Nonlacunar Stroke Research Articles

Atherosclerotic Plaque Ulceration in the Symptomatic Internal Carotid Artery Is Associated With Nonlacunar Ischemic Stroke

Atherosclerotic carotid plaque ulceration is considered a marker of previous plaque rupture and subsequent thromboembolism. It can be accurately detected with multidetector CTA. We hypothesized that atherosclerotic plaque ulceration is associated with nonlacunar ischemic stroke rather than lacunar stroke. Prospectively, 750 consecutive patients with transient ischemic attack or ischemic stroke symptoms in the anterior cerebral circulation were evaluated for the presence of atherosclerotic plaque ulceration in the symptomatic carotid artery with multidetector CTA. Patients with stroke attributable to cardiac embolism or other specific etiologies and patients with amaurosis fugax were excluded. Ischemic strokes in the remaining 534 patients were classified as nonlacunar (n=236) or lacunar (n=298) based on clinical symptoms and multidetector CT of the brain. Ulceration was defined as extension of contrast material beyond the vascular lumen into the surrounding plaque. Plaque ulceration in the symptomatic carotid artery was more common in nonlacunar strokes (n=47; 20%) as compared to lacunar strokes (n=20; 7%; P<0.001). After adjustment for age, gender, cardiovascular risk factors, and degree of stenosis, ulcerations were independently associated with nonlacunar stroke compared to lacunar stroke (odds ratio, 2.70; 95% confidence interval, 1.43-5.09). Atherosclerotic carotid plaque ulceration is associated with nonlacunar ischemic stroke, independent of the degree of carotid stenosis. These results suggest that nonlacunar stroke and lacunar stroke are caused by different pathophysiological mechanisms.

A Systematic Review of Dynamic Cerebral and Peripheral Endothelial Function in Lacunar Stroke Versus Controls

The etiology of cerebral small vessel disease is unknown. An association with endothelial dysfunction has been suggested. We systematically assessed all relevant studies of dynamic endothelial function in patients with lacunar stroke as a marker of small vessel disease. We searched for studies of cerebral or peripheral vascular reactivity in patients with lacunar or cortical (ie, large artery atheromatous) ischemic stroke or nonstroke control subjects. We calculated standardized mean difference (SMD) in vascular reactivity+/-95% CIs between small vessel disease and control groups. Sixteen publications (974 patients) were included. In lacunar stroke, cerebrovascular reactivity (n=534) was reduced compared with age-matched normal (SMD -0.94, 95% CI -1.17 to -0.70), but not age+risk factor-matched control subjects (SMD 0.08, 95% CI -0.36 to 0.53) or cortical strokes (SMD -0.29, 95% CI -0.69 to 0.11); forearm flow-mediated dilatation (n=401) was reduced compared with age-matched normal control subjects (SMD -1.04, 95% CI -1.33 to -0.75) and age+risk factor-matched control subjects (SMD -0.94, 95% CI -1.26 to -0.61), but not cortical strokes (SMD -0.23, 95% CI -0.55 to 0.08). Endothelial dysfunction is present in patients with lacunar stroke but may simply reflect exposure to vascular risk factors and having a stroke, because a similar degree of dysfunction is found in cortical (large artery atheromatous) stroke. Current data do not confirm that endothelial dysfunction is specific to small vessel stroke. Future studies should include control subjects with nonlacunar stroke.

