Dual energy CT in the management of antiplatelet therapy in patients with acute ischemic stroke for carotid obstruction.

BACKGROUND AND PURPOSE: Acute tandem occlusions often require carotid stenting. Combination of mechanical and pharmacologic therapies in addition to antiplatelet drugs administered to prevent acute stent thrombosis might increase the risk of intracerebral hemorrhage. We present a protocol of antiplatelet regimen based on early post-procedural dual-energy CT (DE-CT). MATERIAL AND METHODS: Fifty consecutive stroke patients with tandem occlusions treated with acute carotid stenting after intracranial thrombectomy and TICI 2b/3 were reviewed. All patients received intravenous lysine acetylsalicylate during the procedure. Dual (aspirin+clopidogrel with or without clopidogrel load, groups A and B, respectively) or mono (aspirin) antiplatelet regimen (group C) was administered 12-24 h later according to brain DE-CT findings. Carotid ultrasonography was performed at 24 h and before discharge. We evaluated the rate of subsequent symptomatic intracranial hemorrhage (SICH) and acute stent thrombosis in each group. RESULTS: Between June 2014 and December 2016, 50 patients were included (mean age 66 years, 76% men, baseline NIHSS 16, median time from symptom onset to recanalization 266 min). According to DE-CT, 24 patients were assigned to group A, 19 to group B and 7 to group C (4 of them had SICH at that time). One patient suffered a subsequent SICH (belonging to group B). There was only one stent thrombosis without clinical repercussions in group B. CONCLUSIONS: DE-CT may contribute to select antiplatelet regimen after acute carotid stenting in tandem occlusions.

No Relationship Between Patent Foramen Ovale and Migraine Frequency.

BACKGROUND: Pathophysiology of migraine is not fully known. A link has been proposed between migraine and patent foramen ovale (PFO). However, there are conflicting data regarding the causal relationship between PFO and migraine. OBJECTIVE: To test a potential association between migraine frequency and PFO by way of an observational, single-center, case-controlled study. METHODS: We studied a total of 130 chronic migraine (CM) and 53 episodic migraine (EM) patients. Transcranial Doppler with agitated saline injection was used to evaluate the presence and degree of PFO. PFO was judged to be present if any signal was detected. The degree of PFO during rest and Valsalva was quantified as follows: small (1-10 microbubbles [MB]), medium (10-25 MB), or large (>25 MB with shower or curtain pattern). PFO detected at rest were considered permanent, while those detected during Valsalva maneuver were classified as latent. RESULTS: The prevalence of PFO was similar in CM and EM patients (53.1% [44.1-62.2] vs 54.7% [40.3-69.1], P = .871). PFO size was significantly larger in the EM group compared to the CM group (35.8% vs 20.3%, P = .037). The presence of permanent PFO was also significantly higher in EM compared to CM (37.7% vs 22.7%, P = .044). No differences were found according to the presence of aura. CONCLUSION: This study indicates that PFO is not more common or larger in CM than in EM patients. These findings do not support a relationship between PFO and migraine frequency.

Safety and Efficacy of Mechanical Thrombectomy in Acute Ischemic Stroke of Anticoagulated Patients-A Prospective Observational Study.

