The prognostic value of pulsatility index, flow velocity, and their ratio, measured with TCD ultrasound, in patients with a recent TIA or ischemic stroke

Wijnhoud AD, Koudstaal PJ, Dippel DWJ. The prognostic value of pulsatility index, flow velocity, and their ratio, measured with TCD ultrasound, in patients with a recent TIA or ischemic stroke.
Acta Neurol Scand: 2011: 124: 238–244.
© 2011 John Wiley & Sons A/S. Background – Increased flow velocities, and combinations of low mean flow velocity (MFV) and a high pulsatility index (PI) are associated with intracranial arterial disease. We investigated the association of MFV and the ratio of PI and MFV (PI–MFV ratio) in the middle cerebral artery (MCA) with recurrence of vascular events in patients with a transient ischemic attack (TIA) or minor ischemic stroke. Methods – Five hundred and ninety‐eight consecutive patients underwent TCD investigation. Outcome events were fatal or non‐fatal stroke and the composite of stroke, myocardial infarction, or vascular death (major vascular events). Hazard ratios (HR) were estimated with Cox proportional hazards multiple regression method, adjusted for age, gender, and vascular risk factors. Results – TCD registration was successful in 489 patients. Mean follow‐up was 2.1 years. Cumulative incidence was 9% for all stroke and 12% for major vascular events. MFV over 60.5 cm/s increased the risk for both stroke (HR 2.8; 95% CI: 1.3–6.0) and major vascular events (HR 2.6; 95% CI: 1.3–5.0). Each unit increase in PI–MFV ratio was associated with a HR 2.8 (95% CI: 1.7–4.8) for stroke and HR 2.2 (95% CI: 1.3–3.6) for major vascular events. Conclusion – In patients with a TIA or non‐disabling ischemic stroke, MFV and the PI–MFV ratio in the MCA are independent prognostic factors for recurrent vascular events.     

The effect of sildenafil citrate (Viagra) on cerebral blood flow in patients with cerebrovascular risk factors

Lorberboym M, Mena I, Wainstein J, Boaz M, Lampl Y. The effect of sildenafil citrate (Viagra) on cerebral blood flow in patients with cerebrovascular risk factors.
Acta Neurol Scand: 2010: 121: 370–376.
© 2009 The Authors Journal compilation © 2009 Blackwell Munksgaard. Objectives – Sildenafil citrate is widely used for erectile dysfunction. The present study examined the short‐term effects of sildenafil administration in individuals with cerebrovascular risk factors, including patients with a history of stroke. Materials and Methods – Twenty‐five consecutive male patients with erectile dysfunction and vascular risk factors were included in the study. A perfusion brain SPECT study was performed at baseline and 1 h after the oral administration of sildenafil. Results – Associations between any of the risk factors and the perfusion scores were not detected, with the exception of stroke. Stroke patients showed significantly more areas with diminished perfusion after sildenafil administration compared to baseline. Conclusions – In patients with diabetes or hypertension, a dose of 50 mg sildenafil does not appear to produce detrimental effects on cerebral blood flow. However, patients with a history of stroke may be at increased risk of hemodynamic impairment after the use of sildenafil.     

Central sleep apnea is associated with increased risk of ischemic stroke in the elderly

Muñoz R, Durán‐Cantolla J, Martinez‐Vila E, Gállego J, Rubio R, Aizpuru F, De La Torre G, Barbé F. Central sleep apnea and risk of stroke in the elderly.
Acta Neurol Scand: 2012: 126: 183–188.
© 2011 John Wiley & Sons A/S. Objectives – Sleep apnea/hypopnea syndrome is a well‐recognized independent risk factor for stroke in middle‐aged population, but controversy remains in older subjects. We examined the possible association between different respiratory parameters and risk of stroke in a prospective population‐based cohort of 394 stroke‐free elderly subjects. Material and Methods – Fully overnight polysomnography was performed at baseline. Over the 6 year follow‐up period, 20 ischemic strokes occurred. Differences in stroke‐free survival between subjects according to central apnea index (CAI) were assessed. Results – We just observed association with incident ischemic stroke on central sleep apnea (CSA) episodes. Obstructive sleep apnea, time passed under 90% oxygen saturation, or arousal index were not associated. The event‐free survival was lowest in the highest CAI group. This association was independent of any other vascular risk factors. Conclusions – CSA is the specific respiratory event associated with stroke in the elderly. Additionally, CSA could be a marker of silent brain ischemia, as a sign of disturbed regulation of central respiratory mechanisms, tentatively of ischemic origin.     

