Favorable Bridging Therapy Based on DWI-FLAIR Mismatch in Patients with Unclear-Onset Stroke.

BACKGROUND AND PURPOSE: Standard selection criteria for revascularization therapy usually exclude patients with unclear-onset stroke. Our aim was to evaluate the efficacy and safety of revascularization therapy in patients with unclear-onset stroke in the anterior circulation and to identify the predictive factors for favorable clinical outcome. MATERIALS AND METHODS: We retrospectively analyzed 41 consecutive patients presenting with acute stroke with unknown time of onset treated by intravenous thrombolysis and/or mechanical thrombectomy. Only patients without well-developed fluid-attenuated inversion recovery changes of acute diffusion lesions on MR imaging were enrolled. Twenty-one patients were treated by intravenous thrombolysis; 19 received, simultaneously, intravenous thrombolysis and mechanical thrombectomy (as a bridging therapy); and 1 patient, endovascular therapy alone. Clinical outcome was evaluated at 90 days by using the mRS. Mortality and symptomatic intracranial hemorrhage were also reported. RESULTS: Median patient age was 72 years (range, 17-89 years). Mean initial NIHSS score was 14.5 ± 5.7. Successful recanalization (TICI 2b-3) was assessed in 61% of patients presenting with an arterial occlusion, symptomatic intracranial hemorrhage occurred in 2 patients (4.9%), and 3 (7.3%) patients died. After 90 days, favorable outcome (mRS 0-2) was observed in 25 (61%) patients. Following multivariate analysis, initial NIHSS score (OR, 1.43; 95% CI, 1.13-1.82; P = .003) and bridging therapy (OR, 37.92; 95% CI, 2.43-591.35; P = .009) were independently associated with a favorable outcome at 3 months. CONCLUSIONS: The study demonstrates the safety and good clinical outcome of acute recanalization therapy in patients with acute stroke in the anterior circulation and an unknown time of onset and a DWI/FLAIR mismatch on imaging. Moreover, bridging therapy versus intravenous thrombolysis alone was independently associated with favorable outcome at 3 months.

[Lateral bulbar infarction due to intracranial dissection and subarachnoid haemorrhage]. / Infarctus latéro-bulbaire sur dissection intracrânienne suivi d'une hémorragie sous-arachnoïdienne.

INTRODUCTION: Intracranial vertebral artery dissecting aneurysms are a recognized cause of subarachnoid hemorrhage and the hemorrhagic recurrence risk after a first rupture of the dissecting aneurysm is high and of poor prognosis. However, when the dissection is discovered in a patient with vertebrobasilar territory ischemia, little is known about the risk of hemorrhagic rupture risk and there is no consensus on management. OBSERVATION: We report the case of a 49-year-old man who developed subarachnoid hemorrhage 48 hours after the occurrence of a latero-bulbar syndrome caused by a spontaneous dissection with occlusion of the right vertebral artery. The subsequent angiography showed a V4 dissecting aneurysm of the right vertebral artery which was treated by stenting and coiling without any complications. CONCLUSION: This case underlines the hemorrhagic risk of an intradural vertebral artery dissection and its possible progression to aneurysm. Subsequent angiographic imaging must be carefully examined to search for aneurysms which may require early specific treatment because of the high risk of recurrent bleeding.

Ischemic stroke and active migraine.

