Predicting ischaemic stroke subtype from presenting systolic blood pressure: the BASIC Project.

OBJECTIVE: We hypothesized that low presenting systolic blood pressure (SBP) predicted cardioembolic stroke aetiology. DESIGN: Active and passive surveillance were used to identify all ischaemic strokes as part of the Brain Attack Surveillance in Corpus Christi (BASIC) population-based study. Multinomial logistic regression was used to examine the association between stroke subtype and first documented SBP in the medical record. SETTING: Nueces County, TX, USA (313,645 residents in 2000). The community is urban with the majority of the population residing in the city of Corpus Christi. The area is served by seven adult acute care hospitals. PATIENTS: Three hundred and eight cases with completed ischaemic stroke and determined subtype aetiology between January 2000 and December 2002. RESULTS: Lower presenting SBP was associated with stroke subtype (P = 0.001). This association remained significant in the final model adjusted for age and history of coronary artery disease. The odds of cardioembolic versus small vessel occlusion increased by 20% (OR = 1.20, 95% CI: 1.07-1.35) for every 10 mmHg decrease in presenting SBP. Other covariates including race/ethnicity, gender, history of hypertension, and diabetes were neither significant predictors of stroke subtype, nor did they confound the association of SBP and stroke subtype. A 5 year increase in age increased the odds of cardioembolic subtype by 25% (OR = 1.25, 95% CI: 1.07-1.47). CONCLUSIONS: Lower initial SBP and older age at ischaemic stroke presentation were associated with cardioembolic stroke. Suspicion of cardioembolic stroke should be increased in those presenting with low SBP.

Acute migraine treatment with droperidol: A randomized, double-blind, placebo-controlled trial.

BACKGROUND: The treatment of a migraine attack can be difficult when first-line medication is unsuccessful and options for parenteral "rescue" therapy are limited. METHODS: A randomized, double-blind, placebo-controlled, dose-ranging, multicenter study was conducted to assess the efficacy and tolerability of droperidol 0.1 mg, 2.75 mg, 5.5 mg, and 8.25 mg for the acute treatment of moderate to severe migraine headache in adults. RESULTS: A total of 331 patients were enrolled; 305 were treated. Headache response at 2 hours was better (p < 0.002) in the treatment groups receiving droperidol IM at doses of 2.75 mg (87%), 5.5 mg (81%), and 8.25 mg (85%) compared with placebo (57%). The percent of patients achieving a pain-free response at 2 hours after treatment was significantly greater than placebo for the droperidol 2.75-mg, 5.5-mg, and 8.25-mg dose groups. The frequency of headache recurrence (within 24 hours) for patients initially responding by 2 hours was lower in patients treated with droperidol than placebo, but differences failed to reach significance. A significantly greater percentage of patients receiving droperidol 2.75 mg reported the elimination of migraine-associated symptoms (nausea, vomiting, photophobia, and phonophobia) than those who received placebo. Although most adverse events were of mild or moderate intensity, anxiety, akathisia, and somnolence were rated as severe in 30% of patients who experienced those symptoms. Hypotension was uncommon. No patient had QT prolongation.

Baseline computed tomography changes and clinical outcome after thrombolysis with recombinant tissue plasminogen activator in acute ischemic stroke.

OBJECTIVE: Intravenous recombinant tissue plasminogen activator (rt-PA) is the only therapy of proven value for patients with acute ischemic stroke (AIS). Controversy exists with regard to the prognostic significance of early computed tomography (CT) changes in patients receiving rt-PA for AIS. The authors retrospectively reviewed all cases of AIS who received intravenous rt-PA for AIS in University of South Alabama hospitals between January 1996 and May 1999. A neuroradiologist, blinded to clinical outcomes, reviewed all baseline CT scans for the presence of the following signs: hyperdense middle cerebral artery (HMCA), loss of gray-white differentiation (LGWD), insular ribbon sign (IRS), parenchymal hypodensity (PH), and sulcal effacement (SE). Modified Rankin Scale (mRS) score was recorded 90 days after thrombolysis, and clinical outcome was dichotomized as favorable (0-1) or unfavorable (2-6). The authors performed both univariate and multivariate analyses to investigate the relationship between early CT signs, baseline clinical variables, and functional outcome as measured by the 90-day mRS scores. Any one early CT finding was detected in 23(64%) patients. The frequency of specific findings were as follows: SE in 13 patients (36%), LGWD in 12 patients (33%), PH in 9 patients (25%), HMCA in 4 patients (11%), and IRS in 3 patients (8%) patients. There was no statistically significant association between the occurrence of these imaging findings and subsequent functional outcome after thrombolysis. The data suggest that the presence of subtle acute CT changes in AIS patients is not predictive of clinical outcome following administration of rt-PA as per National Institute of Neurological Disorders and Stroke protocol.

