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1.
J Stroke Cerebrovasc Dis ; 29(2): 104504, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31761735

RESUMO

BACKGROUND: Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery. METHODS: We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported. RESULTS: Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02). CONCLUSIONS: The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.


Assuntos
Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/epidemiologia , Infarto da Artéria Cerebral Anterior/epidemiologia , Infarto da Artéria Cerebral Média/epidemiologia , Insuficiência Vertebrobasilar/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Artéria Cerebral Anterior/diagnóstico por imagem , Artéria Cerebral Anterior/fisiopatologia , Artéria Basilar/diagnóstico por imagem , Artéria Basilar/fisiopatologia , Artéria Carótida Interna/fisiopatologia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/fisiopatologia , Angiografia Cerebral/métodos , Circulação Cerebrovascular , Angiografia por Tomografia Computadorizada , Bases de Dados Factuais , Feminino , Humanos , Infarto da Artéria Cerebral Anterior/diagnóstico por imagem , Infarto da Artéria Cerebral Anterior/fisiopatologia , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/fisiopatologia , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/fisiopatologia , Valor Preditivo dos Testes , Prevalência , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados Unidos/epidemiologia , Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/fisiopatologia , Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/fisiopatologia
2.
J Stroke Cerebrovasc Dis ; 29(2): 104516, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31791651

RESUMO

BACKGROUND AND PURPOSE: ASPECTS (Alberta Stroke Program Early CT Score) is a 10-point topographic CT scan score that has been shown to be a strong prognostic factor in acute ischemic stroke. We investigated whether all ASPECTS regions have the same prognostic value. METHODS: Clinical characteristics, ASPECTS, and 3-month modified Rankin Scale (mRS) data were retrospectively collected in 350 patients who were diagnosed with middle cerebral artery (MCA) territory stroke. To describe the 3-month mRS data, an ordered categorical approach was applied using a proportional odds model. Furthermore, external validation was performed using additional data from 30 patients. RESULTS: As expected, ASPECTS was an independently important predictor. However, when 10 regions were analyzed separately, the M1, M2, and M3 regions, related to MCA cortex, were not found to predict 3-month mRS scores in the final model. The odds ratios for ischemic change in other regions (except M1, M2, and M3) ranged from 2.6 to 3.8. Moreover, among clinical characteristics, only age was identified as a significant predictor. The sensitivity and specificity of the final model in the external validation were 91% and 88%, respectively. CONCLUSIONS: All ASPECTS regions did not have the same predictive power for functional outcomes, defined as the 3-month mRS. The implementation of a proportional odds model allowed a proper description of the ordered categorical nature of the mRS and the identification of relevant predictors.


Assuntos
Infarto da Artéria Cerebral Média/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Feminino , Humanos , Infarto da Artéria Cerebral Média/fisiopatologia , Infarto da Artéria Cerebral Média/reabilitação , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Recuperação de Função Fisiológica , Reprodutibilidade dos Testes , Estudos Retrospectivos , Reabilitação do Acidente Vascular Cerebral , Fatores de Tempo
3.
J Stroke Cerebrovasc Dis ; 29(2): 104467, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31767525

RESUMO

BACKGROUND AND AIM: Although fluid-attenuated inversion recovery vascular hyperintensities may be frequently seen in acute large-artery ischemic stroke, reports on their prognostic utility had been conflicting due to lack of quantitative evaluation of the perfusion status based on the signal intensity. We hypothesized that greater hyperintensity represents more severe hypoperfusion. METHODS: Overall, 27 patients with acute occlusion of the proximal middle cerebral artery were divided into 2 groups, based on their signal intensity in the insular segment of middle cerebral artery on the affected side, relative to that of the insular cortex: the low signal intensity group (hypo- or isointense signals, n = 12) and the high signal intensity group (hyperintense signals, n = 15). Using dynamic susceptibility contrast magnetic resonance imaging, we assessed the time of the maximum value of the residue function and mean transit time, in the entire middle cerebral artery cortical area and diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score regions, including the corona radiata. RESULTS: The high signal intensity group had significantly longer time of the maximum value of the residue function in all the diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score regions, except the M3 and M6 regions, and significantly longer mean transit time in the M1 and M4 regions. CONCLUSIONS: Quantitative analysis of the perfusion parameters revealed more severely compromised and widely disturbed perfusion status in the high signal intensity group than in the low signal intensity group.


