Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000017100.68294.52
A. Feydy, R. Carlier, A. Roby-Brami, B. Bussel, F. Cazalis, L. Pierot, Y. Burnod, M. Maier
Background and Purpose— The goal of this study was to characterize cortical reorganization after stroke and its relation with the site of the stroke-induced lesion and degree of motor recovery using functional MRI (fMRI). Methods— Fourteen stroke patients with an affected upper limb were studied longitudinally. Three fMRI sessions were performed over a period of 1 to 6 months after stroke. Upper limb recovery, Wallerian degeneration of the pyramidal tract, and responses to transcranial magnetic stimulation were assessed. Results— Two main patterns of cortical reorganization were found. Pattern 1 was focusing, in which, after initial recruitment of additional ipsilateral and contralateral areas, activation gradually developed toward a pattern of activation restricted to the contralateral sensorimotor cortex in 9 patients. Five patients were found to have pattern 2, persistent recruitment, in which there was an initial and sustained recruitment of ipsilateral activity. Occurrence of recruitment or focusing seemed to depend mainly on whether the primary motor cortex (M1) was lesioned; persistent recruitment was observed in 3 of 4 patients with M1 injury, and focusing was seen in 8 of 10 patients with spared M1. These patterns had no relation to the degree of recovery; in particular, focusing did not imply recovery. However, there was a clear relation between the degree of recovery and the degree of Wallerian degeneration. Conclusions— These results suggest that ipsilateral recruitment after stroke corresponds to a compensatory corticocortical process related to the lesion of the contralateral M1 and that the process of compensatory recruitment will persist if M1 is lesioned; otherwise, it will be transient.
{"title":"Longitudinal Study of Motor Recovery After Stroke: Recruitment and Focusing of Brain Activation","authors":"A. Feydy, R. Carlier, A. Roby-Brami, B. Bussel, F. Cazalis, L. Pierot, Y. Burnod, M. Maier","doi":"10.1161/01.STR.0000017100.68294.52","DOIUrl":"https://doi.org/10.1161/01.STR.0000017100.68294.52","url":null,"abstract":"Background and Purpose— The goal of this study was to characterize cortical reorganization after stroke and its relation with the site of the stroke-induced lesion and degree of motor recovery using functional MRI (fMRI). Methods— Fourteen stroke patients with an affected upper limb were studied longitudinally. Three fMRI sessions were performed over a period of 1 to 6 months after stroke. Upper limb recovery, Wallerian degeneration of the pyramidal tract, and responses to transcranial magnetic stimulation were assessed. Results— Two main patterns of cortical reorganization were found. Pattern 1 was focusing, in which, after initial recruitment of additional ipsilateral and contralateral areas, activation gradually developed toward a pattern of activation restricted to the contralateral sensorimotor cortex in 9 patients. Five patients were found to have pattern 2, persistent recruitment, in which there was an initial and sustained recruitment of ipsilateral activity. Occurrence of recruitment or focusing seemed to depend mainly on whether the primary motor cortex (M1) was lesioned; persistent recruitment was observed in 3 of 4 patients with M1 injury, and focusing was seen in 8 of 10 patients with spared M1. These patterns had no relation to the degree of recovery; in particular, focusing did not imply recovery. However, there was a clear relation between the degree of recovery and the degree of Wallerian degeneration. Conclusions— These results suggest that ipsilateral recruitment after stroke corresponds to a compensatory corticocortical process related to the lesion of the contralateral M1 and that the process of compensatory recruitment will persist if M1 is lesioned; otherwise, it will be transient.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"39 1","pages":"1610-1617"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82093540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000016507.94646.E6
E. Stolz, T. Gerriets, R. Bödeker, M. Hügens-Penzel, M. Kaps
Background— In recent studies, coma, cerebral hemorrhage, older age, and infectious origin have been identified as prognostic factors in cerebral venous thrombosis (CVT). However, no studies of the prognosis of CVT have evaluated hemodynamic factors. However, it is conceivable that the presence or absence and the efficiency of venous collaterals, as well as recanalization, may have an impact on brain tissue damage and hence on the prognosis of acute CVT. Methods— Twenty-six patients with acute CVT (mean age, 40±15 years) were recruited prospectively. All patients were treated with intravenous heparin, followed by oral anticoagulation for 12 months, except for 2 patients who were lost to follow-up after hospital discharge. Neurological deficits were graded on the National Institute of Health Stroke Scale on admission, at hospital discharge, and at 90±14 days after admission. The functional clinical outcome was graded on the modified Rankin Scale on day 90 after admission. All patients received a venous transcranial duplex sonography (TCCS) on admission and were followed up in case of a pathological result until normalization was recorded (mean follow-up, 316±395 days; range, 13 to 1180 days). Results— Initial TCCS was pathological in 18 of 26 patients (69%). Four distinct venous drainage types were identified: increased drainage to the cavernous sinus and to the deep cerebral veins, flow reversal in the basal veins, and either compensatory increased or reversed flow in the transverse sinus. Initially normal venous TCCS or normalized TCCS within 90 days was significantly related to favorable outcome. Conclusions— TCCS can be used to evaluate venous drainage patterns in acute CVT. Furthermore, initially normal and normalization of initially pathological venous TCCS within 90 days is related to a favorable outcome in this disease.
