Branko Malojčić

Control of main risk factors after ischaemic stroke across Europe: data from the stroke-specific module of the EUROASPIRE III survey

Background Previous cross-sectional surveys in different European countries within the EUROASPIRE programme demonstrated a high prevalence of modifiable risk factors, unhealthy lifestyles and inadequate drug treatment in coronary heart disease patients. Comparable data for ischaemic stroke patients is lacking. Methods A stroke-specific study module was added to the EUROASPIRE III core survey. This cross-sectional multicentre survey included consecutive patients with first-ever ischaemic stroke from four European countries. Data were obtained from medical records, patient interviews and patient examinations within 6–36 months after the stroke event. Control of modifiable risk factors after stroke was evaluated against contemporary European guidelines. Results A total of 881 patients was recruited. Median age was 66 years, 37.5% were female; average time from the stroke event to interview was 550 days. At the time of the interview, 17.6% of stroke patients smoked cigarettes, 35.5% had a body mass index ≥30 kg/m2, 62.4% showed elevated blood pressure and 75.7% exhibited elevated LDL cholesterol levels. Antiplatelet drugs or oral anticoagulants were used by 87.2%, antihypertensive medication by 84.4% and statins by 56.8% of stroke patients. Among patients using antihypertensive drugs and lipid-lowering medication at the time of the interview, 34.3% and 34.4%, respectively, achieved target blood pressure and total cholesterol values according to current European guidelines. Conclusion The EUROASPIRE III stroke-specific module shows that secondary prevention and risk factor control in patients after ischaemic stroke need to be improved in four European centres at the time of the study since about half of patients are not achieving risk factor targets defined in European guidelines.

The differential diagnosis of acute transverse myelitis

The clinical and paraclinical characteristics of acute transverse myelitis (ATM) were analyzed in 31 patients. In some patients there was clinical evidence of complete transection, in others of only partial lesions. Magnetic resonance imaging (MRI) in the acute phase in the first group was normal, but showed cord atrophy subsequently. It is probable that the clinical picture was due to parenchymatous neuronal lesions, analogous to those of axonal polyneuropathy. In the patients with incomplete transverse lesions, the most common finding was demyelination. In the patients with circumscribed demyelinating lesions, the symptoms and MRI were suggestive of clinically isolated syndromes (CIS) predictive of multiple sclerosis (MS). Extensive demyelination was indicative of acute disseminated encephalomyelitis (ADEM) due to hyperergic vasculopathy or various forms of chronic vasculitis. In two patients with variable clinical symptoms, a vascular malformation was the cause of the clinical presentation, and in one patient demyelination was due to the disc compression.

The Reliability and Validity of the Mini-Mental State Examination in the Elderly Croatian Population

Aim: The aim of this study was standardization and validation of the Mini-Mental State Examination (MMSE) in the general Croatian aging population. Methods: Three-hundred and forty-four participants underwent the MMSE test, 217 cognitively healthy subjects without neurological and psychiatric disorders and 127 patients with mild cognitive impairment (MCI) or dementia. Results: The optimal cutoff point for screening of the general Croatian population (cognitively healthy vs. MCI and dementia) is 26/27; in the Croatian population aged ≥65 years, the cutoff point is 24/25, whereas for screening of highly educated persons (≥14 years of education) aged ≥65 years a higher cutoff point should be used (26/27). Conclusions: MMSE results when standardized and validated in a certain population might better contribute to recognition of the individuals at risk that should be directed to dementia outpatient clinics.

