Patients with Acute Lacunar Infarction Have Benefit from Intravenous Thrombolysis.

INTRODUCTION: Usefulness of intravenous thrombolysis in patients with acute lacunar cerebral infarction is questionable. The aim of this study was to evaluate the efficacy and safety of intravenous thrombolysis in patients with lacunar infarction in comparison with patients with nonlacunar infarction as well as with patients with lacunar infarction who were not treated with intravenous thrombolysis. MATERIALS AND METHODS: In the first part of the study, among patients with acute ischemic stroke treated with intravenous thrombolysis, characteristics and outcomes of 46 patients with lacunar and 221 patients with nonlacunar infarction were compared. In the second part, 46 patients with lacunar infarction treated with intravenous thrombolysis were compared with 45 lacunar infarction patients who were not treated with intravenous thrombolysis. RESULTS: Patients with lacunar infarction had a lower National Institutes of Health Stroke Scale score (9.2 versus 13.9, P < .001), a greater Alberta Stroke Program Early computed tomography (CT) score (9.7 versus 9.2, P = .002), a lower prevalence of atrial fibrillation (6.5% versus 41.2%, P < .001), and significantly more frequently an excellent outcome after 3 months (76.1% versus 36.2%, P < .001) compared with patients with nonlacunar infarction. Among patients with lacunar infarction, an excellent outcome at discharge was significantly more frequent in the intravenous thrombolysis group (41.3% versus 15.6%, P = .01), and the length of hospitalization was significantly shorter (9.5 days versus 14.3 days, P = .002). There was no hemorrhagic transformation among patients with lacunar infarction treated with intravenous thrombolysis. CONCLUSION: Intravenous thrombolysis has proven to be effective and safe in patients with lacunar infarction and should always be applied if there are no absolute contraindications.

A CASE OF PROBABLE NEUROSARCOIDOSIS PRESENTING AS UNILATERAL OPHTHALMOPLEGIA.

Sarcoidosis is a multisystem disease of unknown etiology, characterized by the presence of noncaseating epithelioid granulomas and accumulation of T lymphocytes and mononuclear phagocytes, which damages the normal structure of tissues. Isolated form of neurosarcoidosis is very rare and difficult to diagnose and requires histologic confirmation of noncaseating granulomas in the nervous tissue. We report a case of a 55-year-old female who had probable isolated neurosarcoidosis based on magnetic resonance imaging findings of relapsing pachymeningitis with an inflammatory process in the apex of the right orbit and pseudotumor inflammation of the superior and lateral recti of the right eye. Diagnosis was further verified by positive response to dual corticosteroid and immunosuppressive therapy. Our case demonstrates the importance of considering isolated neurosarcoidosis as a potential underlying etiology of painful ophthalmoplegia, even without systemic manifestation of the disease.

The effect of post stroke depression on functional outcome and quality of life.

In spite of being a common and important complication of stroke, post stroke depression is often overlooked, so its impact on stroke outcome remains under recognized. The aim of the study was to determine the effect of depression on functional outcome and quality of life in stroke patients. The study included 60 patients treated for their first clinical stroke, 30 of them diagnosed with depression and 30 patients without depression. Testing was done in all patients two and six weeks after stroke. Depression was diagnosed according to the Mini International Neuropsychiatry Interview, DSM-IV diagnostic criteria, and depression severity was quantified by the Hamilton Depression Rating Scale; functional impairment was determined by the Barthel Index; and post stroke quality of life was assessed by the Short Form 36 (SF-36) questionnaires. The patients with depression had significantly more severe functional disability both at baseline and after rehabilitation treatment, although the potential for functional recovery in depressed patients was less than in non-depressed ones. The quality of life in patients with post stroke depression was impaired more severely in all SF-36 domains compared with non-depressed stroke patients, with the domains of the role of emotional functioning and social relations being most severely affected.

[Factors predisposing to cervical artery dissection].

INTRODUCTION: Cervical artery dissection is a major cause of cerebral ischemia in young adults and can lead to various clinical symptoms, some of which are benign (e.g. headache, neck pain, Horner's syndrome, and cranial nerve palsy). However, most patients have a stroke or transient ischemic attack. EPIDEMIOLOGY: The incidence of cervical artery dissection is low and is estimated to be around 2.6 per 100,000 inhabitants. Mortality and short-term recurrence rates are low: however; they may have been underestimated. PATHOPHYSIOLOGY: Although the pathophysiology is still unclear constitutional and partly genetic susceptibility of the arterial wall has been proposed as a causal factor; triggered by infection or minor trauma. PREDISPOSING FACTORS: In addition to the trauma to the neck, other risk fractors have been suggested, such as infection, migraine, hyperhomocisteinamia, and the 67TT genotype of the 5,10-methylene-tetrahydrofolate reductase gene although evidence is sparse. GENETIC FACTORS: Cervical artery dissection is now considered a multifactorial disease caused by several genetic abnormalities and environmental factors acting synergistically. CONCLUSION: Research aimed at improving our understanding of the environmental and genetic factors predisposing to cervical artery dissection and assessment of long-term outcomes of this disease is needed. Better understanding of the underlying pathophysiology and the natural history of the disease through large prospective multicentre cohorts could also be helpful to improve therapeutic and preventive strategies. Several mutlticentre efforts are already under way to meet these needs.

