[Prognostic factors for long-term mortality and risk of stroke in patients with transient ischemic attacks]

The aim of the present study was to evaluate the natural course of patients with transient ischaemic attacks and to determine prognostic factors concerning long-term mortality and the incidence of stroke. 159 patients, who were hospitalized after transient ischaemic attacks at the Neurological University Department Vienna during the years 1976 to 1985, were asked about the further course of their illness using questionnaires. 22 patients had moved to unknown addresses and the return rate of the remaining questionnaires was 73.0%. Thus, the results of 100 patients were included in the present study. The follow-up period was 71 +/- 32 months (x +/- s; range: 19-135 months). During the follow-up period, 11 patients had died and 25 had eventually incurred full-blown cerebral infarction. The following variables were analyzed for their prognostic relevance with respect to long-term mortality and stroke occurrence: sex, age, vessel territority involved clinically, number of vessel territories involved clinically, number of strokes, and severity of clinical symptoms. The clinical symptoms (motor deficits, sensory deficits, speech disorders, visual field defects and organic mental syndrome) were graded semiquantitatively and added up to a "total score". Age had a significant influence on survival, but not on stroke occurrence. All other variables had no significant impact on long-term mortality and stroke occurrence. It is concluded that transient ischaemic attacks are warning symptoms of an impending stroke. However, prognostic assumptions cannot be made of the basis of clinical features in this subacute stage. Thus, all patients suffering from transient ischaemic attacks should have a comprehensive and thorough vascular investigation as soon as possible.

[Persistent changes in tissue-type plasminogen activator and plasminogen activator inhibitor fibrinolytic parameters in patients following juvenile ischemic cerebral infarct]

In diseases associated with thrombotic or thromboembolic complications, a reduction in the fibrinolytic potential may contribute to the risk to develop thrombosis. To investigate whether juvenile cerebral infarction is associated with a permanent defect of the fibrinolytic system we measured the main components of the fibrinolytic system, tissue plasminogen activator (t-PA) and its fast acting inhibitor (PAI) in plasma samples of 21 patients (aged 21-44 years) 3-24 months after the acute event. The data obtained were compared to those from thirteen healthy young volunteers (22-46 years). A direct effect of known risk factors on the fibrinolytic system could be excluded because patients avoided their risk factors immediately after the ischemic cerebral attack. Hypertension and the combination of oral contraceptives and smoking had been the most striking original risk factors. Levels of t-PA antigen and t-PA activity before and after venous occlusion, or PAI activity were not different between patients and controls suggesting that at least a permanent decrease in the activity of the fibrinolytic system does not exist in these patients. However, our findings do not exclude that a temporary defect in fibrinolysis might have contributed to the acute onset of the thrombotic cerebral event possibly induced by the risk factors originally present.

Is aphasia an additional prognostic factor in ischemic stroke with regard to the severity of hemiparesis in the subacute stage?

The outcome of 122 patients with ischemic stroke in the left carotid territory (ascertained by CT) was investigated using mailed questionnaires after a mean follow-up time of 60.7 months (SD 20.5 months). Patients who had had cerebrovascular accidents others than TIA prior to the stroke were not included in the study. The relationship between the degree of aphasia in the postacute stage and the long-term outcome was evaluated with regard to the severity of motor deficits. With respect to survival, recurrent stroke, single activities of daily living such as dressing, personal hygiene, walking, feeding, bowel management and overall self-care status, the outcome of patients was not dependent on the severity of aphasia. Aphasia did also not serve as a prognostic factor in returning to work after left hemispheric cerebral infarction. Our results indicate that in presence of motor deficits the severity of aphasia in the subacute stage does not additionally influence the long-term outcome after left hemispheric cerebral infarction.

[Prognosis of social reintegration following stroke]

From the socio-economic point of view, early prediction of outcome after stroke is of essential value. The longterm prognosis of 310 patients suffering from ischemic stroke, was therefore investigated by means of questionnaires. The mean follow-up period was 62.5 (S.D. 21.9) months. The results of patients who had suffered cerebrovascular accidents other than ischemic stroke or only transient ischemic attacks were not included. It had been the aim of the study to determine the predictive value of some clinical variables and symptoms in the subacute stage as regards the familial and social functioning handicaps to be expected later on. Between the number of strokes as well as the severity of some clinical signs (motor deficits, sensory deficits, speech disorders, organic mental syndrome) on the one hand, and the restrictions experienced in familial functioning on the other hand, a clear cut correlation was found. As regards social functioning, two additional predictors of unfavourable outcome could be identified: age, and lesion within the left hemisphere. The findings indicate that some clinical variables and symptoms in the subacute stage are of great predictive value concerning the ensuing handicap in familial and social functioning. These variables may help to develop individual strategies as regards the further social management and support (e.g. discharge arrangements, care services, rehabilitation programs).

