Sudden Onset Of Neurological Deficit Research Articles

Frequency of Atrial Fibrillation in Patients of Ischemic Stroke Presenting in Emergency

Background: Stroke also known as cerebrovascular accident is sudden onset of neurological deficit due to vascular injury. About 87% of strokes are ischemic, the rest being hemorrhagic. Atrial fibrillation is an arrhythmia in which there is irregularly irregular heart beat which can lead to thrombus formation and then cardioembolic stroke. Objective: The study objective was to determine the frequency of atrial fibrillation in patients of ischemic stroke presenting in Emergency Department of the Hospital and its associations. Study Design: Retrospective observational study. Settings: Department of ???, DHQ Hospital Narowal Pakistan. Duration: Record of patients presented at DHQ Hospital Narowal form 03-03-2022 to 03-03-2023 reviewed. Methods: After taking ethical approval from head of the institution (Ref No. 451/PA-MS, dated 03-03-2023) medical record of patients presented with focal neurological deficit at DHQ Hospital Narowal during this period was reviewed.134 patients who fulfilled the inclusion criteria were included in the study. Information regarding their demographic data was noted in the performa. Record of CT Scan brain plain or report of CT brain and ECG findings were noted. Results: Amongst 134 participants, the mean age of participants was noted to be 52.93 ± 16.82 years. There were 44.8% male patients while remaining were females. Hypertension was present in 67.2% patients while 51.5% of patients were smoker. Atrial fibrillation was present in 37.3% patients. By using chi-square test, significant association was observed between presence of atrial fibrillation and gender, different age groups and smoking with p-value < 0.005. There was no significant association observed between atrial fibrillation and hypertension having p-value >0.05. Conclusion: Atrial fibrillation was present in 37.3% patients of ischemic stroke presenting in Emergency Department of the Hospital. Effect modifiers have significant effect except hypertension on the presence of atrial fibrillation.

Prevalence of Newly Diagnosed Hypertension in Stroke Patients Presented to Tertiary Care Hospitals in Rawalpindi

Background and Aim: Stroke is defined as the sudden onset of neurological deficits caused by vascular supply disruption to brain-specific region, contributing as a major factor for mortality and morbidity worldwide. Globally, approximately two-thirds cases of stroke are caused by hypertension as a major risk factor. The purpose of the current study was to determine the prevalence of stroke patients with newly diagnosed hypertension admitted to tertiary care hospital. Materials and Methods: This cross-sectional study was carried out on 205 stroke patients admitted to the Department of General Medicine, Benazir Bhutto Hospital and Holy Family Hospital, Rawalpindi from April 2021 to March 2022. Prior to study conduction, ethical approval was taken from the institute research and ethical committee. Written informed consent was obtained from each individual. All the participants underwent physical examination after using antihypertensive medication besides detailed history. Blood pressure was measured using standard mercury Sphygmomanometer. Patient having blood pressure ≥ 140/90 mm Hg was considered as hypertensive after measurement with difference of 10 minutes time span. SPSS version 25 was used for data analysis. Results: The overall mean age was 59.6 ± 8.5 years. Of the total 205 stroke patients, there were 140 (68.3%) males and 65 (31.7%) females. Out of 205 patients, 60.5% were rural and 39.5% were urban. The literacy rate was 63.9%. Family history of smoking, diabetes mellitus (DM), and hypertension (HTN) among study population were found in 83 (40.5%), 76 (37.1%), and 71 (34.4%) respectively. Based on computed tomography presentations, the prevalence of newly diagnosed hypertension (HTN) was 122 (59.5%). Out of 122 newly diagnosed hypertensive stroke patients, the incidence of ischemic stroke and hemorrhagic was 67 (54.9%) and 55 (45.1%) respectively. The mean value of diastolic and systolic blood pressure was 86.32 ± 12.62 and 125.59 ± 19.97 mm of Hg respectively. Conclusion: The present study concluded that the prevalence of newly diagnosed hypertension was found higher among stroke cases. Early diagnosis of hypertension by proper screening and effective treatment can reduce the mortality and morbidity caused by stroke and hypertension. Keywords: Hemorrhage, HTN, Ischemia, Stroke.

