Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment.

BACKGROUND AND PURPOSE: In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion. METHODS: We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes. RESULTS: Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P<0.001). Distal embolization was associated with an inability to attempt EST: after distal embolization, 26/63 (41.3%) could not have attempted EST because of the new clot location, while in cases without distal embolization, only 8/249 (3.2%) were unable to have attempted EST (P<0.001). Among patients who received IV tPA, 13/242 (5.4%) had sufficient symptom improvement that a catheter angiogram was not performed; 6/342 (2.5%) had improvement to within 2 points of their baseline NIHSS. At catheter angiogram, 2/229 (0.9%) of patients who had received tPA had complete recanalization without distal embolization. Both IV tPA and EST recanalization were associated with improved long-term outcome. CONCLUSIONS: IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.

Usefulness of Consciousness Sedation with Dexmedetomidine and Pentazocine during Endovascular Treatment for Acute Stroke.

We investigated the safety and efficacy of consciousness sedation with dexmedetomidine (DEX) during the endovascular treatment of patients with acute cerebral infarction. Between April 2014 and November 2016, 38 stroke patients underwent endovascular thrombectomy (EVT) under local anesthesia and DEX consciousness sedation. The continuous intravenous administration of low-dose DEX (0.3-0.4 µg/kg/h) was started before entering the operating room. Patients not completely immobilized received an iv bolus of pentazocine (PTZ) and/or DEX (0.5-0.6 µg/kg/h). EVT was performed using a stent retriever and/or direct thrombo-aspiration. DEX sedation was stopped as soon as the operation was finished. A stent retriever was used in 8 (21.1%), direct thrombo-aspiration in 10 (26.3%), a stent retriever plus thrombo-aspiration in 14 (36.8%), and other devices in 6 patients (15.8%). Reperfusion exceeding 50% (thrombolysis in cerebral infarction >2b) was obtained in 30 patients (78.9%). DEX sedation alone immobilized 24 patients (63.2%), 14 (36.8%) required the additional injection of DEX or PTZ when EVT devices were navigated to the lesion. The administration of DEX and PTZ elicited no significant respiratory depression or cardiac dysfunction interfering with the procedures. Consciousness sedation by DEX was effective during the endovascular treatment of acute stroke patients. Under DEX sedation and the injection of PTZ, EVT was possible without significantly changing the patients' vital signs.

[Cerebellar Infarction After Carbon Monoxide Poisoning and Hyperbaric Oxygen Therapy]. / Kleinhirninfarkt nach CO-Intoxikation und hyperbarer Sauerstofftherapie.

We report on a patient who developed a space-occupying cerebellar infarction with occlusive hydrocephalus after a poisoning with carbon monoxide with the intention to commit suicide. A neurosurgical and intensive care therapy were needed. The patient's survival without severe neurological deficits could be secured due to the early detection of the intracerebral lesions.

Acute bithalamic infarct manifesting as sleep-like coma: A diagnostic challenge.

Bilateral thalamic infarction (BTI) typically presents as a sleep-like coma (SLC) without localizing signs, posing a diagnostic challenge that may lead the treating physician to search for toxic or metabolic causes and delay treatment. We review our experience with BTI of different etiologies, and emphasize the critical role of timely imaging, diagnosis, and management in a series of 12 patients with a presentation of SLC and acute BTI who were managed in our Medical Centers from 2006-2015. In 11/12, urgent head CT scans showed normal brain tissue, while diffusion-weighted (DWI) MRI revealed symmetric bilateral thalamic hyperintense lesions with variable degrees of brainstem involvement. In 1/12, CT scans revealed a contralateral subacute stroke from a thalamic infarct 1month earlier with a unilateral hyperintense lesion on DWI-MRI. From clinical and imaging findings (DWI-MRI, CT angiography and venography), etiology was attributed to embolic causes (cardio-embolism, artery-to-artery mechanism), small vessel disease, or deep sinus vein thrombosis secondary to dural arteriovenous (AV) fistula. Three patients had good outcomes after prompt diagnosis and optimal treatment in <3hours (intravenous tissue plasminogen activator in two patients cardio-embolic etiology and neuro-endovascular repair in one patient with venous infarction due to a dural AV fistula). The diagnosis was made beyond the therapeutic window in seven patients, who were left with significant neurological sequelae. Higher awareness of BTI presenting as SLC is warranted. Optimal patient management includes urgent DWI-MRI. In cases of BTI, further imaging workup is indicated to provide a comprehensive assessment for etiology. Early diagnosis and prompt, targeted intervention are crucial.

