Posterior Circulation Syndrome Research Articles

Clinico-topographic evaluation of anterior versus posterior acute ischemic stroke and correlation with early mortality-based scale prediction

Posterior circulation ischaemic strokes (PCIs) are a clinical syndrome associated with ischemia related to stenosis, in situ thrombosis, or embolic occlusion of the posterior circulation and differ from anterior circulation ischaemic strokes (ACIs) in many aspects. In this study, ACIs and PCIs were evaluated in terms of clinico-radiological and demographic aspects, and the relevance of objective scales to early disability and mortality was investigated. The definition of ACIS or PCIS was classified according to the Oxfordshire Community Stroke Project (OCSP). There are mainly two groups divided into ACIs and PCIs. ACIs were included as total anterior circulation syndrome (TACS), partial anterior circulation syndrome (PACS) (right and left), and lacunar syndrome (LACS) (right and left), and PCIs were posterior circulation syndrome (POCS) (right and left). Arrival NIH Stroke Scale/Score (NIHSS) and Glasgow Coma Scale (GCS) scores were evaluated in clinical assessment and modified SOAR Score for Stroke (mSOAR) was for early mortality-based scale prediction. All data were compared, and mean, IQR (if applicable) values and ROC curve analysis were determined. A total of 100 AIS patients, 50 of whom were ACIs and 50 were PCIs, were included in the study and were evaluated within the first 24h. Hypertension was the most common disease for both groups. The second most common was hyperlipidemia (82%) in the ACIs and diabetes mellitus (40%) in the PCIs. The frequency of right hemisphere ischemia was higher in ACIs (63.6%) and PCIs (48%). The mean NIHSS and GCS score (also median IQR) was higher in the right ACIs and the highest NIHSS mean was in the right partial anterior circulation syndrome (PACS) (respectively median (IQR): 9.5 (13) and median (IQR):14.5 (3)). The mean NIHSS and GCS score of bilateral posterior circulation syndrome (POCS) were the highest in PCIs (median (IQR):3 (17), (IQR):15 (4) respectively). The mSOAR mean was the highest in the right PACS in ACIs (median (IQR):2.5 (2)) and in bilateral POCs among PCIs (median(IQR):2(2)). The association of PCIs with hyperlipidemia and the male gender was interpreted, and anterior infarcts were found to cause higher early clinical disability scores. The NIHSS scale was effective and reliable, especially in anterior acute strokes, but also emphasized the necessity of using the GCS assessment together in the first 24h in the assessment of PCIs. mSOAR scale is a helpful predictor in estimating early mortality not only in ACIs but also in PCIs, similar to GCS.

MEASUREMENT OF WALKING IMPAIRMENT RECOVERY AFTER STROKE

Introduction: One of the most important goals in rehabilitating patients affected by stroke is re-establishing independent movement by activating as many motor patterns as possible and changing existing preexisting abnormal motor patterns Objective: To determine recovery level with the accent on motor functions recovery in a patient affected by an ischemic stroke for the first time. The study included patients with anterior circulation syndrome, posterior circulation syndrome, and lacunar syndrome in the acute and post-acute phases of physical therapy and rehabilitation.Material and methods: We conducted a prospective study, which included a total of 90 patients with the first onset of ischemic stroke. The first group consisted of 30 patients with the anterior circulation syndrome of; the second group of 30 patients with the posterior circulation syndrome and the third group of 30 patients with the lacunar syndrome. At the beginning of their early rehabilitation treatment at the Clinic of Physical Medicine and Rehabilitation, the Bamford Scale was used in the initial assessment of the clinical classification of stroke. After the rehabilitation treatment and six months after the stroke, an assessment of motor functions and improvement in overall functionality was performed using a six-minute walk test.Results: The six-minute walk test in all the studied groups showed significant improvement six months after the stroke compared to testing done immediately after their rehabilitation treatment (p = 0.01 anterior circulation, p = 0.05 posterior circulation, p = 0.01 lacunar syndrome). The six-minute walk test was statistically significantly better in patients with lacunar syndrome compared to patients with posterior circulation syndrome after the rehabilitation treatment (p = 0.005) and six months after stroke; p = 0.02.Conclusion: The importance of rehabilitation in the acute and post-acute phases of patients with first ischemic stroke is evident. The six-minute walk test in all studied groups showed statistically significant improvement after six months post-stroke period compared to post-rehabilitation testing. The results were statistically significantly better in patients with lacunar syndrome compared to patients with posterior circulation syndrome after the physical treatment and the time period of six months after the stroke.

