The vanishing of the ACoA syndrome after aneurysmal subarachnoid haemorrhage: New era, different management, fewer problems?

Historically, a specific set of symptoms has been related to the rupture and repair of anterior communicating artery (ACoA) aneurysms. These consequences were defined as the 'ACoA syndrome' and included observations of severe memory loss, confabulation and personality or behavioural changes. These observations correspond to neuropsychological impairments in memory, executive functions and social cognition. However, in more recent studies, the existence of such a distinct syndrome has been called into question. We aimed to investigate the existence of the ACoA syndrome, by combining analysis of our own data with a systematic review of the literature. Memory, executive functions and social cognition of subarachnoid haemorrhage patients with ACoA aneurysms (N = 28) were compared to patients with aneurysms in other locations (N = 66). Results showed no significant differences. Subsequently, a systematic review of the existing literature on the ACoA syndrome was performed using Embase and PubMed until October 2022. Studies that investigated cognitive functions after rupture and repair of ACoA aneurysms were included. The search yielded 847 unique entries and after screening titles and abstracts, 648 records were excluded. 199 full-text articles were assessed for eligibility and 55 articles were included. Evidence was found for the ACoA syndrome in studies between 1960 and 2000, with impairments in memory and executive problems in the majority of studies. However, the majority of studies from 2000 did not demonstrate a distinct ACoA syndrome, although neuropsychological measurements improved. This coincides with the changes in the management of ACoA aneurysms over the past decades, such as the emergence of endovascular treatment and improvement of neurointensive care. Therefore, we hypothesize that the management techniques of ACoA aneurysms until around 2000, i.e. mainly conventional clipping, could be related to the presence of symptoms of the ACoA syndrome.

Reliability of the intracerebral hemorrhage score for predicting outcome in patients with intracerebral hemorrhage using oral anticoagulants.

BACKGROUND AND PURPOSE: The intracerebral hemorrhage (ICH) score is the most widely used and validated prognostic model for estimating 30-day mortality in ICH. However, the score was developed and validated in an ICH population probably not using oral anticoagulants (OACs). The aim of this study was to determine the performance of the ICH score for predicting the 30-day mortality rate in the full range of ICH scores in patients using OACs. METHODS: Data from admitted patients with ICH were collected retrospectively in two Dutch comprehensive stroke centers. The validity of the ICH score was evaluated by assessing both discrimination and calibration in OAC and OAC-naive patient groups. RESULTS: A total of 1752 patients were included of which 462 (26%) patients were on OAC. The 30-day mortality was 54% for the OAC cohort and 34% for the OAC-naive cohort. The 30-day mortality was higher in the OAC cohort for ICH score 1 (33% vs. 12.5%; odds ratio, 3.4; 95% confidence intervals, 1.1-10.4) and ICH score 2 (53% vs. 26%; odds ratio, 3.2; 95% confidence intervals, 1.2-8.2) compared with the predicted mortality rate of the original ICH score. Overall, the discriminative ability of the ICH score was equally good in both cohorts (area under the curve 0.83 vs. 0.87, respectively). CONCLUSIONS: The ICH score underestimated the 30-day mortality rate for lower ICH scores in OAC-ICH. When estimating the prognosis of ICH in patients using OAC, this underestimation of mortality must be taken into account.

Distribution of perioperative stroke in cardiac surgery.

BACKGROUND AND PURPOSE: The recent literature suggests that a cardiac origin in ischaemic stroke is more frequent than previously assumed. However, it is not always clear which patients benefit from additional cardiac investigations if obvious cardiac pathology is absent. METHODS: A single-center retrospective observational study was performed with 7454 consecutive patients admitted to the intensive care unit after cardiac surgery in the period 2006-2015 and who had postoperative brain imaging. Cerebral imaging was studied for the occurrence of stroke including subtype and involved vascular territory. It was assumed that all perioperative thromboembolic strokes are of cardiac origin. Data obtained from a hospital cohort of consecutive patients who received a diagnosis of ischaemic stroke were used for comparison. RESULTS: Thromboembolic stroke occurred in 135 cardiac surgery patients in 56 (41%) of whom the posterior cerebral circulation was involved. In the control group, 100 out of 503 strokes (20%) were located in the posterior cerebral circulation. The relative risk for a posterior location for stroke after cardiac surgery compared to patients with ischaemic stroke without prior cardiac surgery was 2.09; 95% confidence interval 1.60-2.72. CONCLUSIONS: Thromboembolic stroke after cardiac surgery occurs twice as often in the posterior cerebral circulation compared to ischaemic strokes in the general population. If confirmed in general stroke cohorts, the consequence of this finding may be that in patients with an ischaemic stroke that involves the posterior cerebral circulation the chance of a cardiac origin is increased and therefore might trigger additional cardiac investigations such as long-term heart rhythm monitoring or echocardiography.

