Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment after Stroke-Early and 12-Month Outcomes in a Comprehensive Stroke Center.

PURPOSE: To compare feasibility, 12-month outcome, and periprocedural and postprocedural risks between carotid artery stent (CAS) placement and carotid endarterectomy (CEA) performed within 1 week after transient ischemic attack (TIA) or mild to severe stroke onset in a single comprehensive stroke center. MATERIALS AND METHODS: Retrospective analysis of prospective data collected from 1,148 patients with ischemic stroke admitted to a single stroke unit between January 2013 and July 2015 was conducted. Among 130 consecutive patients with symptomatic carotid stenosis, 110 (10 with TIA, 100 with stroke) with a National Institutes of Health Stroke Scale (NIHSS) score < 20 and a prestroke modified Rankin Scale (mRS) score < 2 were eligible for CAS placement or CEA and treated according to the preference of the patient or a surrogate. Periprocedural (< 48 h) and postprocedural complications, functional outcome, stroke, and death rate up to 12 months were analyzed. RESULTS: Sixty-two patients were treated with CAS placement and 48 were treated with CEA. Several patients presented with moderate or major stroke (45.8% CEA, 64.5% CAS). NIHSS scores indicated slightly greater severity at onset in patients treated with a CAS vs CEA (6.6 ± 5.7 vs 4.2 ± 3.4; P = .08). Complication rates were similar between groups. mRS scores showed a significant improvement over time and a significant interaction with age in both groups. Similar incidences of death or stroke were shown on survival analysis. A subanalysis in patients with NIHSS scores ≥ 4 showed no differences in complication rate and outcome. CONCLUSIONS: CAS placement and CEA seem to offer early safe and feasible secondary stroke prevention treatments in experienced centers, even after major atherosclerotic stroke.

Endovascular Stroke Treatment of Acute Tandem Occlusion: A Single-Center Experience.

PURPOSE: To evaluate outcomes and prognostic factors in patients with acute ischemic stroke caused by tandem internal carotid artery/middle cerebral artery occlusion undergoing endovascular treatment. MATERIALS AND METHODS: Characteristics of consecutive patients with tandem occlusion (TO) were extracted from a prospective registry. Collateral vessel quality on pretreatment computed tomographic (CT) angiography was evaluated on a 4-point grading scale, and patients were dichotomized as having poor or good collateral flow. Outcome measures included successful reperfusion according to Thrombolysis In Cerebral Infarction score, good outcome at 3 months defined as a modified Rankin scale score ≤ 2, symptomatic intracranial hemorrhage (ICH; sICH), and mortality. RESULTS: A total of 72 patients with TO (mean age, 65.6 y ± 12.8) were treated. Intravenous thrombolysis was performed in 54.1% of patients, and a carotid stent was inserted in 48.6%. Successful reperfusion was achieved in 64% of patients, and a good outcome was achieved in 32%. sICH occurred in 12.5% of patients, and the overall mortality rate was 32%. Univariate analysis demonstrated that good outcome was associated with good collateral flow (P = .0001), successful reperfusion (P = .001), and lower rate of any ICH (P = .02) and sICH (P = .04). On multivariate analysis, good collateral flow (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.04-0.75; P = .01) and age (OR, 1.08; 95% CI, 1.01-1.15; P = .01) were the only predictors of good outcome. The use of more than one device for thrombectomy was the only predictor of sICH (OR, 10.74; 95% CI, 1.37-84.13; P = .02). CONCLUSIONS: Endovascular treatment for TO resulted in good outcomes. Collateral flow and age were independent predictors of good clinical outcomes at 3 months.

Proposal for a Vascular Computed Tomography-Based Grading System in Posterior Circulation Stroke: A Single-Center Experience.

