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J Stam

Publications and source records attributed to J Stam.

At least 19 recordsLinked to original sources
PubMed2006

[Endarterectomy should not be offered routinely to patients with asymptomatic carotid stenosis].

A recent trial revealed a reduction in ischaemic infarcts after carotid endarterectomy in patients with asymptomatic carotid stenosis. However, the number needed to treat (NNT) was 19 to prevent one stroke in 5 years, a modest effect in comparison to the trials with symptomatic patients (a NNT of only 6 in patients with a symptomatic stenosis of 70-99%). Furthermore, the number of surgical complications outweighs the benefits of surgery during the first two years after treatment. Finally, the benefits also included the prevention of contralateral strokes, whereas it is unlikely that these are prevented by endarterectomy. Therefore, endarterectomy should not be performed routinely in asymptomatic persons.

Carotid Stenosis↗
PubMed2006

EFNS guideline on the treatment of cerebral venous and sinus thrombosis.

Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed due to the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis, and symptomatic therapy including control of seizures and elevated intracranial pressure. We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence, but consensus was clear we stated our opinion as good practice points. Patients with CVST without contraindications for anticoagulation should be treated either with body weight-adjusted subcutaneous LMWH or dose-adjusted intravenous heparin (good practice point). Concomitant intracranial haemorrhage related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulation after the acute phase is unclear. Oral anticoagulation may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with 'mild' hereditary thrombophilia. Indefinite anticoagulation (AC) should be considered in patients with two or more episodes of CVST and in those with one episode of CVST and 'severe' hereditary thrombophilia (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate anticoagulation and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without intracranial haemorrhage (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. Antioedema treatment (including hyperventilation, osmotic diuretics and craniectomy) should be used as life saving interventions (good practice point).

Anticoagulants↗
PubMed2006

Observer variation in the evaluation of lumbar herniated discs and root compression: spiral CT compared with MRI.

Spiral CT is considered the best alternative for MRI in the evaluation of herniated discs. The purpose of this study was to compare radiological evaluation of spiral CT with MRI in patients suspected of herniated discs. 57 patients with lumbosacral radicular syndrome underwent spiral CT and 1.5 T MRI. Two neuroradiologists independently evaluated 171 intervertebral discs for herniation or "bulge" and 456 nerve roots for root compression, once after CT and once after MRI. We compared interobserver agreement using the kappa statistic and we performed a paired comparison between CT and MRI. For detection of herniated or bulging discs, we observed no significant difference in interobserver agreement (CT kappa 0.66 vs MRI kappa 0.71; p = 0.40). For root compression, we observed significantly better interobserver agreement at MRI evaluation (CT kappa 0.59 vs MRI kappa 0.78; p = 0.01). In 30 of 171 lumbar discs (18%) and in 54 of 456 nerve roots (12%), the observers disagreed on whether CT results were similar to MRI. In the cases without disagreement, CT differed from MRI in 6 discs (3.5%) and in 3 nerve roots (0.7%). For radiological evaluation of lumbar herniated discs, we found no evidence that spiral CT is inferior to MRI. For evaluating lumbar nerve root compression, spiral CT is less reliable than MRI.

Adult↗
PubMed2005

[The practice guideline 'CVA' from the Dutch College of General Practitioners; a response from the perspective of neurology].

The practice guideline for the treatment of ischemic stroke, issued by the Dutch College of General Practitioners, is a timely and most welcome update. It incorporates the new evidence and the important changes in stroke treatment of the past years, and is a good starting point for the collaboration between general practitioners and neurologists in the care of patients with a cerebrovascular accident. The guideline acknowledges the evidence for the benefit ofthrombolysis, but is somewhat vague concerning the magnitude of the effect because it compares the net effect of treatment (which incorporates the risk of bleeding) and the number of cerebral haemorrhages. Furthermore, the discussion of minor stroke could lead to the erroneous conclusion that such patients can be safely cared for at home. Apart from these reservations, the guideline fully agrees with the need to treat all patients with a cerebral infarct, in the absence of contraindications, with thrombolysis within three hours, and to offer specialised care in a dedicated stroke-unit.

Hospitalization↗
PubMed2005

Symptomatic and asymptomatic abnormalities in patients with lumbosacral radicular syndrome: Clinical examination compared with MRI.

