RESUMO
BACKGROUND: Decompressive craniectomy (DC) reduces mortality without increasing the risk of very severe disability among patients with life-threatening massive cerebral infarction. However, its efficacy was demonstrated before the era of endovascular thrombectomy trials. It remains uncertain whether DC improves the prognosis of patients with malignant middle cerebral artery (MCA) infarction receiving endovascular therapy. METHODS: We pooled data from two trials (DEVT and RESCUE BT studies in China) and patients with malignant MCA infarction were included to assess outcomes and heterogeneity of DC therapy effect. Patients with herniation were dichotomized into DC and conservative groups according to their treatment strategy. The primary outcome was the rate of mortality at 90 days. Secondary outcomes included disability level at 90 days as measured by the modified Rankin Scale score (mRS) and quality-of-life score. The associations of DC with clinical outcomes were performed using multivariable logistic regression. RESULTS: Of 98 patients with herniation, 37 received DC surgery and 61 received conservative treatment. The median (interquartile range) was 70 (62-76) years and 40.8% of the patients were women. The mortality rate at 90 days was 59.5% in the DC group compared with 85.2% in the conservative group (adjusted odds ratio, 0.31 [95% confidence interval (CI), 0.10-0.94]; P=0.04). There were 21.6% of patients in the DC group and 6.6% in the conservative group who had a mRS score of 4 (moderately severe disability); and 10.8% and 4.9%, respectively, had a score of 5 (severe disability). The quality-of-life score was higher in the DC group (0.00 [0.00-0.14] vs 0.00 [0.00-0.00], P=0.004), but DC treatment was not associated with better quality-of-life score in multivariable analyses (adjusted ß Coefficient, 0.02 [95% CI, -0.08-0.11]; p=0.75). CONCLUSIONS: DC was associated with decreased mortality among patients with malignant MCA infarction who received endovascular therapy. The majority of survivors remained moderately severe disability and required improvement on quality of life. CLINICAL TRIAL REGISTRATION: The DEVT trial: http://www.chictr.org. Identifier, ChiCTR-IOR-17013568. The RESCUE BT trial: URL: http://www.chictr.org. Identifier, ChiCTR-INR-17014167.
Assuntos
Craniectomia Descompressiva , Avaliação da Deficiência , Infarto da Artéria Cerebral Média , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , China , Craniectomia Descompressiva/mortalidade , Craniectomia Descompressiva/efeitos adversos , Estado Funcional , Infarto da Artéria Cerebral Média/mortalidade , Infarto da Artéria Cerebral Média/cirurgia , Infarto da Artéria Cerebral Média/terapia , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/fisiopatologia , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
A disrupted blood-brain barrier (BBB) with extravasation of macromolecules plays a critical role in the development of malignant middle cerebral artery infarction (MMI). Proteinuria is considered a marker of generalized endothelial dysfunction, including BBB disruption. This study aimed to clarify whether proteinuria identified in the acute stage of stroke is associated with MMI development. Patients with infarctions involving the middle cerebral artery territory were reviewed. Urine samples collected within 8 hours after stroke were analyzed using urine dipsticks. Patients were divided into proteinuria (urine dipstick reading of 1â +â to 4+) and nonproteinuria groups. MMI was present if either signs of uncal herniation or a progressive conscious disturbance were recorded along with a midline shiftâ >â 5 mm identified on follow-up computed tomography (CT). Among the 1261 patients identified between January 2010 and June 2019, 138 were eligible for final analyses. Patients in the MMI group had lower Alberta Stroke Program Early CT Scores (ASPECTS), higher National Institutes of Health Stroke Scale scores, and a greater proportion of proteinuria than those in the non-MMI group. Four multivariate logistic regression models were used to clarify the role of proteinuria in MMI development. In model 1, proteinuria was significantly associated with MMI after adjusting for age, sex, dyslipidemia and ASPECTS (ORâ =â 2.987, 95% CIâ =â 1.329-6.716, Pâ =â .0081). The risk of developing MMI in patients with proteinuria remained significant in model 2 (ORâ =â 3.066, 95% CIâ =â 1.349-6.968, Pâ =â .0075) after adjusting for estimated glomerular filtrate rate (eGFR)â <â 60ml/min/1.73 m2 in addition to variables in model 1. In model 3, proteinuria was still significantly associated with MMI after adjusting for age, sex, dyslipidemia, ASPECTS, hypertension, diabetes, and atrial fibrillation (ORâ =â 2.521, 95% CIâ =â 1.075-5.912, Pâ =â .0335). In model 4, the risk of developing MMI in patients with proteinuria remained significant (ORâ =â 2.579, 95% CIâ =â 1.094-6.079, Pâ =â .0304) after adjusting for eGFRâ <â 60ml/min/1.73 m2 in addition to variables in model 3. Proteinuria is independently associated with MMI development. Proteinuria may be a clinically accessible predictor of MMI development.
