Association Between Onset-to-Door Time and Clinical Outcomes After Ischemic Stroke

Background and Purpose—

The role of early hospital arrival in improving poststroke clinical outcomes in patients without reperfusion treatment remains unclear. This study aimed to determine whether early hospital arrival was associated with favorable outcomes in patients without reperfusion treatment or with minor stroke.

Methods—

This multicenter, hospital-based study included 6780 consecutive patients (aged, 69.9±12.2 years; 63.9% men) with ischemic stroke who were prospectively registered in Fukuoka, Japan, between July 2007 and December 2014. Onset-to-door time was categorized as T 0-1 , ≤1 hour; T 1-2 , >1 and ≤2 hours; T 2-3 , >2 and ≤3 hours; T 3-6 , >3 and ≤6 hours; T 6-12 , >6 and ≤12 hours; T 12-24 , >12 and ≤24 hours; and T 24- , >24 hours. The main outcomes were neurological improvement (decrease in National Institutes of Health Stroke Scale score of ≥4 during hospitalization or 0 at discharge) and good functional outcome (3-month modified Rankin Scale score of 0–1). Associations between onset-to-door time and main outcomes were evaluated after adjusting for potential confounders using logistic regression analysis.

Results—

Odds ratios (95% confidence intervals) increased significantly with shorter onset-to-door times within 6 hours, for both neurological improvement ( T 0- 1 , 2.79 [2.28–3.42]; T 1-2 , 2.49 [2.02–3.07]; T 2-3 , 1.52 [1.21–1.92]; T 3-6 , 1.72 [1.44–2.05], with reference to T 24- ) and good functional outcome ( T 0-1 , 2.68 [2.05–3.49], T 1-2 2.10 [1.60–2.77], T 2-3 1.53 [1.15–2.03], T 3-6 1.31 [1.05–1.64], with reference to T 24- ), even after adjusting for potential confounding factors including reperfusion treatment and basal National Institutes of Health Stroke Scale. These associations were maintained in 6216 patients without reperfusion treatment and in 4793 patients with minor stroke (National Institutes of Health Stroke Scale ≤4 on hospital arrival).

Conclusions—

Early hospital arrival within 6 hours after stroke onset is associated with favorable outcomes after ischemic stroke, regardless of reperfusion treatment or stroke severity.

[Two cases of ischemic cerebrovascular disease with only memory disturbance as neurological symptom and abnormal MR findings]

Case 1 involved a 77-year-old man admitted to our hospital after he lost almost all memory of work on the day before. Diffusion-weighted imaging (DWI) revealed spotty hyperintensities in the bilateral hippocampi, which were considered responsible for the amnesia. Transesophageal echocardiography (TEE) showed severe aortic arch atheroma, 6.8 mm in diameter with extension to the branch. Aortogenic embolism to the bilateral hippocampi was diagnosed. Case 2 involved a 66-year-old woman admitted to our hospital because she had lost all memory of the 5 hours she was out. She had transient anterograde amnesia. DWI revealed no ischemic lesions, but magnetic resonance angiography (MRA) revealed branch occlusion of the right posterior cerebral artery. MRA on hospital day 7 revealed partial recanalization. TEE showed aortic arch atheroma of 3.9 mm in diameter with extension to the branch. In both cases, aortogenic embolism to the hippocampus might have been causally related to transient memory disturbance. In patients with acute memory disturbance, the possibility of ischemic stroke should be considered.

Day-by-Day Blood Pressure Variability and Functional Outcome After Acute Ischemic Stroke

Background and Purpose—

The relationship between blood pressure (BP) variability and functional outcome in patients with acute ischemic stroke remains unclear. This study aimed to elucidate whether in-hospital day-by-day BP variability is associated with functional outcome after acute ischemic stroke.

Methods—

Using the Fukuoka Stroke Registry, we included 2566 patients with a first-ever ischemic stroke who had been functionally independent before the onset and were hospitalized within 24 hours. BP was measured daily, and its variability was assessed by SD, coefficients of variance, and variations independent of mean. Poor functional outcome was assessed by modified Rankin Scale scores ≥3 at 3 months.

Results—

After adjustment for multiple confounding factors including age, sex, risk factors, stroke features, baseline severity, thrombolytic therapy, antihypertensive agents, and mean BP, day-by-day BP variability during the subacute stage (4–10 days after onset) was independently associated with a poor functional outcome (multivariable-adjusted odds ratios [95% confidence interval] in the top versus bottom quartile of systolic BP variability, 1.51 [1.09–2.08] for SD; 1.63 [1.20–2.22] for coefficients of variance; 1.64 [1.21–2.24] for variations independent of mean). Similar trends were also observed for diastolic BP variability. These trends were unchanged in patients who were not treated with antihypertensive drugs. In contrast, no association was found between indices of BP variability during the acute stage and functional outcome after adjusting for potential confounders.

Conclusions—

These data suggest that intraindividual day-by-day BP variability during the subacute stage is associated with the 3-month functional outcome after acute ischemic stroke.

Abstract T P109: Prediction Of Asymptomatic Cerebrovascular Diseases Before Bypass Surgery For Peripheral Artery Disease

Background & Purpose: Cerebrovascular disease (CVD) and peripheral artery disease (PAD) sometimes coexist with each other. We investigated predictive factors for CVD before bypass surgery for PAD.

Subjects & Methods: For the present study, 200 consecutive PAD patients who were planned to undergo a bypass surgery for their lower extremity artery were included. Before the surgery, all patients were studied by ankle brachial index (ABI), duplex carotid ultrasonography, magnetic resonance imaging (MRI) including diffusion weighted imaging (DWI), and MR angiography. A stenosis of ≥50% or occlusion of the major intracranial or extracranial cerebral arteries was defined as a significant CVD. We also investigated the predictive factors for significant cerebrovascular lesions.

Results: Of the total 200 patients (137 men; 69%, 74±9 years old) studied, a significant CVD of the intracranial or extracranial cerebral arteries was observed in 104 (52%) patients: 57 (29%) in intracranial arteries and 68 (34%) in extracranial arteries. There were asymptomatic ischemic lesions on MRI in 116 (59%) patients. Among them, 13 (7%) patients had asymptomatic high-intense lesions on DWI. In patients with significant CVDs, dyslipidemia (63% vs 47%, p=0.0455), diabetes mellitus (67% vs 37%, p<0.001), prior ischemic stroke (65% vs 48%, p=0.0328), and prior ischemic heart disease (63% vs 46%, p=0.0189) were more frequent, and ABI value was lower (0.34 vs 0.45, p=0.0369) in comparison to patients without CVDs. On ROC curve analysis, the most accurate ABI cut-off value for predicting significant CVDs was 0.46. Prevalence of CVDs tended to increase with the increasing number of risk factors described above (44% in patient with 1, 56% in patient with 2, 71% in patient with 3, 69% in patient with 4, 80% in patient with 5; P<0.0001 for armitage trend). On multivariate analysis, dyslipidemia (OR, 1.93; 95% CI, 1.00-3.81) and diabetes mellitus (OR, 3.06; 95% CI, 1.62-5.86) were independent predictors for significant CVDs.

Conclusions: In PAD patients before the bypass surgery, significant CVDs were observed in 52%. Dyslipidemia and diabetes mellitus were independent predictors for significant CVDs. Number of the predictive factors was also important for predicting CVDs.

