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Henry J.M. Barnett, also known as Barney, was a renowned neurologist born in 1922 in Newcastle, United Kingdom. He initially wanted to study biology but was convinced by his father to pursue medicine. Barnett became an expert in syringomyelia and later focused on stroke research. He conducted influential clinical trials on the use of aspirin and surgical interventions for stroke prevention. By the time of his death in 2016, Barnett had made significant contributions to the management of stroke and received numerous honors for his work. [Extracted from the article]

OBJECTIVE Our aim is to compare the effect of type 2 diabetes on recurrent major cardiovascular events (MCVE) for patients with symptomatic vascular disease at different locations. RESEARCH DESIGN AND METHODS A total of 6,841 patients from the single-center, prospective Second Manifestations of ARTerial disease (SMART) cohort study from Utrecht, the Netherlands, with clinically manifest vascular disease with (n = 1,155) and without (n = 5,686) type 2 diabetes were monitored between 1996 and 2013. The effect of type 2 diabetes on recurrent MCVE was analyzed with Cox proportional hazards models, stratified for disease location (cerebrovascular disease, peripheral artery disease, abdominal aortic aneurysm, coronary artery disease, or polyvascular disease, defined as ≥2 vascular locations). RESULTS Five-year risks for recurrent MCVE were 9% in cerebrovascular disease, 9% in peripheral artery disease, 20% in those with an abdominal aortic aneurysm, 7% in coronary artery disease, and 21% in polyvascular disease. Type 2 diabetes increased the risk of recurrent MCVE in coronary artery disease (hazard ratio [HR] 1.67; 95% CI 1.25-2.21) and seemed to increase the risk in cerebrovascular disease (HR 1.36; 95% CI 0.90-2.07), while being no risk factor in polyvascular disease (HR 1.12; 95% CI 0.83-1.50). Results for patients with peripheral artery disease (HR 1.42; 95% CI 0.79-2.56) or an abdominal aortic aneurysm (HR 0.93; 95% CI 0.23-3.68) were inconclusive. CONCLUSIONS Type 2 diabetes increased the risk of recurrent MCVE in patients with coronary artery disease, but there is no convincing evidence that it is a major risk factor for subsequent MCVE in all patients with symptomatic vascular disease. [ABSTRACT FROM AUTHOR]

Aims:Adiposity is associated with an increased but also with a decreased risk for successive vascular events or mortality in patients with different manifestations of vascular disease. In this study we directly compare the risk of general adiposity or abdominal obesity on the occurrence of new vascular events or mortality in these patients.Methods:Patients with cerebrovascular disease (CVD; n=973), coronary artery disease (CAD; n=2339) or peripheral arterial disease (PAD; n=894) were prospectively followed for the occurrence of a vascular event or death. The median follow-up was 4.5 years. Adiposity was assessed with body mass index (BMI), waist circumference (WC) and determination of intra-abdominal fat through ultrasound. Cox proportional hazards models were used to evaluate the risk for new vascular events, vascular mortality and all-cause mortality.Results:CAD patients had a 12% increased risk for vascular mortality with 1 BMI unit increase (hazard ratio (HR) 1.12; 95% confidence interval (CI) 1.05-1.20) and a 25% increased risk with 1cm increase in intra-abdominal adipose tissue (HR 1.25; 95% CI 1.12-1.39). The risk for all-cause mortality was increased by 3% (HR 1.03; 95% CI 1.01-1.05) with 1 cm increase in WC and was increased by 15% (HR 1.15; 95% CI 1.06-1.25) with 1 cm increase in intra-abdominal adipose tissue. In PAD patients there was an inverse relationship between BMI and vascular mortality (HR 0.93; 95% CI 0.87-0.98) and all-cause mortality (HR 0.90; 95% CI 0.86-0.94). In CVD patients there was no relation between obesity and vascular events or mortality.Conclusion:General adiposity is associated with an increased risk for vascular mortality in CAD patients and a decreased risk for (vascular) mortality in PAD patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: In patients with acute ischaemic stroke and hyperglycaemia, prolonged strict glycaemic control may improve clinical outcome. The question is how to achieve this prolonged strict glycaemic control. In this study, the efficacy and safety of two regimens with different basal to meal related insulin ratio are described. METHODS: 33 patients with ischaemic stroke and hyperglycaemia at admission were randomised in an open design to receive: (1) conventional glucose lowering therapy, (2) strict glucose control with predominantly basal insulin using intravenous insulin or (3) strict glucose control with predominantly meal related insulin using subcutaneous insulin in the first 5 days after stroke. The target range of glucose control for the last two groups was 4.4–6.1 mmol/l. 16 consecutive patients without hyperglycaemia at admission were included to serve as normoglycaemic controls. RESULTS: The median area under the curve (AUC) in the meal related insulin group was 386 mmol/lx58 h (range 286–662) for days 2–5, and did not differ from the hyperglycaemic control group (median AUC 444 mmol/lx58 h; range 388–620). There was also no difference in median AUC of the basal insulin group (453 mmol/lx58 h, range 347–629) and the hyperglycaemic control group on days 2–5. In the first 12 hours, glucose profiles were lower in the groups treated with strict glucose control; median AUC was 90 mmol/lx12 h (range 77–189) for the hyperglycaemic control group versus 81 mmol/lx12 h (range 60–118) for the meal related insulin group (p = 0.03) and 74 mmol/lx12 h (range 52–97) for the basal insulin group (p = 0.008). CONCLUSION: In intermittently fed ischaemic stroke patients, strict glycaemic control between day 2 and day 5 with two different basal bolus regimens did not result in lower glucose profiles due to postprandial hyperglycaemia. Continuous enteral feeding may therefore be needed to achieve prolonged strict glycaemic control in acute stroke patients. [ABSTRACT FROM AUTHOR]

