Clinical Characteristics of Patients with Acute Ischemic Stroke Previously Vaccinated Against COVID-19.

OBJECTIVES: The aim of this study was to examine the clinical characteristics of patients with acute ischemic stroke which were previously vaccinated against Coronavirus Disease 2019 (COVID-19) and determine whether the vaccine had impact on outcome. MATERIALS AND METHODS: In this observational cohort study we analyzed the clinical characteristics of 58 patients with ischemic stroke, previously vaccinated against COVID-19. We analyzed demographic characteristics, risk factors, type of stroke and outcome. We also compared outcome of those patients with outcome in stroke patients hospitalized in the same period but not vaccinated, patients hospitalized during the pandemic, before vaccination began, and stroke patients hospitalized before the pandemic. Further, we compared mortality rate with mortality rate in patients who had acute ischemic stroke and COVID-19 simultaneously. RESULTS: The mean age of the patients was 71.0 years, most were male (58.6%), mostly with risk factors for stroke. In the largest number of patients, 17 (29.3%), the etiopathogenetic mechanism of stroke was atherosclerosis of the large arteries. Mortality in vaccinated patients was identical to mortality in stroke patients before pandemic, without significant difference from mortality in unvaccinated patients (13.8% versus 8.6%; p= 0.23). The mean NIHSS and mRS score at discharge for all examined groups were without significant difference. A significant difference in mortality was found between COVID-19 positive and COVID-19 negative stroke patients (37.8% versus 18.1%; p=0.001). CONCLUSIONS: There are no significant differences in clinical characteristics of stroke in vaccinated compared to unvaccinated patients. We did not find a connection between vaccination and stroke.

Patients with Acute Lacunar Infarction Have Benefit from Intravenous Thrombolysis.

INTRODUCTION: Usefulness of intravenous thrombolysis in patients with acute lacunar cerebral infarction is questionable. The aim of this study was to evaluate the efficacy and safety of intravenous thrombolysis in patients with lacunar infarction in comparison with patients with nonlacunar infarction as well as with patients with lacunar infarction who were not treated with intravenous thrombolysis. MATERIALS AND METHODS: In the first part of the study, among patients with acute ischemic stroke treated with intravenous thrombolysis, characteristics and outcomes of 46 patients with lacunar and 221 patients with nonlacunar infarction were compared. In the second part, 46 patients with lacunar infarction treated with intravenous thrombolysis were compared with 45 lacunar infarction patients who were not treated with intravenous thrombolysis. RESULTS: Patients with lacunar infarction had a lower National Institutes of Health Stroke Scale score (9.2 versus 13.9, P < .001), a greater Alberta Stroke Program Early computed tomography (CT) score (9.7 versus 9.2, P = .002), a lower prevalence of atrial fibrillation (6.5% versus 41.2%, P < .001), and significantly more frequently an excellent outcome after 3 months (76.1% versus 36.2%, P < .001) compared with patients with nonlacunar infarction. Among patients with lacunar infarction, an excellent outcome at discharge was significantly more frequent in the intravenous thrombolysis group (41.3% versus 15.6%, P = .01), and the length of hospitalization was significantly shorter (9.5 days versus 14.3 days, P = .002). There was no hemorrhagic transformation among patients with lacunar infarction treated with intravenous thrombolysis. CONCLUSION: Intravenous thrombolysis has proven to be effective and safe in patients with lacunar infarction and should always be applied if there are no absolute contraindications.

Outcome after intravenous thrombolysis in embolic stroke of undetermined source compared to cardioembolic stroke.

