Journal of Stroke & Cerebrovascular Diseases - Articles in Press

Clinical Properties of Regional Thalamic Hemorrhages - Corrected Proof

2012-05-14

Background: Thalamic hemorrhage constitutes 6% to 25% of intracerebral hemorrhages. Vascular lesions affecting the thalamus may cause a variety of clinical symptoms. This retrospective study aims to evaluate localization of hemorrhage and clinical symptoms in patients with thalamic hemorrhage.Methods: One hundred and one patients with thalamic hemorrhage were examined retrospectively in our department. Hemorrhages were classified into 5 groups according to computed tomography: medial (thalamoperforate), anterolateral (tuberothalamic), posterolateral (thalamogeniculate), dorsal (posterior choroidal), and global. The relation between volume, localization, and penetration to adjacent structures/ventricles of hemorrhage and risk factors, clinical features, and prognosis were evaluated.Results: The study group included 101 patients. Eighty-two percent of the patients had hypertension, 19.8% had diabetes mellitus, 14.9% had cardiac disease, and 5.9% had chronic renal failure. Mean blood pressure was 173/101 mm Hg. Decreased Glasgow coma scale was significantly higher in the global hemorrhage group than in all regional groups (Chi-square, 10.54; P = .002). Medial group hemorrhages had a significantly higher rate than anterolateral, posterolateral, and dorsal intraventricular expansion. Out of speech disorders, 49% of patients had a right thalamic lesion (especially dysarthria) and 51% of patients had a left thalamic lesion (mostly aphasia).Conclusions: In the study, we detected that the most important risk factor in thalamic hemorrhage is hypertension. The prognosis is worse in global and medial group hemorrhages, especially those which rupture to the ventricle, than the other groups. Thalamic lesions cause a variety of symptoms, including forms of aphasia, such as crossed dextral aphasia.

Combination of Noninvasive Neurovascular Imaging Modalities in Stroke Patients: Patterns of Use and Impact on Need for Digital Subtraction Angiography - Corrected Proof

2012-05-14

Background: The diagnostic work-up of acute stroke relies on the use of proper imaging studies. We sought to determine the use of a combination of 2 noninvasive tests, namely magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) in diagnosing vascular lesions and the necessity for a subsequent digital subtraction angiography (DSA) for the definitive diagnosis.Methods: Patients admitted to 2 comprehensive stroke centers between January 2008 and July 2010 who had an equivocal initial noninvasive test were reviewed. The proportions of patients who underwent CTA and MRA in combination and those who required additional DSA for definitive diagnosis were determined. The diagnostic yield and impact on management in patients with CTA and MRA combination was compared with patients who underwent CTA and MRA followed by DSA.Results: Among a total of 1063 patients (mean age ± SD 63 ± 16), 384 (36%) underwent >1 vascular imaging study. There was no difference in the rates of cardiovascular risk factors and stroke subtype between different combination groups. The agreement between CTA and MRA was high (concordance 81%). Among the 164 patients who underwent both CTA and MRA, a DSA was required for resolution/confirmation in only 27 (16%) patients. Among these 27, DSA findings changed the clinical decision-making in 22 (82%) patients (11 stenotic severities and 11 diagnoses of arteriovenous fistula, aneurysm, or dissection).Conclusions: In our experience, a combination of CTA and MRA was frequently used in patients in whom the initial noninvasive imaging was determined insufficient. The combination of findings from CTA and MRA were considered adequate in a large portion of patients resulting in a lower requirement for DSA and higher treatment impact from DSA.

Thrombolysis Outcomes among Obese and Overweight Stroke Patients: An Age-and National Institutes of Health Stroke Scale–matched Comparison - Corrected Proof

Raymond C.S. Seet, Yi Zhang, Eelco F.M. Wijdicks, Alejandro A. Rabinstein — 2012-05-14

Background: Whether obese and overweight stroke patients respond differently to intravenous thrombolysis is unclear. The purpose of this study is to determine the influence of obesity and risk components of metabolic syndrome to stroke recovery in patients undergoing intravenous thrombolysis.Methods: Outcomes after recombinant tissue plasminogen activator treatment were compared between obese (body mass index [BMI] >30 kg/m2), overweight (BMI 25-30 kg/m2), and normal weight (BMI <25 kg/m2) patients. The association between BMI, risk components of the metabolic syndrome, and dose of recombinant tissue plasminogen activator per kilogram of body weight to stroke outcomes were assessed in a multivariable model.Results: A total of 169 patients (mean age 75 years; baseline National Institutes of Health Stroke Scale score 11) were included. No differences in the frequency of symptomatic intracranial hemorrhage and poor functional recovery were observed among obese, overweight, and normal weight patients. A linear trend toward worse stroke recovery was observed in patients with a greater number of metabolic risk components (P for trend .043). By contrast, there were no significant associations between the number of risk components of metabolic syndrome with respect to symptomatic intracranial hemorrhage. Using stepwise regression analyses, age, baseline stroke severity, and the number of risk components of the metabolic syndrome accounted for 52% variation in functional recovery after intravenous thrombolysis.Conclusions: Acute stroke outcomes do not differ between obese and overweight patients undergoing intravenous thrombolysis. The number of metabolic risk components contributes more significantly to functional recovery following intravenous thrombolysis.

Predictors of In-Hospital Mortality and the Risk of Symptomatic Intracerebral Hemorrhage after Thrombolytic Therapy with Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke - Corrected Proof

Mohamed Al-Khaled, Christine Matthis, Jürgen Eggers — 2012-05-14

Recombinant tissue-plasminogen activator (rt-PA) therapy improves functional outcome in patients with acute ischemic stroke (AIS) but is associated with serious complications, including symptomatic intracerebral hemorrhage (sICH). This study aimed to determine the independent predictors of in-hospital mortality (IHM) and the risk of sICH after rt-PA therapy. A total of 1007 patients (mean age, 72 ± 12 years; 52% women; mean National Institutes of Health Stroke Scale [NIHSS] score, 11.6 ± 5.6) with AIS treated with rt-PA were enrolled in this study during a 42-month period beginning in November 2007. Univariate and multivariate regression analyses were performed to estimate the predictors of IHM. Eighty-three of the 1007 patients (8.2%) died during hospitalization (mean duration of hospitalization, 10 ± 1.8 days). Logistic regression estimated the following independent predictors for IHM: age ≥80 years (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-3.0; P = .031), aphasia (OR, 2.0; 95% CI, 1.1-3.4; P = .017), altered consciousness (OR, 3.6; 95% CI, 2.0-6.2; P < .001), hypertension (OR, 4; 95% CI, 1.4-11.6; P = 0.012), sICH (OR, 5.9; 95% CI, 2.9-11.9; P < 0.001), and pneumonia during hospitalization (OR, 3.0; 95% CI, 1.8-5.0; P < .001). After rt-PA therapy, 58 patients (5.8%) sustained sICH, 16 (28%) of whom died. Increased age (P = .008), higher NIHSS score (P = .011), and atrial fibrillation (P = .025) were correlated with sICH. The findings from this study may help clinicians estimate the prognosis and risk of sICH in patients with AIS treated with rt-PA.

Cause-Specific Mortality after Stroke: Relation to Age, Sex, Stroke Severity, and Risk Factors in a 10-Year Follow-Up Study - Corrected Proof

2012-05-14

We investigated cause-specific mortality in relation to age, sex, stroke severity, and cardiovascular risk factor profile in the Copenhagen Stroke Study cohort with 10 years of follow-up. In a Copenhagen community, all patients admitted to the hospital with stroke during 1992-1993 (n = 988) were registered on admission. Evaluation included stroke severity, computed tomography scan, and a cardiovascular risk profile. Cause of death within 10 years according to death certificate information was classified as stroke, heart/arterial disease, or nonvascular disease. Competing-risks analyses were performed by cause-specific Cox regression after multiple imputation of missing data, assuming that values were missing at random. Death was due to stroke in 310 patients (31%), to heart/arterial disease in 209 patients (21%), and to nonvascular diseases in 289 patients (29%); 180 patients were still alive after 10 years (18%). Stroke was the dominant cause of death during first year, with an absolute risk of 20.2% versus 5.2% for heart/arterial disease and 6.5% for nonvascular disease. The subsequent absolute risk of death per year was 2.8% for stroke, 4.5% for heart/arterial disease, and 5.2% for nonvascular disease. Death after stroke was associated with older age, male sex, greater stroke severity, and diabetes regardless of the cause of death. Previous stroke and hemorrhagic stroke were associated with death by stroke, ischemic heart disease was associated with death by heart/arterial disease and atrial fibrillation was associated with death by cardiovascular disease (stroke or heart/arterial disease). Hypertension, smoking, and alcohol consumption were not associated with cause-specific death.

High-dose Argatroban Therapy for Stroke: Novel Treatment for Delayed Treatment and the Recanalization Mechanism - Corrected Proof

Hiroaki Ishibashi, Mizuho Koide, Satoko Obara, Yukiko Kumasaka, Kenichi Tamura — 2012-05-10

Background: There has been little effective treatment in patients with cerebral infarction at >24 hours after onset. We assessed the effects of high-dose argatroban therapy in delayed administration, and investigated the mechanism based on our clinical findings.Methods: Argatroban 30 mg was first administered for 15 minutes intravenously, and then 90 mg for 60 minutes followed by 60 mg for 60 minutes were infused continuously. The change of vascular obstruction caused by the treatment was assessed with magnetic resonance angiography.Results: In 4 patients studied, high-dose argatroban resulted in 100% recanalization of occluded vessels (5/5), even though argatroban was administrated >24 hours after onset. On the other hand, when an inadequate dose of argatroban was administered, a hemorrhage was identified. This supports our hypothesis that high-dose argatroban promotes recanalization by deactivating thrombin and exerting an anticoagulant effect on the vascular endothelium.Conclusions: High-dose argatroban is an effective treatment for cerebral infarction and offers a novel therapeutic approach for delayed hospitalized patients at >24 hours after onset. Additional studies are necessary to identify the cellular and molecular mechanisms and determine the adequate dose in order to reduce risks of complication.

