Decision-making and frontoparietal resting-state functional connectivity among impulsive-compulsive diagnoses. Insights from a Bayesian approach

The Iowa Gambling Task (IGT) is one of the most widely used paradigms for assessing decision-making. An impairment in this process may be linked to several psychopathological disorders, such as obsessive-compulsive disorder (OCD), substance abuse disorder (SUD) or attention-deficit/hyperactivity disorder (ADHD), which could make it a good candidate for being consider a transdiagnostic domain. Resting-state functional connectivity (rsFC) has been proposed as a promising biomarker of decision-making. In this study, we aimed to identify idiosyncratic decision-making profiles among healthy people and impulsive-compulsive spectrum patients during the IGT, and to investigate the role of frontoparietal network (FPN) rsFC as a possible biomarker of different decision-making patterns. Using functional near-infrared spectroscopy (fNIRS), rsFC of 114 adults (34 controls; 25 OCD; 41 SUD; 14 ADHD) was obtained. Then, they completed the IGT. Hybrid clustering methods based on individual deck choices yielded three decision-makers subgroups. Cluster 1 (n = 27) showed a long-term advantageous strategy. Cluster 2 (n = 25) presented a maladaptive decision-making strategy. Cluster 3 (n = 62) did not develop a preference for any deck during the task. Interestingly, the proportion of participants in each cluster was not different between diagnostic groups. A Bayesian general linear model showed no credible differences in the IGT performance between diagnostic groups nor credible evidence to support the role of FPN rsFC as a biomarker of decision-making under the IGT context. This study highlights the importance of exploring in depth the behavioral and neurophysiological variables that may drive decision-making in clinical and healthy populations.

Endarterectomy, Stenting, or Medical Treatment for Symptomatic Carotid Near-Occlusion: Results from CAOS, a Multicenter Registry Study

BACKGROUND AND PURPOSE

The treatment of symptomatic carotid near-occlusion is controversial. Our aim was to analyze the results of carotid endarterectomy and carotid artery stent placement in patients with symptomatic carotid near-occlusion and to identify factors related to technical failure, periprocedural complications, and restenosis.

MATERIALS AND METHODS

We conducted a multicenter, prospective nonrandomized study. Patients with angiography-confirmed carotid near-occlusion were included. We assessed the revascularization rate and periprocedural stroke or death. Twenty-four-month clinical and carotid imaging follow-up was performed, and rates of carotid restenosis or occlusion, ipsilateral stroke, and mortality were analyzed. Carotid artery stent placement, carotid endarterectomy, and medical treatment were compared.

RESULTS

One hundred forty-one patients were included. Forty-four carotid artery stent placement and 23 carotid endarterectomy procedures were performed within 6 months after the event. Complete revascularization was achieved in 83.6%, 81.8% in the carotid artery stent placement group and 87% with carotid endarterectomy (P = .360). Periprocedural stroke or death occurred in 6% (carotid artery stent placement = 2.3%; carotid endarterectomy = 13%; P = .077) and was not related to revascularization failure. The carotid restenosis or occlusion rate was 8.3% (5% restenosis, 3.3% occlusion); with carotid artery stent placement it was 10.5%; and with carotid endarterectomy it was 4.5% (P = .419). The 24-month cumulative rate of ipsilateral stroke was 4.8% in the carotid artery stent placement group, 17.4% for carotid endarterectomy, and 13.1% for medical treatment (P = .223). Mortality was 12%, 4.5%, and 5.6%, respectively (P = .422). Revascularization failure and restenosis occurred more frequently in patients with full collapse compared with patients without full collapse (33.3% versus 5.6%, P = .009; 21.4% versus 2.9%, P = .032, respectively).

CONCLUSIONS

Carotid artery stent placement and carotid endarterectomy are associated with high rates of failure and periprocedural stroke. Carotid near-occlusion with full collapse appears to be associated with an increased risk of technical failure and restenosis. Carotid near-occlusion revascularization does not seem to reduce the risk of stroke at follow-up compared with medical treatment.

Dyslipidemias and stroke prevention: recommendations of the Study Group of Cerebrovascular Diseases of the Spanish Society of Neurology

OBJECTIVE

We present an update of the Spanish Society of Neurology's recommendations for prevention of both primary and secondary stroke in patients with dyslipidaemia.

