Stroke in the very elderly: characteristics and outcome in patients aged ≥85 years with a first-ever ischemic stroke.

BACKGROUND: Epidemiological and clinical features of very elderly patients with stroke are still uncertain. Our aim was to study the patient characteristics and outcomes in the very elderly (aged ≥85 years) with a first-ever ischemic stroke in the National Acute Stroke Israeli Survey (NASIS) registry. METHODS: The NASIS registry is a nationwide prospective hospital-based study performed triennially (2004, 2007, 2010). Patients with ischemic stroke aged ≥85 years were compared with those 65-84 years old regarding their baseline characteristics, stroke severity, etiology of stroke and stroke outcomes. Logistic regression analyses were used to adjust for potential confounders. Stroke severity was determined according to the National Institute of Health Stroke Scale (NIHSS) score. RESULTS: The proportion of very elderly (≥85 years) patients among the NASIS population increased from 18.3% in 2004 to 19.9% in 2007 and 24.5% in 2010 (p for trend = 0.005). The percentage of women was higher in patients aged ≥85 years (p < 0.0001). Atrial fibrillation, congestive heart disease and prior disability were significantly more common, while diabetes, current smoking and dyslipidemia were less frequent in the very elderly. The very elderly presented with more severe strokes: 36.3% of the ≥85-year-old patients had an NIHSS score ≥11 compared with 22.0% in the younger age group (p < 0.05). CONCLUSIONS: There is an increasing proportion of very elderly subjects, mostly women, among first-ever ischemic stroke patients. Current information on age-specific aspects of stroke in the very elderly is crucial to set up successful prevention pathways and implementing well-organized stroke care for this population.

Vasomotor reactivity as a predictor for syncope in patients with orthostatism.

OBJECTIVES: Syncope in patients with orthostatic hypotension (OH) may be the result of impaired cerebral autoregulation. Cerebral autoregulation status can be determined by assessing cerebral vasomotor reactivity (VMR). We assessed and compared VMR in patients with OH with and without syncope. MATERIAL AND METHODS: Twenty-nine patients with OH underwent transcranial Doppler (TCD) and the Diamox test (1 g acetazolamide IV) for assessing VMR during elaboration of their OH syndrome. The percent difference between cerebral blood flow velocities (BFV) in the middle cerebral (MCA) and vertebral (VA) arteries before and after acetazolamide was defined as VMR%. We considered increases of BFV of ≥ 40% as being indicative of good VMR and classified our study patients as having good or impaired VMRs accordingly. RESULTS: Mean VMR% values of the MCA and VA in patients with OH with syncope (n = 12) were significantly lower as compared with patients with OH without syncope (n = 17): 25.2 ± 20.5% and 42.5 ± 18.6%; 20.9 ± 15.5% and 40.8 ± 28.5%, respectively (P < 0.05). CONCLUSIONS: Among patients with OH, we found an association between the presence of syncope and impaired VMR. Assessment of VMR among patients with OH may predict those who are at higher risk to faint and fall and to support more aggressive intervention.

Characteristics of first ever ischemic stroke in the very elderly: profile of vascular risk factors and clinical outcome.

PURPOSE: Age is the most significant non-modifiable risk factor for ischemic stroke (IS). With increasing expectancy of life, the majority of IS patients will be elderly subjects. We studied the epidemiological, clinical and rehabilitation features of patients aged ≥85 years with first-ever IS. METHODS: Demographic data, prevalence of risk factors, etiology of stroke, severity of neurological deficit, major complications and mortality rates were collected from a hospital-based stroke registry and compared between patients at the age of 65-84 and ≥85. Clinical assessment was performed by means of the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS). RESULTS: Among 216 patients aged ≥85 years there was significantly higher proportion of a history of atrial fibrillation than in 128 patients at the age of 65-84 years and lower prevalence of hypertension, diabetes mellitus, hyperlipidemia and smoking. Large artery atherosclerosis was more frequently identified in the older patients (49% vs. 32%, p=0.002). Although NIHSS scores on admission were lower in the older patients they were more disabled at discharge. CONCLUSIONS: With respect to the patients aged <85 years very old IS patients showed different vascular risk factors profile, clinical and rehabilitation course. These findings suggest specializing stroke care in the very elderly.

Long-term follow-up of patients with asymptomatic occlusion of the internal carotid artery with good and impaired cerebral vasomotor reactivity.

