Survival Functional Outcome Research Articles

Corticosteroids for acute ischaemic stroke

The majority of strokes are due to cerebral infarction. Ischaemic cerebral tissue tends to develop cytotoxic oedema which, if the blood-brain barrier is disrupted, may be followed by vasogenic oedema. Large infarcts can develop life-threatening massive oedema. Early treatment with corticosteroids could theoretically help reduce both cytotoxic and vasogenic oedema and so improve the clinical outcome after a stroke. To assess the effect of corticosteroids in acute presumed ischaemic stroke. We searched the Cochrane Stroke Group Trials Register (last searched: 17 February 2011). Published randomised trials comparing corticosteroids with placebo or a control group in people with acute (presumed or definite) ischaemic stroke. Trials were included if treatment began within 48 hours of stroke onset and if clinical outcomes were assessed. Two review authors independently applied the inclusion criteria, assessed trial quality and extracted the data. Eight trials involving 466 people were included. Details of trial quality that may relate to bias were not available for most trials. No difference was shown in the odds of death within one year (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.57 to 1.34). Treatment did not appear to improve functional outcome in survivors. Seven trials reported neurological impairment but pooling the data was impossible because no common scale or time interval was used. The results were inconsistent between individual trials. The only adverse effects reported were small numbers of gastrointestinal bleeds, infections and deterioration of hyperglycaemia across both groups. The results are unchanged since the previous update. There is not enough evidence to evaluate corticosteroid treatment for people with acute presumed ischaemic stroke. The conclusions are unchanged since the previous update.

Edaravone for acute intracerebral haemorrhage

Intracerebral haemorrhage (ICH) causes significant morbidity and mortality. Prognosis for ICH patients is poor. Edaravone may be safe and effective in reducing the risk of early death and improving long-term functional outcomes in survivors. To assess the safety and efficacy of edaravone for acute ICH. We searched the Cochrane Stroke Group Trials Register (March 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2 2010), the Chinese Stroke Trials Register (August 2010), MEDLINE (1950 to August 2010), EMBASE (1980 to March 2010) and 12 Chinese databases (August 2010). We also searched ongoing trials registers, reference lists, relevant conference proceedings and contacted companies manufacturing edaravone. Randomised controlled trials (RCTs) in which edaravone was compared with placebo, or edaravone plus routine treatment was compared with routine treatment alone, in patients with acute ICH. Two review authors independently assessed trial quality and extracted data, collected adverse events data and contacted trialists for missing information. We included 10 RCTs involving 768 participants; quality was generally poor. For all trials, the control group was usual care/routine therapy (not placebo), treatment allocation and outcome evaluations were not blinded or not described, and the primary outcome (death or dependency at the end of long-term follow-up) was not reported. Only one trial reported deaths, indicating that edaravone treatment did not decrease the number of deaths significantly either during the scheduled treatment (RR 0.62, 95% CI 0.11 to 3.50) or at three month follow-up (RR 0.93, 95% CI 0.20 to 4.32). Four studies assessed activities of daily living (ADL) but ADL score was not improved significantly (MD 21.65, 95% CI -6.98 to 50.28) at the end of long-term follow-up. Combining data from all studies, edaravone treatment did increase the rate of improvement of neurological impairment (RR 1.48, 95% CI 1.29 to 1.69) until the end of the scheduled treatment, but it is not clear that this translates to any longer-term benefit of clinical importance. Reported adverse events with edaravone were mild and were common (9%), but there was no significant difference in adverse effect between the two groups (RR 2.09, 95% CI 0.71 to 6.19). All 10 studies were inconclusive in finding a beneficial or deleterious effect provided by edaravone for the treatment of ICH. Further high quality, large scale RCTs are required.

Predictors of independent living status in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study.

