New cerebral microbleeds in ischemic stroke patients on warfarin treatment: Two-year follow-up

Objective

Cerebral microbleeds (CMBs) are known to be indicative of bleeding-prone microangiopathy. Little is known about the significance of CMBs in anticoagulated patients. We determined the frequency of new CMBs in ischemic stroke patients who had been receiving warfarin treatment for 2 years.

Methods

A total of 204 ischemic stroke patients on warfarin therapy for 2 years underwent a repeat MRI. We compared demographic features, vascular risk factors, and radiological findings of patients with and without new CMBs.

Results

New CMBs on gradient-echo MRI were found in 29 of 204 patients (10%). Of 35 patients who had CMBs in the original study, 9 developed new CMBs after 2 years (26%), compared with 20 of the 169 patients (12%) who did not have CMBs at baseline (p = 0.03). Patients with new CMBs were older than patients without CMBs (p = 0.04), and the frequency of leukoaraiosis was significantly higher (p = 0.02). The mean duration of warfarin treatment was not significantly different between the patients with and without new CMBs (p = 0.28).

Conclusion

This longitudinal study suggested that the presence of CMBs at baseline increased the frequency of new CMBs in patients on warfarin therapy.     

Predictors of tracheostomy in patients with spontaneous intracerebral hemorrhage

Background

One third of patients with intracerebral hemorrhage (ICH) require mechanical ventilation; in most, tracheostomy may be necessary. Limited data exist about predictors of tracheostomy in ICH. The aim of our study is to identify predictors of tracheostomy in ICH.

Methods

We reviewed medical records of patients seen in our institution between 2005 and 2009, using ICD-9 codes for ICH, for admission clinical and radiological parameters. A stepwise logistic regression model was used to identify tracheostomy predictors.

Results

Ninety patients with ICH were included in the analysis, eleven of which required tracheostomy. Patients requiring a tracheostomy were more likely to have a large hematoma volume (≥30 mL) (63.4% vs. 29.1%, p = 0.037), intraventricular hemorrhage (81.8% vs. 27.8%, p < 0.0001), hydrocephalus (81.8% vs. 8.8%, p < 0.0001), admission GCS < 8 (81.8% vs. 5.1%, p < 0.0001), intubation ≥ 14 days (54.5% vs. 1.27%, p < 0.0001) and pneumonia (63.6% vs. 17.7%, p = 0.003). Stepwise logistic regression yielded admission GCS (OR = 80.55, p = 0.0003) and intubation days (OR = 87.49, p < 0.006) as most important predictors.

Conclusion

We could potentially predict the need for tracheostomy early in the course of ICH based on the admission GCS score; duration of intubation is another predictor for tracheostomy. Early tracheostomy could decrease the time, and therefore risks of prolonged endotracheal intubation and length of hospital stay.     

CT perfusion-guided versus time-guided mechanical recanalization in acute ischemic stroke patients

Objective

Perfusion studies are increasingly used to triage acute stroke patients for endovascular recanalization therapies. We compare the safety and efficacy of CT perfusion (CTP)-guided to time-guided mechanical recanalization in acute ischemic stroke (AIS) patients.

Methods

A review was conducted on 132 patients, 94 undergoing CTP-guided and 38 undergoing time-guided (maximum 8 h from symptom onset) mechanical recanalization at our institution.

Results

The rate of partial-to-complete recanalization did not differ between the CTP and the non-CTP group (78.7% vs. 81.6%, respectively, p = 0.71). ICH occurred respectively in 18.1% in the CTP group versus 31.6% in the non-CTP group (p = 0.06). The overall in-hospital mortality rate was significantly lower in the CTP group (15.9% vs. 36.8%, p = 0.04). In multivariable analysis, CTP-guided patient selection was an independent negative predictor of in-hospital mortality (OR = 3.2; p = 0.01). CTP-guided patient selection, however, was not a predictor of favorable outcome (Modified Rankin Scale 0–2 or 0–3).

