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ABSTRACT: BACKGROUND AND PURPOSE: Patients with transient ischaemic attack (TIA) with a high risk of imminent stroke can be identified with the ABCD(2) score and findings on MRI and CT angiography. The predictive value of transcranial color-coded sonography (TCCS) has not been evaluated in this setting. METHODS: A retrospective analysis was conducted of patients consecutively treated for TIA or minor stroke in a TIA clinic within 24 h of symptom onset. Agreement between TCCS and MRI three-dimensional time-of-flight images for the diagnosis of proximal (internal carotid artery, vertebral artery, basilar artery, circle of Willis and main stem of the middle cerebral artery) >50% stenosis or occlusion of the intracranial symptomatic artery was evaluated. The sensitivity, specificity, predictive values and likelihood ratio of TCCS for predicting recurrent TIA/stroke at 7 days were calculated. RESULTS: Of 159 patients with a TIA or minor stroke within the last 24 h, 142 had a readable acoustic temporal bone window (89.3%). TCCS and MRI were performed within 4 h of each other in 116 patients. MRI showed a symptomatic proximal intracranial steno-occlusive lesion in six patients. Agreement between MRI and TCCS was perfect (κ coefficient = 1). Recurrent TIA/stroke occurred in 10 patients (eight TIA and two minor strokes). All recurrences occurred within 24 h of symptom onset. A symptomatic proximal intracranial steno-occlusive lesion was found on TCCS in 4/10 patients with recurrence and 3/132 patients without recurrence [sensitivity 40%; specificity 97.7%; likelihood ratio 18.1; odds ratio (95% CI) adjusted for ABCD(2) score 31.5 (4.5-218.6)]. CONCLUSION: Our study shows that TCCS can be used to guide triage of patients with TIA.
European Journal of Neurology 05/2013; · 3.69 Impact Factor
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ABSTRACT: BACKGROUND AND PURPOSE:Patterns of DWI findings that predict recurrent ischemic events after TIA are well-established, but similar assessments of intracranial MRA findings are not available. We sought to determine the imaging characteristics of MRA that are predictive of early recurrent stroke/TIA in patients with TIA.MATERIALS AND METHODS:We performed a retrospective analysis of 129 consecutive patients with a clinical diagnosis of TIA in whom MR imaging was done within 24 hours of symptom onset. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of >50% stenosis or occlusion of symptomatic intracranial arteries for recurrent stroke/TIA at 7 days after TIA. We used logistic regression analysis to adjust for the clinical ABCD(2) score. We performed this analysis for symptomatic steno-occlusive lesions at any site and symptomatic steno-occlusive lesions on proximal large intracranial arteries (internal carotid artery, vertebral artery, basilar artery, and circle of Willis).RESULTS:Forty-two (32.5%) patients had acute ischemic lesions on DWI; 16 (12.4%) had significant MRA lesions, of which 11 (8.5%) were on proximal vessels. Nine patients had early recurrence (TIA, 7; minor stroke, 2). Only patients with proximal MRA lesions were at higher risk of early recurrence independent of the ABCD(2) score (adjusted odds ratio, 5.5; 95% confidence interval, 1.1-27.8; P = .04).CONCLUSIONS:Proximal lesions of cerebral arteries seen on MRA were predictive of recurrent stroke/TIA at 7 days. These findings suggest that MRA could be used to improve the selection of patients with TIA at high risk of early recurrent stroke/TIA.
American Journal of Neuroradiology 06/2012; · 2.93 Impact Factor
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ABSTRACT: We attempted to classify causes of ischemic stroke in young adults using a progressive diagnostic algorithm and the ASCO (atherosclerosis, small-vessel disease, cardiac source, other cause) classification system.
Patients aged 16-54 years consecutively treated for acute ischemic stroke in a tertiary stroke unit were included in this retrospective analysis. Causes of stroke were classified using the ASCO system, which assigns a graded level of likelihood to each potential cause in individual patients. The initial etiologic workup included brain imaging, magnetic resonance or CT angiography of cerebral and cervical vessels, EKG, and routine blood studies. Patients without a definite cause of ischemic stroke after initial evaluation underwent transesophageal echocardiography.
We included 318 patients (195 men and 123 women); 131 patients were aged 16-44 years, and 187 were aged 45-54 years. A definite cause of stroke (ASCO grade 1) could be identified in 145 patients (45.5%). An uncertain cause of stroke (ASCO grade 2) was found in 59 (18.5%) further patients. Most (130 of 145) definite causes were identified by initial evaluation. The 2 major definite or uncertain causes of stroke were patent foramen ovale associated with atrial septal aneurysm (PFO-ASA) (20 of 131 [15.3%]) and dissection of the cervical or cerebral artery (19 of 131 [14.5%]) in patients aged 16-44 years and large-vessel atherosclerosis (37 of 187 [19.8%]) and PFO-ASA (23 of 187 [12.3%]) in patients aged 45-54 years.
Our findings suggest that PFO-ASA may be a major cause of ischemic stroke in young adults.
Neurology 06/2011; 76(23):1983-8. · 8.31 Impact Factor
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ABSTRACT: The mechanisms underlying impairment of dynamic cerebral autoregulation in diabetes are not well known. Cardiovascular autonomic neuropathy (CAN) could contribute to dynamic cerebral autoregulation impairment. In this study, we assessed the association between CAN and impairment of dynamic cerebral autoregulation in patients with type 1 diabetes.
