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Background and objectivesInvestigations of rapid neurologic improvement (RNI) in patients with acute cerebral ischemia (ACI) have focused on RNI occurring after hospital arrival. However, with stroke routing decisions and interventions increasingly migrating to the prehospital setting, there is a need to delineate the frequency, magnitude, predictors, and clinical outcomes of patients with ACI with ultra-early RNI (U-RNI) in the prehospital and early postarrival period.MethodsWe analyzed prospectively collected data of the prehospital Field Administration of Stroke Therapy-Magnesium (FAST-MAG) randomized clinical trial. Any U-RNI was defined as improvement by 2 or more points on the Los Angeles Motor Scale (LAMS) score between the prehospital and early post-emergency department (ED) arrival examinations and classified as moderate (2-3 point) or dramatic (4-5 point) improvement. Outcome measures included excellent recovery (modified Rankin Scale [mRS] score 0-1) and death by 90 days.ResultsAmong the 1,245 patients with ACI, the mean age was 70.9 years (SD 13.2); 45% were women; the median prehospital LAMS was 4 (interquartile range [IQR] 3-5); the median last known well to ED-LAMS time was 59 minutes (IQR 46-80 minutes), and the median prehospital LAMS to ED-LAMS time was 33 minutes (IQR 28-39 minutes). Overall, any U-RNI occurred in 31%, moderate U-RNI in 23%, and dramatic U-RNI in 8%. Any U-RNI was associated with improved outcomes, including excellent recovery (mRS score 0-1) at 90 days 65.1% (246/378) vs 35.4% (302/852), p < 0.0001; decreased mortality by 90 days 3.7% (14/378) vs 16.4% (140/852), p < 0.0001; decreased symptomatic intracranial hemorrhage 1.6% (6/384) vs 4.6% (40/861), p = 0.0112; and increased likelihood of being discharged home 56.8% (218/384) vs 30.2% (260/861), p < 0.0001.DiscussionU-RNI occurs in nearly 1 in 3 ambulance-transported patients with ACI and is associated with excellent recovery and decreased mortality at 90 days. Accounting for U-RNI may be useful for routing decisions and future prehospital interventions. TRIAL REGISTRATION INFORMATION: clinicaltrials.gov. Unique identifier: NCT00059332.

Approximately 15% of all ischemic strokes (IS) occur in young adults and adolescents. To date, only limited prior public health and research efforts have specifically addressed stroke in the young. Early diagnosis remains challenging because of the lack of awareness and the relative infrequency of stroke compared with stroke mimics. Moreover, the causes of IS in the young are heterogeneous and can be relatively uncommon, resulting in uncertainties about diagnostic evaluation and cause-specific management. Emerging data have raised public health concerns about the increasing prevalence of traditional vascular risk factors in young individuals, and their potential role in increasing the risk of IS, stroke recurrence, and poststroke mortality. These issues make it important to formulate and enact strategies to increase both awareness and access to resources for young stroke patients, their caregivers and families, and health care professionals. The American Academy of Neurology recently convened an expert panel to develop a consensus document concerning the recognition, evaluation, and management of IS in young adults and adolescents. The report of the consensus panel is presented herein.

Most of the blood supplied to the brain travels through the left and right internal carotid arteries (ICA). The dissection of an internal carotid is recognized more and more often as a cause of stroke, now that angiography (X-ray examination of blood vessels) is safer and performed more frequently. In a dissection, blood enters the muscular wall of the artery through a damaged or defective area. The pressure of the blood may then force apart layers of muscle cells; this tearing apart of the tissue is the ''dissection.'' The expanding reservoir of blood in the dissection may force closed the normal pathway for blood flow through the artery. Three patients are reported in whom unusual visual symptoms led to the diagnosis of a dissecting aneurysm of the internal carotid artery. While transient blindness in one eye (amaurosis fugax) may occur in cases of carotid dissection, in the present patients the visual symptoms were visual figures. One patient saw bright dots, and one saw scintillating snowflakes. The third patient saw grey triangles outlined in bright red or blue against a glaring background. These symptoms resemble the ''aura'' described by some migraine sufferers preceding an attack. However, in all three cases the presence of other neurological symptoms led to imaging studies, which revealed the dissection of the internal carotid artery. These cases illustrate that visual illusions resembling an aura need not indicate the onset of migraine, but may indicate the development of a dissecting aneurysm of the carotid artery. (Consumer Summary produced by Reliance Medical Information, Inc.)

