Stroke etiology and collaterals: atheroembolic strokes have greater collateral recruitment than cardioembolic strokes.

BACKGROUND AND PURPOSE: Chronic hypoperfusion from athero-stenotic lesions is thought to lead to better collateral recruitment compared to cardioembolic strokes. It was sought to compare collateral flow in stroke patients with atrial fibrillation (AF) versus stroke patients with cervical atherosclerotic steno-occlusive disease (CASOD). METHOD: This was a retrospective review of a prospectively collected endovascular database. Patients with (i) anterior circulation large vessel occlusion stroke, (ii) pre-treatment computed tomography angiography (CTA) and (iii) intracranial embolism from AF or CASOD were included. CTA collateral patterns were evaluated and categorized into two groups: absent/poor collaterals (CTA collateral score 0-1) versus moderate/good collaterals (CTA collateral score 2-4). CT perfusion was also utilized for baseline core volume and evaluation of infarct growth. RESULTS: A total of 122 patients fitted the inclusion criteria, of whom 88 (72%) had AF and 34 (27%) CASOD. Patients with AF were older (P < 0.01) and less often males or smokers (P = 0.04 and P < 0.01 respectively). Baseline National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were comparable between groups. Collateral scores were lower in the AF group (P = 0.01) with patients having poor collaterals in 28% of cases versus 9% in the CASOD group (P = 0.03). Mortality rates (20% vs. 0%; P = 0.02) were higher in the AF patients whilst rates of any parenchymal hemorrhage (6% vs. 26%; P < 0.01) were higher in the CASOD group. On multivariable analysis, CASOD was an independent predictor of moderate/good collaterals (odds ratio 4.70; 95% confidence interval 1.17-18.79; P = 0.03). CONCLUSIONS: Atheroembolic strokes seem to be associated with better collateral flow compared to cardioembolic strokes. This may in part explain the worse outcomes of AF-related stroke.

Even Small Decreases in Blood Pressure during Conscious Sedation Affect Clinical Outcome after Stroke Thrombectomy: An Analysis of Hemodynamic Thresholds.

BACKGROUND AND PURPOSE: The adverse effects of general anesthesia in stroke thrombectomy have been attributed to intraprocedural hypotension, yet optimal hemodynamic targets remain elusive. Identifying hemodynamic thresholds from patients without exposure to general anesthesia may help separate the effect of hypotension from the effect of anesthesia in thrombectomy outcomes. Therefore, we investigated which hemodynamic parameters and targets best correlate with outcome in patients treated under sedation with monitored anesthesia care. MATERIALS AND METHODS: We performed a retrospective analysis of a prospectively collected data base of patients with anterior circulation stroke who were successfully reperfused (modified TICI ≥ 2b) under monitored anesthesia care sedation from 2010 to 2015. Receiver operating characteristic curves were generated for the lowest mean arterial pressure before reperfusion, both as absolute values and relative changes from baseline. Cutoffs were tested in binary logistic regression models of poor outcome (90-day mRS > 2). RESULTS: Two-hundred fifty-six of 714 patients met the inclusion criteria. In a multivariable model, a ≥10% mean arterial pressure decrease from baseline had an OR for poor outcome of 4.38 (95% CI, 1.53-12.56; P < .01). Other models revealed that any mean pressure of <85 mm Hg before reperfusion had an OR for poor outcome of 2.22 (95% CI, 1.09-4.55; P = .03) and that every 10-mm Hg drop in mean arterial pressure below 100 mm Hg had an OR of 1.28 (95% CI, 1.01-1.62; P = .04). CONCLUSIONS: A ≥10% mean arterial pressure drop from baseline is a strong risk factor for poor outcome in a homogeneous population of patients with stroke undergoing thrombectomy under sedation. This threshold could guide hemodynamic management of patients during sedation and general anesthesia.

Racial and geographic differences in fish consumption: the REGARDS study.

