Canadian Neurological Scale Score Research Articles

English

BACKGROUND Platelet size, measured as mean platelet volume (MPV), is a marker of platelet function and is positively associated with indicators of platelet activity, including aggregation and release of thromboxane A2, platelet factor 4, and thromboglobulin.1 Larger platelets are metabolically more active, produce more prothrombotic factors, aggregate more easily & act as index of homeostasis and its dysfunction thrombosis.2 The purpose of this study was to examine the relationship between platelet indices and stroke, as well as its severity and outcome. METHODS This was a prospective observational case control study. This study was conducted with 105 non-diabetic, non-hypertensive ischemic stroke patients who had no history of previous thrombotic events and who had not previously taken any antiplatelet medications. These patients were examined within 24 hours of onset of symptoms and severity of stroke was calculated by Canadian neurological scale (CNS). The results were compared with 105 age and sex match controls. RESULTS Mean age of patients was 61.72 ± 12 and of controls was 62.85 ± 10.68. Based on the CNS score, participants were allocated into two groups; the first group were those who had a comprehension deficit (1st group, 43 patients) and the second group were those without a comprehension deficit (2nd group, 62 patients). Mean values for platelet distribution width (PDW) & MPV in 1st group was 18.329 and 12.55 respectively and in 2nd group was 16.98 and 11.48 respectively. The mean value of PDW and MPV for stroke patients was 17.53 ± 0.76 and 11.92 ± 0.58 and was significantly higher than mean value of PDW & MPV respectively in controls, which were 15.47 ± 0.26 and 10.43 ± 0.23. PDW & MPV was found to be significantly associated with severity of motor deficit. CONCLUSIONS Larger studies may be required to determine its utility in day-to-day clinical practice. However, platelet indices can be used for predicting the severity of deficit in patients of acute ischemic stroke. KEYWORDS Platelet Indices, Stroke

Screening for Dysphagia in Adult Patients with Stroke: Assessing the Accuracy of Informal Detection.

Early identification of dysphagia by screening is recommended best practice for patients admitted to hospital with acute stroke. Screening can reduce the risk of pneumonia and promote stroke recovery, yet some institutions do not utilize a formal screening protocol. This study assessed the accuracy of informal dysphagia detection prior to implementation of a formal screening protocol. We conducted a secondary analysis of data captured between 2003 and 2008 from a sample of 250 adult stroke survivors admitted to a tertiary care centre. Using a priori criteria, patient medical records were reviewed for notation about dysphagia; if present, the date/time of notation, writer's profession, and suggestion of dysphagia presence. To assess accuracy of notations indicating dysphagia presence, we used speech language pathology (SLP) assessments as the criterion reference. There were 221 patient medical records available for review. Patients were male (56%), averaged 68years (SD=15.0), with a mean Canadian Neurological Scale score of 8.1 (SD=3.0). First notations of swallowing by SLP were excluded. Of the remaining 170 patients, 147 (87%) had first notations (104 by nurses; 40 by physicians) within a median of 24.3h from admission. Accuracy of detecting dysphagia from informal notations was low, with a sensitivity of 36.7% [95% CI, 24.9, 50.1], but specificity was high (94.2% [95% CI, 86.5, 97.9]). Informal identification methods, although timely, are suboptimal in their accuracy to detect dysphagia and leave patients with stroke at risk for poor health outcomes. Given these findings, we encourage the use of psychometrically validated formal screening protocols to identify dysphagia.

