Impact of obesity on stroke outcome after intravenous thrombolysis.

BACKGROUND AND PURPOSE: Obesity is an established risk factor for stroke and has reached epidemic proportions. However, its impact on intravenous thrombolysis applied for acute ischemic stroke is not well known. We aimed to compare the clinical outcome and safety after intravenous thrombolysis in obese (body mass index ≥30 kg/m²) and nonobese (body mass index <30 kg/m²) patients with ischemic stroke. METHODS: Data of 304 consecutive patients with stroke (251 nonobese and 53 obese) treated with intravenous thrombolysis were studied. We assessed the rate of favorable outcome (modified Rankin Scale score 0 or 1), mortality, and symptomatic intracranial hemorrhage in the 2 groups. RESULTS: Obese patients presented more often with diabetes mellitus (30.2% versus 12.4%, P<0.01) and arterial hypertension (77.4% versus 61.4%, P=0.03) as compared with their nonobese counterparts. At 3 months, the rate of favorable outcome was lower in obese compared with nonobese patients (50.9% versus 68.1%, P=0.02). More obese than nonobese patients died (13.2% versus 4.0%, P=0.01), whereas the rate of symptomatic intracranial hemorrhage was similar in the 2 groups (1.9% versus 1.6%, P=1.0). After multivariable adjustment, obesity still remained an independent predictor of unfavorable outcome (P=0.04) and mortality (P=0.04). CONCLUSIONS: Our data indicate that obesity is an independent predictor of unfavorable clinical outcome and mortality in acute ischemic stroke treated with intravenous thrombolysis.

Outcomes of intravenous thrombolysis in posterior versus anterior circulation stroke.

BACKGROUND AND PURPOSE: Intravenous thrombolysis is an approved treatment for anterior (ACS) and posterior (PCS) circulation stroke. However, no randomized controlled trial has investigated safety and efficacy of intravenous thrombolysis according to stroke territory, although PCS is assumed to differ from ACS in many ways. We aimed to compare the safety and clinical outcome of intravenous thrombolysis applied to patients with PCS and ACS. METHODS: Prospectively collected data of 883 consecutive patients with acute ischemic stroke (788 ACS, 95 PCS) treated with intravenous thrombolysis in 3 Swiss stroke centers were analyzed. Presenting characteristics, symptomatic intracranial hemorrhage, mortality, and favorable outcome (modified Rankin scale 0 or 1) at 3 months were compared between patients with PCS and ACS. RESULTS: As compared with patients with ACS, those with PCS were younger (mean age, 63 versus 67 years, P=0.012) and had a lower mean baseline National Institutes of Health Stroke Scale score (9 versus 12, P<0.001). Patients with PCS less often had symptomatic intracranial hemorrhage (0% versus 5%, P=0.026) and had more often a favorable outcome (66% versus 47%, P<0.001). Mortality was similar in the 2 groups (PCS, 9%; ACS, 13%; P=0.243). After multivariable adjustment, PCS was an independent predictor of lower symptomatic intracranial hemorrhage frequency (P=0.001), whereas stroke territory was not associated either with favorable outcome (P=0.177) or with mortality (P=0.251). CONCLUSIONS: Our study suggests that PCS is associated with a lower risk of symptomatic intracranial hemorrhage after intravenous thrombolysis as compared with ACS, whereas favorable outcome and mortality were similar in the 2 stroke territories.

Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data.

BACKGROUND AND PURPOSE: The safety and efficacy of thrombolysis in cervical artery dissection (CAD) are controversial. The aim of this meta-analysis was to pool all individual patient data and provide a valid estimate of safety and outcome of thrombolysis in CAD. METHODS: We performed a systematic literature search on intravenous and intra-arterial thrombolysis in CAD. We calculated the rates of pooled symptomatic intracranial hemorrhage and mortality and indirectly compared them with matched controls from the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. We applied multivariate regression models to identify predictors of excellent (modified Rankin Scale=0 to 1) and favorable (modified Rankin Scale=0 to 2) outcome. RESULTS: We obtained individual patient data of 180 patients from 14 retrospective series and 22 case reports. Patients were predominantly female (68%), with a mean±SD age of 46±11 years. Most patients presented with severe stroke (median National Institutes of Health Stroke Scale score=16). Treatment was intravenous thrombolysis in 67% and intra-arterial thrombolysis in 33%. Median follow-up was 3 months. The pooled symptomatic intracranial hemorrhage rate was 3.1% (95% CI, 1.3 to 7.2). Overall mortality was 8.1% (95% CI, 4.9 to 13.2), and 41.0% (95% CI, 31.4 to 51.4) had an excellent outcome. Stroke severity was a strong predictor of outcome. Overlapping confidence intervals of end points indicated no relevant differences with matched controls from the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. CONCLUSIONS: Safety and outcome of thrombolysis in patients with CAD-related stroke appear similar to those for stroke from all causes. Based on our findings, thrombolysis should not be withheld in patients with CAD.