Abstract T MP60: Impact of Aortic Arch Atheroma for Stroke Recurrence in Patients With or Without Atrial Fibrillation

Background & Purpose: In patients with embolic stroke of undetermined source, aortic arch atheroma evaluated using transesophageal echocardiography (TEE) is a possible embolic source. We investigated the impact of embolic sources including aortic arch atheroma for a stroke recurrences and death.

Methods: Among the consecutive 1545 acute stroke patients, 542 patients who were admitted within 24 hours after the symptom onset, with ischemic lesions in the cortex or cerebellum on the diffusion-weighted image, NIH stroke scale of 7 or less, and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. All 542 patients underwent TEE to search for embolic sources. According to the categories of embolic sources, patients were classified into 4 groups: patients with severe aortic arch atheroma of 4mm or more in diameter (group A; n=167), patients with cardiogenic embolic sources such as atrial fibrillation or intracardiac thrombus (group C; n=93), patients with both factors as described above (group B; n=88), and other patients (group O; n=194). We followed them up for average period of 3.2 years, and investigated the frequency of stroke recurrences and death from any cause according to embolic sources.

Results: Stroke recurrences were observed in 12.0% patients in group A, 11.8% patients in group C, 18.2% patients in group B, and 6.7% patients in group O respectively (p=0.0371). Stroke recurrences and death from any cause occurred in 14.4%, 15.1%, 21.6% and 6.7% patients respectively (p=0.0041). Kaplan-Meier curve analysis revealed a significant difference in the recurrence-free survival among the four groups (p=0.0076, log-rank test). Stroke recurrence was more frequent in group B than group C patients especially in the early phase from the onset. On COX proportional-hazards model analysis and diabetes mellitus (HR 1.73, p=0.0264) and aortic arch atheroma of 4mm or more (HR 1.86, p=0.0146) were significant predictors for stroke recurrences and death from any cause.

Conclusions: Severe aortic arch atheroma can independently be associated with stroke recurrences and death, furthermore, a combination of aortic arch atheroma and cardiogenic embolic sources showed more frequent events than each of them alone.

Abstract T P70: Outcome of Japanese Minor Stroke Patients Treated Without Intravenous Recombinant Tissue Plasminogen Activator Within 4.5 Hours After the Symptom Onset ~Fukuoka Stroke Registry~

Background & Purpose: Patients with minor stroke with the initial NIH stroke scale score of 4 or less were often treated without recombinant tissue plasminogen activator (rt-PA) even when they are admitted within 4.5 hours after the symptom onset. We investigated the outcome of minor stroke within 4.5 hours after the symptom onset without intravenous recombinant tissue plasminogen activator therapy.

Methods: Among consecutive 6246 acute ischemic stroke patients who were admitted to the 7 stroke centers, 963 patients with admission within 4.5 hours after the symptom onset, ischemic lesions on diffusion-weighted image, NIH stroke scale of 4 or less, and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. Thirty-four (3.5%) of the 963 patients were treated with intravenous rt-PA. In other 926 patients, we observed a neurological deterioration (a NIHSS score worsening of ≥2-point) and stroke recurrence during the first 3 weeks. A good outcome (3 months) at was defined as mRS of 0 or 1.

Results: Stroke recurrence and neurological deterioration occurred in 3.7% and 9.2% of 926 patients during the first 3 weeks. A good outcome 3 months after admission was observed in 82.3%. Atrial fibrillation and diabetes mellitus were less frequent in patients with than without a good outcome. The initial NIH stroke scale score, LDL-cholesterol, glucose, HbA1c, d-dimer, and CRP values were lower, and the initial HDL-cholesterol and estimated GFR values were higher in patients with than without a good outcome. On multivariate analysis, age (OR 0.94, 95%CI 0.92~0.97), the initial NIH stroke scale score (OR 0.60, 95%CI 0.48~0.74), LDL-cholesterol (OR 0.99, 95%CI 0.98~1.00), and D-dimer (OR 0.92, 95%CI 0.85~0.99) were negatively associated with a good outcome. With regard to the ROC curve analysis, the most accurate cut-off value for predicting a good outcome was 74 years in age, 2 in NIH stroke scale score, 137mg/ml in LDL-cholesterol, and 0.80μg/ml in D-dimer.

Conclusions: In minor stroke patients treated without rt-PA, age of 75 years or more, NIH stroke scale score of 3 or more, LDL-cholesterol of 138mg/ml or more, or D-dimer of 0.80μg/ml or more could be negative predictor for a good outcome. In such patients, treatment with rt-PA may be considered.

Abstract W P167: Lacunar Infarction and Hypertensive Intracerebral Hemorrhage-Similarities and Differences of Two Different Clinical Entities of Cerebral Small-Vessel Disease

Introduction: Lacunar infarction (Lac) and hypertensive intracerebral hemorrhage (ICH) are known as cerebral small-vessel disease in which hypertension plays a pivotal role in the development of pathology. However, it is unclear why some patients suffer from cerebral infarction and others bleed. We compared the background of these two groups, and examined differences and similarities between them.

Methods: Between February 2008 and January 2013, 1149 patients were admitted to our institution within 1 week after the onset of stroke. A database was prospectively constructed with this consecutive patients’ cohort and data were analyzed retrospectively. Among the patients, 138 had Lac and 109 had ICH.

Results: Age, sex, and BMI were not different between the groups. Medication prior to the onset of stroke was more common in Lac than in ICH (77.5% vs. 55.1%; p<0.001). The frequency of antiplatelet therapy, blood pressure-lowering therapy, and lipid-lowering therapy was not different between the groups. Treatment for diabetes mellitus (DM) was significantly more frequent in Lac than in ICH (29.0% vs. 8.3%; p<0.001). Calcification of the aortic arch was significantly more common in Lac than in ICH (62.2% vs. 43.3%; p=0.009). Smoking, past history of stroke, and familial history of stroke were not different between the groups. Left-sided stroke was significantly more common in Lac than in ICH (63.8% vs. 50.4%; p=0.004). On admission, triglycerides, total cholesterol (Chol), HDL-Chol, LDL-Chol, total protein, serum albumin, and blood sugar levels were not different between the groups. HbA1c levels on admission were significantly higher in Lac than in ICH (6.4+/-1.3% vs. 5.9+/-1.0%; p=0.004).

Conclusions: Lac and ICH have similar backgrounds. However, left-sided stroke, calcification of the aortic arch, and a medical history of DM are more common in Lac than in ICH patients. HbA1c values on admission are higher in Lac than in ICH patients. This suggests that there are subgroups of Lac in which the pathological process is different from that in ICH. Therefore, endothelial damage induced by DM may play a role in some patients with Lac, and left-sided propensity and a tendency for aortic arch calcification suggest that some aortogenic embolisms may be diagnosed as Lac.

Abstract 163: Carotid Stenosis and Stroke Recurrence in Minor Stroke Patients With Atrial Fibrillation

Background & Purpose: Both atrial fibrillation (AF) and carotid stenosis (CS) can be associated with acute stroke recurrence and consequent bad outcome even in minor stroke. We investigated stroke recurrence and outcome in Japanese minor stroke patients with AF and/or CS.

Subjects & Methods: Among the consecutive 6246 stroke patients who were admitted to the 7 stroke centers within 7 days after the onset, 634 patients with acute ischemic stroke with AF, the initial NIH stroke scale score of 7 or less, and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. We observed an acute stroke recurrence during 3 weeks.

