BackgroundThe time–benefit relationship of endovascular thrombectomy (EVT) according to the size of the core infarct has been incompletely explored in prior studies. We investigated whether ...established infarct core size on baseline imaging modifies the relationship between onset-to-reperfusion time (OTR) and functional outcomes in patients with acute ischemic stroke treated with EVT.MethodsWe analyzed a database containing individual patient data pooled from three prospective Solitaire stent retriever studies. The inclusion criteria were treatment with a Solitaire device and achievement of substantial reperfusion (modified Thrombolysis in Cerebral Infarction 2b–3). Main analyses were performed in patients with baseline Alberta Stroke Program Early CT Scores (ASPECTSs) of 7–10.ResultsAmong the 305 patients (mean age 67±13 years, 58% women), the proportions of patients in different categories of pretreatment infarct extent were: small (ASPECTS 9–10) 52.0%, moderate (ASPECTS 7–8) 37.1%, and large (ASPECTS 0–6) 7.6%. The mean OTR was 297±95 min. At 3 months, 60.1% of the patients achieved a good outcome. For OTRs of 2–8 hours, the rates of good outcomes at all time points were higher with higher baseline ASPECTS but declined with similar steepness. Both baseline ASPECTS (OR 1.23 (95% CI 1.04 to 1.45)) and OTR (every 30 min delay, OR 0.80 (95% CI 0.73 to 0.88)) were independently associated with a good 3-month outcome. No interaction between OTR and baseline ASPECTS was observed.ConclusionsAlthough patients with higher baseline ASPECTS are more likely to have good clinical outcomes at all OTR intervals after 2 hours, this benefit consistently declines with time, even in patients with a small infarct core, reinforcing the need to treat all patients as quickly as possible.
Objective
To investigate pathological findings in the susceptibility weighted imaging (SWI) of patients experiencing convulsive (CSE) or non-convulsive status epilepticus (NCSE) with focal ...hyperperfusion in the acute setting.
Methods
Twelve patients (six with NCSE confirmed by electroencephalogram (EEG) and six patients with CSE with seizure event clinically diagnosed) underwent MRI in this acute setting (mean time between onset of symptoms and MRI was 3 h 8 min), including SWI, dynamic susceptibility contrast MR imaging (DSC) and diffusion-weighted imaging (DWI). MRI sequences were retrospectively evaluated and compared with EEG findings (10/12 patients), and clinical symptoms.
Results
Twelve out of 12 (100 %) patients showed a focal parenchymal area with pseudo-narrowed cortical veins on SWI, associated with focal hyperperfused areas (increased cerebral blood flow (CBF) and mean transit time (MTT) shortening), and cortical DWI restriction in 6/12 patients (50 %). Additionally, these areas were associated with ictal or postical EEG patterns in 8/10 patients (80 %). Most frequent acute clinical findings were aphasia and/or hemiparesis in eight patients, and all of them showed pseudo-narrowed veins in those parenchymal areas responsible for these symptoms.
Conclusion
In this study series with CSE and NCSE patients, SWI showed focally pseudo-narrowed cortical veins in hyperperfused and ictal parenchymal areas. Therefore, SWI might have the potential to identify an ictal region in CSE/NCSE.
Key Points
•
The focal ictal brain regions show hyperperfusion in DSC MR-perfusion imaging.
•
SWI shows focally diminished cortical veins in hyperperfused ictal regions.
•
SWI has the potential to identify a focal ictal region in CSE/NCSE.
A 76-year-old man with a history of arterial hypertension, obstructive sleep apnea, dyslipidemia, family history of cardiovascular events, prestroke and overweight presented 90 minutes after acute ...onset of right-sided sensorimotor hemiparesis, hemiataxia and dysarthria (National Institutes of Health Stroke Scale (NIHSS) 9/42).
Magnetic resonance imaging (MRI) revealed a pontine ischemia and MR angiography showed a thrombus in the middle to distal portion of the basilar artery. Owing to the location, an occlusion of one lumen of a fenestrated basilar artery was suspected. Fearing the risk of peripheral dislocation, intravenous thrombolysis was withheld after an interdisciplinary discussion and direct endovascular thrombectomy (Solitaire stent retriever) was successfully performed by passing the stent retriever specifically through the affected lumen and between the thrombus and the vascular wall, which would normally be avoided. Angiography after complete reperfusion (Thrombolysis in Cerebral Infarction grade 3) confirmed a fenestration in the middle to distal portion of the basilar artery where the thrombus was initially located (blue and green arrow). Follow-up MRI after 24 hours showed only minimal ischemic damage in the left pontine area, and the patient was discharged home with ambulatory physiotherapy for residual minimal gait disturbance (NIHSS 0).
The aim of this study was to investigate variant patterns of cortical venous oxygenation during status epilepticus (SE) using susceptibility-weighted imaging (SWI).
We analyzed magnetic resonance ...imaging (MRI) scans of 26 patients with clinically witnessed prolonged seizures and/or EEG-confirmed SE. All MRI exams encompassed SWI, dynamic susceptibility contrast perfusion MRI (MRI-DSC) and diffusion-weighted imaging (DWI). We aimed to identify distinct patterns of SWI signal alterations that revealed regional or global increases of cerebral blood flow (CBF) and DWI restrictions. We hypothesized that SWI-related oxygenation patterns reflect ictal or postictal patterns that resemble SE or sequelae of seizures.
