Stroke
MARCH-APRIL VOL. 10
1979 NO. 2
A Journal of Cerebral Circulation Summary of Ninth International Salzburg Conference on Cerebrovascular Disease, Salzburg, Austria, September 27-30, 1978 PREPARED BY JOHN STIRLING MEYER, M.D.1 AND WILLIAM HASS, M.D.2
Chairman of the Conference: HELMUT LECHNER, M.D. 3 Organizing Secretaries: ERWIN O T T , M.D.* AND A. ARANIBAR, M.D. 4 Advisory
Board: J O H N MARSHALL, M.D., 5 D. H. INGVAR, 6 MARTIN REIVICH, 7 AND J. S. MEYER, M.D. 1
DR. W. D. OBRIST (Philadelphia, PA) discussed problems of unstable compartmental size in grossly pathological brain tissues during 133Xe inhalation measurements of rCBF referred to as "slippage." He offered 2 solutions to this problem in addition to the widely used slope indices as an index of blood flow. These are 1) computation of mean flow for all tissue compartments over a 10 min interval, mathematically equivalent to the height-over area method applied to carotid injection method, 2) holding the size of F, and F2 constant between studies. Both the stability and reliability of these 2 approaches were satisfactory. Dr. F. Sakai (Houston, TX) presented validation data of the 133Xe inhalation method for measuring rCBF from the brain stem and cerebellar areas (BSC) in both baboons and humans. The probes have extra long collimators and are held in the suboccipital region over the cerebellum by means of a helmet. Isocount geometry, defined by moving a point source of 133Xe through the baboon brain in situ, confirmed satisfactory counts from the brain stem. Inhalation BSC values in the baboon were in good agreement with arterial injection values. BSC values decrease
with sleep, sedation and anesthesia and increase with activation and epileptic seizures. In human volunteers with tracheostomy and laryngectomy BSC values measured without the possibility of nasopharyngeal contamination were in good agreement with those measured via a face mask. Dr. J-C. Baron (Boston, MA.) compared 133Xe inhalation measures of rCBF during right hand work (30 squeezes of a rubber bulb per min). Seven of 11 volunteers showed rCBF increases in the left sensorimotor area. The mean increase was 17% and the localization was statistically significant. In 4 of these 7 subjects compressed spectral analysis of the EEG showed diffuse, bilateral changes in EEG activity which became more uniform i.e. monorhythmic with increased power. Dr. A. Fenske (Mainz, W. Germany) reported 133Xe inhalation measurements in patients with arteriovenous malformations (AVM), hydrocephalus and focal ischemic lesions. In AVM rCBF was increased, in hydrocephalus cerebral autoregulation was impaired and in the focal ischemic lesions rCBF was reduced in a manner correlating with the clinical and arteriographic findings. They reported 133Xe inhalation rCBF measurement as a clinically useful method, a view which was confirmed in the discussion led by Dr. L. Symon (London, England). Dr. A. S. Brown (Edinburg, Scotland) reported rCBF measurements after 133Xe inhalation or intravenous injections of the isotope. They have found the measurements satisfactory and reliable in 25 adults and children with major cerebrovascular disorders. The results correlated well with the clinical condition. Dr. W. D. Heiss (Vienna, Austria) reported a good correlation among serial rCBF measurements after intracarotid and intravenous injection of 133Xe using Obrist's program. Regionality appeared better defined
'Chief Cerebrovascular Research, Houston VA Medical Center, Director, Baylor Center for Cerebrovascular Research, Department of Neurology, Baylor College of Medicine, Houston, TX 77211. 2 Professor, Department of Neurology, New York University Medical Center, 550 First Avenue, New York, NY 10016. 'President, Austrian Society of Neurology, Dean and Chairman, Department of Neurology and Psychiatry, Graz, Austria. 'Assistant Professor, Psychiatrisch-Neurologischen Klinik der Universitat Graz, Auenbruggerplatz 22, A-8036, Graz, Austria. 'Professor, Institute of Neurology, National Hospital, Queen Square, London WC1, N3BG United Kingdom. "Professor, Department of Clinical Neurophysiology, University Hospital of Lund, S221-85, Lund, Sweden. 'Professor and Director, Stroke Center, Department of Neurology, University of Pennsylvania, Philadelphia, PA.
