Serum Prealbumin Levels on Admission as a Prognostic Marker in Stroke Patients Treated with Mechanical Thrombectomy.

INTRODUCTION: Prealbumin is a marker of malnutrition and inflammation. It has been associated with poor prognosis in cardiovascular disease, but less is known in stroke patients. Our objective was to evaluate the association of prealbumin levels at admission with prognosis in patients with stroke treated with mechanical thrombectomy. METHODS: Retrospective study of a prospective database of consecutive patients treated with mechanical thrombectomy. Clinical, radiological, and blood parameters including serum prealbumin, and prognostic variables such as respiratory infection, in-hospital mortality, and the modified Rankin scale at 3 months were collected. RESULTS: We included 319 patients between 2018 and 2019. Prealbumin levels were significantly lower in patients older than 80 years, women, patients with a prestroke Rankin score >2, a glomerular filtrate rate <60 mL/min, and in those with atrial fibrillation. Regarding prognostic variables, prealbumin levels were not associated with respiratory infection. Low prealbumin levels were associated with poor functional prognosis (Rankin score >2), in-hospital mortality, and 3-month mortality. In multivariate analysis, prealbumin was an independent risk factor associated with mortality at 3 months, OR 0.92 [0.86-0.98], p = 0.019. CONCLUSION: Lower prealbumin levels at admission behaved as an independent predictor of long-term mortality in patients treated with mechanical thrombectomy. These results should be replicated in other cohorts.

Efficacy and Safety of Endovascular Treatment in Acute Tandem Carotid Occlusions: Analysis of a Single-Center Cohort.

INTRODUCTION: Acute ischemic strokes with tandem occlusions, which represent 10-20% of all ischemic strokes, have a particularly poor prognosis. Since emergent treatment of tandem lesions has not been specifically addressed in randomized trials, there is an absence of standardized management. OBJECTIVE: We sought to assess the efficacy and safety of acute endovascular treatment in stroke due to tandem occlusions in our center and compare the results with previous reports. METHODS: From a prospective registry we analyzed data of 99 consecutive patients (males: 77.7%, mean age ± SD: 67.5 ± 9.5 years) with stroke due to tandem occlusions who underwent treatment with emergent carotid stenting and intracranial mechanical thrombectomy. Successful recanalization was defined as a TICI score of 2b-3 and a good functional outcome was defined as a modified Rankin scale score ≤2 at 90 days. Symptomatic intracranial hemorrhage (sICH) was considered when associated with worsening on the National Institutes of Health Stroke Scale (≥4 points). RESULTS: A successful recanalization rate was achieved in 87.8 and 48.5% of the patients had a good functional outcome. sICH and mortality rates were 12.1 and 20.2%, respectively, and 21.2% of the patients received combined treatment with intravenous thrombolysis, which did not affect neither the prognosis nor the recanalization or sICH rates. The time from symptom onset to recanalization and the degree of recanalization were the main factors associated with prognosis and the occurrence of sICH. CONCLUSIONS: Our results suggest that endovascular treatment with emergent carotid stenting and intracranial thrombectomy in patients with acute stroke due to tandem occlusions is an effective and safe procedure.

Endovascular reconstruction of internal carotid artery dissection in patients with acute ischemic stroke using the Wingspan stent.

OBJECTIVE: The purpose of this study is to demonstrate our experience in endovascular reconstruction of carotid dissections using the Wingspan Stent System™ (Boston Scientific, Natick, MA, USA), a device we use because of its high radial force and its navigation in extreme curves. METHODS: We treated 11 consecutive patients with acute ischemic stroke due to carotid dissection with the Wingspan stent, in the cervical carotid artery. RESULTS: Functional evaluation revealed that 10 of the 11 patients were independent at 3 months post surgery and that the 11 stents used were found to be patent at the 6-month follow-up digital subtraction angiography (DSA). CONCLUSIONS: The Wingspan stent is an alternative to classic carotid stents and flow diverters for the treatment of cervical internal carotid artery (ICA) dissection associated with ectasias or large loops. The device remains patent over the long term and it is not associated with arterial wall complications.

Dilemma in the emergency setting: hypomagnesemia mimicking acute stroke.

