Malignant middle cerebral artery infarction: a clinical study of 32 patients.

BACKGROUND AND OBJECTIVE: Malignant middle cerebral artery infarction is a devastating type of ischemic stroke whose clinical predictors remain scarcely known. The present study aims to improve the knowledge about the prognosis factors through an analysis of a malignant middle cerebral artery infarction sample of patients from our stroke registry. MATERIAL AND METHODS: From a total of 1,396 patients with ischemic stroke in the middle cerebral artery included in the "Sagrat Cor Hospital of Barcelona Stroke Registry", we identified 32 patients with malignant middle cerebral artery infarction (2.3%). Demographic, anamnestic, clinical, and outcome variables in this subgroup of patients were compared with those of the middle cerebral artery. The independent predictive value of each variable on the development of malignant middle cerebral artery infarction was assessed with a logistic regression analysis. RESULTS: The mean age was 74.7 (SD, 11.4) years and 50% were males. In-hospital death was observed in eight patients (25%) and early bad prognosis (in-hospital death or severe residual focality at discharge) was present in 16 patients (50%). Decreased consciousness (OR: 4.17; 95% CI: 2.02-8.61), presence of nausea or vomiting (OR: 3.65; 95% CI: 1.40-8.49), and heavy smoking (> 20 cigarettes/day; OR: 2.62; 95% CI: 1.03-6.64) appeared to be independent prognostic factors for malignant middle cerebral artery infarction in the multivariate analysis. CONCLUSIONS: Malignant middle cerebral artery infarction is an infrequent clinical condition associated with poor prognosis and high mortality rate. In our sample, decreased consciousness, nausea or vomiting, and heavy smoking are the main clinical factors associated.

Nineteen-year trends in risk factors, clinical characteristics and prognosis in lacunar infarcts.

BACKGROUND: Cardiovascular risk factors, clinical features and early outcome of first-ever cerebral lacunar infarcts from 1986 to 2004, using the Sagrat Cor Hospital of Barcelona Stroke Registry, were assessed and compared with data from patients with nonlacunar infarction. METHODS: The study population consisted of 566 patients with lacunar infarct and 1,516 patients with nonlacunar infarct. Secular trends for the periods 1986-1992, 1993-1998 and 1999-2004 were analyzed. RESULTS: Age and the percentage of very old patients (≥85 years old) increased significantly (p < 0.001) throughout the time period. There was a significant decrease in the percentage of patients with hypertension, but the percentage of patients with chronic obstructive pulmonary disease increased. The use of brain magnetic resonance imaging (MRI) also increased significantly. The median length of hospital stay decreased significantly. CONCLUSIONS: Significant changes over a 19-year period included an increase in the patients' age, frequency of very old patients (≥85 years old) and use of MRI studies, whereas the frequency of hypertension and length of hospital stay decreased.

Clinical predictors of lacunar syndrome not due to lacunar infarction.

BACKGROUND: Lacunar syndrome not due to lacunar infarct is poorly characterised. This single centre, retrospective study was conducted to describe the clinical characteristics of patients with lacunar syndrome not due to lacunar infarct and to identify clinical predictors of this variant of lacunar stroke. METHODS: A total of 146 patients with lacunar syndrome not due to lacunar infarction were included in the "Sagrat Cor Hospital of Barcelona Stroke Registry" during a period of 19 years (1986-2004). Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The characteristics of these 146 patients with lacunar syndrome not due to lacunar infarct were compared with those of the 733 patients with lacunar infarction. RESULTS: Lacunar syndrome not due to lacunar infarct accounted for 16.6% (146/879) of all cases of lacunar stroke. Subtypes of lacunar syndromes included pure motor stroke in 63 patients, sensorimotor stroke in 51, pure sensory stroke in 14, atypical lacunar syndrome in 9, ataxic hemiparesis in 5 and dysarthria-clumsy hand in 4. Valvular heart disease, atrial fibrillation, sudden onset, limb weakness and sensory symptoms were significantly more frequent among patients with lacunar syndrome not due to lacunar infarct than in those with lacunar infarction, whereas diabetes was less frequent. In the multivariate analysis, atrial fibrillation (OR = 4.62), sensorimotor stroke (OR = 4.05), limb weakness (OR = 2.09), sudden onset (OR = 2.06) and age (OR = 0.96) were independent predictors of lacunar syndrome not due to lacunar infarct. CONCLUSIONS: Although lacunar syndromes are highly suggestive of small deep cerebral infarctions, lacunar syndromes not due to lacunar infarcts are found in 16.6% of cases. The presence of sensorimotor stroke, limb weakness and sudden onset in a patient with atrial fibrillation should alert the clinician to the possibility of a lacunar syndrome not due to a lacunar infarct.

[In-hospital mortality in middle cerebral artery infarcts: clinical study of 1355 patients]. / Mortalidad hospitalaria en los infartos isquémicos de la arteria cerebral media: estudio de 1,355 pacientes.