{"title":"Intracranial Venous Hemodynamics Is a Factor Related to a Favorable Outcome in Cerebral Venous Thrombosis","authors":"E. Stolz, T. Gerriets, R. Bödeker, M. Hügens-Penzel, M. Kaps","doi":"10.1161/01.STR.0000016507.94646.E6","DOIUrl":"https://doi.org/10.1161/01.STR.0000016507.94646.E6","url":null,"abstract":"Background— In recent studies, coma, cerebral hemorrhage, older age, and infectious origin have been identified as prognostic factors in cerebral venous thrombosis (CVT). However, no studies of the prognosis of CVT have evaluated hemodynamic factors. However, it is conceivable that the presence or absence and the efficiency of venous collaterals, as well as recanalization, may have an impact on brain tissue damage and hence on the prognosis of acute CVT. Methods— Twenty-six patients with acute CVT (mean age, 40±15 years) were recruited prospectively. All patients were treated with intravenous heparin, followed by oral anticoagulation for 12 months, except for 2 patients who were lost to follow-up after hospital discharge. Neurological deficits were graded on the National Institute of Health Stroke Scale on admission, at hospital discharge, and at 90±14 days after admission. The functional clinical outcome was graded on the modified Rankin Scale on day 90 after admission. All patients received a venous transcranial duplex sonography (TCCS) on admission and were followed up in case of a pathological result until normalization was recorded (mean follow-up, 316±395 days; range, 13 to 1180 days). Results— Initial TCCS was pathological in 18 of 26 patients (69%). Four distinct venous drainage types were identified: increased drainage to the cavernous sinus and to the deep cerebral veins, flow reversal in the basal veins, and either compensatory increased or reversed flow in the transverse sinus. Initially normal venous TCCS or normalized TCCS within 90 days was significantly related to favorable outcome. Conclusions— TCCS can be used to evaluate venous drainage patterns in acute CVT. Furthermore, initially normal and normalization of initially pathological venous TCCS within 90 days is related to a favorable outcome in this disease.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"33 1","pages":"1645-1650"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88143977","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000018684.86293.AB
K. Muir
Background and Purpose— Tissue substrates for action of neuroprotective agents may be absent in a significant proportion of strokes. Pathophysiological heterogeneity is a possible contributor to negative neuroprotective trials. Methods— Stroke subtypes and their individual outcomes in neuroprotective trial control populations were used to derive models incorporating accuracy of clinical classification and probability of an ischemic penumbra. With the use of treatment effect sizes from successful trials (predominantly of reperfusion therapies), sample sizes for neuroprotective trials were calculated. The potential influence of altered recruitment strategies was explored. Results— The proportion of informative patients in 2 large neuroprotective trials was probably only 27% to 30%. Optimistically, this proportion may be 50%; pessimistically, it may be only 17%. These figures necessitate a sample size of 3700 to 4500 subjects per group; at best, 1800 to 2200 are needed per group with optimistic assumptions about treatment effect. Strategies to enhance the proportion with tissue substrate for neuroprotection could reduce sample size to 500 per group and simultaneously reduce the total number of patients screened compared with inclusive trials. Conclusions— Population heterogeneity alone may be sufficient to explain negative neuroprotective trials because even in the largest trials to date sample size is inadequate to detect effect size equivalent to those with thrombolysis, and it is possible that they have been severely underpowered. Reliable trials with inclusive entry criteria may be too large to be commercially feasible for novel compounds. Both sample size and total number of patients needing to be screened should be reduced by restricting entry to patients more likely to have a tissue target.
{"title":"Heterogeneity of Stroke Pathophysiology and Neuroprotective Clinical Trial Design","authors":"K. Muir","doi":"10.1161/01.STR.0000018684.86293.AB","DOIUrl":"https://doi.org/10.1161/01.STR.0000018684.86293.AB","url":null,"abstract":"Background and Purpose— Tissue substrates for action of neuroprotective agents may be absent in a significant proportion of strokes. Pathophysiological heterogeneity is a possible contributor to negative neuroprotective trials. Methods— Stroke subtypes and their individual outcomes in neuroprotective trial control populations were used to derive models incorporating accuracy of clinical classification and probability of an ischemic penumbra. With the use of treatment effect sizes from successful trials (predominantly of reperfusion therapies), sample sizes for neuroprotective trials were calculated. The potential influence of altered recruitment strategies was explored. Results— The proportion of informative patients in 2 large neuroprotective trials was probably only 27% to 30%. Optimistically, this proportion may be 50%; pessimistically, it may be only 17%. These figures necessitate a sample size of 3700 to 4500 subjects per group; at best, 1800 to 2200 are needed per group with optimistic assumptions about treatment effect. Strategies to enhance the proportion with tissue substrate for neuroprotection could reduce sample size to 500 per group and simultaneously reduce the total number of patients screened compared with inclusive trials. Conclusions— Population heterogeneity alone may be sufficient to explain negative neuroprotective trials because even in the largest trials to date sample size is inadequate to detect effect size equivalent to those with thrombolysis, and it is possible that they have been severely underpowered. Reliable trials with inclusive entry criteria may be too large to be commercially feasible for novel compounds. Both sample size and total number of patients needing to be screened should be reduced by restricting entry to patients more likely to have a tissue target.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"35 1","pages":"1545-1550"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90247781","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000018011.66817.41
H. Roberts, W. Dillon, A. Furlan, L. Wechsler, H. Rowley, N. Fischbein, R. Higashida, C. Kase, Gregory A. Schulz, Ying Lu, Carolyn M. Firszt