Differences in demographic characteristics and risk factors in patients with spontaneous vertebral artery dissections with and without ischemic events.

BACKGROUND AND PURPOSE: Spontaneous vertebral artery dissection (sVADs) mainly cause cerebral ischemia, with or without associated local symptoms and signs (headache, neck pain, or cervical radiculopathy), or with local symptoms and signs only. METHODS: We compared the presenting characteristics of consecutive patients with single sVADs and ischemic events and those with local symptoms and signs only. RESULTS: Of the 186 patients with first-ever unilateral sVAD, 165 (89%) presented with cerebral ischemia, and 21 (11%) presented with local symptoms and signs only. Patients with sVAD and ischemia were more often male (63% vs 29%; P=0.002), older (mean+/-SD age, 43.6+/-9.9 vs 38.6+/-9.0 years; P=0.027), and smokers (14% vs 3%; P=0.010), but less often, they had a history of migraine without aura (17% vs 38%; P=0.025) than did patients without ischemia. The multivariate analysis confirmed independent associations between male sex (P=0.024), increasing age (0.027), and smoking (P=0.012) and sVADs causing cerebral ischemia. CONCLUSIONS: These results suggest that men, older patients, and smokers with sVADs may be at increased risk for ischemic events.

Impact of intravenous thrombolysis on functional outcome in patients with mild ischemic stroke without large vessel occlusion or rapidly improving symptoms.

BACKGROUND: Optimal treatment strategy in patients with mild ischemic stroke remains uncertain. While functional dependency or death has been reported in up to one-third of non-thrombolyzed mild ischemic stroke patients, intravenous thrombolysis is currently not recommended in this patient group. Emerging evidence suggests two risk factors-rapid early improvement and large vessel occlusion-as main associates of unfavorable outcome in mild ischemic stroke patients not undergoing intravenous thrombolysis. AIMS: To analyze natural course as well as safety and three-month outcome of intravenous thrombolysis in mild ischemic stroke without rapid early improvement or large vessel occlusion. METHODS: Mild ischemic stroke was defined by a National Institute of Health Stroke Scale score ≤6. We used the modified Rankin Scale (mRS) to compare three-month functional outcome in 370 consecutive mild ischemic stroke patients without early rapid improvement and without large vessel occlusion, who either underwent intravenous thrombolysis (n = 108) or received best medical treatment (n = 262). RESULTS: Favorable outcome (mRS ≤ 1) was common in both groups (intravenous thrombolysis: 91%; no intravenous thrombolysis: 90%). Although intravenous thrombolysis use was independently associated with a higher risk of asymptomatic hemorrhagic transformation (OR = 4.62, p = 0.002), intravenous thrombolysis appeared as an independent predictor of mRS = 0 at three months (OR = 3.33, p < 0.0001). CONCLUSIONS: Mild ischemic stroke patients without rapidly improving symptoms and without large vessel occlusion have a high chance of favorable three-month outcome, irrespective of treatment type. Patients receiving intravenous thrombolysis, however, more often achieved complete remission of symptoms, which particularly in mild ischemic stroke may constitute a meaningful endpoint.

R2-recanalization of spontaneous carotid artery dissection.

BACKGROUND AND PURPOSE: We set out to investigate the predictors and time course for recanalization of spontaneous dissection of the cervical internal carotid artery (SICAD). METHODS: We prospectively included 249 consecutive patients (mean age, 45+/-11 years) with 268 SICAD. Ultrasound examinations were performed at presentation, during the first month, and then at 3, 6, and 12 months, and clinical follow-ups after 3, 6, and 12 months. RESULTS: Of 268 SICADs, 20 (7.5%) presented with

Intravenous thrombolysis in stroke attributable to cervical artery dissection.

