Progression of carotid near-occlusion to complete occlusion: related factors and clinical implications.

BACKGROUND: The clinical consequences and factors related to the progression from a carotid near-occlusion (CNO) to a complete occlusion are not well established. Our aim is to describe the rate, predictive factors and clinical implications of the progression to complete carotid occlusion (PCCO) in a population of patients with symptomatic CNO. METHODS: We conducted a multicenter, nationwide, prospective study from January 2010 to May 2016. Patients with angiography-confirmed CNO were included. We collected information on demographic data, clinical manifestations, radiological and hemodynamic findings, and treatment modalities. A 24 month carotid-imaging follow-up of the CNO was performed. RESULTS: 141 patients were included in the study, and carotid-imaging follow-up was performed in 122 patients. PCCO occurred in 40 patients (32.8%), and was more frequent in medically-treated patients (34 out of 61; 55.7%) compared with patients treated with revascularization (6 out of 61; 9.8%) (p<0.001). 7 of the 40 patients with PCCO (17.5%) suffered ipsilateral symptoms. Factors independently related with PCCO in the multivariate analysis were: age ≥75 years (OR 2.93, 95% CI 1.05 to 8.13), revascularization (OR 0.07, 95% CI 0.02 to 0.20), and collateral circulation through the ipsilateral ophthalmic artery (OR 3.25, 95% CI 1.01 to 10.48). CONCLUSIONS: PCCO occurred within 24 months in more than half of the patients under medical treatment. Most episodes of PCCO were not associated with ipsilateral symptoms. Revascularization reduces the risk of PCCO.

Mechanical thrombectomy for basilar artery thrombosis: a comparison of outcomes with anterior circulation occlusions.

BACKGROUND AND PURPOSE: The benefits of mechanical thrombectomy (MT) in basilar artery occlusions (BAO) have not been explored in recent clinical trials. We compared outcomes and procedural complications of MT in BAO with anterior circulation occlusions. METHODS: Data from the Madrid Stroke Network multicenter prospective registry were analyzed, including baseline characteristics, procedure times, procedural complications, symptomatic intracranial hemorrhage (SICH), modified Rankin Scale (mRS), and mortality at 3 months. RESULTS: Of 479 patients treated with MT, 52 (11%) had BAO. The onset to reperfusion time lapse was longer in patients with BAO (median (IQR) 385 min (320-540) vs 315 min (240-415), p<0.001), as was the duration of the procedures (100 min (40-130) vs 60 min (39-90), p=0.006). Moreover, the recanalization rate was lower (75% vs 84%, p=0.01). A trend toward more procedural complications was observed in patients with BAO (32% vs 21%, p=0.075). The frequency of SICH was 2% vs 5% (p=0.25). At 3 months, patients with BAO had a lower rate of independence (mRS 0-2) (40% vs 58%, p=0.016) and higher mortality (33% vs 12%, p<0.001). The rate of futile recanalization was 50% in BAO versus 35% in anterior circulation occlusions (p=0.05). Age and duration of the procedure were significant predictors of futile recanalization in BAO. CONCLUSIONS: MT is more laborious and shows more procedural complications in BAO than in anterior circulation strokes. The likelihood of futile recanalization is higher in BAO and is associated with greater age and longer procedure duration. A refinement of endovascular procedures for BAO might help optimize the results.

Mechanical thrombectomy in patients with medical contraindications for intravenous thrombolysis: a prospective observational study.

