Intravenous thrombolysis and mechanical recanalization for acute ischemic stroke in deep brain stimulation patients: a case series.

BACKGROUND: Intravenous thrombolysis (IVT) and endovascular mechanical thrombectomy therapy (MT) are well established in the treatment of acute ischemic stroke. It is currently unclear whether these treatments can be applied in patients with previous deep brain stimulation (DBS) surgery and how long the interval to the DBS operation should be. METHODS: Four patients with ischemic stroke and IVT or MT were included in this retrospective case series. Data on demographics, genesis, severity and course of the stroke and the DBS indication were extracted and evaluated. Furthermore, a literature review was conducted. Outcomes and hemorrhagic complications after IVT, MT or intra-arterial thrombolysis in patients with prior deep brain stimulation surgery and intracranial surgery were analyzed. RESULTS: Four patients with acute ischaemic stroke and previous DBS surgery were treated with IVT (2 patients), MT (1) or a combined therapy of IVT and MT (1). The time interval to the previous DBS surgery was between 6 and 135 months. In these four patients, no bleeding complications occurred. The literature review revealed four publications with a total of 18 patients, who were treated with IVT, MT or intra-arterial thrombolysis. Of these 18 patients, only 1 had undergone deep brain stimulation surgery, the other 17 patients had received brain surgery for other reasons. Bleeding complications occurred in four of the 18 reported patients, but not in the DBS case. All four patients with bleeding complications were reported to have died as a result. In three of the four patients with fatal outcome, surgery was less than 90 days before the onset of stroke. CONCLUSION: IVT and MT were tolerated by four patients with ischemic stroke more than 6 months after DBS surgery without bleeding complications.

S2k guideline for diving accidents.

For the purposes of this guideline, a diving accident is defined as an event that is either potentially life-threatening or hazardous to health as a result of a reduction in ambient pressure while diving or in other hyperbaric atmospheres with and without diving equipment. This national consensus-based guideline (development grade S2k) presents the current state of knowledge and recommendations on the diagnosis and treatment of diving accident victims. The treatment of a breath-hold diver as well as children and adolescents does not differ in principle. In this regard only unusual tiredness and itching without visible skin changes are mild symptoms. The key action statements: on-site 100% oxygen first aid treatment, immobilization/no unnecessary movement, fluid administration and telephone consultation with a diving medicine specialist are recommended. Hyperbaric oxygen therapy (HBOT) remains unchanged as the established treatment in severe cases, as there are no therapeutic alternatives. The basic treatment scheme recommended for diving accidents is hyperbaric oxygenation at 280 kPa.

Impact of leukoaraiosis or blood pressure on clinical outcome, mortality and symptomatic intracerebral hemorrhage after mechanical thrombectomy in acute ischemic stroke.

We aimed to study the impact of leukoaraiosis (LA) and blood pressure (BP) on clinical outcome, mortality and symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). We analyzed data retrospectively from 521 patients with anterior large vessel occlusion treated with MT. LA was dichotomized in 0-2 (absent-to-moderate) versus 3-4 (moderate-to-severe) according to the van Swieten scale. Various systolic (SBP) and diastolic (DBP) BP parameters during the first 24 h were collected. Multivariable logistic regressions were performed to identify predictors of a poor 90-day outcome, mortality and sICH. LA was significantly associated with poor outcome (OR 3.2; p < 0.001) and mortality (OR 3.19; p = 0.008), but not sICH (p = 0.19). Higher maximum SBP was significantly associated with poor outcome (OR per 10 mmHg increase = 1.21; p = 0.009) and lower mean DBP was a predictor of mortality (OR per 10 mmHg increase = 0.53; p < 0.001). In the univariate analysis high SBP variability was associated with poor outcome, mortality and sICH, but not in the multivariate model. There was no association between BP and sICH. Severity of LA, SBP variability, high maximum SBP and low DBP are associated with either poor outcome or mortality in AIS patients undergoing MT. However, neither LA nor BP were associated with sICH in our cohort. Thus, mechanisms of the negative impact on outcome remain unclear. Further studies on impact of BP course and its mechanisms and interventions are needed to improve outcome in patients undergoing MT.

Thrombus Density in Acute Basilar Artery Occlusion Depends on Slice Thickness and the Method of Manual Thrombus Delineation.