1576 Background: With increased success of treatments for pediatric cancers, attention has focused on functional outcomes of survivors. This study examines factors that predict independent living in adult survivors of childhood cancer. Methods: Adult survivors of childhood cancers (n = 6047) and siblings (n = 2,326), all of whom were ≥ 25 years of age, completed a long-term follow-up questionnaire that assessed adaptive, neurocognitive, and psychological functioning, as well as demographic information and health status. Survivors were a mean age of 34.2 years (range 25-54) at study. Logistic regression models (expressed as odds ratio [OR] and 95% confidence interval [CI]) were used to predict risk of dependent living based on demographic, neuropsychological, physical functioning and treatment variables. Results: Compared to siblings, survivors were more than twice as likely to live dependently (OR = 2.07, 95% CI 1.77-2.42), adjusted for age, gender and race. In multivariate logistic regression analyses, risk factors for dependent living among survivors included: racial/ethnic minority status (OR = 2.60, 95% CI 2.02-3.36), cranial radiation therapy in dose dependent fashion (> 0 to ≤ 24 Gy OR = 1.35, 95% CI 1.11-1.65; > 24 Gy OR = 3.63, 95% CI 2.82-4.68), attention and processing speed problems (OR = 1.91, 95% CI 1.57-2.33), depression (OR = 1.61, 95% CI 1.23-2.10), poor physical functioning (OR = 1.96, 95% CI 1.53-2.50), and use of neuroleptic, anticonvulsant, or psychostimulant medication (OR=3.05, 95% CI 2.30-4.03). Factors associated with independent living included: older age at diagnosis (6 to < 12 years of age [OR = 0.71, 95% CI 0.58- 0.86], ≥ 12 years of age [OR = 0.43, 95% CI 0.33-0.55] compared to those diagnosed < 6 years), older current age (> 35 years of age; OR = 0.50, 95% CI 0.40-0.62), and having received non-CNS-directed chemotherapy (compared to those with a treatment history of only radiation and/or surgery [OR = 0.69, 95% CI 0.53-0.89]). Conclusions: Adult survivors of childhood cancer are less likely to live independently compared to siblings. Specific neurocognitive, medical and psychological late effects are strongly associated with extended dependency on others in adulthood. No significant financial relationships to disclose.

Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation

A Glasgow Coma Scale (GCS) score of 3 on presentation in patients with severe traumatic brain injury due to blunt trauma has been recognized as a bad prognostic factor. The reported mortality rate in these patients is very high, even approaching 100% in the presence of fixed and dilated pupils in some series. Consequently, there is often a tendency to treat these patients less aggressively because of the low expectations for a good recovery. In this paper, the authors' purpose is to report their experience in the management of this patient population, analyzing the mortality rate, prognostic factors, and functional outcome of survivors. The authors performed a retrospective review of patients who presented between 1997 and 2007 with blunt head trauma and a GCS score of 3. Demographics, mechanism of injury, examination, blood alcohol level, associated injury, intracranial pressure (ICP), surgical procedures, and outcome were all recorded. A total of 189 patients met the inclusion criteria and were included in this study. The overall mortality rate was 49.2%. At the 6-month follow-up, 13.2% of the entire series achieved a good functional outcome (Glasgow Outcome Scale [GOS] score of 1 or 2). The patient population was then divided into 2 groups: Group 1 (patients who survived [96]) and Group 2 (patients who died [93]). Patients in Group 1 were younger (mean 33.3 +/- 12.8 vs 40.3 +/- 16.97 years; p = 0.002) and had lower ICP on admission (mean 16.3 +/- 11.1 vs 25.7 +/- 12.7 mm Hg; p < 0.001) than those in Group 2. The difference between the 2 groups regarding sex, mechanism of injury, hypotension on admission, alcohol, surgery, and associated injuries was not statistically significant. The presence of bilateral fixed, dilated pupils was found to be associated with the highest mortality rate (79.7%). Although not statistically significant because of the sample size, pupil status was also a good predictor of the functional outcome at the 6-month follow-up; a good functional outcome (GOS Score 1 or 2) was achieved in 25.5% of patients presenting with bilateral reactive pupils, and 27.6% of patients presenting with a unilateral fixed, dilated pupil, compared with 7.5% for those presenting with bilateral fixed, nondilated pupils, and 1.4% for patients with bilateral fixed, dilated pupils. Overall, 50.8% of patients survived their injury and 13.2% achieved a good functional outcome after at 6 months of follow-up (GOS Score 1 or 2). Age, ICP on admission, and pupil status were found to be significant predictive factors of outcome. In particular, pupil size and reactivity appeared to be the most important prognostic factor since the mortality rate was 23.5% in the presence of bilateral reactive pupils and 79.7% in the case of bilateral fixed, dilated pupils. The authors believe that patients having suffered traumatic brain injury and present with a GCS score of 3 should still be treated aggressively initially since a good functional outcome can be obtained in some cases.