[Syncopal consciousness disorders and drop attacks from the neurologic viewpoint]

The most important neurological disorders leading to syncope and/or drop attack are presented. With respect to epilepsy it is important to consider generalized absence seizures (petit mal), generalized tonic-clonic seizures (grand mal) and some types of complex partial seizures. Additionally, some sleep and arousal disorders must be mentioned, such as narcolepsy, disorders of excessive somnolence associated with sleep-induced respiratory impairment, as well as the Kleine-Levin-Critchley syndrome. Vagotonic, asympathicotonic, sympathicotonic and central autonomic disorders are comprised in the group of autonomic attacks. Among other brain diseases manifesting syncope and/or drop attack, cerebrovascular disorders are of major importance in view of their high incidence. Psychogenic seizures also have to be taken into account in the differential diagnosis.

[Does alcohol consumption promote the manifestation of strokes? Considerations on pathophysiology]

Arterial hypertension is the most important risk factor in all types of stroke. The significance of alcohol in the pathogenesis of stroke is less well defined. Chronic alcoholism leads to an elevation of blood pressure. Thus, the association between alcohol and stroke might be the blood pressure effect of alcohol. However, some studies have shown a significant influence of alcohol on the incidence of stroke--especially of intracerebral haemorrhage and subarachnoid haemorrhage--even after adjustment for blood pressure. Many possible pathomechanisms are discussed. Alcohol inhibits aggregation of thrombocytes, and chronic alcohol abuse may induce thrombocytopenia, which could lead to a haemorrhagic stroke. Alcohol withdrawal leads to rebound thrombocytosis. Acute alcohol ingestion induces a decrease in fibrinolytic activity and an increase in factor VIII activity, which enhances the thrombotic potential. Additionally, alcohol increases plasma osmolarity, erythrocyte aggregability, haematocrit and blood viscosity, and decreases deformability of erythrocytes. The effects of alcohol on cerebral blood flow are still under debate; there is a deterioration in autoregulation of cerebral blood flow anyway. In animal studies alcohol induced dose-dependent vasospasm of the cerebral blood vessels, which could be a possible pathomechanism in ischaemic, as well as in haemorrhagic stroke. Chronic alcoholism is the most common cause of secondary non-ischaemic cardiomyopathy, which can lead to cerebral embolism via rhythm disorders or intracardiac thrombus formation.(ABSTRACT TRUNCATED AT 250 WORDS)

The course of alcoholism. Long-term prognosis in different types

The disease concept of alcoholism was first introduced into the medical literature by Magnus Huss in 1984. Since that time many authors have attempted to define therapy-related sub-groups of chronic alcoholics but have been unsuccessful until now because alcoholism represents a complex development and becomes apparent in various clinical pictures. As the method of cross-sectional investigations does not seem to be able to produce reliable results, we performed a prospective long-term study of 444 alcoholics. The methodological claims in literature were taken into consideration like selection criteria, programmes and goals of therapy, follow-up rate and time, etc. Careful observation of the pertinent parts of the pathogenetic pathway leading to chronic alcoholism enabled the authors to establish 4 sub-groups of alcoholics relevant for treatment.

Unilateral stenosis of the vertebral artery--secondary finding with no prognostic relevance?

