Progressing haemorrhagic stroke: categories,causes, mechanisms and managements

Haemorrhagic stroke is a severe stroke subtype with high rates of morbidity and mortality. Although this condition has been recognised for a long time, the progressing haemorrhagic stroke has not received adequate attention, and it accounts for an even worse clinical outcome than the nonprogressing types of haemorrhagic stroke. In this review article, we categorised the progressing haemorrhagic stroke into acute progressing haemorrhagic stroke, subacute haemorrhagic stroke, and chronic progressing haemorrhagic stroke. Haematoma expansion, intraventricular haemorrhage, perihaematomal oedema, and inflammation, can all cause an acute progression of haemorrhagic stroke. Specific ‘second peak’ of perihaematomal oedema after intracerebral haemorrhage and ‘tension haematoma’ are the primary causes of subacute progression. For the chronic progressing haemorrhagic stroke, the occult vascular malformations, trauma, or radiologic brain surgeries can all cause a slowly expanding encapsulated haematoma. The mechanisms to each type of progressing haemorrhagic stroke is different, and the management of these three subtypes differs according to their causes and mechanisms. Conservative treatments are primarily considered in the acute progressing haemorrhagic stroke, whereas surgery is considered in the remaining two types.     

The impact of delays in computed tomography of the brain on the accuracy of diagnosis and subsequent management in patients with minor stroke

OBJECTIVES: To determine the proportion of haemorrhagic strokes misdiagnosed as infarcts on computed tomography (CT) in patients with mild stroke, and the implications for health care. METHODS: Patients with mild stroke presenting as inpatients or outpatients four or more days after stroke to our stroke service (catchment population 500 000) were recruited prospectively. They underwent detailed clinical examination and brain imaging with CT and magnetic resonance imaging (MRI) on the day of presentation. CT and MR images were examined independently to identify infarct, primary intracerebral haemorrhage, haemorrhagic transformation, or non-vascular lesion. RESULTS: In 228 patients with mild stroke (median time from stroke to scan 20 days), primary intracerebral haemorrhage was identified by CT in two patients (0.9%; 95% confidence interval (CI), 0.1% to 3.1%) and MRI in eight (3.5%; 1.5% to 6.8%). Haemorrhagic transformation was identified by CT in three patients (1.3%; 0.1% to 5.6%) and MRI in 15 (6.6%; 3.7% to 10.6%). The earliest time primary intracerebral haemorrhage was not identified on CT was 11 days. CONCLUSIONS: CT failed to identify 75% of primary intracerebral haemorrhages, equivalent to 24 patients per 1000 (95% CI, 14 to 37) with mild strokes. To detect haemorrhages reliably, CT would need to have been performed within about eight days. Rapid access to neurovascular clinics with same day CT brain imaging is required to avoid inappropriate secondary prevention. Increased public awareness of the need to seek urgent medical attention after stroke should be encouraged. MRI should be considered in late presenting patients.     

Change in incidence and aetiology of intracerebral haemorrhage in Oxfordshire, UK, between 1981 and 2006: a population-based study

