Edwin D. Cacayorin

Is Intra-Arterial Thrombolysis Safe After Full-Dose Intravenous Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke?

Background and Purpose— The optimal approach for acute ischemic stroke patients who do not respond to intravenous recombinant tissue plasminogen activator (IV rt-PA) is uncertain. This study evaluated the safety and response to intra-arterial thrombolytics (IATs) in patients unresponsive to full-dose IV rt-PA. Methods— A case series from a prospectively collected database on consecutive acute ischemic stroke patients treated with IATs after 0.9 mg/kg IV rt-PA during a 7-year interval was collected. Primary outcome measures included symptomatic intracranial hemorrhage and mortality. As indicators of response, secondary outcome measures were recanalization and discharge disposition. Results— Sixty-nine patients (mean±SD age, 60±13 years; range, 26 to 85 years; 55% male) with a median pretreatment National Institutes of Health Stroke Scale score of 18 (range, 6 to 39) were included. IV rt-PA was started at 124±32 minutes (median, 120 minutes) and IAT, at 288±57 minutes (median, 285 minutes). IATs consisted of reteplase (n=56), alteplase (n=7), and urokinase (n=6), with an average total dosage of 2.8 U, 8.6 mg, and 700 000 U, respectively. Symptomatic intracranial hemorrhage occurred in 4 of 69 (5.8%) patients; 3 cases were fatal. Recanalization was achieved in 50 (72.5%) and a favorable outcome (home or inpatient rehabilitation) in 38 (55%). Conclusions— IAT therapy after full-dose IV rt-PA in patients with persisting occlusion and/or lack of clinical improvement appears safe compared with IV rt-PA alone or low-dose IV rt-PA followed by IAT. A high rate of recanalization and favorable outcome can be achieved.

Cerebral mycotic aneurysms treated with a neuroform stent: technical case report.

OBJECTIVE AND IMPORTANCE: We describe the first documented endovascular treatment of proximal intracranial mycotic aneurysms by a self-expanding, flexible, dedicated, intracranial Neuroform stent. Treatment with this stent rapidly obliterated the aneurysms, eliminated the need for additional coiling, and maintained the patency of the parent arteries. CLINICAL PRESENTATION: A 47-year-old male patient with infective endocarditis presented with ischemic stroke and minimal subarachnoid hemorrhage. Cerebral angiography demonstrated a fusiform aneurysm of the supraclinoid segment of the left internal carotid artery and horizontal segment of the left middle cerebral artery, with superimposing side-wall focal aneurysms. Despite antibiotic therapy, the focal aneurysms progressively enlarged, as demonstrated on a subsequent cerebral angiogram at Day 11. INTERVENTION: A 4-mm × 2-cm Neuroform stent was deployed along the fusiform aneurysm of the left supraclinoid internal carotid artery and the horizontal middle cerebral artery M-1 segment encompassing the focal side-wall aneurysms with preserved patency of the parent arterial segments. CONCLUSION: Endovascular stent placement can be an effective treatment for proximal intracranial mycotic aneurysms that fail to respond to medical therapy.Accepted, September 7, 2005. OBJECTIVE AND IMPORTANCE: We describe the first documented endovascular treatment of proximal intracranial mycotic aneurysms by a self-expanding, flexible, dedicated, intracranial Neuroform stent. Treatment with this stent rapidly obliterated the aneurysms, eliminated the need for additional coiling, and maintained the patency of the parent arteries. CLINICAL PRESENTATION: A 47-year-old male patient with infective endocarditis presented with ischemic stroke and minimal subarachnoid hemorrhage. Cerebral angiography demonstrated a fusiform aneurysm of the supraclinoid segment of the left internal carotid artery and horizontal segment of the left middle cerebral artery, with superimposing side-wall focal aneurysms. Despite antibiotic therapy, the focal aneurysms progressively enlarged, as demonstrated on a subsequent cerebral angiogram at Day 11. INTERVENTION: A 4-mm 2-cm Neuroform stent was deployed along the fusiform aneurysm of the left supraclinoid internal carotid artery and the horizontal middle cerebral artery M-1 segment encompassing the focal side-wall aneurysms with preserved patency of the parent arterial segments. CONCLUSION: Endovascular stent placement can be an effective treatment for proximal intracranial mycotic aneurysms that fail to respond to medical therapy.

Computed tomography of the cervical carotid artery: significance of the lucent defect.

To investigate the clinical significance of lucent defects in computed tomography (CT) scans of the cervical carotid artery plaque, we studied 95 patients with recent symptoms of hemispheric ischemia. Using multiple linear regression analysis, we estimated the strength of the association of symptoms with laterality of carotid artery lucent lesions, stenoses, and ulcerations observed in CT scans. Hemispheric symptoms correlated strongly with ipsilateral carotid lucent lesions (partial p less than 0.025) and with ipsilateral severe (greater than 75%) carotid stenosis (partial p less than 0.025). Carotid artery ulcerations had a weaker association (partial p less than 0.1), and stenoses of mild and moderate degrees showed none. The overall performance of all three plaque complications was highly significant (p less than 0.005). The lucent defect indicates a morphologic change in the carotid plaque that plays an important role in the development of symptoms of hemispheric ischemia. This is in agreement with the notion that the lucent defect is the image of intraplaque hemorrhage and/or necrosis, which are complications central to the development of symptomatic carotid disease.

