Immediate anticoagulation with heparin for first-ever ischemic stroke in the carotid artery territories observed within 5 hours of onset.

OBJECTIVE: To evaluate the safety and possible efficacy of heparin sodium anticoagulation within 5 hours of the onset of first-ever nonlacunar ischemic strokes in the internal carotid artery territories. DESIGN: Pilot study, prospective and open. SETTING: Inpatient stroke unit. PATIENTS: Of 360 stroke patients observed during 13 months, 45 (12.5%) were included in the study. INTERVENTIONS: Heparin sodium was administered intravenously, starting with a bolus of 10,000 U, followed by continuous infusion over 4 days at a rate adjusted to maintain an activated partial thromboplastin time ratio between 2 and 2.5. The mean interval from stroke to treatment was 197 minutes. RESULTS: Two patients had cerebral hemorrhage, one of which was fatal. None had extracranial major bleeding, while six had minor bleeding. The conditions of 23 patients improved, 16 patients were stable, and six patients worsened by day 1, while 29 patients improved, eight patients were stable, and eight patients worsened by day 7. Six patients died by the first month and five more by the sixth month. Twenty-one patients were self-sufficient, both at 1 and 6 months. Hemorrhagic complications were unrelated to any investigated factor. Multivariate analysis indicated that short-term outcome was predicted only by infarct size (P < .0001) and long-term outcome by infarct size (P = .002) and large vessel status (P = .0235). CONCLUSIONS: Our study suggests that immediate heparin treatment for ischemic carotid stroke is feasible and generally safe and that patients whose conditions improve are those with smaller infarct size and no evidence of large vessel obstruction.

Transcranial Doppler in acute ischemic stroke of the middle cerebral artery territories.

UNLABELLED: We have investigated the reliability of transcranial doppler compared with cerebral angiography in acute ischemic stroke in the middle cerebral artery territories. We studied 48 patients, 28 men and 21 women, mean age 68.1 (range 54-75), observed within 5 h of the onset of ischemic stroke in the middle cerebral artery territory. Ultrasound evaluation (duplex scanner and transcranial doppler) and cerebral angiography were carried out in close sequence immediately after CT scan. CT was repeated by Day 7 to estimate the infarct size: 27/48 patients had intracranial arterial obstructions. An acoustic temporal "window" was not found in 6.25%. Transcranial doppler showed a sensitivity of 80.0% and a specificity of 90.0% compared with cerebral Angiography for patients with patent acoustic temporal "windows". Accuracy was 79.2%, when patients with no "windows" were included. With respect to intracranial internal carotid artery and middle cerebral artery mainstem, transcranial doppler showed a sensitivity of 95.0%, and a specificity of 92.0%. Including patients with no windows, accuracy was 87.5%. CONCLUSIONS: Our data suggest that Transcranial Doppler can be reliably used to demonstrate intracranial internal carotid artery or middle cerebral artery mainstem obstructions in the acute phase of a brain infarction.

Cardiovascular reflexes in Parkinson's disease: long-term effects of levodopa treatment on de novo patients.

Twelve parkinsonian patients (6 men and 6 women), mean age 60.5 years, range 47-72, were examined with autonomic test when de novo and after 2 years of continuous levodopa treatment. They were all free from any disease interfering with autonomic examination. When de novo they had a significant decrease of heart rate response to deep breathing and to laying to standing tests if compared with an age- and sex-matched control group (15.6 +/- 8.8 vs. 28.6 +/- 12.1, P less than 0.01 and 7.0 +/- 7 vs. 14.2 +/- 5, P less than 0.01). After 2 years of levodopa treatment they had a non-significant decrease of heart rate response to deep breathing test (21.8 +/- 10.6, P N.S.) and a still significant decrease of heart rate response to laying to standing test, but at a lesser level (7.7 +/- 7.0, P less than 0.05). Furthermore, they showed a significant decrease of the systolic and MAP orthostatic pressure to tilting table (-9.2 +/- 12.0 vs. +4.9 +/- 8.9 and -4.5 +/- 8.4 vs. +4.7 +/- 5.1, both P less than 0.01) probably due to medication. The other tests were never significant. We hazard as possible explanation an action of levodopa on dopaminergic neurons in the nucleus dorsalis of vagus.