BACKGROUND: UK stroke mortality data suggest that the incidence of haemorrhagic stroke has fallen in the past 20 years, but these data do not include deaths of individuals aged 75 years or over. Trends in the older population might differ, since cause varies with age. Our aim was to investigate changes in the population-based incidence of intracerebral haemorrhage according to age and likely aetiology. METHODS: We used data from the Oxford Community Stroke Project (OCSP; 1981-86) and the Oxford Vascular Study (OXVASC; 2002-06) to investigate changes in the incidence of intracerebral haemorrhage with time, above and below age 75 years, together with associated risk factors and premorbid medications. Incidences were standardised to the 2001 census population of England and Wales. FINDINGS: In the population aged under 75 years the incidence of intracerebral haemorrhage decreased substantially (rate ratio 0.53, 95% CI 0.29-0.95; p=0.03), but the number of cases of intracerebral haemorrhage at all ages were similar in OXVASC and OCSP (52 vs 55 cases) as the proportion of cases occurring at 75 years and over tended to increase (2.0, 0.8-4.6; p=0.09). The incidence of intracerebral haemorrhage associated with premorbid hypertension (blood pressure >or=160/100 mm Hg) fell overall (0.37, 0.20-0.69; p=0.002), but the incidence of intracerebral haemorrhage associated with antithrombotic use was increased (7.4, 1.7-32; p=0.007). Above age 75 years the proportion of cases who were non-hypertensive with lobar bleeds and presumed to have had mainly amyloid-related haemorrhages, also increased (4.0, 1.1-17; p=0.003). INTERPRETATION: There has been a substantial fall in hypertension-associated intracerebral haemorrhage over the past 25 years, but not in the overall number of cases of intracerebral haemorrhage in older age-groups, in part due to a rise in intracerebral haemorrhage associated with antithrombotic use. These trends, along with the expected increase in prevalence of amyloid angiopathy with the ageing population, suggest that, in contrast to projections based on mortality data below age 75 years, absolute number of cases of intracerebral haemorrhage might increase in future.     

Pharmacotherapy prior to and in acute haemorrhagic stroke. The use of pharmacotherapy and drugs-associated outcomes in real-world practice – findings from the Polish Hospital Stroke Registry

Background and purposeHaemorrhagic stroke is associated with substantial mortality and disability, thus prevention and appropriate treatment of acute intracerebral haemorrhage is crucial. We aimed to evaluate the use and the early and late outcomes impact of drugs administered before and in acute haemorrhagic stroke in a real-world practice.Material and methodsHaemorrhagic stroke patients hospitalized between 1^st March 2007 and 29^th February 2008 and reported in Polish Hospital Stroke Registry were analysed. Fully anonymous data were collected with standardized, authorized access, web-based questionnaire. Multivariate regression models were used to adjust for case-mix and evaluate the impact of drugs used prior to or in acute haemorrhagic stroke on outcomes. The early outcomes were defined as in-hospital mortality or poor outcome (death or dependency – modified Rankin Scale ≥ 3) at hospital discharge, while late outcomes covered one-year survival.ResultsA total of 3111 haemorrhagic stroke patients (mean age: 68.9 years; females: 46.7%) was reported. The analysis of pharmacotherapy showed low preventive use of hypotensive agents in hypertensive patients, high consumption of antibiotics and still overuse of vasoactive or neuroprotective compounds in acute haemorrhagic stroke. Regression models confirmed expected negative impact on stroke outcomes associated with oral anticoagulants but not antiplatelets and inconsistent impact of statins used prior to or in acute haemorrhagic stroke.ConclusionsPreventive underuse of hypotensive compounds contribute substantially to haemorrhagic stroke risk. The high consumption of antibiotics and neuroprotective or vasoactive compounds in haemorrhagic acute stroke reflect the need to improved quality and evidence-based clinical practice.     

Prior use of statins and outcome in patients with intracerebral haemorrhage

Background:  Pre-treatment with cholesterol lowering drugs of the statin family may exert protective effects in patients with ischaemic stroke and subarachnoid haemorrhage but their effects are not clear in patients with intracerebral haemorrhage (ICH).
Methods:  We recruited patients admitted to our University Hospital with an acute ICH and analysed pre-admission demographic variables, pre-morbid therapy, clinical and radiological prognostic markers and outcome variables including 90-day modified Rankin score and NIH stroke scale score (NIHSS).
Results:  We recruited 399 patients with ICH of which 101 (25%) were using statins. Statin users more often had vascular risk factors, had significantly lower haematoma volumes ( P  = 0.04) and had lower mortality rates compared with non-users (45.6% vs. 56.1%; P  = 0.11). However, statin treatment did not have a statistically significant impact on mortality or functional outcome on multiple logistic regression analysis.
Conclusions:  Treatment with statins prior to ICH failed to show a significant impact on outcome in this analysis despite lower haematoma volumes.     

