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Multiple acute cerebral infarcts (MACIs) detected by diffusion-weighted imaging (DWI) may indicate an unstable source of thromboembolism. The authors studied 119 consecutive acute ischemic stroke patients within 24 hours of onset with DWI. MACIs were present in 20 patients (16.8%). During the follow-up period, there were 15 recurrent strokes, 3 acute coronary syndromes, and 5 deaths. MACI was the only significant independent predictor for vascular events and death (odd ratio [OR]] = 4.34; p = 0.001) and stroke recurrence (OR = 5.93; p = 0.001).

The purpose of this study was to investigate the long-term prognosis of patients with carpal tunnel syndrome (CTS). We prospectively followed-up patients with CTS for 80 weeks. Thirty cases had been treated with a single injection of methylprednisolone acetate and another 30 with a 10-day course of prednisolone. At the end of the follow-up period, there were no significant differences in symptoms as measured by global symptom score and in the proportion of patients who progressed to decompressive surgery. Few patients who were not operated on (11.4%) remain asymptomatic.

Background Symptomatic brain hemorrhage was a significant cause of periprocedural stroke or death following stenting in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial, which called into question the safety of Wingspan stenting for intracranial atherosclerosis. This study analyzed the role of a learning curve in the safety and outcome of Wingspan stenting from the experience of 95 consecutive patients at a single center. Methods In this prospective study the endpoints were major stroke or death (modified Rankin Scale score >3) within 30 days, other neurological complications, technical procedural problems, technical success in completion of angioplasty and stenting and recurrent ischemic stroke in the corresponding vascular territory after 30 days. Data splitting into quarters was used for learning curve analysis. Results The periprocedural major stroke or death rate was 4.2% (4/95), minor stroke rate was 5.3% (5/95), total 9.5% (9/95). The technical procedural problem rate was 11.6% (11/95) and the technical success rate was 93.7% (89/95). The 89 patients were followed for 38.9±22.7 months (median 40.8, range 0.2–72, 3463 patient-months) after stenting. The risk of recurrent ischemic stroke in the corresponding vascular territory was 0.7% per patient per year (2/3463 patient-months). Guidewire- or angioplasty-related hemorrhage was the major cause of periprocedural major stroke or death (3/4, 75%) and did not occur in the last quarter. Periprocedural intracerebral hemorrhage was uncommon and perforator stroke did not occur. Conclusions There may be a learning curve for mastering the safety precautions of Wingspan stenting for intracranial atherosclerosis.

Factor VII deficiency is an uncommon coagulation disorder that patient usually presents with bleeding diathesis, but thrombotic event has been reported. We report a case of unusual clinical presentation in a patient with undiagnosed factor VII deficiency who presented with acute ischemic stroke.

Objective To examine the impact of anxiety on health-related quality of life (HRQOL) of stroke survivors. Design Cross-sectional study. Setting Acute stroke unit in a regional hospital. Participants Patients (N=374) from an acute stroke unit. Interventions Not applicable. Main Outcome Measures The presence of anxiety was defined as a score of ≥8 on the anxiety subscale of the Hospital Anxiety Depression Scale. HRQOL was measured by the total score and 12 domain scores of the Stroke Specific Quality of Life (SSQOL) scale. Demographic characteristics and history of medical conditions were also recorded. Clinical characteristics were obtained using the following scales: National Institutes of Health Stroke Scale, Barthel Index, Mini-Mental State Examination, and Geriatric Depression Scale (GDS). Results Eighty-six (23%) stroke survivors had anxiety. The anxiety group had significantly more women (62.8% vs 35.1%), higher GDS scores (7.5±4.5 vs 3.5±3.6), and lower scores for total SSQOL (3.9±0.6 vs 4.5±0.6) and SSQOL domains of energy (2.0±1.2 vs 3.4±1.4), mood (3.6±1.5 vs 4.6±0.9), personality (3.4±1.7 vs 4.4±1.1), and thinking (2.4±1.2 vs 3.5±1.4), after adjustment for sex and GDS score. In subsequent multivariate regression analysis, the Hospital Anxiety Depression Scale anxiety score was negatively associated with the SSQOL total score ( r =−.154) and 5 of the 12 domain scores, namely energy ( r =−.29), mood ( r =−.102), personality ( r =−.195), thinking ( r =−.136), and work/productivity ( r =−.096). Conclusions Anxiety has a negative effect on HRQOL of stroke survivors, independent from depression. Interventions for anxiety should improve stroke survivors' quality of life.

Background: External counterpulsation (ECP) is a noninvasive method used to augment cerebral perfusion but the optimal use of ECP in ischemic stroke has not been well documented. We aim to investigate the effects of increasing ECP treatment pressure on cerebral blood flow and blood pressure (BP). Methods: We recruited 38 acute ischemic stroke patients with large artery occlusive disease and 20 healthy elderly. Mean cerebral blood flow velocities (CBFV) of bilateral middle cerebral artery were monitored using transcranial dopper. Continuous beat-to-beat BP was measured via finger cuffs. We started ECP treatment pressure from 150mmHg, then gradually increased to 187.5mmHg, 225mmHg and 262.5mmHg. CBFV and BP were recorded before ECP and during each pressure increment respectively for 3 minutes. CBFV data of patients was analyzed based on whether it was ipsilateral or contralateral to the infarct. Results: Median NIHSS of stroke patients was 5.5 and mean time after stroke onset was 5.24 days. Mean BP was significantly elevated from baseline in both groups after ECP started. BP increase percentages of two groups similarly kept augmented following raised ECP pressure and reach maximium at 262.5mmHg (patients 16.9% vs. controls 16.52% compared with baseline). Under different ECP pressures, ipsilateral mean CBFV of stroke patients increased 5.15% (150mmHg), 4.35% (187.5mmHg), 4.55% (225mmHg) and 3.52% (262.5mmHg) from baseline. All were significantly higher than baseline but did not differ among different pressures. Contralateral mean CBFV changed likewise (5.16%, 4.02%, 3.7% and 3.34% increase from baseline). Mean CBFV of controls under ECP pressures did not increase from baseline. Conclusion: The increasing treatment pressure of external counterpulsation continuously augments blood pressure but not cerebral blood flow velocity of ischemic stroke patients with large artery occlusive disease. Cerebral blood flow velocity of stroke patients significantly increases from baseline under ECP pressure of 150mmHg but it reaches a plateau as ECP pressure further raises. Among 4 ECP pressures above, 150mmHg is the optimal treatment pressure for ischemic stroke due to higher risks of hypertension-related complications in acute stroke with higher ECP pressure.

Background and Purpose: Ethnic differences have been reported between Asians and Whites in the prevalence of certain stroke subtypes. However, it is unknown if such differences exist with respect to manifestations of cerebral small vessel disease. We compared the prevalence of white matter lesions [WML], lacunes, and microbleeds between Han Chinese and White Australian individuals randomly selected from their respective populations. Methods: Magnetic resonance imaging (1.5 Tesla) was performed on participants of the Shanghai Aging Study (n=321, mean age 69±6 years) and Tasmanian Study of Cognition and Gait (n=397, mean age 72±7 years). A single expert rater recorded measures of WML, lacunes, and microbleeds. We compared lesion prevalence between age- and gender-matched subgroups from the two study population. Among all subjects (n=718), we used multivariable logistic regression to examine if ethnicity was associated with the presence of these lesions. Results: The prevalence rates of confluent WML, lacunes, and microbleeds among Chinese and Whites were 37% vs. 34% (p=0.09), 29% vs. 34% (p=0.24), and 9% vs. 11% (p=0.59), respectively. Subgroup analysis among age- and gender- matched subjects confirmed that confluent WML was more common among Chinese (38.5%) than Whites (28.4%, p=0.01). In multivariable regression, Chinese had a higher risk of confluent WML (odds ratio 1.53, 95% confidence interval 1.04-2.24, p=0.03) independent of other risk factors, but no differences were seen for lacunes and micro bleeds. Conclusion: In this population-based cross-national comparison, Chinese had a greater risk of moderate-to-severe WML than white Australians, but had a similar risk of lacunes and microbleeds.

