Onset Of Cerebrovascular Disease Research Articles

Impact of early refined nursing program on prognosis of middle-aged and elderly patients with cognitive dysfunction combined with cerebral infarction.

Cerebral infarction is a local or extensive necrosis of brain tissue. Subsequently, the corresponding neurological deficits appear. The incidence of cerebrovascular diseases in China is increasing gradually. After the onset of cerebrovascular disease, the most common sequelae include movement disorders, language disorders, and cognitive dysfunction. To investigate the effect of early refined nursing program on the prognosis of middle-aged and elderly patients with cerebral infarction combined with cognitive dysfunction. A retrospective study was conducted to divide 60 patients with cerebral infarction and cognitive impairment into an experimental group (n = 32) and a control group (n = 28). The experimental group received early intensive care every day, and the control group received daily routine care. The scores of the Mini-Mental State Examination (MMSE) and the Trail Making Test (TMT), as well as the latency and amplitude of the event-related potential P300, were used as main indicators to evaluate changes in cognitive function, and changes in BDNF, TGF-β, and GDNF expression were used as secondary indicators. Both groups experienced notable enhancements in MMSE scores, with the experimental group demonstrating higher scores than the control group (experimental: 28.75 ± 2.31; control: 25.84 ± 2.87). Moreover, reductions in TMT-A and TMT-B scores were observed in both groups (experimental: TMT-A 52.36 ± 6.18, TMT-B 98.47 ± 10.23; control: TMT-A 61.48 ± 7.92, TMT-B 112.63 ± 12.55), with the experimental group displaying lower scores. P300 Latency decreased (experimental: 270.63 ms ± 14.28 ms; control: 285.72 ms ± 16.45 ms), while amplitude increased (experimental: 7.82 μV ± 1.05 μV; control: 6.35 μV ± 0.98 μV) significantly in both groups, with superior outcomes in the experimental cohort. Additionally, the levels of the growth factors BDNF, TGF-β1, and GDNF surged (experimental: BDNF 48.37 ng/mL ± 5.62 ng/mL, TGF-β1 52.14 pg/mL ± 4.28 pg/mL, GDNF 34.76 ng/mL ± 3.89 ng/mL; control: BDNF 42.58 ng/mL ± 4.73 ng/mL, TGF-β1 46.23 pg/mL ± 3.94 pg/mL, GDNF 30.25 ng/mL ± 2.98 ng/mL) in both groups, with higher levels in the experimental group. For middle-aged and elderly patients with cerebral infarction and cognitive dysfunction, early refined nursing can significantly improve their cognitive function and prognosis.

Head CT Scans in the Emergency Department during the COVID-19 Pandemic: Use or Overuse?

The COVID-19 pandemic seemed to mainly involve the respiratory system, but it was realized that it could affect any organ, including the CNS. The pandemic has followed a wave-like trend, with its peaks being due to the COVID-19 different variants and the introduction of the vaccine, which led to an apparent reduction in hospitalizations but also brought about perplexities related to its adverse effects. The aim of this study was to analyze the changes in the use of head CT/contrast CT and their impacts on the onset of cerebrovascular disease in our emergency department during the COVID-19 period and the vaccine rollout. Patients ≥ 18 years old admitted to our emergency department from January 2018 to September 2021 were enrolled. The patients were divided into three groups. The COVID-19 period included patients who visited our emergency department from 1 March 2020 to 31 January 2021; the vaccine period was considered to range from 1 February 2021 to 30 September 2021. The patients who visited the emergency department from 1 January 2018 to 31 January 2020 were considered the controls. We found an increase in head CT/contrast CT requests during the COVID-19 period and increase in head contrast CT during the vaccine period, without an increase in the incidence of cerebrovascular disease. The uncertainty regarding the possible thrombotic events associated with COVID-19 and its vaccine increased the relative use of head CT/contrast CT by about 20% compared to the control period.

