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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses infection in cerebrovascular disease, including infection before and after acute ischemic stroke, infection and pediatric stroke, and virus vasculopathy among other things.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EBacterial Infections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EViral Infections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInflammatory Diseases\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EInfection Before and After Acute Ischemic Stroke\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003E\u201cExtensive data now exist for a link between peripheral infection and stroke risk, especially acute bacterial infection,\u201d said Hedley Emsley, MRCP, Royal Preston Hospital \u0026amp; University of Liverpool, Preston, UK.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EA recent review of the literature revealed that the prevalence of infection in the week that precedes acute ischemic stroke (AIS) ranges between 10% to 35%, during which time infection confers a 2- to 3-fold increased stroke risk [Emsley HCA \u0026amp; Hopkins SJ. \u003Cem\u003ELancet Neurol\u003C\/em\u003E 2008]. This short window of elevated risk points to infection as a potential stroke trigger, with the highest risk period coinciding with the high-level proinflammatory phase of the immune response.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EPoststroke infection complicates up to 30% of ischemic strokes, wherein both mortality (10% of deaths within 30 days of admission are due to pneumonia) and functional outcomes are adversely affected. The most consistently reported predictors of poststroke infection are advanced age, greater baseline stroke severity, total anterior circulation infarction, and dysphagia [Emsley HCA \u0026amp; Hopkins SJ. \u003Cem\u003ELancet Neurol\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003E\u201cThe presence of infection has several implications for clinical practice,\u201d said Dr. Emsley. In terms of antecedent infection, vulnerable individuals may have a short-term increased stroke risk that is associated with acute systemic infection. Prevention is key; thus, adherence to vaccination schedules (eg, influenza) is important in vulnerable individuals. Evidence for poststroke \u201cbrain-induced\u201d immunodepression derives from a range of studies. Most recently, results from the Preventive Antibacterial Therapy in Acute Ischemic Stroke (PANTHERIS) trial, suggested that markers of immunodepression are predictive of poststroke infection [Klehmet J et al. \u003Cem\u003ENeuroscience\u003C\/em\u003E 2009].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EInfectious Burden: A New Modifiable Risk Factor for Atherosclerosis?\u003C\/h2\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EAtherosclerosis has a very large inflammatory component or could be considered an inflammatory condition. Mitchell Elkind, MD, Columbia University, New York, NY, said he believes that it is unlikely that there is one \u201cstroke bug\u201d that accounts for stroke. What is much more likely\u2014if infection does play a role in atherosclerosis, stroke risk, and cardiac risk\u2014is that several different infections may \u003Cem\u003Ein sum\u003C\/em\u003E contribute to an inflammatory burden that in turn contributes to atherosclerosis and potentially stroke. These mechanisms most likely also interact with host factors, genetic factors (in terms of ability to respond to infection), and perhaps other environmental factors as well (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/1\/9\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022\u0026#x201C;Burden\u0026#x201D; of Infectious Disease?\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2133546512\u0022 data-figure-caption=\u0022\u0026#x201C;Burden\u0026#x201D; of Infectious Disease?\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/1\/9\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/1\/9\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/1\/9\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11479\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003E\u201cBurden\u201d of Infectious Disease?\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EDr. Elkind presented results from an ongoing population-based study of ischemic stroke incidence in an urban, multiethnic population (The Northern Manhattan Study) that used a quantitative weighted index to assess the risk of stroke associated with infectious burden. The results of this study lend support to the idea that past or chronic exposure to common infections, perhaps by exacerbating inflammation, contributes to atherosclerosis and stroke risk. Infectious burden also was associated with carotid plaque thickness and mortality. This study is limited by several factors: only 5 serologies were examined (\u003Cem\u003EC. pneumonia\u003C\/em\u003E IgA, \u003Cem\u003EH. pylori\u003C\/em\u003E IgG, CMV IgG, HSV 1 IgG, and HSV 2 IgG), there were no data on the virulence of any of the pathogens or the clinical history of the subjects, and stroke subtypes were not examined. In addition, the results showed only association, not causation.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003E\u201cIn the future,\u201d said Dr. Elkind, \u201cit will be important to look at additional pathogens (perhaps periodontal disease) and to include clinical data on the frequency and severity of infections as well as data on other subclinical measures of atherosclerosis.\u201d\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EInfection and Pediatric Stroke\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EHeather J. Fullerton, MD, University of California, San Francisco, CA, discussed the results of 2 studies: the Kaiser Pediatric Stroke Study (KPSS), a retrospective cohort study that included 370 stroke cases, 97 of which were non-neonatal ischemic strokes; and the International Pediatric Stroke Study (IPSS), a multicenter, observational study that involved 1,187 cases of ischemic stroke, 676 of which were non-neonatal.