Safety and outcomes of routine endovascular thrombectomy in large artery occlusion recorded in the SITS Register: An observational study

BACKGROUND AND OBJECTIVE

We aimed to evaluate the safety and outcomes of thrombectomy in anterior circulation acute ischaemic stroke recorded in the SITS-International Stroke Thrombectomy Register (SITS-ISTR) and compare them with pooled randomized controlled trials (RCTs) and two national registry studies.

METHODS

We identified centres recording ≥10 consecutive patients in the SITS-ISTR with at least 70% of available modified Rankin Scale (mRS) at 3 months during 2014-2019. We defined large artery occlusion as intracranial internal carotid artery, first and second segment of middle cerebral artery and first segment of anterior cerebral artery. Outcome measures were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial haemorrhage (SICH) per modified SITS-MOST.

RESULTS

Results are presented in the following order: SITS-ISTR, RCTs, MR CLEAN Registry and German Stroke Registry (GSR). Median age was 73, 68, 71 and 75 years; baseline NIHSS score was 16, 17, 16 and 15; prior intravenous thrombolysis was 62%, 83%, 78% and 56%; onset to reperfusion time was 289, 285, 267 and 249 min; successful recanalization (mTICI score 2b or 3) was 86%, 71%, 59% and 83%; functional independence at 3 months was 45.5% (95% CI: 44-47), 46.0% (42-50), 38% (35-41) and 37% (35-41), respectively; death was 19.2% (19-21), 15.3% (12.7-18.4), 29.2% (27-32) and 28.6% (27-31); and SICH was 3.6% (3-4), 4.4% (3.0-6.4), 5.8% (4.7-7.1) and not available.

CONCLUSION

Thrombectomy in routine clinical use registered in the SITS-ISTR showed safety and outcomes comparable to RCTs, and better functional outcomes and lower mortality than previous national registry studies.

Safety and Outcomes of Thrombectomy in Ischemic Stroke With vs Without IV Thrombolysis

OBJECTIVE

To test the hypothesis that IV thrombolysis (IVT) treatment before endovascular thrombectomy (EVT) is associated with better outcomes in patients with anterior circulation large artery occlusion (LAO) stroke, we examined a large real-world database, the Safe Implementation of Treatment in Stroke-International Stroke Thrombectomy Register (SITS-ISTR).

METHODS

We identified centers recording ≥10 consecutive patients in the SITS-ISTR, with at least 70% available modified Rankin Scale (mRS) scores at 3 months during 2014 to 2019. We defined LAO as intracranial internal carotid artery, first and second segment of middle cerebral artery, and first segment of anterior cerebral artery. Main outcomes were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial hemorrhage (SICH) per modified SITS-Monitoring Study. We performed propensity score-matched (PSM) and multivariable logistic regression analyses.

RESULTS

Of 6,350 patients from 42 centers, 3,944 (62.1%) received IVT. IVT + EVT-treated patients had less frequent atrial fibrillation, ongoing anticoagulation, previous stroke, heart failure, and prestroke disability. PSM analysis showed that IVT + EVT-treated patients had a higher rate of functional independence than patients treated with EVT alone (46.4% vs 40.3%, p < 0.001) and a lower rate of death at 3 months (20.3% vs 23.3%, p = 0.035). SICH rates (3.5% vs 3.0%, p = 0.42) were similar in both groups. Multivariate adjustment yielded results consistent with PSM.

CONCLUSION

Pretreatment with IVT was associated with favorable outcomes in EVT-treated LAO stroke in the SITS-ISTR. These findings, while indicative of international routine clinical practice, are limited by observational design, unmeasured confounding, and possible residual confounding by indication.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that IVT before EVT increases the probability of functional independence at 3 months compared to EVT alone.

Use of intracranial stent as rescue therapy after mechanical thrombectomy failure-9-year experience in a comprehensive stroke centre

PURPOSE

There is no established rescue treatment in patients with mechanical thrombectomy (MT) failure. Our aim is to analyse whether the use of an intracranial stent improves prognosis in these patients.

METHODS

Retrospective analysis of a prospective cohort of patients with ischemic stroke due to middle cerebral artery occlusion (MCA) or distal intracranial carotid artery (ICA) occlusion, from September 2009 to April 2019 in our comprehensive stroke care centre. Patients with MT failure were identified and dichotomized into two groups according to whether or not an intracranial stent was implanted. We analysed clinical outcomes in both groups.

RESULTS

There was MT failure in 60 patients (14%) of the 433 with large vessel occlusion in distal ICA and proximal MCA. A stent was placed in 20 of them (33.3%). Compared to patients without rescue stenting, they showed better rates of independence at 3 months (mRS ≤ 2) 45% vs 2.5% (p < 0.001) and lower mortality 15% vs 50% (p = 0.009), maintaining statistical significance after multivariate analysis, without a significant increase of the rate of symptomatic intracranial haemorrhage (p = 0.209).

CONCLUSION

Placement of an intracranial stent as rescue therapy after MT failure was associated with better clinical outcome without significant increase in haemorrhagic complications. We believe that this procedure should be appraised in these patients.

