Background
Mechanical thrombectomy is the standard of care, in selected patients, for acute ischemic stroke with large vessel occlusion but its use in patients with stroke secondary to infective ...endocarditis is controversial. We report three cases of acute ischemic stroke treated by mechanical thrombectomy and we propose an extensive review of the literature to evaluate the clinical safety and efficacy of thrombectomy in patients with stroke secondary to infective endocarditis.
Methods
A comprehensive literature search was performed following a pre-specified protocol of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Case reports, cases series, cross-sectional studies, case control studies, randomized controlled trials or nonrandomized controlled trials were considered that included endocarditis-related acute ischemic stroke patients who underwent mechanical thrombectomy.
Results
The database search yielded 431 relevant records published until January 2020. Nineteen articles fulfilled the eligibility criteria that described thirty patients. After the thrombectomy, 13.3% of the patients experienced intracranial haemorrhage. After the procedure, the median National Institutes of Health Stroke Scale score dropped from 15 (IQR 7) to 2.5 (IQR 5.75). At 90 days, mortality was 23.3% while 46.7% of the patients were functionally independent (mRS ≤ 2).
Discussion
Based on our review, the use of mechanical thrombectomy in patients with large vessel occlusion due to endocarditis-associated stroke might improve patient outcome but it should be considered on a case by case base as the safety has not been well established yet. Further research on risk stratification is needed to drive clinician during the decision-making process.
To combine MRI-based cortical morphometry and diffusion white matter tractography to describe the anatomical correlates of repetition deficits in patients with primary progressive aphasia (PPA).
The ...traditional anatomical model of language identifies a network for word repetition that includes Wernicke and Broca regions directly connected via the arcuate fasciculus. Recent tractography findings of an indirect pathway between Wernicke and Broca regions suggest a critical role of the inferior parietal lobe for repetition. To test whether repetition deficits are associated with damage to the direct or indirect pathway between both regions, tractography analysis was performed in 30 patients with PPA (64.27 ± 8.51 years) and 22 healthy controls. Cortical volume measurements were also extracted from 8 perisylvian language areas connected by the direct and indirect pathways.
Compared to healthy controls, patients with PPA presented with reduced performance in repetition tasks and increased damage to most of the perisylvian cortical regions and their connections through the indirect pathway. Repetition deficits were prominent in patients with cortical atrophy of the temporo-parietal region with volumetric reductions of the indirect pathway.
The results suggest that in PPA, deficits in repetition are due to damage to the temporo-parietal cortex and its connections to Wernicke and Broca regions. We therefore propose a revised language model that also includes an indirect pathway for repetition, which has important clinical implications for the functional mapping and treatment of neurologic patients.
Microglial activation contributes to both inflammatory damage and repair in experimental ischemic stroke. However, because of the logistical challenges, there have been few clinical imaging studies ...directly describing inflammatory activation and its resolution after stroke. The purpose of our pilot study was to describe the spatio-temporal profile of brain inflammation after stroke using 18kD translocator protein (TSPO) positron emission tomography (PET) with magnetic resonance (MR) co-registration in the subacute and chronic stage after stroke.
Three patients underwent magnetic resonance imaging (MRI) and PET scans with TSPO ligand
CPBR28 15 ± 3 and 90 ± 7 days after an ischaemic stroke. Regions of interest (ROI) were defined on MRI images and applied to the dynamic PET data to derive regional time-activity curves. Regional uptake was quantified as standardised uptake values (SUV) over 60 to 90 min post-injection. ROI analysis was applied to identify binding in the infarct, and in frontal, temporal, parietal, and occipital lobes and cerebellum excluding the infarcted area.
The mean age of participants was 56 ± 20.4 years and mean infarct volume was 17.9 ± 18.1 ml.
CPBR28 showed increased tracer signal in the infarcted area compared to non-infarcted areas of the brain in the subacute phase of stroke (Patient 1 SUV 1.81; Patient 2 SUV 1.15; Patient 3 SUV 1.64).
CPBR28 uptake returned to the level of non-infarcted areas at 90 days Patient 1 SUV 0.99; Patient 3 SUV 0.80). No additional upregulation was detected elsewhere at either time point.
The neuroinflammatory reaction after ischaemic stroke is limited in time and circumscribed in space suggesting that post-ischaemic inflammation is tightly controlled but regulatory mechanisms.
Background and purpose
The global COVID‐19 pandemic led many stroke centres worldwide to shift from in‐person to telemedicine consultations to assess patients with transient ischaemic attacks (TIAs). ...We aimed to investigate the impact of telemedicine during the COVID‐19 pandemic on the management and outcome of the patients with TIA.
Methods
We retrospectively analysed data from a registry of consecutive TIA patients assessed at the Stroke Department, Imperial College Health Care Trust, London, during the national lockdown period (between March 23 2020 and 30 June 2020). As controls, we evaluated the clinical reports and stroke quality metrics of patients presenting to the TIA clinic in the same period of 2019.
Results
Between 23 March 2020 and 30 June 2020, 136 patients were assessed using the telemedicine TIA clinic, compared to 180 patients evaluated with face‐to‐face consultation in the same period in 2019. Patients’ characteristics were similar in both groups. At 3 months after the TIA, there were no significant differences in the proportion of patients admitted to the hospital for recurrent TIA/stroke or any other cardiovascular cause from the 2020 period compared to the same period in 2019.
