Morgan Crowe

Carotid plaque inflammation on 18F-fluorodeoxyglucose positron emission tomography predicts early stroke recurrence.

Symptomatic carotid stenosis is associated with a 3‐fold risk of early stroke recurrence compared to other stroke subtypes. Current carotid imaging techniques rely on estimating plaque‐related lumen narrowing but do not evaluate intraplaque inflammation, a key mediator of plaque rupture and thromboembolism. Using combined 18F‐fluorodeoxyglucose positron‐emission tomography (FDG‐PET)/computed tomography, we investigated the relation between inflammation‐related FDG uptake and stroke recurrence.

Plaque Inflammation and Unstable Morphology Are Associated With Early Stroke Recurrence in Symptomatic Carotid Stenosis

Background and Purpose— Although symptomatic carotid stenosis is associated with 3-fold increased risk of early stroke recurrence, the pathophysiologic mechanisms of high early stroke risk have not been established. We aimed to investigate the relationship between early stroke recurrence after initial symptoms and histological features of plaque inflammation and instability in resected carotid plaque. Methods— Carotid endarterectomy tissue from consecutive patients with ipsilateral stenosis ≥50% and recent symptoms were analyzed using a validated histopathologic algorithm (Oxford Plaque Study [OPS] system). Nonprocedural stroke recurrence before carotid endarterectomy was ascertained at 7, 28, and 90 days after initial symptoms. Results— Among 44 patients meeting eligibility criteria, 27.3% (12/44) had stroke recurrence after initial stroke/transient ischemic attack but before carotid endarterectomy. Compared with patients without recurrence, stroke recurrence was associated with dense macrophage infiltration (OPS grade ≥3; 91.7% versus 37.5%; P=0.002), extensive (>25%) fibrous cap disruption (90.9% versus 37%; P=0.004), neovascularization (OPS grade ≥2; 83.3% versus 43.8%; P=0.04), and low plaque fibrous content (OPS grade <2; 50% versus 6.3%; P=0.003). Early recurrence rates were 82.3% (confidence interval, 49.2%–98.8%) in patients with extensive plaque macrophage infiltration (OPS grade ≥3) compared with 22.2% (confidence interval, 3.5%–83.4%) in those with OPS grade <3 (log-rank P=0.009). On multivariable Cox regression, including OPS macrophage grade (≥3 or <3), age, and severity of stenosis (50%–69% or ≥70%), plaque inflammation was the only variable independently predicting stroke recurrence (adjusted hazard ratio, 9; confidence interval, 1.1–70.6; P=0.04). Conclusions— Plaque inflammation and other vulnerability features were associated with highest risk of stroke recurrence and may represent therapeutic targets for future stroke prevention trials.

Celiac disease in older people.

In recent years, there has been increasing recognition that the classical textbook presentation of celiac disease with a malabsorption syndrome and a flat jejunal mucosa is only part of a broad spectrum of clinical and histological features associated with gluten sensitivity. Diagnosis of this treatable condition is often delayed or missed because of a failure to appreciate that celiac disease can present at any age and that symptoms are often subtle and not clearly related to gastrointestinal disease. Nonspecific symptoms and nutritional deficiencies are especially common in older patients and may not always be investigated thoroughly. Use of serological screening tests has improved ease of detection of celiac disease in patients without classical symptoms.

Assessment and management of transient ischaemic attack--the role of the TIA clinic.

BackgroundAs the risk of early stroke following transient ischaemic attack (TIA) is increasingly recognised, the management of patients presenting with symptoms suggestive of TIA presents a clinical challenge.MethodsAnalysis of prospectively collected data on patients referred to a TIA clinic in St. Vincent’s University Hospital, between January 2003 and July 2004.ResultsOne-hundred- and -seventeen (117) patients (mean age 75.5 years) were assessed. The majority (79%) were referred from Accident and Emergency and 61% were seen within one week of referral. Seventy-two patients (62%) had a final diagnosis of cerebrovascular disease (56 TIA, 16 completed strokes), of whom five (7%) and four (5.5%) had severe (> 70%) and moderate (> 50%) symptomatic carotid artery stenosis, respectively, whilst seven patients (10%) had newly diagnosed atrial fibrillation, five of whom were anticoagulated. Non-cerebrovascular diagnoses were made in twenty-seven patients (24%).ConclusionA TIA clinic, in co-ordination with Accident & Emergency Services, provides a safe and efficient alternative to hospital admission for patients with TIA symptoms and a low early stroke risk.