Introduction: High thrombus attenuation on CT has been suggested as a predictor of successful recanalization. It is as well speculated that thrombi of different density may be susceptible to different methods of mechanical thrombectomy. In this study we sought to determine the effect of different methods of manual thrombus delineation and reconstructed slice thickness on thrombus density. Material and Methods: Fifty-six patients with acute occlusion of the basilar artery treated with endovascular therapy were retrospectively included. Clinical, demographic, radiological and outcome parameters were collected. Two raters measured absolute and relative thrombus density employing three different methods (one region of interest, three regions of interest, whole thrombus delineation) and using three different reconstructed slice thicknesses (0.625, 2.5 and 5 mm) of the original admission CT. Results: Thirty-nine patients were successfully recanalized (thrombolysis in cerebral infarction score ≥ 2b). Good clinical outcome (modified Rankin scale ≤ 2) occurred significantly more often in the recanalized group (36 vs. 6%, p = 0.023, Fisher's exact test), in the non-recanalized group symptomatic intracranial hemorrhage occurred more often (9 vs. 29%, p = 0.001, Fisher's exact test). Absolute and relative thrombus density were largely different between methods and slice thicknesses. Multiple regression showed a decrease of thrombus density with increasing slice thickness (ß = −3.98, p < 0.001) and logistic regression showed a statistically significant but very small relation between density and recanalization (ß = 0.006, odds ratio (95% confidence interval) = 1.006 (1.003−1.01), p < 0.001). Conclusions: The methods for manual thrombus delineation and reconstructed slice thickness had a significant influence on absolute and relative thrombus density. Density alone may be of limited value as a predictive marker for recanalization success in acute occlusion of the basilar artery. Standards for density measurements must be defined when comparing different studies and when evaluating different methods of mechanical thrombectomy.

Delirium on stroke units: a prospective, multicentric quality-improvement project.

BACKGROUND: Post-stroke delirium (POD) in patients on stroke units (SU) is associated with an increased risk for complications and poorer clinical outcome. The objective was to reduce the severity of POD by implementing an interprofessional delirium-management. METHODS: Multicentric quality-improvement project on five SU implementing a delirium-management with pre/post-comparison. Primary outcome was severity of POD, assessed with the Nursing Delirium Screening Scale (Nu-DESC). Secondary outcome parameters were POD incidence, duration, modified Rankin Scale (mRS), length of stay in SU and hospital, mortality, and others. RESULTS: Out of a total of 799 patients, 59.4% (n = 475) could be included with 9.5% (n = 45) being delirious. Implementation of a delirium-management led to reduced POD severity; Nu-DESC median: pre: 3.5 (interquartile range 2.6-4.7) vs. post 3.0 (2.2-4.0), albeit not significant (p = 0.154). Other outcome parameters were not meaningful different. In the post-period, delirium-management could be delivered to 75% (n = 18) of delirious patients, and only 24 (53.3%) of delirious patients required pharmacological treatments. Patients with a more severe stroke and POD remained on their disability levels, compared to similar affected, non-delirious patients who improved. CONCLUSIONS: Implementation of delirium-management on SU is feasible and can be delivered to most patients, but with limited effects. Nursing interventions as first choice could be delivered to the majority of patients, and only the half required pharmacological treatments. Delirium-management may lead to reduced severity of POD but had only partial effects on duration of POD or length of stay. POD hampers rehabilitation, especially in patients with more severe stroke. REGISTRY: DRKS, DRKS00021436. Registered 04/17/2020, www.drks.de/DRKS00021436 .

[Pitfalls in the diagnosis of delirium]. / Fallstricke in der Diagnostik des Delirs.

BACKGROUND: The diagnosis of delirium is challenging and requires precise definitions in both clinical routine and in studies. AIM: To point out various pitfalls in the clinical diagnosis of delirium and discuss solutions. METHODS: Review. RESULTS: Common problems include (a) clinical judgment of staff vs. the use of valid assessment tools, (b) different lists of criteria for delirium that may consider the symptoms of delirium differently and thus lead to inclusion or exclusion of patients, (c) different assessment tools that test the symptoms of delirium to different extents and thus have different accuracy, (d) patients with limited communication abilities, such as aphasia, where common tests often fail and alternative procedures may be more effective; (e) the decision whether to test delirium once, twice, three times, or more frequently in 24 h has consequences on the incidence and duration of delirium, (f) the end of delirium, often defined retrospectively as a delirium-free interval or prospectively as the time of transfer or occurrence of an exclusion criterion, can lead to considerable measurement inaccuracies. CONCLUSIONS: Although not all problems can be definitively answered, transparent definition, performance, and documentation of diagnostic procedures are recommended.

