Relationship between augmentation index and acute ischemic stroke subtype

The aim of the present study was to explore the relationship between augmentation index (AIx) and vascular risk factors according to stroke subtypes. Patients were eligible for this study if they experienced their first ischemic stroke within the preceding 7 days and were 45 years of age or older. AIx was measured by applanation tonometry (SphygmoCor, AtCor Medical, Sydney, Australia) and ischemic stroke was classified according to the Trial of Org 10172 in the Acute Stroke Treatment (TOAST) classification system. A total of 189 patients were enrolled. The most frequent stroke subtype was lacune (76, 40.2%), followed by stroke of undetermined etiology, negative work-up (SUDn) (59, 31.2%), large artery atherosclerosis (LAA) (31, 16.4%), and cardioembolism (23, 12.2%). While there were no significant differences among the groups for hemodynamic indices, AIx at 75 beats per minute (AIx@75) was higher in lacune subtype (29.6%) than SUDn (28.4%), LAA (26.6%), and cardioembolism (24.8%) (p = 0.064). The AIx@75 was significantly related to age (r = 0.189), sex (r = 0.252), peripheral systolic blood pressure (SBP) (r = 0.189), peripheral diastolic blood pressure (DBP) (r = 0.191), and peripheral mean arterial pressure (MAP) (r = 0.327). Multiple linear regression analysis revealed that age, sex, peripheral SBP, peripheral DBP and peripheral MAP were significant (p < 0.002). This study showed that arterial stiffness is increased in acute lacunar infarction. Considering the pathogenesis of lacunar infarction and the potential interconnected causes of arterial stiffness, our findings indicate that increased arterial stiffness in acute lacunar infarction may be related to the pathogenesis of lacunar infarction.     

Association between pneumonia in acute stroke stage and 3-year mortality in patients with acute first-ever ischemic stroke

The influence of pneumonia in acute stroke stage on the clinical presentation and long-term outcomes of patients with acute ischemic stroke is still controversial. We investigate the influence of pneumonia in acute stroke stage on the 3-year outcomes of patients with acute first-ever ischemic stroke. Nine-hundred and thirty-four patients with acute first-ever ischemic stroke were enrolled and had been followed for 3 years. Patients were divided into two groups according to whether pneumonia occurred during acute stroke stage or not. Clinical presentations, risk factors for stroke, laboratory data, co-morbidities, and outcomes were recorded. The result showed that a total of 100 patients (10.7%) had pneumonia in acute stroke stage. The prevalence of older age, atrial fibrillation was significantly higher in patients with pneumonia in acute stroke stage. Total anterior circulation syndrome and posterior circulation syndrome occurred more frequently among patients with pneumonia in acute stroke stage (P < 0.001 and P = 0.009, respectively). Multivariate Cox regression revealed that pneumonia in acute stroke stage is a significant predictor of 3-year mortality (hazard ratio = 6.39, 95% confidence interval = 4.03–10.11, P < 0.001). In conclusion, pneumonia during the acute stroke stage is associated with increased risk of 3-year mortality. Interventions to prevent pneumonia in acute stroke stage might improve ischemic stroke outcome.     

Clinical characteristics of patients with ischemic stroke following the 2016 Kumamoto earthquake

To investigate the clinical characteristics of patients with ischemic stroke following the 2016 Kumamoto earthquake. We retrospectively studied patients with ischemic stroke admitted to our hospital for 12 weeks following the earthquake. We compared the clinical backgrounds and characteristics of the patients: before (the same period from the previous 3 years) and after the earthquake; and the early (first 2 weeks) and late (subsequent 10 weeks) phases. A total of 194 patients with ischemic stroke were admitted to our hospital after the earthquake; 496 (165.3/year) patients were admitted before the earthquake. No differences between the two groups were noted for the clinical backgrounds, characteristics, or biomarkers. Past history of sleeping in a shelter or small vehicle was found in 13% and 28% of patients, respectively. Sleeping in a shelter (27% vs. 10%, p = 0.013) was found more frequently in patients during the early phase than during the late phase after the earthquake. Admission of patients with ischemic stroke increased after the earthquake; however no differences between before and after the earthquake were noted for their clinical characteristics. To prevent ischemic stroke following earthquakes, mental stress and physical status of evacuees must be assessed.     

