Intracardiac myxomas in Carney complex are significant causes of cardiovascular morbidity and mortality through embolic stroke and heart failure. The genetic, clinical and laboratory characteristics of Carney complex-related strokes from atrial myxomas have not been described before. The PRKAR1A gene is mutated in more than 60% of the cases of Carney complex.
Methods and Results
We studied patients with strokes and cardiac myxomas that were hospitalized in our institution and elsewhere: a total of 7 patients with 16 recurrent atrial myxomas and more than 14 episodes of strokes were identified. Neurological deficits were reported; in one patient, an aneurysm developed at the site of a previous stroke. All patients were female, most had presented with Cushing syndrome, and all had additional tumors or other Carney complex manifestations. Other than gender, although there was a trend for patients being overweight and hypertensive, no other risk factors were identified. A total of 5 patients (71%) had a PRKAR1A mutation; all mutations (c418_419delCA, c.340delG/p.Val113fsX15, c.353_365del13/p.Ile118fsX6, c.491_492delTG/p.Val164fsX4, c.177+1G>A) were located in exons 3–5 and introns 2–3, and all led to a non-sense PRKAR1A mRNA.
Female Carney complex patients appear to be at a high risk for recurrent atrial myxomas that lead to multiple strokes. Early identification of a female patient with Carney complex is of paramount importance for the early diagnosis of atrial myxomas and the prevention of strokes.
The etiology behind and physiological significance of spontaneous oscillations in the low-frequency spectrum in both systemic and cerebral vessels remain unknown. Experimental studies have proposed that spontaneous oscillations in cerebral blood flow reflect impaired cerebral autoregulation (CA). Analysis of CA by measurement of spontaneous oscillations in the low-frequency spectrum in cerebral vessels might be a useful tool for assessing risk and investigating different treatment strategies in carotid artery disease (CAD) and stroke. We reviewed studies exploring spontaneous oscillations in the low-frequency spectrum in patients with CAD and ischemic stroke, conditions known to involve impaired CA. Several studies have reported changes in oscillations after CAD and stroke after surgery and over time compared with healthy controls. Phase shift in the frequency domain and correlation coefficients in the time domain are the most frequently used parameters for analyzing spontaneous oscillations in systemic and cerebral vessels. At present, there is no gold standard for analyzing spontaneous oscillations in the low-frequency spectrum, and simplistic models of CA have failed to predict or explain the spontaneous oscillation changes found in CAD and stroke studies. Near-infrared spectroscopy is suggested as a future complementary tool for assessing changes affecting the cortical arterial system.
Cerebral autoregulation; low frequency oscillations; stroke; carotid artery disease; transcranial Doppler; near-infrared spectroscopy
More than a quarter of ischemic strokes (IS) are excluded from thrombolysis due to unknown time of symptom onset. Recent evidence suggests that a mismatch between DWI and FLAIR imaging could be used as a surrogate for the time of stroke onset. We compared used the DWI–FLAIR mismatch and the FLAIR/DWI ratio to estimate the time of onset in a group of patients with nocturnal strokes and unknown time of onset.
We used a prospectively collected acute IS patient database with MRI as the initial imaging modality. Nineteen selected nocturnal stroke patients with unknown time of onset were compared with 22 patients who had an MRI within 6 hours from stroke onset (control A) and 19 patients who had an MRI between 6 and 12 hours (control B). DWI and FLAIR signal was rated as normal or abnormal. FLAIR/DWI ratio was calculated from independent DWI and FLAIR ischemic lesion volumes using semiautomatic software.
The DWI–FLAIR mismatch was different among groups (unknown 43.7%, control A 63.6%, control B 10.5%; FFH p=0.001). There were significant differences in FLAIR/DWI ratio among the 3 groups (unknown: 0.05±0.12, control A: 0.17±0.15, control B: 0.04±0.06; KW p<0.0001). Post-hoc pair wise comparisons showed that FLAIR/DWI ratio from the unknown group was significantly different from control B (p=0.0045), but not different from control A. DWI volumes were not different among the 3 groups.
A large proportion of nocturnal IS patients with unknown time of stroke initiation have a DWI-FLAIR mismatch suggesting a recent stroke onset.
Acute ischemic stroke; Fluid Attenuated Inversion Recovery; Diffusion-Weighted Imaging; circadian pattern; sleep
To examine whether lipid lowering medications (LLMs) and especially statin drugs can delay cognitive decline and dementia onset in individuals with and without Mild Cognitive Impairment (MCI) at baseline.
