Comment in:

N Engl J Med. 2008 Apr 10;358(15):1638; author reply 1638-9.

Platelet activation and atherothrombosis.

Center of Excellence on Aging, G. d'Annunzio University Foundation, Chieti, Italy.

PMID: 18077812 [PubMed - indexed for MEDLINE]

Comment in:

N Engl J Med. 2008 Apr 3;358(14):1518; author reply 1520-1.

N Engl J Med. 2008 Apr 3;358(14):1518; author reply 1520-1.

N Engl J Med. 2008 Apr 3;358(14):1519-20; author reply 1520-1.

N Engl J Med. 2008 Apr 3;358(14):1519; author reply 1520-1.

Patent foramen ovale and cryptogenic stroke in older patients.

Department of Cardiology, University Hospital Freiburg, Freiburg, Germany. handkem@uhbs.ch

BACKGROUND: Studies to date have shown an association between the presence of patent foramen ovale and cryptogenic stroke in patients younger than 55 years of age. This association has not been established in patients 55 years of age or older. METHODS: We prospectively examined 503 consecutive patients who had had a stroke, and we compared the 227 patients with cryptogenic stroke and the 276 control patients with stroke of known cause. We examined the prevalences of patent foramen ovale and of patent foramen ovale with concomitant atrial septal aneurysm in all patients, using transesophageal echocardiography. We also compared data for the 131 younger patients (< 55 years of age) and those for the 372 older patients (> or = 55 years of age). RESULTS: The prevalence of patent foramen ovale was significantly greater among patients with cryptogenic stroke than among those with stroke of known cause, for both younger patients (43.9% vs. 14.3%; odds ratio, 4.70; 95% confidence interval [CI], 1.89 to 11.68; P<0.001) and older patients (28.3% vs. 11.9%; odds ratio, 2.92; 95% CI, 1.70 to 5.01; P<0.001). Even stronger was the association between the presence of patent foramen ovale with concomitant atrial septal aneurysm and cryptogenic stroke, as compared with stroke of known cause, among both younger patients (13.4% vs. 2.0%; odds ratio, 7.36; 95% CI, 1.01 to 326.60; P=0.049) and older patients (15.2% vs. 4.4%; odds ratio, 3.88; 95% CI, 1.78 to 8.46; P<0.001). Multivariate analysis adjusted for age, plaque thickness, and presence or absence of coronary artery disease and hypertension showed that the presence of patent foramen ovale was independently associated with cryptogenic stroke in both the younger group (odds ratio, 3.70; 95% CI, 1.42 to 9.65; P=0.008) and the older group (odds ratio, 3.00; 95% CI, 1.73 to 5.23; P<0.001). CONCLUSIONS: There is an association between the presence of patent foramen ovale and cryptogenic stroke in both older patients and younger patients. These data suggest that paradoxical embolism is a cause of stroke in both age groups. 2007 Massachusetts Medical Society

PMID: 18046029 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 Aug 30;357(9):885-96.

Continuous-flow ventricular assist device.

PMID: 18046035 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 Aug 9;357(6):572-9.

Acute ischemic stroke.

PMID: 18032775 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 Aug 9;357(6):562-71.

NXY-059 for the treatment of stroke.

PMID: 18032772 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 Aug 9;357(6):572-9.

Acute ischemic stroke.

PMID: 18038463 [PubMed - indexed for MEDLINE]

Comment in:

Curr Cardiol Rep. 2008 Jul;10(4):301-2.

Kardiol Pol. 2008 Feb;66(2):222-5; discussion 225-6.

N Engl J Med. 2007 Nov 15;357(20):2078-81.

N Engl J Med. 2008 Mar 20;358(12):1298-9; author reply 1299-301.

N Engl J Med. 2008 Mar 20;358(12):1298; author reply 1299-301.

N Engl J Med. 2008 Mar 20;358(12):1299; author reply 1299-301.

Perspect Vasc Surg Endovasc Ther. 2008 Jun;20(2):223-4.

Prasugrel versus clopidogrel in patients with acute coronary syndromes.

Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.

