Risk factors for primary cerebral hemorrhage: a population-based study--the Stroke Registry of Dijon

Etiologic Profile of Childhood Stroke from North India: Is It Different from Developed World?

OBJECTIVE

To describe the etiology of childhood arterial-ischemic stroke from a developing country and assess short-term neurologic outcome.

METHODS

Prospective observational study. Consecutive children between the age of >28 days to <12 years, admitted with the diagnosis of arterial-ischemic stroke were enrolled during the study period from January 2017 to December 2018. Short-term neurologic outcome was assessed with Pediatric Cerebral Performance Category (PCPC) scale and Pediatric Stroke Outcome Measure (PSOM).

RESULTS

We enrolled 76 children with arterial-ischemic stroke, with a median age of 24 months (interquartile range 12-69), and 43 (57%) were boys. The most common risk factor for childhood arterial-ischemic stroke was arteriopathy in 59 (77%), followed by cardiovascular disorder in 12 (16%) children. Among 59 children with arteriopathy, 32 (42%) had infection-associated arteriopathies, 10 (13%) had mineralizing angiopathy, 10 (13%) had moyamoya disease. Pediatric stroke risk factors were classified according to Pediatric Stroke Classification and CASCADE primary classification. Short-term neurologic outcome was assessed at 3 months in 62 (82%) survivors. Among stroke survivors, 33 (61%) had sensory-motor deficits, and 24 (39%) had severe neurologic disability (PCPC ≥ 4). The presence of fever, encephalopathy, low Glasgow coma score at presentation, seizures, and infection-associated arteriopathy predicted severe neurologic disability at follow-up.

CONCLUSION

The risk factors for pediatric arterial-ischemic stroke are different from developed countries in our cohort. Infection-associated arteriopathies, mineralizing angiopathy, and moyamoya disease are the most common risk factors in our cohort. Two-thirds of pediatric stroke survivors have neurologic disability at short-term follow-up.

Combined therapy of intensive statin plus intravenous rt-PA in acute ischemic stroke: the INSPIRE randomized clinical trial

OBJECTIVE

To investigate the safety and efficacy of intensive statin in the acute phase of ischemic stroke after intravenous thrombolysis therapy.

METHODS

A total of 310 stroke patients treated with rt-PA were randomly scheduled into the intensive statin group (rosuvastatin 20 mg daily × 14 days) and the control group (rosuvastatin 5 mg daily × 14 days). The primary clinical endpoint was excellent functional outcome (mRS ≤ 1) at 3 months, and the primary safety endpoint was symptomatic intracranial hemorrhage (sICH) in 90 days.

RESULTS

The intensive statin users did not achieve a favorable outcome in excellent functional outcome (mRS ≤ 1) at 3 months compared with controls (70.3% vs. 66.5%, p = 0.464). Intensive statin also not significantly improved the overall distribution of scores on the modified Rankin scale, as compared with controls (p = 0.82 by the Cochran-Mantel-Haenszel test). The incidence of primary safety endpoint events (sICH) in 90 days did not significantly differ between the intensive statin group and control group (0.6% vs. 1.3%, p > 0.999).

CONCLUSION

The INSPIRE study indicated that intensive statin therapy may not improve clinical outcomes compared with the low dose of statin therapy in AIS patients undergoing intravenous thrombolysis, and the two groups had similar safety profile.

CLINICAL TRIAL REGISTRATION

URL: http://www.chictr.org . Unique identifier: ChiCTR-IPR-16008642.

Platelet count and mean volume in acute stroke: a systematic review and meta-analysis

Changes of mean platelet volume (MPV) and platelet count (PC) could be a marker or a predictor of acute stroke (AS). We conducted a systematic review and meta-analysis of the published literature on the reporting of MPV and PC in AS. Studies were included in accordance with Patient Population or Problem, Intervention, Comparison, Outcomes, and Setting framework. The PRISMA strategy was used to report findings. Risk of bias was assessed with the Newcastle-Ottawa Scale. We included 34 eligible articles retrieved from the literature. PC was significantly lower in AS patients [standardized mean difference (SMD) = - 0.30, (95% CI: - 0.49 to - 0.11), N = 2492, P = .002] compared with controls (N = 3615). The MPV was significantly higher [SMD = 0.52 (95% CI: 0.28-0.76), N = 2739, P < .001] compared with controls (N = 3810). Subgroup analyses showed significantly lower PC in both ischemic stroke (Difference SMD = -0.18, 95% CI: -0.35-0.01) and hemorrhagic stroke (-0.94, -1.62 to -0.25), but only samples by citrate anticoagulant showed significantly lower result for patients compared to controls (-0.36, -0.68 to -0.04). Ischemic stroke patients had higher MPV (0.57, 0.31-0.83), and samples by Ethylenediaminetetraacetic acid (EDTA) anticoagulant showed significantly higher result for patients compared to controls (0.86, 0.55-1.17). PC and MPV appeared to be significantly different between patients with AS and control populations. MPV was significantly higher in ischemic stroke and PC was significantly lower in both ischemic and hemorrhagic strokes. These characteristics might be related to AS and associated with it. It is advisable to pay attention to elapsed time between phlebotomy and hematology analysis, anticoagulant and hemocytometer types in AS.

SYSTEMATIC REVIEW REGISTRATION

This meta-analysis is registered on the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42017067864 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=67864).

Association between diabetes mellitus and the occurrence and outcome of intracerebral hemorrhage

OBJECTIVE

Whether diabetes mellitus (DM) is a risk factor for spontaneous intracerebral hemorrhage (ICH) and influences outcome after ICH remains unclear.

METHODS

One reviewer searched Ovid MEDLINE and Embase 1980-2014 inclusive for studies investigating the associations between DM and ICH occurrence or DM and ICH case fatality. Two reviewers independently confirmed each study's eligibility, assessed risk of bias, and extracted data. One reviewer combined studies using random effects meta-analysis.

RESULTS

Nineteen case-control studies involving 3,397 people with ICH and 5,747 people without ICH found an association between DM and ICH occurrence (unadjusted odds ratio [OR] 1.23, 95% confidence interval [CI] 1.04-1.45; I(2) = 22%), which did not differ between 17 hospital-based and 2 population-based studies (pdiff = 0.70), and was similar in the 16 studies that controlled for age and sex (unadjusted OR 1.15, 95% CI 0.95-1.40; I(2) = 14%). This association was not identified in 3 population-based cohort studies in which ICH occurred in 38 (0.66%) of 5,724 people with DM and 448 (0.57%) of 78,702 people without DM (unadjusted risk ratio [RR] 1.27, 95% CI 0.68-2.36; I(2) = 69%). DM was associated with a higher case fatality by 30 days or hospital discharge in 18 cohort studies involving 813 people with DM and 3,714 people without DM (unadjusted RR 1.52, 95% CI 1.28-1.81; I(2) = 49%).

CONCLUSIONS

The findings suggest that there may be modest associations between DM and ICH occurrence and outcome, but further information from large, population-based studies that account for confounding is required before the association can be confirmed.

Influence of intracerebral hemorrhage location on incidence, characteristics, and outcome: population-based study

BACKGROUND AND PURPOSE

The characteristics of intracerebral hemorrhage (ICH) may vary by ICH location because of differences in the distribution of underlying cerebral small vessel diseases. Therefore, we investigated the incidence, characteristics, and outcome of lobar and nonlobar ICH.

