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4-07-39 Simple clinical distinction of stroke type
Cerebrovascular 12 (30.7%) as partial anterior circulation infarction (PACI), 3 (7.6%) as posterior circulation infarction (POCI) and 16 (41 .O%) as lacunar infarction (LACI). Embolic sources were found in 4 (50%) of TACI, in 11 (91 .S%) of PACI, in 1 (33.3%) of POCI and in 10 (62.5%) of LACI (p = 0.043). Although the incidence of probable and possible sources of cardiac embolus is high in hemispheric infarct combined (TACI and PACI = 15/20, 75%); we have found a similarly high incidence in patients with lacunar infarct syndromes (p = 0.48). This suggests that cardiac sources of embolism should not be excluded a priori in patients with clinically and radiologically defined lacunar infarcts.
4-07-35 Geun-Ho Dankook
Vestibular system findings in patients with vertebrobasilar dolichoectasia Lee, Jae-II Kim. Department Universitv. Chonan, Korea
of Neurology;
College
of Medicine,
Impairment of the vestibular system has been reported in patients with vertebrobasilar dolichoectasia (VD), but little is known about the underlying cause of the symptoms. Vestibular tests (including assessment of nystagmus, eye tracking test, caloric test and rotational test) and computerized dynamic posturography were performed in 18 patients with vestibular symptoms associated with VD. Abnormal test results were observed in 10 cases (55.6%). Among patients with abnormal vestibular test findings, 25.3% had evidence suggesting peripheral impairment, 32.8% evidence suggesting central dysfunction. After posturcgraphy, 35% of patients showed vestibular impairment or visual-referenced response in sensory organization test. Increased long-latency reflexes during the motor control test were observed in 17% of the patients. Brainstem and cerebellar ischemia and impaired blood supply to the vestibular labyrinth may play an important role in the genesis of the vestibular dysfunction in patients with VD.
4-07-36
Prevalence of non-atherosclerotic markers in young oriental patients with acute ischemic stroke
S.H. Lee, H. Tjia. Department Singapore
of Neurology,
Tan Tack Seng Hospital,
Aim: We described the characteristic of non-atherosclerotic markers in young oriental patients with acute ischemic stroke. Methods: Sixty-eight patients who were less than 46 years of age were identified from the prospective hospital-based Moulmein Stroke Registry. All were examined by a neurologist and tested for protein S (PS), protein C (PC), antithrombin Ill (AT), antinuclear antibodies (ANA), anticardiolipin antibodies (ACA), lupus anticoagulant (LA), partial thromboplastin time (PTT), and VDRL. Results: Mean age was 40 f 6 yrs, male 71%, Chinese 80%, Malays 12%, and Indians 8%. Atherosclerotic risk factors were: smoking history (SM) 42%, hypertension (HTN) 36%, diabetes mellitus (DM) 16%, mean cholesterol 6.07 mmol/l, cardiac embolism 6%, and internal carotid artery stenosis 6%. Immune markers were: ANA 5 (7%), [titer-l/640 (1) 11160 (1) l/40 (3)]; ACA 3 (4%) (titer-59, 24, 13 GPL U/L); and LA 2 (3%). None had prolonged PTT, and one had positive VDRL associated with syphilis. Procoagulant markers were: PS 2 (titer-53%, 69%) PC 1 (titer-67%) and AT3 1 (titer-74%). One patient who has primary antiphospholipid syndrome had positive ANA, ACA, LA, and low PC. Another patient had positive ANA and low PS. Each of the 10 patients with positive markers had one atherosclerotic risk factor (SM 4, HTN 4, DM 2); 5 had hemispheric infarct, and 5 lacunar infarct. Conclusions: 1) Non-atherosclerotic markers (15%) are infrequent in young oriental stroke patients. 2) They are associated with large and smallvessel infarcts. 3) Their close association with atherosclerotic markers raises doubt whether they are genuine markers of stroke or simply predictors of atherosclerosis 4) Further control studies are necessary to determine whether non-atherosclerotic markers are independent predictors of ischemic stroke and to clarify the possible interaction between non-atherosclerotic markers and atherosclerotic risk factors.
