Later onset does occur in the disease of vanishing white matter, and both MRS and histopathology are compatible with a primary axonopathy rather than primary demyelination.

SUMMARYThe interobserver agreement for the diagnosis of a cerebral transient ischemic attack (TIA) was investigated in a pool of eight senior and interested neurologists from the same department. They interviewed 56 patients in alternating pairs. The diagnosis was based on internationally accepted criteria. The agreement rates were corrected for chance (kappa statistics). Both neurologists agreed that 36 patients had a TIA and 12 had not, but they disagreed about 8 patients (kappa = 0.65; for perfect agreement kappa would be 1.0). The Vascular territory (carotid or vertebrobasilar) was agreed upon in only 24 of the 36 patients in whom both diagnosed TIA's (kappa = 0.31). We concluded that currently the diagnosis of a TIA, made by a single neurologist, is a poorly defined entity.Stroke Vol 15, No 4, 1984

To try and improve the interobserver agreement for the diagnosis of TIA, we used a checklist in which the symptoms were recorded in plain language, instead of in abstract diagnostic terms such as amaurosis fugax. Criteria for a diagnosis of TIA were similarly phrased and recommended to all observers. Eight senior neurologists and ten neurology residents interviewed 72 patients in random pairs. In 64 cases the observers agreed on the diagnosis (kappa value = 0.77). After a short discussion between the two observers the agreement increased to a maximum (kappa = 1.0). However, in 29 of the 144 interviews the diagnosis would have been different, had the recommended criteria been fully applied. In 28 of these the observer had diagnosed TIA on insufficient evidence. Six "misinterpretations" led to disagreement for the diagnosis and only these were corrected by the observers during their discussion. The present design has led to a maximal agreement for the diagnosis of TIA between two observers, but the agreement between such a pair and the common diagnostic criteria was not yet ideal. The precision of the diagnosis could be improved if details of the required symptoms are discussed in general as well as for each patient.

SUMMARY We studied the relation between blood pressure and type of cerebral infarction (large or lacunar) in 134 patients with acute hemispheral infarcts that were detectable by computed tomography and that could not be attributed to causes other than atherothrombotic arterial disease. Lacunae were present in 26 patients, and systolic blood pressures were higher in this group than in the 108 patients with large infarcts. The overlap was so wide, however, that large infarcts predominated at every level of blood pressure. The presence of a lacune can be inferred only from the combination of clinical signs and, most important, computed tomography. For the past few years we had adopted this policy in our department, although epidemiological studies indicate that hypertension is common in all types of stroke.7 Since the advent of computed tomography (CT) we have found not only large cortical infarcts in patients with severe hypertension, but we have also been surprised to find lacunar infarcts in some normotensive patients. This experience has been confirmed from several centres.8 9We have been prompted by these inconsistencies to review the blood pressure readings in a large series of patients with acute brain infarcts due to arterial disease.

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