BACKGROUND: Cerebral hemodynamic status might be prognostic for either the symptomatic or asymptomatic course of carotid occlusive disease. It is determined by evaluating cerebral vasomotor reactivity (VMR). We assessed VMR in asymptomatic patients with total occlusion of the internal carotid artery (ICA) and followed them to evaluate the role of impaired VMR in predicting ischaemic stroke (IS). METHODS: Thirty-five patients (21 men, mean age ± SD 68 ± 7.5 years) with unilateral asymptomatic ICA occlusion were studied by transcranial Doppler and the Diamox test (intravenous 1.0 g acetazolamide) and followed for 48 months or until reaching the end-points of IS, transient ischaemic attack, or vascular death. VMR% was evaluated by recording the percent differences in peak systolic blood flow velocities in each middle cerebral artery at baseline and after Diamox administration. RESULTS: Based on VMR% calculations, 14 (40%) patients had good VMRs and 21 (60%) had impaired VMRs. The global annual risk of ipsilateral ischaemic events was 5.7%. The annual ipsilateral ischaemic event risk was 1.8% in patients with good VMRs, whilst it was 7.1% in patients with impaired VMRs. An impaired VMR was significantly correlated with ipsilateral IS (Kaplan-Meier log rank statistic, P = 0.04). CONCLUSIONS: Our results support the value of VMR assessment for identifying asymptomatic patients with carotid occlusion who belong to a high-risk subgroup for IS. New trials using extracranial-to-intracranial bypass surgery in patients with asymptomatic ICA occlusion and impaired VMRs are warranted.

Transcranial Doppler for evaluation of idiopathic intracranial hypertension.

OBJECTIVES: The value of transcranial Doppler (TCD) ultrasonography in assessing patients with Idiopathic Intracranial Hypertension (IIH) is uncertain. We sought to determine the contribution of TCD to their evaluation. MATERIALS AND METHODS: Twenty-three patients with suspected IIH underwent TCD. Mean blood flow (BFV), peak systolic (PSV) and end-diastolic (EDV) velocities, and pulsatility (PI) and resistance (RI) indexes were obtained in the middle cerebral (MCA) and vertebral (VA) arteries and compared (Student's t-test) between patients with confirmed IIH and controls. IIH patients and controls were comparable in terms of age, gender and weight. RESULTS: The mean +/- SD BFV(MCA), PSV(MCA), EDV(MCA) and PI(VA) in the 13 IIH patients were higher than in the ten controls (59 +/- 6.8, 94 +/- 28.5, 43 +/- 12.4, 0.86 +/- 0.16 and 50 +/- 8.6, 72 +/- 25.8, 32 +/- 11.5, 0.58 +/- 0.45 respectively, P < 0.05) but still within normal values. The mean +/- SD PI(MCA), RI(MCA) and RI(VA) values in the IIH patients and controls were similar. CONCLUSIONS: TCD parameters had no useful unique features for monitoring IIH patients.

Cerebral vasomotor reactivity of bilateral severe carotid stenosis: is stroke unavoidable?

We evaluated the cerebral hemodynamic features of severe bilateral carotid stenosis by assessing and comparing cerebral vasomotor reactivity (VMR) in the middle cerebral (MCA) and vertebral arteries (VA) by transcranial Doppler and the Diamox (1 g acetazolamide i.v.) test. VMR was evaluated by recording the percentage differences in peak systolic blood flow velocity in each MCA and VA at baseline and by the Diamox test. Twenty-eight symptomatic (SCAS) and 31 asymptomatic (ACAS) patients with bilateral severe (>70%) internal carotid artery stenosis were studied. The mean MCA VMR% was 29 +/- 26.9% in SCAS and 43.2 +/- 26.8% in ACAS patients (P < 0.01). Their respective mean VA VMR% was 30.2 +/- 36.5% and 39.6 +/- 24.4% (P = NS). VMR% of the symptomatic MCA side in SCAS patients was significantly lower than the opposite side (20.5 +/- 31.1% and 39.2 +/- 37.9% respectively; P < 0.03). In contrast, the VA VMR% of both sides in SCAS patients remained similar (28.1 +/- 39.3% and 34.6 +/- 47.9% respectively; P = NS). VMR% of the MCA and VA in ACAS patients was also similar for both sides of bilateral carotid stenosis. The cerebral hemodynamic features differ between SCAS and ACAS patients with bilateral carotid occlusive disease in the anterior part of the circle of Willis. An independent cerebral vascular reserve capacity of the posterior circulation is proposed.

Cerebral vasomotor reactivity of the posterior circulation in patients with carotid occlusive disease.