BACKGROUND AND PURPOSE: The present study was conducted with the objective of evaluating the safety of primary mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO) stroke and comorbidities that preclude treatment with IV thrombolysis (IVT), compared with patients who received standard IVT treatment followed by MT. Secondary objectives were to analyse the recanalization rate and outcomes. METHODS: A prospective observational multicenter study (FUN-TPA) that recruited patients treated within 4.5 hours of symptom onset was performed. Treatments were IVT followed by MT if occlusion persisted, or primary MT when IVT was contraindicated. Outcome measures were procedural complications, symptomatic intracranial hemorrhage (SICH), recanalization rate, National Institutes of Health Stroke Scale (NIHSS) score at 7 days, modified Rankin Scale (mRS) score and mortality at 90 days. RESULTS: Of 131 patients, 21 (16%) had medical contraindications for IVT and were treated primarily with MT whereas 110 (84%) underwent IVT, followed by MT in 53 cases (40%). The recanalization rate and procedural complications were similar in the two groups. There were no SICHs after primary MT vs 3 (6%) after IVT+MT. Nine patients (43%) in the primary MT group achieved independence (mRS 0-2) compared with 36 (68%) in the IVT+MT group (p=0.046). Mortality rates in the two groups were 14% (n=3) vs 4% (n=2) (p=0.13). Adjusted ORs for independence in patients receiving standard IVT+MT vs MT in patients with medical contraindications for IVT were 2.8 (95% CI 0.99 to 7.98) and 0.24 (95% CI 0.04 to 1.52) for mortality. CONCLUSIONS: MT is safe in patients with potential comorbidity-derived risks that preclude IVT. MT should be offered, aiming for prompt recanalization, to patients with LVO stroke unsuitable for IVT. TRIAL REGISTRATION NUMBER: NCT02164357; Results.

Enhanced brain-derived neurotrophic factor delivery by ultrasound and microbubbles promotes white matter repair after stroke.

Ultrasound-targeted microbubble destruction (UTMD) has been shown to be a promising tool to deliver proteins to select body areas. This study aimed to analyze whether UTMD was able to deliver brain-derived neurotrophic factor (BDNF) to the brain, enhancing functional recovery and white matter repair, in an animal model of subcortical stroke induced by endothelin (ET)-1. UTMD was used to deliver BDNF to the brain 24 h after stroke. This technique was shown to be safe, given there were no cases of hemorrhagic transformation or blood brain barrier (BBB) leakage. UTMD treatment was associated with increased brain BDNF levels at 4 h after administration. Targeted ultrasound delivery of BDNF improved functional recovery associated with fiber tract connectivity restoration, increasing oligodendrocyte markers and remyelination compared to BDNF alone administration in an experimental animal model of white matter injury.

Stroke Patients' Recognition and Knowledge of Their Own Vascular Risk Factors: A Sociocultural Study.

BACKGROUND: We aimed to study the knowledge of vascular risk factors (VRFs) among patients with stroke and the elements influencing this knowledge using analysis tools from the fields of social and health anthropology. METHODS: A prospective, cross-sectional and observational study in a cohort of patients who had suffered a stroke within the prior 3-12 months. Semistructured, in-depth interviews were conducted by a social anthropologist to evaluate patients' general knowledge of VRF and specifically of their own VRF. RESULTS: Overall, 96 patients were included, 56.3% male, mean age 61.6 years. Nearly all patients (97.9%) had at least 1 VRF. When asked to name their VRFs, 45.8% named stress, 29.2% dyslipidemia, 28.1% hypertension, 28.1% cigarette smoking, and 13.5% diabetes. The VRFs most frequently recognized by patients as their own were stress, hypertension, dyslipidemia, cigarette smoking, and cardiac disease. Only 15.6% acknowledged all their VRFs, while 52.1% acknowledged some of them and 32.3% failed to recognize any. Naming stress as a VRF (odds ratio [OR] = .204; 95% confidence interval [CI]: .076-.553) was associated with a lower likelihood of acknowledging at least 1 VRF, whereas working outside the home (OR = 11.314; 95% CI, 1.277-100.232) and having 2 or more VRFs (OR = 3.191; 95% CI, 1.032-9.875) were associated with a higher probability of correctly recognizing at least one of their own VRF. CONCLUSIONS: VRF knowledge is poor in patients with stroke. Stress was the risk factor that patients identified more frequently and it was associated with poorer knowledge of their own VRF.

Reparative therapy for acute ischemic stroke with allogeneic mesenchymal stem cells from adipose tissue: a safety assessment: a phase II randomized, double-blind, placebo-controlled, single-center, pilot clinical trial.

