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issn:1468-330
1.  Stroke in patients with human immunodeficiency virus infection 
Objective
To report the nature of stroke in patients infected with human immunodeficiency virus (HIV) in a region with high HIV seroprevalence and describe HIV associated vasculopathy.
Methods
Patients with first ever stroke, infected with HIV and prospectively included in the stroke register of the Groote Schuur Hospital/University of Cape Town stroke unit were identified and reviewed.
Results
Between 2000 and 2006, 67 of the 1087 (6,1%) stroke patients were HIV infected. Of these, 91% (n = 61) were younger than 46 years. Cerebral infarction occurred in 96% (n = 64) of the HIV positive patients and intracerebral haemorrhage in 4% (n = 3). HIV infected young stroke patients did not demonstrate hypertension, diabetes, hyperlipidaemia or smoking as significant risk factors for ischaemic stroke. Infection as a risk factor for stroke was significantly more common in HIV positive patients (p = 0.018, OR 6.4, CI 3.1 to 13.2). In 52 (81%) patients with ischaemic stroke, an aetiology was determined. Primary aetiologies comprised infectious meningitides/vasculitides in 18 (28%) patients, coagulopathy in 12 (19%) patients and cardioembolism in nine (14%) patients. Multiple aetiologies were present in seven (11%) patients with ischaemic stroke. HIV associated vasculopathy was identified in 13 (20%) patients. The HIV associated vasculopathy manifested either extracranially (seven patients) as total or significant carotid occlusion or intracranially (six patients) as medium vessel occlusion, with or without fusiform aneurysmal dilation, stenosis and vessel calibre variation.
Conclusion
Investigation of HIV infected patients presenting with stroke will determine an aetiology in the majority of patients. In our cohort, 20% of patients demonstrated evidence of an HIV associated vasculopathy.
doi:10.1136/jnnp.2007.116103
PMCID: PMC2095583  PMID: 17470469
2.  Relation between cognitive dysfunction and reduced vital capacity in amyotrophic lateral sclerosis 
Background
Many patients with amyotrophic lateral sclerosis (ALS) with cognitive impairment have fronto‐temporal dysfunction. Whereas in some patients with ALS the fronto‐temporal dysfunction is undoubtedly due to the degenerative process associated with the disease, in others dysfunction cannot be accounted for by an irreversible degenerative process alone, as it also appears to involve a reversible process. We hypothesised that reduced vital capacity can be a key contributor to the fronto‐temporal dysfunction observed in patients with ALS.
Objective
To investigate the association between fronto‐temporal dysfunction and reduced vital capacity in ALS.
Methods
16 consecutive patients who conformed to a diagnosis of definite or probable ALS (El escorial criteria) were grouped by vital capacity, and their clinical characteristics and cognitive functions, including disease duration, attention, executive function and memory, were measured.
Results
Patients with a reduced vital capacity performed significantly poorer in memory retention (p = 0.028), retrieval efficacy (p = 0.003), spoken verbal fluency (p = 0.03) and spoken verbal fluency indexes (p = 0.016) than those with a normal vital capacity.
Conclusion
The fronto‐temporal dysfunction in ALS might be attributable to potentially reversible secondary effects associated with reduced vital capacity, as well as to the primary degenerative process.
doi:10.1136/jnnp.2006.111195
PMCID: PMC2095584  PMID: 17557798
3.  [No title available] 
PMCID: PMC2095585
5.  Differential impact of cerebral white matter changes, diabetes, hypertension and stroke on cognitive performance among non‐disabled elderly. The LADIS study 
Background and purpose
Age related white matter changes (ARWMC) are frequent in non‐demented old subjects and are associated with impaired cognitive function. Our aim was to study the influence of vascular risk factors and ARWMC on the neuropsychological performance of an independent elderly population, to see if vascular risk factors impair cognition in addition to the effects of ARWMC.
Methods
Independent subjects, aged 65–84 years, with any degree of ARWMC were assessed using a comprehensive neuropsychological battery including the Mini‐Mental State Examination (MMSE), VADAS‐Cog (Alzheimer's disease assessment scale) and the Stroop and Trail Making test. Vascular risk factors were recorded and ARWMC (measured by MRI) were graded into three classes. The impact of vascular risk factors and ARWMC on neuropsychological performance was assessed by linear regression analyses, with adjustment for age and education.
