Molecular Mechanisms and Pathophysiology of Acute Stroke: Recent Advances and Controversies

Stroke is a prevalent neurological disorder defined as an abnormality in brain function resulting from the disruption of cerebral circulation [...].

Predictive Clinical Factors of In-Hospital Mortality in Women Aged 85 Years or More with Acute Ischemic Stroke

INTRODUCTION

There are limited data on the outcome of acute ischemic stroke oldest old women. We assessed clinical risk factors for in-hospital mortality in women aged 85 years or more with acute ischemic stroke.

METHODS

This single-center retrospective cohort study included 506 women aged ≥ 85 years collected from a total of 4,600 patients with acute cerebral infarction registered in an ongoing 24-year hospital stroke database. The identification of clinical risk factors for in-hospital mortality was the primary endpoint of the study.

RESULTS

The mean (± standard deviation) age of the patients was 88.6 ± 3.2 years. Stroke subtypes were cardioembolic infarcts in 37.7% of patients, atherothrombotic infarcts in 30.8%, infarcts of unknown cause and lacunar infarcts in 26.1% each, and infarcts of unusual cause in 11.5%. The in-hospital mortality rate was 20.4% (n = 103). Cardioembolic infarct accounted for 67% of all deaths (n = 69). Sudden stroke onset (OR 1.87, 95% CI 1.14-3.06), altered consciousness (OR 7.05, 95% CI 4.36-11.38) and neurological, cardiac, respiratory, and hemorrhagic events during hospitalization were independent risk factors for death, whereas lacunar infarction was a protective factor (OR 0.10, 95% CI 0.01-0.82).

CONCLUSION

The oldest old age segment of women with acute ischemic infarction is a subgroup of stroke patients with unfavorable prognosis and high in-hospital mortality associated with sudden stroke onset, altered consciousness and medical complications developed during hospitalization. Lacunar infarction as stroke subtype showed a favourable prognosis.

Gender Predicts Differences in Acute Ischemic Cardioembolic Stroke Profile: Emphasis on Woman-Specific Clinical Data and Early Outcome-The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry

Background and Objectives: Acute ischemic cardioembolic stroke (CS) is a clinical condition with a high risk of death, and can lead to dependence, recurrence, and dementia. Materials and Methods: In this study, we evaluated gender differences and female-specific clinical data and early outcomes in 602 women diagnosed with CS from a total of 4600 consecutive acute stroke patients in a single-center hospital stroke registry over 24 years. A comparative analysis was performed in women and men in terms of demographics, cerebrovascular risk factors, clinical data, and early outcomes. Results: In a multivariate analysis, age, hypertension, valvular heart disease, obesity, and internal capsule location were independent variables associated with CS in women. The overall in-hospital mortality rate was similar, but the group of women had a greater presence of neurological deficits and a higher percentage of severe limitation at hospital discharge. After the multivariate analysis, age, altered consciousness, limb weakness, and neurological, respiratory, gastrointestinal, renal, cardiac and peripheral vascular complications were independent predictors related to early mortality in women. Conclusions: Women with CS showed a differential demographic and clinical profile and worse early outcomes than men. Advanced age, impaired consciousness, and medical complications were predictors of stroke severity in women with CS.

Acute Spontaneous Lobar Cerebral Hemorrhages Present a Different Clinical Profile and a More Severe Early Prognosis than Deep Subcortical Intracerebral Hemorrhages-A Hospital-Based Stroke Registry Study

Acute spontaneous intracerebral hemorrhage (ICH) is the most severe stroke subtype, with a high risk of death, dependence, and dementia. Knowledge about the clinical profile and early outcomes of ICH patients with lobar versus deep subcortical brain topography remains limited. In this study, we investigated the effects of ICH topography on demographics, cerebrovascular risk factors, clinical characteristics, and early outcomes in a sample of 298 consecutive acute ICH patients (165 with lobar and 133 with subcortical hemorrhagic stroke) available in a single-center-based stroke registry over 24 years. The multiple logistic regression analysis shows that variables independently associated with lobar ICH were early seizures (OR 6.81, CI 95% 1.27−5.15), chronic liver disease (OR 4.55, 95% CI 1.03−20.15), hemianopia (OR 2.55, 95% CI 1.26−5.15), headaches (OR 1.90, 95% CI 1.90, 95% IC 1.06−3.41), alcohol abuse (>80 gr/day) (OR 0−10, 95% CI 0.02−0,53), hypertension (OR 0,41, 95% CI 0.23−0−70), sensory deficit (OR 0.43, 95% CI 0.25−0.75), and limb weakness (OR: 0.47, 95% CI 0.24−0.93). The in-hospital mortality was 26.7% for lobar and 16.5% for subcortical ICH. The study confirmed that the clinical spectrum, prognosis, and early mortality of patients with ICH depend on the site of bleeding, with a more severe early prognosis in lobar intracerebral hemorrhage.