Background and Purpose:— Intracranial arterial stenosis (ICAS) is the predominant cause of ischemic stroke or transient ischemic attack (TIA) in Asia. Change of signal intensities (SI) across an ICAS on magnetic resonance angiography (MRA) may reflect hemodynamic severity of such lesions. Methods:— In-patients with a symptomatic single ICAS of anterior circulation on 3D time-of-flight MRA were recruited. Baseline and 1-year follow-up data were collected. Signal intensity ratio (SIR) was calculated to represent change of SIs across an ICAS on maximum intensity projections: SIR=(mean post-stenotic SI - mean background SI)/(mean pre-stenotic SI - mean background SI). Acute infarct volume was measured on diffusion-weighted images (DWI). Relationships of SIR and baseline characteristics as well as 1-year outcomes were evaluated. Results:— Thirty-six subjects (86.1% males, mean age 55.0 years) were recruited. Overall, mean SIR was 0.84±0.23. Mean SIR of the 23 (63.9%) anatomically severe stenoses was insignificantly lower than the 13 (36.1%) moderate stenoses (0.80±0.23 versus 0.92±0.21, p=0.126). The median baseline infarct volume for the 28 (77.8%) subjects with lesions on DWI was 2.40 cm 3 (IQR 0.80 to 5.78). SIR and acute infarct volume were significantly, linearly and negatively correlated, Spearman correlation coefficient being -0.471 (p=0.011). Two patients (5.6%) had recurrent ischemic strokes at 1-year follow-up. SIR values or acute infarct volumes were unrelated to 1-year outcomes in this initial study. Conclusion:— Change of signal intensity across ICAS on MRA may reflect hemodynamic and functional severity of the lesion. Future studies are warranted to further verify the relationship between this index and prognosis of stroke patients.

Background and Purpose— Carotid atherosclerosis is not neglectable as a cause for stroke in China, despite of low prevalence. This study was performed to evaluate the association between its ultrasonographic markers with metabolic syndrome (MetS). Methods— This was a community-based cross-sectional study. Demographics, common vascular risk factors, and results of fasting blood analysis were collected at baseline. MetS was defined as ≥3 following conditions or receiving specific treatment: abdominal obesity, elevated triglycerides, low high-density lipoprotein cholesterol, hypertension and impaired fasting blood glucose. All subjects underwent carotid duplex ultrasonography. Mean carotid intima-media thickness (CIMT) of bilateral common carotid arteries was used as the CIMT value for a single subject. CIMT within the 4th quartile was regarded as increased CIMT. Carotid plaque was defined as a focal CIMT of >1.5 mm. Results— A total of 653 subjects (mean age 55.1±10.4; 47.2% male) were recruited. MetS was found in 188 (28.8%) subjects (30.8% in male and 27.0% in female). Mean CIMT was 0.74±0.12 mm. Increased CIMT and carotid plaques were detected in 163 (25.0%) and 95 (14.5%) subjects, respectively. In multivariate linear regression, CIMT significantly increased with increasing numbers of MetS components (P Conclusion— MetS may be independently associated with early stage but not later and advanced stages of carotid atherosclerosis in community residents in China.

Carotid atherosclerosis should not be neglected as a cause for stroke in China, despite its low prevalence. This study was performed to evaluate the association between ultrasonographic markers for different stages of carotid atherosclerosis and metabolic syndrome.This was a community-based study in Hong Kong. Metabolic syndrome was defined as having three or more of the following conditions or receiving specific treatment for these conditions: Abdominal obesity, elevated triglycerides, low high-density lipoprotein cholesterol, hypertension, and impaired fasting blood glucose. All subjects underwent carotid duplex ultrasonography. Mean carotid intima media thickness (CIMT) of bilateral common carotid arteries was used as the CIMT value for a single subject. CIMT within the 4(th) quartile was regarded as increased CIMT. Carotid plaque was defined as a focal CIMT of1.5 mm. A carotid plaque obstructing ≥50% of vessel lumen was considered as carotid stenosis.A total of 653 subjects (mean age 55.1±10.4; 47.2% male) were recruited. Metabolic syndrome was found in 188 (28.8%) subjects (30.8% in males and 27.0% in females). Mean CIMT was 0.74±0.12 mm. Increased CIMT, carotid plaque, and carotid stenosis were detected in 163 (25.0%), 95 (14.5%), and 6 (1.4%) subjects, respectively. In multivariate linear regression, CIMT significantly increased with increasing numbers of metabolic syndrome components (P0.001). In multivariate logistic regression analysis, metabolic syndrome was independently associated with increased CIMT [odds ratio (OR) 1.17; 95% confidence interval (CI) 1.11-2.64; P=0.014), but not presence of carotid plaque (OR 1.50; 95% CI 0.92-2.46; P=0.108).Metabolic syndrome may be independently associated with the early stage but not the later and advanced stages of carotid atherosclerosis in community residents in China.

Background and Purpose— Occlusive radiation vasculopathy (ORV) predisposes head-and-neck cancer survivors to ischemic strokes. Methods— We analyzed the digital subtraction angiography acquired in 96 patients who had first-ever transient ischemic attack or ischemic strokes attributed to ORV. Another age-matched 115 patients who had no radiotherapy but symptomatic high-grade (>70%) carotid stenoses were enrolled as referent subjects. Digital subtraction angiography was performed within 2 months from stroke onset and delineated carotid and vertebrobasilar circulations from aortic arch up to intracranial branches. Two reviewers blinded to group assignment recorded all vascular lesions, collateral status, and infarct pattern. Results— ORV patients had less atherosclerotic risk factors at presentation. In referent patients, high-grade stenoses were mostly focal at the proximal internal carotid artery. In contrast, high-grade ORV lesions diffusely involved the common carotid artery and internal carotid artery and were more frequently bilateral (54% versus 22%), tandem (23% versus 10%), associated with complete occlusion in one or both carotid arteries (30% versus 9%), vertebral artery (VA) steno-occlusions (28% versus 16%), and external carotid artery stenosis (19% versus 5%) (all P Conclusions— ORV angiographic features and corresponding collaterals are distinct from atherosclerotic patterns at initial stroke presentation. Clinical decompensation, despite more extensive collateralization, may precipitate stroke in ORV.

Background and Purpose. Inflammation exists in inception, progression, and reperfusion of acute ischemic stroke. Insightful understanding of correlation in inflammatory mediators and stroke severity with intracranial artery stenosis may improve rational stroke therapy. Methods. We prospectively recruited 977 patients with acute noncardioembolic ischemic stroke with MCA stenosis by MRA as none to mild ( Results. The levels of WBC, HCY, and hs-CRP had no significant differences in patients with categorized MCA stenosis (all . Higher levels of WBC, HCY, and hs-CRP were found in patients with 1-year poor outcome (all , but only hs-CRP is an independent predictor (OR 1.06, 95% CI 1.027–1.093, . The combination of any two of increased hs-CRP (>3 mg/L), WBC (>6.91 × 10 9/L), and HCY (>15 μmol/L) had higher power in predicting 1-year poor outcome than the single elevated mediator. Conclusions. Elevated hs-CRP independently predicts 1-year poor outcome in acute stroke. The combination of increased hs-CRP, WBC, or HCY had a stronger predictive value in poor outcome than individual elevated mediator.