Comparison of Post-Stroke Functional Recovery between Ischemic and Hemorrhagic Stroke Patients: A Prospective Cohort Study

pathophysiologic mechanism that underlies each stroke type may give different outcome in post-stroke patients. This study aimed to compare the improvement of functional outcome between both types of stroke among stroke patients admitted to Dr. Hasan Sadikin General Hospital (RSHS). Methods: Consecutive sampling was carried out on first-ever stroke patients admitted to neurological inpatient unit of RSHS from September 2015 to October 2015. Functional recovery, measured by subtracting Canadian Neurological Scale (CNS) on day-8 and day-1 of admission, was compared among two subgroups and analyzed using Mann-Whitney U test. Baseline characteristics were collected and analyzed. Results: Total of thirteen stroke patients was included in this study: ten ischemic stroke and three hemorrhagic stroke patients. CNS score improvement between ischemic and hemorrhagic stroke patients was not significantly different. However, hemorrhagic stroke had higher score than ischemic stroke with 0.30 CNS score difference. Conclusions: CNS improvement between ischemic and hemorrhagic stroke was not significantly different. DOI: 10.15850/amj.v4n2.1069

Adult stroke registry in West Africa: Profile of 334 in-patients in the University of Benin Teaching Hospital, Benin City, Nigeria

Background: Profiling of stroke types in sub-Saharan Africa until recently has been done in part with the clinical diagnosis, where neuroimaging is not affordable or accessible. Objective: To profile all first-ever stroke using cranial computed tomography (CT) scan. Methods: Three hundred and thirty-four first-ever stroke had demographic data as well as the duration of admission or time to event (outcome), stroke type and severity, volume of hemorrhage in cases of parenchymal hemorrhage captured from the stroke unit register. Operationally outcome was defined as discharge to follow-up or discharge against medical advice (DAMA) or all-cause in-hospital mortality, stroke type was defined by cranial CT as cerebral infarct or intracerebral hemorrhage (ICH) or subarachnoid hemorrhage. Stroke severity was defined by the Canadian Neurological Scale (CNS) and the National Institutes of Health Stroke Score (NIHSS). Data were analyzed as appropriate. Results: Mean age was 62.63 ± 14.90 years, comprising 190 (56.9%) males and 144 (43.1%) females. Mean duration of admission was 12.91 ± 11.38 days. Totally, 251 had cerebral infarct (75.15%), 81 (24.25%) had ICH, 2 (0.60%) had subarachnoid hemorrhage. A total of 177 (51.19%) were discharged to follow-up, 15 (4.50%) were DAMA with acute case fatality of 148 (44.31%). Mean CNS score was 2.85 ± 2.57 and mean NIHSS was 17.29 ± 5.15. Age, time to outcome and NIHSS were the predictors of outcome (survival or discharged to follow-up and all-cause mortality) (odds ratio [OR] =1.043, P = 0.016, OR = 0.923, P = 0.001, OR = 2.467, P < 0.001 respectively) and NIHSS was the only predictor of survival (hazard ratio = 0.872, P < 0.001). Conclusion: This neuroimaging profiling of acute stroke type and outcome is expected to be an improvement over reviews based largely on the presumptive diagnosis.

Red cell distribution width and neurological scoring systems in acute stroke patients.

ObjectivesThe purpose of the present study was to evaluate the association between the red blood cell distribution width (RDW) and the Glasgow Coma Scale (GCS), Canadian Neurological Scale (CNS), and National Institutes of Health Stroke Scale (NIHSS) scores in patients who had acute ischemic stroke.MethodsThis prospective observational cohort study included 88 patients who have had acute ischemic stroke and a control group of 40 patients who were evaluated in the Emergency Department for disorders other than acute ischemic stroke. All subjects had RDW determined, and stroke patients had scoring with the GCS, CNS, and NIHSS scores. The GCS, CNS, and NIHSS scores of the patients were rated as mild, moderate, or severe and compared with RDW.ResultsStroke patients had significantly higher median RDW than control subjects. The median RDW values were significantly elevated in patients who had more severe rather than milder strokes rated with all three scoring systems (GCS, CNS, and NIHSS). The median RDW values were significantly elevated for patients who had moderate rather than mild strokes rated by GCS and CNS and for patients who had severe rather than mild strokes rated by NIHSS. The area under the receiver operating characteristic curve was 0.760 (95% confidence interval, 0.676–0.844). Separation of stroke patients and control groups was optimal with RDW 14% (sensitivity, 71.6%; specificity, 67.5%; accuracy, 70.3%).ConclusionIn stroke patients who have symptoms <24 hours, the RDW may be useful in predicting the severity and functional outcomes of the stroke.

