John Volpi

Mechanical Thrombectomy Outcomes With and Without Intravenous Thrombolysis in Stroke Patients: A Meta-Analysis

Background and Purpose— Whether prior intravenous thrombolysis provides any additional benefits to the patients undergoing mechanical thrombectomy for large vessel, acute ischemic stroke remains unclear. Methods— We conducted a meta-analysis of 13 studies obtained through PubMed and EMBASE database searches to determine whether functional outcome (modified Rankin Scale) at 90 days, successful recanalization rate, and symptomatic intracerebral hemorrhage rate differed between patients who underwent mechanical thrombectomy with (MT+IVT) and without (MT−IVT) pre-treatment with intravenous thrombolysis. Results— MT+IVT patients compared with MT−IVT patients had better functional outcomes (modified Rankin Scale score, 0–2; summary odds ratio [OR], 1.27 [95% confidence interval (CI), 1.05–1.55]; P=0.02; n=1769/1174), lower mortality (OR, 0.71 [95% CI, 0.55–0.91]; P=0.006; n=1774/1202), and higher rate of successful recanalization (OR, 1.46 [95% CI, 1.09–1.96]; P=0.01; n=1652/1216) without having increased odds of symptomatic intracerebral hemorrhage (OR, 1.11 [95% CI, 0.69–1.77]; P=0.67; n=1471/1143). A greater number of MT+IVT patients required ⩽2 passes with a neurothrombectomy device to achieve successful recanalization (OR, 2.06 [95% CI, 1.37–3.10]; P=0.0005; n=316/231). Conclusions— Our results demonstrated that MT+IVT patients had better functional outcomes, lower mortality, higher rate of successful recanalization, requiring lower number of device passes, and equal odds of symptomatic intracerebral hemorrhage compared with MT−IVT patients. The results support the current guidelines of offering intravenous thrombolysis to eligible patients even if they are being considered for mechanical thrombectomy. Because the data are compiled from studies where the 2 groups differed based on eligibility for intravenous thrombolysis, randomized trials are necessary to accurately evaluate the added value of intravenous thrombolysis in patients treated with mechanical thrombectomy.

Cardiac MRI improves identification of etiology of acute ischemic stroke

Background: An accurate subtype classification of acute ischemic stroke is important in clinical practice as it can greatly influence patient care in terms of acute management and devising secondary stroke prevention strategies. Approximately, one third of ischemic strokes are cryptogenic despite a comprehensive workup. Diagnostic workup for detecting cardioaortic sources of cerebral embolism commonly includes transthoracic echocardiography (TTE). However, TTE has a limited diagnostic power to detect some of the cardioaortic abnormalities and additional imaging modalities are often needed to accurately assess such abnormalities. Purpose: We evaluated the feasibility of cardiovascular magnetic resonance (CMR) imaging to detect the cardioaortic sources of ischemic stroke. Methods: A total of 106 patients were included, of which 85 had an ischemic stroke and 21 had a transient ischemic attack (TIA). Routine diagnostic workup (RDW) included brain diffusion-weighted image MRI, telemetry, magnetic resonance angiography/CT angiography of head and neck, carotid duplex ultrasonography, laboratory studies and TTE. Patients additionally underwent CMR. Subtype assignment was performed in accordance with the Stop Stroke Study of the Trial of Org 10172 in Acute Stroke Treatment classification system by a stroke neurologist after reviewing the admission notes and diagnostic test results. A second subtype classification was assigned with an additional criterion defined based on delayed enhancement (DE)-CMR findings. Additionally, the presence of non-coronary artery disease (CAD) scarring was assessed in ischemic stroke patients and compared with the TIA patients as the control group. Results: RDW detected cardioaortic embolism (CAE) stroke in 32 (37.6%) patients and cryptogenic stroke in 23 patients (27.1%). Addition of CMR resulted in a 26.1% reduction in the rate of cryptogenic strokes (6 patients). Furthermore, DE-CMR findings allowed for reclassification of three additional cryptogenic subtypes, resulting in a 39.1% reduction of cryptogenic stroke rate. Non-CAD scarring was detected in 13 (15.3%) stroke patients as opposed to only 1 (4.8%) TIA patient. Conclusions: CMR is a valuable tool for the detection of CAE sources in patients with cryptogenic ischemic stroke and provides clinicians with a unique set of information that may substantially change the long-term management of these patients. DE-CMR also detects non-CAD scarring, which may indicate a predisposition to ischemic stroke. Further studies with larger samples and long-term follow-up are needed to further evaluate the clinical significance of our findings.

