Low-density lipoprotein subfraction,carotid artery intima-media thickness,nitric oxide,and tumor necrosis factor alpha are associated with newly diagnosed ischemic stroke

Objectives:

Small dense (sd) low-density lipoprotein (LDL), tumor necrosis factor (TNF) alpha (α), and nitric oxide (NO) have recently emerged as important stroke risk factors. The aim of the study was to investigate the effects of increased levels of small LDL particle size, TNF-α and NO on the developed ischemic stroke and increased carotid artery intima-media thickness (CIMT).

Materials and Methods:

A total of 29 women and 25 men (a total of 54 ischemic stroke patients) and a similar age group of 50 controls (29 females and 21 males) were included in the study. CIMT, C-reactive protein (CRP), TNF-α, NO, and lipid subfraction test of the two groups were measured.

Results:

The mean LDL particle size was smaller in patients with stroke than in the controls (26.8 ± 0.31 nm vs. 27.0 ± 0.31 nm, P = 0.003). sd-LDL, TNF-α, NO, CRP, right CIMT, and left CIMT were higher in patients with stroke than in the controls (respectively; 8.2 ± 7.8 mg/dL vs. 3.3 ± 3.5 mg/dL, P < 0.001;75.6 ± 25.0 pg/mL vs. 65.4 ± 9.1 pg/mL, P = 0.009;76.4 ± 53.3 mmol/L vs. 41.5 ± 27.0 mmol/L, P < 0.001;1.9 ± 2.6 mm vs. 0.4 ± 0.3 mm P < 0.001;0.97 ± 0.38 mm vs. 0.83 ± 0.15 mm, P = 0.007;1.04 ± 0.44 mm vs. 0.87 ± 0.19 mm, P = 0.010).

Conclusion:

These results show that sd-LDL is independently associated with the incidence of stroke and may be a risk factor in the development of stroke. In addition, TNF-α, NO, right CIMT, and left CIMT may be a risk factor in the development of ischemic stroke.Key Words: Carotid artery intima-media thickness, ischemic stroke, lipid subfraction, small dense-low-density lipoprotein, tumor necrosis factor-alpha     

Association between Ischemic Stroke and Vascular Shear Stress in the Carotid Artery

Background and Purpose

Vascular shear stress is essential for maintaining the morphology and function of endothelial cells. We hypothesized that shear stress in the internal carotid artery (ICA) may differ between patients with ischemic stroke and healthy control subjects.

Methods

ICA shear stress was calculated in 143 controls and 122 patients with ischemic stroke who had a normal ICA or an ICA with <50% stenosis. The stroke group included patients who presented with a first-ever or recurrent ischemic stroke but excluded cardioembolic stroke and uncertain etiologies. Of the 122 patients, 107 (87.7%) and 15 (12.3%) patients were categorized as first-ever and recurrent stroke, respectively.

Results

Carotid diameters were significantly larger, and both peak-systolic and end-diastolic velocities were significantly lower in patients with ischemic stroke than in controls (all p values <0.05). Mean values of peak-systolic and end-diastolic shear stress in both ICAs were significantly lower in patients with ischemic stroke in models that adjusted for age, sex, and vascular risk factors (p for trend <0.05). The ICA shear stress was lowest in patients with recurrent stroke or the subtype of small-vessel occlusion. Higher peak-systolic and end-diastolic shear stresses in both ICAs were independently and negatively associated with ischemic stroke after adjusting for potential confounders (all p values <0.05).

Conclusions

ICA shear stresses were significantly lower in patients with ischemic stroke than in control subjects. Future studies should attempt to define the causal relationship between carotid arterial shear stress and ischemic stroke.     

Correlation of intracranial atherosclerosis with carotid stenosis in ischemic stroke patients

Introduction:

Carotid stenosis is a major risk factor for ischemic stroke. However, the effect of carotid stenosis on the site of stroke is still under investigation.

Aims:

This study aimed to elucidate how the presence of carotid stenosis influenced the pattern of stroke and also how it interacted with other risk factors for stroke.

