Stroke and acute myocardial infarction in the thrombolytic era: clinical correlates and long-term prognosis.

Thirteen (1.8%) of 708 patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) I, II and III trials developed a stroke. Four strokes were hemorrhagic and nine were nonhemorrhagic. Of five prespecified risk factors for intracranial hemorrhage (age greater than 65 years, history of hypertension, history of prior cerebrovascular disease, aspirin use and acute hypertension), two patients had two risk factors and one patient had one risk factor. However, 80% of patients without intracranial hemorrhage had at least one risk factor and 31% had two risk factors. No patient with a prior stroke or transient ischemic attack (all greater than 6 months previously) had an intracranial hemorrhage. Of three prespecified risk factors for nonhemorrhagic stroke (atrial fibrillation, prior cerebrovascular disease and large anterior wall infarction), only the occurrence of a large anterior myocardial infarction (with ejection fraction less than 45%) was a predictor (p = 0.0015). The in-hospital death rate was 25% for patients with hemorrhagic stroke versus 11% for patients with a non-hemorrhagic stroke and 6% for those patients without a stroke. Furthermore, the hospital stay was greater than 50% longer in patients who had a stroke than in those who did not. Thus, intracranial hemorrhage remains an unpredictable risk in patients treated with thrombolytic therapy and cerebral infarction is related to anterior myocardial infarction and poor left ventricular function. Both types of stroke are associated with substantial morbidity and mortality.

Cheiralgia paresthetica in diabetes mellitus.

Cheiralgia paresthetica is a sensory mononeuropathy of the superficial ramus of the radial nerve. A case is presented here in a patient with diabetes mellitus.

Tapia's syndrome. The erratic evolution of an eponym.

The syndrome first described in 1904 by the Spanish otolaryngologist, Antonio Garcia Tapia, has been variously interpreted by subsequent authors such that there is little current agreement as to the site of the lesion responsible for the condition or the specific symptoms included in this disorder. The confusion arose in part because Tapia's original patient had associated neurologic findings. Careful review of Tapia's reports reveals (1) that he regarded the syndrome as consisting of ipsilateral hemiplegia of the larynx and tongue with normal function of the soft palate and (2) that he believed the lesion resulting in these signs was outside the CNS.

Babinski's sign in medieval, Renaissance, and baroque art.

In 1896, Joseph François Babinski first described his well-known sign of dorsiflexion of the big toe on stimulating the sole of the foot. However, unknown to Babinski, several painters had previously demonstrated this phenomenon in their paintings. Sandro Botticelli (1445-1510), a Florentine Renaissance painter, demonstrated this reflex in his Madonna and Child with Angels 400 years before the publication of Babinski's discovery. Botticelli used live infants as models for his paintings. Gentile da Fabriano (d 1427) in his Adoration of the Kings, demonstrates a similar response of toe extension in the infant Jesus when one of the Magi kisses the baby's foot. Similarly, Jacob Schick von Kempter, a 16th century German painter, in his Coronation of the Virgin demonstrates the extensor plantar response in the infant. Correggio (1492-1534), in northern Italy captured the extension and flare of the baby's toes in his Madonna and Child with Mary Magdalen. Raphael (1483-1520) presented the extensor plantar responses in the child when sole pressure is applied in Small Cowper Madonna. Leonardo da Vinci, with his nude model drawings (1503-1507) seemed to have been aware of this response. There is no indication that any of these artists fully understood the physiology behind the response; therefore, the value of this sign in neurologic disease must still rely on Babinski's demonstration several hundred years after its initial demonstration in artistic literature.

A multicenter study of anticoagulation parameters when using heparin and warfarin.

Anticoagulation with heparin and warfarin is used in the treatment of several diseases including cerebrovascular disease. While the most effective therapeutic range of anticoagulation is unclear, some investigators have found an increased risk of bleeding complications with more intense anticoagulation. Recent studies have suggested that lower levels of anticoagulation may be as efficacious as high levels but with a reduced incidence of bleeding complications. In order to better assess the anticoagulation parameters used by neurologists and house officers, we performed a questionnaire survey at six major medical centers. Responses were obtained from 30 attending neurologists and 52 house officers. Attending physicians and house officers selected mean partial thromboplastin times of 57.7 s and 63.3 s, respectively. The mean prothrombin time (PT) was 21.0 s for attending neurologists and 19.4 s for house officers. The average PT ratio was 1.82 for attending neurologists and 1.69 for house officers. Forty percent of attending neurologists and 17.7% of house officers specified PT ratios of 2.0 or greater. These results indicate that many physicians may be using warfarin in dosages above recommended guidelines.

Silent aspiration following stroke.

