Background and Purpose-Ischemic stroke patients in atrial fibrillation (AF) have a 10% to 20% risk of recurrent stroke.Warfarin reduces this risk by two thirds. However, warfarin is underutilized in this patient group. We performed a prospective study to determine the reasons why warfarin is not started in these patients. Methods-All patients with AF-associated ischemic stroke over a 12-month period were identified. Demographic and other data, including whether warfarin was commenced or recommended at discharge, and if not why not, were recorded. Results-Ninety-three of 412 (23%) ischemic stroke patients had paroxysmal or permanent AF. Of these patients, 17 (18%) died, 48 (52%) were discharged home, and 28 (30%) were discharged to institutional care. Only 13 of 64 (20%) patients with known AF were taking warfarin at stroke onset. Warfarin was started (or recommended) in 35 of 76 (46%) survivors. Of those not commenced on warfarin, 32 (78%) were dependent (PϽ0.001) and 23 (56%) were discharged to institutional care (PϽ0.001). Warfarin was not started because of severe disability and frailty in 13 (32%), risk of falls in 12 (30%), and limited life expectancy in 4 (10%). Conclusions-In this cohort of patients with AF, warfarin was primarily underutilized before stroke onset, and it was too late to use anticoagulation, in approximately half, once a stroke had occurred. The decision to start or continue anticoagulation requires clinical judgment and should be made on a case by case basis after a complete risk benefit assessment.

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Aim: In 1997, a survey of New Zealand physicians' opinions on the management of stroke was carried out. Since then, there have been a number of advances in stroke therapy. We have repeated the 1997 survey to assess changes in physicians' opinions on stroke management.Methods: A questionnaire was sent to 293 physicians responsible for patients admitted with acute stroke to hospitals throughout New Zealand. It included questions on the management of acute stroke and secondary prevention and was based on the 1997 questionnaire.Results: Responses were received from 211 physicians of whom 174 (82%) managed patients with an acute stroke. The number of respondents who thought that stroke units were efficacious has increased (57% in 1997 to 89%, P < 0.001). The use of aspirin acutely (P < 0.001) and intravenous tissue plasminogen activator (P = 0.006) has also increased. In 2004, antihypertensive therapy for secondary stroke prevention would be commenced if the blood pressure was 150/90 by 98% of respondents and 140/90 by 70% of respondents. In 2004, a statin would be commenced if the total cholesterol level was 4.0 mmol/L by 56% of respondents and 5.0 mmol/L by 91% of respondents.Conclusions: This survey has shown important changes in the management of ischaemic stroke over the past 7 years.

Purpose: Functional MRI provides a novel method for the demonstration of diaschisis. Crossed cerebellar diaschisis has been demonstrated acutely post-stroke, associated with motor recovery. We assessed the hypothesis that diaschisis within the visual system could be demonstrated using serial fMRI studies, comparing activation sites between the acute stroke period and the chronic recovery stage.Methods: Patients with first-ever stroke involving the visual pathways were examined with fMRI 4-10 days after stroke and at 6 months. 14 coronal slices beginning at primary visual cortex were selected for gradient echo echoplanar imaging with corresponding coronal T1, MRA and high-resolution axial 3D SPGR images. Patients detected changes in a central fixation cross while viewing stimuli designed to activate striate and ventral extrastriate cortex (fusiform, lingual gyri): images of faces, scrambled faces and 50% grey in alternating 20 secepochs. t-test maps (uncorrected p < 0.001) were obtained for FACE vs GREY condition, and overlaid on corresponding native T1 images.Results: 5 patients were studied (mean age = 63+/ ÀSE10 years): 1 right MCA and 4 PCA (3 right, 1 left) infarcts. All patients displayed absent or reduced activation in ventral extrastriate sites remote from the infarct. 3 patients (2 PCA, 1 MCA) were shown to have a return of activation to these sites at 6 months. The patient with MCA infarction demonstrated the most dramatic restitution of ipsilesional fusiform activation, while both patients with no restitution had right PCA infarcts involving fusiform gyrus.Conclusions: Our study reveals unique evidence of dynamic ipsilesional diaschisis within connected regions of the visual system, particularly within ventral extrastriate sites. Diaschisis within the visual system has not been previously demonstrated using fMRI. We provide further evidence of the importance of intact striate cortex for the function of the ventral visual system.Aim: We aim to use genetic linkage studies to find new gene mutations causing familial motor neurone disorders, and to determine their relevance for sporadic forms of disease.Methods: A large family of English origin shows distal hereditary motor neuropathy (dHMN) with autosomal dominant inheritance. With informed consent, 22 members of this family were examined. Genomic DNA was extracted from the participating individuals. PCR was performed for microsatellite markers in the known HMN loci. A genome wide search using 382 microsatellites (spaced at an average of 10cM) was performed to further map disease to a chromosomal locus in this family (AGRF, Melbourne).Results: The family demonstrated significant evidence for linkage with a theoretical maximum logarithm of odds (LOD) score 4.956 (mean LOD score 3.82 at q = 0) and possible exclusion of 8cM on either side of an unlinked marker (simulation analysis with SIMLINK Version 4.1 package). The data was analysed using the MLINK programme from the LINKAGE package. The condition was modelled as an autosomal dominant trait with disease p...