Shared Neuroanatomical Substrates for Co-occurring Swallowing and Communication Impairments after Acute Stroke

INTRODUCTION

Post-stroke dysphagia and communication impairments occur in two-thirds of acute stroke survivors. Identifying the shared neuroanatomical substrate for related impairments could facilitate the development of cross-system therapies. Our purpose was to elucidate discrete brain regions predictive of the combined presence of dysphagia alongside dysarthria and/or aphasia post-stroke.

METHODS

We included 40 right (RHS) and 67 left hemisphere (LHS) patients from an acute ischemic stroke cohort with lesions demarcated on diffusion weighted imaging. We undertook binary non-parametric voxel-lesion symptom mapping with a false discovery rate of p <0.05 for co-occurring dysphagia, dysarthria, and aphasia (LHS only). If no voxels survived the threshold, a cluster analysis of >20 voxels involving an uncorrected p <0.01 was applied to identify brain regions associated with the co-occurring impairments.

RESULTS

Cluster analyses revealed that dysphagia and dysarthria were associated with insular and superior temporal gyrus (STG) involvement after RHS and with basal ganglia (BG), internal capsule, and thalamic involvement after LHS. Co-occurring dysphagia, dysarthria, and aphasia were associated with BG, STG, and insular cortex involvement.

DISCUSSION

Our findings highlight the role of the insula and structures of the BG in co-occurrence patterns involving dysphagia, dysarthria, and aphasia. These newly identified biomarkers may inform new rehabilitation therapeutic targets for treating cross-system functions.

Longitudinal assessment of imatinib's effect on the blood-brain barrier after ischemia/reperfusion injury with permeability MRI

Acute ischemic stroke (AIS) often results in degeneration of the blood-brain barrier (BBB), which can lead to vasogenic edema and an increased risk of intracerebral hemorrhage. Imatinib is an agent that may be able to protect the BBB and reduce the risk of the harmful consequences of BBB degeneration. We sought to measure the effect of Imatinib on the BBB after experimental stroke longitudinally in vivo with permeability dynamic contrast-enhanced MRI. Ischemia/reperfusion injury was induced with a transient middle cerebral artery occlusion surgery. Rats were given Imatinib at 2 and 20 h after stroke onset. Post-assessment included neurologic functioning, MR imaging, Evans Blue extravasation, Western blot, and immunohistology assay. Imatinib protected the BBB by 24 h but failed to decrease BBB permeability at an earlier time-point. Imatinib also reduced infarct volume, edema, and improved neurologic functioning by 24 h. Rats treated with Imatinib also had a higher expression of the BBB structural protein Zona ocludens-1 and a reduction in nuclear factor-kappa beta (NF-κβ) activation. Imatinib is a promising agent to protect the BBB after AIS, but its effect on the BBB may not become prominent until 24 h after the onset of ischemia. This finding may help elucidate Imatinib's role in the clinical management of AIS and influence future study designs.

Abstract 20: Relationship Between Physician Annual Volume And Stroke Mortality - Results From the Ontario Stroke Registry

Objective: Previous studies have demonstrated an inverse relationship between hospital volume and stroke mortality. However, little is known about the effect of physician volume on stroke mortality.

Methods: We used the Ontario Stroke Registry (OSR) to identify a cohort of stroke/TIA patients admitted to 11 regional stroke centers in Ontario, Canada (Jul 2003 - Mar 2008). The most responsible admitting physician was identified by linking the OSR data to the Discharge Abstract Database maintained by the Canadian Institute for Health Information. The risk of death after discharge was determined through linkages to the Ontario Registered Persons Database. Patients were divided into quintiles based on the annual volumes of the most responsible physicians. Multivariable analyses of physician volume effect were conducted using random effects hierarchical logistic regression models, adjusting for patient characteristics (sex, age, severity, stroke type, comorbidity and in-hospital care), physician characteristic (physician type, annual volume) and hospital characteristics (annual volume). Risk-adjusted mortality rates were calculated to determine if there was a threshold effect for physician volume.

Results: There were 14,285 admitted stroke/TIA patients who were treated by 783 physicians. Physician volume had an inverse relationship with in-hospital mortality and 30-day mortality (p<0.0001). Risk-adjusted rates are shown in Figure.

