Josep-Lluis Martí-Vilalta

Favorable Outcome of Ischemic Stroke in Patients Pretreated with Statins

Background and Purpose— Statins may be beneficial for patients with acute ischemic stroke. We tested the hypothesis that patients pretreated with statins at the onset of stroke have less severe neurological effects and a better outcome. Methods— We prospectively included consecutive patients with ischemic stroke of <4-hour duration. We recorded demographic data, vascular risk factors, Oxfordshire Classification, National Institutes of Health Stroke Scale (NIHSS) score, admission blood glucose and body temperature, cause (Trial of Org 10172 in Acute Treatment [TOAST] criteria), neurological progression at day 3, previous statin treatment, and outcome at 3 months. We analyzed the data using univariate methods and a logistic regression with the dependent variable of good outcome (modified Rankin Scale [mRS] 0 to 1, Barthel Index [BI] 95 to 100). Results— We included 167 patients (mean age 70.7±12 years, 94 men). Thirty patients (18%) were using statins when admitted. In the statin group, the median NIHSS score was not significantly lower and the risk of progression was not significantly reduced. Favorable outcomes at 3 months were more frequent in the statin group (80% versus 61.3%, P =0.059 with the mRS; 76.7% versus 51.8%, P =0.015 with the BI). Predictors of favorable outcome with the BI were: NIHSS score at admission (OR: 0.72; CI: 0.65 to 0.80; P <0.0001), age (OR: 0.96; CI: 0.92 to 0.99; P =0.017), and statin group (OR: 5.55; CI: 1.42 to 17.8; P =0.012). Conclusions— Statins may provide benefits for the long-term functional outcome when administered before the onset of cerebral ischemia. However, randomized controlled trials will be required to evaluate the validity of our results.

Lesions in the left arcuate fasciculus region and depressive symptoms in multiple sclerosis

Depression is a common mood disturbance in multiple sclerosis (MS) patients. Epidemiologic data suggest a causative relationship between depressive symptoms and cerebral demyelination, although a specific lesion site responsible for depressed mood has not been identified. Given that depression in neurologic disease is closely related to frontal and temporal lobe damage, we focused our study on investigating the extent to which lesions in the white matter connecting both cerebral lobes may account for depressive symptoms in MS. Forty-five patients were assessed using the Beck Depression Inventory and an MRI protocol conceived to quantify lesions separately in the basal, medial, and lateral frontotemporal white matter. The presence of lesions in the left suprainsular white matter, the region that mainly includes the arcuate fasciculus, was specifically associated with depressive symptoms, accounting for a significant 17% of the depression score variance. Although a multifactorial origin is suspected for depression in MS, this finding gives support to the existence of a direct negative effect of demyelination on mood.

Motion of the cerebellar tonsils in Chiari type I malformation studied by cine phase-contrast MRI

We studied the effects on CSF dynamics at the foramen magnum and the clinical significance of the abnormal tonsillar motion in 14 patients with Chiari type I malformation and 14 control subjects using cine phasecontrast MRI.Dynamic MRI consisted of axial and sagittal cine phase-contrast sequences. CSF and tonsillar motion were qualitatively and quantitatively evaluated, and the subarachnoid space at the foramen magnum measured. In Chiari patients, cine phase-contrast MRI detected the abnormal pulsatile motion of the cerebellar tonsils, which produced a selective obstruction of CSF flow from the cranial cavity to the spine. The amplitude of the tonsillar pulsation and the severity of the arachnoid space reduction were associated with the symptom of cough-strain headache, but not with the presence of syringomyelia. The finding of abnormal valve dynamics of the cerebellar hernia revealed by cine phase-contrast MRI conforms to the pathophysiologic mechanisms suggested in pressure register studies and opens a new possibility in the presurgical assessment of Chiari patients with exertional symptoms. NEUROLOGY 1995;45: 1746-1753

