Extracranial venous hemodynamics in multiple sclerosis: a case-control study.

OBJECTIVES: A chronic state of impaired cerebral and cervical venous drainage, termed chronic cerebrospinal venous insufficiency (CCSVI), has recently been implicated in the pathogenesis of multiple sclerosis (MS). We performed a color-coded Doppler sonography case-control study to externally validate the CCSVI criteria. METHODS: We prospectively evaluated consecutive patients with clinically definite MS and healthy volunteers using extracranial and transcranial color-coded Doppler sonography. The recently developed neurosonology criteria for CCSVI detection were used for interpretation of ultrasound assessments. The presence of venous reflux in cervical veins was assessed both in the sitting and upright position during a short period of apnea and after Valsalva maneuver. RESULTS: We recruited 42 patients with MS (mean age 39 ± 11 years, 17 men) and 43 control individuals (mean age 38 ± 12 years, 16 men). Very good/excellent intrarater and interrater agreement (κ values 0.82-1.00) was documented in 3 out of 5 CCSVI criteria. There was no evidence of stenosis or nondetectable Doppler flow in cervical veins in patients and controls. Reflux in internal jugular vein (IJV) was documented in 1 patient (2%) and 1 control subject (2%), both in sitting and supine posture during apnea. After performing Valsalva maneuver, we documented the presence of IJV valve incompetence in 3 patients with MS (7%) and 4 healthy volunteers (9%; p > 0.999). CONCLUSIONS: With established reproducibility of venous ultrasound testing, our data argue against CCSVI as the underlying mechanism of MS. Without further independent validation of CCSVI, potentially dangerous endovascular procedures, proposed as novel therapy for MS, should not be performed outside controlled clinical trials.

Multicenter external validation of the ABCD2 score in triaging TIA patients.

OBJECTIVES: A simple clinical score (ABCD(2) score) has been introduced to triage TIA patients with a high early risk of stroke. External validation studies have yielded inconsistent results regarding the predictive ability of the ABCD(2) score. We aimed to prospectively validate the former score in a multicenter case series study. METHODS: We prospectively calculated the ABCD(2) score (age [> or = 60 years: 1 point]; blood pressure [systolic >140 mm Hg or diastolic >90 mm Hg: 1[; clinical features [unilateral weakness: 2, speech disturbance without weakness: 1, other symptom: 0]; duration of symptoms [ <10 minutes: 0, 10-59 minutes: 1, > or = 60 minutes: 2]; diabetes mellitus [yes: 1]) in consecutive TIA patients hospitalized in 3 tertiary care neurology departments across 2 different racial populations (white and Asian). RESULTS: The 7-day and 90-day risks of stroke in the present case series (n = 148) were 8% (95% CI 4%-12%) and 16% (95% CI 10%-22%). The ABCD(2) score accurately discriminated between TIA patients with high 7-day (c statistic 0.72, 95% CI 0.57-0.88) and 90-day (c statistic 0.75, 95% CI 0.65-0.86) risks of stroke. The 90-day risk of stroke was 7-fold higher in patients with an ABCD(2) score >3 points (28%, 95% CI 18%-38%) than in patients with an ABCD(2) score < or = 3 points (4%, 95% CI 0%-9%). After adjustment for stroke risk factors, race, history of previous TIA, medication use before the index TIA and secondary prevention treatment strategies, an ABCD(2) score of >2 was associated with a nearly 5-fold greater 90-day risk of stroke (hazard ratio 4.65, 95% CI 1.04-20.84, p = 0.045). CONCLUSION: Our findings externally validate the usefulness of the ABCD(2) score in triaging TIA patients with a high risk of early stroke in a multiethnic sample of hospitalized patients. The present data support current guidelines endorsing the immediate hospitalization of patients with an ABCD(2) score >2.

Incidence and case fatality of subarachnoid haemorrhage in Northern Greece: the Evros Registry of Subarachnoid Haemorrhage.

