The use of routine EEG in acute ischemic stroke patients without seizures: generalized but not focal EEG pathology is associated with clinical deterioration.

PURPOSE: Specialized electroencephalography (EEG) methods have been used to provide clues about stroke features and prognosis. However, the value of routine EEG in stroke patients without (suspected) seizures has been somewhat neglected. We aimed to assess this in a group of acute ischemic stroke patients in regard to short-term prognosis and basic stroke features. METHODS: We assessed routine (10-20) EEG findings in 69 consecutive acute ischemic stroke patients without seizures. Associations between EEG abnormalities and NIHSS scores, clinical improvement or deterioration as well as MRI stroke characteristics were evaluated. RESULTS: Mean age was 69 ± 18 years, 43 of the patients (62.3%) were men. Abnormal EEG was found in 40 patients (58%) and was associated with higher age (p = 0.021). The most common EEG pathology was focal slowing (30; 43.5%). No epileptiform potentials were found. Abnormal EEG in general and generalized or focal slowing in particular was significantly associated with higher NIHSS score on admission and discharge as well as with hemorrhagic transformation of the ischemic lesion. Abnormal EEG and generalized (but not focal) slowing were associated with clinical deterioration ( p = 0.036, p = 0.003). Patients with lacunar strokes had no EEG abnormalities. CONCLUSIONS: Abnormal EEG in general and generalized slowing in particular are associated with clinical deterioration after acute ischemic stroke. The study demonstrates the value of routine EEG as a simple diagnostic tool in the evaluation of stroke patients especially with regard to short-term prognosis.

The Impact of Body Mass Index on the Thrombolytic Treatment of Acute Ischemic Stroke.

BACKGROUND: Body weight and body mass index (BMI) are regularly assessed factors in stroke patients for manifold reasons. However, their potential role specifically in intravenous thrombolysis has not been thoroughly examined. METHODS: Data from 865 consecutive acute ischemic stroke patients treated with intravenous thrombolysis were analyzed. Patients were divided into different BMI categories (underweight, normal weight, overweight, obese) and compared based on the following factors: time window of treatment, clinical scores National Institute of Health Stroke Scale Score (NIHSS), modified Rankin scale (mRS) on admission and discharge, risk factors, stroke characteristics and thrombolysis complications. Recombinant tissue plasminogen activator (rtPA) doses relative to body weight and blood volume were also assessed. In a separate analysis, patients weighing up to 100 and >100 kg were compared. RESULTS: Eighteen patients (2.1%) were underweight, 336 (38.8%) overweight, 194 (22.4%) obese and 317 (36.7%) had normal weight. Higher BMI category was associated with younger age, thrombolytic treatment later than 4.5 h, arterial hypertension, diabetes and higher relative rtPA dose relative to blood volume (p < 0.001). There were no significant differences concerning NIHSS and mRS scores or thrombolysis complications. Forty-six patients (5.3%) weighed over 100 kg. They were younger (p = 0.002) and treated later than patients under 100 kg (p < 0.001). Mean rtPA dose relative to body weight and to blood volume was significantly lower (0.7 vs. 0.9 mg/kg, p < 0.001 and 13 vs. 13.9 mg/l, p < 0.001). There was a marginal difference in NIHSS score improvement ≥4 points (26.1 vs. 40.2%, p = 0.038); otherwise, no outcome differences were found. CONCLUSION: BMI category does not significantly influence clinical outcome after thrombolysis. However, relevant NIHSS improvement was found more often in patients weighing up to 100 kg compared to those over 100 kg. Interestingly, patients with higher BMI or weight >100 kg were thrombolysed later than other patients.

Etiologic and Clinical Characterization of Patients with Recurrent Spontaneous Intracerebral Hemorrhage.

BACKGROUND: The impact of recurrent stroke has been extensively addressed with regard to ischemic stroke, revealing potentially different etiologies of recurrent events in the individual patient. In contrast, data on recurrent intracerebral hemorrhage (ICH) are scarce, especially considering etiologic characterization. We aimed to determine the etiology of recurrent ICH at each event to identify potential etiologic changes. PATIENTS AND METHODS: We analyzed the data of patients admitted to our stroke unit with recurrent ICH between 1998 and 2014 with regard to clinical characteristics and etiology. RESULTS: Thirty-three patients (2.6%) with recurrent ICH were identified. Mean age (mean ± SD) at the initial event was 69 ± 9 and 72 ± 9 years at recurrence. Median interval between events was 18 months. Mean National Institutes of Health Stroke Scale (first/second event) was 4/9 at admission and 2/8 at discharge. Over 30% of patients developed symptomatic epilepsy. Etiologic distribution was (first/second event) the following: probable cerebral amyloid angiopathy (CAA) (12/20), possible CAA (3/0), hypertensive (5/4), anticoagulation (4/3), vascular malformation (2/4), ischemia with secondary hemorrhage (4/0), vasculitis (0/1), undetermined (4/0). CONCLUSIONS: Recurrent ICH is rare, CAA being its most common etiology. Etiology of ICH may differ between the first/second event in about 10%. The findings indicate the need of a complete and distinct work-up including MRI in every instance of ICH recurrence.

