Transient ischemic attack without self-awareness of symptoms witnessed by bystanders: analysis of the PROMISE-TIA registry.

BACKGROUND AND PURPOSE: A transient ischemic attack (TIA) can occur without self-awareness of symptoms. We aimed to investigate characteristics of patients with a tissue-based diagnosis of TIA but having no self-awareness of their symptoms and whose symptoms were witnessed by bystanders. METHODS: We used data from the multicenter registry of 1414 patients with a clinical diagnosis of TIA. For patients without evidence of ischemic lesions on imaging, clinical characteristics were compared between patients with and without self-awareness of their TIA symptoms. RESULTS: Among 896 patients (559 men, median age of 70 years), 59 (6.6%) were unaware of their TIA symptoms, but had those symptoms witnessed by bystanders. Patients without self-awareness of symptoms were older and more frequently female, and more likely to have previous history of stroke, premorbid disability, and atrial fibrillation, but less likely to have dyslipidemia than those with self-awareness. Patients without self-awareness of symptoms arrive at hospitals earlier than those with self-awareness (P < 0.001). ABCD2 score was higher in patients without self-awareness of symptoms than those with self-awareness (median 5 vs. 4, P = 0.002). Having no self-awareness of symptoms was a significant predictor of ischemic stroke within 1 year after adjustment for sex, ABCD2 score, and onset to arrival time (hazard ratio = 2.44, 95% confidential interval: 1.10-4.83), but was not significant after further adjustment for arterial stenosis or occlusion. CONCLUSIONS: Patients with a TIA but having no self-awareness of their symptoms might have higher risk of subsequent ischemic stroke rather than those with self-awareness, suggesting urgent management is needed even if patients have no self-awareness of symptoms.

Features of cardioembolic stroke with persistent and paroxysmal atrial fibrillation - a study with the Japan Stroke Registry.

BACKGROUND AND PURPOSE: The stroke severity on admission and clinical outcomes were compared between ischaemic stroke patients with non-valvular atrial fibrillation (NVAF) of the persistent (PeAF) and paroxysmal (PAF) types. METHODS: The study comprised 9293 patients with cardioembolic stroke and NVAF who were registered in the Japanese stroke databank: 6522 had PeAF (70.2%) and 2771 had PAF (29.8%). Stroke severity on admission and the clinical outcomes on discharge were retrospectively compared between these patient groups. RESULTS: The National Institutes of Health Stroke Scale score on admission (median, interquartile range) was 10 (3-20) for PeAF patients and 7 (2-17) for PAF patients, indicating that stroke severity on admission was significantly worse in PeAF patients than PAF patients (P < 0.001). Good outcomes (modified Rankin scale score ≤2) were achieved by 45% PeAF patients and 53% PAF patients. Thus, PeAF patients had significantly poorer clinical outcomes than PAF patients (P < 0.001). In-hospital mortality was significantly higher amongst PeAF patients (11%) than PAF patients (8%) (P < 0.001). Multivariate analysis of factors contributing to clinical outcomes showed that PeAF was a contributing factor for in-hospital mortality (odds ratio 1.261; 95% confidence interval 1.011-1.652; P = 0.045). CONCLUSIONS: Amongst cardioembolic stroke patients with NVAF, those with PeAF have significantly higher stroke severity on admission than those with PAF, and PeAF is a factor contributing to in-hospital mortality. Thus, our study suggests that the type of atrial fibrillation affects stroke severity and clinical outcomes following cerebral infarction.

Usefulness of MRA-DWI mismatch in neuroendovascular therapy for acute cerebral infarction.

