Race-Ethnicity and Cerebral Small Vessel Disease – Comparison between Chinese and White Populations

Background and Aim

Studies in stroke patients suggest that lacunar stroke and intracerebral hemorrhage might be more common in Chinese than Whites. We hypothesized that other manifestations of subclinical cerebral small vessel disease, namely white matter hyperintensities (WMH), lacunes, and microbleeds, are also more common in Chinese than Whites. We compared the community prevalence of these lesions between Han Chinese and White Australians.

Methods

Magnetic resonance imaging (1·5-Tesla) was performed on participants of the Shanghai Aging Study ( n = 321, mean age 69 ± 6 years) and Tasmanian Study of Cognition and Gait ( n = 397, mean age 72 ± 7 years). A single-rater recorded measures of WMH, lacunes, and microbleeds. We compared lesion prevalence between age- and gender-matched subgroups from the two cohorts. Among all subjects ( n = 718), we performed multivariable logistic regression to examine if race-ethnicity was independently associated with these lesions.

Results

Among age- and gender-matched subjects, confluent WMH were significantly more prevalent in Chinese (38·5%) than Whites (28·4%; P = 0·01). There was no difference in the prevalence of lacunes (Chinese 29·1% vs. Whites 29·5%, P = 0·93) and microbleeds (Chinese 10·1% vs. 9·0%, P = 0·67) between Chinese and Whites. In multivariable logistic regression, Chinese ethnicity was associated with confluent WMH (odds ratio 1·7, 95% confidence interval 1·1–2·6, P = 0·01), but no differences were seen for lacunes and microbleeds. The association between Chinese ethnicity with confluent WMH became insignificant when subjects with history of stroke were excluded.

Conclusions

In this population-based cross-national comparison, Han Chinese had a higher prevalence of confluent WMH than White Australians, but had a similar prevalence of lacunes and microbleeds.

A novel missense mutation in CCDC88C activates the JNK pathway and causes a dominant form of spinocerebellar ataxia

Background

Spinocerebellar ataxias (SCAs) are a group of clinically and genetically diverse and autosomal-dominant disorders characterised by neurological deficits in the cerebellum. At present, there is no cure for SCAs. Of the different distinct subtypes of autosomal-dominant SCAs identified to date, causative genes for only a fraction of them are currently known. In this study, we investigated the cause of an autosomal-dominant SCA phenotype in a family that exhibits cerebellar ataxia and pontocerebellar atrophy along with a global reduction in brain volume.

Methods and results

Whole-exome analysis revealed a missense mutation c.G1391A (p.R464H) in the coding region of the coiled-coil domain containing 88C (CCDC88C) gene in all affected individuals. Functional studies showed that the mutant form of CCDC88C activates the c-Jun N-terminal kinase (JNK) pathway, induces caspase 3 cleavage and triggers apoptosis.

Conclusions

This study expands our understanding of the cause of autosomal-dominant SCAs, a group of heterogeneous congenital neurological conditions in humans, and unveils a link between the JNK stress pathway and cerebellar atrophy.

Comparative effects of antihypertensive drugs on stroke outcome in China

BACKGROUND

Antihypertensive drugs are useful in the prevention of stroke; however, much debate surrounds which class of agent provides the most benefit post-stroke.

AIMS

The aim of this study was to examine the impact of different classes of antihypertensive agent on stroke outcome using data from the ChinaQUEST study, a prospective, hospital-based stroke registry undertaken across 62 hospitals in China.

METHODS

Logistic regression analysis was used to determine the comparative associations of different antihypertensive medications when initiated in-hospital post-stroke on the following poor outcomes in stroke survivors at three- and 12 months post-stroke: (1) death and dependency, based on modified Rankin Scale scores 3-5; (2) death; and (3) dependency.

RESULTS

Of the 6416 patients with baseline data, 3986 (62%) were on at least one antihypertensive agent. After adjustment for baseline characteristics and concomitant therapies, there were no differences in outcomes between therapies at three- and 12 months, but at 12 months, calcium channel blocker use was associated with reduced risks of death/dependency (odds ratio 0·78, P  = 0·001) and death (odds ratio 0·66, P < 0·001). In addition, angiotensin-converting enzyme inhibitor/angiotensin II receptor antagonist use was associated with reduced risk of death (odds ratio 0·76, P  = 0·009), whereas both beta-blockers and diuretics were shown to increase the risk of death/dependency and death but had no effect on the risk of dependency.