Clinical study on the combined effectiveness of Mashasaptaka Kwatha and Marsha Nasya with Mashasaptaka Taila in Pakshaghata (cerebrovascular accident-infarct)

Background: Pakshaghata is one among Vataja Nanatmaja Vyadhis which are considered as Mahavyadhis. Pakshaghata can be correlated with Hemiplegia, the commonest pathology of which is cerebrovascular accident (stroke). Stroke is defined as sudden onset of neurologic deficit from vascular mechanism. 85% of all strokes are ischemic and 15% are hemorrhagic. Aims And Objectives: To evaluate the combined effectiveness of Mashasaptaka Kwatha and Marsha Nasya with Mashasaptaka Taila in the management of Pakshaghata (Cerebrovascular Accident-infarct). Methods: Thirty diagnosed subjects of Pakshaghata (CVA due to infarct) were administered with Mashasaptaka Kwatha and Marsha Nasya with Mashasaptaka Taila for 7 days. The data of patients was recorded before and after treatment using an elaborate proforma. Assessment was done based on the primary and secondary outcome measures. For statistical analysis, Wilcoxon Signed Rank test, McNemar tests were used. Results: In this study it was found that there was statistically significant relief in the symptoms of Pakshaghata (Cerbrovascular accident-infarct). Conclusion: Relief in the symptoms was achieved by the drugs having properties such as Vatakaphahara, Anulomana, Brimhana, Srotoshodhana etc. Hence, Mashasaptaka Kwatha and Marsha Nasya with Mashasaptaka Taila for 7 days is effective in the management of Pakshaghata (Cerebrovascular accident-infarct).

Emergency endoscopic surgery for pituitary apoplexy presenting as cerebral infarction in a limited resources condition: A case report.

Introduction and importancePituitary apoplexy is defined as a sudden onset of neurologic deficit due to infarction or hemorrhage of the pituitary tumor. We report a case of emergency endoscopic surgery for pituitary apoplexy presenting as cerebral infarction due to ICA compression in a limited resources condition.Case presentationA 38-year-old female presented with acute onset of severe headache, decreased level of consciousness, decreased visual acuity bilaterally, aphasia, and right hemiparesis. Computed tomography angiography showed a hyperdense sellar mass with stenosis of the left ICA. The patient underwent emergent endoscopic transsphenoidal surgery for sellar decompression.Clinical discussionThe epidermiology, presentation and diagnosis and strategy of treatments as well as their outcomes were discussed.ConclusionPituitary apoplexy should be taken into consideration in a patient with increasing headache and neuro-ophthalmic symptoms. Pituitary apoplexy presenting as cerebral infarction is rare. The aim of surgery in emergency setting was sellar decompression. Endoscopic transsphenoidal surgery was an effective treatment.

Osteopathia Striata with Cranial Sclerosis Associated with Moyamoya Disease in a 3-Year-Old Girl

We present a very rare case of osteopathia striata with cranial sclerosis (OSCS) due to a mutation in the WTX gene, with an unusual association with moyamoya disease (MMD). This is the first documented case to our knowledge where OSCS and MMD have occurred in conjunction. A 3-year-old girl presented with osteopathia striata with cranial sclerosis with a history of Pierre Robin syndrome. She had previously had cleft palate repair and was now electively admitted for an anterior 2/3rds cranial vault remodeling procedure for osteopathia striata. Postoperatively she developed left-sided focal seizures and left-sided weakness. Subsequent imaging revealed acute right frontal and medial right parietal infarcts and bilateral supraclinoid ICA occlusion, consistent with moyamoya disease. Early diagnosis and intervention will alter the prognosis and life expectancy of patients with OSCS and MMD. MMD should be a differential diagnosis following the sudden onset of neurological deficits and focal seizures postoperatively in the pediatric population. In cases where associated comorbidities are high risk, a conservative approach to the treatment of MMD may be indicated.

