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INTRODUCTION: The use of endovascular thrombectomy (EVT) has dramatically increased in recent years. However, most existing studies used an upper age limit of 80 and data regarding the safety and efficacy of EVT among nonagenarians is still lacking. METHODS: 767 consecutive patients undergoing EVT for large vessel occlusion (LVO) in three participating centers were recruited into a prospective ongoing database. Demographic, clinical and imaging characteristics were documented. Statistical analysis was done to evaluate EVT outcome among nonagenarians compared to younger patients. RESULTS: The current analysis included 41 (5.4%) patients older than 90 years. Compared to younger patients, nonagenarians were more often female (78% versus 50.3%, p ≤ 0.001), had worse baseline mRS scores (2 [0-3] versus 0 [0-2], p < 0.001), higher rates of hypertension and hyperlipidemia and a higher admission NIHSS (20 [14-23] versus 16 [11-20], p < 0.001). No differences were found between groups regarding the involved vessel, stroke etiology, time from symptoms to door or symptoms to EVT, successful recanalization rates and hemorrhagic transformation rates. Nonagenarians had worse mRS at 90 days (5 [3-6] versus 3 [2-5], p = 0.001), similar discharge NIHSS (5 [1-11] versus 4 [1-11], p = 0.78) and higher mortality rates (36.6% versus 15.8%, p < 0.001). All nonagenarians with baseline mRS 4 have died within 90 days. 36.4% of nonagenarian patients with baseline MRS of 3 or less had favorable outcome. DISCUSSION: This study demonstrates that nonagenarian stroke patients with baseline mRS of 3 or less benefit from EVT with no significant difference in the rate of favorable outcome compared to octogenarians.
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Isquemia Encefálica , Procedimentos Endovasculares , Acidente Vascular Cerebral , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Estudos de Coortes , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Nonagenários , Estudos Prospectivos , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Trombectomia , Resultado do TratamentoRESUMO
INTRODUCTION: The COVID-19 pandemic overwhelmed health-care systems worldwide, and medical care for other acute diseases was negatively impacted. We aimed to investigate the effect of the COVID-19 outbreak on admission rates and in-hospital care for acute stroke and transient ischemic attack (TIA) in Israel, shortly after the start of the pandemic. METHODS: We conducted a retrospective observational study, based on data reported to the Israeli National Stroke Registry from 7 tertiary hospitals. All hospital admissions for acute stroke or TIA that occurred between January 1 and April 30, 2020 were included. Data were stratified into 2 periods according to the timing of COVID-19 restrictions as follows: (1) "pre-pandemic" - January 1 to March 7, 2020 and (2) "pandemic" - March 8 to April 30, 2020. We compared the weekly counts of hospitalizations between the 2 periods. We further investigated changes in demographic characteristics and in some key parameters of stroke care, including the percentage of reperfusion therapies performed, time from hospital arrival to brain imaging and to thrombolysis, length of hospital stay, and in-hospital mortality. RESULTS: 2,260 cases were included: 1,469 in the pre-COVID-19 period and 791 in the COVID-19 period. Hospital admissions significantly declined between the 2 periods, by 48% for TIA (rate ratio [RR] = 0.52; 95% CI 0.43-0.64) and by 29% for stroke (RR = 0.71; 95% CI 0.64-0.78). No significant changes were detected in demographic characteristics and in most parameters of stroke management. While the percentage of reperfusion therapies performed remained unchanged, the absolute number of patients treated with reperfusion therapies seemed to decrease. Higher in-hospital mortality was observed only for hemorrhagic stroke. CONCLUSION: The marked decrease in admissions for acute stroke and TIA, occurring at a time of a relatively low burden of COVID-19, is of great concern. Public awareness campaigns are needed as patients reluctant to seek urgent stroke care are deprived of lifesaving procedures and secondary prevention treatments.
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COVID-19 , Hospitalização/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Sistema de Registros , Estudos RetrospectivosRESUMO
We examined to what extent clinical assessment alone can predict subtle acute cerebral infarction on magnetic resonance imaging (MRI). Of the 72 patients presented to the emergency department (ED) with transient neurological deficits, 26 (36.1%) were predicted to be "positive" and 46 (63.9%) "negative" for transient ischemic attack/minor stroke by two independent neurologists. Twenty patients (27.8%) had acute restricted diffusion on MRI. Clinical assessment showed substantial agreement with MRI findings (Kappa = 0.75), sensitivity (95.0%), specificity (86.5%), positive-likelihood ratio 7.06, and negative-likelihood ratio 0.06. Neurological assessment has an excellent predicting value for MRI-confirmed acute cerebral infarction and a key role in the facilitation of effective patient care in the ED.
