We report the case of a young woman affected by an aneurysmal subarachnoid haemorrhage (SAH) and numerous anatomic abnormalities. A Transcranial Colour-Coded Duplex Sonography, performed with the aim ...of monitoring the vasospasm, showed a non-pulsatile flow with loss of sharp systolic peak and lowering of mean flow velocities in the right extracranial Internal Carotid Artery (ICA) and all its intra-cranial branches. This event suggested a possible concomitant acute right ICA sub-occlusion with a lack of collateral circulation. This type of flow is typically found in systemic and brain arteries of patients undergoing to venous–arterial extracorporeal membrane oxygenation or to left ventricular assist devices. The absence of an adequate cerebral collateral circulation might be the explanation for this type of atypical flow. Aneurysms and arterial dissections contribute to SAH and ischemic stroke events, leading to long-term physical and cognitive disability. In our case, the prompt neurosonological diagnosis leaded to patient’s good outcome.
Purpose
Acute ischemic stroke (AIS) due to tandem lesions (TLs) of extracranial Internal Carotid Artery and Anterior Cerebral Circulation are challenging for endovascular treatment (EVT). This study ...aims to evaluate feasibility, safety and efficacy of EVT for TLs’ AIS, with or without emergent carotid artery stenting (eCAS), in a real-life scenario.
Methods
Retrospective review of prospectively collected non-randomized thrombectomy databases from five stroke centers between 2015 and 2019. Consecutive patients with TLs’ AIS were selected. Clinical, neuroimage and procedure features, as well as antiplatelet therapy regimen, were evaluated. Primary outcome was 90-day mRS ≤ 2. Secondary outcomes included: mTICI score 2b-3, extracranial recanalization, procedural complications, symptomatic intracerebral hemorrhage (SICH) and 90-day mortality.
Results
Two hundred twenty-seven patients were enrolled (67.8% males; mean age 65.9 ± 12.9 years). We obtained mTICI 2b-3 in 77.1%, extracranial recanalization in 86.8%, 90-day mRS (available in 201/227 cases) ≤ 2 in 49.8%. Procedural complications occurred in 16.7%, SICH in 9.7%; 90-day mortality rate (available in 201/227 cases) was 14.4%. The strongest predictors of good clinical outcome were young age (
p
< 0.0001), low baseline NIHSS (
p
= 0.008), high baseline ASPECTS (
p
< 0.0001), good collateral flow (
p
= 0.013) and extracranial recanalization (
p
= 0.001). The most significant predictors of SICH were low baseline ASPECTS (
p
< 0.0001), occurrence of complications (
p
< 0.0001) and eCAS (
p
= 0.002).
Conclusion
In our real-life series, the EVT for TLs’ AIS was feasible, safe and effective in improving 90-day functional outcome with acceptable morbi-mortality rates. ECAS increased the risk of SICH, independently from the antiplatelet therapy regimen.
Acute ischemic stroke with isolated occlusion of the M2-segment middle cerebral artery (MCA) has not been a focus of trials on mechanical thrombectomy (MT) thus far. We aimed to assess outcomes in ...stroke patients treated with different endovascular procedures versus direct MT alone for isolated M2-MCA occlusion. We conducted a cohort study on data from 506 stroke patients with isolated M2-MCA occlusion who were enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke cohort. We calculated odds ratio (OR) with confidence interval (CI) of different endovascular procedures (vs direct MT alone) for outcomes after adjustment for age, enrollment period, pre-stroke mRS score, NIHSS score, ASPECT score, onset-to-groin time, and procedure time. Endovascular procedures were direct MT alone (n = 156), intravenous thrombolysis (IVT) plus MT (n = 266), MT plus intra-arterial thrombolysis (IAT) (n = 43), and IAT alone (n = 41). MT plus IAT was associated with higher rates of TICI 2b/3 (OR 3.281, 95% CI 1.006–10.704), 3-month mRS 0–1 (OR 4.153, 95% CI 1.267–13.612), and 3-month mRS 0–2 (OR 4.497, 95% CI 1.485–13.617). IAT alone was associated with lower rates of TICI 3 (OR 0.348, 95% CI 0.139–0.874) and TICI 2b/3 (OR 0.369, 95% CI 0.144–0.948). IVT plus MT was associated with higher rate of asymptomatic ICH (OR 2.526, 95% CI 1.145–5.571). No significant difference was found between different endovascular procedures and direct MT alone as regards symptomatic ICH and 3-month death. In stroke patients with isolated M2-MCA occlusion, MT plus IAT was associated with better outcomes as compared with direct MT alone.
Background and Purpose:
Recent findings suggested that non-stenosing atherosclerosis (NSA) may play an important pathogenic role, especially in cryptogenic strokes. Furthermore, arterial stiffness ...has been suggested to be a useful tool in identifying patients with embolic stroke of undetermined source (ESUS) with poor neurological prognosis. In this view, the aim of our study was to assess the association between carotid NSA and arterial stiffness in ESUS patients, in order to better define the cardiovascular risk profile of this subgroup of patients.
