Early neurological and cognitive impairments in subclinical cerebrovascular disease.

BACKGROUND: The subclinical cerebrovascular disease (SCVD) is an important public health problem with demonstrated prognostic significance for stroke, future cognitive decline, and progression to dementia. The earliest possible detection of the silent presence of SCVD in adults at age at risk with normal functioning is very important for both clinical doctors and scientists. MATERIALS AND METHODS: Seventy-seven adult volunteers, recruited during the years 2005-2007, with mean age 58.7 (standard deviation 5.9) years, were assessed by four subtests from the Cambridge Neuropsychological Test Automated Battery (CANTAB)-Eclipse cognitive assessment system. We used a questionnaire survey for the presence of cerebrovascular risk factors (CVRFs) such as arterial hypertension, smoking and dyslipidemia, among others, as well as instrumental (Doppler examination) and neurological magnetic resonance imaging (MRI) procedures. Descriptive statistics, comparison (t-test, Chi-square) and univariate methods were used as followed by multifactor logistic regression and receiver operating characteristics analyses. RESULTS: The risk factor questionnaire revealed nonspecific symptoms in 44 (67.7%) of the subjects. In 42 (64.6%) of all 65 subjects, we found at least one of the conventional CVRFs. Abnormal findings from the extra- and trans-cranial Doppler examination were established in 38 (58.5%) of all studied volunteers. Thirty-four subjects had brain MRI (52.3%), and abnormal findings were found in 12 (35.3%) of them. Two of the four subtests of CANTAB tool appeared to be potentially promising predictors of the outcome, as found at the univariate analysis (spatial working memory 1 [SWM1] total errors; intra-extra dimensional set 1 [IED1] total errors [adjusted]; IED2 total trials [adjusted]). We established that the best accuracy of 82.5% was achieved by a multifactor interaction logistic regression model, with the role CVRF and combined CANTAB predictor "IED total ratio (errors/trials) × SWM1 total errors" (P = 0.006). CONCLUSIONS: Our results have contributed to the hypothesis that it is possible to identify, by noninvasive methods, subjects at age at risk who have mild degree of cognitive impairment and to establish the significant relationship of this impairment with existing CVRFs, nonspecific symptoms and subclinical abnormal brain Doppler/MRI findings. We created a combined neuropsychological predictor that was able to clearly distinguish between the presence and absence of abnormal Doppler/MRI findings. This pilot prognostic model showed a relatively high accuracy of >80%; therefore, the predictors may serve as biomarkers for SCVD in subjects at age at risk (51-65 years).

Associations between serum selenium and total plasma homocysteine during the acute phase of ischaemic stroke.

BACKGROUND/AIMS: Risk of ischaemic stroke (IS) was associated with total homocysteine (tHCY). On the other hand, serum selenium (Se) exhibited anti-aging and cardiopreventive effects. Se and tHCY showed relationships in animals but these were contradictory or inconclusive in humans; therefore, we searched for such associations in acute IS. METHODS: Ninety-four participants aged around 47 years were identified and 39 patients versus 46 healthy controls were analysed. Clinical, laboratory (blinded) and risk factor questionnaire methods were used. Comparison, correlation and multifactorial regression analyses were applied. RESULTS: IS patients were similar to controls concerning age and gender. IS was prevalent in the carotid system (76.9%); 82.1% had a subacute onset. IS patients expressed higher tHCY (14.65 +/- 9.79 micromol/l) and lower Se levels (1.3 +/- 0.5 micromol/l). Twice as many IS patients (23%) had optimal Se levels of <1.01 mumol/l. Subjects with hyperhomocysteinaemia (tHCY > or =15 micromol/l) showed lower Se levels during IS; Se accounted for 15.4% of tHCY variations (R = -0.393; p = 0.015) with unit change increasing tHCY by 8.25 units. Se remained predictive of tHCY levels after adjustments (vitamin B6, fibrinogen, triglycerides). CONCLUSIONS: Lower Se was observed during acute IS, being inversely associated with and predicting increased tHCY levels. Of note, there were more IS patients with suboptimal Se than controls.

Major vascular events after transient ischaemic attack and minor ischaemic stroke: post hoc modelling of incidence dynamics.

BACKGROUND: Only few follow-up studies have compared the long-term risk of such major vascular events (MVE) as myocardial infarction (MI) and/or stroke following transient ischaemic attack (TIA) or minor ischaemic stroke (MIS). Estimates of relative risk and cumulative long-term occurrence of MVE may provide better information and contribute to the optimization of treatment decisions. METHODS: In the current post hoc modelling study with unique data from Bulgaria, we analysed 183 consecutive patients with TIA (n = 89) or MIS (n = 94), aged >40 years, who were prospectively followed over 36 months for non-fatal or fatal MVE. The cumulative survival, hazard and risks (with 95% confidence intervals) for MVE (combined or by stratification) were calculated by Kaplan-Meier analysis and adjusted (age, sex) by multivariate Cox proportional hazard models. A set of regression models was then applied to MVE incidence (per 100 patients; 4-month intervals). RESULTS: Median follow-up was 36 months (interquartile range 30.8-36.0); no differences by age or sex were found (p > 0.05). The risk of non-fatal or fatal MVE was approximately 28% (stroke 19.7%, MI 8.2%). The adjusted cumulative risk of stroke was 0.21 versus 0.10 for MI. The odds ratio of TIA versus MIS was 0.75 (95% CI 0.43-1.32), i.e. lower for stroke (0.63, 0.31-1.25) than for MI (1.12, 0.40-3.14). The risk of non-fatal MVE was higher in MIS than in TIA (p(Breslow) = 0.0497), especially for non-fatal stroke (p = 0.0325). Time series regression models provided best estimates of the different outcome dynamics in TIA versus MIS (R(2)(TIA) = 0.969 with b(power) = 1.04 vs. R(2)(MIS) = 0.989 with b(linear) = 0.84; p(1-tailed) = 0.04) over the study period. CONCLUSIONS: The age- and sex-adjusted cumulative 36-month hazard of MVE is higher after MIS than after TIA, but MVE fatality was higher after TIA than after MIS. Although stroke incidence was higher (up to 3 times that of MI), with the highest difference between months 8 and 18, MI fatality was always higher in absolute, relative or adjusted terms. The above alarming patterns and increasing, diverging tendencies for MVE indicate a higher long-term cumulative risk after MIS compared with TIA. These results confirm our hypothesis of a differential risk of TIA versus MIS and, at least, point toward equal importance of therapies aimed at preventing MVE in both types of preceding conditions (TIA or MIS) and the increased fatality after MI, in particular in patients with TIA.

