Association between blood pressure, white matter lesions, and atrophy of the medial temporal lobe

BACKGROUND

Blood pressure level is associated with the risk of clinical Alzheimer disease (AD), yet the underlying mechanisms are unclear. High blood pressure levels may cause cerebral small-vessel pathology, which contributes to cognitive decline in patients with AD. Alternatively, in persons with high blood pressure, increased numbers of neurofibrillary tangles and amyloid plaques at autopsy have also been observed, suggesting direct links between blood pressure and AD.

OBJECTIVE

To investigate the association of blood pressure and markers of small-vessel disease (white matter lesions [WMLs] on MRI) with hippocampal and amygdalar atrophy on MRI-potential in vivo indicators of Alzheimer pathology.

METHODS

In 1995 to 1996, 511 nondemented elderly subjects (age 60 to 90) underwent MRI. The extent of WMLs was assessed, and volumes of the hippocampus and amygdala were measured. Blood pressure levels were assessed at the time of MRI and 5 years before the MRI.

RESULTS

Higher diastolic blood pressure 5 years before MRI predicted more hippocampal atrophy in persons untreated for hypertension (per SD increase -0.10 mL [95% CI -0.19 to -0.02, p = 0.02]). Conversely, in persons treated for hypertension, a low diastolic blood pressure was associated with more severe atrophy. Persons with more WMLs on MRI more often had severe atrophy of the hippocampus and amygdala.

CONCLUSION

Blood pressure and indicators of small-vessel disease in the brain may be associated with atrophy of structures affected by Alzheimer pathology.

Anticoagulation in atrial fibrillation and flutter

Atrial fibrillation and atrial flutter are important risk factors for stroke. Based on a literature search, pathogenesis of thromboembolism, risk assessment in patients, efficacy of anticoagulation therapy and its alternatives are discussed. Special emphasis is put on issues like paroxysmal atrial fibrillation, atrial flutter and anticoagulation surrounding catheter ablation and cardioversion. A strategy for anticoagulation around the time of pulmonary vein ablation is suggested.

C-Reactive Protein and Cerebral Small-Vessel Disease

Background— Inflammatory processes are involved in the development and consequences of atherosclerosis. Whether these processes are also involved in cerebral small-vessel disease is unknown. Cerebral white matter lesions and lacunar brain infarcts are caused by small-vessel disease and are commonly observed on MRI scans in elderly people. These lesions are associated with an increased risk of stroke and dementia. We assessed whether higher C-reactive protein (CRP) levels were related to white matter lesion and lacunar infarcts.

Methods and Results— We based our study on 1033 participants of the population-based Rotterdam Scan Study for whom complete data on CRP levels were available and who underwent brain MRI scanning. Subjects were 60 to 90 years of age and free of dementia at baseline. Six hundred thirty-six subjects had a second MRI scan on average 3.3 years later. We used multivariate regression models to assess the associations between CRP levels and markers of small-vessel disease. Higher CRP levels were associated with presence and progression of white matter lesions, particularly with marked lesion progression (ORs for highest versus lowest quartile of CRP 3.1 [95% CI 1.3 to 7.2] and 2.5 [95% CI 1.1 to 5.6] for periventricular and subcortical white matter lesion progression, respectively). These associations persisted after adjustment for cardiovascular risk factors and carotid atherosclerosis. Persons with higher CRP levels tended to have more prevalent and incident lacunar infarcts.

Conclusions— Inflammatory processes may be involved in the pathogenesis of cerebral small-vessel disease, in particular, the development of white matter lesions.

