Visual field defect after ischemic stroke-impact on mortality.

OBJECTIVES: We aimed to investigate the impact of visual field defects (VFD) on mortality in ischemic stroke patients. MATERIALS AND METHODS: All patients with acute infarction and a clinically detected VFD from February 2006 to December 2013 in the NORSTROKE Registry (n = 506) were included and compared with ischemic stroke patients with normal visual fields (n = 2041). A record of patients who had died per ultimo April 2015 was obtained from the central registry at Haukeland University Hospital. RESULTS: Patients with VFD were significantly older (75.0 vs 69.8, P < .001) than patients with normal visual fields. The majority of patients with VFD was male, had higher cardiovascular morbidity prestroke, and were more likely to have shorter median time from symptom onset to admission (1.7 hours vs 2.7 hours, P < .001). Baseline National Institute of Health Stroke Scale (NIHSS) score was higher (12.7 vs 3.5, P < .001) as was modified Rankin Scale (mRS) score (3.5 vs 1.9, P < .001) and Barthel Index was lower (51.9 vs 84.8, P < .001) day 7. VFD was associated with increased mortality on Kaplan-Meier plots. Hazard ratio was significantly higher for patients with VFD after adjusting for age, sex, employment prior to infarction, married prior to infarction, institutionalization prior to infarction, prior myocardial infarction, atrial fibrillation, smoking, Barthel Index score and i.v. thrombolysis with Cox regression (hazard ratios [HR] 1.30, CI 1.07-1.56, P = .007). CONCLUSIONS: Having a visual field defect after ischemic stroke is independently associated with increased mortality. This should be addressed when selecting candidates for thrombolysis and in the rehabilitation process.

Less thrombolysis in posterior circulation infarction-a necessary evil?

OBJECTIVES: Patients with posterior circulation infarction (PCI) have more subtle symptoms than anterior circulation infarction (ACI) and could come too late for acute intervention. This study aimed to describe the clinical presentation, management, and outcome of PCI in the NORSTROKE registry. METHODS: All patients with PCI admitted to the Department of Neurology at Haukeland University Hospital and registered in the NORSTROKE database 2006-2013 were included (n=686). Patients with ACI (n=1758) were used for comparison. RESULTS: Patients with PCI were younger (68.2 vs 71.8, P<.001), had longer median time from symptom onset to admission (3.8 hours vs 2.2 hours, P<.001), and were less likely to arrive at hospital within 4.5 hours from symptom onset (56.2% vs 72.5%, P<.001, ictus known). Patients with PCI scored lower on baseline National Institute of Health Stroke Scale (NIHSS) total score (3.2 vs 6.3, P<.001), and lower or equally on all items of NIHSS, except for ataxia in two limbs. Patients with PCI were less likely to receive i.v. thrombolytic treatment (9.9% vs 21.5%, OR 0.66, CI 0.47-0.94). On day 7, patients with PCI scored lower on NIHSS (2.8 vs 4.9, P<.001), modified Rankin Scale (2.0 vs 2.3, P<.001), and higher on Barthel Index (84.5 vs 76.0, P<.001). CONCLUSIONS: Our study is, to our knowledge, the largest series reporting comprehensively on PCI verified by diffusion-weighted imaging. PCI patients are younger than ACI and have better outcome. PCI and ACI are equally investigated in the acute setting, but thrombolysis rates remain 50% lower in PCI.

Vision problems in ischaemic stroke patients: effects on life quality and disability.

BACKGROUND AND PURPOSE: Vision problems after cerebral infarction are an increasingly acknowledged problem. Our aim was to investigate the effect on quality of life and post-stroke disability. METHODS: Patients admitted to the Stroke Unit, Department of Neurology, Haukeland University Hospital, between February 2006 and July 2008 with acute cerebral infarction were prospectively registered in the NORSTROKE Registry. Patients received a postal questionnaire at least 6 months after stroke. The questionnaire included 15D©, EuroQol 5D (EQ-5D(™) ), the Hospital Anxiety and Depression Scale (HADS), the Fatigue Severity Scale (FSS) and the Barthel Index (BI). RESULTS: Of 328 responders, 83 (25.4%) reported a vision problem. Vision problems were associated with older age (71.8 years vs. 66.5 years, P = 0.001), higher National Institutes of Health Stroke Scale score on admission (5.9 vs. 3.8, P < 0.001), higher modified Rankin Scale day 7 (2.0 vs. 1.4, P < 0.001) and lower BI day 7 (85.7 vs. 93.9, P = 0.002). Patients with vision problems had lower median EQ-5D utility score (0.62 vs. 0.80, P < 0.001), lower median 15D utility score (0.73 vs. 0.89, P < 0.001), higher median HADS score (12 vs. 5, P < 0.001), higher median FSS score (5.6 vs. 4.3, P < 0.001) and lower median BI (95 vs. 100, P < 0.001) on long-term follow-up. Patients with self-reported vision problems scored lower on all sub-scores of BI on follow-up (all P < 0.001). CONCLUSION: One in four patients reported a vision problem on follow-up after cerebral infarction. Vision problems after cerebral infarction reduce quality of life and are associated with increased disability. Thorough diagnostic evaluation and targeted rehabilitation is important.