Is It Acute Stroke or Not - A Prospective Observational Study from a Multidisciplinary Emergency Department.

BACKGROUND: Acute stroke is a medical emergency with various clinical presentations. Since the introduction of systemic thrombolytic treatment, stroke diagnosis has been made quickly and with great caution, and the trend of rapid presentation at hospitals has increased. METHODS: In our multidisciplinary Emergency Department, we prospectively collected and analysed data of consecutive patients presenting with suspected acute stroke (SAS) or transient ischemic attack (TIA). RESULTS: Four hundred ten patients (200 men, mean age 68 ± 16, range 17-93 years) with SAS were admitted of which 105 were prehospitally announced as within the time-window for thrombolytic treatment (TW). Diagnosis of acute stroke/TIA was retained in 147 (35.9%). The initially reported TW <4.5 h was wrong in 35.3%. Thrombolysis was performed in 27 patients (23.5% of ischemic stroke patients; 6.6% of all SAS). Diagnosis of another neurologic disease was made in 62 (15.1%). Major differential diagnoses came from the field of internal medicine, psychiatry or otorhinolaryngology. One hundred fifty patients (36.6%) were rapidly discharged. CONCLUSION: About half the number of our patients admitted for SAS did not suffer from an acute neurologic disease. Residual symptoms post-stroke might be partly responsible for initial misinterpretation. The crucial difference between symptom onset and symptom recognition needs to be emphasized to improve the prehospital assessment of the TW.

Vertebral Artery Hypoplasia Does Not Influence Lesion Size and Clinical Severity in Acute Ischemic Stroke.

BACKGROUND: Vertebral artery hypoplasia (VAH) is common, but its role in acute ischemic stroke (AIS) is uncertain. We aimed to evaluate the frequency, characteristics, and role of VAH in a large typical cohort of patients with AIS. METHODS: Up to 815 AIS patients (52.8% men, mean age 70 ± 14 years) were included in the study. All patients received a stroke work-up including brain imaging and duplex ultrasound. VAH was defined by a vessel diameter of less than or equal to 2.5 mm or a difference to the contralateral side of greater than 1:1.7. Vascular risk factors and stroke features were recorded. The subgroup of patients with posterior circulation AIS and magnetic resonance imaging was analyzed additionally, including the parameter of stroke extent. RESULTS: Up to 111 patients (13.6%) had VAH, with a mean diameter of 2.4 ± .4 mm. Patients with VAH were significantly younger (P = .037) and more often male (P = .033). There was no difference considering the National Institutes of Health Stroke Scale and modified Rankin Scale scores on admission or history of stroke. The distribution of patients without VAH was significantly different among the groups with anterior, posterior, and both circulations ischemia (P = .009). In the group with posterior circulation stroke, 36 patients (20.9%) had VAH. There were no differences in age, sex, history of stroke, risk factors, vascular territory, stroke size, or etiology. VAH patients had less often embolic stroke patterns (P = .009). CONCLUSIONS: VAH is more common in patients with posterior circulation stroke and in younger patients. Apart from that, we found no clear evidence that VAH would be a predisposing factor for stroke or that it increased the risk for larger ischemic lesions in the posterior circulation.

Atherosclerosis in intracranial, extracranial, and coronary arteries with aortic plaques in patients with ischemic stroke of undetermined etiology.