Vertigo in Acute Stroke Is a Predictor of Brain Location but Is Not Related to Early Outcome: The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry

BACKGROUND

Vertigo is an uncommon symptom among acute stroke victims. Knowledge about the clinical profile, the brain location, and the early outcome in stroke patients with cerebrovascular diseases and vertigo remains limited.

OBJECTIVES

In this study, the effects of vertigo on cerebral topography and early prognosis in cerebrovascular diseases were investigated.

METHODS

A comparative analysis in terms of demographics, risk factors, clinical characteristics, stroke subtypes, cerebral and vascular topography, and early outcome was performed between patients with presence or absence of vertigo on a sample of 3743 consecutive acute stroke patients available from a 24-year ongoing single-center hospital-based stroke registry.

RESULTS

Vertigo was present in 147 patients (3.9%). Multiple logistic regression analysis showed that variables independently associated with vertigo were: location in the cerebellum (OR 5.59, CI 95% 3.24-9.64), nausea or vomiting (OR 4.48, CI 95% 2.95-6.82), medulla (OR 2.87, CI 95% 1.31-6.30), pons (OR 2.39, CI 95% 1.26-4.51), basilar artery (OR 2.36, CI 95% 1.33-4.17), ataxia (OR 2.33, CI 95% 1.41-3.85), and headache (OR 2.31, CI 95% 1.53-3.49).

CONCLUSION

The study confirmed that the presence of vertigo was not related with increased in-hospital mortality or poor prognosis at hospital discharge. Vertigo is mainly related to non-lacunar vertebrobasilar stroke with topographic localization in the cerebellum and/or brainstem.

The Behaviour of Home Advantage during the COVID-19 Pandemic in European Rink Hockey Leagues

The primary purpose of the present study was to compare the home advantage (HA) and the home team performance in the most relevant European rink hockey leagues (Spanish, Portuguese and Italian), considering the presence or absence of spectators in the competition venues due to the effect of COVID-19 restrictions. The sample was composed of 1665 rink hockey matches (654 from the Spanish league, 497 from the Portuguese league, and 514 from the Italian league) played between the 2018-2019 and 2020-2021 seasons. The HA and match variables comparisons were established using several negative binomial regression models. Results showed that the effect of HA did not disappear despite playing without spectators but decreased from 63.99% to 57.41% (p = 0.002). Moreover, the comparison of the match variables showed that playing with spectators benefited local teams' performance, especially in the Portuguese and Italian leagues. Playing with spectators favoured local team performance in rink hockey matches, which is more evident in some analysed leagues. However, as HA does not disappear entirely without spectators, it is necessary to study other relevant performance factors that are not directly or indirectly attributable to crowd behaviour in rink hockey performance analyses.

Contribution of "Omic" Studies to the Understanding of Cadasil. A Systematic Review

CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is a small vessel disease caused by mutations in NOTCH3 that lead to an odd number of cysteines in the epidermal growth factor (EGF)-like repeat domain, causing protein misfolding and aggregation. The main symptoms are migraines, psychiatric disorders, recurrent strokes, and dementia. Omic technologies allow the massive study of different molecules for understanding diseases in a non-biased manner or even for discovering targets and their possible treatments. We analyzed the progress in understanding CADASIL that has been made possible by omics sciences. For this purpose, we included studies that focused on CADASIL and used omics techniques, searching bibliographic resources, such as PubMed. We excluded studies with other phenotypes, such as migraine or leukodystrophies. A total of 18 articles were reviewed. Due to the high prevalence of NOTCH3 mutations considered pathogenic to date in genomic repositories, one can ask whether all of them produce CADASIL, different degrees of the disease, or whether they are just a risk factor for small vessel disease. Besides, proteomics and transcriptomics studies found that the molecules that are significantly altered in CADASIL are mainly related to cell adhesion, the cytoskeleton or extracellular matrix components, misfolding control, autophagia, angiogenesis, or the transforming growth factor β (TGFβ) signaling pathway. The omics studies performed on CADASIL have been useful for understanding the biological mechanisms and could be key factors for finding potential drug targets.

Differential Characteristics of Ischemic and Hemorrhagic Stroke in Patients with Cerebral Small Vessel Disease

Background

Small vessel disease (SVD) is the underlying anatomical substrate for both lacunar infarction and subcortical hemorrhage.

