Cerebral Cavernous Malformation Associated With Left Middle Cerebral Artery (MCA) Aneurysm and Bilateral Internal Carotid Artery (ICA) Dissections.

Cerebral cavernous malformations (CCMs) are the second most common type of cerebral vascular lesions. They are often associated with other vascular lesions, typically developmental venous anomalies. CCMs are not known to be associated with cerebral aneurysms and there is a paucity of literature on this occurrence. We report the case of a patient who presented with a focal seizure from a symptomatic CCM with acute hemorrhage and was incidentally found to have a cerebral aneurysm and bilateral internal carotid artery (ICA) dissections secondary to fibromuscular dysplasia. The presence of a cerebral aneurysm has clinical implications as these patients will need closer monitoring.

In acute ischemic stroke patients with smoking incidence, are more women than men more likely to be included or excluded from thrombolysis therapy?

BACKGROUND: Clinical factors associated with exclusion from recombinant tissue plasminogen activator in both men and women are not completely understood. The aim of this study is to determine whether there is a gender difference in clinical risk factors that excluded ischemic stroke patients with a history of smoking from recombinant tissue plasminogen activator. METHODS: Retrospective data from a stroke registry were analyzed, and multivariable linear regression models were used to determine gender differences. Logistic regression models determined exclusion clinical risk factors for thrombolysis in male and female acute ischemic stroke patients with a history of smoking, while sequentially adjusting for sociodemographic, clinical, and stroke-related variables. The Kaplan-Meier survival analysis was used to determine the exclusion probabilities of men and women with a history of smoking within the stroke population. RESULTS: Of the 1,446 acute ischemic stroke patients eligible for recombinant tissue plasminogen activator, 379 patients with a history of smoking were examined, of which 181 received recombinant tissue plasminogen activator while 198 were excluded from receiving recombinant tissue plasminogen activator. Of the 198 patients, 75 females and 123 males were excluded from receiving recombinant tissue plasminogen activator. After multivariable adjustment for age, National Institutes of Health scores, and stroke-related factors, females who present with weakness/paresis on initial examination (OR = 0.117, 95% CI, 0.025-0.548) and men who present with a history of previous transient ischemic attack (OR = 0.169, 95% CI, 0.044-0.655), antiplatelet medication use (OR = 0.456, 95% CI, 0.230-0.906), and weakness/paresis on initial examination (OR = 0.171, 95% CI, 0.056-0.521) were less likely to be excluded from recombinant tissue plasminogen activator (thrombolysis therapy). CONCLUSIONS: In an ischemic stroke population with a history of smoking, female smokers are more likely to be excluded from thrombolysis therapy in comparison to men, even after adjustment for confounding variables.

Gender and thrombolysis therapy in acute ischemic stroke patients with incidence of obesity.

OBJECTIVE: To investigate clinical risk factors that were associated with gender differences in thrombolysis therapy in stroke patients with incidence of obesity. METHOD: Retrospective data of obese acute ischemic stroke patients were extracted from a stroke registry between January 2010 and June 2016. Gender differences in exclusion from rtPA or thrombolysis therapy were determined following an adjustment for differences in demographics, clinical risk factors using multiple regression analysis. Significant interactions between variables in the regression models were determined using variance inflation factors. RESULTS: A total of 1105 obese stroke patients were admitted, 549 were excluded from rtPA of which 51.7% were males and 48.3% were females. Among obese male stroke patients, age > 80 years (OR = 1.029, 95% CI, 1.005-1.054, P = 0.016), a history of peripheral vascular disease (OR = 3.008, 95% CI, 0.989-9.153, P = 0.052), and an elevated diastolic blood pressure (OR = 1.018, 95% CI, 1.001-1.035, P = 0.038) were associated with exclusion from rtPA therapy. In obese female stroke patients, coronary artery disease was associated with exclusion from rtPA (OR = 2.478, 95% CI, 1.270-4.836, P = 0.008) while antihypertensive therapy was associated with inclusion for rtPA (OR = 0.326, 95% CI, 0.139-0.764). CONCLUSION: Elderly obese male stroke patients with elevated diastolic blood pressure, history of peripheral vascular disease, and obese female stroke patients with a history of coronary artery disease were more likely to be excluded from rtPA.

Gender and thrombolysis therapy in stroke patients with incidence of dyslipidemia.