Probability of Cardioembolic vs. Atherothrombotic Pathogenesis of Cryptogenic Strokes in Older Patients

Some clinical, laboratory, ECG, and echocardiographic parameters could provide useful indications to assess the probability of cardioembolism or atherothrombosis in cryptogenic strokes. We retrospectively examined 290 patients with ischemic stroke aged ≥60years, divided into 3 groups: strokes originating from large artery atherothrombosis (n=92), cardioembolic strokes caused by paroxysmal atrial fibrillation (n=88) and cryptogenic strokes (n=110). In addition to echocardiographic and routine clinical-laboratory variables, neutrophil:lymphocyte ratio, red blood cell distribution width, mean platelet volume, P wave and PR interval duration and biphasic inferior P waves, both on admission and after 7 to 10days, were also considered. By multiple logistic regression, cardioembolic strokes were compared with large artery atherothrombosis strokes, and beta coefficients were rounded to produce a scoring system. Late PR interval ≥188ms, left atrium ≥4cm, left ventricular end-diastolic volume <65ml, and posterior circulation syndrome were associated with paroxysmal atrial fibrillation (positive scores). In contrast, male gender, hypercholesterolemia, and initial platelet count ≥290×109/L were associated with atherothrombosis of large arteries (negative scores). The algebraic sum of these scores produced values indicative of cardioembolism if >0 (positive predictive value 89.1%), or of atherothrombosis, if ≤0 (positive predictive value 72.5%). The area under the receiver operating characteristic curve was 0.85. Among cryptogenic strokes, 41.5% had a score >0 (probable atrial fibrillation) and 58.5% had a score ≤0 (possible atherothrombosis). In conclusion, a scoring system based on electrocardiogram, laboratory, clinical and echocardiographic parameters can provide useful guidance for further investigations and secondary prevention in older patients with cryptogenic stroke.

Ischemic Stroke Subtypes: Socio-demographic Factors, Risk Factors, and Outcomes in Southern Sri Lanka.

Stroke is a heterogeneous, catastrophic disease. A comprehensive clinical analysis of ischemic stroke (IS) risk factors and outcomes is crucial for optimum management in resource-poor settings. A prospective cross-sectional study of acute cerebrovascular disease (ACVD) involving 592 patients was conducted in a tertiary care center in Sri Lanka from November 2018 to May 2019. We aimed to describe the ACVD subtypes and the relationship of IS subtypes and subtype-categories (as defined by the Oxfordshire Community Stroke Project clinical classification) with risk factors, severity, and outcome. The majority (63.3%) had IS. Partial anterior circulation syndromes (PACS), total anterior circulation syndrome (TACS), posterior circulation syndromes (POCS), and lacunar syndromes (LACS) accounted for 102 (29.7%), 58 (16.9%), 88 (25.7%) and 95 (27.7%) of the cases, respectively. The most common PACS sub-category was higher-cerebral-dysfunction-with-homonymous-hemianopia (HCD+HH,39 cases;38.2%). Cerebellar-signs-without-long-tract-signs (CS-LTS) sub-category constituted the highest among POCS (47 cases; 53.4%). The leading sub-category within LACS was pure-motor (PM) strokes (43 cases; 45.3%).Patients aged ≥50 years (adjusted-OR [AOR]2.439; 95%CI,1.163-5.116;P=.018), IHD(AOR 2.520; 95%CI,1.347-4.713; P=.004) and BMI>23kg/m2(AOR 2.607; 95% CI,1.420-4.784; P=.002) were 2.5 times more likely to associate with TACS. Patients with a history of TIA (AOR 1.910; 95%CI,1.036-3.524; P=.038) and arrhythmias (AOR 5.933; 95%CI,3.294-10.684; P<.001) were 1.9 and 5.9 times more likely to be associated with POCS respectively. Those with hypertension were 2.3 times more likely to associate with LACS (AOR 2.233; 95%CI,1.270-3.926; P=.005).NIHSS(P<.001), mRS on admission (P=.001) and in 3 months (P<.001), deaths during hospital stay (P=.003) and within 28 days (P<.001) had a stronger relationship with individual stroke subtypes. The comparative risk of different IS subtypes depends on different risk factors. The findings of this study demonstrate that sub-categories within each stroke subtype may behave independently with regard to risk factors and outcomes, thus warranting the need for individual assessment.

