166 research outputs found
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
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
Interobserver agreement for 10% categories of angiographic carotid stenosis
BACKGROUND AND PURPOSE: Although the reliability of the assessment of severe 70% to 99% carotid stenosis by carotid angiography has been proven excellent, this may not necessarily be the case for a more detailed classification of carotid stenoses by 10% categories.
METHODS: Angiograms of the carotid arteries were assessed pairwise by three independent, experienced observers. The measurements of the degree of stenosis of both the carotid bifurcation and the internal carotid artery were made according to the European Carotid Surgery Trial method. Kappa statistics were used to assess the agreement beyond chance for severe (70% to 99%) carotid stenosis (kappa 1) and for 10% categories of carotid stenosis (kappa 2). The penalty scores were adjusted by weights for the relative difference in risk (RDR) of stroke in the ipsilateral carotid distribution between the 10% categories (kappa 3). An adjustment of the RDR method was made by assuming that only patients with a severe carotid stenosis would undergo surgery, and the penalty would be 0 if no disagreement would exist about the indication for surgery (kappa 4). An even further adjustment (kappa 5) was made by assuming that assessment of the rate of carotid stenosis by one or both observers would lead to different treatment recommendations in 50% of the cases, and accordingly the penalty for disagreement (RDR) was halved.
RESULTS: One hundred twenty-one carotid bifurcations in 65 patients with a transient ischemic attack or nondisabling stroke were assessed. The intraclass correlation between the exact estimates of carotid stenosis was .90 (95% confidence interval, .85 to .92). The mean difference in stenosis between the two raters was 0.8% (95% confidence interval, -2.1% to 3.7%). kappa 1 to kappa 5 equaled 0.80, 0.40, 0.79, 0.91, and 0.92, respectively.
CONCLUSIONS: Interobserver agreement for distinct 10% categories of angiographic carotid stenosis is moderate, but when realistic risk- and decision-based weights are used, agreement between experienced observers can be almost perfect
Platelet activation and lipid peroxidation in patients with acute ischemic stroke
BACKGROUND AND PURPOSE: Both platelet activation and lipid peroxidation are potential sources of vasoactive eicosanoids that can be produced via the cyclooxygenase pathway, ie, thromboxane (TX) A2, or by free radical-catalyzed peroxidation of arachidonic acid, ie, isoprostanes. We investigated the biosynthesis of TXA2 and F2-isoprostanes, as reflected by the urinary excretion of 11-dehydro-TXB2 and 8-epi-prostaglandin (PG) F2 alpha respectively, in 62 consecutive patients (30 men, 32 women; mean age, 67 +/- 14 years) with acute ischemic stroke.
METHODS: At least two consecutive 6-hour urine samples were obtained during the first 72 hours after onset of symptoms. Urinary eicosanoids were measured by previously described radioimmunoassays.
RESULTS: Repeated periods of enhanced thromboxane biosynthesis were found in 52% of patients. Urinary 11-dehydro-TXB2 averaged 221 +/- 207 (mean +/- SD; n = 197; range, 13 to 967) pmol/mmol creatinine in 30 patients treated with cyclooxygenase inhibitors (mostly aspirin) at the time of study versus 392 +/- 392 (n = 186; range, 26 to 2533) in 32 untreated patients (P .05). The correlation between the two metabolites was moderate in both untreated patients (r = .41, P < .001) and patients with cyclooxygenase inhibitors (r = .31, P < .001). In a multiple regression analysis, increased thromboxane production was independently associated with severity of stroke on admission, atrial fibrillation, and treatment with cyclooxygenase-inhibiting drugs.
CONCLUSIONS: We conclude that during the first few days after an acute ischemic stroke (1) platelet activation occurs repeatedly in a cyclooxygenase-dependent fashion; (2) platelet activation is not associated with concurrent changes in isoprostane biosynthesis; (3) platelet activation is independently associated with stroke severity and atrial fibrillation; and (4) isoprostane biosynthesis is largely independent of platelet cyclooxygenase activity
A short screening instrument for poststroke dementia : the R-CAMCOG
BACKGROUND AND PURPOSE: The CAMCOG is a feasible cognitive screening
instrument for dementia in patients with a recent stroke. A major
disadvantage of the CAMCOG, however, is its lengthy and relatively complex
administration for screening purposes. We therefore developed the
Rotterdam CAMCOG (R-CAMCOG), based on the original version. Our aim was to
reduce the estimated administration time to 15 minutes or less and to
retain or perhaps even improve its diagnostic accuracy. METHODS: We
analyzed the item scores on the CAMCOG of 300 consecutive stroke patients,
after exclusion of patients with a severe aphasia or lowered consciousness
level, who were entered in the Rotterdam Stroke Databank. The diagnosis of
dementia was made independent of the R-CAMCOG score, on the basis of
clinical examination and neuropsychological test results. The R-CAMCOG was
constructed in 3 steps. First, items with floor and ceiling effects were
removed. Next, subscales with no additional diagnostic value were
excluded. Finally, we removed items that did not contribute to the
homogeneity of the subscales. The diagnostic accuracy of the R-CAMCOG and
the original CAMCOG was determined by means of the area under the receiver
operating characteristic (ROC) curve. RESULTS: In the 3 steps, the number
of items was reduced from 59 to 25, divided over the subscales
orientation, memory (recent, remote, and learning), perception, and
abstraction. The subscale orientation did not reach significance in a
logistic regression model but was included in the R-CAMCOG because of its
high face validity in dementia screening. Internal validation with ROC
analysis suggests that the R-CAMCOG and the CAMCOG are equally accurate in
screening for poststroke dementia (area under the curve was 0.95 for both
tests). CONCLUSIONS: The R-CAMCOG has overcome the disadvantages of the
original CAMCOG. It is a promising, short, and easy-to-administer
screening instrument for poststroke dementia. It seems to be sufficiently
accurate for this purpose, but the test has yet to be validated in a
separate, independent study
Trends in stroke incidence rates and stroke risk factors in Rotterdam, the Netherlands from 1990 to 2008
Stroke incidence rates have decreased in developed countries over the past 40 years, but trends vary across populations. We investigated whether age-and-sexspecific stroke incidence rates and associated risk factors as well as preventive medication use have changed in Rotterdam in the Netherlands during the last two decades. The study was part of the Rotterdam Study, a large populationbased cohort study among elderly people. Participants were 10,994 men and women aged 55-94 years who were stroke-free at baseline. Trends were calculated by comparing the 1990 subcohort (n = 7516; baseline 1990-1993) with the 2000 subcohort (n = 2883; baseline 2000-2001). Poisson regression was used to calculate incidence rates and incidence rate ratios in age-and-sex-specific strata. We further compared the prevalence of stroke risk factors and preventive medication use in the two subcohorts. In the 1990 subcohort 467 strokes occurred during 45,428 person years; in the 2000 subcohort 115 strokes occurred in 18,356 person years. Comparing the subcohorts, incidence rates decreased by 34% in men, but remained unchanged in women. Blood pressure levels increased between 1990 and 2000, whereas the proportion of current cigarette smokers decreased in men, but not in women. There was a strong increase in medication use for treatment of stroke risk factors across all age categories in both sexes. Our findings suggest that in Rotterdam between 1990 and 2008 stroke incidence rates have decreased in men but not in women
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