Vida Demarin

Acute neurological stroke care in Europe: results of the European Stroke Care Inventory

Following the 1997 Recommendations of the EFNS Task Force on Acute Neurological Stroke Care (European Journal of Neurology, 1997: 4:435–441) a European Inventory was undertaken to assess the development of acute stroke care in the EFNS member countries and to give an estimate of the needs based on 1997 data.

Mild cognitive impairment in symptomatic and asymptomatic cerebrovascular disease

We tried to evaluate and to compare usefulness of two brief cognitive tests in early detection of cognitive decline in subjects with increased cerebrovascular (CV) risk. As CV risk factors are recognised as important in etiology of dementia, we also aimed to determine the possible associations of specific CV risk factors and cognitive results. Patients (PGs) with first-ever stroke or TIA (N=110) and CV symptoms-free controls (CGs) with CV risk factors present (N=45) matched for age, gender and education level were tested using Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) on admission, at three- and six-month points. In all subjects, detailed CV risk factors profile was assessed. We observed the decrement in cognitive performance during the six-month study period in both groups, more evident if MoCA (p<0.001) than if MMSE was used (p=0.022). Six months after first stroke/TIA 83.6% PGs scored below normal range on MoCA. In PGs, positive associations for cognitive decrement and multiple CV risk factors (>2) were found (p=0.034 for MMSE; p=0.002 for MoCA). In CGs, positive associations were found for cognitive decrement and arterial hypertension with increased IMT values (p<0.001 for MMSE) and for multiple CV risk factors and arterial hypertension (p=0.003 for MoCA). The use of MoCA could aid to early recognition of cognitive deficits in persons with increased CV risk. Individuals with multiple CV risk factors seem to have increased risk of cognitive decline.

Lifestyle Risk Factors for Ischemic Stroke and Transient Ischemic Attack in Young Adults in the Stroke in Young Fabry Patients Study

Background and Purpose— Although many stroke patients are young or middle-aged, risk factor profiles in these age groups are poorly understood. Methods— The Stroke in Young Fabry Patients (sifap1) study prospectively recruited a large multinational European cohort of patients with cerebrovascular events aged 18 to 55 years to establish their prevalence of Fabry disease. In a secondary analysis of patients with ischemic stroke or transient ischemic attack, we studied age- and sex-specific prevalences of various risk factors. Results— Among 4467 patients (median age, 47 years; interquartile range, 40–51), the most frequent well-documented and modifiable risk factors were smoking (55.5%), physical inactivity (48.2%), arterial hypertension (46.6%), dyslipidemia (34.9%), and obesity (22.3%). Modifiable less well-documented or potentially modifiable risk factors like high-risk alcohol consumption (33.0%) and short sleep duration (20.6%) were more frequent in men, and migraine (26.5%) was more frequent in women. Women were more often physically inactive, most pronouncedly at ages <35 years (18–24: 38.2%; 25–34: 51.7%), and had high proportions of abdominal obesity at age 25 years or older (74%). Physical inactivity, arterial hypertension, dyslipidemia, obesity, and diabetes mellitus increased with age. Conclusions— In this large European cohort of young patients with acute ischemic cerebrovascular events, modifiable risk factors were highly prevalent, particularly in men and older patients. These data emphasize the need for vigorous primary and secondary prevention measures already in young populations targeting modifiable lifestyle vascular risk factors. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique Identifier: NCT00414583.

Factors Influencing In-Hospital Delay in Treatment With Intravenous Thrombolysis

Background and Purpose— Shortening door-to-needle time (DNT) for the thrombolytic treatment of stroke can improve treatment efficacy by reducing onset-to-treatment time. The goal of our study was to explore the association between DNT and outcome and to identify factors influencing DNT to better understand why some patients are treated late. Methods— Prospectively collected data from the Safe Implementation of Treatments in Stroke-East registry (SITS-EAST: 9 central and eastern European countries) on all patients treated with thrombolysis between February 2003 and February 2010 were analyzed. Multiple logistic regression analysis was used to identify predictors of DNT ⩽60 minutes. Results— Altogether, 5563 patients were treated with thrombolysis within 4.5 hours of symptom onset. Of these, 2097 (38%) had DNT ⩽60 minutes. In different centers, the proportion of patients treated with DNT ⩽60 minutes ranged from 18% to 84% (P<0.0001). Patients with longer DNT (in 60-minute increments) had less chance of achieving a modified Rankin Scale score of 0 to 1 at 3 months (adjusted OR, 0.86; 95% CI, 0.77–0.97). DNT ⩽60 minutes was independently predicted by younger age (in 10-year increments; OR, 0.92; 95% CI, 0.87–0.97), National Institutes of Health Stroke Scale score 7 to 24 (OR, 1.44; 95% CI, 1.2–1.7), onset-to-door time (in 10-minute increments; OR, 1.19; 95% CI, 1.17–1.22), treatment center (P<0.001), and country (P<0.001). Conclusions— Thrombolysis of patients with older age and mild or severe neurological deficit is delayed. The perception that there is sufficient time before the end of the thrombolytic window also delays treatment. It is necessary to improve adherence to guidelines and to treat patients sooner after arrival to hospital.

Prevalence of Vertigo, Dizziness, and Migrainous Vertigo in Patients With Migraine

Objective.— The aim of this study was to determine the lifetime prevalence of vertigo and dizziness in patients with migraine as compared with controls and to establish the lifetime prevalence of migrainous vertigo.

