospectively. Hematoma size was measured in patients admitted on or before postbleed day 2. Baseline models for hematoma growth were constructed using backwards stepwise logistic regression. Genotyping of single-nucleotide polymorphisms for 13 genes involved in hemostasis was performed, and the results were individually included in the above baseline models to test for independent association of hematoma expansion.Results: During the study period, 82 patients were enrolled in the study and had complete data. The mean age was 65.9 ± 14.9 years, and 38% were female. Only von Willebrand factor was associated with absolute and relative hematoma growth in univariate analysis (P < .001 and P = .007, respectively); von Willebrand factor genotype was independently predictive of relative hematoma growth but only approached significance for absolute hematoma growth (P = .002 and P = .097, respectively).Conclusions: Our genomic analysis of various hemostatic factors identified von Willebrand factor as a potential predictor of hematoma expansion in patients with ICH. The identification of von Willebrand factor single-nucleotide polymorphisms may allow us to better identify patients who are at risk for hematoma enlargement and will benefit the most from treatment. The relationship of von Willebrand factor with regard to hematoma enlargement in a larger population warrants further study.

Low-Normal Systolic Blood Pressure and Secondary Stroke Risk - Corrected Proof

Bruce Ovbiagele — 2012-01-16

A recent observational study of >20,000 patients with recent ischemic stroke suggested that systolic blood pressure (SBP) maintained in a low-normal range may be associated with increased risk of recurrent stroke, especially within the first 6 months after the first stroke. Using a distinct cohort, the current study aimed to independently evaluate the relationship between low-normal SBP levels and risk of recurrent stroke through analysis of a trial dataset involving 3680 patients with recent noncardioembolic ischemic stroke aged ≥35 years recruited from 56 centers between September 1996 and May 2003 and followed for 2 years. Subjects were categorized based on their mean in-trial SBP value as low-normal (<120 mm Hg), high-normal (120 to <140 mm Hg), or high (>140 mm Hg). The primary outcome was stroke. Multivariate analyses used competing-risks Cox regression models. The rate of recurrent stroke was 9.1% in the low-normal group, 6.7% in the high-normal group, and 10% in the high group. The difference in recurrent stroke rate between the low-normal and high-normal groups was more prominent within the first 6 months (low-normal, 4.5%; high-normal, 2.5%; high, 3.4%) than after 6 months (low-normal, 4.6%; high-normal, 4.2%; high, 6.6%). Over the study period, compared with the high-normal group, the risk of the primary outcome trended higher in the low-normal group (adjusted hazard ratio, 1.47; 95% confidence interval, 0.94-2.29; P = .09) and was higher in the high group (adjusted hazard ratio, 1.39; 95% confidence interval, 1.08-1.79; P = .01). These results support the recently described pattern of increased risk of recurrent stroke in patients with low-normal SBP levels, especially within the first 6 months after first stroke. However, this study likely was not sufficiently powered to detect more than a strong statistical trend underlying this relationship.

Stroke Literacy, Behavior, and Proficiency in a South Florida Population - Corrected Proof

John A. Morren, Efrain D. Salgado — 2012-01-16

Background: Our goal was to assess stroke literacy, behavior, and proficiency in our South Florida service population.Methods: Data were obtained from the 2006 to 2010 Cleveland Clinic Florida annual “stroke prevention screening” questionnaires. “Stroke risk factor awareness” was attributed to participants correctly identifying at least 5 out of the 7 stroke risk factors presented. “Stroke symptom awareness” was assigned if one correctly selected all 5 listed stroke symptoms and not any of the 3 inappropriate responses. Participants had “stroke literacy” if they: (1) demonstrated stroke risk factor awareness; (2) demonstrated stroke symptom awareness; and (3) they correctly identified the brain as where a stroke occurs. To assess appropriate “stroke behavior,” respondents had to choose “call 911 immediately” if one were to experience stroke symptoms. “Stroke proficiency” was attributed to individuals showing both stroke literacy and appropriate stroke behavior.Results: There were a total of 298 participants. Sixty-seven percent of participants correctly identified the brain as the organ where stroke occurs. Almost three-fourths (74.2%) demonstrated stroke risk factor awareness, 28.2% had stroke symptom awareness, 17.8% had stroke literacy, 87.9% declared appropriate stroke behavior, and 16.1% had stroke proficiency.Conclusions: Stroke behavior and stroke proficiency are useful novel concepts in stroke epidemiology. Although our South Florida community is relatively well-educated and affluent, there are tangible gaps in knowledge, attitudes, and behavior as it pertains to stroke, similar to that seen in less advantaged populations. We recommend intensified usage of the media with information provided by qualified health professionals in a variety of formats and languages appropriate to the ethnic and cultural diversities that define this population.

Correlation of Elevated Troponin and Echocardiography in Acute Ischemic Stroke - Corrected Proof

Amir Darki, Michael J. Schneck, Anoop Agrawal, Arti Rupani, John T. Barron — 2012-01-13

Background: Previous research has revealed a higher prevalence of elevated cardiac troponin T or I levels amongst patients admitted with stroke, which has been associated with increased cardiovascular events, higher mortality rates, and poor inpatient prognosis. Because cardiac comorbidities account for almost 20% of deaths after ischemic stroke, it is important to understand the relationship between troponin elevation, cardiac events, and acute ischemic stroke (AIS).Methods: We evaluated 137 consecutive patients ≥18 years of age who presented within 48 hours of AIS onset. All patients had laboratory markers drawn on admission, including troponin and brain natriuretic peptide, along with transthoracic echocardiogram with Doppler. The mean age of our study population was 71.7 ± 14.6 years.Results: Twenty-four of 137 patients (17.5%) had a positive troponin level. Sixteen of 24 (67%) patients with a positive troponin level had a new wall motion abnormality on echocardiogram that was suggestive of unstable atherosclerotic disease. On statistical analysis, we found a significant association between troponin and brain natriuretic peptide elevation with positive segmental wall motion abnormality on echocardiogram.Conclusions: These study findings represent a new paradigm of interpreting elevated cardiac biomarkers and may help with risk stratification and diagnosis of patients presenting with AIS.

Transoral Carotid Ultrasonography Using A Micro Convex Probe with B-flow Imaging for Extracranial Internal Carotid Artery Dissection - Corrected Proof

2012-01-13

We report on transoral carotid ultrasonography using a micro convex probe with B-flow imaging for determining spontaneous extracranial internal carotid artery dissection just below the petrous portion. A 49-year-old man suffered cortical and subcortical infarction in the region of the right middle cerebral artery. Magnetic resonance angiography on the third day of admission revealed spontaneous recanalization of the right internal carotid artery associated with an intimal flap–like structure at the petrous portion. Transoral carotid ultrasonography using a micro convex probe revealed right extracranial internal carotid artery dissection, showing an increased diameter of the right extracranial internal carotid artery with double lumen formation, stenosis of the true lumen, and a mobile intimal flap in B-flow imaging. Transoral carotid ultrasonography using a micro convex probe was helpful to attempt a self-expanding stent for recanalizing right extracranial internal carotid artery dissection. The patient recovered and was discharged ambulatory. The size of the micro convex probe was optimum for transoral carotid ultrasonography in our patient. Micro convex probe is more commonly used than the standard transoral carotid ultrasonography probe, which lacks versatility. We consider that transoral carotid ultrasonography using a micro convex probe could be routinely used for ultrasonographic evaluation of extracranial internal carotid artery dissection.

Antithrombotic Management of Stroke Patients Before Colonoscopy - Corrected Proof

2012-01-13

Background: Uncertainty exists regarding the management of antithrombotic medications in ischemic stroke and transient ischemic attack (TIA) patients around the time of colonoscopy. We sought to evaluate whether there was a difference in adverse events among patients who continued medications and those who had temporary discontinuation.Methods: Using a hospital administrative database, electronic charts of patients with a diagnostic code for stroke or TIA and a procedural code for colonoscopy were reviewed. Information collected included baseline demographics, medical history, and antithrombotic medications. Outcome measures were stroke (ischemic and hemorrhagic), myocardial infarction, venous thromboembolism, and major systemic bleeding (i.e., requiring transfusion) up to 4 weeks after the procedure among patients who had medications continued versus temporarily discontinued.Results: One hundred seventy-seven patients met inclusion criteria. Antithrombotic medication was temporarily discontinued in 42 patients and continued in 135 patients. Comparing patients who had medications held to those who had medications continued, stroke occurred in 1 (2.4%) versus 0 (0%; P = .237) patients; myocardial infarction in no patients in either group; venous thromboembolism in 0 (0%) versus 1 (0.7%; P > .99) patients; and major system bleeding in 2 (4.8%) versus 4 (3.0%; P = .628) patients.Conclusions: In this retrospective analysis, there was no significant difference in the occurrence of stroke, myocardial infarction, venous thromboembolism, and major bleeding between patients who had medications continued around the time of colonoscopy versus those who had temporary discontinuation. A prospective, randomized controlled study is warranted to further elucidate this issue.