The outcome of 142 patients suffering from ischemic cerebral circulation disorders was followed up over a period of 33 months on average. The spontaneous course of 25 patients with unilateral, hemodynamically ineffective stenoses of the vertebral artery was compared with that of 107 patients without vertebral artery stenoses. Within the first 12 months, novel clinically manifest cerebrovascular events were observed in 16.0% of patients without vertebral artery stenosis (deaths 5.0%), but in only 4.3% of the patients with vertebral artery stenosis (no deaths). Within 30 months, only 2 of the 13 patients with vertebral artery stenosis had suffered a new cerebrovascular attack. At the end of the observation period, 39.3% of the patients without vertebral artery stenosis and 48.0% of the patients with vertebral artery stenosis were significantly disabled in their social life or had died. An additional unilateral hemodynamically irrelevant vertebral artery stenosis did not influence the rate of reinfarction or the remission of neurological deficits, independently of age, the degree of the circulatory disorder, the vascular territory involved, the presence of an organic psychosyndrome, or of additional stenoses in the carotid arteries. Consequently, a vertebral artery stenosis narrowing the vessel diameter to less than 1/3 is without prognostic relevance.

High-dose penicillin therapy in meningopolyneuritis Garin-Bujadoux-Bannwarth. Clinical and cerebrospinal fluid data

Clinical data of 19 patients with meningopolyneuritis Garin-Bujadoux-Bannwarth (MPN-GBB), treated with 2 X 10 million units intravenous sodium penicillin for 10 days, were evaluated at the beginning of therapy, 3 weeks thereafter, and 6 months after onset of the neurological disease. Cerebrospinal fluid (CSF) was analysed in 14 patients at the onset of therapy and 3 1/2 weeks thereafter. At the same interval antibodies against B. burgdorferi were measured by enzyme-linked immunosorbent assay (ELISA) in the CSF and sera of 12 patients. Clinical data and all CSF results, with exception of specific antibody titers, were compared with those of patients who had suffered from MPN-GBB between 1979 and 1983, and who had not received antibiotic or corticosteroid therapy. Comparing the clinical data of all treated patients with those of all non-treated controls, no significant difference could be observed. A significant improvement could however be detected in those patients who had their treatment begun 5 weeks within onset of the neurological disease. Changes in CSF 3 1/2 weeks after onset of treatment showed slight differences when compared with controls.

Fettstoffwechselstörungen ein Risikofaktor des zerebralen Insults?

Die Bedeutung von Hyperlipoproteinämien als Risikofaktor für zerebrale Durchblutungsstörungen ist umstritten.

In den meisten retrospektiv konzipierten Studien wurden bei Patienten mit klinisch manifesten zerebrovaskulären Ereignissen Störungen des Lipidstoffwechsels festgestellt, vor allem eine Erhöhung der LDLsowie eine Erniedrigung der HDL-Werte.

Hingegen lassen die Ergebnisse der umfangreichen Prospektivstudien keine oder nur partielle Zusammenhänge zwischen Hyperlipoproteinämien und der Manifestation zerebrovaskulärer Erkrankungen erkennen.

In dem vorliegenden Literaturüberblick werden die Ergebnisse der wichtigsten Studien zum Thema vorgestellt, die möglichen Ursachen der differenten Resultate werden diskutiert.

Prognostische Kriterien beim »juvenilen Insult«

165 von 172 Patienten mit zerebralen Durchblutungsstörungen auf ischämischer Basis wurden nach einem durchschnittlichen Beobachtungszeitraum von 58 Monaten neuerlich klinisch untersucht; 7 Patienten waren nach Reinsulten bereits verstorben.

Der Schweregrad der sozialen Beeinträchtigung am Ende des Beobachtungszeitraums wurde semiquantitativ • kategorisiert, allfällige weitere ischämische Ereignisse wurden anamnestisch erfaßt.

Um den möglichen Einfluß des Erstmanifestationsalters der zerebrovaskulären Erkrankung auf die Langzeitprognose zu überprüfen, wurden die Ergebnisse von Patienten im Alter von bis zu 40 Jahren mit denen von Patienten im Alter von über 40 Jahren verglichen.

Bei den älteren Patienten kam es innerhalb der ersten 12 Monate bzw. auch innerhalb der ersten 3 Jahre nach der Erstmanifestation nicht wesentlich häufiger zu neuerlichen zerebrovaskulären Ereignissen als bei den jüngeren Patienten, allerdings wurden zum Unterschied gegenüber der jüngeren Gruppe vereinzelt Todesfälle registriert.

Der Schweregrad der sozialen Beeinträchtigung war bei älteren Patienten am Ende des Beobachtungszeitraums höher als für jüngere Patienten, die Detailergebnisse waren für verschiedene Subgruppen jedoch unterschiedlich.

