Telmisartan and the prevention of recurrent stroke

The most common risk factor for stroke and cardiovascular diseases is hypertension. Accordingly the prolonged lowering of blood pressure after a stroke reduces the risk of recurrent stroke. In addition, inhibition of the renin–angiotensin system in high-risk patients reduces the rate of subsequent cardiovascular events, including stroke. This study ( Published on 27^th August 2008 on New England Journal of Medicine web site) which was presented recently in Nice, France in the second day of the 17^th European stroke conference (May 2008) has evaluated the effects of therapy with an angiotensin-receptor blocker, telmisartan, initiated early after a stroke.

In a multicenter trial involving 20,332 patients who recently had an ischaemic stroke, Yusuf et al randomly assigned 10,146 to receive telmisartan (80 mg daily) and 10,186 to receive placebo. The primary outcome was recurrent stroke. Secondary outcomes were major cardiovascular events (death from cardiovascular causes, recurrent stroke, myocardial infarction, or new or worsening heart failure) and new-onset diabetes.

 A total of 880 patients (8.7%) in the telmisartan group and 934 patients (9.2%) in the placebo group had a subsequent stroke. Major cardiovascular events occurred in 1367 patients (13.5%) in the telmisartan group and 1463 patients (14.4%) in the placebo group. New-onset diabetes occurred in 1.7% of the telmisartan group and 2.1% of the placebo group.

The study concluded that therapy with telmisartan initiated soon after an ischaemic stroke and continued for 2.5 years did not significantly lower the rate of recurrent stroke, major cardiovascular events, or diabetes.

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 More and more studies are published at present regarding the risk of stroke following a TIA. The most recent study which is published in Arch Neurol.2008; 65 (6): 733-737 was a cohort one with objectives to quantify the early risk of ischaemic stroke in the territory of a stenotic intracranial artery after TIA. The other aim of the study is to identify clinical and imaging features associated with increased risk of stroke in the territory among patients with TIA.
The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) study enrolled patients having TIA or nondisabling stroke within the preceding 3 months and demonstrating corresponding 50% to 99% stenosis of a major intracranial artery on angiography.
The authors calculated the cumulative risk of stroke in the territory of the symptomatic artery during the first 90 days after randomization among patients having TIA alone as a qualifying event compared with patients having stroke alone. They assessed selected factors for association with stroke among patients having TIA as the qualifying event.
The results showed that the 90-day risk of ischaemic stroke in the arterial territory was 6.9% after TIA compared with 4.7% after stroke. Among patients having TIA alone as the qualifying event, 60.0% (15 of 25) of all strokes in the arterial territory occurred in the first 90 days compared with 34.4% (11 of 32) among patients having stroke alone as the qualifying event. Among subjects with TIA, the presence of cerebral infarct on baseline neuroimaging was the only statistically significant predictor of higher risk of early stroke.
The paper concluded that among individuals having intracranial atherosclerotic disease with TIA, most subsequent strokes in the territory of a stenotic intracranial artery occur early (ie, 90 days).  

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Insulin resistance is associated with hyperglycemia and dyslipidemia and promotes atherosclerosis. As such it can be regarded as a risk factor for cerebrovascular diseases. Although insulin resistance is associated with adipocytokines, little is known about the association in patients with stroke without diabetes mellitus. The aim of the current study ( Journal of stroke and cerebravascular diseases 2008;17,4: 174-180) was to examine the relationship among insulin resistance, visceral fat area, and adipocytokines in patients with stroke.
The authors studied 60 patients with stroke and no history of diabetes mellitus who had hyperglycemia or hypertriglyceridemia or reduced fasting plasma high-density lipoprotein cholesterol. They measured insulin resistance, the plasma level of tumor necrosis factor (TNF)-α, adiponectin, and the visceral fat area. Insulin resistance was defined by the homeostasis model assessment and the level of insulin at 120 minutes after consuming oral glucose.
The authors classified two groups (insulin sensitive or insulin resistant). In all, 21 of 60 patients (35.0%) had insulin resistance and 35 (58.3%) had hyperinsulinemia. Compared with insulin-sensitive patients with stroke (n = 18), insulin-resistant patients with stroke (n = 21) had significantly wider visceral fat areas and a high level of plasma TNF-α. The plasma level of adiponectin in insulin-resistant patients with stroke was similar to that in insulin-sensitive patients.
This important study concluded that insulin-resistant patients with stroke had a large amount of visceral fat and increased levels of TNF-α. It was recommended that obese patients with stroke should be examined for insulin resistance to reduce the risk of the development of atherosclerosis.