Long-term health-related quality of life after decompressive hemicraniectomy in stroke patients with life-threatening space-occupying brain edema.

BACKGROUND: Although randomized clinical trials have reported significant improvement in mortality and functional outcome as measured with modified Rankin Scale (mRS) or Barthel index (BI) in stroke patients with space-occupying anterior circulation infarctions treated with hemicraniectomy, many clinicians are still concerned about the long-term health-related quality of life (HRQoL). AIM: Assessment of HRQoL after hemicraniectomy to holistically reevaluate clinical outcome. METHODS: Eleven patients (6 men, 5 women; mean age 48 (SD 5.8) years) were examined at 9-51 months after hemicraniectomy. Test batteries comprised NIH stroke scale, BI, mRS, neuropsychological tests (Visual Object and Space Perception Battery and clock test), and HRQoL-scales (Short Form 36 Health Survey (SF-36), Nottingham Health Profile (NHP), Questions on Life Satisfaction, Hospital Anxiety and Depression Scale and EQ-5D). RESULTS: Median values for NIHSS, BI and mRS were 11.5, 55 and 3.5. In HRQoL-scales, subscales related to physical mobility and functioning were consistently severely impaired, while subscales related to psychological well-being were impaired to a lesser extent. Mean scores for physical functioning and physical role were 10.5 and 12.5 in the SF-36, and 61.3 and 43.3 for physical mobility and energy in the NHP; emotional role and mental health scored 63.3 and 66.4 (SF-36), scores for emotional reaction and social isolation were 18.9 and 16.0 (NHP), respectively. CONCLUSION: Although, physical components of HRQoL are highly impaired, these stroke patients achieved a satisfying level of psychological well-being which was endorsed by a nearly unanimous retrospective appraisal of life-saving hemicraniectomy.

Tuberothalamic artery infarctions following coil embolization of ruptured posterior communicating artery aneurysms with posterior communicating artery sacrifice.

BACKGROUND AND PURPOSE: Ischemic complications after coil embolization of the PcomA aneurysms are not thoroughly understood, especially in cases in which the PcomA is sacrificed. Our purpose was to examine the preoperative angiographic features and pattern of postoperative cerebral infarctions exhibited by patients who underwent embolization of ruptured PcomA aneurysms with PcomA sacrifice. MATERIALS AND METHODS: A retrospective review identified 14 patients with ruptured PcomA aneurysms who underwent embolization of the aneurysms in combination with PcomA sacrifice. Preoperative angiographic data, including the Allcock test, postoperative DWI, and neurologic status, were examined. RESULTS: Elimination of the aneurysm was complete in all cases. Postoperative DWI indicated 7 cases with infarctions (infarction group) and 7 cases without infarctions (noninfarction group). All patients in the infarction group developed infarctions in the vicinity of the tuberothalamic artery. In all 14 cases, a preoperative Allcock test demonstrated a retrograde filling of the PcomA through the P1 segment. The incidence of negative visualizations of the P1 segment on vertebral angiograms was significantly higher in the infarction group (100%) than in the noninfarction group (0%; P = .00058). The mean PcomA diameters, PcomA/P1 ratios, and aneurysm sizes observed in the infarction group were significantly greater than those in the noninfarction group (P < .05, P < .01, and P < .02, respectively). Tuberothalamic artery infarction caused hemiparesis and memory disturbance, which were associated with unfavorable outcomes. CONCLUSIONS: After the coil occlusion of ruptured PcomA aneurysms with PcomA sacrifice, tuberothalamic artery infarctions tended to occur in cases exhibiting negative visualization of the P1 segment, even when collateral flow was observed with the Allcock test.

Endovascular angioplasty and stent placement in venous hypertension related to dural arteriovenous fistulas and venous sinus thrombosis.

Venous hypertension in lateral sinuses resulting from dural arteriovenous fistula (DAVF) and venous sinus thrombosis (VST) can manifest with severe neurological deficits, such as infarction or intracerebral hemorrhage. It has been proved that venous hypertension plays a significant role in the evolution and progression of DAVF and VST. The definite treatment in complicated conditions such as multiple DAVFs or multiple sinus occlusions is still unknown. Traditional transarterial embolization, transvenous embolization or radiosurgery alone has limited effects on these conditions. We reported one case with venous hypertension presenting with severe neurological symptoms. The case had quick clinical recovery after correction of venous hypertension by endovascular angioplasty and stent placement in occluded lateral sinuses. Accordingly, we propose this method can be an ideal treatment option either in single or staged therapy of venous hypertension related to DAVFs and VST.

