Brain ; pathology ; Humans ; Hyponatremia ; complications ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Myelinolysis, Central Pontine ; diagnosis ; etiology ; pathology ; physiopathology ; therapy ; Osmolar Concentration ; Osmosis ; Osmotic Pressure ; Risk Factors ; Time Factors

Brain ; blood supply ; diagnostic imaging ; Brain Ischemia ; blood ; diagnosis ; diagnostic imaging ; Combined Modality Therapy ; methods ; Humans ; Male ; Middle Aged ; Monitoring, Physiologic ; Stroke ; drug therapy ; physiopathology ; Tomography, X-Ray Computed

No abstract available.
Arteries* ; Middle Cerebral Artery ; Stroke*

Cerebrovascular Circulation ; drug effects ; Computer Systems ; Fibrinolytic Agents ; administration & dosage ; pharmacology ; Humans ; Infarction, Middle Cerebral Artery ; drug therapy ; physiopathology ; Infusions, Intravenous ; Male ; Middle Aged ; Regional Blood Flow ; drug effects ; Thrombolytic Therapy ; Tissue Plasminogen Activator ; administration & dosage ; pharmacology

INTRODUCTIONTranscranial Doppler (TCD) is an established tool for the non-invasive assessment of cerebral blood flow. Since TCD results vary with the skills and experience of the sonographer, it requires validation against contrast angiography. We evaluated the diagnostic accuracy of TCD against computed tomography angiography (CTA) and the feasibility of the latter as an additional screening tool in our acute ischaemic stroke patients.

MATERIALS AND METHODSOur stroke unit manages about 700 patients annually. Acute stroke patients undergo TCD for vascular assessment of major arteries of the circle of Willis. Randomly selected acute stroke patients with significant stenosis on TCD underwent high-resolution cranial CTA with multidetector helical scanner. CTA was performed within 24 hours of TCD and images were interpreted by a neuroradiologist blinded to TCD findings. An independent neurosonologist reevaluated TCD if CTA findings were contradictory. Additional information by either modality was also noted.

RESULTSFifteen patients (12 men, mean age 61 +/- 15years) with cerebral ischaemia and moderate (>50%) stenosis in > or =1 large intracranial arterial segment on routine TCD were evaluated by CTA. Compared with 21 segments of significant stenosis on CTA, TCD showed 16 true-positive, 3 false-positive and 5 false-negative results (sensitivity: 76.2%, positive predictive value: 84.2%). In 3 cases, TCD showed findings complementary to CTA (real-time embolisation, collateral flow patterns, evidence of distal M2 branch occlusion).

CONCLUSIONTCD in our neurovascular laboratory shows a satisfactory agreement with cranial CTA in evaluating patients with cerebral ischaemia. TCD can provide additional real-time dynamic findings complementary to information provided by CTA.

Aged ; Brain Ischemia ; diagnosis ; Cerebral Angiography ; Female ; Humans ; Male ; Middle Aged ; Pilot Projects ; Singapore ; Tomography, X-Ray Computed ; Ultrasonography, Doppler, Transcranial

BACKGROUND AND AIMIntravenously-administered tissue plasminogen activator (IV-TPA) induces thrombolysis and remains the only FDA-approved therapy for acute ischaemic stroke. IV-TPA thrombolysis has been approved recently in Singapore for acute stroke. Continuous exposure of clot to 2-MHz pulsed-wave transcranial Doppler (TCD) ultrasound during IV-TPA infusion is known to augment thrombolysis. We aimed to determine the feasibility, safety and efficacy of ultrasound-assisted thrombolysis in acute ischaemic stroke in Singapore.

SUBJECTS AND METHODSConsecutive patients with acute ischaemic stroke due to intracranial arterial-occlusions were treated with standard IV-tPA and continuously monitored with 2-MHz TCD according to the CLOTBUST-trial protocol. Arterial recanalisation was determined with Thrombolysis in Brain Ischemia (TIBI) flow-grading system. Safety and efficacy of ultrasoundassisted thrombolysis were assessed by rates of symptomatic intracranial haemorrhage (sICH) and functional recovery at 1 month, respectively.

