Cerebral and extracerebral vasoreactivity in symptomatic lacunar stroke patients: a case-control study

BACKGROUND

Whether cerebral artery endothelial dysfunction is a key factor of symptomatic lacunar stroke and cerebral small vessel disease remains unclear.

METHODS

Cerebral and extracerebral vasoreactivity were measured in 81 patients with recent symptomatic lacunar stroke and in 81 control subjects matched for main vascular risk factors. Cerebral vasoreactivity and carotid endothelial-dependent vasodilation were measured after five-minutes of carbon dioxide-induced hypercapnia. Brachial endothelial-dependent vasodilation was assessed after hyperemia induced by deflating a cuff around the forearm previously inflated to 200 mmHg for four-minutes. Carotid and brachial endothelial-independent vasodilation were measured five-minutes after administration of sublingual nitroglycerin 300 μg. Brain magnetic resonance imaging were analyzed in lacunar stroke patients.

RESULTS

One-month after stroke onset, patients had more severely impaired cerebral vasoreactivitys than matched controls (mean ± standard deviation, 14·4 ± 12·1% vs. 19·4 ± 17·4%; P = 0·049). Severe alterations of both carotid and brachial endothelial-dependent and at a lesser degree of carotid and brachial endothelial-independent vasodilation were observed in both groups. After adjustment for confounders, subjects with a cerebral vasoreactivity value in the two lower tertiles (≤19·6%) were more likely to have had a symptomatic lacunar stroke (adjusted odds ratio, 3·78; 95% confidence interval, 1·42 to 10·08; P = 0·008). Only alteration of brachial endothelial-independent vasodilation correlated with parenchymal abnormalities, namely microbleeds and leukoaraiosis.

CONCLUSIONS

While abnormalities in extracerebral vasoreactivity seem related to vascular risk factors, the severity of endothelial dysfunction in cerebral arteries may be determinant in the occurrence of symptomatic lacunar stroke in patients with small vessel disease.

Abstract 2365: Impact of Socioeconomic Level on Cardiovascular Risk in Ischemic Stroke Patients: The OPTIC Registry

Background : The impact of socioeconomic factors (SEF) on the risk of future vascular events in stroke patients has been understudied. The Outcomes in Patients with TIA and Cerebrovascular disease (OPTIC) registry included patients in secondary prevention of stroke.

Objective : to stratify the risk of vascular event recurrence in patients with cerebral infarction according to presence of PAD, ankle-brachial index (ABI), known coronary artery disease (CAD), involvement of several arterial beds, geographic variations and SEF.

Method : Between January 2007 and December 2008, 3635 patients aged 45 years or older were enrolled in the OPTIC registry from 245 sites in 17 countries in the following regions: Latin America (1543 patients), Middle East (1041 patients), North Africa (834 patients), and South Africa (217 patients). PAD was present in 7.8%, ABI in 22%, CAD in 12.8%, and 31.1% were unemployed, 26.2% had less than 2 school years, 23% of patients had no health insurance, 12.8% lived in rural area, 8.4% lived alone, 7.5% did not live in a house/flat. Primary endpoint included vascular death (VD), myocardial infarction (MI) and stroke.

Results : During median follow-up of 731 days, 524 patients had at least 1 primary event; 190 patients had VD, 88 nonfatal MI, and 296 nonfatal stroke. The estimated risk of primary endpoint was 15.6% (95%CI, 14.4-17.0%) at 2-year. The risk increased with the number of vascular beds involved from 13.1% to 30.7% (p for trend<0.001). Using patients from Latin America as reference, age-sex-adjusted HR was 1.29 (95%CI, 1.04-1.60) for Middle East, 1.31 (95%CI, 0.90-1.89) for South Africa, and 1.64 (95%CI, 1.32-2.04) for North Africa. The absolute additional risk of having a primary endpoint ranged between, 4.7% for unemployed patients to 17.5% for patients not living in a house/flat. In multivariate analysis, living in rural area, not living in a house/flat, unemployment status, no health insurance cover, and less than 2-years school were associated with an increased cardiovascular risk (all adjusted p<0.004). There was a stepwise increase in the primary endpoint with the number of low SEF ranging from 13% to 62% (adjusted p-value for trend<0.001).