2014 Canadian Stroke Congress Abstracts

d’Esterre, CD1, 3 Qazi, E1, 3 Patil, S1, 3 Almekhlafi, M3, 1 Lee, T2, 3 Demchuk, A1, 3 Goyal, M1, 3 Menon, B1, 3; 1. University of Calgary, Calgary, AB; 2. University of Western Ontario, London, ON; 3. Calgary Stroke Program, Calgary, AB Background : For ischemic stroke, CT Perfusion (CTP) may change thrombolytic/endovascular treatment decisions when compared to NCCT/CTA alone. Two distinct thresholds may be useful in this regard: separation of 1) non-salvageable tissue (infarct core) from salvageable electrically silent tissue (penumbra), and 2) penumbra from benign oligemia (hypoperfused, but will survive if clot persists). Methods : CTP (120s,8cm) was performed on 180 patients within 12hrs of ischemic stroke. Two patient cohorts were analyzed: (1) recanalization (TICI 2b,3) 6s. For group (2) CBF, CBV, and Tmax values were obtained from within the final infarct region, and total ipsilateral hemisphere, excluding infarction. CBF, CBV and Tmax were used in univariate regression models. Results : For group (1)[n=11], mean time from CTP to recanalization was 60±19min. CBF parameter (thresholds for gray and white matter 7.2 and 5.2 ml•min-1•(100g)-1) had the highest sensitivity (90.9%) and specificity (81.8%) for infarction. For group (2)[n=15], the Tmax parameter (thresholds for gray and white matter 11.3s and 11.8s) had the highest sensitivity (86.6%) and specificity (80.0%) for penumbra. Conclusion : Knowing the status of recanalization within 90mins of CTP allows for accurate delineation of infarct core, as …

The effects of reciprocal inhibition on motor function and brain functional network connectivity of stroke patients

Objective To investigate the effects of reciprocal inhibition on motor function connectivity in the brains of stroke patients.Methods Thirty patients with stroke were randomly divided into a treatment group (n =15) and a control group (n =15).The control group underwent normal limb positioning,medium frequency electrotherapy,circulated compression of the limbs,etc.The treatment group received conventional rehabilitation treatment plus reciprocal inhibition treatment for 30 min daily,6 times a week for 4 weeks.All of the patients were assessed before and after treatment using the Canadian neurological scale (CNS),the Frenchay activities index (FAI),the motricity index (MI) and functional magnetic resonance imaging of the motor cortex in a resting state (rs-fMRI).Results In both groups the average CNS,FAI and MI scores improved significantly.Compared with the control group,the changes in FAI and MI scores in the treatment group improved significantly more.The coefficient of functional connectivity of the bilateral motor cortex decreased significantly after treatment in both groups.In the treatment group the motor cortex functional connectivity correlated significantly with the improvements in MI scores.Conclusions Reciprocal inhibition can accelerate the improvement of extremity motor function and ability in the activities of daily living significantly after stroke.It reduces functional connectivity in the bilateral motor cortex in ways significantly correlated with improvements in motor function. Key words: Reciprocal inhibition; Resting-state functional magnetic resonance imaging; Stroke

High-sensitivity C-reactive protein, lipoprotein-related phospholipase A2, and acute ischemic stroke.