[Predictable risk of cerebral infarction following a transient ischaemic attack]

To date most studies that have addressed prognostic factors in patients who have had a transient ischaemic attack (TIA) have determined the risk of cerebral infarction during the first 3 years following TIA. Two recent studies have investigated the very long-term and very short-term risks. The long-term study found that the risk unexpectedly increased after 3 years. The short-term study found the very early risk of cerebral infarct (< 7 days) to be substantial at 10%. The proposed ABCD score enables the physician to easily identify patients at particularly high risk: (A) 1 point for age > or =6o years, (B) 1 for systolic blood pressure >140 mmHg and/or diastolic pressure >90 mmHg, (C) 2 points for unilateral weakness, 1 for speech disturbance without weakness, (D) 2 points for an attack lasting > or =1 h and 1 point for an attack lasting 10-59 min. A patient with a total score of 5 has a risk of 12.1% of developing a cerebral infarct within 7 days. In a patient with a score of 6 this risk is 31.4%.

Dietary fatty acids and the risk of Parkinson disease: The Rotterdam Study

BACKGROUND

Unsaturated fatty acids are important constituents of neuronal cell membranes and have neuroprotective, antioxidant, and anti-inflammatory properties.

OBJECTIVE

To determine if a high intake of unsaturated fatty acids might be associated with a lower risk of Parkinson disease (PD).

METHODS

In the Rotterdam Study, a prospective population-based cohort study of people ages > or =55, the association between intake of unsaturated fatty acids and the risk of incident PD was evaluated among 5,289 subjects who were free of dementia and parkinsonism and underwent complete dietary assessment at baseline. PD was assessed through repeated in-person examination, and the cohort was continuously monitored by computer linkage to medical records. The data were analyzed using Cox proportional hazards regression models.

RESULTS

After a mean follow-up of 6.0 years, 51 participants with incident PD were identified. Intakes of total fat, monounsaturated fatty acids (MUFAs), and polyunsaturated fatty acids (PUFAs) were significantly associated with a lower risk of PD, with an adjusted hazard ratio per SD increase of energy-adjusted intake of 0.69 (95% CI 0.52 to 0.91) for total fat, of 0.68 (95% CI 0.50 to 0.94) for MUFAs, and 0.66 (95% CI 0.46 to 0.96) for PUFAs. No associations were found for dietary saturated fat, cholesterol, or trans-fat.

CONCLUSION

These findings suggest that high intake of unsaturated fatty acids might protect against Parkinson disease.

Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study

BACKGROUND

Determinants of survival and of risk of vascular events after transient ischaemic attack (TIA) or minor ischaemic stroke are not well defined in the long term. We aimed to restudy these risks in a prospective cohort of patients after TIA or minor ischaemic stroke (Rankin grade< or =3), after 10 years or more.

METHODS

We assessed the survival status and occurrence of vascular events in 2473 participants of the Dutch TIA Trial (recruitment in 1986-89; arterial cause of cerebral ischaemia). We included 24 hospitals in the Netherlands that recruited at least 50 patients. Primary outcomes were all-cause mortality and the composite event of death from all vascular causes, non-fatal stroke, and non-fatal myocardial infarction. We assessed cumulative risks by Kaplan-Meier analysis and prognostic factors with Cox univariate and multivariate analysis.

FINDINGS

Follow-up was complete in 2447 (99%) patients. After a mean follow-up of 10.1 years, 1489 (60%) patients had died and 1336 (54%) had had at least one vascular event. 10-year risk of death was 42.7% (95% CI 40.8-44.7). Age and sex-adjusted hazard ratios were 3.33 (2.97-3.73) for age over 65 years, 2.10 (1.79-2.48) for diabetes, 1.77 (1.45-2.15) for claudication, 1.94 (1.42-2.65) for previous peripheral vascular surgery, and 1.50 (1.31-1.71) for pathological Q waves on baseline electrocardiogram. 10-year risk of a vascular event was 44.1% (42.0-46.1). After falling in the first 3 years, yearly risk of a vascular event increased over time. Predictive factors for risk of vascular events were similar to those for risk of death.

INTERPRETATION

Long-term secondary prevention in patients with cerebral ischaemia still has room for further improvement.

Incidence of parkinsonism and Parkinson disease in a general population: the Rotterdam Study

OBJECTIVE

To investigate the incidence of parkinsonism and Parkinson disease (PD) in the general population using in-person screening along with clinical data.

