Novel Pyridazin-3(2H)-one-Based Guanidine Derivatives as Potential DNA Minor Groove Binders with Anticancer Activity

Novel aryl guanidinium analogues containing the pyridazin-3(2H)-one core were proposed as minor groove binders (MGBs) with the support of molecular docking studies. The target dicationic or monocationic compounds, which show the guanidium group at different positions of the pyridazinone moiety, were synthesized using the corresponding silyl-protected pyridazinones as key intermediates. Pyridazinone scaffolds were converted into the adequate bromoalkyl derivatives, which by reaction with N,N'-di-Boc-protected guanidine followed by acid hydrolysis provided the hydrochloride salts 1-14 in good yields. The ability of new pyridazin-3(2H)-one-based guanidines as DNA binders was studied by means of DNA UV-thermal denaturation experiments. Their antiproliferative activity was also explored in three cancer cell lines (NCI-H460, A2780, and MCF-7). Compounds 1-4 with a bis-guanidinium structure display a weak DNA binding affinity and exhibit a reasonable cellular viability inhibition percentage in the three cancer cell lines studied.

Pyridazinones containing dithiocarbamoyl moieties as a new class of selective MAO-B inhibitors

A novel class of potential MAO-B inhibitors was designed and synthesized in good yield by combining the pyridazinone moiety with the dithiocarbamate framework, two relevant pharmacophores for drug discovery. The biological results obtained for the different pyridazinone/dithiocarbamate hybrids (compounds 8-14) indicated that most of them reversibly and selectively inhibit the hMAO-B in vitro with IC₅₀ values in the µM range and exhibit not significant cellular toxicity. The analogues 9a₁, 11a₁, 12a₂, 12b₁ and 12b₂, which present the dithiocarbamate fragment derivatized with a piperidin-1-yl or pyrrolidin-1-yl group and placed at C3 or C4 of the diazine ring, were the most attractive compounds of these series. Molecular modeling studies were performed to analyze the binding mode to the enzyme and the structure activity relationships of the titled compounds, as well as to predict their drug-like properties.

Synthesis, biological evaluation and molecular modeling studies of phthalazin-1(2H)-one derivatives as novel cholinesterase inhibitors

A series of donepezil analogues based on phthalazin-1(2H)-one scaffold was studied as hChEIs. The biological results revealed that the structural modifications proposed significantly affected ChE inhibitory potency as well as selectivity AChE/BuChE.

Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit of a reference hospital

OBJECTIVE

To analyze whether the application of Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit (ICU) of a reference hospital.

DESIGN

Observational study with pre and post intervention analysis.

SETTING

ICU of a reference hospital.

PATIENTS

We design projects and a value stream map of flow and compared pre and post intervention.

INTERVENTIONS

We recorded demographic data, patient transfers by EMS for lack of beds and delay times in the discharge from ICU to ward. Multidisciplinary meetings and perform daily visual panel, with high priority ICU discharge. We promote temporary relocation of critically ill patients in other special areas of the hospital. We performed a professional satisfaction questionnaire with pre and post implementation of process. We make a statistical analysis of pre and post-intervention comparisons.

RESULTS

We planned for 2013 and progressively implemented in 2014. Analysis of patients entering the critical process flow 1) evaluate patients who must transfer for lack of beds, focusing on a diagnosis: pre 10/22 vs. 3/21 post (P=.045); 2) analysis of time delay in the discharge from the ICU to ward: 360.8±163.9minutes in the first period vs. 276.7±149.5 in the second (P=.036); and 3) personal professional satisfaction questionnaire, with 6.6±1.5 points pre vs. 7.5±1.1 in post (P=.001). Analysis of indicators such as the ICU acquired infections, length of ICU stay, the rate of re-admissions and mortality, with no significant differences between the two periods.

CONCLUSIONS

The application of Lean techniques in the critically ill process had a positive impact on improving patient flow within the health region, noting a decrease of transfers outside the region due to lack of beds, reduced delayed discharge from ICU to conventional ward and increased satisfaction of ICU professionals.

4-[(tert-Butyl-diphenyl-sil-yloxy)meth-yl]pyridazin-3(2H)-one

In the title compound, C₂₁H₂₄N₂O₂Si, the carbonyl group of the heterocyclic ring and the O atom of the silyl ether group are placed toward opposite sides and the tert-butyl and pyridazinone moieties are anti-oriented across the Si—O bond [torsion angle = −168.44 (19)°]. In the crystal, mol­ecules are assembled into inversion dimers through co-operative N—H⋯O hydrogen bonds between the NH groups and O atoms of the pyridazinone rings of neighbouring mol­ecules. The dimers are linked by π–π inter­actions involving adjacent pyridazinone rings [centroid–centroid distance = 3.8095 (19) Å], generating ladder-like chains along the b-axis direction. The chains are further linked into a two-dimensional network parallel to the ab plane through weak C—H⋯π inter­actions.

5-[(tert-Butyl-diphenyl-sil-yloxy)meth-yl]pyridazin-3(2H)-one

In the title compound, C₂₁H₂₄N₂O₂Si, a new pyridazin-3(2H)-one derivative, the carbonyl group of the heterocyclic ring and the O atom of the silyl ether are located on the same side of the pyridazinone ring and the C—C—O—Si torsion angle is −140.69 (17)°. In the crystal, mol­ecules are linked by pairs of strong N—H⋯O hydrogen bonds into centrosymmetric dimers with graph-set notation R₂²(8). Weak C—H⋯π inter­actions are also observed.