Methods:
We enrolled 100 patients with ESUS (52 males, 48 females) and 48 patients with ischemic stroke from atherosclerosis. All patients underwent clinical and neuroimaging examination. A 24-h heart rate and blood pressure monitoring was performed in order to evaluate systolic, diastolic and mean blood pressure, pulse pressure, and arterial stiffness index (ASI).
Results:
NSA was present in 48 patients. In comparison with non-NSA-ESUS, in NSA-ESUS the mean age was higher, neurological deficit was more severe, hypertension, and diabetes were more common; systolic blood pressure, pulse pressure, and ASI were higher. In particular NSA-ESUS had ASI levels similar to strokes due to atherosclerosis.
Conclusions:
Our findings shed light on specific cardiovascular risk profiles underlying different subtypes of ESUS, suggesting the presence of increased arterial stiffness in NSA-ESUS patients with a risk factors profile similar to strokes due to atherosclerosis.
Ischemic Stroke after Heart Transplantation Acampa, Maurizio; Lazzerini, Pietro Enea; Guideri, Francesca ...
Journal of stroke,
05/2016, Letnik:
18, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Cerebrovascular complications after orthotopic heart transplantation (OHT) are more common in comparison with neurological sequelae subsequent to routine cardiac surgery. Ischemic stroke and ...transient ischemic attack (TIA) are more common (with an incidence of up to 13%) than intracranial hemorrhage (2.5%). Clinically, ischemic stroke is manifested by the appearance of focal neurologic deficits, although sometimes a stroke may be silent or manifests itself by the appearance of encephalopathy, reflecting a diffuse brain disorder. Ischemic stroke subtypes distribution in perioperative and postoperative period after OHT is very different from classical distribution, with different pathogenic mechanisms. Infact, ischemic stroke may be caused by less common and unusual mechanisms, linked to surgical procedures and to postoperative inflammation, peculiar to this group of patients. However, many strokes (40%) occur without a well-defined etiology (cryptogenic strokes). A silent atrial fibrillation (AF) may play a role in pathogenesis of these strokes and P wave dispersion may represent a predictor of AF. In OHT patients, P wave dispersion correlates with homocysteine plasma levels and hyperhomocysteinemia could play a role in the pathogenesis of these strokes with multiple mechanisms increasing the risk of AF. In conclusion, stroke after heart transplantation represents a complication with considerable impact not only on mortality but also on subsequent poor functional outcome.
Background/Objectives: Arterial stiffness (AS) is an independent predictor of cardiovascular events and is associated with a poor prognosis. While AS may represent a novel therapeutic target, recent ...evidence shows that it is sexually dimorphic. The aim of this study was to evaluate relative sex differences in arterial stiffness and their possible impact on the outcome of acute ischemic stroke. Methods: We retrospectively evaluated a cohort of adult patients with the following inclusion criteria: acute ischemic stroke, which occurred within 24 h from the onset of symptoms, confirmed through neuroimaging examinations, additional evaluations including extracranial and transcranial arterial ultrasound examinations, transthoracic echocardiography, a 12-lead resting ECG, and continuous 24 h in-hospital blood pressure monitoring. Based on the 24 h blood pressure monitoring, the following parameters were evaluated: systolic blood pressure, diastolic blood pressure, mean blood pressure, pulse pressure, and arterial stiffness index (ASI). The modified Rankin scale (mRS) was assessed at 90 days to evaluate the 3-month clinical outcome, defining an unfavorable outcome as an mRS score ≥ 3. To assess the factors associated with unfavorable outcomes, a stepwise logistic regression model was performed on the total sample size, and the analyses were replicated after stratifying by sex. Results: A total of 334 patients (176 males, 158 females) were included in the analysis. There was a significant sex-dependent impact of ASI on the 90-day unfavorable Rankin score (mRS score ≥ 3) as only men had a reduced likelihood of favorable outcomes with increasing arterial stiffness (OR:1.54, 95% CI: 1.06–2.23; P-interaction = 0.023). Conclusions: The influence of ASI on the 3-month functional outcome after acute ischemic stroke is at least in part sex-related, suggesting that, in males, higher ASI values are associated with a worse outcome.
Cerebral collateral circulation is a network of arterial anastomotic channels capable of providing supplementary perfusion to brain regions in response to ischemic insults. Arterial stiffness could ...negatively affect collateral circulation development, by means of its effects on the structural intracerebral vasculature.
The aim of our study is to investigate a possible link between arterial stiffness and presence of collateral circulation in patients with acute ischemic stroke.
113 patients (age: 74±12 years) with acute anterior ischemic stroke underwent neuroimaging examination and 24-hour blood pressure monitoring. Arterial Stiffness Index (ASI) and Pulse Pressure (PP) were assumed as surrogate measures of arterial stiffness. Collateral circulation was evaluated by means of the collateral grading system that was scored on a scale of 0-3.
