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To identify and compare the operating characteristics of existing prehospital stroke scales to predict true strokes in the hospital.

We aimed to compare the rates of thrombolysis utilization for acute ischemic stroke in hospitals with neurology residency (NR) to those of other teaching (OT) and nonteaching (NT) hospitals.

Approximately 15 of all ischemic strokes (IS) occur in young adults and adolescents. To date, only limited prior public health and research efforts have specifically addressed stroke in the young. Early diagnosis remains challenging because of the lack of awareness and the relative infrequency of stroke compared with stroke mimics. Moreover, the causes of IS in the young are heterogeneous and can be relatively uncommon, resulting in uncertainties about diagnostic evaluation and cause-specific management. Emerging data have raised public health concerns about the increasing prevalence of traditional vascular risk factors in young individuals, and their potential role in increasing the risk of IS, stroke recurrence, and poststroke mortality. These issues make it important to formulate and enact strategies to increase both awareness and access to resources for young stroke patients, their caregivers and families, and health care professionals. The American Academy of Neurology recently convened an expert panel to develop a consensus document concerning the recognition, evaluation, and management of IS in young adults and adolescents. The report of the consensus panel is presented herein.

To test the hypothesis that microvascular brain pathology is associated with late-life motor impairment.

To review current literature on neurology telemedicine and to discuss its application to patient care, neurology practice, military medicine, and current federal policy.

The purpose of the study was to test the hypothesis that a higher level of childhood adversity is associated with increased risk of cerebral infarction in old age.

We systematically investigated clinical, laboratory, radiologic, and pathologic features, including treatment and prognosis, of stroke syndromes in 30 patients, six from our institution and 24 from the literature, with systemic lupus erythematosus (SLE) and symptomatic large cerebral vessel occlusive disease, documented by angiography or autopsy. The average age at stroke onset was 35 years, and the diagnosis of SLE was made on average 4.4 years prior to that. At least 86 had active SLE at the time of their stroke. Headache was common at onset. We found major intracranial or extracranial vessel occlusive process by (1) thrombus, (2) dissection, (3) fibromuscular dysplasia or vasculitis, and (4) atherosclerosis. The presumed mechanisms were coagulopathy, cardiogenic embolism, large cerebral vessel vasculitis or occlusive vasculopathy, cervical arterial dissection, and premature atherosclerosis. The short-term death rate was 40 and the recurrent stroke rate was 13. We conclude that symptomatic large cerebral vessel occlusive disease in SLE generally occurs several years after the diagnosis of SLE, usually during the active phase of the disease, is related to heterogeneous mechanisms, and carries a relatively poor short-term outcome.

We report three cases of cervical internal carotid artery (ICA) dissection, which presented with visual symptoms resembling the migraine aura. When prolonged and especially when associated with other neurologic symptoms, such transient and positive visual phenomena can be manifestations of ICA dissection that mimic migraine.

Symptomatic common carotid artery occlusion (CCAO) is rare. We studied 17 patients with ischemic cerebrovascular symptoms and unilateral CCAO on angiography to help clarify clinical and radiologic features. Mean age was 62 years; 65 were women. Predominant symptoms and signs included visual-ipsilateral monocular or retrochiasmal symptoms (88), motor weakness (88), sensory disturbance (59), dizziness/lightheadedness (53), and syncope (24). Dysarthria, headache, or involuntary limb shaking occurred less frequently. Positionally related symptoms occurred in approximately two-thirds of the patients. TIAs were often multiple and preceded a stroke or occurred without subsequent stroke in 82. Hemispheric TIAs contralateral to the CCAO occurred in 41. Ten patients (59) suffered stroke, seven (70) of which were ipsilateral to the CCAO. Vascular risk factors included cigarette use (76), hypertension (71), diabetes mellitus (41), and hyperlipidemia (41); 82 had two or more risk factors. Known cardiac disease was present in 59. CCAO was present at the origin of the vessel in most patients. Most had atherosclerotic narrowing of multiple extracranial large vessels. During follow-up, none of the patients had a spontaneous second infarct; five had TIAs, including two with amaurosis fugax, all in the CCAO territory. More restricted external carotid collaterals may, in part, explain the higher frequency of ipsilateral stroke and contralateral TIAs than reported for internal carotid occlusion.