Conclusions

CTP-based patient selection was associated with lower ICH and mortality rates. Favorable outcomes, however, did not differ between the 2 groups. These results may suggest a possible benefit in terms of in-hospital mortality with CTP-guided triage of AIS patients for endovascular treatment.     

Cognitive dysfunctions and cerebral microbleeds in adult patients with haemophilia A: A clinical and MRI pilot-study

Background

Studies providing information about the cognitive profile of adult haemophiliacs are lacking.

Aims

To assess the neuropsychological profile in a group of Haemophiliac patients; to detect asymptomatic cerebral microbleeds (CMBs) and any correlation between CMBs and cognitive dysfunctions; to verify how several contributing factors may determine cognitive dysfunctions and/or Magnetic Resonance Imaging (MRI) findings.

Methods

Adult haemophiliacs without history of brain bleeding were prospectively enrolled on Padua Haemophilia Centre. Patients underwent: i) “Short Neuropsychological Test” assessing cognitive functions (Short Neuropsychological Examination) to obtain an overall cognitive performance (OCP) profile standardised on a cohort matched for age, sex, cultural profile; ii) MRI of the brain to evaluate areas of brain atrophy or haemorrhagic lesions. We collected information on anti-haemorrhagic treatment, cardiovascular risk profile, viral infections, birth trauma.

Results

49 adults with haemophilia (31 severe-moderate, 18 mild) were enrolled. 73% of patients presented a reduction in OCP. According to OCP, no significant difference between severe and mild haemophilia was observed though scores tended to be worse in severe haemophilia (mean Z score 0.20 ± 0.10 vs s0.15 ± 0.11). Considering risk factors, OCP correlated significantly with coronary artery disease (p = 0.02). MRI findings in 44 patients, indicated CMBs were inversely related to OCP (R = − 0.32 p < 0.05). CMBs were associated with cardiovascular risk factors (p = 0.018).

Conclusions

Adult haemophiliacs seem to present high prevalence of mild cognitive dysfunctions that doesn’t correlate with the severity of haemophilia probably for the few number of patients evaluated. OCP impairment seems to be related to the presence of CMBs and of risk factors for cardiovascular disease.     

Blood pressure management in acute intracerebral haemorrhage guidelines are poorly implemented in clinical practice

Background

Optimal management of blood pressure (BP) in spontaneous intracerebral haemorrhage (ICH) is controversial. We assessed adherence to BP guidelines and its management in ICH in a tertiary Canadian Stroke Centre.

Methods

We conducted a retrospective analysis of 142 CT confirmed primary ICH patients admitted within 24 h of symptoms between 2005 and 2006. Initial practice with respect to BP control was reviewed and compared with current guidelines. This retrospective sample was compared with a prospective cohort participating in a BP lowering trial for the attainment of pre-defined BP targets. We also assessed the effect of BP treatment on hematoma expansion and mortality.

Results

Blood pressure treatment orders were established in 73% of the 142 patients (median age 71 years, 61% male). Only 26% of patients had target orders as advised in the current AHA guidelines. Only 54% achieved BP targets as compared with 83% of the prospective cohort within 1 h. Patients with established BP orders were more likely to have repeat brain imaging (70.2%) than those without (39.5%; p = 0.001 Mortality rates were 29.8% and 47.4% in those with and without BP targets respectively (p = 0.051).

Conclusions

Management of BP varies considerably and there appears to be little adherence to recommended guidelines. Targets are achieved more rapidly if a BP treatment protocol is utilized.     

Microvascular retinal abnormalities in acute intracerebral haemorrhage and lacunar infarction

Background

Retinal microvascular changes have been previously associated with cerebral MRI markers of small vessel disease (SVD). Whether retinal changes differ between patient with intracerebral haemorrhage (ICH) and patients with lacunar infarction (LI) caused by small vessel disease has been poorly investigated.

