A one year prospective study of neurogenic stuttering following stroke: incidence and co-occurring disorders

In this prospective study, data on incidence, stuttering characteristics, co-occurring speech disorders, and recovery of neurogenic stuttering in a large sample of stroke participants were assessed. Following stroke onset, 17 of 319 participants (5.3%; 95% CI, 3.2-8.3) met the criteria for neurogenic stuttering. Stuttering persisted in at least 2.5% (95% CI, 1.1-4.7) for more than six months following the stroke. Participants with comorbid aphasia presented with a significantly higher frequency of stuttering compared to the group without aphasia (U=13.00, p((1-tailed))=.02) but no difference was found for participants with co-occurring dysarthria and/or cognitive problems. Participants with neurogenic stuttering did not differ from those without stuttering in terms of stroke risk factors or stroke etiologic subtypes. Although the incidence of stuttering following stroke is lower than that for aphasia or dysarthria, these results show that clinicians should take neurogenic stuttering into account when assessing stroke participants' speech and language.

LEARNING OUTCOMES

: Readers will be able to: (1) understand the need for systematic, prospective studies in neurogenic stuttering; (2) know the incidence and prevalence of neurogenic stuttering following stroke; and (3) know how neurogenic stuttering co-occurs with other speech-language disorders following stroke.

Genetics of atrial fibrillation and possible implications for ischemic stroke

Atrial fibrillation is the most common cardiac arrhythmia mainly caused by valvular, ischemic, hypertensive, and myopathic heart disease. Atrial fibrillation can occur in families suggesting a genetic background especially in younger subjects. Additionally recent studies have identified common genetic variants to be associated with atrial fibrillation in the general population. This cardiac arrhythmia has important public health implications because of its main complications: congestive heart failure and ischemic stroke. Since atrial fibrillation can result in ischemic stroke, one might assume that genetic determinants of this cardiac arrhythmia are also implicated in cerebrovascular disease. Ischemic stroke is a multifactorial, complex disease where multiple environmental and genetic factors interact. Whether genetic variants associated with a risk factor for ischemic stroke also increase the risk of a particular vascular endpoint still needs to be confirmed in many cases. Here we review the current knowledge on the genetic background of atrial fibrillation and the consequences for cerebrovascular disease.

Genetic associations with brain microbleeds: Systematic review and meta-analyses

OBJECTIVE

We performed a systematic review and meta-analyses to assess the evidence for genetic associations with brain microbleeds (BMBs).

METHODS

We sought all published studies of the association between any genetic polymorphism and BMBs studied in a total of >100 people. We critically appraised studies, and calculated pooled odds ratios (ORs) using the generic inverse variance fixed effects method. We used I² and χ² statistics to assess heterogeneity, and fail-safe N estimates to assess the robustness of our results.

RESULTS

Only the APOE ε2/3/4 polymorphism had been studied in >100 people (10 studies, 7,351 participants). Compared with people with the ε3/ε3 genotype, carriers of the ε4 allele (ε4+) were statistically significantly more likely to have BMBs in any location (ε4+ vs ε3/ε3: pooled OR 1.22, 95% confidence interval [CI] 1.05-1.41, p = 0.01). For strictly lobar BMBs, this association appeared slightly stronger (ε4+ vs ε3/ε3: pooled OR 1.35, 95% CI 1.10-1.66, p = 0.005). The association of ε4+ genotypes with strictly lobar BMBs was reasonably robust to potential publication and reporting biases.

CONCLUSIONS

Given the known associations of APOE alleles with lobar intracerebral hemorrhage and cerebral amyloid angiopathy, these findings support the concept that strictly lobar BMBs may be an imaging biomarker of cerebral amyloid angiopathy.

Cost of hospitalization for cerebrovascular disorders in Belgium

BACKGROUND

There is only scarce information on the incidence and costs of stroke in Belgium. Knowledge of these figures permits targeted allocation of resources and aids cost efficacy estimates.

METHODS

We analysed a nationwide administrative database used for reimbursement of hospitals in Belgium. This database allows analysis of the rate of all hospital admissions for TIA, acute ischemic stroke, intracranial hemorrhage and carotid surgery or angioplasty. We compared the costs of hospitalization for stroke and related disorders with the costs of hospitalization for coronary artery disease.

RESULTS

There were 32970 admissions for stroke related disorders in 2007 at a cost of 191.6 million EUROS. There was a decline of 4.7% of the rate of hospitalization for stroke and associated disorders over the period 2002-2007. Despite this decline the total costs did not diminish substantially. In 2007 stroke and related disorders accounted for 2.0% of all Belgian hospitalizations, whereas coronary artery disease hospitalization accounted for 4.4%. The length of stay was longer for stroke and associated disorders. The average cost of hospitalizations in 2007 for stroke related disorders was 6188 EURO and the average cost of coronary artery related disorders was 5026 EURO.

