Computed tomographic changes of the brain and clinical outcome of patients with seizures and epilepsy after an ischaemic hemispheric stroke.

It is not well established whether seizures and epilepsy after an ischaemic stroke increase the disability of patients. Seventy-two patients with delayed seizures after a hemispheric infarct (37 with a single seizure and 35 with epilepsy) were included in the study. The modified Rankin scale was used to compare disability of the patients at 1 month after stroke and at 2 weeks after single or the last seizure, in case of epilepsy. The size of the X-ray hypoattenuation zone was compared on computed tomographic (CT) scans, performed in the weeks after the stroke and 1 week after single or repeated seizures. Lesion size was determined by superimposing the CT slices on digital cerebral vascular maps, on which the contours of the infarct area were delineated. The extent of the infarcts was expressed as the percentage fraction of the total surface area of the cerebral hemisphere. Groups with a single seizure and with epilepsy were mutually compared. Infarcts predominated in the parieto-temporal cortical regions. In the overall group the median Rankin score worsened significantly after seizures. The average size of the X-ray hypoattenuation zone was also significantly increased on the CT scans after the seizures, compared with those after stroke, without clear evidence of recent infarction. Mutual comparison of patients with a single seizure episode and of those with epilepsy showed only a trend of more severe disability and of increase in lesion size in the post-stroke epilepsy group. Delayed seizures and epilepsy after ischaemic stroke are accompanied by an increase in lesion size on CT and by worsening of the disability of the patients. This study does not allow to determine whether this is due to stroke recurrence or due to additional damage as a result of the seizures themselves.     

Comparison of Asymmetry in Cerebral Blood Flow Between Brain Hemispheres Using Digital Subtraction Angiography

BACKGROUND AND PURPOSE: Recently, endovascular techniques have gained significant therapeutic potential for both treatment and prevention of stroke. Cerebral angiography, which is an essential component of these procedures, has been used to provide morphological information regarding condition of blood vessels. In this study, we propose to determine the possibility of acquiring information regarding cerebral blood flow (CBF) in addition to morphologic information from data routinely available during angiography. METHODS: Digital subtraction angiography sequences were obtained for eight patients having occlusive disease in internal carotid artery (ICA) territories. Two regions-of-interest (ROIs) corresponding to the two brain hemispheres on AP view were delineated. For each image, the average pixel value within each ROI was calculated and used to generate time-density curves. Indices obtained from each curve were compared with each other and with the results obtained from the single photon emission computed tomography (SPECT) studies performed a pre- or postangiography procedure. RESULTS: Comparison between ICA stenosis and cerebral perfusion measurements revealed that cerebral perfusion deficit can be independent of arterial occlusive disease. The indices obtained from the time-density curves exhibit a correlating trend with the results from SPECT studies. However, lack of sufficient sample data prevented any meaningful statistical analysis to be conducted. CONCLUSIONS: We have developed a technique for utilizing the angiographic data for the important task of routinely and easily measuring CBF. Availability of CBF measurements during cerebral angiography may favorably impact upon the appropriate use of endovascular procedures and potentially contribute to the reduction of morbidity and mortality associated with stroke.     

醒脑静注射液治疗缺血性中风急性期随机对照试验的系统评价

目的 系统评价醒脑静注射液治疗缺血性中风急性期的疗效及安全性。方法 集醒脑静注射液治疗缺血性中风急性期随机对照试验文献，筛选合格研究，应用Jadad评分法进行质量评价，运用异质性检验、Meta-分析、漏斗图分析、敏感性分析等方法统计相关数据。结果 项研究符合纳入标准，Jadad评分所有研究得分均低于3分，属低质量文献。Meta-分析结果显示，总有效率比较的相对危险度（RR值）=1．04，99％的可信区间（CI值）为（0．88，1．23）。结论 前尚无充分证据证实醒脑静注射液治疗缺血性中风急性期的疗效及安全性。要进一步验证醒脑静注射液治疗缺血性中风急性期的疗效及安全性，尚需进行设计合理、执行严格、多中心大样本且随访时间足够的随机对照试验。     

