Gustavo Zapata-Wainberg

Futile Interhospital Transfer for Endovascular Treatment in Acute Ischemic Stroke The Madrid Stroke Network Experience

Background and Purpose— The complexity of endovascular revascularization treatment (ERT) in acute ischemic stroke and the small number of patients eligible for treatment justify the development of stroke center networks with interhospital patient transfers. However, this approach might result in futile transfers (ie, the transfer of patients who ultimately do not undergo ERT). Our aim was to analyze the frequency of these futile transfers and the reasons for discarding ERT and to identify the possible associated factors. Methods— We analyzed an observational prospective ERT registry from a stroke collaboration ERT network consisting of 3 hospitals. There were interhospital transfers from the first attending hospital to the on-call ERT center for the patients for whom this therapy was indicated, either primarily or after intravenous thrombolysis (drip and shift). Results— The ERT protocol was activated for 199 patients, 129 of whom underwent ERT (64.8%). A total of 120 (60.3%) patients required a hospital transfer, 50 of whom (41%) ultimately did not undergo ERT. There were no differences in their baseline characteristics, the times from stroke onset, or in the delays in interhospital transfers between the transferred patients who were treated and those who were not treated. The main reasons for rejecting ERT after the interhospital transfer were clinical improvement/arterial recanalization (48%) and neuroimaging criteria (32%). Conclusions— Forty-one percent of the ERT transfers were futile, but none of the baseline patient characteristics predicted this result. Futility could be reduced if repetition of unnecessary diagnostic tests was avoided.

A collaborative system for endovascular treatment of acute ischaemic stroke: the Madrid Stroke Network experience.

The complexity and expense of endovascular treatment (EVT) for acute ischaemic stroke (AIS) can present difficulties in bringing this approach closer to the patients. A collaborative node was implemented involving three stroke centres (SCs) within the Madrid Stroke Network to provide round‐the‐clock access to EVT for AIS.

Bilateral Earlobe Creases

An 84-year-old man with hypertension, diabetes, and hypercholesterolemia presented to the emergency department with a 6-hour history of visual difficulty. Physical examination revealed a right homonymous hemianopia.

Mechanical thrombectomy for basilar artery thrombosis: a comparison of outcomes with anterior circulation occlusions

Background and purpose The benefits of mechanical thrombectomy (MT) in basilar artery occlusions (BAO) have not been explored in recent clinical trials. We compared outcomes and procedural complications of MT in BAO with anterior circulation occlusions. Methods Data from the Madrid Stroke Network multicenter prospective registry were analyzed, including baseline characteristics, procedure times, procedural complications, symptomatic intracranial hemorrhage (SICH), modified Rankin Scale (mRS), and mortality at 3 months. Results Of 479 patients treated with MT, 52 (11%) had BAO. The onset to reperfusion time lapse was longer in patients with BAO (median (IQR) 385 min (320–540) vs 315 min (240–415), p<0.001), as was the duration of the procedures (100 min (40–130) vs 60 min (39–90), p=0.006). Moreover, the recanalization rate was lower (75% vs 84%, p=0.01). A trend toward more procedural complications was observed in patients with BAO (32% vs 21%, p=0.075). The frequency of SICH was 2% vs 5% (p=0.25). At 3 months, patients with BAO had a lower rate of independence (mRS 0–2) (40% vs 58%, p=0.016) and higher mortality (33% vs 12%, p<0.001). The rate of futile recanalization was 50% in BAO versus 35% in anterior circulation occlusions (p=0.05). Age and duration of the procedure were significant predictors of futile recanalization in BAO. Conclusions MT is more laborious and shows more procedural complications in BAO than in anterior circulation strokes. The likelihood of futile recanalization is higher in BAO and is associated with greater age and longer procedure duration. A refinement of endovascular procedures for BAO might help optimize the results.

The Direct Referral to Endovascular Center criteria: a proposal for pre‐hospital evaluation of acute stroke in the Madrid Stroke Network

For patients with acute ischaemic stroke due to large‐vessel occlusion, it has recently been shown that mechanical thrombectomy (MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT‐providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation (RACE) have been developed to predict large‐vessel occlusion at a pre‐hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy.

