Effectiveness of home rehabilitation program for ischemic stroke upon disability and quality of life: a randomized controlled trial

Background

To develop and examine the effectiveness of individual 6-month home rehabilitation program in ischemic stroke patients upon disability and quality of life at 2 years.

Methods

This is a prospective randomized controlled trial (RCT) in 60 patients with recent ischemic stroke. They were randomly assigned to receive either home rehabilitation program once a month for 6 months with audiovisual materials (intervention group) or usual care (control group). We collected outcome data after discharge from the hospital until 2 years. The Barthel index (BI), the modified Rankin Scale (mRS) and utility index (EQ-5D) were measured for function, disability and quality of life respectively.

Results

At 2 years, the BI was significantly improved in the intervention group more than the control group: 97.2 ± 2.8 vs. 76.4 ± 9.4, p < 0.001. The good outcome, defined as BI 95–100, or mRS 0 or 1. For BI, there were 29 patients (96.7%) in intervention group vs 12 patients (42.9%) in usual care group (95% CI, 42.0, 85.0, p = 0.03). For mRS, there were 28 patients (93.3%) in intervention group vs 9 patients (32.1%) in usual care group (95% CI, 38.2, 87.0, p = 0.02). Number needed to treat for good outcome in mRS was 2.0 (95% CI: 1.0, 1.3). The mean (SD) of utility index in intervention group and control group were 0.9 ± 0.02 and 0.7 ± 0.04 respectively (p = 0.03). There was no significant interaction in baseline characteristics and treatment outcome.

Conclusions

Early home rehabilitation program in the first 6 months period after ischemic stroke leads to more rapid improvement in function, reducing disability and increase quality of life than usual care.     

Outcome of Chlamydia pneumoniae associated acute ischemic stroke in elderly patients: a case-control study

Background

Limited data exists about the role of Chlamydia pneumoniae elderly patients with acute ischemic stroke.

Objective

To study the role of C. pneumoniae in elderly patients (age more than 65 years) with acute ischemic stroke and its impact on stroke out come.

Methods

We recruited 100 elderly patients with acute ischemic stroke and 100 age and sex matched controls over a period of 2 years. IgG and IgA anti C. pneumoniae antibodies were measured by microimmunofluorescence technique in patients and controls. Good outcome was defined as a Modified Rankin score (mRS) of ≤2.

Results

We found C. pneumoniae antibodies in 35% stroke patients and in 18% control subjects (p = 0.01). Good out come at 90 days follow up was found in 20/35(57.1%) seropositive stroke patients compared to 37/65(56.9%) seronegative stroke patients (p = 0.9).

Conclusions

C. pneumoniae antibody positivity was independently associated with ischemic stroke in elderly patients and its presence does not alter the stroke outcome.     

Prediction of infarct growth and neurologic deterioration in patients with positive perfusion-diffusion mismatch

Background

To assess the value of baseline clinical severity and perfusion–diffusion mismatch as predictors for further infarct growth and clinical outcome.

Methods

Patients with acute ischemic stroke and initial perfusion–diffusion mismatch within 72 h were enrolled. Baseline perfusion defects on time-to-peak (TTP) and cerebral blood volume (CBV) maps were measured. Infarct volume and stroke severity were assessed by diffusion-weighted image (DWI) and NIHSS, and were repeatedly assessed 7 days later. The predictive value of baseline NIHSS and perfusion defects on further infarct growth and neurologic deterioration was determined.

Results

Fifty-two patients (mean age 68.3 ± 12.8 years, 42% women) were enrolled. CBV defects were significantly associated with infarct growth (CBV, p = 0.02). Initial stroke severity, but not TTP and CBV mismatch (p = 0.65 and 0.76, respectively), significantly inversely correlated with neurologic deterioration (p = 0.001).