METHODS

In a population-based, prospective inception cohort study of ICH, we used multiple overlapping sources of case ascertainment and follow-up to identify and validate ICH diagnoses in 2010 to 2011 in an adult population of 695 335.

RESULTS

There were 128 participants with first-ever primary ICH. The overall incidence of lobar ICH was similar to nonlobar ICH (9.8 [95% confidence interval, 7.7-12.4] versus 8.6 [95% confidence interval, 6.7-11.1] per 100 000 adults/y). At baseline, adults with lobar ICH were more likely to have preceding dementia (21% versus 5%; P=0.01), lower Glasgow Coma Scale scores (median, 13 versus 14; P=0.03), larger ICHs (median, 38 versus 11 mL; P<0.001), subarachnoid extension (57% versus 5%; P<0.001), and subdural extension (15% versus 3%; P=0.02) than those with nonlobar ICH. One-year case fatality was lower after lobar ICH than after nonlobar ICH (adjusted odds ratio for death at 1 year: lobar versus nonlobar ICH 0.21; 95% confidence interval, 0.07-0.63; P=0.006, after adjustment for known predictors of outcome). There were 4 recurrent ICHs, which occurred exclusively in survivors of lobar ICH (annual risk of recurrent ICH after lobar ICH, 11.8%; 95% confidence interval, 4.6%-28.5% versus 0% after nonlobar ICH; log-rank P=0.04).

CONCLUSIONS

The baseline characteristics and outcome of lobar ICH differ from other locations.

HindIII polymorphism in the lipoprotein lipase gene and hypertensive intracerebral hemorrhage in the Chinese Han population

BACKGROUND

To investigate the relationship between the HindIII polymorphism and hypertensive intracerebral hemorrhage (HIH) and lipid metabolism.

METHODS

A polymerase chain reaction-restriction fragment length polymorphism assay and the chain termination DNA sequencing method were used to determine the HindIII genotypes of 267 subjects, which included 120 cerebral hemorrhagic patients and 147 controls. The fasting levels of lipids and glucose in the plasma were used to measure the effect of genotype on HIH risk factors.

RESULTS

The frequency of the T allele of the HindIII polymorphism in the HIH group was 90.8%. The frequency of the G allele was 9.2%. In the control group, the frequencies were 82.3% T and 17.7% G, which indicated that the proportion of the G allele in the HIH patient group was significantly lower than in the control group (P<.05). The frequency of GG+GT genotypes in HIH patients (P<.05) and the plasma triglyceride (TG) levels in these patients (P<.05) were also lower than in the control group. The levels of plasma TG, low-density lipoprotein cholesterol, glucose, systolic blood pressure, and diastolic blood pressure in the HIH group were higher than in the controls (P<.05). After controlling for risk factors related to HIH, the HindIII G allele was negatively correlated with the incidence of HIH (odds ratio=.417, 95% confidence interval: .193-.901).

CONCLUSIONS

The HindIII G allele may be a protective factor against the development of HIH among the Han Chinese population.

Noncommunicable diseases: current status of major modifiable risk factors in Korea

A noncommunicable disease (NCD) is a medical condition or disease that is by definition non-infectious and non-transmissible among people. Currently, NCDs are the leading causes of death and disease burden worldwide. The four main types of NCDs, including cardiovascular disease, cancer, chronic lung disease, and diabetes, result in more than 30 million deaths annually. To reduce the burden of NCDs on global health, current public health actions stress the importance of preventing, detecting, and correcting modifiable risk factors; controlling major modifiable risk factors has been shown to effectively reduce NCD mortality. The World Health Organization's World Health Report 2002 identified tobacco use, alcohol consumption, overweight, physical inactivity, high blood pressure, and high cholesterol as the most important risk factors for NCDs. Accordingly, the present report set out to review the prevalence and trends of these modifiable risk factors in the Korean population. Over the past few decades, we observed significant risk factor modifications of improved blood pressure control and decreased smoking rate. However, hypertension and cigarette smoking remained the most contributable factors of NCDs in the Korean population. Moreover, other major modifiable risk factors show no improvement or even worsened. The current status and trends in major modifiable risk factors reinforce the importance of prevention, detection, and treatment of risk factors in reducing the burden of NCDs on individuals and society.

Predictors for cognitive decline in patients with confluent white matter hyperintensities

BACKGROUND

Although patients harboring confluent white matter hyperintensities (WMH) are at high risk of cognitive decline, this risk varies among individuals. We investigated the predictors for cognitive decline in stroke patients with confluent WMH.

METHODS

We followed up 100 stroke patients with confluent WMH who were participants of the VITAmins TO Prevent Stroke study for 2 years. We investigated the association between clinical features, apolipoprotein E status, imaging measures (infarcts, microbleeds, volumes of WMH, cortical gray matter [cGM], lateral ventricles, and hippocampi), and B vitamins with changes in cognitive measures (clinical dementia rating scale, Mini-Mental State Examination, Mattis dementia rating scale--initiation/perseveration subscale). We performed Pittsburgh compound B imaging among dementia converters.

RESULTS

Multivariate regression analysis showed that increase in clinical dementia rating scale grade was associated with cGM atrophy, absence of hyperlipidemia, and lower diastolic blood pressure at baseline. cGM atrophy and absence of hyperlipidemia were also associated with deterioration in Mini-Mental State Examination and Mattis dementia rating scale--initiation/perseveration subscale scores. Pittsburgh compound B retention typical of Alzheimer's disease was found only in 10% of dementia converters. Incident stroke and B vitamins were not associated with cognitive decline.

CONCLUSIONS

Among stroke patients with confluent WMH, cGM atrophy and absence of hyperlipidemia are important predictors for cognitive decline. Significant cognitive decline can occur in the absence of incident stroke or Alzheimer's pathology.

Statin pretreatment may increase the risk of symptomatic intracranial haemorrhage in thrombolysis for ischemic stroke: results from a case-control study and a meta-analysis

The influence of statins on the results of intravenous thrombolysis for ischemic stroke is controversial. We studied the risks and benefits of statin pretreatment (SP) in patients treated with intravenous alteplase (t-PA) at our institution, and included our data to a meta-analysis of previous related studies. We reviewed prospectively collected data from consecutive patients with acute ischemic stroke treated with IV rt-PA at our institution over the past 9 years. We compared symptomatic intracranial haemorrhage (SICH), favourable short-term outcome (decrease of ≥4 points on the NIHSS score after 24 h from baseline assessment), favourable long-term outcome (mRS score ≤2 at 3 months) and mortality rates between statin-pretreated (SPP) and nonstatin-pretreated patients (NSPP). We performed a systematic search through MEDLINE/PubMed and Embase datasets to identify similar English language studies. A total of 182 patients were included (mean age 68.3 ± 11.4 years, 54.3% men). There were no significant differences between SPP and NSPP regarding SICH (3.3 vs. 1.7%, p = 0.47), favourable short-term outcome (44.8 vs 56%, p = 0.31) and favourable long-term outcome rates (40 vs 44.1%, p = 0.84). In a meta-analysis of 1,055 patients, SP was neither related to long-term functional outcome nor mortality, but it was a risk factor for SICH (OR 1.99, 95% CI 1.03-3.84, p = 0.04). Statin pretreatment may increase the risk of SICH in patients receiving IV t-PA for ischemic stroke, though it does not influence the 3 months outcome. Prospective studies are needed to confirm this safety concern.