Autoantibodies, or antibodies directed against some of the body's own molecules, are being identified in an increasing number of disorders. While in some disorders the autoantibodies may only be a result of the pathologic process, in others the autoantibodies may play a direct role in the progression of the disease. Antiphospholipid antibodies have been observed both in a number of disease conditions as well as in some individuals with no apparent symptoms. The most widely studied antiphospholipid antibodies are anticardiolipin and the closely related lupus anticoagulant. Studies of patients with lupus erythematosus, in which autoantibodies are featured with a prominence unequalled in most disorders, revealed an association of antiphospholipid antibodies and stroke. Since the initial observation, antiphospholipid antibodies have been found to be associated with stroke in patients without signs of lupus. The association of cerebrovascular and neurologic disease with antiphospholipid antibodies was observed in 48 cases in the present study. Twenty-three patients had cerebral infarcts and 12 had transient cerebral ischemia (impaired blood flow to the brain) lasting less than 24 hours. Other neurological symptoms observed included visual disturbances in one eye, temporary amnesia, and severe vascular headache. In 79 percent of the patients, at least one other risk factor for stroke was present, including smoking, hypertension, diabetes, or dyslipidemia (abnormal amounts of blood lipids). It should be mentioned, however, that the mean age of the patients in the present study was 43 years, less than that of patients with atherosclerotic stroke. In 21 percent of the patients, however, no risk factor other than antiphospholipid antibodies was present; these patients are considered to be examples of ''primary antiphospholipid syndrome.'' The role of antiphospholipid antibodies in the pathogenesis of disease remains controversial, however. While there is some suggestion that antiphospholipid antibodies may contribute to abnormal coagulation mechanisms, such abnormalities have not been clearly elucidated. The authors suggest that greater uniformity in the testing and reporting of antiphospholipid antibodies among stroke patients will help to clarify some of these issues. (Consumer Summary produced by Reliance Medical Information, Inc.)

In older patients, the most common cause of cerebral hemorrhage is high blood pressure. In younger patients, most cerebral hemorrhages occur as the result of physical trauma; of the cases which do not involve trauma, most involved the rupture of a malformed blood vessel. However, some drugs may cause intracerebral hemorrhages. Among these drugs are cocaine and the free-base form popularly called 'crack'. Recently, a patient reported developing a severe headache about one hour after smoking crack. The patient also had difficulty coordinating movements of his right hand and foot. The headache persisted the following day, and the patient developed both nausea and double vision. The patient had neither high blood pressure (hypertension) nor a history of bleeding disorders. CT scan and magnetic resonance imaging revealed a hemorrhage in the pons, part of the brainstem that lies below the cerebellum. Until modern imaging techniques became available, it had generally been considered that a hemorrhage in the pons was usually fatal. However, it is now clear that an intracranial hemorrhage in this region is more common than has been previously thought. However, hemorrhages in the pons are rarely the result of hypertension or the other more common causes of intracranial hemorrhage. In the case of this patient, there appears to be no likely cause of an intracranial hemorrhage except for the cocaine use. Most hemorrhages that have been observed as a result of cocaine use have been lobar hemorrhages (within a lobe of the cerebral cortex). While it has been suggested that patients who experience an intracranial hemorrhage as the result of cocaine use probably had some sort of pre-existing blood vessel malformation, no such vascular malformation could be identified in this case. (Consumer Summary produced by Reliance Medical Information, Inc.)