Churg–Strauss Syndrome with Concomitant Occurrence of Ischemic Stroke and Relapsing Purpura - Corrected Proof

2012-01-03

A 77-year-old woman suffering from chronic bronchial asthma and chronic atrial fibrillation who had had a previous ischemic stroke presented to our emergency unit with gait disturbance. She had new-onset truncal ataxia, right hemiparesis, and right sensory disturbance related to the previous stroke. Her lower legs were slightly swollen and had a reddened appearance. Her medical history included mitral valve replacement because of severe mitral valve regurgitation. Her white blood cell count was 8600/μL, mainly consisting of eosinophils (4480/μL; 52.1%). Serum nonspecific immunoglobulin E was elevated to 1600 IU/mL (normal range <170 IU/mL). She was taking warfarin for secondary stroke prevention, and on admission her prothrombin time international normalized ratio was 3.06. Diffusion-weighted magnetic resonance imaging revealed a fresh infarct in the right cerebellum. No stenosis or occlusion was shown in the cervicocephalic arteries on magnetic resonance angiography or carotid ultrasound. No emboligenic diseases, except for atrial fibrillation, were identified. On day 3, an extensive itchy, purpuric rash appeared on her lower limbs. The rash remitted and recurred spontaneously for several weeks. A skin biopsy specimen of the purpuric lesions revealed massive eosinophilic infiltration of the dermis and eosinophilic vasculitis involving small vessels. We diagnosed the patient with Churg–Strauss syndrome (CSS). Skin lesions and eosinophilia disappeared after oral corticosteroid therapy. In this case, cerebellar infarction occurred with purpuric rash despite well-controlled anticoagulation. Patients with CSS may suffer from ischemic stroke when the condition of CSS deteriorates.

Influence of Experimental Subarachnoid Hemorrhage on Nicotine-induced Contraction of the Rat Basilar Artery in Relation to Arachidonic Acid Metabolites Signaling Pathway - Corrected Proof

Xu Ji, Aimin Wang, Cristina C. Trandafir, Kazuyoshi Kurahashi — 2012-01-03

Background: Smoking is one of the most important risk factors for cerebral circulatory disorders. The purpose of this study was to investigate the influence of experimental subarachnoid hemorrhage (SAH) on nicotine-induced contraction (arachidonic acid metabolites) in the basilar arteries of rats.Methods: Rats were killed at 1 hour and 1 week after blood injection, and the basilar artery was isolated and cut into a spiral strip.Results: Testing of cyclooxygenase-1 (COX-1) and 5-lipoxygenase (5-LOX) inhibitors revealed no significant differences in their effects on normal and SAH (1 hour and 1 week). Phospholipase C (PLC) inhibitor (1-(6-((17beta-3-methoxyestra-1,3,5(10)-trien-17yl)amino)hexyl)-1H-pyrrole-2,5,-dione [U-73122]) slightly inhibited contraction of SAH (1 hour and 1 week) when compared to controls. Phospholipase A2 (PLA2) inhibitor (manoalide) and cytosolic PLA2 (cPLA2) inhibitor (arachidonyltrifluoromenthylketone [AACOCF3]) more strongly attenuated contraction in SAH (1 hour and 1 week) than in controls. Secreted PLA2 (sPLA2) inhibitor (indoxam), PLC inhibitor (2-nitro-4-carboxyphenyl N, N-diphenylcarbamate [NCDC]), and COX-2 inhibitors (nimesulide, (5-methanesulfonamido-6-(2,4-difluorothiophenyl)-1-indanone) [L-745337], and celecoxib) only slightly inhibited contraction of SAH (1 week) when compared to normal and SAH (1 hour). The calcium-independent PLA2 (iPLA2) inhibitor bromoenol lactone (BEL) showed greater inhibition of contraction in SAH (1 hour) when compared to normal and SAH (1 week).Conclusions: One week after exposure to SAH, PLC, sPLA2, and COX-2 activity were enhanced and cPLA2 activity was inhibited. One hour after exposure to SAH, PLC activity was enhanced and cPLA2 and iPLA2 activity was inhibited. Such changes of inflammatory arachidonic acid metabolites by smoking after SAH may play important roles in fatal cerebral circulatory disorders, suggesting important implications for the etiology and pathogenesis of SAH.

Contralateral Glossoplegia in A Lower Pontine Infarction - Corrected Proof

Bon D. Ku, Hak Young Rhee, Sung Sang Yoon — 2011-12-30

A 65-year old man developed sudden dysarthria, dysphagia, right-sided weakness, and sensory loss. The neurologic examination revealed left-sided tongue deviation caused by right glossoplegia. A magnetic resonance imaging scan revealed an elongated acute infarction from the left ventromedial portion of the lower pons extending to the dorsal pontine tegmentum area. The ipsilateral tongue deviation of the patient may result from interruption of the contralateral crossed corticohtpoglossal projection. This finding suggests that the possibility of the corticohypoglossal decussation may exist just above the pontomedullary junction, with individual variability.

Vertebral Artery Stenting for the Treatment of Bow Hunter’s Syndrome: Report of 4 Cases - Corrected Proof

2011-12-30

Bow hunter’s syndrome (BHS) is a rare condition resulting from vertebrobasilar insufficiency secondary to mechanical occlusion or stenosis of the vertebral artery (VA) due to head rotation. Traditionally, surgical intervention with C1-C2 fusion or VA decompression was the mainstay of therapy. Endovascular intervention was rarely performed to treat BHS. We reviewed the neurointerventional database from July 2005 to October 2010 to identify all cases of BHS treated with VA stenting. Here we report clinical, technical, and outcome data for 4 patients with BHS who were treated with VA stenting. In all 4 of these patients, stenting was performed in the V2 segment (C2-C6) of the VA without significant technical difficulties. All patients reported symptomatic relief, and only minor or no residual stenosis was detected by dynamic digital subtraction angiography. Our findings indicate that VA stenting for the treatment of BHS is feasible, safe, and clinically effective. Endovascular techniques might offer an alternative, minimally invasive therapy for the treatment of BHS.

“Code Stroke”: Hospitalized versus Emergency Department Patients - Corrected Proof

Nada El Husseini, Larry B. Goldstein — 2011-12-30

Stroke rapid-response (“code stroke”) teams facilitate the evaluation and treatment of patients presenting to emergency departments (EDs). Little is known about the usefulness of code stroke systems for patients hospitalized primarily for other conditions. We hypothesized that the yield of code stroke evaluations would be lower in hospitalized than in ED patients, and sought to identify potential targets for quality improvement efforts. Diagnoses and management of in-hospital and ED code stroke patients were assessed retrospectively in a Joint Commission–certified primary stroke center over a 1-year period. A total of 93 in-hospital and 204 ED code strokes were identified during this period. Compared with the ED patients, the hospitalized patients were less likely to have had a stroke/transient ischemic attack (26.8% vs 51.4%; P < .0001) and less likely to have been treated with a thrombolytic agent (odds ratio, 0.27; 95% confidence interval, 0.07-0.97: P = .03). Conditions not necessitating immediate neurologic care accounted for 63.4% of in-hospital strokes, compared with 31.3% of ED code strokes (P < .0001). “Altered mental status” was the sole presenting symptom in 48% of the hospitalized patients, compared with only 10% of ED patients (P < .0001), and was the only clinical feature independently associated with a stroke mimic in the hospitalized patients (odds ratio, 63.52; 95% confidence interval, 7.37-547.69; P = .0002). There was no association between a final diagnosis of a stroke mimic and patient age, sex or race-ethnicity or nursing shift. The proportions of patients with acute ischemic stroke and patients treated with thrombolytics after activation of in-hospital code stroke were small, and were lower than those of patients with ED code stroke in the same hospital over the same time period. Developing a standardized assessment protocol for hospitalized patients with altered mental status may improve the efficacy of care.