OBJECTIVE: We investigated the association of cerebral and coronary artery atherosclerosis with the presence, burden and type of atherosclerotic plaques of the aorta (AP) in patients with ischemic stroke of undetermined etiology. METHODS: 48 consecutive patients (32 males, mean age 68 ± 11 years) with acute ischemic stroke of unknown etiology after thorough stroke workup were investigated using ECG-gated CT-Angiography (CTA) for the detection of embolic AP. Intima media thickness (IMT), presence of carotid plaques and stenosis ≥ 50% and intracranial stenosis were assessed as parameters of cerebral atherosclerosis, the Agatston score (AS) and coronary artery stenosis ≥ 50% (CAS) in CTA as parameters of coronary atherosclerosis. Plaque burden was classified as mild or severe and plaque types were classified according to their morphology in calcified, non-calcified or mixed. RESULTS: APs were found in 36 patients (75%). AP presence was associated with higher IMT values (p = 0.029), intracranial stenosis (p = 0.047), CAS (p = 0.033) and AS (p = 0.026). Twenty-three of 31 (74.2%) patients with both carotid atherosclerosis and AP revealed plaque calcification (p = 0.041). Ten of 14 (71.4%) patients with AP and intracranial stenosis had calcified plaques (p = 0.030). AP in more than one aortic segment was found in patients with bilateral carotid stenosis ≥ 50% (p = 0.038), intracranial stenosis (p = 0.042), high IMT (p = 0.040) and higher AS (p = 0.019). CONCLUSIONS: Aortic atherosclerotic plaques are common in patients with ischemic stroke of undetermined etiology and in particular those with carotid, intracranial and coronary atherosclerosis or high IMT values. In these patients, CTA of aorta should be seriously considered.

Risk prediction of subsequent early stroke in patients with transient ischemic attacks.

BACKGROUND: Prognostic clinical scores (ABCD2 and ABCD3-I), as well as specific clinical signs and symptoms (e.g. fluctuations) have been used to predict early stroke risk in patients admitted to hospital after transient ischemic attacks (TIAs). We compared the utility of these scores and signs for prognosis and outcome. METHODS: 235 patients with TIAs admitted to our Comprehensive Stroke Center entered the study. Patients were monitored over 3 days with detailed brain imaging [diffusion-weighted imaging (DWI) was performed either directly on admission or within 24 h from admission and was repeated in cases of stroke recurrence], vascular ultrasound imaging, repeated neurological scoring and continuous ECG monitoring. Duration, fluctuation of symptoms, clinical patterns of initial signs and/or symptoms as well as general patient characteristics and stroke risk factors, including atrial fibrillation (AF), were analyzed and recorded in our stroke databank. Fluctuation of symptoms was defined as the complete remitting and relapsing of TIA symptoms for ≥2 times in the acute phase within the first 24 h. This differs from the 'dual TIA' definition of the ABCD3-I score, which is defined as 'an earlier TIA within 7 days of the index event'. ABCD2 and ABCD3-I scores were calculated and the patients were placed into three categories: 'low', 'moderate' and 'high' risk for every score. Risk associations were assessed by the χ(2) test and the φ-coefficient. RESULTS: Out of 235 patients, 17 patients (7.2%) experienced an early stroke during hospitalization (mean duration 7.4 ± 2.7 days). ABCD2 scores failed to predict early stroke (p = 0.544). ABCD3-I scores correlated better with early stroke recurrences (p = 0.021). Positive DWI findings (6/17; 35.3%), presence of carotid stenosis (3/17; 17.6%) or AF (1/17; 5.9%) alone failed to predict early stroke. Fluctuations of symptoms, however, showed a significant prediction for early stroke after TIA: 13/17 (76.5%) patients (p < 0.001). The combination of symptom fluctuation and MR-DWI-positive findings (4/17; 23.5%) also turned out to be statistically significant in this regard (p = 0.003), while the combination of symptom fluctuations with carotid stenosis ≥50% did not (p = 0.151). Combining fluctuations with carotid stenosis and DWI-positive findings did not improve the result (p = 0.029). CONCLUSIONS: While the ABCD3-I score is indeed very useful, symptom fluctuations seem to be the best available and an easily accessible and applicable parameter for individual prediction of a high early stroke risk after TIAs.

Transient ischemic attack patients with fluctuations are at highest risk for early stroke.