Practicability and Diagnostic Yield of One-Stop Stroke CT with Delayed-Phase Cardiac CT in Detecting Major Cardioembolic Sources of Acute Ischemic Stroke : A Proof of Concept Study.

PURPOSE: Recurrent stroke is considered to increase the incidence of severe disability and death. For correct risk assessment and patient management it is essential to identify the origin of stroke at an early stage. Transthoracic echocardiography (TTE) is the initial standard of care for evaluating patients in whom a cardioembolic source of stroke (CES) is suspected but its diagnostic capability is limited. Transesophageal echocardiography (TEE) is considered as gold standard; however, this approach is time consuming, semi-invasive and not always feasible. We hypothesized that adding a delayed-phase cardiac computed tomography (cCT) to initial multimodal CT might represent a valid alternative to routine clinical echocardiographic work-up. MATERIAL AND METHODS: Patients with suspected acute cardioembolic stroke verified by initial multimodal CT and subsequently examined with cCT were included. The cCT was evaluated for presence of major CES and compared to routine clinical echocardiographic work-up. RESULTS: In all, 102 patients with suspected acute CES underwent cCT. Among them 60 patients underwent routine work-up with echocardiography (50 TTE and only 10 TEE). By cCT 10/60 (16.7%) major CES were detected but only 4 (6.7%) were identified by echocardiography. All CES observed by echocardiography were also detected by cCT. In 8 of 36 patients in whom echocardiography was not performed cCT also revealed a major CES. CONCLUSION: These preliminary results show the potential diagnostic yield of delayed-phase cCT to detect major CES and therefore could accelerate decision-making to prevent recurrence stroke. To confirm these results larger studies with TEE as the reference standard and also compared to TTE would be necessary.

Correction to: Endovascular stroke treatment's impact on malignant type of edema (ESTIMATE).

The original keywords were not sufficiently precise in describing the article content. Therefore, the key words were amended to include hemicraniectomy and malignant edema.

Automated versus manual imaging assessment of early ischemic changes in acute stroke: comparison of two software packages and expert consensus.

AIM: The purpose of our study was to compare the agreement of both the total Alberta Stroke Program Early CT Score (ASPECTS) and region-based scores from two automated ASPECTS software packages and an expert consensus (EC) reading with final ASPECTS in a selected cohort of patients who had prompt reperfusion from endovascular thrombectomy (EVT). METHODS: ASPECTS were retrospectively and blindly assessed by two software packages and EC on baseline non-contrast-enhanced computed tomography (NCCT) images. All patients had multimodal CT imaging including NCCT, CT angiography, and CT perfusion which demonstrated an acute anterior circulation ischemic stroke with a large vessel occlusion. Final ASPECTS on follow-up scans in patients who had EVT and achieved complete reperfusion within 100 min from NCCT served as ground truth and were compared to total and region-based scores. RESULTS: Fifty-two patients met our study criteria. Moderate agreement was obtained between both software packages and EC for total ASPECTS and there was no significant difference in overall performance. However, the software packages differed with respect to regional contribution. In this cohort, the majority of infarcted regions were deep structures. Package A was more sensitive in cortical areas than the other methods, but at a cost of specificity. EC and software package B had greater sensitivity, but lower specificity for deep brain structures. CONCLUSION: In this cohort, using the final ASPECTS as ground truth, no clinically significant difference was observed for total ASPECT score between human or automated packages, but there were differences in the characteristics of the regions scored. KEY POINTS: • Some national stroke guidelines have incorporated ASPECTS in their recommendations for selecting patients for endovascular therapy. • Computer-aided diagnosis is a promising tool to aid the evaluation of early ischemic changes identified on CT. • Software packages for automated ASPECTS assessment differed significantly with respect to regional contribution without any significant difference in the overall ASPECT score.

