Caroline Arquizan

Early and late seizures after cryptogenic ischemic stroke in young adults

Objectives: To assess the incidence and predictive factors of early and late seizures after ischemic stroke in young adults. Methods: A total of 581 patients (aged 18 to 55 years) with recent cryptogenic ischemic stroke were prospectively enrolled at 30 neurology departments and followed for 37.8 ± 9.7 months. Early seizures (occurring within 7 days of stroke) were assessed by chart review and late seizures were prospectively recorded at each follow-up visit. Clinical and brain imaging findings were reviewed by two neurologists and two neuroradiologists who were blinded to the occurrence of seizures. Results: Fourteen of the 581 patients (2.4%) developed early seizures, 71% of which occurred within the first 24 hours. Rankin scale ≥3 (odds ratio [OR] 3.9, 95% CI 1.2 to 12.7) and cortical involvement (OR 7.7, 95% CI 1.0 to 61.1) were independently associated with early seizures. Late seizures occurred only in patients with hemispheric stroke (n = 20). The risk of first late seizure was 3.1% (95% CI 1.4 to 4.8) within 1 year and 5.5% (95% CI 3.1 to 7.9) within 3 years. The mean delay between stroke and first late seizure was 12.9 months (0.3 to 33.9). Late seizures were associated with early seizure (hazard ratio [HR] 5.1, 95% CI 1.8 to 14.8), cortical signs (HR 4.5, 95% CI 1.6 to 13.1), and size of infarct superior to one-half hemisphere (HR 9.7, 95% CI 3.1 to 30.8). Eleven of the 20 patients with late seizure experienced recurrences (multiple in eight) on antiepileptic drug treatment. Most of them were seizure free at the end of the follow-up. Conclusion: Epilepsy is rarely a major problem in young cryptogenic ischemic stroke survivors. Early seizures are associated with stroke disability and cortical involvement. Early seizures, cortical signs, and large infarct are independent risk factors for late seizures.

Rescue, Combined, and Stand-Alone Thrombectomy in the Management of Large Vessel Occlusion Stroke Using the Solitaire Device: A Prospective 50-Patient Single-Center Study Timing, Safety, and Efficacy

Background and Purpose— Large vessel occlusion in ischemic stroke is associated with a high degree of morbidity. When intravenous thrombolysis fails, mechanical thrombectomy can provide an alternative and synergistic method for flow restoration. In this study we evaluate the safety and efficacy of our stroke management protocol (RECOST study). Methods— Fifty consecutive ischemic stroke patients with large vessel occlusion were included. After clinical and MRI imaging assessment, 3 treatment strategies were selected according to time of symptom onset and location of vessel occlusion: rescue therapy; combined therapy; and stand-alone thrombectomy (RECOST study). MRI ASPECT score <5 was the main exclusion criterion. Mechanical thrombectomy was performed exclusively with the Solitaire flow restoration device. Clinical outcome was assessed after treatment, on day 1, and at discharge. Results— Mean patient age was 67.6 years, mean NIHSS score was 14.7, and mean ASPECT score was 6 on presentation. Vessel occlusions were in the middle cerebral artery (40%), the internal carotid artery (28%), and the basilar artery (32%). Rescue treatment represented 24%, combined therapy represented 56%, and stand-alone thrombectomy represented 20%. Mean recanalization time from symptoms onset was 377 minutes, with overall recanalization rate TICI 3 of 84%. NIHSS score at discharge was 6.5, with 60% of patients demonstrating NIHSS score 0 to 1 or an improvement of >9 points. Symptomatic complication rate was 10%. At 3 months, 54% of patients had a modififed Rankin scale score of 0 to 2, with an overall mortality rate of 12%. Conclusions— The present integrated stroke management protocol (RECOST study) demonstrated rapid, safe, and effective recanalization. We postulate that the Solitaire device contributed to high recanalization and patient selection using MRI ASPECT score to low and complication rates, therefore avoiding futile and dangerous interventions.

Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke

BACKGROUND Trials of patent foramen ovale (PFO) closure to prevent recurrent stroke have been inconclusive. We investigated whether patients with cryptogenic stroke and echocardiographic features representing risk of stroke would benefit from PFO closure or anticoagulation, as compared with antiplatelet therapy. METHODS In a multicenter, randomized, open‐label trial, we assigned, in a 1:1:1 ratio, patients 16 to 60 years of age who had had a recent stroke attributed to PFO, with an associated atrial septal aneurysm or large interatrial shunt, to transcatheter PFO closure plus long‐term antiplatelet therapy (PFO closure group), antiplatelet therapy alone (antiplatelet‐only group), or oral anticoagulation (anticoagulation group) (randomization group 1). Patients with contraindications to anticoagulants or to PFO closure were randomly assigned to the alternative noncontraindicated treatment or to antiplatelet therapy (randomization groups 2 and 3). The primary outcome was occurrence of stroke. The comparison of PFO closure plus antiplatelet therapy with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 2, and the comparison of oral anticoagulation with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 3. RESULTS A total of 663 patients underwent randomization and were followed for a mean (±SD) of 5.3±2.0 years. In the analysis of randomization groups 1 and 2, no stroke occurred among the 238 patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet‐only group (hazard ratio, 0.03; 95% confidence interval, 0 to 0.26; P<0.001). Procedural complications from PFO closure occurred in 14 patients (5.9%). The rate of atrial fibrillation was higher in the PFO closure group than in the antiplatelet‐only group (4.6% vs. 0.9%, P=0.02). The number of serious adverse events did not differ significantly between the treatment groups (P=0.56). In the analysis of randomization groups 1 and 3, stroke occurred in 3 of 187 patients assigned to oral anticoagulants and in 7 of 174 patients assigned to antiplatelet therapy alone. CONCLUSIONS Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation. (Funded by the French Ministry of Health; CLOSE ClinicalTrials.gov number, NCT00562289.)

Aneurysmal forms of cervical artery dissection : associated factors and outcome.

Background and Purpose — The natural history of aneurysmal forms of cervical artery dissection (CAD) is ill defined. The aims of this study were to assess (1) clinical and anatomic outcome of aneurysmal forms of extracranial internal carotid artery (ICA) and vertebral artery (VA) dissections and (2) factors associated with aneurysmal forms of CAD. Methods — Seventy-one consecutive patients with CAD were reviewed. Aneurysmal forms of CAD were identified from all available angiograms by 2 neuroradiologists. The frequency of arterial risk factors, of multiple vessel dissections, and of artery redundancies was compared in patients with and without aneurysm. Patients with aneurysm were invited by mail to undergo a final clinical and radiological evaluation. Results — Of the 71 patients, 35 (49.3%) had a total of 42 aneurysms. Thirty aneurysms were located on a symptomatic artery (ICA, 23; VA, 7) and 12 on an asymptomatic artery (ICA, 10; VA, 2). Patients with aneurysm had multiple dissections of cervical vessels (18/35 versus 7/36;P =0.005) and arterial redundancies (20/35 versus 11/36;P =0.02) more frequently than patients without aneurysm. They were also more often migrainous (odds ratio=2.7 [95% CI, 0.8 to 8.5]) and tobacco users (odds ratio=2.2 [95% CI, 0.7 to 6.3]). Clinical and anatomic follow-up information was available for 35 (100%) and 33 patients (94%), respectively. During a mean follow-up of >3 years, no patient had signs of cerebral ischemia, local compression, or rupture. At follow-up, 46% of the aneurysms involving symptomatic ICA were unchanged, 36% had disappeared, and 18% had decreased in size. Resolution was more common for VA than for ICA aneurysms (83% versus 36%). None of the aneurysms located on an asymptomatic ICA had disappeared. Conclusions — Although aneurysms due to CAD frequently persist, patients carry a very low risk of clinical complications. This favorable clinical outcome should be kept in mind before potential harmful treatment is contemplated.