Risk factors for and incidence of subtypes of ischemic stroke

The TOAST classification divides patients with ischemic stroke into five subgroups according to the presumed etiological mechanism. The aims of the present study were to evaluate the distribution of the different etiological stroke subtypes in a hospital-based sample of stroke patients, and to investigate the association between important risk factors and stroke subtypes. A total of 210 patients with a first-ever ischemic stroke admitted to the stroke unit of Asker and B?rum Hospital in Norway between February 2007 and July 2008 were enrolled in the study. Information on vascular risk factors was collected at admittance, examination of neurological deficits was carried out during their stay, and classification was made according to the TOAST criteria. According to the TOAST classification, 24 (11.4%) of the patients suffered from large vessel disease, 66 (31.4%) from cardioembolic disease, 66 (31.4%) from small vessel disease and 54 (25.7%) from a stroke of undetermined etiology. The presence of hyperlipidemia and atrial fibrillation varied significantly between the different subtypes. In multivariate analyses, hyperlipidemia [odds ratio (OR) 2.46, 95% confidence interval (CI) 1.32-4.60] and current smoking (OR 2.06, 95% CI 1.04-4.08) were the only variables that were related to small vessel disease. Small vessel disease was observed more frequently and large vessel disease less frequently than previously reported. Small vessel disease was significantly associated with hyperlipidemia and current smoking. Our study supports the view that the etiology of lacunar strokes is multifactorial.     

Anticoagulation-related reduction of first-ever stroke severity in Chinese patients with atrial fibrillation

Atrial fibrillation (AF) is an independent risk factor for ischemic stroke and warfarin related anticoagulation has been recommended as an effective treatment for stroke prevention. We aimed to determine whether pre-stroke oral anticoagulation therapy would reduce initial stroke severity in AF patients with first-ever ischemic stroke. We identified consecutive patients who developed first-ever ischemic stroke and were eligible for anticoagulation therapy from the China National Stroke Registry. Multivariate logistic analysis was used to assess the association between warfarin usage and initial stroke severity, measured by the National Institutes of Health Stroke Scale (NIHSS) and the Glasgow Coma Scale (GCS). Of 9519 patients, 1140 (11.98%) had AF, including 440 (38.6%) without known AF before presentation, 561 (49.2%) with known AF but not taking warfarin, and 139 (12.2%) with known AF who were taking warfarin. Compared to patients with known AF but not on warfarin, the odds ratio (OR) of having a major stroke (NIHSS ⩾4) was lower in patients with known AF who were on warfarin (OR = 0.68; 95% confidence interval [CI] 0.57–0.84). The OR of developing a severe coma (GCS 3–8) was also reduced in the warfarin group (OR = 0.71; 95% CI 0.56–0.91). In conclusion, pre-stroke warfarin therapy lowered the severity of the first-ever ischemic stroke in patients with known AF. Considering its efficacy in stroke prevention and the significant under-usage of warfarin in China, the primary prevention of stroke in AF patients should be reinforced.     

Association between gastrointestinal bleeding and 3-year mortality in patients with acute,first-ever ischemic stroke

The influence of gastrointestinal bleeding on clinical presentation and outcomes of patients with acute ischemic stroke remains controversial. We investigate the effect of gastrointestinal bleeding on the outcomes of patients with acute, first-ever ischemic stroke. We enrolled 934 patients with acute, first-ever ischemic stroke and followed up them for 3 years. Patients were divided into 2 groups according to the presence or absence of gastrointestinal bleeding during acute stroke stage. Clinical presentation, stroke risk factors, laboratory data, co-morbidities, and outcomes were recorded. Seventy-six (8.1%) patients had gastrointestinal bleeding at admission. The prevalence of old age, atrial fibrillation, and previous transient ischemic attack was higher in patients with gastrointestinal bleeding (P < 0.001, P = 0.038, and P = 0.018, respectively). Total anterior circulation syndrome occurred more frequently among patients with gastrointestinal bleeding (P < 0.001). The mean length of acute ward stay, initial impaired consciousness, and stroke in evolution were higher in patients with gastrointestinal bleeding (P < 0.001, P < 0.001, and P < 0.001, respectively). The occurrence of pneumonia and dependent functional outcome were higher in patients with gastrointestinal bleeding (P < 0.001 and P < 0.001, respectively). A multivariate Cox regression analysis revealed that gastrointestinal bleeding is a significant risk factor for 3-year all-cause mortality (hazard ratio = 2.76; 95% confidence interval = 1.61–4.72; P < 0.001). In conclusion, gastrointestinal bleeding is associated with increased risk of 3-year mortality in patients with acute, first-ever ischemic stroke. Prophylactic therapies for gastrointestinal bleeding might improve ischemic stroke outcome.     