Aim

To assess predictive factors of ischemic or hemorrhagic stroke in patients with cerebral SVD.

Materials and Methods

Prospective hospital-based stroke registry ("The Sagrat Cor Hospital of Barcelona Stroke Registry") in an acute-care teaching hospital in Barcelona, Spain. From 4597 acute stroke patients included in the stroke registry over a 24-year period, 440 cases of lacunar stroke and 210 of subcortical intracerebral hemorrhage were selected. Demographics, clinical characteristics, risk factors, and early outcome were compared. Predictors of lacuna versus subcortical hemorrhage were assessed by multivariate analyses.

Results

In a logistic regression model based on demographics, risk factors, clinical features and outcome, dyslipidemia (odds ratio [OR] 2.06 (95% confidence interval (CI) 1.17-3.62) and diabetes (OR 1.97, 95% CI 1.19-3.26) were independent risk factors for lacunar infarction. Anticoagulation therapy (OR 0.05, 95% CI 0.01-0.28), sudden onset (OR 0.51, 95% CI 0.33-0.78), motor symptoms (OR 0.44, 95% CI 0.26-0.76), headache (OR 0.23, 95% CI 0.12-0.41), altered consciousness (OR 0.10, 95% CI 0.05-0.21), respiratory complications (OR 0.19, 95% CI 0.08-0.46), and in-hospital death (OR 0.08, 95% CI 0.02-0.36) were predictors of subcortical hemorrhage.

Conclusion

Identification of differential clinical and prognostic profile between ischemic and hemorrhagic consequences of underlying cerebral SVD is useful for risk stratification in the current process pursuing precision medicine.

Guillain-Barré-Strohl syndrome and COVID-19: Case report and literature review

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A case of an acute demyelinating polyneuropathy during infection by SARS-CoV-2.

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SARS-CoV-2 has also been shown to affect the peripheral nervous system.

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Guillain-Barré syndrome (GBS) due to SARS-CoV-2 is a rare complication.

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Some GBS have led to hypothesize a possible parainfectious pathogenesis.

In recent months, the new beta-coronavirus has caused a pandemic with symptoms affecting mainly the respiratory system. It is established that the virus may play a neurotropic role and in recent months several cases of Guillain-Barré-Strohl syndrome (GBS) have been reported in patients infected with COVID-19. We report the case of a 54-year-old patient with acute demyelinating polyneuropathy during infection by SARS-CoV-2 who progressed clinically to require assisted ventilation. After several weeks of specific symptomatic treatment, the patient had a favorable outcome. In conclusion, despite being a rare complication, we think it is important to consider the possibility of diffuse involvement of the peripheral nervous system in patients with COVID-19 to adjust clinical monitoring and treatment in these cases.

Cardioembolic Stroke: Risk Factors, Clinical Features, and Early Outcome in 956 Consecutive Patients

BACKGROUND

There is little information about the early clinical features of cardioembolic stroke before complementary examinations.

OBJECTIVE

The aim of this study was to identify risk factors, clinical features, and early outcomes of cardioembolic stroke.

METHODS

Retrospective study based on prospectively collected data available from a university medical center hospitalbased stroke registry. Consecutive patients diagnosed with cardioembolic infarction were selected and compared to those diagnosed with an atherothrombotic stroke. Predictors of cardioembolic infarction were assessed by multivariate analysis.

RESULTS

From a cohort of 4597 consecutive patients, we studied 956 patients diagnosed with cardioembolic infarction (80 years [standard deviation (SD) 9.14]; 63% women) and 945 with atherothrombotic infarction (77.01 years [SD 9.75]; 49.8% women). The univariate comparative analysis reported that advanced age (≥ 85 years), female gender, atrial fibrillation (AF), ischemic heart disease, and congestive heart failure were significantly more frequent in the cardioembolic group, whereas hypertension, diabetes, peripheral vascular disease, heavy smoking, hyperlipidemia, and previous transient ischemic attack were significant in the atherothrombotic group. In the logistic regression model, AF (odds ratio [OR] 15.75, 95% confidence interval [CI]: 12.14-20.42), ischemic heart disease (OR 3.12, 95% CI: 2.16-4.5), female gender (OR 1.56, 95% CI: 1.22-2.00), and sudden-onset (OR 1.97, 95% CI: 1.54-2.51), were independent significant predictors of cardioembolic stroke.

CONCLUSIONS

Potential cardioembolic stroke requires a comprehensive evaluation, since early classification and identification through predictors would improve effective management.

