RESUMO
BACKGROUND AND PURPOSE: White matter hyperintensities (WMH) are a predictor of stroke among elderly individuals. This study aimed to evaluate the association between WMH severity and the risk of recurrent vascular events among Asian patients with ischaemic stroke with small-vessel disease (SVD) including micro/macrobleeds and lacunes. METHODS: Data from participants (n = 1454) in the PICASSO (PreventIon of CArdiovascular Events in iSchemic Stroke Patients with High Risk of Cerebral HemOrrhage) trial were reviewed. The severity of WMH in baseline brain magnetic resonance imaging scans was assessed using the Fazekas scale. The association between WMH severity and stroke (ischaemic or hemorrhagic) and major vascular events (MVEs) (a composite of stroke/myocardial infarction/vascular death) was assessed. RESULTS: Study patients had a significant burden of SVD: Fazekas score 0 (n = 2), 1 (n = 426), 2 (n = 650) and 3 (n = 376) [median Fazekas score 2 (mean follow-up, 1.9 ± 1.3 years)]. The stroke incidence rate per 100 personyears was 2.6 in the Fazekas 0-1 group, 3.6 in the Fazekas 2 group and 7.0 in the Fazekas 3 group, and the rates for MVEs were 3.3, 4.3 and 7.6, respectively. Compared with the Fazekas 0-1 group, the Fazekas 3 group was associated with a higher risk of stroke [adjusted hazard ratio (HR), 2.15; 95% confidence interval (CI), 1.19-3.88; P = 0.011], ischaemic stroke (adjusted HR, 2.11; 95% CI, 1.07-4.15; P = 0.031), hemorrhagic stroke (adjusted HR, 3.72; 95% CI, 1.09-12.70; P = 0.036) and MVEs (adjusted HR, 2.09; 95% CI, 1.20-3.66; P = 0.010). CONCLUSION: Advanced WMH in Asian patients with ischaemic stroke with SVD burden was associated with an increased risk of recurrent vascular events. It may exert an effect as a prognostic indicator in high risk of recurrent vascular events.
Assuntos
Isquemia Encefálica/etiologia , Hemorragia Cerebral/etiologia , Doenças de Pequenos Vasos Cerebrais/complicações , Acidente Vascular Cerebral/etiologia , Substância Branca/diagnóstico por imagem , Idoso , Isquemia Encefálica/diagnóstico por imagem , Hemorragia Cerebral/diagnóstico por imagem , Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Prognóstico , Acidente Vascular Cerebral/diagnóstico por imagemRESUMO
BACKGROUND AND PURPOSE: The association between past stroke subtypes and recurrent stroke subtypes in non-cardiogenic stroke remains unknown. METHODS: Patients with ischaemic stroke who had a past history of large-artery disease (LAD) or small-artery disease (SAD) subtypes were assessed. LAD was subdivided into intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS). LAD stroke mechanisms were categorized as artery-to-artery embolism, in situ thrombotic occlusion and local branch occlusion, while SAD was subdivided into lacunar infarction (LI) and branch atheromatous disease (BAD) on the basis of magnetic resonance imaging findings. The relationship between past and current strokes was analyzed. RESULTS: Among the 202 patients enrolled, the LAD group (nâ =â 111) had 64 and 47 patients with ICAS and ECAS, and the SAD group (nâ =â 91) had 63 and 28 patients with LI and BAD, respectively, at the time of past stroke. Patients with LAD developed LAD-associated strokes most often (nâ =â 99, 89.2%), and patients with SAD developed SAD most often (nâ =â 69, 75.8%; Pâ <â 0.001). Patients with ICAS were more likely to develop ICAS later (nâ =â 46, 79.3%), whereas those with ECAS developed ECAS more often (nâ =â 31, 75.6%; Pâ <â 0.001). Patients with ICAS presenting with artery-to-artery embolism more often developed artery-to-artery embolism later (nâ =â 26, 72.2%), whereas those with local branch occlusion developed recurrent local branch occlusion most often (nâ =â 10, 66.7%, Pâ =â 0.005). In the SAD group, patients with BAD developed LAD more frequently than the LI group (nâ =â 11, 39.3% vs. nâ =â 9, 14.3%, Pâ =â 0.022). CONCLUSIONS: The subtypes and mechanisms of recurrent stroke are significantly influenced by those of the past stroke.