Body mass index classification misses subjects with increased cardiometabolic risk factors related to elevated adiposity

CONTEXT

Body mass index (BMI) is widely used as a measure of overweight and obesity, but underestimates the prevalence of both conditions, defined as an excess of body fat.

OBJECTIVE

We assessed the degree of misclassification on the diagnosis of obesity using BMI as compared with direct body fat percentage (BF%) determination and compared the cardiovascular and metabolic risk of non-obese and obese BMI-classified subjects with similar BF%.

DESIGN

We performed a cross-sectional study.

SUBJECTS

A total of 6123 (924 lean, 1637 overweight and 3562 obese classified according to BMI) Caucasian subjects (69% females), aged 18-80 years.

METHODS

BMI, BF% determined by air displacement plethysmography and well-established blood markers of insulin sensitivity, lipid profile and cardiovascular risk were measured.

RESULTS

We found that 29% of subjects classified as lean and 80% of individuals classified as overweight according to BMI had a BF% within the obesity range. Importantly, the levels of cardiometabolic risk factors, such as C-reactive protein, were higher in lean and overweight BMI-classified subjects with BF% within the obesity range (men 4.3 ± 9.2, women 4.9 ± 19.5 mg l(-1)) as well as in obese BMI-classified individuals (men 4.2 ± 5.5, women 5.1 ± 13.2 mg l(-1)) compared with lean volunteers with normal body fat amounts (men 0.9 ± 0.5, women 2.1 ± 2.6 mg l(-1); P<0.001 for both genders).

CONCLUSION

Given the elevated concentrations of cardiometabolic risk factors reported herein in non-obese individuals according to BMI but obese based on body fat, the inclusion of body composition measurements together with morbidity evaluation in the routine medical practice both for the diagnosis and the decision-making for instauration of the most appropriate treatment of obesity is desirable.

[Therapeutic use and profile of toxicity of the FOLFOX4 regimen]

INTRODUCTION

Since the publication of the MOSAIC test results in 2004, the FOLFOX4 regimen has been established as an adjuvant treatment which is recommended in stage III colorectal cancer. The aim of this study is to assess the use of this regimen in our field and to describe its toxicity.

METHODS

Descriptive study of treatments with FOLFOX4 prescribed between April 2005 and March 2007. The data was obtained from the Farhos Oncología programme and clinical records. The following data was collected: age, gender, diagnosis, stage of the illness (TNM classification) and adverse reactions, expressing severity according to Common Toxicity Criteria 2.0.

RESULTS

The FOLFOX4 regimen was prescribed for 39 patients (24 men and 15 women) with an average age of 59. The diagnoses were: 28 colon cancer (4 stage II, 17 stage III, and 7 stage IV), 10 rectal cancer (1 stage II, 4 stage III, and 5 stage IV) and 1 stage IV gastric cancer. The most frequent adverse reactions were peripheral neuropathy (82 %), neutropenia (56.4 %) and diarrhoea (53.9 %.) When the study was completed, 9 patients continued active treatment with the regimen (average 6.8 cycles.) Of the 30 remaining patients only 16 people completed the 12 planned cycles. 14 patients stopped their treatment (an average of 8.1 cycles) due to toxicity in 10 cases, clinical progression in 3 cases and one patient died. Of the total 368 cycles administered, 68 suffered administration delays and 22 had the dosage reduced.

CONCLUSION

The use of the FOLFOX4 regimen has been adjusted to uses with some solid scientific evidence, but its toxicity has limited its use and has made administering the planned dosage levels difficult.

[Diffusion-weighted magnetic resonance in deep cerebral venous thrombosis]

Changes in the apparent diffusion coefficient (ADC) are well established in acute ischemic stroke of arterial origin. However, ADC behaviour and its prognostic significance in cerebral venous thrombosis (CVT) are not fully understood. Diffusion-weighted imaging (DWI) findings in a 34-year old woman with deep cerebral venous thrombosis are described. Recent literature concerning DWI and cerebral venous thrombosis is also reviewed. A MRI performed within 7 hours from onset revealed hyperintensities in deep grey matter bilaterally (FLAIR/T2), without changes in ADC maps, suggesting vasogenic edema. After anticoagulation a new MRA disclosed complete recanalization of venous thrombosis. Despite her good clinical outcome the MRI showed hemorrhagic lesions suggesting venous infarct. Lesions detected in acute CVT with DWI may have normal ADC values. There is no good correlation between the acute ADC values and clinical and radiological evolution. The prognostic value of ADC in the acute phase of CVT remains unsettled.

alpha(1)-antichymotrypsin polymorphism: a risk factor for hemorrhagic stroke in normotensive subjects

BACKGROUND AND PURPOSE

Although genetic factors may be important in the pathogenesis of ischemic stroke (IS), little is known on the potential role of genes in most cases of hemorrhagic stroke (HS). Preliminary data showed that the TT genotype of the alpha(1)-antichymotrypsin (ACT) gene polymorphism was associated with HS, although it remained unsettled whether prevalence of this polymorphism might differ between hypertensive and normotensive HS.

METHODS

Ninety-nine patients with HS, 182 patients with IS (symptomatic control subjects), and 80 asymptomatic control subjects were genotyped for the ACT polymorphism using polymerase chain reaction amplification. Chronic hypertension was recorded in 66 patients with HS.