Objective

The study aims to compare the frequency of retinal changes between patients with LI and patients with ICH at the acute stage of stroke-related SVD.

Methods

Microvascular wall signs (arteriolar occlusion, arteriovenous nicking, focal arterial narrowing) and retinopathy lesions (microanevrysms, cotton wool spots, retinal haemorrhages, hard exudates) were assessed by retinography up to three months after stroke onset.

Results

Forty-eight non-diabetic patients with acute stroke-related to SVD (26 LI, 22 ICH) were recruited prospectively in the study. Retinal wall signs (arteriovenous nicking, and focal arterial narrowing) were found in more than three quarters of subjects and most often bilaterally in both groups. Retinopathy lesions (cotton wool spots, retinal haemorrhages) were found more frequently in ICH patients than in LI patients (22.2% vs. 15.4%, 50% vs. 34% respectively, P > 0.005). The frequency of bilateral cotton wool spots and of bilateral retinal haemorrhages was significantly higher in ICH patients than in LI patients (12.5% vs. 0%, P = 0.012, 41.2% vs. 7.7%, P = 0.029 respectively).

Conclusion

These results confirm the high frequency of microvascular alterations in patients with hypertension-related SVD leading to LI or ICH and suggest that retinal tissue alterations are more frequent in ICH than in LI. Further investigations are needed to investigate the mechanisms underlying this difference.     

A practical prediction model for early hematoma expansion in spontaneous deep ganglionic intracerebral hemorrhage

Objective

Early hematoma expansion is a known cause of morbidity and mortality in patients with intracerebral hemorrhage (ICH). The goal of this study was to identify clinical predictors of ICH growth in the acute stage.

Materials and methods

We studied 201 patients with acute (<6 h) deep ganglionic ICH. Patients underwent CT scan at baseline and hematoma expansion (>33% or >12.5 ml increase) was determined on the second scan performed within 24 h. Fourteen clinical and neuroimaging variables (age, gender, GCS at admission, hypertension, diabetes mellitus, kidney disease, stroke, hemorrhagic, antiplatelet use, anticoagulant use, hematoma density heterogeneity, hematoma shape irregularity, hematoma volume and presence of IVH) were registered. Additionally, blood pressure was registered at initial systolic BP (i-SBP) and systolic BP 1.5 h after admission (1.5 h-SBP). The discriminant value of the hematoma volume and 1.5 h-SBP for hematoma expansion were determined by the receiver operating characteristic (ROC) curves. Factors associated with hematoma expansion were analyzed with multiple logistic regression.

Results

Early hematoma expansion occurred in 15 patients (7.0%). The cut-off value of hematoma volume and 1.5 h-SBP were determined to be 16 ml and 160 mmHg, respectively. Hematoma volume above 16 ml (HV > 16) ([OR] = 5.05, 95% CI 1.32–21.36, p = 0.018), hematoma heterogeneity (HH) ([OR] = 7.81, 95% CI 1.91–40.23, p = 0.004) and 1.5 h-SBP above 160 mmHg (1.5 h-SBP > 160) ([OR] = 8.77, 95% CI 2.33–44.56, p = 0.001) independently predicted ICH expansion. If those three factors were present, the probability was estimated to be 59%.

Conclusions

The presented model (HV > 16, HH, 1.5 h-SBP > 160) can be a practical tool for prediction of ICH growth in the acute stage. Further prospective studies are warranted to validate the ability of this model to predict clinical outcome.     

Weekly variation of hospital admissions for stroke in Nis (Serbia)

Objectives

Weekly variability in stroke occurrence could be related to the change in behaviors of patients or medical personnel that occur during certain periods of the week. The aim of the present study was to examine the weekly variation in hospital admissions for stroke in Nis (Serbia), as well as to investigate how the demographic factors influenced these changes.