Triglycerides and risk of hemorrhagic stroke vs. ischemic vascular events: The Three-City Study

BACKGROUND

Few studies have assessed the relationship between triglycerides and the risk of hemorrhagic stroke, which contrasts the considerable number of studies about triglycerides and ischemic vascular events. We analyzed the association pattern between triglycerides and incident intracerebral hemorrhage as compared with coronary events and ischemic stroke, in a large cohort of elderly.

METHODS

Population-based, prospective cohort study among 8393 men and women participating in the Three-City Study, aged > or = 65 years at baseline. Fasting blood lipids, including triglycerides, were measured at baseline. Fatal and non-fatal strokes and coronary events were adjudicated and validated by scientific committees. Cox proportional hazards models were used to adjust for potential confounders.

RESULTS

During a mean follow-up of 5.0 years, 36 hemorrhagic strokes, 143 ischemic strokes, and 393 coronary events occurred. An increased level of triglycerides was associated with an increased risk of ischemic vascular events. Conversely, a low level of triglycerides (< or = 0.94 mmol/L) was associated with an increased risk of hemorrhagic stroke (adjusted hazard ratio 2.35; 95% confidence interval 1.18-4.70). The relationship with hemorrhagic stroke was mainly apparent in men, in individuals with high blood pressure, and in those with low levels of cholesterol.

CONCLUSIONS

In this large cohort of elderly men and women, low triglycerides levels were associated with an increased risk of hemorrhagic stroke and a decreased risk of ischemic vascular events. The association between triglycerides and hemorrhagic stroke was particularly strong in men, in subjects with high blood pressure and in those with low cholesterol levels.

Low level of low-density lipoprotein cholesterol increases hemorrhagic transformation in large artery atherothrombosis but not in cardioembolism

BACKGROUND AND PURPOSE

Low cholesterol level is known to be associated with increased cerebral hemorrhage. However, the associations of hemorrhagic transformation (HTf) after acute ischemic stroke and the low levels of total cholesterol (TC) or low-density lipoprotein cholesterol (LDLC) are largely undiscovered.

METHODS

Of the 1034 patients with acute ischemic stroke who were consecutively admitted to our hospital, 377 patients with stroke attributable to large artery atherothrombosis (LAA; n=210) or cardioembolism (n=167) were selected for this study. Demographic and clinical information was collected and HTf was evaluated through follow-up T2*-weighted gradient-echo MRI performed usually within 1 week after stroke. Measurement of lipid parameters included TC, LDLC, high-density lipoprotein cholesterol, and triglyceride.

RESULTS

Of the 377 patients, HTf was noted in 74 patients (19.6%). When patients were divided into 4 groups according to their TC and LDLC levels, the incidence of HTf was significantly elevated in the lowest quartile of each TC (P<0.01) and LDLC (P<0.01) level in LAA subgroup, but not in cardioembolism. After adjusting covariates, a low level of LDLC (OR, 0.46 per 1 mmol/L-increase; 95% CI, 0.22-0.98) was independently associated with HTf in LAA, but not in cardioembolism. There was no significant association between low levels of TC (OR, 0.63 per 1 mmol/L-increase; 95% CI, 0.35-1.15) and HTf in LAA.

CONCLUSIONS

Low levels of LDLC, and possibly TC, are associated with greater risk of hemorrhagic transformation after acute ischemic stroke attributable to LAA.

Aspects of intracerebral hematomas--an update

BACKGROUND

In Norway, there are approximately 16000 strokes each year and 15% of these are caused by intracerebral hematomas. Intracerebral hemorrhage (ICH) results from the rupture of blood vessels within the brain parenchyma. ICH occurs as a complication of several diseases, the most prevalent of which is chronic hypertension. When hemorrhage develops in the absence of a pre-existing vascular malformation or brain parenchymal lesion, it is denoted primary ICH. Secondary ICH refers to hemorrhage complicating a pre-existing lesion. Primary ICH is the most common type of hemorrhagic stroke, accounting for approximately 10% of all strokes. Despite aggressive management strategies, the 30-day mortality remains high, at almost 50%, with the majority of deaths occurring within the first 2 days. At 6 months, only 20-30% achieve independent status.

MATERIAL AND METHODS

This article is based on clinical experience, modern therapeutic guidelines for the treatment of intracerebral hematomas and up-to-date medical literature found in Medline. The article discusses the pathophysiology, clinical aspects, treatment, and the prognosis of intracerebral hematomas.

RESULTS AND DISCUSSION

Advances in diagnosis, prognosis, pathophysiology, and treatment over the past few decades have significantly advanced our knowledge of ICH; however, much work still needs to be carried out. Future genetic and epidemiologic studies will help identify at-risk populations and hopefully allow for primary prevention. Randomized controlled studies focusing on novel therapeutics should help to minimize secondary injury and hopefully improve morbidity and mortality.

Liver cirrhosis, other liver diseases, and risk of hospitalisation for intracerebral haemorrhage: a Danish population-based case-control study

Background

Liver diseases are suspected risk factors for intracerebral haemorrhage (ICH). We conducted a population-based case-control study to examine risk of ICH among hospitalised patients with liver cirrhosis and other liver diseases.

Methods

We used data from the hospital discharge registries (1991–2003) and the Civil Registration System in Denmark, to identify 3,522 cases of first-time hospitalisation for ICH and 35,173 sex- and age-matched population controls. Among cases and controls we identified patients with a discharge diagnosis of liver cirrhosis or other liver diseases before the date of ICH. We computed odds ratios for ICH by conditional logistic regressions, adjusting for a number of confounding factors.

Results

There was an increased risk of ICH for patients with alcoholic liver cirrhosis (adjusted OR = 4.8, 95% CI: 2.7–8.3), non-alcoholic liver cirrhosis (adjusted OR = 7.7, 95% CI: 2.0–28.9) and non-cirrhotic alcoholic liver disease (adjusted OR = 5.4, 95%CI:3.1–9.5) but not for patients with non-cirrhotic non-alcoholic liver diseases (adjusted OR = 0.9, 95%CI:0.5–1.6). The highest risk was found among women with liver cirrhosis (OR = 8.9, 95%CI:2.9–26.7) and for patients younger than 70 years (OR = 6.1, 95%CI:3.4–10.9). There were no sex- or age-related differences in the association between other liver diseases (alcoholic or non-alcoholic) and hospitalisation with ICH.

Conclusion

Patients with liver cirrhosis and non-cirrhotic alcoholic liver disease have a clearly increased risk for ICH.

Monocyte count is an underlying marker of lacunar subtype of hypertensive small vessel disease

BACKGROUND

In the hypertensive small vessel disease (HSVD), it remains unclear why some patients develop lacunar infarcts (LIs) whilst others develop deep intracerebral hemorrhages (dICHs). Inflammation might be related to LI, and leukocyte and monocyte counts are regarded as an inflammatory marker of ischemic stroke.

OBJECTIVE

We investigated the relationship between leukocyte and monocyte counts determined in the first 24 h after stroke onset in HSVD patients.

METHODS

We prospectively studied 236 patients with first acute stroke because of HSVD (129 LI and 107 dICH). We analyzed demographic data, vascular risk factors, and white blood cell count subtypes obtained in the first 24 h after stroke.