Conclusions

In patients with mismatch, those with severe symptoms initially are more likely to have infarct growth, while those with minor symptoms tend to suffer from larger extent of neurologic deterioration within 1 week. CBV is associated with further infarct growth but not clinical deterioration.     

Surgical treatment of unruptured intracranial aneurysms in a low-volume hospital--outcome and review of literature

Background

The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature.

Methods

A retrospective review of all consecutive craniotomies for UIA from July 1999 through June 2009 was performed. Morbidity was defined as modified Rankin Scale (mRS) ≥ 3 and evaluated six weeks after surgery. Cognitive function was evaluated at rehabilitation-to-home discharge. A PubMed database search (2001–2011) seeking retrospective, single-center studies reporting on surgical outcome of UIAs was performed.

Results

There were 47 procedures performed in 42 patients to treat 50 UIAs (mean of 5 annual craniotomies). The mean age was 54.7 ± 12.1 years and mean aneurysm size was 7.6 ± 4.0 mm. Favorable outcome (mRS 0–2) at six weeks after surgery was achieved in 45 of 47 procedures (95.7%). Aneurysm size ≥ 12 mm was statistically significant related to adverse outcome defined as mRS change ≥ 1 (71% vs. 29%; p = 0.018). Five patients (10.6%) with favorable neurological outcome (mRS 2) presented with cognitive impairment at rehabilitation-to-home discharge. There was no significant difference in overall morbidity and mortality comparing low- and high-volume hospitals (4.0% vs. 4.8%; p = 0.85).

Conclusions

Low-volume hospitals may achieve good results for surgical treatment of UIAs. The results indicate that defining numeric operative volume thresholds is not feasible to guide centralization of aneurysm treatment.     

Association between metabolic syndrome and previous ischemic lesions in patients with intracranial atherosclerotic stroke

Objectives

To elucidate the relationship between MetS and ischemic stroke, we evaluated the association of MetS and individual components with frequency of ischemic stroke lesions and investigated the independent associations between them in acute ischemic stroke patients.

Patients and methods

We evaluated 370 acute ischemic stroke patients who underwent brain magnetic resonance (MR) imaging and MR angiography. The stroke subgroups were categorized as intracranial large artery atherosclerosis (IC-LAA, n = 151), extracranial large artery atherosclerosis (EC-LAA, n = 35), and nonatherosclerosis (NA, n = 184). MetS was defined using the criteria of the International Diabetes Federation.

Results

Patients with IC-LAA group showed a higher rate of MetS and previous ischemic lesions (predominantly deep gray/white matter) than those with EC-LAA and NA (all P < 0.001). The number of previous ischemic lesions showed a tendency to increase as the number of MetS components increased in the IC-LAA group (P = 0.004). In the IC-LAA group, age (OR, 1.04) and MetS (OR, 3.28) were independently associated with previous ischemic lesions (all P < 0.001), which was prominent with more severe MetS components after adjustment for risk factors (P < 0.001). Among the component conditions, high blood pressure, impaired fasting glucose, and abdominal obesity were more associated with previous ischemic lesions (all P < 0.001) than low high-density lipoprotein and high triglyceride levels (P = 0.010 and 0.028, respectively).

Conclusion

Our study showed a strong association between MetS and previous ischemic lesions, more in patients with IC-LAA.     

Recovery of posterior communicating artery aneurysm-induced oculomotor nerve paresis after endovascular treatment

Objective

Recovery of aneurysm-induced oculomotor nerve paresis (ONP) after endosaccular coiling has not yet been adequately assessed. The aim of this study was to investigate the factors that affect the outcome of ONP after endovascular treatment of posterior communicating artery (PcomA) aneurysms.

Materials and methods

We retrospectively evaluated the clinical characteristics and the outcome of oculomotor nerve function in a series of 36 patients with ONP due to PcomA aneurysms treated by endovascular coiling. Univariate analysis was applied to test the association between ONP recovery and clinical variables.