Materials and Methods:

Thirty-eight patients with ischemic stroke were included in this study and were investigated with carotid artery Doppler and magnetic resonance angiography for carotid stenosis and intracranial stenosis in the circle of Willis, respectively. Other known risk factors of stroke were also studied in and compared between the subgroups with and without carotid stenosis.

Results:

In patients without carotid stenosis, anterior cerebral artery was the commonest site of stenosis. In patients with carotid stenosis, middle cerebral artery was the commonest site of stenosis. Overall, middle cerebral artery was the commonest territory of stroke. Patients with hypertension, diabetes and history of smoking had preferential stenosis of the anterior cerebral artery.     

Correlation between serum neuron specific enolase and functional neurological outcome in patients of acute ischemic stroke

Context:

The use of biomarkers to predict stroke prognosis is gaining particular attention nowadays. Neuron specific enolase (NSE), which is a dimeric isoenzyme of the glycolytic enzyme enolase and is found mainly in the neurons is one such biomarker.

Aims:

This study was carried out on patients of acute ischemic stroke with the aims to determine the correlation between NSE levels on the day of admission with infarct volume, stroke severity, and functional neurological outcome on day 30.

Materials and Methods:

Seventy five patients of acute ischemic stroke admitted in the Department of Medicine were included in the study. Levels of NSE were determined on day 1 using the human NSE ELISA kit (Alpha Diagnostic International Texas 78244, USA). Volume of infarct was measured by computed tomography (CT) scan using the preinstalled software Syngo (version A40A) of Siemen''s medical solutions (Forchheim, Germany). Stroke severity at admission was assessed using Glasgow coma scale (GCS) and functional neurological outcome was assessed using modified Rankin scale (mRS) on day 30.

Statistical Analysis Used:

Statistical analysis was performed using the SPSS software for windows version 15.0 (SPSS).

Results:

A positive correlation was found between concentration of NSE on day 1 and infarct volume determined by CT scan (r = 0.955, P < 0.001). A strong negative correlation was found between GCS at presentation and concentration of NSE on day 1 (r = −0.806, P < 0.001). There was a positive correlation between NSE levels at day 1 and functional neurological outcome assessed by mRS at day 30 (r = 0.744, P < 0.001).

Conclusions:

Serum levels of NSE in first few days of ischemic stroke can serve as a useful marker to predict stroke severity and early functional outcome. However, larger studies with serial estimation of NSE are needed to establish these observations more firmly.Key Words: Glasgow coma scale, infarct volume, ischemic stroke, modified Rankin scale, neuron specific enolase     

Angiotensinogen gene polymorphism and ischemic stroke in East Asians A meta-analysis

OBJECTIVE: To investigate the association between angiotensinogen gene M235T polymorphism and ischemic stroke in East Asians. DATA RETRIEVAL: A computer-based online search was conducted in PubMed, Google scholar, China National Knowledge lnfrastructure database between January 1990 and April 2012 for relevant studies. The were angiotensinogen or AGT, polymorphism or genetic and ischemic stroke or cerebral infarction. SELECTION CRITERIA: Case-controlled studies addressing the correlation between angiotensinogen gene M235T polymorphism and ischemic stroke in East Asians were included. The distribution of genotypes in the included studies was tested for Hardy-Weinberg equilibrium. Quality evaluation of the included studies was conducted by two physicians. Statistical analyses were carried out using Stata 12.0 software for meta-analysis. Heterogeneity tests, sensitivity analysis and publication bias were also conducted. MAIN OUTCOME MEASURES: The association between angiotensinogen gene M235T polymorphism and ischemic stroke risk in East Asians was assessed. RESULTS: Six relevant studies involving 891 patients with ischemic stroke and 727 controls were included in this meta-analysis. Results showed that there was a significant association between angiotensinogen gene M235T polymorphism and the risk of ischemic stroke in East Asians (T vs. M: odds ratio (OR) = 1.54, 95% confidence interval (CI) = 1.10-2.16; TT vs. MM: OR = 2.24, 95%CI = 1.37-3.66; TT vs. MT: OR = 1.76, 95%CI = 1.41-2.20; MM + MT vs. TT: OR = 0.57, 95%CI = 0.46-0.70). Sensitivity analysis confirmed that the study results were stable and reliable, with no publication bias. CONCLUSION: The angiotensinogen gene M235T polymorphism is associated with ischemic stroke in East Asians, and the TT genotype and T allele are risk factors for ischemic stroke.     