Mean Platelet Volume in the Early Phase of Acute Ischemic Stroke Is Not Associated with Severity or Functional Outcome

Background: Previous studies reported an increase of mean platelet volume (MPV) in patients with acute ischemic stroke. However, its correlation with stroke severity has not been investigated. Moreover, studies on the association of MPV with functional outcome yielded inconsistent results. Methods: We included all consecutive ischemic stroke patients admitted to CHUV (Centre Hospitalier Universitaire Vaudois) Neurology Service within 24 h after stroke onset who had MPV measured on admission. The association of MPV with stroke severity (NIHSS score at admission and at 24 h) and outcome (Rankin Scale score at 3 and 12 months) was analyzed in univariate analysis. The χ² test was performed to compare the frequency of minor strokes (NIHSS score ≤4) and good functional outcome (Rankin Scale score ≤2) across MPV quartiles. The ANOVA test was used to compare MPV between stroke subtypes according to the TOAST classification. Student’s two-tailed unpaired t test was performed to compare MPV between lacunar and nonlacunar strokes. MPV was generated at admission by the Sysmex XE-2100 automated cell counter (Sysmex Corporation, Kobe, Japan) from EDTA blood samples. Results: There was no significant difference in the frequency of minor strokes (p = 0.46) and good functional outcome (p = 0.06) across MPV quartiles. MPV was not associated with stroke severity or outcome in univariate analysis. There was no significant difference in MPV between stroke subtypes according to the TOAST classification (p = 0.173) or between lacunar and nonlacunar strokes (10.50 ± 0.91 vs. 10.40 ± 0.81 fl, p = 0.322). Conclusions: MPV, assessed within 24 h after ischemic stroke onset, is not associated with stroke severity or functional outcome.

Differing Risk Factor Profiles of Ischemic Stroke Subtypes

Differences in risk factor profiles between lacunar and other ischemic stroke subtypes may provide evidence for a distinct lacunar arteriopathy, but existing studies have limitations. We overcame these by pooling individual data on 2875 patients with first-ever ischemic stroke from 5 collaborating prospective stroke registers that used similar, unbiased methods to define risk factors and classify stroke subtypes. We compared risk factors between lacunar and nonlacunar ischemic strokes, altering the comparison groups in sensitivity analyses, and incorporated these data into a meta-analysis of published studies. Unadjusted and adjusted analyses gave similar results. We found a lower prevalence of cardioembolic source (adjusted odds ratio, 0.33; 95% CI, 0.24 to 0.46), ipsilateral carotid stenosis (odds ratio, 0.21; 95% CI, 0.14 to 0.30), and ischemic heart disease (odds ratio, 0.75; 95% CI, 0.58 to 0.97) in lacunar compared with nonlacunar patients but no difference for hypertension, diabetes, or any other risk factor studied. Results were robust to sensitivity analyses and largely confirmed in our meta-analysis. Hypertension and diabetes appear equally common in lacunar and nonlacunar ischemic stroke, but lacunar stroke is less likely to be caused by embolism from the heart or proximal arteries, and the lower prevalence of ischemic heart disease in lacunar stroke provides additional support for a nonatherosclerotic arteriopathy causing many lacunar ischemic strokes. Our findings have implications for how clinicians classify ischemic stroke subtypes and highlight the need for additional research into the specific causes of and treatments for lacunar stroke.

Toward fully automated processing of dynamic susceptibility contrast perfusion MRI for acute ischemic cerebral stroke

We developed fully automated software for dynamic susceptibility contrast (DSC) MR perfusion-weighted imaging (PWI) to efficiently and reliably derive critical hemodynamic information for acute stroke treatment decisions. Brain MR PWI was performed in 80 consecutive patients with acute nonlacunar ischemic stroke within 24 h after onset of symptom from January 2008 to August 2009. These studies were automatically processed to generate hemodynamic parameters that included cerebral blood flow and cerebral blood volume, and the mean transit time (MTT). To develop reliable software for PWI analysis, we used computationally robust algorithms including the piecewise continuous regression method to determine bolus arrival time (BAT), log-linear curve fitting, arrival time independent deconvolution method and sophisticated motion correction methods. An optimal arterial input function (AIF) search algorithm using a new artery-likelihood metric was also developed. Anatomical locations of the automatically determined AIF were reviewed and validated. The automatically computed BAT values were statistically compared with estimated BAT by a single observer. In addition, gamma-variate curve-fitting errors of AIF and inter-subject variability of AIFs were analyzed. Lastly, two observes independently assessed the quality and area of hypoperfusion mismatched with restricted diffusion area from motion corrected MTT maps and compared that with time-to-peak (TTP) maps using the standard approach. The AIF was identified within an arterial branch and enhanced areas of perfusion deficit were visualized in all evaluated cases. Total processing time was 10.9 ± 2.5 s (mean ± s.d.) without motion correction and 267 ± 80 s (mean ± s.d.) with motion correction on a standard personal computer. The MTT map produced with our software adequately estimated brain areas with perfusion deficit and was significantly less affected by random noise of the PWI when compared with the TTP map. Results of image quality assessment by two observers revealed that the MTT maps exhibited superior quality over the TTP maps (88% good rating of MTT as compared to 68% of TTP). Our software allowed fully automated deconvolution analysis of DSC PWI using proven efficient algorithms that can be applied to acute stroke treatment decisions. Our streamlined method also offers promise for further development of automated quantitative analysis of the ischemic penumbra.