Eine für ältere Patienten gegenüber der jüngeren Gruppe signifikant ungünstigere Prognose wurde bei Vorliegen folgender Konstellationen errechnet: kompletter Schlaganfall, klinisch betroffenes Karotis-Stromgebiet, angiographisch nachgewiesene Stenosen bzw. Verschlüsse.

Hingegen bestand kein signifikanter Unterschied in der Prognose zwischen älteren und jüngeren Patienten bei Vorliegen folgender Konstellationen: passagere zerebrale Durchblutungsstörung, klinisch betroffenes vertebrobasiläres Gebiet, mehrere klinisch betroffene Gefäßgebiete, Angiogramm ohne Stenosen bzw. Verschlüsse, Angiogramm mit ausschließlich hochgradigen Stenosen bzw. Verschlüssen.

Die als allgemein gültig angesehene Annahme, die Prognose nach ischämisch bedingten zerebrovaskulären Erkrankungen sei für jüngere Patienten generell günstiger als für ältere Patienten, muß nach den vorliegenden Ergebnissen relativiert werden.

Der Einfluß eines erhöhten Hämatokrits auf die Manifestation von Schlaganfällen

Die Ergebnisse mehrerer Studien sprechen dafür, daß erhöhte Hämatokritbzw. Hämoglobinwerte mit einer erhöhten Inzidenz zerebrovaskulärer Erkrankungen einhergehen. Mehrfach beschrieben ist auch eine signifikant inverse Beziehung zwischen dem Hämatokrit und dem Cerebral Blood Flow, der bei Patienten mit Anämie gewöhnlich erhöht, bei Patienten mit Polyzythämie im allgemeinen erniedrigt ist.

Als entscheidender Faktor wird der Einfluß des Hämatokrits auf die Viskosität des Blutes angenommen. Andererseits ist die Viskosität des Blutes auch von zahlreichen anderen Faktoren abhängig, wie z.B. der Schubspannung, der Fibrinogenkonzentration, der Verformbarkeit und Aggregationsneigung der Erythrozyten wie auch der Plasmaviskosität.

Einer erhöhten Viskosität des Blutes dürfte vor allem dann pathogenetische Bedeutung zukommen, wenn lokal hämodynamisch relevante Stenosen bestehen bzw. wenn wie in sehr kleinkalibrigen Gefäßen die Schubspannung sehr niedrig ist.

Nachdem die Blutviskosität nicht nur vom Hämatokritwert, sondern auch von zahlreichen anderen Faktoren beeinflußt wird und die Details der pathophysiologischen Abläufe bisher keineswegs lückenlos bekannt sind, ist ein direkter Einfluß der Hämatokritwerte auf die Schlaganfallsinzidenz vorläufig nur mit Vorbehalt anzunehmen.

[Chronic alcoholism--alcohol sequelae--causes of death]

In this study 444 chronic alcoholic patients, hospitalized at the beginning of this study, were followed up for 4 to 7 years (31). During this time 101 patients died (23.2%), with whom severeness of disease as well as the extent of social depravation could be identified as factors influencing mortality. Beginning in January of 1982 we investigated mortality of the population of a village with a similar socio-cultural background (working situation, rural population, wine-growing area). As it was possible to cooperate with the local general practitioner, who has been living and working in this village since 1946, knowing all the troubles and sorrows, we could get data of each person having died. We collected data on each dead of this village until we had 101 definitely not alcohol addicted cases as control group. For getting this number of cases we had to investigate data of 116 dead, because 15 of them met the diagnostic criteria for chronic alcoholism. Sociodemographic data, social development, diseases and causes of death were recorded in all groups of investigation. In the group of formerly hospitalized chronic alcoholic patients we found a preponderance of men as well as a significantly shorter life-time (alcoholic group: 50 +/- 9.8 years, control group 73.9 +/- 12.5 years). Besides alcohol misuse other factors influencing mortality could be elaborated (e. g. stressing or discriminating working situation, incontinuous and/or unsatisfying partnership, additional criminal acts etc.) separating the chronic alcoholic group (with former hospitalisation) from the control group in a significant way. Concerning the disease leading to death, chronic alcoholic patients more frequently had suffered from liver damage (with break of oesophagus blood vessels) as well as from auto-destructive behaviour patterns (like suicide, masked accidents) compared to the non-alcoholic group. This control group died significantly more frequent because of cardio-vascular diseases, often accompanied by cerebral deficits.