Adherence to Guidelines by Emergency Medical Services During Transport of Stroke Patients Receiving Intravenous Thrombolytic Infusion - Corrected Proof

2012-05-10

Background: The “drip and ship” paradigm among acute ischemic stroke (AIS) patients has resulted in expansion of thrombolytic treatment in patients eligible for intravenous (IV) recombinant tissue plasminogen activator (rt-PA). It remains controversial whether the settings within the emergency medical services (EMS) transport are adequate for IV rt-PA infusion. We sought to determine EMS adherence to guidelines during the transport of drip and ship AIS patients treated with IV rt-PA while being transferred to comprehensive stroke centers (CSCs) and the effect of nonadherence on outcome upon discharge.Methods: A retrospective evaluation of patients transferred to our CSC was conducted to determine the rates of adherence to quality parameters during EMS transport with infusion of IV rt-PA. Favorable outcome was defined as modified Rankin Scale (mRS) score ≤1 upon discharge.Results: Among the 40 patients studied (55% men; mean age 71.9 ± 13.9 years), 38 patients received vital sign monitoring at 10- to 20-minute intervals. The mean transit time was 37.7 ± 20.2 minutes. Of the 39 patients with blood pressure (BP) monitoring, 7 patients had at least 1 episode of BP elevation above the recommended parameters (>180/105 mm Hg); only 1 of those was treated with an antihypertensive agent. Five of the 40 patients were considered to have worsened between the outside ED and CSC ED evaluations without IV rt-PA discontinuation during transfer. The rate of favorable outcome of patients who had interim neurologic deterioration without discontinuation of IV rt-PA or BP >180/105 mm Hg without antihypertensive treatment was similar to those who experienced neither event (41.7% and 35.7%; P = .736).Conclusions: Efforts are required to improve EMS adherence to guidelines in patients receiving IV rt-PA during EMS transport in anticipation of broader use of the “drip and ship” paradigm.

Prevention of Poststroke Depression: Does Prophylactic Pharmacotherapy Work? - Corrected Proof

2012-05-03

Background: Given the negative influence of poststroke depression (PSD) on functional recovery, cognition, social participation, quality of life, and risk for mortality, the early initiation of antidepressant therapy to prevent its development has been investigated; however, individual studies have offered conflicting evidence. The present systematic review and meta-analysis examined available evidence from published randomized controlled trials (RCTs) evaluating the effectiveness of pharmacotherapy for the prevention of PSD to provide updated pooled analyses.Methods: Literature searches of 6 databases were performed for the years 1990 to 2011. RCTs meeting study inclusion criteria were evaluated for methodologic quality. Data extracted included the antidepressant therapy used, treatment timing and duration, method(s) of assessment, and study results pertaining to the onset of PSD. Pooled analyses were conducted.Results: Eight RCTs were identified for inclusion. Pooled analyses demonstrated reduced odds for the development of PSD associated with pharmacologic treatment (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.22-0.53; P < .001), a treatment duration of 1 year (OR 0.31; 95% CI 0.18-0.56; P < .001), and the use of a selective serotonin reuptake inhibitor (OR 0.37; 95% CI 0.22-0.61; P < .001).Conclusions: The early initiation of antidepressant therapy, in nondepressed stroke patients, may reduce the odds for development of PSD. Optimum timing and duration for treatment and the identification of the most appropriate recipients for a program of indicated prevention require additional examination.

Risk of Spontaneous Intracranial Hemorrhage in HIV-infected Individuals: A Population-based Cohort Study - Corrected Proof

2012-05-03

Background: We studied the association between HIV infection, antiretroviral medications, and the risk of spontaneous intracranial hemorrhage.Methods: We performed a cohort and nested case control study in an administrative database. We selected all HIV-positive individuals presenting between 1985 and 2007. Each HIV-positive subject was matched with 4 HIV-negative individuals. We used a Poisson regression model to calculate rates of intracranial hemorrhage according to HIV status. We conducted a case -control study nested within the cohort of HIV-positive individuals to look at the effect of antiretroviral medications. Odds ratios for antiretroviral exposure were obtained using conditional logistic regression.Results: There were 7,053 HIV-positive and 27,681 HIV-negative subjects, representing 138,704 person-years. There were 49 incident intracranial hemorrhages, 29 in HIV-positive and 20 in HIV-negative individuals. The adjusted hazard ratio for intracranial hemorrhage in HIV-positive compared to HIV-negative patients was 3.28 (95% confidence interval [CI] 1.75-6.12). The effect was reduced to 1.99 (95% CI 0.92-4.31) in the absence of AIDS-defining conditions, and increased to 7.64 (95% CI 3.78-15.43) in subjects with AIDS-defining conditions. Hepatitis C infection, illicit drug or alcohol abuse, intracranial lesions, and coagulopathy were all strongly associated with intracranial hemorrhage (all P < .001). In the case control study, 29 cases of ICH in HIV-positive individuals were matched to 228 HIV-positive controls. None of the antiretroviral classes were associated with an increase in the odds ratio of intracranial hemorrhage.Conclusions: The risk of intracranial hemorrhage in HIV-positive individuals seems to be mostly associated with AIDS-defining conditions, other comorbidities, or lifestyle factors. No association was found between use of antiretroviral medications and intracranial hemorrhage.

The Effect of Carotid Endarterectomy on Cerebral Blood Flow and Cognitive Function - Corrected Proof

2012-05-03

Background: The effect of carotid endarterectomy on cognitive function is not fully understood. This study aims to characterize changes in cerebral blood flow after carotid endarterectomy and to determine if patients with improvement in cerebral blood flow have improved cognitive function after endarterectomy.Methods: Cerebral blood flow was measured preoperatively and 1 month postoperatively using phase contrast magnetic resonance angiography. Preoperative flow impairment was defined as ipsilateral flow at least 20% less than contralateral flow. Improvement in flow was defined as an absolute increase of at least 0.10 in flow ratio from pre- to postoperative assessments. Patients underwent cognitive testing preoperatively and at 1, 6, and 12 months postoperatively.Results: Twenty-four patients with unilateral carotid stenosis were enrolled from 3 sites. Preoperative internal carotid artery (ICA) and middle cerebral artery (MCA) flow impairment was observed in 50% and 22% of patients, respectively. Patients with preoperative flow impairment had an average of 0.25 and 0.16 absolute improvement in flow ratio in the ICA and MCA vessels, respectively; this was statistically significant for patients with baseline ICA flow impairment (P < .01). One hundred percent of patients with improvement in MCA flow had a significant improvement in attention compared to 56% of patients without MCA flow improvement (P = .06). Clinically significant improvements in all 4 cognitive domains were observed at 1 year (P < .01).Conclusions: Patients with baseline impairment of MCA blood flow were more likely to experience improvement in flow after revascularization. Improvement in MCA blood flow was associated with greater cognitive improvement in attention and executive functioning.

Bilateral Medial Medullary Infarction: A Systematic Review - Corrected Proof

Jitphapa Pongmoragot, Sujatha Parthasarathy, Daniel Selchen, Gustavo Saposnik — 2012-04-30

Bilateral infarction of the medial medulla (MMI) is rare. Limited information is available on clinical characteristics, etiology, and prognosis. High-resolution neuroimaging has a major role in elucidating the underlying stroke mechanism. The aim of this systematic review was to analyze the clinical presentations, stroke mechanisms, and outcomes in patients with bilateral MMI. We performed a systematic review of the literature from 1992-2011 that reported on clinical presentations, stroke mechanism, and/or outcomes in patients with magnetic resonance imaging–proven bilateral MMI. Medline, EMBASE, and Web of Science Scholars Portal were searched without language restriction. Two reviewers independently assessed identified studies to determine eligibility, validity, and quality. The primary outcome was inpatient mortality; a secondary outcome was case fatality at 12 months. We identified 138 articles from Medline, EMBASE, and Scholars Portal including the MeSH terms “brainstem infarction,” “medulla,” and “bilateral.” Twenty-nine articles met our inclusion criteria, including a total of 38 cases with bilateral MMI, and included in our study. These 38 patients had a mean age of 62.2 years and were predominately male (74.2%). The most common clinical presentations were motor weakness in 78.4%, dysarthria in 48.6%, and hypoglossal palsy in 40.5%. The most common vascular pathology was vertebral artery atherosclerosis, in 38.5%. The clinical outcome was poor (mortality, 23.8%; dependency, 61.9%). Bilateral medial medullary infarction is a rare stroke syndrome. Clinical presentations were mostly rostral medullary lesions. Large-artery atherosclerosis and branch disease were the most common stroke mechanisms. The clinical outcome was usually poor.