BACKGROUND: It is assumed that most cases of embolic stroke of undetermined source (ESUS) are of cardioembolic origin. The data about outcome after the treatment with intravenous thrombolysis (IVT) for this type of acute ischemic stroke (AIS) are limited. We aimed to compare clinical characteristics and outcomes after IVT for AIS between patients with ESUS and cardioembolic stroke (CS). METHODS: This study was a single center retrospective analysis of stroke patients treated with IVT. The Trial of ORG 10172 in Acute Stroke Treatment criteria were used to establish stroke etiology subtype at 3 months, while ESUS was considered a subset of stroke of undetermined etiology, defined according to 2014 international criteria. Functional outcome was assessed at 3 months and defined as excellent (modified Rankin scale 0-1) and favorable (modified Rankin scale 0-2). RESULTS: Total of 394 patients were treated with IVT; 113 had a cardioembolism, 88 had undetermined stroke subtype, of which 62 met the ESUS criteria. Patients with ESUS were on average younger (63.7 years versus 69.7 years, p = 0.001), had a lower National Institutes of Health Stroke Scale (NIHSS) score on admission (12 versus 15, p = 0.002) and lower prevalence of antiplatelets use (27.4% versus 42.5%, p = 0.04) compared with CS patients. Favorable outcome was more likely in ESUS patients, at discharge (48.4% versus 24.0%, p = 0.002) and after 3 months (71.0% versus 37.2%, p < 0.001). Hemorrhagic transformation was less frequent (17.7% versus 33.6%, p = 0.03) in ESUS patients. Independent predictors of 3­month favorable outcome were ESUS, the absence of leukoaraiosis on computed tomography (CT) and absence of diabetes as a risk factor. CONCLUSION: Patients with ESUS had better outcome after IVT than patients with CS, which can be attributed to younger age and milder strokes in these patients.

Psychiatric consequences of stress after a vehicle accident.

BACKGROUND: Vehicle accidents are a common cause of disease and death among people over 30 years of age. Essentially, reaction to stress due to the vehicle accident does not differ from the reaction to other stress factors. There are still no uniform viewpoints about the kind of sequels and their percentage representation after vehicle accidents. SUBJECTS AND METHODS: The research was provided as a prospective study, included 150 subjects who had vehicle accident minimum 2 years prior to the examination. A questionnaire adjusted to the needs of the research and a battery of psychological tests was used. RESULTS: Affective disorders occurred in 35.33% of subjects, 65% of persons suffer from travel anxiety, 9% of the total number of examinees doesn't drive any more, 65% have somatisational dysfunctions of the vegetative nervous system, while the posttraumatic stress disorder is present in 36% of subjects. CONCLUSION: In 87.4% of persons psychiatric consequences last over two years. Long term consequences in 60% of subjects occur as a combination of multiple psychiatric disorders, so the posttraumatic stress disorder and affective disorders never occur one at a time.

The Impact of Comorbidity on Rehabilitation Outcome after Ischemic Stroke.

Comorbidity decreases survival but it still remains unknown to what extent functional recovery after ischemic stroke is affected. The aim of this research was to determine the prevalence of the most common comorbidities in patients with ischemic stroke and to examine their predictive value on the functional status and recovery. In order to obtain relevant information for this research, we conducted a prospective study over a two-year period. It included patients with acute/subacute ischemic stroke who had inhospital rehabilitation treatment in our institution. Functional status of the patients was evaluated by the following three aspects at the beginning and at the end of rehabilitation treatment: Rivermead Mobility Index was used for mobility, Barthel Index for independence in activities of daily living, and modified Rankin Scale for total disability. Modified Charlston Comorbidity Index was used to assess comorbidity. Multivariate analysis was applied to evaluate the impact of recorded comorbidities on the patient functional outcome. Independent predictors of rehabilitation success in our study were the value of modified Charlston Comorbidity Index, atrial fibrillation and myocardial infarction. Our study demonstrated that patients with more comorbidities had worse functional outcome after stroke, so it is important to consider the comorbidity status when planning the rehabilitation treatment.

Association between Apolipoproteins AI and B and Ultrasound Indicators of Carotid Atherosclerosis.