Assuntos
Circulação Cerebrovascular , Imagem de Difusão por Ressonância Magnética , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Angiografia por Ressonância Magnética , Artéria Cerebral Média/diagnóstico por imagem , Imagem de Perfusão/métodos , Idoso , Idoso de 80 Anos ou mais , Velocidade do Fluxo Sanguíneo , Feminino , Humanos , Infarto da Artéria Cerebral Média/fisiopatologia , Masculino , Artéria Cerebral Média/fisiopatologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença
4.
J Stroke Cerebrovasc Dis ; 29(2): 104488, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31787498

RESUMO

BACKGROUND: We aimed to assess the correlation of lesion location and clinical outcome in patients with large hemispheric infarction (LHI). METHODS: We analyzed admission MRI data from the GAMES-RP trial, which enrolled patients with anterior circulation infarct volumes of 82-300 cm3 within 10 hours of onset. Infarct lesions were segmented and co-registered onto MNI-152 brain space. Voxel-wise general linear models were applied to assess location-outcome correlations after correction for infarct volume as a co-variate. RESULTS: We included 83 patients with known 3-month modified Rankin scale (mRS). In voxel-wise analysis, there was significant correlation between admission infarct lesions involving the anterior cerebral artery (ACA) territory and its middle cerebral artery (MCA) border zone with both higher 3-month mRS and post-stroke day 3 and 7 National Institutes of Health Stroke Scale (NIHSS) total score and arm/leg subscores. Higher NIHSS total scores from admission through poststroke day 2 correlated with left MCA infarcts. In multivariate analysis, ACA territory infarct volume (P = .001) and admission NIHSS (P = .005) were independent predictors of 3-month mRS. Moreover, in a subgroup of 36 patients with infarct lesions involving right MCA-ACA border zone, intravenous (IV) glibenclamide (BIIB093; glyburide) treatment was the only independent predictor of 3-month mRS in multivariate regression analysis (P = .016). CONCLUSIONS: Anterior extension of LHI with involvement of ACA territory and ACA-MCA border zone is an independent predictor of poor functional outcome, likely due to impairment of arm/leg motor function. If confirmed in larger cohorts, infarct topology may potentially help triage LHI patients who may benefit from IV glibenclamide. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01794182.


Assuntos
Artéria Cerebral Anterior/diagnóstico por imagem , Cérebro/irrigação sanguínea , Imagem de Difusão por Ressonância Magnética , Extremidades/inervação , Infarto da Artéria Cerebral Anterior/diagnóstico por imagem , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/diagnóstico por imagem , Administração Intravenosa , Idoso , Artéria Cerebral Anterior/fisiopatologia , Circulação Cerebrovascular , Ensaios Clínicos como Assunto , Ensaios Clínicos Fase II como Assunto , Avaliação da Deficiência , Feminino , Glibureto/administração & dosagem , Humanos , Hipoglicemiantes/administração & dosagem , Infarto da Artéria Cerebral Anterior/fisiopatologia , Infarto da Artéria Cerebral Anterior/terapia , Infarto da Artéria Cerebral Média/fisiopatologia , Infarto da Artéria Cerebral Média/terapia , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/fisiopatologia , Admissão do Paciente , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
5.
J Stroke Cerebrovasc Dis ; 29(2): 104542, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31836359

RESUMO

OBJECTIVES: The aim of this study was to explore the role of the vessel diameter at the site of middle cerebral artery (MCA) occlusion in acute ischemic stroke patients who underwent mechanical thrombectomy (MT) regarding technical aspects, safety, and clinical outcomes. METHODS: In a retrospective analysis, cerebral artery diameters were measured using digital subtraction angiography in patients with isolated M1 or M2 occlusions undergoing MT. Associations between occluded vessel, occlusion diameter and outcomes were analyzed using logistic regression models adjusting for prespecified prognostic factors. RESULTS: 168 patients with M1 occlusions and 98 patients with M2 occlusions who underwent MT were included. Mean vessel diameters at M1 and M2 occlusion sites differed significantly (2.15 +/- .36 1.55 +/- .38, P < .001). Vessel diameters at the occlusion site and occluded vessel segment did not predict good functional outcome (aOR 1.2 CI .28-5.26, P = .659; aOR .84 CI .35-2.03, P = .841) or mortality (aOR .21 CI .04-1.01, P = .215; aOR 1.36 CI .55-3.37, P = .676). No significant differences in successful recanalization, good functional outcome, mortality, procedural complications, and intracranial hemorrhages between M1 and M2 occlusions was observed. CONCLUSIONS: In this study no significant effect of the MCA vessel diameter on successful recanalization, good functional outcome, or mortality of acute ischemic stroke patients treated with MT could be detected. However, these findings need to be confirmed in further studies.


