Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke.

BACKGROUND: Trials of patent foramen ovale (PFO) closure to prevent recurrent stroke have been inconclusive. We investigated whether patients with cryptogenic stroke and echocardiographic features representing risk of stroke would benefit from PFO closure or anticoagulation, as compared with antiplatelet therapy. METHODS: In a multicenter, randomized, open-label trial, we assigned, in a 1:1:1 ratio, patients 16 to 60 years of age who had had a recent stroke attributed to PFO, with an associated atrial septal aneurysm or large interatrial shunt, to transcatheter PFO closure plus long-term antiplatelet therapy (PFO closure group), antiplatelet therapy alone (antiplatelet-only group), or oral anticoagulation (anticoagulation group) (randomization group 1). Patients with contraindications to anticoagulants or to PFO closure were randomly assigned to the alternative noncontraindicated treatment or to antiplatelet therapy (randomization groups 2 and 3). The primary outcome was occurrence of stroke. The comparison of PFO closure plus antiplatelet therapy with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 2, and the comparison of oral anticoagulation with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 3. RESULTS: A total of 663 patients underwent randomization and were followed for a mean (±SD) of 5.3±2.0 years. In the analysis of randomization groups 1 and 2, no stroke occurred among the 238 patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet-only group (hazard ratio, 0.03; 95% confidence interval, 0 to 0.26; P<0.001). Procedural complications from PFO closure occurred in 14 patients (5.9%). The rate of atrial fibrillation was higher in the PFO closure group than in the antiplatelet-only group (4.6% vs. 0.9%, P=0.02). The number of serious adverse events did not differ significantly between the treatment groups (P=0.56). In the analysis of randomization groups 1 and 3, stroke occurred in 3 of 187 patients assigned to oral anticoagulants and in 7 of 174 patients assigned to antiplatelet therapy alone. CONCLUSIONS: Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation. (Funded by the French Ministry of Health; CLOSE ClinicalTrials.gov number, NCT00562289 .).

Predictive factors of brain death in severe stroke patients identified by organ procurement and transplant coordination in Lorrain, France.

There are no established predictive factors to identify patients at the acute phase of severe stroke with a high probability of presenting brain death (BD). We retrospectively collected clinical and paraclinical data of consecutive patients at the acute phase of severe stroke with a potential progression to BD through the hospital organ procurement and transplant coordination system in five centres in Lorrain (France) between 1 January 2012 and 31 December 2013. Final endpoint was adjudicated BD. Of 400 included patients, 91 (23%) presented adjudicated BD. Initial Glasgow Coma Scale score ≤6 (P = 0.008), herniation (P = 0.009), hydrocephalus (P = 0.019), initial systolic blood pressure >150 mmHg (P = 0.002), past history of alcohol abuse (P = 0.019) and stroke volume >65 ml (P = 0.040) were significantly associated with BD progression. Two prognostic scores for stroke with unquantifiable or quantifiable volume were built according to the number of risk factors presented. Following internal validation, the respective bias-corrected predictive performance (c-index) of the two scores was 72% (95% confidence interval: 67-78%) and 77% (95% confidence interval: 72-82%). These scores could form the basis of a simple tool of six criteria to help physicians make the difficult decision of intensive care unit management to preserve organs in potential donors.

Report of a recurrent cerebral venous thrombosis in a young athlete.

BACKGROUND: Reports of occurrence of deep vein thrombosis during intensive sport are scarce. While a few cases have been described in the cerebral territory, these are only in the context of traumatism or anabolic agent consumption. Thus, causality with exercise remains uncertain and the mechanisms hypothetic. We present the case of a young athlete who experienced two episodes of severe cerebral venous thromboses (CVT), both during intensive training, in the absence of any other known thrombogenic factor. CASE PRESENTATION: A healthy 26-year-old man presented a thrombosis of the superior sagittal sinus during recent intensive training for a triathlon. Investigation at the time found no drug or anabolic steroid consumption, or any hematologic or coagulation disturbance. Anticoagulation therapy was initiated for 10 months with good outcome. One year later, soon after returning to intensive exercise, mainly running, the patient presented a thrombosis of the straight sinus complicated by bithalamic hyperintensities observed on T2 magnetic resonance imaging sequences. Anticoagulation treatment was reinitiated and led to repermeabilization of the cerebral vein and reversibility of thalamic abnormalities. Four months later, the patient was free of headache and had no cognitive impairment. He continues to practice intensive sport with vitamin K antagonist as preventive treatment. CONCLUSION: This is the first case report of recurrent CVT in a context of intensive sport, without any other thrombogenic features, suggesting a causal link. Intensive exercise should be considered as a potential promoting factor of CVT and investigated during routine examination.

