Demographic and medical characteristics of the patient

The most important demographic predictors of dementia after stroke, in sufficiently powered studies, are increasing age and low education level, but not gender when the analysis is adjusted for age 5 . The risk of dementia after stroke is higher in patients who were already dependent before stroke 5 . Pre-stroke cognitive decline without dementia, assessed by standardized questionnaires, is also associated with a higher risk of dementia after stroke 5, 32 . Diabetes mellitus, atrial...

CT angiography

Cerebral and cervical CT angiography is performed using intravenous administration of 50 ml of iodinated contrast material at a rate of 3 ml per second, and an acquisition delay of about 15 seconds. Data acquisition is performed from the origin of the aortic arch branch vessels to the circle of Willis and reconstructed as maximum-intensity projections (MIP) (Figure 3.3E) and three-dimensional reconstructions (Figure 3.3B). Figure 3.3. Same patient as in Figure 3.2. Upper row imaging at 12 hours...

Multiple overlapping causes of ischemic stroke

In some patients multiple overlapping causes of ische-mic stroke are identified. In such cases, whether these findings are purely coincidental or represent the cause of the infarct is not clear. For example, patients with clinical and neuroimaging features that are compatible with lacunar infarction may have associated findings of large artery atherosclerosis or a cardioembolic source (most commonly atrial fibrillation). In one study, 4 of all stroke patients had small artery disease coexisting...

Cryptogenic ischemic stroke

Patients experiencing a TIA stroke frequently have no determined etiology after standard diagnostic evaluation. Previous reports show that 20-25 of stroke survivors are classified as cryptogenic stroke, but it is a matter of debate which strokes should be labeled cryptogenic - what level of evidence is needed for accepting a finding or risk factor as the cause Such debate has surrounded PFO, which can be an incidental finding or possibly an underlying mechanism methods for distinguishing...

Role of functional imaging in stroke patients

The functional deficit after a focal brain lesion is determined by the localization and the extent of the tissue damage recovery depends on the adaptive plasticity of the undamaged brain, especially the cerebral cortex, and of the non-affected elements of the functional network. Since destroyed tissue usually cannot be replaced in the adult human brain, improvement or recovery of neurological deficits can be achieved only by reactivation of functionally disturbed but morphologically preserved...

Extracranial ultrasound in acute stroke

The most important diagnostic question in ultrasono-graphy is which extra- and intracranial vessel(s) is are stenotic or occluded and can it they be responsible for the clinical symptoms. Note that clinically silent sten-otic processes might also influence the cerebral circulation. Because ofthe interactions between extra- and intra-cranial hemodynamics, both extracranial and intracra-nial ultrasound techniques should be performed in acute stroke. Similarly, clinically silent stenoses should be...

Diagnostic brain perfusion imaging in stroke patients

The availability of new ultrasound contrast agents (UCAs) and the development of contrast-specific imaging modalities have established the application of ultrasound in stroke patients for visualization of brain perfusion deficits. The UCAs consist of micro-bubbles composed of a gas that is associated with various types of shells for stabilization. Because of their small size, they can pass through the microcirculation. There are interactions between ultrasound and microbubbles at low ultrasound...

Prognostic value of ultrasound in acute stroke

During recent years, ultrasound has become an important non-invasive imaging technique for bedside monitoring of acute stroke therapy and prognosis. By providing valuable information on temporal patterns of recanalization, ultrasound monitoring may assist in the selection of patients for additional pharmacological or interventional treatment. Ultrasound also has an important prognostic role in acute stroke. A prospective, multicenter, randomized study confirmed that a normal MCA finding is...

Overall lifestyle patterns and stroke risk

Recently, in the analysis of the data from the Health Professionals Follow-up Study and from the Nurses' Health Study the impact on stroke risk of a combination of healthy lifestyle characteristics was evaluated and the burden of stroke that may be attributed to these unhealthy lifestyle choices was calculated 31 . Diet and other lifestyle factors were updated from self-reported questionnaires. A low-risk healthy lifestyle was defined as (i) not smoking, (ii) a body mass index < 25kg m2,...

Diagnosis of coronary heart disease in stroke patients

When caring for stroke patients in the acute or rehabilitation phase, it is necessary to be aware of clinical symptoms of myocardial ischemia such as chest pain or exertional dyspnea, or electrocardio-graphic abnormalities such as ST-depression, T-wave abnormalities or newly developing Q-waves 20 . The detection of myocardial injury can be improved by measuring serum levels of troponin T or troponin I, biomarkers which are found to be highly specific for myocardial necrosis 24 . Elevated...

Myocardial infarction as a cause of embolism

Cardiogenic embolism from a left ventricular thrombus may occur as a complication of acute or subacute myocardial infarction or due to a ventricular aneur-ysm in the chronic phase of a large, mainly anterior wall infarction 27 . The incidence of left ventricular thrombi early after myocardial infarction has declined in recent years, most probably due to changes in the acute therapy of myocardial infarction, which now comprises intensive anticoagulant therapy and percutaneous coronary...

Relative risk of dementia after stroke

In the Rochester study, the relative risk of dementia (i.e. the risk of dementia in stroke survivors divided by the risk of dementia in stroke-free controls) was 8.8 one year after stroke, then declined progressively to 2.5 after 10 years, and 2.0 after 25 years 22 . The risk of AD was also doubled after 25 years 22 . In the Framingham study, the results were similar 10 years after stroke, after adjustment for age, gender, education level and exposure to individual risk factors for stroke 29 ....

Preexisting silent brain lesions in stroke patients

Silent infarcts, i.e. cerebral infarcts seen on CT or MRI scans that have never been associated with a relevant neurological deficit, are associated with an increased risk of dementia after stroke 5 . Their influence is more important when the follow-up is longer in the Lille study, silent infarcts were associated with dementia after stroke at year 3 25 but not at year 2 and in the Maastricht study silent infarcts were independently related to dementia after 12 months, but not after 1 or 6...