Hospital-based stroke care in Ireland: results from one regional register

BackgroundMost patients with acute stroke are admitted to hospital. If stroke services in this country are to be improved, we need accurate and reliable information about the types of stroke patients being admitted, their present management and outcome.AimsTo examine the demography, severity, level of investigation, length of stay, mortality and discharge location of prospectively identified consecutive stroke admissions to three general hospitals in South East Dublin.ResultsThree hundred and twenty nine consecutive stroke admissions to three general hospitals in South East Dublin were registered using the European Stroke Database over 50 weeks. The mean age was 73.3 years, whilst 20.1% patients were under 65 years. Prior to admission, 90% of patients were community dwelling with 14.9% of patients being dependent in activities of daily living. 22.4% of patients had some depression in level of consciousness on admission. The overall mortality rate was 26.1% whilst 136 (41.3%) were discharged home, 50 (15.2%) went to institutional care and 45 (13.7%) went to non general hospitals secondary rehabilitation units. The mean length of stay was 31.3 days.The combined poor outcome measure (mortality plus percentage of patients discharged to institutional care), was lower in one hospital compared to the other two hospitals (29.3% versus 44.65%, p≥ 0.05) probably reflecting case mix. Stroke accounted for 4.2% of all bed days in the major general hospital in this area. The overall CT scan rate was 84.5%, with 18.2% of CT scans showing a haemorrhagic component and two patients (0.8%) having brain tumours. Carotid doppler examinations were carried out in 37% of patients.ConclusionThe results demonstrate the high mortality and prolonged hospital stay for stroke patients in this area and emphasise the need for co-ordinated stroke care and regular audit to ensure most effective use of hospital resources.

Serum lipids associated with inflammation-related PET-FDG uptake in symptomatic carotid plaque

Objective: We hypothesized that serum lipids, which experimental data suggest may be key initiators of carotid plaque inflammation, would be associated with plaque inflammation on 18fluorodeoxyglucose (FDG)-PET in patients with acutely symptomatic carotid stenosis. Methods: In this cohort study, consecutive patients with acute symptomatic internal carotid artery (ICA) stenosis (≥50%) underwent carotid PET-CT. We quantified plaque FDG uptake as follows: (1) average maximum standardized uptake values (SUVmax) across 10 regions of interest (ROI); (2) highest single ROI SUV measure (SUVROImax); (3) averaged mean SUV across 10 ROIs (SUVmean). Results: Sixty-one patients were included. Plaque inflammatory FDG SUVmax was associated with increasing tertiles of low-density lipoprotein (LDL) (trend p = 0.004), total cholesterol (p = 0.009), and triglycerides (p = 0.01), and with lower high-density lipoprotein (HDL) (p = 0.005). When analyzed as a continuous variable, LDL was associated with symptomatic ICA SUVmean (Spearman rho 0.44, p = 0.009), SUVROImax (rho 0.33, p = 0.01), and SUVmax (rho 0.35, p = 0.06). Total cholesterol was associated with SUVmean (rho 0.33, p = 0.009), with trends for SUVmax (rho 0.24, p = 0.059) and SUVROImax (rho 0.23, p = 0.08). Triglycerides were associated with SUVmax (rho 0.32, p = 0.01) and SUVROImax (rho 0.35, p = 0.005). HDL was associated with lower SUVmax (rho −0.37, p = 0.004) and SUVROImax (rho −0.44, p = 0.0004). On multivariable linear regression analysis adjusting for age, sex, degree of carotid stenosis, statins, and smoking, LDL (p = 0.008) and total cholesterol (p = 0.04) were independently associated with SUVmax. Conclusion: Serum LDL and total cholesterol were associated with acutely symptomatic carotid plaque FDG uptake, supporting experimental data suggesting lipids may promote plaque inflammation, mediating rupture and clinical events.

Prevalence of risk factors for ischaemic stroke and their treatment among a cohort of stroke patients in Dublin.