CONCLUSION

This study suggests that early initiation of calcium channel blockers is associated with improved outcome after stroke. Further randomized studies are warranted to confirm these findings and to delineate differential beneficial effects of antihypertensive therapy in stroke prevention.

Evaluation of carotid angioplasty and stenting for radiation-induced carotid stenosis

BACKGROUND AND PURPOSE

We aimed to evaluate the procedural safety, clinical, and angiographic outcome of carotid angioplasty and stenting for high-grade (≥70%) radiation-induced carotid stenosis (RIS) using atherosclerotic stenosis (AS) as a control.

METHODS

In this 6-year prospective nonrandomized study, we compared the carotid angioplasty and stenting outcome of 65 consecutive patients (84 vessels) with RIS with that of a control group of 129 consecutive patients (150 vessels) with AS. Study end points were 30-day periprocedural stroke or death, ipsilateral ischemic stroke, technical success, procedural characteristics, instent restenosis (ISR; ≥50%) and symptomatic ISR.

RESULTS

The median follow-up was 47.3 months (95% confidence interval, 26.9-61.6). Imaging assessment was available in 74 vessels (RIS) and 120 vessels (AS) in 2 years. Comparing RIS group with AS group, the rates of periprocedural stroke or death were 1.5% (1/65) versus 1.6% (2/129; P=1); ipsilateral ischemic stroke rates were 4.6% (3/65) versus 4.7% (6/129; P=1); the annual risks of ipsilateral ischemic stroke were 1.2% (3 patient/254.7 patient year) versus 1.2% (6 patient/494.2 patient year; P=0.89); technical success rates were both 100%. Stenting of common carotid artery and the use of multiple stents was more common in the RIS group (P=0 in both cases); ISR rates were 25.7% (19/74) versus 4.2% (5/120; P<0.001); symptomatic ISR rates were 6.8% (5/74) versus 0.8% (1/120; P=0.031).

CONCLUSIONS

The safety, effectiveness, and technical difficulty of carotid angioplasty and stenting for RIS are comparable with that for AS although it is associated with a higher rate of ISR.

CLINICAL TRIAL REGISTRATION

This trial was not registered as enrollment started in 2006.

Risk factors for incident dementia after stroke and transient ischemic attack

BACKGROUND

We hypothesized that chronic brain changes are important substrates for incident dementia after stroke and transient ischemic attack (TIA).

METHODS

We compared clinical and imaging features between patients with consecutive stroke/TIA with (n = 88) and without (n = 925) incident dementia at 3 to 6 months after a stroke/TIA. Pittsburg compound B (PiB) positron emission tomography was performed in 50 patients, including those with (n = 37) and without (n = 13) incident dementia.

RESULTS

Age, history of diabetes mellitus, severity of white matter changes (WMCs), and medial temporal lobe atrophy (MTLA) were associated with incident dementia. Alzheimer's disease (AD)--like PiB retention was found in 29.7% and 7.7% (P = .032) of patients with and without incident dementia, respectively.

CONCLUSIONS

Chronic brain changes including WMCs, MTLA, and AD pathology are associated with incident dementia after stroke/TIA. Interventions targeting these chronic brain changes may reduce burden of vascular cognitive impairment.

Chinese consensus statement on the evaluation and intervention of collateral circulation for ischemic stroke

Background

Collateral circulation is becoming more significant in the individual management strategy of ischemic stroke, there are more data updated recently.

Aim

To make the further acknowledgment of the evaluation and how to improving collateral flow, for better treatment selection.

Method

A panel of experts on stroke providing related statement based on review the results from most up‐to‐date clinical research.

Results

DSA is the gold standard in evaluating all levels of collaterals. CTA can be used for evaluating leptomeningeal collaterals, MRA for CoW, TCD or TCCS can be used as screening tool for primary evaluation. The treatment modalities include direct interventions, such as Extracranial–Intracranial bypass, and indirect interventions, as External counterpulsation and pressor therapy. The consideration of methodology to augment and improve can be considered on an individual basis.

Discussion

In this consensus, we interpret the definition, neuroimaging evaluation, intervention and potential strategy on collaterals in the future.