Pressing Issues in COVID-19: Probable Cause to Seize SARS-CoV-2 for Its Preferential Involvement of Posterior Circulation Manifesting as Severe Posterior Reversible Encephalopathy Syndrome and Posterior Strokes.

Since December 2019, a novel Severe Acute Respiratory Syndrome coronavirus 2 from China has rapidly spread worldwide. Although respiratory involvement is the mainstay of coronavirus disease 2019 (COVID-19), systemic involvement has recently drawn more attention. In particular, a number of recent articles have shed light on the nervous system as one of the possible targets. At our institution, we observed 15 patients with acute brain vascular manifestations; most interesting, we had a higher prevalence of the posterior circulation acute impairment. In our series, 7 patients had acute posterior cerebral injury: 1, hemorrhagic posterior reversible encephalopathy syndrome; 5, posterior circulation ischemic stroke; and 1, parieto-occipital hemorrhagic stroke. On the basis of our evidence and previous basic science reports, we believe a common etiopathogenetic thread may connect ischemic/hemorrhagic events of the posterior circulation and posterior reversible encephalopathy syndrome in the setting of COVID-19.

CLINICAL FEATURES OF CANCER ASSOCIATED ISCHEMIC STROKE

Cerebrovascular disease is the second most common cause of central nervous system involvement in cancer patients after metastases. Procoagulant substances secreted by tumour cells, cancer therapy, and embolus from tumour have been implicated in ischemic stroke (IS) in cancer patients. Four thousand twenty patients with IS were prospectively recorded to the Istanbul Medical School Stroke Registry from August 1997 to May 2016. Ninety-two patients with IS and cancer and 3928 IS patients without cancer constituted the two groups. Hypertension, hyperlipidemia, and congestive heart failure were less commonly encountered in cancer stroke patients. Lacunar and posterior circulation syndromes were less common and total anterior circulation syndrome was more common in cancer patients (p<0.001). Multiple territory infarcts were more frequently seen in patients having overt or non-overt disseminated intravascular coagulopathy (DIC) compared to those without DIC. Median survival was significantly shorter in patients with cancer-related stroke. Cancer associated stroke without other underlying etiology is a specific group of stroke patients presenting with multiple territorial infarcts, overt or non-overt disseminated intravascular coagulopathy, and poor prognosis.

Association between pneumonia in acute stroke stage and 3-year mortality in patients with acute first-ever ischemic stroke

The influence of pneumonia in acute stroke stage on the clinical presentation and long-term outcomes of patients with acute ischemic stroke is still controversial. We investigate the influence of pneumonia in acute stroke stage on the 3-year outcomes of patients with acute first-ever ischemic stroke. Nine-hundred and thirty-four patients with acute first-ever ischemic stroke were enrolled and had been followed for 3years. Patients were divided into two groups according to whether pneumonia occurred during acute stroke stage or not. Clinical presentations, risk factors for stroke, laboratory data, co-morbidities, and outcomes were recorded. The result showed that a total of 100 patients (10.7%) had pneumonia in acute stroke stage. The prevalence of older age, atrial fibrillation was significantly higher in patients with pneumonia in acute stroke stage. Total anterior circulation syndrome and posterior circulation syndrome occurred more frequently among patients with pneumonia in acute stroke stage (P<0.001 and P=0.009, respectively). Multivariate Cox regression revealed that pneumonia in acute stroke stage is a significant predictor of 3-year mortality (hazard ratio=6.39, 95% confidence interval=4.03–10.11, P<0.001). In conclusion, pneumonia during the acute stroke stage is associated with increased risk of 3-year mortality. Interventions to prevent pneumonia in acute stroke stage might improve ischemic stroke outcome.