Neurological disorders in the Global Burden of Disease 2010 study.

BACKGROUND: The Global Burden of Disease study (GBD) is a large international initiative to collect and systematize data on disease burden expressed in non-economic terms, to allow comparisons across different disease conditions and countries. OBJECTIVES: To use data from the large GBD 2010 database to determine the importance of neurological disorders in Norway, and to compare it with global data on the same disorders. MATERIALS AND METHODS: Relevant data were extracted from the Lancet publication from December 2012, and from the interactive website of the Institute of Health Metrics and Evaluation on GBD. RESULTS: Neurological disorders (Alzheimer's disease, Parkinson's disease, multiple sclerosis, epilepsy, migraine and tension-type headache, other neurological disorders) account for 5-6% of the disease burden in Norway, which is more than it does globally. When also stroke, low back pain and neck pain are included, 10% of the disease burden in Norway is represented by neurological disorders. CONCLUSIONS: Neurological disorders are of great public health importance. This knowledge is useful in dimensioning and organizing healthcare systems and necessary when planning education of health personnel on all levels.

The Norwegian Brain Council ('Hjernerådet')--united efforts are necessary!

There is a strong tradition of neuroscience in Norway, and Norwegian neurologists have been actively involved in developing partnerships between all those who recognize the importance of the brain and of brain diseases. It was therefore unsurprising that Norwegian neurologists took the initiative in establishing the Norwegian Brain Council (NBC). NBC was founded in 2007 and now comprises 27 organizations and institutions. It includes all those who work with brain research and brain diseases in Norway, as well as all relevant user organizations. Industries and businesses that are related to brain disease may be partners, but do not have full membership. The main mission of NBC is to provide information about the brain and brain diseases for both lay people and public authorities, including politicians, and to promote better treatment for patients with brain diseases and more research in neuroscience. The council has firm ties to the European Brain Council (EBC). NBC plans to follow the initiative taken by EBC in organizing a 'Month of the Brain' in 2013 and a 'Year of the Brain' in 2014. These initiatives could provide an impetus for greater focus on brain diseases, which is essential in order to meet the considerable challenges that are posed by brain diseases in the years to come.

Visual impairment in stroke patients--a review.

Approximately 30% of all stroke patients suffer from post-stroke visual impairment. Hemianopia is the most common symptom, but also neglect, diplopia, reduced visual acuity, ptosis, anisocoria, and nystagmus are frequent. Partial or complete recovery of visual disorders can occur, but many patients suffer permanent disability. This disability is often less evident than impairment of motor and speech functions, but is negatively correlated with rehabilitation outcome and can lead to a significant reduction in day-to-day functioning. To be visually impaired after stroke reduces quality of life and causes social isolation because of difficulties in navigating/orientating in the surroundings. A thorough diagnosis including targeted examination and later follow-up with eye examination and perimetry is essential in order to establish the extent of the visual impairment and to select the best rehabilitation strategy. Patients seem to profit from visual rehabilitation focused on coping strategies.

Diagnosis and rehabilitation of visual field defects in stroke patients: a retrospective audit.

OBJECTIVE: Visual field defects (VFD) after stroke can cause significant disability and reduction in quality of life. Adequate diagnosis of VFD and referral to visual rehabilitation are important to improve outcome. Our aim was to conduct a retrospective clinical audit to investigate how neurologists detect and follow up VFD in stroke patients in a university hospital in Norway. METHODS: All patients registered in the Bergen NORSTROKE Registry from February 2006 to May 2009 with (1) occipital lobe infarctions and (2) non-occipital infarction and clinically detected VFD were included in the study. Their medical records were reviewed for referral to perimetry for examination of VFD and for referral to a visual rehabilitation program within the first year after brain injury. RESULTS: Of 353 patients, 34 (9.6%) were referred to perimetry and 8 (2.3%) to visual rehabilitation. Patients referred to perimetry were younger (65.1 vs. 74.7 years, p < 0.001), had lower modified Rankin Scale scores (2.53 vs. 3.47, p = 0.003), and scored lower on the National Institutes of Health Stroke Scale upon admission (6.68 vs. 13.90, p < 0.001). Men were more often referred to perimetry than women (73.5 vs. 26.5%, p < 0.001), and those referred were younger (61.2 vs. 75.8 years, p = 0.03). CONCLUSIONS: Only few patients were referred to perimetry, and even fewer were offered visual rehabilitation. Age and gender were negative predictors for referral. Neurologists' awareness of the significant disability related to VFD must be increased. Focused diagnostics on visual impairment and early referral to a visual rehabilitation program should be mandatory in stroke unit services.

