Outcome in very severe stroke

Functional outcome after stroke with severe disability (Barthel Index<60 points) was analyzed retrospectively in one hundred patients, including seventy-three with nonhemorrhagic stroke and twenty-seven with hemorrhagic stroke admitted to our neurorehabilitation center between 1986 and 2000. Neurological deficits and functional disabilities were assessed with the Barthel Index at admission to rehabilitation and after the rehabilitation program in survivors. The rehabilitation therapy was based on the Bobath concept. Patients were not discharged until neurological and functional stability had been reached. There was no difference for age, length of stay, Barthel Index scores at admission and discharged between the groups. Gain in the Barthel Index scores between admission and discharge (p=0.005) resulted from more efficiency in the group with hemorrhagic stroke. These patients appeared to exhibit better functional gain at discharge from rehabilitation than nonhemorrhagic patients. This observation points out that long-term outcome is also better for patients who experience hemorrhagic stroke.     

Brain development of very preterm and very low-birthweight children in childhood and adolescence: a meta-analysis

Aim The aim of this article was to clarify the impact and consequences of very preterm birth (born <32wks of gestation) and/or very low birthweight ([VLBW], weighing <1500g) on brain volume development throughout childhood and adolescence. Method The computerized databases PubMed, Web of Knowledge, and EMBASE were searched for studies that reported volumetric outcomes during childhood or adolescence using magnetic resonance imaging and included a term‐born comparison group. Fifteen studies were identified, encompassing 818 very preterm/VLBW children and 450 term‐born peers. Average reductions in the total brain volume, white matter volume, grey matter volume, and in the size of the cerebellum, hippocampus, and corpus callosum were investigated using meta‐analytic methods. Results Very preterm/VLBW children were found to have a significantly smaller total brain volume than the comparison group (d=?0.58; 95% confidence interval [CI] ?0.43 to ?0.73; p<0.001), smaller white matter volume (d=?0.53; CI ?0.40 to ?0.67; p<0.001), smaller grey matter volume (d=?0.62; CI ?0.48 to ?0.76; p<0.001), smaller cerebellum (d=?0.74; CI ?0.56 to ?0.92; p<0.001), smaller hippocampus (d=?0.47; CI ?0.26 to ?0.69; p<0.001), and smaller corpus callosum (d=?0.71; CI ?0.34 to ?1.07; p<0.001). Reductions have been associated with decreased general cognitive functioning, and no relations with age at assessment were found. Interpretation Very preterm/VLBW birth is associated with an overall reduction in brain volume, which becomes evident in equally sized reductions in white and grey matter volumes, as well as in volumes of diverse brain structures throughout childhood and adolescence.     

Institutional care for the very old. Results of the Munich study of the very old

In a two-wave community study in Munich, Germany, a representative sample of 402 people older than 85 years was restudied 1 year later. In the first cross-section a total of 358 (89.1%) subjects were interviewed. One year later 263 (73.5%) subjects were reexamined. Several diagnostic systems were used. We analysed the living situation in different risk groups. Women, singles and the older ones more often lived in institutions. Women suffering from dementia and men suffering from depression were more often in homes. Need for care and subjective health status influenced the living situation.     

Senile plaques in very aged cats

Senile plaques were found in the cerebral cortices of three very aged cats (more than 18 years old). The plaques consisted of a coarse assembly of silver staining-positive materials, and was morphologically different from the well-known classical, primitive, and diffuse plaques. Congophilic amyloid angiopathy was observed in a few cortical arterioles of the oldest cat (20 years old). The senile plaques and a few cortical blood vessels were immunopositive for amyloid β-protein (Aβ). Aβ-positive materials were also sparsely distributed in the cortical neuropil but did not form senile plaques there. These findings should help to clarify the development of senile plaques and the early stage of Aβ deposition. Received: 29 May 1995 / Revised, accepted: 28 September 1995     

Electroconvulsive therapy in the very old

At least one study has questioned the safety of electroconvulsive therapy (ECT) in the very old. In this study, the authors reviewed a 5-year experience with ECT at two university psychiatric services for patients 75 years of age or older. Both outcomes and complications were reviewed. Nineteen of 22 patients (86.3%) were ECT responders. Five patients (22.7%) suffered complications which varied from minor to substantial. ECT was found to be an effective and reasonably safe treatment for depression in the very old.     

