Early neurological deterioration following thrombolysis for minor stroke with isolated internal carotid artery occlusion.

BACKGROUND AND PURPOSE: Better understanding the incidence, predictors and mechanisms of early neurological deterioration (END) following intravenous thrombolysis (IVT) for acute stroke with mild symptoms and isolated internal carotid artery occlusion (iICAo) may inform therapeutic decisions. METHODS: From a multicenter retrospective database, we extracted all patients with both National Institutes of Health Stroke Scale (NIHSS) score <6 and iICAo (i.e. not involving the Willis circle) on admission imaging, intended for IVT alone. END was defined as ≥4 NIHSS points increase within 24 h. END and no-END patients were compared for (i) pre-treatment clinical and imaging variables and (ii) occurrence of intracranial occlusion, carotid recanalization and parenchymal hemorrhage on follow-up imaging. RESULTS: Seventy-four patients were included, amongst whom 22 (30%) patients experienced END. Amongst pre-treatment variables, suprabulbar carotid occlusion was the only admission predictor of END following stepwise variable selection (odds ratio = 4.0, 95% confidence interval: 1.3-12.2; P = 0.015). On follow-up imaging, there was no instance of parenchymal hemorrhage, but an intracranial occlusion was now present in 76% vs. 0% of END and no-END patients, respectively (P < 0.001), and there was a trend toward higher carotid recanalization rate in END patients (29% vs. 9%, P = 0.07). As compared to no-END, END was strongly associated with a poor 3-month outcome. CONCLUSIONS: Early neurological deterioration is a frequent and highly deleterious event after IVT for minor stroke with iICAo, and is of thromboembolic origin in three out of four patients. The strong association with iICAo site-largely a function of underlying stroke etiology-may point to a different response of the thrombus to IVT. These findings suggest END may be preventable in this setting.

Management and outcome of cerebral venous thrombosis after head trauma: A case series.

Cerebral venous thrombosis (CVT) is an underdiagnosed complication of head trauma. To date, initiation of anticoagulation is still a matter of debate because of the risk of worsening traumatic hemorrhage. This report describes a case series of five patients admitted for head injury complicated by CVT. The main associated radiological signs were skull fractures crossing the venous sinus and adjacent traumatic hematoma. In four patients, anticoagulation was introduced within 48-72h of CVT diagnosis, with no subsequent hemorrhagic complications. The present report and data from the literature raise the question of systematic additional venoscans when confronted by associated radiological features of post-traumatic CVT. The safety of anticoagulation in selected patients is also discussed.

[Stroke and cornea verticillata revealing Fabry's disease in a female]. / Accident vasculaire cérébral ischémique et cornée verticillée révélant une maladie de Fabry chez une femme.

INTRODUCTION: Fabry's disease is a X-linked lysosomal storage disorder caused by an alpha-galactosidase A deficiency responsible for the accumulation of glycosphingolipids. Males are more severely and frequently affected than females. We report the case of a female who presented a stroke revealing Fabry's disease. CASE REPORT: An 53-year-old woman, with cardiovascular risk factors and two previous transient ischemic attacks, was admitted with a brutal right hemiparisia. Cerebral MRI showed multiple white matter lesions in the cerebral hemispheres with multiple lacunar infarcts and ectatic vessels, cardiac echography revealed a hypertrophic concentric cardiomyopathy, and slit-lamp examination demonstrated a cornea verticillata. The sequencing of the alpha-galactosidase gene (GLA) revealed the c.150_151del mutation responsible for a loss of function. DISCUSSION: As in the present case, ophthalmological examination is very useful to determine Fabry's disease as a cause of young onset stroke. Females may be affected by X-linked disease, as the Fabry's disease. Fabry's disease among females is mainly characterized by the involvement of the nervous and cardiovascular systems. The specific treatment is based on an enzyme replacement therapy by recombinant enzyme with cardiovascular benefit. Despite the presence of cardiovascular risk factors, this case demonstrates the importance of thorough standardized investigations including ophthalmological examination of young patients with stroke.

The G79A polymorphism of protein Z gene is an independent risk factor for cerebral venous thrombosis.

BACKGROUND AND PURPOSE: Protein Z (PZ), a vitamin Kdependent protein, plays a role in inhibiting coagulation. Its plasma level or PZ gene polymorphisms have been discussed as risk factors for stroke with conflicting results reported between various studies. Only one of these polymorphisms was studied in a cohort of patients suffering from cerebral venous thrombosis (CVT). METHODS: We performed a retrospective genetic study comparing 100 healthy controls to 54 patients referred to our hemostasis unit after CVT occurrence. We compared the distribution of three PZ gene polymorphisms that may influence PZ plasma levels: A-13G in the promoter and G79A in intron F were tested using previously described techniques, and we developed a technique to evaluate the G-103A in intron A. RESULTS: The G79A polymorphism was significantly more frequent in patients than in controls (p = 0.012): the presence of at least one A allele led to an odds ratio of 2.57 with a 95 % confidence interval of 1.23-5.34. The A-13G polymorphism also showed a nonsignificant trend towards a higher prevalence in patients. CONCLUSION: The G79A polymorphism of the PZ gene was shown to be a new independent risk factor for cerebral venous thrombosis. Nevertheless, these results have to be confirmed by a prospective study including plasma PZ evaluation.

[Acute headaches]. / Céphalées aiguës.

Etiologic diagnosis of acute headache is made by accurate history of the pain and systematic examination in search of associated signs: the aim of this reasoning procedure is identification of secondary (organic) headache disorders which are infrequent but are needing urgent evaluation and care from primary headaches whose various methods of treatment are specific.

[Rebleeding from a vertebral artery dissection in a child: an inflammatory vasculopathy?]. / Resaignement d'une dissection d'artère vertébrale chez un enfant : une vasculopathie inflammatoire ?

We present a case of a rebleeding remote from a vertebral artery dissection associated with subarachnoid haemorrhage. A 7-year-old boy without any antecedent presented a traumatic dissection of the vertebral artery with subarachnoid haemorrhage. After a conservative treatment, the morphology of the vertebral artery became normal and the boy was asymptomatic. Four months later, a rebleeding occurred on the same vertebral artery, whose morphological review was normal. Mechanisms and cases of rebleeding in the literature are discussed. An inflammatory vasculopathy was suspected and discussed.

Antiphospholipid antibodies in the acute phase of cerebral ischaemia in young adults: a descriptive study of 139 patients.

A total of 139 young stroke patients were consecutively examined and tested for antiphospholipid antibodies (APLA) to evaluate the role of these antibodies in cerebral ischaemia before the age of 45. APLA were found in 28.8% of patients. Two factors, hypertriglyceridaemia and alcohol abuse, were significantly more frequent in patients with a positive APLA test. The demographic characteristics, other risk factors, history of prior thrombotic events and distribution of aetiopathogenic types of cerebral ischaemia were not different in patients with or without APLA. Laboratory assays for APLA were highly positive for only two patients, who both had autoimmune diseases. These results suggest that with the exception of a clinical context of antiphospholipid syndrome or other autoimmune diseases, the usefulness of this diagnostic tool in the management of cerebral ischaemia remains limited.