Could high blood pressure be the cause of acute spontaneous spinal epidural hematoma?
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Acute Disease↗
Biomedical subjects
Konstantinos Spengos
Publications and source records attributed to Konstantinos Spengos.
Intraoperative radial nerve injury during coronary artery surgery--report of two cases.
BACKGROUND: Peripheral nerve injury and brachial plexopathy are known, though rare complications of coronary artery surgery. The ulnar nerve is most frequently affected, whereas radial nerve lesions are much less common accounting for only 3% of such intraoperative injuries. CASE PRESENTATIONS: Two 52- and 50-year-old men underwent coronary artery surgery. On the first postoperative day they both complained of wrist drop on the left. Neurological examination revealed a paresis of the wrist and finger extensor muscles (0/5), and the brachioradialis (4/5) with hypoaesthesia on the radial aspect of the dorsum of the left hand. Both biceps and triceps reflexes were normoactive, whereas the brachioradialis reflex was diminished on the left. Muscles innervated from the median and ulnar nerve, as well as all muscles above the elbow were unaffected. Electrophysiological studies were performed 3 weeks later, when muscle power of the affected muscles had already begun to improve. Nerve conduction studies and needle electromyography revealed a partial conduction block of the radial nerve along the spiral groove, motor axonal loss distal to the site of the lesion and moderate impairment in recruitment with fibrillation potentials in radial innervated muscles below the elbow and normal findings in triceps and deltoid. Electrophysiology data pointed towards a radial nerve injury in the spiral groove. We assume external compression as the causative factor. The only apparatus attached to the patients' left upper arm was the sternal retractor, used for dissection of the internal mammary artery. Both patients were overweight and lying on the operating table for a considerable time might have caused the compression of their left upper arm on the self retractor's supporting column which was fixed to the table rail 5 cm above the left elbow joint, in the site where the radial nerve is directly apposed to the humerus. CONCLUSION: Although very uncommon, external compression due to the use of a self retractor during coronary artery surgery can affect--especially in obese subjects--the radial nerve within the spiral groove leading to paresis and should therefore be included in the list of possible mechanisms of radial nerve injury.
Case Reports↗
Validation of the ABCD score in identifying individuals at high early risk of stroke after a transient ischemic attack: a hospital-based case series study.
BACKGROUND AND PURPOSE: A simple score derived in the Oxfordshire Community Stroke Project (ABCD score) was able to identify individuals at high early risk of stroke after a transient ischemic attack (TIA) both in a population-based and a hospital-referred clinic cohort. We aimed to further validate the former score in a cohort of hospitalized TIA patients. METHODS: We retrospectively reviewed the emergency room and hospital records of consecutive patients hospitalized in our neurological department with a definite TIA according to the World Health Organization (WHO) criteria during a 5-year period. The 6-point ABCD score (age [<60 years=0, > or =60 years=1]; blood pressure [systolic < or =140 mm Hg and diastolic < or =90 mm Hg=0, systolic >140 mm Hg and/or diastolic >90 mm Hg=1]; clinical features [unilateral weakness=2, speech disturbance without weakness=1, other symptom=0]; duration of symptoms [<10 minutes=0, 10 to 59 minutes=1, > or =60 minutes=2]) was used to stratify the 30-day stroke risk. RESULTS: The 30-day risk of stroke in the present case series (n=226) was 9.7% (95% CI, 5.8% to 13.6%). The ABCD score was highly predictive of 30-day risk of stroke (ABCD=0 to 2: 0%, ABCD=3: 3.5% [95% CI, 0% to 8.2%], ABCD=4: 7.6% [95% CI, 1.2% to 14.0%], ABCD=5: 21.3% [95% CI, 10.4% to 33.0%], ABCD=6: 31.3% [95% CI, 8.6% to 54.0%]; log-rank test=23.09; df=6; P=0.0008; P for linear trend across the ABCD score levels <0.00001). After adjustment for stroke risk factors, history of previous TIA, medication use before the index TIA, and secondary prevention treatment strategies, an ABCD score of 5 to 6 was independently (P<0.001) associated with an 8-fold greater 30-day risk of stroke (hazard ratio, 8.01; 95% CI, 3.21 to 19.98). CONCLUSIONS: Our findings validate the predictive value of the ABCD score in identifying hospitalized TIA patients with a high risk of early stroke and provide further evidence for its potential applicability in clinical practice.
Aged↗
Presymptomatic neuromuscular disorders disclosed following statin treatment.
