Neurology May 2009 Volume 72 Issue 21

Background: No randomized study has yet compared efficacy and safety of aspirin and anticoagulants in patients with spontaneous dissection of the cervical carotid artery (sICAD).Methods: Prospectively collected data from 298 consecutive patients with sICAD (56% men; mean age 46 +/- 10 years) treated with anticoagulants alone (n = 202) or aspirin alone (n = 96) were retrospectively analyzed. Admission diagnosis was ischemic stroke in 165, TIA in 37, retinal ischemia in 8, and local symptoms and signs (headache, neck pain, Horner syndrome, cranial nerve palsy) in 80 patients, while 8 patients were asymptomatic. Clinical follow-up was obtained after 3 months by neurologic examination (97% of patients) or structured telephone interview. Outcome measures were 1) new cerebral ischemic events, defined as ischemic stroke, TIA, or retinal ischemia, 2) symptomatic intracranial hemorrhage, and 3) major extracranial bleeding.Results: During follow-up, ischemic events were rare (ischemic stroke, 0.3%; TIA, 3.4%; retinal ischemia, 1%); their frequency did not significantly differ between patients treated with anticoagulants (5.9%) and those treated with aspirin (2.1%). The same was true for hemorrhagic adverse events (anticoagulants, 2%; aspirin, 1%). New ischemic events were significantly more frequent in patients with ischemic events at onset (6.2%) than in patients with local symptoms or asymptomatic patients (1.1%).Conclusions: Within the limitations of a nonrandomized study, our data suggest that frequency of new cerebral and retinal ischemic events in patients with spontaneous dissection of the cervical carotid artery is low and probably independent of the type of antithrombotic treatment (aspirin or anticoagulants).(C)2009AAN Enterprises, Inc.

Background: We recently observed that 13% of 1,008 consecutive adults aged 15-49 years with first-ever ischemic stroke had one or more silent brain infarcts (SBIs), and more than 5% presented with leukoaraiosis on CT or MRI. We sought to investigate the features of and risk factors for magnetic resonance (MR)-defined SBIs and leukoaraiosis in these patients.Methods: We analyzed the radiologic features of SBIs and leukoaraiosis in MR-scanned patients (n = 669) blinded to clinical data and examined their relation with subtype of the overt stroke. We used logistic regression to identify factors predisposing to SBIs and leukoaraiosis.Results: Of the 669 patients included, 86 (13%) had SBIs, 50 (7%) had leukoaraiosis, 17 (3%) had both, and 550 had no SBIs or leukoaraiosis and served as controls. The majority (54%) had a single SBI, 20% had two SBIs, and 27% had three or more SBIs. Most SBIs were located in basal ganglia (39%) or subcortical regions (21%), but cerebellar SBIs also were rather frequent (15%). Leukoaraiosis was mainly mild to moderate. Independent risk factors for SBIs were type 1 diabetes (odds ratio [OR] 5.78, 95% confidence interval 2.37-14.10), obesity (OR 2.12, 1.07-4.19), smoking (OR 1.69, 1.05-2.72), and increasing age (OR 1.08, 1.04-1.13). Risk factors for leukoaraiosis were type 1 diabetes (OR 9.75, 3.39-28.04), obesity (OR 2.42, 1.04-5.68), female sex (OR 2.25, 1.16-4.34), and increasing age (OR 1.19, 1.10-1.29). Small-vessel disease was the predominant cause of stroke in both those with SBIs (31%) and leukoaraiosis (44%).Conclusions: Silent brain infarcts and leukoaraiosis are not uncommon among young stroke patients-type 1 diabetes being the strongest risk factor.(C)2009AAN Enterprises, Inc.

