Insertable cardiac monitors after cryptogenic stroke--a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation.

BACKGROUND AND PURPOSE: Recently, the CRYSTAL AF trial detected paroxysmal atrial fibrillation (AF) in 12.4% of patients after cryptogenic ischaemic stroke (IS) or cryptogenic transient ischaemic attack (TIA) by an insertable cardiac monitor (ICM) within 1 year of monitoring. Our aim was (i) to assess if an AF risk factor based pre-selection of ICM candidates would enhance the rate of AF detection and (ii) to determine AF risk factors with significant predictive value for AF detection. METHODS: Seventy-five patients with cryptogenic IS/TIA were consecutively enrolled if at least one of the following AF risk factors was present: a CHA2DS2-VASc score ≥4, atrial runs, left atrium (LA) size >45 mm, left atrial appendage (LAA) flow ≤0.2 m/s, or spontaneous echo contrast in the LAA. The electrocardiographic and echocardiographic criteria were chosen as they have been repeatedly reported to predict AF; the same applies for four of the six items of the CHA2DS2-VASc score. The study end-point was the detection of one or more episodes of AF (≥2 min). RESULTS: Seventy-four patients underwent implantation of an ICM; one patient had AF at the date of implantation. After 6 months, AF was detected in 21/75 patients (28%), after 12 months in 25/75 patients (33.3%). 92% of AF episodes were asymptomatic. LA size >45 mm and the presence of atrial runs were independently associated with AF detection [hazard ratio 3.6 (95% confidence interval 1.6-8.4), P = 0.002, and 2.7 (1.2-6.7), P = 0.023, respectively]. CONCLUSIONS: The detection rate of AF is one-third after 1 year if candidates for an ICM after cryptogenic IS/TIA are selected by AF risk factors. LA dilation and atrial runs independently predict AF.

Microalbuminuria: a potential prognostic marker for acute stroke.

INTRODUCTION: Stroke is potentially preventable through risk factor reduction. Over the past decade, the role of microalbuminuria (MA) as a risk factor for chronic diseases has become apparent. The aim of this study was to determine the prognostic value of MA in acute stroke patients. MATERIALS AND METHODS: Patients with acute ischemic stroke admitted to our stroke unit were included in this study. Clinical history and vascular risk factors were recorded. Severity of stroke and outcome were assessed by NIHSS and modified Rankin scale (mRS) upon admission and discharge. Urinary albumin excretion was measured in 24-h urine samples. Multivariate analysis was performed to investigate predictors of poor outcome. RESULTS: MA was found in 43% of 138 patients and was associated with elevated levels of C-reactive protein (CRP), glucose at baseline, and HbA1c; higher rates of diabetes mellitus and atrial fibrillation; higher systolic blood pressure; greater age; and higher premorbid mRS, NIHSS upon admission/discharge, and mRS upon discharge. In a multivariate analysis, MA (OR 5.07, 95%CI 2.18-11.77; p = 0.004), premorbid mRS (OR 2.030, 95%CI 1.369-3.011; p = 0.0001), and NIHSS upon admission (OR 1.116, 95%CI 1.044-1.193; p = 0.001) were independent predictors of poor outcome upon discharge. CONCLUSION: MA was frequently found in acute ischemic stroke patients. It was associated with severe neurological deficit upon admission and severe functional impairment upon discharge. MA in the acute phase was shown to be an independent predictor of poor outcome. The association between MA and CRP levels points to potential linkage of MA to the inflammatory response in acute stroke.

Association of non-diabetic hyperglycemia with autonomic shift in acute ischaemic stroke.