BACKGROUND: Omega-3 fatty acids from fish have been shown to have favorable effects on platelet aggregation, blood pressure, lipid profile, endothelial function, and ischemic stroke risk, but there are limited data on racial and geographic differences in fish consumption. METHODS: Reasons for Geographic and Racial Differences in Stroke (REGARDS) is a national cohort study that recruited 30,239 participants age ≥45 years with oversampling from the southeastern Stroke Belt and Buckle and African Americans (AAs). Centralized phone interviewers obtained medical histories and in-home examiners measured weight and height. Dietary data for this cross-sectional analysis were collected using the self-administered Block98 Food Frequency Questionnaire (FFQ). Adequate intake of nonfried fish was defined as consumption of ≥2 servings per week based on American Heart Association guidelines. After excluding the top and bottom 1% of total energy intake and individuals who did not answer 85% or more of questions on the FFQ, the analysis included 21,675 participants. RESULTS: Only 5,022 (23%) participants consumed ≥2 servings per week of nonfried fish. In multivariable analysis, factors associated with inadequate intake of nonfried fish included living in the Stroke Belt (vs non-Belt) (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.77-0.90) and living in the Stroke Buckle (vs non-Belt) (OR 0.89, 95% CI 0.81-0.98); factors associated with ≥2 servings per week of fried fish included being AA (vs white) (OR 3.59, 95% CI 3.19-4.04), living in the Stroke Belt (vs non-Belt) (OR 1.32, 95% CI 1.17-1.50), and living in the Stroke Buckle (vs non-Belt) (OR 1.17, 95% CI 1.00-1.36). CONCLUSIONS: Differential consumption of fish may contribute to the racial and geographic disparities in stroke.

Warfarin vs aspirin for symptomatic intracranial stenosis: subgroup analyses from WASID.

The WASID trial showed no advantage of warfarin over aspirin for preventing the primary endpoint of ischemic stroke, brain hemorrhage, or vascular death. In analyses of selected subgroups, there was no definite benefit from warfarin. Warfarin reduced the risk of the primary endpoint among patients with basilar artery stenosis, but there was no reduction in stroke in the basilar artery territory or benefit for vertebral artery stenosis or posterior circulation disease in general.

Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial.

BACKGROUND: Hyperglycemia during acute ischemic stroke may augment brain injury, predispose to intracerebral hemorrhage (ICH), or both. METHOD: To analyze the relationship between admission glucose level and clinical outcomes from acute ischemic stroke, the authors performed multivariate regression analysis with the National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator (rt-PA) Stroke Trial data. Neurologic improvement was defined as improvement on the NIH Stroke Scale by 4 or more points from baseline to 3 months, or a final score of zero. Favorable outcome was defined as both Glasgow Outcome score of 1 and Barthel Index 95 to 100 at 3 months. Symptomatic ICH was defined as CT-documented hemorrhage temporally related to clinical deterioration within 36 hours of treatment. Potential confounding factors were controlled, including acute treatment (rt-PA or placebo), age, baseline NIH Stroke Scale score, history of diabetes mellitus, stroke subtype, and admission blood pressure. RESULTS: There were 624 patients enrolled within 3 hours after stroke onset. As admission glucose increased, the odds for neurologic improvement decreased (odds ratio [OR] = 0.76 per 100 mg/dL increase in admission glucose, 95% CI 0.61 to 0.95, p = 0.01). The relation between admission glucose and favorable outcome depended on admission mean blood pressure (MBP): as admission MBP increased, the odds for favorable outcome related to increasing admission glucose levels progressively decreased (p = 0.02). As admission glucose increased, the odds for symptomatic ICH also increased (OR = 1.75 per 100 mg/dL increase in admission glucose, 95% CI 1.11 to 2.78, p = 0.02). Admission glucose level was not associated with altered effectiveness of rt-PA. CONCLUSIONS: In patients with acute ischemic stroke, higher admission glucose levels are associated with significantly lower odds for desirable clinical outcomes and significantly higher odds for symptomatic ICH, regardless of rt-PA treatment. Whether this represents a cause and effect relationship remains to be determined.

