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PubMed2004

Nanobacteria-caused mitral valve calciphylaxis in a man with diabetic renal failure.

We have found that nanobacteria, recently discovered Gram-negative atypical bacteria, can cause local calciphylaxis on the mitral valve in a setting of high-calcium X phosphorous product in the blood. We present the case of a 33-year-old man with diabetic renal failure on continuous ambulatory peritoneal dialysis who died as a result of multiple brain infarcts due to embolizations from mitral valve vegetations. Systemic calciphylaxis was not present. Spectrometric analysis of the mitral valve vegetations showed that they were composed of calcium phosphate, carbonate apatite form, and fibrin. The electron microscopy of the thrombotic vegetation demonstrated nanobacterium as a nidus for carbonate apatite formation. Investigation for the presence of nanobacteria in the multiple organs involved in systemic calciphylaxis may be of help in elucidating the pathogenesis of this frequently fatal disorder.

Adult↗
PubMedDate not supplied

The significance of prestroke aspirin dosage in fatal outcome of acute stroke.

BACKGROUND: Aspirin is an effective and generally accepted treatment drug during the acute stage of ischemic brain infarction. The association between the pretreatment aspirin dosage and fatal outcome among these treated patient groups has not been analyzed previously. OBJECTIVE: The aim of the study was to evaluate 14- and 30-day poststroke survival in patients treated with 325 mg immediately on admission to the hospital for prestroke antiaggregation/anticoagulation treatment. METHODS: This prospective study was conducted in a government tertiary care facility. The medical records of all 1245 patients admitted to the hospital for stroke from 1997 to 2002 were reviewed. The association between demographic parameters, stroke risk factors, stroke subtype, prestroke antiaggregation/anticoagulation treatment, and risk of fatal poststroke outcome, 14 days and 30 days after the event, was analyzed using Cox survival analyses. RESULTS: During the 14-day poststroke period, 320 patients (25%) died. By day 30 poststroke, 386 patients (31%) had died. Older age, female gender, chronic heart disease, and cardiac arrhythmias were associated with increased risk of increased fatal outcome. Mortality was higher in patients with stroke caused by cardioembolism (P < 0.0001) and was significantly lower in patients with small-vessel occlusion (P < 0.0001). Prestroke medium-dose aspirin treatment was associated with a relative reduction in 30-day poststroke period mortality (P < 0.0001). Conversely, prestroke low-dose aspirin treatment was associated with increased mortality (P < 0.0001). CONCLUSION: Prestroke medium-dose aspirin treatment was associated with reduced 30-day poststroke mortality, whereas low-dose prestroke aspirin therapy was associated with increased 30-day poststroke mortality.

Aged↗
PubMed1979

Stroke registration in Göteborg, Sweden, 1970-75. Incidence and fatality rates.

Strokes occurring among persons between 15 and 65 years of age (population 300 000) have been registered since 1970 in Göteborg, Sweden. Control of the validity showed that less than 10% of all cases of stroke were undetected. During the period Nov. 15, 1970-May 14, 1975, 986 stroke events occurred in 941 patients, giving an annual average incidence rate of 73 (89 for men and 58 for women) per 100 000 individuals 15-65 years of age. The incidence for all ages was estimated to be about 200/100 000. The rates were higher for men than for women in all age groups. There was a female preponderance for subarachnoid haemorrhage but a male preponderance for other types of stroke. Incidence rates increased with age, most rapidly for brain infarcts and unspecified stroke. Fatality rates levelled out 3 weeks after onset of stroke; they were high for subarachnoid and intracerebral haemorrhage and low for cerebral infarction and unspecified stroke. Incidence rates were lower than those found in two similar studies from Denmark and Finland, and even greater variations were found with respect to types of stroke. Fatality rates were similar to those reported by other authors.

Adolescent↗
PubMed1991

Pathogenetic mechanism of stroke in non-valvular atrial fibrillation: follow-up of stroke patients with and without atrial fibrillation.

