The APOE polymorphism and 1-year outcome in ischemic stroke: genotype-gender interaction.

OBJECTIVE: In human genetic studies an effect of the apolipoprotein E gene (APOE) polymorphism on the risk, course and prognosis in chronic and acute nervous system disorders was established. We aimed to evaluate whether the APOE genotype is related to acute neurological impairments due to ischemic stroke (IS), and to outcomes (up to 1 year) indicated by severe functional disability, dependence in daily living or death. MATERIALS AND METHODS: A total of 657 patients (326 men, 331 women), divided into the three groups: E2 (APOEepsilon2/epsilon3 subjects), E3 (APOEepsilon3/epsilon3 subjects), and E4 (APOEepsilon3/epsilon4 and epsilon4/epsilon4 subjects), were analyzed. RESULTS: There was no association between the APOE genotype and baseline clinical characteristics, severity of neurological impairments during acute stroke, and 1-year outcome, when analyzing whole patient population. APOE gene interacted with gender in predicting severity of acute neurological deficit and post-stroke mortality within the period up to 1 year after the IS. Gender-stratified analysis indicated the E4 genotype as a significant independent positive predictor of death within 1 year after stroke incidence in men patients. CONCLUSION: Ischemic stroke severity and outcome may be affected by complex interactions between gender and genetic factors that warrant further exploration.

Dynamics of LDL oxidation in ischemic stroke patients.

OBJECTIVE: Oxidative modification of human low density lipoprotein (LDL) plays an important role in the development of atherosclerosis. The aim of this study was to evaluate the oxidative modification of LDL in the group of patients with ischemic stroke. MATERIAL AND METHODS: In the group of 43 patients 3 months after ischemic stroke and in the age and sex-matched control group, the kinetics of LDL oxidation and level of vitamin E were estimated. The susceptibility of LDL to oxidation was evaluated in isolated LDL exposed to in vitro oxidation. In 26 patients, after diet change, clinical and laboratory investigations were repeated 9 months later. RESULTS: In the patient group, susceptibility of LDL to oxidation was enhanced, lag phase was significantly shorter in comparison with the control group. After a change in diet, significant elongation of the lag phase was observed. CONCLUSION: Diet change improves LDL resistance to oxidation and may influence prognosis in stroke patients.

[Headache concurrent with the onset of ischemic stroke]. / Ból glowy towarzyszacy wystepowaniu udaru niedokrwiennego mózgu.

The aim of the study was to assess the occurrence of headache in acute ischaemic stroke and its association with type, aetiology and localization of stroke. 342 patients with stroke were analysed. Their average age was 70.8 +/- 13.1. Headache was observed in 17.8% stroke patients. There was no correlation between headache and size of ischaemic lesion in CT. Headache was observed in 43.1% of patients with small foci localized in deep structure, and in 33.3% of large cortical-subcortical foci. The analysis between the frequency of headache and type of stroke according OCSP classification revealed that headache occurred statistically significant more frequent in POCI.

[EEG value in cases of epileptic seizures in early phase of stroke]. / Wartosc badania EEG u pacjentów z napadami padaczkowymi we wczesnej fazie udaru mózgu.

The aim of our work was to assess the usefulness of EEG in patients with seizures in acute phase of stroke. EEG patterns of 54 patients with epileptic seizures at the onset of stroke were evaluated: 45 of ischaemic, 6 of haemorrhagic origin and 3 with lacunar stroke as confirmed by CT or MR examination. Out of 40 patients, who had a single or multiple seizures at the onset of stroke, EEG revealed focal slow waves in 90% and in 22.5% they were accompanied by interictal epileptiform discharges. None of those patients had recurrent seizures during the time of hospitalisation irrespectively of applying antiepileptic drugs. In the remaining 14 patients prolonged disturbances of consciousness were observed. EEG examination revealed simple partial status epilepticus (SE) in 10 and complex partial SE in 4 of them. In 11 of those patients EEG disclosed fragments of periodic lateralized epileptiform discharges (PLED) interrupted by seizure activity. The findings indicate that in patients with seizures in the acute phase of stroke EEG examination is very helpful in making the proper therapeutic decision by recognizing the SE. The introduction of antiepileptic drugs is generally not necessary in stroke patients with single seizures.

