Cerebral Microbleeds are Associated with Higher Mortality Among Ischemic Stroke Patients.

BACKGROUND: Several studies have shown that cerebral microbleeds (CMBs) increase the risk of long-term stroke-related mortality. The purpose of this study was to determine if the existence and burden of CMBs are a predictor of in-hospital death among patients with acute ischemic stroke (AIS). METHODS: We studied consecutive ischemic stroke patients who admitted to our tertiary center over a 2-year period (2013-2014). Patients who underwent thrombolysis were excluded. Baseline characteristics of patients, number and topography of CMBs, white matter lesions, and spontaneous symptomatic hemorrhagic transformation were recorded. Outcome measure in our study was in-hospital death. RESULTS: Out of 1126 consecutive AIS patients evaluated in this study, 772 patients included in the study (mean age 61.9 ± 14.2years [18-95 years], 51.6% men, and 58.2% African American). CMBs were present on the magnetic resonance imaging (MRI) sequences of 124 (16.1%) patients. The overall rate of in-hospital mortality was 4.1%. The presence or absence of CMBs was not predictive of in-hospital mortality (P = .058). After adjusting for potential confounders, the presence of ≥4 CMBs on T2*-weighted MRI was independently (P = .004) associated with a higher likelihood of in-hospital death (odds ratio: 6.6, 95% confidential interval: 2.50 and 17.46) in multivariable logistic regression analyses. Older age, higher National Institute of Health stroke scale, and history of atrial fibrillation were also associated with greater chance of in-hospital death. CONCLUSIONS: The presence or absence of CMBs was not predictive of in-hospital mortality. However, the presence of multiple CMBs was associated with a higher in-hospital mortality rate among AIS patients.

Safety of Intravenous Thrombolysis in Chronic Intracranial Hemorrhage: A Five-Year Multicenter Study.

INTRODUCTION: Although the recently updated U.S. alteplase label removed "history of intracranial hemorrhage (ICH)" as a contraindication, there are very limited data on the safety of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with chronic ICH. We sought to evaluate IVT safety in AIS patients with a history of ICH. METHODS: We analyzed consecutive AIS patients treated with IVT at 3 tertiary stroke centers during a 5-year period. We identified AIS treated with IVT with clinical history and neuroimaging confirmation of prior ICH. The safety measure was symptomatic ICH (sICH) defined according to European Cooperative Acute Stroke Study-III criteria combined with the clinical deterioration of 4 points or higher in the National Institutes of Health Stroke Scale (NIHSS) or death. RESULTS: Of the 1212 AIS patients treated with IVT, 7 (.6%) (mean age 72 ± 11 years, 57% men, median NIHSS: 5 points, interquartile range: 2-8) had a history of ICH (hematoma volume: 1-21 cm3, elapsed time between previous ICH and AIS: 1.5-12 years, 5 located in basal ganglia and 2 in periventricular white matter). Patients with previous ICH did not differ in terms of demographics and admission stroke severity in comparison with the rest. The 2 groups had similar rates of sICH (0% [0/7] versus 3.6%, P = .61) and in-hospital mortality (0% [0/7] versus 6.0%, P = .50). CONCLUSION: Our study indicates that IVT might be safe among AIS patients with a history of chronic ICH. Further research with a larger sample size is required to confirm our finding and define the shortest time interval between the hemorrhagic and ischemic events that can be associated with the safe administration of IVT.

Racial Difference in Cerebral Microbleed Burden among Ischemic Stroke Patients.