A practical approach to migraine headache.

Headache is a common problem in primary care practice. Migraine accounts for the vast majority of patients seeking treatment for their headaches. The ability to simplify the evaluation and treatment of these patients translates into patient's relief and increased productivity.

An analysis of the "carry-over effect" following successful short-term treatment of transformed migraine with divalproex sodium.

OBJECTIVE: To determine whether successful short-term prophylactic treatment of transformed migraine may be followed by a continued respite from headaches once the treatment has been discontinued ("carry-over effect"). BACKGROUND: The optimal duration of prophylactic treatment for pervasive headache and for migraine, in particular, is unknown. METHODS: We prospectively evaluated a series of patients with transformed migraine, all of whom were managed according to a uniform treatment protocol involving prophylactic therapy with divalproex sodium for a period not exceeding 12 weeks. All patients reporting a positive treatment response were followed for at least 2 months after the discontinuation of divalproex sodium, and the incidence of the carry-over effect in that group was assessed. RESULTS: A short-term carry-over effect occurred in 12 (60%) of 20 patients, but more sustained relief occurred in only 8 (40%). CONCLUSIONS: The successful short-term treatment of transformed migraine with divalproex sodium will often produce a short-term carry-over effect, but this response will be sustained only in a minority of patients.

Headache in Chiari malformation: a distinct clinical entity?

A relatively common group of developmental anomalies of the posterior fossa and its contents make up the Chiari malformations. The most common of these anomalies are the Chiari malformations type I and type II. Many patients with these defects are asymptomatic, but many of them suffer from headaches. Although the prevalence of common primary headache disorders in patients with Chiari malformations is similar to that of the general population, a particular type of occipital headaches occurs more frequently in patients with a Chiari malformation. In the two patients described in the illustrative case presentations, the major complaint was headache. Both had Chiari malformation type I diagnosed. Chiari malformation should be considered in the differential diagnosis of patients who complain of exertional headache. Exertional headaches or worsening of pain during Valsalva's maneuver should prompt clinical suspicion of an underlying intracranial lesion and warrants further evaluation by appropriate neuroimaging studies.

Leg weakness in neurosarcoidosis.

A 22-year-old man had leg weakness and decreased hearing. A diagnosis of neurosarcoidosis was made, based on neuroimaging studies and lymph node biopsy. Post-treatment neuroimaging, in particular magnetic resonance imaging along with clinical course, is useful in monitoring response to therapy.

Cluster headache: Horton's cephalalgia revisited.

BACKGROUND: Cluster headache (CH), though not fully characterized until this century, is a relatively common primary headache disorder. METHODS: We reviewed pertinent literature on CH and related cephalalgias. RESULTS: We found that CH typically occurs in middle-aged men and has a characteristic cyclic temporal pattern. During the cluster cycle, CH paroxysms last from 15 to 180 minutes and are manifested by excruciating periorbital or upper facial pain. Associated autonomic symptoms such as lacrimation, rhinorrhea, conjunctival injection, and Horner's syndrome are common in CH. Its pathophysiology is not entirely understood, though it may include a complex cascade of autonomic, immunologic, and vascular phenomena. CONCLUSIONS: Although its pathophysiology is still not completely understood, we present the most recent evidence regarding the underlying anatomic and biochemical basis for CH. We also present an update on the modern management of CH, including the appropriate use of standard and novel abortive and prophylactic agents, as well as more invasive treatment.

An interregional comparative study of headache clinic populations.

We present a comparative study between headache clinic populations from 2 inherently different regions of the United States. Using standardized methods, 1 of us (JFR) prospectively evaluated 578 new patients attending the headache clinic at the University of California in San Diego. In a similar manner, we subsequently evaluated 115 new patients presenting to the headache clinic at the University of South Alabama in Mobile, Alabama. We found few differences between the 2 populations. These differences more likely reflect regional variations in healthcare delivery or methodologic artifact than intrinsic dissimilarities.

Accuracy of paramedic diagnosis of stroke.