BACKGROUND AND OBJECTIVES: To determine clinical predictors of in-hospital mortality in patients with middle cerebral artery infarcts (MCAI). PATIENTS AND METHODS: Data from 1.355 patients with MCAI were obtained from consecutive strokes included in the "Sagrat Cor Hospital of Barcelona Stroke Registry". Demographic, clinical, neuroimaging and outcome variables in the subgroup of patients who died were compared with those in the surviving subgroup. The independent predictive value of each variable on the development of death was assessed with a logistic regression analysis. Two predictive models were constructed. A first model was based on demographic, risk factors and clinical variables (total 14 variables). A second model was based on demographic, risk factors, clinical and outcome variables (total 20). RESULTS: In-hospital death was observed in 235 patients (17.3%). Early seizures (OR=4.49; CI 95%: 1.77-11.40), 85 years old or more (OR=2.61; CI 95%: 1.88-2.60), atrial fibrillation (OR=2.57; CI 95%: 1.89-3.49), limb weakness (OR=2.55; CI 95%: 1.40-4.66), cardiac heart disease (OR=2.33; CI 95%: 1.43-3.80) and sensory symptoms (OR=2.29; CI 95%: 1.68-3.12) appeared to be independent prognostic factors of in-hospital mortality in the first predictive model. In addition to these variables, cardiac complications (OR=5.50: CI 95%: 3.21-9.40), peripheral vascular complications (OR=3.74; CI 95%: 1.58-8.85), previous cerebral infarct (OR=1.89: CI 95%: 1.27-2.80), infections (OR=1.82; CI 95%; 1.27-2.61), and lacunar infarcts (OR=0.02; CI 95%: 0.01-0.17), appeared to be independent prognostic factors of in-hospital mortality in the second model. CONCLUSIONS: Clinical features easily obtained at the patient's bedside help clinicians to predict in-hospital mortality in patients with MCAI. Early seizures and age 85 years old or more, were the main clinical predictors of in-hospital mortality.

Trends in risk factors, stroke subtypes and outcome. Nineteen-year data from the Sagrat Cor Hospital of Barcelona stroke registry.

BACKGROUND: Prospective stroke registries allow analyzing important aspects of the natural history of acute cerebrovascular events. Using the Sagrat Cor Hospital of Barcelona Stroke Registry, we aimed to determine trends in risk factors, stroke subtypes, prognosis and in-hospital mortality over 19 years in hospitalized stroke patients. METHODS: The study population consisted of 2,416 first-ever stroke patients (ischemic stroke, n = 2,028; intracerebral hemorrhage, n = 334) included in the stroke registry up to December 31, 2004. Temporal trends in stroke patient characteristics for the periods 1986-1992, 1993-1998 and 1999-2004 were assessed. RESULTS: Age was significantly different among the analyzed periods (p < 0.001), showing an increment in older patients throughout time. Hypertension (p = 0.001), diabetes (p = 0.004), ischemic heart disease (p = 0.002) and atrial fibrillation increased (p = 0.000) as opposed to heavy smoking (p = 0.000) and history of TIA (p = 0.025). The mortality rate and the length of hospital stay decreased (p = 0.001), whereas transfer to convalescent/rehabilitation units increased (p = 0.001). CONCLUSIONS: An improvement in acute-stroke management and possibly evolution of cerebrovascular risk factors is reflected by changes in the risk factors and outcome of first-ever stroke patients admitted to a stroke unit over a 19-year time span.

Thalamic haemorrhage vs internal capsule-basal ganglia haemorrhage: clinical profile and predictors of in-hospital mortality.

BACKGROUND: There is a paucity of clinical studies focused specifically on intracerebral haemorrhages of subcortical topography, a subject matter of interest to clinicians involved in stroke management. This single centre, retrospective study was conducted with the following objectives: a) to describe the aetiological, clinical and prognostic characteristics of patients with thalamic haemorrhage as compared with that of patients with internal capsule-basal ganglia haemorrhage, and b) to identify predictors of in-hospital mortality in patients with thalamic haemorrhage. METHODS: Forty-seven patients with thalamic haemorrhage were included in the "Sagrat Cor Hospital of Barcelona Stroke Registry" during a period of 17 years. Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The region of the intracranial haemorrhage was identified on computerized tomographic (CT) scans and/or magnetic resonance imaging (MRI) of the brain. RESULTS: Thalamic haemorrhage accounted for 1.4% of all cases of stroke (n = 3420) and 13% of intracerebral haemorrhage (n = 364). Hypertension (53.2%), vascular malformations (6.4%), haematological conditions (4.3%) and anticoagulation (2.1%) were the main causes of thalamic haemorrhage. In-hospital mortality was 19% (n = 9). Sensory deficit, speech disturbances and lacunar syndrome were significantly associated with thalamic haemorrhage, whereas altered consciousness (odds ratio [OR] = 39.56), intraventricular involvement (OR = 24.74) and age (OR = 1.23), were independent predictors of in-hospital mortality. CONCLUSION: One in 8 patients with acute intracerebral haemorrhage had a thalamic hematoma. Altered consciousness, intraventricular extension of the hematoma and advanced age were determinants of a poor early outcome.