Systolic Blood Pressure Within 24 Hours After Thrombectomy for Acute Ischemic Stroke Correlates With Outcome

Background Current guidelines suggest treating blood pressure above 180/105 mm Hg during the first 24 hours in patients with acute ischemic stroke undergoing any form of recanalization therapy. Currently, no studies exist to guide blood pressure management in patients with stroke treated specifically with mechanical thrombectomy. We aimed to determine the association between blood pressure parameters within the first 24 hours after mechanical thrombectomy and patient outcomes. Methods and Results We retrospectively studied a consecutive sample of adult patients who underwent mechanical thrombectomy for acute ischemic stroke of the anterior cerebral circulation at 3 institutions from March 2015 to October 2016. We collected the values of maximum, minimum, and average values of systolic blood pressure, diastolic blood pressure, and mean arterial pressures in the first 24 hours after mechanical thrombectomy. Primary and secondary outcomes were patients’ functional status at 90 days measured on the modified Rankin scale and the incidence and severity of intracranial hemorrhages within 48 hours. Associations were explored using an ordered multivariable logistic regression analyses. A total of 228 patients were included (mean age 65.8±14.3; 104 males, 45.6%). Maximum systolic blood pressure independently correlated with a worse 90‐day modified Rankin scale and hemorrhagic complications within 48 hours (adjusted odds ratio=1.02 [1.01–1.03], P=0.004; 1.02 [1.01–1.04], P=0.002; respectively) in multivariable analyses, after adjusting for several possible confounders. Conclusions Higher peak values of systolic blood pressure independently correlated with worse 90‐day modified Rankin scale and a higher rate of hemorrhagic complications. Further prospective studies are warranted to identify whether systolic blood pressure is a therapeutic target to improve outcomes.

Lunapark trenine binmeye bağlı iki taraflı internal karotid ve vertebral arter diseksiyonu ile beraber retinal arter oklüzyonu: Olgu sunumu ve literatür incelemesi

We present the first case of a woman with no significant medical history who developed dissections of bilateral carotid and bilateral vertebral arteries, as well as a retinal artery occlusion, after a roller coaster ride. A 35-year-old woman developed right-sided neck pain followed by a frontal headache immediately after a roller coaster ride. Five days after the incident, she developed complete loss of vision in her right eye for two hours. Subsequently, the vision improved but remained significantly decreased. On presentation, her visual acuity was 20/200 in the right and 20/20 in the left eye. Her fundus exam revealed retinal edema in the superotemporal retinal artery distribution without any visible emboli. Her neurological exam was otherwise normal. The cerebral angiogram showed bilateral internal carotid and vertebral artery dissections. The patient remained stable with conservative therapy without further worsening of vision or any new neurological deficits. Outcomes for cervicocephalic arterial dissection are usually favorable, but early diagnosis is critical for initiation of appropriate treatment of possible complications. Physicians must have a high index of suspicion for arterial dissection when patients note any headache, neck pain or vertigo triggered by violent motion after leisure activities such as roller coaster rides.

Transient Ischemic Attack in the Setting of Carotid Atheromatous Disease with a Persistent Primitive Hypoglossal Artery Successfully Treated with Stenting: A Case Report.

Fetal brain perfusion is supplied by the primitive dorsal aorta anteriorly, longitudinal neural arteries posteriorly, and anastomotic transverse segmentals. Most notable of these connections are the primitive trigeminal, otic, hypoglossal, and proatlantal arteries. With cranial-cervical circulatory maturation and development of the posterior communicating segments and vertebro-basilar system, these primitive segmental anastomoses normally regress. Anomalous neurovascular development can result in persistence of these anastomoses. Due to its territory of perfusion, the persistent primitive hypoglossal artery (PPHA) is associated with vertebral artery and posterior communicating artery hypoplasia or aplasia. As a consequence, primary blood supply to the hindbrain comes chiefly from this single artery. Although usually clinically silent, PPHA is susceptible to common cerebrovascular disorders including athero-ischemic disease and saccular aneurysmal dilation to name a few. We present a case of transient ischemic attack in a patient with a PPHA and proximal atherosclerotic disease treated by endovascular stenting.

