Safety of standard-dose (.9-mg/kg) alteplase intravenous thrombolysis for acute ischemic stroke in Afro-Caribbeans, French West Indies.

BACKGROUND: Pharmacobiologic data suggested that people of African ancestry were more sensitive to the recombinant tissue plasminogen activator, alteplase, than Caucasians. Furthermore, the higher incidences of hypertension and diabetes mellitus in black populations could contribute to a higher cerebral bleeding risk. However, standard-dose (.9-mg/kg) alteplase safety for stroke has never been evaluated in blacks. This study was undertaken to evaluate standard-dose alteplase safety to treat strokes in an Afro-Caribbean population. METHODS: Parenchymal hemorrhage and symptomatic intracerebral hemorrhage rates in Afro-Caribbean Martinicans given standard-dose alteplase for acute stroke were evaluated based on prospectively collected data from 2007 to 2010 and compared with those from studies on predominantly Caucasian stroke victims. RESULTS: Parenchymal hemorrhage type 2 and symptomatic intracerebral hemorrhages, as defined by the third European Cooperative Acute Stroke Study, respectively, occurred in 15 (10.1%) and 12 (8.1%) of the 148 thrombolyzed Afro-Caribbeans, respectively. This excess bleeding risk (parenchymal hemorrhage type 2) concerned more patients >70 than those 70 years of age or lesser (respectively, 17.6% [13 of 74] vs. 2.7% [2 of 74]). Older age was the only factor significantly associated with a higher parenchymal hemorrhage type 2 risk (P = .02). CONCLUSIONS: The excess hemorrhagic risk after standard-dose alteplase infusion into older Afro-Caribbean patients warrants further study to determine the possible role of cerebral microangiopathy and should be evaluated in different black populations.

Infarction in the anterior choroidal artery territory: clinical progression and prognosis factors.

This study was undertaken to describe the still poorly known evolving profile of anterior choroidal artery (AChA) infarctions, identify their prognosis factors, and evaluate responses to intravenous (IV) thrombolysis. During 42 months, we prospectively enrolled patients with an isolated AChA stroke. Clinical and radiologic parameters were compared between patients with or without progression, defined as any clinical worsening. Factors associated with poor outcome (dependence or death) were tested, and IV thrombolysis responses were assessed. For the 100 of 1234 (8.1%) analyzed patients with AChA stroke (predominantly lacunar syndrome [88%]), mean admission and maximum National Institutes of Health Stroke Scale (NIHSS) scores were 4.4 and 5.2, respectively. Arterial hypertension (78%) and diabetes (30%) were the main vascular risk factors. Despite low 3-month mortality (3%), 26% of the patients were dependent; 46 patients with progressive stroke (over 56 ± 56 hours, 1.6 mean successive plateaus) had higher risks of dependence (P < .0001). An acute-phase NIHSS score of 6 or more significantly increased the risk of poor outcome (P < .0001). Maximum NIHSS score and progression were independently associated with poor outcome. Among 21 patients given IV thrombolysis, 12 AChA strokes continued to progress, leaving 8 disabled at 3 months. Almost half of AChA strokes progress during the first 2 to 3 days. Maximum acute-phase NIHSS scores and progression were independently associated with poor outcome, also strongly predicted by an NIHSS score of 6 or more at any time. Our unconvincing experience with IV thrombolysis means new therapeutic options and trials are needed, especially for patients with clinical progression and/or NIHSS score of 6 or more.

A new therapeutic strategy for acute ischemic stroke: sequential combined intravenous tPA-tenecteplase for proximal middle cerebral artery occlusion based on first results in 13 consecutive patients.

