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Background and Purpose- We aimed to evaluate the impact of brain atrophy on long-term clinical outcome in patients with acute ischemic stroke treated with endovascular therapy, and more specifically, to test whether there are interactions between the degree of atrophy and infarct volume, and between atrophy and age, in determining the risk of futile reperfusion. Methods- We studied consecutive patients with acute ischemic stroke with proximal anterior circulation intracranial arterial occlusions treated with endovascular therapy achieving successful arterial recanalization. Brain atrophy was evaluated on baseline computed tomography with the global cortical atrophy scale, and Evans index was calculated to assess subcortical atrophy. Infarct volume was assessed on control computed tomography at 24 hours using the formula for irregular volumes (A×B×C/2). Main outcome variable was futile recanalization, defined by functional dependence (modified Rankin Scale score >2) at 3 months. The predefined interactions of atrophy with age and infarct volume were studied in regression models. Results- From 361 consecutive patients with anterior circulation acute ischemic stroke treated with endovascular therapy, 295 met all inclusion criteria. Futile reperfusion was observed in 144 out of 295 (48.8%) patients. Cortical atrophy affecting parieto-occipital and temporal regions was associated with futile recanalization. Total global cortical atrophy score and Evans index were independently associated with futile recanalization in an adjusted logistic regression. Multivariable adjusted regression models disclosed significant interactions between global cortical atrophy score and infarct volume (odds ratio, 1.003 [95%CI, 1.002-1.004], P<0.001) and between global cortical atrophy score and age (odds ratio, 1.001 [95% CI, 1.001-1.002], P<0.001) in determining the risk of futile reperfusion. Conclusions- A higher degree of cortical and subcortical brain atrophy is associated with futile endovascular reperfusion in anterior circulation acute ischemic stroke. The impact of brain atrophy on insufficient clinical recovery after endovascular reperfusion appears to be independently amplified by age and by infarct volume.
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Isquemia Encefálica/cirurgia , Córtex Cerebral/diagnóstico por imagem , Procedimentos Endovasculares , Acidente Vascular Cerebral/cirurgia , Trombectomia , Idoso , Idoso de 80 Anos ou mais , Atrofia , Córtex Cerebral/patologia , Feminino , Seguimentos , Humanos , Leucoaraiose/diagnóstico por imagem , Masculino , Futilidade Médica , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
We present the case of a male with a history of nasal polyposis underwent bilateral nasosinusal endoscopic surgery. He went to the emergency department because of having behavioral changes and left frontal headache. An emergency CT showed nasal-sinus polyposis and several nodular lesions with a characteristic "ring" enhancement and perilesional edema. These findings were compatible facial mucocele complicated with rupture of the bone wall of the left frontal sinus and frontal abscess. Urgent surgery was performed, with left frontal craniectomy and drainage of the abscesses. Mucoceles are benign slowly growing lesions which can associate important complications. The most frequent are abscesses and the invasion of neighboring structures. It is very important to remember that frontal mucoceles can cause intracranial invasion when there is an erosion of the internal osseous table.
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Cocaine is a widespread recreational drug that has the potential to induce neurological vascular diseases, including ischaemic and haemorrhagic stroke. Although arterial vasospasm has been suggested as a pathogenic factor in the development of neurovascular complications, it remains unclear whether cocaine users carry an increased risk to suffer iatrogenic vasospasm during endovascular procedures. We report the case of two patients with a history of cocaine abuse, who developed unusual severe vasospasms during different interventional procedures. The first case occurred in a middle-aged woman with an unruptured left internal carotid artery bifurcation aneurysm who was scheduled for treatment by remodelling assisted coiling. Just after the placement of the remodelling balloon, a severe occlusive vasospasm interrupted the procedure. The second case happened to a 46-year-old man with a non-aneurysmal subarachnoid haemorrhage and a symptomatic vasospasm in the right-sided anterior circulation who developed another occlusive vasospasm after the first attempt at transluminal balloon angioplasty. Further research is needed to establish a relation between cocaine use and increased risk of iatrogenic vasospasm in endovascular procedures, but we suggest practitioners be extremely cautious when treating this subgroup of patients.