Stroke patients with brain infarction and non-valvular atrial fibrillation (NVAF, n = 88) or sinus rhythm (SR, n = 188), treated at a population-based stroke unit, were studied for 5 years. Within 1 month, 13% of NVAF and 2% of SR patients (P less than 0.01) had either a stroke recurrence or systemic embolism. After 5 years, the corresponding figures were 26 and 25%, respectively. The 1-month and 5-year mortality values were 35 and 78% in the NVAF group vs. 7 and 52% in the SR group (P less than 0.01). Age, ischaemic heart disease and function group on arrival at the hospital were independent risk factors for death. The main cause of death was ischaemic heart disease in the NVAF group, and complications to the initial stroke or a stroke recurrence in the SR group. Thus a higher risk of death, stroke recurrence and peripheral embolism was evident only during the first month after stroke.

Aged↗
PubMed2004

Comparison of Gas-less laparoscopy-assisted surgery, hand-assisted laparoscopic surgery and pure laparoscopic surgery for radical nephrectomy.

BACKGROUND: We report our experience with Gas-less laparoscopy-assisted surgery (Gas-less LAS), hand-assisted laparoscopic surgery (HALS) and pure laparoscopic surgery (LS) for renal carcinoma and compare the characteristics and usefulness of these methods. METHODS: Seventeen, 14 and 16 patients were subjected to Gas-less LAS, HALS and LS, respectively. The study started with Gas-less LAS and then gradually shifted to HALS and LS. We evaluated the operative and postoperative parameters for each group. The learning curve effect was evaluated based on data from the first 10 cases of each group, which were operated on by the same surgeon and operation team. RESULTS: The learning curve of operation times in the LS group demonstrated that the operation time for this procedure is acceptable even in early-stage cases. Differences in mean operative time between the three surgical groups, excluding the conversion cases, were not statistically significant; however, there was a significant difference in blood loss volume between the groups (P </= 0.001). Operation time tended to be shorter in Gas-less LAS and the frequency of parental analgesia administration tended to be reduced in the LS group when compared to the other two groups. Of the total 47 patients treated, two cases were converted to open surgery. The major postoperative complication was one case of brain infarction in the HALS group. One patient in the LS group developed a lung metastasis 11 months after the operation. CONCLUSION: As minimally invasive operative techniques, these three methods do not differ significantly in terms of surgical outcome; however, LS tended to be slightly superior in terms of postoperative pain control and cosmetic appearance.

Carcinoma, Renal Cell↗
PubMed2004

Different cytokine levels in thrombolysis patients as predictors for clinical outcome.

Thrombolytic therapy not always improves clinical outcome in ischemic stroke patients. This could cause lymphomonocyte accumulation in the infarcted brain area. These produce an excessive amount of proinflammatory cytokines, such as IL-1 beta, IL-6 and TNF-alfa. The aim of our study was to determine ILs levels in fibrinolytic therapy treated patients, compared with healthy controls and to evaluate if the varying levels can predictors of neurological outcome. Eighteen patients underwent thrombolytic treatment with t-PA within 3 h. Plasma levels of IL-1 beta, IL-6, TNF-alfa and IL-10 were determined by ELISA method before and within 24 h after t-PA infusion and compared with controls. Significantly higher levels of IL-1 beta and Il-6 emerged in stroke patients before treatment compared with the control group (P < 0.05 and 0.04, respectively). Slightly higher plasma levels of TNF-alfa and lower plasma levels of IL-10 were also found at base line in stroke patients. After thrombolytic treatment no significant variations were observed in the levels of TNF-alfa and IL-6, whereas a trend toward lower values for IL-1 beta and higher levels for IL-10 was observed. Positive correlations among the values of IL-6, TNF-alfa and National Institute of Health Stroke Scale (NIHSS) at discharges were observed. A similar correlation with modified Rankin scale score at 3 month was found. Pre-treatment cytokine status seems to influence pre-and long-term clinical outcome. Therefore an investigation into the possible predictor of cytokines seem worthy.

Aged↗
PubMedDate not supplied

Epilepsy after stroke.