Intracranial artery dissection.

The aim of this narrative review is to evaluate the pathogenesis, clinical features, diagnosis, treatment and prognosis of intracranial artery dissection (IAD). IAD is a rare and often unrecognized cause of stroke or subarachnoid haemorrhage (SAH), especially in young adults. Two types of IAD can be identified: a subintimal or subadventitial dissection. It is suggested that a subintimal dissection results in luminal stenosis, thromboembolism and subsequently cerebral ischaemia, whilst a subadventitial IAD could result in the formation of a pseudo-aneurysm and compression on brainstem or cranial nerves. Rupture of such a dissecting aneurysm causes SAH. The exact cause of IAD remains unknown but several factors are associated with its development. Diagnosis is based on clinical presentation and specific features seen on multimodal neuroimaging. The management of IAD depends on the clinical presentation. In the case of cerebral ischaemia, anticoagulants or antiplatelet agents are used, whilst in the case of SAH endovascular treatment is primarily advocated. Prognosis depends on clinical presentation. Presentation with SAH has a worse prognosis.

The sNIHSS-4 predicts outcome in right and left anterior circulation strokes.

BACKGROUND AND PURPOSE: Stroke severity measured by the National Institutes of Health Stroke Scale (NIHSS) is a strong predictor of functional outcome. A short version, the sNIHSS-5, scoring only strength in right and left leg, gaze, visual fields and language, was developed for use in the prehospital setting. Because scoring both legs in anterior circulation strokes is not contributive, we assessed the value of a 4-item score (the sNIHSS-4), omitting the item 'strength in the unaffected leg', in predicting stroke outcome. METHODS: The study population consisted of anterior circulation ischemic stroke patients who participated in the LUB-INT-9 trial. We included all patients in whom the following data were available: NIHSS within 6h after stroke onset and daily between days 2 and 5, and the 12-week modified Rankin Scale (mRS) score. Poor outcome was defined as a mRS score>3. RESULTS: There was an excellent correlation between the NIHSS and sNIHSS-4 at all time points for both left and right-sided strokes. Scores at day 2 were a good predictor of poor outcome. Cutoff scores for NIHSS and sNIHSS-4 at day 2 were 15 and 5 in left hemispheric strokes, and 12 and 4 in right hemispheric strokes. CONCLUSION: The sNIHSS-4 is as good as the NIHSS at predicting stroke outcome in both right and left anterior circulation strokes.

Pre-stroke use of beta-blockers does not affect ischaemic stroke severity and outcome.

BACKGROUND AND PURPOSE: It is unclear whether pre-stroke beta-blockers use may influence stroke outcome. This study evaluates the independent effect of pre-stroke use of beta-blockers on ischaemic stroke severity and 3 months functional outcome. METHODS: Pre-stroke use of beta-blockers was investigated in 1375 ischaemic stroke patients who had been included in two placebo-controlled trials with lubeluzole. Stroke severity was assessed by either the National Institute of Health Stroke Scale (NIHSS) or the European Stroke Scale (ESS). A modified Rankin scale (mRS) score of >3 at 3 months was used as measure for the poor functional outcome. RESULTS: Two hundred and sixty four patients were on beta-blockers prior to stroke onset, and 105 patients continued treatment after their stroke. Pretreatment with beta-blockers did not influence baseline stroke severity. There was no difference in stroke severity between nonusers and those on either a selective beta(1)-blocker or a non-selective beta-blocker. The likelihood of a poor outcome at 3 months was not influenced by pre-stroke beta-blocker use or beta-blocker use before and continued after stroke onset. CONCLUSIONS: Pre-stroke use of beta-blockers does not appear to influence stroke severity and functional outcome at 3 months.