Assuntos
Arteriosclerose Intracraniana/diagnóstico , Arteriosclerose Intracraniana/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Recidiva , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND AND PURPOSE: Along with intracranial atherosclerotic disease (ICAD), moyamoya disease (MMD) is the most common cause of middle cerebral artery (MCA) occlusion in Asians. Although they have differing vascular wall pathologies, conventional angiographic evaluation methods cannot easily differentiate MMD from ICAD in certain situations, such as in young patients with atherosclerotic risk factors. High resolution magnetic resonance imaging (HR-MRI) findings for the diseased segments of MCAs in MMD and symptomatic ICAD were compared to further elucidate differences in arterial wall changes. METHODS: Angiographically confirmed patients, 12 MMD and 20 ICAD, who suffered a stroke due to MCA occlusion were recruited and underwent HR-MRI. The size of the outer diameter and other stenotic vessel wall characteristics revealed by HR-MRI, including enhancement, eccentricity and other lesion patterns, were analyzed by two independent reviewers in a blind fashion. RESULTS: MMD patients were younger than ICAD patients (32.92 ± 11.08 years vs. 51.85 ± 11.97 years; mean ± SD) and displayed a smaller outer diameter in the stenotic portion (1.61 ± 0.43 mm for MMD vs. 3.03 ± 0.53 mm for ICAD, P < 0.0001). Eccentric lesions (three of 12 in MMD vs. 19 of 20 in ICAD, P < 0.0001) and focal enhancements in diseased areas (two of seven in MMD vs. 13 of 17 in ICAD, P = 0.061) were less common in MMD cases. CONCLUSIONS: Our HR-MRI findings show that MMD is associated with smaller, concentric occlusive lesions which are rarely enhanced compared with symptomatic ICAD, consistent with the results of previous pathological reports. HR-MRI may therefore have utility in differentiating MMD from ICAD.
Assuntos
Diagnóstico Diferencial , Arteriosclerose Intracraniana/diagnóstico , Imageamento por Ressonância Magnética/métodos , Doença de Moyamoya/diagnóstico , Adulto , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND AND PURPOSE: A cardiogenic embolus could reach the posterior circulation through the right vertebral artery because of a relatively larger diameter in cases of left vertebral artery hypoplasia. Hence, we investigated whether left vertebral artery hypoplasia is associated with cardiac embolisms with atrial fibrillation in the posterior circulation and its functional outcomes. MATERIALS AND METHODS: In this monocentric retrospective study, patients with acute cardioembolic stroke with atrial fibrillation were enrolled and underwent CT or neck MRA, which visualized the aortic arch and subclavian arteries. The laterality and size of vertebral artery hypoplasia were recorded. Posterior circulation stroke, basilar artery occlusion, and the functional outcomes after 3 months were investigated. RESULTS: This study included 407 patients; the patients with left vertebral artery hypoplasia experienced a higher rate of posterior circulation stroke (19 versus 73; 42.2% versus 20.2%; P = .001) and basilar artery occlusion (5 versus 10; 11.1% versus 2.8%; P = .005) than the patients without left vertebral artery hypoplasia. Multivariate analysis revealed that left vertebral artery hypoplasia showed an association with lower odds of achieving a good functional outcome 3 months after the stroke (OR = 0.4; 95% CI, 0.2-0.9; P = .027). CONCLUSIONS: Patients with cardioembolic stroke and left vertebral artery hypoplasia had posterior circulation stroke, basilar artery occlusion, and poor functional outcomes after 3 months.