The care of HIV-infected adults in rural areas of the United States.

OBJECTIVE: This study describes the population of HIV-infected adults receiving care in rural areas of the United States and compares HIV care received in rural and urban areas. METHODS: Interviews were conducted with a nationally representative sample of 367 HIV-infected adults receiving health care in rural areas and 2806 HIV-infected adults receiving health care in urban areas of the contiguous United States. RESULTS: We estimate that 4800 HIV-infected persons received medical care in rural areas during the first half of 1996. Patients in rural HIV care were more likely than patients in urban HIV care to receive care from providers seeing few (<10) HIV-infected patients (38% vs. 3%; p <.001). Rural care patients were less likely than urban care patients to have taken highly active antiretroviral agents (57% vs. 73%; p <.001) or Pneumocystis carinii pneumonia prophylactic medication when indicated (60% vs. 75%; p =.006). CONCLUSIONS: Few American adults received HIV care in rural areas of the United States. Our findings suggest ongoing disparities between urban and rural areas in access to high-quality HIV care.

Stroke awareness among Georgia adults: epidemiology and considerations regarding measurement.

BACKGROUND: To design and evaluate interventions for reducing the impact of stroke in Georgia, we assessed knowledge of signs, risk factors, and burden of stroke. METHODS: Adults in Georgia were studied with a random digit dial telephone survey. RESULTS: Answering an unaided question, 39% of 602 respondents named > or =1 stroke warning sign. Awareness was considerably greater when assessed with prompted questions. Most respondents (70%) said they would call 911 if someone had a stroke; almost all (95%) considered stroke an emergency. Risk factor awareness ranged from 97% (previous stroke) to 69% (diabetes). Altogether, 6% reported having had a stroke; 48% reported a stroke in their family. CONCLUSIONS: Georgia adults have low awareness of stroke warning signs. Our findings underscore the importance of conducting an effective educational campaign. Furthermore, a need exists for questions on stroke awareness that approximate more closely the situation in which a person must identify a potential stroke.

Cocaine use and hypertension are major risk factors for intracerebral hemorrhage in young African Americans.

OBJECTIVE: To determine the risk factors for intracerebral hemorrhage (ICH) in African Americans aged 18 to 45 years. African Americans are at a higher risk for ICH than Whites, particularly in the younger age groups. However, few data are available regarding the factors that contribute to the high risk of ICH among younger African Americans. DESIGN: A case-control study. SETTINGS: A university-affiliated public hospital. PARTICIPANTS: One hundred and twenty-two African-American patients admitted with non-traumatic ICH to Grady Memorial Hospital (Atlanta, Ga.) and 366 age- and sex matched African-American controls selected from a nationally representative sample of the civilian, non-institutionalized US population. MAIN OUTCOME MEASURE: Association between ICH and various demographic and clinical factors determined by stepwise logistic regression. RESULTS: Cocaine use (OR 6.1, 95% CI 3.3-11.8), hypertension (OR 5.2, 95% CI 3.2-8.7) and alcohol use (OR 1.9, 95% CI 1.1-3.3) were independently associated with increased risk for ICH. CONCLUSIONS: Cocaine use, hypertension and alcohol use contributed to the high risk of ICH observed in younger African Americans. Primary preventive strategies are required to reduce the high frequency of modifiable risk factors predisposing younger African Americans to ICH.

Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset.