METHODS

In the Rotterdam study, a prospective population-based cohort study of people aged > or =55 years, the authors assessed age- and sex-specific incidence rates of parkinsonism and PD among 6,839 participants who were free of parkinsonism at baseline. Case finding involved in-person screening at baseline and two follow-up visits, and additional information was obtained through continuous monitoring of the cohort by computer linkage to general practitioners' and pharmacy records.

RESULTS

After a mean follow-up period of 5.8 years, 132 subjects with incident parkinsonism were identified, of whom 67 (51%) had PD. The incidence of parkinsonism and PD increased with age, with incidence rates for PD increasing from 0.3 per 1000 person-years in subjects aged 55 to 65 years, to 4.4 per 1000 person-years for those aged > or =85 years. The overall age-adjusted incidence rate of any parkinsonism was not different in men and women, but men seem to have a higher risk for PD (male-to-female ratio, 1.54; 95% CI, 0.95 to 2.51).

CONCLUSION

Incidence rates for parkinsonism and Parkinson disease were higher than those reported by most previous studies, possibly because of the authors' intensive case-finding methods involving in-person screening.

Non–adherence to aspirin or oral anticoagulants in secondary prevention after ischaemic stroke

BACKGROUND

The effectiveness of medication is influenced by treatment adherence. After TIA or minor disabling stroke patients usually are advised to take antithrombotic medication. Stroke patients are an interesting group of patients with respect to adherence, since cardiovascular risk factors and stroke may (indirectly) negatively influence brain function, which can affect adherence. We investigated determinants of non-adherence in patients who used aspirin or oral anticoagulation after cerebral ischaemia of arterial origin.

METHODS

Data of patients prospectively followed in two clinical trials (the Dutch TIA Trial and the Stroke Prevention In Reversible Ischaemia Trial) were analysed with Cox proportional hazards modelling.

RESULTS

In the two trials 3796 patients were treated with aspirin. During a mean follow-up of 2.1 years, 689 patients (18%) prematurely stopped treatment, 305 (8 %) did so without a clear medical reason (non-adherence). Age >or= 65 years and the use of 300 instead of 30 mg of aspirin were independently associated with non-adherence. Diastolic blood pressure of >or= 90 mmHg and dizziness were associated with better adherence. Of 651 patients on oral anticoagulation, 143 patients (22 %) stopped after a mean follow-up of 1.0 year, 66 (10 %) did so because of nonadherence. No statistically significant determinants for non-adherence were identified.

CONCLUSION

As found in the literature on nonadherence in general, age of >or= 65 years and a higher dose of aspirin (300 mg versus 30 mg) were independently associated with non-adherence with aspirin treatment that was prescribed for secondary prevention after cerebral ischaemia of arterial origin. Older patients may require extra encouragement to continue antithrombotic treatment. Lower doses of aspirin may improve treatment adherence.

[The practice guideline 'TIA' (first revision) from the Dutch College of General Practitioners; a response from the perspective of neurology]

The revised TIA guideline is a significant improvement: the diagnosis 'TIA' no longer depends on the symptoms having disappeared within 24 h, the criteria for referral to a neurologist have been widened, and the antithrombotic treatments for the various manifestations of cardiovascular disease have been harmonised.

Diagnostic value of the Rotterdam-CAMCOG in post-stroke dementia

BACKGROUND AND OBJECTIVE

Specific screening tests to detect post-stroke dementia are lacking. We recently reported that an adaptation of the Cambridge Cognitive Examination (CAMCOG), the Rotterdam-CAMCOG, had excellent sensitivity and specificity for detecting post-stroke dementia. In this study, we externally validated the diagnostic accuracy of the R-CAMCOG in a new, representative cohort of stroke patients.

