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To assess the prognostic value of computed tomography (CT) in hyperacute middle cerebral artery (MCA) infarcts.The CT features, total CT score, and National Institutes of Health Stroke Scale (NIHSS) score were correlated with the 30-day mortality in 16 patients with a hyperacute MCA infarct.Admission NIHSS scores were significantly lower in the survival group (P = 0.016). The extent of infarct, attenuation of corticomedullary differentiation, and total CT score were associated with 30-day mortality (P0.05). In prediction of mortality, extent of an infarct67% gave sensitivity, specificity, positive predictive value, and negative predictive value rates of 86%, 100%, 100%, and 90%, respectively. Attenuation of corticomedullary differentiation gave sensitivity, specificity, positive predictive value, and negative predictive value rates of 86%, 89%, 86%, and 89%, respectively. An NIHSS score28 gave sensitivity, specificity, positive predictive value, and negative predictive value rates of 86%, 67%, 67%, and 86%, respectively. A CT score4 gave sensitivity, specificity, positive predictive value, and negative predictive value rates of 86%, 78%, 75%, and 88%, respectively.Computed tomography features and the admission NIHSS score are important predictors of survival in hyperacute extensive MCA infarcts.

Background : Little is known about the performance of the Geriatric Depression Scale (GDS) in the screening of post-stroke depression (PSD) among Chinese elderly. Methods : Three months after the index stroke, a research assistant administered the 15-item GDS to 127 Chinese elderly patients with acute stroke who were consecutively admitted to a general hospital. A psychiatrist, who was blind to the GDS scores, administered the Structured Clinical Interview for DSM-IV to all patients and made DSM-IV diagnosis of depression, which served as the benchmark for judging the performance of GDS in screening PSD. Results : The optimal cut-off point of GDS was 6/7. The sensitivity, specificity, positive and negative predictive values of GDS and the area under the receiver operating characteristic curve, were 89, 73, 37, 98 and 90%, respectively. Limitations : The sample size was small and there was no separate analysis of the performance of GDS for subtypes of PSD. Conclusions : Due to its low positive predictive value, a more specific instrument should supplement GDS in screening PSD in Chinese elderly.

To prospectively evaluate accuracy of sonography for diagnosis of carpal tunnel syndrome (CTS) in patients clinically suspected of having the disease in one or both hands.A prospective cohort of 133 patients suspected of having CTS were referred to a teaching hospital between October 2001 and June 2002 for electrodiagnostic study. One hundred twenty patients (98 women, 22 men; mean age, 49 years; range, 19-83 years) underwent sonography within 1 week after electrodiagnostic study. Radiologist was blinded to electrodiagnostic study results. Seventy-five patients had bilateral symptoms; 23 patients, right-hand symptoms; and 22 patients, left-hand symptoms (total, 195 symptomatic hands). Cross-sectional area of median nerve was measured at three levels: immediately proximal to carpal tunnel inlet, at carpal tunnel inlet, and at carpal tunnel outlet. Flexor retinaculum was used as a landmark to margins of carpal tunnel. Optimal threshold levels (determined with classification and regression tree analysis) for areas proximal to and at tunnel inlet and at tunnel outlet were used to discriminate between patients with and patients without disease. Sensitivity, specificity, and false-positive and false-negative rates were derived on the basis of final diagnosis, which was determined with clinical history and electrodiagnostic study results as reference standard.For right hands, sonography had sensitivity of 94% (66 of 70); specificity, 65% (17 of 26); false-positive rate, 12% (nine of 75); and false-negative rate, 19% (four of 21) (cutoff, 0.09 cm(2) proximal to tunnel inlet and 0.12 cm(2) at tunnel outlet). For left hands, sensitivity was 83% (53 of 64); specificity, 73% (24 of 33); false-positive rate, 15% (nine of 62); and false-negative rate, 31% (11 of 35) (cutoff, 0.10 cm(2) proximal to tunnel inlet).Sonography is comparable to electrodiagnostic study in diagnosis of CTS and should be considered as initial test of choice for patients suspected of having CTS.

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.

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.

Objective To compare preemptive analgesia and preclosure analgesia in reducing wound pain after laparoscopic operation. Design Randomised, double-blind and placebo control. Setting University referral centre. Population Infertile women undergoing diagnostic laparoscopy with or without additional procedures. Methods One hundred and forty-four women were randomised to receive 10 mL of 1% lignocaine at the surgical sites before incision and 10 mL of normal saline before closure of incision (the preemptive group), saline before incision and lignocaine before closure of incision (the preclosure group) and saline at the surgical sites both before incision and closure of incision (the placebo group). Main outcome measures Post-operative wound pain measured by linear visual analogue scale and amount of analgesic use. Results The women in the preclosure group had significantly lower pain scores at 2, 4 and 24 hours than those in the placebo group, whereas the women in the preemptive group only showed significantly lower pain scores at 2 hours than the placebo group. The pain score at 24 hours in the preclosure group was significantly lower than that in the preemptive group. There was no significant difference in the post-operative analgesic requirement among the three groups. Conclusion The preclosure analgesia is better than preemptive analgesia and no analgesia in reducing post-operative wound pain.

Objectives: Although stroke associated with small vessel disease (SSVD) can induce both motor and cognitive impairment, the latter has received less attention. We aimed to evaluate the frequency of the varying severity levels of cognitive impairment, the determinants of severe cognitive impairment, and the association of cognitive impairment with functional outcome after SSVD. Methods: Consecutive patients admitted to hospital because of SSVD were assessed at 3 months after stroke. We performed a semi-structured clinical interview to screen for cognitive symptoms. Severity of cognitive symptoms was graded according to the Clinical Dementia Rating Scale (CDR). Performance on psychometric tests (Mini-Mental State Examination, Alzheimer’s Disease Assessment Scale (cognition subscale), Mattis Dementia Rating Scale (initiation/perseverence subscale; MDRS I/P)) of patients of different CDR gradings was compared with that of 42 healthy controls. Basic demographic data, vascular risk factors, stroke severity (National Institute of Health Stroke Scale; NIHSS), pre-stroke cognitive decline (Informant Questionnaire on Cognitive Decline in the Elderly; IQCODE), functional outcome (Barthel index; BI), Instrumental Activities Of Daily Living; IADL), and neuroimaging features (site of recent small infarcts, number of silent small infarcts, white matter changes) were also compared among the groups. Regression analyses were performed to find predictors of severe cognitive impairment and poor functional outcome. Results: Among the 75 included patients, 39 (52%) complained of cognitive symptoms. The number of patients in each CDR grading was as follows: 39 (52%) had a CDR of 0, 26 (34.7%) had a CDR of 0.5, 10 (13.3%) had a CDR of ⩾1. Pre-stroke IQCODE and previous stroke predicted CDR⩾1. The NIHSS was associated with more impaired BI. The NIHSS and MDRS I/P contributed most to impaired IADL. Conclusions: Half of the patients with SSVD complained of varying severity of cognitive problems 3 months after stroke. Pre-stroke cognitive decline and previous stroke predict severe cognitive impairment post stroke. Stroke severity and executive dysfunction contribute most to a poor functional outcome.