BACKGROUND: The management and risk of early stroke are unclear in patients with fluctuating neurological symptoms. We aimed to evaluate the clinical course of these patients presenting within 24 h after onset of acute cerebral ischemia symptoms. METHODS: All patients with transient ischemic signs/symptoms consecutively admitted to our Emergency Stroke Unit were recruited. Patients were neurologically examined and underwent prompt CCT plus MRI imaging for visualization of early signs of ischemia. RESULTS: Among 122 patients, 84 (69%) had single symptoms, 33 (27%) showed rapidly relapsing and remitting symptoms - in 5 cases (4%) symptom duration could not reliably be assessed. 11/122 (9%) suffered a stroke during hospitalization. ABCD(2) scores did not predict early strokes: 2/11 (18.2%) were in the 'lower risk', 7/11 (63.6%) in the 'moderate risk' and only 2/11 (18.2%) in the 'high risk' group (p = 0.103). 3/11 patients (27.3%) revealed lesions in neuroimaging, but surprisingly 8/11 (72.7%, p = 0.132) did not. However, patients with fluctuations in neurological status were significantly more likely to suffer a stroke: 9/122 versus 2/122 with stable symptoms (p < 0.05). Patients with small vessel disease were common in all (53/ 122; 43.4%) and within those who suffered an early stroke (6/11; 54.5%). CONCLUSIONS: Patients with unstable transient ischemic attacks immediately after onset of clinical symptoms are at high risk for subsequent stroke - they may benefit from Stroke Unit management and potential early thrombolysis once they develop strokes.

Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke: A Randomized Clinical Trial.

Importance: Transferring patients with large-vessel occlusion (LVO) or intracranial hemorrhage (ICH) to hospitals not providing interventional treatment options is an unresolved medical problem. Objective: To determine how optimized prehospital management (OPM) based on use of the Los Angeles Motor Scale (LAMS) compares with management in a Mobile Stroke Unit (MSU) in accurately triaging patients to the appropriate hospital with (comprehensive stroke center [CSC]) or without (primary stroke center [PSC]) interventional treatment. Design, Setting, and Participants: In this randomized multicenter trial with 3-month follow-up, patients were assigned week-wise to one of the pathways between June 15, 2015, and November 15, 2017, in 2 regions of Saarland, Germany; 708 of 824 suspected stroke patients did not meet inclusion criteria, resulting in a study population of 116 adult patients. Interventions: Patients received either OPM based on a standard operating procedure that included the use of the LAMS (cut point ≥4) or management in an MSU (an ambulance with vascular imaging, point-of-care laboratory, and telecommunication capabilities). Main Outcomes and Measures: The primary end point was the proportion of patients accurately triaged to either CSCs (LVO, ICH) or PSCs (others). Results: A predefined interim analysis was performed after 116 patients of the planned 232 patients had been enrolled. Of these, 53 were included in the OPM group (67.9% women; mean [SD] age, 74 [11] years) and 63 in the MSU group (57.1% women; mean [SD] age, 75 [11] years). The primary end point, an accurate triage decision, was reached for 37 of 53 patients (69.8%) in the OPM group and for 63 of 63 patients (100%) in the MSU group (difference, 30.2%; 95% CI, 17.8%-42.5%; P < .001). Whereas 7 of 17 OPM patients (41.2%) with LVO or ICH required secondary transfers from a PSC to a CSC, none of the 11 MSU patients (0%) required such transfers (difference, 41.2%; 95% CI, 17.8%-64.6%; P = .02). The LAMS at a cut point of 4 or higher led to an accurate diagnosis of LVO or ICH for 13 of 17 patients (76.5%; 6 triaged to a CSC) and of LVO selectively for 7 of 9 patients (77.8%; 2 triaged to a CSC). Stroke management metrics were better in the MSU group, although patient outcomes were not significantly different. Conclusions and Relevance: Whereas prehospital management optimized by LAMS allows accurate triage decisions for approximately 70% of patients, MSU-based management enables accurate triage decisions for 100%. Depending on the specific health care environment considered, both approaches are potentially valuable in triaging stroke patients. Trial Registration: ClinicalTrials.gov identifier: NCT02465346.

Validation and comparison of imaging-based scores for prediction of early stroke risk after transient ischaemic attack: a pooled analysis of individual-patient data from cohort studies.