METHODS

The R-CAMCOG and an extensive neuropsychological examination were administered, independently of each other, in 121 patients aged 55 and over with a stroke in the preceding three to nine months. The gold standard diagnosis of dementia was based on the results of the extensive neuropsychological examination, clinical presentation, and information from a close relative, as well as DSM-IV criteria.

RESULTS

Of the 121 patients, 35 had dementia (29%). The diagnostic accuracy at the pre-specified cut-off point of 33/34 was established through receiver operating characteristic (ROC) analyses (sensitivity 66%, specificity 94%). At a cut-off point of 36/37 sensitivity would be 83% and specificity 78%.

CONCLUSION

The R-CAMCOG is a useful screening tool for post-stroke dementia in a clinical setting.

The -148 C/T fibrinogen gene polymorphism and fibrinogen levels in ischaemic stroke: a case-control study

BACKGROUND

To determine whether -148 C/T fibrinogen gene promoter polymorphism increases stroke risk by modifying the fibrinogen level.

DESIGN

A case-control study of patients with first ever ischaemic stroke, confirmed by computed tomography.

METHODS

Venous blood samples were collected for fibrinogen and routine coagulation tests one week after the stroke, and after three months in about half the patients. Population controls were age and sex matched. -148 C/T fibrinogen polymorphism was determined by polymerase chain reaction followed by digestion with restriction enzymes HindIII/AluI.

RESULTS

There were 124 patients and 125 controls, mean age 56 years (range 18 to 75); 34 patients (27%) and 41 controls (33%) were heterozygous for -148 C/T fibrinogen polymorphism; six patients (5%) and five controls (4%) had the T/T genotype. The odds ratio of ischaemic stroke associated with CC homozygotes v T carriers was 0.8 (95% confidence interval, 0.5 to 1.4). Relative risk for ischaemic stroke associated with fibrinogen levels in the highest quartile was 3.9 (1.9 to 8.4) at one week, decreasing to 1.4 (0.6 to 3.3) at three months.

CONCLUSIONS

-148 C/T fibrinogen gene polymorphism was not a strong risk factor for ischaemic stroke. High fibrinogen levels early after acute stroke probably represent an acute phase response.

Variations in estrogen receptor alpha gene and risk of dementia, and brain volumes on MRI

The role of estrogens in Alzheimer's disease (AD) is controversial. We investigated the association between well-recognized, and potentially functional, polymorphisms in the estrogen receptor (ER) alpha gene and the risk of AD in a prospective study of 6056 Caucasian older men and women aged 55 years and over. In a subset of 468 participants, we assessed volumes of the hippocampus and amygdala, which have a high density of ER alpha, with brain magnetic resonance imaging (MRI) (1.5 T MR unit). During a total of 35 405 person-years of follow-up (mean per persons 5.8 years), 312 new cases of dementia were detected, of whom 230 were diagnosed with AD. Neither the PvuII nor the XbaI polymorphism or haplotypes thereof were associated with the risk of all-cause dementia or AD. In contrast, we found that nondemented women who carried the PvuII p allele or haplotype 'px' had smaller amygdalar volumes on MRI in an allele-dose-dependent fashion. Total amygdalar volume was 4.50 (SE 0.10) in PP genotype, 4.45 (SE 0.06) in Pp genotype, and 4.18 ml (SE 0.08) in pp genotype (P trend=0.008). Further studies are required to investigate whether this smaller amygdalar volume has functional significance.

Spinal dural arteriovenous fistulas: long-term follow-up of 44 treated patients

To assess the long-term clinical course of 44 patients treated for a spinal dural arteriovenous fistula, patients were re-examined after a median follow-up of 5.7 years. In total, 70% of patients rated their activities of daily life as better or much better than before treatment. In most patients, gait disturbances and muscle strength had improved after treatment, with reduced disability; problems with micturition, defecation, and erection tended to remain unchanged.

Spinal Dural Arteriovenous Fistulas Are Not Associated With Prothrombotic Factors

Background and Purpose— The cause of spinal dural arteriovenous fistulas (SDAVF) is unknown. In intracranial dural arteriovenous fistulas, an association with factor V Leiden mutation has been found. Therefore, we studied the association between prothrombotic factors and SDAVF.