BACKGROUND: Anticoagulated patients (APs) are excluded from the acute stroke management with alteplase in Europe, not in the United States. They could benefit from mechanical thrombectomy (MT), which was not undoubtedly proven. There are scarce data about its results in such patients. The authors' aim is to analyze the efficacy and safety of MT in APs presenting with an acute stroke in our institution. METHODS: Prospective observational study comparing 30 APs and 109 non-anticoagulated patients (N-APs) underwent direct MT without alteplase. Demographic data, clinical severity (National Institutes of Health Stroke Scale [NIHSS]), efficacy (recanalization thrombolysis in cerebral infarction [TICI] ≥ 2b and modified Rankin Scale score ≤ 2 at 3 months), and security (symptomatic intracranial hemorrhage [SICH], mortality at 3 months) were compared between both groups. RESULTS: In both groups men were more frequent (63.3% of APs were men and 61.5% of N-APs were men). Mean age was 73 in APs and 67.2 in N-APs. Median NIHSS was similar (17 APs; 16 N-APs), also TICI greater than or equal to 2b (93.3% APs; 89.9% N-APs). The 3-month modified Rankin Scale score less than or equal to 2 was 46.7% in APs and 55.2% in N-APs (P = .40). SICH was present in 16.7% of APs and 8.3% of N-APs (P = .15). Mortality at 3 months was 6.7% in APs and 19% in N-APs (P = .08). CONCLUSIONS: MT is a valid treatment option in APs. It achieves an efficacy as in N-APs with a tendency to suffer more from SICH, but lower mortality. We hypothesize that cardioembolic clots may be easier to be removed than atherotrombotics, and that embolic stroke in APs might be less severe than that in N-APs or might suffer less of other complications than atherotrombotics.

Convexity subarachnoid haemorrhage secondary to internal carotid stenosis: an indication for revascularisation.

With increasing prevalence due to an ageing population, carotid artery stenosis is a significant cause of stroke morbidity and mortality. The indication for revascularisation treatment in symptomatic carotid stenosis is widely documented and accepted in the scientific community. However, treatment of asymptomatic carotid stenosis remains controversial. We report a case of a 78-year-old woman who was admitted with a convexity subarachnoid haemorrhage (cSAH) secondary to an asymptomatic high-grade carotid artery stenosis. Two months later, she suffered an atherothrombotic ischaemic stroke and was referred to surgery. Transcranial Doppler studies showed impaired cerebral vasoreactivity and, after endarterectomy, the patient developed a reperfusion syndrome; both findings consisting of exhausted collaterals as the underlying mechanism. We propose that cSAH secondary to a high-grade internal carotid artery stenosis is a high risk marker for stroke, and revascularisation therapy should be considered.

Analysis of endovascular treatment of ruptured microaneurysms compared with ruptured larger aneurysms.

OBJECTIVE: To retrospectively analyze the complications and outcome of the endovascular treatment of ruptured microaneurysms compared with the treatment of ruptured larger aneurysms. METHODS: 40 ruptured cerebral microaneurysms treated by endovascular techniques were selected retrospectively and compared with 207 larger ruptured cerebral aneurysms treated by endovascular techniques during the same time period. Medical charts and imaging studies were reviewed to analyze baseline clinical and epidemiologic characteristics, procedural complications, and clinical outcomes RESULTS: Cerebral microaneurysms had a higher incidence of intraoperative technical ruptures (13.5% vs 2.9%, p<0.005). The number of thromboembolic complications was not increased. Patient prognosis was similar for the two groups (mean modified Rankin Scale score 1.81 vs 2.09, p>0.1). CONCLUSIONS: Coiling of cerebral microaneurysms has a reasonable safety profile with good clinical outcomes, similar to coiling of larger aneurysms. In our experience, the systematic use of remodeling balloons, operator experience, and the ability to manage complications are the reasons for the satisfactory results.

OnabotulinumtoxinA decreases interictal CGRP plasma levels in patients with chronic migraine.

OnabotulinumtoxinA (onabotA) has shown efficacy in chronic migraine (CM). Its mechanism of action, however, remains obscure. We have analysed whether treatment with onabotA is able to induce changes in interictal plasma calcitonin gene-related peptide (CGRP) concentrations, which have been shown to be increased in patients with CM. Calcitonin gene-related peptide levels were determined in samples obtained from the right antecubital vein using ELISA, outside a migraine attack and having taken no symptomatic medication in the previous 24 hours, in 83 patients with CM (average age 44 years; 94% females) before and 1 month after treatment with 155 to 195 U of onabotA. CGRP levels after onabotA treatment (median, 51.89 pg/mL; range, 199.4-10.2) were significantly lower as compared with CGRP levels obtained before onabotA treatment (median, 74.09 pg/mL; range, 241.0-11.4; P = 0.001). Pretreatment CGRP levels in responders (76.85 pg/mL) were significantly higher than those seen in nonresponders (50.45 pg/mL; P = 0.001). One month after treatment, the CGRP levels did not change in nonresponders (51.89 pg/mL; P not significant), but significantly decreased in responders (52.48 pg/mL; P = 0.003). A number of demographic factors, clinical features, and comorbidities were not different in responders as compared with those of nonresponders. These results confirm that interictal CGRP levels can be of help in predicting the response to onabotA and suggest that the mechanism of action of onabotA in CM is the reversal of sensitization as a result of the inhibition of CGRP release.

