Data-driven machine-learning analysis of potential embolic sources in embolic stroke of undetermined source

BACKGROUND AND PURPOSE

Hierarchical clustering, a common 'unsupervised' machine-learning algorithm, is advantageous for exploring potential underlying aetiology in particularly heterogeneous diseases. We investigated potential embolic sources in embolic stroke of undetermined source (ESUS) using a data-driven machine-learning method, and explored variation in stroke recurrence between clusters.

METHODS

We used a hierarchical k-means clustering algorithm on patients' baseline data, which assigned each individual into a unique clustering group, using a minimum-variance method to calculate the similarity between ESUS patients based on all baseline features. Potential embolic sources were categorised into atrial cardiopathy, atrial fibrillation, arterial disease, left ventricular disease, cardiac valvulopathy, patent foramen ovale (PFO) and cancer.

RESULTS

Among 800 consecutive ESUS patients (43.3% women, median age 67 years), the optimal number of clusters was four. Left ventricular disease was most prevalent in cluster 1 (present in all patients) and perfectly associated with cluster 1. PFO was most prevalent in cluster 2 (38.9% of patients) and associated significantly with increased likelihood of cluster 2 [adjusted odds ratio: 2.69, 95% confidence interval (CI): 1.64-4.41]. Arterial disease was most prevalent in cluster 3 (57.7%) and associated with increased likelihood of cluster 3 (adjusted odds ratio: 2.21, 95% CI: 1.43-3.13). Atrial cardiopathy was most prevalent in cluster 4 (100%) and perfectly associated with cluster 4. Cluster 3 was the largest cluster involving 53.7% of patients. Atrial fibrillation was not significantly associated with any cluster.

CONCLUSIONS

This data-driven machine-learning analysis identified four clusters of ESUS that were strongly associated with arterial disease, atrial cardiopathy, PFO and left ventricular disease, respectively. More than half of the patients were assigned to the cluster associated with arterial disease.

Rivaroxaban versus aspirin for secondary prevention of ischaemic stroke in patients with cancer: a subgroup analysis of the NAVIGATE ESUS randomized trial

BACKGROUND AND PURPOSE

Cancer is a frequent finding in ischaemic stroke patients. The frequency of cancer amongst participants in the NAVIGATE ESUS randomized trial and the distribution of outcome events during treatment with aspirin and rivaroxaban were investigated.

METHODS

Trial participation required a recent embolic stroke of undetermined source. Patients' history of cancer was recorded at the time of study entry. During a mean follow-up of 11 months, the effects of aspirin and rivaroxaban treatment on recurrent ischaemic stroke, major bleeding and all-cause mortality were compared between patients with cancer and patients without cancer.

RESULTS

Amongst 7213 randomized patients, 543 (7.5%) had cancer. Of all patients, 3609 were randomized to rivaroxaban [254 (7.0%) with cancer] and 3604 patients to aspirin [289 (8.0%) with cancer]. The annual rate of recurrent ischaemic stroke was 4.5% in non-cancer patients in the rivaroxaban arm and 4.6% in the aspirin arm [hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.78-1.24]. In cancer patients, the rate of recurrent ischaemic stroke was 7.7% in the rivaroxaban arm and 5.4% in the aspirin arm (HR 1.43, 95% CI 0.71-2.87). Amongst cancer patients, the annual rate of major bleeds was non-significantly higher for rivaroxaban than aspirin (2.9% vs. 1.1%; HR 2.57, 95% CI 0.67-9.96; P for interaction 0.95). All-cause mortality was similar in both groups.

CONCLUSIONS

Our exploratory analyses show that patients with embolic stroke of undetermined source and a history of cancer had similar rates of recurrent ischaemic strokes and all-cause mortality during aspirin and rivaroxaban treatments and that aspirin appeared safer than rivaroxaban in cancer patients regarding major bleeds. www.clinicaltrials.gov (NCT02313909).