The Frontal Assessment Battery in the Differential Diagnosis of Dementia

Aim: The Frontal Assessment Battery (FAB) has been used in different clinical settings as a valuable quick bedside test for executive dysfunction. The aim of the study was to evaluate clinical utility of the FAB for differential diagnosis of Alzheimer disease (AD), subcortical vascular cognitive impairment (scVCI), and frontotemporal lobar degeneration (FTLD). Methods: Scores of the total FAB test and subtests were compared between consecutive series of 37 patients with AD, 31 patients with scVCI, 13 patients with FTLD, and 29 cognitively healthy individuals. Results: There was no statistically significant difference in the total FAB scores among the groups of patients with dementia. When comparing subtest scores, patients with FTLD had significantly lower scores on the lexical fluency subtest compared to the patients with AD (P < .001) or scVCI (P < .001); patients with scVCI had significantly lower scores on the motor series subtest compared to patients with FTLD (P = .02) and AD (P = .035) and on conflicting instructions subtest compared to patients with AD (P = .033). Conclusion: Some FAB subtests might enhance diagnostic accuracy taking into account clinical history and other tests of executive function.

Ultrasound and dynamic functional imaging in vascular cognitive impairment and Alzheimer’s disease

BackgroundThe vascular contributions to neurodegeneration and neuroinflammation may be assessed by magnetic resonance imaging (MRI) and ultrasonography (US). This review summarises the methodology for these widely available, safe and relatively low cost tools and analyses recent work highlighting their potential utility as biomarkers for differentiating subtypes of cognitive impairment and dementia, tracking disease progression and evaluating response to treatment in various neurocognitive disorders.MethodsAt the 9th International Congress on Vascular Dementia (Ljubljana, Slovenia, October 2015) a writing group of experts was formed to review the evidence on the utility of US and arterial spin labelling (ASL) as neurophysiological markers of normal ageing, vascular cognitive impairment (VCI) and Alzheimer’s disease (AD). Original articles, systematic literature reviews, guidelines and expert opinions published until September 2016 were critically analysed to summarise existing evidence, indicate gaps in current knowledge and, when appropriate, suggest standards of use for the most widely used US and ASL applications.ResultsCerebral hypoperfusion has been linked to cognitive decline either as a risk or an aggravating factor. Hypoperfusion as a consequence of microangiopathy, macroangiopathy or cardiac dysfunction can promote or accelerate neurodegeneration, blood-brain barrier disruption and neuroinflammation. US can evaluate the cerebrovascular tree for pathological structure and functional changes contributing to cerebral hypoperfusion. Microvascular pathology and hypoperfusion at the level of capillaries and small arterioles can also be assessed by ASL, an MRI signal. Despite increasing evidence supporting the utility of these methods in detection of microvascular pathology, cerebral hypoperfusion, neurovascular unit dysfunction and, most importantly, disease progression, incomplete standardisation and missing validated cut-off values limit their use in daily routine.ConclusionsUS and ASL are promising tools with excellent temporal resolution, which will have a significant impact on our understanding of the vascular contributions to VCI and AD and may also be relevant for assessing future prevention and therapeutic strategies for these conditions. Our work provides recommendations regarding the use of non-invasive imaging techniques to investigate the functional consequences of vascular burden in dementia.

Hemodynamic monitoring of middle cerebral arteries during cognitive tasks performance.

The aim of this study was to obtain temporal pattern and hemispheric dominance of blood flow velocity (BFV) changes and to assess suitability of different cognitive tasks for monitoring of BFV changes in the middle cerebral arteries (MCA).

Blood flow velocity changes in anterior cerebral arteries during cognitive tasks performance.

OBJECTIVE Transcranial Doppler sonography (TCD) enables monitoring of blood flow velocities (BFVs) in basal cerebral arteries during different cognitive tasks performance with great temporal resolution. So far, BFVs changes during mental activity were monitored primarily in middle cerebral arteries (MCAs) and little is known about these changes in anterior cerebral arteries (ACAs). AIM To determine the effect of different cognitive tasks performance on BFV changes and hemispheric dominance in ACAs and to assess the most suitable activation test for monitoring of BFV changes in ACAs. METHODS Fourteen right-handed, healthy subjects aged 20-26 were included in the study. BFVs in both ACAs were recorded simultaneously during performance of cognitive tasks designed to activate frontal lobes: phonemic verbal fluency test (pVFT), Stroop tests and Trail Making Tests (TMTs). RESULTS A statistically significant BFV increase was recorded in both ACAs during performance of all cognitive tasks. Statistically significant right ACA dominance was found during performance of pVFT and TMTB. The most significant BFV increase was obtained during performance of TMTB. CONCLUSION Our result addressed cognitive tests with great activation potential for monitoring of ACAs that might be used in distinguishing of healthy individuals and patients with neurovascular or neurodegenerative diseases.