Intraprocedural Prediction of Hemorrhagic Cerebral Hyperperfusion Syndrome After Carotid Artery Stenting - Corrected Proof

2011-12-30

Hyperperfusion syndrome (HPS) is a rare but severe complication after carotid artery stenting (CAS). Reliable methods for predicting HPS remain to be developed. We aimed to establish a predictive value of hemorrhagic HPS after CAS. Our retrospective study included 136 consecutive patients who had undergone CAS. We determined the cerebral circulation time (CCT) by measuring the interval between the point of maximal opacification of the terminal portion of the internal carotid artery and the cortical vein. We calculated intraprocedural CCT changes (ΔCCT) by subtracting postprocedural CCT values from preprocedural CCT values. The mean ΔCCT was 0.9 ± 0.9 seconds; 3 patients (2.2%) with prolonged ΔCCT (2.7, 5.4, and 5.8 seconds) developed HPS. The cutoff time of 2.7 seconds predicted hemorrhagic HPS retrospectively with 100% sensitivity and 99% specificity. Our findings suggest that post-CAS HPS can be predicted by using the ΔCCT value obtained by intraprocedural digital subtraction angiography. Patients with a ΔCCT >2.7 seconds require careful intensive hemodynamic and neurologic monitoring after CAS.

Efficacy of Endovascular Revascularization in Elderly Patients with Acute Large Vessel Occlusion: Analysis from the RESCUE-Japan Retrospective Nationwide Survey - Corrected Proof

2011-12-30

Background: The purpose of this study was to evaluate the efficacy of endovascular treatment (EVT) in elderly patients (≥75 years of age) with acute large-vessel occlusion (LVO).Methods: A total of 229 patients with acute LVO treated by EVT in 2008 were registered from 68 medical centers in Japan. Among the total of 229 patients, 89 were elderly patients. We retrospectively investigated the treatment efficacy of EVT and patient outcome, and compared the parameters between the elderly and the nonelderly group.Results: Recanalization after EVT was equally obtained in both groups (P = .71). There was no significant difference in the favorable outcome (modified Rankin Scale [mRS] 0-2) between the elderly and nonelderly groups (30.3% vs 33.6%; P = .61), whereas poor outcome (mRS 5 and 6) was observed more in the elderly group than in the nonelderly group (48.3% vs 32.1%; P = .01). In patients with any recanalization (Thrombolysis in Myocardial Infarction grading system 1-3), the rates of favorable outcome in both groups were similar (39.7% vs 42.6%; P = .71). In contrast, in patients without recanalization, there was a significant difference in the poor outcome between the elderly and the nonelderly groups (76.2% vs 46.7%; P = .046). Symptomatic intracranial hemorrhage occurred in 6.7% in the elderly group and in 11.4% in the nonelderly group (P = .23).Conclusions: The elderly population could achieve favorable outcomes comparable to the nonelderly population, especially when they achieve any recanalization by EVT. Elderly patients should not be excluded from recanalization therapy with EVT because of age.

Clopidogrel Responsiveness in Stroke Patients on a Chronic Aspirin Regimen - Corrected Proof

2011-12-30

This study evaluated the antiplatelet effects of clopidogrel (CPG) in patients sustaining acute ischemic stroke who were already receiving chronic outpatient aspirin therapy (81-325 mg/day). Platelet function was measured using 3 different “point-of-care” platelet function analyzers: the Thrombelastograph hemostasis system, the Accumetrics VerifyNow system, and the Chronolog 570VS impedance aggregometer. Platelet function was assessed before administration of a 300-mg CPG loading dose and again at 26 hours and 64 hours after this loading dose along with a 75-mg daily maintenance dose. All 3 instruments detected marked inhibition of platelet function at 26 hours and 64 hours after CPG administration. There were significant variations among the 3 instruments in monitoring antiplatelet responses to aspirin and CPG; however, these variations were eliminated when the platelet function results were corrected for baseline platelet variability. The percentage of patients who were poor responders to CPG after switching from aspirin depended on the measurement instrument used, but was higher at 26 hours after CPG administration than at 64 hours after CPG administration. Our findings indicate that poor response to antiplatelet agents in general, and to CPG in particular, is a function of the measuring instrument. The correction for baseline platelet variability results in similar levels of platelet inhibition measured by the 3 platelet function analyzers. Future studies are warranted to examine the association between ex vivo CPG-induced platelet inhibition and clinical outcomes in patients with ischemic stroke.

Intracranial Hemorrhage as the Initial Presentation of Disseminated Intravascular Coagulation in Association with Malignancy - Corrected Proof

Atsuhiro Kojima, Shunichi Okui — 2011-12-30

A 76-year-old man presented with a sudden disturbance of consciousness and right hemiplegia. An initial computed tomographic examination revealed multiple hematomas. The laboratory studies were highly suggestive of disseminated intravascular coagulation, although the underlying diseases were unknown at the time of admission. Despite various attempts at management, including replacement therapy, bleeding was not controlled and the patient died on day 5. An autopsy revealed the presence of prostate and rectal cancers. This case illustrates the fact that a fatal intracranial hemorrhage can be the first manifestation of disseminated intravascular coagulation in association with malignancy.

Population Trends and Disparities in Outpatient Utilization of Neurologists for Ischemic Stroke - Corrected Proof

Sudeep Karve, Rajesh Balkrishnan, Eric Seiber, Milap Nahata, Deborah A. Levine — 2011-12-26

Background: Inpatient stroke utilization may be decreasing over time and may vary by patient demographics. Less is known about temporal trends and demographic variations in outpatient stroke utilization. We assessed ischemic stroke (IS)–related outpatient utilization across physician specialty and time, exploring any demographic variability, using recent US population-based data.Methods: We identified all outpatient medical visits for IS by adults (≥18 years) using the National Ambulatory Medical Care Survey (NAMCS) years 1998 to 2009. Physician numbers were derived from American Medical Association or American Osteopathic Association data by NAMCS. We assessed IS-related outpatient visits to neurologists and generalists over time and by patient demographics.Results: We identified 9.7 million IS-related visits from 1998 to 2009. The rate of IS-related visits to neurologists increased from 0.56 million visits in 1998 to 2000 to 0.90 million visits in 2007 to 2009, representing a 62% increase over the study period. The rate of IS-related visits to generalists declined from 2.0 million visits in 1998 to 2000 to 1.6 million visits in 2007 to 2009 (18% decrease). Between 1998 and 2009, the number of neurologists increased by 23% and the number of generalists grew by 19%. The IS visit rate per 100 physicians increased by 90% for neurologists but decreased by 31% for generalists. Fewer ambulatory IS-related visits to neurologists were reported among stroke survivors who were older, female, nonwhite, or living in rural areas.Conclusions: Between 1998 and 2009, IS-related outpatient utilization increased substantially to neurologists but declined to generalists. We identified demographic variations in outpatient utilization of neurologists that potentially lead to disparities in stroke evaluation and management.

Telestroke in South Carolina - Corrected Proof

Christos Lazaridis, Stacia M. DeSantis, Edward C. Jauch, Robert J. Adams — 2011-12-26

Background: The administration of thrombolysis to eligible patients is often limited to centers with expertise. This study was intended to report on the safety and efficacy (in increasing thrombolysis availability) of telemedicine in the acute assessment and treatment of stroke patients presenting to hospitals in distant locations from a designated stroke center.Methods: A web-based telestroke tool (remote evaluation of acute ischemic stroke at Medical University of South Carolina [REACH-MUSC]), was implemented to provide acute stroke care 24 hours per day, 7 days per week to 12 community hospitals in South Carolina.Results: Nine hundred sixty-five consults were performed. Among the 525 patients with a National Institutes of Health Stroke Score >3, 185 (35.7%) were treated with intravenous tissue plasminogen activator (t-PA) alone, 15 (2.9%) received combination of intravenous and intra-arterial thrombolysis/thrombectomy, and 11 (2.1%) were treated with intra-arterial therapy alone. Of those who received intravenous t-PA, 119 (64.3%) were transferred to the hub; the medians (interquartile range) for onset to treatment for the intravenous t-PA and the intravenous t-PA and intra-arterial groups were 152 (range 115-193) minutes and 147 (range 107-179) minutes, respectively. Three patients (1.6%) who received intravenous t-PA alone experienced symptomatic intracerebral hemorrhage. The most common reason for not receiving thrombolysis was patient presentation outside the time window for treatment.Conclusions: Telestroke can have a major impact in increasing thrombolysis rates in remote areas from specialized centers, and in particular in areas where t-PA is underutilized.