Background and Purpose— The purpose of this study was to evaluate the role of noncontrast CT in the selection of patients to receive thrombolytic therapy for acute ischemic stroke and to predict radiological and clinical outcomes. Methods— One hundred eighty patients with stroke due to middle cerebral artery (MCA) occlusion were randomized 2:1 within 6 hours of onset to receive intra-arterial recombinant prourokinase plus intravenous heparin or intravenous heparin only. Four hundred fifty-four CT examinations were digitized to calculate early infarct changes, infarct volumes, and hemorrhagic changes among the 162 patients treated as randomized (108 recombinant prourokinase–treated patients and 54 control patients). CT changes were correlated with baseline stroke severity, angiographic clot location, collateral vessels, and outcome at 90 days. Results— Baseline CT scans, 120 (75%) of 159, showed early infarct–related abnormalities. The baseline CT abnormality volume was not correlated with the baseline National Institutes of Health Stroke Scale (NIHSS) score (r =−0.11) but was correlated weakly with the outcome (r =0.17, P <0.05). Compared with patients with M2 occlusions, patients with M1 MCA occlusions had significantly higher baseline NIHSS scores (P <0.05), more basal ganglia involvement on CT, and larger hypodensity volumes on follow-up CTs. Compared with patients with partial or no collateral supply, patients with full collateral supply had lower baseline NIHSS scores, significantly smaller baseline CT infarct volumes, and less cortical involvement (P <0.05). Conclusions— Noncontrast CT is not correlated with baseline stroke severity and does not predict outcome in patients with stroke due to MCA occlusion. However, baseline CT changes, clinical presentation, and the evolution of CT changes are influenced by clot location and the presence of a collateral supply.
{"title":"Computed Tomographic Findings in Patients Undergoing Intra-arterial Thrombolysis for Acute Ischemic Stroke due to Middle Cerebral Artery Occlusion: Results From the PROACT II Trial","authors":"H. Roberts, W. Dillon, A. Furlan, L. Wechsler, H. Rowley, N. Fischbein, R. Higashida, C. Kase, Gregory A. Schulz, Ying Lu, Carolyn M. Firszt","doi":"10.1161/01.STR.0000018011.66817.41","DOIUrl":"https://doi.org/10.1161/01.STR.0000018011.66817.41","url":null,"abstract":"Background and Purpose— The purpose of this study was to evaluate the role of noncontrast CT in the selection of patients to receive thrombolytic therapy for acute ischemic stroke and to predict radiological and clinical outcomes. Methods— One hundred eighty patients with stroke due to middle cerebral artery (MCA) occlusion were randomized 2:1 within 6 hours of onset to receive intra-arterial recombinant prourokinase plus intravenous heparin or intravenous heparin only. Four hundred fifty-four CT examinations were digitized to calculate early infarct changes, infarct volumes, and hemorrhagic changes among the 162 patients treated as randomized (108 recombinant prourokinase–treated patients and 54 control patients). CT changes were correlated with baseline stroke severity, angiographic clot location, collateral vessels, and outcome at 90 days. Results— Baseline CT scans, 120 (75%) of 159, showed early infarct–related abnormalities. The baseline CT abnormality volume was not correlated with the baseline National Institutes of Health Stroke Scale (NIHSS) score (r =−0.11) but was correlated weakly with the outcome (r =0.17, P <0.05). Compared with patients with M2 occlusions, patients with M1 MCA occlusions had significantly higher baseline NIHSS scores (P <0.05), more basal ganglia involvement on CT, and larger hypodensity volumes on follow-up CTs. Compared with patients with partial or no collateral supply, patients with full collateral supply had lower baseline NIHSS scores, significantly smaller baseline CT infarct volumes, and less cortical involvement (P <0.05). Conclusions— Noncontrast CT is not correlated with baseline stroke severity and does not predict outcome in patients with stroke due to MCA occlusion. However, baseline CT changes, clinical presentation, and the evolution of CT changes are influenced by clot location and the presence of a collateral supply.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"71 1","pages":"1557-1567"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79597773","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000018081.33541.E3
A. Al-Sadat, Mohammad F Sunbulli, S. Chaturvedi
Background and Purpose— Our aim was to determine current usage patterns of intravenous heparin for patients with acute ischemic stroke. Methods— A survey was undertaken of 280 neurologists from the United States and 270 neurologists from Canada. Brief vignettes were presented for the following 5 scenarios: stroke in evolution, atrial fibrillation-related stroke (A FIB), vertebrobasilar stroke, carotid territory stroke, and multiple transient ischemic attacks. The effect of medicolegal factors was also ascertained. Statistical comparisons were done with chi-squared testing. Results— US neurologists were significantly more likely than Canadian neurologists to use intravenous heparin for patients with stroke in evolution (51% versus 33%, P <0.001), vertebrobasilar stroke (30% versus 8%, P <0.001), carotid territory stroke (31% versus 4%, P <0.001), and multiple transient ischemic attacks (47% versus 9%, P <0.001). The vast majority of US and Canadian neurologists would use intravenous heparin for acute stroke patients with A FIB (88% and 84%, respectively). US neurologists more often cited medicolegal factors as a potential influence on the decision-making process than Canadian neurologists (33% versus 10%, P <0.001). Conclusions— In several clinical scenarios, US neurologists were significantly more likely than Canadian neurologists to use intravenous heparin. Fears regarding medicolegal consequences may partially explain the treatment disparity. Despite the publication of 4 clinical trials, which have not shown any long-term benefit for patients with acute stroke and A FIB (International Stroke Trial, Heparin in Acute Embolic Stroke Trial) or cardioembolic stroke (Trial of Org 10172 in Acute Stroke Treatment, the Tinzaparin in Acute Ischemic Stroke Trial), both US and Canadian neurologists would use intravenous heparin in large numbers for this condition. Further studies are warranted to investigate the lack of impact of “negative” studies on clinician behavior.