4-07-37
Determinants of early mortality of oriental patients
S.H. Lee, H. Tjia. Department Singapore
of Neurology
in ischemic stroke
Tan Tack Seng Hospital,
Background: There is scanty data concerning the determinants of earty mortality in stroke populations with predominant intracranial atherosclerotic disease. Aim: To determine the prognostic factors of inhospital mortality in oriental stroke patients. Methods: We analysed 1366 consecutive acute ischemic stroke patients from the prospective hospital-based Moulmein Stroke Registry. All patients were examined by a neurologist within 24 hours of admission and coded with a standard protocol. Large infarct was defined as infarct affecting more than the equivalent of one lobe. The patients were also grouped into small
Diseases
s221
vessel (lacunar) and large vessel (nonlacunar) infarcts. Variables identified by univartate analyses were entered into a regression analysis. Results: There were 90 (7%) cases of inhospital mortality. The predictor of inhospital mortality were impaired consciousness at admission (p = 0.0001, OR = 9.39, 95% Cl = 5.12 to 17.25). previous stroke (p = 0.0007, OR = 2.65, 95% Cl = 1.49 to 4.66) large infarct (p = 0.0173, OR = 2.04, 95% Cl = 1.14 to 3.7) and large vessel infarct (p = 0.009, OR = 2.97, 95% Cl = 1.31 to 6.78). Conclusion: Impaired consciousness is the most powerful independent predictor of early mortality, controlling for previous stroke, large infarct size, and large vessel infarct. This suggests that in addition to extent of parenchymal damage, strategic involvement of the reticular activating system or its projections may have a detrimental effect on survival. These findings will affect selection of patients for early treatment, and therapeutic strategies that reduce the extent of parenchymal damage should improve outcome of ischemic stroke. The possible association between damage to the reticular activating system and impaired survival requires further study.
4-07-38
Silent cerebral lesions in patients with chronic chagas disease (CCD). Preliminary data
S. Lepera ‘, J.M. Wainstein2, M. Vallasa3, M. Cohen ‘, J.P. Chiale3, R.C. Rey ’ , R.E.P. Sica ’ ’ Div. Neuroiogia, Htal. Ramos Mejia, Bs.As., Argentina, *Div. Radiolcgia, Htal. Ramos Mejia, &As., Argentina, 3Div. Cardiologia, Htal. Ramos Mejia, BsAs., Argentina Chagas Disease is an endemic South American Trypanosomiasis. In Argentina 7.2% of the population is infected. The usual clinical manifestations are myocardiopathies (MP). Non ischemic dilated MP is considered the third frequent source of cardioembolic stroke in our series (Rey et al, 1992). Objective: to assess the frequence of silent cerebral lesions in CCD patients with different grades of MP. Design-Methods: we have submitted 30 patients with CCD, (21 men, age x 51.5) to a systematic prospective and blind design including cardiological and neurological examination and cerebral TC scan. MPs were classified following Rossembaum criteria. Neurologic exam was considered positive when focal signs in more than one hemicorporal area were found, or when there was relationship between focal signs and asymmetric miotatic reflexes. Patients were searched for habitual cerebrovascular risk factor (RF). Results: Fourteen patients (46.7%) had MP Ill, ten (33.3%) MP II, five (16.7%) MP IV and one (3.3%) MP I. Four patients had abnormal neurological exam and no focal lesion in their TC scans. Twenty two patients had RF. Cerebral TC scans were normal in twenty one patients (70%). We found two (6.6%) with focal ischemic lesions (one of them without RF, with MP Ill). Seven patients (23%) (4 with RF) had cerebral atrophy greater than expected for their age, with MP II and Ill. Discussion: We could not demonstrate in our study that the presence of silent cerebral lesions is related to the grade of MP, it may be due to the little number of MP of high grade in our population. But, seven of our patients had cerebral atrophy, greater than expected for their age. This may be related to previous reports on neuropsychological impairment in CCD (Mangone et al, 1992). Our findings suggest a different lesional pathway from vascular involvement in CCD, it will be necessary to study a greater number of patients to confirm this.
4-07-39
Simple clinical distinction
of stroke type
T. Lepic, T. Ilic, A. Jovcic, D. Djordjevic, V. Martic, Neurolog) Military Medical Academy; Belgrade,
R. Raicevic.
Clinic of
Yugoslavia
Early distinction between cerebral hemorrhage and infarction is very important since clinical management of the two types of stroke differs substantially. Distinction between cerebral hemorrhage and ischemic stroke is usually made by computed tomography (CT). Clinical methods for stroke type distinction are interesting for early orientation in home of patients and emergency unit. We investigated 420 patients in aim to determine diagnostic value of simple method for stroke type distinction, exclusively on clinical grounds. Definite diagnosis was obtained by brain CT examination. There were 316 patients with cerebral infarction and 104 with cerebral hemorrhage. Considering numerous risk factors for stroke we undertake multiple regression analysis, and extracted only 5 clinical parameters. Headache, bilateral extensor plantar response and diastolic hypertension (1110 mm Hg) indicated on cerebral hemorrhage, while cardiac diseases, unilateral extensor response and previous TIA suggested on ischaemic infarction. Results showed positive predictive value of 67% for cerebral hemorrhage, and 74% for infarction with accuracy of 71%. Comparing our results with two widely accepted scoring systems (Siriraj stroke score, Bessons score) we did not find a statistically significant difference. Hence, we proposed this simple clinical method as valuable diagnostic tool, especially in primary care settings.
