Reliability of Hand-Held Transcranial Doppler with M-mode Ultrasound in Middle Cerebral Artery Measurement.

PURPOSE: To determine the intra- and interrater agreement of mean flow velocity (MFV) and pulsatility index (PI) measurement in middle cerebral arteries, assessed by transcranial Doppler (TCD) with M-mode. METHODS: Masked experienced neurosonologists performed TCD with M-mode using handheld probe in healthy adult volunteers. The Bland-Altman method for concordance and intraclass correlation coefficient were used. RESULTS: Seventy-seven healthy volunteers and seven raters participated (3 on regular TCD shift and 4 off-shift). The intrarater absolute mean difference between measurements was 5.5 cm/s [95% confidence interval (CI), 4.7-6.3] for MVF and 0.073 (95% CI, 0.063-0.083) for PI. The difference between MFV measurements was significantly higher in off-shift raters (p = 0.015). The interrater absolute mean difference between measurements was 6.5 cm/s (95% CI, 5.5-7.5) for MVF and 0.065 (95% CI, 0.059-0.071) for PI. No influence was found for the middle cerebral artery side, volunteer's sex, or age, and there was no significant difference between raters. The intraclass correlation coefficient was 82.2% (95% CI 77.8-85.6) and 72.9% (95% CI 67.4-77.6) for MFV and PI, respectively. CONCLUSIONS: There exists good intra- and interrater agreement in MFV and PI measurements using M-mode TCD. These results support the use of this noninvasive tool and are important for clinical and investigational purposes.

Trombolisis intravenosa en cuadros imitadores de isquemia cerebral: experiencia de un centro / Thrombolysis in stroke mimics: experience in 10 cases

Background: The effectiveness of intravenous thrombolysis (IVT) in cerebral ischemia is time dependent. Stroke mimics (SM) are frequent in emergency rooms. The effort to reduce door to needle time, can lead to administer thrombolytics to SM. Aim: To describe the frequency and prognosis of SM treated with IVT. Material and Methods: Prospective analysis of all patients evaluated in a Chilean private clinic between December 2004 and July 2015 with a suspected acute ischemic stroke (AIS). We calculated the number of SM that were treated with IVT. In these patients, we analyzed the presence of symptomatic cerebral hemorrhage defined as the presence of a neurological deterioration of four points or more on the National Institute of Health Stroke Scale, the presence of extracranial bleeding according to Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries criteria and the patient’s functional status at three months by modified Rankin scale (MRS). Results: We evaluated 1,417 patients with suspected AIS, of which 240 (16.9%) were finally diagnosed as SM. A total of 197 patients were treated with IVT, of these 10 (5%) corresponded to SM. All SM patients treated with thrombolytic drugs were functionally independent at 3 months and showed no bleeding complications. Conclusions: Occasionally SM patients were treated with IVT. This treatment was not associated with bleeding complications and the prognosis of these patients at three months was favorable.

Intraventricular Bleeding and Hematoma Size as Predictors of Infection Development in Intracerebral Hemorrhage: A Prospective Cohort Study.

BACKGROUND: Acute intracerebral hemorrhage (ICH) is associated with increased susceptibility to bacterial infection. The physiopathology of this phenomenon is not very clear. We conducted a prospective observational study investigating the correlation and independent predictors of infections in patients with ICH. PATIENTS AND METHODS: Patients admitted between April 1997 and June 2013 with ICH diagnosis were evaluated for inclusion and exclusion criteria. RESULTS: Two hundred twenty-two patients were included in this study. Ninety four patients (42.6%) presented with an infection during hospitalization being more common than pneumonia (30%) and urinary tract infections (14%). Intraventricular hemorrhage (IVH) (95% confidence interval [CI], 62.7% versus 39.3%; P < .001) and higher ICH score (95% CI, 2.31% versus 1.67%; P = .0014) were more common in patients who had infections. We found the following risk factors for having an infection in patients with ICH: IVH (odds ratio [OR] 2.3; 95% IC, 1.3-4.1), each point of ICH score (OR 1.3; 95% CI, 1.1-1.6), and having a hematoma volume larger than 30 cc (OR 2.0; 95% CI, 1.1-3.5). The localization of the hematoma was not found to be relevant. CONCLUSIONS: ICH score, size of the hematoma, and presence of IVH are independent risk factors for having an infection after ICH.