Previously unknown thyroid dysfunction in patients with acute ischemic stroke

Bengtsson D, Brudin L, Wanby P, Carlsson M. Previously unknown thyroid dysfunction in patients with acute ischemic stroke.
Acta Neurol Scand: 2012: 126: 98–102
© 2011 John Wiley & Sons A/S. Objectives – Opinions differ regarding the clinical significance of subclinical thyroid disorders. The aim of the present study was to evaluate the prevalence and influence of previously unknown overt or subclinical thyroid dysfunction in patients with acute ischemic stroke and to look for differences between cardio‐embolic and non‐embolic ischemic stroke. Material and methods – A total of 153 Swedish patients diagnosed with first‐time acute ischemic stroke were included in the study and categorized for suspected cardio‐embolic (n = 30) or non‐embolic (n = 123) ischemic stroke depending on the presence of atrial fibrillation (AF). Blood samples were taken 48 h or earlier after onset of stroke symptoms. Results – Previously, unknown overt or subclinical thyroid dysfunction was found in 12%. Previously, unknown overt or subclinical hyperthyroidism was more common in the AF group (13%) compared to the non‐AF group (3%), P = 0.048. Patients with AF had slightly higher concentrations of free T4 (15 vs 14 pm ; P < 0.001), but there was no significant difference in concentrations of S‐TSH or prevalence of thyroperoxidase (TPO) antibodies between the groups. Conclusions – In patients with first‐time acute ischemic stroke, unknown thyroid dysfunction is common, and unknown overt or subclinical hyperthyroidism is associated with cardio‐embolic stroke.     

Sunlight exposure is important for preventing hip fractures in patients with Alzheimer's disease, Parkinson's disease, or stroke

Iwamoto J, Takeda T, Matsumoto H. Sunlight exposure is important for preventing hip fractures in patients with Alzheimer’s disease, Parkinson’s disease, or stroke.
Acta Neurol Scand: 2012: 125: 279–284.
© 2011 John Wiley & Sons A/S. Objectives – Hypovitaminosis D as a result of malnutrition or sunlight deprivation, increased bone resorption, low bone mineral density (BMD), or an increased risk of falls may contribute to an increased risk of hip fractures in patients with neurological diseases, including Alzheimer’s disease, Parkinson’s disease, and stroke. The purpose of this study was to clarify the efficacy of sunlight exposure for reducing the risk of hip fractures in patients with such neurological diseases. Methods – The English literature was searched using PubMed, and randomized controlled trials evaluating the efficacy of sunlight exposure for reducing the risk of hip fractures in patients with Alzheimer’s disease, Parkinson’s disease, and stroke were identified. The relative risk and the 95% confidence interval were calculated for individual randomized controlled trials, and a pooled data analysis (meta‐analysis) was performed. Results – Three randomized controlled trials were identified. Sunlight exposure improved hypovitaminosis D and increased the BMD. The relative risk (95% confidence interval) of hip fractures was 0.22 (0.05, 1.01) for Alzheimer’s disease, 0.27 (0.08, 0.96) for Parkinson’s disease, and 0.17 (0.02, 1.36) for stroke. The relative risk (95% confidence interval) calculated for the pooled data analysis was 0.23 (0.10, 0.56) (P = 0.0012), suggesting a significant risk reduction rate of 77%. Conclusion – The present meta‐analysis added additional evidence indicating the efficacy of sunlight exposure for reducing the risk of hip fractures in patients with Alzheimer’s disease, Parkinson’s disease, and stroke.     