Conclusion

Assessment of collateral circulation is crucial for selecting therapeutic options, predicting infarction volume and making prognosis after ischemic stroke. Data is still needed to provide therapeutic evidence for many new developed technologies. Until more evidence is available, the clinical significance of applying the new technologies is unclear and perhaps limited.

Abnormal organization of white matter network in patients with no dementia after ischemic stroke

Structural changes after ischemic stroke could affect information communication extensively in the brain network. It is likely that the defects in the white matter (WM) network play a key role in information interchange. In this study, we used graph theoretical analysis to examine potential organization alteration in the WM network architecture derived from diffusion tensor images from subjects with no dementia and experienced stroke in the past 5.4-14.8 months (N = 47, Mini-Mental Screening Examination, MMSE range 18-30), compared with a normal control group with 44 age and gender-matched healthy volunteers (MMSE range 26-30). Region-wise connectivity was derived from fiber connection density of 90 different cortical and subcortical parcellations across the whole brain. Both normal controls and patients with chronic stroke exhibited efficient small-world properties in their WM structural networks. Compared with normal controls, topological efficiency was basically unaltered in the patients with chronic stroke, as reflected by unchanged local and global clustering coefficient, characteristic path length, and regional efficiency. No significant difference in hub distribution was found between normal control and patient groups. Patients with chronic stroke, however, were found to have reduced betweenness centrality and predominantly located in the orbitofrontal cortex, whereas increased betweenness centrality and vulnerability were observed in parietal-occipital cortex. The National Institutes of Health Stroke Scale (NIHSS) score of patient is correlated with the betweenness centrality of right pallidum and local clustering coefficient of left superior occipital gyrus. Our findings suggest that patients with chronic stroke still exhibit efficient small-world organization and unaltered topological efficiency, with altered topology at orbitofrontal cortex and parietal-occipital cortex in the overall structural network. Findings from this study could help in understanding the mechanism of cognitive impairment and functional compensation occurred in patients with chronic stroke.

Intra-arterial revascularisation therapy for acute ischaemic stroke: initial experience in a Hong Kong hospital

OBJECTIVES

To assess the outcome of acute ischaemic stroke patients who received intra-arterial therapy in our unit.

DESIGN

Case series.

SETTING

A tertiary hospital in Hong Kong.

PATIENTS

Patients with ischaemic stroke due to large artery occlusion treated within 6 hours from symptom onset between January 2007 and May 2011.

INTERVENTION

Acute intra-arterial revascularisation therapy.

MAIN OUTCOME MEASURES

Primary outcome was functional independence (modified Rankin Scale score of ≤ 2) at 3 months. Secondary outcome was rate of recanalisation. Safety outcomes were symptomatic intracranial haemorrhage and 3-month mortality.

RESULTS

Twenty-one patients with a mean age of 67 years fulfilled the inclusion criteria. Their mean National Institutes of Health Stroke Scale score was 18. The mean onset-to-puncture time was 212 minutes. Nine received intra-arterial tissue plasminogen activator alone, 11 had an adjunctive mechanical thrombectomy, and one received balloon angioplasty without tissue plasminogen activator. At the end of the procedure, thrombolysis grade 2a or better was attained in 18 (86%) of the patients, and 8 (38%) achieved functional independence at 3 months. Rates of symptomatic intracranial haemorrhage and 3-month mortality were 10% and 24%, respectively.

CONCLUSION

In this setting, intra-arterial revascularisation therapy appeared safe and efficacious for this selected group of ischaemic stroke patients with large artery occlusions. Experience gained from this pilot study may help improve clinical outcomes of such patients.

CHIMES-I: sub-group analyzes of the effects of NeuroAiD according to baseline brain imaging characteristics among patients randomized in the CHIMES study

RATIONALE

The clinical effects of neuroprotective and/or neurorestorative therapies may vary according to location and size of the ischemic injury. Imaging techniques can be useful in stratifying patients for trials that may be beneficial against particular ischemic lesion characteristics.

AIM

To test the hypothesis that the efficacy of NeuroAiD compared with placebo in improving functional outcome and reducing neurological deficit in patients with cerebral infarction of intermediate severity varies between sub-groups of patients randomized in the main Chinese Medicine Neuroaid Efficacy on Stroke study when categorized according to baseline imaging characteristics.