A retrospective follow-up of 200 consecutive stroke patients [ischemic brain infarction (IBI) 157, intracerebral hemorrhage (ICH) 20, subarachnoid hemorrhage (SAH) 23] who were in need of ambulatory rehabilitation was conducted for a mean period of 40 months after stroke. Epilepsy developed in 33 (17%) patients. The occurrence of epilepsy was 14% in IBI, 15% in ICH, and 35% in SAH. Significantly more patients developed epilepsy in the SAH group than in the IBI group (8 of 23 vs. 22 of 157, p less than 0.05). Of the 33 patients, 15% had their first seizures within the first 2 weeks after stroke, and 55% developed epilepsy in 6 months. Forty-eight percent of the patients had generalized seizures. Antiepileptic drug (AED) treatment was started in 28 of 33 patients, of whom 17 still had seizures during follow-up. Epilepsy was an important consequence of stroke among patients who needed rehabilitation, especially in SAH patients. In most, this was due to arterial spasm leading to IBI.

Anticonvulsants↗
PubMed2006

SCN5A mutation associated with cardiac conduction defect and atrial arrhythmias.

INTRODUCTION: We aimed at identifying the molecular defect underlying the clinical phenotype of a Finnish family with a cardiac conduction defect and atrial arrhythmias. METHODS AND RESULTS: A large Finnish family was clinically evaluated (ECG, 24-hour ambulatory ECG, echocardiography). We performed linkage analysis with markers flanking the SCN5A gene and subsequently sequenced the SCN5A gene. Five family members had atrial arrhythmias and intracardiac conduction defects, and due to bradycardia needed a pacemaker when adolescents. No heart failure or sudden cardiac death was observed. Left ventricle dilatation was seen in one individual and three individuals had a slightly enlarged right ventricle. Premature death due to stroke occurred in one subject during the study, and two other members had suffered from stroke at young age. Linkage analysis favored the role of the SCN5A gene in disease pathogenesis, and direct sequencing disclosed D1275N mutation. This alteration was present not only in all six affected individuals, but also in two young individuals lacking clinical symptoms. CONCLUSIONS: Cardiac conduction defect and atrial arrhythmias in a large Finnish family appear to result from the SCN5A D1275N mutation. Although no sudden cardiac death was recorded in the family, at least three affected members had encountered brain infarction at the age of 30 or younger.

Atrial Fibrillation↗
PubMed1988

Atherosclerotic carotid disease in asymptomatic individuals: An histological study of 53 cases.

The carotid bifurcation was studied histologically in 53 consecutive autopsies from persons over 65 years of age who were asymptomatic for carotid artery disease and showed no carotid related brain infarcts. The autopsy material is considered to be representative for the population in Oslo. The area stenosis was determined morphometrically in histological sections and the cases were examined for the occurrence of atherosclerotic plaques, calcifications, plaque hemorrhages, ulcerations, and mural thrombi. About one half of the cases had more than 50% stenosis. There was increasing frequency of plaque hemorrhages, ulcerations and mural thrombi with increasing stenosis. When the stenosis exceeded 60%, most cases had small recent and old plaque hemorrhages and one half had ulcerations and mural thrombi. In addition, numerous healed ulcerations and organized thrombi were seen. It is concluded that plaque complications are frequent in cases with stenosis and that most of them apparently heal without giving rise to symptoms. The presence of such lesions in asymptomatic cases must therefore be interpreted with caution.

Aged↗
PubMed2006

Cognitive impairments in acute lacunar stroke.

BACKGROUND: The present study investigated the prevalence of cognitive deficits in acute lacunar stroke, validated the Mini Mental State Examination (MMSE) in detecting cognitive impairments in lacunar patients, and identified predictors of such deficits. METHODS: Seventy-one patients with lacunar stroke performed a comprehensive cognitive screening between day 2 and day 7 of their stay. The test battery included Trail Making Test A, Verbal Fluency, Object Learning Test, Ullevål Aphasia Screening, and Assessment of Stroke and other Brain Damage regarding motor apraxia, rational apraxia and visuospatial ability. RESULTS: Exactly 57.7% scored outside cutoff in at least one of the cognitive tests. Using a rigorous cutoff for MMSE (28/29 points) and the test battery as comparison, the sensitivity and specificity of MMSE were 0.69 and 0.67, respectively. Only male sex was significantly related to the presence of cognitive deficits (pathologic score on at least one of the tests--odds ratio 4.41, 95% confidence interval 1.45-13.43). CONCLUSION: Many lacunar stroke patients suffer cognitive problems. Male patients are at particular risk. MMSE failed to identify 30% of the patients diagnosed with cognitive deficits, and we suggest that lacunar stroke patients be offered a comprehensive cognitive screening, even when MMSE is normal.

