Magnetic resonance and clinical cerebrovascular disease. An update

MRI is becoming the imaging modality of choice in patients with ischemic cerebrovascular disease although CT is still the test of choice to exclude acute hemorrhagic stroke. We have briefly reviewed characteristic features of ischemic and hemorrhagic cerebrovascular disease as well as vascular anomalies as seen on MRI. In time MRS should provide useful noninvasive metabolic data to complement the anatomical data in patients with cerebrovascular disease.     

Internal carotid velocity measurements in children with cerebrovascular disease

Internal carotid artery flow velocity was evaluated by the Doppler ultrasound method in 32 children with cerebrovascular disease. The average maximal blood velocity (A/L) and end-diastolic blood velocity (d) were compared with each other as indices of blood flow velocity. The right and left mean A/L and d of moyamoya disease were significantly lower than those observed in normal children. The A/L and d of the affected side both in internal carotid artery occlusion and in middle cerebral artery occlusion were also significantly low. In the subarachnoid hemorrhage after rupture, these values were significantly low. In basilar artery occlusion, these values were similar to those in normal children. The results of this study indicate that Doppler ultrasound assessment of internal carotid flow velocity provides noninvasive reliable information for the diagnosis of cerebrovascular disease in childhood.     

An attempt to determine the intellectual strengths and weaknesses of EMR children

The performance of 101 educable mentally retarded (EMR) children on four annual administrations of the Stanford-Binet Intelligence Scale was analyzed using Sattler's standard deviation method and his Binetgram. Few of the children showed strengths and weaknesses until the original criteria were relaxed, and even then there was little stability over time. The findings suggest that this approach holds little promise for interpreting the Stanford-Binet performance of EMR children.     

Neuropsychological evaluation of children after ischemic cerebrovascular disease

The purpose of this study is to associate neuropsychological evaluation with neuroimaging results in children with cerebral tomography indicating ischemic cerebrovascular disease (ICVD). Neuroimaging, neurological exams and neuropsychological instruments were used to evaluate five children. The study revealed that the cognitive and perceptive skills in two children were normal and motor sequele in four cases. The rhythm, visual and speech receptive skills remained unchanged. In four cases the SPECT exam showed regions with hypoperfusion and in four cases the EEG was normal. Neuropsychological, neurological and image indication some degree of sequele demonstrating the importance of follow up of children who had suffered cerebrovascular disease.     

Racial differences in ischemic cerebrovascular disease.

Purpose: To evaluate racial differences in extracranial carotid atherosclerosis and vascular risk factors in patients with symptomatic cerebrovascular disease. Background: There are conflicting data on racial differences in certain vascular risk factors and prevalence of large-vessel versus small-vessel disease in patients with stroke. Methods: We prospectively studied 211 consecutive patients admitted to our stroke service. There were 71 African-American, 114 Caucasian, 20 Hispanic, and 6 other patients. Extracranial vascular stenosis was assessed with a carotid duplex (CD) scan. Risk factors monitored included race, age, history of hypertension (HTN), diabetes mellitus (DM), prior stroke, hyperlipidemia, smoking, cardiac disease (congestive heart failure, atrial fibrillation), and family history of stroke. Cholesterol and triglyceride blood levels, and computed tomography/magnetic resonance imaging results were obtained in most cases. Results: Significant differences were found between Caucasians and African-Americans in several variables. Caucasians had more frequent hypertriglyceridemia and a higher rate of cardiac disease. African-Americans had more frequent lacunar infarcts. There was a trend toward decreased risk of CD scan abnormality, and more HTN and prior stroke in African-Americans. There were no differences in the presence of DM, both HTN and DM, abnormal cholesterol (including high- and low-density lipoprotein) values, and smoking history. Except for the difference in lacunar infarction, there were no differences in the type of stroke. Conclusions: Our data indicate a greater risk of cardiac disease and hypertriglyceridemia in Caucasians with cerebrovascular disease. There was a trend for Caucasians to have more extracranial carotid disease, and a trend for African-Americans to have more hypertension and prior stroke, although the difference did not reach significance. Consistent with prior racial studies, we found African-Americans to have more lacunar strokes than Caucasians.     

Dipyridamole plus aspirin in cerebrovascular disease.