Assuntos
Nefropatias , Acidente Vascular Cerebral , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico , Modelos Logísticos , Proteinúria , Estudos Retrospectivos , Estados UnidosRESUMO
RATIONALE: We report on a patient whose arcuate fasciculus (AF) and corticobulbar tract (CBT) recovered following an infarct in the middle cerebral artery (MCA) territory, demonstrated on serial diffusion tensor tractography (DTT). PATIENT CONCERNS: The patient showed moderate conduction aphasia on the Western Aphasia Battery with an aphasia quotient of 46.5 (spontaneous speech: 35.0, auditory comprehension: 36.0, and naming: 53.1) at 1 month after onset. His aphasia improved with an aphasia quotient of 49 (spontaneous speech: 71.0, auditory comprehension: 52.0, and naming: 59.0) at 10 months after onset. DIAGNOSIS: A 44-year-old right-handed male patient presented with aphasia and quadriplegia, which occurred at the onset of an infarct in the left MCA territory. INTERVENTION: Diffusion tensor imaging data were acquired twice (1 month and 10 months after onset). OUTCOMES: On one-month DTT, the discontinuation of the left AF and severe narrowing of the right CBT were observed. However, on ten-month DTT, the left AF was connected to the opposite AF by a new tract that passed through the splenium of corpus callosum, and the right CBT had become thicker. LESSONS: We believe that our results suggest a recovery mechanism of injured AF and CBT in stroke patients.
Assuntos
Afasia , Encéfalo , Área de Broca , Infarto da Artéria Cerebral Média , Área de Wernicke , Adulto , Afasia/diagnóstico , Afasia/etiologia , Afasia/reabilitação , Encéfalo/irrigação sanguínea , Encéfalo/diagnóstico por imagem , Imagem de Tensor de Difusão/métodos , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/fisiopatologia , Infarto da Artéria Cerebral Média/reabilitação , Masculino , Vias Neurais/patologia , Vias Neurais/fisiopatologia , Reabilitação Neurológica/métodos , Tratos Piramidais/patologia , Recuperação de Função Fisiológica , Fonoterapia/métodos , Resultado do TratamentoRESUMO
Background Outcomes after stroke as a result of large-vessel occlusion in patients with prestroke disability were compared between endovascular therapy (EVT) and medical management. Methods and Results Of 2420 patients with acute stroke with large-vessel occlusion in a prospective, multicenter, nationwide registry in Japan, patients with prestroke modified Rankin Scale scores 2 to 4 with occlusion of the internal carotid artery, or M1 of the middle cerebral artery were analyzed. The primary effectiveness outcome was the favorable outcome, defined as return to at least the prestroke modified Rankin Scale score at 3 months. Safety outcomes included symptomatic intracranial hemorrhage. A total of 339 patients (237 women; median 85 [interquartile range (IQR), 79-89] years of age; median prestroke modified Rankin Scale score of 3 [IQR, 2-4]) were analyzed. EVT was performed in 175 patients (51.6%; mechanical thrombectomy, n=139). The EVT group was younger (p<0.01) and had lower prestroke modified Rankin Scale scores (p<0.01) than the medical management group. The favorable outcome was seen in 28.0% of the EVT group and in 10.9% of the medical management group (p<0.01). EVT was associated with the favorable outcome (adjusted odds ratio, 3.01; 95% CI, 1.55-5.85; mixed effects multivariable model with inverse probability of treatment weighting). Symptomatic intracranial hemorrhage rates were similar between the EVT (4.0%) and medical management (4.3%) groups (p=1.00). Conclusions Patients who underwent EVT showed better functional outcomes than those with medical management. Given proper patient selection, withholding EVT solely on the basis of prestroke disability might not offer the best chance of favorable outcome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02419794.
