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Stroke Alert: A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Interim Chair and Neurologist-in-Chief, Director, Division of Stroke & Critical Care Neurology, Weill Cornell Medical College and New York Presbyterian Hospital
Rotational Vertebral Artery Syndrome: A Vascular Cause of Isolated Vertigo
Source: Noh Y, et al. Rotational vertebral artery syndrome due to compression of nondominant vertebral artery terminating in posterior inferior cerebellar artery. J Neurol 2011; Online DOI 10.1007/s00415-011-6005-1.
Rotational vertebral artery syndrome (RVAS) is a rare syndrome usually caused by compression of the dominant vertebral artery in the neck with extreme head rotation to the contralateral side. Most symptomatic patients have stenosis or hypoplasia of one vertebral artery. At the same time that vertigo occurs, there is usually nystagmus, with the direction of the fast phase on the same side as the compressed vertebral artery. The authors described a patient with a hypoplastic vertebral artery that ended in the posterior inferior cerebellar artery with symptoms occurring during head turn in the direction opposite the hypoplastic artery. This example suggests that ischemia of the inferior cerebellum or lateral medulla explains the symptoms and signs of RVAS.
Stroke Outcome Prediction After Middle Cerebral Artery Territory Infarction
Source: Vora NA, et al. A 5-item scale to predict stroke outcome after cortical middle cerebral artery territory infarction. Validation from results of the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) study. Stroke 2011;42:645-649.
The authors retrospectively reviewed 129 patients over a 2-year period and considered clinical, laboratory, and imaging parameters as potential predictors of outcome. Inclusion criteria were unilateral hemispheric infarcts within the middle cerebral artery territory. The primary outcome measure was favorable recovery, as defined by modified Rankin Score < 2 at 30 days. A multivariable model was used to develop a five-item scale to predict stroke recovery.
Five independent predictors of outcome were: age (odds ratio [OR] = 1.09, P = 0.001), NIH Stroke Scale (OR = 1.17, P = 0.003), infarct volume (OR=1.01, P = 0.03), admission white blood cell count (OR = 1.16, P = 0.04), and presence of hyperglycemia (OR = 4.2, P = 0.04). Combining these variables into a point scale improved their prediction value, and when applied to the DEFUSE study population for validation, achieved a sensitivity of 83% and specificity of 86%.
Lowering Blood Pressure Reduces Hematoma Growth After Acute Intracerebral Hemorrhage
Source: Arima H, et al, for the Intensive Blood Pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT) Investigators. Lower treatment blood pressure is associated with greatest reduction in hematoma growth after acute intracerebral hemorrhage. Hypertension 2010;56:852-858.
Interact included 404 patients with acute intracere-bral hemorrhage (ICH), elevated systolic blood pressure (BP) (150 to 220 mmHg), and capacity to lower BP within 6 hours of onset. CT was performed at baseline and at 24 hours to compare hematoma size. There was no significant association between baseline systolic BP levels and hematoma volume. Maximum reduction in hematoma growth occurred in the one-third of patients with the lowest on-treatment systolic BP levels (median = 135 mmHg). Intensive BP reduction to systolic levels between 130 and 140 mmHg is likely to provide maximum protection against hematoma growth.
Dementia Occurs in Approximately 20% of Patients After a First Stroke
Source: Bejot Y, et al. Prevalence of early dementia after first-ever stroke. A 24-year population-based study. Stroke 2011;42:607-612.
From 1985 to 2008, all first-ever strokes in the city of Dijon, France (150,000 inhabitants) were recorded, and among those patients who were testable (3201/3948 or 81%), 20.4% had post-stroke dementia. The prevalence of post-stroke dementia in patients with lacunar disease was 7 times higher than in patients with intracerebral hemorrhage. Age, vascular risk factors, presence of hemiplegia, and use of prestroke antiplatelet medications were associated with an increased prevalence of post-stroke dementia.