RESULTS

The ACT-TT genotype was more prevalent in patients than in asymptomatic or symptomatic control subjects: 26%, 15%, and 16%, respectively. The ACT-TT genotype was obtained in 33% of HS who lacked arterial hypertension (P<0.05). After adjustment for age, gender, and vascular risk factors, the ACT-TT genotype remained independently associated with HS (OR 2.80, 95% CI 1.19 to 6.58, compared with asymptomatic control subjects; OR 1.79, 95% CI 0.95 to 3.40, compared with symptomatic control subjects). In analyses restricted to HS in normotensive patients, the ORs were 3.10 (95% CI 1.10 to 8.68) and 2.53 (95% CI 1.04 to 6.18), respectively.

CONCLUSIONS

These findings confirm in a larger series of patients the association between the ACT-TT genotype and HS. This polymorphism is more prevalent in normotensive bleedings. Pathological studies will be required to establish whether the ACT-TT genotype facilitates proteolytic rupture of vessels that harbor amyloidotic changes or another form of nonhypertensive cerebral angiopathy.

Proinflammatory cytokines and early neurological worsening in ischemic stroke

BACKGROUND AND PURPOSE

The mechanisms for clinical deterioration in patients with ischemic stroke are not completely understood. Several proinflammatory cytokines are released early after the onset of brain ischemia, but it is unknown whether inflammation predisposes to neurological deterioration. We assessed the implication of interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha in early neurological worsening in ischemic stroke.

METHODS

Two hundred thirty-one patients consecutively admitted with first-ever ischemic cerebral infarction within the first 24 hours from onset were included. Neurological worsening was defined when the Canadian Stroke Scale (CSS) score fell at least 1 point during the first 48 hours after admission. IL-6 and TNF-alpha were determined in plasma and cerebrospinal fluid (CSF; n=81) obtained on admission.

RESULTS

Eighty-three patients (35.9%) deteriorated within the first 48 hours. IL-6 in plasma (>21.5 pg/mL; OR 37.7, CI 11.9 to 118.8) or in CSF (>6.3 pg/mL; OR 13.1, CI 2.2 to 77.3) were independent factors for early clinical worsening, with multiple logistic regression. The association was statistically significant in all ischemic stroke subtypes as well as in subjects with cortical or subcortical infarctions. IL-6 in plasma was highly correlated with body temperature, glucose, fibrinogen, and infarct volume. CSF and plasma concentrations of TNF-alpha were also higher in patients who deteriorated, but the differences observed did not remain significant on multivariate analysis.

CONCLUSIONS

In addition to participating in the acute-phase response that follows focal cerebral ischemia, IL-6 levels on admission are associated with early clinical deterioration. The association between IL-6 and early neurological worsening prevails without regard to the initial size, topography, or mechanism of the ischemic infarction.

Alpha(1)-antichymotrypsin gene polymorphism in patients with stroke

BACKGROUND AND PURPOSE

A role for proteolytic enzymes has been suggested in the pathogenesis of stroke. In a search for new genetic factors, we investigated the gene polymorphism of the serine protease inhibitor alpha(1)-antichymotrypsin (ACT) in patients with stroke.

METHODS

Two hundred twenty patients with acute ischemic stroke (n=182) and primary intracerebral hemorrhage (n=38) and 70 control subjects without clinical cerebrovascular disease were genotyped for the ACT polymorphism.

RESULTS

The ACT-TT genotype was more frequent in patients with primary intracerebral hemorrhage than in patients with ischemic stroke (31.6% versus 16.4%, P:<0.05) or in control subjects (21.4%, P:=0.1). After adjusting for age, gender, and vascular risk factors, the ACT-TT genotype was associated with primary intracerebral hemorrhage, with an OR of 2.3 (95% CI 1.0 to 5. 2) compared with ischemic stroke and an OR of 1.8 (95% CI 0.85 to 9. 65) compared with controls.

CONCLUSIONS

Pending confirmation in a larger study, our results suggest that the ACT-TT genotype might be a risk factor for primary cerebral hemorrhage.

Comparison of the acute-phase response in patients with ischemic stroke treated with high-dose heparin or aspirin

Experimental studies have suggested that unfractionated heparin (UH) has antiinflammatory properties. It is unknown whether UH also has these properties in patients with acute ischemic stroke. Within 12-24 h of treatment onset we measured the acute-phase response as reflected by the erythrocyte sedimentation rate (ESR) and total number of leukocytes (x10(9)/l) in 706 consecutive patients with acute ischemic stroke treated with full-dose UH (n=450), or 300 mg/day aspirin (n=256). Clinical outcome (Mathew scale) at hospital discharge and the effect of factors such as treatment (UH and aspirin), and acute phase response were assessed using multivariate analyses adjusted for baseline confounders and incident complications. Separate models were created for patients with lacunar and nonlacunar stroke. Whereas there were not differences at baseline between the two treatment groups, total leukocyte counts (8. 0+/-4.1 vs. 8.6+/-3.2, P<0.01) and ESR (21.7+/-20.9 vs. 25.2+/-22.9, P<0.05) were statistically significantly lower in patients treated with UH. This effect of UH was more accentuated in patients with nonlacunar stroke. Overall, leukocytes (7.2+/-2.3 vs. 8.4+/-4.0, P<0. 01), and ESR (15.7+/-17.2 vs. 24.3+/-22.2, P=0.0001) were lower in patients with complete early recovery and this effect was restricted to patients with nonlacunar stroke. Whereas baseline impairment, symptomatic bleeding and stroke recurrence were independent negative outcome predictors, the use of UH was positively associated with early recovery in all patients. This study shows that full-dose UH reduces the acute-phase reaction that follows ischemic stroke more effectively than aspirin. The prognostic implications of such effect seem more notable in patients with nonlacunar stroke.