Assuntos
Arteriopatias Oclusivas , Fibrilação Atrial , AVC Embólico , Acidente Vascular Cerebral , Insuficiência Vertebrobasilar , Humanos , Artéria Vertebral/diagnóstico por imagem , AVC Embólico/complicações , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico por imagem , Aorta Torácica , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Arteriopatias Oclusivas/complicações , Insuficiência Vertebrobasilar/complicações , Insuficiência Vertebrobasilar/diagnóstico por imagemRESUMO
OBJECTIVES: Specific guidelines for initial dosing of warfarin in ischaemic stroke patients have not been developed. Therefore, we have developed an age- and weight-adjusted warfarin initiation nomogram (AW-WIN) for ischaemic stroke patients and then evaluated the efficacy and safety of AW-WIN compared with physician-determined warfarin dosing (PDWD). METHODS: The age- and weight-adjusted warfarin initiation nomogram was administered to 104 acute ischaemic stroke patients between January 2008 and February 2009. A historical control group (PDWD) of 96 patients was selected from comparable patients who were discharged with warfarin during the previous year. Time-to-therapeutic international normalized ratios (INRs) and the incidence of excessive anticoagulation were compared in the AW-WIN and PDWD groups. RESULTS: The general characteristics, risk factors, and stroke mechanism of the AW-WIN and PDWD groups did not differ significantly. The mean time to INR ≥ 2.0 was significantly shorter in the AW-WIN than in the PDWD group (4.9 ± 0.7 vs. 6.2 ± 0.8 days, P = 0.0008). After adjustment for potential confounding variables, the AW-WIN group reached target INR faster than the PDWD group (hazard ratio, 1.76; 95% confidence interval, 1.26-2.45; P = 0.001). The time-to-therapeutic INR ≥1.7 was shorter (P = 0.0002), the proportion of patients with therapeutic INR (2-3) at 5 days was higher (P = 0.002), and the rate of excessive anticoagulation of ≥3.5 INR during hospitalization was lower (P = 0.024) in the AW-WIN than in the PDWD group. CONCLUSIONS: AW-WIN reduces the time to target INR and the risk of excessive anticoagulation. AW-WIN may be an efficient and safe method of anticoagulation during the acute phase of ischaemic stroke.
Assuntos
Anticoagulantes/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Varfarina/administração & dosagem , Fatores Etários , Idoso , Peso Corporal , Feminino , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Nomogramas , Fatores de RiscoRESUMO
BACKGROUND AND PURPOSE: Lateral thalamic infarction (LTI) is usually caused by small vessel disease (SVD), i.e., occlusion of the deep perforator. However, focal atherosclerotic posterior cerebral artery disease (PCAD) may produce LTI via thrombotic occlusion of the perforator. We aimed to investigate the prevalence of PCAD in LTI and differences in clinical and imaging findings between LTIs associated with PCAD and SVD. METHODS: We retrospectively evaluated 58 consecutive patients with isolated LTI who underwent diffusion-weighted imaging (DWI) and MR angiography (MRA) within 7 days after stroke onset. Patients were divided into two groups: those with PCAD and those with SVD. Clinical syndromes were divided into pure sensory stroke (PSS) and sensory stroke plus (SS-plus), i.e., the concomitant presence of motor dysfunction or ataxia. Clinical and imaging findings were compared between these two groups. RESULTS: Of the 58 patients, 13 (22.4%) had PCAD. PSS was more frequently associated with SVD than with PCAD (57.8% vs. 23.1%, P=0.032). Initial DWI lesion volume (cm³) was significantly larger in PCAD than in patients with SVD (0.38±0.13 vs. 0.33±0.22, P=0.025). Among the 23 patients (39.7%) who underwent follow-up DWI, patients with PCAD showed a significantly greater increase in subacute lesion volume than those with SVD (P=0.019). Although National Institutes of Health Stroke Scale scores did not differ at admission (P=0.185), they were significantly higher at discharge in PCAD than in patients with SVD (P=0.012). CONCLUSIONS: Our data suggest that PCAD is an important cause of LTI, being related to SS-plus, larger lesion volume, and worse clinical outcomes.