Author(s): Leng, Xinyi; Wong, Ka Sing; Soo, Yannie; Leung, Thomas; Zou, Xinying; Wang, Yongjun; Feldmann, Edward; Liu, Liping; Liebeskind, David S | Abstract: BackgroundIntracranial arterial stenosis (ICAS) is the predominant cause of ischemic stroke and transient ischemic attack in Asia. Change of signal intensities (SI) across an ICAS on magnetic resonance angiography (MRA) may reflect its hemodynamic severity.MethodsIn-patients with a symptomatic single ICAS detected on 3D time-of-flight MRA were recruited from 2 hospitals. Baseline and 1-year follow-up data were collected. Signal intensity ratio (SIR) [ = (mean post-stenotic SI -mean background SI)/(mean pre-stenotic SI - mean background SI)] was evaluated on baseline MRA to represent change of SIs across an ICAS. Acute infarct volume was measured on baseline diffusion-weighted images (DWI). Relationships between SIR and baseline characteristics as well as 1y outcomes were evaluated.ResultsThirty-six subjects (86.1% males, mean age 55.0) were recruited. Overall, mean SIR was 0.84±0.23. Mean SIRs were not significantly different between the 23 (63.9%) anatomically severe stenoses and the 13 (36.1%) anatomically moderate stenoses (0.80±0.23 versus 0.92±0.21, p = 0.126). SIR was significantly, linearly and negatively correlated to acute infarct volume on DWI (Spearman correlation coefficient -0.471, p = 0.011). Two patients (5.6%) had recurrent ischemic strokes at 1y, not related to SIR values.ConclusionsChange of signal intensities across an ICAS on MRA may reflect its hemodynamic and functional severity. Future studies are warranted to further verify the relationships between this index and prognosis of patients with symptomatic ICAS.

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.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.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.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.

AIM: To assess whether the presence of the hyperintense middle cerebral artery (MCA) sign, detected using magnetic resonance imaging (MRI), has any prognostic value in subacute infarction. The results were also compared with computed tomography (CT). MATERIALS AND METHODS: Twenty-five consecutive patients with suspected subacute ischaemic stroke (6–48 h after onset of symptoms) underwent MRI and CT assessment. The incidence of intraluminal thrombus demonstrated by conventional T1 and T2-weighted images was assessed. The results were correlated with National Institutes of Health Stroke Scale (NIHSS). RESULTS: Hyperintense MCA was identifiable on T1-weighted images in 77.8% patients, on T2-weighted images in 61.1% patients, and in 38.9% patients using CT. Patients with intraluminal thrombus identified by MRI had more severe stroke (mean NIHSS of 12.2±8.0 versus 4±3.2 respectively, p=0.003). CONCLUSIONS: The presence of hyperintense MCA by MRI is associated with higher NIHSS and may therefore have a prognostic value.

Background: Apathy is common in stroke survivors. Unlike poststroke depression, apathy after stroke has not been extensively investigated and the significance of the location of infarcts in the development of apathy following a stroke is unknown. This study examined the association between poststroke apathy (PSA) and the location of infarcts. Methods: A cohort of 185 patients with acute ischemic stroke admitted to the Stroke Unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the index stroke, a psychiatrist administered the Apathy Evaluation Scale (AES). PSA was defined as an AES score of 37 or above. The presence and location of infarcts were evaluated with magnetic resonance imaging. Results: Altogether 185 patients met the entry criteria and formed the study sample; 20 (10.8%) had PSA. PSA patients were older and had higher stroke severity and more depressive symptoms. The PSA group also had lower levels of physical and cognitive functioning. Compared with the non-PSA group, PSA patients were more likely to have acute pontine infarcts (35.0% vs. 11.5%; p = 0.011). They had a higher mean number (0.5 ± 0.7 vs. 0.1 ± 0.3; p = 0.003) and larger volume (0.6 ± 1.4 vs. 0.1 ± 0.3 ml; p = 0.002) of acute pontine infarcts. Six variables were entered into the predictive regression model: age, the presence, number and volume of acute pontine infarcts, the number of old infarcts and periventricular white matter hyperintensities scores. The volume of infarcts remained an independent predictor of PSA in the multivariate analysis, with an odds ratio of 3.9 (p = 0.007). The Geriatric Depression Scale, National Institutes of Health Stroke Scale, Barthel Index and Mini-Mental State Examination scores were also entered into the subsequent associative regression model; the volume of acute pontine infarcts remained a significant predictor (odds ratio = 3.8). Conclusions: This is the first report of an association between pontine infarcts and the risk of PSA. The results suggest that pontine infarcts may play a role in the development of PSA. The importance of acute pontine infarcts in the pathogenesis of PSA warrants further investigation.

White matter hyperintensities (WMH) are common in stroke. The influence of WMH on health-related quality of life (HRQoL) following a lacunar stroke is unknown. This study evaluated the impact of WMH on HRQoL in acute lacunar stroke. A cohort of 160 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the index stroke, a research assistant administered the Short Form-36 (SF-36) to assess HRQoL. The severity of WMH was evaluated with magnetic resonance imaging (MRI). In univariate analysis, the severity of deep WMH (DWMH) negatively correlated with patients' vitality (VT; p < 0.05), social function (SF; p < 0.001), role-emotional (RE; p < 0.01), mental health (MH; p < 0.01), and mental component summary (MCS; p < 0.001) scores of HRQoL. DWMH was independently associated with all of the above five SF-36 scores (p < 0.05) in linear regression analysis. These findings suggest that DWMH has a significant impact on the HRQoL of stroke survivors. The importance of DWMH in the long-term HRQoL in lacunar stroke warrants further investigation.

Background and Purpose— We explored the association between pulsatility index (PI) as derived from transcranial Doppler ultrasound with various measures of small vessel disease in the community. Methods— We performed transcranial Doppler and magnetic resonance imaging in 205 consecutive community-dwelling elderly subjects who were participants of the Shanghai Aging Study. We investigated the association between middle cerebral artery (MCA) PI with measures of white matter lesions (WML), lacunes, and microbleeds. Results— Multiple logistic regression found that MCA PI was associated with severe WML (odds ratio, 1.33 per 0.1 increase in PI; 95% confidence interval, 1.04–1.70; P =0.02). At optimal MCA PI cut-off, the area under curve, positive predictive value, and negative predictive value were 0.70 (95% confidence interval, 0.60–0.80), 34.9%, and 85.6%, respectively, for detection of severe WML. No association was found between MCA PI and measures of lacunes or microbleeds. Conclusions— PI correlates with WML severity. With a high negative predictive value, the chance of having severe WML with a normal PI is low. Transcranial Doppler may guide selective magnetic resonance imaging scanning for the detection of WML in the community.

Objective To evaluate the relation between poststroke pain and suicidality (SI) in Chinese patients with first or recurrent stroke. Design Cross-sectional survey. Setting Acute stroke unit of a university-affiliated general hospital. Participants Patients (N=496) with acute ischemic stroke admitted to the Acute Stroke Unit. Interventions Not applicable. Main Outcome Measures Patients were interviewed 3 months after the index stroke. SI was assessed with the Geriatric Mental State Examination. Pain was evaluated with the Faces Pain Rating Scale-Revised (FPS-R). The association between FPS-R scores and SI was examined and adjusted for potential confounders, including marital status, depression, neurologic deficits assessed by the National Institute of Health Stroke Scale, and functioning measured by the Barthel Index. Results Thirty-seven (7.5%) of the patients had SI (the SI group). Compared with the non-SI group, patients in the SI group were more likely to experience pain (59.5% vs 37.7%), had a higher mean FPS-R score (6.0±2.5 vs 4.5±2.3), and had an FPS-R score of >4 (43.2% vs 15.9%). After adjustment for possible confounders, the FPS-R score of >4 (odds ratio=2.9) remained a significant predictor of SI in the subsequent forward logistic regression models. Conclusions These findings should alert clinicians that the early identification and treatment of pain may reduce suicide risk in patients with stroke.