BACKGROUND: Identification of patients at highest risk of early stroke after transient ischaemic attack has been improved with imaging based scores. We aimed to compare the validity and prognostic utility of imaging-based stroke risk scores in patients after transient ischaemic attack. METHODS: We did a pooled analysis of published and unpublished individual-patient data from 16 cohort studies of transient ischaemic attack done in Asia, Europe, and the USA, with early brain and vascular imaging and follow up. All patients were assessed by stroke specialists in hospital settings as inpatients, in emergency departments, or in transient ischaemic attack clinics. Inclusion criteria were stroke-specialist confirmed transient ischaemic attack, age of 18 years or older, and MRI done within 7 days of index transient ischaemic attack and before stroke recurrence. Multivariable logistic regression was done to analyse the predictive utility of abnormal diffusion-weighted MRI, carotid stenosis, and transient ischaemic attack within 1 week of index transient ischaemic attack (dual transient ischaemic attack) after adjusting for ABCD2 score. We compared the prognostic utility of the ABCD2, ABCD2-I, and ABCD3-I scores using discrimination, calibration, and risk reclassification. FINDINGS: In 2176 patients from 16 cohort studies done between 2005 and 2015, after adjusting for ABCD2 score, positive diffusion-weighted imaging (odds ratio [OR] 3·8, 95% CI 2·1-7·0), dual transient ischaemic attack (OR 3·3, 95% CI 1·8-5·8), and ipsilateral carotid stenosis (OR 4·7, 95% CI 2·6-8·6) were associated with 7 day stroke after index transient ischaemic attack (p<0·001 for all). 7 day stroke risk increased with increasing ABCD2-I and ABCD3-I scores (both p<0·001). Discrimination to identify early stroke risk was improved for ABCD2-I versus ABCD2 (2 day c statistic 0·74 vs 0·64; p=0·006). However, discrimination was further improved by ABCD3-I compared with ABCD2 (2 day c statistic 0·84 vs 0·64; p<0·001) and ABCD2-I (c statistic 0·84 vs 0·74; p<0·001). Early stroke risk reclassification was improved by ABCD3-I compared with ABCD2-I score (clinical net reclassification improvement 33% at 2 days). INTERPRETATION: Although ABCD2-I and ABCD3-I showed validity, the ABCD3-I score reliably identified highest-risk patients at highest risk of a stroke after transient ischaemic attack with improved risk prediction compared with ABCD2-I. Transient ischaemic attack management guided by ABCD3-I with immediate stroke-specialist assessment, urgent MRI, and vascular imaging should now be considered, with monitoring of safety and cost-effectiveness. FUNDING: Health Research Board of Ireland, Irish Heart Foundation, Irish Health Service Executive, Irish National Lottery, National Medical Research Council of Singapore, Swiss National Science Foundation, Bangerter-Rhyner Foundation, Swiss National Science Foundation, Swisslife Jubiläumsstiftung for Medical Research, Swiss Neurological Society, Fondazione Dr Ettore Balli (Switzerland), Clinical Trial Unit of University of Bern, South Korea's Ministry for Health, Welfare, and Family Affairs, UK Wellcome Trust, Wolfson Foundation, UK Stroke Association, British Heart Foundation, Dunhill Medical Trust, National Institute of Health Research (NIHR), Medical Research Council, and the NIHR Oxford Biomedical Research Centre.

Temporal seizure focus and status epilepticus are associated with high-sensitive troponin I elevation after epileptic seizures.

OBJECTIVE: Postictal elevation of high-sensitive troponin I (TNI), a highly specific biomarker for myocardial ischemia, has been reported. We aimed at evaluating its association of high-sensitive troponin I (TNI) with seizure type and focus, as well as vascular risk factors. METHODS: TNI was measured in 247 patients admitted to our clinic via the emergency room with an acute epileptic seizure. TNI control measurements were performed in 61.5% of cases. All patients underwent electroencephalography and cerebral imaging. Seizure focus - when possible - was determined using results from these examinations as well as clinical data. RESULTS: Of 247 patients, 133 (53.8%) were men, the mean age was 59 ± 18 years. 70 (28.3%) patients had focal and 177 (71.7%) generalized seizures. Status epilepticus was present in 38 cases (15.4%). Mean TNI was 0.05 ± 0.17. TNI was elevated in 27 patients (10.9%). Higher age, status epilepticus and temporal seizure focus were significantly associated with TNI elevation in multivariate analysis. In 21 (13.8%) of the patients with TNI control measurement, TNI was continuously elevated. Higher age and temporal seizure focus were significantly associated with continuously high TNI. Coronary heart disease and vascular risk factors were significantly associated with high TNI only in univariate analysis. No patient had a symptomatic myocardial ischemia. DISCUSSION: Postictal TNI elevation is relatively common in older patients with status epilepticus or temporal seizure focus. These data support the concept of relevant and possibly dangerous ictal effects on cardiac function especially in temporal lobe seizures. Although the risk of manifest postictal myocardial infarction seems to be very low, selected patients could profit from closer monitoring.

Cerebrospinal fluid findings after epileptic seizures.