Clinical study of 99 patients with pure sensory stroke.

OBJECTIVE: We report a clinical description of pure sensory stroke based on data collected from a prospective acute stroke registry. METHODS: From 2500 acute stroke patients included in a hospital-based prospective stroke registry over a 12-year period, 99 were identified as having pure sensory stroke. RESULTS: Pure sensory stroke accounted for 4.7% of all acute stroke patients, 5.4% of acute ischemic stroke, and 17.4% of lacunar syndromes. Complete hemisensory syndrome was present in 80 patients and incomplete hemisensory syndrome in 19 (cheiro-oral syndrome 12, cheiro-oral-pedal 6, isolated oral syndrome 1). The lacunar hypothesis was fulfilled in 88% of patients. Atherothrombotic infarction occurred in 8 patients, intracerebral hemorrhage in 3, and stroke of undetermined cause in 1. Hemorrhagic pure sensory stroke was diagnosed in 1% of all cases of hemorrhagic stroke (n = 270) in the database. Outcome was good (in-hospital mortality 0%, symptom-free at discharge 41.5%). After multivariate analysis, absence of disability at discharge, hypertension, diabetes, hyperlipidemia, and thalamic (56.5%) and corona radiata (4%) locations were clinical and topographic variables significantly associated with pure sensory stroke. CONCLUSIONS: Pure sensory stroke is an infrequent cerebrovascular syndrome, in which the lacunar hypothesis is supported. Most patients had thalamic lacunar infarction. Incomplete hemisensory syndromes were also caused by a lacunar infarct in 84% of patients. Hemorrhagic pure sensory stroke accounted only for 3% of the cases. The prognosis is good with striking similarity to other lacunar strokes. There are important differences between pure sensory stroke and nonlacunar strokes.

[Trends in risk factors, clinical characteristics and prognosis in primary intracerebral haemorrhage (1986-2004)]. / Variaciones en el perfil clínico y pronóstico de las hemorragias intracerebrales no traumáticas (1986-2004).

BACKGROUND AND OBJECTIVES: Cardiovascular risk factors, clinical features and early outcome of first-ever primary intracerebral haemorrhage (PIH) from 1986 to 2004 using the Sagrat Cor Hospital of Barcelona Stroke Registry were assessed, and compared with data from patients with first-ever ischemic stroke. PATIENTS AND METHODS: The study population consisted of 380 patients with PIH and 2,082 patients with ischemic stroke. Secular trends for the periods 1986-1992, 1993-1998 and 1999-2004 were analyzed. RESULTS: Age increased significantly (P<.001) throughout the 3 study periods and there was a significant increase in the percentage of patients with atrial fibrillation, chronic obstructive pulmonary disease (COPD) and lobar topography. The use of brain magnetic resonance imaging (MRI) also increased significantly throughout the study periods. In comparison with ischemic stroke in-hospital death was more frequent (28,2 vs. 12%) and lacunar syndrome (9,5 vs. 31,4%) and symptom-free patients at discharge were less frequent in the intracerebral haemorrhage group (6,1 vs. 18,3%). CONCLUSIONS: Significant changes over a 19-year period included an increase in the patient's age, frequency of COPD and atrial fibrillation and use of MRI imaging studies. PIH is a severe subtype of stroke with a higher risk of early death and lower asymptomatic frequency at discharge than ischemic cerebral infarct.

Clinical characteristics of acute lacunar stroke in women: emphasis on gender differences.

There are few studies analyzing features of ischemic stroke subtypes in women. We assessed gender differences in lacunar stroke subtype based on data collected from a prospective stroke registry in Barcelona, Spain. Lacunar ischemic stroke was diagnosed in 310 (8.1 %) women and 423 (11.1 %) men of a total of 3,808 consecutive stroke patients included in a prospective hospital-based stroke registry, in Barcelona, Catalonia (Spain), over a period of 19 years. Independent factors for lacunar stroke in women were assessed by multivariate analysis. Women accounted for 42 % of all lacunar stroke patients (n = 733) in the registry and 11.4 % of all patients with ischemic stroke (n = 2,704). Very old age (85 years or older) was found in 20.3 % in women versus 11.1 % in men (P < 0.0001). In the logistic regression analysis, obesity [odds ratio (OR) = 4.24], prolonged hospital stay (>12 days) (OR = 1.59), arterial hypertension (OR = 1.50), and age (OR = 1.06) were significant variables independently associated with lacunar stoke in women, whereas peripheral vascular disease (OR = 0.51), chronic obstructive pulmonary disease (OR = 0.46), renal dysfunction (OR = 0.13), and heavy smoking (OR = 0.04) were independent variables for lacunar stroke in men. Women with lacunar stroke were remarkably older and presented with obesity and hypertension more frequently than did men. Lacunar stroke severity was similar in men and women. These findings in lacunar stroke patients could be explained by differences in gender for ischemic stroke in general.

