Frequency and Timing of Endovascular Therapy in Acute Stroke Patients: A Population-Based Analysis Using the Bremen Stroke Register.

BACKGROUND AND PURPOSE: In patients with large vessel occlusions (LVOs), endovascular treatment (ET) has become the standard of care, so that the potential number of these patients needs to be considered for the effective implementation of comprehensive stroke services. However, population-based data on the incidence of ET are scarce. METHODS: Using our prospective stroke register, in which all endovascular procedures on the 557,464 inhabitants of the city of Bremen are included, we performed a population-based analysis on the frequency and timing of ET in acute stroke patients with LVOs in the year 2017. RESULTS: Out of a total of 1,448 acute ischemic stroke patients, 173 patients (12%) had received ET (161 patients in the anterior circulation and 12 patients in the posterior circulation). Among these, 95 patients were inhabitants of Bremen. The population-based incidence thus was 17 (95% confidence interval [CI]: 14-21) ET cases per 100,000 person-years. The number of stroke procedures per month varied from 9 to 19 (median: 14.5; interquartile range [IQR]: 12-17). The number of stroke procedures per month and 100,000 inhabitants varied from 0.7 to 2.1 (median: 1.4; IQR: 0.9-1.7). Many procedures (53%) were performed during nonwork hours (between 17:00 h and 06:59 h or weekends). CONCLUSIONS: Approximately 12% of all ischemic stroke patients received ET, and the incidence of ET was 17 (95% CI: 14-21) cases per 100,000 person-years. However, despite being a high-volume center, the absolute number of stroke procedures per month was low, and many patients were treated during nonwork hours.

Pure alexia with intact perception of complex visual stimuli: a case study.

After a stroke involving the left occipitotemporal cortex our patient shows a word-length effect and has problems to identify letters or numbers in strings of symbols. But he is normal in identifying isolated letters and in non-verbally categorizing even complex images such as faces or natural scenes. His cortical lesion is stretching from the visual word form area (VWFA) anteriorly causing additional problems to name visual stimuli and to match acoustic stimuli with images. We conclude that our patient suffers from pure alexia without deficits to identify even complex visual stimuli. Our results directly contradict several explanations for letter-by-letter reading.

Midlevel visual deficits after strokes involving area human V4.

We present the results of 51 stroke patients with free central visual fields of which about half suffer from clear deficits of midlevel vision undetected by standard clinical tests. These patients yield significantly elevated thresholds for detection and/or discrimination between forms defined by motion, colour, or line orientation ('texture'). As demonstrated by voxel-based lesion-symptom mapping (VLSM) the underlying lesions involve mainly area human V4 (hV4) located in the posterior third of the fusiform gyrus and extending into the lingual gyrus. Patient's detection thresholds correlate only very weakly between the submodalities tested, indicating partly separate neural networks on mid-level vision for colour, motion, and texture detection. Correlations are far stronger for form discrimination tasks, indicating partly shared mechanisms for even simple form discrimination of distinct visual submodalities. We conclude that deficits of visual perception are far more common after strokes in visual brain areas than is apparent in clinical practice. Our results further clarify the functional organization of midlevel visual cortical areas.

Recurrent stroke after cervical artery dissection.

OBJECTIVE: Cervical artery dissection (CAD) accounts for 10-20% of all strokes in young adults, but no randomised controlled trial has investigated the best secondary prevention after ischaemic stroke or transient ischaemic attack (TIA). Because only small numbers of patient with CAD have been prospectively documented and followed up, the authors aimed to investigate the prognosis under various prevention regimens. METHODS: 30 German departments of neurology with acute stroke units prospectively documented 250 patients with acute ischaemic stroke or TIA due to CAD. A central follow-up (median 31 months) assessed recurrent stroke, recurrent CAD and death in 198 patients. RESULTS: CAD was found more often in the carotid arteries (52.0%) than in the vertebral arteries (46.8%). Thirteen patients (5.2%, CI 3.1% to 8.6%) suffered a recurrent stroke during the acute hospital stay. The rate of recurrent CAD during the first year was 1.7% (95% CI 0.3% to 3.6%). The cumulative recurrent stroke rate during the first year was 10.7% (95% CI 6.5% to 14.9%) and 14.0% (95% CI 8.9% to 19.1%) over 3 years. After discharge, the rate of recurrent stroke up to 6 months in patients treated with anticoagulants was 2.0% (95% CI 0.6% to 7.1%) and in those treated with antiplatelets 16.7% (95% CI 5.8% to 39.2%), which was statistically significant (HR 0.11; CI 0.02 to 0.69, p=0.02). CONCLUSIONS: This observational study confirms a high risk of early recurrent stroke following acute IS or TIA due to CAD. Whether anticoagulation provides any benefit over antiplatelets needs to be investigated in a randomised controlled trial.

