Covert stroke after non-cardiac surgery: a prospective cohort study.

BACKGROUND: Overt stroke after non-cardiac surgery has a substantial impact on the duration and quality of life. Covert stroke in the non-surgical setting is much more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac, non-carotid artery surgery. METHODS: We undertook a prospective, international cohort study to determine the incidence of covert stroke after non-cardiac, non-carotid artery surgery. Eligible patients were ≥65 yr of age and were admitted to hospital for at least three nights after non-cardiac, non-carotid artery surgery. Patients underwent a brain magnetic resonance study between postoperative days 3 and 10. The main outcome was the incidence of perioperative covert stroke. RESULTS: We enrolled a total of 100 patients from six centres in four countries. The incidence of perioperative covert stroke was 10.0% (10/100 patients, 95% confidence interval 5.5-17.4%). Five of the six centres that enrolled patients reported an incident covert stroke, and covert stroke was found in patients undergoing major general (3/27), major orthopaedic (3/41), major urological or gynaecological (3/22), and low-risk surgery (1/12). CONCLUSIONS: This international multicentre study suggests that 1 in 10 patients ≥65 yr of age experiences a perioperative covert stroke. A larger study is required to determine the impact of perioperative covert stroke on patient-important outcomes. CLINICAL TRIAL REGISTRATION: NCT01369537.

Identification of penumbra and infarct in acute ischemic stroke using computed tomography perfusion-derived blood flow and blood volume measurements.

BACKGROUND AND PURPOSE: We investigated whether computed tomography (CT) perfusion-derived cerebral blood flow (CBF) and cerebral blood volume (CBV) could be used to differentiate between penumbra and infarcted gray matter in a limited, exploratory sample of acute stroke patients. METHODS: Thirty patients underwent a noncontrast CT (NCCT), CT angiography (CTA), and CT perfusion (CTP) scan within 7 hours of stroke onset, NCCT and CTA at 24 hours, and NCCT at 5 to 7 days. Twenty-five patients met the criteria for inclusion and were subsequently divided into 2 groups: those with recanalization at 24 hours (n=16) and those without (n=9). Penumbra was operationally defined as tissue with an admission CBF <25 mL x 100 g(-1) x min(-1) that was not infarcted on the 5- to 7-day NCCT. Logistic regression was applied to differentiate between infarct and penumbra data points. RESULTS: For recanalized patients, CBF was significantly lower (P<0.05) for infarct (13.3+/-3.75 mL x 100 g(-1) x min(-1)) than penumbra (25.0+/-3.82 mL x 100 g(-1) x min(-1)). CBV in the penumbra (2.15+/-0.43 mL x 100 g(-1)) was significantly higher than contralateral (1.78+/-0.30 mL x 100 g(-1)) and infarcted tissue (1.12+/-0.37 mL x 100 g(-1)). Logistic regression using an interaction term (CBFxCBV) resulted in sensitivity, specificity, and accuracy of 97.0%, 97.2%, and 97.1%, respectively. The interaction term resulted in a significantly better (P<0.05) fit than CBF or CBV alone, suggesting that the CBV threshold for infarction varies with CBF. For patients without recanalization, CBF and CBV for infarcted regions were 15.1+/-5.67 mL x 100 g(-1) x min(-1) and 1.17+/-0.41 mL x 100 g(-1), respectively. CONCLUSIONS: We have shown in a limited sample of patients that CBF and CBV obtained from CTP can be sensitive and specific for infarction and should be investigated further in a prospective trial to assess their utility for differentiating between infarct and penumbra.

Treatment of acute disseminated encephalomyelitis with intravenous immunoglobulin.

Acute disseminated encephalomyelitis (ADEM) is a presumed immune-mediated, demyelinating disease of the CNS for which the standard treatment is high-dose steroids. We describe two patients with ADEM in whom treatment with IV methylprednisolone coincided with deterioration in their clinical status. They were subsequently treated with IV immunoglobulin and exhibited dramatic clinical improvement, with return to their previous level of functioning.

Functional neuroanatomy in the pre-Hippocratic era: observations from the Iliad of Homer.