Methods— Factor V Leiden mutation, factor II mutation, protein S, protein C, factor VIII, von Willebrand factor, antithrombin III, and lupus anticoagulant were determined by means of standard laboratory tests in 40 patients and 119 control subjects matched for sex and age.

Results— Factor V Leiden mutation was not found in the patient group and was found twice in the control group. Factor II mutation was found in 1 patient and in none of the control subjects. There was no decreased activity of protein S, protein C, factor VIII, von Willebrand factor, or antithrombin III in patients in comparison with controls. Lupus anticoagulant was not found in the patient group and once in the control subjects.

Conclusions— We conclude that it is unlikely that prothrombotic factors are involved in the pathogenesis of spinal dural arteriovenous fistulas, but subtle associations are not ruled out.

The impact of APOE on myocardial infarction, stroke, and dementia: the Rotterdam Study

It is unclear how the APOE genotype contributes to the incidence of vascular diseases and dementia. In a population-based sample (n = 6,852) with complete follow-up, APOE was weakly associated with myocardial infarction and not related with stroke. In the absence of epsilon4, the incidence of dementia would be 25.8% lower; in the absence of epsilon2/epsilon3, 2.8% higher. Risk estimates of dementia, specified for age, sex, and APOE, are provided for counseling. APOE is not strongly related to vascular diseases, but contributes substantially to dementia incidence.

Do antiphospholipid antibodies increase the long-term risk of thrombotic complications in young patients with a recent TIA or ischemic stroke?

BACKGROUND

The purpose of our study was to determine the relative risk of thrombotic events in young patients with a recent TIA or ischemic stroke and positive antiphospholipid antibodies (aPL).

METHODS

We included 128 consecutive patients aged 18-45 years with a recent TIA or ischemic stroke. All patients underwent computed tomography scanning and were screened for cardiovascular risk factors, cardiac disorders and large vessel disease. Lupus anticoagulant (LA) was screened for by an APTT-based assay and a diluted PT-assay. Anticardiolipin antibodies (aCL) were tested by enzyme-linked immunosorbent assay, using cardiolipin and anti-human IgG and IgM. Thrombotic events could be TIA, stroke, myocardial infarction, deep venous thrombosis or pulmonary embolism. Product limit estimates of the time free of TIA or stroke and of the time free of any thrombotic event were made. The relative risk was estimated by means of a Cox proportional hazards regression model.

RESULTS

Of the 128 patients, 22 (17.2%) had aPL. The mean follow-up was 3 years and 3 months (range 41 days to 6 yrs). The incidence of any thrombotic event per 100 patient years of follow-up was 9.0, and the incidence of recurrent stroke or TIA was 7.9. The relative risk of any thrombotic event in patients with aPL was 0.9 (95% CI: 0.3-2.4) and for recurrent ischemic stroke or TIA 0.7 (95% CI: 0.3-2.2).

CONCLUSION

In young patients with a recent TIA or ischemic stroke, aPL do not seem to be a strong risk factor for recurrent stroke or TIA, nor for other thrombotic complications.

Measuring progression of cerebral white matter lesions on MRI

OBJECTIVE

To evaluate the concordance of a volumetric method for measuring white matter lesion (WML) change with visual rating scales.

METHODS

The authors selected a stratified sample of 20 elderly people (mean age 72 years, range 61 to 88 years) with an MRI examination at baseline and at 3-year follow-up from the community-based Rotterdam Scan Study (RSS). Four raters assessed WML change with four different visual rating scales: the Fazekas scale, the Scheltens scale, the RSS scale, and a new visual rating scale that was designed to measure change in WML. The authors assessed concordance with a volumetric method with scatter plots and correlations, and interobserver agreement with intraclass correlation coefficients.