Stroke Size Correlates with Functional Outcome on the Simplified Modified Rankin Scale Questionnaire - Corrected Proof

Askiel Bruno, Neel Shah, Abiodun E. Akinwuntan, Brian Close, Jeffrey A. Switzer — 2012-04-30

Background: Acute stroke size is one of the factors impacting functional outcome. To further validate the simplified modified Rankin Scale questionnaire (smRSq), we tested its correlation with stroke size.Methods: We screened 60 ischemic stroke patients with acute brain images available for stroke volume measurement who were enrolled in 2 smRSq reliability studies. Inclusion criteria were acute ischemic stroke visible on computed tomography (CT) or magnetic resonance imaging (MRI) and the smRSq scored at least 3 months after stroke. We excluded patients with disabilities from a previous stroke. One investigator who was blinded to the functional outcomes measured stroke volumes with a specialized computer program (Analyze). We used MRI when both MRI and CT were available. We classified strokes into 2 size categories: lacunar type measuring ≤6.28 cm3, which corresponds to a cylinder with a maximum diameter and height of 2.00 cm, or strokes >6.28 cm3. The Spearman correlation analysis compared the smRSq between the lacunar type and the larger strokes.Results: Thirty-two patients qualified for this analysis with a mean age of 59 ± 15 years, and 17 (53%) were men. Lacunar stroke volumes (n = 17) ranged from 0.03 to 4.58 cm3, and the larger stroke volumes (n = 15) ranged from 11.52 to 250.02 cm3. Lacunar strokes were associated with lower smRSq scores (median 1) than the larger strokes (median 4; r = 0.68; R2 = 0.46; P < .001).Conclusions: Acute stroke size correlates well with the smRSq, supporting its validity in assessing functional outcome after stroke.

Time to Stroke Magnetic Resonance Imaging - Corrected Proof

James F. Burke, Jeremy B. Sussman, Lewis B. Morgenstern, Kevin A. Kerber — 2012-04-30

Background: Recent guidelines on stroke neuroimaging from the American Academy of Neurology (AAN) recommend magnetic resonance imaging (MRI) over computed tomography (CT) for stroke diagnosis when patients present within 12 hours of onset. We sought to estimate the proportion of stroke MRI that is performed within 12 hours.Methods: Using the best available data, we estimated total time from symptom onset to MRI with a Monte Carlo simulation. We modeled 3 times to MRI: time to presentation, time to emergency department (ED) MRI, and time to inpatient MRI. Total time to MRI was estimated by summing these time components while varying model parameters around our base model. Sensitivity analyses assessed the relative importance of model parameters to overall MRI timing.Results: In 2009, we estimate that 66% of stroke patients underwent MRI, 14% received an MRI in the ED, and 68% of all MRIs were obtained on hospital day 0 or 1. We estimate that 29% (95% confidence interval 24-33%) of stroke MRIs are obtained within 12 hours of onset. Sensitivity analyses revealed that even large clinical changes (eg, decreasing time to presentation) would only moderately influence this proportion. For example, if mean time to presentation were reduced to 30 minutes (from the base case estimate of 16 hours), the proportion of stroke MRI performed within 12 hours would only increase to 55.3%.Conclusions: Stroke guidelines favor the use of MRI over CT only during the first 12 hours from symptom onset, yet less than one-third of stroke MRIs are actually performed within this timeframe.

Microembolic Signals in Patients with Acute Nonembolic Stroke - Corrected Proof

Gregory Telman, Elliot Sprecher, Efim Kouperberg — 2012-04-27

Background: The nature of microembolic signals (MES) in patients without apparent sources of embolism remains elusive. We hypothesize that MES in acute stroke patients without an embolic source may represent a transient phenomenon related to blood rheology or clot dissolving, in which case the characteristics of such MES would differ from those with definitive sources of emboli.Methods: We compared the intensity and duration of 250 MES in 62 acute nonembolic stroke patients (stroke group) and 217 MES in 57 patients with asymptomatic carotid stenosis (≥50%; carotid group).Results: The duration of MES was significantly different between the 2 groups (24.86 ± 0.89 ms in the carotid group v 18.8 ± 0.83 in the stroke group; P < .001). When comparing the groups for MES with an intensity higher than 6 dB, a highly significant difference in the duration of MES was found (27.87 ± 1.26 ms in the carotid group v 18.57 ± 1.29 ms in the stroke group; P < .0001). A strong linear relationship between the duration and intensity of MES was found for the carotid group, but not for the stroke group.Conclusions: There are significant differences between the characteristics of MES in acute stroke patients as compared with MES in patients with carotid plaques. There is a strong correlation between the intensity and duration of MES from a definitive embolic source, which is absent from MES in patients with nonembolic stroke. These findings may point to the different mechanisms of MES origin in the examined groups.

Clinical Features and Racial/Ethnic Differences among the 3020 Participants in the Secondary Prevention of Small Subcortical Strokes (SPS3) Trial - Corrected Proof

2012-04-19

This study examined the baseline characteristics, racial/ethnic differences, and geographic differences among participants in the Secondary Prevention of Small Subcortical Strokes (SPS3) study. The SPS3 trial enrolled patients who experienced a symptomatic small subcortical stroke (lacunar stroke) within the previous 6 months and an eligible lesion on detected on magnetic resonance imaging. The patients were randomized, in a factorial design, to antiplatelet therapy (aspirin 325 mg daily plus clopidogrel 75 mg daily vs aspirin 325 mg daily plus placebo) and to one of two levels of systolic blood pressure targets (“intensive” [<130 mmHg] or “usual” [130-149 mmHg]). A total of 3020 participants were recruited from 81 clinical sites in 8 countries. In this cohort, the mean age was 63 years, 63% were men, 75% had a history of hypertension, and 37% had diabetes. The racial distribution was 51% white, 30% Hispanic, and 16% black. Compared with white subjects, black subjects were younger (mean age, 58 years vs 64 years; P <.001) and had a higher prevalence of hypertension (87% vs 70%; P <.001). The prevalence of diabetes was higher in the Hispanic and black subjects compared with the white subjects (42% and 40% vs 32%; both P <.001). Tobacco smoking at the time of qualifying stroke was much more frequent in the Spanish participants than in subjects from North America and from Latin America (32%, 22%, and 9%, respectively; P <.001). Mean systolic blood pressure at study entry was 4 mmHg lower in the Spanish subjects compared with the North American subjects (P <.01). The SPS3 cohort is the largest magnetic resonance imaging–defined series of patients with S3. Among the racially/ethnically diverse SPS3 participants, important differences in patient features and vascular risk factors could influence prognosis for recurrent stroke and response to interventions.

Study of Hemostatic Biomarkers in Acute Ischemic Stroke by Clinical Subtype - Corrected Proof

2012-04-19

Background: We studied the usefulness of hemostatic biomarkers in assessing the pathology of thrombus formation, subtype diagnosis, prognosis in the acute phase of cerebral infarction, and differences between various hemostatic biomarkers.Methods: Our study included 69 patients with acute cerebral infarction who had been hospitalized within 2 days of stroke onset. Fibrin monomer complex (FMC), soluble fibrin (SF), D-dimer, thrombin–antithrombin III complex, fibrinogen, antithrombin III, and fibrin/fibrinogen degradation products (FDPs) were assayed as hemostatic biomarkers on days 1, 2, 3, and 7 of hospitalization.Results: In the cardioembolic (CE) stroke group, FMC and SF levels were significantly higher on days 1 and 2 of hospitalization, and D-dimer levels were significantly higher on day 1 of hospitalization, compared to the noncardioembolic (non-CE) stroke group. FDP levels were significantly higher at all times in the CE group compared to the non-CE group. Neither the National Institute of Health Stroke Scale (NIHSS) used during hospitalization nor the modified Rankin Scale (mRS) used at discharge found any significant correlations to hemostatic biomarkers, but the NIHSS score during hospitalization was significantly higher in the CE group than in the non-CE group.Conclusions: Measurements of hemostatic biomarkers, such as FMC, SF, and D-dimer on the early stage of cerebral infarction are useful for distinguishing between CE and non-CE stroke.

Balance of Symptomatic Pulmonary Embolism and Symptomatic Intracerebral Hemorrhage with Low-dose Anticoagulation in Recent Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials - Corrected Proof

Chamila M. Geeganage, Nikola Sprigg, Matthew W. Bath, Philip M.W. Bath — 2012-04-19

Background: The current consensus is that anticoagulation therapy has no role acutely in the management of ischemic stroke, although there is still debate for specific conditions, such as cerebral venous thrombosis and cervical dissection. In addition, anticoagulation is used in the prevention of venous thromboembolic events. We assess the balance between preventing symptomatic pulmonary embolism (sPE) and causing symptomatic intracerebral hemorrhage (sICH) in patients with recent stroke who were randomized to low-dose subcutaneous anticoagulation in trials.Methods: We systematically searched the Cochrane Library, Medline, Embase, and Science Citation Index for prospective randomized controlled trials assessing the effect of heparin and other antithrombotic therapies in patients with acute/early ischemic stroke. Included trials had to record information on pulmonary embolism and sICH. Risk ratios (RRs) were calculated for sICH per sPE for each trial using a random effects model.Results: We identified 15 trials of low-dose subcutaneous anticoagulation. The trials studied low molecular weight heparin, heparinoids, and unfractionated heparin. The ratio of sICH to sPE was increased with low molecular weight heparin (RR 2.1; 95% confidence interval [CI] 1.03-4.28), but was in approximated unity with heparinoids (RR 1.27; 95% CI 0.31-5.17) and unfractionated heparin (RR 0.99; 95% CI 0.65-1.52).Conclusions: Prophylactic/low-dose heparin increased sICH by more than they reduced sPE in patients with recent ischemic stroke. Therefore, their routine acute use cannot be recommended, but they may still be relevant in patients at very high risk of PE (eg, morbid obesity, previous venous thromboembolism, and inherited thrombophilia) or if started later, although trials have not assessed these issues.