We evaluated the hemodynamic features of the posterior circulation in patients with severe carotid stenosis by assessing and comparing cerebral vasomotor reactivity (VMR) in the middle cerebral (MCA) and vertebral arteries (VA) by transcranial Doppler and the Diamox (1 g acetazolamide i.v.) test. Sixty symptomatic and 111 asymptomatic patients with unilateral severe (>70%) internal carotid artery stenosis were studied. The VMR was 19.2 +/- 18.9% for the MCA ipsilateral to the stenosis and 27.3 +/- 17.4% on the contralateral side (P < 0.0001) for all patients. It was 18.2 +/- 23.2% for the VA ipsilateral to the stenosis and 19.7 +/- 21% on the contralateral side (P = NS). The symptomatic patients' VMR of the MCA on the side of stenosis and the opposite side were 19.2 +/- 17.6 and 29 +/- 17.2%, respectively (P < 0.03). The VMR of the VA remained similar (15.1 +/- 21 and 21.6 +/- 6%, respectively, P = NS). The asymptomatic patients' VMR of the MCA on the side of the stenosis was also lower (19.2 +/- 19.7 vs. 26.5 +/- 17.5% on the opposite side, P < 0.001). In contrast, the VMR in the VA was similar (19.8 +/- 21.4 and 18.7 +/- 19.5%, respectively, P < 0.6, NS). Thus, the VMR of the posterior circulation remained similar regardless of carotid stenosis and a symptomatic/asymptomatic course of carotid occlusive disease, suggesting an independent cerebral vascular reserve capacity of the posterior circulation.

Stroke in hospitalized patients: are there special risk factors?

BACKGROUND AND PURPOSE: The occurrence of stroke in patients hospitalized for various illnesses remains a particular challenge for neurologists. Determining the potential causes for these particular cerebrovascular events may help to define the population at risk and to take measures in order to prevent stroke during hospitalization. The aim of our study was to evaluate the potential risk factors associated with stroke, which occurred in patients hospitalized for other illnesses. METHODS: This retrospective case-control study based on data of patients who underwent an ischemic stroke while being hospitalized not because of stroke and a control group of patients admitted during the same period who were matched for age and sex to the study patients. Common vascular risk factors, e.g. fever, leukocytosis, blood pressure, hemoglobin, cardiac arrhythmia and dehydration, were compared between the study and control groups. RESULTS: Of 2,247 consecutive patients with ischemic stroke, the stroke had occurred during hospitalization not related to any surgical procedure in 80 (3.5%). Six parameters were found as being significant independent risk factors for in-hospital stroke: fever and leukocytosis during hospitalization, elevated diastolic and unstable blood pressure, dehydration and past history of myocardial infarction. CONCLUSION: Careful monitoring of temperature, blood count, blood pressure, and clinical and laboratory signs of dehydration is needed to prevent in-hospital stroke.

TCD and the Diamox test for testing vasomotor reactivity: clinical significance.

Transcranial Doppler sonography has become widely used in assessing cerebral vasomotor reactivity which provides information regarding cerebral autoregulation and collateral circulation. Cerebral vasomotor reactivity is defined as a shift between cerebral blood flow or cerebral blood velocity before and after administration of a potent vasodilatory stimulus test. Three such tests are currently used for this purpose: the apnea test, CO2 inhalation and the Diamox test (i.v. acetazolamide), all of which are based on the dilatatory response of cerebral blood flow to hypercapnia. Certain advantages of the Diamox test were described, but each of the three tests has its strong and weak points, and this will be the topic under discussion. There are several practical applications of the combined TCD and the vasodilatory tests in assessing of cerebral vasomotor reactivity: 1. To evaluate the intracranial hemodynamic status in patients with carotid occlusive disease with the intent of predicting the occurrence of ischemic brain events. 2. To compare intracranial hemodynamics before and after carotid endarterectomy. 3. To compare autoregulation and collateral circulation in the different parts of the circle of Willis. 4. To predict dementia after stroke. In summary, the potential clinical usefulness of combined TCD and provocative vasodilatory tests has been clearly shown. Further large scale studies are needed in order to augment the applications of cerebral vasomotor reactivity assessment in the clinical setting.

Are there any unique epidemiological and vascular risk factors for ischaemic strokes that occur in the morning hours?