Reversed flow in the basilar artery in acute vertebrobasilar ischemia

Acute vertebrobasilar ischemia is a potentially sinister pathology with high mortality and poor functional outcome in survivors. We report the findings of multi-modal assessment (MRI and cerebrovascular ultrasonography) of cerebral hemodynamics in a patient who suffered from acute brainstem infarction with National Institute of Health Stroke Scale (NIHSS) score of 16 points. Our patient demonstrated reversal of blood flow in the basilar artery on the second day of his stroke and this was associated with significant and rapid clinical recovery over the following 2 days (NIHSS score dropped to 4 points). He had recovered completely when seen in the outpatient clinic 3 months later.

Rhythmic Auditory-Motor Entrainment Improves Hemiparetic Arm Kinematics During Reaching Movements: A Pilot Study

Purpose: Recovery of skilled upper limb movement remains a critical focus of rehabilitation in individuals post stroke. Conventional treatments, however, have demonstrated limited capability to produce substantial improvements in poststroke quality of movement. Recently, rhythmic auditory stimulation (RAS) has emerged as efficacious in improving and normalizing limb movements in neurologically impaired populations. This pilot study examined changes in pre- to post-RAS reach kinematics and functional outcomes in survivors of stroke. Method: Five individuals in the chronic poststroke phase participated in a 2-week program of RAS training. Kinematic reaching variables were trunk, shoulder, and elbow segment contribution; movement time; and reach velocity. Functional outcomes were the Wolf Motor Function Test, Motor Activity Log, and Fugl-Meyer Assessment. Results: Post-RAS assessment of reaching kinematics revealed a significant (p < .05) decrease in compensatory trunk movement, increase in shoulder flexion, and a slight increase in elbow extension. Movement time and velocity significantly improved post RAS. Significant gains were observed on all functional assessments. Conclusions: Post RAS, participants demonstrated substantial decreases in compensatory reaching movements. These changes in motor control strategy were paralleled by gains in functional abilities, suggesting that reduced reliance on compensatory movements may translate to improved performance of daily activities.

Post–Cardiac Arrest Syndrome

The contributors to this statement were selected to ensure expertise in all the disciplines relevant to post–cardiac arrest care. In an attempt to make this document universally applicable and generalizable, the authorship comprised clinicians and scientists who represent many specialties in many regions of the world. Several major professional groups whose practice is relevant to post–cardiac arrest care were asked and agreed to provide representative contributors. Planning and invitations took place initially by e-mail, followed a series of telephone conferences and face-to-face meetings of the cochairs and writing group members. International writing teams were formed to generate the content of each section, which corresponded to the major subheadings of the final document. Two team leaders from different countries led each writing team. Individual contributors were assigned by the writing group cochairs to work on 1 or more writing teams, which generally reflected their areas of expertise. Relevant articles were identified with PubMed, EMBASE, and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Drafts of each section were written and agreed on by the writing team authors and then sent to the cochairs for editing and amalgamation into a single document. The first draft of the complete document was circulated among writing team leaders for initial comment and editing. A revised version of the document was circulated among all contributors, and consensus was achieved before submission of the final version for independent peer review and approval for publication. This scientific statement outlines current understanding and identifies knowledge gaps in the pathophysiology, treatment, and prognosis of patients who regain spontaneous circulation after cardiac arrest. The purpose is to provide a resource for optimization of post–cardiac arrest care and to pinpoint the need for research focused on gaps in knowledge that would potentially improve outcomes …

The New Injury Severity Score: Better Prediction of Functional Recovery after Musculoskeletal Injury