Background Delirium is a complex neuropsychiatric syndrome characterized by disturbances of consciousness, attention, cognition, and perception. It may be the presenting feature of acute stroke, but more often it complicates the clinical course in the early stage of rehabilitation. Risk factors for delirium are older age, pre-existing cognitive decline, metabolic disturbances, infections, and polypharmacy. Recognition of delirium in patients with stroke is important because of its association with a longer stay in the hospital, a poor functional outcome, and an increased risk of developing dementia. The diagnosis may be difficult because of the fluctuating course and the neurological deficits that are caused by the stroke. Nonpharmacological preventive measures, early identification, and additional medical intervention are the key measures in the management of delirium after stroke. Conclusion This review describes incidence, risk factors, pathophysiology, diagnostic tools, and management of delirium in patients with a recent stroke. [ABSTRACT FROM AUTHOR]

Background and aim: As non-randomised studies have suggested that surgical decompression may reduce mortality in patients with space occupying hemispheric infarction, randomisation may be considered unethical in controlled trials testing this treatment strategy. We studied differences in recall of information and in appreciation of the informed consent procedure between representatives included in the Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial (HAMLET) and representatives of patients participating in the randomised trial of Paracetamol (Acetaminophen) In Stroke (PAlS). Methods: 1 year after study inclusion, we contacted 30 consecutive representatives who had given informed consent for participation of their relative in HAMLET, and 30 for PAlS. Recall of trial details and appreciation of the informed consent procedure were investigated using standardised questionnaires and compared between the two groups. Results: All 30 PAlS representatives and 28 HAMLET representatives were interviewed. Participation of their relative in a clinical trial was remembered by 86% of HAMLET and 40% of PAlS representatives (p<0.001). HAMLET representatives remembered more trial details (effect of the treatment under study (61% vs 3%, p<0.001); randomised treatment allocation (71% vs 0%, p<0.001 )). With respect to appreciation of the informed consent procedure, we found no differences between the groups: in each trial, four representatives (14% vs 13%) had considered the question of randomisation unacceptable. Conclusions: Participation of patients in a randomised controlled trial of surgical decompression for space occupying infarction is generally considered acceptable by their representatives, and recall of trial details is better than in a trial in which less vital issues are at stake. [ABSTRACT FROM AUTHOR]

Stroke has a major impact on survivors. Our study was designed to describe the mental status and health-related quality of life (HRQoL) in long-term survivors of TIA or minor ischaemic stroke (MIS) and evaluate associations of mental and physical factors with HR-QoL. A random sample of the 10-year survivors of the Dutch TIA Trial (DTT) and the dutch participants of the European Atrial Fibrillation Trial (EAFT) were interviewed by postal questionnaire (n = 468) and at home (n = 198). Demographic data, mental health status (depression (CES-D), cognition (CAMCOG)), and health perception (SF-36 and Euroqol) were measured. 198 long-term survivors were included; mean age was 72.5 (SD 8.7 years), 22% was depressed (CES-D ≥ 16) and 15% had cognitive dysfunction (CAMCOG < 80). The overall HR-QoL did not differ much from the norm population. Physical disability, occurrence of a major stroke and comorbidity of locomotion or the heart were independently associated with a low health perception. Despite varying amounts of disability, the majority of long-term survivors of a TIA or MIS rated their quality of life as rather good. Physical factors, rather than mental status were independently related to a decrease in perceived health. [ABSTRACT FROM AUTHOR]