Focal Hypoperfusion in Acute Ischemic Stroke Perfusion CT: Clinical and Radiologic Predictors and Accuracy for Infarct Prediction

BACKGROUND AND PURPOSE

Perfusion CT may improve the diagnostic performance of noncontrast CT in acute ischemic stroke. We assessed predictors of focal hypoperfusion in acute ischemic stroke and perfusion CT performance in predicting infarction on follow-up imaging.

MATERIALS AND METHODS

Patients from the Acute STroke Registry and Analysis of Lausanne data base with acute ischemic stroke and perfusion CT were included. Clinical and radiologic data were collected. We identified predictors of focal hypoperfusion using multivariate analyses.

RESULTS

From the 2216 patients with perfusion CT, 38.2% had an acute ischemic lesion on NCCT and 73.3% had focal hypoperfusion on perfusion CT. After we analyzed 104 covariates, high-admission NIHSS, visual field defect, aphasia, hemineglect, sensory deficits, and impaired consciousness were positively associated with focal hypoperfusion. Negative associations were pure posterior circulation, lacunar strokes, and anticoagulation. After integrating radiologic variables into the multivariate analyses, we found that visual field defect, sensory deficits, hemineglect, early ischemic changes on NCCT, anterior circulation, cardioembolic etiology, and arterial occlusion were positively associated with focal hypoperfusion, whereas increasing onset-to-CT delay, chronic vascular lesions, and lacunar etiology showed negative association. Sensitivity, specificity, and positive and negative predictive values of focal hypoperfusion on perfusion CT for infarct detection on follow-up MR imaging were 66.5%, 79.4%, 96.2%, and 22.8%, respectively, with an overall accuracy of 76.8%.

CONCLUSIONS

Compared with NCCT, perfusion CT doubles the sensitivity in detecting acute ischemic stroke. Focal hypoperfusion is independently predicted by stroke severity, cortical clinical deficits, nonlacunar supratentorial strokes, and shorter onset-to-imaging delays. A high proportion of patients with focal hypoperfusion developed infarction on subsequent imaging, as did some patients without focal hypoperfusion, indicating the complementarity of perfusion CT and MR imaging in acute ischemic stroke.

Thrombolysis and thrombectomy in patients treated with dabigatran with acute ischemic stroke: Expert opinion

Systemic thrombolysis with rt-PA is contraindicated in patients with acute ischemic stroke anticoagulated with dabigatran. This expert opinion provides guidance on the use of the specific reversal agent idarucizumab followed by rt-PA and/or thrombectomy in patients with ischemic stroke pre-treated with dabigatran. The use of idarucizumab followed by rt-PA is covered by the label of both drugs.

ASTRAL, DRAGON and SEDAN scores predict stroke outcome more accurately than physicians

BACKGROUND AND PURPOSE

ASTRAL, SEDAN and DRAGON scores are three well-validated scores for stroke outcome prediction. Whether these scores predict stroke outcome more accurately compared with physicians interested in stroke was investigated.

METHODS

Physicians interested in stroke were invited to an online anonymous survey to provide outcome estimates in randomly allocated structured scenarios of recent real-life stroke patients. Their estimates were compared to scores' predictions in the same scenarios. An estimate was considered accurate if it was within 95% confidence intervals of actual outcome.

RESULTS

In all, 244 participants from 32 different countries responded assessing 720 real scenarios and 2636 outcomes. The majority of physicians' estimates were inaccurate (1422/2636, 53.9%). 400 (56.8%) of physicians' estimates about the percentage probability of 3-month modified Rankin score (mRS) > 2 were accurate compared with 609 (86.5%) of ASTRAL score estimates (P < 0.0001). 394 (61.2%) of physicians' estimates about the percentage probability of post-thrombolysis symptomatic intracranial haemorrhage were accurate compared with 583 (90.5%) of SEDAN score estimates (P < 0.0001). 160 (24.8%) of physicians' estimates about post-thrombolysis 3-month percentage probability of mRS 0-2 were accurate compared with 240 (37.3%) DRAGON score estimates (P < 0.0001). 260 (40.4%) of physicians' estimates about the percentage probability of post-thrombolysis mRS 5-6 were accurate compared with 518 (80.4%) DRAGON score estimates (P < 0.0001).

