Susanne Horner

White matter signal abnormalities in normal individuals: correlation with carotid ultrasonography, cerebral blood flow measurements, and cerebrovascular risk factors.

We studied 52 asymptomatic subjects using magnetic resonance imaging, and we compared age-matched groups (51-70 years old) with and without white matter lesions with respect to carotid ultrasonography, cerebral blood flow (xenon-133 injection), and cerebrovascular risk factors. In the group with white matter signal abnormalities, we noted a higher frequency of extracranial carotid artery disease, a lower mean gray matter blood flow (F1), and a significant reduction (p less than 0.05) in blood flow of the slow-flowing (F2) compartment. Hypertension, diabetes mellitus, and cardiac diseases (p less than 0.002) were found more often in this group. Our results indicate that a higher incidence of changes known to be associated with an increased risk for stroke exists in the presence of white matter lesions in normal elderly individuals.

β-Fibrinogen Gene Polymorphism (C148→T) Is Associated With Carotid Atherosclerosis

Abstract—Polymorphisms at the β-fibrinogen locus have been shown to be associated with plasma concentration of fibrinogen and coronary heart disease. The effect of the genetic heterogeneity of fibr...

Assessment of Cerebrovascular Risk Profiles in Healthy Persons: Definition of Research Goals and the Austrian Stroke Prevention Study (ASPS)

The advent of new laboratory methods and noninvasive imaging modalities has extended the diagnostic possibilities in normal individuals. This article elaborates the new options for the assessment of stroke risk offered by these techniques. In this context we present the Austrian Stroke Prevention Study, which is the first prospective long-term investigation of normals that includes Doppler sonography, magnetic resonance imaging and single photon emission computed tomography. The design, utility and limitations of this study are discussed.

The Bradykinesia Akinesia Incoordination Test (BRAIN TEST), an objective and user-friendly means to evaluate patients with parkinsonism.

The BRAIN TEST©, a computerized alternating finger tapping test, was performed on 154 patients with parkinsonism to assess whether the test could be used as an objective tool to evaluate reliably the severity of Parkinsons disease (PD). Patients were instructed to tap two marked computer keyboard keys as fast and as accurately as possible for 60 seconds. The test generates the following variables: (1) kinesia score (KS)—number of keystrokes/min, (2) akinesia time (AT)—cumulative time that keys are depressed, (3) dysmetria score (DS)—a weighted score generated from incorrectly hit keys and corrected for speed, and (4) arrhythmia score (AS)—variance of the time interval between individual keystrokes. Among parkinsonian patients, we found a significant correlation between the four test parameters and PD rating scores of the Hoehn & Yahr, Schwab & England, and Unified PD Rating Scales (KS, AS, and AT p <0.001 and DS p <0.05). When compared with 73 parkinsonian patients 73 age‐ and sex‐matched control subjects showed significantly higher KS and lower AT (p <0.001) as well as lower DS and AS (p = 0.05). The BRAIN TEST© is a reliable and practical tool for evaluating the severity of parkinsonism and for distinguishing subjects with parkinsonism from normal control subjects. A version of the BRAIN TEST© is available by FTP on the worldwide web (http://www.anaesthetist.com/software/brain.htm).

Symptomatic stenosis of the vertebrobasilar arteries: results of extra- and intracranial stent-PTA

Background and purpose:  About half of all transient ischaemic attacks (TIAs) or strokes in the posterior circulation are caused by the arterial stenosis. The purposes of this study were to determine the safety of stent‐assisted percutaneous transluminal angioplasty (stent‐PTA) and its efficacy for the prevention of recurrent stroke in patients with symptomatic artery stenosis in the extra‐ and intracranial posterior circulation.

Cerebral Hemodynamic Changes following Treatment with Erythropoietin

Adverse hemorheologic effects induced by erythropoietin (EPO) treatment of renal anemia may pose a cerebrovascular risk. We therefore investigated the changes in cerebral perfusion, cerebral blood flow velocity (BFV) and neuropsychologic performance in 11 patients (mean age 37 years) receiving EPO. In response to EPO there was a significant (p less than 0.01) increase in hematocrit (35%), hemoglobin (43%) and whole-blood viscosity (50% at high and 90% at low shear rate). The initially increased blood flow velocity dropped significantly (p less than 0.05) and returned toward normal values in the middle cerebral arteries and the basilar artery (22 and 19% decrease, respectively). Global cerebral blood flow (CBF) decreased by 10% (not significant). The score of the Wechsler Adult Intelligence Scale digit symbol test improved significantly (p less than 0.01) after EPO treatment. None of the patients developed cerebrovascular symptoms or side effects. We conclude that the hematologic and rheologic changes following EPO treatment cause CBF and BFV to return toward normal and improve neuropsychologic performance in patients with end-stage renal disease.