Inflammatory biomarkers in blood of patients with acute brain ischemia

Although many failed surrogate markers are provided in the literature, inflammation may contribute to the outcome of ischemic stroke. In 50 consecutive patients with acute ischemic stroke, in the absence of symptoms and signs of concomitant infection, we evaluated a panel of biomarkers reported to be variably associated with brain ischemia, and correlate their serum level with the brain lesion volume and clinical outcome. Infarct size was calculated on computed tomography (CT) scans by means of the Cavalieri's method. Neurological impairment was scored by using the Glasgow Coma Scale, Glasgow Outcome Scale and National Institutes of Health (NIH) scales at stroke onset and 3-month follow-up. Some markers showed a direct significant correlation with both initial and final NIH scale and with infarct size, particularly tumor necrosis factor alpha (TNF-alpha) (P=0.002), intercellular adhesion molecule-1 (P<0.01) and matrix metalloproteinase-2/9 (P=0.001). In contrast to previous reports, interleukin-6 (IL-6) serum level showed a significant inverse correlation with both final neurological impairment and infarct size (P<0.001). This novel finding allows us suggesting that IL-6, in the context of a complex pro-inflammatory network occurring during stroke, is associated with neuroprotection rather than neurotoxicity in patients with ischemic brain injury.     

Effective pulmonary blood flow in children with acute asthma attack requiring hospitalization

In children with acute obstructive lung disease gas exchange is affected by ventilation-perfusion mismatch and the degree of bronchoconstriction. Standard lung function measurements do not reflect the impairment in gas exchange. Alternatively, the effective pulmonary blood flow (EPBF), that is, the proportion of the cardiac output that is supplying well-ventilated lung units, can give accurate and noninvasive estimates of ventilation-perfusion mismatch. We measured EPBF with the argon freon ?22 rebreathing technique in children with acute severe asthma to assess their response to nebulized salbutamol and to determine whether induced changes in the EPBF could be predicted from baseline measurements. Twenty-four children admitted with an acute asthma attack had spirometry and triplicate EPBF measurements before and after nebulized salbutamol. Eighteen patients had repeated tests 50 days later when fully recovered; 4 patients were taking methylxanthines on at least one occasion. The mean forced expiratory volume in 1 sec (FEV₁) rose from 55% of predicted to 66% after salbutamol and to 83% with recovery. The mean coefficients of variation for EPBF measurements on the three test occasions were 11.3%, 8.2%, and 9%. Except in children on methylxanthines, the EPBF values were reduced during the acute asthma attack (median, 2.53 L/min/m²; range, 1.99–3.60 L/min/m²) compared with paired values obtained after recovery (median, 2.89 L/min/m²; range, 2.2Eb4.04 L/min/m²) (P = 0.009). Salbutamol caused a highly significant increase in EPBF from 2.88 L/min/m² (range, 1.86–3.80) before treatment to 3.34 L/min/m² (range, 2.264.65) immediately afterwards (P = 0.0003). The spirometric indices did not relate to the changes in the EPBF values. However, when the effective stroke volume index was calculated in 11 patients, the changes induced by nebulized salbutamol had a significant inverse relation with the pretreatment FEV, (P = 0.61; P = 0.02). In conclusion, the argon freon-22 rebreathing technique can be used successfully and reproducibly to measure EPBF in children with an acute asthma attack. Except in children taking methylxanthines, EPBF during the acute attack is reduced and rises significantly after salbutamol. EPBF values after recovery were significantly higher than the presalbutamol values during the attack. Spirometric indices do not relate to the EPBF changes but are inversely related to the effective stroke volume changes. Pediatr Pulmonol. 1994; 17:370–377. © 1994 Wiley-Liss, Inc.     

有训练者和无训练者的心功能和无氧阈的关系

本文观察了10名游泳运动员和10名实验室工作人员在递增负荷运动中心功能的变化及其与无氧阈的关系.结果为:(1)游泳队员的无氧阈值明显高于无训练的实验室工作人员;(2)运动中每搏量稳定时的强度与无氧阈强度是密切相关的;(3)运动至无氧阈强度以后,心输出量的增加主要靠心率的增加来维持;(4)无训练者在运动一开始就动用心力储备,增加心率和每搏量,而游泳队员则在运动至40W以后才开始增加心率和每搏量.这些结果表明,无氧阈与心功能具有很密切的关系,可用它来反映心功能的好坏.     