Longitudinal, observational study of 3,069 cognitively healthy elderly, ages 75 years and older, who were enrolled in the Ginkgo Evaluation of Memory Study. Primary outcome measure was the time to adjudicated all-cause dementia and Alzheimer dementia (AD). Secondary outcome measure was the change in global cognitive function over time measured by 3MSE and ADAS-cog scores.
Among participants without MCI at baseline current use of statins was consistently associated with a reduced risk of all cause dementia (HR 0. 79, 95% confidence interval, 0.65–0.96, p=0.021) and AD (HR 0.57, 95% confidence interval, 0.39–0.85, p= 0.005). In participants who initiated statin therapy lipophilic statins tended to reduce dementia risk more than nonlipophilic agents. In contrast there was no significant association between LLM use (including statins), dementia onset or cognitive decline in individuals with baseline MCI. However, in individuals without MCI at baseline there was a trend for a neuroprotective effect of statins on cognitive decline.
Statins may slow the rate of cognitive decline and delay the onset of AD and all cause dementia in cognitively healthy elderly individuals whereas individuals with MCI may not have comparable cognitive protection from these agents. However, the results from this observational study need to be interpreted with caution and will require confirmation by randomized clinical trials stratifying treatment groups based on MCI status at baseline.
Cognitive function; 3HMG-ACoA reductase inhibitors; Mild Cognitive Impairment; dementia
Mexican Americans have increased stroke risk and lower fracture risk compared with non-Hispanic whites, but little is known about post-stroke fracture risk in Mexican Americans. The objective was to describe post-stroke fracture risk in a bi-ethnic population and to compare risk by ethnicity.
In the Brain Attack Surveillance in Corpus Christi Project, strokes were identified through hospital surveillance (2000–2004) and validated by neurologists (n=2,389). Inpatient claims for fractures were ascertained (2000–2004) and cross-referenced with strokes. Survival free from fracture (any and hip) post-stroke was estimated and compared by ethnicity. Cox regression was used to test the association of ethnicity and fracture risk adjusted for confounders. Interaction terms for ethnicity and age were considered.
Mean age was 71 years (sd=13); 54% were Mexican American; 52% were women. Mean follow-up was 4 years. There were 105 fractures (hip 33%). Survival free of any fracture and of hip fracture did not differ by ethnicity in unadjusted analyses. Increasing age, female gender, intracerebral hemorrhage and greater stroke severity were associated with risk of any fracture, but ethnicity was not. Ethnicity was associated with risk of hip fracture but this association was modified by age (p=0.02), where Mexican Americans were protected from hip fractures at younger but not older ages.
Stroke patients were at high fracture risk, with a 10% risk at 5 years. Mexican Americans were protected from hip fractures at younger but not older ages. Both elderly Mexican Americans and non-Hispanic whites should be targeted for fracture prevention post-stroke.
Aphasia is a disabling chronic stroke symptom but the prognosis for patients presenting with aphasia in the hyperacute window has not been well characterized. The purpose of this study is to assess the prognosis for recovery of language function in subjects presenting with aphasia due to ischemic stroke within 12 hours of symptom onset.
Subjects presenting with aphasia were identified from a prospective cohort study of 669 subjects presenting emergently with acute stroke. Subjects were characterized by demographics, serial clinical exams, unenhanced CT and CT angiography. Aphasia severity was assessed by NIHSS exams performed at baseline, discharge and 6 months. Demographic, clinical and imaging factors were assessed for prognostic impact.
Aphasia was present in 30% of subjects (n=204). Of the 166 aphasic patients alive at discharge (median 5 days), aphasia improved in 57% and resolved in 38%. In the 102 aphasic subjects evaluated at 6 months, aphasia improved in 86% and completely resolved in 74% of subjects. Among aphasic subjects with “mild” stroke (initial NIHSS<5), aphasia resolved in 90% of subjects by 6 months. Factors significantly associated with better outcome included clinically and radiographically smaller strokes and lower pre-stroke disability.
