Related factors with orolingual angioedema after intravenous alteplase in acute ischemic stroke: results from a single-center cohort and meta-analysis.

INTRODUCTION: Orolingual angioedema (OA) after intravenous thrombolysis (IVT) with alteplase in acute stroke can be a life-threatening complication. Our aim was to describe its incidence, clinical features, and related factors. PATIENTS AND METHODS: We analyzed a single-center cohort of stroke patients treated with IVT in an 8-year period. We compared patients with (OA+) and without OA (OA-). A meta-analysis of previous studies was performed to identify factors related with OA. RESULTS: OA occurred in 7 out of 512 patients (1.37%; 95% CI 0.86-1.88%). Previous hypertension, diabetes, and treatment with ACE inhibitors were more frequent in OA+ compared to OA- patients (100% vs 58%, p = 0.045; 71.4% vs 21.8%, p = 0.008; and 71.4% vs. 16.6%, p = 0.002). Three out of 4 cases with unilateral OA had a contralateral insular infarct. The meta-analysis included 13 studies: 5720 stroke patients treated with IVT and 209 cases of OA. Factors related with OA were ACE inhibitor treatment (RR 5.33 [95% CI 3.07-9.26]) female sex (RR 1.94 [95% CI 1.24-3.03]), hypertension (RR 2.64 [95% CI 1.79-3.90]), diabetes (RR 1.60 [95% CI 1.16-2.21]), and dyslipidemia (RR 1.46 [95% CI 1.00-2.12]). The effect of insular infarct was inconclusive: positive when considering complete infarcts (RR 1.97 [95% CI 1.18-3.29]) and absent when partial infarcts were also included. CONCLUSIONS: OA occurred in 1.37% of the IVT-treated stroke patients. Previous treatment with ACE inhibitors, hypertension, diabetes, dyslipidemia, and female sex were associated with OA. The effect of insular infarct needs to be clarified in further studies.

Acute Stroke Care during the COVID-19 Pandemic: Reduction in the Number of Admissions of Elderly Patients and Increase in Prehospital Delays.

INTRODUCTION: We analyzed whether the coronavirus disease 2019 (COVID-19) crisis affected acute stroke care in our center during the first 2 months of lockdown in Spain. METHODS: This is a single-center, retrospective study. We collected demographic, clinical, and radiological data; time course; and treatment of patients meeting the stroke unit admission criteria from March 14 to May 14, 2020 (COVID-19 period group). Data were compared with the same period in 2019 (pre-COVID-19 period group). RESULTS: 195 patients were analyzed; 83 in the COVID-19 period group, resulting in a 26% decline of acute strokes and transient ischemic attacks (TIAs) admitted to our center compared with the previous year (p = 0.038). Ten patients (12%) tested positive for PCR SARS-CoV-2. The proportion of patients aged 65 years and over was lower in the COVID-19 period group (53 vs. 68.8%, p = 0.025). During the pandemic period, analyzed patients were more frequently smokers (27.7 vs. 10.7%, p = 0.002) and had less frequently history of prior stroke (13.3 vs. 25%, p = 0.043) or atrial fibrillation (9.6 vs. 25%, p = 0.006). ASPECTS score was lower (9 [7-10] vs. 10 [8-10], p = 0.032), NIHSS score was slightly higher (5 [2-14] vs. 4 [2-8], p = 0.122), onset-to-door time was higher (304 [93-760] vs. 197 [91.25-645] min, p = 0.104), and a lower proportion arrived within 4.5 h from onset of symptoms (43.4 vs. 58%, p = 0.043) during the CO-VID-19 period. There were no differences between proportion of patients receiving recanalization treatment (intravenous thrombolysis and/or mechanical thrombectomy) and in-hospital delays. CONCLUSION: We observed a reduction in the number of acute strokes and TIAs admitted during the COVID-19 period. This drop affected especially elderly patients, and despite a delay in their arrival to the emergency department, the proportion of patients treated with recanalization therapies was preserved.

Visual Aids for Patient, Family, and Physician Decision Making About Endovascular Thrombectomy for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Rapid decision making optimizes outcomes from endovascular thrombectomy for acute cerebral ischemia. Visual displays facilitate swift review of potential outcomes and can accelerate decision processes. METHODS: From patient-level, pooled randomized trial data, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of endovascular thrombectomy for patients with acute cerebral ischemia and large vessel occlusion using (1) automated (algorithmic) and (2) expert-guided joint outcome table specification. RESULTS: For the full 7-category modified Rankin Scale, thrombectomy added to IV tPA (intravenous tissue-type plasminogen activator) alone had number needed to treat to benefit 2.9 (95% confidence interval, 2.6-3.3) and number needed to harm 68.9 (95% confidence interval, 40-250); thrombectomy for patients ineligible for IV tPA had number needed to treat to benefit 2.3 (95% confidence interval, 2.1-2.5) and number needed to harm 100 (95% confidence interval, 62.5-250). Visual displays of treatment effects on 100 patients showed: with thrombectomy added to IV tPA alone, 34 patients have better disability outcome, including 14 more normal or near normal (modified Rankin Scale, 0-1); with thrombectomy for patients ineligible for IV tPA, 44 patients have a better disability outcome, including 16 more normal or nearly normal. Displays also showed that harm (increased modified Rankin Scale final disability) occurred in 1 of 100 patients in both populations, mediated by increased new territory infarcts. The person-icon figures integrated these outcomes, and early side-effects, in a single display. CONCLUSIONS: Visual decision aids are now available to rapidly educate healthcare providers, patients, and families about benefits and risks of endovascular thrombectomy, both when added to IV tPA in tPA-eligible patients and as the sole reperfusion treatment in tPA-ineligible patients.