Results
638 patients (74.1 (5) years old, 55% women) were included. Patients with severe ARWMC performed significantly worse on global tests of cognition, executive functions, speed and motor control, attention, naming and visuoconstructional praxis. Diabetes interfered with tests of executive function, attention, speed and motor control, memory and naming. Arterial hypertension and stroke influenced executive functions and attention. The effect of these vascular risk factors was independent of the severity of ARWMC, age and education.
Conclusion
ARWMC is related to worse performance in executive function, attention and speed. Diabetes, hypertension and previous stroke influenced neuropsychological performance, independently of the severity of ARWMC, stressing the need to control vascular risk factors in order to prevent cognitive decline in the elderly.
doi:10.1136/jnnp.2006.110361
PMCID: PMC2095587  PMID: 17470472
6.  [No title available] 
PMCID: PMC2095588
7.  Case control study of diffusion tensor imaging in Parkinson's disease 
Background
Preliminary work has shown that diffusion tensor MRI (DTI) may contribute to the diagnosis of Parkinson's disease (PD).
Objectives
We conducted a large, prospective, case control study to determine: (1) if fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values on DTI in the basal ganglia and substantia nigra are different between patients with PD and healthy controls; and (2) the predictive value of these parameters and their clinical utility.
Methods
DTI imaging was carried out in patients with PD and controls. FA and ADC values were obtained from various brain structures on the DTI scan using the diffusion tensor taskcard. The structures studied were: caudate, putamen, globus pallidus, thalamus and substantia nigra.
Results
151 subjects (73 PD patients, 41 men, 32 women; mean age 63.6 years) and 78 age and sex matched control subjects were studied. The FA value of the substantia nigra in patients with PD was lower compared with controls (0.403 vs 0.415; p = 0.001). However, no significant differences were demonstrated for FA or ADC values of other structures. Multiple regression analysis revealed that the clinical severity of PD correlated inversely with the FA value in the substantia nigra in patients with PD (regression coefficient −0.019). No single FA value had both a high positive and negative predictive power for PD.
Conclusions
We demonstrated in a large, prospective, case control study that the FA value in the substantia nigra on DTI was lower in PD compared with healthy controls, and correlated inversely with the clinical severity of PD. Further longitudinal studies would be helpful to assess the clinical utility of serial FA measurements of the substantia nigra in objective quantification of disease progression and monitoring of the therapeutic response.
doi:10.1136/jnnp.2007.121525
PMCID: PMC2095589  PMID: 17615165
8.  Chiari malformation and sleep related breathing disorders 
Objective
To estimate the frequency, mechanisms and predictive factors of sleep apnoea syndrome (SAS) in a large group of children and adults with type I (CMI) and II (CMII) Chiari malformation (CM).
Background
The anatomical and functional integrity of both respiratory circuits and lower cranial nerves controlling the upper airway is necessary for breathing control during sleep. These latter structures may be altered in CM, and a few investigations have reported CM related sleep disordered breathing.
Methods
Forty‐six consecutive unrelated patients with CM (40 CMI, six CMII), of which 20 were children (eight males) and 26 were adults (12 males), underwent physical, neurological and oto‐rhino‐laryngoscopic examination, MRI and polysomnography.
Results
SAS was present in 31 (67.4%) of the patients with CM (70% of CMI, 50% of CMII, including mainly children). Sixty per cent of children with CM exhibited SAS, including 35% with obstructive (OSAS) and 25% with central (CSAS) sleep apnoea syndrome. SAS was observed in 73% of CM adults (57.7% OSAS, 15.4% CSAS). Severe SAS was found in 23% of CM adults. Multiple regression analysis revealed that age, type II Chiari and vocal cord paralysis predicted the central apnoea index.
