摘要:

Background and PurposeArteriovenous malformations (AVMs) have an overall 2% to 4% annual risk of hemorrhage. The purpose of this study was to determine whether specific clinical and radiographic factors predispose AVMs to bleed and to predict the bleeding risk for individual AVM patients.MethodsWe reviewed the clinical histories and cerebral angiograms of 315 AVM patients who underwent stereotactic radiosurgery at our center. One half of the patient data (analysis cohort) was used to determine risk factors for bleeding and to construct AVM hemorrhage risk groups. These risk groups were then tested with the second half of the patient data (test cohort).ResultsThe mean AVM volume was 4.0 +/- 3.4 mL (approximate maximum diameter of 2 cm). One hundred ninety-six initial hemorrhages occurred in 10 348 patient-years for an annual initial bleed rate of 1.89%; 44 of these 196 patients had a repeat bleed in 591 patient-years for an annual rebleed rate of 7.45%. The overall crude annual hemorrhage rate was 2.40%. Multivariate analysis revealed three factors associated with hemorrhage: history of a prior bleed (relative risk [RR], 9.09; 95% confidence interval [CI], 5.44 to 15.19; P < .001), a single draining vein (RR, 1.66; 95% CI, 1.13 to 2.38; P < .01), and a diffuse AVM morphology (RR, 1.64; 95% CI, 1.12 to 2.46; P < .01). Four AVM hemorrhage risk groups were constructed on the basis of the significant factors. The annual rate of bleeding was 0.99% for low-risk AVMs, 2.22% for intermediate-low-risk AVMs, 3.72% for intermediate-high-risk AVMs, and 8.94% for high-risk AVMs.ConclusionsAnalysis of a large group of AVM patients who underwent stereotactic radiosurgery demonstrated that small AVMs have an annual hemorrhage risk similar to that of the general AVM population. AVM patients have a wide variability of bleeding risk that can be predicted from their clinical presentation and the angiographic characteristics of the AVM. The management of AVM patients should be based not only on the morbidity of the proposed treatment but also those factors that predispose individual patients to either a low or high hemorrhage risk.(Stroke. 1996;27:1-16.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background and PurposeFirst-degree relatives of patients with subarachnoid hemorrhage (SAH) have a three to seven times greater risk of SAH than second-degree relatives and than the general population. If hypertension, which is in part genetically determined, contributes to this increased risk, the frequency of hypertension and its sequelae would be expected to be higher in first- than in second-degree relatives of patients with SAH.MethodsWe compared the reported frequency of hypertension, stroke, and coronary heart disease between 1290 first- and 3588 second-degree relatives of a prospective series of patients with SAH.ResultsThe relative risk adjusted for age and survival status in first-degree relatives was 2.3 (95% confidence interval [CI], 1.9 to 2.9) for hypertension, 1.8 (95% CI, 1.3 to 2.4) for stroke, and 1.9 (95% CI, 1.5 to 2.3) for coronary heart disease.ConclusionsHypertension is a familial factor contributing to the risk of SAH. Hypertension should be sought and treated in first-degree relatives of patients with SAH to reduce the increased risk of cerebrovascular and cardiovascular diseases.(Stroke. 1996;27:7-9.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background and PurposeMarfan syndrome is a heritable disorder of connective tissue caused by a deficiency of the glycoprotein fibrillin. In several publications and neurological textbooks, a relationship between Marfan syndrome and intracranial aneurysms has been assumed.MethodsThe records of 135 patients classified as having Marfan syndrome who visited the Amsterdam Marfan clinic or were admitted to the departments of neurology and neurosurgery and the records of all patients with a subarachnoid hemorrhage or intracranial aneurysm who visited or were admitted to the departments of neurology and neurosurgery between January 1, 1982, and January 1, 1994, were retrieved. The literature was reviewed regarding Marfan syndrome and intracranial aneurysms.ResultsNo patient visiting the Marfan clinic had a symptomatic intracranial aneurysm. No patient with Marfan syndrome had been admitted with a ruptured intracranial aneurysm at the departments of neurology or neurosurgery in this period, while during that period 826 patients with symptomatic intracranial aneurysms had been admitted. During follow-up of 129 of the 135 patients with Marfan syndrome (2850 retrospective patient observation years and 581 prospective patient observation years), none presented a symptomatic intracranial aneurysm. The suggested relationship between Marfan syndrome and intracranial aneurysms is based mainly on 10 case reports. However, the diagnosis of Marfan syndrome is doubtful in several of these reports. Several large studies of patients with Marfan syndrome did not mention a ruptured intracranial aneurysm as a clinical manifestation.ConclusionsWe conclude that there is insufficient evidence to presume a relationship between symptomatic intracranial aneurysms and Marfan syndrome on the basis of currently available data.(Stroke. 1996;27:10-12.