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Isquemia Encefálica , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Infarto Cerebral/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Humanos , Imageamento por Ressonância Magnética , Acidente Vascular Cerebral/diagnóstico por imagemRESUMO
Background and Purpose- The diagnosis of transient ischemic attack is challenging. Evidence of acute ischemia on MRI diffusion-weighted imaging is highly variable and confirmed in only about one-third of patients. This study investigated the significance of blood-brain barrier dysfunction (BBBD) mapping in patients with transient neurological deficits, as a diagnostic and prognostic biomarker required for risk stratification and stroke prevention. Methods- We used dynamic contrast-enhanced MRI to quantitatively map BBBD in a prospective cohort study of 57 patients diagnosed with transient ischemic attack/minor stroke and 50 healthy controls. Results- Brain volume with BBBD was significantly higher in patients compared with controls ( P=0.002). BBBD localization corresponded with the clinical presentation in 41 patients (72%) and was more extensive in patients with acute infarct on diffusion-weighted imaging ( P=0.05). Patients who developed new stroke during follow-up had a significantly greater BBBD at the initial presentation ( P=0.03) with a risk ratio of 5.35 for recurrent stroke. Conclusions- This is the first description of the extent and localization of BBBD in patients with transient ischemic attack/minor stroke. We propose BBBD mapping as a valuable tool for detection of subtle brain ischemia and a promising predictive biomarker required for risk stratification and stroke prevention.
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Barreira Hematoencefálica/diagnóstico por imagem , Ataque Isquêmico Transitório/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Barreira Hematoencefálica/metabolismo , Estudos de Coortes , Feminino , Humanos , Ataque Isquêmico Transitório/metabolismo , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: Over the last decade, acute stroke treatment has gone through significant changes. The changes started with the intravenous tPA treatment and were followed by intra-arterial thrombectomy ( IAT). IAT became established only three years ago after a number of positive trials were published. OBJECTIVES: To determine if the changes in stroke guidelines affected the percentage of patients treated with IV tPA or IAT, and if increased experience improved rapidity of treatment. METHODS: A retrospective, single academic center study extrapolated from the Soroka Stroke Database between the dates of January 2013 and July 2017. Analysis of descriptive statistics was conducted and some of the results were shown in the graph in order to demonstrate trends. RESULTS: Between January 2013 and July 2017, 3656 patients were admitted to Soroka Medical Center with the diagnosis of ischemic stroke. During the study period, there was a 50-minute decrease in median time for door-to-CT scan, although the door-to-needle time for tPA treatment did not change. However, over the study period, there was an increase in the percentage of patients receiving IV tPA from 10% to 14% and a 12% increase in the number of patients undergoing IAT. CONCLUSIONS: Soroka data reflect the changes in stroke treatment guidelines. DISCUSSION: Our study demonstrates a mild increase in the percentage of patients being treated with IV tPA together with a very sharp increase in the percentage of stroke patients undergoing IAT. This data directly reflects the guideline changes of the last decade. We also saw a significant improvement in door-CT time.
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Acidente Vascular Cerebral , Trombectomia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual , Centros Médicos Acadêmicos , Fibrinolíticos , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/terapia , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure without a clear cause. PURPOSE: To investigate dynamic imaging findings in IIH and their relation to mechanisms underlying intracranial pressure normalization. STUDY TYPE: Prospective. POPULATION: Eighteen IIH patients and 30 healthy controls. FIELD STRENGTH/SEQUENCE: T1 -weighted, venography, fluid attenuation inversion recovery, and apparent diffusion coefficients were acquired on 1.5T scanner. ASSESSMENT: The dural sinus was measured before and after lumbar puncture (LP). The degree of sinus occlusion was evaluated, based on 95% confidence intervals of controls. We studied a number of neuroimaging biomarkers associated with IIH (sinus occlusion; optic nerve; distribution of cerebrospinal fluid into the subarachnoid space, sulci and lateral ventricles (LVs); Meckel's caves; arachnoid granulation; pituitary and choroid plexus), before and after LP, using a set of specially developed quantification techniques. STATISTICAL TESTS: Relationships among various biomarkers were investigated (Pearson correlation coefficient) and linked to long-term disease outcomes (logistic regression). The t-test and the Wilcoxon rank test were used to compare between controls and before and after LP data. RESULTS: As a result of LP, the following were found to be in good accordance with the opening pressure: relative compression of cerebrospinal fluid (R = -0.857, P < 0.001) and brain volumes (R = -0.576, P = 0.012), LV expansion (R = 0.772, P < 0.001) and venous volume (R = 0.696, P = 0.001), enlargement of the pituitary (R = 0.640, P = 0.023), and shrinkage of subarachnoid space (R = -0.887, P < 0.001). The only parameter that had an impact on long-term prognosis was cross-sectional size of supplemental drainage veins after LP (sensitivity of 92%, specificity of 20%, and area under the curve of 0.845, P < 0.001). DATA CONCLUSION: We present an approach for quantitative characterization of the intracranial venous system and its implementation as a diagnostic assistance tool. We conclude that formation of supplementary drainage veins might serve as a long-lasting compensatory mechanism. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:913-927.
