Intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) is recommended to treat acute ischemic stroke (AIS) with a large vessel occlusion (LVO). Most hospitals do not have on-site MT ...facilities, and most patients need to be transferred secondarily after IVT (drip and ship), which may have an effect on the neurologic outcome.
To compare the functional independence at 3 months between patients treated under the drip-and-ship paradigm and those treated on site (mothership).
This study used a prospectively gathered registry of patients with AIS to select patients admitted through the Saint-Antoine and Tenon (drip and ship) or the Fondation Rothschild (mothership) hospitals from January 1, 2013, through April 30, 2016. The study included patients older than 18 years treated with bridging therapy for AIS with LVO of the anterior circulation. Among the 159 patients who received MT at the mothership, 100 had been transferred after IVT from the drip-and-ship hospitals and 59 had received IVT on site.
The main outcome was 3-month functional independence (modified Rankin scale score ≤2). Both groups were compared using a multivariate linear model, including variables that were significantly different in the 2 groups.
During the study period, 497 patients were hospitalized at the drip-and-ship and mothership hospitals for an AIS eligible to reperfusion therapy; 11 patients had a basilar artery occlusion and were excluded, leaving 100 patients in the drip-and-ship group (mean age, 73 years; age range, 60-81 years; 57 men 57.0%) and 59 in the mothership group (mean age, 70 years; age range, 58-82 years; 29 men 49.2%). The proportion of patients with a favorable neurologic outcome at 3 months was similar in both groups (drip and ship, 61 61.0%; mothership, 30 50.8%; P = .26), even after adjusting the analysis for the baseline National Institutes of Health Stroke Scale score, diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, and general anesthesia (P = .82). Patients had less severe conditions in the drip-and-ship group (median baseline National Institutes of Health Stroke Scale score, 15 vs 17 P = .03; median diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, 7.5 vs 7 P = .05). Process times were longer in the drip-and-ship group (onset-to-needle time, 150 vs 135 minutes; onset-to-puncture time, 248 vs 189 minutes; and onset-to-recanalization time, 297 vs 240 minutes; P < .001). Both groups were similar in terms of substantial recanalization (Thrombolysis in Cerebral Ischemia scores 2B to 3; drip and ship, 84 84.0%; mothership, 47 79.7%; P = .49) and symptomatic hemorrhagic transformation (drip and ship, 2 2.0%; mothership, 2 3.4%; P = .63).
This study found that patients treated under the drip-and-ship paradigm also benefit from bridging therapy, with no statistically significant difference compared with those treated directly in a comprehensive stroke center.
Randomized studies have reported low rates of atrial fibrillation (AF) after patent foramen ovale (PFO) closure (<6%) but have relied on patient-reported symptomatic episodes, so the true incidence ...and timing of AF after PFO closure remain unknown.
The aim of this study was to prospectively determine the incidence, timing, and determinants of supraventricular arrhythmia following PFO closure on the basis of loop recorder monitoring.
Cardiac monitoring was proposed to all patients after PFO closure from June 2018 to October 2021 at a single center by means of implantable loop recorder monitoring in patients considered at higher risk for AF (age ≥ 55 years, associated cardiovascular risk factors, prior palpitations, or documented supraventricular ectopic activity) or 4-week external loop recorder monitoring in other patients. The primary endpoint was the incidence of AF, atrial flutter, or supraventricular tachycardia lasting >30 seconds within 28 days of the procedure. Determinants of the primary endpoint were assessed using a stepwise logistic regression model.
A total of 225 patients were included. The primary endpoint occurred in 47 patients (20.9%), including 13 (9.9%) and 24 (28.9%) among patients monitored with external loop recorders and implantable loop recorders, respectively. Overall, the median delay from procedure to arrhythmia was 14.0 days (IQR: 6.5-19.0 days), and one-half of these patients reported symptomatic episodes. Determinants of the primary endpoint were older age (adjusted OR: 1.67 per 10-year increase; 95% CI: 1.18-2.36), device left disc diameter ≥25 mm (adjusted OR: 2.67; 95% CI: 1.19-5.98) and male sex (adjusted OR: 4.78; 95% CI: 1.96-11.66).
Using loop recorder monitoring for ≥28 days, supraventricular arrhythmia was diagnosed in 1 in 5 patients, with a median delay of 14 days, suggesting that this postprocedural event has so far been underestimated.
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Carotid webs are an under-recognized embolic source in patients with cryptogenic stroke. Limited resources currently exist to assist clinicians in stroke prevention for patients with symptomatic ...carotid webs (SCW). We aimed at analysing the clinical, radiological and procedural features of stroke patients with SCW undergoing endovascular thrombectomy (EVT), and to describe the histopathological composition of their occlusive thrombi.
In a single-center observational study on consecutive patients with ischemic stroke treated by EVT, carotid web was defined symptomatic when it was ipsilateral to the ischemic lesion in a patient classified with stroke of otherwise undetermined etiology. Clinical, radiological and procedural data of patients with SCW were evaluated. Histopathological examination of the retrieved thrombi was performed.