Background Short course of dual antiplatelet therapy for early secondary prevention is a promising treatment for patients with minor stroke or transient ischemic attack at high risk of recurrence. Methods We examined the efficacy and safety of dual antiplatelets in patients with transient ischemic attack or minor stroke, defined as National Institute of Health Stroke Scale scores 0–3, in a subgroup analysis of Clopidogrel plus aspirin versus Aspirin alone for Reducing embolization in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR) study. Microembolic signals on transcranial Doppler monitoring was used as surrogate marker for recurrent stroke risk. Patients with ≥1 microembolic signals at baseline were randomized to receive dual therapy (aspirin 75–160 mg daily and clopidogrel 300 mg day 1 then 75 mg daily) or monotherapy (aspirin 75–160 mg daily) for seven-days. Results Sixty-five of 100 patients recruited had transient ischemic attack or minor stroke: 30 received dual therapy and 35 received monotherapy. Mean onset-to-randomization was 2·3 days in dual therapy group and 3·2 days in monotherapy group ( P = 0·03). At day 7, the proportion of patients with ≥1 microembolic signals was 9 of 29 patients in dual therapy group and 18 of 34 patients in monotherapy group (adjusted relative risk reduction 41·4%, 95% CI 29·8–51·1, P < 0·001). The median number of microembolic signals on day 7 was 0 in dual therapy group and 1·0 in monotherapy group ( P = 0·046). No patients had intracranial or severe systemic hemorrhage. Conclusions Early dual therapy with clopidogrel and aspirin reduces microembolic signals in patients with minor ischemic stroke or transient ischemic attack, without causing significant bleeding complications.

Objectives We investigated the relationships of biomarkers of various pathophysiologic pathways including high-sensitivity C-reactive protein (hs-CRP), lipocalin-2 (LCN2), myeloperoxidase (MPO) and matrix metalloproteinases 9 (MMP9) with mortality in stroke patients. Design and methods hs-CRP, LCN2 and MPO concentrations in 92 patients were determined using enzyme-linked immunosorbent assays. MMP9 mRNA concentrations were determined using real-time quantitative reverse transcription-polymerase chain reaction. Results Twelve patients (13.0%) died at 6 months and 34 patients (37.0%) died at 5 years. The independent predictors for 6-month mortality were hs-CRP (adjusted OR = 16.0) and LCN2 (adjusted OR = 16.9), while for 5-year mortality was hs-CRP (adjusted OR = 5.56). For patients with hs-CRP > 3.4 mg/L, an increase in LCN2 was associated with 2.5-fold higher 6-month mortality, while an increase in normalized MMP9 mRNA was associated with 5.8-fold higher 6-month and 1.5-fold higher 5-year mortality. Conclusion hs-CRP was the most significant independent predictor of both short- and long-term mortality after stroke, with LCN2 and MMP9 mRNA each adding further to the risk stratification.

Objective Cerebral microbleeds (CMBs) are common in stroke survivors. The clinical significance of CMBs in the development of suicidality (SI) following stroke is unknown. This study examined the association between SI and CMBs. The aim of the study reported here was to determine the relationship between CMBs and SI in ischemic stroke survivors. Methods: A cohort of 367 patients with acute ischemic stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. SI was assessed with the Geriatric Mental State Examination at three months following the subjects' index stroke. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS). A qualified psychiatrist administered the Chinese version of the Structured Clinical Interview for DSM-IV to diagnose depressive disorders. The presence and location of CMBs were evaluated with magnetic resonance imaging (MRI). Results Compared with the non-SI patients, SI patients were more likely to have CMBs in any brain region (36.6% vs. 20.2%, p=0.017), specifically more lobar (29.3% vs. 13.5%, p=0.008) and thalamic CMBs (19.5% vs. 7.5%, p=0.018). Presence of CMBs (odds ratio was 2.5, p=0.026) and lobar CMBs (odds ratio 2.6, p=0.034) were independent predictors of SI in the multivariate analysis. Conclusions The results suggest that lobar CMBs may play roles in the development of SI. The importance of CMBs in the pathogenesis of SI in stroke survivors warrants further investigation.

Background: Radiation-induced vasculopathy (RIV) predisposes survivors of head-and-neck cancers to refractory ischemic strokes. We aimed to investigate the angiographic extent and morphological attributes of symptomatic RIV. Methods: The study was approved by the Institutional Review Board and each participant provided an informed consent. One hundred thirty patients with ischemic strokes attributed to high-grade carotid stenoses (>60%) were recruited for digital subtraction angiograms (DSA). Among the enrolled patients, 65 had prior curative intent radiotherapy for head-and-neck cancers. The remaining 65 control patients who had no radiotherapy were presumed to have atherosclerotic vasculopathy. DSA revealed both carotid and vertebro-basilar circulations from the level of aortic arch up to intracranial branches. A radiologist blind to the group assignment recorded the distribution and characteristics of both stenotic and non-stenotic lesions. Fetal variant or incompetence of the circle of Willis, if any, was also documented. Results: The baseline characteristics of RIV and control patients were comparable except a lower prevalence of hypertension and diabetes mellitus in RIV group (p were atherosclerotic. Atherosclerotic stenoses were predominantly focal, involving the internal carotid artery adjacent to the bifurcation (93/103, 90.29%). RIV stenoses, in contrast, harbored more frequently at common carotid artery (96/176, 54.55%) and was associated with more tandem lesions (29.23% vs 10.77%, p Conclusion: Radiation-induced carotid disease was frequently bilateral and associated with concurrent tandem and vertebra-basilar steno-occlusions. Fetal variant or incompetence of the Circle of Willis may potentiate further the hemodynamic insufficiency.

Background and Purpose— This study examined the association between poststroke anxiety symptoms (PSA) and frontal lobe infarcts. Methods— A cohort of 693 patients was recruited. PSA was defined as an anxiety subscale of the Hospital Anxiety and Depression Scale score of 8 or above. The presence and location of infarcts were evaluated with MRI. Results— Compared with the non-PSA group, PSA patients were more likely to have right frontal acute infarcts. Right frontal infarcts remained independent predictors of PSA in the multivariate analysis, with an odds ratio of 4.44 ( P =0.002). Conclusions— The results suggest that right frontal acute infarcts may play a role in the development of PSA.

Lack of efficacy and safety data among Chinese patients with stroke have contributed to the slow development of stroke thrombolysis as standard-of-care for these patients. We examined a retrospective cohort of 57 patients who received intravenous alteplase for acute ischemic stroke to identify predictors of outcome, including age, stroke severity, onset-to-treatment time, and early ischemic changes on brain CT scan. Overall, the mean National Institute of Health Stroke Scale (NIHSS) score was 15.7 and the mean onset-to-treatment time was 142 minutes. Twenty-nine (51%) patients had a favorable outcome with modified Rankin Scale (mRS) score of ⩽2 at three months. Ten (17.5%) patients were deceased at three months. Four (7%) patients developed symptomatic intracranial hemorrhage (sICH). For patients aged >80 years ( n = 18), five (28%) achieved favorable outcome, six (33%) were deceased at three months and three (17%) had sICH. Prognosis was worst for patients with NIHSS score >25 ( n = 5); one (20%) was dependent (mRS 4) and the other four (80%) were deceased. Multivariate analysis found that the Alberta Stroke Program Early CT Score (ASPECTS) was associated with favorable outcome (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1–3.0), and mortality (OR 0.5, 95% CI 0.3–0.9). Our findings showed advanced age and severe stroke were associated with less favorable outcome in Chinese patients receiving intravenous alteplase, ASPECTS can be used reliably to identify patients at risk of poor outcomes. Further studies are warranted.