Results: Acute stroke recurrence was observed in 27 (4.3%) patients. Major cerebral artery stenosis of 50% or more in diameter was observed in 159 (25.1%) patients, and among them 43 (6.8%) had carotid stenosis. Any major artery stenosis was more frequent in patients with than without stroke recurrence (55.6% vs 23.7%, p=0.0002). Carotid stenosis was more frequent in patients with than without stroke recurrence (25.9% vs 5.9%, p<0.0001). The initial NIHSS score was not different between patients with and without an acute stroke recurrence. Dyslipidemia, diabetes mellitus, and history of brain hemorrhage were more frequent, and HDL cholesterol and estimated GFR values were lower, and HbA1c, fasting glucose, BUN, and D-dimer values were higher, intima-media thickness 0f the common carotid artery was thicker in patients with than without an acute stroke recurrence. On the multivariate analysis, carotid stenosis (OR 4.93, 95%CI 1.60~15.2) and D-dimer value (OR 1.13, 95%CI 1.00~1.28) had a positive association with an acute stroke recurrence. Among 43 patients with both AF and CS, 7 had an acute stroke recurrence. With regard to the acute antithrombotic treatment, 5 patients were treated with only anticoagulant agents and other 2 patients were treated with both anticoagulant and antiplatelet agents.

Conclusions: Carotid stenosis was a significant predictor for an acute stroke recurrence in patients with atrial fibrillation. Optimal antithrombotic treatment in the acute phase in stroke patients with both AF and CS should be investigated.

Abstract T P98: Effect of Atrial Fibrillation and/or Large Artery Atherosclerosis on Stroke Recurrence and Long-term Outcome in Japanese Minor Stroke ~Fukuoka Strok Registry~

Background & Purpose: Atrial fibrillation (AF) and large artery atherosclerosis (LAA) can be associated with a bad outcome even in minor stroke. We investigated stroke recurrence and outcome in Japanese minor stroke patients with AF and/or LAA.

Subjects & Methods: Among the consecutive 6246 stroke patients who were admitted to the 7 stroke centers within 7 days after the onset, 3725 patients with acute ischemic stroke with the initial NIH stroke scale score of 7 or less and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. In accordance with AF and intracranial or extracranial LAA (stenosis of 50% or more in diameter), they were classified into 4 subgroups: patients without both AF and LAA (Group A, n=2154), patients with only AF (Group B, n=475), patients with only LAA (Group C, n=937), and patients with both AF and LAA (Group D, n=159). We observed stroke recurrence and outcome during one year.

Results: On the multivariate analysis, age (OR, 0.94; 95%CI 0.93~0.95), initial NIH stroke scale score (OR, 0.70; 95%CI, 0.67~0.74), chronic kidney disease (OR, 0.72; 95%CI, 0.55~0.95), initial HbA1c value (OR 0.87, 95%CI 0.79~0.95), and LAA (OR 0.70, 95%CI 0.55~0.88) had a negative association with a good outcome. Acute stroke recurrences within 3 weeks after the onset were observed in 2.0%, 2.5%, 6.1%, and 9.4% in Group A-D patients respectively (p<0.0001). Stroke recurrences during 1 year were observed 7.0%, 10.7%, 11.6%, and 13.8% in Group A-D patients respectively (p<0.0001). A good outcome (mRS of 0-1) 1 year after the onset was observed in 77.0%, 6.4%, 67.9%, and 65.8% in Group A-D patients respectively (p<0.0001). With regard to the Kaplan-Meier method, there was a significant difference in stroke recurrence among the 4 subgroups, and stroke recurrences were most frequent in Group D (p<0.0001, Log-rank test).

Conclusions: In Japanese minor stroke, age, NIH stroke scale score, chronic kidney disease, HbA1c, and LAA were significant predictors for the long-term outcome. In patients with both AF and LAA, stroke recurrences were most frequent, especially in the acute phase, and a long-term good outcome was least frequent consequently.

Low diastolic blood pressure was one of the independent predictors of ischemia-like findings of electrocardiogram in patients who underwent coronary angiography

BACKGROUND

The underlying cause of a high cardiovascular event rate in the population with low diastolic blood pressure (DBP) has not been fully elucidated.

METHODS AND RESULTS

The relationship between DBP and ischemia-like findings on electrocardiography (ECG) was investigated in 187 patients who underwent coronary angiography. Patients with conditions affecting ECG (e.g. patients taking digitalis or those with old myocardial infarction, complete right bundle branch block, or hypokalemia) were excluded from the analyses. Ischemia-like ECG was defined as having one or more of the following: borderline Q wave [Minnesota code (MC) I 3], ST depression (MC IV 1-3), negative T wave (MC V 1-3), and complete left bundle branch block (MC VII 1). Based on this definition, 70 of 187 patients (37%) had ischemia-like ECG. Compared with the group without it, the group with ischemia-like ECG included more females (p<0.01), and had lower values of body mass index (p = 0.01), DBP (p<0.01), estimated glomerular filtration rate (p<0.01), left ventricular ejection fraction (LVEF; p<0.01), and higher values of age (p<0.01) and left ventricular mass index (LVMI; p<0.01). The severity of coronary artery disease did not differ between the groups. Receiver operating characteristics curve analysis revealed that 74.5 mmHg was the optimal cut-off point of DBP to predict ischemia-like ECG (area under curve, 0.63; 95% confidence interval, 0.55-0.71, p = 0.003). There were no significant relationships between systolic blood pressure and ischemia-like ECG. A multivariate analysis showed that female sex, low DBP (≤ 74.5 mmHg), LVMI, and LVEF were the significant factors for the ischemia-like ECG. The odds ratio of low DBP was 2.53 (95% confidence interval, 1.19-5.40; p = 0.02).

CONCLUSIONS

Low DBP was one of the significant predictors of the ischemia-like ECG in the present study. Myocardial ischemia may be a part of the cause of high cardiovascular morbidity in the population with low DBP.

Abstract WP288: High Non-HDL Cholesterol Is Associated With Acute Neurological Deterioration In Ischemic Stroke Patients: the Fukuoka Stroke Registry (FSR)

Background and Purpose: Several studies have shown that non-HDL cholesterol, defined as total cholesterol minus HDL cholesterol, was one of the risk factors for coronary heart diseases. However, the relationship between non-HDL cholesterol and cerebrovascular diseases remains unclear. We assessed the hypothesis that high non-HDL cholesterol may affect the outcome in acute ischemic stroke patients.

Methods: The FSR is a multicenter prospective registry of acute stroke patients admitted to seven stroke centers in Fukuoka, Japan. From June 2007 to March 2012, 5995 patients were enrolled. Among them, 1915 patients who fulfilled the following criteria were included in the present study: (1) first-ever, (2) ischemic stroke, (3) hospitalization within 24 hours after onset, (4) modified Rankin scale (mRS) of 0 or 1 before onset. Patients were divided into quartiles based on the value of non-HDL cholesterol (mg/dL); G1 (non-HDL <120), G2 (120 ≤non-HDL <140), G3 (140 ≤non-HDL <160), G4 (non-HDL ≥160). Neurological severity was evaluated by National Institute of Health Stroke Scale (NIHSS). A NIHSS increase of ≥1-point during the first 21 hospital days was defined as an acute neurological deterioration, and a mRS of 2 or more at discharge as a functional dependence.

Results: The worse the non-HDL cholesterol grade became (from G1 to G4), the lower age (p<0.0001), the frequency of male (p=0.003) and initial NIHSS score (p<0.001) were, and the higher blood pressure (p<0.0001), body mass index (p<0.0001) on admission, and the frequency of dyslipidemia (p<0.0001) were. As non-HDL cholesterol grade was worse, the frequency of acute neurological deterioration (p=0.008) and functional dependence at discharge increased (p=0.036). Multivariate logistic regression analysis revealed that as non-HDL cholesterol grade was worse, acute neurological deterioration was more prevalent (p for trend = 0.016) and the worst grade (G4) was independently associated with acute neurological deterioration (Odds Ratio 1.66; 95% CI 1.06-2.61; p=0.026) compared to G1.