Assuntos
Estenose das Carótidas , Procedimentos Endovasculares , Infarto da Artéria Cerebral Média , Hemorragias Intracranianas , AVC Isquêmico , Complicações Pós-Operatórias , Trombectomia , Ativador de Plasminogênio Tecidual , Idoso de 80 Anos ou mais , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/fisiopatologia , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Estado Funcional , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/fisiopatologia , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/etiologia , AVC Isquêmico/diagnóstico , AVC Isquêmico/tratamento farmacológico , AVC Isquêmico/etiologia , AVC Isquêmico/cirurgia , Japão/epidemiologia , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Trombectomia/efeitos adversos , Trombectomia/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversosRESUMO
Growth arrest and DNA damage-inducible protein 34 (GADD34), one of the key effectors of negative feedback loops, is induced by stress and subsequently attempts to restore homeostasis. It plays a critical role in response to DNA damage and endoplasmic reticulum stress. GADD34 has opposing effects on different stimulus-induced cell apoptosis events in many nervous system diseases, but its role in ischemic stroke is unclear. In this study, we evaluated the role of GADD34 and its distribution in a rat cerebral ischemic model. The results showed that GADD34 was increased in the cortex and contributed to brain injury in ischemic rats. Furthermore, treatment with a GADD34 inhibitor reduced the infarct volume, improved functional outcomes, and inhibited neuronal apoptosis in the cortical penumbra after ischemia. The role of GADD34 in ischemic stroke was associated with the dephosphorylation of eukaryotic translation initiation factor 2α (eIF2α) and phosphorylation of p53. In addition, the GADD34 level was increased in plasma exosomes of cerebral ischemic rats. These findings indicate that GADD34 could be a potential therapeutic target and biomarker for ischemic stroke.
Assuntos
Antígenos de Diferenciação/metabolismo , Cinamatos/farmacologia , Infarto da Artéria Cerebral Média/diagnóstico , Proteínas Proto-Oncogênicas/metabolismo , Traumatismo por Reperfusão/prevenção & controle , Tioureia/análogos & derivados , Animais , Antígenos de Diferenciação/sangue , Biomarcadores/sangue , Biomarcadores/metabolismo , Cinamatos/uso terapêutico , Modelos Animais de Doenças , Fator de Iniciação 2 em Eucariotos/sangue , Fator de Iniciação 2 em Eucariotos/metabolismo , Exossomos/metabolismo , Humanos , Infarto da Artéria Cerebral Média/sangue , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/tratamento farmacológico , Masculino , Fosforilação/efeitos dos fármacos , Proteínas Proto-Oncogênicas/antagonistas & inibidores , Proteínas Proto-Oncogênicas/sangue , Ratos , Traumatismo por Reperfusão/etiologia , Tioureia/farmacologia , Tioureia/uso terapêutico , Proteína Supressora de Tumor p53/sangue , Proteína Supressora de Tumor p53/metabolismoRESUMO
Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.
Assuntos
COVID-19/complicações , Trombose das Artérias Carótidas/cirurgia , Procedimentos Endovasculares , Infarto da Artéria Cerebral Média/cirurgia , Acidente Vascular Cerebral/etiologia , Trombectomia , Idoso , Trombose das Artérias Carótidas/diagnóstico , Trombose das Artérias Carótidas/etiologia , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/etiologiaRESUMO
RATIONALE: Systemic lupus erythematosus (SLE) is an important cause of stroke, more than a half the cases present as acute ischemic stroke. Thrombolysis is an effective choice in most cases, but for large vessel occlusion, mechanical thrombectomy is more effective. Here we reported a case of SLE-related stroke with left middle cerebral artery (MCA) occlusion, who was successfully treated by MT and tirofiban. PATIENT CONCERN: A 38-year-old female suffered from right hemiplegia and aphasia for 8âhours. She was diagnosed with SLE 20âyears ago, and neuropsychiatric SLE was considered 8âmonths before this onset. One month ago, glucocorticoids were discontinued by herself because of deterioration of bilateral femoral head osteonecrosis. DIAGNOSIS: Left MCA occlusion was confirmed by computed tomography perfusion. INTERVENTION: Immediate mechanical thrombectomy was performed and tirofiban was given to prevent re-occlusion of left MCA. Twenty fourhours later oral antiplatelet was given after intracranial hemorrhage was ruled out. OUTCOMES: Her neurological symptom improved several days later, and she was transferred to further rehabilitation. At 4 months follow-up she can live independently with mild hypophrasia. There was no further events of ischemic stroke in 1-year follow-up. LESSONS: Mechanical thrombectomy is a highly effective and indispensable treatment for SLE related large vessel occlusion. In addition, tirofiban may reduce vessel reocclusion in special cases such as SLE and artery stenosis.