Background International guidelines recommend oral anticoagulation in patients with atrial fibrillation according to their level of stroke risk. This study aimed to determine oral anticoagulation use in atrial fibrillation patients with recent ischemic stroke and examine factors that impact such management in China. Methods Among the patients with acute ischemic stroke ( n = 4782) from the China QUality Evaluation of Stroke Care and Treatment study, a multicenter, prospective, 62-hospital registry in China, there were 499 (10%) (mean age 70 ± 12 years, 49% female) with documented atrial fibrillation with outcome data over 12 months of follow-up. Logistic regression analysis was used to identify the independent predictors of oral anticoagulation use in these patients. Results Of the 499 stroke patients with atrial fibrillation, oral anticoagulation use was 20% overall but varied from 8% prestroke and 11% in-hospital (poststroke), to 13% and 10% at three-months and 12 months, respectively. Oral anticoagulation use was independently associated with younger age (odds ratio 0·95, 95% confidence interval 0·93–0·97, P < 0·001), nonmanual occupation (odds ratio 0·44, 95% confidence interval 0·25–0·80, P = 0·006), and less cardiovascular risk factors (odds ratio 0·81, 95% confidence interval 0·68–0·96, P = 002). Conclusions These data indicate oral anticoagulation use is lower in stroke patients with atrial fibrillation in China than that in Western countries, being applied more often in those of younger age, nonmanual occupation, and having less cardiovascular risk factors.

Background and purpose Of the stroke types, intracerebral hemorrhage is the most debilitating and fatal. The aim of the current study was to determine factors that influence the severity and in-hospital mortality after primary intracerebral hemorrhage. Methods Data were collected retrospectively on 1268 patients with primary intracerebral hemorrhage admitted to stroke units at participating hospitals in Guangzhou between January 2005 and August 2008. Logistic regression analysis was used to determine factors associated with severity on admission and in-hospital mortality. Results Of the 1268 patients, 20·4% were reported to have a severe stroke on admission, and the in-hospital mortality rate was 12·5%. Severity on admission was strongly associated with Glasgow Coma Scale score on admission (odds ratio = 0·89, 95% confidence interval 0·85–0·94) and hematoma location. Notably, basal ganglia hemorrhages were associated with increased severity (odds ratio = 1·40, 95% confidence interval 1·03–1·90), and cerebellar hemorrhages were associated with reduced severity (odds ratio = 0·29, 95% confidence interval 0·10–0·84). In-hospital mortality was not only correlated with Glasgow Coma Scale score on admission (odds ratio = 0·79, 95% confidence interval 0·74–0·84) and basal ganglia location (odds ratio = 0·47, 95% confidence interval 0·26–0·83), but also with dysnatremia (odds ratio =1·91, 95% confidence interval 1·08–3·40) and comorbidities such as upper gastrointestinal hemorrhage (odds ratio = 2·28, 95% confidence interval 1·33–3·91), pneumonia (odds ratio = 3·50, 95% confidence interval 2·17–5·63), urinary incontinence (odds ratio = 2·22, 95% confidence interval 1·40–3·51), and renal dysfunction (odds ratio = 2·28, 95% confidence interval 1·42–3·65). Conclusion Glasgow Coma Scale score and hematoma locations were independently associated with severity on admission and in-hospital mortality after primary intracerebral hemorrhage. The study also highlights the deleterious effect of comorbidities on in-hospital mortality following primary intracerebral hemorrhage in China.

BACKGROUND: Angioplasty and stenting using nitinol stents is a recognized treatment option for intracranial atherosclerosis. OBJECTIVE: To identify procedure-related factors that may affect patient safety and technical outcome. METHODS: In this prospective study of 57 consecutive patients, the primary end points were intraprocedural technical problems, periprocedure morbidity, and complications. Major periprocedure complication was defined as all stroke or death at 30 days. Technical failure was defined as the inability to complete the procedure because of technical or safety problems. Procedure failure was defined as a procedure outcome of technical failure or major periprocedure complication. Secondary end points were procedure-related factors that may affect patient safety and technical outcome. RESULTS: Procedure failure rate was 12.3% (7/57) (major periprocedure complication rate, 5.3% [3/57]; technical failure rate, 7% [4/57]). Initial failure in tracking of balloon or stent occurred in 20 patients, other technical problems occurred in 11 patients, including kinking or trapping of balloon catheter (2 cases), difficulty in unsheathing of stent (3 cases), forward migration of stent during deployment (4 cases), trapping of nose cone after stent deployment (1 case), fracture of delivery system (2 cases), and guidewire fracture (1 case). Unfavorable vascular morphology signified by the presence of 2 or more reverse curves along the access path was found to associate with initial failure in the tracking of instruments (OR = ∞), and occurrence of other technical problems (OR = 25). CONCLUSION: Procedure-related factors could be identified and lead to improvements in patient safety and technical outcome. Tortuous vascular morphology is a key factor to be overcome.

BACKGROUND Age-related white matter changes (WMC) increase risk of cognitive and functional decline. They are considered as target for preventive trials. However, using magnetic resonance imaging (MRI) to screen for subclinical WMC is not cost-effective. We explored the clinical utility of transcranial Doppler ultrasound (TCD) in the evaluation of WMC. We hypothesized that the pulsatility index (PI) of TCD correlates with severity of WMC. METHODS Among 100 stroke patients with WMC, we obtained the mean PI of middle cerebral artery (MCA) and vertebral basilar artery (VB). We investigated the association between PI and WMC volume. We also obtained PI of 50 subjects who had no WMC on MRI and explored the ability of PI values in differentiating subjects with and without WMC. RESULTS Multivariate linear regressions found that mean MCA PI and mean VB PI were independent predictors for total WMC volume (beta = .43, P < .001 and beta = .37, P < .001, respectively). Mean MCA PI significantly differentiated patients with WMC from those without WMC (area under curve [AUC] .85 [95% confidence interval .78-.91]) with an optimal cut-off value at 1.15 that yielded sensitivity and specificity of 73.7% and 82%, respectively. AUC for mean VB PI was .81 (95% confidence interval .74-.88) with cut-off value at 1.06 that yielded sensitivity and specificity of 70% and 75%, respectively. CONCLUSIONS PI correlates with volume of WMC. It may help to differentiate those with and without WMC in stroke patients. Further study evaluating the clinical utility of TCD in screening for subclinical WMC among community elderly is warranted.

Background and purpose Impaired autonomic function is common in the acute poststroke phase but little is known about its effects on functional outcome after acute ischemic stroke. This study sought to investigate the impact of autonomic dysfunction by Ewing's classification on functional outcome 2months after acute ischemic stroke. Methods 34 consecutive acute ischemic stroke patients within 7days after onset were enrolled. On admission, autonomic function was assessed by Ewing's battery tests. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS), autonomy in activities of daily living by the Barthel Index (BI), and global disability by the modified Rankin Scale (mRS). BI and mRS were also evaluated 2months after ischemic stroke onset. Results On admission, eight patients were diagnosed as minor autonomic dysfunction and 26 patients as relatively severe autonomic dysfunction. The prevalence of relatively severe autonomic dysfunction in ischemic stroke patients was 76.5%. There were no significant differences in baseline characteristics between the minor and severe autonomic dysfunction groups. 2months after stroke onset, the mean BI score of patients with minor autonomic dysfunction and severe autonomic dysfunction increased from 76.3±15.3 on admission to 95.0±7.1, 66.5±15.2 on admission to 74.8±15.9 respectively. The mean BI score after 2-month stroke onset and the change in BI from admission to 2-month outcome (delta BI) in patients with severe autonomic dysfunction were lower than those in patients with minor autonomic dysfunction (all P Conclusions Autonomic dysfunction occurs in acute stroke patients. Relatively severe autonomic dysfunction is related to an unfavorable functional outcome in patients with acute ischemic stroke.