Relationships between recent intraplaque hemorrhage and stroke risk factors in patients with carotid stenosis: the HIRISC study.

OBJECTIVE: Intraplaque hemorrhage (IPH) is an emerging marker of plaque instability. However, little is known about the relationships between IPH and traditional risk factors and whether these relationships differ between symptomatic and asymptomatic disease. METHODS AND RESULTS: Two hundred thirty-four patients with symptomatic (n=114) or asymptomatic (n=120) carotid stenosis underwent high-resolution plaque magnetic resonance imaging. Seventy-five patients had recent IPH (symptomatic, 33%; asymptomatic, 31%). In symptomatic stenosis, recent IPH was independently associated with degree of stenosis (odds ratio [OR]=4.21, 1.61-10.98 for North American Symptomatic Carotid Endarterectomy Trial >35%; OR=2.92, 1.18-7.24 for European Carotid Surgery Trial >60%), qualifying event (OR=4.13; 1.11-15.32 for stroke or hemispheric transient ischemic attack ≥1 hour versus transient ischemic attack <1 hour or ocular symptoms), time from ischemic event (OR=6.65, 1.56-28.35 for ≤2 weeks; OR=2.24, 0.87-5.81 for 2-12 weeks versus >12 weeks; P for trend=0.03). In asymptomatic stenosis, IPH was only associated with stenosis severity >70% by ECST (OR=6.65; 1.95-22.73) but not by the NASCET method. CONCLUSIONS: Our findings support the potential link between recent IPH and risk of ipsilateral stroke in symptomatic disease but also imply that prognostic studies should adjust for known stroke risk factors in multivariate analyses. In asymptomatic stenosis, the potential predictive value of recent IPH is less likely to be confounded by stroke risk factors.

Cerebral venous thrombosis due to essential thrombocythemia and worsened by heparin-induced thrombocytopenia and thrombosis.

This case describes the medical history of a 61-year-old woman treated for cerebral venous thrombosis (CVT) leading to diagnosis of essential thrombocythemia (ET). During treatment with unfractionated heparin, after initial improvement of clinical state, signs of cerebral hypertension reappeared. Although the platelet count decreased, heparin-induced thrombocytopenia (HIT) was only suspected 2 days later when it dropped below the standard 150 × 10(9) L(-1) threshold. HIT diagnosis was confirmed by the presence of anti-PF4/heparin IgG. This late finding was the cause of the extension of CVT with worsening of cerebral hypertension necessitating decompressive craniectomy. Elevated basal platelet count due to ET can delay diagnosis and treatment of HIT. In this case, physicians should be more attentive to platelet count variations rather than thrombocytopenia threshold.

Intravenous thrombolysis in thromboembolic occlusion of the A1 segment of the left anterior cerebral artery only.

This case describes the treatment of an 84-year-old male patient with acute bi-frontal ischemic stroke, due to thromboembolic occlusion of the A1 segment of the left anterior cerebral artery (ACA) only. The National Institutes of Health Stroke Scale (NIHSS) was 11. Intravenous fibrinolysis was performed with a good outcome. Repermeabilization of both ACA was demonstrated by imaging and, 24 h after treatment, NIHSS was 0. Although intravenous thrombolysis is mostly used for middle cerebral artery occlusion, this case emphasizes the benefit of this treatment for an ischemic stroke due to embolization of the A1 segment of the left ACA only. It is all the more original in that it describes an unusual treatment for this arterial territory, and with this anatomic particularity.

Outcome of patients with large vessel occlusion stroke after first admission in telestroke spoke versus comprehensive stroke center.