RESULTS

For assessment of change in WML, the Fazekas, Scheltens, and periventricular part of the RSS scale showed little correlation with volumetrics, and low interobserver agreement. The authors' new WML change scale and the subcortical part of the RSS scale showed good correlation with volumetrics. After additional training, the new WML change scale showed good interobserver agreement for measuring WML change.

CONCLUSIONS

Commonly used visual rating scales are not well suited for measuring change in white matter lesion severity. The authors' new white matter lesion change scale is more accurate and precise, and may be of use in studies focusing on progression of white matter lesions.

Arterial oxygen saturation, COPD, and cerebral small vessel disease

OBJECTIVE

To study whether lower arterial oxygen saturation (SaO(2)) and chronic obstructive pulmonary disease (COPD) are associated with cerebral white matter lesions and lacunar infarcts.

METHODS

We measured SaO(2) twice with a pulse oximeter, assessed the presence of COPD, and performed MRI in 1077 non-demented people from a general population (aged 60-90 years). We rated periventricular white matter lesions (on a scale of 0-9) and approximated a total subcortical white matter lesion volume (range 0-29.5 ml). All analyses were adjusted for age and sex and additionally for hypertension, diabetes, body mass index, pack years smoked, cholesterol, haemoglobin, myocardial infarction, and left ventricular hypertrophy.

RESULTS

Lower SaO(2) was independent of potential confounders associated with more severe periventricular white matter lesions (score increased by 0.12 per 1% decrease in SaO(2) (95% confidence interval 0.01 to 0.23)). Participants with COPD had more severe periventricular white matter lesions than those without (adjusted mean difference in score 0.70 (95% confidence interval 0.23 to 1.16)). Lower SaO(2) and COPD were not associated with subcortical white matter lesions or lacunar infarcts.

CONCLUSION

Lower SaO(2) and COPD are associated with more severe periventricular white matter lesions.

Risk of Intracerebral Hemorrhage in Patients With Arterial Versus Cardiac Origin of Cerebral Ischemia on Aspirin or Placebo

Background and Purpose— Patients who are anticoagulated after cerebral ischemia have a 19-fold-higher risk of intracerebral hemorrhage (ICH) if they had an arterial rather than a cardiac source. To determine whether this excess risk of ICH was due to the underlying disease (cerebral ischemia of arterial versus cardiac origin) or whether it depended on the antithrombotic regimen, we studied the risk of ICH in arterial versus cardiac origin of cerebral ischemia in patients who received aspirin or no antithrombotic drugs.

Methods— Individual patient data of patients who received aspirin or placebo after cerebral ischemia were obtained from 9 clinical trials. Presence of atrial fibrillation was considered evidence of a cardiac source. Otherwise, events were considered of arterial origin. Cox proportional-hazards modeling was used for univariate and multivariate analyses.

Results— Fifty-four ICHs occurred in 16 625 patient-years in the aspirin-treated patients, and 7 ICHs occurred in 4317 patient-years in those on placebo. After multivariate adjustment for age, sex, current smoking, history of hypertension and diabetes, and aspirin dose (aspirin-treated patients only), the hazard ratio for ICH in patients with an arterial versus a cardiac source was 0.74 (95% confidence interval, 0.30 to 1.82) for aspirin-treated patients and 4.34 (95% confidence interval, 0.35 to 54) for placebo-randomized patients.

Conclusions— Our findings do not confirm the previous finding of an excess risk of ICH in patients with cerebral ischemia of arterial origin. Therefore, it seems that having cerebral ischemia of arterial origin by itself is not associated with an increased risk of ICH, but only in combination with high-intensity anticoagulation.

[Modifiable determinants of delayed hospital admission following a cerebrovascular accident]

OBJECTIVE

To identify the modifiable determinants of delayed hospital admission of stroke patients.

DESIGN

Multicentre observational study.