BACKGROUND: Dual-antiplatelet therapy with aspirin and a thienopyridine is a cornerstone of treatment to prevent thrombotic complications of acute coronary syndromes and percutaneous coronary intervention. METHODS: To compare prasugrel, a new thienopyridine, with clopidogrel, we randomly assigned 13,608 patients with moderate-to-high-risk acute coronary syndromes with scheduled percutaneous coronary intervention to receive prasugrel (a 60-mg loading dose and a 10-mg daily maintenance dose) or clopidogrel (a 300-mg loading dose and a 75-mg daily maintenance dose), for 6 to 15 months. The primary efficacy end point was death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. The key safety end point was major bleeding. RESULTS: The primary efficacy end point occurred in 12.1% of patients receiving clopidogrel and 9.9% of patients receiving prasugrel (hazard ratio for prasugrel vs. clopidogrel, 0.81; 95% confidence interval [CI], 0.73 to 0.90; P<0.001). We also found significant reductions in the prasugrel group in the rates of myocardial infarction (9.7% for clopidogrel vs. 7.4% for prasugrel; P<0.001), urgent target-vessel revascularization (3.7% vs. 2.5%; P<0.001), and stent thrombosis (2.4% vs. 1.1%; P<0.001). Major bleeding was observed in 2.4% of patients receiving prasugrel and in 1.8% of patients receiving clopidogrel (hazard ratio, 1.32; 95% CI, 1.03 to 1.68; P=0.03). Also greater in the prasugrel group was the rate of life-threatening bleeding (1.4% vs. 0.9%; P=0.01), including nonfatal bleeding (1.1% vs. 0.9%; hazard ratio, 1.25; P=0.23) and fatal bleeding (0.4% vs. 0.1%; P=0.002). CONCLUSIONS: In patients with acute coronary syndromes with scheduled percutaneous coronary intervention, prasugrel therapy was associated with significantly reduced rates of ischemic events, including stent thrombosis, but with an increased risk of major bleeding, including fatal bleeding. Overall mortality did not differ significantly between treatment groups. (ClinicalTrials.gov number, NCT00097591 [ClinicalTrials.gov].) Copyright 2007 Massachusetts Medical Society.

PMID: 17982182 [PubMed - indexed for MEDLINE]

Comment in:

J Radiol. 2008 Apr;89(4):457-8.

N Engl J Med. 2008 Feb 21;358(8):853-4; author reply 854-5.

N Engl J Med. 2008 Feb 21;358(8):853; author reply 854-5.

N Engl J Med. 2008 Feb 21;358(8):854; author reply 854-5.

Incidental findings on brain MRI in the general population.

Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands.

BACKGROUND: Magnetic resonance imaging (MRI) of the brain is increasingly used both in research and in clinical medicine, and scanner hardware and MRI sequences are continually being improved. These advances are likely to result in the detection of unexpected, asymptomatic brain abnormalities, such as brain tumors, aneurysms, and subclinical vascular pathologic changes. We conducted a study to determine the prevalence of such incidental brain findings in the general population. METHODS: The subjects were 2000 persons (mean age, 63.3 years; range, 45.7 to 96.7) from the population-based Rotterdam Study in whom high-resolution, structural brain MRI (1.5 T) was performed according to a standardized protocol. Two trained reviewers recorded all brain abnormalities, including asymptomatic brain infarcts. The volume of white-matter lesions was quantified in milliliters with the use of automated postprocessing techniques. Two experienced neuroradiologists reviewed all incidental findings. All diagnoses were based on MRI findings, and additional histologic confirmation was not obtained. RESULTS: Asymptomatic brain infarcts were present in 145 persons (7.2%). Among findings other than infarcts, cerebral aneurysms (1.8%) and benign primary tumors (1.6%), mainly meningiomas, were the most frequent. The prevalence of asymptomatic brain infarcts and meningiomas increased with age, as did the volume of white-matter lesions, whereas aneurysms showed no age-related increase in prevalence. CONCLUSIONS: Incidental brain findings on MRI, including subclinical vascular pathologic changes, are common in the general population. The most frequent are brain infarcts, followed by cerebral aneurysms and benign primary tumors. Information on the natural course of these lesions is needed to inform clinical management. Copyright 2007 Massachusetts Medical Society.

PMID: 17978290 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 Jun 28;356(26):2704-12.

