Long-term effects of neck irradiation on cardiovascular autonomic function: a study in nasopharyngeal carcinoma patients after radiotherapy.

INTRODUCTION: Baroreflex failure has been reported as a late sequalum of neck radiotherapy. In this study we investigated cardiovascular autonomic function in patients after neck radiotherapy to determine predictive factors associated with outcome. METHODS: Eighty-nine patients with nasopharyngeal carcinoma were evaluated ≥6 months after radiotherapy for cardiovascular autonomic function and compared with 48 control subjects. Inflammatory markers and carotid intima-media thickness were also assessed. RESULTS: Autonomic parameters of heart rate response to deep breathing and Valsalva ratio were significantly lower in the patient group. Cardiovascular autonomic impairment was generally mild with relative sparing of the efferent cardiovagal pathway. By univariate and multivariate analyses, the time after radiotherapy and C-reactive protein level were significantly associated with the degree of cardiovascular autonomic dysfunction. CONCLUSIONS: Radiation-induced cardiovascular autonomic impairment is a dynamic and progressive process that occurs long after radiotherapy. Chronic inflammation plays a major role in this process.

The effect of decreasing statin's dosage on LDL-C levels after target levels achieved.

OBJECTIVE: Evidences from clinical trials had demonstrated that statins reduce the risk of cardio-cerebral vascular events. But lipid lowering therapy (LLT) was suboptimal in stroke patients and clinically, observation of reducing the dosage of statins is common when target low density lipoprotein cholesterol (LDL-C) level achieved. We aim to explore the changes in lipid profile after reducing statin's dosage when target LDL-C level achieved. METHODS: One hundred and three consecutive stroke patients follow up at out-patient clinic (44 women, 59 men) were recruited. Twenty two patients had their statin's dosage decreased to half while eighty one patients had their initial statin's dosage maintained after target LDL-C (less than 100mg/dL) level achieved. Lipid profile before and after LLT adjustment were compared. RESULTS: The follow-up LDL-C level was significant higher while the percentage of patients with LDL-C level less than 100 mg/dL was significant lower in patients with statin's dosage decreased. For all patients, regardless the adjustment of LLT, the percentage of patients with LDL-C level less than 100 mg/dL was significant lower in follow- up lipid profile comparing with the baseline, but only the follow-up total cholesterol and LDL-C level were significant higher in the patients group with reduced statin's dosage. No significant change was found in follow-up high density-lipoprotein cholesterol and triglyceride level in either group. CONCLUSION: More patients had LDL-C level more than 100 mg/dL after dosage of statins decreased. We suggested that only for absolute contraindication or adverse effects of statins should we adjust LLT, it is better to maintain the dosage of statins after target level achieved. The impact of lipid profile changed after LLT adjustment on clinical outcomes needs further studied.

Effects of long-term antiepileptic drug monotherapy on vascular risk factors and atherosclerosis.