Assuntos
Doenças Arteriais Cerebrais/patologia , Infarto da Artéria Cerebral Posterior/patologia , Artéria Cerebral Posterior/patologia , Tálamo/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Arteriais Cerebrais/complicações , Doenças Arteriais Cerebrais/fisiopatologia , Feminino , Humanos , Infarto da Artéria Cerebral Posterior/etiologia , Infarto da Artéria Cerebral Posterior/fisiopatologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tálamo/fisiopatologiaRESUMO
BACKGROUND AND PURPOSE: Currently, the characteristics of carotid plaques are considered important factors for identifying subjects at high risk of stroke. This study aimed to test the hypothesis that carotid plaque composition assessed by CTA is associated with an increased risk of future major adverse cardiovascular events among asymptomatic subjects with moderate-to-severe carotid artery stenosis. MATERIALS AND METHODS: This single-center, retrospective cohort study included 194 carotid plaques from 176 asymptomatic subjects with moderate-to-severe carotid artery stenosis. The association of CTA-determined plaque composition with the risk of subsequent adverse cardiovascular events was analyzed. RESULTS: During a median follow-up of 41 months, the adverse cardiovascular event incidence among 194 carotid plaques was 19.6%. There were significant differences in plaque Hounsfield units (P < .001) and spotty calcium presence (P < .001) between carotid plaques from subjects with and without subsequent adverse cardiovascular events. Multivariable analysis revealed carotid plaque Hounsfield unit density (P < .001) and spotty calcium (P < .001) as independent predictors of subsequent adverse cardiovascular events. In association with moderate carotid artery stenosis, the plaque Hounsfield unit values were significantly lower among carotid plaques from subjects who experienced subsequent adverse cardiovascular events (P = .002), strokes (P = .01), and cardiovascular deaths (P = .04); the presence of spotty calcium was significantly associated with the occurrence of adverse cardiovascular events (P = .001), acute coronary syndrome (P = .01), and cardiovascular death (P = .04). CONCLUSIONS: Carotid plaque Hounsfield unit density and spotty calcium were independent predictors of a greater risk of adverse cardiovascular event occurrence.
Assuntos
Estenose das Carótidas , Placa Aterosclerótica , Artérias Carótidas , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Humanos , Placa Aterosclerótica/complicações , Placa Aterosclerótica/diagnóstico por imagem , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND AND PURPOSE: Biological aspirin resistance (AR) has been recognized as an important cause of clinical AR. Recent studies have reported the beneficial effects of cilostazol for the prevention of cardiovascular diseases. This study investigated whether addition of cilostazol to aspirin in ischaemic stroke patients can reduce AR. METHODS: In this double-blind multicenter trial, 244 aspirin users with ischaemic stroke were randomly assigned to receive cilostazol 100 mg twice daily or to placebo. Antiplatelet function was assessed using the VerifyNow Aspirin system. The primary end-point was the incidence of AR, which was measured as aspirin resistance unit (ARU) > or =550 after 4-week treatment. RESULTS: The incidence of AR after treatment in cilostazol group was not significantly different from that in placebo (8.8% vs. 10.9%, P = 0.578). However, AR decreased from 12.8% to 8.8% in cilostazol group, whereas it was not changed in the placebo group. The mean ARU after treatment were also lower in the cilostazol group (456.9 +/- 56.0 vs. 470.7 +/- 67.2, P = 0.081). Cilostazol addition did not prolong bleeding time. CONCLUSIONS: Although this was a negative study, our findings disclosed a trend toward enhanced antiplatelet effects when cilostazol was added to aspirin in ischaemic stroke patients. Combination of aspirin and cilostazol might be a treatment option in the ischaemic stroke patients with AR.
Assuntos
Aspirina/uso terapêutico , Isquemia Encefálica/tratamento farmacológico , Resistência a Medicamentos/efeitos dos fármacos , Inibidores da Agregação Plaquetária/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Tetrazóis/uso terapêutico , Aspirina/administração & dosagem , Tempo de Sangramento , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Cilostazol , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/administração & dosagem , Prognóstico , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Tetrazóis/administração & dosagem , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to compare the effects of antihypertensive agents on cerebral blood flow (CBF) in hypertensive patients with previous ischemic stroke. MATERIALS AND METHODS: In this double-blind, multi-center, non-inferiority trial, 196 patients were randomized to cilnidipine 10-20 mg or losartan 50-100 mg once daily for 4 weeks. Baseline and follow-up CBF as measured by single photon emission computed tomography were obtained in 167. The primary endpoint was the global CBF change. The secondary endpoints were the CBF change in the hemisphere ipsilateral to the index stroke, non-impairment of global CBF and blood pressure (BP) reduction. RESULTS: Global CBF increased significantly in the cilnidipine arm (9.0 +/- 29.6%, P = 0.0071) and the losartan arm (11.4 +/- 31.4%, P = 0.0012), and these changes were not different between the two groups (P = 0.607). However, the estimated difference in percentage global CBF change between the two groups was -2.43% (97.5% CI, -13.06% to 8.21%), which crossed the predetermined non-inferiority margin of -8.6%. Ipsilesional hemispheric CBF change, non-impairment of global CBF and BP reduction were similar in the two groups. CONCLUSIONS: This trial failed to prove the non-inferiority of cilnidipine to losartan regarding global CBF change. Both the treatments, however, increase the global CBF despite BP lowering.
