Frequency and predictors for angiographically improved inflow of contrast medium after carotid angioplasty and stenting.

Percutaneous transluminal carotid angioplasty and stenting (PTAS) can result in immediate improvement in cerebral blood flow (CBF) evident through faster transit of contrast medium on angiography. To evaluate frequency and predictors of changes in inflow of contrast medium before and after PTAS, we reviewed 86 patients (mean age 68.6 +/- 9.1 years) treated for symptomatic or asymptomatic carotid stenosis. Clinical data and lesion characteristics were extracted from charts and digital angiograms, respectively. Perfusion change was assessed qualitatively by comparing pre- and poststenting images matched for projection and time from injection. Improved inflow was defined on the basis of spatial or temporal distribution of contrast medium: grade -1: fewer vessels visible after stenting; 0: no change; 1: more distal small arteries visible; 2: time-matched poststenting image showing a capillary blush; 3: time-matched poststenting image showing small veins, 4 time-matched poststenting image showing large veins and sinuses. Faster inflow of contrast medium was observed in 74% of patients (grades 1: 34%,and 4: 4.7%). In linear regression analysis, higher degrees of ipsilateral stenosis were associated with greater changes in inflow of contrast medium (P < 0.05). Right internal carotid lesions were associated with greater change in inflow than left-sided lesions (P < 0.01). In 31 patients (36%) we initially showed contralateral anterior cerebral artery (ACA) filling, and in 39% of these, normal filling was restored after stenting. Lesser contralateral carotid stenosis was associated with crossed ACA filling and with restoration of normal filling pattern after stenting. Faster appearance of a contrast-medium blush is seen in most cases of carotid angioplasty and stenting and depends on the degree of hemodynamic inflow obstruction relieved by stenting.

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.

Who should be screened for asymptomatic carotid artery stenosis? Experience from the Western New York Stroke Screening Program.

OBJECTIVE: Identification of significant asymptomatic carotid artery stenosis (ACAS) is important because of the stroke-risk reduction observed with carotid endarterectomy. The authors developed and validated a simple scoring system based on routinely available information to identify persons at high risk for ACAS using data collected during a community health screening program at various sites in western New York. A total of 1331 unselected volunteers without previous stroke, transient ischemic attack, or carotid artery surgery were evaluated by personal interview and duplex ultrasound. The main outcome measure was carotid artery stenosis > 60% by duplex ultrasound. In the derivation set (n = 887), 4 variables were significantly associated with ACAS > 60%: age > 65 years (odds ratio [OR] = 4.1, 95% confidence interval [CI] = 2.6-6.7), current smoking (OR = 2.0, 95% CI = 1.2-3.5), coronary artery disease (OR = 2.4, 95% CI = 1.5-3.9), and hypercholesterolemia (OR = 1.9, 95% CI = 1.2-2.9). Three risk groups (low, intermediate, and high) were defined on the basis of total risk score assigned on the basis of the strength of association. The scheme effectively stratified the validation set (n = 444); the likelihood ratio and posttest probability for ACAS in the high-risk group were 3.0 and 35%, respectively, and in the intermediate and low-risk groups were 1.4 and 20% and 0.4 and 7%, respectively. Routinely available information can be used to identify persons in the community at high risk for ACAS. Doppler ultrasound screening in this subgroup may prove to be cost-effective and have an effect on stroke-free survival.

Quality of life and its relationship to brain lesions and atrophy on magnetic resonance images in 60 patients with multiple sclerosis.