[Thrombolysis in stroke mimics: Experience in 10 cases]. / Trombolisis intravenosa en cuadros imitadores de isquemia cerebral: experiencia de un centro.

BACKGROUND: The effectiveness of intravenous thrombolysis (IVT) in cerebral ischemia is time dependent. Stroke mimics (SM) are frequent in emergency rooms. The effort to reduce door to needle time, can lead to administer thrombolytics to SM. AIM: To describe the frequency and prognosis of SM treated with IVT. MATERIAL AND METHODS: Prospective analysis of all patients evaluated in a Chilean private clinic between December 2004 and July 2015 with a suspected acute ischemic stroke (AIS). We calculated the number of SM that were treated with IVT. In these patients, we analyzed the presence of symptomatic cerebral hemorrhage defined as the presence of a neurological deterioration of four points or more on the National Institute of Health Stroke Scale, the presence of extracranial bleeding according to Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries criteria and the patient's functional status at three months by modified Rankin scale (MRS). RESULTS: We evaluated 1,417 patients with suspected AIS, of which 240 (16.9%) were finally diagnosed as SM. A total of 197 patients were treated with IVT, of these 10 (5%) corresponded to SM. All SM patients treated with thrombolytic drugs were functionally independent at 3 months and showed no bleeding complications. CONCLUSIONS: Occasionally SM patients were treated with IVT. This treatment was not associated with bleeding complications and the prognosis of these patients at three months was favorable.

Multiple myxomatous aneurysms with bypass and clipping in a 37-year-old man.

BACKGROUND: Cardiac myxoma is the most common cardiac tumor. Neurologic complications are seen in 20%-35%, most frequently embolic ischemic stroke, and rarely secondary to intracranial aneurysms. The mechanism of aneurysm formation in these patients is speculative. METHODS: We report, herein, a 37-year-old male with a cardiac myxoma who experienced repeated ischemic stroke and intracerebral hematoma despite resection of heart tumor, secondary to multiple cerebral aneurysm. RESULTS: We offered him surgery with a bypass and clipping, because growing of aneurysm was not suitable for endovascular treatment. CONCLUSION: Bypass and clipping are possible options in this type of disease. Aneurysm biopsy supports mycotic theory of aneurysm formation.

Accuracy of diffusion-weighted imaging in the diagnosis of stroke in patients with suspected cerebral infarct.

BACKGROUND AND PURPOSE: The accuracy of diffusion-weighted imaging (DWI) for the diagnosis of acute cerebral ischemia among patients with suspected ischemic stroke arriving to an emergency room has not been studied in depth. METHODS: DWI was performed in 712 patients with acute or subacute focal symptoms that suggested an acute ischemic stroke (AIS), 609 of them with AIS. RESULTS: DWI demonstrated a sensitivity of 90% and specificity of 97%, a positive likelihood ratio of 31 and a negative likelihood ratio of 0.1 for detecting AIS. The overall accuracy was 95%. Of those patients who demonstrated abnormal DWI studies, 99.5% were AIS patients, and of those patients with normal DWI studies 63% were stroke mimics. CONCLUSIONS: DWI is accurate in detecting AIS in unselected patients with suspected AIS; a negative study should alert for nonischemic conditions.

Exclusion criteria for intravenous thrombolysis in stroke mimics: an observational study.