Balance and mobility in acute stroke: Association with subgroups of stroke and socio-demographic characteristics

Aims. The main purpose was to investigate balance and mobility in the acute phase post-stroke regarding the Oxfordshire Community Stroke Project (OCSP) classification, as well as to determine the relationship between balance, mobility and socio-demographic characteristics in patients with first-ever stroke or transient ischaemic attack. Methods. A cross-sectional study of 183 participants. The Berg Balance Scale (BBS), Figure-of-Eight test (Fig8), Maximal Walking Speed (MWS) and Timed Up and Go (TUG) were assessed. The OCSP subgroups were total anterior circulation syndromes (TACS); partial anterior circulation syndromes (PACS); posterior circulation syndromes (POCS) or lacunar syndromes (LACS). Major findings. Mean age was 72 years and 48.6% were women. Male, cohabitant and younger participants scored significantly better on the BBS compared with females, those living alone and older participants. Despite impaired balance and mobility usually following strokes in the brain stem and cerebellum, the POCS group scored on the same level as LACS and PACS groups regarding balance and mobility. Only the TACS group had significantly lower BBS, TUG and MWS scores than the other participants. Conclusions. The results show that being younger, male and a cohabitant were significantly associated with better balance in the acute phase post-stroke. The TACS group differed significantly from the other OCSP groups, performing worse regarding balance and mobility.

The Study Of The Spectrum Of Vertigo With Special Reference To Vertigo Of Vascular Origin

Objectives: To outline the spectrum of vertigo, to elaborate the significance of vascular causes of vertigo, to advocate use of MRI / MRA of carotid artery and vetebrobasilar arterial system in patients with isolated or syndromic vertigo especially when one or more risk factors for a cerebrovascular accident are present. Study design: Prospective study(2009-2011). Results: 91 patients who preened with vertigo were prospectively studied. BPPV, Meniere’s disease and vestibular neuritis comprised about 60% of patients. Posterior circulation syndrome and vertebrobasilar insufficiency was strongly suspected in 13 patients (14.3%). Compression of 8th nerve and cerebellar vermis were documented to be the cause of vertigo in 7 patients (7.7%), cervical vertigo was seen in 6(6.6%) patients. 4 patients (4.4%) had vertigo as a manifestation of complicated CSOM. 3 (3.3%) patients had metabolic vascular syndrome out of which one patient died of stroke about 6 months after his presentation as recurrent episodic vertigo. No diagnosis could be made in 3 patients. Conclusion:A detailed history should be obtained and an elaborate vestibular and neuro-otologic examination done in a patient of vertigo. A diagnosis can be reached in more than 90% of patients. Peripheral vertigo is more common that central vertigo with BPPV, meniere’s disease and acute vestibular neuritis accounting for more than 60% of all cases of vertigo. Vascular causes form a significant group of vertigo patients. Vertigo especially recurrent and syndromic with 1 or more risk factors should not be overlooked and should be regarded a precursor of a future stroke. Patients of vertigo with vascular risk factors like age (elderly), hypertension, smoking, diabetes mellitus, hyperlipidemia and cardiac disease should be evaluated for vertebrobasilar insufficiency by specific investigations like MRI brain, MRA carotids and vertebrobasilar arteries, Doppler USG and risk factors for vascular disease modified by drugs (hypolipidemic, antihypertensive, aspirin) and behavioural changes. Abnormal vessel loops can compress VIII nerve and cause vertigo. These can be reliably diagnosed by MRA. Vertigo can be caused in patients with cervical spondylosis especially in previously diseased vessels (due to atherosclerosis, vasculitis) which get easily compressed by cervical osteophytes. Bangladesh Journal of Medical Science Vol. 12 No. 02 April’13 Page 192-198 DOI: http://dx.doi.org/10.3329/bjms.v12i2.14949

CT perfusion improves diagnostic accuracy and confidence in acute ischaemic stroke

Background and objectiveCT perfusion (CTP) is rapid and accessible for emergency ischaemic stroke diagnosis. The feasibility of introducing CTP and diagnostic accuracy versus non-contrast CT (NCCT) in a tertiary hospital...

Care and Charges for Acute Cerebral Infarction Inpatients in China: A Hospital Based Study in Soochow

Objective The objective of the present study is to evaluate the current status of care and charges of acute ischaemic stroke in a university teaching hospital in China, and to identify the main determinants of such charges. Methods Acute ischaemic stroke patients from July 2009 to June 2010 were considered. We examined demographic data, clinical data, hospital care and outcomes at discharge and hospital charges retrospectively. The influence of medical factors on total charges was analyzed. Results The mean initial National Institutes of Health Stroke Scale score of all acute ischaemic stroke patients was 7.2 points. Thirteen percents were total anterior circulation syndrome, 20% were partial anterior circulation syndrome, 7% were posterior circulation syndrome and 60% were lacunar syndrome. The mean hospital length of stay (LOS) was 8.5 days. All patients underwent neuroimaging studies, 2% of whom received thrombolysis, 93% received traditional Chinese medicine injection, 83% received antiplatelet and 6% received anticoagulation therapy, only 29% received in-hospital rehabilitation. The mean hospital charges per patient was ¥9230.2 (US$1357.3), of which 56.2% was attributed to the charges for medications, 13.4% for imaging studies, 12.1% for laboratory examinations. Total hospital charges were correlated strongly with LOS, admission to care unit, and computed tomography angiography or digital subtraction angiography of the brain. Conclusions Total hospital charges correlates significantly with hospital LOS, admission to care unit, investigation with computed tomography angiography or digital subtraction angiography of the brain, while clinical syndromes do not influence total charges independently. The cost of drug is the largest portion of the mean hospital charge. A treatment protocol in acute ischaemic stroke might optimise cost. (Hong Kong j.emerg.med. 2011;18:383-390)