Conclusion: The frequency of acute neurological deterioration is significantly higher in ischemic stroke patients with higher plasma non-HDL cholesterol on admission.

Abstract WP188: Cardiac Diastolic Dysfunction Is Associated With Poor Functional Outcome In Ischemic Stroke Patients

Background and Purpose: Some studies reported that cardiac diastolic dysfunction was related to poor prognosis in heart failure, however, its relationship with acute stroke has not yet been clear. We assessed the hypothesis that cardiac diastolic dysfunction may affect the outcome in acute ischemic stroke patients.

Methods: Among 938 consecutive acute stroke patients admitted to Steel Memorial Yawata Hospital, Kitakyushu, Japan within 7 days after the symptom onset from January 2008 to March 2012, 460 patients with ischemic lesions on the initial diffusion-weighted image, prior modified Rankin scale (mRS) of 0 or 1, and available E/E’ values (one of the parameters of cardiac diastolic function in transthoracic echocardiography) evaluated after admission were included into the final statistical analysis. Patients were divided into quartiles according to E/E’ values; Q1 (less than 10), Q2 (10-13), Q3 (14-15), Q4 (more than 15). A NIH stroke scale score worsening of ≥1-point during the first 21 hospital days was defined as an acute neurological deterioration. A modified Rankin scale (mRS) of 2 or more was defined as a poor outcome. We also observed stroke recurrence or any death during one year from the onset.

Results: Age (p<0.0001), frequency of female (p<0.0001), initial NIH stroke scale score (p=0.0184), and frequency of diabetes mellitus (p=0.0304), hypertension (p=0.0344), and severe valvular heart diseases (p=0.0008) showed a stepwise increase in Q1-Q4 in order. A poor outcome 3 months after the onset was observed in 15%, 27%, 24%, and 49% in the Q1-4 patients respectively. A stroke recurrence or any death occurred in 6%, 11%, 11%, and 17% in the Q1-4 patients respectively. On the multivariate logistic regression analysis, the worst E/E’ grade (Q4) was independently associated with a poor outcome 3 months after the onset (Odds Ratio 2.7; 95% CI 1.01-7.14; p=0.0463) and stroke recurrence or any death (Odds Ratio 5.2; 95% CI 1.59-18.9; p=0.0058), however, it was not associated with an acute neurological deterioration and a poor outcome on the discharge.

Conclusions: Severe cardiac diastolic dysfunction might be associated with a poor outcome and long-term stroke recurrence in ischemic stroke patients.

Effects of intravenous nicorandil on the mid-term prognosis of patients with acute heart failure syndrome

BACKGROUND

Acute heart failure syndrome (AHFS) remains a major clinical challenge because of its poor prognosis. Nicorandil, a hybrid compound of a potassium-channel opener and nitric oxide donor, has been reported to improve the prognosis of ischemic heart disease. We sought to evaluate the effect of intravenous nicorandil on the mid-term prognosis of AHFS.

METHODS AND RESULTS

A total of 402 consecutive patients who were hospitalized for AHFS were divided into 2 groups according to the use of intravenous nicorandil: 78 patients in the Nicorandil group and 324 patients in the Control group. During the 180-day follow-up, death or rehospitalization for heart failure occurred in 7 patients in the Nicorandil group (9.0%) and in 75 patients (23.2%) in the Control group. Event-free survival rates were significantly higher in the Nicorandil group than in the Control group (P=0.006). Multivariate Cox hazard analysis revealed that age (hazard ratio (HR)=1.066, P<0.0001), systolic blood pressure (HR=0.983, P=0.0023), New York Heart Association class III/IV (HR=6.550, P<0.0001), log creatinine (HR=3.866, P=0.0106), and use of intravenous nicorandil (HR=0.179, P<0.0001) were significant predictive factors for the occurrence of death or rehospitalization for heart failure.

CONCLUSIONS

Intravenous nicorandil treatment from the urgent phase of AHFS may improve the prognosis.

Abstract 3362: Neurological Deterioration And Stroke Recurrence In The Acute Phase Of Japanese Minor Stroke ∼ Fukuoka Stroke Registry ∼

Background & Purpose: A neurological deterioration in the acute phase can be associated with a bad outcome even in the minor stroke. We investigated the predictive factors for an acute neurological deterioration in minor stroke.

Subjects & Methods: Among the consecutive 3062 stroke patients who were admitted to the 7 stroke centers in Fukuoka prefecture Japan within 7 days after the onset, 2113 patients with acute ischemic stroke with the initial NIH stroke scale score of 7 or less and preclinical modified Rankin scale of 0 or 1 were included in the present study. We observed a neurological deterioration (a NIH stroke scale score worsening of ≥1-point), stroke recurrence, or any death during the first 21 hospital days.

Results: A neurological deterioration with or without stroke recurrence was observed in 338 (16%) patients. Baseline NIH stroke scale score was not different between patients with and without a neurological deterioration. With regard to the TOAST classification, a neurological deterioration was most frequent in Large-artery atherosclerosis (18.3%), followed by Others (18.2%), Cardioembolism (15.6%), and Small-vessel occlusion (12.2%) in order. In accordance with the site of ischemic lesions, a neurological deterioration was most frequent in patients with both cortex or cerebellar lesions and deep perforating artery lesions (20.2%). A preexisting warfarin use was less frequent (6.8% vs 10%, p=0.0624), diabetes mellitus (42% vs 32%, p=0.0007) and a stenosis of ≥50% in the major brain artery (35% vs 28%, p=0.0133) were more frequent, and the initial values of low density lipoprotein (LDL) cholesterol (122.1±36.5 vs 116.6±34.7 mg/dl, p=0.0100), blood glucose (144.9±66.5 vs 138.9±60.1 mg/dl, p=0.0969), and HbA1c (6.05±1.42 vs 5.91±1.23, p=0.0801) were higher in patients with than without a neurological deterioration. Maximum intima-media thickness of the common carotid artery was relatively thicker in patients with than without a neurological deterioration (1.87±1.55 vs 1.69±0.97 mm, p=0.0624). On multivariate analysis, a stenosis of ≥50% in the major brain artery (OR, 1.40; 95%CI 1.07∼1.85), ischemic lesions including deep perforating artery area (OR, 1.47; 95%CI, 1.10∼1.96), LDL cholesterol (OR, 1.00; 95%CI, 1.00∼1.01), and diabetes mellitus (OR 1.70, 95%CI 1.21∼2.39) had a positive association, and preexisting warfarin use (OR 0.61, 95%CI 0.39∼0.98) had a negative association with a neurological deterioration.

Conclusions: The major brain artery stenotic lesion, the site of ischemic lesions, LDL cholesterol, and diabetes mellitus were significant predictor for a neurological deterioration in the acute phase of minor stroke. A preexisting warfarin use might decrease the risk of a neurological deterioration.

Abstract 3984: Neurological Deterioration And Stroke Recurrence In The Acute Phase Of Ischemic Stroke In The Deep Perforating Artery Territory ∼ Fukuoka Stroke Registry ∼

Background & Purpose: A neurological deterioration in the acute phase can be associated with a bad outcome even in the minor stroke. We investigated the predictive factors for an acute neurological deterioration or stroke recurrence in the deep perforating artery territory stroke.