PURPOSE: Long-term therapy with antiepileptic drugs (AEDs) has been associated with metabolic consequences that lead to an increase in risk of atherosclerosis in patients with epilepsy. We compared the long-term effects of monotherapy using different categories of AEDs on markers of vascular risk and the atherosclerotic process. METHODS: One hundred sixty adult patients who were receiving AED monotherapy, including two enzyme-inducers (carbamazepine, CBZ; and phenytoin, PHT), an enzyme-inhibitor (valproic acid, VPA), and a noninducer (lamotrigine, LTG) for more than 2 years, and 60 controls were enrolled in this study. All study participants received measurement of common carotid artery (CCA) intima media thickness (IMT) by B-mode ultrasonography to assess the extent of atherosclerosis. Other measurements included body mass index, and serum lipid profile or levels of total homocysteine (tHcy), folate, uric acid, fasting blood sugar, high sensitivity C-reactive protein (hs-CRP), or thiobarbituric acid reactive substances (TBARS). KEY FINDINGS: Long-term monotherapy with older-generation AEDs, including CBZ, PHT, and VPA, caused significantly increased CCA IMT in patients with epilepsy. After adjustment for the confounding effects of age and gender, the CCA IMT was found to be positively correlated with the duration of AED therapy. Patients with epilepsy who were taking enzyme-inducing AED monotherapy (CBZ, PHT) manifested disturbances of cholesterol, tHcy or folate metabolism, and elevation of the inflammation marker, hs-CRP. On the other hand, patients on enzyme-inhibiting AED monotherapy (VPA) exhibited an increase in the levels of uric acid and tHcy, and elevation of the oxidative marker, TBARS. However, no significant alterations in the markers of vascular risk or CCA IMT were observed in patients who received long-term LTG monotherapy. SIGNIFICANCE: Patients with epilepsy who were receiving long-term monotherapy with CBZ, PHT, or VPA exhibited altered circulatory markers of vascular risk that may contribute to the acceleration of the atherosclerotic process, which is significantly associated the duration of AED monotherapy. This information offers a guide for the choice of drug in patients with epilepsy who require long-term AED therapy, particularly in aged and high-risk individuals.

Radiotherapy Is Associated with an Accelerated Risk of Carotid Atherosclerosis in Patients with Nasopharyngeal Carcinoma: A Nine-Year Prospective Follow-Up Study.

Radiation-related extracranial vasculopathy is a common late effect after radiation in patients with nasopharyngeal carcinoma (NPC). We proposed the hypothesis that radiation-related extracranial vasculopathy is a progressive process that can begin immediately after radiotherapy and persist for a longer period, and inflammation and oxidative stress may play a pivotal role in this process. Thirty-six newly diagnosed NPC patients were assessed with B-mode ultrasound for the common carotid artery (CCA) intima media thickness (IMT) measurement as well as surrogate markers at three different stages (baseline, immediately after concurrent chemoradiation therapy (CCRT), and 9 years after enrollment). A healthy control group was also recruited for comparison. Surrogate markers including a lipid profile, HbA1c, inflammation, oxidative stress, and platelet activation markers were assessed. The mean CCA IMT in the NPC group were increased immediately after CCRT (p = 0.043). The mean CCA IMT value after a 9-year follow-up also showed a significant increase in NPC and control group, respectively (p < 0.0001 and p < 0.0001, paired t test). The annual increase mean CCA IMT (mm) was 0.053 ± 0.025 and 0.014 ± 0.013 in NPC and control group, respectively (p < 0.0001). The baseline high sensitivity CRP (hs-CRP), thiol, TBARS, and CD63 level were significantly higher in the NPC group (hs-CRP, p = 0.001, thiol, p < 0.0001, TBARS, p = 0.05, and CD63 level, p = 0.04). The thiol and TBARS levels were significantly lower in NPC patients immediately after CCRT (thiol, p < 0.0001, and TBARS, p = 0.043). The CD62P level was significantly higher while the thiol level was significantly lower in the NPC group after a 9-year follow-up (CD62P level, p = 0.007; and thiol level, p = 0.004). Radiation-related extracranial vasculopathy is a progressive process that begins immediately after radiotherapy with significantly increased carotid IMT compared to the control group during the 9-year follow-up. Chronic inflammation and oxidative stress might serve to drive the process and also contribute to increased platelet activation.

Acute/subacute cerebral infarction (ASCI) in HIV-negative adults with cryptococcal meningoencephalitis (CM): a MRI-based follow-up study and a clinical comparison to HIV-negative CM adults without ASCI.