Gender differences in acute stroke: Istanbul medical school stroke registry

We aimed to investigate gender differences in Turkish stroke patients. Demographics, risk factors, clinical and etiologic subtypes, laboratory findings, clinical course, and in-hospital prognosis of 1 522 patients with ischemic stroke (IS) and 320 patients with intracerebral hemorrhage prospectively registered in the Istanbul Medical School Stroke Registry (1994-2004) were analyzed separately. The mean age of IS patients was higher in females (n : 751) (P<0.0001). In males, smoking, ischemic heart disease, peripheral arterial disease, posterior circulation syndromes, and strokes due to large-artery atherosclerosis were more common (P<0.0001 for each). Prestroke disability, atrial fibrillation (P<0.0001), hypertension (P=0.041), modified Rankin Scale (mRS) 3-5 at admission (P<0.0001), total anterior circulation syndrome (P<0.0001), and cardioembolic stroke (P<0.0001) were more frequent in females. Female gender was an independent predictor of poor outcome (mRS 3-6). Gender differences were observed exclusively in patients with IS. Although our patients were younger than those reported, gender differences were similar.

Quantitative EEG in ischemic stroke: Correlation with infarct volume and functional status in posterior circulation and lacunar syndromes

Objective The significant impact of stroke on health care results in an unmet need for efficient stroke care in resources limited environments. Practical, inexpensive and easy to obtain predictive EEG parameters have been suggested in anterior circulation syndromes. We investigated whether EEG parameters are of additional predictive value with regard to lesion volume and short-term functional outcome in lacunar (LACS) and posterior circulation (POCS) syndromes of presumed ischemic origin. Methods Sixty (60) patients presenting with LACS or POCS were incrementally included. EEG parameters were correlated with volume of ischemia and functional status. Predictive values for definite stroke and unfavourable outcome were calculated using receiver operating characteristic (ROC) curves and logistic regression modelling. Results The pairwise derived brain symmetry index (pdBSI) emerged as independent predictor for definite stroke in patients presenting with LACS and POCS (odds ratio (OR) 2.69, 95% confidence interval (CI) 1.24–5.82, p = 0.012) and in patients with a National Institutes of Health Stroke Scale (NIHSS) score of 0 at EEG recording (OR 7.67, 95% CI 1.24–47.32, p = 0.026). In ROC analysis, the (delta + theta)/(alpha + beta) ratio (DTABR) predicted unfavourable outcome at day 7 with an accuracy of 83% in LACS but not in POCS. In logistic regression, unfavourable outcome in LACS was predicted by nominal NIHSS with marginal significance (OR 1.84, 95% CI 1.00–3.37, p = 0.05), while in categorical modelling, DTABR > 2.4 displayed a statistically significant ominous odd ratio of 13.00 (95% CI 1.11–152.35, p = 0.041) with identical predicted and observed values. Conclusions EEG may be of additional value by confirming or excluding definite stroke after resolution of symptoms in lacunar and posterior circulation syndromes of presumed ischemic origin and prognosticating short-term functional status in lacunar syndrome. Significance These findings may have an impact on stroke care.