The prognosis for full recovery of aphasia present in the hyperacute window is good. Radiographic and clinical markers indicating lesser extent of ischemia correlated to greater recovery. Given the excellent prognosis for language recovery in mild stroke, the net benefit of thrombolysis in such cases is uncertain.
aphasia; prognosis; stroke; recovery
Stroke symptoms are common among people without a history of stroke or transient ischemic attack; however, it is unknown if particular attention should be focused on specific symptoms for subgroups of patients.
Using baseline data from 26,792 REasons for Geographic and Racial Differences in Stroke (REGARDS) participants without a history of transient ischemic attack or stroke, we assessed the association between age, sex, race, current smoking, hypertension and diabetes and the six stroke symptoms in the Questionnaire for Verifying Stroke-Free Status.
The mean age of participants was 64.4 ± 9.4 years, 40.7% were black and 55.2% women. After multivariable adjustment, older persons more often reported an inability to understand (odds ratio [OR] = 1.16 per 10 years older age, 95% confidence interval [CI]: 1.07–1.25) and unilateral vision loss (OR=1.09, 95% CI: 1.01–1.18) and less often reported numbness (OR=0.83, 95% CI: 0.79–0.87) and weakness (OR=0.85, 95% CI: 0.80–0.90). Women reported difficulty communicating more often than men (OR=1.36, 95% CI: 1.19–1.56). The OR for blacks compared to whites for each of the six stroke symptoms was increased, markedly so for unilateral numbness (OR=1.97, 95% CI: 1.81–2.16), unilateral weakness (OR=1.96, 95% CI: 1.76–2.18) and inability to understand (OR=1.87, 95% CI: 1.61–2.18). Current smoking, hypertension, and diabetes were associated with higher ORs for each stroke symptom.
The association of risk factors with six individual stroke symptoms studied was not uniform, suggesting the need to emphasize individual stroke symptoms in stroke awareness campaigns when targeting populations defined by risk.
individual stroke symptoms; stroke symptoms; risk factors
Telemedicine can provide stroke evaluations to areas with limited available expertise. Telestroke reliability has been established. Decision-making efficacy has been shown in the STRokE DOC trial. No prospective trial has assessed long term telestroke outcomes.
Materials and Methods
In an IRB approved trial (NCT00936455), we contacted patients originally enrolled in the NIH STRokE DOC trial. A telephone script was used to verify consent. Patients were asked standardized questions of disposition, mRS, mortality and recurrent stroke for 2 retrospective time points (6 & 12 months after event) and 1 current time point. Blind was maintained. Primary outcome measures of mortality and %mRS(0-1) at 6 months are reported. The Wilcoxon Rank-Sum was used for continuous variables and Fisher’s Exact was used for categorical variables.
Of the original 222 participants, 75 patients or surrogates were able to be contacted. Time from enrollment was 3.96 ±1.0 years (Min 2.33,Max 5.45). Mean NIHSS score was 8±7 (5±8 telephone, 12±8 telemedicine; p=0.002). IV rt-PA rate was 31%. Six month mRS(0-1) outcomes were not different at 42%. Mortality after imputing to entire study sample was not different at 18%. There was no difference in recurrent stroke (p=0.61). Eighty-six percent reported being home at 6 months.
This study reports a good 6 month outcome for stroke patients evaluated by telemedicine or telephone. This design is limited by time since original enrollment and resultant inability to contact participants. Though this study can add to the limited data on telemedicine outcomes, a prospective trial is needed.
Stroke; Telemedicine; Telestroke; Outcome; Assessment
Stroke survivors should recognize and control vascular risk factors to prevent recurrent strokes. We therefore assessed the prevalence, treatment and control of hypertension, diabetes, and dyslipidemia among stroke survivors versus stroke-free controls.
Cross-sectional analysis from the Reasons for Geographic And Racial Differences in Stroke (REGARDS) Study cohort, which includes oversampling from the Stroke Belt and African Americans. Patients were interviewed by telephone then visited for blood pressure, glucose, and lipid measurements. There were 2,830 participants reporting a past stroke or TIA (“stroke survivors”) and 24,886 participants without past stroke or TIA (controls). Outcome measures included the recognition, treatment, and control of hypertension, diabetes, and dyslipidemia.