OBJECTIVE: To determine the characteristics of acute ischemic stroke (IS) in patients with active migraine in a prospective stroke registry. METHODS: The authors studied the characteristics of patients admitted to a population-based primary-care center with IS and active migraine. The diagnosis of previous migraine was made based on replies to International Headache Society-based questions. Patients with migraine were divided into two age groups, one below 45 years of age and one 45 years or older, and compared by univariate and multivariate analysis with age-matched control subjects with IS, but without migraine. RESULTS: Of the 3,502 patients with acute IS, 130 (3.7%) had active migraine; 66 of these were younger than 45 years and 64 were 45 years or older (15.8% and 2.1% of the total for the corresponding age group). The proportion of women was significantly higher in both groups of patients with migraine (74% and 63% in the younger and older groups) than in control subjects. In young migraineurs, the posterior circulation involvement and the presence of patent foramen ovale were characteristic. In the younger migraine group, nine patients developed IS during a typical attack of migraine with aura, and 15 during migraine attack without aura in the absence of any other determined cause. In the older group, surprisingly, absence of vascular risk factors (previous hypertension, ischemic heart disease, and cigarette smoking) was characteristic. CONCLUSIONS: Migraine is frequent in young patients with IS and infrequent in older patients with IS. Patients with IS and migraine are mainly women with stroke features that are age dependent.

Imidazoline-induced neuroprotective effects result from blockade of NMDA receptor channels in neuronal cultures.

Imidazolines have been shown to be neuroprotective in focal and global ischemia in the rat. However, their mechanism of action is still unclear. We have studied the neuroprotective effects of imidazolines against NMDA-induced neuronal death and hypoxic insult in cerebellar and striatal neuronal cultures. All of the imidazolines tested decreased the NMDA-mediated neurotoxicity in a non-competitive manner. Antazoline was the most effective (IC(50) of 5 microM, maximal neuroprotection reaching 90% at 100 microM). The neuroprotective effects were still present when the imidazolines were applied during the post-insult period. Antazoline, idazoxan and guanabenz also showed neuroprotective effects against hypoxia-induced neuronal death (neuroprotection reaching 95% for antazoline at 100 microM). Antazoline was still active if applied during the reoxygenation period (15% neuroprotection). To determine the mechanism of the neuroprotective effects, the possible interaction of imidazolines with NMDA receptors was studied. Imidazolines dose-dependently and non-competitively inhibited NMDA currents. As found for the neuroprotective effects, antazoline was the most effective imidazoline, with an IC(50) of 4 microM and a maximal inhibition of 90% at 100 microM. This blockade was rapid, reversible and voltage-dependent. We compared these effects to those of the classical non-competitive antagonist of NMDA channels, MK-801. In contrast to imidazolines, blockade of the NMDA current by MK-801 was voltage-independent and reversible only at positive potentials. When co-applied with MK-801, antazoline prevented the long lasting blockade of the NMDA current by MK-801. These results are consistent with the existence of overlapping binding sites for these drugs on the NMDA receptor channel. They indicate that imidazolines exert a strong neuroprotective effect against excitotoxicity and hypoxia in cerebellar and striatal primary neuronal cultures by inhibiting NMDA receptors. Since these effects were non-competitive, imidazolines appear to be interesting new drugs with therapeutic potential.

Neuroprotective activity of antazoline against neuronal damage induced by limbic status epilepticus.

Imidazoline drugs exert neuroprotective effects in cerebral ischaemia models. They also have effects against mouse cerebellar and striatal neuronal death induced by N-methyl-D-aspartate (NMDA) through the blockade of NMDA currents. Here, we investigated the effects of antazoline on NMDA toxicity and current in rat hippocampal neuronal cultures, and on an in vivo model of status epilepticus. In hippocampal cultures, antazoline (30 microM) decreased NMDA-mediated neurotoxicity and also blocked the NMDA current with voltage-dependent and fast-reversible action (inhibition by 85+/-3% at -60 mV). Status epilepticus was induced by injecting pilocarpine (200 nmol) directly into the right pyriform cortex of male adult rats. The rats then received immediately three consecutive i.p. injections at 30-min intervals of either PBS (control group) or antazoline at 10 mg/kg (low-dose group) or at 45 mg/kg (high-dose group). During the 6-h recording, status epilepticus lasted more than 200 min in all groups. In the high-dose group only, seizures completely ceased 1 h after the third injection of antazoline, then started again 1 h later. Rats were killed 1 week later, and Cresyl Violet-stained sections of their brain were analysed for damage quantification. On the ipsilateral side to the pilocarpine injection, pyriform cortex and hippocampal CA1 and CA3 areas were significantly protected in both antazoline-treated groups, whilst prepyriform and entorhinal cortices were only in the high-dose group. On the contralateral side to the pilocarpine injection, only the hippocampal CA3 area was significantly protected in the low-dose group, but all investigated structures were in the high-dose group. In conclusion, antazoline is a potent neuroprotective drug in different models of neuronal primary culture, as previously shown in striatal and cerebellar granule neurons [Neuropharmacology 39 (2000) 2244], and here in hippocampal neurons. Antazoline is also neuroprotective in vivo in the intra-pyriform pilocarpine-induced status epilepticus model.