BackgroundSerum biomarkers may be useful for early diagnosis of acute ischemic stroke, exclusion of other diseases that may mimic stroke, and prediction of infarct volume. We evaluated serum high-sensitivity C-reactive protein (hs-CRP) and lipoprotein-related phospholipase A2 (Lp-PLA2) in patients who had acute ischemic stroke.MethodsIn 200 patients who presented to an emergency service (acute ischemic stroke, 102 patients; control with no stroke, 98 patients), stroke patients were evaluated with the Canadian neurological scale and diffusion-weighted magnetic resonance imaging, and all patients were evaluated with the Glasgow coma scale and their serum hs-CRP level and Lp-PLA2 activity were assessed. The volume of stroke lesions was calculated from magnetic resonance images.ResultsPatients who had stroke had higher mean serum hs-CRP level (stroke, 7±6 mg/dL; control, mean ± standard deviation 1±1 mg/dL; P≤0.001) and Lp-PLA2 activity (stroke, mean ± standard deviation 113±86 nmol/min/mL; control, mean ± standard deviation 103±50 nmol/min/mL; P≤0.001) than control patients who did not have stroke. The mean hs-CRP level and Lp-PLA2 activity were higher in patients who had greater stroke severity (lower Canadian neurological scale score) and were higher in patients who had larger volume strokes.ConclusionHigher hs-CRP level and Lp-PLA2 activity are significantly associated with more severe neurologic impairment and larger infarct size in patients who have acute ischemic stroke. These biomarkers may be useful for rapid diagnosis and prediction of ischemic tissue volume in the early stage of ischemic stroke. These findings may be important for health care facilities that have limited access to emergency computed tomography scanning for the diagnosis of stroke.

Comparison of three instruments to assess changes of motor impairment in acute hemispheric stroke: the Stroke Impairment Assessment Set (SIAS), the National Institute of Health Stroke Scale (NIHSS) and the Canadian Neurological Scale (CNS)

Purpose: The purpose was to compare the performance of three representative instruments to measure changes of motor recovery with acute hemispheric stroke. Method: In 41 consecutive patients with acute hemispheric infarction, motor recovery was assessed within 3 days of onset and then every 2 weeks until the 12th week with the Stroke Impairment Assessment Set (SIAS), the National Institutes of Health stroke scale (NIHSS) and the Canadian Neurological Scale (CNS). We analyzed the relationships among the corresponding subscales of the three instruments with the Spearman’s rank correlation method, and compared their responsiveness by plotting the temporal profiles of scores of each instrument and by testing the significance of changes over time with the Friedman test. Results: High correlations were observed among the three instruments at each examination point. However, the SIAS scores were more widely dispersed at the same NIHSS and CNS scores. Friedman test revealed that the scores changed significantly during the observation period with the SIAS and the CNS but not with the NIHSS. The changes were detected later with the CNS than with the SIAS. Conclusions: Although the assessment results with the three instruments were highly inter-correlated, the SIAS performed better with respect to responsiveness to changes.Implication for RehabilitationWhen providing rehabilitation services to patients with stroke, it is important to document objectively the level of their impairment from the acute stage and during the entire course of rehabilitation with standardized instrument, and to predict their functional outcomes as early and accurately as possible.This study therefore compared three representative instruments with established psychometric properties, the SIAS, the NIHSS and the CNS, with respect to their ability to document motor impairment and their responsiveness to recovery in patients with acute hemispheric stroke.

Quality of Life of Stroke Survivors: A 3-Month Follow-up Study

The assessment of stroke survivors' quality of life (QoL) is essential for planning poststroke therapy strategies. This study aimed to assess, compare, and identify predictors of unsatisfactory QoL in different dimensions of stroke survivors at 1 month and 3 months poststroke. A total of 125 stroke survivors were recruited from 4 public hospitals under the auspices of the Department of Medical Services, Bangkok Metropolitan Administration, Thailand, and followed for 3 months. QoL was assessed using the self-administered SF-36 Health Survey, version 2.0. Six specific dimensions of QoL--physical function, role-physical, bodily pain, general health, vitality, and role-emotional--were significantly improved at 3 months poststroke; however, 2 dimensions--social function and mental health--were not. Multiple logistic regression analysis revealed that at 1 month poststroke, significant predictors of unsatisfactory QoL were being dependent (Barthel Index score <80), severe cognitive impairment (Canadian Neurological Scale score <7), right hemisphere lesions, being single or widowed, age ≥ 60 years, and being unemployed poststroke. At 3 months poststroke, significant predictors of unsatisfactory QoL were being dependent (Barthel Index score <80), severe cognitive impairment (Canadian Neurological Scale score <7), being single or widowed, being unemployed poststroke, and self-supporting/other support for treatment fees. This follow-up study demonstrated a significant improvement in QoL from 1 month to 3 months poststroke. Predictors of QoL varied both over time poststroke and over the specific dimensions of QoL being considered.