Comparison of stroke ward care versus mobile stroke teams in the Hungarian stroke database project

Although previous studies have proved that both stroke wards and mobile stroke teams are considerably better than non-specialized stroke care, an unresolved debate in vascular neurology is whether or not stroke wards provide better outcomes in some specific cases to stroke victims. Our prospective, multicenter, cohort study compared dedicated stroke wards versus specialist stroke team care at general hospital wards in 11 centers nationwide for 8743 consecutive stroke events during 18 months. Twenty-eight-day case-fatality rate was 12.6% at stroke wards versus 15.2% at stroke teams for all patients ( P  = 0.002), and stroke ward care also predicted better outcome when analyzed with multivariate logistic regression model (odds ratio 1.701; confidence interval: 1.025–2.822). Case-fatality rates were not significantly different in patients with modified Rankin score ≥2 (case-fatality rate: 17.8% vs. 20.3%; P  = 0.163), and over 60 (case-fatality rate: 14.8% vs. 15.9%; P  = 0.250), however these patients were more probably at home after 4 weeks when treated at stroke wards (56.1% vs. 50.6%; P  = 0.03, and 69.5% vs. 64.5%; P  = 0.004). In our study, stroke ward admission provided lower case-fatality rate below 60 and for those independent prior to their strokes, and lower institutionalization over 60 and amongst previously dependent patients, when compared with stroke teams.     

Outcome after brain haemorrhage

Between 10 and 20% of strokes are due to intracerebral haemorrhage. The 1-month case fatality is about 42% in unselected cohorts. This relatively low incidence (compared with ischaemic stroke) and high early case fatality means that relatively few patients are available for long-term follow-up and therefore the available data on prognosis are imprecise. Moreover, improvements in diagnostic methods, such as the introduction of gradient echo MRI, which is very sensitive to intracerebral haemorrhage, are altering the types of patients being entered into studies of prognosis. Despite these methodological difficulties, it does appear that the overall prognosis with respect to survival and residual disability is similar to that for ischaemic stroke of equivalent clinical severity. Greater age and stroke severity, whether graded by neurological score or extent of haemorrhage on imaging, are both associated with increased case fatality and poorer functional outcomes. There is no definite evidence of differential recovery between ischaemic and haemorrhagic stroke. Epileptic seizures occur more commonly after haemorrhagic stroke (about 8 per 100 patient-years) compared with ischaemic stroke and more commonly in lobar rather than basal ganglia haemorrhage. There is no reliable evidence to indicate that the risk of recurrent stroke after haemorrhage differs from that after ischaemic stroke. However, strokes due to haemorrhage, like those due to infarction, are heterogeneous not only in terms of severity but also in their causes. The causes (e.g. amyloid angiopathy, hypertension, coagulation deficits) are likely to influence the risk of subsequent stroke. Pooling of data from community-based studies of haemorrhagic stroke that have used consistent definitions and methods represents the only feasible way to obtain more precise data on prognosis after intracerebral haemorrhage.     

Influence of antiplatelet pre‐treatment on the risk of intracranial haemorrhage in acute ischaemic stroke after intravenous thrombolysis

Background: Pre‐treatment with antiplatelet agents (AP) is present amongst 30% of acute stroke patients. Previous studies have shown conflicting results on the effect of these drugs regarding haemorrhagic transformation after thrombolytic therapy. The hypothesis that pre‐treatment with AP may increase the risk of cerebral haemorrhage (ICH) after intravenous tissue plasminogen activator (tPA) was assessed. Methods: Retrospective study of consecutive prospectively registered patients with acute ischaemic stroke treated with iv tPA (n = 235) in the last 5 years. Baseline characteristics and prior AP therapy were registered on admission. Computed tomography (CT) scan was performed on admission and 24–36 h after tPA. ICH was classified according to the ECASS II criteria into haemorrhagic infarction and parenchymal haematoma (PH). Symptomatic intracerebral haemorrhage (SICH) was defined as a worsening of ≥ 4 points in the NIHSS score during the first 36 h in any haemorrhage subtype. Results: Seventy‐two (30.6%) patients were pre‐treated with AP (55 aspirin, 14 clopidogrel, 2 aspirin + clopidogrel, 1 triflusal). PH was observed in 33 (14.1%) patients (PH1 13, PH2 12, PHr 8) of whom 16 were symptomatic. Male gender (78.8% vs. 21.2%, P = 0.036), prior AP therapy (54.5% vs. 26.9%, P = 0.001), stroke severity (median NIHSS, 17 vs. 12, P = 0.005) and early CT signs of infarction (12.5% vs. 2.1%, P = 0.004) were associated with PH. The adjusted odds ratios of PH for patients pre‐treated with AP therapy was 3.5 (1.5–7.8, P = 0.002) and for SICH 1.9 (0.6–5.9, P = 0.2). Conclusions: Pre‐treatment with AP is associated with an increased risk of PH after intravenous thrombolysis in patients with acute ischaemic stroke.     