Endovascular stroke treatment's impact on malignant type of edema (ESTIMATE).

BACKGROUND AND PURPOSE: In patients with acute ischemic stroke and large vessel occlusion, the prognosis has improved tremendously since the implementation of endovascular thrombectomy (EVT). The effect of EVT on the incidence of malignant middle cerebral artery infarctions (MMI) has not been studied before. METHODS: ESTIMATE, a multicenter retrospective study, evaluates data of ischemic stroke patients with occlusion in the anterior circulation in the years of 2007-2015 comparing three treatment options (no therapy; IV-TPA; IV-TPA plus EVT or EVT only). Primary endpoint of the study was the incidence of MMI on follow-up imaging and mortality rates. Secondary endpoints were functional outcome, further clinical and imaging data. Logistic and Cox-regression models with a propensity score weighting approach were applied to evaluate differences between treatment groups. RESULTS: In 2161 patients over 9 years, EVT reduced the MMI rates significantly: patients without acute stroke treatment had increased odds for MMI of 1.57 [95% confidence interval (CI) 1.49-1.65]. In contrast, after treatment with IV-TPA, only we observed an OR of 0.88 (95% CI 0.83-0.94, p < 0.001), and after EVT an OR of 0.80 (95% CI 0.76-0.85, p < 0.001). This was more pronounced in larger pretreatment infarctions (ASPECTS < 5, p < 0.01). IV-TPA also lowers the MMI rates but not to the same extent. EVT-treated patients had increased survival rates (p < 0.05) and the best functional outcome at discharge. CONCLUSIONS: The findings of this study illustrate that occurrence of MMI and mortality rates was significantly reduced in patients treated with EVT.

Advanced CT for diagnosis of seizure-related stroke mimics.

BACKGROUND AND PURPOSE: It is assumed that up to 30 % of clinically diagnosed acute ischaemic strokes (AIS) are actually stroke mimics (SM). Our aim was to evaluate the usefulness of advanced CT including CT angiography (CTA) and CT perfusion (CTP) findings when distinguishing AIS from seizure-related SM. METHODS: Over a 22-month period data were gathered of patients who presented to our stroke centre with AIS-like symptoms and were examined immediately with an advanced CT, analysed and evaluated by two experienced neuroradiologists who preferred SM rather than AIS. All these patients additionally received electroencephalography and follow-up imaging. CTA was the important feature to exclude vessel occlusion or haemodynamic relevant stenosis. Perfusion patterns were retrospectively analysed qualitatively. RESULTS: The most common perfusion abnormality was cortical hyperperfusion (22/37 [59.5 %] patients) followed by a hypoperfusion pattern with a cortical-subcortical involvement (15/37 [40.5 %] patients) without evidence of vessel occlusion or stenosis. Seizure-related hyper- and hypoperfusion patterns typically crossed the normal anatomical vascular territories boundaries. CONCLUSION: Beyond its use in core and penumbra estimation, advanced CT provides important information to emergency physicians in the difficult clinical diagnosis when differentiating between AIS and seizure-related symptoms with an important impact on therapeutic decision-making. KEY POINTS: • Advanced CT helps to differentiate between ischaemic strokes and stroke mimics. • Seizure-related perfusion patterns are distinct from ischaemia hypoperfusion. • Advanced CT could improve rapid adequate treatment for AIS and seizure events.

Decompression illness with hypovolemic shock and neurological failure symptoms after two risky dives: a case report.

Hypovolemia is known to be a predisposing factor of decompression illness (DCI) while diving. The typical clinically impressive neurological symptoms of DCI may distract from other symptoms such as an incipient hypovolemic shock. We report the case of a 61-year-old male Caucasian, who presented with an increasing central and peripheral neural failure syndrome and massive hypovolemia after two risky dives. Computed tomography (CT) scans of the chest and Magnetic resonance imaging scans of the head revealed multiple cerebral and pulmonary thromboembolisms. Transesophageal echocardiography showed a patent foramen ovale (PFO). Furthermore, the patient displayed hypotension as well as prerenal acute kidney injury with elevated levels of creatinine and reduced renal clearance, indicating a hypovolemic shock. Early hyperbaric oxygen (HBO) therapy reduced the neurological deficits. After volume expansion of 11 liters of electrolyte solution (1000 mL/h) the cardiopulmonary and renal function normalized. Hypovolemia increases the risk of DCI during diving and that of hypovolemic shock. Early HBO therapy and fluid replacement is crucial for a favorable outcome.

