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1.
Cerebrovasc Dis Extra ; 11(2): 81-86, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34469885

RESUMO

BACKGROUND AND PURPOSE: The short-term benefits of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) have been widely documented, yet there is limited evidence to show that this is sustained in the long term. We aimed to determine whether the benefit of EVT on functional outcome at 3 months is maintained at 12 months and the factors correlating with functional independence and quality of life. METHODS: Data for analysis came from a prospective registry of consecutive patients undergoing EVT at a single Comprehensive Stroke Center (Oct 2018-Sep 2019). A phone interview was conducted for 12-month patient outcomes. Functional outcome was assessed by the modified Rankin Scale (mRS). Quality of life was determined by return to usual place of residence, work, or driving and calculation of a health utility index using the European Quality of Life-5 Dimensions questionnaire (EQ-5D-3L). RESULTS: Of the 151 patients who underwent EVT during the study period, 12-month follow-up was available for 145 (96%). At 12 months, 44% (n = 64) of patients were functionally independent (mRS 0-2) compared to 48% at 3 months. Mortality at 12 months was 26% compared to 17% at 3 months. Significant predictors of functional independence at 12 months were younger age and lower baseline National Institutes of Health Stroke Scale. Better quality of life significantly correlated with return to usual place of residence and driving. CONCLUSION: Three-month functional independence was sustained at 12 months, indicating that EVT remains beneficial for patients with AIS in the longer term.


Assuntos
Procedimentos Endovasculares , AVC Isquêmico/terapia , Trombectomia , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Estado Funcional , Humanos , AVC Isquêmico/diagnóstico , AVC Isquêmico/mortalidade , AVC Isquêmico/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Recuperação de Função Fisiológica , Sistema de Registros , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
2.
BMJ Case Rep ; 14(8)2021 Aug 24.
Artigo em Inglês | MEDLINE | ID: mdl-34429290

RESUMO

Penetrating trauma due to nail gun is an uncommon yet important clinical entity. There are numerous case reports describing these injuries, yet few describe those resulting in cerebrovascular injury. Laceration of cerebral blood vessels may result in significant intracranial haemorrhage and cerebral ischaemia, with catastrophic consequences. In the present study, we report a female patient who was shot in the face with a nail gun in a domestic assault. The nail entered her right cavernous sinus and lacerated her right internal carotid artery causing a pseudoaneurysm and a caroticocavernous fistula. This report details the approach to, and pitfalls of, managing a cerebrovascular injury due to penetrating intracranial nail. Catheter cerebral angiography is essential in the diagnosis and treatment of these injuries. Best treatment and outcomes require clinicians with expertise in endovascular and surgical repair strategies.


Assuntos
Falso Aneurisma , Fístula Carotidocavernosa , Traumatismos Craniocerebrais , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Falso Aneurisma/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Fístula Carotidocavernosa/diagnóstico por imagem , Fístula Carotidocavernosa/etiologia , Fístula Carotidocavernosa/cirurgia , Angiografia Cerebral , Feminino , Humanos
4.
Cerebrovasc Dis ; 50(2): 156-161, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33561856

RESUMO

BACKGROUND AND PURPOSE: The benefit of bridging intravenous thrombolysis (IVT) in acute ischaemic stroke patients eligible for endovascular thrombectomy (EVT) is unclear. This may be particularly relevant where reperfusion is achieved with multiple thrombectomy passes. We aimed to determine the benefit of bridging IVT in first and multiple-pass patients undergoing EVT ≤6 h from stroke onset to groin puncture. METHODS: We compared 90-day modified Rankin Scale (mRS) outcomes in 187 consecutive patients with large vessel occlusions (LVOs) of the anterior cerebral circulation who underwent EVT ≤6 h from symptom onset and who achieved modified thrombolysis in cerebral ischaemia (mTICI) 2c/3 reperfusion with the first pass to those patients who required multiple passes to achieve reperfusion. The effect of bridging IVT on outcomes was examined. RESULTS: Significantly more first-pass patients had favourable (mRS 0-2) 90-day outcomes (68 vs. 42%, p = 0.001). Multivariate analysis showed an association between first-pass reperfusion and favourable outcomes (OR 2.25; 95% CI 1.08-4.68; p = 0.03). IVT provided no additional benefit in first-pass patients (OR 1.17; CI 0.42-3.20; p = 0.76); however, in multiple-pass patients, it reduced the risk of disabling stroke (mRS ≥4) (OR 0.30; CI 0.10-0.88; p = 0.02) and mortality (OR 0.07; CI 0.01-0.36; p = 0.002) at 90 days. CONCLUSION: Bridging IVT may benefit patients with anterior circulation stroke with LVO who qualify for EVT and who require multiple passes to achieve reperfusion.