BACKGROUND AND PURPOSE: Follow-up imaging data from stroke patients without angiographically apparent arterial occlusions at symptom onset are lacking. We reviewed our Emergency Management of Stroke (EMS) trial experience to determine the clinical and imaging outcomes of patients with ischemic stroke who showed no arterial occlusion on angiograms obtained within 4 hours of symptom onset. METHODS: All patients in this report were participants in the EMS trial that was designed to address the safety and potential efficacy of combined IV and intraarterial thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke. RESULTS: Thirty-five patients were randomized to receive either IV rt-PA (n = 17) or placebo (n = 18), followed by cerebral angiography. No symptomatic arterial occlusion was evident in 10 (29%) of the 34 patients. Eight (80%) of 10 patients without angiographically apparent clot within 4 hours of symptom onset had a new cerebral infarction confirmed on follow-up brain imaging. The median 72-hour infarction volume was 2.4 cc (range, 1-30 cc). Four of the 10 "no-clot" patients had a favorable 3-month outcome as assessed by Barthel Index (score, 95 or 100) and modified Rankin Scale (score, 0 or 1). The six remaining patients had 3-month Rankin Scale scores of 1 (Barthel of 90), 2, 3, 4, or 5. CONCLUSION: Acute ischemic stroke patients with a neurologic deficit but a negative angiogram during the first 4 hours after symptom onset usually develop image-documented cerebral infarction, and approximately half suffer from long-term functional disability. The two most likely explanations for negative angiograms are very early irreversible ischemic damage despite recanalization or ongoing ischemia secondary to clot in non-visible penetrating arterioles or in the microvasculature.

Clinical deterioration following improvement in the NINDS rt-PA Stroke Trial.

BACKGROUND AND PURPOSE: Little is known in regard to cerebral arterial reocclusion after successful thrombolysis. In the absence of arteriographic information, the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Trial investigators prospectively identified clinical deterioration following improvement (DFI) as a possible surrogate marker of cerebral arterial reocclusion after rt-PA-induced recanalization. Also, we identified any significant clinical deterioration (CD) even if not preceded by improvement. This observational analysis was designed to determine the incidence of DFI and CD in each treatment group, to identify baseline or posttreatment variables predictive of DFI or CD, and to determine any relationship between DFI, CD, and clinical outcome. METHODS: DFI was defined as any 2-point deterioration on the NIH Stroke Scale after an initial 2-point improvement after treatment. CD was defined as any 4-point worsening after treatment compared with baseline. All data were collected prospectively by investigators blinded to treatment allocation. A noncontrast brain CT was mandated when a 2-point deterioration occurred. All cases were validated by a central review committee. RESULTS: DFI was identified in 81 of the 624 patients (13%); 44 were treated with rt-PA and 37 were treated with placebo (P:=0.48). DFI occurred more often in patients with a higher baseline NIH Stroke Scale score. CD within the first 24 hours occurred in 98 patients (16% of all patients); 43 were given rt-PA and 55 were given placebo (P:=0.19). Baseline variables associated with CD included a less frequent use of prestroke aspirin and a higher incidence of early CT changes of edema or mass effect or dense middle cerebral artery sign. Patients with CD had higher rates of increased serum glucose and fibrin degradation products, and they also had higher rates of symptomatic intracranial hemorrhage and death. Patients who experienced either DFI or CD were less likely to have a 3-month favorable outcome. CONCLUSIONS: We found no association between DFI, CD, and rt-PA treatment, and no clinical evidence to suggest reocclusion. Deterioration was strongly associated with stroke severity and poor outcome and was less frequent in patients whose stroke occurred while they were on aspirin.

Predicting prognosis after stroke: a placebo group analysis from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial.

BACKGROUND: Physicians are often asked to predict outcome after acute stroke. Very little information is available that can reliably predict the likelihood of severe disability or death. OBJECTIVE: To develop a practical method for predicting a poor outcome after acute ischemic stroke. METHODS: Data from the placebo arms of Parts 1 and 2 of the National Institute of Neurological Disorders and Stroke rt-PA [recombinant tissue plasminogen activator] Stroke Trial were used to identify variables that could predict a poor outcome, defined as moderately severe disability, severe disability, or death (Modified Rankin Scale score >3) 3 months after stroke. RESULTS: Baseline variables that predicted poor outcome were the NIH Stroke Scale (NIHSS) >17 plus atrial fibrillation, yielding a positive predictive value (PPV) of 96% (95% CI, 88 to 100%). The best predictor at 24 hours was NIHSS >22, yielding a PPV of 98% (95% CI, 93 to 100%). The best predictor at 7 to 10 days was NIHSS >16, yielding a PPV of 92% (95% CI, 85 to 99%). CONCLUSIONS: Patients with a severe neurologic deficit after acute ischemic stroke, as measured by the NIHSS, have a poor prognosis. During the first week after acute ischemic stroke, it is possible to identify a subset of patients who are highly likely to have a poor outcome. These findings require confirmation in a separate study.