Traumatic cervical artery dissection in head injury: the value of follow-up brain imaging.

INTRODUCTION: Traumatic cervical artery dissection (TCAD) is a relative infrequent complication of traumatic brain injury (TBI). Since TCAD is associated with morbidity in a considerable percentage of patients, it is important to obtain clues for recognising TCAD in this category of patients. METHODS: Retrospective case-cohort study in severe TBI patients. RESULTS: Five patients with traumatic cervical artery dissection after severe TBI, leading to ischemic strokes, are described. Secondary deterioration to coma was present in four out of five patients during admission. The diagnosis of TCAD was delayed in most cases because the secondary deterioration was often attributed to multisystem problems related to trauma patients, i.e. shock or hypoxia or medication effects. Local clinical symptoms and signs suggestive of TCAD are difficult to detect in this patient group. In all patients, the CT-scan on admission demonstrated no abnormalities. A follow-up scan at day 2 revealed that in all patients abnormalities in the vascular territories had evolved. CONCLUSION: With this case-cohort study we underline the importance of considering TCAD in severe TBI patients and emphasise the role for standard follow-up brain imaging. Also possible treatment consequences are discussed.

Effect of selective serotonin re-uptake inhibitors (SSRIs) on functional outcome in patients with acute ischemic stroke treated with tPA.

BACKGROUND: Selective serotonin re-uptake inhibitors (SSRIs) may have therapeutic potential in the treatment of ischemic stroke by effects on neuronal cell survival and the plasticity of brain processes. In the present study, we investigated whether prior treatment with a SSRI is associated with more favorable functional outcome in a cohort of patients with acute ischemic stroke treated with tissue plasminogen activator (tPA). METHODS: In a prospective observational cohort study of 476 acute ischemic stroke patients treated with tPA we investigated the relationship between prior SSRI treatment and functional outcome at 3 months. Ischemic stroke subtypes were defined according to the Oxfordshire Community Stroke Project Classification. Favorable outcome was defined as a modified Rankin Scale score

tPA treatment for acute ischaemic stroke in patients with leukoaraiosis.

BACKGROUND AND PURPOSE: Whether leukoaraiosis on baseline CT is associated with an increased risk of symptomatic intracerebral haemorrhage (sICH) or poor outcome following tissue plasminogen activator (tPA) treatment for acute ischaemic stroke is still a matter of debate. OBJECTIVE: To investigate the relationship between the presence and severity of leukoaraiosis on baseline CT and the risk of sICH and functional outcome after tPA treatment for acute ischaemic stroke. METHODS: A single-center observational cohort study with a retrospective analysis on consecutive patients with ischaemic stroke treated with tPA in the period 2002-2008. Outcome measures were the occurrence of sICH and functional outcome at 3 months. RESULTS: Of the 400 patients, 24% had leukoaraiosis on their baseline CT. Eleven patients (11%) with leukoaraiosis versus thirteen (4%) patients without leukoaraiosis had a sICH [odds ratio (OR) 2.85 95%-CI 1.23-6.60, P = 0.02]. Multivariate analysis showed a non-significant trend towards an association of leukoaraiosis and sICH (OR 1.9, 95%-CI 0.78-4.68, P = 0.16). Leukoaraiosis was independently associated with poor functional outcome (OR 2.39, 95%-CI 1.21-4.72, P = 0.01). No difference was observed in the outcome measures amongst patients with moderate or severe leukoaraiosis. CONCLUSION: Our study demonstrates that patients treated with tPA and leukoaraiosis on their baseline CT are at greater risk of sICH and have a worse functional outcome compared to patients without leukoaraiosis. It is important to note that these results should not lead to exclusion of patients with leukoaraiosis for tPA treatment.

Statin use and functional outcome after tissue plasminogen activator treatment in acute ischaemic stroke.

