Inflammatory markers and conventional atherosclerotic risk factors in acute ischemic stroke: comparative study between vascular disease subtypes.

BACKGROUND: Large vessel atherosclerosis and small vessel disease are two major causes of ischemic stroke. In patients with large vessel disease, the lesions can be located in the extracranial carotid or intracranial arteries. OBJECTIVE: To search for the differences of risk factors and inflammatory markers among patients with each subtype of vascular disease. MATERIAL AND METHOD: Patients with acute ischemic stroke who had large vessel atherosclerosis or small vessel disease were studied. Patients with large vessel atherosclerosis were subdivided into extracranial carotid and intracranial stenosis groups. Blood samples were collected for c-reactive protein, erythrocyte sedimentation rate, hemoglobin A1C fibrinogen, fasting plasma glucose, cholesterol, triglyceride, and low-density and high-density lipoproteins. Risk factors and results of the blood tests between the groups of patients were compared. RESULTS: There were 116 patients in the study. Sixty-three patients had large vessel disease, whereas 53 patients had small vessel disease. More prevalence of diabetes and higher c-reactive protein were significantly found in patients with large vessel disease. C-reactive protein on admission was also higher in patients with extracranial carotid stenosis than those with intracranial stenosis. Serum cholesterol and low-density lipoprotein was significantly higher in patients with intracranial stenosis than those with small vessel extracranial disease. CONCLUSION: Diabetes and higher c-reactive protein on admission were associated with large vessel disease. c-reactive protein was also higher in patients with extracranial carotid stenosis but their cholesterol and low-density lipoprotein were significantly lower than those with intracranial disease.

Grave prognosis on spontaneous intracerebral haemorrhage: GP on STAGE score.

BACKGROUND AND OBJECTIVE: Spontaneous intracerebral haemorrhage (ICH) is more common in Asia than in western countries, and has a high mortality rate. A simple prognostic score for predicting grave prognosis of ICH is lacking. Our objective was to develop a simple and reliable score for most physicians. MATERIAL AND METHOD: ICH patients from seven Asian countries were enrolled between May 2000 and April 2002 for a prospective study. Clinical features such as headache and vomiting, vascular risk factors, Glasgow coma scale (GCS), body temperature (BT), blood pressure on arrival, location and size of haematoma, intraventricular haemorrhage (IVH), hydrocephalus, need for surgical treatment, medical treatment, length of hospital stay and other complications were analyzed to determine the outcome using a modified Rankin scale (MRS). Grave prognosis (defined as MRS of 5-6) was judged on the discharge date. RESULTS: 995 patients, mean age 59.5 +/- 14.3 years were analyzed, after exclusion of incomplete data in 87 patients. 402 patients (40.4%) were in the grave prognosis group (MRS 5-6). Univariable analysis and then multivariable analysis showed only four statistically significant predictors for grave outcome of ICH. They were fever (BT > or = 37.8 degrees c), low GCS, large haematoma and IVH. The grave prognosis on spontaneous intracerebral haemorrhage (GP on STAGE) score was derived from these four factors using a multiple logistic model. CONCLUSION: A simple and pragmatic prognostic score for ICH outcome has been developed with high sensitivity (82%) and specificity (82%). Furthermore, it can be administered by most general practitioners. Validation in other populations is now required.

Effectiveness of constraint-induced movement therapy in chronic stroke patients.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of constraint-induced movement therapy (CIMT) in dexterity with Action Research Arm Test (ARA test), hand grip strength, pinch strength of affected upper extremity in chronic stroke patients. MATERIAL AND METHOD: An observer-blinded randomized control trial, 69 chronic stroke patients were allocated either to constraint-induced movement technique (n = 33) or conservative treatment (n = 36). The CIMT group received 6 hours of daily affected-upper-extremity training and restrained unaffected upper extremities for 5 days per week, totally 2 weeks. The control group received bimanual-upper-extremity training by conservative neurodevelopmental technique without restrained unaffected upper extremities for 2 weeks. RESULTS: The CIMT group had ARA scores, pinch strength of affected upper extremities statistically significant higher than the control group at p < 0.05, but the hand grip strength had no statistically significant difference, p > 0.05. CONCLUSIONS: CIMT of unaffected upper extremities has an advantage for chronic stroke patients which may be an efficacious technique of improving motor activity and exhibiting learned nonuse.

Hemifacial spasm: results of treatment with low dose botulinum toxin injection.

BACKGROUND: Hemifacial Sapsm (HFS) is a common movement disorder in Thailand. Botulinum toxin type A (BTA) is an effective and safe treatment for this condition. The success of BTA treatment depends on the experience of the clinician. OBJECTIVE: To study the demographic data, efficacy and safety of low dose BTA injection in HFS patients. SETTING: The Spastic and Dystonia Clinic, Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital. DESIGN: Open-label, prospective case-series study. PATIENTS: All patients with HFS referred for BTA injection from December 1st, 1995 to November 30th, 2003. METHOD: Sex, age, side of spasm, onset of symptoms before BTA injection, underlying diseases, sites of BTA injection, dose of each BTA treatment, duration of response, efficacy, and side-effects were analyzed. 3-5 units of BOTOX were intramuscularly injected per site to all muscles that had spasm. After injection, a 20-minute cold compression on the first day was followed by 20-minute warm compression with massage at each injection site per day for 14 days. RESULTS : A total of 112 patients with HFS were treated with 874 BTA treatments. There were 71 females (63.4%) and 41 males (36.6%). The mean age was 45 years. 75 patients (67%) were affected on the left side. Mean duration of symptoms was 3.4 years. The sites of injection were orbicularis occuli and orbicularis oris muscles in all 874 treatments (100%). The mean dose of all treatments was 25 units. The mean initial dose was 30.5 units. The mean dose for subsequent injection was 23 units. The mean duration between treatments was 4.7 months. The mean initial duration was 3.5 months. The mean duration for subsequent injection was 4.8 months. The outcomes of treatment assessed at 4 weeks after injection classified as excellent (>80% improvement) were found in 845 treatments (96.7%). Most treatments had no complication (91.9%). Ptosis, facial paresis and double vision were mild and transient, lasting 1-4 weeks. There were no long-term complications of BTA treatment in the present series. CONCLUSION: Low dose BTA injection is an effective treatment for hemifacial spasm patients. There was a longer duration of response in subsequent injections and a lower complication rate in the present study when compared to others.

Straight artery sign in extracranial carotid artery dissection.

BACKGROUND AND PURPOSE: Magnetic resonance imaging (MRI) has become generally accepted as a non-invasive method to provide the definitive diagnosis of cervicocerebral vessel dissection. The finding of an intramural hematoma on axial MR images is the characteristic sign of the disease. However, there has been no previous report of the characteristic magnetic resonance angiographic (MRA) findings. METHOD: The authors retrospectively reviewed MRI and MRA findings of patients with spontaneous extracranial carotid dissection. The most striking finding on MRA was the straightness of the affected artery when compared to the non-affected side of the same patient. For quantitative measurement, "Carotid Straightness Index (CSI)" was developed to measure the straightness of the arteries and compared the indices of both extracranial internal carotid arteries in the same patient. RESULTS: The patients' age range was from 21-55 years (mean 38 years). There were 6 males and 3 females. All patients had the classical "Straight artery sign" on the MRA. The carotid straightness index was significantly higher in the affected artery when compared to the normal side of the same patient. CONCLUSION: The straight artery sign and the carotid straightness index can be very useful for early detection of the extracranial carotid dissection. It can be found in early stage disease or in less severe forms of carotid dissection where significant narrowing is not demonstrated.