Pregnancy after an ischemic stroke

A multicenter French study 79 conducted with 373 consecutive women who had an ischemic stroke between 15 and 40 years of age and followed-up over a 5-year period found an overall risk of recurrent stroke of 0.5 at year 5 (95 CI 0.3-0.95) in periods without pregnancy and 1.8 (95 CI 0.5-7.5) during pregnancies and puerperium, without significant difference. Therefore young women who have had an ischemic stroke have an overall low risk of recurrence during a subsequent pregnancy and do not...

Secondary prevention after ischemic stroke in young adults

The main characteristics of ischemic stroke occurring in young patients, i.e. their causes, the overall good outcome and interference with hormonal life in women (contraception, pregnancy and future menopause), influence secondary prevention after stroke. As for elderly subjects, secondary prevention measures mainly depend on the presumed cause. For this reason, an extensive and early diagnostic work-up is required, as well as an extensive evaluation of risk factors. The overall management of...

Management of acute ischemic stroke and its complications

General management of elevated blood pressure, blood glucose and body temperature Monitoring the blood pressure (BP), glucose levels and temperature in acute stroke patients is an often neglected matter although it may have an important impact upon the patients' outcome. In the Tel Aviv stroke register, recorded between the years 2001 and 2003, 32 of acute stroke patients in the emergency room had glucose levels higher than 150 mg dl, higher systolic BP than 140 mmHg was found in 77 of the...

Hypertensive blood pressure values in acute ischemic stroke

Several observations have demonstrated spontaneous elevation of blood pressure in the first 24-48 hrs after stroke onset with a significant spontaneous decline after a few days 1-3 . Several mechanisms may be responsible for the increased blood pressure, including stress, pain, urinary retention, Cushing effect due to increased intracranial pressure and the activation of the sympathetic, renin-angiotensin and ACTH-cortisol pathways. Despite the increased prevalence of hypertension following...

Controlling BP in the acute stroke phase

The theory that elevated systemic BP may compensate for the decreased cerebral blood flow in the ischemic region led to attempts to elevate blood pressure as a treatment for acute ischemic stroke. The hemody-namic and metabolic impact of pharmacologically increased systemic blood pressure on the ischemic core and penumbra was evaluated in rats. The mild induced hypertension was found to increase collateral flow and oxygenation and to improve cerebral metabolic rate of oxygen in the core and...

Stroke risk and PFO

It is uncertain whether the recurrence rate of stroke in patients with cryptogenic stroke is dependent on the presence of a PFO. In one observational study of patients treated with aspirin, the incidence of recurrent stroke was higher in patients with than without PFO 47 . In a further prospective randomized study, the recurrence rate of stroke was the same in those with or without PFO in those treated with either warfarin or aspirin 44 . The question of whether subjects from the general...

Anticoagulation

The rationale for immediate anticoagulation therapy in patients with definite and acute CVT is to stop pro-thrombotic processes and allow endogenous fibrino-lysis to recanalize the occluded veins and sinuses. However, concern has been raised about the possible dangers of anticoagulation in the presence of hemor-rhagic venous infarction, found in up to 40 of all CVT patients 2 . The issue has been addressed in two small randomized controlled trials 6, 8 that compared anticoagulant treatment with...

Arterial dissection uncommon clinical presentations

Bogousslavsky et al. 37 found an incidence of arterial dissection of 2.5 in 1200 consecutive first stroke patients. Under the age of 45 the incidence of cervical artery dissection (CAD) is much higher at 10-25 and CAD is the second leading cause of stroke in younger adults 38 . Most patients with dissections are between 30 and 50 years of age, and the mean age is approximately 40 years. The annual incidence of cervical internal carotid artery dissection was found to be 3.5 per 100000 in those...

Atrial fibrillation

Loop Recorder Implant

AF is a cardiac arrhythmia, defined by the absence of P waves and varying RR distances in the electrocardiogram. AF is a common arrhythmia and its prevalence increases with age up to 9 at age 80-89 years (Figure 7.1). Approximately 85 of the individuals with AF are between 65 and 85 years of age 1 . Apart from hemodynamic consequences due to the loss of atrial contraction and symptoms, such as palpitations, AF may lead to embolic stroke or peripheral or mes-enteric embolism. Compared to...

Blood pressure and outcome

Analysis of 17 398 patients in the International Stroke Trial 4 demonstrated a U-shaped relationship between baseline systolic blood pressure and both early death and late death or dependency. Both high blood pressure and low blood pressure were independent prognostic factors for poor outcome. Early death increased by 17.9 for every 10 mmHg below 150 mmHg (P < 0.0001) and by 3.8 for every 10 mmHg above 150 mmHg (P 0.016). A prospective study among 1121 patients admitted within 24 hours from...

Cardioembolism

The main causes of cardioembolism in young patients are listed in Table 14.1. A few of them deserve more detail. Atrial fibrillation is associated with a very low risk of cerebral emboli in young people when occurring in the absence of underlying cardiopathy (lone atrial fibrillation) and of vascular risk factors. However, it confers a high risk of cerebral emboli when there are Table 14.1. Main cardiac sources of cerebralischemia in young adults. atrial fibrillation associated with...

Cerebral amyloid angiopathy CAA

CAA refers to the deposition of amyloid proteins into the cerebral vessel walls with degenerative changes. Hereditary forms of CAA are known but CAA is most commonly sporadic and related to amyloid p (Ap) peptide deposition. This deposition is seen in the walls of small arteries and arterioles of the lepto-meninges, cerebral and cerebellar cortices, and less often in capillaries and veins. Overlaps with Alzheimer's disease are known and therefore old age and positive ApoE e4 allele are major...