BACKGROUND AND PURPOSE: The etiology of hyperglycemia in acute stroke remains controversial. It is unclear whether hyperglycemia arises as an epiphenomenon of stroke or as a reflection of underlying diabetes. Autonomic shift to sympathetic overactivity has been repeatedly observed in acute stroke. We hypothesize that hyperglycemia in acute stroke relates to autonomic imbalance and that the respective deleterious effects on stroke outcome may be cross-linked. METHODS: A total of 75 non-diabetic patients with ischaemic stroke were included in a prospective study. Glucose levels at admission, fasting glucose, and glucose profiles were recorded. Autonomic function was quantified by the assessment of spontaneous baroreflex sensitivity (BRS) using a cross-correlation method. Demographic and clinical data including stroke volumes and admission National Institute of Heath Stroke Scale scores were included into the analysis. Functional outcome at 90 days was assessed using the modified Rankin Scale. RESULTS: Hyperglycemia was correlated with decreased BRS independent of stroke severity or volume (r = -0.46, P < 0.001). In two separate regression models, glucose levels and BRS independently predicted unfavorable outcome at 3 months (OR = 1.06, CI = 1.02-1.11, P = 0.004 and OR = 0.75, CI = 0.56-0.99, P = 0.04). However, combining the models, only glucose levels (OR = 1.06, CI = 1.02-1.11, P = 0.004) remained independent predictor of outcome at 3 months. CONCLUSIONS: We observed an association between hyperglycemia and decreased BRS in non-diabetic patients, suggesting that hyperglycemic reaction in acute stroke may reflect stroke-related autonomic changes. Moreover, outcome effects of autonomic changes and hyperglycemia seem to be interdependent, putatively having the sympatho-vagal imbalance as common underlying mechanism. The possible therapeutic relevance of this finding warrants further studies.

Critical thresholds for cerebrovascular reactivity after traumatic brain injury.

INTRODUCTION: Pressure-reactivity index (PRx) is a useful tool in brain monitoring of trauma patients, but the question remains about its critical values. Using our TBI database, we identified the thresholds for PRx and other monitored parameters that maximize the statistical difference between death/survival and favorable/unfavorable outcomes. We also investigated how these thresholds depend on clinical factors such as age, gender and initial GCS. METHODS: A total of 459 patients from our database were eligible. Tables of 2 × 2 format were created grouping patients according to survival/death or favorable/unfavorable outcomes and varying thresholds for PRx, ICP and CPP. Pearson's chi square was calculated, and the thresholds returning the highest score were assumed to have the best discriminative value. The same procedure was repeated after division according to clinical factors. RESULTS: In all patients, we found that PRx had different thresholds for survival (0.25) and for favorable outcome (0.05). Thresholds of 70 mmHg for CPP and 22 mmHg for ICP were identified for both survival and favorable outcomes. The ICP threshold for favorable outcome was lower (18 mmHg) in females and patients older than 55 years. In logistic regression models, independent variables associating with mortality and unfavorable outcome were age, GCS, ICP and PRx. CONCLUSION: The prognostic role of PRx is confirmed but with a lower threshold of 0.05 for favorable outcome than for survival (0.25). Results for ICP are in line with current guidelines. However, the lower value in elderly and in females suggests increased vulnerability to intracranial hypertension in these groups.

What comes first? The dynamics of cerebral oxygenation and blood flow in response to changes in arterial pressure and intracranial pressure after head injury.

BACKGROUND: Brain tissue partial oxygen pressure (Pbt(O(2))) and near-infrared spectroscopy (NIRS) are novel methods to evaluate cerebral oxygenation. We studied the response patterns of Pbt(O(2)), NIRS, and cerebral blood flow velocity (CBFV) to changes in arterial pressure (AP) and intracranial pressure (ICP). METHODS: Digital recordings of multimodal brain monitoring from 42 head-injured patients were retrospectively analysed. Response latencies and patterns of Pbt(O(2)), NIRS-derived parameters [tissue oxygenation index (TOI) and total haemoglobin index (THI)], and CBFV reactions to fluctuations of AP and ICP were studied. RESULTS: One hundred and twenty-one events were identified. In reaction to alterations of AP, ICP reacted first [4.3 s; inter-quartile range (IQR) -4.9 to 22.0 s, followed by NIRS-derived parameters and CBFV (10.9 s; IQR: -5.9 to 39.6 s, 12.1 s; IQR: -3.0 to 49.1 s, 14.7 s; IQR: -8.8 to 52.3 s for THI, CBFV, and TOI, respectively), with Pbt(O(2)) reacting last (39.6 s; IQR: 16.4 to 66.0 s). The differences in reaction time between NIRS parameters and Pbt(O(2)) were significant (P<0.001). Similarly when reactions to ICP changes were analysed, NIRS parameters preceded Pbt(O(2)) (7.1 s; IQR: -8.8 to 195.0 s, 18.1 s; IQR: -20.6 to 80.7 s, 22.9 s; IQR: 11.0 to 53.0 s for THI, TOI, and Pbt(O(2)), respectively). Two main patterns of responses to AP changes were identified. With preserved cerebrovascular reactivity, TOI and Pbt(O(2)) followed the direction of AP. With impaired cerebrovascular reactivity, TOI and Pbt(O(2)) decreased while AP and ICP increased. In 77% of events, the direction of TOI changes was concordant with Pbt(O(2)). CONCLUSIONS: NIRS and transcranial Doppler signals reacted first to AP and ICP changes. The reaction of Pbt(O(2)) is delayed. The results imply that the analysed modalities monitor different stages of cerebral oxygenation.