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Hipertensão Intracraniana/diagnóstico por imagem , Pressão Intracraniana/fisiologia , Imageamento por Ressonância Magnética/métodos , Neuroimagem/métodos , Adulto , Estudos Transversais , Feminino , Humanos , Hipertensão Intracraniana/fisiopatologia , Masculino , Estudos Prospectivos , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND AND PURPOSE: Endovascular therapy is increasingly used in acute ischemic stroke treatment and is now considered the gold standard approach for selected patient populations. Prior studies have demonstrated that eventual patient outcomes depend on both patient-specific factors and procedural considerations. However, these factors remain unclear for acute basilar artery occlusion stroke. We sought to determine prognostic factors of good outcome in acute posterior circulation large vessel occlusion strokes treated with endovascular therapy. METHODS: We reviewed our prospectively collected endovascular databases at 2 US tertiary care academic institutions for patients with acute posterior circulation strokes from September 2005 to September 2015 who had 3-month modified Rankin Scale documented. Baseline characteristics, procedural data, and outcomes were evaluated. A good outcome was defined as a 90-day modified Rankin Scale score of 0 to 2. The association between clinical and procedural parameters and functional outcome was assessed. RESULTS: A total of 214 patients qualified for the study. Smoking status, creatinine levels, baseline National Institutes of Health Stroke Scale score, anesthesia modality (conscious sedation versus general anesthesia), procedural length, and reperfusion status were significantly associated with good outcomes in the univariate analysis. Multivariate logistic regression indicated that only smoking (odds ratio=2.61; 95% confidence interval, 1.23-5.56; P=0.013), low baseline National Institutes of Health Stroke Scale score (odds ratio=1.09; 95% confidence interval, 1.04-1.13; P<0.0001), and successful reperfusion status (odds ratio=10.80; 95% confidence interval, 1.36-85.96; P=0.025) were associated with good outcome. CONCLUSIONS: In our retrospective case series, only smoking, low baseline National Institutes of Health Stroke Scale score, and successful reperfusion status were associated with good outcome in patients with posterior circulation stroke treated with endovascular therapy.
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Procedimentos Endovasculares/métodos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia , Insuficiência Vertebrobasilar/complicações , Insuficiência Vertebrobasilar/terapia , Idoso , Idoso de 80 Anos ou mais , Creatinina/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Reperfusão , Estudos Retrospectivos , Fatores de Risco , Fumar/epidemiologia , Terapia Trombolítica , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Studies have demonstrated consistent associations between cardiovascular illness and particulate matter (PM) <10 and <2.5 µm in diameter, but stroke received less attention. We hypothesized that air pollution, an inflammation progenitor, can be associated with stroke incidence in young patients in whom the usual risk factors for stroke are less prevalent. We aimed to evaluate the association between stroke incidence and exposure to PM <10 and <2.5 µm, in a desert area characterized by a wide range of PM. METHODS: We included all members of the largest health maintenance organization in Israel, who were admitted to a local hospital with stroke between 2005 and 2012. Exposure assessment was based on a hybrid model incorporating daily satellite remote sensing data at 1-km spatial resolution. We performed case-crossover analysis, stratified by personal characteristics and distance from main roads. RESULTS: We identified 4837 stroke cases (89.4% ischemic stroke). Interquartile range of PM <10 and <2.5 µm was 36.3 to 54.7 and 16.7 to 23.3 µg/m(3), respectively. The subjects' average age was 70 years; 53.4% were males. Associations between ischemic stroke and increases of interquartile range average concentrations of particulate matter <10 or <2.5 µm at the day of the event were observed among subjects <55 years (odds ratio [95% confidence interval], 1.11 [1.02-1.20] and 1.10 [1.00-1.21]). Stronger associations were observed in subjects living within 75 m from a main road (1.22 [1.03-1.43] and 1.26 [1.04-1.51]). CONCLUSIONS: We observed higher risk for ischemic stroke associated with PM among young adults. This finding can be explained by the inflammatory mechanism, linking air pollution and stroke.
