Efficacy, safety, and clinical outcome of modern mechanical thrombectomy in elderly patients with acute ischemic stroke.

BACKGROUND: The average life expectancy is increasing worldwide, surpassing 80 years in some countries. Recently, mechanical thrombectomy (MT) using modern devices and techniques has led to improved clinical outcomes following acute ischemic stroke. However, thus far, it remains uncertain whether MT is effective in elderly patients aged over 80 years. METHODS: Between July 2013 and June 2016, 207 patients with acute ischemic stroke in the anterior circulation received MT at our center. The applied MT strategies were forced arterial suction thrombectomy (FAST) and stent retriever thrombectomy. Patients were divided into those <80 years (n = 173) and those ≥80 years (n = 34). We compared clinical and angiographic parameters between groups. RESULTS: The median age was 67.5 in the younger group and 82 in the elderly group; 92.5% of the younger group and 70.6% of the elderly group received MT via the FAST technique. Angiographic outcomes, including procedural time, mTICI 2b-3 reperfusion (85.5% vs. 82.4%, p = 0.633), and symptomatic intracranial hemorrhage, were not different between the groups. A favorable clinical outcome rate was significantly higher in the younger group (62.4% vs. 44.1%, p = 0.047). Younger age, a low NIHSS score, and fast onset to reperfusion time were favorable prognostic factors in elderly patients. CONCLUSION: Modern MT in elderly patients with acute ischemic stroke is safe and effective compared to younger patients despite a lower favorable clinical outcome. Our findings may suggest that an appropriate MT strategy with respect to the location of the target occlusion and vascular tortuosity might be helpful to achieve fast reperfusion and improved outcomes for elderly patients.

Bone subtraction 3D CT venography for the evaluation of cerebral veins and venous sinuses: imaging techniques, normal variations, and pathologic findings.

OBJECTIVE: Varying anatomic characteristics and clinical and radiologic manifestations are diagnostic challenges in the evaluation of the cerebral vein and of venous sinus diseases. The purpose of this article is to introduce bone subtraction CT venography and review normal variations and diseases involving the cerebral veins and venous sinuses. CONCLUSION: Knowledge of the normal variations and pathologic findings will be helpful for the accurate diagnosis of diseases involving the cerebral venous system. Bone subtraction CT venography offers complete 3D visualization of the cerebral venous system and can be useful for the evaluation of the cerebral vein and venous sinus diseases.

Endovascular thrombectomy for M2 occlusions: comparison between forced arterial suction thrombectomy and stent retriever thrombectomy.

BACKGROUND: To date there has been no direct comparison of two frequently used endovascular thrombectomy (EVT) methods (forced arterial suction thrombectomy (FAST) and stent retriever thrombectomy) in M2 occlusions. We review our experiences with EVT performed using FAST and stent retriever thrombectomy in such cases. METHODS: The subjects comprised 41 patients with an M2 occlusion who underwent EVT (25 with FAST, 16 with stent retriever thrombectomy). The patients' data were retrospectively analyzed to evaluate the technical characteristics and angiographic outcome of the two EVT techniques. RESULTS: Thrombolysis In Cerebral Infarction (TICI) grades 2b-3 using the first chosen technique did not differ significantly between the two techniques (FAST 64.0% vs stent retriever thrombectomy 81.2%, p=0.305). Time from groin puncture to reperfusion was significantly shorter for stent retriever thrombectomy (53.0 vs 38.5 min; p=0.045). Distal embolization occurred in three cases (12.0%) in the FAST group and in four (26.7%) in the stent retriever group (p=0.362). However, the two techniques did not differ significantly in the final TICI 2b-3 rate (72.0% vs 87.5%; p=0.441). A frequent angiographic finding regarding the failure of FAST was that the M2 occlusion was located immediately after severe acute angulation between M1 and M2. CONCLUSIONS: Stent retriever thrombectomy may provide faster reperfusion than FAST, while the FAST technique might be associated with lower distal embolization and a higher reperfusion rate for the first thrombectomy attempt, but without any significant difference in clinical outcome. When choosing the EVT method for M2 occlusions, consideration of the location of the occlusion and tortuosity between M1 and M2 might be helpful to achieve a better angiographic outcome.

Comparison of Solitaire thrombectomy and Penumbra suction thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion.