Background and Purpose— Both dementia and stroke are major health problems in Chinese societies. Stroke is a frequent cause of dementia. Only a few studies have been published on poststroke dementia (PSDE), none of which has investigated a consecutive stroke cohort in Asian patient populations. The objective of this study was to examine the prevalence and clinical correlates of PSDE in Chinese stroke patients in Hong Kong. Methods— Two hundred eighty stroke patients consecutively admitted to the medical wards of a university-affiliated regional hospital were interviewed by a psychiatrist 3 months after stroke. The presence of dementia and vascular dementia was diagnosed according to the Diagnostic and Statistical Manual , 4th edition. In addition, a wide range of demographic and clinical variables were examined. Results— Fifty-five participants (20%) had PSDE. Univariate analysis found that PSDE was associated with age; level of education; prestroke Rankin Scale score; prestroke Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) score; National Institutes of Health Stroke Scale (NIHSS) best language score, dysarthria score, and total score; urinary incontinence; cortical infarct; leukoaraiosis; bilateral lesions; number of lesions; involvement of middle cerebral artery circulation; and cerebral atrophy index. Multivariate logistic regression suggested that prestroke IQCODE score, NIHSS total score, leukoaraiosis, involvement of middle cerebral artery territory, and cerebral atrophy index were independent risk factors of PSDE. After removal of 22 patients with prestroke dementia, which was defined as a prestroke IQCODE score ≥4.0, the frequency of PSDE dropped to 15.5%. Furthermore, involvement of the middle cerebral artery territory and cerebral atrophy index were replaced by level of education and bilateral lesions as independent predictors in the final logistic model. Conclusions— PSDE is common among Chinese stroke patients in Hong Kong. Its frequency is comparable to that in white populations. The clinical determinants of PSDE, after the exclusion of patients with prestroke dementia, include premorbid level of cognitive function, severity of stroke, leukoaraiosis, level of education, and bilateral lesions.

Objectives: Frontal Assessment Battery (FAB) is a valid and reliable screening test for evaluating executive dysfunction among whites with frontal and subcortical degenerative lesions. We studied the properties of a Chinese version of FAB (CFAB) in evaluating executive dysfunction among Chinese stroke patients with small subcortical infarct. Methods: Concurrent validity was evaluated using Wisconsin Card Sorting Tst (WCST) and Mattis Dementia Rating Scale– Initiation/Perseveration Subset (MDRS I/P) among 41 controls and 30 stroke patients with small subcortical infarct. Discriminant validities of CFAB and its subitems were compared with those of MiniMental State Examination (MMSE). Internal consistency, test-retest, and interrater reliability of CFAB were evaluated. Results: The CFAB had low to good correlation with various executive measures: MDRS I/P (r = 0.63, p < 0.001), number of category completed (r = 0.45, p < 0.001), and number of perseverative errors (r = �0.37, p < 0.01) of WCST. Among the executive measures, only number of category completed had significant but small contribution (6.5%, p = 0.001) to the variance of CFAB. A short version of CFAB using three items yielded higher overall classification accuracy (86.6%) than that of CFAB full version (80.6%) and MMSE (77.6%). Internal consistency (alpha = 0.77), test-retest reliability (rho = 0.89, p < 0.001), and interrater reliability (rho = 0.85, p < 0.001) of CFAB were good. Conclusion: Although CFAB is reliable, it is only moderately valid in evaluating executive dysfunction among Chinese stroke patients with small subcortical infarct. The clinical use of CFAB in the evaluation of executive dysfunction among this group of patients cannot be recommended at this stage.

Background: Small subcortical infarct (SSI) occurs more frequently among Chinese than Caucasians. Apart from small vessel disease, SSI is also associated with intracranial large artery disease. We aimed to study the frequency of SSI with and without intracranial large artery disease among Chinese stroke patients. Methods: Magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and diffusion weighted imaging (DWI) were performed among consecutive Chinese stroke patients admitted to our acute stroke unit over a 6-month period. Results: Among the 257 patients with ischemic stroke, 71 patients (27.6%) had SSI. Twelve patients (16.9%) had relevant intracranial large artery disease and three patients (4.2%) had lone relevant extracranial carotid artery disease. No patient had an identifiable cardiac embolic source or other miscellaneous cause. Excluding patients with relevant intracranial large artery disease and extracranial carotid artery disease, the frequency of SSI associated with presumed small vessel disease among patients with ischemic stroke was 21.7%. Patients with SSI associated with intracranial large artery disease had greater number of acute infarcts and slightly greater stroke severity and cognitive impairment than those with presumed small vessel disease. Conclusion: Our present study suggests that the higher frequency of SSI among Chinese may be in part related to a higher frequency of intracranial large artery disease rather than to a higher frequency of small vessel disease.

Background and Purpose— Cerebral microbleeds (MBs) detected by gradient-echo MRI are considered evidence of advanced microangiopathy with potential for further bleeding. The goal of this study was to determine whether the presence of MBs is a risk factor for subsequent intracerebral hemorrhage among patients with acute ischemic stroke. Methods— We prospectively examined patients hospitalized with acute cerebral infarction with gradient-echo T2*-weighted MRI for the presence of MBs. We recorded demographics, medical history, and stroke severity. Patients were then followed up for the development of stroke, other vascular events, and death. Results— One hundred twenty-one consecutive patients with a mean age of 67.96±10.97 years were recruited. MBs were present in 43 patients (35.5%). During follow-up of 27.15±11.68 months, 16 patients had recurrent stroke. There was no difference between patients with or without MB for the development of ischemic stroke (5 and 6 respectively, P =0.841). However, 4 patients (9.3%) with MBs and 1 patient (1.3%) without an MB had intracerebral hemorrhage during follow-up ( P =0.053). Of the 5 patients who developed subsequent intracerebral hemorrhages, 3 were treated with aspirin and 2 with anticoagulation. Two of the intracerebral hemorrhages occurred in the site where asymptomatic MBs were found at baseline. Conclusions— MBs appear to be a risk factor for subsequent intracerebral hemorrhage among patients with ischemic stroke in this small cohort of Chinese stroke patients. A large cohort study is required to confirm this observation.

Background and Purpose. Usually, microembolic signal (MES) monitoring is performed for MESs arising from downstream sources. The aim of this study is to describe the special characteristics of MESs originating from nearby sources in the middle cerebral artery (MCA). Methods. We analyzed 265 MESs detected in 5 patients (the study group) who had acute ischemic strokes within the territory of MCA stenoses and 48 MESs detected in 7 patients (the control group) from proximal sources: severe internal carotid artery stenoses and prosthetic heart valves. MESs were recorded with a 2-MHz, bigate transducer. We performed offline analyses of the recorded MESs using both post–fast Fourier transform (FFT) spectra and pre-FFT time domain signals. MESs were divided into 3 types–focused frequency signals (FFSs), bottom-frequency signals (BFSs), and multifrequency signals (MFSs)–according to the frequencies of the signals displayed on the post-FFT spectra. Results. In the study group, among 265 MESs, 245 (92.5%) were MFSs, 11 (4.2%) were FFSs, and 9 (3.4%) were BFSs. In the control group, among 48 MESs, 45 (93.5%) were FFSs, 2 (4.2%) were MFSs, and 1 (2.%) was a BFS. There was significant difference in MES type between MCA stenoses and other embolic sources (P < .05). On the post-FFT spectra, MFSs recorded from MCA stenoses occupied multiple frequencies along the vertical axis, and the low-frequency parts were usually bidirectional. On the pre-FFT time domain signals, the highest frequency parts presented distorted, amplitude-modulated sine waves, and the low-frequency parts presented totally irregular waves. The amplitudes of the low-frequency parts diminished with time in the proximal channel but enlarged with time in the distal channel over a short period. Conclusion. MESs recorded from MCA stenoses may have special characteristics of multiple frequencies on both post-FFT spectra and pre-FFT time domain signals. Our findings may represent rotating or vibrating emboli as they are just dislodged from the thrombus and are moving from the vessel wall to the center. Further clinical and laboratory studies are needed to confirm this hypothesis.