BACKGROUND: Preliminary findings suggest that statins may have a neuroprotective effect in patients with acute ischaemic stroke. This study investigated whether patients on prior statin therapy and treated with tissue plasminogen activator (tPA) for acute ischaemic stroke have a better functional outcome than statin-naïve patients. METHODS: In a prospective observational cohort study of 476 acute ischaemic stroke patients treated with tPA we investigated the relationship between prior statin use and functional outcome at 3 months, the occurrence of symptomatic intracerebral haemorrhage (SICH) and early in-hospital mortality. Ischaemic stroke subtypes were defined according to the TOAST classification. Favourable outcome was defined as a modified Rankin Scale score < or =2. RESULTS: Of the 476 patients included, 98 (20.6%) used a statin at stroke presentation. In the entire cohort, 45.6% of patients had a favourable outcome with no difference between patients with or without statin therapy (45.9 vs. 45.5%, p = 0.94). In the multivariable analysis, statin use was not associated with favourable outcome (OR = 1.1, 95% CI = 0.6-1.9, p = 0.87). In none of the different stroke subtype groups was statin use associated with favourable outcome. Finally, statin use was not an independent risk factor of SICH or of early in-hospital mortality. CONCLUSION: Prior statin therapy in patients with acute ischaemic stroke treated with tPA is not associated with a more favourable outcome, and this is independent of stroke subtype.

Thrombolysis for acute ischemic stroke.

In the last decennium, thrombolytic therapy has changed the management of acute ischemic stroke. Randomized clinical studies have demonstrated that intravenous thrombolysis with tissue plasminogen activator improves functional outcomes. Recently the time window for intravenous thrombolysis has been extended from 3 to 4.5 hours after stroke onset, which will allow more stroke patients to benefit from this treatment. Currently several studies are investigating how to improve recanalization rates of thrombolytic therapy. In this review several aspects of intravenous and intra-arterial thrombolysis are discussed.

Hyperdense middle cerebral artery sign and outcome after intravenous thrombolysis for acute ischemic stroke.

BACKGROUND: The presence of a hyperdense middle cerebral artery sign (HMCAS) on baseline brain CT is associated with poor clinical outcome in stroke patients treated with intravenous recombinant tissue plasminogen activator (tPA). It remains uncertain whether the presence of HMCAS is associated with acute neurological deterioration after tPA treatment. OBJECTIVE: To evaluate the effect of HMCAS in routinely intravenous tPA-treated patients with anterior circulation stroke on acute neurological deterioration, the 3-month functional outcome and the occurrence of symptomatic ICH. METHODS: We analyzed data from a single stroke unit registry of 384 consecutive patients with anterior circulation infarction, treated with intravenous tPA. Logistic regression models were used to assess if HMCAS was independently associated with predefined outcome definitions. RESULTS: We found a HMCAS in 104 patients (27%). The HMCAS was related to the risk of early neurological deterioration (p=0.04) and poor functional outcome (p<0.001) on univariate analysis. The incidence of symptomatic ICH was not significantly different between patients with and without HMCAS (7% versus 6%, p=0.81). In the multivariable analysis, the presence of HMCAS was significantly associated with a poor outcome (p=0.004). CONCLUSIONS: The HMCAS is associated with early neurological deterioration and poor functional outcome, but not with symptomatic ICH.

Fatigue, depression and disability accumulation in multiple sclerosis: a cross-sectional study.

OBJECTIVE: To investigate the influence of disability and the speed of disability accumulation on fatigue and depression in a large cohort of patients with multiple sclerosis (MS). METHODS: A total of 412 patients completed the Fatigue Severity Scale (FSS) and Center for Epidemiological Studies Depression Scale (CESD). The patients were registered at our outpatient department and demographic and disease specific data were compared between patients with and without severe fatigue (FSS > or = 5.0) and clinically significant depressive symptoms (CESD > or = 16). We investigated the association of Expanded Disability Status Scale (EDSS) scores, multiple sclerosis severity scores (MSSS) and either CESD scores or FSS-scores with severe fatigue and clinically significant depressive symptoms in a multivariable logistic regression model, with adjustment for possible confounders. RESULTS: Only CESD scores were independently associated with severe fatigue. FSS scores and female gender were independently associated with clinically significant depressive symptoms. Neither EDSS nor MSSS scores were independently associated with fatigue or depression. CONCLUSION: In patients with MS, fatigue and depression are strongly associated with each other but not with the degree of disability or the speed of disability accumulation.

Does smoking influence outcome after intravenous thrombolysis for acute ischaemic stroke?