Efficacy of New Measures Saving Time in Acute Stroke Management: A Quantified Analysis.

BACKGROUND: Time to treatment remains the most important factor in acute ischemic stroke prognosis. We quantified the effect of new interventions reducing in-hospital delays in acute stroke management and assessed its repercussion on door-to-imaging (DTI), imaging-to-needle (ITN), and door-to-needle (DTN) times. METHODS: Prospective registry of consecutive stroke patients who were candidates for reperfusion therapy attended in a tertiary care hospital from February 1 to December 31, 2014. A series of measures aimed at reducing in-hospital delays were implemented. We compared DTI, ITN, and DTN times between patients who underwent the interventions and those who did not. RESULTS: 231 patients. DTI time was lower when personal history was reviewed and tests were ordered before patient arrival (2.5 minutes saved, P = .016) and when electrocardiogram was not made (5.4 minutes saved, P < .001). Not performing a computed tomography angiography and not waiting for coagulation results from laboratory before intravenous thrombolysis (25.5%) reduced ITN time significantly (14 and 12 minutes saved, respectively, P < .001). These interventions remained as independent predictors of a shorter ITN and DTN time. Completing all steps resulted in the lowest DTI and ITN times (13 and 19 minutes, respectively). CONCLUSIONS: Every measure is an important part of a chain focused on saving time in acute stroke: the lowest DTI and ITN times were obtained when all steps were completed. Measures shortening ITN time produced a greater impact on DTN time reduction; therefore, ITN interventions should be considered a critical part of new protocols and guidelines.

A Rare Case of Stroke as a Complication After Percutaneous Mechanical Thrombectomy in a Patient with Intermediate-High Risk Pulmonary Embolism and Patent Foramen Ovale.

We present an extremely rare case of a patient with intermediate-high risk pulmonary embolism treated with percutaneous mechanical thrombectomy, complicated with stroke as a form of paradoxical embolism through a previously unknown patent foramen ovale. We reviewed the literature for indications, efficacy, and safety of this procedure, as well as for experience on this technique in patients with patent foramen ovale. LEARNING POINTS: Some authors propose percutaneous mechanical thrombectomy as an aggressive treatment of intermediate-high risk pulmonary embolism.Pending clinical trials, percutaneous mechanical thrombectomy seems to reduce right ventricle overload in these patients, with rare adverse effects.To our knowledge, this is the first reported case of stroke as a complication of the procedure. These patients should be screened for patent foramen ovale before the procedure.

Spinal epidural abscess caused by Streptococcus agalactiae in an immunocompetent patient. / Absceso epidural espinal por Streptococcus agalactiae en un paciente inmunocompetente.

BACKGROUND: Streptococcus agalactiae is an uncommon microorganism that causes spinal epidural abscess (SEA) and usually affects individuals with a predisposing condition or potential source of infection. CASE DESCRIPTION: We present the case of an immunocompetent 53-year-old patient with an unremarkable past medical history who developed progressive low extremity weakness, bowel and bladder dysfunction and genital sensory impairment. A neurological exam on admission revealed flaccid proximal paraparesis, T10 sensory level, atonic anal sphincter and normal myotatic reflexes. Urgent neuroimaging showed a large thoracic epidural spinal abscess. Laminectomy and abscess drainage were immediately performed and systemic antibiotic treatment was initiated. Abscess cultures revealed Streptococcus agalactiae. After an exhaustive workup no predisposing factors or local or systemic source for the infection were found. CONCLUSIONS: We report a singular case of spinal epidural abscess caused by Streptococcus agalactiae in a healthy patient with no predisposing factors. This case also highlights the importance of an early diagnosis and treatment to obtain a better neurological outcome.

Cerebral amyloid angiopathy-related transient focal neurological episodes: A transient ischemic attack mimic with an increased risk of intracranial hemorrhage.