Background and Purpose. To evaluate the accuracy of B0 echo planar imaging (EPI) sequences for the detection of intracerebral bleeds. Methods. One hundred patients with acute strokes had magnetic resonance imaging and computed tomography (CT) examinations performed within 48 hours after the onset of symptoms. The detectability of intracerebral bleeds by the B0 EPI sequences was assessed. The results were compared to the gradient echo (GRE) sequence and CT brain examinations. The results of the GRE sequences were used as the gold standard. Results. The B0 EPI sequences detected 11 out of 11 acute, intracerebral hematomas; 6 out of 8 acute hemorrhagic strokes; 2 out of 2 acute, intraventricular hemorrhages; 8 out of 8 old hemorrhagic infarcts; 1 out of 1 subarachnoid hemorrhages; and 11 out of 22 patients with microbleeds. For the detection of acute, intracerebral hematomas and acute, hemorrhagic infarcts, B0 EPI sequences had a sensitivity of 89.5%, a specificity of 100%, and an accuracy of 98%. CT had a sensitivity of 57.9%, a specificity of 100%, and an accuracy of 92%. B0 EPI sequences did not miss any acute or chronic hemorrhages detected by CT examinations. Conclusions. B0 EPI sequences could not replace GRE images for the detection of both acute and chronic hemorrhages. Their sensitivity for the detection of acute and chronic blood products, however, was comparable, if not superior, to that of CT examinations.

Background Little is known about the performance of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) in the screening of post-stroke dementia (PSDE). Methods At 3 months after the index stroke, a research assistant administered the IQCODE to relatives of 189 Chinese patients with acute stroke who were consecutively admitted to a general hospital. A psychiatrist, who was blind to the IQCODE scores, interviewed all 189 patients and made DSM-IV diagnosis of dementia, which served as the benchmark for judging the performance of IQCODE in screening PSDE. Results The optimal cut-off point of IQCODE was 3.40. The sensitivity, specificity, and positive and negative predictive values of IQCODE, and the area under the receiver operating characteristic curve, were 88%, 75%, 33%, 98%, and 0.88, respectively. Conclusions When used as a sole instrument, IQCODE does not appear to be useful in screening PSDE in Chinese elderly. Copyright © 2003 John Wiley & Sons, Ltd.

Background. Hemodynamic changes and consequent low-density lipoprotein (LDL) filtration play an important role in the atherosclerotic plaque development of coronary arteries. In this pilot controlled case study, we aimed to investigate the correlation between parameters derived from computational fluid dynamics (CFD) simulation and risks (both current and long-term) of coronary atherosclerosis. Methods. We reconstructed geometric models from the baseline computed tomography (CT) angiography of two subjects, one patient and one healthy control, and performed CFD simulations. We estimated the current risk of ischemia by fractional flow reserve (FFR). We estimated the potential risk of plaque development by wall shear stress (WSS) and LDL filtration rate with follow-up clinical imaging validation. We investigated the effects of simulation methods (transient/static) and rheological models (Newtonian/Carreau–Yasuda) by comparing the corresponding results (FFR, WSS and LDL filtration rate) in the patient's left anterior descending coronary artery. Results. In baseline CFD simulation, FFR indicated mild current ischemic risk of the patient, in accordance with existing angina pectoris. Baseline WSS and LDL filtration rate results were related with in vivo plaque development. The plaque-growth locations in follow-up CT angiogram coincided with areas of low WSS and high LDL filtration rate in the baseline simulation. The LDL filtration rate delineated more specific risky areas than WSS. Between transient and static results, the difference of FFR was less than 5% in the whole model. As to WSS and LDL filtration rate the transient/static difference was within 20% in most areas, but rose up to 50% for WSS and even higher for LDL filtration rate, in areas with low WSS and high LDL filtration rate. As to rheological effects, Newtonian/Carreau–Yasuda difference was negligible for FFR throughout the model, within 30% for WSS and LDL filtration rate in major areas, and 50% or higher in certain segments where low WSS and high LDL filtration rate existed. Conclusion. CFD results appeared to be related with in vivo development of coronary atherosclerosis. Simulated FFR and its threshold value 0.8 demonstrated the ischemic risk. Both WSS and LDL filtration rate could indicate areas of plaque growth.

Summary Aims The purpose of this study was to discuss the relationship between blood pressure and prognosis of patients with symptomatic intracranial arterial stenosis. Methods Data on 2426 patients with symptomatic intracranial large artery stenosis and occlusion who participated in the Chinese Intracranial Atherosclerosis (CICAS) study were analyzed. According to the JNC 7 criteria, blood pressure of all patients was classified into one of the four subgroups: normal, prehypertension, hypertension stage I, and hypertension stage II. Poor outcomes were defined as death and functional dependency (mRS 3-5) at discharge or at 1 year. Results For patients with intracranial stenosis of 70% to 99%, the rate of poor outcome at discharge was 19.3%, 23.5%, 26.8%, and 39.8% (P = 0.001) for each blood pressure subgroup. For patients with intracranial large artery occlusion, the rates were 17.6%, 22.1%, 29.5%, and 49.8%, respectively (P

Background: Success in clinical trials of intracranial atherosclerosis (ICAS) hinges upon the definition of high-risk patients. Noninvasive computational fluid dynamics (CFD) of stenotic lesions may enhance therapeutic decision-making, yet the wide hemodynamic variation may limit the snapshot data of CFD. We determined whether different physiologic parameters may change downstream cerebral hemodynamics in patients with ICAS. Methods: Based on degree of stenosis, patients were divided into a moderate (50-69%) and severe group (70-99%). CFD models were made using CTA source images of patients with symptomatic middle cerebral artery stenosis. Inlet boundary conditions were defined using three ranges (2.5, 50, and 97.5 percentiles) of systolic BP (109.2, 158, and 225 mmHg) and hematocrit (27.3, 40.2, and 48.8). According to systolic BP and hematocrit, 9 distinct scenarios were simulated. Ratio of pressure was calculated using the simulated pressure at pre- and post-stenotic segments. Ratio of shear strain rate (SSR) and velocity were assessed between throat and proximal normal segment. A linear mixed model was used for the statistical analysis of repeated simulations. Results: Among the 56 patients, 32 (57.1%) patients had moderate stenosis and 24 (42.9%) had severe stenosis. Patients with severe stenosis showed unfavorable hemodynamics in terms of ratio of pressure, velocity, and SSR comparing with moderate stenosis group. A linear mixed model revealed that ratio of pressure was predicted by systolic BP X stenosis group interaction (p = 0.036). These pressure drops were associated with systolic BP (p Conclusions: Downstream blood flow may be significantly altered by systolic BP along with severity of stenosis. As individual patient’s specific anatomy influences hemodynamics, physiologic conditions may superimpose further changes in post-stenotic blood flow in patients with ICAS.

