Cognitive assessment protocol design in the ISSYS (Investigating Silent Strokes in hYpertensives: a magnetic resonance imaging Study)

Hypertension and silent cerebrovascular lesions (SCL) detected by brain magnetic resonance imaging (MRI) are associated with an increased risk of cognitive decline. In a prospective observational study in 1000 hypertensive patients, aged 50-70 years, with no prior history of stroke or dementia, we will study the presence of mild cognitive impairment (MCI) and the relationship between SCL and cognition. All participants will be assessed by means of the Dementia Rating Scale-2 (DRS-2) and will undergo a brain MRI. In order to better characterize MCI and future dementia risk in our cohort, those patients that are suspected to be cognitively impaired according to the DRS-2 results will have a further neurological evaluation and complete neuropsychological testing. Follow-up for the entire cohort is planned to last for at least 3 years.

[Knowledge about stroke symptoms and attitude towards them in the population]

INTRODUCTION

To know the meaning of stroke symptoms and to perceive them as an emergency is a decisive factor to reduce hospital admission delay. The aim of the study is to analyze the degree of recognition of stroke symptoms by the patients, their attitude towards them, and which factors contribute to a better knowledge on cerebrovascular diseases.

METHODS

A total of 292 patients diagnosed of stroke were studied prospectively, following a protocol designed for data collection that included 76 variables. Univariate and multivariate analyses were conducted to identify which variables were independently associated with a better interpretation of stroke symptoms and emergency perception.

RESULTS

Only 34% of all patients recognized they were suffering a stroke. The background that was independently associated with a better interpretation of symptoms included previous stroke (odds ratio [OR]: 3.97), institutionalized subjects (old people's home) (OR: 3.20), motor symptoms (OR: 1.92) and more serious stroke (OR: 1.05). Only 31% of all patients, 41% of whom had recognized stroke symptoms, decided to go immediately to hospital or call for an ambulance. Variables that were independently associated with a better perception of emergency included cardioembolic stroke (OR: 2.62), not having hypertension (OR: 0.48) and a correct interpretation of stroke symptoms (OR: 0.62).

CONCLUSION

Only 14% of all patients have a good knowledge about stroke and correctly act when it occurs. It is necessary to develop education programs aimed at the population that emphasize the emergency when symptoms suggesting stroke appear.

[Posterior spinal artery infarction and nonbacterial thrombotic endocarditis]

Nonbacterial thrombotic endocarditis (NBTE) has been described as an important complication in patients affected by different kind of illnesses, above all underlying malignancies. Fifty % of the patients affected by NBTE will have embolic events in different organs. The poverty of specific symptomatology appears to difficult seriously its diagnosis. In fact, systemic embolic infarctions are usually asymptomatic, except when central nervous system is involved. We present a patient affected by NBTE with an asymptomatic cervical spinal cord infarction, which diagnosis was made by pathologic study. The difficulty to explore typical sings of spinal lesion and the absence of previous reported cases of NBTE with posterior spinal artery infarction, make this one fairly interesting. We think that fibrinoplatelet embolism from NBTE should be included in the etiology of the posterior spinal artery infarction.

[Migraine-infarct in patients treated with beta-blockers]

Migraine in itself is a potential cause of cerebral infarct in young adults. However the mechanism of migrainous ictus is open to discussion. Some drugs (oral anticonceptives, ergotaminics) could favor its appearance. Three cases has described in the medical literature of migraine patients in whom betablockers administration has been related with onset of an ischemic ictus. We present two new cases of this association. Nonselective betablockers provoke an increase in platelet activity by stimulation of platelet alpha-2 receptors; this together with their vasoconstrictor effect could favor the apparition of cerebral infarction in patients with migraine. We suggest, following other authors, to include non selective betablockers in the group of drugs which have to be carefully managed in the patients with migraine, especially in those with the classical type (migraine with aura) in whom an initial vasoconstriction has been suggested.