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Cholinergic deficits might contribute to vascular cognitive impairment. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is a genetic form of subcortical ischaemic vascular dementia. It represents a homogeneous disease process, and because of CADASIL's early onset, comorbid AD pathology is rare. Dichgans M et al, did a multicentre, 18-week, placebo-controlled, double-blind, randomised parallel-group trial to determine whether the cholinesterase inhibitor donepezil improves cognition in patients with CADASIL (Lancet Neurology 2008; 7:310-318)
The trial assigned 168 patients with CADASIL (mean age 54•8 years) to 10 mg donepezil per day (n=86) or placebo (n=82) by a computer-generated randomisation protocol. The primary endpoint was change from baseline in the score on the vascular AD assessment scale cognitive subscale (V-ADAS-cog) at 18 weeks. Analysis was done by intention to treat.
The records of 161 patients were analyzed. There was no significant difference between donepezil (n=84) and placebo (n=77) in the primary endpoint.
The trial concluded that Donepezil had no effect on the primary endpoint, the V-ADAS-cog score in CADASIL patients with cognitive impairment. Improvements were noted on several measures of executive function, but the clinical relevance of these findings is not clear. The findings may have implications for future trial design in subcortical vascular cognitive impairment. 

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Whether intravenous tissue plasminogen activator (alteplase) is effective beyond 3 h after onset of acute ischaemic stroke is unclear. The authors of this interesting study ( The Lancet Neurology Early Online Publication, 22 Febuary 2008) aimed to test whether alteplase given 3–6 h after stroke onset promotes reperfusion and attenuates infarct growth in patients who have a mismatch in perfusion-weighted MRI (PWI) and diffusion-weighted MRI (DWI).
The authors prospectively and randomly assigned 101 patients to receive alteplase or placebo 3–6 h after onset of ischaemic stroke. PWI and DWI were done before and 3–5 days after therapy, with T2-weighted MRI at around day 90. The primary endpoint was infarct growth between baseline DWI and the day 90 T2 lesion in mismatch patients. Major secondary endpoints were reperfusion, good neurological outcome, and good functional outcome. Patients, caregivers, and investigators were unaware of treatment allocations. Primary analysis was per protocol.
The researchers randomly assigned 52 patients to alteplase and 49 patients to placebo. Mean age was 71•6 years, and median score on the National Institutes of Health stroke scale was 13. 85 of 99 (86%) patients had mismatch of PWI and DWI.
The authors concluded that reperfusion was more common with alteplase than with placebo and was associated with less infarct growth (p=0•001), better neurological outcome (p<0•0001), and better functional outcome (p=0•010) than was no reperfusion.
Alteplase was non-significantly associated with lower infarct growth and significantly associated with increased reperfusion in patients who had mismatch. The researchers went on to say that because reperfusion was associated with improved clinical outcomes, phase III trials beyond 3 h after treatment are warranted. 

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In order to estimate the impact on long term survival of functional status at six months after ischaemic stroke, a research team from Norway and UK ( BMJ 2008;336:376-379 ) designed a prospective cohort study included three cohorts: Oxfordshire community stroke project, Lothian stroke register, and the first international stroke trial (in the United Kingdom).
The participants were 7710 patients with ischaemic stroke registered between 1981 and 2000 and followed up for a maximum of 19 years.
The Main outcome measure is functional status at six months after stroke assessed with modified Rankin scale.
The results showed that in a combined analysis of all three cohorts, among patients who survived to assessment six months after the index stroke, the subsequent median length of survival among those independent in daily living and those dependent was 9.7 years and 6.0 years respectively. In a combined analysis of the Oxfordshire and Lothian cohorts, subsequent median survival fell progressively from 12.9 years for patients with a Rankin score of 0-1 at six months after the stroke to 2.5 years for patients with a Rankin score of 5. All previously stated differences in median survival were significant. The influence of functional outcome on survival remained significant (P<0.05) in each cohort after adjustment for relevant covariates (such as age, presence of atrial fibrillation, visible infarct on computed tomography, subtype of stroke) in a Cox’s regression model.
The research concluded that functional status six months after an ischaemic stroke is associated with long term survival. Early interventions that reduce dependency at six months might have positive effects on long term survival.  