OBJECTIVE: To describe observations of neurological significance made in the Iliad of Homer and to interpret these relative to pre-Hippocratic concepts of health and disease in Ancient Greece. METHODS: English translations of the Iliad were analyzed for references of neurological significance, and the Homeric Greek was subsequently reviewed for accuracy. Findings are discussed in the context of ancient Greek ideas regarding anatomy and physiology, early descriptions and conceptualizations of the nervous system, ancient Greek theories concerning illness and disease, and the practice of medicine in the pre-Hippocratic era. RESULTS: Descriptions of injuries sustained by soldiers fighting in the Trojan War represent some of the earliest case histories of neurotrauma. Passages in the Iliad describe immediate death after penetrating head trauma with injury to the brain or the brainstem, make reference to clinical signs of brain injury, and mention neurological signs and symptoms after damage to the spinal cord, brachial plexus, and peripheral nerves. CONCLUSION: The Iliad of Homer contains many descriptions of traumatic injury to the nervous system and provides us with 3,000-year-old references to some of the basic principles of functional neuroanatomy.

Familial autoimmune myastenia gravis: four patients involving three generations.

BACKGROUND: Familial autoimmune myasthenia gravis (MG) is rare, although a genetic role for the development of autoimmune MG is suggested by concordance in monozygotic twins and the increased frequency of other autoimmune diseases in family members of myasthenics. METHODS: A patient with a family history of MG was evaluated in hospital. Relatives were interviewed and medical records examined for details regarding the diagnosis of MG in three other family members. RESULTS: The index case first experienced symptoms of MG at age 75 years. She developed generalized MG and required corticosteroids and immunosuppressive therapy to control her disease. Her father developed predominantly bulbar symptoms of MG at age 75 years. He died of complications experienced following a gastrostomy placed for continued difficulty swallowing. His brother developed similar symptoms of MG in his early 60s and died shortly after thymectomy. A 46-year-old nephew of the index case is also beginning to exhibit signs of generalized MG. Acetylcholine receptor antibodies were strongly positive in the index case and her nephew. (The assay was not available for her father and uncle). CONCLUSIONS: Four individuals in three successive generations had diagnoses of autoimmune MG. Study of familial cases such as these may clarify the contribution of genetic factors to the development of this disease.

A case of thyrotoxicosis and reversible systolic cardiac dysfunction.

A woman with congestive heart failure and reduced left ventricular ejection fraction associated with hyperthyroidism is reported. Congestive heart failure resolved and left ventricular ejection fraction normalized within three weeks of treatment of her hyperthyroidism. The literature on previously reported cases of reversible systolic heart failure associated with hyperthyroidism is reviewed and the possible mechanisms leading to systolic dysfunction and congestive heart failure in thyrotoxicosis are discussed. One such mechanism may be the action of thyroid hormone on altering gene expression in cardiac cells; another could be the chronic tachycardia associated with thyrotoxicosis. Although it is a not a common cause of systolic heart failure, thyrotoxicosis should be considered in the differential diagnosis of cardiomyopathies because it is a potentially reversible cause.

CT perfusion quantification of small-vessel ischemic severity.

BACKGROUND AND PURPOSE: Cerebral blood flow (CBF) abnormalities are previously demonstrated in white matter disease. A gradation of change may exist between patients with mild and more severe white matter disease. An association between blood brain barrier dysfunction, increasing age and white matter disease is also suggested. The purpose of this study was to quantify and correlate white matter disease severity and CT perfusion (CTP)-derived CBF and to determine whether permeability surface abnormality increases with white matter disease severity. MATERIALS AND METHODS: One hundred twenty patients with strokelike symptoms underwent CTP and MR imaging. Of these, 35 patients (15 women, 20 men; age, 66 +/- 15.7 years) with rapidly resolving symptoms and normal imaging characteristics consistent with transient ischemic attack were retrospectively reviewed and constituted the study cohort. Two blinded neurologists rated white matter severity, assigning age-related white matter change (ARWMC) scores. Patients were dichotomized a priori into mild and moderate-to-severe. CBF, cerebral blood volume (CBV), mean transit time (MTT), and permeability surface product maps were calculated for periventricular and subcortical white matter regions and average white and gray matter. Associations with white matter severity were tested by uni- and multivariate logistic regression analyses. Receiver operating characteristic analysis was performed. RESULTS: White matter disease was mild in 26 patients and moderate-to-severe in 9. Age was associated with increased likelihood of having moderate-to-severe white matter disease (P = .02). ARWMC correlated with subcortical (r = -0.50, P < .001) and average CBF (r = -0.55, P < .001). White matter severity was associated with subcortical (P = .03) and average (P = .03) white matter CBF, with a trend toward periventricular white matter CBF (P = .05). Uni- and multivariate analysis controlling for the confounding effect of age demonstrated significant association between white matter severity and subcortical (P = .032) white matter CBF. Area under the curve was 0.82. No permeability surface abnormality was found. CONCLUSIONS: CTP-derived subcortical white matter CBF is independently associated with white matter disease severity.