Conclusion: Higher physician annual volume is associated with lower stroke mortality at the regional stroke centers (average volume: 180~370 patients/year). A minimum annual volume of seeing stroke patients by admitting physicians should be recommended. Shifting the care of more stroke patients to high-volume physicians could potentially reduce mortality after stroke.

Abstract WP392: Reducing Readmissions through Secondary Stroke Prevention Clinics

Introduction: Secondary Stroke Prevention Clinics (SPCs) were established in Ontario to provide the opportunity for appropriate patients to access best practice stroke care approaches to reduce the risk of recurrent stroke/TIA. Previous evaluations have shown that SPCs provide high quality care based on evidence-based performance measures; however the impact of SPCs on readmission rates has not been examined. Information on the proportion of patients who are readmitted to hospital for stroke/TIA after being seen at an SPC is important to understanding the role of SPCs in preventing stroke/TIA in Ontario.

Methods: The Ontario Stroke Registry’s SPIRIT-SPC database was used to identify patients with presumed stroke/TIA referred to 13 SPCs between January 2007 and April 2011. Patients with a first clinic visit and an index stroke/TIA event between January 2007 and September 2010 were linked to Canadian Institute of Health Information (CIHI) inpatient database to calculate stroke-related readmission rates. Patients with elective admissions were excluded. The rates were based on the four years of data and were age- and sex- adjusted.

Results: The study included 15,163 patients from SPIRIT-SPC seen at 13 SPCs in Ontario. The mean age was 66 years (±14) and 49.3% of patients were female. Seventy-eight percent (n= 11,777) of patients had an index stroke/TIA event reported on the SPC referral and of these only 60% (n = 9,040) had an ED visit or inpatient admission record in the CIHI databases capturing the index stroke/TIA event. The median time from referral to initial visit was 11 days. The stroke/TIA 30-, 90- and 180-day readmission rates following the SPC first visit were 0.7%, 1.3% and 1.8%, respectively. Variation in readmission rates across 13 SPCs ranged from 0 - 6%.

Conclusion: Stroke/TIA-related readmission rates among patients seen at the 13 SPCs in Ontario patients are lower than what is reported in the literature and lower than observed among patients discharged from acute hospitals following a stroke/TIA ED visit or in-hospital stay. The lower rates observed at the 13 clinics may reflect less severe patients being seen at SPCs. Risk-adjusted models will be taken into consideration for future studies.

Abstract 3794: Investigating Gender Differences in Secondary Stroke Prevention Care in Ontario

Introduction: In Ontario, more women than men (51% vs. 49% in 2009/10) are admitted for stroke or transient ischemic attack (TIA). Women are also older when they experience stroke or TIA (78 vs. 72 median years) and have strokes resulting in greater disability. Best practice stroke care indicates secondary stroke prevention is essential to reducing the likelihood of recurrent vascular events following stroke or TIA. There is currently limited information about whether or not gender differences exist in the type of care delivered at Secondary Stroke Prevention Clinics (SPCs). This study examined whether or not gender differences in the quality of care exist at SPCs across Ontario.

Methods: Subjects included all consecutive stroke/TIA patients seen at 21 of 33 designated SPCs in Ontario participating in the Registry of the Canadian Stroke Network’s Stroke Performance Indicators for Reporting Improvement & Translation (SPIRIT-SPC) web-based data collection. Patients with presumed stroke/TIA referred to SPCs between January 2007 and April 2011 were identified for this study. We excluded referrals not initiated as a direct result of an acute stroke/TIA event within the past 3 months, non-strokes, and incomplete referrals/visits. We compare the performance rate for seven quality of care indicators related to secondary prevention between men and women.