DEVELOPMENT

We performed a systematic review to evaluate the main aspects of the management of dyslipidaemias in primary and secondary stroke prevention and establish a series of recommendations.

CONCLUSIONS

In primary prevention, the patient's vascular risk should be determined in order to define target values for low-density lipoprotein cholesterol. In secondary prevention after an atherothrombotic stroke, a target value <55mg/dL is recommended; in non-atherothombotic ischaemic strokes, given the unclear relationship with dyslipidaemia, target value should be established according to the vascular risk group of each patient. In both primary and secondary prevention, statins are the drugs of first choice, and ezetimibe and/or PCSK9 inhibitors may be added in patients not achieving the target value.

Dyslipidemias and stroke prevention: Recommendations of the Study Group of Cerebrovascular Diseases of the Spanish Society of Neurology

OBJECTIVE

We present an update of the Spanish Society of Neurology's recommendations for prevention of both primary and secondary stroke in patients with dyslipidaemia.

DEVELOPMENT

We performed a systematic review to evaluate the main aspects of the management of dyslipidaemias in primary and secondary stroke prevention and establish a series of recommendations.

CONCLUSIONS

In primary prevention, the patient's vascular risk should be determined in order to define target values for low-density lipoprotein cholesterol. In secondary prevention after an atherothrombotic stroke, a target value <55 mg/dL is recommended; in non-atherothombotic ischaemic strokes, given the unclear relationship with dyslipidaemia, target value should be established according to the vascular risk group of each patient. In both primary and secondary prevention, statins are the drugs of first choice, and ezetimibe and/or PCSK9 inhibitors may be added in patients not achieving the target value.

The risk of recurrent stroke at 24 months in patients with symptomatic carotid near-occlusion: results from CAOS, a multicentre registry study

BACKGROUND AND PURPOSE

The risk of recurrent stroke amongst patients with symptomatic carotid near-occlusion (SCNO) has not been clearly established, and its management remains controversial. The aim was to define the 24-month risk of recurrent stroke and to analyse the effect of the different treatment modalities (medical treatment and revascularization) in a population of patients with SCNO.

METHODS

A multicentre, nationwide, prospective study from January 2010 to May 2016 was performed. Patients with angiography-confirmed SCNO were included. The primary end-point was ipsilateral ischaemic stroke including periprocedural events within 24 months following the presenting event. Revascularization results and periprocedural complications, ipsilateral transient ischaemic attack, disabling or fatal stroke, and mortality were also noted.

RESULTS

The study population comprised 141 patients from 17 Spanish centres. Seventy patients (49.6%) were treated by revascularization (carotid stenting in 47, endarterectomy in 23). Complete revascularization was achieved in 58 patients (83%). Periprocedural stroke or death occurred in 5.7%. The 24-month cumulative incidence of the primary end-point was 11.1% (95% confidence interval 5.8-16.4; n = 15), 12% in the medical treatment group and 10.2% in the revascularization group, log-rank P = 0.817. The cumulative rates of ipsilateral ischaemic stroke or transient ischaemic attack, disabling or fatal stroke, and mortality, were 17%, 4.5% and 7.5%, respectively.

CONCLUSIONS

The rate of ipsilateral ischaemic stroke in patients with SCNO seems to be lower than the known rate associated with severe carotid stenosis without near-occlusion. The potential benefit of revascularization in the prevention of stroke in patients with SCNO may be influenced by the effectiveness and safety of the procedure.

Glycemia in Acute Stroke II study: a call to improve post-stroke hyperglycemia management in clinical practice

BACKGROUND AND PURPOSE

The aim of the study was to analyze the effect of conventional glucose management, which aimed to maintain glucose levels <155 mg/dL (8.5 mmol/L), on glucose control and the outcomes of patients with acute ischaemic stroke (IS) in a clinical practice setting.

METHODS

This was a multicenter, prospective cohort study of patients with acute IS. Patients were classified into four groups based on their initial 48-h capillary glucose levels and the administration of and response to corrective treatment: (i) untreated and maximum glucose levels <155 mg/dL (8.5 mmol/L) within the first 48 h; (ii) treated and good responders [glucose levels persistently <155 mg/dL (8.5 mmol/L)]; (iii) treated and non-responders [any glucose values ≥155 mg/dL (8.5 mmol/L) during the 24 h after the start of corrective treatment]; and (iv) untreated with any glucose value ≥155 mg/dL (8.5 mmol/L). The primary outcome was death or dependence at 3 months (blinded rater).

