Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial

BACKGROUND

Deep vein thrombosis (DVT) and pulmonary embolism are common after stroke. In small trials of patients undergoing surgery, graduated compression stockings (GCS) reduce the risk of DVT. National stroke guidelines extrapolating from these trials recommend their use in patients with stroke despite insufficient evidence. We assessed the effectiveness of thigh-length GCS to reduce DVT after stroke.

METHODS

In this outcome-blinded, randomised controlled trial, 2518 patients who were admitted to hospital within 1 week of an acute stroke and who were immobile were enrolled from 64 centres in the UK, Italy, and Australia. Patients were allocated via a central randomisation system to routine care plus thigh-length GCS (n=1256) or to routine care plus avoidance of GCS (n=1262). A technician who was blinded to treatment allocation undertook compression Doppler ultrasound of both legs at about 7-10 days and, when practical, again at 25-30 days after enrolment. The primary outcome was the occurrence of symptomatic or asymptomatic DVT in the popliteal or femoral veins. Analyses were by intention to treat. This study is registered, number ISRCTN28163533.

FINDINGS

All patients were included in the analyses. The primary outcome occurred in 126 (10.0%) patients allocated to thigh-length GCS and in 133 (10.5%) allocated to avoid GCS, resulting in a non-significant absolute reduction in risk of 0.5% (95% CI -1.9% to 2.9%). Skin breaks, ulcers, blisters, and skin necrosis were significantly more common in patients allocated to GCS than in those allocated to avoid their use (64 [5%] vs 16 [1%]; odds ratio 4.18, 95% CI 2.40-7.27).

INTERPRETATION

These data do not lend support to the use of thigh-length GCS in patients admitted to hospital with acute stroke. National guidelines for stroke might need to be revised on the basis of these results.

FUNDING

Medical Research Council (UK), Chief Scientist Office of Scottish Government, Chest Heart and Stroke Scotland, Tyco Healthcare (Covidien) USA, and UK Stroke Research Network.

The feminisation of British neurology: implications for workforce planning

As in other hospital specialties, an increasing proportion of neurology trainees are female. To predict the workforce implications it is necessary to determine what life choices future neurologists will make. A questionnaire survey of life choices was administered to neurology consultants and trainees, general medical senior house officers, and medical students. Of the 344 respondents, 3% of specialist registrars (SpRs) and 4.6% of consultants work part time. Eighty-seven per cent of female and 22% of male junior doctors plan to work part time for, on average, 7.5 and 1.5 years respectively. Thirty percent of consultants also plan to work part time. A number of SpRs (14.3%) and consultants (6%) have taken a career break while 37.5% of SpRs and 18.2% of consultants are planning a career break. The changing demands of both sexes will have a greater impact on the neurology workforce than the increasing proportion of women alone. Increased part-time working will require additional trainees to ensure service requirements are met.

Assessment of cerebral haemodynamics and vascular reserve in patients with symptomatic carotid artery occlusion: an integrated MR method

We describe an MR-based methodology designed to study cerebral haemodynamic compromise in patients with symptomatic carotid occlusions. We present the results of eight patients who underwent MR angiography of the cervical carotids and circle of Willis, MR imaging of the brain and dynamic gadolinium MR perfusion studies before and after the injection of the carbonic anhydrase inhibitor acetazolamide. All patients showed increased transit times in the symptomatic hemisphere at rest indicating reduced flow. The transit time asymmetries became more pronounced after acetazolamide in all patients because of failed vasodilatation on the affected side. There was an inverse correlation between the degree of increased transit time and the degree of collateralisation around the circle of Willis. We believe that demonstration of both macroscopic vascular anatomy and microvascular reserve is important when assessing patients with possible low-flow states and the described method is a robust means of obtaining that data.

Stroke management in Europe. Pan European Consensus Meeting on Stroke Management

Stroke is a leading cause of death and disability in Europe. Standards of care vary widely, and the introduction of simple standards will improve mortality and morbidity. It has been shown, in the absence of any medical treatment for acute stroke, that improving the organization of care for people with stroke significantly improves outcome. Recommendations are made for simple changes to the organization of care. Preventative measures after first stroke reduce incidence of subsequent stroke: these could be made widely available. Rehabilitation for those with persisting disability should be patient centred and commence immediately after the patient is alert and medically stable. Urgent research is required to find out which components of rehabilitation are important, and measures should be in place to ensure that all who require rehabilitation receive it from appropriately trained professionals. Population-based monitoring systems covering incidence, case fatality, mortality and disability should be put in place in all European Member States by the year 2005.

The Hillsborough tragedy

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Motor recovery following acute stroke

There is little information available from which normal patterns of recovery from acute stroke can be ascertained. Most attention has been directed towards functional recovery in stroke patients but the neurological basis on which this occurs needs to be documented in a large cohort of patients. One hundred and fifty-seven patients admitted to hospital with a clinical diagnosis of acute stroke were examined daily for up to 28 days to determine the patterns of recovery of limb tone, power and reflexes. Changes in these variables during the first 28 days after stroke are described.

Acetylcholine receptor antibody synthesis in lymphocyte cultures

The synthesis of immunoglobulin and acetylcholine receptor antibody by lymphocytes extracted from the peripheral blood and thymus of patients with myasthenia gravis was investigated using the Marbrook culture system. Small amounts of immunoglobulin were synthesised by thymic lymphocytes cultured in medium without mitogen for 14 days and acetylcholine receptor antibody activity was detectable in cultures from 3 out of 5 patients with thymic hyperplasia. Addition of Pokeweed mitogen to the cultures increased both IgG and acetylcholine receptor antibody synthesis and under these conditions receptor antibody activity was detectable in all 5 thymic lymphocyte cultures studied. Peripheral blood lymphocytes also produced small amounts of IgG when cultured in the absence of mitogen but acetylcholine receptor antibody levels were undetectable. In the presence of Pokeweed mitogen, however, peripheral blood lymphocytes synthesised increased amounts of IgG and acetylcholine receptor antibody activity was detectable in cultures of lymphocytes from 3 out of 4 patients. The amount of acetylcholine receptor antibody per microgram IgG, the specific activity, was greater in cultures of thymic lymphocytes than the specific activity of IgG in serum, suggesting that the hyperplastic thymus may be a major site of acetylcholine receptor antibody synthesis. Therefore it should be possible to use the culture system described to investigate the processes involved in the breakdown of self-tolerance in myasthenia gravis.

Effect of anticonvulsant drugs on urinary excretion of gamma-glutamyl transferase in women

Excretion of gamma-glutamyl transferase was found to be significantly higher in a group of epileptic patients on long-term anticonvulsant therapy than in normal subjects. The losses, which may reflect renal enzyme induction, were unrelated to drug dose or duration of therapy and were significantly lower than those found in normal healthy pregnant women at term.