Mild cognitive decline in nearly half lacunar stroke patients

Mild cognitive impairment is present in nearly half of patients with lacunar stroke, according to a study published online Aug. 18 in the Annals of Neurology.

28 aug 2012—Mild cognitive impairment (MCI) is present in nearly half of patients with lacunar stroke, according to a study published online Aug. 18 in the Annals of Neurology.

Claudia Jacova, Ph.D., of the University of British Columbia in Vancouver, Canada, and associates conducted a study to characterize, and estimate the prevalence of, neuropsychological impairment in 1,636 English-speaking lacunar stroke patients. Using published norms, raw scores were converted to z scores. Participants underwent neuropsychological testing at baseline and those with impairment (z score of ≤1.5) in memory and/or non-memory domains were classified as having MCI.

The researchers found that the average z scores at baseline testing were below zero. The largest deficits were seen in measures of episodic memory (range of means, −0.65 to −0.92), verbal fluency (mean, −0.89), and motor dexterity (mean, −2.5). Of the participants, 47 percent were classified as having MCI, which included 36 percent amnestic, 37 percent amnestic multidomain, and 28 percent non-amnestic. Forty-one percent of those with Rankin score of 0 to 1 and Barthel score of 100 percent had MCI.

"In this large, well-characterized cohort of lacunar stroke patients, MCI was present in nearly half, including many with minimal or no physical disabilities," the authors write. "Cognitive dysfunction in lacunar stroke patients may commonly be overlooked in clinical practice but may be as important as motor and sensory sequelae."

Study medication was donated by Sanofi/BMS USA.

More information: Abstract 
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Moderate to intense exercise may protect the brain

Older people who regularly exercise at a moderate to intense level may be less likely to develop the small brain lesions, sometimes referred to as "silent strokes," that are the first sign of cerebrovascular disease, according to a new study published in the June 8, 2011, online issue of Neurology.

13 june 2011--"These 'silent strokes' are more significant than the name implies, because they have been associated with an increased risk of falls and impaired mobility, memory problems and even dementia, as well as stroke," said study author Joshua Z. Willey, MD, MS, of Columbia University in New York and a member of the American Academy of Neurology. "Encouraging older people to take part in moderate to intense exercise may be an important strategy for keeping their brains healthy."

The study involved 1,238 people who had never had a stroke. Participants completed a questionnaire about how often and how intensely they exercised at the beginning of the study and then had MRI scans of their brains an average of six years later, when they were an average of 70 years old.

A total of 43 percent of the participants reported that they had no regular exercise; 36 percent engaged in regular light exercise, such as golf, walking, bowling or dancing; and 21 percent engaged in regular moderate to intense exercise, such as hiking, tennis, swimming, biking, jogging or racquetball.

The brain scans showed that 197 of the participants, or 16 percent, had small brain lesions, or infarcts, called silent strokes. People who engaged in moderate to intense exercise were 40 percent less likely to have the silent strokes than people who did no regular exercise. The results remained the same after the researchers took into account other vascular risk factors such as high blood pressure, high cholesterol and smoking. There was no difference between those who engaged in light exercise and those who did not exercise.

"Of course, light exercise has many other beneficial effects, and these results should not discourage people from doing light exercise," Willey said.

The study also showed that the benefit of moderate to intense exercise on brain health was not apparent for people with Medicaid or no health insurance. People who exercised regularly at a moderate to intense level who had Medicaid or no health insurance were no less likely to have silent infarcts than people who did no regular exercise. "It may be that the overall life difficulties for people with no insurance or on Medicaid lessens the protective effect of regular exercise," Willey said.

Provided by American Academy of Neurology

Study: Plavix plus aspirin helps prevent strokes

By MARILYNN MARCHIONE

ORLANDO, Fla.,01 april 2009 – Taking the blood thinner Plavix along with aspirin helped prevent strokes and heart attacks in people with a common heartbeat abnormality that puts them at high risk of these problems, doctors reported Tuesday.

The treatment is for atrial fibrillation, a rhythm disorder that 2.2 million Americans have. It occurs when the upper parts of the heart quiver instead of beating properly. This allows blood to pool and form clots that can travel to the brain, causing a stroke.

The usual treatment is the blood thinner warfarin, sold as Coumadin and in generic form. But finding the right dose is tricky — too little and patients can have a stroke; too much and they can have life-threatening bleeding. Patients on the drug must go to the doctor often for blood tests to monitor their dose.

For these reasons, as many as half of patients take aspirin instead of warfarin, even though aspirin is much less effective at preventing strokes.

Dr. Stuart Connolly of McMaster University in Hamilton, Ontario, led a study testing whether adding clopidogrel, sold as Plavix by French-based Sanofi-Aventis SA, could help.

The study involved 7,554 patients in the United States and 32 other countries who were not able or chose not to take warfarin. All were treated with aspirin; half also were given Plavix.

After nearly four years of followup, the dual drug treatment lowered a combined measure — heart attacks, heart-related deaths, strokes and blood clots — by 11 percent. There were 924 of these problems in patients on aspirin alone but only 832 in those also getting Plavix.

However, the combination treatment raised the risk of serious bleeding — 251 cases versus 162 for those on aspirin alone.