BACKGROUND AND PURPOSE: Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is a very severe neurological disease with a high mortality rate and poor clinical outcomes. In this study, we compared our experience of mechanical thrombectomy using the Solitaire stent (Solitaire thrombectomy) and manual aspiration thrombectomy using the Penumbra reperfusion catheter (Penumbra suction thrombectomy) in patients with AIS caused by BAO. MATERIALS AND METHODS: Between March 2011 and December 2011, 13 patients received Solitaire thrombectomy. In January 2012, the Korean Food and Drug Administration banned the use of the Solitaire stent as a thrombectomy device, and a further 18 patients received Penumbra suction thrombectomy until December 2013. We compared parameters between patients treated with each device. RESULTS: Successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b: 84.6% vs 100%, p=0.168) and clinical outcomes (judged by the modified Rankin Scale scores recorded at 3 months: 3.6±2.6 vs 3.2±2.6, p=0.726) were not significantly different between the two groups. However, complete recanalization rates (TICI score of 3: 23.1% vs 72.2%, p=0.015) and total procedure times (101.9±41.4 vs 62.3±34.8 min, p=0.044) were significantly higher, and shorter, respectively, in patients treated by Penumbra suction thrombectomy. CONCLUSIONS: The two thrombectomy devices were associated with similar recanalization rates and clinical outcomes in patients with AIS caused by BAO. However, Penumbra suction thrombectomy seemed to allow more rapid and complete recanalization than Solitaire thrombectomy.

Initial factors affecting the clinical outcome after successful recanalization via MR-based mechanical thrombectomy in patients with acute ischemic stroke due to basilar artery occlusion.

BACKGROUND AND PURPOSE: To determine the initial factors, including patient characteristics, stroke etiology and severity, time factors, and imaging findings, that could affect the clinical outcome of patients with acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) where successful recanalization was achieved via mechanical thrombectomy. METHODS: Between March 2011 and December 2014, 35 patients with AIS caused by BAO received MRI/MR angiography-based mechanical thrombectomies, and recanalization was achieved with a Thrombolysis In Cerebral Infarction score of >2b. The patients were divided into a good outcome group (n=19), defined as those with a modified Rankin Scale (mRS) score of 0-2 at 3 months after stroke onset, and a poor outcome group (n=16), defined as a mRS score of 3-6. The differences between the groups were analyzed. RESULTS: Initial National Institutes of Health Stroke Scale (NIHSS) score (good vs poor: 17.9±8.9 vs 27.6±8.5, p=0.003), posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) based on initial diffusion-weighted images (DWI) (good vs poor: 7.8±1.6 vs 5.4±1.8, p=0.001), pc-ASPECTS based on contrast staining on the post-thrombectomy control CT (good vs poor: 9.2±1.5 vs 6.3±2.2, p<0.001), and presence of contrast staining in the brainstem on that CT (good vs poor: 15.8% vs 81.6%, p<0.001) were significantly different between the groups. CONCLUSIONS: Patients with AIS caused by BAO with a lower initial NIHSS score, fewer lesions on initial DWI, and less contrast staining on the post-thrombectomy control CT have higher probabilities of a good clinical outcome after successful recanalization via a mechanical thrombectomy.

Carotid stent infection: a rare but potentially fatal complication of carotid artery stenting.

Infections involving endovascular devices are rare and, to our knowledge, only three cases of infection with an inserted carotid stent have ever been reported. A 68-year-old man underwent carotid artery stenting (CAS) of the left proximal internal carotid artery. Two days after CAS the patient developed a high fever and investigation showed that the inserted carotid stent was infected. The infection could not be controlled despite adequate antibiotic therapy. Eventually a rupture of the carotid artery occurred and the patient underwent emergency resection of the left carotid bifurcation in addition to stent removal and reconstruction with a saphenous vein interposition graft. The patient recovered fully without any neurological sequelae.

Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience.

BACKGROUND: The feasibility, safety and effectiveness of emergency carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to proximal internal carotid artery (ICA) stenosis or occlusion are still controversial. In this study we analyzed our experience with eCAS in patients with AIS. METHODS: Twenty-two eCAS procedures for proximal ICA stenosis or occlusion were performed in 22 patients at our institution between January 2011 and November 2013. The mean time from stroke symptom onset to presentation was 204 min (range 50-630 min) and the mean initial score on the National Institutes of Health Stroke Scale (NIHSS) was 12.55 (range 5-23). Ten patients had total occlusion of the proximal ICA and the remaining 12 patients had near total occlusion or severe stenosis (mean degree 90.7%, range 80-100%). Eleven patients also had tandem occlusion on the more distal intracranial arteries. RESULTS: Successful stent insertion was achieved in all patients and additional thrombectomy using a Solitaire stent or Penumbra aspiration catheter achieved a Thrombolysis In Cerebral Infarction grade of more than 2a in all patients with distal tandem occlusion. Procedure-related complications occurred in one patient (cerebral hyperperfusion syndrome) who recovered successfully. The mean NIHSS score at discharge was 3.55 (range 0-18). The mean modified Rankin Scale score at 3 months was 1 ± 1.67 (range 0-6). CONCLUSIONS: eCAS in patients with AIS due to proximal ICA stenosis or occlusion appears to be a technically feasible and effective method for achieving good clinical outcomes.

