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Rivaroxaban was not superior to aspirin with regard to the prevention of recurrent stroke after an initial embolic stroke of undetermined source and was associated with a higher risk of bleeding. (Funded by Bayer and Janssen Research and Development; NAVIGATE ESUS ClinicalTrials.gov number, NCT02313909 .).

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.

eversible cerebral vasoconstriction syndrome (RCVS) is characterized by recurrent thunderclap headaches, radiographic evidence of vasoconstriction with subsequent resolution, and a normal or near-normal cerebrospinal fluid profile. More than one-half of cases of RCVS occur postpartum or in association with exposure to serotonergic or adrenergic medications. 1 The syndrome is considered relatively rare, but its exact incidence is unknown. Because cerebral angiography-a requisite for diagnosis-is not always performed in symptomatic patients with recurrent thunderclap headache and/or transient neurological symptoms, the disorder is probably underrecognized. A high index of suspicion is necessary to diagnose RCVS, especially on initial presentation. The initial presentation of RCVS is not limited to recurrent thunderclap headache but can also include encephalopathy and seizures. Brain imaging can show cortical subarachnoid hemorrhage, intraparenchymal hemorrhage, or vasogenic edema. 1-6 Reversible cerebral vasoconstriction syndrome is traditionally considered to have a monophasic and benign clinical course. However, the clinical course after the establishment of the diagnosis has not been thoroughly studied. Previous reports detail transient ischemic attacks and cerebral infarction occurring as late as 2 weeks after the diagnosis of RCVS, some-IMPORTANCE Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by recurrent thunderclap headaches and evidence of vasoconstriction with subsequent resolution. The clinical course of RCVS is traditionally considered monophasic and benign. However, recurrent episodes of focal neurological symptoms have been described after initial presentation. OBJECTIVE To define the frequency, timing, and consequences of clinical worsening in patients with diagnosis of RCVS. DESIGN, SETTING, AND PARTICIPANTS Retrospective observational study of consecutive patients with RCVS at 2 referral institutions for neurological disease. MAIN OUTCOME AND MEASURE Clinical worsening after diagnosis of RCVS. We defined clinical worsening as new permanent or transient neurological deficits (compared with presenting signs and symptoms) or new onset of seizures. We performed a logistic regression analysis to assess associations between patient characteristics and clinical worsening. Functional outcome was assessed at 1 to 3 months using the modified Rankin score. RESULTS We identified 59 patients (median age, 47 years; interquartile range, 32-54 years) with RCVS. Twenty patients (34%) experienced clinical worsening after a median of 2.5 days (range, several hours to 14 days). Eight of the 20 patients who worsened had permanent deficits, including 4 who died. We did not find an association between age, sex, smoking, migraine, acute or chronic hypertension, peripartum state, or use of serotonergic drugs with clinical worsening. Clinical worsening was associated with radiological infarction (P = .001) and worse functional outcome (P < .004). Functional outcome was favorable (modified Rankin score...

Background and Purpose-Postpartum angiopathy (PPA), a rare cause of stroke in the puerperium, is heralded by severe headaches within 1-2 weeks after delivery. Angiography demonstrates segmental vasoconstriction that often resolves spontaneously. PPA is generally regarded as benign. We aimed to define clinical presentations, radiological findings, and outcomes of patients with PPA. Methods-We retrospectively reviewed patients from 3 centers with acute neurological symptoms and angiography showing vasoconstriction in the postpartum period. Patients without neuroimaging and with diagnoses of cerebral venous sinus thrombosis and aneurysmal hemorrhage were excluded. Patient characteristics, clinical symptoms, neuroimaging findings, and clinical condition at hospital discharge were collected. Results-Eighteen patients (mean age, 31 years; range, 15-41) were identified. Median gestation was 38 weeks. Twelve (67%) had a history of prior uneventful pregnancy. Neurological symptoms began on median day 5 postpartum and included headache (nϭ16, 89%), focal deficit (nϭ9, 50%), visual disturbance (nϭ8, 44%), encephalopathy (nϭ6, 33%), and seizure (nϭ5, 28%), often in combination. Brain imaging was abnormal in most (nϭ13, 72%). The most common abnormalities were intracranial hemorrhage (nϭ7, 39%), vasogenic edema (nϭ6, 35%), and infarction (nϭ6, 35%). Clinical outcomes were markedly variable with full recovery seen in 9 (50%), death after a fulminant course in 4 (22%), and residual deficits in 5 (28%). Conclusions-In contrast to prior reports, this group of patients with PPA had a higher proportion of nonbenign outcomes.Most patients who undergo neuroimaging have parenchymal abnormalities, which are most often stroke (hemorrhagic or ischemic) or reversible vasogenic edema. (Stroke. 2012;43:670-676.)

Background and Purpose-Several lines of evidence point toward a relationship between infection and atherosclerotic vascular disease. Thus, infection and inflammation often precede ischemic neurological events. Transient alterations in coagulation and direct arterial invasion by certain microorganisms have been reported. Helicobacter pylori infection is the major cause of peptic ulcer disease and appears to be a risk factor for ischemic cerebrovascular disease. However, in contrast to other chronic infectious agents, H pylori has not been consistently isolated from atherosclerotic lesions. Methods-We investigated the presence of H pylori in 38 atherosclerotic plaques obtained at carotid endarterectomy by using morphological and immunohistochemical techniques and a highly sensitive polymerase chain reaction method. We performed immunohistochemical detection of intercellular adhesion molecule-1, a marker related to inflammatory cell response. We also examined 7 carotid arteries obtained at autopsy from subjects without carotid atherosclerosis. Results-H pylori DNA was found in 20 of 38 atherosclerotic plaques. Ten of the H pylori DNA-positive plaques also showed morphological and immunohistochemical evidence of H pylori infection. None of 7 normal carotid arteries was positive for H pylori. Intercellular adhesion molecule-1 was expressed in 75% of H pylori-positive plaques and in 22% of H pylori-negative plaques. The presence of the microorganism was associated with male sex but was independent of age, vascular risk factor profile, and prior neurological symptoms. Conclusions-H

Background:

Impairments in the protein C pathway and endogenous fibrinolysis may contribute to the increased risk for brain infarction after recent (< or = 1 week) infection/inflammation. A decrease in the circulating anticoagulant APC may be related to elevated antiphospholipid antibody titers.