Associations of obesity measures with subtypes of ischemic stroke in the ARIC Study.

BackgroundAssociations between obesity and lacunar, nonlacunar thrombotic, and cardioembolic stroke are not firmly established.MethodsBody mass index (BMI), waist circumference, and waist-to-hip ratio (WHR) were recorded at baseline between 1987 and 1989 in the Atherosclerosis Risk in Communities (ARIC) Study for 13 549 black and white adults who were aged from 45 to 64 years and had no history of cardiovascular disease or cancer. The incidence of ischemic stroke subtypes was ascertained from surveillance of hospital records over a median follow-up of 16.9 years. Cox proportional hazards regression analyses adjusted for age, sex, race, education, smoking status and cigarette years, usual ethanol intake, and leisure time sports index were used to estimate hazard ratios (HRs).ResultsThe ARIC sample at baseline was 43.8% men and 27.3% blacks; mean age was 53.9 years. Mean BMI, waist circumference, and WHR were 27.7 kg/m2, 96.8 cm, and 0.92, respectively. The associations of lacunar (n = 138), nonlacunar (n = 338), and cardioembolic (n = 122) ischemic stroke incidence with obesity measures were all generally positive and linear. The HRs for the highest versus lowest quintile of the 3 obesity measures ranged from 1.43–2.21 for lacunar stroke, 1.90–2.16 for nonlacunar stroke, and 2.37–2.91 for cardioembolic stroke.ConclusionsAlthough different pathophysiological mechanisms may exist, the incidences of lacunar, nonlacunar, and cardioembolic stroke were all significantly positively associated with the degree of obesity, regardless of the measure used.

Differences Between Ischemic Stroke Subtypes in Vascular Outcomes Support a Distinct Lacunar Ischemic Stroke Arteriopathy

Whether and how the arterial pathology underlying lacunar ischemic stroke differs from the atherothrombotic processes causing most other ischemic strokes is still debated. Different risks of recurrent stroke and MI after lacunar versus nonlacunar ischemic stroke may support a distinct lacunar arteriopathy. We prospectively followed a hospital-based cohort of 809 first-ever ischemic stroke patients for 1 to 4 years. We compared risks of death, recurrent stroke, and MI in patients with lacunar versus nonlacunar stroke, and performed an updated meta-analysis of recurrent stroke subtype patterns. During 1725 person-years of follow-up, 109 patients had a recurrent stroke and 31 had MI. All patients at baseline, and 93% with recurrent stroke, had brain imaging and more than half with recurrent stroke had diffusion-weighted MRI. Overall, there was no difference in recurrence risk after lacunar vs nonlacunar stroke, although there was a trend toward a lower recurrence risk in the early weeks after lacunar stroke. Lacunar recurrence was more likely after lacunar than nonlacunar stroke (OR, 6.5; 95% CI, 2.4-17.5; updated meta-analysis OR, 6.8; 95% CI, 4.2-11.2). MI risk was nonsignificantly lower after lacunar than nonlacunar stroke (rate ratio, 0.5; 95% CI, 0.2-1.1; rate ratio after excluding patients with previous ischemic heart disease: 0.3; 95% CI, 0.1-0.9). Our finding of a trend toward a lower MI risk after lacunar vs nonlacunar stroke and confirmation of both a lower early recurrence risk after lacunar stroke and a tendency of recurrent stroke subtypes to "breed true" support the notion of a distinct nonatherothrombotic lacunar arteriopathy.

