ABSTRACT
BACKGROUP AND PURPOSE
There are limited data regarding the diagnostic yield of transcranial color‐coded Doppler (TCCD) in acute encephalitis. We present our preliminary observations of ...consecutive ultrasound evaluations in 2 patients with acute encephalitis and we review the possible diagnostic role of TCCD in such cases.
METHODS
We describe two cases of acute encephalitis that presented with aphasia and confusion and underwent repeat TCCD evaluation at baseline and after 48 hours in both patients. We also critically review the current literature regarding potential TCCD applications in acute central nervous system infections.
RESULTS
Serial TCCD evaluations revealed the following triad of abnormal findings in both patients: (i) elevated pulsatility index (PI) in the left middle cerebral artery (M1 MCA) at baseline (>1.2), (ii) increased PI in left M1 MCA by >25% in comparison to right M1 MCA, and (iii) decrease in PI in left M1 MCA by >25% at the follow‐up evaluation at 48 hours. The decrease in PI in left M1 MCA coincided with symptom improvement in both patients.
DISCUSSION
The focal transient increase in left M1 MCA PI may be attributed to focally increased intracranial pressure or peripheral vasospasm of distal left MCA branches. Since there are limited reports in the literature concerning TCCD evaluation of patients with central nervous system infections, our preliminary findings require independent confirmation in a larger series of patients.
Highlights • ‘Yin-Yang’ sign represents a partially thrombosed, true or false aneurysm. • BA dissection causes subarachnoid hemorrhage, brainstem ischemia or compression. • Patients with intracranial ...artery dissection may not receive iv thrombolysis. • Ruptured basilar artery dissections may be treated with stent placement.
AbstractObjectiveEvaluating the safety and efficacy of mechanical thrombectomy (MT) in acute stroke patients due to emergent large vessel occlusion (ELVO) with high international-normalized-ratio ...(INR). MethodsConsecutive ELVO patients treated with MT were evaluated from two centers. Outcome measures included symptomatic-intracranial-hemorrhage(sICH), three-month mortality, successful reperfusion(SR), and 3-month functional-independence(FI; mRS-scores of 0–2). Additionally, a meta-analysis of available cohort studies was performed to evaluate safety and efficacy of MT in ELVO patients with high INR. ResultsA total of 315 ELVO patients were evaluated. Of those 10 patients had INR >1.7 mean age 63.5 ± 15, median NIHSS-score: 17 points (IQR 14–22),and remaining 305 ELVO patients had INR ≤ 1.7 (mean age 62 ± 14.4, median NIHSS-score: 17 points (IQR 12–21). Patients with high INR did not differ in terms of sICH (10.0% vs. 6.9%; p = .706), 3-month mortality (20.0% vs. 24.2%; p = .762), SR (88.9% vs. 69.4%; p = .209) and 3-month FI (50% vs. 49.3%; p = .762) compared to the rest. Meta-analysis of available studies ( n = 5) showed that high INR was not related to sICH (OR: 0.94, 95%CI: 0.42–2.07; p = .88), 3-month mortality (OR: 1.07, 95%CI: CI 0.72–1.60; p = .73) and 3-month FI (OR: 0.69, 95%CI: 0.34–1.40; p = .30). ConclusionsMT can be performed safely and effectively in ELVO patients with high INR.
There is a paucity of knowledge in the literature relating to the extent of clot burden and stroke etiology. In this study, we measured the Extracted Clot Area (ECA) retrieved during endovascular ...treatment (EVT) and investigated relationships with suspected etiology, administration of intravenous thrombolysis and recanalization.
As part of the multi-institutional RESTORE registry, the ECA retrieved during mechanical thrombectomy was quantified using ImageJ. The effect of stroke etiology (Large-artery atherosclerosis (LAA), Cardioembolism, Cryptogenic and other) and recombinant tissue plasminogen activator (rtPA) on ECA and recanalization outcome (mTICI) was assessed. Successful recanalization was described as mTICI 2c-3.