BACKGROUND: Apolipoproteins A-I and B (apoA-I and apoB) may be better indicators of the risk of cardiovascular and cerebrovascular diseases than conventional risk factors (RFs). The onset of ischemic stroke (IS) may be preceded by the development of atherosclerotic changes in carotid arteries, which can be detected by ultrasound. Only a certain % of patients with IS have an (underlying) carotid etiology. OBJECTIVE: The aim of our study was to determine the association between ultrasound indicators of carotid atherosclerosis and the presence of apolipoproteins and other biomarkers in patients with IS. METHODS: The study included 120 patients with clinically first, non-cardioembolic ischemic stroke in the carotid circulation. For all patients the following data were recorded: risk factors (hypertension, diabetes, hyperlipoproteinemia, smoking, obesity, metabolic syndrome, (MetS) hyperhomocysteinemia and inflammation), and levels of blood pressure, glucose, glycosylated hemoglobin, lipids, apoA-I and apoB apolipoproteins, body mass index, homocysteine, and C-reactive protein (CRP). Carotid duplex ultrasound was used to measure carotid intima media thickness (cIMT) and determine the presence of an unstable (hypoechogenic) plaque. RESULTS: The most significant associations were found between cIMT and older age (ß=0.230; p=0.006), lower concentrations of apoA-I (ß=-0.244; p=0.008) and a higher apoB/apoA-I ratio (ß=0.247; p=0.007). The presence of a hypoechogenic plaque was most significantly associated with increased concentrations of apoB (OR=2.29; 95% CI=4.9-173.5; p<0.0001), the presence of MetS (OR=9.2; 95% CI=2.9-29.2; p<0.0001) and elevated CRP (OR=2.7; 95% CI=1.1-6.9; p = 0.046). CONCLUSION: Among RFs and their biomarkers, apoA-I, apoB and the apoB/apoA-I ratio showed strong association with ultrasound indicators of carotid atherosclerosis in IS patients.

A CASE OF PROBABLE NEUROSARCOIDOSIS PRESENTING AS UNILATERAL OPHTHALMOPLEGIA.

Sarcoidosis is a multisystem disease of unknown etiology, characterized by the presence of noncaseating epithelioid granulomas and accumulation of T lymphocytes and mononuclear phagocytes, which damages the normal structure of tissues. Isolated form of neurosarcoidosis is very rare and difficult to diagnose and requires histologic confirmation of noncaseating granulomas in the nervous tissue. We report a case of a 55-year-old female who had probable isolated neurosarcoidosis based on magnetic resonance imaging findings of relapsing pachymeningitis with an inflammatory process in the apex of the right orbit and pseudotumor inflammation of the superior and lateral recti of the right eye. Diagnosis was further verified by positive response to dual corticosteroid and immunosuppressive therapy. Our case demonstrates the importance of considering isolated neurosarcoidosis as a potential underlying etiology of painful ophthalmoplegia, even without systemic manifestation of the disease.

The effect of post stroke depression on functional outcome and quality of life.

In spite of being a common and important complication of stroke, post stroke depression is often overlooked, so its impact on stroke outcome remains under recognized. The aim of the study was to determine the effect of depression on functional outcome and quality of life in stroke patients. The study included 60 patients treated for their first clinical stroke, 30 of them diagnosed with depression and 30 patients without depression. Testing was done in all patients two and six weeks after stroke. Depression was diagnosed according to the Mini International Neuropsychiatry Interview, DSM-IV diagnostic criteria, and depression severity was quantified by the Hamilton Depression Rating Scale; functional impairment was determined by the Barthel Index; and post stroke quality of life was assessed by the Short Form 36 (SF-36) questionnaires. The patients with depression had significantly more severe functional disability both at baseline and after rehabilitation treatment, although the potential for functional recovery in depressed patients was less than in non-depressed ones. The quality of life in patients with post stroke depression was impaired more severely in all SF-36 domains compared with non-depressed stroke patients, with the domains of the role of emotional functioning and social relations being most severely affected.

Atrial myxoma as a cause of stroke: emboli detection and thrombolytic treatment.

It presents a case of a 42-year-old female patient who was admitted to the stroke unit for right-sided hemiplegia and global aphasia, without conventional stroke risk factors. As the patient presented within the therapeutic time window and had no contraindications for thrombolysis, intravenous thrombolytic treatment was initiated. Brain CT showed multiple hypodense partly confluent lesions in the territory of the left middle cerebral artery. For the purpose of determining the etiology of the stroke, TCD was performed and after cerebral microemboli were detected, transthoracic echocardiography was indicated, the finding of which showed the presence of a myxoma in the left atrium. The patient underwent surgery and thereafter her neurological deficits improved.

[Factors predisposing to cervical artery dissection].

