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Objective: We aimed to investigate the role of pretreatment collateral status in predicting the efficacy and safety of endovascular treatment (EVT) in acute ischaemic stroke due to cervical and/or cerebral arterial occlusions.Methods: Relevant full-text articles published since 1 January 2000, investigating correlations between collateral status and any efficacy or safety outcome in patients undergoing EVT in cohort or case-control studies, or randomised clinical trials, were retrieved by PubMed and manual search. Two authors extracted data from eligible studies and assessed study quality. Risk ratios (RR) were pooled for good versus poor collaterals for outcomes based on a random-effects model. Sensitivity and subgroup analyses were conducted.Results: In total, 35 (3542 participants) and 23 (2652 participants) studies were included in qualitative review and quantitative meta-analysis, respectively. Overall, good pretreatment collaterals increased the rate of favourable functional outcome at 3 months (RR=1.98, 95% CI 1.64 to 2.38; p<0.001), and reduced the risks of periprocedural symptomatic intracranial haemorrhage (RR=0.59, 95% CI 0.43 to 0.81; p=0.001) and 3-month mortality (RR=0.49, 95% CI 0.38 to 0.63; p<0.001), as compared with poor collaterals, in patients with acute ischaemic stroke under EVT. No individual study could alter the estimate of overall effect of collateral status, but there were moderate to significant heterogeneities between subgroups of studies with different modes of EVT, different arterial occlusions and different collateral grading methods.Conclusions: Good pretreatment collateral status is associated with higher rates of favourable functional outcome, and lower rates of symptomatic intracranial haemorrhage and mortality, in patients with acute ischaemic stroke receiving endovascular therapies. [ABSTRACT FROM AUTHOR]

Background Cerebral microbleeds may contribute to cognitive deficits in stroke. Cognitive impairment that does not meet the criteria for dementia (cognitive impairment no dementia) is common in stroke, and patients with such impairment can revert to normal cognition. Aims and hypothesis This study examined the association between cerebral microbleeds and the reversion of cognitive impairment no dementia. Method A total of 328 Chinese patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong participated in the study. All subjects were assessed for cognitive impairment no dementia with a neuropsychological test battery at three- and 15 months following the index stroke. Of the 180 patients with cognitive impairment no dementia at three-months poststroke, 143 (79·4%) attended the 15-month follow-up. Twenty-nine subjects had reverted from cognitive impairment no dementia to normal cognitive status (reverters), 98 were nonreverters and 16 had progressed to dementia. Results In univariate analysis, the reverters were found to be younger, less likely to have hypertension and cerebral microbleeds, and to have smaller white matter hyperintensity volumes. In multivariate analysis, the absence of cerebral microbleeds remained an independent predictor of reversion with an odds ratio of 4·3. Absence of deep cerebral microbleeds predicted the reversion of the language domain, whereas the absence of lobar cerebral microbleeds predicted the reversion of the visuomotor speed domain. Conclusions The results suggest that the absence of cerebral microbleeds may be associated with a higher likelihood of a reversible cognitive impairment in stroke patients. The mechanism of how this occurs is not well understood. [ABSTRACT FROM AUTHOR]

Objectives: Insomnia is a common complaint in stroke survivors. The purpose of this study was to investigate the clinical and magnetic resonance imaging (MRI) correlates of insomnia symptoms in Chinese ischemic stroke survivors. Methods: A comprehensive psychiatric assessment was performed involving 508 ischemic stroke patients 3 months after their first-ever or recurrent acute stroke. Insomnia symptoms were evaluated with a standard insomnia questionnaire. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS).The evaluation of the MRI scans focused on infarctions, white matter lesions, and microbleeds. Results: One hundred and eight-six patients (36.6% of the sample) had insomnia symptoms. Sixty-four patients (12.6%) had insomnia symptoms with daytime consequences. In the multivariate logistic regression analysis, GDS score (OR = 1.157, p<0.001) and acute frontal lobe infarction (OR = 1.933, p = 0.039) were significant predictors of insomnia symptoms, while the GDS score (OR = 1.251, p<0.001) and diabetes mellitus (OR = 1.959, p¼0.017) were significant predictors of insomnia symptoms with daytime consequences. Conclusions: Insomnia symptoms have a multi-factorial origin in stroke. Besides depressive symptoms, frontal lobe infarction and diabetes mellitus predict insomnia symptoms. [ABSTRACT FROM AUTHOR]