OBJECTIVE: To determine the frequency of symptomatic and asymptomatic herniated discs and root compression in patients with lumbosacral radicular syndrome (LRS) and to correlate clinical localization with MRI findings. METHODS: Fifty-seven patients with unilateral LRS were included in the study. Using the visual analogue scale, two physicians independently localized the most likely lumbar level of complaints. These clinical predictions of localizations were correlated with the MRI findings. RESULTS: MRI showed abnormalities on the symptomatic side in 42 of 57 patients (74%). In 30% of the patients, MRI confirmed an abnormality at the exact same level as determined after clinical examination. On the asymptomatic side, MRI showed abnormalities in 19 of 57 patients (33%), 13 (23%) of these patients had asymptomatic root compression. CONCLUSIONS: In more than two-thirds of the patients with unilateral LRS there was no exact match between the level predicted by clinical examination and MRI findings. These discrepancies complicate the decision whether or not to operate.

Adult↗
PubMed2005

Thyroid diseases and cerebrovascular disease.

BACKGROUND AND PURPOSE: Acute cerebral ischemia has been described in different diseases of the thyroid gland, and not only as a result of thyrotoxic atrial fibrillation and cardioembolic stroke. The purpose of this review is to summarize the studies on the relationship between thyroid diseases and cerebrovascular diseases, discussing the main findings for overt hyperthyroidism and hypothyroidism, as well as for subclinical thyroid dysfunction. SUMMARY OF REVIEW: In overt hyperthyroidism, cardioembolic stroke is clearly associated to thyrotoxic atrial fibrillation, and in subclinical hyperthyroidism with serum thyroid-stimulating hormone levels <0.1 mU/L, the incidence of atrial fibrillation is increased. Although in vitro and in vivo studies indicate a hypercoagulability state in hyperthyroidism, there is insufficient evidence to prove that this state leads to an increased risk of cardiac emboli. However, the hypothesis that overt hyperthyroidism may cause acute cerebral venous thrombosis is intriguing. Possible associations between hyperthyroidism and Moyamoya or Giant cell arteritis have only been described in case reports. There is enough evidence that overt hypothyroidism is associated with several traditional and newer atherosclerotic risk factors, especially hypertension, hyperlipidemia, and hyperhomocysteinemia. For subclinical hypothyroidism, these associations are less certain. Hypothyroidism has been associated with signs of aortic or coronary atherosclerosis, but no case-control or cohort studies have ever investigated hypothyroidism as a possible risk factor for atherothrombotic stroke. CONCLUSIONS: Hyperthyroidism is associated with atrial fibrillation and cardioembolic stroke. Hypothyroidism is associated with a worse cardiovascular risk factor profile and leads to progression of atherosclerosis. Associations between hyperthyroidism and acute cerebral venous thrombosis, Moyamoya, and Giant cell arteritis have been suggested, but sound evidence is lacking. Additional studies are needed to clarify these issues.

Antiphospholipid Syndrome↗
PubMed2002

Retinal arterial changes correlate with cerebral small-vessel disease.

OBJECTIVE: To examine the relation between retinal artery disease and cerebral small-vessel disease (SVD). METHODS: In a prospective cohort of patients with symptomatic atherosclerotic disease, the authors performed retinal photographs and brain MRI. Two ophthalmologists, not aware of the MR results, independently assessed retinal arterial narrowing, crossings, sclerosis, and tortuosity according to standard scoring lists. Two observers independently assessed white matter lesions (WML) and lacunar infarcts on the MR images. Lesions were considered abnormal only when both ophthalmologists or MR raters agreed. Cerebral SVD was defined as the presence of WML or lacunar infarcts. RESULTS: In 179 patients, retinal photographs and brain MRI were performed. Of the 108 patients with MR signs of SVD, 92% had at least one retinal vascular abnormality; of the 71 patients without SVD, 77% had retinal pathology (p < 0.01). All types of retinal vascular pathology occurred more frequently in patients with SVD, but only retinal arterial narrowing and sclerosis differed significantly. In the 109 normotensive patients, the presence of any retinal vascular change correlated with signs of SVD (p = 0.01). CONCLUSION: Pathologic changes in the retinal arteries parallel changes in the small cerebral arteries that cause WML and lacunes, both in hypertensive and in normotensive patients.

Aged↗
PubMed2002

Anticoagulation for cerebral sinus thrombosis.