Conclusions
Our analysis showed that during the pandemic, our telemedicine consultations of TIA patients were not associated with an increased 3‐month rate of recurrent TIA/stroke or cardiovascular hospital admissions. More robust studies looking at this model of care will be needed to assess its long‐term effects on patients and health care systems.
We examined the impact of the coronavirus disease 2019 (COVID-19) pandemic on our regional stroke thrombectomy service in the UK.
This was a single-center health service evaluation. We began testing ...for COVID-19 on 3 March and introduced a modified "COVID Stroke Thrombectomy Pathway" on 18 March. We analyzed the clinical, procedural and outcome data for 61 consecutive stroke thrombectomy patients between 1 January and 30 April. We compared the data for January and February ("pre-COVID," n = 33) versus March and April ("during COVID," n = 28).
Patient demographics were similar between the 2 groups (mean age 71 ± 12.8 years, 39% female). During the COVID-19 pandemic, (a) total stroke admissions fell by 17% but the thrombectomy rate was maintained at 20% of ischemic strokes; (b) successful recanalization rate was maintained at 81%; (c) early neurological outcomes (neurological improvement following thrombectomy and inpatient mortality) were not significantly different; (d) use of general anesthesia fell significantly from 85 to 32% as intended; and (e) time intervals from onset to arrival, groin puncture, and recanalization were not significantly different, whereas internal delays for external referrals significantly improved for door-to-groin puncture (48 interquartile range (IQR) 39-57 vs. 33 IQR 27-44 minutes, p = 0.013) and door-to-recanalization (82.5 IQR 61-110 vs. 60 IQR 55-70 minutes, p = 0.018).
The COVID-19 pandemic has had a negative impact on the stroke admission numbers but not stroke thrombectomy rate, successful recanalization rate, or early neurological outcome. Internal delays actually improved during the COVID-19 pandemic. Further studies should examine the effects of the COVID-19 pandemic on longer term outcome.
The evidence for mechanical thrombectomy in acute basilar artery occlusion has until now remained inconclusive with basilar artery strokes associated with high rates of death and disability. This ...systematic review and meta-analysis will summarize the available evidence for the effectiveness of mechanical thrombectomy in acute basilar artery occlusion compared to best medical therapy.
We conducted a systematic review and meta-analysis of randomized controlled trials using Embase, Medline and the Cochrane Central Register of Controlled Trials (CENTRAL). We calculated risk ratios (RRs) and 95% confidence intervals (CIs) to summarize the effect estimates for each outcome.
We performed a random effects (Mantel-Haenszel) meta-analysis of the four included randomized controlled trials comprising a total of 988 participants. We found a statistically significant improvement in the rates of those with a good functional outcome (mRS 0-3, RR 1.54, 1.16-2.06, p = 0.003) and functional independence (mRS 0-2, RR 1.69, 1.05-2.71, p = 0.03) in those who were treated with thrombectomy when compared to best medical therapy alone. Thrombectomy was associated with a higher level of sICH (RR 7.12, 2.16-23.54, p = 0.001) but this was not reflected in a higher mortality rate, conversely the mortality rate was significantly lower in the intervention group (RR 0.76, 0.65-0.89, p = 0.0004).
Our meta-analysis of the recently presented randomized controlled studies is the first to confirm the disability and mortality benefit of mechanical thrombectomy in basilar artery stroke.
It has been postulated that autism spectrum disorder is underpinned by an 'atypical connectivity' involving higher-order association brain regions. To test this hypothesis in a large cohort of adults ...with autism spectrum disorder we compared the white matter networks of 61 adult males with autism spectrum disorder and 61 neurotypical controls, using two complementary approaches to diffusion tensor magnetic resonance imaging. First, we applied tract-based spatial statistics, a 'whole brain' non-hypothesis driven method, to identify differences in white matter networks in adults with autism spectrum disorder. Following this we used a tract-specific analysis, based on tractography, to carry out a more detailed analysis of individual tracts identified by tract-based spatial statistics. Finally, within the autism spectrum disorder group, we studied the relationship between diffusion measures and autistic symptom severity. Tract-based spatial statistics revealed that autism spectrum disorder was associated with significantly reduced fractional anisotropy in regions that included frontal lobe pathways. Tractography analysis of these specific pathways showed increased mean and perpendicular diffusivity, and reduced number of streamlines in the anterior and long segments of the arcuate fasciculus, cingulum and uncinate--predominantly in the left hemisphere. Abnormalities were also evident in the anterior portions of the corpus callosum connecting left and right frontal lobes. The degree of microstructural alteration of the arcuate and uncinate fasciculi was associated with severity of symptoms in language and social reciprocity in childhood. Our results indicated that autism spectrum disorder is a developmental condition associated with abnormal connectivity of the frontal lobes. Furthermore our findings showed that male adults with autism spectrum disorder have regional differences in brain anatomy, which correlate with specific aspects of autistic symptoms. Overall these results suggest that autism spectrum disorder is a condition linked to aberrant developmental trajectories of the frontal networks that persist in adult life.
Basilar artery occlusion (BAO) is a neurological emergency associated with a high risk for adverse outcomes. This review provides evidence on the therapeutic efficacy of intravenous thrombolysis ...(IVT) and endovascular therapy (EVT) in the treatment of BAO. Historically considered the primary intervention for acute ischemic stroke, IVT has been progressively combined with EVT, which has emerged from recent studies demonstrating clinical benefits, notably in patients presenting with severe stroke. Several randomised controlled trials have shown that EVT improves patient outcomes in select clinical contexts. Future research directions could address therapeutic treatment thresholds, combination strategies, and long-term outcomes.
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