Stroke survivors more likely had unrecognized hypertension (18.7% vs. 13.5%, p<0.0003), unrecognized Stage 2 hypertension (4.4% vs. 2.2%, p<0.0006), and unrecognized diabetes (4.2% vs. 3.2%, p<0.026) versus controls. Stroke survivors were more likely treated for hypertension (92.4% vs. 89.0%, p<0.0001), diabetes (88.3% vs. 81.4%, p<0.0001), and dyslipidemia (76.3% vs. 61.9%, p<0.0001). However despite treatment, stroke survivors were more likely to have hypertension (33.3% vs. 30.4%, p=0.0074) and Stage 2 hypertension (9.1 % vs. 7.6%, p=0.017). Predictors of unrecognized and undertreated risk factors in stroke survivors include increasing BMI, black race, and lower education.
Despite having a past stroke or TIA, stroke survivors had higher rates of unrecognized hypertension, unrecognized diabetes, and undertreated hypertension. Better efforts are needed to help stroke survivors recognize and control vascular risk factor to prevent recurrent stroke.
Stroke in young adults is more common in India and Sri Lanka and the reasons for this are not well understood. The current study was conducted to elucidate the risk factors and radiologic features in young people (age < 45 years) with ischemic stroke. Sociodemographic data, stroke risk factor information, and laboratory investigations were recorded in 41 cases with first-ever ischemic stroke. Most common risk factors for stroke in the 15- to 45-year-old age group were: hypertension, 8 (21%); family history of stroke, 7 (18%); transient ischemic attack, 6 (16%); hyperlipidemia, 3 (8.0%); and diabetes, two (5%). Age group younger than 15 years included 3 girls and one had a mass attached to the posterior mitral valve leaflet. Our observations underscore the importance of the presence of hypertension, family history of stroke, and transient ischemic attack in young adults and thus to adopt preventative strategies.
Stroke in young; Sri Lanka; family history
Sleep apnea affects over half of acute ischemic stroke patients and is associated with poor stroke outcomes. This pilot study assessed the feasibility of a randomized, sham-controlled continuous positive airway pressure trial in acute ischemic stroke patients.
Subjects identified to have sleep apnea based on an apnea-hypopnea index ≥ 5 on overnight polysomnography or portable respiratory monitoring within 7 days of stroke symptom onset were randomized to receive active or sham continuous positive airway pressure for 3 months. Objective usage was ascertained by compliance data cards. Subjects, treating physicians, and outcome assessors were masked to intervention allocation.
Among 87 consented subjects, 74 were able to complete sleep apnea screening, 54 (73%) of whom had sleep apnea; 32 agreed to randomization. Of the 15 who commenced active titration, 11 (73%) took the device home, and 8 (53%) completed the 3 month follow-up. Of the 17 subjects who commenced sham titration, 11 (65%) took the sham device home and completed the 3 month follow-up. The median cumulative usage hours over the 90 days were similar in the active group (53 hours (IQR: 22, 173)) and the sham group (74 hours (17, 94)) and blinding to condition was successfully maintained.
This first-ever, randomized, sham-controlled trial of continuous positive airway pressure in patients with recent stroke and sleep apnea showed that sham treatment can be an effective placebo.
An evidenced based approach to detecting and treating dysphagia needs to be informed by costs and risks associated with pneumonia. In this study the cost of pneumonia during hospitalization after stroke and the effect of pneumonia on mortality were estimated. The effect of pneumonia on mortality and cost for different levels of risk were also analyzed.
The data come from the 2005 and 2006 Nationwide Inpatient Sample. Regression models, including the propensity for pneumonia, were used to estimate the in hospital mortality associated pneumonia, and the marginal cost of pneumonia on the hospitalization. A stratified analysis based on quintile of propensity for pneumonia was also undertaken.
There were 183, 976 hospitalizations for stroke in the sample. The adjusted relative risk of death associated with pneumonia was 2.0 (95% CI 1.9–2.1). The average marginal cost of pneumonia on the hospitalization was $27,633 (95% CI $27,078–$27,988). The quintile of hospitalizations with the highest propensity for pneumonia had the highest average marginal cost associated with pneumonia and the lowest adjusted relative risk of death. There was an inverse relationship between adjusted relative risk of death and propensity for pneumonia.
Pneumonia after stroke is associated with higher mortality and hospitalization costs. Patients with the lowest risk for pneumonia have the highest risk for death associated with pneumonia. Screening is important at all levels of risk.
Patients with recent transient ischemic attack or stroke caused by 70–99% stenosis of a major intracranial artery are at high risk of recurrent stroke on usual medical management, suggesting the need for alternative therapies for this disease.
