ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background and PurposeThe aim of the study was to investigate the efficacy and safety of the selective serotonin reuptake inhibitor citalopram in treating poststroke depression, since available treatments are usually poorly tolerated.MethodsA 6-week double-blind, placebo-controlled trial was undertaken. Diagnosis and outcome were determined using the Hamilton Depression Scale, and unwanted effects were measured using the UKU side effect rating scale. Sixtysix consecutive depressed patients from an unselected population of 285 stroke patients aged 25 to 80 years entered the trial 2 to 52 weeks after stroke. They were assigned to equally sized treatment and placebo groups. The initial level of depression was comparable in the two groups (mean baseline Hamilton Depression scores, 19.4 and 18.9, respectively). Demographic parameters were also comparable in the two groups.ResultsSignificantly greater improvement was seen in patients treated with citalopram (10 to 40 mg/d) for 3 and 6 weeks, both when including all patients (intention-to-treat analysis,p<.05) and excluding patients who dropped out during the first 3 weeks (efficacy analysis,P<.005). Half of the 28 patients who entered the trial 2 to 6 weeks after stroke recovered within 1 month, independent of the treatment given. This indicates a high degree of spontaneous recovery in the early phase after stroke. In contrast, recovery was infrequent in placebo group patients who became depressed 7 weeks or more after stroke. No serious side effects related to the treatment were detected; those present were mild and usually transient.ConclusionsThis trial demonstrates that the selective serotonin reuptake inhibitor citalopram offers an advantageous new treatment of poststroke depression that is both safe and effective.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background and PurposeThe aim of this study was to characterize the response of the hypothalamic-pituitary-adre-nal system in the first hours of ischemic stroke and to relate its extent to the occurrence of acute confusional state, volume of brain damage, and clinical outcome.MethodsThe secretion of corticotropin (adrenocorticotropic hormone [ACTH]) and cortisol was studied in 23 patients by determinations at hours 4, 6, 8, 10, and 14 and days 1, 3, 5, and 7 after onset of symptoms. Acute confusional state (DSM-III-R criteria), extent of lesion (volumetry of computed tomographic scans), and neurological and functional outcome (Scandinavian Stroke Scale, Barthel Index scores) were assessed.ResultsThe massive neuroendocrine response observed consisted of an initial phase with concomitantly increased levels of ACTH and cortisol and a second phase with decreased levels of ACTH while high concentrations of cortisol persisted. Initial levels of ACTH but not cortisol were significantly increased in patients with acute confusional state and significantly correlated with volume of brain lesion and neurological and functional outcome.ConclusionsAn early and persisting activation of the hypothalamic-pituitary-adrenal axis was observed in relation to severity of disease. Its characteristic biphasic pattern suggests an initial central stimulation of release of ACTH followed by feedback suppression concomitant with an increased susceptibility of the adrenal gland. Because these hormones are known to exacerbate hypoxic injury to neurons, their massive release in hyperacute stroke may increase the extent of brain damage.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background and PurposeVentricular enlargement and white matter lesions are frequent findings on cerebral magnetic resonance imaging scans of elderly subjects. In demented subjects they seem related to the severity of the dementia, but in nondemented subjects their clinical significance is less clear. We investigated the relation of size of the lateral ventricles and white matter lesions with cognitive function in a population-based random sample of nondemented elderly persons.MethodsThe study population consisted of 90 subjects, aged 65 to 84 years, who were randomly selected from the cohort of the Rotterdam Study, and who were not demented. The presence of white matter lesions and the ventricle-to-brain ratio were assessed on magnetic resonance scans. Participants were tested with a neuropsychological battery that covered a broad range of cognitive functions.ResultsVentricular enlargement and white matter lesions were both and independently associated with poorer performance on all tests. After adjustment for age and sex, ventricular enlargement was significantly associated with worse scores on tests assessing global cognitive function (Mini-Mental State Examination,P=.02;Groninger Intelligence Test,P=.01), memory (Word List Learning delayed recall, P = .03), and executive control functions (Stroop part II, P=.02; Trail Making Test B,P<.01); for white matter lesions the differences were significant for tests measuring executive control functions and mental speed (Trail Making Test A and B,P=.01 andP<.01, respectively; verbal fluency,P=.01), and memory (Word List Learning delayed recall,P=.04).ConclusionsThis study suggests that white matter lesions are primarily related to impairment of subcorticofrontal functions, whereas enlargement of the lateral ventricles is associated with disturbances of cortical functions as well.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background and PurposeRandomized clinical trials have shown that carotid endarterectomy decreases the risk of subsequent stroke in patients with high-grade carotid stenosis and ipsilateral transient ischemic attack or minor stroke. The benefit of surgery is highly dependent on surgical risk. We previously found that patients with ipsilateral hemispheric symptoms were at greater risk of carotid endarterectomy complications compared with those who were asymptomatic or had nonipsilateral symptoms. The goals of the present study were (1) to identify preoperative clinical factors that may increase the risk of complications after carotid endarterectomy in patients with ipsilateral hemispheric symptoms and (2) to develop a risk index based on this patient-level data.MethodsRecords from 1160 carotid endarterectomies performed at 12 academic medical centers composed the primary data set. Hospital charts for the admission during which carotid endarterectomy was performed were systematically reviewed by abstractors using a defined protocol. The present analysis was carried out on data from the subset of patients who had carotid endarterectomy for ipsilateral hemispheric symptoms. Candidate variables were identified based on univariate Fisher's exact tests orx2tests. A risk index was then developed using those variables with a greater than 90% probability of being associated with adverse outcomes.ResultsOf the 697 patients with ipsilateral symptoms, 8.5% had either stroke, myocardial infarction, or died during the postoperative period of hospitalization. Those over the age of 75 had a greater risk of myocardial infarction (6.6% versus 2.3%,P=.024) but not of stroke or death (P<.10). The overall frequencies of adverse outcomes were also higher in the 5 patients with complete ipsilateral carotid occlusions (40% versus 8.2%, p<.01), the 28 patients with ipsilateral intraluminal thrombus (17.9% versus 8.1%,P=.01), and the 65 patients with ipsilateral carotid siphon stenosis (13.9% versus 7.9%,P=.10). There were no differences in adverse outcomes among those with different degrees of ipsilateral stenosis (30% to 49%, 50% to 69%, and 70% to 99%). Adverse outcome rates were similar regardless of the type of symptom (transient ischemic attack, recent ipsilateral minor stroke, remote ipsilateral minor stroke). There were no significant differences in adverse outcome rates based on sex, race, history of angina, recent myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, hypertension, degree of stenosis of the contralateral carotid artery, or presence of ulceration in the ipsilateral artery (Fisher's exact tests,P>.10). A count of variables with greater than 90% probability of being associated with adverse outcomes (age ≤75 years or angiographic evidence of ipsilateral carotid occlusion, stenosis in the region of the carotid siphon, or intraluminal thrombus) was used to form a simple risk index. “High-risk” patients (one or more risk factors) had more than two times the risk of complications compared with “low-risk” patients who had no risk factors (odds ratio, 2.18; 95% confidence interval, 1.25 to 3.81).ConclusionsCertain preoperative clinical variables may place patients with ipsilateral symptoms at greater risk of perioperative complications after carotid endarterectomy. Prospective validation of a simple risk index would provide an additional method for assessing preoperative risk in endarterectomy candidates.