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Metabolic syndrome is a combination of medical problems that include high blood pressure, raised the LDL (bad lipid) and low HDL (good lipid) in addition to the disturbances in blood glucose level which might lead to diabetes mellitus or to glucose intolerance. This can happen in an overweight person with male style of obesity (abdominal obesity).
More than 47 million individuals in the United States meet the criteria for the metabolic syndrome. The relation between the metabolic syndrome and stroke risk in multiethnic populations has not been well characterized.
As part of the Northern Manhattan Study, 3298 stroke-free community residents were prospectively followed up for a mean of 6.4 years. The metabolic syndrome was defined according to guidelines established by the National Cholesterol Education Program Adult Treatment Panel III ( Stroke 2008; 39:30).
The results of this study showed that more than 44% of the cohort had the metabolic syndrome (48% of women vs 38% of men, P<0.0001), which was more prevalent among Hispanics (50%) than whites (39%) or blacks (37%). The metabolic syndrome was associated with increased risk of stroke and vascular events after adjustment for sociodemographic and risk factors.
The effect of the metabolic syndrome on stroke risk was greater among women than men and among Hispanics compared with blacks and whites. The etiologic fraction estimates suggest that elimination of the metabolic syndrome would result in a 19% reduction in overall stroke, a 30% reduction of stroke in women; and a 35% reduction of stroke among Hispanics.
The study concluded that metabolic syndrome is an important risk factor for ischaemic stroke, with differential effects by sex and race/ethnicity.
 

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Studies to date have shown an association between the presence of patent foramen ovale and cryptogenic stroke in patients younger than 55 years of age. This association has not been established in patients 55 years of age or older.
The research team from Departments of Cardiology and Angiology, Neurology and Neurophysiology, and Medical Biometry and Statistics (M.O.), University Hospital Freiburg, Freiburg, Germany, prospectively examined 503 consecutive patients who had had a stroke (NEJM 2007; 357, 22: 2262-2268)
They compared the 227 patients with cryptogenic stroke and the 276 control patients with stroke of known cause. They examined the prevalences of patent foramen ovale and of patent foramen ovale with concomitant atrial septal aneurysm in all patients, using transesophageal echocardiography.
The researchers also compared data for the 131 younger patients (<55 years of age) and those for the 372 older patients ( 55 years of age).
The prevalence of patent foramen ovale was significantly greater among patients with cryptogenic stroke than among those with stroke of known cause, for both younger patients and older patients. Even stronger was the association between the presence of patent foramen ovale with concomitant atrial septal aneurysm and cryptogenic stroke, as compared with stroke of known cause, among both younger patients and older patients. Multivariate analysis adjusted for age, plaque thickness, and presence or absence of coronary artery disease and hypertension showed that the presence of patent foramen ovale was independently associated with cryptogenic stroke in both the younger group and the older group.
The research concluded that there is an association between the presence of patent foramen ovale and cryptogenic stroke in both older patients and younger patients. These data suggest that paradoxical embolism is a cause of stroke in both age groups.  

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Spontaneous recovery and possible fluctuation in left visual neglect, and its relation to stroke severity, basic activities of daily living (ADL) and extended ADL were examined at 10 days, at 3, 6, and 12 months after onset according to the study published in Eur Neurol. 2007 Sep 7;58(4):210-214. The authors are all from Tampere University Hospital, Department of Neurology and Rehabilitation,Tampere, Finland.
Twenty-one of 56 right hemisphere stroke patients had visual neglect. Three visual neglect recovery groups were identified: continuous, fluctuating and poor recovery. The authors focused on the comparison of the continuous and the fluctuating recovery groups. As expected at the acute phase the fluctuating recovery group had larger infarcts, more severe neglect and stroke, and a lower level of basic ADL compared to the continuous recovery group.
In the continuous recovery group stable recovery was detected up to 6 months according to this study, whereas in the fluctuating recovery group recovery was incoherent in neglect and in extended ADL. The researchers concluded that a minimum follow-up period of 6 months including the evaluation of extended ADL is recommended for neglect patients due to possible fluctuation in visual neglect. 

