Kari Murros

Prognostic Value and Determinants of First-Day Mean Arterial Pressure in Spontaneous Supratentorial Intracerebral Hemorrhage

BACKGROUND AND PURPOSEnThe onset of spontaneous intracerebral hemorrhage (ICH) is often accompanied by transient blood pressure (BP) elevation. The prognostic value and the determinants of this BP reaction have not entirely been solved, and the present study was focused on these questions.nnnMETHODSnFrom 1985 to 1991 in Central Finland (population, 246,000), a total of 425 patients had first-ever ICH verified by CT or necropsy. The hematoma was supratentorial in 337 patients. Of the 306 patients with supratentorial ICH who had CT, 282 had the BP measured at least once within 24 hours of onset, and they formed the study population. The case notes and CT films were reviewed, and mean arterial pressure (MAP) was calculated from the highest BP reading.nnnRESULTSnThe fatality rate was high; 43% of the patients were dead within 28 days of onset. Six independent predictors of the 28-day survival were identified by multiple logistic regression; these predictors were consciousness on admission, first-day MAP, subarachnoid spread of the bleed, lateral shift of hemispheral midline structures, admission blood glucose, and vomiting. The MAPs varied between 66.7 and 203.3 mm Hg, and the cutoff points of the MAP quartiles were 118, 132, and 145 mm Hg. Patients in the first three MAP quartiles had relatively fair outcome, with 71%, 65%, and 60%, respectively, alive 28 days after onset. This was in sharp contrast to the fourth quartile, with only 33% surviving the first 28 days (log-rank, P < .0001 to P = .0010). Patients unconscious/ comatose on admission had significantly higher MAPs than did those who were alert or somnolent/disoriented (ANOVA, P = .0079). However, at all levels of consciousness, the 28-day fatality rate increased from the first to the fourth MAP quartile: 69% in the alert, 186% in the somnolent/disoriented, and 45% in the unconscious/comatose patients. Stepwise multiple regression analysis gave four independent predictors of the first-day MAP: hypertension, age (in an inverse fashion), admission blood glucose, and hematoma volume.nnnCONCLUSIONSnThe most important predictor of the 28-day survival was the level of consciousness on admission, followed by first-day MAP. Hypertension was the most important predictor of the first-day MAP, followed by age, which had an inverse effect on the MAP level. At all levels of consciousness, high first-day MAP (especially if > 145 mm Hg) worsened the 28-day survival rate.

A randomized, double-blind, placebo-controlled trial of nimodipine in acute ischemic hemispheric stroke.

Background and Purpose A randomized, double‐blind, placebo‐controlled multicenter trial was conducted to test the hypothesis that nimodipine would improve the functional outcome in acute ischemic hemispheric stroke. Methods A total of 350 patients were randomized to nimodipine 120 mg/d PO or matching placebo for 21 days. Randomization was stratified by onset of therapy, age, and stroke severity. Treatment was begun within 48 hours of onset. The patients had neurological evaluation on admission, on days 1, 7, and 21, and at 3 and 12 months. The primary end points were Rankin grade, neurological score, and mobility at 12 months. Results We did not find any differences in the functional outcome between the treatment groups or between the stratified subgroups. We were also unable in post hoc analyses to find any groups of patients who benefited from nimodipine. During the first month and at 3 months the case‐fatality rate was higher in the nimodipine‐treated patients than in those on placebo (P=.004 and P=.030, respectively), but at the 1‐year follow‐up this difference had lost statistical significance. During the first week nimodipine had a statistically significant lowering effect on both systolic (P=.005) and diastolic (P=.013) blood pressure. Conclusions Nimodipine did not improve the functional outcome of acute ischemic hemispheric stroke. The early case‐fatality rate was higher in the nimodipine group, possibly due to the blood pressure‐lowering effect of nimodipine. (Stroke. 1994;25:1348‐1353.)