Hypertension and incident dementia in community-dwelling elderly Yoruba Nigerians

Ogunniyi A, Lane KA, Baiyewu O, Gao S, Gureje O, Unverzagt FW, Murrell JR, Smith‐Gamble V, Hall KS, Hendrie HC. Hypertension and incident dementia in community‐dwelling elderly Yoruba Nigerians.
Acta Neurol Scand: 2011: 124: 396–402.
© 2011 John Wiley & Sons A/S. Objectives – To investigate the relationship between hypertension and dementia incidence in community‐dwelling elderly Yoruba (aged 70 years and above) because of sparse information on dementia and its risk factors in developing countries. Materials and Methods – Community‐based, prospective study of consenting elderly Yoruba using two‐stage design. Blood pressure was measured during the baseline evaluation at 2001 and hypertension was defined as BP ≥ 140/90 mmHg. Diagnosis of dementia and normal cognition was by consensus using standard criteria. Non‐demented subjects from the 2001 evaluation wave were re‐evaluated during the 2004 and 2007 waves for dementia. Logistic regression was used to examine the association of baseline hypertension and incident dementia, after adjusting for age, gender, education, and histories of stroke and smoking. P‐values <0.05 were considered significant. Results – During the 6‐year follow‐up, 120 individuals developed dementia, while 1633 remained non‐demented. The frequency of hypertension in the demented group was significantly higher than in the non‐demented (70.0% vs 60.2%, P = 0.034). Baseline hypertension was a significant risk factor for dementia (OR = 1.52; 95% CI 1.01–2.30). Higher systolic, diastolic or pulse pressure was associated with increased risk (P < 0.05). Participants with diastolic BP ≥ 90 mmHg were at a significantly greater risk than those with readings below 70 mmHg (OR = 1.65; 95% CI 1.01–2.69). Conclusions – Hypertension was associated with increased risk of dementia in elderly Yoruba and its appropriate treatment may lower the risk.     

Ten-year risk for myocardial infarction in patients with first-ever stroke: a community-based study

Appelros P, Gunnarsson KE, Terént A. Ten‐year risk for myocardial infarction in patients with first‐ever stroke: a community‐based study.
Acta Neurol Scand: 2011: 124: 383–389.
© 2011 John Wiley & Sons A/S. Background – Stroke and coronary heart disease (CHD) share common risk factors. The risk for stroke patients to have a myocardial infarction (MI) has not been fully explored. Methods – Three hundred and seventy‐seven first‐ever stroke patients were ascertained prospectively. The 10‐year incidence of MI was examined by register searches. The results were compared to the general Swedish population. Predictors for MI were identified using univariate and multivariate analysis. Results – The cumulative incidence of MI over 10 years was 25.0/100 (95% confidence interval (CI), 19.5–31.5), 26.5 for men, (95% CI, 18.9–45.8) and 23.4 for women (95% CI, 16.0–32.9). Compared to the general population, the relative risk for stroke patients having a MI was 1.6 for men (95% CI, 1.12–2.37) and 1.9 for women (95% CI, 1.27–2.90). In multivariate analysis, CHD before the stroke (MI, angina pectoris, coronary artery bypass grafting, or percutaneous transluminal coronary angioplasty) and peripheral artery disease were significant predictors for MI. Conclusion – The risk for MI is significantly higher, for both male and female stroke patients, compared to the general population. Stroke patients with previous CHD and peripheral artery disease are at highest risk. Stroke patients should receive adequate secondary prevention, and cardiac complaints must be taken seriously.     