Транзиторна ішемічна атака й ішемічний інсульт у Міжнародній класифікації хвороб 11-го перегляду

У статті наведено аналіз розділу 8B0–8B2 «Цереброваскулярні хвороби» Міжнародної класифікації хвороб 11-го перегляду, яка офіційно вступить в силу у 2022 році. Діагнози транзиторної ішемічної атаки і церебрального ішемічного інсульту можуть кодуватися в блоках «Церебральна ішемія» (8B10, 8B11, 8B1Y, 8B1Z), 8B22 «Деякі уточненi цереброваскулярні захворювання» і 8B23 «Цереброваскулярні розлади». При відповідності стану пацієнта критеріям інсульту і неможливості уточнення типу інсульту за допомогою нейровізуалізації або інших методів обстеження може використовуватися код 8B20 «Інсульт, що не уточнений як ішемічний або геморагічний». Коди блока 8B25 «Наслідки цереброваскулярного захворювання» повинні застосовуватися через 1 місяць чи пізніше після початку цереброваскулярного захворювання.

Acute cerebrovascular disease following COVID-19: a single center, retrospective, observational study

Background and purposeCOVID-19 is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Apart from respiratory complications, acute cerebrovascular disease (CVD) has been observed in some patients...

Questionnaire survey on the prescription of renal replacement therapy for acute phase patients on maintenance dialysis who developed cerebrovascular disease.

There is limited information about acute phase renal replacement therapy (RRT) for maintenance hemodialysis patients after the onset of cerebrovascular disease. This study aimed to investigate which modality of renal replacement therapy is currently selected in practice. We conducted a mail-based survey in 317 dialysis facilities that were certified by three academic societies that focus on dialysis, neurology, and neurosurgery in Japan. We received responses from 103 facilities (32.5%). In cases of cerebral infarction (CI) and intracerebral hemorrhage (ICH), more than 80% of the facilities selected only intermittent RRT, and 22.3% (CI)/8.7% (ICH) of the facilities selected intermittent HD which is the same setting in normal conditions. Although continuous hemodiafiltration and peritoneal dialysis are recommended in the Japanese guidelines, these were selected in only a few facilities: 16.5% and 0% in CI, 16.5% and 1% in ICH, respectively. RRT on the day of onset tended to be avoided, irrespective of the duration following the last HD session. Furthermore, physicians preferred to modify anticoagulants and reduce dialysis performance in the acute phase. This questionnaire survey uncovered a gap between guidelines and actual practice, even in hospitals accredited as educational facility, which is a novel and important finding. Further studies with larger sample sizes are needed to determine the optimal modality of RRT for the acute phase of cerebrovascular disease.

Thyroid Disease as a Risk Factor for Cerebrovascular Disease

Thyroid disease is the medical condition impairing function of the thyroid. Among this disorder category, hyperthyroidism is that the thyroid gland produces excessive amounts of thyroid hormones whereas hypothyroidism is that the thyroid gland does not produce enough thyroid hormone. Various studies have supported the comorbid association between thyroid disease and cardiovascular disorder. However, there is insufficient evidence to prove the relationship between cerebrovascular disease (CVD) and thyroid disease. In this study, we tried to verify that thyroid disease increases the risk of CVD development employing a population-based database, National Health Insurance Research Database of Taiwan. A total of 16,808 hyperthyroidism cases and 5793 hypothyroidism patients with corresponding control subjects were studied, respectively. Hazard ratio (HR) by the Cox regression was used to quantify risk of CVD in different groups of subjects, that is, case patients versus matched controls. Further stratification studies for risk factors of CVD were performed to evaluate the comorbid association between CVD and hyperthyroidism/hypothyroidism. Evaluation results have shown that hyperthyroidism increased 38% of the hazard of developing follow-up CVD (adjusted HR, 1.38) whereas hypothyroidism increased even higher the risk (adjusted HR, 1.89). Further stratification studies for risk factors of CVD suggested that the comorbid association between hypothyroidism and CVD was comparable to those influences from cardiac risk factors, such as diabetes mellitus, hyperlipidemia, hypertension, or renal failure and so forth. Thyroid disease may predispose to onset of CVD. Advanced analysis is required to investigate the pathologic mechanism underlying the association between CVD and thyroid disease.