It is well recognized that statins affect muscular tissue adversely and that their use is associated with clinically important myositis, rhabdomyolysis, mild elevation of serum creatine kinase (CK) levels, myalgias, muscle weakness, muscle cramps, and persistent myalgias or serum CK level elevations after statin treatment is discontinued. The association between statins and the disclosure of presymptomatic metabolic myopathy is another underrated phenomenon related to statin therapy that was recently recognized in rare cases. The purpose of this report is to provide additional support for this association and to report other neuromuscular disorders that have also been seen following statin intake. The present case series illustrates that statins may act as unmasking agents in asymptomatic patients with a latent neuromuscular disorder. Thus, it may be postulated that statin intake may be a sufficient insult to precipitate neuromuscular symptoms and substantially increase muscle enzymes in presymptomatic patients with an abnormal neuromuscular substrate. In conclusion, muscular symptoms or increased serum CK levels persisting after statin treatment discontinuation should alert the clinician to pursue further diagnostic evaluations for the detection of potential underlying neuromuscular diseases.
Biopsy↗
Common carotid artery intima-media thickness and the risk of stroke recurrence.
BACKGROUND AND PURPOSE: Increased common carotid artery intima-media thickness (CCA-IMT) has been associated with an increased risk of myocardial infarction and stroke. We investigated the relationship between CCA-IMT and recurrent stroke in a cohort of ischemic stroke patients. METHODS: High-resolution B-mode ultrasonographic measurements of the CCA-IMT were performed in a consecutive series of 238 patients hospitalized in our institution with first-ever ischemic stroke. Stroke risk factors and secondary prevention therapies were documented. Patients were followed-up prospectively and the outcome event of interest was recurrent stroke. RESULTS: During a mean follow-up period of 28.9 months (range: 6 to 60 months), 27 recurrent strokes were documented. Patients who experienced recurrent cerebrovascular events had significantly (P=0.005) higher CCA-IMT values (1.01 mm, 95% CI:0.92 to 1.11 mm) than subjects who were free of stroke recurrence (0.88 mm, 95% CI:0.85 to 0.91 mm). After adjustment for baseline characteristics, risk factors and stroke subtypes and secondary prevention therapies increasing CCA-IMT was found to be an independent predictor of stroke recurrence. For each increment of 0.1 mm in CCA-IMT the probability of experiencing recurrent stroke increased by 18.0% (95% CI:2.0% to 36.0%, P=0.027). CONCLUSIONS: Increased CCA-IMT values are associated with a higher risk of long-term stroke recurrence.
Acute Disease↗
Blood pressure management in acute stroke: a long-standing debate.
Although elevated blood pressure (BP) levels are a common complication of acute stroke, whether of ischaemic or haemorrhagic type, a long-standing debate exists regarding the management of post-stroke hypertension. In the absence of solid, randomised data from controlled trials, the current observational evidence allows different approaches, since theoretical arguments exist for both lowering BP in the setting of acute stroke (reduce the risk of stroke recurrence, of subsequent oedema formation, of rebleeding and haematoma expansion in patients with cerebral bleeding) as well as leaving raised BP levels untreated (avoid reduction in cerebral perfusion pressure and blood flow to viable ischaemic tissue in the absence of normal autoregulation). The present review will summarize the evidence for and against the therapeutic manipulation of BP in acute stroke provided by the currently available observational studies and randomised trials, consider the ongoing clinical trials in this area and address the present recommendations regarding this conflicting issue.
Antihypertensive Agents↗
Seasonal variation of Bell's palsy in Athens, Greece - a hospital-based retrospective evaluation over fifteen years.
Epidemiological data on the incidence of Bell's palsy (BP) are conflicting. The aim of this retrospective study was to evaluate the variation of cases of BP acutely presented in the emergency room of our department over a 15-year period (January 1990 to December 2004). We examined the monthly and seasonal distribution of BPs among 36,312 patients who came to our emergency services and compared it with the assumed equal distribution of cases over the year (null hypothesis) using chi(2) techniques. During the observation period 1,252 of all patients (3.45%) presented due to BP. A decline during the summer was observed, in contrast to a peak documented during the autumn and winter. January and July were the months with the highest and lowest frequency of BP, respectively. Statistical analysis revealed a significantly different seasonal (chi(2) = 10.569; d.f. = 3; p = 0.014) and monthly (chi(2) = 25.445; d.f. = 11; p = 0.008) pattern of BP cases. The distribution of cases of BP shows a significant variation with a decline during the summer and an increase during the colder period of the year. A similar pattern has been described for reactivated herpetic ocular infections. Since a similar pathogenetic mechanism is regarded as the main cause of BP, the chronobiological aspects and the influence of meteorological factors on the reactivation of latent infections deserves further prospective evaluation.