Computed tomographic evaluation of cervical carotid plaque complications.

Twenty five patients with manifestations of cerebrovascular ischemic disease were evaluated with high resolution computed tomography of the neck, following intravenous infusion of a contrast agent. Computed tomography images of extracranial carotid arteries revealed atherosclerotic plaque formations and their complications: stenosis, occlusion, ulceration, calcification and mural lucent defects. Histologic analysis of 15 endarterectomy specimens obtained from symptomatic patients who had computed tomography images of discrete lucent defects in carotid plaques demonstrated subintimal hemorrhage of varying age in 13, focal necrosis in 1 and excessive subintimal thickening in 1. It is concluded that lucent images observed in computed tomography of extracranial carotid arteries represent vascular wall lesions within carotid plaques suggestive of subintimal hemorrhage, focal necrosis and/or excessive subintimal thickening. Computed tomography of the extracranial carotid arteries is a relatively non-invasive method that permits the diagnosis of plaque hemorrhages in symptomatic and asymptomatic carotid arteries.

Computed tomographic evaluation of extracranial carotid artery disease

Axial computed tomographic (CT) scans after intravenous contrast infusion were used to image the cervical carotid arteries of patients with cerebral ischemic symptoms. Standard transfemoral cervical carotid and cerebral angiography was the principal diagnostic modality used in all patients studied. The angiographic results were compared to the CT images and to the gross and microscopic endarterectomy pathological specimens, when available. Examples of the various types of abnormalities that can be visualized using CT scans are presented. The CT scan was useful for determining the presence of degenerative atheromatous changes including carotid artery calcification, subintimal hemorrhage, carotid occlusion, carotid segmental occlusion, and carotid pseudoocclusion, as well as carotid artery dissection. The scans were particularly useful for identification of atheromatous carotid artery disease when the carotid angiogram appeared nearly normal and for identifying the cause of postoperative carotid stenosis. CT scanning allows visualization of the carotid artery wall and lumen rather than just the lumen and, consequently, can sometimes add helpful information about the pathological processes affecting this artery.

MR of post traumatic spinal cord lesions Unexpected improvement of hemorrhagic lesions

Fifteen patients who sustained spinal cord trauma were evaluated by MR within 72 hours of injury. Nine patients had hemorrhagic and six had nonhemorrhagic traumatic spinal cord lesions. Three patients with hemorrhagic and all six patients with nonhemorrhagic lesions showed some degree of neurological improvement on follow-up examinations. In two of the three patients with hemorrhagic lesions who improved, the hemorrhage was extensive. This supports the observation that hemorrhagic lesions are not always associated with a poor clinical outcome.

Uterine hemorrhage due to arteriovenous malformation in a teenage girl: Diagnosis and management

Abstract An 18-year-old girl was evaluated because of severe uterine bleeding. The onset of each episode was abrupt. The bleeding failed to respond to steroidal oral contraceptives. Uterine curettage revealed a benign endometrium. Endocrine and coagulation studies were normal. Arteriovenous malformation was diagnosed by hysteroscopy and angiography studies. Retrograde femoral catheterization and embolization of the malformation did not totally alleviate the bleeding. The patient elected a hysterectomy rather than another embolization procedure.

Dynamic computed tomography: intracranial applications.

&NA; Rapid sequential computed tomography of the brain after the bolus injection of contrast material provides invaluable information as to the characteristic blood flow of intracranial lesions in a noninvasive manner. Plotted dynamic curves permit accurate diagnosis of particularly difficult cases of infarcts and neoplasms. Dynamic computed tomographic (CT) scanning has become a part of the CT work‐up for infarcts, which has allowed their earlier demonstration, detected as areas of hypoperfusion not clearly evident on an initial conventional CT study. Quantitative assessment of vasogenic edema and hypoperfusion are helpful in establishing the diagnosis of infarction and neoplasia. Orbital and parasellar neoplasms can be distinguished accurately from vascular lesions. Dynamic CT studies complemented conventional film screen arteriography in the evaluation of three cases of intracavernous internal carotid artery aneurysm, defining thrombus formation and wall thickness and thus influencing the therapeutic approach. In addition, this modality is useful in differentiating jugular fossa neoplasm from vascular malformation. This review elaborates on the technique involved in dynamic CT scanning and the subsequent results. (Neurosurgery 16:573‐578, 1985)

Spinal vascular tumors: dilemmas in diagnosis and management.

Three case reports of spinal vascular tumors illustrate the need for well-organized and thorough neuroradiological and neurosurgical planning to achieve an initial cure without delay and to avoid inadequate operative procedures.

Case of “Slow” Stroke from Carotid Artery Occlusion Treated by Delayed but Cautious Endovascular Intervention

In a challenging case of carotid occlusion with slowly evolving stroke, we used brain imaging to facilitate endovascular revascularization resulting in the relief of the patients symptoms. Patients with carotid occlusion and continued neurological worsening or fluctuations present enormous treatment challenges. These patients may present “slow” strokes with subacute infarcts that present significant challenges and risks during attempts at revascularization of the occluded artery. We present such a case in which we used multimodal imaging techniques, including MR-perfusion, to facilitate endovascular revascularization. Our approach of delayed but cautious intra-arterial thrombolytic therapy, guided by brain imaging, and followed by stent placement across the residual stenosis, enabled revascularization of the occluded artery without overt in-hospital complications.