In patients with ischemic stroke (IS) or transient ischemic attack (TIA) and cortical superficial siderosis (cSS), there are few data regarding the risk of future cerebrovascular events and also about the benefits and safety of antithrombotic drugs for secondary prevention. We investigated the associations of cSS and stroke risk in patients with recent IS or TIA.
Background: Stroke is a major cause of morbidity and mortality. Liver enzymes, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transpeptidase (GGT), are markers of liver diseases with potential cardiovascular implications. Objective: This study aimed to investigate the prospective association between liver enzymes and stroke risk. Methods: We analyzed data from 3,379 men and 4,007 women without cardiovascular disease and registered in the Suita Study; a Japanese population-based prospective cohort study. The hazard ratios (HRs) and 95% confidence intervals (95% CIs) of stroke risk were estimated per quintiles of ALT, AST, and GGT in men and women. Results: Within a median follow-up period of 16.7 years, 438 incident stroke events were diagnosed. In men, compared to the second quintiles, the fifth (highest) quintiles of liver enzymes showed increased stroke risks: HRs (95% CIs) = 2.07 (1.35, 3.18) in ALT, 1.66 (1.10, 2.53) in AST, and 1.76 (1.11, 2.81) in GGT. The associations did not change with cerebral infarction risk: HRs (95% CIs) = 2.09 (1.24, 3.50) in ALT, 1.84 (1.11, 3.06) in AST, and 1.74 (1.00, 3.04) in GGT, respectively. The lowest ALT, AST, and GGT quintiles tended to show increased stroke and cerebral infarction risks, yet these associations were statistically insignificant. No such associations were shown in women. Conclusion: Elevated ALT, AST, and GGT levels were associated with increased stroke and cerebral infarction risks among Japanese men.
The purpose of this study was to determine the safety and efficacy of intravenous recombinant tissue-type plasminogen activator (0.6 mg/kg alteplase) within 3 hours of stroke onset in Japanese patients outside the indications in the European license.Of the 600 patients who were treated with recombinant tissue-type plasminogen activator, 422 met the inclusion criteria of the European license (IN group) and 178 did not (OUT group).The OUT group was inversely associated with any intracerebral hemorrhage (adjusted OR, 0.50; 95% CI, 0.29-0.84), positively associated with an unfavorable outcome (2.48; 1.55-3.94) and mortality (2.04; 1.02-4.04), and not associated with symptomatic intracerebral hemorrhage (0.53; 0.11-1.79) or complete independency (0.65; 0.40-1.03) after multivariate adjustment.Functional and vital outcomes 3 months after low-dose recombinant tissue-type plasminogen activator in patients outside the European indications were less favorable compared with those included in the indications; however, the risk of intracerebral hemorrhage was not.
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Purpose: Intravenous nicardipine is commonly used to reduce elevated blood pressure (BP) in acute intracerebral hemorrhage (ICH). We determined factors associated with nicardipine dose and the association of the dose with clinical outcomes in hyperacute ICH. Methods: Hyperacute (<3 h from onset) ICH patients with initial systolic BP (SBP) >180 mmHg were registered in a multicenter observational study (the SAMURAI-ICH study). All patients initially received 5mg/h of intravenous nicardipine to lower BP. The dose was adjusted to maintain SBP between 120 and 160 mmHg based on BPs measured every 15 min during the initial 2 h and every 60 min in the following 22 h. Maximum hourly and total doses during the initial 24 h were calculated. Associations of the doses with neurological deterioration (a decrease of ≥2 in GCS or an increase of ≥4 in NIHSS score at 72 h after treatment initiation), hematoma expansion (>33% from baseline to 24 h), and unfavorable outcome (modified Rankin Scale score 4-6 at 3 months) were assessed. Results: Of 211 patients in the registry, 206 patients (81 women, 65.8±11.8 years old) whose nicardipine data were available throughout 24-h observation were studied. Initial BP was 201.9±15.9/107.9±15.1 mmHg. Median time to reach target SBP range was 30 min (IQR 15-45). Maximum and total doses were 9.1±4.2mg/h and 123.7±100.2mg/day, respectively. Multivariate analyses revealed that male sex [standardized regression coefficient (β)=0.20, p=0.0030 for maximum dose; β=0.25, p=0.0002 for total dose], age (β= -0.28, p=0.0002; β= -0.25, p=0.0005) and initial SBP (β=0.19, p=0.0018; β=0.18, p=0.0021) were independently associated with both maximum and total doses. Body weight (β=0.20, p=0.0084) was independently associated with total dose. After multivariate adjustment, maximum dose (per 1mg/h; OR 1.25, 95% CI 1.09-1.45; p=0.0022) was independently and total dose (per 10mg/day; OR 1.06, 95% CI 0.998-1.132; p=0.0555) tended to be associated with neurological deterioration. Nicardipine dose was not associated with hematoma expansion and unfavorable outcome. Conclusions: Nicardipine dosage is roughly predictable with sex, age, body weight and initial SBP in acute ICH. Maximum hourly nicardipine dose was associated with neurological deterioration.
