Kerstin Sander

Evaluation of C-Reactive Protein Measurement for Assessing the Risk and Prognosis in Ischemic Stroke: A Statement for Health Care Professionals From the CRP Pooling Project Members

Background and Purpose— Several studies have shown, in different populations, that modest elevation of plasma C-reactive protein (CRP) in the range seen in apparently healthy individuals is a strong predictor of future vascular events. Elevated plasma CRP concentrations are also associated with an increased risk of cerebrovascular events and an increased risk of fatal and nonfatal cardiovascular events in ischemic stroke patients. These epidemiological and clinical observations suggest that determination of plasma CRP concentrations could be used as an adjunct for risk assessment in primary and secondary prevention of cerebrovascular disease and be of prognostic value. The aim of this review is to summarize the evidence for CRP as an independent predictor of cerebrovascular events in at-risk individuals and ischemic stroke patients and to consider its usefulness in evaluating prognosis after stroke. Summary of Review— CRP fulfils most of the requirements of a new risk and prognostic predictor, but several issues await further confirmation and clarification before this marker can be included in the routine evaluation of stroke patients and subjects at risk for cerebrovascular disease. Potentially important associations have been established between elevated plasma CRP concentrations and increased efficacy of established therapies, particularly lipid-lowering therapy with statins. Conclusion— At present, there is not sufficient evidence to recommend measurement of CRP in the routine evaluation of cerebrovascular disease risk in primary prevention, because there is insufficient evidence as to whether early detection, or intervention based on detection, improves health outcomes, although shared risk of cardiovascular disease indicates this may be of value. In secondary prevention of stroke, elevated CRP adds to existing prognostic markers, but it remains to be established whether specific therapeutic options can be derived from this.

Cardiac Troponins and N-Terminal Pro-Brain Natriuretic Peptide in Acute Ischemic Stroke Do Not Relate to Clinical Prognosis

Background and Purpose— The prognostic value of cardiac troponins and natriuretic peptide in acute ischemic stroke is uncertain. We measured cardiac troponin T (cTnT), cardiac troponin I (cTnI), and N-terminal pro-brain natriuretic peptide (NT-proBNP) at admission in acute ischemic stroke patients without evident myocardial damage. Methods— In 174 consecutive patients with MRI-confirmed ischemic stroke, serial measurements of cTnT, cTnI, and NT-proBNP were performed at 3 different time points in the hyperacute phase (at admission, on days 1 and 2). Relation of laboratory values to risk factors, stroke subtype classification, and clinical outcome after 3 months was analyzed. Results— The highest proportion of raised parameters was found at day 2 for cTnI in 8 of 103 (7.8%), at day 3 for cTnT in 8 of 174 (4.6%), and NT-proBNP in 114 of 174 (65.5%) patients. Proportion of patients with good outcome was significantly reduced in the group with highest NT-proBNP quartile. However, using multivariate regression analysis, no significant relation to morbidity and mortality was found for cTnT, cTnI, or NT-proBNP. Significant impact on the outcome was detected for lesion size, insular involvement, sex, age, and stroke severity. Conclusions— NT-proBNP is raised in nearly two thirds of acute stroke patients, whereas elevated cardiac troponins are found only in a small number of acute ischemic stroke patients. Neither NT-proBNP nor cardiac troponins influence clinical outcome if other risk factors are considered.

Vitamin D Deficiency, Cognitive Impairment and Dementia: A Systematic Review and Meta-Analysis

Background: Recent preventive strategies for patients with cognitive impairment include the identification of modifiable somatic risk factors like vitamin D deficiency. Methods: A systematic literature research and meta-analysis were conducted to assess the association of cognitive impairment and vitamin D deficiency. Results: Data from cross-sectional and longitudinal studies suggest an association between cognitive impairment and vitamin D deficiency. Meta-analysis of 5 cross-sectional and 2 longitudinal studies comprising 7,688 participants showed an increased risk of cognitive impairment in those with low vitamin D compared with normal vitamin D (OR 2.39, 95% CI 1.91–3.00; p < 0.0001). Conclusions: Methodological limitations of these studies comprise heterogeneity of study populations, different forms of cognitive assessment, the problem of reverse causality, different definitions of vitamin D deficiency and inconsistent control for confounders. As the value of vitamin D substitution in cognitive impairment remains doubtful, a long-time major placebo-controlled randomized trial of vitamin D supplementation in participants with mild cognitive impairment (MCI) should be started.