113
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by the intracarotid method when compared with the intravenous method. Dr. T. Jones (London, England) reported results of measurement of cerebral oxygen utilization by positron emission tomography (PET) and cerebral blood flow measured by 133Xe in 16 patients with cerebrovascular insufficiency (TIAs and RINDs) before and after superficial temporal to middle cerebral artery anastomosis (STA-MCA by-pass). The group as a whole showed consistently reduced regional blood flow and low normal or reduced regional oxygen extraction in the ischemic areas. The best candidates for surgery appeared to be those with low flow but relatively well preserved oxygen extraction. Dr. M. ReiVich (Philadelphia, PA) showed illustrations of local increases of cerebral glucose uptake measured by PET scanning following regional somatosensory stimulation by stroking of the hand with a brush after the intravenous injection of 18F labelled fluorodeoxyglucose. The opposite hand area of the motor and sensory cortex (both frontal and parietal) showed increased deoxyglucose uptake in the order of 15-20%. Visual stimulation in one homonymous visual field produced increased deoxyglucose utilization in the opposite visual cortex (Areas 17, 18 and 19). Meaningful auditory stimuli, presented as a taped recording of a story presented to either the left or right ear, produced an increase in glucose metabolism maximal in the right temporal cortex no matter which ear was stimulated although some increase of metabolism in the left temporal region also resulted. In the discussion, mention was made of a chronic schizophrenic studied by Reivich, in which there was a decrease of CMR glucose in both frontal regions. In general, in normal subjects, gray matter glucose consumption is about 4 times that of white matter. Because of the relatively long half-life of 18F labelled deoxyglucose 2 serial studies cannot be done on the same day. Dr. D. A. Stump (Houston, TX) showed there were no significant changes in rCBF during white noise stimulation to either or both ears. Single words articulated by human voice on tape produced increases in rCBF in the posterior temporal regions which were more marked in the left hemisphere of right-handed individuals. In the discussion, Dr. D. H. Ingvar (Lund, Sweden) pointed out that these non-invasive techniques have the potential for localizing functional events in the brain and, in general, cognitive events cause greater increases of rCBF and brain work than simple, non-meaningful, sensory input. Dr. S. Hoyer (Heidelberg, W. Germany) reported on measurements of cerebral blood flow, glucose and oxygen consumption in the behavioral disorders. In general, in agitated dementias, Korsakov's dementia and psychoses associated with seizures, average CBF and CMR are increased. In productive schizophrenia, the values are within normal limits, in non-productive schizophrenia, Alzheimer's disease and multi-infarct dementia the values are reduced and correlate well with the behavioral state estimated by the rating scale
VOL 10, No 2, MARCH-APRIL 1979
of the Association for Methodology and Documentation in Psychiatry (AMP). Dr. H. R. Miiller (Basel, Switzerland) presented an ingenious Doppler flow monitoring technique for continuing analysis of flow through the superficial temporal artery from the time of surgery through a period of 10 days after surgery. Average flow rates through the STA-MCA shunt were 40-50 ml/min. The range was 10-96 ml/min with poor results characterizing those patients at the lower end of the flow spectrum. Dr. H. Einsiedel-Lechtape (Munich, W. Germany) reported extensive angiographic studies of 50 patients suffering from unilateral occlusion of the internal carotid artery in the neck, in whom, in all cases, the ipsilateral intracranial vascular tree had been well opacified by collateral circulation via the ophthalmic artery or the circle of Willis. This permitted evaluation of arterial embolic lesions distal to the complete occlusion in the neck. Thirty-four of the 50 patients had evidence of additional intracranial occlusions on the side of the carotid occlusion. Thirty-three of these 34 patients had completed stroke. In the other 16 patients, in whom there was no evidence of distal, presumably embolic, branch occlusions, only 4 had completed stroke. The other 12 patients exhibited no neurologic symptoms or, at most, minimal neurological deficit. Dr. R. Lazzari (L'Aquila, Italy) showed by neuropsychological testing that patients with transient ischemic attacks (TIAs) demonstrated measurable impairment in the Wechsler Bellevue test. Likewise, Dr. V. Rivera and F. Perez (Houston, TX) showed subtle impairments of visual and verbal memory tasks in patients with mild unilateral cerebral infarcts. Patients