© 2015 Tang et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated, Background: Both apathy and suicide are common in poststroke patients. However, the association between poststroke apathy and suicide-related ideation (SI) in Chinese stroke patients is not clear and poorly understood. The aim of this study was to examine the association between apathy and SI in stroke. Methods: A cross-sectional study was conducted to investigate the association in 518 stroke survivors from Acute Stroke Unit of the Prince of Wales Hospital in Hong Kong. Geriatric Mental State Examination-Version A (GMS) and Neuropsychiatric Inventory-apathy subscale (NPI-apathy) were employed to assess poststroke SI and apathy, respectively. Patients' clinical characteristics were obtained with the following scales: the National Institutes of Health Stroke Scale (NIHSS), the Mini-Mental State Examination (MMSE), and the Geriatric Depression Scale (GDS). Results: Thirty-two (6.2%) stroke survivors reported SI. The SI group had a significantly higher frequency of NPI-apathy than the non-SI group (31.2% vs 5.3%, p < 0.001). The SI group also had higher GDS scores (10.47 ± 3.17 vs 4.24 ± 3.71, p < 0.001). Regression analysis revealed that NPI-apathy (OR 2.955, 95% CI 1.142-7.647, p = 0.025) was a significant predictor of SI. The GDS score also predicted SI (OR 1.436, 95% CI 1.284-1.606, p < 0.001). Conclusions: The current findings show that poststroke apathy is an independent predictor of SI 3 months after stroke. Early screening for and intervention targeting apathy through medication and psychological treatments may be necessary to improve stroke patients' apathy and reduce SI., This project is supported by the Health and Medical Research Fund, grant reference number is 01120376.

To investigate the optimal values of flow velocity on transcranial Doppler (TCD) in grading the severity of middle cerebral artery (MCA) stenosis in comparison with magnetic resonance angiography (MRA).Both TCD and MRA examinations were performed on 148 asymptomatic patients. The peak flow velocities of each MCA were recorded. Severity of MCA stenosis on MRA was classified as normal-mild (50% lumen diameter reduction), moderate (50%-75%), and severe-void (75% and void of flow signal).Among 296 MCAs evaluated, normal-mild stenosis was found in 75 (25%), moderate stenosis in 112 (38%), and severe stenosis in 109 (37%). The mean of systolic velocity (Vs) of MCA differed significantly among these three groups: mean Vs = 121.83 +/- 22.52 cm/s in the normal-mild group; 155.96 +/- 21.62 cm/s for the moderate group; and 199.39 +/- 43.86 cm/s for the severe group (P.001). The optimal cutoff velocity for detection of MCA (50%) stenosis was found at Vs140 cm/s on TCD (area under the ROC curve is 0.87, P0.001). The best cutoff points for grading severity of on TCD were 140 cm/s and 180 cm/s.TCD enables grading of the severity of MCA stenosis according to the flow velocity. This method provides a noninvasive and reliable method for grading MCA stenosis and allows longitudinal monitoring of the relationship between clinical outcome and hemodynamic change.

Although most therapeutic efforts and experimental stroke models focus on the concept of complete occlusion of the middle cerebral artery as a result of embolism from the carotid artery or cardiac chamber, relatively little is known about the stroke mechanism of intrinsic middle cerebral artery stenosis. Differences in stroke pathophysiology may require different strategies for prevention and treatment. We prospectively studied 30 consecutive acute ischemic stroke patients with middle cerebral artery stenosis detected by transcranial Doppler and magnetic resonance angiography. Patients underwent microembolic signal monitoring by transcranial Doppler and diffusion-weighted magnetic resonance imaging. Characteristics of acute infarct on diffusion-weighted magnetic resonance imaging were categorized according to the number (single or multiple infarcts) and the pattern of cerebral infarcts (cortical, border zone, or perforating artery territory infarcts). The data of microembolic signals and diffusion-weighted magnetic resonance imaging were assessed blindly and independently by separate observers. Diffusion-weighted magnetic resonance imaging showed that 15 patients (50%) had single acute cerebral infarcts and 15 patients had multiple acute cerebral infarcts. Among patients with multiple acute infarcts, unilateral, deep, chainlike border zone infarcts were the most common pattern (11 patients, 73%), and for single infarcts, penetrating artery infarcts were the most common (10 patients, 67%). Microembolic signals were detected in 10 patients (33%). The median number of microembolic signals per 30 minutes was 15 (range, 3-102). Microembolic signals were found in 9 patients with multiple infarcts and in 1 patient with a single infarct (p = 0.002, chi(2)). The number of microembolic signals predicted the number of acute infarcts on diffusion-weighted magnetic resonance imaging (linear regression, adjusted R(2) =0.475, p < 0.001). Common stroke mechanisms in patients with middle cerebral artery stenosis are the occlusion of a single penetrating artery to produce a small subcortical lacuna-like infarct and an artery-to-artery embolism with impaired clearance of emboli that produces multiple small cerebral infarcts, especially along the border zone region.

Background — Serial changes of flow velocities of transcranial Doppler ultrasound (TCD) in symptomatic middle cerebral artery (MCA) occlusive disease may be related to the occurrence of further vascular events, but prospective data are lacking. Methods — We conducted a prospective study on patients with cerebral ischemia who were hospitalized with symptomatic MCA stenosis or occlusion. We repeated TCD examinations 6 months after the initial examinations and recorded any stroke or coronary events during this period. The changes of MCA flow velocities were categorized as normalized artery, stable artery, and progressed artery, which were determined according to the changes of MCA velocities at 6 months. Results — We studied 143 consecutive patients who had relevant MCA occlusive diseases (107 with stenosis and 36 with occlusion). At 6 months, the velocities in the MCA returned to normal in 42 patients (29%), they were stable in 80 patients (62%), and they progressed in 13 patients (9%). The number of clinical events varied significantly among the 3 groups: there were 2 patients (4.8%) with clinical events in the normal group, 11 patients (12.5%) with clinical events in the stable group, and 5 patients (38.5%) with clinical events in the progressed group ( P =0.004). The 18 recurrent events included 10 recurrent strokes, 5 transient ischemic attacks, and 3 acute coronary syndromes. Conclusions — Progression of MCA occlusive diseases is associated with an increased risk of vascular events. Further studies are required to establish the value of serial TCD examinations in predicting future clinical events.

Proper assessment of intracranial arteries by transcranial Doppler sonography (TCD) in patients with intracranial stenoses is occasionally made difficult by an insufficient temporal bone window, an unfavourable insonation angle, or low flow velocity or volume. This condition is frequently found in Chinese. In these cases, echocontrast could be helpful. We investigated 48 temporal windows of 24 acute Chinese stroke patients with insufficient native transtemporal insonation conditions before and after the application of the echo enhancer Levovist® (galactose/palmitic acid) by an injection pump. We classified the signal quality from four segments of the main intracranial arteries: anterior cerebral artery (A1), main stem of the middle cerebral artery (MCA, M1), intracranial segment of the carotid artery (C1), and posterior cerebral artery (P1). The signal quality was classified as follows: 0 = no signal, 1 = poor, envelope curve does not follow spectrum, 2 = adequate, envelope curve follows spectrum. As compared to the pre-contrast scans, echocontrast allowed for more segments to be evaluated by pulsed Doppler sonography. Before Levovist, only 12% of the segments could be detected, after Levovist 63%. For all arteries, signal quality was better after Levovist, p between 0.0180 and 0.0003. In 3 patients, MCA stenoses with peak systolic Doppler flow velocities above 160 cm/s were found only after Levovist. In patients with poor pre-contrast detection, echocontrast-enhanced TCD allows for more arterial segments to be insonated and for the detection of stenoses unnoted during the non-enhanced investigation.

