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THE LANCET Neurology Vol 2 July 2003 http://neurology.thelancet.com390

Results presented at the 12th EuropeanStroke Conference (Valencia, Spain,21–24 May) strongly suggest thattreatment with abciximab, a plateletaggregation antagonist, is beneficial forpatients with acute ischaemic stroke(AIS) who present after the initial 3 hwindow for alteplase treatment.

Standard treatment for AIS involvesthe use of alteplase, a thrombolytic agentthat breaks down the offending clot.However, this is only recommendedwithin 3 h of symptom onset, and onlyabout 30% of patients arrive in this timewindow.

“Abciximab has the advantage that itdemonstrates a beneficial effect between3 h and 6 h”, says Antonio Dávalos(Hospital Josep Trueta, Gerona, Spain).“This is the first treatment we have forthis time window.”

The AbESTT trial involved 400patients with AIS treated 3–6 h aftersymptom onset with either abciximab

(0·25mg/kg plus 0·125 mg/kg/min for12 h) or placebo.

The results showed very significantimprovements in the outcome of theabciximab-treated patients, whethermeasured in terms of the modifiedRankin scale (MRS), Barthel index,National Institute of Health Stroke Scale(NIHSS), or by the new concept ofMRS-responder status (improvementwith respect to baseline stroke severity).

As expected, the sooner abciximabtreatment was started, the better theoutcome: if started within 5 h, just overhalf of patients achieved a high MRSscore of 0 or 1 at 3 months comparedwith about a third of patients givenplacebo; if treatment began after 5 h theresponse rates fell to 43% and 44%,respectively. Improvements were similarin patients both older and younger than75 years.

“These results are very exciting”,says Dávalos. “A large number of people

may be able to benefit from this.” Also reporting on the trial, Werner

Hacke (Heidelberg University,Germany) told conference delegatesthat abciximab treatment was moreeffective against slight and moderatestrokes. 40% of patients with an NIHSSscore of 4–7 were MRS responders at3 months compared with 25% ofpatients given placebo; among thosewith an NIHSS of 8–14, 47% ofpatients given abcimixab wereresponders at 3 months compared with33% of patients given placebo. Noimprovements were seen, however, inpatients with severe stroke.

“These results are very encouragingbut the drug needs to be evaluated in aphase III trial to substantiate its clinicaleffectiveness and assess the risk ofadverse events”, comments TimothyIngall (The Mayo Clinic, Scottsdale,AZ USA).Adrian Burton

Abciximab extends treatment window for stroke

Test identifies tendency to violence

Newsdesk

From a psychopathic killer’s point of view, there isnothing wrong about their crime. This thinking aloneshould set alarm bells ringing, but psychopaths areaccomplished liars, and parole boards and prisonassessors often fail to predict who is potentiallydangerous. Now, researchers at Cardiff University,UK, have developed a psychological test that exposespsychopathic murderers’ abnormal cognitive associationsto violence (Nature 2003 423: 497–98). The test, which isdifficult to fake, provides an insight into the criminalmind and could help to identify those psychopaths whoare most likely to kill.

Identification of psychopathic people has never beeneasy. Cold-blooded, remorseless, and sometimes violentin the extreme, they are also adept at feigning emotions.As a consequence, risk-assessment is fraught withdifficulties. The most reliable method used in prisonstoday is the Psychopathy Checklist-Revised (PCL-R),which assesses psychopathic individuals to identify thosewho are most violent and likely to reoffend.Unfortunately, the PCL-R is time consuming and requiresspecially trained staff to administer it.

To overcome these drawbacks, forensic clinicalpsychologist Nicola S Gray developed a computer taskthat only takes 10 min. The test is based on an individual’sreaction time to pleasant and unpleasant words flashingup on a screen. “We’ve come up with this task to serve,hopefully, as a ‘new age’ tool”, she says. Gray and

colleagues adapted the Implicit Association Test—whichpsychologists use to quantify beliefs that people may wishto disguise—to reveal carefully concealed prejudicesabout violence in psychopathic murderers.

The team spent 18 months at Grendon andSpringhill Prisons, Buckinghamshire, UK, where theyinterviewed 121 male offenders on admission. Theyfound that the 13 psychopathic killers (diagnosedinitially by the PCL-R) showed more positive reactionsto violence than non-psychopathic murderers and otheroffenders—a view that, the authors speculate, mayunderpin their actions.

“This is an interesting approach”, comments RobertHare (University of British Columbia, Vancouver,Canada), who devised the PCL-R, “and it is consistentwith a large body of research on language and emotion inpsychopaths”. Hare cautions, however, that the resultsreflect group differences that do not apply to eachindividual, casting doubts on its value as a usefulpredictive tool for violence and murder.

“We need to carry out more research on thistechnique before we can apply it in the real world”, Grayacknowledges. If the test’s reliability and validity areborne out, however, it would open up many possibilities.“We now have data on paedophiles which also suggestthat this could become an important tool that can beapplied to all sorts of offenders”, she adds. Lisa Melton