Cortical laminar necrosis related to migrainous cerebral infarction.

We present a 29-year-old woman with a long history of attacks of migraine with and without visual aura. She was a heavy smoker (20 cigarettes/d) and was currently taking oral contraceptives. During a typical migraine attack with aura, she developed dysarthria, left brachial hemiparesis and hemihypoesthesia and brief and autolimited left clonic facial movements. Four hours after onset, vascular headache and focal sensorimotor neurological deficit were the only persisting symptoms and, on seventh day, she was completely recovered. Brain magnetic resonance imaging on day 20 after onset showed a subacute ischemic lesion in the right temporo-parietal cortex compatible with cortical laminar necrosis (CLN). Extensive neurological work-up done to rule out other known causes of cerebral infarct with CLN was unrevealing. Only ten of 3.808 consecutive stroke patients included in our stroke registry over a 19-year period fulfilled the strictly defined International Headache Society criteria for migrainous stroke. The present case is the unique one in our stroke registry that presents CLN related to migrainous cerebral infarction. Migrainous infarction can result in CLN.

[Relapsing non-traumatic intracerebral hemorrhage: study of 28 patients]. / Hemorragia intracerebral no traumática recurrente: estudio de 28 pacientes.

BACKGROUND AND OBJECTIVE: To characterize the clinical factors and prognosis and identify determinants of hemorrhage recurrence (HCR) in patients with acute non-traumatic intracerebral hemorrhage. PATIENTS AND METHOD: Stroke patterns were studied in 28 consecutive recurrent non-traumatic intracerebral hemorrhage patients admitted to the Department of Neurology of the Sagrat Cor Hospital of Barcelona for a 19 year period. Demographic, risk factors, clinical, neuroimaging and outcome variables were analyzed and compared with patients with first-ever non-traumatic intracerebral hemorrhage (n=380) to identify predictors of hemorrhage recurrence. Significant variables were entered into a multivariate logistic regression analysis. RESULTS: HCR accounted for 6.8% of all patients with acute consecutive non-traumatic intracerebral hemorrhages. The HCR were mostly lobar (67.9%). Other topographies include: thalamus (10.7%), capsule-ganglionar (7.1%), intraventricular (3.6%) and multiple topographies (10.7%). Although the HCR have poor prognosis, it is not worse compared to the first-ever intracerebral hemorrhages, both at the high hospital mortality (17.9 vs. 28.2%) as the low frequency of absence of limitation at discharge (3.6 vs. 6.1%). The clinical profile significantly associated with HCR was: valvular heart disease (odds ratio [OR] 5.32; 95% confidence interval [95% CI] 1.45-19.47), lobar topography (OR 3.53, 95% IC 1.53-8.13), and the presence of nausea and vomiting (OR 2.43, 95% IC 1.06-5.52). CONCLUSIONS: HCR constitute less than one tenth of non-traumatic intracerebral hemorrhages and are most commonly located in the brain lobes. Although the prognosis is serious, this is no worse during the acute phase, than of the first-ever non-traumatic intracerebral hemorrhages. Clinical profiles were different in recurrent non-traumatic intracerebral hemorrhage patients when compared to first-ever non-traumatic intracerebral hemorrhage patients.

[Recurrent ischemic stroke. Study of 605 patients]. / Infartos cerebrales recurrentes: estudio de 605 pacientes.

BACKGROUND AND OBJECTIVES: To characterize the clinical factors and prognosis and identify determinants of ischemic stroke recurrence in acute stroke. PATIENTS AND METHODS: Recurrent stroke patterns were studied in 605 consecutive patients admitted with a second or further ischemic stroke to the Department of Neurology of the Sagrat Cor Hospital of Barcelona over a 17 year period. Demographic, risk factors, clinical, neuroimaging and outcome variables were analyzed and compared with patients with first-ever cerebral infarction (n=2.099) to identify predictors of ischemic recurrent stroke. Significant variables were entered into a multivariate logistic regression analysis. RESULTS: Ischemic recurrent strokes accounted for 22.4% of all acute consecutive ischemic strokes. Frequency of ischemic stroke recurrence were significantly different among ischemic stroke subtypes: 26.2% in atherothrombotic, 24.4% in cardioembolic, 21.8% in lacunar stroke, 15.8% in infarcts of unusual etiology and 12% infarctions of uncertain etiology. The overall in-hospital mortality and symptom free at discharge in recurrent vs. non-recurrent stroke patients rate was 16.2 vs. 12% (p=0.005) and 17.8 vs. 27.3% (p=0.0001) respectively. Previous intracerebral hemorrhage (OR=3.07; 95% CI, 1.51-6.25), intermittent claudication (OR=1.39; 95% CI, 1.01-1.90), arterial hypertension (OR=1.32; 95% CI, 1.09-1.59), diabetes mellitus (OR=1.26; 95% CI, 1.02-1.56), age (OR=1.02; 95% CI, 1.01-1.03), female gender (OR=0.63; 95% CI, 0.52-0.77), headache (OR=0.62; 95% CI, 0.44-0.87) and bulbar topography (OR=0.21; 95% CI, 0.05-0.89) were independent clinical variables related to ischemic stroke recurrence. CONCLUSIONS: About one in every four patients with ischemic stroke had an ischemic stroke recurrence. In-hospital mortality is 16.2% and clinical profiles were different in ischemic stroke recurrence when compared to first-ever ischemic stroke patients.