Background and Purpose: Intracranial artery dissection (IAD) can cause subsequent ischemic stroke, hemorrhagic stroke or both. Although radiological findings of IAD widely include aneurysmal dilatation, segmental stenosis, or occlusion, it is unclear to what extent of each finding related to incident stroke. We tested whether findings by digital subtraction angiography (DSA) assessments were associated with increased risks of ischemic and hemorrhagic stroke in patients with IAD Methods: We retrieved data on consecutive patients with IAD within one month from onset who underwent DSA from single-center prospective cohort databases from February 2011 to November 2016. DSA was used to determine fusiform or irregular aneurysmal dilation, intimal flap or double lumen, and pearl-and-string sign according to proposed imaging diagnostic criteria. We assessed clinical and radiographic variables associated with IAD and subsequent stroke subtypes using logistic regression analyses. Result: Of the total 105 patients with IAD (mean age, 52±2 years; 30% men), 92 patients had DSA assessments. Among them, 36 patients had acute ischemic stroke (AIS) or transient ischemic attack (TIA) and 40 patients had subarachnoid hemorrhage (SAH). In multivariate analysis, current smoking (odds ratio [OR], 2.78; 95% confidence interval (CI), 1.00-8.00) and string sign (stenosis) (OR 3.24, 95% CI, 1.04-10.81) were associated with AIS/TIA, whereas intimal flap (OR, 15.44; 95% CI, 5.05-55.73) and irregular aneurysm dilatation (OR, 24.94; 95% CI, 7.34-119.04) were associated with SAH. Conclusion: Patients who developed AIS/TIA were related to current smoking and string sign, and patients who developed SAH were related to intimal flap and fusiform or irregular aneurysmal dilatation.
A 67-year-old woman was transported to our hospital with abnormal sensation in the left temporal region and unstable gait. She had a history of increased urinary frequency without medication. Head CT showed intracerebral hemorrhage in the left dorsal medulla oblongata. On the day of admission, she became aware of difficulty in urination and the volume of residual urine was 100 ml. Cystometry revealed normal voiding sensation and relatively lower intravesical pressure during voiding effort. The maximum cystometric capacity was also mildly decreased. The lower urinary tract dysfunction in this patient was diagnosed as detrusor underactivity. An α1-adrenoreceptor antagonist, urapidil, was started and her residual urine was decreased. Urapidil was terminated on the 14th day of onset, but her lower urinary tract symptoms did not recur thereafter. The brain MR imaging with magnetization-prepared 2 rapid acquisition gradient-echoes (MP2RAGE) clearly demonstrated a small hematoma in the dorsolateral medulla with surrounding edema. The perihematomal edema initially spread to involve the left lateral tegmentum of the medulla, but it almost disappeared in the follow-up MP2RAGE imaging on the 21st day. At the medulla level, the descending tract from the pontine micturition center is assumed to lie lateral tegmentum. The lower urinary tract dysfunction in this case was presumed to be caused by damage to the descending tract from the pontine micturition center, and the disappearance of perihematomal edema and the compensation by the contralateral tract would have contributed to the early improvement of symptoms.
Abstract A contributing factor to the failure of trials of neuroprotectants in acute ischemic stroke may be the differing vulnerability to ischemia of white compared with gray matter. To address this issue, we determined to establish the existence of potentially viable tissue in white matter and its evolution to infarction or salvage in both gray and white matter compartments in patients with ischemic stroke. Twenty‐seven patients (mean age, 73.4 years) at a median of 16.5 hours after symptom onset were studied using the hypoxic marker 18 F‐misonidazole with positron emission tomography (PET). Tissue was segmented using an magnetic resonance probabilistic map. Although there was a greater volume of initially “at‐risk tissue” in gray matter (58.3cm 3 , 29.9–93.0cm 3 ) than white matter (42.0cm 3 , 15.8–74.0cm 3 ; p < 0.001) at the time of PET imaging, a higher proportion of this was still potentially viable in white matter (41.4%, 4.6–74.5%) than in gray matter (23.6%, 3.2–61.1%; p < 0.05). However, a similar proportion in each compartment spontaneously survived. These data provide evidence for the existence of potentially salvageable tissue in human white matter and is consistent with it having a similar or even greater resistance to ischemia than gray matter. For the latter possibility, alternative therapeutic strategies may be required for its salvage. Ann Neurol 2004;56:695–701
The relationship between left ventricular (LV) function and AF detection in embolic stroke of undetermined source (ESUS) patients with insertable cardiac monitors (ICMs) remains unclear. We investigated the association between LV function and AF detection in patients with ESUS after ICMs implantation.
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