BACKGROUND: This study evaluated the usefulness of MR angiography (MRA)-diffusion-weighted imaging (DWI) mismatch in neuroendovascular therapy over 3 h after onset of acute cerebral infarction. METHODS: The subjects were 14 cases (age, 73 ± 8.4 years) who had an anterior circulation deficit on DWI/MRA on arrival and underwent neuroendovascular therapy over 3 h after onset. MRA-DWI mismatch (MDM) (+) was defined as 'major artery lesion (+) and diffusion-weighted image-Alberta Stroke Program Early CT Score (DWI-ASPECTS) ≥6'; MDM (-) was defined as 'major artery lesion (+) and DWI-ASPECTS <6'. RESULTS: Reperfusion was achieved in nine of 14 patients (64%) undergoing neuroendovascular therapy. Within the reperfusion group, in the five MDM (+) patients and the four MDM (-) patients, the outcome was a favorable clinical response in the MDM (+) group. The modified Rankin Scale (mRS) scores after 90 days were 0-2 in 3 (60%) and 3-6 in 2 (40%) of the MDM (+) group patients and 0-2 in 0 (0%) and 3-6 in 4 (100%) of the MDM (-) group patients. In the MDM (+) group, a good outcome was achieved. However, the number of cases was small, so this was not a significant difference. Within the non-reperfusion group, in the three MDM (+) patients and the two MDM (-) patients, the mRS scores after 90 days were 0-2 in 1 (33%) and 3-6 in 2 (67%) of the MDM (+) group patients and 0-2 in 0 (0%) and 3-6 in 2 (100%) of the MDM (-) group patients. In both groups, the outcome was poor. CONCLUSIONS: With neuroendovascular therapy, a good outcome with reperfusion was achieved in the MDM (+) group compared to the MDM (-) group. This suggests that the presence or absence of MDM may be useful in determining prognosis after reperfusion.

Functional outcome in patients with pontine infarction after acute rehabilitation.

We examined the clinical features of patients with pontine infarction in the acute stage and the factors affecting functional prognosis and outcome. Lesions, neurological manifestations at initial physical status examinations, cognitive function, swallowing function and outcome [activities of daily living (ADL), status of nutritional intake at discharge and destination after discharge] were evaluated in 68 patients (47 males and 21 females) who had pontine lesions with acute phase cerebral infarction. The mean length of stay was 24.4 days. The symptoms (number of patients) observed included paralysis (50), dysarthria (47), ataxia (18), diplopia (11), dysphagia (49) and poor cognitive performance (37). The types of lesions (number of patients) included lacunar infarcts in the ventral pontine area (15), lacunar infarcts in the dorsal pontine area (13) and large lacunar infarcts (LLIs) (41). After hospital discharge, 23 patients were discharged home, 44 were transferred to another hospital and 1 died. Twenty-three patients were on a regular diet, 22 were receiving a dysphagia diet and 22 were on enteral feeding at discharge. Patients with LLIs more frequently had poor cognitive performance, paralysis, dysphagia at discharge and a tendency for a longer length of stay compared with patients who had lacunar infarct. Most patients who returned home were those who were younger in age, had fewer neurological symptoms, had better cognitive function and ADL performance, and could ingest food. In an acute hospital, age, neurological symptoms, ADL, cognitive function, and dysphagia were considered important factors for determining the outcome in patients with pontine infarction.

Functional dissociation between Kana and Kanji: agraphia following a thalamic hemorrhage.

We report the case of a 61-year-old woman with a left thalamic hemorrhage causing agraphia of Kanji (morphograms). Single-photon emission computed tomography (SPECT) showed a decrease in the blood flow in the left thalamus from the superior temporal convolution to the parietal lobe, as well as in the frontal lobe while computed tomography showed no remarkable lesions in the cortex. The agraphia in this case may be due to the thalamic lesion itself, but the SPECT findings strongly suggest that a secondary cortical lesion may be involved in producing the higher cognitive disorder.

Newly identified pair of proteasomal subunits regulated reciprocally by interferon gamma.