Acute Disease↗
Diurnal blood pressure changes in stroke subtypes.
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Blood Pressure↗
Spinal cord stroke in a ballet dancer.
Fibrocartilaginous embolism of the intervertebral disc represents an uncommon cause of spinal cord infarction. We present the case of a previously healthy 30-year old ballet dancer who noted acute severe neck pain shortly after an intensive training session and developed weakness and numbness of both arms, as well as difficulties in emptying the bladder and bowel. Her clinical presentation and neuroimaging studies including diffusion weighted imaging were consistent with a spinal cord infarction in the anterior spinal territory at the C3-C6 spinal cord level. Although no histological confirmation was obtained, lack of evidence of other plausible diagnoses in the setting of the patient's clinical presentation and neuroimaging findings made fibrocartilaginous embolism the most likely etiopathogenetic mechanism of spinal stroke.
Accidents, Occupational↗
Extensive corpus callosum infarction: an uncommon pattern of watershed ischaemia?
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Angiography, Digital Subtraction↗
Twenty-four-hour heart rate and blood pressure are additive markers of left ventricular mass in hypertensive subjects.
BACKGROUND: We investigated whether mean heart rate (HR(24)) and blood pressure (BP) parameters during 24-h ambulatory BP monitoring (ABP) are independent or additive markers of left ventricular (LV) mass in subjects with newly diagnosed, untreated hypertension. METHODS: A total of 250 patients (40% women, 60% men; mean age 59.6 +/- 11 years) with essential hypertension who were attending the outpatient Hypertension Unit were studied. All patients underwent 24-h ABP and HR monitoring as well as echocardiography for assessment of left ventricular (LV) dimensions and function. RESULTS: A decreasing HR24 or increasing ABP parameters (ie, systolic, diastolic, mean BP, and pulse pressure) were associated with increasing LV mass (P < .001) and wall thickness (P < .01). In multivariate analysis, after adjusting for age, gender, body surface area, body mass index, hematocrit, glucose, cholesterol, smoking, and each of the measured ABP parameters separately, decreasing HR24 was independently related to increasing LV mass in addition to ABP and body size parameters (P < .001). The addition of HR24 in different multivariate models for prediction of LV mass significantly increased the adjusted model r2 (range of r2 change: 0.039 to 0.064, P for change <.05). Decreasing HR24 or HR during daytime (6 am to 10 pm) was associated with a higher likelihood of LV hypertrophy in addition to ABP parameters (adjusted odds ratio 0.92 (CI 0.87 to 0.98), per 1 beat/min greater HR24 P = .002 and 0.93 (CI: 0.87 to 0.98), per 1 beat/min greater HR in the daytime P = .017). CONCLUSION: The 24-h HR and BP during ABP are independent and additive markers of increased LV mass in untreated hypertensive individuals.
Blood Pressure↗
Primary prevention of arterial thromboembolism in the oldest old with atrial fibrillation--a randomized pilot trial comparing adjusted-dose and fixed low-dose coumadin with aspirin.
BACKGROUND: Anticoagulation therapy remains largely underused in older people with atrial fibrillation (AF). The aim of this pilot trial was to investigate the effects of low-intensity adjusted-dose and fixed-dose coumadin on the incidence of arterial thromboembolism and bleeding, as well as the efficacy of anticoagulation monitoring in elderly AF patients. METHODS: In this open-label, randomized trial we recruited patients over 75 years of age without previous stroke or systemic embolism. Patients were randomized into three groups, with group A receiving aspirin 100 mg/day, group B fixed-dose coumadin 1 mg/day; and group C adjusted-dose coumadin with a target range of international normalized ratios (INR) between 1.6 and 2.5. Primary endpoints (ischemic strokes and systemic embolisms) and secondary endpoints (deaths, myocardial infarctions, and major bleeding events) were prospectively documented. RESULTS: The study was discontinued 6 months after the enrollment of the first patient for safety reasons. During this period, 45 patients were recruited (15 patients in group A, 14 in group B, and 16 in group C). Over a mean follow-up period of 3.7 months (range: 1-6 months), two patients from group B developed a dangerous prolongation of the INR (7.0 and 4.2), which led to the discontinuation of fixed-dose coumadin. Another patient from the same group experienced a major bleeding event 1 month after enrollment in the study (INR: 5.5). The percentage of INR measurements within the target range was significantly (p<0.001) lower in group B (48.7%) than in group C (83.7%). CONCLUSIONS: Older people receiving fixed-dose oral anticoagulants may be at risk of developing a dangerous prolongation of their INR.
Journal Article↗
Intramedullary spinal cord metastases in a patient with small-cell lung cancer.