Haemorrhagic Transformation after Ischaemic Stroke in Patients Taking Non-vitamin K Antagonist Oral Anticoagulants.

BACKGROUND AND PURPOSE: To evaluate the frequency and outcome of haemorrhagic transformation (HT) after ischaemic stroke in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). METHODS: Patients with stroke on treatment with a NOAC were prospectively enrolled in this multicentre observational study between February 2012 and 2015. Brain imaging at admission and follow-up imaging until day 7 were reviewed for HT. Functional outcome was assessed by the modified Rankin scale (mRS) before the index event, at discharge, and at 3-months. RESULTS: 231 patients without recanalisation therapy (no-RT), and 32 patients with RT were eligible for analysis. Any HT was present at admission in 9/231 no-RT patients (3.9%, 95% CI 2.0 to 7.3) and in none of the patients with RT. In patients with follow-up imaging (no-RT, n=129, and RT, n=32), HT was present in 14.0% (no-RT; 95% CI, 8.9 to 21.1), and 40.6% (RT, 95% CI, 25.5 to 57.8), respectively. After adjustment for stroke severity, this difference between the no-RT and RT groups became non-significant. Symptomatic ICH was observed in 1 patient per group. HT was not associated with unfavourable outcome (mRS 3-6) at 3-months in multivariable analysis. Resumption of OAC after stroke was delayed in patients with HT compared to those without (15 d [IQR, 5-26] vs. 1 d [0-4], P<0.001). CONCLUSIONS: The frequency and severity of HT after stroke on NOAC appears similar to previous reports for vitamin K antagonists and no anticoagulation. Whether asymptomatic HT should delay resumption of preventive anticoagulation requires further investigation.

Successful recanalization in acute basilar artery occlusion treated with endovascular therapy is independent of thrombus length.

BACKGROUND AND PURPOSE: As previously demonstrated, the recanalization rate and clinical outcome in patients with anterior circulation stroke treated with IV thrombolysis (IVT) depend on clot characteristics such as thrombus length and thrombus density. In patients with basilar artery occlusion (BAO) treated with IVT, the recanalization rate has also been shown to depend on thrombus length, although no cut-off value beyond which recanalization would seem impossible has been determined. We aim to evaluate the correlation of clot characteristics with recanalization rate and outcome in patients with BAO treated with endovascular therapy (EVT). METHODS: We retrospectively assessed 51 consecutive patients with BAO treated with EVT. Thrombus length and thrombus density (in Hounsfield units, HU) were measured on thin slice non-enhanced cranial CT scan before treatment. Thrombolysis In Myocardial Infarction grade 2-3 was considered successful recanalization and 3-month modified Rankin Scale score 0-2 was considered a favorable outcome. To evaluate the correlation of clot characteristics with recanalization rate and outcome, a binary logistic regression test was computed. RESULTS: Neither thrombus length nor thrombus density correlated with recanalization rate (OR 1.02, 95% CI 0.94 to 1.11, p=0.58 and OR 1.09, 95% CI 0.97 to 1.23, p=0.13, respectively). Thrombus density and thrombus length were not significantly different in patients with (n=41, 80.4%) or without (n=10, 19.6%) successful recanalization (52.3 HU vs 48.4 HU, p=0.07 and 8.2 mm vs 7.5 mm, p=0.91). However, higher clot density was correlated with a favorable outcome (OR 1.31, 95% CI 1.08 to 1.59, p=0.006) whereas thrombus length was not correlated with clinical outcome (OR 0.94, 95% CI 0.86 to 1.03, p=0.20). CONCLUSIONS: Successful recanalization does not depend on thrombus length in patients with BAO treated with EVT. Recanalization can therefore be achieved despite high clot burden. Additionally, a high density of thrombi was a strong predictor of a favorable outcome.

Comparison of Perfusion CT Software to Predict the Final Infarct Volume After Thrombectomy.