Long-term experience with onabotulinumtoxinA in the treatment of chronic migraine: What happens after one year?

BACKGROUND: OnabotulinumtoxinA (onabotA) has shown its efficacy over placebo in chronic migraine (CM), but clinical trials lasted only up to one year. OBJECTIVE: The objective of this article is to analyse our experience with onabotA treatment of CM, paying special attention to what happens after one year. PATIENTS AND METHODS: We reviewed the charts of patients with CM on onabotA. Patients were injected quarterly during the first year but the fifth appointment was delayed to the fourth month to explore the need for further injections. RESULTS: We treated 132 CM patients (mean age 47 years; 119 women). A total of 108 (81.8%) showed response during the first year. Adverse events, always transient and mild-moderate, were seen in 19 (14.4%) patients during the first year; two showed frontotemporal muscle atrophy after being treated for more than five years. The mean number of treatments was 7.7 (limits 2-29). Among those 108 patients with treatment longer than one year, 49 (45.4%) worsened prior to the next treatment, which obliged us to return to quarterly injections and injections were stopped in 14: in 10 (9.3%) due to a lack of response and in four due to the disappearance of attacks. In responders, after an average of two years of treatment, consumption of any acute medication was reduced by 53% (62.5% in triptan overusers) and emergency visits decreased 61%. CONCLUSIONS: Our results confirm the long-term response to onabotA in three-quarters of CM patients. After one year, lack of response occurs in about one out of 10 patients and injections can be delayed, but not stopped, to four months in around 40% of patients. Except for local muscle atrophy in two cases treated more than five years, adverse events are comparable to those already described in short-term clinical trials.

Increased VIP levels in peripheral blood outside migraine attacks as a potential biomarker of cranial parasympathetic activation in chronic migraine.

AIM: The aim of this article is to determine vasoactive intestinal peptide (VIP) levels outside migraine attacks in peripheral blood as a potential biomarker for chronic migraine (CM). METHODS: Women older than 17 and diagnosed as CM were recruited. Matched healthy women with no headache history and women with episodic migraine (EM) served as control groups, together with a series of patients with episodic cluster headache in a pain-free period. VIP levels were determined in blood samples obtained from the right antecubital vein by ELISA outside a migraine attack, the patients having taken no symptomatic medication the day before. For ethical reasons, preventives were not stopped. RESULTS: We assessed plasma samples from 119 women with CM, 33 healthy women, 51 matched women with EM and 18 patients (16 males) with cluster headache matched for age. VIP levels were significantly increased in CM (165.1 pg/ml) as compared to control healthy women (88.5 pg/ml) and episodic cluster headache patients (101.1 pg/ml). VIP levels in EM (134.9 pg/ml) were significantly higher compared to controls and numerically lower than those of CM. Thresholds of 71.8 and 164.5 pg/ml optimized the sensitivity and specificity to differentiate CM from healthy controls and EM, respectively. Variables such as age, CM duration, the presence of aura, analgesic overuse, depression, fibromyalgia, vascular risk factors, history of triptan consumption or kind of preventive treatment did not significantly influence VIP levels. CONCLUSION: Increased interictal VIP level measured in peripheral blood could be a biomarker helping in CM diagnosis, though it does not clearly differentiate between EM and CM.

CGRP and VIP levels as predictors of efficacy of Onabotulinumtoxin type A in chronic migraine.

