Ralf W. Baumgartner

Background: Detection of multiple acute brain infarcts (MABI) by diffusion weighted magnetic resonance imaging (DWI) may provide information about stroke mechanism in (1) acute lacunar stroke, where evidence of MABI suggests a cause other than small artery disease (SAD), such as embolism or vasculitis (type 1 MABI); or (2) acute non-lacunar stroke, where MABI in the territory of at least two of the aortic branches supplying the brain indicates the presence of aortic or cardiac embolism rather than artery to artery embolism (type 2 MABI). Objective: To evaluate the prevalence of MABI and their impact on aetiological classification and prevention of stroke in patients with acute ischaemic stroke examined with DWI. Methods: 182 consecutive patients defined by DWI were evaluated. Stroke aetiology was classified according to the TOAST criteria, though “lacunar stroke” included patients with possible aetiologies other than SAD. Results: Type 1 MABI were detected in 21/72 patients (29%) with lacunar stroke, and type 2 MABI in 8/110 (7%) with non-lacunar stroke. A possible stroke mechanism different from SAD was found in nine type 1 MABI cases (43%): cardiac embolism (4); other determined aetiology (3); aortic embolism (2). Cardiac (2) or aortic (1) sources of embolism were detected in eight type 2 MABI cases. MABI patients with cardiac or aortic sources of embolism were treated with warfarin, the remainder with aspirin. Conclusions: Detection of type 1 MABI in patients with lacunar stroke improved diagnostic confidence and the choice of antithrombotic treatment. Further study is needed on stroke prevention in MABI cases caused by SAD alone.

Background: There is limited information about predictors of outcome and recurrence of ischaemic stroke affecting young adults. Objective: To assess the predictive value of the presenting characteristics for both outcome and recurrence in young stroke victims. Methods: Clinical and radiological data for 203 patients aged 16 to 45 years were collected prospectively; they comprised 11% of 1809 consecutive patients with ischaemic stroke. The National Institutes of Health stroke scale (NIHSS), the Bamford criteria, and the trial of ORG 10172 in acute stroke treatment (TOAST) classification were used to define stroke severity, subtype, and aetiology. The clinical outcome of 198 patients (98%) was assessed using the modified Rankin scale (mRS) and categorised as favourable (score 0–1) or unfavourable (score 2–6). Results: Stroke was caused by atherosclerotic large artery disease in 4%, cardioembolism in 24%, small vessel disease in 9%, another determined aetiology in 30%, and undetermined aetiology in 33%. Clinical outcome at three months was favourable in 68%, unfavourable in 29%, and lethal in 3%. Thirteen non-fatal stroke, two fatal strokes, and six transient ischaemic attacks (TIA) occurred during a mean (SD) follow up of 26 (17) months. High NIHSS score, total anterior circulation stroke, and diabetes mellitus were independent predictors of unfavourable outcome or death (pConclusions: Severe neurological deficits at presentation, total anterior circulation stroke, and diabetes mellitus predict unfavourable outcome. Previous TIA are associated with increased risk of recurrence.

Our purpose was to study the preventive effect of the calcium channel blocker flunarizine on headache, postural ataxia, and memory deficits occurring during decompression to high altitude in a randomized, placebo-controlled, double-blind study. After 7-day pretreatment with the study drugs, 20 healthy men were investigated at 490 m and 0.5, 2, 4, and 6 h later at a simulated altitude of 4559 m. Headache severity was evaluated on a 4-point scale. Sway path and anteroposterior and lateral sway were recorded with open and closed eyes by static posturography. Short- and long-term memory was studied by testing the recall of verbal and figural material immediately and 2 h after presentation, respectively. Blood pressure (BP) and arterial oxygen saturation (Sa_O2) were also assessed. Headache scores showed a trend to be lower in the flunarizine group that was significant after 4 and 6 h. Headache scores expressed as difference from baseline values showed a nonsignificant trend to be lower at 4 and 6 h in subjects treated with flunarizine. Postural stance, memory, BP, and Sa_O2 were similar in both treatment groups. Although the low number of investigated subjects may have prevented the detection of a significant therapeutic effect of flunarizine, the present data do not show that flunarizine is effective for prevention of headache, postural ataxia, and neurocognitive deficits occurring at simulated high altitude.

Ischemic infarcts of the thalamus involve one or two of its four arterial territories that are usually supplied by the posterior cerebral (PCA) and the posterior communicating (PCoA) arteries. We rep...