BACKGROUND: The second European Stroke Prevention Study (ESPS-2) recently reported a substantial benefit of dipyridamole combined with aspirin over aspirin alone in the prevention of stroke. This appears to be at odds with previous studies suggesting that dipyridamole adds nothing to aspirin alone. OBJECTIVES: To review and compare the results of ESPS-2 and previous studies of dipyridamole plus aspirin and aggregate them in a meta-analysis. METHODS: We combined the detailed data provided by the Antiplatelet Trialists' Collaboration on the previous studies of dipyridamole plus aspirin with the results from ESPS-2. The data on the previous trials were listed in the appendix of the 1994 publication of the Antiplatelet Trialists' Collaboration. RESULTS: The results of our meta-analysis demonstrate that for the outcome of nonfatal stroke, ESPS-2 overwhelms previous data, which, even in the aggregate, did not include enough patients or outcome events to exclude efficacy for the combination of dipyridamole and aspirin. Differences between ESPS-2 and previous studies, which may have contributed to different results, include the doses and preparations of aspirin and dipyridamole. CONCLUSIONS: The ESPS-2 showed that dipyridamole alone prevents stroke. More importantly, it showed a substantial benefit for dipyridamole combined with aspirin over aspirin alone. When the ESPS-2 data are aggregated with the 14 previous trials of dipyridamole combined with aspirin over aspirin alone, the combination reduces the risk of stroke by 23% over aspirin alone. Nevertheless, important questions remain unanswered. We conclude that another randomized clinical trial showing a significant benefit of the combination of dipyridamole plus aspirin over aspirin alone may be needed before the addition of dipyridamole to aspirin is widely accepted for prevention of stroke.     

Suicidal behaviour. An attempt to modify the environment. Part IV.

A study was undertaken of 76 males patients (following suicidal attempts) admitted in 1962 and 1963 to Holywell Hospital, a psychiatric hospital in Antrim, Norther Ireland. Their age, psychiatric condition, personality, intelligence, civil state, social class, religion, etc., were reviewed and the findings were compared with the findings in: (a) 100 suicidal females treated in the same hospital for the same reason in the same 2 years; (b) a group of 45 suicidal males admitted to the same hospital in 1971, and (c) a group of 91 suicidal female subjects treated in Holywell in 1971. The aim of the inquiry was to find out: (a) whether there were any sex-linked differences between these groups; (b) whether there were any changes in methods used in suicidal attempts in the last decade, and (c) whether our hypothesis about gain-motivation in many suicidal attempts was correct. The results of the study showed that: (a) sex and all personal and social factors reviewed were of little significance in the incidence of suicidal attempts and in the methods employed in their execution; (b) in both 1971 groups there was a shift from violent to non-violent means, and (c) two-thirds of all patients, irrespective of sex, social class, religion, etc., not only claimed having tried to achieve some personal gains, but apparently did achieve them by their suicidal behaviour. This seems to support our hypothesis that in many cases suicidal behaviour is in fact an attempt to modify the environment to the patient's benefit.     

Condon's multiple-response phenomenon in severely dysfunctional children: An attempt at replication

The present study was conducted in an attempt to replicate the findings of William Condon on multiple entrainment and dyssynchronous behavioral organization in autistic children. Three autistic and two normal children were filmed while being presented with five discrete auditory stimuli. Microkinesic analyses of the children's motor responses were performed in relation to three hypotheses designed to support the double-response and dyssynchrony effects. No firm evidence of multiple-responding to single sound was found for the autistic or normal children. There was some indication of dyssynchronous, or awkward, response organization for the autistic children, in comparison to the smooth-flowing body movements of the normal children.This project was carried out through the support of Research Grant No. 606-1240-44 from the Department of National Health and Welfare (M. M. K.) and by funding from both the University of Victoria Research and Travel Fund and the British Columbia Medical Association (C. D. W.). A more detailed report of this research is available from the senior author.We acknowledge with thanks the excellent technical film work of Mr. R. Rivers of the Audio-Visual Department of the Clarke Institute of Psychiatry. His willingness not only to make moving film but to spend time with our subjects is much appreciated by us as well as by the children themselves. We also thank the children and their parents for participating so willingly in our work. We are also grateful to Mrs. Linda Hill Brand of the University of Victoria for her painstaking and intelligent analysis of the film. Finally, we thank Dr. Leo Lazar, chief psychologist, Child and Adolescent Service, for providing us with funds for film.     

History of occlusive cerebrovascular disease I. from Wepfer to Moniz.

Occlusive cerebrovascular disease of carotid and vertebral arteries was described by Wepfer in 1658 and by Willis in 1665. Wepfer thought apoplexy resulted from occlusive disease of the vessels. Willis described collateral channels between these vessels, which prevented the development of stroke.