BACKGROUND: Stroke mimics (SMs) are frequent in emergency departments (EDs), but are treated infrequently with intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis. We aimed at identifying the factors that lead to the exclusion of SMs from thrombolytic therapy. METHODS: Consecutive patients presenting to the ED between December 2004 and March 2011 with symptoms that suggested acute ischemic stroke were included. RESULTS: Eight hundred forty-two patients were included in this study; 113 (13.4%) were considered SMs; these patients were younger (P = .01), more frequently diabetic (P = .001), arrived later to the ED (P = .03), had lower National Institutes of Health Stroke Scale scores (P < .001), and higher frequencies of negative diffusion-weighted imaging studies (P = .002). The most common causes of cases of SM were toxic metabolic disorders (n = 34 [30.1%]) and seizures (n = 22 [19.5%]). The most frequent cause of consultation was aphasia (n = 43 [37.6%]). SM patients had a total of 152 contraindications for rt-PA, with 34 (30%) patients having >1 contraindication. The most frequent of these were being beyond the therapeutic window for thrombolysis (n = 96) and having deficits not measurable by the National Institutes of Health Stroke Scale or very mild symptoms before the start of rt-PA (n = 37). Twenty-four (21.2%) patients had both contraindications simultaneously. Two patients (1.76%) in the SM group were candidates for rt-PA but did not receive this treatment because they or their family rejected it. Of 729 stroke patients, 87 (11.9%) did receive rt-PA. CONCLUSIONS: SM patients frequently had exclusion criteria for systemic thrombolysis, the most frequent being presenting beyond the established thrombolytic window.

Prognosis of cryptogenic ischemic stroke: a prospective single-center study in Chile.

Approximately 25%-40% of ischemic strokes are considered of unknown cause (ie, cryptogenic). The available information on associated risk factors, functional outcome, and recurrence of this subtype of stroke is limited, especially for the Chilean population. We conducted a prospective cohort study of 380 patients aged ≥ 18 years admitted consecutively to a stroke unit with demonstrated ischemic stroke. The stroke subtypes were classified according to the Trial of Org 10172 in Acute Stroke Treatment criteria. The modified Rankin Scale score and Barthel Index were used to assess functional outcome. The Kaplan-Meier product-limit method and Cox proportional hazards regression analysis were used to identify predictors of recurrent stroke during the follow-up period (mean, 2.1 years). Cryptogenic stroke (CS) was diagnosed in 76 patients (20%), 55.2% of them male, with a mean age of 62 ± 17 years. CS was the third most common stroke subtype after the large-artery disease (29%) and cardioembolic (24.4%) subtypes. After adjustment for age and sex, no vascular risk factors or laboratory parameters assessed at the time of admission were found to be predictive of CS. The CS subtype had the lowest rate of stroke recurrence at the end of the follow-up period (n = 4; 2.5% per year; odds ratio, 0.32; 95% confidence interval, 0.11-0.91; P = .022), a favorable functional outcome (mean modified Rankin Scale score, 2; mean Barthel Index, 77), and no increase in mortality risk (odds ratio, 0.73; 95% confidence interval, 0.29-1.77; P = .48). Our findings demonstrate that patients with no definite etiology identified after an extensive workup are at lower risk of recurrence and more likely to have a favorable outcome. No risk factors distinguish CS from other stroke subtypes in our study population.

Impacto de intervención temprana a cuidadores de pacientes secuelados de un accidente cerebrovascular: estudio piloto / Impact of early intervention for stroke caregivers: a pilot study