Chapter Summary

Etiology intracerebral hemorrhage (ICH) is classified into primary (80 to 85 ) and secondary (15 to 20 ) causes. Hypertensive ICH (more than 50 of primary ICH typically in basal ganglia) most likely results from rupture of lipohyalinoic arteries followed by secondary arterial ruptures at the periphery of the enlarging hematoma. Thirty percent are found in association with cerebral amyloid angiopathy. Cerebral amyloid angiopathy (CAA 30 at primary ICH, typically lobar bleedings) refers to the...

Cognitive recovery after stroke

Besides defined neuropsychological syndromes, cognitive impairment after a stroke is very common and may persist in the postacute and also the chronic phase. Individual assessment includes evaluation of several aspects of attention, intelligence, memory, executive functions and personality prior to devising an individual treatment schedule, which can be neu-ropsychologically specific but should also be interdisciplinary, as the impairment usually has an impact on several aspects of the...

Complications

An increase in the bleeding volume is an early complication of ICH. The frequency of increased bleeding is high, though it might not be clear in all cases whether growth of volume is due to rebleeding or continuous bleeding. Brott et al. showed that growth, defined as a 33 increase of hematoma volume on CT, occurred in 26 of 103 patients within 4 hours after the first symptoms. Another 12 had growth within the following 20 hours. Hemorrhage growth was significantly associated with clinical...

Conclusion

The etiologies of ischemic stroke in the young are multiple and the outcome is good in most patients. New causes should now be identified. Diagnostic work-up (additionally to the standard work-up as in older patients) Intensive patient interview about the presence of headache, tinnitus, drug abuse, family history careful skin examination careful fundoscopic examination and in selected patients serology for syphilis and HIV, electrophoresis of proteins, antiphospholipid antibodies and testing...

CVT in elderly patients

Only recently, older patients were identified as a distinct subgroup of CVT patients. In ISCVT, about 8 of all patients were older than 65 years 27 . In general, these patients presented with clinical symptoms and signs different from those in younger patients isolated intracranial hypertension was uncommon, whereas disturbances of mental status, alertness and the level of consciousness were common. Carcinoma was found more often in older patients with CVT. The prognosis was worse, with half of...

CVT in neonates

While the symptomatology, etiology and therapy of CVT in older children resemble those of adult CVT in most respects, in neonates the causes, clinical presentation, outcome, and management are very different. Manifestation of CVT in neonates seems to be associated with maternal risk factors (hypertension, pre- eclampsia, gestational or chronic diabetes mellitus). The vast majority of neonates present with an acute illness at the time of diagnosis, most often dehydration, cardiac defects, sepsis...

Delirium

Delirium is a disturbance of consciousness, with a change in cognition or development of a perceptual disturbance, which develops over a short period, fluctuates during the course of the day and cannot be explained by pre-existing dementia (Table 12.7). Stroke is a rare cause of delirium. On the other hand, delirium often (15-48 ) complicates acute stroke 25-28 . Delirium must be differentiated clinically from disorientation in time, topographical disorientation, delusions and hallucinations,...

Dyslipidemia

Older epidemiological studies found no relationship between total serum cholesterol level and overall stroke incidence 111 . This might be due to different relationships for ischemic and intracerebral hemorrhages. In prospective cohort studies stroke risk was found to be positively associated with serum cholesterol level in ischemic stroke but negatively for intra-cerebral hemorrhages 112 . Age, sex and vascular risk factors can modify the relationship between blood cholesterol and vascular...

Emboli monitoring and acute stroke

TCD identifies microembolic signs (MES) in intra-cranial circulation. The ultrasound distinguishes signal characteristics through embolic materials -solid or gaseous - from erythrocyte flow velocity. Microembolic signals appear as signals of high intensity and short duration within the Doppler spectrum as a result of their different acoustic properties compared to the circulating blood. MES have been proven Table 4.4. Fast-track neurovascular ultrasound examination (Chernyshev et al. 11 ). Use...

Etiology

CVT may be due to infectious and non-infectious causes. Septic CVT is observed as a complication of bacterial infections of the visceral cranium, namely otitis, sinusitis, mastoiditis and bacterial meningitis. The infectious agents reach the cerebral sinuses ascending Table 11.1. Potentialcauses of and risk factors associated with cerebralvenous thrombosis 3, 4, 14 . Mutations in the methylenetetrahydrofolate reductase (MTHFR) gene Systemic infectious disease Inflammatory disease Systemic lupus...

Flow thresholds for preservation of function and morphological integrity

The different energy requirements for maintenance of membrane function and for propagation of information (signals) lead to different thresholds of energy consumption and consequently blood flow required for preservation of neuronal function and morphological integrity. The range of perfusion between those limits - a blood flow level below which neuronal function is impaired and a lower threshold below which irreversible membrane failure and morphological damage occur - was called the ischemic...

Functional magnetic resonance imaging fMRI

FMRI measures signals that depend on the differential magnetic properties of oxygenated and deoxygenated hemoglobin, termed the blood-oxygen-level-dependent (BOLD) signal, which gives an estimate of changes in oxygen availability 14 . This means that mainly the amount of deoxyhemoglobin in small blood vessels is recorded, which depends on the flow of well- oxygenated arterial blood (CBF), on the outflow of O2 to the tissue (CMRO2) and on the cerebral blood volume (CBV) 15 . The magnitude of...

Heparin for cardioembolic stroke

The International Stroke Trial investigated the use of aspirin and subcutaneous unfractionated heparin in a two-by-two factorial design. The beneficial effects of aspirin have already been discussed but the study also identified three fewer deaths within 14 days per 1000 patients treated with heparin (non-significant) and significantly fewer early recurrent strokes (2.9 vs. 3.8 ) and pulmonary emboli (0.5 vs. 0.8 ) 14 . After 6 months, however, the mortality rate was identical in those patients...