Tang W-K, Lu J-Y, Liang H, Chan T-T, Mok V, Ungvari GS, Wong K-S. Is insomnia associated with suicidality in stroke? Objective To evaluate the relationship between insomnia and suicidality (SI) in Chinese patients with first or recurrent stroke. Design Cross-sectional survey. Setting Acute stroke unit of a general hospital. Participants Patients (N=787) with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong. Interventions Not applicable. Main Outcome Measures Suicidality (SI) was assessed with the Geriatric Mental State Examination at 3 months after subjects' index stroke. Insomnia symptoms were evaluated with a standard insomnia questionnaire. The association between insomnia symptoms and SI was examined and adjusted for potential confounders, including age, sex, marital status, previous stroke, depression, fatigue, Mini-Mental State Examination score, and neurologic deficits measured with the National Institutes of Health Stroke Scale. Results Eighty-seven patients (11.1%) were found to have SI (SI group). Frequent awakening was significantly more common in the SI group than in the non-SI group and remained a significant predictor of SI in forward logistic regression analysis (odds ratio, 1.7) after adjusting for possible confounders. Conclusions These findings should alert clinicians to the potential danger of insomnia and the importance of its early identification and treatment in stroke patients.

Increased cerebral blood flow velocity of basilar artery (BA) is common but often neglected. By using digital subtraction angiography (DSA) to detect intracranial large artery stenosis, we performed transcranial Doppler (TCD) to evaluate cerebral hemodynamic changes of stroke patients.Acute stroke patients with TCD-detected raised peak systolic velocity (PSV) in BA (≥100 cm/second) were recruited.Among 91 recruited patients, BA stenosis (50%) was confirmed by using DSA in 29 patients (32%), among which 20 patients (70.0%) had coexistent internal carotid artery (ICA) and vertebral artery (VA) stenoses. Among patients without BA stenosis (n = 62, 68%), severe stenosis or occlusion of ICA was evaluated in 22 patients (22/62, 35.4%) and severe stenosis or occlusion of VA was detected in 22 patients (22/62, 35.4%). Among the values of PSV (120, 140, 160, and 180 cm/second) and the stenotic-to-prestenotic ratio (SPR) (1.5, 2.0, 2.5, and 3.0), 160 cm/second was found to show the highest predictive value (area under the receiver operator characteristic curve: .75, 95% CI: .65-.86), with a sensitivity of .70 and a specificity of .81.Apart from an intrinsic BA stenosis, high-grade steno-occlusion of ICA or VA may contribute a lot to induce an elevated flow velocity in BA. A higher value of cutoff point may increase the accuracy of diagnosing BA stenosis.

Background The risk of a subsequent stroke following a minor stroke is high. However, there are no effective rating scales to predict recurrent stroke following a minor one. Therefore, we assessed the risk factors associated with recurrent ischemic stroke or transient ischemic attack (TIA) within one year of minor stroke onset in order to identify possible risk factors. Methods Eight hundred and sixty-three non-cardioembolic ischemic stroke patients in the Chinese IntraCranial AtheroSclerosis Study that presented with minor stroke, defined as an admission National Institutes of Health stroke scale (NIHSS) score of ≤3, were consecutively enrolled in our study. Clinical information and imaging features upon admission, and any recurrent ischemic stroke or TIA within one year was recorded. Cox regression was used to identify risk factors associated with recurrent ischemic stroke or TIA within the year following stroke onset. Results A total of 50 patients (6.1%) experienced recurrent ischemic stroke or TIA within one year of minor stroke onset. Multivariate Cox regression model identified lower admission NIHSS score (HR, 1.75; 95% CI, 1.32 to 2.33; P

Understanding how symptomatic intracranial atherosclerotic disease (ICAD) evolves with current medical therapy may inform secondary stroke prevention.In a prospective academic-initiated study, we recruited 50 patients (mean age = 63.4 ± 9.0 years) with acute strokes attributed to high-grade (≥70%) intracranial atherosclerotic stenosis for 3-dimensional rotational angiograms before and after intensive medical therapy for 12 months. Treatment targets included low-density lipoprotein ≤ 70mg/dl, glycosylated hemoglobin (HbA1c) ≤ 6.5%, and systolic blood pressure ≤ 140 mmHg. We analyzed infarct topography and monitored microembolic signal in recurrent strokes. The reference group was a published cohort of 143 ICAD patients.Overall, the stenoses regressed from 79% at baseline (interquartile range [IQR] = 71-87%) to 63% (IQR = 54-74%) in 1 year (p 0.001). Specifically, the qualifying lesions (n = 49) regressed (stenosis reduced10%) in 24 patients (49%), remained quiescent (stenosis same or ±10%) in 21 patients (43%), and progressed (stenosis increased10%) in 4 patients (8%). There was no difference in intensity of risk factor control between groups of diverging clinical or angiographic outcomes. Higher HbA1c at baseline predicted plaque regression at 1 year (odds ratio = 4.4, 95% confidence interval = 1.4-14.5, p = 0.006). Among the 6 patients with recurrent strokes pertaining to the qualifying stenosis, 5 patients had solitary or rosarylike acute infarcts along the internal or anterior border zones, and 2 patients showed microembolic signals in transcranial Doppler ultrasound.A majority of symptomatic high-grade intracranial plaques had regressed or remained quiescent by 12 months under intensive medical therapy. Artery-to-artery thromboembolism with impaired washout at border zones was a common mechanism in stroke recurrence.

Background and Purpose— Single subcortical infarction (SSI) may be classified as proximal SSI (pSSI) or distal SSI (dSSI) according to its location within the middle cerebral artery territory. Few studies have examined the differences in clinical outcome between the two. Our study investigated such differences in patients with pSSI or dSSI and examined their baseline characteristics and indicators for small-vessel disease. Methods— We prospectively enrolled 400 patients with SSI (208 pSSI and 192 dSSI) who had no middle cerebral artery disease on MR angiography. Data compared included clinical information, lesion size, prevalence of lacune and leukoaraiosis at baseline, National Institutes of Health Stroke Scale score and modified Rankin Scale score at discharge, and any deterioration during admission or recurrence of ischemic stroke Results— In multivariable logistic regression analysis, dSSI was independently associated with patient’s history of stroke, admission National Institutes of Health Stroke Scale score ≤3, Fazekas score ≥3, presence of lacune, but not hyperlipidemia. Patients with dSSI had shorter length of hospital stay, lower rate of functional dependence at discharge (modified Rankin Scale score ≥2), and lower deterioration or recurrence risk of ischemic stroke in 1 year. Multivariable logistic regression analysis showed that factors associated with higher deterioration or recurrence risk of ischemic stroke at 1 year included female sex, history of coronary heart disease, pSSI, and not on antithrombotics Conclusions— Compared with pSSI, patients with dSSI likely had small-vessel diseases but better clinical outcome.

