Massimo Camerlingo

Dementia After First Stroke

BACKGROUND AND PURPOSE Cognitive deficits may significantly worsen the quality of life after stroke. Our aim was to determine the frequency of dementia in a consecutive series of previously nondemented patients between the ages of 40 and 79 years at 3 months after a first ischemic stroke. METHODS All patients admitted to our department during an 18-month period who met the above criteria were visited and tested and underwent a CT scan 3 months after their stroke. Dementia was diagnosed according to criteria of the National Institute of Neurological Disorders and Stroke and AIREN, but cases with aphasia were not excluded. RESULTS Of 304 patients admitted for stroke, 146 were eligible for study. Eleven refused to participate, 25 were dead at 3 months, and 110 were tested. Fifteen patients were demented (13.6%; 95% confidence interval [CI], 7.8% to 21.5%), and six had severe isolated aphasia, neglect, or memory deficit (5.4%). Excluding patients with aphasia, 5.0% of cases showed dementia (95% CI, 1.6% to 11.3%). The frequency of dementia was 24.6% (95% CI, 14.5% to 37.3%), considering only patients with supratentorial lesions and with residual deficits of elementary functions (paresis, sensory deficits) at the time of examination. Demented patients had significantly more diabetes (P<.029), atrial fibrillation (P=.032), aphasia at entry (P<.001), large middle cerebral artery infarctions (P=.001), and a more severe neurological deficit at entry (P=.003) and at 3 months (P=.001). At CT scan, demented patients had a larger mean volume of the recent lesion (P<.001) and more lesions in the frontal lobe (P=.041). An exploratory multivariate analysis selected age between 60 and 69 years (odds ratio [OR], 45.8; 95% CI, 2.9 to 726.0), diabetes (OR 59.4; 95% CI, 4.3 to 821.0), aphasia (OR, 14.8; 95% CI, 2.0 to 111.0), a large middle cerebral artery infarction (OR, 30.0; 95% CI, 2.7 to 334.0), and lesions of the frontal lobe (OR, 9.8; 95% CI, 1.3 to 72.8) as significant independent correlates of poststroke dementia. CONCLUSIONS Dementia is relatively frequent after a clinical first stroke in persons younger than 80 years, and aphasia is very often associated with poststroke dementia. If aphasic patients are not considered, it may be necessary to screen a very large number of subjects to collect an adequate sample of demented cases.

Intravenous Heparin Started Within the First 3 Hours After Onset of Symptoms as a Treatment for Acute Nonlacunar Hemispheric Cerebral Infarctions

Background and Purpose— Heparin is widely used for acute stroke to prevent thrombus propagation and/or multiple emboli generation, although there is, as yet, no demonstrated efficacy. However, all of the available clinical studies allowed long intervals from stroke to treatment. The purpose of this study was to try an intravenous regimen of unfractionated heparin the acute cerebral infarction starting treatment within the first 3 hours of the onset of symptoms. Methods— The study was an outcome evaluator-blind design trial. Patients had to display signs of a nonlacunar hemispheric infarction. Selected patients were randomly allocated to receive intravenous heparin sodium or saline. Heparin was infused at a rate to maintain activated partial thromboplastin time ratio 2.0 to 2.5 × control for 5 days. The primary end point was recovery of a modified Rankin score zero to 2 at 90 days of stroke at phone interview by a single physician blind to treatment. Safety end points were death, symptomatic intracranial hemorrhages, and major extracranial bleedings by 90 days of stroke. Results— A total of 418 stroke patients were included. In the heparin group, there were more self-independent patients (38.9% versus 28.6%; P=0.025). In addition, in the same group, there were fewer deaths (16.8% versus 21.9%; P=0.189), more symptomatic brain hemorrhages (6.2% versus 1.4%; P=0.008), and more major extracerebral bleedings (2.9% versus 1.4%; P=0.491). Conclusions— Intravenous heparin sodium could be of help in the earliest treatment of acute nonlacunar hemispheric cerebral infarction, even keeping into account an increased frequency of intracranial symptomatic brain hemorrhages.

Prognostic factors in first-ever stroke in the carotid artery territory seen within 6 hours after onset.