BACKGROUND: Treatment of cerebral sinus thrombosis with anticoagulants has been controversial. Anticoagulants may prevent new venous infarcts, neurologic deterioration, and pulmonary embolism but may also promote haemorrhages. OBJECTIVES: To review the available evidence regarding the effectiveness and safety of anticoagulant therapy in patients with confirmed cerebral sinus thrombosis. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched 18 March 2002). We also searched MEDLINE (1966-Oct 2001), EMBASE (1980-Feb 2002) and the Cochrane Controlled Trials Register (Cochrane Library, 2002 Issue 1) and contacted authors to identify additional published and unpublished studies. SELECTION CRITERIA: Unconfounded randomised controlled trials in which anticoagulant therapy was compared with placebo or open control in patients with cerebral sinus thrombosis (confirmed by intra-arterial contrast or magnetic resonance angiography). DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted outcomes for each of the two treatment groups (anticoagulant treatment and control). The outcome data for each patient are analysed in the treatment group to which the patient was originally allocated ('intention to treat' analysis). A weighted estimate of the treatment effects across trials (relative risk, absolute risk reduction) is calculated using the Cochrane statistical software. MAIN RESULTS: Two small trials involving 79 patients fulfilled the inclusion criteria. One trial (20 patients) examined the efficacy of intravenous, adjusted dose unfractionated heparin. The other trial (59 patients) examined high dose, body weight adjusted, subcutaneous, low-molecular weight heparin (Nadroparin). Anticoagulant therapy was associated with a pooled relative risk of death of 0.33 (95 % CI 0.08 to 1.21) and of death or dependency of 0.46 (95 % CI 0.16 to 1.31). No new symptomatic intracerebral haemorrhages were observed. One major gastro-intestinal haemorrhage occurred after anticoagulant treatment. Two control patients (placebo) had a diagnosis of probable pulmonary embolism (one fatal). REVIEWER'S CONCLUSIONS: Based upon the limited evidence available, anticoagulant treatment for cerebral sinus thrombosis appeared to be safe and was associated with a potentially important reduction in the risk of death or dependency which did not reach statistical significance.

Anticoagulants↗
PubMed2001

Clinical features and prognostic factors of cerebral venous sinus thrombosis in a prospective series of 59 patients. For The Cerebral Venous Sinus Thrombosis Study Group.

The prognosis of cerebral venous sinus thrombosis (CVST) is variable, and outcome may range from complete recovery to death. Prognostic factors to predict outcome in the acute phase of CVST have not been analysed in a prospective study. Prognostic factors in patients enrolled in a clinical treatment trial were prospectively investigated. Poor outcome after 12 weeks, defined as death or dependency (Oxford handicap score > or =3), was used as the principle outcome measure. Univariate relations between possible prognostic factors and outcome at 12 weeks were analyzed with chi(2) tests. Treatment and all factors associated with prognosis (p< or = 0.25) were forced into a logistic regression model with a forward selection procedure. Fifty nine patients (50 women, nine men) were studied, with a mean age of 37 years (range 18 to 80 years). After 12 weeks 10 patients (17%) had a poor outcome. The univariate identified factors related to poor outcome were papilloedema, altered consciousness, coma, age older than 33 years, diagnostic delay < or =10 days, intracerebral haemorrhage, and involvement of the straight sinus. Isolated intracranial hypertension and a delta sign on CT were associated with good outcome. In the multivariate analysis coma and cerebral haemorrhage were significantly associated with a poor outcome, with odds ratios of 8.2 (95% confidence interval (95% CI) 1. 3-50.1) and 20.7 (95% CI 1.6-264.3) respectively. Involvement of the straight sinus was also weakly, but not significantly, associated with poor outcome. In conclusion, coma and intracerebral haemorrhage are independent predictors for poor outcome of CVST.

Adolescent↗
PubMed2000

[Neuroradiologic intervention in two patients with cerebral sinus thrombosis].

Two patients with cerebral sinus thrombosis were successfully treated with neuroradiological intervention procedures, one with local thrombolysis and the other with mechanical thrombosuction using a hydrolyser catheter. The first patient, a 20-year-old woman, was treated with asparaginase for acute lymphatic leukaemia. She lapsed into coma with extensor posturing due to superior sagittal and right transverse sinus thrombosis. She recovered completely after local thrombolysis with 2,940,000 units urokinase, administered over a period of 40 hours. The second patient was a 29-year-old man who presented with clinical deterioration after seizures due to superior sagittal, left transverse and straight sinus thrombosis. A CT-scan demonstrated bilateral haemorrhagic cerebral infarctions. Since the risk of haemorrhage during thrombolysis with urokinase was considered to be high, mechanical thrombosuction with a hydrolyser catheter was performed. This procedure took only 4 hours. The patient recovered completely in two weeks. These cases add further evidence to the effectiveness of thrombolysis and thrombosuction in selected patients with severe cerebral sinus thrombosis.