Background/Aims: This study aimed to determine the clinical and neuroimaging correlates of the presence of neuropsychiatric symptoms in stroke patients with age-related confluent white matter hyperintensities (WMH). Methods: The Neuropsychiatric Inventory was utilized to detect the presence of 12 symptoms. Multivariate logistic regression models were used to identify clinical and neuroimaging correlates of the presence of symptoms. Results: Seventy-seven stroke patients (mean WMH volume: 39.5 cm3) were recruited. Thirty patients (39%) had ≥1 neuropsychiatric symptom. Poor executive function was associated with the presence of any symptoms and symptoms other than depression. More severe left frontal WMH was associated with depression. Conclusion: Executive dysfunction and left frontal WMH are correlated with neuropsychiatric symptoms in these patients. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objective Although cerebral small vessel disease (SVD) is closely associated with late life depression, patients with even severe SVD may have no depressive symptoms. We postulate that concurrent brain atrophy may also involve in the pathogenesis of depressive symptoms in SVD. We aimed to investigate the relevance of brain atrophy in predicting depressive symptoms among patients with severe SVD. Methods We recruited 45 lacunar stroke patients who had diffuse white matter lesion (WML) and varying severity levels of depressive symptoms. We used a quantitative hybrid warping method to determine the volume of 99 brain regions for each patient. We assessed severity of depressive symptoms using the depression score of the hospital anxiety and depression scale (HADS-D). We first performed correlation analysis of each brain variable with the depression score. Significant variables were then entered separately into linear regression analysis to explore predictors of HADS-D, with adjustment of relevant clinical variables. Results The mean age (SD) of the 45 participants was 74.6 (8.3) years. The mean HADS-D score was 3.5, with score ranging from 0 to15. Variables that had a significant correlation coefficient with HADS-D were gender, hypertension, Oxford handicap scale, left inferior frontal gyrus, right subthalamic nucleus, left posterior limb of internal capsule, and right cerebellum. Regression analyses showed that only left inferior frontal gyrus atrophy (β = -0.354, p = 0.017) predicted HADS-D score after adjusted for other relevant clinical variables. Conclusion Concurrent atrophy of left inferior frontal gyrus is associated with depressive symptoms in elderly patients with severe SVD. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Summary: Background: Few randomised clinical trials have investigated the use of antithrombotic drugs for early secondary prevention of stroke or transient ischaemic attack in patients with intracranial atherosclerotic stenosis. Microembolic signals, detected by transcranial doppler, are a surrogate marker of future stroke risk and have been used to show treatment efficacy in patients with extracranial carotid stenosis. We aimed to investigate whether treatment with clopidogrel plus aspirin reduced the number of microembolic signals detected with transcranial doppler ultrasound compared with aspirin alone in patients with recent stroke. Methods: The clopidogrel plus aspirin for infarction reduction in acute stroke or transient ischaemic attack patients with large artery stenosis and microembolic signals (CLAIR) trial was a randomised, open-label, blinded-endpoint trial. Between Oct 28, 2003, and Nov 19, 2008, patients with acute ischaemic stroke or transient ischaemic attack who had symptomatic large artery stenosis in the cerebral or carotid arteries and in whom microembolic signals were present on transcranial doppler were randomly assigned within 7 days of symptom onset to receive clopidogrel (300 mg for the first day, then 75 mg daily) plus aspirin (75–160 mg daily) or aspirin alone (75–160 mg daily) for 7 days. Patients were randomly assigned in blocks of four or six by use of a randomisation website. Monitoring of microembolic signals on transcranial doppler was done on days 2 and 7. The primary endpoint was the proportion of patients who had microembolic signals on day 2. Analysis was by modified intention to treat. All analyses were done by an investigator masked to both patient identity and the day the recording was taken. This trial is registered with the Centre for Clinical Trials, Chinese University of Hong Kong, number CUHK_CCT00164. Findings: 100 patients were randomly assigned to clopidogrel plus aspirin (n=47) or aspirin monotherapy (n=53). 93 of 100 patients had symptomatic intracranial stenosis in either the intracranial internal carotid artery or the middle cerebral artery: 45 of 46 in the dual therapy group and 48 of 52 in the monotherapy group. At day 2, 14 of 45 patients in the dual therapy group and 27 of 50 patients in the monotherapy group for whom data were available had at least one microembolic signal on transcranial doppler (relative risk reduction 42·4%, 95% CI 4·6–65·2; p=0·025). Adverse events were similar in the two groups. No patients had intracranial or severe systemic haemorrhage, but two patients in the dual therapy group had minor haemorrhages. Interpretation: Combination therapy with clopidogrel and aspirin is more effective than aspirin alone in reducing microembolic signals in patients with predominantly intracranial symptomatic stenosis. Clinical trials are now warranted to investigate whether this combination treatment also results in a reduction in stroke incidence. Funding: Research Grant Council Earmarked Grant and Asian Stroke Research Grant, Chinese University of Hong Kong. [Copyright &y& Elsevier]