Introducción: Los cuidadores de personas secueladas de un Accidente Cerebro Vascular (ACV), perciben que durante los primeros meses carecen de la información necesaria sobre el proceso de su familiar, afectando sobre su estado afectivo y percepción de estrés. Objetivo: Evaluar la intervención realizada a cuidadores de pacientes secuelados de un ACV como factor protector en el estado afectivo y de carga en los cuidadores. Sujetos y métodos: Se reclutaron cuidadores directos, de personas con secuelas de ACV, según Escala de Rankin durante el período hospitalario. Se realizo un taller teórico práctico, consistentes en 4 sesiones; 3 durante el periodo hospitalario del usuario y 1 dentro del primer mes posterior al alta, los temas tratados eran organización y distribución de la rutina, integración de rutinas de tiempo libre y relajación y manejo del paciente en el hogar. Se evalúo a los cuidadores con escalas diagnósticas de carga emocional (Zarit, Indice de Esfuerzo del Cuidador) y ansiedad (Goldberg). Resultados: Luego del taller hubo una reducción significativa de 20 por ciento en el número de cuidadores con depresión (p=0,036) y 37 por ciento en el número de cuidadores con ansiedad (p=0,034.). Asimismo hubo una disminución significativa en el puntaje de sobrecarga emocional del cuidador medido mediante la escala de Zarit (p = 0,044). Conclusiones: La intervención evaluada en el presente estudio piloto parece ser una medida que contribuye en disminuir la sobrecarga emocional y ansiedad del cuidador.

Background: Caregivers of ischemic stoke damaged patients feels during the first months after the event a lack of information on how to help their relative, affecting the sense of stress and anxiety. We made an intervention to caregivers of the stroke unit of the University of Chile Hospital, in 2008.Objective: Determine whether the intervention to caregivers of stroke damaged patients is a protective factor in their emotional state and stress on caregivers. Subjects and methods: Direct healthy caregivers were recruited with a severe impaired family member within the hospitalization period. Intervention was conducted in 4 sessions, 3 during the hospital period and 1 in his home within the first month after discharge, where the issues discussed with caregiver was self-care and patient management. To measure the intervention we evaluated before the workshop and 2 months after the last session with some standardized tests (Zarit, Caregiver Stress Index) and anxiety (Goldberg). Results: After the intervention there was a significant 20 percent reduction in the number of caregivers with depression (p=0.036) and 37percent in the number of caregivers with anxiety (p=0.034.). There was also a significant decrease in the score of caregiver's emotional overload measured by the Zarit scale (p=0.044). Conclusions: The intervention evaluated in this pilot study appears to be an effective measure in reducing the emotional overload and anxiety of the caregiver, with an evident improvement in their mood.

Comparison of humoral neuroinflammation and adhesion molecule expression in two models of experimental intracerebral hemorrhage.

BACKGROUND: Inflammatory cascades contribute to secondary injury after intracerebral hemorrhage (ICH) via humoral factors and cell-mediated cytotoxicity. Several experimental models were previously developed to analyze post-hemorrhagic neuroinflammation. However, neuroinflammatory markers have not been compared face-to-face between these models so far, and therefore, pathophysiological conclusions drawn from only one individual model may not be valid. METHODS: We compared neuroinflammatory pathways in the two most common murine models: striatal injection of autologous blood or collagenase. Expression of pro- and anti-inflammatory cytokines (IL-1, TNF-α, IFN-γ, IL-6, TGF-ß and IL-10) as well adhesion molecule expression (VCAM-1, ICAM-1) was analyzed by RT-PCR at several time points after ICH induction. Outcome and physiological parameters were compared between the models. RESULTS: Both models induced a profound and dynamic increase in the expression of pro-inflammatory cytokines and adhesion molecules. However, blood injection resulted in significantly more pronounced alteration of these markers than collagenase injection. This difference was associated with worse outcome after blood injection compared to the collagenase model despite equal ICH volumes. CONCLUSIONS: This is the first study performing a face-to-face comparison of neuroinflammatory pathways in the two most widely used murine ICH models, revealing substantial differences between the models. This discrepancies need to be taken into account in designing future studies employing experimental ICH models, especially when analyzing neuroinflammatory pathways and therapies.

Hemostatic therapy in experimental intracerebral hemorrhage associated with the direct thrombin inhibitor dabigatran.