Predictors for Cerebral Edema in Acute Ischemic Stroke Treated With Intravenous Thrombolysis

BACKGROUND AND PURPOSE

Cerebral edema (CED) is a severe complication of acute ischemic stroke. There is uncertainty regarding the predictors for the development of CED after cerebral infarction. We aimed to determine which baseline clinical and radiological parameters predict development of CED in patients treated with intravenous thrombolysis.

METHODS

We used an image-based classification of CED with 3 degrees of severity (less severe CED 1 and most severe CED 3) on postintravenous thrombolysis imaging scans. We extracted data from 42 187 patients recorded in the SITS International Register (Safe Implementation of Treatments in Stroke) during 2002 to 2011. We did univariate comparisons of baseline data between patients with or without CED. We used backward logistic regression to select a set of predictors for each CED severity.

RESULTS

CED was detected in 9579/42 187 patients (22.7%: 12.5% CED 1, 4.9% CED 2, 5.3% CED 3). In patients with CED versus no CED, the baseline National Institutes of Health Stroke Scale score was higher (17 versus 10; P<0.001), signs of acute infarct was more common (27.9% versus 19.2%; P<0.001), hyperdense artery sign was more common (37.6% versus 14.6%; P<0.001), and blood glucose was higher (6.8 versus 6.4 mmol/L; P<0.001). Baseline National Institutes of Health Stroke Scale, hyperdense artery sign, blood glucose, impaired consciousness, and signs of acute infarct on imaging were independent predictors for all edema types.

CONCLUSIONS

The most important baseline predictors for early CED are National Institutes of Health Stroke Scale, hyperdense artery sign, higher blood glucose, decreased level of consciousness, and signs of infarct at baseline. The findings can be used to improve selection and monitoring of patients for drug or surgical treatment.

Unnecessary overuse. Study of "inadvisable practices" for patients with atrial fibrillation

OBJECTIVE

To identify overuse (diagnostic, therapeutic and self-care practices that represent risks that outweigh the potential benefits) in patients with atrial fibrillation.

METHOD

The study was based on qualitative research techniques. Using the "Metaplan" technique, we identified and ordered potentially inappropriate, ineffective and inefficient practices. By means of a consensus conference, we then established a number of "inadvisable practice" measures (relatively common practices that should be eliminated based on the scientific evidence or clinical experience). Professionals from the specialties of cardiology, haematology, neurology, internal medicine, family medicine and nursing participated in the consensus.

RESULTS

We developed a catalogue of 19 "inadvisable practices" related to the diagnosis, treatment and care of anticoagulated patients that were inappropriate, had questionable effectiveness or were ineffective, as well as 13 beliefs or behaviours for anticoagulated patients that could result in injury or were useless or inefficient.

CONCLUSION

The "inadvisable practices" approach helps identify practices that represent greater risks than benefits for patients. It seems appropriate to include algorithms in the clinical decision-making support systems that consider this information for the diagnosis, treatment and for home care. For this last case, recommendations have also been prepared that define specific contents for the healthcare education of these patients.

Impact of clinical training on supra-aortic duplex and transcranial doppler examination concordance

Sonographic tests are observer-dependent. With 1,527 consecutive patients, 22 trainees were assessed at baseline and after a hands-on 1:1 program, with a pre-examination median of 76 studies/trainee. We evaluated the required number of supervised examinations to reach a 0.80 kappa index (ki). Statistics included linear and exponential generalized estimating equation models. In the exponential model, 76 studies for carotid-duplex and >102 for vertebral-duplex and transcranial Doppler were needed for a 0.80 ki. "Relevant-categories" after-training ki was 0.80 in carotid-duplex and transcranial Doppler but 0.60 in vertebral-duplex. A fixed training does not guarantee a high ki. Measuring the acquired skills of every trainee would improve quality. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:571-579, 2016.

How predictors and patterns of stroke recurrence after a TIA differ during the first year of follow-up

The highest risk of subsequent stroke after a TIA occurs within the first week after the index event. However, the risk of stroke recurrence (SR) remains high during the first year of follow-up. We studied the temporal pattern and predictors of SR (at 7 days and from 7 days to 1-year follow-up). Between April 2008 and December 2009, we included 1,255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). We determined the short-term (at 7 days) and long-term (from 8 days to 1 year) risk of SR. Patients who underwent short-term recurrence and long-term recurrence were compared with regard to clinical findings, vascular territories, and etiology. Enough information (clinical variables and extracranial vascular imaging) was assessed in 1,137 (90.6 %) patients. The 7-day stroke risk was 2.6 %. 32 (3.0 %) patients had an SR after 7-day follow-up. Multiple TIA (HR 3.50, 1.67-7.35, p = 0.001) and large artery atherosclerosis (HR 2.51, 1.17-5.37, p = 0.018) were independent predictors of early SR, whereas previous stroke (HR 1.40, 1.03-1.92, p = 0.034) and coronary heart disease (2.65, 1.28-5.50, p = 0.009) were independent predictors of late SR. Notoriously, 80 % of SR happened in the same territory of the index TIA at 7-day follow-up, whereas only 38 % during the long-term follow-up (p < 0.001). Different predictors of SR were identified throughout the follow-up period. Moreover, the ischemic mechanism differed in early and late stroke recurrences.