Out of 1430 patients with large vessel occlusion stroke treated by EVT, 11(0.7%) were found to have a SCW. Patients with SCW had a median age of 47 years old (IQR 38–50), they were prevalently women (55%), mostly of African ethnicity (91%). Each of the 11 patients achieved successful angiographic reperfusion (mTICI 2b-3) after EVT. For secondary prevention, elective endovascular carotid stenting was performed in 5 (55%) patients, while 1 (9%) was treated by surgical endoarterectomy. Histological analysis of the retrieved thrombi performed in 4 patients showed a mixed composition with variable red blood cell content.
EVT is feasible in large vessel occlusion stroke related to SCW. Procedures of carotid revascularization appear to be feasible therapeutic options for secondary prevention. The histopathological analysis of cerebral thrombi may provide new insights on stroke pathogenesis in patients with SCW.
•Patients with symptomatic carotid web (SCW) account for about 3% of cryptogenic strokes.•Endovascular thrombectomy is feasible in large vessel stroke related to SCW.•Procedures of carotid revascularization are feasible prevention strategies.•Thrombus histology may provide new pathogenetic insights in SCW patients.
Wilson disease (WD) is a rare genetic condition that results from a build‐up of copper in the body. It requires life‐long treatment and is mainly characterized by hepatic and neurological features. ...Copper accumulation has been reported to be related to the occurrence of heart disease, although little is known regarding this association. We have conducted a systematic review of the literature to document the association between WD and cardiac involvement. Thirty‐two articles were retained. We also described three cases of sudden death. Cardiac manifestations in WD include cardiomyopathy (mainly left ventricular (LV) remodeling, hypertrophy, and LV diastolic dysfunction, and less frequently LV systolic dysfunction), increased levels of troponin, and/or brain natriuretic peptide, electrocardiogram (ECG) abnormalities, and rhythm or conduction abnormalities, which can be life‐threatening. Dysautonomia has also been reported. The mechanism of cardiac damage in WD has not been elucidated. It may be the result of copper accumulation in the heart, and/or it could be due to a toxic effect of copper, resulting in the release of free oxygen radicals. Patients with signs and/or symptoms of cardiac involvement or who have cardiovascular risk factors should be examined by a cardiologist in addition to being assessed by their interdisciplinary treating team. Furthermore, ECG, cardiac biomarkers, echocardiography, and 24‐hours or more of Holter monitoring at the diagnosis and/or during the follow‐up of patients with WD need to be evaluated. Cardiac magnetic resonance imaging, although not always available, could also be a useful diagnostic tool, allowing assessment of the risk of ventricular arrhythmias and further guidance of the cardiac workup.
Cerebral venous thrombosis is a rare cause of stroke. Imaging is essential for diagnosis. Although digital subtraction angiography is still considered by many to be the gold standard, it no longer ...plays a significant role in the diagnosis of cerebral venous thrombosis. MRI, which allows for imaging the parenchyma, vessels and clots, and CT are the reference techniques. CT is useful in case of contraindication to MRI. After presenting the radio-anatomy for MRI, we present the different MRI and CT acquisitions, their pitfalls and their limitations in the diagnosis of cerebral venous thrombosis.
Background and purpose
Acute ischaemic stroke patients with cerebral small vessel disease (CSVD), including cerebral microbleeds (CMBs) and white matter hyperintensities (WMHs), have worse outcomes. ...The effect was investigated of two blood pressure strategies (intensive vs. standard) and blood pressure variability (BPV) after reperfusion according to CSVD burden in the BP TARGET trial.
Methods
Patients with available magnetic resonance imaging at baseline were included. CMBs were described as absent or present and WMH severity was described according to the Fazekas classification (0–1, absent–mild; 2–3, moderate to severe). Outcomes consisted of any intracerebral hemorrhage (ICH) at 24 h and favorable outcome at 90 days (modified Rankin Scale score between 0 and 2).
Results
In all, 246 patients were included. The intensive systolic blood pressure target was not associated with lower rates of ICH or favorable outcome according to CSVD subgroups (all p values >0.35). Several BPV parameters were associated with increased odds of ICH in patients with CMBs but not in patients without CMBs (diastolic blood pressure coefficient of variation, odds ratio 2.06, 95% confidence interval CI 1.13–3.77, in patients with ≥1 CMB vs. 0.94, 95% CI 0.68–1.31, in patients without CMBs, phet = 0.026). Several diastolic BPV parameters were associated with worse outcomes in patients with severe WMHs but not in patients without WMHs (diastolic blood pressure coefficient of variation, odds ratio 0.32, 95% CI 0.17–0.61, in patients with severe WMHs vs. 1.09, 95% CI 0.67–1.79, in patients without WMHs; phet = 0.003).
Conclusion
No effect of the intensive systolic blood pressure management strategy was found on ICH occurrence or functional outcome according to CSVD burden. BPV was associated with higher odds of ICH in patients with CMBs and worse outcome in patients with moderate‐to‐severe WMHs.