A Malignant Case of Acute Promyelocytic Leukemia with Occlusion of Carotid Artery by Tumor Thrombus - Corrected Proof

Selena Nicholas-Bublick, John Irlam, Gretchen Tietjen — 2011-12-19

We report an unusual and malignant presentation of acute promyelocytic leukemia (APL) resulting in thrombosis of a cervicocephalic artery by tumor in a healthy 37-year-old woman. The patient’s rapid decline and multiorgan involvement proved to be a diagnostic and therapeutic challenge, and despite the efforts of a coordinated multidisciplinary health care team, she suffered a cardiac arrest and died within 48 hours of presentation to the emergency department. Autopsy revealed an APL-related tumor thrombus obstructing the left internal carotid artery, which to the best of our knowledge has not yet been described as a cause of fatal stroke.

Prestroke Dementia is Associated with Poor Outcomes after Reperfusion Therapy among Elderly Stroke Patients - Corrected Proof

2011-12-19

Background: In elderly acute stroke patients, reperfusion therapy is often withheld. We sought to determine whether prestroke dementia contributed to poor outcomes after reperfusion therapy in these patients.Methods: All consecutive patients ≥80 years of age who received intravenous (IV) or intra-arterial reperfusion therapy (IAT) were identified in our Get With the Guidelines Stroke (GWTG-S) database. Vascular risk factors, presence of dementia, and outcomes were abstracted from the medical record. Dementia was recorded when listed in the medical history or when under medical treatment. Primary outcome was in-hospital mortality. Secondary outcome was discharge destination, “favorable” (home or rehabilitation facility) versus “unfavorable” (skilled nursing facility, hospice, or death). Multivariate logistic regression models were used to assess outcomes.Results: Of 153 patients, 72% received IV tissue plasminogen activator (tPA), 35% IAT, and 7% both. The mean age was 85.8 ± 4.6 years; 13.6% had prestroke dementia. The in-hospital mortality rate was 35%. The likelihood of death increased with National Institutes of Health Stroke Scale (NIHSS; odds ratio [OR] 1.14; 95% confidence interval [CI] 1.07-1.21), IAT (OR 3.43; 95% CI 1.70-6.92), and dementia (OR 3.61; 95% CI 1.39-9.37), and decreased with IV tPA (OR 0.34; 95% CI 0.17-0.71). Increasing NIHSS (OR 0.90; 95% CI 0.85-0.95), symptomatic intracranial hemorrhage (OR 0.08; 95% CI 0.01-0.67), IAT (OR 0.43; 95% CI 0.22-0.84), and dementia (OR 0.37; 95% CI 0.14-0.97) decreased the likelihood of favorable discharge. In multivariate analysis, only NIHSS (OR 1.13; 95% CI 1.06-1.22) and dementia (OR 5.64; 95% CI 1.88-16.89) independently predicted death and unfavorable discharge destination.Conclusions: Among the elderly, prestroke dementia is a powerful independent predictor of in-hospital mortality after acute reperfusion therapy for stroke. Future investigations of thrombolysis outcomes in the elderly are warranted.

A Patient with Deep Cerebral Venous Sinus Thrombosis in whom Neuroendovascular Therapy was Effective - Corrected Proof

2011-12-19

A 63-year-old man presented with aphasia. A computed tomographic scan of the head revealed hemorrhagic infarction in the left temporal lobe. Magnetic resonance venography (MRV) revealed no flow from the straight sinus and left transverse sinus to the sigmoid sinus, indicating cerebral venous sinus thrombosis (CVST). Because of rapidly deteriorating consciousness despite heparin infusion, neuroendovascular therapy was performed, recanalization was achieved, and the level of consciousness improved. In Western countries, neuroendovascular therapy is often aggressively performed in patients with worsening symptoms despite anticoagulation. However, in Japan, such reports are extremely rare. We recommend neuroendovascular therapy for deep CVST resistant to anticoagulant therapy.

Long-Term Prediction of Functional Outcome After Stroke Using the Alberta Stroke Program Early Computed Tomography Score in the Subacute Stage - Corrected Proof

2011-12-16

Stroke patients who arrive at hospital more than 24 hours after symptom onset could benefit from a simple means of assessing long-term prognosis in this subacute stage. We evaluated whether clinical factors along with ischemic injury assessed subacutely using the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) had predictive value for functional independence after stroke. Computed tomography (CT) scans obtained ≥2 days after first-ever ischemic stroke were scored independently and retrospectively by 3 stroke neurologists using the ASPECTS. Functional outcome was measured using the Functional Independence Measure, which assesses the amount of caregiver assistance required by patients during daily activities. Multiple linear regression was used to develop a predictive model for functional prognosis at 1 month, 3 months, and 1 year poststroke. For our 55 patients, CT scanning was done on average 4 days poststroke. The interrater agreement for subacute ASPECTS was excellent, with a κ-weighted value of 0.90. Lesions involving the frontal and superior parietal ASPECTS regions were significant predictors of lower Functional Independence Measure scores at all 3 time points studied. In combination with such factors as age, marital status, and the severity of initial neurologic deficit, a subacute ASPECTS score >5 had significant predictive value for greater functional independence at 3 months (R2 = 0.701; P < .001) and 1 year (R2 = 0.528; P < .001) poststroke. Our data indicate that in the subacute stage, ASPECTS is reliable and can help predict which patients may be likely to regain functional independence up to 1 year after sustaining ischemic stroke.

A Case of Posterior Cerebral Artery Dissection Presenting with Migraine-Like Headache and Visual Field Defect: Usefulness of Fast Imaging Employing Steady-State Acquisition (FIESTA) for Diagnosis - Corrected Proof

Koichi Haraguchi, Kentaro Toyama, Takeo Ito, Masahiro Hasunuma, Yasuo Sakamoto — 2011-12-16

We report a 34-year-old woman with sudden onset of unilateral migraine-like headache and right homonymous hemianopsia. Fast imaging employing steady-state acquisition (FIESTA) of the posterior cerebral artery captured an intimal flap and a pseudolumen, leading to a diagnosis of posterior cerebral artery dissection. This case was considered a spontaneous posterior cerebral artery dissection causing migraine-like headache. The treatment of migraine-like headache hinges on correct diagnosis. In this case, FIESTA was very useful in diagnosing an intracranial artery dissection.

Intravenous Thrombolysis in Thai Patients with Acute Ischemic Stroke: Role of Aging - Corrected Proof

Pornpatr A. Dharmasaroja, Sombat Muengtaweepongsa, Permphan Dharmasaroja — 2011-12-16

Background: Intravenous thrombolysis is a standard treatment in eligible acute ischemic stroke (AIS) patients. However, the advisability of treating patients >80 years of age is still debated. The aim of this study was to evaluate the role of aging on the outcomes in Thai patients treated with intravenous thrombolysis.Methods: Patients with AIS treated with intravenous recombinant tissue-plasminogen activator (rtPA) between June 2007 and November 2010 were included. The demographics and measured outcome variables were compared between patients ≤70 and >70 years of age. Patients were also classified into 4 subgroups by the age ranges: ≤60 years, 61 to 70 years, 71 to 80 years, and ≥81 years of age.Results: Two hundred sixty-one patients were included. Seventeen patients (6.5%) were >80 years old. Higher mortality (20.2% vs 5.1%; P < .001) and symptomatic intracerebral hemorrhage (7.7% vs 1.2%; P = .004) were found in the patients >70 years of age when compared with younger patients, and the rate of favorable outcome was lower (38.1% vs 55.4%; P = .010). Higher mortality rates were seen with increasing age: 3%, 8%, 20%, and 21% in patients aged ≤60, 61 to 70, 71 to 80, and ≥81 years of age, respectively.Conclusions: Thai stroke patients >70 years of age may carry a higher risk of mortality when treated with intravenous rtPA compared to patients ≤70 years of age.