[Diagnosis and outcome of cervical artery dissection].

INTRODUCTION: Spontaneous dissection of the cervical artery is a rare non-atherosclerotic vascular disease of unknown aetiology and unclear pathogenesis that may be a cause of ischemic stroke in young adults. DIAGNOSIS: Precise diagnosis of dissection of the cervical artery--carotid or vertebral--is possible with cervical axial magnetic resonance imaging and magnetic resonance angiography. TREATMENT: The recommended treatment in the acute phase of cervical artery dissection is anticoagulant or antithrombotic therapy, aimed at preventing a primary or recurrent ischemic event. There have been as yet no results of randomized controlled studies comparing efficacy of both treatments. An ongoing randomized multicentre study is expected to provide answers about the effects of these treatments in cervical artery dissection. OUTCOME: Complete resolution of arterial abnormalities is achieved in around 46% of stenoses. 33% of occlusions, and 12% of dissecting aneurysms. RECURRENT EVENTS: Recurrence of cerebral ischemia and cervical artery dissection seems to be rare, although some data suggest that early ischemic and late cervical artery dissection recurrences could be underestimated. MORTALITY AND FUNCTIONAL OUTCOME: In comparison with other causes of stroke in young adults, the functional outcome of cervical artery dissection is good in contrast to its socio-professional effects, which may be unsatisfactory. The mortality rate of cervical artery dissection is low, although it may be underestimated since some patients with malignant infarction die before the diagnosis is established. CONCLUSION: Further research is warranted to improve our understanding of the underlying pathophysiology, to assess the long-term outcome, and ultimately to provide treatment and prevention strategies.

[The most frequent causes of ischemic stroke in young adults].

INTRODUCTION: Pathogenesis of ischemic stroke in young adults is heterogeneous, thus making differential diagnosis very broad. MATERIAL AND METHODS: The study comprised 60 ischemic stroke patients of both sexes aged 15-45 years who were treated at the Department of Neurology of the Clinical Centre of Vojvodina. Information about sex and age, detailed history, risk factors for ischemic stroke were obtained for all patients who underwent neurological examination as well. Diagnostic procedures applied in all patients included brain computed tomography and/or magnetic resonance imaging, routine laboratory tests, Doppler imaging of extra and endocranial blood vessels and coagulation tests. Contrast and/ or transesophageal echocardiography, immunological blood assays, magnetic resonance angiography and/or computed tomography angiography and/or conventional angiography, immunological tests, assessment of levels of natural coagulation inhibitors, toxicological examination, etc. were performed in selected patients. RESULTS: Causes of ischemic stroke were determined according to the Trial of ORG 10172 in Acute Stroke Treatment criteria. The most frequent were the so called other causes of ischemic stroke, which were found in 26.7% patients. The second most frequent cause was cardiac embolisation, found in 25%. The cause of ischemic stroke remained undetermined in 21.7% of all patients. CONCLUSION: Aetiology of ischemic stroke in young adults is diverse and demands thorough diagnostic evaluation.

A case series of 22 patients with internal carotid artery dissection.

The aim of this study was to analyze the spectrum of clinical presentations of internal carotid artery dissection. Twenty-two patients with internal carotid artery dissection, mean age 39.02, were evaluated over the past ten years. Magnetic resonance imaging and magnetic resonance angiography were used to establish the diagnosis. Facial and neck pain and Horner's syndrome were the only presenting symptoms in 4 patients (without brain infarction); facial pain, Horner's syndrome and contralateral sensorimotor deficit in 6; headache and contralateral sensorimotor deficit in 2; contralateral sensorimotor deficit with or without speech impairment in 10. Internal carotid artery dissection was triggered by a trauma in 7, whereas it was spontaneous in 15. Magnetic resonance imaging revealed infarction in 18 patients. A good outcome (modified Rankin score 0-2) was seen in 20 patients. The spectrum of clinical presentations of internal carotid artery dissection is variable. Internal carotid artery dissection is not necessarily accompanied by infarction on magnetic resonance imaging.