Low protein C and incidence of ischemic stroke and coronary heart disease: the Atherosclerosis Risk in Communities (ARIC) Study.

Protein C is an important plasma natural anticoagulant. Although protein C deficiency increases risk of venous thrombosis, it remains uncertain whether low protein C increases risk of atherothrombosis. To examine whether low protein C may be a risk factor for ischemic stroke or coronary events in a prospective population-based study. The Atherosclerosis Risk in Communities Study assessed protein C antigen by ELISA at baseline in 1987-89 and followed participants (n = 13 879) for incident ischemic stroke or coronary events through 2005. Over a median of 16.9 years of follow-up, 613 ischemic strokes and 1257 coronary heart disease events occurred. Protein C was inversely associated with incidence of ischemic stroke. Adjusted for multiple risk factors, the rate ratios (95% CIs) from highest to lowest quintiles were 1.0, 1.16 (0.90-1.50), 1.22 (0.94-1.58), 1.18 (0.90-1.55) and 1.52 (1.17-1.98). This inverse association was stronger for non-lacunar and cardioembolic stroke than for lacunar stroke. In contrast, there was a positive association between protein C and coronary heart disease in incompletely adjusted models, but no association after adjustment for plasma lipids. In this cohort study, low protein C was a risk factor for incident ischemic stroke but not coronary heart disease. Levels of protein C associated with stroke risk were not restricted to the traditional 'deficient' range for protein C (< 0.5 percentile), suggesting that other etiologies for a lower protein C, or genetic variants associated with more subtle changes in protein C, are playing a role in disease pathogenesis.

Abnormal Blood Pressure Circadian Rhythm in Acute Ischaemic Stroke: are Lacunar Strokes Really Different?

A pathologically reduced or abolished circadian blood pressure variation has been described in acute stroke. However, studies on alterations of circadian blood pressure patterns after stroke and stroke subtypes are scarce. The objective of this study was to evaluate the changes in circadian blood pressure patterns in patients with acute ischaemic stroke and their relation to the stroke subtype. We studied 98 consecutive patients who were admitted within 24 h after ischaemic stroke onset. All patients had a detailed clinical examination, laboratory studies and a CT scan study of the brain on admission. To study the circadian rhythm of blood pressure, a continuous blood pressure monitor (Spacelab 90217) was used. Patients were classified according to the percentage fall in the mean systolic blood pressure or diastolic blood pressure at night compared with during the day as: dippers (fall> or =10-20%); extreme dippers (> or =20%); nondipper (<10%); and reverse dippers (<0%, that is, an increase in the mean nocturnal blood pressure compared with the mean daytime blood pressure). Data were separated and analysed in two groups: lacunar and nonlacunar infarctions. Statistical testing was conducted using the SSPS 12.0. Methods We studied 60 males and 38 females, mean age: 70.5+/-11 years. The patient population consisted of 62 (63.2%) lacunar strokes and 36 (36.8%) nonlacunar strokes. Hypertension was the most common risk factor (67 patients, 68.3%). Other risk factors included hypercholesterolaemia (44 patients, 44.8%), diabetes mellitus (38 patients, 38.7%), smoking (24 patients, 24.8%) and atrial fibrillation (19 patients, 19.3%). The patients with lacunar strokes were predominantly men (P=0.037) and had a lower frequency of atrial fibrillation (P=0.016) as compared with nonlacunar stroke patients. In the acute phase, the mean systolic blood pressure was 136+/-20 mmHg and diastolic blood pressure was 78.7+/-11.8. Comparing stroke subtypes, there were no differences in 24-h systolic blood pressure and 24-h diastolic blood pressure between patients with lacunar and nonlacunar infarction. However, patients with lacunar infarction showed a mean decline in day-night systolic blood pressure and diastolic blood pressure of approximately 4 mmHg [systolic blood pressure: 3.9 (SD 10) mmHg, P=0.003; diastolic blood pressure 3.7 (SD 7) mmHg, P=0.0001] compared with nonlacunar strokes. Nonlacunar strokes showed a lack of 24-h nocturnal systolic blood pressure and diastolic blood pressure fall. The normal diurnal variation in systolic blood pressure was abolished in 87 (88.9%) patients, and the variation in diastolic blood pressure was abolished in 76 (77.5%) patients. On comparing lacunar and nonlacunar strokes, we found that the normal diurnal variation in systolic blood pressure was abolished in 53 (85.4%) lacunar strokes and in 34 (94.4%) nonlacunar strokes (P=nonsignificant). In terms of diurnal variation in diastolic blood pressure, it was abolished in 43 (69.3%) lacunar strokes and in 33 (91.6%) nonlacunar strokes (P=0.026). Our results show clear differences in the blood pressure circadian rhythm of acute ischaemic stroke between lacunar and nonlacunar infarctions by means of 24-h blood pressure monitoring. The magnitude of nocturnal systolic and diastolic blood pressure dip was significantly higher in lacunar strokes. Besides, patients with lacunar strokes presented a higher percentage of dipping patterns in the diastolic blood pressure circadian rhythm. Therefore, one should consider the ischaemic stroke subtype when deciding on the management of blood pressure in acute stroke.