with right-hemispheric stroke performed less well on automated behavioral self-assessment of visual memory tasks while patients with left hemispheric stroke did less well on verbal memory tasks. Dr. J. S. Meyer (Houston, TX) reported that patients with organic dementia of all types failed to show the normal increase of rCBF measured by 133Xe inhalation of gray matter (Fg) during behavioral activation (listening to music, counting, watching) seen in age-matched, normal, elderly subjects. Both normals and demented patients showed a decline in gray matter weight and in Fg with advancing age but in Alzheimer's (AD) multi-infarct dementia (MID) the decrease of Fg is greater in demented subjects than in age matched controls or in mixtures of the 2 (AD + MID). MID can be identified by the CO2 inhalation test, the usual rCBF increase is diminished in MID but increased or exaggerated in AD since the flow values are low due to decreased cerebral metabolism. Dr. Z. Kaneko (Osaka, Japan) reported on visual and auditory hallucinations of 7 patients with vertebral basilar insufficiency studied with vertebral blood flow measurements using the Doppler technique. The hallucinations were associated with decreased vertebral arterialflow.Visual hallucinations in all 7 patients consisted of halos and change of body image. Auditory and olfactory hallucinations were present in 2. In some, attacks could be precipitated
Downloaded from http://stroke.ahajournals.org/ by guest on June 27, 2016
NINTH SALZBURG CONFERENCE/Meyer by vertebral artery compression and carotid sinus stimulation. In 2 patients hallucinations were reported during sleep onset associated with REM-like phenomena. Dr. B. Nilsson (Lund, Sweden) reported 23 patients with small, intracerebral hematomas confirmed by CT scan. Seven of the patients were conscious, without nausea or vomiting. Five of these 7 had blood free CSF. Hematomas of 2 cm or less were localized in the putamen-thalamus in 6, and in the frontal lobe in 1. Only 1 patient died, 1 had severe, persistent deficit and 5 made complete recovery or had minimal residual deficit. Dr. A. Alavi (Los Angeles, CA) discussed a large series of patients with head trauma studied by transmission tomography (XCT) and positron emission tomography (PET). The XCT is preferred in acute head injury, for detecting intracranial hematomas and diffuse cerebral swelling and for postoperative follow up. Radionuclide scans lack the specificity of XCT scans. Dr. L. Symon (London, England) described his experiments using the baboon stroke model with middle cerebral artery occlusion in which the rCBF, measured by the hydrogen clearance technique, was correlated with the production of cerebral edema assessed during life by impedance measurements and intracranial pressure measurements. Water measurements in tissue were made with kerosene bromobenzene columns of graded density. In the experiments terminal flow in the most densely ischemic area was 7.0 ± 5.4 ml/lOOg/min and in the surrounding zone 8.4 ± 6.7 ml/100 g/min. In both the most densely ischemic and the surrounding zones there was statistically significant water increase in the ischemic brain tissue at 1 Vi h. Detailed analysis suggests that significant movement of water into brain tissue occurs when flow falls below 20 ml/100g brain/min. Dr. K-A. Hossmann (Cologne, W. Germany) reported on studies of gerbils submitted to occlusion of both carotid arteries. Post ischemic treatment with 30 mg/kg pentobarbital administered 5 min after the onset of the ischemia resulted in a decrease in mortality from 70 to 45%, but if given after 30 min did not ameliorate mortality. Dr. A. Hartmann (Heidelberg, W. Germany) gave a progress report on a controlled trial of dexamethasone 1 mg/kg/body weight daily in baboons after middle cerebral artery occlusion compared to an untreated series. The mortality rate was less in the dexamethosone-treated group compared to the control group and rCBF was higher in the treated group although the clinical outcome did not seem appreciably different between groups. Dr. J. M. Caille (Bordeaux, France) reported the status of a multi-drug anti-edema treatment program in 27 patients with cerebral ischemic infarction. The drugs used were glycerol, spirolactone, methylprednisolone and ACTH. The drug effectiveness was estimated by serial CT scans. Treatment was begun within 72 h after onset and patients were assigned
115