Assuntos
Procedimentos Endovasculares , Fibrinolíticos/administração & dosagem , AVC Isquêmico/tratamento farmacológico , Trombectomia , Terapia Trombolítica , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fibrinolíticos/efeitos adversos , Estado Funcional , Humanos , Infusões Intravenosas , AVC Isquêmico/diagnóstico , AVC Isquêmico/mortalidade , AVC Isquêmico/fisiopatologia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento
6.
J Phycol ; 56(5): 1232-1244, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32396981

RESUMO

Lake snow, caused by the freshwater centric diatom Lindavia intermedia, has become problematic in several large, oligotrophic New Zealand lakes over the past decade. Macroaggregates produced by L. intermedia foul fishing lines, intake screens, and water filters, and have a negative impact on recreational values. It was confirmed that the fibers constituting lake snow are composed of chitin, two chitin synthase genes (chs1 and 2) from L. intermedia were characterized, new qPCR-based tools to quantify the abundance of the species and measure expression of chs2 relative to the reference gene act1 (the product of which has cytoskeletal functions) were developed. The strong heterogeneity and mucilaginous nature of lake snow samples create particular difficulties for calibrations of gene or transcript copy numbers with cell densities and obtaining high yields of mRNA. However, data collected from four lakes during November 2018 and February and May 2019 show that abundance of L. intermedia is always high when lake snow is also abundant, but that a full range of L. intermedia abundance can occur when lake snow is absent, suggesting that chitin production is not obligate in L. intermedia. This result is consistent with the available data for chs2 expression, which suggest higher transcription when lake snow is abundant. Lake snow production by L. intermedia therefore requires an as yet undetermined stimulus independent of cell abundance.


Assuntos
Diatomáceas , Neve , Quitina , Quitina Sintase/genética , Lagos , Nova Zelândia , Reação em Cadeia da Polimerase
7.
J Clin Neurosci ; 70: 247-249, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31540859

RESUMO

We present a case demonstrating histopathological clot findings after endovascular thrombectomy for acute ischaemic stroke in a 38 year-old male with systemic lupus erythematosus and antiphospholipid syndrome (APS). The differential diagnosis was embolism of a suspected Libman-Sacks vegetation or less likely an in-situ thrombosis. Clot analysis provided guidance with patient management and anticoagulation was commenced. The utility of clot analysis in this case provides support for routine clot analysis, which has been standard practice at our institution, and is likely to evolve as endovascular thrombectomy becomes more widely accessible.


Assuntos
Síndrome Antifosfolipídica/complicações , Síndrome Antifosfolipídica/diagnóstico , Lúpus Eritematoso Sistêmico/complicações , Acidente Vascular Cerebral/etiologia , Trombose/patologia , Adulto , Procedimentos Endovasculares , Humanos , Masculino , Acidente Vascular Cerebral/cirurgia , Trombectomia
8.
Respirol Case Rep ; 7(6): e00435, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31139415

RESUMO

Continuous positive airway pressure (CPAP) therapy is very often the treatment of choice for obstructive sleep apnoea (OSA). The association between intracranial hypertension and spontaneous cerebrospinal fluid (CSF) rhinorrhoea is being increasingly recognized among patients with OSA. However, spontaneous CSF rhinorrhoea following initiation of CPAP therapy for OSA is very rarely documented in the literature. In this report, we describe a 53-year-old woman with severe OSA who, while being evaluated for possible intracranial hypertension, developed spontaneous CSF rhinorrhoea and CSF aspiration pneumonitis as a complication of CPAP therapy. Magnetic resonance imaging confirmed fluid tracks at the skull base, and a nasal swab demonstrated positive ß2-transferrin. Computer tomography (CT) chest showed findings consistent with CSF aspiration pneumonitis. Resolution of both CSF leak and pneumonitis were noted following treatment with azetozolamide and curative endoscopic trans-nasal surgery along with ventriculoperitoneal shunt.

