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Background Long-term campaigns to improve stroke awareness, such as the campaign conducted in the Czech Republic since 2006, have not been effective. However, the small subpopulation that noticed the campaign had better stroke awareness than the population that did not. To better understand this awareness campaign responsiveness and to design more successful future campaigns, predictors of noticing campaigns were identified. Materials and Methods This study is a secondary analysis of cross-sectional nationwide survey data of the Czech population older than 40 years, collected in 2009. The survey used a 3-stage random sampling method (area, household, and household member) and personal semistructured interview questionnaires concerning participants' stroke knowledge, demographic characteristics, medical history, and stroke information sources. To identify the association between these variables and whether the campaign was noticed (the primary outcome of the study), multivariate binary logistic regression analysis was used. Results A total of 601 participants were surveyed (90% response rate), 19% of them stated that they noticed the stroke awareness campaign. Primary independent predictors of campaign efficiency were heart disease (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.0-3.2), obesity (OR, 2.4; 95% CI, 1.3-4.7), and current smoking (OR, .4; 95% CI, .3-.7). Conclusions Tobacco smokers in particular should be targeted by stroke awareness campaigns, for example, through health warning labels on cigarette packs. People with some stroke risk factors, such as heart disease and obesity, are responsive to information about stroke. Therefore, educational campaigns should target the groups with increased risk of stroke.

Background: The effect of brain-vessel pathology on mortality in 57 consecutive PD patients was studied. Methods: Baseline clinical, neuropsychological, ultrasonographic (US), and MR data obtained from patients who died (n = 18) during a 4-year follow-up period were compared with the data of patients who survived. Results: US/MRI data displayed a more-severe vascular impairment in deceased patients. Differences were significant between both groups with respect to age, clinical and cognitive status, intima-media thickness, and resistance index (indicators of large and small vessel impairment). The sum score of white-matter hyperintensities was significantly higher among decedents. A cluster analysis displayed two clusters that differed in the two parameters (i.e. in age and in sum score). Conclusions: This study provides evidence that comorbid atherosclerosis and otherwise subclinical impairment of brain vessels may contribute to mortality in PD. The vascular pathology may act in association with other comorbidities on the terrain of progressive neurodegenerative pathology. (C) 2012 Movement Disorder Society

Introduction: Stroke can cause unilateral paresis of the diaphragm. It is, however, unknown if diaphragm paresis can lead to post-stroke pneumonias. We aimed to evaluate whether the location of post-stroke paresis influenced the location of pneumonia. Methods: This is a retrospective study of all patients admitted to stroke unit in 2006- 2009 with a diagnosis of acute ischemic stroke or intracerebral hemorrhage who had hemiparesis or hemiplegia, and who were diagnosed with unilateral pneumonia based on chest radiogram. Results: Of 1394 patients with a diagnosis of stroke, 64 (5%) patients met the study criteria. Of 35 patients with motor deficit on the left side, 18 (51%) developed pneumonia on the left and 17 (49%) on the right side (p=0.90). Of 29 patients with motor deficit on the right side, 17 (59%) developed pneumonia on the right and 12 (41 %) on the left side (p=0.51). Thus, of all 64 patients, 35 (55%) had pneumonia on the same side as the paresis and 29 (45%) on the contralateral side (p=0.60). Conclusions: There was no significant occurrence of pneumonia on the side of paresis. Therefore, the side of paresis is not likely to be a helpful clinical marker of diaphragm paresis.

Background: Public awareness campaigns are conducted to increase stroke awareness, yet evidence of their long-term effectiveness is limited. Since 2006, the Czech Stroke Society has conducted an educational campaign throughout the Czech Republic (CR) to increase awareness about stroke. This report evaluates the effectiveness of this campaign by comparing the results of a nationwide survey on stroke awareness in 2009 with the results from 2005. Methods: In 2009, a nationwide survey was conducted throughout the CR using the same methodology as in 2005 and employing a 3-stage random sampling method (area, household, and household member sampling). Participants >40 years of age were personally interviewed via a structured questionnaire concerning their knowledge and ability to correctly respond to stroke as assessed by the validated Stroke Action Test (STAT). The primary outcome measure was the difference in a STAT score >50% (i.e. respondents chose to call 911 for >50% of stroke symptoms) between 2005 and 2009. Campaign intensity was characterized by a systematic search for media messages about stroke in the CR. Results: A total of 601 interviews were obtained (90% response rate) in 2009 (592 people were interviewed in 2005). A STAT score >50% was achieved by 18% of the respondents both in 2005 and 2009 (p = 0.89). There was no increase in the knowledge of risk factors or warning signs between 2005 and 2009. Respondents who noticed the campaign (19%) had better STAT scores than respondents who did not (25 vs. 17%; p = 0.038). A systematic search revealed that the campaign had reasonable intensity because there were 978 media reports about stroke between 2006 and 2008. Conclusions: A medium-intensity educational campaign, based on donated advertising media, failed to increase stroke awareness. However, if the campaign had reached more people, it might have been effective. Therefore, in the future, paid advertising media should accompany free media, although such approach would require a substantially larger budget. Awareness campaigns should be constantly evaluated for their effectiveness to develop more successful strategies.