Admission blood glucose and short term survival in primary intracerebral haemorrhage: a population based study

Background: The role of admission blood glucose level on the prognosis of patients with intracerebral haemorrhage has not been elucidated. Objective: To examine this association on the basis of an epidemiologically representative patient material. Methods: 249 500 people living in the catchment area of the Central Hospital of Central Finland. The diagnosis of ICH was established if verified by cranial computed tomography (CT) or autopsy. Results: Of the 416 patients who fulfilled the diagnostic criteria, 30 died before admission and 386 were admitted to the Central Hospital. All 329 patients (290 nondiabetics and 39 diabetics) with both admission blood glucose and cranial CT data were included in the study. The mean blood glucose level was 10.6 mmol/l for nondiabetics who died on the day of onset, 8.6 mmol/l for those dying during days 1 to 28, and 6.8 mmol/l for the 28 day survivors. The corresponding figures for diabetics were 13.9 mmol/l, 12.5 mmol/l, and 9.3 mmol/l. In both nondiabetics and diabetics, patients who died had significantly higher mean glucose than the 28 day survivors (p<0.0001 versus pu200a=u200a0.029). However, blood glucose of the surviving diabetics was as high as that of the deceased nondiabetics (9.3 mmol/l versus 9.1 mmol/l). In nondiabetics, admission blood glucose was associated with parameters signifying severe stroke; disturbed consciousness, large haematoma volume and shift of cerebral midline structures, and high admission mean arterial pressure. In logistic regression analysis, high admission blood glucose in nondiabetics was a significant predictor of death during the first 28 days of onset (odds ratio 1.22, 95% CI 1.07 to 1.40). Conclusions: High admission blood glucose predicts increased 28 day case fatality rate in both nondiabetic and diabetic patients with ICH. Because high admission blood glucose was associated with markers of severe stroke, we are inclined to support the stress theory; high admission blood glucose is the result of a serious ICH.

Factors Delaying Hospital Admission After Acute Stroke

BACKGROUND AND PURPOSEnClinical trials of new drugs that reverse neurological deficits when used in the first hours of stroke onset suggest that early hospital admission is important. We analyzed a database of patients with acute stroke to determine the factors that delay hospital admission.nnnMETHODSnWe analyzed all patients with their first stroke during 1993 in the province of Central Finland (population, 256 000). Patients referred to the Central Hospital, the only tertiary referral hospital in the area, were included in the study.nnnRESULTSnOf the patients with first stroke, 363 (79%) were admitted to the Central Hospital. The stroke subtype was confirmed in 356 (98%) patients with CT scan, and the patient population included 272 (75%) with brain infarction, 51 (14%) with intracerebral hemorrhage, and 40 (11%) with subarachnoid hemorrhage. The most important factor associated with a delay in reaching the hospital was the referral pattern. The median delay was 2 hours for patients brought directly to the Central Hospital, 8 hours if a physician at the local health center was consulted, and 47 hours if the patient was first admitted to the health center for observation. Other factors associated with a delay were ischemic stroke and stroke onset in the evening or night or during the weekend.nnnCONCLUSIONSnThe majority of patients who are candidates for acute stroke trials arrive at the hospital after prolonged delays for multiple reasons. Public and medical personnel education could result in signficant reduction in these delays.

Serum cortisol and outcome of ischemic brain infarction

The predictive value of serum cortisol level on the prognosis in acute brain infarction of the carotid circulation territory was studied in 101 patients younger than 70 years. The levels of 7 a.m. and 7 p.m. serum cortisol were measured initially and at 1 week. All patients underwent a computed cerebral tomography (CT) within 2 days of the onset of symptoms, and a second CT 3 weeks or 3 month later. Serum cortisol values predicted the stroke outcome. Both the 7 a.m. and the 7 p.m. values in the initial and 1-week samples correlated positively with the severity of hemiparesis on the corresponding days. The 7 p.m. values predicted better than the 7 a.m. values the functional outcome and case fatality during the 3 month follow-up. Initially and at 1 week, the median 7 p.m. serum cortisol values were statistically significantly higher in those with frontally extending infarcts than in those with non-frontal infarcts. Both 7 a.m. fasting blood glucose and glycosylated hemoglobin (HbA1c) measurements were taken within 3 days of the onset in 95 cases. The patients were diagnosed to have prestroke normoglycemia (n = 73) and hyperglycemia (n = 22) on the basis of the HbA1c level. A highly significant (P = 0.0001) correlation was demonstrated between the initial 7 p.m. cortisol and 7 a.m. fasting blood glucose values in those with prestroke normoglycemia, suggesting that hyperglycemia during the acute phase of stroke is a stress response.