Importance of cardiovascular risk profile for in-hospital mortality due to cerebral infarction.

INTRODUCTION AND OBJECTIVES: To investigate cardiovascular risk profiles and their prognostic implications in patients with different subtypes of cerebral infarction. METHODS: The study involved the retrospective analysis of data from a hospital stroke registry on 2704 consecutive CI patients who were admitted between 1986 and 2004. Of the 2704 strokes recorded, 770 were classified as thrombotic, 763 as cardioembolic, 733 as lacunar, 324 as undetermined and 114 as atypical. Multivariate analysis was used to compare cardiovascular risk profiles in each subtype and their influence on inhospital mortality. RESULTS: Arterial hypertension (AH) was present in 55.5%, atrial fibrillation (AF) in 29.8%, and diabetes mellitus in 23.4%. The in-hospital mortality rate was 12.9%, and in-hospital mortality was independently associated with AF (odds ratio [OR]=2.33; 95% confidence interval [CI], 1.84-2.96), and heart failure (HF) (OR=1.96; 95% CI, 1.33-2.89). In patients with thrombotic stroke, the cardiovascular risk factors associated with in-hospital mortality were HF (OR=2.87; 95% CI, 1.45-5.71), AF (OR=1.80; 95% CI, 1.09-2.96) and age (OR=1.06; 95% CI, 1.04-1.08). In patients with cardioembolic stroke, they were peripheral vascular disease (OR=2.18; 95% CI, 1.17-4.05), previous cerebral infarction (OR=1.75; 95% CI, 1.16-2.63), HF (OR=1.71; 95% CI, 1.01-2.90), and age (OR=1.06; 95% CI, 1.04-1.08). In those with undetermined stroke, they were AH (OR=3.68; 95% CI, 1.78-7.62) and age (OR=1.05; 95% CI, 1.01-1.09). CONCLUSIONS: Each cerebral infarction etiologic subtype was associated with its own cardiovascular risk profile. Consequently, the cardiovascular risk factors associated with mortality were also different for each ischemic stroke subtype.

Clinical implications of headache in lacunar stroke: relevance of site of infarct.

OBJECTIVE: To assess whether the infarction topography influenced upon the incidence of headache and the likelihood of neurological recovery in lacunar infarction. BACKGROUND: The relationship between topography of infarction and the incidence of headache as well as the influence of headache on neurological outcome in patients with lacunar stroke are still unclear. METHODS: In a cohort of 387 patients with neuroimaging-proven acute lacunar infarction collected from a prospective hospital-based stroke registry over a 12-year period, 43 patients (11.1%) presented with headache within a 72-hour interval of stroke onset. RESULTS: Headache was more common in deep brain gray matter or brainstem lacunar infarction than in supratentorial white matter lacunar infarction (14.9% vs 8%, P < .033), but lacunar infarctions in the supratentorial white matter had less frequently absence of limitation at discharge (15.1% vs 25.1%, P < .013). In deep brain gray matter or brainstem lacunar infarction, early neurological recovery decreased from 26.2% to 19.2% when headache was present at stroke onset. In the multivariate analysis, dysarthria-clumsy hand and absence of headache in deep brain gray matter or brainstem lacunar infarction were independent predictors of favorable outcome. CONCLUSIONS: In patients with lacunar infarction, headache at stroke onset was more common in deep brain gray matter or brainstem topographies than in supratentorial white matter lesions. In deep brain gray matter or brainstem lacunar infarctions, early neurological recovery was less likely when headache was present.

Stroke-related headache: a clinical study in lacunar infarction.