4-07-35 Geun-Ho Dankook
Vestibular system findings in patients with vertebrobasilar dolichoectasia Lee, Jae-II Kim. Department Universitv. Chonan, Korea
of Neurology;
College
of Medicine,
Impairment of the vestibular system has been reported in patients with vertebrobasilar dolichoectasia (VD), but little is known about the underlying cause of the symptoms. Vestibular tests (including assessment of nystagmus, eye tracking test, caloric test and rotational test) and computerized dynamic posturography were performed in 18 patients with vestibular symptoms associated with VD. Abnormal test results were observed in 10 cases (55.6%). Among patients with abnormal vestibular test findings, 25.3% had evidence suggesting peripheral impairment, 32.8% evidence suggesting central dysfunction. After posturcgraphy, 35% of patients showed vestibular impairment or visual-referenced response in sensory organization test. Increased long-latency reflexes during the motor control test were observed in 17% of the patients. Brainstem and cerebellar ischemia and impaired blood supply to the vestibular labyrinth may play an important role in the genesis of the vestibular dysfunction in patients with VD.
4-07-36
Prevalence of non-atherosclerotic markers in young oriental patients with acute ischemic stroke
S.H. Lee, H. Tjia. Department Singapore
of Neurology,
Tan Tack Seng Hospital,
Aim: We described the characteristic of non-atherosclerotic markers in young oriental patients with acute ischemic stroke. Methods: Sixty-eight patients who were less than 46 years of age were identified from the prospective hospital-based Moulmein Stroke Registry. All were examined by a neurologist and tested for protein S (PS), protein C (PC), antithrombin Ill (AT), antinuclear antibodies (ANA), anticardiolipin antibodies (ACA), lupus anticoagulant (LA), partial thromboplastin time (PTT), and VDRL. Results: Mean age was 40 f 6 yrs, male 71%, Chinese 80%, Malays 12%, and Indians 8%. Atherosclerotic risk factors were: smoking history (SM) 42%, hypertension (HTN) 36%, diabetes mellitus (DM) 16%, mean cholesterol 6.07 mmol/l, cardiac embolism 6%, and internal carotid artery stenosis 6%. Immune markers were: ANA 5 (7%), [titer-l/640 (1) 11160 (1) l/40 (3)]; ACA 3 (4%) (titer-59, 24, 13 GPL U/L); and LA 2 (3%). None had prolonged PTT, and one had positive VDRL associated with syphilis. Procoagulant markers were: PS 2 (titer-53%, 69%) PC 1 (titer-67%) and AT3 1 (titer-74%). One patient who has primary antiphospholipid syndrome had positive ANA, ACA, LA, and low PC. Another patient had positive ANA and low PS. Each of the 10 patients with positive markers had one atherosclerotic risk factor (SM 4, HTN 4, DM 2); 5 had hemispheric infarct, and 5 lacunar infarct. Conclusions: 1) Non-atherosclerotic markers (15%) are infrequent in young oriental stroke patients. 2) They are associated with large and smallvessel infarcts. 3) Their close association with atherosclerotic markers raises doubt whether they are genuine markers of stroke or simply predictors of atherosclerosis 4) Further control studies are necessary to determine whether non-atherosclerotic markers are independent predictors of ischemic stroke and to clarify the possible interaction between non-atherosclerotic markers and atherosclerotic risk factors.