BACKGROUND AND PURPOSE: It remains uncertain whether current smoking influences outcome in patients with acute ischaemic stroke. OBJECTIVES: To evaluate the effect of current smoking in routinely tissue plasminogen activator (tPA)-treated stroke patients on the 3-month functional outcome and the occurrence of symptomatic intracerebral hemorrhage (ICH). METHODS: We analyzed data from a single stroke care unit registry of 345 consecutive patients with ischaemic stroke, treated with tPA. Logistic regression models were used to assess if smoking was independently associated with 3-months good outcome defined as a modified Rankin Scale score of < or =2, and the occurrence of symptomatic ICH. RESULTS: In the multivariable models, smoking was not associated with a good outcome or a decreased risk of symptomatic ICH. CONCLUSION: Current smoking did not affect functional outcome at 3 months or the risk of symptomatic ICH in patients routinely treated with tPA for ischaemic stroke.

Parity and secondary progression in multiple sclerosis.

BACKGROUND: Pregnancy has a well-documented effect on relapses in multiple sclerosis (MS), whereas little is known about the impact of pregnancy and childbirth on the risk of secondary progression. OBJECTIVE: To investigate the association of parity and secondary progression in women with MS. METHODS: The association of the number of births and secondary progression was studied in a hospital-based cohort of 277 women with MS. Data were analysed in a multivariable logistic regression model, with adjustment for possible confounders. RESULTS: Parity was not independently associated with secondary progression, while the factors disease duration (OR per year increase: 1.05, 95% CI 1.03 to 1.09) and use of immunomodulatory treatments (OR 0.23, 95% CI 0.08 to 0.65) were independently associated with secondary progression. CONCLUSION: We found no evidence that parity influences the risk of secondary progression in MS. Further population-based studies on the association of pregnancy and childbirth on the long-term prognosis of MS are needed.

Development and validation of a predictive outcome score of cerebral venous thrombosis.

BACKGROUND AND PURPOSE: Cerebral venous thrombosis (CVT) is a rare disease with a variable outcome. The aim of this study was to develop and validate a predictive outcome score for CVT patients. METHODS: The score was based on the 8 predictive variables of poor outcome (modified Rankin Scale score>2) from the International Study on Cerebral Vein and Dural Sinus Thrombosis: age >37, male, mental status disorder, coma, intracranial hemorrhage, deep CVT, CNS infection, and malignancy. To assign a weighted index (WI), the natural logarithm of the hazard ratio of each variable was calculated, multiplied by 10 and rounded to the nearest integer. The individual score of each patient was the sum of the WI. The validation sample consisted of a retrospective single center cohort of 90 CVT patients. RESULTS: Sixteen patients (18%) had a poor outcome. The predictive score had an area under the receiver operating characteristic curve of 0.81 (95% CI 0.71-0.90). The cut-off score with the maximum sum of sensitivity and specificity was a score> or =14 with sensitivity of 88% (81%-95%) and specificity of 70% (61%-79%). The predictive value of a score<14 for good outcome was 96% (92%-100%), whereas the predictive value of a score> or =14 for poor outcome was 39% (29%-49%). CONCLUSIONS: This relatively simple predictive outcome score may be useful in CVT patients. A cut-off score of 14 reliably predicts good outcome, but is less accurate in predicting poor outcome.

An often unrecognized cause of thunderclap headache: reversible cerebral vasoconstriction syndrome.

Thunderclap headache (TCH) can have several causes of which subarachnoid hemorrhage (SAH) is most common and well known. A rare cause of TCH is the reversible cerebral vasoconstriction syndrome (RCVS) which is characterized by a reversible segmental vasoconstriction of the intracranial vessels. We describe two patients with TCH due to RCVS and the probable precipitating factor, namely, cannabis and an anti-migraine drug. In RCVS, cerebrospinal fluid examination is (near) normal, in contrast to SAH and (primary) cerebral vasculitis. Brain MRI may be normal or shows infarction. MRA can demonstrate vasoconstriction of the great arteries, but a normal MRA does not rule out the diagnosis. Caliber changes on cerebral angiography cannot adequately differentiate between RCVS and vasculitis. Calcium-channel antagonists may be a good therapy and repeated transcranial Doppler ultrasonography can be a reliable non-invasive investigation to monitor the effect of treatment and demonstrate reversibility of the vasoconstriction.