Meningioma and associated cerebral infarction in three dogs

BackgroundIn dogs, meningiomas mostly cause chronic progressive clinical signs due to slow tumor growth.Case presentationIn contrast, three dogs were presented with the history of chronic generalized tonic-clonic seizures and peracute deterioration with sudden onset of neurological deficits in accordance with an extensive unilateral forebrain lesion. Magnetic resonance imaging examinations of the dogs revealed a well-delineated extraaxial T2W hyperintense mass in the rostral forebrain with homogeneous contrast enhancement. Additionally, an intraaxial, well-demarcated, unilateral lesion was apparent in the parenchyma supplied by the middle cerebral artery. In two cases, necropsy revealed meningothelial meningioma in the rostral fossa and marked eosinophilic neuronal necrosis, a sign of ischemia, focal malacia, edema and gliosis in the temporal lobe and hippocampus because of a focal thrombosis of the middle cerebral artery. In the third case symptomatic treatment resulted in improvement of clinical signs enabling a good quality of life for the patient.ConclusionsIn dogs with structural epilepsy caused by meningioma, acute deterioration of clinical signs can be associated with ischemic infarctions as a potential complication.

Acute spontaneous epidural hematoma of cervical spine presenting as quadriparesis in a young patient: a case report

Introduction: Spontaneous spinal epidural hematoma (SSEH) is a relatively uncommon pathology of the spine. The incidence of SSEH is approximately 0.1 – 1 per 100,000 individuals. SSEH can cause acute spinal cord compression and rapid onset of neurologic deficits. Although rare, SSEH must be considered in the differential diagnosis of patients presenting with sudden onset of neurologic symptoms without a history of trauma.Case presentation: We report a case of a 19-year-old female patient who presented with sudden onset of weakness of all four limbs with pain in the upper cervical region. She has no history of trauma. Magnetic Resonance Imaging (MRI) of the spine was done, which showed an epidural mass in the cervical region, causing severe cord compression. Emergency cervical laminectomy and evacuation of epidural hematoma has was done with excellent post-operative recovery.Conclusion: Spontaneous spinal epidural hematoma is a relatively rare entity of the spine. The signs and symptoms of this rare condition are non-specific. In patients presenting with a sudden onset of neurologic deficits, the condition should be one of the differential diagnoses. MRI is the investigation of choice in patients suspected to have SSEH. Early surgical intervention results in a better outcome. The level of preoperative neurologic deficit, the severity of the condition, and operative interval are important factors affecting the postoperative outcome.Keywords: cervical spine, laminectomy, spontaneous spinal epidural hematoma

Spontaneous spinal epidural hematoma presenting with paraparesis: A case report and review of literature

Spontaneous spinal epidural hematoma (SSEH) is a rare and devastating clinical entity. The incidence is considered to be 1 in million/year. SSEH manifests due to accumulation of blood in the epidural space causing compression of the spinal cord and leading to acute neurological deficit. Although it is a rare condition, it must be considered in nontraumatic patients with sudden onset of neurological deficit. Magnetic resonance imaging (MRI) serves as the modality of choice in diagnosing spinal epidural hematoma. Decompressive laminectomy and hematoma evacuation is considered as the mainstay of treatment, although conservative treatment can be tried in limited cases. Here, we present the case of a 48-year-old male who presented with progressive neurologic deficit. MRI revealed spinal epidural hematoma at T10-L4 level with cord compression which was promptly evacuated. Functional recovery was achieved after the surgical intervention.

Clinilcal evaluation on concept of Avarana and its influence in Pakshagata

Ayurvedic literature highlights the symptoms of Pakshagata as Chesta Nivritti either in Vama or Dakshina Parshwa along with Ruja and Vakstambha. Pakshaghata being one among the Vataja Nanatmaja Vyadhi is considered as Mahavata Vyadhi, it can occur either due to Dhatukshaya or Margavarana. Pakshaghata can be correlated with Hemiplegia, which results from cerebrovascular accident - stroke. Stroke is defined as sudden onset of neurologic deficit from vascular mechanism 85% is ischemic and 15% are primary hemorrhages. According to the World Health Organization, 15 million people suffer from stroke world wide each year, of these, 5 million die and another 5 million are permanently disabled. Modern science believes that the brain tissues once damaged completely cannot be repaired by the therapies leading to permanent neurological deficit. Hence, the disease has a poor prognosis, making the person disabled dependent. In present article deals with aetiopathogenesis, clinical features and the role of Avarana and management of disease the Pakshagata from Ayurvedic classics

A prospective study of electrocardiographic and echocardiographic changes in patients with cerebrovascular accidents