INTRODUCTION: While telestroke allows early intravenous thrombolysis (IVT) for ischemic strokes in spoke centers, mechanical thrombectomy (MT) for large vessel occlusion (LVO) is mainly performed at comprehensive stroke centers (CSCs). We aimed to compare 3 month outcome in patients with LVO after admission to a spoke center using telestroke compared with first CSC admission in our large regional stroke network, irrespective of final treatment decision. METHODS: All consecutive LVO patients who were admitted to one of six spoke centers or to the regional CSC within 6 hours of symptom onset were prospectively included from September 1, 2015 to August 31, 2017. All patients admitted to spoke centers were assessed on site with cerebral and vessel imaging. Primary outcome was 3 month favorable outcome (modified Rankin Scale score of 0-2). RESULTS: Distances between spoke centers and CSC ranged from 36 to 77 miles. Among 207 included patients, 132 (63.8%) were first admitted to CSCs and 75 (36.2%) to spoke centers. IVT was administered more in spoke centers (81.3% vs 53.8%, p<0.0001) while MT was performed less (26.7% vs 49.2%, p=0.001) and with a longer time from onset (303 vs 200 min, p<0.0001). No difference was found in 3 month favorable outcome between spoke centers compared with CSCs (32.0% and 35.1%, respectively; OR=0.68; 95% CI 0.42 to 1.10; p=0.12). CONCLUSIONS: Despite different distribution of reperfusion therapies for LVO patients managed by telemedicine, we could not demonstrate a difference in functional outcome according to admission location in a large area with long distances between centers.

High-resolution MR imaging of the cervical arterial wall: what the radiologist needs to know.

The emergence of high-resolution rapid imaging methods has enabled magnetic resonance (MR) imagers to noninvasively image the fine internal structure of cervical arterial walls. In this article, a comprehensive guide to performing high-resolution MR imaging of cervical arteries is provided, including the choice of coils, sequences, and imaging parameters, as well as tips for optimal image quality. Explanations and illustrations are given of using high-resolution MR imaging to quantify plaque volume, determine atherosclerotic plaque burden, depict plaque composition, and ultimately identify unstable plaque before it leads to a clinical event. Finally, the role of high-resolution MR imaging in the diagnosis of cervical dissection and inflammatory disease of the arterial wall is emphasized.

A direct aspiration first pass technique with the new ARC catheter for thrombectomy of large vessel occlusion strokes: A multicenter study.

BACKGROUND AND PURPOSE: A direct aspiration first pass technique involves first-line aspiration to remove the thrombus through a large-bore aspiration catheter in large vessel strokes. The aim of this study was to assess safety and clinical outcomes with a direct aspiration first pass technique using the new ARC catheter. METHODS: A retrospective analysis of prospectively collected data from three university hospitals was performed between June 2016 and May 2018. The following parameters of all acute ischemic stroke interventions using the ARC catheter were analyzed: use of intravenous thrombolysis, National Institutes of Health Stroke Scale scores at presentation and discharge, successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3), procedure duration, procedure-related complications and 90-day clinical outcome (modified Rankin Scale score). RESULTS: In total, 41 patients were included in the study and anterior circulation occlusion was noted in 35 (85%). The median National Institutes of Health Stroke Scale at admission was 18 and prior intravenous thrombolysis was administered in 35 patients (85%). Only six (15%) patients required the use of a rescue stent retriever. Successful reperfusion was achieved in 40 patients (98%) with a median procedure time of 32 minutes. No catheter-related complications were observed. Symptomatic intracerebral hemorrhage occurred in one patient (2%). Median National Institutes of Health Stroke Scale at discharge was 3; 49% were independent and 10% died at 90 days. CONCLUSIONS: In the present study, the ARC catheter allowed a 98% successful reperfusion rate. The complication rate was in line with those of previous a direct aspiration first pass technique publications.

Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Strokes Treated by Thrombectomy: A Review of the TITAN Collaboration.