Prediction of Upper Limb Recovery in the Acute Phase of Cerebrovascular Disease: Evaluation of “Functional Hand” Using the Manual Function Test

Prediction of upper limb function recovery in the acute phase of cerebrovascular disease can help clarify goal setting in rehabilitation and subsequently shorten hospital stay. The present study aimed to develop regression equations that can be used to predict the Manual Function Test (MFT) score 3weeks after onset and to determine the optimal cutoff MFT score for the identification of "Functional Hand." In all, 190 patients with cerebrovascular disease were included in this study. The baseline survey performed within 1week after onset assessed sociodemographic profiles, medical profiles, and acute symptoms. MFT was performed to determine the cutoff score to indicate Functional Hand. We used stepwise multiple regression analysis to establish the prediction equations with the best fit for the MFT score 3weeks after onset. In addition, the sensitivity and specificity of the MFT as an indicator of Functional Hand with cutoff values were determined. The multiple regression analysis showed that the following factors had a significant influence on the MFT: Brunnstrom recovery stage, cognitive function, range of motion, age, and sensation. The area under the curve was .93 for the MFT score as an indicator of Functional Hand. The cutoff MFT score to identify Functional Hand was 22/21 points, with a sensitivity and specificity of 91.1% and 82.1%, respectively. Our findings helped develop regression equations that can be used to predict the MFT score 3weeks after onset of cerebrovascular disease by evaluating factors reportedly associated with upper limb function recovery.

Causes of prehospital delay in stroke patients in an urban aging society

PurposePrehospital delay is the major cause of treatment delay in cerebrovascular disease (CVD). An increasing number of elderly people reside alone or with their spouse with limited support from younger generations. The aim of this study was to identify the factors that may affect prehospital delay in our aging society, and examine the role of lifestyle on prehospital delay. MethodsWe retrospectively analyzed data for 469 consecutive patients who were hospitalized within 2 weeks of the onset of CVD between May 2007 and March 2009. Prehospital delay was defined as the time from the onset to arrival at our hospital. ResultsThere was no significant difference in prehospital delay between 91 patients who lived alone and 378 patients who lived with other people. We also analyzed whether lifestyle factors were causes of prehospital delay in the 378 patients who lived with other people. Living with a spouse was associated with a significant prehospital delay compared with patients living in a nursing home or those living with two or more generations. There were significant differences in prehospital delay between those living alone or with other people, and between those living with a spouse or with other people. Living with a spouse and living alone were associated with the prehospital delay. Knowledge of recombinant tissue plasminogen activator and the use of emergency medical systems were associated with a shorter prehospital delay, whereas visiting local doctors and the patient's recognition of symptoms increased the prehospital delay. The onset of CVD after office hours, National Institute of Health Stroke Scale score ≤ 4 at the initial visit, and prior stroke did not affect the prehospital delay. ConclusionHealth care promotion should target patients living alone as well as patients living with a spouse, especially in aging societies.

Diffusional kurtosis imaging analysis in patients with hypertension

Hypertension is associated with substantial morbidity in Japan. The aim of this work was to evaluate whether hypertension is associated with white matter microstructural changes by using diffusional kurtosis imaging (DKI). We explored the regional patterns of white matter alteration in 15 hypertensive middle-aged male participants and 11 normotensive controls by using DKI-based whole-brain analysis. In addition, we investigated whether the observed white matter microstructural changes were related to systolic or diastolic blood pressure by using Pearson's correlation coefficient analysis. Mean diffusional kurtosis (MDK) values were significantly higher in hypertensive participants than in normotensive participants (P<0.05; family-wise error correction for multiple comparisons), indicating widespread microstructural changes in white matter. Moreover, we noted a statistically significant positive correlation between systolic and diastolic blood pressure and MDK values of the whole brain. Our study suggests that microstructural white matter changes occur in middle-aged men with hypertension, even before the onset of cerebrovascular disease. Thus, DKI might be used as a screening tool for risk of cerebrovascular disease. This highlights the need to further elucidate the relationship between hypertension and DKI of the brain.

Chronic perfusion of angiotensin II causes cognitive dysfunctions and anxiety in mice

High blood pressure is a major risk factor in the onset of cerebrovascular diseases and cognitive impairment. However, mechanisms by which these occur remain unclear and treatments are, therefore, ineffective to prevent cognitive decline related to cardiovascular diseases. Angiotensin II is a peptide involved in the onset and maintenance of hypertension and its effect on cognition was studied acutely but never chronically. Hence, the aim of this study is to evaluate whether chronic hypertensive levels of angiotensin II infusion alter cognitive functions in C57BL6 mice. In this study we used subcutaneous mini-pumps containing a concentration of angiotensin II (1900ng/kg/min) that induces malignant hypertension or a saline solution for 14 and 21days. Blood pressure was carefully monitored by a non-invasive tail-cuff method every week throughout the experiment. Spatial memory was assessed using the Morris water maze test and anxiety was measured by the elevated plus maze and the open field tests. The results indicate learning and spatial memory deficit as well as an anxious behavior induced by angiotensin II, in comparison to the vehicle group, starting at the 3rd week of perfusion. The motricity and visual acuity were equivalent in angiotensin II perfused mice compared to their respective control. These results suggest a strong relationship between angiotensin II and the development of cognitive dysfunctions and anxiety along with sustained high blood pressure.