BACKGROUND AND PURPOSE: Accurate prehospital diagnosis of acute stroke may lead to fewer delays in hospital presentation. In addition, prehospital personnel soon may be administering therapies to patients with presumed stroke. We sought to determine the sensitivity and positive predictive value (PPV) of paramedic diagnosis of stroke in Mobile, Alabama, and to evaluate the impact of an educational program on paramedic diagnostic capability. METHODS: We collected data from all paramedic-diagnosed stroke patients transported to a University of South Alabama hospital by Mobile Fire Medics. Final diagnosis was determined by a neurologist and classified as stroke or nonstroke (i.e., PPV). Paramedic diagnoses for all hospitalized stroke patients transported by Mobile Fire Medics were also reviewed (i.e., sensitivity). Sensitivity and PPV were calculated for the period 6/13/95 to 3/13/97. In addition, both indices were calculated for the period before (6/13/95 to 5/5/96) and after (6/25/96 to 3/13/97) an 8-week intensive educational program. RESULTS: Seventy-one hospitalized stroke patients were transported by Mobile Fire Medics during the study period. Paramedics correctly identified 67 patients in total (94% sensitivity), 29 during the pre-education period (91% sensitivity), and 29 during the posteducation period (97% sensitivity; P=.33). Twenty-five patients were incorrectly diagnosed with stroke (73% PPV), 15 during the pre-education period (66% PPV), and 9 during the posteducation period (76% PPV; P=.30). CONCLUSION: Although paramedics in Mobile misdiagnose few patients with acute stroke, there is a tendency toward overdiagnosis. An educational intervention resulted in a trend toward improved accuracy of diagnosis, but this did not reach statistical significance.

Migrainous stroke causing thalamic infarction and amnesia during treatment with propranolol.

We report a case of migraine-associated ischemic stroke causing amnesia, wherein treatment with propranolol may have been contributory. The possible mechanisms involved in migrainous stroke occurring in association with use of propranolol are discussed.

Guillain-Barré syndrome and cytomegalovirus infection during pregnancy.

We report a case of Guillain-Barré syndrome and associated cytomegalovirus infection during pregnancy. A 15-year-old black adolescent had progressive ascending paralysis and vague sensory symptoms during week 10 of her first pregnancy. Diagnosis of Guillain-Barré syndrome was confirmed by electrophysiologic findings consistent with acute demyelinating polyradiculoneuropathy. A mild elevation of anti-GM1 antibodies was also detected. The patient improved with plasmapheresis treatment; however, fetal death occurred 10 weeks later. Cytomegalovirus placentitis was confirmed histologically. Acute demyelinating polyneuropathy during pregnancy warrants consideration of a concomitant, primary maternal and fetal cytomegalovirus infection.

Transitory cognitive impairment with brief generalized spike-wave paroxysm: a clinical counterexample to the three-second rule.

The topic of transitory impairment of consciousness with spike wave bursts has been of interest to neurologists for years. Based on some early experiments, a 3-second rule was formulated and has found its way into the conventional wisdom of neurology. It states that, in order to result in impairment of consciousness, a spike-wave burst must be of at least 3 seconds' duration. We discuss a case which poses a clinical counterexample to that rule.

Prevalence of epilepsy in a rural community of Guatemala.

We conducted a cross-sectional epidemiological study to assess the prevalence and patterns of epilepsy in a small rural village of Guatemala (population 2,111); 1,882 subjects (97.3%) were surveyed. By adminIstering the World Health Organization (WHO) standard questionnaire and performing neurological examinations, we detected 16 cases of epilepsy. The crude prevalence rate for this community was 8.5 in 1,000 general population for this form. The most common type of seizure was generalized tonic-clonic seizures (GTCS, 50%), followed by complex partial seizures (CPS, 37.5%), simple partial seizures (SPS, 6.2%) and generalized atonic seizures (6.2%). The age-specific prevalence ratio was highest among the group aged 20-29 years, although the difference between that group and the other age groups was not statistically signifICant (z<2, P>0.05). Fourteen persons (87.5%) had sought medical care for their seizures at least once in their lifetime, 5 (31.25%) were receiving an antiepileptic drug (AED), and 9 (56.25%) had previously received treatment and 2 (12.5%) had never been treated for their illness. Phenobarbital was the most common AED prescribed; 7 persons had positive family history of epilepsy, 5 reported a history of significant head trauma, 4 had history of central nervous system disease, and 1 had a history of chronic alcohol intake.