30 Informant-Reported Decline Associates with Silent Acute Stroke Lesions and Worse Small Vessel Disease in Mild Stroke Patients

Introduction

Small vessel disease (SVD) commonly causes stroke and dementia. Early clinical predictors of disease progression are lacking. We aimed to determine whether informant reports of chronic cognitive/functional decline, prerequisites for dementia diagnosis, are associated with (a)baseline SVD burden, measured by Fazekas scores and (b)SVD change, measured by incident subcortical Diffusion-weighted Imaging (DWI) lesions.

Method

We prospectively recruited patients with mild ischaemic stroke, performed diagnostic MRI, and invited participants to repeat MRI 3- to 6-monthly. Informants completed the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) prior to baseline visit, a 16-item questionnaire which assesses patients’ cognitive and functional decline in the preceding ten years. Scores range from 1–5: a score above 3.3 has high sensitivity/specificity for dementia post-stroke. We conducted linear regression with IQCODE as the dependent variable, adjusting for age, sex, baseline MoCA, disability (modified Rankin Scale).

Results

We recruited 106 participants (mean age 67 years;range 40–86;33% female). Ninety-three informant questionnaires were returned. IQCODE associated with baseline Fazekas score; Fazekas 6 (β = 0.28, p = 0.04) vs. Fazekas 3 (β = 0.03, p = 0.67), R2 = 0.11, adjusted for age, sex, baseline MoCA, disability.

Incident DWI lesions were common (15/106; 14/15 subcortical; no active embolic sources; median 67 days post-stroke). Four were asymptomatic, two reported stroke-like symptoms and nine had neuropsychiatric/non-focal symptoms. IQCODE was higher in those with a new lesion vs. without (β = 0.21, p = 0.02), R2 = 0.09, while age (β = −0.004, p = 0.19), MoCA (β = −0.006, p = 0.56) and disability (β = 0.06, p = 0.2) were not.

Conclusions

Higher SVD burden and incident, mostly “silent” stroke lesions associate more strongly with informant concerns of cognitive/functional decline than age or objective cognitive tests. These findings are novel in an ischaemic stroke population and the first to assess IQCODE/SVD progression. Future work should determine whether combining informant reports with imaging features of small vessel disease improves early detection of dementia.

Actinomyces meyeri brain abscess following dental extraction

We describe the rare occurrence of an Actinomyces meyeri cerebral abscess in a 55-year-old woman following a dental extraction. This patient presented with a 2-day history of hemisensory loss, hyper-reflexia and retro-orbital headache, 7 days following a dental extraction for apical peridonitis. Neuroimaging showed a large left parietal abscess with surrounding empyema. The patient underwent craniotomy and drainage of the abscess. A. meyeri was cultured. Actinomycosis is a rare cause of cerebral abscess. The A. meyeri subtype is particularly rare, accounting for less than 1% of specimens. This case describes an unusually brief course of the disease, which is usually insidious. Parietal lobe involvement is unusual as cerebral abscesses usually have a predilection for the frontal and temporal regions of the brain. Although there are no randomised trials to guide therapy, current consensus is to use a prolonged course of intravenous antibiotics, followed by 6-12 months of oral therapy.

Prevalence and predictors of influenza and pneumococcal vaccine uptake in patients with diabetes

The Irish Immunisation Guidelines recommend that people with diabetes mellitus receive the seasonal influenza and pneumococcal vaccines. We aimed to gather data on seasonal influenza vaccine uptake over the previous twelve months, to determine pneumococcal vaccine uptake over a lifetime, and to identify predictors that may influence likelihood of vaccine uptake. A combination of retrospective medical record review and patient questionnaire was undertaken over a three-month period in a diabetes outpatient clinic. Two hundred patients, 28.5% (n=57) with type 1 and 70.5% (n=141) with type 2 diabetes were questioned. Uptake of seasonal influenza vaccine in the previous year was 64.5%. Reported lifetime uptake rate of pneumococcal vaccine was 22%. Increasing age, increasing duration of diabetes and history of recent GP visits significantly increased frequency of influenza vaccination over a five-year period. Significant predictors of influenza vaccination over the previous 12 months included those receiving GP recommendation [OR 10.6 (95% CI 4.3-26.4)] and those aged over 65 [OR 2.8 (1.008-7.8)]. Significant predictors of pneumococcal vaccine uptake included GP recommendation [OR=63 (10-388)] and chronic kidney disease [OR=22 (1.5-312)]. Increased uptake of vaccines is desirable and may be improved by general practices targeting subsets of the population and annual auditing.

A double blind placebo controlled trial of azathioprine in the treatment of primary Sjögren's syndrome

OBJECTIVE

To establish whether there is a place for low dose azathioprine (AZA) as a disease modifying agent in patients with uncomplicated primary Sjögren's syndrome (SS).

METHODS

Twenty-five patients with primary SS were entered into a double blind, placebo controlled trial of AZA (1 mg/kg/day) for a period of 6 months.

RESULTS

Six patients, all receiving active drug, withdrew because of side effects. There was no significant change in disease activity variables when measured clinically, serologically, or histologically.

CONCLUSION

This trial suggests that low dose AZA does not have a role as a disease modifying agent in SS.