Pro-inflammatory and anti-inflammatory cytokines in acute ischemic stroke and their relation to early neurological deficit and stroke outcome

OBJECTIVES Our aim was to explore (i) the difference in concentration of IL-6, TNF-alpha and IL-10 between acute ischemic stroke patients and control individuals; (ii) the association of plasma cytokine concentration with stroke severity at admission assessed by NIHSS and stroke outcome in 90 days assessed by Barthel index (BI) and modified Rankin scale (mRS). MATERIALS AND METHODS Study included 68 stroke patients admitted within 12 h of symptoms onset and 71 controls. RESULTS IL-6 was increased in patients relative to controls (P=0.035) and this increase was associated with severe stroke (P=0.007) and worse outcome (P=0.030 and 0.019; assessed by BI and mRS, respectively), whereas IL-10 was decreased (P=0.044) and associated with better outcome (P=0.043). TNF-alpha did not differ between studied groups (P=0.302). CONCLUSIONS Increased IL-6 and reduced IL-10 concentrations are present in early stroke period and are associated with a degree of neurological deficit and/or stroke outcome.

Polymorphism of apoprotein E (APOE), methylenetetrahydrofolate reductase (MTHFR) and paraoxonase (PON1) genes in patients with cerebrovascular disease.

Abstract Although controversial, data on the genetic polymorphism of apoprotein E (APOE), methylenetetrahydrofolate (MTHFR) and paraoxonase (PON1) genes implicate their role in the development of cerebrovascular disease. The aim of this study was to assess the association of polymorphism of APOE, MTHFR and PON1 genes in 56 stroke and 36 carotid stenosis patients, and in 124 control subjects by PCR-restriction fragment length polymorphism analysis. In the stroke group a significantly different MTHFR genotype distribution (p=0.004, odds ratio for T/T of 17.571), but no significant difference in APOE and PON1 allele and genotype distribution compared to the control was found. The carotid stenosis group exhibited a significantly different APOE allele and genotype distribution (p=0.023, odds ratio APOE∊3∊4 of 4.24), but no significant difference in the MTHFR and PON1 allele and genotype distribution from the control group. The preliminary results obtained in this study revealed an association of the MTHFR and APOE gene polymorphism with cerebrovascular disease, suggesting a significant risk for stroke in subjects who are homozygous for the T allele and for carotid stenosis in subjects having APOE∊3∊4 genotype. Additional studies in larger patient groups are needed to confirm these observations.

Maternal cerebral circulation in normal and abnormal pregnancies

Background. Abnormal pregnancies are usually associated with an impairment of maternal cerebral circulation which is mainly a consequence of generalized vasospasm and cerebral edema. The pathogenesis of vasospasm has still been a matter of controversy. The aim of this study was to evaluate maternal cerebral blood flow velocity (CBFV) changes in normal and abnormal pregnancies, and to correlate CBFV findings with the severity of symptoms in abnormal pregnancies.

Cognitive performance in asymptomatic patients with advanced carotid disease

Objective: In the absence of stroke or transient ischemic attack, patients with advanced carotid stenosis or occlusion (ICAs/o) are considered asymptomatic, yet they are prone to mostly subtle cognitive impairment. Background: The Mini-Mental State Examination (MMSE) often fails to detect mild cognitive impairment. The Montreal Cognitive Assessment (MoCA) is more sensitive in recognizing such changes. Methods: Scores on the MoCA and MMSE were compared in 70 asymptomatic patients with ICAs/o and 70 controls matched for demographic variables and vascular risk factors. Results: MMSE scores fell mostly within the normal range in both patients and controls. Differences were significant for total MoCA scores (P<0.001). Patients with ICAs/o performed worse on visuospatial and executive function (P=0.018), abstraction (P<0.001), and delayed recall (P<0.001). Lower MoCA scores were associated with diabetes (odds ratio=6.41; 95% confidence interval, 1.277-32.220; P=0.024) and older age (odds ratio=0.86; 95% confidence interval, 0.780-0.956; P=0.004). Patients with diabetes performed worse on delayed recall (P<0.001), and patients with hypertension were worse on the MoCA naming subtest (P=0.04). Conclusions: The MoCA successfully identified reduced cognitive status in patients with ICAs/o. The MoCA subtest scores revealed a pattern of cognitive impairment similar to that documented in other studies using more extensive neuropsychological tests. MoCA could be used as part of the clinical evaluation of patients with ICAs/o.

Epilepsy and serotonin (5HT): Variations of 5HT-related genes in temporal lobe epilepsy

Several lines of evidence point to the role of serotonin (5HT) neurotransmission in the epileptogenesis. The present preliminary study investigated possible association of the temporal lobe epilepsy (TLE) with the polymorphisms in several 5HT-related genes, including serotonin transporter (5HTT), monoamine oxidase A (MAO-A) and serotonin receptors 5HT-1A, 5HT-1B and 5HT-2C. All participants (101 TLE patients and 170 healthy controls) were unrelated individuals of Croatian origin. 5HT-1B allele 861G was found to be slightly overrepresented in the patient group (p=0.0385). No significant differences between groups were observed for the other tested polymorphisms. Within the limitations imposed by the size of our sample, negative findings suggest that the respective loci do not make considerable contribution to the etiopathogenesis of TLE. Further examination of 5HT-1B gene, which yielded positive result at a trend level, is possibly warranted.