Results

Thirty-six consecutive patients (20 women, 16 men; mean age, 54.3 ± 9 years) presenting with ONP underwent endosaccular coiling were enrolled in this study. Subarachnoid hemorrhage was present in 21 patients. The mean size of the aneurysms was 9.3 ± 3.9 mm. ONP was complete in 14 patients (38.9%) and partial in 22 patients (61.1%) at admission. Seventeen patients (47.2%) had complete recovery of oculomotor nerve function, 15 had incomplete recovery (41.7%), and 4 (11.1%) remained unchanged after treatment. Factors showing significant association with recovery of oculomotor nerve function were the length and degree of ONP before treatment (P = 0.035 and P = 0.019, respectively).

Conclusions

Endosaccular coiling of PcomA aneurysms in patients with ONP resulted in cure or improvement of oculomotor nerve dysfunction in the majority of patients. The length and degree of preoperative ONP were the statistically significant predictors of complete ONP recovery.     

Associations of cigarette smoking with intracranial atherosclerosis in the patients with acute ischemic stroke

Background

Although cigarette smoking has been established as an important risk factor for stroke, the effect on the atherosclerotic stenosis, which are based on observational studies, have been controversial. We set out to examine the differences in the risk factors between smokers and nonsmokers and to investigate the association of cigarette smoking with cerebral arterial stenosis.

Methods

A total of 989 consecutive patients with acute noncardioembolic ischemic stroke were prospectively enrolled from June 2004 to January 2010. The risk factor profiles were compared between smokers and nonsmokers. We analyzed the degree of stenosis in all MRA, and evaluated influencing factors in the patients with intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) who were randomly matched by age and sex.

Results

There were differences in the distribution of risk factors between the 467 (70.0%) nonsmokers and the 215 (30.0%) smokers. Nonsmokers were older (71.7 ± 11.0 versus 61.7 ± 12.0, p < 0.001) and had a higher frequency of hypertension than smokers had (75.4% versus 64.0%, p = 0.002). When smokers and nonsmokers were age- and sex-matched, smoking was more prevalent in patients with ICAS than with ECAS (32.9% versus 28.2%). Conditional regression analysis revealed that smoking and hypertension increased the odds of ICAS [smoking, odds ratio (OR): 1.83, p = 0.026; hypertension, OR: 1.84, p = 0.01], whereas hyperlipidemia increased the odds of ECAS (OR: 1.87, p = 0.034).

Conclusion

The distributions of the major risk factors for ischemic stroke were different between smokers and nonsmokers. Cigarette smoking may be more associated with ICAS than with ECAS after adjusting for potential risk factors.     

Atrial fibrillation predicts good functional outcome following intravenous tissue plasminogen activator in patients with severe stroke

Objective

Atrial fibrillation (AF) is associated with poor outcome after intravenous thrombolysis probably due to greater pretreatment stroke severity. We conducted this retrospective study to determine whether AF is an independent predictor for clinical outcome in patients stratified by initial stroke severity.

Methods

A total of 143 acute ischemic stroke patients who received intravenous thrombolysis within 3 h after onset were enrolled. The patients were categorized according to the baseline stroke severity by National Institute of Health Stroke Scale (NIHSS) score (≤10 vs. >10) and the presence of AF or not. Favorable 90-day outcome was defined as a modified Rankin Scale (mRS) score < 2.

Results

Among the 100 patients with severe stroke (NIHSS > 10), those with AF (n = 52) had a higher proportion of favorable 90-day outcome than those without AF (31% vs. 8%, P = 0.005). After adjustment for age, baseline glucose level, and onset to treatment time, the difference remained significant (odds ratio 5.80, 95% confidence interval 1.63–20.68). In patients with mild stroke (NIHSS ≤ 10), no difference in clinical outcome was found between AF (n = 20) and non-AF (n = 23) groups.

Conclusion

Presence of AF was associated with favorable 90-day outcome following intravenous thrombolysis in patients with severe stroke at baseline, while the association did not exist in patients with mild stroke.     