Safe implementation of thrombolysis in stroke-monitoring study in Italy

Background and purpose:  The safe implementation of thrombolysis in stroke-monitoring (SITS-MOST) study was an unique opportunity to test in Italy, where only few centres were expert in thrombolytic treatment before, safety and efficacy of i.v. alteplase within 3 h of ischaemic stroke outside the setting of clinical trials.
Methods:  In Italy to participate in the study the clinical centres had to possess organizational and structural characteristics certified by Regional Health Authorities.
Results:  Seventy-one centres were activated, 56 (79%) treated patients of which 41 (73%) had never used thrombolysis before the study. Globally, 586 patients were included. Baseline median National Institute of Health Stroke Scale of Italian patients was 13 vs. 12 in other European centres ( P  = 0.0001). Symptomatic intracerebral haemorrhage as per the NINDS/Cochrane definition, mortality and independence (modified Rankin Scale 0–2) rates at 3 months occurred respectively in 6.7% (95% CI: 4.8–9.1), 11.7% (9.2–14.6) and 51.6% (47.4–55.7) of Italian patients compared with 7.3% (6.7–8.0) ( P  = 0.56), 11.2% (10.4–12.1) ( P  = 0.75) and 55.1% (53.8–56.4) ( P  = 0.09) in the European patients and in 8.6% (40/65; 6.3–11.6), 17.3% (14.1–21.1) and 50.1% (44.5–54.7) of the patients treated in the pooled randomized controlled trials.
Conclusions:  The SITS-MOST study showed that in Italy i.v. alteplase is safe and effective in routine clinical use also in non-expert centres.     

Associations between meteorological variables and acute stroke hospital admissions in the west of Scotland

Background –  We combined a large clinical stroke registry with the UK Met Office database to assess the association between meteorological variables and specific clinical subtypes of acute stroke.
Methods –  We used negative binomial regression and Poisson regression techniques to explore the effect of meteorological values to hospital with acute stroke. Differential effects of atmospheric conditions upon stroke subtypes were also investigated.
Results –  Data from 6389 patients with acute stroke were examined. The mean age (SD) was 71.2 (13.0) years. About 5723 (90%) patients suffered ischaemic stroke of which 1943 (34%) were lacunar. Six hundred and sixty-six patients (10%) had haemorrhagic stroke. Every 1°C increase in mean temperature during the preceding 24 h was associated with a 2.1% increase in ischaemic stroke admissions ( P  = 0.004). A fall in atmospheric pressure over the preceding 48 h was associated with increased rate of haemorrhagic stroke admissions ( P  = 0.045). Higher maximum daily temperature gave a greater increase in lacunar stroke admissions than in other ischaemic strokes ( P  = 0.035).
Conclusion –  We report a measurable effect of atmospheric conditions upon stroke incidence in a temperate climate.     