We aimed to evaluate ictally-induced CSF parameter changes after seizures in adult patients without acute inflammatory diseases or infectious diseases associated with the central nervous system. In total, 151 patients were included in the study. All patients were admitted to our department of neurology following acute seizures and received an extensive work-up including EEG, cerebral imaging, and CSF examinations. CSF protein elevation was found in most patients (92; 60.9%) and was significantly associated with older age, male sex, and generalized seizures. Abnormal CSF-to-serum glucose ratio was found in only nine patients (5.9%) and did not show any significant associations. CSF lactate was elevated in 34 patients (22.5%) and showed a significant association with focal seizures with impaired consciousness, status epilepticus, the presence of EEG abnormalities in general and epileptiform potentials in particular, as well as epileptogenic lesions on cerebral imaging. Our results indicate that non-inflammatory CSF elevation of protein and lactate after epileptic seizures is relatively common, in contrast to changes in CSF-to-serum glucose ratio, and further suggest that these changes are caused by ictal activity and are related to seizure type and intensity. We found no indication that these changes may have further-reaching pathological implications besides their postictal character.

Epilepsy and the hippocampus.

The association between epilepsy and the hippocampus is well known and important. Mesial temporal epilepsy with hippocampal sclerosis is a syndromic diagnostic entity and indeed a quite common one. There are different theories on the pathophysiological pathways, as the hippocampus is often involved in seizures, even if they are not generated there. Whether hippocampal sclerosis is a cause or the effect of seizures is a subject of ongoing debate, but the predominant opinion is that seizures probably do not cause relevant hippocampal volume loss in the mature brain. A diagnosis of epilepsy with hippocampal sclerosis is made based on typical semiological signs and symptoms, interictal and ictal EEG findings, cerebral imaging, and neuropsychological testing. Antiepileptic medication is indicated as a first-line treatment. Should the epilepsy prove to be medically intractable, which is commonly the case in these patients, an early evaluation regarding epilepsy surgery must be performed. Different epilepsy surgery techniques are available, from minimal ones like the selective amygdalohippocampectomy to more extensive ones like additional temporal lobe resection. Postoperative results concerning seizures and neuropsychological outcomes are very encouraging and depend on various predictive factors. Alternative procedures like stereotactic radiofrequency amygdalohippocampectomy and hippocampal stimulation are currently being assessed, partly with very promising results.

Thrombolysis in patients with lacunar stroke is safe: an observational study.

Research suggests that the etiology of lacunar stroke is different from that of other stroke subtypes. This could imply an altered response to thrombolysis, but data concerning the efficacy of rt-PA in lacunar stroke is limited and inconsistent. From our prospectively collected stroke database, we identified patients with an MRI-confirmed purely lacunar stroke that were treated in our Stroke Unit between 2004 and 2011. We compared both the clinical course (NIHSS, deterioration, mRS at 3 months) and the MRI findings between patients who either received or did not receive rt-PA. In comparison to patients who obtained standard medical care (n = 468), acute lacunar stroke patients treated with rt-PA (n = 69) were more severely affected on admission (median NIHSS of 5 vs. 3; p < 0.001) and presented less frequently with a lacunar syndrome (74 vs. 88 %; p = 0.003). The clinical course was more favorable in patients treated with rt-PA (median NIHSS improvement of 3 vs. 1; p < 0.001), while functional deficit after 3 months was similar in both groups (median mRS of 2; p = 0.211). Overall complication rates did not differ significantly between the two groups, but while we did not detect symptomatic intracranial hemorrhage, hemorrhagic transformation was more frequent in thrombolyzed patients (11.6 vs. 1.9 %; p = 0.001). Patients with acute lacunar stroke benefited from thrombolysis without additional complications. Thus, patients with suspected acute lacunar stroke or lacunar syndrome should not be treated differently than other stroke populations.

Asymptomatic and symptomatic carotid stenosis: an obsolete classification?

Since many years, clinical decisions about the management of patients with carotid stenosis have been based on the distinction between "asymptomatic" and "symptomatic" presentations. This was also reflected by the design of previous studies on the surgical versus conservative treatment and of current studies on interventional treatment versus surgery. Both terms, however, only address different phases of activity of the one and the same condition and blur the significant message that carotid stenosis is a most important marker of systemic atherosclerosis, which is accompanied by a much higher risk of cardiovascular events rather than stroke. As a consequence, early diagnosis and followup during best medical treatment, life-style management, regular cardiovascular assessment, and good control of all vascular risk factors should be recommended in all patients with carotid stenosis-whether identified in the long-lasting "silent" or short-lasting "vulnerable" period lasting only a few weeks after cerebral ischemia. Patients in this short time window benefit from additional carotid intervention, under the condition of an individually favorable benefit-risk ratio ("individual vulnerability").

