Early neurologic decline in acute ischemic stroke patients receiving thrombolysis with large vessel occlusion and mild deficits.

BACKGROUND: We sought to determine the rate of early neurologic decline (END) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) who presented with mild deficits and received intravenous tissue plasminogen activator (IVtPA). METHODS: Among 1022 patients with AIS who received IVtPA from 2014 to 2019, we identified 313 (30.6%) with LVO, of which 94 (30%) presented with National Institute of Health Stroke Scale (NIHSS) score ≤7. Thirteen patients were excluded, leaving 81 for analysis. END was defined as NIHSS worsening of ≥4 points within 24 hours. RESULTS: Among 81 patients with LVO and low NIHSS score, the mean age was 65.8 years (range 25-93) and 41% were female. The mean time to IVtPA from last known well was 2.5 hours (range 0.8-7). LVO sites were as follows: 5 (6%) carotid, 23 (28%) M1, and 53 (65%) M2 occlusions. Among the 81 patients, 28 (34.6%) had END, and these patients were older (70.8 vs 63.2 years, p=0.036). The mean change in NIHSS score at 24 hours in those with END was 10.4 (range 4-22). Patients with END were less likely to be discharged home (25% vs 66%, p=0.004). CONCLUSIONS: Among patients with LVO AIS who received IVtPA, 30% presented with initial mild deficits. END occurred in one-third of LVO patients with initial mild deficits despite receiving IVtPA. Clinicians should be aware that the natural history of LVO with initial mild deficits is not benign and these patients are eligible for rescue thrombectomy in the 24-hour window if they deteriorate.

Acute brain infarcts after spontaneous intracerebral hemorrhage: a diffusion-weighted imaging study.

BACKGROUND AND PURPOSE: We aimed to determine the prevalence of acute brain infarcts using diffusion-weighted imaging (DWI) in patients with spontaneous intracerebral hemorrhage (ICH). METHODS: We collected data on consecutive patients with spontaneous ICH admitted to our institution between August 1, 2006 and December 31, 2008 and in whom DWI was performed within 28 days of admission. Patients with hemorrhage attributable to trauma, tumor, aneurysm, vascular malformation, and hemorrhagic conversion of arterial or venous infarction were excluded. Restricted diffusion within, contiguous with, or immediately neighboring the hematoma or chronic infarcts was not considered abnormal. Using multivariable logistic regression, we evaluated potential predictors of DWI abnormality including clinical and radiographic characteristics and treatments. A probability value <0.05 was considered significant in the final model. RESULTS: Among 118 spontaneous ICH patients (mean 59.6 years, 47.5% male, and 31.4% white) who also underwent MRI, DWI abnormality was observed in 22.9%. The majority of infarcts were small (median volume 0.25 mL), subcortical (70.4%), and subclinical (88.9%). Factors independently associated with DWI abnormality were prior ischemic stroke (P=0.002), MAP lowering by > or =40% (P=0.004), and craniotomy for ICH evacuation (P=0.001). CONCLUSIONS: We found that acute brain infarction is relatively common after acute spontaneous ICH. Several factors, including aggressive blood pressure lowering, may be associated with acute ischemic infarcts after ICH. These preliminary findings require further prospective study.

Histopathologic description of Wingspan stent in acute ischemic stroke.

OBJECTIVE AND IMPORTANCE: We report the histopathologic examination of Wingspan stent in acute ischemic stroke. CLINICAL PRESENTATION: A 75-year-old female presented with acute left-hemiplegia due to right carotid terminus occlusion. Mechanical embolectomy was unsuccessful. INTERVENTION: A Wingspan stent was placed from the distal intracranial carotid artery to the proximal middle cerebral artery stem and established partial antegrade flow. The patient died of malignant infarction on post-stroke day 7. At autopsy, embolized calcified atherosclerotic plaque fragments were noted within a non-occlusive thrombus over which the Wingspan stent was deployed. There was no evidence of intimal or media dissection or perforator ostium occlusion. CONCLUSION: Our case provides a rare pathological description of intracranial stent placement in the setting of acute ischemic stroke.

Diffusion weighted imaging in heroin-associated spongiform leukoencephalopathy.

BACKGROUND: Heroin-associated spongiform leukoencephalopathy (HASL) is a rare complication of heroin abuse. We report a case that highlights the increased sensitivity of diffusion weighted imaging (DWI) compared with T2-weighted imaging in the acute setting of HASL. METHODS: Single case report. RESULTS: A 36-year-old male with a history of heroin abuse (snorting) presented with a 3-day history of lethargy. MRI brain revealed restricted diffusion involving the globus pallidum and cerebral cortex bilaterally that was not seen on fluid-attenuated inversion recovery (FLAIR) images. The patient was diagnosed with acute HASL. Repeated MRI FLAIR at 3 months confirmed the development of atrophy and T2 hyperintensity in the subcortical white matter, consistent with leukoencephalopathy. Neurological exam at 3-month follow-up was nonfocal. CONCLUSIONS: Restricted diffusion, which likely corresponds to electron microscopic findings of fluid entrapment between the myelin lamellae, may be detectable earlier than changes on FLAIR. Clinicians should be aware of the neuroimaging findings of HASL and the increased sensitivity of MRI DWI over T2-weighted images in detecting HASL acutely.

A prospective trial of elective extubation in brain injured patients meeting extubation criteria for ventilatory support: a feasibility study.