Imaging of penumbra

Based on the threshold concept of brain ischemia, the penumbra can be localized on quantitative flow images using established flow thresholds. A more direct approach is the imaging of threshold-dependent biochemical disturbances and demarcating the mismatch between disturbances which occur only in the infarct core and others which also affect the penumbra 59 (Figure 1.7). Under experimental conditions the most reliable way to localize the infarct core is the loss of ATP on bioluminescent images...

Incidence and prevalence rates

ICH, like ischemic stroke, has a clear age-dependent incidence rate, occurring slightly earlier in life than ischemic attacks. Most population-based registries report an incidence of 10 per 100 000 per year, and variations exist towards higher rates in some populations. A decrease of rates has been reported over time from several regions of the world. While the exact reasons for this decline are not known, it is reasonable to assume that a decline in rates as well as severity of arterial...

Incidence of newonset dementia in stroke survivors

Incidence studies are limited by similar methodological issues 5 . The incidence of dementia after stroke depends on whether the study excluded patients with pre-existing cognitive decline or dementia or not. Many so-called PSDs are not actually new-onset dementia, but pre-existing dementia revealed after stroke, pre-existing dementia being present in 7-16 of stroke patients, and often undiagnosed before stroke 15-21 . In a community-based study conducted over a 25-year period, the cumulative...

Infective endocarditis and stroke

Ischemic and hemorrhagic strokes occur in 10 to 23 of patients with endocarditis and cluster during the period of untreated infection 29-31 . Among patients with endocarditis and stroke, the mitral valve seems to be more frequently affected than the aortic valve 30, 31 . Native valves as well as prosthetic valves may be affected by endocarditis, leading to stroke. Stroke patients with prosthetic valves have a worse prognosis than patients with native valves 32, 33 . Despite the availability of...

Intracerebral hemorrhage

Hemorrhages into the brain occur unexpectedly and are often lethal events. Typical warning signs are not known rarely a feeling of unsteadiness, dizziness or a tingling sensation can precede an intracere-bral hemorrhage (ICH), but such symptoms do not have localizing value such as in ischemia, where stroke-like warning signs (transient attacks) can occur days or weeks before the onset of a stroke. Often enough only a history of elevated blood pressure is known. Thus, for most patients, it comes...

Isolated cranial nerves

Stroke in the brainstem is typically indicated by (a) ipsilateral cranial nerve (III-XII) palsy (single or multiple) together with contralateral motor or sensory deficit, (b) bilateral motor and or sensory deficits or (c) disorders of conjugate eye movements. Rarely, cranial nerve palsy without any sensory or motor deficits may indicate a focal brainstem ischemia. Two out of 22 patients with focal ischemic lesions in the mesencephalon had an isolated palsy of the oculomotor nerve 14 . Thomke et...

Lacunar stroke syndromes

Lacunes are defined as small subcortical infarcts less than 1.5 cm in diameter occurring in perforator territories. Together with leukoaraiosis, microbleeds, and hypertensive (deep) intracerebral hemorrhages, they are part of the spectrum of small-vessel disease. This disease is tightly related to chronic hypertension, but diabetes, male gender, increasing age, smoking, previous lacunar TIA or stroke, and coronary artery disease are also risk factors. About 20 of all strokes are considered to...

Language disorders

Language disorders, or aphasia, occur following peri-sylvian lesions (middle cerebral artery territory) of the left hemisphere and have a marked impact on the individual quality of life, autonomy and the ability to return to work or previous activities. Since these lesions are circumscribed, the conceptual representation system is not affected and these patients are not demented. This is an important distinction that should be explained to the family and caregivers. Language disorders occur...

Large artery atherosclerosis

Atherosclerosis of the major vessels supplying the brain is an important mechanism in ischemic stroke. Although the common occurrence of atherosclerosis in the region of the carotid bifurcation was observed early in the twentieth century, and the mechanism of distal embolization in causing strokes was proposed, it was widely assumed that most cerebral ischemic strokes were caused by in situ middle cerebral artery (MCA) thrombosis. The full implications of extracranial atherosclerosis for...

Large artery atherosclerosis in the aortic arch

The link between atherosclerosis of the aortic arch and ischemic stroke was not clearly recognized until the early 1990s when autopsy studies revealed a high prevalence of such lesions in particular in patients with cryptogenic strokes 7 . At that time examination of the aortic arch was not part of the routine echocardiographic examination. Protruding aortic atheromas (> 4-5 mm) have been found to be 3-9 times more common in stroke patients than in healthy controls. Later studies have...

Lifestyle factors

Stroke prevalence has been associated with individual lifestyle factors (e.g. smoking, exercise, body mass index (BMI), alcohol consumption) in several studies. Healthy lifestyle in general was considered in one large prospective cohort study of healthy women. In this study, healthy lifestyle, consisting of abstinence from smoking, low-normal body mass index, moderate alcohol consumption, regular exercise and healthy diet, was found to be associated with a reduction in ischemic stroke (RR 0.3...

Mechanisms of cerebral ischemia resulting from extracranial and intracranial large artery atherosclerosis

Artery-to-artery embolism is considered the most common mechanism of TIA and ischemic stroke due to large artery atherosclerosis. Thrombosis at the site of an atherosclerotic lesion is due to interplay between the vessel wall lesion, blood cells and plasma factors. Severe stenosis alters blood flow characteristics, and turbulence replaces laminar flow when the degree of stenosis exceeds about 70 . Platelets are activated when exposed to abnormal or denuded endothelium in the region of an...