Background: Cerebrovascular accident also called as stroke is defined as the sudden onset of neurological deficit that can be attributable to a focal vascular cause. Many studies in the past have demonstrated the fact that neurological abnormalities produce Electrocardiographic changes without any underlying cardiac lesions. Present study is done to analyze different changes in Electrocardiogram and echocardiographic patterns in the cases of cerebrovascular accidents and to assess whether these different changes have got any prognostic significance in these patients.Methods: In this study 100 patients of acute stroke admitted between May 2011 to August 2012 in Vydehi institute of medical sciences and research centre were considered and subjected to CT scan of brain, Electrocardiogram and 2D echocardiography within 24 hours of admission. Follow-up was done within the hospital to know the prognosis of all the patients.Results: Out of 100 patients majority of them had ischemic stroke accounting for 80% and remaining 20% of patients had haemorrhagic stroke. Abnormal Electrocardiographic changes were seen in 64% patients and 58% patients showed abnormal Echocardiography. ECG changes seen are Tachycardia, QTc prolongation, T wave inversion, ST depression, U waves and Bradycardia. Commonly seen echocardiographic changes were LV dysfunction, mitral valve abnormality, aortic valve abnormality. Overall mortality in patients with abnormal ECG was 28.12% compared to 11.11% in patients with normal ECG and it was statistically not significant. Overall mortality in patients with abnormal 2D echocardiography was 31.03% compared to patients with normal 2D Echocardiography which was 4.76% and it was statistically significant.Conclusions: From this study we conclude that ECG abnormalities in stroke patients do not have any prognostic significance. But LV dysfunction has prognostic significance in predicting mortality in cerebrovascular accident.

A prospective study of electrocardiographic and echocardiographic changes in patients with cerebrovascular accidents

Background: Cerebrovascular accident also called as stroke is defined as the sudden onset of neurological deficit that can be attributable to a focal vascular cause. Many studies in the past have demonstrated the fact that neurological abnormalities produce Electrocardiographic changes without any underlying cardiac lesions. Present study is done to analyze different changes in Electrocardiogram and echocardiographic patterns in the cases of cerebrovascular accidents and to assess whether these different changes have got any prognostic significance in these patients.Methods: In this study 100 patients of acute stroke admitted between May 2011 to August 2012 in Vydehi institute of medical sciences and research centre were considered and subjected to CT scan of brain, Electrocardiogram and 2D echocardiography within 24 hours of admission. Follow-up was done within the hospital to know the prognosis of all the patients.Results: Out of 100 patients majority of them had ischemic stroke accounting for 80% and remaining 20% of patients had haemorrhagic stroke. Abnormal Electrocardiographic changes were seen in 64% patients and 58% patients showed abnormal Echocardiography. ECG changes seen are Tachycardia, QTc prolongation, T wave inversion, ST depression, U waves and Bradycardia. Commonly seen echocardiographic changes were LV dysfunction, mitral valve abnormality, aortic valve abnormality. Overall mortality in patients with abnormal ECG was 28.12% compared to 11.11% in patients with normal ECG and it was statistically not significant. Overall mortality in patients with abnormal 2D echocardiography was 31.03% compared to patients with normal 2D Echocardiography which was 4.76% and it was statistically significant.Conclusions: From this study we conclude that ECG abnormalities in stroke patients do not have any prognostic significance. But LV dysfunction has prognostic significance in predicting mortality in cerebrovascular accident.

Application of Muse Cell Therapy to Stroke.

Stroke is defined as a sudden onset of neurologic deficits arising from cerebrovascular complications. It is the second common cause of death around the world and the major cause of disability. Because brain is an organ with complicated neural networks and neurons are highly differentiated, it has been traditionally considered to possess a limited potential for regeneration. The number of stroke patients is increasing, and stroke represents a serious problem from the viewpoint of the national medical economy. Even with the current sophisticated treatments, more than half of stroke patient survivors remain disabled. Therefore, it is imperative to develop a new treatment for promoting functional recovery and repair of the lost neurological circuit. Multilineage-differentiating stress-enduring (Muse) cells are endogenous non-tumorigenic stem cells with pluripotency. After transplantation, Muse cells recognize the injured site through their specific receptor for damage signal, home preferentially into these tissues and spontaneously differentiate into tissue-compatible cells to replace the lost cells, and repair the tissue, delivering functional and structural regeneration. These properties are desirable for the treatment of strokes and advantageous compared to other stem cell therapies. Here, we describe the current status of stem cell therapies for stroke and future possibilities of Muse cell therapy.