Peripheral iron metabolism in patients with focal cerebral ischemia

To ascertain the possible role of iron as a risk factor for cerebral ischemia, we studied the serum levels of iron, transferrin and ferritin in 42 patients between the third and seventh days after a cerebral ischemic event (transient ischemic attack, reversible ischemic neurological deficit or cerebral infarction) and in 62 matched controls. The serum levels of iron did not differ significantly between cerebral ischemic patient and control groups. Serum transferrin levels were lower and ferritin higher in stroke patients than in controls. These values were not influenced by age, blood pressure, or smoking and alcohol drinking habits. These results suggest that iron stores could be related to the risk for cerebral ischemia.

Importance of cerebral artery recanalization in patients with stroke with and without neurological improvement after intravenous thrombolysis

BACKGROUND AND PURPOSE

Recanalization status after intravenous thrombolysis (IVT) in patients with ischemic stroke is a reference point to proceed with a rescue reperfusion intervention, although early neurological improvement (NI) may preclude endovascular procedures. We aimed to evaluate the importance of restoration of blood flow at the arterial occlusion site in subgroups of patients with stroke stratified by early NI after IVT.

METHODS

The following patients were recruited from the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register: (1) with baseline vessel occlusion documented by computed tomographic (CT) or magnetic resonance (MR) angiography and follow-up angioimaging between 22 and 36 hours after IVT available; and (2) with dense cerebral artery sign on admission CT scan and results of follow-up CT reported. Recanalization at 24 hours was defined as absence of vessel occlusion or as resolution of dense cerebral artery sign on follow-up 22- to 36-hour imaging. NI was assessed at 2 hours and 24 hours after IVT and was defined as improvement by 20% from baseline National Institute of Health Stroke scale score. Primary outcome measure was independence, defined as modified Rankin scale score 0 to 2 after 3 months.

RESULTS

Of 28136 cases registered between December 2003 and November 2009, 5324 cases (19%) met the inclusion criteria. Patients with both NI at 2 hours post-treatment and vessel recanalization had the best chances to achieve independence at 3 months (adjusted odds ratio, 15.8; 95% confidence interval, 12.5-20.0), followed by those who had NI despite persistent occlusion (adjusted odds ratio, 4.7; 95% confidence interval, 3.6-6.1); and those without NI despite recanalization (adjusted odds ratio, 2.7; 95% confidence interval, 2.2-3.3).

CONCLUSIONS

Recanalization of an occluded artery in acute stroke is associated with favorable functional outcome both in patients with and without NI after IVT. In future evaluations of mechanical thrombectomy and other additional strategies, recanalization should be considered in patients with persisting occlusion after IVT even after significant NI.

Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJECTIVE

To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment.

MATERIAL AND METHODS

A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed.

RESULTS

The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm.

CONCLUSIONS

SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

[Neurovascular intervention in the acute phase of cerebral infarction]

BACKGROUND AND PURPOSE

Endovascular therapies in acute ischaemic stroke may offer benefits to patients that are not eligible for standard use of intravenous tissue activator plasminogen (iv t-PA) or when this is not effective. Our aim is to present the initial experience in with endovascular techniques in the Community of Madrid.

METHODS

We present data from our registry of acute ischaemic strokes treated with endovascular re-perfusion therapies in five University Hospitals in Madrid (Spain) during the period 2005-2009. We recorded demographic data, vascular risk factors, risk severity with the NIHSS (National Institute of Health Stroke Scale), endovascular techniques, complications and mortality rates. Functional outcome and neurological disability at 90 days was defined by the modified Rankin scale (mRs).

RESULTS

A total of 41 patients were treated with endovascular therapies. Mean age was 58.6 ± 19.9, and 56.1% were males. Of those 22 patients had an anterior circulation stroke and 19 had a posterior circulation stroke. Baseline NIHSS score was: median, 17 [range, 2-34]; 7 patients had previously received iv t-PA. The following endovascular techniques were performed: mechanical disruption (26 patients), intra-arterial infusion of t-PA (26 patients), angioplasty and stenting (5 patients), mechanical use of MERCI device (3 patients). Partial or total re-canalization was achieved in 32 patients (78%). Only one patient had a symptomatic cerebral haemorrhage. Three months after stroke, 53.6% of the patients were independent (mRs ≤ 2) and overall mortality rate was 19.5%.

CONCLUSIONS

Acute ischaemic stroke is a potentially treatable medical emergency within the first hours after the onset of symptoms. Stroke endovascular procedures constitute an alternative for patients with iv t-PA exclusion criteria or when this is not effective.

Mother tongue lost while second language intact: insights into aphasia

Cortical representations of the native language and a second language may have different anatomical distribution. The relationships between the phonologic and orthographic forms of words continue to be debated. We present a bilingual patient whose competence in his mother tongue was disrupted following brain ischaemia. Semantic units were accessible only as isolated letters in written as well as oral language presentation. His second language appeared completely unaffected. Whole word system disturbance of both orthography and phonology pathways of the native language could explain this presentation. It is a great opportunity to learn about the language neural network when a bilingual subject presents with brain ischaemia.

[Thrombolysis in Madrid: is there improvement in the 4 years temporal analysis?]

INTRODUCTION

Thrombolysis in acute ischemic stroke (IS) is limited by the short time window. However, this can be improved with adequate coordination of all the professionals and procedures involved in acute stroke treatment.