Variant rs1906591 on chromosome 4q25 confers increased risk of cardioembolic stroke in Chinese patients

Ischemic stroke (IS) is a heterogeneous multifactorial disorder caused by both genetic and environmental factors. A genome-wide association study on stroke in Caucasians identified a variant on chromosome 4q25 that is significantly associated with IS, with the strongest risk for cardioembolic stroke (CES). The current study aims to investigate the association of the rs1906591 variant on 4q25 with IS through a case-control study in a Chinese Han population. A total of 712 IS patients and 774 control subjects were involved in the current research. Stroke subtyping was performed according to the Trial of Org 10172 in Acute Stroke Treatment criteria. The genotypes were determined using the SNaPshot technique. The association of the genotypes with the risk of IS was estimated using logistic regression analysis. The rs1906591 single nucleotide polymorphism variant was associated with the CES subtype in both recessive and additive models (recessive model: odds ratio [OR] = 2.58, 95% confidence interval [CI] 1.47–4.53, p = 0.001, adjusted OR = 2.71, 95% CI 1.48–4.96, p = 0.001; additive model: OR = 2.50, 95% CI 1.19–5.25, p = 0.015, adjusted OR = 2.83, 95% CI 1.24–6.50, p = 0.013). This result indicates that patients with the AA genotype have a higher rate of CES than other genotypes. However, the rs1906591 variant was not significantly associated with the overall incidence of stroke or other stroke subtypes. The rs1906591 variant is significantly associated with CES in the Chinese Han population, but not with other stroke subtypes.     

Nonapnea sleep disorders are associated with subsequent ischemic stroke risk: a nationwide,population-based,retrospective cohort study

Background and objectivesObstructive sleep apnea (OSA) is related to an increased risk for stroke and cardiovascular disease. However, studies investigating the relationship between nonapnea sleep disorders (NSD) and the risk for subsequent ischemic stroke are scant. The objective of our study was to assess the association between NSD and the risk for acute ischemic stroke among patients in Taiwan.MethodsWe conducted our longitudinal nationwide, population-based, retrospective study using Taiwan’s National Health Insurance Research Database (NHIRD) from January 1997 to December 2001. All study participants were followed until the incidence of ischemic stroke, or until censoring due to death; until withdrawal from the insurance program; or until they were lost to follow-up by the end of 2010. Cox proportional hazard regression analysis was used to assess the association between NSD and subsequent ischemic stroke risk.ResultsWe analyzed the data collected from 94,160 participants as a comparison cohort and 47,080 participants as a NSD cohort with the diagnosis date as the index date. The age range of cohorts was 20.0–101.7 years and 64% were women. The average follow-up duration was 9.61 years for the NSD cohort and 9.42 years for the reference cohort. Overall, the ischemic stroke incidence was 1.48-fold higher in the NSD cohort than in the reference cohort (8.87 vs 6.00/1000 individual-years), with an adjusted hazard ratio (HR) of 1.19 after controlling for age, sex, and comorbidities. Our study also showed a 1.35-fold significantly higher risk for developing ischemic stroke in men compared to women. The adjusted HR was 31.2 for elderly patients compared with participants aged ⩽35 years.ConclusionsOur nationwide, population-based, retrospective cohort study provides evidence that patients with NSD were at increased risk for developing ischemic stroke compared to patients without diagnosed sleep disorder, with men and the elderly being at greatest risk.     