Background Although patients harboring confluent white matter hyperintensities (WMH) are at high risk of cognitive decline, this risk varies among individuals. We investigated the predictors for cognitive decline in stroke patients with confluent WMH. Methods We followed up 100 stroke patients with confluent WMH who were participants of the VITAmins TO Prevent Stroke study for 2 years. We investigated the association between clinical features, apolipoprotein E status, imaging measures (infarcts, microbleeds, volumes of WMH, cortical gray matter [cGM], lateral ventricles, and hippocampi), and B vitamins with changes in cognitive measures (clinical dementia rating scale, Mini-Mental State Examination, Mattis dementia rating scale—initiation/perseveration subscale). We performed Pittsburgh compound B imaging among dementia converters. Results Multivariate regression analysis showed that increase in clinical dementia rating scale grade was associated with cGM atrophy, absence of hyperlipidemia, and lower diastolic blood pressure at baseline. cGM atrophy and absence of hyperlipidemia were also associated with deterioration in Mini-Mental State Examination and Mattis dementia rating scale—initiation/perseveration subscale scores. Pittsburgh compound B retention typical of Alzheimer's disease was found only in 10% of dementia converters. Incident stroke and B vitamins were not associated with cognitive decline. Conclusions Among stroke patients with confluent WMH, cGM atrophy and absence of hyperlipidemia are important predictors for cognitive decline. Significant cognitive decline can occur in the absence of incident stroke or Alzheimer's pathology.

Chen Y-K, Wong KS, Mok V, Ungvari GS, Tang WK. Health-related quality of life in patients with poststroke emotional incontinence. Objective To assess the effect of poststroke emotional incontinence (PSEI) on health-related quality of life (HRQOL). Design Cross-sectional observational study. Setting Psychiatric clinic. Participants Stroke survivors (N=385; consecutive series) discharged from the acute stroke unit between December 2004 and June 2007. Interventions Not applicable. Main Outcome Measures Chinese (Hong Kong) version of the 36-Item Short Form Health Survey (SF-36) for HRQOL. Results Fifty-eight (15.1%) patients had PSEI. After adjustment for possible demographic and clinical confounders, subjects with PSEI had significantly lower physical and mental summary scores, particularly in the General and Mental Health, Social Function, and Role–Emotional subscales of the SF-36. Conclusion PSEI has an independent effect on HRQOL. Longitudinal studies of stroke are warranted to confirm and extend this finding.

Single nucleotide polymorphisms (SNPs) in the apolipoprotein A5 gene (APOA5) are associated with hypertriglyceridaemia in our population. We studied the associations of SNPs in APOA5 with the metabolic syndrome (MetS) in the Hong Kong and Guangzhou Chinese.We genotyped five tagging SNPs in 1330 unrelated subjects from the Hong Kong Cardiovascular Risk Factor Prevalence Study cohort with follow-up after a median interval of 6·4 years; 1952 subjects from the Guangzhou Biobank Cohort Study-Cardiovascular Disease Subcohort were used to replicate the findings. The MetS was defined according to the consensus criteria proposed jointly by several organizations in 2009.The SNP rs662799 (-1131TC) was associated with the MetS (odds ratio = 1·47, P = 0·00082) and the number of its components present (regression coefficient = 0·204, P = 4·6 × 10(-5) ) after adjusting for age, sex, smoking, drinking and education in Hong Kong subjects at baseline. Similar association of this SNP was found in Hong Kong subjects at follow-up (P = 0·010 and 0·00021, respectively) and in Guangzhou subjects (P = 0·0041 and 0·017, respectively). The association of rs662799 with the number of the MetS components was significant regardless of age, sex, obesity and alcohol drinking, but almost disappeared after further adjusting for plasma triglycerides.Our results showed that the -1131TC polymorphism in APOA5 was associated with the MetS because of its strong effect on plasma triglycerides. This may partly explain the higher cardiovascular risk in people with this polymorphism.

Although age-related confluent white-matter lesion (WML) is an important substrate for cognitive impairment, the mechanisms whereby WML induces cognitive impairment are uncertain. The authors investigated cognitive predictors in patients with confluent WML.Among 100 patients with ischaemic stroke with confluent WML on MRI, the authors assessed executive function and global cognition by the Mattis Dementia Rating Scale--Initiation/Perseveration Subscale (MDRS I/P) and Mini-Mental State Examination (MMSE), respectively. All volumetric measures were corrected for intracranial volume. The authors investigated the association between basic demography, vascular risk factors, APOE status, WML volume, infarct measures (volume, number, location), microbleed number, atrophy measures (global, central, regional) and cognitive performance. The authors also performed Pittsburgh Compound B (PIB) imaging among seven cognitive impaired patients with stroke.WML was no longer related to cognitive performance after adding atrophy into regression equations. Multivariate regression models showed that cortical grey matter volume independently accounted for performance on both the MDRS I/P (β=0.241, p=0.045) and MMSE (β=0.243, p=0.032). Models examining frontal subregions revealed that volumes of both left (β=0.424, p0.001) and right (β=0.219, p=0.045) lateral frontal orbital gyri predicted MDRS I/P, whereas education (β=0.385, p0.001) and left lateral frontal orbital gyrus (β=0.222, p=0.037) predicted MMSE. Volumes of WML and cognitively relevant brain regions were significantly associated. Seven patients with PIB imaging showed no uptake pattern typical of Alzheimer's disease, suggesting a predominantly vascular aetiology for the cognitive impairment and brain changes in these patients.Cognitive impairment in patients with confluent WML is mediated by global and frontal cortical atrophy.

Background Cerebral microbleeds (CMBs) are common in stroke survivors, although their clinical significance in the development of psychiatric conditions following stroke remains unknown. This study examines the association between post-stroke depression (PSD) symptom severity and CMBs. Methods Amongst the 4088 patients with acute ischemic stroke who had been admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong, between December 2004 and May 2009, 994 patients were recruited. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all 994 patients and made a diagnosis of PSD three months after the index stroke. PSD symptom severity was assessed with the 15-item Geriatric Depression Scale (GDS). Seventy-eight patients were found to have PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging (MRI). Results Seventy-eight patients (7.8%) had PSD. CMBs were identified in 20 PSD patients. Relative to the no-CMB group, the mean GDS score of patients with lobar CMBs was significantly higher (12.6±2.6 versus 10.4±2.5, p=0.01 after adjusting for age, sex, global cognitive functions, neurological deficits and white matter hyperintensities). Limitations Patients with more severe stroke, those who died before the three-month follow-up and those who became depressed later were excluded, as were those unable to give their consent due to dementia or aphasia. These selection biases may limit the generalizability of the findings. Conclusions The results suggest that lobar CMBs may contribute to PSD symptom severity. The importance of CMBs in the pathogenesis of other psychiatric disorders in stroke survivors and other patient populations warrants further investigation.

Tang W-K, Lu J-Y, Mok V, Ungvari GS, Wong K-S. Is fatigue associated with suicidality in stroke? Objective To evaluate the relationship between poststroke fatigue 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 with acute ischemic stroke (N=595) admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong. Interventions Not applicable. Main Outcome Measures SI was assessed with the Geriatric Mental State Examination at 3 months after the subjects' index stroke. Fatigue was evaluated using the Fatigue Severity Scale (FSS). The association between the mean FSS score and SI was examined and adjusted for potential confounders, including age, sex, marital status, previous stroke, depression, Mini-Mental State Examination score, and neurologic deficits in terms of the National Institutes of Health Stroke Scale score. Results Seventy-six (12.8%) of the patients had SI (the SI group). The FSS score was significantly higher in the SI group (4.0±1.4 vs 2.8±1.2). The FSS score remained a significant predictor of SI in the subsequent forward logistic regression (odds ratio=1.5), adjusting for the possible confounders. Conclusions These findings should alert clinicians that early identification and treatment of fatigue may reduce the suicidal risk in stroke patients.

Objective Despite extensive research on post-stroke depression (PSD), the role of white matter hyperintensities (WMHs) in its pathogenesis remains uncertain. The aim of this study was to evaluate the relationship between WMHs and PSD in Chinese patients with first or recurrent stroke. Methods A cohort of 994 patients with acute ischaemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all patients and made a diagnosis of PSD 3 months after the index stroke. 78 (7.8%) patients had PSD; 78 stroke patients matched according to age and sex but without PSD served as a control group. The severity and location of WMHs were evaluated with MRI. Results In comparison with the non-PSD group, patients in the PSD group were more likely to have severe deep WMHs (12.8% vs 1.3%; p=0.009). Severe deep WMHs remained an independent predictor of PSD in the multivariate analysis with an OR of 13.8 (p=0.016). Conclusion The results suggest that WMHs may play a role in the development of PSD. The importance of WMHs in the treatment and outcome of PSD warrants further investigation.