The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial is an ongoing, randomized, multicenter, two-arm trial that will determine whether intracranial angioplasty and stenting adds benefit to aggressive medical management alone for preventing the primary endpoint (any stroke or death within 30 days after enrollment or after any revascularization procedure of the qualifying lesion during follow-up, or stroke in the territory of the symptomatic intracranial artery beyond 30 days) during a mean follow-up of 2 years in patients with recent TIA or stroke caused by 70–99% stenosis of a major intracranial artery. Aggressive medical management in both arms consists of aspirin 325 mg per day, clopidogrel 75mg per day for 90 days after enrollment, intensive risk factor management primarily targeting systolic blood pressure < 140 mm Hg (< 130 mm Hg in diabetics) and low density cholesterol < 70 mg / dl, and a lifetsyle modification program. The sample size required todetect a 35% reduction in the rate of the primary endpoint from angioplasty and stenting based on the log-rank test with an alpha of 0.05, 80% power, and adjusting for a 2% loss to follow-up and 5% crossover from the medical to the stenting arm is 382 patients per group.
This is the first randomized trial to compare intracranial angioplasty and stenting with medical therapy and to incorporate intensive management of multiple risk factors and a lifestyle modification program in the study design. Hopefully, the results of the trial will lead to more effective therapy for this high-risk disease.
Our goal was to develop decision guides to predict the presence of a high risk source of embolus and to predict a change in management following transesophageal echocardiography (TEE) in subjects who present with a first cerebral ischemic event. We conducted a retrospective review of subjects ≥18 years who underwent TEE after a first ischemic event and were admitted to our stroke service from 2004-2007 (n=287). A high risk source of embolus and a change in clinical management (including medication changes or subsequent testing) were analyzed as separate endpoints using multivariate techniques and receiver-operator characteristic curves. 14.3% of subjects had a high risk source while an additional 61.3% had a potential (or low risk) source of embolus. Increasing age and no history of diabetes mellitus were independently associated with a high risk source of embolus. TEE would be recommended for non-diabetic individuals who are ≥66 years (sensitivity: 68%, specificity: 76%). The area under the curve (AUC) for detecting a high risk source was 0.773. TEE results changed medications or clinical management in 30.3% of patients. Current smokers were less likely to undergo a change in management. The AUC was uninformative (0.56) for predicting changes in management. Subjects presenting with a first ischemic event who are ≥66 years may benefit from TEE. While changes in management occurred in at least 30% of our cohort, no factors could be identified that predicted a change in management better than chance alone.
Transesophageal echocardiography; cardioembolic sources; patient care management
The workup of patients with suspected subarachnoid haemorrhage (SAH) presenting late is complicated by loss of diagnostic sensitivity of CT brain imaging and cerebrospinal fluid (CSF) bilirubin levels.
A prospective, longitudinal study on CSF ferritin levels in SAH.
Serial CSF samples from 14 aneurysmal SAH cases requiring extraventricular drainage (EVD) were collected. The control group consisted of 44 patients presenting with headaches suspicious of SAH. In 9 cases a traumatic spinal tap occurred. CSF ferritin levels were significantly higher following SAH compared to controls (p<0.0001). The upper reference range of CSF ferritin is 12 ng/mL and there was no significant difference between a traumatic (mean 9.0 ng/mL) or normal spinal tap (3.9 ng/mL, p=0.59). CSF ferritin levels increased following the SAH from an average of 65 ng/mL (day 1) to 1750 ng/mL (day 11, p<0.01). Both the Fisher and Columbia CT score significantly correlated with CSF ferritin levels.
CSF ferritin levels increase after a SAH and may potentially provide additional diagnostic information in patients with suspected SAH who present late to clinic.
ferritin; bilirubin; biomarker; subarachnoid haemorrhage; cerebrospinal fluid
Patients with minor ischemic stroke (MIS) are frequently excluded from thrombolytic therapy. Denial of therapy to these patients, however, remains controversial. We compared outcomes in patients with MIS who received IV t-PA with those untreated.
We selected adult patients with stroke onset within 3 hours from a prospectively collected stroke registry. MIS was defined as an admission National Institutes of Health Stroke Scale (NIHSS) score ≤5. The primary outcome was a 90 day mRS of 0–1. Secondary outcomes were Barthel index (BI) ≥95 at 90 days, symptomatic intracranial hemorrhage (sICH) and death. Multivariable logistic regression was performed to determine the association between outcomes, adjusting for age, history of diabetes and admission NIHSS. Reasons for t-PA exclusion were obtained.