Serum indoleamine 2,3-dioxygenase and kynurenine aminotransferase enzyme activity in patients with ischemic stroke

We investigated the activation and pathophysiological roles of indoleamine 2,3-dioxygenase (IDO) and kynurenine aminotransferase (KAT) in patients with ischemic stroke. Patients were recruited from the acute stroke unit of a general hospital within 24 hours post-stroke. The immune transmission turbidity method was used to determine the concentration of serum high-sensitivity C-reactive protein (hsCRP), apolipoprotein A-1 and apolipoprotein B. The concentrations of triglyceride, cholesterol, high density lipoprotein (HDL), low density lipoprotein and non-esterified fatty acids were determined using an enzymatic method. Tryptophan (TRP), kynurenine (KYN) and kynurenine acid (KYNA) concentrations were determined by high performance liquid chromatography. The National Institutes of Health Stroke Scale (NIHSS) was used to assess the neurological deficits at admission and 3 weeks post-stroke. The IDO and KAT activity ratio were calculated by KYN/TRP and KYNA/KYN, respectively. The correlation between hsCRP and IDO, KAT and NIHSS score was also analyzed. A total of 81 patients with ischemic stroke and 35 normal controls were recruited. Lower TRP, KYNA, HDL and KAT activity ratio were found in the stroke group compared to the control group (p < 0.05). The levels of hsCRP and IDO activity ratio were much higher in the stroke group than the control group (p < 0.01). The IDO activity in patients with ischemic stroke showed a positive correlation with hsCRP (r = 0.425, p = 0.027). In addition, hsCRP and IDO levels were positively associated with the NIHSS score both at admission and 3 weeks post-stroke. These data suggest an inflammatory response characterized by up-regulated IDO activation in ischemic stroke, which might be closely relevant to its pathophysiology.     

ACE I/D polymorphism in different etiologies of ischemic stroke

OBJECTIVES: Data concerning an association between angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and ischemic stroke (IS) remain inconsistent. Results of some studies suggest that DD genotype may be a risk factor for small vessel disease (SVD) stroke. Here, we investigated whether this polymorphism is associated with IS of different etiologies in a Polish population. SUBJECTS AND METHODS: Ischemic stroke etiology was established according to the TOAST criteria. We studied 92 stroke patients with large vessel disease and their 184 matched controls; 96 stroke patients with SVD and 192 controls; 180 patients with cardioembolic stroke (CE) and 180 controls. ACE I/D polymorphism was determined using the polymerase chain reaction method. RESULTS: The distribution of ACE genotypes and alleles was essentially the same in all analyzed IS subtypes and their matched controls. CONCLUSIONS: We failed to find an association between ACE polymorphism and etiological subtypes of IS in a Polish population.     

Supplementation of folic acid and vitamin B12 reduces plasma levels of asymmetric dimethylarginine in patients with acute ischemic stroke

Increased levels of asymmetric dimethylarginine (ADMA) have been observed in patients with acute ischemic stroke. We aimed to investigate the correlation between ADMA and ischemic stroke, and evaluate the effect of supplementation of folic acid and vitamin B₁₂ on concentrations of ADMA. Patients were randomized into intervention and non-intervention groups within 3 days after symptom onset. Intervention group patients were treated with folic acid (5 mg daily) and vitamin B₁₂ (500 μg twice daily) for 12 weeks. ADMA and homocysteine (Hcy) concentrations were measured before treatment (baseline) and 2 and 12 weeks after treatment. The laboratory measures were also collected from healthy controls. Eighty five subjects were enrolled in this study, from whom 72 with complete baseline and follow-up laboratory data were included in the present analysis. Thirty four patients were assigned to the intervention group and 38 patients to the non-intervention group. Sixty people were enrolled as healthy controls. Levels of ADMA and Hcy were raised (p < 0.05) in patients with acute ischemic stroke. With supplementation of both folic acid and vitamin B₁₂, the levels of ADMA and Hcy decreased significantly at 2 and 12 weeks (p < 0.05). The present study reconfirmed that ADMA can be regarded as a risk biomarker for acute ischemic stroke. We observed that with supplementation of folic acid and vitamin B_12, levels of ADMA were decreased in patients with acute ischemic stroke.     