Height and Risk of Incident Intraparenchymal Hemorrhage: Atherosclerosis Risk in Communities and Cardiovascular Health Study Cohorts - Corrected Proof

2011-12-16

Background: Height is inversely associated with incident coronary disease and total stroke, but few studies have examined the association between height and intraparenchymal hemorrhage (IPH). We hypothesized that height would be inversely associated with incident IPH in the combined cohorts of the Atherosclerosis Risk in Communities Study and the Cardiovascular Health Study.Methods: Data on Caucasian and African American participants were used to estimate the association of height at baseline with incident IPH verified by clinician review of medical records and imaging reports. Sex-specific Cox proportional hazards regression models were used to calculate hazard ratios.Results: A total of 20,983 participants initially free of stroke (11,788 women and 9195 men) were followed for an average of 15.9 years (standard deviation [SD] 5.1 years). Incident IPH occurred in 115 women and 73 men. Sex, but not age, race, study, or blood pressure, modified the association (P = .03). After adjustment for risk factors (age, systolic blood pressure, triglycerides, low-density lipoprotein cholesterol, fibrinogen, and race), among women, height was significantly inversely associated with incident IPH (hazard ratio [HR] per SD [6.3 cm] was 0.81; 95% confidence interval [CI] 0.66-0.99; P = .04). The HR for tertile 3 vs 1 in women was 0.63 (95% CI 0.37-1.08). Among men, height was not linearly associated with incident IPH (HR per SD [6.7 cm] was 1.09; 95% CI 0.84-1.40; P = .52).Conclusions: This large prospective study provides evidence that shorter height may be a risk factor for incident IPH in women.

Variability in the Use of Intravenous Thrombolysis for Mild Stroke: Experience Across the SPOTRIAS Network - Corrected Proof

2011-12-16

Background: Current guidelines do not define the lower severity threshold for thrombolysis. In this study, we describe the variability of treatment of mild stroke patients across a network of academic stroke centers.Methods: Stroke centers within the Specialized Program of Translational Research in Acute Stroke (SPOTRIAS) prospectively collect data on patients treated with intravenous recombinant tissue plasminogen activator (IV rt-PA), including demographics, pretreatment National Institutes of Health Stroke Scale (NIHSS) scores, and in-hospital mortality. We examined the variability in proportion of total tissue plasminogen activator–treated patients in the NIHSS categories (0-3, 4-5, or ≥6) and associated outcomes.Results: A total of 2514 patients with reported NIHSS scores were treated with IV rt-PA between January 1, 2005 and December 31, 2009. The proportion of patients with mild stroke (NIHSS scores of 0-3) who were treated with IV rt-PA varied substantially across the centers (2.7-18.0%; P < .001). There were 5 deaths in the 256 treated with an NIHSS score of 0-3 (2.0%). The proportion of treated patients across the network with an NIHSS score of 0 to 3 increased from 4.8% in 2005 to 10.7% in 2009 (P = .001).Conclusions: There is substantial variability in the proportion of treated patients who have mild stroke across the SPOTRIAS centers, reflecting a paucity of data on how to best treat patients with mild stroke. Randomized trial data for this group of patients are needed to clarify the use of rt-PA in patients with the mildest strokes.

Bilateral Caudate Nucleus Infarction Associated with a Missing A1 Segment - Corrected Proof

2011-12-16

We describe a case of bilateral caudate nucleus infarction caused by cardioembolic stroke associated with a variant circle of Willis. The patient was an 81-year-old man with atrial fibrillation who presented with a sudden disturbance of consciousness. When he became more alert a few days later, he was abulic with no spontaneous speech or activity. A magnetic resonance imaging scan of the brain revealed cerebral infarction of bilateral caudate nucleus heads and the left frontal lobe. The left A1 segment was absent on 3-dimensional computed tomography angiography. One year later, abulia had completely resolved. Bilateral caudate nucleus infarction with variant circle of Willis is rare.

Comparison of the Effects of High- and Low-frequency Repetitive Transcranial Magnetic Stimulation on Upper Limb Hemiparesis in the Early Phase of Stroke - Corrected Proof

Nobuyuki Sasaki, Saneyuki Mizutani, Wataru Kakuda, Masahiro Abo — 2011-12-16

Background: Recently, high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) and low-frequency rTMS (LF-rTMS) are reported to improve motor function significantly in chronic hemiparetic stroke patients. However, few studies have investigated the safety and efficacy of these rTMS modalities introduced during the early phase of stroke. The purpose of this study was to clarify the rTMS modality that is more beneficial for upper limb hemiparesis in the early phase of stroke using a randomized controlled trial.Methods: Twenty-nine patients with a hemispheric stroke lesion in the early phase of stroke were examined. Patients were randomly assigned into 3 groups: the HF-rTMS group (10 Hz rTMS to the lesional hemisphere [n = 9]), the LF-rTMS group (1 Hz rTMS to the nonlesional hemisphere [n = 11]), and the sham stimulation group [n = 9]). Patients received sessions for 5 consecutive days. Grip strength and tapping frequency were assessed before and after the intervention. Motor improvement of the affected upper limb after intervention was compared among the 3 groups.Results: All patients completed the 5-day protocol. Both the HF-rTMS and LF-rTMS groups had significant increases in both grip strength and tapping frequency. Comparison of the extent of improvement showed a more significant increase in grip strength and tapping frequency in the HF-rTMS group compared to the sham stimulation group (each P < .05), and no difference between the LF-rTMS group and the sham stimulation group.Conclusions: HF-rTMS applied to the lesional hemisphere in the early phase of stroke was more beneficial for motor improvement of the affected upper limb than LF-rTMS.

Reply - Corrected Proof

Shunya Takizawa — 2011-12-16

I appreciate Dr. Turin’s interest in our article. Analysis of regional differences in the incidence of stroke, even within Japan, is complicated, because many factors may influence the conclusions, including regional differences of pollutants, temperature, lifestyle factors (such as salt, smoking, and alcohol consumption levels), and the distribution of facilities (urban or rural areas) contributing data to the Japanese Standard Stroke Registry Study (JSSRS). Turin et al pointed out the regional difference in pollutants related to motorized vehicles in Japan. In the 1990s, Japan’s environmental legislation was tightened. For example, to cope with NOx pollution problems from existing vehicle fleets in highly populated metropolitan areas, the Ministry of the Environment adopted the “Law Concerning Special Measures to Reduce the Total Amount of Nitrogen Oxides Emitted from Motor Vehicles in Specified Areas” in 1992. In 2009, nitrogen oxide levels at 582 offices were within the regulatory threshold (100% of general offices, 95.7% of offices in metropolitan areas). Therefore, we think pollutants may not be a major contributor to the regional difference in incidence of stroke, at least in Japan. In addition, the fact that the 163 facilities contributing data to JSSRS are unevenly distributed in urban and rural areas makes it difficult to evaluate the effect of pollutants on incidence of stroke in our study.

Transient Total Mesencephalic Locked-in Syndrome After Bilateral Ptosis Due To Basilar Artery Thrombosis - Corrected Proof

Yasunori Fujimoto, Yu-ichiro Ohnishi, Akatsuki Wakayama, Toshiki Yoshimine — 2011-12-16

Locked-in syndrome (LIS) usually occurs as a result of pontine lesions and has been classified into various categories on the basis of neurologic conditions, of which transient total mesencephalic LIS is extremely rare. A 53-year-old man presented with bilateral ptosis followed by a total locked-in state. In the clinical course, the patient successfully recovered with only left slight hemiparesis and skew deviation remaining. Magnetic resonance imaging revealed multiple ischemic lesions caused by thrombosis at the top of basilar artery, including the bilateral cerebral peduncles, tegmentum of the midbrain, and the right cerebellar hemisphere. Antecedent bilateral ptosis before the locked-in state may be related to ischemia in the central caudal nucleus of the oculomotor nuclei. We should pay attention to this easily missed condition during the treatment of ischemic stroke involving the basilar artery.

Development of Transdural Anastomosis After Craniotomy in a Patient With Atherothrombotic Carotid Occlusion - Corrected Proof

2011-12-16

Development of transdural anastomosis is extremely rare in the patients with atherosclerotic cerebrovascular disease. We report a rare case of development of transdural anastomosis after craniotomy in the patient with atherothrombotic carotid occlusion.

Racial and Ethnic Disparities in the Use of Intravenous Recombinant Tissue Plasminogen Activator and Outcomes for Acute Ischemic Stroke - Corrected Proof

Deena M. Nasr, Waleed Brinjikji, Harry J. Cloft, Alejandro A. Rabinstein — 2011-12-12

Racial and ethnic disparities in acute stroke care in the United States have been previously reported. This study investigated possible racial and ethnic disparities in the administration and outcome of recombinant tissue plasminogen activator (rtPA) therapy for acute ischemic stroke in whites, blacks, Hispanics, and Asian/Pacific Islanders. Using the National Inpatient Sample for 2001-2008, we selected patients with a primary diagnosis of acute ischemic stroke who received treatment with rtPA. Patient data were stratified by race (white, black, Hispanic, and Asian/Pacific Islander). We analyzed the association of patient race on rtPA utilization rate, in-hospital morbidity (ie, discharge to long-term facility), intracranial hemorrhage (ICH) rate, and in-hospital mortality. We performed a multivariate logistic regression analysis to determine independent predictors of poor outcomes. White patients had a higher rate of tPA utilization than black and Hispanic patients (2.3% vs 1.8% and 2.0%, respectively; P < .0001 for both groups). There was no difference in the rate of tPA utilization between whites and Asian/Pacific Islanders (2.3% vs 2.2% P = .07). Multivariate analysis of morbidity, mortality, and ICH rates found that Asian/Pacific Islanders had significantly higher rates of mortality (odds ratio, 1.22, 95% confidence interval, 1.03-1.44; P = .02) and ICH (odds ratio, 2.01; 95% confidence interval, 1.91-2.11; P < .0001) compared with whites. rtPA utilization was greater in white and Asian/Pacific Islander patients than in black and Hispanic patients. Asian/Pacific Islander race was associated with increased risk of ICH and mortality after rtPA administration.