Intravenous thrombolysis in stroke patients with hyperdense middle cerebral artery sign

Background and purpose:  We assessed the safety and efficacy of intravenous thrombolysis (IVT) in acute stroke patients with hyperdense middle cerebral artery sign (HMCAS).
Patients and methods:  Data from consecutive patients with acute (within 6 h of symptom onset) ischaemic stroke admitted between January 1999 and November 2007, in whom HMCAS was diagnosed on admission CT scan was retrospectively analysed. Seventy-one patients, admitted within the 3-h window, were treated with IVT, whilst further 42, admitted 3–6 h after symptom onset, were not. At 3-month clinical follow-up, outcome, mortality at 3 months and incidence of symptomatic intracranial haemorrhage were evaluated.
Results:  The two groups were comparable concerning age, stroke risk factors, prior antithrombotic treatment and NIHSS scores on admission. Good outcome (mRS score ≤ 1) was observed in 12/71 (17%) patients who were treated with IVT and in 1/42 (2%) patients who were not ( P  = 0.02). IVT treatment was identified as independent predictor of good outcome ( P  = 0.05). Mortality was 20% in patients treated with IVT and 12% in remaining patients ( P  = 0.3). Symptomatic intracranial haemorrhage occurred in 1 patient of each group (2%).
Conclusions:  These findings suggest that IVT in patients with HMCAS results in significantly better outcome, without significantly influencing mortality.     

Cost Effectiveness of t-PA Therapy

The previous decline of the incidence of stroke is now less apparent. Most of this decline was in ischaemic stroke; the changes in haemorrhagic stroke are less certain.
We have documented on our stroke data bank in Toronto the stroke frequency. We collected retrospective data of 182 admissions for cerebral haemorrhage. 126 (69%) were direct admissions to emergency and 56 (31%) were referral. In hospital mortaility rate was higher in the emergency group than in the referral group (52% vs 19.6%). Moreover, patients from the referral group were found to have predominant lobar haemorrhage and less proportion of central lesion. In 1976, 10.1% of strokes admitted rate in the week was 47%. In 1997, 10% of strokes were haemorrhagic but the mortality rate was 37% ( P > 0.05).
Although some of these differences probably represent referral bias, these data indicate a decline in mortality but not incidence.     

Factors affecting the occurrence of symptomatic intracerebral haemorrhage after intravenous thrombolysis depending on the haemorrhage definition

Background and purposeSymptomatic intracerebral haemorrhage (sICH) remains the most feared complication of systemic thrombolysis in patients with ischaemic stroke. The aim of the study was to analyze the impact of different factors on the occurrence of sICH, depending on definition used.Material and methodsWe retrospectively evaluated the influence of several factors on the occurrence of sICH (according to definitions used in ECASS2, SITS-MOST and NINDS studies) in 200 patients treated with systemic thrombolysis from 2006 to 2011. Multivariate analysis of impact of individual variables on the occurrence of haemorrhagic transformation (HT) and parenchymal haemorrhage type 2 (PH2) were performed.ResultsHaemorrhagic transformation occurred in 35 cases (17.5%). SICH was found in 10 cases according to ECASS2, in 7 cases according to SITS and in 13 cases according to NINDS. Older age was related to higher risk of sICH, regardless which definition was used (ECASS2: p = 0.014, SITS-MOST: p = 0.048, NINDS: p = 0.008), and female sex was related to higher risk of sICH according to NINDS and ECASS2 definition (p = 0.002 and p = 0.04, respectively). Blood glucose level and high NIHSS score (> 14 pts) were found as risk factor of sICH in ECASS2 definition (p = 0.044 and p = 0.03, respectively). In multivariate logistic regression higher NIHSS scores were associated with HT independent of age, gender and glucose level (p = 0.012). Multivariate analysis showed no impact of age, gender, severity of stroke and glucose level on presence of PH2.ConclusionsDefinition of sICH can determine variables that are related to a high risk of this complication. In our study most factors correlated with sICH using the ECASS2 definition.     