Recurrent Hyperperfusion Syndrome and Intracerebral Hemorrhage after Recanalization of the Extracranial Carotid Artery

Thirteen months later, in November 2002, she was referred for treatment of a carotid restenosis. The patient had been asymptomatic since the first procedure. When assessed at our institution, the patient showed a residual mild, right hemiparesis. Doppl er ultrasound revealed 80% stenosis of the left ICA and common carotid artery (CCA). There was also a high-grade left external carotid artery stenosis. The vessels of the posterior circulation appeared normal. Transcranial Doppler (TCD) studies revealed reduced left middle cerebral artery (MCA) flow velocities (VL; left MCA: VL systolic 0.8 m/s, VL diastolic 0.35 m/s; right MCA: VL systolic 1.2 m/s, VL diastolic 0.4 m/s). There was no evidence of any extraintracranial collateral vascularization or cross-flow to the left ICA territory via the circle of Willis. Brain CT revealed a parenchymal defect after ICH in the left frontoparietal region. 99 Tc HMPAO-SPECT showed reduced radionuclide tracer uptake in the left ICA territory, which further decreased after acetazolamide challenge. Selective intra-arterial angiography revealed 1 80% left CCA stenosis and 1 50% left ICA stenosis according to NASCET ( fig. 1 ). The intracerebral angiogram was normal. Uneventful carotid artery stenting (CAS) was performed. On the first day after CAS, color Doppler ultrasound revealed normal VL in the region of the The term cerebral hyperperfusion syndrome (HS) was coined by Sundt et al. [1] in 1981 to describe a rare complication of carotid endarterectomy (CEA) which may appear with severe unilateral headaches, seizures and focal symptoms related to cerebral edema or intracerebral hemorrhage (ICH) and is considered to result from a major increase in ipsilateral cerebral blood flow above the metabolic demands of the brain. Obvious risk factors include long-standing hypertension, high-grade stenosis, poor collateral blood flow and contralateral carotid occlusion [2–4] . Several mechanisms such as a paralysis of cerebral autoregulatory mechanisms, a break-down of the baroreceptor-reflex and an axon-like trigeminovascular reflex have been implicated in the pathophysiology of hyperperfusion and in the evolution of the cerebral HS [2] . Once it is associated with ICH, the prognosis tends to be poor [2, 4] . We here illustrate the obvious role of endothelial damage in the development of intracerebral bleeding with the imaging findings in a rare case of a recurrent cerebral HS.

[Gender aspects of Ischemic stroke. An analysis of the Austrian Stroke-Unit Registry].