4-07-37
Determinants of early mortality of oriental patients
S.H. Lee, H. Tjia. Department Singapore
of Neurology
in ischemic stroke
Tan Tack Seng Hospital,
Background: There is scanty data concerning the determinants of earty mortality in stroke populations with predominant intracranial atherosclerotic disease. Aim: To determine the prognostic factors of inhospital mortality in oriental stroke patients. Methods: We analysed 1366 consecutive acute ischemic stroke patients from the prospective hospital-based Moulmein Stroke Registry. All patients were examined by a neurologist within 24 hours of admission and coded with a standard protocol. Large infarct was defined as infarct affecting more than the equivalent of one lobe. The patients were also grouped into small
Diseases
s221
vessel (lacunar) and large vessel (nonlacunar) infarcts. Variables identified by univartate analyses were entered into a regression analysis. Results: There were 90 (7%) cases of inhospital mortality. The predictor of inhospital mortality were impaired consciousness at admission (p = 0.0001, OR = 9.39, 95% Cl = 5.12 to 17.25). previous stroke (p = 0.0007, OR = 2.65, 95% Cl = 1.49 to 4.66) large infarct (p = 0.0173, OR = 2.04, 95% Cl = 1.14 to 3.7) and large vessel infarct (p = 0.009, OR = 2.97, 95% Cl = 1.31 to 6.78). Conclusion: Impaired consciousness is the most powerful independent predictor of early mortality, controlling for previous stroke, large infarct size, and large vessel infarct. This suggests that in addition to extent of parenchymal damage, strategic involvement of the reticular activating system or its projections may have a detrimental effect on survival. These findings will affect selection of patients for early treatment, and therapeutic strategies that reduce the extent of parenchymal damage should improve outcome of ischemic stroke. The possible association between damage to the reticular activating system and impaired survival requires further study.
4-07-38
Silent cerebral lesions in patients with chronic chagas disease (CCD). Preliminary data
S. Lepera ‘, J.M. Wainstein2, M. Vallasa3, M. Cohen ‘, J.P. Chiale3, R.C. Rey ’ , R.E.P. Sica ’ ’ Div. Neuroiogia, Htal. Ramos Mejia, Bs.As., Argentina, *Div. Radiolcgia, Htal. Ramos Mejia, &As., Argentina, 3Div. Cardiologia, Htal. Ramos Mejia, BsAs., Argentina Chagas Disease is an endemic South American Trypanosomiasis. In Argentina 7.2% of the population is infected. The usual clinical manifestations are myocardiopathies (MP). Non ischemic dilated MP is considered the third frequent source of cardioembolic stroke in our series (Rey et al, 1992). Objective: to assess the frequence of silent cerebral lesions in CCD patients with different grades of MP. Design-Methods: we have submitted 30 patients with CCD, (21 men, age x 51.5) to a systematic prospective and blind design including cardiological and neurological examination and cerebral TC scan. MPs were classified following Rossembaum criteria. Neurologic exam was considered positive when focal signs in more than one hemicorporal area were found, or when there was relationship between focal signs and asymmetric miotatic reflexes. Patients were searched for habitual cerebrovascular risk factor (RF). Results: Fourteen patients (46.7%) had MP Ill, ten (33.3%) MP II, five (16.7%) MP IV and one (3.3%) MP I. Four patients had abnormal neurological exam and no focal lesion in their TC scans. Twenty two patients had RF. Cerebral TC scans were normal in twenty one patients (70%). We found two (6.6%) with focal ischemic lesions (one of them without RF, with MP Ill). Seven patients (23%) (4 with RF) had cerebral atrophy greater than expected for their age, with MP II and Ill. Discussion: We could not demonstrate in our study that the presence of silent cerebral lesions is related to the grade of MP, it may be due to the little number of MP of high grade in our population. But, seven of our patients had cerebral atrophy, greater than expected for their age. This may be related to previous reports on neuropsychological impairment in CCD (Mangone et al, 1992). Our findings suggest a different lesional pathway from vascular involvement in CCD, it will be necessary to study a greater number of patients to confirm this.
4-07-39
Simple clinical distinction
of stroke type
T. Lepic, T. Ilic, A. Jovcic, D. Djordjevic, V. Martic, Neurolog) Military Medical Academy; Belgrade,
R. Raicevic.
Clinic of
Yugoslavia
Early distinction between cerebral hemorrhage and infarction is very important since clinical management of the two types of stroke differs substantially. Distinction between cerebral hemorrhage and ischemic stroke is usually made by computed tomography (CT). Clinical methods for stroke type distinction are interesting for early orientation in home of patients and emergency unit. We investigated 420 patients in aim to determine diagnostic value of simple method for stroke type distinction, exclusively on clinical grounds. Definite diagnosis was obtained by brain CT examination. There were 316 patients with cerebral infarction and 104 with cerebral hemorrhage. Considering numerous risk factors for stroke we undertake multiple regression analysis, and extracted only 5 clinical parameters. Headache, bilateral extensor plantar response and diastolic hypertension (1110 mm Hg) indicated on cerebral hemorrhage, while cardiac diseases, unilateral extensor response and previous TIA suggested on ischaemic infarction. Results showed positive predictive value of 67% for cerebral hemorrhage, and 74% for infarction with accuracy of 71%. Comparing our results with two widely accepted scoring systems (Siriraj stroke score, Bessons score) we did not find a statistically significant difference. Hence, we proposed this simple clinical method as valuable diagnostic tool, especially in primary care settings.