Allogeneic Umbilical Cord Blood Infusion for Adults with Ischemic Stroke: Clinical Outcomes from a Phase I Safety Study

Stroke is a major cause of death and long‐term disability, affecting one in six people worldwide. The only currently available approved pharmacological treatment for ischemic stroke is tissue plasminogen activator; however, relatively few patients are eligible for this therapy. We hypothesized that intravenous (IV) infusion of banked unrelated allogeneic umbilical cord blood (UCB) would improve functional outcomes in patients with ischemic stroke. To investigate this, we conducted a phase I open‐label trial to assess the safety and feasibility of a single IV infusion of non‐human leukocyte antigen (HLA) matched, ABO matched, unrelated allogeneic UCB into adult stroke patients. Ten participants with acute middle cerebral artery ischemic stroke were enrolled. UCB units were matched for blood group antigens and race but not HLA, and infused 3–9 days post‐stroke. The adverse event (AE) profile over a 12 month postinfusion period indicated that the treatment was well‐tolerated in these stroke patients, with no serious AEs directly related to the study product. Study participants were also assessed using neurological and functional evaluations, including the modified Rankin Score (mRS) and National Institute of Health Stroke Scale (NIHSS). At 3 months post‐treatment, all participants had improved by at least one grade in mRS (mean 2.8 ± 0.9) and by at least 4 points in NIHSS (mean 5.9 ± 1.4), relative to baseline. Together, these data suggest that a single i.v. dose of allogeneic non‐HLA matched human UCB cells is safe in adults with ischemic stroke, and support the conduct of a randomized, placebo‐controlled phase 2 study. Stem Cells Translational Medicine 2018;7:521–529

Cryptogenic Stroke with a Patent Foramen Ovale:: Medical Therapy, Percutaneous Intervention, or Surgery CRYPTOGENIC STROKE WITH A PATENT FORAMEN OVALE BEDEIR, ET AL

More than one third of ischemic strokes have an unidentifiable cause. Patent foramen ovale (PFO) plays a controversial role in this subset of patients. The evidence for and against the hypothesis of paradoxical embolism is reviewed and we discuss the optimal management of a PFO under different circumstances. doi: 10.1111/jocs.12693 (J Card Surg 2016;31:156–160)

Cryptogenic Stroke with a Patent Foramen Ovale:: Medical Therapy, Percutaneous Intervention, or Surgery

More than one third of ischemic strokes have an unidentifiable cause. Patent foramen ovale (PFO) plays a controversial role in this subset of patients. The evidence for and against the hypothesis of paradoxical embolism is reviewed and we discuss the optimal management of a PFO under different circumstances. doi: 10.1111/jocs.12693 (J Card Surg 2016;31:156–160)

A pox upon your house

Herpes zoster ophthalmicus (HZO) is a common viral infectious disorder affecting the ophthalmic division of the trigeminal nerve. A small subset of HZO patients present with the ophthalmic symptoms, but without an accompanied rash, a condition described as Herpes zoster sine herpete. Although HZO is well known to be associated with other central nervous system abnormalities, encephalitis and cerebral infarction are atypical and uncommon. We report an unusual case of presumed unilateral Herpes zoster ophthalmicus sine herpete that presented with trigeminal pain and uveitis and then progressed to encephalitis and bilateral cerebral infarctions despite treatment with acyclovir and corticosteroids. The diagnosis of HZV was confirmed by polymerase chain reaction testing on the cerebrospinal fluid.

Cardiac MRI improves identification of etiology of ischemic stroke

Background Stroke is the third leading cause of death in the United States. Ischemic etiologies account for the vast majority of all cases of stroke from which about 20-25% have a cardiogenic cause. Transthoracic echocardiography (TTE) is widely used as the initial test for evaluating patients with a suspected cardioembolic of stroke while additional studies are often required to further detect a cardiac source in patients with unremarkable TTE. While transesophageal echocardiography (TEE) has provided clinicians with invaluable information in these cases, most physicians find it cumbersome at best and patients it extremely uncomfortable. CMR is a novel imaging modality that is increasingly being used in assessing patients with cardiovascular disease. The noninvasive nature of this test makes it an attractive option for evaluating strokes for which a TTE is non-diagnostic. In this study, we assessed the feasibility of using CMR as an imaging modality additional to TTE for detection of cardioembolic strokes.