http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2013 , Hindawi Publishing Corporation . All rights reserved. Wed, 05 Jun 2013 15:50:46 +0000 http://www.hindawi.com/isrn/stroke/2013/587954/ High blood pressure (BP) is common in acute stroke and is independently associated with a poor outcome. Lowering BP might improve outcome if cerebral blood flow (CBF) is unaffected in the presence of dysfunctional autoregulation. We investigated the effect of telmisartan on systemic and cerebral haemodynamics in patients with recent stroke. Patients with ischaemic stroke (<5 days) were randomised to 90 days of telmisartan (80 mg) or placebo. CBF (primary outcome) was measured using xenon CT at baseline and 4 hours. BP and transcranial doppler (TCD) were performed at baseline, 4 hours after-treatment, and on days 4, 7, and 90. Cerebral perfusion pressure and zero filling pressure (ZFP) were calculated. Of a planned 24 patients, 17 were recruited. Telmisartan significantly accentuated the fall in systolic and diastolic BP over 90 days (treatment-time interaction , resp.) but did not alter BP at 4 hours after treatment (171/99 versus 167/87 mmHg), CBF, or CBF velocity. ZFP was significantly lower in the treatment group . Impairment at 7 days and dependency at 90 days did not differ between the groups. In this underpowered study, telmisartan did not significantly alter BP or CBF after the first dose. Telmisartan reduced BP over the subsequent 90 days and significantly lowered ZFP. This trial is registered with ISRCTN 41456162. Gillian M. Sare, Andrew Ghadami, Sandeep Ankolekar, Timothy England, Fiona Hammonds, Margaret Adrian, Judith Clarke, Lynn Stokes, Dorothee Auer, and Philip M. W. Bath Copyright © 2013 Gillian M. Sare et al. All rights reserved. Wed, 22 May 2013 14:28:08 +0000 http://www.hindawi.com/isrn/stroke/2013/974236/ Objective. To determine whether routine laboratory parameters are predictors of early mortality after acute ischemic stroke (AIS). Methods. The cohort consisted of 522 consecutive patients with AIS presenting to the emergency department (ED) at a tertiary referral center during a 27-month period, residing within the surrounding ten counties. Serum laboratory values were obtained for all patients and categorized according to whether the levels were low, normal, or high. These laboratory results were evaluated as potential predictors of 90-day mortality using Cox proportional hazards models. The associations were summarized by calculating risk ratios (RRs) and 95% confidence intervals (CI). Results. The presence of elevated white blood cell count (RR 2.2, 95% CI 1.5–3.4), low bicarbonate (RR 4.2, 95% CI 2.6–6.7), low calcium (RR 2.9, 95% CI 1.4–5.9), and high glucose (RR 1.3, 95% 1.1–1.6) were each univariately associated with significantly higher mortality within the first 90 days. Based on fitting a multivariate Cox regression model, elevated white blood cell count, low bicarbonate, and high glucose were each identified as being jointly associated with early mortality (). Conclusion. Early leukocytosis, acidosis, and hyperglycemia and hypocalcemia in AIS appear to be associated with early mortality. Whether addressing these factors will impact survival remains to be investigated. Latha Ganti, Rachel M. Gilmore, Amy L. Weaver, and Robert D. Brown Jr. Copyright © 2013 Latha Ganti et al. All rights reserved. Sun, 28 Apr 2013 17:52:32 +0000 http://www.hindawi.com/isrn/stroke/2013/954825/ Background. The significance of the Hyperdense Middle Cerebral Artery Sign (HMCAS) is uncertain. Aims. This prospective study investigated the sensitivity, specificity, prevalence, prognosis, interobserver variability, and associated clinical features of HMCAS in acute ischemic stroke. Methods. Initial CT scans of 117 patients with acute ischemic stroke or transient ischemic attack (TIA) and 65 age-matched controls were reported independently by two neuroradiologists blinded to diagnosis. Details of initial stroke severity and comorbidities were collected, and outcome on the modified Rankin scale (mRS) was assessed at 3–6 months. Results. HMCAS was seen in 15% of all ischemic strokes and 25% of all middle cerebral artery (MCA) strokes; specificity was 100%. HMCAS was associated with more severe initial deficit and atrial fibrillation. Only 21% of patients with a first-ever MCA stroke and HMCAS had a good outcome () compared to 55% of those without the sign (). Interobserver agreement was only 0.747 (Kappa statistic). Conclusion. The prevalence, specificity, sensitivity, and clinical associations of HMCAS were similar to previous reports. This study confirmed prospectively that HMCAS was associated with a poorer outcome at 3 to 6 months and demonstrated interobserver variability in detection of the sign. Patrick Aouad, Andrew Hughes, Nishant Valecha, Yash Gawarikar, Kate Ahmad, Ross O'Neil, Murali Guduguntla, and Christian Lueck Copyright © 2013 Patrick Aouad et al. All rights reserved. Wed, 27 Mar 2013 18:13:15 +0000 