[Brain stem syndrome after cervical chiropractic manipulations]. / Zespól pniowy po manipulacjach szyjnych.

This is a case report of a 41-year old man who had ischaemic lesion in the pons following chiropractic manipulation. He had brainstem syndrome with right hemiparesis. He improved. After 4 a year follow-up he is in a very good condition.

[Selective mechanical dilatation of brain arteries: intracranial angioplasty]. / Wybiórcze mechaniczne poszerzenie tetnic mózgowych--wewnatrzczaszkowa angioplastyka.

Intracranial vascular stenosis of haemodynamic significance is underappreciated both clinically and diagnostically. It is thought to be the cause of cerebral ischaemia in 8% of patients. Now it is possible to perform dilatation of the intracranial arterial stenosis by modern intraarterial angioplasty. Two cases are presented of successful dilatation of middle cerebral artery trunk stenosis. Diagnostic problems, follow up and pharmacological treatment as well as technique of intravascular treatment is described.

[Comparison of neurological status in patients treated in a stroke unit with those treated in classical care model]. / Porównanie stanu neurologicznego u chorych leczonych w oddziale udarowym z chorymi leczonymi w klasycznym modelu opieki.

140 patients with stroke (69 men and 71 women) aged 71.7 +/- 12.4 treated in the general neurology were compared with 102 patients (46 men, 56 women) aged 71.5 +/- 11.2 treated in the stroke unit during the period 1.11.95 to 31.10.97. Neurological status and state of environmental dependency during the discharge time were similar in both groups, but the state of motor performance was significantly better in the group of patients treated in the stroke unit. In the stroke unit collaboration between nurses and rehabilitants makes it possible to increase the time of rehabilitation and to introduce the elements of exercises which can be done by patients under control of nurse.

[PLED pattern and its clinical significance in stroke patients]. / Zmiany w eeg typu PLED i ich kliniczne znaczenie u chorych z udarem mózgu.

The pathophysiological connection between periodic lateralized epileptiform discharges (PLED) and epileptic seizures is still not clear. In the study clinical data and EEG findings were analysed in 22 patients aged 43-90 years with a history of stroke in whom EEG disclosed PLED. Eleven patients were studied in the acute phase of stroke and 11 were studied years after stroke when the diagnosis was established of poststroke epilepsy. In 2 patients in acute stroke group single epileptic seizures occurred and 5 had partial status epilepticus. In the group with poststroke epilepsy 4 had single seizures and 4 had epileptic status with partial epilepsy seizures. Thus, in 15 out of 22 patients PLEDs were noted after epileptic seizures. In all cases PLED appearance was connected with consciousness disturbances, lasting 1 to 17 days. In 6 cases PLED pattern was interrupted by seizure activity over one hemisphere, in 3 of them partial epileptic seizures were associated with it. In acute phase of stroke neuroimaging demonstrated the presence of fresh ischaemic foci, but in cases of poststroke epilepsy no such fresh foci were observed. These results suggest that PLED frequently can be associated with epilepsy, and in some patients it can be a bioelectrical manifestation of partial status epileptic.

[Epileptic seizures in post-stroke patients]. / Napady padaczkowe u chorych po udarze mózgu.

We were investigating the frequency of early (within 30 days) and late (within 12 months) poststroke epileptic seizures, in our group consisting of 483 patients with stroke (423 cases of ischaemic stroke and 60 cases of haemorrhagic stroke) and without prior diagnosis of epilepsy. In 28 (5.8%) cases early seizures were observed. The most common type of early seizures were generalised seizures, slightly less frequent were simple partial seizures. EEG usually showed focal slow waves or non-specific slowing of background activity. Among 195 one-year survivors late seizures occurred in 6 (3.1%). 5 of them had ischaemic stroke. 30 day and 12 months fatality in the group of patients with seizures was not significantly higher than in all stroke patients.

