Acute Calcific Cerebral Embolism Large Vessel Occlusion: A Unique Stroke Mechanism With Hard Challenges.

We present the case of an ischemic stroke associated with partially occlusive acute calcified cerebral emboli large vessel occlusion (CCE LVO). No revascularization strategy guidelines have been established for this unique acute ischemic stroke population, although many studies have reported impaired and inconsistent responses to both thrombolysis and thrombectomy. The patient in this case report, unfortunately, experienced a failed attempt at complete thrombolysis, resulting in a poor clinical outcome. Endovascular thrombectomy was not performed because of incomplete obstruction and risk of injury. Follow-up imaging revealed an acute ischemic stroke at the large middle cerebral artery and a new intraparenchymal hemorrhage with complete absence of the previously identified calcified embolus. This case and current literature demonstrate that more data are needed to determine the best revascularization approach for patients with CCE LVO stroke. With tissue plasminogen activator marginally effective in these patients, thrombectomy should be considered in highly unstable, clinically symptomatic patients even only with partial vessel occlusion.

Post-thrombectomy intracranial blooming artifact.

Mechanical thrombectomy is a procedure used for the treatment of acute ischemic stroke in patients with large vessel occlusions. Usually with a low complication rate, we present a case with a complication post-thrombectomy not previously described in the literature noted on imaging as "blooming artifact".

Early Anticoagulation or Antiplatelet Therapy Is Critical in Craniocervical Artery Dissection: Results from the COMPASS Registry.

INTRODUCTION: Craniocervical artery dissection (CeAD) is a leading cause of stroke in the young patient population. Recent studies reported a low rate of major adverse cardiac events (MACEs) in patients with CeAD, with no significant difference between patients randomized to anticoagulation or antiplatelet therapy. OBJECTIVE: To compare the effectiveness of anticoagulation and antiplatelet therapy in patients with CeAD. METHODS: All CeAD patients from 2015 to 2017 were consecutively identified by an electronic medical record-based application and enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging and graded using the Denver scale for blunt cerebrovascular injury. Patients were followed for 12 months for MACE defined as stroke, transient ischemic attack (TIA), or death. RESULTS: The cohort included 111 CeAD patients (age 53 ± 15.9 years, 56% Caucasian, 50% female). CeAD was detected by magnetic resonance (5%), computed tomography (88%), or catheter angiography (7%). CeAD was noted in the carotid (59%), vertebral (39%), and basilar (2%) arteries, 82% of which were extracranial dissections. CeAD was classified as grade I, II, III, and IV in 16, 33, 19, and 32%, respectively. A total of 40% of dissections were due to known trauma. A predisposing factor was noted in the majority (78%) of patients, including violent sneezing (21%), carrying a heavy load (19%), sports/recreational activity (11%), chiropractic manipulation (9%), abrupt/prolonged rotation of head (9%), and prolonged phone use (9%). At presentation, 41% had a stroke, 5% had TIA, 39% had headache, and 36% were asymptomatic. Favorable outcome defined as a modified Rankin Scale score of 0-2 was noted in 68% at 3 months and 71% at 12 months. The rate of MACEs at 3 and 12 months was 11 and 14%, respectively, with more events observed in patients who were not receiving anticoagulation/antiplatelet therapy due to contraindications (p = 0.008). CONCLUSIONS: We report diagnostic characteristics, as well as short- and long-term outcomes of CeAD. A high MACE rate was observed within the first 2 weeks of CeAD diagnosis, notably in patients not initiated on anticoagulation or antiplatelet therapy.

Stroke in primary hyperoxaluria type I.

We report the case of a 27-year-old man with a history of previously undiagnosed renal disease that presented with multiple cerebrovascular infarctions. Workup for traditional causes of cerebrovascular infarction including cardiac telemetry, multiple echocardiograms, and hypercoagulative workup was negative. However, a transcranial Doppler detected circulating microemboli at the rate of 14 per hour. A serum oxalate level greater than the supersaturation point of calcium oxalate was detected, providing a potential source of the microemboli. Furthermore, serial imaging recorded rapid mineralization of the infarcted territories. In the absence of any proximal vessel irregularities, atherosclerosis, valvular abnormalities, arrhythmias, or systemic shunt as potential stroke etiology in this patient, we propose that circulating oxalate precipitate may be a potential mechanism for stroke in patients with primary oxalosis.

Drip, Ship, and Grip, then Slice and Dice: Comprehensive Stroke Center Management of Cervical and Intracranial Emboli.