Assuntos
Infarto da Artéria Cerebral Média/terapia , Lúpus Eritematoso Sistêmico/complicações , Trombectomia/métodos , AVC Trombótico/terapia , Tirofibana/administração & dosagem , Adulto , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/imunologia , Lúpus Eritematoso Sistêmico/imunologia , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/cirurgia , Imagem de Perfusão , AVC Trombótico/diagnóstico , AVC Trombótico/imunologia , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
ABSTRACT: Disrupted blood-brain barrier (BBB) in patients with ischemic stroke plays a critical role in malignant middle cerebral artery infarction (MMI) development.Cerebral white matter changes (WMC), particularly in the deep subcortical area or in severe one, may be also underlain by disrupted BBB. It is unclear whether the presence of WMC with potential premorbid disruption of BBB makes patients susceptible to MMI. Therefore, this study aimed to clarify any putative relationship between the MMI and WMC in terms of their severity and locations.In this case-control study, patients with infarction in the middle cerebral artery territory were retrospectively reviewed. Brain magnetic resonance images were analyzed according to Fazekas scale, and identified WMC were divided into periventricular WMC (PV-WMC) and deep subcortical WMC (deep-WMC). Patients were scored as having WMC, PV-WMC, deep-WMC, severe PV-WMC, and severe deep-WMC according to the severity and locations. Patients were defined as having MMI if either a progressive conscious disturbance or signs of uncal herniation was recorded in combination with a midline shift >5âmm identified on the follow-up computed tomography.Among 297 patients admitted between July 2009 and February 2015, 92 patients were eligible for final analysis. Compared to patients without MMI, patients with MMI had a higher score of National Institutes of Health Stroke Scale, a larger infarct volume, and an increasingly greater proportion of severe PV-WMC, deep-WMC, and severe deep-WMC, respectively. After adjustment for sex, age, infarct volume, and history of hypertension, severe deep-WMC (odds ratio [OR]â=â6.362, 95% confidence interval [CI]â=â1.444-28.023, Pâ=â.0144) and severe PV-WMC (odds ratio = 5.608, 95% confidence intervalâ=â1.107-28.399, Pâ=â.0372) were significantly associated with MMI development.MMI and WMC are significantly associated such that MMI development is more likely when PV-WMC or deep-WMC is more severe. We hypothesize that Fazekas scale-defined severe deep-WMC and PV-WMC may be considered as clinically approachable predictors of MMI development. These findings support that the WMC with potential premorbid disrupted BBB may make patients susceptible to MMI, and further prospective study should be conducted to clarify this hypothesis.
Assuntos
Barreira Hematoencefálica/fisiopatologia , Infarto da Artéria Cerebral Média , AVC Isquêmico , Substância Branca , Idoso , Estudos de Casos e Controles , Correlação de Dados , Imagem de Difusão por Ressonância Magnética/métodos , Suscetibilidade a Doenças , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/epidemiologia , Infarto da Artéria Cerebral Média/fisiopatologia , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/patologia , Masculino , Índice de Gravidade de Doença , Taiwan/epidemiologia , Tomografia Computadorizada por Raios X/métodos , Substância Branca/diagnóstico por imagem , Substância Branca/patologia , Substância Branca/fisiopatologiaRESUMO
INTRODUCTION AND GOAL: There is scarce and contradictory data on B-cell lymphoma 2 (Bcl2), member of the Bcl-2 antiapoptotic molecules family of intrinsic apoptosis pathway, in ischemic stroke patients. The objective of this study was to determine whether there is an association between blood Bcl2 concentrations and mortality of ischemic stroke patients. MATERIAL AND METHODS: Five Intensive Care Units participated in this prospective and observational study of patients with severe malignant middle cerebral artery infarction (MMCAI). Severe MMCAI was diagnosed when acute infarction was present in 50% or more of said region and with a Glasgow Coma Scale (GCS) score of less than 9 points. Serum samples were collected at the time of MMCAI diagnosis. FINDINGS: Higher serum Bcl2 concentrations (p = 0.001), lower platelet count (p = 0.01) and lower GCS (p = 0.002) were found in non-survivors (n = 28) than in MMCAI survivors (n = 28). Serum Bcl2 levels had an area under the curve for mortality prediction of 75% (95% CI = 62%-88%; p < 0.001). Patients with serum Bcl2 levels > 43.6 ng/mL had higher mortality rate according to Kaplan-Meier analysis (Hazard ratio=10.0; 95% CI = 3.4-29.5; p < 0.001). Multiple logistic regression showed an association between serum Bcl2 and mortality at 30 days (OR = 1.041; 95% CI = 1.006-1.077; p = 0.02) controlling for GCS and platelet count. CONCLUSIONS: This study reports for the first time the higher blood Bcl2 concentrations in non-surviving ischemic stroke patients than in survivors and the association between elevated blood Bcl2 and mortality in ischemic stroke patients.
