G. Tsivgoulis

U‐shaped relationship between mortality and admission blood pressure in patients with acute stroke

Objective.  To evaluate the relationship between systolic blood pressure (SBP) or diastolic blood pressure (DBP) on admission and early or late mortality in patients with acute stroke.

Common carotid arterial stiffness and the risk of ischaemic stroke

In the present case–control study we aimed to investigate the association of common carotid arterial (CCA) stiffness with ischaemic stroke (IS) and to determine whether this relationship was independent of conventional risk factors including CCA intima‐media thickness (CCA‐IMT). CCA distensibility, defined as the change of CCA‐diameter during the cardiac cycle, and CCA‐IMT were evaluated by means of high‐resolution B‐mode carotid ultrasound examination in consecutive, first‐ever IS patients (n = 193) and in age‐ and sex‐matched control subjects (n = 106). The CCA distensibility (inverse of CCA stiffness) was significantly (P = 0.007) lower in IS (0.353 mm, 95% CI: 0.326–0.379) than in control subjects (0.415 mm, 95% CI: 0.378–0.451) even after adjusting for blood pressure values, diastolic CCA‐diameter and height. The multivariate logistic regression procedure selected CCA‐IMT and CCA distensibility as the only independent predictor variables of IS. Each 1 SD increase in the CCA‐IMT and each 1 SD decrease in the CCA distensibility independently increased the likelihood of IS by 167.0% (OR: 2.67, 95% CI: 1.80–3.96, P < 0.001) and 59.0% (OR: 1.59, 95% CI: 1.22–2.07, P = 0.001) respectively. Increased CCA stiffness is associated with IS independent of conventional risk factors and CCA‐IMT. The causal interrelationship between the elastic properties of the CCA and the risk of stroke deserves further investigation by longitudinal studies.

Twenty four hour pulse pressure predicts long term recurrence in acute stroke patients

Objectives: The impact of different blood pressure (BP) components during the acute stage of stroke on the risk of recurrent stroke is controversial. The present study aimed to investigate by 24 hour BP monitoring a possible association between acute BP values and long term recurrence. Methods: A total of 339 consecutive patients with first ever acute stroke underwent 24 hour BP monitoring within 24 hours of ictus. Known stroke risk factors and clinical findings on admission were documented. Patients given antihypertensive medication during BP monitoring were excluded. The outcome of interest during the one year follow up was recurrent stroke. The Cox proportional hazard model was used to analyse association of casual and 24 hour BP recordings with one year recurrence after adjusting for stroke risk factors, baseline clinical characteristics, and secondary prevention therapies. Results: The cumulative one year recurrence rate was 9.2% (95% CI 5.9% to 12.3%). Multivariate Cox regression analyses revealed age, diabetes mellitus, and 24 hour pulse pressure (PP) as the only significant predictors for stroke recurrence. The relative risk for one year recurrence associated with every 10 mm Hg increase in 24 hour PP was 1.323 (95% CI 1.019 to 1.718, p = 0.036). Higher casual PP levels were significantly related to an increased risk of one year recurrence on univariate analysis, but not in the multivariate Cox regression model. Conclusions: Elevated 24 hour PP levels in patients with acute stroke are independently associated with higher risk of long term recurrence. Further research is required to investigate whether the risk of recurrent stroke can be reduced to a greater extent by decreasing the pulsatile component of BP in patients with acute stroke.

Moyamoya syndrome in a Caucasian woman with Turner's syndrome

Moyamoya disease is a rare cerebral arteriopathy of unknown etiology characterized by bilateral obliteration of the internal carotid artery and its branches, with the concomitant development of an abnormal basal meshwork of collateral vessels. Moyamoya syndrome shows a similar angiographic pattern but is usually associated with different diseases and risk factors [1]. Turner’s syndrome (TS) is one of the most common chromosomal anomalies and has been related with different arteriopathies [2,3]. A 47-year-old Greek woman of small stature with a history of hypertension, cataract, and primary amenorrhea presented because of an over 6 days progressing left side hemiparesis with severe hemineglect. Magnetic resonance imaging revealed multiple ischemic lesions of the right hemisphere affecting both the cortical and subcortical structures (Fig. 1a). Magnetic resonance angiography (MRA) demonstrated hypoplastic common carotid arteries and intracranial obstruction of both internal carotid arteries. Both hemispheres were supplied from the vertebrobasilar system through leptomeningeal collaterals (Fig. 1b). These imaging findings are typical for Moyamoya. Because of the adult onset of the disease and the coexistence of risk factors, this case should be rather classified as Moyamoya syndrome. Because of the short stature and the dysgonadal features, further chromosomal examination was conducted. The 46,X,i(Xq) karyotype established the diagnosis of TS. A literature review revealed only a single case of a Japanese girl with TS [karyotype: 45,X/46,X,i(Xq) associated with Moyamoya disease [4]. Congenital malformations of the heart and the major vessels are frequently seen among the patients with TS [5]. Fibromuscular dysplasia affecting the cerebral and renal arteries has also been associated with TS [2]. It is additionally regarded as possible cause of Moyamoya syndrome [1]. Moreover, several cases of Japanese patients with TS suffering stroke because of unilateral or bilateral occlusion, stenosis or dissection of the internal carotid artery have been described [6,7]. According to the angiographic findings, in some of these cases, a Stage 1 Moyamoya cannot be definitely excluded [1]. Considering the pathogenesis of Moyamoya, both the familial occurrence and the higher rates among Japanese patients indicate a genetic predisposition.