CONCLUSIONS

ASTRAL, DRAGON and SEDAN scores predict outcome of acute ischaemic stroke patients with higher accuracy compared to physicians interested in stroke.

Small-vessel occlusion versus large-artery atherosclerotic strokes in diabetics: Patient characteristics, outcomes, and predictors of stroke mechanism

INTRODUCTION

Diabetes mellitus exerts a detrimental effect on cerebral vasculature affecting both macrovasculature and microvasculature. However, although ischaemic stroke is typically included among macrovascular diabetic complications, it is frequently omitted from microvascular diabetic complications. We aimed to compare the proportion of large-artery atherosclerotic and small-vessel occlusion strokes among diabetic stroke patients, explore their differences and outcomes, and assess potential mechanisms which may determine why some diabetic patients suffer large-artery atherosclerotic stroke whereas others suffer small-vessel occlusion stroke.

METHODS

We pooled data of diabetic patients from four prospective ischaemic stroke registries (Acute Stroke Registry and Analysis of Lausanne (ASTRAL), Athens, Austrian, and Helsinki Stroke Thrombolysis Registries). Stroke severity and prognosis were assessed with National Institutes of Health Stroke Scale (NIHSS) and ASTRAL scores, respectively; functional outcome with three-month modified Rankin score (0-2 considered as favourable outcome). Logistic-regression analysis identified independent predictors of large-artery atherosclerotic stroke.

RESULTS

Among 5412 patients, 1069 (19.8%) were diabetics; of them, 232 (21.7%) had large-artery atherosclerotic and 205 (19.2%) small-vessel occlusion strokes. Large-artery atherosclerotic stroke had higher severity than small-vessel occlusion stroke (median NIHSS: 6 vs. 3, p < 0.001), worse prognosis (median ASTRAL score: 23 vs. 19, p < 0.001), and worse three-month outcome (60.3% vs. 83.4% with favourable outcome, p < 0.001). In logistic-regression analysis, peripheral artery disease (odds ratio: 4.013, 95% confidence interval: 1.667-9.665, p < 0.01) and smoking (odds ratio: 1.706, 95% confidence interval: 1.087-2.675, p < 0.05) were independently associated with large-artery atherosclerotic strokes.

CONCLUSION

In the diabetic stroke population, small-vessel occlusion and large-artery atherosclerotic strokes occur with similar frequency. Large-artery atherosclerotic strokes are more severe and have worse outcome than small-vessel occlusion strokes. The presence of peripheral artery disease and smoking independently predicted large-artery atherosclerotic stroke.

Statin treatment is associated with improved prognosis in patients with AF-related stroke

BACKGROUND/OBJECTIVES

The most recent ACC/AHA guidelines recommend high-intensity statin therapy in ischemic stroke patients of presumably atherosclerotic origin. On the contrary, there is no specific recommendation for the use of statin in patients with non-atherosclerotic stroke, e.g. strokes related to atrial fibrillation (AF). We investigated whether statin treatment in patients with AF-related stroke is associated with improved survival and reduced risk for stroke recurrence and future cardiovascular events.

METHODS

All consecutive patients registered in the Athens Stroke Registry with AF-related stroke and no history of coronary artery disease nor clinically manifest peripheral artery disease were included in the analysis and categorized in two groups depending on whether statin was prescribed at discharge. The primary outcome was overall mortality; the secondary outcomes were stroke recurrence and a composite cardiovascular endpoint comprising of recurrent stroke, myocardial infarction, aortic aneurysm rupture or sudden cardiac death during the 5-year follow-up.