Complementary examinations other than neuroimaging and neurosonology in acute stroke

The etiologic diagnosis of cerebrovascular diseases requires non-routine complementary examinations to be performed. Thus, in specific cases, after neuroimaging (computed tomography/magnetic resonance imaging cerebral scan sequences) and neurosonology (Doppler test of the supra-aortic trunks, transcranial echography and echocardiography), which academically allow us to classify the patients according to their etiologic stroke subtype, further examinations must be used to make a correct etiologic diagnostic. The present review aims to update knowledge about the usefulness of the different tests of blood and urine, plain chest radiography, X-ray of the spine, skull and abdomen, lumbar puncture, electroencephalography, evoked potentials, polysomnography, and pathologic examination after biopsy of the artery, skin, muscles, nerves, meninges, and brain, in the management of patients who have suffered an acute stroke.

GRECOS Project (Genotyping Recurrence Risk of Stroke): The Use of Genetics to Predict the Vascular Recurrence After Stroke

BACKGROUND AND PURPOSE

Vascular recurrence occurs in 11% of patients during the first year after ischemic stroke (IS) or transient ischemic attack. Clinical scores do not predict the whole vascular recurrence risk; therefore, we aimed to find genetic variants associated with recurrence that might improve the clinical predictive models in IS.

METHODS

We analyzed 256 polymorphisms from 115 candidate genes in 3 patient cohorts comprising 4482 IS or transient ischemic attack patients. The discovery cohort was prospectively recruited and included 1494 patients, 6.2% of them developed a new IS during the first year of follow-up. Replication analysis was performed in 2988 patients using SNPlex or HumanOmni1-Quad technology. We generated a predictive model using Cox regression (GRECOS score [Genotyping Reurrence Risk of Stroke]) and generated risk groups using a classification tree method.

RESULTS

The analyses revealed that rs1800801 in the MGP gene (hazard ratio, 1.33; P=9×10^-03), a gene related to artery calcification, was associated with new IS during the first year of follow-up. This polymorphism was replicated in a Spanish cohort (n=1.305); however, it was not significantly associated in a North American cohort (n=1.683). The GRECOS score predicted new IS (P=3.2×10^-09) and could classify patients, from low risk of stroke recurrence (1.9%) to high risk (12.6%). Moreover, the addition of genetic risk factors to the GRECOS score improves the prediction compared with previous Stroke Prognosis Instrument-II score (P=0.03).

CONCLUSIONS

The use of genetics could be useful to estimate vascular recurrence risk after IS. Genetic variability in the MGP gene was associated with vascular recurrence in the Spanish population.

[Stroke in young adults: incidence and clinical picture in 280 patients according to their aetiological subtype]

BACKGROUND AND OBJECTIVE

To assess the clinical features and incidence rate of stroke in young adults (less than 55 years of age).

METHODS

Hospital-based descriptive study of 280 young inpatients consecutively admitted for stroke over a period of 24 years. We conducted a comparison with the remaining 4,312 patients admitted for stroke.

RESULTS

Stroke in young adults represented 6.1% of all strokes, 5.7% of transient ischaemic attacks, 5.8% of cerebral infarctions and 8.4% of brain haemorrhages. However, reported minimal frequency of cardioembolic (2.1%) and atherothrombotic (3.4%) infarctions, accounted for 5.9% of lacunar and for 10.7% of essential infarctions and showed a maximum frequency in those infarctions of unusual aetiology (36%). Factors independently associated with stroke in young adults were cigarette smoking (OR 4.23; 95% CI 3.02-5.93; P=.000), unusual aetiology (OR 4.97; 95% CI 3.15-7.84; P=.000), headache (OR 4.57; 95% CI 2.59-8.07; P=.000), alcohol abuse (OR 3.93; 95% CI 2.46-6.29; P=.000), oral contraceptives (OR 14.07; 95% CI 2.37-83.40; P=.004), atrial fibrillation (OR 0.15; 95% CI 0.08-0.28; P=.000), arterial hypertension (OR 0.43; 95% CI 0.33-0.57; P=.000), COPD (OR 0.20; 95% CI 0.09-0.44; P=.000), atherothrombotic infarction (OR 0.51; 95% CI 0.34-0.77; P=.001), female sex (OR 0.71; 95% CI 0.52-0.97; P=.029), diabetes mellitus (OR 0.66; 95% CI 0.46-0.98; P=.030), ischaemic heart disease (OR 0.56; 95% CI 0.33-0.95; P=.032) and intermittent claudication (OR 0.48; 95% CI 0.24-0.94; P=.033).