BACKGROUND: Stroke mimics may account for up to 30% of all acute stroke consultations. However, in the emergency setting, accurate diagnosis is not always possible. METHODS: Case report and review of the literature. RESULTS: A 73-year-old woman was admitted to the emergency department with acute aphasia and right hemiparesis. The National Institute of Health Stroke Score was 21, compatible with severe stroke, so she received thrombolysis. Laboratory testing demonstrated severe hypomagnesemia. She had been taking proton pump inhibitors for years and neuroimaging did not demonstrate signs of acute ischemic disease. After correcting the metabolic alterations with intravenous and oral supplemental magnesium, the patient was discharged asymptomatic. No further episodes have been registered to date. CONCLUSION: Hypomagnesemia might cause acute neurological symptoms that could be confused with stroke. A careful history is essential for diagnosis but suspicion of stroke mimic should not prevent tPA administration.

[Utility of treatment with atorvastatin 40 mg plus ezetimibe 10 mg versus atorvastatin 80 mg in reducing the levels of LDL cholesterol in patients with ischaemic stroke or transient ischaemic attack]. / Utilidad del tratamiento con atorvastatina 40 mg más ezetimiba 10 mg frente a atorvastatina 80 mg en la reducción de los niveles de colesterol LDL en pacientes con ictus isquémico o ataque isquémico transitorio.

INTRODUCTION: After an ischaemic stroke, to reduce LDL cholesterol (LDLc) levels decreases the risk of recurrence. The risk of recurrence is lower with more intense reductions in LDLc levels. AIM: To evaluate the efficacy and security of atorvastatin 40 mg plus ezetimibe 10 mg after ischaemic stroke or transient ischaemic attack (TIA). PATIENTS AND METHODS: We retrospectively evaluated stroke or TIA patients admitted to our hospital who received atorvastatin 40 mg plus ezetimibe 10 mg (n = 34) or atorvastatin 80 mg (n = 52) at discharge. We analyzed changes in lipid parameters and established as a primary outcome LDLc <= 70 mg/dL and/or reduction in LDLc >= 50%. Furthermore, safety parameters were assessed. RESULTS: Predictors associated with primary outcome achievement were treatment with atorvastatin 40 mg plus ezetimibe 10 mg (odds ratio: 11.94; 95% CI: 2.82-50.64; p = 0.001) and male (odds ratio: 4.76; 95% CI: 1.35-16.67; p = 0.02). Treatment with atorvastatin 40 mg plus ezetimibe 10 mg achieved significantly greater reductions in LDLc (p < 0.001), total cholesterol (p < 0.001) and non-HDLc (p < 0.001). Both treatments were safe and well tolerated, with a low number of secondary effects. CONCLUSIONS: Compared with atorvastatin 80 mg, atorvastatin 40 mg plus ezetimibe 10 mg increases the likelihood of achieving LDLc goals after ischaemic stroke or transient ischaemic attack. Both treatments were safe and well tolerated.

TITLE: Utilidad del tratamiento con atorvastatina 40 mg mas ezetimiba 10 mg frente a atorvastatina 80 mg en la reduccion de los niveles de colesterol LDL en pacientes con ictus isquemico o ataque isquemico transitorio.Introduccion. Tras un ictus isquemico, reducir los niveles de colesterol LDL (LDLc) disminuye el riesgo de recurrencia. El riesgo de recurrencia es menor con reducciones mas intensas de las cifras de LDLc. Objetivo. Evaluar la eficacia y seguridad del tratamiento hipolipemiante combinado con atorvastatina 40 mg mas ezetimiba 10 mg tras un ictus isquemico o ataque isquemico transitorio (AIT). Pacientes y metodos. Evaluacion de la eficacia del tratamiento con atorvastatina 40 mg mas ezetimiba 10 mg (n = 34) frente a atorvastatina 80 mg (n = 52) en la modificacion de parametros lipidicos tras un ictus isquemico o AIT. Se establecio como objetivo primario la obtencion de niveles de LDLc <= 70 mg/dL o la reduccion de las cifras de LDLc >= 50%. Adicionalmente se evaluo la presencia de efectos secundarios en ambos grupos. Resultados. Se observo un incremento significativo de las probabilidades de alcanzar el objetivo primario en el grupo tratado con atorvastatina 40 mg mas ezetimiba 10 mg (odds ratio: 11,94; intervalo de confianza al 95%: 2,82-50,64; p = 0,001) y en los varones (odds ratio: 4,76; intervalo de confianza al 95%: 1,35-16,67; p = 0,02). El tratamiento con atorvastatina 40 mg mas ezetimiba 10 mg obtuvo reducciones superiores de LDLc (p < 0,001), colesterol total (p = 0,001) y no HDLc (p < 0,001). Ambos tratamientos fueron seguros, con escaso numero de efectos secundarios. Conclusiones. En comparacion con atorvastatina 80 mg, el tratamiento con atorvastatina 40 mg mas ezetimiba 10 mg incrementa la probabilidad de alcanzar los objetivos de LDLc. Ambos tratamientos son seguros y bien tolerados.

