Amyloid spell – A close mimic of transient ischemic attack!

Transient focal neurological episodes, also called amyloid spells occur as recurrent, transient episodes of spreading paresthesia seen in 14% of cerebral amyloid angiopathy (CAA) patients. An 81-year-old gentleman with coronary artery disease and a left ventricular clot was on anticoagulant treatment. He presented with three episodes of tingling in the left fingers spreading to the left arm and left leg, each lasting for 10 min. Magnetic resonance imaging of the brain with susceptibility imaging showed convexity hemorrhage, and curvilinear blooming in sulcal spaces of the right cerebral convexity and left precuneus. Warfarin was stopped. He was treated with clobazam, aspirin, and atorvastatin. He improved, so was discharged after 2 days. Amyloid spells can be confused with transient ischemic attack (TIA) or its mimics and the treatment given for TIA can lead to intracranial hemorrhage in CAA patients. Radiological features aid in the diagnosis of CAA and antiplatelets need to be administered cautiously in patients with suspected TIA.

MTHFR Gene (C677t) Polymorphism in Ischemic Stroke, its Subtypes and Hemorrhagic Stroke in a South Indian Population.

Objective: We investigated the association of MTHFR C677T polymorphism with ischemic stroke, its subtypes and hemorrhagic stroke in a South Indian Population from Andhra Pradesh. Methods: Six hundred and twenty ischemic stroke patients, 220 hemorrhagic stroke patients and 620 age and sex matched healthy controls, were included in the present study. The polymorphism was determined using PCR-RFLP technique. Results: The strength of association between genotypes and stroke types was measured by the odds ratio with 95% confidence interval and chi-squared analysis. We found significant association of the CT genotype with ischemic stroke as well as haemorrhagic stroke (p<0.05). Further, evaluating the association of this polymorphism with stroke subtypes, we found significant association with intracranial large artery (p<0.05), lacunar stroke (p<0.05) and undetermined etiology (p<0.05). However, there was no significant difference in genotypic or allelic frequencies between ischemic and hemorrhagic strokes. Conclusion: Our study suggests that MTHFR (C677T) is an important risk factor for ischemic stroke, its subtypes and hemorrhagic stroke in the South Indians from Andhra Pradesh but it cannot help in distinguishing between the two types of stroke.

Glutamate carboxypeptidase II (GCPII) genetic variants as determinants of hyperhomocysteinemia: Implications in stroke susceptibility.

The rationale of this case-control study is to ascertain whether glutamate carboxypeptidase II (GCPII) variants serve as determinants of hyperhomocysteinemia and contribute to the etiology of stroke. Hyperhomocysteinemia was observed in stroke cases compared to controls (14.09 ± 7.62 mmol/L vs. 8.71 ± 4.35, P<0.0001). GCPII sequencing revealed two known variants (R190W and H475Y) and six novel variants (V108A, P160S, Y176H, G206R, G245S and D520E). Among the haplotypes of GCPII, all wild-haplotype H0 showed independent association with stroke risk (OR: 9.89, 95% CI: 4.13-23.68), while H2 representing P160S variant showed reduced risk (OR: 0.17, 95% CI: 0.06-0.50). When compared to subjects with H2 haplotype, H0 haplotype showed elevated homocysteine levels (18.26 ± 4.31 mmol/L vs. 13.66 ± 3.72 mmol/L, P = 0.002) and reduced plasma folate levels (7.09 ± 1.19 ng/ml vs. 8.21 ± 1.14 ng/ml, P = 0.007). Using GCPII genetic variants, dietary folate and gender as predictor variables and homocysteine as outcome variable, a multiple linear regression model was developed. This model explained 36% variability in plasma homocysteine levels. To conclude, GCPII haplotypes influenced susceptibility to stroke by influencing homocysteine levels.

Incidence of recurrent stroke in primary care during preventive treatment based on perindopril with or without indapamide.

BACKGROUND: Although the risk reduction of recurrent stroke with angiotensin converting enzyme-inhibitors with or without a diuretic has been demonstrated under randomized double blind conditions of the PROGRESS study, it is unclear whether the benefit is reflected in primary care practice and in populations with different demographic and clinical characteristics. AIM: To assess the effect and acceptability of perindopril with or without indapamide prevention of recurrent stroke, as reflected by its incidence. SETTING AND DESIGN: Multicentre, prospective, observational study in the setting of primary care throughout India. MATERIALS AND METHODS: Patients with a stable stroke or transient ischaemic attack (TIA) received a 12-month perindopril +/- indapamide-based regimen, similar to that used in PROGRESS. The principal outcome was the annual incidence of recurrent stroke. Statistical Analysis: Summary statistics and the Kaplan-Meier procedure. RESULTS: The mean age of 298 patients was 58.3 years (SD=12.6). 229 (77.5%) had an ischaemic stroke; 231 (77.5%) were hypertensive; 200 (85.5%) were receiving aspirin and 81 (27.2%) statins. During the 12-month perindopril-based treatment, there were 8 (2.7%) recurrent strokes, with a Kaplan-Meier estimate of strokes plus TIA of 3.3% (95% CI, 1.0-5.6). CONCLUSIONS: The incidence of recurrent stroke is similar to that observed under double blind randomized conditions in the treatment arm of the PROGRESS study. This suggests that perindopril +/- indapamide-based prevention may be effective in reducing risk of recurrent stroke, (although the uncontrolled study design does not actually demonstrate this), in the setting of day-to-day clinical practice and among patients with different demographic and clinical characteristics than the PROGRESS population.