Results: Of the 14,966 stroke/TIA patients with at least one SPC visit, 47.2% were female and the mean age in years was 69 for women and 67 for men. Significant gender differences were found in referral reason and source, risk factors, and final diagnosis made after the first SPC visit. Women were more likely to be referred for query stroke (61.1% vs. 57.7%) and referred by an emergency or family physician (82.5% vs. 79.6%) compared to men. In terms of risk factors associated with stroke, compared to men, fewer women had a history of smoking; dyslipidemia, diabetes, and previous stroke, however, more females were obese. A higher percentage of women were diagnosed with TIA or query stroke after the first SPC visit (33.2% vs. 26.3%). Significant gender differences were observed in 3 of 7 performance indicators. Women had lower rates of neuroimaging (F=91.5%, M=92.6%, p<0.05), carotid imaging (F=87.4%, M=89.2%, p<0.05) and antithrombotics (F=91.2%, M=92.5%, p<0.05). No significant differences were found in access, time to assessment, and prescriptions for anticoagulants among patients with atrial fibrillation.

Conclusion: Women are less likely to receive diagnostic imaging and antithrombotic prescriptions at or prior to a SPC visit compared to males. As best practice stroke care recommends all patients with presumed stroke/TIA should receive appropriate diagnostic evaluation and treatment, there is a need to eliminate gender gaps in secondary prevention care.

Steal physiology is spatially associated with cortical thinning

BACKGROUND

The physiological impact of severely impaired cerebral autoregulatory vascular reactivity on cortical integrity is unknown. The purpose of this study is to determine the relationship between severe impairment of autoregulatory flow control associated with steal phenomenon and its impact on cortical thickness.

METHODS

250 blood oxygen level dependent (BOLD) MRI cerebrovascular reactivity (CVR) studies were reviewed in order to identify subjects with severe unilateral exhausted cerebrovascular reserve demonstrating steal physiology but with normal appearing cortex on fluid attenuated inversion recovery imaging. 17 patients meeting the inclusion criteria were identified. A reconstructed inflated cortical surface map was created for every subject using Freesurfer software (http://surfer.nmr.mgh.harvard.edu/). The region of interest (ROI) reflecting the steal physiology was determined by overlaying the subject's CVR map on to the cortical surface map. This ROI was compared with the corresponding area in the healthy hemisphere which provided control cortical thickness measurement in each subject.

RESULTS

The hemisphere with steal physiology showed an 8% thinner cortex (2.23+/-0.28 mm) than the corresponding healthy hemisphere (2.42+/-0.23 mm) (p=0.0005).

CONCLUSIONS

Our findings indicate that a spatial correspondence exists between impairment of autoregulatory capacity with steal physiology and cortical thinning.

Delay to Diagnosis in Acute Pediatric Arterial Ischemic Stroke

Background and Purpose— For the clinician, the diagnosis of arterial ischemic stroke (AIS) in children is a challenge. Prompt diagnosis of pediatric AIS within 6 hours enables stroke-specific thrombolytic and neuroprotective strategies.

Methods— We conducted a retrospective study of prospectively enrolled consecutive cohort of children with AIS, admitted to The Hospital for Sick Children, Toronto, from January 1992 to December 2004. The data on clinical presentation, symptom onset, emergency department arrival, neuroimaging and stroke diagnosis were recorded. The putative predictors of delayed diagnosis were selected a priori for analysis.

Results— A total of 209 children with AIS were studied. The median interval from symptom onset to AIS diagnosis was 22.7 hours (interquartile range: 7.1 to 57.7 hours), prehospital delay (symptom onset to hospital arrival) was 1.7 hours (interquartile range: 49 minutes to 8.1 hours), and the in-hospital delay (presentation to diagnosis) was 12.7 hours (interquartile range: 4.5 to 33.5 hours). The initial assessment was completed in 16 minutes and initial neuroimaging in 8.8 hours. The diagnosis of AIS was suspected on initial assessment in 79 (38%) children and the initial neuroimaging diagnosed AIS in 47%. The parent’s help seeking action, nonabrupt onset of symptoms, altered consciousness, milder stroke severity, posterior circulation infarction and lack of initial neuroimaging at a tertiary hospital were predictive delayed AIS diagnosis.

Conclusion— In the diagnosis of AIS, significant prehospital and in-hospital delays exist in children. Several predictors of the delayed AIS diagnosis were identified in the present study. Efforts to target these predictors can reduce diagnostic delays and optimize the management of AIS in children.