[Rare pathomorphologic findings in complicated migraine]

137 patients suffering from classical or complicated migraine were investigated in the Neurology Department of the University of Vienna between 1971 and 1984. 13 of these patients were found to have pathological alterations and their case histories are presented. Clinically, 11 patients suffered from migraine accompagnée (in 2 cases accompanied by epileptic seizures), 1 patient had ophthalmoplegic migraine and 1 had a subarachnoid haemorrhage imitating migraine. The underlying pathological findings were: 1 tumour, 4 arteriovenous malformations, 4 aneurysms, 1 arterio-venous shunt, 1 pathological vascular network, 1 Moya-Moya syndrome and 1 intracerebral haemorrhage without detectable source of bleeding. 8 of the patients underwent successful surgery and most of them showed subsequent clinical improvement. The family history was positive in only 2 patients. The time interval between the occurrence of the first symptoms and the establishment of the final diagnosis was up to 25 years. The neurologist should undertake extensive investigation of the patient, including cerebral angiography, if the following criteria apply: hemicrania consistently on the same side; change in type of headache after a number of years; uniform complicating neurological symptoms; additional occurrence of epileptic seizures; manifestation of neurological symptoms after the prodromal phase; persistent neurological signs without remission; negative family history; persisting diffuse or locally accentuated EEG changes; pathological CAT results.

[Status of oral contraceptives as a risk factor in cerebrovascular diseases]

A critical review of the relevant literature revealed that the incidence of subarachnoid haemorrhage is increased in women taking oral contraceptives and the mortality rate is higher. The data concerning correlation between the use of oral contraceptives and other cerebrovascular disorders are less conclusive. Taking oral contraceptives seems to result in a higher risk of stroke, but there is no definite correlation to the incidence of strokes with a fatal outcome. However, in the case of the coexistence of more than one risk factor, including cigarette smoking, the risk of cerebrovascular disease is considerably increased for women using oral contraceptives. Age also seems to be a significant factor. Women older than 44 should avoid oral contraceptives in general; women between 35 and 44 should use oral contraceptives only if additional risk factors are absent, i.e. if they are non-smokers. Indeed, in the presence of this or other risk factors younger women should also avoid taking oral contraceptives.

[Prognostic significance of initial loss of consciousness in cerebrovascular disorders]

An initial loss of consciousness is of grave prognostic significance in patients with acute ischaemic cerebrovascular disorders, both as regards the early course as well as the long-term prognosis. The aim of this study was to assess the prognostic importance of an initial loss of consciousness in patients who had survived the acute stage. Thus, 133 out of 139 patients suffering from ischaemic cerebrovascular disorders who survived the first 3 weeks after a stroke were clinically re-examined after a mean follow-up period of more than two years. The other 6 patients had died as a result of a second stroke in the post-acute period. Patients with an initial loss of consciousness suffered cerebrovascular disturbances or fatal strokes in the follow-up period slightly more frequently than patients without an initial loss of consciousness. However, there were no convincing differences between the two groups. Indeed, on follow up, patients with an initial loss of consciousness were slightly less socially disabled than patients without an initial loss of consciousness. The results suggest that an initial loss of consciousness is no longer a factor of prognostic importance in patients who have survived the initial stage.

[Therapy of organic psychosyndromes of cerebrovascular origin with a vasoactive drug combination]

Concrete cross-sectional studies of the organic brain syndrome, carried out periodically, attempt to establish for the parameters evaluation of substrate damage--and different noopsychopathological rating-scales for the measurement of brain capacity impairment. Beyond the level of the purely correlative-statistical point of view of the relationship between parameter and score changes, demanding for a quantitative model which could provide not only a description, but also an explanation for such a relationship. The fact that there can only be a question here of a "quantitative causality" embracing non-specificity of toxic substances and relative to acute and chronic diffuse organic brain syndromes. It results, that quantitative causality meets the requirements of an exponential function model and that one can validate such models through correlative-statistical methods. This has already been carried out by Ball and Taylor.