Sixteen patients were examined during nonconvulsive status epilepticus (NCSE) as confirmed by EEG, a further ten patients suffered from witnessed and prolonged seizure episode ahead of imaging without initial EEG. MRI patterns of 15 of the 26 patients revealed generalized hyperoxygenation by SWI in keeping with either global or multifocal cortical hyperperfusion. Eight patients revealed a focal hyperoxygenation pattern related to focal CBF increase and three patients showed a focal deoxygenation pattern related to focal CBF decrease.
SWI-related hyper- and deoxygenation patterns resemble ictal and postictal CBF changes within a range from globally increased to focally decreased perfusion. In all 26 patients the SWI patterns were in keeping with ictal hyperperfusion (hyperoxygenation patterns) or postictal hypoperfusion (deoxygenation patterns) respectively. A new finding of this study is that cortical venous patterns in SWI can be not only focally, but globally attenuated. SWI may thus be considered as an alternative contrast-free MR sequence to identify perfusion changes related to ictal or postictal conditions.
The aim of this study was to investigate baseline characteristics and outcome of patients after endovascular therapy (EVT) for acute large vessel occlusion (LVO) in relation to their history of ...symptomatic vascular disease and sex.
Consecutive EVT-eligible patients with LVO in the anterior circulation admitted to our stroke center between 04/2015 and 04/2020 were included in this observational cohort study. All patients were treated according to a standardized acute ischaemic stroke (AIS) protocol. Baseline characteristics and successful reperfusion, recurrent/progressive in-hospital ischaemic stroke, symptomatic in-hospital intracranial hemorrhage, death at discharge and at 3 months, and functional outcome at 3 months were analyzed according to previous symptomatic vascular disease and sex.
995 patients with LVO in the anterior circulation (49.4% women, median age 76 years, median admission NIHSS score 14) were included. Patients with multiple vs. no previous vascular events showed higher mortality at discharge (20% vs. 9.3%,
OR = 1.43,
= 0.030) and less independency at 3 months (28.8% vs. 48.8%,
OR = 0.72,
= 0.020). All patients and men alone with one or multiple vs. patients and men with no previous vascular events showed more recurrent/progressive in-hospital ischaemic strokes (19.9% vs. 6.4% in all patients,
OR = 1.76,
= 0.028) (16.7% vs. 5.8% in men, age-adjustedOR = 2.20,
= 0.035). Men vs. women showed more in-hospital symptomatic intracranial hemorrhage among patients with one or multiple vs. no previous vascular events (23.7% vs. 6.6% in men and 15.4% vs. 5.5% in women, OR = 2.32,
= 0.035/
OR = 2.36,
= 0.035).
Previous vascular events increased the risk of in-hospital complications and poorer outcome in the analyzed patients with EVT-eligible LVO-AIS. Our findings may support risk assessment in these stroke patients and could contribute to the design of future studies.
To evaluate the hybrid treatment of severe stenosis or occlusion of the proximal innominate artery (IA) and common carotid artery (CCA) via surgical cutdown of the CCA and distal clamping for ...cerebral protection against thromboembolic events during retrograde stenting.
Consecutive patients undergoing retrograde stenting of proximal IA and CCA stenosis or occlusion via surgical cutdown of the CCA and with distal clamping for prevention of embolization, with or without concomitant endarterectomy of the carotid bifurcation, between April 1999 and August 2015 were reviewed. Perioperative and long-term outcomes were assessed.
Thirty-five patients underwent a total of 36 successful interventions. One patient underwent staged bilateral stenting. Additional concomitant carotid endarterectomy was performed in 13 patients (36%). No new neurological symptoms neither perioperatively nor in-hospital were recorded. Thirty-day follow-up revealed 1 new ipsilateral and 1 new contralateral stroke (6%) with completely patent stents, no reinterventions, and 2 unrelated deaths (6%). Median follow-up was 56 months (range: 1-197). After 5 and 10 years, the Kaplan-Meier estimated overall survival rate was 85% and 52%. Primary assisted patency rate was 94% during follow-up. Overall freedom from reintervention was 91%. Three reinterventions were performed during the first postoperative year. Three new neurological events occurred during follow-up, 1 ipsilateral (3%) and 2 contralateral (6%). The ipsilateral event occurred during the first year and both contralateral events during the second year postoperatively.
The retrograde hybrid approach to proximal IA and CCA disease is a safe procedure with surgical outflow control preventing perioperative stroke in ipsilateral carotid territory. Most relevant in-stent stenoses/occlusions and new neurological events occurred within the first 2 years, suggesting these patients should undergo regular monitoring early postoperatively. High patency rates without further neurological events can be expected thereafter.