[Intensive care management [corrected] of patients with intracerebral hemorrhage]. / Intensivmedizinische Versorgung von Patienten mit intrazerebraler Blutung.

Approximately 10-15% of acute strokes are caused by non-aneurysmatic intracerebral hemorrhage (ICH) and incidences are expected to increase due to an aging population. Studies from the 1990s estimated mortality of ICH to be as high as 50%. However, these figures may partly be attributed to the fact that patients suffering from ICH frequently received only supportive therapy and the poor prognosis may therefore be more a self-fulfilling prophecy. Recently it has been shown that treatment in a specialized neurological intensive care unit alone was associated with better outcomes after ICH. In recent years considerable efforts have been undertaken in order to develop new therapies for ICH and to assess them in randomized controlled trials. Apart from admission status, hemorrhage volume is considered to be the main prognostic factor and impeding the spread of the hematoma is thus a basic therapeutic principle. The use of activated factor VIIa (aFVIIa) to stop hematoma enlargement has been assessed in two large randomized controlled trials, however the promising results of the dose-finding study could not be confirmed in a phase III trial. Although hemostatic therapy with aFVIIa reduced growth of the hematoma it failed to improve clinical outcome. Similar results were found in a randomized controlled trial on blood pressure management in acute ICH. The link between reduction of hematoma growth and improved outcome is therefore still lacking. Likewise the value of surgical hematoma evacuation remains uncertain. In the largest randomized controlled trial on surgical treatment in ICH so far, only a small subgroup of patients with superficial hemorrhages seemed to benefit from hematoma evacuation. Whether improved intensive care can contribute to improved outcome after ICH will be shown by data obtained in the coming years.

Patient outcomes in historical comparators compared with randomised-controlled trials.

BACKGROUND: Decompressive hemicraniectomy for malignant middle cerebral artery infarction has long been controversial. Recently, data from randomised-controlled trials have shown that the procedure is life-saving and improves outcome. However, these randomised-controlled trials were difficult to conduct, because of ethical considerations due to high mortality in control groups. While the use of historical comparators may not be ideal for phase III efficacy trials, these data may be useful to inform the selection of trial populations. We sought to replicate the findings of the DESTINY trial of decompressive surgery in malignant middle cerebral artery infarction using the Virtual International Stroke Trials Archive, to determine whether historical comparators could be used as an alternative to control groups in situations where randomised-controlled trials are infeasible or regarded as unethical due to the high mortality under conservative treatment. METHODS: We extracted data on patients from Virtual International Stroke Trials Archive who displayed signs of malignant middle cerebral artery infarction (baseline National Institutes of Health Stroke Scale> or =20, LOC1A score of > or =1 on the National Institutes of Health Stroke Scale at baseline, lesion volume > or =145 cm(3)). We used a chi(2)-test and logistic regression (adjusting for baseline National Institutes of Health Stroke Scale) to compare the functional outcomes (modified Rankin scores and Barthel index) at the last available follow-up assessment between the DESTINY surgical and the Virtual International Stroke Trials Archive comparator groups. We assessed 90-day survival rates using a Kaplan-Meier analysis and Cox proportional hazards modelling (adjusting for the baseline National Institutes of Health Stroke Scale score). RESULTS: Fewer patients in the Virtual International Stroke Trials Archive comparator group (n=6/32, 19% with a 90-day follow-up) achieved a good functional outcome by mRS at the final follow-up, when compared with the DESTINY surgical group (n=8/17, 47% with a 6-month follow-up; chi(2)-test, P=0.04). This difference persisted after adjusting for baseline National Institutes of Health Stroke Scale (logistic regression, P=0.04), but not when accounting for patient age (P=0.66). Analysis of Barthel index at the final follow-up revealed no significant difference between the two groups (chi(2)-test, P=0.07), although a trend towards a better outcome in the DESTINY group was observed. In contrast with the findings of the DESTINY trial, we found no significant difference in 90-day survival rates between the surgical (88%) and the Virtual International Stroke Trials Archive (72%) comparator groups (Cox proportional hazards model, P=0.24). CONCLUSION: The beneficial effects of decompressive hemicraniectomy on survival were not confirmed using a historical comparator dataset. Our observations might be due to the fact that patients with malignant middle cerebral artery infarction are usually excluded from clinical trials of drug efficacy, and patients identified from Virtual International Stroke Trials Archive may not have been truly representative of patients with malignant middle cerebral artery infarction. This mismatch could be rectified through recruitment of population-based studies and stroke registries to Virtual International Stroke Trials Archive to increase the number of patients eligible for entry into the comparator patient data pool.