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background and PurposeIn a group of patients with highgrade asymptomatic carotid artery stenosis, we prospectively determined the prevalence and radiological characteristics of clinically asymptomatic brain infarction evident on computed tomography. Risk factors and extent of carotid disease were also determined.MethodsPatients randomized into the Asymptomatic Carotid Atherosclerosis Study (ACAS) underwent a neurological history, a detailed stroke/transient ischemic attack questionnaire, and a detailed neurological examination. Computed tomography scans were examined by standardized criteria developed as part of a quality-control program supervised by a neuroradiologist. The presence, location, and size of all cerebral infarctions evident by computed tomography were determined.ResultsAmong 1132 patients, 848 had no history of stroke or transient ischemic attack. One hundred twenty-six patients (15%) had a silent infarct; 95 (11%) had one, 24 (3%) had two, and 7 (1%) had three or more infarcts. The infarct size was small and deep for 117 patients (72%), less than one-half lobe for 45 (28%), and one-half to less than one lobe for 1 (0.5%). The silent infarcts were evenly distributed ipsilaterally and contralaterally to the study artery but were significantly more frequent in the right hemisphere (P<.05). Factors associated with silent infarction were abnormal gait (P<.001), abnormal deep tendon reflexes or plantar responses (P=.038), but not degree of carotid stenosis. Silent infarction was less frequent among this totally asymptomatic cohort (15%) compared with those with transient ischemic attacks (34/139, 25%;P<.001).ConclusionsSilent infarction in the setting of asymptomatic carotid stenosis is not uncommon, but silent infarctions are rarely sizable. The clinical significance of silent cerebral infarction in patients with asymptomatic carotid artery stenosis has yet to be established.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background and PurposeCarotid plaque ulceration is used as one of the determinants in deciding which patients should be submitted to carotid endarterectomy. Uncertainties about its importance persist. Its detection by angiography is an important consideration.MethodsThe detection of ulceration by angiography was compared with observations during endarterectomy in the first 500 patients recruited into the North American Symptomatic Carotid Endarterectomy Trial. This represents the first multicenter compilation of data on this subject and the largest series of patients with both arteriographic and direct surgical observation.ResultsSensitivity and specificity of detecting ulcerated plaques were 45.9% and 74.1%, respectively. The positive predictive value of identifying an ulcer was 71.8%. These results remained unchanged with differing degrees of carotid stenosis and were confirmed by analyses based on receiver operating characteristic (ROC) methodology. The area under the ROC curve (Az) was estimated to be 0.61 (95% confidence interval, 0.55 to 0.67).ConclusionsThese observations from a multicenter study confirm that little agreement exists between angiography and surgical observation in detecting carotid plaque ulceration.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background and PurposeThe aim of this study was to assess the prevalence of extracranial carotid artery atherosclerosis and its relation to principal cardiovascular risk factors at different ages in a sample of the general population.MethodsB-mode ultrasonography was used to investigate the carotid district in 457 subjects (231 men and 226 women; mean age, 55.4±18.7 years; range, 18 to 97 years) in the metropolitan area. The ultrasonographic findings were then related to risk factors.ResultsCarotid plaques were found in 178 subjects (38.9%). The prevalence of atherosclerosis, number of plaques, and severity of stenosis were observed to increase with age. Age (P<.0001), cigarette smoking (P<.0001), male sex (P<.001), total cholesterol (P<.05), and, inversely, the ratio of high-density lipoprotein cholesterol to total cholesterol (P<.05) were found to be independently associated with carotid atherosclerosis. Stratified analysis by sex and age showed effect modifications by age on cigarette smoking, total cholesterol, and the ratio of high-density lipoprotein cholesterol to total cholesterol. After multivariate analysis including interaction terms, cigarette smoking and cholesterol levels were no longer found to be associated with carotid atherosclerosis in elderly subjects. Age (P<.01), total cholesterol (P<.05), and diabetes (P<.05) were positively related to the severity of vascular narrowing.ConclusionsThere is a high prevalence of asymptomatic carotid atherosclerosis in the general population, particularly among the very old. The association between risk factors and carotid atherosclerosis is less pronounced in the elderly than in younger subjects.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background and PurposeWe sought to assess the safety and efficacy of ganglioside GM, in acute (<48 hours), anterior circulation ischemic stroke.MethodsWe screened more than 5000 patients at 13 centers in a randomized, double-blind, placebo-controlled, parallel-treatment, clinical trial and enrolled 287 patients. They received 100 mg GM, or placebo intramuscularly daily for 28 days and were evaluated regularly for 84 days. Number of deaths, the Toronto Stroke Scale, and the Barthel Index were primary outcomes; improvements on the Fugl-Meyer Scale and on a neuropsychological battery were secondary outcomes.ResultsThe groups were balanced for severity, side of stroke, age, sex, race, years of schooling, prior illness, and depression scores. Analyzable data were available on 275 patients; 217 patients completed the trial. Protocol-specified primary and secondary outcome measures showed no significant difference between treatment arms. However, improvement from baseline in the motor component of the Toronto Stroke Scale favored the GM1-treated group at day 28 when GM1treatment stopped (P=.020);at day 84, the difference still favored the GM1-treated group (P=.057). All 10 components of the Barthel Index, the Fugl-Meyer Scale, and four of the five tests in the neuropsychological battery also favored the GM1group. Adverse experiences were similar in the two groups.ConclusionsGM1is safe. However, since only certain post hoc tests showed statistically significant differences or trends favoring GM1, another clinical trial is needed to demonstrate efficacy.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