Swan-Ganz catheter-related pulmonary valve infective endocarditis: a case report.

We report the case of a 29-year-old man with decompensated alcoholic cardiomyopathy who developed a Staphylococcal pulmonic valve infective endocarditis during hemodynamic monitoring, as a consequence of catheter-related bacteremia. As experimentally demonstrated, the damaging role of the pulmonary artery catheter on the endocardial surface plays a major role in the pathogenesis of related right-sided infective endocarditis. Occurrence of bacteremia in a catheterized patient should be considered as a high risk situation, and righ-heart infective endocarditis must be suspected whenever patient presents fever or bacteremia without obvious site of infection. Doppler echocardiography is the reference diagnosis procedure.

[Pituitary tumour as a presenting symptom of a systemic lymphoma]. / Syndrome tumoral hypophysaire révélateur d'un lymphome systémique.

Pituitary non Hodgkin malignant lymphomas are rare. We report a case of large cell systemic lymphoma with pituitary and meningeal localizations in a 40-year-old patient. The clinical picture was panhypopituitarism with MRI appearance of pituitary adenoma and VII and VIII cranial nerves involvement. Diagnosis was made by identification of lymphomatous cells in CSF. The patient deceased in less than one year despite chemotherapy.

[Cerebrovascular complications and hereditary protein S deficiency: 2 cases]. / Accidents vasculaires cérébraux et déficit héréditaire en protéine S: 2 cas.

Hereditary protein S deficiency (HSPD) is a predisposing factor to recurrent venous thrombosis but is not currently associated with stroke. We report two cases of HSPD revealed by stroke in young adults. The first one was a 36-year-old patient whith a pure motor hemiplegia, who gradually recovered without sequelae. Total and free protein S was decreased (55 and 10%). One of his brothers died from pulmonary embolism at 20 years and a sister had low protein S level without clinical signs. The second case was a 26-year-old patient who had a right hemiplegia with aphasia due to an infarction in middle cerebral artery area. He partially recovered, but the course of the illness was complicated by deep venous thrombosis of the lower limbs and pulmonary embolism. Total and free serum protein S level was severely decreased (25 and 0%). The patient's mother and one of his sisters also had low protein S but never had clinical complications. In both case, dupplex scanning, transcranial doppler, echocardiography, serum antithrombin III and protein C were normal. Cigarette smoking was the only risk factor for arterial disease. These two cases suggest that HSPD must be investigated in young patients with stroke, even in cases of lacunar stroke.

[Infarction of the caudate nucleus or anterior striato-capsular infarction?]. / Infarctus du noyau caudé ou infarctus striato-capsulaires antérieurs?

Eight patients with caudate nucleus infarcts are reported. The main clinical findings were often transient facio-brachial weakness (6 patients), depression (4 patients), subcortical aphasia with decreased spontaneous verbal activity (2 patients), and aboulia (2 patients). The ischemic lesions of caudate nucleus often extend into the adjacent anterior limb of the internal capsule and the anterior putamen owing to vascularization pattern. The specific clinical picture of this entity also includes lesions of nearby white matter tracts. Risk factors, etiology of infarcts, clinical findings and prognosis were similar to those reported in striato-capsular infarcts. We suggest replacing the term caudate infarct by anterior striato-capsular infarct.