[Arterial pathology in migraine: endothelial dysfunction and structural changes in the brain and systemic vasculature]. / Patologia arterial en la migraña: disfuncion endotelial y cambios estructurales en la vasculatura cerebral y sistemica.

INTRODUCTION: The pathophysiology underlying the association between migraine and other non-atherosclerotic vascular diseases is largely unknown. Endothelial dysfunction has been proposed as a common link. Besides, endothelial dysfunction is considered as a predictor of structural changes in the arterial walls. AIM: To review the current knowledge about the functional (endothelial dysfunction) and structural (arterial stiffness and atherosclerotic diseases) arterial properties associated with migraine. DEVELOPMENT: Studies of biological markers of endothelial dysfunction in peripheral blood, systemic and cerebral vasoreactivity, arterial stiffness indexes and direct visualization of macroscopic changes in the arterial wall have shown differences between patients with and without migraine, as well as between the different migraine subtypes. CONCLUSIONS: Endothelial dysfunction, as a predictor of structural changes in arteries, has been proposed as an early marker for vascular pathology associated with migraine. In migraine patients there is an increase of biomarkers of endothelial dysfunction, but the correlation with vasoreactivity studies does not allow definite conclusions. Available data do not allow to conclude that migraine is associated with macroscopic alterations outside the cerebral arterial bed.

TITLE: Patologia arterial en la migraña: disfuncion endotelial y cambios estructurales en la vasculatura cerebral y sistemica.Introduccion. La fisiopatologia subyacente a la asociacion entre migraña y otras enfermedades vasculares sistemicas no aterotromboticas no se conoce con certeza. La disfuncion endotelial se ha propuesto como nexo comun. A su vez, la disfuncion endotelial se considera como precursora de cambios estructurales en las paredes arteriales. Objetivo. Revisar el conocimiento actual acerca de las alteraciones funcionales (disfuncion endotelial) y estructurales (rigidez arterial y cambios ateroescleroticos) del lecho arterial asociadas a la migraña. Desarrollo. Estudios de marcadores biologicos de disfuncion endotelial en sangre periferica, vasorreactividad sistemica y cerebral, calculo de indices de rigidez arterial y visualizacion directa de cambios macroscopicos en la pared arterial han mostrado diferencias entre pacientes con y sin migraña, asi como entre los distintos subtipos de migraña. Conclusiones. La disfuncion endotelial, como precursora de cambios estructurales a nivel arterial, se postula como sustrato de la patologia vascular asociada a la migraña. La alteracion de marcadores biologicos es sugestiva de disfuncion endotelial en los pacientes con migraña; sin embargo, la correlacion con estudios de vasorreactividad no permite establecer conclusiones definitivas. Los datos disponibles no permiten concluir que la migraña se asocie con alteraciones macroscopicas fuera del lecho arterial cerebral.

[Migraine as a vascular risk factor]. / La migraña como factor de riesgo vascular.

INTRODUCTION: Migraine and stroke are associated with a higher frequency than expected. Numerous studies have shown a significant, but controversial, association between migraine and vascular disease, not only in cerebral but also in other arterial beds. The full spectrum of this relationship includes coexisting stroke and migraine, stroke with clinical features of migraine and migraine-induced stroke. Why migraine is a risk factor and how it leads to stroke is not entirely understood, possibly because the mechanisms involved are multiple, complex and interrelated. AIM: Emphasizing the most recent papers, we review critically the current knowledge about the causal relationship between migraine and vascular disease and discuss its pathophysiology. DEVELOPMENT: Migraine is an independent risk factor for stroke, especially for young women with frequent migraine with aura attacks, who smoke and use oral contraceptives. Migraine has also been associated with lesions in the white matter and in other vascular territories. Potential pathogenic mechanisms include endothelium and vascular smooth muscle dysfunction, hypercoagulability, cortical spreading depression, genetic factors, patent foramen ovale, unfavourable vascular risk profile, arterial dissection and migraine-specific treatment. CONCLUSION: Considering that cerebrovascular disease is a major cause of disability and mortality and that migraine is a risk factor for vascular disease, understanding the relationship between migraine and vascular disease is necessary to reduce risks and optimize management and treatment.