Early CT changes and outcome of ischemic stroke.

Although recombinant tissue plasminogen activator (rt-PA) was rapidly implemented as part of the emergency care of acute stroke, its use in daily clinical practice still remains controversial in many countries. The most important question is criteria for careful selection of subgroup of patients for this treatment. It has been hypothesized that early computed tomography (CT) changes of ischemia are risk factors for symptomatic intracerebral hemorrhage and poor outcome. We conducted a prospective outcome study of patients with acute ischemic stroke (IS) admitted to the hospital within 6 h of symptom onset. Experienced neuroradiologists blind to the clinical outcome of the patients read all CT scans carried out in the emergency room. Early CT changes were defined as in European Cooperative Acute Stroke Study (ECASS) 2. There were 150 patients (75 males, mean age 72.5 +/- 9.0) with acute IS (54.7% with mild stroke and 45.3% with severe stroke). Early CT changes were presented with tissue hypodensity - 55.7%, effacement of sulci - 41.3%, hyperdensity of middle cerebral artery (MCA) - 13.3%, hypodensity of lentiform - 20.7%, loss of insular ribbon sign - 28.7%. Follow-up after 30 days showed that 44% of the patients were discharged home, 20% were discharged to rehabilitation facilities, 22% were discharged to chronic care institutions and 14% died. Data were statistically analyzed. Our data suggest that early signs on CT scan could not predict outcome of patients with acute IS.

Antibodies to brain antigens following stroke.

Cerebral necrosis following stroke exposes brain antigens to the immune system, potentially initiating an antibody response. The authors measured levels of antibodies to specific neuronal antigens, neurofilaments (NF), and a ubiquitous antigen, cardiolipin (CL), in 45 patients following an acute first-ever stroke, within 48 hours, and 1, 3, and 6 months later. The mean levels of anti-NF antibodies were elevated compared with baseline at 1, 3, and 6, months (p = 0.012, 0.002, and 0.003 by paired t-test). Anti-CL levels did not change significantly.

The Tel Aviv Stroke Registry. 3600 consecutive patients.

BACKGROUND AND PURPOSE: We undertook to estimate the frequency of various risk factors and the type and severity of stroke in different ethnic groups documented in a large hospital-based stroke registry. Tel Aviv is a metropolis with about 400000 inhabitants and about 600000 daily visitors and workers. The Tel Aviv Medical Center (TAMC) is the only tertiary medical care facility to which all patients with acute stroke are referred. Israel is a country with a heterogeneous population, of which a significant proportion was born abroad. The people differ in their genetic background, as well as in their early environmental conditions, lifelong diet, and other habits. This variety has proved to be a fertile ground for the study of different neurological diseases, including stroke. METHODS: A prospective hospital-based registry using systematic computer coding of data of all consecutive stroke patients admitted to the TAMC has been conducted since May 1988. Different aspects of the amassed data were analyzed statistically. RESULTS: From May 1988 until April 1994, 3600 stroke patients were admitted to the TAMC. The mean age was 73.2 years, and 58.2% were males. Cerebral infarctions were diagnosed in 80.9%, primary intracerebral hemorrhages in 8.0%, and transient ischemic attacks in 11.1%. There were 861 patients (24%) who were admitted with recurrent strokes. Past medical history of hypertension was the major risk factor (occurring in 52.2% of the patients), followed by ischemic heart disease (29.7%), diabetes mellitus (25.2%), smoking (17.0%), atrial fibrillation (14.3%), and hyperlipidemia (8.4%). Ischemic heart disease and atrial fibrillation were more frequent in patients from Europe and America (Ashkenazi group), whereas diabetes mellitus and smoking were more prominent in the other groups. The in-hospital mortality rate was 13.8% and was similar in both ethnic groups. CONCLUSIONS: This registry allows the study of the risk factors, natural history, and clinical manifestations of stroke in different ethnic groups.

Carotid endarterectomy without angiography.

Between 1 January 1990 and 1 September 1994 a total of 109 carotid endarterectomies were performed without preoperative angiography. Only two cases were considered by the surgeon to have a poor correlation between the duplex examination results and intraoperative findings; the outcome was good in both. The perioperative mortality rate was 1.8 per cent, one patient dying from sudden haematoma causing asphyxia and the other from unrelated causes following a myocardial revascularization procedure. Two non-disabling strokes also occurred. These results suggest that carotid endarterectomy based on carotid duplex scanning alone without preoperative angiography is safe in selected patients.

[Carotid endarterectomy without angiography].

Duplex scanning has emerged as an accurate noninvasive method of evaluating patients with extracranial cerebrovascular disease; it has research, clinical and economic implications. The risks associated with cerebral angiography are numerous and well-known. During 1990-1995, 227 carotid endarterectomies (CEA) were performed without preoperative arteriography in 192 patients. 91% were performed under local anesthesia. Indications for surgery without angiography were: renal insufficiency (in 5), allergy to contrast material (11), and need for urgent surgery (25). In 81% CEA was performed due to the preference of both the neurologist and surgeon. In only 2 cases there was a discrepancy in duplex evaluation. 3 patients had postoperative strokes (total stroke rate 1.56%), only 1 of which was disabling (0.52%). 2 died during the immediate postoperative period (mortality 1.04%): 1 on the 2nd postoperative day due to asphyxia caused by a huge neck hematoma which appeared suddenly after discharge (related death, 0.52%); the other died several days after coronary surgery which followed CEA (unrelated death). Our study confirms that patients with well-defined symptoms, appropriate physical findings, and concurrent CT and duplex scans, can safely undergo CEA without preoperative angiography. It is extremely important however, that the duplex scan be a reliable study from a laboratory which has validated its results by sequential comparison of previous duplex and angiographic data. Angiography remains appropriate in patients with atypical symptoms; with conflicting findings between history, physical and duplex data; when there is proximal disease; or in an asymptomatic patient when the duplex scan suggests total occlusion.