Introduction: Endovascular therapy has been shown to be an effective and safe treatment for tandem occlusion. The endovascular therapeutic strategies for tandem occlusions strokes have not been adequately evaluated and the best approach is still controversial. The TITAN (Thrombectomy in TANdem occlusions) registry was a result of a collaborative effort to identify the best therapeutic approach for acute ischemic stroke due to tandem lesion. In this review, we aim to summarize the main findings of the TITAN study and discuss the challenges of treatment for tandem occlusion in the era of endovascular thrombectomy. Methods: A review of the data from the multicenter international observational and non-randomized TITAN registry was performed. The TITAN registry included acute ischemic stroke patients with tandem lesions (proximal intracranial occlusion and cervical carotid artery occlusion or stenosis>90%) who were treated with thrombectomy with or without carotid artery stenting. Results: Prior intravenous thrombolysis and emergent cervical carotid stenting were associated with higher reperfusion (mTICI 2b-3 and mTICI 3) rates at the end of the intervention. Poor outcome did not occur more frequently after stenting than after conservative treatment of the cervical carotid lesion. Emergent carotid stenting with antithrombotic agents and intracranial thrombectomy yielded higher reperfusion rate and good outcome (90 day mRS 0-2) compared to other strategies (carotid artery stenting and thrombectomy without antithrombotic, angioplasty and thrombectomy, or thrombectomy alone). Pretreatment intravenous thrombolysis was not associated with increased risk of hemorrhagic complications. Likewise, periprocedural unfractionated heparin did not modify the efficacy and safety results. Etiology of carotid artery lesion (atherosclerosis vs. dissection) did not emerge as predictor of outcome or recanalization. Conclusion: Emergent stenting of the cervical carotid lesion with antithrombotic agents in conjunction to thrombectomy appears to be the best treatment strategy for acute ischemic strokes with tandem lesions. These findings will be further investigated in the ongoing randomized controlled TITAN trial.

Rapid Successful Reperfusion of Basilar Artery Occlusion Strokes With Pretreatment Diffusion-Weighted Imaging Posterior-Circulation ASPECTS <8 Is Associated With Good Outcome.

Background The association between time to reperfusion and clinical outcome is well known in anterior circulation strokes, whereas the impact of main time metrics remains unknown in posterior circulation strokes. We investigated the clinical effect of different time intervals from symptom onset to reperfusion on the 90-day clinical outcome in acute ischemic stroke patients with basilar artery occlusion, and especially in the subset population presenting a low stroke volume on baseline diffusion-weighted imaging. Methods and Results We studied patients included in the prospective, multicenter, observational ETIS (Endovascular Treatment in Ischemic Stroke) registry who had had basal artery occlusion and had achieved successful reperfusion (modified Thrombolysis In Cerebral Infarction 2b-3). Three time intervals (onset to reperfusion, onset to imaging, and imaging to reperfusion) were considered in all patients and separately in patients with pc- ASPECTS (posterior-circulation Alberta Stroke Program Early Computed Tomography Score) <8 and ≥8 on baseline diffusion-weighted imaging. The primary end point was good outcome defined as 90-day modified Rankin Scale scores of 0 to 2. Among the 95 included patients, 38 (40%) achieved a good outcome. In all patients, no significant association was found between the different time intervals and outcome. In patients evaluated with diffusion-weighted imaging (n=61) at baseline, a significant negative association was found between imaging-to-reperfusion time for patients with pc- ASPECTS <8 (adjusted odds ratio=0.4 per 30-minute increase; 95% CI 0.18-0.85; P=0.02) compared with those with pc- ASPECTS ≥8. Conclusions In patients with basilar artery occlusion and pc- ASPECTS <8 at baseline diffusion-weighted imaging, clinical outcome is highly dependent on the time from imaging to reperfusion, which suggests that rapid endovascular reperfusion should be performed after imaging in these patients.

Mothership versus drip and ship for thrombectomy in patients who had an acute stroke: a systematic review and meta-analysis.