Objectives Injury Severity Score (ISS) is the most widely used method of assessing severity of injury in blunt trauma. It has been recognized that, by only allowing the score to consider the worst injury for each body system, ISS underestimates the problems of multiple musculoskeletal injuries. The New ISS (NISS) allows the three most severe injuries to be scored, irrespective of region affected, and may give better prediction of functional recovery in these patients. Methods A prospective cohort study of 200 patients with musculoskeletal injuries, examining the predictive value of ISS and NISS on functional recovery as measured by patient-derived outcome measures (Short Form-36, Sickness Impact Profile, and Musculoskeletal Function Assessment). Results NISS was greater than ISS in 34 patients (17%). NISS showed closer correlation with total scores and subscores of the outcomes measures than did ISS (Spearman's rho ranked test, P < 0.05). Conclusions NISS, a simple modification from ISS, better predicts functional outcomes in survivors of musculoskeletal trauma, and offers an improvement in the assessment of effectiveness of trauma care delivery.

Prediction of functional rehabilitation outcomes in clients with stroke

Objectives: To evaluate the validity of the Neurobehavioral Cognitive Status Examination (NCSE or Cognistat) and to determine its effects in order to estimate the functional outcomes of survivors with stroke.Methods: The present study first studied the factor structure NCSE in 148 Chinese survivors with stroke (aged 45–91 years). They were admitted to hospital consecutively and recruited prospectively. The relationship of NCSE with Functional Independence Measures (FIM), a set of measures commonly adopted as an indicator of the outcome of rehabilitation, was studied.Results: One hundred and forty-eight patients with stroke (49.3% male, 50.7% female), with a mean age of 70.38 and an average number of years of education of 3.50 years joined the study. A two-factor NCSE structure was obtained, namely verbal-spatial and integrated cognition, accounting for 62.77% of the variance. A significant relationship between NCSE factors and the functional status of clients with stroke on admission and upon discharge, as well as age, years of education and length of hospital stay were indicated.Conclusions: This study supports a systematic relationship between cognitive factors and functional outcome in Chinese patients with stroke. Similarities and differences in the NCSE factor structure between the population with stroke and general neurological populations were discussed and the utility of NCSE in stroke rehabilitation, such as its predictive validity in functional independence is suggested.

Vertigo with rebound nystagmus as an initial manifestation in a patient with basilar artery occlusion

Basilar artery occlusion (BAO) is generally associated with a high mortality rate and a poor functional outcome in survivors. Recently, we encountered a patient with BAO, initially manifesting as vertigo and rebound nystagmus, subsequently followed by bilateral sudden deafness and dysarthria and terminating in a coma state within an interval of 6 h. A review of his history showed he had had two episodes of transient vertigo 2 weeks before the major stroke, and the neurological decline of BAO was heralded by the vertiginous symptoms. Restated, patients with BAO often have transient vertiginous attacks preceding fatal stroke. Therefore, those with vertigo and nystagmus may be signaling a forthcoming stroke event, something that should be considered for clinicians seeing vertiginous patients.

Functional recovery following rehabilitation after hemorrhagic and ischemic stroke

Kelly PJ, Furie KL, Shafqat S, Rallis N, Chang Y, Stein J. Functional recovery following rehabilitation after hemorrhagic and ischemic stroke. Arch Phys Med Rehabil 2003;84:968–72. Objectives:To quantify recovery after rehabilitation therapy and to identify factors that predicted functional outcome in survivors of intracerebral hemorrhage (ICH) compared with cerebral infarction. Design:Retrospective study of consecutive ICH and cerebral infarction admissions to a rehabilitation hospital over a 4-year period. Setting:Free-standing urban rehabilitation hospital. Participants:A total of 1064 cases met the inclusion criteria (545 women, 519 men; 871 with cerebral infarction, 193 with ICH). Interventions:Not applicable. Main Outcome Measures:Functional status was measured using the FIM™ instrument, recorded at admission and discharge. Recovery was quantified by the change in FIM total score (ΔFIM total score). Outcome measures were total discharge FIM score and ΔFIM total score. Univariate and multivariate analyses were performed. Results:Total admission FIM score was higher in patients with cerebral infarction than in patients with ICH (59 vs 51, P=.0001). No difference in total discharge FIM score was present. Patients with ICH made a significantly greater recovery than those with cerebral infarction (ΔFIM total score, 28 vs 23.3; P=.002). On multivariate analysis, younger age, longer length of stay, and admission FIM cognitive subscore independently predicted total discharge FIM and ΔFIM total score. The severity of disability at admission, indicated by total admission FIM score, independently predicted total discharge FIM score, but not ΔFIM total score. The ICH patients with the most severely disabling strokes had significantly greater recovery than cerebral infarction patients with stroke of similar severity. Conclusions:The patients with ICH had greater functional impairment than the cerebral infarction patients at admission, but made greater gains. Patients with the most severely disabling ICH improved more than those with cerebral infarction of comparable severity. Initial severity of disability, age, and duration of therapy best predicted functional outcome after rehabilitation.