Assuntos
Infarto da Artéria Cerebral Média/sangue , AVC Isquêmico/sangue , Proteínas Proto-Oncogênicas c-bcl-2/sangue , Idoso , Biomarcadores/sangue , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/mortalidade , AVC Isquêmico/diagnóstico , AVC Isquêmico/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Espanha , Regulação para CimaRESUMO
OBJECTIVES: this study determines recovery in physical activity and activities of daily living in the early stages after cardiogenic internal carotid artery infarction. MATERIALS AND METHODS: this retrospective comfort study compares assessment data for 334 patients: 150 patients had atherosclerotic infarction (67 internal carotid artery, 87 middle cerebral artery) and 180 had cardiogenic infarction (32 internal carotid artery infarction, 148 middle cerebral artery). We used Brunnstrom recovery score, posture assessment scale for stroke, and functional independence measure. RESULTS: on initial assessment, median Brunnstrom recovery for the cardiogenic internal carotid artery infarction group was I-II in the upper limb, I in the finger, I-II in the lower limb, and IV or higher in all other groups. The median Postural Assessment Scale for Stroke score for the cardiogenic internal carotid artery infarction group was 0; all other groups scored 14 or higher. The median Functional Independence Measure for the cardiogenic internal carotid artery infarction group was 18 (maximum of 100) and the median score for other infarct groups was 25-50 (maximum 126), with P < .01. After a month, final assessment results for the cardiogenic internal carotid artery infarction group were much lower than for the other groups. Only both internal carotid artery infarctions were compared. Atherosclerotic infarctions showed recovery across assessments, except understanding, onset, and memory (P < .01), and cardiogenic infarctions did not change from the initial assessment in all criteria assessed. CONCLUSIONS: adapting cardiogenic internal carotid artery infarction as a stroke recovery model is difficult.
Assuntos
Atividades Cotidianas , Estenose das Carótidas/reabilitação , Infarto da Artéria Cerebral Média/reabilitação , Atividade Motora , Reabilitação do Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Artéria Carótida Interna/fisiopatologia , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/fisiopatologia , Avaliação da Deficiência , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/fisiopatologia , Masculino , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoAssuntos
COVID-19 , Embolia Paradoxal , Embolia Intracraniana , Acidente Vascular Cerebral , Embolia Paradoxal/complicações , Embolia Paradoxal/diagnóstico , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/etiologia , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/etiologia , SARS-CoV-2 , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologiaRESUMO
Identification and localization of ischemic stroke (IS) lesions is routinely performed to confirm diagnosis, assess stroke severity, predict disability and plan rehabilitation strategies using magnetic resonance imaging (MRI). In basic research, stroke lesion segmentation is necessary to study complex peri-infarction tissue changes. Moreover, final stroke volume is a critical outcome evaluated in clinical and preclinical experiments to determine therapy or intervention success. Manual segmentations are performed but they require a specialized skill set, are prone to inter-observer variation, are not entirely objective and are often not supported by histology. The task is even more challenging when dealing with large multi-center datasets, multiple experimenters or large animal cohorts. On the other hand, current automatized segmentation approaches often lack histological validation, are not entirely user independent, are often based on single parameters, or in the case of complex machine learning methods, require vast training datasets and are prone to a lack of model interpretation. Methods: We induced IS using the middle cerebral artery occlusion model on two rat cohorts. We acquired apparent diffusion coefficient (ADC) and T2-weighted (T2W) images at 24 h and 1-week after IS induction. Subsets of the animals at 24 h and 1-week post IS were evaluated using histology and immunohistochemistry. Using a Gaussian mixture model, we segmented voxel-wise interactions between ADC and T2W parameters at 24 h using one of the rat cohorts. We then used these segmentation results to train a random forest classifier, which we applied to the second rat cohort. The algorithms' stroke segmentations were compared to manual stroke delineations, T2W and ADC thresholding methods and the final stroke segmentation at 1-week. Volume correlations to histology were also performed for every segmentation method. Metrics of success were calculated with respect to the final stroke volume. Finally, the trained random forest classifier was tested on a human dataset with a similar temporal stroke on-set. Manual segmentations, ADC and T2W thresholds were again used to evaluate and perform comparisons with the proposed algorithms' output. Results: In preclinical rat data our framework significantly outperformed commonly applied automatized thresholding approaches and segmented stroke regions similarly to manual delineation. The framework predicted the localization of final stroke regions in 1-week post-stroke MRI with a median Dice similarity coefficient of 0.86, Matthew's correlation coefficient of 0.80 and false positive rate of 0.04. The predicted stroke volumes also strongly correlated with final histological stroke regions (Pearson correlation = 0.88, P < 0.0001). Lastly, the stroke region characteristics identified by our framework in rats also identified stroke lesions in human brains, largely outperforming thresholding approaches in stroke volume prediction (P<0.01). Conclusion: Our findings reveal that the segmentation produced by our proposed framework using 24 h MRI rat data strongly correlated with the final stroke volume, denoting a predictive effect. In addition, we show for the first time that the stroke imaging features can be directly translated between species, allowing identification of acute stroke in humans using the model trained on animal data. This discovery reduces the gap between the clinical and preclinical fields, unveiling a novel approach to directly co-analyze clinical and preclinical data. Such methods can provide further biological insights into human stroke and highlight the differences between species in order to help improve the experimental setups and animal models of the disease.