9.
Front Neurol ; 10: 254, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30949120

RESUMO

Background: Elderly patients account for 30% of acute ischemic stroke (AIS) but are under-represented in randomized controlled trials of endovascular thrombectomy (EVT). Meta-analysis of "real world" studies evaluating 90-day outcomes in elderly patients ≥80 years have been limited to small numbers undergoing EVT with older generation devices. Methods: A retrospective analysis of 181 prospectively collected patients who received EVT for anterior circulation AIS at an Australian center over 2.5-years. The study aims to determine (i) 90-day functional outcomes (modified Rankin Scale mRS 0-2) in patients ≥80 vs. <80 years, (ii) the interaction of prognostic factors and age and (iii) compare our data to those previously reported using a meta-analysis of outcomes in observational studies using second generation thrombectomy devices. Results: We analyzed 2,387 patients (≥80 years, n = 649; <80 years, n = 1,738) from 14 studies including our study (≥80 years, n = 71; <80 years, n = 110). Twenty-eight percent of our and 30% of the meta-analysis elderly cohort achieved good 90-day mRS compared to 55 and 52%, respectively of younger patients (p < 0.001). Twenty-seven percent of our and 26% of the meta-analysis elderly cohort died compared to 16% (p = 0.07) and 15% (p < 0.0001), respectively of younger patients. Baseline NIHSS≥16 correlated with poor prognosis in elderly (OR 16.4; 95% CI 4.49-59.91, p < 0.001) and younger (OR 8.73;95% CI 3.35-22.80, p < 0.001) patients. Prior rt-PA was associated with favorable outcome in younger (OR 2.90; 95%CI 1.29-6.52, p = 0.01) patients only. Conclusion: EVT has less favorable outcomes in elderly patients. However, results are better than outcomes in historical controls not treated with thrombectomy providing further support for EVT in the elderly.

10.
Can J Neurol Sci ; 46(3): 331-336, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30867075

RESUMO

BACKGROUND: Endovascular thrombectomy (EVT) has shown efficacy in acute ischemic stroke (AIS) patients with infective endocarditis (IE). The possibility to undertake advanced histopathological clot analysis following EVT offers a new avenue to establish the etiological basis of the stroke - which is often labelled "cryptogenic." In this paper, we present our findings from four consecutive patients with IE who underwent EVT following an AIS at our tertiary referral comprehensive stroke centre. METHODS: Comprehensive histopathological analysis of clot retrieved after EVT, including morphology, was undertaken. RESULTS: The consistent observation was the presence of dense paucicellular fibrinoid material mixed/interspersed with clusters of bacterial cocci. This clot morphology may be specific to septic embolus due to IE unlike incidental bacteraemia and could possibly explain the refractoriness of such clots to systemic thrombolysis. CONCLUSION: Detailed morphological and histopathological analysis of EVT-retrieved clots including Gram staining can assist in etiological classification of the clot. Understanding the composition of the clot may be of clinical value in early diagnostics and mapping treatment planning in IE.


Assuntos
Endocardite/complicações , Endocardite/diagnóstico , Embolia Intracraniana/patologia , Acidente Vascular Cerebral/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Isquemia Encefálica/cirurgia , Procedimentos Endovasculares , Feminino , Humanos , Embolia Intracraniana/microbiologia , Embolia Intracraniana/cirurgia , Masculino , Sepse/complicações , Acidente Vascular Cerebral/cirurgia , Trombectomia , Trombose/microbiologia , Trombose/patologia
11.
J Neurointerv Surg ; 11(7): 694-698, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30552166

RESUMO

BACKGROUND: The Pipeline Embolisation Device with Shield technology (PED-Shield) is suggested to have reduced thrombogenicity. This reduced thrombogenicity may make it possible to use safely in the acute treatment of aneurysmal subarachnoid haemorrhage (aSAH) on single antiplatelet therapy (SAPT). OBJECTIVE: To evaluate the safety and efficacy of the off-label use of PED-Shield with SAPT for the acute treatment of aSAH. METHODS: Patients who underwent acute treatment of ruptured intracranial aneurysms with the PED-Shield with SAPT were retrospectively identified from prospectively maintained databases at three Australian neurointerventional centres. Patient demographics, aneurysm characteristics, clinical and imaging outcomes were reviewed. RESULTS: Fourteen patients were identified (12 women), median age 64 (IQR 21.5) years. Aneurysm morphology was saccular in seven, fusiform in five, and blister in two. Aneurysms arose from the anterior circulation in eight patients (57.1%). Six (42.9%) patients were poor grade (World Federation of Neurological Societies grade ≥IV) SAH. Median time to treatment was 1 (IQR 0.5) day. Complete or near complete aneurysm occlusion (Raymond-Roy <3) was achieved in 12 (85.7%) patients at the end of early-acute follow-up (median day 7 after SAH). Permanent, treatment-related morbidity occurred in one (7.1%) patient and one (7.1%) treatment-related death occurred. The use of a postoperative heparin infusion (n=5) was associated with a higher rate of all complications (80.0% vs 11.1%, p=0.023) and symptomatic complications (60% vs 0.0%, p=0.028). No symptomatic ischaemic or haemorrhagic complications were observed in the patients who did not receive a post-operative heparin infusion. Nine (64.3%) patients were functionally independent on discharge from the treatment centre. CONCLUSION: The PED-Shield may be safe to use in the acute treatment of ruptured intracranial aneurysms with SAPT. Further investigation with a formal treatment registry is needed.