{"title":"Use of Intravenous Heparin by North American Neurologists: Do the Data Matter?","authors":"A. Al-Sadat, Mohammad F Sunbulli, S. Chaturvedi","doi":"10.1161/01.STR.0000018081.33541.E3","DOIUrl":"https://doi.org/10.1161/01.STR.0000018081.33541.E3","url":null,"abstract":"Background and Purpose— Our aim was to determine current usage patterns of intravenous heparin for patients with acute ischemic stroke. Methods— A survey was undertaken of 280 neurologists from the United States and 270 neurologists from Canada. Brief vignettes were presented for the following 5 scenarios: stroke in evolution, atrial fibrillation-related stroke (A FIB), vertebrobasilar stroke, carotid territory stroke, and multiple transient ischemic attacks. The effect of medicolegal factors was also ascertained. Statistical comparisons were done with chi-squared testing. Results— US neurologists were significantly more likely than Canadian neurologists to use intravenous heparin for patients with stroke in evolution (51% versus 33%, P <0.001), vertebrobasilar stroke (30% versus 8%, P <0.001), carotid territory stroke (31% versus 4%, P <0.001), and multiple transient ischemic attacks (47% versus 9%, P <0.001). The vast majority of US and Canadian neurologists would use intravenous heparin for acute stroke patients with A FIB (88% and 84%, respectively). US neurologists more often cited medicolegal factors as a potential influence on the decision-making process than Canadian neurologists (33% versus 10%, P <0.001). Conclusions— In several clinical scenarios, US neurologists were significantly more likely than Canadian neurologists to use intravenous heparin. Fears regarding medicolegal consequences may partially explain the treatment disparity. Despite the publication of 4 clinical trials, which have not shown any long-term benefit for patients with acute stroke and A FIB (International Stroke Trial, Heparin in Acute Embolic Stroke Trial) or cardioembolic stroke (Trial of Org 10172 in Acute Stroke Treatment, the Tinzaparin in Acute Ischemic Stroke Trial), both US and Canadian neurologists would use intravenous heparin in large numbers for this condition. Further studies are warranted to investigate the lack of impact of “negative” studies on clinician behavior.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"12 1","pages":"1574-1577"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74304346","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000016926.77114.A6
J. Cauraugh, Sangbum Kim
Background and Purpose— Overcoming chronic hemiparesis from a cerebrovascular accident (CVA) can be challenging for many patients, especially after the first 12 months after the CVA. With the use of established motor control theories, the present study investigated electromyogram (EMG)-triggered neuromuscular stimulation and bilateral coordination training. Methods— Twenty-five CVA subjects volunteered to participate in this motor recovery protocol study. Subjects were randomly assigned to 1 of 3 groups: (1) coupled protocol of EMG-triggered stimulation and bilateral movement (n=10); (2) EMG-triggered stimulation and unilateral movement (n=10); or (3) control (n=5). All participants completed 6 hours of rehabilitation during a 2-week period according to group assignments. Motor capabilities of the wrist and fingers were evaluated on the basis of 3 categories of motor tasks in a pretest-posttest control group design. Results— Significant findings for the (1) number of blocks moved in a functional task, (2) chronometric reaction times to initiate movements, and (3) sustained muscle contraction capability all favored the coupled bilateral movement training and EMG-triggered neuromuscular stimulation protocol group. In addition, the unilateral movement/stimulation group exceeded the control group in the number of blocks moved and rapid onset of muscle contractions. Conclusions— This new evidence is convincing in that subjects in the coupled protocol group were able to demonstrate enhanced voluntary motor control across 3 categories of tasks. Chronic hemiparesis decreased considerably in the wrist and fingers as CVA patients expanded their motor repertoire.