SiPP (Stroke in Pregnancy and Postpartum): A prospective, observational, international, multicentre study on pathophysiological mechanisms, clinical profile, management and outcome of cerebrovascular diseases in pregnant and postpartum women.

RATIONALE: Cerebrovascular diseases associated with pregnancy and postpartum period are uncommon; however, they can have an important impact on health of both women and foetus or newborn. AIMS: To evaluate the frequency, characteristics and management of cerebrovascular events in pregnant/postpartum women, to clarify pathophysiological mechanisms underlying the occurrence of these events including biomolecular aspects, and to assess the short- and long-term cerebrovascular and global cardiovascular outcome of these patients, their predictors and infant outcome. METHODS AND DESIGN: This is an observational, prospective, multicentre, international case-control study. The study will include patients with cerebrovascular events during pregnancy and/or within six months after delivery. For each included case, two controls will be prospectively recruited: one pregnant or puerperal subject without any history of cerebrovascular event and one non-pregnant or non-puerperal subject with a recent cerebrovascular event. All controls will be matched by age, ethnicity and type of cerebrovascular event with their assigned cases. The pregnant controls will be matched also by pregnancy weeks/trimester. Follow-up will last 24 months for the mother and 12 months for the infant. SUMMARY: To better understand causes and outcomes of uncommon conditions like pregnancy/postpartum-related cerebrovascular events, the development of multisite, multidisciplinary registry-based studies, such as the Stroke in Pregnancy and Postpartum study, is needed in order to collect an adequate number of patients, draw reliable conclusions and give definite recommendations on their management.

Endovascular therapy versus thrombolysis in patients with large vessel occlusions within the anterior circulation aged ≥80 years.

BACKGROUND AND PURPOSE: In patients with large vessel occlusions, endovascular treatment (ET) has been shown to be superior to intravenous thrombolysis (IVT) in recent trials. However, the effectiveness of ET in elderly patients is uncertain. METHODS: Using our stroke database, we compared the rates of good outcome (modified Rankin scale (mRS) ≤2), excellent outcome (mRS 0-1), poor outcome (mRS 5-6) at discharge, in-hospital death, infarct size, and symptomatic intracranial hemorrhage (SICH) in patients aged ≥80 years with distal intracranial carotid artery, M1 and M2 occlusions during two time periods. RESULTS: From January 2008 to October 2012, 217 patients were treated with IVT and, from November 2012 to October 2017, 209 patients received ET with stent retrievers (with or without IVT). Significantly more patients in the ET group than in the IVT group had a good outcome (25% vs 16%, P<0.05), as well as an excellent outcome (12% vs 4%, P<0.01). Significantly fewer patients in the ET group than in the IVT group died (14% vs 22%, P<0.05) or had a poor outcome (35% vs 52%, P<001). The SICH rates were lower after ET than after IVT (1% vs 6%, P<0.01), and the infarct sizes were smaller after ET than after IVT. CONCLUSIONS: Compared with IVT, the routine use of ET significantly improved the early clinical and radiological outcome in patients with anterior circulation large vessel occlusions aged ≥80 years. Nevertheless, poor outcome rates were high so the role of ET needs to be defined further in this population.

Endovascular Therapy versus Thrombolysis in Patients with Mild Strokes and Large Vessel Occlusions within the Anterior Circulation.