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Intracerebral haemorrhage constitutes an often fatal sequela of thrombolytic therapy in patients with ischaemic stroke. Early blood–brain barrier disruption may play an important role, and the astroglial protein S100B is known to indicate blood–brain barrier dysfunction. The authors of this research investigated whether elevated pretreatment serum S100B levels predict haemorrhagic transformation (HT) in thrombolyzed patients with stroke (Stroke. 2007; 38:2491.)
The authors retrospectively included 275 patients with ischaemic stroke (mean age of 69±13 years; 46% female) who had received thrombolytic therapy within 6 hours of symptom onset. S100B levels were determined from pretreatment blood samples. Follow-up brain scans were obtained 24 hours after admission, and HT was classified as either haemorrhagic infarction or parenchymal haemorrhage.
HT occurred in 80 patients (29%; 45 haemorrhagic infarction, 35 parenchymal haemorrhage). Median S100B values were significantly higher in patients with HT.
The study concluded that elevated S100B serum levels before thrombolytic therapy constitute an independent risk factor for haemorrhagic transformation in patients with acute stroke. Unfortunately, the diagnostic accuracy of S100B is too low for it to function in this context as a reliable biomarker in clinical practice.  

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Intracranial aneurysms can be treated with endovascular or surgical techniques. The authors provide an objective comparison of these treatments, using data from single-centre studies, multicentre studies with and without independent outcome ascertainment, and randomised clinical trials (Lancet Neurology 2007; 6:816- 825).
The authors compared the outcomes of patients who were candidates for endovascular treatment, surgical treatment, or both. In patients with ruptured intracranial aneurysms, rates of aneurysm obliteration were higher, and need for second treatment was lower, after surgery than after endovascular treatment. However, in observational studies and randomised trials, outcome at discharge, at 2–6 months, and at 1 year, and later survival, were all better after endovascular treatment than after surgery. The results suggest that the higher rates of incomplete obliteration and retreatment after endovascular treatment do not affect patients' clinical outcome. In observational studies of patients with unruptured intracranial aneurysms, discharge outcomes were better and hospital costs were lower after endovascular treatment than after surgery. These patients showed no difference between the two treatments in 1-year outcomes and later rebleeding, although few data were available for this comparison.

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The relative importance of previous diagnosis and hereditary prothrombotic risk factors for cerebral venous thrombosis (CVT) in children in determining risk of a second cerebral or systemic venous thrombosis (VT), compared with other clinical, neuroimaging, and treatment variables, is unknown.
The European Thromboses Study Group (Lancet Neurology 2007; 6:595-603)followed up the survivors of 396 consecutively enrolled patients with CVT, aged newborn to 18 years (median 5•2 years) for a median of 36 months (maximum 85 months). In accordance with international treatment guidelines, 250 children (65%) received acute anticoagulation with unfractionated heparin or low-molecular weight heparin, followed by secondary anticoagulation prophylaxis with low-molecular weight heparin or warfarin in 165 (43%).
The results showed that of 396 children enrolled, 12 died immediately and 22 (6%) had recurrent VT (13 cerebral; 3%) at a median of 6 months (range 0•1–85). Repeat venous imaging was available in 266 children. Recurrent VT only occurred in children whose first CVT was diagnosed after age 2 years; the underlying medical condition had no effect.
The study concluded that age at CVT onset, non-administration of anticoagulation, persistent venous occlusion, and presence of G20210A mutation in factor II predict recurrent VT in children. Secondary prophylactic anticoagulation should be given on a patient-to-patient basis in children with newly identified CVT and at high risk of recurrent VT. Factors that affect recanalisation need further research.