{"title":"Two Coupled Motor Recovery Protocols Are Better Than One: Electromyogram-Triggered Neuromuscular Stimulation and Bilateral Movements","authors":"J. Cauraugh, Sangbum Kim","doi":"10.1161/01.STR.0000016926.77114.A6","DOIUrl":"https://doi.org/10.1161/01.STR.0000016926.77114.A6","url":null,"abstract":"Background and Purpose— Overcoming chronic hemiparesis from a cerebrovascular accident (CVA) can be challenging for many patients, especially after the first 12 months after the CVA. With the use of established motor control theories, the present study investigated electromyogram (EMG)-triggered neuromuscular stimulation and bilateral coordination training. Methods— Twenty-five CVA subjects volunteered to participate in this motor recovery protocol study. Subjects were randomly assigned to 1 of 3 groups: (1) coupled protocol of EMG-triggered stimulation and bilateral movement (n=10); (2) EMG-triggered stimulation and unilateral movement (n=10); or (3) control (n=5). All participants completed 6 hours of rehabilitation during a 2-week period according to group assignments. Motor capabilities of the wrist and fingers were evaluated on the basis of 3 categories of motor tasks in a pretest-posttest control group design. Results— Significant findings for the (1) number of blocks moved in a functional task, (2) chronometric reaction times to initiate movements, and (3) sustained muscle contraction capability all favored the coupled bilateral movement training and EMG-triggered neuromuscular stimulation protocol group. In addition, the unilateral movement/stimulation group exceeded the control group in the number of blocks moved and rapid onset of muscle contractions. Conclusions— This new evidence is convincing in that subjects in the coupled protocol group were able to demonstrate enhanced voluntary motor control across 3 categories of tasks. Chronic hemiparesis decreased considerably in the wrist and fingers as CVA patients expanded their motor repertoire.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"62 1","pages":"1589-1594"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90698011","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000017220.78722.D7
S. Kurl, T. Tuomainen, J. Laukkanen, K. Nyyssönen, T. Lakka, J. Sivenius, J. Salonen
Background and Purpose— There are no prospective studies to determine whether plasma vitamin C modifies the risk of stroke among hypertensive and overweight individuals. We sought to examine whether plasma vitamin C modifies the association between overweight and hypertension and the risk of stroke in middle-aged men from eastern Finland. Methods— We conducted a 10.4-year prospective population-based cohort study of 2419 randomly selected middle-aged men (42 to 60 years) with no history of stroke at baseline examination. A total of 120 men developed a stroke, of which 96 were ischemic and 24 hemorrhagic strokes. Results— Men with the lowest levels of plasma vitamin C (<28.4 &mgr;mol/L, lowest quarter) had a 2.4-fold (95% CI, 1.4 to 4.3;P =0.002) risk of any stroke compared with men with highest levels of plasma vitamin C (>64.96 &mgr;mol/L, highest quarter) after adjustment for age and examination months. An additional adjustment for body mass index, systolic blood pressure, smoking, alcohol consumption, serum total cholesterol, diabetes, and exercise-induced myocardial ischemia attenuated the association marginally (relative risk, 2.1; 95% CI, 1.2 to 3.8;P =0.01). Adjustment for prevalent coronary heart disease and atrial fibrillation did not attenuate the association any further. Furthermore, hypertensive men with the lowest vitamin C levels (<28.4 &mgr;mol/L) had a 2.6-fold risk (95% CI, 1.52 to 4.48;P <0.001), and overweight men (≥25 kg/m2) with low plasma vitamin C had a 2.7-fold risk (95% CI, 1.48 to 4.90;P =0.001) for any stroke after adjustment for age, examination months, and other risk factors. Conclusions— Low plasma vitamin C was associated with increased risk of stroke, especially among hypertensive and overweight men.
{"title":"Plasma Vitamin C Modifies the Association Between Hypertension and Risk of Stroke","authors":"S. Kurl, T. Tuomainen, J. Laukkanen, K. Nyyssönen, T. Lakka, J. Sivenius, J. Salonen","doi":"10.1161/01.STR.0000017220.78722.D7","DOIUrl":"https://doi.org/10.1161/01.STR.0000017220.78722.D7","url":null,"abstract":"Background and Purpose— There are no prospective studies to determine whether plasma vitamin C modifies the risk of stroke among hypertensive and overweight individuals. We sought to examine whether plasma vitamin C modifies the association between overweight and hypertension and the risk of stroke in middle-aged men from eastern Finland. Methods— We conducted a 10.4-year prospective population-based cohort study of 2419 randomly selected middle-aged men (42 to 60 years) with no history of stroke at baseline examination. A total of 120 men developed a stroke, of which 96 were ischemic and 24 hemorrhagic strokes. Results— Men with the lowest levels of plasma vitamin C (<28.4 &mgr;mol/L, lowest quarter) had a 2.4-fold (95% CI, 1.4 to 4.3;P =0.002) risk of any stroke compared with men with highest levels of plasma vitamin C (>64.96 &mgr;mol/L, highest quarter) after adjustment for age and examination months. An additional adjustment for body mass index, systolic blood pressure, smoking, alcohol consumption, serum total cholesterol, diabetes, and exercise-induced myocardial ischemia attenuated the association marginally (relative risk, 2.1; 95% CI, 1.2 to 3.8;P =0.01). Adjustment for prevalent coronary heart disease and atrial fibrillation did not attenuate the association any further. Furthermore, hypertensive men with the lowest vitamin C levels (<28.4 &mgr;mol/L) had a 2.6-fold risk (95% CI, 1.52 to 4.48;P <0.001), and overweight men (≥25 kg/m2) with low plasma vitamin C had a 2.7-fold risk (95% CI, 1.48 to 4.90;P =0.001) for any stroke after adjustment for age, examination months, and other risk factors. Conclusions— Low plasma vitamin C was associated with increased risk of stroke, especially among hypertensive and overweight men.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"17 1","pages":"1568-1573"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85671234","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000018012.65108.86