OBJECTIVE: To describe the characteristics of headache related to lacunar stroke based on data collected from a prospective hospital-based stroke registry over a 12-year period. Demographics, clinical variables, and prognostic features of lacunar stroke in patients with and without headache are compared. BACKGROUND: Stroke-related headache has been largely investigated, but there is little clinical data on headache in individualized stroke subtypes. METHODS: The cohort of 484 patients with lacunar infarction was selected. Forty-five (9.3%) presented headache within a 72-hour interval of stroke onset. Predictors of lacunar infarction with headache were assessed by logistic regression analysis. RESULTS: The intensity of headache was mild in severity and poorly localized (diffuse or bilateral headache). Tension-type headache was present in 36 patients (80%) and 9 patients (20%) presented nausea or vomiting while experiencing mild pulsating pain. The frequency of headache was 17% in patients with atypical lacunar syndrome, 12% in dysarthria-clumsy hand, 11.5% in pure sensory stroke, 9.4% in sensorimotor stroke, and 7.1% in pure motor hemiparesis. When patients with lacunar infarction with and without headache were compared, female sex, diabetes mellitus, nausea and vomiting, and mesencephalic topography were significantly more frequent and dysarthria and frequency of symptom free at discharge were less frequent in the headache group. In the multivariate analysis, mesencephalic topography (odds ratio [OR] 16.62), nausea and vomiting (OR 13.27), sex female (OR 2.29), diabetes mellitus (OR 1.96), and age (OR 0.95) were predictors of lacunar infarction with headache. CONCLUSIONS: Headache at the onset of a lacunar infarction is uncommon. Mesencephalic topography, nausea and vomiting, female sex, diabetes, and age were independent variables significantly associated with lacunar infarction with headache. These findings contribute to knowledge of stroke-related headache in patients with lacunes.

Prognostic value of very early seizures for in-hospital mortality in atherothrombotic infarction.

We studied the influence of very early seizures (within 48 h of stroke onset) on in-hospital mortality in a cohort of 452 consecutive patients with atherothrombotic infarction. These patients were selected from 2000 consecutive acute stroke patients registered in a prospective hospital-based stroke registry in Barcelona, Spain. A comparison of data between the nonseizure (n = 442) and seizure (n = 10) groups was made. Predictors of very early seizures were assessed by multivariate analysis. The in-hospital mortality rate was significantly higher in atherothrombotic stroke patients with very early seizures than in those without seizures (70 vs. 19.5%, p < 0.001). Independent predictors of in-hospital mortality included very early seizures, congestive heart failure, atrial fibrillation, 85 years of age or older, altered consciousness, dizziness, parietal and pons involvement, and respiratory and cardiac complications. After multivariate analysis, atherothrombotic infarction of occipital topography and decreased consciousness appeared to be independent predictors of atherothrombotic stroke with very early seizures. Very early seizures constitute an important risk factor for in-hospital mortality after atherothrombotic stroke.

Predicting spontaneous early neurological recovery after acute ischemic stroke.

We assessed predictors of spontaneous early neurological recovery after acute ischemic stroke by means of multivariate analysis in a cohort of 1,473 consecutive patients treated at one academic center. At hospital discharge, spontaneous neurological improvement or good outcome was defined as grades 0-2 of the Rankin scale, and poor outcome (no improvement or in-hospital death) as grades 3-5. Spontaneous recovery of neurological deficit at the time of discharge from the hospital was observed in 16% of patients with cerebral infarction (n = 238). Dysarthria-clumsy hand syndrome improved in 44% of patients and was the only variable significantly associated with in-hospital functional recovery in three logistic regression models that in addition to lacunar syndromes, included demographic variables, cardiovascular risk factors, and clinical variables [odds ratio (OR) 2.56], neuroimaging findings (OR 2.48), and outcome data (OR 2.39), respectively. Clinical factors related to severity of infarction available at stroke onset have a predominant influence upon in-hospital outcome and may help clinicians to assess prognosis more accurately. Our work gives a contribution into prognostic factors after acute ischemic stroke. With regard to patterns of stroke, dysarthria-clumsy hand syndrome was a significant predictor of spontaneous in-hospital recovery in ischemic stroke patients.

Variaciones en el perfil clínico y pronóstico de las hemorragias intracerebrales no traumáticas (1986-2004) / Trends in risk factors, clinical characteristics and prognosis in primary intracerebral haemorrhage (1986-2004)

Fundamento y objetivo: Analizar las variaciones de los factores de riesgo y el perfil clínico de las hemorragias intracerebrales no traumáticas (HIC) entre 1986 y 2004 a partir del registro de ictus del Hospital del Sagrat Cor, y comparar los datos de las HIC con los de los infartos cerebrales. Pacientes y método: Estudio hospitalario de 380 pacientes consecutivos con HIC y 2.082 pacientes con infarto cerebral. Se efectúa un análisis comparativo de las tendencias y variaciones clínicas observadas entre los períodos 1986-1992, 1993-1998 y 1999-2004. Resultados: La edad se incrementó significativamente (p < 0,001) durante los 3 períodos de estudio y se observó un aumento significativo en la frecuencia de fibrilación auricular, enfermedad pulmonar obstructiva crónica (EPOC) y de topografía cerebral lobular. El uso de la resonancia magnética (RM) cerebral también aumentó de forma significativa a través del período de estudio. En comparación con los infartos cerebrales, en las HIC fue más frecuente la mortalidad hospitalaria (28,2 frente al 12%) y menos habituales la presencia de un síndrome lacunar (9,5 frente al 31,4%) y la ausencia de sintomatología neurológica al alta hospitalaria (6,1 frente al 18,3%). Conclusiones: Se observan variaciones clínicas significativas durante dicho período de tiempo de 19 años, con un incremento en la edad de presentación, en la frecuencia de fibrilación auricular y EPOC y en el uso de la RM cerebral. La HIC constituye un subtipo de ictus grave con una mayor mortalidad precoz y una menor frecuencia de ausencia de sintomatología al alta hospitalaria en comparación con los infartos cerebrales (AU)