Conclusions : vascular risk in stroke patients in North and South Africa, Middle East and Latin America varies not only with the number of arterial beds involved but also with socio-economic variables, particularly poor health insurance cover, not living in a house/flat and low education level

Atherogenic dyslipidemia in patients with transient ischemic attack

BACKGROUND AND PURPOSE

There is mounting evidence that atherogenic dyslipidemia (ie, low high-density lipoprotein cholesterol combined with high triglyceride concentrations) is an independent predictor of high cardiovascular risk and possibly of stroke.

METHODS

All patients included in the SOS-TIA cohort underwent an initial standardized evaluation, including medical history, physical examination, routine blood biochemistry, and diagnostic testing, and were followed for 1 year. Lipid profile was evaluated under fasting conditions. Atherogenic dyslipidemia was defined as high-density lipoprotein cholesterol blood concentration ≤ 40 mg/dL and triglycerides ≥ 150 mg/dL.

RESULTS

Among 1471 consecutive patients with transient ischemic attack (TIA) or minor stroke, overall prevalence of atherogenic dyslipidemia was 5.8%, but varied from 4.6% to 11.1%, depending on final diagnosis (possible TIA or TIA with a cerebral ischemic lesion, respectively). Prevalence of atherogenic dyslipidemia was independently associated with male sex, diabetes, and body mass index, but not with ABCD2 score. Atherogenic dyslipidemia also strongly associated with symptomatic intracranial stenosis ≥ 50% (adjusted odds ratio, 2.77; 95% CI, 1.38-5.55), but not with symptomatic extracranial stenosis ≥ 50% (adjusted odds ratio, 1.20; 95% CI, 0.64-2.26). Despite appropriate secondary prevention treatment, 90-day stroke risk was greater in patients with versus without atherogenic dyslipidemia (4.8% versus 1.7%; P=0.04).

CONCLUSIONS

The atherogenic dyslipidemia phenotype in patients with TIA may be associated with intracranial artery stenosis and higher risk of early recurrent stroke. Additional data are needed to confirm these findings and to assess the best way to reduce important residual risk in such patients.

Impact of a combined intravenous/intra-arterial approach in octogenarians

BACKGROUND

Intravenous (IV) alteplase is not currently recommended in octogenarian patients, and the benefit/risk ratio of endovascular (intra-arterial, IA) therapy remains to be determined. The aim of this study was to determine the impact of a combined IV-IA approach in octogenarians.

METHODS

From a single-centre interventional study, we report age-specific outcomes of patients treated by a combined IV-IA thrombolytic approach. Patients ≥80 years with documented arterial occlusion treated by conventional IV thrombolysis constituted the control group.

RESULTS

Among 84 patients treated by the IV-IA approach, those ≥80 years (n = 25) had a similar rate of early neurological improvement to that of patients <80 years, whereas the 90-day favourable outcome rate was lower in octogenarians (adjusted odds ratio, OR, 0.21; 95% confidence interval, CI, 0.06-0.75). No difference in symptomatic intracranial haemorrhage was observed whereas a higher rate of 90-day mortality (adjusted OR, 3.27; 95% CI, 0.76-14.14) and asymptomatic intracranial haemorrhage (adjusted OR, 6.39; 95% CI, 1.54-26.63) were found in patients ≥80 years old. Among octogenarians, and compared to IV-thrombolysis-treated patients (n = 24), patients treated by the IV-IA approach had a higher rate of recanalization (76 vs. 33%, p = 0.003) associated with increased early neurological improvement (32 vs. 8%, p = 0.07). Although there was a higher rate of asymptomatic intracranial haemorrhage (44 vs. 8%, p = 0.005) observed in the IV-IA group, no difference existed in symptomatic intracranial haemorrhage rates and 90-day favourable outcome.

CONCLUSION

The IV-IA approach in octogenarians was associated with lower efficacy at 3 months and higher mortality and asymptomatic haemorrhagic complications than in patients <80 years old. Definite recommendations cannot be given, but an endovascular approach may cause more harm than positive effects in patients over 80 years and should not be considered outside an approved protocol.