This study examined the validity and reliability of the Neuropsychiatric Inventory Questionnaire version (NPI-Q), a proxy-reported format of the interview-based NPI, in assessing neuropsychiatric symptoms in 173 patients with stroke or transient ischemic attack (TIA) having cognitive impairment. The NPI-Q was validated against the NPI as a gold standard. Informants took approximately 7 minutes to complete the NPI-Q. Bland-Altman analysis revealed a bias of 0.7 points, with 95% limits of agreement between −8.6 and 10.0 between the total symptom scores of the NPI and NPI-Q. The NPI-Q correlated significantly with the NPI in individual and total symptom scores and caregiver distress scores. In predicting presence of symptoms on the NPI, the NPI-Q yielded, on average, sensitivity of 74.1% and specificity of 79.5%. On the NPI-Q, informants tended to overreport symptoms in patients with less severe symptoms but underreport with increasing symptom severity. Internal consistency of the NPI-Q was acceptable (Cronbach's α = 0.756). One-week test–retest reliability of the NPI-Q was excellent (intraclass correlation coefficient = .990). The NPI-Q is a valid and reliable instrument for screening neuropsychiatric symptoms in patients with stroke and TIA.

Background: Rapid eye movement (REM) sleep behavior disorder (RBD) is a sleep disturbance in which patients enact their dreams while in REM sleep. The behavior is typically violent in association with violent dream content, so serious harm can be done to the patient or the bed partner. The prevalence of RBD is well-known in Parkinson's disease, Lewy body dementia, and multiple systems atrophy. However, its prevalence and causes in stroke remained unclear. The aim of this study was to determine factors influencing the appearance of RBD in a prospective cohort of patients with acute ischemic stroke. Methods: A total of 2,024 patients with first-ever or recurrent acute ischemic stroke were admitted to the Acute Stroke Unit at the Prince of Wales Hospital between January 2010 and November 2011; 775 of them received an MRI scan. Within 2~days of admission, a research nurse collected demographic and clinical data and assessed the severity of each stroke using the National Institute of Health Stroke Scale (NIHSS). One hundred and nineteen of the 775 patients meeting study entry criteria formed the study sample. All eligible participants were invited to attend a research clinic 3~months after the onset of the index stroke. In the attendance, a research assistant administered the MMSE and the 13-item RBD questionnaire (RBDQ). Results: Among 119 stroke patients, 10.9\% were exhibited RBD, defined as an REM sleep behavior disorder questionnaire score of 19 or above. The proportion of patients with acute brainstem infarct was significantly higher in RBD patients than those without RBD. Compared with patients without RBD, RBD patients were more likely to have brainstem infarcts and had smaller infarct volumes. In a multivariate analysis, in which stroke location and infarct volume were inserted, brainstem infarcts were an independent predictor of RBD (odds ratio = 3.686; P = 0.032). Conclusions: The results support the notion of a predominant role of brainstem injury in the development of RBD and suggest that patients with brainstem infarcts RBD should be evaluated by a clinical neurologist. \copyright 2014 Tang et al.; licensee BioMed Central Ltd.

We aim to investigate the correlation between presence of anterior temporal artery (ATA), the first major branch of middle cerebral artery (MCA), on conventional angiography and clinical outcome in patients with acute atherosclerotic M1-MCA occlusion. Consecutive patients with acute atherosclerotic M1-MCA occlusion from Nanjing Stroke Registry Program (NSRP) between January 2007 and December 2012 were included in this study. All patients underwent MRI followed by conventional angiography. From their data, we analyzed baseline characteristics, infarction patterns, DWI-ASPECTS, and collateral circulation. The correlation of ATA presence and good clinical outcome, modified Rankin Scale (mRS) score ≤2, at 3 months was also calculated. In 98 patients meeting entry criteria, the presence of ATA was found in 44 patients. Patients with ATA present were found to have less hypertension (p = 0.042), lower baseline National Institutes of Health Stroke Scale (NIHSS) (p = 0.043), more small infarcts in perforating artery territory (p = 0.013), and a higher number of DWI-ASPECTS ≥7 (p = 0.034). Binary logistic regression analysis showed an adjusted odds ratio of 4.45 for a good outcome in patients with ATA presence (95 % CI 1.52 to 13.03, p = 0.007). The presence of ATA can be used as a predictor of good outcome in patients with acute atherosclerotic M1-MCA occlusion.

Cerebral white matter hyperintensities (WMH) are a consequence of cerebral small vessel disease. Statins have been shown to reduce recurrent stroke among patients with various stroke subtypes, including lacunar stroke, which also arises from small vessel disease. In this study, we investigated the hypothesis that prestroke statin use would reduce the progression of WMH and/or cognitive decline among stroke patients with confluent WMH. Patients (n = 100) were participants of the VITAmins To Prevent Stroke magnetic resonance imaging substudy. All patients had confluent WMH on magnetic resonance imaging at baseline. Eighty-one patients completed the 2-year follow-up. We assessed general cognition and executive function using the mini-mental state examination and Mattis dementia rating scale–initiation/perseveration subscale, respectively. We compared the change in volume of WMH and cognition between prestroke statin use and prestroke nonstatin use groups. We also evaluated the effects of prestroke statin use on incident lacunes and microbleeds. The prestroke statin use group (n = 51) had less WMH volume progression (1.54 ± 4.52 cm3 vs 5.01 ± 6.00 cm3, p = 0.02) compared with the prestroke nonstatin use group (n = 30). Multivariate linear regression modeling identified prestroke statin use as an independent predictor of WMH progression (β = –0.31, p = 0.008). Prestroke statin use was also associated with less decline (Mattis dementia rating scale–initiation/perseveration subscale; β = 0.47, p = 0.001). No association was observed with changes in mini-mental state examination scores. There were no between group differences on incident lacunes or incident microbleeds. Prestroke statin use may reduce WMH progression and decline in executive function in stroke patients with confluent WMH.

BACKGROUND Radiation-induced carotid stenosis in patients with head and neck tumors can cause significant mortality and morbidity. This study examined the incidence of stenosis in the extracranial carotid arteries of nasopharyngeal carcinoma patients after radiotherapy. METHODS The extracranial carotid arteries of 71 (53 male and 18 female; mean age of 53.6 years) postradiation patients with nasopharyngeal carcinoma were examined with color Doppler ultrasound. The distribution of the arterial stenosis and the degree of stenosis were documented. The results were compared with the control group, which comprised 51 newly diagnosed nasopharyngeal carcinoma patients (35 male and 16 female, mean age of 48.8 years) before radiotherapy. Incidences of risk factors for arterial stenosis such as hypertension, smoking, and hypercholesterolemia also were studied in these two groups. RESULTS There was no significant difference in the incidence of risk factors between the two groups. Arterial stenosis was, however, more common in the postradiation group than the preradiation group (56 of 71 vs. 11 of 51). The common/internal carotid arteries (CCA/ICA) were most commonly involved (55 of 71 vs. 11 of 51; P 50% reduction of luminal diameter) was only found in the postradiation group (21 of 71 in CCA/ICA, 11 of 71 in ECA, 4 of 71 in VA). CONCLUSIONS This study showed that radiation could cause significant carotid stenosis. Ultrasound examinations for these patients therefore are necessary for early detection and possible intervention of this late radiation-induced complication. Cancer 2001;92:2357–63. © 2001 American Cancer Society.