RESULTSFive consecutive patients (mean age 58 years, 3 men and 3 of Chinese ethnicity) were included. Mean time elapsed between symptom onset and presentation to emergency room was 98 minutes (range, 50 to 135 minutes) while the mean time interval between symptom onset to IV-TPA bolus was 144 minutes (range, 125 to 180 minutes). Partial or complete recanalisation with reduction in the stroke severity was noted in 4 out of the 5 patients during IV-TPA infusion (mean change in NIHSS = 4 points; range 2 to 8 points). None of our patients developed sICH while 4 patients demonstrated good functional outcome at 1 month.

CONCLUSIONSOur preliminary study demonstrates the feasibility, safety and efficacy of ultrasound-assisted thrombolysis in acute ischaemic stroke in Singapore. Continuous TCD-monitoring during IV-TPA infusion provides real-time information, enhances thrombolysis and improves functional outcomes in acute ischaemic stroke.

Aged ; Brain Infarction ; diagnostic imaging ; Female ; Fibrinolytic Agents ; administration & dosage ; Humans ; Infusions, Intravenous ; Male ; Middle Aged ; Thrombolytic Therapy ; methods ; Tissue Plasminogen Activator ; administration & dosage ; Ultrasonography, Interventional ; methods

No abstract available.
Aneurysm, False ; Carotid Artery Injuries*

INTRODUCTION: Diabetes increases the risk of ischaemic stroke especially among Asians. This study aims to investigate contemporaneous long-term cardiovascular outcomes of ischaemic stroke patients with diabetes in a multi-ethnic Asian cohort. METHODS: Consecutive patients with ischaemic stroke were recruited from the National University Hospital, Singapore. Data on age, gender, ethnicity, risk factors (including diabetes status and body mass index [BMI]), stroke severity and mechanisms were collected. These patients were followed up until the day of the first cardiovascular event or July 2016, whichever was earlier. The primary endpoint was the time from enrolment to the first occurrence of a composite of cerebrovascular and coronary artery events. RESULTS: Between July 2011 and December 2013, 720 patients (mean age 60.6 years, 71% men, 43% with diabetes, median National Institute Health Stroke Severity scale 2) were enrolled and followed up. A total of 175 cardiovascular events occurred during a median follow-up of 3.25 years (6.90 events per 1,000 person-month), comprising 133 cerebrovascular and 42 coronary artery events. The adjusted hazard ratio of diabetes was 1.50 (95% CI 1.08-2.10). In a multivariable Cox proportional hazards model, Malay and Indian ethnicities, BMI <23kg/m2 and a prior diagnosis of diabetes were identified as independent predictors of recurrent cardiovascular events. CONCLUSION Our study provides quantitative data on the event rates of ischaemic stroke patients with diabetes. These findings provide insights on stroke predictors in a multi-ethnic Asian population, which may have implications in the design of future interventional studies.

Background/Aims: Non-alcoholic fatty liver disease (NAFLD) is associated with the development of cardiovascular disease. While existing studies have examined cardiac remodeling in NAFLD, there has been less emphasis on the development of carotid atherosclerosis and stroke. We sought to conduct a meta-analysis to quantify the prevalence, risk factors, and degree of risk increment of carotid atherosclerosis and stroke in NAFLD. Methods: Embase and Medline were searched for articles relating to NAFLD, carotid atherosclerosis, and stroke. Proportional data was analysed using a generalized linear mixed model. Pairwise meta-analysis was conducted to obtain odds ratio or weighted mean difference for comparison between patients with and without NAFLD. Results: From pooled analysis of 30 studies involving 7,951 patients with NAFLD, 35.02% (95% confidence interval [CI], 27.36–43.53%) had carotid atherosclerosis with an odds ratio of 3.20 (95% CI, 2.37–4.32; P<0.0001). Pooled analysis of 25,839 patients with NAFLD found the prevalence of stroke to be 5.04% (95% CI, 2.74–9.09%) with an odds ratio of 1.88 (95% CI, 1.23–2.88; P=0.02) compared to non-NAFLD. The degree of steatosis assessed by ultrasonography in NAFLD was closely associated with risk of carotid atherosclerosis and stroke. Older age significantly increased the risk of developing carotid atherosclerosis, but not stroke in NAFLD. Conclusions This meta-analysis shows that a stepwise increment of steatosis of NAFLD can significantly increase the risk of carotid atherosclerosis and stroke development in NAFLD. Patients more than a third sufferred from carotid atherosclerosis and routine assessment of carotid atherosclerosis is quintessential in NAFLD.