Contrast-enhanced sonothrombolysis in acute ischemic stroke patients without intracranial large-vessel occlusion.

BACKGROUND: Contrast-enhanced sonothrombolysis (CEST) leads to a more rapid recanalization in acute ischemic stroke caused by intracranial large-vessel occlusion (LVO). Animal studies have shown that CEST also may be safe and efficient in treating the ischemic microcirculation in the absence of LVO. The exact mechanism behind this treatment effect is not known. We aimed to assess safety and efficacy of CEST in acute ischemic stroke patients included in the Norwegian Sonothrombolysis in Acute Stroke Study (NOR-SASS) without LVO on admission CT angiography (CTA). METHODS: NOR-SASS was a randomized controlled trial of CEST in ischemic stroke patients treated with intravenous thrombolysis within 4.5 hours after stroke onset. Patients were randomized to either CEST or sham CEST. In this study, patients were excluded if they had partial or total occlusion on admission CTA, ultrasound-resistant bone window, had received CEST with incorrect insonation as compared to stroke location on Magnetic resonance imaging (MRI), or were stroke mimics. RESULTS: Of the 183 patients included in NOR-SASS, a total of 83 (45.4%) patients matched the inclusion criteria, of which 40 received CEST and 43 sham CEST. There were no patients with symptomatic intracranial hemorrhage (sICH) in the CEST group. Rates of asymptomatic ICH, microbleeds, and mortality were not increased in the CEST group. Neurological improvement at 24 hours and functional outcome at 90 days were similar in both groups. CONCLUSION: CEST is safe in ischemic stroke patients without intracranial LVO. There were no differences in clinical outcomes between the treatment groups.

Elevated body temperature in ischemic stroke associated with neurological improvement.

OBJECTIVES: Some studies suggest that high body temperature within the first few hours of ischemic stroke onset is associated with improved outcome. We hypothesized an association between high body temperature on admission and detectable improvement within 6-9 hours of stroke onset. MATERIALS AND METHODS: Consecutive ischemic stroke patients with NIHSS scores obtained within 3 hours and in the interval 6-9 hours after stroke onset were included. Body temperature was measured on admission. RESULTS: A total of 315 patients with ischemic stroke were included. Median NIHSS score on admission was 6. Linear regression showed that NIHSS score 6-9 hours after stroke onset was inversely associated with body temperature on admission after adjusting for confounders including NIHSS score <3 hours after stroke onset (P<.001). The same result was found in patients with proximal middle cerebral occlusion on admission. CONCLUSIONS: We found an inverse association between admission body temperature and neurological improvement within few hours after admission. This finding may be limited to patients with documented proximal middle cerebral artery occlusion on admission and suggests a beneficial effect of higher body temperature on clot lysis within the first three hours.

Acute cerebral infarcts in multiple arterial territories associated with cardioembolism.

OBJECTIVES: It is generally believed that cardioembolism is the main cause of multiple acute cerebral infarcts (MACI). However, there are surprisingly few DWI studies and results are conflicting. Based on a large prospective study we hypothesized that MACI are associated with cardioembolism. MATERIALS AND METHODS: We studied 2697 patients with acute cerebral infarcts between February 2006 and October 2013 who were prospectively registered in The Bergen NORSTROKE Registry. Among them, 2220 (82.3%) patients underwent magnetic resonance imaging (MRI) and 2125 (96%) of these 2220 patients had DWI lesions. Only patients with DWI lesions were included. MACI were defined as at least two DWI lesions in at least two different arterial territories. RESULTS: MACI were detected in 187/2125 (8.8%) patients with DWI lesions. MACI patients were older and more often females. MACI were associated with cardioembolism (P = 0.042), especially atrial fibrillation (P = 0.002). Other associations were symptomatic internal carotid artery (ICA) stenosis (P = 0.014), asymptomatic ICA stenosis (P = 0.036), and higher NIHSS score on admission (P < 0.001). Among patients with no cardioembolism, 34 (35%) with MACI had symptomatic ICA stenosis versus 268 (25.0%) with non-MACI (P = 0.037); 20 (20%) with MACI had asymptomatic ICA stenosis versus 134 (13%) with non-MACI (P = 0.031). In the logistic regression analysis, cardiac embolism and symptomatic ICA stenosis were independently associated with MACI. CONCLUSIONS: Acute cerebral infarcts in more than one arterial territory occur among almost 10% of the patients and are associated with cardioembolism.