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background and PurposeAfter a craniotomy for cerebral aneurysm, postoperative mortality can be significant. Previous studies have shown that hospitals performing frequent highrisk procedures (such as coronary artery bypass) have a lower mortality than hospitals where these procedures are performed infrequently.MethodsThe Statewide Planning and Research Cooperative System of the New York State Department of Health reviewed all discharges in New York State from 1987 through 1993 for the diagnoses of subarachnoid hemorrhage and/or cerebral aneurysm and for patients with the procedure code for craniotomy for ruptured or unruptured cerebral aneurysm. Inhospital mortality and length of stay were examined in relation to the volume of craniotomies for aneurysm performed at each individual hospital.Results30 craniotomies per year for cerebral aneurysm compared with hospitals performing less surgery (8.8% versus 15.5%, P < .0001). For all patients who underwent craniotomy for unruptured cerebral aneurysm (n = 1604), there was an identical 43% (95% confidence interval, 14% to 73%) reduction in mortality in hospitals performing more than 30 craniotomies per year for cerebral aneurysm (4.6% versus 8.1%, P = .0087).ConclusionsHospitals that frequently perform aneurysm operations have lower mortality rates for patients undergoing craniotomy for cerebral aneurysm than hospitals that perform fewer operations.(Stroke. 1996;27:18-23.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background and PurposeThe aim of the study was to observe patients on a stroke unit and to compare their activity with that of patients on conventional hospital wards to identify aspects of rehabilitation practice that might account for differences in outcome.MethodsStroke patients admitted to the hospital were observed on three 8-hour shifts over 3 consecutive days. An observer recorded, at 10-minute intervals, where patients were, what they were doing, and whether their positioning was as recommended by rehabilitation therapists. Patients on a stroke unit were compared with those on conventional wards.ResultsStroke unit patients spent less time by their beds and more time in other locations on the ward (P < .001). There were significant differences in the frequency of behaviors observed in the two types of ward (P < .001). Stroke unit patients had significantly more interaction with nurses and therapists (P < .001). They were also more often in the recommended position (P less than .001).ConclusionsThe proportion of time in therapeutic activity was low in all locations, with patients spending many hours sitting and doing nothing. Despite this, stroke unit patients had more therapeutic contact with staff and were more often in the recommended position. These two features may account for some of the differences in outcome.(Stroke. 1996;27:18-23.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background and PurposeThere is some evidence from previous studies that idiopathic normal-pressure hydrocephalus (NPH) of the elderly might be linked to vascular leukoencephalopathy. The purpose of this study was to examine the prevalence and impact of vascular risk factors and vascular diseases in idiopathic NPH compared with a control cohort.MethodsThe prevalence of arterial hypertension; diabetes mellitus; hypercholesterolemia; hyperlipidemia; smoking; obesity; and cardiac, cerebrovascular, and other arteriosclerotic diseases was assessed in 65 patients with idiopathic NPH. The findings were compared with those of 70 patients with comparable age distribution. To describe the differences of the prevalences of vascular risk factors, odds ratios were obtained by univariate and multivariate analyses.ResultsThe univariate analysis revealed significant associations between idiopathic NPH and arterial hypertension (prevalence, 54 of 65 [83%]; control group, 25 of 70 [36%]; P < .001) and diabetes mellitus (prevalence, 31 of 63 [49%]; control group, 20 of 70 [29%]; P < .015) but not with other vascular risk factors. After multivariate regression analysis, only hypertension remained significantly associated with NPH (P < .0001). There was also a significant association between NPH and cardiac (P < .001), cerebral arteriosclerotic (P = .007), and other arteriosclerotic diseases (P = .001). A positive association was found between the severity of clinical symptoms of NPH and the presence of hypertension, especially for gait disturbance. The presence of hypertension was not related to the duration of NPH.ConclusionsOur data show a highly significant association between idiopathic NPH and arterial hypertension. Arterial hypertension might be involved in the pathophysiological mechanisms promoting idiopathic NPH.(Stroke. 1996;27:24-29.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background and PurposeVascular dementia (VD) has been an ill-defined term thus far. Recently detailed criteria for the diagnosis of VD have been proposed (Alzheimer's Disease Diagnostic and Treatment Centers [ADDTC], 1992; Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV], 1994; International Classification of Diseases, 10th revision [ICD-10], 1992, 1993; and National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences [NINDS-AIREN], 1993). Until now the clinical feasibility of these diagnostic guidelines has not been evaluated.MethodsThis study aimed to compare these criteria in an unselected sample of 167 elderly patients (mean age, 72.0 +/- 9.9 years) admitted with probable dementia.ResultsThe number of cases that could be classified as VD differed widely between the various diagnostic guidelines. According to DSM-IV criteria, 45 cases were diagnosed as VD. Twenty-one cases fulfilled the ICD-10 research criteria, but only 12 met the NINDS-AIREN criteria for VD. Twenty-three cases were classified as ischemic VD as defined by the ADDTC criteria. The concordance was very poor since only 5 cases met the criteria for VD of all diagnostic guidelines.ConclusionsOur results show that the classification according to different diagnostic guidelines yields rather distinct groups of patients. The reasons responsible for these findings are as follows: (1) different criteria for dementia, (2) limitation to ischemic VD in the ADDTC criteria, (3) no further differentiation of VD into subtypes according to CT or MRI findings (DSM-IV), and (4) the multifactorial etiopathology of VD. Major diagnostic difficulties ensue from the very frequent cases with white matter lesions, since their etiology and classification remain widely unknown.