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Transtornos Relacionados ao Uso de Cocaína/complicações , Complicações Intraoperatórias/etiologia , Vasoespasmo Intracraniano/etiologia , Adulto , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Índice de Gravidade de DoençaRESUMO
Introducción. Aunque la arterioesclerosis intracraneal es una causa importante de ictus, la actitud terapéutica no está claramente establecida. En este sentido, el estudio SAMMPRIS comparó el tratamiento médico intensivo con la angioplastia y colocación de stent, con resultados favorables al tratamiento farmacológico. Estos resultados podrían, en parte, deberse al dispositivo utilizado (stent Wingspan ®). Caso clínico. Varón de 71 años con una estenosis grave de la arteria basilar, en quien se repetían episodios de focalidad neurológica transitoria a pesar del tratamiento con doble antiagregación y estatinas. En estas circunstancias se decidió realizar una arteriografía terapéutica con angioplastia y colocación de un stent Solitaire ® para optimizar resultados y se logró una estenosis residual del 40%. La evolución fue favorable y los controles posteriores muestran una mínima progresión. Conclusión. Según nuestro conocimiento, éste es el primer caso publicado de tratamiento de una estenosis crítica de la arteria basilar mediante la colocación de un stent Solitaire ® (AU)
Introduction. Although intracranial arteriosclerosis is an important cause of stroke, the therapeutic attitude has still not been clearly established. Hence, the SAMMPRIS study compared intensive medical treatment with angioplasty and stent placement, with outcomes favouring the pharmacological treatment. These results could be partly due to the device used (Wingspan ® stent). Case report. A 71-year-old male with a severe stenosis of the basilar artery, who suffered repeated episodes of transient neurological focus despite being treated with antiplatelet therapy and statins. Given the circumstances, the decision was made to perform a therapeutic arteriography with angioplasty and placement of a Solitaire ® stent in order to optimise results, a residual stenosis of 40% being achieved. Subsequent progress was favourable and the control tests carried out showed a minimum progression. Conclusions. As far as we know, this is the first case of critical stenosis of the basilar artery being treated by placement of a Solitaire® stent to be reported in the literature (AU)
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Humanos , Masculino , Idoso , Insuficiência Vertebrobasilar/cirurgia , Procedimentos Endovasculares/métodos , Stents , Angioplastia com Balão/métodos , Ataque Isquêmico Transitório/cirurgia , Recidiva , Arteriosclerose Intracraniana/cirurgiaRESUMO
INTRODUCTION: Although intracranial arteriosclerosis is an important cause of stroke, the therapeutic attitude has still not been clearly established. Hence, the SAMMPRIS study compared intensive medical treatment with angioplasty and stent placement, with outcomes favouring the pharmacological treatment. These results could be partly due to the device used (Wingspan® stent). CASE REPORT: A 71-year-old male with a severe stenosis of the basilar artery, who suffered repeated episodes of transient neurological focus despite being treated with antiplatelet therapy and statins. Given the circumstances, the decision was made to perform a therapeutic arteriography with angioplasty and placement of a Solitaire® stent in order to optimise results, a residual stenosis of 40% being achieved. Subsequent progress was favourable and the control tests carried out showed a minimum progression. CONCLUSIONS: As far as we know, this is the first case of critical stenosis of the basilar artery being treated by placement of a Solitaire® stent to be reported in the literature.
TITLE: Tratamiento endovascular de una estenosis critica basilar con dispositivo stent Solitaire ®: primera experiencia en nuestro centro.Introduccion. Aunque la arterioesclerosis intracraneal es una causa importante de ictus, la actitud terapeutica no esta claramente establecida. En este sentido, el estudio SAMMPRIS comparo el tratamiento medico intensivo con la angioplastia y colocacion de stent, con resultados favorables al tratamiento farmacologico. Estos resultados podrian, en parte, deberse al dispositivo utilizado (stent Wingspan ®). Caso clinico. Varon de 71 años con una estenosis grave de la arteria basilar, en quien se repetian episodios de focalidad neurologica transitoria a pesar del tratamiento con doble antiagregacion y estatinas. En estas circunstancias se decidio realizar una arteriografia terapeutica con angioplastia y colocacion de un stent Solitaire ® para optimizar resultados y se logro una estenosis residual del 40%. La evolucion fue favorable y los controles posteriores muestran una minima progresion. Conclusion. Segun nuestro conocimiento, este es el primer caso publicado de tratamiento de una estenosis critica de la arteria basilar mediante la colocacion de un stent Solitaire ®.