Abstract: Background: This study aimed to compare changes in plasma β-globin DNA and serum S100 protein to diagnose stroke and for predicting mortality and morbidity. Methods: Patients with stroke-like symptoms presenting to the emergency department of a Hong Kong hospital were recruited. Plasma DNA was analyzed for the β-globin gene with fluorescent-based PCR. S100 concentrations were determined using ELISA. Primary outcomes were diagnosis of stroke, mortality, and modified Rankin Score (mRS) after 6 months. Results: One hundred ninety-seven consecutive patients recruited, 118 (60%) ischemic stroke, 35 (18%) hemorrhage and 44 (22%) with no acute neuroimaging changes. Serum S100 and plasma DNA were increased in 126 (p <0.0010) and 36 (p =0.21) stroke patients respectively vs. controls. Median plasma DNA was higher in hemorrhagic stroke than those without (1725 vs. 1050 kilogenome-equivalents/l, p =0.0104). Median plasma DNA was higher in mRS>2 vs. mRS≤2 (1350 vs. 1025, p =0.0103), and higher in non-survivors vs. survivors (1625 vs. 1050, p =0.0070). Median serum S100 higher in mRS>2 patients vs. mRS≤2 (0.152 vs. 0.131 μg/l, p =0.0003). The odds ratio (OR) of discriminating hemorrhagic from non-hemorrhagic stroke with DNA was 4.24 (95% CI 1.88–9.56); S100 and DNA together give an OR of 16.55. Conclusion: For stroke diagnosis, S100 performs better than DNA; DNA is a better marker for hemorrhage. For diagnosis of hemorrhagic stroke, combined S100 and DNA performs better than either alone. Plasma DNA and serum S100 predict morbidity and mortality in stroke. [Copyright &y& Elsevier]

Microbleeds (MBs) detected by gradient-echo T2*-weighted MRI (GRE-T2*),white matter changes and lacunar infarcts may be regarded as manifestations of microangiopathy. The establishment of a quantitative relationship among them would further strengthen this hypothesis. We aimed to investigate the frequency and the number of MBs in patients hospitalized with lacunar infarcts and their quantitative relationship with the severity of white matter changes (WMC) and the number of old lacunar infarcts. We performed a hospital-based survey of patients with acute lacunar infarct. Eighty-two consecutive Chinese patients with acute lacunar infarcts on diffusion-weighted imaging were recruited in 2002. The number of MBs, number of old lacunar infarcts on T2-weighted imaging and the severity of WMC on MRI on admission were recorded. MBs were detected in 22 (27%) patients. The number of MBs ranged from 1 to 42 (mean 6.59, median 3). Advancing age and previous transient ischemic attacks or cerebrovascular accidents (TIA/CVA) were more common in patients with MBs than those without. There were significant correlations among the number of MBs, extent of WMC and number of lacunar infarcts: lacunar infarcts and MBs (r = 0.297, p = 0.007); lacunar infarct and WMC (r = 0.331, p = 0.002); WMC and MBs (r = 0.522, p < 0.0001). In conclusion, linear associations exist among MBs, WMC and lacunar infarcts. Our results suggest that all three may have a shared pathogenesis such as advanced microangiopathy. [ABSTRACT FROM AUTHOR]

Objective: To identify determinants associated with increasing severity of middle cerebral artery (MCA) stenosis in asymptomatic Chinese type 2 diabetic patients with and without MCA stenosis determined using transcranial Doppler. Conventional risk factors contribute to the pathogenesis of ischemic stroke, and differences in the pattern of these may explain the heterogeneity of disease presentation in different populations. In Chinese patients, MCA stenosis is the most commonly identified intracranial vascular lesion.Research Design and Methods: Anthropometric and fasting biochemical parameters were compared between type 2 diabetic patients with MCA stenosis in one (n = 185) or both (n = 200) vessels and 1,492 type 2 diabetic patients without evidence of stenosis.Results: Increasing MCA stenotic vascular involvement was associated with significantly increasing age, duration of diabetes, systolic blood pressure, and LDL cholesterol, but with lower glucose levels. There was also an increased prevalence of hypertension, dyslipidemia, and use of blood pressure-and glucose-lowering agents in the patients with MCA stenosis. Concomitant significant increases in the prevalence of peripheral vascular disease and retinopathy were also observed in the patients with MCA stenosis.Conclusions: Transcranial Doppler examination identified stenosis in one or both MCAs in over one-fifth of the Chinese type 2 diabetic subjects without symptoms of cerebrovascular disease. A number of conventional cardiovascular risk factors were closely associated with MCA stenosis. This technique may allow the identification of a particularly high-risk group, and further studies are required to determine whether asymptomatic MCA stenosis is predictive of primary cerebrovascular events and whether intensive treatment of risk factors would reduce the risk. [ABSTRACT FROM AUTHOR]