Electro Stimulation of Paretic Muscles and Chinese Acupuncture Are for the Rehabilitation in Patients with Stroke (P01.177)

Objective: To evaluate the efficacy and safety of Chinese Acupuncture (CA) and Electro stimulation of paretic muscles (ESPM) for rehabilitation in stroke outcomes patients. Background CA is a well known and completely developed system of ancient China. It works according points are on the acupuncture channels of human body. ESPM is a method for releasing paresis. Design/Methods: The author observed two groups with equal number of 36 patients in each other for 110 days. The first group of patients was treated only by ESPM therapy and another one was treated by both methods of using CA and ESPM in the same shortage of time. The results of treatment were evaluated by lowering pyramidal pathologic, increasing the strength and volume of movement in paralytic extremities and were estimated using scale of stroke outcomes. As a scale were using Canadian Neurological Scale (CNS) and American Heart Association (AHA) Stroke Outcome Classification Score. Also, the improving of outcomes was evaluated by the tools monitoring included EMG and dopplering of brain blood circulation. Results: In ESPM group of scientific investigation the improvement was in summary 17,9 % according the scale of stroke outcomes and the blood circulation has increased on 7,2 %. The group that had been treating by both: ESPM and CA, responded by 28,4 % of the increasing of the strength and volume of movement in paralytic extremities those were estimated by the scale of stroke outcomes and the improvement of blood circulation was 9,6%. EMG was approximately of the same pattern. ESPM and CA were well tolerated and they were without any complications. Conclusions: This trial demonstrates that ESPM and CA are of high efficacious and well tolerated when administered as ways for rehabilitation in patients suffering of stroke outcomes. Disclosure: Dr. Aslanyan has nothing to disclose.

Care and outcomes in patients with ischemic stroke with and without preexisting dementia

To describe clinical characteristics and evaluate processes of care and outcomes at discharge in patients with ischemic stroke with and without preexisting dementia. Retrospective cohort study using the Registry of the Canadian Stroke Network including patients presenting with an acute ischemic stroke between 2003 and 2008. Preexisting dementia was defined as any type of dementia that was present prior to the index stroke case. Palliative patients were excluded. Demographic information, clinical presentation, selected process measures (e.g., thrombolysis, admission to stroke unit, carotid imaging, stroke prevention), pneumonia, death, disability, and disposition at discharge were analyzed. Among 9,304 eligible patients with an acute ischemic stroke, 702 (9.1%) had a history of dementia. Patients with dementia were older (mean age 81 vs 70 years; p < 0.001), had more severe strokes (Canadian Neurological Scale score <4, 20.7% vs 10.5%; p < 0.001), and were more likely to have atrial fibrillation (22.8% vs 15.3%; p < 0.001) than those without dementia. Patients with dementia were slightly less likely to be admitted to a stroke unit (63% vs 67.6%; odds ratio [OR] 0.82, 95% confidence interval [CI] 0.70-0.96) or to receive thrombolysis (10.5% vs 15.7%; OR 0.63, 95% CI 0.49-0.81). There were no differences in other performance measures. Patients with preexisting dementia had higher disability at discharge (OR 3.20, 95% CI 2.64-3.87) and were less likely to be discharged to their prestroke place of residence (24% vs 45%; p < 0.001). In patients with stroke, preexisting dementia is associated with high rates of disability and institutionalization, representing an increasing challenge for the health care system.