Transient ischaemic attacks and minor strokes (analyses and clinically significant comparisons).

UNLABELLED: The transient ischaemic attacks (TIA) and minor strokes are independent predictors of disabling strokes with a high medical and social value. PURPOSE: Analysis and comparison of the data from the clinical monitoring of TIA and minor stroke patients in correlation with the different duration of the transient neurological deficit. PATIENTS AND METHODS: 234 patients were monitored clinically in the Clinic of Cerebrovascular Diseases, University Hospital "St. George"-Plovdiv between 2002 and 2004. Clinical data were collected for 79 patients who met the clinical criteria for TIA and 155 patients who met the clinical criteria for minor stroke. Our protocol included medical history, cardiac and neurological examinations, assessment of cerebrovascular risk factors and laboratory tests. The instrumental assessment included CT scan, MRI and Doppler examination. The data were processed using descriptive statistics, non-parametric methods and charts. RESULTS: The comparative analysis between the TIA and minor stroke patients shows a significant difference only in the number of registered conductive disturbances, which are more frequent in the TIA patients. In the TIA group the significantly more frequent features are acute onset of the neurological deficit, significantly more frequent normal CT scan images or lacunar infarctions findings. In the minor stroke group the significantly more frequent features are the subacute onset, more frequent CT findings of vascular encephalopathy or CT scans revealing one large ischaemic zone. CONCLUSIONS: The differences may be explained with the dominant pathogenetic mechanisms in each of the conditions: microembolisation of extracranial vascular origin in TIA and local thrombosis or cardioembolisation in minor stroke. Previous vascular damage in minor stroke patients is more evident.

A case of encephalomyelopolyneuropathy in vitamin B12 deficiency.

UNLABELLED: A case of a 44-years-old patient with unusual clinical presentation of encephalomyelopolyneuropathy in vitamin B12 deficiency is presented. The disease manifested itself with gastrointestinal bleeding, which necessitated emergency hospitalisation in surgical clinic. Clinical examinations revealed atrophic gastritis, pernicious anemia, neurological and mental complications. The diagnosis was made according to the following criteria: physical examination--smooth tongue, atrophic gastritis, mild hepatosplenomegaly; laboratory findings--pernicious anemia, low vitamin B12 serum levels; neurological examination--syndrome of combined damage of the posterior and lateral columns of the spinal cord; magnetic resonance imaging--typical hyperintense areas on T2-weighted images in the posterior columns in the cervical regions of the spinal cord; transcranial magnetic stimulation--prolonged central motor conduction time of the motor evoked potentials bilaterally; psychological examination--cognitive decline. After treatment with vitamin B12 an improvement of the hematological findings, neurological deficit and cognitive impairments was found. CONCLUSION: Neurological complications could be an early manifestation of vitamin B12 deficiency. In diagnostic aspect similar complaints require examination of the serum levels of vitamin B12. The delay in diagnosis and inadequate therapy bear the risk of incomplete recovery of the neurological deficit. The current problem of "cognitive decline" necessitates routine examination of the serum levels of vitamin Bl2 in all patients with initial cognitive impairments and their prompt and approapriate treatment.

Nonrheumatic atrial fibrillation and left ventricular hypertrophy in the prognosis of reversible ischaemic neurological deficit.

Nonrheumatic atrial fibrillation (NRAF) and left ventricular hypertrophy (LVH) have long been recognised as risk factors for cerebral ischaemia and as predictors of recurrent vascular events. In the present study we aimed at determining the value of NRAF and LVH as predictors of recurrent vascular events in a cohort of patients with a first-ever episode of reversible ischemic neurological deficit (RIND). The study included 54 patients (37 men and 17 women, aged 62 +/- 9.6 yrs) who had suffered RIND; they were followed up for 30 days after the stroke in clinical conditions and for 12 months as outpatients. The patients were studied during the hospital stay by means of routine tests (electrocardiography, standard laboratory tests) and specialised studies (computer tomography, echocardiography). By the end of the one-year outpatient follow up there were 8 (14.8%) recurrent cerebrovascular events. By combining the statistically significant cerebrovascular risk factors (male sex, sudden onset of the event and moderately high systolic and diastolic blood pressure) with factors not reaching statistical significance (LVH, NRAF) we developed a statistically significant prediction model for patients with RIND.