Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and recent cerebral ischemia

A number of studies have demonstrated the efficacy of oral anticoagulant therapy in reducing the risk of stroke and systemic embolism in patients with nonrheumatic atrial fibrillation. However, both the targeted and the actual levels of anticoagulation differed widely among the studies, and a number of studies failed to report standardized prothrombin-time ratios as international normalized ratios (INRs). We therefore performed an analysis to determine the intensity of oral anticoagulant therapy in nonrheumatic atrial fibrillation that provides the best balance between the prevention of thromboembolism and the occurrence of bleeding complications

The diagnosis of transient ischemic attacks

The diagnosis of transient ischemic attack (TIA) is fraught with difficulty, since the diagnosis rests entirely upon the history of the patient's symptoms and the neurologist's skill in questioning the patient. The aim of this thesis is to investigate various measures to improve the reliability in making this diagnosi

901-97 Stroke and Long-term Anticoagulant Therapy in 3404 Post-Myocardial Infarction Patients

In a randomized, double-blind, placebo controlled trial (ASPECT) we studied 3404 post-myocardial infarction patients who suffered a stroke during long-term anticoagulant therapy. The duration of treatment ranged from 1 day to six years. Three years following randomization, 2% of the patients on anticoagulant therapy had a stroke compared to 4% in placebo.The incidence of stroke analyzed on “intention-to-treat” was 0.7 per 100 patient-years in the anticoagulant group and 1.2 per 100 patient-years in placebo, a hazard ratio (HR) of 0.60 with a 95% confidence interval (Cl) of 0.40 to 0.90, a 40% reduction in the risk of stroke in the anticoagulated group. A total of 19 intracranial bleeding was observed. The risk of hemorrhages was 8 times greater for anticoagulated patients compared to placebo. Eight of the 17 bleedings were fatal in the anticoagulant group and no fatal hemorrhages occurred in placebo. A total of 15 cerebral infarctions occurred in the anticoagulated group and 43 in placebo. Of the 14 hemorrhagic strokes, 6 were within INR 3.0–4.0 and 8 with an INR>4.0, Of the 7 non-hemorrhagic strokes, 2 were at INR<2, 3 within INR 3.0–4.0, 1 at INR>4.0, and no measurement was available in one patient. The total number of patients who died or were severely disabled as a result of cerebral stroke amounted to 13 in the anticoagulated group, compared to 18 in placebo.ConclusionThe results of the ASPECT trial indicated that long-term anticoagulant therapy substantially reduced the risk of stroke in post-myocardial infarction patients. The increased risk of bleeding complications associated with anticoagulant therapy was offset by a marked reduction in ischemic events

Argyll Robertson pupils in lymphocytic meningoradiculitis (Bannwarth's syndrome)

Sir: Lymphocytic meningoradiculitis or Bannwarth's syndrome is clinically characterised by severe radicular pains with sensory and motor impairment and cranial nerve palsies, especially unilateral or bilateral facial weakness.'`4 The syndrome is probably a European variety of Lyme disease, 5 which is caused by a spirochete, Borrelia burgdorferi,6 and transmitted by the bite of a tick. In Bannwarth's syndrome antibodies to the same7 or to closely related8 spirochetes are found. CSF findings such as elevated protein and pleocytosis' - 3 are consistent with aseptic meningitis. The disease is often self-limiting, but the course of the disease and the duration of pain may be shortened by high doses of penicillin given intravenously. 9 In some cases it may be difficult to distinguish Bannwarth's syndrome from neurosyphilis. We present such a case. ..

International epidemiology of intracerebral hemorrhage

Intracerebral hemorrhage is the second most common subtype of stroke. In recent decades our understanding of intracerebral hemorrhage has improved. New risk factors have been identified; more knowledge has been obtained on previously known risk factors; and new imaging techniques allow for in vivo assessment of preclinical markers of intracerebral hemorrhage. In this review the latest developments in research on intracerebral hemorrhage are highlighted from an epidemiologic point of view. Special focus is on frequency, etiologic factors and pre-clinical markers of intracerebral hemorrhage

Secondary prevention after cerebral ischaemia of presumed arterial origin: is aspirin still the touchstone?

Patients who have had a transient ischaemic attack or nondisabling ischaemic stroke of presumed arterial origin have an annual risk of death from all vascular causes, non-fatal stroke, or non-fatal myocardial infarction that ranges between 4% and 11% without treatment. In the secondary prevention of these vascular complications the use of aspirin has been the standard treatment for the past two decades. Discussions about the dose of aspirin have dominated the issue for some time, although there is no convincing evidence for any difference in effectiveness in the dose range of 30-1300 mg/day. A far greater problem is the limited degree of protection offered by aspirin: the accumulative evidence from trials with aspirin alone and only for cerebrovascular disease of presumed arterial origin as qualifying event indicates that a dose of aspirin of at least 30 mg/day prevents only 13% of serious vascular complications

The CODECS study:COgnitive DEficits in Cerebellar Stroke

Part of the extra-pyramidal system, the cerebellum is more and more recognized by its non-motor functions known as the cerebellar cognitive affective syndrome. Several studies have identified disturbances specifically in executive and attentional functions after focal cerebellar lesions. However, most studies were performed in small and heterogeneous patient groups. Furthermore, there is a substantial variation in the methodology of assessment. Here, we present the results of a large and homogeneous cohort of patients with isolated uniform cerebellar lesions. After three months post-stroke all patients underwent structural neuroimaging to confirm an isolated lesion and were given neuropsychological testing. The results show that cerebellar lesions relate to mild but long-term cognitive impairment in a broad spectrum of neurocognitive functions compared to normative values. These findings confirm involvement of the cerebellum in cognitive processing and supports the theory of ‘dysmetria of thought’ based upon uniform cerebellar processing in multiple cognitive domains. This study highlights the following results: 1-Cognitive impairments after isolated cerebellar stroke is confirmed in several cognitive domains. 2-Semantic and phonemic fluency are most affected in cerebellar stroke patients. 3-Verbal deficits show an age-independent long term effect post-stroke and should be studied further in depth. 4-Cognitive disorders after cerebellar stroke are more prominent in women than men.</p