BACKGROUND: When untreated, dyslipidemia is a higher risk factor for stroke and stroke-related mortality in men than in women. However, when dyslipidemia is treated the risk reduction is the same, but men benefited from mortality reduction more than women. Whether there is a gender difference in exclusion criteria for the use of recombinant tissue plasminogen activator (rtPA) or thrombolysis therapy in an acute ischemic stroke subpopulation with dyslipidemia is yet to be investigated. METHOD: In a dyslipidemic stroke population obtained from a stroke registry, gender differences in exclusion risk factors were determined using clinical and demographic variables. Univariate analysis compared the recombinant tissue plasminogen activator (rtPA) group and the no rtPA group. Multiple regression analysis was used to determine demographic and clinical factors associated with inclusion and exclusion for rtPA in the total dyslipidemic stroke population and the subsets of the male and female population. The regression model was tested using the Hosmer-Lemeshow test, for the overall correct classification percentage. Significant interactions and multicollinearity between independent variables were examined using variance inflation factors. RESULTS: A total of 769 patients presented with acute ischemic stroke with incidence dyslipidemia; 325 received rtPA while 444 were excluded from rtPA. Of those excluded from rtPA, 54.30% were female and 45.72% were male. In an adjusted analysis, female patients with increased age (OR = 1.024, 95% CI, 1.001-1.047, P < 0.05), with a history of carotid artery stenosis (OR = 7.063, 95% CI, 1.506-33.134, P < 0.05), and previous stroke (OR = 1.978, 95% CI, 1.136-3.442, P < 0.05) were more likely to be excluded from rtPA. Male patients with atrial fibrillation (OR = 2.053, 95% CI, 1.059-3.978, P = 0.033), carotid artery stenosis (OR = 2.400, 95% CI, 1.062-5.424, P = 0.035), and previous stroke (OR = 1.785, 95% CI, 1.063-2.998, P = 0.028) were more likely to be excluded from rtPA. CONCLUSION: Although there are some similarities in the clinical risk factors for exclusion in both male and female stroke patients with incidence of dyslipidemia, there are differences as well. Elderly female stroke patients with incidence of dyslipidemia are more likely to be excluded from rtPA, even after adjustment for the effect of confounding variables. Further research should focus on how identified clinical risk factors can be targeted and managed to improve the use of rtPA in elderly female acute ischemic stroke population with incidence of dyslipidemia.

Predictors of thrombolysis in the telestroke and non telestroke settings for hypertensive acute ischemic stroke patients.

BACKGROUND: In acute ischemic stroke patients, telestroke technology provides sustainable approaches to improve the use of thrombolysis therapy. How this is achieved as it relates to inclusion or exclusion of clinical risk factors for thrombolysis is not fully understood. We investigated this in a population of hypertensive stroke patients. METHODS: Structured data from a regional stroke registry that contained telestroke and non telestroke patients with a primary diagnosis of acute ischemic stroke with history of hypertension were collected between January 2014 and June 2016. Clinical risk factors associated with inclusion or exclusion for recombinant tissue plasminogen activator (rtPA) in the telestroke and non telestroke were identified using multiple regression analysis. Associations between variables and rtPA in the regression models were determined using variance inflation factors while the fitness of each model was determined using the ROC curve to predict the power of each logistic regression model. RESULTS: The non telestroke admitted more patients (62% vs 38%), when compared with the telestroke. Although the telestroke admitted fewer patients, it excluded 11% and administered thrombolysis therapy to 89% of stroke patients with hypertension. In the non telestroke group, adjusted odd ratios showed significant associations of NIH stroke scale score (OR = 1.059, 95% CI, 1.025-1.093, P < 0.001) and coronary artery disease (OR = 2.003, 95% CI, 1.16-3.457, P = 0.013) with inclusion, while increasing age (OR = 0.979, 95% CI, 0.961-0.996, P = 0.017), higher INR (OR = 0.146, 95% CI, 0.032-0.665, P = 0.013), history of previous stroke (OR = 0.39, 95% CI, 0.223-0.68, P = 0.001), and renal insufficiency (OR = 0.153, 95% CI, 0.046-0.508, P = 0.002) were associated with rtPA exclusion. In the telestroke, only direct admission to the telestroke was associated with rtPA administration, (OR = 4.083, 95% CI, 1.322-12.611, P = 0.014). CONCLUSION: The direct admission of hypertensive stroke patients to the telestroke network was the only factor associated with inclusion for thrombolysis therapy even after adjustment for baseline variables. The telestroke technology provides less restrictive criteria for clinical risk factors associated with the inclusion of hypertensive stroke patients for thrombolysis.