Carotid stent infection: a rare but potentially fatal complication of carotid artery stenting.

Infections involving endovascular devices are rare and, to our knowledge, only three cases of infection with an inserted carotid stent have ever been reported. A 68-year-old man underwent carotid artery stenting (CAS) of the left proximal internal carotid artery. Two days after CAS the patient developed a high fever and investigation showed that the inserted carotid stent was infected. The infection could not be controlled despite adequate antibiotic therapy. Eventually a rupture of the carotid artery occurred and the patient underwent emergency resection of the left carotid bifurcation in addition to stent removal and reconstruction with a saphenous vein interposition graft. The patient recovered fully without any neurological sequelae.

Retrospective assessment of the implementation of critical pathway in stroke patients in a single university hospital.

OBJECTIVE: To evaluate the effects of the implementation of critical pathway (CP) in stroke patients treated at a single university hospital. METHODS: A retrospective medical review collected data from 497 patients who had suffered acute stroke in the rehabilitation center. Stroke outcomes were compared between before and after the implementation of CP based on factors including demographic factors, stroke characteristics, pre-existing medical conditions, medical complications, functional states, and length of stay (LOS). RESULTS: After the implementation of CP, the patients showed significantly higher stage for upper proximal (p=0.008) and lower extremity (p=0.001) on Brunnstrom stage and significantly lower scores for modified Rankin Scale (p=0.003) at transfer. For those with pre-existing medical conditions, there were significantly increased osteoarthritis (p=0.002) and valvular heart disease (p=0.011). Regarding medical complications during acute inpatient rehabilitation, there were significantly decreased shoulder pain (p=0.001) and dysphagia (p=0.017), and significantly increased gastrointestinal symptoms (p=0.001). Functional gain and efficiency of stroke patients during rehabilitation center hospitalization did not significantly change after implementation of CP. But, shorter LOS of total hospitalization, pre-rehabilitation center hospitalization, and rehabilitation center hospitalization were evident. CONCLUSION: After the implementation of CP, patients less often developed complications and displayed no changes in functional gain and efficiency. They had shorter LOS of total hospitalization, pre-rehabilitation center hospitalization and rehabilitation center hospitalization.

Carotid artery stenting in patients with near occlusion: a single-center experience and comparison with recent studies.

OBJECTIVE: The optimal management strategy for carotid artery near occlusion is still controversial. Nevertheless, prior studies about carotid artery stenting in patients with near occlusion reported both technically and clinically inspiring results. To define the effectiveness, safety, and clinical outcomes of carotid artery stenting in patients with near occlusion, we analyzed our experiences and compared with recent studies. METHODS: We performed 24 carotid artery stenting procedures in 24 patients with near occlusion between January 2010 and July 2012. The patient group comprised 20 men (83.3%) and four women (16.7%) with a mean age of 69.5 years (range, 53-85 years). Eighteen patients had prior stroke or transient ischemic attack (75%), and six patients were asymptomatic (25%). RESULTS: Successful stent insertion was achieved in 23 of 24 patients (95.8%). Cerebral hyperperfusion syndrome and post-procedural vascular events occurred in four patients, and all of these developed within 24h after the procedure (17.4%; two: hyperperfusion syndrome, two: acute myocardial infarction). The mean follow-up period after carotid artery stenting was 16.7±9.2 months (range, 6-32 months). No stroke related to carotid artery stenting or significant restenosis of the inserted stent developed during the follow-up period. CONCLUSIONS: Carotid artery stenting in patients with near occlusion seems to be a technically feasible and effective method to prevent stroke recurrence. But hyperperfusion syndrome and post-procedural vascular event rates may be high, as shown in this study.

The effect of extracorporeal shock wave therapy on lower limb spasticity in subacute stroke patients.