Assuntos
Aneurisma Roto/terapia , Prótese Vascular/tendências , Aneurisma Intracraniano/terapia , Inibidores da Agregação Plaquetária/administração & dosagem , Hemorragia Subaracnóidea/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/epidemiologia , Austrália/epidemiologia , Prótese Vascular/efeitos adversos , Embolização Terapêutica/métodos , Embolização Terapêutica/tendências , Feminino , Heparina/administração & dosagem , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/epidemiologia , Resultado do Tratamento , Adulto Jovem
12.
Front Neurol ; 9: 501, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30026722

RESUMO

Background: Trials have demonstrated efficacy for endovascular thrombectomy (EVT) for anterior circulation acute ischaemic stroke (AIS) up to 24-h from symptom onset. The magnitude of effect suggests benefit may exist beyond 24-h. Objectives: To perform a retrospective review of all patients undergoing EVT for anterior circulation LVO stroke beyond 24-h from symptom onset and assess safety and efficacy. Methods:A prospectively maintained database of EVT patients treated at two comprehensive stroke centers between January 2016 and December 2017 was retrospectively screened. Patients undergoing EVT for anterior circulation AIS >24-h from symptom onset were selected. Results: A total of 429 AIS patient underwent EVT in the study period. Five patients treated >24-h from symptom onset were identified. The median age was 72 (range 42-84); median ASPECTS 8 (range 6-8); median baseline-NIHSS 9 (range 4-17); and median time from symptom onset to groin puncture 44 h and 55 min (range 25:07-90:10). One patient underwent CT perfusion imaging. The remaining four patients were selected based on non-contrast CT brain and CT-angiography. Two patients had tandem cervical carotid lesions and underwent acute stenting. Modified thrombolysis in cerebral ischaemia (mTICI) 3 reperfusion was achieved in four patients. No hemorrhagic transformation occurred. All patients were alive at 90-day follow-up. Four patients achieved functional independence at 90-days (mRS 0-2). Conclusion: Endovascular thrombectomy for AIS patients beyond 24-h from symptom onset appears to be safe and effective in this limited study. There is a need for further evidence-based trials of benefit vs. risk in very prolonged time windows.

13.
Front Neurol ; 9: 301, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29867718

RESUMO

Objective: To explore the effects of reperfusion grade rates on clinical outcomes in the setting of stent-retriever-based reperfusion therapy for anterior circulation stroke in early time windows. Methods: Systematic searching of Medline and Embase databases was performed to identify stroke trials of stent-retriever-based therapy versus standard care. Mixed effects meta-regression was used to analyze the trial-level association between reperfusion rates and clinical outcomes. Results: A total of five trials met the inclusion criteria (n = 1,287). Rates of successful reperfusion [modified thrombolysis in cerebral ischemia grade 2b/3] demonstrated strong evidence for an association with good functional outcomes [modified Rankin scale score (mRS) 0-2] OR 1.59 (95% CI 1.16, 2.19) p = 0.019 and very strong evidence for an association with excellent functional outcomes (mRS 0-1) OR 2.10 (95% CI 1.46, 3.01) p = 0.007. In addition, there was weak evidence for an association with symptomatic intracranial hemorrhage OR 0.54 (95% CI 0.28, 1.04) p = 0.057 and mortality OR 0.69 (95% CI 0.69, 1.01) p = 0.053. Conclusion: In early, stent-retriever-based acute ischemic stroke treatment, reperfusion appears to be a major predictor of outcomes. Every 10% increase in the rates of successful reperfusion is associated with an 11% increase in the probability of achieving good and 17% increase in the probability of achieving excellent outcomes. Symptomatic intracranial hemorrhage and mortality may be decreased as reperfusion rates are improved.

