Stroke or transient ischemic attacks with basilar artery stenosis or occlusion: clinical patterns and outcome.

BACKGROUND: Basilar artery occlusion (BAO) is associated with a high mortality rate, although cases with spontaneous favorable outcomes have recently been reported, and basilar artery stenosis (BAS) has received little consideration until now. OBJECTIVE: To study the prognostic clinical factors by testing numerous combinations of admission status characteristics of patients with brain ischemia caused by BAO or BAS. METHODS: We conducted a retrospective review from the Lausanne Stroke Registry (group 1) of patients with stroke or transient ischemic attack caused by BAS less than 50% or BAO as diagnosed by magnetic resonance angiography who were not treated by thrombolysis. Neurologic findings on admission were correlated with outcomes. We compared clinical patterns associated with poor outcomes in group 1 with those in patients with stroke who died from BAO or BAS (confirmed at autopsy) (group 2). RESULTS: Eighty-eight patients were studied. The outcomes of patients with stroke in group 1 (35/43) was poor (severe disability or death) in 54% of cases. A statistical analysis revealed that 4 factors-dysarthria, pupillary disorders, lower cranial nerve involvement, and consciousness disorders on admission-were strongly (P<.001) associated with poor outcomes. The multivariate analysis showed that the outcome was poor in 100% of cases in which consciousness disorders or the combination of the remaining 3 factors were present, whereas in the absence of these factors, a poor outcome was reported in only 11%. In 87% of the 45 patients with stroke in group 2, the same clinical patterns were present on admission. CONCLUSIONS: The prognosis of BAS greater than 50% or BAO is diverse and certain clinical characteristics seem to predict a lower risk of poor outcome. Their presence may help to decide the most suitable therapy.

Coexisting causes of ischemic stroke.

BACKGROUND: Coexistence of multiple potential causes of cerebral infarct (MPCI) has been poorly studied. OBJECTIVE: To determine the risk factors, clinical findings, and topographical patterns of patients with at least 2 potential causes of cerebral infarct. DESIGN: Data analysis from a prospective acute stroke registry (the Lausanne Stroke Registry, Lausanne, Switzerland) in a community-based primary care center. RESULTS: Among 3525 patients with first-ever ischemic stroke consecutively admitted to a primary care stroke center, 250 patients (7%) had at least 2 MPCIs, with the following subgroups: large artery disease and a cardiac source of embolism (LAD + CSE) (43%), small artery disease and CSE (SAD + CSE) (34%), LAD + SAD (18%), and LAD + SAD + CSE (5%). Hypertension, cardiac ischemia, and a history of atrial fibrillation predominated in the LAD + SAD + CSE subgroup (P<.001), while cigarette smoking was more prevalent in the LAD + SAD subgroup (P<.05). A decreased level of consciousness and speech disorders were more common in the LAD + CSE subgroup (P<.001). Lacunar syndromes predominated in the LAD + SAD subgroup. Pure motor stroke was the most frequent lacunar syndrome in all subgroups, but sensory motor stroke predominated in the LAD + CSE subgroup (P<.05). The outcome at 1 month was worse in the LAD + CSE and SAD + CSE subgroups (P<.001). Other stroke characteristics and clinical features did not differ significantly between the 4 subgroups of patients with MPCI. CONCLUSIONS: Our findings suggest that MPCIs are uncommon. The most frequent association is LAD + CSE. Topographical patterns of stroke and clinical characteristics in patients with MPCI only rarely allow emphasis of a preeminent cause. Arch Neurol. 2000;57:1139-1144

Do transient ischemic attacks have a neuroprotective effect?

OBJECTIVE: To determine whether TIAs have a neuroprotective effect. BACKGROUND: Ischemic tolerance or preconditioning, which protects the brain against stroke, has been demonstrated in animal models of cerebral ischemia. Because TIA may represent a clinical model of ischemic tolerance, patients with TIA before cerebral infarction (CI) may therefore have a better outcome than patients without TIA before CI. METHODS: A total of 2,490 patients admitted consecutively to a primary care center for first-ever CI in the anterior circulation were divided into two groups on the basis of the presence or absence of prior ipsilateral TIAs. Duration of TIA was classified into three groups (<10 minutes, 10 to 20 minutes, and >20 minutes). The severity of the neurologic picture on admission and functional disability after stroke were compared between patients with and without TIAs. RESULTS: A total of 293 (12%) of the 2,490 patients had prior ipsilateral TIAs before CI. Risk factors did not differ between patients with or without TIAs, whereas the topography and etiology of ischemic stroke did differ (p < 0.001). Patients without prior TIAs had a more severe clinical picture on admission, with a greater reduction of consciousness (p = 0.009). Patients with previous TIAs had a more favorable outcome than those without TIAs (67% versus 58%, p = 0.004). After adjustment for confounding variables, TIAs lasting 10 to 20 minutes were still associated with a favorable outcome (odds ratio, 1.98; 95% confidence interval, 1.27 to 3.08; p = 0.002). The interval between TIA and CI influenced the outcome (p = 0.007). CONCLUSIONS: This study suggests that ischemic tolerance may play a role in patients with ipsilateral TIAs before CI, allowing better recovery from a subsequent ischemic stroke.

