Ischemic Stroke Feske, Steven K.
The American journal of medicine,
December 2021, 2021-12-00, 20211201, Letnik:
134, Številka:
12
Journal Article
Recenzirano
This concise review of the epidemiology, pathophysiology, evaluation, acute management, and prevention of ischemic stroke targets internists, family practitioners, and emergency physicians who manage ...patient with stroke.
One of the most important causes of neurological morbidity and mortality in the world is ischemic stroke. It can be a result of multiple events such as embolism with a cardiac origin, occlusion of ...small vessels in the brain, and atherosclerosis affecting the cerebral circulation. Increasing evidence shows the intricate function played by the immune system in the pathophysiological variations that take place after cerebral ischemic injury. Following the ischemic cerebral harm, we can observe consequent neuroinflammation that causes additional damage provoking the death of the cells; on the other hand, it also plays a beneficial role in stimulating remedial action. Immune mediators are the origin of signals with a proinflammatory position that can boost the cells in the brain and promote the penetration of numerous inflammatory cytotypes (various subtypes of T cells, monocytes/macrophages, neutrophils, and different inflammatory cells) within the area affected by ischemia; this process is responsible for further ischemic damage of the brain. This inflammatory process seems to involve both the cerebral tissue and the whole organism in cardioembolic stroke, the stroke subtype that is associated with more severe brain damage and a consequent worse outcome (more disability, higher mortality). In this review, the authors want to present an overview of the present learning of the mechanisms of inflammation that takes place in the cerebral tissue and the role of the immune system involved in ischemic stroke, focusing on cardioembolic stroke and its potential treatment strategies.
Endovascular therapy for stroke is generally avoided if the cerebral infarction is large. In a trial conducted in Japan, the percentage of patients who had a good functional outcome at 90 days was ...higher with endovascular therapy than with medical care, but there were more cerebral hemorrhages with endovascular therapy.
Current stroke guidelines do not facilitate the expedient diagnosis of inflammatory stroke. At UCLH, we have integrated intracranial vessel wall imaging (iVWI) into our stroke pathway to overcome ...this barrier. We present a case, where iVWI facilitated the diagnosis and helped us interpret a further asymptomatic stroke event.A 36-year-old man presented with left sided facial weakness. He had type 2 diabetes, hypertension, obesity, and hypercholesterolaemia. CT showed a right MCA/ACA infarct with severe bilateral ICA stenosis. MRI confirmed a borderzone infarct. The patient was treated with anti-platelets, a statin and continued ramipril and amlodipine. iVWI imaging identified an unexpected inflammatory vasculopathy. His CSF was supportive of CNS inflammation, and thus, commenced on prednisolone and empirical valaciclovir. His 3-month interval scan showed new asymptomatic borderzone infarcts that were concordant with hypoperfusion injury, and temporally linked with the initiation of indapamide by his GP, this was subsequently stopped. His vasculopathy remained static. A six-month interval scan showed no new lesion, and improvement of his inflammatory vasculopathy. Using iVWI, we were able to diagnose an inflammatory vasculopathy that could have been missed. The case also highlighted that excessive early reduction of blood pressure can contribute to hypoperfusion related stroke.
We provided Alexa devices-Amazon Echo Show and Echo Spot to a 56- year old patient recovering from an ischaemic stroke at home. Amazon Echo device is a WiFi connected device driven by Alexa, a voice ...assistant. We trained our patient on the use and control of the devices using her voice and provided technical know how. Once set up, she was able to use the voice control to perform several tasks-listening to news listening to music and radioplaying sounds for meditationturning on and off lightssetting up alarms for medicationssetting up times for doing scheduled exercisemaking hands free phone callsThis was especially useful when her carer was not present by her side. Later on we added Amazon cloud cam to the set up so that family members could remotely monitor her activity.She was able to make the physiotherapy sessions fun and interesting with the help of apps running on the devices upon voice prompts.In the emerging economies the joint family structure is breaking down. The relatives working as informal carers are disappearing fast. The main care is often provided by the privately hired nurses or health care assistants provided by local agencies. The cost of such private care is high. In this background, the voice activated cloud devices could play a significant role in the rehabilitation following a stroke.