H. Kato, M. Izumiyama, K. Izumiyama, A. Takahashi, Y. Itoyama
Background and Purpose— Gradient-echo T2*-weighted MRI is uniquely sensitive to detect silent, old hemosiderin deposits, but the clinical significance of such “microbleeds” remains to be determined. Therefore, we investigated the incidence and the number of microbleeds among different stroke subtypes and the correlation with stroke recurrence and the severity of leukoaraiosis. Methods— This study consisted of 213 patients (73.5±9.1 years old, 104 men and 109 women), who were classified according to stroke subtypes into atherothrombotic infarction (24 patients), cardioembolic infarction (23 patients), lacunar infarction (66 patients), intracerebral hemorrhage (35 patients), and control (65 patients) groups. Gradient-echo T2*-weighted MRI was performed with a 1.5 T system, and asymptomatic microbleeds were located and counted. Results— The incidence and the number of microbleeds were significantly greater in patients with intracerebral hemorrhage (71.4% and 9.1±13.8, respectively) and lacunar infarction (62.1% and 7.4±16.1) compared with patients with cardioembolic infarction (30.4% and 2.5±5.6), atherothrombotic infarction (20.8% and 0.63±1.53), and controls (7.7% and 0.09±0.34). There was a correlation between the number of microbleeds and the severity of periventricular hyperintensity (r =0.626, P <0.0001). There was also a correlation between the number of microbleeds and the number of intracerebral hemorrhages (r =0.689, P <0.0001) or lacunar infarctions (r =0.514, P <0.0001). The locations of microbleeds were subcortical white matter (31.8%), thalamus (24.8%), basal ganglia (19.8%), brain stem (12.0%), and cerebellum (11.7%). Conclusions— The findings suggest that microbleeds on T2*-weighted MRI are an indicator of advanced small artery disease of the brain with an increased risk for bleeding. This result should be taken into consideration when treating patients with stroke, and further studies are required.
背景与目的- T2加权梯度回声MRI对无症状的、陈旧的含铁血黄素沉积具有独特的敏感性，但这种“微出血”的临床意义仍有待确定。因此，我们研究了不同脑卒中亚型的微出血发生率和数量，以及与脑卒中复发和白质病严重程度的相关性。方法:213例患者(73.5±9.1岁，男性104例，女性109例)，按脑卒中亚型分为动脉粥样硬化血栓性梗死(24例)、心栓性梗死(23例)、腔隙性梗死(66例)、脑出血(35例)和对照组(65例)。在1.5 T系统下行T2*加权梯度回声MRI，定位并计数无症状微出血。结果:脑出血患者(分别为71.4%和9.1±13.8)和腔隙性梗死(分别为62.1%和7.4±16.1)的微出血发生率和数量明显高于心栓性梗死(30.4%和2.5±5.6)、动脉粥样硬化性血栓性梗死(20.8%和0.63±1.53)和对照组(7.7%和0.09±0.34)。微出血数与心室周围高强度程度有相关性(r =0.626, P <0.0001)。微出血数与颅内出血数(r =0.689, P <0.0001)或腔隙性梗死数(r =0.514, P <0.0001)也存在相关性。微出血部位为皮质下白质(31.8%)、丘脑(24.8%)、基底节区(19.8%)、脑干(12.0%)和小脑(11.7%)。结论:研究结果表明，T2加权MRI显示的微出血是晚期脑小动脉疾病的一个指标，出血风险增加。在治疗中风患者时应考虑到这一结果，并需要进一步的研究。
{"title":"Silent Cerebral Microbleeds on T2*-Weighted MRI: Correlation with Stroke Subtype, Stroke Recurrence, and Leukoaraiosis","authors":"H. Kato, M. Izumiyama, K. Izumiyama, A. Takahashi, Y. Itoyama","doi":"10.1161/01.STR.0000018012.65108.86","DOIUrl":"https://doi.org/10.1161/01.STR.0000018012.65108.86","url":null,"abstract":"Background and Purpose— Gradient-echo T2*-weighted MRI is uniquely sensitive to detect silent, old hemosiderin deposits, but the clinical significance of such “microbleeds” remains to be determined. Therefore, we investigated the incidence and the number of microbleeds among different stroke subtypes and the correlation with stroke recurrence and the severity of leukoaraiosis. Methods— This study consisted of 213 patients (73.5±9.1 years old, 104 men and 109 women), who were classified according to stroke subtypes into atherothrombotic infarction (24 patients), cardioembolic infarction (23 patients), lacunar infarction (66 patients), intracerebral hemorrhage (35 patients), and control (65 patients) groups. Gradient-echo T2*-weighted MRI was performed with a 1.5 T system, and asymptomatic microbleeds were located and counted. Results— The incidence and the number of microbleeds were significantly greater in patients with intracerebral hemorrhage (71.4% and 9.1±13.8, respectively) and lacunar infarction (62.1% and 7.4±16.1) compared with patients with cardioembolic infarction (30.4% and 2.5±5.6), atherothrombotic infarction (20.8% and 0.63±1.53), and controls (7.7% and 0.09±0.34). There was a correlation between the number of microbleeds and the severity of periventricular hyperintensity (r =0.626, P <0.0001). There was also a correlation between the number of microbleeds and the number of intracerebral hemorrhages (r =0.689, P <0.0001) or lacunar infarctions (r =0.514, P <0.0001). The locations of microbleeds were subcortical white matter (31.8%), thalamus (24.8%), basal ganglia (19.8%), brain stem (12.0%), and cerebellum (11.7%). Conclusions— The findings suggest that microbleeds on T2*-weighted MRI are an indicator of advanced small artery disease of the brain with an increased risk for bleeding. This result should be taken into consideration when treating patients with stroke, and further studies are required.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"26 1","pages":"1536-1540"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76026166","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000016405.06729.83
