Background: We aimed to validate three widely used scales in stroke research in a multiethnic Brazilian population. Methods: The National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index (BI) were translated, culturally adapted and applied by two independent investigators. The mRS was applied with or without a previously validated structured interview. Interobserver agreement (kappa statistics) and intraclass correlation coefficients were calculated. Results: 84 patients underwent mRS (56 with and 28 without a structured interview), 57 BI and 62 NIHSS scoring. Intraclass correlation coefficient was 0.902 for NIHSS and 0.967 for BI. For BI, interobserver agreement was good (kappa = 0.70). For mRS, the structured interview improved interobserver agreement (kappa = 0.34 without a structured interview; 0.75 with a structured interview). Conclusion: The NIHSS, BI and mRS show good validity when translated and culturally adapted. Using a structured interview for the mRS improves interobserver concordance rates.

Objective: To investigate the causes of fever in subarachnoid hemorrhage (SAH) and examine its relationship to outcome. Background: Fever adversely affects outcome in stroke. Patients with SAH are at risk for cerebral ischemia due to vasospasm (VSP). In these patients, fever may be both caused by, and potentiate, VSP-mediated brain injury. Methods: The authors prospectively studied patients admitted to a neurologic intensive care unit with nontraumatic SAH, documenting Hunt–Hess grade, Fisher group, Glasgow Coma Score, bacterial culture data, daily transcranial Doppler mean velocities, and maximum daily temperatures. Patients were classified as febrile (temperature above 38.3 °C for at least 2 consecutive days) or afebrile (no fever or isolated episodes of temperature above 38.3 °C). VSP was verified by either transcranial Doppler or angiographic criteria. Rankin scale scores on discharge were dichotomized into good (0 to 2) or poor (3 to 6) outcomes. Results: Ninety-two consecutive patients were studied. Thirty-eight patients were classified as febrile. No source for infection was found in 10 of 38 (26%) patients. In a multivariate analysis, three variables independently predicted fever occurrence: ventriculostomy (OR, 8.5 [CI, 2.4 to 29.7]), symptomatic VSP (OR, 5.0 [CI, 1.03 to 24.5]), and older age (OR, 1.75 per 10 years [CI, 1.02 to 3.0]). Poor outcome was related to fever (OR, 1.4 per each day febrile [CI, 1.1 to 1.88]), older age (OR, 1.64 per 10 years [CI, 1.04 to 2.58]), and intubation (OR, 21.8 [CI, 5.6 to 84.5]). Conclusion: Fever in SAH is associated with vasospasm and poor outcome independently of hemorrhage severity or presence of infection.

Sporadic cerebral amyloid angiopathy (CAA) is the most common cause of symptomatic lobar intracerebral hemorrhage (ICH) in elderly people and results from cerebrovascular amyloid-β deposition, preferentially involving cortical and leptomeningeal small vessels.^1-4 Frequently, CAA is present in the brain of patients with Alzheimer disease, but it can also have an independent contribution in age-related cognitive decline.^5,6

Background: High blood pressure, although the main modifiable risk factor for stroke, may have a beneficial effect in maintaining brain perfusion after acute ischemia. The authors assessed the effects of blood pressure variation in the first 24 hours of stroke onset. Methods: The authors prospectively studied consecutive patients admitted in the first 24 hours after stroke onset. Patients were classified according to the NIH Stroke Scale (NIHSS) and Oxfordshire Stroke Classification Scale (OSCS). Stroke etiology was defined according to Trial of ORG 10172 in Acute Stroke Treatment classification. After 3 months, outcome was assessed using Rankin and Barthel scales, with poor outcome defined as Rankin score > 2 or Barthel score < 70. Results: A total of 115 patients were admitted between January 2001 and October 2002. Median NIHSS was 4.5; main stroke etiology was cardioembolism (30%). After 3 months, 44 (39%) patients had a poor outcome. Predictors of poor outcome in univariable analyses (p < 0.05) were as follows: total anterior circulation classification on OSCS, nonlacunar stroke etiology, older age, higher NIHSS score, lack of antiplatelet use, higher body temperature, lower diastolic blood pressure on admission, and a larger degree of systolic blood pressure reduction. In the multivariable analysis, remaining predictors of poor outcome included the following: NIHSS score (OR = 1.55 per 1 point increase; 95% CI = 1.28 to 1.87; p < 0.001) and degree of systolic blood pressure reduction in the first 24 hours (OR = 1.89 per 10% decrease; 95% CI = 1.02 to 3.52; p = 0.047). Conclusion: Blood pressure reduction in the first 24 hours of stroke onset is independently associated with poor outcome after 3 months.

Background and Purpose —Small infarcts in the territory of penetrator arteries were described as causing a number of distinct clinical syndromes. The vascular pathophysiology underlying such infarcts is difficult to ascertain without careful pathological study. However, the occurrence of multiple, small infarcts, linked closely in time but dispersed widely in the brain, raises the possibility of an embolic mechanism. The current study determines the frequency and clinical characteristics of patients with well-defined lacunar syndromes and the diffusion-weighted imaging (DWI) evidence of multiple acute lesions. Methods —Sixty-two consecutive patients who presented to the emergency room with a clinically well-defined lacunar syndrome were studied by DWI within the first 3 days of admission. Results —DWI showed multiple regions of increased signal intensity in 10 patients (16%). A hemispheric or brain stem lesion in a penetrator territory that accounted for the clinical syndrome (“index lesion”) was found in all. DWI-hyperintense lesions other than the index lesion (“subsidiary infarctions”) were punctate and lay within leptomeningeal artery territories in the majority. As opposed to patients with a single lacunar infarction, patients with a subsidiary infarction more frequently ( P <0.05) harbored an identifiable cause of stroke. Conclusions —Almost 1 of every 6 patients presenting with a classic lacunar syndrome has multiple infarctions demonstrated on DWI. This DWI finding usually indicates an identifiable cause of stroke and therefore may influence clinical decisions regarding the extent of etiologic investigations and treatment for secondary prevention.