Meningitis caused by Pseudallescheria boydii treated with voriconazole

Meningitis caused by Pseudallescheria boydii is an uncommon infection of the CNS that usually has a poor prognosis and a difficult treatment. We describe a case of chronic meningitis caused by P. boydii in an immunocompetent host that was successfully treated with voriconazole, a new antifungal agent.

Interaction between interleukin-6 and the natural anticoagulant system in acute stroke

Inflammatory reactions mediated by cytokines are involved in the pathogenesis of acute stroke. Decrease in circulating levels of protein C (PC) and protein S (PS) induced by inflammatory cytokines has been postulated as a potential mechanism for a procoagulant tendency during acute stroke. The procoagulant state associated with impairments in natural anticoagulants may induce microvascular obstruction leading to a tissue perfusion reduction that worsens cerebral ischemia. Interleukin-6 (IL-6) regulate the synthesis of C4b-binding protein (C4BP), an acute-phase protein that also regulates PS plasma levels. We measured IL-6, C4BP, erythrocyte sedimentation rate (ESR), total and free PS and PC in 44 patients with acute ischemic stroke to determine if IL-6 decreases circulating levels of natural anticoagulants through the C4BP pathway and if these acute changes in natural anticoagulants may have clinical implications. Patients with higher levels of IL-6 had more severe neurologic deficits on admission, greater infarct size, higher levels of acute-phase reactants, and lower levels of free PS. IL-6 was significantly correlated with C4BP, ESR, and free PS levels. PC levels were also lower in the group of patients with greater IL-6, but differences were not statistically significant. No correlations were found between C4BP and natural anticoagulants. Severe neurologic deficit, greater infarct volume, atrial fibrillation, increased levels of inflammatory parameters (ESR and IL-6), and reduced levels of free PS were associated with disabling stroke at 3 months, but only neurologic severity and ESR remained as independent predictors of stroke disability on multiple regression analysis. Inflammatory reactions mediated by IL-6 during the acute phase of stroke influence the modulation of free PS. However, variations in free PS levels do not have implications for clinical outcome in stroke patients. The link between proinflammatory cytokines and free PS in the acute phase of stroke is not related to the C4BP pathway.

Ex vivo response to aspirin differs in stroke patients with single or recurrent events: a pilot study

The dose of aspirin for secondary stroke prevention and the clinical meaning of ex vivo platelet abnormalities are debated. We assessed prospectively 39 noncardioembolic stroke patients in which 300 mg/day aspirin had proved effective (n=24) or ineffective (n=15) to prevent recurrent ischemic events. We evaluated platelet aggregation induced by arachidonic acid, adenosine diphosphate and epinephrine, and the sensitivity of platelets to increasing concentrations of the synthetic thromboxane mimetic U46619. Aggregation studies were repeated while subjects received 300 (study phase 1), and 600 (study phase 2) mg/day aspirin, respectively. Overall, arachidonic acid-induced platelet aggregation was less effectively inhibited during study phase 1 compared to phase 2. Arachidonic acid and epinephrine promoted a stronger platelet aggregation in aspirin nonresponders than in aspirin responders while taking 300 mg/day aspirin. On the other hand, 600 mg/day effectively inhibited platelet function in both clinical groups. A lower sensitivity to thromboxane receptors was also found during phase 1 of the study, although the response was similar between aspirin responders and nonresponders. This pilot study suggests that 300 mg/day aspirin is less effective than 600 mg/day to block the cyclooxygenase pathway in noncardioembolic stroke and, incomplete cyclooxygenase inhibition is associated with recurrent thromboembolic events despite adequate aspirin compliance. It is likely that patients could receive a more efficacious stroke prevention if the dose of aspirin is tailored to individual needs as reflected by laboratory findings.

Polymorphonuclear leukocyte elastase in patients with stroke

INTRODUCTION/OBJECTIVES

Polymorphonuclear leukocytes (PMNL) are involved in the pathogenesis of acute cerebral ischemia and atherosclerosis. Elastase is one of the proteolytic enzymes released by activated PMNL. We evaluated whether plasma levels of elastase-inhibitor complexes (EIC) are related to acute cerebral damage or with extension of carotid atherosclerosis in patients with stroke.

METHODS

Plasma levels of EIC were determined in 44 patients during acute and chronic phases of stroke. We recorded in all patients vascular risk factors, clinical severity on admission, infarct volume, and extension of carotid atherosclerosis using B-mode ultrasound exam.

RESULTS

EIC levels were not different between acute and chronic phases of stroke. Eleven patients (25%) had increased values of EIC. On multiple regression analysis diabetes, dislipemia, and coronary disease were predictors of abnormal EIC levels. EIC levels were not related to neurological severity on admission, infarct volume, or carotid atherosclerosis.

CONCLUSION

EIC levels in stroke patients are associated to the presence of vascular risk factors and may reflect cellular inflammatory aspects of chronic vessel disease. However, whether elastase contributes to the development of carotid atherosclerosis in patients with stroke remains unknown.