Simultaneous Onset of Anterior and Middle Cerebral Artery Dissections with an Old Vertebral Artery Dissection - Corrected Proof

2012-04-16

Multiple arterial dissections in the anterior circulation with simultaneous onset are extremely rare. We report a patient with infarctions caused by simultaneous arterial dissections in the right anterior cerebral artery and the left middle cerebral artery and discuss the characteristic feature of this vascular disorder. A 53-year-old woman presented with a severe headache and a mild aphasia. Magnetic resonance imaging revealed multiple acute cerebral infarctions in the left temporal and right frontal lobes. The initial angiographic findings revealed arterial dissections of the anterior cerebral, left middle cerebral, and right vertebral arteries. The follow-up angiographic examination found improvement of the stenosis in both the anterior cerebral and middle cerebral arteries. We have concluded that the lesion of the vertebral artery was not in an acute stage, because no interval change was seen during the radiologic evaluation. She underwent conservative therapy, and her symptoms disappeared. Multiple arterial dissections are rare, especially those developing simultaneously in different arteries. This is the first case of multiple arterial dissections of the different arteries in the anterior circulation manifesting cerebral infarction simultaneously.

Higher On-admission Serum Triglycerides Predict Less Severe Disability and Lower All-cause Mortality after Acute Ischemic Stroke - Corrected Proof

Slaven Pikija, Vladimir Trkulja, Lucija Juvan, Marija Ivanec, Dunja Dukši — 2012-04-16

Background: High(er) on-admission triglyceride (TG) levels have been suggested as an independent predictor of better outcomes of the acute ischemic stroke. Data regarding poststroke physical disabilities have been contradictory. We aimed to investigate the relationship between fasting on-admission TG and development of disability and all-cause mortality over a 2.5-year period.Methods: This prospective observational study included 83 acute ischemic stroke patients (29 cardioembolic; 41% men; median age 76 years) followed-up for 28 to 30 months and assessed for physical disability using the Modified Rankin scale (mRS) at 1 week and 3, 12, and 24 months poststroke. TGs were considered as a continuous and a binary variable (≤1.27 [n = 43] and >1.27 mmol/L [n = 43]).Results: Higher TGs (continuous or binary) were independently (default adjustments: stroke type, severity at presentation, age, atrial fibrillation, preindex event antiplatelet use, infarct volume, postindex event antiplatelet, statin and angiotensin-converting enzyme inhibitor use, on-admission fasting cholesterol, mean platelet volume, and glomerular filtration rate) were associated with: (1) higher odds of mRS 0 to 2 (none/mild disability) across the assessments (overall odds ratio [OR] 2.73 [95% confidence interval {CI} 1.15-6.38] and OR 3.57 [95% CI 1.04-12.3], respectively); (2) lower odds of mRS worsening between any 2 consecutive assessments (overall OR 0.44 [95% CI 0.20-0.96] and OR 0.35 [95% CI 0.16-0.77], respectively); (3) lower risk of all-cause mortality (hazard ratio 0.47 [95% CI 0.23-0.96] and hazard ratio 0.45 [95% CI 0.21-0.98], respectively).Conclusions: These data suggest that higher fasting TGs on-admission predict less severe disability, reduced disability progression, and all-cause mortality in patients with acute ischemic stroke.

Antihypertensives Are Administered Selectively in Emergency Department Patients with Subarachnoid Hemorrhage - Corrected Proof

2012-04-12

Elevated blood pressure is common in patients with acute subarachnoid hemorrhage (SAH). American Heart Association guidelines do not specify a blood pressure target, but limited data suggest that systolic blood pressure (SBP) ≥160 mmHg is associated with increased risk of rebleeding and neurologic decline. In a population-based study, we determined the frequency of antihypertensive therapy in emergency department (ED) patients with SAH and the proportion of those patients with SBP ≥160 mmHg who received this therapy. In 2005, nontraumatic SAH cases were retrospectively ascertained at 16 hospitals in our region by screening for International Classification of Diseases Ninth Revision diagnostic codes 430-436. Blood pressure was recorded at ED presentation and also before and after any treatment with antihypertensives. Hypotension was defined as SBP <100 mmHg. The Mann-Whitney U test and χ2 test were used for comparisons. Our cohort comprised 82 patients with SAH presenting to an ED; 4 patients were excluded. The median age of the included patients was 54 years, 74.4% were female, 29.5% were black, and 31 (39.7%) had SBP ≥160 mmHg. Antihypertensive therapy was given to 22 of 31 patients (70.9%) with SBP ≥160 mmHg and to 4 of 47 patients (8.5%) with SBP <160 mmHg. No patients became hypotensive after receiving treatment. Age, sex, Glascow Coma Scale score, and National Institutes of Health Stroke Scale score were similar between treated and untreated patients. In the absence of definitive evidence, current blood pressure management in local EDs appears reasonable. Further studies of blood pressure management in acute SAH are warranted.

Toward a Modern Delivery of Stroke Care in Emerging Economies - Corrected Proof

Felipe de los Ríos la Rosa, Joseph P. Broderick — 2012-04-09

Noncommunicable diseases are now a major source of mortality and disability in the developing world. Stroke incidence and prevalence is on the rise and is of particular interest because of its elevated mortality and morbidity. Developing countries bear the brunt of this disease, which hampers efforts to achieve economic and societal growth. Effective strategies to control this disease should focus on prevention without neglecting acute therapies.

Angiogram-Negative Subarachnoid Hemorrhage: Outcomes Data and Review of the Literature - Corrected Proof

Scott Boswell, William Thorell, Steve Gogela, Elizabeth Lyden, Dan Surdell — 2012-04-01

Spontaneous subarachnoid hemorrhage (SAH) is most commonly caused by rupture of a saccular aneurysm or other structural pathologies. Occasionally, no structural cause for the hemorrhage can be identified by radiographic imaging. These hemorrhages, termed angiogram-negative SAH, are generally considered to have a better prognosis than aneurysmal SAH. Angiogram-negative SAH subgroups include benign perimesencephalic SAH (PMH) and aneurysmal-type SAH. Outcome data for these subgroups differ from those for the group as a whole. We report data for 31 patients who presented to our institution from 2006 to the present. We performed a retrospective chart review, and report outcome data that include rates of rehemorrhage, hydrocephalus, vasospasm, permanent ischemic deficits, headaches, and outcomes based on modified Rankin Scale scores. We also performed a review of the literature and meta-analysis of the data therein. We compared rates of complications in the PMH subgroup and the diffuse-type hemorrhage subgroup. The chart review revealed no poor outcomes and no rehemorrhages in the patients with PMH. In the diffuse hemorrhage subgroup, 1 patient had a rehemorrhage and 2 patients had a poor outcome. Our literature review found an OR of 6.23 for a good outcome for PMH versus diffuse-type hemorrhage, and an OR of 2.78 for rehemorrhage in PMH versus diffuse-type hemorrhage. Angiogram-negative SAH is not a benign entity. Complications are present but are significantly reduced, and outcomes are improved, compared with aneurysmal SAH.

Regional Differences in Emergency Medical Services Use for Patients with Acute Stroke (Findings from the National Hospital Ambulatory Medical Care Survey Emergency Department Data File) - Corrected Proof

2012-04-01

Background: Our objectives were to describe the proportion of stroke patients who arrive by ambulance nationwide and to examine regional differences and factors associated with the mode of transport to the emergency department (ED).Methods: Patients with a primary discharge diagnosis of stroke based on previously validated International Classification of Disease, 9th revision codes were abstracted from the National Hospital Ambulatory Medical Care Survey for the years 2007 to 2009. We excluded subjects <18 years of age and those with missing data. Using logistic regression, we identified independent predictors of arrival by ambulance to the ED.Results: Overall, 566 patients met the entry criteria, representing 2,153,234 patient records nationally, based on 2010 US census data. Of these, 50.4% arrived by ambulance. After adjustment for potential confounders, age was associated with use of an ambulance. In addition, patients residing in the west and south had lower odds of arriving by ambulance for stroke when compared to northeast (South: odds ratio [OR] 0.45 and 95% confidence interval [CI] 0.26-0.76; West: OR 0.45 and 95% CI 0.25-0.84; Midwest: OR 0.56 and 95% CI 0.31-1.01). Compared to the Medicare population, privately insured and self-insured patients had lower odds of arriving by ambulance (OR for private insurance 0.48 and 95% CI 0.28-0.84; OR for self-payers 0.36 and 95% CI 0.14-0.93). Gender, race, urban or rural location of ED, and safety net status was not independently associated with ambulance use.Conclusions: Patients with stroke arrive by ambulance more frequently in the Northeast than in other regions of the United States. Identifying reasons for this difference may be useful in improving stroke care.