(Stroke. 1996;27:30-36.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background and PurposeAlthough insulin resistance and hyperinsulinemia play a crucial role in the pathogenesis of atherosclerosis, little is known about their roles in ischemic stroke. The purpose of this study was to clarify whether insulin resistance and hyperinsulinemia are causative factors in the pathogenesis of ischemic stroke.MethodsThirty-four consecutive patients with ischemic stroke, who were normotensive, nondiabetic, and not obese, were classified into three groups--atherothrombotic infarction (n = 16), lacunar infarction (n = 10), and cardioembolic infarction (n equals 8)--based on clinical findings, brain imaging, and cerebral angiography. Both oral glucose tolerance tests and lipid analyses were performed. Insulin sensitivity was determined by the steady state plasma glucose method with the use of octreotide acetate. Data were compared with those of healthy control subjects (n = 15).ResultsSteady state plasma glucose levels were significantly higher in the atherothrombotic infarction group compared with control subjects and the other two stroke groups, indicating the presence of insulin resistance in patients with atherothrombotic infarction. In the atherothrombotic infarction group, the 2-hour insulin area (area under the plasma insulin concentration curve) during a 75-g oral glucose tolerance test was significantly increased and dyslipidemic changes (increased triglyceride and apolipoprotein B, decreased high-density lipoprotein) were observed, whereas these changes were not found in the lacunar infarction and cardioembolic stroke groups.ConclusionsInsulin resistance in association with compensatory hyperinsulinemia and dyslipidemia may be an important pathogenetic factor underlying the development of athero-thrombotic infarction.(Stroke. 1996;27:37-43.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background and PurposeA common missense mutation in coagulation factor V (Arg 506 Gln) creates phenotypic resistance to the anticoagulant effects of activated protein C and predisposes carriers to venous thrombosis. To assess a correlation between this common hypercoagulable state and ischemic cerebrovascular disease, we have compared the prevalence of this mutation in a group of stroke patients with that in several control patient groups.MethodsThe presence of the factor V Arg 506 Gln mutation was determined by a direct polymerase chain reaction-based assay on peripheral blood leukocytes from 161 elderly patients with acute ischemic stroke, 116 elderly patients with stroke risk factors but without acute stroke, 54 healthy elderly control subjects, and 287 younger control individuals (197 blood donors and 90 neonates).ResultsThe prevalence of the heterozygous Arg 506 Gln factor V mutation was not significantly different in the elderly stroke patients (2.5%) compared with either of the agematched control groups (2% to 4%). The prevalence of this mutation was significantly higher in each of two younger control groups (approximately 8%) than in the elderly stroke patients (2.5%).ConclusionsThe common factor V Arg 506 Gln mutation predisposing to venous thrombosis is not a significant genetic risk factor for ischemic stroke in the elderly.(Stroke. 1996;27:44-88.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Background and PurposeNear-infrared spectroscopy is a technique that can potentially monitor changes in cerebral oxygenation. There are at present limited clinical data regarding the value of this technology in relating neurological outcome to cerebrovascular hemoglobin oxygen saturation (Sco2). This investigation reports changes in Sco2due to carotid cross-clamping during carotid endarterectomy in awake patients.MethodsSco2was monitored in 38 adult patients undergoing 41 carotid endarterectomies under regional anesthesia. Ipsilateral and contralateral hemispheres were monitored simultaneously during 36 operations, with ipsilateral monitoring alone in the remaining 5 operations.ResultsNo significant difference was detected between ipsilateral and contralateral Sco2during preclamp or postclamp periods. Carotid cross-clamping caused a statistically significant (P < .01) decrease in the ipsilateral Sco2, which decreased from 71.8 +/- 6.91% to 65.8 +/- 8.2%, while the contralateral Sco2remained stable at 70.5 +/- 7.5% and 70.3 +/- 7.9%. The change in ipsilateral Sco2ranged from positive 2.6% to negative 28.6% of the preclamp value. The difference between ipsilateral and contralateral Sco2during cross-clamping was statistically significant (P < .001). The duration of cross-clamping was 39 +/- 11 minutes (range, 18 to 89 minutes). The decrease in ipsilateral Sco2was highly variable from patient to patient and did not correlate with the duration of cross-clamping.ConclusionsThese results suggest that carotid artery occlusion causes a statistically significant but variable decrease in Sco2in the majority of patients. Data in this investigation provide a range of Sco2values that was not associated with a clinically detectable neurological dysfunction.(Stroke. 1996;27:49-55.)

ISSN:0039-2499    

出版商:OVID    

年代:1996

数据来源: OVID