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The analysis of many different studies on the characteristics of headaches provides data to help predict the type of cerebrovascular disease according to headache patterns. Lack of headache at onset, sentinel headache, or associated vomiting is predictive of ischemic stroke. A history of throbbing headache is predictive of developing headache during a stroke. A headache preceding the cerebrovascular event (sentinel headache) has been a common occurrence in most studies, reported in up to 60% of patients. The coexistence of headache and stroke encompasses a large spectrum of possibilities, including stroke caused by migraine headache, migraine developing after a stroke, and non-migraine headache occurring in relation to stroke. A higher incidence of patent foramen ovale (PFO) in migraine with aura patients suggests that cardiac microemboli affecting the vertebrobasilar circulation may participate in the migrainous mechanisms of these patients.
Introduction: Brief cognitive tests such as the Mini-mental State Examination (MMSE) and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) have been used to detect cognitive impairment and dementia in studies of stroke patients. However, there are few data on their validity for such use. We have evaluated their validity in detecting cognitive impairment not dementia (CIND) and dementia in a community-based sample of first-ever stroke patients.
Methods: The standardized MMSE (S-MMSE) and the 16-item IQCODE were administered to 79 patients 1 year after a first-ever stroke. CIND and dementia were diagnosed independently using a comprehensive cognitive battery. The performances of the two tests were evaluated using receiver operating characteristic (ROC) analyses. Combined performance was evaluated when their scores were used in parallel (the “or rule”), in series (the “and rule”) or as a weighted sum (the “weighted sum rule”).
Results: Both tests were extremely poor at detecting CIND individually and in combination. For dementia, at traditional cut-points, the S-MMSE (≤23) was insensitive (0.50, 95% CI 0.16–0.84) and the IQCODE (≥3.30) nonspecific (0.63, 95% CI 0.51–0.75). An acceptable balance between sensitivity and specificity was achieved for dementia using the “or rule” combination, but with only modest positive predictive value.
Conclusions: The S-MMSE and the IQCODE were individually poor at detecting CIND and dementia after a nonaphasic first-ever stroke. The combination was useful in detecting dementia but it does not replace the need for detailed neuropsychological tests.
Objectives: To outline the development, structure, data assumptions, and application of an Australian economic model for stroke (Model of Resource Utilization, Costs, and Outcomes for Stroke [MORUCOS]).
Methods: The model has a linked spreadsheet format with four modules to describe the disease burden and treatment pathways, estimate prevalence-based and incidence-based costs, and derive life expectancy and quality of life consequences. The model uses patient-level, community-based, stroke cohort data and macro-level simulations. An interventions module allows options for change to be consistently evaluated by modifying aspects of the other modules. To date, model validation has included sensitivity testing, face validity, and peer review. Further validation of technical and predictive accuracy is needed. The generic pathway model was assessed by comparison with a stroke subtypes (ischemic, hemorrhagic, or undetermined) approach and used to determine the relative cost-effectiveness of four interventions.
Results: The generic pathway model produced lower costs compared with a subtypes version (total average first-year costs/case AUD$15,117 versus AUD$17,786, respectively). Optimal evidence-based uptake of anticoagulation therapy for primary and secondary stroke prevention and intravenous thrombolytic therapy within 3 hours of stroke were more cost-effective than current practice (base year, 1997).
Conclusions: MORUCOS is transparent and flexible in describing Australian stroke care and can effectively be used to systematically evaluate a range of different interventions. Adjusting results to account for stroke subtypes, as they influence cost estimates, could enhance the generic model.
The fundamental importance of the concept of the ischemic penumbra is the recognition that ischemic processes may be reversible. Although founded on the concept of critical changes of blood flow, the ischemic penumbra can also be described in molecular terms. A molecular delineation of the ischemic core employs analyses of appropriate proteins, many of which have a short half-life and hence rapid reductions in concentration. Multitracer PET imaging with 15O allows generation of quantitative brain maps for CBF, CMRO2, OEF, cerebral blood volume (CBV), and regional cerebral metabolic rate of glucose. Evolving MRI techniques are useful for assessment of penumbral tissue in acute stroke. DWI is increasingly available in the setting of acute stroke, and for rapid acquisition it is performed using echoplanar magnetic resonance imaging methods. The blood oxygen level dependent (BOLD) technique has been used to differentiate perfused and non-perfused tissues during experimental ischemia in cats.
Historical references for stroke as a cause of seizures date back to Greco-Roman times when Hippocrates in 400 BC described epilepsy as a disease of the brain due to natural rather than supernatural causes. Hippocrates described older persons with paralysis following seizures consistent with seizures occurring at the onset of stroke. However, it was not until 1864 that Hughling Jackson clearly documented stroke as a cause of epilepsy. Jackson noted that ‘it is notuncommonto find when a patient has recovered or is recovering from hemiplegia, the result of embolism of the middle cerebral artery, or ofsomebranch of this vessel, that he is attacked by convulsions beginning in some part of the paralysed region’. (Taylor, 1958). Since these times it has become clear that stroke is an important cause of seizures and epilepsy, particularly in the older age group. There are, however, some important questions still to be answered.
Post stroke seizures – comparison of cerebral infarction with hemorrhage
Timing and frequency of seizures
Reports on the frequency of seizures at the onset of, and following, stroke vary quite widely because of differing stroke patient populations, sample sizes studied, follow up periods, definitions used for stroke and seizures, use of investigations such as computerized tomography (CT) and types of statistical analysis. In most studies to date the follow-up period was less than a few weeks, so the documentation of later onset or recurring seizures is limited. Studies of early and late onset poststroke seizures where patients with prestroke seizures, were largely excluded and CT was used in the diagnosis of cerebral ischemia or hemorrhage in 90% or more of patients, are summarized in Table 13.1.
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