14.
J Neurointerv Surg ; 10(7): 638-643, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29760013

RESUMO

INTRODUCTION: Cerebral collateral circulation has been studied extensively in ischemic stroke where it has been shown to be a predictor of reperfusion, final infarct size, and outcome. Little is known about the significance of the collaterals in the setting of aneurysmal subarachnoid hemorrhage (aSAH). We sought to evaluate the effect of cerebral vasospasm on the development of cerebral collaterals following aneurysmal subarachnoid hemorrhage and the effects of the latter on delayed cerebral ischemia (DCI). METHODS: We retrospectively evaluated 64 aSAH patients with evidence of DCI between day 5 and 7, enrolled in a prospectively maintained observational cohort study. Angiograms were evaluated by four blinded neurointerventionalists. We compared good collateral grades to poor collateral grades, additionally we compared enrolled individuals with any collaterals versus patients who had no collaterals. RESULTS: Inter-rater reliability for collateral grades was substantial (weighted kappa 0.632). Mild vasospasm was more frequent in patients with poor collateral grades compared with patients with good collateral grades (32% vs 4% P=0.012). There was no difference between the collateral groups with regards to DCI, functional, or cognitive outcome. Patients adjudicated to have any collaterals were more likely to have severe vasospasm (62% vs 33% P=0.023) and less likely to have mild vasospasm (37% vs 9% P=0.007). In a multivariable model, vasospasm severity remained associated with collateral status, while aneurysm location was not. CONCLUSIONS: The severity of vasospasm following aSAH was associated with the development of collaterals. There was no difference between collateral grades with regards to DCI or outcome.


Assuntos
Circulação Colateral , Índice de Gravidade de Doença , Hemorragia Subaracnóidea/diagnóstico por imagem , Vasoespasmo Intracraniano/diagnóstico por imagem , Adulto , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico por imagem , Circulação Cerebrovascular/fisiologia , Estudos de Coortes , Circulação Colateral/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Hemorragia Subaracnóidea/complicações , Vasoespasmo Intracraniano/complicações
15.
J Cereb Blood Flow Metab ; 38(11): 1911-1923, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-28737109

RESUMO

Post-ischemic vasodynamic changes in infarcted brain parenchyma are common and range from hypo- to hyperperfusion. In the present study, appearance of the lenticulostriate arteries (LSAs) on postinterventional 3T time-of-flight (TOF)-MRA suggestive for altered post-stroke vasodynamics following thrombectomy was investigated. Patients who underwent thrombectomy for a proximal MCA occlusion and for whom postinterventional 3T TOF-MRA (median at day 3) was available, were included in this retrospective analysis (n=98). LSA appearance was categorized into presence (LSA-sign+) or absence (LSA-sign-) of vasodilatation in the ischemic hemisphere. Functional outcome was determined using the modified Rankin scale (mRS). LSA-sign+ was observed in 64/98 patients. Hypertension (adjusted OR: 0.171, 95% CI: 0.046-0.645) and preinterventional IV rtPA (adjusted OR: 0.265, 95% CI: 0.088-0.798) were associated with absence of the LSA-sign+. In multivariate logistic regression, LSA-sign+ was associated with substantial neurologic improvement (adjusted OR: 10.18, 95% CI: 2.69-38.57) and good functional outcome (discharge-mRS ≤ 2, adjusted OR: 7.127, 95% CI: 1.913-26.551 and day 90 mRS ≤ 2, adjusted OR: 3.786, 95% CI: 1.026-13.973) after correcting for relevant confounders. For all clinical endpoints, model fit improved when including the LSA-sign term (p<0.05). Asymmetrical dilatation of LSAs following successful thrombectomy indicates favorable neurologic and mid-term functional outcomes. This may indicate preserved cerebral blood flow regulatory mechanisms.