Background: The Oxfordshire Community Stroke Project (OCSP) classification is a stroke classification based on clinical features collected at bedside. Previous studies reported good correlation between vascular abnormalities and OCSP mainly in populations not at risk of intracranial atherosclerosis. There have been limited data on the relationship between intracranial atherosclerosis and the OCSP classification. Methods: Consecutive Chinese patients admitted to a regional hospital with acute ischemic stroke were studied in Hong Kong. Stroke subtype was classified as total or partial anterior circulation infarct (TACI or PACI), posterior circulation infarct (POCI), or lacunar infarct (LACI), according to the OCSP method. Transcranial Doppler (TCD) was performed whenever possible to evaluate the intracranial arteries as well as the carotid arteries. National Institute of Health Stroke Scale (NIHSS) was used to assess the severity of stroke on admission. Results: Six hundred and ninety-nine consecutive patients were studied. On admission, 24 patients were classified as TACI (3.4%), 96 PACI (13.7%), 111 POCI (15.9%), and 468 LACI (67.0%). Of the 345 patients who had TCD evidence of intracranial or carotid artery abnormalities, 75% had intracranial involvement only, 5% extracranial involvement only and 20% had both intracranial and extracranial involvement. The frequencies of arterial abnormalities were found in 58% of TACIs, 48% of PACIs, 48% of POCIs and 50% of LACIs. There was no evidence that the frequencies of arterial abnormalities were different between the OCSP groups (P=0.8). Middle cerebral artery velocity was abnormal in 9 TACIs (38%), 32 PACIs (33%), 35 POCIs (32%) and 177 LACIs (38%) (P=0.6). Vertebrobasilar velocities were abnormal in 4 TACIs (17%), 20 PACIs (21%), 29 (26%) and 87 LACIs (19%) (P=0.3). The OCSP subtypes were associated with POCIs the severity of stroke. NIHSS score of ≥9 was found in 83% of TACIs, 18% of PACIs, 9% of POCIs, and 12% of LACIs (P<0.0001). Conclusions: OCSP classification is not significantly related to the presence of vascular abnormalities among patients with predominantly intracranial atherosclerosis. [Copyright &y& Elsevier]

Background: Despite doubts about their efficacy and concern about their safety, antithrombotic agents are often used to treat acute ischemic stroke. Recent experience in patients with other thromboembolic disorders suggests that low-molecular-weight heparin, which requires only subcutaneous administration once or twice daily, may be more effective and safer than standard (unfractionated) heparin. Methods: We conducted a randomized, double-blind, placebo-controlled trial comparing two dosages of low-molecular-weight heparin with placebo in the treatment of ischemic stroke. Patients were randomly assigned within 48 hours of the onset of symptoms to receive high-dose nadroparin (4100 anti–factor Xa IU twice daily), low-dose nadroparin (4100 IU once daily), or placebo subcutaneously for 10 days. The primary measure of outcome was death or dependency regarding activities of daily living six months after randomization. Secondary outcomes were death, hemorrhagic transformation of the infarction, and other complications at 10 days, and death or dependency at 3 months. Results: A total of 2750 patients were screened for the study. Among 312 patients randomized, 306 had outcomes that were analyzed at six months. Forty-five patients (45 percent) in the high-dose group, 53 patients (52 percent) in the low-dose group, and 68 patients (65 percent) in the placebo group died or became dependent. There was a significant dose-dependent effect among the three study groups in favor of low-molecular-weight heparin (P = 0.005 by the chi-square test for trend). No significant differences among the groups in the occurrence of secondary outcomes were observed at 10 days. Conclusions: For patients with ischemic stroke treated within 48 hours of the onset of symptoms, low-molecular-weight heparin was effective in improving outcomes at six months. (N Engl J Med 1995;333:1588-93.) [ABSTRACT FROM AUTHOR]

Abstract: Objectives: : Paraoxonase (PON1), an enzyme associated with high-density lipoprotein (HDL) particles, inhibits oxidation and atherogenesis. We sought to investigate the association of the PON1 Q192R polymorphism with stroke and heart disease. Design and methods: : In a case control study, we genotyped 242 ischemic stroke, 231 myocardial infarction (MI), and 310 healthy control subjects, all Chinese. Results: : R-containing genotypes (R+) were associated with vascular disease, OR = 1.5, P = 0.03. RR was increased in MI patients who were either smokers (OR = 3.1, P = 0.01), male, or younger than 60. R+ but not RR genotypes were increased in stroke patients, particularly large artery type (OR = 2.6 and P = 0.02 for R+, OR = 1.0 for RR) or among smokers. The relative dearth of RR in stroke might be due to earlier MI or death in at-risk people, such as smokers. R+ genotypes were increased with stroke in hypertensive (OR = 2.1, P = 0.02) but not normotensive (OR = 1.0) subjects. Conclusions: : PON1 192R+ genotypes were associated with stroke and MI, particularly in subsets of patients, in patterns suggesting a possible survivor effect. [Copyright &y& Elsevier]