BACKGROUND: Acute/subacute cerebral infarction (ASCI) in HIV-negative cryptococcal meningoencephalitis (CM) adults has rarely been examined by a series of MRI-based follow-up study. We studied a series of MRI follow-up study of CM adults and compared the clinical characters of those with ASCI and those without ASCI. METHODS: The clinical characteristics and a series of brain MRI findings of seven CM adults with ASCI were enrolled for analysis. The clinical characteristics of another 30 HIV-negative CM adults who did not have ASCI were also included for a comparative analysis. RESULTS: The seven HIV-negative CM adults with ASCI were four men and three women, aged 46-78 years. Lacunar infarction was the type of ASCI, and 86% (6/7) of the ACSI were multiple infarctions distributed in both the anterior and posterior cerebrovascular territories. The seven CM patients with ASCI were significantly older and had a higher rate of DM and previous stroke than the other 30 CM adults without ASCI. They also had a higher incidence of consciousness disturbance at presentation and had a poor prognosis. CONCLUSION: ASCI was found in 18.9% (7/37) of HIV-negative CM adults. Serial MRI follow-up studies may allow a better delineation of ASCI in this specific group of infectious disease and multiple lacunar infarctions was the most common type. Older in age and presence of DM and previous stroke were the significant underlying conditions. CM patients with ASCI also had a poor therapeutic outcome.

Effect of erythropoietin on level of circulating endothelial progenitor cells and outcome in patients after acute ischemic stroke.

INTRODUCTION: Erythropoietin (EPO) enhances the circulating level of endothelial progenitor cells (EPCs), which has been reported to be associated with prognostic outcome in ischemic stroke (IS) patients. The aim of this study was to evaluate the time course of circulating EPC level and the impact of EPO therapy on EPC level and clinical outcome in patients after acute IS. METHODS: In total, 167 patients were prospectively randomized to receive either EPO therapy (group 1) (5,000 IU each time, subcutaneously) at 48 h and 72 h after acute IS, or serve as placebo (group 2). The circulating level of EPCs (double-stained markers: CD31/CD34 (E1), CD62E/CD34 (E2) and KDR/CD34 (E3)) was determined using flow cytometry at 48 h and on days 7 and 21 after IS. EPC level was also evaluated once in 60 healthy volunteers. RESULTS: Circulating EPC (E1 to E3) level at 48 h after IS was remarkably higher in patients than in control subjects (P < 0.02). At 48 h and on Day 7 after IS, EPC (E1 to E3) level did not differ between groups 1 and 2 (all P > 0.1). However, by Day 21, EPC (E1 to E3) level was significantly higher in group 1 than in group 2 (all P < 0.03). Additionally, 90-day recurrent stroke rate was notably lower in group 1 compared with group 2 (P = 0.022). Multivariate analysis demonstrated that EPO therapy (95% confidence interval (CI), 0.153 to 0.730; P = 0.006) and EPC (E3) (95% CI, 0.341 to 0.997; P = 0.049) levels were significantly and independently predictive of a reduced 90-day major adverse neurological event (MANE) (defined as recurrent stroke, National Institutes of Health Stroke scale ≥8, or death). CONCLUSIONS: EPO therapy significantly improved circulating EPC level and 90-day MANE. TRIAL REGISTRATION NUMBER: ISRCTN: ISRCTN96340690.

Impact of estimated-weight-base dose of alteplase in acute stroke treatment on clinical outcome.

Dosing of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke treatment is often based on estimated body weight (BW) worldwide in routine clinical practice due to infeasible of accurate BW measurement. The aim of our study is to explore the impact of estimated BW when dosing rt-PA in acute ischemic stroke treatment on clinical outcome. Between January 2013 to May 2018, 126 acute ischemic stroke patients received intravenous rt-PA treatment based on estimated BW dosage were recruited. All patients had actual BW measured in ward after treatment. Based on the dosage of rt-PA given, patients were categorized into three groups, standard dose (0.8-1.0 mg/kg), overdose (>1.0 mg/kg), and underdose (<0.8 mg/kg). Among all 126 patients, 101 (80.2%) patients were treated with standard dose, 12 (9.5%) patients with overdose, and 13 (10.3%) patients with underdose of rt-PA respectively. There was no significant difference between demographic characteristics, pre-morbid risk factors, National Institutes of Health Stroke Scale (NIHSS) score at 24 h, NIHSS score at discharge, modified Rankin scale (mRS) within 0 to 2 in discharge or in 3 months after the event within the three groups. There was also no significant difference in hemorrhagic transformation and symptomatic intracranial hemorrhage (SICH). In conclusion, calculation of the dose of rt-PA based upon the estimated BW to treat acute ischemic stroke patients had no negative impact on the clinical outcome in our study.