BACKGROUND: Few studies have evaluated the possible beneficial effect of the administration of stem cells in the early stages of stroke. Intravenous administration of allogeneic mesenchymal stem cells (MSCs) from adipose tissue in patients with acute stroke could be a safe therapy for promoting neurovascular unit repair, consequently supporting better functional recovery. We aim to assess the safety and efficacy of MSC administration and evaluate its potential as a treatment for cerebral protection and repair. MATERIALS: A Phase IIa, prospective, randomized, double-blind, placebo-controlled, single-center, pilot clinical trial. Twenty patients presenting acute ischemic stroke will be randomized in a 1:1 proportion to treatment with allogeneic MSCs from adipose tissue or to placebo (or vehicle) administered as a single intravenous dose within the first 2 weeks after the onset of stroke symptoms. The patients will be followed up for 2 years. Primary outcomes for safety analysis: adverse events (AEs) and serious AEs; neurologic and systemic complications, and tumor development. Secondary outcomes for efficacy analysis: modified Rankin Scale; NIHSS; infarct size; and biochemical markers of brain repair (vascular endothelial growth factor, brain-derived neurotrophic factor, and matrix metalloproteinases 9). RESULTS AND CONCLUSIONS: To our knowledge, this is the first, phase II, pilot clinical trial to investigate the safety and efficacy of intravenous administration of allogeneic MSCs from adipose tissue within the first 2 weeks of stroke. In addition, its results will help us define the best criteria for a future phase III study.

El ultrasonido con dispositivos portátiles es útil para el diagnóstico del ictus agudo / Portable ultrasound equipment of use in diagnosing acute ictus

La ecografía Doppler transcraneal (EDTC) y el dúplex carotídeo (DC) pueden realizarse mediante dispositivos portátiles, lo que permite su utilización junto a la cama del paciente en el Servicio de Urgencias y en la sala de neuro intervencionismo. Ambas técnicas permiten el diagnóstico del estado del árbol vascular cerebral y facilitan un diagnóstico rápido y una decisión terapéutica adecuada. Existe una creciente utilización del dúplex transcraneal (DuTC), que nos permite, además, la valoración del parénquima cerebral, lo que es especialmente útil en la monitorización de la evolución de las hemorragias cerebrales, el efecto masa intracraneal y la hidrocefalia. Finalmente, la EDTC tiene un efecto terapéutico, ya que potencia la recanalización con activador tisular del plasminógeno (tPA). La EDTC, el DuTC y el DC son herramientas diagnósticas excelentes que deberían utilizarse en la evaluación inmediata de todos los pacientes con ictus isquémico o hemorrágico agudo.

Transcranial Doppler (TCD) and carotid duplex (CD) can be used as portable tests, thus allowing for bedside use in the Emergency Service and Neurointerventional Room. Both tests broaden the abilities of the stroke neurologist to rapidly evaluate the vascular tree, facilitating a rapid diagnosis and appro-priate therapeutic decisions. There is a growing use of transcranial duplex (TCDu), which also allows assessment of the brain parenchyma, which is especially useful in monitoring the evolution of brain hemorrhage, intracranial mass effect and hydrocephalus. Finally, the TCD has a therapeutic effect be-cause it enhances arterial recanalization after tPA administration. The TCD, TCDu and CD are excellent diagnostic tools that should be used in all patients with ischemic or hemorrhagic stroke.

A prediction model for unstable carotid atheromatous plaque in acute ischemic stroke patients: proposal and internal validation.

The aim of this prospective study was to analyze the utility of a gray-scale median (GSM) system for identifying unstable plaques and to design and validate a prediction model for unstable plaques in symptomatic atheromatous carotid arteries. Fifty-two patients with non-cardioembolic cerebral infarction were included in the study. The receiver operating characteristic analysis revealed 76% sensitivity and 82% specificity for a GSM of 29 (p < 0.001) as a cutoff point for unstable plaques. A logistic regression model indicated that a GSM <29, male gender and not having been treated with angiotensin-converting enzyme inhibitors were independently associated with an unstable plaque classification. A probability model for unstable plaques was achieved by combining the strength of each variable (high blood pressure, hypercholesterolemia, smoking, previous stroke, anti-hypertensive drugs, calcium channel blockers, intima-media thickness). The model was tested with receiver operating characteristic curve analysis (p < 0.001) and validated by the leave-one-out cross-validation method (p < 0.001). The prediction model based on a GSM <29, male gender and not having been treated with angiotensin-converting enzyme inhibitors resulted in a probable unstable plaque assessment.