Outcomes of mechanical endovascular therapy for acute ischemic stroke: a clinical registry study and systematic review

BACKGROUND AND PURPOSE

Recanalization is a powerful predictor of stroke outcome in patients with arterial occlusion. Intravenous recombinant tissue plasminogen activator is limited by its recanalization rate, which may be improved with mechanical endovascular therapy (MET). However, the benefit and safety of MET remain to be determined. The aim of this study was to give reliable estimates of efficacy and safety outcomes of MET.

METHODS

We analyzed data from our prospective clinical registry and conducted a systematic review of all previous studies using MET published between January 1966 and November 2009.

RESULTS

From April 2007 to November 2009, 47 patients with acute stroke were treated with MET at Bichat Hospital. The literature search identified 31 previous studies involving a total of 1066 subjects. In the meta-analysis, including our registry data, the overall recanalization rate was 79% (95% CI, 73-84). Meta-analysis of clinical outcomes showed a pooled estimate of 40% (95% CI, 34-46; 27 studies) for favorable outcome, 28% (95% CI, 23-33; 28 studies) for mortality, and 8% (95% CI, 6-10; 27 studies) for symptomatic intracranial hemorrhage. The likelihood of a favorable outcome increased with the use of thrombolysis (OR, 1.99; 95% CI, 1.23-3.22) and with proportion of patients with isolated middle cerebral artery occlusion (OR per 10% increase, 1.14; 95% CI, 1.04-1.25).

CONCLUSIONS

MET is associated with acceptable safety and efficacy in stroke patients, and it may be a therapeutic option in those presenting with isolated middle cerebral artery occlusion.

Yield of systematic transcranial Doppler in patients with transient ischemic attack

OBJECTIVE

Urgent evaluation and treatment of transient ischemic attack (TIA) patients in a dedicated TIA clinic may reduce the 90-day stroke risk by 80%. ABCD2 (Age, Blood pressure, Clinical features, Duration, Diabetes) score and magnetic resonance imaging abnormalities help to identify patients at high risk of stroke. Our aim was to determine whether the use of transcranial Doppler (TCD) examination on arrival at the TIA clinic yields additional information that facilitates the identification of patients at high risk of stroke recurrence.

METHODS

Between January 2003 and December 2007, 1,881 patients were admitted to SOS-TIA clinic (a TIA clinic with around-the-clock access). Clinical and vascular assessment included TCD performed by a neurologist immediately after admission. Stroke prevention measures were initiated on arrival, in accordance with guidelines. All patients were followed for 1 year after presentation to the SOS-TIA clinic.

RESULTS

A total of 1,823 TCD examinations were performed within 4 hours of admission. Intracranial narrowing or occlusion was found in 8.8% of patients, and was independently associated with age, hypertension, and diabetes. After 1-year follow-up on best preventive therapy, the incidence of recurrent vascular events (intracranial revascularization for TIA recurrence, stroke, myocardial infarction, and vascular death combined) was 7.0% in patients with intracranial narrowing or occlusion and 2.4% in those without (log-rank, p = 0.007). The hazard ratio of combined outcome for the presence of intracranial narrowing or occlusion was 2.29 (95% confidence interval [CI], 1.15-4.56; p = 0.02) in multivariate analysis including age, gender, hypertension, and diabetes, and was 2.50 (95%CI, 1.24-5.05; p = 0.01) in multivariate analysis including ABCD2 score > or =4.

INTERPRETATION

Immediate TCD examination on arrival at the TIA clinic is feasible and could help to identify patients at high risk of vascular events recurrence. This study supports a systematic intracranial vascular examination in the initial management of TIA.

Prevalence of subdiaphragmatic visceral infarction in cardioembolic stroke

BACKGROUND

A substantial proportion of ischemic strokes have an embolic mechanism, but the source of embolism is not detected. Coexistence of subdiaphragmatic visceral infarction (SDVI; e.g., renal, splenic, hepatic, bowel infarction) may be a suggestion of a common source of embolism. One large autopsy study found SDVI in 21.5% of patients with fatal stroke.