BACKGROUND: In patients with large vessel occlusions, endovascular treatment (ET) has been shown to be superior to intravenous thrombolysis (IVT) in recent trials. However, it is currently unclear if patients with mild strokes also benefit from ET. METHODS: We compared the discharge rates of good outcome (modified Rankin scale [mRS] ≤2), very good outcome (mRS 0-1), symptomatic intracranial hemorrhages (SICH), and infarct sizes in patients with mild strokes (admission National Institutes of Health Stroke Scale ≤10) and distal intracranial carotid artery, M1, and M2 occlusions during two time periods. RESULTS: From 1/2008 to 10/2012 160 patients (mean age: 72 ± 12 years) were treated with IVT, and from 11/2012 to 11/2016 145 patients (mean age: 71 ± 13 years,) received ET with or without IVT. The clinical results were comparable between both treatment groups (59% after ET vs. 56% after IVT, p = 0.5 for an mRS 0-2) and (38% after ET vs. 32% after IVT, p = 0.3 for an mRS 0-1). In the subgroup of patients with an mRS ≤6, the early outcome did not differ significantly between ET and IVT either. The rates of SICH as well as the infarct sizes were not significantly different after ET compared with IVT. CONCLUSION: Compared with IVT, the routine use of ET did not significantly improve the early clinical or radiological outcome in patients with mild strokes and anterior circulation large vessel occlusions. Further randomized trials are urgently needed to determine the role of ET in this cohort.

Musical, visual and cognitive deficits after middle cerebral artery infarction.

The perception of music can be impaired after a stroke. This dysfunction is called amusia and amusia patients often also show deficits in visual abilities, language, memory, learning, and attention. The current study investigated whether deficits in music perception are selective for musical input or generalize to other perceptual abilities. Additionally, we tested the hypothesis that deficits in working memory or attention account for impairments in music perception. Twenty stroke patients with small infarctions in the supply area of the middle cerebral artery were investigated with tests for music and visual perception, categorization, neglect, working memory and attention. Two amusia patients with selective deficits in music perception and pronounced lesions were identified. Working memory and attention deficits were highly correlated across the patient group but no correlation with musical abilities was obtained. Lesion analysis revealed that lesions in small areas of the putamen and globus pallidus were connected to a rhythm perception deficit. We conclude that neither a general perceptual deficit nor a minor domain general deficit can account for impairments in the music perception task. But we find support for the modular organization of the music perception network with brain areas specialized for musical functions as musical deficits were not correlated to any other impairment.

Endovascular therapy versus thrombolysis in patients with anterior circulation stroke in everyday clinical practice.

BACKGROUND: In patients with large vessel occlusions, endovascular treatment has been shown to be superior to intravenous thrombolysis in recent trials. AIMS: The aim of this study was to analyze the impact of endovascular treatment on clinical and radiological outcome in everyday clinical practice. METHODS: We compared the rates of good outcome (modified Rankin scale ≤ 2 at discharge), in-hospital death, symptomatic intracranial hemorrhages, and infarct sizes in patients with distal intracranial carotid artery, M1 and M2 occlusions during two time periods. RESULTS: From January 2008 to October 2012, a total of 509 patients were treated with intravenous thrombolysis and from November 2012 to December 2014, a total of 270 patients received endovascular treatment with stent retrievers (with or without intravenous thrombolysis). Significantly, more patients in the endovascular treatment group than in the intravenous thrombolysis group had a good outcome (37% vs. 27%, p < 0.01). The infarct sizes were significantly smaller after endovascular treatment than intravenous thrombolysis, whereas the symptomatic intracranial hemorrhages rates and in-hospital mortality were comparable between both treatment groups. The positive impact of endovascular treatment on clinical outcome was most pronounced in patients ≥75 years (31% endovascular treatment vs. 19% intravenous thrombolysis, p < 0.01), in patients with M1 occlusions (43% endovascular treatment vs. 25% intravenous thrombolysis, p < 0.01) and in patients with an admission National Institutes of Health Stroke Scale ≥ 14 (24% endovascular treatment vs. 11% intravenous thrombolysis, p < 0.05). CONCLUSION: In everyday clinical practice and compared with intravenous thrombolysis, endovascular treatment significantly improved clinical outcome and was associated with smaller infarctions. This beneficial effect appeared to be highest in older patients, more severely affected patients, and in those with M1 occlusions.

Impact of collateral circulation on early outcome and risk of hemorrhagic complications after systemic thrombolysis.

