PAIS 2 (Paracetamol [Acetaminophen] in Stroke 2): Results of a Randomized, Double-Blind Placebo-Controlled Clinical Trial.

BACKGROUND AND PURPOSE: Subfebrile body temperature and fever in the first days after stroke are strongly associated with unfavorable outcome. A subgroup analysis of a previous trial suggested that early treatment with paracetamol may improve functional outcome in patients with acute stroke and a body temperature of ≥36.5°C. In the present trial, we aimed to confirm this finding. METHODS: PAIS 2 (Paracetamol [Acetaminophen] in Stroke 2) was a multicenter, randomized, double-blind, placebo-controlled clinical trial. We aimed to include 1500 patients with acute ischemic stroke or intracerebral hemorrhage within 12 hours of symptom onset. Patients were treated with paracetamol in a daily dose of 6 g or matching placebo for 3 consecutive days. The primary outcome was functional outcome at 3 months, assessed with the modified Rankin Scale and analyzed with multivariable ordinal logistic regression. Because of slow recruitment and lack of funding, the study was stopped prematurely. RESULTS: Between December 2011 and October 2015, we included 256 patients, of whom 136 (53%) were allocated to paracetamol. In this small sample, paracetamol had no effect on functional outcome (adjusted common odds ratio, 1.15; 95% confidence interval, 0.74-1.79). There was no difference in the number of serious adverse events (paracetamol n=35 [26%] versus placebo n=28 [24%]). CONCLUSIONS: Treatment with high-dose paracetamol seemed to be safe. The effect of high-dose paracetamol on functional outcome remains uncertain. Therefore, a large trial of early treatment with high-dose paracetamol is still needed. CLINICAL TRIAL REGISTRATION: URL: http://www.trialregister.nl. Unique identifier: NTR2365.

Quality of Life after Young Ischemic Stroke of Mild Severity Is Mainly Influenced by Psychological Factors.

BACKGROUND: Long-term prognosis in terms of quality of life (QoL) in young stroke patients is of importance because they usually have a long life expectancy and extensive daily life demands. We aimed at determining which medical and psychological factors influence the QoL in young stroke patients (<50 years), after long-term follow-up. METHODS: Young ischemic stroke patients admitted to the St. Elisabeth Hospital and the TweeSteden Hospital, Tilburg, the Netherlands, between 2000 and 2010 were included. One hundred seventy patients and 61 controls filled out the following questionnaires: (1) the Hospital Anxiety and Depression Scale, (2) the Fatigue Assessment Scale, and (3) the shortened World Health Organization Quality of Life scale. Using linear multiple regression analysis, we assessed the factors influencing QoL. RESULTS: QoL did not differ significantly between patients (median modified Rankin Scale score at follow-up, 0) and controls after a mean follow-up of 4.5 (standard deviation, 2.8) years. The presence of excessive fatigue was associated with lower scores on all domains of the QoL (P ≤ .003), but not for general health domain (P = .010). Similarly, depression was associated with worse QoL on the physical (P = .004) and psychological (P = .001) domains and anxiety with lower scores on the psychological (P < .001) QoL domain. No relationship was found between stroke-specific factors and QoL. CONCLUSIONS: Fatigue and to a lesser extent depression and anxiety affect the QoL in young adults after ischemic stroke of mild severity. Therefore, young stroke patients should be informed about, screened, and, if possible, treated for fatigue, depression, and anxiety.

Long-term cognitive outcome of ischaemic stroke in young adults.

BACKGROUND: Long-term prognosis in terms of cognition in young stroke patients is very important because these patients usually still have a long life expectancy and rather extensive daily life demands. However, little is known on cognitive deficits in these patients. We aimed to evaluate cognitive function in young stroke patients (<50 years) after long-term follow-up. METHODS: Young adults with first-ever ischaemic stroke admitted to St. Elisabeth Hospital or the TweeSteden Hospital, Tilburg, the Netherlands, between January 2000 and December 2010 were included. Patients with severe aphasia or pre-existent cognitive impairment were excluded. Cognitive functioning was assessed using a neuropsychological examination focussing on the following cognitive domains: visual perception, visual and verbal memory, mental speed, and executive functioning. Raw scores were compared to the scores of 61 controls using a multivariate analysis of variance with adjustment for education level. RESULTS: The 96 participants (median age at index event 43.0 years; 45.8% male) performed worse than controls on the Stroop Color-Word Test Part 1 (p < 0.001) and on the Symbol-Digit Substitution Task (p < 0.001), both assessing mental speed. Patients had significantly lower scores on the learning slope of the Word Pair test (p = 0.002) assessing verbal memory. Patients performed better on the Rey-Osterrieth Complex Figure than controls (p < 0.001). CONCLUSIONS: In young patients with ischaemic stroke, mental slowness is present even up to 10 years after stroke. When counselling these patients, doctors should actively try to assess the presence of cognitive deficits, also after a long period of follow-up.