High prevalence of unrecognized cerebral infarcts in first-ever stroke patients with cardioembolic sources

Background:  With magnetic resonance imaging (MRI) analysis, we investigated the prevalence, clinical significance, and factors related to the presence of unrecognized cerebral infarcts in patients with first-ever ischaemic stroke.
Methods:  We consecutively included patients who were admitted with first-ever stroke. Unrecognized cerebral infarct was defined as an ischaemic infarction or primary intracerebral hemorrhage on MRI irrelevant to the index stroke, without acute lesions on diffusion-weighted image.
Results:  Of the total 203 patients, 78 (39.4%) patients were observed as having unrecognized cerebral infarct. Patients with high-risk cardioembolic sources (e.g., atrial fibrillation) more frequently had unrecognized stroke than those without ( P  = 0.008, 21/36 [58.3%] vs. 57/167 [34.1%]). On univariate analysis, male sex ( P  = 0.027) and cardioembolic source ( P  = 0.008) were associated with the presence of unrecognized cerebral infarcts. After adjustment for gender, age and risk factors, the presence of cardioembolic sources independently increased the risk of unrecognized cerebral infarct ( P  = 0.002, odds ratio 3.56, 95% confidence interval 1.58–8.02). Regarding clinical outcome at 3 months, the presence of unrecognized cerebral infarct was not associated with the poor clinical outcome.
Conclusion:  In our study, the presence of cardioembolic sources was an independent risk factor for the unrecognized cerebral infarct in patients with first-ever stroke.     

Thrombolysis in acute ischaemic stroke within 3 hours of symptom onset: a report of the first 100 cases

BACKGROUND AND PURPOSE: The aim of the study was to present our initial experience with the use of intravenous thrombolytic therapy in patients with acute ischaemic stroke in the 2nd Department of Neurology of the Institute of Psychiatry and Neurology in the years 2003-2007. MATERIAL AND METHODS: The patients were selected and treated with recombinant tissue plasminogen activator (rt-PA, alteplase) according to the SITS-MOST (Safe Implementation of Thrombolysis in Stroke - Monitoring Study) protocol. RESULTS: We present the data on the first 100 patients treated with rt-PA in our department. The mean age of the treated patients was 67 years, the initial neurological deficit measured in the National Institutes of Health Stroke Scale (NIHSS) was 8 pts., the door-to-needle time was 82 minutes. At 3-month follow-up, 61% of patients had achieved modified Rankin scale score of 0-2. Fourteen percent had died within three months of stroke onset. We observed 2 symptomatic intracerebral haemorrhages and there were 17 cases of secondary asymptomatic haemorrhagic transformations (6 cases with haemorrhagic infarct type 2, 11 cases with primary intracerebral haemorrhage, and 6 cases with remote primary intracerebral haemorrhage type 1). CONCLUSIONS: Our results are consistent with the previous experience of other stroke centres and confirm that rt-PA is safe and effective in ischaemic stroke treatment also in the Polish population.     

Quality of life among young patients with ischaemic stroke compared with patients with multiple sclerosis

Objectives –  We aimed to evaluate the quality of life among young ischaemic stroke (IS) patients at long-term follow-up by comparing them with multiple sclerosis (MS) patients with secondary progressive course. The mean age at stroke onset was 41.6 years.
Methods –  Nottingham Health Profile scores were obtained from 191 IS patients 6 years (mean) after the index stroke, from 337 MS patients 5 years (mean) after the onset of the secondary progressive course and from 216 controls.
Results –  The mean age of IS patients was 47.8 years and MS patients 44.5 years at follow-up. The MS patients as a group had worse subscores than the IS patients. When adjusting for physical mobility, complaints of fatigue ( P  = 0.012) were more frequent among MS patients, whereas pain ( P  < 0.001) and sleep ( P  = 0.007) disturbances were more frequent among IS patients.
Conclusion –  The comparison of IS and MS patients highlights the importance of pain and sleep disturbances among IS patients when adjusting for physical mobility.     