Heparin in acute stroke with atrial fibrillation: clinical relevance of very early treatment

BACKGROUND

The risk-benefit ratio of early vs late heparinization for acute stroke with nonvalvular atrial fibrillation remains unsettled.

OBJECTIVE

To clarify the relationship between timing to heparinization and functional outcome in acute cardioembolic stroke.

DESIGN

Consecutive case series.

SETTING

Referral center.

PATIENTS

In 231 patients with stroke and nonvalvular atrial fibrillation, intravenous or subcutaneous heparin administered with the goal of achieving an activated partial thromboplastin time (APTT) 1.5 to 2.0 times control values. Delay to the initiation of heparin therapy was less than 6 hours from the onset of symptoms in 74 patients and between 6 and 48 hours in 157 patients. Functional outcome (Rankin scale) was assessed 9 +/- 3 (mean +/- SD) days from stroke onset using multivariate analysis and including in the model treatment delay, risk factors (eg, age, hypertension, diabetes, hypercholesterolemia, previous stroke, and heart disease), initial neurological severity, and baseline computed tomographic findings (eg, early signs of infarction and white matter abnormalities). Clinical symptoms on admission (Mathew score) and baseline radiological findings were evaluated in all subjects. The bleeding rate was assessed on subsequent computed tomographic (CT) scans (obtained 7 +/- 2 days after stroke). The relationship between APTT ratios and stroke recurrence or hemorrhagic worsening was also tested.

MAIN OUTCOME MEASURES

Functional outcome at hospital discharge and incidence of early recurrent strokes and bleeding complications.

RESULTS

Mortality (9%), hemorrhagic worsening (3.4%), and early stroke recurrence (2.1%) occurred in the hospital. Complete recovery was associated with age younger than 70 years (odds ratio [OR], 0.21; 95% confidence interval [CI], 0.05-0.70), a baseline Mathew score higher than 74 (OR, 11.5; 95% CI, 4.95-26.70), normal baseline CT findings (OR, 8.86; CI, 3.99-19.60), and early heparinization (OR, 1.7; 95% CI, 1.10-2.50). Targeted APTT ratios were achieved at 24 hours in fewer than 50% of patients. Whereas stroke recurrence was associated with lower mean APTT ratios, higher mean APTT ratios were observed in patients with symptomatic bleeding, especially on the day of bleeding. Age, admission stroke severity, blood pressure, and baseline CT findings did not predict hemorrhagic worsening.

CONCLUSIONS

Delaying anticoagulation in alert patients with stroke and nonvalvular atrial fibrillation is not endorsed by the initial severity of symptoms or the early signs of infarction on CT scan. Functional recovery is improved the sooner heparin is administered. These findings suggest that heparin also has therapeutic properties. However, close APTT monitoring is warranted to lessen the incidence of untoward complications.

[Heparin in acute cerebral ischemia]

Non fractionated heparin is used in neurovascular disease because of its antithrombolytic action. Therefore, the design of the clinical studies performed to date has emphasized these actions. However, the results obtained in the most recent clinical studies have been discouraging, not only because they have demonstrated its lack of efficacy, but also because the use of this heparin has been followed by an excessive number of complications. This article provides critical comments on the possible causes of these results and underlines the most recent advances obtained in the knowledge of the mechanism of action of this drug. Particularly, its potential antiinflammatory role is emphasized as are the experimental requisites required for this antiinflammatory action to be fully expressed. Based on the results shown it is concluded that it is necessary to prospectively evaluate the role of heparin in acute ischemic ictus.

Cytokine-induced inflammation and long-term stroke functional outcome

Inflammatory reactions are involved in the pathogenesis of cerebral ischemia. Cytokines exacerbate brain ischemic injury by several mechanisms and they activate the synthesis of acute-phase reactants. We evaluated the association between cytokine-induced inflammation and functional outcome in 41 patients with acute ischemic stroke. Blood samples for interleukin-1 receptor antagonist (IL-1ra), erythrocyte sedimentation rate (ESR), c-reactive protein (CRP) and polymorphonuclear leukocyte (PMNL) count were taken within 48 h from stroke onset. Functional outcome was assessed at six months with the Modified Rankin Scale. Patients with a Rankin score > or = 3 were classified as dependent outcome. The effect of inflammatory variables on outcome was analyzed by logistic regression. Mathew score <75 on admission, atrial fibrillation, non-lacunar infarct size, ESR>13 mm/h in men or >20 mm/h in women, PMNL count >8 x 10(9)/l, CRP>0.8 mg/dl and IL-1ra>500 pg/ml were associated with dependent outcome. On multiple logistic regression, severe stroke on admission, non-lacunar infarct size and ESR remain in the predictive model of outcome with a sensitivity and specificity of 76 and 80%, respectively. This study suggests that in addition to clinical evaluation and neuroimaging, measurement of ESR may be useful for the early detection of stroke patients with poor long-term functional outcome.

Blood pressure and functional recovery in acute ischemic stroke

BACKGROUND AND PURPOSE

The relevance of elevated blood pressure in acute ischemic stroke and its most appropriate management are unresolved. We aimed to evaluate the rate of functional recovery with relation to early blood pressure management in patients with ischemic stroke.

