Large Culprit Plaque and More Intracranial Plaques Are Associated with Recurrent Stroke: A Case-Control Study Using Vessel Wall Imaging.

BACKGROUND AND PURPOSE: Intracranial atherosclerotic plaque features are potential factors associated with recurrent stroke, but previous studies only focused on a single lesion, and few studies investigated them with perfusion impairment. This study aimed to investigate the association among whole-brain plaque features, perfusion deficit, and stroke recurrence. MATERIALS AND METHODS: Patients with ischemic stroke due to intracranial atherosclerosis were retrospectively collected and categorized into first-time and recurrent-stroke groups. Patients underwent high-resolution vessel wall imaging and DSC-PWI. Intracranial plaque number, culprit plaque features (such as plaque volume/burden, degree of stenosis, enhancement ratio), and perfusion deficit variables were recorded. Logistic regression analyses were performed to determine the independent factors associated with recurrent stroke. RESULTS: One hundred seventy-five patients (mean age, 59 [SD, 12] years; 115 men) were included. Compared with the first-time stroke group (n = 100), the recurrent-stroke group (n = 75) had a larger culprit volume (P = .006) and showed more intracranial plaques (P < .001) and more enhanced plaques (P = .003). After we adjusted for other factors, culprit plaque volume (OR, 1.16 per 10-mm3 increase; 95% CI, 1.03-1.30; P = .015) and total plaque number (OR, 1.31; 95% CI, 1.13-1.52; P < .001) were independently associated with recurrent stroke. Combining these factors increased the area under the curve to 0.71. CONCLUSIONS: Large culprit plaque and more intracranial plaques were independently associated with recurrent stroke. Performing whole-brain vessel wall imaging may help identify patients with a higher risk of recurrent stroke.

Assessing sexual dysfunction among stroke survivors and barriers to address this issue by physicians at a Latin American reference hospital.

BACKGROUND: Sexual dysfunction affects at least one half of patients after a stroke. Problems related to sexual function are rarely assessed or addressed by physicians. OBJECTIVE: To determine the frequency and factors associated with sexual dysfunction among stroke survivors and self-reported barriers of physicians to discuss sexual dysfunction during regular consultation. METHODS: We administered a questionnaire to a cross-sectional sample of stroke survivors to assess the frequency and factors associated with sexual dysfunction and the aspects of sexuality most commonly affected by stroke in a reference hospital in Peru. A qualitative approach was used to determine the willingness to address sexual issues and related barriers among neurology physicians participating in the study. RESULTS: Among 150 patients, sexual dysfunction was identified in 89 (59%). Only 10% self-reported their sexual function as optimal. Markedly decreased frequency of sexual encounters (49%) and markedly decreased sexual desire (33%) were the aspects of sexual function most commonly reported by patients after a stroke. Fear of having a new stroke [OR:3.2, 95% CI (1.5-6.3)], depression [OR:2.1, 95% CI (1.0-4.3)], and self-perception of having impaired motor function [OR:2.5, 95% CI (1.2-5.0)] were significantly associated with sexual dysfunction. In the qualitative assessment of physicians (N = 15), when asked how often they addressed sexual aspects during regular consultation with a stroke survivor, none answered "very often", and only 8 (51%) answered "sometimes". At the end of the study, 10 (66%) physicians verbalized the perception that addressing this issue encouraged their patents to be more open to personal concerns and prompted a stronger doctor-patient relationship. CONCLUSION: Sexual dysfunction affected more than a half of stroke survivors, and was significantly associated with depression, fear of having a new stroke, and with the self-perception of impaired motor function. Addressing sexual issues during the regular consult by physicians was infrequent. Barriers reported by physicians included limited time during regular consultation and the belief that this issue should be addressed under the scope of other specialties.

Seizures after decompressive hemicraniectomy for ischaemic stroke.

OBJECTIVE: The risk of seizures after malignant middle cerebral artery (MCA) infarction with decompressive hemicraniectomy (DHC) is uncertain. Also unknown is how this complication influences survivors' recovery and quality of life. METHODS: We retrospectively reviewed medical charts of all patients admitted to Harborview Medical Center between 1 January 2002 and 31 June 2011 for space-occupying MCA ischaemic stroke and who underwent DHC. Survivors and their surrogates were invited to participate in a telephone or in-person interview. RESULTS: Fifty-five patients were followed for a median of 311 days (IQR 134-727). Twenty-seven patients (49%) had seizures, 25 (45%) developed epilepsy and 21 (38%) achieved moderate disability or better (modified Rankin Scale score ≤3) by 1 year after stroke onset. The only factor significantly associated with seizure occurrence was male gender. Median time from stroke to first seizure was 222 days, with a cluster of first seizures within weeks after cranioplasty; only two of the first seizures occurred right around the time of stroke onset. Follow-up time was significantly longer for patients with seizures (605 days, IQR 297-882) than for those without (221 days, IQR 104-335). Of the 20 patients interviewed, 12 achieved moderate disability or better, 15 experienced a seizure with 6 indicating the seizure was a major drawback. Regardless, all 20 would have chosen DHC again. CONCLUSIONS: In this case series, patients were at high risk of developing seizures after malignant MCA stroke with DHC, especially after cranioplasty. Assuming these findings are replicated, means should be sought to reduce the occurrence of this complication.