treatment on a random basis. Clinical and CT examinations were repeated at days 1, 3, 7, 10, 15, 20, and 30. Clinical scoring and CT average density scoring (based on area of edema, density and midline shift) were carried out. Preliminary data indicate that spirolactone-treated patients showed the greatest clinical improvement followed by those treated with glycerol. Prednisolone produced the greatest reduction of edema. Interpretation of the data was complex and required more patients. However there was excellent correlation between the clinical course and the degree of cerebral edema measured by hypodensity and the surface of the ischemic area, i.e., good parallelism between clinical data and CT scanning. Dr. M. Harrison (London, England) found significant reductions of serotonin in the ischemic hemisphere of the gerbil after unilateral carotid ligation. This change was more predictable and remarkable than changes in dopamine, norepinephrine and their metabolites, MOPEG and 5HIAA. However, 5-HT changes did not necessarily relate to the neurological deficit. Dr. V. C. Hachinski (Toronto, Canada) reported on polysomnographic findings during sleep in stroke patients. It was shown that preservation of Stage II sleep is associated with good prognosis. Fifty patients with cerebral infarction and 10 with TIAs have been studied. The TIA patients were not different from controls and served as controls but 1 patient went on to have a massive left hemispheric infarct after control recordings had been completed. In this patient the most striking immediate change was the dissolution of the normal sleep architecture recorded from both sides of the brain but particularly from the right hemisphere. On the second night no REM sleep could be recorded from either hemisphere. On the infarcted side only theta and delta activity was recorded and accounted for 75% of the recording time. Sleep spindles were virtually absent. Over the uninfarcted hemisphere the duration of delta activity was unchanged and sleep spindles were present although less plentiful, briefer, and not as well formed. REM returned on the third night and by the ninth night had been restored to the prestroke level. Dr. J. W. Norris (Toronto, Canada) discussed the nature of cardiac disorders after stroke. Cardiac arrhythmias were observed more frequently {p < 0.001) in 312 stroke patients compared to 92 controls in an intensive care unit without stroke. Those with hemispheric strokes had more arrhythmias (p < 0.05) than those with brain stem lesions. Underlying cardiac disease was present in 96 of those with cardiac dysrhythmias including 54 cases with potential sources of cerebral emboli. In the remaining 59 stroke patients with arrhythmias, no relationship was evident between the arrhythmia and the acute cerebrovascular lesion. Patients with stroke had significantly elevated [p < 0.05) serum cardiac enzyme levels (5GOT, LDH, CPK and CPK MB). Plasma norepinephrine (NE), epinephrine (E), and dopamine (D) were significantly elevated in cases of
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ischemic stroke whether normotensive or hypertensive. The author concluded that cardiac arrhythmias, elevated myocardial serum enzyme levels, ECG changes of acute myocardial ischemia and elevated plasma catecholamines occur in acute cerebrovascular lesions, are inter-related, and may play a significant part in morbidity and mortality. Dr. W. Hass (New York, NY) reported that cimetidine given with aspirin therapy in patients with TIAs sharply reduced gastric side effects of aspirin in patients with recent ulcer or upper gastrointestinal bleeding. Dr. D. J. Thomas (London, England) reported that even minor changes in the viscosity of the blood altered cerebral blood flow in the opposite direction. The Framingham study had shown that otherwise healthy men and women with hemoglobin levels in the high normal range (exceeding 15 and 14g respectively) had doubled chance of developing a stroke. Dr. Thomas found significant inverse relationships between CBF as measured by the intravenous 133Xe
VOL 10, No 2, MARCH-APRIL
1979
clearance technique and hematocrit and whole blood viscosity. Following venisection carried out in the hematology clinic for blood dyscrasias with reduction of hematocrit from 0.49 to 0.426, CBF increased from 41.4 to 62.1 ml/lOOg/min. These patients often admitted to symptoms with high hematocrit including headache, lethargy and slowing of thought. Psychological tests showed significant improvement after venisection in patients treated for hematological disorders with high hematocrit. Dr. E. Ott (Graz, Austria) demonstrated increased blood viscosity in patients with recent cerebral infarction and that these acute rheological changes contributed to the reduced blood flow in stroke. Dr. G. Ladurmer (Graz, Austria) correlated CT scans with pathological observations at necropsy in 37 cases of cerebral infarction made 2.5-8 days after the CT scans. CT scanning was accurate in 83% of ischemic infarcts and 91% of hemorrhagic lesions. Contrast enhancement greatly increased the detection rate which could be due to damage to blood-brain barrier, hyperemia or neovascularization.
