Koenraad Nieboer

Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator in a Stroke Patient Treated with Dabigatran

Apixaban is increasingly used in clinical practice (1), but data on the bleeding risk in patients treated with recombinant tissue plasminogen activator (rt-PA) while taking apixaban are nonexistent. A 74-year-old right-handed man presented with abrupt onset of global aphasia. He was known with a partial right hemianopsia secondary to a left occipital intracerebral hemorrhage five-years earlier and with paroxysmal nonvalvular atrial fibrillation treated with apixaban 5 mg bid. The National Institutes of Health Stroke Scale (NIHSS) score was 8. Noncontrast computed tomography (CT) of the brain showed no signs of acute intracranial pathology. Perfusion-CT revealed hypoperfusion in the territory of the left middle cerebral artery (Fig. 1a). An ostial stenosis of the left internal carotid artery was diagnosed on CT angiography (Fig. 1b). After informed consent by proxy, i.v. rt-PA therapy (0·9 mg/kg; total dose 81 mg) was administered at 4·5 h after symptom onset and 8·5 h after apixaban intake. Platelet count, prothrombin time, activated partial thromboplastin time, and fibrinogen levels were normal, as was creatinine clearance. The patient experienced an excellent recovery (NIHSS score 1) without signs of new infarction or intracranial hemorrhage on repeat CT. As apixaban is commonly used in patients with elevated stroke risk (1), therapeutic decision-making with regard to thrombolytic therapy may not uncommonly pose problems in the near future. Our case report illustrates that further study on the safety of rt-PA in this patient population is justified. Ann De Smedt*, Melissa Cambron, Koenraad Nieboer, Maarten Moens, Robbert-Jan Van Hooff, Laetitia Yperzeele, Kristin Jochmans, Jacques De Keyser, and Raf Brouns

Complete metabolic tumour response, assessed by 18-fluorodeoxyglucose positron emission tomography (18FDG-PET), after induction chemotherapy predicts a favourable outcome in patients with locally advanced non-small cell lung cancer (NSCLC)

BACKGROUND 18FDG-PET and multislice computerized axial tomography (CT) scan are used for diagnosis, staging and response evaluation in NSCLC patients. The correlation between the response assessment by both imaging techniques and survival was assessed in patients with unresectable stage III NSCLC treated with induction chemotherapy followed by consolidation radiotherapy. METHODS Thirty-one patients, enrolled in a phase II study evaluating the efficacy and toxicity of a novel triplet induction chemotherapy (paclitaxel, carboplatin and gemcitabine) (PACCAGE) before consolidation radiotherapy, were evaluated by CT and 18FDG-PET at baseline and after three cycles of chemotherapy. The correlation between CT and 18FDG-PET response and time to progression and overall survival was analyzed using the Kaplan-Meier estimates of survival and the log rank test. RESULTS Ten patients with a complete response (CR) on 18FDG-PET had a significantly longer time to progression and overall survival than patients with a non-CR (median 19.9 months versus 9.8 months, p=0.026, and median >49 months versus 14.4 months, p=0.004, respectively). Twenty patients with a partial CT response (PR) had a significantly longer time to progression (median 15 months versus 9.4 months, p=0.001) than patients with a non-PR but the difference in overall survival only showed a trend (23.3 months versus 14.4 months, p=0.093). CONCLUSIONS A CR on 18FDG-PET following induction chemotherapy for locally advanced, unresectable NSCLC seems to be a more powerful prognostic marker for survival compared to PR on CT.

Body packing: a review of general background, clinical and imaging aspects

To avoid detection at border crossings or airport customs, drug trafficking is increasingly performed by intra-corporeal concealment. Body packers may ingest packets of varying size and containing varying drugs (mostly cocaine, heroin and cannabis) mixed with other compounds, while body pushers will insert packets in the rectum or vaginal cavity. Body packing may lead to potential life-threatening complications with acute overdose syndromes after packet rupture and intestinal obstruction with possible ensuing bowel rupture being the most significant complications. Physicians including radiologists should be aware of the capabilities of imaging techniques to screen for presence of drug packets as well as the potential complications. Although conventional radiography has long been and still is the most important imaging modality for screening for presence of intestinal packets, the better test characteristics in conjunction with the decreasing radiation exposure, will likely render computed tomography (CT) more important in the future. For imaging of symptomatic patients, CT already is the modality of choice. Besides these modalities, ultrasound and magnetic resonance imaging will be discussed in this paper, together with more general background and clinical information.