Subjects &Methods: Among the consecutive 3062 stroke patients who were admitted to the 7 stroke centers in Fukuoka prefecture Japan within 7 days after the onset, 1141 patients with infarcts supplied by deep perforating artery with the initial NIH stroke scale score of 7 or less and preclinical modified Rankin scale of 0 or 1 were included in the present study. We observed a neurological deterioration (a NIH stroke scale score worsening of ≥1-point), stroke recurrence, or any death during the first 21 hospital days.

Results: A neurological deterioration with or without stroke recurrence was observed in 196 (17.2%) patients. Baseline NIH stroke scale score was not different between patients with and without a neurological deterioration (2.7±1.9 vs 2.7±1.7). With regard to the TOAST classification, a neurological deterioration was most frequent in Large-artery atherosclerosis (27.8%), and was least frequent in Small-vessel occlusion (12.3%). The site of ischemic lesions was not associated with a neurological deterioration. A preexisting warfarin use was less frequent (7% vs 11%, p=0.0472), dyslipidemia (62% vs 53%, p=0.0182) and a stenosis of ≥50% in the major brain artery (26% vs 16%, p=0.0009) were more frequent, the values of low density lipoprotein (LDL) cholesterol was higher (124.6±36.3 vs 119.4±33.8 mg/dl, p=0.0495) and high density lipoprotein (HDL) was lower (50.7±14.1 vs 53.8±14.4 mg/dl, p=0.0056) in patients with than without a neurological deterioration. Diabetes mellitus was relatively more frequent in patients with than without a neurological deterioration (43% vs 36%, p=0.0669). On multivariate analysis, a stenosis of ≥50% in the major brain artery (OR, 2.44; 95%CI 1.44∼4.17) had a positive association with a neurological deterioration. Initial HDL values (OR, 0.99; 95%CI, 0.97∼1.00) and preexisting warfarin use (OR, 0.38; 95%CI, 0.13∼1.11) tended to be negatively associated with a neurological deterioration.

Conclusions: The major brain artery stenotic lesion was a significant predictor for an acute neurological deterioration or stroke recurrence in the deep perforating artery territory stroke. A preexisting warfarin use and high HDL value might decrease the risk of a neurological deterioration.

Flat and depressed lesions of the colon and rectum: Pathogenesis and clinical management

INTRODUCTION

It is not clear whether flat lesions play a role in the pathogenesis of colorectal carcinoma. Flat lesions are being increasingly recognised with new colonoscopic techniques.

MATERIALS AND METHODS

A total of 10,939 consecutive colonoscopies were performed over a 9-year period. After bowel preparation with polyethylene glycol electrolyte lavage solution, high-resolution video colonoscopy and indigocarmine spraying were performed to detect flat lesions. All lesions suggesting neoplastic change were removed by polypectomy or surgery. Cancers invading beyond the submucosal layer were excluded from this analysis. The gross appearance of flat-type lesions was classified as flat elevated type or flat depressed type based on the presence or absence of central depression.

RESULTS

A total of 5408 neoplastic lesions were index lesions, including 5035 adenomas and 373 carcinomas (124 with submucosal invasion). The prevalence of flat depressed and flat elevated lesions were 2.8% and 18.1%, respectively. Submucosal invasion rates were 17.1% in the flat depressed, 0.8% in the flat elevated, 1.6% in the sessile, 4.0% in pedunculated lesions and 9.3% in creeping lesions. The submucosal invasion rate in the flat depressed lesions was significantly higher than in any others, except for creeping lesions (P = 0.06). The percentage of flat elevated and flat depressed carcinomas among all carcinomas invading the submucosa was 6.5% and 21.0%, respectively.

CONCLUSION

Flat lesions were common during routine colonoscopy. One-quarter of colorectal cancers may be derived from flat lesions. Training in dye spray technique may result in a higher detection rate of flat colonic lesions.

Microsatellite instability in inflamed and neoplastic epithelium in ulcerative colitis

BACKGROUND

Several genetic alterations have been documented in dysplasia and cancer developing in ulcerative colitis (UC). However, the microsatellite instability (MSI) status has rarely been described, especially in the inflamed epithelium of UC.

AIMS

To study MSI status during neoplastic and inflammatory changes in UC.

METHODS

Seventy five surgically resected samples of colorectal mucosa, taken from 16 colectomy specimens of patients with UC were examined: five patients had a long duration with dysplasia or cancer (UC-LD with neoplasm), seven patients had a long duration without neoplastic changes (UC-LD without neoplasm), and four patients had a short duration without neoplastic changes (UC-SD). In addition to MSI status examined by six microsatellite markers, p53 expression was compared among the three groups.

RESULTS

With regard to non-neoplastic inflamed epithelium, MSI in two or more loci (MSI> or =2) was seen more frequently in the UC-LD without neoplasm group than in the UC-SD group (six of 14 v one of 12; p = 0.060), and significantly more often than in the UC-LD with neoplasm group (six of 14 v two of 23; p = 0.016). In the UC-LD without neoplasm group, MSI> or =2 was detected significantly more frequently in patients with severe inflammation than in those with mild inflammation (six of nine v none of five; p = 0.028). With regard to neoplastic epithelium in the UC-LD with neoplasm group, MSI in two or more loci was found in three of 17, and p53 overexpression was seen in 11 of 17 of the neoplastic lesions.

CONCLUSIONS

A high incidence of MSI in long standing UC with severe inflammation probably reflects genomic instability caused by repeated inflammatory stress. Thus, the influence of inflammation should be considered when estimating MSI in UC. It is possible that changes in p53 expression are important in the development of cancer in UC.

Brain ischemia following bilateral carotid occlusion during development of hypertension in young spontaneously hypertensive rats--importance of morphologic changes of the arteries of the circle of Willis

The present study was designed to examine the effect of morphologic changes of the arteries of the circle of Willis on cerebral blood flow (CBF) and metabolism in young spontaneously hypertensive rats (SHR). CBF in the parietal cortex was measured by the hydrogen clearance method before and during a one-hour bilateral carotid artery occlusion (BCO), and supratentorial brain metabolites were determined by standard enzymatic methods at a one-hour BCO. The internal diameters of the main arteries of the circle of Willis were estimated morphologically. With increase in age, systemic arterial pressure at rest was significantly raised, while cortical CBF tended to decrease and calculated cerebral vascular resistance increased. During BCO, CBF and supratentorial metabolism (adenosine triphosphate and lactate/pyruvate ratio) tended to be better preserved in two-month-old rats as compared with those in one- or three-month-old rats. The internal diameter of the posterior communicating artery (PcomA) was significantly smaller in the one-month-old group than in the other groups, while the diameter of the internal carotid artery was significantly smaller in rats aged three months than those in rats aged one or two months. It is indicated that cortical CBF reduction and impairment of supratentorial metabolism following occlusion of carotid arteries, at least in part, depend on the morphologic changes of the arteries of the circle of Willis associated with age and development of hypertension in young SHR.

[A case of idiopathic hemochromatosis associated with gastric cancer]

A 76-year-old male was admitted to our hospital because of general fatigue in June 1987. He had received total gastrectomy against gastric carcinoma two years previously. The examinations revealed the elevation of GOT, GPT and gamma-GTP, and increased CT number of the liver. Specimen of the liver biopsy showed deposition of iron and slight fibrosis. He was diagnosed as idiopathic hemochromatosis. He was given deferoxamine, and his elevated GOT, GPT and gamma-GTP were normalized. Idiopathic hemochromatosis is frequently associated with various malignancies including hepatic carcinoma. However, only a few cases of idiopathic hemochromatosis associated with gastric carcinoma have been reported.