We evaluated dynamic cerebral autoregulation (DCA) in patients with type 1 diabetes and no history of cerebrovascular disease. DCA was assessed with transcranial Doppler using the correlation coefficient index Mx method. Mx was calculated from slow changes in mean cerebral blood flow velocity and mean arterial blood pressure. Increase in Mx indicates weaker DCA, with a threshold for impaired DCA above 0.3. Moderate CAN was defined as reduced heart rate variability (HRV) on the following tests: deep controlled breathing, Valsalva maneuver or initiation of active standing. Severe CAN was defined as reduced HRV associated with orthostatic hypotension.
60 patients were included (M/F: 33/27; mean age ± SD: 46 years ± 11.5). 23 patients had moderate CAN and 15 patients severe CAN. DCA was impaired in 37 patients. CAN was associated with impaired DCA (p = 0.005). Impairment of DCA was more pronounced in patients with severe CAN (p = 0.019). Glycosylated haemoglobin (HbA1c) was associated with impaired DCA in univariate analysis (p = 0.05). In multivariate analysis, only CAN was associated with impaired DCA (p = 0.007) whereas HbA1c was not (p = 0.161).
CAN was associated with impaired DCA in type 1 diabetes. The magnitude of DCA impairment increased with the severity of CAN.
Autonomic neuroscience: basic & clinical 10/2010; 160(1-2):59-63. · 1.82 Impact Factor
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ABSTRACT: Obstructive sleep apnea syndrome (OSAS) is an independent risk factor for stroke. Impairment of cerebral autoregulation may play a potential role in the pre-disposition to stroke of OSAS patients. In this study, we aimed to assess dynamic cerebral autoregulation (DCA) during wakefulness in OSAS patients and a group of matched controls.
Patients and controls were examined in the morning after an overnight complete polysomnography. Mean cerebral blood flow velocity (CBFV) in the middle cerebral artery and mean arterial blood pressure (ABP) were continuously recorded using transcranial Doppler and Finapres. DCA was assessed using the Mx autoregulatory index. Mx is a moving correlation coefficient between mean CBFV and mean ABP. More positive value of Mx indicates worse autoregulation.
Eleven OSAS patients (mean age +/- SD; 52.6 +/- 7.9) and 9 controls (mean age +/- SD; 49.1 +/- 5.3) were enrolled. The mean apnea-hypopnea index (AHI) in the OSAS group was of 22.7 +/- 11.6. No significant difference was found between the two groups as for age, body mass index, mean ABP and endtidal CO(2) pressure. Cerebral autoregulation was impaired in OSAS patients compared with controls (Mx index: 0.414 +/- 0.138 vs. 0.233 +/- 0.100; P = 0.009). The severity of autoregulation impairment correlated to the severity of the sleep respiratory disturbance measured by the AHI (P = 0.003).
Cerebral autoregulation is impaired in patients with OSAS during wakefulness. Impairment of cerebral autoregulation is correlated with the severity of OSAS.
European Journal of Neurology 02/2009; 16(3):386-91. · 3.69 Impact Factor
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ABSTRACT: Whereas International Headache society (IHS) criteria of carotidynia were defined in 1988, its validity as a distinct nosological entity has recently been questioned, leading this entity to be removed from the second IHS classification in 2004. We report the case of a 30-year-old woman who developed a pain located at the left carotid bulb, associated with typical findings on ultrasonography and MRI. We discuss new criteria and denomination of this clinical entity.
European Journal of Neurology 07/2007; 14(6):704-5. · 3.69 Impact Factor
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ABSTRACT: The Gildenberg-Laitinen Adapter Device for X-Ray (GLAD-X/LS) frame is a positioning device that allows the use of the same fiducial points as the Brown-Robert-Wells (BRW) system. Thus it permits treatment planning to be accomplished by the Radionics X-knife Radiosurgery Program. We investigated the commissioning and clinical benefits of the GLAD-X/LS for fractionated stereotactic radiotherapy (FSRT) in patients who were unable to tolerate the Gill-Thomas-Cosman (GTC) frame.
Commissioning of the GLAD-X/LS system was done via use of a Rando Phantom. A target volume of 2 x 2 x 2 cm was drilled into the phantom head. An ion chamber and thermoluminescence dosimetric chips (TLDs) were implanted in the target. A simulated treatment course consisting of 5 stereotactic radiotherapy fractions (300 cGy, 30 mm collimator) was delivered to the phantom head. A total of 27 patients who could not tolerate the GTC frame were treated using the GLAD-X/LS system. A total of 35 isocenters were used; the median number of treatment fractions was eight. Reproducibility of the x, y, and z coordinates was examined and correlated to the same determined using orthogonal port films. Relocation accuracy and reproducibility were further assessed comparing the x, y, and z coordinates of the target center with multiplanar reconstructed coronal and sagittal images. Patient tolerance of the device was also evaluated daily throughout the treatment.
The measured TLD and ion chamber doses were within 3% of the prescribed dose at the isocenter. The same dose accuracy was also found at incremental distances of 5 mm, 10 mm, and 15 mm from the isocenter. All patients tolerated the treatment and the device well. Six patients experienced mild ear canal pain, and softer or smaller earpieces were substituted. The mean relocation accuracy was 1.5 mm +/- 0.8.
The GLAD-X/LS system has excellent accuracy and reproducibility with the mean relocation accuracy of 1.5 mm +/- 0.8. The device is well-tolerated by patients, with no significant complications. Larger scale studies are necessary before routine use can be recommended for the administration of FSRT.
International Journal of Radiation OncologyBiologyPhysics 07/2003; 56(2):592-8. · 4.11 Impact Factor