Pulmonary Disease in Cystic Fibrosis: Assessment with Chest CT at Chest Radiography Dose Levels

PURPOSE To investigate a computed tomographic (CT) protocol with iterative reconstruction at conventional radiography dose levels for the assessment of structural lung abnormalities in patients with cystic fibrosis ( CF cystic fibrosis ). MATERIALS AND METHODS In this institutional review board-approved study, 38 patients with CF cystic fibrosis (age range, 6-58 years; 21 patients <18 years and 17 patients >18 years) underwent investigative CT (at minimal exposure settings combined with iterative reconstruction) as a replacement of yearly follow-up posteroanterior chest radiography. Verbal informed consent was obtained from all patients or their parents. CT images were randomized and rated independently by two radiologists with use of the Bhalla scoring system. In addition, mosaic perfusion was evaluated. As reference, the previous available conventional chest CT scan was used. Differences in Bhalla scores were assessed with the χ(2) test and intraclass correlation coefficients ( ICC intraclass correlation coefficient s). Radiation doses for CT and radiography were assessed for adults (>18 years) and children (<18 years) separately by using technical dose descriptors and estimated effective dose. Differences in dose were assessed with the Mann-Whitney U test. RESULTS The median effective dose for the investigative protocol was 0.04 mSv (95% confidence interval [ CI confidence interval ]: 0.034 mSv, 0.10 mSv) for children and 0.05 mSv (95% CI confidence interval : 0.04 mSv, 0.08 mSv) for adults. These doses were much lower than those with conventional CT (median: 0.52 mSv [95% CI confidence interval : 0.31 mSv, 3.90 mSv] for children and 1.12 mSv [95% CI confidence interval : 0.57 mSv, 3.15 mSv] for adults) and of the same order of magnitude as those for conventional radiography (median: 0.012 mSv [95% CI confidence interval : 0.006 mSv, 0.022 mSv] for children and 0.012 mSv [95% CI confidence interval : 0.005 mSv, 0.031 mSv] for adults). All images were rated at least as diagnostically acceptable. Very good agreement was found in overall Bhalla score ( ICC intraclass correlation coefficient , 0.96) with regard to the severity of bronchiectasis ( ICC intraclass correlation coefficient , 0.87) and sacculations and abscesses ( ICC intraclass correlation coefficient , 0.84). Interobserver agreement was excellent ( ICC intraclass correlation coefficient , 0.86-1). CONCLUSION For patients with CF cystic fibrosis , a dedicated chest CT protocol can replace the two yearly follow-up chest radiographic examinations without major dose penalty and with similar diagnostic quality compared with conventional CT.

Intravenous thrombolysis with recombinant tissue plasminogen activator in a stroke patient treated with apixaban

Apixaban is increasingly used in clinical practice (1), but data on the bleeding risk in patients treated with recombinant tissue plasminogen activator (rt-PA) while taking apixaban are nonexistent. A 74-year-old right-handed man presented with abrupt onset of global aphasia. He was known with a partial right hemianopsia secondary to a left occipital intracerebral hemorrhage five-years earlier and with paroxysmal nonvalvular atrial fibrillation treated with apixaban 5 mg bid. The National Institutes of Health Stroke Scale (NIHSS) score was 8. Noncontrast computed tomography (CT) of the brain showed no signs of acute intracranial pathology. Perfusion-CT revealed hypoperfusion in the territory of the left middle cerebral artery (Fig. 1a). An ostial stenosis of the left internal carotid artery was diagnosed on CT angiography (Fig. 1b). After informed consent by proxy, i.v. rt-PA therapy (0·9 mg/kg; total dose 81 mg) was administered at 4·5 h after symptom onset and 8·5 h after apixaban intake. Platelet count, prothrombin time, activated partial thromboplastin time, and fibrinogen levels were normal, as was creatinine clearance. The patient experienced an excellent recovery (NIHSS score 1) without signs of new infarction or intracranial hemorrhage on repeat CT. As apixaban is commonly used in patients with elevated stroke risk (1), therapeutic decision-making with regard to thrombolytic therapy may not uncommonly pose problems in the near future. Our case report illustrates that further study on the safety of rt-PA in this patient population is justified. Ann De Smedt*, Melissa Cambron, Koenraad Nieboer, Maarten Moens, Robbert-Jan Van Hooff, Laetitia Yperzeele, Kristin Jochmans, Jacques De Keyser, and Raf Brouns