Accuracy of Computed Tomographic Angiography Compared to Digital Subtraction Angiography in the Diagnosis of Intracranial Stenosis and its Impact on Clinical Decision-making - Corrected Proof

2012-03-30

Background: Few studies to date have examined the accuracy of computed tomographic angiography (CTA) compared to digital subtraction angiography (DSA) in diagnosing intracranial stenosis. The purpose of this study was to compare CTA to DSA in diagnosing intracranial stenosis and to explore the impact of the addition of DSA on the management of stroke patients.Methods: We retrospectively reviewed all ischemic stroke or patients with transient ischemic attack who underwent CTA and DSA within 30 days of each other at our institution between January 2008 and July 2011. For each study, 2 blinded observers rated the degree of stenosis of 11 intracranial vessels. Disagreements were adjudicated by a third blinded observer. Sensitivity, specificity, negative predictive value, and receiver operating characteristic curves were determined using DSA as the criterion standard. All patient charts were reviewed to determine if the addition of DSA to CTA impacted clinical management.Results: Six hundred twenty-seven arterial segments were reviewed. The sensitivity of CTA to diagnose stenosis >50% was 96.6% (95% confidence interval [CI] 88.1-99.6), specificity 99.4% (95% CI 98.1-99.9), and negative predictive value 99.6% (95% CI 98.4-99.9). The intraclass correlation between CTA and DSA measurements was 0.96 (95% CI 0.95-0.97). Five of 57 patients underwent intracranial stenting procedures during the study period. All 5 lesions were correctly characterized as having >70% stenosis on CTA. Of the remaining 52 patients, none had clinical management change based on DSA findings.Conclusions: CTA has a high sensitivity and specificity compared to DSA to diagnose intracranial stenosis. The addition of DSA to CTA may not affect clinical management in most patients with suspected stenosis.

Thromobolysis for Acute Ischemic Stroke: Is Intra-arterial Better than Intravenous? A Treatment Effects Model - Corrected Proof

William J. Powers — 2012-03-30

Background: Three randomized trials of intra-arterial thrombolysis (IAT) for acute ischemic stroke ≤6 hours were conducted without intravenous tissue plasminogen activator (IV-tPA) treatment of patients in the control groups now known to benefit.Methods: The effect of IV-tPA treatment on 130 control subjects in the Prolyse in Acute Cerebral Thromboembolism (PROACT), PROACT II, and Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial (MELT) studies was modeled using linearly weighted time-dependent odds ratios (ORs) from pooled IV-tPA trials. In the PROACT trials, the model assumed that 50% (36/73) were treated at 4.5 hours, the median time to arteriography. For MELT, the model assumed treatment at arrival plus 90 minutes based on hospital arrival times obtained from the principal investigator. The OR of 1.31 for all 130 controls (91 presumed treated ≤4.5 hours; OR 1.44) was applied to the original control data to derive the adjusted control outcome, and this was compared to the IAT group. Sensitivity analyses were performed.Results: Meta-analysis of the original data revealed a statistically significant benefit for IAT (P = .03). After adjustment for the effect of IV-tPA in controls, there was no longer a significant treatment benefit for IAT (P = .26). Loss of significant IAT treatment benefit persisted if either the OR for benefit of IV-tPA or the number of treated controls was more than halved. These 3 randomized trials of IAT for acute ischemic stroke ≤6 hours would not likely have shown a benefit if eligible controls had been treated with IV-tPA.Conclusions: Whether IAT is superior to IV-tPA in IV-tPA–eligible patients or better than placebo in IV-tPA–ineligible patients remains to be determined.

Use of Direct Thrombin Inhibitor for Treatment of Cerebral Venous Thrombosis - Corrected Proof

Sonny Fong Kwong Hon, Ho Lun Terrance Li, Pui Wai Cheng — 2012-03-29

Cerebral venous thrombosis is an uncommon condition with difficulties in diagnosis and treatment. There is limited study on the best treatment option for this disease. The mainstay of treatment remains systemic anticoagulation with a lengthy duration of warfarin, which has a troublesome unpredictable drug effect, various drug and food interactions, and an increased risk of bleeding. Recent availability of direct thrombin inhibitor provides an alternative option of systemic anticoagulation in various thromboembolism conditions. We report 2 cases of cerebral venous thrombosis treated with a direct thrombin inhibitor with good clinical and radiologic results.

Efficacy and Safety of Single versus Dual Antiplatelet Therapy for Coiling of Unruptured Aneurysms - Corrected Proof

2012-03-22

Background: Although the efficacy of antiplatelet therapy for coiling of unruptured cerebral aneurysms has been reported, regimens for this therapy are not yet well established. The aim of this retrospective study was to analyze correlations among the modes of antiplatelet use, aneurysmal configuration, coiling methods, and complications to elucidate the optimal antiplatelet therapy for coiling.Methods: The study population comprised 154 patients with unruptured aneurysms who underwent coiling with antiplatelet therapy at our institution between 2001 and 2009. The patients were categorized by mode of antiplatelet therapy (single [n = 64] or dual [n = 90]), neck size (wide [n = 80] or narrow [n = 74]), and technique used (simple [n = 42] or adjunctive [n = 112]). The incidences of hemorrhagic/ischemic complications and abnormalities on postprocedural diffusion-weighted magnetic resonance imaging (DWI) in each group were statistically assessed.Results: Hemorrhagic complications occurred in 1 case (1.5%) with single antiplatelet therapy and in 2 cases (2.2%) with dual antiplatelet therapy. Symptomatic ischemic complications occurred in 5 cases (7.8%) with single therapy and in 4 cases (4.4%) with dual therapy. Abnormalities were detected by DWI in 27 cases (42%) with single therapy and in 31 cases (34%) with dual therapy. No significant difference was found between modes of antiplatelet therapy even when the technique used was taken into account. In cases of wide neck, however, there were significant differences in the rate of symptomatic ischemic complications (single, 21.7%; dual, 3.5%; P = .014) and DWI abnormalities (single, 37.8%; dual, 20.9%; P = .048).Conclusion: Our data suggest that dual antiplatelet therapy may better prevent ischemic complications from coiling for wide-necked aneurysms compared with single antiplatelet therapy.

Intravenous Recombinant Tissue Plasminogen Activator Thrombolysis in Acute Ischemic Stroke due to Middle Cerebral Artery Dissection - Corrected Proof

Ryosuke Doijiri, Chiaki Yokota, Rieko Suzuki, Kazunori Toyoda, Kazuo Minematsu — 2012-03-19

Beneficial effect of recombinant tissue plasminogen activator (rtPA) in cerebral arterial dissection is controversial. We experienced a 45-year-old man with acute ischemic stroke due to middle cerebral artery dissection, who was treated with rtPA. Characteristic vascular findings indicating dissection became evident only in subsequent angiographic examinations. Our case indicates that serial angiographic examinations should be essential after acute thrombolytic therapy, especially in young patients who are at a high risk of cerebral arterial dissection.

Association of Deep Venous Thrombosis with Calf Vein Diameter in Acute Hemorrhagic Stroke - Corrected Proof

2012-03-19

We investigated the association between the development of deep venous thrombosis (DVT) and calf vein diameter in patients with acute hemorrhagic stroke. We measured the maximum diameter of paralytic side posttibial veins (PTVs) and peroneal veins (PVs) in 49 patients with intracerebral hemorrhage on admission and at 2 weeks after stroke onset by ultrasonography. We also examined for the presence or absence of DVT, and then analyzed the association of DVT with the maximum vein diameter. At 2 weeks after stroke, DVTs were detected in PTVs in 7 patients and in PVs in 6 patients. The maximum calf vein diameters at 2 weeks were significantly greater in patients with DVT compared with those without DVT (PTV, P = .033; PV, P = .015). Although calf vein diameter at admission did not influence the future incidence of DVT in patients with intracerebral hemorrhage, the presence of DVT was associated with calf vein dilatation.

Heparin-induced Thrombocytopenia in Essential Thrombocytosis - Corrected Proof

2012-03-19

We report a 67-year-old woman with essential thrombocytosis who developed cerebral infarction and heparin-induced thrombocytopenia during treatment for the cerebral infarction. She developed additional cerebral infarcts, acute femoral artery occlusion, and thrombophlebitis of her lower extremities. She was successfully treated with argatroban. This is the first report of a patient with essential thrombocytosis who developed heparin-induced thrombocytopenia and serious conditions, which included multiple thromboembolisms and coagulation disorders mimicking disseminated intravascular coagulation.

Cognitive Impairment and Dementia After Intracerebral Hemorrhage: A Cross-sectional Study of a Hospital-based Series - Corrected Proof

2012-03-15

Background: Frequencies of cognitive impairment and dementia have not been assessed in spontaneous intracerebral hemorrhage (ICH).The objective of this study was to determine the frequencies and patterns of cognitive impairment and dementia in a cross-sectional study of consecutive patients hospitalized in a single university medical center.Methods: Of 183 consecutive patients hospitalized between 2002 and 2006, 80 survivors were contacted and 78 were included (mean time since stroke 40 months). Thirty patients were scored with the Informant Questionnaire on Cognitive Decline in the Elderly and Instrumental Activities of Daily Living in a telephone interview, and 48 underwent a comprehensive clinical and neuropsychological assessment.Results: Dementia was observed in 18 of 78 patients (23%; 95% confidence interval [CI] 13-32%) and cognitive impairment without dementia was seen in 37 of 48 patients (77%; 95% CI 65-89%). The cognitive disorders mainly concerned episodic memory (52%), psychomotor speed (44%), and executive function (37%), followed by language and visuoconstructive abilities. In a logistic regression analysis, Rankin score >1 at discharge and hemorrhage volume were the initial factors to be selected as a predictor of long-term dementia.Conclusions: This single-center, cross-sectional study revealed that the prevalence of dementia and cognitive impairment without dementia after ICH are high and are similar to those observed in cerebral infarct. Further longitudinal, prospective studies are required to assess accurately the prevalence, mechanisms and predictors of post-ICH dementia.