RESULTS

The multivariate analysis showed that LI subtype of HSVD was correlated with hyperlipidemia (P < 0.0001), a higher monocyte count (P = 0.002), and showed a trend with current smoking (P = 0.051), whereas dICH subtype was correlated with low serum total cholesterol (P = 0.003), low serum triglycerides (P < 0.0001), and high neutrophil count (P = 0.050).

CONCLUSIONS

In patients who developed HSVD-related stroke, high monocyte count, current smoking, and hyperlipidemia are prothrombotic factors related to LI, whereas low cholesterol and triglyceride values are related to dICH. Monocyte count might be an inflammatory risk marker for the occlusion of small vessels in hypertensive patients.

Evidence for linkage of red blood cell size and count: genome-wide scans in the Framingham Heart Study

Red blood cell (RBC) count and size are major criteria for evaluating anemia and related hematology disease diagnoses. While environmental factors influence RBC count (RBCC) and size, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH), studies have indicated that each of these measures has a substantial genetic component. So far, no linkage analysis or genome scan has been reported. We carried out 10 cM genome-wide scans on RBCC, MCV, and MCH in a community-based Caucasian cohort, the Framingham Heart Study, using 325 pedigrees with 1,144 individuals genotyped and phenotyped. Using variance-component linkage methods, heritabilities were estimated as 56, 52, and 52% after covariate adjusted for RBCC, MCV, and MCH, respectively. For RBCC, we found a maximum LOD score of 3.2 on chromosome 19, 24 cM (7.0 Mbp). Near this region, there lie a few important candidate genes, including erythropoietin receptor and erythroid Krüppel-like factor. For linkage analyses for MCV and MCH, there were coinciding maximized LOD scores on chromosome 11, 9 cM (5.2 Mbp) with values of 3.8 and 3.6, respectively. Under the peak resides the hemoglobin beta cluster - several beta-like genes, which are important candidates for RBC size. In subsequent analyses, we excluded individuals with low MCV to assess the possible influence of beta-thalassemia carriers, and there continued to be evidence for linkage in the same region on chromosome 11p15 (LOD scores of 2.6 and 2.7 for MCV and MCH, respectively). For MCV, we also identified a new region on chromosome 6q24 with a LOD score of 2.9. These findings suggest that further studies are warranted to identify potential causal genetic variants for RBC size and count and related erythrocyte indices.

Statins and stroke prevention

Over the past decade, statins have been proven to significantly decrease coronary events in primary and secondary prevention of coronary artery disease. Recent clinical trials have indicated that statins significantly reduce stroke risk in patients with vascular disease. The Cholesterol Treatment Trialists' Collaborators in a meta-analysis including 90,056 patients found that the use of statins determined a significant 17% proportional reduction in the incidence of first-ever stroke of any type per 1 mmol/l low-density lipoprotein (LDL) cholesterol reduction. During an average of 5 years of treatment, the reduction in the overall incidence of stroke was about one sixth per 1 mmol/l LDL cholesterol decrease meaning that 8 fewer participants have any stroke per 1,000 among those with preexisting coronary artery disease at baseline, compared with 5 fewer per 1,000 among the participants with no such history. It is not known whether these findings might be due to the cholesterol reduction effect of statins or to pleiotropic effects of statins, such as improved endothelial function, decreased platelet aggregability, and reduced vascular inflammation. In secondary prevention of stroke, the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study found that treatment with atorvastatin reduced the risk of recurrent cerebrovascular events in patients with recent stroke or transient ischemic attack but no history of heart disease. Combining the results of patients with no history of heart disease from the SPARCL study and Heart Protection Study in a mini meta-analysis, compared with placebo, statins were associated with a barely nonsignificant difference in recurrent stroke (OR = 0.87, 95% CI = 0.75-1.01, p = 0.07) and a significant difference in the occurrence of major vascular events (OR = 0.78, 95% CI = 0.68-0.88, p = 0.0001) at final follow-up.

Risk factors for primary intracerebral hemorrhage in patients in Izumo City, Japan

The annual incidence rate of primary intracerebral hemorrhage (ICH) in Izumo City, Japan, appears to be the highest rate among those reported. Despite improvement of management and surgical therapy, the overall morbidity and mortality after ICH are still high. The author investigated the risk factors for ICH in patients in Izumo. A case-control study of 242 patients (137 men and 105 women with ages ranging from 34 to 97 years) with primary ICH was conducted in Izumo between 1991 and 1998. Hypertension, diabetes mellitus, heart disease, liver disease, alcohol consumption, cigarette smoking, and serum levels of total cholesterol, aspartate aminotransferase, and alanine aminotransferase were assessed as possible risk factors for ICH by using conditional logistic regression. The prevalence of hypertension among ICH patients was 77% and the odds ratio (OR) for hypertension was 17.07 (95% CI: 8.30-35.09), which are much higher than figures reported from Western countries. The OR for hypertension was higher in individuals < or = 69 years of age than in those > or = 70 years of age and lower for lobar hemorrhage than for hemorrhages at other sites. High serum total cholesterol (> or = 220 mg/dl) was the second most important risk factor for ICH (OR: 2.52; 95% CI: 1.23-5.14), and low total cholesterol (< 160 mg/dl) decreased the risk of ICH (OR: 0.47; 95% CI: 0.27-0.82). In contrast, heart disease decreased the risk of ICH, and there was no observed association between alcohol consumption, cigarette smoking, or diabetes mellitus and ICH. This study conducted in Izumo suggests that hypertension is the most important risk factor for ICH and contrary to most previous studies indicates that serum total cholesterol concentration is also positively associated with the risk of ICH. In contrast, heart disease may decrease the risk of ICH.

Statin Therapy for Secondary Stroke Prevention: Evidence Catches Up to Practice

Current approaches for the secondary prevention of ischemic stroke include the aggressive use of antithrombotic therapy, particularly antiplatelet agents, and carotid endarterectomy for eligible patients. Blood pressure lowering with angiotensin converting enzyme inhibitors and diuretics in hypertensives, glucose control to a hemoglobin A1C of less than 7% in diabetics, and statin therapy in patients with hyperlipidemia and/or cardiovascular disease are also important measures forsecondary prevention of stroke. Support for the routine use of statin therapy in all patients with ischemic stroke, regardless of lipid profile or a history of cardiovascular disease, has been, until recently, of debate. Clinical evidence found in studies such as the SPARCL trial and the Heart Protection Study now support the routine use of statin therapy in all ischemic stroke patients. This article focuses on the potential and proven benefits of statins in ischemic stroke.

Prevention of stroke and dementia by statin therapy: Experimental and clinical evidence of their pleiotropic effects

Stroke and dementia are major causes of disability in most countries. Epidemiological studies have demonstrated that statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) are likely to reduce the risk for developing these formidable disorders. The favorable outcomes in statin users may be attributable to not only cholesterol-dependent actions, but also various cholesterol-independent actions called "pleiotropic effects." Several clinical trials have suggested that statins decrease the incidence of stroke, especially ischemic stroke. Statins improve endothelial function, inhibit platelet activation, reduce blood coagulability, and suppress inflammatory reactions, all of which may contribute to the beneficial effects of the therapy. Statins also reduce the risk of vasospasm caused by subarachnoid hemorrhage (SAH). In addition, statins might inhibit the development and progression of Alzheimer's disease (AD), the dominant type of dementia in most industrialized countries, upstream of the amyloid cascade. In vitro studies have shown that statins modulate the metabolism of the beta-amyloid precursor protein (APP) and reduce the extracellular level of its proteolytic product, amyloid-beta (Abeta). The aggregated Abeta is cytotoxic, leading to formation of neurofibrillary tangles and neuronal loss in the brain. Inflammatory processes are active in AD and may contribute significantly to AD pathology. We review the experimental background regarding the pleiotropic effects of statins and summarize clinical trials that examined the preventative effects of statin therapy on stroke and dementia. We include current trials in which statin therapy is initiated within 24 hr of onset of acute ischemic stroke.