Spontaneous Epidural Hematoma of Cervical Spine.

Spontaneous cervical epidural hematoma is an uncommon cause of acute spinal cord compression. This is a rare idiopathic condition that leads to acute onset of neurologic deficits, which if not recognized early can have catastrophic consequences. Acute cervical epidural hematoma is definitely a condition of neurologic emergency. Although it is a rare condition, it must be considered in nontraumatic patients with sudden onset of neurologic deficits. Patients with spontaneous spinal epidural hematoma typically present with acute onset of severe back pain, and they rapidly develop signs of compression of the spinal cord or cauda equina. Here, we present a case of a 31-year-old man who presented with acute onset of neck pain with radicular component with progressive neurologic deficit. Emergent magnetic resonance imaging revealed cervical extradural hematoma with cord compression that was promptly evacuated. Functional recovery was achieved within 48 hours. The level of preoperative neurologic deficit and its severity, as well as operative interval, are important factors significantly affecting the postoperative outcome.

Papillary fibroelastoma, unusual cause of stroke in a young man: a case report

BackgroundPapillary fibroelastoma is the third most common primary benign tumor with an incidence of up to 0.33% in autopsy series; it accounts for approximately 75% of all cardiac valvular tumors.Case presentationWe describe a rare case of a 28-Year-old man that while playing football, had a sudden onset of neurological deficit: aphasia, right hemiparesis and right facial numbness. Transthoracic echocardiography (TTE) showed a 10x10 mm mass attached to the anterior mitral valve leaflet. The patient was treated surgically for the prevention of further embolic complications. Histologic examination of the resected mass revealed a papillary fibroelastoma. It is the third most frequent primary cardiac tumor, after myxoma and fibroma, and the most common primary tumor of heart valves. Despite the benign nature of this tumor, it carries very high risk of embolic complications. The successful complete resection of the papillary fibroelastoma is curative and the long-term postoperative prognosis is excellent.ConclusionsDifferential diagnosis of cardiac masses requires clinical informations, laboratory tests, blood cultures and appropriate use of imaging modalities. Papillary fibroelastoma is a potential cause of embolic stroke in the young. The prompt surgical excision of papillary fibroelastoma is curative and the long-term postoperative prognosis is excellent.

Abstract TMP107: Regular Dental Care Reduces the Risk for Ischemic Stroke: Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Prior epidemiological studies have shown that periodontal disease (PD), also referred to as gum disease, is an independent risk factor for ischemic stroke. We assessed the hypothesis that users of regular dental care may have a lower risk for incident ischemic stroke and specific stroke subtype when compared with users of episodic dental care. Methods: In this prospective, longitudinal community-based cohort study, participants without prior stroke were assessed for dental care utilization represented by patient-reported responses to questionnaires. The pattern of dental care utilization was classified as regular use (every year), episodic use (as needed), or no use (never). Episodic visits, or visits as needed, are considered signs of inadequate utilization of dental care. These participants were followed for incident ischemic strokes. Ischemic stroke diagnoses were defined as sudden onset of neurological deficit(s) lasting ≥24 hours along with neuroimaging confirmation. Strokes were further classified according to etiologic subtype as thrombotic, lacunar, or cardioembolic stroke subtype according to criteria adopted from the National Survey of Stroke. Results: Of 11,242 participants (mean age±SD=62.8±5.6, 56% female, 78% white and 22% African-American) assessed for dental care utilization at the fourth ARIC visit (1996-1998). Over a 15-year follow-up period a total of 583 participants had incident ischemic stroke events, of who 19% were lacunar, 29% were cardioembolic and 45% were of the thrombotic stroke subtype. After adjustment for confounders (race/center, age, gender, BMI, hypertension, diabetes, LDL level, smoking, and education), regular dental care utilization was associated with lower risk for ischemic stroke overall compared with episodic dental users (adjusted HR 0.77, 95% CI 0.63-0.94). Regular dental care specifically lowered the risk of thrombotic stroke subtype (adjusted HR 0.75, 95% CI 0.56-0.99). Conclusions: Results from this prospective cohort study demonstrates an independent association between regular dental care utilization with a lower ischemic stroke risk. Further, we report the highest impact of regular dental care in lowering risk of the thrombotic stroke subtype.

