Angioplasty and stenting of atherosclerotic middle cerebral arteries with Wingspan: evaluation of clinical outcome, restenosis, and procedure outcome

BACKGROUND AND PURPOSE

MCA is a common location of intracranial stenosis. It is relatively more peripherally located and of a smaller caliber, and could therefore be a site technically more challenging and risky for angioplasty and stenting. The study aimed to evaluate the clinical outcome, restenosis rate, and procedural safety of Wingspan stent placement for atherosclerosis in the MCA compared with stenosis in other arteries.

MATERIALS AND METHODS

Patients who underwent Wingspan stent placement for symptomatic intracranial stenosis of ≥70% (or stenosis of ≥50% for recurrent ischemia despite medical therapy) were recruited prospectively and allocated into a study group (MCA stenosis, n=35) and a control group (other stenosis, n=25). Primary end points were the following: 1) all stroke or death rate at 1 year, and 2) significant in-stent restenosis rate at 1 year. Secondary end points were the following: 1) periprocedural complications within 24 hours, rate of TIA during the procedure, all stroke or death rate within 30 days; and 2) the inability to complete the procedure due to technical problems.

RESULTS

Results of study group versus the control group were the following: degree of stenosis, 78.4 ± 10.9% versus 72.5 ± 11.2% (P value=.0456); diameter of stenosis, 0.6 ± 0.3 versus 1.0 ± 0.5 mm (P=.0017); all stroke or death rate at 1 year, 14.3% versus 12% (OR=1.22); in-stent restenosis rate at 1 year, 10% versus 10.5% (OR=1.05); periprocedural complication rate at 24 hours, 2.9% versus 4% (OR=0.70); TIA rate during the procedure, 8.6% versus 4% (OR=2.25); all stroke or death rate at 30 days, 5.7% versus 12% (OR=0.44); and technical failure rate, 2.9% versus 0%.

CONCLUSIONS

In this study, there were no significant differences in procedural safety, patient outcome, and restenosis rates of stent placement between the group with MCA stenosis and the group with stenoses located at other sites.

Gabapentin for the treatment of carpal tunnel syndrome: a randomized controlled trial

OBJECTIVE

Based on its efficacy in treating neuropathic pain, gabapentin may be effective for the treatment of carpal tunnel syndrome (CTS). The purpose of this study was to evaluate the efficacy of gabapentin for symptom relief in CTS.

METHODS

We conducted a randomized, double-blinded, placebo-controlled trial recruiting patients with newly diagnosed idiopathic CTS of more than a period of three months. Diagnosis was based on characteristic symptoms with electrophysiological confirmation. Patients were randomly assigned to an active group receiving gabapentin (starting dose 300 mg once daily to a target of 900 mg daily) or a placebo group. Primary end-point was the global symptom score (GSS), which was measured at baseline, two, and eight weeks.

RESULTS

There was no significant difference in baseline variables between the two treatment groups. Hundred and forty patients were enrolled in the study, of whom 71 were randomly assigned to gabapentin group and 69 assigned to placebo group. Both gabapentin and placebo produced significant improvement in symptoms at two and eight weeks. The GSS at 2 and 8 weeks was 16.4 (SD 9.4) and 13.4 (SD 9.7), respectively, in the active group versus 14.9 (SD 9.0) and 12.5 (SD 8.9) in the control group (P < 0.01). But by eight weeks, the mean reduction in symptom severity of patients on gabapentin [-10.4 (SD 10.8)] was not significant when compared with placebo [-8.7 (SD 8.1), P < 0.39]. Adverse events were not severe and included dizziness, somnolence, and headache.

CONCLUSIONS

Gabapentin did not produce a significant reduction in symptom severity compared with placebo over an eight-week period.

An expedited stroke triage pathway: the key to shortening the door-to-needle time in delivery of thrombolysis

OBJECTIVES

To assess time management of stroke thrombolysis triage and functional outcomes in patients receiving recombinant tissue plasminogen activator for hyperacute stroke, and identify bottlenecks in delivery of the treatment.