BACKGROUND: Onabotulinumtoxin type A (onabotA) has shown efficacy in chronic migraine (CM). Its precise mechanism of action, however, is unknown. OBJECTIVE: To analyze a potential relationship between calcitonin gene-related peptide (CGRP) and vasoactive intestinal peptide (VIP) levels and response to onabotA in CM. METHODS: Adult patients with CM were recruited. Matched healthy subjects with no headache history served as controls. CGRP and VIP levels were determined in samples obtained from the right antecubital vein by ELISA outside of a migraine attack and having taken no symptomatic medication prior to treatment with onabotA. OnabotA was administered according to the PREEMPT protocol every 12 weeks for at least two treatment cycles. A patient was considered as a moderate responder when both: (1) moderate-severe headache episodes were reduced by between 33 and 66%; (2) subjective benefit in a visual scale of 0-100 was recorded by the patient of between 33-66%. Patients were considered as excellent responders when both items improved >66%. Those without improvement of at least one-third in the two items were considered as nonresponders. RESULTS: We assessed plasma samples from 81 patients with CM and 33 healthy controls. CGRP and VIP levels were significantly increased in CM population vs controls. CGRP and, to a lesser degree, VIP levels were significantly increased in responders vs nonresponders. For CGRP, a threshold of 72 pg/mL positively correlated with 95% of nonresponders. The probability of being a responder to onabotA was 28 times higher in patients with a CGRP level above the threshold of 72 pg/mL. Even though the sensitivity for the calculated threshold for VIP was poor, the probability that CM patients with low CGRP levels will respond to onabotA was significantly higher in those patients with high VIP levels. CONCLUSIONS: Interictal CGRP and, to a lesser degree, VIP levels measured in peripheral blood are of great help in predicting response to onabotA.

Chronic migraine does not increase posterior circulation territory (PCT) infarct-like lesions.

UNLABELLED: Two population-based studies have found an increased prevalence of posterior circulation territory (PCT) infarct-like lesions in migraine, which seemed to increase with attack frequency. OBJECTIVE: To determine whether chronic migraine (CM) patients are at increased risk of PCT infarct-like lesions. METHODS: We prospectively obtained brain MRIs from adult women fulfilling CM criteria. To keep radiologists blinded we also obtained brain MRIs in 15 episodic migraine (EM) patients. MRIs were acquired on a 1.5 T unit. Protocol included whole brain weighted images in sagittal T1 (5 mm slices), axial FLAIR T2 (3 mm) and combined proton density and T2 fast spin echo (3 mm). Two independent neuroradiologists carefully analyzed all the images. RESULTS: One hundred women with CM participated. Their ages ranged from 18 to 68 years (mean 43.7) and the length of CM ranged from 0.5 to 38 years (mean 9.8). Sixty-three patients (63%) had at least one vascular risk factor. Thirty-three met analgesic overuse criteria. Fifty-one had a history of migraine with aura attacks, though aura frequency was below one per month in all patients except one. Eleven were not on preventatives. We found PCT infarct-like lesions in only 6 CM patients aged 42-64 years (mean age 54 years) who had at least two vascular risk factors. CONCLUSIONS: As frequency of PCT infarct-like lesions in our CM patients was in the low range than that found for EM in general population studies, we conclude that frequency of migraine attacks itself is not a factor increasing PCT infarct-like lesion risk.

Interictal increase of CGRP levels in peripheral blood as a biomarker for chronic migraine.