Background: Different types of neuropsychological visual memory tasks have been created to quantify deficits associated with right hemisphere dysfunction. There are reports of visual memory impairment after right anterior temporal lobe resection (ATR) compared to left ATR for the processing of faces, abstract designs, and spatial locations, but there are also studies showing no between-group differences. One potential reason for the conflicting results is the use of group mean changes, which mask individual differences.Methods: Proportions of individual subjects with decline, no change, or improvement in memory for spatial locations, abstract designs, and unfamiliar faces were evaluated in 83 individuals who underwent a standard ATR (47 right, 36 left) and were left hemisphere language dominant.Results: Type of visual memory ability was an important factor as there were differential individual declines found for memory for spatial locations after right ATR compared to left ATR (27.3% vs 5.9%), but not memory for abstract designs or face memory. Logistic regression indicated that the odds of a spatial memory decline were six times higher for patients who underwent right ATR than left ATR.Conclusions: Memory for spatial locations appears to be particularly vulnerable to decline when a patient undergoes right-anterior temporal lobe resection (ATR) and when the patient has better spatial memory before surgery. Results provide proportions of subjects with significant change to help clinicians and patients make better informed decisions about risks associated with undergoing right ATR.(C)2009AAN Enterprises, Inc.

Background: There is almost no longitudinal information about measured cognitive performance during the menopause transition (MT).Methods: We studied 2,362 participants from the Study of Women's Health Across the Nation for 4 years. Major exposures were time spent in MT stages, hormone use prior to the final menstrual period, and postmenopausal current hormone use. Outcomes were longitudinal performance in three domains: processing speed (Symbol Digit Modalities Test [SDMT]), verbal memory (East Boston Memory Test [EBMT]), and working memory (Digit Span Backward).Results: Premenopausal, early perimenopausal, and postmenopausal women scored higher with repeated SDMT administration (p <= 0.0008), but scores of late perimenopausal women did not improve over time (p = 0.2). EBMT delayed recall scores climbed during premenopause and postmenopause (p <= 0.01), but did not increase during early or late perimenopause (p >= 0.14). Initial SDMT, EBMT-immediate, and EBMT-delayed tests were 4%-6% higher among prior hormone users (p <= 0.001). On the SDMT and EBMT, compared to the premenopausal referent, postmenopausal current hormone users demonstrated poorer cognitive performance (p <= 0.05) but performance of postmenopausal nonhormone users was indistinguishable from that of premenopausal women.Conclusions: Consistent with transitioning women's perceived memory difficulties, perimenopause was associated with a decrement in cognitive performance, characterized by women not being able to learn as well as they had during premenopause. Improvement rebounded to premenopausal levels in postmenopause, suggesting that menopause transition-related cognitive difficulties may be time-limited. Hormone initiation prior to the final menstrual period had a beneficial effect whereas initiation after the final menstrual period had a detrimental effect on cognitive performance.(C)2009AAN Enterprises, Inc.

Migraine, especially migraine with aura (MA), is an established risk factor for ischemic lesions of the brain. Recent evidence has also linked migraine to a broader range of ischemic vascular disorders including angina, myocardial infarction, coronary revascularization, claudication, and cardiovascular mortality. The mechanisms which link migraine to ischemic vascular disease remain uncertain and are likely to be complex. Cortical spreading depression, the presumed substrate of aura, may directly predispose to brain lesions and that would explain why MA is consistently demonstrated as a risk factor for cerebral ischemia, while for migraine without aura (MO), the evidence is less consistent. Additionally, individuals with migraine have a higher prevalence of risk factors known to be associated with cardiovascular disease (CVD), including hypertension, diabetes, and hyperlipidemia. The increased prevalence of CVD risk factors is also higher for MA than for MO. Since the evidence linking migraine and CVD is getting robust, neurologists should be aware of this association. Individuals with MO seem to be at little increased risk of CVD. MA is associated with an increased risk of ischemic stroke and likely also for other ischemic CVD events. Accordingly, heightened vigilance is recommended for modifiable cardiovascular risk factors in migraineurs, especially with MA. Ultimately, it will be important to determine whether MA is a modifiable risk factor for CVD and if preventive medications for migraine or antiplatelet therapy might reduce the risk of CVD in patients with MA.(C)2009AAN Enterprises, Inc.