The Toronto Bedside Swallowing Screening Test (TOR-BSST): development and validation of a dysphagia screening tool for patients with stroke

BACKGROUND AND PURPOSE

Dysphagia occurs in 55% of all acute stroke patients. Early identification of dysphagia from screening can lead to earlier treatments and thereby reduce complications. We designed and validated a new bedside dysphagia screening tool-the Toronto Bedside Swallowing Screening Test (TOR-BSST) for stroke survivors in acute and rehabilitative settings.

METHODS

The TOR-BSST initially contained 5 items with proven high predictive ability for dysphagia. Trained screeners administer and score the TOR-BSST in less than 10 minutes. Trained nurses from 2 acute and 2 rehabilitation facilities administered the TOR-BSST to consecutively admitted stroke inpatients. A positive screen identified patients at risk for dysphagia. Blinded repeat screenings were conducted within 24 hours. Test-retest reliability was established with the first 50 administrations at an ICC=0.92 (CI, 0.85 to 0.96). Items were eliminated if they contributed <or=5% to the total score and were judged clinically impractical. 20% of all enrolled patients were randomly allocated to gold standard videofluoroscopic assessment of swallowing and findings rated independently by 4 blinded experts. Adequate validity was set at sensitivity >or=90% and negative predictive value >or=90%.

RESULTS

311 stroke inpatients were enrolled; 103 acute and 208 rehabilitation. Screening was positive in 59.2% acute and 38.5% rehabilitation patients. The pharyngeal sensation item did not meet inclusion criteria and was eliminated. The TOR-BSST demonstrated excellent validity with sensitivity at 91.3% (CI, 71.9 to 98.7), and negative predictive values at 93.3% in acute and 89.5% in rehabilitation settings.

CONCLUSIONS

The TOR-BSST is a simple accurate tool to identify stroke patients with dysphagia regardless of severity and setting.

Development and implementation of the Ontario Stroke System: the use of evidence

Introduction

The Ontario Stroke System was developed to enhance the quality and continuity of stroke care provided across the care continuum.

Research Objective

To identify the role evidence played in the development and implementation of the Ontario Stroke System.

Methods

This study employed a qualitative case study design. In-depth interviews were conducted with six members of the Ontario Stroke System provincial steering committee. Nine focus groups were conducted with: Regional Program Managers, Regional Education Coordinators, and seven acute care teams. To supplement these findings interviews were conducted with eight individuals knowledgeable about national and international models of integrated service delivery.

Results

Our analyses identified six themes. The first four themes highlight the use of evidence to support the process of system development and implementation including: 1) informing system development; 2) mobilizing governmental support; 3) getting the system up and running; and 4) integrating services across the continuum of care. The final two themes describe the foundation required to support this process: 1) human capacity and 2) mechanisms to share evidence.

Conclusion

This study provides guidance to support the development and implementation of evidence-based models of integrated service delivery.

Preadmission antithrombotic treatment and stroke severity in patients with atrial fibrillation and acute ischaemic stroke: an observational study

BACKGROUND

Vitamin K antagonists (eg, warfarin) substantially reduce the risk of ischaemic stroke in patients with atrial fibrillation. Additionally, therapeutic anticoagulation at time of acute stroke admission might reduce in-hospital mortality and disability. We assessed the association between preadmission antithrombotic treatment and initial stroke severity, neurological deterioration, major vascular events during hospital stay, and death or disability at discharge in patients with acute ischaemic stroke and atrial fibrillation.

METHODS

We identified consecutive patients with acute ischaemic stroke and atrial fibrillation, admitted to 11 hospitals in Ontario, Canada, from the Registry of the Canadian Stroke Network (2003-05). Logistic regression was used to assess the association between antiplatelet treatment, subtherapeutic warfarin treatment (admission international normalised ratio [INR] < 2), therapeutic warfarin treatment (admission INR > or = 2), and clinical outcome. Stroke severity was measured using the Canadian neurological scale (CNS) and was categorised into mild (CNS > 7) and severe stroke (CNS < or = 7). Disability was measured with the modified-Rankin scale (mRS) and was categorised into strokes associated with no or mild-moderate dependency (mRS 0-3) and with severe dependency or death (mRS 4-6).

