PFO and ASA are significantly associated with ischemic stroke in patients younger than 55 years. Further studies are needed to establish whether an association exists between PFO and ischemic stroke in those older than 55.

Background and Purpose-The modified Rankin Scale (mRS) is widely used to assess global outcome after stroke. The aim of the study was to examine rater variability in assessing functional outcomes using the conventional mRS, and to investigate whether use of a structured interview (mRS-SI) reduced this variability. Methods-Inter-rater agreement was studied among raters from 3 stroke centers. Fifteen raters were recruited who were experienced in stroke care but came from a variety of professional backgrounds. Patients at least 6 months after stroke were first assessed using conventional mRS definitions. After completion of initial mRS assessments, raters underwent training in the use of a structured interview, and patients were re-assessed. In a separate component of the study, intrarater variability was studied using 2 raters who performed repeat assessments using the mRS and the mRS-SI. The design of the latter part of the study also allowed investigation of possible improvement in rater agreement caused by repetition of the assessments. Agreement was measured using the statistic (unweighted and weighted using quadratic weights). Results-Inter-rater reliability: Pairs of raters assessed a total of 113 patients on the mRS and mRS-SI. For the mRS, overall agreement between raters was 43% (ϭ0.25, w ϭ0.71), and for the structured interview overall agreement was 81% (ϭ0.74, w ϭ0.91). Agreement between raters was significantly greater on the mRS-SI than the mRS (PϽ0.001).Intrarater reliability: Repeatability of both the mRS and mRS-SI was excellent (ϭ0.81, w Ն0.94). Conclusions-Although individual raters are consistent in their use of the mRS, inter-rater variability is nonetheless substantial. Rater variability on the mRS is thus particularly problematic for studies involving multiple raters. There was no evidence that improvement in inter-rater agreement occurred simply with repetition of the assessment. Use of a structured interview improves agreement between raters in the assessment of global outcome after stroke.

The likelihood of rupture of unruptured intracranial aneurysms that were less than 10 mm in diameter was exceedingly low among patients in group 1 and was substantially higher among those in group 2. The risk of morbidity and mortality related to surgery greatly exceeded the 7.5-year risk of rupture among patients in group 1 with unruptured intracranial aneurysms smaller than 10 mm in diameter.

Background and Purpose-The modified Rankin Scale is widely used to assess changes in activity and lifestyle after stroke, but it has been criticized for its subjectivity. The purpose of the present study was to compare conventional assessment on the modified Rankin Scale with assessment through a structured interview. Methods-Sixty-three patients with stroke 6 to 24 months previously were interviewed and graded independently on the modified Rankin Scale by 2 observers. These observers then underwent training in use of a structured interview for the scale that covered 5 areas of everyday function. Eight weeks after the first assessment, the same observers reassessed 58 of these patients using the structured interview. Results-Interrater reliability was measured with the statistic (weighted with quadratic weights). For the scale applied conventionally, overall agreement between the 2 raters was 57% ( w ϭ0.78); 1 rater assigned significantly lower grades than the other (Pϭ0.048). On the structured interview, the overall agreement between raters was 78% ( w ϭ0.93), and there was no overall difference between raters in grades assigned (Pϭ0.17). Rankin grades from the conventional assessment and the structured interview were highly correlated, but there was significantly less disagreement between raters when the structured interview was used (Pϭ0.004). Conclusions-Variability and bias between raters in assigning patients to Rankin grades may be reduced by use of a structured interview. Use of a structured interview for the scale could potentially improve the quality of results from clinical studies in stroke.

Patients take less medication than prescribed in many disease areas but evidence for suboptimal therapy adherence in Parkinson's disease (PD) is limited. A single-center observational study of antiparkinsonian medication was undertaken using electronic monitoring (MEMS; Aardex, Zug, Switzerland) over 3 months. Of 68 patients approached, 6 declined and 8 dropped out, leaving 54 patients (taking 117 preparations) with available data. Poorer compliance was associated significantly with younger age, with taking more antiparkinsonian tablets per day, with higher depression scores, and with poorer quality of life. Of the 54 evaluable patients, 11 (20%) had average total compliance of under 80% (underusers) and 43 (80%) had average total compliance of over 80% (satisfactory adherence). Underusers had median total compliance of 65% (interquartile range, 37-74) versus 98% (interquartile range, 93-102) in the satisfactory adherence group. Timing compliance (number of doses taken in the correct time interval) was poor in both underusers (median, 11%; interquartile range, 2-20) and those with satisfactory adherence (median, 25%; interquartile range, 11-73). In conclusion, poorer compliance is associated with younger age, depression, and more tablets per day, and one-fifth of PD patients underuse medication. Consideration of drug therapy adherence has implications in the management of PD.

SUMMARY Basal ganglia calcification was found as an incidental finding in 42 out of 7000 patients who underwent computed tomography. The calcification showed on plain skull radiography when the maximum density on computed tomography exceeded 100 Hounsfield units. The 26 patients with basal ganglia calcification detected on computed tomography who were available for follow-up, were investigated with matched controls. No clinical features of basal ganglia calcification were noted. Twenty-four patients had no significant metabolic abnormality and two patients had parathyroid disorder identified.Basal ganglia calcification identified radiographically has been associated with any one of 24 conditionsl 2 (table) with treatable parathyroid disease being the most common of these associations.3 Computed tomography (CT) has identified basal ganglia calcification more sensitively than plain skull radiographs,2 4-9 but the incidence of disease including parathyroid disorder in the CT group has been less.2 4-7 This study was carried out to correlate radiographically basal ganglia calcification on CT with that on plain skull radiographs; to attempt to define any systemic metabolic mechanism of basal ganglia calcification formation; and to investigate the possibility of early detection of treatable parathyroid disease.

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Background and Purpose-Polymorphism of the apolipoprotein E gene (APOE) may influence outcome after traumatic brain injury and intracerebral hemorrhage, with the ⑀4 allele being associated with poorer prognosis. We investigated APOE allele distribution in acute stroke and the effect of the ⑀4 allele on outcome. Methods-APOE genotypes were determined in 714 stroke patients: 640 ischemic stroke and 74 intracerebral hemorrhage patients. The survival effect of the ⑀4 allele was assessed with the use of a stratified log-rank test. A Cox proportional hazards regression model was used to estimate the independent effect of ⑀4 dose (0, 1, or 2) on survival, and logistic regression was used to determine the effect on 3-month outcome (good if alive at home, poor if in care or dead). Results-Allele distribution matched the general population with no difference between the ischemic and hemorrhagic groups. Survival in the entire cohort was unaffected by ⑀4 dose. Improved survival with increasing ⑀4 dose was found in the ischemic group (relative hazardϭ0.76 per allele; Pϭ0.04). If transient ischemic attacks were excluded, a trend for improved survival persisted (Pϭ0.06). With intracerebral hemorrhage, a trend was seen toward reduced survival with ⑀4 (Pϭ0.07, log-rank test). Three-month outcome in the ischemic group was unaffected by ⑀4 dose, and a trend toward poorer outcome with ⑀4 was seen for intracerebral hemorrhage (Pϭ0.10). Conclusions-The APOE ⑀4 allele had divergent effects on survival and outcome in ischemic and hemorrhagic strokes in this population. The reported adverse effect on patients with intracerebral hemorrhage was supported. The favorable survival effect on ischemic stroke patients requires further study. (Stroke. 1998;29:1882-1887.)