Background: Although cognitive impairment early after stroke is a powerful predictor of long-term functional dependence and dementia, little is known about the characteristics and determinants of cognitive dysfunction in acute stroke. Methods: We administered a neuropsychological examination covering 7 cognitive domains to 190 patients within 3 weeks after a first stroke. We also assembled lesion characteristics, clinical factors at admission, demographic characteristics and vascular risk factors. Multivariate logistic regression adjusted for age, gender and education was performed to examine determinants of acute cognitive impairment. Results:Overall, 74% of patients with a cortical stroke, 46% with a subcortical stroke and 43% with an infratentorial stroke demonstrated acute cognitive impairment.Disorders in executive functioning (39%) and visual perception/construction (38%) were the most common. The prevalence and severity of deficits in executive functioning, language, verbal memory and abstract reasoning was more pronounced following left compared to right cortical stroke (all p < 0.05). Intracerebral haemorrhage (OR = 5.6; 95% CI = 1.2–25.4) and cortical involvement of the stroke (OR = 3.6; 95%, CI = 1.3–9.9) were independent determinants of acute cognitive impairment, whereas premorbid moderate alcohol consumption exerted a protective effect (OR = 0.4; 95% CI = 0.1–1.1). Conclusions:Cognitive impairment is common in the first weeks after stroke, with executive and perceptual disorders being the most frequent. Intracerebral haemorrhage, cortical involvement of the lesion and premorbid moderate alcohol consumption are independently associated with acute cognitive impairment. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Stroke may have a major effect on survivors and on the healthcare system. Aims: To study the functional status and use of healthcare facilities in long-term survivors of a transient ischaemic attack (TIA) or minor ischaemic stroke (MIS) and evaluate associations with baseline and follow-up characteristics. Methods: Follow-up of patients who had participated in the Dutch TIA Trial or the European Atrial Fibrillation Trial was extended to a mean period of 15.6 years. Patients were interviewed through a postal questionnaire (n = 468) and a sample of this group was also interviewed at home (n = 198). Demographic data, information on comorbidity, functional status (Barthel Index, Frenchay Activities Index and modified Rankin Scale) and use of healthcare facilities were recorded. Results: About one third of the survivors interviewed at home experienced any residual disability and 26% were moderately to severely handicapped. Factors associated with poor functional status were advanced age and the presence of any infarct on a baseline computed tomography scan, the recurrence of a new major stroke or the presence of comorbidity of locomotion. One third of survivors used any kind of professional care, which was predominantly related to the functional status at fallow-up. Conclusions: Recurrent stroke and the presence of comorbidity of locomotion are important determinants of long-term disability of survivors of a TIA or an MIS, which, in turn, is strongly associated with the long-term use of professional care. The need for measuring comorbidity with regard to functional status is recommended in research on stroke outcome. [ABSTRACT FROM AUTHOR]

Background and Purpose: Type 2 diabetes mellitus (DM2) is associated with an increased risk of stroke. DM2 is also associated with cognitive impairments. Vascular dysfunction, such as impaired cerebrovascular reserve capacity (CVR), may be a determinant of these changes, but previous studies on CVR in DM2 have provided variable results in selected populations of patients. We aimed to examine CVR in a population-based sample of DM2 patients. Methods: The CO2 reactivity of the middle cerebral artery was examined using transcranial Doppler ultrasonography in 81 DM2 patients and 38 controls. In DM2 patients CVR was correlated with diabetic parameters, vascular risk factors and cognitive functioning.Results: CVR was similar in patients and controls (51 vs. 49%). Within the DM2 group, there was no statistically significant relationship between CVR and DM duration, HbA1c, albuminuria, blood pressure, intima-media thickness and cognition. CVR tended to be lower in diabetic patients with retinopathy [46 vs. 55%, mean difference: –7.9 (confidence interval –18.0, 2.2)]. Conclusion: We conclude that CVR is not impaired in unselected patients with DM2 and probably does not, therefore, play a major role in the aetiology of cognitive impairment. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Retinal infarction and transient monocular blindness (TMB) are associated with an increased risk of future ischaemic stroke. Little information is available on the type of subsequent ischaemic strokes that may occur (anterior or posterior circulation and small vessel or large vessel). Aim: To analyse the type of stroke after TMB. Methods: Patients with transient or permanent retinal ischaemia were selected from three prospective studies: the Dutch TIA Trial, the Dutch Amaurosis Fugax Study and the European/Australian Stroke Prevention in Reversible Ischaemia Trial. On follow-up the type of stroke was classified according to the supply territory and the type of vessel involved. Results: 654 patients were included. During a mean follow-up of 5.2 years, 42 patients were found to have had a cerebral or retinal infarct, of which 27 occurred in the carotid territory ipsilateral to the symptomatic eye, 9 in the territory of the contralateral carotid artery and 6 were infratentorial strokes. Thirty patients had a large-vessel infarct, four had a small-vessel infarct and eight had a retinal infarct. Characteristics associated with a notable increased risk for subsequent stroke or retinal infarction were age ~65 years, a history of stroke, a history of intermittent claudication, diabetes mellitus, Rankin score more than three attacks of retinal ischaemia and any degree of ipsilateral carotid stenosis on duplex ultrasonography observation. Conclusion: Ischaemic strokes after TMB or retinal infarction were found to be mainly large-vessel infarcts in the territory of the ipsilateral carotid artery. TMB and retinal infarction are probably manifestations of large-vessel disease. [ABSTRACT FROM AUTHOR]

