Factors associated with recurrent stroke and recanalization in patients presenting with isolated symptomatic carotid occlusion.

BACKGROUND AND PURPOSE: Patients with symptomatic internal carotid artery (ICA) occlusion constitute a small proportion of stroke/transient ischaemic attack patients who are at increased risk of early stroke recurrence and poor outcome. The optimal medical treatment for patients with symptomatic ICA occlusion who are ineligible for thrombolysis or thrombectomy is unknown. METHODS: Consecutive patients presenting at a single center with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) were retrospectively reviewed. Those treated with intravenous thrombolysis or intra-arterial thrombolysis/thrombectomy were excluded. Patients were divided into two groups based on whether they experienced recurrent in-hospital stroke. RESULTS: The selected study population (n = 33) represented a small (20.4%) proportion of all newly symptomatic carotid occlusions, who nevertheless had an elevated risk of recurrent stroke during admission (24.2%). Of the variables examined (age, gender, admission National Institutes of Health Stroke Scale score, vascular risk factors, atrial fibrillation, prior stroke/transient ischaemic attack and anticoagulation within 48 h of presentation), only anticoagulation was significantly associated with a lower risk of in-hospital recurrent stroke. Anticoagulated patients showed a decreased incidence of stroke recurrence within the first week (6.7% vs. 38.9%, P = 0.032) and fewer strokes or deaths at 1 month (13.3% vs. 47.1%, P = 0.040). Hemorrhagic transformation was not observed in any patient. On follow-up imaging, ICA recanalization was significantly more frequent in anticoagulated patients (46.2% vs. 9.1%, P = 0.047). CONCLUSION: Patients with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) represent a small but high risk subgroup of patients with carotid occlusion. Early anticoagulation was associated with fewer recurrent strokes and increased ICA recanalization. Larger scale prospective studies may be justified.

Warfarin vs aspirin for symptomatic intracranial stenosis: subgroup analyses from WASID.

The WASID trial showed no advantage of warfarin over aspirin for preventing the primary endpoint of ischemic stroke, brain hemorrhage, or vascular death. In analyses of selected subgroups, there was no definite benefit from warfarin. Warfarin reduced the risk of the primary endpoint among patients with basilar artery stenosis, but there was no reduction in stroke in the basilar artery territory or benefit for vertebral artery stenosis or posterior circulation disease in general.

Perioperative stroke associated with postoperative epidural analgesia.

A patient with an epidural catheter for postoperative analgesia developed a stroke in association with a hypotensive episode resulting from a bolus of local anesthetic. After undergoing resection for femoral chondrosarcoma under epidural anesthesia, the patient received a continuous infusion of epidural morphine for postoperative analgesia. Lidocaine 1% (10 mL in divided doses) was administered through the catheter for breakthrough pain. The patient experienced a hypotensive episode and was noted to have a motor and cortical sensory deficit of the left arm and leg 8 hours after the hypotensive episode. Clinical presentation and subsequent workup were consistent with a watershed infarction. The patient recovered full neurologic function before discharge. Postoperative hypotension from epidural analgesia may be associated with stroke; however, a cause-and-effect relationship usually cannot be established with certainty.

A systematic review of cost-effectiveness research of stroke evaluation and treatment.

BACKGROUND AND PURPOSE: This work was undertaken to review research addressing the cost-effectiveness of stroke-related diagnostic, preventive, or therapeutic interventions. METHODS: We performed searches of MEDLINE, Excerpta Medica online, HealthSTAR, and Sciences Citation Index Expanded and examined the reference lists of the studies and reviews obtained. From these, we selected studies that reported an incremental analysis of cost per effect, in which the effect measure was life-years or quality-adjusted life-years. We abstracted data from each study using a standardized reporting form. Twenty-six articles met the eligibility criteria and were included in the review. RESULTS: The methodological quality of the articles reviewed has improved compared with previously reported. Many stroke evaluation and treatment policies may result in benefits to health that are considered worth their cost. Some interventions were considered cost-ineffective (anticoagulation in low-risk nonvalvular atrial fibrillation and surveillance with duplex ultrasound after endarterectomy). Different studies addressing the cost-effectiveness of screening asymptomatic carotid stenosis resulted in strikingly divergent conclusions, from being cost-effective to being detrimental. Other studies omitted important costs that, if included, would likely have had profound impact on their cost-effectiveness estimates. CONCLUSIONS: Given the divergent conclusions drawn from studies addressing similar questions, it may be premature to use the results of cost-effectiveness research in developing stroke policy and practice guidelines. Successful implementation of such evaluations in the care of patients with stroke will depend on further standardization of methodology and critical appraisal of reported findings.

End-stage Alzheimer's disease. Glasgow Coma Scale and the neurologic examination.

OBJECTIVE: To characterize the cognitive and neurologic features of patients with end-stage Alzheimer's disease using a standard neurologic examination and the Glasgow Coma Scale. DESIGN: Case series. SETTING: Local community nursing homes. PATIENTS: Forty patients with Alzheimer's disease were drawn from previously enrolled subjects in the Rochester Alzheimer's Disease Project with Clinical Dementia Rating scores of 3, 4, or 5. MAIN OUTCOME MEASURES: Scores on the Glasgow Coma Scale and cognitive screening examinations and the prevalence of neurologic manifestations such as primitive reflexes and extrapyramidal signs were compared across the Clinical Dementia Rating groups. RESULTS: When compared with patients in the Clinical Dementia Rating stages 3 and 4, patients with a stage 5 scored significantly lower on the Glasgow Coma Scale, with the discriminating subscales being verbal and motor responses. Primitive reflexes, myoclonus, and dyskinesia were increasingly prevalent in the more terminal stages. Cognitive screening assessments did not discriminate between groups. CONCLUSIONS: Rudimentary neurologic functions can be readily assessed and, when viewed together with the Glasgow Coma Scale, may circumvent the "floor effect" frequently encountered when using the currently available cognitive and functional scales and, thereby, better define patients with end-stage Alzheimer's disease.

Wasp sting-associated cerebral infarction: a role for cerebrovascular sympathetic innervation.

A 38-year-old man, stung repeatedly by wasps on the left face and neck, had his left internal carotid artery occluded 2 days later. A mechanism for ischemic stroke involving the sympathetic innervation of cerebral vasculature is suggested.

A controlled study of folic acid treatment in three fragile X syndrome males.

Three fragile X syndrome males were given 10 mg folic acid daily in a multiple-baseline, placebo study. Objective measures of memory skills, compliance, and behavioral appropriateness were taken during baseline, placebo, and treatment conditions. No change was evident in these variables during the drug trial. Thus, the findings shed doubt on the effectiveness of folic acid in increasing intellectual functioning or reducing behavior problems in individuals with fragile X syndrome. These results underscore the importance of operationally defined variables, double-blind observation and placebo treatment in elucidating the effects of folic acid.