METHODS

Four hundred eighty-one consecutive ischemic stroke patients were admitted to the Neurology Service within 20.9+/-10.5 hours of symptoms onset as part of the Barcelona Downtown Stroke Registry, including 235 patients who received oral antihypertensive agents within <24 hours after stroke onset. Demographic, clinical (Mathew scale), and CT scan findings were collected prospectively. Mean arterial pressure (MAP) was recorded before hospital arrival and at 7 AM on days 1, 2, and 7 of hospitalization. The primary end point was complete functional recovery at day 7 defined as a score of 0 to 1 on the modified Rankin scale.

RESULTS

Two hundred fifty-two patients achieved complete recovery on day 7. Using logistic regression, independent predictors of complete recovery included mild impairment at stroke presentation, lack of history of hypertension, and absence of brain edema on CT scan. Also, a 20% to 30% drop in MAP on day 2 after stroke onset almost tripled the odds of full recovery (odds ratio, 2.9; 95% CI, 1.3 to 6.3). MAP tended to normalize after stroke in all subjects, more rapidly if hypotensive agents were administered. Brain edema was also less frequent in patients with a greater drop in blood pressure. Despite the fact that a drop in MAP >30% from baseline was observed in 49 patients, this preceded worsening stroke in only 4 patients. Conversely, worsening stroke occurred in 51 patients despite stable blood pressure.

CONCLUSIONS

These results suggest that complete recovery in ischemic stroke is facilitated by a moderate blood pressure reduction when brain edema develops, most likely as the result of a more adequate cerebral perfusion pressure. Conversely, stroke worsening due to pharmacological hypoperfusion is exceptional.

[Plasma homocysteine levels in patients with ischemic cerebral infarction]

BACKGROUND

Moderate hyperhomocysteinemia is an independent risk factor for stroke. The relationship between homocysteinemia and stroke and its related factors are unknown in Spain.

PATIENTS AND METHODS

We determined plasma homocysteine concentrations in 80 stroke patients and in 48 control subjects without vascular risk factors. Folate, vitamin B12 and creatinine concentrations were also measured in stroke patients.

RESULTS

Total plasma homocysteine concentrations were higher in stroke patients compared to controls (11.2 [SD 3.2] mumol/l versus 8.1 [2.6] mumol/l; p < 0.001). Hyperhomocysteinemia was present in 20% of patients and in 2.2% of controls (odds ratio [OR] = 5.75; 95% CI = 1.24-53.4; p < 0.01). Homocysteine values were related to vitamin B12 (r = 0.28; p < 0.05) and creatinine concentrations (r = 0.24; p < 0.05). Multiple regression analysis showed that about 15% of the variation in plasma homocysteine concentrations could be predicted by the values of vitamin B12 (p < 0.001) and creatinine (p < 0.05). Homocysteine values were unrelated to age, sex, folate concentrations, atherosclerotic subtype or to the presence of vascular risk factors.

CONCLUSIONS

Moderate hyperhomocysteinemia was present in about 20% of stroke patients in our series. Homocysteine plasma level was not related with other stroke risk factors or with the atherosclerotic subtype of stroke, but it was partially related with the renal function parameters and the serum levels of vitamin B12.

Sympathetic skin response in patients with lateral medullary syndrome

We have carried out a prospective study of the sympathetic skin response (SSR) in 21 patients with lateral medullary syndrome (LMS), with the aim of identifying the most common pattern of SSR abnormalities and its possible correlation with clinical and radiological findings. The amplitude of the SSR recorded in the ipsilateral hand to the infarct was abnormally reduced in the patients as a group. However, using different stimulation and recording sites, and considering only the presence or absence of the response, we identified 5 different patterns of SSR abnormalities: 1. Normal responses; 2. Bilaterally absent responses to stimulation of the ipsilateral supraorbital nerve but not to other stimulation sites; 3. Absent responses in the side ipsilateral to the stroke, with normal responses in the contralateral side; 4. A combination of patterns 2 and 3; and 5. Absent responses to all stimuli. All patients with ipsilateral facial sensory loss had absent SSR to ipsilateral supraorbital nerve stimulation, while there was only a positive correlation between abnormal contralateral facial sensation and preservation of the SSR (Fisher's exact test P=0.003). No correlation was found between the pattern of SSR abnormalities and the infarct topography, assessed with the MRI. Our findings suggest that the damage to the SSR circuits of patients with LMS is not uniform, and follows an heterogeneous distribution independent from the MRI findings, and poorly related to the clinical sensory manifestations.

Ballistic movements due to ischemic infarcts after intravenous heroin overdose: report of two cases

Stroke is an infrequent but recognized complication of heroin addiction. Two heroin addicts, aged 34 and 19 years, developed ballistic movements after intravenous heroin overdose. Patient 1 presented bilateral ballism 1 week after intravenous heroin injection. Magnetic resonance imaging (MRI) showed bilateral ischemic lesions of the globus pallidus, suggesting a generalized cerebral hypoxia during the comatose state as pathogenic mechanism. Patient 2 presented an acute left hemiballismus when consciousness was restored with naloxone. MRI demonstrated an ischemic infarct in the right striatum. An embolic mechanism of stroke was suspected in this patient, considering the normal results of blood analysis, echocardiogram and cerebral arteriograms. Ballistic movements ceased after administration of haloperidol; both patients remained without abnormal movements thereafter.

[Factors associated to aspirin failure for secondary stroke prevention]

BACKGROUND

It is not settled whether aspirin (ASA) failure may be predicted in stroke and transient ischemic attack (TIA) patients. The risk of ASA failure may be predicted by analyzing the epidemiological traits of patients with stroke or TIA.