OBJECTIVE: To evaluate the effect of extracorporeal shock wave therapy (ESWT) on lower limb spasticity in subacute stroke patients. METHODS: We studied thirty hemiplegic subacute stroke patients with ankle plantar flexor spasticity. ESWT was applied for 1 session/week, with a total of 3 sessions at the musculotendinous junction of medial and lateral gastrocnemius muscles. Patients were evaluated both clinically and biomechanically at baseline, after sham stimulation, and at immediately 1 week and 4 weeks after ESWT. For clinical assessment, Modified Ashworth Scale (MAS), clonus score, passive range of motion of ankle, and Fugl-Myer Assessment for the lower extremity were used. A biomechanical assessment of spasticity was conducted by an isokinetic dynamometer. Two parameters, peak eccentric torque (PET) and torque threshold angle (TTA), were analyzed at the velocities of 60°/sec, 180°/sec, and 240°/sec. RESULTS: After sham stimulation, there were no significant changes between each assessment. MAS and PET (180°/sec and 240°/sec) were significantly improved immediately and 1 week after ESWT. However, these changes were not significant at 4 weeks after ESWT. PET (60°/sec) and TTA (60°/sec, 180°/sec, and 240°/sec) were significantly improved immediately after ESWT. Yet, these changes were not significant at 1 week and 4 weeks after ESWT as well. CONCLUSION: Lower limb spasticity in subacute stroke patients was significantly improved immediately after ESWT. Although the therapeutic effect of ESWT reduced with time and therefore was not significant at 4 weeks after ESWT, the degree of spasticity was lower than that of the baseline. Future studies with a larger sample of patients are warranted in order to verify the protocols which can optimize the effect of ESWT on spasticity.

Vigabatrin-induced generalized epileptiform discharges in a patient with focal epilepsy.

Vigabatrin (VGB) may aggravate clinical seizures and epileptiform discharges especially in the patients with generalized epilepsy. This report is about the repetitive appearance of generalized spike-and-wave complexes in a patient with focal epilepsy. Though there were constant appearances of the generalized epileptiform discharges on the consecutive electroencephalograms (EEGs) taken over approximately four years under VGB monotherapy, clinical provocation of primary generalized seizures was not occurred. Because of the repetitive observations of the generalized epileptiform discharges, valproic acid was added and the tapering of VGB was started. On the EEG taken during the tapering period of VGB and another EEG after the discontinuation of VGB, the generalized epileptiform discharges were completely disappeared. Through observation in this case, we suggests that the use of VGB could induce generalized epileptiform discharges without clinical seizure induction for long term period.

A case of spontaneous spinal epidural hematoma mimicking a stroke.

INTRODUCTION: For intravenous (IV) thrombolytic therapies to be effective, a correct diagnosis of acute ischemic stroke must be made within 3 hours from the onset of symptoms, a relatively short window period. However, obtaining a diagnosis in the time frame is not easy; a wide variety of conditions mimic a stroke, including seizures, migraine, and even a spinal mass, and often these are diagnosed as acute ischemic stroke and receive thrombolytic therapy. CASE REPORT: A patient presented suffering progressive and fluctuating painful triparesis coupled with acute onset dissociated sensory loss. The patient complained of dysarthria and transient altered mentality at the onset of symptoms; therefore, we suspected an ischemic infarction of the brainstem and spinal cord accompanied by vertebral artery dissection. As the time at diagnosis was 2 hours 30 minutes after symptom onset, we started IV thrombolytic treatment using recombinant tissue plasminogen activator. Magnetic resonance imaging during the recombinant tissue plasminogen activator infusion revealed a spontaneous spinal epidural hematoma (SSEH) of the cervical and thoracic spine, leading the patient to undergo an emergency surgery. CONCLUSIONS: SSEH is an uncommon clinical condition, and a manifestation of SSEH with anterior spinal artery syndrome is also rare. Furthermore, an emergency operation after IV thrombolytic treatment is an extraordinary situation.

Relationship between Hyperventilation-Induced Electroencephalographic Changes and PCO2 Level.