Conclusion
SAS is highly prevalent in all age groups of patients suffering from CM. CSAS, a rare condition in the general population, was common among the patients with CM in our study. Sleep disordered breathing associated with CM may explain the high frequency of respiratory failures observed during curative surgery of CM. Our results suggest that SAS should be systematically screened for in patients with CM, especially before surgery.
doi:10.1136/jnnp.2006.108779
PMCID: PMC2095590  PMID: 17400590
9.  Distal lenticulostriate artery aneurysm in deep intracerebral haemorrhage 
Aneurysms of the distal lenticulostriate artery (LSA) are rare. Only 16 cases have been reported in the literature. Early detection and treatment of these aneurysms is also difficult because of their deep location, small size and angioarchitecture. We report two additional patients with aneurysms, arising from the distal LSA, who presented with deep intracerebral haemorrhage. The conclusions drawn from our experience and a comprehensive review of the literature include the following. (1) A distal LSA aneurysm should be considered in young (mean 38.5 years) and non‐hypertensive (80%) patients with deep intracerebral haemorrhage. (2) These aneurysms are frequently very small (<5 mm). Therefore, they cannot be detected on initial angiograms in some cases. (3) These aneurysms have higher rates of associated vascular lesions. Deep intracerebral haemorrhage, even in those over the age of 50 years, can still be due to underlying, treatable structural abnormalities, and should not be dismissed as being a result of hypertension. In addition, a more comprehensive diagnostic approach seems to be warranted in younger patients and those without known hypertension.
doi:10.1136/jnnp.2007.120204
PMCID: PMC2095591  PMID: 18024696
10.  Comparison of the inflammatory burden of truly asymptomatic carotid atheroma with atherosclerotic plaques contralateral to symptomatic carotid stenosis: an ultra small superparamagnetic iron oxide enhanced magnetic resonance study 
Background
Inflammation is a recognised risk factor for the vulnerable atherosclerotic plaque. The aim of this study was to explore whether there is a difference in the degree of magnetic resonance (MR) defined inflammation using ultra small superparamagnetic iron oxide (USPIO) particles within carotid atheroma in completely asymptomatic individuals and the asymptomatic carotid stenosis contralateral to the symptomatic side.
Methods
20 symptomatic patients with contralateral disease and 20 completely asymptomatic patients underwent multi‐sequence MR imaging before and 36 h after USPIO infusion. Images were manually segmented into quadrants and signal change in each quadrant was calculated following USPIO administration. Mean signal change was compared across all quadrants in the two groups.
Results
The mean percentage of quadrants showing signal loss was 53% in the contralateral group compared with 31% in completely asymptomatic individuals (p = 0.025). The mean percentages showing enhancement were 44% and 65%, respectively (p = 0.024). The mean signal difference between the two groups was 8.6% (95% CI 1.6% to 15.6%; p = 0.017).
Conclusions
Truly asymptomatic plaques seem to demonstrate inflammation but not to the extent of the contralateral asymptomatic stenosis to the symptomatic side. Inflammatory activity may be a significant risk factor in asymptomatic disease.
doi:10.1136/jnnp.2007.118901
PMCID: PMC2095592  PMID: 17578854
11.  [No title available] 
PMCID: PMC2095593
12.  Stroke in patients with human immunodeficiency virus infection 
What is the impact of HIV and HIV therapy on the nature of stroke and stroke management?
doi:10.1136/jnnp.2007.122416
PMCID: PMC2095594  PMID: 18024688
13.  A history of loss of consciousness or post‐traumatic amnesia in minor head injury: “conditio sine qua non” or one of the risk factors? 
Objective
A history of loss of consciousness (LOC) or post‐traumatic amnesia (PTA) is commonly considered a prerequisite for minor head injury (MHI), although neurocranial complications also occur when LOC/PTA are absent, particularly in the presence of other risk factors. The purpose of this study was to evaluate whether known risk factors for complications after MHI in the absence of LOC/PTA have the same predictive value as when LOC/PTA are present.
Methods
A prospective multicentre study was performed in four university hospitals between February 2002 and August 2004 of consecutive blunt head injury patients (⩾16 years) presenting with a normal level of consciousness and a risk factor. Outcome measures were any neurocranial traumatic CT finding and neurosurgical intervention. Common odds ratios (OR) were estimated for each of the risk factors and tested for homogeneity.
Results
2462 patients were included: 1708 with and 754 without LOC/PTA. Neurocranial traumatic findings on CT were present in 7.5% and were more common when LOC/PTA was present (8.7%). Neurosurgical intervention was required in 0.4%, irrespective of the presence of LOC/PTA. ORs were comparable across the two subgroups (p>0.05), except for clinical evidence of a skull fracture, with high ORs both when LOC/PTA was present (OR = 37, 95% CI 17 to 80) or absent (OR = 6.9, 95% CI 1.8 to 27). LOC and PTA had significant ORs of 1.9 (95% CI 1.0 to 2.7) and 1.7 (95% CI 1.3 to 2.3), respectively.