Emergent Angioplasty and Stent Placement Recanalization Without Thrombolysis in Acute Middle Cerebral Artery Occlusions - Corrected Proof

Xin-Bin Guo, Lai-Jun Song, Sheng Guan — 2011-12-12

A significant proportion of patients with infarcts from large-vessel lesions have shown a poor response to systemic thrombolysis. Stents have been used to recanalize occluded or severely stenosed intracranial arteries in patients with acute stroke. This study evaluated the feasibility, efficacy, and safety of intracranial artery recanalization for acute middle cerebral artery (MCA) occlusion using emergent angioplasty and stent placement without thrombolysis. All patients from a retrospectively collected database who met the inclusion criteria and were treated with an intracranial stent for acute MCA occlusion were included. Treatment comprised angioplasty and stenting without interventional thrombolytic therapy. Recanalization was assessed by angiography immediately after stent placement based on the Thrombolysis in Myocardial Infarction (TIMI) score. Complications related to the procedure and outcomes were assessed. Neurologic status was evaluated before and after treatment. Eleven patients were treated with emergent angioplasty and stent placement. Partial or complete recanalization (TIMI 2 and 3) was achieved in 11 patients (100%) assessed by digital subtraction angiography immediately after MCA stenting. One patient died due to reocclusion of MCA 2 days after the procedure. Among the survivors, 7 patients (70%) had a good outcome (modified Rankin Scale score, 0-2) and 3 patients (30%) had a moderate outcome (modified Rankin Scale score, 3). Follow-up computed tomography angiography or magnetic resonance angiography revealed mild restenosis in 2 of the 10 patients. This preliminary experience demonstrates the technical feasibility and high rate of recanalization with emergent angioplasty and stenting without thrombolysis in patients with acute MCA occlusion.

Gender Difference in Stroke Case Fatality: An Integrated Study of Hospitalization and Mortality - Corrected Proof

David DeVries, Ying Zhang, Ming Qu, Jihyun Ma, Ge Lin — 2011-12-06

Background: Providing regional and state-specific prognosis factors for stroke patients has both clinical and public health importance. Results from previous studies of sex difference in stroke case fatality have been mixed. The current study links stroke hospitalizations to community-based mortality records to examine sex difference in stroke case fatality and associated prognosis factors.Methods: Hospital discharge data and death certificate data from January 2005 to December 2009 in Nebraska were linked. Multivariable logistic regression was used to estimate sex differences in 30-day mortality, and the Cox proportional hazard model was used to predict overall survival.Results: A total of 15,806 patients were included. Females were more likely to die during the 30 days after stroke hospitalization. However, there was no significant difference in overall survival in the multivariate analysis that controlled for age, comorbidity, and rehabilitation factors. Females were more likely to have comorbidities, such as atrial fibrillation, anemia, and heart failure, while males were more likely to have chronic kidney disease. In addition, males were more likely to receive rehabilitation services after stroke.Conclusions: Among persons hospitalized with a stroke in Nebraska between 2005 and 2009, the crude case fatality rate was 50% higher in women. However, after accounting for age and other variables, adjusted mortality rates were essentially the same for men and women.

Identifying a High Stroke Risk Subgroup in Individuals With Heart Failure - Corrected Proof

2011-12-06

Background: Heart failure (HF) is associated with an overall stroke rate that is too low to justify anticoagulation in all patients. This study was conducted to determine if vascular risk factors can identify a subgroup of individuals with heart failure with a stroke rate high enough to warrant anticoagulation.Methods: The REGARDS study is a population-based cohort of US adults aged ≥45 years. Participants are contacted every 6 months by telephone for self- or proxy-reported stroke and medical records are retrieved and adjudicated by physicians. Participants were characterized into 3 groups: HF without atrial fibrillation (AF), AF with or without HF, and neither HF nor AF. Cardiovascular risk factors at baseline were compared between participants with and without incident stroke in HF and AF. Stroke incidence was assessed in risk factor subgroups in HF participants.Results: Of the 30,239 participants, those with missing/anomalous data were excluded. Of the remaining 28,832, 1360 (5%) had HF without AF, 2528 (9%) had AF, and 24,944 (86%) had neither. Previous stroke/transient ischemic attack (TIA; P = .0004), diabetes mellitus (DM; P = .03), and higher systolic blood pressure (P = .046) were associated with increased stroke risk in participants with HF without AF. In participants with HF without AF, stroke incidence was highest in those with previous stroke/TIA and DM (2.4 [1.1, 4.0] per 100 person-years).Conclusions: The combination of previous stroke/TIA and DM increases the incidence of stroke in participants with HF without AF. No analyzed subgroup had a stroke rate high enough to make it likely that the benefits of warfarin would outweigh the risks.

CHADS2- and CHA2DS2VASc Scores and Embolic Risk in Left Ventricular Hypertrabeculation/Noncompaction - Corrected Proof

Claudia Stöllberger, Christian Wegner, Josef Finsterer — 2011-12-06

Background: Left ventricular hypertrabeculation/noncompaction (LVHT) is associated with stroke or embolism (S/E). The aim of this study was to assess if the Congestive heart failure, Hypertension, Age >75 years, Diabetes, and Stroke (CHADS2) and CHA2DS2VASc scores are different between LVHT-patients with and without stroke/embolism.Methods: Records of LVHT patients were retrospectively screened. For stroke classification, the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria were applied, for peripheral embolism angiographic findings. Baseline data were compared between patients with and without S/E.Results: In 26 of 169 patients (15%), stroke (n = 24) or peripheric embolism (n = 2) had occurred. S/E etiology was either cardioembolic (n = 18), atherosclerotic (n = 5), or undetermined (n = 3). S/E occurred before (n = 17) and after (n = 9) diagnosis of LVHT/NC. The prevalence of hypertension (62 vs 35%; P < .05), CHADS2, and CHA2DS2-VASc scores were higher in patients with than without S/E (2.85 vs 1.26 and 3.69 vs 1.93, respectively; P < .001).Conclusions: S/E in LVHT is not always cardioembolic, but may also have an atherosclerotic cause. The CHADS2 score may be useful for clinical decision-making about oral anticoagulation for the prevention of S/E in LVHT patients.

Cerebral Infarcts Associated with Adenomyosis Among Middle-aged Women - Corrected Proof

2011-12-06

Cerebral infarcts associated with hypercoagulability in malignant tumors have been well recognized. However, reports on cerebral infarcts in patients with a benign gynecologic tumor, such as adenomyosis, are extremely limited. We report the cases of 4 patients with adenomyosis and cerebral infarcts, all without obvious evidence of conventional causes of cerebral infarcts. Brain magnetic resonance imaging revealed multiple cerebral infarcts in both cortical and subcortical areas in all the patients and in different arterial territories in 3 patients. Two patients also had systemic embolism in the fingers or kidneys. One patient had thrombi in the brachiocephalic trunk and left subclavian artery. The levels of coagulation markers were elevated in the acute phase of cerebral infarcts. Although cerebral infarcts might be uncommon in adenomyosis patients, these patients might be potentially at risk of developing cerebral infarcts associated with hypercoagulability related to increased mucinous tumor marker levels, menstruation-related coagulopathy, or increased tissue factor expression levels. Additional study is required to determine the mechanism underlying the development of cerebral infarcts in adenomyosis; however, physicians need to pay particular attention to those who have hypercoagulability with adenomyosis among middle-aged women.