CONCLUSIONS

Stroke in young adults is infrequent (6.1% of the total), but represents the highest frequency of cerebral infarcts of unusual aetiology (36%). We conclude that stroke in younger patients presents its own and differentiated clinical profile.

Clinical characteristics of acute lacunar stroke in young adults

INTRODUCTION

Acute lacunar stroke in subjects under 55 years of age has been poorly characterized.

METHODS

We assessed the clinical features of lacunar stroke in 51 patients aged ≤55 years (84.5% men, mean standard deviation [SD] age 49.8 [5.2] years) collected from a prospective hospital-based stroke registry in Barcelona, Catalonia, Spain.

RESULTS

This subset of young lacunar stroke patients accounted for only 5.2% of all lacunar strokes, 1.2% of all ischemic strokes, and 1.1% of all acute strokes included in the registry over a 24-year period. In the multivariate analysis, factors independently associated with acute lacunar stroke in patients aged ≤55 years were alcohol consumption (>60 g/day) (odds ratio [OR] = 6.67), heavy smoking (>20 cigarettes/day) (OR = 3.02), obesity (OR = 2.81), essential etiology (OR = 2.73), and headache at stroke onset (OR = 2.45).

CONCLUSION

Characterization of the clinical profile of acute lacunar stroke in younger patients contributes to a better knowledge of the full clinical expression of this ischemic stroke subtype.

Malignant middle cerebral artery infarction: a clinical study of 32 patients

BACKGROUND AND OBJECTIVE

Malignant middle cerebral artery infarction is a devastating type of ischemic stroke whose clinical predictors remain scarcely known. The present study aims to improve the knowledge about the prognosis factors through an analysis of a malignant middle cerebral artery infarction sample of patients from our stroke registry.

MATERIAL AND METHODS

From a total of 1,396 patients with ischemic stroke in the middle cerebral artery included in the "Sagrat Cor Hospital of Barcelona Stroke Registry", we identified 32 patients with malignant middle cerebral artery infarction (2.3%). Demographic, anamnestic, clinical, and outcome variables in this subgroup of patients were compared with those of the middle cerebral artery. The independent predictive value of each variable on the development of malignant middle cerebral artery infarction was assessed with a logistic regression analysis.

RESULTS

The mean age was 74.7 (SD, 11.4) years and 50% were males. In-hospital death was observed in eight patients (25%) and early bad prognosis (in-hospital death or severe residual focality at discharge) was present in 16 patients (50%). Decreased consciousness (OR: 4.17; 95% CI: 2.02-8.61), presence of nausea or vomiting (OR: 3.65; 95% CI: 1.40-8.49), and heavy smoking (> 20 cigarettes/day; OR: 2.62; 95% CI: 1.03-6.64) appeared to be independent prognostic factors for malignant middle cerebral artery infarction in the multivariate analysis.

CONCLUSIONS

Malignant middle cerebral artery infarction is an infrequent clinical condition associated with poor prognosis and high mortality rate. In our sample, decreased consciousness, nausea or vomiting, and heavy smoking are the main clinical factors associated.

Clinical Characteristics and Outcome of the Capsular Warning Syndrome: A Multicenter Study

Background

The capsular warning syndrome is defined as recurrent transient lacunar syndromes that usually precede a capsular infarction. Several aspects regarding the clinical management are controversial. We report the clinical and radiological characteristics of a multicenter series of patients with capsular warning syndrome, as well as their functional outcome during the follow-up.

Aims

We sought to describe the clinico-radiological spectrum of the capsular warning syndrome and to report the functional outcomes and recurrences of these patients during the follow-up.

Methods

We conducted a multicenter study that collected clinical and radiological data from patients with capsular warning syndrome during 2003–2013. Capsular warning syndrome was defined as the succession of three or more motor or sensory-motor lacunar syndromes within a period of 72 h, with complete recovery between them. We recorded the functional outcome (favorable when Rankin scale score ≤2) and recurrences during follow-up.

Results

Our study included 42 patients whose mean age was 66·4 ± 10 years; 71·4% of them were men. The mean number of episodes before a permanent neurological impairment occurred or before a complete recovery of symptoms was 5·1 ± 2·3. Up to 30 patients (71·2%) had an acute infarct visible on the neuroimaging (computed tomography/magnetic resonance imaging). The internal capsule was the most frequent infarct location (50%), but other locations were noted. Twelve patients (28·6%) received thrombolysis in the acute phase. A favorable outcome was observed in 39 patients (92·9%). After a mean follow-up of 35 ± 29 months, only one patient suffered a recurrent ischemic stroke.