Microbleeds

MRI visualizes acute and chronic hematomas, but also old, clinically non-apparent cerebral microbleeds that are not detected on CT. Microbleeds have a hypointense appearance on MRI and are usually smaller than 5-10 mm. Pathological studies have shown that microbleeds seen with GRE MRI usually correspond to hemosiderin-laden macrophages adjacent to small vessels and are indicative of previous extravasation of blood 35 . One review 36 included 53 case series studies involving 9073 participants,...

Middle cerebral artery MCA

The middle cerebral artery (MCA) is also designated the Sylvian artery, from Jacques Dubois, known as Jacobus Sylvius (1489-1555), a linguist and anatomist in Paris. The artery is subdivided into the M1 segment, from which start the deep perforating lenticulostriate arteries, the M2 segment, corresponding to the segment after the bifurcation into superior and inferior divisions, and the M3 segment, including the insular part. The M4 segments, the leptomeningeal arteries, arise from the M3...

Motor and somatosensory deficits

Motor function may be impaired by damage to a widely distributed network, involving multiple cortical representations and complex fiber tracts. The degree of motor impairment and the potential for recovery depends on the site of the lesion, the association of lesions in cortical areas and in fiber tracts and the involvement of deep gray structures, e.g. the basal ganglia, thalamus and brainstem. The patterns of altered metabolism and blood flow and the patterns of activation after stimuli or...

Neuroradiology

PART A IMAGING OF ACUTE ISCHEMIC AND HEMORRHAGIC STROKE CT, PERFUSION CT, CT ANGIOGRAPHY NCCT can be performed in less than a minute with a helical CT scanner, and is considered sufficient to select patients for intravenous thrombolysis with iv-RTP within 4.5 hours, or endovascular treatment within 6 hours. It is a highly accurate method for identifying acute intracerebral hemorrhage and subarachnoid hemorrhage, but quite insensitive for detecting acute ischemia. The approximate sensitivity of...

Other definite causes of cerebral ischemia

These are actually the most frequent causes of cerebral ischemia when a cause can be identified. Figure 14.3. Brain MRI of a CADASIL patient showing severe white matter abnormalities and lacunas. Cervical artery dissections are the leading cause of cerebral ischemia in the young in Western countries when a cause can be clearly identified 7, 38 . In most cases no trauma can be identified, or the trauma is mild and a causal relationship between a trivial trauma and dissection is even disputable...

Other diagnostic findings

The diagnosis of CVT is based on the detection of venous thrombosis by the neuroimaging techniques described above. As differential diagnosis of CVT comprises a large number of diseases, diagnostic workup in patients with the final diagnosis of CVT requires extensive laboratory exams as well as other auxiliary testing lumbar puncture, EEG and trans-cranial Doppler ultrasound are often performed, but most findings are nonspecific. Most routine laboratory findings in the acute phase of aseptic...

Physical inactivity

Several prospective longitudinal population studies have shown the protective effect of regular physical activity for stroke in women and men. In a meta-analysis of 18 cohort and five case-control studies, physically highly active individuals had a lower risk of stroke and lower stroke mortality than those with low activity (RR 0.7 95 CI 0.7-0.8). Similarly, moderately active individuals had a lower risk of stroke, compared with those who were inactive (RR 0.8 95 CI 0.7-0.9) 51 . A similar...

Poststroke aphasia

Studies of glucose metabolism in aphasia after stroke have shown metabolic disturbances in the ipsilateral hemisphere caused by the lesion and contralateral hemisphere caused by functional deactivation (dia-schisis) (review in 26 ). In right-handed individuals with language dominance in the left hemisphere, the left temporo-parietal region, in particular the angular gyrus, supramarginal gyrus and lateral and transverse superior temporal gyrus are the most frequently and consistently impaired,...

Poststroke dementia

Stroke is an important risk factor for dementia and cognitive decline. According to the NINDAS-AIREN criteria, in order to make the diagnosis of post-stroke dementia (PSD) the patient has to be demented, with either historical, clinical or radiological evidence of cerebrovascular disease and the two disorders must be reasonably related 77 . On the other hand, according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-4) 78 , vascular dementia is diagnosed by the...

Poststroke depression

Post-stroke depression is a prominent and persistent mood disturbance characterized by depressed mood or lack of interest or lack of pleasure (anhedonia) in all or almost all activities. Post-stroke depression has two subtypes with depressive features and similar to a major depressive episode. Figures related to the epidemiological features of post-stroke depression are highly variable, because they depend on the setting of the study, the time since stroke, the case mix and the criteria method...

Poststroke seizures

Epilepsy is one of the most common serious neurological disorders and is associated with numerous social and psychological consequences. Stroke is the most commonly identified etiology of secondary epilepsy and accounts for 30 of newly diagnosed seizures in patients older than 60 years 48 . Although recognized as a major cause of epilepsy in the elderly, many questions still arise regarding the epidemiology, treatment and outcome of post-stroke seizures. The common definition of epilepsy...

Prehospital care and referral

The essential building blocks for prehospital stroke care are the emergency medical service (EMS) organization consisting of an emergency response center (ERC), the EMS providers and the admitting stroke center, all of which should be involved in planning the prehospital critical pathway. The general emergency phone number 112 (in Finland) (911 in the United States) is the first link in the chain of survival and recovery for acute stroke patients. National stroke-awareness campaigns always...

Prevalence of dementia in stroke survivors

Prevalence studies include both dementia pre-existing to stroke and new-onset dementia occurring after stroke 5 . The prevalence of PSD ranges from 5.9 to 32 , depending on the mean age of the study population, exclusion or not of patients with aphasia or severe physical disability, mortality rates, delay between stroke onset and cognitive assessment, and criteria used for the diagnosis of dementia 5, 12 . Dementia is 3.5-5.8-fold more frequent in patients who have had a stroke than in...

