Use of direct thrombin inhibitor for treatment of cerebral venous thrombosis.

Cerebral venous thrombosis is an uncommon condition with difficulties in diagnosis and treatment. There is limited study on the best treatment option for this disease. The mainstay of treatment remains systemic anticoagulation with a lengthy duration of warfarin, which has a troublesome unpredictable drug effect, various drug and food interactions, and an increased risk of bleeding. Recent availability of direct thrombin inhibitor provides an alternative option of systemic anticoagulation in various thromboembolism conditions. We report 2 cases of cerebral venous thrombosis treated with a direct thrombin inhibitor with good clinical and radiologic results.

The clinical course of multiple sclerosis patients in Hong Kong.

BACKGROUND: Multiple sclerosis (MS) has a low prevalence in Hong Kong. OBJECTIVE: To reassess MS prevalence in Hong Kong and to examine associated risk factors for relapsing-remitting type MS patients to reach Kurtzke's Extended Disability Status Scale (EDSS) of 6.0, i.e. when walking aid was needed. DESIGN: Retrospective observational study on MS patients over 11 years. SETTING: Three tertiary hospitals in Hong Kong. RESULTS: A hundred and six patients were recruited. Female to male ratio was 3.2:1 and the prevalence was 4.8 per 100,000. 95 were relapsing-remitting (RR) type. The mean disease duration was 12.7 years (range: 1-45 years) and the duration of follow up was 11.0+/-0.8 (mean+/-SE) years. The initial mean EDSS was 1.59 and the latest mean EDSS was 4.26. 38 (40%) RR type MS patients progressed to EDSS 6.0 after a mean duration of 6.0 years. With Cox regression analysis, patients with older age (>35y) of onset (HR 2.57; 95% CI:1.29-5.11), higher EDSS of 2.0 or more upon presentation (HR 2.19; 95%CI: 1.12-4.26) were associated with progression to EDSS of 6.0, while there was a tendency towards slower disease progression for patients initially presenting with optic symptoms (HR 0.52; 95%CI: 0.23-1.16). The number of relapses and use of interferon could not be shown to have significant effect on disease progression. CONCLUSIONS: The local period prevalence ratio of MS was 4.8 per 100,000. Older age of onset and higher EDSS upon initial presentation were independent predictors for progression to EDSS of 6.0.

Coexisting cerebral infarction in Alzheimer's disease is associated with fast dementia progression: applying the National Institute for Neurological Disorders and Stroke/Association Internationale pour la Recherche et l'Enseignement en Neurosciences Neuroimaging Criteria in Alzheimer's Disease with Concomitant Cerebral Infarction.

OBJECTIVES: To determine whether patients with Alzheimer's disease (AD) and coexisting cerebral infarction (CI) that satisfy the National Institute for Neurological Disorders and Stroke/Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) neuroimaging criteria for vascular dementia (VaD) progress faster than those who do not satisfy the neuroimaging criteria. DESIGN: Retrospective cohort study. SETTING: Multidisciplinary memory clinic in a tertiary hospital. PARTICIPANTS: One hundred thirty consecutive patients with AD, with or without CI, followed up regularly for more than 1 year. MEASUREMENTS: The patients were classified according to the distribution and severity of CI as defined according to the NINDS-AIREN neuroimaging criteria into those with AD and no CI (AD-N), those with AD and CI not fulfilling neuroimaging criteria (AD-I), and those with AD and CI fulfilling neuroimaging criteria (AD-V), and their differences in dementia progression were tested. The loss of independence, indicated by institution admission or a clinical dementia rating (CDR) score of 3, was defined as the endpoint for a poor outcome. RESULTS: The mean age was 75.8, and 68.5% were women. The initial Mini-Mental State Examination (MMSE) score was 15.3+/-0.4, and the average duration of follow up was 30.4 months. Fifty-four patients had reached study endpoint at the time of analysis. AD-V (hazard ratio (HR)=3.1, 95% confidence interval (CI)=1.2-8.2), use of psychotropic drugs (HR=2.7, 95% CI=1.1-6.4), and initial MMSE score (HR=0.9, 95% CI=0.8-1.0) were independent predictors of poor outcome in the Cox regression model. CONCLUSION: In AD, co-occurrence of CI with distribution and severity as defined in the NINDS-AIREN neuroimaging criteria for VaD is associated with faster dementia progression.

Low-molecular-weight heparin compared with aspirin for the treatment of acute ischaemic stroke in Asian patients with large artery occlusive disease: a randomised study.

