Large supratentorial infarctions play an important role in early mortality and severe disability from stroke. However, data concerning these types of infarction are scarce. Using data from the Lausanne Stroke Registry, we studied patients with a CT-proven infarction of the middle cerebral artery (MCA) territory that covered at least two of three MCA subterritories (deep, superficial anterior [superior] and posterior [inferior] territory). We compared these patients with patients presenting more limited infarction in the MCA territory. Our study group of large MCA (laMCA) infarction contained 208 patients, corresponding to 7.6% of all ischemic infarctions in the Lausanne Stroke Registry. Seventy-two patients had complete infarction in the whole MCA territory (coMCA). Internal carotid artery (ICA) occlusion (41%) and ICA dissection (12%) were more common than in limited superficial MCA (lsMCA) infarct and anterior circulation infarct (p < 0.001). Among the patients without ICA occlusion, atrial fibrillation (33%; p < 0.002) and cardiogenic embolism in general (54%; p < 0.001) were more frequent in laMCA than in lsMCA infarct. Severe neurologic deficit (hemiplegia and hemisensory loss in the face, arm and leg, hemianopia, global aphasia, reduced consciousness) was more common than in other types of infarct. A combination of these symptoms had a positive predictive value for laMCA infarction of 0.73 (sensitivity for left side laMCA infarcts, 0.56). Mortality (17%) and severe disability (50%) were higher with laMCA than for other infarcts (p < 0.001). Sixteen of the 35 deaths could be attributed to brain edema. Reduced consciousness, hemianopia, and coMCA infarction were independent predictors of death or severe disability; for death only, coma was an independent predictor. Patients who died because of brain edema were younger than patients whose death was due to other causes (mean age, 57 versus 73 years; p < 0.001); they also died sooner (mean time of death after stroke, 5 versus 37 days; p < 0.001). Furthermore, patients who developed coma on the day of admission were more likely to die because of brain death (p < 0.001). Large middle cerebral artery infarction is associated with cardiogenic embolism, ICA occlusion, and ICA dissection. It is a major predictor of death and severe disability, although a lower frequency of malignant brain infarction was found than previously reported.

The prognosis of BAS greater than 50% or BAO is diverse and certain clinical characteristics seem to predict a lower risk of poor outcome. Their presence may help to decide the most suitable therapy.

The present pilot study evaluated the effect of botulinum toxin A on primarily non-dystonic tremors using accelerometry in a single-blind, placebo-controlled design. Resting, postural, intention, or head tremor were assessed before and approximately 1 month after intramuscular saline and botulinum toxin A (25–50 U) respectively. Half of the patients showed > 30% placebo effect. Tremor in 10 of 17 patients (60%) studied improved further after botulinum toxin A (range 30–95%), exceeding the placebo effect by > 30%. Nine patients demonstrated clinically significant focal weakness in the extensor muscles after botulinum toxin A which interfered with fine movements. Patients were subdivided into PD-like and ET-like tremor(s). Both groups experienced large placebo effects for resting tremor, with little or no further improvement after botulinum toxin A. The improvement in postural tremor after botulinum toxin A, of 40% in the PD-like and 57% in the ET-like groups, however, was approximately twice that of placebo. In conclusion, botulinum toxin A exerts a modest tremorlytic effect, however the dose, and its distribution over the sites injected, need to be optimised to minimise focal weakness.

Two top class cyclists, 23 and 24, complained of intermittent acute claudica tion at maximal effort due to a stenotic endofibrosis of the external iliac artery. Symptoms disappeared after endarterectomy and venous patch arterioplasty. This pathology is probably the consequence of repeated and long continued haemodynamic stress acting on the external iliac artery which would be respon sible, in certain subjects, for an exaggerated bend due to the sitting position of the competitor. High cardiac output and adaptive hypertension must also be of importance.

Conclusions-Clinical, procedural and angiographic variables increase the risk for early closure and restenosis after endoluminal stenting. The prediction models described above need to be validated prospectively. (Br HeartJ7 1995;74:592-597)