OBJECTIVE: The aim of this study is to investigate the role of a computed tomography angiography (CTA)-based approach in patients undergoing mechanical thrombectomy for vertebrobasilar stroke treatment. METHODS: A CTA and digital subtraction angiography (DSA) retrospective analysis of patients with acute vertebrobasilar stroke treated with thrombectomy was performed. A modified Rankin Scale score of 3 or lower at 3 months was considered as favorable outcome. The posterior circulation ASPECTS (pc-ASPECTS) was evaluated on CTA and vertebrobasilar segments involved in the occlusion were assessed using a 6-point posterior circulation computed tomography angiography (pc-CTA) vascular score aimed at evaluating the posterior circulation vascular pattern including collaterals. The primary end point was the correlation between pc-CTA and outcome; secondary end points included the concordance between CTA-DSA images and the correlation between pc-ASPECTS and outcome. RESULTS: Fifteen patients with vertebrobasilar stroke were retrospectively analyzed. All patients in coma showed a bad outcome (P = .01) and all patients with an alert state showed a good outcome (P = .004). An excellent interobserver agreement for pc-CTA (P = .001) was observed with poor interobserver agreement for pc-ASPECTS (P = .21). No significant correlations between pc-ASPECTS and clinical outcome were observed. Patients with good outcome had a lower pc-CTA (P = .02). The patency of the distal third of the basilar artery and both posterior cerebral arteries was related with good outcome. CONCLUSION: The pc-CTA seems to have prognostic value in patients with vertebrobasilar stroke undergoing mechanical thrombectomy. It may be used as an additional prognostic triage technique in this subgroup of stroke patients.

Intra-arterial thrombectomy versus standard intravenous thrombolysis in patients with anterior circulation stroke caused by intracranial arterial occlusions: a single-center experience.

BACKGROUND: Severely impaired patients with persisting intracranial occlusion despite standard treatment with intravenous (IV) administration of recombinant tissue plasminogen activator (rtPA) or presenting beyond the therapeutic window for IV rtPA may be candidates for interventional neurothrombectomy (NT). The safety and efficacy of NT by the Penumbra System (PS) were compared with standard IV rtPA treatment in patients with severe acute ischemic stroke (AIS) caused by large intracranial vessel occlusion in the anterior circulation. METHODS: Consecutive AIS patients underwent a predefined treatment algorithm based on arrival time, stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS) score, and site of arterial occlusion on computed tomographic angiography (CTA). NT was performed either after a standard dose of IV rtPA (bridging therapy [BT]) or as single treatment (stand-alone NT [SAT]). Rates of recanalization, symptomatic intracranial bleeding (SIB), mortality, and functional outcome in NT patients were compared with a historical cohort of IV rtPA treated patients (i.e., controls). Three-month favourable outcome was defined as a modified Rankin Scale (mRS) score ≤2. RESULTS: Forty-six AIS patients were treated with NT and 51 with IV rtPA. The 2 groups did not differ with regard to demographics, onset NIHSS score (18.5±4 v 17±5; P=.06), or site of intracranial occlusion. Onset-to-treatment time in the NT and IV rtPA groups was 230 minutes (±78) and 176.5 (±44) minutes, respectively (P=.001). NT patients had significantly higher percentages of major improvement (≥8 points NIHSS score change at 24 hours; 26% v 10%; P=.03) and partial/complete recanalization (93.5% v 45%; P<.0001) compared to controls. Treatment by either SAT or BT similarly improved the chance of early recanalization and early clinical improvement. No significant differences were observed in the rate of SIB (11% v 6%), 3-month mortality (24% v 25%), or favorable outcome (40% v 35%) between NT and IV rtPA patients. CONCLUSIONS: Despite significantly delayed time of intervention, NT patients had higher rates of recanalization and early major improvement, with no differences in symptomatic intracranial hemorrhages. Early NIHSS score improvement did not translate into better 3-month mortality or outcome. NT seems a safe and effective adjuvant treatment strategy for selected patients with severe AIS secondary to large intracranial vessel occlusion in the anterior circulation.

Carotid artery wall thickness in patients with obstructive sleep apnea syndrome.