Assuntos
Angiografia Digital , Angiografia Cerebral/métodos , Infarto da Artéria Cerebral Média/terapia , Artéria Cerebral Média/diagnóstico por imagem , Trombectomia , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/mortalidade , Infarto da Artéria Cerebral Média/fisiopatologia , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/fisiopatologia , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
6.
World Neurosurg ; 135: 245-251, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31881346

RESUMO

BACKGROUND: Mobile calcified emboli are a rare cause of large vessel occlusion and acute ischemic stroke and pose unique challenges to standard mechanical thrombectomy techniques. Intracranial stenting has been reported as a rescue maneuver in cases of failed mechanical thrombectomy owing to dissection or calcified atherosclerotic plaques, but its use for calcified emboli is not well described. CASE DESCRIPTION: We present 2 cases of acute ischemic stroke caused by mobile calcified emboli. Standard mechanical thrombectomy techniques using aspiration catheters and stent-retrievers failed to remove these emboli, so intracranial stenting was successfully performed in each case, albeit after overcoming unique challenges associated with the stenting of calcified emboli. We also review the literature on intracranial stenting as a salvage therapy for failed mechanical thrombectomy. CONCLUSIONS: Mobile calcified emboli are rare causes of acute ischemic stroke. Intracranial stenting can be used to successfully treat calcified emboli when mechanical thrombectomy has failed.


Assuntos
Infarto da Artéria Cerebral Média/cirurgia , Embolia Intracraniana/cirurgia , Complicações Pós-Operatórias/cirurgia , Stents , Trombectomia , Adulto , Idoso , Valva Aórtica/patologia , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Calcinose/diagnóstico por imagem , Calcinose/cirurgia , Doenças das Artérias Carótidas/diagnóstico por imagem , Estenose das Carótidas , Angiografia Cerebral , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Embolia Intracraniana/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Falha de Tratamento
7.
Nat Commun ; 10(1): 5504, 2019 12 03.
Artigo em Inglês | MEDLINE | ID: mdl-31796741

RESUMO

3D histology, slice-based connectivity atlases, and diffusion MRI are common techniques to map brain wiring. While there are many modality-specific tools to process these data, there is a lack of integration across modalities. We develop an automated resource that combines histologically cleared volumes with connectivity atlases and MRI, enabling the analysis of histological features across multiple fiber tracts and networks, and their correlation with in-vivo biomarkers. We apply our pipeline in a murine stroke model, demonstrating not only strong correspondence between MRI abnormalities and CLARITY-tissue staining, but also uncovering acute cellular effects in areas connected to the ischemic core. We provide improved maps of connectivity by quantifying projection terminals from CLARITY viral injections, and integrate diffusion MRI with CLARITY viral tracing to compare connectivity maps across scales. Finally, we demonstrate tract-level histological changes of stroke through this multimodal integration. This resource can propel investigations of network alterations underlying neurological disorders.


Assuntos
Conectoma , Processamento de Imagem Assistida por Computador , Imagem por Ressonância Magnética , Microscopia , Animais , Automação , Axônios/metabolismo , Modelos Animais de Doenças , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/patologia , Camundongos Endogâmicos C57BL , Reprodutibilidade dos Testes , Software , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/patologia
9.
Stroke ; 50(4): 901-908, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-31633899

RESUMO

Background and Purpose: Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0­5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core. Methods: Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days. Result: Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P<0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10­4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P=0.55; adjusted odds ratio, 0.50; 95% CI, 0.14­1.73). Conclusions: Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.