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Angioplastia com Balão , Stents , Insuficiência Vertebrobasilar/terapia , Idoso , Angiografia Cerebral , Dislipidemias/complicações , Humanos , Hipertensão/complicações , Imageamento Tridimensional , Ataque Isquêmico Transitório/etiologia , Masculino , Insuficiência Vertebrobasilar/complicações , Insuficiência Vertebrobasilar/diagnóstico por imagemRESUMO
TITLE: Resolucion espontanea de una fistula dural arteriovenosa tipo IV.
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Malformações Vasculares do Sistema Nervoso Central/fisiopatologia , Espasmo Hemifacial/etiologia , Angiografia Digital , Malformações Vasculares do Sistema Nervoso Central/complicações , Angiografia Cerebral , Humanos , Hipertensão/complicações , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Policitemia/complicações , Remissão Espontânea , Índice de Gravidade de DoençaRESUMO
No disponible
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Humanos , Masculino , Pessoa de Meia-Idade , Dura-Máter , Fístula Arteriovenosa/diagnóstico , Remissão EspontâneaRESUMO
BACKGROUND AND PURPOSE: Selection of best responders to reperfusion therapies could be aided by predicting the duration of tissue-at-risk viability, which may be dependant on collateral circulation status. We aimed to identify the best predictor of good collateral circulation among perfusion computed tomography (PCT) parameters in middle cerebral artery (MCA) ischemic stroke and to analyze how early MCA response to intravenous thrombolysis and PCT-derived markers of good collaterals interact to determine stroke outcome. METHODS: We prospectively studied patients with acute MCA ischemic stroke treated with intravenous thrombolysis who underwent PCT before treatment showing a target mismatch profile. Collateral status was assessed using a PCT source image-based score. PCT maps were quantitatively analyzed. Cerebral blood volume (CBV), cerebral blood flow, and Tmax were calculated within the hypoperfused volume and in the equivalent region of unaffected hemisphere. Occluded MCAs were monitored by transcranial Duplex to assess early recanalization. Main outcome variables were brain hypodensity volume and modified Rankin scale score at day 90. RESULTS: One hundred patients with MCA ischemic stroke imaged by PCT received intravenous thrombolysis, and 68 met all inclusion criteria. A relative CBV (rCBV) >0.93 emerged as the only predictor of good collaterals (odds ratio, 12.6; 95% confidence interval, 2.9-55.9; P=0.001). Early MCA recanalization was associated with better long-term outcome and lower infarct volume in patients with rCBV<0.93, but not in patients with high rCBV. None of the patients with rCBV<0.93 achieved good outcome in absence of early recanalization. CONCLUSIONS: High rCBV was the strongest marker of good collaterals and may characterize durable tissue-at-risk viability in hyperacute MCA ischemic stroke.