Microalbuminuria in cerebrovascular disease: a modifiable risk factor?

Stroke is potentially preventable through risk factor modification. Over the past decade, there has been considerable interest on microalbuminuria as a risk factor for chronic diseases. The concept of microalbuminuria was originally introduced, about 25 years ago, to clinical practice as a useful marker of nephropathy. Since then various studies reported an association of microalbuminuria with the increased risk of cardiovascular events and all cause of mortality in subjects with or without diabetes. The presence of microalbuminuria was related to left ventricular dysfunction, stroke, and myocardial infarction. Microalbuminuria may be a predictor of stroke but further studies are required. However data on prognostic significance and therapeutic consequence, particularly in haemorrhagic stroke are lacking. This review focuses on the importance of microalbuminuria for cerebrovascular disease, stressing the clinical and therapeutic implications using antihypertensive therapy to control the urinary albumin excretion.

Intensive care management of acute stroke: general management.

For a long time, patients with severe stroke were facing therapeutic nihilism of the attending physicians. Implementation of do-not-resuscitate-orders may have lead to self-fulfilling prophecies and to a pessimistic overestimation of prognosis of severe stroke syndromes. However, there have been great advances in intensive care management of acute stroke patients and it has been shown that treatment on a specialised neurological intensive care unit improves outcome. In this review, we will present a summary of the current state-of-the-art intensive care management of acute stroke patients. After presenting an overview on general management of stroke intensive care patients, special aspects of neurological intensive care of acute large middle cerebral artery stroke, intracerebral haemorrhage and subarachnoid haemorrhage will be discussed. In part II of the review, surgical management options for acute stroke will be discussed in detail.

Bilateral facial palsy: Epstein-Barr virus, not Lyme disease.

Bilateral facial palsy is frequently linked with lyme disease. We report a patient with bilateral facial palsy due to Epstein-Barr virus infection but with Borrelia burgdorferi IgM in serum caused by polyclonal B-lymphocyte stimulation.

[Recommendations of the European Stroke Initiative for the diagnosis and treatment of spontaneous intracerebral haemorrhage]. / Empfehlungen der European Stroke Initiative für Diagnose und Behandlung spontaner intrazerebraler Blutungen.

This article summarises the recommendations for the management of managing patients with intracerebral haemorrhage published in 2006 by the European Stroke Initiative (EUSI) on behalf of the European Stroke Council (ESC), the European Neurological Society (ENS), and the European Federation of Neurological Societies (EFNS).

[Vitreous hemorrhage complicating age-related macular degeneration. Apropos of 18 cases]. / Hémorragie intravitréenne compliquant la dégénérescence maculaire liée à l'âge. A propose de 18 cas.