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Summary of Ninth International Salzburg Conference on Cerebrovascular Disease, Salzburg, Austria, September 27-30, 1978. Stroke. 1979;10:113-116 doi: 10.1161/01.STR.10.2.113 Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1979 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://stroke.ahajournals.org/content/10/2/113.citation
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MARCH-APRIL VOL. 10
1979 NO. 2
A Journal of Cerebral Circulation Summary of Ninth International Salzburg Conference on Cerebrovascular Disease, Salzburg, Austria, September 27-30, 1978 PREPARED BY JOHN STIRLING MEYER, M.D.1 AND WILLIAM HASS, M.D.2
Chairman of the Conference: HELMUT LECHNER, M.D. 3 Organizing Secretaries: ERWIN O T T , M.D.* AND A. ARANIBAR, M.D. 4 Advisory
Board: J O H N MARSHALL, M.D., 5 D. H. INGVAR, 6 MARTIN REIVICH, 7 AND J. S. MEYER, M.D. 1
DR. W. D. OBRIST (Philadelphia, PA) discussed problems of unstable compartmental size in grossly pathological brain tissues during 133Xe inhalation measurements of rCBF referred to as "slippage." He offered 2 solutions to this problem in addition to the widely used slope indices as an index of blood flow. These are 1) computation of mean flow for all tissue compartments over a 10 min interval, mathematically equivalent to the height-over area method applied to carotid injection method, 2) holding the size of F, and F2 constant between studies. Both the stability and reliability of these 2 approaches were satisfactory. Dr. F. Sakai (Houston, TX) presented validation data of the 133Xe inhalation method for measuring rCBF from the brain stem and cerebellar areas (BSC) in both baboons and humans. The probes have extra long collimators and are held in the suboccipital region over the cerebellum by means of a helmet. Isocount geometry, defined by moving a point source of 133Xe through the baboon brain in situ, confirmed satisfactory counts from the brain stem. Inhalation BSC values in the baboon were in good agreement with arterial injection values. BSC values decrease
with sleep, sedation and anesthesia and increase with activation and epileptic seizures. In human volunteers with tracheostomy and laryngectomy BSC values measured without the possibility of nasopharyngeal contamination were in good agreement with those measured via a face mask. Dr. J-C. Baron (Boston, MA.) compared 133Xe inhalation measures of rCBF during right hand work (30 squeezes of a rubber bulb per min). Seven of 11 volunteers showed rCBF increases in the left sensorimotor area. The mean increase was 17% and the localization was statistically significant. In 4 of these 7 subjects compressed spectral analysis of the EEG showed diffuse, bilateral changes in EEG activity which became more uniform i.e. monorhythmic with increased power. Dr. A. Fenske (Mainz, W. Germany) reported 133Xe inhalation measurements in patients with arteriovenous malformations (AVM), hydrocephalus and focal ischemic lesions. In AVM rCBF was increased, in hydrocephalus cerebral autoregulation was impaired and in the focal ischemic lesions rCBF was reduced in a manner correlating with the clinical and arteriographic findings. They reported 133Xe inhalation rCBF measurement as a clinically useful method, a view which was confirmed in the discussion led by Dr. L. Symon (London, England). Dr. A. S. Brown (Edinburg, Scotland) reported rCBF measurements after 133Xe inhalation or intravenous injections of the isotope. They have found the measurements satisfactory and reliable in 25 adults and children with major cerebrovascular disorders. The results correlated well with the clinical condition. Dr. W. D. Heiss (Vienna, Austria) reported a good correlation among serial rCBF measurements after intracarotid and intravenous injection of 133Xe using Obrist's program. Regionality appeared better defined
'Chief Cerebrovascular Research, Houston VA Medical Center, Director, Baylor Center for Cerebrovascular Research, Department of Neurology, Baylor College of Medicine, Houston, TX 77211. 2 Professor, Department of Neurology, New York University Medical Center, 550 First Avenue, New York, NY 10016. 'President, Austrian Society of Neurology, Dean and Chairman, Department of Neurology and Psychiatry, Graz, Austria. 'Assistant Professor, Psychiatrisch-Neurologischen Klinik der Universitat Graz, Auenbruggerplatz 22, A-8036, Graz, Austria. 'Professor, Institute of Neurology, National Hospital, Queen Square, London WC1, N3BG United Kingdom. "Professor, Department of Clinical Neurophysiology, University Hospital of Lund, S221-85, Lund, Sweden. 'Professor and Director, Stroke Center, Department of Neurology, University of Pennsylvania, Philadelphia, PA.