Early stroke detection and extent: impact of experience and the role of computed tomography angiography source images.

AIM: To test the performance of computed tomography angiography "source images" (CTA-SI) versus unenhanced CT (NCCT) for stroke detection and extent using the Alberta Stroke Programme Early CT Score (ASPECTS), and examine the effect of experience and clinical history. MATERIALS AND METHODS: Studies of 23 consecutive patients presenting within 4.5h were analysed by three reviewers of varying experience. Each reviewer, blinded to clinical information reviewed a random order of NCCT and CTA-SI and documented side of infarct and the ASPECTS. The readings were repeated for CTA-SI with and without clinical information. Performance measures and observer agreement were calculated. Applying an ASPECTS threshold of

Seizures during stroke thrombolysis heralding dramatic neurologic recovery.

Seizures during thrombolytic therapy for ischemic stroke have not previously been described as a favorable prognostic sign. We report three patients with severe stroke (NIH Stroke Scale [NIHSS] score 15 to 20) who experienced a seizure during tissue plasminogen activator (tPA) infusion. While initially raising alarm about possible hemorrhage, the seizures heralded dramatic recovery (an immediate 15-point NIHSS score improvement after tPA; NIHSS score 0 or 1 at 24 hours). We propose that the seizures during thrombolysis may indicate cortical reperfusion and/or hyperperfusion due to early recanalization of an acutely occluded intracranial artery.

Role of heme oxygenase-1 in the biogenesis of corpora amylacea.

Corpora amylacea (CA) are glycoproteinaceous inclusions that accumulate in the human brain during normal aging and to a greater extent in Alzheimer's disease. We previously demonstrated that, in cultured rat astroglia, cysteamine (CSH) upregulates heme oxygenase-1 (HO-1) and promotes the transformation of normal mitochondria into CA-like inclusions. In the current study, primary cultures of neonatal rat astroglia were exposed to 880 micro M CSH for three months in the presence or absence of dexamethasone, a suppressor of HO-1 gene transcription. Cells were double-labeled with periodic acid-Schiff reagent (PAS) and antisera against ubiquitin, HO-1, or a mitochondrial epitope. CA were quantified and their immunostaining characteristics analyzed using confocal microscopy. HO-1 immunofluorescence was more abundant in cultures exposed to CSH alone relative to untreated control cultures and cultures exposed to both CSH and dexamethasone. Mature CA appeared as large (5-50 microM), spherical or polygonal, intensely PAS-positive inclusions within glial cytoplasm or deposited extracellularly. The inclusions manifested intense rim and, less commonly, homogeneous or stippled patterns of immunoreactivity for ubiquitin, HO-1, and the mitochondrial marker. Monolayers exposed to CSH exhibited 660% more CA relative to untreated controls (P < 0.05). Numbers of CA in cultures exposed to CSH were diminished by co-administration of 50 microg/ml dexamethasone (P < 0.05 relative to CSH alone) or 100 microg/ml dexamethasone (P < 0.05 relative to CSH alone). Numbers of CA in cultures co-treated with CSH and 50 microg/ml dexamethasone or 100 microg/ml dexamethasone were not significantly different from untreated control values. Up-regulation of HO-1 may contribute to the formation of CA in aging astroglia.