Acute Disease↗
PubMed1999

Brain adenosine receptors as targets for therapeutic intervention in neurodegenerative diseases.

Adenosine acts as a neurotransmitter in the brain through the activation of four specific G-protein-coupled receptors (the A1, A2A, A2B, and A3 receptors). The A1 receptor has long been known to mediate neuroprotection, mostly by blockade of Ca2+ influx, which results in inhibition of glutamate release and reduction of its excitatory effects at a postsynaptic level. However, the development of selective A1 receptor agonists as antiischemic agents has been hampered by their major cardiovascular side effects. More recently, apparently deleterious effects have been reported following the activation of other adenosine receptor subtypes, namely, the A2A and the A3 receptors. In particular, selective A2A receptor antagonists have been demonstrated to markedly reduce cell death associated with brain ischemia in the rat, suggesting that the cerebral A2A receptor may indeed contribute to the development of ischemic damage. The beneficial effects evoked by A2A antagonists may be due to blockade of presynaptic A2A receptors (which are stimulatory on glutamate release) and/or to inhibition of A2A receptor-mediated activation of microglial cells. Even more puzzling data have been reported for the A3 receptor subtype, which can indeed mediate both cell protection and cell death, simply depending upon the degree of receptor activation and/or specific pathophysiological conditions. In particular, a mild subthreshold activation of this receptor has been associated with a reinforcement of the cytoskeleton and reduction of spontaneous apoptosis, which may play a role in "ischemic preconditioning" of the brain, according to which a short ischemic period may protect the brain from a subsequent, sustained ischemic insult that would be lethal. In contrast, a robust and prolonged activation of the A3 receptor has been shown to trigger cell death by either necrosis or apoptosis. Such apparently opposing actions may be reconciled by hypothesizing that adenosine-mediated cell killing during ischemia may be aimed at isolating the most damaged areas to favor those parts of the brain that still retain a chance for functional recovery. In fact, both A3 receptor-mediated cell death and A2A receptor-mediated actions may be viewed as an attempt to selectively kill irreversibly damaged cells in the "core" ischemic area, in order to save space and energy for the surrounding live cells in the "pneumbra" area. Hence, the pharmacological modulation of the A2A and A3 receptors via selective ligands may represent a novel strategy in the therapeutic approach to pathologies characterized by acute or chronic neurodegenerative events.

Adenosine↗
PubMed1981

Sickle-cell disease in a British urban community.

Seventy cases of sickle-cell disease were identified in the London Borough of Brent from records dating back to 1962. All but three were still alive and, with one exception, were recalled for confirmation of the diagnosis and to provide personal and family histories. The group consisted of 22 individuals with homozygous sickle-cell anaemia (Hb SS), 12 with sickle-cell/beta-thalassaemia double heterozygosity, 34 with sickle-cell/haemoglobin C disease (Hb SC), and two with the combination of haemoglobin S and hereditary persistence of fetal haemoglobin. They were predominantly of West Indian origin, more than half had been born in Britain, and most were aged under 25. The records for 304 patient admissions between 1962 and 1979 were analysed. There were 199 sickle-cell-disease-related admissions, 61 unrelated to sickle-cell disease, and 44 for pregnancy or its complications. Admissions per patient-year averaged less than one, except for children with Hb SS under the age of 5 years, who were admitted more frequently. The commonest reasons for admission were painful crises (74% of all admissions) and the "chest syndrome" (21%). There were four pneumococcal infections, all in children with Hb SS under the age of 8 years; all recovered. Three patients, aged 10, 15, and 50 years, died. The two children with Hb SS died in their sleep without gross evidence of sickling at necropsy. Multiple brain infarcts were found at necropsy in the 50-year-old woman with Hb SC who, having survived nine uneventful pregnancies, succumbed to an infection after cryosurgery to the cervix. Obstetric records were available for 18 term pregnancies in 11 women. Three antenatal sickling crises and three postpartum thromboembolic complications were encountered. There were no maternal or perinatal deaths. Fifteen asymptomatic individuals with sickle-cell disease were diagnosed as a result of routine screening procedures. There are likely to be many such individuals currently undiagnosed in the community. They urgently need identification because of their increased risks from pregnancy, surgery, and infection.