BACKGROUND: The effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke due to large vessel occlusion is time-dependent. While only stroke centers with endovascular capabilities perform MT, many patients who had a stroke initially present to the closest primary stroke centers capable of administering earlier intravenous thrombolysis, and then require to be transferred to a comprehensive stroke center for MT. PURPOSE: To compare the outcomes of this care pathway (drip and ship (DS)) with that whereby patients are directly transferred to a comprehensive stroke center (mothership (MS)). METHODS: We performed a systematic review and meta-analysis of published studies using several electronic databases to determine whether successful reperfusion (modified Thrombolysis In Cerebral Infarction ≥2b), functional independence at 90 days (modified Rankin Scale score ≤2), symptomatic intracranial hemorrhage, and 90-day mortality differed between those who underwent MT with the DS or the MS treatment pathway. Outcomes were meta-analyzed and the results expressed as adjusted relative risk (aRR) for the primary analysis and unadjusted relative risk (uRR) for secondary analysis. RESULTS: Eight studies including 2068 patients were selected, including one study reporting results fully adjusted for baseline characteristics. Patients undergoing MS had better functional independence than those undergoing DS (uRR=0.87, 95% CI 0.81 to 0.93; aRR=0.87, 95% CI 0.77 to 0.98). No difference was found between the treatment pathways in successful reperfusion (uRR=1.05, 95% CI 0.95 to 1.15; aRR=1.00, 95% CI 0.92 to 1.10), symptomatic intracranial hemorrhage (uRR=1.37, 95% CI 0.91 to 2.06; aRR, 1.53, 95% CI 0.79 to 2.98), and 90-day mortality (uRR=1.00, 95% CI 0.84 to 1.19; aRR=1.21, 95% CI 0.89 to 1.64). CONCLUSIONS: Patients who had an acute ischemic stroke admitted directly to a comprehensive stroke center (MS patients) with endovascular capacities may have better 90-day outcomes than those receiving DS treatment. However, major limitations of current evidence (ie, retrospective studies and selection bias) suggest a need for adequately powered studies. Multicenter randomized controlled trials are expected to answer this question.

Bilateral optic neuropathy related to severe anemia in a patient with alcoholic cirrhosis: a case report and review of the literature.

Anemia appears frequently in patients with alcoholic liver disease (ALD) but has never been linked to bilateral nonarteritic anterior ischemic optic neuropathy (NAION). A 65-year-old woman with a medical history of alcoholic cirrhosis was admitted for bilateral NAION. On admission, she was found to have a low arterial pressure and severe normocytic anemia (48 g/L). The anemia was related to chronic bleeding due to antral gastritis along with other factors associated with ALD. The applied treatment consisted of urgent transfusion followed by high doses of proton-pump inhibitors, iron and vitamin supplementation, and support in lifestyle measures. Her hemoglobin levels remained stable after 2 years but the patient still suffered from visual loss. This case highlights the link between anemia and bilateral NAION in ALD patients. The optic nerve head is prone to infarction in this context due to the vascularization characteristics of ALD. Hemoglobin levels should be monitored in ALD patients to avoid the severe complication of NAION.

Spontaneous cervical artery dissection in patients aged over 70 years: two cases and systematic literature review.

OBJECTIVE: Spontaneous cervical artery dissection (CAD) is a cerebrovascular disease typically considered to affect the young population. Literature reports cases in the elderly only as incidental findings, making the diagnosis unlikely in older patients. Incidence and pathogeny in this specific population remain to be assessed. METHODS: We reviewed patients aged over 70 years admitted for spontaneous CAD in the Stroke Unit of the University Hospital of Nancy (northeastern France) over a period of 12 years as well as all reported cases in literature. RESULTS: During this period, only two patients aged over 70 years were diagnosed with internal carotid artery dissection in our center. The first patient was diagnosed with the typical radiological feature of long tapered stenosis due to mural hematoma. The second patient presented with the classic painful Horner syndrome. Literature review identified only two case reports and eight studies with an age range above 70 years. Headache was present in nearly all documented cases. Radiological features were the same as those usually described in younger patients. CONCLUSIONS: Even if spontaneous CAD in patients aged over 70 years would appear to be rare, it does occur with comparable clinical and radiological features as in the younger population. CAD is probably underdiagnosed in this population due to a higher prevalence of more common causes of stroke at this age. However, a simple investigation into headache or the Horner syndrome during the patient's diagnostic workup would lead to adapted exploration of cervical arteries and improve detection of CAD in the elderly.

Idiopathic Intracranial Hypertension: Prognostic Factors and Multidisciplinary Management.

BACKGROUND: Idiopathic intracranial hypertension (IIH) mostly affects young obese women and can lead to permanent visual impairment. However, prognostic factors and therapeutic strategy remain unclear. METHODS: We retrospectively collected data from all patients diagnosed and managed for IIH in our university center from January 2001 to December 2016. RESULTS: Seventy-nine patients were diagnosed with IIH. Bilateral transverse sinus stenosis (TSS) was found in 74% of the population. Visual outcome at 6 months was poor for 46% of patients, including all patients presenting weight gain of at least 5% since diagnosis (p < 0.001), whereas mean body mass index at diagnosis was not different between patients with poor versus good outcome (32.9 ± 7.7 versus 34.6 ± 9.4 kg·m-2). Other significant factors of poor prognosis were bilateral TSS (OR = 5.2; 95 CI: 1.24-24.9; p = 0.024). Thirteen patients with poor outcome after 6-month assessment underwent unilateral TSS stenting leading to visual improvement in 11 cases. CONCLUSION: Weight gain, rather than initial weight, emerged as the leading factor of poor visual outcome in patients with IIH, followed by presence of bilateral TSS. Consequently, first-line treatment must include dietary measures to control weight. Unilateral stenting appears to be a safe second-line treatment option for patients with bilateral TSS.