Restenosis Is More Frequent After Carotid Stenting Than After Endarterectomy: The EVA-3S Study

Background and Purpose— Carotid angioplasty and stenting (CAS) may be more often associated with residual or recurrent stenosis than carotid endarterectomy (CEA). We compared the rates of restenosis in patients treated with CAS or CEA in the EVA-3S trial. Methods— Five hundred seven patients (242 treated by CAS and 265 by CEA) had carotid ultrasound follow-up (mean carotid ultrasound follow-up, 2.1 years) according to a predefined protocol. Carotid restenosis of 50% to 69% was diagnosed on planimetry, whereas carotid restenosis of ≥70% or occlusion was diagnosed using either planimetry or velocity criteria. Results— The rate of carotid restenosis of ≥50% or occlusion was significantly higher after CAS (12.5%) than after CEA (5.0%; time ratio, 0.16; 95% CI, 0.03–0.76; P=0.02). The rates of severe restenosis of ≥70% or occlusion were low and did not differ significantly between the 2 groups (3-year rates are 3.3% in the CAS group and 2.8% in the CEA group). Age at baseline was the only vascular risk factor significantly associated with carotid restenosis. Our study could not detect any effect of carotid restenosis on ipsilateral stroke. Conclusions— The short-term rate of carotid restenosis of ≥50% or occlusion is ≈2.5-times more common after CAS than after CEA, a difference accounted for by an excess risk in moderate restenosis. More data with longer follow-up are needed to assess the rates of late severe restenosis and to determine the relation between restenosis and recurrent stroke over time.

Stent Retrievers in Acute Ischemic Stroke: Complications and Failures during the Perioperative Period

BACKGROUND AND PURPOSE: Stent retriever–assisted thrombectomy promotes high recanalization rates in acute ischemic stroke. Nevertheless, complications and failures occur in more than 10% of procedures; hence, there is a need for further investigation. MATERIALS AND METHODS: A total of 144 patients with ischemic stroke presenting with large-vessel occlusion were prospectively included. Patients were treated with stent retriever–assisted thrombectomy ± IV fibrinolysis. Baseline clinical and imaging characteristics were incorporated in univariate and multivariate analyses. Predictors of recanalization failure (TICI 0, 1, 2a), and of embolic and hemorrhagic complications were reported. The relationship between complication occurrence and periprocedural mortality rate was studied. RESULTS: Median age was 69.5 years, and median NIHSS score was 18 at presentation. Fifty patients (34.7%) received stand-alone thrombectomy, and 94 (65.3%) received combined therapy. The procedural failure rate was 13.9%. Embolic complications were recorded in 12.5% and symptomatic intracranial hemorrhage in 7.6%. The overall rate of failure, complications, and/or death was 39.6%. The perioperative mortality rate was 18.4% in the overall cohort but was higher in cases of failure (45%; P = .003), embolic complications (38.9%; P = .0176), symptomatic intracranial hemorrhages (45.5%; P = .0236), and intracranial stenosis (50%; P = .0176). Concomitant fibrinolytic therapy did not influence the rate of recanalization or embolic complication, or the intracranial hemorrhage rate. Age was the only significant predictive factor of intracranial hemorrhage (P = .043). CONCLUSIONS: The rate of perioperative mortality was significantly increased in cases of embolic and hemorrhagic complications, as well as in cases of failure and underlying intracranial stenoses. Adjunctive fibrinolytic therapy did not improve the recanalization rate or collateral embolic complication rate. The rate of symptomatic intracranial hemorrhage was not increased in cases of combined treatment.

Long-Term Follow-Up Study of Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis Trial

Background and Purpose— We aimed at comparing the long-term benefit–risk balance of carotid stenting versus endarterectomy for symptomatic carotid stenosis. Methods— Long-term follow-up study of patients included in Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S), a randomized, controlled trial of carotid stenting versus endarterectomy in 527 patients with recently symptomatic severe carotid stenosis, conducted in 30 centers in France. The main end point was a composite of any ipsilateral stroke after randomization or any procedural stroke or death. Results— During a median follow-up of 7.1 years (interquartile range, 5.1–8.8 years; maximum 12.4 years), the primary end point occurred in 30 patients in the stenting group compared with 18 patients in the endarterectomy group. Cumulative probabilities of this outcome were 11.0% (95% confidence interval, 7.9–15.2) versus 6.3% (4.0–9.8) in the endarterectomy group at the 5-year follow-up (hazard ratio, 1.85; 1.00–3.40; P=0.04) and 11.5% (8.2–15.9) versus 7.6% (4.9–11.8; hazard ratio, 1.70; 0.95–3.06; P=0.07) at the 10-year follow-up. No difference was observed between treatment groups in the rates of ipsilateral stroke beyond the procedural period, severe carotid restenosis (≥70%) or occlusion, death, myocardial infarction, and revascularization procedures. Conclusions— The long-term benefit–risk balance of carotid stenting versus endarterectomy for symptomatic carotid stenosis favored endarterectomy, a difference driven by a lower risk of procedural stroke after endarterectomy. Both techniques were associated with low and similar long-term risks of recurrent ipsilateral stroke beyond the procedural period. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00190398.