Assuntos
Procedimentos Endovasculares , Infarto da Artéria Cerebral Média/terapia , Embolia Intracraniana/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Embolia Intracraniana/diagnóstico por imagem , Japão , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores Sexuais , Trombectomia , Tomografia Computadorizada por Raios X , Resultado do Tratamento
10.
J Stroke Cerebrovasc Dis ; 28(12): 104458, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31662241

RESUMO

BACKGROUND: Computed tomography angiogram (CTA) derived from computed tomography perfusion (CTP) has been proposed to avoid addition of separate CT perfusion protocol for selection of large vessel occlusion in acute stroke patients. Previous studies have validated this technique for proximal large vessel occlusions. In this study, we test reliability for identifying M2 occlusions on CTA derived from CTP. METHODS: Through a retrospective search of the institutional thrombectomy database, we identified 28 cases with M2-MCA occlusion, of which 24 met the inclusion criteria for analysis. An additional 20 cases without M2-MCA occlusion (either normal or M1-MCA occlusion) were randomly mixed in the database to reduce observer bias. The baseline images of the CTP study in these 48 cases were then independently analyzed by 3 readers with varying level of expertise. The digital subtraction angiography (DSA) images were also independently reviewed where available. The percentage of agreement among reviewers as well as the probability of agreement of the reviewers, when compared to the DSA findings was also calculated. RESULTS: The observed agreement for the image quality amongst the 3 readers (n = 48) varied between 0.78 and 0.95 and tended to be higher for the M1 segment MCA and lower for distal M2-MCA. The observed agreements comparing 3 image reviewers versus DSA in M2 patients (n = 24) was 98% for identifying occlusion (95% CI 95%-100%), 94% for identifying proximal M2 occlusion (95% CI 88%-98%), and 91% (95% CI 84%-97%) and 90% (95% CI 83%-95%), respectively for correctly identifying inferior and superior branch of M2 occlusion. CONCLUSION: CTA data derived from CT Perfusion study preserves diagnostic yield for correctly identifying M2 occlusion.


Assuntos
Angiografia Cerebral , Circulação Cerebrovascular , Angiografia por Tomografia Computadorizada , Meios de Contraste/administração & dosagem , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Iopamidol/administração & dosagem , Artéria Cerebral Média/diagnóstico por imagem , Tomografia Computadorizada Multidetectores , Imagem de Perfusão/métodos , Bases de Dados Factuais , Humanos , Infarto da Artéria Cerebral Média/fisiopatologia , Artéria Cerebral Média/fisiopatologia , Variações Dependentes do Observador , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos
11.
Clin Nucl Med ; 44(11): 907-910, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31592826

RESUMO

A 70-year-old woman had spontaneous resolution of an embolism in her right middle cerebral artery (MCA) (day 1); another embolism occurred in her left MCA (day 3), which was promptly removed. On day 5, F-FDG PET/CT performed for staging mediastinal lymphoma showed marked FDG accumulation in the left MCA territory, whereas a defect was seen in the right insular region. Eventually, bilateral lesions developed irreversible infarction. Anaerobic metabolism and/or inflammation in acute-phase infarction were the supposed mechanism for the increased accumulation of FDG in her left MCA territory.


Assuntos
Fluordesoxiglucose F18/metabolismo , Infarto da Artéria Cerebral Média/metabolismo , Artéria Cerebral Média/metabolismo , Doença Aguda , Idoso , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/diagnóstico por imagem , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons
12.
Sichuan Da Xue Xue Bao Yi Xue Ban ; 50(3): 344-349, 2019 May.
Artigo em Chinês | MEDLINE | ID: mdl-31631601

RESUMO

Objective: To determine the value of applying multimodal ultrasound (mUS) in SD rats of cerebral ischemic model at super early stage (5-15 min after modeling). Methods: Fifteen focal cerebral ischemic models were established in SD rats with thinning skulls using the suture method. Gray-scale ultrasound, contrast-enhanced ultrasound, and enhanced color Doppler (CECDUS) were performed before and immediately after the modeling to observe the location of the in-cranial suture, perfusion of the right hemisphere, and color flow signal of the middle cerebral artery and the anterior cerebral artery, respectively.A modified neurological deficit score (mNSS) and 2, 3, 5-triphenyltetrazolium chloride (TTC) stains were obtained three hours later to confirm the successful modeling as the gold standard. The positive rate detected by mUS was compared with the gold standard using McNemar tests. Results: One rat died and 14 rats completed the experiment.mUS imaging detected 71% (10/14) positive signals, no significant difference compared with the gold standard (64%, 9/14) ( P>0.05). A hyperechoic double-line at the bottom of the right brain and focal hypoperfused areas in the right hemisphere were observed by gray scale ultrasound and contrast-enhanced ultrasound in the successfully modeled rats, respectively. The CECDUS found no blood flow in the anterior and middle cerebral arteries. Time intensity curve (TIC) analyses indicated significant changes in peak intensity (PI), area under the curve (AUC), wash in slope (WIS), and time to peak (TTP) after successful modeling. Conclusion: Multimodal ultrasound can assess modeling success quickly and accurately immediately after the establishment of ischemic model of SD rats.