Transesophageal Echocardiographic Findings Are Independent and Relevant Predictors of Ischemic Stroke in Patients with Nonvalvular Atrial Fibrillation

Background and Purpose

Not only clinical factors, including the CHADS₂ score, but also echocardiographic findings have been reported to be useful for predicting the risk of ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, it remains to be determined which of these factors might be more relevant for evaluation of the risk of stroke in each patient.

Methods

In 490 patients with NVAF who underwent transesophageal echocardiography (TEE), we examined the long-term incidence of ischemic stroke events (mean follow-up time, 5.7±3.3 years). For each patient, the predictive values of gender, the CHADS₂ risk factors (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, history of cerebral ischemia), the CHADS₂ score, and the findings on echocardiography, including TEE risk markers, were assessed.

Results

The ischemic stroke rate was significantly correlated with the CHADS₂ score (p<0.05). According to the results of univariate analyses, age ≥75 years, history of cerebral ischemia, CHADS₂ score ≥2, and presence of TEE risk were significantly correlated with the incidence of ischemic stroke. Cox proportional hazards regression analyses identified age ≥75 years and presence of TEE risk as significant predictors of subsequent ischemic stroke events in patients with NVAF. As compared with that in persons below 75 years of age without TEE risk, the ischemic stroke rate was significantly higher in persons who were ≥75 years of age with TEE risk (4.3 vs. 0.56%/year, adjusted hazard ratio=8.94, p<0.001).

Conclusions

TEE findings might be more relevant predictors of ischemic stroke than the CHADS₂ score in patients with NVAF. The stroke risk was more than 8-fold higher in patients aged ≥75 years with TEE risk.     

Time course of inflammatory cytokines in acute ischemic stroke patients and their relation to inter-alfa trypsin inhibitor heavy chain 4 and outcome

Background:

Biomarker for prognosis of stroke is urgently needed for the management of acute ischemic stroke (AIS) patients.

Objective:

To evaluate the course of inflammatory cytokines in AIS patients and its comparison with inter-alfa trypsin inhibitor heavy chain 4 (ITIH4) and outcome after AIS.

Materials and Methods:

A panel of 12 inflammatory cytokines and ITIH4 were estimated in serial blood samples collected at admission, 24 h, 48 h, 72 h, 144 h and at discharge of AIS patients (n = 5).

Results:

Out of the 12 cytokines, only interleukin (IL)-2, tumor necrosis factor-alfa (TNF-α), IL-10, IL-6, IL-1B and IL-8 were in the measurable range of the kit (10 pg/mL). We found high IL-2 at admission, which decreased (P < 0.05) in the follow-up samples. TNF-α initially increases (P < 0.05) at 24 h followed by gradual decrease (P < 0.05) after 72 h. IL-10 decreases initially (P < 0.05) till 72 h as compared with its level at admission and then increases (P < 0.05) after 144 h. Similarly, ITIH4 was down-regulated in the early 72 h followed by further increase with improvement of the patient. ITIH4 correlates with IL-10 and computed tomography scan infarct volume. Serum IL-6, IL-1B and IL-8 increased in the AIS patients, but did not show any pattern.

Conclusions:

Serial measurement of IL-10, IL-2 and TNF-α and ITIH4 may be useful for the follow-up of clinical outcome after AIS.     

Systematic review of long-term Xingnao Kaiqiao needling effcacy in ischemic stroke treatment

OBJECTIVE:

To systematically evaluate the long-term effect and safety of Xingnao Kaiqiao needling method in ischemic stroke treatment.