[Central apnea with consciousness impairment due to Listeria rhombencephalitis sequelae]. / Apnées centrales avec troubles de la vigilance, séquelle de rhombencéphalite listérienne.

Listeria neuromeningitis presents as febrile rhombencephalitis in half the patients, often with persistent sequelae such as cranial nerve palsy. We report the case of a man who developed central apnea with simultaneous consciousness impairment subsequent to an infectious disease. Magnetic resonance imaging showed low signal intensities in T1 and T2, particularly in the medulla. Neither acidosis, hypoxia nor hypercapnea stimulated the respiratory centers during episodes of apnea; ventilation started again only with strong voluntary stimulation. Pons and medulla lesions of the reticular formation were probable as well as lesions of the automatic respiratory system and could explain the central origin of the apnea in this patient.

[Recurrent acute polyneuropathy and cutaneous vasculitis]. / Polyneuropathie aiguë récidivante et vasculite cutanée.

A patient with relapsing cutaneous vasculitis presented 3 times in 10 years with an acute extensive neuropathy and respiratory failure which fully recovered. The relationships between Guillain-Barré syndrome and vasculitis are discussed.

[Hypertensive encephalopathy as revealing symptom of Takayasu's arteritis]. / Encéphalopathie hypertensive révélatrice d'une maladie de Takayasu.

A 29-year-old patient presented with Takayasu's arteritis which was revealed by heart failure, epilepsy, right hemiparesis and fever. Transient abnormalities of MRI and CSF (raised protein and cell content) were initially observed. The hypothesis of a hypertensive encephalopathy is suggested.

[Arterial thrombolysis and angioplasty in atheromatous basilar artery occlusion]. / Thrombolyse par voie artérielle et angioplastie dans l'occlusion athéromateuse du tronc basilaire.

Basilar occlusions treated with conventional therapy (anticoagulants or antiplatelets) have a poor outcome (80p. cent mortality). This unfavorable outcome may require a treatment within 6 hours by intra-arterial thrombolysis, sometimes followed by percutaneous transluminal angioplasty (PTA) in case of atherothrombotic occlusion due to a tight atherosclerotic stenosis. A 48 year-old patient, presented with left hemiparesis, left multimodal hypoesthesia, paralytic dysarthria. CT-scan showed a spontaneous hyperdensity of the basilar artery and arterial occclusion was confirmed by angiography, which showed an atherothrombotic occlusion involving the proximal part of the vessel. Intra-arterial thrombolysis began five hours after the onset with 0,25mg/kg of Rt-Pa (Actilyse((R))), given by bolus followed by 4 others bolus of 10mg. After a total dose of 60mg, arterial recanalization was obtained showing a tight atherosclerotic stenosis involving the proximal part of the basilar artery. PTA was performed 18 hours later with a ballon inflation at 6 atmospheres during 20 seconds. It allowed to decrease the stenosis from 80p. cent to 60p. cent. The patient recovered and MRI at D20 showed a small right lateral infarct involving the pons. Our study confirms the usefulness of intra-arterial thrombolysis in basilar artery occlusion. Consecutive PTA may be proposed in case of associated atherosclerotic stenosis, and the interest of PTA is further discussed.

[Hypokalaemic paralysis as a presentation of adrenal tumor]. / Paralysie hypokaliémique révélatrice d'une tumeur surrénalienne.

A 24-year-old patient presented with flaccid quadriplegia due to severe hypokaliemia, initially presumed to have been induced by glycyrrhizin. Persistence of low potassium levels and hypertension led to the diagnosis of primary hyperaldosteronism related to an adrenal cortical tumor. After surgery, the patient recovered from hypertension and hypokaliemia.