Effects of acute superior cervical ganglionectomy on cerebral blood flow and metabolism in stroke-prone spontaneously hypertensive rats subjected to cerebral ischaemia

1. The effects of acute bilateral superior cervical ganglionectomy on cerebral blood flow and metabolism were investigated in stroke-prone spontaneously hypertensive rats (SHRsp), before and during cerebral ischaemia. 2. The resting cerebral blood flow was comparable between the control and denervated animals. 3. There was no significant difference in cerebral blood flow or concentration of tissue energy metabolites (adenosine triphosphate [ATP], lactate and pyruvate) between the sham-operated control and denervated animals during ischaemia. 4. The results suggest that sympathetic innervation of cerebral vessels originating from superior cervical ganglia may not play a major role in the progression of cerebral ischaemia in SHRsp.

Meningioma developed 25 years after radiation therapy for Cushing's disease

A 44-year-old woman who had been therapeutically irradiated with 45 Gy to the sellar lesion for Cushing's disease has been in remission for 25 years. A large but asymptomatic brain tumor was accidentally found in the right middle fossa by a routine follow-up computed tomography. Upon surgical removal of the tumor, the histology revealed a fibroblastic meningioma. Although the incidence of meningioma following irradiation to pituitary adenoma is rare, a follow-up computed tomography should be taken to any possible late onset, and curable complication.

Disseminated intravascular coagulation in a patient with progressive systemic sclerosis associated with necrotizing angiitis and generalized lymphadenopathy

A 47-year-old woman with progressive systemic sclerosis developed disseminated intravascular coagulation in the course of her terminal illness. She also had complicating necrotizing angiitis and generalized lymphadenopathy. The likely relationship between disseminated intravascular coagulation and vasculitis is discussed.

[A case of hepatocellular carcinoma associated with chronic renal failure on haemodialysis]

A 36 years old man with chronic renal failure on haemodialysis therapy presented with a hepatic mass which was diagnosed by ultrasonography, and was admitted to our hospital. Computer tomography and hepatic angiography revealed hepatocellular carcinoma of the right anterior superior segment of the liver. His liver function test, alpha-fetoprotein (AFP) and carcinoembryonic antigen levels in the serum were within the normal range. HBs antigen was also negative. Resection of right antero-superior segment was done following transcatheter arterial embolization. The tumor was homogeneous and light yellowish in color, and well demarcated by the capsule. Nontumorous tissue did not show either fibrosis or any inflammatory reaction. In general, hepatocellular carcinoma is associated with a positive HBs antigen and altered liver function. We here report a rare case of hepatocellular carcinoma in a man who was undergoing haemodialysis treatment for chronic renal failure with normal liver function test and negative HBs antigen.

[A case of alcoholic cirrhosis demonstrating long-term poor-visualization of the hepatic image on 99mTc-phytate scintigraphy]

A 27-year-old female patient with alcoholic cirrhosis was reported. She was admitted to the hospital because of jaundice and ascites after heavy drinking. She had a history of drinking Japanese Sake in quantities of more than 5 go/day (900 ml/day) for 7 years. On admission, she was icteric, and had both hepatosplenomegaly and ascites. Laboratory data showed an elevation of serum transaminase and bilirubin, and a decrease in the albumin and prothrombin values. A biopsy specimen of the liver showed pericellular fibrosis, fatty change, Mallory bodies and regenerative nodules, and revealed findings compatible with alcoholic cirrhosis. A 99mTc-N-pyridoxyl-5-methyltryptophan scintigram showed hepatomegaly. On the 99mTc-phytate scintigram, the uptake of radioisotope to the liver was markedly decreased with the increased uptake to the spleen and bone marrow. Even 6 months after the onset, poor visualization of the hepatic image on 99mTc-phytate scintigram continued. This is the first report of alcoholic cirrhosis demonstrating a long-term poor visualization of the hepatic image on 99mTc-phytate scintigraphy.

Effect of thromboxane synthetase inhibitor on cerebral circulation and metabolism during experimental cerebral ischemia in spontaneously hypertensive rats

The protective effect of thromboxane synthetase inhibitor, OKY-046, on brain ischemia was studied in spontaneously hypertensive rats. Cerebral ischemia was developed by bilateral carotid artery ligation (BCL) for 1 or 3 h and thereafter, circulation was restored for 15 min. OKY-046, 5 or 30 mg/kg, or saline as control was administered i.v. before BCL. Neither blood pressure nor blood gases were altered by OKY-046 or saline injection. During BCL, cerebral cortical blood flow was reduced to 25 and 15% of the resting value at 30 and 60 min, respectively, and these changes were not different among the groups. In rats with ischemia longer than 1 h, the blood flow was well preserved by OKY-046, 30 mg/kg, to 10-17% of the resting level, thus significantly higher than that (less than 5%) in non-treated rats. After 15 min recirculation, the supratentorial lactate level was lower and adenosine triphosphate (ATP) was higher in OKY-046-treated rats than in the saline-treated ischemic rats. Plasma thromboxane B2 was increased markedly in 1 h ischemic-reperfused rats without treatment and the increase was almost completely inhibited by OKY-046. In contrast, 6-keto-prostaglandin F1 alpha was increased 8.5-fold after ischemia and the increase was not affected by the treatment. OKY-046 seems to have an antiischemic effect on acutely induced cerebral ischemia. Selective inhibition of thromboxane A2 production and an inversely high level of prostaglandin I2 may be an important contribution to protection of the microcirculation during ischemia and preservation of ischemic cerebral metabolism.

Regional cerebral blood flow and metabolism in patients with transient global amnesia: a positron emission tomography study

In four patients who experienced transient global amnesia (TGA), clinical features and neuroradiological findings including positron emission tomography (PET) were studied within three months of the episodes, and compared with those in seven cases with cerebral transient ischaemic attacks (TIA). None of TGA patients had a previous history or significant risk factors for the cerebrovascular diseases. Their electroencephalogram, brain CT and angiogram for the head and neck were almost normal. PET study showed better preserved cerebral blood flow and oxygen metabolism in each area of the brain in patients with TGA compared with those with TIA in whom focal reductions of flow and metabolism were evident. These observations suggest that TGA is caused by reversible circulatory and/or metabolic disturbance, of which mechanism might be different from that in TIA.

Cerebrospinal fluid lactate in patients with diabetes mellitus and hypoglycaemic coma

Cerebrospinal fluid (CSF) lactate and pyruvate concentrations were determined in 20 patients with diabetes mellitus but without disturbance of consciousness and five who recovered from hypoglycaemic coma. CSF lactate was slightly but significantly higher in diabetes mellitus (1.78, SEM 0.04 m mol/l) than that in 15 control subjects (1.40, SEM 0.05 m mol/l). In those who recovered from hypoglycaemic coma, CSF lactate was markedly elevated to 2.45-4.43 m mol/l. CSF glucose concentrations, however, were substantially the same between treated hypoglycaemic and diabetes mellitus groups. These findings indicate that CSF lactate levels increase with glycaemic levels in diabetes mellitus owing to enhanced glucose influx into glycolytic pathway of the brain, and also increases in treated hypoglycaemic coma probably due to mitochondrial dysfunction or damage.