Patients and methods

The main data source for this study was the Nis Stroke Registry. During the study period (1996–2007) a total of 9675 stroke patients were registered. According to stroke subtypes, all registered patients were divided into three groups: patients with subarachnoid hemorrhage (SAH) (438 or 4.5%), patients with intracerebral hemorrhage (ICH) (1576 or 16.3%) and patients with ischemic stroke (IS) (6946 or 71.8%). Analyses were conducted separately for SAH, ICH and IS. Each stroke type was stratified by gender, age group and education level.

Results

We have showed that there is a significant weekly variability in the number of SAH (p = 0.028) and IS (p < 0.001) admissions, with the minimum number of admissions on Sundays (39.27 and 14.04% less than expected), and the maximum one on Tuesdays (21.46% more than expected) and Wednesdays (10.96% more than expected), respectively. We have also registered more SAH (p = 0.015) and IS (p < 0.001) admissions on weekdays than on weekend days.

Conclusion

Results of this hospital-based study confirm that there is a pattern in the variation of the number of stroke admissions on the weekly level. Reasons for the weekly variation of hospital admissions for stroke cannot be determined from the present study.     

Increased intracranial pressure is associated with the development of acute lung injury following severe traumatic brain injury

Objective

This study investigated the relationship among intracranial pressure (ICP), the development of acute lung injury (ALI) and systemic inflammatory response syndrome (SIRS) following a severe traumatic brain injury (TBI).

Methods

Post-traumatic ICP was continuously monitored for the first week following injury in a series of consecutive patients with isolated severe TBI. The initial ICP and the duration of intracranial hypertension (ICH) were calculated. The risk factors associated with the development of ALI and SIRS were evaluated.

Results

Of the 86 patients enrolled, 22 patients developed ALI and 52 patients developed SIRS during the observation period. The patients with ALI presented with a significantly higher initial ICP (31.3 ± 7.8 mmHg vs. 23.0 ± 8.8 mmHg, p < 0.001) and a longer duration of ICH (16.8 ± 6.5 h vs. 11.9 ± 6.0 h, p = 0.002) than those without ALI. The incidence of both ALI and SIRS increased with increasing initial ICP, and the presence of SIRS was associated with a fourfold increase in the risk of developing ALI (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.2–13.0).

Conclusions

Increased ICP is associated with increased risks of developing ALI and SIRS following severe TBI. Future studies designed to verify the causative relationship between increased ICP and the systemic responses are warranted.     

The loudness dependence of the auditory evoked potential (LDAEP) in schizophrenia,bipolar disorder,major depressive disorder,anxiety disorder,and healthy controls

Background

Serotonergic dysfunction in schizophrenia, bipolar disorder, major depressive disorder, anxiety disorder, and healthy controls was evaluated by measuring the activity of the loudness dependence of the auditory evoked potential (LDAEP).

Methods

The 357 subjects who were evaluated comprised 55 normal controls, 123 patients with major depressive disorder, 37 with bipolar disorder, 46 with schizophrenia, 37 with panic disorder (PD), 31 with generalized anxiety disorder (GAD), and 28 with post-traumatic stress disorder (PTSD).

Results

LDAEP was significantly stronger in healthy controls than in patients with either bipolar disorder (p = 0.025) or schizophrenia (p = 0.008), and significantly stronger in patients with major depressive disorder than in those with bipolar disorder (p = 0.01) or schizophrenia (p = 0.03). LDAEP did not differ significantly between patients with major depressive disorder and healthy control subjects (p = 0.667), or between healthy control subjects and patients with anxiety disorder, including PD (p = 0.469), GAD (p = 0.664), and PTSD (p = 0.167).

Conclusion

The findings of the present study reveal that patients with major psychiatric disorders exhibit different strengths of LDAEP according to their serotonin-related pathology. Studies controlled for psychotropic medication, menstruation cycle, and smoking are needed.     