Serial NIHSS scores in patients with acute cerebral infarction.

AIM: To study time course of neurological deficits in patients with acute cerebral infarction admitted shortly after stroke onset. METHODS: Serial NIHSS scores were obtained whenever feasible in patients admitted because of cerebral infarction within 3 h of symptom onset. Patients receiving and not receiving thrombolysis were compared. Short-term outcome was defined as NIHSS score and modified Rankin score 7 days after stroke onset. The hyperacute phase was defined as the time between stroke onset and the 6- to 9-h interval after stroke onset, acute phase as the time between the 6- to 9-h interval and the 21 to 27-h interval, and the subacute phase as the time between the 21- to 27-h interval and 7 days after stroke onset. RESULTS: Serial NIHSS scores were obtained in 552 patients within three hours of stroke onset. There was a significant improvement (P < 0.001) comprising 62% of the total improvement in the hyperacute phase. There was no significant improvement in the acute phase and a small significant improvement in the subacute phase (P < 0.01). CONCLUSION: Our study demonstrates a hyperacute phase with rapid improvement probably due to early recanalization, an acute phase with no significant improvement and slow improvement in the subacute phase. Different pathophysiological mechanisms are likely involved in the different phases.

Can the cardiovascular family history reported by our patients be trusted? The Norwegian Stroke in the Young Study.

BACKGROUND AND PURPOSE: Family history (FH) is used as a marker for inherited risk. Using FH for this purpose requires the FH to reflect true disease in the family. The aim was to analyse the concordance between young and middle-aged ischaemic stroke patients' reported FH of cardiovascular disease (CVD) with their parents' own reports. METHODS: Ischaemic stroke patients aged 15-60 years and their eligible parents were interviewed using a standardized questionnaire. Information of own CVD and FH of CVD was registered. Concordance between patients and parents was tested by kappa statistics, sensitivity, specificity, predictive values and likelihood ratios. Regression analyses were performed to identify patient characteristics associated with non-concordance of replies. RESULTS: There was no difference in response rate between fathers and mothers (P = 0.355). Both parents responded in 57 cases. Concordance between patient and parent reports was good, with kappa values ranging from 0.57 to 0.7. The patient-reported FH yielded positive predictive values of 75% or above and negative predictive values of 90% or higher. The positive likelihood ratios (LR+) were 10 or higher and negative likelihood ratios (LR-) were generally 0.5 or lower. Interpretation regarding peripheral arterial disease was limited due to low parental prevalence. Higher age was associated with impaired concordance between patient and parent reports (odds ratio 1.05; 95% confidence interval 1.01-1.09; P = 0.020). CONCLUSIONS: The FH provided by young and middle-aged stroke patients is in good concordance with parental reports. FH is an adequate proxy to assess inherited risk of CVD in young stroke patients.

Recurrent ischemic stroke is associated with the burden of risk factors.

AIM: To determine the characteristics of acute ischemic stroke patients admitted to hospital with history of prior ischemic stroke(s). We hypothesized that there is an association between the number of risk factors and prior ischemic stroke irrespective of age. METHODS: All patients with acute ischemic stroke admitted to Haukeland University Hospital between 2006 and 2013 were registered in the NORSTROKE database. Variables included prior ischemic stroke(s) (based on self-report and patient records), risk factors, TOAST classification, and CT and MRI findings. Comparison was made between patients with prior ischemic stroke and first-ever ischemic stroke. Multivariate analyses were performed. RESULTS: In total, 2697 patients were included and 461 (17.1%) had a history of prior ischemic stroke(s). Logistic regression analyses showed that prior ischemic stroke was associated with the number of risk factors, leukoaraiosis, hypertension, atrial fibrillation, and atherosclerosis. CONCLUSION: History of prior ischemic stroke in patients with acute ischemic stroke was associated with the burden of risk factors, atherosclerosis, and atrial fibrillation compared to first-ever ischemic stroke. This has important implications for secondary preventive treatment.

Early neurological worsening in acute ischaemic stroke patients.