An analysis of Methylenetetrahydrofolate reductase and Glutathione S-transferase omega-1 genes as modifiers of the cerebral response to ischemia

BackgroundCerebral ischemia involves a series of reactions which ultimately influence the final volume of a brain infarction. We hypothesize that polymorphisms in genes encoding proteins involved in these reactions could act as modifiers of the cerebral response to ischemia and impact the resultant stroke volume. The final volume of a cerebral infarct is important as it correlates with the morbidity and mortality associated with non-lacunar ischemic strokes.MethodsThe proteins encoded by the methylenetetrahydrofolate reductase (MTHFR) and glutathione S-transferase omega-1 (GSTO-1) genes are, through oxidative mechanisms, key participants in the cerebral response to ischemia. On the basis of these biological activities, they were selected as candidate genes for further investigation. We analyzed the C677T polymorphism in the MTHFR gene and the C419A polymorphism in the GSTO-1 gene in 128 patients with non-lacunar ischemic strokes.ResultsWe found no significant association of either the MTHFR (p = 0.72) or GSTO-1 (p = 0.58) polymorphisms with cerebral infarct volume.ConclusionOur study shows no major gene effect of either the MTHFR or GSTO-1 genes as a modifier of ischemic stroke volume. However, given the relatively small sample size, a minor gene effect is not excluded by this investigation.

Lesion neuroanatomy of the Sustained Attention to Response task

The Sustained Attention to Response task is a classical neuropsychological test that has been used by many centres to characterize the attentional deficits in traumatic brain injury, ADHD, autism and other disorders. During the SART a random series of digits 1-9 is presented repeatedly and subjects have to respond to each digit (go trial) except the digit '3' (no-go trial). Using voxel-based lesion symptom mapping (VLSM) in a consecutive series of 44 ischemic unifocal non-lacunar hemispheric stroke patients we determined the neuroanatomy of 4 SART parameters: commission and omission error rate, reaction time variability and post-error slowing. Lesions of the right inferior frontal gyrus significantly increased commission error rate. Lesions of the middle third of the right inferior frontal sulcus (IFS) reduced post-error slowing, a measure of how well subjects can utilize errors to adjust cognitive resource allocation. Omissions and reaction time variability had less localising value in our sample. To conclude, commission errors and post-error slowing in the SART mainly probe right inferior frontal integrity.