Giant Serpentine Aneurysm of the Distal Anterior Cerebral Artery - Corrected Proof

Nobuo Senbokuya, Kazuya Kanemaru, Hiroyuki Kinouchi, Toru Horikoshi — 2011-12-06

We report a case of a 38-year-old man with a giant serpentine aneurysm arising from the distal anterior cerebral artery. This aneurysm grew from a fusiform aneurysm to a huge aneurysm within 5 months before manifesting as a mass lesion. The aneurysm was largely filled with thrombus, and 4 distal branches arose from the aneurysm dome. Selective balloon test occlusion of the distal anterior cerebral artery using an intravascular technique was performed to confirm the tolerance of the brain tissue. The balloon test occlusion elicited adequate leptomeningeal collateral circulation and no neurologic symptoms; thus, the aneurysm was treated with trapping and resection. The patient had no ischemic complications after the surgery and returned to his job 1 month later. No ischemia developed in the 2 years after surgery. Selective balloon test occlusion of the distal cerebral artery using an intravascular technique can be a very useful tool in planning the therapeutic strategy for a complicated distal cerebral aneurysm.

Wake-up Stroke Within 3 Hours of Symptom Awareness: Imaging and Clinical Features Compared to Standard Recombinant Tissue Plasminogen Activator Treated Stroke - Corrected Proof

2011-12-01

Background: Patients with wake-up stroke (WUS) are excluded from thrombolysis because of unknown time of symptom onset. Previous studies have reported similar stroke severity and early ischemic changes (EICs) in patients with WUS and stroke of known onset. These studies, however, included patients within a large timeframe to imaging or did not quantify EICs. The aim of our study was to quantify EICs of patients with WUS presenting within 3 hours of symptom recognition compared to standard 3-hours recombinant tissue plasminogen activator (rt-PA)–treated patients and assess the extent of ischemic lesion and functional independence at follow-up.Methods: Patients were selected from our prospectively collected stroke database. Baseline and follow-up computed tomographic scans were graded with Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Clinical outcome measures were modified Rankin Scale score, mortality, and symptomatic intracerebral hemorrhage.Results: Demographic features, risk factors, stroke severity, and baseline ASPECTS were similar in both groups. WUS and rt-PA–treated patients had similar tissue outcome (median ASPECTS 7.0 vs 7.5; P = .202). Functional outcome was more favorable in rt-PA–treated patients (61.6% vs 43.1%; odds ratio [OR] 2.12; 95% confidence interval [CI] 1.05-4.28; P = .037). After adjusting for age, stroke severity, treatment, and EICs in less than one-third of middle cerebral artery territory, rt-PA and National Institutes of Health Stroke Scale scores remained the only significant predictors of outcome (OR 7.76; 95% CI 2.40-25.05; P = .001 and OR 0.74; 95% CI 0.67-0.82; P < .001, respectively).Conclusions: Within 3 hours of symptom recognition, patients with WUS have EICs similar to rt-PA–treated patients. It is reasonable to expect that selected WUS patients might benefit from thrombolysis within 3 hours of symptom awareness.

Clinical Evaluation of Lacunar Infarction and Branch Atheromatous Disease - Corrected Proof

Taizen Nakase, Shotaroh Yoshioka, Masahiro Sasaki, Akifumi Suzuki — 2011-12-01

Patients with branch atheromatous disease (BAD) are more likely to experience neurologic deficits compared with those with lacunar infarction (LI), although both disorders are forms of intracranial deep brain infarction. We clinically evaluated patients with BAD (n = 42) and LI (n = 57) to investigate why patients with BAD tend to experience progressing stroke. Patients presenting to our hospital with acute ischemic stroke between April 2008 and March 2009 were screened. LI was defined as an intracerebral lesion <15 mm in diameter and fewer than 3 slices or a lesion within the pontine parenchyma. BAD was defined as an intracerebral lesion of ≥15 mm in diameter and more than 3 slices or a lesion extending to the surface of the pontine base observed on diffusion-weighted magnetic resonance imaging. Progressing stroke was defined as a >2-point increase in the National Institutes of Health Stroke Scale within 48 hours of stroke onset. Progressing stroke was significantly more prevalent in the BAD group compared with the LI group (38.1% vs 12.3%). Diabetes mellitus with a high low-density lipoprotein level was significantly prevalent in patients with progressing BAD. When BAD in the cerebrum and BAD in the pons were analyzed separately, a low-density lipoprotein level >140 mg/dL was the most prevalent risk factor for progressing BAD in the cerebrum, and patient age was the strongest risk factor for progressing BAD in the pons. Vascular lesions asvsessed by magnetic resonance angiography were significantly abundant in both progressing LI and BAD. Our findings suggest that BAD may have a poorer prognosis than LI. Poorly controlled diabetes and hyperlipidemia could lead to atherosclerosis of the branch artery, resulting in worsening of BAD.

Recurrent Lobar Intracerebral Hemorrhage in Tangier Disease - Corrected Proof

Wuwei Feng, Evgeny Sidorov, Kara Smith, Magdy Selim — 2011-12-01

We report a patient with familial α-lipoprotein deficiency (Tangier disease) who presented with recurrent lobar intracerebral hemorrhages and accumulating microbleeds on T∗2-weighted magnetic resonance imaging, suggestive of probable cerebral amyloid angiopathy. This case provides new insight into the links between the Adenotriphosphate-Binding Cassette A1 (ABCA1) transporter gene mutation in Tangier disease and apolipoprotein-E expression in the brain and supports further investigation of the potential role of ABCA1 transporter in cerebral amyloid angiopathy.

Screening for NOTCH3 Gene Mutations Among 151 Consecutive Korean Patients With Acute Ischemic Stroke - Corrected Proof

2011-12-01

Background: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a single-gene disorder of cerebral small blood vessels caused by mutations in the NOTCH3 gene. The initial detection of CADASIL may be more difficult among Asian populations because common clinical phenotypes and neuroimaging findings are not frequently found in these populations. The purpose of this study was to screen the NOTCH3 gene for mutations among consecutive patients with acute ischemic stroke from our region in Korea.Methods: Between April 2008 and March 2009, 151 consecutive patients with acute ischemic stroke were screened for NOTCH3 mutations. All patients underwent a detailed clinical examination and structured interview for clinical symptoms and family history. We reviewed brain magnetic resonance imaging data from stroke patients to assess the severity of white-matter hyperintensity lesions, the number of cerebral microbleeds, and the number of lacunar infarctions. Polymerase chain reaction was used to screen exons 3, 4, 6, 11, and 18 of the NOTCH3 gene.Results: Among 151 consecutive patients with acute ischemic stroke, 6 patients (4.0%; 95% confidence interval [CI] 0.9-7.1) possessed a NOTCH3 gene mutation. All patients exhibited the same R544C mutation in exon 11. Four of these 6 patients presented with large artery atherosclerosis. The prevalence of CADASIL in patients with neuroimaging features consistent with advanced small-vessel disease was 36.0% (95% CI 8.0-64.8).Conclusions: In this region, NOTCH3 gene mutations are frequently found in acute stroke patients who present with neuroimaging features consistent with advanced small-vessel disease.

A Case of Embolic Stroke Imitating Atherothrombotic Brain Infarction Before Massive Hemorrhage from An Infectious Aneurysm Caused by Streptococci - Corrected Proof

2011-12-01

Early detection followed by treatment with antibiotics in conjunction with direct or endovascular surgery is integral in the management of patients with intracranial infectious aneurysms. These aneurysms often manifest as massive intracranial hemorrhages, which severely deteriorate the outcome. It is very important to detect infectious aneurysms before they rupture. Although usually associated with infective endocarditis, these aneurysms can occur in a variety of clinical settings. We present a case of α-Streptococcus–provoked infectious aneurysm in a patient without infective endocarditis, initially presenting as atherothrombotic-like brain infarction, before massive intracranial hemorrhage. The present case alerts clinicians to keep in mind possible development of infectious aneurysms, even in patients who appear to be suffering from atherothrombotic stoke, especially in patients presenting with signs of infection.