DATA RETRIEVAL:

We retrieved relevant random and semi-random controlled trials that used the Xingnao Kaiqiao needling method to treat ischemic stroke compared with various control treatments such as conventional drugs or other acupuncture therapies. Searched databases included China National Knowledge Infrastructure, Weipu Information Resources System, Wanfang Medical Data System, Chinese Biomedical Literature Database, Cochrane Library, and PubMed, from May 2006 to July 2014.

SELECTION CRITERIA:

Two authors independently conducted literature screening, quality evaluation, and data extraction. The quality of articles was evaluated according to the Cochrane Reviewers’ Handbook 5.1, and the study was carried out using Cochrane system assessment methods. RevMan 5.2 was used for meta-analysis of the included studies.

MAIN OUTCOME MEASURES:

Mortality rate, recurrence rate, and disability rate were observed.

RESULTS:

Nine randomized and semi-randomized controlled trials treating 931 cases of ischemic stroke were included in this review. Meta-analysis results showed that there were no significant differences in mortality reduction (risk ratio (RR) = 0.58, 95% confidence interval (CI): 0.17–1.93, Z = 0.89, P = 0.37) or recurrence rate (RR = 0.55, 95%CI: 0.18–1.70, Z = 1.04, P = 0.30) of ischemic stroke patients between the Xingnao Kaiqiao needling and control treatment groups. However, the Xingnao Kaiqiao needling method had a tendency towards higher efficacy in mortality reduction and recurrence rates. The Xingnao Kaiqiao needling method was significantly better than that of the control treatment in reducing disability rate (RR = 0.51, 95%CI: 0.27–0.98, Z = 2.03, P < 0.05).

CONCLUSION:

The Xingnao Kaiqiao needling method has a better effect than control treatment in reducing disability rate. The long-term effect of Xingnao Kaiqiao needling against ischemic stroke is better than that of control treatment. However, the limitations of this study limit the strength of the conclusions. Randomized controlled trials with a strict, reasonable design, and multi-center, large-scale samples and follow-up are necessary to draw conclusions about Xingnao Kaiqiao needling.     

N-terminal pro-brain natriuretic peptide levels and short term prognosis in acute ischemic stroke

Background:

Sparse published data are available regarding the prognostic importance of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with acute ischemic stroke.

Materials and Methods:

We prospectively studied 74 consecutive patients presenting with acute ischemic stroke within 24 hours of onset. All of them underwent laboratory and imaging evaluation and were treated as per guidelines. In all subjects, plasma NT-proBNP levels were measured at initial admission and again on day 7.

Results:

Their mean age was 54 ± 13.5years; there were 49 males; 18 (24%) patients died during the hospital stay. A statistically significant negative correlation between log NT-proBNP and Glasgow coma scale (GCS) score (P < 0.001); and a significant positive correlation between log NT-proBNP and National Institutes of Health Stroke Scale (NIHSS) score (P < 0.001) were observed. Baseline log NT-proBNP levels were higher among non-survivors compared with survivors (6.7 ± 0.47 vs. 5.37 ± 0.62; P = 0.06); day 7 log NT-proBNP levels were significantly higher in non-survivors compared with survivors (7.3 ± 0.26 vs. 4.5 ± 0.4; P = 0.000). In survivors, there was a statistically significant decline in log NT-proBNP levels from baseline to day 7 (5.3710 ± 0.620 vs. 4.5320 ± 0.451; P < 0.001). In contrast, among non-survivors, log NT-proBNP levels showed a statistically significant increase from baseline to day 7 (4.5322 ± 0.451 vs. 7.2992 ± 0.263; P < 0.001). On receiver operator characteristic curve (ROC) analysis, at a cut-off value of ≥ 6.0661, log NT-proBNP had a sensitivity and specificity of 98.2 and 88.9, respectively, in predicting death.

Conclusions:

Plasma log NT-pro-BNP level appears to be a useful biological marker for predicting in-hospital mortality inpatients presenting with acute ischemic stroke.     