Cerebral cysticercosis as a risk factor for stroke in young and middle-aged people.

BACKGROUND AND PURPOSE: A probable association between cerebral cysticercosis and susceptibility to stroke, especially among young and middle-aged patients, has been reported. We examined the association between cerebral cysticercosis and stroke and the possible factors causing this association. METHODS: In 169 stroke patients (75 males and 94 females) under 65 years of age admitted to our neurology department, we evaluated the following possible risk factors: arterial hypertension, diabetes, cardiac disease, hyperlipidemia, smoking, alcohol abuse, and cerebral cysticercosis. In 169 control patients under 65 years of age matched by sex and age, we evaluated the same possible risk factors for stroke. RESULTS: In the univariate matched analyses, the frequencies of cerebral cysticercosis (p < 0.001), arterial hypertension (p < 0.001), cardiac disease (p < 0.001), hyperlipidemia (p < 0.05), and alcohol abuse (p = 0.05) were higher in the stroke patients than in the control patients. After controlling for possible confounding factors, we found that arterial hypertension (p < 0.001), cardiac disease (p < 0.001), and cerebral cysticercosis (p < 0.001) were independent risk factors for stroke. CONCLUSIONS: Cerebral cysticercosis should be considered a risk factor for stroke in young and middle-aged individuals.

Disección de carotida: reporte de 5 casos

Describimos cinco pacientes entre 14 y 33 años de edad que presentaron Enfermedad Cerebro Vascular Aguda secundaria a disección de la arteria carótidea interna. Cuatro pacientes tuvieron antecedentes traumáticos. El intervalo entre el trauma y la enfermedad Cerebro Vascular Aguda fue de 3 semanas. Todos los pacientes tuvieron en la Tomografía Cerebral infartos en el territrorio de la arteria cerebral media. La angiografía carotídea realizada hasta 10 meses después del evento vascular agudo mostró doble lumen en dos pacientes; signo de la cuerda en un paciente; oclusión total temprana en otro y en el restante oclusión total tardía. Cuatro pacientes recibieron antiagregación plaquetaria. Ningún paciente falleció y en cuatro pacientes la hemiparesia mejoró hasta permitirles una vida autónoma. Concluímos que la disección de la carótida, patología escasamente reportada en nuestro país puede ser causa de Enfermedad Cerebro Vascular Aguda especialmente en el adulto joven.

Cerebral cysticercosis and stroke.

BACKGROUND AND PURPOSE: In 1985 we initiated a protocol for examining the relationship between cerebral cysticercosis and stroke. METHODS: In 420 stroke patients admitted to our department, our standard protocol of tests included blood tests, cardiac investigations, angiography, and immunologic cerebrospinal fluid measures. We assessed the following possible risk factors: arterial hypertension, diabetes, cardiopathy, high levels of cholesterol and triglycerides, smoking, alcohol abuse, and cerebral cysticercosis. RESULTS: Of the 420 patients with stroke, we found cerebral cysticercosis in 31, five of whom were greater than 65 years of age and 26 of whom were less than or equal to 65 years. We determined that cerebral cysticercosis was the only possible risk factor for stroke in one of the five older patients and 15 of the 26 younger and middle-aged patients. Cortical infarctions were found in five of the 31 patients, with cerebral cysticercosis and lacunar infarctions in nine of these patients. One patient had intracystic hemorrhage. In 16 cases, neurological deficit was related to single or multiple cysts, colloids, granulomas, diffuse lesions, or pericystic edema. All patients with cerebral cysticercosis quickly recovered from their neurological deficit, except one who had a hemorrhagic cyst and died and another who remained disabled. CONCLUSIONS: We established that, in patients with neurocysticercosis, occlusion of the small cortical or penetrating vessels at the base of the brain caused by arteriopathy was the most common mechanism of the stroke. Moreover, there is a probable association between cerebral cysticercosis and the susceptibility to stroke, particularly among young and middle-aged patients.