Malignant Hypertension with Reversible Brainstem Hypertensive Encephalopathy and Thrombotic Microangiopathy - Corrected Proof

Ichiro Deguchi, Akira Uchino, Hiromichi Suzuki, Norio Tanahashi — 2012-03-14

A 42-year-old woman presented with headache and nausea. Severe hypertension, renal dysfunction, thrombocytopenia, and anemia were present. A magnetic resonance imaging (MRI) scan of her head revealed widespread hyperintense lesions located in the brainstem and cerebellum on T2-weighted and fluid-attenuated inversion recovery imaging. Hypertensive encephalopathy was suspected, and antihypertensive therapy was started. A second MRI of the patient's head on day 12 of hospitalization revealed that the hyperintensities in the brainstem and cerebellum had almost disappeared, and that thrombocytopenia, anemia, and renal dysfunction had also gradually improved. Test results led to a diagnosis of malignant hypertension. This patient was regarded as suffering from malignant hypertension with reversible brainstem hypertensive encephalopathy (RBHE) and thrombotic microangiopathy (TMA). RBHE and TMA are known to occur as complications of malignant hypertension, but there has been no previous report of them occurring simultaneously. RBHE and TMA related to malignant hypertension are both conditions that can be improved by the rapid institution of antihypertensive therapy, and as such, early diagnosis and treatment are important. When treating patients with malignant hypertension, the possibility that it may be complicated by both RBHE and TMA must be kept in mind.

The Relationship between Knowledge and Risk for Heart Attack and Stroke - Corrected Proof

Cameron Lambert, Seth Vinson, Frances Shofer, Jane Brice — 2012-03-12

Background: Stroke and myocardial infarction (MI) represent 2 of the leading causes of death in the United States. The early recognition of risk factors and event symptoms allows for the mitigation of disability or death. We sought to compare subject knowledge of stroke and MI, assess subject risk for cardiovascular disease, and determine if an association exists between knowledge and risk.Methods: In this cross-sectional survey, adult, non–health care professionals were presented with a written knowledge test and risk assessment tool. Subjects were classified into 3 categories of cardiovascular risk. Associations were then calculated between knowledge, risk, and population demographics.Results: Of 500 subjects approached, 364 were enrolled. The subjects were mostly white, middle-aged, and high school educated. Gender and income were evenly distributed. Forty-eight (14%) subjects were identified as ideal risk, 130 (38%) as low risk, and 168 (49%) as moderate/high risk. MI and stroke knowledge scores decreased as cardiovascular risk increased (85%, 79%, and 73% for ideal, low, and moderate/high risk groups, respectively; P < .001). In addition, regardless of risk category, stroke knowledge scores were always lower than heart attack knowledge scores.Conclusions: Knowledge about stroke and MI was modest, with knowledge of MI exceeding that of stroke at every level of risk. Subjects with higher risk were less knowledgeable about the stroke signs, symptoms, and risk factors than those of MI.

Recurrent Intracerebral Hemorrhage in Patients with Hypertension is Associated with APOE Gene Polymorphism: A Preliminary Study - Corrected Proof

Usha K. Misra, Jayantee Kalita, Bindu I. Somarajan — 2012-03-12

Background: Recurrent intracerebral hemorrhage (ICH) in patients with hypertension has been reported in Asia and is attributed to poor control of blood pressure, but there may be a genetic basis. This study evaluates the roles of apolipoprotein E (APOE) and α-1 antichymotrypsin (ACT) genes in patients with recurrent hypertensive ICH and compares patients with nonrecurring hypertensive ICH and normal controls.Methods: Thirty-three recurrent and 101 nonrecurrent patients with hypertension and ICH were included. The demographic, stroke risk factors, and computed tomographic or magnetic resonance imaging findings were recorded. Magnetic resonance angiography or digital subtraction angiography and vasculitic profile were done in recurrent group to exclude secondary causes of ICH. APOE and ACT gene polymorphisms were assessed with polymerase chain reaction studies in patients with ICH and 188 healthy controls.Results: The demographic and clinical variables were similar in patients with recurrent and nonrecurrent ICH, but patients with recurrent ICH were older (61.1 vs 57.2 years). In the recurrent ICH group, only 7 (10%) out of 69 episodes were lobar; the remaining were deep-seated hematomas. In the nonrecurrent group, 7 (6.9%) patients had lobar ICH. The E2 (odds ratio 4.32; 95% confidence interval 1.65-11.28; P = .003) and E4 alleles of APOE (odds ratio 11.33; 95% confidence interval 5.37-23.02; P < .0001) were significantly related to recurrent ICH compared to healthy controls. The E4 allele was also independently related to recurrent compared to nonrecurrent ICH, even after adjustment for stroke risk factors (odds ratio 25.99; 95% confidence interval 11.65-57.97; P < .0001). ACT gene polymorphism, however, was not related to recurrent ICH compared to controls and nonrecurrent ICH.Conclusions: APOE polymorphism may contribute to the recurrence of hypertensive ICH.

Interleukin-6 Gene -174 G/C Promoter Polymorphism Predicts Severity and Outcome in Acute Ischemic Stroke Patients from North India - Corrected Proof

2012-03-12

Background: A guanine/cytosine (G/C) substitution occurring in position -174 of the interleukin-6 (IL-6) gene promoter changes the expression of IL-6 circulating proteins. We evaluated the occurrence of IL-6 -174 G/C polymorphism in patients with acute ischemic stroke and studied its association with stroke severity, outcome, and mortality.Methods: One hundred patients with acute ischemic stroke and 120 age and sex-matched healthy controls were studied. Genotyping was performed using polymerase chain reaction and restriction enzyme analysis. Serum levels of IL-6 were measured using enzyme-linked immunosorbent assay. Stroke was classified using Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Severity was assessed by the National Institutes of Health Stroke Scale. Outcome measures included modified Rankin Scale (mRS) and Barthel Index (BI) scores at 7 days and 3 and 6 months. Mortality/survival was assessed using the Kaplan–Meier analysis.Results: The frequency of GG, GC, and CC genotypes did not differ significantly between cases and controls. No association was seen between TOAST subtype and genotype. At the time of admission, stroke was more severe in patients with the GC genotype (P = .03) and less severe in the GG genotype (P = .04). The GC genotype was also associated with higher serum IL-6 levels and poor short-term (BI P = .001; mRS P = .003) and long-term outcomes (BI P = 9 × 10−5; mRS P = 9 × 10−5), while the GG genotype had significantly lower serum IL-6 levels and better short and long-term outcomes (BI P = 3 × 10−5; mRS P = 2 × 10−4). There was significantly lesser mortality in the GG genotype and more in the GC genotype based on the Kaplan–Meier analysis.Conclusions: Patients with the GC genotype had more severe strokes with poorer short and long-term outcomes and increased mortality. The GG genotype was associated with less severe strokes, better short and long-term prognosis, and survival. The GG genotype appears to be protective against stroke severity, outcome, and mortality.

Cerebellar Infarction Originating from Vertebral Artery Stenosis Caused by a Hypertrophied Uncovertebral Joint - Corrected Proof

Jong Mun Choi, Hyeok Jin Hong, Suk Ki Chang, Sung Han Oh — 2012-02-27

We report a case of cerebellar infarction originating from vertebral artery stenosis caused by a hypertrophied uncovertebral joint. A 38-year-old man presented with sudden onset of headache, dizziness, and dysarthria. The magnetic resonance imaging scan of the brain revealed acute infarction in the right cerebellar hemisphere in the territory of the posterior inferior cerebellar artery (PICA) and superior cerebellar artery (SCA). Magnetic resonance, 3-dimensional computed tomographic, and conventional angiography revealed severe right vertebral artery stenosis by extrinsic compression of the hypertrophied right C5–C6 uncovertebral joint. The diagnosis was acute cerebellar infarction, which was probably caused by embolism from the right vertebral artery stenosis that was caused by the hypertrophied C5–C6 uncovertebral joint. C5–C6 anterior discectomy and fusion were performed together with direct uncovertebral joint decompression. Postoperative 3-dimensional computed tomographic angiography revealed improvement in antegrade filling in the right vertebral artery. The imaging findings for this patient and the pathogenesis of cerebellar infarction for our patient are discussed.

Using Routine Data for Quality Assessment in NeuroNet Telestroke Care - Corrected Proof

2012-02-24

Background: Systematic clinical trials are often unavailable to evaluate and optimize operational telestroke networks. In a complementary approach, readily available routine clinical data were analyzed in this study to evaluate the effect of a telestroke network over a 4-year period.Methods: Routine clinical data from the HELIOS hospital information system were compared before and after implementation of the NeuroNet concept, including neurologic acute stroke teleconsultations, standard operating procedures, and peer review quality management in 3 hospital cohorts: 5 comprehensive stroke centers, 5 NeuroNet hospitals, and 5 matched control hospitals.Results: During the study period, the rate of thrombolytic therapy increased by 4.8% in NeuroNet hospitals, while ischemic stroke in-hospital mortality decreased (relative risk reduction ∼29% in NeuroNet and control hospitals). The odds ratio for thrombolytic therapy in comprehensive stroke centers compared to NeuroNet hospitals was reduced from 3.7 to 1.3 between 2006 and 2009. Comprehensive stroke care coding according to German Diagnosis Related Groups definitions increased by 45% in NeuroNet (P < .0001) and by 18% in control hospitals.Conclusions: Routine clinical data on in-hospital mortality, the rate of thrombolytic therapy, and comprehensive stroke care coding reflect different aspects of acute stroke care improvement related to the implementation of the telemedical NeuroNet concept and unified quality management (standard operating procedure teaching concept, peer review process). Similar evaluation processes could contribute to quality monitoring in other telestroke networks.