Assuntos
Artérias/diagnóstico por imagem , Doença Cerebrovascular dos Gânglios da Base/diagnóstico por imagem , Circulação Cerebrovascular/fisiologia , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Recuperação de Função Fisiológica/fisiologia , Idoso , Idoso de 80 Anos ou mais , Artérias/patologia , Doença Cerebrovascular dos Gânglios da Base/patologia , Encéfalo/irrigação sanguínea , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Feminino , Hemodinâmica/fisiologia , Humanos , Infarto da Artéria Cerebral Média/patologia , Infarto da Artéria Cerebral Média/cirurgia , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombectomia , Vasodilatação/fisiologia
16.
Neurosurgery ; 83(3): 416-421, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-28973669

RESUMO

BACKGROUND: Transcranial Doppler ultrasound is a standard screening tool for vasospasm after subarachnoid hemorrhage. Prevention of vasospasm-induced delayed cerebral ischemia after subarachnoid hemorrhage depends on optimization of cerebral perfusion pressure, which can be challenged by neurogenic stress cardiomyopathy. Intra-aortic balloon pumps have been utilized to augment cerebral perfusion, but they change the transcranial Doppler waveform, altering its interpretability for vasospasm screening. OBJECTIVE: To assess the features of the transcranial Doppler waveform that correlate with vasospasm. METHODS: We retrospectively reviewed cases of subarachnoid hemorrhage that underwent same-day transcranial Doppler ultrasound and angiography. Transcranial Doppler waveforms were assessed for mean velocity, peak systolic velocity, balloon pump-augmented diastolic velocity, and a novel feature, "delta velocity" (balloon pump-augmented velocity - systolic velocity). Relationship of flow velocity features to vasospasm was estimated by generalized estimating equation models using a Gaussian distribution and an exchangeable correlation structure. RESULTS: There were 31 transcranial Doppler and angiography pairings (12 CT angiography/19 digital subtraction angiography) from 4 patients. Fourteen pairings had proximal vasospasm by angiography. Delta velocity was associated with proximal vasospasm (coefficient -6.8 [95% CI -9.8 to -3.8], P < .001). There was no significant correlation with proximal vasospasm for mean velocity (coefficient -13.0 [95% CI -29.3 to 3.4], P = .12), systolic velocity (coefficient -8.7 [95% CI -24.8 to 7.3], P = .29), or balloon pump-augmented velocity (coefficient -15.3 [95% CI -31.3 to 0.71], P = .06). CONCLUSION: Delta velocity, a novel transcranial Doppler flow velocity feature, may reflect vasospasm in patients with subarachnoid hemorrhage and intra-aortic balloon pumps.


Assuntos
Contrapulsação/métodos , Hemorragia Subaracnóidea/complicações , Ultrassonografia Doppler Transcraniana/métodos , Vasoespasmo Intracraniano/diagnóstico , Vasoespasmo Intracraniano/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Vasoespasmo Intracraniano/fisiopatologia
17.
Front Neurol ; 8: 272, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28674513

RESUMO

BACKGROUND: Striatocapsular infarcts (SCIs) are defined as large subcortical infarcts involving the territory of more than one lenticulostriate artery. SCI without concomitant ischemia in the more distal middle cerebral artery (MCA) territory [isolated SCI (iSCI)] has been described as a rare infarct pattern. The purpose of this study was to assess the prevalence of iSCI in patients treated with endovascular thrombectomy (ET), to evaluate baseline and procedural parameters associated with this condition, and to describe the clinical course of iSCI patients. METHODS: A retrospective analysis of 206 consecutive patients with an isolated MCA occlusion involving the lenticulostriate arteries and treated with ET was performed. Baseline patient and procedural characteristics and ischemic involvement of the striatocapsular and distal MCA territory [iSCI, as opposed to non-isolated SCI (niSCI)] were analyzed using multivariate logistic regression models. Prevalence of iSCI was assessed, and clinical course was determined with the rates of substantial neurological improvement and good functional short- and mid-term outcome (discharge/day 90 Modified Rankin Scale ≤2). RESULTS: iSCI was detected in 53 patients (25.7%), and niSCI was detected in 153 patients (74.3%). Successful reperfusion [thrombolysis in cerebral infarction (TICI) 2b/3] [adjusted odds ration (aOR) 8.730, 95% confidence interval (95% CI) 1.069-71.308] and good collaterals (aOR 2.100, 95% CI 1.119-3.944) were associated with iSCI. In successfully reperfused patients, TICI 3 was found to be an additional factor associated with iSCI (aOR 5.282, 1.759-15.859). Patients with iSCI had higher rates of substantial neurological improvement (71.7 vs. 37.9%, p < 0.001) and higher rates of good functional short- and mid-term outcome (58.3 vs. 23.7%, p < 0.001 and 71.4 vs. 41.7%, p < 0.001). However, while iSCI patients, in general, had a more favorable outcome, considerable heterogeneity in outcome was observed. CONCLUSION: High rates of successful reperfusion (TICI 2b/3) and in particular, complete reperfusion (TICI 3) are associated with iSCIs. The high prevalence of iSCI in successfully reperfused patients with good collaterals corroborates previous concepts of iSCI pathogenesis. iSCI, once considered a rare pattern of cerebral ischemia, is likely to become more prevalent with increases in endovascular stroke therapy. This may have implications for patient rehabilitation and pathophysiological analyses of ischemic damage confined to subcortical regions of the MCA territory.