Interferon (IFN) gamma induces replacements of the proteasomal subunits X and Y by LMP7 and LMP2, respectively, resulting in an alteration of the proteolytic specificity. We found a third pair of proteasome subunits expressed reciprocally in response to IFN-gamma. Molecular cloning of a cDNA encoding one subunit designated as Z, downregulated by IFN-gamma, showed that it is a novel proteasomal subunit with high homology to MECL1, which is markedly induced by IFN-gamma. Thus, IFN-gamma induces subunit replacements of not only X and Y by LMP7 and LMP2, respectively, but also of Z by MECL1, producing proteasomes responsible for immunological processing of endogenous antigens. When processed from their precursors, three pairs of the 10 homologous, but distinct, beta-type subunits of eukaryotic proteasomes, that is, X/LMP7, Y/LMP2, and Z/MECL1, have an NH2-terminal threonine residue, assumed to be part of a catalytic center. These findings suggest that the altered molecular organization of the proteasome induced by IFN-gamma may be responsible for acquisition of its functional change.

Spin structure and spin Hall magnetoresistance of epitaxial thin films of the insulating non-collinear antiferromagnet SmFeO3.

We report a combined study of imaging the antiferromagnetic (AFM) spin structure and measuring the spin Hall magnetoresistance (SMR) in epitaxial thin films of the insulating non-collinear antiferromagnet SmFeO3. X-ray magnetic linear dichroism photoemission electron microscopy measurements reveal that the AFM spins of the SmFeO3(1 1 0) align in the plane of the film. Angularly dependent magnetoresistance measurements show that SmFeO3/Ta bilayers exhibit a positive SMR, in contrast to the negative SMR expected in previously studied collinear AFMs. The SMR amplitude increases linearly with increasing external magnetic field at higher magnetic fields, suggesting that field-induced canting of the AFM spins plays an important role. In contrast, around the coercive field, no detectable SMR signal is observed, indicating that the SMR of the AFM and canting magnetization components cancel out. Below 50 K, the SMR amplitude increases sizably by a factor of two as compared to room temperature, which likely correlates with the long-range ordering of the Sm ions. Our results show that the SMR is a sensitive technique for non-equilibrium spin systems of non-collinear AFMs.

ATP-Dependent inactivation and sequestration of ornithine decarboxylase by the 26S proteasome are prerequisites for degradation.

The 26S proteasome is a eukaryotic ATP-dependent protease, but the molecular basis of its energy requirement is largely unknown. Ornithine decarboxylase (ODC) is the only known enzyme to be degraded by the 26S proteasome without ubiquitinylation. We report here that the 26S proteasome is responsible for the irreversible inactivation coupled to sequestration of ODC, a process requiring ATP and antizyme (AZ) but not proteolytic activity. Neither the 20S proteasome (catalytic core) nor PA700 (the regulatory complex) by itself contributed to this ODC inactivation. Analysis with a C-terminal mutant ODC revealed that the 26S proteasome recognizes the C-terminal degradation signal of ODC exposed by attachment of AZ, and subsequent ATP-dependent sequestration of ODC in the 26S proteasome causes irreversible inactivation, possibly unfolding, of ODC and dissociation of AZ. These processes may be linked to the translocation of ODC into the 20S proteasomal inner cavity, centralized within the 26S proteasome, for degradation.

Yeast counterparts of subunits S5a and p58 (S3) of the human 26S proteasome are encoded by two multicopy suppressors of nin1-1.

Nin1p, a component of the 26S proteasome of Saccharomyces cerevisiae, is required for activation of Cdc28p kinase at the G1-S-phase and G2-M boundaries. By exploiting the temperature-sensitive phenotype of the nin1-1 mutant, we have screened for genes encoding proteins with related functions to Nin1p and have cloned and characterized two new multicopy suppressors, SUN1 and SUN2, of the nin1-1 mutation. SUN1 can suppress a null nin1 mutation, whereas SUN2, an essential gene, does not. Sun1p is a 268-amino acid protein which shows strong similarity to MBP1 of Arabidopsis thaliana, a homologue of the S5a subunit of the human 26S proteasome. Sun1p binds ubiquitin-lysozyme conjugates as do S5a and MBP1. Sun2p (523 amino acids) was found to be homologous to the p58 subunit of the human 26S proteasome. cDNA encoding the p58 component was cloned. Furthermore, expression of a derivative of p58 from which the N-terminal 150 amino acids had been removed restored the function of a null allele of SUN2. During glycerol density gradient centrifugation, both Sun1p and Sun2p comigrated with the known proteasome components. These results, as well as other structural and functional studies, indicate that both Sun1p and Sun2p are components of the regulatory module of the yeast 26S proteasome.