CONCLUSION

The cost of hospitalization for stroke and related disorders is high. Although coronary artery disease is more frequent and has a larger impact on the health care expenditures, the average cost per hospitalization is higher for stroke and related diseases. This is mainly due to the longer hospitalization duration for stroke.

Lesion evidence for the critical role of the intraparietal sulcus in spatial attention

Based on lesion mapping studies, the inferior parietal lobule and temporoparietal junction are considered the critical parietal regions for spatial-attentional deficits. Lesion evidence for a key role of the intraparietal sulcus, a region featuring prominently in non-human primate studies and human functional imaging studies of the intact brain, is still lacking, probably due to the exceptional nature of isolated intraparietal sulcus lesions. We combined behavioural testing and functional imaging in two patients with a focal intraparietal sulcus lesion sparing the inferior parietal lobule and temporoparietal junction to examine the critical contribution of the intraparietal sulcus to spatial attention. Case H.H. had a focal ischaemic lesion (1.8 cm3) that was confined to the posterior segment of the left intraparietal sulcus, whereas Case N.V. had a partially reversible lesion of the middle segment of the right intraparietal sulcus extending into the superior parietal lobule (13.8 cm3). The performance of these cases was contrasted with five cases with a classical inferior parietal lesion, as well as with a group of 31 age-matched controls. In the behavioural study, the patients performed an orientation discrimination task on a peripheral target (eccentricity 7.6°) that was preceded by a central spatial cue. We manipulated both the cue validity (17% trials with an invalid spatial cue) and the presence of a competing distracter in the visual field contralateral to the target (17% double stimulation trials). The ability of the patients with an intraparietal sulcus lesion to reorient their spatial focus of attention and to select between competing stimuli was impaired for contralesional targets compared with controls, similarly to what we saw in the inferior parietal group. Furthermore, we could observe that the deficit in Case N.V. resolved with regression of the lesion. To further evaluate the correspondence between spatial-attentional deficits and the intraparietal sulcus lesions, we ascertained the functional integrity of the inferior parietal lobule and temporoparietal junction in Case H.H. using event-related functional magnetic resonance imaging with the same task as in the behavioural study. The intraparietal sulcus lesion of this patient did not affect the task-related activation of the inferior parietal lobule or temporoparietal junction. Additionally, a resting-state functional magnetic resonance imaging study in Case H.H. and 62 controls revealed that the lesion in Case H.H. did not affect the topology of the ventral attention network nor the strength of its main inter- and intrahemispheric connections. Our findings demonstrate that the human superior parietal cortex critically contributes to spatially selective attention.

Expanded ATXN2 CAG repeat size in ALS identifies genetic overlap between ALS and SCA2

OBJECTIVES

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder of motor neurons that results in progressive muscle weakness and limits survival to 2-5 years after disease onset. Intermediate CAG repeat expansions in ataxin 2 (ATXN2), the causative gene of spinocerebellar ataxia type 2 (SCA2), have been implicated in sporadic ALS. We studied ATXN2 in a large cohort of patients with sporadic and familial ALS.

METHODS

We determined ATXN2 CAG repeat size in 1,948 sporadic and familial ALS cases and 2,002 controls from Belgium and the Netherlands.

RESULTS

In controls, the maximal ATXN2 repeat size was 31. In sporadic ALS, a significant amount of longer repeat sizes (≥ 32, range 32-39) were encountered (in 0.5% or 10/1,845 ALS cases, vs 0% in controls, p = 0.0006). Receiver operating characteristic analysis showed that a cutoff of ≥ 29 appeared optimal to discriminate ALS from control (p = 0.036, odds ratio [OR] 1.92, 95% confidence interval [CI] 1.04-3.64). A meta-analysis with the previously published results from the United States showed that the association between a repeat length of ≥ 29 and ALS became stronger (p < 0.0001, OR 2.93, 95% CI 1.73-4.98). In unexplained familial ALS, we found an intermediate repeat expansion of 31 and a homozygous repeat expansion of 33 each in 1.1% of families. The phenotype of patients with ALS with expanded repeat sizes ranged from rapidly progressive typical ALS to slowly progressive ALS with reduced sensory nerve action potentials.

CONCLUSION

Our data reveal a novel genetic overlap between ALS and SCA2.