Autonomic Dysfunction Contributes to Impairment of Cerebral Autoregulation in Patients with Epilepsy.

Patients with epilepsy frequently experience autonomic dysfunction and impaired cerebral autoregulation. The present study investigates autonomic function and cerebral autoregulation in patients with epilepsy to determine whether these factors contribute to impaired autoregulation. A total of 81 patients with epilepsy and 45 healthy controls were evaluated, assessing their sudomotor, cardiovagal, and adrenergic functions using a battery of autonomic nervous system (ANS) function tests, including the deep breathing, Valsalva maneuver, head-up tilting, and Q-sweat tests. Cerebral autoregulation was measured by transcranial Doppler examination during the breath-holding test, the Valsalva maneuver, and the head-up tilting test. Autonomic functions were impaired during the interictal period in patients with epilepsy compared to healthy controls. The three indices of cerebral autoregulation-the breath-holding index (BHI), an autoregulation index calculated in phase II of the Valsalva maneuver (ASI), and cerebrovascular resistance measured in the second minute during the head-up tilting test (CVR2-min)-all decreased in patients with epilepsy. ANS dysfunction correlated significantly with impairment of cerebral autoregulation (measured by BHI, ASI, and CVR2-min), suggesting that the increased autonomic dysfunction in patients with epilepsy may augment the dysregulation of cerebral blood flow. Long-term epilepsy, a high frequency of seizures, and refractory epilepsy, particularly temporal lobe epilepsy, may contribute to advanced autonomic dysfunction and impaired cerebral autoregulation. These results have implications for therapeutic interventions that aim to correct central autonomic dysfunction and impairment of cerebral autoregulation, particularly in patients at high risk for sudden, unexplained death in epilepsy.

Comparison of carotid artery stenting performance between cardiologists and neuroradiologists: one medical center's experience.

PURPOSE: To report the experience of carotid artery angioplasty with stenting (CAS) by cardiologists (CV) and neuroradiologists (NR) in an area with less incidence of extracranial artery stenosis. METHODS: From 1999 to 2008, 210 patients with 231 stents were collected by claim records from the administrative office and reviewed by one independent neurologist. Outcome measures were peri-procedural adverse events (AE), restenosis and recurrent ipsilateral stroke (RS) rate, categorized into treatment groups by either CV or NR. RESULTS: The average age was 69.0 years and 82.9 % of the patients were men. 63.8% of the patients with 62.8% stents were treated by CV and the remaining 36.2% of patients with 37.2% stents were done by NR. Symptomatic CAS was evident in 70.1% of the CV cases and 83.0% in NR treated patients (P = 0.017). The peri-procedural AE rate was 31.6%; 35.9% in CV group and 24.4% in the NR group (P = 0.071). RS rate was 4.8% in 663.3 days; 4.1% in 920.8 days in the CV group and 5.8% in 354.2 days in the NR group (P = 0.865). The restenosis rate was 10.9% in 630.5 days; 5.4% in the CV group in 224.8 days and 20.6% in the NR group in 817.8 days (P = 0.007). CONCLUSIONS: The restenosis and recurrent stroke rates after carotid artery stenting in Taiwan appears to be consistent with other published and well organized trials. Measures to minimize peri-procedural AR rates are definitely warranted.

Association of carotid intima-media thickness with the risk of sudden sensorineural hearing loss.