急性缺血性脑卒中CISS分型与危险因素相关性分析

目的探讨急性缺血性卒中中国缺血性卒中亚型（CISS）分型与不同危险因素的关系。方法回顾性分析连续登记的急性缺血性脑梗死患者,记录其危险因素,并按CISS分型标准将急性缺血性卒中分为5种类型并分析相关因素对其发生风险的影响。结果在纳入标准的212例急性缺血性卒中患者中,大动脉粥样硬化型99例（46.7%）、心源性卒中型35例（16.5%）、穿支动脉疾病45例（21.2%）、其他病因型5例（2.4%）、病因不确定型28例（13.2%）。吸烟者、高血压病、冠心病、心房颤动者在5亚型间比例差异具有统计学意义（P〈0.05）。相关和回归分析显示冠心病、心房颤动与心源性卒中亚型有正相关性（β=1.34、2.206,P〈0.05）,高血压病与穿支动脉疾病亚型有相关性,为正相关性（β=1.074,P〈0.05）。结论不同类型缺血性脑卒中与不同的危险因素有关,心房颤动、冠心病是心源性卒中亚型的危险因素,高血压病是穿支动脉疾病亚型的危险因素。     

Increasing pressure of external counterpulsation augments blood pressure but not cerebral blood flow velocity in ischemic stroke

External counterpulsation (ECP) is a noninvasive method used to augment cerebral perfusion but the optimal use of ECP in ischemic stroke has not been well documented. We aimed to investigate the effects of ECP treatment pressure on cerebral blood flow and blood pressure (BP). We recruited 38 ischemic stroke patients with large artery occlusive disease and 20 elderly controls. We commenced ECP treatment pressure at 150 mmHg and gradually increased to 187.5, 225 and 262.5 mmHg. Mean cerebral blood flow velocities (CBFV) of bilateral middle cerebral arteries and continuous beat-to-beat BP were recorded before ECP and during each pressure increment for 3 minutes. Patient CBFV data was analyzed based on whether it was ipsilateral or contralateral to the infarct. Mean BP significantly increased from baseline in both stroke and control groups after ECP commenced. BP increased in both groups following raised ECP pressure and reached maximum at 262.5 mmHg (patients 16.9% increase versus controls 16.52%). The ipsilateral CBFV of patients increased 5.15%, 4.35%, 4.55% and 3.52% from baseline under the four pressures, respectively. All were significantly higher than baseline but did not differ among different ECP pressures; contralateral CBFV changed likewise. Control CBFV did not increase under variable pressures of ECP. ECP did increase CBFV of our patients to a roughly equal degree regardless of ECP pressure. Among the four ECP pressures tested, we recommend 150 mmHg as the optimal treatment pressure for ischemic stroke due to higher risks of hypertension-related complications with higher pressures.     

Intravenous thrombolysis,mechanical embolectomy,and intracranial stenting for hyperacute ischemic stroke in a patient with moyamoya disease

The Japanese translation of moyamoya means “puff of smoke” and refers to the angiographic appearance of dilated collateral vessels seen during chronic progressive narrowing of the intracranial supraclinoid portions of the internal carotid arteries. Despite cerebral ischemia being the most common presenting symptom, 20% to 40% of adults suffer a hemorrhagic stroke. Due to the lack of evidence and histopathologic findings, intravenous and endovascular reperfusion therapy is typically avoided. This case study presents a patient with moyamoya disease in the hyperacute phase of ischemic stroke. The patient received full dose (0.9 mg/kg) tissue plasminogen activator and subsequently underwent a mechanical clot extraction and Wingspan stent (Stryker, Kalamazoo, MI, USA) placement. The use of these options in the setting of moyamoya disease is novel. This demonstrates that moyamoya disease may not be an absolute contraindication to revascularization in hyperacute ischemic stroke and underscores that many perceived contraindications to thrombolytic and mechanical revascularization therapies are relative.     