Doing the math, patients still come out ahead on the combination, Connolly said. For every 1,000 patients treated for three years, it would prevent 28 strokes and six heart attacks, and lead to 20 bleeding cases. Bleeding often is treated with transfusions and is not as likely to prove fatal.

"For the first time in 20 years, there's a new treatment for atrial fibrillation," Connolly said.

Results were presented Tuesday at an American College of Cardiology conference and published online by the New England Journal of Medicine.

The study was sponsored by Sanofi, and Connolly and other authors have consulted for the company. Plavix costs about $4 a day.

"Warfarin was, and remains, first-line therapy — this does not change that," said Dr. Richard Page, cardiology chief at the University of Washington School of Medicine in Seattle and an American Heart Association spokesman.

But for those who can't tolerate it, the Plavix-aspirin combo gives a better option than aspirin alone, he said. Page has consulted for Sanofi in the past.

On Saturday, other doctors at the cardiology conference reported on another potential treatment for atrial fibrillation — an experimental heart device called the Watchman aimed at preventing clots from reaching the brain. A federal Food and Drug Administration panel meets to consider it on April 23.

Carotid Artery Surgery in Dead Heat with Angioplasty and Stenting

By John Gever
PARIS, 06 sept 2008-- Medium-term efficacy is about the same for carotid endarterectomy versus angioplasty and stenting, said researchers here and in Germany. In two randomized studies involving nearly 1,500 patients and two to four years of follow-up, rates of ipsilateral stroke and death were nearly equal when events within the first month were excluded. The four-year risk of ipsilateral stroke after the first 30 days was 1.26% (95% CI 0% to 3%) for stented patients compared with 1.97% (95% CI 0% to 4%) for patients undergoing endarterectomy, reported Jean-Louis Mas, M.D., of the Hôpitaux Sainte-Anne, and colleagues online in Lancet Neurology. They were reporting final results from the EVA-3S (Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis) trial, in which 262 patients with recent-onset symptoms were randomized to one of the two procedures.
Reported simultaneously was a study by Peter Ringleb, M.D., of the University of Heidelberg, Germany, and his colleagues in the international SPACE (Stent-Protected Angioplasty versus Carotid Endarterectomy) collaboration.
In their 1,214-patient randomized trial, 12 stented patients and 10 receiving surgery suffered ipsilateral strokes after day 30, with two years of follow-up. They calculated a hazard ratio for non-periprocedural ipsilateral stroke of 1.17 (95% CI 0.51 to 2.70) on an intent-to-treat basis.
Both groups had previously reported 30-day results in which rates of death and stroke were significantly higher for angioplasty and stenting than for endarterectomy. In their current report, Dr. Mas and colleagues acknowledged that "the safety of carotid stenting needs to be improved before it can be used as an alternative to carotid endarterectomy."
But for patients who avoid the short-term hazards, they added, "carotid stenting is as effective as carotid endarterectomy for medium-term prevention of ipsilateral stroke, at least for the first 4 years after the perioperative period."
Dr. Ringleb and colleagues found that even when the higher periprocedural rates of death and stroke were included in the results, there was no significant difference in outcomes for the two procedures.
They calculated intent-to-treat hazard ratios for periprocedural events plus late ipsilateral strokes of 1.10 (95% CI 0.75 to 1.61) for stenting relative to endarterectomy.
Cumulative two-year risks on the same basis were 9.5% for stenting versus 8.8% for endarterectomy.
Despite the similarities in rates of late strokes, the SPACE investigators found restenosis in 10.7% of stented patients compared with 4.6% of the endarterectomy group (P=0.0009).
But only two of the stented patients with restenosis showed neurological symptoms, the researchers said.
They also argued that the ultrasound technology they used to measure the vascular lumen may overestimate stenosis in stented vessels.
In an accompanying editorial, A. Ross Naylor, M.D., M.B.Ch.B., of the University of Leicester, England, noted that most previous studies have found in favor of endarterectomy over angioplasty and stenting.
The SPACE and EVA-3S results are unlikely to overturn that judgment, he said, but they do offer some intriguing new insights.
"The most important finding ... is recognition that the average annual risk of ipsilateral stroke is 1% or less, irrespective of whether the patient was treated by carotid endarterectomy or [stenting]," Dr. Naylor wrote.
He also found it notable that the SPACE study found equivalent late stroke rates despite the higher apparent incidence of restenosis in the stented patients. Dr. Naylor said the finding suggested restenosis "is a relatively benign pathology."
A third major result from the studies, according to Dr. Naylor, was that outcomes for angioplasty and stenting seemed to be strongly influenced by age, with older patients faring less well.
He said the next step should be a pooled analysis of data from all the large randomized trials, including two still underway. The goal would be to identify subgroups who benefit the most, and least, from the two procedures, as well as other aspects of treatment that affect outcomes.

Primary source: Lancet NeurologySource reference:Mas J-L, et al "Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial" Lancet Neurology 2008; DOI: 10.1016/S1474-4422(08)70195-9.

Additional source: Lancet NeurologySource reference: Eckstein H-H, et al "Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial" Lancet Neurology 2008; DOI: 10.1016/S1474-4422(08)70196-0. Additional source: Lancet NeurologySource reference: Naylor A "Stenting versus endarterectomy: the debate continues" Lancet Neurology 2008; DOI: 10.1016/S1474-4422(08)70197-2.