Hypertension after experimental cerebral ischemia: candesartan provides neurovascular protection

BACKGROUND

After ischemic stroke, hypertension increases the risk of recurrence, hemorrhage and fatal cerebral edema, but blood pressure (BP) lowering in the acute stroke period is controversial due to fears of infarct extension and worsened outcomes.

OBJECTIVE

To determine whether BP lowering with candesartan, initiated at reperfusion, can reduce neurovascular damage and improve outcome in a model of hypertension after experimental ischemic stroke.

METHODS

Male Wistar rats (280-305 g) underwent 3 h of middle cerebral artery occlusion (MCAO). At reperfusion, either saline (n = 18) or candesartan 1 mg/kg (n = 18) was administered intravenously. BP was measured by telemetry for 2 days before and 24 h after MCAO. Neurologic function was assessed and sacrifice occurred at 24 h after occlusion. Brain tissue was analyzed for infarct size, hemoglobin content and edema.

RESULTS

Mean BP increased from 96 to 124 mmHg immediately upon MCAO and decreased to 114 mmHg after reperfusion, remaining elevated for 24 h (P < 0.001) in the saline group. Candesartan reduced BP back to baseline and BP remained lower than in saline-treated animals until sacrifice (P < 0.001). Infarct size (54 versus 38%, P = 0.01) and hemoglobin content (23.4 versus 10.0 microg/g tissue; P = 0.03) and edema (17.97 versus 11.33%, P < 0.0001) were lower in the candesartan group. In addition, neurologic function at 24 h was improved (P = 0.0036) in the candesartan group.

CONCLUSIONS

Candesartan administered after reperfusion in acute ischemic stroke reduces neurovascular damage and improves outcome.

Intracerebral Hemorrhage

INTRODUCTION

Intracerebral hemorrhage (ICH) occurs from the rupture of small vessels into the brain parenchyma and accounts for approximately 10% of all strokes in the United States, and carries with it a significantly high morbidity and mortality.

SUMMARY

This article reviews the course and management of ICH. The most common chronic vascular diseases that lead to ICH are chronic hypertension and cerebral amyloid angiopathy. Additional factors that predispose to ICH include vascular malformations, chronic alcohol use, hypocholesterolemia, and use of anticoagulant medications. The understanding of mechanisms leading to ICH has advanced significantly, but questions regarding site predilection and timing of spontaneous hemorrhage still remain. Management in the acute setting is first focused on reducing hematoma expansion. Although no specific therapy has yet been proven effective, promising agents, particularly recombinant Factor VIIa, are on the horizon. Subsequent care is focused on controlling hemostasis, hemodynamics, and intracranial pressure in efforts to minimize secondary brain injury.

CONCLUSION

The morbidity and mortality associated with ICH remain high despite recent advances in our understanding of the clinical course of ICH. Novel preventive and acute treatment therapies are needed and may be on the horizon.

[Discharge prescription for ischemic stroke patients]

Stroke is a major public health issue: it affects 120 000 people in France each year. The yearly recurrence rate is thought to reach 8 percent. Secondary prevention of stroke is thus crucial and focuses on controlling vascular risk factors most often associated with antiplatelet agents. Therapeutic objectives are set depending on the individual's global cardiovascular risk. The PROGRESS study has shown the relevance of systematic blood pressure lowering using an angiotensin-converting-enzyme inhibitor (perindopril) in combination with a diuretic (indapamide) in secondary prevention of stroke, including in normotensive patients. If possible, blood pressure should be below 130/85 mmHg. Statins are indicated in stroke patients with hypercholesterolemia, coronary heart disease, diabetes mellitus or carotid stenosis, the target LDL-cholesterol level being below 1 g/L (2.58 mmol/L). There is a wide consensus on treating patients with symptomatic carotid stenoses > or = 70 percent by thrombo-endarterectomy and stroke associated with atrial fibrillation by anticoagulants. Management should be global and include changes in dietary behavior, tobacco and/or alcohol withdrawal, and regular exercising. Patient-specific therapeutic education should be offered in order to improve compliance.

A Systematic Comparison of the Quality and Volume of Published Data Available on Novel Risk Factors for Stroke versus Coronary Heart Disease

BACKGROUND

To identify new treatments to prevent stroke, it is important that we have reliable data on potential novel risk factors.

METHODS

We studied seven novel vascular risk factors [apo-lipoprotein (b), C-reactive protein, Chlamydia pneumoniae, fibrin-D dimer, fibrinogen, Helicobacter pylori and lipoprotein (a)] and compared the amount of published data on their relations with ischaemic stroke versus acute coronary events by systematic review of all studies published up to 2003.

RESULTS

From a total of 22,875 abstracts reviewed, 266 eligible studies were identified (167 case-control studies and 99 cohort studies). Two hundred and eleven (79%) studies included coronary events as an outcome for the purpose of a risk factor analysis. In 186 (70%) studies, coronary events were the only outcome that was analysed. Only 73 (27%) studies included stroke or TIA as an outcome event, and only 45 studies (17%) reported risk factor analyses for ischaemic stroke separately. These results were qualitatively consistent across the risk factors studied and the relative lack of data on risk factors for stroke was even greater in prospective cohort studies.

CONCLUSION

Data on novel risk factors for stroke are lacking compared with the equivalent data for acute coronary events, and there are very few data on specific subtypes of ischaemic stroke.

Effect of untreated hypertension on hemorrhagic stroke

BACKGROUND AND PURPOSE

Stroke is the third leading cause of death and the leading cause of disability in the United States. Intracerebral hemorrhage and subarachnoid hemorrhage represent approximately 20% of all stroke cases and have a mortality rate of 40% to 50%. Hypertension is an important risk factor for these subtypes of stroke. We sought to determine whether untreated hypertension carries a different risk from treated hypertension for hemorrhagic stroke.

METHODS

Cases of hemorrhagic stroke in the greater Cincinnati region were identified by screening all area hospital emergency rooms, radiology reports, and International Classification of Diseases 9 codes. Medical records were reviewed for risk factors and medication use. Cases of hemorrhagic stroke were approached for enrollment into the genetic sampling and interview arm. If subjects agreed, the case was matched by age, race, and gender to population-based controls.

RESULTS

Between May 1997 and December 2002, we recruited 549 cases of hemorrhagic stroke, of which 322 were intracerebral hemorrhage and 227 were subarachnoid hemorrhage. Untreated hypertension was found to be a significant risk factor for hemorrhagic stroke (odds ratio [OR]=3.5 [2.3 to 5.2]; P<0.0001) as was treated hypertension (OR=1.4 [1.0 to 1.9]; P=0.03). Insurance status of "self-pay" or Medicaid was a significant risk factor for untreated hypertension (OR=2.7 [1.6 to 4.4]). We estimate that 17% to 28% of hemorrhagic strokes among hypertensive patients would have been prevented if they had been on hypertension treatment.