Background and Purpose— The ABCD 2 score is able to predict the short-term risk of stroke after a transient ischemic attack/minor stroke. We aimed to explore its predictive value for long-term recurrent stroke. Methods— Consecutive patients with a transient ischemic attack/minor stroke, hospitalized during a 2-year period, were followed up to document any further stroke and death stratified by a 7-point ABCD 2 score. Result— A total of 490 patients were followed for an average of 40.5 months (SD, 10.7 months). Further stroke were identified in 76 (15.5%) patients and 62 (12.7%) patients died during follow-up. Multivariate Cox regression analysis showed that an ABCD 2 score >4 was found to be an independent risk factor for further stroke (hazard ratio, 2.27; 95% CI, 1.36 to 3.80) and for death (hazard ratio, 1.68; 95% CI, 0.99 to 2.85). Conclusions— In addition to predicting short-term stroke risk, ABCD 2 score is a useful tool to predict long-term stroke risk after a transient ischemic attack or minor ischemic stroke.

Background and purpose Concurrent small vessel, intracranial and extracranial large artery disease (SLAD) is common in Asian but its impact on cognitive and functional outcomes is unclear. We aimed to evaluate the clinical, cognitive and functional outcomes in ischemic stroke patients with SLAD. Methods Chinese ischemic stroke patients with diffuse white matter lesions (WMLs) were recruited as part of the VITATOPS Trial. They were studied with MRI and MRA of brain. Various neuropsychiatric batteries were used to assess the cognitive functions. Results Totally 97 patients with acute ischemic stroke and diffuse WMLs were included, of whom 44 (45%) had SLAD. Patients with SLAD had lower Mini Mental State Examination (MMSE) when compared with the patients without SLAD. They had more behavioral symptoms and caused more stress in caregivers as assessed by the Neuropsychiatric Inventory (NPI). Multivariate regression analysis showed SLAD contributed significantly to MMSE, NPI Patient (NPI P) and NPI Care Giver (NPI CG). Among 44 patients with SLAD, 30 (68%) had severe cognitive impairment. They were older and less educated. They had more diabetes and poorer performance in neuropsychiatric tests including Mattis Dementia Rating Scale Initiation/Perseveration subset (MDRS I/P) and Clinical Dementia Rating (CDR). They also had poorer functional outcomes as assessed by Barthel Index (BI) and Instrumental activities of daily living (IADL). Conclusions This was the first MRA-based study to take into consideration the clinical, cognitive and functional outcomes in ischemic stroke patients with SLAD. Patients with SLAD had poorer cognitive and functional outcomes when compared to patients without SLAD.

Single nucleotide polymorphisms (SNPs) in the apolipoprotein A5 (APOA5) gene have been associated with hypertriglyceridaemia. We investigated which SNPs in the APOA5 gene were associated with triglyceride levels in two independent Chinese populations. In all, 1375 subjects in the Hong Kong Cardiovascular Risk Factor Prevalence Study were genotyped for five tagging SNPs chosen from HapMap. Replication was sought in 1996 subjects from the Guangzhou Biobank Cohort Study. Among the five SNPs, rs662799 (-1131TC) was strongly related to log-transformed triglyceride levels among Hong Kong subjects (Β0.192, P2.6 × 10 13). Plasma triglyceride level was 36.1% higher in CC compared to TT genotype. This association was confirmed in Guangzhou subjects (Β0.159, P1.3 × 10 12), and was significantly irrespective of sex, age group, obesity, metabolic syndrome, hypertension, diabetes, smoking and alcohol drinking. The odds ratios and 95% confidence interval for plasma triglycerides 1.7 mmol/l associated with TC and CC genotypes were, respectively, 1.81 (1.37-2.39) and 2.22 (1.44-3.43) in Hong Kong and 1.27 (1.05-1.54) and 1.97 (1.42-2.73) in Guangzhou. Haplotype analysis suggested the association was due to rs662799 only. The corroborative findings in two independent populations indicate that the APOA5-1131TC polymorphism is an important and clinically relevant determinant of plasma triglyceride levels in the Chinese population. © 2010 Macmillan Publishers Limited All rights reserved., link_to_OA_fulltext

Background and Purpose: The purpose of this study was to evaluate the effect of metabolic syndrome on ischemic stroke in Chinese subjects with type 2 diabetes. Methods: Anthropometric parameters (waist circumference and body mass index), blood pressure, and plasma biochemical (lipid and glycemic profiles) were collected. Subjects with type 2 diabetes were categorized by the criteria of the updated Adult Treatment Panel III (ATP III) with the modified definitions of obesity in Asians. Transcranial Doppler was performed to define middle cerebral artery stenosis. Results: Of 2,197 patients (age 55.4 ± 11.3 years; male 40.8%; median follow-up period 8.7 years, interquartile range 7.8–9.5 years) without symptoms of cerebrovascular disease, evidence of middle cerebral artery stenosis was identified in 272 subjects (12.4%). According to NCEP ATP III criteria, 1,324 (60.3%) patients had MetS at baseline. Ischemic stroke occurred in 184 (8.4%, 184/2197) patients during follow-up. Patients with incident stroke had a higher prevalence of MetS compared with those without stroke (p = 0.004), and the number of components of MetS was also significantly increased in patients with stroke (p = 0.001). Cox regression demonstrated that MetS was not associated with incident stroke. Conclusions: In Chinese type 2 diabetic patients, metabolic syndrome does affect stroke occurrence with a higher stroke incidence among those with metabolic syndrome, but stroke occurrence seems to be better explained by other vascular risk factors than by metabolic syndrome.

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.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.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, p = 0.017) were significant predictors of insomnia symptoms with daytime consequences.Insomnia symptoms have a multi-factorial origin in stroke. Besides depressive symptoms, frontal lobe infarction and diabetes mellitus predict insomnia symptoms.

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.

Background and Purposes: Until now, limited data are available about the potential effect of coexisting small vessel disease (SVD) on the long-term outcome of stroke patients with intracranial large artery atherosclerosis (ILAA). Methods: A prospective study was performed on 293 patients with symptomatic ILAA, who were divided into 4 groups (group I, single intracranial large artery atherosclerosis (SILAA) without SVD; group II, multiple intracranial large arteries atherosclerosis (MILAA) without SVD; group III, SILAA with SVD; group IV, MILAA with SVD) and followed up for recurrent stroke or death. Results: The 3-year cumulative risks of recurrent stroke were 18% for SILAA without SVD, 38% for MILAA without SVD, 21% for SILAA with SVD and 34% for MILAA with SVD. The 3-year cumulative risks of death were 6, 7, 20 and 22%, respectively. Compared with SILAA without SVD, more recurrent stroke occurred in MILAA without SVD (log-rank 3.83; p = 0.050) and MILAA with SVD (log-rank 7.79; p = 0.014), and the higher risk of death (log-rank 9.472; p = 0.002) was found in group MILAA with SVD. A Cox proportional-hazards regression model showed that MILAA with SVD may be a predictor of recurrent stroke (hazard ratio 2.001; 95% CI 1.108–3.934; p = 0.044), and a borderline predictor for death (hazard ratio 3.180; 95% CI 0.895–10.987; p = 0.073). Conclusion: Coexisting SVD is very common and may predict poor outcome in stroke patients with symptomatic ILAA.