Neurogenic dysphagia following stroke is not limited to brainstem involvement. Among 21 patients with stroke, one-third demonstrated only unilateral signs. In eight patients with silent aspiration, less subjective complaints, weaker cough, and dysphonia occurred more often. Videofluoroscopy must be used liberally in unilateral and bilateral strokes.

Neurologic presentation of decompression sickness and air embolism in sport divers.

In a retrospective study of scuba divers with neurologic injuries, we found that mild symptoms were common. Seventy divers had decompression sickness, most often with paresthesias or numbness, rarely with paresis. Thirty-nine divers had air embolism that often caused unconsciousness or mild symptoms of cerebral injury. Many divers with neurologic decompression sickness gave histories of dives that were within conventional limits, and many with air embolism gave no history of breath-holding during ascent. Mild symptoms sometimes regressed spontaneously. Recompression delays were responsible for poor responses to therapy.

Notalgia paresthetica.

Notalgia paresthetica was described by Astwazaturow in 1934. We have seen six cases in the past year, suggesting that it is not rare. This sensory neuritis affects the posterior rami of several spinal nerves (arising from thoracic segments T2 to T6), causing pruritus, burning, and dysesthesias. Examination reveals hypesthesia. Although the cause is not known, the course seems benign. The posterior rami of these five dorsal roots traverse a 90-degree course through the multifidus spinae muscle, making them unique among the posterior rami.

Handcuffs and cheiralgia paresthetica.

Cheiralgia paresthetica has been reported in the past, but the exact etiology is unknown. We present two cases that occurred secondary to handcuff placement.

Aspiration in bilateral stroke patients.

Seventy patients with bilateral strokes underwent neurologic and videofluoroscopic barium swallowing examinations; 34 (48.6%) aspirated. Patients with aspiration were more likely to have posterior circulation strokes, abnormal cough, abnormal gag, and dysphonia. However, patients likely to aspirate can be identified best by the presence of an abnormal voluntary cough, an abnormal gag reflex, or both. The prediction of patients at risk for aspiration was not improved by additional clinical information (ie, presence of dysphonia or bilateral neurologic signs).

Aspiration in bilateral stroke patients: a validation study.

We validated the predictive accuracy of an "old" regression model in a "new" sample of bilateral stroke patients (N = 38). Abnormal gag reflex and impaired voluntary cough accurately predicted radiographically verified aspiration in both samples. A final model, using both samples, grouped patients into three risk strata: low risk of 14% (cough and gag normal), moderate risk of 46% to 51% (one of two behaviors abnormal); and high risk of 87% (cough and gag abnormal).

Mental neuropathy from systemic cancer.

Nineteen patients with mental neuropathy secondary to systemic cancer are described. In nine patients, the numb chin was the presenting symptom of a neoplasm. Nine patients had lymphoreticular malignancies, and the others had a variety of solid tumors. Radiograms of the mandible were abnormal in 5 of 12 patients. The cerebrospinal fluid contained malignant cells in two. Resolution, complete or partial, occurred in 16 of 19 patients receiving radiation or chemotherapy, including 8 who received chemotherapy alone. Sixteen of the 19 patients died within 17 months of the onset of the neuropathy. A nontraumatic mental neuropathy should initiate a search for cancer.

A follow-up survey of clinical practices for the use of heparin, warfarin, and aspirin.

OBJECTIVE: To determine whether anticoagulation practices have changed when heparin and warfarin are used to treat cerebrovascular disease, and to determine the dosage of aspirin used to treat carotid territory transient ischemic attacks (TIAs). BACKGROUND: A 1987 study documented that neurologists and neurology house officers were using excessive amounts of heparin and warfarin. Recent studies have demonstrated the efficacy and safety of low-intensity anticoagulation for preventing strokes, but no data are available on how these findings have affected the treatment practices of clinicians. DESIGN/METHODS: Questionnaires were sent to neurology staff at 10 medical centers. The questions dealt with the use of heparin, warfarin, and aspirin in stroke/transient ischemic attack patients. The nonparametric Wilcoxon rank sum test was used for analyzing the responses. RESULTS: Ninety-three physicians responded compared with 52 in the prior study. Most (56 of 92; 61%) did not use an IV heparin bolus. The mean partial thromboplastin time (PTT) was 55 seconds, which was significantly less than the mean PTT of 62 seconds (p = 0.006) in the prior study. The mean prothrombin time (PT) fell to 16.0 seconds (range, 12.5 to 20.0) compared with a mean of 19.9 seconds (range, 15.0 to 27.0; p < 0.001) in the earlier study. There was a significant fall in the mean PT ratio from 1.74 (range, 1.20 to 2.25) to 1.49 (range, 1.12 to 2.50; p < 0.001). Most respondents used 325 mg qd of aspirin for treating TIAs. CONCLUSIONS: At the centers studied, neurologists and neurology house officers are using less intense anticoagulation when treating stroke patients now than in 1986. This concurs with recent studies demonstrating the efficacy and safety of low-intensity anticoagulation in some clinical settings. The use of 325 mg/d of aspirin is common, although the data supporting its efficacy compared with higher doses are unclear.