Hemostasis system condition and endothelium functions during various pathogenesis types of ischemic strokes in the acute and regenerative periods

It is revealed, that pathological changes in the plasmatic and platelets-vascular part of a hemostasis are expressed to a lesser degree in the acute period of the lacunar stroke in comparison with a nonlacunar stroke. Safety of antithrombotic properties of a vascular wall in the given subgroup is confirmed. Dis - tinctions in the hemostasis profile of various pathogenesis types of strokes disappear in the early regenerative period of stroke, lasting haemostatic activation with hyperfirinogenemia, and increase in markers of thrombosis, strengthening of spontaneous platelet’s aggregation, as well as increase of level of a marker endothelium dysfunction remains with the expressed decrease in reactance endothelium.

CD40 Ligand and MCP-1 as Predictors of Cardiovascular Events in Diabetic Patients with Stroke

Up-regulation of soluble CD40 ligand (sCD40L) and of monocyte chemoattractant protein-1 (MCP-1) has been found in diabetes and in patients with acute cerebral ischemia. We asked whether (i) the two molecules are similarly upregulated among non-lacunar and lacunar diabetic strokes and (ii) sCD40L and/or MCP-1 predict the risk of cardiovascular events in this setting. Ninety patients with type 2 diabetes mellitus presenting with an acute ischemic stroke (compared with 45 control subjects) were evaluated on admission and up to 36 months (median 24 months) after the event. Diabetic patients with acute stroke had higher plasma CD40L and MCP-1 than controls (p<0.0001), with no significant differences among lacunar and non-lacunar strokes. On multiple regression analysis, only higher sCD40L quartiles and older age were associated with higher MCP-1 quartiles. Forty-eight percent of patients experienced vascular events. Cox regression analysis showed that only the presence of higher sCD40L values independently predicted the recurrence of vascular events. Up-regulation of inflammatory molecules, such as CD40L and MCP-1, is involved in the advanced stage of atherosclerotic cerebro-vascular disease and is associated with increased risk of recurrence of cardiovascular events.

Weather as a Trigger of Stroke

Background: The conclusions of previous studies show little agreement concerning the relationship between weather and the incidence of stroke. We analyse the relationship between daily meteorological conditions and daily as well as seasonal stroke incidence. Methods: 1,286 consecutive strokes assessed during 3 years (2001–2003) from the reference area of Hospital del Mar were classified as intracerebral haemorrhage (ICH) (n = 243) or ischaemic stroke (IS) (n = 1,043). IS was divided in non-lacunar stroke (NLS) (n = 732) and lacunar stroke (LS) (n = 311). Daily meteorological data were obtained from ‘Observatori Fabra’ of Barcelona: atmospheric pressure (AP), relative humidity, maximum, minimum, and mean temperatures, and the variation of all these measures compared with the previous day. Results: Total stroke (TS) incidence showed little association with AP (coefficient of confidence, CC: –0.072; p = 0.022), but was higher with the AP variations (CC: 0.127; p < 0.001). NLS were related to AP falls (OR: 2.41; p < 0.001) whilst ICHs were associated with AP rises (OR: 2.07; p = 0.01). NLS and temperature showed an inverse correlation; however, it lost its significance after adjusting for AP variations. The daily incidences of NLS and ICH were higher in autumn and in winter, but depended strongly on the daily variations of AP. No other associations were found. Conclusions: The incidences of NLS and ICH are related to AP changes compared with the previous day. AP changes largely explain the seasonal and daily variations in the incidence of stroke. These data may help to explain the controversy in previous studies and to promote studies focused on the trigger mechanisms of stroke.

Is it possible to define salvageable ischemic penumbra using semiquantitative rCBF levels derived from MR perfusion-weighted imaging?