RESULTS

Of 948 patients, 306 (32%) were not on antithrombotic treatment, 292 (31%) were receiving antiplatelet treatment, 238 (25%) were receiving warfarin with a subtherapeutic INR, and 112 (12%) were receiving warfarin with a therapeutic INR on admission. Compared with those not receiving antithrombotic therapy, antiplatelet therapy (odds ratio 0.7; 95% CI 0.5-0.995) and therapeutic warfarin (0.4; 0.2-0.6) were associated with a reduction in severe stroke at admission. Therapeutic warfarin was also associated with a reduction in the odds of severe disability or death at discharge (0.5; 0.3-0.9).

INTERPRETATION

Therapeutic warfarin is associated with reduced severity of ischaemic stroke at presentation and reduced disability or death at discharge in patients with atrial fibrillation. Antiplatelet treatment is associated with a more modest reduction than warfarin in baseline stroke severity.

Telestroke: a multi-site, emergency-based telemedicine service in Ontario

A telestroke service was established in Ontario in 2002. Six neurologists on four campuses of two academic health centres of the University of Toronto participated in the call roster to support emergency physicians in two northern cities, North Bay and Sudbury. Videoconferencing units were provided in the hospitals and in the homes of the neurologists. PC workstations were used to access computed tomography (CT) images. In the first 34 months' operation, a total of 88 patient consultations were conducted. Twenty-six patients received tissue plasminogen activator (t-PA). Although the number of consultations was relatively low, the feasibility of telemedicine for acute stroke care was demonstrated. The economics remain to be explored. The telestroke model is a viable alternative to the provision of acute stroke care for communities that have CT scanners, but no access to a resident neurologist.

Prediction of hemorrhage in acute ischemic stroke using permeability MR imaging

Increased risk of hemorrhagic transformation (HT) limits the general use of thrombolytic therapy in acute ischemic stroke (AIS). This study shows that early blood-brain barrier defects in AIS can be assessed by using permeability MR imaging. Significantly increased permeability was found in 3 patients who later hemorrhaged. This method indicates the potential for identifying patients at higher risk of HT and offers the use of physiologic imaging rather than time from onset of symptoms to guide treatment decisions.

Sex Differences in Stroke Care and Outcomes

Background— Stroke is an important cause of death and disability in women as well as men. However, little is known about sex differences in stroke care and outcomes.

Methods— The Registry of the Canadian Stroke Network (RCSN) captured data on patients with stroke seen at acute care hospitals across Canada. We used data from phase 1 (July 2001 to February 2002) and phase 2 (June to December 2002) of the RCSN to compare stroke presentation, management, and 6-month outcomes in women and men using multivariable regression techniques to adjust for age and other factors.

Results— The study sample included 3323 patients, with 1527 women. Stroke symptoms at presentation were similar in women and men, except that women were more likely to present with headaches and were less likely to have brain stem or cerebellar symptoms. There were no sex differences in the use of neuroimaging, thrombolysis, antithrombotic therapy, or consultations. Women were less likely than men to receive care on an acute stroke unit, but this difference was no longer significant after adjustment for age and other factors. Women were more likely than men to be discharged to long-term care and had greater disability at 6 months. Mortality and quality of life at 6 months were similar in women and men.

Conclusions— Among patients participating in the RCSN, there were no major sex differences in stroke presentation or management. Compared with men, women were more often institutionalized and had a slightly worse functional status at 6 months after stroke.

Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism

CONTEXT

Intravenous tissue-type plasminogen activator can be beneficial to some patients when given within 3 hours of stroke onset, but many patients present later after stroke onset and alternative treatments are needed.

OBJECTIVE

To determine the clinical efficacy and safety of intra-arterial (IA) recombinant prourokinase (r-proUK) in patients with acute stroke of less than 6 hours' duration caused by middle cerebral artery (MCA) occlusion.

DESIGN

PROACT II (Prolyse in Acute Cerebral Thromboembolism II), a randomized, controlled, multicenter, open-label clinical trial with blinded follow-up conducted between February 1996 and August 1998.