Adolescent↗
PubMed2002

Hepatopulmonary syndrome: prevalence and predictive value of various cut offs for arterial oxygenation and their clinical consequences.

BACKGROUND: The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, arterial deoxygenation, and pulmonary vascular dilatation. The reported prevalence of HPS in cirrhotic patients varies between 4% and 19%, and various threshold values defining arterial deoxygenation have been used and recommended previously. However, it is not known how the prevalence of HPS differs using different cut off values for arterial deoxygenation. METHODS: We studied 127 patients for the presence of HPS using transthoracic contrast echocardiography for detection of pulmonary vasodilation, pulmonary function tests, and blood gas analysis. RESULTS: Ninety eight patients were included in the study, of whom 33 (34%) had a positive contrast echocardiography. Using an increased alveolar-arterial difference for the partial pressure of oxygen (AaDO(2)) as an indication of hypoxaemia, the prevalence of HPS was considerably higher (>15 mm Hg, 32%; >20 mm Hg, 31%; and >age related threshold, 28%) than using reduced partial pressure of arterial oxygen (PaO(2)) as a threshold (<80 mm Hg, 19%; <70 mm Hg, 15%; and <age related threshold, 15%). For AaDO(2) as the cut off, the positive predictive value for a diagnosis of HPS was low (34%, 37%, and 53%, respectively). In contrast, PaO(2) as a cut off had considerably higher positive predictive values (44%, 93%, and 94%, respectively). Introducing PaO(2) <65 mm Hg as the cut off, the positive predictive value increased to 100%. Dyspnoea was more often present in patients with "clinically significant" HPS (57%) compared with "subclinical HPS" (8%), and patients without HPS (6%). The Child-Pugh score correlated significantly with the severity of HPS. Two of five liver transplanted patients with "subclinical HPS" had embolic brain infarcts, possibly induced by venous emboli passing through dilated intrapulmonary vessels. CONCLUSIONS: Defining arterial hypoxaemia in HPS by different, previously used, cut off values for arterial oxygenation leads to a wide variation in the prevalence of HPS in the same sample of cirrhotic patients.

Aged↗
PubMed2005

A randomised phase II study of interleukin-1 receptor antagonist in acute stroke patients.

OBJECTIVES: The cytokine interleukin (IL)-1 mediates ischaemic brain damage in rodents. The endogenous, highly selective, IL-1 receptor antagonist (IL-1ra) protects against ischaemic cerebral injury in a range of experimental settings, and IL-1ra causes a marked reduction of cell death when administered peripherally or at a delay in transient cerebral ischaemia. We report here the first randomised, double blind, placebo controlled trial of recombinant human IL-1ra (rhIL-1ra) in patients with acute stroke. METHODS: Patients within 6 hours of the onset of symptoms of acute stroke were randomised to rhIL-1ra or matching placebo. Test treatment was administered intravenously by a 100 mg loading dose over 60 seconds, followed by a 2 mg/kg/h infusion over 72 h. Adverse events and serious adverse events were recorded for up to 3 months, serial blood samples were collected for biological markers up to 3 months, and 5-7 day brain infarct volume was measured by computed tomography. RESULTS: No adverse events were attributed to study treatment among 34 patients randomised. Markers of biological activity, including neutrophil and total white cell counts, C reactive protein, and IL-6 concentrations, were lower in rhIL-1ra treated patients. Among patients with cortical infarcts, clinical outcomes at 3 months in the rhIL-1ra treated group were better than in placebo treated. CONCLUSIONS: These data suggest that rhIL-1ra is safe and well tolerated in acute stroke. In addition, rhIL-1ra exhibited biological activity that is relevant to the pathophysiology and clinical outcome of ischaemic stroke. Our findings identify rhIL-1ra as a potential new therapeutic agent for acute stroke.