METHOD

We performed diffusion-weighted magnetic resonance abdominal imaging and subsequently performed it in consecutive patients with stroke or TIA and a history of nonvalvular atrial fibrillation.

RESULTS

Among 27 patients, 6 had SDVI (3 recent renal, 1 recent splenic, and 3 old splenic infarction). The median time between onset of ischemic stroke and abdominal MRI was 8 days (interquartile range 3-15 days). No predictive factor of SDVI was found in this study population with respect to demographic or ultrasound characteristics.

CONCLUSIONS

One in 5 patients with nonfatal cardioembolic stroke or TIA may be associated with subdiaphragmatic visceral infarction (SDVI). Further study should evaluate the frequency of SDVI in patients with stroke of unknown cause.

Comparison of intravenous alteplase with a combined intravenous-endovascular approach in patients with stroke and confirmed arterial occlusion (RECANALISE study): a prospective cohort study

BACKGROUND

The efficacy of intravenous (IV) alteplase is restricted by the speed of recanalisation and the site of the occlusion. The aim of this study was to ascertain the effect of a combined IV-endovascular approach (intra-arterial alteplase and, if required, additional thrombectomy) in patients with stroke due to arterial occlusion.

METHODS

We compared recanalisation rates, neurological improvement at 24 h, and functional outcome at 3 months between two periods (February, 2002, to March, 2007, vs April, 2007, to October, 2008) in patients in a prospective registry who were treated with different regimens of alteplase within 3 h of symptom onset. Patients with confirmed occlusion who were treated before April, 2007, were treated with IV alteplase; after April, 2007, patients were treated with a systematic IV-endovascular approach. Analysis was by intention to treat.

FINDINGS

46 (87%) of 53 patients treated with the IV-endovascular approach achieved recanalisation versus 56 (52%) of 107 patients in the IV group (adjusted relative risk [RR] 1.49, 95% CI 1.21-1.84; p=0.0002). Early neurological improvement (NIHSS score of 0 or 1 or an improvement of 4 points or more at 24 h) occurred in 32 (60%) patients in the IV-endovascular group and 42 (39%) patients in the IV group (adjusted RR 1.36, 0.97-1.91; p=0.07). Favourable outcome (mRS of 0-2 at 90 days) occurred in 30 (57%) patients in the IV-endovascular group and 47 (44%) patients in the IV group (adjusted RR 1.16, 0.85-1.58; p=0.35). The mortality rate at 90 days was 17% in both groups, and symptomatic intracranial haemorrhage was reported in five (9%) patients in the IV-endovascular group and in 12 (11%) patients in the IV group. Better clinical outcome was associated with recanalisation in both groups and with time to recanalisation in the IV-endovascular group.

INTERPRETATION

An IV-endovascular approach is associated with higher recanalisation rates than is IV alteplase in patients with stroke and confirmed arterial occlusion. In patients treated with an IV-endovascular approach, a shorter time from symptom onset to recanalisation is associated with better clinical outcomes.

Outcomes of Intravenous Recombinant Tissue Plasminogen Activator Therapy According to Gender

Background and Purpose— The natural history of stroke is worse in women than in men. Controversial data have been published on the efficacy of thrombolysis with recombinant tissue plasminogen activator (rtPA) according to gender. We evaluated gender differences in the efficacy and safety outcomes of intravenous rtPA using a clinical registry and systematic review.

Methods— Since January 2002, we collected baseline characteristics and efficacy and safety outcomes for patients who received intravenous rtPA in our center. We performed a systematic PubMed literature search for previous observational studies that examined gender effects on outcomes after intravenous rtPA treatment.

Results— No gender difference in good outcome at 3 months (adjusted OR for women, 1.41; 95% CI, 0.76 to 2.60) and in 90-day mortality (adjusted OR, 1.38; 95% CI, 0.59 to 3.19) was found in our registry. We identified 16 studies that evaluated the gender effect among intravenous rtPA-treated patients. None of these studies supported a gender difference in favorable outcome, and one suggested an increased risk of mortality in men. In unadjusted partial meta-analysis in 4074 women and 5840 men including our registry data, we found a trend toward a lower risk of symptomatic intracranial hemorrhage in women (crude OR, 0.87; 95% CI, 0.68 to 1.10).

