David Školoudík

Assessment of relationship between acute ischemic stroke and heart disease--protocol of a prospective observational trial.

BACKGROUND Stroke and acute myocardial infarction are the leading causes of death and disability in industrialized countries. Multiple interactions exist between the various forms of cardiovascular and cerebrovascular diseases, and risk factors for development of stroke and major cardiovascular events are similar. There is currently no clear link between acute coronary syndrome and stroke, although it has been repeatedly described. In addition, there are currently no clear recommendations for how to proceed in the case of signs of myocardial damage in patients with acute stroke and how to manage the next follow-up. METHODS-DESIGN: In this prospective observational trial, 500 consecutive ischemic stroke patients admitted at the Comprehensive Stroke Center will be enrolled within 12 h from stroke onset. The set of examinations will consist of: 1) Acute brain computed tomography or magnetic resonance imaging 2) Laboratory tests: A) within 12 h from stroke onset: NT pro B-type of natriuretic peptide, pro-atrial natriuretic peptide, creatinekinase MB, troponin T (cTnT), interleukin 6, procalcitonin, high sensitive C-reactive protein and D-dimers. B) control level of cTnT after 4 h from admission C) non-acute laboratory samples within 60 h from stroke onset: glycated haemoglobine, serum lipids; 3) Electrocardiogram (ECG) on admission and 4 h from stroke onset; 4) Transesophageal or transthoracal echocardiography and 24-h ECG-Holter within 15 days from stroke onset; 5) Neurosonological examination within 60 h from stroke onset; 6) Thirty patients with a positive finding of acute myocardial ischemia (ECG, cTnT) will be examined by coronary angiography (CAG); 7) Epidemiological data will be acquired. STATISTICS The epidemiological characteristics of the whole sample of patients; correlation between differences between group of cardioembolic ischemic stroke patients and group of patients with ischemic stroke of another etiology; correlation of infarction volume on DWI-MRI with the level of cTnT; correlation of the ECG findings with the level of cTnT and clinical signs; correlation of the CAG findings with level of cTnT and ECG findings will be statistically evaluated at the 5% level of statistical significance. CONCLUSION The main goal of the project is to improve identification of patients with acute coronary syndrome and with concurrent acute ischemic stroke as these patients require specific treatment and secondary prevention of ischemic events. TRIAL REGISTRATION Clinicaltrials.gov NCT01541163.

Paroxysmal atrial fibrillation in young cryptogenic ischemic stroke: A 3-week ECG Holter monitoring study.

BACKGROUND Atrial fibrillation is known very frequent cause of ischemic stroke. Undetected paroxysmal atrial fibrillation (PAF) is thus often considered a possible cause of cryptogenic ischemic stroke (CIS). The aim of this prospective study was to detect PAF using ECG Holter monitoring and determinate whether prolongation of the Holter monitoring to 3 weeks would increase the detection rates of PAF in young CIS patients ≤ 50 years. METHODS The study set consisted of IS patients ≤ 50 years enrolled in the HISTORY (Heart and Ischemic STrOke Relationship studY) study (NCT01541163). CIS was defined according to the TOAST criteria including the absence of ultrasonographic or angiographic signs of atherosclerosis, vasculitis or dissection. Admission ECG, serum levels of high sensitive Troponin T (hs TnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP), markers of thrombophilia, transoesophageal echocardiography (TEE) and 24-hour ECG-Holter monitoring were performed in all patients. In case of negative 24-h ECG Holter, an additional 3-weeks monitoring was done. RESULTS Of the 105 enrolled patients ≤ 50 years, 95 (90%) were identified as cryptogenic (49 males, mean age 39.1 ± 8.2 years). All CIS patients had normal admission ECG. In total, PAF was detected in 9 (9.5%, 95% CI: 3.5% - 17.8%) patients; in two during 24-h ECG Holter and in seven during 3-weeks Holter monitoring. Patients with PAF had more frequently elevated admission hs TnT and NT-proBNP levels (P - 0.0001). CONCLUSIONS PAF was detected in 9.5% of young CIS patients and 3-weeks ECG Holter monitoring increased the detection rate.

Management of acute basilar artery occlusion: Should any treatment strategy prevail?