113
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by the intracarotid method when compared with the intravenous method. Dr. T. Jones (London, England) reported results of measurement of cerebral oxygen utilization by positron emission tomography (PET) and cerebral blood flow measured by 133Xe in 16 patients with cerebrovascular insufficiency (TIAs and RINDs) before and after superficial temporal to middle cerebral artery anastomosis (STA-MCA by-pass). The group as a whole showed consistently reduced regional blood flow and low normal or reduced regional oxygen extraction in the ischemic areas. The best candidates for surgery appeared to be those with low flow but relatively well preserved oxygen extraction. Dr. M. ReiVich (Philadelphia, PA) showed illustrations of local increases of cerebral glucose uptake measured by PET scanning following regional somatosensory stimulation by stroking of the hand with a brush after the intravenous injection of 18F labelled fluorodeoxyglucose. The opposite hand area of the motor and sensory cortex (both frontal and parietal) showed increased deoxyglucose uptake in the order of 15-20%. Visual stimulation in one homonymous visual field produced increased deoxyglucose utilization in the opposite visual cortex (Areas 17, 18 and 19). Meaningful auditory stimuli, presented as a taped recording of a story presented to either the left or right ear, produced an increase in glucose metabolism maximal in the right temporal cortex no matter which ear was stimulated although some increase of metabolism in the left temporal region also resulted. In the discussion, mention was made of a chronic schizophrenic studied by Reivich, in which there was a decrease of CMR glucose in both frontal regions. In general, in normal subjects, gray matter glucose consumption is about 4 times that of white matter. Because of the relatively long half-life of 18F labelled deoxyglucose 2 serial studies cannot be done on the same day. Dr. D. A. Stump (Houston, TX) showed there were no significant changes in rCBF during white noise stimulation to either or both ears. Single words articulated by human voice on tape produced increases in rCBF in the posterior temporal regions which were more marked in the left hemisphere of right-handed individuals. In the discussion, Dr. D. H. Ingvar (Lund, Sweden) pointed out that these non-invasive techniques have the potential for localizing functional events in the brain and, in general, cognitive events cause greater increases of rCBF and brain work than simple, non-meaningful, sensory input. Dr. S. Hoyer (Heidelberg, W. Germany) reported on measurements of cerebral blood flow, glucose and oxygen consumption in the behavioral disorders. In general, in agitated dementias, Korsakov's dementia and psychoses associated with seizures, average CBF and CMR are increased. In productive schizophrenia, the values are within normal limits, in non-productive schizophrenia, Alzheimer's disease and multi-infarct dementia the values are reduced and correlate well with the behavioral state estimated by the rating scale
VOL 10, No 2, MARCH-APRIL 1979
of the Association for Methodology and Documentation in Psychiatry (AMP). Dr. H. R. Miiller (Basel, Switzerland) presented an ingenious Doppler flow monitoring technique for continuing analysis of flow through the superficial temporal artery from the time of surgery through a period of 10 days after surgery. Average flow rates through the STA-MCA shunt were 40-50 ml/min. The range was 10-96 ml/min with poor results characterizing those patients at the lower end of the flow spectrum. Dr. H. Einsiedel-Lechtape (Munich, W. Germany) reported extensive angiographic studies of 50 patients suffering from unilateral occlusion of the internal carotid artery in the neck, in whom, in all cases, the ipsilateral intracranial vascular tree had been well opacified by collateral circulation via the ophthalmic artery or the circle of Willis. This permitted evaluation of arterial embolic lesions distal to the complete occlusion in the neck. Thirty-four of the 50 patients had evidence of additional intracranial occlusions on the side of the carotid occlusion. Thirty-three of these 34 patients had completed stroke. In the other 16 patients, in whom there was no evidence of distal, presumably embolic, branch occlusions, only 4 had completed stroke. The other 12 patients exhibited no neurologic symptoms or, at most, minimal neurological deficit. Dr. R. Lazzari (L'Aquila, Italy) showed by neuropsychological testing that patients with transient ischemic attacks (TIAs) demonstrated measurable impairment in the Wechsler Bellevue test. Likewise, Dr. V. Rivera and F. Perez (Houston, TX) showed subtle impairments of visual and verbal memory tasks in patients with mild unilateral cerebral infarcts. Patients with right-hemispheric stroke performed less well on automated behavioral self-assessment of visual memory tasks while