Cerebral air embolism: neurologic manifestations, prognosis, and outcome.

Background: Cerebral air embolism (CAE) is an uncommon medical emergency with a potentially fatal course. We have retrospectively analyzed a set of patients treated with CAE at our comprehensive stroke center and a hyperbaric medicine center. An overview of the pathophysiology, causes, diagnosis, and treatment of CAE is provided. Results: We retrospectively identified 11 patients with cerebral venous and arterial air emboli that highlight the diversity in etiologies, manifestations, and disease courses encountered clinically. Acute-onset stroke syndrome and a progressive impairment of consciousness were the two most common presentations in four patients each (36%). Two patients (18%) suffered from an acute-onset coma, and one (9%) was asymptomatic. Four patients (36%) were treated with hyperbaric oxygen therapy (HBTO), high-flow oxygen therapy without HBOT was started in two patients (18%), two patients (18%) were in critical care at the time of diagnosis and three (27%) received no additional treatment. CAE was fatal in five cases (46%), caused severe disability in two (18%), mild disability in three (27%), and a single patient had no lasting deficit (9%). Conclusion: Cerebral air embolism is a dangerous condition that necessitates high clinical vigilance. Due to its diverse presentation, the diagnosis can be missed or delayed in critically ill patients and result in long-lasting or fatal neurological complications. Preventative measures and a proper diagnostic and treatment approach reduce CAE's incidence and impact.

Case report: Susac syndrome-two ends of the spectrum, single center case reports and review of the literature.

Susac syndrome is a rare and enigmatic complex neurological disorder primarily affecting small blood vessels in the brain, retina, and inner ear. Diagnosing Susac syndrome may be extremely challenging not only due to its rarity, but also due to the variability of its clinical presentation. This paper describes two vastly different cases-one with mild symptoms and good response to therapy, the other with severe, complicated course, relapses and long-term sequelae despite multiple therapeutic interventions. Building upon the available guidelines, we highlight the utility of black blood MRI in this disease and provide a comprehensive review of available clinical experience in clinical presentation, diagnosis and therapy of this disease. Despite its rarity, the awareness of Susac syndrome may be of uttermost importance since it ultimately is a treatable condition. If diagnosed in a timely manner, early intervention can substantially improve the outcomes of our patients.

Dosing of tissue plasminogen activator often differs from 0.9 mg/kg, but does not affect the outcome.

BACKGROUND: The safety and efficacy of low- and high-dose intravenous tissue plasminogen activator (t-PA) for the treatment of acute ischemic stroke are poorly understood. In this multicenter study, we examined the relationships between different doses of t-PA and outcome. METHODS: Between 2006 and 2010, patients were enrolled if they were treated with t-PA on the basis of estimated body weight and on the subsequent availability of actual body weight. Based on the actual weight, patients were divided into lower (<0.85 mg/kg), standard (0.85-0.95 mg/kg), and higher (>0.95 mg/kg) t-PA dose groups. Differences in the outcomes of these groups were compared in terms of functional recovery (modified Rankin Scale [mRS] 0-1) at 3 months and the incidence of parenchymal hemorrhages on follow-up computed tomographic scans. RESULTS: This cohort study included 272 patients: 171 (63%) patients received the standard t-PA dose, 62 (23%) a lower dose, and 39 (14%) a higher dose. At 3 months, 51% of the standard dose patients achieved a mRS score of 0 to 1, compared with 50% in the lower dose and 44% in the higher dose groups. Parenchymal hemorrhage occurred in 4.7%, 6.5%, and 7.7% of patients in standard, lower, and higher dose groups, respectively. Compared with standard dose groups, no significant differences in functional recovery and parenchymal hemorrhage were observed in the lower and higher dose groups. CONCLUSIONS: In clinical practice, the actual dose of t-PA often differs from the recommended dose of 0.9 mg/kg, but this has no significant impact on the outcome after t-PA treatment.

Outcome of patients with negative CT angiography results for arterial occlusion treated with intravenous thrombolysis.

BACKGROUND AND PURPOSE: Stroke patients without evidence of arterial occlusion may not be suitable candidates for thrombolytic therapy. In our study, we investigated the outcomes of patients with negative CT angiography results for arterial occlusion. METHODS: The study included patients treated within 3 hours after symptom onset with intravenous thrombolysis for significant neurological deficit between August 2003 and June 2007. All of the patients were documented with negative CT angiography results for arterial occlusion by independent reviews. Outcome measurements included modified Rankin score at 3 months, incidence of intracranial hemorrhage, and infarction volume on control CT. The predictors of unfavorable outcome (modified Rankin score, 2-6) were identified by multivariate logistic regression. RESULTS: Altogether, 173 patients received intravenous thrombolysis; of those, 138 underwent CT angiography. The CT angiography results were negative for arterial occlusion in 39 (28%) of the patients: mean age, 71+/-10 years; 16 (41%) female; median baseline NIHSS, 11. At 3 months, modified Rankin score of 0 to 1 was achieved in 18 (46%) of the patients; 6 (15%) died; and 3 (8%) had symptomatic parenchymal hemorrhage. The median infarct volume was 1.5 cm(3). The independent predictors of unfavorable clinical outcome were higher age (OR, 1.1; 95% CI, 1.01-1.27), and baseline NIHSS >12 (OR, 18.8; 95% CI, 1.4 to 261). One patient had encephalitis diagnosed. CONCLUSIONS: Negative baseline CT angiography is not uncommon. The risk of intracerebral hemorrhage after thrombolytic therapy for patients without evidence of arterial occlusion is similar to the risk carried in an unselected patient population. Given the prognosis, thrombolytic therapy seems justified; however, etiology other than stroke should be considered.