RESULTS

Among 1602 stroke patients, 404 (25.2%) with AF-related stroke were included in the analysis, of whom 102 (25.2%) were discharged on statin. On multivariate Cox-proportional-hazards model, statin treatment was independently associated with a lower mortality (hazard-ratio (HR): 0.49, 95%CI:0.26-0.92) and lower risk for the composite cardiovascular endpoint during the median 22 months follow-up (HR: 0.44, 95%CI:0.22-0.88), but not with stroke recurrence (HR: 0.47, 95%CI:0.22-1.01, p: 0.053).

CONCLUSIONS

In this long-term registry of patients with AF-related stroke, statin treatment was associated with improved survival and reduced risk for future cardiovascular events.

Improving prediction of recanalization in acute large-vessel occlusive stroke

BACKGROUND

Recanalization in acute ischemic stroke with large-vessel occlusion is a potent indicator of good clinical outcome.

OBJECTIVE

To identify easily available clinical and radiologic variables predicting recanalization at various occlusion sites.

METHODS

All consecutive, acute stroke patients from the Acute STroke Registry and Analysis of Lausanne (2003-2011) who had a large-vessel occlusion on computed tomographic angiography (CTA) (< 12 h) were included. Recanalization status was assessed at 24 h (range: 12-48 h) with CTA, magnetic resonance angiography, or ultrasonography. Complete and partial recanalization (corresponding to the modified Treatment in Cerebral Ischemia scale 2-3) were grouped together. Patients were categorized according to occlusion site and treatment modality.

RESULTS

Among 439 patients, 51% (224) showed complete or partial recanalization. In multivariate analysis, recanalization of any occlusion site was most strongly associated with endovascular treatment, including bridging therapy (odds ratio [OR] 7.1, 95% confidence interval [CI] 2.2-23.2), and less so with intravenous thrombolysis (OR 1.6, 95% CI 1.0-2.6) and recanalization treatments performed beyond guidelines (OR 2.6, 95% CI 1.2-5.7). Clot location (large vs. intermediate) and tandem pathology (the combination of intracranial occlusion and symptomatic extracranial stenosis) were other variables discriminating between recanalizers and non-recanalizers. For patients with intracranial occlusions, the variables significantly associated with recanalization after 24 h were: baseline National Institutes of Health Stroke Scale (NIHSS) (OR 1.04, 95% CI 1.02-1.1), Alberta Stroke Program Early CT Score (ASPECTS) on initial computed tomography (OR 1.2, 95% CI 1.1-1.3), and an altered level of consciousness (OR 0.2, 95% CI 0.1-0.5).

CONCLUSIONS

Acute endovascular treatment is the single most important factor promoting recanalization in acute ischemic stroke. The presence of extracranial vessel stenosis or occlusion decreases recanalization rates. In patients with intracranial occlusions, higher NIHSS score and ASPECTS and normal vigilance facilitate recanalization. Clinical use of these predictors could influence recanalization strategies in individual patients.

Intravenous insulin treatment in acute stroke: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Poststroke hyperglycemia has been associated with unfavorable outcome. Several trials investigated the use of intravenous insulin to control hyperglycemia in acute stroke. This meta-analysis summarizes all available evidence from randomized controlled trials in order to assess its efficacy and safety.

METHODS

We searched PubMed until 15/02/2013 for randomized clinical trials using the following search items: 'intravenous insulin' or 'hyperglycemia', and 'stroke'. Eligible studies had to be randomized controlled trials of intravenous insulin in hyperglycemic patients with acute stroke. Analysis was performed on intention-to-treat basis using the Peto fixed-effects method. The efficacy outcomes were mortality and favorable functional outcome. The safety outcomes were mortality, any hypoglycemia (symptomatic or asymptomatic), and symptomatic hypoglycemia.

RESULTS

Among 462 potentially eligible articles, nine studies with 1491 patients were included in the meta-analysis. There was no statistically significant difference in mortality between patients who were treated with intravenous insulin and controls (odds ratio: 1.16, 95% confidence interval: 0.89-1.49). Similarly, the rate of favorable functional outcome was not statistically different (odds ratio: 1.01, 95% confidence interval: 0.81-1.26). The rates of any hypoglycemia (odds ratio: 8.19, 95% confidence interval: 5.60-11.98) and of symptomatic hypoglycemia (odds ratio: 6.15, 95% confidence interval: 1.88-20.15) were higher in patients treated with intravenous insulin. There was no heterogeneity across the included trials in any of the outcomes studied.