Acute Disease↗
PubMed2007

Polymorphisms of the renin-angiotensin system are associated with blood pressure, atherosclerosis and cerebral white matter pathology.

BACKGROUND: The renin-angiotensin system is involved in the development of hypertension, atherosclerosis and cardiovascular disease. We studied the association between the M235T polymorphism of the angiotensinogen gene (AGT) and the C573T polymorphism of the angiotensin II type 1 receptor (AT1R) and blood pressure, carotid atherosclerosis and cerebrovascular disease. METHODS: We genotyped over 6000 subjects from the Rotterdam Study and more than 1000 subjects from the Rotterdam Scan Study. We used logistic regression and univariate analyses, adjusting for age and sex with, for AGT, the MM and, for AT1R, the TT genotype as reference. RESULTS: We found that AGT-235T increased systolic (p for trend = 0.03) and diastolic blood pressure (p for trend = 0.04). The prevalence of carotid plaques was increased 1.25-fold (95% CI 1.02-1.52) in AGT-TT carriers. There was a significant increase in mean volume deep subcortical white matter lesions (WML) for AGT-TT carriers (1.78 ml vs 1.09 ml in the reference group; p = 0.008). A significant interaction was found between AGT and AT1R, further increasing the effect on periventricular and subtotal WML (p for interaction = 0.02). We found a non-significant increased risk of silent brain infarction for AGT-TT carriers and AT1R-CC carriers, but no effect on stroke. CONCLUSION: We found an association between AGT and blood pressure, atherosclerosis and WML. Also, we found synergistic effects between AGT and AT1R on the development of WML. These findings raise the question of whether the renin-angiotensin system may be a therapeutic target for the prevention of cerebral white matter pathology.

Aged↗
PubMed1994

Mechanisms of cerebral artery thrombosis: a histopathological analysis on eight necropsy cases.

The mechanisms of thrombus formation in atherosclerotic cerebral arteries are still controversial, although intraplaque haemorrhage and rupture of the atheromatous plaques have been proposed. A histopathological analysis of segments of the thrombosed large intracranial arteries was carried out on eight patients who died within 28 days after brain infarction. The study revealed occlusive thrombi in six and mural thrombi in two, developing mostly at the site of greatest stenosis or just distal to it. The histological characteristics of the thrombosed arteries were plaque rupture in three, intramural haemorrhage in one, ulceration in one, and thrombosis in the absence of plaque rupture or intramural haemorrhage in three. Occlusive emboli distal to the site of cerebral artery thrombosis (intracranial artery-to-artery thromboembolism) were observed in two. The following conclusions were drawn from the study: 1) plaque rupture or intraplaque haemorrhage is not a sine qua non for cerebral artery thrombosis; 2) occlusions occur at the site of greatest luminal compromise or just distal to it, and 3) non-occlusive mural thrombosis can occur in the absence of plaque rupture and eventually lead to local occlusion or distal embolisation.

Aged↗
PubMed2002

Clipping of cerebral aneurysm under hypothermic cardiac arrest and simultaneous coronary artery bypass grafting: case report.

This report describes a case where joint neurological and cardiac surgery teams cooperated to perform simultaneous procedures of clipping a complex internal carotid artery under hypothermic cardiac arrest and coronary artery bypass grafting. A 69 year old man was evaluated for complaints of double vision, pain behind his right eye, and progressively worsening headaches. Examination showed bilateral upgoing toes and difficulty performing a tandem gait. The patient had a history of myocardial infarction. Brain MRI showed a 1.6 cm diameter, partially thrombosed aneurysm of the right internal carotid artery and posterior communicating artery. Cardiac catheterisation showed critical coronary artery disease of the distal segment of the right coronary artery with 90% stenosis of the midcircumflex artery and an ejection fraction of 40%. After initial exposure of the aneurysm, the cardiac team instituted hypothermic cardiac arrest (21 degree C). The aneurysmal sac was collapsed and dissected from the surrounding perforators. An encircling fenestrated clip was applied and a small part of the neck of the aneurysm was further clipped with straight clips. The cardiac surgery team performed the coronary artery bypass grafting procedure. The patient recovered fully, returned to his normal activities, and is functioning independently.

Aged↗

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