[Carotid artery disease in patients with ischemic stroke. Results of year-long observation conducted within the framework of prospective epidemiological studies, Warsaw, 1991-1992]. / Zwezenie tetnicy szyjnej wewnetrznej u chorych z niedokrwiennym udarem mózgu. Wyniki rocznej obserwacji prowadzonej w ramach prospektywnych badan epidemiologicznych, Warszawa 1991-1992.

A cohort of 297 patients with ischaemic stroke were followed for one year. Doppler ultrasonography, done in 219 patients (109 women and 110 men), aged 68.0 +/- 12.6, revealed a concomitant carotid artery occlusive disease (CAD) in 76 patients (34.7%), 34 women and 42 men, aged 66.5 +/- 11.1, 45 of them had high grade stenosis (> 75%) or occlusion. Claudication, myocardial infarction and hypercholesterolaemia diagnosed before the onset of stroke was found more often in patients with CAD, 11.1%, 22.2% and 4.4% was versus 2.8%, 12.3% and 1.4% in patients without CAD. Prevalence of other stroke risk factors, hypertension, diabetes, angina in both groups of patients was similar. Severe stenosis or occlusion was diagnosed more often among men (58%) and among smokers (55%), in the group of patients without CAD than 48% and 42% respectively. The onset of stroke was preceded more often by TIA--24% in group with CAD, versus 17% in patients without CAD. Neurological state on admission, test by Stroke Severity Scale and Weakness Score according to SDB, was similar in both groups of patients but prognosis was worst among patients with CAD, 13.5% of them developed recurrent stroke versus 7% in group without CAD. In Kaplan-Meier analysis one year cumulative survival rates were lower in the group of the patients with severe stenosis or occlusion.

[Post-stroke epilepsy]. / Padaczka poudarowa.

The frequency of cerebrovascular aetiology of epilepsy is estimated at 3-30%, and the rate is significantly higher in studies carried out in developed world. Early seizures, variously defined by different authors (usually as those occurring within first week or first two weeks after stroke) occur in 2.5-6% of patients, in most of them within the first 24 hours after stroke. Early seizures constitute a major risk factor of poststroke epilepsy, but in many patients seizures do not recur after acute phase of stroke. The pathophysiology of poststroke seizures is not fully elucidated, probably it is different for early and late seizures. Several investigations evaluated the connection between seizures and localization of vascular foci, the results are not consistent; most investigators believe that seizures occur more frequently in cases of cortical localization of the focus. Seizures are more common in haemorrhagic than in ischaemic strokes. The most common type of seizures are simple partial seizures, the rarest are complex partial seizures. The prognostic value of EEG is of little importance: nevertheless, in poststroke patients who had at least one seizure, diffuse slowing of background activity or PLED are associated with increased risk of seizure recurrence. Early seizures do not require long-term antiepileptic treatment; late seizures usually well respond to treatment.

Transesophageal echocardiographic findings in patients with anterior and posterior circulation infarcts.