Assessment of Moyamoya Disease Using Multidetector Row Computed Tomography - Corrected Proof

2012-02-24

The recent introduction of multidetector row computed tomography (MDCT) scanners has enabled high-resolution 3-dimensional reconstruction. The purpose of this study was to establish a method to evaluate moyamoya disease using computed tomography angiography (CTA), specifically MDCT. Twenty-four patients (48 sides total) with moyamoya disease diagnosed by magnetic resonance angiography (MRA) were evaluated by means of CTA using MDCT by 3 independent observers, and the resulting 144 sides were analyzed. CTA and MRA were compared in terms of the steno-occlusive changes exhibited in each vessel. CTA and MRA scores were assigned on the basis of the severity of occlusive changes in the internal carotid artery, middle cerebral artery, anterior cerebral artery, and posterior cerebral artery. CTA scores were significantly correlated with MRA scores (P < .0001), and the 2 scores were in complete agreement in 57 sides (39.6%). The mean CTA score was significantly lower than the mean MRA score (P < .0001). Compared with CTA, MRA overestimated occlusion in 115 of the 576 vessels assessed. The mean MRA score was significantly higher in the overestimation group than in the good correlation group (P < .0001). CTA had a significantly higher rate of detection of moyamoya-affected vessels (P = .0001). Our data indicate that CTA using MDCT is a more reliable technique than MRA for diagnosing moyamoya disease. The ability to perform CTA quickly is a significant benefit for patients with moyamoya disease, particularly in pediatric and emergency cases.

Acute Central Retinal Artery Occlusion Treated with Intravenous Recombinant Tissue Plasminogen Activator - Corrected Proof

Richard J. Nowak, Hardik Amin, Kimberly Robeson, Joseph L. Schindler — 2012-02-20

Central retinal artery occlusion (CRAO) causes ischemic stroke of the eye. We report a case of CRAO that was successfully treated with intravenous recombinant tissue plasminogen activator (rt-PA) and review the current literature. A 64-year-old right-handed man presented to the emergency department with acute left eye amaurosis. An ophthalmologic assessment revealed a left afferent pupillary defect, minimal visual acuity, macular edema with a cherry red spot, and multiple emboli in the inferotemporal arcade of the left eye. A neurologic examination was otherwise nonfocal; neuroimaging was normal. Acute CRAO was diagnosed, and rt-PA was administered intravenously 185 minutes after symptom onset. A repeat examination 4.5 hours after treatment found improved vision, reduced macular edema, and no emboli. An ophthalmologic evaluation 10 days later found a visual acuity of 20/200 in the left eye and bilateral arterial sclerosis without evidence of retinal emboli or macular edema. This case illustrates that intravenous rt-PA may be an effective therapeutic option for CRAO in select patients. Given the current literature and the recommended established safety window for thrombolytics in acute ischemic cerebral stroke, it is reasonable to administer intravenous treatment for CRAO within 4.5 hours after symptom onset. Nevertheless, it is critical that a prospective clinical trial confirm the efficacy, safety, and time window for treatment.

Optimal Timing and Duration of Continuous Electrocardiographic Monitoring for Detecting Atrial Fibrillation in Stroke Patients - Corrected Proof

Laurent Suissa, Sylvain Lachaud, Marie Hélène Mahagne — 2012-02-20

Background: Several studies have suggested that after ischemic stroke, continuous electrocardiographic (ECG) monitoring (CEM) increases the atrial fibrillation (AF) detection rate. However, optimal CEM terms of use are not clear. The aim of our study was to evaluate the usefulness of CEM in detecting AF and define optimal terms of the use of CEM.Methods: We prospectively enrolled consecutive patients with acute ischemic stroke who were admitted to the stroke unit without AF on baseline ECG. We compared 2 strategies of AF detection: the first using CEM and the second with routine clinical practice (24-hour Holter ECG and additional ECGs). Adjusted odds ratios for the association between AF diagnosis and the use of CEM stratified by monitoring duration were calculated using multivariate logistic regression analysis.Results: Of the 1166 patients included, 220 (18.87%) had AF on baseline ECG and were excluded. Of the 946 remaining patients, 592 underwent CEM. The prevalence of AF using CEM was 12.50% compared 2.26% using the routine strategy. After adjustment (demographic data, vascular risk factors, and National Institutes of Health Stroke Scale scores), using CEM increased 5.29 fold the odds of finding AF (95% confidence interval [CI] 2.43-11.55) compared to the routine strategy. The adjusted odds ratio (9.82; 95% CI 3.01-32.07) was maximum for the first day of monitoring and decreased later. Beyond 5 days, CEM usefulness was not significantly higher than the routine strategy.Conclusions: We suggest that in order to enhance the detection rate of AF, CEM could be generalized in the stroke unit. It must be started early in patients with acute stroke and prolonged over a minimum of 4 days.

Recurrent Left Atrial Myxomas in Carney Complex: A Genetic Cause of Multiple Strokes that can be Prevented - Corrected Proof

2012-02-17

Background: Intracardiac myxomas in Carney complex are significant causes of cardiovascular morbidity and mortality through embolic stroke and heart failure. The genetic, clinical, and laboratory characteristics of Carney complex–related strokes from atrial myxomas have not been described. The regulatory subunit (R1A) of the protein kinase gene (PRKAR1A) is mutated in >60% of patients with Carney complex.Methods: We studied patients with strokes and cardiac myxomas that were hospitalized in our institution and elsewhere; a total of 7 patients with 16 recurrent atrial myxomas and >14 episodes of strokes were identified.Results: Neurologic deficits were reported; in 1 patient, an aneurysm developed at the site of a previous stroke. All patients were females, were also diagnosed with Cushing syndrome, and all had additional tumors or other Carney complex manifestations. Other than gender, although there was a trend for patients being overweight and hypertensive, no other risk factors were identified. A total of 5 patients (71%) had a PRKAR1A mutation; all mutations (c418_419delCA, c.340delG/p.Val113fsX15, c.353_365del13/p.Ile118fsX6, c.491_492delTG/p.Val164fsX4, and c.177+1G>A) were located in exons 3 to 5 and introns 2 to 3, and all led to a non-sense PRKAR1A mRNA.Conclusions: Female patients with Carney complex appear to be at a high risk for recurrent atrial myxomas that lead to multiple strokes. Early identification of a female patient with Carney complex is of paramount importance for the early diagnosis of atrial myxomas and the prevention of strokes.

Bilateral Thalamic Infarct Caused by Spontaneous Vertebral Artery Dissection in Pre-eclampsia with HELLP Syndrome: A Previously Unreported Association - Corrected Proof

2012-02-17

Cerebrovascular accidents are not rare during pregnancy and the postpartum period. Pre-eclampsia is a common condition that is characterized by proteinuria and de novo hypertension that may be complicated by hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Spontaneous cervical artery dissection has been rarely reported in the postpartum period but never in association with HELLP syndrome. We describe a case of pre-eclampsia and HELLP syndrome complicated in the postpartum period by bilateral thalamic infarct as result of left vertebral artery dissection. We speculated about the possible common etiopathologic mechanisms involved in this previously unreported association.

Troponin Elevation Predicts Atrial Fibrillation in Patients with Stroke or Transient Ischemic Attack - Corrected Proof

Isabelle Beaulieu-Boire, Nancy Leblanc, Léo Berger, Jean-Martin Boulanger — 2012-02-17

Background: Atrial fibrillation (AF) is a major cause of ischemic stroke. Cardiac troponin (cTnI) is a marker of myocardial damage and may predict arrhythmia. We sought to determine if increased cTnI levels were a predictor of new-onset AF in ischemic stroke or patients with transient ischemic attack (TIA).Methods: Consecutive patients who presented to Charles-Lemoyne Hospital between October 2006 and November 2010 with a diagnosis of acute ischemic stroke or TIA, without a history of AF, with a baseline measurement of cTnI were included in the study. The primary outcome was new-onset AF on 24-hour Holter measurement within 1 week of admission in patients without AF on the baseline electrocardiogram (ECG). Secondary outcomes included AF on Holter measurement, death, myocardial infarction (MI), and stroke within 3 months.Results: A total of 408 patients were included. Forty-six patients (11.3%) had elevated cTnI levels. These patients were older and had a higher prevalence of coronary artery disease and diabetes. AF on baseline ECG or 24-hour Holter measurement was present in 51 patients (12.5%) and was more frequent among patients with increased cTnI levels compared to patients with normal cTnI levels (34.7% vs 9.7%; P = .004 multivariate analysis). Elevated cTnI levels also predicted the composite outcome of stroke, MI, and death at 3 months (50.0% vs 16.1%; P = .0001).Conclusions: cTnI elevation predicts new-onset AF on 24-hour Holter measurement in patients with acute ischemic stroke or TIA and may indicate a poorer prognosis and a higher risk of stroke, MI, and death at 3 months.

Safety of Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Saccular Intracranial Aneurysms - Corrected Proof

2012-02-17

Background: It is not known if the presence of unruptured intracranial aneurysms can increase the risk of hemorrhage after thrombolysis for acute ischemic stroke. The goal of our study was to evaluate the risk of hemorrhage after intravenous tissue plasminogen activator in acute stroke patients with intracranial aneurysms.Methods: This is a retrospective analysis of consecutive cases of patients with acute ischemic stroke who were treated with intravenous tissue plasminogen activator at Mayo Clinic between March 2002 and June 2011 and who were evaluated with invasive or noninvasive intracranial angiography. Univariate analyses were performed with the t, Chi-square, and Fisher exact tests where appropriate.Results: Intracranial angiograms were performed in105 patients (85 magnetic resonance angiography, 19 computed tomography angiography, and 1 catheter arteriography). The mean age of the patients was 69 ± 14 years. The mean National Institutes of Health Stroke Scale score at admission was 8 ± 5. A total of 12 incidental saccular aneurysms were found in 10 (9.5%) patients, and all 10 of these patients were white. There were no subarachnoid hemorrhages during the hospital stay in any patient with or without intracranial aneurysm. The rates of symptomatic intracranial hemorrhage and 3-month clinical outcomes were similar in patients with or without intracranial aneurysms.Conclusions: Intravenous thrombolysis was safe among our patients with acute ischemic stroke and incidental intracranial saccular aneurysm.

