Pre-stroke physical activity is associated with fewer post-stroke complications, lower mortality and a better long-term outcome.

BACKGROUND AND PURPOSE: Physical activity is associated with a reduced incidence of first-time stroke. However, few studies have examined the effect of pre-stroke physical activity on post-stroke complications and clinical outcomes. METHODS: A total of 39 835 cases of stroke registered in the nationwide stroke registry system of Taiwan between 2006 and 2009 were analyzed according to five levels of severity as determined by National Institutes of Health Stroke Scale score upon hospital admission. Pre-stroke physical activity was defined in the Taiwan Stroke Registry as dedicated leisure-time physical activity for at least 30 min/day for 3 days/week for more than 6 months. A Cox model was used to compare complications and outcomes between active and inactive groups. RESULTS: The active and inactive groups were similar in age distribution and stroke type distribution, but the active group had better National Institutes of Health Stroke Scale scores upon admission. The active group also had significantly fewer post-stroke complications. Active patients had lower hospital mortality and better functional outcomes upon discharge as per the modified Rankin Scale. Improved functional status in the active group was significant at 1, 3 and 6 months post-stroke. CONCLUSION: Dedicated leisure-time physical activity for at least 30 min/day, at least three times per week for more than 6 months was associated with decreased stroke severity, fewer post-stroke complications, lower mortality and better outcomes.

Stenting versus medical treatment for severe symptomatic intracranial stenosis.

BACKGROUND AND PURPOSE: Intracranial atherosclerosis is especially prevalent in Asians, but intracranial stent placement and medical treatment for severe intracranial stenosis are controversial. Thus, we compared long-term outcomes of these 2 therapeutic approaches in an Asian population. MATERIALS AND METHODS: Patients with angiographically proved severe (≥70%) symptomatic intracranial atherosclerosis, with or without stent placement, were retrospectively reviewed at a single center between 2002 and 2009, with adjustments for age, sex, vascular risk factors, degree of baseline stenosis, and baseline functional status. RESULTS: Of the 114 patients followed from 3 to 36 months (mean, 17.3 months) after initial diagnosis, 53 received 56 stents in addition to medical treatment (stent-placement group), and 61 matched patients received only medical treatment (medical group). Total clinical events, including stroke, TIA, and vascular death, were 12 (22.6%) and 15 (24.6%) in the stent-placement and medical groups, respectively (P = .99). The stent-placement group had significantly better functional outcomes than the medical group (94.3% versus 78.7% for mRS scores of 0-3, P = .045). Most events in the stent-placement group occurred within the first week of the periprocedural period (17.0%) as minor embolic or perforator infarctions, and the rate of events decreased thereafter (5.7%, P = .07). Stent placement over the perforator-rich MCA and BA independently predicted periprocedural events on multivariate regression analysis. In the medical group, events increased in frequency (21.7%) and severity with time. CONCLUSIONS: Although the total ischemic event rate was similar in the 2 groups during a 3-year follow-up, the stent-placement group had a more favorable functional outcome despite minor periprocedural strokes.

Contribution of intracranial vertebral artery asymmetry to vestibular neuropathy.

OBJECTIVES: To test the hypothesis that vertebral artery hypoplasia (VAH) may affect the lateralisation of vestibular neuropathy (VN), probably through haemodynamic effect on the vestibular labyrinth. METHODS: 69 patients with unilateral VN were examined with a magnetic resonance angiographic (MRA) and caloric test. 50 healthy subjects served as controls. The diagnosis of intracranial VAH was based on MRA if <0.22 cm in VA diameter and a diameter asymmetry index >40%. The authors then correlated the canal paretic side with the VAH side. RESULTS: MRA study revealed 29 VAH (right/left: 23/6) in VN subjects and six VAH in controls (right/left: 5/1). The RR of VAH in VN subjects compared with controls was elevated (RR=2.2; 95% CI 1.8 to 2.8). There was a high accordance rate between the side of VAH and VN. Among 29 patients with unilateral VAH, 65.5% (N=19) had an ipsilateral VN, in which left VAH showed a higher accordance rate (83.3%) than the right side (60.9%). VN subjects with vascular risk factors also had a higher VAH accordance rate (81%) than those without (25%). CONCLUSIONS: VAH may serve as a regional haemodynamic negative contributor and impede blood supply to the ipsilateral vestibular labyrinth, contributing to the development of VN, which could be enhanced by atherosclerotic risk factors and the left-sided location.