BACKGROUND AND PURPOSE: Computed tomographic perfusion represents an interesting physiological imaging modality to select patients for reperfusion therapy in acute ischemic stroke. The purpose of our study was to determine the accuracy of different commercial perfusion CT software packages (Philips (A), Siemens (B), and RAPID (C)) to predict the final infarct volume (FIV) after mechanical thrombectomy. METHODS: Single-institutional computed tomographic perfusion data from 147 mechanically recanalized acute ischemic stroke patients were postprocessed. Ischemic core and FIV were compared about thrombolysis in cerebral infarction (TICI) score and time interval to reperfusion. FIV was measured at follow-up imaging between days 1 and 8 after stroke. RESULTS: In 118 successfully recanalized patients (TICI 2b/3), a moderately to strongly positive correlation was observed between ischemic core and FIV. The highest accuracy and best correlation are shown in early and fully recanalized patients (Pearson r for A=0.42, B=0.64, and C=0.83; P<0.001). Bland-Altman plots and boxplots demonstrate smaller ranges in package C than in A and B. Significant differences were found between the packages about over- and underestimation of the ischemic core. Package A, compared with B and C, estimated more than twice as many patients with a malignant stroke profile (P<0.001). Package C best predicted hypoperfusion volume in nonsuccessfully recanalized patients. CONCLUSIONS: Our study demonstrates best accuracy and approximation between the results of a fully automated software (RAPID) and FIV, especially in early and fully recanalized patients. Furthermore, this software package overestimated the FIV to a significantly lower degree and estimated a malignant mismatch profile less often than other software.

Transient filament occlusion of the middle cerebral artery in rats: does the reperfusion method matter 24 hours after perfusion?

BACKGROUND: There are two widely used transient middle cerebral artery occlusion (MCAO) methods, which differ in the use of unilateral or bilateral carotid artery reperfusion (UNICAR and BICAR). Of the two methods, UNICAR is easier to perform. This study was designed to comprehensively compare the two reperfusion methods to determine if there are any differences in outcomes. RESULTS: The UNICAR and BICAR groups each included 9 rats. At baseline, the average pO(2) was 20.54 ± 9.35 and 26.43 ± 7.39, for the UNICAR and BICAR groups, respectively (P = 0.519). Changes in pO(2), as well as other physiological parameters measured within the ischemic lesion, were similar between the UNICAR and BICAR groups during 90 min of MCAO and the first 30 min of reperfusion (all P > 0.05). Furthermore, both the Bederson score and Garcia score, which are used for neurological assessment, were also similar (both P > 0.05). There were also no significant differences in T2WI lesion volume, DWI lesion volume, PWI lesion volume, or TTC staining infarct volume between the two groups (all P > 0.05). CONCLUSION: UNICAR and BICAR have similar capability for inducing acute brain ischemic injury and can be considered interchangeable up to 24 hours after reperfusion.

The correlation between quantitative T2' and regional cerebral blood flow after acute brain ischemia in early reperfusion as demonstrated in a middle cerebral artery occlusion/reperfusion model of the rat.

INTRODUCTION: qT2'-maps are calculated by subtracting T2- from T2*-relaxation rates. They are oxygen-sensitive and depict oxygen extraction. In several studies they have been used to describe the penumbra in patients with acute ischemic stroke. No correlation between rCBF and qT2' has been performed to date. In this study a correlation between rCBF and qT2' was performed in a temporary middle cerebral occlusion-reperfusion model of the rat. MATERIALS AND METHODS: Temporary middle cerebral artery occlusion was performed on seven Sprague-Dawley rats. After 60 min of occlusion and 90 min of reperfusion MRI was performed including DWI, dynamic susceptibility contrast-weighted MR imaging (DSC-MRI) and qT2'. ROIs were placed inside the DWI lesion and transferred to rCBF- and qT2'-maps. rCBF and qT2' were compared to corresponding tissue in the contralateral hemisphere. RESULTS: qT2' was lower in the infarcted areas when compared to the contralateral hemisphere. Correlation between rCBF and qT2' was r = 0.41, p = 0.14 (Pearson's correlation coefficient), when corrected for outliers it was r = 0.58, p = 0.04. CONCLUSION: Our results show that there is a moderate correlation between rCBF and qT2'. qT2'-maps could be used to explore cerebral perfusion without the application of contrast agent or radiation.