BACKGROUND AND PURPOSE: Epidemiological studies have suggested a pathophysiological link between sleep apnea syndrome and cerebrovascular diseases. The mechanism by which sleep disturbance can affect the predisposition to developing stroke is not clear. The aim of this study was to investigate whether patients with obstructive sleep apnea syndrome have an increase in atherosclerosis indicators at the carotid artery level. METHODS: We included 23 male patients with severe obstructive sleep apnea syndrome (respiratory disturbance index >30). Intima-media thickness and the presence of steno-occlusive lesions in the common carotid arteries were investigated with B-mode high-resolution ultrasonography. Results of the ultrasonographic examination were compared with those of a group of 23 subjects without obstructive sleep apnea syndrome who were matched for age and comorbid factors. RESULTS: The intima-media thickness of the common carotid arteries of patients with obstructive sleep apnea syndrome was significantly higher (P<0.0001) than that of control subjects (1.429+/-0.34 versus 0.976+/-0.17 mm). CONCLUSIONS: Results of the present study show that carotid wall thickness is increased in patients with severe sleep apnea syndrome. There is strong evidence that an increase in the thickness of the carotid artery wall is a valid marker of the risk of stroke. For this reason, our finding seems to further strengthen the hypothesis that patients with obstructive sleep apnea syndrome are at risk of developing cerebrovascular diseases regardless of the association with other vascular risk factors.

Efficacy and tolerability of pregabalin versus topiramate in the prophylaxis of chronic daily headache with analgesic overuse: an open-label prospective study.

OBJECTIVES: Medication-overuse headache is one of the most disabling headaches. Antiepileptic drugs have been considered a promising strategy as prophylactic treatment in these patients, even if their use often has been limited by low tolerability or safety. The objective of this study was to evaluate the efficacy and safety of pregabalin compared with topiramate for the prophylaxis of chronic daily headache with medication overuse using an open-label prospective study. METHODS: After a 2-month baseline period (T0), 100 consecutive patients with medication overuse headache were assigned to receive 150 mg/d pregabalin or 100 mg/d topiramate. After a titration period of 4 weeks, a follow-up visit was scheduled every 2 months (T1 and T2) to evaluate headache frequency, the amount of rescue medication intake, and disability. RESULTS: Of the 46 pregabalin-treated patients, the mean monthly headache frequency significantly decreased from 21.8 ± 4.8 (T0) to 5.1 ± 3.8 (T2), and the monthly number of days with medication intake decreased from 15.1 ± 4.8 (T0) to 2.9 ± 1.9 (T2). Similarly, of the 42 topiramate-treated patients, the mean monthly headache frequency decreased from 21.8 ± 4.9 (T0) to 5.3 ± 3.5 (T2), and the mean monthly number of days with medication intake decreased from 15.1 ± 3.7 (T0) to 2.6 ± 1.5 (T2). A significant improvement of disability score was reported in both groups. CONCLUSIONS: Similar to topiramate, pregabalin seems to be an effective and well-tolerated preventive therapy in chronic headache and a new option in the management of withdrawal from abused drugs in patients with analgesic overuse, a difficult-to-treat population.

Changes in cerebrovascular reactivity following low-frequency repetitive transcranial magnetic stimulation.

OBJECTIVES: Repetitive Transcranial Magnetic Stimulation (rTMS) potential therapeutic uses have been explored in many conditions including stroke. However, its potential effects on cerebral hemodynamics have not been deeply considered. Transcranial Doppler ultrasonography (TCD) is a promising tool in detecting focal changes of cerebral blood flow velocity (CBFV) and cerebrovascular reactivity (CRV) induced by rTMS. We evaluated possible changes in CBFV and CVR in healthy volunteers. METHODS: Low-frequency (1 Hz) and Sham rTMS were applied over the motor cortex (M1) of the left hemisphere of healthy volunteers. CBFV and CVR were evaluated in the ipsilateral middle cerebral artery (MCA). CVR to hypercapnia was derived from the breath-holding index (BHI). Subjects were randomly assigned to real or sham stimulation. RESULTS: Maximal CBFV of MCA tended to decrease after 1 Hz M1 rTMS. Low-frequency 1Hz M1 rTMS increased BHI (measured in MCA) immediately after rTMS, and the observed effect vanished after 15 min when applied over M1. We did not observe any significant change in Pulsatility Index (PI) and Resistance Index (RI) measures in all conditions. No significant changes of above mentioned parameters were observed in the sham stimulation group. CONCLUSIONS: Low-frequency rTMS induces a significant modulation of CVR in healthy subjects. This effect should be relevant in acute stroke patients with impaired cerebral autoregulation.