Do silent brain infarctions predict the development of dementia after first ischemic stroke?

BACKGROUND AND PURPOSE: Silent brain infarctions (SBI) are common findings in advanced age, but their relationship to dementia is still uncertain. The present study was designed to evaluate whether SBI predict the development of dementia after first clinical ischemic stroke. METHODS: We blindly studied admission CT scans of 175 consecutive nondemented patients presenting with ischemic stroke that clinically was their first stroke episode. SBI were defined as CT evidence of infarcts not compatible with the acute event. The patients were subsequently followed for their mental state for 5 years. Survival analysis, wherein onset of dementia was the end point, was performed on the total sample population and conducted separately on those with and without SBI at admission. RESULTS: Dementia developed in 56 patients (32%), including 22 of the 63 (35%) with SBI and 34 of the 112 (30%) without SBI. Thus, dementia was not related to SBI. CONCLUSIONS: Our data indicate that SBI do not predict the development of dementia after stroke.

EEG as predictor of dementia following first ischemic stroke.

INTRODUCTION: Predictive factors for occurrence of vascular dementia may help identify patients at increased risk of developing this condition. Our purpose was to evaluate the prognostic value of early EEG findings in patients after first ischemic cerebral stroke on the development of dementia. MATERIAL AND METHODS: We performed routine EEG recordings in 199 consecutive non-demented patients with first-ever ischemic stroke, within 48 h of the event. The patients were subsequently followed for their mental state for 2 years. Survival analysis, wherein onset of dementia was the end-point, was performed on the total sample population and conducted separately on those who had normal EEG at time of the event and on those who had abnormal EEG findings (focal or diffuse slowing). RESULTS: Patients with abnormal EEG at baseline had 2.6 times the risk of developing dementia than those who had normal EEG; this odds ratio was statistical significant (CL: 1.3-5.1, p = 0.003). Development of dementia was not related to any specific EEG abnormal pattern. CONCLUSIONS: Abnormal EEG performed close to the first ischemic stroke appears to be an indicator of subsequent cognitive decline, probably because it indicates cortical involvement by the stroke or an underlying indolent cerebral degeneration.

Interrater agreement in evaluation of stroke patients with the unified neurological stroke scale.

BACKGROUND: We sought to determine interrater agreement in evaluation of stroke patients with the Unified Form for Neurological Stroke Scales (UFNSS). SUMMARY OF REPORT: Fifty inpatients were independently examined by three neurologists. Kendall coefficients of concordance were computed for the different items of the UFNSS. There was a high concordance among the raters. The best agreements were obtained for motor functions and the worst for grading of eye movements. CONCLUSIONS: The UFNSS was shown to be reliable for evaluation of motor functions, verbal communication, orientation, and vigilance in stroke patients.

Failure of aspirin treatment after stroke.

BACKGROUND AND PURPOSE: Despite its low efficacy, aspirin is the most widely used drug for secondary stroke prevention. The reasons why stroke recurs while patients are on aspirin are unknown. We have analyzed a series of patients who had recurrent strokes while on aspirin. METHODS: Out of 2231 consecutive patients who were admitted to the Tel Aviv Medical Center from May 1988 through December 1992 with the diagnosis of ischemic stroke, 129 admissions were due to recurrent ischemic strokes while the patients were already on aspirin, and these were defined as aspirin failures. The clinical characteristics of those patients in whom aspirin treatment failed were compared with three control groups, each comprising 129 patients who had had only a single ischemic stroke and were then taking aspirin. One control group was matched for aspirin dose and date of first stroke; another control group was matched for age, sex, and date of first stroke; and a third control group was matched for age, sex, date of first stroke, and aspirin dose. Statistical analysis was carried out by two-tailed Student's t test and chi 2 test. RESULTS: The average period until stroke was longer for patients on higher aspirin doses. Patients matched for aspirin dose and date of first stroke did not differ significantly in age (72.4 years in aspirin failures versus 74.2 years in the first control group) and sex (89 versus 94 men, respectively). Matching for age, sex, and date of first stroke but not for aspirin dose demonstrated a trend toward high frequency of aspirin failure in patients taking lower doses of aspirin (chi 2 test for trend = 3.5; P = .06). Comparison of aspirin-failure patients with a control group matched for age, sex, date of first ischemic stroke, and aspirin dose demonstrated that these patients more commonly had statistically significant hyperlipidemia (odds ratio, 2.6; 95% confidence interval, 1.0 to 6.8; P = .04) and ischemic heart disease (odds ratio, 2.3; 95% confidence interval, 1.3 to 3.9; P = .002). CONCLUSIONS: We conclude that age and sex do not influence the efficacy of aspirin. Lower aspirin dose in patients with stroke recurrence suggests that aspirin doses of 500 mg daily or more should be used in secondary stroke prevention. Hyperlipidemia and ischemic heart disease are risk factors for stroke recurrence despite aspirin treatment, which requires further clinical and laboratory evaluation.