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Poluentes Atmosféricos/efeitos adversos , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Exposição Ambiental/efeitos adversos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Estudos Cross-Over , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND: There are multiple clinical and radiographic factors that influence outcomes after endovascular reperfusion therapy (ERT) in acute ischemic stroke (AIS). We sought to derive and validate an outcome prediction score for AIS patients undergoing ERT based on readily available pretreatment and posttreatment factors. METHODS: The derivation cohort included 511 patients with anterior circulation AIS treated with ERT at 10 centers between September 2009 and July 2011. The prospective validation cohort included 223 patients with anterior circulation AIS treated in the North American Solitaire Acute Stroke registry. Multivariable logistic regression identified predictors of good outcome (modified Rankin score ≤2 at 3 months) in the derivation cohort; model ß coefficients were used to assign points and calculate a risk score. Discrimination was tested using C statistics with 95% confidence intervals (CIs) in the derivation and validation cohorts. Calibration was assessed using the Hosmer-Lemeshow test and plots of observed to expected outcomes. We assessed the net reclassification improvement for the derived score compared to the Totaled Health Risks in Vascular Events (THRIVE) score. Subgroup analysis in patients with pretreatment Alberta Stroke Program Early CT Score (ASPECTS) and posttreatment final infarct volume measurements was also performed to identify whether these radiographic predictors improved the model compared to simpler models. RESULTS: Good outcome was noted in 186 (36.4%) and 100 patients (44.8%) in the derivation and validation cohorts, respectively. Combining readily available pretreatment and posttreatment variables, we created a score (acronym: SNARL) based on the following parameters: symptomatic hemorrhage [2 points: none, hemorrhagic infarction (HI)1-2 or parenchymal hematoma (PH) type 1; 0 points: PH2], baseline National Institutes of Health Stroke Scale score (3 points: 0-10; 1 point: 11-20; 0 points: >20), age (2 points: <60 years; 1 point: 60-79 years; 0 points: >79 years), reperfusion (3 points: Thrombolysis In Cerebral Ischemia score 2b or 3) and location of clot (1 point: M2; 0 points: M1 or internal carotid artery). The SNARL score demonstrated good discrimination in the derivation (C statistic 0.79, 95% CI 0.75-0.83) and validation cohorts (C statistic 0.74, 95% CI 0.68-0.81) and was superior to the THRIVE score (derivation cohort: C statistic 0.65, 95% CI 0.60-0.70; validation cohort: C-statistic 0.59, 95% CI 0.52-0.67; p < 0.01 in both cohorts) but was inferior to a score that included age, ASPECTS, reperfusion status and final infarct volume (C statistic 0.86, 95% CI 0.82-0.91; p = 0.04). Compared with the THRIVE score, the SNARL score resulted in a net reclassification improvement of 34.8%. CONCLUSIONS: Among AIS patients treated with ERT, pretreatment scores such as the THRIVE score provide only fair prognostic information. Inclusion of posttreatment variables such as reperfusion and symptomatic hemorrhage greatly influences outcome and results in improved outcome prediction.
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Isquemia Encefálica/terapia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reperfusão , Índice de Gravidade de Doença , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do TratamentoRESUMO
Lumbar puncture opening pressure (LPOP) exceeding 250mmH2O is key in diagnosing idiopathic intracranial hypertension (IIH), per revised Friedman's criteria. Some patients do not meet LPOP criteria (with or without papilledema), despite having IIH-related symptoms and neuroimaging findings. This study aimed to investigate the radiological findings and clinical symptoms in patients suspected of having IIH without meeting the LPOP criteria. We retrospectively evaluated cerebral venous sinus stenosis using the conduit Farb score (CFS) and other radiological findings suggestive of IIH by computed tomography venography and magnetic resonance venography in females ≥ 18 years-old with chronic headaches, suspected IIH, and LPOP < 250 mm. Eighty-eight women (56 with LPOP < 200 mm H2O and 32 with LPOP ranging between 200 and 250mmH2O) were included. Among patients with LPOP 200-250mmH2O, 40% (12) exhibited three or more radiological findings supporting IIH, compared to 17% (8) in the LPOP < 200 mmH2O group (p = 0.048). Cerebral venous stenosis (CFS ≤ 5) was observed in 80% (24) of those with LPOP 200-250 mmH2O, contrasting with 40% (19) of those with LPOP < 200 mmH2O (p < 0.001). Cerebral venous stenosis was significantly more common in patients with LPOP 200-250 mmH2O than < 200 mmH2O, suggesting that they may benefit from IIH treatment.