BACKGROUND AND PURPOSE: We conducted this study to define the relationship between the hyperventilation-induced EEG changes (HV-EEG changes) and PCO2. METHODS: In consecutive EEG recordings of 190 patients, we gathered data on PCO2 during the hyperventilation procedure. The data included baseline PCO2 (B-PCO2), PCO2 after 5 min of hyperventilation (5 min-PCO2), the mean value of the PCO2 (M-PCO2), and the difference between B-PCO2 and 5 min-PCO2 (ΔPCO2). We divided the enrolled patients into two groups by hyperventilation response (response group and no-response group), presence of epilepsy (epileptic group and non-epileptic group) and age (child-adolescent group and adult group) repeatedly. We compared the four variables between the two groups in each pair. RESULTS: ΔPCO2 was 14.2±5.0 mmHg (mean±SD) in response group (n=48) and 12.4±5.0 in no-response group (n=142; p=0.033) for all the patients. For adult patients only, 5 min-PCO2 was 24.3±3.4 in response group (n=30) and 26.2±4.6 in no-response group (n=115; p=0.048), and ΔPCO2 was 15.8±4.0 and 12.9±5.0, respectively (p=0.004). In non-epileptic patients, 5min-PCO2 was 23.4±2.2 in response group (n=7) and 26.3±3.8 in no-response group (n=44; p=0.026), and ΔPCO2 was 15.9±4.3 and 12.7±3.9, respectively (p=0.053). CONCLUSIONS: In adults and non-epileptic patients, ΔPCO2 and 5 min-PCO2 may be crucial to the induction of EEG changes by hyperventilation. PCO2 could be a crucial factor for provoking HV-EEG changes in a limited group of patients.

A case of broncho-paraspinal fistula induced by metallic devices: delayed complication of thoracic spinal surgery.

We present a case report of a 45-year-old woman with spontaneous pneumocephalus accompanied by pneumorrhachis of the thoracic spine, which is a very rare condition generally associated with trauma and thoracic or spinal surgery. The patient had undergone an operation about 10 years earlier to treat a giant cell tumor of the thoracic spine. During the operation, a metallic device was installed, which destroyed the bronchus and caused the formation of a broncho-paraspinal fistula. This is the suspected cause of her pneumocephalus and pneumorrhachis. To our knowledge, this is a very rare case of pneumocephalus accompanied by pneumorrhachis induced by metallic device, and when considering the length of time after surgery these complications presented are also exceptional.

Incidentally discovered a self-inflicted a nail in the brain of schizophrenia patient.

The self-infliction of foreign bodies into the brain represents rare a clinical phenomenon that has been reported primarily in cases involving accidents and suicide attempts. However, various motivations for self-injurious behaviors as well as suicide attempts have been reported, especially in patients with psychotic illnesses. A 47-year-old man with a history of schizophrenia presented to our hospital due to the presence of a nail on his plain skull X-ray. He diagnosed paranoid type of schizophrenia about 17 years earlier, and his psychiatric symptoms were well controlled by medication. Interestingly, he was not aware of the presence of the nail in his brain and showed no neurological deficits. In the course of detailed history taking, we discovered that the nail was driven into his brain during a hallucinatory experience that had occurred more than 10 years earlier. Because we believed that removing the nail from his brain would be more dangerous than maintaining the status quo, the nail was not removed. This is a very rare case of a self-inflicted injury involving inserting a nail into the brain under the influence of hallucinations. The absence of adverse effects or neurological symptoms/signs related to the presence of a foreign metallic body in the brain for over 10 years is exceptional.

Serial magnetic resonance images of a right middle cerebral artery infarction : persistent hyperintensity on diffusion-weighted MRI over 8 months.

A lesion that is hyperintense on diffusion-weighted imaging (DWI) and hypointense on the apparent diffusion coefficient (ADC) map is a characteristic magnetic resonance imaging (MRI) finding in acute ischemic infarction. In some cases, however, these findings can persist for a few months after infarct onset. It is thought that these finding reflect the different evolution speeds of the infarcted tissue. We report a patient with a right middle cerebral artery territory infarction with persistent hyperintensity on DWI and hypointensity on the ADC map for over 8 months. To our knowledge, this is the most persistent case of hyperintensity lesion on DWI and the serial MRI images of this patient provide important information on the evolution of infarcted tissue.

MRI in Tolosa-Hunt syndrome associated with facial nerve palsy.

A 44-year-old woman developed a severe right frontotemporal headache, retro-orbital pain, and, later, diplopia owing to right sixth nerve palsy. The brain MRI demonstrated strong enhancement of the right cavernous sinus. The sixth nerve palsy and headache improved with steroid therapy after 6 weeks. At that time, she suffered right peripheral facial nerve palsy. Enhancement of the distal canalicular and labyrinthic segment of the right facial nerve was found on contrast-enhanced MRI. To our knowledge, this is a very rare case of Tolosa-Hunt syndrome with facial nerve palsy, with simultaneous enhancement of the cavernous sinus and facial nerve on contrast-enhanced MRI.