Oxfordshire Community Stroke Project Clinical Stroke Syndrome and Appearances of Tissue and Vascular Lesions on Pretreatment CT in Hyperacute Ischemic Stroke Among the First 510 Patients in the Third International Stroke Trial (IST-3)

The Oxfordshire Community Stroke Project (OCSP) clinical stroke syndrome classification correlates well with the stroke lesion in established ischemic stroke, but there are few data in patients with hyperacute stroke. We wished to assess whether the OCSP correlated with the site and size of the ischemic lesion and location of cerebral vessel lesion on computed tomography (CT) in hyperacute stroke. Prospective study of ischemic stroke patients presenting within 6 hours of onset in the Third International Stroke Trial (IST-3), a randomized, controlled trial of rt-PA. OCSP syndrome was assigned by a computer-based algorithm. The CT assessment was made by a neuroradiologist blinded to clinical details. We assessed baseline data and CT findings for the first 510 patients; early tissue ischemic changes were present in 329/510 (65%) total anterior circulation syndrome (TACS) - 79%; partial anterior circulation syndrome (PACS) - 57%, lacunar syndrome (LACS) - 40%; posterior circulation syndrome (POCS) - 33%. The site and size of ischemic change on CT was compatible with the clinical syndrome in 79%, 37%, 2%, and 14%, respectively. Assuming that all patients with a normal CT scan will develop an incompatible lesion these numbers reflected the "worst possible scenario." For the "best possible scenario" we presumed that those with a normal CT will develop concordant ischemic change and the proportions were 100%, 80%, 62% and 81%, respectively. The hyperattenuated artery sign was seen in 206/510 (40%); (TACS 54%; PACS 35%, LACS 5%, and POCS 19%). Within 6 hours of stroke, in patients with a nonlacunar syndrome, the OCSP syndrome correlated well with the pattern of ischemic change on CT. For clinicians who wish to restrict the use of thrombolytic therapy to large-artery ischemic stroke, concordance of clinical and CT appearances may give greater confidence in making therapeutic decisions in hyperacute stroke. In centers where immediate access to MR is limited, use of the classification may help focus use of MR on patients with suspected LACS and POCS. The utility of the classification may further increase if IST-3 establishes that the OCSP syndrome significantly modifies response to thrombolytic therapy.

When to Expect Negative Diffusion-Weighted Images in Stroke and Transient Ischemic Attack

The frequency of DWI negative cerebral ischemia and clinical factors associated with such a circumstance is not well understood. We performed MRI including diffusion-weighted imaging (DWI) in patients with stroke and transient ischemic attack (TIA) within 24 hours of symptom onset and again at 30 days. Of 401 patients, 103 (25.6%) had an initial negative DWI study. In the DWI negative group, among the stroke patients, 6/26 (23.1%) had infarcts on follow-up MRI (4 lacunar and 2 posterior circulation syndromes) and 1 had a rMTT deficit. Among the TIA patients, 4/63 (6.3%) showed rMTT deficits and 2/63 (3.2%) had infarcts on follow-up MRI. Baseline perfusion weighted imaging sequences may detect ischemia in a small proportion of DWI negative cases. Only those with brain stem location or lacunar syndrome were DWI negative initially and yet had a follow-up imaging confirmation of infarct or a final clinical diagnosis of stroke.

Is Leukoaraiosis on CT an accurate surrogate marker for the presence of microbleeds in acute stroke patients?

Microbleeds (MB) detected on gradient echo magnetic resonance images (GRE) are a potential risk factor for intracerebral hemorrhage after thrombolysis or oral anticoagulation. We assessed whether the presence of MB could be predicted from the extent of white matter disease (WMD) on computed tomography (CT). We studied consecutive TIA or ischemic stroke patients who presented to the ER and who underwent both CT and GRE. WMD was rated on CT using a three point scale by two independent observers. The presence of MB was assessed on GRE. Logistic regression was used to predict the presence of MB on GRE. 199 consecutive patients underwent both CT and GRE. MB were identified on GRE in 56 patients (28.1%). After adjustment for age and sex, MB were more frequent in patients with leukoaraiosis (OR 2.8 per 1-point increase on the Van Swieten scale, p<0.001) and in patients presenting with a lacunar or posterior circulation syndrome (OR 2.0, p=0.048). The area under the ROC-curve derived from the logistic model was 0.70 (95% CI 0.61-0.79). Age, sex, hypertension, diabetes or the presence of left ventricular hypertrophy on ECG were not different in patients with or without MB. White matter disease on CT is associated with the presence of microbleeds on GRE. However, leukoaraiosis does not detect the presence of MB accurately enough to be considered a surrogate marker.