INTRODUCTION: Cervical artery dissection is a major cause of cerebral ischemia in young adults and can lead to various clinical symptoms, some of which are benign (e.g. headache, neck pain, Horner's syndrome, and cranial nerve palsy). However, most patients have a stroke or transient ischemic attack. EPIDEMIOLOGY: The incidence of cervical artery dissection is low and is estimated to be around 2.6 per 100,000 inhabitants. Mortality and short-term recurrence rates are low: however; they may have been underestimated. PATHOPHYSIOLOGY: Although the pathophysiology is still unclear constitutional and partly genetic susceptibility of the arterial wall has been proposed as a causal factor; triggered by infection or minor trauma. PREDISPOSING FACTORS: In addition to the trauma to the neck, other risk fractors have been suggested, such as infection, migraine, hyperhomocisteinamia, and the 67TT genotype of the 5,10-methylene-tetrahydrofolate reductase gene although evidence is sparse. GENETIC FACTORS: Cervical artery dissection is now considered a multifactorial disease caused by several genetic abnormalities and environmental factors acting synergistically. CONCLUSION: Research aimed at improving our understanding of the environmental and genetic factors predisposing to cervical artery dissection and assessment of long-term outcomes of this disease is needed. Better understanding of the underlying pathophysiology and the natural history of the disease through large prospective multicentre cohorts could also be helpful to improve therapeutic and preventive strategies. Several mutlticentre efforts are already under way to meet these needs.

[Diagnosis and outcome of cervical artery dissection].

INTRODUCTION: Spontaneous dissection of the cervical artery is a rare non-atherosclerotic vascular disease of unknown aetiology and unclear pathogenesis that may be a cause of ischemic stroke in young adults. DIAGNOSIS: Precise diagnosis of dissection of the cervical artery--carotid or vertebral--is possible with cervical axial magnetic resonance imaging and magnetic resonance angiography. TREATMENT: The recommended treatment in the acute phase of cervical artery dissection is anticoagulant or antithrombotic therapy, aimed at preventing a primary or recurrent ischemic event. There have been as yet no results of randomized controlled studies comparing efficacy of both treatments. An ongoing randomized multicentre study is expected to provide answers about the effects of these treatments in cervical artery dissection. OUTCOME: Complete resolution of arterial abnormalities is achieved in around 46% of stenoses. 33% of occlusions, and 12% of dissecting aneurysms. RECURRENT EVENTS: Recurrence of cerebral ischemia and cervical artery dissection seems to be rare, although some data suggest that early ischemic and late cervical artery dissection recurrences could be underestimated. MORTALITY AND FUNCTIONAL OUTCOME: In comparison with other causes of stroke in young adults, the functional outcome of cervical artery dissection is good in contrast to its socio-professional effects, which may be unsatisfactory. The mortality rate of cervical artery dissection is low, although it may be underestimated since some patients with malignant infarction die before the diagnosis is established. CONCLUSION: Further research is warranted to improve our understanding of the underlying pathophysiology, to assess the long-term outcome, and ultimately to provide treatment and prevention strategies.

Does massive cerebral venous thrombosis mean poor outcome?

A 21-year-old woman taking oral contraceptives presented with headaches, nausea, vomiting and somnolence. The next day she had a generalized tonic-clonic seizure after which her neurological condition deteriorated. CT and MRI showed multiple cerebral haemorrhages, while MR venography revealed extensive dural sinus and venous thrombosis involving almost all sinuses, great cerebral vein of Galen and internal cerebral veins. Two weeks after initiation of the anticoagulant treatment the patient recovered completely with complete recanalization of all cerebral sinuses and veins. Although the patient had conditions which were indicative of poor outcome, her neurological deficit improved completely, which correlated with recanalization of the thrombosed vessels.

[The most frequent causes of ischemic stroke in young adults].