Belgian global implementation of cardiovascular and stroke risk assessment study: methods and baseline data of the BELGICA-STROKE STUDY

OBJECTIVES

BELGICA-STROKE is a longitudinal study to enhance the use of online cardiovascular risk prediction scores based on the SCORE 10-year risk estimates for fatal cardiovascular disease (adapted for Belgium) and the Framingham 10-year stroke risk and to evaluate their impact on the cardiovascular risk profile of hypertensive patients. Methods and baseline characteristics are described here.

DESIGN

Prospective, multicenter study in primary care.

METHODS

General practitioners (N = 810) recruited consecutive hypertensive patients aged >40 years who were not at blood pressure goal and assessed them every 4 months. The estimated 10-year risks for fatal cardiovascular disease and stroke were available on a secured, specially designed study website. The calculated risk profile of a patient was modifiable by adding treatment goals in order to increase awareness and motivation of both physician and patient. An automated feedback on goal-level attainment and both cardiovascular risk scores was provided.

RESULTS

Mean age of the 15,744 patients was 66.3 years: 51.9% were men, 77.8% had excess weight, 19.4% were smokers, and 25.9% had diabetes. Left ventricle hypertrophy was present in 20.0%, atrial fibrillation in 5.8%. Mean blood pressure was 153.8/88.2 mmHg, mean cholesterol 211.5 mg/dl. Most patients (89.2%) received antihypertensive medication, of which 36.9% was monotherapy. Mean estimated 10-year stroke risk was 19.1%, and mean estimated 10-year fatal cardiovascular disease risk 5.9%.

CONCLUSIONS

The 10-year estimated stroke and fatal cardiovascular disease risks were moderate to high in hypertensive patients not at goal blood pressure, emphasizing the importance of global cardiovascular risk factor assessment.

Does medical specialty influence the treatment of asymptomatic carotid stenosis? a Belgian multidisciplinary survey

AIM

The aim of this study was to supplement the few data that exist regarding the potential effect of the referring medical specialty on the proposed treatment for asymptomatic carotid stenosis.

METHODS

In a web survey, we presented Belgian cardiologists, neurologists and vascular surgeons with two fairly uncomplicated case vignettes on asymptomatic carotid stenosis differing only in the degree of stenosis (70-80% in case 1 and >80% in case 2).

RESULTS

In both cases the suggested therapies were different per medical specialty (P<0.000002 and P<0.00002, respectively). Cardiologists were more conservative and vascular surgeons were more aggressive. Preferred therapies for both cases differed statistically significantly (odds ratio 8.63; 95% confidence interval 5.11-14.58). Suggesting a different therapy or not for case 1 and case 2 was also different per medical specialty (P<0.035). Cardiologists were most inclined to suggest a different therapy and vascular surgeons the least. Nobody switched to a more conservative treatment. Younger physicians suggested a more conservative approach (P<0.014).

CONCLUSION

Different medical specialties prefer different treatments for asymptomatic carotid stenosis. Also, younger physicians seem more conservative. We elaborate on the different reasons that could explain these findings.

The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial

BACKGROUND

Raised blood pressure is common in acute stroke, and is associated with an increased risk of poor outcomes. We aimed to examine whether careful blood-pressure lowering treatment with the angiotensin-receptor blocker candesartan is beneficial in patients with acute stroke and raised blood pressure.

METHODS

Participants in this randomised, placebo-controlled, double-blind trial were recruited from 146 centres in nine north European countries. Patients older than 18 years with acute stroke (ischaemic or haemorrhagic) and systolic blood pressure of 140 mm Hg or higher were included within 30 h of symptom onset. Patients were randomly allocated to candesartan or placebo (1:1) for 7 days, with doses increasing from 4 mg on day 1 to 16 mg on days 3 to 7. Randomisation was stratified by centre, with blocks of six packs of candesartan or placebo. Patients and investigators were masked to treatment allocation. There were two co-primary effect variables: the composite endpoint of vascular death, myocardial infarction, or stroke during the first 6 months; and functional outcome at 6 months, as measured by the modified Rankin Scale. Analyses were by intention to treat. The study is registered, number NCT00120003 (ClinicalTrials.gov), and ISRCTN13643354.