Adult↗
PubMed2000

[Thrombolytic therapy of brain infarct: the end of beginning].

Thrombolysis by intravenous application of thrombolytic drugs may improve the outcome of patients with a brain infarct, but it also entails risks. The effect of recombinant tissue plasminogen activator (rtPA) was compared with placebo in three medium-sized randomized controlled clinical trials. One study, performed in North America, showed a clear benefit of rtPA administered within 3 hours after the onset of symptoms. Two European trials showed a less strong effect, but the number of patients who were independent after 3 months' follow-up was also larger after treatment with rtPA within 6 hours. A meta-analysis of all three trials demonstrates a significant advantage of rtPA over placebo for all the usual outcome measures, without significant excess mortality in the rtPA group. The chance of being able to live independently increases by about 8% after treatment with rtPA. In conclusion there is now sufficient evidence to start with thrombolytic treatment for cerebral infarcts in hospitals with a stroke unit, if a number of additional quality standards for the acute diagnosis and treatment of stroke patients are met.

Acute Disease↗
PubMed2000

Long-term outcome of cognition and functional health after cerebral venous sinus thrombosis.

The authors examined cognition and functional health of 57 patients with sinus thrombosis 1 year or more after enrollment in a randomized trial of anticoagulant treatment or placebo. Eight patients died and two declined participation. Of the remaining 47 patients, 16 (35%) had cognitive impairments, 3 (6%) were dependent, 19 (40%) had symptoms that led to restrictions in lifestyle, and 19 (40%) could not resume their previous level of economic activity. Outcome after sinus thrombosis may be less favorable than reported previously, and was not significantly influenced by treatment.

Adult↗
PubMed2000

Thyrotoxicosis as a predisposing factor for cerebral venous thrombosis.

Thyroid storm is a rare and life-threatening complication of untreated thyrotoxicosis. A number of neurological complications have been described in association with thyrotoxicosis. We report the case of a 28-year-old woman with a thyroid storm on the basis of Graves' disease and probably triggered by a surgical procedure. She developed cerebral venous thrombosis (CVT) of the left transverse and rectus sinus with a venous infarction of the left thalamus. Except for an increased factor VIII clotting activity there were no thrombophilic abnormalities. Similar cases have been described in the literature and the reported incidence of the combination of CVT and thyrotoxicosis is significantly higher than expected by chance alone (0.1 x 10(-6) per year vs. 0.0032 x 10(-6)/year). This case is consistent with the assumption that thyrotoxicosis, probably through a factor VIII-mediated hypercoagulability, may be a predisposing factor for the development of CVT.

Adult↗
PubMed1999

[Creative mathematics with clopidogrel; exaggeration of the preventive effect by manufacturer].

A number of Dutch medical journals recently carried an advertisement stating that clopidogrel treatment reduced the number of ischaemic complications with 26%, compared with aspirin treatment. This is a miscalculation: the actual reduction is 0.51% in absolute rates, and 8.7% in relative terms. The error by Sanofi-Synthelabo arose by comparison of the event rates for clopidogrel (5.32%) as well as for aspirin (5.83%) with that in an imaginary placebo group (7.77%), yielding a reduction of ischaemic complications of 2.45% and 1.94% respectively; erroneous comparison of these two numbers leads to a difference of 26%.

Advertising↗
PubMed1999

[Physical diagnostics--tendon reflexes].

Clinical examination of the tendon reflexes is helpful in localising lesions in the nervous system, which is an important step in the diagnosis of neurological disorders. The large intra- and interindividual variations of reflex amplitudes make interpretation difficult. Published interobserver agreement studies provide conflicting results. The diagnostic specificity of unequivocally abnormal reflexes is moderate to good (70-95%, decreasing with increasing age), but the sensitivity is lower (50-70%), both for peripheral and for central lesions. This implies that the finding of a clearly abnormal reflex pattern is often helpful, but the finding of normal reflexes usually does not exclude a neurological lesion.

Brain Diseases↗