Background and Purpose: We sought to detect prognostic factors related to functional outcome during the first 6 hours after a first‐ever stroke in the carotid artery territory. Methods: All patients with these characteristics seen during a 3‐year period were included. Outcome was evaluated according to a modified Rankin scale. The following variables were examined at univariate analysis: sex, age, severity of deficit at entry and at day 7, level of consciousness at entry, time after symptom onset, history of smoking, history of hypertension, diabetes, myocardial infarction, atrial fibrillation, rheumatic heart disease, dilated cardiomyopathy, all potential cardioembolic sources, presence of a consistent lesion on computed tomography at entry and at days 5‐9, and the size of such lesion. Results: All entry criteria were met by 172 patients. Age ≥70 years, a Canadian Neurological Scale score <6.5 at entry and at day 7, atrial fibrillation, presence of a potential cardioembolic source, and a “large” lesion (involving more than half the cerebral lobe) on computed tomography at days 5‐9 were associated with a significantly worse outcome both at 30 days and at 6 months. After multivariate analysis, a Canadian Scale score <6.5 at entry (p < 0.0001) and atrial fibrillation (p = 0.005) were associated with a significant handicap or death at 30 days, whereas only a Canadian Scale score <6.5 (p < 0.0001) was associated with a worse prognosis at 6 months. An association of age ≥70 years with a worse outcome at 6 months was of borderline significance (p = 0.054). Conclusions: Some prognostic indicators are available during the first few hours after onset of a carotid ischemic stroke and may be useful in the stratification of patients in clinical trials. Severity of deficit is the most important indicator, whereas the presence of atrial fibrillation worsens the prognostic outlook with respect to early handicap but not mortality. (Stroke 1993;24:532‐535)

Polyneuropathy in hypothyroidism: clinical, electrophysiological and morphological findings in four cases.

Clinical, neurophysiological and morphological studies of four patients with polyneuropathy and secondary hypothyroidism are reported. Neurophysiological studies revealed signs of muscle denervation and reduction of conduction velocity in all the patients. Sural nerve biopsies showed axonal degeneration in all cases but one. All the patients were treated with replacement therapy and clinical symptomatology and neurophysiological parameters improved in all patients.

Intra-arterial thrombolysis in acute ischaemic stroke: experience with a superselective catheter embedded in the clot.

OBJECTIVES--To report experience of intra-arterial thrombolysis for acute stroke, performed with a microcatheter navigated into the intracranial circulation to impale the clot. METHODS--Patients were selected on the following criteria: (1) clinical examination suggesting a large vessel occlusion in stroke patients between 18 and 75 years; (2) no radiographic signs of large actual ischaemia on CT at admission; (3) angiographically documented occlusion of the middle cerebral artery (MCA) stem or of the basilar artery (BA), without occlusion of the ipsilateral extracranial internal carotid artery or of both the vertebral arteries; (4) end of the entire procedure within six hours of stroke. 12 patients with acute stroke were recruited, eight of whom had occlusion of the MCA stem and four of the BA. Urokinase was used as the thrombolytic agent. RESULTS--Complete recanalisation in six MCA stem and in two BA occurred, and partial recanalisation in two MCA stem and one BA. There was no recanalisation in one BA. A clinically silent haemorrhage occurred in two patients, and a parenchymal haematoma in one patient, all in MCA occlusions. At four months five patients achieved self sufficiency (four with MCA and one with BA occlusion). Six patients were dependent (three totally), and one died. CONCLUSIONS--The strict criteria of eligibility allowing the enrollment of very few patients and the procedure itself, requiring particular neuroradiological expertise, make this procedure not routine. Nevertheless, the approach can be considered a possible option for patients with acute ischaemic stroke.

Experience with a questionnaire administered by emergency medical service for pre-hospital identification of patients with acute stroke

Abstract We prospectively verified whether an ad-hoc questionnaire administered by phone supports pre-hospital suspicion of stroke in the order to reduce the time before care is given. Form June 1996 to May 1997, physicians of the Emergency Medical Service in the area of Bergamo, Italy asked all people calling for a patient with symptoms and signs suggesting a cerebral vascular injury to immediately answer some questions on common symptoms and signs of stroke. The medical records of the patients hospitalized at Ospedali Riuniti of Bergamo were reviewed at the end of the study by a single neurologist, skilled in stroke management and blinded to the questionnaires. Sensitivity and specificity, in addition to positive and negative predictive values, of single questions versus final diagnosis were assessed. Logistic regression analysis was also performed to identify those questions useful to suspect strokes. We collected 143 valid questionnaires, related to 63 men and 80 women, aged 34–99 years (mean, 71.8 years). The question concerning headache had the lowest sensitivity and specificity, respectively 57.1% and 36.5%, and teh question concerning leg palsy had the highest sensitivity and specificity, respectively 82.0% and 52.4%. Multivariate analysis identified questions on facial and leg palsy as independent predictors of a final diagnosis of stroke. A few questions on motor deficits proposed by emergency medical service operators may be useful in the pre-hospital identification of stroke patients. Concordance of any questions versus final diagnosis of stroke was, however, far to be satisfying. Thus, our experience supports the need for an educational program to improve the efficiency of a pre-hospital diagnosis of stroke.