OBJECTIVES: Neurological worsening in acute ischaemic stroke patients is common with significant morbidity and mortality. AIMS: To determine the factors associated with early neurological worsening within the first 9 h after onset of acute ischaemic stroke. MATERIALS & METHODS: The National Institute of Health Stroke Scale (NIHSS) was used to assess stroke severity. Early neurological worsening was defined as NIHSS score increase ≥4 NIHSS points within 9 h of symptom onset compared to NIHSS score within 3 h of symptom onset. Patients with early neurological worsening were compared to patients with unchanged or improved NIHSS scores. RESULTS: Of the 2484 patients admitted with ischaemic stroke, 552 patients had NIHSS score within 3 h of symptom onset, and 44 (8.0%) experienced early neurological worsening. The median NIHSS on admission was 8.4 in both groups. Early neurological worsening was associated with low body temperature on admission (P = 0.01), proximal compared to distal MCA occlusion (P = 0.007) and with ipsilateral internal carotid artery stenosis >50% or occlusion (P = 0.04). Early neurological worsening was associated with higher NIHSS day 7 (P < 0.001) and higher mortality within 7 days of stroke onset (P = 0.005). CONCLUSIONS: Early neurological worsening has serious consequences for the short-term outcome for patients with acute ischaemic stroke and is associated with low body temperature on admission, and with extracranially and intracranially large-vessel stenosis or occlusion.

Age dependency of ischaemic stroke subtypes and vascular risk factors in western Norway: the Bergen Norwegian Stroke Cooperation Study.

OBJECTIVES: Age dependency of acute ischaemic stroke aetiology and vascular risk factors have not been adequately evaluated in stroke patients in Norway. Aims of this study were to evaluate how stroke subtypes and vascular risk factors vary with age in a western Norway stroke population. MATERIALS AND METHODS: Patients aged 15-100 years consecutively admitted to our neurovascular centre with acute ischaemic stroke between 2006 and 2012 were included. The study population was categorized as young (15-49 years), middle-aged (50-74 years) or elderly (≥ 75 years). Stroke aetiology was defined by TOAST criteria. Risk factors and history of cardiovascular disease were recorded. RESULTS: In total, 2484 patients with acute cerebral infarction were included: 1418 were males (57.3%). Mean age was 70.8 years (SD ± 14.9), 228 patients were young, 1126 middle-aged, and 1130 were elderly. The proportion of large-artery atherosclerosis and of small-vessel occlusion was highest among middle-aged patients. The proportion of cardioembolism was high at all ages, especially among the elderly. The proportion of stroke of other determined cause was highest among young patients. Some risk factors (diabetes mellitus, active smoking, angina pectoris, prior stroke and peripheral artery disease) decreased among the elderly. The proportions of several potential causes increased with age. CONCLUSION: The proportion of stroke subtypes and vascular risk factors are age dependent. Age 50-74 years constitutes the period in life where cardiovascular risk factors become manifest and stroke subtypes change.

Mild stroke: safety and outcome in patients receiving thrombolysis.

OBJECTIVES: The aim of this study was to compare the short-term clinical outcome of patients with acute cerebral ischemia and mild symptoms receiving rt-PA with that of patients with acute cerebral ischemia and mild symptoms not treated with rt-PA, and to investigate the frequency of symptomatic intracranial hemorrhage (sICH) in these patients. MATERIALS AND METHODS: All patients with confirmed ischemic stroke/TIA and mild symptoms were included. Mild symptoms were defined as NIHSS score≤5 on admission. Functional outcome was assessed with modified Rankin Scale (mRS) at day 7 or at earlier discharge. Excellent outcome was defined as mRS=0. sICH was defined according to both NINDS and ECASS III criteria. RESULTS: Of 2753 patients with confirmed ischemic stroke/TIA admitted between February 2006 and February 2013, 966 (35.3%) were excluded because of having admission NIHSS>5. A total of 1791 patients presented with mild symptoms on admission (NIHSS≤5), of which 158 (8.8%) patients received rt-PA. Treatment with rt-PA and early admission were independently associated with excellent outcome. Higher NIHSS score on admission and prior ischemic stroke were independently associated with poor outcome. Three (1.9%) sICH were diagnosed in rt-PA-treated patients and one (0.1%) in patients not receiving rt-PA. CONCLUSIONS: This study highlights the efficacy of rt-PA in patients with acute cerebral ischemia presenting with mild symptoms and confirms the low-risk profile of this treatment.

Diffusion-weighted lesions in acute ischaemic stroke patients with migraine.