Prognosis

The vital and functional prognosis ofpatients with acute CVT, as established in the ISCVT cohort, is astonishingly favorable, with an overall death or dependency rate of about 15 2 . Long-term predictors of poor prognosis are the presence of CNS infection, malignancy, deep venous system thrombosis, intracranial hemorrhage, coma upon admission, age and male sex. In the acute phase of CVT, the case fatality is around 4-8 2, 14 . The main causes of acute death are transtentorial herniation...

QT prolongation

Prolongation of ventricular repolarization manifests as a prolongation of the QT interval on the electrocardiogram. QT prolongation may be associated with torsades de pointes tachycardia. Torsades de pointes are often self-limited and are associated with palpitations, dizziness or syncope. Degeneration into ventricular fibrillation and sudden cardiac death can occur. In addition to the congenital long QT syndrome many drugs, such as antiarrhythmic drugs class IA and III, antibiotics,...

Recent infection and stroke

Several studies have supplied evidence that acute infection in the week preceding stroke is an independent risk factor for cerebral infarction (odds ratio 3.414.5) 1-3 . Especially bacterial respiratory and urinary tract infections can trigger ischemic stroke 4 . Since a heterogeneous group of microbial pathogens is involved, the systemic inflammatory response is probably more important than microbial invasion per se. However, a detailed molecular understanding of events that lead to a higher...

Recurrence of cerebral venous thrombosis

After the acute phase of CVT, anticoagulation is continued not only to facilitate the recanalization of the occluded cerebral veins, but also in order to prevent the recurrence of intra- or extracerebral thrombosis. Recurrent CVT may be difficult to diagnose, if follow-up MRI or MRV examinations are not available. Therefore, it seems feasible to repeat MR venography in CVT patients after 4-6 months, as further recana-lization cannot be expected after this point. This follow-up venography may...

References

Kreisler A, Godefroy O, Delmaire C, Debachy B, Leclercq M, Pruvo JP, et al. The anatomy of aphasia revisited. Neurology 2000 4 1117-23. 2. Martin A. The representation of object concepts in the brain. Annu Rev Psychol 2007 58 25-45. 3. Saur D, Lange R, Baumgaertner A, Schraknepper V, Willmes K, Rijntjes M, et al. Dynamics of language reorganization after stroke. Brain 2006 129 1371-1384. 4. Plaut D, McClelland J, Seidenberg M, Patterson K. Understanding normal and impaired word reading. Psychol...

Regulation of blood flow

In the intact brain, cerebral blood flow is tightly coupled to the metabolic requirements of tissue (metabolic regulation) but the flow rate remains essentially constant despite alterations in blood pressure (autoregulation). An important requirement for metabolic regulation is the CO2 reactivity of cerebral vessels, which can be tested by the application of carbonic anhydrase inhibitors or CO2 ventilation. Under physiological conditions, blood flow doubles when CO2 rises by about 30 mmHg and...

Rehabilitation of speech disorders

Aphasia with its affection of different modalities, including speech, comprehension, reading, and writing, is a common consequence of stroke, mainly of the left hemisphere. Because of its enormous impact on patients' lives rehabilitative therapy is mandatory and uses principles such as forced-use for treatment concepts 85 . Even more than in other therapeutic modalities, the importance of a high treatment intensity has been demonstrated a meta-analysis 86 shows that studies which demonstrated a...

Skin examination

Skin examination is an important step in the search for a cause. It should be performed with the patient naked, and requires the advice of a dermatologist when necessary. The examination should focus on the search for features of abnormal skin elasticity, varicose veins, spontaneous ecchymosis, abnormal scars (in favor of Ehlers-Danlos disease) papulosis (in favour of malignant atrophic papulosis, so-called Degos disease) livedo racemosa (in favor of Sneddon disease) neurofibromas and taches...

Smallvessel disease

Infarcts due to small-vessel disease of the brain were first recognized by French neurologists and neuropathologists in the nineteenth century, who also coined the term lacune from the autopsy finding of a small cavitation. However, the importance of lacunar infarcts as one of the main ischemic stroke subtypes was not clearly recognized until the investigations of C. Miller Fisher in the 1960s, who on the basis of careful clinico-pathological observations laid the foundation for our...

Smallvessel occlusion

Lacunar infarcts are small infarcts of less than 15 mm located in the deep white matter, basal ganglia and brainstem. They are the consequence of the occlusion of a single deep perforating intracerebral artery of less than 400 m in diameter. These perforators have no collaterals and their occlusion always leads to an infarct. The short-term outcome is usually good, but the risk is cognitive decline and dementia in the event of recurrences. Lipohyalinosis of the deep perforators Arterial...

Stroke unit care

A stroke unit is defined as an organized inpatient area that exclusively or nearly exclusively takes care of stroke patients and is managed by a multidisciplinary team of specialists who are knowledgeable about stroke care. The most distinctive features are a multi-disciplinary team specialized in the care of stroke patients (i.e. medical staff, nursing staff and therapists with expertise in stroke and rehabilitation), educational programs for the staff, involvement of care-givers, written care...

Takotsubo syndrome

Takotsubo syndrome (TTS), also known as apical ballooning, is a reversible neuromyocardial failure which resembles acute myocardial infarction clinically and electrophysiologically in patients with normal coronary arteries 63 . TTS is clinically characterized by sudden onset of anginal chest pain, dyspnea or syncope. Initially, the ECG shows ST elevation, which turns into negative T-waves a few hours or days later, which may persist for months 64, 65 . Reversible akinesia or hypokinesia affects...

The basilar artery BA

The BA lies on the ventral surface of the brainstem and vascularizes the pons, the mesencephalon and the middle and upper cerebellum through the AICA and SCA. Its territory can be subdivided into three parts on a ventro-dorsal level 11 . The anteromedial territory receives its blood supply from the paramedian arteries, the anterolateral territory from the short circumferential arteries (or anterolateral arteries) and the dorsolateral territory from the long circumferential arteries (or...