http://www.hindawi.com/isrn/stroke/2013/838292/ The outcome of middle cerebral artery (MCA) aneurysm clipping depends on the presence of subarachnoid hemorrhage (SAH). Moreover, it is influenced by anatomical features of the aneurysm and its parent artery. We hypothesized that morphological characteristics of the aneurysm may be predictive for postoperative outcome. Therefore, we identified radiographic assessable details that predicted the surgical difficulty and the risk for new ischemia. The angiograms of 151 consecutive patients (82 presenting with SAH) were analyzed in a standardized fashion focusing on 12 defined morphological aspects. The results were correlated to intraoperative rupture and to postoperative ischemia. Aneurysms presenting with SAH were associated with irregular shape, larger maximum diameter, and larger dome-to-base distance (DBD) and were located more frequently on the M2 segment. Multivariate analysis revealed 6 independent predictors for intraoperative rupture: SAH, location on M2 segment, DBD, maximum diameter, diameter of the parent MCA, and the presence of branching vessel. Independent predictors of surgery-related ischemia were identified: SAH, irregular shape, location on M2 segment, DBD, and the neck-to-vessel ratio (NVR). In MCA aneurysms, independent predictors for the risk of rupture intraoperatively and for the postsurgical outcome were the presence of SAH, location on the M2-segment, size (DBD), and the broadness of the neck. Karl-Michael Schebesch, Martin Proescholdt, Kathrin Steib, Odo-Winfried Ullrich, Andreas Herbst, Janine Rennert, and Alexander Brawanski Copyright © 2013 Karl-Michael Schebesch et al. All rights reserved. Mon, 04 Mar 2013 18:13:48 +0000 http://www.hindawi.com/isrn/stroke/2013/467398/ Objectives. To identify predictors of emotional distress and psychological wellbeing in stroke survivors 2–5 years after discharge from comprehensive rehabilitation. Material and Methods. The Hospital Anxiety and Depression Scale (HADS), the General Health Questionnaire (GHQ-30), and questions regarding life situations were mailed to former patients. Multiple regression analyses were performed. Results. The responses from 68 participants (37% women), of an average age of 58 years old, were used. Emotional distress (HADS > 10) was identified in 41%. Well-being (GHQ-30 < 6) was identified in 46%. Not surprisingly, there was a strongly negative association between well-being (GHQ-30 < 6) and emotional distress (HADS > 10) at follow up. Dependency in toileting during rehabilitation predicted emotional distress 2–5 years later. Finally, well-being at followup was predicted by age > 65 years, independent mobility, perceiving proxies as supportive, and being in employment. Conclusions. Dependence in the activities of daily living 3–6 months after-injury predicted emotional distress 2–5 years after-stroke. Being over 65 years, having an occupation, proxy support and being less dependent all predicted well-being. Emotional distress and well-being were clearly negatively associated. Gender, education, marital status, and type of stroke were not associated with the outcome measures. H. Bergersen, A.-K. Schanke, and K. S. Sunnerhagen Copyright © 2013 H. Bergersen et al. All rights reserved. Thu, 14 Feb 2013 14:29:40 +0000 http://www.hindawi.com/isrn/stroke/2013/913942/ Background. Multiple, simultaneous, acute cerebral infarcts in different arterial territories are usually secondary to embolic occlusion of multiple cerebral arteries. We observed, however, that no cardiac or aortic source could be found in many of these patients. We therefore undertook this study to attempt to identify other factors that may be important in the causation of these infarcts. Materials and Methods. We performed a five-year retrospective review of all patients with multiple, near simultaneous, acute cerebral infarcts detected on diffusion-weighted MRI scans. Results. We identified 78 patients with acute infarcts, in different cerebral arterial territories. We found a cardiac embolic source in 15 (19 percent) patients. Forty-one patients (53%) had no obvious cause for their infarcts after detailed cardiovascular and hematological evaluation. In 16 of these patients (20% of all 78 patients), all with a history of chronic hypertension who had multiple, acute, small (<2 cms), deep subcortical or superficial cortical infarcts (and most, 93%, with extensive evidence of chronic small vessel disease on MRI FLAIR images), blood pressure was low or normal on initial presentation (mean arterial pressure, MAP: 85 ± 11.4 mm Hg). Analysis of the last prestroke blood pressure, within the previous 1 to 11 days available in 13 of 16 patients, revealed much higher BP (MAP: 113.6 ± 11.3 mm Hg), indicating a mean drop of 25.1 percent (range 11 to 44 percent). Two weeks after the stroke, blood pressure had risen again to greater than 160/100 mm Hg (MAP: 128.2 ± 14.3). Conclusion. Our study suggests that transient drop in blood pressure in high-risk