Conclusion
Known risk factors have comparable ORs in MHI patients with or without LOC or PTA. MHI patients without LOC or PTA need to be explicitly considered in clinical guidelines.
doi:10.1136/jnnp.2007.117143
PMCID: PMC2095595  PMID: 17470468
14.  Measuring cognitive change in older adults: reliable change indices for the Mini‐Mental State Examination 
Background
In clinical and research settings, the Mini‐Mental State Examination (MMSE) is commonly used to measure cognitive change over time. The interpretation of changes in MMSE is often difficult. They do not necessarily result from true clinical change. Their interpretation requires comparison with normative data for change. However, MMSE change norms are lacking for long intervals.
Objective
To examine what is a reliable change in MMSE for long follow‐up periods commonly used in clinic. To provide normative data for change.
Methods
A sample of 119 cognitively normal individuals, aged 75 years and over, who participated in the Leipzig Longitudinal Study of the Aged (LEILA 75+). All participants were tested six times at 1.5 year intervals with the MMSE over a mean period of 7.1 years. Reliable change indices were computed for a common confidence interval (90%).
Results
In repeated assessments with 1.5 year intervals, a change in MMSE of at least 2–4 points indicated a reliable change at the 90% confidence level.
Conclusion
Small changes in MMSE can be interpreted only with great uncertainty. They have a reasonable probability of being caused by measurement error, regression to the mean or practice.
doi:10.1136/jnnp.2006.109074
PMCID: PMC2095596  PMID: 17442763
15.  [No title available] 
PMCID: PMC2095597
16.  External validation of a six simple variable model of stroke outcome and verification in hyper‐acute stroke 
We aimed to validate a previously described six simple variable (SSV) model that was developed from acute and sub‐acute stroke patients in our population that included hyper‐acute stroke patients. A Stroke Outcome Study enrolled patients from 2001 to 2002. Functional status was assessed at 6 months using the modified Rankin Scale (mRS). SSV model performance was tested in our cohort. 538 acute ischaemic (87%) and haemorrhagic stroke patients were enrolled, 51% of whom presented to hospital within 6 h of symptom recognition. At 6 months post‐stroke, 42% of patients had a good outcome (mRS ⩽2). Stroke patients presenting within 6 h of symptom recognition were significantly older with higher stroke severity. In our Stroke Outcome Study dataset, the SSV model had an area under the curve of 0.792 for 6 month outcomes and performed well for hyper‐acute or post-acute stroke, age < or ⩾75 years, haemorrhagic or ischaemic stroke, men or women, moderate and severe stroke, but poorly for mild stroke. This study confirms the external validity of the SSV model in our hospital stroke population. This model can therefore be utilised for stratification in acute and hyper-acute stroke trials.
doi:10.1136/jnnp.2007.118802
PMCID: PMC2095598  PMID: 18024695
17.  Identification of “high risk” asymptomatic carotid stenosis: we need to get a better yield from invasive treatments 
Inflammatory activity is higher in those patients who have controlateral symptoms than in those without any history of cerebrovascular disorders, suggesting that inflammation of atheroma may be a systemic event, and that symptoms in one territory may increase the risk in other territories
doi:10.1136/jnnp.2007.125880
PMCID: PMC2095599  PMID: 18024689
18.  Recurrent lacunar infarction following a previous lacunar stroke: a clinical study of 122 patients 
Objective
To determine clinical variables related to recurrent lacunar infarction following a previous lacunar stroke.
Methods
A total of 122 out of 733 consecutive patients with lacunar infarction collected from a hospital based registry between 1986 and 2004 were readmitted because of a recurrent lacunar infarction. In a subset of 59 patients, cognition was assessed using the Mini‐Mental State Examination (MMSE). Predictors of lacunar infarction recurrence were assessed by logistic regression analysis.