Vascular events, mortality, and preventive therapy following ischemic stroke in the elderly.

BACKGROUND: The authors studied mortality, vascular events, and preventive therapies following ischemic stroke among adults aged > or =65 years. METHODS: The authors identified 546 subjects with first ischemic stroke during 1989 to 2001 among Cardiovascular Health Study participants. Deaths, recurrent strokes, and coronary heart disease (CHD) events were identified over 3.2 years (median) follow-up. RESULTS: During the first year of follow-up, rates were 105.4/1,000 for recurrent stroke and 59.3/1,000 for CHD. After the first year, the stroke rate was 52.0/1,000 and the CHD rate was 46.5/1,000. Cardioembolic strokes had the highest mortality (185.4/1,000) and recurrence rates (86.6/1,000). Lacunar strokes had the lowest mortality (119.3/1,000) and recurrence rates (43.0/1,000). Age and male sex predicted death and CHD, but not recurrence. Outcomes did not differ by race. Following stroke, 47.8% used aspirin and 13.5% used other antiplatelet agents; 52.6% of patients with atrial fibrillation used warfarin; 31.3% of hyperlipidemic subjects, 57.0% of diabetic patients, and 81.5% of hypertensive patients were drug-treated; and 40.0% of hypertensive patients had blood pressure (BP) <140/90 mm Hg. Older subjects were less likely to use lipid-lowering therapy, women were less likely to have BP <140/90 mm Hg, and low-income subjects were less likely to use diabetes medications. CONCLUSIONS: Recurrent strokes were nearly twice as frequent as coronary heart disease (CHD) events during the first year after initial stroke, but stroke and CHD rates were similar after the first year. Preventive drug therapies were underused, which may reflect clinical uncertainty due to the lack of clinical trials among the elderly. Utilization was lower among the oldest patients, women, and low-income individuals.

Association of cholesterol with stroke risk varies in stroke subtypes and patient subgroups.

OBJECTIVE: To perform a health maintenance organization-based case-control study to evaluate the association of total and high density lipoprotein (HDL) cholesterol with the risk of stroke subtypes and in patient subgroups. METHODS: Cases had a confirmed incident ischemic stroke (n = 1,242) or hemorrhagic stroke (n = 313). Controls (n = 6,455) were identified in a companion myocardial infarction study. Risk of stroke was modeled using logistic regression. RESULTS: The highest total cholesterol quintile was associated with an increased risk of ischemic stroke compared to the lowest quintile (OR = 1.6, 95% CI 1.3 to 2.0) with the strongest subtype associations for atherosclerotic stroke (OR = 3.2) and lacunar stroke (OR = 2.4). The highest HDL cholesterol quintile was associated with a decreased risk of ischemic stroke compared to the lowest quintile (OR = 0.8, CI 0.6 to 1.0). Subgroup analyses suggested that the total cholesterol association was more important for patients < 66 years of age and those with HDL < 50 mg/dL; the HDL association was more important for patients without diabetes or atrial fibrillation. The second through fourth total cholesterol quintiles were associated with a decreased risk of hemorrhagic stroke compared to the lowest quintile (OR = 0.7, CI 0.5 to 1.0). CONCLUSIONS: Higher total and lower HDL cholesterol levels were associated with increased risk of ischemic stroke, especially certain stroke subtypes and patient subgroups. The lowest levels of total cholesterol were associated with an increased risk of all hemorrhagic strokes.

Will neurology residents with large student loan debts become academicians?

Medical education in the United States is expensive, with 4-year tuition at some institutions totaling more than 150,000 US dollars. Most US graduates have student debt burdens. Using an internet survey, we tested the hypothesis that high student debt adversely affects neurology residents' desire to pursue careers in academic neurology. The results indicate median year 2000 US graduate neurology resident student debt is in the 50,000 to 75,000 US dollars range and that this debt burden may deter US graduates from pursuing careers in academic neurology.

Intra-arterial urokinase for acute ischemic stroke: factors associated with complications.