OBJECTIVES: There is increasing knowledge about an association between migraine and ischaemic stroke. Cortical spreading depression (CSD) is the probable biological substrate of migrainous aura. To investigate the influence of CSD on the apparent stroke - migraine association, we hypothesized that magnetic resonance (MR) diffusion weighted images of acute ischaemic stroke patients would reveal an association between small cortical infarctions and migraine. METHODS: We included all patients admitted to the Bergen stroke unit between 2006 and 2012 with verified acute ischaemic stroke by MR imaging. Patients were grouped in a migraine and a no-migraine group. Baseline data and clinical characteristics were analysed between the groups. Imaging data were analysed with respect to infarct location and size. Multivariate analyses were performed to adjust for confounders and provide risk estimates for observed associations. RESULTS: A total of 1703 subjects were enrolled, 787 subjects were excluded due to uncertain or unobtainable migraine diagnosis, leaving 196 and 720 subjects in the migraine and no-migraine group, respectively. The migraine group was younger and included a higher proportion of females. There were more infarctions due to cardio-embolism (P=0.015) and fewer due to small vessel disease (P=0.018) in the migraine group. A higher rate of patients in the migraine group presented symptoms from the posterior circulation (P=0.008). Migraine was associated with cortical infarctions (OR 1.8 CI: 1.3-2.5, P=0.001). Migraine was also associated with small infarctions (OR 1.9 CI: 1.04-3.5, P=0.038). CONCLUSIONS: Migraine was associated with small cortical infarctions. This association may be due to cortical spreading depression.

Is smoking associated with favourable outcome in tPA-treated stroke patients?

BACKGROUND: Smoking has been associated with improved outcome in thrombolysed patients with myocardial infarction and higher recanalization rates in stroke patients treated with tissue plasminogen activator (tPA). We hypothesized a positive association between smoking and favourable outcome in stroke patients treated with tPA and no such association in acute stroke patients not treated with tPA, suggesting a beneficial effect of smoking on thrombolysis with tPA. METHODS: Stroke patients treated with tPA and stroke patients not treated with tPA, but presenting within 6 h after stroke onset, were included in two separate groups. Three groups were defined according to smoking habits: current smoking, previous smoking and no smoking. Functional outcome by modified Rankin Scale (mRS) was assessed after 1 week or at discharge, if discharged earlier. Favourable outcome was defined as mRS 0 or 1. RESULTS: A total of 399 patients were treated with tPA (94 current smokers, 148 previous smokers and 157 non-smokers), whereas 424 patients were not treated with tPA (90 current smokers, 164 previous smokers and 170 non-smokers). Current smoking was independently associated with favourable outcome in patients treated with tPA when adjusted for confounders (OR 2.08, 95% CI 1.09-3.95, P = 0.025). There was no such association in acute stroke patients not treated with tPA (OR 1.26, 95% CI 0.67-2.36, P = 0.472). CONCLUSION: Our study showed an association between current smoking and favourable short-term outcome in stroke patients treated with tPA, but not in acute stroke patients not treated with tPA. This may indicate a more effective thrombolysis with tPA in smokers.

Ischemic stroke in patients older and younger than 80 years.

OBJECTIVES: To compare short-term outcome and long-term mortality in old and younger patients with ischemic stroke. We hypothesized that short-term outcomes in patients≥80 and <80 years with no neurological worsening are similar. METHODS: The National Institute of Health Stroke Scale (NIHSS) was used to assess stroke severity. Short-term outcome was determined by the NIHSS score 7 days after stroke onset. Neurological worsening was defined as NIHSS score worsening >3 points. Risk factors, prior diseases, complications, and long-term mortality were registered. RESULTS: The study includes 592 patients≥80 years and 1275 patients<80 years. High NIHSS score on admission and day 7, neurological worsening, and complications were significantly more frequent among patients≥80 years. In patients with no neurological worsening, improvement in NIHSS score on day 7 was not associated with age≥80 years (P=0.75). Long-term mortality was associated with the number of risk factors in both age groups (P<0.05). CONCLUSION: Avoiding neurological worsening may have a large potential for reducing the difference in short-term outcome between old and young stroke patients by preventing treatable complications including pneumonia. Risk factor burden is important for long-term survival in both stroke patients≥80 years and <80 years.

Body temperature and major neurological improvement in tPA-treated stroke patients.