Abstract WP193: Gum Disease and Ischemic Stroke Risk in the Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Gum, or periodontal disease (PD) is a risk factor for cardiovascular disease. We assessed the graded association of PD levels with incident ischemic stroke as well as the etiological stroke subtypes in the Atherosclerosis Risk in Communities (ARIC) study. Methods: PD was assessed by full-mouth periodontal measurements from 6 sites per tooth, in subjects without prior stroke and categorized into periodontal profile class (PPC). A Latent Class Analysis was used to identify 7 distinct PPCs using the entire cohort that included tooth level periodontal measurements and tooth loss. Stroke diagnoses were based on computer derived diagnosis medical record review and imaging confirmation. Classification required evidence of sudden onset of neurological deficit(s) lasting ≥24 hours. Strokes were classified according to etiology as thrombotic, lacunar, and cardioembolic subtypes. Results: At the fourth ARIC visit (1996-1998), a cohort of 6711 subjects (mean age±SD=62.3±5.6, 55% female, 81% white and 19% African-American) were assessed for PD. A total of 299 incident ischemic strokes (47% thrombotic, 26% cardioembolic and 20% lacunar) occurred over a 15-year period. The seven levels of PPC showed a graded association with incident ischemic stroke as noted in the figure. Participants with mild PD (adjusted HR 1.9 95% CI 1.2-3.0), moderate PD group (adjusted HR 2.1 95% CI 1.2-3.5) and severe PD (adjusted HR 2.2 95% CI 1.3-3.8) had an increased risk of incident ischemic stroke, compared with participants without PD after adjustment for confounders (age, race, gender, BMI, hypertension, diabetes, LDL cholesterol, smoking and education). There were class specific associations noted between PD with cardioembolic and thrombotic stroke subtypes. Conclusions: A graded association was noted between incident ischemic stroke and increasing levels of PPC. Further, we report class specific associations between PD with cardioembolic and thrombotic stroke subtypes.

CHILDHOOD POSTERIOR CIRCULATION ISCHEMIC STROKE: AN UNCOMMON CEREBROVASCULAR DISEASE. CASE REPORT

Introduction: Stroke is characterized as a sudden onset of neurological deficit that results from a c erebrovascular event. Themost commonly identified causes of ischemic stroke in children are cerebral arteriopathies, congenital, or acquired cardiac diseases,sickle cell disease, and thrombophilias. In children, due to the low incidence and absence of specific methods to assessand measure correctly this entity, stroke recognition is usually delayed. Case Report: A 20 months-old girl was admitted to theemergency department presenting a history of two episodes of vomits, irritability, continuous crying, and strabismus that startedsuddenly. On neurological assessment, it was found divergent strabismus with right medial rectus muscle palsy and reduced rightpupillary reflex to light associated with instable gait. Brain magnetic resonance imaging (MRI) showed an ischemic lesion on theright pontomesencephalic region. The patient received clinical support. On the fifth day, she was discharged with a prescription ofaspirin, good clinical conditions, stable gait, and persistence of the divergent strabismus. Conclusion: Posterior circulation ischemicstroke is an important cause of morbidity and mortality on pediatric population and must be remembered to avoid diagnosisdelay.

Effects of valsartan on morbidity and mortality in uncontrolled hypertensive patients with high cardiovascular risks: KYOTO HEART Study