BackgroundThe majority of strokes are due to ischaemia. Risk factors include atrial fibrillation, hypertension and smoking. The incidence can be reduced by addressing these risk factors. This study examines the prevalence of risk factors and their treatment in a cohort of patients with ischaemic stroke registered on a Dublin stroke database.MethodsPatients admitted to any of three acute hospitals with a diagnosis of stroke during a one-year period in 1997/98 were registered on a database using the European Stroke Database format. Data relating to common risk factors were analysed.ResultsThere were 238 ischaemic stroke cases registered. The most frequent medical risk factors were: hypertension (45%), atrial fibrillation (27.3%), and previous disabling or non-disabling stroke (33.2%). There was an increasing trend with advancing age for atrial fibrillation (p<0.001). Some 23% (54/233) were current smokers. A significantly higher proportion of patients with no medical risk factors were smokers or consumed excessive alcohol compared with those who had medical risk factors.ConclusionMedical risk factors for stroke were common among stroke patients and not optimally treated, particularly with regard to atrial fibrillation and previous stroke. Smoking was a major behavioural risk factor among younger patients and much health gain could be achieved in this group through primary prevention strategies.

Antithrombotic treatment at onset of stroke with atrial fibrillation, functional outcome, and fatality: a systematic review and meta-analysis

Background In atrial fibrillation–associated stroke, conflicting data exist regarding association between therapeutic vitamin K-antagonist anticoagulation (International Normalized Ratio 2–3) and early death and functional outcome, and few data exist relating to late outcome in ischemic and haemorrhagic atrial fibrillation–stroke. Aim We performed a systematic review and meta-analysis of oral anticoagulation at stroke onset, death and functional outcome. Methods We performed a systematic review, searching multiple sources. Studies were included if outcomes in atrial fibrillation–associated stroke were reported stratified by pre-stroke antithrombotic status, with documented International Normalized Ratio at onset. Outcomes were survival and good functional outcome (modified Rankin score 0–2) at discharge/30 days, and at one-year. Results Of eight studies (3552 patients) in ischemic stroke, International Normalized Ratio ≥ 2 compared with other treatments (International Normalized Ratio < 2, antiplatelet, or no anti-thrombotic) was associated with good outcome [pooled odds ratio 1·9 (95% confidence interval) 1·5–2·5, P < 0·001] and improved survival at 30 days discharge (pooled odds ratio for death 0·4, confidence interval 0·2–0·5, P < 0·001). The net benefit remained after inclusion of haemorrhagic stroke (odds ratio for good outcome 1·89, confidence interval 1·45–2·46, P < 0·001). At one-year, improved functional outcome for International Normalized Ratio ≥ 2 (pooled odds ratio 1·7, confidence interval 1·0–2·7, P = 0·04) and survival (odds ratio for death 0·5, confidence interval 0·4–0·8, P = 0·001) were also observed. Conclusions Therapeutic International Normalized Ratio at stroke onset was associated with early and late improved survival and functional recovery suggesting sustained benefit for warfarin anticoagulation for stroke outcome in atrial fibrillation patients. Long-term outcome data following stroke in patients taking new oral anticoagulants is required.

Staphylococcus epidermidis as a cause of meningitis.

SummaryA case of meningitis due to Staphylococcus epidermidis is described. The problems of diagnosis of infection due to coagulase negative staphylococci and features of the pathogenesis and treatment of this specific case are discussed. The potential pathogenicity of Staphylococcus epidermis is noted.

Interpreting Errors in Temporal Orientation in Older Hospital Patients

Normal variation in temporal orientation has been examined in community dwelling, healthy older subjects but not in elderly hospital patients. We examined the validity of errors in different aspects of temporal orientation as a guide to the presence or absence of cognitive impairment orientation in elderly hospital patients in 150 consecutive patients on the day after admission to an acute geriatric unit. Cognitive impairment (delirium or dementia or both) was diagnosed without reference to temporal orientation. Optimum cutoffs for error scores on the different aspects of temporal orientation (date/year/month/day of the week/time of day) were calculated to maximize the sum of sensitivity and specificity for detection of cognitive impairment. Of the 150 patients, 45 (30%) had cognitive impairment. The best cutoffs for detection of cognitive impairment were an error of more than 3 days in the date; any error in the year, month, or day of the week; and an error of more than 1 h in identifying the time of day. Error in identifying the year had the highest positive likelihood ratio (6.4 [95% confidence interval 4.0–10.3]) for detecting cognitive impairment and the lowest negative likelihood ratio (0.1 [0.04–0.3]) for the exclusion of cognitive impairment. Failure to identify the year correctly is the aspect of temporal orientation most closely related to cognitive impairment.