Factors delaying hospital arrival of patients with acute stroke

Background:

Low rates of thrombolysis for ischemic stroke in India and other developing countries have been attributed to delays in presentation to the hospital.

Materials and Methods:

A prospective study was carried out during a 12-month period ending December 2012 in the department of Neurology, Malabar Institute of Medical Sciences, Kerala, India, to look for the factors contributing to delay in hospital arrival of patients with acute stroke. Patients and or their relatives were interviewed within 48 hours of admission using a structured questionnaire.

Results:

A total of 264 patients attending the emergency department were included. There were 170 men and 94 women. The mean age was 61.5 ± 12.4 years. A total of 67 (25%) patients presented within 4 hours of stroke onset. Factors associated with early arrival (multivariate logistic regression analysis) were distance 15 km or less from hospital (P 0.03, odds ratio (OR) 2.7), directly reaching the stroke department (P < 0.001, OR 9.7), history of coronary artery disease (P 0.001, OR 3.84), higher educational status (P 0.001, OR 3.7), and presence of hemiplegia (P 0.001, OR 5.5).

Conclusions:

We found a considerable delay in the early arrival of patients to our stroke department. Health promotion strategies to improve community awareness of early symptoms of stroke, education of local physicians about the importance of early referrals to the stroke centers, and wider availability and use of ambulance services are promising methods to help expedite presentation to hospital post stroke and thereby improve the management of stroke in India.     

Clinicoanatomical correlation in stroke related aphasia

Context:

With advances in neuroimaging, traditional views regarding the clinicoanatomic correlation in stroke patients with aphasia are being challenged and it has been observed that lesions at a given cortical or subcortical site may manifest with different aphasia profiles.

Aims:

To study as to whether there is a strict clinicoanatomical correlation between the type of aphasia and lesion site in patients with first ever stroke.

Settings and Design:

Observational study, based in a tertiary care center.

Materials and Methods:

Stroke patient''s ≥18 years of age were screened and those with first ever stroke and aphasia were subjected to a detailed stroke workup and language assessment using the Hindi version of Western Aphasia Battery (WAB). Statistical analysis was done with χ² test with Yates correction and Kruskal-Wallis test. The level of significance was set at P < 0.05.

Results:

Overall aphasia was detected in 27.9% of the 260 screened cases with stroke. Amongst 60 cases with first ever stroke and aphasia, the aphasia type was: Global (33.33%), Broca''s (28.3%), transcortical motor (13.33%), transcortical sensory (10%), Wernicke''s (8.33%), anomic (5%), and conduction (1.67%) aphasia. A definite correlation between the lesion site and the type of aphasia as per the traditional classification was observed in 35% cases only.

Conclusions:

No absolute correlation exists between the lesion site and the type of clinical aphasia syndrome in majority of the patients with cortical and subcortical stroke.     

Coexisting Carotid Atherosclerosis in Patients with Intracranial Small- or Large-Vessel Disease

Background and Purpose

The coexistence of carotid atherosclerosis in ischemic stroke patients with small-vessel disease (SVD) or intracranial large-vessel disease (ICLVD) was investigated using carotid duplex ultrasonography, and whether its coexistence affected the clinical prognosis was determined.

Methods

Ischemic stroke patients with SVD or ICLVD were enrolled (n=103). Risk factors, demographic data, and National Institutes of Health Stroke Scale (NIHSS) scores were obtained for all of the subjects. Early neurological progression was defined by an increase in NIHSS score during the first 7 days. Carotid ultrasonography was performed to measure the intima-media thickness (IMT) and carotid plaques.

Results

Among the 103 patients who were retrospectively enrolled in this study (56 with SVD and 47 with ICLVD), 66 (64.1%) had an atherosclerotic plaque and 23 (22.3%) had increased IMT. Increased IMT was observed more frequently in ICLVD than in SVD [15/47 (31.9%) vs. 8/56 (14.3%), p=0.032]. An atherosclerotic plaque was observed on subsequent carotid ultrasonographic examination in 28 (50%) of the 56 patients whose computed tomography angiography scans of the neck vessels were interpreted as normal. There was no association between presence of atherosclerotic change and early neurologic progression (p=0.94).