The scope of the problem

Stroke is the second leading cause of death worldwide in the adult population, the first being coronary heart disease 2 . Of note, stroke is an increasing problem in developing countries, 87 of stroke deaths occurring in low- and middle-income countries 2-4 . Stroke is the fourth leading cause of disease burden (as measured in disability-adjusted life years DALYs ) after heart disease, HIV AIDS and unipolar depressive disorders 2 . In the 1990s, it caused about 4.4 million deaths worldwide in...

The thalamus

The thalamus is a centrally situated structure with extensive reciprocal connections with the cortex, basal Figure 8.1. Carotid artery (1) basilar artery (2) posterior cerebral segment P1 (3) segment P2 (4) posterior communicating artery (5) tuberothalamic artery (6) paramedian arteries (7) thalamogeniculate artery (8) posterior choroidalartery (9). Source Barth et al. in Bogousslavsky J, Caplan L, eds. Stroke Syndromes. Cambridge Cambridge University Press 2001 461. Figure 8.1. Carotid artery...

The vascular origin of cerebrovascular disease

All cerebrovascular diseases (CVD) have their origin in the vessels supplying or draining the brain. Therefore, knowledge of pathological changes occurring in the vessels and in the blood is essential for understanding the pathophysiology of the various types of CVD and for the planning of efficient therapeutic strategies. Changes in the vessel wall lead to obstruction of blood flow, by interacting with blood constituents they may cause thrombosis and blockade of blood flow in this vessel. In...

The vertebral artery VA and the posterior inferior cerebellar artery PICA

The vertebral arteries give origin to two arteries before joining to form the basilar artery the anterior spinal artery, which supplies the medial medulla oblongata and the upper cervical cord, and the PICA, which supplies the inferior cerebellum and the dorsolateral medulla. The latter structure may also receive direct (long circumferential) branches from the vertebral artery. Three classic clinical syndromes are recognized in their territory the medial medullary stroke (or Dejerine syndrome)...

Thrombolysis

In respect of acute interventions, one of the most significant advances during the last two decades has been the introduction of intravenous thrombolysis as a standard therapy for a well-selected population of patients with acute ischemic stroke. At present, the only thrombolytic agent licensed in Europe for the treatment of ischemic stroke is recombinant-tissue plasminogen activator (rtPA), alteplase. The evidence for its use comes from six landmark clinical trials the Alteplase Thrombolysis...

Timing and intensity

Clinical studies indicate that an early start and high intensity of therapies are decisive for a favorable long-term outcome. On the basis of pathophysiological data, the first 3 weeks after stroke are considered as a particularly promising period in animal models active training leads to better functional recovery and sprouting, whereas inactivity results in additional loss of ability 12, 20, 23 . However, some experimental studies in rats show that very early (starting within 24 hours) and...

Ultrasound diagnosis of intracranial stenosis and occlusion

Intracranial disease corresponds to approximately 8-10 of acute ischemic stroke, depending on gender and race. Diagnosis is frequently reached through Table 4.1. Highlights of the guidelines of the European Federation of NeurologicalSocieties 5 . Table 4.1. Highlights of the guidelines of the European Federation of NeurologicalSocieties 5 . Ultrasonography is the non-invasive screening technique indicated for the study of vessels involved in causing symptoms of carotid stenosis Transcranial...

Urinary tract infections

Urinary tract infections (UTI) are common infections post-stroke, since many patients have indwelling catheters in place, which convey a significant risk of infection. Asymptomatic occurrence of bacteria in the urine (bacteriuria) needs to be distinguished from a true infection. Signs of UTI include mild irritative symptoms, such as frequency and urgency, dysuria, fever, and severe systemic manifestations, such as bacteremia and sepsis. Microbiological examination of a urine specimen confirms...

Visual agnosia

The human brain has two parallel visual systems a ventral occipito-temporal stream, whose main function is the recognition of visual stimuli (the what system) and a dorsal occipito-parietal stream, whose main function is the spatial localization of visual stimuli (the where system) 20 . The paradigm of human dysfunction of the ventral system is visual agnosia while that of the dorsal system is Balint's syndrome. Visual agnosias are disorders of visual recognition and are one of the clinical...

Chronic infections and stroke

Atherosclerosis is a common disease and a major risk factor for stroke. Its etiology can largely be explained by the classic risk factors (age, gender, genetic predisposition, hypertension, diabetes, hypercholesterolemia, diet, smoking, low physical activity, etc.). Additionally, pathogens such as Helicobacter pylori, cytomegalovirus, herpes simplex virus and Chlamydia pneumoniae have been proposed to be associated with atherosclerosis. Most studies on the infectious etiology of atherosclerosis...

Watershed infarcts WS

Watershed (or borderzone) infarcts represent about 5 of all strokes. They involve the junction of distal regions of two arterial systems. Pathophysiologically, systemic hemodynamic failure, tight stenosis (or occlusion) of a cervical or intracranial artery 26 , or embolic occlusion of an intracerebral artery are implicated. Recently, a combination of these mechanisms has been proposed 27 hypoperfusion due to severe arterial stenosis or occlusion would impair the reserve of brain areas becoming...

Motor rehabilitation

Motor impairment is the most common deficit in stroke, often resulting in reduced independence and mobility. Beside the concepts of physical, occupational and other therapies (see below) the following methods are aimed especially at motor recovery. Walking is an important objective in stroke rehabilitation, conventional gait training programs on the floor being routine practice. With the aim of enhancing the efficacy of gait training and also of easing the burden on the therapists, three groups...