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Pseudotumor Cerebral , Punção Espinal , Humanos , Feminino , Adulto , Pseudotumor Cerebral/diagnóstico por imagem , Pseudotumor Cerebral/fisiopatologia , Pseudotumor Cerebral/complicações , Estudos Retrospectivos , Pessoa de Meia-Idade , Constrição Patológica/diagnóstico por imagem , Flebografia/métodos , Tomografia Computadorizada por Raios X/métodos , Masculino , Adulto Jovem , Papiledema/diagnóstico por imagem , Papiledema/etiologiaRESUMO
Background/objectives: The aim of this study was to evaluate the long-term outcomes of a cohort of ophthalmologically resolved female idiopathic intracranial hypertension (IIH) patients. Methods: Our cross-sectional study included adult females with at least 6 months of ophthalmologically resolved IIH. Patients with papilledema or who underwent IIH-targeted surgical intervention were excluded. Participants completed a questionnaire consisting of medical information, the Migraine Disability Assessment Scale (MIDAS) and the Headache Impact Test (HIT-6). Electronic medical records and the results of imaging upon diagnosis were retrospectively reviewed. Results: One-hundred-and-four participants (mean age 35.5 ± 11.9 years) were included (7.85 ± 7 years post-IIH diagnosis). Patients with moderate-severe disability according to the MIDAS scale (n = 68, 65.4%) were younger (32.4 ± 8.9 vs. 41.5 ± 14.4 year-old, p < 0.001), had a shorter time interval from IIH diagnosis (5.9 ± 5.3 vs. 11.7 ± 8.5 years, p < 0.001), and had lower FARB scores (indicating a more narrowed transverse-sigmoid junction; 1.28 ± 1.82 vs. 2.47 ± 2.3, p = 0.02) in comparison to patients with low-mild disability scores. In multivariate analysis, a lower FARB score (OR 1.28, 95% CI 0.89-1.75, p = 0.12) and younger age (OR 1.09, 95% CI 0.98-1.19, p = 0.13) showed a trend toward an association with a moderate-severe MIDAS score. Moreover, in the sub-analysis of patients with a moderate-severe MIDAS scale score, the 10 patients with the highest MIDAS scores had a low FARB score (1.6 ± 1.1 vs. 2.7 ± 2.4, p = 0.041). Conclusions: High numbers of patients with ophthalmologically resolved IIH continue to suffer from related symptoms. Symptoms may be associated with the length of time from the diagnosis of IIH and a lower FARB score.
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While the typical patient with idiopathic intracranial hypertension (IIH) is an obese female of childbearing age, there are unique patient populations, such as non-obese females, that have not been well studied. Characterizing this subpopulation may increase awareness our of it, which may prevent underdiagnosis and improve our understanding of IIH's underlying pathophysiology. We retrospectively reviewed electronic medical records and compared the clinical and radiological characteristics of non-obese (BMI < 30) and obese (BMI > 30) female patients with IIH. Two hundred and forty-six patients (age 32.3 ± 10) met our inclusion criteria. The non-obese patients (n = 59, 24%) were significantly younger than the obese patients (29.4 ± 9.9 vs. 33.2 ± 10.2, p = 0.004) and had higher rates of severe papilledema (Friesen 4-5; 25.4% vs. 11.8%, p = 0.019), scleral flattening (62.7% vs. 36.9%, p = 0.008), and optic nerve dural ectasia (78.0% vs. 55.6%, p = 0.044). Non-obese patients also had a tendency to have a higher lumbar puncture opening pressure (368 ± 92.7 vs. 344 ± 76.4, p = 0.062). Non-obese patients were three times more likely to present with a combination of scleral flattening and optic nerve dural ectasia (OR = 3.00, CI: 1.57-5.72, χ2 = 11.63, α < 0.001). Overall, non-obese females with IIH were found to have a more fulminant presentation, typified by higher rates of severe papilledema and radiological findings typical for IIH.
