Patients with stroke secondary to isolated anterior cerebral artery (ACA) occlusions have poor outcomes. Whether tandem occlusions (TO) of the extracranial internal carotid (ICA) and the ACA carry ...even worse outcomes that remain unknown.
Patients with TO involving ICA and ACA occlusions were identified from 14 participating centers from the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) project which is a multicenter, observational, cohort study with prospective accrual of data followed by retrospective data analysis. Patients with isolated ACA stroke served as controls.
Included were 92 patients with isolated ACA and 16 patients with ICA-ACA TO stroke. On univariate analyses, patients with TO had more severe strokes on admission median NIHSS (IQR) 13.5 (9-21) vs. 8 (5-12),
= 0.003 and were more often treated with thrombectomy (81 vs. 40%,
= 0.002). Mortality rates were higher among TO patients (31 vs. 11%,
= 0.03). Rates of favorable functional outcomes were numerically lower among TO patients (38 vs. 60%) but the difference was not statistically significant (
= 0.09). On multivariate analyses, the presence of TO did not modify the chances for favorable outcomes.
TO stroke with ICA and isolated ACA involvement is rare and results in more severe initial neurological deficits and higher mortality compared to those seen in patients with isolated ACA stroke.
This review highlights the latest advancements achieved in the revascularization of arterial occlusions associated with an acute ischemic stroke affecting the posterior circulation. It delves into ...the frequency and outcomes based on specific arterial segments and presents current evidence supporting revascularization treatments, including intravenous thrombolysis and endovascular thrombectomy.
Comprehensive evidence for treatment across major arterial segments of the posterior circulation -- vertebral artery, basilar artery, posterior cerebral artery, cerebellar arteries, and multilevel posterior occlusions -- is provided. Additionally, the latest findings from randomized clinical trials on basilar artery occlusion are explored alongside results from extensive retrospective analyses of isolated vertebral and posterior cerebral artery occlusions.
Current research supports the treatment decision in acute ischemic strokes of the posterior circulation using both intravenous thrombolysis and endovascular thrombectomy. This review also emphasizes existing knowledge gaps in the management of these strokes and advocates for more randomized clinical trials, notably concerning the posterior cerebral artery (currently ongoing), isolated vertebral artery, and multilevel posterior circulation occlusions.
The National Institutes of Health Stroke Scale (NIHSS) is commonly used to triage and monitor the evolution of stroke victims. Data regarding NIHSS knowledge in nurses and physicians working with ...stroke patients are scarce, and a progressive decline in specific knowledge regarding this challenging scale is to be expected even among NIHSS certified personnel. This protocol was designed according to the CONSORT-eHealth (Consolidated Standards of Reporting Trials) guidelines. It describes the design of a randomized controlled trial whose primary objective is to determine if nurses and physicians who work in stroke units improve their NIHSS knowledge more significantly after following a highly interactive e-learning module than after following the traditional didactic video. Univariate and multivariable linear regression will be used to analyze the primary outcome, which will be the difference between the score on a 50-question quiz answered before and immediately after following the allocated learning material. Secondary outcomes will include knowledge retention at one month, assessed using the same 50-question quiz, user satisfaction, user course duration perception, and probability of recommending the allocated learning method. The study is scheduled to begin during the first semester of 2022.
Schwannomas are benign tumours that originate from the myelin sheath of peripheral nerves. They are characterised by a slow growth tendency. Benign schwannomas represent 35% of the head and neck ...district tumours. Hypoglossal schwannomas account for 5% of non-vestibular schwannomas, and malignant schwannomas occur very rarely. In the present case report, the case of a 49-year-old man who presented with paraesthesias in the left parotid and submandibular region, associated with sensation of foreign bodies and dysphagia for solids, is described. A clinical examination revealed the presence of an ovoid palpable mass in the lateral-cervical region of the neck. The patient subsequently underwent excisional surgery, and neuropathological evaluation of the specimen confirmed the diagnosis of benign schwannoma with Antoni areas A and B. Despite the rarity of schwannomas, this condition should be considered in differential diagnoses for masses localised in the neck, as in cases where they reach considerable sizes (>3 cm in diameter). Surgery therefore represents the first-choice treatment.