Outcome of intravenous recombinant tissue plasminogen activator for acute ischemic stroke in patients aged over 80 years.

AIM: Practitioners are faced with a substantial challenge when considering recombinant tissue plasminogen activator (rt-PA) therapy for older patients with ischemic stroke. Patients aged over 80 years suffer from the most severe cerebral infarcts. The benefit of rt-PA treatment compared with single standard care only in stroke units remains to be clearly assessed. METHODS: We collected data from 321 patients aged over 80 years admitted for acute cerebral infarction to the stroke unit of Nancy University Hospital in France between 1 January 2009 and 31 December 2012. Patients were stratified into two groups: treated or not with rt-PA. Baseline characteristics and outcome were collected and compared between both groups. Good outcome at 3 months was defined as modified Rankin Scale score ≤2. RESULTS: The 55 patients treated with rt-PA had a higher National Institute of Health Stroke Scale score on admission than those without (15 vs 5; P < 0.001). They were more likely to have intracranial haemorrhage (20 vs 5%; P < 0.001) without an increased mortality rate (28 vs 27%; P = 0.95). Multivariate analysis showed a more favorable outcome (odds ratio 7, 95% confidence interval 3-16.5; P < 0.001). Slightly higher percentages of patients with modified Rankin Scale ≤2 were found after intention-to-treat analysis (49 vs 45%) and after exclusion of patients with baseline modified Rankin Scale >2 (57 vs 54 %), but without reaching significance (P > 0.05). CONCLUSIONS: Rt-PA therapy would appear to improve prognosis in the elderly with ischemic stroke. This suggests that age alone should no longer be a barrier to rt-PA therapy. Geriatr Gerontol Int 2016; 16: 843-849.

Cerebral ischemic events in patients with pancreatic cancer: A retrospective cohort study of 17 patients and a literature review.

Stroke is a dramatic complication of pancreatic cancer with mechanisms related to oncological disease. A better description of the characteristics of cerebrovascular events would help better understand the pathogeny and protect vulnerable patients. We thus conducted a descriptive analysis of clinical, biological, and radiological features of patients from our centers and literature.We reviewed consecutive cases of patients who presented cerebrovascular events and pancreatic cancer in 4 stroke units in Lorrain (France) between January 1, 2009 and March 31, 2015, and all reported cases of literature. We identified 17 cases in our centers and 18 reported cases. Fifty-seven per cent of patients were male. Median age was 63 ±â€Š14 years and ranged from 23 to 81 years. All cerebral events were ischemic. At the onset of stroke, pancreatic cancer had already been diagnosed in 59% of the patients in our centers for a mean time of 5.4 months. Five of them (29%) were being treated with gemcitabine and 2 (12%) with folfirinox. Adenocarcinoma at metastatic stage was reported in 82% of cases overall. Brain imaging revealed disseminated infarctions in 64%. High median levels of D-dimer (7600 ±â€Š5 × 10 µg/L), C-reactive protein (63 ±â€Š43 mg/L), and elevated prothrombin time (19 ±â€Š6 seconds) were found. Thirty-six per cent of patients explored with echocardiography were diagnosed with nonbacterial thrombotic endocarditis. Ten of our patients received anticoagulant therapy as secondary stroke prevention without any documented recurrence. Nevertheless, outcome was poor with a median survival time of 28 ±â€Š14 days after stroke onset. Cerebral ischemic events occur at advanced stages of pancreatic cancer, most likely by a thromboembolic mechanism. Disseminated infarctions and high D-dimer, C-reactive protein levels, and a high prothrombin time are the most constant characteristics found in this context. All patients should be screened for nonbacterial thrombotic endocarditis as this etiology supports the use of anticoagulant therapy.