Early superficial temporal artery to middle cerebral artery bypass in acute ischemic stroke

Objective

To evaluate the effects and safety of superficial temporal artery–middle cerebral artery (STA–MCA) anastomosis in the early stage after an acute ischemic event and the improvement of present symptoms in patients with intracranial atherosclerotic occlusive disease with stroke/stroke in progress.

Methods

From 2006 to 2010, 20 patients (15 males and five females) with atherosclerotic cerebrovascular disease were treated with an STA–MCA bypass. All of the patients presented with an acute ischemic stroke or stroke in progress despite maximal medical treatment. The patients underwent an STA–MCA bypass within 7 days from symptom onset. The clinical outcome and hemodynamic study of the 20 patients were preoperatively and postoperatively investigated. A pooled analysis was performed, and the results were compared with those obtained from other delayed STA–MCA bypass studies.

Results

Among the 20 patients who underwent an early STA–MCA bypass, fourteen (70%) patients achieved a good functional outcome (mRS 0, n = 3; mRS 1, n = 9; mRS 2, n = 2). Prior to surgery, the mean basal regional cerebral blood flow (rCBF) and cerebrovascular reserve capacity (CVR) in the symptomatic hemisphere were 37.3 ± 4.3 ml/100 g/min and −1.68 ± 2.9%. The mean basal rCBF and CVR had significantly increased postoperatively, and no reperfusion-induced hemorrhage had occurred. In the pooled analysis, no significant differences were observed in the clinical outcome (P = 0.328) or in the incidence of postoperative complications (P = 0.516) between patients who underwent an early STA–MCA bypass and in patients who underwent a delayed STA–MCA bypass in previous studies.

Conclusions

In this study, which consisted of 20 carefully selected patients with acute ischemic stroke, an early STA–MCA bypass was safely and effectively performed, and in some cases, an early STA–MCA bypass resulted in rapid neurological improvement. An early STA–MCA bypass was beneficial in select patients who had acute ischemic stroke with imaging evidence of a small infarction.     

Common carotid intima media thickness as a marker of clinical severity in patients with symptomatic extracranial carotid artery stenosis

Objectives

Increased common carotid artery intima-media thickness (CCA-IMT) is a risk factor for ischemic stroke and especially large vessel atherothrombotic infarction. However, the potential association of stroke severity with the intima-media thickening has not been previously studied. We sought to investigate the association between CCA-IMT and clinical severity of ischemic stroke in patients with symptomatic extracranial carotid artery stenosis (SCAS).

Patients and methods

Consecutive patients with acute, first-ever ischemic stroke and SCAS (50%–99%) were prospectively evaluated. All subjects underwent IMT measurements at the far wall of CCA. Stroke severity was assessed using the National Institute of Health Stroke Scale (NIHSS) on hospital admission and Barthel Ambulatory Index (BI) at hospital discharge.

Results

CCA-IMT was strongly correlated to NIH (Spearman's correlation coefficient: r = 0.546, p < 0.001) and BI (r = −0.450, p < 0.001) in the study population (n = 102). A 0.1 mm increase in CCA-IMT was independently associated with increasing NIHSS-scores on hospital admission (β: 0.510; p < 0.001) and decreasing BI-scores at hospital discharge (β: −0.483; p < 0.001) even after adjustment for demographic characteristics and cardiovascular risk factors. After including baseline stroke severity (NIHSS) in the multivariate linear regressions models evaluating early functional outcome, only NIHSS was independently related to BI (standardized linear regression coefficient: −0.776, p < 0.001), while the initial association between IMT and BI did not retain its statistical significance (β: −0.074, p = 0.276).

Conclusions

Increased CCA-IMT is independently associated with more severe stroke on admission in patients with SCAS.     