Assuntos
Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/patologia , Algoritmos , Animais , Encéfalo/patologia , Isquemia Encefálica/patologia , Imagem de Difusão por Ressonância Magnética/métodos , Modelos Animais de Doenças , Humanos , Processamento de Imagem Assistida por Computador/métodos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/patologia , Aprendizado de Máquina , Masculino , Ratos , Ratos Sprague-DawleyRESUMO
OBJECTIVE: This study aimed to develop a predictive model of early neurological deterioration (END) in patients with acute ischemic stroke (AIS). METHODS: The present retrospective cohort study considered patients with AIS who were admitted to a tertiary hospital in Shenzhen, China between January 2014 and December 2018. An increase of 2 points or more on the National Institute of Health Stroke Scale (NIHSS) within 7 days indicated END. We selected baseline clinical, laboratory, and neuroimaging variables to construct predictive models through multivariate logistic regression. The receiver operating characteristic curve and calibration plots were calculated. RESULTS: A total of 391 patients with AIS were enrolled in the study. END was observed in 64 (16.4%) cases. A prediction model developed from the initial NIHSS score, middle cerebral artery stenosis, and carotid stenosis of≥ 50% showed good discriminative ability: area under the receiver operating characteristic curve, 0.870 (95%CI, 0.813-0.911); threshold, -1.570; specificity, 84.40%; sensitivity, 75.00%; positive predictive value, 48.48%; and a negative predictive value, 94.52%. CONCLUSION: Our predictive model developed from the initial NIHSS score, middle cerebral artery stenosis, and carotid stenosis of ≥ 50% could identify patients with AIS who were at risk of developing END. The model requires validation by larger studies performed at other institutions.
Assuntos
Estenose das Carótidas/complicações , Regras de Decisão Clínica , Avaliação da Deficiência , Infarto da Artéria Cerebral Média/complicações , AVC Isquêmico/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/fisiopatologia , Progressão da Doença , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/fisiopatologia , AVC Isquêmico/etiologia , AVC Isquêmico/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND: Inflammatory response plays an important role in the process of ischemic stroke. Rapid, sustained and complete reperfusion is the most important modifiable prognostic factor for a favorable clinical outcome in patients receiving endovascular treatment (EVT). The studies related to the clot contents regarding the high level of leukocyte clots that are difficult to recanalize are quite remarkable. We aimed to investigate the relationship between Neutrophil to lymphocyte ratio and recanalization at the first pass thrombectomy. METHODS: Study was conducted from February 2015 to December 2018. Patients with stroke were treated with mechanical thrombectomy. The normality of distribution of continuous variables was tested by Shapiro-Wilk test. The Mann-Whitney U test and Chi-square test was used to assess relations between variables. ROC curve analysis was performed to determine the cut-off value for NLR. RESULTS: There were 84 patients included the study, the mean age 62.8 ± 12.9; 61.9% (52/84) that were female; median (IQR 25-75) NIHSS 16 (14-19) treated with stent-retriever-based thrombectomy. The distribution of NLR was skewed (p value for 1-sample Kolmogorov-Smirnov test: <0.001). In terms of recanalization outcomes, the patients with NLR < 3.51 showed a significantly higher rates of successful recanalization (AUC = 0.671 ± 0.06; p = 0.005). CONCLUSION: This study demonstrates that higher admission NLR values are independent predictors of unsuccessful recanalization first pass in MCA M1 occlusion of stroke patients treated with mechanical stent-retriever-based thrombectomy. Future large cohort and structural analysis of thrombi studies are needed to further explore the role of NLR as a prognostic neuroinflammatory biomarker for successful recanalization in EVT of stroke.