The authors abstracted the records of 43 patients treated with intra-arterial urokinase for acute ischemic stroke to identify predictors of serious complications. Sixteen (37%) had such a complication. Higher urokinase dose (>1.5 x 10(6) U), higher mean arterial blood pressure before treatment (>130 mm Hg), basilar occlusive strokes, and severe strokes were most predictive of these complications. Although urokinase is no longer manufactured, these findings identify patients at risk for complications from other intra-arterial thrombolytics.

Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies.

BACKGROUND: Withdrawal of support in patients with severe brain injury invariably leads to death. Preconceived notions about futility of care in patients with intracerebral hemorrhage (ICH) may prompt withdrawal of support, and modeling outcome in patient populations in whom withdrawal of support occurs may lead to self-fulfilling prophecies. METHODS: Subjects included consecutive patients with supratentorial ICH. Radiographic characteristics of the hemorrhage, clinical variables, and neurologic outcome were assessed. Attitudes about futility of care were examined among members of the departments of neurology and neurologic surgery through a written survey and case presentations. RESULTS: There were 87 patients with supratentorial ICH; overall mortality was 34.5% (30/87). Mortality was 66.7% (18/27) in patients with Glasgow Coma Score < or = 8 and ICH volume > 60 cm(3). Medical support was withdrawn in 76.7% (23/30) of patients who died. Inclusion of a variable to account for the withdrawal of support in a model predicting outcome negated the predictive value of all other variables. Patients undergoing surgical decompression were unlikely to have support withdrawn, and surgery was less likely to be performed in older patients (p < 0.01) and patients with left hemispheric hemorrhage (p = 0.04). Survey results suggested that practitioners tend to be overly pessimistic in prognosticating outcome based upon data available at the time of presentation. CONCLUSIONS: The most important prognostic variable in determining outcome after ICH is the level of medical support provided. Withdrawal of support in patients felt likely to have a "poor outcome" biases predictive models and leads to self-fulfilling prophecies. Our data show that individual patients in traditionally "poor outcome" categories can have a reasonable neurologic outcome when treated aggressively.

Somatosensory potentials, CSF creatine kinase BB activity, and awakening after cardiac arrest.

OBJECTIVE: To examine the utility of somatosensory evoked potential (SEP) peaks and CSF creatine kinase BB isoenzyme activity (CKBB) in predicting nonawakening from coma due to cardiac arrest. BACKGROUND: Accurate predictors of neurologic outcome in patients comatose after cardiac arrest are needed to improve medical decision making. METHODS: A total of 72 comatose patients had bilateral median SEPs, and of these, 52 had CSF and CKBB. Awakening was defined as following commands or having comprehensible speech. Both short (N1) and long (N3) latency SEP peaks were analyzed. Nonparametric analyses were used. RESULTS: For patients who had both tests, CKBB > or = 205 U/L predicted nonawakening with a sensitivity of 49% and a specificity of 100%. Bilateral absence of the N1 peak predicted nonawakening with a sensitivity of 53% and a specificity of 100%. Using CKBB > or = 205 U/L, bilaterally absent SEP N1 peaks, or both predicted nonawakening with a sensitivity of 69% and a specificity of 100%. Using CKBB > or = 205 U/L, bilaterally absent N1 peaks, bilateral N3 > or = 176 msec or absent, or some combination predicted nonawakening with a sensitivity of 78% and a specificity of 100%. CONCLUSION: The combination of an absent N1 peak and elevated CKBB performs better than either alone in predicting nonawakening after cardiac arrest. Prolonged or absent N3 latency may increase sensitivity. These results should be interpreted with caution given the small number of patients and the possibility of a self-fulfilling prophecy.

Extravasation of radiographic contrast is an independent predictor of death in primary intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Hematomas that enlarge following presentation with primary intracerebral hemorrhage (ICH) are associated with increased mortality, but the mechanisms of hematoma enlargement are poorly understood. We interpreted the presence of contrast extravasation into the hematoma after CT angiography (CTA) as evidence of ongoing hemorrhage and sought to identify the clinical significance of contrast extravasation as well as factors associated with the risk of extravasation. METHODS: We reviewed the clinical records and radiographic studies of all patients with intracranial hemorrhage undergoing CTA from 1994 to 1997. Only patients with primary ICH were included in this study. Univariate and multivariate logistic regression analyses were performed to determine the associations between clinical and radiological variables and the risk of hospital death or contrast extravasation. RESULTS: Data were available for 113 patients. Contrast extravasation was seen in 46% of patients at the time of CTA, and the presence of contrast extravasation was associated with increased fatality: 63.5% versus 16.4% in patients without extravasation (P=0.011). There was a trend toward a shorter time (median+/-SD) from symptom onset to CTA in patients with extravasation (4.6+/-19 hours) than in patients with no evidence of extravasation (6.6+/-28 hours; P=0.065). Multivariate analysis revealed that hematoma size (P=0.022), Glasgow Coma Scale (GCS) score (P=0.016), extravasation of contrast (P=0.006), infratentorial ICH (P=0.014), and lack of surgery (P<0.001) were independently associated with hospital death. Variables independently associated with contrast extravasation were hematoma size (P=0.024), MABP >120 mm Hg (P=0.012), and GCS score of

Medical complications of ischemic stroke and length of hospital stay: experience in Seattle, Washington.