BACKGROUND AND PURPOSE: Intravenous thrombolysis (IVT) for stroke seems to be beneficial independent of the underlying etiology. Whether this is also true for cervical artery dissection (CAD) is addressed in this study. METHODS: We used the Swiss IVT databank to compare outcome and complications of IVT-treated patients with CAD with IVT-treated patients with other etiologies (non-CAD patients). Main outcome and complication measures were favorable 3-month outcome, intracranial cerebral hemorrhage, and recurrent ischemic stroke. Modified Rankin Scale score

Comparison of intraarterial and intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign.

BACKGROUND AND PURPOSE: It is unclear whether intraarterial (IAT) or intravenous (IVT) thrombolysis is more effective for ischemic stroke with hyperdense middle cerebral artery sign (HMCAS) on computed tomography (CT). The aim of this study was to compare IAT and IVT in stroke patients with HMCAS. METHODS: Comparison of data from 2 stroke units with similar management of stroke associated with HMCAS, except that 1 unit performed IAT with urokinase and the other IVT with plasminogen activator. Time to treatment was up to 6 hours for IAT and up to 3 hours for IVT. Outcome was measured by mortality and the modified Rankin Scale (mRS), dichotomized at 3 months into favorable (mRS 0 to 2) and unfavorable (mRS 3 to 6). RESULTS: One hundred twelve patients exhibited a HMCAS, 55 of 268 patients treated with IAT and 57 of 249 patients who underwent IVT. Stroke severity at baseline and patient age were similar in both groups. Mean time to treatment was longer in the IAT group (244+/-63 minutes) than in the IVT group (156+/-21 minutes; P=0.0001). However, favorable outcome was more frequent after IAT (n=29, 53%) than after IVT (n=13, 23%; P=0.001), and mortality was lower after IAT (n=4, 7%) than after IVT (n=13, 23%; P=0.022). After multiple regression analysis IAT was associated with a more favorable outcome than IVT (P=0.003) but similar mortality (P=0.192). CONCLUSIONS: In this observational study intraarterial thrombolysis was more beneficial than IVT in the specific group of stroke patients presenting with HMCAS on CT, even though IAT was started later. Our results indicate that a randomized trial comparing both thrombolytic treatments in patients with middle cerebral artery occlusion is warranted.

Ultrasound diagnosis of spontaneous carotid dissection with isolated Horner syndrome.

BACKGROUND AND PURPOSE: Isolated Horner syndrome without associated cranial nerve palsies or ischemic symptoms is an important presentation of spontaneous internal carotid artery dissection (sICAD). Ultrasound is often used as a screening method in these patients because cervical MRI is not always available on an emergency basis. Current knowledge on ultrasound findings in patients with sICAD presenting with isolated Horner syndrome is limited. METHODS: Patients were recruited from prospective cervical artery dissection databases of 3 tertiary care centers. Diagnosis of sICAD was confirmed by cervical MRI and MR angiography or digital subtraction angiography in all patients. Data on Doppler sonography and color duplex sonography examinations performed within 30 days of symptom onset were analyzed. RESULTS: We identified 88 patients with Horner syndrome as the only sign of sICAD. Initial ultrasound examination was performed in 72 patients after a mean time interval from symptom onset to examination of 11 (SD 8) days. The overall frequency of false-negative ultrasound findings was 31% (22 of 72 patients). It showed stenosis >or=80% or occlusion in 34 (47%) patients, and stenosis

Serum cholesterol levels do not influence outcome or recovery in acute ischemic stroke.

OBJECTIVE: To examine the influence of admission serum cholesterol levels (SCL) on severity of initial neurological deficit, neurological outcome at month 3 and neurological recovery in patients with acute first-ever ischemic stroke. METHODS: Prospectively collected data from 889 consecutive patients with first-ever acute ischemic stroke were retrospectively analysed. Patients who suffered a recurrent ischemic stroke (n=22) or died (n=30) during the follow-up period were excluded from this study. Age, gender, arterial hypertension, diabetes mellitus, smoking, stroke etiology, SCL and severity of neurological deficit, using the National Institute of Health Stroke Scale (NIHSS), at presentation (NIHSS0) and after 3 months (NIHSS1), were assessed. Neurological recovery was defined as difference in NIHSS score (Delta(NIHSS)), according to Delta(NIHSS)=NIHSS0 - NIHSS1. RESULTS: Data from 837 patients (66% men, age: 62 +/- 14 years) were analysed. NIHSS1 was 2.3 +/- 1.8 and Delta(NIHSS) was 3.4 +/- 3. Clinically insignificant correlations between SCL and NIHSS0 (r=-0.13, p=0.0002), NIHSS1 (r=-0.09, p=0.001) and Delta(NIHSS) (r=-0.1, p=0.03) were evident. Multivariate binary logistic regression analysis revealed smoking (p=0.008), stroke etiology (p=0.023) and NIHSS0 (p<0.001) but not age, gender, arterial hypertension, diabetes mellitus or SCL as predictors for Delta(NIHSS). CONCLUSION: Our data suggest that SCL in patients with acute ischemic stroke are not associated with neurological deficit on admission, outcome or neurological recovery.