Frequency and natural history of fatigue after stroke: a systematic review of longitudinal studies

BackgroundFatigue is a common and distressing symptom after stroke. Stroke survivors and health professionals need to know whether fatigue is likely to improve, or get worse over time; and whether there is a temporal association with depression or anxiety, which might provide a target for treatment,Aims and objectivesTo systematically review all longitudinal observational studies which have assessed fatigue on at least two separate time points after stroke onset to determine its frequency, natural history and temporal relationship with anxiety and/or depression.MethodWe systematically searched MEDLINE, EMBASE, CINAHL and PsychInfo using the keywords “fatigue” and “stroke” and their associated terms or synonyms. Data were extracted regarding time points after stroke where fatigue was assessed, frequency of fatigue at each time point and any reported associations with anxiety and/or depression.Results101 full texts were retrieved after scrutinising the titles and abstracts. Nine fulfilled our inclusion criteria. Fatigue was assessed at a variety of time points after stroke (from admission—to 36 months). The frequency of fatigue ranged from 35%–92% at the first time point. Frequency of fatigue declined across time points in seven of the studies (n = 764) and increased in two studies (n = 195). Three papers found significant associations between fatigue and mood at the same time point. The single study investigating temporal associations between fatigue and mood disorders reported that depression predicted subsequent fatigue.ConclusionsFatigue is present soon after stroke onset and remains common in the longer term. There is little evidence regarding the temporal relationship between fatigue and mood: this is an area where further research is needed.     

Carotid webs associated with ischemic stroke. Updated general review and research directions

Carotid web (CaW) is an intimal variant of fibromuscular dysplasia strongly associated with ipsilateral cerebral infarction. Although considered rare, it is a recent and increasing concern for physicians involved in stroke diagnosis and management. The present general review relies on a systematic literature analysis and aims to update readers on the latest knowledge in the field of symptomatic CaW (syCaW). CaW associated with ipsilateral cerebral infarction or transient ischemic attack has been identified in 189 patients. Ischemic strokes (IS) mostly occur in middle age (mean 46 years) and predominately in females (66%). The high frequency of African descendant patients among case reports and series (58%) suggests an ethnic susceptibility for CaW development. CaW features are characterised by a shelf-like intraluminal defect on contrast sagittal imaging, a linear defect that splits the lumen on axial section, a post-contrast stagnation rostral to the lesion and a frequent contralateral mirrored CaW (26.6%). An artery-to-artery embolism mechanism is widely accepted via CaW blood stasis, thrombus formation and clot fragmentation scattered by blood flow. Therefore, cerebral infarctions are often large related to a high proportion of proximal occlusion (62.5%). CaW confers a high rate of IS recurrence despite standard anti-platelet treatment that reaches 33.3% of patients prospectively followed with a median time to event of one year. Although no randomised therapeutic studies are available, surgery (n = 39) or stenting (n = 50) have been often proposed and seem to avoid recurrences. CaW clearly emerges as a cause of cryptogenic embolic stroke and should be systematically investigated in routine. A large number of points remain to be elucidated and CaW patients should be steadily included in registries and randomised therapeutic studies.     

The role of fibroblast growth factor receptor 4 polymorphisms in the susceptibility and clinical features of ischemic stroke

Some polymorphisms in the fibroblast growth factor receptor 4 gene (FGFR-4) have been correlated with coronary artery disease, however, the role of polymorphisms in the FGFR-4 gene in ischemic stroke remain unknown. A total of 270 patients with ischemic stroke and 297 controls were recruited. Stroke subtype was classified and clinical severity of stroke in patients was evaluated. The polymorphisms in the FGFR-4 were genotyped. There were no significant differences of genotype distributions and allele frequencies of rs145302848C/G and rs147603016G/A between stroke patients and controls (all p > 0.05). However, genotype frequencies and allele frequencies at rs351855G/A (Gly388Arg) were significantly different between stroke patients and controls (both p < 0.001). With the rs351855GG genotype as a reference, the presence of rs351855AA homozygote had a significantly increased risk for stroke (adjusted odds ratio 2.663; 95% confidence interval 1.673–4.229, p < 0.001). The polymorphisms at rs145302848C/G and rs147603016G/A did not influence the susceptibility of stroke in this study. All FGFR-4 polymorphisms were not associated with clinical features such as Trial of Org 10172 in Acute Stroke Treatment subtype or stroke severity as indicated by mean National Institutes of Health Stroke Scale scores. Our study suggests a positive association between FGFR-4 gene polymorphism at rs351855G/A and susceptibility to ischemic stroke.     