Vitreous hemorrhage as a complication of Age-Related Macular Degeneration (ARMD) is not a frequent event: 19 cases (out of 18 patients) are reported, corresponding to 0.6% of the patients with ARMD seen in the Department of Ophthalmology of Créteil between January 1st, 1979 and December 31, 1986. The relation between ARMD and vitreous hemorrhage was easy to establish on fundus examination after the resorption of the hemorrhage. However, during the acute hemorrhagic phase, the diagnosis was helped by the other eye fundus examination: this second eye presented with ARMD lesions in 15 out of 18 cases (78.9%). The most challenging differential diagnosis was the choroidal melanoma, when a subretinal hematoma hindered all underlying structures. Vitreous hemorrhages originated generally from well developed subretinal new vessels (17 cases out of 19) arising from the choroid. A retinal pigment epithelium tear, spontaneous or secondary to photocoagulation, was suspected to be the cause of the vitreous hemorrhage in one eye. Finally drugs (3 cases) and systemic diseases (6 cases) seemed to play a role. Visual prognosis is poor in most cases, as the result of the destruction of the macular photoreceptors (six eyes only retained a visual acuity equal or better than 20/400). Laser photocoagulation of the subretinal new vessels was possible for 5 eyes and allowed stabilisation of visual acuity in 2 eyes and improvement in one eye. Vitreous hemorrhage cleared in 16 out of 19 during the follow-up period and vitrectomy was therefore not performed in our series and not indicated at early stages.

[2 new visual acuity tests for children: the Cadet letters and Cadet images]. / Deux nouveaux tests d'acuité visuelle pour enfants: le Cadet lettres et le Cadet images.

The authors present two new visual tests for preschool children: the Cadet letters and the Cadet images, work of the Cadet (Cercle d'Action et de Dépistage des Troubles visuels de l'enfant). The Cadet lettres prospects the angular acuity of children on and after three years. The Cadet images prospects the psychomorphoscopic visual acuity of children on and after two years.

[Inflammatory complications and anterior chamber implants after intracapsular extraction of the lens]. / Complications inflammatoires et implants de chambre antérieure après extraction intracapsulaire du cristallin.

We studied the degree of inflammatory reaction after 43 non-complication intracapsular cataract extractions with anterior chamber lens implantation. Two types of implants were used that varied only by the shape and composition of their loops. Inflammation was more frequent and more severe with polypropylene loops. However, the degree of the inflammatory reaction did not interfere with the final visual results. The anatomic position of the loops did not noticeably influence the degree of inflammation but did seem to affect the final visual acuity.

[Prevention of symblepharon in severe ocular burns. Apropos of 3 cases]. / Prévention du symblépharon dans les brûlures oculaires graves. A propos de 3 cas.

The prevention of symblepharon formation in severe ocular burns can be achieved simply, innocuously and economically, by the application of hen's egg allantoic membrane. Three cases of burns caused by tear gas, sulphuric acid and quicklime were treated by this procedure. The operative procedures, including the membrane preparation and dissection techniques, and methods of applying this membrane to the eye are described. The various advantages of this very old technique, which is apparently not very well-known, are discussed.

Comparison of intra-and extracellular buffering of clinically used buffer substances: tris and bicarbonate.

A large and important group of acid-base disturbances are the metabolic acidoses. In general, every type of metabolic acidosis can be treated with infusion of base when the underlying cause of the disturbances is removed. In our medical centers, the use of tris and bicarbonate is common. For a long time they were competitive agents and until now it was not possible to decide by available clinical methods which of these substances was more suitable for correction of metabolic acidosis. The intracellular pH of the whole rat (mean lcf-pH) was determined from the distribution of 14C labelled DMO (5,5-dimethyl-2,4-oxazolidinedione) and monitored for 6 h following intravenous application of tris or sodiumbiarbonate in a dose of 10 mmol per kg body mass. Arterial plasma pH and PCO2 were also measured. To determine and compare the effectiveness of the two buffer substances, intra- and extracellular bicarbonate were calculated from the Henderson-Hasselbalch equation. It was found that the buffering following bicarbonate infusion is more effective in both body compartments. Sodiumbicarbonate should be preferred in daily practice.