OBJECTIVES: The aim of this study was to assess the role of transesophageal echocardiography in detecting the source of cerebral embolism in ischemic stroke patients and to evaluate the difference in occurrence of heart abnormalities in anterior and posterior circulation infarcts. MATERIAL AND METHODS: The study group included 104 patients, 51 males and 53 females with ischemic stroke without significant atherosclerosis in the carotid arteries. Age of the patients ranged from 14 to 82 years (mean 55). The clinical picture of stroke suggested the embolic etiology, 34 of them had atrial fibrillation. Transthoracic and transesophageal echocardiography were performed in all patients. All patients were separated as anterior or posterior circulation infarcts. The control group consisted of 100 patients aged from 14 to 73 years (mean 53) without stroke history. RESULTS: Transesophageal echocardiography (TEE) examination revealed left atrial thrombus in 12%, left atrial spontaneous contrast in 16%, interatrial communication in 31%, mitral valve prolapse in 20%, atrial septal aneurysm in 14%, ventricular thrombus in 6% and aortic atheromas of 5 mm or more in size in 7% of stroke patients. In the control group left atrial spontaneous contrast was found in 10%, interatrial communication in 17%, mitral valve prolapse in 4%, atrial septal aneurysm in 8%, neither atrial nor ventricular thrombi were found. At least one abnormal TEE finding was present in 70 (67%) of stroke patients. Abnormal TEE findings were more often seen in patients with anterior circulation infarct than in those with posterior circulation infarcts, although the difference was not statistically significant. Left atrial thrombus and mitral valve prolapse occurred statistically significantly more often in stroke patients than in the control group. CONCLUSIONS: Echocardiographic examination is often abnormal in patients with ischemic stroke. The study did not reveal the statistically significant difference in the prevalence of abnormal transesophageal echocardiography findings between patients with anterior and posterior circulation infarcts.

Stroke recurrence among 30 days survivors of ischemic stroke in a prospective community-based study.

A cohort of 209 patients (105 men and 104 women), who survived 30 days after 'first ever-in-lifetime ischemic stroke' were followed for one year. Predictors of survival were examined by log-rank test and Cox proportional hazards method. Twenty-four patients had a stroke recurrence (11.4%). Thirteen of the patients with recurrent stroke (54%) died because of the sequelae of the second stroke. Stroke recurred in 16% of patients with stroke due to atherosclerosis, in 12.5% of patients with cardioembolic stroke, and in 4.4% of patients with lacunar stroke. The life table cumulative risk of death at 6 and 12 months for patients with recurrent stroke was statistically higher (22% and 57%) than patients without recurrent stroke (13% and 29% respectively). History of untreated hypertension prior to the initial stroke (RR = 1.7, 95% Cl 1.2-4.1, p < 0.05) was an independent predictor of recurrence. In 134 patients (64.9%) aspirin was initiated during the first month after stroke. Only 81 patients (39.8%) continued aspirin treatment for the whole year. Life table cumulative risk of mortality among the patients treated with aspirin was 8% at 6 months and 12% at 1 year compared to 19% at 6 months and 45% at 12 months for those untreated with aspirin. We conclude that the high risk of recurrent stroke in Poland could be redaced by increased use of anti-platelets therapy and anti-hypertensive therapy after ischemic stroke.

[Lacunar strokes: clinical conditions vs. localization of lesions in neuroimaging studies]. / Udary zatokowate: stan kliniczny a lokalizacja ognisk w badaniach neuroobrazujacych.

Clinical records of 89 patients with lacunar stroke were reviewed, to evaluate the occurrence of neurological syndrome and to correlate the frequency of its signs with the localization of ischaemic lesions seen in neuroimaging examinations. "Pure" motor paresis (50%) and sensory-motor paresis (27%) were the most common clinical syndromes. The localization in putamen and corona radiata (37%), or in anterior part of the internal capsule and in the head of the caudate nucleus (35%) were the most frequent sites of localization. In the group of patients with lesions in anterior part of internal capsule or with lesions in putamen and corona radiata "pure" motor paresis was the most common clinical syndrome. Additionally, in the group of patients with lesions in putamen and corona radiata sensory motor paresis was also frequently observed (44%). During one year of follow-up 22 patients died. Dysarthria and disability (Barthel Index < 60) were the independent predictors of one year mortality. Non-neurological complications were the main cause of death.

[Annual survival rates in lacunar stroke in relation to neurological status, risk factors and applied anti-aggregation treatment]. / Roczne wskazniki przezycia w udarach zatokowatych w zaleznosci od obciazenia czynnikami ryzyka i stosowanego leczenia antyagregacyjnego.