RESULTS

A total of 213 patients were included. Ninety-seven (45.5%) patients developed glucose levels ≥155 mg/dL (8.5 mmol/L), 69 (71.1%) underwent corrective treatment and 31 patients underwent no corrective treatment at the physician's discretion [28 of whom had isolated values ≥155 mg/dL (8.5 mmol/L)]. Only 11 (16%) patients responded to conventional treatment, whereas 58 (84%) patients were non-responsive. Non-responders showed a twofold higher risk of death or dependence at 3 months (odds ratio, 2.472; 95% confidence interval, 1.096-5.576; P = 0.029).

CONCLUSIONS

Lack of response to conventional treatment for glucose management in acute IS is frequent and associated with poor outcomes.

Recurrence of stroke amongst women of reproductive age: impact of and on subsequent pregnancies

BACKGROUND AND PURPOSE

The risk of recurrence of stroke after pregnancy is poorly known.

METHODS

This was an observational study of women younger than 45 years of age with transient ischaemic attack (TIA), cerebral infarction (CI), cerebral venous thrombosis (CVT) or intracerebral hemorrhage (ICH) treated in a stroke unit (January 1996-2011). The clinical data were prospectively collected in a database. Information on reproductive history after stroke was obtained using telephone surveys (2011). The variables were demographic data, vascular risk factors, stroke type, outcomes, medical advice concerning pregnancies after stroke, number of pregnancies after stroke, neurological assessment during pregnancy, antithrombotic treatments during pregnancy/puerperium, fertility treatments administered and information about hemorrhagic/ischaemic stroke recurrence.

RESULTS

Overall, 102 women were included: 24 TIA, 64 CI (four large vessel disease, 14 cardioembolic, 12 small vessel disease, 17 undetermined etiology, 17 uncommon etiology), 12 CVT and two ICH. Mean age at the time of first stroke was 35 (±7.5) years. Median follow-up was 7.4 years (range 1-17). Thirty-two pregnancies occurred in 27 patients (previous diagnosis: four TIA, 17 CI, five CVT and one ICH). One woman became pregnant using in vitro fertilization. Only eight pregnancies were followed up by a neurologist. Of 26 pregnancies without previous history of ICH, 18 (62%) underwent preventive antithrombotic treatment. No recurrence of stroke was observed during pregnancy/puerperium. Of the women without pregnancies after the first cerebrovascular event, four CIs and three TIAs were observed.

CONCLUSION

The recurrence of stroke after pregnancy is very low, which should be considered when counseling these patients.

How predictors and patterns of stroke recurrence after a TIA differ during the first year of follow-up

The highest risk of subsequent stroke after a TIA occurs within the first week after the index event. However, the risk of stroke recurrence (SR) remains high during the first year of follow-up. We studied the temporal pattern and predictors of SR (at 7 days and from 7 days to 1-year follow-up). Between April 2008 and December 2009, we included 1,255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). We determined the short-term (at 7 days) and long-term (from 8 days to 1 year) risk of SR. Patients who underwent short-term recurrence and long-term recurrence were compared with regard to clinical findings, vascular territories, and etiology. Enough information (clinical variables and extracranial vascular imaging) was assessed in 1,137 (90.6 %) patients. The 7-day stroke risk was 2.6 %. 32 (3.0 %) patients had an SR after 7-day follow-up. Multiple TIA (HR 3.50, 1.67-7.35, p = 0.001) and large artery atherosclerosis (HR 2.51, 1.17-5.37, p = 0.018) were independent predictors of early SR, whereas previous stroke (HR 1.40, 1.03-1.92, p = 0.034) and coronary heart disease (2.65, 1.28-5.50, p = 0.009) were independent predictors of late SR. Notoriously, 80 % of SR happened in the same territory of the index TIA at 7-day follow-up, whereas only 38 % during the long-term follow-up (p < 0.001). Different predictors of SR were identified throughout the follow-up period. Moreover, the ischemic mechanism differed in early and late stroke recurrences.

Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJECTIVE

To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment.

MATERIAL AND METHODS

A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed.

RESULTS

The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm.