BACKGROUND: Major neurological improvement (MNI) at 24 hours represents a marker of early recanalization in ischaemic stroke. Although low body temperature is considered neuroprotective in cerebral ischaemia, some studies have suggested that higher body temperature may promote clot lysis in the acute phase of ischaemic stroke. We hypothesized that higher body temperature was associated with MNI in severe stroke patients treated with tPA, suggesting a beneficial effect of higher body temperature on clot lysis and recanalization. METHODS: Patients with ischaemic stroke or transient ischaemic attack (TIA) treated with tPA between February 2006 and August 2012 were prospectively included and retrospectively analysed. Body temperature was measured upon admission. MNI was defined by a ≥8 point improvement in NIHSS score at 24 hours as compared to NIHSS score on admission. No significant improvement (no-MNI) was defined by either an increase in NIHSS score or a decrease of ≤2 points at 24 hours in patients with an admission NIHSS score of ≥8. RESULTS: Of the 2351 patients admitted with ischaemic stroke or TIA, 347 patients (14.8%) were treated with tPA. A total of 32 patients (9.2%) had MNI and 56 patients (16.1%) had no-MNI. Patients with MNI had higher body temperatures compared with patients with no-MNI (36.7°C vs 36.3°C, P = 0.004). Higher body temperature was independently associated with MNI when adjusted for confounders (OR 5.16, P = 0.003). CONCLUSION: Higher body temperature was independently associated with MNI in severe ischaemic stroke patients treated with tPA. This may suggest a beneficial effect of higher body temperature on clot lysis and recanalization.

Etiology of first-ever ischaemic stroke in European young adults: the 15 cities young stroke study.

BACKGROUND AND PURPOSE: Risk factors for IS in young adults differ between genders and evolve with age, but data on the age- and gender-specific differences by stroke etiology are scare. These features were compared based on individual patient data from 15 European stroke centers. METHODS: Stroke etiology was reported in detail for 3331 patients aged 15-49 years with first-ever IS according to Trial of Org in Acute Stroke Treatment (TOAST) criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-vessel occlusion (SVO), other determined etiology, or undetermined etiology. CE was categorized into low- and high-risk sources. Other determined group was divided into dissection and other non-dissection causes. Comparisons were done using logistic regression, adjusting for age, gender, and center heterogeneity. RESULTS: Etiology remained undetermined in 39.6%. Other determined etiology was found in 21.6%, CE in 17.3%, SVO in 12.2%, and LAA in 9.3%. Other determined etiology was more common in females and younger patients, with cervical artery dissection being the single most common etiology (12.8%). CE was more common in younger patients. Within CE, the most frequent high-risk sources were atrial fibrillation/flutter (15.1%) and cardiomyopathy (11.5%). LAA, high-risk sources of CE, and SVO were more common in males. LAA and SVO showed an increasing frequency with age. No significant etiologic distribution differences were found amongst southern, central, or northern Europe. CONCLUSIONS: The etiology of IS in young adults has clear gender-specific patterns that change with age. A notable portion of these patients remains without an evident stroke mechanism according to TOAST criteria.

Safety of off-label stroke treatment with tissue plasminogen activator.

BACKGROUND: Many patients with acute ischaemic stroke do not receive intravenous thrombolysis due to contraindications. We aimed to assess safety, short-term clinical development, short-term outcome and mortality in patients treated off-label with tissue plasminogen activator (tPA). METHODS: Stroke patients treated with tPA within 4.5 h after symptom onset during 2006-2011 were prospectively included. Patients with contraindications to tPA according to national guidelines were compared to patients without any of these contraindications. Separate analyses were performed on patients who had compatible contraindications and did not receive tPA. Primary outcome was rate of symptomatic intracerebral haemorrhage (SICH). Secondary outcomes were short-term clinical development, short-term outcome and 30-day mortality. RESULTS: Of the 265 patients who received tPA, 135 patients (50.9%) had formal contraindications and 130 patients (49.1%) had no such contraindications. Rates of SICH were similar for patients with or without contraindications (P = 0.305). Patients with contraindications to tPA had a similar rate of clinical improvement (P = 0.504), a trend of less favourable outcome (P = 0.052) and higher mortality (P = 0.005) than patients without contraindications. Logistic regression analysis showed no association between presence of contraindications to tPA and short-term outcome or mortality when adjusted for age, sex and admission National Institute of Health Stroke Scale score. Short-term outcome and mortality were similar in patients with contraindications who received tPA and patients with contraindications who did not receive tPA (n = 134). CONCLUSIONS: Intravenous thrombolysis with tPA may be safe and efficient in stroke patients with a number of formal contraindications to tPA. Prospective randomized trials are imperative to clarify the need for a re-evaluation of the current contraindications to tPA.