We identified 133 patients with MIS; 59 patients received IV t-PA. Admission NIHSS was higher in the t-PA treated group (mean±SD); 3.4±1.4; 1.9±1.3; p< 0.0001. Other baseline characteristics were not significantly different between groups. At 90 days, 57.6% in the t-PA and 68.9% in the untreated group had a mRS of 0–1 (OR 0.93, 95% CI: 0.39–2.2, p=0.87). BI of 95–100 was achieved in 75% of patients in the IV t-PA group vs. 78.9% in the untreated group; (OR 1.18, 95% CI: 0.43–3.23, p=0.74).There were 3 deaths (5.1%) in the IV t-PA group vs. 3 (4.1%) in the controls.
In our sample, patients with MIS treated with IV t-PA have similar outcomes as patients not receiving thrombolysis. A randomized trial or larger observational study is needed confirm or reject these findings.
Recruitment challenges are common in acute stroke clinical trials. In a population-based study, we determined eligibility and actual enrollment for a successful, phase II acute stroke clinical trial. We hypothesized that missed opportunities for enrollment of eligible patients occurred frequently, despite the success of the trial.
In 2005, acute ischemic stroke (AIS) cases in our region were identified at all 17 local hospitals as part of an epidemiologic study. The Combined Approach to Lysis Utilizing Eptifibatide and rt-PA (CLEAR) trial assessed the safety of this combination in AIS patients within 3 hours of symptom onset. In 2005, we determined the proportion of AIS patients who were eligible for CLEAR and the proportion that were actually enrolled.
At 8 participating hospitals, 33 (2.8%) of 1175 AIS patients were eligible for CLEAR. Of 33 eligible patients, 18 (54.5%) were approached for enrollment, 4 (12.1%) refused, 1 (3.0%) was not consentable, and 13 (39.4%) were enrolled. Of the 15 not approached for enrollment in the trial, 10 were evaluated by the stroke team; 7 received rt-PA. Enrollment was not associated with night or weekend presentation.
Although the CLEAR trial was successful in meeting its delineated recruitment goals, our findings suggest enrollment could have been more efficient. Three out of 4 patients approached for enrollment participated in the trial. Eligible patients who were not approached and those treated with rt-PA but not enrolled represent targets for improving enrollment rates.
clinical trials; emergency medicine; acute stroke; thrombolysis
Stroke patients often display deficits in language function such as correctly naming objects. Our aim was to evaluate the reliability and the patterns of post-stroke language recovery using a picture identification task during fMRI at 4T.
Material and Methods
4 healthy and 4 left MCA stroke subjects with chronic (>1 year) aphasia. Ten fMRI scans were performed for each subject over a 10-week period using a picture identification task. Active condition involved presenting subjects with a panel of 4 figures (e.g., drawings of 4 animals) every 6 seconds; subjects indicated which figure matched the written name in the center. Control condition was same/different judgment task of pairs of geometric figures (squares, octagons or combination) presented every 6 seconds. Thirty-second active/control blocks were repeated 5 times each; responses were recorded.
Patients and controls exhibited similar demographic characteristics: age (46 vs. 53 years), personal handedness (EHI; 89 vs. 95), familial handedness (93 vs. 95) or years of education (14.3 vs. 14.8). For the active condition, controls performed better than patients (97.7% vs. 89.1%, p<0.001); performance was similar for the control condition (99.5% vs. 98.8%, p=0.23). During fMRI, controls exhibited bilateral, L>R positive blood oxygenation-level dependent (BOLD) activations in frontal and temporal language areas and symmetric retro-splenial and posterior cingulate areas and symmetric negative BOLD activations in bilateral fronto-temporal language networks. However, the patient group showed positive BOLD activations predominantly in peri-stroke areas and negative BOLD activations in the unaffected (right) hemisphere. Both the control and patient groups displayed high activation reliability (as measured by the ICC) in left frontal and temporal language areas, although the ICC in frontal regions of the patients was spread over a much larger peri-stroke area.
