Summary Background The aim of the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) was to assess the safety and efficacy of intravenous alteplase as thrombolytic therapy ...within the first 3 h of onset of acute ischaemic stroke. Under European Union regulations, SITS-MOST was required to assess the safety profile of alteplase in clinical practice by comparison with results in randomised controlled trials. Methods 6483 patients were recruited from 285 centres (50% with little previous experience in stroke thrombolysis) in 14 countries between 2002 and 2006 for this prospective, open, monitored, observational study. Primary outcomes were symptomatic (a deterioration in National Institutes of Health stroke scale score of ≥4) intracerebral haemorrhage type 2 within 24 h and mortality at 3 months. We compared mortality, the proportion of patients with symptomatic intracerebral haemorrhage as per the Cochrane definition, and functional outcome at 3 months with relevant pooled results from randomised controlled trials. Findings Baseline characteristics of patients in SITS-MOST were much the same as those in the pooled randomised controlled trials. At 24 h, the proportion of patients with symptomatic intracerebral haemorrhage (per the SITS-MOST protocol) was 1·7% (107/6444; 95% CI 1·4–2·0); at 7 days, the proportion with the same condition as per the Cochrane definition was 7·3% (468/6438; 6·7–7·9) compared with 8·6% (40/465; 6·3–11·6) in the pooled randomised controlled trials. The mortality rate at 3 months in SITS-MOST was 11·3% (701/6218; 10·5–12·1) compared with 17·3% (83/479; 14·1–21·1) in the pooled randomised controlled trials. Interpretation These data confirm that intravenous alteplase is safe and effective in routine clinical use when used within 3 h of stroke onset, even by centres with little previous experience of thrombolytic therapy for acute stroke. The findings should encourage wider use of thrombolytic therapy for suitable patients treated in stroke centres.
Ultrasound characteristics of carotid web Fontaine, Louis; Guidolin, Brigitte; Viguier, Alain ...
Journal of neuroimaging,
September/October 2022, Volume:
32, Issue:
5
Journal Article
Peer reviewed
Open access
Background and Purpose
Carotid web (CaW) is a cause of recurrent ischemic stroke that remains underdiagnosed using Duplex ultrasound (DUS). Improved methods and description of its ultrasound's ...features could allow better detection of CaW. Ultrasound microflow imaging (MFI) is a blood flow imaging technique sensitive to slow flow that could increase CaW detection. This study aimed to describe ultrasound features of CaW using B‐mode imaging and MFI.
Methods
In a retrospective monocentric study, patients with CaW on CT angiography who underwent DUS examination of carotid arteries were included. DUS was performed by two nonblinded experienced neurosonologists. The specificity of CaW ultrasound features was evaluated using a group of patients with carotid atherosclerotic plaque (AP).
Results
Twenty‐four patients with CaW were included. Mean age (standard deviation) was 48 years (11). Seventeen (71%) were females. Fifteen (63%) CaWs were symptomatic. MFI was available for 22 patients. B‐mode imaging demonstrated the characteristic CaW appearance in 19/24 (79%) patients as a protruding triangular iso‐hypoechoic lesion on longitudinal view. CaW were detected on axial view in only 9/24 (38%) patients. MFI displayed slow blood flow above CaW during systole and allowed it delineation, appearing as a thin triangular endoluminal defect in 18/22 (82%) cases. Based on MFI and B‐mode, 21/22 (95%) CaWs were visible, including three CaWs only with MFI. These ultrasound features were not found among 24 patients with AP.
Conclusion
We report the ultrasound features from a series of 24 CaW. The use of MFI in addition to B‐mode imaging improved the detection rate of CaW.
Risks and benefits of intravenous thrombolysis for patients with stroke > 80 years of age are unclear. We examined outcomes and symptomatic intracerebral hemorrhage rates in ≤ 80- and > 80-year-old ...patients in the Safe Implementation of Treatment in Stroke International Stroke Thrombolysis Register.
We compared mortality and independence (modified Rankin Scale 0 to 2) at 3 months and symptomatic intracerebral hemorrhage (per Safe Implementation of Treatment in Stroke ≥ 4-point deterioration in National Institutes of Health Stroke Scale within 36 hours and Type 2 parenchymal hemorrhage and per National Institute of Neurological Disorders and Stroke any increase in National Institutes of Health Stroke Scale and any hemorrhage) of 1831 patients > 80 years of age with 19 411 patients ≤ 80 years of age compliant with other European licensing criteria.
The > 80-year-old group (median, 83 years) had more severe strokes (median National Institutes of Health Stroke Scale 14 versus 12), lower levels of prestroke independence (modified Rankin Scale 0 to 1, 82% versus 93%), and a larger proportion of females (59% versus 39%) compared with the younger group (68 years). Symptomatic intracerebral hemorrhage was not significantly increased after adjustment for other risk factors in those >80 years of age compared with those ≤ 80 years of age (per Safe Implementation of Treatment in Stroke 1.8% versus 1.7%, P = 0.70, adjusted OR, 0.90, 95% CI, 0.73 to 1.09; P = 0.28; per National Institute of Neurological Disorders and Stroke 9.5% versus 7.8%, P < 0.005, adjusted OR, 0.96, 95% CI, 0.87 to 1.06, P = 0.42). The patients >80 years of age had a higher mortality rate (30% versus 12%; P < 0.005; adjusted OR, 1.53; 95% CI, 1.43 to 1.65; P < 0.005) and reduced independence (35% versus 57%; P < 0.005; adjusted OR, 0.73; 95% CI, 0.68 to 0.78; P < 0.005).