Risk factor impact on blood flow velocities and clinical outcomes of stented cervical and intracranial stenoses: preliminary observations

Objectives

The role of angioplasty/stenting procedures, neurointerventionist experience, vascular risk factors, medical treatment and blood flow velocities were analysed to identify possible causes of intra-stent restenosis (ISR) following stenting of cervical and/or intracranial arteries, assuming progressive atherosclerosis to be the shared mechanism in both territories.Patients. 26 cerebrovascular patients subjected to stenting of severe (≥85%) symptomatic or asymptomatic carotid stenoses or moderate-to-severe (≥50%) intracranial or vertebral stenoses were included.

Methods

Clinical, radiological and ultrasonographic follow-up data were analysed retrospectively.

Results

Overall, stenting of the internal carotid artery (ICA) induced significant reductions in peak systolic velocities at 2 years (96 ± 31 cm/s vs. 358.2 ± 24.9 cm/s at baseline). The procedure-related ischemic complications rate was 7.4% (one hemispheric stroke and one TIA). The rate of ISR ≤ 50% was 8% in the ICA at 2 years; was 50% in the common carotid artery (CCA) at 1 year, with concomitant distal ICA stenosis in 75% of CCA stenting, but all ISR were asymptomatic. Patients with ISR of the ICA were significantly younger (56.8 ± 4.5 vs. 71.3 ± 3.6 years, P = 0.042) and had significantly more risk factors (5.5 ± 0.9 vs. 3 ± 0.3, P = 0.012). No ISR ≥ 70% was detected.

Conclusions

ISR is relatively infrequent and, when present, it is mild and asymptomatic. Restenosis is more frequent in younger patients and those with several risk factors, and it may also be related to stenting of previous carotid endarterectomy.     

Carboxypeptidase U (TAFIa) decreases the efficacy of thrombolytic therapy in ischemic stroke patients

Introduction

Thrombolytic therapy improves clinical outcome in patients with acute ischemic stroke but is compromised by symptomatic intracranial hemorrhage and an unpredictable therapeutic response. In vitro and in vivo data suggest that activation of procarboxypeptidase U (proCPU) inhibits fibrinolysis.

Aims

To investigate whether the extent of proCPU activation is related to efficacy and safety of thrombolytic therapy in ischemic stroke patients.

Methods

In twelve patients with ischemic stroke who were treated with intravenous (n = 7) or intra-arterial (n = 5) thrombolysis, venous blood samples were taken at different time points before, during and after thrombolytic therapy. ProCPU and carboxypeptidase U (CPU, TAFIa) plasma concentrations were determined by HPLC. The maximal CPU activity (CPU_max) and the percentage of proCPU consumption during thrombolytic therapy were calculated. The efficacy and safety of the thrombolytic therapy were assessed by evolution of the clinical deficit, recanalisation, final infarct volume, thrombolysis-induced intracranial hemorrhage and mortality.

Results

No correlations between CPU_max or proCPU consumption and patient or stroke characteristics were found. However, CPU_max is associated with evolution of the clinical deficit and achieved recanalisation. ProCPU consumption is related to the risk of intracranial hemorrhage, mortality and final infarct volume.

Conclusions

Irrespective of patient and stroke characteristics, CPU_max and proCPU consumption during thrombolytic treatment for ischemic stroke are parameters for therapeutic efficacy and safety. Further evaluation of the clinical applicability of these parameters and further investigation of the potential role for CPU inhibitors as adjunctive therapeutics during thrombolytic treatment may be of value.     

Patent foramen ovale increases the risk of acute ischemic stroke in patients with acute pulmonary embolism leading to right ventricular dysfunction

Background

Patent foramen ovale (PFO) is an established risk factor for ischemic stroke. Since acute right ventricular dysfunction (RVD) observed in patients with PE can lead to right-to-left inter-atrial shunt via PFO, we hypothesized that PFO is a risk factor for ischemic stroke in PE with significant right ventricular dysfunction.