BACKGROUND: Medical complications of ischemic stroke can increase length of hospital stay (LOS). Stroke clinical pathways aim to reduce costs by decreasing LOS through standardization of care and avoidance of complications. MATERIALS AND METHODS: Using a population-based, state-mandated, hospital discharge database, we sought to analyze the effects of common medical complications of incident ischemic stroke on LOS in Seattle, Washington from 1990 to 1994. All nonstroke medical complications listed in the discharge diagnoses with a 5% or greater frequency were entered with age and gender into linear regression models. LOS was the dependent variable. RESULTS: The inclusion criteria was met by 4,757 hospitalizations. Congestive heart failure (9.5%), urinary tract infection (9.3%), pneumonia (7.1%), age (mean, 75), and gender (57% female) were all entered into the linear regression models. The presence of congestive heart failure was associated with an increased LOS of 24% (15% to 33%), urinary tract infection of 41% (31% to 51%), and pneumonia of 52% (40% to 65%). Multiplying the increases in LOS by the prevalence of the complications led to estimated LOS savings of 9.8% (7.1% to 12.4%). Pneumonia was associated with an odds ratio of 3.7 (2.8 to 4.8), congestive heart failure 2.0 (1.5 to 2.6), and urinary tract infection 0.6 (0.4 to 0.8) for hospital fatality. CONCLUSIONS: Each complication was associated with large and significant increases in the LOS. The potential LOS savings in these patients may be 10%, if all such complications could be avoided. Associations with increased LOS and risk of in-hospital death indicate a strong need to continue to avoid such medical complications of ischemic stroke.

Cerebrospinal fluid creatine kinase BB isoenzyme activity and neurologic prognosis after cardiac arrest.

OBJECTIVE: To assess the relationship between CSF creatine kinase BB isoenzyme activity (CSF CKBB) and neurologic outcome after cardiac arrest in clinical practice. BACKGROUND: CSF CKBB reflects the extent of brain damage following cardiac arrest. METHODS: To help with prognosis, treating physicians ordered CSF CKBB tests on 474 patients over 7.5 years; 351 of these patients had experienced a cardiac arrest. Assays were performed in one laboratory using agarose electrophoresis. By chart review, we determined awakening status for all patients, defined as the patient having comprehensible speech or following commands. RESULTS: CSF CKBB was usually sampled 48 to 72 hours after cardiac arrest and was strongly associated with awakening (p < < 0.001). The median was 4 U/l for 61 patients who awakened and 191 U/l for 290 who never awakened. For those who awakened, 75% of CKBB levels were < 24 U/l, and for those who never awakened, 75% were > 86 U/l. The highest value in a patient who awakened was 204 U/l, a cutoff that yielded a specificity of 100% of never awakening but a sensitivity of forty-eight percent. Only nine patients who awakened had CSF CKBB values greater than 50 U/l, and none regained independence in activities of daily living. Only three unconscious patients were still alive at last contact, with follow-up of 63, 107, and 109 months. Using logistic regression, the probability of never awakening given a CSF CKBB result can be estimated as: 1/(1 + L), where L = e raised to (0.1267 - 0.0211 x CSF CKBB [U/l]). CONCLUSION: CSF CKBB measurement helps to estimate degree of brain damage and thus neurologic prognosis after cardiac arrest. However, results of this retrospective study could reflect in part a self-fulfilling prophecy.

Laterality of appendicular tardive dyskinesia in chronic schizophrenia.

The notion that the neuropathology of schizophrenia is lateralized is supported, in part, by findings of asymmetries in tardive dyskinesia (TD). To verify the existence of asymmetric TD, this study used the AIMS examination to look for lateralization of limb movements in a sample of 58 patients with TD. Patients with schizophrenia were compared with patients with affective and schizoaffective disorders. Asymmetry was seen in the majority of patients, regardless of psychiatric diagnosis. There was no preference for one side over the other. In a subgroup of 16 patients rates repeatedly over 13 weeks, the presence and sidedness of asymmetry fluctuated. At least four ratings were needed to accurately predict the presence and sidedness of "persistent" asymmetry. This study does not support the notion that there is a consistent, lateralized asymmetry of TD in patients with schizophrenia. Moreover, it raises questions about the reliability of assessment of persistent laterality in TD using a single exam.