We studied cerebral blood flow (CBF) with the 133xenon inhalation technique in 92 migraine patients (49 classic/complicated, 43 common), aged 19 to 85 years, in the headache-free period. We compared results to 49 control subjects, aged 22 to 80 years. CBF declined with age in both groups, but at a slower rate in migraine patients, a difference most pronounced in classic migraine. CBF was lower in migraine patients than in controls under 48 years of age. In addition, regional asymmetry of blood flow was found more frequently in young migraine patients than in controls. These results suggest that differences exist in cerebrovascular resistance tone in migraine patients, which may contribute to the threshold for a migraine attack and result in differing age-related changes in blood flow.

Lupus anticoagulants and anticardiolipin antibodies are antiphospholipid antibodies (APLAb) with related antigenic specificities and are newly recognized markers for an increased risk of thrombosis. We studied 48 patients who presented with cerebral or visual dysfunction associated with APLAb to help clarify the diagnostic, clinical, laboratory, radiologic, and pathologic features in these patients. Most patients presented with transient cerebral ischemia or cerebral infarction. Recurrent and stereotypic events were frequent. Visual disturbances resulted from amaurosis fugax, retinal arterial or venous occlusion, occipital ischemia, diplopia, and migraine-like disturbances. Three patients presented with severe atypical classic migraine. Recurrent infarcts of brain and eye were significantly associated with the presence of cigarette smoking, hyperlipidemia, and a positive antinuclear antibody. During 44.4 patient-years of prospective follow-up, the combined stroke and systemic thrombotic event rate was 0.27 events per patient-year and was 0.54 events per patient-year if TIA and death were included. Forty (83) of the patients did not have systemic lupus erythematosus (SLE). Thrombocytopenia was present in 15 (31) and a false-positive VDRL in 11 (23) of the patients. Cerebral angiography was normal or revealed large-vessel occlusion or stenosis without changes suggestive of vasculitis. Patients with only transient dysfunction generally had normal radiologic studies, including angiography. Organs and arterial vessels studied pathologically revealed thrombotic occlusive disease without vasculitis. APLAb are strongly associated with an immune-mediated thrombotic tendency, generally in the absence of SLE. Other stroke risk factors may add to the risk of recurrent ischemic events in patients with APLAb.

Prior to the antibiotic (AB) era, cavernous sinus thrombosis (CST) was almost uniformly fatal. AB therapy has significantly reduced mortality, but additional treatment with anticoagulants (AC) has remained controversial. We reviewed our experience with seven cases, as well as the literature since Lyons' 1941 introduction of AC treatment, to determine effectiveness, complications, and morbidity among survivors. We divided the cases into (1) those treated with AB alone, and (2) those treated with a combination of AB and AC. We found no conclusive evidence for reduction of mortality when AC was used in combination with AB. However, early AC therapy reduced morbidity (blindness, stroke, ophthalmoplegia, hypopituitarism, focal seizures, and vascular steal syndrome), whereas delayed or inadequate use provided no apparent benefit above AB therapy alone. Complications of AC therapy were rare; cerebral venous thrombosis occurred frequently, but in association with dural sinus thrombosis as a direct result of the disease. We conclude that AC therapy is indicated early in the treatment of CST to reduce morbidity among survivors.

The authors examined the relationships between sex and race and antithrombotics prescribed at discharge in the Michigan Medicare population using retrospective medical record abstraction (n 2,715) for the period January 1, 2001, to June 30, 2001. There were no differences in the use of antithrombotics at discharge by race or sex and no differences in the prescribing of aspirin, warfarin, aspirin/extended release dipyridamole, or clopidogrel by race or sex after adjustment for confounders.