Ischemic events associated with unruptured intracranial aneurysms: multicenter clinical study and review of the literature.

OBJECTIVE: To determine the prevalence, clinical characteristics, and long-term outcomes in cases involving transient ischemic attacks (TIAs) or ischemic strokes secondary to embolization from unruptured intracranial aneurysms. METHODS: We identified all available patients with intracranial aneurysms and ischemic strokes in three university-affiliated hospitals, using either International Classification of Diseases-9th Revision codes or local registries. Patients with clinically or radiologically detected cerebral infarctions distal to intracranial aneurysms, in the absence of other causes for the infarctions, were included. An aneurysmal embolic source was considered highly probable by the primary neurosurgeon/neurologist in all cases. Follow-up data for the patients were acquired through reviews of clinical visits or telephone interviews. A review of the literature was performed to identify characteristics of previously reported patients. RESULTS: Ischemic strokes or TIAs attributable to embolization from the aneurysmal sac were observed for 9 of 269 patients (3.3%) with unruptured aneurysms. Of these nine patients, five were women and four were men (mean age, 62 yr; age range, 45-72 yr). Symptomatic aneurysms were located in the middle cerebral artery (n = 4), internal carotid artery (n = 3), posterior cerebral artery (n = 1), or vertebral artery (n = 1). The mean maximal diameter was 12.5 mm (range, 5-45 mm). Six patients underwent surgical treatment, of whom two experienced postoperative cerebral infarctions referable to the distribution of the artery harboring the aneurysm. Two patients were treated with aspirin, and one patient received no treatment. The mean follow-up period was 38 months (range, 1-60 mo). None of the patients experienced additional ischemic events during the follow-up period. Among the 41 previously reported patients, conservative treatment was used for 20 patients (mean follow-up period, 50.7 +/- 44.5 mo). Four of the 20 patients experienced recurrent TIAs, 1 patient experienced worsening of symptoms, and 1 patient died during the follow-up period. A total of 21 patients underwent surgical treatment (mean follow-up period, 33.6 +/- 32.3 mo). Of these patients, only one experienced recurrent TIAs. Two patients experienced postoperative seizures, and one patient died during the follow-up period. All recurrent symptoms with either surgical or conservative treatment were transient, and no patient experienced a major or disabling stroke during the follow-up period. CONCLUSION: Ischemic events can occur distal to both small and large unruptured intracranial aneurysms (predominantly in the anterior circulation). The long-term risk of recurrent ischemic events, particularly major or disabling strokes, seems to be low with either surgical or conservative treatment.

National probability samples in studies of low-prevalence diseases. Part II: Designing and implementing the HIV cost and services utilization study sample.

OBJECTIVE: The design and implementation of a nationally representative probability sample of persons with a low-prevalence disease, HIV/AIDS. DATA SOURCES/STUDY SETTING: One of the most significant roadblocks to the generalizability of primary data collected about persons with a low-prevalence disease is the lack of a complete methodology for efficiently generating and enrolling probability samples. The methodology developed by the HCSUS consortium uses a flexible, provider-based approach to multistage sampling that minimizes the quantity of data necessary for implementation. STUDY DESIGN: To produce a valid national probability sample, we combined a provider-based multistage design with the M.D.-colleague recruitment model often used in non-probability site-specific studies. DATA COLLECTION: Across the contiguous United States, reported AIDS cases for metropolitan areas and rural counties. In selected areas, caseloads for known providers for HIV patients and a random sample of other providers. For selected providers, anonymous patient visit records. PRINCIPAL FINDINGS: It was possible to obtain all data necessary to implement a multistage design for sampling individual HIV-infected persons under medical care with known probabilities. Taking account of both patient and provider nonresponse, we succeeded in obtaining in-person or proxy interviews from subjects representing over 70 percent of the eligible target population. CONCLUSIONS: It is possible to design and implement a national probability sample of persons with a low-prevalence disease, even if it is stigmatized.