PATIENTS AND METHODS

A multicenter, observational, prospective study conducted in IS patients treated with intravenous recombinant tissue plasminogen activator between January 2003 and May 2007 was performed. A descriptive analysis of epidemiologic and clinical variables was conducted. Temporal analysis of safety, efficacy and quality parameters was carried out with the Auto-Regressive Integrated Moving Average (ARIMA) (p, d, q) models.

RESULTS

From January 2003 to 2007, 324 patients were included (56% males; median age: 65.6). A total of 53.6 % became independent at 3 months (score 0-2 on the Modified Rankin Scale). Mortality rate 3 months after treatment was 15.7% and 3.7% suffered symptomatic intracranial bleeding. The temporal analysis showed a significant increase of thrombolysis, from a mean of 2 procedures per month to 20 (p<0.0001). There was a significant increase in the percentage of 3-month independent patients (0.83% [ARIMA] (1, 0, 1) p<0.0001).

CONCLUSIONS

Intravenous thrombolysis is a safe and effective procedure for the treatment of IS in the clinical practice. As the experience of all the professionals involved in IS treatment increases, the number of patients who receive iv rtPA increases, with better outcome. Temporal analysis by ARIMA models is useful in planning health policies.

Thrombolysis for ischaemic stroke and glioblastoma multiforme: a case report

OBJECTIVE

To report the uncomplicated use of systemic thrombolysis for stroke in a patient with a misdiagnosed glioblastoma multiforme mimicking brain ischaemia and to suggest that new clinical situations question the stated exclusion criteria for intravenous thrombolysis.

PATIENT

A 57-year-old male presented at the emergency room with a sudden aphasia.

MEASUREMENT AND MAIN RESULTS

After Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) exclusion criteria were ruled out, intravenous alteplase was administered. The patient presented with tonic-clonic seizures 17 min after perfusion completion, requiring phenytoine administration. Additional computed tomography scan did not show haemorrhagic transformation or brain oedema. A left temporal lobe glioblastoma multiforme was diagnosed after magnetic resonance imaging and neurosurgery. The patient became asymptomatic on the seventh day.

CONCLUSION

Any history of central nervous system neoplasm is considered a contraindication to thrombolysis, but the true risk of systemic thrombolysis-precipitated intracranial bleeding is unknown. Further data are needed to establish real haemorrhage risk in this clinical condition.

Risk of ischemic stroke and lifetime estrogen exposure

BACKGROUND

Estrogen loss has been related to higher incidence of stroke in postmenopausal women, but randomized trials have demonstrated an increased risk of stroke in women receiving hormone replacement therapy (HRT).

OBJECTIVE

To assess the relationship between exposure to endogenous ovarian hormones and the risk of noncardioembolic ischemic stroke.

METHODS

We conducted a multicenter, age-matched, case-control study in postmenopausal women (case: nonembolic ischemic stroke; control: no stroke) comparing duration of ovarian activity or lifetime estrogen exposure, which was defined as age at menarche to age at menopause. Embolic cardiopathy and unreliable gynecologic data were exclusion criteria. Cardiovascular disease risk factors were recorded. The relationships of the principal variables to the risk of stroke were assessed using a conditional logistic regression analysis.

RESULTS

There were 430 cases and 905 controls in the study. In the multivariate analysis, hypertension (odds ratio [OR]: 2.73; 95% CI: 2.09 to 3.58; p < 0.0001), diabetes (OR: 3.38; 95% CI: 2.53 to 4.52; p < 0.0001), hyperlipidemia (OR: 1.31; 95% CI: 1.01 to 1.7; p = 0.045), lifespan of ovarian activity <34 years (OR: 1.51; 95% CI: 1.13 to 2.03; p = 0.005), and menarche at <13 years of age (OR 1.49; 95% CI: 1.15 to 1.92; p = 0.002) were independently related to an increased risk of stroke. Obesity (OR: 0.73; 95% CI: 0.56 to 0.95; p = 0.021) was related to a lower risk of stroke.

CONCLUSIONS

Longer lifetime exposure to ovarian estrogens may protect against noncardioembolic ischemic stroke. However, a very early age of exposure onset could be disadvantageous.

[Pontine stroke secondary to a foramen magnum meningioma]

INTRODUCTION

Meningioma is one of the most frequent tumours affecting the central nervous system, with an estimated incidence of between 15 and 20% of all brain tumours. They are generally benign and slow growing. Their appearing as a cerebral infarction is very rare.

CASE REPORT

A right-handed 75-year-old female patient with a personal history of arterial hypertension, who visited the Emergency Department because of the sudden onset of severe dysarthria, accompanied by loss of strength in the left limbs, supranuclear facial palsy on the left side and Horner syndrome on the right. A computerised tomography scan of the brain revealed a lacunar infarct in said location, with no other appreciable damage. The neurovascular study included a transcranial Doppler, which was unable to insonate the left vertebral artery or the basilar artery. Magnetic resonance imaging of the head revealed a foramen magnum meningioma, with vertebrobasilar vascular distortion. The patient progressed favourably and was submitted to radiosurgery.