Assuntos
Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Isquemia Encefálica/epidemiologia , Bloqueadores dos Canais de Cálcio/uso terapêutico , Di-Hidropiridinas/uso terapêutico , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Losartan/uso terapêutico , Doença Aguda , Idoso , Encéfalo/diagnóstico por imagem , Isquemia Encefálica/diagnóstico por imagem , Circulação Cerebrovascular/fisiologia , Método Duplo-Cego , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada de Emissão de Fóton ÚnicoRESUMO
BACKGROUND: Atherosclerotic middle cerebral artery (MCA) disease may produce subcortical infarction either in the upper part (corona radiata, CR) or in the lower area (internal capsule, IC) of the pyramidal tract. The study aimed to see whether the location of MCA stenosis (proximal vs distal) determines the location of subcortical infarction. METHODS: 62 consecutive patients who developed an acute (<72 h) infarction either on the CR or IC confirmed by diffusion-weighted MRI due to corresponding focal MCA M1 stenosis assessed by MR angiography were studied. The distance between the MCA origin and the centre of stenotic portion (S) and that between the MCA origin and its bifurcation site (M) were measured. Based on the S/M ratio, stenotic lesions were divided into "proximal' and "distal'. The relationship between the location of arterial stenosis and the location of infarcts was analysed. RESULTS: Thirteen of 31 patients (41.9%) with proximal M1 stenosis had IC lesions, while 26 (83.9%) of 31 patients with distal stenosis had CR lesions (p = 0.025). The S/M ratio in patients with the CR infarcts (mean (SD) 0.65 (0.21) was significantly greater than in those with the IC infarcts (0.48 (0.23)) (p = 0.007). In addition, the National Institutes of Health Stroke Scale score at admission was higher in patients with proximal M1 stenosis than in those with distal stenosis (6 vs 3.5; p = 0.04). CONCLUSIONS: The results suggest that perforating arteries arising from the distal M1 segment are related to infarcts involving the upper part of pyramidal tract, while those from proximal segment are related to lower lesions.
Assuntos
Infarto da Artéria Cerebral Média/patologia , Cápsula Interna/patologia , Arteriosclerose Intracraniana/patologia , Artéria Cerebral Média/patologia , Tratos Piramidais/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral , Constrição Patológica , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Cápsula Interna/irrigação sanguínea , Cápsula Interna/diagnóstico por imagem , Arteriosclerose Intracraniana/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Tratos Piramidais/irrigação sanguínea , Tratos Piramidais/diagnóstico por imagem , Estudos RetrospectivosRESUMO
BACKGROUND: Despite its proven effect, anticoagulation is not recommended to the acute ischaemic stroke due to the risk of bleeding complications. The purpose of this study is development of individualized warfarin initiation program for acute or subacute stroke patients. METHODS: Among stroke patients who regularly visited out-patient clinics, we included patients who have continuously taken the same dose of warfarin as the prothrombin time remained at target International Nomarlized Ratio (INR). We assessed potential variables that affect the maintenance dose of warfarin. Using these variables, we developed an individualized warfarin initiation program. RESULTS: The median warfarin maintenance dose (interquartile range) in the 321 included patients was 4 (3-5) mg per day. Age (adjusted R(2) = 0.221, P < 0.001) and body weight (added to age, adjusted R(2) = 0.238, P = 0.008) were significant predicting factors of the dose. We classified the maintenance doses into high (HG), standard, and low group (LG) based on the distribution of maintenance doses. Decision tree analysis categorized younger (
Assuntos
Anticoagulantes/administração & dosagem , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle , Trombose/tratamento farmacológico , Varfarina/administração & dosagem , Fatores Etários , Idoso , Anticoagulantes/efeitos adversos , Índice de Massa Corporal , Esquema de Medicação , Feminino , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Resultado do Tratamento , Varfarina/efeitos adversosRESUMO
BACKGROUND: With magnetic resonance imaging (MRI) analysis, we investigated the prevalence, clinical significance, and factors related to the presence of unrecognized cerebral infarcts in patients with first-ever ischaemic stroke. METHODS: We consecutively included patients who were admitted with first-ever stroke. Unrecognized cerebral infarct was defined as an ischaemic infarction or primary intracerebral hemorrhage on MRI irrelevant to the index stroke, without acute lesions on diffusion-weighted image. RESULTS: Of the total 203 patients, 78 (39.4%) patients were observed as having unrecognized cerebral infarct. Patients with high-risk cardioembolic sources (e.g., atrial fibrillation) more frequently had unrecognized stroke than those without (P = 0.008, 21/36 [58.3%] vs. 57/167 [34.1%]). On univariate analysis, male sex (P = 0.027) and cardioembolic source (P = 0.008) were associated with the presence of unrecognized cerebral infarcts. After adjustment for gender, age and risk factors, the presence of cardioembolic sources independently increased the risk of unrecognized cerebral infarct (P = 0.002, odds ratio 3.56, 95% confidence interval 1.58-8.02). Regarding clinical outcome at 3 months, the presence of unrecognized cerebral infarct was not associated with the poor clinical outcome. CONCLUSION: In our study, the presence of cardioembolic sources was an independent risk factor for the unrecognized cerebral infarct in patients with first-ever stroke.