Assuntos
Procedimentos Endovasculares , Infarto da Artéria Cerebral Média/sangue , Infarto da Artéria Cerebral Média/cirurgia , AVC Isquêmico/sangue , AVC Isquêmico/cirurgia , Linfócitos , Trombólise Mecânica , Neutrófilos , Stents , Idoso , Biomarcadores , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , AVC Isquêmico/diagnóstico , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Prognóstico , Estudos RetrospectivosAssuntos
Doenças Cerebelares/complicações , Cerebelo/patologia , Encefalocele/complicações , Infarto da Artéria Cerebral Média/complicações , Hipertensão Intracraniana/complicações , Imageamento por Ressonância Magnética/métodos , Oftalmoplegia/etiologia , Doenças Cerebelares/diagnóstico , Encefalocele/diagnóstico , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Hipertensão Intracraniana/diagnóstico , Pessoa de Meia-Idade , Oftalmoplegia/diagnóstico , Oftalmoplegia/fisiopatologiaRESUMO
Endovascular thrombectomy in acute ischaemic stroke commonly uses aspiration catheters, either alone or in combination with stent retrievers. The Penumbra Aspiration System (Penumbra, Alameda, California, USA) was first approved by the US Food and Drug Administration in 2007, with low reported device-related complications. We present a case of a previously unreported complication related to malfunction of a Penumbra aspiration catheter during stroke thrombectomy resulting in a carotid-cavernous fistula.
Assuntos
Fístula Carótido-Cavernosa , Angiografia por Tomografia Computadorizada/métodos , Falha de Equipamento , Infarto da Artéria Cerebral Média , Complicações Intraoperatórias , AVC Isquêmico , Artéria Cerebral Média , Trombectomia , Dispositivos de Acesso Vascular/efeitos adversos , Idoso , Fístula Carótido-Cavernosa/diagnóstico , Fístula Carótido-Cavernosa/etiologia , Fístula Carótido-Cavernosa/cirurgia , Análise de Falha de Equipamento , Feminino , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/cirurgia , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/cirurgia , AVC Isquêmico/etiologia , AVC Isquêmico/fisiopatologia , AVC Isquêmico/terapia , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/cirurgia , Trombectomia/efeitos adversos , Trombectomia/instrumentação , Trombectomia/métodos , Resultado do TratamentoRESUMO
A potential complication after intravenous administration of recombinant tissue plasminogen activators (rtPAs) for thrombolysis in acute ischaemic stroke is orolingual angioedema, with an incidence of 0.4%-7.9%. In the herewith reported case, we discuss potential links between a history of sarcoidosis and the occurrence of orolingual angioedema after rtPA administration. Sarcoidosis is often accompanied by an elevated ACE level. In contrast, low ACE levels appear to play a role in the pathomechanism currently assumed to trigger angioedema, that is, the activation of the bradykinin and complement pathways. Medication with ACE inhibitors is considered a risk factor for angioedema. Based on these considerations, the patient was also treated with icatibant, a bradykinin B2-receptor antagonist, which has been found useful in recent publications on treating orolingual angioedema after intravenous lysis in ischaemic stroke.
Assuntos
Angioedema/terapia , Bradicinina/análogos & derivados , Infarto da Artéria Cerebral Média/terapia , Sarcoidose/complicações , Terapia Trombolítica/efeitos adversos , Angioedema/induzido quimicamente , Bradicinina/uso terapêutico , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infusões Intravenosas , Intubação Intratraqueal , Lábio/irrigação sanguínea , Pessoa de Meia-Idade , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/efeitos adversos , Língua/irrigação sanguínea , Falha de TratamentoRESUMO
We present an unusual case of acute ischaemic stroke secondary to thrombosed mycotic aneurysm with subsequent early aneurysmal rupture and subarachnoid haemorrhage, successfully treated with endovascular coil embolisation of the thrombosed segment. Imaging correlates are presented demonstrating successful endovascular management despite vessel occlusion precluding angiographic visualisation of the aneurysmal segment. Imaging and clinical follow-up is provided demonstrating durable occlusion and excellent clinical outcome with full functional recovery.