Characteristics of very poor outcome schizophrenia

The authors compared 21 "Kraepelinian" schizophrenic patients who had been ill and dependent on others for the past 5 years with 76 chronic schizophrenic patients in remission or with exacerbations requiring hospitalization. The Kraepelinian patients met the criteria for schizophrenia by more diagnostic systems than the exacerbated patients, were less responsive to haloperidol, had more severe negative symptoms, and had similarly severe positive symptoms. They had cerebral ventricles that were more asymmetrical and a greater family history of schizophrenia spectrum disorders than the other chronic patients. These data suggest that patients with 5 years of illness and complete dependency on others may represent a subgroup of schizophrenia.     

Low-dose methylphenidate in the very old

Two patients, aged 104 and 91 years, who presented with medical problems and depression were successfully treated with 1.25 to 5 mg of methylphenidate without evidence of tolerance or toxicity. Benefits were sustained for more than 8 months on smaller amounts of this central nervous system stimulant than has been previously reported.     

Complement activation in very early Alzheimer disease

The activation of the classical complement (C)-system in early-stage Alzheimer disease (AD) and nondemented aging was examined with immunohistochemistry in subjects assessed by the Clinical Dementia Rating (CDR). Activation (staining for C3 and C4 fragments) was found in all brains with amyloid deposits, including all nondemented (CDR 0) cases, with either small numbers of diffuse plaques or with sufficient plaques and tangles to indicate preclinical AD. Staining for C3 and C4 increased in parallel with plaque density in very mild to severe clinical AD. A subset of very mild AD (CDR 0.5) cases also showed C1q (on plaques) and C5b-9 (on neuritic plaques and tangles), whereas these C-fragments were consistently found in severe AD (CDR 3). Mirror section (split-face) analysis showed that C1q, C3, and apoJ (clusterin) occurred on the same plaques. However, C-system regulators CD59, CR1, DAF, and MCP were not detected on plaques or tangles at any stage, indicating that C-activation related to AD is incompletely controlled.     

Intravenous TPA for very old stroke patients

BACKGROUND: Although thrombolysis in patients with advanced age is considered more risky, some may benefit from TPA treatment. We studied safety and recanalization/recovery in patients older than 80 years treated with TPA and compared them with younger stroke patients. METHODS: We studied patients treated with intravenous TPA and divided them into younger (<80 years) and older (> or =80 years) groups for comparison. Diagnostic transcranial Doppler was completed before bolus, and patients were consequently monitored for up to 2 h when feasible. Clinical data included NIH Stroke Scale score, symptomatic intracranial hemorrhage (ICH) and discharge disposition. RESULTS: We studied 127 younger (mean 63 years, range 31-79) and 56 older patients (mean 84 years, range 80-93). Median baseline NIH Stroke Scale score was higher in the older group (18 vs. 14 points, NS). Occlusion locations, onset to needle time (median 130 vs. 120 min) as well as improvement at 24 h (median 5 vs. 4 points) were similar in both groups. Transcranial Doppler monitoring showed similar partial or complete recanalization rates (66 vs. 66%), onset to recanalization time (median 160 vs. 158 min) and reocclusion rates (26 vs. 25%). Symptomatic and fatal ICH was not higher in the older group (7.1 and 3.5% vs. 6.3 and 3.9%, NS). There was higher mortality among older patients (20 vs. 11%, NS). At discharge, 23% of older patients went home, 41% underwent rehabilitation and 16% were transferred to skilled nursing facilities, compared with 31, 43 and 15% respectively, in the younger group. CONCLUSION: After intravenous TPA treatment, patients over 80 years of age have similar recanalization, short-term improvement and symptomatic ICH rates compared with younger patients. However, older patients tend to have higher in-hospital mortality.