Assuntos
Infarto da Artéria Cerebral Média/diagnóstico por imagem , Animais , Área Sob a Curva , Modelos Animais de Doenças , Camundongos , Perfusão , Ratos , Ratos Sprague-Dawley , Ultrassonografia
13.
J Stroke Cerebrovasc Dis ; 28(11): 104365, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31530482

RESUMO

A 64-year-old woman was admitted to our hospital 48 minutes after sudden onset of dysphasia and right hemiplegia. Head computed tomography revealed small infarcts in the left putamen and 4-dimensional computed tomography angiography depicted high-degree stenosis in the left middle cerebral artery and delayed filling of the contrast media in the left middle cerebral artery territory. The patient underwent intravenous tissue plasminogen activator treatment. On day 5 of hospitalization, the patient underwent conventional cerebral angiography, revealing internal carotid artery to middle cerebral artery dissection. Fortunately, subarachnoid hemorrhage as an adverse effect did not occur, although iv-tPA was administered without detecting middle cerebral artery dissection.


Assuntos
Angiografia Digital , Dissecação da Artéria Carótida Interna/diagnóstico por imagem , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada , Fibrinolíticos/administração & dosagem , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
14.
World Neurosurg ; 132: 300-302, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31525479

RESUMO

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic disorder associated with infertility treatment. The main pathology of OHSS is intravascular dehydration and hyperestrogenemia. In mild cases, abdominal symptoms are the main symptoms, but in severe cases, thrombosis such as cerebral infarction may occur. CASE DESCRIPTION: A 36-year-old woman was undergoing infertility treatment in obstetrics and gynecology for infertility. She received HMG-HCG therapy and artificial insemination 1 week before onset, and on the day of onset she had mild abdominal distension and was suspected of having OHSS. She was prescribed aspirin for prevention of thrombosis. She presented with right upper hemiparesis and aphasia. Magnetic resonance imaging showed left middle cerebral artery occlusion. We performed mechanical thrombectomy and finally achieved Thrombolysis in Cerebral Infarction 3 recanalization. We suspected embolism as the etiology of cerebral infarction and started anticoagulation therapy. Various examinations were conducted to investigate the embolism source, but no anatomic abnormality or thrombophilia factors were observed. Because the patient had OHSS since admission, we concluded that OHSS was suspected as the cause of the stroke. CONCLUSIONS: We experienced the first case of mechanical thrombectomy for middle cerebral artery occlusion suspected to be caused by OHSS. It is necessary to suspect OHSS involvement if young women, especially those on infertility treatment, show neurologic deficits.


Assuntos
Infarto da Artéria Cerebral Média/cirurgia , Síndrome de Hiperestimulação Ovariana/diagnóstico , Trombectomia/métodos , Adulto , Angiografia Cerebral , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/etiologia , Imagem por Ressonância Magnética , Síndrome de Hiperestimulação Ovariana/complicações
15.
World Neurosurg ; 132: 103-105, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31493595

RESUMO

BACKGROUND: We present a case of a concurrent rupture of a middle cerebral artery (MCA) aneurysm and thrombosis of the associated vessel. CASE DESCRIPTION: A male patient presented with acute onset of hemiparesis and nuchal pain. A computed tomography scan revealed a right sided frontotemporal intracerebral hemorrhage and a basal subarachnoid hemorrhage. Owing to obliteration of the M1 segment of the MCA, no aneurysm was visible on digital subtraction angiography. Because of otherwise typical imaging for a subarachnoid hemorrhage, surgical exploration of the MCA was performed. During surgery, a thrombosed MCA bifurcation aneurysm was identified, clipped, and subsequently, endovascular (partly) recanalization of the MCA was performed. CONCLUSIONS: In extremely rare cases of aneurysm rupture and subsequent thrombosis of the associated vessel, a 2-stage approach seems to be feasible. In the present case, initial surgical securing of the aneurysm followed by endovascular recanalization of the occluded vessel provided good results.