BACKGROUND Acute basilar artery occlusion (BAO) is relatively infrequent form of acute ischemic stroke associated with severe and persisting neurological deficit and high mortality rate (to 86%). Early recanalization is essential for good clinical outcome but the most effective treatment approach remains unestablished. Several treatment strategies are currently available but their safety and efficacy have only been tested in retrospective/prospective case series. Randomized controlled trials (RCTs) are lacking. METHODS AND RESULTS We searched the PubMed database for assessments of recanalization rate and clinical outcome in BAO patients treated with various treatment methods. The results show that antithrombotics are least effective while specific reperfusion therapies including intravenous thrombolysis (IVT) and various types of intra-arterial therapy (IAT) are more so. Less than half of BAO patients reach independent outcome following IVT with a recanalization rate 52-78%. Even though IAT recanalizes BAO more frequently (in up to 100%), the higher recanalization rate is not necessarily associated with better outcome. CONCLUSIONS Good clinical outcome is strongly dependent on recanalization time. Thus, the concept of bridging therapy, combining widely available IVT with IAT, was introduced and is usually considered a rescue strategy in non-responders to IV alteplase. A trend to better outcome in patients treated with bridging therapy in some studies, has to be confirmed by large RCTs.

Brain iron accumulation in Wilson's disease: A longitudinal imaging case study during anticopper treatment using 7.0T MRI and transcranial sonography: Wilson's and Iron Case Study

Level of Evidence: 5

Laboratory-Based Markers as Predictors of Brain Infarction During Carotid Stenting: a Prospective Study

AIM New ischemic lesions in the brain can be detected in approximately 50% of patients undergoing carotid artery stenting (CAS). We wished to discover the laboratory-based predictors of new infarctions in the brain after CAS. METHODS All consecutive patients with internal carotid artery stenosis of ≥70% with indication for CAS were enrolled in a prospective study for 16 months. All patients used dual antiplatelet therapy for ≥7 days before CAS. Neurologic examination and magnetic resonance imaging (MRI) of the brain were undertaken before and at 24 h after CAS. Samples of venous blood were collected at ＜24 h before CAS for the evaluation of hematology, reticulocytes, coagulation markers (PT, APTT, Fbg, Clauss), vWF antigen, PAI-1 activity, PAI-1 polymorphism 4G/5G, and the multiplate (aspirin and clopidogrel) resistance test. Blood samples for the assessment of anti-Xa activity were collected during CAS. Differences in the values of laboratory markers between patients with and without new ischemic lesions of the brain on control MRI were evaluated. RESULTS The cohort comprised 81 patients (53 males; mean age, 67.3±7.2 years). New ischemic infarctions in the brain on control MRI were found in 46 (56.8%) patients. Three of seven patients with resistance to aspirin or clopidogrel had a new ischemic infarction in the brain. No significant differences for particular markers were found between patients with and without an ischemic lesion in the brain. CONCLUSION A high risk of a new ischemic infarction in the brain was detected in patients undergoing CAS, but a laboratory-based predictor of such an infarction could not be identified.

Comparison of brain vessel imaging from transtemporal and transcondylar approaches using contrast-enhanced transcranial color-coded duplex sonography and Virtual Navigator

AIMS The transcondylar approach is a new and used for detection of chronic cerebro-spinal venous insufficiency (CCSVI) and intracranial venous reflux in patients with multiple sclerosis. The aim of this study was to assess the ability of native and contrast enhanced (CE-) transcranial color-coded duplex sonography (TCCS) to detect flow and reflux in deep cerebral veins and intracranial venous sinuses from transcondylar and transtemporal approaches. METHODS Brain magnetic resonance imaging and TCCS from transtemporal and transcondylar approaches using the new technology - Fusion Imaging - in 8 volunteers and 5 patients with multiple sclerosis. RESULTS Using TCCS and CE-TCCS, the arteries of the circle of Willis could be detected from the transtemporal approach in 13/13 subjects in both examinations, while detection of the venous system was possible in 7/13 and 9/13 subjects, respectively. However, the arteries of the circle of Willis and venous system were detected through the transcondylar approach in only 5/13 (P=0.041) and 1/13 (P=0.031) subjects using TCCS, and in 12/13 (P=0.921) and 7/13 (P=0.687) subjects using CE-TCCS, respectively. CONCLUSIONS The results reveal that the TCCS transcondylar approach has serious limitations for the standard detection of intracranial venous reflux.