Conclusions— These results suggest no gender difference in outcome among patients treated with intravenous rtPA.

Prevalence of nephroangiosclerosis in patients with fatal stroke

BACKGROUND

Glomerular filtration rate and decline in renal function can be improved by global cardiovascular prevention. However, the prevalence of nephroangiosclerosis in patients with stroke is unknown.

METHODS

Using an autopsy data bank, we studied the prevalence of nephroangiosclerosis in 820 consecutive autopsies of neurologic patients.

RESULTS

Among the 820 autopsies, 354 had pathologic evidence of stroke and 466 had other neurologic diseases. Nephroangiosclerosis was found in 39.8% (95% confidence interval [CI], 34.7-44.9) of patients with stroke vs 9.0% (95% CI, 6.4-11.6) in patients with other neurologic diseases. The odds ratio (OR) for nephroangiosclerosis, adjusted for age and sex, was 4.37 (95% CI, 2.92-6.52), and was 2.94 (95% CI, 1.83-4.74) after further adjustment for cardiovascular risk factors. Among the 354 stroke patients, the prevalence of nephroangiosclerosis was similar in patients with brain infarction and in those with brain hemorrhage, in patients with or without parenchymal abnormalities related to small-vessel disease, and across ischemic stroke subtypes except for those with coexisting causes. After multivariable analysis, nephroangiosclerosis was independently associated with age and history of hypertension in patients with stroke, and with age in those with other neurologic diseases.

CONCLUSIONS

Nephroangiosclerosis is common in patients with fatal stroke. The association is independent of age, sex, and other cardiovascular risk factors. Impaired renal function should be monitored and prevented in stroke patients with high blood pressure.

Acute blindness

A 15-year-old man presenting with cortical blindness as the initial symptom of mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) is reported. He showed fluctuating consciousness and severe occipital headache with nausea and vomiting. T2 and diffusion-weighted magnetic resonance imaging showed high signal intensity in the occipital lobes. Electroencephalography showed diffuse sharp waves with focal epileptic discharges over the posterior region. The nature of stroke-like episodes and seizure mechanisms is unexplained in MELAS. Consequently, the possible mechanisms of the cortical blindness in this case are discussed.

PDGF up-regulates CSF-1 gene transcription in ameloblast-like cells

Macrophage colony-stimulating factor (CSF-1) is a key regulatory cytokine for amelogenesis, and ameloblasts synthesize CSF-1. We hypothesized that PDGF stimulates DNA synthesis and regulates CSF-1 in these cells. We determined the effect of PDGF on CSF-1 expression using MEOE-3M ameloblasts as a model. By RT-PCR, MEOE-3M expressed PDGFRs and PDGF A- and B-chain mRNAs. PDGF-BB increased DNA synthesis and up-regulated CSF-1 mRNA and protein in MEOE-3M. Cells transfected with CSF-1 promoter deletion constructs were analyzed. A PDGF-responsive region between -1.7 and -0.795 kb, containing a consensus Pea3 binding motif, was identified. Electrophoretic mobility shift assay (EMSA) showed that PDGF-BB stimulated protein binding to this motif that was inhibited in the presence of anti-Pea3 antibody. Analysis of these data provides the first evidence that PDGF-BB is a mitogen for MEOE-3M and increases CSF-1 protein levels, predominantly by transcription. Elucidation of the cellular pathways that control CSF-1 expression may provide novel strategies for the regulation of enamel matrix formation.

A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects

BACKGROUND

Diagnosis and treatment of cerebral and retinal transient ischaemic attacks (TIAs) are often delayed by the lack of immediate access to a dedicated TIA clinic. We evaluated the effects of rapid assessment of patients with TIA on clinical decision making, length of hospital stay, and subsequent stroke rates.

METHODS

We set up SOS-TIA, a hospital clinic with 24-h access. Patients were admitted if they had sudden retinal or cerebral focal symptoms judged to relate to ischaemia and if they made a total recovery. Assessment, which included neurological, arterial, and cardiac imaging, was within 4 h of admission. A leaflet about TIA with a toll-free telephone number for SOS-TIA was sent to 15 000 family doctors, cardiologists, neurologists, and ophthalmologists in Paris and its administrative region. Endpoints were stroke within 90 days, and stroke, myocardial infarction, and vascular death within 1 year.