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Volume Sanguíneo/fisiologia , Isquemia Encefálica/sangue , Isquemia Encefálica/patologia , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/patologia , Idoso , Biomarcadores , Circulação Cerebrovascular/fisiologia , Circulação Colateral/fisiologia , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Infarto da Artéria Cerebral Média/sangue , Infarto da Artéria Cerebral Média/patologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Terapia Trombolítica , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Extending the therapeutic window of intravenous thrombolysis for acute ischemic stroke beyond the established 4.5-hour limit is of critical importance in order to increase the proportion of thrombolysed stroke patients. In this setting, the capacity of MRI to select acute stroke patients for reperfusion therapies in delayed time windows has been and is being tested in clinical trials. However, whether the more available and cost-effective perfusion computed tomography (PCT) may be useful to select candidates for delayed intravenous thrombolysis remains largely unexplored. We aimed to evaluate the safety and efficacy of PCT-guided intravenous thrombolysis beyond 4.5 h after stroke onset. METHODS: We prospectively studied all consecutive acute ischemic stroke patients treated with intravenous tissue plasminogen activator (tPA) in our stroke unit between January 2008 and December 2010. Patients treated within 0- 4.5 h were treated according to non-contrast CT (NCCT) criteria. Beyond 4.5 h, patients received intravenous tPA according to PCT criteria, i.e. an infarct core on cerebral blood volume (CBV) maps not exceeding one third of the middle cerebral artery (MCA) territory and tissue at risk as defined by mean transit time-CBV mismatch greater than 20%. Predetermined primary endpoints were symptomatic hemorrhagic transformation and favorable long-term outcome, while early neurological improvement and MCA recanalization were considered secondary endpoints. Statistical analysis included bivariate comparisons between the two groups for each endpoint and logistic regression models when significance was found in bivariate analyses. This study was approved by our local ethics committee. RESULTS: A total of 245 patients received intravenous thrombolysis. After the groups were matched by baseline National Institutes of Health Stroke Scale score, 172 patients treated at <4.5 h and 43 patients treated at >4.5 h were finally included. Early and late groups were comparable regarding baseline variables; only cardioembolic etiology was more frequent in the >4.5 h group. Rates of symptomatic hemorrhagic transformation (2.9% in the <4.5 h group vs. 2.3% in the >4.5 h group; p = 1.0) and good long-term outcome (64.5 vs. 60.5%, respectively; p = 0.620) were similar between the groups. However, delayed intravenous thrombolysis was independently associated with a worse early clinical course [odds ratio (OR) 2.07, 95% confidence interval (CI) 1.04-4.1; p = 0.038] and lower 2-hour MCA recanalization rates (OR 0.4, 95% CI 0.17-0.92; p = 0.03). CONCLUSION: Primary safety and efficacy endpoints were comparable between the early and delayed thrombolysis groups. The results of our exploratory study may justify a randomized clinical trial to test the safety and efficacy of PCT-guided intravenous thrombolysis in acute ischemic stroke patients presenting beyond 4.5 h from symptom onset.
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Isquemia Encefálica/tratamento farmacológico , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Tomografia Computadorizada por Raios X/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Injeções Intravenosas/métodos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Perfusão/métodos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do TratamentoRESUMO
Objetivo. Estudiar la frecuencia, seguridad y eficacia de la trombólisis intravenosa guiada por tomografía computarizadade perfusión (TCP) mediante la identificación de tejido cerebral rescatable en ictus isquémicos a priori excluidos por criteriostradicionales (SITS-MOST y ECASS-3). Pacientes y métodos. Incluimos ictus isquémicos no lacunares consecutivos. Tras tomografía convencional, se realizó TCP en los siguientes supuestos: inicio 4,5-6 h, desconocido o al despertar, signos precoces de infarto extenso, ictus menoro grave, e inicio con crisis epiléptica o pérdida de conciencia. Se indicó alteplasa intravenosa 0,9 mg/kg si: ausencia de infarto establecido en tomografía simple, core en mapa de volumen sanguíneo cerebral menor de un tercio del