METHOD

In the period from 1 October 1998 to 31 May 1999, before thrombolysis was an accepted treatment for ischaemic stroke in the Netherlands, we interviewed 252 consecutively admitted patients with stroke upon admission. The patients were asked to describe their symptoms and personal reaction to the stroke event in everyday language. The study was carried out in 14 regional hospitals and one university hospital in the Netherlands. The determinants of delay were calculated by means of multiple linear regression analysis.

RESULTS

A total of 252 patients took part in the study: 136 men and 116 women, of whom 130 (52%) were 75 years of age or older. The median time from onset of symptoms to calling in any professional assistance was 60 minutes. The median time from onset of symptoms to arrival at the hospital was 5 hours and 10 minutes. One-third (n = 87; 34%) of the patients reached the hospital within 2.5 hours. Nearly half of the patients (46%) recognised their symptoms as a stroke. Patients who had not recognised their symptoms as a stroke (54%) and patients who had waited until their symptoms had worsened (20%) waited longer before calling in professional assistance than those who did not. Hospital admission was delayed in patients who had waited until their symptoms had worsened, and in those who had first called a family physician (87%). On the other hand, a more rapid admission was achieved in case of referral by the family physician by telephone and also after transportation by ambulance (77%).

CONCLUSION

The modifiable determinants of delayed calling for professional help by stroke patients were the fact that they did not recognise the symptoms as a stroke, and the circumstance that they waited until the symptoms would disappear or become worse. This latter circumstance, referral by the family physician by telephone and transportation by ambulance, were modifiable determinants of delayed hospital admission.

Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischaemic attack

BACKGROUND

People with nonrheumatic atrial fibrillation (NRAF) who have had a transient ischaemic attack (TIA) or a minor ischaemic stroke are at high risk of recurrent stroke.

OBJECTIVES

The objective of this review was to assess the effect of anticoagulants for secondary prevention, after a stroke or TIA, in patients with NRAF.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (9 June 2003) and contacted trialists.

SELECTION CRITERIA

Randomised trials comparing oral anticoagulants with control (no therapy) or placebo in people with NRAF and a previous TIA or minor ischaemic stroke. Control groups on aspirin did not meet the selection criteria.

DATA COLLECTION AND ANALYSIS

Both reviewers assessed trial quality and extracted data.

MAIN RESULTS

Two trials involving 485 people were included. Follow-up time was 1.7 years in one trial and 2.3 years in the other. Anticoagulants reduced the odds of recurrent stroke by two-thirds (odds ratio (OR) 0.36, 95% confidence interval (CI) 0.22 to 0.58). The odds of all vascular events was shown to be almost halved by treatment (OR 0.55, 95% CI 0.37 to 0.82). The odds of major extracranial haemorrhage was increased (OR 4.32, 95% CI 1.55 to 12.10). No intracranial bleeds were reported among people given anticoagulants.

REVIEWERS' CONCLUSIONS

The evidence suggests that anticoagulants are beneficial, without serious adverse effects, for people with NRAF and recent cerebral ischaemia.

Type 2 diabetes and atrophy of medial temporal lobe structures on brain MRI

AIM/HYPOTHESIS

Type 2 diabetes increases the risk not only of vascular dementia but also of Alzheimer's disease. The question remains whether diabetes increases the risk of Alzheimer's disease by diabetic vasculopathy or whether diabetes influences directly the development of Alzheimer neuropathology. In vivo, hippocampal and amygdalar atrophy on brain MRI are good, early markers of the degree of Alzheimer neuropathology. We investigated the association between diabetes mellitus, insulin resistance and the degree of hippocampal and amygdalar atrophy on magnetic resonance imaging (MRI) accounting for vascular pathology.

METHODS

Data was obtained in a population-based study of elderly subjects without dementia between 60 to 90 years of age. The presence of diabetes mellitus and, in non-diabetic subjects, insulin resistance was assessed for 506 participants in whom hippocampal and amygdalar volumes on MRI were measured. We assessed the degree of vascular morbidity by rating carotid atherosclerosis, and brain white matter lesions and infarcts on MRI.