BACKGROUND: Epidemiological data on subarachnoid haemorrhage incidence and case-fatality rates are scarce in the south-eastern Mediterranean region. We conducted a population-based study in Evros Province, located in north-eastern Greece, to determine subarachnoid haemorrhage incidence over a 5-year period (2001-2005). METHODS: Evros Province has a well-defined, largely homogeneous population with healthcare organised around a single tertiary-care University Hospital. We organised a prospective computerised registry of permanent Evros residents admitted or transferred to our hospital with a diagnosis of subarachnoid haemorrhage. Standard World Health Organization definitions and overlapping case-finding methods were used to identify all cases of first ever in a lifetime subarachnoid haemorrhage in all age groups, occurring during the study period. The diagnosis was confirmed by computed tomography scan in all hospitalised cases. Sudden deaths attributable to subarachnoid haemorrhage were systematically recorded province-wide by our forensic department and are included in the study. RESULTS: During the 5-year period, 51 cases of subarachnoid haemorrhage were recorded (28 men, 23 women; mean age 59+/-17 years). The crude annual incidence rates were 8.3/100,000 persons (95% confidence interval: 5.5-12.0) for men, 7.5/100,000 (4.8-11.3) for women and 7.9/100,000 (5.9-10.4) for all subjects. The standardised incidence rates for groups aged 45-84 years in the European population were 9.3/100,000 (5.8-12.8) for men, 6.5/100,000 (3.7-9.4) for women and 7.9/100,000 (5.7-10.2). The 28-day case-fatality rates for men, women and all subjects were 36% (21-54%), 35% (19-55%) and 35% (24-49%), respectively. CONCLUSIONS: The incidence and case-fatality rate of subarachnoid haemorrhage haemorrhage in Greece appear to be similar to other developed countries. No gender differences in subarachnoid haemorrhage incidence and case-fatality rate were documented.

Sleep architecture in stroke and relation to outcome.

The aim of this study was to investigate sleep architecture in stroke patients, and correlate possible disturbances with the topography, severity and outcome of stroke and the presence of sleep-disordered breathing (SDB). In total, 62 acute stroke patients and 16 age- and gender-matched hospitalised controls underwent polysomnographic studies. Sleep architecture was analysed according to the topography of lesion, severity (National Institutes of Health Stroke Scale) and outcome (Barthel Index) of stroke. We found that sleep architecture is disturbed in stroke patients, regardless of SDB. Stroke patients (without SDB) have reductions in total sleep time and sleep efficiency, reduced stage II and slow wave sleep, increased wakefulness during sleep and increased sleep latency. Rapid eye movement (REM) sleep is reduced when SDB is also present. REM sleep is relatively preserved in cerebellar strokes, as opposed to other topographies. Sleep stages I and REM are negatively associated with stroke severity, and the latency to REM sleep is positively correlated with a good outcome. Sleep architecture is impaired in stroke patients (with fragmentation, increased wakefulness and reduced slow wave sleep), and this correlates with severity and outcome. Sleep disturbances should be investigated and addressed in these patients. Further studies are needed to confirm these findings and assess the clinical and therapeutic implications.

Impact of dopamine transporter single photon emission computed tomography imaging using I-123 ioflupane on diagnoses of patients with parkinsonian syndromes.

To assess the impact of I-123 ioflupane single photon emission computed tomography (SPECT) imaging on classifying patients with striatal dopaminergic deficits. Sixty-one patients with an initial diagnosis of parkinsonism or uncertain tremor disorder were screened and followed-up for one year. All patients were re-examined by two neurologists at our centre and were classified as having neurodegenerative or non-neurodegenerative disorders. Patients underwent I-123 ioflupane SPECT imaging. SPECT studies were blindly evaluated and classified as normal or abnormal (indicative of neurodegenerative disorders). The overall agreement of the SPECT imaging results with the initial classification was 65.6% (kappa=0.229, p=0.074) but was 90.2% (kappa=0.782, p<0.001) with the classification of the neurologists at our centre. I-123 ioflupane SPECT imaging is a valuable method in the evaluation of patients presenting clinically with uncertain parkinsonian syndromes or for whom diagnostic doubt exists.