Noninvasive assessment of spontaneous baroreflex sensitivity and heart rate variability in patients with carotid stenosis.

BACKGROUND: Previous limited observations have suggested that atherosclerosis may affect the distensibility of the carotid sinus and then impair the baroreflex sensitivity (BRS). No studies have been done to compare the BRS and heart rate variability (HRV) in patients with carotid stenosis and normal controls. METHODS: A convenience-consecutive sample of 118 patients with transient ischemic attack or minor stroke 3 months to 1 year before (mean 6 months) who met the study criteria were referred to the neurovascular laboratory of the study hospital. Forty-three age-matched healthy adults were recruited as the normal controls. The inclusion criteria for participation were (1) no diabetes mellitus, (2) no history, symptoms or ECG signs of coronary artery disease or myocardial infarction, and (3) presence of carotid stenosis greater than or equal to 50%. The diagnosis of carotid stenosis was made using color-coded duplex ultrasound with published criteria. We categorized the patients into two groups: group 1 had moderate stenosis (50-75%) and group 2 had high-grade stenosis (75-99%). Instantaneous systolic blood pressure (SBP) and heart rate of all participants were assessed noninvasively using servo-controlled infrared finger plethysmography. The fluctuation in SBP as well as the interpulse interval (IPI) was divided into three components at specific frequency ranges by fast Fourier transform as high frequency (HF; 0.15-0.4 Hz), low frequency (LF; 0.04-0.15 Hz) and very low frequency (VLF; 0.004-0.04 Hz). The BRS was expressed as (1) transfer function with its magnitude in the HF and LF ranges, (2) BRS index alpha, and (3) regression coefficient by sequence analysis. The HRV was expressed as total power and power in the three frequency ranges (HF, LF and VLF). RESULTS: The final analysis included 99 patients (mean age 72 +/- 6 years, 79 male) and 43 healthy controls (mean age 68 +/- 7 years, 30 male). Forty-three patients were classified as group 1 (stenosis 50-75%) and 56 as group 2 (stenosis 75-99%). There was no significant difference in the IPI between patients and controls (p value = 0.8637). We observed a significant decrease in all three HRV components (VLF, LF and HF) in the patients; however, there were no differences between the two patient groups with various degrees of stenosis. All the indices of BRS, including the magnitude of SBP-IPI transfer function at LF and HF, the computed BRS index alpha and the regression coefficient of sequence analysis, revealed similar results. Patients exhibited a significant reduction in the BRS (p < 0.001) compared with controls, and no difference was found between the two groups of patients. CONCLUSIONS: Our study linked significant carotid stenosis to two important autonomic markers (BRS and HRV) that may have prognostic value for patients with cardiovascular events. Further prospective studies are needed to explore whether or not the decreased BRS and HRV can be predictors for poor cardiovascular prognosis, or even for shortened life span in general, in patients with significant carotid stenosis.

Increased arterial wave reflection may predispose syncopal attacks.

BACKGROUND: The incidence of syncope increases with age, while aging is also associated with increased arterial wave reflection. HYPOTHESIS: The study was undertaken to determine whether increased arterial wave reflection is a predisposing factor of syncope. METHODS: We recruited 38 patients (28 men and 10 women, mean age 57.2 +/- 20.3 years, range 17-87 years) with a history of syncope within 6 months of entry. The etiology of syncope was documented for each patient by a complete assessment of vasomotor function and cerebral flow. All patients received a comprehensive echocardiographic evaluation of cardiac structure and function. Carotid augmentation index (AI) was estimated noninvasively with the tonometry technique. The results were compared with those from 54 age- and gender-matched controls. RESULTS: The most frequent diagnoses of syncope were postural hypotension (13 patients) and cerebrovascular dysautoregulation (10 patients), and the cause could not be determined in 9 patients. Compared with the control group, the syncope group had a greater AI (20 +/- 21 vs. 10 +/- 15%, p = 0.013). Subgroup analysis of 20 patients aged > 50 years and with the aforementioned diagnoses showed even more striking results: AI, 29 +/- 10 vs. 11 +/- 15%, p < 0.001. The enhanced augmentation in the patients remained when age, systolic blood pressure, height, and heart rate were accounted for. Analysis of the carotid pulse wave suggested that both the timing and intensity of wave reflection were enhanced in patients with a history of syncope compared with controls. CONCLUSIONS: Our results support the hypothesis that enhanced arterial wave reflection is associated with the occurrence of syncope, especially in the elderly.