It is now accepted that the incidence of ischaemic stroke is significantly increased in the morning. Any attempts to prevent its occurrence must be based on determining the mechanisms, special risk factors and appropriate protective measures needed during this vulnerable period. We studied the epidemiological features of morning stroke and reviewed the records of 2312 consecutive patients recorded prospectively in the Tel Aviv Stroke Register. Information about time of stroke onset was obtained from the patient, family members or other observers. The study parameters of age, sex, vascular distribution (carotid versus vertebrobasilar), ischaemic heart disease, myocardial infarction, diabetes mellitus, arterial hypertension, smoking, hyperlipidaemia, stroke severity and recurrence were compared between patients with morning stroke and those with stroke occurring at other times. In 599 patients (34%) stroke occurred between 06:00 and 10:00 h. No evaluated parameter was found to be statistically different among the morning stroke patients compared with stroke occurring at other times (P < 0.2). Patients with arterial hypertension and ischaemic heart disease and male patients had a greater likelihood of stroke occurrence between 22:00 and 02:00 h (P < 0.05). Our data suggest that none of the common vascular risk factors could explain the morning peak of stroke occurrence. The next step in the quest for understanding the phenomenon of circadian variation is to identify other physiological factors and the effects of pharmacological agents in morning stroke protection.

Vasomotor reactivity in the ophthalmic artery: different from or similar to intracerebral vessels?

OBJECTIVE: In order to evaluate hemodynamic features of ophthalmic arteries in patients with severe carotid artery stenosis, we assessed and compared vasomotor reactivity in the middle cerebral and ophthalmic arteries. METHODS: Sixty-five patients (25 symptomatic, 40 asymptomatic) with severe (70-99%) internal carotid artery stenosis were studied using transcranial Doppler and the Diamox test. RESULTS: Vasomotor reactivity was found to be similar in the middle cerebral and ophthalmic arteries on the side of severe carotid stenosis in both symptomatic and asymptomatic patients. In contrast, the vasomotor reactivity of the ophthalmic arteries was significantly different from that of the middle cerebral arteries on the side of the normal or the non-significantly stenotic side of the internal carotid artery. CONCLUSIONS: These data suggest a specific autoregulative response of the ophthalmic artery compared to that of the middle cerebral artery and may shed light on the role of the ophthalmic artery in oculovascular hemodynamics.

Stroke during sleep: epidemiological and clinical features.

Stroke during sleep is an unexplored area of vascular neurology and its pathogenesis; clinical significance and prevention still remain uncertain. The aim of our study was to determine the epidemiological and clinical patterns of ischemic stroke occurring during sleep. Consecutive patients (n = 1822) with acute ischemic stroke recorded in the Tel Aviv Stroke Register were studied. Stroke during sleep was determined whenever focal neurological deficit was verified to have occurred while the patient had been asleep. The comparisons between patients with stroke during sleep and while awake were performed using the t test with Bonferroni correction and the chi(2) test for age, sex, vascular risk factors (i.e. ischemic heart disease, myocardial infarction, atrial fibrillation, arterial hypertension, hyperlipidemia, diabetes mellitus, peripheral vascular disease, smoking), vascular distribution (carotid versus vertebrobasilar) and severity of stroke (mild, moderate or severe). Data regarding the onset of stroke (during sleep or while awake) were available for 1,671 patients. A minority of strokes occurred during sleep (n = 311, 18.6%), and stroke during sleep was severer (chi(2) = 11.9, p < 0.002). No significant differences were found in terms of age, sex and vascular distribution between the two groups. None of the vascular risk factors was found to be more frequent in stroke during sleep. Strokes occurring during sleep were found to be severer than those with onset while awake. However, no specific clinical patterns of risk factor profiles could be identified in these patients. Hemodynamic factors may play an important role in the occurrence of stroke during sleep, and this issue should be further investigated.

Is impaired cerebral vasomotor reactivity a predictive factor of stroke in asymptomatic patients?

BACKGROUND AND PURPOSE: Identification of the subgroup of asymptomatic patients with severe internal carotid artery stenosis and high risk of stroke has important clinical implications. Cerebral vasomotor reactivity provides information regarding intracranial hemodynamic features and might have a prognostic value in predicting cerebrovascular ischemic events, especially in patients with carotid stenosis. The aim of our study was to assess the cerebral vasomotor reactivity in asymptomatic patients with carotid stenosis and evaluate its role in stroke occurrence. METHODS: Cerebral vasomotor reactivity was assessed using transcranial Doppler ultrasonology and the Diamox test (intravenous administration of 1.0 g acetazolamide) in 44 asymptomatic patients with severe (> 70%) internal carotid artery stenosis. Patients were followed up prospectively (mean, 2 years). RESULTS: Cerebral vasomotor reactivity was estimated as good (> 40% increase of blood flow velocity in the middle cerebral artery ipsilateral to the carotid stenosis after undergoing the Diamox test) in 23 patients; it was impaired in the other 21. During the follow-up period, the overall annual rate for ipsilateral stokes was 2.3%; it was 7.9% for all ischemic cerebral events. No strokes or transient ischemic attacks occurred in the former group, but there were 7 cerebral ischemic events (2 strokes [1 fatal] and 5 transient ischemic attacks) in the latter group. There was a statistically significant correlation between cerebral ischemic events and impaired cerebral vasomotor reactivity (P = .009). CONCLUSIONS: The data of this preliminary study suggest an important role of impaired cerebral vasomotor reactivity in predicting ischemic cerebral events. Preventive vascular surgery might be considered in this high-risk subgroup of asymptomatic patients with severe carotid stenosis.