Ischaemic stroke at a young age is a serious event--final results of a population-based long-term follow-up in Western Norway.

BACKGROUND AND PURPOSE: Our population-based long-term follow-up of young ischaemic stroke patients and controls showed 10-fold increased mortality and fivefold increased arterial event rate nearly 12 years after study inclusion. We now assess memory, anxiety, depression and sleep in relation to employment and functional outcome, treatment goals and results from a last alive-dead survey. METHODS: Patients (n = 232) ≤ 49 years with an index-stroke between 1988 and 1997 were retrospectively selected and compared with age- and sex-matched controls (n = 453). At follow-up from 2004 to 2005, 144 (77%) of 187 patients were clinically examined. Self-assessment information about memory problems, anxiety, depression, sleeping problems, education and employment was compared with answers from standardized questionnaires from 167 controls. Functional outcome was measured by the modified Rankin Scale (mRS). RESULTS: Patients compared with controls had more memory problems (41.0% vs. 5.4%, P < 0.001), anxiety (19.4% vs. 9%, P = 0.009), depression (29.2% vs. 13.2%, P = 0.001) and sleeping problems (36.1% vs. 19.2%, P = 0.001). In the multiple regression analysis male gender (OR 9.3, 95%CI 0.10-0.61, P = 0.002), normal memory (OR 12.7, 95%CI 0.07-0.47, P < 0.001) and mRS 0-1 (OR 15.7, 95%CI 0.002-0.12, P < 0.001) were factors for full-time employment. Blood pressure was < 140/90 mmHg in 39% of patients, 49% stopped smoking and 38.2% used statins. After a mean observation time of 18.3 years, 63 (27.2%) of 232 patients were dead. CONCLUSIONS: Our data show a heterogeneous prognosis and high mortality even for long-time survivors of ischaemic stroke at a young age. Prospective studies of young stroke patients and controls are necessary for direct comparison.

Clinical implications of increased use of MRI in TIA.

BACKGROUND: Transient ischemic attack has been redefined as a tissue-based diagnosis and MRI recommended as the preferred imaging modality. We aimed to investigate whether an increased use of MRI leads to a decrease in the proportion of TIA as compared to cerebral infarction. We also sought to see whether DWI-positive patients with transient ischemic symptoms <24 h differ from DWI-negative TIA patients in terms of performed diagnostic investigations and clinical characteristics. METHODS: Patients admitted with cerebral infarction or TIA in the period 2006-2011 were prospectively registered. The use of MRI in patients with transient ischemic symptoms <24 h and proportion of TIA were annually recorded. DWI-positive and DWI-negative patients with transient ischemic symptoms <24 h were compared in univariate analyses regarding baseline data, diagnostic investigations, and etiology. Multivariate analyses were performed to identify predictors of DWI lesions. RESULTS: The use of MRI increased from 65.0% in 2006-2008 to 89.0% in 2009-2011 (P < 0.001). The proportion of TIA as compared to cerebral infarction decreased from 12.2% in 2006-2008 to 8.3% in 2009-2011 (P = 0.002). DWI-positive patients were more often examined with 24-h Holter monitoring (P < 0.001) and echocardiography (P < 0.001). Lower age (P < 0.001) and prior myocardial infarction (P < 0.029) were independently associated with DWI lesions in patients with transient ischemic symptoms <24 h. CONCLUSIONS: An increased use of MRI and a tissue-based TIA definition resulted in a decrease in the proportion of TIA at discharge as compared to cerebral infarction. DWI-positive patients had a more extensive cardiac work-up and were associated with lower age and prior myocardial infarction.

Risk factor burden predicts long-term mortality in young patients with arterial cerebral infarction.