Objective To examine whether intravenous recombinant tissue plasminogen activator (rt-PA) treatment given in the acute phase of ischaemic stroke has a favourable effect on cognitive and functional outcome at six months post-stroke. Methods The present study included 92 patients with a first-ever symptomatic infarct, of whom 25 (27%) were subjected to rt-PA treatment in the first three hours post-stroke. Multivariate logistic regression analyses adjusted for stroke severity, education, age, and sex were performed to examine whether rt-PA treatment influenced cognitive outcome (assessed with a neuropsychological examination covering 7 cognitive domains), basic ADL independence (modified Barthel Index ≥19), and instrumental ADL independence (Frenchay Activities Index ≥15) after six months. Results The adjusted odds ratio for intact cognition was 1.0 (95% CI 0.2 to 4.3), that for basic ADL outcome 13.5 (95 % CI 1.4 to 129.4) and for instrumental ADL 7.1 (95 % CI 1.2 to 42.2). Conclusion Our findings suggest that rt-PA treatment is associated with a favourable basic and instrumental ADL outcome, but not with a beneficial cognitive outcome after 6 months. [ABSTRACT FROM AUTHOR]

Background: Neurodevelopmental treatment (NDT) is a rehabilitation approach increasingly used in the care of stroke patients, although no evidence has been provided for its efficacy. Objective: To investigate the effects of NOT on the functional status and quality of life (QoL) of patients with stroke during one year after stroke onset. Methods: 324 consecutive patients with stroke from 12 Dutch hospitals were included in a prospective, non-randomised, parallel group study. In the experimental group (n = 223), nurses and physiotherapists from six neurological wards used the NDT approach, while conventional treatment was used in six control wards (n = 101). Functional status was assessed by the Barthel index. Primary outcome was "poor outcome", defined as Barthel index <12 or death after one year. QoL was assessed with the 30 item version of the sickness impact profile (SA-SIP30) and the visual analogue scale. Results: At 12 months, 59 patients (27%) in the NDT group and 24(24%) in the non-NOT group had poor outcome (corresponding adjusted odds ratio= 1.7(95% confidence interval, 0.8 to 3.5)). At discharge the adjusted odds ratio was 0.8 (0.4 to 1.5) and after six months it was 1.6 (0.8 to 3.2). Adjusted mean differences in the two QoL measures showed no significant differences between the study groups at six or 12 months after stroke onset. Conclusions: The NDT approach was not found effective in the care of stroke patients in the hospital selling. Health care professionals need to reconsider the use of this approach. [ABSTRACT FROM AUTHOR]