Lacunar stroke accounts for 20-25% of all ischaemic strokes. It is believed that the prognosis in this stroke is relatively good, with annual mortality being 9.8% to 11.3%. In the analysis of the Warsaw Stroke Register this mortality was much higher--about 25%. The purpose of the present study was to assess the factors increasing the probability of death in lacunar stroke based on a one-year follow-up of 113 patients (67 males and 48 females), mean age 67.3 +/- 11.2 treated at the II Department of Neurology, Institute of Psychiatry and Neurology. The total one-year mortality was 23%. In the group of patients dying in that year hypertension was found in 88% and diabetes in 27%, while in the surviving group these diseases were found in 72% and 18% respectively. The differences between groups were not significant. Considering the effect of other risk factors (age, fitness status assessed with modified Barthel index) it was demonstrated that the risk of death increased with increasing age (relative risk 1.03, 95% CI 1.001-1.05) and with the degree of dependence on the help of others, Barthel index < 60 (RR = 1.49.95%, CI 1.24-1.66). In the analysis of the effect of antiaggregation treatment the mortality was lower in aspirin-treated patients (300 mg daily) with cumulated annual survival rate 79.8 as compared to the not treated patients in whom it was 58.2. The difference was not significant, probably due to small number of cases.

High case-fatality rates in the Warsaw stroke registry.

We studied 1-year survival in 297 patients with first-even-in-lifetime ischemic stroke (FEL-IS) selected from a population-based study of stroke in the Mokotow district of Warsaw. Case fatality rates were 29% at 30 days and 51% at 1 year. These case fatality rates are significantly higher than in other industrialized countries. Early deaths were primarily caused by neurological sequelae of stroke or complications of immobility, whereas late deaths (>30 days) were primarily caused by stroke recurrence or complications of immobility. Predictors of survival were analyzed by life table methods. Adverse predictors of 1-year survival included greater age, low activities of daily living scores, atrial fibrillation, greater weakness, congestive heart failure, and untreated hypertension. Patients with stroke recurrence were more likely to die in the first year. We hypothesize that stroke severity contributes to high case-fatality rates by increasing death caused by both direct neurological sequelae and complications of immobility. Medical comorbidity probably contributes to high case-fatality rates in Poland by increasing stroke recurrence rates and by increasing deaths caused by immobility. We hypothesize that high case-fatality rates in Poland could be reduced by improved rehabilitation of stroke patients to avoid deaths caused by immobility and by better control of medical comorbidity in stroke patients.

Factors predicting 30-day mortality in the Warsaw stroke registry.

UNLABELLED: Poland has high mortality and morbidity due to stroke. Our prospective population-based study conducted in Warsaw in 1991-1992 showed a stroke incidence similar to other European countries. However, 30-day case mortality rates were much higher. Our aim was to explore factors predicting 30-day mortality in Warsaw. The study population consisted of all patients with first-ever-in-a-lifetime strokes admitted to the Department of Cerebrovascular Diseases during the 2-year prospective population-based stroke registry. Cases with uncertain stroke type were excluded from analysis. During the 2-year study period, 633 patients with stroke were registered (462 with first-ever-in-a-lifetime stroke); 351 of them completed full diagnostic procedures, and 297 were diagnosed with ischemic stroke (IS) and 54 with intracerebral hemorrhage (ICH). A logistic regression model for IS identified 7 independent variables predicting 30-day mortality: increasing age, decreased consciousness at the onset of stroke, extraocular movement disorder, severity of motor weakness, congestive heart failure, kidney diseases, and chronic obstructive pulmonary diseases (COPD). A logistic regression model for ICH identified two independent predictor variables: extraocular movement disorders and decreased consciousness. Comparison of the Warsaw Stroke Registry with the Stroke Data Bank (SDB) revealed higher prevalences of heart disease (angina and atrial fibrillation) and COPD in the Warsaw population. Comorbidity of medical diseases with stroke probably contributed to higher mortality in the Warsaw as opposed to U.S. PATIENT SAMPLE: Disorders of consciousness at the onset of stroke were more severe in Warsaw than in the U.S. SAMPLE: Stroke type, severity of weakness score, and severity of stroke scale were similar for the SDB and Warsaw populations. In Poland, high levels of medical comorbidity rather than stroke severity probably account for poor short-term prognosis in stroke.