territorio de la arteria cerebral media, mismatch > 20% entre mapas de tiempo de tránsito medio y volumen sanguíneo cerebral, y consentimiento informado. Las variables pronósticas fueron parámetros de seguridad-eficacia del SIST-MOST.Resultados. De mayo de 2009 a abril de 2010, 66 pacientes con ictus isquémico a priori no candidatos para trombólisis intravenosa fueron estudiados con TCP. Las indicaciones fueron: > 4,5 h en 18 pacientes, ictus del despertar o inicio desconocido en 25, signos precoces extensos en 6, inicio con crisis epilépticas en 11, e ictus menor (escala del ictus del NationalInstitute of Health < 4) en seis. Veintinueve (44%) recibieron trombólisis intravenosa de acuerdo con los hallazgos de la TCP. De ellos, 2 (6,9%) sufrieron transformación hemorrágica sintomática y 18 (62,1%) alcanzaron un Rankin igual o menor a 2 al tercer mes. Conclusión. Una alta proporción de pacientes con ictus isquémico, excluibles a priori según criterios tradicionales, podríarecibir trombólisis intravenosa de manera eficaz-segura utilizando protocolo de TCP. No obstante, estos hallazgos necesitaríanconfirmación en ensayos clínicos aleatorizados (AU)
Aim. To study the frequency, safety and efficacy of perfusion computed tomography (PCT), through identification of brain tissue-at-risk, to guide intravenous thrombolysis in stroke patients with regulatory exclusion criteria (SITS-MOST andECASS-3). Patients and methods. We studied consecutive acute non-lacunar ischemic stroke patients. After conventional CT wasconsidered eligible, PCT was performed in the following circumstances: 4.5 to 6 h window, wake-up stroke or unknowntime of onset; extent early infarct signs on CT; minor or severe stroke; seizures or loss of consciousness. Intravenous 0.9 mg/kg alteplase was indicated if: cerebral blood volume lesion covered < 1/3 of middle cerebral artery territory;mismatch > 20% between mean transit time and cerebral blood volume maps existed; and informed consent. SITS-MOST safety-efficacy parameters were used as endpoint variables. Results. Between May 2009-April 2010, 66 hyperacute ischemic stroke patients a priori not eligible for intravenous thrombolysis underwent PCT. Indications were: > 4.5 h in 18 patients, wake up stroke or unknown onset in 25, extentinfarct signs in 6, seizures at onset in 11, and minor stroke (NIHSS < 4) in 6. Twenty-nine (44%) of them finally received intravenous thrombolysis. Symptomatic hemorrhagic transformation occurred in 2 (6.9%) patient and 18 (62.1%) achieved a modified Rankin scale score equal or less than 2 on day 90. Conclusion. A high proportion of acute stroke patients with SITS-MOST and ECASS-3 exclusion criteria can be safely andefficaciously treated with intravenous thrombolysis using a PCT selection protocol. However randomized control trials willbe needed to confirm our results (AU)
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Humanos , Tomografia Computadorizada por Raios X/métodos , Terapia Trombolítica/métodos , Acidente Vascular Cerebral/terapia , Seleção de Pacientes , Infusões Intravenosas/métodos , Fibrinolíticos/administração & dosagemRESUMO
OBJETIVO: Revisar la presentación, diagnóstico y tratamiento de una entidad poco frecuente como los aneurismas de la arteria renal.MÉTODOS: Presentamos el caso de un paciente monorreno con un aneurisma renal calcificado sintomático.RESULTADOS: Los aneurismas de la arteria renal pueden provocar hipertensión, hematuria, dolor en flanco, o ser totalmente asintomáticos. Las causas más frecuentes son laarteriosclerosis y la displasia fibromuscular y el diagnóstico se basa en la tomografía computerizada y en la angiografía. El tratamiento puede ser quirúrgico, endovascular o expectante.CONCLUSIONES: Los aneurismas de la arteria renal son una patología sobre la que, por su baja prevalencia, no existen pautas claras de actuación. El número de casos diagnosticados ha aumentado en las últimas décadas y el tratamiento endovascular se muestra como una buena opción(AU)
OBJECTIVE: To review presentation, diagnosis and treatment of renal artery aneurysms, a very uncommon disease.METHODS: We report the case of a male with a calcified renal artery aneurysm in a solitary kidney.RESULTS: Symptomatic effects may be hypertension, hematuria or flank pain. Arteriosclerosis and medial dysplasia are the most frequent causes and diagnosis is based on CT scan and angiography.CONCLUSIONS: The renal artery aneurysm is a disease with low prevalence and there is no clear protocol for management. The number of cases has increased over the last decades and endovasculrar treatment is a good therapeutic option(AU)