[Effect of Xinnao Shutong capsule on apoptosis after cerebral ischemia and reperfusion in rats].

OBJECTIVE: To study apoptosis-regulating cytokines and apoptosis on focal cerebral ischemia and reperfusion in rats treated with Xinnao Shutong capsule. METHOD: Rat models of focal cerebral ischemia and reperfusion were established by thread ligation in middle cerebral artery occlusions (MCAO). After 24 hours, the brains were removed to detect changes of protein expression of Bax, Bcl-2, Fas, Fas-L and caspase-3 by immuno-hisochemistry, and apoptosis of cortical neurons by TUNEL RESULT: Compared to control, brain cortex have decreasing the protein expression of Bcl-2 and the ratio of Bcl-2/Bax, increasing the protein expression of Bax, Fas, Fas-L and caspase-3 of ischemia and reperfusion models group (P < 0.01). Xinnao Shutong capsule group could increase the protein expression of Bcl-2 and the ratio of Bcl-2/Bax, and obviously decrease the protein expression of Bax, Fas, Fas-L and caspase-3, then reduce the number of apoptotic cells of cortex (P < 0.01). CONCLUSION: Xinnao Shutong capsule protect injured rat brain tissue, may be related to decrease neuronal apoptosis and adjusted protein expression of apoptosis-regulating cytokines.

Blood flow disturbance in perforating arteries attributable to aneurysm surgery.

OBJECT: The object of this study was to investigate patients with cerebral infarction in the area of the perforating arteries after aneurysm surgery. METHODS: The authors studied the incidence of cerebral infarction in 1043 patients using computed tomography or magnetic resonance imaging and the affected perforating arteries, clinical symptoms, prognosis, and operative maneuvers resulting in blood flow disturbance. RESULTS: Among 46 patients (4.4%) with infarction, the affected perforating arteries were the anterior choroidal artery (AChA) in nine patients, lenticulostriate artery (LSA) in nine patients, hypothalamic artery in two patients, posterior thalamoperforating artery in five patients, perforating artery of the vertebral artery (VA) in three patients, anterior thalamoperforating artery in nine patients, and recurrent artery of Heubner in nine patients. Sequelae persisted in 21 (45.7%) of the 46 patients; 13 (28.3%) had transient symptoms and 12 (26.1%) were asymptomatic. Sequelae developed in all patients with infarctions in perforating arteries in the area of the AChA, hypothalamic artery, or perforating artery of the VA; in four of five patients with posterior thalamoperforating artery involvement; and in two of nine with LSA involvement. The symptoms of anterior thalamoperforating artery infarction or recurrent artery of Heubner infarction were mild and/or transient. The operative maneuvers leading to blood flow disturbance in perforating arteries were aneurysmal neck clipping in 21 patients, temporary occlusion of the parent artery in nine patients, direct injury in seven patients, retraction in five patients, and trapping of the parent artery in four patients. CONCLUSIONS: The patency of the perforating artery cannot be determined by intraoperative microscopic inspection. Intraoperative motor evoked potential monitoring contributed to the detection of blood flow disturbance in the territory of the AChA and LSA.

Absence epilepsy associated with moyamoya disease. Case report.

The authors present the case of a 6-year-old girl with typical absence epilepsy induced by hyperventilation associated with moyamoya disease (MMD). A diffuse 3-Hz spike-and-wave complex induced by hyperventilation was apparent on an electroencephalogram, and her seizures were intractable to medication. Significant ischemia in the bilateral frontal lobes was present. The epilepsy disappeared after superficial temporal artery-middle cerebral artery anastomosis with encephalomyosynangiosis on both sides. In the treatment of children with intractable absence epilepsy, the possibility of underlying MMD and indications that revascularization surgery may be needed should be taken into consideration.

[Experimental research on effect of human mesenchymal stem cells induced by shenqi fuzheng injection in cerebral infarction].

OBJECTIVE: To investigate the effect of shenqi fuzheng injection (SFI) in inducing differentiation of human mesenchymal stem cells (hMSCs) in brain stem and its effect on nervous function in model rats of cerebral infarction. METHODS: Middle cerebral artery occlusion model rats were made, and hMSCs was injected into their brain after being amplified in vitro and incubated with SFI for 0.5 h, then the survival, migration and differentiation of hMSCs in brain stem as well as the change of nervous function in model rats were observed. RESULTS: The post-transplantation reject reaction to hMSCs was low, it could survive as long as 6 weeks or more. No difference in area of infarction was shown before and after transplantation. Immunohistochemical staining showed that hMSCs expressed human neuron specific enolase (NSE), neurofilament (NF) and glial fibrillary acid protein (GFAP). The limb-kinetic function and tactile perception were improved in the model rats. CONCLUSION: SFI can induce hMSCs differentiate into neurons in vivo, and hMSCs may be the ideal germinal cells for treating cerebral infarction.