Background and objectives: Cardiovascular risk factors, clinical features and early outcome of first-ever primary intracerebral haemorrhage (PIH) from 1986 to 2004 using the Sagrat Cor Hospital of Barcelona Stroke Registry were assessed, and compared with data from patients with first-ever ischemic stroke. Patients and methods: The study population consisted of 380 patients with PIH and 2,082 patients with ischemic stroke. Secular trends for the periods 1986-1992, 1993-1998 and 1999-2004 were analyzed. Results: Age increased significantly (P < .001) throughout the 3 study periods and there was a significant increase in the percentage of patients with atrial fibrillation, chronic obstructive pulmonary disease (COPD) and lobar topography. The use of brain magnetic resonance imaging (MRI) also increased significantly throughout the study periods. In comparison with ischemic stroke in-hospital death was more frequent (28,2 vs. 12%) and lacunar syndrome (9,5 vs. 31,4%) and symptom-free patients at discharge were less frequent in the intracerebral haemorrhage group (6,1 vs. 18,3%). Conclusions: Significant changes over a 19-year period included an increase in the patient's age, frequency of COPD and atrial fibrillation and use of MRI imaging studies. PIH is a severe subtype of stroke with a higher risk of early death and lower asymptomatic frequency at discharge than ischemic cerebral infarct (AU)

Hemorragia intracerebral no traumática recurrente: estudio de 28 pacientes / Relapsing non-traumatic intracerebral hemorrhage: study of 28 patients

Fundamento y objetivo. Analizar las características demográficas, pronósticas y el perfil clínico relacionado con las hemorragias intracerebrales no traumáticas recurrentes (HCR). Pacientes y método. Estudio hospitalario descriptivo de 28 pacientes consecutivos ingresados durante un período de 19 años por presentar HCR. Se efectúa una comparación con 380 pacientes con una primera hemorragia intracerebral no traumática. Resultados. Las HCR representan el 6,8% del total de hemorragias intracerebrales primarias. Las HCR fueron mayoritariamente lobulares (67,9%). Otras topografías incluyen: el talámo (10,7%), la región capsuloganglionar (7,1%), la zona intraventricular (3,6%) y la topografía múltiple (10,7%). Aunque las HCR tienen mal pronóstico evolutivo, este no es peor en comparación con el de las primeras hemorragias cerebrales primarias, tanto por su elevada mortalidad hospitalaria (17,9 frente al 28,2%), como por su baja frecuencia de ausencia de limitación al alta hospitalaria (3,6 frente al 6,1%). El perfil clínico significativamente asociado con las HCR fue: presencia de valvulopatía (odds ratio [OR] 5,32; intervalo de confianza del 95% [IC 95%] 1,45-19,47), la topografía lobular (OR 3,53; IC 95% 1,53-8,13) y la presencia de náuseas y vómitos (OR 2,43; IC 95% 1,06-5,52). Conclusiones. Las HCR constituyen menos de una décima parte de las hemorragias intracerebrales no traumáticas ingresadas en el Servicio de Neurología, siendo más frecuentes las localizadas en los lóbulos cerebrales. Aunque su pronóstico es grave, este no es peor -durante su fase aguda- que el de las primeras hemorragias intracerebrales. Las HCR presentan un perfil clínico propio y diferenciado(AU)

Background and objetive. To characterize the clinical factors and prognosis and identify determinants of hemorrhage recurrence (HCR) in patients with acute non-traumatic intracerebral hemorrhage. Patients and method. Stroke patterns were studied in 28 consecutive recurrent non-traumatic intracerebral hemorrhage patients admitted to the Department of Neurology of the Sagrat Cor Hospital of Barcelona for a 19 year period. Demographic, risk factors, clinical, neuroimaging and outcome variables were analyzed and compared with patients with first-ever non-traumatic intracerebral hemorrhage (n=380) to identify predictors of hemorrhage recurrence. Significant variables were entered into a multivariate logistic regression analysis. Results. HCR accounted for 6.8% of all patients with acute consecutive non-traumatic intracerebral hemorrhages. The HCR were mostly lobar (67.9%). Other topographies include: thalamus (10.7%), capsule-ganglionar (7.1%), intraventricular (3.6%) and multiple topographies (10.7%). Although the HCR have poor prognosis, it is not worse compared to the first-ever intracerebral hemorrhages, both at the high hospital mortality (17.9 vs. 28.2%) as the low frequency of absence of limitation at discharge (3.6 vs. 6.1%). The clinical profile significantly associated with HCR was: valvular heart disease (odds ratio [OR] 5.32; 95% confidence interval [95% CI] 1.45-19.47), lobar topography (OR 3.53, 95% IC 1.53-8.13), and the presence of nausea and vomiting (OR 2.43, 95% IC 1.06-5.52). Conclusions. HCR constitute less than one tenth of non-traumatic intracerebral hemorrhages and are most commonly located in the brain lobes. Although the prognosis is serious, this is no worse during the acute phase, than of the first-ever non-traumatic intracerebral hemorrhages. Clinical profiles were different in recurrent non-traumatic intracerebral hemorrhage patients when compared to first-ever non-traumatic intracerebral hemorrhage patients(AU)