Assuntos
Infarto Cerebral/epidemiologia , Cardiopatias/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Análise de Variância , Infarto Cerebral/classificação , Infarto Cerebral/complicações , Infarto Cerebral/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Eletrocardiografia/métodos , Feminino , Cardiopatias/complicações , Humanos , Angiografia por Ressonância Magnética/métodos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Prevalência , Radiografia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/classificação , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/radioterapiaRESUMO
BACKGROUND AND PURPOSE: Some patients develop major neurological complications after carotid revascularization procedures, despite the lack of new infarcts or classical hyperperfusion syndrome. METHODS: In four patients who developed major neurological deficits after carotid revascularization procedures, but without evidence of new ischemic infarcts or hyperperfusion, we performed post-procedural MRI [diffusion-weighted image (DWI), perfusion-weighted image (PWI), pre-and post-contrast fluid-attenuated inversion recovery (FLAIR) image] immediately after and 1 day after the procedure. RESULTS: Post-gadolinium FLAIR images on 1 day after the procedures showed prominent leptomeningeal enhancements in the revascularized hemispheres. These radiological findings disappeared on follow-up FLAIR images accompanied by the clinical improvement over the following several days after the procedures. CONCLUSION: Reperfusion syndrome may be associated with transient severe neurological deficits after carotid revascularization in patients without new ischemic events or classical hyperperfusion syndrome.
Assuntos
Encéfalo/fisiopatologia , Revascularização Cerebral/efeitos adversos , Doenças do Sistema Nervoso/etiologia , Traumatismo por Reperfusão/complicações , Idoso , Idoso de 80 Anos ou mais , Mapeamento Encefálico , Artérias Carótidas/fisiopatologia , Diagnóstico por Imagem , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Doenças do Sistema Nervoso/fisiopatologia , Traumatismo por Reperfusão/fisiopatologiaRESUMO
BACKGROUND: Although basilar artery atherosclerotic disease (BAD) is frequent in patients with pontine base infarction, it remains unknown whether BAD is related to the lesion size or clinical outcome. METHODS: We studied 56 patients with unilateral pontine base infarction who underwent (i) diffusion-weighted MRI within 48 h after stroke onset and (ii) follow-up MRI and MR angiography in the subacute stage. Neurologic progression was defined as increased National Institutes of Health Stroke Scale score by > or = 2 during admission. Clinical outcome was dichotomized as good and poor (> or = 3) according to the modified Rankin Scale at 1 month after stroke onset. RESULTS: Twenty-two patients (39%) had BAD and 15 patients (27%) had neurologic progression. Follow-up MRI performed at median 3.5 +/- 1.1 days after the initial MRI showed the lesion volume significantly increased (P < 0.001). The BAD was not significantly related to demographic characteristics, risk factors, initial and follow-up lesion volume, neurologic progression and clinical outcome, but was closely related to the subacute increase in lesion volume (P = 0.004 for 20% increase, P = 0.029 for 50% increase). CONCLUSIONS: BAD is related to subacute increase in lesion volume, but not to ultimate poor clinical outcome in patients with pontine base infarction.