Holmes’ tremor as a delayed complication of thalamic stroke

Movement disorders are not commonly associated with stroke. Accordingly, thalamic strokes have rarely been associated with tremor, pseudo-athetosis and dystonic postures. We present a 75-year-old man who developed a disabling tremor 1 year after a posterolateral thalamic stroke. This tremor had low frequency (3–4 Hz), did not disappear on focus and was exacerbated by maintaining a static posture and on target pursuit, which made it very difficult to perform basic functions. MRI demonstrated an old ischemic lesion at the left posterolateral thalamus. Treatment with levodopa led to symptom control. Lesions in the midbrain, cerebellum and thalamus may cause Holmes’ tremor. Delayed onset of symptoms is usually seen, sometimes appearing 2 years after the original injury. This may be due to maturation of a complex neuronal network, leading to slow dopaminergic denervation. Further studies are needed to improve our understanding of this unique disconnection syndrome.     

Acute stroke with major intracranial vessel occlusion: Characteristics of cardioembolism and atherosclerosis-related in situ stenosis/occlusion

Acute ischemic stroke with major intracranial vessel occlusion is commonly due to cardioembolic or atherosclerosis-related in situ stenosis/occlusion, and immediate identification of these subtypes is important to establish the optimal treatment strategy. The aim of this study was to clarify the differences in clinical presentation, radiological findings, neurological temporal courses, and outcomes between these etiologies, which have not been fully evaluated. Consecutive emergency patients with acute ischemic stroke were retrospectively reviewed. Among them, patients with stroke with major intracranial vessel occlusion were analyzed with a focus on clinical and radiological findings, and a comparison was performed for those with cardioembolic or atherosclerosis-related in situ stenosis/occlusion. Of 1053 patients, 80 had stroke with acute major intracranial vessel occlusion (45 with cardioembolic and 35 with atherosclerosis-related in situ stenosis/occlusion). Interestingly, the susceptibility vessel sign (SVS) on T2-weighted MR angiography was more frequently detected in cardioembolic stroke (80.0%) than in atherosclerosis (in situ stenosis: 5.9%, chronic occlusion: 14.3%). Moreover, the proximal intra-arterial signal (IAS) on arterial spin labeling MRI and the distal IAS on fluid attenuated inversion recovery MRI was less frequently detected in chronic occlusion (27.3% and 50.0%, respectively) than in acute occlusion due to cardioembolic or in situ stenosis. Multivariate regression analysis showed that the SVS was significantly related to cardioembolism (adjusted odds ratio (OR): 21.68, P = 0.004). Clinical characteristics of acute stroke with major intracranial vessel occlusion differ depending on the etiology. The SVS and proximal/distal IAS on MRI are useful to distinguish between cardioembolic and atherosclerotic-related in situ stenosis/occlusion.     

C-reactive protein and long-term ischemic stroke prognosis

C-reactive protein (CRP) is an inflammatory biomarker of inflammation and may reflect progression of vascular disease. Conflicting evidence suggests CRP may be a prognostic biomarker of ischemic stroke outcome. Most studies that have examined the relationship between CRP and ischemic stroke outcome have used mortality or subsequent vascular event as the primary outcome measure. Given that nearly half of stroke patients experience moderate to severe functional impairments, using a biomarker like CRP to predict functional recovery rather than mortality may have clinical utility for guiding acute stroke treatments. The primary aim of this study was to systematically and critically review the relationship between CRP and long-term functional outcome in ischemic stroke patients to evaluate the current state of the literature. PubMed and MEDLINE databases were searched for original studies which assessed the relationship between acute CRP levels measured within 24 hours of symptom onset and long-term functional outcome. The search yielded articles published between 1989 and 2012. Included studies used neuroimaging to confirm ischemic stroke diagnosis, high-sensitivity CRP assay, and a functional outcome scale to assess prognosis beyond 30 days after stroke. Study quality was assessed using the REMARK recommendations. Five studies met all inclusion criteria. Results indicate a significant association between elevated baseline high sensitivity CRP and unfavorable long-term functional outcome. Our results emphasize the need for additional research to characterize the relationship between acute inflammatory markers and long-term functional outcome using well-defined diagnostic criteria. Additional studies are warranted to prospectively examine the relationship between high sensitivity CRP measures and long-term outcome.