BACKGROUND AND PURPOSE: Intravenous tissue-type plasminogen activator (IV tPA) frequently fails to recanalize proximal middle cerebral artery (MCA-M1) obstructions, preventing favorable outcomes. Only neurointerventional procedures prevail in these cases, but well-equipped centers remain scarce. A new therapeutic strategy consisting of a second IV thrombolysis with low-dose tenecteplase was applied. METHODS: Consecutive patients with an MCA-M1 occlusion that did not reopen at the end of IV tPA perfusion received IV tenecteplase (0.1 mg/kg). Partial or complete thrombolysis in myocardial infarction recanalization (Thrombolysis In Myocardial Infarction grade 2/3) and intracerebral hemorrhage were assessed by magnetic resonance aging approximately 24 hours later. Clinical outcomes at 3 months were evaluated with the modified Rankin score. RESULTS: Among 40 patients with MCA-M1 occlusions who received IV tPA, 13 were treated according to the protocol of sequential combined IV thrombolytics. Baseline National Institutes of Health Stroke Scale score was 15. At a mean of 16.8 hours after IV thrombolysis, the recanalization rate was 100% (2 with Thrombolysis In Myocardial Infarction grade 2, 11 with Thrombolysis In Myocardial Infarction grade 3). Intracerebral hemorrhage occurred in 4 of 13 (31%) patients, with no symptomatic hemorrhage. Good clinical outcomes (modified Rankin score = 0/1) were achieved in 9 of 13 (69%) patients. Functional outcomes were very similar to those of 13 patients with early IV-tPA recanalization. Among 4 patients treated as protocol violations, 1 presented with a lack of recanalization and a parenchymal hematoma type 2. CONCLUSIONS: For patients with MCA-M1 occlusions treated with IV tPA but without early recanalization, a second bolus of IV tenecteplase (0.1 mg/kg) may be a relatively safe, effective, and easy option in carefully selected cases, but additional studies are needed to confirm these findings.

Association between basilar artery hypoplasia and undetermined or lacunar posterior circulation ischemic stroke.

BACKGROUND AND PURPOSE: The aim of the current study was to determine the prevalence of basilar artery hypoplasia (BAH) and to evaluate whether BAH is a possible risk factor for posterior circulation stroke (PCS). METHODS: Basilar artery diameter was assessed by MRI in 685 consecutive ischemic stroke patients. BAH frequency, defined as a diameter <2 mm, was measured and compared between anterior circulation stroke and PCS groups. RESULTS: Thirty-seven patients had BAH (5.2%): 15 of 195 (7.7%) in PCS and 22 of 490 (4.5%) in anterior circulation stroke (P=0.2). In undetermined or lacunar stroke patients, BAH frequency was higher in PCS than in anterior circulation stroke (14/97, 14.4% vs 10/216, 4.6%; P=0.005). National Institutes of Health Stroke Scale score was <4 in 65%. Localization of stroke was predominant in pons or cerebellar territories (71.4%). Half of PCS and BAH patients showed small pontic-penetrating arteries infarcts. CONCLUSIONS: Our study suggests that BAH is associated with PCS in lacunar or undetermined stroke. Patients often had minor stroke and infarctions that were usually small and frequently located in pontine-penetrating artery territories.

Prehospital transfer medicalization increases thrombolysis rate in acute ischemic stroke. A French stroke unit experience.

OBJECTIVES: Narrow therapeutic window is a major cause of thrombolysis exclusion in acute ischemic stroke. Whether prehospital medicalization increases t-PA treatment rate is investigated in the present study. PATIENTS AND METHODS: Intrahospital processing times and t-PA treatment were analyzed in stroke patients calling within 6h and admitted in our stoke unit. Patients transferred by our mobile medical team (SAMU) and by Fire Department (FD) paramedics were compared. RESULTS: 193 (61.6%) SAMU patients and 120 (38.4%) FD patients were included within 30 months. Clinical characteristics and onset-to-call intervals were similar in the two groups. Mean door-to-imaging delay was deeply reduced in the SAMU group (52 vs. 159 min, p<0.0001) and was <25 min in 50% of SAMU patients and 14% of FD patients (p<0.0001). SAMU management was the only independent factor of early imaging (p=0.0006). t-PA administration rate was higher in SAMU group than in FD group (42% vs. 28%, p=0.04). Proportion of patients with delayed therapeutic window was higher in FD group than in SAMU group (38% vs. 26%, p<0.0001). CONCLUSION: Prehospital transfer medicalization promotes emergency room bypass, direct radiology room admission and high thrombolysis rate in acute ischemic stroke.

Fluid-attenuated inversion recovery vascular hyperintensity: an early predictor of clinical outcome in proximal middle cerebral artery occlusion.