Gamma knife surgery of the pituitary: new treatment for thalamic pain syndrome.

OBJECT: Although reports in the literature indicate that thalamic pain syndrome can be controlled with chemical hypophysectomy, this procedure is associated with transient diabetes insipidus. It was considered reasonable to attempt gamma knife surgery (GKS) to the pituitary gland to control thalamic pain. METHODS: Inclusion criteria in this study were poststroke thalamic pain, failure of all other treatments, intolerance to general anesthetic, and the main complaint of pain and not numbness. Seventeen patients met these criteria and were treated with GKS to the pituitary. The target was the pituitary gland together with the border between the pituitary stalk and the gland. The maximum dose was 140 to 180 Gy. All patients were followed for more than 3 months. CONCLUSIONS: An initial significant pain reduction was observed in 13 (76.5%) of 17 patients. Some patients experienced pain reduction within 48 hours of treatment. Persistent pain relief for more than 1 year was observed in five (38.5%) of 13 patients. Rapid recurrence of pain in fewer than 3 months was observed in four (30.8%) of 13 patients. The only complication was transient diabetes insipidus in one patient. It would seem that GKS of the pituitary might have a role to play in thalamic pain arising after a stroke.

[Spontaneous extra-cranial vertebral artery dissection accompanied with multiple cerebral infarctions due to re-canalization].

In this paper we report a case of vertebral artery occlusion caused by spontaneous extra-cranial vertebral artery dissection accompanied with cerebellar and thalamic infarctions due to recanalization. Furthermore, after a nine-week time lapse we performed PTA/stenting. A 62-year-old man with vertigo, dysarthria and nuchal pain without injury was admitted to our hospital. Emergent cerebral angiography revealed an occlusion of the right vertebral artery and the right PICA. The patient's symptoms gradually improved owing to local-fibrinolysis with urokinase for the right PICA via the left vertebral artery. Follow-up angiography (2 weeks later) showed re-canalization and dissection of the right vertebral artery. Treatment for spontaneous extra-cranial vertebral artery dissection is chosen, depending on whether there is co-lateral circulation or not. We obtained a good result using PTA/Stenting in this case of spontaneous extra-cranial vertebral artery dissection within nine weeks after onset.

Trasplante de epiplón para infarto isquémico del cerebro / Omental transplantation for brain ischemic infarct

Estudios previos sugieren que es posible revascularizar estructuras subcorticales. Presentamos a una mujer de 66 años de edad con afasia motora, severa disfasia sensorial, hemiplejía espástica, hemi-anestesia y dolor talámico en sus miembros derechos por trombosis de la arteria cerebral media izquierda, quien recibió un trasplante de epiplón sobre el espacio perforado anterior. Después de cirugía presentó hemi-hipoestesia, desaparición del dolor talámico y mejoría de la disfasia sensorial. Estos resultados confirman que es factible mejorar la función de estructura corticales y subcorticales en isquemia y penumbra isquémica por medio del omento

Neural grafting to experimental neocortical infarcts improves behavioral outcome and reduces thalamic atrophy in rats housed in enriched but not in standard environments.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate whether grafting of fetal neocortical tissue 1 week after focal brain ischemia improved behavioral outcome and reduced secondary thalamic atrophy. METHODS: One week after distal ligation of the right middle cerebral artery in spontaneously hypertensive male rats, blocks of fetal neocortex (embryonic day 17) were homografted to rats housed in standard or enriched environments. Control infarcted nongrafted rats were housed in the enriched environment. Behavioral outcome was repeatedly tested until the rats were killed 20 weeks after the ligation. Ten days earlier, a mixture of 2% Fluoro-Gold and 10% biotinylated dextran amine was injected into the transplants for retrograde and anterograde tracing of graft-host connections. RESULTS: Grafted and nongrafted rats with enriched housing performed significantly better than grafted rats with standard housing on a rotating pole and a prehensile traction test. Grafted "enriched" rats were moreover significantly better than grafted "standard" rats and nongrafted enriched rats in a rotation test and a postural and locomotor tail position test. In the latter test, nongrafted enriched rats performed significantly better than grafted standard rats. The lesion-induced atrophy in posterior thalamus with its major sensorimotor cortex relay nuclei was significantly reduced in grafted enriched rats compared with nongrafted enriched rats. Afferent and efferent graft-host connections were identified in both grafted groups. Graft volumes did not differ. CONCLUSIONS: Neural grafting enhanced functional outcome and reduced thalamic atrophy only when combined with housing in enriched environments.

