Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
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J Stroke Cerebrovasc Dis · May 2011
Case ReportsRecanalization of middle cerebral artery and intracranial aneurysm in the same ischemic territory with intravenous administration of recombinant tissue plasminogen activator: case report.
We report a case of middle cerebral artery (MCA) embolism accompanied by unruptured intracranial aneurysm in the same ischemic MCA territory, successfully treated with intravenous administration of recombinant tissue plasminogen activator (rt-PA). A 66-year-old right-handed man presented with abruptly decreased consciousness and right motor paralysis. He had a National Institute of Health Stroke Scale (NIHSS) score of 26 points on admission. ⋯ The patient's NIHSS and modified Rankin Scale scores were each 1 at 3 months after onset. Recanalization of both the occluded MCA and the occluded intracranial aneurysm in the same ischemic territory was neuroradiologically confirmed. This case illustrates that the efficacy, safety, and risk of hemorrhage during intravenous thrombolysis for acute ischemic stroke patients with unruptured intracranial aneurysm merit further examination.
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J Stroke Cerebrovasc Dis · Mar 2011
ReviewCerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL): from discovery to gene identification.
Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL) is a single-gene disorder directly affecting the cerebral small blood vessels, that is caused by mutations in the HTRA1 gene encoding HtrA serine peptidase/protease 1 (HTRA1). CARASIL is the second known genetic form of ischemic, nonhypertensive, cerebral small-vessel disease with an identified gene, along with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). The exact prevalence of CARASIL is currently unknown, and to date approximately 50 patients have been reported, most of them from Japan and two from China. ⋯ CARASIL is a prototype single-gene disorder of cerebral small vessels secondary to and distinct from CADASIL. CARASIL-associated mutant HTRA1 exhibited decreased protease activity and failed to repress transforming growth factor-β family signaling, indicating that the increased signaling causes arteriopathy in CARASIL. Therefore, HTRA1 represents another new gene to be considered in future studies of cerebral small-vessel diseases, as well as alopecia and degenerative vertebral/disk diseases.
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J Stroke Cerebrovasc Dis · Mar 2011
Randomized Controlled Trial Comparative StudyIntravenous insulin therapy in the maintenance of strict glycemic control in nondiabetic acute stroke patients with mild hyperglycemia.
Several reports indicate that mild hyperglycemia (plasma glucose level [PGL] ≥7.0 and ≤10.0 mmol/L [≥126 and ≤180 mg/dL]) is associated with poor prognosis in nondiabetic patients who sustain acute ischemic stroke (AIS). Insulin therapy to maintain PGL <7.0 mmol/L (<126 mg/dL) has been reported to be beneficial in critically ill patients, but the safety and efficacy of this approach in patients with AIS are not well established. In a prospective, open-label study, 50 consecutive nondiabetic patients with AIS admitted within 12 hours of ictus and with a PGL ≥7.0 and ≤10.0 mmol/L (≥126 and ≤180 mg/dL) were randomized to receive either a 24-hour intravenous (IV) insulin infusion (ISI) adjusted to maintain PGL within 4.5-7.0 mmol/L (81-126 mg/dL) (ISI group; n=26) or treatment with subcutaneous insulin if PGL was >10.0 mmol/L (>180 mg/dL) (control group [CG]; n=24). ⋯ There was no significant between-group difference in neurologic status at admission (median NIHSS score, 10±3 vs 10±2) and 24 hours later (8±2 vs 9±3). At 30 days, the median NIHSS score was 4±3 in the ISI group and 7±4 in the CG (P=.04). Our findings indicate that in nondiabetic AIS patients with mild hyperglycemia, IV insulin therapy aimed at maintaining strict glycemic control (PGL 4.5-7.0 mmol/L [81-126 mg/dL]) is relatively safe and may improve stroke outcome.
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J Stroke Cerebrovasc Dis · Mar 2011
Risk of thrombolytic therapy for acute ischemic stroke in patients with current malignancy.
Little is known about the risk of thrombolysis in patients with malignancy, because these patients have been excluded from most clinical trials. We reviewed our acute ischemic stroke (AIS) database for clinical outcomes and complications in patients with current malignancy (CM) who received thrombolytic therapy. Consecutive AIS patients receiving thrombolysis between January 2003 and December 2006 were retrospectively abstracted in accordance with the American Stroke Association's Get With the Guidelines-Stroke definitions and charts were reviewed for history of malignancy. ⋯ Mortality was attributable largely to medical comorbidities, not to symptomatic ICH. Our data suggest that thrombolysis may be a reasonable option for patients with malignancy who have acceptable medical comorbidities and performance status. Further research is warranted.
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J Stroke Cerebrovasc Dis · Jan 2011
Racial/ethnic disparities in emergency department waiting time for stroke patients in the United States.
Emergency department waiting time (EDWT), the time from arrival at the ED to evaluation by an emergency physician, is a critical component of acute stroke care. We assessed racial/ethnic differences in EDWT in a national sample of patients with ischemic or hemorrhagic stroke. We identified 543 ED visits for ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 433.x1, 434.xx, and 436.xx) and hemorrhagic stroke (ICD-9-CM codes 430.xx, 431.xx, and 432.xx) in persons age ≥ 18 years representing 2.1 million stroke-related ED visits in the United States using the National Hospital Ambulatory Medical Care Survey for years 1997-2000 and 2003-2005. ⋯ These differences persisted after adjustment (blacks: odds ratio [OR] = 2.08, 95% confidence interval [CI] = 1.05-4.09; Hispanics: OR = 1.07, 95% CI = 0.52-2.22). Blacks, but not Hispanics, had significantly longer EDWT than whites. The longer EDWT in black stroke patients may lead to treatment delays and sub-optimal stroke care.