Background
Posterior circulation and anterior circulation strokes share many clinical, pathogenetic and radiological features, although some clinical signs are highly specific to posterior ...circulation strokes. Arterial stenosis and occlusions occur in significant numbers in both acute posterior circulation and anterior circulation strokes, making them good candidates for endovascular treatment. Among posterior circulation strokes, basilar artery occlusions stand out because of the diagnostic and acute treatment challenges.
Methods
We reviewed the literature on clinical stroke syndromes and neuroimaging findings and systematically describe for each anatomical site of stroke the detailed clinical and radiological information (anatomical representation, diffusion weighted imaging and angiographic sequences). The principles of neuroimaging of posterior circulation strokes and the prognosis for each stroke localization are also discussed.
Review summary
Stroke syndromes in the territories of the vertebral, basilar, cerebellar, and posterior cerebral arteries are presented. Features typical of posterior circulation strokes are highlighted, including patterns of basilar artery occlusions. Clinical severity and prognosis of posterior circulation strokes are highly variable, and given that they are more difficult to detect on CT-based neuroimaging, magnetic resonance imaging is the technique of choice in suspected posterior circulation strokes. Rapid identification of arterial occlusion patterns may provide prognostic information and support acute revascularization decisions.
Conclusions
Posterior circulation stroke syndromes tightly reflect lesion localization and arterial occlusion patterns. Although many clinical and pathogenetic features are similar to anterior circulation strokes, notable differences exist in terms of clinical presentation, stroke mechanism, prognosis, and response to acute recanalization.
The relative value of computed tomography (CT) and magnetic resonance imaging (MRI) in acute ischemic stroke (AIS) is debated. In May 2018, our center transitioned from using CT to MRI as first-line ...imaging for AIS. This retrospective study aims to assess the effects of this paradigm change on diagnosis and disability outcomes.
We compared all consecutive patients with confirmed diagnosis of AIS admitted to our center during the MRI-period (May 2018-August 2022) and an identical number of patients from the preceding CT-period (December 2012-April 2018). Univariable and multivariable analyses were performed to evaluate outcomes, including the number and delay of imaging exams, the rate of missed strokes, stroke mimics treated with thrombolysis, undetermined stroke mechanisms, length of hospitalization, and 3-month disability.
The median age of the 2972 included patients was 76 years (interquartile range, 65-84), and 46% were female. In the MRI-period, 80% underwent MRI as first acute imaging. The proportion of patients requiring a second acute imaging modality for diagnostic ± revascularization reasons increased from 2.1% to 5% (
<0.05), but it decreased in the subacute phase from 79.0% to 60.1% (
<0.05). In thrombolysis candidates, there was a 2-minute increase in door-to-imaging delay (
<0.05). The rates of initially missed AIS diagnosis was similar (3.8% versus 4.4%,
=0.32) and thrombolysis in stroke mimics decreased by half (8.6% versus 4.3%;
<0.05). Rates of unidentified stroke mechanism at hospital discharge were similar (22.8% versus 28.1%;
=0.99). The length of hospitalization decreased from 9 (interquartile range, 6-14) to 7 (interquartile range, 4-12) days (
=0.62). Disability at 3 months was similar (common adjusted odds ratio for favorable Rankin shift, 0.98 95% CI, 0.71-1.36;
=0.91), as well as mortality and symptomatic intracranial hemorrhage.
A paradigm shift from CT to MRI as first-line imaging for AIS seems feasible in a comprehensive stroke center, with a minimally increased delay to imaging in thrombolysis candidates. MRI was associated with reduced thrombolysis rates of stroke mimics and subacute neuroimaging needs.
In a large trial, the estimated incidence of stroke, systemic embolism, hemorrhage, or death was 2.8 percentage points lower to 0.5 percentage points higher with early than with later use of direct ...oral anticoagulants.
Little is known on the role of mismatch profile in patients undergoing early endovascular treatment (EVT). We aimed to describe pretreatment perfusion parameters and mismatch profiles in anterior ...circulation large vessel occlusion acute ischemic stroke undergoing EVT in the early time window and assess their association with time from stroke onset and outcomes.