CONTEXT: Disease-modifying multiple sclerosis (MS) therapeutic trials continue to rely on physical disability as the main clinical outcome measure, while the impact of treatment on quality of life (QOL) is poorly understood. Weak correlations exist between physical disability and the disease burden as shown using conventional brain magnetic resonance imaging (MRI), indicating poor sensitivities of these measures alone in defining the clinical course of MS. OBJECTIVES: To investigate the impact of MS on QOL; to determine whether impaired QOL in patients with MS was related to any regional brain abnormalities assessed using conventional MRI sequences; and to determine if the severity of MS as assessed by the Expanded Disability Status Scale (EDSS) and clinical course was associated with worsening QOL. DESIGN, SETTING, AND PATIENTS: Prospective, cross-sectional study of 60 consecutive patients with MS treated in a community-based, university-affiliated MS clinic. MAIN OUTCOME MEASURES: Assessments of QOL using the Multiple Sclerosis Quality of Life-54 Instrument were correlated with the scores of the EDSS, clinical course, and findings on brain MRI. RESULTS: Quality of life was significantly impaired in patients with MS and was worse in patients with secondary-progressive MS compared with those with relapsing-remitting MS. Brain MRI lesions and atrophy were associated with impaired QOL with respect to sexual dysfunction, overall mental health, and limitations due to physical and emotional dysfunction. Correlations between MRI results and QOL assessments were much stronger for hypointense lesions and atrophy on T1-weighted images than for hyperintense lesions on T2-weighted images and were insignificant for lesions on contrast-enhanced images. Higher EDSS scores were associated with impairments in most physical and mental health QOL scales but were weakly correlated with cognitive and sexual dysfunction. CONCLUSIONS: In patients with MS, QOL is impaired and is associated with increasing neurologic disability. Quality of life assessments are related in part to brain lesions and atrophy shown on MRI. Assessments of QOL provide unique information not readily evaluated by EDSS and may be useful as secondary clinical outcome measures. Arch Neurol. 2000;57:1485-1491

Fatigue in multiple sclerosis and its relationship to depression and neurologic disability.

We studied multiple sclerosis fatigue (MSF) and its relationship to depression and disability. Seventy-one patients [50 relapsing-remitting, 21 secondary progressive] were grouped by Fatigue Severity Scale (FSS) into MS-fatigue (MSF) (FSS>/=5; n=46) or MS-nonfatigue (MSNF) (FSS

Brain MRI lesions and atrophy are related to depression in multiple sclerosis.

It is unclear whether brain MRI lesions are associated with depression in multiple sclerosis (MS). Neurological dysfunction in depressed (n= 19) and non-depressed (n = 29) MS patients was rated by expanded disability status scale (EDSS). EDSS was weakly predictive of the presence of (p = 0.03) and severity of (p = 0.01) depression. After correcting for EDSS, the presence of depression was predicted by superior frontal and superior parietal hypointense TI lesions (p<0.01); the severity of depression was predicted by superior frontal, superior parietal and temporal TI lesions, lateral and third ventricular enlargement, and frontal atrophy (p<0.01). Depression was not related to bright T2 lesions or enhancement. We conclude that atrophy and cortical-subcortical disconnection due to frontal and parietal white matter destructive lesions may contribute to depression in MS.

Intraventricular CSF pulsation artifact on fast fluid-attenuated inversion-recovery MR images: analysis of 100 consecutive normal studies.

BACKGROUND AND PURPOSE: CSF pulsation artifact is a pitfall of fast fluid-attenuated inversion-recovery (FLAIR) brain MR imaging. We studied ventricular CSF pulsation artifact (VCSFA) on axial FLAIR images and its relationship to age and ventricular size. METHODS: Fast FLAIR axial images were obtained on a 1.5-T unit (8000/150/2 [TR/TE/ excitations], inversion time = 2200, field of view = 24 cm, matrix = 189x256, and 5-mm interleaved sections). Two observers rated VCSFA (hyperintensity on FLAIR images) in the lateral, third, and fourth ventricles by using a three-point ordinal scale in 100 consecutive subjects (ages 20-86 years) with normal brain MR studies. Left-to-right third ventricular width was also measured. RESULTS: Seventy-two subjects had VCSFA in at least one ventricular cavity. The fourth ventricle was the most common site of VCSFA (n = 58), followed by the third ventricle (n = 47) and the lateral ventricles (n = 13). VCSFA was usually severe in the third and fourth ventricles and less severe in the lateral ventricles. Fourth ventricular VCSFA was significantly associated with third ventricular VCSFA. Increasing third ventricular size and, to a lesser extent, increasing age was significantly associated with VCSFA. Ghost pulsation of VCSFA occurred across the brain parenchyma in the phase-encoding direction. VCSFA seen in the fourth ventricle on axial FLAIR images disappeared on sagittal FLAIR images in one subject. CONCLUSION: VCSFA on axial FLAIR images represents inflow artifact caused by inversion delay and ghosting effects. VCSFA might obscure or mimic intraventricular lesions, especially in the third and fourth ventricles. Although common in adults of all ages, VCSFA is associated with advancing age and increasing ventricular size. Thus, altered CSF flow dynamics that occur with ventriculomegaly and aging contribute to VCSFA on axial FLAIR MR images.