Partnership and cooperation is necessary to improve and expand neurology.

BACKGROUND: Brain disorders have a large impact on society, representing one third of the total burden of disease. Neurology is more than before divided into fields of highly specialized branches. OBJECTIVE: To assess the need for co-operation in neuromedicine to achieve optimal results for patient treatment, diagnosis and care. DISCUSSION: Co-operation regarding patients with disorders in the brain and nervous system should involve medical specialists, general practitioners, other professionals, patients and carers. Optimal co-operation represents both an institutional and personal challenge. The principle of joint action between several subspecialists should also have consequences for educational systems and requirements. Formalised co-operation is well established in medical research, and principles for good practice in neuroscience have relevance also for clinical medicine. How to organise the optimal treatment is therefore not only a challenge for neurologists, but also for the total health system within hospitals and in society. CONCLUSION: Open-handedness and a willingness to co-operate should be a hallmark for neurologists.

Cardiovascular and urological dysfunction in spinal cord injury.

OBJECTIVE: A spinal cord injury (SCI) above the sixth thoracic vertebra interrupts the supraspinal control of the sympathetic nervous system causing an imbalance between the sympathetic and the parasympathetic nervous system. This article focuses on the symptoms, treatment and examination of autonomic disturbances of the cardiovascular and the urinary system after a SCI. METHODS: A non-systematic literature search in the PubMed database. RESULTS: Frequent complications in the acute phase of cervical and high thoracic SCI are bradyarrhythmias, hypotension, hypothermia/hyperthermia, increased neurogenic shock, vagovagal reflex, supraventricular/ventricular ectopic beats, vasodilatation and congestion. Serious complications in the chronic phase of SCI are orthostatic hypotension, impaired cardiovascular reflexes, autonomic dysreflexia (AD), reduced sensation of cardiac pain, loss of reflex cardiac acceleration, quadriplegic cardiac atrophy due to loss of left ventricular mass and pseudo-myocardial infarction. AD is associated with a sudden, uncontrolled sympathetic response, triggered by stimuli below the injury. It may cause mild symptoms like skin rash or slight headache, but also severe hypertension, cerebral haemorrhage and death. Early recognition and prompt treatment are important. Urinary autonomic dysfunctions include hyperreflexia or areflexia of detrusor and/or sphincter of the bladder. CONCLUSIONS: Patients with SCI have a high risk of cardiovascular complications, AD and urinary autonomic dysfunction both in the acute phase and later, affecting their prognosis and quality of life. Knowledge of cardiovascular and urological complications after SCI is important for proper diagnosis and treatment.

Myasthenia gravis in pregnancy and birth: identifying risk factors, optimising care.

Women with myasthenia gravis (MG) have increased risk of pregnancy complications and an adverse pregnancy outcome. This study examined risk factors for such complications in order to improve the care for pregnant MG women. Through the Medical Birth Registry of Norway, 73 MG mothers with 135 births were identified. Their obstetrical and clinical records were examined. Data on pregnancy, delivery and the newborn were combined with information on mother's disease. The risk for neonatal MG was halved if the mother was thymectomized (P = 0.03). Children with neonatal MG were more likely to display signs of foetal distress during delivery (P = 0.05). Only in one-third of the pregnancies did the patient see a neurologist during pregnancy. These patients used MG medication more often during pregnancy (P = 0.001), and were more likely to be thymectomized (P = 0.007). They also had a higher rate of elective sections (P = 0.009). Thymectomy may have a protective effect against neonatal MG. Neonatal MG can cause foetal distress during delivery. Most MG women benefit from being examined by a neurologist during pregnancy, to minimize risks and select the best delivery mode in collaboration with obstetricians.

Artrogryposis multiplex congenita -- a rare fetal condition caused by maternal myasthenia gravis.

OBJECTIVES: To look at the occurrence of arthrogryposis multiplex congenita in newborn of mothers with myasthenia gravis (MG) and factors connected to this. MATERIAL AND METHODS: We retrospectively studied 176 births by 79 MG mothers, recorded in the Medical Birth Registry of Norway (MBRN). Four (2.2%) newborns (including one pair of twins) born with severe skeletal anomalies were identified. RESULTS: All four children died. Three had findings consistent with arthrogryposis multiplexa congenita (AMC), one had a fetal akinesia deformation sequence (FADS). The mother of the child with FADS had previously given birth to a child with neonatal MG. She was now in complete MG remission. The mother of the twins with AMC later gave birth to a child with neonatal MG. CONCLUSION: Siblings of an affected child -- either with neonatal MG or AMC -- have an increased risk to develop either neonatal MG or AMC. As this appears to be independent of the MG mother's clinical state, it is important to discuss previous pregnancy outcomes with all female MG patients.