TIA, stroke, and the bicuspid aortic valve.

Congenital bicuspid aortic valve, one of the most common congenital heart abnormalities, may become infected, may calcify, and may cause progressive stenosis or progressive insufficiency. While no previous reports suggested cerebral emboli in the absence of valvular infection, we studied four such cases. In all, cerebral angiography was normal and no extracardiac source of emboli was demonstrated. Microthrombus formation and valvular thickening with incompetence could eventuate in embolization.

Ocular bobbing in metabolic encephalopathy: clinical, pathologic, and electrophysiologic study.

A patient with atypical ocular bobbing resulting from metabolic encephalopathy is described. Neurologic examination showed no signs of brainstem dysfunction, and postmortem examination failed to disclose any changes in sites associated with ocular bobbing in other reports. However, brainstem auditory evoked responses showed evidence of bilateral dysfunction of brainstem white matter. This is the first demonstration of functional disturbance in brainstem loci that are thought to be responsible for the infrequently observed ocular bobbing in metabolic encephalopathy.

Unilateral asterixis: motor integrative dysfunction in focal vascular disease.

In three patients we found unilateral asterixis in limbs contralateral to a discrete lesion adjacent to the internal capsule. Etiology was vascular in each, with no metabolic or toxic disturbance. Unilateral asterixis bespeaks focal disease arising from lesions in the thalamus or internal capsule and is a sign of motor integrative dysfunction.

Botulinum toxin for blepharospasm: single-fiber EMG studies.

In four patients who received periocular injections of botulinum toxin for blepharospasm, abnormal neuromuscular transmission was demonstrated by single-fiber EMG in arm muscles. The time course with which the abnormalities developed and cleared, as well as the inverse relationship between the neuromuscular jitter and the firing rate in the abnormal muscles, indicated that the toxin caused the abnormalities in arm muscles. No weakness was detected clinically in muscles distant from the face, but the abnormal neuromuscular transmission indicates that the toxin spread remotely from the site of injection.

Aspiration following stroke: clinical correlates and outcome.

Among 47 patients with stroke evaluated clinically and videofluoroscopically, one-half aspirated. Patients with combined cerebral-brainstem strokes with bilateral cranial nerve signs were at greatest risk, but aspiration also occurred in the context of unilateral signs. Dysphonia was the common clinical characteristic of aspirating patients. Single chest roentgenograms were of limited value in predicting aspiration. Outcome was favorable following compensatory oral feeding programs.

Spinal cord infarction: etiology and outcome.

We reviewed 44 cases of ischemia and infarction of the spinal cord at two university hospitals. Three patients experienced transient ischemic attacks. Etiologies of completed strokes were diverse and included rupture and surgical repair of aortic aneurysms, aortic dissection, aortic rupture and thrombosis, global ischemia, anterior spinal artery embolism, repair and thrombosis of spinal arteriovenous malformations, hematomyelia, epidural hematoma, cervical osteophytosis, celiac plexus block, systemic lupus erythematosus, coagulopathy, and decompression sickness. Motor function improved in 12 patients, was substantial in only one, and occurred largely within the first 2 to 4 weeks. Favorable ambulatory outcome correlated with improving neurologic examinations and relatively preserved strength in hip abductors and knee extensors. More extensive deficits without initial improvement portended a more severe prognosis. Autonomic dysfunction, pain, paresthesia, and depression were common and impeded recovery in some patients. The mean level of deficit was at T-8 and in cases of global ischemia was at T-9, which leads us to dispute the classical view of a midthoracic watershed zone of ischemic vulnerability near T-4.

Natural history of cerebral complications of coronary artery bypass graft surgery.

We reviewed 1,669 patients who survived coronary artery bypass graft surgery between 1969 and 1981. A total of 75 cerebral complications were identified, including (1) altered mental state, (2) stroke, and (3) seizure in 64 patients (3.8%). Altered mental state (delirium, hypoxic-metabolic encephalopathy) occurred in 57 (3.4%). Postoperative arrhythmias were associated with an increased risk of altered mental state. Cerebral infarction occurred in 13 (0.8%). Patients who suffered stroke had a higher occurrence of carotid bruits and history of peripheral vascular disease. Seizures occurred in five patients (0.3%). Mortality in patients with a neurologic complication was 29%.