CONCLUSIONS

This meta-analysis of randomized controlled trials does not support the use of intravenous insulin in hyperglycemic stroke patients to improve mortality or functional outcome. The risk of hypoglycemia is increased, however.

Ankle-brachial index long-term outcome after first-ever ischaemic stroke

BACKGROUND AND PURPOSE

Ankle-brachial blood pressure index (ABI) is a clinical tool to identify the presence of peripheral artery disease. There is a scarcity of data associating ABI with long-term outcome in patients with IS. The association between ABI and long-term outcome in patients with first-ever acute IS was assessed.

METHODS

Ankle-brachial blood pressure index was assessed in all consecutive patients with a first-ever acute IS admitted at Alexandra University hospital (Athens, Greece) between January 2005 and December 2010. ABI was considered normal when > 0.90 and ≤ 1.30. The Kaplan-Meier product limit method was used to estimate the probability of 5-year composite cardiovascular event-free (defined as recurrent stroke, myocardial infarction or cardiovascular death) and overall survival. A multivariate analysis was performed to assess whether ABI is an independent predictor of 5-year mortality and dependence.

RESULTS

Amongst 653 patients, 129 (19.8%) with ABI ≤ 0.9 were identified. Five-year cumulative composite cardiovascular event-free and overall survival rates were better in normal ABI stroke patients (log-rank test: 7.22, P = 0.007 and 23.40, P < 0.001, respectively). There was no difference in 5-year risk of stroke recurrence between low and normal ABI groups (hazard ratio, HR = 1.23, 95% CI 0.68-2.23). In multivariate Cox regression analysis, independent predictors of 5-year mortality included age (HR = 2.55 per 10 years, 95% CI 1.86-3.48, P < 0.001), the National Institutes of Health Stroke Scale (per point increase HR = 1.12, 95% CI 1.08-1.16, P < 0.001), and low ABI (HR = 2.22, 95% CI 1.22-4.03, P = 0.009). Age (HR = 1.21 per 10 years, 95% CI 1.01-1.45, P = 0.04) and low ABI (HR = 1.72, 95% CI 1.11-2.67, P = 0.01) were independent predictors of the composite cardiovascular end-point.

CONCLUSIONS

Low ABI in patients with acute IS is associated with increased 5-year cardiovascular event risk and mortality. However, ABI does not appear to predict long-term stroke recurrence.

An integer-based score to predict functional outcome in acute ischemic stroke: the ASTRAL score

OBJECTIVE

To develop and validate a simple, integer-based score to predict functional outcome in acute ischemic stroke (AIS) using variables readily available after emergency room admission.

METHODS

Logistic regression was performed in the derivation cohort of previously independent patients with AIS (Acute Stroke Registry and Analysis of Lausanne [ASTRAL]) to identify predictors of unfavorable outcome (3-month modified Rankin Scale score >2). An integer-based point-scoring system for each covariate of the fitted multivariate model was generated by their β-coefficients; the overall score was calculated as the sum of the weighted scores. The model was validated internally using a 2-fold cross-validation technique and externally in 2 independent cohorts (Athens and Vienna Stroke Registries).

RESULTS

Age (A), severity of stroke (S) measured by admission NIH Stroke Scale score, stroke onset to admission time (T), range of visual fields (R), acute glucose (A), and level of consciousness (L) were identified as independent predictors of unfavorable outcome in 1,645 patients in ASTRAL. Their β-coefficients were multiplied by 4 and rounded to the closest integer to generate the score. The area under the receiver operating characteristic curve (AUC) of the score in the ASTRAL cohort was 0.850. The score was well calibrated in the derivation (p = 0.43) and validation cohorts (0.22 [Athens, n = 1,659] and 0.49 [Vienna, n = 653]). AUCs were 0.937 (Athens), 0.771 (Vienna), and 0.902 (when pooled). An ASTRAL score of 31 indicates a 50% likelihood of unfavorable outcome.