Impact of Remote Ischemic Preconditioning Preceding Coronary Artery Bypass Grafting on Inducing Neuroprotection (RIPCAGE trial)

Background: Neurological complications after coronary artery bypass grafting (CABG) reduce quality of life, increase mortality, and inflate resource utilization. The risk of postoperative neurological complications parallels the increasing risk burden of the contemporary patient population. We evaluated the efficacy of remote ischemic preconditioning (RIPC) on inducing neuroprotection. Methods: Seventy patients undergoing first‐time CABG were randomly assigned to RIPC or a sham procedure. Structural brain magnetic resonance imaging (MRI) was complemented with functional connectivity MRI to gain a whole‐brain global connectivity analysis. Paired neurocognitive and MRI data were acquired pre‐ and postoperatively. The primary end point was a composite of new ischemic brain lesions and neurocognitive impairment. Secondary end points included brain connectivity profiles, pooled ischemic volumes, and individual components of the primary outcome. The Shapiro–Wilk test was used to determine whether a data set followed a normal distribution. The Fisher exact test was used to calculate the measures of association for categorical variables, whereas continuous data were tested with either the Mann–Whitney U test or the Student t test. Results: There was no between‐group difference in the incidence of the primary end point (9 [27%] in the RIPC group vs 8 [24%] in the control group, odds ratio, 1.17 [95% confidence interval, 0.34‐4.06]; P = 1.0). Although RIPC did not reduce the incidence of brain ischemia (8/33 [24%] vs 7/33 [21%]; P = 1.0), the pooled ischemic volume was lower in the RIPC group (157 [interquartile range, 125‐231] vs 777 [interquartile range, 564‐965] mm3; P = .004). Postoperative neurocognition was marginally superior in the RIPC group as evidenced by a lower absolute number of abnormal neurocognitive tests in the RIPC group (7/99 [7%] vs 16/99 [16%]; odds ratio, 0.40 [95% confidence interval, 0.14‐1.09]; P = .074). Robust reductions of functional connectivity profiles for the associative thalamus were documented in both groups, irrespective of RIPC (RIPC group, t = 3.31; P < .01; and the control group, t = 3.52; P < .01). Conclusions: Silent brain ischemia occurs frequently after CABG. RIPC did not reduce the incidence of the primary outcome. However, RIPC significantly reduced the pooled volume of ischemic brain lesions. Surgery adversely affected global brain connectivity, with RIPC conferring no demonstrable protection. The association of RIPC with superior neurocognitive test scores failed to cross the threshold for significance. Graphical abstract Figure. No Caption available.

Acknowledgement to the Reviewers

The editor-in-chief extends her appreciation to the editorial board members and to all ad hoc reviewers whose comments and criticisms ensure the timeliness and quality of the papers published in this journal. We are especially grateful to those members of the editorial board who, after serving for many years, have retired from the board, and we look forward to the new colleagues who will join us. Finally, we thank all of you, authors and contributors, who give this journal the international standing in the research into dementing disorders that it enjoys.

Young-onset dementia and MRI changes in a patient with subclinical liver cirrhosis due to chronic hepatitis C

Young-onset dementia (before age of 65) is relatively infrequent and presents a challenge in everyday neurological practice due to wide spectrum of clinical presentations and diversity of underlying etiology. When cognitive deficits are accompanied with liver dysfunction different etiologies should be considered. We present a case report of a young patient with subclinical decompensated liver disease due to underlying chronic hepatitis C, presented with the mildest form of hepatic encephalopathy spectrum, called minimal (subclinical) hepatic encephalopathy and characteristic MRI changes.