[Balloon catheter technic and embolization--new therapeutic approaches in cerebral and spinal blood vessel malformations]

Balloon catheter and embolization techniques continue to gain importance in the therapy of cerebral and spinal vascular malformations. These methods are applied either preoperatively to improve outset conditions for the operation or as an independent therapeutic measure to partially or completely bypass the malformation. So far the balloon catheter and embolization techniques are applied only within a limited field. Nevertheless, this fairly recently developed method is already indispensable in the therapeutic repertory. There are as yet no generally acknowledged principles with regard to indications for these procedures. Therefore, neurologists, neurosurgeons and neuroradiologists have to be included in the process of decision making.

[The cerebral angiogram in patients with complicated migraine]

38 patients (mean age: 29 years) were investigated by means of complete 4-vessel angiography: all of them were suffering from complicated migraine without detectable vascular malformation. Stenoses of the great craniocervical vessels were found in 11 patients (28.9%), but there was not a single case of vascular occlusion. A correlation between the localization of the stenosis, the localization of the headache and the presumed region of the transient cerebral function disturbance was found only in a few patients. Concerning the morphological changes of the small intracranial arterial branches, there was hardly any difference between clinically affected and non-affected territories of the middle cerebral artery. The angiograms of the 38 cases of complicated migraine were compared with the angiograms of 40 patients suffering from strokes in the young and those of 49 patients with transient ischaemic attacks. There were remarkably fewer stenoses or occlusions in the great craniocervical arteries of patients suffering from complicated migraine (28.9%) than in the vessels of cases of stroke in the young (52.5%). However, the incidence was comparable with the results in patients with transient ischaemic attacks (34.7%). The degree of morphological changes in the small intracranial arterial branches is likely to depend primarily on the patient's age and less on the diagnosis. The results suggest that in almost 30% of patients with complicated migraine-even at juvenile age-stenoses of the great craniocervical vessels might be found.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cerebral angiography in complicated migraine--reactions, incidents]

Seventy-one patients (ages: 15-58 years) suffering from complicated migraine were investigated by means of cerebral angiography which was not performed during an attack. Angiography was carried out to exclude stenoses or occlusions of the cranio-cervical vessels and above all vascular malformations (arterial aneurysms, arteriovenous angiomas). In 18 cases (25.4%) organic lesions were found, including three vessel malformations (4.2%). Thirty-one patients (43.7%) suffered from headache reactions or other complications during or within 24 h following angiography. In 15 cases (21.1%) attacks of complicated migraine were observed, three patients (4.2%) suffered from headache and bilateral flickering visual disturbances, another 11 patients (15.5%) developed headache and vegetative symptoms requiring therapeutic management. One patient (1.4%) got an epileptic seizure, another patient (1.4%) developed a generalized urticaria exanthema. There were more headache reactions in women than in men. However, the highest percentage of reactions was observed in patients in whom migraine headache had occurred clearly set off from the transient cerebral functional disturbances. Neurological complications (transient functional disturbances) occurred in 16 of 71 patients (22.5%). The neurological complication rate was significantly (P less than 0.001) higher than that in an unselected group of patients (3.0%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term prognosis of patients with juvenile infarct. Catamnestic results]

Seventy patients suffering from ischemic cerebrovascular disease had had their first attack before the age of 40 years. Of these patients 57 were re-examined 84 months (mean) after the initial event. Within 48 months, 22 of 51 patients (43.1%) without surgical treatment had recurrent ischemic events (78.6% patients with transient ischemic attacks, 33.3% patients with protracted reversible deficits, 28.6% patients with completed stroke). Of all patients 31.5% had their first recurrent attack during the first year, most of them during the first few months after the initial event. In spite of the considerably higher recurrence rate, patients with initial transient ischemic attacks or protracted reversible deficits had a lower degree of social disability at the end of the follow-up period than patients with an initial completed stroke. In 72.2% of the patients with recurrent events the ischemic focus was found in a vascular area different from the one originally concerned. Patients with arterial hypertension during the follow-up period had a somewhat less-favorable long-term prognosis, but nicotine abuse or relative body weight had no influence on the degree of social disability at the end of the follow-up period. In general, long-term prognosis was rather favorable, 78.4% of the patients being fully capable of work at the end of the follow-up period. Nevertheless, results point to the necessity of complete diagnostic evaluation without delay and introduction of individual therapy for patients suffering from "juvenile stroke."