CONCLUSIONS

The case reported here is unique, since it describes a meningioma of the posterior fossa that appears in the form of the initial symptoms of a pontine stroke due to a vascular disorder.

[Stroke and intracranial stenosis: clinical profile in a series of 134 patients in Spain]

INTRODUCTION

Intracranial stenoses (IS) are known to be a manifestation of atherosclerosis and a cause of cerebral ischemia, although very few clinical reports have appeared describing such patients in our milieu.

OBJECTIVE

The aim of this study was to describe the vascular risk factors, clinical presentation, radiological characteristics, aetiological role played in strokes and the vessels affected in a series of Spanish patients suffering from stroke and IS.

PATIENTS AND METHODS

We conducted a retrospective descriptive study of patients admitted to the Cerebrovascular Pathology Unit with strokes and IS between 1990 and 2001. Data collected included: age, sex, arterial hypertension (AHT), diabetes (Db), hypercholesterolemia (HC), smoking (Sm), ischemic or emboligenic heart disease, intermittent claudication, carotid atheromatosis, clinical presentation of stroke and earlier lesions in computerised axial tomography (CAT) scans of the brain.

RESULTS

132 patients; 187 stenotic vessels: 65.7% males, mean age 68.3 years. AHT 65%, Db 39%, HC 40%, Sm 43%, ischemic heart disease 22%, emboligenic heart disease 17%, intermittent claudication 13%.

CLINICAL PRESENTATION

TIA 16%, LACI 33%; PACI 25%, TACI 4%, POCI 19%. Significant carotid atheromatosis 26.5%. Symptomatic IS 50%: mean age 63.3 years, 64% females. Arteries affected: vertebral (VA) 28%; middle cerebral (MCA) 27%; carotid siphon 21%; basilar (BA) 10% (65% symptomatic); anterior cerebral (ACA) 5% and posterior cerebral (CPA) 4%. Normal cranial CAT scan 24%, lacunar infarcts 42%, territorial 32%; leukoaraiosis 17%.

CONCLUSIONS

Patients with stroke and IS display different clinical profiles according to their sex (males: a higher number of vascular risk factors and clinical involvement of other territories; females are more symptomatic, AHT and HC); they usually present clinically as lacunar syndromes, with a scarce amount of significant atheromatous carotid involvement, except IS of the VA, and IS of the BA are the most symptomatic.

[Antioxidant enzymes in acute cerebral infarction]

BACKGROUND AND PURPOSE

Oxidative modification of DNA, protein and lipids by reactive oxygen peroxides plays an important role in acute cerebral infarction. The biological antioxidant defence system against oxidative stress is an integrated array of enzymes such as superoxide dismutase (SOD), catalase (CAT) and glutathion peroxidase (GPx). The purpose of this work was: 1. To investigate the evolution of SOD and CAT activities as possible markers of oxidative activity in patients with acute cerebral infarction. 2. To establish the relationship between the type of stroke and the activity of these two enzymes. 3. To analyze the relationship between the degree of neurological deficits of patients with stroke and SOD and CAT activities.

PATIENTS AND METHODS

This is a prospective study comprising 45 patients with acute cerebral infarction (24 females and 21 males), aged from 48 to 96. The infarcts were classified in atherotrombotics and cardioembolics. SOD and CAT activities were measured on days 1, 3, 6 and 15.

RESULTS

Activities of SOD and CAT in patients on admission were lower than those of controls and showed a gradual increase over time. The activity mean of SOD was significantly higher in cardioembolic infarctions than in atherotrombotic infarctions (p < 0.05). SOD activity was significantly lower for Mathew score > 60, while CAT activity was higher.

CONCLUSIONS

Our findings suggest that there is a progressive increase in SOD and CAT activity during ictus evolution, a different activity of SOD and CAT in cardioembolic and atherotrombotic infarctions, and that there is a relationship between activity of antioxidant enzymes and Mathew's score.

Neurosonology in cerebral ischemia: future application of transcranial Doppler in acute stroke

Transcranial Doppler (TCD) has become a general practice in recent years in the diagnostic study of patients with cerebral ischemia. This is due to the fact that it is a rapid, noninvasive, reproducible and dynamic examination of intracranial circulation. In the acute phase of cerebral infarction, it can detect MCA occlusion with a good correlation with angiographic findings and, what is even more important, the patients who will later suffer lacunar infarctions almost always show a normal Doppler examination. Acute abnormalities can also demonstrate the mechanism of the clinical signs; the examination informs us of the existence of collaterals and severe occlusions or stenoses of the extracranial arteries, and can change the priority in the search for the etiological diagnosis. The diagnosis of intracranial stenoses as a cause of clinical signs is another immediate application of TCD, right from the acute phase. If in the future anticoagulation is shown to be an optimum treatment for secondary prophylaxis in intracranial stenoses, TCD will probably become the diagnostic technique of choice. The ability to predict the prognosis based on parameters obtained by TCD opens up the possibility of using it as an auxiliary technique for the selection of patients for reperfusion treatment, having in its favor that it is quick and easy to perform, and therefore suitable for treatment monitoring. It seems clear that the data obtained by Doppler in the first 6 h are a good predictor of both spontaneous improvement and early impairment, which could help to avoid treatment in patients in whom a rapid improvement can be expected. Finally, the hemodynamic data of the TCD could be of inestimable value in the assessment and monitoring of intracranial hypertension treatments and for hemodynamic management of the patient, allowing the treatment margins of the acute phase of arterial hypertension to be reliably established without compromising the perfusion pressure. In conclusion, TCD will possibly be more widely used in the future in the acute phase of cerebral infarction as a guide to diagnostic procedures, for treatment selection and for monitoring of cerebral hemodynamics.