Primary angiitis of the central nervous system: description of the first fifty-two adults enrolled in the French cohort of patients with primary vasculitis of the central nervous system.

To describe characteristics and outcomes of a multicenter cohort of patients diagnosed as having primary angiitis of the central nervous system (PACNS).

Is Patent Foramen Ovale a Family Trait?: A Transcranial Doppler Sonographic Study

Background and Purpose— Patent foramen ovale (PFO) is a frequent finding in young patients with stroke. The aim of this study was to assess whether PFO is a family trait. Methods— Sixty-two consecutive patients younger than 60 years of age with ischemic stroke and 62 age and gender-matched control siblings were examined by means of contrast transcranial Doppler (TCD) of the middle cerebral artery, using a standardized protocol. The reliability of TCD examination in our laboratory was assessed against transesophageal echocardiography (TEE). All TCD recordings were reviewed by a blinded experienced observer from another center. Disagreements between readers were resolved by unblinded consensus review. Results— Siblings of patients with PFO had a significantly higher prevalence of PFO than had siblings of patients without PFO (61.5% versus 30.6%; OR 3.64 [1.3 to 10.5];P =0.015). The &kgr; statistics indicated that agreement of pairs (patients/control siblings) was not due to chance. The strength of the association was sex dependent. In women pairs, prevalence of a PFO was 76.5% in siblings of patients with PFO and 25% in siblings of patients without PFO, giving an OR of 9.8 (95% CI 2 to 47.9;P <0.01). In contrast, in men, no significant difference was observed in the prevalence of PFO between siblings of patients with or without PFO (respectively 33.3% and 35%), giving an OR of 0.9 (95% CI 0.2 to 4.9;P =0.9). Conclusions— This study suggests that, in women, PFO is a family trait.

Mechanical thrombectomy with the Solitaire device in acute basilar artery occlusion

Aims To evaluate the efficacy and safety of mechanical thrombectomy with the Solitaire FR device in revascularization of patients with acute basilar artery occlusion (ABAO) and to identify the predictive factors for clinical outcome. Methods This prospective single-center study included 31 patients with acute ischemic stroke attributable to ABAO treated within the first 24 h after onset of symptoms with the Solitaire device. Nineteen patients simultaneously received intravenous thrombolysis. Recanalization rates after stent retrieval were determined and the clinical outcome and mortality rate were assessed 180 days after treatment. Results The mean ±SD age of the patients was 61±17 years, the median prethrombectomy NIH Stroke Scale score was 38 (IQR 9–38) and the median Glasgow Coma Scale (GCS) score was 7 (IQR 4–14). Successful recanalization (TICI 3 or 2b) was achieved in 23 patients (74%). Five symptomatic intracranial hemorrhages were related to the procedure. Ten symptomatic distal migrations of thrombotic material occurred. A favorable outcome, defined as a modified Rankin Score (mRS) of 0–2, was observed in 35% of patients (11/31). Overall mortality rate was 32% (10/31). In the univariate analysis, elevated baseline glucose (p=0.008) was significantly associated with a poor outcome (mRS >2), whereas a tendency towards significance was observed with age (p=0.06), GCS on admission (p=0.07) and symptom-related lesions on T2 sequences (p=0.10). Patients with successful recanalization tended to have a better outcome (p=0.20). Conclusion Mechanical thrombectomy with the Solitaire FR device can rapidly and effectively contribute to a high rate of recanalization and improve functional outcome in patients with ABAO and has an acceptable complication rate.