DESIGN

Prospective study.

SETTING

A university teaching hospital in Hong Kong.

PATIENTS

Patients with suspected hyperacute stroke referred to the stroke thrombolysis team during October 2008 to September 2009.

MAIN OUTCOME MEASURES

Time performance records including door-to-stroke team, door-to-needle, and onset-to-thrombolysis times. Functional outcomes by modified Rankin Scale score at 3 months, and thrombolysis-related complications including haemorrhagic transformations and mortality.

RESULTS

During the 12-month period, 95 thrombolysis calls were received; recombinant tissue plasminogen activator was given intravenously to 17 (18%) of the patients and intra-arterially to 11 (12%). The mean (standard deviation) door-to-stroke team and the door-to-needle times for intravenous recombinant tissue plasminogen activator patients were 33 (25) and 80 (25) minutes, respectively; both were about 20 minutes longer than that recommended by the National Institute of Neurological Disorders and Stroke. The mean National Institute of Health Stroke Scale score for patients received intravenous recombinant tissue plasminogen activator was 16 (standard deviation, 7). The mean (standard deviation) onset-to-treatment time was 144 (42) minutes. Nine (53%) patients who received intravenous recombinant tissue plasminogen activator achieved favourable outcomes at 3 months, with a modified Rankin Scale score of 0 to 1. Symptomatic haemorrhage and mortality occurred in one (6%) patient.

CONCLUSION

A dedicated stroke triage pathway is essential to ensure efficient and safe delivery of thrombolysis therapy. Improvements in door-to-stroke team time through integration with emergency medicine staff and neuroradiologists may improve thrombolysis eligibility.

Reversible Cerebral Vasoconstriction Syndrome with Posterior Leucoencephalopathy after Oral Contraceptive Pills

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden-onset recurrent ‘thunderclap’ headaches with reversible multifocal narrowing of the cerebral arteries, often associated with focal neurological deficits from ischaemic or haemorrhagic stroke. It has been associated with exposure to vasoconstrictive drugs, pregnancy, migraine, and a variety of other conditions. Whereas the pathophysiology of RCVS remains unclear, changes in the levels of female hormones are considered important because RCVS predominantly affects women and is frequently associated with pregnancy. We report a patient with angiographically confirmed RCVS whose MRI showed reversible brain oedema, suggesting an overlap between RCVS and the reversible posterior leucoencephalopathy syndrome. The only identified risk factor was oral contraceptive pills started 1 month prior to onset, supporting a role for female reproductive hormones in precipitating this overlap syndrome.

A registry of tuberculous meningitis in Hong Kong

BACKGROUND

A prospective observational study of the presentation, diagnosis, treatment and outcome of tuberculous meningitis (TBM).

METHODS

Demographic characteristics, clinical information, treatment and progress of TBM patients were followed. Their outcomes were ascertained every 6 months for 3 years after diagnosis. Prognostic factors associated with death or full recovery were examined using multivariate Cox's and logistic regression models, respectively.

RESULTS

Between 1993 and 2000, 166 TBM patients were recruited. Their mean age was 42.9, 153 were Chinese and 81 were males; 92% received HRZS (H = isoniazid; R = rifampicin; Z = pyrazinamide; S = streptomycin), HRZE (E = ethambutol) or HRZES. Steroids were given to 105 patients, with no significant effect on outcome. After 3 years of follow-up, 110 patients had completely recovered, 20 survived with disability and 26 died. Death was significantly associated with older age, lower cerebrospinal fluid (CSF) lymphocyte and poorer consciousness levels at the time of presentation, while full recovery was associated with younger age, being female and absence of complications.

CONCLUSIONS

Relatively good outcomes of TBM cases were documented in this Hong Kong study with a case-fatality ratio of 15.7% (26/166) up to 3 years. Early recognition, diagnosis and administration of effective treatment regimens were probably the most important factors in reducing mortality and morbidity.