Quality of life among stroke survivors evaluated 1 year after stroke: experience of a stroke unit

BACKGROUND AND PURPOSE

We sought to study overall and domain-specific quality of life in stroke survivors 1 year after stroke and to identify variables that could predict quality of life after stroke.

METHODS

We followed up for 1 year a cohort of 118 patients consecutively admitted to our stroke unit at San Carlos University Hospital in Madrid, Spain. The final series at 1-year follow-up consisted of 90 survivors (41 women and 49 men; mean age, 68 years; range, 32 to 90 years). A cross-sectional, descriptive design was developed. Patients completed a questionnaire that included socioeconomic variables, Hamilton Rating Scale for Depression, Sickness Impact Profile (SIP), Short Form 36, Frenchay Index, Barthel Index, Rankin Scale, and Scandinavian Stroke Scale. Independent variables were sex, age, functional status, motor impairment, and depression. We developed an ANOVA model for statistical analysis.

RESULTS

We interviewed 79 patients with ischemic and 11 with hemorrhagic stroke. Thirty-eight percent of patients scored in the depressed range. Variables related to depression were status as a housewife, female sex, inability to work because of disability, and diminished social activity (P:<0.0001). Mean total SIP (24.3), SIP psychosocial dimension (27.5), and SIP physical dimension (21.2) were correlated with disability, female sex, motor impairment, and depression (P:<0.0001).

CONCLUSIONS

Functional status and depression were identified as predictors of quality of life. Patients independent in their activities of daily living suffered from a deterioration of the psychosocial dimension of the SIP.

[Blood flow in patients with intracerebral hemorrhage. Does there exist the associated hypoperfusion? A transcranial Doppler study]

OBJECTIVE

To evaluate, using transcranial Doppler, changes in parameters in patients with cerebral hematoma, as compared with controls, for detection of possible regional hypoperfusion.

PATIENTS AND METHODS

We studied 24 patients with cerebral hematomas and 15 healthy volunteers. The volume of the hematoma and the hypodense area was determined by computerized axial tomography of the skull at the time of admission. The average speed and index of pulsation of the anterior, middle and posterior cerebral arteries were measured in both hemispheres using transcranial Doppler within the first 100 hours. The differences between the averages were analysed using the ANOVA test and the correlations with Pearson's coefficient of correlation.

RESULTS

The average speeds, except in the anterior cerebral artery, were lower in both hemispheres in the patients than in the controls (p < 0.001). There were interhemispherical differences in the average speeds in the patients (p = 0.06). The indices of pulsatility were greater in both hemispheres in the patients than in the controls (p < 0.001). These differences were independent of age, sex and arterial blood pressure. The average speed in the ipsilateral middle cerebral artery showed excellent correlation with the size of the hypodense area (r = -0.92) and the hematoma (r = -0.89). The indices of pulsatility showed little correlation with the size of the lesion. There was moderate correlation between transcranial Doppler and clinical scales.

CONCLUSION

Transcranial Doppler detects cerebral hypoperfusion in patients with hematoma. The excellent correlation of the average speed in the middle cerebral artery with the size of the lesion and the low correlation of the indices of pulsatility, which did not show interhemispherical asymmetry, suggest that the mechanisms of hipoperfusion are different from the intracranial hypertension.

Bihemispheric contribution to motor recovery after stroke: A longitudinal study with transcranial doppler ultrasonography

BACKGROUND

Both cerebral hemispheres seem to contribute to motor recovery after stroke. We studied the effect of motor activity on cerebral blood flow in both hemispheres at different stages of stroke evolution.

METHODS

Thirty patients with hemiplegic stroke and 30 controls were included. Patients were examined within the first week (T1), 1 month (T2) and 6 months after stroke (T3). All subjects performed a 2-min sequential thumb-to-finger opposition task while blood flow velocities in both middle cerebral arteries were measured with transcranial Doppler ultrasonography (TCD).

RESULTS

Contralateral movement caused a higher increase in blood flow velocity than ipsilateral movement in controls (p < 0.0001). On the healthy side, patients showed a striking increase with ipsilateral movement (affected hand), which was similar to the increase with contralateral movement (normal hand) at all stages. On the damaged side, the increase with contralateral movement (affected hand) was low and was similar to the increase with ipsilateral movement (normal hand) at T1 and T2; however, at T3 the increase with contralateral movement was higher and the pattern of response was similar to that found in controls.

CONCLUSIONS

TCD can trace the evolution of brain motor output following stroke. Compensatory activation of the healthy side of the brain may be already present soon after stroke, whereas function of the damaged side may improve during several months.

[Cerebral activation during movement of both hands. A study with transcranial Doppler]

INTRODUCTION AND OBJECTIVE

In healthy persons, the force carried out by a group of muscles doing bilateral exercise with maximum effort is less than that done during unilateral exercise. The nervous control of movement is probably different in these two cases. Our objective was to study and compare cerebral activation on movement of one and of both hands by means of transcranial Doppler (TCD).

