D. Trystram

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.

Does Aneurysmal Wall Enhancement on Vessel Wall MRI Help to Distinguish Stable From Unstable Intracranial Aneurysms

Background and Purpose— Arterial wall enhancement on vessel wall MRI was described in intracranial inflammatory arterial disease. We hypothesized that circumferential aneurysmal wall enhancement (CAWE) could be an indirect marker of aneurysmal wall inflammation and, therefore, would be more frequent in unstable (ruptured, symptomatic, or undergoing morphological modification) than in stable (incidental and nonevolving) intracranial aneurysms. Methods— We prospectively performed vessel wall MRI in patients with stable or unstable intracranial aneurysms. Two readers independently had to determine whether a CAWE was present. Results— We included 87 patients harboring 108 aneurysms. Interreader and intrareader agreement for CAWE was excellent (&kgr;=0.85; 95% confidence interval, 0.75–0.95 and &kgr;=0.90; 95% confidence interval, 0.83–0.98, respectively). A CAWE was significantly more frequently seen in unstable than in stable aneurysms (27/31, 87% versus 22/77, 28.5%, respectively; P<0.0001). Multivariate logistic regression, including CAWE, size, location, multiplicity of aneurysms, and daily aspirin intake, revealed that CAWE was the only independent factor associated with unstable status (odds ratio, 9.20; 95% confidence interval, 2.92–29.0; P=0.0002). Conclusions— CAWE was more frequently observed in unstable intracranial aneurysms and may be used as a surrogate of inflammatory activity in the aneurysmal wall.

Three-dimensional dynamic time-resolved contrast-enhanced MRA using parallel imaging and a variable rate k-space sampling strategy in intracranial arteriovenous malformations

To evaluate the effectiveness of three‐dimensional (3D) dynamic time‐resolved contrast‐enhanced MRA (TR‐CE‐MRA) using a combination of a parallel imaging technique (ASSET: array spatial sensitivity encoding technique) and a time‐resolved method (TRICKS: time‐resolved imaging of contrast kinetics) and to compare it with 3D dynamic TR‐CE‐MRA using ASSET alone in the assessment of intracranial arteriovenous malformations (AVMs).

Reversible cerebral angiopathy: efficacy of nimodipine.

Reversible cerebral angiopathy (RCA) is responsible for disabling headache and potential stroke complications. Most patients respond poorly to analgesics. We describe four patients with typical RCA whose headache rapidly disappeared after IV nimodipine treatment was initiated.

Reversible angiopathy and encephalopathy after blood transfusion.

Sirs: Neurological complications have rarely been described after blood transfusion [1, 2]. We report a case of reversible angiopathy and encephalopathy after a blood transfusion in a patient with chronic severe anaemia. Case report – A 48-year-old black woman with a 11-year history of schizophrenia was admitted in a psychiatric department on 16 January 2001 for dysthymic and behaviour disturbances. She had been receiving neuroleptics (haloperidol: Haldol® and cyamemamazine: Tercian®) and antihistamine drug (hydroxysine: Atarax®) for 2 years. She had had a moderate hypertension since 1998, but received no treatment. A severe chronic anaemia (haemoglobin: 3 g/dl, haematocrit: 13 %, reticulocytes: 73.109/dl) due to chronic bleeding from myoma uteri was discovered. She received 5 packed red blood cell transfusion of 200 ml. Haemoglobin subsequently increased to 8 g/dl and haematocrit to 29 % in seven hours. Six days after the transfusion, she had a first generalized seizure. She underwent a conservative hysterectomy on 14 February. Ketamine (Ketalar®), propofol (Diprivan®), sufentanil (Sufenta®)and rocuronium (Esmeron®) were used for anaesthesia. Four days later, she developed repeated focal and generalized seizures with stupor, loss of consciousness rapidly leading to status epilepticus. A right hemiparesis was observed. She was referred to an intensive care unit and required assisted ventilation. Seizures disappeared within 48 hours after being treated by sodium valproate. On 24 February she had a recurrence of status epilepticus. Phenobarbital was added and she improved rapidly. Repeated measures of blood pressure showed values under 160/95 mm Hg. Blood glucose, electrolytes, urea, ESR and coagulation tests were normal. Antinuclear antibodies, neutrophil antinuclear cytoplasm antibodies, rheumatoid factor, blood cultures, serum titres for Treponema, Chlamydia, Mycoplasma, Coxiella, Rickettsia, Lyme Borrelia, cytomegalovirus, HIV, hepatitis B and C were all negative. Haemoglobin electrophoresis was normal. Analysis of CSF showed 8/mm3 white cells, 22/mm3 red cells; CSF glucose was 4.8 mmol/L and protein was 0.58 g/L. Transthoracic echocardiography was normal. MRI performed just before the first admission in intensive care medicine showed slight cortical and subcortical hyperintensities on Fluid Attenuated Inversion Recovery (FLAIR) sequences with normal to increased apparent diffusion coefficient (up to 126 % with respect to controlateral normal appearing brain region) (ADC) on diffusion-weighted sequences (Fig. 1). One lesion located on the left putamino-caudate nucleus was haemorrhagic on T1-weighted sequences. Multiple segmental narrowing of the circle of Willis and its branches were seen on 3D TOF MR angiography and on conventional cerebral angiography (Fig. 2). Transcranial Doppler ultrasound showed increased peak systolic velocity to 140 cm/s in the left middle cerebral artery. Spontaneously the patient regained consciousness and the focal deficit resolved within 7 days. On MRI performed 10 days later, all lesions had disappeared except for the left putamino-caudate one. Arterial stenosis was no longer visible on 3-months MRA followup. Discussion – Our patient had reversible angiopathy and encephalopathy for which blood transfusion was the only trigger found after an extensive search for other aetiology. None of the drugs used has known sympathomimetic effects and could explain vasospasm [3]. Neurological complications of blood transfusion seem rare. A few cases of acute hypertensive leukoencephalopathy have been observed in anaemic patients with chronic renal failure who received blood transfusion or erythropoietin [2, 4]. But, to date, only one case of angiopathy, attributed to a LETTER TO THE EDITORS