INTRODUCTION: Pathogenesis of ischemic stroke in young adults is heterogeneous, thus making differential diagnosis very broad. MATERIAL AND METHODS: The study comprised 60 ischemic stroke patients of both sexes aged 15-45 years who were treated at the Department of Neurology of the Clinical Centre of Vojvodina. Information about sex and age, detailed history, risk factors for ischemic stroke were obtained for all patients who underwent neurological examination as well. Diagnostic procedures applied in all patients included brain computed tomography and/or magnetic resonance imaging, routine laboratory tests, Doppler imaging of extra and endocranial blood vessels and coagulation tests. Contrast and/ or transesophageal echocardiography, immunological blood assays, magnetic resonance angiography and/or computed tomography angiography and/or conventional angiography, immunological tests, assessment of levels of natural coagulation inhibitors, toxicological examination, etc. were performed in selected patients. RESULTS: Causes of ischemic stroke were determined according to the Trial of ORG 10172 in Acute Stroke Treatment criteria. The most frequent were the so called other causes of ischemic stroke, which were found in 26.7% patients. The second most frequent cause was cardiac embolisation, found in 25%. The cause of ischemic stroke remained undetermined in 21.7% of all patients. CONCLUSION: Aetiology of ischemic stroke in young adults is diverse and demands thorough diagnostic evaluation.

A case series of 22 patients with internal carotid artery dissection.

The aim of this study was to analyze the spectrum of clinical presentations of internal carotid artery dissection. Twenty-two patients with internal carotid artery dissection, mean age 39.02, were evaluated over the past ten years. Magnetic resonance imaging and magnetic resonance angiography were used to establish the diagnosis. Facial and neck pain and Horner's syndrome were the only presenting symptoms in 4 patients (without brain infarction); facial pain, Horner's syndrome and contralateral sensorimotor deficit in 6; headache and contralateral sensorimotor deficit in 2; contralateral sensorimotor deficit with or without speech impairment in 10. Internal carotid artery dissection was triggered by a trauma in 7, whereas it was spontaneous in 15. Magnetic resonance imaging revealed infarction in 18 patients. A good outcome (modified Rankin score 0-2) was seen in 20 patients. The spectrum of clinical presentations of internal carotid artery dissection is variable. Internal carotid artery dissection is not necessarily accompanied by infarction on magnetic resonance imaging.

Non-atherosclerotic arteriopathy as the cause of ischemic stroke among young adults.

The study comprised 100 ischemic stroke patients of both sexes aged 15-45 years who were treated at the Clinic of Neurology of the Clinical Center of Vojvodina in the period January 2001-September 2004. All study subjects were divided into three age groups: 15-25, 26-35 and 36-45 years. Sex, age and risk factors for cerebrovascular disease were determined in all patients. Diagnostic procedures applied in all patients included brain computed tomography and/or magnetic resonance imaging, routine laboratory tests, Doppler imaging of extra and endocranial blood vessels and coagulation tests. Contrast and/or transesophageal echocardiography, immunological blood assays, magnetic resonance angiography and/or computed tomography angiography and/or conventional angiography, thrombophilia markers, antiphospholipid antibodies and toxicological examination, etc. were performed in selected patients. Non-atherosclerotic arteriopathies were found in 8% of all study subjects, and were the most frequent cause of stroke in the age group 15-25. Carotid artery dissection was the most frequent diagnosis overall, found in 6% of all patients. Fibromuscular dysplasia and systemic vasculitis were diagnosed in one patient each. Moyamoya disease, Takayasu disease, infectious and isolated vasculitis of the CNS were not found in our patients.

Optimal therapy of epilepsy by measuring serum concentration of antiepileptic drugs with least adverse effects.

The study comprised 150 epileptic patients treated at the Institute of Neurology of the Clinical Centre Novi Sad. The optimal therapy with least adverse effects and seizures was achieved in patients in whom measurement of serum concentration of antiepileptic drugs was performed. Patients were divided into five groups with respect to the therapy they received: I--carbamazepane; II--valproic acid; III--polytherapy with phenobarbitone and diphenylhydantoin; IV--phenobarbitone and valproic acid; and V--phenobarbitone, valproic acid and carbamazepine. No adverse effects were recorded in over 60% of patients on monotherapy, 35% of patients who received two anticonvulsants, and 30% of patients who received three anticonvulsants. Significant correlation between drug dosage and blood drug concentration (r > 0.5) was found in polytherapy with phenobarbitone, carbamazepine and valproic acid (r = 0.66); and phenobarbitone and diphenylhydantoin (r = 0.53).