Spectral analysis of arterial blood pressure and cerebral blood flow velocity during supine rest and orthostasis.

This study evaluates the effect of orthostasis on the low frequency (LF, 0.04 to 0.15 Hz) fluctuations in the blood flow velocity of the middle cerebral artery (MCAFV) in relation to its arterial blood pressure (ABP) equivalent to further define and quantify this relationship in cerebrovascular regulation. Spectral analysis was performed on 22 healthy subjects during supine rest and head-up tilt. The power in the LF range can be used to quantify the LF fluctuations, and four types of LF power data could be obtained for each individual: LF power of supine MCAFV, LF power of supine ABP, LF power of tilt MCAFV, and LF power of tilt ABP. By comparing LF power of MCAFV with LF power of ABP, two power ratios could be generated to describe the flow-pressure relationship during supine rest and head-up tilt, respectively, supine power ratio (LF power of supine MCAFV/ LF power of supine ABP) and tilt power ratio (LF power of tilt MCAFV/ LF power of tilt ABP). In addition, an index for dynamic autoregulation in response to orthostasis can be calculated from these two power ratios (tilt power ratio/supine power ratio). The authors found that this index was dependent on the extent of orthostatic MCAFV changes, and the dependency could be mathematically expressed (r = 0.61, P = .0001), suggesting its involvement in cerebrovascular regulation. Moreover, these data further support the previous observation that the LF fluctuations of MCAFV might result from modulation of its ABP equivalent, and the modulation effect could be quantified as the power ratio (LF power of MCAFV/ LF power of ABP). These observations could be an important step toward further insight into cerebrovascular regulation, which warrants more research in the future.

Colour doppler imaging for diagnosis of intracranial hypotension.

BACKGROUND: Measurement of CSF pressure is the only known way to confirm the diagnosis of intracranial hypotension. We aimed to assess colour doppler flow imaging (CDFI) for measurement of blood flow of the superior ophthalmic vein for the diagnosis of intracranial hypotension. METHODS: We enrolled 25 consecutive patients with orthostatic headache who had clinical features of intracranial hypotension. We defined low-pressure headache as cerebrospinal-fluid pressure below 60 mm H2O. We used CDFI to measure the diameter and maximum flow velocity of the superior ophthalmic vein in all patients. Magnetic resonance imaging of the brain and lumbar puncture with measurement of cerebrospinal-fluid pressure within 24 h were also done after sonographic examination. The control group comprised 13 healthy individuals of a similar age; in addition, those patients who had orthostatic headache without low pressure served as a control group for the patients. FINDINGS: Of the 25 patients recruited for this study, 13 satisfied the criteria for low-pressure headache. The remaining 12 patients with normal cerebrospinal-fluid pressure had transformed migraine (five patients) or chronic tension-type headache (seven patients), and therefore served as the control group for the patients. The mean diameter of the superior ophthalmic vein was substantially larger in the patients with intracranial hypotension (3.9 [SD 0.2] mm) than in the healthy controls (2.6 [0.4] mm) and the controls from the patients' group (2.7 [0.2] mm) (p<0.0001). The mean maximum flow velocity was significantly higher in the intracranial-hypotension group (17.0 [SD 3.4] cm/s) than in the healthy controls (7.9 [1.1] cm/s) and the other patients (7.3 [1.7] cm/s) (p<0.0001). Seven patients with intracranial hypotension were reassessed after treatment with epidural blood patch. After this treatment the clinical symptoms were relieved and there was a striking reversal of the superior ophthalmic vein flow. INTERPRETATION: CDFI to measure blood flow of the superior ophthalmic vein provides a practical, simple, and non-invasive diagnostic method for suspected intracranial hypotension.

