Gregory Telman

Size of PFO and amount of microembolic signals in patients with ischaemic stroke or TIA.

Background and purpose:  The inter‐relation between the size of patent foramen ovale (PFO) by transesophageal echocardiography (TEE) and the amount of microembolic signals (MES) on transcranial doppler (TCD) is still not determined.

TCD evaluation before and after stenting in patients with severe primary carotid artery stenosis versus restenosis.

Purpose: To evaluate cerebral hemodynamics before and after carotid angioplasty and stenting (CAS) using transcranial Doppler (TCD). Methods: Sixty-eight patients (52 men; mean age 69±9.5 years) with severe carotid stenosis (83.4%±10.2%) were examined by TCD before and 2 months after CAS. Thirty-two (47%) patients had primary carotid stenosis and 36 (53%) had restenosis after carotid endarterectomy (CEA). A broad TCD protocol was employed to estimate cerebral hemodynamics, including assessment of velocities (V) and asymmetry of cerebral blood flow velocity (CBFV) in the middle cerebral artery, (MCA) anterior cerebral artery (ACA), and basilar artery (BA); the pulsatility indexes; and flow acceleration. Results: Ipsilateral MCA mean velocities before stenting were 46.3±12.6 cm/s in the primary stenosis group and 47.1±12.3 cm/s in restenosis group; after stenting, the velocities were 53.8±12.1 and 52.7±9.6 cm/s, respectively (p<0.005 for both groups). MCA asymmetry by Vmean before CAS was higher in the primary stenosis group (27.6%±2.4% versus 19.8%±2.3%, p<0.05). After stenting, this index was significantly lower in both groups: 16.4%±2.4% and 12.3%±2.3%, respectively (p<0.0001 for each group). All other TCD parameters improved significantly in both groups after CAS as well (p<0.05), showing the strong hemodynamic effect of this procedure. Conclusion: CAS effectively improves cerebral hemodynamics in patients with severe primary and restenosis of the internal carotid artery.

Embolic potential and ultrasonic characteristics of plaques in patients with severe unilateral carotid restenosis more than one year after surgery

PURPOSE The purpose of the study is to investigate the embolic potential as well as ultrasonic characteristics of plaques in patients presenting with severe unilateral restenosis at least 1 year after carotid endarterectomy (CEA), compared with patients with severe unilateral primary carotid stenosis. METHODS We used transcranial Doppler (TCD) to monitor microembolic signals (MES) and Doppler ultrasound to classify types and density of plaques in 27 patients with restenosis after CEA and in 97 patients with primary stenosis. RESULTS Mean period between surgery and examination in patients with restenosis was 36.7+/-30.5 months (range 12-96). The groups were similar in distribution of main vascular risk factors. There were 36 (37.1%) patients with MES on TCD in primary stenosis versus 11 (40.7%) in restenosis group (NS). An average number of MES in primary stenosis group was 2.9+/-3.5/30 min and in restenosis group -3.4+/-2.9 (NS). There was no difference in distribution of plaques by echogenicity as well as by density. After adjustment by age, sex, and main risk factors, no influence was found for the effect of stenosis or restenosis on either the presence or the amount of emboli, as well as on the ultrasonic character of plaques. CONCLUSION Carotid plaques in patients with severe unilateral carotid restenosis at least 1 year after surgery and in patients with primary lesions are similar in their embolic potential and ultrasonic characteristics.

Young patient with acute ischemic stroke due to papillary carcinoma of the thyroid

Hypercoagulability is a condition predisposing to arterial or venous thrombosis and is associated frequently with malignancy. We present a rare acute ischemic stroke in a young patient that was the presenting feature for a newly diagnosed papillary carcinoma of the thyroid. Extensive vascular and hematological work-up was normal except for a large patent foramen ovale (PFO). This finding, along with the association of most vascular events with hypercoagulability being of venous origin, makes the mechanism of paradoxical embolism through the large PFO the probable cause of stroke in our patient.

Ethnic Differences in Ischemic Stroke of Working Age in Northern Israel

BACKGROUND There are currently no comparative data about ethnic differences in ischemic stroke in Arab and Jewish populations. METHODS Data on 727 consecutive Arab and Jewish patients of working age (<or=65 years) with stroke were compared for risk profile, etiology, subtyping, and immediate functional outcome. RESULTS The mean age was 59.4 +/- 8.2 years for the Jewish and 53.7 +/- 8.6 years for the Arab patients (P = .03). Higher prevalence of diabetes was found in the Arab patients after adjustment by age, sex, and main vascular risk factors (P < .0001). After adjustment, a higher prevalence of normal transesophageal echocardiography results in the Arab population was found. Small vessel disease-related strokes were significantly more frequent in the Arab patients, whereas large vessel disease-related strokes and strokes resulting from multiple causes were significantly more frequent in the Jewish patients. No correlations were found between the high prevalence of diabetes (or any other examined factor) and the predominance of small vessel disease-related strokes in the Arab patients and large vessel disease-related strokes in the Jewish patients. There was no difference found in treatment or outcome between the Arab and the Jewish patients. CONCLUSIONS There are substantial differences in the risk profiles and subtyping of strokes between Arab and Jewish patients of working age.