INTRODUCTION: To assess the safety and feasibility of recruiting mechanically ventilated patients with brain injury who are solely intubated for airway protection and randomising them into early or delayed extubation, and to obtain estimates to refine sample-size calculations for a larger study. The design is a single-blinded block randomised controlled trial. A single large academic medical centre is the setting. METHODS: Sixteen neurologically stable but severely brain injured patients with a Glasgow Coma Score (GCS) of 8 or less were randomised to early or delayed extubation until their neurological examination improved. Eligible patients met standard respiratory criteria for extubation and passed a modified Airway Care Score (ACS) to ensure adequate control of respiratory secretions. The primary outcome measured between groups was the functional status of the patient at hospital discharge as measured by a Modified Rankin Score (MRS) and Functional Independence Measure (FIM). Secondary measurements included the number of nosocomial pneumonias and re-intubations, and intensive care unit (ICU) and hospital length of stay. Standard statistical assessments were employed for analysis. RESULTS: Five female and eleven male patients ranging in age from 30 to 93 years were enrolled. Aetiologies responsible for the neurological injury included six head traumas, three brain tumours, two intracerebral haemorrhages, two subarachnoid haemorrhages and three ischaemic strokes. There were no demographic differences between the groups. There were no unexpected deaths and no significant differences in secondary measures. The difference in means between the MRS and FIM were small (0.25 and 5.62, respectively). These results suggest that between 64 and 110 patients are needed in each treatment arm to detect a treatment effect with 80% power. CONCLUSIONS: Recruitment and randomisation of severely brain injured patients appears to be safe and feasible. A large multicentre trial will be needed to determine if stable, severely brain injured patients who meet respiratory and airway control criteria for extubation need to remain intubated.

Clinical spectrum of reversible posterior leukoencephalopathy syndrome.

BACKGROUND: Reversible posterior leukoencephalopathy syndrome (RPLS) is characterized by neuroimaging findings of reversible vasogenic subcortical edema without infarction. The clinical syndrome of RPLS typically involves headache, encephalopathy, visual symptoms, and seizures. OBJECTIVE: To retrospectively identify patients with RPLS with a characteristic clinical presentation and neuroimaging abnormalities and documented improvement on repeated neuroimaging. DESIGN: Retrospective. SETTING: Mayo Clinic. PATIENTS: Thirty-six patients with RPLS. MAIN OUTCOME MEASURES: Associated comorbid medical conditions, presenting clinical symptoms, duration of clinical symptoms, diagnostic test results (magnetic resonance imaging, electroencephalography, and lumbar puncture), and time to clinical and neuroimaging recovery. RESULTS: We identified 38 episodes of RPLS in 36 patients (20 females and 16 males) with a mean age of 44.7 years. Comorbid conditions included hypertension (53%), renal disease (45%), dialysis dependency (21%), malignancy (32%), and transplantation (24%). Presenting symptoms included clinical seizures (87%), encephalopathy (92%), visual symptoms (39%), and headache (53%). Mean peak systolic blood pressure at presentation was 187 mm Hg. Clinical symptoms resolved after a mean of 5.3 days. Atypical neuroimaging features included significant frontal involvement in 22 episodes (58%), gray matter lesions in 16 (42%), unilateral lesions in 2 (5%), hemorrhage in 2 (5%), recurrent RPLS in 2 (5%), confluent lesions in 2 (5%), and foci of permanent injury in 10 (26%). Twenty-two episodes (58%) had brainstem/cerebellar involvement on neuroimaging. CONCLUSIONS: This is the largest clinical series to date of RPLS with confirmed neuroimaging improvement. Clinical recovery occurred in most patients within days. The condition was rarely isolated to the parieto-occipital white matter, and atypical neuroimaging features were frequent.

Central nervous system manifestations of cardiac myxoma.

BACKGROUND: Neurologic complications can be the initial manifestation of atrial myxoma. Prompt diagnosis is of paramount significance to prevent recurrent complications. OBJECTIVE: To identify patients with neurologic complications attributed to atrial myxoma. DESIGN, SETTING, AND PATIENTS: With institutional review board approval, we retrospectively reviewed the medical records of 74 consecutive patients with pathologically confirmed cardiac myxoma at the Mayo Clinic from January 1, 1993, through December 31, 2004. MAIN OUTCOME MEASURES: Discharge and follow-up modified Rankin score. RESULTS: Nine of the 74 patients with cardiac myxoma (12%) presented with neurologic manifestations in the setting of atrial myxoma. Mean age was 48.5 years (range, 17-70 years). There were 6 females and 3 males. Among patients with myxoma and neurologic symptoms, ischemic cerebral infarct was the most common neurologic manifestation (8 patients [89%]). No patients had concomitant cardiac symptoms. The size of the atrial myxoma was variable, with a mean diameter of 2.7 (range, 0.4-6.5) cm. Most of the atrial myxomas causing neurologic symptoms demonstrated a mobile component on transesophageal echocardiography (8 patients [89%]). Two patients (22%) had pathologic evidence of systemic myxomatous emboli. One patient with intracerebral hemorrhage had pathologically confirmed intracranial metastatic myxoma and myxoma-induced aneurysmal dilatation. CONCLUSIONS: Neurologic complications are associated with cardiac myxoma in some patients with myxoma and, when they occur, frequently present with cerebral infarction. The mobility, not the size, of the myxoma appears to be related to embolic potential. Potential delayed neurologic complications relevant to patients with tumor embolization include myxoma-induced cerebral aneurysm and myxomatous metastasis, which can mimic the clinical picture of central nervous system vasculitis or infective endocarditis.