MATERIAL AND METHODS

We studied 30 healthy volunteers (19 men and 11 women; average age 65.4 +/- 9.5 years). Using transtemporal TCD we assessed the relative changes in average velocity of flow in both middle cerebral arteries during the exercise of sequential opposition of the fingers of one hand and of both hands.

RESULTS

The activity due to the exercise of the hand contralateral to the hemisphere being studied was greater than that due to exercise of both hands together, both on the right side (p < 0.001) and on the left (p < 0.001).

CONCLUSIONS

The functional activity of each cerebral hemisphere is not necessarily greater when both hands are exercised than when the contralateral hand is used, and may even be less. The possible increase in activity due to the additional contribution to ipsilateral movement in the first case may be compensated by simultaneous transhemispherical inhibition.

[The stroke chain: from the onset of symptoms to the emergency services]

INTRODUCTION

The treatment of stroke by thrombolysis or other methods (neuroprotection, basic care, etc.) is more effective the sooner it is begun. The main reasons for patients not receiving treatment during the acute phase of their illness are slowness in reaching hospital and delay in emergency assessment once they arrive there. It is necessary to identify the factors involved in these delays so as to modify what can be improved and establish guidelines.

DEVELOPMENT

In the chain of events leading to arrival in hospital there are independent factors related to the social and health characteristics of the patients, their attitudes to illness, characteristics of the stroke itself and of the health district. Analysis of the system for response to stroke patients is extremely important before investing in measures to be applied during the acute phase. This analysis should be based on the different stages at which delays may occur. Outside the hospital, the systems to be recognized are those of the patient and his family, contact with prehospital care teams and transport to the hospital of reference. Hospital care involves making contact on arrival at the Emergency Department, and the response of the neurologist or stroke team who give the initial treatment.

CONCLUSIONS

Programmes of education and improvement in the organization of the different protagonists at the various stages reduce the time lost by delay.

[Oculocerebral syndrome: an infrequent pathological manifestation of carotid occlusion]

INTRODUCTION

The simultaneous occurrence of impaired visual and ipsilateral hemisphere symptoms is uncommon. It is associated with carotid pathology.

CLINICAL CASES

We present three cases under the name of oculocerebral syndrome, in which there were symptoms of monocular ischemia and ipsilateral cerebral ischemia. In two of these cases the monocular vision loss was transient, and in the third case it was permanent due to occlusion of the central retinal artery. In all three cases there was evidence of obstruction of the internal carotid artery.

CONCLUSION

The pathological process involved may be mixed, embolic-hemodynamic.

[Right sensory-motor syndrome as the presentation of a spontaneous cervico-thoracic epidural hematoma]

INTRODUCTION

A spontaneous cervical epidural hematoma is an infrequent cause of cord compression. The commonest clinical presentations are with paraparesia and tetraparesia. Transient hemiparesia is very rare and a sensory-motor syndrome is exceptional.

CLINICAL CASE

A 38 year old man had sudden onset of spontaneous interscapular vertebral pain with bilateral root radiation. A few minutes later he started to have weakness and sensory loss in his right limbs. On clinical examination there was pain on pressure over the spinal apophyses of the T4 and T5 vertebrae, hemiparesia and hemi-hypoalgesia of the right limbs. After ten hours this had all returned to normal. MRI of the cord showed an epidural hematoma extending from C6 to T2. Coagulation studies and spinal arteriography were normal.

CONCLUSIONS

The sensory motor syndrome is an unusual form of presentation of a spontaneous cervico-thoracic epidural hematoma. Root pain is a symptom of great value for orientation of a syndrome which would otherwise seem to be of central origin. The explanation for this clinical findings may be compression of both lateral cord pathways due to their particular blood distribution. Regarding therapeutic approach, this should be conservative, with close observation to see whether it will resolve spontaneously in a short period of time.

Risk factors of stroke after percutaneous transluminal coronary angioplasty

Objective: to determine possible risk factors of a stroke after percutaneous transluminal coronary angioplasty (PTCA). Design: this is a retrospective evaluation of a consecutive group of 4088 patients undergoing PTCA between 1988 and 1995. We have studied the incidence, clinical characteristics, risk factors, and outcome. Results: seven patients, six males and one female (0.17%) developed a stroke after this procedure. In comparison with the control group, the stroke group did not differ regarding age or gender. The existence of a stroke (six located in the brain, and one in the spinal cord), represented 1.24% of all complications (P < 0.001), and 5% of all deaths (P < 0.01) of PTCA. Three patients developed TIA, two patients developed hemorrhagic strokes (in which they received previous thrombolytic therapy), and the other two patients suffered from an ischemic stroke. The statistically significant risk factors of a stroke after PTCA included: intracoronary thrombolytic therapy (P < 0.01), hypercholesterolemia (P < 0.001) and a prior PTCA (P < 0.05). Conclusions: although these procedural complications are infrequent, they are usually serious and important risk factors which could be identified prior to the procedure. These risk factors would allow identification of patients who are prone to a stroke after PTCA. Intracranial hemorrhage occurred only after thrombolytic therapy, and the factors related to hemorrhagic strokes were probably different from those predisposed to ischemic strokes and TIA. Copyright 1998 Lippincott Williams & Wilkins