Apolipoprotein E and first-ever ischaemic stroke in Greek hospitalized patients.

The association between apolipoprotein E (ApoE) polymorphism and stroke is still controversial. This study investigated the potential association between ApoE genotypes and stroke subtypes, and risk factors for ischaemic stroke in Greek patients hospitalized with their first-ever ischaemic stroke. One hundred patients (70 men and 30 women; mean age +/- SD 60.7 +/-9.8 years) were included in the study. The control group comprised 96 age- and sex-matched healthy volunteers. Cerebral infarction was classified as atherothrombotic, cardioembolic or lacunar small-vessel stroke. The three common ApoE alleles (E2, E3 and E4) were determined using the semi-nested polymerase chain reaction. No significant difference in the ApoE alleles was found between patients and controls. Similarly, there was no significant association between ApoE alleles and stroke subtypes, common risk factors for ischaemic stroke and neck vessel stenosis. Although the sample size was small, these results do not support a role for ApoE polymorphism in the pathogenesis of ischaemic stroke.

Simultaneous, painless, homolateral oculomotor and trochlear nerve palsies in a patient with type 2 diabetes mellitus. Neuropathy or brainstem infarction?

Combined palsies of cranial nerves, especially of the oculomotor nerves, are distinctly uncommon, even in patients with diabetes mellitus. We present a patient with type 2 diabetes mellitus, arterial hypertension and hyperlipidaemia, who had simultaneous oculomotor and trochlear nerve palsies. An MRI scan showed multiple brainstem ischaemic infarcts. The patient was treated with intensified insulin regimen and clopidogrel. Symptoms gradually improved, and at 9 months there was no further improvement.

Carotid plaque echomorphology and serum vascular endothelial growth factor levels.

Neovascularization in atherosclerotic plaques plays an essential role in the progression and rupture of plaques. Vascular endothelial growth factor (VEGF) is an important angiogenic factor. Echomorphologic evaluation of carotid plaques using computer-assisted imaging was found to have a good correlation with the histology of the lesion. The aim of this study was to investigate whether the serum VEGF level could be a determinant of the echomorphology of the carotid plaque. In 28 carotid plaques causing 60-99% stenosis, serum VEGF levels and the mean gray value (MGV) of three-dimensional image of the carotid plaques were measured. A statistically significant inverse correlation was found between serum VEGF concentrations and MGVs (Spearman's correlation coefficient: -0.415, p = 0.028). Our finding indicates that in patients with > or =60% carotid stenosis the serum VEGF levels are associated with the echogenicity of the atherosclerotic plaque.

Retrospective study of febrile seizures: subsequent electroencephalogram findings, unprovoked seizures and epilepsy in adolescents.

A retrospective questionnaire to determine the prevalence of febrile seizures was given to adolescents (16- and 17-year-olds) in the final 2 years of secondary school at the five schools in Alexandroupolis, Greece. Parents were interviewed, and clinical and electroencephalographic examinations were performed in all adolescents with a history of febrile seizures. Of 1708 adolescents, 56 (3.3%) had experienced at least one febrile seizure. Of these, 44 (78.6%) were simple and 12 (21.4%) were complex febrile seizures. Recurrent seizures occurred in 22 cases (39.3%), and the mean age at onset was 25.1 months. There was a positive first-degree family history in eight cases (14.3%) and this increased to 27.3% in cases with recurrent seizures. Two of the adolescents (3.6%) had had one unprovoked seizure before the age of 3 years, and another two children developed epilepsy. Epileptiform electroencephalogram discharges were observed in only one case (1.8%) with generalized tonic-clonic epilepsy.