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UK stroke mortality data suggest that the incidence of haemorrhagic stroke has fallen in the past 20 years, but these data do not include deaths of individuals aged 75 years or over. Trends in the older population might differ, since cause varies with age. The aim of this study was to investigate changes in the population-based incidence of intracerebral haemorrhage according to age and likely aetiology (Lancet Neurology, Early Online Publication, 1 May 2007).
The authors used data from the Oxford Community Stroke Project (OCSP; 1981–86) and the Oxford Vascular Study (OXVASC; 2002–06) to investigate changes in the incidence of intracerebral haemorrhage with time, above and below age 75 years, together with associated risk factors and premorbid medications. Incidences were standardised to the 2001 census population of England and Wales.
The findings showed that in the population aged under 75 years the incidence of intracerebral haemorrhage decreased substantially), but the number of cases of intracerebral haemorrhage at all ages were similar in OXVASC and OCSP as the proportion of cases occurring at 75 years and over tended to increase.
The incidence of intracerebral haemorrhage associated with premorbid hypertension (blood pressure ≥160/100 mm Hg) fell overall, but the incidence of intracerebral haemorrhage associated with antithrombotic use was increased.
The study concluded that there has been a substantial fall in hypertension-associated intracerebral haemorrhage over the past 25 years, but not in the overall number of cases of intracerebral haemorrhage in older age-groups, in part due to a rise in intracerebral haemorrhage associated with antithrombotic use. These trends, along with the expected increase in prevalence of amyloid angiopathy with the ageing population, suggest that, in contrast to projections based on mortality data below age 75 years, absolute number of cases of intracerebral haemorrhage might increase in future. 

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Dysphagia in stroke is linked with increased risk of pneumonia, increased length of stay and poorer outcomes. This study (J Clin Neurosci. 2007 Apr 12) followed a cohort of 88 acute ischaemic stroke patients admitted to hospitals in Perth, Western Australia, over 30 days.
There were 8/88 deaths (9%). Infections were treated in 25/80 survivors (31%). Presence and severity of dysphagia were measured at 2 and 7 days post-stroke. Respiratory tract infections occurred at significantly higher rates for dysphagics (p<0.05). At 2 days post-stroke, the odds ratio (OR) of chest infection for dysphagics was 1.45. Survivors who were "nil by mouth" 2 days post-stroke were significantly more likely to develop pneumonia (p=0.01). At 7 days post-stroke, dysphagics were again more likely to develop pneumonia (p=0.014).
The total anterior circulation infarcts demonstrated more severe and prolonged dysphagia than other stroke subtypes. 

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Incidence and Risk Factors for Stroke in Type 2 Diabetic Patients

Type 2 diabetes mellitus is a strong predictor of cerebrovascular disease, yet few studies have assessed the incidence of stroke and the role of other risk factors in unselected type 2 diabetes mellitus populations.
The researchers prospectively followed-up 14 432 type 2 diabetes mellitus patients, aged 40 to 97 years, with and without a history of cardiovascular disease at enrollment, and they estimated the incidence of stroke and the hazards ratios with respect to clinical variables (Stroke. 2007;38:1154).
During a 4-year follow-up, 296 incident stroke events were recorded. In persons with no history of cardiovascular disease, the age-standardized incidence of stroke (per 1000 person-years) was 5.5 in men and 6.3 in women.
In persons with a history of cardiovascular disease, it was 13.7 in men and 10.8 in women. The hazards ratios of stroke incidence varied according to age, sex, and history of cardiovascular disease. Among men with no history, HbA1c and smoking were predictors of stroke. Among patients with a history, the risk factors were, in men, therapy with insulin plus oral agents, treated high total cholesterol and low HDL cholesterol, whereas in women microvascular complications were a risk factor. Previous stroke was a strong predictor of stroke in both sexes.
Age and previous stroke are the main predictors of stroke in diabetes. The combined role of Hba1c, microvascular complications, low HDL cholesterol, and treatment with insulin plus oral agents highlights the importance of diabetic history and clinical background in the development of stroke.  

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The evolution of stroke in Quebec

The objective of this research (Neurology 2007; 68: 1122-1127) is to estimate changes in rates of cerebral infarction and intracerebral heamorrhage, comorbidity profile, and case fatality rates in Quebec over 15 years.
A population-based admission-to-discharge cohort study was conducted, selecting first stroke events from hospital discharge data (MedEcho) from 1988 to 2002.
In this study (involving 101,831 persons with cerebral infarctions and 11,215 persons with intracerebral heamorrhages), there was a downturn in the rates of cerebral infarction over 15 years, especially during the last 5 years (32.5% decline for men and 25.5% for women). A concomitant increase in rates of intracerebral heamorrhage, 28% increase for men (2%/year) and 22% for women (1.6%/year), was also noted. Although age and comorbidity of the population increased, case fatality decreased over time. Age and type of stroke were strong predictors for early ( 7 days) and later (8 to 30 days) case fatality, whereas comorbidity was important only for later death. In-hospital bed stay declined dramatically over time for all discharge destinations.
A significant decrease in rates of cerebral infarction and a rise in rates of intracerebral heamorrhage were noted in Quebec over 15 years. Age and comorbidity of the population increased. Although stroke is increasingly a condition of the elderly, ill population, case fatality and in-hospital bed stay declined over time.  