Conclusions

Capsular warning syndrome preceded an ischemic infarction in 71·2% of patients. In addition to the internal capsule, other locations were noted. The most effective treatment remains unclear. The functional prognosis is favorable in most patients and recurrences are rare.

Gender differences and woman-specific trends in acute stroke: results from a hospital-based registry (1986-2009)

OBJECTIVE

We assessed gender differences and women-specific secular trends in stroke.

METHODS

Data from 2318 women and 2274 men with first-ever stroke collected from the Sagrat Cor Hospital Stroke Registry of Barcelona between 1986 and 2009 were analyzed.

RESULTS

Patient's age increased significantly from a mean of 74.5 years in 1986-1992 to 81.2 years in 2004-2009 (P < 0.001). Patients aged ≥ 85 years increased from 18.5% to 38.5% (P = 0.0001) as were patients with hypertension, atrial fibrillation, and cardioembolic stroke. The in-hospital death decreased from 17.6% to 11% (P = 0.02), median length of hospital from 14 to 9 days (P = 0.0001) and prolonged hospital stay (> 12 days) from 59.7% to 33.7% (P = 0.0001). Lacunar infarction was more frequent in men (21.5% vs. 16.2%, P = 0.0003) and cardioembolic infarction in women (26% vs. 15.6%, P = 0.0001). Acute stroke in women continues to be a severe disease with high risk of death in the immediate post-stroke phase (13.5%) and low probability of early full neurological recovery (13.9% vs. 11.8%, P = 0.029).

CONCLUSION

Women differ from men in the distribution of risk factors and stroke subtype, stroke severity, and outcome. An increase in the patient's age, hypertension, atrial fibrillation and cardioembolic infarction, as well as a decrease mortality and length of hospitalization over a 24-year period was recorded.

Efficacy of continuous positive airway pressure treatment on 5-year survival in patients with ischaemic stroke and obstructive sleep apnea: a randomized controlled trial

The main purpose of the present analysis is to assess the influence of introducing early nasal continuous positive airway pressure (nCPAP) treatment on cardiovascular recurrences and mortality in patients with a first-ever ischaemic stroke and moderate-severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) ≥20 events h(-1) during a 5-year follow-up. Patients received conventional treatment for stroke and were assigned randomly to the nCPAP group (n = 71) or the control group (n = 69). Cardiovascular events and mortality were registered for all patients. Survival and cardiovascular event-free survival analysis were performed after 5-year follow-up using the Kaplan-Meier test. Patients in the nCPAP group had significantly higher cardiovascular survival than the control group (100 versus 89.9%, log-rank test 5.887; P = 0.015) However, and also despite a positive tendency, there were no significant differences in the cardiovascular event-free survival at 68 months between the nCPAP and control groups (89.5 versus 75.4%, log-rank test 3.565; P = 0.059). Early nCPAP therapy has a positive effect on long-term survival in ischaemic stroke patients and moderate-severe OSA.

Clinical characteristics of acute lacunar stroke in women: emphasis on gender differences

There are few studies analyzing features of ischemic stroke subtypes in women. We assessed gender differences in lacunar stroke subtype based on data collected from a prospective stroke registry in Barcelona, Spain. Lacunar ischemic stroke was diagnosed in 310 (8.1 %) women and 423 (11.1 %) men of a total of 3,808 consecutive stroke patients included in a prospective hospital-based stroke registry, in Barcelona, Catalonia (Spain), over a period of 19 years. Independent factors for lacunar stroke in women were assessed by multivariate analysis. Women accounted for 42 % of all lacunar stroke patients (n = 733) in the registry and 11.4 % of all patients with ischemic stroke (n = 2,704). Very old age (85 years or older) was found in 20.3 % in women versus 11.1 % in men (P < 0.0001). In the logistic regression analysis, obesity [odds ratio (OR) = 4.24], prolonged hospital stay (>12 days) (OR = 1.59), arterial hypertension (OR = 1.50), and age (OR = 1.06) were significant variables independently associated with lacunar stoke in women, whereas peripheral vascular disease (OR = 0.51), chronic obstructive pulmonary disease (OR = 0.46), renal dysfunction (OR = 0.13), and heavy smoking (OR = 0.04) were independent variables for lacunar stroke in men. Women with lacunar stroke were remarkably older and presented with obesity and hypertension more frequently than did men. Lacunar stroke severity was similar in men and women. These findings in lacunar stroke patients could be explained by differences in gender for ischemic stroke in general.