BACKGROUND Available studies suggest gender-related differences in the management of stroke patients. We therefore aimed to address this issue in a large cohort of ischemic stroke patients admitted to Stroke-Units in Austria. METHODS The database contained information on 15746 prospectively documented cases for descriptive statistical analysis. RESULTS A total of 13831 (6670 women) were classified as ischemic stroke. Concerning risk factors and stroke aetiology female stroke patients were more likely to have a history of atrial fibrillation (31.1% vs. 20.8%, p<0.001) and suffered more often from cardioembolic strokes (19.9% vs. 15.5%) than males. Women were significantly older than men (mean age in years: 73.4+/-13.8 vs. 67.8+/-12.7, p<0.001), had a more severe neurologic deficit at admission (NIH-SS: 7.7 vs. 6.0, Barthel-Index: 52.2 vs. 62.3, p<0.001) and at discharge (NIH-SS: 5.3 vs. 4.2, Barthel-Index: 65.0 vs. 73.9, p<0.001) and were more severely handicapped at 3-month follow-up (Rankin-Score: 2.1 vs. 1.6, p<0.001). However, when comparing age decades statistically significant differences concerning the higher neurological deficit and dependency in women were present only in patient groups over 70 years. Furthermore, women showed a significantly higher in-Stroke-Unit complication rate (20.2% vs. 16.5%, p<0.001) and risk of death (3.5% vs. 2.4%, p<0.001). The 3-month mortality rate was also higher in women (10.9% vs. 7.7%, p<0.001). Concerning stroke management, we did not find a disadvantage of women vs. men regarding the delay between stroke onset and hospital admission (median: 120 vs. 124 min), delay and frequency of first cerebral imaging, frequency of thrombolysis (7.4% vs. 7.8%, n.s.) and of secondary prevention with antiplatelet therapies (76.4% vs. 76.2%, n.s.). Despite their higher prevalence of atrial fibrillation, female patients were not put on oral anticoagulation more often than men (19.4% vs. 20.6%, at 3 months, n.s.). CONCLUSIONS This analysis of a large patient population did not show gender disparities in the quality of management of stroke patients treated in Austrian Stroke-Units. However, women had a worse outcome after stroke, which appears to be related primarily to greater deficits at onset in combination with higher age and associated factors. We also confirmed the prominent role of cardiac disorders especially for female stroke patients.SummaryBACKGROUND: Available studies suggest gender-related differences in the management of stroke patients. We therefore aimed to address this issue in a large cohort of ischemic stroke patients admitted to Stroke-Units in Austria. METHODS: The database contained information on 15746 prospectively documented cases for descriptive statistical analysis. RESULTS: A total of 13831 (6670 women) were classified as ischemic stroke. Concerning risk factors and stroke aetiology female stroke patients were more likely to have a history of atrial fibrillation (31.1% vs. 20.8%, p < 0.001) and suffered more often from cardioembolic strokes (19.9% vs. 15.5%) than males. Women were significantly older than men (mean age in years: 73.4 ± 13.8 vs. 67.8 ± 12.7, p < 0.001), had a more severe neurologic deficit at admission (NIH-SS: 7.7 vs. 6.0, Barthel-Index: 52.2 vs. 62.3, p < 0.001) and at discharge (NIH-SS: 5.3 vs. 4.2, Barthel-Index: 65.0 vs. 73.9, p < 0.001) and were more severely handicapped at 3-month follow-up (Rankin-Score: 2.1 vs. 1.6, p < 0.001). However, when comparing age decades statistically significant differences concerning the higher neurological deficit and dependency in women were present only in patient groups over 70 years. Furthermore, women showed a significantly higher in-Stroke-Unit complication rate (20.2% vs. 16.5%, p < 0.001) and risk of death (3.5% vs. 2.4%, p < 0.001). The 3-month mortality rate was also higher in women (10.9% vs. 7.7%, p < 0.001). Concerning stroke management, we did not find a disadvantage of women vs. men regarding the delay between stroke onset and hospital admission (median: 120 vs. 124 min), delay and frequency of first cerebral imaging, frequency of thrombolysis (7.4% vs. 7.8%, n.s.) and of secondary prevention with antiplatelet therapies (76.4% vs. 76.2%, n.s.). Despite their higher prevalence of atrial fibrillation, female patients were not put on oral anticoagulation more often than men (19.4% vs. 20.6%, at 3 months, n.s.). CONCLUSIONS: This analysis of a large patient population did not show gender disparities in the quality of management of stroke patients treated in Austrian Stroke-Units. However, women had a worse outcome after stroke, which appears to be related primarily to greater deficits at onset in combination with higher age and associated factors. We also confirmed the prominent role of cardiac disorders especially for female stroke patients.ZusammenfassungGRUNDLAGEN: Geschlechtsspezifische Unterschiede in der Versorgung von SchlaganfallpatientInnen erscheinen aufgrund bisheriger Untersuchungen möglich. Wir wollten dieser Frage deshalb auch innerhalb jener großen Kohorte von PatientInnen nachgehen, welche mit akutem ischämischem Schlaganfall an einer österreichischen Schlaganfall-Einheit aufgenommen wurden. METHODIK: In der Datenbank standen 15746 prospektiv dokumentierte Fälle für eine deskriptive statistische Auswertung zur Verfügung. ERGEBNISSE: 13831 (6670 Frauen) waren als ischämischer Schlaganfall klassifiziert worden. In Bezug auf Risikofaktoren und Schlaganfallursache wiesen weibliche Schlaganfallpatienten häufiger eine Flimmerarrhythmie auf (31,1 % vs. 20,8 %, p < 0,001) und erlitten auch häufiger einen kardioembolischen Schlaganfall (19,9 % vs. 15,5 %). Die weiblichen Schlaganfallpatienten waren im Mittel signifikant älter als die betroffenen Männer (73,4 ± 13,8 vs. 67,8 ± 12,7 Jahre, p < 0,001), zeigten ein signifikant größeres neurologisches Defizit sowohl bei der Aufnahme (NIH-SS: 7,7 vs. 6,0, Barthel-Index: 52,2 vs. 62,3, p < 0,001) als auch bei der Entlassung (NIH-SS: 5,3 vs. 4,2, Barthel-Index: 65,0 vs. 73,9, p < 0,001) und waren auch zum Zeitpunkt der 3-Monats Kontrolle schwerer behindert (Rankin-Skala: 2,1 vs.1,6, p < 0,001). Bei einem Vergleich innerhalb der Altersdekaden waren die größeren neurologischen Defizite und Behinderungsgrade der Frauen allerdings nur in der Altersgruppe von über 70 Jahren statistisch signifikant. Während des Aufenthaltes an der Schlaganfall-Einheit zeigten Frauen eine signifikant höhere Komplikationsrate (20,2 % vs. 16,5 %, p < 0,001) und verstarben öfters (3,5 % vs. 2,4 %, p < 0,001). Die 3-Monats Mortalitätsrate war ebenfalls für weibliche Patienten höher (10,9 % vs. 7,7 %, p < 0,001). Es fand sich aber keine Benachteiligung des weiblichen Geschlechts bezüglich der Latenz zwischen Beginn der Schlaganfallsymptomatik und der Krankenhausaufnahme (Medianwert: 120 vs. 124 Minuten), Latenz und Häufigkeit der ersten zerebralen Bildgebung, Thrombolyserate (7,4 % vs. 7,8 %, n.s.) und Sekundärprävention mittels Thrombozytenaggregationshemmern (76,4 % vs. 76,2 %, n.s.). Allerdings waren die Schlaganfallpatientinnen trotz der höheren Prävalenz der Flimmerarrhythmie nicht häufiger antikoaguliert (19,4 % vs. 20,6 %, nach 3 Monaten, n.s.). SCHLUSSFOLGERUNGEN: Die Analyse dieser umfangreichen Patientenpopulation ergab keine geschlechtsspezifischen Unterschiede in Bezug auf die Qualität des Managements der an österreichischen Schlaganfall-Einheiten behandelten SchlaganfallpatientInnen. Allerdings zeigten Frauen eine größere Einschränkung nach dem Schlaganfall, welche aber in erster Linie auf das schon schwerere Ausgangsdefizit in Zusammenhang mit höherem Lebensalter und assoziierten Faktoren zurückzuführen ist. Es bestätigte sich der Stellenwert kardiogener Erkrankungen welche den weiblichen Schlaganfall offenbar besonders beeinflussen.