Blood glucose, glycosylated haemoglobin, and outcome of ischemic brain infarction

From August 1987 through December 1989 all consecutive conscious patients younger than 70 years with a recent (less than 48 h) brain infarction of the carotid territory were prospectively included in the study. Blood samples for fasting blood glucose and glycosylated haemoglobin (HbA1c) were taken after a median delay of 23 h of the onset of symptoms. The severity of hemiparesis was assessed on admission, at 1 week, 3 weeks, and 3 months. The functional outcome was assessed at 3 months. Computed cerebral tomography was performed on admission, and later on at 3 weeks or 3 months. The brain infarct volume was measured from the CTs. The patients were diagnosed to have prestroke normoglycemia (n = 76) and prestroke hyperglycemia (n = 23) on basis of the HbA1c level. The case fatality rate, severity of hemiparesis, functional outcome, and infarct size did not differ between these 2 groups. On the other hand, fasting blood glucose level of the non-diabetics correlated strongly with the severity of hemiparesis and predicted stroke outcome. A statistically significant correlation was observed between blood glucose values and the volumes of cortical infarcts in non-diabetics. Because prestroke blood glucose level, in contrast to post-stroke blood glucose level, did not have any predictive value concerning stroke outcome it is concluded that high fasting blood glucose values after stroke reflect a stress response to a more severe ischemic brain lesion.

Low plasma uric acid level in Parkinson's disease

Earlier studies suggest that low plasma uric acid level is a risk factor for Parkinsons disease (PD), and that uric acid associates with iron‐binding proteins. We therefore decided to examine plasma uric acid levels and markers of peripheral iron metabolism in PD patients and healthy controls. For the study, 40 patients with PD and 29 controls underwent clinical screening, laboratory testing, and body mass index (BMI) measurement. The average consumption of different foodstuffs and dairy products was estimated. Plasma uric acid level was significantly lower in the patients than in the controls. There were no significant differences in the levels of plasma iron parameters, but plasma uric acid correlated strongly with serum ferritin both in the patient and the control group. The BMI was slightly lower in the patients compared with the controls despite equal daily calorie consumption. Plasma uric acid level is low in patients with PD, which may have implications for both the disease pathogenesis and treatment recommendations.

Cigarette smoking and subarachnoid haemorrhage: a population-based case-control study.

Smoking habits were analysed in 114 patients with subarachnoid haemorrhage, less than 70 years old, obtained from an epidemiological study. One control, matched for age, sex, and domicile, was selected for each patient. Current cigarette smokers were significantly more prevalent among cases than controls, and the relative risk of subarachnoid haemorrhage compared with non-smokers was 2.7 in men and 3.0 in women. The so called metastatic emphysema theory with increased elastolytic activity in the serum of smokers is proposed as biochemical basis for the increased risk of subarachnoid haemorrhage.

Effect of Nimodipine on Final Infarct Volume after Acute Ischemic Stroke

Placebo-controlled clinical trials with nimodipine in acute ischemic stroke have not fulfilled the early optimistic expectations. Nimodipine has in some experimental studies, when administered either before or up to 90 min after induction of cerebral ischemia, resulted in a reduction of infarct size. No studies on the effects of nimodipine on infarct size in man have been published. We measured the infarct volumes in the admission and control CT examinations 3 weeks to 3 months later in 153 patients who had participated in a multicenter, randomized and placebo-controlled study. No statistically significant differences overall were found within or between the treatment groups. Subgroup analyses revealed in the placebo, but not in the nimodipine arm, an increase in the median infarct volumes if the treatment was started within 24 h of onset, and if the volume in the admission CT was less than median. A beneficial effect of nimodipine in prevention of infarct size increase in these circumstances cannot be excluded.

Altered N100-potential associates with working memory impairment in Parkinson’s disease

The diagnosis of cognitive impairment and dementia often occurring with Parkinson’s disease (PD) is still based on the clinical picture and neuropsychological examination. Ancillary methods to detect cognitive decline in these patients are, therefore, needed. Alterations in the latencies and amplitudes of evoked response potential (ERP) components N100 and P200 have been described in PD. Due to limited number of studies their relation to cognitive deficits in PD remains obscure. The present study was designed to examine if alterations in the N100- and P200-potentials associate with neuropsychological impairment in PD. EEG-ERP was conducted to 18 PD patients and 24 healthy controls. The patients underwent a thorough neuropsychological evaluation. The controls were screened for cognitive impairment with Consortium to Establish Alzheimer’s disease (CERAD)—testing and a normal result were required to be included in the study. The N100-latency was prolonged in the patients compared to the controls (pxa0=xa00.05). In the patients, the N100 latency correlated significantly with a visual working memory task (pxa0=xa00.01). Also N100 latency was prolonged and N100 amplitude habituation diminished in the patients achieving poorly in this task. We conclude that prolonged N100-latency and diminished amplitude habituation associate with visual working memory impairment in PD.