Hemidystonia secondary to carotid artery gunshot injury.

A 9-year-old boy was accidentally shot at close range with a pistol. The bullet entered through the left anterior neck and severed the left common carotid artery. Emergency surgery was performed with an end-to-end anastomosis. He recovered gradually from severe right-sided hemiparesis. CT scans demonstrated left parietal infarction. Within months he developed right hemidystonia, which progressed over the next few years. The movement disorder was refractory to medical therapy. MR scans showed a large demarcated defect in the left parietal lobe extending to the occipital lobe, to the insula and to the posterior ventral putamen. At age 18 the patient underwent a staged left-sided thalamotomy. The hemidystonia improved postoperatively but later partially recurred.

Angiolipoma of thalamus presenting with abrupt onset suggestive of cerebrovascular disease.

A 25-year-old man had angiolipoma of the left thalamus producing sudden severe headache, coma, right hemiparalysis, and aphasia as usually observed in cerebrovascular disease. The patient remained right hemiparalytic and aphasic after removal of the thalamic lesion. A vascular lesion was also detected angiographically in the left lateral ventricular choroid plexus but was not excised. Only 3 intracranial angiolipomas including the current instance were on record. However, it was only in our patient that the lesion suddenly presented with intracerebral hemorrhage. The pathogenesis of the angiolipoma was suggested to be associated with maldifferentiation of mesenchyme and/or its derivatives toward the vascular and adipose tissue within the same mass, resulting in the formation of the angiolipoma.

Contralateral stenosis and stump pressures: parameters to identify the high risk patient undergoing carotid endarterectomy under local anaesthesia.

Carotid endarterectomy (CEA) under local anaesthesia (LA) enables the assessment of the two parameters of stump pressure and contralateral stenosis as predictors of neurological complications both intra- and postoperatively. Over a 7 year period, 175 carotid endarterectomies were performed under LA and of these, stump pressure measurements and angiographic findings were recorded on 99 patients. There were no deaths, two patients (2.0%) suffered a perioperative stroke (CVA) and one (1.0%) a transient ischaemic attack (TIA). An additional eight patients "obtunded" while the internal carotid artery was clamped, with complete resolution upon revascularisation in all but one patient who recovered fully within 24 h. Patients with contralateral occlusion or > or = 80% stenosis were more likely to develop complications (6/25 vs. 5/74 p < 0.03) and stump pressures were significantly lower in patients suffering an event (34.36 +/- 23.15 vs. 55.57 +/- 27.58, p < 0.02). By combining contralateral stenosis (> or = 80%) and stump pressure (< or = 35 mmHg), a "high risk" group of 42 patients in whom eight of the 11 events occurred, were identified. Contralateral stenosis and low stump pressures can be used in combination to identify high risk patients likely to develop neurological complications during or following CEA.

[Use of biological vicarious biofeedback in the rehabilitation of patients with brain damage]. / Zastosowanie biologicznego zastepczego sprzezenia zwrotnego w rehabilitacji chorych z uszkodzeniami mózgu.

The mechanisms of feedback not controlled by our consciousness play an essential role in the functions of the central nervous system in the process of programming of activities, behaviour and control of these functions. In case of deviations or errors of activities the possibility of their immediate correction exists. Brain damage after trauma or caused by tumour disturbs these normal feedback mechanisms producing very varying symptom complexes. In such cases it is advantageous to introduce vicarious feedback based mainly on visual and auditory afferentation. The authors present own original methods used in the rehabilitation of such patients using vicarious feedback with elbow crutch with light and sound signalling in walk learning, and platform for attitude stability exercises. The earlier obtained results of rehabilitation by this method in a large group of patients after stroke, and preliminary observations of patients after trauma and after tumour operations justify recommendation of the method.

Unruptured fusiform aneurysms of the posterior circulation with thalamic infarction.

Three patients with unruptured fusiform aneurysms of the posterior circulation presented with nonhemorrhagic thalamic infarctions. All of the aneurysms were seen on enhanced computed tomographic (CT) scans preangiographically. Although unruptured fusiform aneurysms are probably a rare cause of nonhemorrhagic thalamic infarction, their importance lies in the therapeutic implications of this diagnosis. In patients with nonhemorrhagic thalamic infarction, we suggest careful scrutiny of the blood vessels on enhanced CT scans.