CONCLUSIONS

The ASTRAL score is a simple integer-based score to predict functional outcome using 6 readily available items at hospital admission. It performed well in double external validation and may be a useful tool for clinical practice and stroke research.

An intravenous insulin protocol for strict glycemic control in acute ischaemic stroke

BACKGROUND AND PURPOSE

There is a J-shaped association between admission glycemia and outcome. We designed an intravenous insulin protocol aiming at rapid and strict glucose control in hyperglycemic ischaemic stroke patients. Here, we describe the initial experience, safety, and efficacy of this protocol to achieve and maintain euglycemia in the first 48h.

METHODS

The protocol is based on parallel scales for adjustment of insulin infusion rate according to current glycemia and the rate of change of glycemia, which was recommended in our stroke unit in 4/2007 in acute ischaemic stroke patients with glycemia >6mM. Data were registered in the Acute Stroke Registry and Analysis of Lausanne (ASTRAL). Capillary blood glycemia was measured hourly with fingerprick test at onset of treatment and after each scale change. Target glycemia was 4.0-6.0mM pre-prandially (5.5-8.0mM post-prandially). Hypokalemia was defined as serum potassium <3.5mM and measured every 12h. Specific algorithms were employed during meals and for patients leaving temporarily the stroke unit for diagnostic or therapeutic workup.

RESULTS

In the 90 protocol patients, the first normoglycemia was achieved within 8h of treatment in 91.1% of patients (median interval 4h (interquartile range (IQR): 3-6). During the median treatment duration of 25.5h (IQR: 19.7-37.7), median glucose reduction was 2.5mM (IQR: 1.3-4.3mM). The overall rate of hypoglycemias was 4.5% and hypokalemias 18.5%. There was a significant increase in the proportion of hypokalemias on the first on-treatment measurement compared to admission (24.4% vs. 8.9%, P=0.002).

CONCLUSIONS

The proposed intravenous insulin protocol controls acute post-stroke hyperglycemia but frequently leads to hypokalemia. This issue needs to be addressed for the protocol to be suitable for use in larger, randomized controlled trial to explore its clinical effect.

Absence of aprataxin gene mutations in a Greek cohort with sporadic early onset ataxia and normal GAA triplets in frataxin gene

Phenotype of patients with the aprataxin gene mutation varies and according to previous studies, screening of aprataxin gene could be useful, once frataxin gene mutation is excluded in patients with normal GAA expansion in frataxin gene. In the present study, we sought to determine possible causative mutations in aprataxin gene (all exons and flanking intronic sequences) in 14 Greek patients with sporadic cerebellar ataxia all but one without GAA expansion in frataxin gene (1 patient was heterozygous). No detectable point mutation or deletion was found in the aprataxin gene of all the patients. Our results do not confirm the previous studies. This difference may be attributed to the different populations studied and possible different genetic background. It is still questionable whether the screening for aprataxin mutation in Greek patients' Friedreich ataxia phenotype is of clinical importance; larger, multicenter studies are necessary to clarify this issue.

Amiodarone: pharmacological profile, animal-model experimental data and clinical use. How important is the vasodilating effect?