Results
First lacunar infarction recurrence occurred in 101 patients (83%) and multiple recurrences in 21. The mean time between first ever lacunar infarction and recurrent lacunes was 58.3 months (range 2–240). In the subset of 59 patients in whom cognition was studied, cognitive impairment, defined as an MMSE score <24, was detected in 16% (8/49) of patients with first lacunar infarction recurrence and in 40% (4/10) of those with multiple lacunar infarction recurrences. In the multivariate analysis, hypertension (odds ratio 2.01, 95% CI 1.23 to 3.30) and diabetes (odds ratio 1.62, 95% CI 1.07 to 2.46) were significant predictors of lacunar stroke recurrence, whereas hyperlipidaemia was inversely associated (odds ratio 0.52, 95% CI 0.30 to 0.90).
Conclusions
Hypertension and diabetes were significant factors related to recurrent lacunar infarction. Hyperlipidaemia appeared to have a protective role. Cognitive impairment was a frequent finding in patients with multiple lacunar infarction recurrences.
doi:10.1136/jnnp.2007.119776
PMCID: PMC2095600  PMID: 17615167
19.  [No title available] 
PMCID: PMC2095601
20.  Glossoplegia in a small cortical infarction 
doi:10.1136/jnnp.2007.116376
PMCID: PMC2095602  PMID: 18024692
21.  Hyperacusis in patients with complex regional pain syndrome related dystonia 
Introduction
In complex regional pain syndrome type 1 (CRPS‐1), patients may have manifestations of central involvement, including allodynia, hyperalgesia or dystonia. We noted that more severely affected patients may experience hyperacusis, which may also reflect central involvement. The aim of this study was to evaluate the occurrence and characteristics of hyperacusis in patients with CRPS related dystonia.
Methods
The presence of hyperacusis, speech reception thresholds (SRT), pure‐tone thresholds (PTT) and uncomfortable loudness (UCL) was evaluated in 40 patients with CRPS related dystonia.
Results
PTT and SRT were normal for all patients. 15 patients (38%) reported hyperacusis and this was associated with allodynia/hyperalgesia and with more affected extremities. UCLs of patients with hyperacusis were significantly lower than UCLs of patients without hyperacusis.
Conclusion
Hyperacusis is common among severely affected patients with CRPS related dystonia and may indicate that the disease spreads beyond those circuits related to sensory–motor processing of extremities.
doi:10.1136/jnnp.2006.111609
PMCID: PMC2095603  PMID: 17470470
22.  [No title available] 
doi:10.1136/jnnp.2004.052654corr1
PMCID: PMC2095604
23.  Retrobulbar optic neuritis: a complication of Lyme disease? 
doi:10.1136/jnnp.2006.113761
PMCID: PMC2095605  PMID: 18024698
24.  Dorsal intramedullary tuberculoma 
doi:10.1136/jnnp.2007.116012
PMCID: PMC2095606  PMID: 18024691
25.  Chronic cluster headache: a French clinical descriptive study 
Background
Cluster headache (CH) is a relatively rare disease and episodic CH is more frequent than chronic CH. Few studies have described the characteristics of patients with chronic CH.
Methods
This was a descriptive study carried out by eight tertiary care specialist headache centres in France participating in the Observatory of Migraine and Headaches (OMH). From 2002 to 2005, OMH collected data from 2074 patients with CH, of whom 316 had chronic CH. From January to June 2005, 113 patients with chronic CH were interviewed using standardised questionnaires during a consultation.
Results
The male to female ratio was 4.65:1. Median age was 42 years. The majority of patients were smokers or former smokers (87%). 46% had primary chronic CH (chronic at onset) and 54% secondary chronic CH (evolving from episodic CH). Most patients had unilateral pain during attacks and 7% had sometimes bilateral pain during an attack. 48% reported a persisting painful state between attacks. Symptoms anteceding pain onset (mainly discomfort/diffuse pain, exhaustion, mood disorders) and auras were reported by 55% and 20% of patients, respectively. The functional impact of chronic CH was estimated as severe by 74% of patients, and 75.7% suffered from anxiety, as assessed by the Hospital Anxiety and Depression scale. There was no substantial difference in clinical presentation between primary and secondary CH.
Discussion
This study confirms the existence of auras and interictal signs and symptoms in patients with chronic CH, and male sex and smoking as CH risk factors. Primary and secondary chronic CH appear equally prevalent. Male sex does not appear to favour the shift from episodic to chronic CH.
doi:10.1136/jnnp.2006.112037
PMCID: PMC2095607  PMID: 17442761

Results 1-25 (18731)