Advancements in understanding the mechanisms of symptomatic lacunar ischemic stroke: translation of knowledge to prevention strategies

Symptomatic lacunar ischemic stroke (25% of all brain infarctions) results from occlusion of a single penetrating artery by microatheromas or lipohyalinosis and rarely from an intracranial atheromatous branch disease. Recurrent lacunar stroke may be associated with more severe clinical features and has been involved in producing lacunar state and vascular subcortical dementia. In the first multicenter randomized clinical trial (SPS3) focused on stroke prevention among patients with recent lacunar stroke, the addition of clopidogrel to aspirin not only did not reduced significantly the risk of recurrent stroke, but also increased significantly the likelihood of hemorrhage and fatal outcome. If lacunar stroke is primarily non-atherothromboembolic, secondary prevention aimed at preventing atheroma progression may not be very effective. The efficacy of drugs that improve endothelial function in lacunar stroke patients remains to be studied in the future.

Cognitive profile in patients with a first-ever lacunar infarct with and without silent lacunes: a comparative study

BACKGROUND

The detection of early neuropsychological abnormalities as precursors of cognitive decline of vascular origin in patients with lacunar stroke is a subject of increasing interest. The objective of this study was to assess whether there were differences in the performance of a battery of neuropsychological tests in first-ever lacunar stroke patients with and without associated silent multiple lacunar infarctions found incidentally on the brain magnetic resonance imaging (MRI) scan.

METHODS

A total of 72 consecutive patients with first-ever lacunar infarction were studied 1 month after stroke. All patients underwent a comprehensive neuropsychological evaluation, which included the California Verbal Learning Test (CVLT), Phonetic Verbal Fluency Test (PMR), Semantic Verbal Fluency Test (category "animals"), Digit Span Forward and Backward from the Wechsler Adult Intelligence Scale (WAIS-III), and Mini-Mental State Examination (MMSE).

RESULTS

A total of 38 patients (52.7%) had silent multiple lacunar infarcts, with corona radiata as the most frequent topography (P < 0.023). White matter hyperintensities (leukoaraiosis) were observed in 81.1% of patients with silent multiple lacunar infarcts and in 50% with a single lacunar infarction (P < 0.007). Patients in both groups showed similar scores in the MMSE, but those with associated silent lacunar infarctions showed a poorer performance in the semantic fluency test (P < 0.008) and in short delayed verbal memory (P < 0.001). In both cases, however, leukoaraiosis was not statistically significant in multivariate linear regression models adjusted by confounding covariates. In these models, multiple silent lacunar infarctions and education were independent predictors of poor performance in the semantic fluency test and in short delayed verbal memory.

CONCLUSIONS

The presence of silent multiple lacunar infarctions documented on brain MRI scans in patients with first-ever lacunar stroke was associated with mild neuropsychological abnormalities, particularly in the performance of executive functions (semantic fluency) and short delayed verbal memory. According to these findings, in the initial stages of small vessel disease, mild neuropsychological abnormalities appear to be related to lacunes rather than to leukoaraiosis or perivascular hyperintensities of vascular cause.

Movement disorders in ischemic stroke: clinical study of 22 patients

Movement disorders (bemichorea-hemiballismus, hemidystonia and isolated tremor) are an uncommon clinical manifestation in ischemic stroke (IS), and their anatomical basis is poorly understood. We analyzed the clinical and neuroimaging characteristics of 22 consecutive patients who bad movement disorders associated with cerebral infarction (MDCI), studied at four institutions over 8 years. In one institution (from the La Alianza-Central Hospital of Barcelona Stroke Registry) nine patients with MDCI were identified among 1099 consecutive first ever stroke patients (0.8%) (908 with IS, 1%). Fifteen out of 22 patients (68%) had hemichorea-hemiballismus, five (23%) hemidystonia and two (9%) isolated tremor. MDCI were more often left sided (n = 15, 68%), being bilateral in one patient (4.5%). A lesion was found on neuroimaging (CT and/or MRI) in 15 patients (68%), in the territory of the posterior cerebral artery (n = 8) and middle cerebral artery (six deep and one superficial). The most commonly involved structure was the thalamus (n = 8, 36.5%). IS subtypes were; presumed lacunar infarcts in 14 patients (64%), atherothrombotic infarcts in two patients (9%), cardioembolic infarcts in two patients (9%) and infarcts of unknown etiology in four patients (18%). Hemichorea-hemiballismus was the most common type of MDCI in our study, usually being the result of a thalamic infarction. The thalamus was the most frequently damaged structure underlying all types of MDCI. There was a striking propensity of MDCI which resulted from nondominant deep hemispheric small vessel infarctions.

