Pseudoperipheral palsy due to cortical infarction.

We present two cases of isolated hand weakness that were initially thought to be due to lower motor neurone lesions until subsequent MRI confirmed strokes in both. Small strokes are important to identify in order to optimise secondary prevention.

Cerebral microbleeds are associated with lacunar stroke defined clinically and radiologically, independently of white matter lesions.

BACKGROUND AND PURPOSE: Associations among microbleeds, white matter lesions (WMLs), and small deep infarcts on imaging have been reported. Because many of these imaging infarcts were asymptomatic, the relationship of microbleeds to clinical lacunar stroke is unclear. An association between microbleeds and clinically defined lacunar stroke might suggest a common causal microangiopathy. METHODS: Patients with lacunar, partial anterior circulation or posterior circulation stroke syndromes and older healthy subjects underwent MRI. Microhemorrhages, infarcts, hemorrhages, and WMLs were coded blind to clinical details. A final clinicoradiologic stroke subtype diagnosis was assigned. RESULTS: Among 308 subjects (67 older healthy and 241 with stroke), 54 patients had microbleeds (17%). Microbleeds were twice as frequent in lacunar than cortical strokes (26% versus 13%, P=0.03) or healthy older subjects (9%) and associated with increasing WML scores (P<0.0001). Lacunar and cortical stroke subtypes and healthy older subjects had similar WML scores. CONCLUSIONS: Microbleeds are associated with lacunar stroke defined clinicoradiologically more than other stroke subtypes but not simply by association with WMLs. This suggests that microbleeds and lacunar stroke have a similar microvascular abnormality.

Antithrombotic therapy in patients with any form of intracranial haemorrhage: a systematic review of the available controlled studies.

Patients with intracranial haemorrhage may sometimes require antithrombotic drugs or be inadvertently given antithrombotic therapy. We systematically reviewed all published trials comparing any antithrombotic agent with control among patients with any form of intracranial haemorrhage. We extracted data on deaths, recurrent intracranial haemorrhage and functional outcome. There were 9 randomised trials of 5 different antithrombotic agents versus control in patients with subarachnoid haemorrhage (6 trials, n = 1,224) or with acute intracerebral haemorrhage (3 trials, n = 819). The overall odds ratio (OR) for death among patients with any intracranial haemorrhage given an antiplatelet agent (8 trials, 1,997 patients) was 0.85 (95% confidence interval, CI, 0.63-1.15), and for recurrent intracranial haemorrhage it was 1.00 (95% CI 0.73-1.37). The corresponding ORs for patients with intraparenchymal cerebral haemorrhage were 0.96 (0.62-1.5) and 1.02 (0.5-1.8), respectively, but 65% of these patients received only a few doses of antithrombotic treatment. The overall OR for death in patients with any intraparenchymal cerebral haemorrhage given heparin compared with control (3 trials, 819 patients, subcutaneous heparin) was 0.96 (95% CI 0.38-2.40), and for recurrent intracranial haemorrhage it was 2.00 (95% CI 0.86-4.70). There were no reliable data on the effects of antithrombotic agents on functional outcome. These scant data do not support reliable conclusions about the safety or otherwise of antithrombotic agents in patients with acute intracranial haemorrhage. Antithrombotic agents should be avoided where possible in patients with acute intracerebral haemorrhage.

Stroke epidemiology studies have underestimated the frequency of intracerebral haemorrhage. A systematic review of imaging in epidemiological studies.

INTRODUCTION: Small primary intracerebral haemorrhages (PICHs) cause mild stroke symptoms and resolve rapidly on CT. Delays in imaging in stroke incidence studies may therefore have inadvertently led to an underestimate of the frequency of small PICHs. OBJECTIVE: To determine whether the rate and timing of CT in community-based stroke incidence studies was adequate to determine accurately the proportion of strokes due to PICH. METHODS: A systematic review of community-based stroke incidence studies that included details on pathological type of stroke, excluding subarachnoid haemorrhage. We extracted information on the proportions of patients scanned, the timing of scans, characteristics of patients that were less likely to be scanned, and the proportion of ischaemic, or haemorrhagic, or unknown strokes. RESULTS: In the 25 studies identified, scanning methods were poorly documented. When mentioned, the median proportion of patients scanned was 63 % (95 % confidence intervals (CI) 60 to 85 %) and mostly performed outside the time for reliable distinction of PICH from ischaemic stroke (median 18.5 days, 95 % CI 7 to 30 days). Patients particularly likely to miss scanning were older, those not admitted to hospital or who died early after stroke. CONCLUSION: The scanning strategy documentation, the proportion of patients scanned and the timing of scanning in stroke incidence studies has been suboptimal. The frequency of a primary intracerebral haemorrhage, and its distribution in different age groups of patients or severities of stroke, has been underestimated. Future incidence studies should adopt more rigorous scanning policies and describe these policies more precisely.