Treatment of sleep disorders may improve fatigue in multiple sclerosis

Objective

In a previous polysomnographic cross-sectional study we found a significant relationship between sleep disorders and multiple sclerosis (MS) related fatigue. The purpose of this open follow-up observation was to compare the impact of treatment of sleep disorders on MS related fatigue measured with the Modified Fatigue Impact Scale (MFIS).

Methods

Non-randomized follow-up observation: treated versus untreated patients, subgroups according to compliance with sleep medical treatment recommendations (univariate, multivariate analysis, multiple logistic regression). 66 MS patients were followed after polysomnography, 49 patients with relevant sleep disorders and 17 without.

Results

Mean MFIS scores decreased from 41.2 to 26.2 (p = 0.025) in patients with good compliance (GC; n = 18), from 42.4 to 32.1 (p = 0.12) in patients with moderate compliance (MC; n = 12), and from 41.6 to 35.5 (p = 0.17) in non-compliant patients (NC; n = 17). Mean MFIS values increased in patients without sleep disorders from 22.9 to 25.4 (NSD; n = 12, p = 0.56). In multiple logistic regression, treatment of sleep disorders predicted decrease of MFIS-values (GC versus NSD odds ratio 13.4; p = 0.015; 95% confidence interval (CI) 1.7–107.2, MC versus NSD odds ratio 13.8; p = 0.028; 95% CI 1.3–143.3).

Conclusions

Sleep medical treatment may improve MS related fatigue when patients adhere to treatment recommendations.     

Autologous bone marrow mononuclear cell implantation for intracerebral hemorrhage—A prospective clinical observation

Background

This study was designed to assess the clinical effect of bone marrow mononuclear cells including mesenchymal stem cell (MSCs) in patients with intracerebral hemorrhage (ICH).

Methods

One hundred patients were divided into a study (n = 60) or a control group (n = 40). Bone marrow mononuclear cells from the same patient were injected to the perihemorrhage area in the base ganglia through an intracranial drainage tube 5.9 days after ICH. National Institute Stroke Scale (NIHSSS) and Barthel index was used to assess neurologic impairment and daily activities, respectively, before and 6 months after intervention.

Results

Six months after implantation, the NIHSS score in the study group was lower than in the control group (10.09 ± 8.86 vs 14.35 ± 10.14, P < 0.01), whereas the Barthel scores were higher (57.39 ± 23.51 vs 46.90 ± 20.29, P < 0.01). Neurological and functional improvement was observed in 52 (86.7%) of the study group patients, and in 17 (42.5%) of the control group patients (P = 0.001). No allergic or other adverse effects were observed in the study group.

Conclusion

Autologous bone marrow mononuclear cell implantation reduced neurological impairment and improved activities of daily living in a selected group of ICH patients. Further studies are required to ascertain the long-term safety and efficacy of this treatment.     

Epilepsy in children with periventricular leukomalacia

Objective

We aimed to analyze the development of epilepsy in a patient group with periventricular leukomalacia followed at a tertiary pediatric neurology center.

Patients and methods

The study included 108 children aged between 2 and 8 years with radiologically proven periventricular leukomalacia who had been regularly observed at the Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Pediatric Neurology outpatient clinic between January 2006 and December 2011.

Results

Neonatal seizures were reported in 22 patients (20.3%), 14 of whom developed epilepsy. A significant correlation was found between neonatal seizures and prematurity and newborn asphyxia (p = 0.013 and p = 0.010, respectively). Epilepsy developed in 35 patients (32.4%), history of neonatal seizures and more severe loss of white matter, periventricular hyperintensity and corpus callosum involvement were found to be correlated with epilepsy (p = 0.001, p = 0.004, p = 0.016, and p = 0.004, respectively). The most common seizure pattern observed was generalized tonic clonic seizures (n = 13) and complex partial seizures (n = 11). Those with focal EEG findings had a significantly better neurodevelopmental and cognitive level than those with multifocal/generalized EEG findings (p = 0.024). Seizures continued with varying frequency in 14 epileptic patients (40%) despite antiepileptic treatment.