patients with left hemispheric stroke did less well on verbal memory tasks. Dr. J. S. Meyer (Houston, TX) reported that patients with organic dementia of all types failed to show the normal increase of rCBF measured by 133Xe inhalation of gray matter (Fg) during behavioral activation (listening to music, counting, watching) seen in age-matched, normal, elderly subjects. Both normals and demented patients showed a decline in gray matter weight and in Fg with advancing age but in Alzheimer's (AD) multi-infarct dementia (MID) the decrease of Fg is greater in demented subjects than in age matched controls or in mixtures of the 2 (AD + MID). MID can be identified by the CO2 inhalation test, the usual rCBF increase is diminished in MID but increased or exaggerated in AD since the flow values are low due to decreased cerebral metabolism. Dr. Z. Kaneko (Osaka, Japan) reported on visual and auditory hallucinations of 7 patients with vertebral basilar insufficiency studied with vertebral blood flow measurements using the Doppler technique. The hallucinations were associated with decreased vertebral arterialflow.Visual hallucinations in all 7 patients consisted of halos and change of body image. Auditory and olfactory hallucinations were present in 2. In some, attacks could be precipitated
Downloaded from http://stroke.ahajournals.org/ by guest on June 27, 2016
NINTH SALZBURG CONFERENCE/Meyer by vertebral artery compression and carotid sinus stimulation. In 2 patients hallucinations were reported during sleep onset associated with REM-like phenomena. Dr. B. Nilsson (Lund, Sweden) reported 23 patients with small, intracerebral hematomas confirmed by CT scan. Seven of the patients were conscious, without nausea or vomiting. Five of these 7 had blood free CSF. Hematomas of 2 cm or less were localized in the putamen-thalamus in 6, and in the frontal lobe in 1. Only 1 patient died, 1 had severe, persistent deficit and 5 made complete recovery or had minimal residual deficit. Dr. A. Alavi (Los Angeles, CA) discussed a large series of patients with head trauma studied by transmission tomography (XCT) and positron emission tomography (PET). The XCT is preferred in acute head injury, for detecting intracranial hematomas and diffuse cerebral swelling and for postoperative follow up. Radionuclide scans lack the specificity of XCT scans. Dr. L. Symon (London, England) described his experiments using the baboon stroke model with middle cerebral artery occlusion in which the rCBF, measured by the hydrogen clearance technique, was correlated with the production of cerebral edema assessed during life by impedance measurements and intracranial pressure measurements. Water measurements in tissue were made with kerosene bromobenzene columns of graded density. In the experiments terminal flow in the most densely ischemic area was 7.0 ± 5.4 ml/lOOg/min and in the surrounding zone 8.4 ± 6.7 ml/100 g/min. In both the most densely ischemic and the surrounding zones there was statistically significant water increase in the ischemic brain tissue at 1 Vi h. Detailed analysis suggests that significant movement of water into brain tissue occurs when flow falls below 20 ml/100g brain/min. Dr. K-A. Hossmann (Cologne, W. Germany) reported on studies of gerbils submitted to occlusion of both carotid arteries. Post ischemic treatment with 30 mg/kg pentobarbital administered 5 min after the onset of the ischemia resulted in a decrease in mortality from 70 to 45%, but if given after 30 min did not ameliorate mortality. Dr. A. Hartmann (Heidelberg, W. Germany) gave a progress report on a controlled trial of dexamethasone 1 mg/kg/body weight daily in baboons after middle cerebral artery occlusion compared to an untreated series. The mortality rate was less in the dexamethosone-treated group compared to the control group and rCBF was higher in the treated group although the clinical outcome did not seem appreciably different between groups. Dr. J. M. Caille (Bordeaux, France) reported the status of a multi-drug anti-edema treatment program in 27 patients with cerebral ischemic infarction. The drugs used were glycerol, spirolactone, methylprednisolone and ACTH. The drug effectiveness was estimated by serial CT scans. Treatment was begun within 72 h after onset and patients were assigned
115