The purpose of this study was to test if magnetic resonance (MR) perfusion-weighted imaging (PWI) can reliably characterize the ischemic penumbra. Sixteen patients with nonlacunar ischemic stroke who were scanned within 24 h after onset of symptoms were selected for the study. In previous studies, the level of regional cerebral blood flow (rCBF) in the normal white matter of the contralateral hemisphere was defined as 22 ml/100 g/min. We used this level as a standard of reference. We hypothesized that rCBF below this level would be amenable to infarct. The lesion-to-white matter ratios of rCBF were measured in the regions of ischemic core ("Core"), infarcted penumbra ("Growth"), salvaged penumbra ("Reversed"), and contralateral normal cortex ("Normal"). The rCBF of "Growth" and "Reversed" areas showed substantial overlap, which hampered the delineation of areas that would become infarcted. The semiquantitative rCBF derived from MR PWI may not accurately characterize the ischemic penumbra.

Wagging the dog‐moving closer to features defined by basic scientists, the protection of prodromal transient ischaemic attacks reveals itself

Wagging the dog‐moving closer to features defined by basic scientists, the protection of prodromal transient ischaemic attacks reveals itself

Preventive Antibacterial Therapy in Acute Ischemic Stroke: A Randomized Controlled Trial

BackgroundPneumonia is a major risk factor of death after acute stroke. In a mouse model, preventive antibacterial therapy with moxifloxacin not only prevents the development of post-stroke infections, it also reduces mortality, and improves neurological outcome significantly. In this study we investigate whether this approach is effective in stroke patients.MethodsPreventive ANtibacterial THERapy in acute Ischemic Stroke (PANTHERIS) is a randomized, double-blind, placebo-controlled trial in 80 patients with severe, non-lacunar, ischemic stroke (NIHSS>11) in the middle cerebral artery (MCA) territory. Patients received either intravenous moxifloxacin (400 mg daily) or placebo for 5 days starting within 36 hours after stroke onset. Primary endpoint was infection within 11 days. Secondary endpoints included neurological outcome, survival, development of stroke-induced immunodepression, and induction of bacterial resistance.FindingsOn intention-to treat analysis (79 patients), the infection rate at day 11 in the moxifloxacin treated group was 15.4% compared to 32.5% in the placebo treated group (p = 0.114). On per protocol analysis (n = 66), moxifloxacin significantly reduced infection rate from 41.9% to 17.1% (p = 0.032). Stroke associated infections were associated with a lower survival rate. In this study, neurological outcome and survival were not significantly influenced by treatment with moxifloxacin. Frequency of fluoroquinolone resistance in both treatment groups did not differ. On logistic regression analysis, treatment arm as well as the interaction between treatment arm and monocytic HLA-DR expression (a marker for immunodepression) at day 1 after stroke onset was independently and highly predictive for post-stroke infections.InterpretationPANTHERIS suggests that preventive administration of moxifloxacin is superior in reducing infections after severe non-lacunar ischemic stroke compared to placebo. In addition, the results emphasize the pivotal role of immunodepression in developing post-stroke infections.Trial RegistrationControlled-Trials.com ISRCTN74386719

