Arterial blood gas analysis predicts futile recanalization in mechanical thrombectomy-treated acute ischemic stroke patients: a multicenter study.

OBJECTIVE: It is known that providing recanalization alone in large vessel occlusions is not sufficient to provide a good 90-day clinical outcome. It is advocated that neuroprotection should be increased before endovascular treatment and that the penumbra should be protected from reperfusion damage after recanalization. However, the effects of blood gas parameters before and after mechanical thrombectomy on clinical outcomes are not clear. The objective of this study is to assess the effectiveness of serial blood gas measures in accurately predicting futile recanalization at an early stage. PATIENTS AND METHODS: This study is a multicenter inquiry that collected data in a prospective manner and analyzed it retrospectively. Patients with a 2b-3 thrombolysis in cerebral infarction (TICI) score after mechanical thrombectomy for recanalization were consecutively analyzed from July 2022 to March 2023. Arterial blood gas parameters, including pH, oxygen saturation (SaO2), partial carbon dioxide pressure (PaCO2), partial oxygen pressure (PaO2), lactate, and bicarbonate (HCO3), were measured at four time points: before mechanical thrombectomy treatment (preoperative), immediately after recanalization (postoperative 1st), during the 3rd hour (postoperative 3rd), and at the 5th hour (postoperative 5th). The patients were categorized into groups based on their modified Rankin Scale (mRS) scores. RESULTS: The study included 136 patients with an average age of 69.71±11.22. The postoperative 1st-hour SaO2 values were lower in the mRS 3-6 group (p=0.038). The postoperative pH and lactate mean were greater in the mRS 3-6 group than in the 0-2 group (p=0.038 and 0.018, respectively). In logistic regression, a unit rise in lactate increased poor functional outcomes 1,632 times (p=0.024). Early neurological recovery was associated with decreased postoperative 3rd-hour lactate (p=0.014). The mean postoperative PaO2 (average of 1, 2, 3 PaO2) was higher in those with symptomatic cerebral bleeding (p=0.044). CONCLUSIONS: Monitoring lactate and pH levels in AIS patients who have had mechanical recanalization can be utilized to predict mortality and morbidity, especially in the first five hours after the procedure. Graphical Abstract: https://www.europeanreview.org/wp/wp-content/uploads/Graphical-abstract-8.jpg.

Is cardioembolic stroke more frequent than expected in acute ischemic stroke due to large vessel occlusion?

INTRODUCTION: Cardioembolic and atherosclerotic occlusions are two leading causes of acute ischemic stroke with large artery occlusion. Cardioembolic cause is more frequent in strokes due to large vessel occlusion among strokes of all types. In this study, we aimed to analyze and determine the rate of cardioembolic cause in patients with LVO treated with mechanical thrombectomy. PATIENTS AND METHODS: This study is a retrospective analysis of 1,169 patients with LVO that were treated with mechanical thrombectomy in 2019. Both anterior and posterior circulation occlusions eligible for thrombectomy were included. RESULTS: Among the 1,169 patients who performed mechanical thrombectomy, there were 52.6 % males with a mean age of 63.2 ± 12.9 years and 47.4% females with a mean age of 67.4 ± 13.3 years. The average NIHSS score was 15.3 ± 4.8. The successful revascularization (mTICI 2b-3) rate was 85.2%, the 90-day good functional outcome rate (mRS 0-2) was 39.8% and mortality (mRS 6) rate was 22.9%. Most common causes of ischemic stroke were cardioembolism in 532/1,169 (45.5%), followed by 461/1,169 (39.5%) undetermined etiologies and others, 175/1,169 (15%) large vessel disease. Atrial fibrillation is found to be the most common cause of cardioembolic stroke with 76.3% incidence. We identified 11 (0.9%) acute stroke patients treated with MT who had recurrent LVO and received repeated MT. A cardioembolic cause was found to cause the recurrent LVO in 7 (63.6%) patients. CONCLUSIONS: In this retrospective study, cardioembolic source seems to constitute majority of causes in acute ischemic strokes due to large vessel occlusions. Further exploration is needed especially in cryptogenic strokes to reveal possible cardioembolic source of emboli.

Comparison of COVID-19 patients who underwent thrombectomy with those in the pre-pandemic period in terms of etiology and prognosis.

OBJECTIVE: We aimed at determining the effectiveness of mechanical thrombectomy (MT) in patients with major vessel occlusion and infected with COVID-19, evaluating its clinical outcome and comparing it with non-COVID patients. PATIENTS AND METHODS: During the pandemic, 729 patients who underwent MT in stroke centers due to Acute Ischemic Stroke (AIS) with large vessel occlusion were evaluated. This study included 40 patients with a confirmed COVID-19 diagnosis by a positive PCR test between March 11, 2020, and December 31, 2020. These patients were compared to 409 patients who underwent MT due to major vessel occlusion between March 11, 2019, and December 31, 2019. RESULTS: Of the patients with AIS who are infected with COVID-19, 62.5% were males, and all patients have a median age of 63.5 ± 14.4 years. The median NIHSS score of the COVID-19 group was significantly higher than that of the non-COVID-19 groups. Dissection was significantly more in the COVID-19 group. The mortality rates at 3 months were higher in the COVID-19 groups compared to non-COVID-19 groups. CONCLUSIONS: This study revealed an increased frequency of dissection in patients with COVID-19. COVID-19-related ischemic strokes are associated with worse functional outcomes and higher mortality rates than non-COVID-19 ischemic strokes.

REVERSIBLE CLINICAL AND MAGNETIC RESONANCE IMAGING FINDINGS IN LATE-ONSET COBALAMIN C DEFECT.