Background
High blood pressure (BP) is associated with worse clinical outcomes in the setting of acute ischemic stroke, but the optimal blood pressure target is still a matter of debate. We aimed to ...study the association between baseline BP and mortality in acute ischemic stroke patients treated by mechanical thrombectomy.
Methods and Results
A total of 1332 acute ischemic stroke patients treated by mechanical thrombectomy were enrolled (from January 2012 to June 2016) in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Linear and polynomial logistic regression models were used to assess the association between BP and mortality and functional outcome at 90 days. Highest mortality was found at lower and higher baseline systolic blood pressure (SBP) values following a J‐ or U‐shaped relationship, with a nadir at 157 mm Hg (95% confidence interval 143‐170). When SBP values were categorized in 10–mm Hg increments, the odds ratio for all‐cause mortality was 3.78 (95% confidence interval 1.50‐9.55) for SBP<110 mm Hg and 1.81 (95% confidence interval 1.01‐3.36) for SBP≥180 mm Hg using SBP≥150 to 160 mm Hg as reference. The rate of favorable outcome was the highest at low SBP values and lowest at high SBP values, with a nonlinear relationship; in unplanned exploratory analysis, an optimal threshold SBP≥177 mm Hg was found to predict unfavorable outcome (adjusted odds ratio 0.47; 95% confidence interval 0.31‐0.70).
Conclusion
In acute ischemic stroke patients treated by mechanical thrombectomy, baseline SBP is associated with all‐cause mortality and favorable outcome. In contrast to mortality, favorable outcome rate was the highest at low SBP values and lowest at high SBP values. Further studies are warranted to confirm these findings.
In addition to exhibiting a severe contralesional deficit, hemianopic patients may also show a subtle ipsilesional visual deficit, called sightblindness (the reverse case of ‘blindsight). We have ...tested for the presence, nature and extent of such an ipsilesional visual field (IVF) deficit in hemianopic patients that we assigned to perform two visual tasks. Namely, we aimed to ascertain any links between this ipsilesional deficit, the lesion side, and the tasks performed or the stimuli used.
We tested left and right homonymous hemianopic (right brain-damaged RBD and left brain-damaged LBD, respectively) patients and healthy controls. Natural-scene images, either non-filtered or filtered in low or high spatial frequency (LSF or HSF, respectively) were presented in the IVF of each subject. For the two tasks, detection (“Is an image present?”) and categorization (“Is the image of a forest or a city?”), accuracy and response time were recorded.
In the IVF the RBD (left hemianopes) patients made more errors on the categorization task than did their matched controls, regardless of image type. In contrast, the only task in which the LBD (right hemianopes) patients made more errors than did the controls was the HSF-images task. Furthermore, in both tasks (detection and categorization), the RBD patients performed worse than did the LBD patients.
Homonymous hemianopic patients do indeed exhibit a specific visual deficit in their IVF, which was previously thought to be unaffected. We have demonstrated that the nature and severity of this ipsilesional deficit is determined by the side of the occipital lesion as well as by the tasks and the stimuli. Our findings corroborate the idea of hemispheric specialization at the occipital level, which might determine the nature and severity of ipsilesional deficits in hemianopic patients.
Summary Background Transthoracic echocardiography (TTE) is the most commonly used method for measuring left ventricular ejection fraction (LVEF), but its reproducibility remains a matter of ...controversy. Speckle tracking echocardiography assesses myocardial deformation and left ventricular systolic function by measuring global longitudinal strain (GLS), which is more reproducible, but is not used routinely in hospital practice. Aim To investigate the feasibility of on-line two-dimensional GLS in predicting LVEF during routine echocardiographic practice. Methods The analysis involved 507 unselected consecutive patients undergoing TTE between August 2012 and November 2013. Echocardiograms were performed by a single sonographer. Echogenicity was noted as good, moderate or poor. Simple linear regression was used to assess the relationship between LVEF and GLS, overall and according to quality of echogenicity. Receiver operating curve (ROC) analysis was used to identify the threshold GLS that predicts LVEF ≤ 40%. Results Mean LVEF was 64 ± 11% and GLS was –18.0 ± 4.0%. A reasonable correlation was found between LVEF and GLS ( r = –0.53; P < 0.001), which was improved when echogenicity was good ( r = –0.60; P < 0.001). GLS explained 28.1% of the variation in LVEF, and for one unit decrease in GLS, a 1.45 unit increase in LVEF was expected. Correlations between LVEF and GLS were –0.51 for patients in sinus rhythm ( n = 490) and –0.86 in atrial fibrillation ( n = 17). Based on ROC analysis, the area under the curve was 0.97 for GLS ≥ –14%, allowing detection of LVEF ≤ 40% with a sensitivity of 95% and specificity of 86%. Conclusion Two-dimensional GLS is easy to obtain and accurately detects LVEF ≤ 40% in unselected patients. GLS may be especially helpful when a suboptimal acoustic window makes LVEF measurement by Simpson's biplane method difficult and in atrial fibrillation patients with low heart rate variability.
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