Wesam A. Alhejily, Mohammed A. Almekhlafi

Background: Cerebral and cardiovascular events can occur simultaneously in a patient and with differential timing. Despite large studies addressing the presence of one diagnosis preceding the other, there are no comparative studies that address the impact of stroke timing difference on coronary event and its subsequent outcomes. In this study we sought to describe the association of cerebrovascular and cardiac events and the impact of the order of the occurrence of these events on patients’ outcomes. Methods: A retrospective longitudinal cohort studyin a single tertiary center (King Abdulaziz University Hospital) from two separate databases were crossed matched to identify patients with both diagnoses, then temporal relationships were identified on both directions (stroke before or after cardiac event). Cardiac events include any suspected acute coronary events that triggered referral for coronary angiogram. We included all patients who underwent coronary angiogram and had a primary admitting diagnosis of stroke. The primary endpoint was the incidence of major adverse cardiac event (MACE), the secondary endpoint was a composite of death, recurrent stroke and rehospitlization within 30 days. Risk assessment was evaluated using odds ratio at 95% confidence intervals. Results: Among 500 stroke patients and 6300 cardiac patients admitted in the span of 5 years, 16 patients were identified with both diagnoses, all had ischemic strokes. The mean age was 56.9±18.5 years, 37.5% were females. The most common cerebrovascular risk factors were hypertension (94%) diabetes (81%), atrial fibrillation (25%), and renal impairment (6%). When classified based on stroke timing, a quarter (n=4) of patients had stroke pre cardiac event (SPRE) and 75% (n=12) had stroke post-cardiac event (SPOST). Comparatively major adverse cardiac events were similar on both group (p=0.58) odds ratio of MACE was 1.3 95% CI (0.6-2.7) vs. 0.8 (0.4-1.6) for patients in the SPRE and SPOST cohorts, respectively. Secondary composite endpoint of death, recurrent stroke and rehospitlization within 30 days was higher in the SPRE group (p=0.0001. This was primarily driven by increased risk of recurrent stroke; odds ratio 2.4 (1.2-4.7) vs. 0.4 (0.2-0.8). The mean time from stroke to cardiac event was 89.5 days compared to 40.5 months from cardiac event to stroke. Conclusions: In this cohort of patients with the diagnoses of both stroke and cardiac events, timing of stroke predicts and prognosticates future outcomes in a differential manner as stroke occurrence before a cardiac event (SPRE) tends to cause more recurrent strokes and possibly more cardiac events than its occurrence after a cardiac event (SPOST). Limitations: This was a small cohort identified retrospectively from a single center.

Okonkwo U. Prosper, Okoye G. Chuba, Ibeneme S. C., Ihegihu Y. E., Egwuonwu V. Afam, Nwankwo M. J., Ummuna J. Onuwa

Background: Motor training after stroke should be targeted to goals that are relevant to the functional needs of the patient in order to facilitate functional recovery. Therefore, combining Proprioceptive Neuromuscular Facilitation (PNF) and Task-specific Balance Training to facilitate Activities of Daily Living (ADL) on stroke survivors with and without cognitive impairment was intentioned in this study. Activities of Daily Living are those activities that people must be able to do routinely to be considered fully independent. Barthel Index is one of the instruments used in measuring ADL. This study evaluated the effect of 12 months Proprioceptive Neuromuscular Facilitation (PNF) and Task Specific Balance Training on Activities of Daily Living in cognitive impaired and cognitive normal stroke survivors. Methods: One hundred of 143 available stroke survivors were recruited using convenience sampling technique in a quasi-experimental study. Those with and without cognitive deficits were assigned into a cognitive impaired group (CIG) and non-cognitive impaired group (NCIG) group, respectively. The patients were grouped into cognitive impaired mean age 55.36±10.2 and cognitive normal mean age 50.20± 13.23 after neuropsychiatric test. Ethical approval was obtained at Nnamdi Azikiwe University Ethical Committee (NAUTHEC), Nnewi. The Proprioceptive Neuromuscular Facilitation comprising rhythmic initiation, repeated contraction, slow reversal and rhythmic stabilization and Task-specific Balance Training TSBT comprising repetitive rising from a chair (10 repetitions), cycle ergometer (10 mins), stepping over obstacle (10 repetitions), backward and forward progression (10 repetitions), turning task (10 repetitions) and standing balance training (10 repetitions). TSBT was applied three times a week, 30mins per session, for 12 months. Four research assistants were trained to assist in each treatment session. The outcome measures applied were mini-mental state examination for determining the neuropsychiatric status of participants at baseline and Berthal index for activities of daily living. Result: The mean Berthel Index (BI) scores was significantly greater than the baseline values for the both CIG (F (1.729, 84.709) = 158.575, p < 0.001, with large effect size (partial eta squared) of .764), and NCIG (F(2.478, 121.409) = 5.787, p < 0.001 with large effect size (partial eta squared) of 0.549). Conclusion: There was improvement in Activities of Daily Living (ADL) of the subacute stroke survivors with and without cognitive impairments after 12 months PNF and Task Specific Balance Training protocol adapted in this study.