Cobalamin C (Cbl C) disease is an inborn error of intracellular cobalamin metabolism. Two distinct clinical types are defined according to the age of onset. We describe an 8 year old girl with late-onset Cbl C disease presenting with neuropsychiatric symptoms. Mutation analysis revealed homozygous c.394C>T (p.R132X) mutation in the MMACHC gene. Serial magnetic resonance imaging (MRI) before and after the treatment are provided. MRI of the brain before treatment showed bilateral patchy focal hyperintensities in the white matter and cortical atrophy. After treatment with intramuscular hydroxycobalamin, oral folinic acid, oral betaine, normalization of MRI findings can be achieved in addition to clinical improvement. We present this case to draw attention to the reversibility of clinical and MRI findings in the late onset Cbl C disease after treatment.

Proximal protection with hybrid stent, a safer combination for carotid artery stenting against carotid endarterectomy?

AIM: Carotid revascularization is an established theurapeutic modality in preventing stroke and death among patients with severe carotid stenosis. Although carotid endarterectomy remains as the primary option, carotid stenting is accepted as an alternative for patients with high risk for carotid endarterectomy. Recently published reports have better results with proximal protection devices when compared with distal protection devices. These studies have revealed less microembolic signals and less periprocedural new ischemic lesions on diffusion weighted magnetic resonance imaging. Stent choice may be also important for these procedures as open cell stent design has advantage of better flexibility whereas closed cell systems have an advantage of better scaffolding. Hybrid stents which are composed of open cells in the proximal and distal part and closed cells in the middle may carry both advantages. The aim of this study is to demonstrate whether combination of proximal protection devices with hybrid stents can be a safe alternative for carotid stenting in terms of periprocedural and 30-day outcomes. METHODS: Here we retrospectively evaluated 68 symptomatic carotid stenosis patients undergoing carotid stenting with hybrid stent (Cristallo Ideale®, Invatec s.r.l., Medtronic, Italy) and proximal protection device (MO.MA®, Invatec s.r.l., Medtronic, Italy). RESULTS: Our results showed only 1 minor stroke in the periprocedural period and during the first 30-day after stenting, with no death or myocardial infarction. CONCLUSION: Although our case number is not large, we propose that carotid stenting may be safer with utilization of proximal protection system and hybrid type carotid stents.

Early outcomes of carotid artery stenting.

BACKGROUND AND AIM: Ischemic cerebrovascular events are the most common reason for patients to be bedridden and the third most common reason for death. Many studies in recent years have demonstrated that carotid artery stenting (CAS) may be an alternative to carotid endarterectomy (CEA). In this study, we aimed to report early outcomes of patients who were treated with CAS in our clinic and discuss practicability, advantages and safety of CAS. METHODS AND FINDINGS: Eighty patients who underwent CAS between December 2009 and May 2011 were eligible. The mean age was 65 years (range, 49 - 89 years). Of the study group, 73.75% were males and 26.25% were female. The percentage of asymptomatic patients was 11.7%, and the remaining patients were symptomatic. A distal embolic protection device (Angioguard®) was used in 22% of the patients whereas, in the other patients (78%), a proximal blockage system (Mo.MA®) was used. Self-expandable hybrid stents were implanted in all patients and post-dilatation was performed after implantation. None of the patients suffered from stroke, myocardial infarction or death due to CAS during their hospital stay. The mean follow-up period was 10 months (range 2 - 18 months) after discharge. None of the patients had died or had a stroke, a transient ischemic attack (TIA), or a myocardial infarction during the follow-up period. Re-stenosis was not observed in the follow-up carotid Doppler ultrasonography; flow rates were within normal limits. CONCLUSION: No major complication was observed during the early follow-up period in patients who underwent CAS in our clinic. Only 2 (2.5%) patients showed transient numbness and weakness and these did not lead to morbidity. In the management guide of extracranial carotid and vertebral artery diseases, CAS, in the light of recent studies, is recommended as an alternative to CEA in recommendations for revascularization. One of the important issues emphasized in this guide is the experience of centers. Very low complication rates after CAS suggested that, with suitable patient selection and an experienced team, similar results may be obtained.

An overview on natural cholinesterase inhibitors--a multi-targeted drug class--and their mass production.

Cholinesterase enzyme family consisting of acetylcholinesterase (AChE) and butrylcholinesterase (BChE) is important in pathogenesis of Alzheimer's disease (AD), explained by "cholinergic hypothesis". Accordingly, deficiency of the neuromediator called "acetylcholine" excessive amount of BChE has been well-described in the brains of AD patients. Consequently, cholinesterase inhibition has become one of the most-prescribed treatment strategies for AD. In fact, cholinesterase inhibitors have been also reported for their effectiveness in some other diseases including glaucoma, myasthenia gravies, as well as Down syndrome, lately. They play a role in the action of mechanism of insecticidal drugs such as carbamate derivatives as well as nerve gases such as malathion and parathion. All these utilizations can make them a multi-targeted drug class putting a special emphasis on AD therapy in the first place. Several inhibitors of cholinesterases with synthetic and natural origins are available in drug market; however, the reasons including side effects, relatively low bioavailability, etc. limit their uses in medicine and there is still a great demand to discover new cholinesterase inhibitors. Galanthamine, an alkaloid derivative isolated from snowdrop (Galanthus nivalis L.), is the latest anticholinesterase drug used against AD. Huperzine A, isolated from Huperzia serrata (Thunb.) Trev. is the most-promising drug candidate with potent anticholinesterase effect and it is a licensed anti-AD drug in China. In this review, a short introduction will be given on known cholinesterase inhibitors and, then, galanthamine and huperzine A will be covered in regard with their cholinesterase inhibitory potentials and mass productions by organic synthesis and in vitro culture techniques.