This study documents the utility of the picture identification task for post-stroke language recovery evaluation. Study data suggest that adult stroke patients utilize functional peri-stroke areas to perform language functions.
stroke; aphasia; aphasia recovery; language; functional MRI
The goal most often stated by persons with stroke is improved walking function. The purpose of this study was to determine the effects of isokinetic strength training on walking performance, muscle strength, and health-related quality of life in survivors of chronic stroke.
Twenty participants (age, 61.2 ± 8.4 years) with chronic stroke were randomized into 2 groups. The experimental group undertook maximal concentric isokinetic strength training, whereas the control group received passive range of motion of the paretic lower extremity 3 times a week for 6 weeks. The Kin-Com Isokinetic Dynamometer (Chattanooga Group Inc., TN) was used for both the strengthening and passive range of motion exercises. The Mann-Whitney U test was used to compare the changes in scores (postintervention minus baseline) between the control and experimental groups for a composite lower extremity strength score, walking speed (level-walking and stair-walking) and health-related quality of life measure (36-Item Short Form Health Survey [SF-36]).
Both the experimental and control groups increased their strength and walking speed postintervention; however, there were no differences in the changes in walking speed between the groups. There was a trend (P = .06) toward greater strength improvement in the experimental group compared with the control group. No changes in SF-36 scores were found in either group.
Intervention aimed at increasing strength did not result in improvements in walking. The results of this study stress the importance of controlled clinical trials in determining the effect of specific treatment approaches. Strength training in conjunction with other task-related training may be indicated.
PMID: 17903837 CAMSID: cams2187
Gait; strength; stroke management
Higher plasma total homocysteine (tHcy) is an established risk factor for cardiovascular disease. The relation between tHcy and carotid artery intima-media thickness (IMT) at the internal carotid artery (ICA)/bulb-IMT and common carotid artery (CCA)-IMT has not been systematically examined. Since the ICA/bulb segment is more prone to plaque formation than the CCA segment, differential associations with tHcy at these sites might suggest mechanisms of tHcy action.
We examined the cross-sectional segment-specific relations of tHcy to ICA/bulb-IMT and CCA-IMT in 2,499 participants from the Framingham Offspring Study, free of cardiovascular disease.
In multivariable linear regression analysis, ICA/bulb-IMT was significantly higher in the fourth tHcy quartile category compared to the other quartile categories, in both the age- and sex-adjusted and in the multivariable-adjusted model (P for trend <0.0001 and <0.01, respectively). We observed a significant age by tHcy interaction for ICA/bulb-IMT (P=0.03) and therefore stratified the analyses by median age (58 years). There was a significant positive trend between tHcy and ICA/bulb-IMT in individuals 58 years of age or older (P-trend <0.01), but not in the younger individuals (P-trend=0.24). For CCA-IMT, no significant trends were observed in any of the analyses.
The segment-specific association between elevated tHcy levels and ICA/bulb-IMT suggests an association between tHcy and plaque formation.
carotid artery; intima-media thickness; homocysteine; atherosclerosis; Framingham Offspring Study
Background and Purpose
Stroke of the right MCA is common. Such strokes often have consequences for emotional experience, but these can be subtle. In such cases diagnosis is difficult because emotional awareness (limiting reporting of emotional changes) may be affected. The present study sought to clarify the mechanisms of altered emotion experience after right MCA stroke. It was predicted that after right MCA stroke the anterior cingulate cortex (ACC), a brain region concerned with emotional awareness, would show reduced neural activity.
Brain activity during presentation of emotional stimuli was measured in six patients with stable stroke, and in 12 age and gender matched non-lesion comparisons using positron emission tomography and the [15O]H2O autoradiographic method.
MCA stroke was associated with weaker pleasant experience and decreased activity ipsilaterally in the ACC. Other regions involved in emotional processing including thalamus, dorsal and medial prefrontal cortex showed reduced activity ipsilaterally. Dorsal and medial prefrontal cortex, association visual cortex and cerebellum showed reduced activity contralaterally. Experience from unpleasant stimuli was unaltered and was associated with decreased activity only in the left midbrain.
Right MCA stroke may reduce experience of pleasant emotions by altering brain activity in limbic and paralimbic regions distant from the area of direct damage, in addition to changes due to direct tissue damage to insula and basal ganglia. The knowledge acquired in this study begins to explain the mechanisms underlying emotional changes following right MCA stroke. Recognizing these changes may improve diagnoses, management and rehabilitation of right MCA stroke victims.