CONCLUSIONS

SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

Efficacy of intravenous thrombolysis according to stroke subtypes: the Madrid Stroke Network data

OBJECTIVES

To identify possible differences in the early response to intravenous thrombolysis (IVT) or in stroke outcome at 3 months, based on stroke subtype in patients with acute ischaemic stroke (IS).

METHODS

Multicentre stroke registry data were used, with prospective inclusion of consecutive patients with acute IVT-treated IS in five acute stroke units. We compared clinical improvement (National Institutes of Health Stroke Scale, NIHSS) at 24 h and at day 7 as well as functional outcome at 3 months (Modified Rankin Scale, mRS) amongst the different stroke subtypes (ICD-10).

RESULTS

In total, 1479 patients were included; 178 (12%) had large vessel disease (LVD) with carotid stenosis ≥ 50%, 175 (11.8%) had other LVD, 638 (43%) had cardioembolism, 60 (4.1%) had lacunar infarction, 72 (4.9%) were patients with IS of other/unusual cause and 356 (24.1%) had unknown/multiple causes. Patients with lacunar infarction had lower stroke severity (median NIHSS 6) whilst cardioembolic IS was the most severe (median NIHSS 14) (P < 0.001). No differences in NIHSS improvement were found at 24 h. LVD patients with carotid stenosis (odds ratio 0.544; 95% CI 0.383-0.772; P = 0.001) were less likely to improve at day 7 after adjustment for age, gender, vascular risk factors and stroke severity. However, adjusted multivariate analysis showed no influence of stroke subtype on stroke outcome (mRS) at 3 months. Age, systolic blood pressure on admission and stroke severity were independently associated with mRS > 2 at 3 months.

CONCLUSION

Although LVD patients with arterial stenosis ≥ 50% improve less than the other aetiologies at day 7, stroke aetiological subtype does not determine differences in IS outcome at 3 months after IVT.

Migraine and hypercoagulable states in ischemic stroke

Background: Whether migraine is associated with a higher prevalence of hypercoagulable states (HS) in ischemic stroke patients is unknown.

Methods: This was a prospective study of patients under 55 years of age with brain ischemia. A systematic questionnaire addressed the antecedent of migraine with aura (MA) or without aura (MO). We investigated the presence of HS by an extensive battery of haematological tests. The presence of patent foramen ovale (PFO) was assessed by trans-oesophageal echocardiography.

Results: A total of 154 patients (95 men; mean ± SD age, 44.12 ± 8.4 years) were included; 44 had migraine, 15 had MA. HS were more frequent in the migraine than non-migraine group (38.6% vs. 16.4%, p < 0.01). The multivariate analysis showed that MO was associated with a 2.88-fold (95% CI, 1.14 to 7.28) increased risk of HS diagnosis. However, in the group of patients with brain infarction under 50 years old, MA, but not MO, was independently associated with HS (OR 6.81; 95% CI, 1.01 to 45.79).

Conclusion: In young patients with ischemic stroke, migraine may be associated with a higher frequency of HS.

Utility of the assessment of echogenicity in the identification of symptomatic carotid artery atheroma plaques in ischemic stroke patients

BACKGROUND AND PURPOSE

Echogenicity of atheroma carotid plaques is related to a higher risk of stroke. Clinical and subjective ultrasound criteria are used to identify symptomatic plaques, but the standardized grayscale median (GSM) value may be an objective tool for this diagnosis. Our aim was to analyze the utility of assessing the echogenicity of atheroma carotid plaques in the identification of symptomatic plaques.

METHODS

Observational prospective study with inclusion of acute noncardioembolic anterior cerebral circulation ischemic stroke patients. Only patients with bilateral atheroma plaques were included. Echogenicity of plaques was measured by a digital and standardized grayscale system in carotid ultrasound B-mode (longitudinal projection) conducted within the first week after admission.

RESULTS

Sixty-six patients were included and 132 plaques were examined. Symptomatic atheroma plaques were less echogenic than asymptomatic ones (GSM 20.0 vs. 29.0; p = 0.002). A ROC curve analysis showed the predictive value of GSM with an AUC of 0.707 (95% CI 0.592-0.823; p = 0.002) and pointed to a value of 24.4 as the optimal cut-off level to identify a plaque as symptomatic (74% sensitivity; 67% specificity). This GSM cut-off point remained significantly associated with a high probability of symptomatic plaque even after the inclusion of the degree of carotid stenosis (either >70% or >50%) in the multivariate logistic regression models.