BACKGROUND: Acute stroke patients with large artery occlusive disease (LAOD) have a distinct pathophysiology and may respond differently to anticoagulation treatments. We compared the efficacy of a low-molecular-weight heparin (LMWH), nadroparin calcium, with aspirin in Asian acute stroke patients with LAOD. METHODS: Acute ischaemic stroke patients with onset of symptoms less than 48 h and LAOD (diagnosed by transcranial doppler imaging, carotid duplex scan, or magnetic resonance angiography) were recruited. Patients were randomly assigned to receive either subcutaneous nadroparin calcium 3800 anti-factor Xa IU/0.4 mL twice daily or oral aspirin 160 mg daily for 10 days, and then all received aspirin 80-300 mg once daily for 6 months. This study is registered at www.strokecenter.org/trials (number 493). FINDINGS: Among 603 patients recruited, 353 (180 LMWH, 173 aspirin) had LAOD (300 had intracranial LAOD only, 42 had both intracranial and extracranial disease, and 11 had extracranial disease only). The proportion of patients with good outcomes at 6 months (Barthel index >or=85) was 73% in the LMWH group and 69% in the aspirin group (absolute risk reduction 4%; 95% CI -5 to 13). Analysis of prespecified secondary outcome measures showed a benefit in outcome for LMWH versus aspirin on the modified Rankin scale dichotomised at 0-1 (odds ratio 1.55, 95% CI 1.02-2.35). Haemorrhagic transformation of infarct and severe adverse events were similar in both groups. Post-hoc analyses of patients without LAOD, and all treated patients, showed similar proportions with a good outcome in aspirin and LMWH groups (78%vs 79% and 73%vs 75%, respectively). INTERPRETATION: Overall, the results do not support a significant benefit of LMWH over aspirin in patients with LAOD. The benefits indicated in most outcome measures warrant further investigation into the use of anticoagulation for acute stroke in patients with large artery atherosclerosis, particularly in intracranial atherosclerosis.

Topiramate for migraine prophylaxis among Chinese population.

We evaluated the efficacy and safety of topiramate for migraine prophylaxis among Chinese patients in a multicenter prospective observational study. We found that topiramate at low doses was effective in preventing migraine headache in Chinese patients and was generally well tolerated. There was no difference in baseline headache frequency or intensity between responders and nonresponders.

A novel mutation (C271F) in the Notch3 gene in a Chinese man with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.

BACKGROUND: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an adult-onset hereditary condition caused by mutations in the Notch3 gene. A Chinese man was studied. METHOD: Electronic microscopy examination of skin biopsy. The Notch3 gene was screened for mutations by polymerase chain reaction and direct DNA sequencing. RESULTS: Electronic microscopy showed the presence of deposits of granular osmiophilic material in dermal capillaries in the index patient. A novel heterozygous C271F in exon 6 was detected in the index patient. This heterozygous C271F mutation was also detected in the asymptomatic elder son but was not detected in the asymptomatic wife of the patient. Allele specific amplification showed that C271F was not detected in 100 normal subjects. CONCLUSION: We established the molecular basis of CADASIL in a Chinese man. Mutation detection assay provides a reliable method for confirming the diagnosis of CADASIL.

The effects of disease severity, use of corticosteroids and social factors on neuropsychiatric complaints in severe acute respiratory syndrome (SARS) patients at acute and convalescent phases.

OBJECTIVE: To evaluate the effects of disease severity, corticosteroids and social factors on neuropsychiatric complaints in severe acute respiratory syndrome (SARS) patients, both during acute and convalescent phases. SUBJECTS AND METHODS: Self-administered mail questionnaires survey to 308 SARS patients after discharging from hospital. Both patients and their families were asked about symptoms related to various neuropsychiatric domains, and the questions covered both acute and convalescent phases. RESULTS: Among the 102 (33%) valid replies, 65% had strong symptoms in convalescent phase as indicated by GHQ28 score >/= 5. In multiple linear regression analysis, use of pulse steroid and total dosages of pulse steroid during hospitalisation were predictive for anxiety-depression, psychosis and behavioural symptoms in acute phase, the effects persisted in convalescent phase. Disease severity had direct correlation with symptoms in all neuropsychiatric domains at acute phase and anxiety-depression and cognition at convalescent phase. Health care workers had more neuropsychiatric complaints in both phases. Severity of symptoms, corticosteroids and social factors explained about half of the variances (R(2) = 52) in anxiety-depression at acute phase and 33% at convalescent phase. CONCLUSION: Severe disease, high dose corticosteroids and being health care workers were independent predictors of neuropsychiatric complaints in both acute and convalescent phases.

Adjustment outcomes in Chinese patients following one-month recovery from severe acute respiratory syndrome in Hong Kong.

This study aimed to examine the short-term adjustment outcomes including distress, self-esteem, and quality of life among Chinese patients after 1-month recovery from severe acute respiratory syndrome (SARS) in Hong Kong and to investigate the predictive abilities of a set of selected variables on the outcomes. At 1-month recovery, 100 SARS survivors (mean age = 37; 66 women) and 184 community subjects completed self-administered questionnaires. In the General Health Questionnaire-28, 61% of the SARS survivors were identified as distressed cases under a conservative cutoff score of 6. Compared with the community sample, SARS survivors had significantly more distress and poor quality of life. Being a healthcare worker, severity of SARS symptoms, steroid dosage, and social support accounted for a portion of variances of different measures. Early psychiatric screening and intervention may be beneficial for the adjustment of SARS survivors after short-term recovery. Future research on the long-term impact of SARS is recommended.