CONCLUSIONS

Untreated hypertension is highly prevalent and an important risk factor for hemorrhagic stroke. We estimate that among hypertensive subjects, approximately one fourth of hemorrhagic strokes would be prevented if all hypertensive subjects received treatment.

Hypercholesterolemia, HMG-CoA reductase inhibitors, and risk of intracerebral hemorrhage: a case-control study

BACKGROUND AND PURPOSE

Several studies have demonstrated an association between hypocholesterolemia and intracerebral hemorrhage (ICH). We tested the hypothesis that hypercholesterolemia or use of HMG-CoA reductase inhibitors (statin) agents, or both, are associated with ICH.

METHODS

This study was part of the preplanned midway analysis of an ongoing, population-based, case-control study of the genetic and environmental risk factors of hemorrhagic stroke. Conditional stepwise logistic regression modeling was used to determine if self-reported hypercholesterolemia or statin use, or both, were independent risk factors for ICH.

RESULTS

Between December 1, 1997, and June 30, 2000, 188 cases of ICH and 366 age-, race-, and gender-matched controls were enrolled. Hypercholesterolemia and statin use were less common among cases than controls: 25% versus 38% (P=0.003) and 9% versus 17% (P=0.03), respectively. Hypercholesterolemia with statin use was associated with less risk of ICH (OR=0.30; P=0.0008) in multivariable analysis after controlling for alcohol use, hypertension, previous stroke, first-degree relative with ICH, education level, and apolipoprotein E alleles.

CONCLUSIONS

Hypercholesterolemia was associated with a lower risk of ICH. We have not found an increased risk of ICH with the widespread use of statins in our population. Given the lack of cholesterol levels in the current study, further studies are needed to determine if lower cholesterol levels secondary to statin use bear the same risk as low cholesterol levels for ICH.

Risk factors for intracerebral hemorrhage in the general population: a systematic review

BACKGROUND AND PURPOSE

Although data on some risk factors for intracerebral hemorrhage (ICH) already are beyond doubt, for other factors, the evidence is less clear. We performed a systematic overview of case-control and cohort studies on risk factors for ICH.

METHODS

We searched MEDLINE, LILACS, EXTRAMED, and Pascal from 1966 to 2001 to identify studies. Studies were included if they met predefined methodological criteria. When possible, 2x2 tables were extracted and combined with the Mantel-Haenszel method. Summary odds ratios (ORs) were calculated for case-control studies, and summary relative risks (RRs) were found for cohort studies and for case-control and cohort studies combined.

RESULTS

Fourteen case-control and 11 cohort studies were identified. We could not always combine the results of case-control and cohort studies. In cohort studies, the crude RR for age (every 10-year increase) was 1.97 (95% confidence interval [CI], 1.79 to 2.16). In case-control studies, the crude OR for high alcohol intake was 3.36 (95% CI, 2.21 to 5.12) and for hypertension was 3.68 (95% CI, 2.52 to 5.38). Two cohort studies showed an increasing risk of ICH with increasing degree of hypertension. In cohort and case-control studies combined, the crude RR for sex (male versus female) was 3.73 (95% CI, 3.28 to 4.25); for current smoking, 1.31 (95% CI, 1.09 to 1.58); and for diabetes, 1.30 (95% CI, 1.02 to 1.67).

CONCLUSIONS

Risk factors for ICH appeared to be age, male sex, hypertension, and high alcohol intake. High cholesterol tends to be associated with a lower risk of ICH. We could not assess whether these risk factors are independent.

Statins and stroke

An important issue for stroke prevention is the identification and treatment of risk factors such as hypercholesterolaemia. The 4 reasons to test if the statins have a role in stroke prevention are: (i) a statistical link between elevated low density lipoprotein-cholesterol or decreased high density lipoprotein-cholesterol and ischaemic stroke; (ii) a reduction in vascular risk with statins in randomised trials in patients with coronary heart disease; (iii) evidence of a decreased plaque progression under statins; and (iv) pooled analyses of primary and secondary prevention trials showing that reduction of total serum cholesterol reduces the incidence of stroke, especially with the highest rate of cholesterol reduction, and in patients with the highest risk of stroke (i.e. with statins in secondary prevention trials). The question of whether statins also have a neuroprotective effect in humans and reduce the risk of post-stroke dementia remains unsettled.

Low concentration of serum total cholesterol is associated with multifocal signal loss lesions on gradient-echo magnetic resonance imaging: analysis of risk factors for multifocal signal loss lesions

BACKGROUND AND PURPOSE

Multifocal signal loss lesions (MSLLs) on T2*-weighted gradient-echo (GE) MRI are believed to be microbleeds histopathologically. Previous epidemiological studies suggested that low serum cholesterol is associated with the increased risk of intracerebral hemorrhage. We investigated risk factors of MSLLs and the relationship between lipid profiles and MSLLs on GE-MRI.

METHODS

We included consecutively 172 patients who underwent brain MRI. MSLLs on GE-MRI were counted by 2 neurologists separately and graded by consensus. The concentrations of lipid profiles were categorized as quartiles, and the MSLLs were graded as absent (total count, 0), mild (1 to 2), moderate (3 to 10), and severe (>10).

RESULTS

The mean concentrations of total cholesterol and low-density lipoprotein cholesterol were significantly lower in patients with a severe degree of MSLLs than in those without MSLL (P<0.05). By multivariate analysis, MSLLs were significantly correlated with hypertension (odds ratio [OR], 3.42; 95% CI, 1.17 to 9.97), leukoaraiosis (OR, 4.62; 95% CI, 2.87 to 7.41), the lowest quartile of serum total cholesterol (<4.27 mmol/L; OR, 10.91; 95% CI, 3.98 to 25.57), and the highest quartile of high-density lipoprotein (>1.47 mmol/L; OR, 3.5; 95% CI, 1.45 to 8.29).

CONCLUSIONS

Our results suggest that both the lipid profile levels and the severity of hypertension may be closely associated with MSLLs on GE-MRI.

Hypolipemic agents for stroke prevention

An important issue for stroke prevention is identification and treatment of risk factors such as hypercholesterolemia. The four reasons to test hypolipidemic agents in stroke prevention are: (i) a statistical link between elevated low-density lipoprotein cholesterol (LDL-c) or decreased high-density lipoprotein cholesterol (HDL-c) and ischemic stroke; (ii) a reduction in vascular risk in randomized trials in patients with coronary heart disease; (iii) evidence of a decreased plaque progression under statins, (iv) pooled analyses of primary and secondary prevention trials showing that reduction of total serum cholesterol reduces the incidence of stroke, especially with the highest rate of cholesterol reduction, and in patients with the highest risk of stroke (i.e., with statins in secondary prevention trials), and (v) prophylactic neuroprotection induced by hypolipidemic agents in animal models of cerebral ischemia. Data provided by trials conducted in subjects with coronary heart disease and in asymptomatic individuals should now be confirmed in stroke patient.

Intracerebral hemorrhage

There is a significant variation in the management of ICH by neurologists, neurosurgeons, and emergency physicians. Most of the randomized clinical therapeutic trials have focused on subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS). Well-organized practice guidelines are now available for the management of ICH. Exciting research areas are being aggressively explored. Medical and surgical interventions for SAH, AIS, and ICH are always time-dependent, which places additional responsibility on the EP to correctly and promptly recognize these conditions to prevent further injury. The time-dependent care of these patients places the EP on the front lines of future stroke care. Special thanks to Dr. Daniel Woo and Dr. Stewart Wright for their assistance in reviewing the manuscript and Amy Hess for preparation of the manuscript.

