Relationship between plasma (D)-dimer level and cerebral infarction volume in patients with nonvalvular atrial fibrillation.

BACKGROUND: Plasma D-dimer level may reflect the activity of thrombus formation in the left atrium of patients with nonvalvular atrial fibrillation (NVAF). Proper anticoagulation with warfarin dramatically decreases the rate of cerebral embolism, reduces stroke severity and subsequent risk of death, as well as the level of D-dimer in NVAF patients. However, the predictive value of D-dimer level on cerebral embolism severity has not been examined. Thus, the purpose of this study was to investigate the association between plasma D-dimer level at admission and infarct size in NVAF patients. METHODS: We identified 124 patients with consecutive ischemic stroke and NVAF who were admitted within 48 h of symptom onset. We measured infarction volume from CT taken after 3 ± 1 days from the onset. Plasma D-dimer levels were measured at the time of admission. Relationships were analyzed between infarction volume and plasma D-dimer levels, cardiovascular risk factors, preadmission medications and admission conditions. We also assessed the influence of D-dimer level on functional outcome in patients with preadmission modified Rankin Scale (mRS) score of 0-1 and patients by tertile of D-dimer level (≤0.83, 0.83-2.16 and ≥2.16 µg/ml). RESULTS: Infarction volume significantly correlated with D-dimer level (r = 0.309, p < 0.001), systolic blood pressure (r = 0.201, p = 0.026), diastolic blood pressure (r = 0.283, p = 0.002), National Institutes of Health Stroke Scale (NIHSS) score on admission (r = 0.546, p < 0.001) and mRS score at discharge (r = 0.557, p < 0.001). Multivariate regression analyses showed that the D-dimer level was significantly associated with infarction volume after adjusting for age, sex, current smoker or not, prothrombin time-international normalized ratio ≥1.6, diastolic blood pressure, CHADS(2) score and NIHSS score on admission. In patients with a preadmission mRS score of 0-1 (n = 108), D-dimer level was significantly associated with NIHSS score at admission (r = 0.318, p < 0.001) and mRS score at discharge (r = 0.310, p = 0.001). Patients in the highest D-dimer tertile group showed worse outcome than those in the middle (p = 0.041) and lowest (p < 0.001) tertiles. CONCLUSIONS: Plasma D-dimer level on admission is significantly related to infarction volume and functional outcome, following cardioembolic stroke in NVAF patients.

Computer-assisted analysis of heterogeneity on B-mode imaging predicts instability of asymptomatic carotid plaque.

BACKGROUND: Computerized assessment of plaque echogenicity by B-mode ultrasonography has demonstrated that the gray-scale median (GSM) pixel intensity of the entire plaque predicts future ischemic stroke in patients with symptomatic carotid stenosis, but not those with asymptomatic stenosis. This study investigated whether plaque heterogeneity (i.e., the distribution of pixel intensities) could predict the instability of asymptomatic plaque. METHODS: By comparison with carotid endarterectomy specimens and the GSM values of known tissues on B-mode images, the GSM values for blood, lipid, muscle/fibrous tissue, and calcification were determined. Then we estimated the percent area of each tissue component for 297 asymptomatic plaques causing 40-99% carotid artery stenosis in 250 patients, and monitored the incidence of atherothrombotic cerebral infarction due to carotid stenosis during follow-up. RESULTS: Eight infarcts occurred during a follow-up period of 22 +/- 15 months. Plaques in the top tertile for the percent area of lipid-like echogenicity (p < 0.05) and in the lowest tertile for calcification (p = 0.06) showed an association with future infarction according to Kaplan-Meier analysis. This association remained significant after adjustment for the severity of carotid stenosis (hazard ratio 4.4 for lipid-like and 0.24 for calcification-like component, both p < 0.05) according to Cox proportional hazards analysis. CONCLUSIONS: The distribution of pixel intensities in carotid plaque on B-mode ultrasonography can be employed to predict instability of asymptomatic plaque and possibly to select patients for interventional procedures. A large-scale investigation will be needed to confirm that estimating the percentage of plaque components relative to the total plaque area can predict ischemic stroke.

Carotid intima-media thickness and risk of cardiovascular events in high-risk patients. Results of the Osaka Follow-Up Study for Carotid Atherosclerosis 2 (OSACA2 Study).

BACKGROUND AND PURPOSE: There is epidemiological evidence that increased carotid intima-media thickness (IMT) is a predictor of cardiovascular disease (CVD) events. However, the significance of carotid IMT in high-risk patients in whom risk factors are managed clinically has not been adequately investigated. The purpose of this study was to determine the usefulness of carotid IMT measurement in such patients. METHODS: The study comprised 900 outpatients with cardiovascular risk factors or established atherosclerosis. Carotid IMT was calculated as the mean bilateral IMT of the common carotid artery, bifurcation, and internal carotid artery. Baseline vascular risk factors, medications, and history of CVD were recorded at the time of enrollment. The incidence of CVD events was determined prospectively. RESULTS: During a mean follow-up period of 2.6 years, there were 64 CVD events. The relative risk (RR) of a CVD event increased with increased IMT. Association between CVD events and carotid IMT was significant after adjustment for risk factors and history of CVD, showing an increased risk per IMT tertile from the middle tertile (RR, 2.5; 95% confidence interval [CI]: 1.0-6.3) to the highest (RR, 3.6; 95% CI: 1.4-9.0). When patients with a history of CVD were excluded (n = 574), the predictive value of IMT was significant even after adjustment for risk factors (hazard ratio per 1 SD IMT increase was 1.57 [95% CI: 1.11-2.20]). CONCLUSIONS: Carotid IMT is an independent predictor of vascular events in high-risk patients in whom risk factors are managed clinically.