[Trends in risk factors, clinical characteristics and prognosis in primary intracerebral haemorrhage (1986-2004)]

BACKGROUND AND OBJECTIVES

Cardiovascular risk factors, clinical features and early outcome of first-ever primary intracerebral haemorrhage (PIH) from 1986 to 2004 using the Sagrat Cor Hospital of Barcelona Stroke Registry were assessed, and compared with data from patients with first-ever ischemic stroke.

PATIENTS AND METHODS

The study population consisted of 380 patients with PIH and 2,082 patients with ischemic stroke. Secular trends for the periods 1986-1992, 1993-1998 and 1999-2004 were analyzed.

RESULTS

Age increased significantly (P<.001) throughout the 3 study periods and there was a significant increase in the percentage of patients with atrial fibrillation, chronic obstructive pulmonary disease (COPD) and lobar topography. The use of brain magnetic resonance imaging (MRI) also increased significantly throughout the study periods. In comparison with ischemic stroke in-hospital death was more frequent (28,2 vs. 12%) and lacunar syndrome (9,5 vs. 31,4%) and symptom-free patients at discharge were less frequent in the intracerebral haemorrhage group (6,1 vs. 18,3%).

CONCLUSIONS

Significant changes over a 19-year period included an increase in the patient's age, frequency of COPD and atrial fibrillation and use of MRI imaging studies. PIH is a severe subtype of stroke with a higher risk of early death and lower asymptomatic frequency at discharge than ischemic cerebral infarct.

Focal cortical thinning is caused by remote subcortical infarcts: spooky action at a distance

In this issue of Neurology®, Duering et al.(1) present compelling proof-of-principle evidence that small subcortical infarcts have remote consequences on gray matter volume. Using MRI scans acquired before and after an incident subcortical infarct, they were able to show that the appearance of a new subcortical infarct was associated with cortical thinning in connected brain regions.

Spontaneous primary intraventricular hemorrhage: clinical features and early outcome

Purpose. Primary hemorrhage in the ventricular system without a recognizable parenchymal component is very rare. This single-center retrospective study aimed to further characterize the clinical characteristics and early outcome of this stroke subtype. Methods. All patients with primary intraventricular hemorrhage included in a prospective hospital-based stroke registry over a 19-year period were assessed. A standardized protocol with 161 items, including demographics, risk factors, clinical data, neuroimaging findings, and outcome, was used for data collection. A comparison was made between the groups of primary intraventricular hemorrhage and subcortical intracerebral hemorrhage. Predictors of primary intraventricular hemorrhage were identified by logistic regression analysis. Results. There were 12 patients with primary intraventricular hemorrhage (0.31% of all cases of stroke included in the database) and 133 in the cohort of subcortical hemorrhage. Very old age (≥85 years) (odds ratio (OR) 9.89), atrial fibrillation (OR 8.92), headache (OR 6.89), and altered consciousness (OR 4.36) were independent predictors of intraventricular hemorrhage. The overall in-hospital mortality rate was 41.7% (5/12) but increased to 60% (3/5) in patients aged 85 years or older. Conclusion. Although primary intraventricular hemorrhage is uncommon, it is a severe clinical condition with a high early mortality. The prognosis is particularly poor in very old patients.

Trends in clinical features and early outcome in patients with acute cardioembolic stroke subtype over a 19-year period

OBJECTIVES

To assess changing trends in clinical characteristics and early outcome of patients with acute cardioembolic stroke (ACS) over a 19-year period.

MATERIALS AND METHODS

Data of 575 patients with first-ever ACS included in the Sagrat Cor Hospital of Barcelona Stroke Registry were analyzed. Changing trends for 1986-1992, 1993-1998, and 1999-2004 periods were compared.

RESULTS

A statistically significant increase (P < 0.001) in the age of patients (74.6 years in 1986-1992 vs. 81.4 years in 1999-2004) and the percentage of patients older than 85 years of age (16% vs. 38.2%) was observed. Patients with hypertension increased from 40.5 to 60.8% (P = 0.001) as were patients with diabetes, chronic bronchitis, and obesity (P = NS). The median length of hospital stay decreased from 18 to 12 days (P = 0.031) and prolonged hospital stay (>12 days) from 18.3 to 13.1 (P = 0.033). In-hospital death rate remained around 20%.

CONCLUSIONS

ACS continues to be a severe ischemic stroke subtype with high risk of in-hospital death. The lack of improvement in the early prognosis over a 19-year period may be explained by an increase in the prevalence of major cardiovascular risk factors and progressive aging of the population.