Intravenous thrombolysis with recombinant tissue plasminogen activator for acute ischemic stroke in a patient treated with rivaroxaban.

Intravenous recombinant tissue plasminogen activator (IV rtPA) s the only approved therapy for acute ischemic stroke [1]. Interational guidelines stipulate that anticoagulant use is a (relative) ontraindication for treatment with IV rtPA. Rivaroxaban is an oral direct factor Xa inhibitor that is increasngly being used in routine clinical practice for primary prevention nd treatment of venous thromboembolism, stroke prevention in onvalvular atrial fibrillation and only in Europe as secondary preention in acute coronary syndromes [2]. It is therefore expected hat clinicians will be increasingly confronted with the question ow to treat acute ischemic stroke in these patients [3]. Data on the leeding risk in patients treated with IV rtPA while taking rivaroxban are lacking. Various commercial assays have been developed o measure the drug concentration, but as these are not yet widely vailable bedside [4], the prothrombin time (PT) is suggested as a imited alternative to assess the presence of anticoagulant effect, specially in urgent situations [5].

Carotid artery dissection: three cases and a review of the literature.

Carotid artery dissections are potentially disabling, probably underdiagnosed, and mainly affect young-aged and middle-aged people. We present three consecutive cases illustrating different clinical presentations and thereby emphasizing the diagnostic challenge of carotid artery dissections for the emergency physician. Neck and facial pain, headache, unilateral pulsatile tinnitus, partial Horner’s syndrome (or oculosympathetic palsy), amaurosis fugax, retinal infarction, and anterior circulation brain ischemia may all occur in isolation or in various combinations. Medical imaging plays a pivotal role in making the right diagnosis. Clinical vigilance is of utmost importance as early diagnosis and timely treatment favor long-term prognosis and even prevent ischemic complications. We review the literature and discuss the pathophysiology, etiology, clinical presentation, diagnosis, imaging techniques, treatment, and prognosis of carotid dissections.

Comparison of ventilation-perfusion single-photon emission computed tomography (V/Q SPECT) versus dual-energy CT perfusion and angiography (DECT) after 6 months of pulmonary embolism (PE) treatment

BACKGROUND The natural evolution of treated symptomatic pulmonary embolism shows often incomplete resolution of pulmonary thrombi. The prevalence of perfusion defects depend on the image modality used. This study directly compares V/Q SPECT with DECT. METHODS A single-center prospective observational cohort study of patients with intermediate risk PE, reassessed at the end of treatment with V/Q SPECT. Abnormal V/Q SPECT images were compared with DECT. RESULTS We compared DECT en V/Q SPECT in 28 consecutive patients with persistent V/Q mismatch on V/Q SPECT, 13 men and 15 woman, mean age 60 (+17), range 23-82 year. One patient was excluded from the final analysis due to inferior quality DECT. In 18/27 (66.7%) the results were concordant between CTPA (persistent embolus visible), DECT (segmentary defects on iodine map) and V/Q SPECT (segmentary ventilation-perfusion mismatch). In 3/18 (11.1% of the total group) the partialy matched V/Q SPECT defect could be explained on DECT lung images by lung infarction. In 6/27 (22.1%) only hypoperfusion was seen on DECT iodine map. In 3/27 (11.1%) results were discordant between V/Q SPECT and DECT images. CONCLUSION Six months after diagnosis of first or recurrent PE, residual pulmonary perfusion-defects encountered on V/Q-SPECT corresponds in the majority of patients with chronic thromboembolic disease seen on DECT. In 22.1% of patients V/Q SPECT mismatch only corresponds with hypoperfusion on iodine map DECT scan. Some (11.1%) of the chronic thromboembolic lesions seen on V/Q SPECT can not be explained by DECT results.