Conclusions

A coexisting atherosclerotic plaque or increased IMT was observed in 71.8% of patients with SVD or ICLVD. Whether the coexistence of carotid atherosclerotic change with either of these conditions affects the clinical prognosis remains to be elucidated.     

Hyponatremia in stroke

Introduction:

Hyponatremia is a common electrolyte disorder encountered in patients of neurological disorders which is usually either due to inappropriate secretion of Antidiuretic hormone (SIADH) or cerebral salt wasting syndrome (CSWS). We conducted this study in a tertiary care hospital to determine the incidence and etiology of hyponatremia in patients of stroke admitted in the hospital.

Materials and Methods:

It was a prospective study done over a period of two years that included established cases of stroke diagnosed on the basis of clinical history, examination and neuroimaging. 1000 stoke patients were evaluated for hyponatremia (serum sodium <130 meq/l). The data was analysed using Chi-square test using SPSS (Statistical package for social science) software.

Results:

Out of 1000 patients, 353 patients had hyponatremia. Out of this 353 patients, 238 (67%) had SIADH and 115 (33%) had CSWS. SIADH was seen in 83 patients who had ischemic stroke and 155 patients of hemorrhagic stroke. CSWS was found in 38 patients with ischemic stroke and 77 patients with hemorrhagic stroke. Statistical analysis revealed that hyponatremia significantly affects the outcome of stroke especially when it is due to CSWS rather than SIADH.

Conclusion:

Incidence of hyponatremia in our study population was 35%. In patients of hyponatremia 67% were having SIADH and 33% were having CSWS. Overall hyponatremia affected the outcome of stroke especially when caused by CSWS. Therefore close monitoring of serum sodium must be done in all patients who are admitted with stroke and efforts must be made to determine the cause of hyponatremia, in order to properly manage such patients thereby decreasing the mortality rate.     

A randomized controlled clinical trial to compare the safety and efficacy of edaravone in acute ischemic stroke

Background and Objective:

Edaravone has potent antioxidant and free radical scavenger properties. Few Japanese studies had demonstrated its neuroprotective role in acute ischemic stroke (AIS). This study aims to evaluate the efficacy of edaravone in terms of functional outcome in a group of Indian patients of AIS.

Materials and Methods:

Fifty patients of AIS were randomly divided into two groups. The study group received 30 mg of edaravone twice daily for 14 days by infusion, while control group received normal saline infusion as placebo. Outcome assessment was done by the Modified Rankin Scale (MRS). MRS score ≤2 at 90 days was considered as a favorable outcome.

Results:

Of 25 patients, 18 (72%) had favorable outcomes (MRS ≤2) at 90 days in edaravone group, while 10 (40%) of 25 patients in placebo group had favorable outcome (P < 0.005). Two patients expired (one in each group) during treatment. The mean Barthel index increased from 41.20 ± 32.70 at baseline to 82.40 ± 18.32 at day 90 in edaravone group as compared with placebo group in which scores were 44.20 ± 22.76 at baseline and 68.20 ± 21.30 at day 90 (P < 0.005).

Conclusions:

We therefore conclude that edaravone effectively improves functional outcome in AIS.     

Chlamydia pneumoniae seropositivity in adults with acute ischemic stroke: A case�Ccontrol study

Background:

Causative role of Chlamydia pneumoniae infection in patients with acute ischemic stroke (AIS) remains unresolved till date.

Aim:

To investigate the role of C. pneumoniae antibodies in AIS.

Materials and Methods:

Patients with AIS and sex- and environment-matched controls were enrolled. Antibodies to C. pneumoniae (IgA, IgG and IgM) were measured using enzyme-linked immunosorbent assay (ELISA).