Twin and family-based studies indicate that genetic factors might be involved in the risk of transient ischemic attack (TIA) and ischemic stroke (IS). Identification of genetic risk factors for new vascular events after cerebral ischemia may target secondary prevention. The overall aim of POLARIS is to study which polymorphisms predispose to new vascular events after TIA/IS and to assess their predictive value. Patients who have had a TIA or IS of presumed arterial origin are included. The study design is twofold. In part one the prevalences of polymorphisms will be compared between 300 long-term survivors of the Dutch TIA Trial (average follow-up 10 years) and 820 patients with recent TIA/IS. In part two a cohort of 820 patients with recent TIA/IS will be followed for the occurrence of vascular events for an average of 3.5 years. Several polymorphisms of interest will be genotyped, including factor V Leiden, prothrombin 20210A, 5,10-methylenetetrahydrofolate reductase, HR2 haplotype factor V and factor XIII Val34Leu. Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objectives: The aetiology of clinical symptoms in patients with severe internal carotid artery (ICA) lesions may be thromboembolic or haemodynamic. The purpose was to assess whether changes in cerebropetal blood flow caused by an ICA occlusion have an effect on clinical symptoms and cerebral metabolism.Methods: Forty three patients with an ICA occlusion who had hemispheric ischaemia (transient ischaemic attack or stroke), retinal ischaemia, or without symptoms, and 34 patients without significant ICA lesions with either hemispheric ischaemia or no symptoms were studied. Magnetic resonance angiography (MRA) was used to investigate total cerebropetal flow (flow in the ICAs plus basilar artery) and the flow in the middle cerebral arteries. Cerebral metabolic changes in the flow territory of the middle cerebral artery were determined with proton MR spectroscopy.Results: Low total cerebropetal flow (r=-0.15, p<0.05) and low middle cerebral artery flow (r=-0.31, p<0.001) were found in patients with an ICA occlusion, but did not correlate with the clinical syndrome. By contrast, patients with prior symptoms of hemispheric ischaemia had decreased cerebral N-acetylaspartate/choline ratios (r=-0.35, p<0.001). However, the presence of an ICA occlusion (and subsequent low flow) did not correlate with low N-acetylaspartate/choline ratios.Conclusion: Neurological deficit caused by (transient) hemispheric ischaemia is associated with low N-acetylaspartate/choline ratios, whereas prior clinical features are not associated with low cerebropetal blood flow, as measured with MR angiography. As a result, differences in cerebropetal flow cannot explain why patients with similar carotid artery disease experience different neurological features. [ABSTRACT FROM AUTHOR]

The incidence and vascular type of recurrent ischaemic stroke was studied in patients with supratentorial transient ischaemic attacks or non-disabling ischaemic strokes, who were treated with aspirin (30 or 283 mg). Patients were divided into groups with small vessel disease (SVD) (n = 1216) or large vessel disease (LVD) (n = 1221) on the grounds of their clinical features and CT at baseline. Patients with evidence of both SVD and LVD (n = 180) were excluded from further analyses. During follow up (mean 2.6 years) annual stroke rate was 3.6% in both groups. Of the 107 patients with SVD at baseline who had recurrent strokes, 83 proved to have an identifiable infarct: 30 (28%) again had a small vessel infarct, 39 (36%) had a large vessel ischaemic stroke and in 14 (13%) the recurrent ischaemic stroke was in the posterior fossa. Of the 110 patients with LVD at baseline and recurrent stroke, 91 had an identifiable infarct: 67 (61%) again had a large vessel ischaemic stroke, 16 (15%) had a small vessel ischaemic stroke, and eight (7%) had the recurrent ischaemic stroke in the posterior fossa. Thus patients with a transient ischaemic attack or non-disabling ischaemic stroke caused by LVD were more likely to have an ischaemic stroke of the same vessel type during follow up than patients with SVD (relative risk 2.2; 95% confidence interval 1.5-3.4). Possible explanations for this difference are: (1) patients with a small vessel ischaemic stroke at baseline had both SVD and LVD or were misdiagnosed; (2) recurrent small vessel ischaemic stroke may have occurred more often than reported, because they were silent or only minimally disabling; (3) recurring large vessel ischaemic strokes occurring in patients initially diagnosed as having SVD might have been related to potential cardiac sources of emboli that had not been previously recognized; (4) the antiplatelet drug aspirin (30 or 283 mg) prescribed in this patient group may have prevented thrombosis in small vessels better than in large vessels. [ABSTRACT FROM AUTHOR]

A considerable proportion of patients discontinue dipyridamole therapy because of headache. Risk indicators for the development of dipyridamole induced headache were identified by means of an exploratory analysis of data from the European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) and the Second European Stroke Prevention Study (ESPS 2). In ESPRIT, dipyridamole induced headache was significantly associated with female sex, absence of hypertension and non-smoking (area under the receiver operator characteristic (ROC) curve 0.63 (95% CI 0.58 to 0.68)) and in ESPS 2 with female sex and absence of ischaemic lesions on imaging (area under the ROC curve 0.64 (95% CI 0.59 to 0.69)). [ABSTRACT FROM AUTHOR]