Retrospective single-center study, including early (<6 hours) EVT-treated large vessel occlusion acute ischemic stroke with baseline perfusion data, assessing perfusion parameters (ischemic core volume, mismatch volume and mismatch ratio) and mismatch profiles (favorable versus unfavorable, based on criteria adopted in EXTEND-IA Extending the Time for Thrombolysis in Emergency Neurological Deficits - Intra-Arterial, SWIFT PRIME Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment, DEFUSE 3 Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3, and DAWN Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo trials). We evaluated their association with time from stroke onset (r
for parameters or χ
for trend for profiles) and association with modified Rankin Scale score >2, symptomatic intracranial hemorrhage, and mortality (multivariate regression analyses each parameter/profile entered into a separate logistic regression model, adjusted for baseline variables associated with each outcome in the univariate analysis at the
<0.1 level).
Among 357 patients, unfavorable mismatch profiles ranged from 21% to 60%, depending on the criterion, and were not correlated with time from stroke onset (
=0.490). All individual perfusion parameters and unfavorable mismatch profiles were associated with poor functional outcome: ischemic core volume adjusted odds ratio (aOR), 1.49 (95% CI, 1.13-1.97
=0.005); penumbral volume aOR, 0.30 (95% CI, 0.10-0.84
=0.022); mismatch ratio aOR, 0.67 (95% CI, 0.50-0.90
=0.007); EXTEND-IA aOR, 2.61 (95% CI, 1.23-5.51
=0.012); SWIFT PRIME aOR, 2.50 (95% CI, 1.30-4.57
=0.006); DEFUSE 3 aOR, 2.28 (95% CI, 1.14-4.57
=0.020); and DAWN aOR, 4.19 (95% CI, 2.13-8.26
<0.001). EXTEND-IA and DEFUSE 3 unfavorable profiles were also independently associated with symptomatic intracranial hemorrhage (aOR, 3.82 95% CI, 1.42-10.3;
=0.008 and aOR, 2.83 95% CI, 1.09-7.36;
=0.033) and death (aOR, 3.26 95% CI, 1.33-8.02;
=0.010 and aOR, 2.52 95% CI, 1.10-5.82;
=0.030).
Pretreatment perfusion parameters and mismatch profiles in early EVT-treated patients were not correlated with time from stroke onset but were independently associated with functional outcome. Mismatch assessment in the early time window may improve EVT patient selection, independently of onset-to-treatment time.
Background and purpose
There is scarce clinical information about the clinical profile of patients with acute ischaemic stroke with previously undiagnosed major vascular risk factors (UMRFs).
Methods
...This was a retrospective analysis of data from the Acute Stroke Registry and Analysis of Lausanne registry between 2003 and 2018 with univariate and multivariate logistic regression analyses comparing clinical profiles of patients with UMRFs to patients with at least one previously diagnosed MRF (DMRF).
Results
In all, 4354 patients (median age 70 years interquartile range 15.2, 44.7% female) were included after excluding 763 (14.9%) for lack of consent and three for missing information. Amongst 1125 (25.8%) UMRF patients, 69.7% (n = 784) had at least one newly diagnosed MRF and the others none. The newly detected MRFs were dyslipidaemia (61.4%), hypertension (23.7%), atrial fibrillation (10.2%), diabetes mellitus (5.2%), ejection fraction <35% (2.0%) and coronary disease (1.0%). Comparing UMRF patients to DMRF patients, multivariate analysis showed a positive association with lower age, non‐Caucasian ethnicity, contraceptive use (<55 years old), smoking (≥55 years old) and patent‐foramen‐ovale‐related stroke mechanism. A negative association was found with pre‐stroke antiplatelet use and higher body mass index. Functional outcome did not differ. Cerebrovascular recurrences were similar between groups.
Conclusions
In this large single‐centre cohort, 69.7% of patients with acute ischaemic stroke and UMRF were newly diagnosed with at least one new MRF, the most common being dyslipidaemia, hypertension or atrial fibrillation. Patients of the UMRF group were younger, more often smokers and on contraceptives, and had more patent‐foramen‐ovale‐related strokes.
PDF