BACKGROUND: In stroke patients, collateral flow can rapidly be assessed on computed tomography angiography (CTA). AIMS: In this study, the impact of baseline collaterals on early outcome and risk of symptomatic intracerebral hemorrhages after systemic thrombolysis in patients with proximal arterial occlusions within the anterior circulation were analyzed. METHODS: Collateralization scores were determined on the CT angiography source images (0 = absent; 1 ≤ 50%, 2 > 50% but <100%, and 3 = 100% collateral filling) of patients with distal intracranial carotid artery and/or M1 segment occlusions treated from 2008 to December 2011. A collateral score of 0 to 1 was designated as poor and 2 to 3 as good collateral vessel status. Outcome variables included in hospital mortality, favorable outcome at discharge (modified Rankin score ≤ 2), and rates of symptomatic intracerebral hemorrhage based on the European-Australasian Acute Stroke Study II definition. RESULTS: Among 246 subjects (mean age of 74 years; median National Institutes of Health Stroke Scale N at admission 14), 205 patients (83%) had good collaterals, whereas 41 patients (17%) had poor collaterals, respectively. Patients with poor collaterals had significantly higher rates of in-hospital mortality (41% vs. 12%, P < 0·001), of symptomatic intracerebral hemorrhage (15% vs. 4·9%, P < 0·05) and had significantly lower rates of favorable early clinical outcome (0% vs. 28%, P < 0·001) compared with those with good collaterals. The grade of collateralization was independently associated with in-hospital mortality (P < 0·001), early clinical outcome (P < 0·01), and rates of symptomatic intracerebral hemorrhage (P < 0·01). CONCLUSION: Patients with proximal arterial occlusions within the anterior circulation and poor baseline collaterals have a poor early functional outcome and high rates of symptomatic intracerebral hemorrhage after systemic thrombolysis. Since similar findings have also been reported after endovascular therapy, strategies to improve collateral blood flow should be assessed in this patient population.

Neurological and neuropsychological characteristics of occipital, occipito-temporal and occipito-parietal infarction.

Neuropsychological deficits after occipital infarction are most often described in case studies and only a small sample of studies has attempted to exactly correlate the anatomical localization of lesions with associated neuropsychological symptoms. The present study investigated a large number of patients (N = 128) in order to provide an overview of neurological and neuropsychological deficits after occipital, occipito-temporal and occipito-parietal infarction. A particular approach of the study was to define exact anatomical correlates of neuropsychological dysfunction by using voxel-based lesion-symptom mapping (VLSM) in 61 patients. In addition to a visual field defect and phosphenes, patients often reported anomia, difficulties in reading and memory deficits. Visual disorders, such as achromatopsia, akinetopsia or prosopagnosia, were rarely reported by the patients. Memory and visual disorders were diagnosed efficiently using simple clinical screening tests, such as the Rey-Osterrieth Complex Figure Test for immediate recall, the Demtect and the Lang Stereo Test. Visual field defects, reading disorders and the perception of phosphenes were associated primarily with lesions of the calcarine sulcus. Anomia and memory deficits were related to lesions of the occipital inferior gyrus, the lingual gyrus and hippocampus, as well as to lesions of principal white matter tracts.

Recurrent Strokes due to Transient Vasospasms of the Extracranial Internal Carotid Artery.

Vasospasms of the intracranial arteries are a well-known complication of subarachnoid hemorrhage and are also frequently encountered in other disorders such as migraine, cerebral vasculitis or reversible cerebral vasoconstriction syndrome. In contrast, recurrent spontaneous vasospasms of the extracranial circulation appear to be extremely rare and have most often been associated with migraine. We present a patient with recurrent strokes due to spontaneous transient vasospastic occlusions of the internal carotid artery (ICA) without migraine over a time period of at least 13 years. Initially, the patient had presented with a bilateral ICA occlusion and a cerebral infarct on the right side. While the right ICA remained occluded, a reopening of the left ICA could be detected 3 days after this initial event. In subsequent years, both duplex sonography and magnetic resonance angiography revealed recurrent occlusions of the left ICA, which resolved spontaneously within days. This case and other rare previous reports indicate that recurrent non-migrainous vasospasms of the extracranial carotid artery likely reflect a distinct entity which can cause ischemic strokes.