Epidemiology of Intracranial Hemorrhage Associated with Oral Anticoagulants in Spain: Trends in Anticoagulation Complications Registry – The TAC 2 Study

Objective: Patients receiving treatment with oral anticoagulants (OACs) are at risk of intracranial hemorrhage (ICH). In this study, we describe the epidemiological and clinical characteristics of patients receiving OACs who experience ICH and compare those receiving vitamin K antagonists (ICH-VKAs) with those receiving direct OACs (ICH-DOACs). Methods: We performed a national, multicenter, descriptive, observational, retrospective study of all adult patients receiving OACs who were admitted to the neurology department with ICH over a 1-year period. The study population was divided into 2 groups (ICH-VKAs and ICH-DOACs). Epidemiological, clinical, radiological, and therapy-related variables, as well as functional outcome, were compared at 3 months. A total of 366 cases were included (331 ICH-VKAs, 35 ICH- DOACs). Results: The crude annual incidence of OAC-induced ICH was 3.8 (95% CI, 2.78–3.41) per 100,000 inhabitants/year. The mean (± SD) age was greater for ICH-DOACs (81.5 ± 8.3 vs. 77.7 ± 8.3 years; p = 0.012). The median (IQR) volume of the hemorrhage was lower for ICH-DOACs (11 [30.8] vs. 25 [50.7] mL; p = 0.03). The functional independence rate at 3 months (modified Rankin Scale, mRS < 3) was similar in both groups, although stroke-related mortality was greater in ICH-VKAs (40 vs. 72.7%; p = 0.02). The most frequently indicated poststroke antithrombotic therapy was DOACs (38.7%). Conclusion: We found that the incidence of OAC-induced ICH was greater than in previous studies. Hemorrhage volume and mortality were lower in ICH-DOACs than in ICH-VKAs. After stroke, DOACs were the most frequently indicated antithrombotic treatment.

Mechanical thrombectomy in orally anticoagulated patients with acute ischemic stroke

Background and purpose To investigate the efficacy and safety of mechanical thrombectomy in patients with acute ischemic stroke according to the oral anticoagulation medication taken at the time of stroke onset. Materials and methods A retrospective multicenter study of prospectively collected data based on data from the registry the Madrid Stroke Network was performed. We included consecutive patients with acute ischemic stroke treated with mechanical thrombectomy and compared the frequency of intracranial hemorrhage and the modified Rankin Scale (mRS) score at 3 months according to anticoagulation status. Results The study population comprised 502 patients, of whom 389 (77.5%) were not anticoagulated, 104 (20.7%) were taking vitamin K antagonists, and 9 (1.8%) were taking direct oral anticoagulants. Intravenous thrombolysis had been performed in 59.8% and 15.0% of non-anticoagulated and anticoagulated patients, respectively. Rates of intracranial hemorrhage after treatment were similar between non-anticoagulated and anticoagulated patients, as were rates of recanalization. After 3 months of follow-up, the mRS score was ≤2 in 56.3% and 55.7% of non-anticoagulated and anticoagulated patients, respectively (P=NS). Mortality rates were similar in the two groups (13.1%and12.4%, respectively). Among anticoagulated patients, no differences were found for intracranial bleeding, mRS score, or mortality rates between patients taking vitamin K antagonists and those taking direct oral anticoagulants. Conclusions Mechanical thrombectomy is feasible in anticoagulated patients with acute ischemic stroke. The outcomes and safety profile are similar to those of patients with no prior anticoagulation therapy.

Pharyngeal-cervical-brachial variant of Guillain-Barré syndrome with predominant bulbar palsy and anti-GM3 IgG antibodies