Methods

55 patients (31 F, 24 M), median age 49 years (range 19–83 years) with confirmed PE underwent echocardiography for RVD and PFO assessment. High risk acute PE was diagnosed in 3 (5.5%) patients, while 16 (29%) hemodynamically stable with RVD patients formed a group with intermediate-risk PE. PFO was diagnosed in 19 patients (34.5%). Diffusion-weighted MRI of the brain for acute ischemic stroke (AIS) was performed in all patients 4.91 ± 4.1 days after admission.

Results

AIS was detected by MRI in 4 patients (7.3%). Only one stroke was clinically overt and resulted in hemiplegia. All 4 AIS occurred in the PFO positive group (4 of 19 patients), and none in subjects without PFO (21.0% vs 0%, p = 0.02). Moreover, all AIS occurred in patients with RVD and PFO, and none in patients with PFO without RVD (50% vs 0%, p = 0.038).

Conclusion

Our data suggest that acute pulmonary embolism resulting in right ventricular dysfunction may lead to acute ischemic stroke in patients with patent foramen ovale. However, the clinical significance of such lesions remains to be determined.     

The sNIHSS-4 predicts outcome in right and left anterior circulation strokes

Background and purpose

Stroke severity measured by the National Institutes of Health Stroke Scale (NIHSS) is a strong predictor of functional outcome.A short version, the sNIHSS-5, scoring only strength in right and left leg, gaze, visual fields and language, was developed for use in the prehospital setting. Because scoring both legs in anterior circulation strokes is not contributive, we assessed the value of a 4-item score (the sNIHSS-4), omitting the item ‘strength in the unaffected leg’, in predicting stroke outcome.

Methods

The study population consisted of anterior circulation ischemic stroke patients who participated in the LUB-INT-9 trial. We included all patients in whom the following data were available: NIHSS within 6 h after stroke onset and daily between days 2 and 5, and the 12-week modified Rankin Scale (mRS) score. Poor outcome was defined as a mRS score > 3.

Results

There was an excellent correlation between the NIHSS and sNIHSS-4 at all time points for both left and right-sided strokes. Scores at day 2 were a good predictor of poor outcome. Cutoff scores for NIHSS and sNIHSS-4 at day 2 were 15 and 5 in left hemispheric strokes, and 12 and 4 in right hemispheric strokes.

Conclusion

The sNIHSS-4 is as good as the NIHSS at predicting stroke outcome in both right and left anterior circulation strokes.     

Long-term health-related quality of life after decompressive hemicraniectomy in stroke patients with life-threatening space-occupying brain edema

Background

Although randomized clinical trials have reported significant improvement in mortality and functional outcome as measured with modified Rankin Scale (mRS) or Barthel index (BI) in stroke patients with space-occupying anterior circulation infarctions treated with hemicraniectomy, many clinicians are still concerned about the long-term health-related quality of life (HRQoL).

Aim

Assessment of HRQoL after hemicraniectomy to holistically reevaluate clinical outcome.

Methods

Eleven patients (6 men, 5 women; mean age 48 (SD 5.8) years) were examined at 9–51 months after hemicraniectomy. Test batteries comprised NIH stroke scale, BI, mRS, neuropsychological tests (Visual Object and Space Perception Battery and clock test), and HRQoL-scales (Short Form 36 Health Survey (SF-36), Nottingham Health Profile (NHP), Questions on Life Satisfaction, Hospital Anxiety and Depression Scale and EQ-5D).

Results

Median values for NIHSS, BI and mRS were 11.5, 55 and 3.5. In HRQoL-scales, subscales related to physical mobility and functioning were consistently severely impaired, while subscales related to psychological well-being were impaired to a lesser extent. Mean scores for physical functioning and physical role were 10.5 and 12.5 in the SF-36, and 61.3 and 43.3 for physical mobility and energy in the NHP; emotional role and mental health scored 63.3 and 66.4 (SF-36), scores for emotional reaction and social isolation were 18.9 and 16.0 (NHP), respectively.