PATIENTS AND METHODS

We evaluated retrospectively 695 stroke or TIA patients admitted to the Downtown Barcelona Stroke Registry, including 54 patients who recurred while on 125-500 mg/day of ASA (group ASA failure), and 178 patients who showed a good clinical response to the same dose of ASA for at least one year of follow-up (group ASA sensitive). Vascular risk factors, stroke subtypes, and clinical and radiological findings were compared in both groups.

RESULTS

On multivariate analysis ASA failure was independently correlated with history of myocardial infarction, nonvalvular atrial fibrillation or hypercholesterolemia. A trend toward age older than 65 was also correlated with ASA failure. On the contrary, periventricular lucencies were a protector factor. Stroke severity at clinical onset and at follow-up was unrelated to the intake of ASA at stroke onset.

CONCLUSIONS

Males or females older than 65 years, with a history of coronary heart disease or atrial fibrillation, serum cholesterol level > 240 mg/dl, and a CT scan showing no evidence of small vessel disease are, respectively, the characteristics most frequently encountered in patients who suffer an ischemic stroke despite preventive treatment with 125-500 mg/day of ASA. Moreover, this treatment does not reduce initial and long-term stroke severity.

Periventricular white matter lucencies in patients with lacunar stroke. A marker of too high or too low blood pressure?

BACKGROUND

Periventricular white matter lucencies (PWML) have been described in stroke patients with arterial hypertension, hypotensive episodes, or increased nocturnal fall of blood pressure (BP). As a result of these mixed factors, the relationship between PWML and BP remains unsettled and the appropriate management of arterial BP in stroke patients with PWML is unknown.

OBJECTIVE

To clarify the relationship between PWML, arterial BP, and cerebral hemodynamics.

DESIGN

Cohort study followed up 6 months after index stroke.

SETTING

Referral center.

PATIENTS

In 41 consecutive patients with first-ever lacunar infarction, the extent of PWML detected on brain magnetic resonance images was measured. Six months after stroke, BP values were monitored during a 24-hour period and transcranial Doppler examinations were performed at rest and following the administration of acetazolamide.

MAIN OUTCOME MEASURES

Correlation of cerebral hemodynamics and BP values with the extent of PWML.

RESULTS

The severity of PWML varied substantially among patients, suggesting that PWML and lacunar infarctions could be due to several different mechanisms. Older age, elevated awake systolic BP, increased cerebrovascular tone, and the interaction between history of heart disease and the lowest heart rate were the strongest independent predictors of the severity of PWML. Diastolic BP and the vasodilatory capacity of the resistance vessels did not predict the severity of PWML.

CONCLUSIONS

Overall, PWML are markers of systolic damage in older lacunar stroke patients with stiffer arteries. In addition, hemodynamic failure may be relevant in patients with concomitant heart disease.

Cervical and facial myoclonus associated with dolichoectasia of the left vertebral artery

A 52-year-old man presented with rapid jerking movements of his head to the right and clonic involuntary twitches involving his left eyelid and cheek. Electromyographic (EMG) recordings were consistent with left sternocleidomastoid and facial asynchronous myoclonus. Magnetic resonance imaging showed the presence of a dolichoectatic left vertebral artery displacing the medulla. Facial involvement and the asynchronism between cervical and facial myoclonus did not support a medullary origin for the movements. A direct compression of the eleventh and seventh cranial nerves by the dolichoectatic left vertebral artery may be the mechanism responsible for myoclonus in our patient.

[The effect of clinical trials on hospital admission for stroke]

OBJECTIVE

To analyze the contribution of clinical trials in the hospital treatment of acute ischaemic cerebrovascular disease.

DEVELOPMENT

In recent studies many trials have been designed for the treatment of the acute phase of this illness. Based on experimental studies, the drugs used in the trial need to be given within a 'therapeutic window' of less than six hours from the onset of the illness. This time factor has led to a radical change in the organization of hospital services dealing with this illness. In order to run clinical trials the medical staff have had to be organized into functional stroke units for the swift protocolized diagnosis of the condition. Also information has to be given to health workers regarding the need for urgent specialized treatment. Several studies have shown that early, specialist treatment reduces morbi-mortality, time spent in hospital and financial cost in these patients.

CONCLUSION

Clinical trials in acute cerebrovascular pathology have formed the basis for the creation of stroke units, led to the drawing up of protocols for the diagnosis and guidelines for treatment. It has also made the medical profession more aware of the importance of early diagnosis and specialized treatment in acute cerebral ischaemia.

Blink reflex in patients with Wallenberg's syndrome

Knowledge of the neural circuits involved in Wallenberg's syndrome (WS) is incomplete. Study of the blink reflex (BR) in patients with WS can help in reaching a better understanding of the physiopathology underlying clinical symptoms and may help in the prediction of clinical outcome. We evaluated the BR in response to supraorbital nerve electrical stimuli in 20 patients with WS. All patients were studied within the 1st week after onset of symptoms, and 10 of them were also studied repeatedly during a follow-up period of 3-12 months. At the first examination the long latency bilateral responses (R2 and R2c) to stimulation of the supraorbital nerve of the affected side were absent in 11, delayed in 4, and normal in 5 patients. At follow-up, there was a normalization of the BR in all patients who had absent or delayed responses at the first examination except for one patient whose responses remained absent at the 9th month. Late responses elicited on the side of the lesion by stimulation of the non-affected supraorbital nerve were normal in all but one patient. This patient died from cardiorespiratory arrest within the 1st month of the illness. One patient with normal BR responses also died in the acute phase. The BR is abnormal in most patients with acute WS and tends to normalize in a mean period of 7 months. BR pattern is not a predictor of early fatal complications in patients with this syndrome.