SETTING

Fifty-four centers in the United States and Canada.

PATIENTS

A total of 180 patients with acute ischemic stroke of less than 6 hours' duration caused by angiographically proven occlusion of the MCA and without hemorrhage or major early infarction signs on computed tomographic scan.

INTERVENTION

Patients were randomized to receive 9 mg of IA r-proUK plus heparin (n = 121) or heparin only (n = 59).

MAIN OUTCOME MEASURES

The primary outcome, analyzed by intention-to-treat, was based on the proportion of patients with slight or no neurological disability at 90 days as defined by a modified Rankin score of 2 or less. Secondary outcomes included MCA recanalization, the frequency of intracranial hemorrhage with neurological deterioration, and mortality.

RESULTS

For the primary analysis, 40% of r-proUK patients and 25% of control patients had a modified Rankin score of 2 or less (P = .04). Mortality was 25% for the r-proUK group and 27% for the control group. The recanalization rate was 66% for the r-proUK group and 18% for the control group (P<.001). Intracranial hemorrhage with neurological deterioration within 24 hours occurred in 10% of r-proUK patients and 2% of control patients (P = .06).

CONCLUSION

Despite an increased frequency of early symptomatic intracranial hemorrhage, treatment with IA r-proUK within 6 hours of the onset of acute ischemic stroke caused by MCA occlusion significantly improved clinical outcome at 90 days.

Canadian guidelines for intravenous thrombolytic treatment in acute stroke. A consensus statement of the Canadian Stroke Consortium

BACKGROUND

The thromobolytic drug, tissue plasminogen activator (tPA) has been approved in the United States for the treatment of acute ischemic stroke amid controversy and concern about the balance of risk and benefit. The Canadian Stroke Consortium (CSC), a national network of neurologists who collaborate on joint projects in stroke medicine, including clinical trials and consensus statements, has developed guidelines for the use of tPA in Canada.

METHODS AND RESULTS

The CSC Board of Directors wrote a preliminary report based on existing publications, including randomized drug trials and the report of a special committee struck by the Stroke Council of the American Heart Association. This draft was circulated to the CSC membership-at-large for suggestions or amendments, to produce this final draft.

CONCLUSIONS

The present guidelines have been devised to represent a Canadian viewpoint of management. The Health Protection Branch of the Ministry of Health of Canada has not yet produced an evaluation. Further modification of these guidelines may be necessary when more data from clinical trials and experience with the drug become available.

Serum creatinine level is an independent risk factor for the angiographic severity of internal carotid artery stenosis in subjects who have previously had transient ischaemic attacks

BACKGROUND

Serum creatinine level has been reported to be related to the incidence of strokes.

OBJECTIVE

To examine the relationship between serum creatinine level and the severity of extracranial carotid artery atherosclerosis.

DESIGN AND METHODS

This is a secondary analysis of data from 88 patients (59 men and 29 women) who had previously had transient ischaemic attacks or minor strokes and had been included in intervention trials of symptomatic carotid disease. Narrowing of internal carotid artery was estimated by angiography. Both internal carotid arteries were measured and the severity was expressed as the sum of percentage stenoses on both sides. The risk profiles of patients with moderate and severe internal carotid artery stenosis were compared.

RESULTS

The sex-adjusted mean serum creatinine concentration in those with severe carotid disease was significantly higher than that in those with moderate disease (106.3 +/- 3.3 versus 91.3 +/- 3.7 mumol/l, P = 0.003), but still within the normal range. The risk of having severe disease was compared with risk of having moderate disease for people ranked by their serum creatinine levels. Univariate logistic regression showed that the odds ratio (OR) for having severe involvement of internal carotid artery was greater for patients in mid-tertile of creatinine values than it was for those in the lowest tertile (OR 6.3, 95% confidence interval 2.0-20.4, P = 0.002). The creatinine levels of patients in these two tertiles were within the normal range. The OR was no greater for patients in the highest tertile of creatinine values, which were slightly elevated above the normal range. These OR did not change after adjustment for age, sex, hypertension or systolic blood pressure, diabetes, smoking and lipid levels.