Factors associated with lobar vs. non-lobar intracerebral hemorrhage

Matsukawa H, Shinoda M, Fujii M, Takahashi O, Yamamoto D, Murakata A, Ishikawa R. Factors associated with lobar vs. non‐lobar intracerebral hemorrhage.
Acta Neurol Scand: 2012: 126: 116–121.
© 2011 John Wiley & Sons A/S. Objectives – The relationship between body mass index (BMI) and stroke subtypes has received more research attention than that between BMI and location of intracerebral hemorrhage (ICH). Lobar hemorrhage (LH) differs from non‐LH primarily in terms of etiology, i.e. cerebral amyloid angiopathy is the main cause of LH. This study aimed to determine the relationship between BMI and ICH. Materials and methods – In this retrospective study involving 460 consecutive patients with ICH, BMI was significantly lower in LH than for other ICH locations. BMI categories were underweight (BMI < 18.5 kg/m²), normal weight (18.5–23.0 kg/m²), overweight (23.0–27.5 kg/m²), or obesity (≥27.5 kg/m²). Outcome at 1 year was evaluated by the modified Rankin Scale (mRS). We investigated the relationship of BMI and other clinical characteristics with LH and non‐LH. Results – LH was associated with age (>70 years), underweight, unfavorable outcome (mRS ≥3), and daily alcohol consumption. Hypertension and intraventricular bleeding were significantly less common in patients with LH than those with non‐LH. Conclusions – Alongside risk factors conventionally thought to be related to LH, underweight may also be a LH‐related factor, specifically in the elderly.     

The gender gap in stroke: a meta-analysis

Giralt D, Domingues‐Montanari S, Mendioroz M, Ortega L, Maisterra O, Perea‐Gainza M, Delgado P, Rosell A, Montaner J. The gender gap in stroke: a meta‐analysis.
Acta Neurol Scand: 2012: 125: 83–90.
© 2011 John Wiley & Sons A/S. Several studies have indicated that gender differences might exist in stroke. Objectives and methods – Our goal was to perform a comprehensive meta‐analysis in order to evaluate and quantify stroke gender disparities through a systematic search of relevant articles published up to October 2009 and addressing gender related differences in ischemic stroke risk factors, stroke subtype and severity, diagnostic tests, and acute phase and secondary prevention treatments. Results – Forty‐five articles were included in the analysis, representing a total of 673,935 patients. Women were globally older than men (+5.2 years) and suffered more hypertension (P = 0.017) and atrial fibrillation (P < 0.001), although they were less likely to drink alcohol (P < 0.001), smoke cigarettes (P < 0.001), present hyperlipidemia (P = 0.033) or diabetes (P = 0.003) than men. Baseline stroke severity was not different between genders. Women suffered more cardioembolic strokes, while men had more atherothrombotic strokes. Moreover, women were less likely to receive stroke‐related treatments, such as antiplatelets (P < 0.001), statins (P < 0.001), and tPA (P < 0.001) than men. Although meta‐regression did not identify age or stroke etiology as sources of heterogeneity, caution should be taken as that analysis was possible only for gender differences in secondary prevention with antiplatelets because of limited data for other end points. Conclusions – Gender differences have been identified on the risk factors profile and diagnostic and therapeutic management of patients with ischemic stroke. Active measures should thus be taken to avoid bias in clinical practice.     

Heart rate variability - a potential early marker of sub-acute post-stroke infections

Günther A, Salzmann I, Nowack S, Schwab M, Surber R, Hoyer H, Witte OW, Hoyer D. Heart rate variability – a potential early marker of sub‐acute post‐stroke infections.
Acta Neurol Scand: 2012: 126: 189–196.
© 2011 John Wiley & Sons A/S. Objective – Infection is the most relevant complication after acute ischemic stroke. Activity of the autonomic nervous system seems to control post‐stroke immunodepression. We investigated heart rate variability (HRV) indices that reflect autonomic readjustments as predictors of post‐stroke infection. Materials and methods – Forty‐three patients with acute ischemic stroke were enrolled in a prospective study. The predictability of sub‐acute infections (day 4 ± 1 after admission) was investigated in 34 patients without acute infection by means of HRV indices obtained in the acute period (48 h after admission). Results – Sub‐acute infection could be predicted in patients without clinical or paraclinical (white blood cell count and C‐reactive protein) signs of infection in the acute period at (i) day: increased HFnorm, reduced LFnorm and LF/HF; (ii) night: reduced LF and VLF (P < 0.05). Conclusions – HRV indices are candidates for early markers of developing post‐stroke infections, preceding routine blood samples. Thus, HRV‐based early diagnosis of post‐stroke infection should be investigated in more detail as it may have implications as a novel tool for timely and appropriate treatment. A corresponding continuous HRV‐based risk assessment using the ECG provided by the routine stroke monitoring system would be possible without any additional burden for patients and staff.     