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INTRODUCTION: The underlying pathophysiology of Transient global amnesia (TGA) remains elusive. Reports of perfusion abnormalities in TGA were inconsistent, but semi-automated analysis of perfusion CT (CTP) may improve reliability and precision of perfusion deficit detection. METHODS: Per institutional protocol, all TGA patients undergo multiphasic contrast-CT with arch to vertex CT angiography, intracranial CT venography, MRI, and EEG upon admission. During the study period consecutive patients diagnosed with TGA underwent CTP during the early acute amnestic phase. We retrospectively reviewed the clinical and radiological findings. RESULTS: Five patients (3 female. median age 71, range 47-74) fulfilled entry criteria. Automated CTP analysis revealed the absence of an ischemic core (defined by CBF < 30%) or conventionally defined clinically relevant hypoperfusion area (defined by Time-to-maximum (Tmax) >6 s) in any of the patients. However, four of the five patients demonstrated territories of benign oligemia defined as Tmax>4 s in areas supplied by the Posterior Cerebral Artery. Three of these four patients had clear involvement of the bilateral medial temporal lobes. None of the patients had epileptic activity on their EEG. Both CTA and MRI were normal apart for small foci of restricted diffusion in the hippocampus of four patients. DISCUSSION: Deficits in perfusion were found in the hippocampi of 60% of patients in the acute phase of TGA using automated image analysis software. This method may provide a quick and simple method to detect these abnormalities. These perfusion abnormalities could help solidify the diagnosis at an early stage and may advance our understanding of this elusive syndrome.
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Amnésia Global Transitória , Acidente Vascular Cerebral , Humanos , Feminino , Idoso , Amnésia Global Transitória/diagnóstico por imagem , Estudos Retrospectivos , Reprodutibilidade dos Testes , Angiografia por Tomografia Computadorizada , Perfusão , Circulação Cerebrovascular/fisiologia , Acidente Vascular Cerebral/diagnósticoRESUMO
Herpes zoster (HZ) represents a serious health problem in the general population due to its abundance and complications. Stroke and acute myocardial infarction are well-documented short-term complications of HZ, primarily due to vasculopathy in the cerebral and coronary arteries. However, no major study to date has specifically demonstrated that HZ is a long-term risk factor for all Major Adverse Cardiac and Cerebrovascular Events (MACCE). A retrospective cohort study was conducted analyzing the association between HZ and MACCE. We compared HZ patients diagnosed between 2001 and 2018 and a matched control group. The model was stratified according to matched pairs and adjusted for age, socioeconomic status, history of dyslipidemia, and prior myocardial infarction (MI). Association between HZ exposure and stroke was assessed through a multivariable Cox regression analysis. The study included 41,930 patients, with 20,965 patients in each group. The risk of MACCE was 19% higher among HZ patients in the first year of follow up (P < 0.001). Antiviral treatment did not positively affect long-term survival among HZ patients (P < 0.001). These results suggest that HZ is a marker of long-term vascular risk. Additional studies will be needed to further evaluate this risk, the impact of HZ vaccination on such risk, and potential mitigation strategies.
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Herpes Zoster , Infarto do Miocárdio , Acidente Vascular Cerebral , Humanos , Estudos Retrospectivos , Herpes Zoster/complicações , Herpes Zoster/epidemiologia , Herpesvirus Humano 3 , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/complicações , Fatores de Risco , Infarto do Miocárdio/complicaçõesRESUMO
BACKGROUND: Fulminant idiopathic intracranial hypertension (FIIH) is characterized by rapid, severe, progressive vision loss and often treated surgically. Cerebral transverse venous stenting (CTVS) is efficacious in IIH patients, but emergent CTVS in FIIH is rarely reported. We present our experience with emergent CTVS in patients with FIIH. METHODS: Since 01/2019, an institutional protocol allowed emergent CTVS in FIIH patients with bilateral transverse sinus stenosis and gradient pressure > 15 on digital subtraction angiography (DSA). We retrospectively analyzed a prospective registry of all IIH patients with details of neurological and neuro-ophthalmological assessments before and after treatment, and subjective assessments of headache and tinnitus were made pre-and post-procedure. RESULTS: 259 IIH patients, including 49 who underwent CTVS, were registered. Among them, five female patients met inclusion criteria for FIIH and underwent emergent CTVS. FIIH patients were younger (18.8 ± 1.64 vs 27.7 ± 4.85, p < 0.01), mean BMI was lower (30.8 ± 10.57 vs 34.6 ± 4.3, p < 0.01), and lumbar puncture opening pressure higher (454 ± vs 361 ± 99.4, p < 0.01) than that of IIH patients. They presented with acute visual loss, severe headache, papilledema, significant bilateral transverse sinus stenosis on CT-venography, and mean dominant side gradient pressure of 26.4 ± 6.2 on DSA. CTVS was performed without significant complications, resulting in remarkable improvement in headache, optical coherence tomography, and visual fields within 1 week. At 1-year follow-up (four patients) and 6-month follow-up (1 patient), there was complete resolution of papilledema and headache, and marked improvement in visual acuity. CONCLUSIONS: In these patients, emergent-CTVS was a safe and effective treatment option for FIIH. Further evaluation is warranted.