MR Imaging-Based Decision in Thrombolytic Therapy for Stroke on Awakening : Report of 2 Cases

SUMMARY: Patients with stroke on awakening are denied the potential benefit of thrombolysis on the grounds that the onset time is unknown. Relying on clinical and MR imaging to indicate the most appropriate treatment could be more rational. We report 2 cases of stroke with unknown onset time. In both cases, anamnesis and MR imaging indicated that we might still be within 6 hours from stroke onset, with salvageable tissue. Arterial recanalization was successfully performed in both cases.

Susceptibility vessel sign on T2* magnetic resonance imaging and recanalization results of mechanical thrombectomy with stent retrievers: A multicentre cohort study

The susceptibility vessel sign (SVS) on T2*‐weighted magnetic resonance imaging has been reported in several studies as a negative predictor of early recanalization after intravenous thrombolysis. The meaning of SVS regarding the results of mechanical thrombectomy with stent retrievers was investigated.

Intracranial Aneurysms: Recurrences More than 10 Years after Endovascular Treatment—A Prospective Cohort Study, Systematic Review, and Meta-Analysis

PURPOSE To assess the efficacy of endovascular treatment (EVT) of intracranial aneurysms for recurrence, bleeding, and de novo aneurysm formation at long-term follow-up (> 10 years after treatment) with magnetic resonance (MR) angiography and to identify risk factors for recurrence through a prospective study and a systematic review of the literature. MATERIALS AND METHODS Clinical examinations and 3-T MR angiography were performed prospectively 10 years after EVT of intracranial aneurysms in a single institution. Ethics committee approval and informed consent were obtained. PubMed, EMBASE, and Cochrane databases were searched to identify studies in which authors reported bleeding and/or aneurysm recurrence rates in patients who received follow-up more than 10 years after EVT. Univariate and multivariate subgroup analyses were performed to identify risk factors (midterm MR angiographic results, aneurysm characteristics, retreatment within 5 years). RESULTS In the prospective study, sac recanalization occurred between midterm and long-term MR angiography in 16 of 129 (12.4%) aneurysms. Grade 2 classification on the Raymond scale at midterm MR angiography (relative risk [RR], 4.16; 99% confidence interval [CI]: 2.12, 8.14) and retreatment within 5 years (RR, 4.67; 99% CI: 1.55, 14.03) were risk factors for late recurrence. In the systematic review (15 cohorts, 2773 patients, 2902 aneurysms), bleeding, aneurysm recurrence, and de novo lesion formation rates were, respectively, 0.7% (99% CI: 0.2%, 2.7%; I(2), 0%; one of 694 patients), 11.4% (99% CI: 7.0%, 18.0%; I(2), 21.6%), and 4.1% (99% CI: 1.7, 9.4%; I(2), 54.1%). Raymond grade 2 initial result (RR, 7.08; 99% CI: 1.24, 40.37; I(2), 82.6%) and aneurysm size greater than 10 mm (RR, 4.37; 99% CI: 1.83, 10.44; I(2), 0%) were risk factors for late recurrence. CONCLUSION EVT of intracranial aneurysm is effective for prevention of long-term bleeding, but recurrences occur in a clinically relevant percentage of patients, a finding that may justify follow-up of selected patients for 10 years or more, such as patients with aneurysms larger than 10 mm or classified as Raymond grade 2 at midterm MR angiography.

Non-invasive diagnosis of intracranial aneurysms

Patients need to be examined for intracranial aneurysms if they have had a subarachnoid hemorrhage. The preferred technique in this situation is CT angiography. Screening can be done for familial forms or for elastic tissue disorders, for which the first line investigation is magnetic resonance angiography. These non-invasive methods have now taken over from conventional angiography that was reserved for the pretreatment phase. A good technical knowledge of these imaging methods, their artifacts and misleading images enables reliable detection of intracranial aneurysms and for an accurate report to be returned to clinicians.

Imagerie vasculaire non invasive et malformations artérioveineuses cérébrales

Resume L’evaluation en imagerie des malformations arterioveineuses (MAV) cerebrales necessite la visualisation selective des differents compartiments de la lesion afin de decider de la strategie therapeutique. L’angiographie cerebrale reste la methode de reference pour l’analyse anatomique des vaisseaux intracrâniens mais les techniques d’imagerie non invasives semblent constituer d’excellentes alternatives. L’angioscanner spirale est rarement realise en raison de la necessite d’injecter de l’iode et de son caractere irradiant. L’angiographie par resonance magnetique (ARM) apporte des informations interessantes et peut etre realisee selon plusieurs techniques : temps de vol sans ou avec injection de gadolinium, contraste de phase, acquisition tridimensionnelle en echo de gradient T1 apres injection de gadolinium et, plus recemment, ARM dynamique avec injection. L’objectif de cette revue est de resumer le principe des differentes techniques d’imagerie vasculaire non invasives et d’etudier l’apport de celles-ci a l’etude des MAV.