Spontaneous intracerebral hemorrhage: epidemiology and clinical presentation

The advent of widespread CT availability has dramatically changed our understanding of the incidence and risk factors regarding intracerebral hemorrhage (ICH). In the pre-CT era, many patients with a small ICH were misclassified having had ischemic strokes and patients with massive ICH or subarachnoid hemorrhage (SAH) were often difficult to classify correctly. The fact that the precise mechanism of spontaneous ICH is often difficult to ascertain without pathologic evidence continues to hamper epidemiologic studies. This article reviews the incidence rates, natural history, epidemiology, and clinical presentations of nontraumatic ICH.

Hepatitis C virus (HCV) infection as a risk factor for spontaneous intracerebral hemorrhage: hospital based case-control study

Hepatitis C Virus (HCV) infection was investigated as a risk factor for intracerebral hemorrhage (ICH) by HCV antibody screening in 462 patients with ICH and 462 control patients with cerebral infarction matched by age and sex. Laboratory examinations of hemostatic parameters and cholesterol level were also performed in patients with ICH. HCV infection was significantly more frequent in patients with ICH than controls (8.7% vs 3.5%, P< 0.01). ICH patients with HCV infection had significantly higher L-alanine:2-oxoglutarate aminotransferase level (P< 0.001), lower cholesterol level (P< 0.05), lower platelet count (P< 0.05), and longer prothrombin time (P< 0.01) than ICH patients without HCV infection, although most of these values were within the normal range. These results demonstrate that HCV infection is a risk factor for spontaneous ICH. Subclinical clotting disorder and/or vessel wall friability resulting from hypocholesteremia may be associated with ICH in patients with HCV infection.

Serum gamma-glutamyl transferase, self-reported alcohol drinking, and the risk of stroke

BACKGROUND AND PURPOSE

There is still conflicting evidence regarding a link between alcohol drinking and the risk of stroke. In most prospective studies, the assessment of the alcohol drinking has been based on self-reporting, which may be unreliable. The aim of the present study was to examine the relationship between stroke and both the self-reported alcohol drinking and the serum gamma-glutamyl transferase (GGT) concentration, which was regarded as a biological marker of alcohol drinking.

METHODS

A prospective cohort study of 14 874 Finnish men and women aged 25 to 64 years who participated in a cardiovascular risk-factor survey in 1982 or 1987. The following risk factors, determined at baseline, were included in data analyses: self-reported alcohol drinking, GGT, smoking, blood pressure, serum cholesterol, and body mass index. The cohorts were followed until the end of 1994. Stroke events were identified through the national death registry and hospital discharge registry by computerized record linkage.

RESULTS

Serum GGT concentration was associated with the risk of total and ischemic stroke in both genders. There was also a significant association among men between GGT and the risk of intracerebral hemorrhage and among women between GGT and the risk of subarachnoid hemorrhage. The relationships remained statistically significant also after adjustment for other risk factors. Self-reported alcohol drinking did not associate with any type of stroke.

CONCLUSIONS

These results support the hypothesis that excessive alcohol drinking is related to an increased risk of stroke. Biological markers of alcohol drinking, such as serum GGT level, are useful for the assessment of risks related to alcohol drinking.

Low density lipoprotein (LDL)-mediated suppression of Lewis lung carcinoma in hypercholesterolemic LDL receptor-deficient mice

An inverse relationship has been reported between cancer risk and cholesterol level, prompting the hypothesis that hypercholesterolemia may be protective against cancer. We tested this hypothesis by evaluating the growth of Lewis lung carcinoma in three different murine models of hypercholesterolemia: Pluronic treated mice, apolipoprotein E (ApoE) deficient mice, and low density lipoprotein receptor (LDL-R) deficient mice. Only the accumulation of LDL-cholesterol in LDL-R deficient mice suppressed tumor growth. Accumulation of chylomicrons, very low density lipoproteins (VLDL), and cholesterol-enriched remnants in the Pluronic treated mice and ApoE deficient mice did not inhibit tumor growth, even though mice in all three models were equally hypercholesterolemic. Taken together, the experimental evidence from our studies indicate that high plasma cholesterol in the form of LDL-cholesterol could have a beneficial effect against cancer in vivo.

Nutritional status in acute stroke: undernutrition versus overnutrition in different stroke subtypes

OBJECTIVES

Nutritional status in the acute stage of stroke has not been properly evaluated in different stroke subtypes. The objective of this study was to investigate the nutritional status of different subtypes of stroke patients.

SUBJECTS AND METHODS

We studied 88 female patients with first-ever strokes. Strokes were divided into cerebral infarction (CI, n=67) and intracerebral hemorrhage (ICH, n=21). We measured the nutritional status of the patients in the acute stage of stroke with the use of 8 parameters including 3 biochemical and 5 anthropometric ones. These variables were assessed in stroke patients and 120 age-matched controls, and were compared with each other.

RESULTS

In the acute stage of stroke, undernourishment was significantly (P=0.000) more prevalent in the ICH group (62%) than in the CI group (25%) or controls (13%). On the other hand obesity was present in 10%, 24% and 17% in patients with ICH, those with CI, and controls, respectively, which was not significantly different (P=0.461). Only abdominal skinfold thickness was significantly greater in patients with CI than in those with ICH or controls. Conclusions - Our results illustrate that undernourishment is prevalent in acute stroke patients, significantly more so in patients with ICH than in those with CI. Stroke patients, especially those with ICH, should receive special nutritional intervention starting immediately after admission.

Relationship between blood pressure and subcortical lesions in healthy elderly people

BACKGROUND AND PURPOSE

The relationship between blood pressure (BP) and heart rate (HR) and MRI assessments of subcortical T2 hyperintensities was evaluated in healthy elderly men and women.

METHODS

Casual and 24-hour ambulatory BPs and HR measurements were taken of 144 elderly individuals, aged 55 to 79 years. Subjects had no evidence of previous health disorders. MRI scans of white matter, subcortical gray matter, and insular subcortex were coded for severity of hyperintensities.

RESULTS

Mean casual BP for the group was 120/72 mm Hg. With age and sex accounted for, individuals with the highest severity rating of white matter hyperintensities had higher casual, awake, and sleep systolic BPs; higher awake diastolic BPs; greater awake systolic BP variability; and a smaller nocturnal fall in systolic and diastolic BPs than individuals with less severe ratings. Higher severity ratings for subcortical gray matter hyperintensities were associated with elevations in casual, awake, and asleep systolic BPs and a smaller HR drop during sleep. Subjects with higher ratings for the insular subcortex had higher systolic and diastolic BPs (casual, awake, and asleep), greater HR variability during sleep, and a smaller nocturnal fall in HR.

CONCLUSIONS

Casual and 24-hour ambulatory BPs and some ambulatory HR measures are associated with subcortical lesions of the brain. Longitudinal studies are needed to further explore the relationship between white matter lesions and cardiovascular measures, as well as the significance of these lesions for cerebrovascular disease in healthy elderly subjects.