Geotopographic and Environmental Characteristics of Communities and the Seasonality of Stroke Occurrences - Corrected Proof

Tanvir Chowdhury Turin, Adrian V. Specogna, Nahid Rumana — 2011-11-24

We read with great interest the study by Takizawa et al that was recently published in the Journal of Stroke and Cerebrovascular Diseases describing seasonality in the occurrence of stroke in Japan. The authors analyzed 35,631 registered stroke cases (29,238 ischemic and 6,393 hypertensive hemorrhagic stroke patients) occurring between 1998 and 2007 from the Japanese Standard Stroke Registry Study (JSSRS) database, which is currently the world’s largest hospital-based stroke database, accumulating records from 163 Japanese institutions throughout Japan. To examine seasonal variation in the incidence of ischemic and nonischemic stroke patients, months were grouped into 4 seasons: spring (March to May), summer (June to August), fall (September to November), and winter (December to February). The authors did not observe any statistically significant seasonal difference in the incidence of ischemic stroke, but the incidence in summer was significantly higher than in winter (incidence ratio 1.035). Regarding the seasonal variation in subtypes of ischemic stroke, lacunar stroke showed significant seasonality with the incidence of summer being significantly higher than in winter (incidence ratio 1.187). Atherothrombotic stroke showed a similar pattern but did not reach statistical significance. Significant seasonality was observed for cardioembolic stroke but for this subtype the incidence in winter was significantly higher than in summer (incidence ratio 1.128). Seasonal difference in hemorrhagic stroke patients was also significant with the incidence in summer being significantly lower than in others seasons. Previous studies in Japan had shown the winter–spring period predominantly to be the higher risk period for stroke incidence and acute case-fatality. On the contrary, studying 12,660 patients with ischemic stroke, the Japan Multicenter Stroke Investigators’ Collaboration (J-MUSIC) study have reported that stroke occurred least frequently in spring, followed by winter, with summer being the highest period of stroke occurrences. Interestingly, the summer high ischemic stroke pattern is similar between the large-scale JSSRS (167 institutions throughout Japan) and J-MUSIC (156 hospitals throughout Japan) studies. On the contrary, the localized community-based studies—predominantly based on a single community and therefore having limited generalizability—revealed higher ischemic stroke occurrences during the colder period of the year and a trough during summer. Can the methodologic difference, being multi-institutional throughout the country or being localized in a single community, be attributed to the differing results observed? It is possible that the multi-institutional studies will be affected by the heterogeneity regarding the topographic and the environmental difference across the institutions’ catchment areas. These factors will influence the sociodemographic characteristic of the corresponding catchment area populations as well. All these may contribute to the different results observed in the 2 multi-institutional country-wide studies in comparison to single-center studies. Community-level factors, such as geographic and demographic features of populations, have been explanatory causes for the observed disparity of stroke incidence/mortality throughout the world. This disparity in stroke incidence and mortality exists within the country level perspectives, too. In the United States, stroke incidence and mortality are highest in some southeastern states which are referred to as the “stroke belt.” In the United Kingdom and Finland, the northern parts of both countries have a higher reported stroke incidence than the southern parts leading to north–south gradient. Even within Japan, northeast prefectures have higher stroke mortalities than other parts of Japan. Additional community-level variables that potentially will have some differences across the geographic locations are the environmental factor of weather and pollution. Though the overall seasonal arrangement will be similar in Japan, the intensities of different seasons will be different across geographic locations (e.g., the intensity of cold will be different between northern parts of Japan in comparison to the southern parts of Japan). Some more urban and rural differences will also affect the impact of seasonality, especially in the perspective of temperature or pollutants. The urban areas will be showing more difference in pollutant, pollen levels across the seasons, especially the pollutants related to motorized vehicles. Although Japan is a country of a relatively homogenous standard of living, the difference of heating systems between the urban and rural houses will also have some effect on the temperature variations across seasons, especially during the winter or early spring. Because of the abovementioned factors and the probable unmeasured confounders in these types of large-scale country-wide studies, caution is warranted in interpreting the results derived from pooling data from different sites. Although Takizawa et al have mentioned that they have considered the geographic location by dividing their study centers in northern and southern regions, they have also acknowledged correctly that it is unclear whether the division of Japan into northern and southern regions was appropriate. In addition, it was not clear from their description what measures they have taken during the analysis plan to address the topologic–geographic differences across the areas of the study institutes. Were the seasonal trends reported by the authors observed among all the institutions similarly, or were the reported findings mainly from institutions who had bigger number of observations contributed to the analysis pool? Along with the current analysis plan adopted by the authors, a regional clustered analysis (making groups of the 163 institutions based on their location and local weather pattern) followed by a meta-analysis taking the heterogeneity of the characteristics of the catchments area population and weather parameters in consideration would have given a more comprehensive understanding about the seasonality of stroke.

Anemia Is Associated with Poor Outcomes in Patients with Less Severe Ischemic Stroke - Corrected Proof

2011-11-21

Anemia is a known predictor of in-hospital mortality among patients with such vascular conditions as acute myocardial infarction, congestive heart failure, and chronic kidney disease. The role of anemia in patients with acute ischemic stroke is less well understood. We sought to examine the association between anemia at hospital admission and the combined outcome of in-hospital mortality and discharge to hospice in patients with acute ischemic stroke. We evaluated data from a retrospective cohort of consecutive ischemic stroke patients presenting within 48 hours of symptom onset at 5 hospitals between 1998 and 2003. Anemia was defined as an admission hematocrit value of <30%. Less severe stroke was defined as an admission National Institutes of Health Stroke Scale score of <10. The outcome was the combined endpoint of in-hospital mortality or discharge to hospice. Among 1306 patients with stroke, anemia was present on admission in 6.4%, and the combined outcome of death or discharge to hospice was present in 10.1%. Anemia was not associated with outcome in patients with severe stroke (anemia, 17.2% [5 of 29] vs no anemia, 28,4% [98 of 345]; P = .20), but was associated with outcome in patients with less severe stroke (anemia, 13.0% [7 of 54] vs no anemia, 2.5% [22 of 878]; P < .0001). After adjustment for stroke severity, admission anemia was independently associated with outcome in patients with less severe stroke (adjusted odds ratio, 4.17; 95% confidence interval, 1.47-11.90), but not in patients with more severe strokes (adjusted odds ratio, 0.82; 95% confidence interval, 0.30-2.22). Our data indicate that anemia is associated with in-hospital mortality or discharge to hospice in patients with less severe ischemic stroke.

Balloon Test Occlusion with the Doppler Velocity Guidewire - Corrected Proof

2011-11-21

Transcranial Doppler ultrasonography is the most commonly used method of cerebrovascular blood flow velocity measurement, but it is subject to certain technical and anatomic limitations. The Doppler velocity guidewire measures blood flow velocity within any vessel during cerebral angiography, overcoming these limitations. We report the first use of this guidewire in the measurement of blood flow velocity during balloon test occlusion, with results similar to simultaneously measured transcranial Doppler ultrasonography. Velocity measurement by Doppler guidewire could be useful in balloon test occlusion for vertebrobasilar circulation, where transcranial Doppler ultrasonography is limited, and provide anatomically specific blood flow velocity measurements in the diagnosis and treatment of stroke and other cerebrovascular diseases.

Preadmission Beta-blockers Are Associated With Decreased Incidence of Neurogenic Stunned Myocardium in Aneurysmal Subarachnoid Hemorrhage - Corrected Proof

Conrad W. Liang, Ricky Chen, Elizabeth Macri, Neeraj Naval — 2011-11-21

Background: Neurogenic stunned myocardium (NSM) is a frequent complication of aneurysmal subarachnoid hemorrhage (aSAH), with a significant impact on disease course. The presumed cause is catecholamine surge at the time of aneurysm rupture. Beta-blockers, which reduce the impact of the catecholamine surge, may decrease the risk of developing NSM.Methods: A chart review of 234 consecutive patients admitted to the Oregon Health and Science University Neurosurgery service between March 6, 2008 and June 23, 2010 with a diagnosis of aneurysmal SAH was performed. This group was further subdivided by patients who received echocardiograms on admission, by gender, and by the prehospital administration of β-blockers.Results: One hundred thirty of 234 patients had echocardiograms on or shortly after admission, and 18 of these developed NSM (13.8%). None of the 22 patients taking prehospital β-blockers developed NSM. Using the Fisher exact test to compare the 2 groups, patients who were administered prehospital β-blockers were significantly less likely to develop stunning compared to those who were not (P = .04). After correcting for other variables using multiple logistic regression analysis, the previous use of β-blockers was still found to be significantly associated with a decreased incidence of NSM after SAH (P = .049). There was no significant difference in hospital length of stay, peribleed stroke, vasospasm, or death. Of the 18 patients with stunning, 15 were women, 5 of whom were on estrogen supplementation. The mean peak troponin elevation of women who developed NSM on estrogen supplementation was significantly higher than for those who were not (mean peak troponin 9.97 ± 2.01 mg/dL; P < .001).Conclusion: Prehospital β-blockers are associated with decreased risk of developing NSM in patients with aSAH. Estrogen may play an additional role in shaping the degree of NSM in women.