"Caplan's Syndrome" - revisited and lessons learned

In the mid 1980s, I had just taken up the Neurology Chair at Tufts University in Boston. Dr Ted Munsat the previous Neurology chairman said to me that the Tufts’ neurology residents would probably not know about Caplan’s syndrome. I thought hard to myself – Caplan’s syndrome. Was he referring to the top-of–the basilar syndrome that I had published in 1980 (Caplan 1980). I asked him if that was what he meant by Caplan’s syndrome. No, he said. I then thought of the other two recent syndromic descriptions- lateral tegmental haemorrhages (Caplan & Goodwin 1982) and cervical vertebral artery dissections (Caplan et al. 1985). These two areas, as well as the top-of the basilar, were about posterior circulation syndromes, well known to be a special interest of mine. I have already discussed awakening of interest in posterior circulation strokes in a previous paper in Practical Neurology (Caplan 2004). ‘No’, Munsat

Risk factors for cerebrovascular deaths in patients operated and irradiated for pituitary tumors.

Vascular mortality, especially cerebrovascular disease (CVD), are the most pronounced cause of mortality in women with hypopituitarism. In a cohort of 342 patients operated and irradiated for pituitary tumors, 31 died from CVD (CVD patients) between 1952 and 1996. The study assessed whether the radiation regimens and duration of symptoms of hypopituitarism before operation differed between the 31 CVD patients and the 62 matched patients from the same cohort who had not died from CVD (control patients). Furthermore, the infarction/hemorrhage ratio, type of clinical stroke syndrome, and time to death after stroke were investigated in the CVD patients and in matched controls from the general population who had died from CVD (population controls). No significant differences in maximum or centrally absorbed dose, maximum or central biological equivalent dose, field size, or number of fraction were recorded between CVD and control patients. A significant difference in the duration of symptoms of hypopituitarism before operation was recorded, but only in women (P = 0.01). There were no significant differences in the infarction/hemorrhage ratio (P > 0.3) of lacunar or posterior circulation syndrome compared with middle cerebral artery syndrome with cortical features (P = 0.22) or the proportion of patients who died within the first month after stroke onset (60% vs. 59%, respectively) between CVD patients and population controls. In conclusion, no significant effect on CVD deaths could be detected for any radiation parameter. A long history of unsubstituted pituitary insufficiency may be a contributing factor to the very high CVD mortality among women. There were no indications of significant differences in type of stroke, clinical stroke syndromes, or stroke fatality between the CVD patients and the population controls.

The Oxfordshire Community Stroke Project classification in the early hours of ischemic stroke and relation to infarct site and size on cranial computed tomography

Background and Purpose: The Oxfordshire Community Stroke Project (OCSP) classification clinically subdivides cerebral infarction into total anterior circulation (TACS), partial anterior circulation (PACS), posterior circulation (POCS) and lacunar (LACS) syndromes. We compared the OCSP classification in patients presenting within 12 hours of onset of stroke with infarct site and size on computed tomography (CT) brain scan at 5 to 7 days. Methods: OCSP classification was prospectively assigned by 1 of 3 observers in 43 patients presenting within 12 hours of stroke. CT brain scan was performed on admission to exclude primary intracerebral hemorrhage. Repeat CT brain scan at 5 to 7 days was used to classify recent visible infarction as total anterior circulation infarction (TACI), partial anterior circulation infarction (PACI), lacunar circulation infarction (LACI), or posterior circulation infarction (POCI). For each OCSP subtype, sensitivity and specificity were calculated by using CT classification as a standard. Results: Median (range) interval from onset of stroke symptoms to OCSP classification was 5.0 (1.5, 11.75) hours. Thirty-seven patients had ischemic stroke, with recent visible infarction in 34 (92%). Sensitivity and specificity of each OCSP subtype was TACS (0.80, 0.82), PACS (0.56, 0.79), LACS (0.33, 0.88), and POCS (1.00, 0.97). Overall, 65% of OCSP subtypes assigned were correct when compared to CT classification. Conclusions: In this small study, we have shown that the OCSP classification within 12 hours of ischemic stroke onset compares with CT classification at 5 to 7 days. Larger studies are required to evaluate the validity of the OCSP classification in the early hours of ischemic stroke in guiding appropriate patient selection for acute stroke therapy and interventions. Copyright © 2001 by National Stroke Association

How well does the Oxfordshire Community Stroke Project classification predict the site and size of the infarct on brain imaging?

OBJECTIVESThe Oxfordshire Community Stroke Project (OCSP) classification is a simple clinical scheme for subdividing first ever acute stroke. Several small studies have shown that when an infarct is visible on...