FINDINGS

2029 patients were randomly allocated to treatment groups (1017 candesartan, 1012 placebo), and data for status at 6 months were available for 2004 patients (99%; 1000 candesartan, 1004 placebo). During the 7-day treatment period, blood pressures were significantly lower in patients allocated candesartan than in those on placebo (mean 147/82 mm Hg [SD 23/14] in the candesartan group on day 7 vs 152/84 mm Hg [22/14] in the placebo group; p<0·0001). During 6 months' follow-up, the risk of the composite vascular endpoint did not differ between treatment groups (candesartan, 120 events, vs placebo, 111 events; adjusted hazard ratio 1·09, 95% CI 0·84-1·41; p=0·52). Analysis of functional outcome suggested a higher risk of poor outcome in the candesartan group (adjusted common odds ratio 1·17, 95% CI 1·00-1·38; p=0·048 [not significant at p≤0·025 level]). The observed effects were similar for all prespecified secondary endpoints (including death from any cause, vascular death, ischaemic stroke, haemorrhagic stroke, myocardial infarction, stroke progression, symptomatic hypotension, and renal failure) and outcomes (Scandinavian Stroke Scale score at 7 days and Barthel index at 6 months), and there was no evidence of a differential effect in any of the prespecified subgroups. During follow-up, nine (1%) patients on candesartan and five (<1%) on placebo had symptomatic hypotension, and renal failure was reported for 18 (2%) patients taking candesartan and 13 (1%) allocated placebo.

INTERPRETATION

There was no indication that careful blood-pressure lowering treatment with the angiotensin-receptor blocker candesartan is beneficial in patients with acute stroke and raised blood pressure. If anything, the evidence suggested a harmful effect.

FUNDING

South-Eastern Norway Regional Health Authority; Oslo University Hospital Ullevål; AstraZeneca; Takeda.

The Causative Classification of Stroke system: an international reliability and optimization study

BACKGROUND

Valid and reliable ischemic stroke subtype determination is crucial for well-powered multicenter studies. The Causative Classification of Stroke System (CCS, available at http://ccs.mgh.harvard.edu) is a computerized, evidence-based algorithm that provides both causative and phenotypic stroke subtypes in a rule-based manner. We determined whether CCS demonstrates high interrater reliability in order to be useful for international multicenter studies.

METHODS

Twenty members of the International Stroke Genetics Consortium from 13 centers in 8 countries, who were not involved in the design and development of the CCS, independently assessed the same 50 consecutive patients with acute ischemic stroke through reviews of abstracted case summaries. Agreement among ratings was measured by kappa statistic.

RESULTS

The κ value for causative classification was 0.80 (95% confidence interval [CI] 0.78-0.81) for the 5-subtype, 0.79 (95% CI 0.77-0.80) for the 8-subtype, and 0.70 (95% CI 0.69-0.71) for the 16-subtype CCS. Correction of a software-related factor that generated ambiguity improved agreement: κ = 0.81 (95% CI 0.79-0.82) for the 5-subtype, 0.79 (95% CI 0.77-0.80) for the 8-subtype, and 0.79 (95% CI 0.78-0.80) for the 16-subtype CCS. The κ value for phenotypic classification was 0.79 (95% CI 0.77-0.82) for supra-aortic large artery atherosclerosis, 0.95 (95% CI 0.93-0.98) for cardioembolism, 0.88 (95% CI 0.85-0.91) for small artery occlusion, and 0.79 (0.76-0.82) for other uncommon causes.

CONCLUSIONS

CCS allows classification of stroke subtypes by multiple investigators with high reliability, supporting its potential for improving stroke classification in multicenter studies and ensuring accurate means of communication among different researchers, institutions, and eras.

Angiotensin Receptor Blockade in Acute Stroke. the Scandinavian Candesartan Acute Stroke Trial: Rationale, Methods and Design of a Multicentre, Randomised- and Placebo-Controlled Clinical Trial (NCT00120003)

Background

Elevated blood pressure following acute stroke is common, and yet early antihypertensive treatment is controversial. ACCESS suggested a beneficial effect of the angiotensin receptor blocker candesartan in the acute phase of stroke, but these findings need to be confirmed in new, large trials.

Aims and design

The Scandinavian Candesartan Acute Stroke Trial is an international randomised, placebo-controlled, double-blind trial of candesartan in acute stroke. We plan to recruit 2500 patients presenting within 30 h of stroke (ischaemic or haemorrhagic) and with systolic blood pressure ≥ 140 mmHg. The recruited patients are randomly assigned to candesartan or placebo for 7-days (doses increasing from 4 to 16mg once daily). Randomisation is performed centrally via a secure web interface. The follow-up period is 6-months. Patients are included from the following nine North-European countries: Norway, Sweden, Denmark, Belgium, Germany, Poland, Lithuania, Estonia and Finland.

Study outcomes

There are two co-primary effect variables:

Funding

The Scandinavian Candesartan Acute Stroke Trial receives basic funding from Norwegian health authorities. AstraZeneca supplies the trial drugs, and AstraZeneca and Takeda support the trial with limited, unrestricted grants.