A case of "young stroke" with ICA intracranial occlusion: pathogenetic implication for dissection in migraine.

The case of a "young stroke" affecting a 22 years old man is reported. Essential clinical features were drowsiness, headache, motor aphasia, right hemiparesis and Claude-Bernard-Horner in the left eye. An extensive investigative protocol was carried out which revealed an occlusion of the intracranial left ICA with subsequent recanalization. The possible causes of the stroke (migraine, dissection or combination of both) are discussed and the importance of a complete evaluation of patients of this kind is stressed.

A case control study of CSF copper, iron and manganese in Parkinson disease.

To elicit possible variations in the CSF concentrations of copper, iron and manganese due to Parkinson disease (PD) or to the stage reached, we tested 11 patients with idiopathic PD, 6 untreated and 5 on long term L-dopa, versus 22 age and sex matched patients with other neurological disorders (control group-CG). The CSF levels of the three metals, measured by electrothermal atomization, did not differ significantly between the PD group and CG or between either of the PD subgroups and CG. Our findings therefore do not support the hypothesis that CSF Cu is a marker of PD.

Acute rhabdomyolysis associated with acute cocaine intoxication. A case report.

We report a case of acute rhabdomyolysis associated with acute intravenous cocaine intoxication in an asymptomatic HIV-positive young man and discuss the possible pathogenetic mechanisms. Recent cocaine use must be considered among the causes of acute rhabdomyolysis without obvious precipitating factors in our country too. The characteristically uncollaborative attitude of habitual drug users may make differential diagnosis very difficult to establish.

Prognostic factors in first-ever stroke in the carotid artery territory seen within 6 hours after onset.

BACKGROUND AND PURPOSE: We sought to detect prognostic factors related to functional outcome during the first 6 hours after a first-ever stroke in the carotid artery territory. METHODS: All patients with these characteristics seen during a 3-year period were included. Outcome was evaluated according to a modified Rankin scale. The following variables were examined at univariate analysis: sex, age, severity of deficit at entry and at day 7, level of consciousness at entry, time after symptom onset, history of smoking, history of hypertension, diabetes, myocardial infarction, atrial fibrillation, rheumatic heart disease, dilated cardiomyopathy, all potential cardioembolic sources, presence of a consistent lesion on computed tomography at entry and at days 5-9, and the size of such lesion. RESULTS: All entry criteria were met by 172 patients. Age > or = 70 years, a Canadian Neurological Scale score < 6.5 at entry and at day 7, atrial fibrillation, presence of a potential cardioembolic source, and a "large" lesion (involving more than half the cerebral lobe) on computed tomography at days 5-9 were associated with a significantly worse outcome both at 30 days and at 6 months. After multivariate analysis, a Canadian Scale score < 6.5 at entry (p < 0.0001) and atrial fibrillation (p = 0.005) were associated with a significant handicap or death at 30 days, whereas only a Canadian Scale score < 6.5 (p < 0.0001) was associated with a worse prognosis at 6 months. An association of age > or = 70 years with a worse outcome at 6 months was of borderline significance (p = 0.054). CONCLUSIONS: Some prognostic indicators are available during the first few hours after onset of a carotid ischemic stroke and may be useful in the stratification of patients in clinical trials. Severity of deficit is the most important indicator, whereas the presence of atrial fibrillation worsens the prognostic outlook with respect to early handicap but not mortality.

Cerebral venous thrombosis in young adults. Experience in a stroke unit, 1988-1994.

We report a series of nine patients younger than 45 years with angiographically-documented cerebral venous thrombosis, consecutively referred to our Stroke Unit from 1988 to 1994. Two of them were men and seven were women. Eight patients initially complained of headache, often associated with other symptoms of increased intracranial pressure. Seven patients had focal motor deficits and four suffered from epileptic seizures. None of the patients died. Only one patient remained severely disabled, whereas the others recovered self-sufficiency within two months. The use of oral contraceptives was closely associated with the occurrence of venous thrombosis in the women. Cerebral venous thrombosis is to be kept in mind in the differential diagnosis of stroke in the young.