Assuntos
Aneurisma Roto/cirurgia , Hemorragia Cerebral/cirurgia , Procedimentos Endovasculares/métodos , Infarto da Artéria Cerebral Média/terapia , Aneurisma Intracraniano/cirurgia , Artéria Cerebral Média/cirurgia , Procedimentos Neurocirúrgicos/métodos , Hemorragia Subaracnóidea/cirurgia , Adulto , Aneurisma Roto/complicações , Hemorragia Cerebral/complicações , Hemorragia Cerebral/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/etiologia , Aneurisma Intracraniano/complicações , Masculino , Artéria Cerebral Média/diagnóstico por imagem , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico por imagem , Tomografia Computadorizada por Raios X
16.
J Clin Neurosci ; 70: 67-71, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31445814

RESUMO

PURPOSE: Mechanical thrombectomy (MT) for acute ischemic stroke (AIS) patients due to emergent large vessel occlusion (ELVO) is standard treatment, the benefits, however, are highly time-sensitive. After patient eligibility for reperfusion therapy is determined by conventional radiological examinations, the time to be transferred from the department of radiological examination to angiography-suites is critical. We speculated that the time required for the diagnosis of AIS might be reduced if we could determine MT eligibility in patients with ELVO at angiography-suites. Modern angiography-suites with flat panel detectors can perform cone beam (CB)-CT. We performed CB-CTA using intravenous injection of contrast agent to evaluate occlusion sites, collateral score, and construction of vessels distal to occlusion sites and determined if CB-CTA could be useful to evaluate patients with ELVO. METHODS: We included 15 patients with ELVO diagnosed by conventional MRI or CT/CTA, and investigated whether CB-CTA was reliable to diagnose occlusion sites. We also studied if collateral score on CB-CTA was associated with prognosis after successful reperfusion by MT by comparison between favorable (modified Rankin scale (mRS) 0-2), and unfavorable outcome group (mRS 3-6). RESULTS: There was strong agreement of occlusion sites between CB-CTA and conventional radiological examination (κ = 0.80). Collateral score determined by CB-CTA was significantly different between favorable outcome and unfavorable outcome group (median collateral score 2.3 v.s. 1.3, p = 0.040). CONCLUSIONS: Although prospective study of AIS patients at a radiography department is indispensable, CB-CTA performed in an angiography-suite might be useful to evaluate patients with ELVO.


Assuntos
Trombose das Artérias Carótidas/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Meios de Contraste/administração & dosagem , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/etiologia , Isquemia Encefálica/terapia , Trombose das Artérias Carótidas/terapia , Feminino , Humanos , Infarto da Artéria Cerebral Média/terapia , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Prognóstico , Reperfusão/métodos , Estudos Retrospectivos , Trombectomia/métodos , Resultado do Tratamento
17.
J Med Case Rep ; 13(1): 260, 2019 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-31426851

RESUMO

BACKGROUND: Although there is an established association between cancer and stroke, the role of malignancy as a causative agent or comorbidity is not always clear. Moreover, there are no established guidelines on the acute treatment of cancer-associated stroke or optimal anticoagulation. This case report illustrates the significance of these practice gaps. CASE PRESENTATION: A 62-year-old Caucasian woman presented to our institute with acute neurological deficits and was found to have an occluded left middle cerebral artery on a computed tomographic angiogram. She was administered intravenous alteplase and underwent unsuccessful endovascular clot retrieval. Besides smoking and her age, she had no cerebrovascular risk factors, and the results of baseline investigations for the cause of stroke were negative. Subsequent computed tomography of the chest, abdomen, and pelvis showed metastatic malignancy, and in the context of a significantly elevated serum cancer antigen 19-9, we suspected a pancreatic primary cancer. A transthoracic echocardiogram demonstrated mitral regurgitation but no visible vegetation. The patient died of her illness. We made a diagnosis of cancer-associated stroke, specifically a likely case of nonbacterial thrombotic endocarditis. CONCLUSIONS: This case highlights the importance of having a high threshold of suspicion for malignancy as a cause of stroke.