[The one and a half vertical syndrome as the only evidence of bilateral thalamo-subthalamic infarction]

INTRODUCTION

The one and a half vertical syndrome consists of paralysis of upward vertical conjugated gaze and monocular paralysis of downward gaze or vice-versa. It occurs as a consequence of a mesencephalodiencephalic lesion, either unilaterally or bilaterally, due to effects on structures such as the interstitial nucleus of Cajal, posterior commissure and rostral interstitial nucleus of the medial longitudinal bundle. The arterial supply of the structures involved in the supranuclear control of vertical gaze depends on the paramedian thalamic arteries (or posterior thalamo-subthalamic arteries) and the paramedian peduncular arteries.

CLINICAL CASE

We present the case of a 58 year old woman with non-insulin dependent diabetes mellitus who presented with sudden onset of diplopia of vertical gaze. On examination there was paralysis of superior vertical conjugated gaze and monocular paralysis of ocular infraversion (one and a half syndrome) with no other pathological findings. Cerebral angioresonance and Doppler studies of the territory supplied by the posterior cerebral artery were normal.

CONCLUSIONS

Both unilateral and bilateral mesencephalodiencephalic infarcts usually present clinically as disorders of consciousness and of conduct (the almost universal form of presentation), involvement of the pyramidal tract, the third cranial nerves and a supranuclear disorder of vertical gaze. The unusual feature of the case we present is a bilateral thalamo-subthalamic infarct which presented solely as a one and a half vertical syndrome with no clinically apparent effect on anatomically adjacent structures. We have not found any similar cases in the literature.

[Dolichoectasia of multiple cranial arteries. Findings on neuroimaging and transcranial Doppler]

INTRODUCTION

Dolichoectasia of the intracranial arteries may give rise to ischaemic or haemorragic pathology and to compression phenomena. Joint dolichoectasia of the whole circle of Willis, in both the anterior and basilar portions extending to the main basal arteries is an unusual finding.

CLINICAL CASE

We describe a 76 year old man who presented with vertigo with vertically downward nystagmus. On neuroimaging studies there was aneurysmal dilation of the left vertebral, basilar and both carotid arteries (in their supra-clinoid portion) and of both medial cerebral arteries. Transcraneal Doppler showed marked reduction in flow rate with normal morphology and pulsation.

CONCLUSION

The combination of non-invasive techniques allows full, reliable evaluation of the swollen arteries and possible complications.

Takayasu's arteritis: transcranial Doppler findings and follow-up

Takayasu's arteritis is an inflammatory disease that produces a narrowing of the aorta and its major branches. The transcranial doppler findings and its value have not been clearly determined. We describe a patient with a history of orthostatic syncopal attacks, and transitory ischemic attacks. Arteriography showed severe narrowings and occlusions of multiple large branches of the aortic arch. Transcranial doppler showed a low flow velocity in both middle cerebral arteries, low pulsatility index and damping in the waveform. After surgery, transcranial doppler ipsilateral to the graft became almost normal and the collateralization pattern had changed. This case provides further evidence that the Takayasu's arteritis leads to relevant changes in the transcranial doppler waveform and that this technique can help in the follow-up of these patients.

[Paramedian thalamo-mesencephalic infarct con triphasic waves]

Triphasic waves are usually associated with metabolic encephalopathies but have been reported in patients with other etiologies. The pathophysiology of this EEG pattern remains poorly understood, although they have been attributed to lesion in the connections between the thalamus and cortex. We report a case of top-of-the-basilar artery occlusion with selective paramedian thalamic-mesencephalic infarct in which triphasic waves were evident on the EEG during clinical hypersomnia. To our knowledge this is the first reported case of triphasic waves with selective paramedian thalamomesencephalic infarct. We conclude that triphasic waves are a nonspecific manifestation of diencephalic dysfunction, probably of the paramedian thalamomesencephalic reticular system.

[The stroke unit a the Clinical Hospital in Madrid]

The outcome in 195 patients admitted in a non-intensive stroke unit was compared to that in 198 patients admitted in general wards during a 12 months period. At admission, both groups were similar in prognostic indicators (age, sex, previous history, level of consciousness and motor impairment). Short-term mortality rates was reduced among patients admitted in stroke unit (p < 0.001). This difference was independent of patient's age, previous history and neurological impairment on admission. The length of stay in the hospital was also reduced (p < 0.001). Among survivors, functional outcome at discharge was better in those admitted in the stroke unit, with a greater proportion of patients independent for activities of daily living. We conclude that stroke unit in an efficient strategy that improves the clinical outcome of patients with acute stroke.

False positive of ADA determination in cerebrospinal fluid

The elevation of ADA in CSF is useful as a diagnostic means for detecting tuberculous meningitis, and in other etiologies such as lymphoma, neurosarcoidosis, fulminant bacterial meningitis, cryptococcal meningitis, neurobrucellosis and AIDS. We report an increase of ADA in CSF in association with SHA. In our case the total activity of ADA was the same as that obtained in serum, which can be interpreted among the false positives of the determination.