DESIGN

This is a retrospective cohort sub-group analysis of patients who participated in the main Chinese Medicine Neuroaid Efficacy on Stroke study, a multicenter, double-blind, placebo-controlled trial that recruited 1100 patients within 72 h of ischemic stroke onset with National Institutes of Health Stroke Scale 6-14 and were randomized to either NeuroAiD or placebo taken four capsules three times daily for three months. Review of the baseline images to classify the acute stroke lesions in terms of size, location, and extent of involvement will be performed retrospectively by two readers who will remain blinded as to treatment allocation and outcomes of the subjects.

STUDY OUTCOMES

The primary efficacy end-point in the main Chinese Medicine Neuroaid Efficacy on Stroke study is the modified Rankin Scale grades at three-months. Secondary efficacy end-points are the National Institutes of Health Stroke Scale score at three-months; difference of National Institutes of Health Stroke Scale scores between baseline and 10 days and between baseline and three-months; difference of National Institutes of Health Stroke Scale sub-scores between baseline and 10 days and between baseline and three-months; modified Rankin Scale at 10 days, one-month, and three-months; Barthel index at three-months; and Mini Mental State Examination at 10 days and three-months. Analysis of these primary and secondary end-points will be performed for sub-groups defined in this study after review of the baseline brain imaging: nonlacunar and lacunar, cortical and sub-cortical, hemispheric vs. brainstem, Alberta Stroke Program Early CT score <7 and 7-10, and score <8 and 8-10.

Comprehensive assessment for autonomic dysfunction in different phases after ischemic stroke

BACKGROUND AND PURPOSE

Studies mostly use the analysis of heart rate variability to measure cardiovascular autonomic regulation in ischemic stroke. Besides power spectral analysis of heart rate variability, this study sought to determine whether autonomic function was impaired during different phases in ischemic stroke by Ewing's battery of autonomic function tests.

METHODS

Ninety-four patients with ischemic stroke (34 patients in acute phase and 60 patients in chronic phase, average six-months after stroke onset) and thirty-seven elderly controls were recruited. Ewing's battery autonomic function tests and power spectral analysis of heart rate variability were performed in all the subjects.

RESULTS

From power spectral analysis of heart rate variability, stroke patients of both acute and chronic phases had significantly lower low frequency power spectral density than controls. From Ewing's battery of autonomic function tests, patients in acute phase showed impairment in two parasympathetic tests (Valsalva ratio: P = 0·002; heart rate response to deep breathing: P < 0·001) and those in chronic phase showed impairment in all parasympathetic tests (all P < 0·05) in comparison with controls.

CONCLUSIONS

The comprehensive assessment indicates that autonomic dysfunction occurs in acute phase of ischemic stroke and may persist up to six-months after stroke. Parasympathetic dysfunction rather than sympathetic dysfunction is predominant after ischemic stroke.

Risk of intracerebral hemorrhage in patients with cerebral microbleeds undergoing endovascular intervention

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMBs) on MRI gradient echo images are hemosiderin deposits, which may predict intracerebral hemorrhage (ICH). The risk of ICH in patients with CMBs could be exacerbated by the use of antithrombotics. The purpose of our study is to prospectively evaluate the risk of ICH in patients with ischemic stroke who receive dual antiplatelet therapy for endovascular intervention.

METHODS

We analyzed MRI of 133 patients admitted consecutively for intra- and extracranial stenting for symptomatic large artery atherosclerosis who received aspirin and clopidogrel. Quantity and location of CMBs were recorded by neuroradiologists independent from the angioplasty team. The primary end point was symptomatic ICH as evident in CT of the brain within 12 weeks of procedure.

RESULTS

CMBs were identified in 23 patients. Mean number of CMBs was 2.3 ± 1.6. Four patients had >5 CMBs. Forty-seven patients had intracranial stents, 84 patients had extracranial stents, and 2 patients had both intracranial and extracranial stents. There was no difference in risk of symptomatic ICH between those with (4.3%) and without CMBs (5.5%) patient with CMBs (P=1.000).

CONCLUSIONS

The presence of a small number of CMBs does not cause a large increase in the short-term risk of symptomatic ICH in patients with ischemic stroke who undergo endovascular intervention with dual antiplatelet therapy. The risk of ICH in patients with ≥ 5 CMBs, however, remains unclear. Further studies with a larger sample size of patients with multiple CMBs are needed.

Is stroke thrombolysis safe and efficacious in Hong Kong?

