Intravenous rt-PA for acute stroke: comparing its effectiveness in younger and older patients.

OBJECTIVE: To study the short and long term differences in outcome between patients > or =80 years of age and those < or =79 years of age who received intravenous recombinant tissue plasminogen activator (iv rt-PA) for acute stroke within the first 3 hours of symptom onset. METHODS: We studied consecutive patients treated with iv rt-PA for acute stroke, with prospective follow up of up to 3 years. Outcome measures included National Institutes of Health Stroke Scale (NIHSS) score, Barthel Index (BI), modified Rankin score (MRS), and stroke mortality. Patients were split into two groups: younger (< or =79 years) and older (> or =80 years). RESULTS: There were 65 patients in the younger cohort and 31 patients in the older. Older patients were more likely to present with more severe baseline stroke (p = 0.04; odds ratio (OR) 3.04; 95% confidence interval (CI) 1.03 to 8.98). Stroke mortality at 90 days was 10.8% in the younger and 32.3% in the older cohort (p = 0.01). At 90 days' follow up, patients in the older cohort with more severe stroke (NIHSS score > or =11) were nearly 10 times more likely to have poor outcome compared with their younger counterparts presenting with severe stroke (p = 0.001; OR = 10.36; 95% CI 2.16 to 49.20). Baseline stroke severity and age were the only independent and equal predictors for stroke outcome. No threshold was found for age or baseline stroke severity predicting outcome. CONCLUSION: Older patients presenting with more severe baseline stroke are much less likely to benefit from iv rt-PA as compared with their younger counterparts.

Return of stuttering after stroke.

The pathophysiology of developmental or acquired stuttering still remains an enigma. In a few cases, the developmental stuttering that had disappeared spontaneously or as a result of therapy reoccurred following a brain lesion. We report on a patient with return of developmental stuttering following a left hemispheric stroke. This case supports the theory that acquired brain lesions may cause a return of stuttering, possibly by interfering with the compensatory mechanism(s) that once had relieved the developmental stuttering.

Thoracic aortic surgery.

Between 1982 and 1989, 119 patients had repair of thoracic aortic pathology. Thirty-seven had repair of ascending aortic aneurysms, with an 11% hospital mortality. Forty-one patients had urgent repair of acute type A aortic dissections, with a 32% hospital mortality. The independent predictors of mortality were the use of crystalloid cardioplegia, aortic dissection, and the use of an intraluminal prosthesis or the inclusion surgical technique. Better grafts and the resection technique has reduced mortality since 1986. Seventeen patients had their primary pathology in the aortic arch, with a 47% hospital mortality. The urgency of the procedure and crystalloid cardioplegia predicted an unsuccessful outcome. Seventeen patients had descending aortic aneurysms repaired, with an 18% mortality. The urgency of surgery was the predictor of mortality. Seven patients had a descending thoracic aortic disruption repaired, with one death (14%). Better graft materials, surgical techniques, and methods of myocardial protection have contributed to the improved results of thoracic aortic surgery in recent years.

Generalized convulsions induced by pentylenetetrazol in the cat: participation of forebrain, brainstem, and spinal cord.

The respective capabilities of forebrain, brainstem, and spinal cord to generate seizures in response to intravenous pentylenetetrazol (PTZ) were determined in intact, precollicular, and spinal cord transected (C2-C3) cats. Threshold doses for the induction of generalized EEG seizures were similar, approximately 26 mg/kg, in all groups, but only in intact cats was this associated with generalized clonic convulsions. In cats with precollicular transection, in spite of an unchanged EEG seizure threshold, induction of convulsions required on average 63 mg/kg of PTZ. They consisted of generalized tonic contractions. In cats with spinal cord transection, convulsions began with a mean dose of 167 mg/kg of PTZ. They consisted of bilateral, frequently asynchronous jerks, although tonic contractions were also observed. These experiments show widespread central nervous system (CNS) sensitivity to PTZ, and demonstrate that (a) ictal EEG activity in the forebrain, normally associated with clonic convulsions, may occur independently from brainstem influence; (b) clonic convulsions in intact cats likely originate from the forebrain with little contribution from the brainstem; and (c) the brainstem and spinal cord can induce tonic and predominantly clonic seizures, respectively, at PTZ levels exceeding those required to induce seizures in intact cats.