Amiodarone, the major representative of class III antiarrhythmic agents, is widely used in the treatment of ventricular and hyperventricular arrhythmias, being specifically useful in the therapy of patients suffering from life threatening ventricular arrhythmias. The combination of antianginal and antiarrthythmic actions of amiodarone is an extremely significant advantage regarding the treatment of patients with chronic atherosclerotic cardiopathy, as heart rate disorders are frequently fatal in coronary heart disease and, reversely, a high percentage of cardiac arrhythmias are caused by coronary heart disease. Since 1980s, several experimental in vitro and in vivo data, as well as clinical studies, regarding both systematic and coronary circulation, support the vasodilative effects of amiodarone. We have previously showed that amiodarone in vitro exerts a vasodilator effect in isolated vessel tissue, mainly via the activation of intracellular calcium binding mechanisms, a fact that differentiates this agent from other coronary vasodilative drugs, such as calcium channel blockers, that affect extracellular calcium ions entrance. Thus, the vasodilative, antianginal and antiarrhythmic actions of amiodarone may be further enhanced by the simultaneous supplementation of calcium channel blockers via synergistic mechanisms, supporting the clinical use of such drug combinations. Finally, as amiodarone and noradrenaline have been reported to exert antagonistic actions, the application of amiodarone is particularly indicated in pathologic conditions characterized by the stimulation of sympathetic nervous system (sympathicotonia).

The neuroprotective role of erythropoietin in the management of acute ischaemic stroke: from bench to bedside

Recombinant human erythropoietin was produced soon after the discovery of the erythropoietin gene in 1985 and since then, it is used in various clinical conditions such as chronic renal failure. Moreover, experimental studies have shown that erythropoietin exerts neuroprotective action as well. Recently, a clinical trial yielded promising results concerning the use of erythropoietin in stroke management. In this review, we summarize the main data which suggest that recombinant human erythropoietin and its analogues may indeed have a role in stroke treatment.

Stroke and conditions that mimic it: a protocol secures a safe early recognition

OBJECTIVE

Certain disorders may be falsely diagnosed as stroke. We examined the efficacy of the diagnostic protocol that is followed in our stroke unit and was designed in order to early differentiate more efficiently between stroke and conditions that mimic it. METHODS-PATIENTS: Three hundred sixty-two elderly patients (196 male, 166 female with average age 74.56 years), who were hospitalized at our stroke center between January of 2005 and June of 2007 and diagnosed at admission as stroke patients, were retrospectively studied in order to investigate if the final diagnosis agreed with the initial diagnosis of stroke on admission.Our diagnostic protocol included medical history of the patient, assessment of state of consciousness, blood pressure, electrocardiogram, complete blood cell count (hematocrit/hemoglobin, leukocytes, platelets), clotting mechanism (prothrombin time, activated partial thromboplastin time), glucose, electrolytes (Na, K, Ca), renal (blood urea nitrogen, creatinine) and liver function (SGOT, SGPT), as well as imaging methods like chest X-Ray and brain CT scan.

RESULTS

In 95% of patients, the final diagnosis agreed with the initial diagnosis of stroke at admission. According to final diagnosis, 344 (95%) of them had stroke -either hemorrhagic or ischemic-, while from the rest 18 (5%), 12 (66.7%) were found to have metastatic neoplasm of brain, 3 (18.7%) had primal tumour of brain, whereas 3 (18.7%) suffered from other diseases (respiratory infection, meningoencephalitis, thyrotoxicosis). The principal symptoms of the conditions that mimicked a stroke were: aphasic disturbances (27.3%), dizziness/fainting (27.3%), headache/diplopia (11.1%), dysarthria (11.1%), hiccup and/or swallow disturbances (5.6%).

CONCLUSION

Our diagnostic protocol seems to ensure a high degree of differential diagnosis between stroke and conditions that mimic it.

Parathyroid crisis as first manifestation of primary hyperparathyroidism

We report the case of a 61-year-old woman who suffered a parathyroid crisis due to a parathyroid adenoma. The patient presented with the typical clinical symptoms of hypercalcemia. Ca(+2) and PTH were markedly increased. Initially, she was treated conservatively until Ca(+2) returned to normal levels. Then, she underwent surgical excision of a newly diagnosed parathyroid adenoma. Parathyroid crisis (PC), also known as parathyroid storm or acute primary hyperparathyroidism, is a rare and serious complication of primary hyperparathyroidism (PH). Fewer than 200 cases have been described in the literature. Prognosis is poor: mortality is 100% in non-operable cases and 20% in cases in which parathyroidectomy is performed. We emphasize the importance of early diagnosis and aggressive treatment.