OBJECTIVE

To investigate the safety and efficacy of stroke thrombolysis in a local hospital.

DESIGN

Historical cohort study.

SETTING

A tertiary hospital in Hong Kong.

PATIENTS

The outcome of acute ischaemic stroke patients treated with intravenous tissue plasminogen activator between October 2008 and May 2011 was compared to those admitted during the same period who were thrombolysis-eligible, but treated conservatively due to unavailability of the thrombolysis service after-hours.

INTERVENTIONS

Intravenous tissue plasminogen activator.

MAIN OUTCOME MEASURES

Primary outcome was functional independence (modified Rankin Scale score of 2 or below) at 3 months. Safety outcomes were symptomatic intracranial haemorrhage and 3-month mortality. Secondary outcomes were hospital length of stay, direct home discharge, and nursing home discharge.

RESULTS

A total of 48 thrombolysis and 63 non-thrombolysis patients were identified. Fifty-two percent of the thrombolysis group achieved functional independence compared to 24% of non-thrombolysis group (P=0.003), without significant increase in mortality (15% vs 13%, P=0.51) or symptomatic intracranial haemorrhage (4% vs 2%, P=0.58). Twenty-nine percent of the thrombolysis group patients were discharged home directly, versus 6% of non-thrombolysis group (P<0.001). Mean length of stay was shorter for the thrombolysis group (25 vs 35 days; P=0.034). A similar percentage from each group was discharged to nursing homes.

CONCLUSION

Implementation of the stroke thrombolysis service in Hong Kong appeared safe and efficacious. Patients who received thrombolysis had better outcomes compared to non-thrombolysis cohort. Further studies are needed to investigate the economics of stroke thrombolysis in Hong Kong, which may help to improve funding for provision of this service.

Grading carotid stenosis using ultrasonic methods

The controversy as to whether Doppler ultrasonic methods should play a role in clinical decision-making in the prevention of stroke is attributable to reported disagreement between angiographic and ultrasonic results and the lack of internationally accepted ultrasound criteria for describing the degree of stenosis. Foremost among the explanations for both is the broad scatter of peak systolic velocities in the stenosis, the criterion that has so far received most attention. Grading based on a set of main and additional criteria can overcome diagnostic errors. Morphological measurements (B-mode images and color flow imaging) are the main criteria for low and moderate degrees of stenosis. Increased velocities in the stenosis indicate narrowing, but the appearance of collateral flow and decreased poststenotic flow velocity prove a high degree stenosis (≥70%), additionally allowing the estimation of the hemodynamic effect in the category of high-degree stenosis. Additional criteria refer to the effect of a stenosis on prestenotic flow (common carotid artery), the extent of poststenotic flow disturbances, and derived velocity criteria (diastolic peak velocity and the carotid ratio). This multiparametric approach is intended to increase the reliability and the standard of reporting of ultrasonic results for arteriosclerotic disease of the carotid artery.

Factors associated with prehospital delays in the presentation of acute stroke in urban China

BACKGROUND AND PURPOSE

Low rates of thrombolysis for ischemic stroke in China have mainly been attributed to delays in presentation to the hospital. This study aimed to evaluate factors associated with these delays.

METHODS

Data were from a prospective, multicenter, hospital-based registry of patients with acute stroke (ChinaQUEST [Quality Evaluation of Stroke Care and Treatment]), which involved 62 hospitals across a variety of economic and geographic regions in China during 2006. Univariate and multivariate analyses were undertaken to determine associations between variables of interest and delays to hospital presentation.

RESULTS

Median time to hospital presentation was 15.0 hours for 6102 cases (interquartile range, 2.8-51.0 hours). A total of 1546 (25%) patients arrived within 3 hours and 2244 (37%) patients arrived within 6 hours after symptom onset. Factors that prolonged time to presentation were: visiting a local doctor before presenting at emergency (OR, 0.48; P<0.001), symptom onset at home (OR, 0.62; P<0.001), transfer to a large (Level III) hospital for management (OR, 0.70; P=0.04), and history of diabetes (OR, 0.78; P=0.01). In contrast, factors that accelerated presentation to the hospital were hemorrhagic stroke (OR, 2.25; P<0.001), history of atrial fibrillation (OR, 1.94; P<0.001), unconsciousness at presentation (OR, 1.91; P<0.001), transfer by ambulance (OR, 1.91; P<0.001), and history of coronary artery disease (OR, 1.20; P=0.04).