Successful Repetitive Intravenous Thrombolysis in a Patient With Recurrent Brainstem Infarctions Due to Megadolichobasilar Ectasia

M EGADOLICHObasilar ectasia i s def ined as marked elongation, widening, and tortuosity of the basilar artery. Intracranial dolichoectasia is associated with an increased risk of ischemic and hemorrhagic stroke and is found in 10% to 12% of patients with stroke. Intravenous (IV) administration of recombinant tissue plasminogen activator (rtPA) is the only approved therapy for acute ischemic stroke but is contraindicated in patients with increased risk of intracranial hemorrhage. Data on the bleeding risk in patients with megadolichobasilar ectasia treated with IV rtPA are nonexistent. We describe a 69-year-old man with megadolichobasilar artery who had 3 ischemic brainstem strokes and good outcome after treatment with IV rtPA twice. On the first occasion, the patient presented with internuclear ophthalmoplegia, left hemiparesis, and ataxia (National Institutes of Health Stroke Scale [NIHSS] score of 7). Conventional noncontrast computed tomography (CT) of the brain showed no abnormality besides a dolichoectatic basilar artery. Perfusion CT revealed hypoperfusion, mainly consisting of ischemic penumbra in the right cerebellar hemisphere. The megadolichobasilar ectasia was confirmed by CT angiography (Figure 1). Because of the invalidating neurological deficit, 0.9 mg/kg of IV rtPA was given 3 hours after the onset of symptoms. It resulted in complete recovery (NIHSS score of 0 at 72 hours after onset). Secondary cerebrovascular prevention was initiated with aspirin, dipyridamole, atorvastatin calcium, and adequate antihypertensive treatment. Three months later, the patient woke with mild left hemiparesis and ataxia (NIHSS score of 5). He was treatedconservatively.Magneticresonance imaging displayed acute cerebral ischemiaattherighthemipontine level. Treatment with antiplatelet agents, statin, and antihypertensive agentswascontinuedand thepatient experienced a gradual functional recuperation (modified Rankin Scale score of 2 at 3 months after stroke). One year after the previous event, the patient was readmitted with decreased consciousness, oculomotor dysfunction, anarthria, ataxia, and severe right hemiparesis and hypesthesia (NIHSS score of 21). Conventional noncontrast CT of the brain was suggestive of a mural thrombus in the megadolichobasilar artery. Administration of IV rtPA 2 hours after symptom onset resulted in complete recovery (NIHSS score of 0 at 72 hours after onset). Magnetic resonance imaging showed a small acute infarction in the left cerebellar hemisphere and residual mural thrombus in the basilar artery (Figure 2). Because of recurrent strokes despite antiplatelet therapy and given the presence of a mural thrombus, secondary prevention with anticoagulation was initiated.

Development and Pilot Testing of 24/7 In-Ambulance Telemedicine for Acute Stroke: Prehospital Stroke Study at the Universitair Ziekenhuis Brussel-Project

Background: In-ambulance telemedicine is a recently developed and a promising approach to improve emergency care. We implemented the first ever 24/7 in-ambulance telemedicine service for acute stroke. We report on our experiences with the development and pilot testing of the Prehospital Stroke Study at the Universitair Ziekenhuis Brussel (PreSSUB) to facilitate a wider spread of the knowledge regarding this technique. Methods: Successful execution of the project involved the development and validation of a novel stroke scale, design and creation of specific hardware and software solutions, execution of field tests for mobile internet connectivity, design of new care processes and information flows, recurrent training of all professional caregivers involved in acute stroke management, extensive testing on healthy volunteers, organisation of a 24/7 teleconsultation service by trained stroke experts and 24/7 technical support, and resolution of several legal issues. Results: In all, it took 41 months of research and development to confirm the safety, technical feasibility, reliability, and user acceptance of the PreSSUB approach. Stroke-specific key information can be collected safely and reliably before and during ambulance transportation and can adequately be communicated with the inhospital team awaiting the patient. Conclusion: This paper portrays the key steps required and the lessons learned for successful implementation of a 24/7 expert telemedicine service supporting patients with acute stroke during ambulance transportation to the hospital.