According to TOAST classification, etiology of ischemic stroke was the following: Large-Artery Atherosclerosis (LAA)(n:41), Cardioembolism (CE)(n:60), Undetermined Etiology (UE)(n:12). Logistic regression analysis showed that good predictors of poor collaterals were ASI (OR 2.78 for 0.1, 95% CI:1.19-6.50, p=0.01) and PP (OR 1.81 for 10 mmHg, 95% CI:1.01-3.22, p=0.04) in stroke from LAA.
Our results suggest that, in patients with ischemic stroke from LAA, arterial stiffness may contribute to the impairment of collateral circulation and, therefore, it could reduce the beneficial effects of acute treatments.
Background and Purpose The influence of stroke etiology on outcomes after endovascular thrombectomy (EVT) is not well understood. We aimed to investigate whether stroke etiology subgrouped as large ...artery atherosclerosis (LAA) and cardiac embolism (CE) influences outcomes in large artery occlusion (LAO) treated by EVT.Methods We included EVT treated LAO stroke patients registered in the Safe Implementation of Treatment in Stroke (SITS) thrombectomy register between January 1, 2014 and September 3, 2019. Primary outcome was successful reperfusion (modified Treatment in Cerebral Infarction 2b-3). Secondary outcomes were symptomatic intracranial hemorrhage (SICH), 3-month functional independence (modified Ranking Scale 0–2) and death. Multivariable logistic regression models were used for comparisons. In addition, a meta-analysis of aggregate data from the current literature was conducted (PROSPERO, ID 167447).Results Of 7,543 patients, 1,903 (25.2%) had LAA, 3,214 (42.6%) CE, and 2,426 (32.2%) unknown, other, or multiple etiologies. LAA patients were younger (66 vs. 74, P<0.001) and had lower National Institutes of Health Stroke Scale score at baseline (15 vs. 16, P<0.001) than CE patients. Multivariable analyses showed that LAA patients had lower odds of successful reperfusion (odds ratio OR, 0.70; 95% confidence interval CI, 0.57 to 0.86) and functional independence (OR, 0.74; 95% CI, 0.63 to 0.85), higher risk of death (OR, 1.44; 95% CI, 1.21 to 1.71), but no difference in SICH (OR, 1.09; 95% CI, 0.71 to 1.66) compared to CE patients. The systematic review found 25 studies matching the criteria. The meta-analysis did not find any difference between etiologies. Conclusions From the SITS thrombectomy register, we observed a lower chance of reperfusion and worse outcomes after thrombectomy in patients with LAA compared to CE etiology, despite more favorable baseline characteristics. In contrast, the meta-analysis did not find any difference between etiologies with aggregate data.
Background and Purpose
The current definition of embolic strokes of undetermined source (ESUS) seems to be too broad, including strokes due to heterogeneous mechanisms, such as atrial cardiopathy and ...other occult cardiac conditions, aortic arch plaques, and non-stenosing atherosclerosis, that can be differently associated with clinical stroke severity at the time of presentation. The aim of our study was to assess the possible association between neurological deficit severity and presence of markers of atrial cardiopathy in ESUS.
Methods
We retrospectively reviewed the medical records of a cohort of 226 ESUS patients (105 M, 121 F), that were divided into two groups according to the severity of neurological deficit (99 mild strokes with NIHSS ≤ 5 and 127 severe strokes with NIHSS >5). The following indices of atrial cardiopathy were evaluated: P wave dispersion, P wave max, P wave min, P wave mean, P wave index, P wave axis, left atrial size.
Results
Patients with severe ESUS were significantly older (74 ± 12 vs. 67 ± 14 years,
P
< 0.001) and female sex was prevalent (67 vs. 36%,
P
> 0.001); they had higher values of P-wave-dispersion (51 ± 14 vs. 46 ± 13,
P
= 0.01), P-wave-max (131 ± 20 vs. 125 ± 15 ms,
P
= 0.01), P-wave-index (16 ± 5 vs. 15 ± 5 ms,
P
= 0.01), left atrial size (20 ± 6 vs. 18 ± 4 cm
2
,
P
= 0.01), left atrial volume index (31 ± 14 vs. 27 ± 11 ml/m
2
,
P
= 0.04), in comparison with mild ESUS. An abnormal P wave axis was detected more frequently in severe ESUS (21 vs. 9%,
P
= 0.01). Furthermore, multivariate logistic regression showed that age (OR = 1.21 for each 5-year increase, 95% CI 1.09–1.35), sex (OR = 3.24 for female sex, 95% CI 1.82–5.76) and PWD (OR = 1.32 for each 10-ms increase, 95% CI 1.07–1.64) were the best subset of associated variables for severe ESUS.
Conclusions
Our findings shed light on specific clinical characteristics of severe ESUS including the presence of atrial cardiopathy that could play a pathogenic role in this subgroup of patients. Searching for atrial fibrillation in these patients is especially important to perform the most appropriate therapy.
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