Mean platelet volume (MPV) increase during acute non-lacunar ischemic strokes

Introduction Mean platelet volume (MPV) has been associated with the prognosis in stroke patients. However, its spontaneous variability during the acute phase of the disease is unknown. Materials and Methods — One hundred and thirty-seven patients with ischemic stroke, aged 75.4 ± 11.0 (SD) years, were classified according to several criteria: National Institutes of Health Stroke Scale (NIHSS) score, maximum lesion diameter on CT scan, Oxfordshire Community Stroke Projects (OCSP) and Trial of ORG 10172 in Acute Stroke Treatment (TOAST) categories. Platelet parameters were determined 1.2 days after the onset of symptoms, and after 3.0 further days. Results The initial MPV was higher in non-lacunar than lacunar strokes (8.30 ± 1.10 vs. 7.95 ± 0.79 fl, P = 0.04), and correlated with the sampling delay with respect to the onset of symptoms, especially in the strokes with lesions > = 4 cm (r = 0.39, P = 0.009), NIHSS > = 11 (r = 0.35, P = 0.02) and of cardioembolic origin (r = 0.35, P = 0.01). Subsequently a late MPV increment was observed in the remaining categories: from 8.20 to 8.38 fl (P = 0.02) in the strokes with lesions < 4 cm, from 8.11 to 8.31 fl (P = 0.01) in the presence of an NIHSS < 11 and from 8.20 to 8.61 fl (P = 0.03) when the occlusion of a large artery was involved. Conclusions Platelet volume is not stable during the acute phase in non-lacunar ischemic strokes, as it increases early in the most severe forms, and later in the remaining subtypes. The release of large and more reactive platelets may contribute to the thrombophilic state associated with ischemic events.

Trends in Incidence, Risk Factors, and Survival in Symptomatic Lacunar Stroke in Dijon, France, From 1989 to 2006

Lacunar infarcts are usually regarded as benign stroke, but population-based studies are required to assess the exact place of this stroke subtype in cerebrovascular pathology. We evaluated trends in incidence rates, risk factor profiles, and survival rates in symptomatic lacunar stroke from a prospective population-based registry from 1989 to 2006. We recorded 2536 ischemic strokes. Among these, 715 (28%) were lacunar infarcts (354 men and 361 women). From 1989 to 2006, we observed a significant rise in the incidence of lacunar stroke in the 2 sexes considered together (relative risk, 1.02; 95% CI, 1.005 to 1.035; P=0.007), whereas the variation was not significant in either men or women when considered separately. Incidence rates significantly increased in young patients under 65 years old (relative risk, 1.049; 95% CI, 1.0175 to 1.0817; P=0.002). Concerning the distribution of cerebrovascular risk factors, lacunar stroke differed from nonlacunar stroke only with regard to the lower prevalence of a history of atrial fibrillation in the former (P<0.001). For lacunar infarcts, survival rates were 96% at 1 month (95% CI, 0.94 to 0.97), 86% at 1 year (95% CI, 0.83 to 0.89), and 78% at 2 years (95% CI, 0.75 to 0.81) and were significantly higher than those for nonlacunar stroke (hazard ratio, 2.05; 95% CI, 1.70 to 2.47; P<0.001). Our results suggest a significant increase in the incidence rates of lacunar stroke with a relatively good short-term prognosis in terms of survival. The association among hypertension, diabetes mellitus, and lacunar stroke was no stronger than the association between these 2 risk factors and nonlacunar stroke.

Transesophageal Echocardiography Findings in Lacunar Stroke

Transesophageal echocardiography (TEE) constitutes a valuable tool in patients with stroke and cardiac embolization, but its indication is controversial in lacunar stroke. The purpose of this study was to assess the findings of TEE in lacunar stroke. Initial symptoms, brain computed tomography or magnetic resonance imaging, and TEE were performed for all patients with ischemic stroke admitted consecutively to our department of neurology. The subtype of ischemic stroke (lacunar v large-vessel stroke) was also reviewed. In all, 124 patients with ischemic stroke were identified and lacunar syndrome occurred in 46. Major risk factor of embolization in patients with lacunar stroke and indication for anticoagulation were detected in 20% (9 of 46). We compared findings in both groups (lacunar v nonlacunar stroke) to evaluate the differences in the presence of major risk factor for embolization, Chi square = 0.07, P = .8 (odds ratio 95% CI = 0.35-2.18). Characteristics of the 9 patients with lacunar stroke and major risk of embolization show that history of lacunar ischemic stroke was present in all the patients of this group. The results of the study suggest that TEE may be necessary to obtain a complete evaluation to optimize preventive treatment in patients with clinical and radiologic presentation that suggest lacunar infarct, particularly in cases with a history of ischemic stroke, in which a potential cardiac source of embolization may be detected.