Early recurrent ischemic stroke in stroke patients undergoing intravenous thrombolysis.

BACKGROUND: We assessed the incidence of early recurrent ischemic stroke in stroke patients treated with intravenous tissue-type plasminogen activator (tPA) and the temporal pattern of its occurrence compared with symptomatic intracranial hemorrhage (ICH). METHODS AND RESULTS: Prospectively collected, population-based data for 341 consecutive acute stroke patients (62% men; mean age, 66 years) treated with tPA according to the National Institute of Neurological Disorders and Stroke study protocol at 8 medical centers in Switzerland (3 academic and 5 community) between January 2001 and November 2004 were retrospectively analyzed. The primary outcome measure was neurological deterioration > or = 4 points on the National Institutes of Health Stroke Scale occurring within 24 hours of tPA treatment and caused either by recurrent ischemic stroke (defined as the occurrence of new neurological symptoms suggesting involvement of initially unaffected vascular territories and evidence of corresponding ischemic lesions on cranial computed tomography scans, in the absence of ICH) or by ICH. Early recurrent ischemic stroke was diagnosed in 2 patients (0.59%; 95% confidence interval, 0.07% to 2.10%) and symptomatic ICH in 15 patients (4.40%; 95% confidence interval, 2.48% to 7.15%). Both recurrent ischemic strokes occurred during thrombolysis, whereas symptomatic ICHs occurred 2 to 22 hours after termination of tPA infusion. CONCLUSIONS: Recurrent ischemic stroke is a rare cause of early neurological deterioration in acute stroke patients undergoing intravenous thrombolysis, with a different temporal pattern compared with that of symptomatic ICH.

Spontaneous and endothelial-independent vasodilation are impaired in patients with spontaneous carotid dissection: a case-control study.

BACKGROUND AND PURPOSE: We undertook this case-control study in patients with unilateral spontaneous dissection of the cervical internal carotid artery to investigate spontaneous and endothelium-independent dilation of the nondissected, contralateral carotid arteries and the ipsilateral brachial artery using high-resolution ultrasound. METHODS: Spontaneous and endothelial-independent (nitroglycerin-mediated) absolute and relative dilation were assessed in the internal and common carotid and brachial arteries of 27 patients with unilateral spontaneous dissection of the cervical internal carotid artery and 27 age- and sex-matched healthy controls. RESULTS: Absolute and relative spontaneous and endothelial-independent dilation of the carotid, but not brachial arteries, were significantly lower in patients as compared with controls. CONCLUSIONS: Vasodilation abnormalities may be a predisposing factor for spontaneous dissection of the cervical internal carotid artery.

Different degrees of hypothermia after experimental stroke: short- and long-term outcome.

BACKGROUND AND PURPOSE: The neuroprotective role of mild therapeutic hypothermia was established in animal models of cerebral ischemia. Still, several issues, including optimal target temperature, remain unclear. The optimal depth of hypothermia in a rat model of focal cerebral ischemia was investigated. METHODS: Eighty-four male Wistar rats (n=84) were subjected to filament occlusion of the middle cerebral artery for 90 minutes. Sixty animals were equally split into 6 groups kept at core temperatures of 37 degrees C, 36 degrees C, 35 degrees C, 34 degrees C, 33 degrees C, and 32 degrees C over a period of 4 hours starting 90 minutes after middle cerebral artery occlusion. Twenty-four hours later, after performing a neuroscore, animals were killed and brains examined for infarct size, edema, and invasion of leukocytes. In the second part, 24 animals (8 per group) were kept at 33 degrees C, 34 degrees C, and 37 degrees C for 4 hours, allowed to survive for 5 days, and underwent additional investigation of transferase dUTP nick-end labeling. RESULTS: In the first part, one animal in each treatment group and 2 animals in group 37 degrees C died. The infarct size and edema were smaller for 34 degrees C and 33 degrees C compared with all other groups (P<0.05) over 24 hours. These animals also had better functional outcome (P<0.05) with an advantage for 34 degrees C versus 33 degrees C (P<0.05). Leukocyte count was lower for 34 degrees C and 33 degrees C as compared with the 37 degrees C group. Similar results were obtained in the second part of the study with an advantage for 34 degrees C versus 33 degrees C. CONCLUSIONS: Our results suggest that the optimal depth of therapeutic hypothermia in temporary middle cerebral artery occlusion is 34 degrees C.