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Abnormal breathing patterns in stroke

The objective of this research is to determine whether central periodic breathing (CPB) is associated with acute involvement of any particular part of the brain, or the extent of total damage in patients with acute stroke ( Journal of Neurology, Neurosurgery, and Psychiatry 2007;78:277-279).
CPB was identified using portable monitoring equipment in patients with stroke on admission. A neuroradiologist classified acute stroke lesions and prior cerebrovascular disease on brain images.
The results showed that among 134 patients with acute stroke, those with CPB were more likely to have a large acute stroke lesion in a cerebral hemisphere (p = 0.01) and more mass effect (p = 0.03). There was no association between CPB and severe prior cerebrovascular disease on imaging (p = 0.76).
The researchers concluded that CPB is related to the acute (not old) lesions, particularly large acute cerebral hemispheric lesions with mass effect. A relationship between lesions in any discrete brain location (unilateral or bilateral) and CPB could not be shown.  

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Depressive Symptoms and Risk of Stroke. The Framingham Study

Emerging evidence raises the possibility of an association between depression and stroke risk. This study (Stroke. 2007; 38:16) sought to examine whether depressive symptoms are associated with an increased risk of cerebrovascular events in a community-based sample.

A prospective study was conducted on 4120 Framingham Heart Study participants aged 29 to 100 years with up to 8 years of follow-up. The Center for Epidemiologic Studies Depression Scale was used to measure depressive symptoms. Incident stroke and transient ischaemic attack (TIA) events were assessed by uniform diagnostic criteria. The association between depressive symptoms and risk of stroke/TIA was analyzed with Cox proportional-hazards models, after adjusting for traditional stroke risk factors.

In participants <65 years, the risk of developing stroke/TIA was 4.21 times greater (P=<0.001) in those with symptoms of depression. After adjusting for components of the Framingham Stroke Risk Profile and education, similar results were obtained. In subjects aged 65 and older, depressive symptoms were not associated with an increased risk of stroke/TIA. Taking antidepressant medications did not alter the risk associated with depressive symptoms.

The study concluded that in this community-based study, depressive symptoms were an independent risk factor for incident stroke/TIA in individuals <65 years. These data suggests that identification of depressive symptoms at younger ages may have an impact on the primary prevention of stroke.

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Clinical Deterioration After Intravenous Recombinant Tissue Plasminogen Activator Treatment .

Patients may experience clinical deterioration (CD) after treatment with intravenous recombinant tissue plasminogen activator (rt-PA). The authors evaluated the ability of flow findings on transcranial Doppler to predict CD and outcomes on modified Rankin Scale (Stroke. 2007; 38:69).
Patients with acute stroke received intravenous rt-PA within 3 hours of symptom onset at four academic centers. CD was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by 4 points or more within 24 hours. Poor long-term outcome was defined by modified Rankin Scale 2 at 3 months. Transcranial Doppler findings were interpreted using the Thrombolysis in Brain Ischaemia flow grading system as persistent arterial occlusion, reocclusion, or complete recanalization. Multiple regression analysis was used to identify transcranial Doppler flow as a predictor for CD after controlling for age, sex, baseline NIHSS, hypertension, and glucose.
A total of 374 patients received intravenous rt-PA at 142±60 minutes (median pretreatment NIHSS score 16 points). At the end of intravenous rt-PA infusion, transcranial Doppler showed persistent arterial occlusion in 219 patients (59%), arterial reocclusion in 54 patients (14%), and complete recanalization in 101 patients (27%). CD occurred in 44 patients: 36 had persistent arterial occlusion or reocclusion (82%), 13 symptomatic intracerebral haemorrhage (29%), and both persistent occlusion/reocclusion and symptomatic intracerebral haemorrhage in 10 patients (23%).
The study concluded that inability to achieve or sustain vessel patency at the end of rt-PA infusion correlates with the likelihood of clinical deterioration and poor long-term outcome. Early arterial reocclusion on transcranial Doppler is highly predictive of CD and poor outcome.