Infartos cerebrales recurrentes: estudio de 605 pacientes / Recurrent ischemic stroke. Study of 605 patients

Fundamento y objetivo: Analizar las características demográficas, pronósticas y el perfil clínico relacionados con los infartos cerebrales recurrentes (ICR).Pacientes y método: Estudio hospitalario descriptivo de 605 pacientes consecutivos ingresados durante un período de 17 años por presentar ICR. Se efectúa una comparación con 2.099 pacientes con un primer infarto cerebral.Resultados: Los ICR representan el 22,4% del total de infartos cerebrales. Se observaron ICR en el 26,2% de los infartos trombóticos, en el 24,4% de los cardioembólicos, en el 21,8% de los lacunares, en el 15,8% de los infartos inhabituales y en el 12% de los infartos esenciales. Los ICR tienen un peor pronóstico que los infartos no recurrentes, presentando una mayor mortalidad hospitalaria (16,2 frente al 12%; p=0,005) y una menor frecuencia de ausencia de limitación al alta hospitalaria (17,8 frente al 27,3%; p=0,0001). El perfil clínico significativamente asociado con los ICR fue: presencia de hemorragia cerebral previa (odds ratio [OR] 3,07; intervalo de confianza del 95% [IC 95%] 1,51-6,25), claudicación intermitente (OR 1,39; IC 95% 1,01-1,90), hipertensión arterial (OR 1,32; IC 95% 1,09-1,59), diabetes mellitus (OR 1,26; IC 95% 1,02-1,56), edad (OR 1,02; IC 95% 1,01-1,03), sexo femenino (OR 0,63; IC 95% 0,52-0,77), cefalea (OR 0,62; IC 95% 0,44-0,87) y la topografía bulbar (OR 0,21; IC 95% 0,05-0,89). Conclusiones: Los ICR constituyen aproximadamente una cuarta parte de los infartos cerebrales, siendo más frecuentes en los infartos trombóticos y en los cardioembólicos. Tienen un peor pronóstico, con una mayor mortalidad hospitalaria y una menor frecuencia de ausencia de limitación al alta. Presentan un perfil clínico diferenciado de los primeros infartos cerebrales (AU)

Background and objectives: To characterize the clinical factors and prognosis and identify determinants of ischemic stroke recurrence in acute stroke. Patients and methods: Recurrent stroke patterns were studied in 605 consecutive patients admitted with a second or further ischemic stroke to the Department of Neurology of the Sagrat Cor Hospital of Barcelona over a 17 year period. Demographic, risk factors, clinical, neuroimaging and outcome variables were analyzed and compared with patients with first-ever cerebral infarction (n=2.099) to identify predictors of ischemic recurrent stroke. Significant variables were entered into a multivariate logistic regression analysis. Results:Ischemic recurrent strokes accounted for 22.4% of all acute consecutive ischemic strokes. Frequency of ischemic stroke recurrence were significantly different among ischemic stroke subtypes: 26.2% in atherothrombotic, 24.4% in cardioembolic, 21.8% in lacunar stroke, 15.8% in infarcts of unusual etiology and 12% infarctions of uncertain etiology. The overall in-hospital mortality and symptom free at discharge in recurrent vs. non-recurrent stroke patients rate was 16.2 vs. 12% (p=0.005) and 17.8 vs. 27.3% (p=0.0001) respectively. Previous intracerebral hemorrhage (OR=3.07; 95% CI, 1.51-6.25), intermittent claudication (OR=1.39; 95% CI, 1.01-1.90), arterial hypertension (OR=1.32; 95% CI, 1.09-1.59), diabetes mellitus (OR=1.26; 95% CI, 1.02-1.56), age (OR=1.02; 95% CI, 1.01-1.03), female gender (OR=0.63; 95% CI, 0.52-0.77), headache (OR=0.62; 95% CI, 0.44-0.87) and bulbar topography (OR=0.21; 95% CI, 0.05-0.89) were independent clinical variables related to ischemic stroke recurrence. Conclusions: About one in every four patients with ischemic stroke had an ischemic stroke recurrence. In-hospital mortality is 16.2% and clinical profiles were different in ischemic stroke recurrence when compared to first-ever ischemic stroke patients (AU)