IntroductionIn the treatment of acute stroke, there are key points to optimize time. In 2022, in our centre some elements were modified to create a new circuit, in order to reduce the time from the ...detection of the stroke, to the moment of the start of treatment.Aim of StudyThere will be better results if we make an early diagnosis and treatment.MethodsOnce the stroke is confirmed, the next step is the election of the optimal treatment. Endovascular treatment is one of the possibilities in which the nursing team plays an important role.In our centre, at the angiosuite, nursing is organized into two roles: a surgical nurse and an assistant nurse. The surgical nurse is who assists in the surgical field during sterile techniques. The assistant nurse has to take care of the patient, to assist the instrumentalist nurse and to communicate with the rest of the hospital units.ResultsHospital Parc Taulí is the referent institution for around 450.000 citizens. It has a neurointerventional radiology team, who attends the acute stroke that requires endovascular treatment. During 2022, the institution has attended 66 patients who required thrombectomy. With the ongoing update of the guidelines, the hospital has reduced the detection-treatment time from 85 to 71 minutes.ConclusionIn order to provide the best attention during an acute stroke, time is the key factor. Nurses have an important role throughout the process, which means that they need to be trained adequately to achieve those required functions.Disclosure of InterestNothing to disclose
IntroductionStroke interventions require a multidisciplinary team approach and the radiology technician plays a vital role in ensuring the success of the procedure.Aim of StudyThis presentation will ...provide an overview of neurological stroke interventions from the radiology technician’s perspective, focusing on day and night situations, logistics and aftercare.MethodsDuring the presentation, various situations will be presented accompanied with our approach (including motivation). Adaptations based on our experience will also be included. We will also discuss the challenges of providing stroke interventions in emergency situations, such as limited resources and time constraints.ResultsAttendees will gain a better understanding of the radiology technician’s role in stroke interventions and the importance of their contribution to the overall success of the procedure.ConclusionEven though the skills possessed by the interventional radiologist are essential for patient‘s recovery, the important role of the radiology technician must not be forgotten!Disclosure of InterestNothing to disclose
IntroductionFirst-pass(FP)-recanalization has been shown to improve outcome in patients with ischemic stroke undergoing mechanical thrombectomy(MT). Data also suggests that FP-recanalization is more ...often associated with complete reperfusion TICI=3 than with TICI=2b. Independently, it was shown that TICI=3 significantly improves functional outcome after mechanical thrombectomyAim of StudyTo evaluate whether early recanalization or complete recanalization TICI=3 are the determinants of improved outcome observed after FP-recanalization.MethodsAll patients prospectively enrolled in the German Stroke Registry-ET (05/2015–12/2021;N=13082) were screened. Inclusion criteria were anterior circulation stroke and successful recanalization TICI≥2b. Good functional outcome was defined as 90d modified Rankin Scale(mRS)≤2. Mediation analysis was performed to evaluate how much of the FP-related improvement in functional outcome is explained by complete reperfusion TICI=3.Results2589 patients were included, 1170(47%) had successful FP recanalization, 797(68% of FP-cases) with TICI=3. FP-recanalization was associated with higher rate of good functional outcome compared to multi-pass with 49.2% vs 37.6%. Mediation analysis suggests that FP-recanalization increases probability of good outcome by 9.6 percentage points vs. multi-pass recanalization. 12.8% (95%CI:7.6%-23%) of this effect was explained by TICI=3 recanalization whereas 87.2% (77%-92%) are explained by other factors associated with FP- recanalization.ConclusionOnly 13% of the FP-related improvement in functional outcome is explained by higher rates of complete recanalization, suggesting significant importance of early recanalization and low number of MT maneuvers. Results may improve the understanding of the importance of FP-reperfusion vs. early TICI=3 and may help to optimize MT treatment strategies.Disclosure of InterestHK has financial interest in Eppdata GmbH.GT received fees as consultant and lecturer from Acandis, Alexion, Amarin, Boehringer Ingelheim, Bayer, BMS/Pfizer, Daiichii Sankyo and Portola. He serves in the board of the TEA Stroke Study and of ESO.JF is consultant for Cerenovus, Medtronic, Microvention, Penumbra, Phenox, Roche, Stryker and Tonbridge. He is stock holder of Tegus Medical, Eppdata and Vastrax. He serves as Associate Editor at JNIS.All other authors have nothing to disclose.
IntroductionAcute stroke treatment with intracranial thrombectomy and stent-PTA of ipsilateral carotid artery stenosis/occlusion (“tandem lesion’ TL) in one session is considered safe. However, the ...risk of stent restenosis after TL treatment is high. Antiplatelet (AP) therapy to prevent restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the procedural safety and 90 days outcome of patients receiving TL treatment under triple-AP with a focus on stent-patency and possible disadvantageous comorbidities.Aim of StudyTo ensure stent patency after TL treatment without putting the patient at risk of recurrent stroke or intracranial hemorrhage.MethodsPatients receiving TL treatment at our institution in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All treatments were with i.v. administration of eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Follow-up was done with duplex imaging at discharge and 90 days, with digital subtraction angiography upon suspected restenosis.Results176 patients were included. No periprocedural death occurred, periprocedural complications rate was 2.3%, in-hospital death rate 13.6%. 92.61% of patients maintained or improved the discharge mRS score at 90 days follow-up. 4.54% had an instent-restenosis within 90 days, no recorded comorbidity rendered significantly disadvantageous for stent patency.ConclusionTL treatment under triple AP was safe in our experience, resulting in a low rate of restenosis and with favorable outcome in 92%. The influence of comorbidities on restenosis could be negligible within the described follow-up period.Disclosure of InterestPhilipp von Gottberg: Nothing to disclose.Ali Khanafer: Nothing to discloseVictoria Hellstern: Proctering for phenox GmbH.Alexandru Cimpocca: Nothing to disclose.Hans Henkes: Proctoring for phenox GmbH, Co-Founder and Co-Owner of CONTARA GmbH
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