Post-Stroke Immunodeficiency: Effects of Sensitization and Tolerization to Brain Antigens

Acute onset of cerebrovascular diseases seems to be related to a number of immunological alternations. After the initial pro-inflammatory response to brain ischemia accompanied by systemic inflammatory response syndrome, stroke interferes with function of the innate and the adaptive immune cells, resulting in systemic immunosuppression. Although post-stroke immunodeficiency could predispose patients to life-threatening infections, it could potentially protect brain via reducing autoimmune reaction to the brain antigens. In this paper, we review current knowledge on the immunological alterations after brain ischemia, particularly effects of infection for stimulation of autoimmune response against brain antigens.

Low HDL cholesterol is associated with the risk of stroke in elderly diabetic individuals: changes in the risk for atherosclerotic diseases at various ages.

OBJECTIVETo clarify the relationship between lipid levels and ischemic heart disease (IHD) and cerebrovascular disease (CVD) in diabetic individuals.RESEARCH DESIGN AND METHODSThe Japan Cholesterol and Diabetes Mellitus Study is a prospective cohort study of 4,014 type 2 diabetic patients (1,936 women; mean ± SD age 67.4 ± 9.5 years). Lipid and glucose levels and other factors were investigated in relation to occurrence of IHD or CVD.RESULTSIHD and CVD occurred in 1.59 and 1.43% of participants, respectively, over a 2-year period. The relation of lower HDL or higher LDL cholesterol to occurrence of IHD in subjects <65 years old was significant. Lower HDL cholesterol was also significantly related to CVD in subjects ≥65 years old and especially in those >75 years old (n = 1,016; odds ratio 0.511 [95% CI 0.239–0.918]; P < 0.05). Stepwise multiple regression analysis with onset of CVD as a dependent variable showed the same result.CONCLUSIONSLower HDL cholesterol is an important risk factor for not only IHD but also CVD, especially in diabetic elderly individuals.

Personal experiences of returning to work following stroke: An exploratory study

A quarter of stroke survivors are of working age; information about the impact of stroke on those who are working is limited. We investigated the expectations and experiences of stroke survivors in relationship to return to work. This qualitative tudy used semi-structured, in-depth interviews with 13 patients working at onset of cerebrovascular disease. Interviews were conducted between 3 months and 8 years post stroke in order to gain an insight into both individuals' initial expectations and their actual experiences in relation to return to work. Full thematic analysis of the interview transcripts was undertaken, findings reported focus on the data relating to work. Work related sub-themes included continuing symptoms affecting plans to return to work, experiences of returning to work (including uncertainty over timing of return and fears about coping at work), changing job or career and the emotional impact of enforced retirement. Information provision, return to work support systems and potential changes in life roles are important aspects to consider when assessing the impact of stroke and managing the consequences in people of working age.

The related causes in very early morning onset of stroke

We investigated the influence of early awakening and related factors on onset of cerebrovascular disease (CVD). Totally 1199 stroke patients, in whom the onset time was known, at 3 reference hospitals were included in this study. The effects of demographic, medical, and pathophysiological factors on the circadian pattern of an unselected series of patients with ischemic stroke were analyzed. Nine-hundred seventeen CVD patients with cerebral infarction (CI), 240 patients with intracerebral hemorrhage (CH), and 42 patients with subarachnoid hemorrhage (SAH) were identified. The greatest portion of strokes (32.5%) occurred between 03:00 and 06:00 a.m. Nearly one half of the strokes in this series occurred in the very early- to mid-morning hours. This analysis of strokes provides strong evidence with a higher risk in the early morning hours (03:00 a.m. to 06:00 a.m.), and lower risk during the night time period (21:00 p.m. to midnight). Approximately 1 of every 3 strokes (1 of 3 ischemic strokes, 1 of 6 hemorrhagic strokes, and 1 of 8 subarachnoid hemorrhages) is attributable to the early morning excess. This difference tried to be explained by three ways: cold weather, religious factors, and physiological mechanisms.