Selected patients with acute ischemic stroke > 80 years of age otherwise fulfilling the intravenous alteplase license criteria have a similar rate of symptomatic intracerebral hemorrhage compared with younger patients and are appropriate candidates for thrombolysis. The higher mortality and the poorer functional outcome are consistent with the overall worse prognosis seen in the natural history of this age group.
Background:
Leptomeningeal enhancement (LME) is a key feature of Susac syndrome (SuS) but is only occasionally depicted on post-contrast T1-weighted images (T1-WI).
Objective:
As post-contrast ...fluid-attenuated inversion recovery (FLAIR) may be more sensitive, our aim was to assess LME in SuS on this sequence.
Methods:
From 2010 to 2020, 20 patients with definite SuS diagnosis were retrospectively enrolled in this multicentre study. Two radiologists independently assessed the number of LME on post-contrast FLAIR and T1-WI acquisitions performed before any treatment. A chi-square test was used to compare both sequences and the interrater agreement was calculated.
Results:
Thirty-five magnetic resonance imagings (MRIs) were performed before treatment, including 19 post-contrast FLAIR images in 17 patients and 25 post-contrast T1-WI in 19 patients. In terms of patients, LME was observed on all post-contrast FLAIR, contrary to post-contrast T1-WI (17/17 (100%) vs. 15/19 (79%), p < 0.05). In terms of sequences, LME was observed on all post-contrast FLAIR, contrary to post-contrast T1-WI (19/19 (100%) vs. 16/25 (64%), p < 0.005). LME was disseminated at both supratentorial (19/19) and infratentorial (18/19) levels on post-contrast FLAIR, contrary to post-contrast T1-WI (3/25 and 9/25, respectively). Interrater agreement was excellent for post-contrast FLAIR (κ = 0.95) but only moderate for post-contrast T1-WI (κ = 0.61).
Conclusion:
LME was always observed and easily visible on post-contrast FLAIR images prior to SuS treatment. In association with other MRI features, it is highly indicative of SuS.
Introduction
Insula plays an integrating role in sensory, affective, emotional, cognitive and autonomic functions in migraine, especially in migraine with aura (MA). Insula is functionally divided ...into 3 subregions, the dorsoanterior, the ventroanterior and the posterior insula respectively related to cognition, emotion, and somatosensory functions. This study aimed at investigating functional connectivity of insula subregions in MA.
Methods
Twenty-one interictal patients with MA were compared to 18 healthy controls (HC) and 12 interictal patients with migraine without aura (MO) and were scanned with functional MRI during the resting state. Functional coupling of the insula was comprehensively tested with 12 seeds located in the right and left, dorsal, middle, ventral, anterior and posterior insula, by using a seed-to-voxel analysis.
Results
Seed-to-voxel analysis revealed, in MA, a strong functional coupling of the right and left antero-dorsal insula with clusters located in the upper cerebellum. The overlap of these cerebellar clusters corresponded to the vermis VI. These functional couplings were not correlated to duration of MA, frequency of MA attacks nor time since last MA attack, and were not found in MO.
Discussion
The anterior insula and superior cerebellum, including vermis VI, are components of the central Autonomic Nervous System (ANS) network. As these regions are involved in the control of cardiovascular parasympathetic tone, we hypothesize that this connectivity may reflect the cardiovascular features of MA.
Conclusion
The anterior dorsal insula is connected with vermis VI in MA patients in the resting state. This connectivity may reflect the cardiovascular features of MA.
Trial registration
NCT02708797.
Background:The relative stability of cerebral blood flow is maintained by the baroreflex and cerebral autoregulation (CA). We assessed the relationship between baroreflex sensitivity (BRS) and CA in ...patients with atherosclerotic carotid stenosis or occlusion.Methods and Results:Patients referred for assessment of atherosclerotic unilateral >50% carotid stenosis or occlusion were included. Ten healthy volunteers served as a reference group. BRS was measured using the sequence method. CA was quantified by the correlation coefficient (Mx) between slow oscillations in mean arterial blood pressure and mean cerebral blood flow velocities from transcranial Doppler. Forty-five patients (M/F: 36/9), with a median age of 68 years (IQR:17) were included. Thirty-four patients had carotid stenosis, and 11 patients had carotid occlusion (asymptomatic: 31 patients; symptomatic: 14 patients). The median degree of carotid steno-occlusive disease was 90% (IQR:18). Both CA (P=0.02) and BRS (P<0.001) were impaired in patients as compared with healthy volunteers. CA and BRS were inversely and strongly correlated with each other in patients (rho=0.58, P<0.001) and in healthy volunteers (rho=0.939; P<0.001). Increasing BRS remained strongly associated with impaired CA on multivariate analysis (P=0.004).Conclusions:There was an inverse correlation between CA and BRS in healthy volunteers and in patients with carotid stenosis or occlusion. This might be due to a relative increase in sympathetic drive associated with weak baroreflex enhancing cerebral vasomotor tone and CA. (Circ J 2014; 78: 2460–2467)
Background:
The study of left atrial (LA) longitudinal strain by speckle tracking is a reliable method for analyzing LA function that could provide relevant information in young patients with ...cryptogenic stroke (CS). The aim of this study was to investigate whether the presence of a patent foramen ovale (PFO) impacts the LA longitudinal strain in a population of young patients with first CS.