Transcranial Doppler monitoring with head-upright tilting in patients with syncope.

BACKGROUND: The aim of our study was to evaluate the effects of orthostatic stress produced by the head-upright tilt test on human cerebral hemodynamics by transcranial Doppler sonography. METHODS: We studied 60 subjects who were divided into two groups; one of normal controls (n = 43) and one of patients suffering from syncope (n = 17). A 30-minute head-upright tilt test was conducted on all subjects, and heart rate and blood pressure were monitored by surface electrocardiography and cuff sphygmomanometry, respectively. Cerebral blood flow velocity and cerebral vasoreactivity were continuously monitored using transcranial Doppler sonography. RESULTS: The maximal decreases in mean blood pressure of controls and patients with syncope were 2.6 +/- 7.8% and 0.5 +/- 7.9% of baseline, respectively. The maximal decreases in mean blood flow velocity in the middle cerebral artery between the two groups reached 19.6 +/- 6.2% and 30.7 +/- 14.1% of baseline, respectively (p < 0.05). The increases in pulsatility index between the two groups were 15.4 +/- 14.3% and 16.9 +/- 21.1% of baseline, respectively. CONCLUSION: The responses of cerebral blood flow to upright tilting differed significantly between normal controls and patients with syncope, implying that the latter may suffer an impairment of cerebral autoregulation. Further studies are needed to ascertain what clinical implications this finding might have.

Transfer function analysis of cerebral hemodynamics in patients with carotid stenosis.

This study evaluates the validity of the transfer function analysis of spontaneous fluctuations of arterial blood pressure (ABP) and blood flow velocity of the middle cerebral artery (MCAFV) as a simple, convenient method to assess human cerebral autoregulation in patients with carotid stenosis. Eighty-three consecutive patients with various degrees of carotid stenosis and 37 healthy controls were enrolled. The carotid stenosis was graded based on the diagnostic criteria of duplex ultrasound. Instantaneous bilateral MCAFV and ABP of all participants were assessed noninvasively using transcranial Doppler sonography and the servocontrolled infrared finger plethysmography, respectively. Spectral analyses of ABP and MCAFV were performed by fast Fourier transform. The fluctuations in ABP as well as in MCAFV were diffracted into three components at specific frequency ranges designated as high-frequency (HF; 0.15 to 0.4 Hz), low-frequency (LF; 0.04 to 0.15 Hz), and very low-frequency (VLF; 0.016 to 0.04 Hz). Cross-spectral analysis was applied to quantify the coherence, transfer phase, and magnitude in individual HF, LF, and VLF components. Transcranial Doppler CO2 vasomotor reactivity was measured with 5% CO2 inhalation. The LF phase angle (r=-0.53, P<0.001); magnitude of VLF (r=-0.29, P=0.002), LF (r=-0.35, P<0.001), and HF (r=-0.47, P<0.001); and CO2 vasomotor reactivity (r=-0.66, P<0.001) were negatively correlated with the severity of stenosis. Patients with unilateral high-grade (greater than 90% stenosis) carotid stenosis demonstrated significant reduction in LF phase angle (P<0.001) and HF magnitude (P=0.018) on the ipsilateral side of the affected vessel compared with their contralateral side. The study also revealed a high sensitivity, specificity, and accuracy using LF phase angle and HF magnitude to detect a high-grade carotid stenosis. A strong correlation existed between the LF phase angle and the CO2 vasomotor reactivity test (r=0.62, P<0.001), and the correlation between the HF magnitude and the CO2 vasomotor reactivity (r=0.44, P<0.001) was statistically significant as well. We conclude that transfer function analysis of spontaneous fluctuations of MCAFV and ABP could be used to identify hemodynamically significant high-grade carotid stenosis with impaired cerebral autoregulation or vasomotor reserve.

Frequency domain analysis of cerebral blood flow velocity and its correlation with arterial blood pressure.

