Ethics, family caregivers, and stroke

Even though stroke caregivers provide valuable care to loved ones, often sacrificing their own life goals and sometimes their health, they are frequently viewed by stroke professionals as irritants or problems. Medical training and medical bioethics literature focus almost exclusively on the physician-patient relationship, which leaves family members with uncertain standing. A family-centered approach allows providers to acknowledge and respect caregivers' needs without sacrificing patients' interests or authority.     

Leukocytosis in acute stroke: Relation to initial stroke severity, infarct size, and outcome: The copenhagen stroke study.

Leukocytosis is a common finding in the acute phase of stroke. A detrimental effect of leukocytosis on stroke outcome has been suggested, and trials aiming at reducing the leukocyte response in acute stroke are currently being conducted. However, the influence of leukocytosis on stroke outcome has not been clarified. Methods: In 763 unselected patients with stroke admitted within 24 hours from onset, we prospectively studied the relation between leukocyte count and outcome considering relevant confounders and predictors such as initial stroke severity, risk factor profile, body temperature, and infection. Results: Univariate, leukocyte count on admission was significantly related to initial stroke severity (assessed by the Scandinavian Stroke Scale), lesion size on computed tomography, mortality, and outcome in survivors. However, multivariate regression analysis revealed that only the relation between leukocytosis and initial stroke severity was independent of other factors, whereas the relations found univariately between leukocytosis and lesion size, mortality, and outcome in survivors disappeared when initial stroke severity was included in the multivariate model. Conclusion: Leukocytosis on admission was related to initial stroke severity but not to outcome. Leukocyte count on admission seems merely to reflect initial stroke severity and is most likely a stress response with no independent influence on outcome. Our study may suggest that attempts aimed merely at lowering leukocyte count in peripheral circulating blood in the acute phase of stroke cannot be expected to improve outcome.     

The relationship between homocysteine, cognition and stroke subtypes in acute stroke

BACKGROUND: Elevations in plasma homocysteine (Hcy) have been associated with an increased risk of stroke and dementia. The mechanisms underlying these associations remain poorly understood. OBJECTIVES: This study examines the relationships between Hcy, cognition, and stroke subtype. We hypothesize that: 1) Hcy levels are inversely related to cognition, 2) Hcy levels are unrelated to stroke subtype, and 3) stroke subtype affects cognition. METHODS: We studied 169 consenting patients admitted for acute stroke during a 4 month period. Blood was drawn for Hcy levels and the Mini-Mental State Examination (MMSE) was administered within 9 days of admission. The Oxfordshire Community Stroke Project Classification was used to characterize stroke subtypes. Correlation between Hcy and MMSE scores was examined as was the relationships between Hcy and stroke subtype, and between stroke subtypes and MMSE scores. RESULTS: A significant inverse correlation between Hcy levels and MMSE scores was demonstrated (r=-0.243, p=0.001). MMSE scores also differed according to the type of stroke, with Total or Partial Anterior Circulation Infarcts (TACI/PACI) scoring lowest (F=8.77, df=2, p<0.001). Hcy levels did not differ between the various stroke subtypes (F=0.21, df=2, p=0.81). Multivariate linear regression analysis showed that age, education, and stroke subtype, but not Hcy, were independent predictors of acute MMSE scores. CONCLUSIONS: In this study sample, there was an inverse relationship between Hcy and cognition in acute stroke patients. However, Hcy was not an independent predictor for cognition in acute stroke after other factors such as stroke subtype and patient age were taken into account. These results suggest that during the acute stage of stroke, stroke subtype is a more important factor in determining cognition than Hcy levels.     

卒中类型、卒中部位与卒中后癫痫的多因素关系

目的探讨卒中类型、卒中部位与卒中后癫痫的多因素关系,为卒中后癫痫的防治提供参考。方法以1804例卒中患者为研究对象,收集其性别、年龄、卒中类型、卒中部位、卒中后癫痫发生的时间等资料,根据卒中后是否发生癫痫,将患者分为卒中后无癫痫组(n=1487)和卒中后癫痫组(n=317),分析卒中后癫痫发作的危险因素。结果共317例卒中后癫痫发作患者,其中早发性癫痫141例(44.48%),迟发性癫痫176例(55.52%)。不同卒中部位及卒中类型的癫痫发病率为17.57%。多因素logistic回归分析显示,卒中部位中的顶叶合并蛛网膜下腔、额叶合并颞叶、额叶合并颞叶和枕叶、单一颞叶是卒中后发生癫痫的危险因素(P<0.01),其中单一颞叶是卒中后早发性癫痫的危险因素(P<0.01)。脑梗死患者常见早发性癫痫(23.66%),脑出血患者常见迟发性癫痫(47.95%)。结论卒中类型中的脑梗死、脑出血、蛛网膜下腔出血与卒中后癫痫有关;卒中部位中顶叶合并蛛网膜下腔、额叶合并颞叶、额叶合并颞叶和枕叶、单一颞叶与卒中后癫痫有关。     

Diabetes, hyperglycaemia, and acute ischaemic stroke

Diabetes and ischaemic stroke often arise together. People with diabetes have more than double the risk of ischaemic stroke after correction for other risk factors, relative to individuals without diabetes. Multifactorial treatment of risk factors for stroke-in particular, lifestyle factors, hypertension, and dyslipidaemia-will prevent a substantial number of these disabling strokes. Hyperglycaemia occurs in 30-40% of patients with acute ischaemic stroke, also in individuals without a known history of diabetes. Admission hyperglycaemia is associated with poor functional outcome, possibly through aggravation of ischaemic damage by disturbing recanalisation and increasing reperfusion injury. Uncertainty surrounds the question of whether glucose-lowering treatment for early stroke can improve clinical outcome. Achievement of normoglycaemia in the early stage of stroke can be difficult, and the possibility of hypoglycaemia remains a concern. Phase 3 studies of glucose-lowering therapy in acute ischaemic stroke are underway.     

TIA, stroke, and mitral valve prolapse

Eight patients with transient ischemic attacks, and three with partial nonprogressive strokes associated with mitral valve prolapse, are reported. No other etiology for their ischemic events was found. Only one episode of ischemia recurred on aspirin treatment, whereas none recurred on sodium warfarin therapy.     

Atrial size, atrial fibrillation, and stroke

M-mode and two-dimensional echocardiographic images were reviewed retrospectively in 20 patients with atrial fibrillation and ischemic stroke with no known valvular disease and in 20 patients with atrial fibrillation without known stroke. Left atrial size was measured and analyzed without knowledge of patient grouping. Two-dimensional echocardiography showed that 90% of the stroke patients had left atrial enlargement compared with only 20% in the nonstroke group. This finding suggests that left atrial enlargement may convey additional stroke risk in patients with atrial fibrillation.     

Turner's syndrome, fibromuscular dysplasia, and stroke

We report a 43-year-old woman who presented with a right frontoparietotemporal ischemic stroke. She had been diagnosed with Turner's syndrome during childhood and had a history of chronic estrogen therapy. Cerebral angiography showed lesions characteristics of fibromuscular dysplasia involving the right internal carotid and right vertebral arteries. We are not aware of any previous reports describing an association between fibromuscular dysplasia and Turner's syndrome. Although chronic estrogen therapy cannot be ruled out as a cause of this patient's stroke, we suggest a possible etiologic relation between these two entities.