Carotid- intima media thickness is independently associated with cognitive decline. The INVADE study.

Increased carotid intima‐media thickness (C‐IMT) is a non‐invasive marker of atherosclerosis and predicts vascular events. Moreover, increasing evidence suggests an association between carotid atherosclerosis and cognitive decline. The purpose of this study is to investigate the relationship between C‐IMT and the development of cognitive impairment in a large population‐based sample.

High-Sensitivity C-Reactive Protein Is Independently Associated With Early Carotid Artery Progression in Women But Not in Men The INVADE Study

Background and Purpose— High-sensitivity C-reactive protein (hsCRP) is known to be associated with atherosclerosis and cardiovascular events. Limited information exists regarding the importance of sex differences for the association between hsCRP and the progression of early stages of atherosclerosis. Therefore, we investigated the effect of hsCRP on early carotid atherosclerosis progression and major vascular risk factors in men and women. Methods— We analyzed the data of INVADE (intervention project on cerebrovascular diseases and dementia in the community of Ebersberg, Bavaria), a prospective, population-based study. In addition to common risk factors, measurements of carotid intima-media-thickness and hsCRP were performed at baseline and after 2 years. Results— Complete baseline data were available for 3387 subjects including 2001 women, and complete follow-up data were available for 2346 subjects. Within this study population, women were older and had higher systolic blood pressure and cholesterol levels. The prevalence of smoking and ischemic heart disease was more frequent in men. The baseline carotid intima-media-thickness was significantly higher in men compared with women (0.82 mm; 95% CI, 0.812 to 0.834 mm versus 0.77 mm; 95% CI, 0.763 to 0.779 mm; P<0.0001). Carotid intima-media-thickness progression after risk factor adjustment was significantly associated with hsCRP in women (P=0.006) but not in men (P=0.39). Conclusions— The association between hsCRP and progression of early carotid atherosclerosis shows sex differences. In further studies analyzing the role of inflammation for cardiovascular diseases and atherosclerosis, these sex differences should be considered.

Embolic Signals in Unselected Stroke Patients Prevalence and Diagnostic Benefit

Background and Purpose— The present study investigated the prevalence of cerebral microemboli detected by transcranial Doppler sonography in unselected stroke and transient ischemic attack (TIA) patients under standard clinical conditions. We aimed to evaluate the feasibility and the value of the method for clinical use. Methods— The records of 937 consecutive patients who were investigated between October 1995 and August 2004 at our institution were reviewed. Stroke or TIA were subtyped using the TOAST classification criteria. Results— Two hundred and eighty-four subjects were excluded because there was an interval of >14 days between onset of symptoms and examination, no definite diagnosis of stroke or TIA at discharge, or an artificial heart valve. Embolic signals (ES) were detected in 37 (5.7%) of the remaining 653 patients. In subjects with positive ES detection the mean interval between symptom onset and ES detection was 4.9 (SD 4.0) days compared with 5.4 (SD 3.5) days in the remaining patients (P=0.01). ES were more common in patients with large-artery atherosclerosis compared with other subtype groups (P<0.001). The proportion of detected signals was influenced by the antihemostatic treatment: ES were found more often in anticoagulated patients than in patients receiving antiplatelet medication (P<0.001). Conclusions— The study shows a high clinical significance of ES in patients with recent stroke attributable to arterio-arterial embolism or of cardiac embolic origin and the high specificity of the technique. Given the low sensitivity shown, ES detection cannot generally be recommended for routine diagnostics in stroke patients.