Results:

A total of 51 patients and 48 controls were enrolled. The IgA seropositivity was significantly associated with AIS (unadjusted odds ratio 3.1; 95% CI 1.38, 6.96; P = 0.005), whereas IgG (unadjusted OR 0.44; 95% CI 0.18, 1.09; P = 0.07) and IgM (unadjusted OR 1.1; 95% CI 0.36, 3.3; P = 0.88) were not. There was no difference in IgA or IgG positivity in different stroke subtypes. On multivariate analysis after adjusting for sex, hypertension, diabetes mellitus, smoking and alcohol, the IgA seropositivity yielded an adjusted OR for stroke (4.72; 95% CI 1.61, 13.83; P = 0.005), while IgG seropositivity did not (OR 0.25; 95% CI 0.08, 0.83; P = 0.23).

Conclusions:

An increased risk of AIS was demonstrated in patients seropositive for C. pneumoniae for IgA antibodies.     

Hurdles in stroke thrombolysis: Experience from 100 consecutive ischemic stroke patients

Background:

Acute management of ischemic stroke involves thrombolysis within 4.5 h. For a successful outcome, early recognition of stroke, transportation to the hospital emergency department immediately after stroke, timely imaging, proper diagnosis, and thrombolysis within 4.5 h is of paramount importance.

Aim:

To analyze the obstacles for thrombolysis in acute stroke patients.

Materials and Methods:

The study was conducted in a tertiary care center in South India. A total of hundred consecutive patients of acute ischemic stroke who were not thrombolysed, but otherwise fulfilled the criteria for thrombolysis were evaluated prospectively for various factors that prevented thrombolysis. The constraints to thrombolysis were categorized into: i) Failure of patient to recognize stroke symptoms, ii) patient''s awareness of thrombolysis as a treatment modality for stroke, iii) failure of patient''s relative to recognize stroke, iv) failure of primary care physician to recognize stroke, v) transport delays, vi) lack of neuroimaging and thrombolysis facility, and vii) nonaffordability.

Results:

The biggest hurdle for early hospital presentation is failure of patients to recognize stroke (73%), followed by lack of neuroimaging facility (58%), nonaffordability (56%), failure of patient''s relative to recognize stroke (38%), failure of the primary care physician to recognize stroke (21%), and transport problems (13%). Awareness of thrombolysis as a treatment modality for stroke was seen only in 2%.

Conclusion:

Considering the urgency of therapeutic measures in acute stroke, there is necessity and room for improvement to overcome various hurdles that prevent thrombolysis.     

The Response of Carotid Intima-Media Thickness to Medical Treatment Is Correlated with That of Intracranial Atherosclerosis

Background and Purpose

Intracranial atherosclerotic stenosis (ICAS) is considered as a major cause of stroke. The carotid intima-media thickness (CIMT), which accurately reflects the burden of generalized atherosclerosis, is also associated with stroke. The aim of this study was to determine the association between the CIMT and ICAS responses to medical treatment.

Methods

This study constituted part of the "Trial of cilostazol in symptomatic intracranial arterial stenosis"-2 that evaluated the ICAS response after randomized antiplatelet treatment. Magnetic resonance angiography and CIMT measurement were performed at baseline and after 7 months of treatment. CIMT was measured using semiautomated software, and was presented as maximum (CIMT-max) and average (CIMT-ave) values. The change in CIMT was compared relative to the ICAS response (i.e., progression, no-change, and regression). Ordinal logistic regression and analysis of covariance (ANCOVA) were used to analyze the association between the responses.

Results

Among the 101 enrolled patients, 85 underwent follow-up CIMT measurement. CIMT increased most in the ICAS progression group (CIMT-max: 0.09±0.23, CIMT-ave: 0.04±0.12), and to a lesser degree in the no-change group (CIMT-max: 0.02±0.16, CIMT-ave: 0.02±0.11), but decreased in patients with ICAS regression (CIMT-max: -0.04±0.11, CIMT-ave: -0.03±0.07; CIMT-max: p=0.010, CIMT-ave: p=0.015). Ordinal logistic regression analysis demonstrated that the change in CIMT-max was independently associated with the ICAS response (p=0.032). However, the ANCOVA revealed that the reverse was not true, in that the ICAS response was not independently associated with the change in CIMT after adjusting for confounding factors.