Varicella-zoster virus vasculopathy. A review description of a new case with multifocal brain hemorrhage.

BACKGROUND: The varicella zoster virus (VZV) is a highly neurotropic virus that, after the primary infection, remains latent in the nerve cells and can reactivate many years later, resulting in various conditions affecting the central nervous system, such as vasculopathy and stroke. METHODS: We report on a review of the published literature that included all case reports identified via PubMed and an additional unpublished case of VZV vasculopathy. All epidemiological, clinical, laboratory, imaging, virologic, treatment and outcome data collected are described. RESULTS: Of the 62 patients, 41.6% were immunocompromised. Ischemic stroke occurred in 77.2% of the patients, comprising cases of isolated (37.1%) and multifocal stroke (17.7%). Multifocal, ischemic and hemorrhagic stroke was only described in the newly reported case. The magnetic resonance imaging results were normal in 2.9% of the cases. The vascular studies (angiography and magnetic resonance angiography [MRA]) revealed signs of angiitis in 74.4% of the cases; the small arteries were involved in 38.5% of the cases, large arteries in 17.7% and mixed in 43.5%. For 95.2% of the patients, the cerebrospinal fluid (CSF) was positive for VZV IgG antibodies, and for 46.1% of the patients, the CSF was positive for polymerase chain reaction (PCR); however, the diagnosis was confirmed in only 3 of 6 biopsies. DISCUSSION: VZV vasculopathy can occur in both immunocompetent and immunosuppressed patients. Neuroimaging can reveal stroke and angiitis, and the detection of VZV-specific IgG antibodies in the CSF is a reliable and highly sensitive diagnostic tool. The multifocal nature of VZV vasculopathy makes biopsy a test with low sensitivity and high morbidity.

Ultrasonography of carotid plaque for the prevention of stroke.

A carotid ultrasonography is a non-invasive technique that provides an accurate and reliable characterization of the broad spectrum of carotid arteriosclerosis, from the intima-media thickness to the atherosclerotic plaque. Carotid ultrasonography has become a useful tool for identifying patients at high risk of stroke and selecting those who can benefit most from revascularization therapies such as carotid endarterectomy and stenting. In addition to the degree of stenosis, plaque echomorphology has emerged in recent years as an important contributory factor to stroke risk. Changes in plaque echogenicity, as measured by the quantitative computer-assisted ultrasonography index, could be a marker of plaque instability as well as an indicator of plaque remodeling, thereby providing the means for monitoring anti-atherosclerosis drugs such as statins.

Young women have poorer outcomes than men after stroke.

BACKGROUND AND PURPOSE: Gender differences in stroke outcome have not been fully assessed in young patients. METHODS: We conducted an observational study of consecutive young ischemic stroke patients (≤ 50 years of age) admitted to a stroke unit (January 1999 to December 2009). Basal data, subtype of ischemic stroke, stroke severity [Canadian Neurological Scale (CNS)], length of hospital stay, inhospital complications, mortality and functional outcome at discharge [modified Rankin Scale (mRS) score] were analyzed. For stroke severity and outcome analyses, 2 age groups were established: 15-30 (very young group) and 31-50 years old (middle-aged young group). RESULTS: A total of 310 patients were enrolled; 128 females and 182 males. The mean age was similar in women and men (41.07 ± 8.6 vs. 42.12 ± 8.2, NS). Migraine was more frequent in women, whereas arterial hypertension, hyperlipidemia, alcohol abuse, current smoking and atherothrombotic infarction were more frequent in men (p < 0.05). Females presented greater stroke severity than men [median CNS (IQR) = 8 (3.5) vs. 9 (2.5), p = 0.014] except in the very young group [median CNS (IQR) = 9 (1.8) vs. 8 (5), p = 0.022]. Female sex was a predictor of unfavorable outcomes (mRS >2) at discharge in the total sample (OR = 3.33; 95% CI = 1.41-7.84) and in the middle-aged young group (OR = 2.62; 95% CI = 1.05-6.53), adjusted by baseline data, stroke subtype, inhospital complications, length of stay and stroke severity. CONCLUSIONS: Female gender is associated with worse outcomes in adult ischemic stroke patients up to 50 years old. However, this effect is not observed in younger patients (15-30 years).