Non invasive assessment of the internal carotid artery in stroke patients

The internal carotid arteries were evaluated with Doppler ultrasound technique in patients with acute cerebrovascular disease. The results of the Doppler examination of 325 vessels were compared to presence of carotid bruits on auscultation. In 126 arteries the findings were also compared with those on aortocervical, single carotid or post-mortal angiography. The Doppler flow reaction was normal in 74% of the vessels, uncertain in 20% and pathologic in 6%. The sensitivity of the Doppler assessment in finding stenosis of more than 75% lumen diameter reduction was 85% with a specificity of 94%. The specificity increased with higher degree of vascular stenosis. Carotid bruits were heard in 34 arteries. The sensitivity of auscultation in detecting stenosis 75% was 47% with a specificity of 83%. The sensitivity fell with higher degree of stenosis. The Doppler procedure is a valuable tool in detecting haemodynamically significant stenoses in the internal carotid artery. The method could serve the following purposes in the clinical situation: 1. Screening procedure for further investigations in TIA and minor stroke patients fit enough to be candidates for vascular surgery. 2. Before blood-pressure can be safely reduced in patients with cerebrovascular disease. 3. For evaluation of the arteriosclerotic process in stroke-patients thereby improving prognostication.

Prognosis in acute stroke with special reference to some cardiac factors

Neurological assessments were done regularly during hospitalization in 283 consecutive patients (mean age 73 yr) with acute cerebrovascular disease treated at the Stroke Unit of Serafimerlasarettet. A preplanned investigation program and strict criteria for diagnosis and treatment were followed. Hospital mortality was 18%. Patients with a major cerebral infarction or haemorrhage often died very early during the hospital period and deaths due to complications increased significantly during the second week. Multivariate analysis regarding mortality showed that a low neurological score and heart failure were the most important factors for the short-term prognosis. In those patients with cerebral infarction, ambulatory capacity and ECG-diagnosed bundle branch block added significantly to the prognostic power of the neurological score. Among the 227 patients discharged alive, 1 and 2-yr mortality was 14 and 18% respectively. Here, the most important long-term prognostic factors were age and ST changes on the ECG. Again, considering only patients with cerebral infarction (N = 190), bundle branch block was found to be the single most useful predictive factor. Prognostication in acute ischemic stroke should thus be based not only on neurological findings but on careful evaluation of associated cardiac disease, especially in the long-term perspective.

Accuracy of bedside diagnosis in stroke

The clinical diagnosis of the type of acute cerebrovascular diseases is often considered unreliable, although this has not been validated prospectively in representative patients. The accuracy of bedside diagnostics was, therefore, tested in 206 patients consecutively admitted to the Stroke Unit of the Serafimerlasarettet in Stockholm. Bedside diagnosis turned out to be correct in 69%. In 24% the diagnoses were altered after hospital investigation and in the remaining 7% no defined preliminary and/or final diagnosis could be made. When the diagnoses were considered "fairly certain" they were accurate in 87%, compared to 53% when regarded as only "probable". The diagnostic accuracy improved during the period studied. Sensitivity in identifying hemorrhages was much lower (39%) than for cerebral infarctions (83%). It is suggested that new investigational methods should be compared with what can be accomplished with bedside methods alone.

Comparative clinical features in patients with myasthenia gravis with systemic lupus erythematosus

The occurrence of myasthenia gravis (MG) with systemic lupus erythematosus (SLE) seems to be more common than random association alone would predict. Moreover, both share immunologic aspects, tissue-directed antibodies and T and B cell abnormalities. To our knowledge, 7 cases of MG in association with SLE have been reported in the English literature in the last 15 yr; in 6 of the 7 cases, MG preceded the SLE; in only 1 reported case and in our case, SLE preceded the MG. The disease that develops later predominates in the prognosis for each patient.

Lack of effect of theophylline on the outcome of acute cerebral infarction

In patients with acute ischemic stroke, dramatic but often transient improvements have been noticed after theophylline injections. Whether better results could be obtained by continuous infusion of the drug was evaluated in a double-blind study. Out of 46 patients with a mean age of 75 years, 22 got theophylline as aminophylline (bolus dose of 230 mg followed by 0.5 mg/kg/h) and 24 placebo during 3 days. The groups were comparable in all aspects at the outset of the trial. Serum theophylline concentrations were kept within the therapeutic range recommended for patients with asthma. No significant difference in outcome was noticed between the groups during the hospital period when repeated neurological assessments by two different scores and mortality were compared.

Sulindac in ankylosing spondylitis. Double-blind evaluation of sulindac and indomethacin

Ankylosing spondylitis affects about 1% of the population. In the past, evaluation of therapy in the management of this disease has been hampered by the lack of availability of objective criteria for following the condition. By using recently developed measurements of spinal mobility and other variables we have compared sulindac, a recently introduced nonsteroidal antiinflammatory drug, and indomethacin in a double-blind six-month parallel study of 30 patients. Sulindac and indomethacin have comparable efficacy and tolerance. Advantages of sulindac include a twice-a-day dose regimen.

Fibrinolytic and hemostatic changes during and after maximal exercise in males

To evaluate changes in fibrinolytic activity, factor VIII and other hematological variables during and after a progressive step increment in work load, 10 healthy male subjects (22-27 yr of age) were exercised to exhaustion on an electromagnetic bicycle ergometer. Blood samples were drawn serially throughout the experiment. Little change in fibrinolytic activity was observed before 70-80% maximum heart rate (MHR) was achieved. Major changes occurred after 80% MHR. Peak values coincided with maximum exercise. In contrast major changes in factor VIII were observed between 95 and 100% MHR with peak values occurring 5-10 min postexercise. An increase in white blood cell count, platelet count, and retention was observed at maximum exercise. One individual failed to demonstrate an increase in either fibrinolytic or factor VIII activity. Relating the data to either the percent maximal oxygen uptake or percent maximal heart rate demonstrates the importance of the exercise protocol and exerting all subjects to the same relative level of physiological work.

Prothrombin complex concentrate (Konyne) in the treatment of hemophilic patients with factor VIII inhibitors

Two prothrombin complex concentrates, Auto-Factor IX and Proplex, have been reported to be effective in controlling bleeding in hemophilic patients with factor VIII inhibitors. A third PCC, Konyne, was used to treat 64 bleeding episodes (130 infusions) in five hemophilic patients with factor VIII inhibitors. Prompt control of bleeding was observed in each instance with doses of 15 to 100 units of factor IX/kg; no complications were encountered. Konyne resulted in in vivo and in vitro shortening of the partial thromboplastin time of patients with factor VIII inhibitors, but the mechanism of action is unknown. If further studies confirm the efficacy and safety of PCC in the treatment of such patients, its use for this purpose could lead to significant saving of factor VIII concentrates.