Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
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J Stroke Cerebrovasc Dis · May 2011
In-hospital mortality in acute ischemic stroke treated with hemicraniectomy in US hospitals.
Hemicraniectomy is a surgical procedure performed to prevent cerebral herniation and death in patients who have sustained a massive ischemic stroke in the anterior circulation territory. Information on in-hospital mortality in patients with large ischemic stroke treated with hemicraniectomy outside randomized trials is lacking. We sought to identify in-hospital mortality associated with hemicraniectomy in a large US sample. ⋯ The rate of hospital utilization of hemicraniectomy varied between 0.04% and 0.06% among all stroke admissions; the trend did not change significantly over the 7-year study period (P = .06). The mortality rate in hemicraniectomy-treated patients was significantly lower than in historical cohorts however, hemicraniectomy remains associated with high in-hospital mortality. The rate of utilization of hemicraniectomy for AIS in US hospitals has remained essentially unchanged.
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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
Review Meta AnalysisMatrix metalloproteinase-9 as a marker for acute ischemic stroke: a systematic review.
Matrix metalloproteinase-9 (MMP-9) is a possible marker for acute ischemic stroke (AIS). In animal models of cerebral ischemia, MMP expression was significantly increased and was related to blood-brain barrier disruption, vasogenic edema formation, and hemorrhagic transformation. The definition of the exact role of MMPs after ischemic stroke will have important diagnostic implications for stroke and for the development of therapeutic strategies aimed at modulating MMPs. ⋯ Moreover, MMP-9 was a predictor of the development of intracerebral hemorrhage in patients treated with thrombolytic therapy. MMP-9 level was significantly increased after stroke onset, with the level correlating with infarct volume, stroke severity, and functional outcome. MMP-9 is a possible marker for ongoing brain ischemia, as well as a predictor of hemorrhage in patients treated with t-PA.