MRI T2 shortening ('black T2') in multiple sclerosis: frequency, location, and clinical correlation.

Abnormal iron deposition occurs in the brains of patients with multiple sclerosis (MS) and may cause MRI T2 shortening ('black T2'; BT2). The frequency, distribution and clinical significance of BT2 in MS is unknown. Analysis of brain MRI scans of 114 MS patients showed BT2 in thalamus (n = 65; 57%), putamen (n = 48; 42%), caudate (n = 27; 24%) and Rolandic cortex (n = 9; 8%). BT2 was significantly related to longer disease duration and advancing neurological disability. Wheelchair-bound patients had worse BT2 in thalamus (p < 0.05), putamen (p < 0.001) and Rolandic cortex (p < 0.05). Patients with secondary progressive disease (n = 34) had worse BT2 in thalamus, putamen and caudate (all p < 0.05) than those with relapsing remitting disease (n = 80). BT2 is proposed as a clinically relevant finding relating to neuronal degeneration in MS.

Identification of patients at risk for periprocedural neurological deficits associated with carotid angioplasty and stenting.

BACKGROUND AND PURPOSE: Transient or permanent neurological deficits can occur in the periprocedural period following carotid angioplasty and stenting (CAS), presumably due to distal embolization and/or hemodynamic compromise. We performed this study to identify predictors of neurological deficits associated with carotid angioplasty and stent placement. METHODS: We reviewed medical records and angiograms in a consecutive series of patients who underwent CAS for symptomatic or asymptomatic cervical internal carotid artery stenosis from June 1996 through December 1998. Using logistic regression analysis, we evaluated the effect of demographic, clinical, intraprocedural, and angiographic risk factors on subsequent development of periprocedural neurological deficits. Periprocedural neurological deficits were defined as new or worsening transient or permanent neurological deficits that occurred during or within 48 hours of the procedure. RESULTS: A total of 111 patients (mean age 68.2+/-9.1 years) who underwent CAS for asymptomatic (n=54) or symptomatic (n=57) stenoses were included in this study. A total of 14 periprocedural neurological deficits (13%) were observed either during (n=4) or after (n=10) the procedure. Three identified variables were independently associated with periprocedural neurological deficits: symptomatic lesion (OR 8.3, 95% CI 1.6 to 42.6), length of stenotic segment >/=11.2 mm (OR 5.2, 95% CI 1.2 to 22.5), and absence of hypercholesterolemia (OR 5.4, 95% CI 1.4 to 20.9). Other variables, including age and degree of stenosis (defined by NASCET criteria), were not associated with periprocedural neurological deficits. CONCLUSIONS: A combination of clinical and angiographic variables can be used to identify patients at risk for periprocedural neurological deficits after CAS. Such identification may help in selection of patients who may benefit from novel pharmacological and mechanical preventive approaches.

Frequency and determinants of postprocedural hemodynamic instability after carotid angioplasty and stenting.