Ischemic stroke is most often caused by an acute extracranial or intracranial thromboembolic lesion obstructing an artery. It has been demonstrated that recanalization is the most important modifiable predictor of a good clinical outcome. Reperfusion strategies focus on early reopening of the vessel to reestablish antegrade flow within the penumbra. Current standard therapy within 4.5 h is intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA, 0.9 mg/kg body weight, maximum dose 90 mg). Thrombolytic therapy appears to be safe and effective across various types of hospitals, if the treatment is conducted by a physician with stroke expertise. New imaging methods (MR diffusion/perfusion, CT perfusion) are being investigated in order to better select patients who are most likely to benefit from recanalization therapy based on current clinical evidence. Neither perfusion imaging with CT or MR nor the mismatch concept are recommended for routine treatment decisions within or beyond the 4.5 h available for IVT. If major vessel occlusion is proven but IVT is contraindicated, intra-arterial thrombolysis (IAT) with tPA or mechanical thrombectomy with the Merci Retriever or Penumbra System may be a treatment option. The availability of IAT generally should not preclude the intravenous administration of tPA in otherwise eligible patients. Intra-arterial treatment can be performed within 8 h after stroke onset. Combining intravenous tPA pretreatment with subsequent IAT or mechanical thrombectomy may improve the recanalization rate and may be used as a rescue therapy in cases of persistent major vessel occlusion after unsuccessful IVT. Despite testing, no thrombolytic agent other than tPA (e.g., IIb/IIIa antagonists, heparin, etc.) has yet been approved for routine practice for either intravenous or intra-arterial application, alone or in combination with tPA. Continuous transcranial Doppler (TCD) monitoring of an occluded vessel may increase the rate of early recanalization after tPA; this effect may be facilitated by the administration of microbubbles. This method is still considered experimental.

Objective Exposure to contrast agents may cause nephrotoxicity. The safety of performing CT angiography without having knowledge of the baseline creatinine level in stroke patients treated with tissue plasminogen activator (tPA) has not been established. Methods This is an observational cohort study, with a historical control group to evaluate the safety of CT angiography performed before tPA treatment given within 3 h of symptom onset. The CT angiography group represents all patients treated with tPA between September/2003 and November/2007 who had CT angiography. The control group consists of all patients treated with tPA between January 1999 and August 2003 when CT angiography was not performed. The primary outcome was a creatinine increase in 24–72 h compared with baseline; the secondary outcome was a creatinine increase by ≥44 μmol/l in 24–72 h and the incidence of symptomatic intracerebral haemorrhage (sICH). Results Baseline parameters between the CT angiography group (164 patients, age 70±11; 91 male) and the control group (77 patients, age 67±11; 45 male) were similar. In the CT angiography group, the mean creatinine increase was −0.89 mmol/l and in the control group 2.2 mmol/l (p=0.42). A creatinine increase of ≥44 μmol/l occurred in five patients (3%) in the CT angiography group and in three patients (4%) in the control group (p=0.50). Also, in the CT angiography group, eight patients (5%) had sICH as compared with three patients (4%) in the control group (p=0.73). Conclusion Contrast agents given for CT angiography, performed in patients with normal and abnormal creatinine level, neither caused renal injury nor interfered with the safety of tPA treatment.