A review on sex differences in stroke treatment and outcome

Appelros P, Stegmayr B, Terént A. A review on sex differences in stroke treatment and outcome.
Acta Neurol Scand: 2010: 121: 359–369.
© 2009 The Authors Journal compilation © 2009 Blackwell Munksgaard. Background – Beyond epidemiological differences, it has been controversial whether any important sex differences exist in the treatment of stroke. In this review paper, the following areas are covered: thrombolysis, stroke unit care, secondary prevention, surgical treatment, and rehabilitation. Additionally, symptoms at stroke onset, as well as outcome measures, such as death, dependency, stroke recurrence, quality of life, and depression are reviewed. Methods – Search in PubMed, tables‐of‐contents, review articles, and reference lists after studies that include information about sex differences in stroke care. Results – Ninety papers are included in this review. Women suffer more from cortical and non‐traditional symptoms. Men and women benefit equally from thrombolysis and stroke unit care. Women with cardioembolic strokes may benefit more from anticoagulant therapy. Most studies have not found any tendency towards sexism in the choice of treatment. Post‐stroke depression and low quality‐of‐life seem to be more common among women. Mortality rates are higher among men in some studies, while long‐term ADL‐dependency seems to be more common among women. Conclusions – Sex differences in stroke treatment and outcome are small, with no unequivocal proof of sex discrimination. Women have less favourable functional outcome because of higher age at stroke onset and more severe strokes.     

Effect of methylphenidate and/or levodopa coupled with physiotherapy on functional and motor recovery after stroke – a randomized,double‐blind,placebo‐controlled trial

Lokk J, Salman Roghani R, Delbari A. Effect of methylphenidate and/or levodopa coupled with physiotherapy on functional and motor recovery after stroke – a randomized, double‐blind, placebo‐controlled trial.
Acta Neurol Scand: 2011: 123: 266–273.
© 2010 John Wiley & Sons A/S. Objective – Amphetamine‐like drugs are reported to enhance motor recovery and activities of daily living (ADL) in stroke rehabilitation, but results from trials with humans are inconclusive. This study is aimed at investigating whether levodopa (LD) and/or methylphenidate (MPH) in combination with physiotherapy could improve functional motor recovery and ADL in patients with stroke. Material and methods – A randomized, double‐blind, placebo‐controlled trial with ischemic stroke patients randomly allocated to one of four treatment groups of either MPH, LD or MPH+LD or placebo combined with physiotherapy was performed. Motor function, ADL, and stroke severity were assessed by Fugl‐Meyer (FM), Barthel index (BI), and National Institute of Health Stroke Scale (NIHSS) at baseline, 15, 90, and 180 days respectively. Results – All participants showed recovery of motor function and ADL during treatment and at 6‐month follow‐up. There were slightly but significant differences in BI and NIHSS compared to placebo at the 6‐month follow‐up. Conclusion – Ischemic chronic stroke patients having MPH and/or LD in combination with physiotherapy showed a slight ADL and stroke severity improvement over time. Future studies should address the issue of the optimal therapeutic window and dosage of medications to identify those patients who would benefit most.     

Outcome of lamotrigine treatment in juvenile myoclonic epilepsy

Bodenstein‐Sachar H, Gandelman‐Marton R, Ben‐Zeev B, Chapman J, Blatt I. Outcome of lamotrigine treatment in juvenile myoclonic epilepsy.
Acta Neurol Scand: 2011: 124: 22–27.
© 2011 John Wiley & Sons A/S. Objectives – To determine the response rate of patients with juvenile myoclonic epilepsy (JME) to lamotrigine (LTG) and identify predictive factors for treatment response. Material and methods – Medical records of 62 patients with JME were reviewed for demographic, clinical, and EEG parameters. We determined clinical response to LTG and compared LTG responders with non‐responders. Results – There were 35 LTG responders (56%) and 27 non‐responders (44%). JME patients without generalized tonic clonic seizures (GTCS) responded better to LTG (P = 0.04). Valproic acid (VPA) failure because of adverse events rather than lack of efficacy (P = 0.069) and delay in diagnosis (P = 0.07) showed a tendency toward good response to LTG. Conclusions – LTG should be considered a drug of first choice for JME patients without GTCS. LTG as second‐line treatment after VPA failure seems more appropriate for those patients whose reason for VPA failure is poor tolerability rather than lack of efficacy.     