Stroke; neuroimaging; alexithymia; depression; nondysphoric depression; positron emission tomography; middle cerebral artery
This study investigated the influence of age, National Institutes of Health Stroke Scale (NIHSS) score, time from stroke onset, infarct location and volume in predicting placement of a percutaneous endoscopic gastrostomy (PEG) tube in patients with severe dysphagia from an acute-subacute hemispheric infarction. We performed a retrospective analysis of a hospital-based patient cohort to analyze the effect of the aforementioned variables on the decision of whether or not to place a PEG tube. Consecutive patients were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes for acute ischemic stroke, Current Procedural Terminology (CPT)-4 codes for a formal swallowing evaluation by a speech pathologist, and procedure codes for PEG placement over a 5-year period from existing medical records at our institution. Only patients with severe dysphagia were enrolled. A total of 77 patients met inclusion criteria; 20 of them underwent PEG placement. The relationship between age (dichotomized; < and ≥75 years), time from stroke onset (days), NIHSS score, acute infarct lesion volume (dichotomized; < and ≥100 cc), and infarct location (ie, insula, anterior insula, periventricular white matter, inferior frontal gyrus, motor cortex, or bilateral hemispheres) with PEG tube placement were analyzed using logistic regression analysis. In univariate analysis, NIHSS score (P =.005), lesion volume (P =.022), and presence of bihemispheric infarction (P =.005) were found to be the main predictors of interest. After multivariate adjustment, only NIHSS score (odds ratio [OR], 1.15; 90% confidence interval [CI], 1.02–1.29; P = .04) and presence of bihemispheric infarcts (OR, 4.67; 90% CI, 1.58–13.75; P =.018) remained significant. Our data indicates that baseline NIHSS score and the presence of bihemispheric infarcts predict PEG placement during hospitalization from an acute-subacute hemispheric infarction in patients with severe dysphagia. These results require further validation in future studies.
Stroke; swallowing recovery; NIHSS score
Our objective was to outline the relationship between age and length of stay (LOS), hospital costs and discharge disposition following carotid endarterectomy (CEA).
Materials and Methods
We identified discharge records from the 2006 Nationwide Inpatient Sample (NIS). The primary outcome was LOS from the surgical procedure to discharge. We examined LOS from procedure to discharge because the time from procedure to discharge may better reflect hospital stay due to the procedure itself for subjects with symptomatic carotid artery disease rather than including days hospitalized for stroke recovery. Secondary endpoints included total LOS, discharge disposition and hospital costs.
There were 118,218 discharge records for CEA and >90% were for asymptomatic carotid disease. The LOS from procedure to discharge and total LOS increased per decade starting with the age range of 70–79 years. Age per decade increased the likelihood of requiring a LOS from procedure to discharge of >1 day. The same trend was seen for requiring a >2 day post-operative stay. Those age ≥80 years required longer post-operative LOS compared to younger ages (OR=1.45 for >1 day and OR=1.45 for >2 days, both p<0.001). Total hospital costs averaged $10,965 for all discharges. For age dichotomized at 80 years, the average cost increased by $845. Also, age ≥80 years was independently associated with discharge to a skilled nursing facility (OR=2.4, 95% CI=2.09–2.76).
Increased hospital LOS and costs were required following CEA as age increased. Morbidity following CEA should be discussed with subjects considering revascularization for asymptomatic disease.
Endarterectomy and angioplasty with stenting have emerged as two alternative treatments for carotid artery stenosis. This study’s objective is to determine cost-effectiveness of carotid artery stenting compared to carotid endarterectomy in symptomatic subjects who are suitable for either intervention.
A Markov analysis of these two revascularization procedures was conducted using direct Medicare costs (2007$ USD) and characteristics of a symptomatic 70-year-old cohort over a lifetime.
In the base case analysis, carotid stenting produced 8.97 quality adjusted life years compared to 9.64 quality adjusted life years for carotid endarterectomy. The incremental cost of stenting was $17,700 and thus, stenting was dominated by endarterectomy. Sensitivity analyses show that the long-term probabilities of major stroke or mortality influenced the results.
In the base case analysis, carotid endarterectomy for patients with symptomatic stenosis has a greater benefit than angioplasty with stenting with lower direct costs. With a 59% probability, CEA will be the optimal intervention when all of the model assumptions are varied simultaneously.
carotid arteries; stenosis; cost-benefit analysis; stroke