We report the case of a 34-year-old female patient complaining of headaches 1 day after childbirth, initially interpreted as postdural puncture headache (PDPH) and treated successfully with an ...epidural blood patch. Five days later, she presented with an acute proportional right sensorimotor hemisyndrome and a new-onset left-sided headache, attributed to a venous stroke from left-sided cerebral sinus venous thrombosis (CSVT). Simultaneously, we found radiologic signs of reversible cerebral vasoconstriction syndrome (RCVS), considered asymptomatic. We administered anticoagulant therapy to the patient, and she showed full motor recovery at 3-month clinical follow-up. PDPH, CSVT, and RCVS are well-known neurologic complications during the peripartum period. All 3 conditions present with headaches, and headache features may overlap, masking co-occurrence and making accurate diagnosis (differentiation) of these diseases difficult. Each disease can potentially lead to disabling deficits, but all respond to specific treatment. Knowledge of the causes of headaches in the peripartum period, their specific clinical characteristics, and potential complications helps to prioritize and interpret diagnostic tests to offer appropriate therapy.
Certain drugs may increase the risk of ischemic stroke (IS). Our goal was to review associations between frequently used drugs and IS. We created an initial list of frequently used drugs to search ...Pubmed/MEDLINE from 1966 to 2020 and reviewed phase III and IV data, case series, and drug authorities' safety warnings to assess a potential association with IS. Drugs were grouped according to the World Health Organization Anatomical Therapeutic Chemical Classification System. Predefined criteria were applied to establish a level of evidence for an association, from A (high level of evidence of association) to E (high level of evidence of absence of association). In addition, we assessed relative risks and reviewed potential mechanisms of IS facilitation. We assessed 81 drugs or drug classes from 11 World Health Organization Anatomical Therapeutic Chemical Groups. We identified a high level of association for erythropoietin, combined contraceptives, oral estrogen replacement therapy, bevacizumab, tamoxifen, and antipsychotics and a moderate level for ponatinib, nilotinib, darunavir, and gonadotropin-releasing hormone agonists. Drug dose and treatment duration may modify the risk. For a substantial number of drugs, we found no association, and for others, there were insufficient data to categorize risk. We identified a high level of association of IS with a limited number of drugs, a potential association with some, and a lack of data for others. The summarized information may help clinicians to estimate the contribution of a drug to an IS, to better assess drug benefit-risk ratios, and to support decisions about using specific drugs.
The Risk of Paradoxical Embolism (RoPE) score stratifies patients with stroke according to the probability of having a patent foramen ovale (PFO), which (through Bayes theorem and simple assumptions) ...can be used to estimate the probability that a PFO is pathogenic in a given subgroup of patients with specific features (ie, a given RoPE score value): a higher PFO prevalence corresponds to a higher probability that a PFO is pathogenic. Among alternative mechanisms in embolic stroke of undetermined source (ESUS), the actual stroke cause may be covert atrial fibrillation. We aimed to validate the RoPE score in a large ESUS population and investigate the rate of stroke recurrence and new incident atrial fibrillation during follow-up according to PFO status and RoPE score.
We pooled data of consecutive patients with ESUS from 3 prospective stroke registries. We assessed RoPE score’s calibration and discrimination for the presence of PFO (and consequently for the probability that it is pathogenic). Multivariate logistic regression analysis was performed to identify factors associated with PFO.
Among 455 patients with ESUS (median age 59 years), 184 (40%) had PFO. The RoPE score’s area under the receiver operating characteristic curve was 0.75. In addition to RoPE score variables, absence of left ventricular hypertrophy, absence of atherosclerosis, and infratentorial lesions were independently associated with PFO. In patients with PFO and RoPE 7 to 10, PFO and RoPE 0 to 6, and without PFO, new incident atrial fibrillation rate was 3.1%, 20.5%, and 31.8%, respectively (log-rank test=6.28, P=0.04). Stroke recurrences in patients with likely pathogenic PFO were not statistically different from other patients.
This multicenter study validates the RoPE score to predict the presence/absence of PFO in patients with ESUS, which strongly suggests that RoPE score is helpful in identifying patients with ESUS with pathogenic versus incidental PFOs. Left ventricular hypertrophy, atherosclerosis, and infratentorial stroke may further improve the score. Low RoPE scores were associated with more incidental atrial fibrillation during 10-year follow-up.
Lymphocytic hypophysitis is a rarely recognized disease that is characterized by inflammatory infiltration and destruction of the pituitary gland. The etiology of lymphocytic hypophysitis is still ...unclear, but an autoimmune pathogenesis has been advocated. In fact, histopathologic specimens reveal a diffuse infiltration of the hypophysis by CD3+ CD4+ T cells and CD20+ plasma cells, and antipituitary antibodies are usually found in sera of affected patients. Although previous cases were found to be correlated only to pregnancy and the postpartum period, recent reports in men and women (without association with pregnancy) suggest a possibly higher prevalence of disease. We present the case of a 55-year-old woman affected by an unusually aggressive form of lymphocytic hypophysitis that infiltrated both cavernous sinuses causing bilateral internal carotid artery occlusion and acute ischemic stroke. Diagnosis was achieved with both a biopsy specimen of the pituitary gland and the detection of antipituitary antibodies. The prompt administration of steroid therapy was effective to obtain regression and stabilization of the disease, but both carotid arteries remained permanently occluded. The natural history of lymphocytic hypophysitis is unpredictable. It usually has a benign evolution, but in exceptional cases the inflammatory process may extend beyond the pituitary gland and infiltrate the surrounding structures. These extremely serious consequences highlight the importance of early diagnosis and treatment of this otherwise curable disease.