CONCLUSIONS

Health promotion strategies to improve community awareness of early symptoms of stroke, establishment of an alert system to cater for patients likely to experience stroke at home, and wider availability and use of ambulance services are promising methods to help expedite presentation to hospital poststroke and thereby improve the management of stroke in China.

Frequency and predictors of proxy-confirmed post-stroke cognitive complaints in lacunar stroke patients without major depression

OBJECTIVE

Many lacunar stroke patients complained of cognitive decline after stroke. This study aims to investigate the factors underlying post-stroke cognitive complaints in these patients.

METHODS

Seventy-five consecutive lacunar stroke patients without major depression were recruited for the study. Stroke severity was measured using NIHSS score and MRI was performed during the acute admission period. At 3 months, objective psychometric performance and depressive symptoms were assessed. Post-stroke cognitive complaints were corroborated by a proxy. Using logistic regression we examined the contribution of demographic features, stroke severity, objective psychometric scores, depressive symptoms, and imaging features (white matter lesion volume and infarct measures) to post-stroke cognitive complaints.

RESULTS

Thirty-two (42.7%) patients had post-stroke cognitive complaints. Patients with post-stroke cognitive complaints had more depressive symptoms and worse psychometric performance than those without. In the multivariate logistic regression model, only the severity of depressive symptoms was independently associated with post-stroke cognitive complaints.

CONCLUSIONS

This study suggests that post-stroke cognitive complaints are frequent among lacunar stroke patients without major depression and are prominently determined by the subclinical depressive symptomatology.

Angioplasty and stenting of atherosclerotic middle cerebral arteries with Wingspan: evaluation of clinical outcome, restenosis, and procedure outcome

BACKGROUND AND PURPOSE

MCA is a common location of intracranial stenosis. It is relatively more peripherally located and of a smaller caliber, and could therefore be a site technically more challenging and risky for angioplasty and stenting. The study aimed to evaluate the clinical outcome, restenosis rate, and procedural safety of Wingspan stent placement for atherosclerosis in the MCA compared with stenosis in other arteries.

MATERIALS AND METHODS

Patients who underwent Wingspan stent placement for symptomatic intracranial stenosis of ≥70% (or stenosis of ≥50% for recurrent ischemia despite medical therapy) were recruited prospectively and allocated into a study group (MCA stenosis, n=35) and a control group (other stenosis, n=25). Primary end points were the following: 1) all stroke or death rate at 1 year, and 2) significant in-stent restenosis rate at 1 year. Secondary end points were the following: 1) periprocedural complications within 24 hours, rate of TIA during the procedure, all stroke or death rate within 30 days; and 2) the inability to complete the procedure due to technical problems.

RESULTS

Results of study group versus the control group were the following: degree of stenosis, 78.4 ± 10.9% versus 72.5 ± 11.2% (P value=.0456); diameter of stenosis, 0.6 ± 0.3 versus 1.0 ± 0.5 mm (P=.0017); all stroke or death rate at 1 year, 14.3% versus 12% (OR=1.22); in-stent restenosis rate at 1 year, 10% versus 10.5% (OR=1.05); periprocedural complication rate at 24 hours, 2.9% versus 4% (OR=0.70); TIA rate during the procedure, 8.6% versus 4% (OR=2.25); all stroke or death rate at 30 days, 5.7% versus 12% (OR=0.44); and technical failure rate, 2.9% versus 0%.

CONCLUSIONS

In this study, there were no significant differences in procedural safety, patient outcome, and restenosis rates of stent placement between the group with MCA stenosis and the group with stenoses located at other sites.

Current management of intracerebral haemorrhage in China: a national, multi-centre, hospital register study

BACKGROUND

We aimed to examine current practice of the management and secondary prevention of intracerebral haemorrhage (ICH) in China where the disease is more common than in Western populations.

METHODS

Data on baseline characteristics, management in-hospital and post-stroke, and outcome of ICH patients are from the ChinaQUEST (QUality Evaluation of Stroke Care and Treatment) study, a multi-centre, prospective, 62 hospital registry in China during 2006-07.