FINDINGS

Between January, 2003, and December, 2005, we admitted 1085 patients with suspected TIA; 574 (53%) were seen within 24 h of symptom onset. 701 (65%) patients had confirmed TIA or minor stroke, and 144 (13%) had possible TIA. 108 (17%) of the 643 patients with confirmed TIA had brain tissue damage. Median duration of symptoms was 15 min (IQR 5-75 min). Of the patients with confirmed or possible TIA, all started a stroke prevention programme, 43 (5%) had urgent carotid revascularisation, and 44 (5%) were treated for atrial fibrillation with anticoagulants. 808 (74%) of all patients seen were sent home on the same day. The 90-day stroke rate was 1.24% (95% CI 0.72-2.12), whereas the rate predicted from ABCD(2) scores was 5.96%.

INTERPRETATION

Use of TIA clinics with 24-h access and immediate initiation of preventive treatment might greatly reduce length of hospital stay and risk of stroke compared with expected risk.

Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion

BACKGROUND AND PURPOSE

Tandem internal carotid and middle cerebral artery occlusion independently predicts poor outcome after intravenous thrombolysis. Recanalization of internal carotid artery dissection by stent-assisted angioplasty has recently been proposed when anticoagulation fails to prevent a new ischemic event. We recently reported a case of tandem internal carotid and middle cerebral artery occlusion with dissection of the internal carotid artery successfully treated with endovascular stent-assisted thrombolysis.

METHODS

We compared clinical outcomes in consecutive patients presenting with tandem internal carotid and middle cerebral artery occlusion with internal carotid artery dissection within 3 hours of symptom onset who were eligible for intravenous thrombolysis, treated by either endovascular stent-assisted thrombolysis or intravenous recombinant tissue-type plasminogen activator (rtPA) when an endovascular therapist was unavailable. National Institutes of Health Stroke Scale scores were obtained at baseline and after 24 hours. The modified Rankin Scale score was used to assess outcomes at 3 months. Arterial recanalization was assessed by magnetic resonance imaging.

RESULTS

Of 10 patients screened, 6 were treated with endovascular therapy and 4 with intravenous rtPA. Before treatment, mean National Institutes of Health Stroke Scale scores were high and comparable in the 2 groups (17 and 16, respectively). In the endovascular group, all patients achieved middle cerebral artery recanalization with subsequent dramatic improvement versus only 1 patient with middle cerebral artery recanalization in the intravenous rtPA group. At 3 months, 4 patients in the endovascular group had a favorable outcome (modified Rankin Scale score=0). In the intravenous rtPA group, 3 patients had a poor outcome (modified Rankin Scale score> or =3).

CONCLUSIONS

Endovascular stent-assisted thrombolysis is a promising treatment in tandem internal carotid and middle cerebral artery occlusion due to internal carotid artery dissection and compares favorably with intravenous rtPA.

Prevalence and determinants of subdiaphragmatic visceral infarction in patients with fatal stroke

BACKGROUND AND PURPOSE

Arterial thromboembolism is a common cause of both visceral and brain infarctions. Because the cause of brain infarction is unknown in up to 39% of patients, the discovery of subdiaphragmatic visceral infarction (SDVI) in this context is important, but its frequency is unknown. We therefore investigated the prevalence of SDVI in subjects who died from stroke. We also evaluated the yield of SDVI diagnosis for stroke subtyping.

METHODS

We performed a case-control study using a series of 815 consecutive autopsies of patients who had died from a neurological disease, including 350 with stroke (260 infarcts and 90 hemorrhages). We systematically assessed the presence of renal, splenic, and mesenteric infarction (no case of spinal cord was recorded) and analyzed their determinants in patients with stroke. Patients with other neurological diseases served as the control group.