Puspita Das Roy, Sounik Sarkar, Anjan Kr Dasgupta, Pradipta Guha, Pradip Sarkar

Microparticles have been of keen interest in biomedical science for last few decades. The correlation of microparticles with different disease profiles, e.g. platelet mediated blood cell disorder, is well known. In this study we aim to use a microparticle based disease marking system based on pro-activator like properties of nanoparticles. Challenging platelet cells with nanoparticles changes their microparticle release profile. The extent of this release can in turn serve as a disease marker for Acute Coronary Syndrome (ACS) patients. Age and sex matched ACS and non-ACS patients have been chosen as subjects. Platelet rich plasma from both case and control groups have been isolated and allowed to interact with gold nanoparticle. For quantification of data a parallel computational method is employed using Matlab Engine. The analysis helped image based representation of the ACS specific microparticle release and their modulation by gold nanoparticle. The polarization flowcytometry is used as label free microparticle marker. The analyses reveal a significant difference in the microparticle population between ACS and non-ACS individuals. The differential of the release is further amplified in presence of gold nanoparticles. It has been observed that there is some significant difference (p value= 0.036) in the production of microparticles between ACS and non-ACS individuals after GNP incubation and this difference between cases and controls can be used further as a signature for ACS. To our knowledge the imaging aided flowcytometric method has for the first time enabled micropatricle classification based on polarization scattering.

Rayaz Jan, Rajiv Kumar Gupta, Parveen Singh, Tajali Shora, Shahid Hussain

Introduction: Stroke is a major public health problem, both in developed and developing world. It causes a lot of morbidity and mortality especially with advancing age and lot of economic burden on the families of those afflicted with stroke. Aim: To find out the association of risk factors like Obesity, Cholesterol, Smoking and Alcohol to the Stroke. Methodology: The present descriptive study was conducted in the calendar year of 2011. The study subjects comprised of the patients who were admitted to Govt. Medical College and Hospital Jammu with sign and symptoms suggestive of stroke. The relevant information of each study subject was recorded on pre-designed and pre-tested proforma. Results: A total of 209 respondents (114 males and 95 females) were interviewed during the course of study. 57.90% (121/209) study subjects were found to be obese. 77.96% (92/118) had cholesterol level on the higher side. Out of 114 males in the current study 60.52% (69/114) were smoker and 62.28% (71/114) were alcoholic. Both smoking and alcohol were found to be statistically significant risk factors for stroke. Conclusions: The results clearly demonstrate that lifestyle factors have a huge impact on the causation of non-communicable diseases in general and stroke in particular and hence the need for primordial prevention at the earliest.

Charan Reddy KV, Jaishree Ghanekar

Cerebrovascular ischemic stroke (CVIS) is the leading cause of death worldwide after cardiovascular disease (CVD) and cancer. Raised serum uric acid (SUA) is the major risk factor for CVIS. However, the relationship between SUA and CVIS is not clear, whether the association is casual or circumstantial. In this case control study, we sought to investigate the prognostic role of SUA in acute CVIS patients and its association with stroke outcomes. Twenty five CVIS patients (16 males & 9 females) and same number of age matched control subjects were recruited for this study. CVIS male patients showed significantly (P<0.001) higher SUA levels than CVIS female patients. A negative correlation was observed between age and SUA levels. We also found a significant inverse correlation of SUA levels with HDL-c, and a positive correlation with triglycerides (r = -0.247; P = 0.001 for HDL-c and r = 0.286, P = 0.001 for triglycerides). Mean SUA levels in CVIS patients were higher on admission, and its association with mortality remained after the adjustment for covariates (Hazard Ratio (HR) = 1.21, 95% confidence interval (CI) 1.07-1.45; P = 0.001). In some of the patients (5 males & 2 females) whose SUA levels were high on admission, consistently raised further during ICU stay were died. These patients belonged to National Institute of Health Stroke (NIHS) Score -9 or quartile 3/4 as per Kaplan–Meier analysis. In conclusion, present results suggest that SUA levels were correlated with all-cause death in CVIS patients. The strong association of SUA levels with CVIS males, compared with the much lesser degree in females regardless of metabolic risk variables, highlights the necessity of intervention studies to determine whether SUA is a potential therapeutic target or mear a prognostic marker of mortality risk.

Juan Nader-Kawachi, Ernesto Anaya-Santacruz, Carlos Peñaherrera-Oviedo, María de la Luz Andrade-Magdalen, Luis Felipe Alva, Fredy Chable-Montero

Differential diagnosis of stroke in young patients includes fibromuscular dysplasia (FMD). As renal arteries are the most frequent target in this disease, early-onset high blood pressure appears as the most common manifestation. Craniocervical vessel disease is less known and often asymptomatic, debuting with ischemic or hemorrhagic stroke. Three histological subtypes of the disease exist, depending on it affecting the tunica media, intima or adventitia of the artery. Stroke is commonly associated with FMD of the middle layer. Cases of intimal FMD are infrequent and there are fewer than 15 reports. We present a case whose diagnosis was fibromuscular dysplasia of the carotid artery intima and provide a review of the available information on the disease.

Sharan Badiger, Prema T. Akkasaligar, Utkarsha Narone

Cerebrovascular accident is the third most common leading cause of death worldwide, after coronary heart disease and cancer. The World Health Organisation defines stroke as “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting for 24 hours or longer, or leading to death with no apparent cause other than of vascular origin”. Among 80% of all cerebrovascular accidents are ischemic, rest being due to haemorrhage. There are many factors which alter the outcome of stroke. Acute hyperglycemic response to stress has been recognized since Claude Bernard’s observations more than a century ago. This “diabetes of injury” exemplifies the obligatory metabolic rearrangements required to cope with critical stress. The concept evolved as glucose became identified as metabolic mirror of the severity and outcome of critical illness.