Ischemic stroke in young adults: classification and risk factors.

Our aim was to analyze an important subgroup represented by young adult patients (19-45 years) with acute ischemic stroke according to stroke classification (including the novel ASCO score), infarct types and risk factors. All patients up to 45 years of age with an acute ischemic stroke confirmed by MRI and treated in our stroke unit from 2006 to 2009 were recruited for this study. Patients were neurologically examined and underwent thorough stroke work-up. One hundred four patients (58 women, 46 men) with a mean age of 38 ± 6.9 years were evaluated. The mean NIHSS score (±SD) was 3 ± 5 on admission and 1 ± 4 on discharge. The classification using TOAST/ASCO (grade 1) was as follows: Macroangiopathic 10.6%/8.7%, cardiac origin 21.2%/10.6%, microangiopathic 9.6%/9.6%, other causes 19.2%/13.5% and undetermined 39.4%/19.2% (for A0S0C0O0). The most common risk factors were smoking (55.2%), hypertension (31.4%) and hyperlipidemia (27.6%). Twenty nine of 74 patients with TEE (39.2%) had a patent foramen ovale (PFO). Hypoplastic posterior circulation (21.9%) and migraine (21.0%) were also quite common. Young adult ischemic stroke patients share many of the characteristic risk factors with the general elderly ischemic stroke population. If regular work-up includes TEE, a high percentage of young patients reveal comorbidities with PFO, hypoplasia of the posterior circulation and migraine. The ASCO classification should be favored for a better classification of coexisting stroke subtypes and lower number of undetermined etiologies in this patient group.

Cerebral microbleeds are uncommon in ischemic stroke associated with nonvalvular atrial fibrillation.

BACKGROUND AND PURPOSE: Patients with cardioembolic ischemic stroke from nonvalvular atrial fibrillation (NVAF) are candidates for long-term anticoagulation. This study examines the prevalence of cerebral microbleeds (MBs) in stroke patients with NVAF. METHODS: A total of 132 consecutive ischemic stroke patients with NVAF admitted to our Stroke Unit were recruited if complete magnetic resonance (MR) imaging studies including T2* imaging had been performed within less than 72 hours. National Institutes of Health Stroke Scale scores were documented and cerebrovascular risk factors were monitored. RESULTS: Among 132 patients (mean age 74.1±9.8 years), only 9 (6.8%) had MBs (mean number 6.2) as detected on T2* MR images. No statistically significant differences between patients without versus with MBs were observed regarding arterial hypertension, diabetes, hyperlipidemia, and coronary heart disease. However, small vessel disease (SVD) was significantly more frequent in patients with MBs than without MBs (44.4% vs. 12.2%; P<.05) and significantly more patients with MBs experienced repeated strokes (44.4% vs. 14.6%; P<.05). CONCLUSIONS: In contrast to studies reflecting a high incidence of MBs in stroke patients of various subtypes, MBs occurred less frequently in patients with cardioembolic acute ischemic stroke associated with NVAF. In patients with severe SVD or repeated cerebrovascular events, special caution should be taken regarding oral anticoagulation.

Features of acute DWI abnormalities related to status epilepticus.

We analyzed the phenomenon of transient regional diffusion-weighted MRI (DWI) hyperintensity in a series of status epilepticus (SE) patients with respect to seizure type, epileptogenic lesions and EEG findings. A prospective series of 54 patients (30 men, 24 women, mean age 61.5 years) admitted with SE was analyzed with regard to clinical semiology, EEG and MRI findings including DWI and EEG recordings in the acute peri-ictal phase. DWI abnormalities occurred most frequently in patients with complex-partial SE (27/50%) and generalized SE (18/33.3%). Forty patients (74.1%) had symptomatic, 13/24.1% cryptogenic and 1/1.9% idiopathic epilepsies. On DWI, the hippocampus was affected in 37/68.5% cases, often in combination with other brain areas (15/40.5%), in particular the pulvinar was affected in 14/25.9% patients. Bilateral DWI changes were found in 8/14.8% patients. No correlation with a specific seizure type was observed. In 21/38.9%, DWI changes were ipsilateral to the epileptogenic brain lesion (p<0.001) and in 5/9.3% contralateral, whereas in the majority of patients, either bilateral changes or no specific epileptogenic lesion were found. EEG abnormalities correlated with lateralization of DWI abnormalities in 44/81.5% (p<0.001). The most common localization of DWI abnormalities associated with ictal activity was the hippocampus and the pulvinar. Combined DWI-MRI and EEG analysis provides clues to seizure localization and propagation, as well as to identify brain structures affected by continuous or frequent ictal activity. This large series of patients with different features (SE type and cause, various epileptogenic lesions) demonstrates the heterogeneity of the phenomenon of peri-ictal DWI changes.