[Prevalence of certain risk factors in lacunar strokes as compared with cortico-subcortical strokes]. / Czestosc wystepowania niektórych czynników ryzyka w udarach zatokowych, w porównaniu z udarami korowo-podkorowymi.

Clinical records were reviewed to analyse occurrence of hypertension and other risk factors that may predispose to the development of lacunar stroke. The comparison of risk factors associated with deep, small, ischaemic lesions of the brain (revealed in 67% by CT, in 31% by MRI and in 2% by autopsy) and large superficial or superficial and deep ischaemic lesions (diagnosed in 89% by CT, 4% by MRI and 7% by autopsy) was done. Hypertension, treated and untreated, was more frequent in lacunar stroke, but the difference was not statistically significant. Statistically significant difference was found in large stenotic lesions of internal carotid artery, which were more common in patients with large superficial or superficial and deep lesions (watershed area) and in moderate stenotic lesions of internal carotid artery, which were more common in patients with lacunar stroke. The results suggests that lacunar stroke may be caused by cerebral embolism from carotid sources.

A prospective community-based study of stroke in Warsaw, Poland.

BACKGROUND AND PURPOSE: Poland is a country with high morbidity and mortality rates from cardiovascular diseases. No recent studies have evaluated the contribution of cerebrovascular diseases to this morbidity and mortality. Our aim was to accurately determine stroke incidence rates in Warsaw, Poland. METHODS: A 2-year prospective and population-based stroke registry was maintained for health care units 2 and 3 in Warsaw, Poland (population, 182,285). Case subjects were ascertained by surveying hospital admissions, outpatient visits, and death certificates. RESULTS: During the 2 years of the study (1991 to 1992), 633 cases of first-event strokes were registered, 462 of which were first ever in a lifetime. Computed tomography or necropsy was performed in 72% of first-ever stroke cases. The crude annual incidence rate for first-ever stroke was 127/100,000 (95% confidence intervals, 111 to 145); the rate standardized to the European population was 111 (95% confidence intervals, 96 to 128). Our incidence rates for first-event strokes were found to be in the middle of the range among other first-event studies. When comparing our first-ever stroke incidence rates with those of comparable studies performed throughout Europe, they were found to be similar for groups aged younger than 65 years but lower in the older age groups. The distribution of ischemic and hemorrhagic stroke subtypes was similar to that of other countries. CONCLUSIONS: This first population-based prospective stroke registry in Poland showed that incidence rates were not high compared with other studies throughout Europe and the world. These stroke incidence rates are not a large contributing factor to high cardiovascular morbidity rates in Poland.

[Collateral circulation in patients with internal carotid artery occlusion depending on the localization of the ischemic stroke. Ultrasonographic study]. / Drogi krazenia obocznego u chorych z niedroznoscia tetnicy szyjnej wewnetrznej w zaleznosci od lokalizacji ogniska niedokrwiennego w mózgu. Badanie ultrasonograficzne.

The relationship between computerized tomography (CT) location of ischaemic strokes and the appearance of collateral circulation on transcranial Doppler ultrasonography (USG-D) was investigated in 30 patients with internal carotid artery occlusion. Evidence of collateral circulation via the anterior communicating artery was observed less frequently (88%) among patients with ischaemic lesions in the anterior and middle cerebral artery distribution, as well as the border zone area between these arteries, than in those with ischaemic strokes in the border zone area between posterior and middle cerebral arteries (100%). In patients in whom focal lesions were not found on CT, good collateral circulation via ophthalmic (100%), anterior communicating (100%) and posterior cerebral (84%) arteries was found on transcranial USG-D.