BACKGROUND: Transient focal neurological episodes (TFNEs) are a recently recognized clinical presentation of cerebral amyloid angiopathy (CAA). Our aim was to describe the clinical and radiological features of a series of patients with AS. METHODS: We included 11 patients presenting with recurrent transient focal neurological symptoms and radiological features related to CAA. RESULTS: Mean age was 76,6 and 5 patients were women. All patients reported transient, stereotyped, and recurrent episodes (6 patients had >10 episodes). Gradual spread of the symptoms was recorded in 9 patients. Initially, 3 patients were misdiagnosed as having recurrent transient ischemic attack (TIA), 6 as having seizures, and 2 as having both. Two patients were prescribed antiplatelet therapy. A cerebral MRI with T2* gradient-recalled echo sequence revealed cortical superficial siderosis (cSS) in 5 patients, cortical microbleeds in 1 patient, and both features in 5 cases. After a median follow-up of 36 months, intracranial hemorrhage (ICH) was recorded in 4 patients. All 4 had cSS in the previous cerebral MRI, and 1 was on antiplatelet therapy. CONCLUSION: CAA-related TFNEs are an underdiagnosed entity, often mimicking TIA, seizures, or migraine aura. This misdiagnosis can lead to the prescription of antiplatelet or anticoagulant therapy, which increases the risk of ICH. Our results suggest that cSS might be a radiological marker that is closely related to an increased risk of bleeding. A T2* gradient-recalled echo MRI should be performed in elderly patients with transient focal neurological symptoms suggestive of CAA.

[Not Available]. / Deficiencia clínica de vitamina A tras bypass gástrico. Descripción de un caso clínico y revisión de la literatura.

La deficiencia de vitamina A es infrecuente en los países desarrollados. La cirugía bariátrica constituye un factor de riesgo de deficiencia de esta vitamina. Se han descrito varios casos en pacientes sometidos a técnicas con un importante componente malabsortivo, como la derivación biliopancreática. En este artículo se describe un caso de deficiencia clínica de vitamina A con manifestaciones oculares y cutáneas tras bypass gástrico y se revisan las publicaciones sobre este tema y las recomendaciones para la prevención de esta importante complicación.

Deficiencia clínica de vitamina A tras bypass gástrico. Descripción de un caso clínico y revisión de la literatura / Vitamin A deficiency after gastric bypass. Case report and review of the literature

La deficiencia de vitamina A es infrecuente en los países desarrollados. La cirugía bariátrica constituye un factor de riesgo de deficiencia de esta vitamina. Se han descrito varios casos en pacientes sometidos a técnicas con un importante componente malabsortivo, como la derivación biliopancreática. En este artículo se describe un caso de deficiencia clínica de vitamina A con manifestaciones oculares y cutáneas tras bypass gástrico y se revisan las publicaciones sobre este tema y las recomendaciones para la prevención de esta importante complicación (AU)

Vitamin A deficiency is uncommon in developed countries. Bariatric surgery emerges a an important risk factor for vitamin A defi ciency and some clinical cases have been described, specially associated with malabsorptive surgical techniques, such as biliopancreatic diversion. In this paper we report a clinical case of a patient who developed blindness, ophthalmological disease and cutaneous alterations secondary to vitamin A deficiency after gastric bypass. A review of other publications and recommendations on this important subject is also included (AU)

Absceso epidural espinal por Streptococcus agalactiae en un paciente inmunocompetente / Spinal epidural abscess caused by Streptococcus agalactiae in an immunocompetent patient

Introducción: Streptococcus agalactiae es un microorganismo causal infrecuente en el absceso epidural espinal (AEE) que generalmente afecta a pacientes con comorbilidades predisponentes y/o alguna potencial fuente de infección. Caso clínico: Presentamos el caso de un paciente de 53años, inmunocompetente y sin antecedentes médicos de interés, que desarrolló un cuadro de dolor lumbar, paraparesia y disfunción de esfínteres en el contexto de un síndrome febril sin foco conocido de una semana de evolución. La exploración neurológica mostró paraparesia flácida proximal, nivel sensitivo T10, esfínter anal atónico y reflejos osteotendinosos normales. La RM medular mostró un extenso AEE dorsal. Se realizó una laminectomía urgente con drenaje del absceso en menos de 24h y se inició antibioterapia empírica. El resultado del cultivo mostró Streptococcus agalactiae. Tras un estudio exhaustivo, no se encontró ninguna enfermedad predisponente ni fuente de la infección. Conclusiones: Describimos un caso infrecuente de AEE causado por Streptococcus agalactiae en un paciente sano sin factores predisponentes. Este caso subraya la importancia del diagnóstico precoz de esta entidad, dado que se puede asociar potencialmente con un mejor pronóstico

Background: Streptococcus agalactiae is an uncommon microorganism that causes spinal epidural abscess (SEA) and usually affects individuals with a predisposing condition or potential source of infection. Case description: We present the case of an immunocompetent 53-year-old patient with an unremarkable past medical history who developed progressive low extremity weakness, bowel and bladder dysfunction and genital sensory impairment. A neurological exam on admission revealed flaccid proximal paraparesis, T10 sensory level, atonic anal sphincter and normal myotatic reflexes. Urgent neuroimaging showed a large thoracic epidural spinal abscess. Laminectomy and abscess drainage were immediately performed and systemic antibiotic treatment was initiated. Abscess cultures revealed Streptococcus agalactiae. After an exhaustive workup no predisposing factors or local or systemic source for the infection were found. Conclusions: We report a singular case of spinal epidural abscess caused by Streptococcus agalactiae in a healthy patient with no predisposing factors. This case also highlights the importance of an early diagnosis and treatment to obtain a better neurological outcome