Dear Editor, Guillain-Barré syndrome (GBS) is an umbrella term that includes a heterogeneous group of related disorders characterized by acute monophasic inflammatory polyneuropathy. Loco-regional variants, though increasingly better defined [1], are infrequent and rare for the general physician, what makes difficult their early diagnosis and treatment. We report a case of pharyngeal-cervical-brachial (PCB) variant with predominant bulbar symptoms in which diagnosis was delayed due to the low initial suspicion of a neurological etiology. A 63-year-old woman with dyslipidemia and a mechanical prosthetic aortic valve presented to the emergency department with a 2-day history of acute dyspnea with steady progression. Aweek before, she had started antibiotic treatment for a respiratory infection with cough and yellowish expectoration. There was no epidemiological history suggestive of a possible foodborne disease. The patient was admitted at the Cardiology Department because of suspected congestive heart failure that was later ruled out. Three days later, the patient developed severe dysphagia and an urgent gastroscopy was performed, showing normal result. Dysphonia appeared the next day, but more investigations including esophagogastroduodenoscopy, fibrolaryngoscopy, neckcomputed tomography (CT), and brain magnetic resonance (MRI) failed to find any abnormalities. Two weeks after clinical onset, on initial assessment by a neurologist, dysphonia was described with no extrinsic or intrinsic ocular motility or other cranial nerve involvement. Strength and sensory examination was normal, and tendon reflexes were preserved. Over the next 2 days, she developed neck flexion and proximal symmetric upper limb weakness. A peripheral nerve disorder was suspected. Investigations including laboratory tests (blood urea, electrolytes, liver and muscle enzymes, protein electrophoresis, B12 vitamin, folic acid, anti-nuclear, anti-acetylcholine receptor, and anti-muscle specific kinase), nerve conduction studies and low frequency repetitive nerve stimulation were normal. The cerebrospinal fluid (CSF) had no cells and a protein level of 23.3 mg/dl on day 15. Due to the acute onset and the rate of disease progression, a dysimmune disease was suspected, and the patient received seven sessions of plasma exchange on alternate days. Gradually clinical improvement was achieved, with mild dysphagia and dysphonia but no limb weakness at discharge. At 1-month follow-up, she had fully recovered. Pending results were received, showing anti-GM3 and anti-GD1b IgG antibodies. In our case study, diagnosis of PCB variant was supported by the rate of disease progression with acute monophasic and steadily progressive oropharyngeal, cervical and brachial weakness, antecedent infective symptoms, good response to immunomodulatory treatment, and positivity for antiganglioside antibodies [2]. Electrophysiological studies and CSF analysis were normal, but according to the most recent diagnostic criteria for GBS, evidence of neuropathy and/or CSF albuminocytological dissociation are not required but rather considered to be supportive features [1, 2]. On one hand, our patient initially had isolated bulbar palsy. This could explain why nerve conduction studies, which are usually performed in limb nerves, failed to find any abnormalities. On the other hand, albuminocytological dissociation is present only in 42% of patients with PCB variant, though lumbar puncture might still be necessary to exclude carcinomatous or lymphomatous meningitis [2, 3]. PCB variant of GBS is an infrequent disease (approximately 2–4% of GBS cases [3]) that can be misdiagnosed as other neurological (brainstem infarction, botulism and myasthenia gravis, dyphteria neuropathy, metabolic, infectious, * Sonia Quintas sonia.qg@gmail.com

The neurologist's approach to cerebral infarct and transient ischaemic attack in patients receiving anticoagulant treatment for non-valvular atrial fibrillation: ANITA-FA study

The aim of this study was to describe the clinical and epidemiological characteristics of acute ischaemic stroke (AIS) in patients with atrial fibrillation (AF) previously treated with oral anticoagulants (OACs) according to the type of OAC prescribed. Also, to analyze the outcomes of the patients and the therapeutic approach adopted by the neurologist in the acute phase and for secondary prevention.

Clinical, imaging and electroencephalographic characterization of three cases of HaNDL syndrome:

Introduction The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) may mimic stroke when patients present with acute/subacute focal neurological deficits. It would be helpful to identify investigations that assist the neurologist in differentiating between HaNDL and stroke. Case reports We describe three cases that proved to be HaNDL, but were initially considered to be strokes. Hypoperfusion was noted in the CT perfusion (CTP) studies in all three cases, which extended beyond any single cerebral arterial supply. The CTP findings suggested a stroke mimic, and there was no improvement on thrombolysis. MRI failed to show any abnormalities in diffusion and EEGs showed non-epileptiform changes. Lumbar punctures demonstrated a lymphocytic pleocytosis. Conclusion The diagnosis of HaNDL is based on clinical and CSF criteria, but neuroimaging, including CT perfusion, can be helpful in differentiating the clinical syndrome from stroke.