BACKGROUND AND PURPOSE—We investigated efficacy and safety of acute revascularization with intravenous thrombolysis (IVT) and endovascular treatment (EVT) in ischemic stroke from isolated posterior ...cerebral artery occlusion, by assessing recanalization, disability, visual, cognitive outcomes, and hemorrhagic complications.
METHODS—For this retrospective single-center cohort study, we selected all consecutive patients with stroke with isolated posterior cerebral artery occlusion from the Acute Stroke Registry and Analysis of Lausanne registry between January 2003 and July 2018, and compared (1) IVT with conservative treatment (CTr) and (2) EVT to best medical therapy (BMT, ie, CTr or IVT) in terms of 3-month disability and visual field defect, and cognitive domains impaired after stroke. Unadjusted analysis, multivariable logistic regression, and propensity score matched analyses were performed.
RESULTS—Among 106 patients with isolated posterior cerebral artery occlusion, 21 received EVT (13 bridging), 34 IVT alone, and 51 CTr. Median age was 76 years, 47% were female and median National Institutes of Health Stroke Scale score was 7. Complete 24-hour recanalization was more frequent with IVT than CTr (51% versus 9%; OR 95% CI=10.62 2.13–52.92) and with EVT compared with BMT (68% versus 34%; OR 95% CI=4.11 1.35–12.53). Higher proportions of good disability, visual and cognitive outcomes were observed in IVT versus CTr, adjORs (95% CI)=1.65 (0.60−4.52), 2.01 (0.58−7.01), 2.94 (0.35−24.4), respectively, and in EVT versus BMT, adjORs (95% CI)=1.44 (0.51−4.10), 4.28 (1.00−18.29), 4.37 (0.72−26.53), respectively. Hemorrhagic complications and mortality did not increase with IVT or EVT.
CONCLUSIONs—We show increased odds of recanalization following IVT and even higher after EVT. We observed a trend for a positive effect on disability, visual, and cognitive outcomes with IVT over CTr and with EVT over BMT.
Background. Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; surgical and endovascular therapy options are debated and long-term complication may occur. Case Report. A ...53-year-old man affected by neurofibromatosis type 1 (NF1) came to our attention for recurrent vertebrobasilar embolic strokes, caused by a primary giant, partially thrombosed, fusiform aneurysm of the left extracranial vertebral artery. The aneurysm was treated by endovascular approach through deposition of Guglielmi Detachable Coils in the proximal segment of the left vertebral artery. Six years later the patient presented stroke recurrence. Cerebral angiography and Color Doppler Ultrasound well characterized the unique hemodynamic condition developed over the years responsible for the new embolic event: the aneurysm had been revascularized from its distal portion by reverse blood flow coming from the patent vertebrobasilar axis. A biphasic Doppler signal in the left vertebral artery revealed a peculiar behavior of the blood flow, alternately directed to the aneurysm and backwards to the basilar artery. Surgical ligation of the distal left vertebral artery and excision of the aneurysm were thus performed. Conclusion. This is the first described case of NF1-associated extracranial vertebral artery aneurysm presenting with recurrent embolic stroke. Complete exclusion of the aneurysm from the blood circulation is advisable to achieve full resolution of the embolic source.
OBJECTIVETo investigate the association between the presence of ipsilateral nonstenotic carotid plaques and the rate of detection of atrial fibrillation (AF) during follow-up in patients with embolic ...strokes of undetermined source (ESUS).
METHODSWe pooled data of all consecutive ESUS patients from 3 prospective stroke registries. Multivariate stepwise regression assessed the association between the presence of nonstenotic carotid plaques and AF detection. The 10-year cumulative probabilities of AF detection were estimated by the Kaplan-Meier product limit method.
RESULTSAmong 777 patients followed for 2,642 patient-years, 341 (38.6%) patients had an ipsilateral nonstenotic carotid plaque. AF was detected in 112 (14.4%) patients in the overall population during follow-up. The overall rate of AF detection was 8.5% in patients with nonstenotic carotid plaques (2.9% per 100 patient-years) and 19.0% in patients without (5.0% per 100 patient-years) (unadjusted hazard ratio HR 0.56, 95% confidence interval CI 0.37–0.84). The presence of ipsilateral nonstenotic carotid plaques was associated with lower probability for AF detection (adjusted HR 0.57, 95% CI 0.34–0.96, p = 0.03). The 10-year cumulative probability of AF detection was lower in patients with ipsilateral nonstenotic carotid plaques compared to those without (34.5%, 95% CI 21.8–47.2 vs 49.0%, 95% CI 40.4–57.6 respectively, log-rank-test11.8, p = 0.001).
CONCLUSIONSAF is less frequently detected in ESUS patients with nonstenotic carotid plaques compared to those without.
CLINICALTRIALS.GOV IDENTIFIERNCT02766205.
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.
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