Influence of Continuous Positive Airway Pressure on Outcomes of Rehabilitation in Stroke Patients With Obstructive Sleep Apnea

In stroke patients, obstructive sleep apnea (OSA) is associated with poorer functional outcomes than in those without OSA. We hypothesized that treatment of OSA by continuous positive airway pressure (CPAP) in stroke patients would enhance motor, functional, and neurocognitive recovery. This was a randomized, open label, parallel group trial with blind assessment of outcomes performed in stroke patients with OSA in a stroke rehabilitation unit. Patients were assigned to standard rehabilitation alone (control group) or to CPAP (CPAP group). The primary outcomes were the Canadian Neurological scale, the 6-minute walk test distance, sustained attention response test, and the digit or spatial span-backward. Secondary outcomes included Epworth Sleepiness scale, Stanford Sleepiness scale, Functional Independence measure, Chedoke McMaster Stroke assessment, neurocognitive function, and Beck depression inventory. Tests were performed at baseline and 1 month later. Patients assigned to CPAP (n=22) experienced no adverse events. Regarding primary outcomes, compared to the control group (n=22), the CPAP group experienced improvement in stroke-related impairment (Canadian Neurological scale score, P<0.001) but not in 6-minute walk test distance, sustained attention response test, or digit or spatial span-backward. Regarding secondary outcomes, the CPAP group experienced improvements in the Epworth Sleepiness scale (P<0.001), motor component of the Functional Independence measure (P=0.05), Chedoke-McMaster Stroke assessment of upper and lower limb motor recovery test of the leg (P=0.001), and the affective component of depression (P=0.006), but not neurocognitive function. Treatment of OSA by CPAP in stroke patients undergoing rehabilitation improved functional and motor, but not neurocognitive outcomes. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00221065.

The Canadian Neurological Scale and the NIHSS: Development and Validation of a Simple Conversion Model

Background: The Canadian Neurological Scale (CNS) and the National Institutes of Health Stroke Scale (NIHSS) are among the most reliable stroke severity assessment scales. The CNS requires less extensive neurological evaluation and is quicker and simpler to administer. Objective: Our aim was to develop and validate a simple conversion model from the CNS to the NIHSS. Methods: A conversion model was developed using data from a consecutive series of acute-stroke patients who were scored using both scales. The model was then validated in an external dataset in which all patients were prospectively assessed for stroke severity using both scales by different observers which consisted of neurology residents or stroke fellows. Results: In all, 168 patients were included in the model development, with a median age of 73 years (20–94). Men constituted 51.8%. The median NIHSS score was 6 (0–31). The median CNS score was 8.5 (1.5–11.5). The relationship between CNS and NIHSS could be expressed as the formula: NIHSS = 23 – 2 × CNS. A cohort of 350 acute-stroke patients with similar characteristics was used for model validation. There was a highly significant positive correlation between the observed and predicted NIHSS score (r = 0.87, p < 0.001). The predicted NIHSS score was on average 0.61 higher than the observed NIHSS score (95% CI = 0.31–0.91). Conclusions: The CNS can be reliably converted to the NIHSS using a simple conversion formula: NIHSS = 23 – 2 × CNS. This finding may have a practical impact by permitting reliable comparisons with NIHSS-based evaluations and simplifying the routine assessment of acute-stroke patients in more diverse settings.