The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta-analysis.

The diagnostic utility of transesophageal echocardiography (TEE) in patients with cryptogenic ischaemic stroke (IS) or transient ischaemic attack (TIA) remains controversial.

Bilateral drop foot due to thoracic disc herniation.

Sir, Thoracolumbar junction lesions are rare and depending on the individually variable location of the spinal cord’s end, disc herniations may present as upper or lower motor neuron disorders, cauda syndromes or even radiculopathies [1–5]. A 54-year-old man presented with bilateral drop foot. First symptoms of weakened dorsiflexion occurred on the left foot 1 year earlier and progressed slowly to the present condition. Six months later the right foot was similarly affected leading to severe disability. No back pain was reported at any time. On examination bilateral weakness in foot dorsiflexion (2+/5) and big toe extension (3/5) was documented, whereas knee flexion was mildly affected (4/5). Both tibialis anterior muscles were atrophic. Except of the diminished patellar reflexes, all other tendon reflexes were normal. Toes were flexor and no other pyramidal signs were observed. No sensory deficit was documented. Anal tonus and reflex were present and no erectile, bladder or bowel dysfunction was reported. Electromyography revealed fibrillations and positive sharp waves, as well as a reduced recruitment pattern with increased amplitudes of motor unit potentials in both tibialis anterior, medial gastrocnemius and gluteus maximus muscles. Conduction studies revealed normal velocity and decreased amplitude of the compound action potential of the right peroneal nerve, which was absent on the left. The sensory nerve action potential from both superficial peroneal nerves, as well as the H-reflex, was within normal range. In accordance with the clinical findings, magnetic evoked potentials revealed normal central latencies, excluding involvement of the corticospinal tracts. Urodynamic studies were also unremarkable. Spinal magnetic resonance imaging showed the caudal cord end located above the upper edge of the L1 vertebral body and also revealed a T11–T12 disc herniation with posterior protrusion and subsequent cord compression with signs of myelopathy, but no contrast enhancement (Fig. 1). Therefore, the patient underwent posterior T11–T12 laminectomy. After 1 year bilateral paresis of foot dorsiflexion and toe extension improved substantially. No additional symptoms occurred and no other muscle group was in the meanwhile affected, practically excluding the differential diagnostic alternative of degenerative anterior horn diseases. Thoracic disc herniations are infrequent accounting for 0.2–0.5% of all disc protrusions. Three-fourths of them occur below T8-level, while T11–T12 protrusion is the commonest [2]. Unilateral or bilateral drop foot is described in patients (cord end at L1–L2) with T12–L1 disc herniations and is considered as the result of an anterior horn lesion (L4–L5 myelotomes). In the present case, where the cord ends more cranially, T11–T12 disc protrusion obviously affects the same segments. Accordingly, the constellation of electrophysiological and clinical findings suggests bilateral anterior horn lesions, affecting mainly L5 and partly L4 and S1 segments. This clinical presentation could be attributed to ischaemic myelopathy caused by thoracic disc protrusion. Bilateral compression of the anterior radiculomedullary arteries, traversing the intervertebral foramen to join the cord and supply both anterior horns, could be assumed. This hypothesis is corroborated by the findings of the anatomic study of Lu et al. [6], who reported that the great medullary artery of Adamkiewicz, which represents the main contributing vessel to the blood supply of the lower thoracic cord and originates at the T10–T12 level, is intradural throughout most of its course and therefore is more vulnerable to compression by a space-occupying lesion such as disc herniation or a fractured fragment. Interestingly, a direct compression of the Adamkiewicz artery in the T9–T10 intervertebral foramen has been reported to cause an ischaemic spinal cord lesion, which was clinically expressed as a BrownSequard syndrome [3]. In conclusion, the present case reminds that lower motor neuron signs including unilateral or bilateral drop foot should be considered as atypical presentations of thoracolumbar disc herniations.

Fatal oral anticoagulant-related intracranial hemorrhage: a systematic review and meta-analysis

Intracranial hemorrhage (ICH) is the most feared complication in patients treated with oral anticoagulants due to non‐valvular atrial fibrillation. Non‐vitamin K oral anticoagulants (NOACs) reduce the risk of ICH compared with vitamin K antagonists (VKAs). We performed a systematic review and meta‐analysis to evaluate the risk of fatal NOAC‐related ICH compared with VKA‐related ICH.

Restless legs syndrome and cerebrovascular/cardiovascular events: Systematic review and meta‐analysis

We performed a systematic review and meta‐analysis to evaluate the proposed association of restless legs syndrome (RLS) with cerebrovascular/cardiovascular outcomes.

Differential leukocyte counts on admission predict outcomes in patients with acute ischaemic stroke treated with intravenous thrombolysis

To determine the association of differential leukocyte counts on admission with efficacy and safety outcomes in patients with acute ischaemic stroke (AIS) treated with intravenous thrombolysis (IVT).