Bacterial meningitis in Hong Kong: 10-years’ experience

OBJECTIVE

We studied the etiology, clinical features and outcome of patients with bacterial meningitis from an urban Chinese city over a 10-years period.

METHODS

We reviewed the files of all persons aged 15-years old or above diagnosed with community-acquired bacterial meningitis from a regional hospital. The clinical findings, relevant laboratory and imaging results as well as outcome were recorded in cases with microbiological evidence of meningitis. Neurosurgical and pediatric patients were excluded.

RESULTS

Sixty-five patients between the ages of 15 and 86 years of age (mean 52 years) were identified of whom 18 (28%) died. The four most common causes were Mycobacteria tuberculosis (46%), Streptococcus pneumoniae (11%), Streptococcus suis (9%) and Klebsiella pneumoniae (8%). Neisseria meningitidis and Haemophilus influenzae were rare pathogens. The annual incidence of community-acquired bacterial meningitis was 1.27/100,000 adults. Delay in treatment was associated with a poorer prognosis (p<0.001, OR=38.84, CI=7.33-205.80).

CONCLUSION

The causative organisms found in this region of China differ from that reported from Europe and the US; tuberculous meningitis is the most common cause of bacterial meningitis.

Early computed tomography features in extensive middle cerebral artery territory infarct: prediction of survival

BACKGROUND

To assess the predictive value of prognosis of different computed tomography (CT) features and National Institutes of Health Stroke Scale score (NIHSS) in acute extensive middle cerebral artery (MCA) infarct.

METHODS

Fifty five patients with acute extensive MCA infarct had the CT performed within 24 hours of the onset of symptoms. A total of 11 CT features were analysed. The age distribution, presence of risk factors, presence of individual CT feature, the total CT score, and the NIHSS were correlated with the 30 day mortality.

RESULTS

Single explanatory variable analysis showed NIHSS, presence of midline shift, midline shift of more than 1 cm, extent of infarct, presence of hydrocephalus, effacement of subarachnoid space/cella media, attenuation of corticomedullary differentiation, and total CT score were associated with the 30 day mortality. Both extent of infarct >67% and attenuation of corticomedullary differentiation gave a sensitivity and specificity of 93% and 95%, respectively, for the prediction of survival. Logistic regression analysis showed that the extent of infarct and NIHSS were the only independent predictors.

CONCLUSIONS

CT features and admission NIHSS are important parameters for prediction of survival in extensive MCA infarct.

Epidemiological study of multiple sclerosis in Hong Kong Chinese: questionnaire survey

OBJECTIVE

To study the epidemiology of multiple sclerosis in Hong Kong Chinese.

DESIGN

Cross-sectional questionnaire survey.

SETTING

Neurology and paediatric neurology departments in Hong Kong from January through June 1999.

PARTICIPANTS

All confirmed multiple sclerosis patients.

MAIN OUTCOME MEASURES

Demographic data, investigation results, Kurtzke's Expanded Disability Status Scale during the last follow-up visit, number of relapses between 1997 and 1998, and treatments used/currently in use.

RESULTS

Fifty-three Chinese multiple sclerosis patients were identified. The prevalence was thus estimated to be 0.77 per 100,000 population. This low prevalence was also noted in other multiple sclerosis studies from South-East Asia (range, 0.8-4 per 100,000 population). The female to male ratio among the Chinese multiple sclerosis sufferers was 9.6:1, a figure somewhat higher than that reported in the other studies from South-East Asia (range, 3.2-6.6:1). The Chinese multiple sclerosis patients in this study also had a high spinal cord involvement (66%) and a low presence of cerebrospinal fluid oligoclonal banding (40%). These findings were different from those in Caucasian multiple sclerosis patients.

CONCLUSION

Multiple sclerosis in Hong Kong Chinese has a low prevalence, a high female to male ratio, and a low cerebrospinal fluid oligoclonal banding presence.