Conclusion

Although, physical components of HRQoL are highly impaired, these stroke patients achieved a satisfying level of psychological well-being which was endorsed by a nearly unanimous retrospective appraisal of life-saving hemicraniectomy.     

Acute ischemic stroke treatment and the occurrence of seizures

Background and objectives

Early intravenous treatment with recombinant tissue plasminogen activator (rt-PA) improves the outcome of patients with an acute ischemic stroke. This retrospective observational study analyses whether rt-PA treatment also prevents the occurrence of early- and late-onset seizures.

Patients and methods

Thirty-eight patients treated with rt-PA were compared to 269 receiving anticoagulants (ACs) and 769 on antithrombotics (ATs) for an acute cardiac- or thrombo-embolic stroke. The epidemiological and clinical data, and the vascular risk factors were determined in the three groups. The incidence, onset and types of seizures were compared.

Results

The patients treated with rt-PA had more severe stroke signs on admission and remained more dependent than those treated with ACs and ATs. The appearance of early-onset seizures was related to the severity of the stroke. The incidence of the late-onset ones tended to be low in the rt-PA group. None of the patients developed status epilepticus or epilepsy.

Conclusion

The occurrence of early-onset seizures in the rt-PA treated group is related to the severity of the stroke and not to the treatment modality. Thrombolysis prevents partly the occurrence of late-onset seizures, probably, by a better reperfusion of the ischemic brain regions.     

Application of depression criteria (DSM-IV) in patients with Parkinson's disease

Introduction

The aim of this study is to analyze the clinical differences between Parkinson's disease patients with major (MD) and minor depression (md) and to see how both affect the quality of life.

Material and methods

118 patients diagnosed with Parkinson's disease. The mean age of onset was 60.4 ± 11.2 years with a mean duration of 8.5 ± 6.2 years. Depression was diagnosed according to DSM-IV-TR criteria. Scores on the Hamilton depression inventory, MMSE, PDQ-39, NPI-10, UPDRS III, and UPDRS IV were recorded.

Results

Twenty-one patients (17.8%) met the criteria of major depression (MD) and 33 (28.0%) those of minor depression (md). The scores on the PDQ-39 and NPI-10 of patients with MD were higher than in patients with md, and control group. The MMSE scores were lower in patients with MD. In 52.2% of the patients with MD, the diagnosis of depression was made prior to that of PD, this occurred only in 24.2% of the patients with md (p < 0.001). The presence of anhedonia was related to cognitive impairment and the presence of neuropsychiatric symptoms.

Discussion

MD is probably a part of the disease process of PD; it is associated with cognitive impairment and may precede motor symptoms.     

Plasma heart-type fatty acid binding protein level in acute ischemic stroke: Comparative analysis with plasma S100B level for diagnosis of stroke and prediction of long-term clinical outcome

Objectives

Heart-type fatty acid binding protein (H-FABP) is enriched in neuronal cell body as well as myocardium, and is rapidly released from damaged neuron into circulation in cerebral ischemia. We performed a comparative analysis between plasma H-FABP and S100B levels in the acute phase of ischemic stroke.

Methods

The present study included 111 consecutive patients with acute ischemic stroke and 127 control subjects. Measurement of plasma H-FABP and S100B levels was conducted during acute phase (<24 h) of stroke. Clinical severities were evaluated by the use of NIHSS scores at admission and mRS score at 3 months after symptom onset.

Results

Both the plasma H-FABP and S100B levels were significantly higher in stroke group than control group. In multiple logistic regression analysis, statistical significance of both markers remained significant after adjusting the vascular risk factors. In the receiver operator characteristic (ROC) curve analysis, neither H-FABP (area under curve [AUC] = 0.71, P < 0.001, sensitivity: 59.5%, specificity: 79.5%) nor S100B (AUC = 0.70, P < 0.001, sensitivity: 54.0%, specificity: 83.5%) showed a favorable degree of diagnostic value to discriminate stroke from stroke mimic. Plasma H-FABP (r = 0.46, P < 0.01) and S100B (r = 0.45, P < 0.01) were correlated with initial NIHSS score, and both marker were significantly higher in patients with poor clinical outcome.