We applied frequency domain analysis to detect and quantify spontaneous fluctuations in the blood flow velocity of the middle cerebral artery (MCAFV). Instantaneous MCAFV of normal volunteers was detected using transcranial Doppler sonography. Spectral and transfer function analyses of MCAFV and arterial blood pressure (ABP) were performed by fast Fourier transform. We found the fluctuations in MCAFV, like ABP, could be diffracted into three components at specific frequency ranges, designated as high-frequency (HF, 0.15 to 0.4 Hz), low-frequency (LF, 0.04 to 0.15 Hz), and very low-frequency (VLF, 0.016 to 0.04 Hz) components. The HF and LF components of MCAFV exhibited high coherence with those of ABP, indicating great similarity of MCAFV and ABP fluctuations within the two frequency ranges. However, it was not the case for the VLF component. Transfer function analysis revealed that the ABP-MCAFV phase angle was frequency-dependent in the LF range (r = -0.79, P < 0.001) but not in the HF range. The time delay between LF fluctuations of ABP and those of MCAFV was evaluated as 2.1 seconds. We conclude that in addition to traditional B-wave equivalents, there are at least two different mechanisms for MCAFV fluctuations: the HF and LF fluctuations of MCAFV are basically secondary to those of ABP, and cerebral autoregulation may operate efficiently in LF rather than HF range. Frequency domain analysis offers an opportunity to explore the nature and underlying mechanism of dynamic regulation in cerebral circulation.

Clinical significance of the ophthalmic artery in carotid artery disease.

A total of 141 subjects with tight stenosis (> or = 75%) or occlusion of internal carotid artery were followed up at intervals 3-6 months regularly for 40 +/- 16 months. The direction of ophthalmic artery flow was used as a parameter of risk indicator on cerebral ischemic events. Eleven patients with bilateral carotid tight stenosis/occlusion were excluded in the analysis. Thus, the 130 carotid arteries were divided into three groups: (1) carotid artery with ipsilateral hemispheric TIA or stroke (85 patients), (2) carotid arteries with contralateral hemispheric TIA/stroke or VBI (15 patients), and (3) carotid arteries of asymptomatic patients (30 patients). The symptomatic carotid artery group (group 1) had significantly more often reversed ophthalmic flow than the other two groups (group 2 and 3, p < 0.001). During follow-up prospectively for four years, 41 patients had cerebral ischemic events, three had cardiac ischemic events and six died of malignancy. Patients with reversed OA flow had more often subsequent cerebral ischemic events than those with forward flow (27 vs 14, p = 0.010). However, the difference remained significant only in the asymptomatic patients (group 3, 4 vs 0, P < 0.001), not for groups 1 and 2, after further analysis. Our work supported that the clinical role of ophthalmic artery collateral varied between asymptomatic and symptomatic patients.

Lack of serum neutralizing antibody against poliovirus in patients with juvenile distal spinal muscular atrophy of upper extremities.

Serum neutralizing antibodies for type 1, 2 and 3 poliovirus were studied in 15 Chinese patients in Taiwan with juvenile distal spinal muscular atrophy of the upper extremities and 15 age-matched normal subjects. Significantly lower serum antibody titers were found in the study group, suggesting that patients with this chronic focal form of acquired motor neuron disease are, to some degree, immunologically unresponsive to the neutralizing epitope of poliovirus.

Lack of cervical paraspinal muscle involvement in juvenile distal spinal muscular atrophy: an electromyographic study on 15 cases.

Electromyography (EMG) of the lower cervical paraspinal muscles was performed in 15 young Chinese males with distal spinal muscular atrophy of the upper extremities. The lack of fibrillation and positive sharp waves in all patients, both in early or active and chronic or steady stages, did not correlate with the EMG status in the affected upper extremity on the same side. This finding is in striking contrast with that in amyotrophic lateral sclerosis.

Juvenile lower cervical spinal muscular atrophy in Taiwan: report of 27 Chinese cases.

Clinical observations as well as electromyographic studies were carried out on 27 Taiwanese Chinese patients deemed to be suffering from a rare, unique and self-limiting variant of lower motor neuron disease affecting the upper limbs with juvenile onset and a marked male preponderance. The results agree with previous descriptions of the disease except for the higher incidence of triceps affection. The term 'juvenile lower cervical spinal muscular atrophy', which describes the disease more accurately, is being proposed. The geographic relevance is discussed.