BACKGROUND: Few data are available on the relationship between fluid-attenuated inversion recovery vascular hyperintensities and proximal middle cerebral artery occlusion prognosis. OBJECTIVES: To assess a fluid-attenuated inversion recovery vascular hyperintensities score (FVHS) and explore its relationship with recanalization status and clinical outcomes after intravenous thrombolysis. DESIGN: Retrospective study. SETTING: Stroke unit in a university hospital. PATIENTS: Consecutive patients with proximal middle cerebral artery occlusion, thrombolysed within 6 hours, were selected from our prospective database. The FVHS (range,0-10; divided into low, medium, and high thirds) was quantified on the magnetic resonance image obtained at admission. Recanalization rates, infarction size (Alberta Stroke Program Early CT Score applied to diffusion weighted imaging [ASPECTS-DWI]), and 3-month functional outcomes (modified Rankin Scale score) were determined. Poor outcomes and large infarctions were defined as a modified Rankin Scale score higher than 2and an ASPECTS-DWI score of 5 or lower, respectively. MAIN OUTCOME MEASURES: Interaction among FVHS,recanalization status, and outcomes. RESULTS: Thirty-four patients had a low FVHS (4), 32 had a medium FVHS (5 or 6), and 39 had a high FVHS (≥7). The rate of poor functional outcome (modified Rankin Scale score >2) was higher for the group with low FVHSs than those with medium FVHSs and high FVHSs(82.3% vs 43.7% and 43.5%, respectively; P.001). Therate of 24-hour large infarctions(ASPECTS-DWI score 5)was higher for those with low FVHSs than those with medium and high FVHSs (88.2% vs 56.2% and 51.3%, respectively;P=.002). The recanalization rate was not associated with FVHS. Multivariate analysis retained low FVHS as an independent early predictor of poor clinical outcome (odds ratio=9.91; 95% CI, 2.01-48.93; P=.004)and large infarction (odds ratio=6.99; 95% CI, 1.78-27.46; P=.005).Low FVHS remained associated with poor outcomes regardless of recanalization status. Early recanalization in patients with a low FVHS decreased the poor functional outcome rate from 100% to 64.7% (P=.02). CONCLUSIONS: The FVHS is an early independent prognostic marker for patients with proximal middle cerebral artery occlusion. Synergy between FVHS and recanalization status appears to be a critical determinant of final outcomes, supporting intensive reperfusion treatment for patients with a low FVHS.

Intracranial hypertension caused by a meningioma compressing the transverse sinus.

We report a 55-year-old woman with intracranial hypertension due to unilateral extrinsic compression of the left transverse sinus by a meningioma. Because of the high risk of the conventional neurosurgical intervention, she underwent an endovascular procedure consisting of a transstenotic stent placement in the left transverse sinus. One month after stenting, her ophthalmological examination revealed complete regression of the bilateral papilledema, with persistent improvement at 1 year. Cerebral venous-stenting could be a safe alternative for patients suffering from intracranial hypertension caused by extrinsic sinus compression.

Respective contributions of vertebroplasty and kyphoplasty to the management of osteoporotic vertebral fractures.

Among individuals aged 50-80 years, 5-20% have one or more vertebral crush fractures. One-third of these patients require treatment for acute or chronic pain. Vertebroplasty and kyphoplasty were introduced over the last two decades as treatments for incapacitating pain from osteoporotic vertebral fractures. Both techniques proved effective and safe in numerous retrospective and prospective studies. They now deserve to be incorporated into the standard treatment strategy for painful and incapacitating vertebral fractures. Kyphoplasty seeks not only to stabilize the vertebra, but also to correct the kyphosis induced by the vertebral body collapse. However, the correction is often limited (less than 15 degrees ) and has not been shown to increase the benefits in terms of pain relief or quality-of-life improvement, compared to vertebroplasty. Kyphoplasty is more costly than vertebroplasty, which is therefore emerging as the treatment of choice. However, a randomized double-blind trial comparing vertebroplasty and kyphoplasty is needed. Furthermore, a randomized comparison of vertebroplasty or kyphoplasty versus noninterventional treatment is needed in patients admitted for pain immediately after a vertebral crush fracture.