OBJECTIVE: The aim was to investigate risk factors separately and in sum in relation to long-term mortality after arterial cerebral infarction in young adults. MATERIALS AND METHODS: Mortality in relation to the number of risk factors (smoking, hypertension, hypercholesterolemia, diabetes mellitus, myocardial infarction, angina pectoris, and intermittent claudication known at the time of the index stroke) and etiology was studied in a population of young adults with first-ever arterial ischemic stroke at an age < 50 years. Cox regression analyses were performed. RESULTS: After a mean follow-up time of 18 years (the longest follow-up study after cerebral infarction in young adults), 12.5% with no risk factor had died while the corresponding frequencies in patients with 1-3 or more risk factors were 18.5%, 25.4%, and 53.1%, respectively (P < 0.001). The number of risk factors was associated with mortality on Cox regression analysis [hazard ratio (HR) = 1.6, P = 0.001]. A separate Cox regression analysis showed mortality to be associated with diabetes mellitus (HR = 3.0, P = 0.001), myocardial infarction (HR = 3.1, P = 0.001), and alcoholism (HR = 6.3, P < 0.001). CONCLUSION: Increasing number of traditional risk factors is associated with long-term mortality in young adults with cerebral infarction indicating aggressive long-term secondary preventive treatment in selected patients.

Middle cerebral artery stenosis: transcranial color-coded sonography based on continuity equation versus CT-angiography.

PURPOSE: Transcranial color-coded sonography (TCCS) and CT-angiography (CTA) are reliable tools for detection of intracranial stenosis. Current ultrasonographic criteria for middle cerebral artery (MCA) stenosis are usually limited to a dichotomized grading (< or ≥ 50 %). As for carotid arteries, continuity equation might provide a more accurate evaluation of degree of MCA stenosis. We aimed to apply continuity equation to calculate degree of MCA stenosis with TCCS and to compare these results with CTA. MATERIALS AND METHODS: All patients admitted to our Neurovascular Center with ischemic stroke or TIA underwent TCCS examination. Degree of MCA stenosis was calculated based on continuity equation as (1 - [PSVprestenotic/PSVintrastenotic] × 100) %. CTA was performed when TCCS detected MCA stenosis, and degree of stenosis was calculated by diameter (D) as: (1 - [Dprestenotic/Dintrastenotic] × 100) %. Correlation between TCCS and CTA results was tested. Continuity equation method was compared to cut-off velocity method for detection of ≥ 50 % MCA stenosis. To assess TCCS inter-observer agreement, evaluation of MCA stenosis was repeated by another neurosonographer in a subgroup of patients. RESULTS: The overall correlation coefficient between TCCS and CTA was 0.85 (p < 0.0001). Correlation coefficient for stenosis defined with CTA as ≥ 50 % was 0.94 (p < 0.0001). TCCS inter-observer agreement on degree of stenosis was 0.85 (p = 0.001). In detection of ≥ 50 % MCA stenosis, continuity equation method showed a sensitivity of 78 % (14/18) and a specificity of 86 % (19/22), while the cut-off velocity method showed a sensitivity of 67 % (12/18) and a specificity of 86 % (19/22). CONCLUSION: This study shows that ultrasonographic evaluation of MCA stenosis applying the continuity equation provides reproducible and accurate results, and is more sensitive in detection of ≥ 50 % MCA stenosis than cut-off velocity method.

Acute stroke centre - the changing focus of stroke unit care. The Bergen NORSTROKE Study.

OBJECTIVES: The basic stroke unit studies selected patients primarily for rehabilitation and did not deal with the critical first hours after stroke. The aim of this study was to analyse a unselected cohort of patients admitted to an acute stroke centre with primary focus on emergency diagnosis and treatment. MATERIALS AND METHODS: All patients with suspected stroke were admitted as emergencies. Patients with definite cerebrovascular disease were prospectively included in the Bergen Stroke Study, patients with other diseases were excluded, but final diagnosis was registered. RESULTS: Fifty per cent of the admitted patients had other diagnosis than stroke. Of 1267 consecutive patients with cerebrovascular disease, 70% had no or minor neurological deficits on admission. After 1 week, 56% were independent, 30% needed long-term rehabilitation, 10% were bedridden and 4% were dead. CONCLUSION: An acute stroke centre today requires a high degree of neurological expertise in assessing patients admitted with possible stroke. Most patients with stroke have no or mild deficits and need above all rapid diagnostic work-up, acute and prophylactic treatment. In-hospital rehabilitation is essential for a smaller number of patients who suffer from persisting neurological deficits after stroke.