Comparison of risk factors and work-up in young and middle-aged patients with TIA and ischaemic stroke

Background:  The transient ischaemic attack (TIA) is accepted as a subtype of resolved ischaemic stroke. In that case, the risk factor profiles as well as the work‐up results of TIA and stroke patients should be similar in both groups. Given that such data are limited, we compared the risk factor profiles and work‐up results in young and middle‐aged patients with TIA and ischaemic stroke.

Pretreatment with aspirin and etiology of first-ever ischemic stroke in young and middle-aged patients

BACKGROUND There are very limited data on the influence of pretreatment with aspirin (ASA) on the etiology of subsequent first-ever ischemic stroke. MATERIALS AND METHODS Five hundred ninety eight patients 65 years old or younger with first-ever ischemic stroke either pretreated (N=167) or not treated with aspirin (N=431) participated. RESULTS The mean age was 56.5+/-6.0 years for patients treated with ASA and 53.1+/-8.9 years for those not treated (p<.0001). All major vascular risk factors except smoking were significantly more frequent among the patients pretreated with aspirin. Logistic regression analysis adjustments for age, gender, and major vascular risk factors revealed an overall significant effect (p<0.0001) of aspirin treatment on the distribution of stroke etiologies. Subsequent separate analyses on stroke etiology subtypes indicated that the incidence of small vessel disease (SVD) related strokes was significantly reduced by pretreatment with aspirin (OR=0.63). Logistic regression analysis showed no influence of aspirin on the likelihood of a favorable or unfavorable outcome, as expressed by Rankin scale. CONCLUSION Pretreatment with ASA has significant influence on the distribution of etiologies of first-ever ischemic stroke in young and middle-aged patients, when the immediate functional stroke outcome is not influenced by ASA pretreatment.

Horner Syndrome After Lymph Node Fine Needle Aspiration

Miosis, ptosis and anhidrosis comprise the Horner (oculosympathetic) syndrome. The most common cause for Horner syndrome is neoplasia, representing 35–60% of cases. Iatrogenic injuries are responsible for 10–18.5% of cases, and traumas such as birth injuries are less common sources of Horner syndrome.1 In the literature, iatrogenic Horner syndrome is frequently described as resulting from different cervical interventions, including surgery and chiropractic manipulations, subclavian and jugular vein catheterization, insertion of a thorax tube and lumbar anesthesia.2-5 We present here a report of Horner syndrome after lymph node fine needle aspiration (LNFNA), which to the best of our knowledge has not yet been described in the literature. A 22-year-old woman was admitted to the neurology department because of right-sided ptosis and miosis, which appeared immediately after LNFNA of the right submandibular lymph node. The patient is a generally healthy person and an officer in the Israeli Defense Forces. She had experienced an upper respiratory tract infection 4 months earlier, characterized by cough and fever. The cough disappeared and was later followed by lymphadenopathy with a sore throat. The lymphadenopathy did not resolve after 4 months, and the patient was referred for LNFNA. The procedure was done under local anesthesia. Immediately after the procedure, the patient felt warmth and numbness on the right side of the face, and a few minutes later the right eyelid dropped. The patient was referred to the emergency department, where her vital signs were determined to be normal. An enlarged submandibular lymph node was felt on the right side of the neck. Neurologic examination revealed a prominent drooping of the right eyelid and extreme miosis without visible reaction to light of the right pupil. There was no impairment of sweating. The results of the rest of the neurologic examination were normal. Computed tomography angiography was immediately performed and did not reveal dissection of the internal carotid artery. On the second day of her hospitalization, there was a slight improvement of the miosis and the pupil began to react to light. Ultrasonography of the neck was performed, but did not reveal hematoma compressing the superior cervical ganglion or the sympathetic fibers. The results of the LNFNA revealed lymphocytes in different stages of maturation, consistent with a reactive node. The patient was discharged with a slight improvement in the Horner syndrome. A follow-up at 1 month showed a further improvement, and the next examination conducted 3 months later revealed almost complete resolution of the Horner syndrome. LNFNA cytology is valuable in the workup of clinical adenopathy. The usefulness of the procedure in the staging and diagnosis of various malignant and lymphoproliferative tumors, as well as in distinguishing reactive hyperplastic lymph nodes from lymphoma, is well established.6 The anatomic substrate for sympathetic innervation to the eye follows a 3-neuron pathway. The first-order neurons originate from the posterolateral hypothalamus, and from there the fibers descend to synapses in the ciliospinal center of Budge-Walley, located in the intermediolateral columns of the spinal cord at the level of C8-T2. Most of the second-order neurons ascend the sympathetic chain and synapse in the superior cervical ganglion. The third-order neurons exit the superior cervical ganglion and form a plexus that surrounds the internal carotid artery. The fibers responsible for sweat branch off at the superior cervical ganglion from the remainder of the oculosympathetic pathway and follow the external carotid artery. In our case, the mechanism of the injury is evident, namely, the needle prick that injured the superior cervical ganglion or the oculosympathetic fibers that exit from it, without injury of the sudomotor fibers. The damage was relatively limited because of the pinpoint character of the needle lesion, thus creating a favorable outcome. In conclusion, iatrogenic Horner syndrome is not a rare condition, but to the best of our knowledge, the