BACKGROUND AND PURPOSE: Dabigatran-etexilate (DE) recently has been approved for stroke prevention in atrial fibrillation. However, lack of effective antagonists represents a major concern in the event of intracerebral hemorrhage (ICH). The aims of the present study were to establish a murine model of ICH associated with dabigatran, and to test the efficacy of different hemostatic factors in preventing hematoma growth. METHODS: In C57BL/6 mice receiving DE (4.5 or 9.0 mg/kg), in vivo and in vitro coagulation assays and dabigatran plasma levels were measured repeatedly. Thirty minutes after inducing ICH by striatal collagenase injection, mice received an intravenous injection of saline, prothrombin complex concentrate (PCC; 100 U/kg), murine fresh-frozen plasma (200 µL), or recombinant human factor VIIa (8.0 mg/kg). ICH volume was quantified on brain cryosections 24 hours later. RESULTS: DE substantially prolonged tail vein bleeding time and ecarin clotting time for 4 hours corresponding to dabigatran plasma levels. Intracerebral hematoma expansion was observed mainly during the first 3 hours on serial T2* MRI. Anticoagulation with high doses of DE increased the hematoma volume significantly. PCC and, less consistently, fresh-frozen plasma prevented excess hematoma expansion caused by DE, whereas recombinant human factor VIIa was ineffective. Prevention of hematoma growth and reversal of tail vein bleeding time by PCC were dose-dependent. CONCLUSIONS: The study provides strong evidence that PCC and, less consistently, fresh-frozen plasma prevent excess intracerebral hematoma expansion in a murine ICH model associated with dabigatran. The efficacy and safety of this strategy must be further evaluated in clinical studies.

Hematoma size as major modulator of the cellular immune system after experimental intracerebral hemorrhage.

Inflammatory cascades are increasingly recognized as an important pathophysiological mechanism in intracerebral hemorrhage (ICH). In contrast, the effect of ICH on the systemic immune system has barely been investigated. We examined the effects of different hematoma volumes on immune cell subpopulations in experimental murine ICH. In C57BL/6 mice, ICH was induced by striatal injection of autologous blood (10, 30 or 50 µL). Control animals received the respective sham operation. Three days after ICH induction, differential blood leukocyte counting was performed. Lymphocyte subpopulations were further characterized by flow cytometry in blood, spleen, lymph node and thymus. Infectious complications were studied using microbiological cultures of blood and lungs. Only after large ICH a marked decrease of leukocyte counts and most lymphocyte subsets was observed in all organs. Despite this general leukocytopenia, a significant, up to 10-fold increase, was detected in the monocyte population after extensive hemorrhage. After moderate ICH induction, only specific lymphocyte subpopulations were differentially affected. Mature thymic cells were unaffected while immature CD4+CD8+ cells were depleted by over 90% after large ICH. A significant proportion of mice with extensive ICH (36.4%) developed spontaneous pneumonia and/or bacteremia while none of the sham operated mice had infectious complications. The ICH size determines the extent of systemic immunomodulation. Large ICH predisposes animals to infections.

Comparative effectiveness of hemostatic therapy in experimental warfarin-associated intracerebral hemorrhage.

BACKGROUND AND PURPOSE: intracerebral hemorrhage associated with oral anticoagulants has a poor prognosis. Current treatment guidelines are based on case series and plausibility only, and a common consensus on effective hemostatic therapy is missing. We compared the effectiveness of diverse hemostatic approaches in a mouse model of warfarin-associated intracerebral hemorrhage. METHODS: male C57BL/6 mice received anticoagulant treatment with warfarin (0.4 mg/kg for 3 days). Intracerebral hemorrhage was induced by striatal injection of collagenase, and 30 minutes later, mice received an intravenous injection of saline (200 µL n=15), prothrombin complex concentrate (100 U/kg, n=10), fresh-frozen plasma (200 µL, n=13), recombinant human Factor VII activated (3.5 mg/kg, n=8 and 10 mg/kg, n=8), or tranhexamic acid (400 mg/kg, n=12). Intracerebral hemorrhage volume was quantified on T2-weighted images after 24 hours. RESULTS: mean hematoma volumes were 7.4 ± 1.8 mm(3) in the nonwarfarin controls and 21.9 ± 5.0 mm(3) in the warfarin group receiving saline. Prothrombin complex concentrate (7.5 ± 2.3 mm(3)) and fresh-frozen plasma (8.7 ± 2.1) treatment resulted in significantly smaller hematoma volume compared with saline. Recombinant human Factor VII activated (10 mg/kg: 14.7 ± 3.4; 3.5 mg/kg: 15.0 ± 6.8 mm(3)) and tranexamic acid (16.2 ± 4.1 mm(3)) were less effective. Water content in the hemorrhagic hemisphere was similar in all groups except for tranexamic acid in which it was significantly increased. CONCLUSIONS: prothrombin complex concentrate and fresh-frozen plasma effectively prevent hematoma growth in murine warfarin-associated intracerebral hemorrhage, whereas Factor VIIa was less effective. Tranexamic acid exacerbates perihematoma edema in this mouse warfarin-associated intracerebral hemorrhage model.