[Traumatic dissection of the internal carotid artery: malignant supratentorial infarction and decompressive treatment]. / Dissection traumatique de la carotide interne cervicale: infarctus malin supra-tentoriel et traitement décompressif.

We present a case report of a thirty-six-year-old right-handed female. She suffered with a malignant space-occupying supratentorial ischemic stroke caused by a traumatic cervical internal carotid artery dissection. She had a car accident and, initially, presented with a normal examination. In two days, she became comatose (Glasgow Coma Scale score was 5) with complete left hemiplegia, right mydriasis and required respiratory assistance despite the medical treatment. It was decided to perform a large right frontotemporoparietal bone flap with large dural plasty. Eighteen months later, with intensive rehabilitation, the results of neuropsychological testing were normal, and the Barthel Index score was 90. The indications for decompressive surgery in malignant space-occupying supratentorial ischemic stroke remains controversial. The age, general condition, neurological examination (consciousness, pupils, deficit), extent of parenchymal hypodensity and attenuated corticomedullary contrast on the brain CT, degree of midline shift, presence of uncal hernation, disparition of the visibility of the mesencephalic cisterns and third ventricle, high level of the intracranial pressure, and perhaps the results of the perfusion-and diffusion-weighted MRI, are the elements to decide (or not decide) decompressive surgery.

[Bacterial meningitis in adults in the intensive care unit. Clinical analysis and study of prognostic factors]. / Méningites bactériennes de l'adulte en réanimation médicale. Analyse clinique et étude des facteurs pronostiques.

OBJECTIVES: Bacterial meningitis frequently leads to hospitalization in the intensive care unit. Despite progress in antibiotics, prognosis remains poor. METHODS: We analyzed the clinical manifestations and complications which occurred in 41 patients admitted to the intensive care unit for bacterial meningitis. A case-control survey was used to determine prognosis factors. RESULTS: All patients required ventilatory assistance and 83% were in a state of coma at admission. Causal germs isolated were: Pneumococci 34%, Listeria 22%, Staphylococcus aureus 17%, and Gram-positive bacilli 12%. Overall mortality was 56%. The main prognosis factors after univariate analysis were age, delay to treatment, presence of septic shock, bacteriemia at admission, low cell count in first lumbar tap, high urea level and low protein level. After multivariate analysis, the following risk factors were retained: low number of leukocytes at first lumbar tap and high urea level. CONCLUSION: The gravity of bacterial meningitis in the intensive care unit appears to be related to the patient's overwhelmed defense system and especially to hemodynamic disorders with acute renal failure and capillary hyperpermeability leading to insufficient cerebral perfusion.

Diffusion-weighted imaging score of the brain stem: A predictor of outcome in acute basilar artery occlusion treated with the Solitaire FR device.

BACKGROUND AND PURPOSE: The prognosis for ischemic stroke due to acute basilar artery occlusion is very poor: Early recanalization remains the main factor that can improve outcomes. The baseline extent of brain stem ischemic damage can also influence outcomes. We evaluated the validity of an easy-to-use DWI score to predict clinical outcome in patients with acute basilar artery occlusion treated by mechanical thrombectomy. MATERIALS AND METHODS: We analyzed the baseline clinical and DWI parameters of 31 patients with acute basilar artery occlusion, treated within 24 hours of symptom onset by using a Solitaire FR device. The DWI score of the brain stem was assessed with a 12-point semiquantitative score that separately considered each side of the medulla, pons, and midbrain. Clinical outcome was assessed at 180 days by using the mRS. According to receiver operating characteristic analyses, the cutoff score determined the optimal positive predictive value for outcome. The Spearman rank correlation coefficient assessed the correlation between the DWI brain stem score and baseline characteristics. RESULTS: Successful recanalization (Thrombolysis in Cerebral Infarction 3-2b) was achieved in 23 patients (74%). A favorable outcome (mRS ≤ 2) was observed in 11 patients (35%). An optimal DWI brain stem score of <3 predicted a favorable outcome. The probability of a very poor outcome (mRS ≥ 5) if the DWI brain stem score was ≥5 reached 80% (positive predictive value) and 100% if this score was ≥6. Interobserver reliability of the DWI brain stem score was excellent, with an intraclass correlation coefficient of 0.97 (95% CI, 0.96-0.99). The DWI brain stem score was significantly associated with baseline tetraplegia (P = .001) and coma (P = .005). CONCLUSIONS: In patients with acute basilar artery occlusion treated by mechanical thrombectomy, the baseline DWI brain lesion score seems to predict clinical outcome.