Incidental Diagnosis of Cerebral Cortical Venous Thrombosis in Postdural Puncture Headache on Brain Computed Tomography.

Diagnosis of cerebral cortical venous thrombosis in patients with postdural puncture headache (PDPH) is usually secondary to changes in headache pattern or cerebral infarctions. Nevertheless, incidental discovery of asymptomatic forms on brain imaging has never been reported before and its management thus remains ill-defined. We describe 2 cases of patients with asymptomatic cortical vein thrombosis in the context of PDPH. In both cases, brain computed tomography (CT) scans showed an isolated cortical vein thrombosis without cerebral damage. Neurological examination revealed the typical orthostatic feature of PDPH, independently of cortical vein thrombosis which was considered as a radiological incidental finding. Clinical and radiological signs resolved after bed rest, oral caffeine, and anticoagulation therapy. Asymptomatic cortical vein thrombosis may be found on radiological exploration, even basic like brain CT scan without contrast, of PDPH. Utility of anticoagulation therapy, which could increase the risk of cerebral hemorrhagic complications in this specific context, has to be assessed.

Spontaneous Intracranial Hypotension: Characteristics of the Serious Form in a Series of 24 Patients.

BACKGROUND: Recommended treatments for spontaneous intracranial hypotension (SIH) range from bed rest only to neurosurgery. However, the serious form of SIH is poorly defined. A better description of patient characteristics and their outcome may help define therapeutic options. METHODS: We reviewed 24 cases of patients with SIH and separated them into 2 groups according to whether or not they presented with signs of severity at admission: disturbance of consciousness, subdural hematomas (SDHs), and cerebral venous thrombosis. RESULTS: Nine patients (37%) were classified as having a serious form of SIH: six (25%) presented SDHs; three (12%) disturbance of consciousness; and one (4%) cerebral venous thrombosis. Bed rest and epidural blood patches (EBPs) were sufficient to treat all patients in the nonserious form group and 4 patients in the serious form group. Two patients (8%) had to undergo cerebrospinal fluid leak repair, and 3 others (12%) evacuation of SDHs. Outcome was good in both groups, with only one (4%) death due to extensive SDHs. Times to diagnosis in the serious form group (63 vs. 35 days, P = 0.052) and to recovery (9 months vs. 5 months, P = 0.088) tended to be higher without reaching difference. CONCLUSIONS: The presence of SDHs, disturbance of consciousness, and a trend toward a longer time to diagnosis and recovery seem to define the serious form of SIH. These patients may require exploration and surgical repair of cerebrospinal fluid leak, only after failure of conservative measures--bed rest and time--and EBP, with good outcome.

Treatment of hemorrhagic intracranial dissections.

OBJECTIVE: To analyze the treatment options in hemorrhagic intracranial dissections. METHODS: This study involved a retrospective review of 27 patients with 29 dissections treated during a 16-year period, mainly by endovascular treatment (EVT). RESULTS: EVT was performed in the acute stage in 12 of the 29 dissections, and occlusion was performed using coils at the dissection site in six dissections and with proximal balloon occlusion in six dissections. Wrapping was performed in one case. In the remaining 16 dissections, which were not treated, mainly for anatomic reasons, three patients died, one from rebleeding. Angiographic follow-up performed in the 13 surviving patients demonstrated an initially misdiagnosed lesion in one and worsening lesions in five that led to delayed EVT in five and surgical clipping in one. One of these dissections, which was located on a dominant vertebral artery, was treated after subsequent rupture using a stent and coils to preserve the patency of the parent vessel. Four ischemic complications related to EVT resulted in a moderate disability in two patients. No rebleeding occurred after EVT, but one patient died because of a poor initial clinical status; the other patients improved. In the 10 patients treated conservatively, four died, three from a poor initial clinical status and one from rebleeding, and six patients had a good clinical outcome. Of the 27 patients, three had rebleeding and one died as a result of that rebleeding. Seventeen patients (63%) had a good recovery, six (22%) had a moderate disability, and four (15%) died. CONCLUSION: EVT provides effective protection against rebleeding. When possible, occlusion with coils at the dissection site is the current method of choice. Another option is parent artery occlusion with balloons, and the use of a stent may preserve vessel permeability in specific cases.