Ischemic stroke as the first manifestation of severe ventricular hypertrabeculation/non-compaction.

A rare congenital myocardial defect, known as left ventricular hypertrabeculation/non-compaction (LVHT), has been occasionally described associated with thrombus formation with a potential systemic embolic risk, but its association with ischemic strokes remains controversial. We report a case of ischemic stroke in a patient with severe LVHT and ventricular dysfunction as a possible etiologic synergistic association. In absence of other embolic sources, a severe LVTH associated with ventricular dysfunction could constitute a potential source of brain embolism, especially in patients with high suspicion of an embolic mechanism of ischemic stroke.

Derrame isquêmico como a primeira manifestação de hipertrabeculação/não-compactação ventricular grave / Ischemic stroke as the first manifestation of severe ventricular hypertrabeculation/non-compaction

Um raro defeito congênito do miocárdio, conhecido como hipertrabeculação/não-compactação do ventrículo esquerdo (HTVE/NCVE) tem sido ocasionalmente descrito em associação com a formação de trombos com um potencial risco embólico sistêmico, mas sua associação com derrames isquêmicos permanece controversa. Reportamos o caso de um derrame isquêmico em paciente com grave (HTVE/NCVE) e disfunção ventricular como uma possível associação sinérgica etiológica. Na ausência de outras fontes embólicas, uma grave HTVE/NCVE associada com disfunção ventricular poderia constituir uma fonte potencial de embolismo cerebral, especialmente em pacientes com alta suspeita de um mecanismo embólico de derrame sistêmico.

A rare congenital myocardial defect, known as left ventricular hypertrabeculation/non-compaction (LVHT), has been occasionally described associated with thrombus formation with a potential systemic embolic risk, but its association with ischemic strokes remains controversial. We report a case of ischemic stroke in a patient with severe LVHT and ventricular dysfunction as a possible etiologic synergistic association. In absence of other embolic sources, a severe LVTH associated with ventricular dysfunction could constitute a potential source of brain embolism, especially in patients with high suspicion of an embolic mechanism of ischemic stroke.

Kinetics of hematoma expansion in murine warfarin-associated intracerebral hemorrhage.

BACKGROUND AND PURPOSE: The burden of intracerebral hemorrhage associated with oral anticoagulants (OAC-ICH) is growing. However, little is known about the pathophysiology of W-ICH. Herein, we refine a mouse model of OAC-ICH using repetitive T2* MRI to describe kinetics of hematoma enlargement, and establish a benchside point of care INR assay (PoC) for assessment of anticoagulation. METHODS: C57/BL6 mice drank warfarin (0.4mg/kg/24h) in their water. ICH was induced by stereotactic injection of collagenase type VII (0.045U) into the left striatum. Hemorrhagic blood volume was quantified by MRI T2* images and on cryosections 48h after ICH induction. Kinetics of hematoma expansion were compared in strongly, moderately, and non-anticoagulated mice using repeated MRI T2* imaging. The PoC INR technique was validated against standard laboratory INR, and tail vein bleeding time (TVBT). RESULTS: PoC INR correlated with central laboratory measurements (r=0.989; p<0.0001) and with TVBT (r=0.982; p<0.0001). Hematoma volume was 21.2+/-6.7mm(3) in heavily (PoC INR 4-5), 12.3+/-4.8 in moderately (INR 2-3), and 8.6+/-3.3 in non-anticoagulated mice (INR<1.2). Hematoma volume determined from cryosections and T2* MRI correlated well (r=0.922). Strength of anticoagulation was associated with neurologic outcome. Hematoma enlargement occurred mainly during the first 3h in anticoagulated mice. CONCLUSIONS: PoC allows repeated benchside INR measurements in individual mice which reflect the level of anticoagulation. Stronger anticoagulation results in larger hematoma volumes. As hematoma enlargement occurs mainly during the first hours, potential hemostatic therapies should be tested early in this OAC-ICH model.