The Tel Aviv Stroke Registry. 3600 consecutive patients.

BACKGROUND AND PURPOSE: We undertook to estimate the frequency of various risk factors and the type and severity of stroke in different ethnic groups documented in a large hospital-based stroke registry. Tel Aviv is a metropolis with about 400000 inhabitants and about 600000 daily visitors and workers. The Tel Aviv Medical Center (TAMC) is the only tertiary medical care facility to which all patients with acute stroke are referred. Israel is a country with a heterogeneous population, of which a significant proportion was born abroad. The people differ in their genetic background, as well as in their early environmental conditions, lifelong diet, and other habits. This variety has proved to be a fertile ground for the study of different neurological diseases, including stroke. METHODS: A prospective hospital-based registry using systematic computer coding of data of all consecutive stroke patients admitted to the TAMC has been conducted since May 1988. Different aspects of the amassed data were analyzed statistically. RESULTS: From May 1988 until April 1994, 3600 stroke patients were admitted to the TAMC. The mean age was 73.2 years, and 58.2% were males. Cerebral infarctions were diagnosed in 80.9%, primary intracerebral hemorrhages in 8.0%, and transient ischemic attacks in 11.1%. There were 861 patients (24%) who were admitted with recurrent strokes. Past medical history of hypertension was the major risk factor (occurring in 52.2% of the patients), followed by ischemic heart disease (29.7%), diabetes mellitus (25.2%), smoking (17.0%), atrial fibrillation (14.3%), and hyperlipidemia (8.4%). Ischemic heart disease and atrial fibrillation were more frequent in patients from Europe and America (Ashkenazi group), whereas diabetes mellitus and smoking were more prominent in the other groups. The in-hospital mortality rate was 13.8% and was similar in both ethnic groups. CONCLUSIONS: This registry allows the study of the risk factors, natural history, and clinical manifestations of stroke in different ethnic groups.

Do silent brain infarctions predict the development of dementia after first ischemic stroke?

BACKGROUND AND PURPOSE: Silent brain infarctions (SBI) are common findings in advanced age, but their relationship to dementia is still uncertain. The present study was designed to evaluate whether SBI predict the development of dementia after first clinical ischemic stroke. METHODS: We blindly studied admission CT scans of 175 consecutive nondemented patients presenting with ischemic stroke that clinically was their first stroke episode. SBI were defined as CT evidence of infarcts not compatible with the acute event. The patients were subsequently followed for their mental state for 5 years. Survival analysis, wherein onset of dementia was the end point, was performed on the total sample population and conducted separately on those with and without SBI at admission. RESULTS: Dementia developed in 56 patients (32%), including 22 of the 63 (35%) with SBI and 34 of the 112 (30%) without SBI. Thus, dementia was not related to SBI. CONCLUSIONS: Our data indicate that SBI do not predict the development of dementia after stroke.

EEG as predictor of dementia following first ischemic stroke.

INTRODUCTION: Predictive factors for occurrence of vascular dementia may help identify patients at increased risk of developing this condition. Our purpose was to evaluate the prognostic value of early EEG findings in patients after first ischemic cerebral stroke on the development of dementia. MATERIAL AND METHODS: We performed routine EEG recordings in 199 consecutive non-demented patients with first-ever ischemic stroke, within 48 h of the event. The patients were subsequently followed for their mental state for 2 years. Survival analysis, wherein onset of dementia was the end-point, was performed on the total sample population and conducted separately on those who had normal EEG at time of the event and on those who had abnormal EEG findings (focal or diffuse slowing). RESULTS: Patients with abnormal EEG at baseline had 2.6 times the risk of developing dementia than those who had normal EEG; this odds ratio was statistical significant (CL: 1.3-5.1, p = 0.003). Development of dementia was not related to any specific EEG abnormal pattern. CONCLUSIONS: Abnormal EEG performed close to the first ischemic stroke appears to be an indicator of subsequent cognitive decline, probably because it indicates cortical involvement by the stroke or an underlying indolent cerebral degeneration.