C-reactive protein predicts carotid atherosclerosis progression in mild to moderate risk and middle-aged patients.

PURPOSE: The Framingham risk score is a popular tool for estimating cardiovascular risk, but there is debate about the value of C-reactive protein. This study investigated the utility of C-reactive protein to predict the progression of atherosclerosis in relation to the Framingham risk score and age. METHODS: This observational study enrolled 164 outpatients (mean age: 61 yr; range: 40 - 75 yr) receiving treatment for classical cardiovascular risk factors. They underwent serial ultrasonographic evaluation of their carotid arteries for 36 +/- 10 months. A carotid intima-media thickness > or = 1.1 mm was defined as plaque, and the number of plaques and plaque score (sum of all plaque thicknesses) were determined. Serum C-reactive protein concentrations and classical risk factors, including body mass index, were measured. RESULTS: C-reactive protein was related to annual changes in the number of plaques and the plaque score (r=0.26 and 0.28; P<0.01 and P<0.001, respectively), as well as the 10-year risk of cardiovascular disease estimated from the Framingham risk score (r=0.335, P<0.001). C-reactive protein was correlated with the annual changes of plaque number and plaque score (beta=0.21 and 0.23; P<0.05 and P<0.01) after adjusting for 10-year cardiovascular and other risk factors, especially in 64 patients comprising the 8-13% 10-year risk group (beta=0.33 for plaque score, P<0.05). CRP also showed a relationship with the progression of carotid atherosclerosis in 71 patients aged < or = 61 yr (beta=0.33 for plaque score, P<0.01). CONCLUSIONS: C-reactive protein can predict the progression of early carotid atherosclerosis in patients with mild to moderate cardiovascular risk and/or middle-aged patients.

Emphysematous cystitis with severe hemorrhagic anemia resulting from diabetes mellitus type 2.

A 48-year-old woman suffering from hematuria was admitted to our hospital due to conscious disturbance. She had lower abdominal phantom tumor, anemia, renal dysfunction, hyperglycemia, metabolic acidosis and electrolyte abnormalities. Because of pelvocaliceal dilatation noted on abdominal ultrasonography, we first diagnosed her as having postrenal failure. With massive blood clots and gas emission from her urethra upon attempting cystoscopy, the remarkable expansion of the urinary bladder and a three-layered structure of gas, urine and complex of blood and debris inside her urinary bladder noted on abdominal CT scan, as well as the increased white blood cell count, we finally concluded our diagnosis as emphysematous cystitis.

Relationship between C-reactive protein and progression of early carotid atherosclerosis in hypertensive subjects.

BACKGROUND AND PURPOSE: Hypertensive outpatients were investigated for C-reactive protein (CRP) and carotid atherosclerosis because the influence of CRP on the progression of subclinical atherosclerosis in hypertensives remains unclear. METHODS: A total of 124 outpatients (aged 40 to 79 years) in treatment for hypertension were enrolled. They underwent repeated ultrasonographic evaluation of the carotid arteries for 35+/-12 months. Focal intima-media thickening of > or =1.1 mm was defined as plaque, and the plaque number, plaque score, and the sum of all plaque thickness were calculated. RESULTS: Multivariate linear regression analysis revealed that CRP, pulse pressure, and systolic blood pressure were related to the annual change of plaque number (beta=0.34, 0.27, and 0.30; all P<0.01) and plaque score (beta=0.38, 0.27, and 0.23; P<0.001, P<0.01, and P<0.05, respectively) independently of other risk factors. In 64 patients taking antihypertensive medications with a blood pressure of <140/90 mm Hg, CRP and the pulse pressure were related to the annual change of plaque number (r=0.40 and 0.26; P<0.01 and P<0.05, respectively) and plaque score (r=0.44 and 0.31; P<0.001 and P<0.05, respectively). CONCLUSIONS: In hypertensive patients being managed by drug therapy or lifestyle modification, CRP is an equivalent or superior independent predictor of the progression of carotid atherosclerosis than the pulse pressure or systolic blood pressure.

Ipsilateral hemiplegia in a lateral medullary infarct--Opalski's syndrome.

A 42-year-old man was admitted complaining of the sudden onset of headache, vomiting, vertigo, and gait disturbance. The authors found hemiparesis of his right limbs, right Homer's syndrome, and decreased pain and temperature sensation of his right face and left limbs. Diffusion-weighted imaging (DWI) showed an acute small infarct located on the right side of the lateral lower medulla. This is the first report of Opalski's syndrome with lower medullary infarction detected by DWI.