A randomized trial on Hemodynamic Optimization of cerebral Perfusion after successful Endovascular therapy in patients with acute ischemic stroke (HOPE).

INTRODUCTION: In patients with acute ischemic stroke (AIS) secondary to intracranial large vessel occlusion (LVO), optimal blood pressure (BP) management following endovascular treatment (EVT) has not yet been established. The randomized trial on Hemodynamic Optimization of cerebral Perfusion after successful Endovascular therapy in patients with acute ischemic stroke (HOPE) (clinicaltrials.gov id: NCT04892511), aims to demonstrate whether hemodynamic optimization using different systolic BP targets following EVT according to the degree of final recanalization, is more effective than currently recommended BP management in improving functional outcomes of patients with AIS. METHODS: HOPE is an investigator-initiated multicentre clinical trial with randomized allocation, open label treatment, and blinded endpoint evaluation (PROBE). Patients with an anterior circulation AIS within 24h of symptom onset, treated with EVT, and showing successful recanalization (mTICI ≥2b) at the end of the procedure, are equally allocated (1:1) to hemodynamic optimization according to the study protocol vs. BP management according to current guidelines (≤180/105mmHg). The protocol includes two different targets of systolic BP depending on the recanalization status (mTICI=2b: 140-160 mmHg; mTICI=2c/3: 100-140 mmHg). The protocol is applied within the first 72h and includes BP lowering as well as vasopressor therapies when needed. The primary outcome is the proportion of favorable outcome (modified Rankin Scale [mRS] 0-2) at 90 days. Secondary outcomes include the shift on the mRS score, neurological deterioration, symptomatic intracerebral haemorrhage and mortality. CONCLUSION: The HOPE trial will provide new information on the safety and efficacy of different BP targets following EVT according to the degree of final recanalization in patients with AIS.

Hypomagnesemia, a Rare Cause of Reversible Ataxia.

Background: A 61-year-old male patient presented with cerebellar syndrome, which had progressively worsened for 10 days, followed by a tonic-clonic seizure. Phenomenology Shown: Blood analysis showed severe hypomagnesemia and a brain MRI showed T2 hyperintensity in the cerebellar hemispheres (Figure 1). Therefore, the final diagnosis was cerebellar syndrome and epileptic seizures secondary to severe hypomagnesemia. Educational Value: In cases of subacute onset of ataxia, the possibility of ataxia secondary to hypomagnesemia should be considered, as it can be diagnosed with a basic blood test and there are potentially life-threatening outcomes in the absence of treatment, with a reversible course following early supplementation.

Progressive Lacunar Strokes: A Predictive Score.

BACKGROUND AND PURPOSE: Progressive lacunar syndromes (PLS) occur in up to 20-30% of patients with lacunar strokes, increasing the risk of long term dependency. Our aim is to develop a predictive score to identify patients at high risk of presenting PLS. METHODS: We derived a risk score for PLS in a cohort of consecutive patients (n=187) presenting with one of the five classic lacunar syndromes (LS) and absence of vascular occlusion, perfusion deficit or symptomatic stenosis. A risk score was developed using the coefficients from the logistic regression model, and receiver operating characteristic (ROC) analysis was conducted to assess the prognostic value of the risk score. Sensitivity, specificity and accuracy were estimated for each total point score. RESULTS: Out of 187 patients included in our sample, 52 (27.8%) presented PLS. Previous history of diabetes mellitus (1 point), diastolic blood pressure at admission (2 points), clinical deficits consistent with a pure motor syndrome (1 point) and asymptomatic intracranial atheromatosis or stenosis in non-symptomatic territory (1 point) were independent predictors for PLS. The estimated area under the ROC curve for this model was 0.77 (95% CI,0.68 - 0.84). CONCLUSION: This score could be a useful tool in routine clinical practice to predict the occurrence of PLS, allowing the identification of those patients with LS who are at high risk of long term dependency due to early neurological worsening, and who would benefit the most from an intensive treatment.