Noise reduction and image quality improvement of low dose and ultra low dose brain perfusion CT by HYPR-LR processing.

PURPOSE: To evaluate image quality and signal characteristics of brain perfusion CT (BPCT) obtained by low-dose (LD) and ultra-low-dose (ULD) protocols with and without post-processing by highly constrained back-projection (HYPR)-local reconstruction (LR) technique. METHODS AND MATERIALS: Simultaneous BPCTs were acquired in 8 patients on a dual-source-CT by applying LD (80 kV, 200 mAs, 14×1.2 mm) on tube A and ULD (80 kV, 30 mAs, 14×1.2 mm) on tube B. Image data from both tubes was reconstructed with identical parameters and post-processed using the HYPR-LR. Correlation coefficients between mean and maximum (MAX) attenuation values within corresponding ROIs, area under attenuation curve (AUC), and signal to noise ratio (SNR) of brain parenchyma were assessed. Subjective image quality was assessed on a 5-point scale by two blinded observers (1: excellent, 5: non-diagnostic). RESULTS: Radiation dose of ULD was more than six times lower compared to LD. SNR was improved by HYPR: ULD vs. ULD+HYPR: 1.9±0.3 vs. 8.4±1.7, LD vs. LD+HYPR: 5.0±0.7 vs. 13.4±2.4 (both p<0.0001). There was a good correlation between the original datasets and the HYPR-LR post-processed datasets: r = 0.848 for ULD and ULD+HYPR and r = 0.933 for LD and LD+HYPR (p<0.0001 for both). The mean values of the HYPR-LR post-processed ULD dataset correlated better with the standard LD dataset (r = 0.672) than unprocessed ULD (r = 0.542), but both correlations were significant (p<0.0001). There was no significant difference in AUC or MAX. Image quality was rated excellent (1.3) in LD+HYPR and non-diagnostic (5.0) in ULD. LD and ULD+HYPR images had moderate image quality (3.3 and 2.7). CONCLUSION: SNR and image quality of ULD-BPCT can be improved to a level similar to LD-BPCT when using HYPR-LR without distorting attenuation measurements. This can be used to substantially reduce radiation dose. Alternatively, LD images can be improved by HYPR-LR to higher diagnostic quality.

Ophthalmodynamometric measurement of central retinal vein pressure as surrogate of intracranial pressure in idiopathic intracranial hypertension.

BACKGROUND: Since a direct non-invasive measurement of the cerebrospinal fluid pressure is not available, it was the purpose of the study to describe the non-invasive determination of the central retinal vein pressure as an estimate of an elevated cerebrospinal fluid pressure. METHODS: A 28-year-old female patient with blurred vision, nuchal pain and prominent optic discs underwent modified ophthalmodynamometry to determine the central retinal vein pressure as surrogate of the intracranial pressure. A Goldmann contact lens with a pressure sensor mounted into its holding ring was placed onto the cornea. Pressure was applied to the globe by slightly pressing the contact lens until the central retinal vein started to pulsate/collapse. RESULTS: Despite an abnormally high central retinal vein pressure (OD: 17 arbitrary units; OS: 33 arbitrary units), the neurological examination including magnetic resonance imaging of the brain was unremarkable on the first day. A lumbar puncture revealed a cerebrospinal fluid pressure of 25 cm H(2)O, which was at the upper limit of the normal range. Over the next 2 days, ophthalmodynamometry showed increasing measurements of the central retinal vein pressure for both eyes, parallel to elevated cerebrospinal fluid pressure measurements by lumbar puncture, leading to the diagnosis of idiopathic intracranial hypertension. After treatment, the cerebrospinal fluid pressure returned to normal levels, parallel to a decrease in the central retinal vein pressure as determined by ophthalmodynamometry. CONCLUSIONS: Ophthalmodynamometry of the central retinal vein was helpful in the diagnosis of an elevated intracranial pressure, with direct lumbar pressure measurement running parallel to the ophthalmodynamometric measurements.