Improving adherence to dementia guidelines through education and opinion leaders. A randomized, controlled trial.

BACKGROUND: Educational methods that encourage physicians to adopt practice guidelines are needed. OBJECTIVE: To evaluate an educational strategy to increase neurologists' adherence to specialty society-endorsed practice recommendations. DESIGN: Randomized, controlled trial. SETTING: Six urban regions in New York State. PARTICIPANTS: 417 neurologists. INTERVENTION: The educational strategy promoted six recommendations for evaluation and management of dementia. It included a mailed American Academy of Neurology continuing medical education course, practice-based tools, an interactive evidence-based American Academy of Neurology-sponsored seminar led by local opinion leaders, and follow-up mailings. MEASUREMENTS: Neurologists' adherence to guidelines was measured by using detailed clinical scenarios mailed to a baseline group 3 months before the intervention and to intervention and control groups 6 months after the intervention. In one region, patients' medical records were reviewed to determine concordance between neurologists' scenario responses and their actual care. RESULTS: Compared with neurologists in the baseline and control groups, neurologists in the intervention group were more adherent to three of the six recommendations: neuroimaging for patients with dementia only when certain criteria are present (odds ratio, 4.1 [95% CI, 1.9 to 8.9]), referral of all patients with dementia and their families to the Alzheimer's Association (odds ratio, 2.8 [CI, 1.7 to 4.8]), and encouragement of all patients and their families to enroll in the Alzheimer's Association Safe Return Program (odds ratio, 10.8 [CI, 3.5 to 33.2]). For the other three recommendations, adherence did not differ between the intervention and the nonintervention groups. Agreement between scenario responses and actual care ranged from 27% to 99% for the six recommendations and was 95% or more for three of the recommendations. CONCLUSION: A multifaceted educational program can improve physician adoption of practice guidelines.

A randomized trial to implement practice recommendations: design and methods of the Dementia Care Study.

The objective of the Dementia Care Study was to design, implement, and evaluate, in a randomized controlled trial a multi-faceted, specialty-society sponsored intervention to encourage neurologists' adoption of practice recommendations. Eligible participants were 417 neurologists in six regions in New York State (NYS) who were identified through the American Academy of Neurology (AAN) Membership Database and the NYS Physician Masterfile. An Advisory Panel of experts on dementia, neurologists who were local opinion leaders, and local representatives of the Alzheimer's Association guided the development of the intervention. The intervention included six components: (1) a mailing of six practice recommendations in a course of continuing medical education (CME) sponsored by the AAN; (2) a mailing of supplementary, practice-based tools; (3) follow-up mailings reinforcing the recommendations; (4) an invitation to an AAN-sponsored seminar; (5) endorsement by opinion leaders; and (6) specialty-society sponsorship and endorsement. The primary outcome measure was neurologists' decision-making, as assessed through a mailed survey that used detailed clinical scenarios. Intervention and control neurologists received the survey six months after the intervention, and a baseline group received it three months prior to the intervention. To evaluate the concordance of responses to scenarios with actual processes of care, we reviewed medical records in one study region. Secondary outcome measures included number of patient referrals received by the local Alzheimer's Associations and by the Association's National Safe Return Program. The specialty society, the opinion leaders, the dementia experts, local advocacy groups, and the study investigators achieved a high degree of collaboration. Specialty societies can integrate within their educational programs the capability to design and evaluate the impact of novel strategies to encourage the adoption of practice recommendations that are linked to improved quality of care.