Conclusion

Almost a third of patients with periventricular leukomalacia develop epilepsy that can be intractable in substantial part. Neonatal seizures and severe MRI findings are important clues that can indicate the development of epilepsy in these patients.     

Factors predicting the development of new onset post-operative Hydrocephalus following trans-sphenoidal surgery for pituitary adenoma

Background

The aim of this retrospective study was to identify the factors which can predict the development of new onset post-operative Hydrocephalus following transsphenoidal surgery for pituitary adenomas.

Methods

A total of 224 patients with the diagnosis of pituitary adenoma and without preoperative Hydrocephalus were identified from 1995 to 2012. Age, gender, tumor volumes, prior craniotomy and irradiation, outcome, hospital stay, CSF leak, infection and functional status of the tumor were included in the model for analysis.

Results

A total of 13 patients (5.8%) developed new onset post-operative Hydrocephalus. Intraoperative and post-operative CSF leaks were noted in 19 (8.5%) and 17 (7.6%) patients respectively. CSF infection was seen in only 7 (3.1%) patients. Age of the patient (p = 0.010), length of hospital stay (p = 0.012), intraoperative CSF leak (p = 0.000), post-operative CSF leak (p = 0.000) and CSF infection (p = 0.000) had shown significant correlation with the de novo onset of postoperative HC. The independent predictors of post-operative HC were post-operative CSF leak [p = 0.002, OR 27.898, 95% CI 3.350–232.311] and intra-operative CSF leak [p = 0.050, OR 7.687, 95% CI 1.003–58.924].

Conclusion

Age of the patient, intra-operative and post-operative CSF leak, CSF infection and duration of hospital stay were correlated with the development of HC. Post-operative and intra-operative CSF leaks were the independent predictors of new onset HC.     

Electrophysiological intermediate biomarkers for oxidative stress in schizophrenia

Objective

Diverse electrophysiological abnormalities have been associated with schizophrenia, but the underlying causes remain elusive. We tested whether the altered oxidative stress in schizophrenia contributes to the electrophysiological abnormalities.

Methods

We used an auditory oddball task to measure mismatch negativity (MMN) and gamma band response on 29 schizophrenia patients and 25 normal controls. Oxidative stress was assessed by monomeric glutathione (GSH, reduced form) and glutathione disulfide (GSSG, oxidized form).

Results

Patients had reduced MMN (p = 0.015) and reduced power of gamma band responses at 21–40 Hz and 41–85 Hz (all p < 0.001). GSH was significantly lower (p < 0.001) while %GSSG was higher (p = 0.023) in patients compared with controls. MMN was correlated with GSH in controls; while 21–40 Hz responses were correlated with GSH in patients. Lower GSH and higher GSSG levels were associated with low community functioning (p = 0.018). Multivariate mediation modeling showed that gamma band at 21–40 Hz was a significant mediator for GSH effect on community functions.

Conclusions

High beta/low gamma range (21–40 Hz) responses may be an intermediate biomarker indexing oxidative stress and its effect on clinical functions.

Significance

Electrophysiological abnormalities and associated clinical functional changes may in part be associated with heightened oxidative stress in schizophrenia.     

Motor and cognitive slowing in multiple sclerosis: An attentional deficit?

Background

Action slowing is frequently observed in multiple sclerosis (MS) patients. Several factors may account for response slowing: motor, perceptual, cognitive deficits, global mental slowing. Our objective was to examine mechanisms accounting for action slowing in MS patients.

Methods

Twenty MS patients, free of visual impairment and of upper limbs sensory–motor deficit underwent previously validated reaction time (RT) tests using visual stimuli. Three tasks were used: (1) motor tapping, (2) simple reaction time (SRT) in a simple and dual task condition, and (3) choice RT (CRT) with varying response probabilities. Results were compared to those of 20 healthy matched subjects.