RESULTS

Subjects with diabetes mellitus had more hippocampal and amygdalar atrophy on MRI compared to subjects without diabetes mellitus. Furthermore, increasing insulin resistance was associated with more amygdalar atrophy on MRI. The associations were not due to vascular morbidity being more pronounced in persons with diabetes mellitus.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes is associated with hippocampal and amygdalar atrophy, regardless of vascular pathology. This could suggest that Type 2 diabetes directly influences the development of Alzheimer neuropathology.

Dietary antioxidants and the risk of ischemic stroke: The Rotterdam Study

In the Rotterdam Study, the authors investigated whether high intake of antioxidants from food is associated with the risk of stroke. Among 5,197 participants who were followed on average for 6.4 years, 227 ischemic strokes occurred. Higher intake of antioxidants was associated with a lower risk of stroke. The relationship was dose-dependent, significant for vitamin C, and most pronounced in smokers. These results agree with the view that high dietary intake of antioxidants, in particular vitamin C and--in smokers--vitamin E, reduces the risk of stroke.

Comparison between measures of atherosclerosis and risk of stroke: the Rotterdam Study

BACKGROUND AND PURPOSE

Several measures of atherosclerosis predict the risk of stroke. However, a comparison between various measures of atherosclerosis is lacking, and limited information exists on the added value of individual measures of atherosclerosis to cardiovascular risk factors. We compared different measures of atherosclerosis in relation to stroke.

METHODS

The study was based on the prospective cohort of the Rotterdam Study and included 6913 participants who did not suffer from previous stroke. At baseline, carotid intima-media thickness and plaques, ankle-arm index, and aortic calcifications were assessed; 3996 participants (53%) had measures of all studied markers of atherosclerosis. After a mean follow-up of 6.1 years, 378 strokes occurred. Data were analyzed with Cox proportional-hazards regression and Akaike information criteria scores.

RESULTS

Carotid intima-media thickness and aortic calcifications were related most strongly to the risk of stroke (relative risk, 2.23 and 1.89; 95% confidence interval, 1.48 to 3.36 and 1.28 to 2.80 for highest versus lowest tertile, respectively). The relations between intima-media thickness, aortic calcifications, and carotid plaques and stroke remained after adjustment for cardiovascular risk factors. Intima-media thickness and aortic calcifications were related to the risk of stroke independently of each other. The relation between ankle-arm index and stroke disappeared after adjustment for cardiovascular risk factors.

CONCLUSIONS

Carotid intima-media thickness and aortic calcifications are stronger predictors of incident stroke than carotid plaque or ankle-arm indexes. They have additional value to each other and to classic risk factors and may reflect different processes.

Spinal dural arteriovenous fistulas: clinical features in 80 patients

The aim of this study was to describe the clinical spectrum of spinal dural arteriovenous fistulas (SDAF) in a large group of patients. We studied the records of 80 patients who were diagnosed with an SDAF in six hospitals over a 15 year period (1985-2001). We extracted data on demographic variables, initial symptoms, symptoms at the time of diagnosis, level of SDAF, and medical history. Most patients were middle aged men, and most SDAF were located in the midthoracic region. The median time to diagnosis of 80 patients with an SDAF was 15 months (range 7 days-197 months). The most common initial symptoms were gait disturbances (34%), numbness (24%), and paresthesias (21%). At the time of diagnosis, most common symptoms were micturition problems (80%), leg weakness (78%), and numbness in the legs or buttocks (69%). The combination of all three symptoms was present in 58% of patients. Any symptoms or signs related to sacral segments had developed in 67 patients (84%). Fifteen patients (19%) had become wheelchair bound. SDAF is difficult to diagnose, and the delay between first symptoms and treatment is often long. In middle aged men who present with disturbances of gait with ascending motor and sensory deficits, and who subsequently report impaired voiding or other sphincter disturbance, SDAF is one of the first diagnoses that should spring to mind.