Evaluation of an intravenous-endovascular strategy in patients with acute proximal middle cerebral artery occlusion.

BACKGROUND AND PURPOSE: IVT administered in acute ischemic stroke provides low recanalization rates in proximal intracranial occlusions, with consequently poor clinical outcome. The safety and efficacy of an IES by using mechanical thrombectomy after IVT failure were assessed in acute MCA occlusions. MATERIALS AND METHODS: Patients presenting with acute MCA occlusion within 4.5 hours with an NIHSS score between 8 and 25 and a DWI ASPECTS of >5 were eligible. From September 2009 to September 2010, mechanical thrombectomy by using the Solitaire FR device was systematically performed if no clinical improvement was observed 1 hour after the initiation of IVT (IES group). Results in terms of clinical outcome were compared with those from an IVT series from January 2007 to August 2009 (IVT group). RESULTS: Alteplase was administered in 123 patients with proximal intracranial occlusion. Fifty-six had a confirmed MCA occlusion: 32 were included in the IVT group; and 24, in the IES group. At 24 hours, the median NIHSS improvement was 8.5 points in the IES group (25%-75% CI, 1.5-13) and 3 points in the IVT group (25%-75% CI, 1-5) (P = .001). At 3 months, 17/22 (77%) patients from the IES group and 15/30 (50%) from the IVT group had an mRS score of ≤2. After adjustment for confounding variables, IES was strongly associated with favorable clinical outcome (77% versus 50%; adjusted odds ratio = 11.9; 95% CI, 1.6-89.1; P < .02). No symptomatic intracranial hemorrhage was observed. CONCLUSIONS: IES by using systematic mechanical thrombectomy after IVT failure safely improves the clinical outcome at 3 months and could represent an interesting alternative in the management of patients with acute MCA occlusion.

Hemorrhagic risk of recent silent cerebral infarct on prethrombolysis MR imaging in acute stroke.

BACKGROUND AND PURPOSE: EIH is a rare complication after thrombolysis in patients with acute stroke, occurring in brain regions without visible ischemic change on pretreatment imaging. RSCIs can be detected by multimodal MR imaging and might be associated with an increased risk of HT postthrombolysis, related to BBBD. We aimed to assess the incidence of RSCI on pretreatment MR imaging and the subsequent risk of HT within RSCI areas on follow-up CT performed <36 hours after rtPA administration and on additional cerebral imaging before patient discharge. MATERIALS AND METHODS: Pretreatment MR imaging was retrospectively analyzed from consecutive patients with stroke who received intravenous or intra-arterial rtPA for 2 years. RSCI was defined on MR imaging as a parenchymal area markedly hyperintense on FLAIR, different from the hyperacute infarct, and mildly-to-markedly hyperintense on DWI or enhanced on postgadolinium T1WI imaging. RESULTS: Eighty-six patients with a median age of 66 years and a median NIHSS score on admission of 15 were studied; 66.3% received rtPA intravenously. The presence of RSCI was identified in 10 patients (11.6%) and was associated with large-vessel-disease etiology (40% versus 5.3%, P < .001) on univariate analysis. No HT was identified within the RSCI areas on any follow-up cerebral imaging. CONCLUSIONS: These preliminary results require validation but suggest that small RSCIs are rather frequent and might not pose a higher risk of postthrombolysis HT.