A total of 550 patients who underwent EVT with any clot retrieved were included in the study. The ECA was significantly larger in the LAA group compared to all other etiologies. The average ECA size of each etiology was; LAA=109 mm2, Cardioembolic=52 mm2, Cryptogenic=47 mm2 and Other=52 mm2 (p=0.014*). LAA patients also had a significantly poorer rate of successful recanalization (mTICI 2c-3) compared to all other etiologies (p=0.003*). The administration of tPA was associated with a smaller ECA in both LAA (p=0.007*) and cardioembolic (p=0.035*) groups.
The ECA of LAA clots was double the size of all other etiologies and this is associated with a lower rate of successful recanalization in LAA stroke subtype. rtPA administration prior to thrombectomy was associated with reduced ECA in LAA and CE clots.
ABSTRACT
Carotid artery disease (CAD) is a common cause of ischemic stroke with high rates of recurrence. Carotid endarterectomy (CEA) or carotid artery stenting (CAS) are highly recommended for the ...secondary prevention of symptomatic CAD during the first 14 days following the index event of transient ischemic attack or minor stroke. CEA or CAS may also be offered in selected cases with severe asymptomatic stenosis. Herein, we review the utility of neurosonology in the diagnosis and pre‐/peri‐interventional assessment of CAD patients who undergo carotid revascularization procedures. Carotid ultrasound may provide invaluable information on plaque echogenicity, ulceration, risk of thrombosis, and rupture. Transcranial Doppler or transcranial color‐coded sonography may further assist by mapping collateral circulation, evaluating the impairment of vasomotor reactivity, detecting microembolization, or reperfusion hemorrhage in real time. Neurosonology examinations are indispensable bedside tools assisting in the diagnosis, risk stratification, peri‐interventional monitoring, and follow‐up of patients with CAD.
Recognizing new-territory ischemic stroke as an uncommon complication of intravenous thrombolysis is very important as it can lead to neurological deterioration during tissue-plasminogen-activator ...infusion.
We report a case of an 80-year-old patient that has been treated with intravenous thrombolysis for right middle cerebral artery acute ischemic stroke. During infusion he had an abrupt neurological deterioration that proved to be a distal embolization of an asymptomatic non-occluding tip-of-the-basilar thrombus to the territory of left posterior cerebral artery that has been missed by the treating neurologist and radiologist in the pretreatment computed tomography angiography. In the thrombectomy that followed, only the right carotid artery has been catheterized and only the right middle cerebral artery was successfully recanalized, leaving the left posterior cerebral artery occlusion untreated.
This case highlights that the use of thrombectomy in clinical practice provides an effective therapeutic option for large vessel occlusion in this setting. However, high clinical suspicion for this rare complication is mandatory to proceed to correct diagnosis and treatment.
Most clots retrieved from patients with acute ischemic stroke are ‘red’ in color. ‘White’ clots represent a less common entity and their histological composition is less known. Our aim was to ...investigate the composition, imaging and procedural characteristics of ‘white’ clots retrieved by mechanical thrombectomy.
Seventy five ‘white’ thrombi were selected by visual inspection from a cohort of 760 clots collected as part of the RESTORE registry. Clots were evaluated histopathologically.
Quantification of Martius Scarlett Blue stain identified platelets/other as the major component in ‘white’ clots’ (mean of 55% of clot overall composition) followed by fibrin (31%), red blood cells (6%) and white blood cells (3%). ‘White’ clots contained significantly more platelets/other (p<0.001*) and collagen/calcification (p<0.001*) and less red blood cells (p<0.001*) and white blood cells (p=0.018*) than ‘red’ clots. The mean platelet and von Willebrand Factor expression was 43% and 24%, respectively. Adipocytes were found in four cases. ‘White’ clots were significantly smaller (p=0.016*), less hyperdense (p=0.005*) on computed tomography angiography/non-contrast CT and were associated with a smaller extracted clot area (p<0.001*) than ‘red’ clots. They primarily caused the occlusion of middle cerebral artery, were less likely to be removed by aspiration and more likely to require rescue-therapy for retrieval.
‘White’ clots represented 14% of our cohort and were platelet, von Willebrand Factor and collagen/calcification-rich. ‘White’ clots were smaller, less hyperdense, were associated with significantly more distal occlusions and were less successfully removed by aspiration alone than ‘red’ clots.
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