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Hipertensão Intracraniana , Papiledema , Pseudotumor Cerebral , Humanos , Feminino , Pseudotumor Cerebral/complicações , Pseudotumor Cerebral/diagnóstico por imagem , Pseudotumor Cerebral/cirurgia , Papiledema/diagnóstico por imagem , Papiledema/etiologia , Papiledema/cirurgia , Estudos Retrospectivos , Constrição Patológica/complicações , Cefaleia/etiologia , Stents/efeitos adversos , Transtornos da Visão/complicações , Cavidades Cranianas , Hipertensão Intracraniana/diagnóstico por imagem , Hipertensão Intracraniana/etiologia , Hipertensão Intracraniana/cirurgiaRESUMO
Background: In acute ischemic stroke (AIS), successful endovascular thrombectomy (EVT) of large vessel occlusion (LVO) necessitates the most suited device. Solitaire-X has longer and larger diameter pusher wires than Solitaire-FR.As the role of a larger pusher-wire diameter is uncertain, we aim to compare procedural, clinical, and radiological outcomes for AIS patients undergoing EVT using either type of Solitaire device. Procedures were performed using the Solumbra technique, which combines a large-bore aspiration catheter with a stentriever. The primary outcome was to compare rates of successful first-pass recanalization (defined as TICI 2b/3 score). The secondary objectives were procedural (rates of successful recanalization), clinical (post-procedural NIHSS and days of hospitalization), and radiological (post-procedural ASPECT score and hemorrhagic transformation) outcome measures. Design: Consecutive AIS patients undergoing EVT for LVO were recruited into a prospective multicenter database at our academic center. We have used Solitaire-FR until October 2020 and Solitaire-X ever since. We retrospectively analyzed our prospective consecutive registry. Included in our analysis are patients undergoing EVT using Solitaire only; patients with tandem lesions or underlying stenosis requiring emergent stenting during the procedure were excluded. The cohort of patients treated with Solitaire-X was compared with a cohort consisting of the most recent consecutive cases undergoing EVT with the Solitaire-FR. Results: A total of 182 (71.9 ± 14, 61% male patients) AIS patients were included in the analysis with both groups (n = 91 each) sharing similar demographic characteristics, premorbid conditions, and stroke characteristics (time from symptom-onset, NIHSS, ASPECTS, occlusion site, and rates of intravenous-tPA treatment). The Solitaire-X group had a higher rate of first-pass recanalization (65.9% vs. 50.5%, p = 0.049). On 24-h post-procedural head-CT, the Solitaire-X group had higher ASPECT scores (6.51 ± 2.9 vs. 5.49 ± 3.4, p = 0.042) and lower post-procedural average bleeding volumes (0.67 ± 2.1 vs. 1.20 ± 3.4 mL, p = 0.041). The Solitaire-X group had shorter duration of hospitalization (16.6 ± 13.1 days vs. 25.1 ± 23.2, p = 0.033). On multivariate analysis, using Solitaire-X was the sole independent predictor of first-pass recanalization (OR 2.17, 95% CI 1.12-4.26, p = 0.023). Conclusion: In our study, the use of the Stentriever-X with a larger pusher-wire diameter was associated with a higher likelihood of first-pass effect and improved procedural, clinical, and radiological outcomes in AIS patients.
RESUMO
Background: The role of intravenous thrombolysis (IVT) as bridging treatment prior to endovascular thrombectomy (EVT) is under debate and better patient selection is needed. Objectives: As the efficacy and safety of IVT diminish with time, we aimed to examine the impact of bridging treatment within different time frames from symptom onset. Design: A retrospective registry study. Methods: Data were extracted from ongoing prospective EVT registries in two large tertiary centers. The current study included IVT-eligible patients with onset to door (OTD) < 4 h. We examined the efficacy and safety of bridging treatment through a comparison of the IVT + EVT group with the direct-EVT group by different time frames. Results: In all, 408 patients (age 71.1 ± 14.6, 50.6% males) were included, among them 195 received IVT + EVT and 213 underwent direct EVT. Both groups had similar characteristics. In the IVT + EVT group only, longer OTD was associated with lower rates of favorable outcome (p = 0.021) and higher rates of hemorrhagic transformation (HT; p = 0.001). In patients with OTD ⩽ 2 h, IVT + EVT compared to direct EVT had higher rates of TICI 2b-3 (86.2% versus 80.7%, p = 0.038). In patients with OTD > 2 h, IVT + EVT had lower rates of favorable outcome (33.3% versus 56.9%, p = 0.021), worse discharge National Institutes of Health Stroke Scale [7 (2-13) versus 3 (1-8), p = 0.024], and higher rates of HT (34.0% versus 8.5%, p < 0.001). Discussion: In this study, we found OTD times to have a significant effect on the impact of IVT bridging treatment. Our study shows that among patients with OTD < 2 h bridging treatment may be associated with higher rates of successful recanalization. By contrast, in patients with OTD > 2 h, bridging treatment was associated with worse outcomes. Further time-sensitive randomized trials are needed.