Mortality and histological findings of the brain during and after cerebral ischemia in male and female spontaneously hypertensive rats

Mortality and pathological changes of the brain during and after cerebral ischemia induced by bilateral carotid artery occlusion (BCO) were studied in male and female spontaneously hypertensive rats (SHR). Systolic arterial blood pressure at rest was significantly higher in male SHR (228 +/- 13 mm Hg, mean +/- S.E.M.) than female (192 +/- 12) (P less than 0.05). The average survival time during permanent occlusion was 11 +/- 6 h (mean +/- S.D.) in male SHR and 17 +/- 7 in female (P less than 0.005), though the cumulative mortality during 24-h ischemia was not different between male (88%) and female SHR (84%). Severe ischemic changes of nerve cells in the brain, especially in the cortex and hippocampus, were observed in 50% of male SHR at 3-h ischemia, while only 15% was observed in female SHR even after 7-h ischemia. After the temporary ischemia followed by reperfusion for 24 h, the mortality was varied between male and female SHR; 0, 31 and 100% after 1-, 3- and 5-h ischemia, respectively, in male SHR and 0% after 1- to 3-h ischemia and 33% after 5- to 7-h ischemia, respectively, in female. Ischemic changes of the brain tissue, such as acidophilic cytoplasm, nuclear degeneration and intercellular edema, were more frequent and severe in male SHR than female after recirculation following 3- or 5-h ischemia. It is concluded that the mortality and post-ischemic viability seem to be determined by the duration of ischemia and also by the degree of the neuronal damage, and female SHR is more tolerated for ischemic insult in comparison to male SHR.

Massive striatal dopamine release in acute cerebral ischemia in rats

Extracellular dopamine, 3,4-dihydroxyphenylacetic acid (DOPAC) and cerebral blood flow were simultaneously determined using in vivo brain dialysis and a hydrogen clearance method in the striatum of spontaneously hypertensive rats during ischemia and after recirculation. Massive striatal dopamine release was demonstrated in acutely induced ischemic brain.

Effect of recirculation on the recovery of cerebral metabolism after experimental cerebral ischemia in male and female spontaneously hypertensive rats

Lactate, pyruvate and adenosine triphosphate (ATP) concentrations in the brain were measured at the end of various periods of cerebral ischemia induced by bilateral carotid occlusion at 1-hour recirculation after the ischemia in spontaneously hypertensive rates (SHR). In both male and female SHR, a progressive and consistent increase in lactate and lactate/pyruvate ratio and a concomitant decrease in ATP were observed in the ischemic periods of 1, 3 or 5 h. Changes of these cerebral metabolites in females were two thirds to one half of those in males at corresponding periods of ischemia. At 1 h after recanalization of the occluded carotid arteries, metabolic derangements of the ischemic brain were little recovered in male SHR exposed to only 1-hour ischemia, whereas in female SHR the decreased ATP levels were recovered close to the nonischemic control level even after 7-hour ischemia. Furthermore, the increased lactate in female was attenuated to only one sixth of that in male at 1-hour recirculation after 5-hour ischemia. It is concluded that the recovery of the cerebral ischemic metabolism by reperfusion is better in female than male SHR, probably because of the smaller metabolic changes during the ischemic insult, and the fact that the degree as well as the duration of ischemia seem to be important factors for sufficient recovery from ischemic impairment of the brain.

Role of adrenal catecholamines in cerebrovasodilation evoked from brain stem

We studied whether adrenal medullary catecholamines (CAs) contribute to the metabolically linked increase in regional cerebral blood flow (rCBF) elicited by electrical stimulation of the dorsal medullary reticular formation (DMRF). Rats were anesthetized (alpha-chloralose, 30 mg/kg), paralyzed, and artificially ventilated. The DMRF was electrically stimulated with intermittent trains of pulses through microelectrodes stereotaxically implanted. Blood gases were controlled and, during stimulation, arterial pressure was maintained within the autoregulated range for rCBF. rCBF and blood-brain barrier (BBB) permeability were determined in homogenates of brain regions by using [14C]iodoantipyrine and alpha-aminoisobutyric acid (AIB), respectively, as tracers. Plasma CAs (epinephrine and norepinephrine) were measured radioenzymatically. DMRF stimulation increased rCBF throughout the brain (n = 5; P less than 0.01, analysis of variance) and elevated plasma CAs substantially (n = 4). Acute bilateral adrenalectomy abolished the increase in plasma epinephrine (n = 4), reduced the increases in flow (n = 6) in cerebral cortex (P less than 0.05), and abolished them elsewhere in brain (P greater than 0.05). Comparable effects on rCBF were obtained by selective adrenal demedullation (n = 7) or pretreatment with propranolol (1.5 mg/kg iv) (n = 5). DMRF stimulation did not increase the permeability of the BBB to AIB (n = 5). We conclude that the increases in rCBF elicited from the DMRF has two components, one dependent on, and the other independent of CAs. Since the BBB is impermeable to CAs and DMRF stimulation fails to open the BBB, the results suggest that DMRF stimulation allows, through a mechanism not yet determined, circulating CAs to act on brain and affect brain function.

Cerebrospinal fluid lactate in patients with hepatic encephalopathy

Cerebrospinal fluid (CSF) lactate and pyruvate concentrations were determined in 16 patients with hepatic encephalopathy before and/or after treatment. CSF lactate was significantly increased to 1.92 +/- 0.11 mmol/l in hepatic encephalopathy before the treatment in comparison to 1.40 +/- 0.05 mmol/l in control subjects. In 9 of 11 patients with moderate or stage 2 encephalopathy, CSF lactate levels were below 2 mmol/l. In contrast, in 4 of 5 patients with stage 3-4 encephalopathy, CSF lactate levels were higher than 2 mmol/l. CSF lactate was decreased with the recovery of neurological symptoms by the treatment. These findings indicate that CSF lactate levels reflect the severity of metabolic impairment of the brain. Hypocapnia was frequently observed in these encephalopathic patients, and arterial PCO2 correlated inversely with CSF lactate and linearly with CSF HCO3-, suggesting that CSF lactic acidosis contributes to hyperventilation in hepatic encephalopathy. It is concluded from present results that metabolic disorder of neuronal cells might be one of the important factors for the development of hepatic encephalopathy.

Lesions of nucleus tractus solitarii globally impair cerebrovascular autoregulation

We studied the effects of acute bilateral electrolytic lesions of the nucleus tractus solitarii (NTS) on regional cerebral blood flow (rCBF) and its autoregulation in rats anesthetized (alpha-chloralose, 40 mg/kg), paralyzed (tubocurarine), and artificially ventilated. rCBF or regional cerebral glucose utilization (rCGU) was measured 30 min after NTS lesions, by the 14C-iodoantipyrine technique or 2-deoxyglucose method, respectively. Cerebrovascular autoregulation was assessed in groups of 4-5 rats at three levels of arterial pressure (AP): 90, 125, and 140 mmHg. AP was lowered by hemorrhage or elevated by intravenous infusion of phenylephrine. NTS lesions did not alter rCBF at 125 mmHg (P greater than 0.05) but resulted in loss of autoregulation (P less than 0.05, analysis of variance). In contrast, lesions of the cuneate nucleus or transection of the baroreceptor afferents did not alter autoregulation. NTS lesions did not affect the reactivity of the cerebrovascular bed to hypercarbia (PaCO2 57.4 +/- 1; n = 5) or hypocarbia (PaCO2 24.4 +/- 1; n = 5) nor the rCGU in any brain regions (P greater than 0.05; n = 5). We conclude that lesions of the NTS impair cerebrovascular autoregulation. The effect is not due to changes in metabolism, nonspecific effects of the lesions, vasoparalysis, or interruption of the baroreceptor reflex arch. Neural pathways originating in or passing through the NTS can regulate the cerebrovascular autoregulation of the entire brain.