Polymorphism in the promoter of lipopolysaccharide receptor CD14 and ischemic cerebrovascular disease.

BACKGROUND AND PURPOSE: A growing amount of evidence suggests that infectious and inflammatory processes may be involved in the initiation of arteriosclerosis, but the mechanisms are conceivably multifactorial and complex. Two European groups have recently demonstrated that a C(-260)-->T polymorphism in the promoter of the CD14 lipopolysaccharide receptor may be a risk factor for coronary artery disease (CAD). The T allele of this polymorphism reportedly increases the expression of CD14 and may be involved in atherogenesis. In the present study we investigated a possible association between the C(-260)-->T polymorphism in the CD14 promoter and the occurrence of symptomatic ischemic cerebrovascular disease (CVD). METHODS: Genotype frequencies of the C(-260)-->T polymorphism in the CD14 promoter were determined in 235 patients with CVD, as confirmed by brain CT and/or MRI, and 309 age- and sex-matched control subjects. RESULTS: The distribution of genotypes was as follows: CVD patients, T:/T: 24.3%, C:/T: 53.2%, and C:/C: 22. 6%; controls, T:/T: 26.9%, C:/T: 50.2%, and C:/C: 23.0%. There was no significant difference between the CD14 promoter genotypes of the CVD patients and the controls (chi(2)=0.601, P:=0.741). We also measured the concentration of serum soluble CD14 and the density of membranous CD14 on monocytes in the CVD patients, but the polymorphism was not associated with either the concentration of soluble CD14 or the density of membranous CD14 (P:=0.358, P:=0.238, respectively). CONCLUSIONS: Our results indicate that the C(-260)-->T polymorphism in the CD14 promoter is not associated with an increased risk for CVD.

Effects of a stable enkephalin analogue, (D-Met2,Pro5)-enkephalinamide, and naloxone on cortical blood flow and cerebral blood volume in experimental brain ischemia in anesthetized cats.

The effects of intracarotid injection of the stable enkephalin analogue (D-Met2,Pro5)-enkephalinamide (ENK) and intravenous administration of naloxone on the cerebrocortical blood flow (dye dilution method) and cerebral blood volume (CBV) (photoelectric method) were investigated during unilateral brain ischemia in anesthetized cats. Both parameters were measured simultaneously in the intact and ischemic (middle cerebral artery occluded) hemispheres. An intracarotid injection of ENK 0.5 mg/kg induced a significant increase in cortical vascular resistance and a -87% decrease in cerebrocortical blood flow from 25 +/- 3 to 4 +/- 3 ml/100 g/min, without CBV alteration in the ischemic hemisphere. Naloxone (1 mg/kg i.v.), on the other hand, induced a marked two-fold increase in cerebrocortical blood flow and a significant elevation of CBV from 5.9 +/- 0.5 to 7.4 +/- 0.7 vol% in the ischemic hemisphere. No change in cerebrocortical blood flow or CBV was observed in the intact hemisphere either after ENK or after naloxone administration. Arterial blood gases and hematocrit remained unchanged. On the basis of the present findings, we conclude that besides other factors, endogenous opioid mechanisms may also participate in ischemic cerebrovascular reactions and the cerebral circulatory effects of naloxone probably reflect its opiate receptor blocking property and not simply its other non-opiate-related actions.

Comparison between the photoelectric method and H2 clearance method for measuring cerebrocortical blood flow in cats.