18.
Br J Neurosurg ; 31(5): 573-579, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28298139

RESUMO

OBJECTIVE: Acute occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. The aim of our study was to retrospectively delineate the feasibility of the combined use of emergent carotid stenting and intra-arterial (IA) Abciximab with intracranial revascularization in the setting of acute ischemic stroke and carotid occlusions at our institution. METHODS: Eleven patients with complete cervical carotid occlusion with or without concomitant intracranial ICA and/or MCA occlusion were identified from a single center, retrospective review of patients admitted to the Stroke unit. We evaluated all cases for complications of emergent cervical ICA recanalization employing carotid stenting and IA Abciximab. RESULTS: All patients had complete cervical carotid occlusion with (n = 8) or without (n = 3) concomitant intracranial ICA and/or MCA occlusion. Successful emergent cervical ICA recanalization was achieved in all cases. All patients were administered IA Abciximab (dose range 6-17 mg, average 11.4 mg) immediately following the cervical carotid stenting. There was complete recanalization in all patients with no procedural morbidity or mortality. A single case (1/11, 9%) developed asymptomatic hemorrhagic transformation. Upon discharge, 9 patients (9/11, 82%) had a mRS of 0-2 and 2 patients (2/11, 18%) had a mRS of 3. CONCLUSIONS: In acute ICA-MCA/distal ICA occlusions, extracranial stenting followed by intracranial IA Abciximab and thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.


Assuntos
Anticorpos Monoclonais/administração & dosagem , Anticoagulantes/administração & dosagem , Isquemia Encefálica/terapia , Estenose das Carótidas/terapia , Fragmentos Fab das Imunoglobulinas/administração & dosagem , Acidente Vascular Cerebral/terapia , Abciximab , Idoso , Angioplastia com Balão/métodos , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/terapia , Isquemia Encefálica/etiologia , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/complicações , Terapia Combinada , Quimioterapia Combinada , Endarterectomia das Carótidas/métodos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Infusões Intra-Arteriais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombose dos Seios Intracranianos/terapia , Stents/efeitos adversos , Acidente Vascular Cerebral/etiologia , Trombectomia/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ativador de Plasminogênio Tecidual/metabolismo , Resultado do Tratamento
19.
Cerebrovasc Dis ; 42(3-4): 170-7, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27111086

RESUMO

BACKGROUND: In the last 12 months, treatment of acute ischaemic stroke secondary to large vessel occlusion has undergone a paradigm shift. The success of endovascular surgery, and in particular, the use of stent-retrievers, is remarkable. SUMMARY: Beyond percentages and p values, the endovascular trials demonstrated, in their similarities and their differences, the critical elements of successful intervention in acute ischaemic stroke. Patient selection based on non-invasive neuroimaging has emerged as a critical step in acute ischaemic stroke management. The more sophisticated imaging-based selection, those assessing collateral blood flow or ischaemic penumbra appear to be associated with better outcomes and possibly fewer complications. The importance of achieving effective, quality reperfusion is also demonstrated, in a remarkably linear fashion, across the 5 published trials. This may emerge as the single most important determinant of functional outcomes. While reperfusion may succeed time as the preeminent modifiable variable, it remains clear that achieving quality reperfusion in a timely manner should remain the goal of all acute stroke programs. KEY MESSAGE: Comparing the recent successful endovascular stroke trials, both between one another, and to their unsuccessful predecessors, emphasizes the importance of patient selection, time and reperfusion. Highlighting these factors allows for a better understanding of the challenges facing clinicians and the changes required to be made in hospital systems in order to achieve a new standard of care in treating acute ischaemic stroke.


Assuntos
Circulação Cerebrovascular , Procedimentos Endovasculares/métodos , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Medicina Baseada em Evidências , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Stents , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Resultado do Tratamento
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