Cardiovascular factors are associated with the pathophysiological features and risk of sudden sensorineural hearing loss (SSNHL). However, little is known about the link between carotid intima-media thickness (IMT), SSNHL risk, and their respective treatment outcomes. In this study, we retrospectively reviewed 47 SSNHL cases and 33 control subjects from a single medical center and compared their demographic data and clinical characteristics, including their carotid IMT and audiological data. Of the 80 enrolled subjects, the proportion of those with high carotid IMT was greater in the SSNHL group (53.2%) than in the control group (21.2%), with an odds ratio (OR) of 4.22 (95% confidence interval (CI) [1.53-11.61], P = 0.004). Notably, high carotid IMT was more common in female SSNHL patients than females in the control group (54.2% vs. 12.5%; OR, 8.27 (95% CI [1.53-44.62]), P = 0.008), particularly in female patients ≥50 years of age (75% vs. 25%; OR, 9.0 (95% CI [1.27-63.9]), P = 0.032). The multivariate regression analyses showed the association between high carotid IMT and SSNHL with an adjusted OR of 4.655 (95% CI [1.348-16.076], P = 0.015), particularly in female SSNHL patients (adjusted OR, 9.818 (95% CI [1.064-90.587], P = 0.044). The carotid IMT was not associated with the treatment outcomes of SSNHL. Our results indicate that early-stage atherosclerosis may be associated with SSNHL, particularly in female patients more than 50 years old.

Long-term antiepileptic drug therapy contributes to the acceleration of atherosclerosis.

PURPOSE: Long-term antiepileptic drug (AED) therapy has been associated with an increase in risk of atherosclerosis. At issue is whether this risk is related to the duration of AED therapy. We evaluated the hypothesis that the cumulative effect of long-term exposure to AEDs plays a pivotal role in the pathogenesis of atherosclerosis in patients with epilepsy. METHODS: One hundred ninety-five patients under long-term AED therapy and 195 healthy age- and sex-matched control subjects received measurement of intima media thickness (IMT) at the far wall of the common carotid artery (CCA) by B-mode ultrasonography to assess the extent of atherosclerosis. Other measurements included body mass index (BMI) and blood lipid profile or homocysteine, folic acid, uric acid, fasting blood sugar, high sensitivity C-reactive protein (hs-CRP), thiobarbituric acid reactive substances (TBARS), and total reduced thiols. RESULTS: CCA IMT was significantly increased in patients with epilepsy, with male subjects exhibiting thicker IMT than their female counterparts. Whereas BMI, homocysteine, hs-CRP, and TBARS were significantly elevated, folic acid and thiols were significantly reduced in patients with epilepsy. Multiple linear regression analysis further revealed that duration of AED therapy, age, gender, and TBARS level (index for oxidative stress) were independently associated with CCA IMT. In addition, the log-transformed CCA IMT increased linearly with duration of AED therapy after adjustments for age, gender, and TBARS level. DISCUSSION: The duration of AED therapy is significantly associated with the acceleration of atherosclerosis in patients with epilepsy, alongside independent contributions of age, gender, and oxidative stress to the atherosclerotic process.

Control of modifiable risk factors in ischemic stroke outpatients by pharmacist intervention: an equal allocation stratified randomized study.

OBJECTIVE: To evaluate the adequacy of management of modifiable risk factors (MRF) in a group of ischemic stroke outpatients and the value of pharmacist intervention in a randomized controlled study in a tertiary referral hospital. METHODS: 160 ischemic stroke outpatients from the same catchment area and with the same financial arrangements for healthcare, went through a 6-month equal allocation stratified randomized study. Routine practice was not altered except for a monthly 1-hour pharmacist-intervention education programme. We evaluated the differences in blood pressure (BP), blood glucose and lipid profiles before and after study. The proportion of patients with adequate management of MRF was studied. RESULTS: There were no differences in the demographic characteristics, MRF and medications prescribed throughout the study. Before the study, the proportions of adequate control of BP in the control and intervention groups were 43% vs. 40% (P = 0.64), lipid 27% vs. 13% (P = 0.09) and glucose 36% vs. 21% (P = 0.15) . At the end of the study, the corresponding proportions were for BP 43% vs. 83% (P = 0.00), lipid 27% vs. 40% (P = 0.16) and glucose 46% vs. 35% (P = 0.40). CONCLUSION: Pharmacist intervention was associated with improved BP control but not with the other MRF. Earlier initiation and longer duration of intervention may improve the outcome further, and whether targeting of high-risk subjects may be particularly rewarding is worthy of investigation.