CONCLUSIONS

The assessment of echogenicity of atheroma carotid plaques by the GSM value combined with clinical characteristics and stenosis degree may be useful in the identification of symptomatic plaques.

[Low sensitivity of the echocardiograph compared with contrast transcranial Doppler in right-to-left shunt]

BACKGROUND

Contrast transcranial Doppler (c-TCD) has a high sensitivity for detecting right-to-left shunt (RLS), and is probably higher than transthoracic echocardiography (TTE) and comparable with transesophageal echocardiography (TEE).

OBJECTIVE

To evaluate the accuracy of echocardiography (TTE and TEE) to detect RLS compared to c-TCD.

MATERIAL AND METHODS

Observational study of patients <55 years old with cerebral ischaemia of undetermined origin (2007-2009). All underwent c-TCD monitoring to detect RLS, at rest and after Valsalva manoeuvre (VM). The TTE and TEE were performed when indicated by our cerebrovascular protocol. The accuracy of TTE and TEE for detecting RLS was calculated by comparing them with c-TCD.

RESULTS

A total of 115 patients with c-TCD, mean age 43.3 (SD 10.3) years, 51.3% male. The TTE was performed in 102, and TEE in 81, patients. RLS detection was higher with c-TCD than with TTE (67.6% vs. 22.5%, P=.001) or TEE (77.8% vs. 53.1%, P=.001). The TTE, compared with c-TCD after MV showed: sensitivity 31.8%, specificity 96.9%, positive predictive value (PPV) 95.6%, negative predictive value (NPV) 40.5% and accuracy 52.9% to detect RLS. TEE, compared with c-TCD after MV showed: sensitivity 63.4%, specificity 83.3%, PPV 93%, NPV 39.4% and accuracy 67.9%. The accuracy of TTE and TEE improved when they were compared with c-TCD at rest.

CONCLUSIONS

TTE and TEE show a considerable number of false negatives for RLS detection. Clinical studies should consider the c-TCD as the best technique to diagnose RLS when a paradoxical embolism is suspected.

Do cerebral venous thrombosis risk factors influence the development of an associated venous infarction?

INTRODUCTION

Cerebral venous thrombosis (CVT) is a multifactorial process with a wide clinical spectrum and many associated risk factors (RF) that could be complicated with venous infarction (VI). We study the influence of RF in the developing of venous infarction in patients with CVT.

PATIENTS AND METHODS

An observational study with consecutive inclusion of patients with CVT diagnosis admitted to the Stroke Unit of a Neurology Department between 1995 and 2007. RF were identified and their distribution according to the presence of VI was analysed.

RESULTS

A total of 52 patients were included (37 female; 71.15%) with mean age of 46.73 years (range 18-78 years). The most frequent RF associated with CVT were thrombophilia (26.92%) and oral contraceptives (OC) (25% of all the patients and in 35.13% of females). The most frequent RF in patients with venous infarction was thrombophilia (40.9%), whilst in the CVT group without venous infarction the use of oral contraceptives predominated (26.7% of the total sample; 38% of females), with thrombophilic states only being detected in 16.5%. No cases of venous infarction were found in the group of patients with oral contraceptives but without an associated thrombophilic state.

CONCLUSION

There appears to be a different profile of associated RF in patients with venous infarction associated to CVT, with the presence of thrombophilia prevailing.

[Hypercoagulability and ischemic stroke in young patients]

INTRODUCTION

Hypercoagulable states have been reported as an established risk factor for cerebral venous thrombosis, but they have also been proposed as a predisposing factor for cerebral ischemia of arterial origin, especially among young patients. This may have implications on therapeutic management and secondary prevention. We have studied the frequency of prothrombotic abnormalities in young patients with ischaemic stroke, as other classic risk factors are less common in this group.

MATERIALS AND METHODS

Observational study with sequential inclusion of patients under 55 with stroke or transient ischaemic attack (TIA) admitted to the Stroke Unit from January 2005 through December 2007. We analysed demographic data, severity and subtype of stroke, risk factors, including the presence of hypercoagulable states, and outcome.