Summary

The Scandinavian Candesartan Acute Stroke Trial is the first large trial of angiotensin receptor blockers in patients with elevated blood pressure and acute stroke, and aims to answer whether treatment with angiotensin receptor blockers is beneficial for this indication.

Posterior reversible encephalopathy syndrome: a rare neurological manifestation in Von Hippel-Lindau disease

We report on a 34-year-old woman, who was recently diagnosed with Von Hippel-Lindau disease (VHL), genetically confirmed. At this moment, she presented with an acute history of arterial hypertension, headache, cortical blindness and epilepsy. On the basis of clinical and magnetic resonance imaging (MRI) criteria the diagnosis of a posterior reversible encephalopathy syndrome (PRES) was made. A iodine 123-Labeled metaiodobenzylguanidine (MIBG) scan revealed the presence of bilateral adrenal pheochromocytomas.

The Belgian experience with intravenous thrombolysis for acute ischemic stroke

PURPOSE

We report the Belgian results of the Safe Implementation of Thrombolysis in Stroke - International Stroke Thrombolysis Register (SITS-ISTR). This prospective observational register evaluates the safety and efficacy of intravenous thrombolysis with rtPA (recombinant tissue Plasminogen Activator) for ischemic stroke in routine clinical practice.

METHODS

We compared the baseline characteristics, treatment delay, rate of symptomatic intracerebral hemorrhage and functional outcome at 90 days after treatment between patients enrolled in centres in Belgium and the non-Belgian SITS-registry population. We performed a multivariate analysis to adjust for differences in demographic and baseline characteristics.

RESULTS

743 patients were enrolled in 42 centers in Belgium between December 2002 and December 2007. These patients were older, had more severe stroke were more frequently female and more frequently had hyperlipidemia and atrial fibrillation. The median stroke onset-to-treatment delay was 140 min vs. 145 min. More patients died and were disabled 3 months after the stroke. A slight, non-significant, increase of symptomatic intracerebral hemorrhage (SICH) as per SITS protocol was observed (2.4 vs. 1.6%, p = 0.15). After adjustment for differences in baseline characteristics, functional independence (mRS < or = 2) at 3 months (OR 0.95, 95% CI 0.86-1.05, p = 0.31) was not different from non-Belgian patients, nor was the rate of SICH. However mortality at 3 months in Belgian patients was slightly higher (OR 1.15, 95% CI 1.02-1.29, p = 0.02).

CONCLUSION

Intravenous thrombolysis for ischemic stroke is safe and effective in the routine clinical use in Belgium. The higher mortality we observed is not related to a higher rate of SICH.

Belgian Fabry study: prevalence of Fabry disease in a cohort of 1000 young patients with cerebrovascular disease

BACKGROUND AND PURPOSE

Data on the prevalence of Fabry disease in patients with central nervous system pathology are limited and controversial. In this study, we assessed the prevalence of Fabry disease in young patients presenting with cerebrovascular disease in Belgium.

METHODS

In this national, prospective, multicenter study, we screened for Fabry disease in 1000 patients presenting with ischemic stroke, transient ischemic attack, or intracranial hemorrhage; unexplained white matter lesions; or vertebrobasilar dolichoectasia. In male patients, we measured alpha-galactosidase A (alpha-GAL A) activity in dried blood spots. Female patients were screened for mutations by exonic DNA sequencing of the alpha-GAL A gene.

RESULTS

alpha-GAL A activity was deficient in 19 men (3.5%), although all had normal alpha-GAL A gene sequences. Enzymatic deficiency was confirmed on repeat assessment in 2 male patients (0.4%). We identified missense mutations in 8 unrelated female patients (1.8%): Asp313Tyr (n=5), Ala143Thr (n=2), and Ser126Gly (n=1). The pathogenicity of the 2 former missense mutations is controversial. Ser126Gly is a novel mutation that can be linked to late-onset Fabry disease.

CONCLUSIONS

alpha-GAL A deficiency may play a role in up to 1% of young patients presenting with cerebrovascular disease. These findings suggest that atypical variants of Fabry disease with late-onset cerebrovascular disease exist, although the clinical relevance is unclear in all cases.

Organisation of inhospital acute stroke care and minimum criteria for stroke care units. Recommendations of the Belgian Stroke Council

There is ample evidence from randomized trials that for patients with stroke, stroke unit care is superior to care in general medical or neurological wards. This evidence, which has been adopted by international guidelines has to be implemented into daily stroke care. This consensus document prepared by the Belgian Stroke Council provides a set of minimum criteria to meet international standards for stroke care. It is intended to provide help in the creation of stroke units in centers who do not currently have one and to provide a benchmark for centres already having organised stroke care.