Evaluation of stroke rehabilitation by randomized controlled studies: a review

In all, 22 reports of 20 randomized, controlled rehabilitation studies were evaluated. In 18 of these, the design of the trial was parallel, with a cross-over format being employed in the remaining 2 instances. Seven studies related to intensive rehabilitation during the early post-acute period. In six others, specific techniques--sometimes associated with traditional physiotherapy procedures--were compared: biofeedback, perceptual retraining, and amphetamine treatment. Eight experiments evaluated speech therapy in aphasia. Frequently, methodological considerations limited the interpretation of the results. The review showed that: 1) as regards activities of daily life and motor function, differences as between rehabilitation in stroke units on the one hand and non-rehabilitation or rehabilitation in medical wards on the other, were detected in relatively few quality studies and remained particularly inconclusive insofar as life in the home environment was concerned; 2) rehabilitation for aphasia and perceptual dysfunction proved effective for at least several months after acute stroke; 3) in general, examination of the reports cited revealed no differences in the effects of biofeedback and perceptual retraining vs conventional physiotherapy; 4) rehabilitation, whether administered by specialists or amateur caregivers purpose-trained by specialists, proved equally effective for aphasia. These conclusions constitute a valuable basis for the development and evaluation of modern rehabilitation programs for stroke patients.     

心导纳图和心阻抗图测量心脏泵血功能的比较

对12只开胸狗做心导纳图、阻抗图,测量(dy/dt)_(max),(dy/dt)_(max)/T_(R-y),(dz/dt)_(max)和(dz/dt)_(max)/T_(R_z)。然后改变测量电极间距L和基础阻抗Z,发现前者可引起(dy/dt)_(max)、(dy/dt)_(max)/T_(R-y)的显著变化;后者可引起(dz/dt)_(max)、(dz/dt)_(max)/T_(R-z)非常显著的变化。由心导纳图、阻抗图所得心脏每搏量(SV)与电磁流量计所测SV的相关系数分别为0.691和0.678。提示两法测量心脏泵血功能有相同的可靠性,但前者受L影响较大,后者对Z_0的变化敏感。     

‘Ischemic tolerance’ phenomenon detected in various brain regions

We investigated the effects of mild and non-lethal ischemic insult on neuronal death following subsequent lethal ischemic stress in various brain regions, using a gerbil model of bilateral cerebral ischemia. Single 10-min ischemia consistently caused neuronal damage in the hippocampal CA1, CA2, CA3 and CA4, layer III/IV of the cerebral cortex, dorsolateral part of the caudoputamen and ventrolateral part of the thalamus. On the other hand, in double ischemia groups, 2-min ischemic insult 2 days before 10-min ischemia exhibited significant protection in the CA1 and CA3 of the hippocampus, the cerebral cortex, the caudoputamen and the thalamus. Five-min ischemic insult 2 days before 10-min ischemia also showed protective effect in the same areas as those of 2-min ischemia except for the CA1 region of the hippocampus, while 1-min ischemic insult exhibited no protective effect in any brain regions. In the immunoblot analysis, both 2- and 5-min ischemia caused increased synthesis of heat shock protein 72 (HSP 72) in the hippocampus, but 1-min ischemia did not. The present study demonstrated that the ‘ischemic tolerance’ phenomenon was widely found in the brain and also suggested that ischemic treatment severe enough to cause HSP 72 synthesis might be needed for induction of ‘ischemic tolerance’.     

A Comparison of Depressive Symptoms in Stroke and Primary Care: Applying Rasch Models to Evaluate the Center for Epidemiologic Studies-Depression Scale

OBJECTIVES: Clinical trials and community-based studies often include the Center for Epidemiologic Studies-Depression scale (CES-D) as a measure of depression outcome. We compared responses to symptom-related items on the CES-D by depressed stroke and primary-care patients for several purposes: 1) to illustrate the use of Item Response Theory (IRT)-based (Rasch) models for comparing scale functioning across different patient subgroups; and 2) to inform clinicians and outcome researchers about scale functioning and depressive symptomatology in stroke- compared with primary care-based depression. METHODS: Two data sources were analyzed, including 32 depressed patients who were 3 months poststroke, and 366 depressed primary-care patients. Presence of depression was based on a CES-D score 16 or higher. Rasch models were used to assess item fit and compare item hierarchies between depressed primary-care and stroke patients. RESULTS: Item hierarchies were similar for poststroke depression and primary care-based depression. Interpersonal disruption items were the most difficult to endorse for both groups. No items misfit the scale in primary-care depression. Items relating to restless sleep, unfriendliness, and crying slightly misfit the scale in stroke patients, that is, may measure a different trait. Differential item functioning (DIF) between the groups was identified for items relating to appetite, restless sleep, crying, and feeling disliked. CONCLUSIONS: Results generally supported the use of the CES-D as measure of depression outcome, particularly in primary care-based depression. DIF may imply that slightly different clusters of depressive symptoms are reported by depressed stroke patients compared with primary care, but this is conjectural given the small stroke sample size and the same items have been previously associated with bias in studies of large nonstroke samples. This study found Rasch models to be useful tools to investigate scale performance for different clinical applications.