Risk reduction of brain infarction during carotid endarterectomy or stenting using sonolysis - Prospective randomized study pilot data

Sonolysis is a new therapeutic option for the acceleration of arterial recanalization. The aim of this study was to confirm risk reduction of brain infarction during endarterectomy (CEA) and stenting (CAS) of the internal carotid artery (ICA) using sonolysis with continuous transcranial Doppler (TCD) monitoring by diagnostic 2 MHz probe, additional interest was to assess impact of new brain ischemic lesions on cognitive functions. Methods: All consecutive patients 1/ with ICA stenosis >70%, 2/ indicated to CEA or CAS, 3/ with signed informed consent, were enrolled to the prospective study during 17 months. Patients were randomized into 2 groups: Group 1 with sonolysis during intervention and Group 2 without sonolysis. Neurological examination, assessment of cognitive functions and brain magnetic resonance imaging (MRI) were performed before and 24 hours after intervention in all patients. Occurrence of new brain infarctions (including infarctions >0.5 cm3), and the results of Mini-Mental State Examination...

Equipment for 3-D Picturing and Measurement of Atherosclerotic Plaque

Equipment for 3-D Picturing and Measurement of Atherosclerotic Plaque This contribution presents a management system with the achieved results of a complex grant project focused on the development of equipment for the 3-D picturing of a carotid artery. This problem was solved during years 2006 - 2008 by specialists from the Faculty of Mechanical Engineering VŠB-TUO, Faculty of Electrical Engineering and Computer Science VŠB-TUO and Neurological Clinic FN Ostrava during the solving of research project GA 101/06/0491 supported by the Czech Science Foundation. The main goal is mechanical system for the exact measurement of Atherosclerotic Plaque (AC plaque) in a carotid artery, including the control system and synchronizations with the heart activity. The obtained pictures enable the necessary analysis and acquisition of data for Atherosclerotic Plaque with appropriate accuracy and recurring measurements. These results open the way for medical use.

Mitochondrial membrane protein-associated neurodegeneration: a case report and literature review

ABSTRACT Mitochondrial membrane protein-associated neurodegeneration (MPAN) is an autosomal recessive disorder caused by mutation in the C19orf12 gene. We report a compound heterozygous c.[32C>T];[205G>A;424A>G] (p.[Thr11Met];[Gly69Arg;Lys142Glu]) Czech patient who manifested with right foot dystonia, impaired handwriting, attention deficit, and signs of iron accumulation on brain MRI. Gradually, he developed dysarthria, spastic-dystonic gait, pedes cavi, and atrophy of leg muscles. Additionally, we report demographic parameters, clinical signs, and allelic frequencies of C19orf12 mutations of all published MPAN cases. We compared the most frequent mutations, p.Thr11Met and p.Gly69ArgfsX10; the latter was associated with younger age at onset and more frequent optic atrophy in homozygotes.

The safety and efficacy of bridging full-dose IV-IA thrombolysis in acute ischemic stroke patients with MCA occlusion: A comparison with IV thrombolysis alone

AIMS Early recanalization of the occluded cerebral artery is substantial for clinical improvement in acute ischemic stroke (IS) patients. The rate of achieved recanalizations using IVT is low. The aim of this study was to compare the safety and efficacy of bridging full-dose intravenous-intraarterial (IV-IA) thrombolysis to IVT alone in acute IS patients with occluded MCA. METHODS Seventy-nine consecutive IS patients with MCA occlusion were treated either with IVT alone (historic controls, Group 1) or with full-dose IV-IA thrombolysis (Group 2). Stroke severity was evaluated using NIHSS, achieved recanalizations using transcranial Doppler (Group 1) or angiography (Group 2). Occurrence of ICH including SICH was evaluated after 24 hours. 90-day clinical outcome was evaluated using modified Rankin Scale (mRS). RESULTS Group 1 consisted of 50 patients (24 males, mean age 70.8±10.2 years) and Group 2 of 29 patients (14 males, mean age 67.8±10.0 years). No difference was found in the initial NIHSS (median 16 vs. 17) and other baseline parameters including time from stroke onset to IVT. Patients treated with bridging therapy had a higher number of achieved MCA recanalization (75.9 vs. 32.0%, P=0.0002), similar number of SICH (6.0 vs. 6.9%, P=1.000) and 34.5% of them achieved mRS 0-2 versus 28.0% of patients treated with IVT (P=0.546). Patients with shorter TR had significantly better clinical outcome (P=0.019). CONCLUSION Bridging IV-IA thrombolysis seems to be safe and more effective than IVT alone in acute stroke patients with MCA occlusion.