[A male patient with acute, reversible blindness]. / Een man met acute, reversibele blindheid.

BACKGROUND: Intra-arterial thrombectomy (IAT) in occlusions of the posterior cerebral artery (PCA) is uncommon and not a proven therapeutic solution, but can be performed in individual cases. CASE DESCRIPTION: An 80 year old man visited the emergency room after experiencing acute blindness. This was caused by a new hemianopia for the left visual field due to an occlusion of the right PCA, on top of a pre-existing hemianopia for the right visual field. Auxiliary testing showed an old ischemic stroke of the right occipital lobe, and a new occlusion of the right PCA. After deliberation with the patient, it was decided to perform IAT, because of the debilitating effect of the current neurological disabilities. IAT was succesfull and the patient completely recovered to the pre-existing level of functioning. CONCLUSION: Although there is no indisputable evidence to suggest that IAT in occlusions of the PCA is safe and effective, this case illustrates that IAT can be considered on an individual basis. Based on individual patient characteristics and shared decision making, IAT can be performed after carefull consideration of the risks and benefits.

A pilot study of rivastigmine in the treatment of delirium after stroke: a safe alternative.

BACKGROUND: Delirium is a common disorder in the early phase of stroke. Given the presumed cholinergic deficiency in delirium, we tested treatment with the acetylcholinesterase inhibitor rivastigmine. METHODS: This pilot study was performed within an epidemiological study. In 527 consecutive stroke patients presence of delirium was assessed during the first week with the confusion assessment method. Severity was scored with the delirium rating scale (DRS). Sixty-two patients developed a delirium in the acute phase of stroke. Only patients with a severe and persistent delirium (defined as a DRS of 12 or more for more than 24 hours) were enrolled in the present study. In total 26 fulfilled these criteria of whom 17 were treated with orally administered rivastigmine with a total dose between 3 and 12 mg a day. Eight patients could not be treated because of dysphagia and one because of early discharge. RESULTS: No major side effects were recorded. In 16 patients there was a considerable decrease in severity of delirium. The mean DRS declined from 14.8 on day one to 8.5 after therapy and 5.6 after tapering. The mean duration of delirium was 6.7 days (range; 2-17). CONCLUSION: Rivastigmine is safe in stroke patients with delirium even after rapid titration. In the majority of patients the delirium improved after treatment. A randomized controlled trial is needed to establish the usefulness of rivastigmine in delirium after stroke. TRIAL REGISTRATION: Nederlands Trial Register NTR1395.

[A man with vision problems after coronary angiography]. / Een man met visusklachten na coronairangiografie.

A 71-year-old man underwent a coronary angiography (CAG). Afterwards he experienced vision loss. Neurologic examination revealed bilateral cortical blindness. A cerebral CT-scan showed occipital hyperdensity, due to contrast accumulation and oedema. There was complete recovery of vision within 2 days. Transient cortical blindness after CAG is a rare complication of iodinated contrast agents.

A double dissociation between somatosensory processing for perception and action.

Human neuropsychology suggests that there are two distinct body representations. Body image and body schema are, respectively, thought to be involved in conscious perceptual judgments and unconscious sensorimotor guidance. The evidence is based on the double dissociation between disorders of perceptual detection and sensorimotor guidance. Until now, research focused on cases that had impaired tactile pressure sensitivity and comparisons of performance were of cases suffering from different types of lesions (peripheral and central). Here, we report a unique double dissociation in two stroke patients with intact basic somatosensory processing (tactile detection). One patient was poor at identifying the position of where she had been touched on a line drawing of a hand, but was able to point accurately towards the actual position on her/his hand itself. The reverse pattern was observed in the other patient. This finding provides further support for separate processing for body image and body scheme.