Is persistent visual neglect associated with poor survival?

BACKGROUND: The association of visual neglect with survival after right hemisphere (RH) stroke has received only limited attention. OBJECTIVE: This study explores the relationship of visual neglect and its spontaneous recovery to survival in a homogenous patient group with first-ever RH stroke. METHODS: Fifty-one RH stroke patients who suffered an infarct between 1994 and 1997 were retrospectively followed for survival until August 31, 2009. Acute-phase neurological, neuropsychological and neuroradiological data were studied to identify predictors of survival. RESULTS: Twenty-eight patients died during the follow-up. Age, education, and poor recovery of visual neglect emerged as significant single predictors of death. The best set of predictors for poor survival in the multivariate model was poor recovery of visual neglect and low education. CONCLUSIONS: Poor recovery of visual neglect is associated with long-term mortality in RH infarct patients. The follow-up of RH patients' neuropsychological performance gives additional information about the prognosis.

PET amyloid ligand [11C]PIB uptake shows predominantly striatal increase in variant Alzheimer's disease.

Variant Alzheimer's disease (VarAD) with spastic paraparesis and presenile dementia is associated with certain mutations of the presenilin 1 (PS-1) gene, particularly those leading to deletion of exon 9 (PS-1Delta E9). VarAD is neuropathologically characterized by the presence of unusually large, Abeta42 positive, non-cored 'cotton wool' plaques (CWPs), also devoid of dystrophic neurites. The aim of the present study was to find out whether [(11)C]PIB would show increased uptake and serve as an in vivo biomarker of amyloid accumulation in VarAD. A further aim was to assess the correspondence of the [(11)C]PIB binding to the amount and type of Abeta deposits in another group of deceased VarAD patients' brains. We studied four patients with VarAD and eight healthy controls with PET using [(11)C]PIB as tracer. Parametric images were computed by calculating the region-to-cerebellum and region-to-pons ratio in each voxel over 60-90 min. Group differences in [(11)C]PIB uptake were analysed with automated region-of-interest (ROI) analysis. [(11)C]PIB uptake was compared to the immunohistochemically demonstrated deposition of Abeta in the brains of another group of four deceased VarAD patients. Patients with VarAD had significantly higher [(11)C] PIB uptake than the control group in the striatum (caudate nucleus and putamen), anterior and posterior cingulate gyrus, occipital cortex and thalamus. In the caudate and putamen [(11)C]PIB uptake, expressed as region-to-cerebellum ratio, was on the average 43% greater than the mean of the control group. The increases in the anterior (28%) and posterior (27%) cingulate gyrus, occipital cortex (21%) and thalamus (14%) were smaller. All VarAD patients showed this similar topographical pattern of increased [(11)C]PIB uptake. The results were essentially similar when the uptake was expressed as region-to-pons ratios. [(11)C]PIB imaging shows increased uptake in patients with VarAD especially in the striatum, and it can be used to detect amyloid accumulation in vivo in these patients. The pattern of increased [(11)C]PIB uptake is different from that described in sporadic Alzheimer's disease and resembles that seen in Alzheimer's disease patients with certain presenilin-1 mutations or amyloid precursor protein gene duplication showing predominantly striatal increase in [(11)C]PIB uptake.

Fluctuation in spontaneous recovery of left visual neglect: a 1-year follow-up.

Spontaneous recovery and possible fluctuation in left visual neglect, and its relation to stroke severity, basic activities of daily living (ADL) and extended ADL were examined at 10 days, at 3, 6, and 12 months after onset. Twenty-one of 56 right hemisphere stroke patients had visual neglect. Three visual neglect recovery groups were identified: continuous, fluctuating and poor recovery. We concentrated on the comparison of the continuous and the fluctuating recovery groups. At the acute phase the fluctuating recovery group had larger infarcts, more severe neglect and stroke, and a lower level of basic ADL compared to the continuous recovery group. In the continuous recovery group stable recovery was detected up to 6 months, whereas in the fluctuating recovery group recovery was incoherent in neglect and in extended ADL. A minimum follow-up period of 6 months including the evaluation of extended ADL is recommended for neglect patients due to possible fluctuation in visual neglect.

Predictors of discharge to home during the first year after right hemisphere stroke.

OBJECTIVES: The aim of this study was to explore predictive factors of the length of hospital stay at the acute stage of right hemisphere stroke. Special attention was paid to the possible role of anosognosia for hemiparesis and anosognosia for neglect in this prediction. PATIENTS AND METHODS: A consecutive series of 57 patients having their first right hemisphere stroke were examined at the acute phase. Forty-nine patients were included in this study and followed-up for 12 months. The examinations were conducted within 2 weeks of onset. The outcome variable was the time (days) from stroke to discharge to home. The predictors were age, gender, size of infarct, neglect, hemiparesis, verbal memory, unawareness of illness, anosognosia for neglect, anosognosia for hemiparesis and presence of a relative at home. RESULTS: Hemiparesis and unawareness of illness lengthened the duration of the hospital stay, the presence of a relative reduced it. Neglect was the best single predictor of poor outcome, but it had no additional value in the combination of the three predictors above. Neither anosognosia for hemiparesis nor anosognosia for neglect were important predictors. CONCLUSION: Hemiparesis, unawareness of illness and presence of a relative at home were the best predictors of the time from right hemisphere stroke to discharge to home.