The photoelectric method using carbon black as a nondiffusible tracer of blood was compared with the hydrogen clearance (H2) method in nine anesthetized cats. A photoelectric apparatus and H2 electrode were applied to a small region of the cerebral cortex (left ectosylvian gyrus) for simultaneous measurement of the regional CBF. The values of CBF(H2) and CBF(photoelectric) were 50.7 +/- 19.2 and 52.1 +/- 14.5 ml.100 g-1.min-1, respectively. CBF(H2) and CBF(photoelectric) were found to correlate well (r = 0.588, p less than 0.01) when changes in CBF were induced by CO2 inhalation, exsanguination, hyperventilation, and occlusion of the middle cerebral artery. The correlation between CBF(H2) and CBF(photoelectric) was much better in the case of intraindividual comparisons (r = 0.957, p less than 0.01). In addition to its merits in common with the H2 clearance method, such as handiness, low cost, and strict regionality, the photoelectric method displayed the following advantages: time-to-time measurements of CBF (less than 20 s), immediate display of the microcirculatory flow pattern, and simultaneous monitoring of cerebral blood volume. However, measurements from deep structures of the brain are better performed by the H2 method despite the disadvantage of the use of a potentially explosive gas.

Constriction/dilatation of the cerebral microvessels by intravascular endothelin-1 in cats.

The effects of intracarotidly injected endothelin (ET)-1 (0.01-3 nmol) on the local cerebral blood volume (CBV) in the parietotemporal cortex were examined by the photoelectric method in 17 anesthetized cats. CBV reflects the cumulative dimensions of the cerebral microvessels. Low doses of ET-1 (0.01 and 0.1 nmol) elicited mild but significant reductions in CBV without changes in the systemic arterial blood pressure (SABP). High doses of ET-1 (3 nmol) initially induced marked declines of CBV, which were attributable to the significant falls in SABP. CBV subsequently exhibited significant increases. The CBV increases were not secondary to the accompanying elevations of SABP, since they were unaffected by inhibition of the SABP changes after preinjection of BQ-123 (1 mg/kg), an ET antagonist specific to the ETA receptors. The CBV increases, however, were prevented by continuous administration of NG-mono-methyl-L-arginine (0.35 mg/kg/min), an inhibitor of nitric oxide synthesis, plus BQ-123. We conclude that while low doses of intravascular ET-1 constrict the cerebral microvessels, high doses of ET-1 dilate the cerebral microvessels through the induction of nitric oxide probably in the cerebrovascular endothelium.

Three-dimensional mapping of local cerebral perfusion in alcoholic encephalopathy with and without Wernicke-Korsakoff syndrome.

Seventeen severe chronic alcoholic patients with and without Wernicke-Korsakoff syndrome (WKS) were examined prospectively after being treated by withdrawal from alcohol. The WKS patients also received thiamine supplements. Three-dimensional measurements of local cerebral blood flow (LCBF) and local partition coefficients (L lambda) were made utilizing xenon contrast computed tomography (Xe CT-CBF). Results were displayed as color-coded brain maps before and after treatment and these were correlated with neurological and cognitive examinations. Before treatment chronic alcoholics without WKS (n = 10) showed diffuse reductions of LCBF values throughout all gray matter including hypothalamus, vicinity of nucleus basalis of Meynert, thalamus, and basal ganglia. Similar, but more severe, reductions were seen in patients with WKS (n = 7), however, white matter perfusion was also reduced. In WKS, most prominent reductions of LCBF were also seen in hypothalamus and basal forebrain nuclei but thalamus, basal ganglia, and limbic systems were severely reduced. After treatment, both groups with alcoholic encephalopathy showed marked clinical improvement and cerebral perfusion was restored toward normal. Chronic alcohol abuse, in the absence of thiamine deficiency, reduces CBF by direct neurotoxic effects. If thiamine deficiency is also present, more severe and localized hemodynamic reductions are superimposed.

Abstinence improves cerebral perfusion and brain volume in alcoholic neurotoxicity without Wernicke-Korsakoff syndrome.