Acute hypertension promotes hemorrhagic transformation in a rabbit embolic stroke model: effect of labetalol

We examined the relationship between acute hypertension following cerebral embolization and subsequent hemorrhagic transformation (HT) in a rabbit embolic stroke model. We have shown previously that the likelihood and severity of hemorrhage were significantly correlated with the magnitude of an acute hypertensive response to embolization. It was not clear, however, whether hypertension actually caused hemorrhage or was merely a marker of more severe stroke. In the current studies, we attempted to clarify the relationship between acute hypertension and HT by either pharmacologically inducing or attenuating the brief hypertensive response to embolization in rabbits. Under halothane anesthesia, two catheters were implanted in the right carotid arteries of male New Zealand white rabbits, one oriented toward the heart and one toward the brain. The animals were allowed to awaken and were embolized using blood clot emboli injected into the middle cerebral artery. Blood pressure was monitored via the second carotid catheter. In the first experiment, hypertension was induced with angiotensin II, administered at the time of embolization or 1 h later. In the second experiment, we attempted to attenuate the hypertensive response using intravenous labetalol. The animals were sacrificed 18 h after embolization and the brains evaluated for hemorrhage. In the first experiment, administration of angiotensin II immediately after embolization did not increase the hypertensive response to embolization further than that spontaneously occurring, and no angiotensin II-related HT was observed. In contrast, an additional angiotensin-II-induced hypertensive episode 1 h after embolization significantly increased the number of 5-mm serial brain sections displaying HT, from 3.0 +/- .3 (mean +/- SE) in Controls to 5.4 +/- .8 in treated animals. In the second experiment, administration of labetalol (15 mg/kg) significantly reduced the number of brain sections with visible HT, from 3.2 +/- .5 in controls to 1.6 +/- .4 in treated animals. Acute hypertension during the first hour after cerebral embolization promotes HT in this rabbit embolic stroke model. Labetalol prevents blood pressure elevation and reduces the extent of HT in the same model.

Stroke in children under 16 years of age. Clinical and etiological difference with adults

OBJECTIVES

The aim of this study was to re-evaluate the clinical features of stroke in children, their outcome and the place of the different mechanisms, in the light of CT-scan and magnetic resonance imaging.

METHODS

A 10-year review of the Dijon Childhood Neurology Clinic experience (1985-1995) identified 54 patients with arterial stroke. Diagnosis was established by CT-scan and angiography and by magnetic resonance imaging from 1987. When an hemorrhagic stroke was identified, a cerebral arteriogram and an investigation of the coagulation factors were performed. When an ischemic stroke was identified, the following tests were performed: an ultrasound examination of the cervical arteries, a cerebral arteriogram, a lumbar puncture, an investigation of the coagulation factors and lipid status, a measurement of homocystine in the plasma and the urine, an electrocardiogram, a Holter procedure and a cardiac echography.

RESULTS

During the 11 full calendar years of this study, we observed 54 stroke patients. There were 31 cases of ischemic stroke, representing some 57% of the total, as well as 23 cases of hemorrhagic stroke, representing 43% of the total. Of the 31 cases with ischemic stroke, 4 had no known predisposing condition, 6 occurred in children with pre-existing heart disease, 2 had moya-moya disease, 2 had leukemia, 2 had a carotid dissection, 1 had an hemolytic-uremic syndrome, and 14 were observed in patients with other associated conditions, such as infections (7 cases) or slight cranial trauma (7 cases). On CT-scan, a basal ganglia infarction was identified in 14 cases. Among the 23 hemorrhagic strokes, 9 were due to arteriovenous malformations, 2 to arterial aneurysm and 5 to cavernomas. Two cases occurred in hemophilia, 2 in idiopathic thrombocytopenic purpura, and 2 after throat infections. One case had no etiologic factor. Clinical course was marked by a low mortality rate even in hemorrhagic stroke, long-lasting seizures, and hemidystonia.

CONCLUSION

This neuro-imaging survey focused on the real place of hemorrhage and basal ganglia infarctions in children under 16 years of age, compared to adulthood. Follow-up demonstrated good or complete resolution of neurological deficits despite the frequent late hemidystonia and late epilepsy.

Low total serum cholesterol and intracerebral hemorrhagic stroke: is the association confined to elderly men? The Kaiser Permanente Medical Care Program

BACKGROUND AND PURPOSE

Epidemiological studies indicate a higher incidence of intracerebral (but not subarachnoid) hemorrhagic stroke among persons with low total serum cholesterol levels. This report further examines the prospective relationship of total serum cholesterol with subsequent intracerebral hemorrhage in a large, well-defined population.

METHODS

The cohort included 61756 enrollees in a health plan from the San Francisco-Oakland metropolitan area (46% men, 63% white), aged 40 to 89 years and free of cardiovascular disease at baseline. Sixteen-year incidence of combined nonfatal and fatal intracerebral hemorrhagic stroke (International Classification of Diseases [ICD], 8th revision, code 431, or ICD, 9th revision, codes 431 and 432) was investigated in relation to serum cholesterol measured in multiphasic health checkups made in 1977 through 1985. Intracerebral hemorrhagic events were ascertained using hospital discharge records and as underlying cause of death by the California Mortality Linkage Information System.

RESULTS

From 1978 through 1993 (average of 10.7 years), there were 386 events (201 in men, 29% fatal; 185 in women, 42% fatal). By multivariate proportional hazards life-table regression analysis, serum cholesterol level below the sex-specific 10th percentile (< 4.62 mmol/L [178 mg/dL] in men), compared with higher cholesterol level, was associated with a significantly increased risk of intracerebral hemorrhage in men aged 65 years or older (relative risk, 2.7; 95% confidence interval, 1.4 to 5.0). An excess risk was also observed among elderly women at the lowest cholesterol range, but a chance finding could not be ruled out. No relationship was seen among men or women aged 40 to 64, and no statistical interaction of low serum cholesterol with hypertension was found in either sex.

CONCLUSIONS

In these data, the association between low serum cholesterol level and intracerebral hemorrhage was confined to elderly men.

Cerebrovascular disease in children under 16 years of age in the city of Dijon, France: a study of incidence and clinical features from 1985 to 1993

Our motivation for undertaking the present survey was to determine the incidence, the distribution, and the clinical features of ischemic and hemorrhagic strokes in children under 16 years old, in a well-defined population-based study. The survey was carried out on the population of the City of Dijon (150,000 inhibitants) from January 1, 1985 to December 31, 1993, collecting prospectively both in adulthood and in childhood (23,877 resident children). Diagnosis of stroke was established on the basis of clinical features and the mechanism was identified by CT scan from 1985 to 1987, and by CT scan and magnetic resonance imaging from 1987 to 1993. When a hemorrhagic stroke was identified, a cerebral arteriogram and an investigation of the coagulation factors were performed. When an ischemic stroke was identified, the following were performed: an ultrasound examination of the cervical arteries, a cerebral arteriogram, a lumbar puncture, an investigation of the coagulation factors and lipid status, a measurement of homocysteine in the plasma and the urine, an electrocardiogram (EKG), a Holter procedure, and a cardiac echography. During the 9 full calendar years of this study we observed 28 stroke patients from a population of 23,877 resident children. There were 17 cases of ischemic stroke, representing some 61% percent of the total, as well as 11 cases of hemorrhagic stroke, 39% percent of the total. The average annual incidence rate was 13.02/100,000 for all strokes, 7.91/100,000 for ischemic strokes, and 5.11/100,000 for hemorrhagic strokes.(ABSTRACT TRUNCATED AT 250 WORDS)