Results

MS patients had: (1) lower motor tapping frequency (p = 0.02); (2) SRT lengthening (p = 0.001) related to a lower proportion of fast responses (p = 0.001) indicating attentional deficit whereas perceptuomotor index was spared (p = 0.5), without higher sensitivity to dual task (p = 0.9); and (3) CRT lengthening (p = 0.001) with spared decision time (p = 0.7).

Conclusions

This study showed that action slowing of MS patient is mainly related to (1) attentional deficit resulting in inability to maintain high level of rapid actions, and (2) subtle motor slowing even in patients without motor deficit on clinical examination, whereas (3) divided attention and decisional process are preserved.     

A population based study of outcomes after evacuation of primary supratentorial intracerebral hemorrhage

Background and Purpose

The role of surgery after primary intracerebral hemorrhage (ICH) is controversial. To explore whether hematoma evacuation after ICH had improved short-term survival or functional outcome we conducted a retrospective observational population-based study.

Methods

We identified all subjects with primary ICH between 1993 and 2008 among the population of Northern Ostrobothnia, Finland. Hematoma evacuation was carried out by using standard craniotomy or through a burr hole. We compared mortality rates and functional outcomes of patients with hematoma evacuation with those treated conservatively.

Results

Of 982 patients with verified ICH during the study period, 127 (13%) underwent hematoma evacuation. Surgically treated patients were significantly younger (mean ± SD, 63 ± 11 vs. 70 ± 12 years; p < 0.001), had larger hematomas (66 ± 36 vs. 28 ± 40 ml; p < 0.001), lower Glasgow Coma Scale scores (median, 11 vs. 14; p < 0.001) and more frequently subcortical hematomas (68% vs. 24%; p < 0.001) than those treated conservatively. In multivariable analysis, hematoma evacuation independently lowered 3-month mortality (adjusted hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.43–0.88; p < 0.03), particularly among patients aged ≤70 years with ≥30 ml supratentorial hematomas (adjusted HR, 0.26; 95% CI, 0.14–0.49; p < 0.001). However, poor outcome was not improved by surgery (adjusted odds ratio 0.71; 95% CI 0.29–1.70).

Conclusions

Improved 3-month survival was observed in patients who had undergone hematoma evacuation relative to patients not undergoing evacuation particularly in the subgroup of patients aged ≤70 years with ≥30 ml supratentorial hematomas. Surgery might improve outcome if cases could be selected more precisely and if performed before deterioration.     

Plasma nitrite levels,total antioxidant status,total oxidant status,and oxidative stress index in patients with tension-type headache and fibromyalgia

Objectives

Tension-type headache (TTH) and fibromyalgia syndrome (FM) are worldwide seen chronic pain syndromes of unknown etiology. Despite the growing body of data on pathophysiology and generation mechanisms of pain; our knowledge on pain mechanisms in both FM and TTH is yet to be limited.

Patients and methods

We investigated the plasma nitrite levels, total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) in 35 TTH, 33 FM patients and 31 healthy controls.

Results

The mean plasma nitrite levels and TAS levels were significantly low and OSI was found to be significantly high in TTH and FM groups compared to the control group (p = 0.001, p = 0.001, p = 0.001 and p = 0.001, respectively). The mean serum TOS levels were also significantly higher in FM group according to the control group (p = 0.034), but there was not a significant difference between TTH and control groups (p = 0.066).

Conclusion

These results indicated that; FM and TTH patients revealed higher oxidative stress index and lower total nitrite levels than healthy controls. We conclude that oxidative stress may have a role in the pathophysiological mechanisms of TTH and FM, although, whether it is the cause or the consequence, is not clear.     