Assuntos
Neoplasias Encefálicas/diagnóstico por imagem , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pancreáticas/diagnóstico por imagem , Antígenos Glicosídicos Associados a Tumores/sangue , Angiografia por Tomografia Computadorizada , Evolução Fatal , Feminino , Humanos , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X
18.
BMJ Case Rep ; 12(8)2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31466979

RESUMO

A 65-year-old man presented in a peri-arrest situation after collapse, he was found hypoxic with ischaemic arms. CT imaging showed massive bilateral pulmonary embolisms (PEs) and an aortic arch embolus extending from brachiocephalic trunk to left subclavian artery. Following intravenous thrombolysis, repeat imaging revealed that the aortic embolus had migrated distally into both axillary arteries and had occluded the right carotid from origin to skull base. Bilateral upper limb embolectomies were carried out from the brachial arteries together with forearm fasciotomies. Left hemianopia related to a right middle cerebral artery territory infarct was managed conservatively; forearm fasciotomy wounds were primarily closed and the patient was discharged on lifelong anticoagulation. A transoesophageal echocardiogram revealed a patent foramen ovale. This case demonstrates a very unusual presentation of concomitant PE and paradoxical saddle aortic arch embolism. A multidisciplinary approach has resulted in an excellent clinical outcome for this complex patient.


Assuntos
Aorta Torácica/patologia , Embolia Paradoxal/complicações , Equipe de Assistência ao Paciente/normas , Embolia Pulmonar/complicações , Idoso , Aorta Torácica/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Ecocardiografia Transesofagiana/métodos , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/terapia , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Masculino , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/terapia , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Terapia Trombolítica/métodos , Resultado do Tratamento
19.
BMC Neurol ; 19(1): 152, 2019 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-31277605

RESUMO

BACKGROUND: Simultaneous cerebral and myocardial infarction is called cardiocerebral infarction (CCI), and is rarely encountered. Because of the narrow time window and complex pathophysiology, CCI is challenging to immediately diagnose and treat. CASE PRESENTATION: A 73-year-old woman suddenly developed right hemiplegia and severe aphasia. Twelve-lead electrocardiography showed tachycardic atrial fibrillation without any significant ST-T change. Magnetic resonance imaging revealed a proximal middle cerebral artery occlusion. She was immediately treated with alteplase at the dosage approved for ischemic stroke followed by mechanical thrombectomy as bridging therapy, and complete recanalization was achieved. Aphasia improved and she began to complain of chest pain, and reported that she had experienced chest discomfort just prior to right limb weakness. Coronary angiography showed a partial filling defect in the right coronary artery with rapid and adequate distal flow, for which percutaneous coronary intervention was not required. Alteplase was suggested to have effectively resolved the coronary emboli. The occlusions of the cerebral and coronary arteries were assumed to have occurred nearly simultaneously and cardiogenic embolism due to atrial fibrillation was considered as the most likely etiology. CONCLUSIONS: As seen in the present case, CCI may benefit from immediate treatment with intravenous tissue plasminogen activator (IV-tPA). Although which of percutaneous coronary intervention or cerebral thrombectomy should be performed first remains unclear, we must decide whether to rescue the brain or heart first in each patient within a limited window of time. This dilemma has recently become evident in this era with mechanical thrombectomy strongly established as an effective intervention for acute ischemic stroke. Close cooperation between stroke physicians and cardiologists is becoming more important.


Assuntos
Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico por imagem , Administração Intravenosa , Idoso , Fibrilação Atrial/complicações , Doença da Artéria Coronariana/complicações , Imagem de Difusão por Ressonância Magnética , Eletrocardiografia , Procedimentos Endovasculares , Feminino , Fibrinolíticos/uso terapêutico , Coração , Humanos , Infarto da Artéria Cerebral Média/terapia , Trombectomia , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
20.
Clin Nucl Med ; 44(10): 842-843, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31348084

RESUMO

This 33-year-old man presented with hemorrhagic stroke manifesting with left hemiparesis and right ptosis. Angiography revealed no patent carotids. The anterior and middle cerebral arteries were filling collaterally through the posterior vertebrobasilar pathway. The presumptive diagnosis was moyamoya disease. The etiology of the bleeding was right basilar tip aneurysm that subsequently had partial coil placement. Months later, the neck of the aneurysm perforated and second coiling was performed. Later on follow-up, patient developed left hand tremor. A radionuclide DATscan revealed total absence of right-sided basal ganglia activity. A possible etiology was occlusion of the middle cerebral artery's lenticulostriate branches.


Assuntos
Gânglios da Base/diagnóstico por imagem , Nortropanos , Adulto , Angiografia Cerebral , Reações Falso-Negativas , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Masculino
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