Conclusions

The ICAS response may be associated with the CIMT response to medical treatment.     

Ischemic complications occurring in the contralateral hemisphere after surgical treatment of adults with moyamoya disease

Objective

Direct revascularization surgery is regarded as the most effective method of treatment of adults with moyamoya disease. These patients, however, have a higher risk of perioperative ischemic complications than do patients with atherosclerotic stroke, and are at risk for ischemic complications in the hemisphere contralateral to the one operated on. We investigated the incidence and risk factors for ischemic stroke in the contralateral hemisphere after surgical treatment of adults with moyamoya disease.

Methods

We retrospectively reviewed the medical records and results of neuroimaging studies on 79 hemispheres of 73 consecutive patients with adult moyamoya disease (mean±SD age, 37.96±11.27 years; range, 18-62 years) who underwent direct bypass surgery over 6 years.

Results

Ischemic complications occurred in 4 of 79 (5.1%) contralateral hemispheres, one with Suzuki stage 3 and three with Suzuki stage 4. Three patients showed posterior cerebral artery (PCA) involvement by moyamoya vessels. Advanced stage of moyamoya disease (Suzuki stages 4/5/6; p=0.001), PCA involvement (p=0.001) and postoperative hypotension (mean arterial blood pressure <80% of preoperative mean arterial blood pressure) on the first (p<0.0001) and second (p=0.003) days after surgery were significantly correlated with postoperative contralateral ischemic complications.

Conclusion

In patients with advanced moyamoya disease and involvement of the PCA, intentional hypotension can result in ischemic stroke in the hemisphere contralateral to the one operated on. Careful control of perioperative blood pressure is crucial for good surgical results.     

Sleeping over a sleep disorder - Awareness of obstructive sleep apnoea as a modifiable risk factor for hypertension and stroke: A survey among health care professionals and medical students

Background:

Obstructive sleep apnoea (OSA) syndrome is an established and modifiable but under recognized risk factor for common disorders like stroke and hypertension.

Objective:

To assess awareness level of health care practitioners and medical students about OSA as a risk factor for stroke and hypertension.

Methods:

Questionnaire based survey with multiple response type and fill in the blanks type questions. The data was compiled and analyzed using SPSS version 19.

Results:

180 participants completed the survey questionnaire. Only 24 (13.3%) identified OSA as a reversible risk factor for ischemic stroke. 11 (6%) participants only could answer OSA as an identified risk factor for hypertension as per Seventh Joint National Committee report.

Conclusion:

This study reveals dismal level of awareness, among health professionals and medical students, about OSA being an established and modifiable risk factor for hypertension and ischemic stroke.     

��-Fibrinogen Gene -455 G/A Polymorphism in Korean Ischemic Stroke Patients

Background and Purpose

We investigated the relationship between the β-fibrinogen gene (FGB) -455 G/A polymorphism and plasma fibrinogen levels in Korean ischemic stroke patients. We also determined whether the frequency of the -455 G/A polymorphism differed between two subtypes of noncardioembolic stroke: large-artery atherosclerosis (LAA) and small-vessel occlusion (SVO).

Methods

A total of 267 patients with noncardioembolic stroke were enrolled. Plasma fibrinogen and other risk factors for stroke were evaluated. FGB -455 G/A genotypes were determined by polymerase chain reaction with restrictive enzyme Hae III and automatic DNA sequencing.

Results

The FGB -455 G/A polymorphism was significantly associated with an elevated plasma fibrinogen level (p<0.001). The frequency of the A allele in Korean stroke patients was 16.7%. However, the frequency of the -455 G/A polymorphism did not differ between LAA and SVO.

Conclusions

The plasma fibrinogen level might be affected by the -455 G/A polymorphism in noncardioembolic stroke patients. However, the LAA and SVO subtypes of ischemic stroke were not affected by the -455 G/A polymorphism.