Conclusion

Although plasma H-FABP is elevated in the acute phase of ischemic stroke, the diagnostic accuracy of H-FABP as a sole marker is not sufficient to be applied in the clinical setting. Plasma H-FABP can be used as a potential marker for stroke prognosis.     

Use of amplitude-integrated electroencephalography (aEEG) and near infrared spectroscopy findings in neonates with asphyxia during selective head cooling

Background

Amplitude-integrated electroencephalogram (aEEG) at <6 h is the best single outcome predictor in term infants with perinatal asphyxia at normothermia. Hypothermia treatment has changed the cutoff values for outcome prediction by using time at onset of normal trace and SWC. Cerebral hemodynamics and oxygenation changes detected by near infrared spectroscopy (NIRS) during hypothermia treatment in aphyxiated neonates are not a well known issue.

Aim

The aim of this study was to investigate the correlations between brain monitoring (amplitude integrated EEG and NIRS) and outcome in asphyxiated full-term infants with moderate/severe hypoxic–ischemic encephalopathy before, during and after hypothermia treatment.

Method

Ten neonates were recruited for hypothermia treatment by using the cool cap entry criteria. aEEG and NIRS were applied in 10 and 8 patients, respectively with moderate and severe hypoxic–ischemic encephalopathy before, just after brain cooling and rewarming periods. Patterns and voltages of aEEG backgrounds sleep–wake cycles (SWC) and NIRS values (TOI% and FTOE) were recorded. During the follow up their outcomes were assessed by using the Bayley Scales of Infant Development II.

Conclusion

Hypothermia changes the predictive value of early aEEG. Normalization of a baby’s aEEG and the appearance of SWCs while being cooled occurs later. In our study one patient had normal aEEG background pattern at 80 and imminent SWC at 90 h after birth and still had normal Bayley scores at 24 months. Time to normal aEEG and SWC appearance should be carefully evaluated during the cooling period. NIRS values were different due to the clinical presentations of the patients.     

Non-conventional risk factors were associated with infarct patterns in ischemic stroke

Objective

Diffusion-weighted imaging (DWI) infarct patterns can play a useful role in the management of ischemic stroke patients, particularly in identifying index stroke mechanisms. Novel vascular risk factors like high sensitivity C-reactive protein (hs-CRP) and the metabolic syndrome have recently been shown to be of prognostic importance following ischemic stroke. We aimed to determine the relationship between these novel factors and infarct patterns noted on DWI.

Methods

A total of 886 patients with acute cerebral infarcts within the MCA territory were prospectively studied. Using the DWI data the patients were divided into four groups: cortical, small (<1 cm) superficial, border-zone, and deep infarcts patterns. The independent associations of various infarct DWI patterns vs. hs-CRP and presence of the metabolic syndrome were evaluated after adjusting for the confounders.

Results

hs-CRP was highest among patients with cortical infarcts, while the metabolic syndrome was most frequent in patients with border-zone infarcts. Compared to the lowest quartile of hs-CRP level, those in the highest quartile were more likely to have the cortical pattern (OR, 3.55; 95% CI, 1.92–6.56; P < 0.001), and less likely to have the deep infarct pattern (OR, 0.49; 95% CI, 0.29–0.81; P = 0.006) in logistic regression analyses. There was an independent association between presence of the metabolic syndrome and the border-zone pattern (OR, 1.75; 95% CI, 1.12–2.73; P = 0.013).

Conclusions

hs-CRP levels and metabolic derangements are independently associated with infarct pattern in acute ischemic stroke, and may be the potential targets for lessening the clinical impact of certain infarct patterns.