Pregnancy, delivery, and birth outcome in women with multiple sclerosis.

Using data from the compulsory Medical Birth Registry of Norway, the authors investigated the effect of maternal multiple sclerosis (MS) on pregnancy, delivery, and birth outcome in 649 births by MS mothers and 2.1 million control births. The mothers with MS had a higher proportion of neonates small for gestational age and also more frequent induction and operative interventions during delivery.

Asymptomatic myasthenia gravis influences pregnancy and birth.

Women with myasthenia gravis (MG) have an increased risk of complications and adverse pregnancy outcome. This study has examined if this is true also for asymptomatic MG. Using data from the Medical Birth Registry of Norway, births of women prior to receiving an MG diagnosis or in complete clinical MG remission were compared with all non-MG births in Norway in the same period (1967-2000). Forty-nine births occurred in 37 women, 11 of them in clinical remission, and six thymectomized. The perinatal mortality was increased (P = 0.02) and induction of birth (P = 0.007) occurred more frequently. Protracted labor occurred more frequently in the target group (P = 0.03). One of the three children that died had Potter's syndrome. Both mothers with children who died were in complete clinical MG remission. One had previously given and one subsequently gave birth to a child with neonatal MG. The results indicate that complications in birth and pregnancy are not only related to clinical MG disease severity but to the underlying immunological dysfunction.

Feasibility of Applying a Stable Isotopic Tracer for Direct Determination of Dry Particulate Deposition to Soybean Plants.

A stable rare-earth isotopic tracer was used to measure the deposition of KNO3 particles on soybean leaves by direct measurement of the tracer on the plant surfaces by thermal-ionization mass spectrometry. Submicrometer particles, made from a solution containing 3 |mg mL-1 neodymium isotope (148Nd, 87.9%) and 1,000 mg mL-1 KNO3, were dispersed with a two-fluid nozzle and released upwind of a soybean field. Total suspended- and size-fractionated-aerosol particles were collected on an open-face filter and in a micro-orifice impactor, respectively, at a distance of 40 m from the release point. Soybean leaves exposed to the plume were collected at distances ranging from 25 to 100 m. As little as 5.5 pg of the tracer (i.e., excess 148Nd) was detected in soybean leaves at signal-to-noise ratios ranging from 7,500 to 240,000, in the presence of 200 to 2,700 pg of naturally occurring Nd. The dry-particle deposition velocity, determined from the ratio of the aerial concentration and directly deposited aerosol (geometric mass mean diameter, 0.20 mm) flux, and its corresponding analytical uncertainty were 0.30 cm sec-1 and 2.5%, respectively.

Attraction of bark beetles (Coleoptera: Scolytidae) to a pheromone trap : Experiment and mathematical models.

The movement of bark beetles near an attractive pheromone source is described in terms of mathematical models of the diffusion type. To test the models, two release experiments involving 47,000 marked spruce bark beetles [Ips typographus (L.)] were performed. The attractive source was a pheromone trap, surrounded by eight concentric rings with eight passive trap stations on each ring. Captures were recorded every 2-10 minutes for the pheromone trap and once for the passive traps. The models were fitted to the distribution in time of the central pheromone trap catch and to the spatial distribution of catch among the passive traps. The first model that gives a reasonable fit consists of two phases: Phase one-After release the beetles move according to a diffusion process with drift towards the pheromone trap. The strength of the drift is inversely proportional to the distance from the traps. Phase two-those beetles attracted to, but not caught by, the pheromone trap are no longer influenced by the pheromone, and their movement is described by a diffusion process without drift. In phase two we work with a loss of beetles, whereas the experiment seems to indicate that the loss of beetles in phase one is negligible. As a second model, the following modification of phase one is considered: After release the beetles move according to a diffusion process without drift, until they start responding to the pheromone (with constant probability per unit time), whereafter they start moving according to a diffusion process with drift. This study, like other release experiments, shows that the efficiency of the pheromone trap is rather low. What is specific for the present investigation is that we try to explain this low efficiency in terms of dynamic models for insect movement. Two factors seem to contribute: Some beetles do not respond to pheromone at all, and some beetles disappear again after having been close to the pheromone trap. It also seems that the motility of the beetles decreased after they ceased responding to the pheromone. Furthermore, the data lend some support to the hypothesis that flight exercise increases the response of the beetles to pheromone.