Brain stem reflexes in patients with Wallenberg's syndrome: correlation with clinical and magnetic resonance imaging (MRI) findings

In spite of the general clinical uniformity of Wallenberg's syndrome (WS), individual patients present with a slightly different clinical picture, and detailed studies with magnetic resonance imaging (MRI) show differences in the topography of the brain stem lesion. Neurophysiological characterization of the lesion in WS has been known for a long time, but there are no studies on the possible correlation between lesion topography and neurophysiological deficit. Assuming that afferents from the three branches of the trigeminal nerve reach different parts of the trigeminal nuclei, we examined the possible correlation between the lesion topography assessed by the MRI and the neurophysiological deficit, assessed by studying the brain stem reflexes in patients with WS within 2 weeks after stroke. Neurophysiological abnormalities were always located in the afferent branch of the reflexes examined, but not all patients exhibited abnormalities in all responses. The ophthalmic branch was involved in 92.8% of patients, and the mandibular branch in 57.1% of patients. The patients with MRI lesions located in the lower medulla had normal responses with infraorbital or mental nerve stimulation. The results of this neurophysiological study confirm the heterogeneity of WS. Whether the neurophysiological identification of different subgoups of patients is relevant for clinical outcome needs further studies.

Contribution of arterial blood pressure to the clinical expression of lacunar infarction

BACKGROUND AND PURPOSE

The relation between symptomatic lacunar infarction, silent stroke, and arterial hypertension is controversial.

METHODS

From 500 patients with ischemic or hemorrhagic stroke admitted to the Downtown Barcelona Stroke Registry between July 1992 and December 1994, we evaluated prospectively the prevalence of silent infarction in 249 patients who had a brain MRI. The association of risk factors with silent infarction was investigated with the use of logistic regression analysis. In a selected group of 43 patients with symptomatic lacunes, we performed at stroke follow-up transcranial Doppler sonography and 24-hour continuous blood pressure monitoring to evaluate whether blood pressure, cerebrovascular tone, and cerebral blood flow at rest and after the administration of 1 g acetazolamide correlated with silent infarction.

RESULTS

A total of 147 silent infarctions were observed in 83 patients (33%). Most silent infarctions corresponded to small deep lesions in the territory of the lenticulostriate arteries. Patients with silent infarctions had higher systolic and diastolic blood pressure at stroke onset. However, on multivariate analysis, age greater than 60 years was the only risk factor associated with silent infarction. In a subgroup of 43 patients with symptomatic lacunes and patent extracranial vessels, systolic and diastolic pressure at stroke onset and diastolic pressure and vascular resistance at stroke follow-up were higher when silent infarctions co-existed. However, cerebral blood flow at rest and after acetazolamide injection were unrelated to silent infarction.

CONCLUSIONS

Silent ischemia in patients with symptomatic lacunar and nonlacunar stroke was only associated with aging. However, a history of arterial hypertension was perhaps unrecognized, since hemodynamic testing and continuous blood pressure monitoring in patients with lacunar stroke suggested that the coexistence of silent lesions indicated a more generalized cerebral arteriolosclerosis.

Early anticoagulation after large cerebral embolic infarction: a safety study

OBJECTIVE

To assess whether hemorrhage after early anticoagulation in nonseptic embolic infarction is related to clinical severity and infarction size.

BACKGROUND

Explicit clinical criteria and timing of anticoagulation after large embolic infarctions are unknown.

METHODS

Out of 171 patients receiving anticoagulation between July 1992 and December 1993, 83 patients with hemispheric embolisms received heparin within 72 hours from onset (activated partial thromboplastin time [aPTT] 1.5 times control value). Stratified by age and sex, a "high-risk" group (46 patients) was defined as those having stroke symptoms involving three or more CNS domains, Mathew Scale score < or = 74, or hemorrhagic infarction on initial CT, and a "low-risk" group (37 patients) as those having stroke symptoms involving fewer than three cortical domains, or Mathew Scale score > 74, and CT showing no blood. Loss of consciousness, seizures, or history of bleeding were exclusion criteria. Repeated CTs (100%) and MRIs (36%) detailed infarctions according to standard maps and evaluated all unexplained clinical worsening.

RESULTS

Prior to therapy, high-risk patients had more severe clinical deficits (p < 0.01), larger infarctions on CT (p < 0.01), and more mass effect (p < 0.01). Hemorrhagic conversion (26% in the high-risk group versus 22% in the low-risk group) and hemorrhagic worsening (4% in the high-risk group versus 13% in the low-risk group) were unrelated to admission clinical severity or infarction size, but they were related to an excessive prolongation of the aPTT (p < 0.01).

CONCLUSIONS

Infarction size and clinical severity in alert patients with nonseptic embolic stroke carries no additional bleeding complications after early anticoagulation. If anticoagulants are deemed necessary, treatment delay seems unjustified. However, rigorous monitoring of the aPTT is strongly advised to keep the level at 1.5 to 2 times control values.