Detection of microembolic signals using power M-mode Doppler sonography in acute stroke patients with intracranial artery stenosis.

PURPOSE: Microembolic signals (MES) can be detected in a variety of clinical situations using conventional transcranial Doppler (TCD) sonography. We studied the prevalence of positive MESs in acute stroke patients with intracranial artery stenosis using power M-mode Doppler (PMD) sonography and also tested the feasibility of this new technique. METHOD: Thirty-three consecutive acute ischemic stroke or transient ischemic attack patients with intracranial large artery occlusive disease were enrolled. PMD/TCD monitoring for 30 minutes was used for MES detection downstream of the stenotic artery within 1 week after stroke onset. Clinical risk factors in emboli-positive and emboli-negative patients were assessed. RESULTS: MESs were detected in 21% (7/33) of patients. No significant differences were found in clinical risk factors between emboli-positive and emboli-negative patients. CONCLUSION: PMD sonography to detect MESs in acute stroke patients is feasible and may be used in future clinical trials regarding MES detection.

Pulsatile tinnitus in a case of traumatic temporal extradural arteriovenous fistula: carotid duplex sonography findings before and after embolization.

Carotid duplex sonography (CDS) is regarded as a screening tool for lateral dural arteriovenous fistulae (AVF). However, data on evaluating long-term effects of endovascular treatment are limited. We report the CDS findings in the feeding arteries of a traumatic temporal extradural AVF before and after transarterial embolization. Volume flow of the left common carotid artery was greater than the right (433 ml/minute versus 294 ml/minute right) and the resistance index of the left external carotid artery was lower than the right (0.69 left versus 0.84 right). Both parameters returned to normal 4 months after embolization, thus confirming successful endovascular treatment.

Serum Levels of Brain-Derived Neurotrophic Factor and Insulin-Like Growth Factor 1 Are Associated With Autonomic Dysfunction and Impaired Cerebral Autoregulation in Patients With Epilepsy.

Background: Brain-derived neurotrophic factor (BDNF) and insulin-like growth factor 1 (IGF-1) may regulate the autonomic nervous system (ANS) in epilepsy. The present study investigated the role of IGF-1 and BDNF in the regulation of autonomic functions and cerebral autoregulation in patients with epilepsy. Methods: A total of 57 patients with focal epilepsy and 35 healthy controls were evaluated and their sudomotor, cardiovagal, and adrenergic functions were assessed using a battery of ANS function tests, including the deep breathing, Valsalva maneuver, head-up tilting, and Q-sweat tests. Cerebral autoregulation was measured by transcranial doppler during the breath-holding test and the Valsalva maneuver. Interictal serum levels of BDNF and IGF-1 were measured with enzyme-linked immunosorbent assay kits. Results: During interictal period, reduced serum levels of BDNF and IGF-1, impaired autonomic functions, and decreased cerebral autoregulation were noted in patients with epilepsy compared with healthy controls. Reduced serum levels of BDNF correlated with age, adrenergic and sudomotor function, overall autonomic dysfunction, and the autoregulation index calculated in Phase II of the Valsalva maneuver, and showed associations with focal to bilateral tonic-clonic seizures. Reduced serum levels of IGF-1 were found to correlate with age and cardiovagal function, a parameter of cerebral autoregulation (the breath-hold index). Patients with a longer history of epilepsy, higher seizure frequency, and temporal lobe epilepsy had lower serum levels of IGF-1. Conclusions: Long-term epilepsy and severe epilepsy, particularly temporal lobe epilepsy, may perturb BDNF and IGF-1 signaling in the central autonomic system, contributing to the autonomic dysfunction and impaired cerebral autoregulation observed in patients with focal epilepsy.