Good outcomes in ischemic stroke patients treated with intravenous thrombolysis despite regressing neurological symptoms.

BACKGROUND AND PURPOSE: We evaluated the clinical course of 19 acute stroke patients with rapid early improvement of neurological deficit within the 3-hour window, treated with intravenous thrombolytics. RESULTS: No patient demonstrated a neurological deterioration during hospitalization. National Institutes of Health Stroke Scale (NIHSS) scores at therapy decision and discharge were 5 (4 to 6) and 0.5 (0 to 1.5), respectively. At 3-month follow-up, 1 patient had died; in remaining patients, NIHSS was 0 (0 to 1) and modified Rankin Scale 0.5 (0 to 1; < or =1 in 15 patients). CONCLUSIONS: Withholding of intravenous thrombolysis because of spontaneous early regression of neurological symptoms may not be justified.

Vertebral artery dissection: presenting findings and predictors of outcome.

BACKGROUND AND PURPOSE: Few data exist about clinical, radiologic findings, clinical outcome, and its predictors in patients with spontaneous vertebral artery dissection (sVAD). METHODS: Clinical characteristics, imaging findings, 3-month outcomes, and its predictors were investigated in consecutive patients with sVAD. RESULTS: One hundred sixty-nine patients with 195 sVAD were identified. Brain ischemia occurred in 131 patients (77%; ischemic stroke, n=114, 67%; transient ischemic attack, n=17, 10%). Three patients with ischemic stroke showed also signs of subarachnoid hemorrhage (SAH); 3 (2%) had SAH without ischemia. The 134 patients with brain ischemia or SAH had head and/or neck pain in 118 (88%) and pulsatile tinnitus in seven (5%) patients. The remaining 35 patients (21%) had isolated head and/or neck pain in 21 (12%) cases, asymptomatic sVAD in 13 (8%), and cervical radiculopathy in one case (1%). Location of sVAD was more often in the pars transversaria (V2; 35%) or atlas loop (V3; 34%) than in the prevertebral (V1; 20%) or intracranial (V4; 11%) segment (P=0.0001). Outcome was favorable (modified Rankin scale score 0 or 1) in 88 (82%) of 107 ischemic stroke patients with follow up. Two (2%) patients died. Low baseline National Institutes of Health Stroke Scale score (P<0.0001) and younger age (P=0.007) were independent predictors of favorable outcome. CONCLUSIONS: sVAD is predominantly located in the pars transversaria (V2) or the atlas loop (V3). Most patients show posterior circulation ischemia. Favorable outcome is observed in most ischemic strokes and independently predicted by low National Institutes of Health Stroke Scale score and younger age.

Influence of intraventricular hemorrhage and occlusive hydrocephalus on the long-term outcome of treated patients with basal ganglia hemorrhage: a case-control study.