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Pulsatile tinnitus constitutes up to 10% of all tinnitus cases. Cerebral venous stenosis is a known etiology of pulsatile tinnitus. Treatment of pulsatile tinnitus secondary to venous stenosis with venous stenting has been reported in the literature but is not performed routinely. We would like to report a case of chronic pulsatile tinnitus treated with venous stent in a patient who previously underwent jugular vein ligation.
Assuntos
Zumbido , Constrição Patológica/complicações , Constrição Patológica/cirurgia , Cavidades Cranianas/cirurgia , Humanos , Veias Jugulares/cirurgia , Stents/efeitos adversos , Zumbido/complicações , Zumbido/cirurgiaRESUMO
Introduction: We aimed to assess the clinical significance of M1-MCA occlusion with visualization of both MCA-M2 segments ["Tilted-V sign" (TVS)] on initial CT angiography (CTA) in patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy (EVT). Methods: Data for patients with consecutive AIS undergoing EVT for large vessel occlusion (LVO) in two academic centers are recorded in ongoing databases. Patients who underwent EVT for M1-MCA occlusions ≤ 6 h from symptom onset were included in this retrospective analysis. Results: A total of 346 patients met the inclusion criteria; 189 (55%) had positive TVS. Patients with positive TVS were younger (68 ± 14 vs. 71 ± 14 years, P = 0.028), with similar rates of vascular risk factors and baseline modified Rankin scores (mRS) 0-2. The rates of achieving thrombolysis in cerebral ischemia (TICI) 2b-3 were similar to the two groups (79%), although successful first-pass recanalization was more common with TVS (64 vs. 36%, p = 0.01). On multivariate analysis, higher collateral score [odds ratio (OR) 1.38 per unit increase, p = 0.008] and lower age (OR 0.98 per year increase, p = 0.046) were significant predictors of TVS. Patients with positive TVS had higher post-procedural Alberta Stroke Program Early CT Score (ASPECTS; 6.9 ± 2.2 vs. 5.2 ± 2.3, p = 0.001), were discharged with lower National Institutes of Health Stroke Score (NIHSS; 6±6 vs. 9±7, p = 0.003) and higher rates of mRS 0-2 (29.5 vs. 12%, p = 0.001), and had lower rates of 90-day mortality (13.2 vs. 21.6%, p = 0.038). However, TVS was not an independent predictor of functional independence (OR 2.51; 95% CI 0.7-8.3). Conclusion: Tilted-V Sign, an easily identifiable radiological marker, is associated with fewer recanalization attempts, better functional outcomes, and reduced mortality.
RESUMO
Current guidelines advocate intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) for all patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). We evaluated outcomes with and without IVT pretreatment. Our institutional protocols allow AIS patients presenting early (<4 h from onset or last seen normal) who have an Alberta Stroke Program Early CT Score (ASPECTS) ≥6 to undergo EVT without IVT pretreatment if the endovascular team is in the hospital (direct EVT). Rates of recanalization and hemorrhagic transformation (HT) and neurological outcomes were retrospectively compared in consecutive patients undergoing IVT+EVT vs. direct EVT with subanalyses in those ≥80 years and ≥85 years. In the overall cohort (IVT+EVT = 147, direct EVT = 162), and in subsets of patients ≥80 years (IVT+EVT = 51, direct EVT = 50) and ≥85 years (IVT+EVT = 19, direct EVT = 32), the IVT+EVT cohort and the direct EVT group had similar baseline characteristics, underwent EVT after a comparable interval from symptom onset, and reached similar rates of target vessel recanalization. No differences were observed in the HT frequency, or in disability at discharge or after 90 days. Patients receiving direct EVT underwent more stenting of the carotid artery due to stenosis during the EVT procedure (22% vs. 6%, p = 0.001). Direct EVT and IVT+EVT had comparable neurological outcomes in the overall cohort and in the subgroups of patients ≥80 and ≥85 years, suggesting that direct EVT should be considered in patients with an elevated risk for HT.