Reversible Cerebral Vasoconstriction Syndrome 3 Months after Blood Transfusion - Corrected Proof

Charles N. Braun, Richard L. Hughes, Patrick J. Bosque — 2012-02-17

Reversible cerebral vasoconstriction syndrome is characterized by the prolonged but reversible constriction of cerebral arteries accompanied by a sudden onset of severe headache, and is sometimes complicated by subarachnoid hemorrhage or cerebral infarction. It is associated with various clinical conditions and treatments, although the precise pathophysiology is not understood. In particular, several cases of this syndrome have been described to occur in middle-aged women within 1 week of a blood transfusion. We encountered a patient with a reversible cerebral vasoconstriction syndrome who became symptomatic 3 months after a blood transfusion. No other cause for the syndrome was found. This case suggests that the risk for the reversible cerebral vasoconstriction may persist for months after blood transfusion.

Validating Imaging Biomarkers of Cerebral Edema in Patients with Severe Ischemic Stroke - Corrected Proof

2012-02-13

Background: There is no validated neuroimaging marker for quantifying brain edema. We sought to test whether magnetic resonance imaging (MRI)–based metrics would reliably change during the early subacute period in a manner consistent with edema and whether they would correlate with relevant clinical endpoints.Methods: Serial MRI studies from patients in the Echoplanar Imaging Thrombolytic Evaluation Trial with initial diffusion-weighted imaging (DWI) lesion volume >82 cm3 were analyzed. Two independent readers outlined the hemisphere and lateral ventricle on the involved side and calculated respective volumes at baseline and days 3 to 5. We assessed interrater agreement, volume change between scans, and the association of volume change with early neurologic deterioration (National Institutes of Health Stroke Scale score worsening of ≥4 points), a 90-day modified Rankin scale (mRS) score of 0 to 4, and mortality.Results: Of 12 patients who met study criteria, average baseline and follow-up DWI lesion size was 138 cm3 and 234 cm3, respectively. The mean time to follow-up MRI was 62 hours. Concordance correlation coefficients between readers were >0.90 for both hemisphere and ventricle volume assessment. Mean percent hemisphere volume increase was 16.2 ± 8.3% (P < .0001), and the mean percent ventricle volume decrease was 45.6 ± 16.9% (P < .001). Percent hemisphere growth predicted early neurologic deterioration (area under the curve [AUC] 0.92; P = .0005) and 90-day mRS 0 to 4 (AUC 0.80; P = .02).Conclusions: In this exploratory analysis of severe ischemic stroke patients, statistically significant changes in hemisphere and ventricular volumes within the first week are consistent with expected changes of cerebral edema. MRI-based analysis of hemisphere growth appears to be a suitable biomarker for edema formation.

Diffusion-weighted Imaging–Fluid Attenuated Inversion Recovery Mismatch in Nocturnal Stroke Patients with Unknown Time of Onset - Corrected Proof

2012-02-13

Background: More than a quarter of patients with ischemic stroke (IS) are excluded from thrombolysis because of an unknown time of symptom onset. Recent evidence suggests that a mismatch between diffusion-weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR) imaging could be used as a surrogate for the time of stroke onset. We compared used the DWI–FLAIR mismatch and the FLAIR/DWI ratio to estimate the time of onset in a group of patients with nocturnal strokes and unknown time of onset.Methods: We used a prospectively collected acute IS patient database with MRI as the initial imaging modality. Nineteen selected nocturnal stroke patients with unknown time of onset were compared with 22 patients who had an MRI scan within 6 hours from stroke onset (control A) and 19 patients who had an MRI scan between 6 and 12 hours (control B). DWI and FLAIR signal was rated as normal or abnormal. FLAIR/DWI ratio was calculated from independent DWI and FLAIR ischemic lesion volumes using semiautomatic software.Results: The DWI–FLAIR mismatch was different among groups (unknown 43.7%; control A 63.6%; control B 10.5%; Fisher-Freeman-Halton test; P = .001). There were significant differences in FLAIR/DWI ratio among the 3 groups (unknown 0.05 ± 0.12; control A 0.17 ± 0.15; control B 0.04 ± 0.06; Kruskal–Wallis test; P < .0001). Post-hoc pairwise comparisons revealed that FLAIR/DWI ratio from the unknown group was significantly different from the control B group (P = .0045) but not different from the control A group. DWI volumes were not different among the 3 groups.Conclusions: A large proportion of patients with nocturnal IS and an unknown time of stroke initiation have a DWI–FLAIR mismatch, suggesting a recent onset of stroke.

Safety of a “Drip and Ship” Intravenous Thrombolysis Protocol for Patients with Acute Ischemic Stroke - Corrected Proof

Simin Mansoor, Ramin Zand, Ameer Al-Wafai, Mervat N. Wahba, Elias A. Giraldo — 2012-02-10

Background: The “drip and ship” approach for intravenous thrombolysis (IVT) is becoming the standard of care for patients with acute ischemic stroke (AIS) in communities without direct access to a stroke specialist. We aimed to demonstrate the safety of our “drip and ship” IVT protocol.Methods: This was a retrospective study of patients with AIS treated with IVT between January 2003 and January 2011. Information on patients’ baseline characteristics, neuroimaging, symptomatic intracerebral hemorrhage (sICH), and mortality was obtained from our stroke registry. A group of patients were treated with IVT by an emergency physician in phone consultation with a board-certified vascular neurologist (BCVN) at 1 of our 3 stroke network–affiliated hospitals (SNAHs). These patients were subsequently transferred to our Joint Commission–certified primary stroke center (CPSC) after completion of IVT (“drip and ship” protocol). The other patients were treated directly by a BCVN at the CPSC.Results: We studied 201 patients treated with IVT. Of them, 14% received IVT at a SNAH (“drip and ship” protocol) and 86% were treated at the CPSC. There were no significant differences between the 2 groups with regard to age, National Institutes of Health Stoke Scale score, stroke symptom onset-to-needle time, sICH, or in-hospital mortality.Conclusions: Our “drip and ship” protocol for IVT is safe. The protocol was not associated with an excess of sICH or in-hospital mortality compared with patients who received IVT at the CPSC.

Suitability of the Montreal Cognitive Assessment versus the Mini-Mental State Examination in Detecting Vascular Cognitive Impairment - Corrected Proof

Masafumi Ihara, Yoko Okamoto, Ryosuke Takahashi — 2012-02-10

The Mini-Mental State Examination (MMSE) has been criticized as being an insufficient screening test for patients with vascular cognitive impairment because of its insensitivity to visuospatial and executive functional deficits. The Montreal Cognitive Assessment (MoCA) was designed to be more sensitive to such deficits, and thus may be a superior screening instrument for vascular cognitive impairment. Twelve patients with extensive leukoaraiosis detected on magnetic resonance imaging (average age, 76.0 ± 8.7 years) underwent neurologic and cognitive testing, including MMSE and the Japanese version of the MoCA (MoCA-J). Accepted cutoff scores of <27 for the MMSE and <26 for the MoCA-J were taken to indicate cognitive impairment. Z-scores were calculated to evaluate the discriminating ability of individual MMSE and MoCA-J subtest scores. Although there was a strong correlation between the total MMSE and total MoCA-J scores (r = 0.90; P < .0001), MMSE scores were skewed toward the higher end of the range (range, 18-30; median, 28), whereas MoCA-J scores were normally distributed (range, 9-28; median, 21). Of the 7 patients with an unimpaired MMSE score, 6 (86%) had an impaired MoCA-J score. Z-scores were >5 for 4 MMSE subtests (orientation, registration, naming, and language) but for only 1 MoCA-J subtest (naming). The MoCA-J better discriminated cognitive status in subjects with extensive leukoaraiosis. Our findings suggest that the MoCA-J is more sensitive than the MMSE in screening for cognitive impairment in patients with subcortical vascular cognitive impairment.

Cerebral Infarct in a Patient with a History of Systemic Arterial and Venous Thrombosis from Essential Thrombocythemia - Corrected Proof

Keun-Tae Kim, Sung-Il Sohn, Kyung-Hee Cho — 2012-02-10

Although essential thrombocythemia (ET) may involve thrombotic complications, including arterial or venous thrombosis, there are no reports of major vascular complications, including both arterial and venous thrombosis, in a patient with ET. We report on a patient with a cerebral infarction affecting the right lateral thalamus and a stenotic lesion of the right posterior cerebral artery. This arterial thrombotic event may be related to ET, which was based on results of a bone marrow biopsy specimen. The patient had experienced previous events of thrombosis, splenic infarction with venous thrombosis, and myocardial infarction. The cause of recurrent ischemic events involving both arterial and venous systems may be sustained elevation of platelet counts. Previous thrombosis is an established risk factor for rethrombosis in patients with ET. Efficient cytoreductive therapy with an antiplatelet agent should be considered for the prevention of recurrent thrombosis.