RESULTS

Renal infarction was the most frequent SDVI (10.2%), whereas mesenteric infarction was rare (1.1%). At least one SDVI was found in 16.9% of patients with stroke (38.7% of patients with a cardioembolic stroke) and in 5.1% of patients with other neurological diseases (adjusted OR=2.12; 95% CI=1.08 to 4.16). Among patients with stroke, a significant heterogeneity in the prevalence of SDVI was found across etiological stroke subgroups with only three patients (3.3%) with hemorrhagic stroke having an SDVI (2 mesenteric and one renal infarction) compared with 56 patients (21.5%) with ischemic stroke (P<0.0001). Among patients with brain infarction and a SDVI, 76.8% had a definite cardiac source of embolism.

CONCLUSIONS

In patients with fatal brain infarction, the prevalence of SDVI is higher than previously thought, especially in those with stroke attributed to cardiac emboli. Seeking SDVI may assist in the etiologic diagnosis of brain infarction.

Ischemia-modified albumin in acute stroke

BACKGROUND

Ischemia-modified albumin (IMA)is a new biological marker of ischemia. Previous studies have found increased serum IMA levels after myocardial ischemia, but no study has investigated the possibility that stroke modifies IMA blood levels.

MATERIALS AND METHODS

We studied 118 consecutive patients presenting within 3 h of the onset of an acute neurological deficit [84 brain infarctions (BI), 18 brain hemorrhages (ICH) and 16 transient ischemic attacks lasting less than 1 h or epileptic seizures]. Serum samples were obtained for all patients at initial presentation and repeated only in patients with stroke at 6, 12 and 24 h. IMA was measured by the albumin-cobalt-binding test (Ischemia Technologies, Denver, Colo., USA).

RESULTS

The initial median IMA (bootstrap 95% confidence interval, CI) was 83 U/ml (79-86) and 86 U/ml (75-90) in patients with BI and ICH, respectively (p = 0.76), and was 73 U/ml (58-79) in others (p = 0.003 compared with BI, and p = 0.017 with ICH). Baseline IMA levels correlated with the National Institutes of Health Stroke Scale [Spearman correlation coefficient: 0.34 (p = 0.002) in BI, 0.61 (p = 0.008) in ICH]. During the first 24 h, IMA levels increased in BI patients (median, 9.1%; bootstrap 95% CI, 5.2-11.5), whereas no change was observed in ICH patients (median, 1.2%; bootstrap 95% CI, -7.8 to 6.8).

CONCLUSIONS

IMA blood levels may be a biomarker for early identification of acute stroke. Further studies are required to investigate the role of IMA in the early detection of acute stroke.

Percutaneous Patent Foramen Ovale (PFO) closure in young patients with both cryptogenic brain infarction and PFO associated with Atrial Septal Aneurysm (ASA)

BACKGROUND

To assess the safety and efficacy of percutaneous patent foramen ovale (PFO) closure for the prevention of recurrent stroke in high-risk patients.

METHODS AND RESULTS

Between January 2002 and March 2005, 40 patients (65% female), mean (SD) age 43 (10) years were identified using the following inclusion criteria: <60 years, recent brain infarction (<3 months), combination of PFO plus atrial septal aneurysm (ASA) and exclusion of any other thromboembolic cause. Percutaneous PFO closure was performed under general anaesthesia and under the guidance of transoesophageal echocardiography (TEE). Aspirin and clopidogrel were given for three months after PFO closure, followed by aspirin alone. Neurological examination was performed every three months.

RESULTS

PFO closure was successful in all patients, using all devices: INTRASEPT in 34 cases, STARFlex in 5 cases and AMPLATZER in one case. At day one, transthoracic echocardiography (TTE) excluded malpositioning of the device or pericardial effusion. At 6 months, TTE and TEE confirmed satisfactory implantation of the device, with no spontaneous shunt. No device related thrombi was observed. Mean patient follow-up was 17+/-7 months (range 12-38) and was 100% complete. No patients suffered from recurrent stroke (neither transient ischaemic attack nor brain infarction).

CONCLUSION

This preliminary experience is encouraging for PFO closure with a 0% risk of stroke recurrence rate in a high-risk subset of patients (< 60 years, recent cryptogenic stroke, PFO plus ASA) and is safe using the current technology. Larger series with longer follow-up and randomised studies are still necessary in this setting before the completion of guidelines.