Unawareness of deficits after right hemisphere stroke: double-dissociations of anosognosias.

OBJECTIVES: The aim was to study whether anosognosia for hemiparesis, anosognosia for neglect and general unawareness of illness double-dissociate, indicating that anosognosias are specific and independent impairments of awareness. On the other hand, anosognosias may be associated with one another and with general cognitive dysfunction, which decreases awareness of deficits. The persistence and predictive value of anosognosias was examined during a 1-year follow-up. PATIENTS AND METHODS: Fifty-seven consecutive patients with acute right hemisphere infarction underwent neurological and neuroradiological examinations, neuropsychological testing and an interview 10 days, 3 months and 1 year after onset. RESULTS: Anosognosia for neglect and anosognosia for hemiparesis double-dissociated, as did unawareness of illness and anosognosia for neglect. Patients showing unawareness of illness or anosognosia for neglect and anosognosia for hemiparesis had poorer orientation and verbal memory than patients who were aware of these defects. Unawareness of illness and anosognosia for hemiparesis disappeared during 3-month follow-up. CONCLUSION: Double-dissociations demonstrate that anosognosias for different defects are independent and specific impairments of awareness, although general cognitive disorder may also reduce awareness of defects. Unawareness of illness and anosognosia for hemiparesis disappear rapidly and can hardly be direct causes of poor long-term recovery. However, transient anosognosia may be associated with persistent disorders which result in poor outcome.

Volumetric measurements of right cerebral hemisphere infarction: use of a semiautomatic MRI segmentation technique.

The applications of a new segmentation software, Anatomatic, in the evaluation of volumetric measurements of brain infarctions and the new Medimag 3D software in the evaluation of 3D image representation of infarctions are described. These programs are applied to magnetic resonance imaging. The aim of this study is to evaluate the use of these software packages in making accurate volumetric measurements in 40 patients with right cerebral infarctions, in determining the correlations between the quantitated lesions and neurological/neuropsychological dysfunctions and in creating realistic 3D views of the infarctions. Using Anatomatic, reproducible infarction volumes were achieved with ease and within a reasonably fast time. Medimag helped achieve realistic 3D representations of the infarctions. When compared, the semiautomatic segmentation proved to be much faster and yielded higher infarction volumes than the manual segmentation technique. Significantly positive correlations between the infarction volumes and neurological dysfunctions and neuropsychological deficit (neglect) helped to explain the effect of volumes on the clinical status of the patients.

Visual neglect as a predictor of functional outcome one year after stroke.

OBJECTIVE: The aim was to study the role of visual neglect in acute right hemisphere brain infarct as a predictor of poor functional outcome during the first year after stroke. In particular, we were interested in the additional value of neglect measures besides hemiparesis, hemianopia, cognitive deficits and age. PATIENTS AND METHODS: A consecutive series of 57 patients with a neuroradiologically verified right hemisphere infarct was examined within 10 days of the stroke. Fifty patients were followed up for 1 year. Neglect was measured with the Conventional and the Behavioural subtests of the Behavioural Inattention Test (BITC and BITB, respectively). The predictors were determined at the 10-day examination. Functional outcome was assessed 3, 6 and 12 months after the onset with the Frenchay Activities Index. RESULTS: Neglect in BITB was the best single predictor, which together with high age formed the best combination of predictors for poor functional outcome at each follow-up. Hemiparesis was also included in this prediction model at the 3-month follow-up, but hemianopia, BITC, or visuoconstructional and memory deficits showed no additional predictive value. However, neglect usually recovered soon. When neurological and cognitive deficits were assessed at the same time as the outcome, hemiparesis rather than neglect was the strongest correlate of poor outcome. CONCLUSION: Neglect in acute stroke is an important predictor of poor functional recovery. Residual neglect, which could be compensated in the follow-up tests, may nevertheless restrict patients' real-life activities and hobbies.

Low plasma antioxidant activity is associated with high lesion volume and neurological impairment in stroke.

BACKGROUND AND PURPOSE: Oxidative stress is probably involved in neuronal damage induced by ischemia-reperfusion. The purpose of this study was to assess the role of antioxidant activity in cerebral ischemic stroke. METHODS: Antioxidant activity of blood plasma and cerebrospinal fluid was assessed in 22 patients with cerebral hemisphere infarction that was verified and quantified by MRI. RESULTS: Low total peroxyl radical trapping potential of plasma, but not of cerebrospinal fluid, was associated with high lesion volume and high neurological impairment assessed by scores on NIH Stroke Scale, Barthel Index, and Hand Motor Score tests. The plasma concentrations of ascorbic acid, alpha-tocopherol, and protein thiols were also associated with the degree of neurological impairment. CONCLUSIONS: These data suggest that the antioxidant activity of plasma may be an important factor providing protection from neurological damage caused by stroke-associated oxidative stress.