Rachel C Brown, T. Davis
Background— This review deals with the role of calcium in endothelial cell junctions of the blood-brain barrier (BBB). Calcium is critical for adherens junction function, but it appears that calcium is also important in regulating tight junction function necessary for the barrier characteristics of cerebral microvessels. Summary of Review— The BBB is critical for brain homeostasis and is located at the cerebral microvessel endothelial cells. These endothelial cells maintain their barrier characteristics via cell-cell contacts made up of adherens and tight junctions. Adherens junctions are calcium dependent; recent evidence suggests that calcium also affects tight junctions. After stroke, there is a disruption of the BBB. Interfering with calcium flux under hypoxic conditions can prevent BBB breakdown. Calcium may alter BBB junction integrity by a number of different signal transduction cascades, as well as via direct interaction of calcium ions with junction proteins. It remains to be determined whether clinical use of calcium channel antagonists is a viable means to reduce BBB disruption after stroke. Conclusions— With the widespread use of calcium channel blockers as clinical treatments for hypertension, which is a risk factor for stroke, the exact role of calcium in modulating BBB integrity needs to be elucidated.
{"title":"Calcium Modulation of Adherens and Tight Junction Function: A Potential Mechanism for Blood-Brain Barrier Disruption After Stroke","authors":"Rachel C Brown, T. Davis","doi":"10.1161/01.STR.0000016405.06729.83","DOIUrl":"https://doi.org/10.1161/01.STR.0000016405.06729.83","url":null,"abstract":"Background— This review deals with the role of calcium in endothelial cell junctions of the blood-brain barrier (BBB). Calcium is critical for adherens junction function, but it appears that calcium is also important in regulating tight junction function necessary for the barrier characteristics of cerebral microvessels. Summary of Review— The BBB is critical for brain homeostasis and is located at the cerebral microvessel endothelial cells. These endothelial cells maintain their barrier characteristics via cell-cell contacts made up of adherens and tight junctions. Adherens junctions are calcium dependent; recent evidence suggests that calcium also affects tight junctions. After stroke, there is a disruption of the BBB. Interfering with calcium flux under hypoxic conditions can prevent BBB breakdown. Calcium may alter BBB junction integrity by a number of different signal transduction cascades, as well as via direct interaction of calcium ions with junction proteins. It remains to be determined whether clinical use of calcium channel antagonists is a viable means to reduce BBB disruption after stroke. Conclusions— With the widespread use of calcium channel blockers as clinical treatments for hypertension, which is a risk factor for stroke, the exact role of calcium in modulating BBB integrity needs to be elucidated.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"37 1","pages":"1706-1711"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89932863","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-06-01DOI: 10.1161/01.STR.0000018974.05768.FB
K. Kohara, Y. Tabara, Yoshikuni Yamamoto, M. Igase, T. Miki
Background and Purpose— In vitro studies have demonstrated that Chlamydia pneumoniae infection of the endothelium increases the expression of adhesion molecules and chemokines, indicating that C pneumoniae infection affects the adhesion and recruitment of leukocytes to the endothelium, which is believed to be involved in the initial steps of atherosclerosis. However, whether chronic C pneumoniae infection increases these molecules in vivo has not been elucidated. Methods— The association between C pneumoniae seropositivity and plasma concentrations of soluble adhesion molecules and a chemokine was investigated in 200 community-dwelling residents free from cardiovascular diseases and medication. Plasma levels of IgA and IgG antibodies to C pneumoniae were measured by enzyme-linked immunosorbent assay. Indices of IgG and IgA antibodies were determined as the ratio to the standardized positive control. The subjects were divided into 3 groups according to the indices of antibodies:C pneumoniae seronegative (n=57, IgA<1.0 and IgG<1.0), C pneumoniae intermediate (n=81, 1.0≤IgA≥1.1 or 1.0≤IgG≥1.1), and C pneumoniae seropositive (n=62, IgA>1.1 and IgG>1.1). Plasma concentrations of soluble forms of intercellular adhesion molecule-1 (ICAM-1), vascular cellular adhesion molecule-1, and monocyte chemoattractant protein-1 were determined by enzyme-linked immunosorbent assay. Results— Plasma concentrations of ICAM-1 (392±118, 398±94, 470±154 ng/mL, P =0.0004) and vascular cellular adhesion molecule-1 (402±146, 419±130, 472±181 ng/mL, P =0.03) were significantly different among the C pneumoniae seronegative, intermediate, and seropositive groups respectively. However, plasma monocyte chemoattractant protein-1 was not significantly different among the 3 groups. Stepwise regression analysis showed that plasma concentration of ICAM-1 was significantly associated with C pneumoniae seropositivity, independent of other known risk factors for atherosclerosis and carotid intima-media thickness. Conclusion— These findings indicate that C pneumoniae seropositivity is associated with higher plasma concentrations of soluble forms of adhesion molecules in the general population. The increase in circulating adhesion molecules may underlie the mechanisms linking C pneumoniae infection and atherosclerosis in vivo.