The Barcelona Stroke Registry

The Barcelona Stroke Registry was established to collect clinical data of hospitalized patients with stroke, in order to study their clinical characteristics and outcome. Data were collected over a 17-year period in 3,577 consecutive patients with first-ever stroke admitted to a stroke unit in two university hospitals in the city of Barcelona (Catalonia, Spain). Patients were generally admitted within 48 h from stroke onset, were evaluated by a neurologist, and clinical data were collected using a standardized protocol. All subjects underwent computerized tomography (CT) examination. Data on the 3,577 patients revealed the following stroke subtypes: cerebral infarction (81%), corresponding to the varieties of atherothrombotic (39.5%), cardioembolic (17.5%), lacunar (11%), unusual (5%), or unknown (8%); and cerebral hemorrhage. We analyzed age distribution (mean age 66 years); risk factors (the most frequent being hypertension, present in 54% of cerebral infarctions and in 65% of hemorrhages); clinical manifestations (the most salient being abrupt onset in one half of the cases; high frequency of decreased consciousness in cardioembolic infarction; headache, seizures and nuclear palsy in ‘unusual’ cerebral infarctions; vomiting and coma in hemorrhage); localizations by vascular territories; mechanisms of the various stroke subtypes; complications (present in one third of patients, with a mortality of 14%), and outcome. Two out of 3 hospitalized stroke patients are first-ever stroke sufferers. Neuroimaging shows a cerebral infarct in 86.5% of cases. Clinical and laboratory investigations cannot determine the mechanism of 8% of infarcts and of 23% of hemorrhages. The high frequency of medical complications, mortality, and disability highlights the need to establish stroke units and stroke registries in order to perform further research into the diagnosis and management of patients with cerebrovascular disease.

Frontal lobe activation during word generation studied by functional MRI

Aims– To further delimit the specific verbal operations occurring in the dorsolateral frontal cortex during the generation of words, methods– different verbal fluency tasks guided by distinct specifications (phonological, semantic, or automatic production of words) were used in a functional magnetic resonance study. The study group comprised 10 right‐handed normal subjects ranging in age from 23 to 27 years. Functional magnetic resonance images were obtained in a 1.5‐Tesla magnet using a spoiled GRASS sequence. Results– Noticeable activation was found during the word generation tasks in the dorsolateral frontal cortex. The region showing the most prominent activation was the posterior part of the left middle frontal gyrus. Nevertheless, the different tasks each had a different activation effect. The phonologically guided generation of words produced the most consistent activation of the middle frontal gyrus, which mainly involved the premotor cortex. Conclusion– The results suggest that operations concerned with the generation of sound sequences, rather than the amount of produced words or their semantics, are responsible for sustained focal activity observed in the frontal lobes during verbal fluency tasks.

Spontaneous primary intraventricular hemorrhage: clinical data, etiology and outcome

Abstract The clinical features, etiology, and neurological outcome in patients with primary intraventricular hemorrhage (PIVH) have rarely been reported. We retrospectively reviewed the clinical data, complementary examinations, outcome, computed tomography (CT) blood amount, and ventricle size of 13 patients (mean age 60 years, five men). We defined PIVH as hemorrhage detected by CT in the ventricular system only. The major symptoms included headache (n = 13), decreased level of consciousness (n = 9), and nausea/vomiting (n = 7). The cause was unknown in five patients; and was associated with arterial hypertension in five, vascular malformations in two, and tumor in one, although arteriography was performed in only five patients. Outcomes were death in three, asymptomatic in six, mild disability in three, and moderate disability in one. Prognosis was not related to clinical or CT data. Clinical features can suggest the diagnosis of PIVH, but cerebral CT is required for confirmation.