Polymorphism in the sorbin and SH3-domain-containing-1 (SORBS1) gene and the risk of brain infarction in the Japanese population: the Fukuoka Stroke Registry and the Hisayama study

Background and purpose:  Sorbin and SH3-domain-containing-1 (SORBS1) is an important adaptor protein in insulin-signalling pathway, and its genetic polymorphism may regulate the activity of insulin resistance. We investigated the association between the SORBS1 T228A polymorphism and ischaemic stroke.
Methods:  Genotyping was achieved by a rapid-cycle PCR and melting curve analysis using fluorescent probes in 1049 incident cases of ischaemic stroke and 1049 age- and sex-matched control subjects recruited from the Hisayama study.
Results:  The allele distributions of the SORBS1 T228A polymorphism were similar amongst cases and controls. The multivariate-adjusted odds ratio (OR) of the AA genotype for ischaemic stroke was 2.897 (95% CI, 0.907–8.018) compared with the TT genotype. In terms of stroke subtype, there was a trend toward a difference in the AA genotypes for lacunar infarction, compared with the TT genotype (OR = 8.740, P  = 0.0510), and combined TT and TA genotypes (OR = 8.768, P  = 0.0505). The other polymorphisms genotyped were not associated with any subtypes of ischaemic stroke. T228A polymorphism of SORBS1 was not associated with the prevalence of diabetes.
Conclusions:  The AA genotype of SORBS1 T228A polymorphism may play a role in lacunar infarction in the Japanese population.     

The ipsilateral cortico-spinal tract is activated after hemiparetic stroke

Background and purpose:  The presence of a projection from the primary motor cortex to the ipsilateral muscles has been established in human, but whether this pathway contributes to functional recovery after stroke is unclear. We investigated whether the ipsilateral tract is activated in hemiparetic stroke.
Methods:  Motor-evoked potentials (MEPs) were simultaneously recorded from the bilateral trapezius or abductor digiti minimi (ADM) muscles after magnetic stimulation to the motor cortex in 40 acute stroke patients.
Results:  At rest, ipsilateral trapezius MEPs were recordable in none of the 24 normal controls, and in 38% of the patients after stimulation to the non-affected hemisphere ( P  < 0.001). With voluntary contraction, ipsilateral trapezius MEPs were elicited in 21% of the normal controls and 73% of the patients ( P  < 0.001). Ipsilateral ADM MEPs were rarely recordable in both controls (0%) and patients (3%). The presence of ipsilateral trapezius MEPs was associated with less severe paresis in the trapezius ( P  = 0.04) and deltoid ( P  = 0.07), but not in the more distal muscles.
Conclusions:  The ipsilateral cortico-spinal tract is acutely facilitated after stroke in the trunk or proximal muscles, but not in the hand muscles. Activation of such pathway appears to partly compensate motor dysfunction of the trunk/proximal muscles.     

Clinical study of 39 patients with atypical lacunar syndrome

The aim of this study was to describe the clinical characteristics of atypical lacunar syndrome (ALS) based on data collected from a prospective acute stroke registry. In total, 2500 acute stroke patients were included in a hospital based prospective stroke registry over a 12 year period, of whom 39 were identified as having ALS and radiologically proven (by computed tomography or magnetic resonance imaging) lacunes. ALS accounted for 1.8% of all acute stroke patients, 2.1% of acute ischaemic stroke, and 6.8% of lacunar syndromes. ALS included dysarthria facial paresis (n = 12) or isolate dysarthria (n = 9), isolated hemiataxia (n = 4), pure motor hemiparesis with transient internuclear ophthalmoplegia (n = 4), pure motor hemiparesis with transient subcortical aphasia (n = 3), unilateral (n = 2) or bilateral (n = 3) paramedian thalamic infarct syndrome, and hemichorea hemiballismus (n = 2). Atypical lacunar syndromes were due to small vessel disease in 96% of patients. Atherothrombotic infarction occurred in one patient and cardioembolic infarct in another, both presenting pure dysarthria. Outcome was good (in hospital mortality 0%, symptom free at discharge 28.2%). After multivariate analysis, the variables of speech disturbances, nausea/vomiting, ischaemic heart disease, and sensory symptoms were found to be significantly associated with ALS. In conclusion, atypical lacunar syndrome is an infrequent stroke subtype (one of each 14 lacunar strokes). ALS occurred in 6.8% of lacunar strokes. Isolated dysarthria or dysarthria facial paresis were the most frequent presenting forms. The prognosis of this infrequent non-classic lacunar syndrome is good.