RESULTS

Nearly all ICH patients (n = 1572) received an intravenous haemodiluting agent such as mannitol (96%) or a neuroprotectant (72%), and there was high use of intravenous traditional Chinese medicine (TCM) (42%). Neurosurgery was undertaken in 137 (9%) patients; being overweight, having a low Glasgow Coma Scale (GCS) score on admission, and Total Anterior Circulation Syndrome (TACS) clinical pattern on admission, were the only baseline factors associated with this intervention in multivariate analyses. Neurosurgery was associated with nearly three times higher risk of death/disability at 3 months post-stroke (odd ratio [OR] 2.60, p < 0.001). Continuation of antihypertensives in-hospital and at 3 and 12 months post-stroke was reported in 732/935 (78%), 775/935 (83%), and 752/935 (80%) living patients with hypertension, respectively.

CONCLUSIONS

The management of ICH in China is characterised by high rates of use of intravenous haemodiluting agents, neuroprotectants, and TCM, and of antihypertensives for secondary prevention. The controversial efficacy of these therapies, coupled with the current lack of treatments of proven benefit, is a call for action for more outcomes based research in ICH.

Age and gender variations in the management of ischaemic stroke in China

BACKGROUND

Stroke is a major health issue in China.

AIMS

We aimed to describe the management of patients admitted to hospitals in China with acute ischaemic stroke, and to determine whether there were any differences by age and gender.

METHODS

Using a multicentre prospective hospital register across all eight major economic (geographic) regions in China, data on the socioeconomic characteristics, medical history, clinical features, and in-hospital investigations, management, and outcomes were collected on consecutive patients with acute stroke due to cerebral ischaemia during a 5-month period in 2006.

RESULTS

Overall, traditional Chinese medicine and neuroprotectant use were remarkably high, with nearly 80% of patients receiving the former and >70% receiving the latter in hospital. Length of hospital stay was also long (median duration 16-days). Multivariate analyses revealed no clinically important differences in management between the genders. For the age-specific analyses, there were significant trends of decreasing use of thrombolysis (P=0·04), warfarin (P=0·01), corticosteroids (P=0·03), and lipid-lowering therapy (P=0·001); however, more assisted feeding (P=0·004) and rising rates of disability and in-hospital complications occurred with increasing age.

CONCLUSIONS

New information is provided regarding the current state of ischaemic stroke management in China. Notably, there is high use of traditional Chinese medicine and neuroprotectants and long lengths of hospital stay. Similar to many other countries, differences in stroke care and management by age and gender also exist to a small extent in China.

Gabapentin for the treatment of carpal tunnel syndrome: a randomized controlled trial

OBJECTIVE

Based on its efficacy in treating neuropathic pain, gabapentin may be effective for the treatment of carpal tunnel syndrome (CTS). The purpose of this study was to evaluate the efficacy of gabapentin for symptom relief in CTS.

METHODS

We conducted a randomized, double-blinded, placebo-controlled trial recruiting patients with newly diagnosed idiopathic CTS of more than a period of three months. Diagnosis was based on characteristic symptoms with electrophysiological confirmation. Patients were randomly assigned to an active group receiving gabapentin (starting dose 300 mg once daily to a target of 900 mg daily) or a placebo group. Primary end-point was the global symptom score (GSS), which was measured at baseline, two, and eight weeks.

RESULTS

There was no significant difference in baseline variables between the two treatment groups. Hundred and forty patients were enrolled in the study, of whom 71 were randomly assigned to gabapentin group and 69 assigned to placebo group. Both gabapentin and placebo produced significant improvement in symptoms at two and eight weeks. The GSS at 2 and 8 weeks was 16.4 (SD 9.4) and 13.4 (SD 9.7), respectively, in the active group versus 14.9 (SD 9.0) and 12.5 (SD 8.9) in the control group (P < 0.01). But by eight weeks, the mean reduction in symptom severity of patients on gabapentin [-10.4 (SD 10.8)] was not significant when compared with placebo [-8.7 (SD 8.1), P < 0.39]. Adverse events were not severe and included dizziness, somnolence, and headache.

CONCLUSIONS

Gabapentin did not produce a significant reduction in symptom severity compared with placebo over an eight-week period.

An expedited stroke triage pathway: the key to shortening the door-to-needle time in delivery of thrombolysis

OBJECTIVES

To assess time management of stroke thrombolysis triage and functional outcomes in patients receiving recombinant tissue plasminogen activator for hyperacute stroke, and identify bottlenecks in delivery of the treatment.

