Safety of early initiation of rivaroxaban or dabigatran after thrombolysis in acute ischemic stroke.

The introduction of direct oral anticoagulants (DOA) in the early stage of cerebral infarction after thrombolysis may reduce the recurrence rate but raises safety concern. We sought to study the feasibility and safety of the introduction of rivaroxaban or dabigatran in this context. Thirty-four consecutive patients admitted for ischemic stroke related to non-valvular atrial fibrillation in whom DOA were given within the first two weeks following intravenous rt-PA were studied. A clinical and radiological monitoring protocol was established to ensure the safety of the prescription. None of the patients experienced symptomatic hemorrhagic transformation or a symptomatic recurrent ischemic event after early rivaroxaban or dabigatran introduction.

Hyperbaric oxygen in the treatment of acute ischemic stroke: an unsettled issue.

Therapy for acute ischemic stroke can be approached in two basic ways: first, by an attempt to restore or improve blood flow in an occluded vascular territory and, second, via therapy directed at the cellular and metabolic targets. As local anoxia and energy failure are the initiating cellular stage in ischemia, the inhalation of oxygen at increased atmospheric pressures might be effective. Treatment of acute focal cerebral ischemia with hyperbaric oxygen (HBO) has been reported in animals and humans. In general, the results of research in animals have suggested a promising role for the use of HBO. More than 400 cases of human ischemic stroke treated with HBO have been reported. In about half of the cases, improvement in status has been claimed on clinical or electroencephalographic grounds. In fact, the effectiveness of HBO in most disease processes other than carbon monoxide poisoning and decompression sickness is a subject of major ongoing debate. This short review will attempt: (1) to recall some early experiments involving HBO in the treatment of acute ischemia: (2) to point out some conflicting results regarding the role of HBO on cellular and metabolic disorders; and (3) to determine the possibility of a future role for HBO therapy in acute ischemic stroke.

Hyperbaric oxygen in the treatment of acute ischemic stroke. A double-blind pilot study.

BACKGROUND AND PURPOSE: The effects of hyperbaric oxygen (HBO) therapy on humans are uncertain. Our study aims first to outline the practical aspects and the safety of HBO treatment and then to evaluate the effect of HBO on long-term disability. METHODS: Patients who experienced middle cerebral artery occlusion and were seen within 24 hours of onset were randomized to receive either active (HBO) or sham (air) treatment. The HBO patients were exposed daily to 40 minutes at 1.5 atmospheres absolute for a total of 10 dives. We used the Orgogozo scale to establish a pretreatment functional level. Changes in the Orgogozo scale score at 6 months and 1 year after therapy were used to assess the therapeutic efficacy of HBO. In addition, we used the Rankin scale and our own 10-point scale to assess long term-disability at 6 months and 1 year. Two sample t tests and 95% confidence intervals were used to compare the mean differences between the two treatment groups. Student's two-tailed test was used to compare the differences between pretherapeutic and posttherapeutic scores at 6 months and 1 year in the two treatment groups. RESULTS: Over the 3 years of study enrollment, 34 patients were randomized, 17 to hyperbaric treatment with air and 17 to hyperbaric treatment with 100% oxygen. There was no significant difference at inclusion between groups regarding age, time from stroke onset to randomization, and Orgogozo scale scores. Neurological deterioration occurred during the first week in 4 patients in the sham group, 3 of whom died; this worsening was clearly related to the ischemic damage. Treatment was also discontinued for 3 patients in the HBO group who experienced myocardial infarction, a worsening related to the ischemic process, and claustrophobia. Therefore, 27 patients (13 in the sham group and 14 in the HBO group) completed a full course of therapy. The mean score of the HBO group was significantly better on the Orgogozo scale at 1 year (P < .02). However, the difference at 1 year between pretherapeutic and posttherapeutic scores was not significantly different in the two groups (P < .16). Moreover, no statistically significant improvement was observed in the HBO group at 6 months and 1 year according to Rankin score (P < .78) and our own 10-point scale (P < .50). CONCLUSIONS: Although the small number of patients in each group precludes any conclusion regarding the potential deleterious effect of HBO, we did not observe the major side effects usually related to HBO. Accordingly, it can be assumed that hyperbaric oxygen might be safe. We hypothesize that HBO might improve outcome after stroke, as we detected an outcome trend favoring HBO therapy. A large randomized trial might be required to address the efficacy of this therapy.

[Early and middle latency auditory evoked potentials in vertebrobasilar strokes]. / Potentiels évoqués auditifs précoces et de latence moyenne dans les accidents vasculaires vertébrobasilaires.

Brainstem auditory evoked potentials (BAEPs) and middle-latency auditory evoked potentials (MLAEPs) have been recorded in 67 patients who had a stroke in well-defined territories of the vertebral and basilar arteries. Either CT scan or MRI have been performed in all cases. BAEPs were abnormal in 41/67 patients and MLAEPs were abnormal in 25/39 patients. BAEPs abnormalities were either bilateral (29/41 cases) or unilateral (12/41 cases). All components of BAEPS were unilaterally absent in four cases and bilaterally in one case. Pa component of MLAEPs was unilaterally delayed or reduced in five cases and bilaterally in 20 cases. Considering the topography of the infarct as shown by CT scan or MRI: medulla oblongata (13 cases): BAEPSs were normal in nine cases; pons (24 cases): BAEPs were abnormal in 16 cases; MLAEPs were abnormal in ten of 15 patients whose BAEPs were abnormal as well; mesencephalon (seven cases): BAEPs were abnormal in only two cases, and MLAEPs were abnormal in two cases one of which BAEPs were normal; in patients with diffuse infarctions either BAEPs or MLAEPs or both were abnormal in all cases. Stimulation of the ear ipsilateral to the lesion disclosed more BAEPs or MLAEPs abnormalities than stimulation of the contralateral ear.

[Hypothalamic insufficiency following irradiation. Late, subacute and curable dementia]. / Insuffisance hypothalamique après irradiation. Démence tardive, subaiguë et curable.

A 31 year-old patient suffered from a subacute and major dementia, sixty months after whole brain irradiation with 54 grays for a pinealoma. Clinical features and biological investigations led to a diagnosis of hypothalamic insufficiency. A dramatic clinical recovery followed therapy with hydrocortisone and thyroxine. An hypothalamic radionecrosis and a vascular mechanism are presumed.