Lipid management in ischemic stroke patients.

OBJECTIVES: In-hospital initiation and maintaining of lipid-lowering therapy (LLT) after discharge is recommended for dyslipidemic stroke patients. However, little is known about actual adherence to treatment in Taiwan. This study aims to describe the current practice of lipid testing and LLT and to identify predictors for patient to receive LLT. METHODS: Between February 2001 and December 2002, a total of 1105 consecutive ischemic stroke patients were prospectively registered. Dyslipidemic ischemic stroke patients were recruited and followed over a 6 months period. RESULTS: In-hospital lipid testing was performed in 91% of all patients and LLT was initiated in 74% (350/476) of dyslipidemic patients. During the 6 months follow-up period, lipid testing was performed in 77% (266/345) and LLT was maintained in 45% (154/345) of patients. However, the target LDL cholesterol level (<100mg/dL) was achieved in only 30% (78/255) of patients. Older patients had a lower chance to receive LLT. CONCLUSIONS: The in-hospital initiation of LLT and lipid testing was considered adequate as compared to other studies. However, after discharge from the hospital, many patients, especially older patients remained untreated. Efforts to close treatment gaps in lipid management require sustained quality improvement efforts. More awareness in this area is needed.

Venturi mask adjuvant oxygen therapy in severe acute ischemic stroke.

BACKGROUND: The effect of oxygen therapy in acute ischemic stroke remains undetermined. OBJECTIVE: To investigate the feasibility of eubaric hyperoxia therapy by Venturi mask (VM) in a group of patients who experienced a severe acute ischemic stroke. DESIGN: Patients experiencing a first-ever large middle cerebral artery infarction were recruited within 48 hours after stroke. Patients were subdivided to undergo therapy with a VM with a fraction of inspired oxygen of 40% or with a nasal cannula. A large middle cerebral artery infarction was defined as a large low-attenuation area of more than one third of the middle cerebral artery territory on brain images. Stroke severity was evaluated by the National Institutes of Health Stroke Scale. RESULTS: Seventeen patients were enrolled in the VM group and 29 in the nasal cannula group. All the demographic and clinical characteristics were equally distributed initially. The mean initial National Institutes of Health Stroke Scale score was 20.5 and 18.9 in the VM and nasal cannula groups, respectively. Atrial fibrillation was found in 11 (65%) patients in the VM and 17 (59%) patients in the nasal cannula groups. The VM therapy was initiated within 13.7 (range, 3.0-41.5) hours after stroke and the duration was 132.9 (range, 48.0-168.5) hours. In-hospital mortality was 1 (6%) in the VM group and 7 (24%) in the nasal cannula group (P=.12). In the VM group, there were fewer incidences of fever (4 [24%] vs 15 [52%]; P=.06), pneumonia (1 [6%] vs 6 [21%]; P=.18), and respiratory failure (3 [18%] vs 8 [28%]; P=.45), but a higher incidence of bedsores (3 [18%] vs 2 [7%]; P=.29). CONCLUSIONS: By using VM therapy with a fraction of inspired oxygen of 40%, there might be less mortality and comorbidities in treated patients who experienced a severe acute ischemic stroke. Further randomized confirmatory studies should explore the decreased mortality in patients who experience a severe acute ischemic stroke, especially in those with a large middle cerebral artery infarction who undergo VM therapy with a fraction of inspired oxygen of 40%.

Screening for high-grade carotid stenosis using a portable ultrasonography instrument.