•High prolactin (PRL) levels are associated with weight gain and impaired metabolic profiles.•Long-term control of hyperprolactinemia can be attained by first-line surgery and medical ...therapy.•Normalization of PRL improves patients’ BMI and fasting glucose levels.•Marginal changes in patients’ metabolic profiles are noted regardless of the primary therapy.•Not dopamine agonists per se, but rather the control of hyperprolactinemia plays a role in metabolic profile alterations.
High prolactin levels have been associated with weight gain and impaired metabolic profiles. While treatment with dopamine agonists (DAs) has been shown to improve these parameters, there is a lack of surgical series on its comparative effect in prolactinoma patients.
In this retrospective, comparative study, consecutive patients with a prolactinoma were enrolled if treated with first-line transsphenoidal surgery (TSS) or with DAs. Patients with prolactinomas of Knosp grade >2 and those with a follow-up <24 months were excluded, as were patients with missing laboratory metabolic parameters at baseline and over the long-term. Effects of either treatment on BMI and the metabolic profile were analyzed, and independent risk factors for long-term obesity were calculated.
Primary treatment was TSS for 12 patients (40%) and DAs for 18 patients (60%). At diagnosis, no significant differences between the two cohorts were observed with regard to adenoma size, Knosp grading, baseline prolactin (PRL) levels, prevalence of hypogonadism, or laboratory metabolic parameters. Mean follow-up was 51.9 months (range, 24–158). Over the long-term, both TSS and DAs led to the control of hyperprolactinemia (92% vs. 72%) and hypogonadism (78% vs. 83%) in the majority of patients. While a significant decrease in patients’ BMI and fasting glucose were observed, changes in the lipid profile were marginal and independent of the treatment modality. At baseline, increased BMI—but not the primary treatment strategy—was an independent predictor of long-term obesity.
Over the long-term, patients’ BMI and FG improve, but changes in the metabolic profile are marginal and independent of the primary treatment. It is presumable that not DAs per se, but rather the control of hyperprolactinemia plays a role in patients’ metabolic profile alterations.
We demonstrated experimentally that inhaled nitric oxide (iNO) dilates hypoperfused arterioles, increases tissue perfusion, and improves neurological outcome following subarachnoid hemorrhage (SAH) ...in mice. We performed a prospective pilot study to evaluate iNO in patients with delayed cerebral ischemia after SAH.
SAH patients with delayed cerebral ischemia and hypoperfusion despite conservative treatment were included. iNO was administered at a maximum dose of 40 ppm. The response to iNO was considered positive if: cerebral artery diameter increased by 10% in digital subtraction angiography (DSA), or tissue oxygen partial pressure (PtiO
) increased by > 5 mmHg, or transcranial doppler (TCD) values decreased more than 30 cm/sec, or mean transit time (MTT) decreased below 6.5 secs in CT perfusion (CTP). Patient outcome was assessed at 6 months with the modified Rankin Scale (mRS).
Seven patients were enrolled between February 2013 and September 2016. Median duration of iNO administration was 23 h. The primary endpoint was reached in all patients (five out of 17 DSA examinations, 19 out of 29 PtiO
time points, nine out of 26 TCD examinations, three out of five CTP examinations). No adverse events necessitating the cessation of iNO were observed. At 6 months, three patients presented with a mRS score of 0, one patient each with an mRS score of 2 and 3, and two patients had died.
Administration of iNO in SAH patients is safe. These results call for a larger prospective evaluation.
Purpose
Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, ...clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication.
Methods
Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID.
Results
Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissection and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS ≤ 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (
p
= 0.041), were more likely to be smokers (44% versus 19%,
p
= 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%,
p
< 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups.
Conclusion
The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy.
The aim of this study was to analyze epileptic seizures and their impact on outcome in patients with stroke treated with endovascular therapy.
From December 1992 to December 2010 we managed 805 ...patients with stroke with endovascular therapy. Epileptic seizures, bleeding complications, and 3-month outcomes were recorded prospectively. Outcomes of patients with early seizures (within 24 hours of stroke onset) and patients with late seizures (>24 hours after stroke) were compared with outcomes of seizure-free patients using uni- and multivariable statistics.
Forty-four of 805 patients (5.5%) had seizures between stroke onset and 3-month follow-up, 26 patients early and 18 late. Outcome of patients with late seizures and seizure-free patients was similar (P=0.144 and 0.807). Patients with early seizures had higher baseline National Institutes of Health Stroke Scale (P=0.023) and were younger (P=0.021) than seizure-free patients. Their mortality rate was 50% compared with 22.3% of the seizure free-patients (P=0.003), and less patients reached a favorable outcome (modified Rankin Scale 0-2): 15.4% and 46.8%, respectively (P=0.001). Early seizures independently predicted an unfavorable outcome (P=0.014; OR, 4.749; 95% CI, 0.376-3.914) and increased mortality (P=0.001; OR, 5.861; 95% CI, 0.770-2.947) in multiregression analysis. Patients with early seizures had a 1.6-fold higher risk for unfavorable outcome and a 2.2-fold higher risk for death compared with seizure-free patients.
Seizures within 24 hours of stroke onset were associated with worse outcome in patients with stroke undergoing endovascular therapy. Our findings confirm a need for trials for prophylactic anticonvulsive treatment in patients receiving endovascular therapy for acute stroke.
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