Methylenehydrofolate reductase (C677T) polymorphism and large artery ischemic stroke subtypes

They‐They TP, Nadifi S, Rafai MA, Battas O, Slassi I. Methylenehydrofolate reductase (C677T) polymorphism and large artery ischemic stroke subtypes.
Acta Neurol Scand: 2011: 123: 105–110.
© 2010 John Wiley & Sons A/S. Background – The role for the methylenetetrahydrofolate reductase C677T gene variants in the risk of ischemic stroke is controversial. Method – This first case–control study including 91 cases affected by ischemic stroke and 182 controls matched for age, sex, and same area was conducted in Casablanca, Morocco. Allele and genotype frequency were characterized by using PCR followed by HinfI enzymatic digestion. Results – We found no statistic association of T allele carriers genetic factors with stroke; odds ratio, 1.1; 95% confidence interval (CI), 0.59–2.04, P = 0.303. The results shown significant association of T allele carriers genetic factors with atherothrombotic subtype stroke (n = 42); odds ratio, 2.1; 95% CI: 1.17–3.8; P = 0.012, and adjusted odds ratio of 6.5; 95% CI: 1.86–23.1, P = 0.003, for TT genotype variant compared with CC wild genotype. Conclusion – We suggested that MTHFR C677T variant may be a determinant of atherothrombotic event of ischemic stroke in Morocco.     

Post-stroke depression and functional independence: a conundrum

Brown C, Hasson H, Thyselius V, Almborg A‐H. Post‐stroke depression and functional independence: a conundrum.
Acta Neurol Scand: 2012: 126: 45–51.
© 2011 John Wiley & Sons A/S. Objectives – People who suffer a stroke are at risk of developing post‐stroke depression (PSD). Not only does this lower their quality of life but it also increases their risk of another stroke or death. This study aimed to investigate the factors associated with PSD in order to better direct rehabilitation efforts aimed at cutting the incidence of PSD. Material and methods – This study was based on all patients admitted to the stroke unit of a hospital in southern Sweden from 1 October 2003 to 30 November 2005. The total number of patients involved was 181. Measures were collected at 2 ± 1 weeks after discharge from hospital, 3 ± 0.5 months after the occurrence of the stroke and 12 ± 1 months after the occurrence of the stroke. Information collected was results from the Center of Epidemiologic Studies Depression Scale and the Barthel Index together with demographic data including age, sex, time since stroke and relationship status. Results – Those patients involved in the study were mainly men (58–59%) and generally those either married or cohabiting (53–57%). The age of respondents ranged from 32 to 92 years with a mean age of 74.0 (95%CI 72.37–75.63) at 2 ± 1 weeks after discharge. The Barthel Index scores ranged from 15 to 100 with means of between 88.7 and 91.7. Between 15% and 19% of the group were clinically depressed during the time frame of the study. The Barthel Index, measuring functional independence in terms of need for assistance with personal activities of daily living (P‐ADL), was consistently associated with PSD. Conclusions – The differences found in levels of depression between those with lower functional independence after a stroke compared to those more independent in P‐ADL, raise the possibility that attention should be paid to therapeutic rehabilitation for stroke patients to help them recover as much functional independence as possible in order to improve their quality of life and lower their chances of developing PSD.     

Statin treatment after a recent TIA or stroke: is effectiveness shown in randomized clinical trials also observed in everyday clinical practice?