BackgroundTiclopidine, an antiplatelet agent, when compared with aspirin has been found to reduce the risk of stroke in high-risk patients, ie, those with recent transient ischemic attack, reversible ischemic neurological deficit, amaurosis fugax, or minor stroke. Its cost-effectiveness in such use, however, is unknown.MethodsWe developed a model of primary stroke prevention in which a hypothetical cohort of 100 high-risk men and women 65 years of age was assumed to receive either ticlopidine (500 mg daily) or aspirin (1300 mg daily). Using published data, we estimated lifetime incidence of stroke, life expectancy (unadjusted and adjusted for changes in quality of life), and lifetime medical care costs associated with each therapy.ResultsPatients who receive ticlopidine would experience two fewer initial strokes per hundred than those treated with aspirin. Life expectancy would be extended by approximately one-half month, and lifetime medical care costs (discounted at 5%) would increase by about $2300. The cost-effectiveness of ticlopidine, compared with aspirin, is estimated to range from $31 200 to $55 500 per quality-adjusted life-year gained as the utility of life after nonfatal stroke is assumed to vary from 0.75 to 0.95.ConclusionsTiclopidine therapy to prevent stroke in high-risk patients is cost-effective by current standards of medical practice.

ISSN:0039-2499    

出版商:OVID    

年代:1994

数据来源: OVID