Pre-Stroke Use of Antihypertensives, Antiplatelets, or Statins and Early Ischemic Stroke Outcomes

Background: The effect of pre-stroke use of antihypertensives, antiplatelets, and statins on initial severity and early outcome of ischemic stroke is uncertain. Methods: We performed a retrospective chart review of 553 consecutive acute ischemic stroke patients presenting to the Montreal General Hospital between April 1st 2002 and October 15th 2005. We defined a severe stroke as a Canadian Neurological Scale score of ≤7 and a poor early outcome as a modified Rankin Scale score of >3 at 10 days post-stroke. Results: In total, 339 patients were included. Superior early functional outcome was associated with the premorbid use of statins (OR = 0.50, 95% CI: 0.25–1.00) and the combination of all 3 medications (OR = 0.37, 95% CI: 0.16–0.87). Angiotensin-II-decreasing agents were associated with an increased risk of severe strokes (OR = 2.13, 95% CI: 1.00–4.52). Conclusions: Pre-stroke use of statins and the combination of antihypertensives, antiplatelets, and statins were both associated with a favorable functional outcome at 10 days post-stroke. Angiotensin-II-decreasing agents were associated with increased initial stroke severity.

Derivation and validation of a simple risk score for predicting 1-year mortality in stroke

Numerous models have been presented for the prognosis in acute stroke; however they have been criticized for being difficult to use, and few have been validated in independent samples. To develop simple risk score models for 1-year mortality in acute stroke in patients > 60 years old and validate the models. From a cohort of 2321 consecutive patients > 60 years of age with acute stroke in one hospital, we randomly selected 800 patients for chart review. Among 737 patients with validated acute stroke, we randomly split the sample into (1) a derivation (60%; n = 442) and (2) a validation sample (40%; n=295). We used logistic regression to develop three models with 2-4 covariates and a corresponding risk score from the derivation sample. The models were validated using area under the receiver operating curves. Three risk score models for 1-year mortality after stroke were developed using combinations of age, Canadian Neurological Scale score (CNSscore) (< or = 3.5 = 0, >3.5 = 1), Charlson comorbidity index and stroke type (ischemic = 0, hemorrhagic = 1). Both 2-variable (Age - 60 + (30*CNSscore)), 3-variable (Age - 60 + (30*CNSscore) + 4*Charlson)) and 4-variable (Age - 60 + (25*CNSscore) + (5*Charlson) + (18*Stroke type)) models reliably predicted the outcome with an area under the receiver operating curve ranging 0.71 to 0.72. Simple models incorporating two to four covariates reliably predicted 1-year mortality. Such models can be used to stratify prognosis in clinical practice, research or intervention trials.

Oxidative stress in acute ischemic stroke

Oxidative stress plays an important role in acute ischemic stroke pathogenesis. Free radical formation and subsequent oxidative damage may be a factor in stroke severity. Serum levels of nitric oxide (NO), malondialdehyde (MDA) and glutathione (GSH) were measured within the first 48 h of stroke in 70 patients. The levels were also correlated with the clinical outcomes using Canadian Neurological Scale (CNS) scores. The results were compared with a control group consisting of 70 volunteers with similar stroke risk factors. Serum NO, MDA and GSH levels were significantly elevated in acute stroke patients. CNS score was negatively correlated with both MDA and NO levels. However, no statistically significant correlation between GSH levels and CNS scores was detected. Our results suggest deleterious effects of oxidative stress on clinical outcome in acute ischemic stroke. The elevation of GSH levels may be an adaptive mechanism during this period.

Effect of single mannitol bolus in intracerebral hemorrhage

Because of existing controversy about use of mannitol in intracerebral hemorrhage (ICH) this open exploratory trial with blinded outcome assessment of single mannitol bolus in ICH was undertaken. CT proven primary supratentorial ICH patients having midline shift of > or =3 mm were randomized into 20% mannitol (1.5 g/kg) and control groups. Clinical evaluation included Glasgow coma scale (GCS) score, Canadian Neurological scale (CNS) score, pupils, breathing, extensor posturing and contra-lateral pyramidal signs. On cranial MRI horizontal (HS), superior sagittal sinus to pontomesencephalic junction (SSS-PMJ) distance and edema hematoma complex were measured. Twelve patients each were in mannitol and control groups. The age, sex, GCS score, CNS score, pupillary asymmetry, contra-lateral pyramidal signs, HS and SSS-PMJ distance in mannitol and control groups did not differ significantly. Mannitol infusion resulted clinical improvement in five patients, which lasted for 30-60 min. HS and SSS-PMJ distance in mannitol and control groups did not change at 30 or 60 min from the baseline. The change in HS and SSS-PMJ distance were also not significantly different between the two groups both at 30 and 60 min. Mannitol led to transient clinical improvement in five patients without significant reduction in HS or SSS-PMJ distance at 30 and 60 min.