BACKGROUND AND PURPOSE: Hemodynamic instability can occur acutely after carotid angioplasty and stent placement (CAS). We performed this study to determine the frequency of hemodynamic instability in a series of patients who underwent CAS and to analyze factors associated with development of postprocedural hemodynamic events. METHODS: We reviewed medical records and angiograms in a series of 51 patients (mean age 68.3+/-8.9 years) who underwent CAS for symptomatic (n=29) or asymptomatic (n=22) carotid artery stenosis. Any episodes of hypotension (systolic blood pressure <90 mm Hg), hypertension (systolic blood pressure >160 mm Hg), or bradycardia (heart rate <60 bpm) that occurred in the acute postprocedural period were recorded. The effect of demographic, clinical, intraprocedural, and angiographic factors on subsequent development of hemodynamic instability was analyzed by logistic regression. RESULTS: The frequency of postprocedural hemodynamic complications in our patient series was as follows: hypotension, 22.4%; hypertension, 38.8%; and bradycardia, 27.5%. Intraprocedural hypotension (odds ratio [OR] 14.6, P=0.024) and history of myocardial infarction (OR 14.1, P=0.04) independently predicted postprocedural hypotension. Postprocedural hypertension was predicted by intraprocedural hypertension (OR 7.6, P=0.01) and previous ipsilateral carotid endarterectomy (OR 7.6, P=0.02). Postprocedural bradycardia was associated with intraprocedural hypotension (OR 74, P=0.001) and intraprocedural bradycardia (OR 12, P=0.008). All events had resolved at the conclusion of the intensive care unit monitoring period (mean 25.7 hours, range 18 to 43 hours). CONCLUSIONS: Postprocedural hemodynamic instability is frequent after CAS and supports the need for monitoring in settings suited to expeditious management of cardiovascular emergencies. Patients who have evidence of hemodynamic instability during the procedure are at highest risk.

Fatigue in multiple sclerosis: cross-sectional correlation with brain MRI findings in 71 patients.

Fatigue is an unexplained but common and disabling symptom in MS. We assessed fatigue in 71 patients with MS and identified MS-fatigue (MSF) and MS-nonfatigue (MSNF) groups. Fatigue severity did not correlate with regional or global MRI plaque load or atrophy assessed by conventional sequences. No significant differences were noted in any MRI measures between MSF and MSNF groups. We suggest that brain MRI disease topography or severity does not explain fatigue in MS and that fatigue is likely due to mechanisms poorly characterized by conventional MRI.

Fluid-attenuated inversion-recovery MR imaging in acute and subacute cerebral intraventricular hemorrhage.

BACKGROUND AND PURPOSE: Fluid-attenuated inversion-recovery (FLAIR) MR imaging may show subarachnoid hemorrhage (SAH) with high sensitivity. We hypothesized that the FLAIR technique is effective and reliable in the diagnosis of cerebral intraventricular hemorrhage (IVH). METHODS: Two observers evaluated the 1.5-T MR fast spin-echo FLAIR images, T1- and T2-weighted MR images, and CT scans of 13 patients with IVH and the FLAIR images of 40 control subjects. RESULTS: IVH appeared bright on the FLAIR images obtained during the first 48 hours and was of variable appearance at later stages. FLAIR MR imaging detected 12 of 13 cases of IVH; no control subjects were falsely thought to have IVH (92% sensitivity, 100% specificity). However, IVH could not be fully excluded in the third ventricle (20%, n = 8) or in the fourth ventricle (28%, n = 11) on some control images because of CSF pulsation artifacts. Two cases had CT-negative IVH seen on FLAIR images. One case had FLAIR-negative IVH seen by CT. Although the sensitivities of conventional MR imaging (92%) and CT (85%) were also high, FLAIR imaging showed IVH more conspicuously than did standard MR imaging and CT in 62% of the cases (n = 8). FLAIR was as good as or better than CT in showing IVH in 10 cases (77%). FLAIR images showed all coexisting SAH. CONCLUSION: FLAIR MR imaging identifies acute and subacute IVH in the lateral ventricles with high sensitivity and specificity. In cases of subacute IVH, conventional MR imaging complements FLAIR in detecting IVH. The usefulness of the FLAIR technique for detecting third and fourth ventricular IVH may be compromised by artifacts. Blood hemoglobin degradation most likely causes the variable FLAIR appearance of IVH after the first 48 hours.