Lingsma HF, Steyerberg EW, Scholte op Reimer WJM, van Domburg R, Dippel DWJ, the Netherlands Stroke Survey Investigators. Statin treatment after a recent TIA or stroke: is effectiveness shown in randomized clinical trials also observed in everyday clinical practice?
Acta Neurol Scand: 2010: 122: 15–20.
© 2009 The Authors Journal compilation © 2009 Blackwell Munksgaard. Aim and background – The benefit of statin treatment in patients with a previous ischemic stroke or transient ischemic attack (TIA) has been demonstrated in randomized clinical trials (RCT). However, the effectiveness in everyday clinical practice may be decreased because of a different patient population and less controlled setting. We aim to describe statin use in an unselected cohort of patients, identify factors related to statin use and test whether the effect of statins on recurrent vascular events and mortality observed in RCTs is also observed in everyday clinical practice. Methods – In 10 centers in the Netherlands, patients admitted to the hospital or visiting the outpatient clinic with a recent TIA or ischemic stroke were prospectively and consecutively enrolled between October 2002 and May 2003. Statin use was determined at discharge and during follow‐up. We used logistic regression models to estimate the effect of statins on the occurrence of vascular events (stroke or myocardial infarction) and mortality within 3 years. We adjusted for confounders with a propensity score that relates patient characteristics to the probability of using statins. Results – Of the 751 patients in the study, 252 (34%) experienced a vascular event within 3 years. Age, elevated cholesterol levels and other cardiovascular risk factors were associated with statin use at discharge. After 3 years, 109 of 280 (39%) of the users at discharge had stopped using statins. Propensity score adjusted analyses showed a beneficial effect of statins on the occurrence of the primary outcome (odds ratio 0.8, 95% CI: 0.6–1.2). Conclusion – In our study, we found poor treatment adherence to statins. Nevertheless, after adjustment for the differences between statin users and non‐statin users, the observed beneficial effect of statins on the occurrence of vascular events within 3 years, although not statistically significant, is compatible with the effect observed in clinical trials.     

D‐dimer levels and stroke progression in patients with acute ischemic stroke and atrial fibrillation

Krarup L‐H, Sandset EC, Sandset PM, Berge E. D‐dimer levels and stroke progression in patients with acute ischemic stroke and atrial fibrillation.
Acta Neurol Scand: 2011: 124: 40–44.
© 2010 John Wiley & Sons A/S. Background – Patients with acute ischemic stroke and atrial fibrillation are at increased risk of stroke progression and recurrence. We sought to assess whether D‐dimer and other markers of hemostatic activation could predict these adverse events in such patients. Method – Blood samples were obtained from patients included in the Heparin in Acute Embolic Stroke Trial. Stroke progression was defined as a ≥3‐point worsening on the Scandinavian Stroke Scale during the first 48 h after randomization. Blood samples were analyzed for D‐dimer, prothrombin fragment 1 + 2, soluble fibrin monomer, and C‐reactive protein. Results – A total of 382 patients were included in the analyses. Levels of D‐dimer and other markers of hemostatic activation were not significantly higher in patients with stroke progression than in other patients (D‐dimer median values: 1025 ng/ml vs 970 ng/ml, P = 0.73). The same was true for recurrent stroke (D‐dimer: 720 ng/ml vs 973 ng/ml, P = 0.96), and the combined endpoint of stroke progression, recurrent stroke, and death (D‐dimer: 991 ng/ml vs 970 ng/ml, P = 0.91). Multivariable analyses did not alter the results. Conclusion – D‐dimer and other markers of hemostatic activation were not associated with stroke progression, recurrent stroke, or death in patients with acute ischemic stroke and atrial fibrillation.     

Predictors for 5-year survival in a prospective cohort of elderly stroke patients