Tuberoinfundibular Dopaminergic Function in Parkinson’s Disease

A deficit of nigrostriatal, mesocortical and mesolimbic dopamine systems in Parkinsons disease is well known. We know less about the involvement of tuberoinfundibular dopamine (TID) systems. In untreated (naive or wash-out) men with Parkinsons disease, we studied TID function through basal and stimulated plasma levels of growth hormone, prolactin and thyrotropin. Only minor abnormalities in prolactin responses to thyrotropin-releasing hormone were found, probably reflecting denervation hypersensitivity. TID function is preserved in men with Parkinsons disease.

C-Reactive Protein Levels in the First Three Hours After Acute Cerebral Infarction

ABSTRACT Background: Although thought to be involved in the precipitation of the acute ischemic stroke, C-reactive protein (CRP) was scarcely investigated in the first few hours of a cerebral infarction. Patients and methods: CRP was measured in a consecutive series of patients within the first 3 h of the onset of a first-ever acute cerebral infarction, and in control inpatients, matched for sex and age (±2 years). Results: Three hundred eighty-seven stroke patients and 387 controls were enrolled. There were 215 men and 172 women in each group. Mean age was 66 years for both. CRP was significantly higher in stroke patients (median 5.0 mg/L, interquartile range [IQR] 2.0–10.0) than controls (median 1.9 mg/L, IQR 0.7–3.9), p < .0001. CRP remained a variable independently associated with stroke in the multiple logistic regression model. Conclusions: CRP appears to be significantly increased already in the first 3 h because of the acute ischemic stroke.

Length of hospitalization of patients with transient ischemic attacks

Objective. To investigate factors that influence length of stay (LOS) in patients hospitalized for transient ischemic attacks (TIAs). This may help to reduce unnecessary days of hospitalization. Design. Retrospective study. Setting. A large, non-academic general hospital. Patients. All patients hospitalized for TIAs during the year 1996–1998 were retrospectively studied. We analyzed the relationship between demographic, clinical and management features and LOS. Results. We studied 157 patients. Median LOS was 8 days (range, 1 to 21 days). Statistical analysis showed that female sex, being hospitalized in 1996, hospitalization from Wednesday through Saturday, and second-level cardiological, neuroradiological and miscellaneous investigations significantly increased LOS. Conclusions. The LOS of patients with TIAs may be reduced through measures that accelerate the diagnostic work-up and by scheduling the admission to the first days of the week, when this is possible.

Predictors of re-canalisation in acute cerebral infarction from occlusion of the terminal internal carotid artery or of the middle cerebral artery mainstem treated with thrombolysis

Objective: We have evaluated the factors of unsuccessful re-canalisation in a large series of patients with hemispheric cerebral infarction treated with thrombolysis. Patients and methods: All patients aged 18–80 years with an acute hemispheric infarction, admitted within the first few hours of symptoms onset, were immediately submitted to Magnetic Resonance both Imaging (MRI) and Angiography (MRA). MRI and MRA were repeated at 24 h of stroke. Re-canalisation was attributed if grade 2 or 3 of Thrombolysis in Myocardial Infarction (TIMI) criteria for the myocardial infarction. Outcome was rated at three months of stroke. Re-canalisation was matched with ageing and with the common risk factors for stroke. Results: One hundred and twenty-one patients, 70 men and 51 women, with a median age of 67 years, were included. Re-canalisation was seen in 62 patients (51%). Twenty-three patients (19%) died by 90 days of stroke. Re-canalisation was associated to survival (1 death vs. 22, p < 0.0001). Regression analysis retained advanced age (Odds ratio 0.37, 95% Confidence interval 0.13–0.98), baseline National Institute of Health Stroke Scale (NIHSS) (Odds ratio 0.94, 95% Confidence interval 0.89–0.98) and diabetes mellitus (Odds ratio 0.28, 95% Confidence interval 0.09–0.84) as factors contrasting re-canalisation. Conclusions: Our study indicates that in patients with proven occlusion of the terminal segment of the internal carotid artery and/or of the mainstem of the Middle Cerebral Artery, re-canalisation at 24 h of the acute ischemic stroke is dramatically associated with survival, and halted by advanced age and diabetes mellitus.