Background Carotid artery stenosis is a late complication of radiotherapy to the neck region. This complication has, however, a significant impact with increased risk of stroke causing mortality and morbidity. Clinicians' awareness of this complication and early detection is therefore important. Methods Eighty patients with nasopharyngeal carcinoma (NPC) who had received radiotherapy were recruited for color Doppler ultrasonography of the carotid arteries. fifty-eight patients with newly diagnosed NPC who had never received any radiotherapy were recruited as controls. All patients with significant carotid stenosis were referred to the neurology clinic for further assessment. Results Twenty-four patients were found to have more than 50% diameter reduction in the extracranial carotid artery. Clinical assessment by a neurologist showed 9 of 24 patients had a history of transient ischemic attack, amaurosis fugax, or stroke. Seven of these patients had clinically detectable neck bruit. Conclusions Clinicians attending to patients after radiotherapy for head and neck cancers should be aware of this long-term complication of radiotherapy. A detailed clinical history and incorporation of auscultation of carotid arteries in routine follow-up of postradiotherapy patients are recommended. © 2001 John Wiley & Sons, Inc. Head Neck 23: 780–784, 2001.

Objective: To identify the clinical and radiologic features of intracerebral hemorrhage (ICH) in aspirin users.Background: Although the benefits of aspirin outweigh its hemorrhagic risks for patients at high risk of vascular diseases, prolonged use of aspirin is associated with an increased risk of ICH.Methods: The authors enrolled consecutive patients with acute stroke who were admitted to a regional hospital from 1993 to 1998 into a stroke registry. From this registry, they identified all stroke patients who had ICH confirmed by CT scan and then selected those taking regular aspirin before ICH as the study group. For each study patient, they selected the immediate next two patients with ICH but not taking aspirin as controls.Results: The authors identified 58 aspirin users and 1193 nonusers among all patients hospitalized for ICH. From the group of nonusers, they selected 116 patients as controls. The locations of the hematoma were different (p = 0.002), with more lobar hematoma in the aspirin group (32.8%) than in the control group (10.3%). Prior cerebrovascular disease was the reason for taking aspirin in 37 (64%) patients but five patients had prior ICH.Conclusions: The propensity for lobar hematoma in aspirin-associated ICH suggests its pathology may be somewhat different from spontaneous ICH among nonaspirin users. Further research to examine the risks and benefits of aspirin use in certain subgroups at risk of both thrombotic and hemorrhagic events is needed.

A prospective randomized trial was conducted in 148 women to compare the efficacy of two regimens of vaginal misoprostol for termination of second trimester pregnancy. Women aged 16-40 years requesting termination of second trimester pregnancy were randomized into two groups. Women in group 1 were given vaginal misoprostol 400 microg every 3 h for a maximum of five doses in 24 h. Women in group 2 were given vaginal misoprostol 400 microg every 6 h for a maximum of three doses in 24 h. If women did not abort in 24 h, the same regimen was repeated. The median induction-abortion interval in group 1 (15.2 h) was significantly shorter (P < 0.01) than that in the group 2 (19.0 h). The percentage of women who achieved successful abortion within 48 h in group 1 (90.5%) was also significantly higher (P < 0.02) than that in group 2 (75.7%). The incidence of fever was more common in group 1 (P = 0.01). It is concluded that the regimen of vaginal misoprostol 400 microg every 3 h with maximum of five doses in 24 h was more effective than the regimen of misoprostol every 6 h in termination of second trimester pregnancy.

To investigate whether subclinical ciliochoroidal effusion and resulting asymptomatic angle narrowing occurs in patients taking topiramate, by ultrasound biomicroscopy (UBM). Chinese patients aged 18–75 years for whom topiramate was indicated were recruited. Examinations including UBM were performed before and 4 weeks after commencement of topiramate. In this pilot of 20 eyes of 20 patients, there were no statistically significant changes in the angle parameters noted on gonioscopy or UBM, including anterior chamber depth, angle-opening distance at 500 μm, trabecular ciliary process distance, trabecular-iris angle, and scleral thickness. Short-term use of topiramate does not induce asymptomatic angle narrowing.

Pregnancy was terminated by repeated doses of vaginal misoprostol in 20 women at a gestational age of less than 9 weeks. The women were given 800 μg of vaginal misoprostol as an initial dose followed by 400 μg of vaginal misoprostol every 3 h for 4 doses. Fourteen women (70%, 95% confidence interval: 48–85%) had a complete abortion. Two women (10%) had a missed abortion, and two (10%) had an ongoing pregnancy. Two women (10%) had an incomplete abortion. The interval between the first dose of misoprostol and the passage of tissue mass was 25.3±34.4 h (median: 15 h).The duration of vaginal bleeding was 23.6±20.4 days (median: 14 days). Side-effects were mild and there was no significant drop in hemoglobin level. Repeated doses of vaginal misoprostol may be an alternative for women who do not want surgical abortion and who live in an area where mifepristone is not available.

A prospective randomized trial was conducted in 140 women to compare the efficacy of vaginal gemeprost with vaginal misoprostol for termination of second trimester pregnancy. Women requesting termination of second trimester pregnancy were randomized into two groups. Group A women were given 1 mg vaginal gemeprost every 3 h for a maximum of five doses in the first 24 h, whereas group B women were given 400 micrograms vaginal misoprostol every 3 h for a maximum of five doses in 24 h. The median induction-abortion interval in the vaginal misoprostol group (14.1 h) was significantly shorter than that in the gemeprost group (19.5 h). The percentage of women who achieved successful abortion within 24 h in the misoprostol group (80.0%) was significantly higher than that in the gemeprost group (58.6%). There was no significant difference in the incidence of side effects between the two groups except for diarrhea, which was more common in the gemeprost group. The incidence of fever was more common in the misoprostol group. It is concluded that vaginal misoprostol is more effective than gemeprost in termination of second trimester pregnancy.

Background and Purpose: External counterpulsation (ECP) is a novel noninvasive method used to augment cerebral blood flow which may benefit ischemic stroke patients. We aimed to explore the association between the degree of cerebral blood flow augmentation by ECP and clinical outcome after acute ischemic stroke. Methods: Acute ischemic stroke patients within 7 days of symptom onset were recruited into this study. On admission, bilateral middle cerebral arteries of subjects were monitored using transcranial Doppler (TCD). Flow velocity changes before, during, and after ECP were, respectively, recorded for 3 minutes. Cerebral augmentation index (CAI) was the increase in percentage of middle cerebral artery mean flow velocity during ECP compared with baseline. TCD data were analyzed based on ipsilateral or contralateral to the infarct side. Modified Rankin Scale (mRS) was evaluated 3 months, 6 months and 1 year after ischemic stroke onset. We stratified the patients into two groups (good outcome: mRS 0~2; poor outcome: mRS 3~6) at each measurement time point. Results: 72 patients were recruited (mean age, 63.8±10.7 years; 87.5% males). At month 6 and year 1 after stroke onset, univariate analysis showed that admission National Institutes of Health Stroke Scale (NIHSS) was significantly lower and ECP therapy duration was longer in good outcome group; while the ipsilateral CAI was significantly lower in good outcome group than those in poor outcome group (3.71±4.94 versus 7.73±7.66, P=0.044; 3.50±4.73 versus 8.58±7.72, P=0.015 respectively). Multivariate logistic regression showed that ipsilateral CAI and baseline NIHSS were independent predictors for a favourable outcome at these two measurement points. Conclusions: The degree of cerebral augmentation on ipsilateral to the infarct side by ECP is found to be an important predictor for long-term good outcome in acute ischemic stroke patients, in addition to the well-known prognostic factors such as NIHSS.