BACKGROUND AND AIMS: Data on the epidemiology of cerebral microbleeds (CMBs) among patients with ischemic stroke are limited. This study compared the number, associated factors, and topography of CMBs between African American and Caucasian ischemic stroke patients in the Mid-South United States. METHOD: We evaluated consecutive ischemic stroke patients admitted to our tertiary stroke center, University of Tennessee Health Science Center, Memphis, Tennessee, in a two-year period. We analyzed T2*-weighted magnetic resonance images for the number, location, and topography of CMBs, as well as patients' demographic and clinical information. RESULTS: Among 760 ischemic stroke patients who were included (mean age was 62.1 ± 13.9 years, 51.4% men), 450 (59.2%) were African American. In comparison with Caucasians, African Americans were about five years younger (P = .000) and had a higher rate of hypertension (80.9% vs. 74.5%, P = .036). Similarly, African Americans had a higher prevalence of diabetes mellitus (P = .001). There was no significant difference between African-Americans and Caucasians in terms of CMBs presence and location. African Americans had a higher number of CMBs in comparison with Caucasians, but the difference was not significant. African Americans were more likely to have CMBs ≥5 (P = .047). Although African American stroke patients had a higher rate of large confluent white matter lesions, there was no significant racial difference regarding the rate and severity of deep white matter lesions. CONCLUSION: We did not observe any differences between African American and Caucasian patients with ischemic stroke patients regarding the presence, number, and location of CMBs. However, our results suggested that the prevalence of multiple CMBs (CMBs ≥5) might be higher among African American stroke patients.

Cerebral Microbleeds and Risk of Intracerebral Hemorrhage Post Intravenous Thrombolysis.

BACKGROUND: Stroke patients who have cerebral micro bleeds (CMBs) could be potentially at a greater risk for symptomatic intracerebral hemorrhage (sICH) than those patients without CMBs. The aim of our study was to investigate whether the presence and burden of CMBs are associated with post IVT sICH. METHODS: In this multicenter study, consecutive patients treated with intravenous tissue plasminogen activator were prospectively identified and analyzed. Patients without magnetic resonance imaging (MRI) within 24 hours of treatment were excluded. CMBs were defined as round or oval, hypointense lesions with associated blooming on T2*-weighted MRI up to 10 mm in diameter. Outcome measures included the occurrence of sICH or death. RESULTS: Of 672 patients with IVT (mean age 62 ± 14 years, 52% men, median admission NIHSS: 7 points), 103 patients had CMBs on T2*-MRI. Ten patients had more than 10, whereas the remaining 93 patients had 1-10 CMBs on T2*-MRI. The rates of sICH did not differ between patients with and patients without 1-10 CMBs (5.8% versus 3.5%; P = .27). However, sICH occurred more frequently (P = .0009) in patients with > 10 CMBs (30%, 95% confidence interval [CI] by the adjusted Wald method: 10%-61%). After adjusting for potential confounders, the presence of >10 CMBs on T2*-MRI was independently (P = .0004) associated with a higher likelihood for sICH (odds ratio [OR]:13.4, 95%CI:3.2-55.9). CONCLUSIONS: Our findings indicate an increased risk of sICH after IVT when more than 10 CMBs are present.

Johann Friedrich Horner and the Repeated Discovery of Oculosympathoparesis: Whose Syndrome Is It?

Disruption of cranial sympathetic tone leads to the symptom complex of miosis, ptosis, and hemifacial anhidrosis. It is widely believed that this phenomenon was discovered in 1869 by the Swiss ophthalmologist Johann Friedrich Horner, and as a result, the term Horner syndrome has become synonymous with the clinical presentation. However, the syndrome that would become Horner syndrome had actually been described several times before his report. François Pourfour du Petit documented the ocular effects of sympathetic trunk lesions in animal studies in 1727. Claude Bernard identified the full clinical triad in animal studies in 1852, and as a result, the condition is sometimes called Bernard syndrome. There were also 2 previous reports of ptosis and miosis resulting from sympathetic nerve damage in humans: 1 by Edward Selleck Hare in 1838 associated with brachial plexus tumor, and the other by Silas Weir Mitchell in 1864 associated with a gunshot wound to the neck. Although Horner was the first to objectively characterize the co-occurrence of vasomotor and ocular changes in a human patient, he did not identify the etiology of the condition, discuss its relationship to the sympathetic nervous system, or reference any of the previous studies in animals or humans. It is possible that a lack of familiarity with previous investigations delayed the full appreciation of the mechanism underlying this disorder.