OBJECT: Only limited data exist addressing the long-term outcome of patients with ganglionic hemorrhage complicated by intraventricular hemorrhage (IVH) and hydrocephalus that requires an external ventricular drain (EVD). The aim of this study was to compare the long-term outcome of patients with pure ganglionic hemorrhage and those requiring an EVD due to additional IVH and hydrocephalus. METHODS: For this study, 116 patients with supratentorial ganglionic hemorrhage and occlusive hydrocephalus were screened. To avoid any bias the authors excluded all patients with nonprimary intracerebral hemorrhage as well as those who received no treatment. Forty patients with IVH and subsequent hydrocephalus were examined, and 40 more patients with pure ganglionic hematomas were matched with regard to age, sex, Glasgow Coma Scale score, need for mechanical ventilation, and, in particular, hematoma volume. Outcome analysis was performed using the Barthel Index and the modified Rankin Scale (mRS). The mean hematoma volume was 25.3 +/- 15.2 ml. The overall long-term outcome was unfavorable (mRS Score 4-6) in 59% of all patients. Good outcome (mRS score < 4) was observed in 25 (62.5%) of 40 patients with hematoma volumes less than 25 ml, compared with eight (20%) of 40 who had hematoma volumes greater than 25 ml (p < 0.05, chi-square test). The need for an EVD was not associated with a worse long-term outcome in patients with comparable hematoma volumes. In contrast, the duration of treatment in the intensive care unit was longer for patients with EVDs than for those who had pure ganglionic hematomas (16 [range 5-29] days compared with 8 [range 2-19] days; p < 0.05, Mann-Whitney U-test), regardless of hematoma volume. CONCLUSIONS: The long-term outcome of treated patients with supratentorial ganglionic hemorrhage with ventricular involvement and occlusive hydrocephalus is comparable to that of patients with similar hematoma volumes but no IVH.

Effects of induced hypertension on intracranial pressure and flow velocities of the middle cerebral arteries in patients with large hemispheric stroke.

BACKGROUND AND PURPOSE: Our aim was to prospectively evaluate the effects of induced arterial hypertension in patients with large ischemic stroke. METHODS: A total of 47 monitoring sessions in 19 patients with acute, complete, or subtotal middle cerebral artery (MCA) territory stroke were performed. Intracranial pressure (ICP) was monitored using a parenchymal catheter. Mean arterial blood pressure (MAP), ICP, and peak mean flow velocity of the middle cerebral arteries (V(m)MCA) were continuously recorded. Patients with acute ICP crises were excluded. After obtaining baseline values, MAP was raised by an infusion of norepinephrine to reach an MAP increase of at least 10 mm Hg. After MAP had reached a peak plateau level, the norepinephrine infusion was stopped. RESULTS: Baseline MAP was 83.6+/-1.6 mm Hg and rose to 108.9+/-2.0 mm Hg after infusion of norepinephrine. ICP slightly increased from 11.6+/-0.9 mm Hg to 11.8+/-0.9 mm Hg (P<0.05). Cerebral perfusion pressure rose from baseline 72.2+/-2 mm Hg to 97+/-1 mm Hg (P<0.0001). V(m)MCA was already higher on the affected side during baseline measurements. At maximum MAP levels, V(m)MCA rose by 25.5+/-5.5 cm/s on the affected side and by 8.6+/-1.6 cm/s on the contralateral side. CONCLUSIONS: In patients with large hemispheric stroke without an acute ICP crisis, induced hypertension enhances cerebral perfusion pressure and augments the V(m)MCA(s), more so on the affected side. The ICP slightly increases; however, this is probably not clinically significant.

Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to prospectively evaluate the effects of body position in patients with large supratentorial stroke. METHODS: We performed 43 monitoring sessions in 18 patients with acute complete or subtotal middle cerebral artery (MCA) territory stroke. Intracranial pressure (ICP) was monitored with a parenchymal probe. Mean arterial blood pressure, ICP, and MCA peak mean flow velocity (VmMCA) were continuously recorded. Patients with acute ICP crises were excluded. After baseline values at a 0 degree supine position were attained, the backrest was elevated in 2 steps of 5 minutes each to 15 degrees and 30 degrees and then returned to 0 degree. RESULTS: Baseline mean arterial pressure was 90.0+/-1.6 mm Hg and fell to 82.7+/-1.7 mm Hg at 15 degrees and 76.1+/-1.6 mm Hg at 30 degrees backrest elevation (P<0.0001). ICP decreased from 13.0+/-0.9 to 12.0+/-0.9 mm Hg at 15 degrees and 11.4+/-0.9 mm Hg at 30 degrees backrest elevation (P<0.0001). As a result, cerebral perfusion pressure decreased from a baseline value of 77.0+/-1.8 to 70.0+/-1.8 mm Hg at 15 degrees and 64.7+/-1.7 mm Hg at 30 degrees backrest elevation (P<0.0001). VmMCA was already higher on the affected side during baseline measurements. VmMCA decreased from 72.8+/-11.3 cm/s at 0 degree to 67.2+/-9.7 cm/s at 15 degrees and 61.2+/-8.9 cm/s at 30 degrees on the affected and from 49.9+/-3.7 cm/s at 0 degree to 47.7+/-3.6 cm/s at 15 degrees and 46.2+/-2.2 cm/s at 30 degrees on the contralateral side (P<0.0001). CONCLUSIONS: In patients with large hemispheric stroke without an acute ICP crisis, cerebral perfusion pressure was maximal in the horizontal position although ICP was usually at its highest point. If adequate cerebral perfusion pressure is considered more desirable than the absolute level of ICP, the horizontal position is optimal for these patients.