The Relationship between Protein C, Protein S and Cytokines in Acute Ischemic Stroke

Objective: The role of inflammation in the pathogenesis of acute ischemic stroke is well known, but its association with the clinical picture is as yet unclear. Material and Methods: In our study, we measured the serum levels of the proinflammatory cytokines interleukin-1β (IL-1β), tumor necrosis factor α (TNFα) and interleukin-6 (IL-6) within the first 50 h of stroke in 60 acute stroke patients, and examined the association with the natural anticoagulants protein C and free protein S. We compared the results with a control group that consisted of 30 volunteers. We also correlated their levels with the clinical outcomes by using the Canadian Neurological Scale (CNS). Results: Neither stroke patients nor the control group had any elevations in IL-1β serum levels. However, the levels of serum IL-6 were significantly higher in stroke patients (13.7 ± 19.46 vs. 4.3 ± 15.88, p = 0.002). In addition, the protein S levels of patients were lower than those of the controls (84.36 ± 27.97 vs. 95.9 ± 25.64, p = 0.007). Although IL-6 showed negative correlation with protein S (r = –0.504, p = 0.000), the other studied cytokines TNFα and IL-1β did not correlate with these natural anticoagulants. Another negative correlation was found between IL-6 and CNS scores (r = –0.451, p = 0.000). In addition, both protein C and protein S positively correlated with CNS (r = 0.263, p = 0.042; r = 0.381, p = 0.003). There was also a positive correlation between protein C and protein S (r = 0.408, p = 0.001). Conclusions: Our results suggest that TNFα and IL1β serum levels are not elevated in the acute phase of stroke and have no correlation with the natural anticoagulants protein C and protein S. However, a decrease in free protein S may be related to elevated IL-6 levels. In addition, increased levels of IL-6 and reduced levels of protein C and protein S may play a role in acute ischemic stroke severity.

Intracerebral Hemorrhage: Outcomes and Eligibility for Factor VIIa Treatment in a National Stroke Registry

Background: Intracerebral hemorrhage (ICH) is a devastating form of stroke for which the lack of treatment options, high mortality rate, and the tendency to severely disable result in high social and economic burden. Methods: We analyzed data in the Registry of the Canadian Stroke Network (RCSN). We sought to: (1) provide a descriptive analysis of ICH; (2) determine the proportion of ICH patients that might have been eligible for treatment with recombinant activated factor VII (rFVIIa) using criteria from a recent phase II trial; (3) compare 6-month outcomes of ICH patients with those of ischemic stroke patients, matched for gender, age, and stroke severity. Results: In the RCSN, 11% of all strokes were nontraumatic ICH. The median Canadian Neurological Scale score was 7. A minority (33%) of patients arrived to the emergency department in less than 3 h from onset. In this cohort, in-hospital mortality was 15%. At 6 months, a further 9% of patients had died and 58% had a slight to no disability (Stroke Impact Scale-16 score ≧75). Approximately 20% of ICH patients would have been eligible for rFVIIa treatment. Compared to ischemic stroke, ICH showed a trend towards increased mortality at discharge (OR: 1.96, CI: 0.99–3.87). At 6-month follow-up, ICH showed increased mortality (OR: 2.27, CI: 1.29–3.97), yet functional outcomes were not significantly different. Conclusion: ICH patients had a higher case-fatality rate when compared to acute ischemic stroke, but survivors had similar functional outcomes. In Canada, about one fifth of ICH patients might potentially benefit from rFVIIa if it is approved, with the major exclusion factor being time.