A 44-year-old woman with livedo reticularis, multiple ischemic strokes, and transient ischemic attacks (Sneddon's syndrome) had anti-phospholipid antibodies—the lupus anticoagulant and anticardiolipin antibodies. This patient provides support for the hypothesis that these antibodies are involved in the pathogenesis of this rare but now potentially treatable disorder.

IV recombinant tissue plasminogen activator (rtPA) within 4.5 hours of symptom onset has been established as an effective therapy for acute ischemic stroke.1Over the past 2 decades, systems of care and quality assurance teams have developed to ensure that all potentially eligible patients receive IV rtPA in a timely and effective manner.2Many neurologists cannot arrive rapidly to the emergency department for in-person acute stroke assessment, and many rural areas lack 24/7 coverage by neurologists. Telemedicine has brought neurologic expertise through real-time audiovisual technical link to the emergency department for assessment of patients within the narrow treatment window.3Studies have shown that telemedicine (telestroke) is superior to a telephone (only) for acute stroke consultation and decision-making.4Patient outcomes from telestroke administration of IV rtPA can rival outcomes from an in-person stroke team treatment.5Multiple health economic analyses have demonstrated high cost-effectiveness for telestroke practice and likely cost savings from both the societal and hospital perspectives.6,7

The use of telemedicine in the ambulance for more precise and rapid prehospital/emergency medical service (EMS) care of patients with acute stroke dates back to 1988 by the University of Maryland TeleBAT (telemedicine for the Brain Attack Team) system.1The TeleBAT Team, which used this approach to determine the patient's NIH Stroke Scale (NIHSS) score, prophetically described a novel approach that could shorten the time to treatment because emergency medical technicians can transmit their videotaped assessment to the emergency room, providing emergency medicine physicians and neurologists with earlier viewing of the stroke patient's condition. Sending visual and audio data of the patient's neurologic status, vital signs, and laboratory data, many components of the clinical pathway (except head CT scanning—which can now be achieved with the mobile stroke units2,3) that lead to recombinant tissue plasminogen activator therapy, can be accomplished in the prehospital setting. Protocols can also be downloaded from the internet and used in the emergency room and ambulance. This integrated approach may lead to highly accurate clinical judgments once reliability and validity issues are addressed.3This past decade has seen tremendous technological progress in advancing prehospital stroke care, including the successful completion of randomized clinical trials of prehospital administration of IV recombinant tissue plasminogen activator after in-field head CT scanning.4,5

An ideal biomarker can accurately predict disease risk stratification. The longstanding link between inflammatory responses and atherosclerotic disease and vascular events suggests great promise for inflammatory measures as biomarkers in stroke and other vascular disease. Recent studies across multiple areas and disciplines have suggested that leukocytes, as an inflammatory marker, and specifically neutrophils, may hold promise in predicting poor outcomes in various cardiovascular diseases (e.g., heart failure, acute coronary syndromes, stable coronary artery disease), including stroke, as well as in neoplasms, infections, and inflammation.1–7The neutrophil count and neutrophil to lymphocyte ratio (NLR) are readily available, inexpensive, and calculated from a complete peripheral blood count with differential. The NLR combines 2 different immune pathways: neutrophils (much quicker response) and lymphocytes (more adaptive long-term response).

Complications associated with the use of cocaine are varied, and include cerebral hemorrhage and ischemia, with vasculitis and vasospasm as possible etiologies.We reviewed selected brain samples from 14 autopsy cases of cocaine-related cerebrovascular disease. Intracerebral or subarachnoid hemorrhage was present in 12 cases. Intracranial arterioles were either normal or showed nonspecific changes. From these observations, we suggest that intracranial hemorrhages occur in the absence of readily detectable vascular abnormalities.