CONCLUSION

Results of this study demonstrate for the first time that serum creatinine level, even within the range of upper normal or mildly elevated levels, is related to the angiographic severity of internal carotid artery disease in patients who have previously had transient ischaemic attacks and that this relationship is independent of classic cardiovascular risk factors.

Assessment of electric differential treatment (EDiT) and Endosan treatment for ovarian cysts and concomitant symptoms

The mechanisms of action and clinical applications of electric differential treatment (EDiT) and Endosan in the treatment of ovarian cysts and concomitant symptoms are reviewed. Possible mechanisms of action include an increased level of cyclic AMP, stimulation of endorphin release, anti-inflammatory action, and steroidogenesis resulting from normalization of intercellular communication. Favorable results in the clinical setting were achieved in the treatment of ovarian cysts. Treatment success was reflected in a significant reduction in overall cyst size as well as amelioration of various concomitant symptoms, including fever, chills, inflammation, and abdominal pain. EDiT and Endosan were shown to have potent analgesic and anti-inflammatory effects. No adverse effects have been reported.

Metabolic and clinical correlates of acute ischemic infarction

We studied cerebral metabolism, anatomy, and clinical status in 36 patients with acute cerebral ischemia. Results from FDG-PET were compared with CT to find the relationships between the metabolic, anatomic, and clinical findings. Metabolic abnormalities seen on PET frequently were more extensive than the corresponding CT findings. The pattern of metabolic abnormality was significantly related to both the type of clinical syndrome and the degree of eventual recovery. No such relationships were found for the CT results. We conclude that studies of cerebral metabolism are of value in establishing prognosis after acute cerebral ischemia. Also, knowledge of the patterns of cerebral dysmetabolism provides a powerful means for the localization of clinical function.

Cerebral glucose consumption following verbal auditory stimulation

We studied the effect of auditory stimulation upon cerebral glucose metabolism in young normals. The stimulus consisted of a non-English discourse which was presented monaurally to 10 normal blindfolded subjects (5 left ear, 5 right); the opposite ear was plugged. Six subjects studied blindfolded and with ears plugged served as controls. Sixteen discrete homologous cortical and subcortical regions of interest were examined. Regional glucose consumption and side-to-side differences in glucose metabolism were analyzed. Monaural stimulation produced significant increases in temporal metabolism contralateral to the side of stimulation. Significant asymmetries in metabolism were found at the temporoparietal junction, inferior parietal region, insula and corpus collosum. The left frontal speech areas remained unaffected. These findings demonstrate that in man the primary auditory pathways retain a contralateral organization. Further, cerebral activation induced by non-meaningful verbal stimulation is widespread within the left temporal and parietal regions but does not impact upon the frontal speech cortices.

Local cerebral metabolic changes in acute ischemic strokes

Positron emission tomography (PET) studies with 18F deoxyglucose were completed in 35 patients with acute ischemic strokes. Twelve cases were studied within 72 h, 23 between 4 and 14 days. Results indicate the functional and prognostic significance of early tomography studies of metabolism, and anticipate possible use of metabolic imaging in the evaluation of treatment.

Antibiotic prophylaxis in high-risk head and neck surgery: one-day vs. five-day therapy

Patients who undergo major contaminated surgery of the head and neck benefit from perioperative antibiotic prophylaxis. This study was developed to determine if 5 days of antibiotic administration would be more effective than 1 day. A multi-institutional prospective randomized double-blind study was designed. Patients who were identified as requiring pedicled flap reconstruction were potential candidates for the study. Later, patients were randomly assigned to receive cefoperazone sodium for either 24 hours or 120 hours. In each case, the drug was administered intravenously, beginning 1 to 2 hours preoperatively and continued for the prescribed period. One hundred nine patients were evaluable. Fifty-three patients were assigned to 1 day of perioperative prophylaxis. Wound infection developed in ten patients (18.9%). Fifty-six patients were assigned to 5 days of perioperative antibiotic prophylaxis. Wound infection developed in 14 (25%) of these patients (P greater than .05). These data suggest that no beneficial effect from administration of antibiotics for longer than 24 hours postoperatively can be achieved in patients who undergo myocutaneous flap reconstruction.