Rate of 24-hour blood pressure decline and mortality after spontaneous intracerebral hemorrhage: a retrospective analysis with a random effects regression model.

OBJECTIVE: To study the effect of decline in blood pressure on mortality in patients with spontaneous intracerebral hemorrhage (ICH). DESIGN: Retrospective chart review. SETTING: University-affiliated teaching hospital. PATIENTS: Consecutive patients admitted with spontaneous ICH over a 3-year period. MEASURES: Blood pressure recordings were obtained from the first 24 hrs. Patients (n = 105) with more than five blood pressure recordings and on average greater than one measurement per 2 hrs were included (mean measurements per patient = 20.3). Mean arterial pressure (MAP) recordings over the first 24 hrs after presentation were regressed on time for each patient. Each patient's MAP was calculated as a slope (change mm Hg/hr). We performed logistic regression analyses to determine the effect of MAP slope on mortality and functional outcome, adjusting for other predictive factors including Glasgow Coma Scale (GCS) score and hematoma volume. The effect of MAP slope on mortality was also evaluated in subsets of patients based on age, gender, initial GCS score, initial MAP, treatment status, hematoma volume, and presence of ventricular blood. MAIN RESULTS: Mean slope of change in MAP was -2.0 mm Hg/hr (+/- 1.9, range -8.5 to +0.6). The slope of MAP (faster rate of decline) within the first 24 hrs was significantly associated with higher mortality (p =.04), independent of initial GCS score and hematoma volume. In subgroup analyses, MAP slope was significantly associated with mortality in men (p = .08), patients with hematoma volume <50 mm3 (p =.08), initial MAP < or = 146 mm Hg (p = .006), and those with initial GCS score > or = 10 (p= .07). MAP slope did not predict functional outcome among survivors. CONCLUSIONS: A rapid decline in MAP within 24 hrs after presentation is independently associated with increased mortality in patients with ICH. A large, prospective, randomized trial is required to confirm these findings.

The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium.

BACKGROUND AND METHODS: In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas. RESULTS: During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men who had had sex with men. Forty-six percent had incomes of less than $10,000 per year, 68 percent had public health insurance or no insurance, and 30 percent received care at teaching institutions. The estimated annual direct expenditures for the care of the patients seen during the first two months of 1996 were $5.1 billion; the expenditures for the estimated 335,000 HIV-infected adults seen at least as often as every six months were $6.7 billion, which is about $20,000 per patient per year. CONCLUSIONS: In this national survey we found that most HIV-infected adults who were receiving medical care had advanced disease. The patient population was disproportionately male, black, and poor. Many Americans with diagnosed or undiagnosed HIV infection are not receiving medical care at least as often as every six months. The total cost of medical care for HIV-infected Americans accounts for less than 1 percent of all direct personal health expenditures in the United States.

Magnetic resonance angiography in patients with brain infarction.

This study evaluated the role of magnetic resonance angiography (MRA) in detecting extra- or intracranial vascular disease in 118 patients with brain infarction and the accuracy of MRA diagnosis when compared with conventional angiography in patients who had both investigations. Magnetic resonance angiography ruled out extra- and intracranial large vessel disease in 36% of the patients. MRA also demonstrated extra- or intracranial disease in 56% (probably symptomatic in 31, possibly symptomatic in 18, and asymptomatic in 17 patients), and provided no information in 8% of the 118 patients. Among the 176 major vessels visualized by both MRA and conventional angiography, conventional angiography confirmed the presence of 9/10 extracranial and 32/40 intracranial large vessel abnormalities detected on MRA. There were two false-negative findings on MRA: occlusion of a distal branch of middle cerebral artery, and an asymptomatic posterior cerebral artery stenosis. Magnetic resonance angiography is a clinically useful method for screening extra- and intracranial disease in patients with brain infarction and selecting high-yield patients for conventional angiography.