Meningitis as a cause of stroke

Meningitis denotes the inflammation of the leptome-ninges, which consist of the pia mater and arachnoid mater. These layers ensheath the spinal cord and brain and confine the subarachnoidal space, which contains cerebrospinal fluid (CSF). Infection of the meninges by bacteria or fungi leads to an inflammatory response which causes the typical clinical symptoms, headache and nuchal rigidity. Depending on the time course, meningitis can be classified as acute or chronic. Acute bacterial...

Hypertension smoking alcohol cholesterol and drugs

Hypertension is the most common risk factor for spontaneous intracerebral hemorrhage and the frequency has been estimated to be between 70 and 80 . The causative role of hypertension is supported by the high frequency of left ventricular hypertrophy in autopsy of patients with ICH. The role of hypertension and the beneficial effect of antihypertensive treatment with regard to risk of ICH were verified in several large clinical trials. In the PROGRESS trial 21 the relative risk of ICH was...

Energy requirements of brain tissue

The energy demand of the nervous tissue is very high and therefore sufficient blood supply to the brain must be maintained consistently. A normal adult male's brain containing approx. 130 billion neurons (21.5 billion in the neocortex) 49 comprises only 2 of total body mass, yet consumes at rest approximately 20 of the body's total basal oxygen consumption supplied by 16 of the cardiac blood output. The brain's oxygen consumption is almost entirely for the oxidative metabolism of glucose, which...

Embolic stroke

Infective endocarditis (IE) is an infection of the endocardium, a thin tissue layer that lines heart valves and mural myocardium (Figure 18.1). The incidence of IE Table 18.1. Infectious causes of stroke and associated mechanisms. Table 18.1. Infectious causes of stroke and associated mechanisms. Staphylococcus aureus, Streptococcus spp., Enterococcus spp., Aspergillus spp., and others Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, and others Mycobacterium...

Clinical and neuroimaging features of cardioembolic ischemic strokes

Although cardioembolism may cause almost any clinical stroke syndrome, some features are statistically linked to this cause and are therefore characteristic (Table 2.3). However, it should be borne in mind that the positive predictive value of clinical features suggesting cardioembolism is very modest, at only about 50 20, 21 . Conversely, some clinical and neuro-imaging syndromes, such as a lacunar syndrome found on dw-MRI to be due to a single small infarct, are very unlikely to be due to...

Bilateral blindness top of the basilar artery

Top Basilar Artery Stroke

Sudden cortical blindness is a rare symptom of TIA or stroke and has been explained by an occlusion of the top of the basilar artery at the origin of the posterior cerebral arteries 11 . The visual field defects may be Figure 9.4. Blind sight. A 65-year-old patient with known Parkinson's disease and vascular risk factors (diabetes mellitus, hypertension, obesity and smoking) suddenly lost muscle tone and consciousness. On admission he was awake, responded to verbalcommands and was partially...

Hyperviscosity and low flow

Blood flow in the brain is determined by the size of blood vessels, blood pressure and hemorrheological factors ofthe blood. Abnormal changes ofblood plasma with hematological disease (e.g. Waldenstrom's macro-globulinemia or paraproteinemia), increase in cell counts (e.g. in diseases such as polycythemia vera, ery-throcytosis or hyperleukotic leukemias), and decreased red cell deformability (sickle-cell anemia, spherocytosis, hemoglobinopathies) lead to a hyperviscous state 9 . Cerebral blood...

Cardioembolic sources major and minor

There are several cardiac disorders that may constitute a source of embolus, but not all sources pose equal threats. They are commonly divided by origin in the heart (atrial, valvular, ventricular) and potential for embolism (high risk versus low or uncertain risk, or major versus minor) (Table 2.2). The clinically most important cardioembolic sources are non-rheumatic atrial fibrillation (AF), infective endocarditis, prosthetic heart valve, recent myocardial infarction, dilated cardiomyopathy,...

Disturbances of emotional expression control

The prevalence of crying in acute stroke patients has been estimated at between 12 and 27 , but disorders of emotional expression control are more frequent (11-40 ) and often appear delayed after stroke onset 37 . This disorder consists of uncontrollable outbursts of laughing, crying or both, with paroxysmal onset, transient duration of seconds or minutes, stereotyped, precipitated by nonspecific or inappropriate stimuli but also by appropriate stimuli in an inappropriate context. Patients...

Intracranial vasculopathies caused by virus and bacterial infection

Intracranial Infection

Varicella zoster virus (VZV) vasculopathy may often be clinically silent but may present with stroke and can be diagnosed because of the following symptoms, signs and findings (for review Nagel et al. 28 ). (1) About two-thirds of patients have a history of zoster rash, particularly ophthalmic-distribution zoster or a history of chicken pox. There is a delay between the onset of zoster chicken pox and the onset of stroke averaging 4.1 months (range between same day and 2.5 years). But about...

Stroke manifestations of systemic disease

Infective and non-infective endocarditis multi-territorial pattern of ischemic stroke Endocarditis of the heart and its valves in particular can be classified into infective and non-infective types. The vast majority of endocarditis is secondary to infections caused by bacterial (Staphylococcus aureus, coagulase-negative Staphylococcus or Enterococcus) or, rarely, fungal (Candida, Aspergillus) organisms 19 . Cerebral embolism from infected valves is the central mechanism of neurological injury...

Clinical syndromes

Clinical presentation of spontaneous ICH depends on site and size. Therefore, clinical investigation as well as neuroimaging are both important for a reliable diagnosis. All attempts to make a probabilistic diagnosis on clinical grounds alone to differentiate between ischemic and hemorrhagic stroke have not been considered satisfactory 45 . In our series of 1539 ICH cases we have located 45 in the putaminal region and in the thalamus, 34 in a lobar location, 5 in the cerebellum, about 4 in the...