Twenty severe chronic alcoholic patients with signs of neurotoxicity but without Wernicke-Korsakoff syndrome were treated by abstinence from alcohol and examined prospectively at intervals thereafter. Serial examinations included detailed medical histories, neurological examinations, cognitive capacity screening examinations, computed tomography scans with measurements of sulcal and ventricular volume, and measurements of regional CBF. All sedatives were withdrawn before CBF measurements were made. Before treatment, gray matter blood flow values were significantly reduced compared with those of age-matched normal volunteers, but white matter blood flow values were normal and the ventricles were enlarged. After abstinence from alcohol, mean gray matter blood flow values and brain volume both increased significantly.

Cerebral atrophy and hypoperfusion improve during treatment of Wernicke-Korsakoff syndrome.

Nineteen patients with sudden onset of impaired recent memory, cerebellar ataxia, peripheral neuropathy, and other signs of Wernicke-Korsakoff syndrome (WKS) were treated and examined prospectively for 3 months. Serial studies included histories, neurological examinations, cognitive capacity screening examinations (CCSE), computed tomography (CT) scans, and measurements of regional CBF. Patients were detoxified and withdrawn from sedatives before CBF measurements were examined. Treatment included alcohol withdrawal, nutritious diet, and 300 mg thiamine daily. Before treatment CCSE scores and blood flow values of both white and gray matter were reduced, particularly within both temporoparietal regions. After treatment of compliant patients (n = 10), white and gray matter blood flow increased concurrently with improved CCSE scores. Abnormal eye signs, ataxia, peripheral neuropathy, and performance of activities of daily living also improved. Cerebral atrophy and ventricular enlargement measured by CT decreased. Early recognition and treatment of WKS in compliant patients permit rapid reversals of cognitive and neurological impairments associated with increased blood flow of gray and white matter and improvements of brain atrophy measured by CT scanning.

Nob1p, a new essential protein, associates with the 26S proteasome of growing saccharomyces cerevisiae cells.

Nob1p, which interacts with Nin1p/Rpn12, a subunit of the 19S regulatory particle (RP) of the yeast 26S proteasome, has been identified by two-hybrid screening. NOB1 was found to be an essential gene, encoding a protein of 459 amino acid residues. Nob1p was detected in growing cells but not in cells in the stationary phase. During the transition to the stationary phase, Nob1p was degraded, at least in part, by the 26S proteasome. Nob1p was found only in proteasomal fractions in a glycerol gradient centrifugation profile and immuno-coprecipitated with Rpt1, which is an ATPase component of the yeast proteasomes. These results suggest that association of Nob1p with the proteasomes is essential for the function of the proteasomes in growing cells.

cDNA cloning and functional analysis of p44.5 and p55, two regulatory subunits of the 26S proteasome.

We have employed cDNA cloning to deduce the complete primary structures of p44.5 and p55, two subunits of PA700, a 700-kDa multisubunit regulatory complex of the human 26S proteasome. These polypeptides consist of 422 and 456 amino acids with calculated molecular masses of 47463 and 52903, and isoelectric points of 6.06 and 7.56, respectively. Computer-assisted homology analysis revealed high sequence similarities of p44.5 and p55 with yeast proteins whose functions are yet unknown. Disruption of the yeast genes, termed NAS4 and NAS5 (non-ATPase subunits 4 and 5), resulted in lethality, indicating that each of the two subunits is essential for proliferation of yeast cells.

Improved method for preparation of ubiquitin-ligated lysozyme as substrate of ATP-dependent proteolysis.

A simple method was developed for preparation of proteins conjugated with ubiquitin. Heat-denatured 125I-labeled lysozyme was highly ubiquitinated by incubation at pH 9.0 with a ubiquitin-protein ligase system consisting of E1, E2 and E3 that had been partially purified from rabbit reticulocytes by affinity chromatography with ubiquitin as a ligand. The resulting conjugates were separated from free lysozyme and other proteins by successive chromatographies on anion and cation ion-exchange resins. The ubiquitinated 125I-lysozymes recovered in the fraction not adsorbed to either resin served as an efficient substrate for ATP-dependent proteolysis in a reticulocyte lysate or with a purified 26 S protease complex. By the present method, 125I-lysozyme-Ub conjugates can be prepared in 3 h with a high yield of 15-20%.