Whiting R, Shen Q, Hung WT, Cordato D, Chan DKY. Predictors for 5‐year survival in a prospective cohort of elderly stroke patients.
Acta Neurol Scand: 2011: 124: 309–316.
© 2011 John Wiley & Sons A/S. Objectives – To examine predictors for 5‐year survival in elderly stroke patients. Materials and Methods – Prospective cohort study of 186 consecutive acute stroke patients aged ≥65 years admitted to Bankstown‐Lidcombe Hospital, Australia 03/2002 to 03/2003. All subjects were followed up in 2007/8, at 5 years post‐stroke, for outcome measures. Logistic regression analysis was performed to predict 5‐year survival using covariables, including functional status, age, stroke type and severity and vascular risk factors. Patients lost to follow‐up (n = 20) were excluded from the analyses. Results – One hundred patients (60%) were dead at study end. Predictors for survival in final logistic regression model were as follows: Glasgow Coma Scale (GCS) on admission (OR 1.49, 95%CI 1.1–2.0, P = 0.01), preadmission functional independence measure (FIM) score (OR 1.04, 95%CI 1.0–1.1, P = 0.01), age (OR 0.93, 95%CI 0.87–0.98, P = 0.01) and atrial fibrillation (OR 0.43, 95% CI 0.19–0.95, P = 0.04). For 5‐year survivors, mean Modified Rankin Scale was 3.1 ± 1.5, total FIM score 85 ± 32, mini‐mental state examination (MMSE) 22 ± 8 and Hospital Anxiety and Depression (HAD) scores 5.4 ± 3.4 and 5.2 ± 3.9, respectively. FIM cognition score was significantly lower at 5 years when compared to baseline (24 ± 8 vs 29 ± 8, P < 0.05) (all scores expressed as mean ± SD). In contrast, MMSE, HAD and total FIM scores were not significantly different at 5 years when compared to baseline. Conclusions – The study identified lower GCS on admission, lower preadmission FIM score, age and atrial fibrillation as negative predictors for 5‐year survival following stroke.     

Strokes in paroxysmal atrial fibrillation have more favorable outcome than in permanent atrial fibrillation

Background – Permanent (ptAF) and paroxysmal (pxAF) atrial fibrillation carry similar risk of ischemic stroke (IS). Objective – Our aim was to compare the course of IS due to ptAF and pxAF. Methods – A prospective, single‐center study was conducted in patients with AF and acute IS with 6‐month follow‐up. Results – We included 178 patients: 70 (39%) with pxAF and 108 (61%) with ptAF. Compared with patients with ptAF, patients with pxAF more often presented with subcortical, mainly lacunar strokes (21% vs 8%, P = 0.01) and were less frequently dependent at discharge (16% vs 42%, P < 0.001) and after 6 months (16% vs 20%, P < 0.001). Strokes in patients with pxAF were more frequently categorized as non‐cardioembolic (35% vs 18%, P = 0.01). In the multivariate analysis, after adjustment for confounding factors (diabetes, chronic heart failure, high risk of thromboembolism and lack of prestroke anticoagulation), ptAF was an important risk factor for unfavorable short‐term (OR 5.4; P < 0.01) and long‐term outcomes (OR 2.6, P = 0.01) of IS. In all patients with AF, the occurrence of non‐cardioembolic stroke was related to a reduced risk of dependence or death in short‐term outcome (OR 0.4, P = 0.04) and marginally influenced long‐term outcome (OR 0.49, P = 0.09). Conclusions – The present study suggests that, compared with patients with ptAF, ISs in patients with pxAF have better outcomes.     

Circadian rhythm of stroke onset during the month of Ramadan

El‐Mitwalli A, Zaher AA, El Menshawi E. Circadian rhythm of stroke onset during the month of Ramadan.
Acta Neurol Scand: 2010: 122: 97–101.
© 2009 The Authors Journal compilation © 2009 Blackwell Munksgaard. Background and purpose – The onset of acute stroke exhibits a circadian pattern occurring more frequently in late morning hours. The objective of this study was to investigate the diurnal pattern of stroke during the month of Ramadan. Patients and methods – We studied consecutive stroke patients 1 month before Ramadan (BR) and during Ramadan (DR) over two successive years 2007 and 2008. The age, gender, risk factor profiles were analyzed. The National Institute of Health and Stroke Scale Score (NIHSS) was used for clinical assessment at admission. The exact time of stroke onset in both groups was obtained. Results – A total of 507 patients were studied: 245 patients in the DR group and 262 patients in the BR group. The age distribution of patients was not significantly different between the two groups. There was no statistically significant difference in the sex ratio, risk factors, and NIHSS score between the two groups (P > 0.05). The higher frequency of stroke onset time in the BR group was in the time between 6:00 a.m. and noon; whereas the frequency was higher between noon and 6:00 p.m. in the DR group. Conclusion – A significant shift of the circadian pattern of stroke onset time from the period between 6:00 a.m. and noon to that between noon and 6:00 pm has been found during the month of Ramadan.