Distribution of snRNPs, splicing factor SC-35 and actin in interphase nuclei: immunocytochemical evidence for differential distribution during changes in functional states.

Small nuclear ribonucleoproteins (snRNPs) play an integral role in the processing of pre-mRNA in eukaryotic nuclei. snRNPs often occur in a speckled intranuclear distribution, together with the non-snRNP splicing factor SC-35. snRNPs have also been shown to be associated with actin in the nuclear matrix, suggesting that both actin and snRNPs may be involved in the processing and transport of transcripts. The work reported here was undertaken to compare the spatial relationship of snRNPs, SC-35, and intranuclear actin in neuronal and non-neuronal cell types. In undifferentiated PC12 cells and in non-neuronal cells growing in association with dorsal root ganglion neurons, confocal immunocytochemistry revealed a typical, speckled distribution of snRNP aggregates, which colocalized with the SC-35 splicing factor. In contrast, a unique snRNP distribution was observed in dorsal root ganglion neurons in vitro and in PC12 cells differentiated by nerve growth factor. In nuclei of these cells, snRNPs were predominantly located at the periphery where they formed a spherical shell apposed to the nuclear envelope. Ultrastructural immunogold labelling of snRNPs in dorsal root ganglion neurons in vitro confirmed this distribution. In contrast, SC-35 remained distributed in a speckled pattern throughout nuclei of dorsal root ganglion neurons and PC12 cells, even in cases where snRNPs were almost exclusively positioned at the nuclear periphery. In non-neuronal cells in dorsal root ganglion cultures and in undifferentiated PC12 cells, snRNP aggregates were frequently associated with actin aggregates, as determined by Nearest Neighbor Analyses. In PC12 cells, this spatial relationship was altered during nerve growth factor-induced differentiation, prior to the time at which these cells showed morphological evidence of differentiation. Specifically, Nearest Neighbor Analyses between snRNP and actin aggregates in PC12 cells exposed to nerve growth factor for 4 hours revealed that snRNP and actin aggregates exhibited a closer association than in undifferentiated cells. These results suggest that sites of pre-mRNA processing and transcription may differ between cell types, and that the functions of snRNPs and actin within interphase nuclei may be related. The results also indicate that the distribution of snRNPs is dynamic and that it may depend upon the functional state of the cell as well as upon its state of differentiation.

Proinflammatory cytokines promote glial heme oxygenase-1 expression and mitochondrial iron deposition: implications for multiple sclerosis.

Proinflammatory cytokines, pathological iron deposition, and oxidative stress have been implicated in the pathogenesis of multiple sclerosis (MS) and experimental autoimmune encephalomyelitis (EAE). HO-1 mRNA levels and mitochondrial uptake of [(55)Fe]Cl(3)-derived iron were measured in rat astroglial cultures exposed to interleukin-1beta (IL-1beta) or tumor necrosis factor-alpha (TNF-alpha) alone or in combination with the heme oxygenase-1 (HO-1) inhibitors, tin mesoporphyrin (SnMP) or dexamthasone (DEX), or interferon beta1b (INF-beta). HO-1 expression in astrocytes was evaluated by immunohistochemical staining of spinal cord tissue derived from MS and control subjects. IL-1beta or TNF-alpha promoted sequestration of non-transferrin-derived (55)Fe by astroglial mitochondria. HO-1 inhibitors, mitochondrial permeability transition pore (MTP) blockers and antioxidants significantly attenuated cytokine-related mitochondrial iron sequestration in these cells. IFN-beta decreased HO-1 expression and mitochondrial iron sequestration in IL-1beta- and TNF-alpha-challenged astroglia. The percentage of astrocytes coexpressing HO-1 in affected spinal cord from MS patients (57.3% +/- 12.8%) was significantly greater (p < 0.05) than in normal spinal cord derived from controls subjects (15.4% +/- 8.4%). HO-1 is over-expressed in MS spinal cord astroglia and may promote mitochondrial iron deposition in MS plaques. In MS, IFN-beta may attenuate glial HO-1 gene induction and aberrant mitochondrial iron deposition accruing from exposure to proinflammatory cytokines.