Corticosteroids for acute ischaemic stroke.

Much of the brain swelling in ischaemic stroke is due to cytotoxic oedema, which is related to cell membrane dysfunction. Early treatment with corticosteroids may help reduce the swelling and improve the outcomes after a stroke. The objective of this review was to assess the effect of corticosteroids in acute presumed ischaemic stroke. We searched the Cochrane Stroke Group trials register (last searched: 10 April 2001) and contacted investigators in the field. Published randomised trials comparing corticosteroids with placebo or control in people with acute (presumed or definite) ischaemic stroke. Trials were included if treatment began within 48 hours of stroke onset and if clinical outcome was assessed. Two reviewers independently applied the inclusion criteria, assessed trial quality and extracted the data. Seven trials involving 453 people were included. Details of trial quality that may relate to bias were not available from most trials. No difference was shown in the odds of death within one year (odds ratio 1.08, 95% confidence interval 0.68 to 1.72). Treatment did not appear to improve functional outcome in survivors. Six trials reported neurological impairment but pooling the data was impossible because no common scale or time interval was used. The results were inconsistent between individual trials. The only adverse effects reported were small numbers of gastrointestinal bleeds, infections and deterioration of hyperglycaemia across both groups. Results unchanged since last update. There is not enough evidence to evaluate corticosteroid treatment for people with acute presumed ischaemic stroke. Conclusions unchanged since last update.

Treatment for displaced intracapsular fracture of the proximal femur

We performed a prospective, randomised trial comparing three treatments for displaced intracapsular fractures of the hip in 280 patients aged 65 to 79 years. The mean patient survival was significantly higher in the group undergoing reduction and internal fixation (79 months) compared with that with a cemented Thompson hemiarthroplasty or a cemented Monk bipolar hemiarthroplasty (61 months and 68 months, respectively). After three years, 32 of 93 patients (34.4%) who had undergone fixation had local complications, necessitating further intervention in 28 (30%). There were no significant differences in the functional outcome in survivors, who were reviewed annually to five years. Either reduction and internal fixation or cemented hemiarthroplasty may be offered as alternative treatments for a displaced intracapsular fracture in a mobile and mentally competent patient under the age of 80 years. The choice of procedure by the patient and the surgeon should be determined by the realisation that the use of internal fixation is associated with a 30% risk of failure requiring further surgery. If this is accepted, however, hemiarthroplasty is avoided, which, in our study has a significantly shorter mean survival time. The use of a bipolar prosthesis has no significant advantage.

Low-molecular-weight heparins or heparinoids versus standard unfractionated heparin for acute ischaemic stroke.

Low molecular weight heparins and heparinoids may be associated with lower risks of haemorrhage and more powerful antithrombotic effects than standard unfractionated heparin. The objective of this review was to compare the effects of low molecular weight heparins or heparinoids with those of unfractionated heparin in people with acute confirmed or presumed ischaemic stroke. We searched the Cochrane Stroke Group trials register and MedStrategy (1995). We also contacted pharmaceutical companies. Date of most recent search: May 2001. Randomised trials comparing heparinoids or low molecular weight heparins with standard unfractionated heparin in people with acute ischaemic stroke. Only trials where treatment was started within 14 days of stroke onset were included. Two reviewers independently selected studies for inclusion, assessed trial quality and extracted the data. Five trials involving 705 people were included. Four trials compared a heparinoid (danaparoid), and one compared a low molecular weight heparin (enoxaparin), with standard unfractionated heparin. Overall, 55/414 (13%) of the patients allocated danaparoid or enoxaparin had deep vein thrombosis compared with 65/291 (22%) of those allocated unfractionated heparin. This reduction was significant (odds ratio 0.52, 95% confidence interval 0.56 - 0.79). However, the number of more major events (pulmonary embolism, death, intra-cranial or extra-cranial haemorrhage) was too small to provide a reliable estimate of more important benefits and risks. No information was reported for recurrent stroke or functional outcome in survivors. Low molecular weight heparin or heparinoid appear to decrease the occurrence of deep vein thrombosis compared to standard unfractionated heparin, but there are too few data to provide reliable information on their effect on other important outcomes, including death and intracranial haemorrhage.