Insular involvement in brain infarction increases risk for cardiac arrhythmia and death

OBJECTIVE

Brain injuries may induce cardiac dysrhythmias and sudden cardiac death.

METHODS

We analyzed 12-lead electrocardiograms of 493 consecutive patients with brain infarction (BI) proved by an magnetic resonance imaging and 493 control subjects matched for age, sex, and center. Insular involvement (insula (+/-)) was assessed by two independent readings of the magnetic resonance imaging scans. Cases were followed for 5 years.

RESULTS

Acute BI was independently associated with heart rate (< or = 64 beats/min), abnormal repolarization, atrial fibrillation, and ventricular and supraventricular ectopic beats. Lower heart rate in BI patients was due to an interaction with smoking (p for interaction = 0.004). Insula(+) group was significantly associated with abnormal repolarization with no interaction with infarct side. Atrial fibrillation by history was also more frequent in the insula(+) than in the insula(-) group (p = 0.07). After adjustment for age, sex, cardiovascular history, and handicap at admission, right insula(+) BI was significantly associated with 2-year all-cause death (hazard ratio, 2.11; 95% confidence interval, 1.27-3.52) and with vascular death (hazard ratio, 2.00; 95% confidence interval, 1.00-3.93). In multivariate analysis including age, sex, cardiovascular history, handicap at admission, and lesion side, increased QTc interval and left bundle branch block were independent predictors of all-cause and vascular mortality at 2 years in right insula(+) patients.

INTERPRETATION

These findings support the notion that right insular involvement may lead to electrocardiographic abnormalities with potential prognostic implications. This could be important for optimal care in patients with right insular infarct.

High blood pressure in early acute stroke: a sign of a poor outcome?

OBJECTIVE

To evaluate the prognostic value of admission blood pressure in patients with acute ischemic stroke by determining whether it contributes to clinical outcome and vascular death.

METHODS

We studied 230 consecutive patients admitted within the first 24 h after the onset of ischemic stroke. We used the first systolic and diastolic blood pressure measurements recorded on admission. The functional outcome was assessed on the basis of mortality or dependency (Rankin Scale > 3) at the 10-day and 6-month visits.

RESULTS

High systolic blood pressure on admission was associated with poor outcome at the 10-day and 6-month visits, independent of the baseline risk factors but not of the severity of the initial stroke (odds ratio, 1.39; 95% confidence interval, 0.50-3.87). The spontaneous decrease in systolic blood pressure within the first 10 days was higher in patients with functional improvement. The admission blood pressure was not significantly associated with total and vascular deaths, except for a threshold effect of diastolic blood pressure.

CONCLUSIONS

After an acute stroke, the relationship between blood pressure and clinical outcome depended on the severity of the stroke on presentation, and on the level and trend of the systolic blood pressure during the first 24 h.

[Thrombolysis and acute cerebral infarction]

Thrombolytic therapy are the most important advance in the management of acute ischemic stroke and has been evaluated in several randomised trials. Thrombolysis with recombinant tissue plasminogen activator (rt-Pa) is effective within 3 h of onset of ischemic stroke and this efficacy is similar between different stroke subtypes. New trials will determine if extension of this time-window can be substantiated. Therapy beyond the 3-hour window, with intra-arterial thrombolysis, appears to improve outcome but are applicable to selected group of patients. Thrombolytic drugs can also carry an important risk (5 % to 10 %) of brain hemorrhage and edema that can prove fatal. The risk of symptomatic intracranial hemorrhage is directly proportional to stroke severity and inversely proportional to time to treatment. There is a growing interest in the use of MRI in acute ischemic stroke. It helps identify location of early cerebral ischemia and provides valuable information not only of the penumbra but also of vessel occlusion. Its use might help in selecting patients who will benefit most from treatment such as thrombolysis. In spite of these results, community use of thrombolytic therapy remains dismally low. Many physicians and medical centers are not presently equipped or willing to give thrombolytic drugs for stroke treatment. Increasing stroke awareness in the community, creating stroke unit and physicians education are necessary to extend the effective use of acute treatment in cerebral infarct to a larger group of patients.