Prognostic value of Pulsatility Index in acute intracerebral hemorrhage

Objective: To investigate whether data obtained by transcranial Doppler (TCD) have prognostic value in patients with intracerebral hemorrhage (ICH). Methods: A prospective study of patients with an acute (<12 hours from onset of symptoms) spontaneous supratentorial ICH was conducted. Mortality was assessed at 30-day follow-up. TCD parameters were obtained from both middle cerebral arteries: systolic, diastolic, and mean velocities and Pulsatility Index (PI) from the affected and unaffected hemispheres. The following variables were included in a univariate analysis: age, sex, hematoma volume, hypodense volume around the hematoma, total volume, midline shift, ventricular size, Glasgow Coma Scale score, intraventricular hemorrhage, body temperature, white cell count, blood glucose, mean blood pressure, and TCD data. A multivariate analysis was performed with variables that showed significance in the univariate analysis. Receiver-operator characteristic (ROC) curves were obtained. Results: Forty-eight patients (age 66.5 ± 12.5 years; 28 men) were studied. Mortality at 30 days was 31%. The only predictor of mortality was the Glasgow Coma Scale score (odds ratio [OR] 0.67, CI 0.53 to 0.84, p = 0.001), whereas the PI from the unaffected hemisphere was correlated with mortality (OR 2.3, CI 0.92 to 5.72, p = 0.07). The area under the ROC curve was 0.92. A cutoff for PI from the unaffected hemisphere of 1.75 showed a specificity of 94% and a sensitivity of 80% as a predictor of death at 30 days. Conclusions: The PI of the unaffected hemisphere may be a predictor of death in acute ICH. These findings suggest that intracranial hypertension is the most likely cause of death in most patients with ICH.

Does Thrombolysis Benefit Patients with Lacunar Syndrome

The efficacy of thrombolysis in clinical stroke subtypes is unclear. We compared the benefit of intravenous rt-PA in 11 patients with lacunar syndrome with that in 33 patients with a non-lacunar syndrome. Patients were matched by NIHSS score and time to treatment. Although no statistically significant differences were detected in outcome, the benefit was greater in the non- lacunar syndrome group.

Wallerian degeneration of the pyramidal tract in capsular infarction studied by magnetic resonance imaging.

Using magnetic resonance imaging, we studied 24 patients with ischemic infarction of the internal capsule. Magnetic resonance imaging detected wallerian degeneration of the pyramidal tract below the capsular lesion in 11 patients (45.8%); all 11 had clinical evidence of pyramidal tract damage. In six additional patients magnetic resonance imaging findings, present only on axial slices, were considered to indicate possible wallerian degeneration. When motor deficit was associated with posterior limb lesions, magnetic resonance imaging detected wallerian degeneration of the pyramidal tract in 78.6% (11) of 14 patients.

Pretreatment hemostatic markers of symptomatic intracerebral hemorrhage in patients treated with tissue plasminogen activator.

Background and Purpose— Symptomatic intracerebral hemorrhage (ICH) is a major complication of thrombolysis in patients with acute ischemic stroke. We analyzed whether baseline hemostatic markers could predict symptomatic ICH (SICH). Methods— In a multicenter study of patients treated with intravenous tissue plasminogen activator (t-PA) within 3 hours of stroke onset, we analyzed the following variables: demographic data, vascular risk factors, blood glucose at admission, time from the onset of symptoms to t-PA infusion, blood pressure, neurological deficit measured by the National Institutes of Health Stroke Scale (NIHSS) score, early signs of ischemia on the baseline computed tomography (CT) scan, and protocol deviations. In blood samples, the following markers of coagulation/fibrinolysis were measured before treatment: fibrinogen, prothrombin fragments 1+2, Factor XIII, Factor VII, &agr;2 antiplasmin, plasminogen activator inhibitor-1 (PAI-1), and thrombin-activatable fibrinolysis inhibitor. ICH was classified according to the European Cooperative Acute Stroke Study (ECASS) II criteria. SICH was defined as a parenchymal hematoma-1 (PH1) or PH2 type, associated with an increase in ≥4 points on the NIHSS score appearing within 36 hours after infusion. Results— We studied 114 patients. Mean age was 68.4±12.7 years, and 61% were men. The median baseline NIHSS score was 14. Mean time to treatment was 153±33 minutes. Eight patients had SICH (7%), and 18 patients (15.7%) had asymptomatic ICH. None of the baseline markers of coagulation/fibrinolysis were associated with SICH. In the multivariate analysis, only NIHSS on admission was an independent risk factor for SICH. Conclusions— None of the hemostatic markers analyzed in our study predicted symptomatic cerebral hemorrhage in patients with ischemic stroke treated with t-PA.