Effects of hypertonic (10%) saline in patients with raised intracranial pressure after stroke.

BACKGROUND AND PURPOSE: The aim of this study was to evaluate the effects of hypertonic saline in stroke patients with increased intracranial pressure (ICP) after conventional therapy with mannitol had failed. METHODS: Twenty-two episodes of ICP crisis occurred in 8 patients in whom the standard treatment of 200 mL of 20% mannitol was not effective. ICP crisis was defined as an increase in ICP of 20 mm Hg (n=18), pupillary abnormality (n=3), or a combination of both (n=1). The patients were treated with 75 mL of 10% saline over the course of 15 minutes. ICP, mean arterial blood pressure, and cerebral perfusion pressure were monitored for 4 hours. Blood gases, hematocrit, hemoglobin, pH, osmolarity, and electrolytes levels were measured before and 15 and 60 minutes after the start of infusion. Treatment was regarded as effective if ICP decreased >10% or the pupillary reaction had normalized. RESULTS: Treatment was effective in all 22 episodes. The maximum ICP decrease was 9.9 mm Hg 35 minutes after the start of infusion. Thereafter, ICP began to rise again. There was no constant effect on mean arterial blood pressure, whereas cerebral perfusion pressure was consistently increased. Blood osmolarity rose by 9 mmol/L and serum sodium by 5.6 mmol/L. Potassium levels, hemoglobin, hematocrit, and pH were slightly decreased. No unexpected side effects were noted. CONCLUSIONS: Infusion of 75 mL hypertonic (10%) saline decreases elevated ICP and increases cerebral perfusion pressure in stroke patients in whom mannitol had failed. The effect on the ICP and cerebral perfusion pressure reaches its maximum after the end of infusion and is seen for 4 hours.

Ischemic lacunar stroke in patients with and without potential mechanism other than small-artery disease.

BACKGROUND AND PURPOSE: Autopsy studies found that lacunar strokes differ in the size of the underlying brain infarct and that small lacunes are usually caused by hypertensive small-artery disease (SAD) and larger ones by atheromatous or embolic perforator occlusion. These findings suggest that larger lacunar infarcts might cause more severe neurological deficits and a higher detection rate on brain imaging compared with lacunar strokes caused by SAD. This prospective observational study was performed to investigate whether (1) neurological outcome, (2) prevalence of stroke risk factors, (3) prevalence of clinically asymptomatic occlusive cerebral artery disease, and (4) detection rate of underlying lacunar infarcts at brain imaging differ in ischemic lacunar strokes with (non-SAD) and without potential etiologies other than SAD. METHODS: Consecutive patients with lacunar stroke (n=244), defined by both clinical findings and brain imaging, were studied. Neurological deficit was quantified at presentation with the use of the National Institutes of Health Stroke Scale (NIHSS) and after 3 months with the NIHSS and the modified Rankin Scale (mRS). Cerebral arteries were investigated by ultrasound. RESULTS: Compared with patients with SAD lacunar strokes (n=155; 64%), patients with non-SAD lacunar strokes (n=89; 36%) had (1) higher NIHSS scores at presentation and higher NIHSS and mRS scores after 3 months (P<0.05); a higher prevalence of (2) hypertension (P<0.05), (3) coronary artery disease (P<0.0001), (4) previous transient ischemic attacks (P<0.01), and (5) asymptomatic stenoses of intracranial cerebral (P<0.01 to P<0.0001) and extracranial carotid (30% to 50% narrowing; P<0.01) arteries; and (6) a higher detection rate of the underlying lesion at brain imaging (P<0.01). CONCLUSIONS: Our data suggest that patients with non-SAD lacunar strokes have a worse clinical outcome and a higher prevalence of large cerebral and coronary artery disease than patients with SAD lacunar strokes.