Intracranial atherosclerosis (ICAS) is an important cause of ischemic stroke throughout the world, accounting for ≈30% to 50% and 10% of ischemic stroke and transient ischemic attack in Asians and whites, respectively.1 Several imaging modalities, such as transcranial Doppler (TCD), magnetic resonance angiography (MRA), computed tomographic angiography (CTA), and digital subtraction angiography (DSA), are used commonly in routine clinical practice to detect and assess ICAS, as well as in selection criteria of clinical trials.2–4 Although some of these imaging modalities yield flow information, such as TCD revealing velocity data or waveform turbulence and time-of-flight MRA (TOF-MRA) depicting arterial patterns based on blood flow, most attention has been drawn to the maximal percent stenosis of the arterial lumen. The focus on severity of stenosis has been reinforced because severe (70%–99%) atherosclerotic stenosis was demonstrated as an independent predictor for stroke recurrence in the territory of the stenotic artery, with the risk of ≈20% at 1 year, in the Warfarin versus Aspirin for Symptomatic Intracranial Disease (WASID) trial.5 However, those patients with a traditionally considered moderate (50%–69%) atherosclerotic stenosis were also at considerable risk of recurrent stroke, ≈10% at 1 year in the WASID study.5,6 In more recent studies, the role of percent stenosis in predicting subsequent stroke risk has been superseded by collateral flow and hemodynamics in the same patient cohort.7,8 Characterization of the atherosclerotic lesion is also represented poorly by percentage of stenosis measured at the narrowest vessel diameter alone. Beyond the maximal luminal stenosis, many other features may reflect the characteristics of ICAS, such as plaque morphology and components, which might also be promising markers in risk stratification of patients with symptomatic ICAS.9 However, from the view of intracranial stenosis, it could also be attributed to causes …

The authors reviewed the clinical and electrophysiological features in 20 consecutive adult patients with Guillain-Barre Syndrome (GBS) admitted to a regional hospital in Hong Kong from 1993 to 1998. The majority of cases in this locality consists of the demyelinating form of GBS; epidemic, acute motor axonal neuropathy is not the predominant form. The incidence of GBS in this region of China was 0.44 per 100,000.

Central autonomic impairment is frequent in ischemic stroke at acute or chronic stages. The mechanism by which these symptoms occur in patients with ischemic stroke has not been elucidated. This study sought to investigate cardiovascular autonomic function in patients with different subtypes of post-acute ischemic stroke.77 ischemic stroke patients [50 patients with large-artery atherosclerosis (LAA) and 27 patients with small-vessel occlusion (SVO), average 6 months after stroke onset] and 37 elderly controls were recruited. All performed Ewing's battery autonomic function tests and power spectral analysis of heart rate variability (HRV).Stroke patients with both LAA and SVO had significantly lower low frequency power spectral density than controls. The prevalence of autonomic dysfunction in both groups (82.0% patients with LAA and 63.0% with SVO) was higher than that in controls (21.6%). Patients with LAA showed impairment of all parasympathetic tests (all P0.05) and one of the sympathetic tests (mean fall in systolic blood pressure on standing: P = 0.058) and those with SVO only showed impairment in two parasympathetic tests (heart rate response to deep breathing: P = 0.010; heart rate response to standing: P = 0.004) in comparison with controls. Patients with LAA had significantly more impairment than those with SVO in some autonomic parameters (Valsalva ratio: P = 0.039; mean fall in systolic blood pressure on standing: P = 0.015).Irrespective of the subtype of the ischemia, post-acute stroke patients showed a parasympathetic cardiac deficit. Additionally, parasympathetic and sympathetic cardiovascular modulations were more severely impaired in patients with LAA.

Background and purpose External counterpulsation (ECP) is a novel method to increase cerebral blood flow, which may benefit acute ischaemic stroke patients. Our aim was to identify whether the hemodynamic effect of ECP is associated with cerebral vasoreactivity to breath-holding. Methods Thirty-seven recent ischaemic stroke patients with large artery steno-occlusive disease were recruited together with 20 healthy controls. All underwent ECP treatment and a breath-holding test combined with transcranial Doppler monitoring on bilateral middle cerebral arteries was performed. The data of the stroke patients were designated as ipsilateral or contralateral based on the side of the infarct, whilst the average of both sides was used in controls. The cerebral augmentation index (CAI) was used to evaluate the augmentation effects of ECP. Cerebral vasoreactivity was assessed by using the breath-holding index (BHI). Results Middle cerebral artery mean flow velocities significantly increased in the stroke group after ECP but not in controls. BHIs were much smaller in the stroke group than in the controls. The CAI did not correlate with the BHI in either the ipsilateral or contralateral side of the stroke group or in controls. For stroke patients, BHI was significantly lower on the ipsilateral side than the contralateral side, but the CAI showed no difference between the two cerebral hemisphere sides. The CAI of stroke patients was significantly related to mean blood pressure change on the ipsilateral side. Conclusion The dynamic augmentation effects of ECP as measured by the CAI were different from the well established vasoreactivity to breath-holding. The CAI is suggested as a measure of how well the brain accommodates blood flow augmentation during ECP.

Background and Purpose: Poststroke fatigue (PSF) is a frequent and persistent problem in stroke survivors. The neuroanatomical model of PSF remains unclear. This study examined the association between PSF and cerebral microbleeds (CMBs). Methods: The sample comprised 199 patients with acute ischemic stroke. A psychiatrist who was blind to the subjects' radiological data administered the Chinese version of the Fatigue Severity Scale. PSF was defined as a Fatigue Severity Scale score of 4.0 or more. The locations of CMBs were evaluated with magnetic resonance imaging within 7 days of admission. Results: Of the 199 patients screened, 47 (23.6%) had PSF. The PSF group had a higher Geriatric Depression Scale score (p < 0.001) and a trend for a higher age (p = 0.074). The proportion of patients with deep CMBs was significantly higher in the PSF group (66.0 vs. 48.7%; p = 0.038). The presence of deep CMBs was a significant independent predictor of PSF with an odds ratio of 2.68 (p = 0.016). Conclusion: The results suggest that deep CMBs are associated with a higher risk of PSF. Further studies are needed to clarify whether CMBs affect the clinical presentation, treatment response and outcome of PSF.

Objective To examine differences in health-related quality of life (HRQOL) in stroke survivors with and without apathy. Design Cross-sectional study. Setting Acute stroke unit in a regional hospital. Participants Stroke survivors (N=391) recruited from the acute stroke unit. Interventions Not applicable. Main Outcome Measures Participants were divided into apathy and nonapathy groups. Participants who scored ≥36 on the Apathy Evaluation Scale, clinician's version formed the apathy group. HRQOL was measured with the 2 component scores, mental component summary (MCS) and physical component summary (PCS), of the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12). Demographic and clinical information were obtained with the National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI), Mini-Mental State Examination (MMSE), and Geriatric Depression Scale (GDS). Results Thirty-six (9%) participants had apathy. The apathy group had significantly lower MCS and PCS scores. After adjusting for sex, education, diabetes mellitus, and NIHSS, MMSE, GDS, and BI scores, the MCS score in the apathy group remained significantly lower. Conclusions Apathy has a significant negative effect on HRQOL in stroke survivors, particularly on their mental health. Interventions for apathy could improve the HRQOL of stroke survivors.