Assuntos
Aneurisma Infectado/diagnóstico , Aneurisma Roto/diagnóstico , Infarto da Artéria Cerebral Média/diagnóstico , Aneurisma Intracraniano/diagnóstico , AVC Isquêmico/etiologia , Hemorragia Subaracnóidea/etiologia , Aneurisma Infectado/complicações , Aneurisma Infectado/microbiologia , Aneurisma Roto/etiologia , Angiografia por Tomografia Computadorizada , Embolização Terapêutica , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/microbiologia , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/microbiologia , AVC Isquêmico/diagnóstico , AVC Isquêmico/terapia , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/microbiologia , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapia , Resultado do TratamentoRESUMO
BACKGROUND: To assess technical and clinical outcomes of an intermediate bore aspiration catheter (AXS Catalyst 5; Stryker) as front-line therapy for M2-M3 acute occlusions. METHODS: A multicentric, retrospective data collection of patients with symptomatic M2-M3 ischemic stroke, treated with direct aspiration first-pass technique was obtained. Time to recanalization, first attempt recanalization, and number of attempts were recorded. Successful recanalization was defined as a modified thrombolysis in cerebral infarction score ≥2b; incidence of procedure-related complications was recorded. National Institutes of Health Stroke Scale at discharge and modified Rankin Scale score at 90 days were evaluated by a dedicated neurologist. RESULTS: A total of 44 acute occlusions of distal M2-M3 segment were treated with a direct aspiration first-pass technique using CAT 5 (mean age 68,4 years). Median NIHSS at baseline was 10. Overall modified thrombolysis in cerebral infarction score ≥2b was obtained in 90,9% of patients with mean time to recanalization of 49,7 minutes and a mean of 1.6 attempts. First-attempt recanalization with CAT 5 was obtained in 52,3% of patients with a mean time to recanalization of 29.2 min. A stent retriever with proximal aspiration was incorporated as a rescue device in 3 cases. No major complications was detected. The median National Institutes of Health Stroke Scale score at discharge was 4. At 90 days, a modified Rankin Scale score of 0-2 was achieved in 70,5% of patients. CONCLUSIONS: ADAPT technique with the intermediate aspiration catheter CAT 5 system achieves successful revascularization and functional independence for patients with acute ischemic stroke secondary to distal M2 occlusions.
Assuntos
Catéteres , Infarto da Artéria Cerebral Média/terapia , Trombectomia/instrumentação , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Feminino , Estado Funcional , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/fisiopatologia , Itália , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Sucção/instrumentação , Trombectomia/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: Space-occupying cerebral edema is the main cause of mortality and poor functional outcome in patients with large cerebral artery occlusion (LVO). We aimed to determine whether recanalization of LVO would augment cerebral edema volume and the impact on functional outcome and quality of life (QoL). MATERIALS AND METHODS: Prospectively, 43 patients with large middle cerebral artery territory infarction or NIHSS ≥ 12 on admission were enrolled. The degree of recanalization (partial and complete versus no recanalization) was assessed by computed tomography (CT)-angiography or Duplex ultrasound more than 24 h after symptom onset. Cerebral edema volume was measured on follow up CTs by computer-based planimetry. Mortality, functional outcome (by modified Ranking Scale (mRS) and Barthel Index (BI)) were assessed at discharge and 12 months, and QoL (by SF-36 and EQ-5D-3L) at 12 months. RESULTS: Mean cerebral edema volume was 333±141 ml without recanalization (n=13, group 1) and 276±140 ml with partial or complete recanalization (n=30, group 2, p= 0.23). There were no significant differences in mortality at discharge (38% versus 23%), at 12 months (58% versus 48%), in functional outcome at discharge (mRS 0-3: 0% both; mRS 4-5: 62% versus 77%) and at 12 months (mRS 0-3: 0% versus 11%; mRS 4-5: 42% versus 41%). The BI improved significantly from discharge to 12 months only in group 2 (p=0.001). Mean physical component score in SF-36 was 25.6±6.4, psychological component score was 41.9±14.1. In the EQ-5D-3L, most patients reported problems with activities of daily living, reduced mobility, and selfcare. CONCLUSIONS: Recanalization of a large cerebral artery occlusion in the anterior circulation territories is not associated with amplification of post-ischemic cerebral edema but may be correlated with better long-term functional outcome. QoL was low and mainly dependent on physical disability. The association between recanalization, collateral status and development of cerebral edema after LVO and the effect on functional outcome and quality of life should be explored in a larger patient population.