OBJECTIVE: To determine calcitonin gene-related peptide (CGRP) levels outside migraine attacks in peripheral blood as a potential biomarker for chronic migraine (CM). METHODS: Women older than 17 years and diagnosed with CM were recruited. Matched healthy women with no headache history and women with episodic migraine (EM) served as control groups, together with a series of patients with episodic cluster headache in a pain-free period. CGRP levels were determined in blood samples obtained from the right antecubital vein by ELISA outside a migraine attack and having taken no symptomatic medication the day before. For ethical reasons, preventatives were not stopped. RESULTS: We assessed plasma samples from 103 women with CM, 31 matched healthy women, 43 matched women with EM, and 14 patients with episodic cluster headache matched for age. CGRP levels were significantly increased in CM (74.90 pg/mL) as compared with control healthy women (33.74 pg/mL), women with EM (46.37 pg/mL), and patients with episodic cluster headache (45.87 pg/mL). Thresholds of 43.45 and 58.22 pg/mL optimize the sensitivity and specificity to differentiate CM from healthy controls and EM, respectively. In the CM group, CGRP levels were significantly increased in women with a history of migraine with aura vs those only experiencing migraine without aura. Variables such as age, analgesic overuse, depression, fibromyalgia, vascular risk factors, history of triptan consumption, or kind of preventative treatment did not significantly influence CGRP levels. CONCLUSION: Increased CGRP level measured in peripheral blood outside migraine attacks and in the absence of symptomatic medication could be a biomarker helping in the diagnosis of CM.

Long term evolution of patients treated in a TIA unit.

BACKGROUND: Transient ischemic attacks (TIA) entail a high risk of stroke recurrence, which depends on the etiology. New organizational models have been created, but there is not much information about the long-term evolution of patients managed according to these premises. Our aim is to refer the follow-up of patients attended according to our model of TIA Unit. METHODS: TIA Unit is located in the Emergency Department and staffed by vascular neurologists. Patients admitted during the Neurology night shift stayed in such Unit <48h with complete etiological study. Preventive treatment is instituted in patients discharged to a high resolution Neurology consult, in order to review in <2 weeks and subsequent follow-up. RESULTS: During a year 161 patients were attended, being admitted to the hospital 8.6%. A total of 1470 hospital days were avoided. Recurrence at 90 days was of 0.6%. Mean follow-up was 18.14 ± 8.02 months (0-34), total recurrence 6.2% (70% cardioembolic strokes). There were no complications derived from treatment. Cardiological events were recorded in 10.6%, neoplastic in 5%, cognitive impairment in 11%. There were 3 deaths unrelated nor to the stroke or its treatment. CONCLUSIONS: This model allows an early diagnosis and treatment of TIA, preventing recurrences of stroke in a long term. It detects atherothrombotic strokes, most of them admitted to the hospital, and it shows a greater difficulty for detecting all cardioembolic strokes. TIA Unit appeared to be safe in using anticoagulation therapy, as the follow-up shows. It shows the same quality of management than hospital admission, with a significant saving in hospital stays.

Fluctuating neurological symptoms in demyelinating disease mimicking an acute ischaemic stroke.

Fluctuating neurological symptoms in an older patient most often point towards a cerebral ischaemic pathology. The authors present a 66-year-old male patient suffering from a fluctuating right hemiparesis, with an initial diagnosis of ischaemic stroke. The brain and cervical MRI showed demyelinating lesions with abnormal cerebrospinal fluid (CSF) and visual evoked potentials and the patient was successfully treated with intravenous corticosteroids. Demyelinating disease in older patients could be more frequent than expected. It should be considered even in older patients with fluctuating neurological symptoms. MRI and CSF analysis are critical to provide an accurate diagnosis.

Sarcoidosis presenting as transient ischemic attack status.

We report a patient who experienced multiple transient ischemic attacks (TIAs) over a 3-month period as the presenting clinical manifestation of sarcoidosis. This previously healthy 27-year-old man was admitted due to several daily episodes of usually left hemiparesis and dysarthria lasting between 15 seconds and 3 minutes. He did not respond to aggressive antithrombotic treatment. Extensive investigations were negative except for a computed tomography body scan showing several small right hilar lymphoadenopathies, which were confirmed by abnormal 67-gallium scintigraphy and 18F-fluorodeoxyglucose positron emission tomography uptakes. The TIA episodes disappeared after the initiation of prednisone therapy. The lymphadenopathy specimens were biopsied via mediastinoscopy, and histological study revealed noncaseating epithelioid granulomatous inflammation consistent with sarcoidosis. Sarcoidosis should be considered in the differential diagnosis of stroke of unknown origin in any young patient, even in the absence of other clinical or laboratory features of sarcoidosis.