Transcranial color-coded duplex sonography (TCCS) enables the reliable assessment of intracranial stenoses (sensitivity 94–100%, specificity 99–100%), occlusions (middle cerebral artery: sensitivity 93–100%, specificity 98–100%) and cross-flow through the anterior (sensitivity 98%, specificity 100%) and posterior (sensitivity 84%, specificity 94%) communicating arteries without using potentially dangerous compression tests, as well as the midline shift in hemispheric infarcts. Ultrasound contrast agents (UCAs) increase the number of conclusive TCCS studies and allow the definite evaluation of intracranial arteries in most patients. TCCS is also useful for diagnosis and monitoring of vasospasm and detection of supratentorial hematomas (sensitivity 94%, specificity 95%) and aneurysms (sensitivity per patient 40–78%, specificity 90–91%), and may identify arteriovenous malformations. New developments are (1) UCAs that may increase the number of conclusive TCCS studies, (2) cerebral perfusion assessment, (3) measurement of arteriovenous cerebral transit time, which might enable the detection of small-vessel disease, and (4) site-targeted UCAs that may improve diagnosis and local drug delivery.

Objective: To investigate recanalisation in the first 12 months after cerebral venous thrombosis. Methods: 33 consecutive patients presenting with cerebral venous thrombosis were enrolled in the study. Diagnosis was made by magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) or catheter angiography. Patients were initially treated with intravenous heparin. Warfarin was given for at least four months. Cerebral MRI and MRV were done at four months and repeated after 12 months if venous thrombosis persisted. Outcome was evaluated by the Rankin scale at 12 months. Results: Outcome at 12 months was good, with a median modified Rankin scale score of 0 (range 0 to 2); 27 patients (82%) had no residual deficits. No patient suffered recurrent cerebral venous thrombosis, deep vein thrombosis, or pulmonary embolism during follow up. After four months, all deep cerebral veins and cavernous sinuses, 94% of superior sagittal sinuses, 80% of straight sinuses, 73% of jugular veins, 58% of transverse sinuses, and 41% of sigmoid sinuses had recanalised. No further recanalisation was observed thereafter. Conclusions: The results suggest that recanalisation only occurs within the first four months following cerebral venous thrombosis and not thereafter, irrespective of oral anticoagulation.

Ce travail de revue présente la prévention secondaire des accidents vasculaire cérébraux par le traitement des facteurs de risque vasculaire, les inhibiteurs de l'agrégation plaquettaire, l'anticoagulation ou les thérapies endovasculaires. Deux études publiées récemment (PROtection aGainst Recurrent Stroke Study (PROGRESS) et la Heart Protection Study (HPS) ont pour la première fois pu démontrer l'efficacité d'un traitement contre l'hypertension et par statines dans la prévention secondaire après un accident vasculaire cérébral. PROGRESS a montré que la combinaison de perindopril et d'indapamide permet de réduire de 43% la survenue d'accidents vasculaires cérébraux ischémiques et hémorragiques chez les patients hypertendus ou normotendus alors que HPS a mis en évidence une diminution de 20% des accidents vasculaires cérébraux ischémiques chez les patients avec des taux sériques normaux ou élevés de cholestérol. Les sténoses carotidiennes symptomatiques avec un resserrement distal > ou égal à 70% sont opérées par endartérectomie; en cas de sténose distale de 50–69% une décision individuelle est prise; une endartérectomie n'est pas indiquée en cas de sténose < 50%. Les patients chez lesquels une source cardiaque d'embolie est mise en évidence doivent être anticoagulés (INR 2.5, intervalle: 2–3) à l'exception des myxomes cardiaques et des endocardites bactériennes. Si aucune intervention chirurgicale sur une artère cérébrale n'est indiquée ou si le patient ne doit pas être anticoagulé, on traite par un inhibiteur de l'agrégation plaquettaire: 100 mg d'aspirine ou la combinaison d'aspirine et de dipyridamol sont le traitement de choix. En cas de récidive d'ischémie sous aspirine ou d'intolérance à l'aspirine, le clopidogrel est prescrit. Comme alternative au clopidogrel en cas de récidive d'ischémie, une anticoagulation (INR 2.0, intervalle: 1.5–2.5) peut être prescrite.

Stability of stance declines at high altitude in subjects with and without acute mountain sickness (AMS), suggesting that postural ataxia might result from different hypoxia-related mechanisms than those causing the signs and symptoms of AMS. The aim of this study was to determine whether short-term oxygen inhalation improves stability of stance assessed by static posturography and/or the symptoms of AMS. Twenty male volunteers with cerebral AMS scores above 0.70 were investigated the first or second morning of their stay at an altitude of 4559 m. Posturographic parameters remained unchanged, whereas cerebral AMS scores decreased (p < 0.001) after inhalation of 3 L/min of oxygen for at least 10 min. We conclude that ataxia of stance assessed by posturography may result from different hypoxia-triggered mechanisms that need more time for recovery than those causing AMS.