Treatment for displaced intracapsular fracture of the proximal femur

We performed a prospective, randomised trial comparing three treatments for displaced intracapsular fractures of the hip in 280 patients aged 65 to 79 years. The mean patient survival was significantly higher in the group undergoing reduction and internal fixation (79 months) compared with that with a cemented Thompson hemiarthroplasty or a cemented Monk bipolar hemiarthroplasty (61 months and 68 months, respectively). After three years, 32 of 93 patients (34.4%) who had undergone fixation had local complications, necessitating further intervention in 28 (30%). There were no significant differences in the functional outcome in survivors, who were reviewed annually to five years. Either reduction and internal fixation or cemented hemiarthroplasty may be offered as alternative treatments for a displaced intracapsular fracture in a mobile and mentally competent patient under the age of 80 years. The choice of procedure by the patient and the surgeon should be determined by the realisation that the use of internal fixation is associated with a 30% risk of failure requiring further surgery. If this is accepted, however, hemiarthroplasty is avoided, which, in our study has a significantly shorter mean survival time. The use of a bipolar prosthesis has no significant advantage.

Relationship between Glasgow coma scale and functional outcome.

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.

Does hyperglycaemia play a role on the outcome of acute ischaemic stroke patients?

A consecutive series of 327 patients (188 males, 139 females; mean age 68.4, SEM 1.33) were hospitalized within 12 h of the onset of their first-ever hemispheric infarct. Three groups of patients were identified: diabetics (n = 70), non-diabetic hyperglycaemics (n = 93) and normoglycaemics (n = 164). Case-fatality ratios at 30 days after stroke were 38.6%, 22.6% and 9.2% (P less than 0.001) respectively, whereas the causes of death and functional outcome of survivors were not significantly different between the groups. Mean admission serum glucose levels (SGLs) of decreased, impaired/unchanged and improved patients within each one of the three groups, were also not significantly different as opposed to their mean Canadian Neurological Scale (CNS) scores at entry (P less than 0.01). Among patients with less severe initial neurological deficit (i.e., CNS score greater than or equal to 7.0), 82.6% of non-diabetic hyperglycaemic subjects fared well, in comparison with 56.5% of diabetic and 70.1% of normoglycaemic individuals. The size of the infarcted areas at the second CT correlated with mean CNS scores (P less than 0.01) but not with mean SGLs on admission. The site of the ischaemic areas did not correlate with mean SGLs at entry. Therefore the influence of initial SGLs on the clinical course of the present series of patients is questionable or, alternatively, varied probably according to the pattern of residual cerebral blood flow after arterial occlusion.

Sudden Bilateral Deafness

Basilar artery occlusion is associated with a high mortality rate and poor functional outcome in survivors. The most common prodromal symptoms are motor and oculomotor deficits. Hearing loss is not a major prodromal symptom. Sudden deafness usually results from either circulatory disturbances or inflammation. Deafness of vascular etiology generally occurs unilaterally. Occlusion of basilar arterial origin suggests that thrombosis is the primary mechanism of stroke, especially in elderly patients. This case highlights the importance of hearing loss as either a main manifestation or a warning of impending brainstem ischemia. Clinicians should be aware of the possibility of vertebrobasilar ischemia in patients with bilateral sudden deafness, even when classic brainstem or cerebellar signs are mild or absent. This case also highlights the importance of prodromal signs and symptoms.