Pre-admission CHA2DS2-VASc score and outcome of patients with acute cerebrovascular events

BACKGROUND The CHA2DS2-VASc score has been recommended for the assessment of thromboembolic risk in patients with atrial fibrillation. Data regarding the association between the pre-admission CHA2DS2-VASc score and the outcome of patients with stroke and TIA are scarce. We aimed to assess the predictive value of pre-admission CHA2DS2-VASc score for early risk stratification of patients with acute cerebrovascular event. METHODS The study group consisted of 8309 patients (53% males, mean age of 70±13.3years) with acute stroke and TIA included in the prospective National Acute Stroke Israeli (NASIS) registry. The two-primary end-points were in-hospital mortality and severe disability at discharge. We divided the study population into 4 groups according to their pre-admission CHA2DS2-VASc score (0-1, 2-3, 4-5, >5). RESULTS Following a multivariate analysis odds ratios (OR) for all-cause mortality increased for CHA2DS2-VASc score >1 (OR=2.1 95% CI=1.2-3.6, OR=1.8 95% CI=1.1-3.2, OR=1.8 95% CI 1.1-3.3, for patients with CHA2DS2-VASc score of 2-3, 4-5 and >5, respectively, p<0.001). OR for severe disability (mRS 4-5) at discharge increased significantly in direct association with the CHA2DS2-VASc score (OR=1.55 95% CI=1.14-2.12, OR=2.42 95% CI=1.8-3.3, OR=3 95% CI 2.19-4.27, for patients with CHA2DS2-VASc score of 2-3, 4-5 and >5, respectively as compared with 0-1, p<0.001). Each 1-point increase in the CHA2DS2-VASc score was associated with a 21% increase in the risk for severe disability. CONCLUSIONS High-risk pre-admission CHA2DS2-VASc score among patients with acute cerebrovascular events is associated with higher in-hospital mortality and severe disability at discharge.

Middle Cerebral Artery Stenosis in Patients with Acute Ischemic Stroke and TIA in Israel

BACKGROUND AND PURPOSE: Middle cerebral artery stenosis is not frequent but a well-established cause of first and recurrent ischemic stroke. Our aim was to investigate middle cerebral artery stenosis in the biethnic (Jewish and Arab) population of patients with acute ischemic stroke and transient ischemic attack in northern Israel. MATERIALS AND METHODS: The study population included 1344 patients from the stroke data registry who had been hospitalized in the neurologic department because of acute ischemic stroke (1041) or TIA (303) and had undergone transcranial Doppler sonographic examination during the hospitalization. RESULTS: Of the 1344 patients, 120 (8.9%) were found to have MCA stenosis. The patients with intracranial stenosis were older and had more vascular risk factors (hypertension, diabetes, and hyperlipidemia) and vascular diseases (ischemic heart and peripheral vascular disease) than those without intracranial stenosis. Logistic regression analysis revealed that diabetes (P = .002) and peripheral vascular disease (P = .01), but not ethnicity, were independent and significant predictors for the presence of MCA stenosis. CONCLUSIONS: An independent and significant correlation was found between MCA stenosis and vascular risk factors (diabetes mellitus) and vascular diseases, thus emphasizing the similarity of intracranial MCA stenosis and other vascular diseases originating from atherosclerosis. There was no influence of ethnicity on intracranial stenosis in our population.