Effects of intravenous glycerol on cerebral blood flow and tissue metabolism in acute cerebral ischemia in spontaneously hypertensive rats

The effects of antiedematous agent with intravenous 10% glycerol on cerebral blood flow (CBF) and metabolism were studied in acute cerebral ischemia experimentally induced by bilateral carotid artery occlusion in spontaneously hypertensive rats (SHR). CBF was measured by the hydrogen clearance technique and brain tissue metabolites such as lactate, pyruvate and ATP in the ischemic brain frozen in situ were determined by the enzymatic method. In comparison with saline-infused SHR, the reduction of CBF in the thalamus following carotid occlusion was significantly small in the glycerol treated SHR. Supratentorial ATP concentration in the 3 hr-ischemic brain was reduced in both groups of rats, but its reduction was significantly smaller in the glycerol-infused group than the other. Lactate and lactate/pyruvate ratio tended to be less increased in the glycerol rats, indicating that ischemic metabolism was restrained by the treatment. The present results strongly suggest that intravenous glycerol is effective against acute cerebral ischemia from the view point of cerebral hemodynamic and metabolism.

Effects of hematocrit on brain metabolism in experimentally induced cerebral ischemia in spontaneously hypertensive rats (SHR)

Brain tissue lactate, pyruvate, and adenosine triphosphate (ATP) were measured 60 min after bilateral carotid ligation in spontaneously hypertensive rats, of which hematocrit (HCT) was varied by exchanging with isovolemic homologous red cells, plasma or whole blood. Supratentorial lactate of the ischemic brain was increased more in high HCT (greater than or equal to 50%) and less in low HCT (30-39%) compared with normal HCT (40-49%). In very low HCT (less than 30%), however, lactate was increased to further extent compared with any other group of HCT (ANOVA p less than 0.0001). Lactate/pyruvate (L/P) ratio of the ischemic brain showed similar changes, namely U-shaped correlation to HCT. In contrast, supratentorial ATP was decreased more markedly in very low HCT, followed by high and normal HCT, and minimally decreased in low HCT, demonstrating an inverse U-shaped relationship to HCT. Mean arterial pressure and arterial acid-base parameters in ischemic animals did not differ among HCT groups. There were no HCT-related changes of brain metabolites in non-ischemic control rats. These findings indicate that cerebral ischemia following carotid ligation is more severe in high HCT but less in low HCT, probably due to hemodynamic effects of HCT changes. When HCT is reduced to below 30%, however, insufficient oxygen supply to the brain or anemic hypoxia may superimpose on ischemia, resulting in more markedly impairment of brain metabolism. The role of HCT as a cause of cerebral ischemia and its severity is discussed.

Intrinsic gamma-aminobutyric acid neurons in the nucleus of the solitary tract and the rostral ventrolateral medulla of the rat: an immunocytochemical and biochemical study

Sympathoexcitatory neurons in the C1 adrenergic area of the rostral ventrolateral medulla (RVL) are tonically inhibited by gamma-aminobutyric acid (GABA). To identify the source of this GABAergic input, the distribution of neurons containing glutamate decarboxylase (GAD) was determined immunocytochemically in rats treated with colchicine. Numerous GAD-stained neurons were located in the nucleus of the solitary tract (NTS) and in RVL. Unilateral lesions in NTS did not alter GABA content or GAD activity in RVL, indicating that the afferent projection from NTS to RVL is not GABAergic. Intrinsic GABAergic neurons in RVL may provide tonic inhibition of vasomotor neurons in the C1 area.

Pulmonary hemorrhage in experimental cerebral ischemia in mongolian gerbils. Brain metabolism and lung pathology

Pulmonary changes in acute cerebral ischemia were studied in anesthetized Mongolian gerbils, in which both carotid arteries were occluded simultaneously. Lactate, pyruvate and adenosine triphosphate (ATP) in the brain were measured as indicators of the severity of cerebral ischemia. Microscopic changes in the lung were arbitrarily scored from 0 (normal) to 3 points (severely affected) by the grade and the extent of lesions. Mean arterial pressure (MAP) was also measured through the cannulated femoral artery before and after carotid artery occlusion in a separate group of animals. Cerebral lactate was increased while ATP decreased in ischemic animals in which pulmonary changes such as intra-alveolar hemorrhages were prominent and frequent. The lung pathology score averaged 1.3 in animals with severe ischemia (lactate greater than or equal to 10 mM/Kg), 0.7 in moderate ischemia (5-10 mM/Kg) and 0.3 in mild or no ischemia (less than 5 mM/Kg), respectively, suggesting that severe brain ischemia may cause fulminant pulmonary changes. The mechanism of pulmonary lesions in acute cerebral ischemia is discussed.

[Protective effects of 4-(o-benzylphenoxy)-N-methylbutylamine hydrochloride (bifemelane) on acutely induced cerebral ischemia in Mongolian gerbils and spontaneously hypertensive rats (SHR)]

Effects of new antihypoxic agent (bifemelane) on survival and brain metabolism were studied in acute cerebral ischemia induced by bilateral carotid artery ligation in mongolian gerbils and SHR. Either 10 mg/kg or 30 mg/kg body weight of bifemelane solved in distilled water was intraperitoneally administered 1 hr in gerbils and 1.5 hrs in SHR prior to carotid ligation, and same amount of vehicle was also given in similar manner for control animals. Brain tissue metabolites such as lactate, pyruvate and ATP were determined by using the enzymatic technique in the ischemic brain frozen in situ 1 hr after carotid ligations in SHR. Mean survival times following carotid ligations were 186 +/- 255 min (+/- SD) in control gerbils, 429 +/- 455 min in those with 10 mg/kg of bifemelane, and 310 +/- 429 min in those with 30 mg/kg respectively, its difference between control and 10 mg/kg group being significant (P less than 0.05). Supratentorial lactate concentrations in the ischemic brains of SHR were substantially the same among the groups, whereas ATP levels were 0.62 +/- 0.24 mM/kg in control animals, 1.10 +/- 0.67 mM/kg in rats with 10 mg/kg of the drug, and 1.13 +/- 0.42 mM/kg in those with 30 mg/kg, respectively. In animals with a high dose pretreatment, the reduction of ATP was significantly smaller than that in control (P less than 0.02), indicating that this agent prevents a decline of high energy phosphate in the ischemic brain although anaerobic metabolites increase similarly in animals of all experiment groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrospinal fluid lactate and pyruvate concentrations in patients with malignant hypertension

Lactate and pyruvate concentrations and acid-base parameters in cerebrospinal fluid (CSF) and arterial blood were measured in 21 patients with malignant hypertension ( MHT ), 19 with benign hypertension (BHT) and 21 normotensive subjects (NT). Average values for CSF lactate and lactate/pyruvate (L/P) ratio were significantly higher in MHT (1.90 +/- 10 mM/1, 19.2 +/- 1.0) than in either BHT (1.50 +/- 0.05 mM/l, 15.7 +/- 0.7) or NT (1.44 +/- 0.04 mM/1, 15.7 +/- 0.4). There was a linear correlation between CSF lactate and CSF pressure (r = 0.565, P less than 0.01), and the latter was also related to mean arterial pressure exceeding 150 mm Hg (r = 0.553, P less than 0.01). Such increases in the acid metabolites in CSF indicate that brain metabolism becomes anaerobic in MHT , probably due to increased intracranial pressure. Increased cerebrovascular permeability is also discussed as participating in causal mechanisms.