hypertensive patients with severe, small vessel disease may sometimes result in small, cerebral infarcts. More research is needed to further clarify and confirm this possibility. Satyakam Bhagavati and Jai Choi Copyright © 2013 Satyakam Bhagavati and Jai Choi. All rights reserved. Wed, 17 Oct 2012 08:12:02 +0000 http://www.hindawi.com/isrn/stroke/2012/562184/ Recent systematic reviews of randomized controlled trials show that the rate of postoperative complications after carotid endarterectomy (CEA) was not significantly different between operations performed under general anesthesia (GA) or local anesthesia (LA). However, these studies were not large enough to draw meaningful conclusions about any difference in mortality. This study therefore aimed to compare a surrogate endpoint of postoperative mortality between GA and LA by using urinary neopterin. 68 consecutive patients admitted electively for CEA were studied. Urinary neopterin levels were assayed preoperatively, immediately postoperatively (PO), 4, 6, 12, and 24 hrs PO. This study compared the level of urinary neopterin between GA and LA. Of the 68 CEAs, 48 operations were performed under GA. Urinary neopterin concentration in LA group increased PO and reached a peak at 6 hrs PO. At this point, the urinary neopterin levels in the GA group (85.3 μmol/mol creatinine) were significantly lower than those under the LA group (123.4 μmol/mol creatinine) (). We found that the level of urinary neopterin level after operation in LA was significantly higher than those under GA. More studies are needed. K. Rerkasem and C. P. Shearman Copyright © 2012 K. Rerkasem and C. P. Shearman. All rights reserved. Fri, 28 Sep 2012 23:01:29 +0000 http://www.hindawi.com/isrn/stroke/2012/976045/ Background. Patients with a history of transient ischemic attack (TIA) are known to be at higher risk for a stroke. We sought to investigate predictors of individual risk for an ischemic stroke within 30 days of a TIA. Methods and Results. A retrospective analysis of 57,585 TIA admissions was collected from 155 United States hospitals. Data describing each admission included demographic and clinical data, and information about the admitting hospital. Cerebrovascular disease was the primary readmission reason (19% of readmissions) in the TIA patient population. The prevalence of 30-day ischemic stroke readmissions was 11 per 1,000 TIA admissions; however, 53% of stroke readmissions occurred within one week. Hierarchal regression models suggested that peripheral vascular disease and hypertensive chronic kidney disease were significant individual stroke risk factors, whereas history of myocardial infarction, essential hypertension, and diabetes mellitus was not associated with significant stroke risk. Certified stroke centers were not associated with significantly lower stroke readmission rates. Conclusions. The results suggest that cardiovascular comorbidities confer the most significant risk for an ischemic stroke within 30 days of a TIA. Interestingly, certified stroke centers do not appear to be associated with significantly lower stroke-readmission rates, highlighting the challenges managing this patient population. Duncan C. Ramsey, Mark G. Burnett, and Matthew C. Cowperthwaite Copyright © 2012 Duncan C. Ramsey et al. All rights reserved. Sun, 24 Jun 2012 11:14:36 +0000 http://www.hindawi.com/isrn/stroke/2012/629589/ Objective. To evaluate the need for information and treatment of poststroke fatigue (PSF) in community-dwelling patients with stroke in The Netherlands. Methods. Data were obtained from a Dutch internet-based questionnaire. The amount of information received about PSF, self-management and other treatment options, and the perceived need for treatment were scored. PSF was assessed with two Visual Numerical Scales of fatigue severity (VNSF), the Fatigue Severity Scale (FSS7), and by scoring the nature (physical versus mental) and onset time of PSF. Results. Data were available of 538 stroke survivors (mean age 52 years, 45% men, and mean time since onset 2.7 years). Severe fatigue (both VNSF items ≥7; 48%) and severe fatigue impact (FSS7 > 5; 68%) were frequent. Most participants (57%) experienced both physical and mental fatigue. Only 17% of the respondents indicated to have had received sufficient information about PSF and 7% about treatment options, whereas 56% expressed a substantial need for treatment. The need for treatment was moderately associated with fatigue severity and fatigue impact, whereas information status was not related to any demographical, fatigue, or stroke characteristic. Conclusions. PSF is a significant symptom after stroke requiring medical attention and treatment. The results of this survey indicate that patients do not receive adequate information on PSF. Aglaia M. E. E. Zedlitz, Michelle van Eijk, Roy P. C. Kessels, Alexander C. H. Geurts, and Luciano Fasotti Copyright © 2012 Aglaia M. E. E. Zedlitz et al. 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