DESIGN

Prospective study.

SETTING

A university teaching hospital in Hong Kong.

PATIENTS

Patients with suspected hyperacute stroke referred to the stroke thrombolysis team during October 2008 to September 2009.

MAIN OUTCOME MEASURES

Time performance records including door-to-stroke team, door-to-needle, and onset-to-thrombolysis times. Functional outcomes by modified Rankin Scale score at 3 months, and thrombolysis-related complications including haemorrhagic transformations and mortality.

RESULTS

During the 12-month period, 95 thrombolysis calls were received; recombinant tissue plasminogen activator was given intravenously to 17 (18%) of the patients and intra-arterially to 11 (12%). The mean (standard deviation) door-to-stroke team and the door-to-needle times for intravenous recombinant tissue plasminogen activator patients were 33 (25) and 80 (25) minutes, respectively; both were about 20 minutes longer than that recommended by the National Institute of Neurological Disorders and Stroke. The mean National Institute of Health Stroke Scale score for patients received intravenous recombinant tissue plasminogen activator was 16 (standard deviation, 7). The mean (standard deviation) onset-to-treatment time was 144 (42) minutes. Nine (53%) patients who received intravenous recombinant tissue plasminogen activator achieved favourable outcomes at 3 months, with a modified Rankin Scale score of 0 to 1. Symptomatic haemorrhage and mortality occurred in one (6%) patient.

CONCLUSION

A dedicated stroke triage pathway is essential to ensure efficient and safe delivery of thrombolysis therapy. Improvements in door-to-stroke team time through integration with emergency medicine staff and neuroradiologists may improve thrombolysis eligibility.

The validity, reliability and clinical utility of the Hong Kong Montreal Cognitive Assessment (HK-MoCA) in patients with cerebral small vessel disease

BACKGROUND/AIMS

To evaluate the psychometric properties of the Hong Kong Montreal Cognitive Assessment (HK-MoCA) in patients with cerebral small vessel disease (SVD).

METHODS

40 SVD patients and 40 matched controls were recruited. Concurrent and criterion validity, inter-rater and test-retest reliability, internal consistency of the HK-MoCA were examined and clinical observations were made.

RESULTS

Performance on the HK-MoCA was significantly predicted by both executive (beta = 0.23, p = 0.013) and non-executive (beta = 0.64, p < 0.001) composite scores. It differentiated SVD patients from controls (area under the curve = 0.81, p < 0.001) with an optimal cutoff at 21/22. Reliability, internal consistency and clinical utility were good.

CONCLUSION

The HK-MoCA is a useful cognitive screening instrument for use in SVD patients.

Long-term prognosis of Chinese patients with a lacunar infarct associated with small vessel disease: a five-year longitudinal study

RATIONALE

Lacunar infarct associated with small vessel disease is a common stroke subtype in China and has a favorable short-term prognosis. Data on its long-term prognosis among Chinese patients are lacking.

AIMS

We aimed to study its long-term prognosis and predictors for poor outcomes.

DESIGN

We followed up to 75 consecutive Chinese stroke patients who had a lacunar infarct for a period of 5 years. Clinical outcomes with respect to mortality and recurrent stroke were noted. We evaluated baseline clinical and imaging predictors for such outcomes using the Cox regression analysis.

STUDY OUTCOMES

Sixteen (21.3%) patients died and 12 (16%) patients had recurrent stroke during follow-up. Twenty-one (28%) patients had combined events of either death and/or recurrent stroke. Univariate Cox regression analysis showed that age, literacy, National Institute of Health Stroke Scale, incident stroke/transient ischemic attack, and white matter lesion volume predicted survival, while, age, National Institute of Health Stroke Scale, systolic blood pressure, hyperhomocysteinemia, silent lacunes, microbleeds, and white matter lesion volume predicted recurrent stroke. Multivariate Cox regression analysis showed that National Institute of Health Stroke Scale (HR 1.25, 95% CI 1.05-1.48) and white matter lesion volume (HR 1.46, 95% CI 1.11-1.92) predicted combined events of mortality and/or recurrent stroke after age adjustment.

CONCLUSION

Approximately one in four patients either died and/or had recurrent stroke within 5 years after a lacunar infarct. Age, stroke severity, and volume of white matter lesion predict a poor long-term prognosis.