D. Daniele

Mechanical Thrombolysis in Ischemic Stroke Attributable to Basilar Artery Occlusion as First-Line Treatment

Background and Purpose— To report results of mechanical disruption or retrieval of thrombus as first-line treatment in patients with stroke attributable to occlusion of the basilar artery, in particular regarding efficiency and safety. Methods— In 12 consecutive patients with acute stroke attributable to basilar occlusion, mechanical disruption or thrombus retrieval using various loop-shaped tools was tried before eventually starting local intra-arterial thrombolysis with recombinant tissue plasminogen activator (r-tPA). Main inclusion criteria were: National Institutes of Health Stroke Scale score >8 or Glasgow Coma Scale score <12; onset or worsening of symptoms <8 hours; no hemorrhages or large hypodensities on computed tomography scan; and occlusion of the basilar artery matching clinical symptoms. Efficiency included recanalization, procedure time, and r-tPA dose; safety was defined as rate of procedure-related complications. Outcome was evaluated at 3 months. Results— Mechanical recanalization was successful in 6 patients. A single brain infarction, possibly attributable to distal embolization, occurred. Three patients had good outcomes. In 5 of 6 remaining patients, the artery was recanalized using r-tPA. A single asymptomatic hemorrhage occurred; 3 patients had good outcomes. Procedure time and r-tPA were significantly less in patients with successful mechanical thrombolysis (43.33 minutes and 13.33 mg versus 112.33 minutes and 55.83 mg, respectively). Conclusion— Mechanical recanalization was effective in half of the patients and at least as safe as local intra-arterial thrombolysis. It allowed to save r-tPA and time. Although the low success rate remains a limit, the excellent and quick anatomical recanalization obtained after successful procedures makes this approach promising.

Brain lesions due to cerebral venous thrombosis do not correlate with sinus involvement.

Abstract Cerebral venous thrombosis may be well tolerated or lead to a brain lesion; availability of collateral venous pathways may explain the great variability of the lesions. This collateral circulation involves mainly medullary and cortical veins. These are difficult to assess neuroradiologically, particularly if thrombosed. Cerebral venous thrombosis is diagnosed usually based on thrombosis of dural sinuses and of the deep venous system. We tried to correlate the site and extent of dural sinus thrombosis with the location and the size of brain lesions in 26 consecutive patients with cerebral venous thrombosis, to investigate whether a simple causal relationship exists. No significant correlation between the extent and site of thrombosis in dural sinuses and the extent and location of brain lesions was found. In some cases a clear relationship between thrombosis of cortical and medullary veins and the lesions was evident. These data suggest that sinus thrombosis alone may be well tolerated in many cases, while involvement of cortical and medullary veins leads to a worse clinical situation.

Periprocedural morbidity and mortality by endovascular treatment of cerebral aneurysms with GDC: a retrospective 12-year experience of a single center.

Despite increasing experience and improved material, endovascular treatment of cerebral aneurysms still has risks linked to the technique itself and to the specificity of the pathology treated. The purpose of this report is to examine procedural technical and clinical negative events, even minimal ones, occurring in this type of treatment. We considered 557 procedures carried out from January 1994 to December 2005 in 533 patients harboring 550 aneurysms. Of the patients, 448 presented with SAH and 85 with unruptured aneurysms. All procedures were performed under general anesthesia. The GDC-10 system was routinely used. Additional devices like the balloon remodeling technique, Trispan and stents were also occasionally used. Every procedural complication occurring during or soon after treatment was registered. Endovascular treatment was completed in 539 out of 557 procedures. There were 18 failures (3.3%). Occlusion of the aneurysm was judged complete in 343 (64%), near complete in 184 (34%) and incomplete in 12 (2%). Procedural complications occurred in 72 (13%) of the cases. The most frequent negative events were thromboembolisms (6.6%) and ruptures (3.9%). Other types (coil migration, transient occlusions of the parent vessel, dissections and early rebleeding) were rarer (2.5%). In the majority of cases there were no clinical consequences. Procedural morbidity and mortality were 1.1 and 1.8%, respectively. Considering the 449 procedures performed in ruptured and the 90 in the unruptured aneurysms separately, morbidity and mortality were 1.1 and 2.2% in the former group and 1.1 and 0% in the latter. Many factors influence the risk of complications. Being progressively aware of this and with increasing experience, the frequency can be limited. Negative events linked to the procedure have more significant serious clinical consequences in patients admitted in a critical clinical condition after SAH, because of the already present changes involving the brain parenchyma and cerebral circulation.

Vertebral artery dissection complicated by basilar artery occlusion successfully treated with intra-arterial thrombolysis: three case reports

Cervical artery dissection is an important cause of stroke in young patients and accounts of 10%–20% of stroke or TIA in patients aged less than 50 years. Basilar artery occlusion (BAO) is an infrequent cause of acute stroke, which invariably leads to death or long-term disability if not recanalized. We describe three patients with BAO caused by vertebral dissection, successfully treated with intra-arterial thrombolysis. The lysis of the occluding embolus was obtained by injection of the thrombolytic drug directly or near the thrombus without haemor-rhagic complications. Our cases confirm the safety and efficacy of intra-arterial thrombolysis in patients with BAO due to a vertebral artery dissection.