We present the case of a 60-year-old male smoker with gait disturbance, lower limb sensory disturbance, and urinary difficulties of subacute onset and progressive course. He had been diagnosed 10 months earlier with limited stage small-cell lung cancer, had received chemotherapy, thoracic radiotherapy, and prophylactic cranial irradiation, and was in remission on follow-up. Examination revealed bilateral pyramidal tract signs, a T9 sensory level, and loss of vibration and position sense in the lower limbs. Gadolinium-enhanced MRI of the cervical and thoracic spinal cord revealed two enhancing intramedullary lesions consistent with metastases. Intramedullary metastases are exceedingly rare, accounting for only 3.4-6% of myelopathies in cancer patients, and they usually coexist with brain or leptomeningeal metastases. The presence of multiple metastases is even rarer, with two lesions found in only 10% of patients with intramedullary disease.
Journal Article↗
Impact of the time rate of blood pressure variation on left ventricular mass.
OBJECTIVES: Blood pressure (BP) changes are steeper in hypertensive than in normotensive individuals, whereas an increased rate of BP fluctuations is associated with medial hypertrophy of the carotid arteries. We evaluated the association between the rate of BP variation derived from ambulatory blood pressure monitoring (ABPM) data analysis and left ventricular mass (LVM). METHODS: ABPM and echocardiographic measurements of LVM were performed in 365 normotensive, 185 white-coat hypertensive (WCH) and 448 uncomplicated hypertensive individuals. RESULTS: The daytime and night-time rate of systolic blood pressure (SBP) and diastolic BP variation were significantly higher in hypertensive than in normotensive (P < 0.001) and WCH (P < 0.05) individuals. In the entire study population multiple linear regression models revealed independent determinants of LVM in the following rank order: body mass index (beta + 0.266, P < 0.001), daytime SBP (beta + 0.264, P < 0.001), male sex (beta +0.220, P < 0.001), age (beta + 0.203, P < 0.001), daytime heart rate (HR; beta - 0.191, P < 0.001), daytime rate of SBP variation (beta + 0.167, P < 0.001), and SBP dipping (beta - 0.132, P < 0.001). A 0.1 mmHg/min increase in the daytime rate of SBP variation correlated with an increment of 7.087 g (95% confidence interval 4.775-9.399) in the LVM. The addition of the daytime rate of SBP variation in the multiple regression model for the prediction of LVM significantly increased the adjusted model R [R change 0.024 (2.4%); P for change < 0.001]. CONCLUSION: Steeper BP variations may produce a greater stress on the left ventricular wall and may have an additive role to body habitus, BP and HR levels in the detection of cardiac hypertrophy. Target-organ damage in hypertensive patients, in addition to BP levels, dipping status and BP variability, may also be related to a steeper rate of BP oscillations.
Adult↗
Assessment of blood pressure control in hypertensive stroke survivors: an ambulatory blood pressure monitoring study.
BACKGROUND: We compared the sensitivity of office blood pressure and ambulatory blood pressure monitoring recordings in evaluating the effectiveness of antihypertensive treatment and identified factors related to inadequate blood pressure control among hypertensive stroke survivors. METHODS: Office blood pressure and ambulatory blood pressure monitoring measurements were performed at 120+/-30 days after ictus in 187 first-ever consecutive hypertensive stroke survivors who were receiving blood pressure-lowering medications according to international guidelines. Handicap was assessed by the modified Rankin Scale. Blood pressure was regarded as controlled if office and daytime ambulatory systolic and diastolic blood pressure values were <140/90 and <135/85 mmHg, respectively. Patients were subclassified according to the degree of their nocturnal systolic blood pressure fall [(mean daytime values-mean night-time values)100/mean daytime values] as dippers (>or=10%), nondippers (>or=0% and <10%) and reverse dippers (<0%). RESULTS: Effective blood pressure control was documented in significantly (P<0.001) fewer patients using ambulatory blood pressure monitoring (32.1%) than those using office recordings (43.3%), whereas in 16% of the study population a masked lack of per-treatment blood pressure control (elevated ambulatory blood pressure in the presence of normal office blood pressure levels) was identified. The distribution of dipping patterns differed significantly (P=0.01) between controlled hypertensive individuals (normal office and ambulatory measurements) and patients with isolated ambulatory hypertension (dippers: 31.3 vs. 10.0%; nondippers:56.9 vs. 53.3%; reverse dippers: 11.8 vs. 36.7%). Logistic regression analysis revealed diabetes mellitus and functional independency (modified Rankin Scale score<2) as independent predictors of inadequate blood pressure control. CONCLUSION: Ambulatory blood pressure monitoring detects a substantial number of treated hypertensive stroke survivors with a masked lack of per-treatment blood pressure control, who present a higher prevalence of abnormal circadian blood pressure patterns (reverse dipping). Diabetes mellitus and poststroke functional independency are the main factors contributing to inadequate blood pressure control.