Effects of valsartan on morbidity and mortality in uncontrolled hypertensive patients with high cardiovascular risks: KYOTO HEART Study: reply In the KYOTO HEART study, stroke was diagnosed by sudden onset of neurological deficit (showing apparent cognitive or physical disabilities) and the presence of intracranial lesions corresponding to the neurological deficit and hospitalization (not for just diagnosis but for treatment). This is an ordinary diagnosis process for stroke treatment by Japanese physicians, and an isolated computed tomography/magnetic resonance imaging abnormality alone was not used to suffice the diagnosis. Although PROBE method was used in this study, the investigators were kept uninformed about the diagnostic criteria which had been independently determined by the Endpoint committee. In fact, among 558 provisional reports, only 238 (42.7%) were accepted as the primary endpoint by the endpoint committee [valsartan add-on: 83 (41.3%); non-angiotensin receptor blocker (ARB) group: 155 (43.4%)]. We believe that the possible bias would be highly unlikely to account for differences. Rather, the PROBE design may put the study close to daily clinical practice. This was described in detail in the ‘Limitation of this study’ in our publication. Regarding the utilization of aspirin and statins at Trial’s end, we at presence have not the data except anti-hypertensive drugs; however, there was no significant difference at baseline between both groups. The result with regard to stroke in KYOTO HEART study appears to be inconsistent with a recent meta-analysis by Messerli et al. of randomized ARB trials with active comparators (RR, 0.86; CI, 0.72–1.02) or placebo (RR, 0.89; CI, 0.78–1.02), although either meta-analysis showed a trend for better stroke prevention in the ARB arm, and the meta-analyses including both placebo and active treatment exhibited a significant reduction (RR, 0.87; CI, 0.77–0.98). Few Asians (especially Japanese) have participated to the large EU/US trials except RENAAL trial, in which subanalyses in Asian and Japanese subpopulations have reported that relative risk reduction rates in the primary endpoint are 35 and 45%, respectively, much higher than 16% in the whole RENAAL. Messerli et al. also commented that Asians may be particularly receptive to the protective effects of ARBs, as shown in RENAAL. Furthermore, mortality by coronary artery disease is one-third of that in USA, and cerebrovascular disease mortality is over 1.5 times higher than in USA. The percentage of cerebral bleeding is two or three times greater in Japan than in Western countries, and cerebral infarction is mostly caused by lacunar type ischaemic stroke due to hypertensive small vessel disease. It is possible that Asians are more susceptible to hypertension-related vascular disease rather than hyperlipidaemiaassociated vascular disease seen in Western countries. Together with JIKEI Heart Study showing impressive stroke benefits of valsartan in Japanese, a drug-specific molecule effect that stimulates preferentially AT2 receptor/NO-mediated vascular protective action (due to higher AT1 selectivity vs. AT2 compared with other ARBs) may be more apparently emerged in Japanese patients and yield an impressive stroke benefit above and independent of blood pressure lowering.

Cardioembolic infarction in the Sagrat Cor-Alianza Hospital of Barcelona Stroke Registry.

To describe the clinical features of cardioembolic infarcts. Cardioembolic infarct was diagnosed in 231 (15.4%) of 1500 consecutive stroke patients included in a prospective stroke registry over an 8-year period. Cardiac sources of emboli included isolated atrial dysrhythmia (57.1%), valvular heart disease (20.3%), and coronary artery disease (18.2%). Patients with cardioembolic stroke showed a significantly higher (P < 0.00001) frequency of sudden onset of neurological deficit (79.7%) and altered consciousness (31.2%) than patients with lacunar infarct (38% and 1.9%) and atherothrombotic infarction (46% and 24%). Eleven patients had a spectacular shrinking deficit and 6 a presumed cardioembolic lacunar infarct. Early recurrent embolisms occurred in 6.5% of patients mostly (60%) within 7 days of initial embolism. In-hospital mortality was 27.3% (0.8% in lacunar infarcts, 21.7% in atherothrombotic infarction, P < 0.00001). Cardioembolic infarction is a severe subtype of stroke with a high risk of early death. Clinical features at stroke onset may help clinicians to differentiate cerebral infarction subtypes and to establish prognosis more accurately.

The growing specter of MRI-defined brain infarcts

The devastating effects of stroke have been recognized since antiquity. As the name stroke implies, this clinical event is characterized by the sudden onset of neurologic deficits related to vascular disease. An initial hint that vascular disease of the brain was far more pervasive than suggested by the occurrence of strokes due to overt brain infarcts came from pathologic studies showing that small subcortical brain infarcts were common in elderly patients who had no history of a stroke.1 With the advent of sophisticated brain imaging, especially MRI, the frequency of brain infarcts could be quantified initially in groups of select patients and eventually in populations of healthy people. These brain infarcts are common and, although often labeled benign and silent, have been associated with an increased risk of subsequent cognitive impairment, dementia, and stroke.2–6 The descriptor covert was suggested to convey the potentially ominous clinical course in patients harboring these MRI-defined brain …