Cortical silent period evoked by transcranial magnetic stimulation in ischemic stroke.

OBJECTIVES: Transcranial magnetic stimulation (TMS) of the motor cortex produces motor evoked potentials (MEPs). Besides this excitatory response, TMS has inhibitory effects. When TMS is performed during voluntary muscle contraction, the MEP is followed by a pause in electromyographic activity (cortical silent period, SP). The aim of this study was to evaluate the clinical usefulness of the SP. METHODS: We studied SP changes in 50 patients with acute hemispheric brain infarction. A stimulator with a round coil and a fixed intensity of 90% of maximum was used to evoke MEPs. RESULTS: SP was elicited on the affected side in 29 of the 50 patients. The mean SP duration was markedly longer on the affected side in the patient group. There were no significant differences between left and right sides in the means of the MEP amplitude ratio (amplitude related to corresponding amplitudes to peripheral electric stimulation) and MEP latencies in the patient group. Prolonged SP was found in 25 of the 29 patients (86%) whereas only 4 (14%) had abnormalities in MEP latency or amplitude ratio. The mean SP duration was significantly prolonged also in a subgroup of 14 patients with normal hand function. CONCLUSIONS: The SP measurement is an easily performed and sensitive method to detect even subclinical disturbances in motor system function in ischemic stroke.

Long-term graft outcome is not necessarily affected by delayed onset of graft function and early acute rejection.

BACKGROUND: Both acute rejection episodes and delayed graft function (DGF) have been shown to be associated with decreased 1-year renal allograft survival. In our center, the incidence and the intensity of acute rejection episodes have been reduced by cyclosporine-based triple-drug therapy. We have also shown that DGF alone is not a risk factor for long-term graft survival. METHODS: We have now investigated whether an acute rejection episode together with DGF significantly effects long-term graft outcome. This study involved 862 first cadaveric renal allografts and 182 regrafts. RESULTS: The incidence of DGF was 33% after first transplants and 44% after retransplants. The overall incidence of acute rejection episodes was 23% in first grafts and 28% in regrafts. After first grafts, there were no statistically significant differences in graft survival rates and half-lives between the early graft function (EGF) and DGF groups with or without acute rejection. In regrafts, graft survival was significantly higher in the EGF group without acute rejection than in the DGF group with acute rejection. However, if all other causes except chronic rejection were censored, the half-life in the EGF group without acute rejection was 17.3 years in first grafts, and in the DGF group with acute rejection, that number was 11.5 years in first grafts; for regrafts, the half-life was 12.3 years and 6.1 years, respectively. CONCLUSIONS: Acute rejection together with DGF could contribute to initial damage to the graft, and this might lead to later chronic allograft failure. In our study, this effect was evident only in the case of retransplants.

The effect of ascorbate and ubiquinone supplementation on plasma and CSF total antioxidant capacity.

Free radicals are thought to be involved in the onset of neuronal disturbances such as Alzheimer's disease, Parkinson's disease, and neuronal ceroid lipofuscinosis. It is also assumed that they play a role in cerebral injury caused by ischemia or trauma. Plasma and cerebrospinal fluid (CSF), Total (peroxyl) Radical-trapping Antioxidant Parameter (TRAP), and the known antioxidant components of TRAP, for instance, ascorbic acid, uric acid, protein sulfhydryl groups, tocopherol, and ubiquinol were analyzed and the remaining unidentified fragment was calculated in five healthy volunteers before and after 4 weeks of ascorbate and ubiquinone (Q-10) supplementation. In CSF, TRAP was significantly lower than in plasma. The major contributor to plasma's antioxidant capacity was uric acid (UA), whereas in CSF it was ascorbic acid (AA). In CSF, AA concentrations were four times higher than in plasma. Oral supplementation of AA (500 mg/d first 2 weeks, 1,000 mg/d following 2 weeks) and Q-10 (100 mg/d first 2 weeks, 300 mg/d following 2 weeks) induced a significant increase in plasma AA and Q-10. Surprisingly, in spite of the high lipophilicity of Q-10, its concentration did not change in CSF. The supplementation of AA increased its concentration in CSF by 28% (p < .05). However, the increase in AA did not result in an increase in CSF TRAP. This indicates that AA had lost one-third of its radical trapping capacity as compared to that in plasma. The facts that AA is the highest contributor to CSF TRAP and its effect on TRAP is concentration dependent could indicate that the peroxyl radical-trapping capacity of CSF is buffered by AA.

Does the biorhythm of morningness or eveningness predict the arterial blood pressure level?

With the aid of a special questionnaire 16 healthy persons were divided to morning or evening types of personalities. Their arterial blood pressure was registered ambulatorily for 24 hours in order to elucidate the difference of blood pressure reactions between the groups. The average maximum blood pressure occurred 3.5 hours later in evening types than in morning types. Individually there were very small differences and it seems that the blood pressure level is more affected by physical activity than by morningness or eveningness.