BACKGROUND AND PURPOSE: We investigated the diagnostic performance of a brief Power Doppler Imaging (PDI) screening examination for carotid artery stenoses using a newly developed portable instrument. METHODS: A highly experienced sonographer screened in total 152 carotid arteries by either continuous wave (cw) Doppler (n= 50) or a lightweight (2.4 kg) portable duplex device (n= 102) in a prospective study of 76 high-risk patients. The screening protocols included either spectrum analysis and frequency shift measurement in both internal carotid arteries with cw-Doppler or determination of area and diameter ratios in transverse and longitudinal views of both carotid arteries in B-mode and with PDI, but without velocity measurement. Both protocols were evaluated against a complete routine duplex ultrasonography examination. RESULTS: According to the complete examination, stenoses were <50% in 73 of 102 (71.6%), 50-75% in 19 of 102 (18.6%), 75-95% in 7 of 102 (6.9%), and occluded in 3 of 102 (2.9%) arteries (PDI cohort), and <50% in 39 of 50 (78%), 50-75% in 8 of 50 (16%), 75-95% in 2 of 50 (4%), and occluded in 1 of 50 (2%) artery (cw-Doppler cohort). Mean screening time was 8.8 +/- 2.5 minute (PDI) and 9.4 +/- 2.6 minute (cw-Doppler). For stenoses >75%, A(z) values (area under the receiver operating characteristics curve) were 0.897 for area ratios, 0.843 for diameter ratios (PDI protocol) and 1.0 for the cw-Doppler protocol. CONCLUSIONS: The diagnostic performance of the cw-Doppler protocol was superior to the PDI protocol. Nevertheless, both protocols appear suitable as inexpensive screening strategies to identify subjects with >75% stenosis measured by carotid Doppler ultrasound. However, these preliminary data need further verification.

Predicting 3-month mortality among patients hospitalized for first-ever acute ischemic stroke.

BACKGROUND: The clinical course of patients with acute ischemic stroke tends to be unstable. Understanding the factors contributing to the progression of stroke is important for the appropriate management of patients. This study investigated the factors related to 3-month mortality at admission in patients with first-ever acute ischemic stroke. METHODS: Patients with first-ever acute ischemic stroke consecutively admitted to a medical center in Taiwan within 48 hours after stroke onset were prospectively followed-up for 3 months. All deaths during this 3-month post-stroke period were analyzed. We evaluated only those characteristics that could be assessed at admission. Multivariate logistic regression analysis was used to identify the main predictors of 3-month stroke-related mortality. RESULTS: In the 360 enrolled patients, the inhospital mortality rate was 7.8% (28 deaths), and the 3-month mortality rate was 9.7% (35 deaths). Twenty-seven deaths (77%) were stroke-related. Risk factors for mortality at 3 months included sex (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.08-9.41; p=0.036), National Institutes of Health Stroke Scale (NIHSS) at admission (per unit increase: OR, 1.17; 95% CI, 1.12-1.22; p<0.001), history of cardiac disease (OR, 2.73; 95% CI, 1.04-7.16; p=0.042), and posterior circulation stroke (OR, 5.25; 95% CI, 1.92-14.36; p=0.001). CONCLUSION: This study of hospital-based data on patients with first-ever acute ischemic stroke in Taiwan found that initial NIHSS, posterior circulation stroke and history of cardiac disease were risk factors for 3-month mortality.

Multiple intracranial arterial stenoses in association with thyrotoxicosis: a case report.

A 26-year-old young man, had Graves' disease in hyperthyroid state, presented with frequent episodic transient left hemiparesis and mild slurred speech lasting for few minutes to 2 hours for one month. Infarction at posterior limb of right internal capsule was found on brain MRI. Angiography revealed multiple intracranial arteries stenoses around the circle of Willis. After treatment with propylthiouracil and aspirin, his thyroid function returned to normal and the patient remained free from stroke.