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003ETo assess infection as a risk factor for stroke, the KPSS investigators identified documented medical encounters for infection during the 4 weeks prior to stroke, or in the same time window in matched controls. Infection was divided into major (ie, sepsis, meningitis) and minor sources. Significantly more children with stroke had a medical encounter for infection in the month prior to their stroke versus controls (32% vs 8%; OR, 7.9; 95% CI, 3.7 to 16.8 for minor infections; 37% vs 8%; OR, 11.8; 95% CI, 5.2 to 26.8 for major + minor infections; both p\u0026lt;0.001). They also had significantly more medical encounters for infection than controls during the last 2 years.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EDr. Fullerton suggested 2 potential mechanisms for infection-related stroke: either the infection is inducing a systemic prothrombotic state or it is causing endothelial injury, leading to arteriopathy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ERecent data have indicated that arteriopathies are the major cause of stroke in otherwise healthy children who present with stroke [Ganeson VJ et al. \u003Cem\u003EAnn Neurol\u003C\/em\u003E 2003]. Data from the KPSS study also show that arteriopathies are related to significant increases in stroke recurrence (5-year cumulative recurrence rate of 66%; 95% CI, 43 to 87; p\u0026lt;0.0001; \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Fullerton HJ et al. \u003Cem\u003EPediatrics\u003C\/em\u003E 2007]. Idiopathic large vessel stenosis was the most common arteriopathy that was seen in both the KPSS and IPSS [LeFond A et al. \u003Cem\u003ECirculation\u003C\/em\u003E in press] studies.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/1\/9\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Arteriopathy is Significant and Increases the Risk of Recurrence of Stroke.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2133546512\u0022 data-figure-caption=\u0022Arteriopathy is Significant and Increases the Risk of Recurrence of Stroke.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/1\/9\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/1\/9\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/1\/9\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11483\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EArteriopathy is Significant and Increases the Risk of Recurrence of Stroke.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EFullerton Pediatrics 2007.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EAlthough idiopathic arteriopathy may be due to trauma, several lines of evidence show that in cases in which there is evidence of progression in the first 2 to 6 months, it may be the result of infection, such as varicella. Other viruses that are associated with cerebral arteriopathies include herpes viruses, enterovirus, and HIV.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EDr. Fullerton said that additional studies of the vascular effects of infection in pediatric stroke are planned to measure associations between infection and stroke (case-control); infection and arteriopathy (cross-sectional); and infection\/arteriopathy and recurrence (prospective cohort), with the long-term goal of developing secondary stroke prevention strategies in children.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EThe Protean Neurological Features of Varicella Zoster Virus Vasculopathy\u003C\/h2\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EUsing a series of case studies, Donald H. Gilden, MD, University of Colorado School of Medicine, Denver, CO, discussed an updated description of varicella zoster virus (VZV) vasculopathies. He noted that they may be uni- or multifocal, that the resulting infarction is deep-seated more than superficial, and that white matter is involved more often than grey. Lesions are more often found in grey-white matter junctions and in both large and small arteries versus either large or small arteries alone. The spinal cord may become infarcted. Contrary to popular opinion, said Dr. Gilden, rash is found in only approximately 63% of patients and is not a requirement for diagnosis. Cerebrospinal fluid pleocytosis may include increased red blood cells but is absent in \u223c30% of cases. Diagnostically, detection of VZV antibodies is superior to identifying VZV DNA. VZV vasculopathies can present with aneurysm, subarachnoid or cerebral hemorrhage, carotid dissection, or even peripheral arterial disease. In closing, Dr. Gilden said, \u201cVZV is the only human virus proven to replicate in arteries.\u201d\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2009 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section ref-list\u0022 id=\u0022ref-list-1\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EFurther Reading\u003C\/h2\u003E\u003Col class=\u0022cit-list ref-use-labels\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022ref-label ref-label-empty\u0022\u003E\u003C\/span\u003E\n            \u003Cdiv class=\u0022cit ref-cit ref-journal no-rev-xref\u0022 id=\u0022cit-9.1.9.1\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Col class=\u0022cit-auth-list\u0022\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-auth\u0022\u003E\u003Cspan class=\u0022cit-name-surname\u0022\u003ENagel\u003C\/span\u003E  \u003Cspan class=\u0022cit-name-given-names\u0022\u003EMA\u003C\/span\u003E\u003C\/span\u003E, \u003C\/li\u003E\u003Cli\u003E\u003Cspan class=\u0022cit-etal\u0022\u003Eet al\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Ccite\u003E. \u003Cabbr class=\u0022cit-jnl-abbrev\u0022\u003ENeurology\u003C\/abbr\u003E \n               \u003Cspan class=\u0022cit-pub-date\u0022\u003E2008\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/9\/1\/9.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzml42\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzml42\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}