BACKGROUND Transcranial Doppler (TCD) is widely applied to evaluate the intracranial large artery stenosis. We aimed to evaluate the accuracy of TCD in detecting siphon internal carotid artery (SICA) stenosis against digital subtraction angiography (DSA). METHODS A total of 145 patients with TCD and DSA performed were recruited. The SICA and other intracranial arteries were evaluated through transorbital and transtemporal acoustic window by TCD. We defined the best cutoff value for significant SICA stenosis by receiver-operating characteristic (ROC) curve analyses and calculated the sensitivity, specificity, and positive and negative predictive values (PPV and NPV). RESULTS Mean age of the patients was 65.7 years (range 28-88 years) and 75.1% (109/145) were men. The peak systolic velocity (PSV) = 120 cm/second had the largest area under the ROC curve (area under the ROC curve = .868) compared with the MFV = 70 cm/second and MFV = 80 cm/second (area under the ROC curve = .822 and .845). So the criteria for SICA stenoses were defined as PSV = 120 cm/second plus additional parameters (abnormal spectrum, circumscribed velocity changes, or side-to-side difference). Twenty-nine patients were diagnosed with SICA stenosis or occlusion on TCD. Fourteen patients had abnormal TCD findings that were not confirmed by DSA. One patient with normal TCD but DSA showed mild (40%) stenoses. Accuracy parameters for TCD were as follows: sensitivity = 96.7% (95% confidence interval [CI]= 80.9-99.8), specificity = 93.9% (95% CI = 89.9-96.4), PPV = 65.9% (95% CI = 50.0-79.1), NPV = 99.6% (95% CI = 97.2-1.0). Most false-positive patients (11 of 15 patients) had other significant intracranial large arteries lesions. CONCLUSIONS The criteria have limited but acceptable sensitivity and specificity in detecting SICA stenoses. Abnormal findings of siphon carotid on TCD require further clarification.

We hypothesize that Pittsburgh compound B (PIB) binding is common in poststroke dementia (PSD) and that cognitive decline may be faster in PIB positive patients. We performed PIB positron emission tomography (PET) among 17 subjects: 10 PSD patients, 4 Alzheimer's disease (AD) patients, and 3 healthy controls. We also compared the rate of change in mini-mental state examination (MMSE) between PIB positive and negative patients. We detected AD-like PIB binding in 4 PSD patients (40%), all the AD patients, and 1 healthy control. The global PIB retention standardized uptake value (SUV) at 35-45 min for PIB positive stroke patients was 1.67 (range 1.56-1.82), which was similar to the AD patients (1.65; range 1.46-1.88) and was lower than PIB negative patients (1.29, range 1.24-1.34). Mean annual MMSE decline for the 4 PIB positive patients was 2.9 and that for the 6 PIB negative patients was 1. This pilot study suggests that PIB PET is feasible for the evaluation of PSD and PIB binding may be common in PSD. Whether presence of PIB binding is associated with a more rapid cognitive decline in PSD requires further study to confirm.

Background: Subclinical brain infarct (SBI) is associated with subsequent stroke and cognitive decline. A longitudinal epidemiological study suggests that statins may prevent development of SBI. We investigated the effects of statins upon development of brain infarct by performing a post-hoc analysis of the Regression of Cerebral Artery Stenosis (ROCAS) study. Methods: The ROCAS study is a randomized, double-blind, placebo-controlled study evaluating the effects of simvastatin 20 mg daily upon progression of asymptomatic middle cerebral artery stenosis among stroke-free individuals over 2 years. A total of 227 subjects were randomized to either placebo (n = 114) or simvastatin 20 mg daily (n = 113). The number of brain infarcts as detected by MRI was recorded at baseline and at the end of the study. The primary outcome measure was the number of new brain infarcts at the end of the study. Results: Among the 227 randomized subjects, 33 (14.5%) had SBI at baseline. At the end of the study, significantly fewer subjects in the active group (n = 1) had new brain infarcts compared with the placebo group (n = 8; p = 0.018). The new brain infarcts of subjects in the active group were subclinical. Among the placebo group, the new brain infarcts of 3 subjects were symptomatic while those of the remaining 5 subjects were subclinical. Among putative variables, multivariate regression analysis showed that only the baseline number of SBIs (OR = 6.27, 95% CI 2.4–16.5) and simvastatin treatment (OR = 0.09, 95% CI 0.01–0.82) independently predicted the development of new brain infarcts. Conclusions: Consistent with findings of the epidemiological study, our study suggests that statins may prevent the development of a new brain infarct.

Background and Purpose— Concurrent atherosclerosis of the intracranial and extracranial cerebrovascular system is common in Asians. The typical lesion patterns and the mechanisms of stroke in patients with concurrent stenoses are unclear. This study aimed to determine these stroke features of such patients in Hong Kong. Methods— We conducted a cross-sectional cohort study in a university hospital from January 2002 to December 2003. Consecutive Chinese patients with acute ischemic stroke underwent CT brain, MRI brain (with MR angiography and diffusion-weighted imaging sequences), and carotid duplex. Results— In total, 251 patients were included in the analysis. Of these, 109 (43%) had concurrent stenoses. Patients who had concurrent stenoses, as compared with those without concurrent stenoses, had more symptomatic stenoses (84% versus 58%; OR, 4.0; 95% CI, 2.1 to 7.3; P P =0.007), more multiple diffusion-weighted imaging lesions (55% versus 37%; OR, 2.1; 95% CI, 1.3 to 3.4; P =0.005), and more infarcts in the territory of the leptomeningeal branches of middle cerebral artery (26% versus 13%; OR, 2.2; 95% CI, 1.2 to 4.3; P =0.01). In multivariate regression analysis, smoking; prior stroke; the presence of concomitant pial infarct, pial infarct, and borderzone infarcts; multiple diffusion-weighted imaging lesions; and symptomatic stenoses were significantly associated with concurrent stenoses. Among patients with concurrent stenoses, those who had tandem lesions, as compared with those who had nontandem lesions, had more perforating artery infarct and borderzone infarcts (27% versus 8%; OR, 4.3; 95% CI, 0.9 to 19.8; P =0.04); more concomitant pial infarct, pial infarct, and borderzone infarcts (18% versus 0%; P =0.02), and more multiple diffusion-weighted imaging lesions (65% versus 23%; OR, 6.2; 95% CI, 2.2 to 17.2; P Conclusions— Concomitant perforating artery infarct, pial infarct, and borderzone infarcts; multiple diffusion-weighted imaging lesions, and infarcts in the leptomeningeal branches of the middle cerebral artery were more common in patients with concurrent stenoses, especially those with tandem lesions. This study suggested that the combination of hemodynamic compromise attributable to concurrent stenoses and artery-to-artery embolization is a common stroke mechanism in these patients.

The Guangzhou Biobank Cohort Study (GBCS, n=30 519, age >or=50 years) was established to examine the effects of genetic and environmental influences on health problems and chronic disease development. Guangzhou is undergoing massive economic development, but from a baseline that had remained unchanged for millennia. The Cardiovascular Disease Subcohort (GBCS-CVD) consists of 2000 participants who have been intensively phenotyped including a range of surrogate markers of vascular disease, including carotid artery intima-media thickness, cerebral artery stenoses, arterial stiffness, ankle-to-brachial blood pressure index and albuminuria, as well as coagulatory and inflammatory markers. Plasma and leukocytes are stored in liquid nitrogen for future studies. Preliminary demographic data show the female volunteers are younger than the male ones, but present with greater levels of adiposity including central obesity (31 vs 16%). Women had more body fat (33 vs 24%) and associated levels of adipokines. Despite this, body mass index and hip circumferences were similar, which contrasts with Caucasian populations. Men had more physician-diagnosed vascular disease (6.1 vs 2.5%), hypertension (42 vs 34%) and hyperglycaemia (36.6 vs 29.6%) than the women, but were less insulin resistant. In men, smoking (40 vs 2%) and drinking alcohol (67 vs 50%) was more common and they also had lower energy expenditures. The genotype distributions of the 15 typed single nucleotide polymorphisms were all in Hardy-Weinberg equilibrium. This article describes the rationale and methodology for the study. Given the comprehensive characterization of demographic and psychosocial determinants and biochemistry, the study provides a unique platform for multidisciplinary collaboration in a highly dynamic setting.