Cognitive Impairment in Patients with Parkinsonism

180 years ago James Parkinson in his original description of paralysis agitans, stated “the senses and intellect are uninjured’.by the disease (Parkinson, 1817). Since then many have disputed this part of the description. In recent years it has become accepted that cognitive impairment is a prominent feature of parkinsonism with a prevalence of 10–15% and an incidence of 48-69/1000 person years of observation (Mayeux et al., 1990; Biggins et al., 1992). Typical patterns of cognitive impairment, named subcortical dementia have been thoroughly discussed by several authors. These changes have been described in parkinsonism and IPD. and in scanty reports in postencephalytic, vascular or Parkinson Plus Syndromes (Cummings et Benson, 1984). So far very little has been said on Atypical Parkinson Syndromes (APS) not fitting in the previous categories. APS in a previous study (Aarsland et al., 1996) was found to by 0.8 as frequent as IPD.

Positionspapier der Österreichischen Gesellschaft für Schlaganfallforschung

ZusammenfassungDer Schlaganfall ist weltweit die dritthäufigste Todesursache und die häufigste Ursache für eine schwere Behinderung im Erwachsenenalter. Jedes Jahr erkranken in Österreich rund 20.000 Menschen daran, etwa 60.000 leiden unter den Schlaganfallfolgen. Neue Erkenntnisse zur Pathophysiologie und Klinik des Schlaganfalls sowie die Einführung moderner diagnostischer Verfahren haben das Management von Schlaganfallpatienten wesentlich geändert.Basierend auf den aktuellen wissenschaftlichen Erkenntnissen und in der Praxis bewährten Verfahren hat die Österreichische Gesellschaft für Schlaganfallforschung ein Positionspapier zu wichtigen Themenbereichen der Versorgung von Schlaganfallpatienten erarbeitet. Die Daten wurden von Arbeitsgruppen in einem systematischen Review gesammelt und im Expertengremium diskutiert, wobei für die Einstufung in Evidenzgrad und Empfehlungsstärke die EFNS-Kriterien verwendet wurden. Es ist geplant, weitere Themen aufzunehmen und das hier vorgestellte Positionspapier alle zwei Jahre einer Überarbeitung zu unterziehen.AbstractStroke is the third most frequent cause of death in the world overall, and the most common reason for severe disablement in adulthood. Every year, a good 20,000 people in Austria suffer strokes, and about 60,000 suffer from sequelae of strokes. New insights into the pathophysiology and clinical aspects of stroke and the introduction of modern diagnostic techniques have led to substantial changes in the management of stroke patients.Based on the current scientific knowledge and techniques that have been tried and tested in practice, the Austrian Society of Stroke Research has prepared a position paper on important subject areas in the treatment of stroke patients. The data were collected by working groups in a systematic review and discussed by the expert committee, the EFNS criteria being used for the classification by level of evidence and strength of recommendations. There are plans to pursue new topics, and to review the position paper presented here every two years.