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Treatment Effects of Antidepressants in Patients with Post-Stroke Depression: A Meta-Analysis

Appropriate treatment of post-stroke depression (PSD) is critically important, considering the negative impact of PSD. Data regarding the treatment efficacy of antidepressants in patients with PSD are conflicting, and the time-dependent effects of antidepressant treatment in this population are unknown. The aim of this mata-analysis is to systematically assess treatment effects of antidepressants in patients with PSD, incorporating data from recent studies.
A total of 1320 patients who met inclusion criteria were identified from 16 RCTs (Ann Pharmacother.2006 Nov 21).
The pooled response rates in the active and placebo groups were 65.18% (234/359) and 44.37% (138/311), respectively. From baseline to endpoint, patients in the active group had significantly greater improvement in depressive symptoms compared with patients in the placebo group. Longer duration of treatment was positively correlated with the degree of improvement in depressive symptoms. No consistent evidence was found for positive antidepressant effects on the recovery of neurologic impairments and improvements in ADLs.
The results of this meta-analysis suggest that use of antidepressants among patients with a diagnosis of PSD is associated with improvement in depressive symptoms. Longer duration of antidepressant treatment may be associated with greater reductions in depressive symptoms.

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Predictors of Incident Dementia in a Population-Based First-Ever Stroke Cohort

Emerging evidence raises the possibility of an association between depression and stroke risk. This study (Stroke. 2007; 38:16) sought to examine whether depressive symptoms are associated with an increased risk of cerebrovascular events in a community-based sample.

A prospective study was conducted on 4120 Framingham Heart Study participants aged 29 to 100 years with up to 8 years of follow-up. The Center for Epidemiologic Studies Depression Scale was used to measure depressive symptoms. Incident stroke and transient ischaemic attack (TIA) events were assessed by uniform diagnostic criteria. The association between depressive symptoms and risk of stroke/TIA was analyzed with Cox proportional-hazards models, after adjusting for traditional stroke risk factors.

In participants <65 years, the risk of developing stroke/TIA was 4.21 times greater (P=<0.001) in those with symptoms of depression. After adjusting for components of the Framingham Stroke Risk Profile and education, similar results were obtained. In subjects aged 65 and older, depressive symptoms were not associated with an increased risk of stroke/TIA. Taking antidepressant medications did not alter the risk associated with depressive symptoms.

The study concluded that in this community-based study, depressive symptoms were an independent risk factor for incident stroke/TIA in individuals <65 years. These data suggests that identification of depressive symptoms at younger ages may have an impact on the primary prevention of stroke.

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Stroke Among Patients With Dizziness, Vertigo, and Imbalance in the Emergency Department

Dizziness, vertigo, and imbalance are common presenting symptoms in the emergency department. Stroke is a leading concern even when these symptoms occur in isolation. The objective of the present study (Stroke. 2006; 37:2484) was to determine the "real-world" proportion of stroke among patients presenting to the emergency department with these dizziness symptoms (DS).
From a population-based study, patients >44 years of age presenting with DS to the emergency department, or directly admitted to the hospital, were identified. Demographics, the frequency of new cerebrovascular events, and the frequency of isolated DS (ie DS with no other stroke screening term or accompanying neurologic signs or symptoms) were assessed. The association of the presenting symptoms with stroke/TIA was also assessed.
Stroke/TIA was diagnosed in 3.2% (53 of 1666) of all patients with DS. Only 0.7% (9 of 1297) of those with isolated DS had a stroke/TIA. Patients with stroke/TIA were slightly older than those without stroke/TIA. Male gender was associated with stroke/TIA, whereas isolated DS was negatively associated with stroke/TIA. Patients with imbalance (dizziness as referent) were more likely to have stroke/TIA.
The proportion of cerebrovascular events in patients presenting with dizziness, vertigo, or imbalance is very low. Isolated dizziness, vertigo, or imbalance strongly predicts a noncerebrovascular cause. The symptom of imbalance is a predictor of stroke/TIA.

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