Insulin resistance and metabolic profile in antipsychotic naïve schizophrenia patients

Objectives

Several studies have suggested insulin resistance related to dyslipidemia and body weight in drug treated schizophrenia patients. Although, insulin resistance or impaired glucose tolerance is also reported in antipsychotic naïve schizophrenia patients, their relationship with dyslipidemic changes and body weight is not well established. The present study was undertaken to examine insulin resistance in antipsychotic naïve schizophrenia patients of this region and to evaluate any association between lipid parameters and body weight with their insulin resistance, if any.

Method

Plasma glucose, total serum cholesterol and its LDL, HDL fractions, and serum insulin levels were measured from fasting blood samples of newly diagnosed, antipsychotic naïve schizophrenia patients (n = 30) and matched control group (n = 25) in a hospital based case control study. Homoeostatic model assessment (HOMA) was done to evaluate insulin resistance.

Results

Means of plasma glucose, total serum cholesterol and its LDL, HDL fractions did not vary significantly (p > 0.05) between cases and control. Insulin resistance was significantly increased (p < 0.05) in drug naïve cases. Multiple linear regression analyses did not show any association (p > 0.05) between insulin resistance and lipid parameters.

Conclusions

Newly diagnosed schizophrenia patients were more prone to insulin resistance in our study population. This was not associated with any dyslipidemic changes as the lipid parameters were not elevated in them compared to the healthy controls. It was not dyslipidemia, but some other common genetic or risk factors that might be responsible for the increased insulin resistance in antipsychotic naïve schizophrenia patients in our study population.     

Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome?

Objectives

To assess the impact of anticoagulants and antiplatelet agents on the severity and outcome of spontaneous non-traumatic intra-cerebral hemorrhage (ICH). To evaluate associations between reversal of anticoagulation and mortality/morbidity in these patients.

Methods

Data was collected on a consecutive cohort of adults presenting with ICH to an academic Emergency Department over a 3-year period starting January 2006.

Results

The final cohort of 245 patients consisted of 125 females (51.1%). The median age of the cohort was 73 years [inter-quartile (IQR) range of 59–82 years]. Antiplatelet (AP) use was seen in 32.6%, 18.4% were using anticoagulant (AC) and 8.9% patients were on both drugs (AC + AP).Patients on AC had significantly higher INR (median 2.3) and aPTT (median 31 s) when compared to patients not on AP/AC (median INR 1.0, median aPTT 24 s; p < 0.001). Similarly patients on AC + AP also had higher INR (median 1.9) and aPTT (median 30 s) when compared to those not on AC/AP (p < 0.001).Hemorrhage volumes were significantly higher for patients on AC alone (median 64.7 cm³) when compared to those not on either AC/AP (median 27.2 cm³; p = 0.05). The same was not found for patients using AP (median volume 20.5 cm³; p = 0.813), or both AC + AP (median volume 27.7 cm³; p = 0.619). Patients on AC were 1.43 times higher at risk to have intra-ventricular extension of hemorrhage (IVE) as compared to patients not on AC/AP (95% CI 1.04–1.98; p = 0.035).There was no relationship between the use of AC/AP/AC + AP and functional outcome of patients. Patients on AC were 1.74 times more likely to die within 7 days (95% CI 1.0–3.03; p = 0.05). No relationship was found between use of AP or AC + AP use and mortality.Of the 82 patients with INR > 1.0, 52 patients were given reversal (minimum INR 1.4, median 2.3). Therapy was heterogeneous, with fresh frozen plasma (FFP) being the most commonly used agent (86.5% patients, median dose 4 U). Vitamin K, activated factor VIIa and platelets were the other agents used. Post reversal, INR normalized within 24 h (median 1.2, IQR 1.1–1.3). There was no association between reversal and volume of hemorrhage, IVE, early mortality (death < 7 days) or functional outcome.

Conclusions

Anticoagulated patients were at 1.7 times higher risk of early mortality after ICH. Reversal of INR to normal did not influence mortality or functional outcome.