Assuntos
Aterosclerose/complicações , Infartos do Tronco Encefálico/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aterosclerose/patologia , Artéria Basilar/patologia , Infartos do Tronco Encefálico/patologia , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ponte/irrigação sanguínea , Ponte/patologia , Prognóstico , Estudos RetrospectivosRESUMO
BACKGROUND: Fluoxetine may improve the poststroke emotional disturbances. The purpose of the present study was to evaluate the efficacy of fluoxetine on quality of life (QOL) over time in stroke patients with emotional disturbances. METHODS: We studied 152 consecutive stroke patients (mean age, 58 years) who had either poststroke depression (PSD), emotional incontinence (PSEI) or anger proneness (PSAP) at an average of 14 months (range = 3-28) after the onset of stroke. The Korean version of SF-36 was used to assess the QOL. The presence of PSD, PSEI and PSAP was also determined with a standardized questionnaire. The subjects were given either 20 mg/day of fluoxetine (n = 76) or placebo (n = 76) for 3 months. Follow-up evaluations were done at 3, 6 and 12 months after the beginning of the treatment. RESULTS: The score in the mental health domain was significantly higher in the fluoxetine group than in the placebo group at the 3-, 6- and 12-month follow-ups. The scores in the general health (p < 0.05) and social functioning (p < 0.05) domains were also significantly higher in the fluoxetine than in the placebo group at 12 months of follow up even if there was no definitive improvement in PSD, PSEI and PSAP at this time. CONCLUSIONS: Fluoxetine is effective in improving QOL, particularly so in the mental health subdomain. Our results suggest that fluoxetine may be used to improve the QOL of stroke patients with emotional disturbances.
Assuntos
Sintomas Afetivos/tratamento farmacológico , Antidepressivos de Segunda Geração/uso terapêutico , Depressão/tratamento farmacológico , Fluoxetina/uso terapêutico , Qualidade de Vida , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Acidente Vascular Cerebral/psicologia , Sintomas Afetivos/etiologia , Idoso , Depressão/etiologia , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/tratamento farmacológico , Inquéritos e Questionários , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: The spatial resolution of 3D time-of-flight MR angiography (TOF-MRA) can be improved within a reasonable examination time by combining 3T and sensitivity encoding technique. We evaluated the diagnostic performance of high-resolution 3D TOF-MRA at 3T in patients with suspected atherosclerotic steno-occlusive disease of the intracranial arteries. MATERIALS AND METHODS: We assessed 160 arteries in 39 patients: 68 distal internal carotid arteries, 68 middle cerebral arteries, and 24 vertebrobasilar arteries. The measured voxel size of 3D TOF-MRA was 0.28 x 0.56 x 1.2 mm(3). Steno-occlusive disease was assessed independently by 2 observers using conventional angiography as the reference standard. RESULTS: According to observers 1 and 2, respectively, 3D TOF-MRA at 3T had a sensitivity of 78%/85% (21/27, 23/27), a specificity of 95%/95% (126/133, 127/133), a positive predictive value of 75%/79% (21/28, 23/29), and a negative predictive value of 95%/97% (126/132, 127/131), using a 50%-99% threshold of diameter stenosis. For detection of complete occlusion, according to observers 1 and 2, respectively, 3D TOF-MRA at 3T had a sensitivity of 100% (13/13), a specificity of 99% (145/147), a positive predictive value of 87% (13/15), and a negative predictive value of 100% (145/145). Interobserver agreement of 3D TOF-MRA was excellent (kappa = 0.81). CONCLUSION: High-resolution 3D TOF-MRA with sensitivity encoding at 3T can be used as a reliable diagnostic tool for the detection of clinically significant steno-occlusive disease of major intracranial arteries.