背景与目的——体外研究表明，肺炎衣原体感染内皮细胞后，黏附分子和趋化因子的表达增加，表明肺炎衣原体感染影响白细胞对内皮细胞的黏附和募集，被认为参与了动脉粥样硬化的初始阶段。然而，慢性肺炎C菌感染是否会在体内增加这些分子尚不清楚。方法-对200名无心血管疾病和无药物治疗的社区居民进行肺炎C血清阳性与血浆可溶性粘附分子和趋化因子浓度之间的关系调查。采用酶联免疫吸附法检测血浆中抗肺炎C的IgA和IgG抗体水平。IgG、IgA抗体指标与标准化阳性对照的比值。根据抗体指标分为3组:肺炎C血清阴性(n=57, IgA1.1和IgG>1.1)。采用酶联免疫吸附法测定血浆中可溶性细胞间黏附分子-1 (ICAM-1)、血管细胞黏附分子-1和单核细胞趋化蛋白-1的浓度。结果-血浆ICAM-1浓度(392±118、398±94、470±154 ng/mL, P =0.0004)和血管细胞粘附分子-1浓度(402±146、419±130、472±181 ng/mL, P =0.03)在肺炎C血清阴性、中间和血清阳性组中分别有显著差异。血浆单核细胞趋化蛋白-1在3组间差异无统计学意义。逐步回归分析显示，血浆ICAM-1浓度与肺炎链球菌血清阳性显著相关，独立于动脉粥样硬化和颈动脉内膜-中膜厚度的其他已知危险因素。结论:这些发现表明，在一般人群中，肺炎C血清阳性与较高的血浆可溶性黏附分子浓度有关。循环黏附分子的增加可能是体内C肺炎感染和动脉粥样硬化联系机制的基础。
{"title":"Chlamydia pneumoniae Seropositivity Is Associated With Increased Plasma Levels of Soluble Cellular Adhesion Molecules in Community-Dwelling Subjects: The Shimanami Health Promoting Program (J-SHIPP) Study","authors":"K. Kohara, Y. Tabara, Yoshikuni Yamamoto, M. Igase, T. Miki","doi":"10.1161/01.STR.0000018974.05768.FB","DOIUrl":"https://doi.org/10.1161/01.STR.0000018974.05768.FB","url":null,"abstract":"Background and Purpose— In vitro studies have demonstrated that Chlamydia pneumoniae infection of the endothelium increases the expression of adhesion molecules and chemokines, indicating that C pneumoniae infection affects the adhesion and recruitment of leukocytes to the endothelium, which is believed to be involved in the initial steps of atherosclerosis. However, whether chronic C pneumoniae infection increases these molecules in vivo has not been elucidated. Methods— The association between C pneumoniae seropositivity and plasma concentrations of soluble adhesion molecules and a chemokine was investigated in 200 community-dwelling residents free from cardiovascular diseases and medication. Plasma levels of IgA and IgG antibodies to C pneumoniae were measured by enzyme-linked immunosorbent assay. Indices of IgG and IgA antibodies were determined as the ratio to the standardized positive control. The subjects were divided into 3 groups according to the indices of antibodies:C pneumoniae seronegative (n=57, IgA<1.0 and IgG<1.0), C pneumoniae intermediate (n=81, 1.0≤IgA≥1.1 or 1.0≤IgG≥1.1), and C pneumoniae seropositive (n=62, IgA>1.1 and IgG>1.1). Plasma concentrations of soluble forms of intercellular adhesion molecule-1 (ICAM-1), vascular cellular adhesion molecule-1, and monocyte chemoattractant protein-1 were determined by enzyme-linked immunosorbent assay. Results— Plasma concentrations of ICAM-1 (392±118, 398±94, 470±154 ng/mL, P =0.0004) and vascular cellular adhesion molecule-1 (402±146, 419±130, 472±181 ng/mL, P =0.03) were significantly different among the C pneumoniae seronegative, intermediate, and seropositive groups respectively. However, plasma monocyte chemoattractant protein-1 was not significantly different among the 3 groups. Stepwise regression analysis showed that plasma concentration of ICAM-1 was significantly associated with C pneumoniae seropositivity, independent of other known risk factors for atherosclerosis and carotid intima-media thickness. Conclusion— These findings indicate that C pneumoniae seropositivity is associated with higher plasma concentrations of soluble forms of adhesion molecules in the general population. The increase in circulating adhesion molecules may underlie the mechanisms linking C pneumoniae infection and atherosclerosis in vivo.","PeriodicalId":22274,"journal":{"name":"Stroke: Journal of the American Heart Association","volume":"20 1","pages":"1474-1479"},"PeriodicalIF":0.0,"publicationDate":"2002-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85049395","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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