Arteriovenous malformations of the brain.

PMID: 17960021 [PubMed - indexed for MEDLINE]

Hypercholesterolemia in primary biliary cirrhosis.

PMID: 17928612 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 May 24;356(21):e21.

Central venous catheterization.

PMID: 17806137 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 May 24;356(21):e21.

Central venous catheterization.

PMID: 17761603 [PubMed - indexed for MEDLINE]

Comment in:

N Engl J Med. 2007 Nov 22;357(21):2203; author reply 2204.

N Engl J Med. 2007 Nov 22;357(21):2203; author reply 2204.

Clinical practice. Acute ischemic stroke.

Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands. h.b.vanderworp@umcutrecht.nl

PMID: 17687132 [PubMed - indexed for MEDLINE]

Comment in:

N Engl J Med. 2007 Nov 22;357(21):2198; author reply 2198-9.

NXY-059 for the treatment of acute ischemic stroke.

Division of Neurology, University of Alberta, Edmonton, Canada.

BACKGROUND: The free-radical-trapping agent NXY-059 showed promise as a neuroprotectant in the Stroke-Acute Ischemic NXY Treatment I (SAINT I) trial, reducing disability when given to patients who had acute ischemic stroke. We sought confirmation of efficacy in a second, larger trial. METHODS: We enrolled 3306 patients with acute ischemic stroke in a randomized, double-blind trial to receive a 72-hour infusion of intravenous NXY-059 or placebo within 6 hours after the onset of stroke symptoms. Our primary end point was the distribution of disability scores on the modified Rankin scale at 90 days. We examined scores on neurologic and activities-of-daily-living scales as secondary end points. We also tested the hypothesis that NXY-059 would reduce alteplase-related intracranial hemorrhages. RESULTS: The efficacy analysis was based on 3195 patients. Prognostic factors were well balanced between the treatment groups. Mortality was equal in the two groups, and adverse-event rates were similar. The distribution of scores on the modified Rankin scale did not differ between the group treated with NXY-059 (1588 patients) and the placebo group (1607 patients; P=0.33 by the Cochran-Mantel-Haenszel test; odds ratio for limiting disability, 0.94; 95% confidence interval [CI], 0.83 to 1.06). Analysis of categorized scores on the modified Rankin scale confirmed the lack of benefit: the odds ratio for trichotomization into modified Rankin scale scores of 0 to 1 versus 2 to 3 versus 4 to 6 was 0.92 (95% CI, 0.80 to 1.06). There was no evidence of efficacy for any of the secondary end points. Among patients treated with alteplase, there was no difference between the NXY-059 group and the placebo group in the frequency of symptomatic or asymptomatic hemorrhage. CONCLUSIONS: NXY-059 is ineffective for the treatment of acute ischemic stroke within 6 hours after the onset of symptoms. (ClinicalTrials.gov number, NCT00061022 [ClinicalTrials.gov].) Copyright 2007 Massachusetts Medical Society.

PMID: 17687131 [PubMed - indexed for MEDLINE]

Case records of the Massachusetts General Hospital. Case 21-2007. A 58-year-old woman with headaches, weakness, and strokelike episodes.

Department of Neurology, Harvard Medical School, USA.

PMID: 17625129 [PubMed - indexed for MEDLINE]

Comment in:

N Engl J Med. 2007 Oct 25;357(17):1774-5; author reply 1775.

Clinical practice. Arteriovenous malformations of the brain.

Department of Neurosurgery, Division of Cerebrovascular Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.

PMID: 17596605 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 Feb 15;356(7):706-13.

Perioperative stroke.

PMID: 17542072 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 Feb 15;356(7):706-13.

Perioperative stroke.

PMID: 17542071 [PubMed - indexed for MEDLINE]

Comment on:

N Engl J Med. 2007 Feb 15;356(7):706-13.

Perioperative stroke.

PMID: 17538095 [PubMed - indexed for MEDLINE]

Images in clinical medicine. Putaminal necrosis.

H.M. Stanley Hospital, St. Asaph LL17 0RS, Wales. diptochatt@yahoo.co.uk

PMID: 17538081 [PubMed - indexed for MEDLINE]