Assuntos
Angiografia Digital/normas , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/patologia , Angiografia por Ressonância Magnética/métodos , Angiografia por Ressonância Magnética/normas , Adulto , Idoso , Artéria Basilar/diagnóstico por imagem , Artéria Basilar/patologia , Artérias Carótidas/diagnóstico por imagem , Artérias Carótidas/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/patologia , Padrões de Referência , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/patologiaRESUMO
BACKGROUND AND PURPOSE: Management of acute symptomatic internal carotid artery (ICA) occlusion remains controversial. We evaluated outcome predictors of a good recovery in patients with acute symptomatic ICA occlusion. MATERIALS AND METHODS: We retrospectively evaluated 33 consecutive patients (men/women, 23/10; mean age, 66 years) with: 1) acute symptomatic ICA occlusion within 6 hours of symptom onset or with mismatch of symptoms and an early infarct area, 2) National Institutes of Health Stroke Scale (NIHSS) score of 6 or more, and 3) attempted endovascular revascularization of the occluded ICA. Various single and multiple variable analyses were conducted to assess the association of 14 predictors with short-term (1-month NIHSS) and long-term (1-year modified Rankin Scale [mRS]) outcomes. RESULTS: Successful recanalization (at or more than grade 2 distal residual occlusion) was obtained in 14 (42%) of 33 and good recovery (mRS Assuntos
Estenose das Carótidas/complicações
, Estenose das Carótidas/cirurgia
, Revascularização Cerebral/métodos
, Acidente Vascular Cerebral/etiologia
, Acidente Vascular Cerebral/prevenção & controle
, Idoso
, Estenose das Carótidas/diagnóstico
, Feminino
, Humanos
, Masculino
, Prognóstico
, Estudos Retrospectivos
, Acidente Vascular Cerebral/diagnóstico
, Resultado do Tratamento
RESUMO
We assessed the association of herpes zoster (HZ) with stroke/transient ischaemic attack (TIA) in the general population according to age with controlling risk factors for stroke, using a nationwide representative cohort. The study was based on a prospective dynamic cohort consisting of 1 million Koreans representing all age groups, genders and geographical areas in the Korea Health Insurance Database. New events of stroke/TIA and HZ were identified using the diagnostic codes in the International Classification of Diseases, tenth revision. The risk for stroke/TIA after HZ was compared with HZ-free stroke/TIA individuals according to age group. A total of 766 179 adults were followed up for 11 years from 2003. The incidence of the first-diagnosed HZ cases was 9.40 per 1000 person-years, and that of the first-diagnosed stroke/TIA cases was 9.77 per 1000 person-years. The risk for stroke/TIA was higher in patients who had previous HZ episodes than in those who had never experienced HZ (incidence rate ratio 1.90; 95% CI 1.85-1.95). In addition, this risk persisted for several years after HZ. The risk of stroke/TIA after HZ gradually decreased with age; adjusted hazard ratio (HR) 2.04 in 18- to 30-year-olds, HR 1.74 in 30- to 40-year-olds, HR 1.43 in 40- to 50-year-olds, HR 1.23 in 50- to 60-year-olds, HR 1.24 in 60- to 70-year-olds, and HR 1.29 in those >70 years old, after controlling risk factors for stroke/TIA. Our findings provide evidence that HZ carries an increased risk of stroke or TIA and that the effect of HZ on stroke decreases with increasing age.
Assuntos
Herpes Zoster/complicações , Ataque Isquêmico Transitório/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , República da Coreia/epidemiologia , Medição de Risco , Adulto JovemRESUMO
BACKGROUND AND PURPOSE: High-resolution MR imaging has recently been introduced as a promising diagnostic modality in intracranial artery disease. Our aim was to compare high-resolution MR imaging with digital subtraction angiography for the characterization and diagnosis of various intracranial artery diseases. MATERIALS AND METHODS: Thirty-seven patients who had undergone both high-resolution MR imaging and DSA for intracranial artery disease were enrolled in our study (August 2011 to April 2014). The time interval between the high-resolution MR imaging and DSA was within 1 month. The degree of stenosis and the minimal luminal diameter were independently measured by 2 observers in both DSA and high-resolution MR imaging, and the results were compared. Two observers independently diagnosed intracranial artery diseases on DSA and high-resolution MR imaging. The time interval between the diagnoses on DSA and high-resolution MR imaging was 2 weeks. Interobserver diagnostic agreement for each technique and intermodality diagnostic agreement for each observer were acquired. RESULTS: High-resolution MR imaging showed moderate-to-excellent agreement (interclass correlation coefficient = 0.892-0.949; κ = 0.548-0.614) and significant correlations (R = 0.766-892) with DSA on the degree of stenosis and minimal luminal diameter. The interobserver diagnostic agreement was good for DSA (κ = 0.643) and excellent for high-resolution MR imaging (κ = 0.818). The intermodality diagnostic agreement was good (κ = 0.704) for observer 1 and moderate (κ = 0.579) for observer 2, respectively. CONCLUSIONS: High-resolution MR imaging may be an imaging method comparable with DSA for the characterization and diagnosis of various intracranial artery diseases.