BACKGROUND AND PURPOSE: Tandem acute thrombotic emboli in the cervical and intracranial arteries are an unusual cause of stroke presenting unique management challenges. In regional systems of acute stroke care anchored by Comprehensive Stroke Centers (CSC), combined fibrinolytic, endovascular, and open surgical intervention is a new therapeutic option. SUMMARY OF CASE: A 28-year-old male underwent retinal surgery, including post-operative neck compression and the next day presented to a primary stroke center with aphasia and right hemiplegia. Intravenous tissue plasminogen activator therapy was initiated and the patient was transferred to a CSC for higher level of care (drip and ship). Imaging at the CSC demonstrated tandem thrombi: a near occlusive lesion at the origin of the left cervical internal carotid artery and a total occlusion of the M1 segment of the left middle cerebral artery. Endovascular thrombectomy with the Solitaire stent retriever resulted in intracranial recanalization (grip). Immediately after the endovascular procedure, open carotid thrombectomy was performed to achieve cervical carotid revascularization without systemic heparinization (slice). Both cervical carotid and intracranial thrombi were processed for proteomic analysis via mass spectrometry (dice). CONCLUSION: Combined fibrinolytic, endovascular, and open surgical intervention can yield revascularization and good clinical outcome in cases of tandem lesions.

Melatonin attenuates calpain upregulation, axonal damage and neuronal death in spinal cord injury in rats.

Multiple investigations in vivo have shown that melatonin (MEL) has a neuroprotective effect in the treatment of spinal cord injury (SCI). This study investigates the role of MEL as an intervening agent for ameliorating Ca(2+)-mediated events, including activation of calpain, following its administration to rats sustaining experimental SCI. Calpain, a Ca(2+)-dependent neutral protease, is known to be involved in the pathogenesis of SCI. Rats were injured using a standard weight-drop method that induced a moderately severe injury (40 g.cm force) at T10. Sham controls received laminectomy only. Injured animals were given either 45 mg/kg MEL or vehicle at 15 min post-injury by intraperitoneal injection. At 48 hr post-injury, spinal cord (SC) samples were collected. Immunofluorescent labelings were used to identify calpain expression in specific cell types, such as neurons, glia, or macrophages. Combination of terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) and double immunofluorescent labelings was used to identify apoptosis in specific cells in the SC. The effect of MEL on axonal damage was also investigated using antibody specific for dephosphorylated neurofilament protein (dNFP). Treatment of SCI animals with MEL attenuated calpain expression, inflammation, axonal damage (dNFP), and neuronal death, indicating that MEL provided neuroprotective effect in SCI. Further, expression and activity of calpain and caspse-3 were examined by Western blotting. The results indicated a significant decrease in expression and activity of calpain and caspse-3 in SCI animals after treatment with MEL. Taken together, this study strongly suggested that MEL could be an effective neuroprotective agent for treatment of SCI.

Sturge-Weber syndrome variant with atypical intracranial findings: case report.

Sturge-Weber syndrome is characterized by a facial port-wine nevus, leptomeningeal angiomatosis, and glaucoma; it is commonly complicated by epilepsy and hemiparesis. We present a patient with a head and neck port-wine nevus, glaucoma, abnormalities of the intracranial deep veins, and untreated communicating hydrocephalus. The patient lacks any radiologic or clinical evidence of cerebral leptomeningeal angiomatosis. Considering that intracranial venous anomalies also are likely compatible with the embryologic explanation of Sturge-Weber syndrome, this child can serve as an unusual example of Sturge-Weber syndrome type II.

Upregulation of calpain correlates with increased neurodegeneration in acute experimental auto-immune encephalomyelitis.

Although calpain up-regulation is well established in experimental auto-immune encephalomyelitis (EAE), a link between increased calpain expression and activity and neurodegeneration has not been examined. Therefore, spinal cord tissue from Lewis rats with EAE was examined to test the hypothesis that increased calpain expression in neurons would correlate with increased cell death and axonal damage in a time-dependent manner following EAE induction. We found that increased calpain expression in EAE corresponded to increased TUNEL-positive neurons and to increased expression of dephosphorylated neurofilament protein, markers of cell death and axonal degeneration, respectively. An increase in internucleosomal DNA fragmentation in EAE spinal cord suggested that cell death was, at least partially, due to apoptosis. Axonal damage was further demonstrated in EAE spinal cord compared with control via morphological analysis, revealing granular degeneration of filament and microtubule integrity, loss of myelin, and mitochondrial damage. Calcium (Ca2+) influx, which is required for calpain activation, was also increased in EAE spinal cord. From these findings, we conclude that increases in Ca2+-induced calpain activity may play a crucial role in neurodegeneration in acute EAE.