Lacunes and other holes: diagnosis, pathogenesis, therapy.

Lacunar ischemic lesions are related to a pathology involving perforators, due to direct changes in the arteries or to an indirect mechanism, such as cardiac or artery to artery embolism, or to hypoperfusion in cases of cardiac failure, or proximal occlusion of large arteries. Changes involving the large intracranial arteries have progressively been taken into consideration as a cause of the disease. This latter aspect is interesting since possible endovascular treatment can be proposed in selected cases. In patients with lacunar syndrome an extended clinical and neuroradiological approach is indicated to choose the most appropriate therapy. Not all lesions recognizable on CT/MR are the expressions of ischemic lesions, this is another important aspect that should be considered in the differential diagnosis.

Computed Tomography in the Diagnosis of Subarachnoid Haemorrhage

Early computed tomography (CT) is very useful in detecting subarachnoid haemorrhage (SAH). It offers a lot of information about the origin, the extent of the haemorrhage and the early complications (hydrocephalus, haematoma). Moreover, CT scan can suggest the site of bleeding aneurysm and the risk of severe vasospasm. In some cases, CT shows a perimesencephalic SAH in which often no aneurysm can be detected. The sensitivity of CT in demonstrating SAH decreases as the time between onset of SAH and CT scanning increases.

Mechanical Thrombolysis Using a Solitaire Stent

Mechanical offers several advantages over drug thrombolysis: in particular, the haemorrhagic risk may be not significantly increased while working out the indications got intravenous drug thrombolysis. Available tools were in our hands inefficient, stiff and dangerous. We found a retrievable stent efficient and easy to handle for this purpose. This experience is described.

Spinal cord ischemia due to vertebral artery dissection

We reviewed clinical and neuroradiological findings in 37 consecutive patients with cervical cord infarction due to vertebral artery dissection diagnosed at our institution from 1996 to 2004. Four patients had clinical and neuroradiological findings consistent with spinal cord ischemia. Three patients had “pencil-like” infarction at C3-C5 level; one patient had an infarction of the anterior horns of the spinal grey matter at C3-C4 level. Symptoms were crural sensory deficit with mild tetraparesis and proximal strength deficit of the arms, respectively. Spinal cord infarction complicated vertebral artery dissection in about 10% of patients of our series. Infarctions involved the most central regions of the spinal cord, with relative sparing of the peripheral white matter tracts. Clinical and MRI pictures were almost typical, and consistent with a hemodynamic mechanism for the lesions. Vertebral artery dissection must be considered in the differential diagnosis in patients with cervical cord infarction.

Endovascular treatment of PICA aneurysms

Considering the segments of PICA (Antero-medullary; latero-postero-medullary; supratonsillar segment and more peripheral branches), 11 aneurysms were located in the antero-medullary segment (at the origin of PICA in 7 and slightly more distal in 4). In one patient, aneurysm was in the latero-postero-medullary segment and in another in the supratonsillar segment associalted to a small cerebellare AVM (figure 1,2). 12 patients suffered of a Sub. Hem. (2 with H.H. 2; 8 with H.H. 3; 2 with H.H. 4); in one case the aneurysm was discovered on MR performed for migraine. In patients with SE treatment was performed early (6-24h) in 8 (1 surgery; 7 endovascular). Four patients were treated 2-3 weeks later one by surgery and 3 by endovascular (2 after an unsucceful clipping). The unruptured aneurysm was treated by endovascular technique. Tecnical Aspects

Cranial Nerve Palsy in Spontaneous Dissection of the Internal Carotid Artery History and Evolution of a Diagnosis

Abstract: In the late 1970s the technical improvement and the widespread use of angiography allowed increasing confidence with radiological and clinical features of spontaneous dissection of the internal carotid artery. If the association with stroke was early clear not as much rapid was the recognition that spontaneous dissection could cause cranial nerve palsy. Lower and more rarely upper cranial nerves can be involved frequently without cerebral ischemia. The etiopathogenesis of this syndrome is not completely clear. It is assumed that mechanical compression and/or ischemia of the nerves due to impairment of supplying arteries are responsible for the syndrome.Zusammenfassung: Ende der 70er Jahre wurde die spontane Dissektion der Arteria carotis interna besonders durch die verbesserte angiographische Technik und ihre infolgedessen verbreiterte Indikation häufiger diagnostiziert und als mögliche Ursache zerebraler ischämischer Insulte erkannt. Mehr Zeit brauchte die Erkenntnis, daß die spontane Dissektion der Arteria carotis interna auch für die periphere Parese der Hirnnerven, besonders der unteren vier, aber auch nicht so selten der oberen, verantwortlich ist. Die Lähmungen können auch isoliert auftreten ohne zerebrale Ischämie, so daß in solchen Fällen der Gedanke einer spontanen Dissektion der Arteria carotis interna als mögliche Ursache in der Differentialdiagnose sehr wichtig ist. Wenn heute dieses Syndrom diagnostiziert wird, ist die Pathogenese der Lähmungen der Hirnnerven noch nicht völlig klar, wenn auch wahrscheinlich ihre direkte Kompression oder aber eine Ischämie durch Beeinträchtigung der versorgenden Gefäße eine Rolle spielt.