Aged↗
Motor and sensory polyneuritis with distal conduction failure as uncommon complication of an acute Rickettsia conorii infection.
Rickettsia conorii is endemic in the Mediterranean region. Infections are mostly benign and neurological involvement is unusual. We describe a case of a man who presented with acute facial nerve palsy followed by flaccid tetraparesis due to an electrophysiologically established polyneuritis with distal conduction failure. Elevated IgM antibody titres for R. conorii were documented by indirect immunofluorescent antibody test. After doxycycline therapy, the patient presented a rapid clinical improvement. Repeated electrophysiological examinations revealed significantly restored compound muscles, and sensory action potentials, corresponding to the clinical course after treatment and ex juvantibus, indicate the causative relation between R. conorii infection and the described clinical syndrome.
Aged↗
Time rate of blood pressure variation is associated with increased common carotid artery intima-media thickness.
The extent of target-organ damage has been positively associated with the magnitude of blood pressure (BP) variability in essential hypertension. However, the clinical implications of the rate of BP changes have never been investigated. We evaluated the association between the rate of systolic BP (SBP) variation derived from ambulatory BP monitoring (ABPM) data analysis and the extent of common carotid artery (CCA) intima-media thickness (IMT) in normotensive (n=280) and in uncomplicated hypertensive subjects (n=234). The 24-hour rate of SBP variation was significantly (P<0.001) higher in hypertensive (0.608 mm Hg/min; 95% confidence interval [CI], 0.595 to 0.622) than in normotensive individuals (0.567 mm Hg/min; 95% CI, 0.555 to 0.578), even after adjusting for baseline characteristics, day-night BP changes, 24-hour heart rate (HR), SBP, and HR variability. In the entire group of patients, multiple linear regression models revealed independent determinants of CCA-IMT in the following rank order: age (P<0.001), 24-hour rate of SBP variation (P<0.001), male gender (P=0.004), cholesterol (P=0.009), and smoking (P=0.014). A 0.1 mm Hg/min increase in the 24-hour rate of SBP variation was associated to an increment of 0.029 mm (95% CI, 0.018 to 0.040) in CCA-IMT independent of BP and HR levels, BP and HR variability, and dipping status. The rate of SBP variation during the morning BP surge correlated independently (P<0.001) to larger CCA-IMT values after adjustment for baseline characteristics and other ABPM parameters. Thus, the rate of BP fluctuations is greater in hypertensive patients and correlates to increased CCA-IMT. This finding indicates that steeper BP variations may produce a greater stress on the vessel wall and consequently result in medial hypertrophy of the large arteries.
Aging↗
Aetiopathogenesis and long-term outcome of isolated pontine infarcts.
BACKGROUND AND PURPOSE: Isolated pontine strokes cause characteristic neurological syndromes and have a good short-term prognosis. The aim of this study was to examine the long-term survival, cumulative recurrence rate and clinical handicap of patients with isolated pontine infarcts of different aetiology. METHODS: One hundred consecutive patients with an isolated pontine infarction were identified by imaging studies and evaluated prospectively. After extensive study, cases were classified according to the aetiopathogenetic mechanisms: stroke due to basilar artery branch disease (BABD), small-artery disease (SAD) and large-artery-occlusive disease (LAOD). During a mean follow-up period of 46 months, stroke presentation and initial course, early and long-term mortality, disability and recurrence were evaluated. RESULTS: BABD was the most frequent cause of isolated pontine ischaemia (43%), followed by SAD (34%) and LAOD (21%). Hypertension was the most prominent risk factor, especially among patients with SAD (94.1%). Neurological impairment on admission was more severe in the LAOD group, followed by BABD. After 1 month patients with LAOD had the highest cumulative mortality (14.3%, p = 0.026) and more severe disability (61.1%, p = 0.001). Five-year mortality rate was 20.6%, 14% and 23.8% in the SAD-, BABD- and in LAOD-group respectively (p = 0.776). Cumulative 5-year recurrence rate was 2.3 % for BABD, 14.3 % for LAOD, and 29.4 % for SAD (p = 0.011). CONCLUSIONS: Overall long-term survival of patients with isolated pontine infarcts is good. Initial differences regarding short-term outcome in infarctions of different aetiology resolve with time. Effective secondary prevention among SAD patients may limit stroke recurrence and positively influence long-term prognosis.
Aged↗