RESULTS

We included 100 patients, of whom 65 were men. The mean age was 42.6 ± 8.9 years, 46% with a hypercoagulable state, and no sex differences. Acquired hyperhomocysteinemia was the most common abnormality (18%), followed by protein C or S deficiency (8%), factor V Leiden mutation (5%) and methyl-tetrahydro-folate-reductase (MTHFR) C677T mutation (5%). Other findings included anticardiolipin antibodies (3%), presence of lupus anticoagulant (2%), thrombocytosis (3%) and G20210A prothrombin gene mutation (3%). No association was found between these states and the presence of other vascular risk factors, or more severe stroke or worse outcomes. There was an increased presence of these abnormalities in patients who were classified as atherothrombotic stroke (p = 0.04).

CONCLUSIONS

The hypercoagulable states are common in young patients with ischaemic stroke, being present in up to 46% of them.

[Development of an acute stroke care pathway in a hospital with stroke unit]

INTRODUCTION

Care pathways (CP) are tools for standardizing the management of patient in certain diseases with a predictable course, and they have demonstrated usefulness in clinical practice. In-hospital stroke CP have been implemented in departments of Neurology, General Medicine or Rehabilitation, however there are few studies developing an integrated CP in hospitals with an acute Stroke Unit (SU). The aim is to develop a CP capable of organizing and homogenizing the stroke assistance, and integrating the quality standards, in a hospital with an Acute Stroke Unit (SU).

METHODS

Members of the Neurology, Rehabilitation, Emergency and Preventive Medicine departments established a schedule of nine fortnightly meetings. Several documents that compound the CP were elaborated following the FOCUS-PDCA model, according with the scientific evidence and the in force clinical guides.

RESULTS

The following documents were elaborated: scientific-technical framework which integrates all processes; information document for patient/relatives on-admission; nurses protocols (social risk, disphagya, falling down risk and pressure ulcers); stroke rehabilitation guidelines for staff; treatment, care and monitoring sheets; recommendations at discharge for patient/relatives; stroke rehabilitation guidelines for patient/relatives; specific didactic units for patient/relatives; patient/relatives satisfaction survey; and quality standard document.

CONCLUSIONS

A stroke CP in a hospital with SU potentially promotes a more organized and efficient stroke care, as well as improve the patient/relatives satisfaction.

[Ultrasound in acute ischemic stroke]

INTRODUCTION

Ultrasound tests are used in the cerebrovascular evaluation of stroke patients. However, the use of Transcranial Doppler (TCD) and carotid duplex ultrasound (CD) within the first hours after stroke onset in the Emergency Service is not a common practice.

RESULTS

TCD and CD can be used as portable tests, thus allowing for bedside use in the Emergency Service. Both tests broaden the abilities of stroke neurologists to rapidly evaluate stroke patients, determine likely mechanism of stroke, and decide on reperfusion and secondary prevention strategies. Furthermore, the ultrasound tests are particularly useful for grading the severity of the arterial patency and enhancing recanalization after tPA administration.

CONCLUSIONS

TCD and CD are excellent diagnostic tools that might be used in all acute stroke patients for immediate evaluation of arterial patency. They make it possible to select treatment and enhance reperfusion after tPA. Carotid and transcranial ultrasound are an essential part of vascular neurology training and practice.

Comparison of the MagNA pure LC automated system and the RiboPure-Blood RNA manual method for RNA extraction from multiple myeloma bone marrow samples conserved in an RNA stabilizer

A total of 62 frozen bone marrow specimens conserved in RNA later (Ambion) were processed using two different extraction methods, the MagNA Pure LC system (MAG; Roche) and the manual RiboPure-Blood RNA method (RIBO; Ambion); Beta glucoronidase RNA (GUS) was amplified by LightCycler PCR to evaluate the quality of both extraction procedures. Less than 1000 GUS copies/ml was detected in 26 of 62 specimens (41.94%) processed by MAG and in five of 62 specimens (8.06%) processed by RIBO. Moreover, RNA recovery from the 62 specimens by MAG is, on average, 2.91 cycle threshold-fold higher than RIBO (P = 0.0008). Furthermore, we compared the extraction times and reagent costs of both methods. In conclusion, RNA extraction using MAG is faster to process 32 samples and less expensive than RIBO but it is not sensitive enough to be employed for research purpose in our laboratory.