Improved Cerebral Vasoreactivity After Statin Administration in Healthy Adults

Background and Purpose. Significant improvements of cerebral vasomotor reactivity during statin treatment were found in patients with cerebral small‐vessel disease. The authors ana lyzed the cerebrovascular CO2 reactivity before and after statin administration in healthy adults using a case‐control study design. Methods. The mean cerebral blood flow velocity (CBFV) of both middle cerebral arteries and the vasomotor reserve capacity (VMRC) were measured by repeated and simultaneous bilateral transcranial Doppler sonography in 25 healthy adults (7 men, mean age 28.8 years [95% confidence interval (CI): 25.7; 31.9]) before, during (days 1, 3, 7, and 14), and after administra tion of 40 mg pravastatin for 14 days as compared to 10 healthy control persons (4 men, mean age 30.6 years [95% CI: 22.9; 38.3]). The VMRC was calculated off‐line as the percentage change of CBFV per 1% increase in end‐tidal CO2 by a blinded investigator. Results. In the statin group, 5 persons were excluded from further analysis. In the remaining 20 volunteers, the authors observed a highly significant effect of statin adminis trationon VMRC(P= .002). The VMRC was significantly increased after statin administration on day 7 as compared to the initial value (3.03 [95% CI: 2.67; 3.38] vs 2.64 [95% CI: 2.41; 2.86]; P= .04). The effect was most pronounced in patients with lower initial VMRC values. In the control group, the VMRC did not differ significantly from baseline at different time intervals. Conclusions. The findings indicate an improvement of cerebral vasoreactivity even after short‐term statin administration in healthy adults. However, this effect was related to baseline vasoreactivity.

Cognitive decline: the relevance of diabetes, hyperlipidaemia and hypertension

Cognitive decline including mild cognitive impairment describes a heterogeneous condition with cognitive changes between normal ageing and dementia. Cognitive impairment can be promoted or caused by treatable somatic factors. In this review, three important cardiovascular risk factors, diabetes mellitus, hypercholesterolaemia and hypertension, and their association with cognitive decline, are assessed. Though there are many hints of a causal association between diabetes mellitus and the development of cognitive decline, definitive proof of a protective effect of antidiabetic treatment by controlled or randomised placebo-controlled studies is needed. In midlife, elevated cholesterol levels comprise a risk factor for cognitive decline. In elderly subjects, cholesterol levels decline and are not clearly associated with cognitive impairment. The evidence for treatment of hypercholesterolaemia by statins solely for prevention of cognitive decline remains unclear. There is an age-dependent relationship between blood pressure and cognitive impairment. Midlife hypertension is associated with an increased risk of developing cognitive decline and antihypertensive treatment may therefore be beneficial, whereas hypertension later in life does not carry the same risk of cognitive dysfunction. Diagnosis of these somatic factors is essential in cognitive impairment, as diligent treatment may improve cognitive performance and postpone the manifestation of dementia.

Intracerebral haematoma without skull fracture by golf ball

Serious head injury is very uncommon in golf and consists mostly of depressed skull fractures. A case of severe intracerebral haematoma without skull fracture caused by a stray golf ball is described and a review of head injuries in golf is provided.

Rehabilitation des Schlaganfalls - Funktionelle Besserung über multimodale Therapieansätze

Stroke is the leading cause of long-term major disability in developed countries, although several improvements could be achieved in acute stroke therapy (e. g. thrombolysis, stroke-unit treatment). Therefore, an early onset of an intensive and multimodal rehabilitation workup is of particular importance to reduce stroke morbidity and stroke-related dependency. Stroke rehabilitation was enhanced due to a better understanding of the natural course of functional reorganisation after stroke and the development of techniques to modulate these processes. During the last years several therapeutic strategies for stroke rehabilitation were studied in controlled clinical trials. Therefore, there are evidence-based recommendations available for some of these therapies. This review summarizes the actual status of evidence-based stroke rehabilitation particular focussing on early rehabilitation.