Does prompt treatment of hypertension after blood pressure check-ups reduce morbidity of cerebrovascular diseases?

In Japan, more than 20 million people utilize blood pressure check-up services in their work places or communities every year. To examine the relationship between prompt treatment of hypertension after these blood pressure check-ups and the severity, age at onset, and type of cerebrovascular diseases in these patients, a study was performed with the cooperation of all 174 independent physicians, 17 hospitals, and 4 welfare homes in the city of N.. All patients aged 50 years or more who visited a physician during the study period in this city were included in the study (n=978). Information on hypertensive control before the onset of cerebrovascular diseases was obtained from 668 patients. The results suggests that for those who had received prompt treatment after early detection of hypertension, the disease was less severe and the onset of the disease was delayed. Among our subjects, 47% of the patients claimed to have received prompt treatment after detection of hypertension. As N. is an ordinary Japanese city in terms of the promotion of health check-up programs, this percentage suggests that blood pressure check-up programs for the early detection of hypertension throughout Japan may have contributed to an overall reduction in severity for almost half of the patients with cerebrovascular diseases.

Immunological functions and clinical course of elderly patients with cerebrovascular diseases

In the elderly, cerebrovascular diseases (CVD) are often complicated by severe infections such as pneumonia. This study aimed to examine the possible relationship at various timepoints of observation between immunological functions and the clinical course and to correlate the changes of immunological functions with CVD lesion side. The study was based on 25 right-handed patients (14 male and 11 female, mean age; male 69.0 years and female 74.9 years) with acute, focal neurological deficits of CVD (5 cerebral bleeding, 20 cerebral infarction; 11 right cerebral lesioned subjects, 14 left cerebral lesioned subjects). All patients were evaluated in terms of lymphocyte counts, T, B cell counts, T cell subsets, lymphocyte transformation and natural killer activity in peripheral blood as indices of immunological functions at various timepoints during the clinical course. Some of these immunological functions decreased within two months (acute stage) after onset of CVD, and some cases with decreased immunological functions developed complications of severe infection such as pneumonia. Patients who had both decreased immunological function and severe infection were 1 out of cases with 7 right cerebral lesions and 6 out of with 9 left cerebral lesions. This study suggests that the decreased immunological function in CVD subjects may be correlated with the site of the CVD lesion. In all left cerebral lesioned subjects, a reduction of immunological functions and a susceptibility to severe infection were not observed in the acute stage of CVD, however, some left cerebral lesion cases may be more closely related than in right cerebral lesion cases. The mechanism remains to be clarified.(ABSTRACT TRUNCATED AT 250 WORDS)

A study on the recent trend and risk factors of cerebrovascular disease.

Six hundred eighty seven cases of cerebrovascular disease, confirmed by C-T scan, were evaluated at Hanyang University Hospital from January 1985, to December 1988, and the following results were obtained. 1) The incidence of cerebral infarction was markedly increased in the last 5 years. 2) Cerebral hemorrhage showed a peak age of incidence in the fifties, cerebral infarction in the sixties. 3) Among the preceding diseases at the onset of cerebrovascular disease, hypertension was the most common. 4) Total lipid, Total-cholesterol/HDL-cholesterol ratio were significantly higher in cerebral infarction than in cerebral hemorrhage. 5) Triglyceride concentration and total cholesterol concentration were also higher in cerebral infarction than those of cerebral hemorrhage, but statistically not significant. 6) In cerebral infarction HDL-cholesterol concentration was significantly lower than that of cerebral hemorrhage. (p less than 0.01.) 7) In cerebral infarction, hematocrit and hemoglobin concentration were significantly higher, respectively, than those of cerebral hemorrhage.