Acute pontine infarct in a 16-year-old man with acute posterior multifocal placoid pigment epitheliopathy. A case report.

A 16-year-old boy recently diagnosed with acute posterior multifocal placoid pigment epitheliopathy (APMPPE) developed an acute infarct in the left pontine region. No relevant abnormalities were found in the brain and cervical angiography, echocardiography, cerebrospinal fluid, and blood samples. Funduscopically, lesions were multiple circumscribed, creamy yellow patches, flat lesions at the level of the retinal pigment epithelium, and the fluorescence angiography confirmed an APMPPE. All visual and neurological symptoms reverted completely after use of steroid. Our patient is the youngest patient with APMPPE and stroke described so far, being the common age presentation between 20 to 40 years.

[Thrombolysis for stroke in a 93-year-old female: report of a case]. / Trombolisis cerebral en el adulto mayor: Caso clínico.

Most studies evaluating the usefulness of intravenous thrombolysis for acute stroke have excluded subjects aged over 80 years. Therefore there is no evidence to support or contraindícate this therapy in this age group. We report a 93 year-old female subjected to intravenous thrombolysis using tissue plasminogen activator (r-tPA), according to the National Institute of Neurological Disorders protocol. The treatment was successful, there were no hemorrhagic complications and three months later, the patient was practically without any disability. Therefore age is not an absolute contraindication for intravenous thrombolysis in elderly subjects.

Trombolisis cerebral en el adulto mayor: Caso clínico / Thrombolysis for stroke in 93 years old female: Report of one case

Most studies evaluating the usefulness of intravenous thrombolysis for acute stroke have excluded subjects aged over 80 years. Therefore there is no evidence to support or contraindícate this therapy in this age group. We report a 93 year-old female subjected to intravenous thrombolysis using tissue plasminogen activator (r-tPA), according to the National Institute of Neurological Disorders protocol. The treatment was successful, there were no hemorrhagic complications and three months later, the patient was practically without any disability. Therefore age is not an absolute contraindication for intravenous thrombolysis in elderly subjects.

Is hypothermia useful in malignant ischemic stroke? Current status and future perspectives.

BACKGROUND AND AIMS: In acute stroke patients, mild and moderate hypothermia with a body temperature (T core) target of 32 degrees C to 34 degrees C is being tested and has shown some promising results. The feasibility of MH to control of ICP increases in patients with malignant ischemic stroke has been proven, but controversy as to its effectiveness and safety still continues. The most recent results of clinical trials and possible future applications of MH in acute stroke patients are analyzed in this review. DESIGN, METHODS AND MATERIAL: A search in MEDLINE/PubMed was performed. The references of selected articles were investigated and the Cochrane Library searched. Articles including severe, massive, malignant or hemispheric ischemic stroke, induced hypothermia, and animal studies with focal cerebral or brain ischemic models were considered. RESULTS: 196 patients with ischemic stroke treated with hypothermia have been reported in eleven small clinical studies, with a mild benefit of MH over the mortality rate and final outcome. CONCLUSIONS: Moderate hypothermia ameliorates ischemic injury by multiple mechanisms. Treatment of acute ischemic stroke patients is feasible, and additional studies, including randomized clinical trials, are warranted.