Methods and Results:
Patients aged 18 to 54 years, treated consecutively in a university hospital for first CS, were included in this study. The presence of a PFO and an atrial septal aneurysm (ASA) was investigated using transesophageal echocardiography and transcranial Doppler. Speckle tracking analysis was performed on transthoracic echocardiography, allowing the measurement of global, passive, and active longitudinal LA strain, corresponding to the reservoir, conduit, and contractile function, respectively. A total of 51 patients were included in the study. In a multivariable analysis, overweight was associated with reduced global and passive LA longitudinal strain (
P
= 0.013 and
P
= 0.018, respectively), and hypertension was associated with reduced active LA longitudinal strain (
P
= 0.049). LA longitudinal strain was not different between patients with PFO or PFO plus ASA and patients without PFO.
Conclusion:
LA longitudinal strain in young subjects with CS was impaired in the presence of overweight and hypertension, but not of PFO or PFO plus ASA.
Migraine with aura (MWA) has been associated with cryptogenic ischemic stroke (CIS) after adjustment for the presence of a patent foramen ovale (PFO) assessed by a transcranial Doppler. This study ...aimed at evaluating the association of MWA with causal PFO assessed by Transesophageal echocardiography (TEE) in CIS.
Patients aged 18-54 years consecutively treated for first acute ischemic stroke in a university hospital stroke unit, between January 2017 and December 2019, were included in this cross-sectional study. Associations between migraine subtypes and PFO were tested for all PFO, possibly causal PFO (PFO with large shunt and/or atrial septal aneurysm ASA), and the probably causal PFO subset (large shunt and/or ASA, plus risk of paradoxical embolism RoPE score ≥ 7). We adjusted the association between migraine subtypes and possibly causal PFO, which included the probably causal subset for age, sex, large artery atherosclerosis, and small vessel disease.
A total of two hundred and two patients with CIS were included, of whom 42/202 (20%) had MWA, 32/202 (15%) had migraine without aura, and 128/202 (63%) had no migraine. MWA was associated with possibly causal PFO (OR = 4.0, 95%CI 1.78-9.3,
< 0.001) and with probably causal PFO (OR = 5.4, 95%CI 2.37-13,
< 0.001). In a multinomial logistic regression analysis, MWA remained associated with possibly causal PFO (OR = 3.24, 95% CI 1.45-7.2,
= 0.004).
In a young adult population with CIS, MWA was strongly associated with possibly causal PFO, i.e., with a large shunt or combined with an interatrial septal aneurysm.
Background The specificities of acute convexity subarachnoid hemorrhage (cSAH) related to cerebral amyloid angiopathy (CAA) and its evolution are not well known. We aimed to describe the ...clinicoradiological pattern, the magnetic resonance imaging (MRI) evolution, and the risk of recurrent bleeding in such patients. Methods Among consecutive patients with an acute nontraumatic cSAH, subjects with available MRI who meet the modified Boston criteria for probable CAA were included. Review of medical records, MRI findings, and follow-up data was performed. Results Twenty-three patients (14 women; mean age ± standard deviation: 75.9 ± 7.3 years) were included. cSAH was revealed by transient focal neurological episodes (TFNEs) in 18 of 23 (78.3%) patients. In all patients, acute cSAH appeared as a sulcal fluid-attenuated inversion recovery hyperintensity and GRE T2 hypointensity. Cortical superficial siderosis and cortical microbleeds, respectively, were observed in 21 (91.3%) and 20 (86.9%) patients. Twenty patients (87%) had available follow-up data with a mean duration of 29.8 ± 20.2 months. Recurrent TFNEs occurred in 40% of patients. Acute cSAH evolved into cortical superficial siderosis in all patients. New subarachnoid bleedings defined by recurrent acute cSAH (n = 8) or extension of siderosis (n = 14) were detected in 83.3% of the patients. Lobar intracerebral hemorrhage (ICH) occurred in 7 patients (35%). Conclusion CAA-related cSAH has a specific pattern defined by a high prevalence of TFNEs and cortical superficial siderosis, with a high risk of recurrent bleeding, either cSAH or lobar ICH. The systematic evolution from cSAH to focal cortical superficial siderosis reveals data on siderosis physiopathology.
...findings from the present analysis confirm a negative association between tissue hypoattenuation and age. ...the relation between age and symptomatic intracerebral haemorrhage could be more ...complex than initially thought.
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