脳虚血, 脳出血に合併した未破裂動脈瘤の手術と問題点

A study was conducted to evaluate the postoperative complications associated with incidental asymptomatic aneurysms in 30 patients with 34 cerebral aneurysms who suffered from ischemic or hemorrhagic cerebrovascular diseases. On postoperative CT scan, seven patients were shown to have developed new infarctions and seven patients had new cerebral or cerebellar hemorrhages. Among the patients who developed new infarctions, the problem was directly due to operative procedures in three cases, and in another two cases the problem was thought to be associated with STA-MCA anastomosis which had been simultaneously performed. The other two cases were considered to be due to hemodynamic ischemia during surgery and anesthesia. Three of the patients with infarction almost totally recovered to their preoperative neurological state.Two of the seven patients with hemorrhage had received preoperative antiplatelet therapy for their original diseases, and one had liver cirrhosis with thrombocytopenia. One received STA-MCA anastomosis as mentioned above and both hemorrhage and infarction developed. Two patients died of late systemic complications.Aside from infarctions confirmed by CT scan, five patients had postoperative focal neurological deterioration, from which they made an almost total recovery. These cases may have been due to transient ischemia. Nine patients suffered postoperative epileptic seizures. On CT scan, one was shown to have multiple cerebral and cerebellar hemorrhages, two to have infarctions, and one to have both. Five patients had no remarkable signs on CT scan except for slight cerebral edema. Five developed status epilepticus, and one died of diffuse cerebral edema secondary to uncontrollable status epilepticus. The other two patients died of late systemic complications after developing an impaired mental state after seizures. There was no correlation between these complications and the patients' age or length of time between the first onset of cerebrovascular disease and surgery for aneurysms. Of the 30 patients, the surgical morbidity rate was 70%, including transient neurological deficits and epilepsy, and the late mortality rate was 13% (four patients), including systemic complications.In conclusion, patients who are found to have aneurysms incidentally during a course of ischemic or hemorrhagic cerebrovascular disease have a high risk in direct surgery, and intensive care should be taken during surgery and in the pre- and postoperative period. Preoperative anticonvulsants, evaluation of coagulation capacity, stable blood pressure during surgery and the postoperative period, and no non-essential procedures other than aneurysm surgery, are important considerations for these patients.

A new method for measuring cerebrospinal fluid flow in shunts

An implantable device for measurement of cerebrospinal fluid (CSF) flow in a ventriculoperitoneal shunt tube has been developed. The unit is energized by an extracorporeal high-frequency generator (200 KHz), and electrolysis creates bubbles in the shunt tube. Velocity of bubble flow is detected by a pair of ultrasonic Doppler probes placed a certain distance apart on the skin surface and in parallel with the implanted tube. The CSF flow rate is calculated taking into account velocity and tube diameter, and is expressed in ml/min. The unit consists of a coil with a capacitor, a silicon diode to rectify the high frequency, and a Zener diode to regulate maximum output voltage of 20 V. The output is fed to a pair of platinum electrodes placed inside the unit's tunnel through which the CSF flows. These components are molded in epoxy resin and coated with medical-grade silicone rubber. In animal experiments, CSF flow rates ranging from 0.033 to 1.0 ml/min could be measured by this flowmeter. Clinically, CSF flow has been measured to date in several cases. In two cases of communicating hydrocephalus occurring after the onset of cerebrovascular disease, and in which the CSF flow was continuously monitored for 24 hours, the flow rate ranged between 0.05 and 0.78 ml/min. The CSF flow rate fluctuates in a 24-hour period, increasing in the morning, especially between 12 midnight and 6 a.m., which suggests a circadian rhythm.

BIOCHEMICAL COMPARISON OF MIGRAINE AND STROKE

SYNOPSISGamma‐aminobutyric acid (GABA) and 3′, 5′‐cyclic adenosine monophosphate (cyclic AMP) were measured in cerebrospinal fluid (CSF) of patients with stroke and vascular headache of migraine type. GABA was elevated in CSF of patients with recent onset of thromboembolic occlusive cerebrovascular disease (CVD) and within 48 hours of an attack of vertebrobasilar ischemia (VBI). Similarly, GABA was elevated in CSF of all patients studied during a migraine attack but not in asymptomatic migraine patients or patients with muscle contraction (tension) headache. CSF cyclic AMP was also elevated in patients with recent onset of thromboembolic occlusive CVD and in patients studied during or within 48 hours of a migraine attack.Since biochemical abnormalities reported herein were common to occlusive CVD and migraine headache, it seems probable that they are due to ischemia associated with both conditions and possibly related to the resultant disorder of cerebral energy metabolism.