Background and Purpose— Stroke patients without evidence of arterial occlusion may not be suitable candidates for thrombolytic therapy. In our study, we investigated the outcomes of patients with negative CT angiography results for arterial occlusion. Methods— The study included patients treated within 3 hours after symptom onset with intravenous thrombolysis for significant neurological deficit between August 2003 and June 2007. All of the patients were documented with negative CT angiography results for arterial occlusion by independent reviews. Outcome measurements included modified Rankin score at 3 months, incidence of intracranial hemorrhage, and infarction volume on control CT. The predictors of unfavorable outcome (modified Rankin score, 2–6) were identified by multivariate logistic regression. Results— Altogether, 173 patients received intravenous thrombolysis; of those, 138 underwent CT angiography. The CT angiography results were negative for arterial occlusion in 39 (28%) of the patients: mean age, 71±10 years; 16 (41%) female; median baseline NIHSS, 11. At 3 months, modified Rankin score of 0 to 1 was achieved in 18 (46%) of the patients; 6 (15%) died; and 3 (8%) had symptomatic parenchymal hemorrhage. The median infarct volume was 1.5 cm 3 . The independent predictors of unfavorable clinical outcome were higher age (OR, 1.1; 95% CI, 1.01–1.27), and baseline NIHSS >12 (OR, 18.8; 95% CI, 1.4 to 261). One patient had encephalitis diagnosed. Conclusions— Negative baseline CT angiography is not uncommon. The risk of intracerebral hemorrhage after thrombolytic therapy for patients without evidence of arterial occlusion is similar to the risk carried in an unselected patient population. Given the prognosis, thrombolytic therapy seems justified; however, etiology other than stroke should be considered.

Numerous recent findings indicate the involvement of a neuroinflammatory reaction in the neurodegeneration in idiopathic Parkinson's disease (PD). We examined 29 consecutive patients with PD, ages 54-84 years, most of whom were moderately impaired (median UPDRS 19; Hoehn-Yahr 3; MMSE 28). A series of serum biomarkers were investigated, and their levels were correlated with the degree of the motor and cognitive impairment. There were no abnormalities of IL-6, acute phase proteins (C-reactive protein, serum amyloid A, alpha 1-antitrypsin, orosomucoid, ceruloplasmin, alpha 2-macroglobulin, transferrin, prealbumin) and factors of the complement system (C1q, C1-INH, C3, C4). A decrease in Mannan-binding lectin (MBL) levels was observed in six patients; an elevation of tumor necrosis factor-alpha (TNF-alpha) was found in 12 patients. No statistically significant correlation was found between the patient's clinical state (neuropsychologic and motor, as expressed by UPDRS III, Hoehn-Yahr, and MMSE) and the immunomarker changes. Our results indicate that the inflammatory process may be reflected in the serum; nevertheless, further research is needed to elucidate the possible clinical implications.

To study the impact of brain vessel pathology on the clinical status of Parkinson's disease (PD), in 57 consecutive patients the clinical and neuropsychological data were compared with clinical MRI signs of vascular impairment and with the ultrasound brain vessel investigations. There was a significant correlation between clinical and cognitive status and intimomedial thickness, which is an indicator of large vessel impairment. Cognitive status was significantly related to the pulsatility index (an indicator of small vessel impairment). This study provides evidence that subclinical vascular pathology could influence the clinical status by contributing to motor and cognitive dysfunction in PD.

Low molecular weight heparin (LMWH) administered immediately after intravenous thrombolysis (IT) may reduce the risk of arterial re-occlusion. Its benefit, however, may not outweigh the risk of intracranial hemorrhage (ICH). We sought preliminary data regarding safety of this combined therapy in an open-label, non-randomized study. The patients received either a standard anticoagulation (AC) starting 24 h after IT (the standard AC group) or AC with 2850 IU of nadroparin, given every 12 h immediately after IT (the early AC group). Sixty patients received IT treatment: 25 in the standard AC group [mean age 66, median National Institutes of Health Stroke Scale (NIHSS) 13, 64% men] and 35 in the early AC group (mean age 68, median NIHSS 13, 69% men). Symptomatic ICH occurred in one patient (4%) in the standard AC group and three patients (8.6%) in the early AC group [odds ratio (OR) 1.8; 95%CI 0.2-12.8]. At 3 months, nine patients in the standard AC group (36%) and 16 patients in the early AC group (45.7%) achieved a modified Rankin scale 0 or 1 (OR 1.2; 95%CI 0.5-3.2). Our study suggests that treatment with LMWH could be associated with higher odds of ICH, although it may not necessarily lead to a worse outcome. This justifies larger clinical trials.

Answer to Letter to the Editor: Vascular risk factors do not contribute to motor and cognitive impairment in Parkinson s Disease by Dr Slawek et al.The autors wish to thank to Dr.Slawek and his colleagues for their interest in our article and for their comments.