treatment on a random basis. Clinical and CT examinations were repeated at days 1, 3, 7, 10, 15, 20, and 30. Clinical scoring and CT average density scoring (based on area of edema, density and midline shift) were carried out. Preliminary data indicate that spirolactone-treated patients showed the greatest clinical improvement followed by those treated with glycerol. Prednisolone produced the greatest reduction of edema. Interpretation of the data was complex and required more patients. However there was excellent correlation between the clinical course and the degree of cerebral edema measured by hypodensity and the surface of the ischemic area, i.e., good parallelism between clinical data and CT scanning. Dr. M. Harrison (London, England) found significant reductions of serotonin in the ischemic hemisphere of the gerbil after unilateral carotid ligation. This change was more predictable and remarkable than changes in dopamine, norepinephrine and their metabolites, MOPEG and 5HIAA. However, 5-HT changes did not necessarily relate to the neurological deficit. Dr. V. C. Hachinski (Toronto, Canada) reported on polysomnographic findings during sleep in stroke patients. It was shown that preservation of Stage II sleep is associated with good prognosis. Fifty patients with cerebral infarction and 10 with TIAs have been studied. The TIA patients were not different from controls and served as controls but 1 patient went on to have a massive left hemispheric infarct after control recordings had been completed. In this patient the most striking immediate change was the dissolution of the normal sleep architecture recorded from both sides of the brain but particularly from the right hemisphere. On the second night no REM sleep could be recorded from either hemisphere. On the infarcted side only theta and delta activity was recorded and accounted for 75% of the recording time. Sleep spindles were virtually absent. Over the uninfarcted hemisphere the duration of delta activity was unchanged and sleep spindles were present although less plentiful, briefer, and not as well formed. REM returned on the third night and by the ninth night had been restored to the prestroke level. Dr. J. W. Norris (Toronto, Canada) discussed the nature of cardiac disorders after stroke. Cardiac arrhythmias were observed more frequently {p < 0.001) in 312 stroke patients compared to 92 controls in an intensive care unit without stroke. Those with hemispheric strokes had more arrhythmias (p < 0.05) than those with brain stem lesions. Underlying cardiac disease was present in 96 of those with cardiac dysrhythmias including 54 cases with potential sources of cerebral emboli. In the remaining 59 stroke patients with arrhythmias, no relationship was evident between the arrhythmia and the acute cerebrovascular lesion. Patients with stroke had significantly elevated [p < 0.05) serum cardiac enzyme levels (5GOT, LDH, CPK and CPK MB). Plasma norepinephrine (NE), epinephrine (E), and dopamine (D) were significantly elevated in cases of
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ischemic stroke whether normotensive or hypertensive. The author concluded that cardiac arrhythmias, elevated myocardial serum enzyme levels, ECG changes of acute myocardial ischemia and elevated plasma catecholamines occur in acute cerebrovascular lesions, are inter-related, and may play a significant part in morbidity and mortality. Dr. W. Hass (New York, NY) reported that cimetidine given with aspirin therapy in patients with TIAs sharply reduced gastric side effects of aspirin in patients with recent ulcer or upper gastrointestinal bleeding. Dr. D. J. Thomas (London, England) reported that even minor changes in the viscosity of the blood altered cerebral blood flow in the opposite direction. The Framingham study had shown that otherwise healthy men and women with hemoglobin levels in the high normal range (exceeding 15 and 14g respectively) had doubled chance of developing a stroke. Dr. Thomas found significant inverse relationships between CBF as measured by the intravenous 133Xe
VOL 10, No 2, MARCH-APRIL
1979
clearance technique and hematocrit and whole blood viscosity. Following venisection carried out in the hematology clinic for blood dyscrasias with reduction of hematocrit from 0.49 to 0.426, CBF increased from 41.4 to 62.1 ml/lOOg/min. These patients often admitted to symptoms with high hematocrit including headache, lethargy and slowing of thought. Psychological tests showed significant improvement after venisection in patients treated for hematological disorders with high hematocrit. Dr. E. Ott (Graz, Austria) demonstrated increased blood viscosity in patients with recent cerebral infarction and that these acute rheological changes contributed to the reduced blood flow in stroke. Dr. G. Ladurmer (Graz, Austria) correlated CT scans with pathological observations at necropsy in 37 cases of cerebral infarction made 2.5-8 days after the CT scans. CT scanning was accurate in 83% of ischemic infarcts and 91% of hemorrhagic lesions. Contrast enhancement greatly increased the detection rate which could be due to damage to blood-brain barrier, hyperemia or neovascularization.
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Summary of Ninth International Salzburg Conference on Cerebrovascular Disease, Salzburg, Austria, September 27-30, 1978. Stroke. 1979;10:113-116 doi: 10.1161/01.STR.10.2.113 Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1979 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628
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