Lavinia Dinia

Outcomes of a contemporary cohort of 536 consecutive patients with acute ischemic stroke treated with endovascular therapy.

Background and Purpose— We sought to assess outcomes after endovascular treatment/therapy of acute ischemic stroke, overall and by subgroups, and looked for predictors of outcome. Methods— We used data from a mandatory, population-based registry that includes external monitoring of completeness, which assesses reperfusion therapies for consecutive patients with acute ischemic stroke since 2011. We described outcomes overall and by subgroups (age ⩽ or >80 years; onset-to-groin puncture ⩽ or >6 hours; anterior or posterior strokes; previous IV recombinant tissue-type plasminogen activator or isolated endovascular treatment/therapy; revascularization or no revascularization), and determined independent predictors of good outcome (modified Rankin Scale score ⩽2) and mortality at 3 months by multivariate modeling. Results— We analyzed 536 patients, of whom 285 received previous IV recombinant tissue-type plasminogen activator. Overall, revascularization (modified Thrombolysis In Cerebral Infarction scores, 2b and 3) occurred in 73.9%, 5.6% developed symptomatic intracerebral hemorrhages, 43.3% achieved good functional outcome, and 22.2% were dead at 90 days. Adjusted comparisons by subgroups systematically favored revascularization (lower proportion of symptomatic intracerebral hemorrhages and death rates and higher proportion of good outcome). Multivariate analyses confirmed the independent protective effect of revascularization. Additionally, age >80 years, stroke severity, hypertension (deleterious), atrial fibrillation, and onset-to-groin puncture ⩽6 hours (protective) also predicted good outcome, whereas lack of previous disability and anterior circulation strokes (protective) as well as and hypertension (deleterious) independently predicted mortality. Conclusions— This study reinforces the role of revascularization and time to treatment to achieve enhanced functional outcomes and identifies other clinical features that independently predict good/fatal outcome after endovascular treatment/therapy.

Diagnosis of right-to-left shunt with transcranial doppler and vertebrobasilar recording

Background and Purpose— Right-to-left shunt (RLS) due to patent foramen ovale is a well-established risk factor for cryptogenic stroke and is highly prevalent in cases of migraine, cluster headache, and obstructive apnea. It can be diagnosed by gaseous-contrast transcranial Doppler, yet in a small percentage of cases it cannot be done owing to an insufficient temporal window. The aim of the study was to compare transtemporal with transoccipital approaches for gaseous-contrast transcranial Doppler for RLS diagnosis. Methods— We evaluated 183 subjects with a standard protocol for RLS diagnosis by simultaneously monitoring the right middle cerebral and vertebrobasilar circulations. Results— Vertebrobasilar recording reached high specificity (100%) and good sensitivity (83.72%) for the diagnosis of RLS after the Valsalva maneuver. For only medium and large shunts, both sensitivity and specificity reached 100%. Time to bubble appearance after injection was higher in the vertebrobasilar circulation (4.36±1.7 vs 6.77±2.5 seconds; P<0.001). There was a positive correlation between the number of bubbles in the right middle cerebral and vertebrobasilar circulation (&kgr;=0.97). Conclusions— Transcranial Doppler with vertebrobasilar monitoring is highly sensitive and specific in detecting RLS, particularly when medium or large. It can be proposed for subjects with an insufficient temporal bone window.

White Matter Lesions Progression in Migraine with Aura: A Clinical and MRI Longitudinal Study

To prospectively evaluate longitudinal changes in white matter lesions (WMLs) in migraineurs with aura, by magnetic resonance imaging (MRI), and to correlate WMLs modifications with patients’ clinical characteristics.

Endothelial progenitor cells in acute ischemic stroke

The levels of circulating endothelial progenitor cells (EPCs) in ischemic stroke have not been studied extensively and reported results are inconsistent. We aimed to investigate the time course, the prognostic relevance, and the variables associated with EPC counts in patients with ischemic stroke at different time points.

Microbleed Burden and Hematoma Expansion in Acute Intracerebral Hemorrhage

Background: Intracranial amyloid and hypertensive angiopathy have been related to impaired blood vessel function and the etiology of intracerebral hemorrhage (ICH). Microbleeds (MBs) are surrogate radiological markers that are associated with these underlying angiopathies. We assessed the hypothesis that MBs are associated with hematoma expansion (HE) in patients with hyperacute ICH. Methods: We studied patients with spontaneous supratentorial ICH within the first 6 h after onset. HE was defined as an increase ≥33% in the volume of hematoma on the follow-up CT in comparison with the admission CT. The volume was calculated using the ABC/2 formula. MBs were detected by specific magnetic resonance sequences (gradient-echo). The presence, number and distribution of MBs were analyzed. Results: Our study included 44 patients. Their mean age was 68.9 ± 11.1 years, and 70.5% of them were men. HE was observed in 14 of the patients (31.8%). HE was more prevalent in patients with more than 10 MBs compared with patients with 1-10 MBs (60 vs 12.5%; p = 0.03). Conclusion: A high burden of MBs is associated with an increased risk of HE in patients with ICH. This is probably a marker of a more severe underlying angiopathy.

Prognostic Value of Plasma β-Amyloid Levels in Patients With Acute Intracerebral Hemorrhage

Background and Purpose— It has been proposed that the deposition of the &bgr;-amyloid peptide (A&bgr;) in the brain parenchyma and brain blood vessels has deleterious effects. We tested the hypothesis that the levels of plasma A&bgr; are related to the outcome in patients with intracerebral hemorrhage. Methods— In a multicenter study, we prospectively included patients with spontaneous intracerebral hemorrhage within the first 24 hours after onset. At admission, we measured plasma A&bgr;40 and A&bgr;42 levels using ELISA techniques. Also, we recorded age, sex, vascular risk factors, National Institutes of Health Stroke Scale score, presence of intraventricular hemorrhage, localization, cause, and volume of the hematoma. We obtained the modified Rankin scale and defined a unfavorable outcome as modified Rankin scale >2 at 3 months. Bivariate and multivariate regression analyses were performed. Results— We studied 160 patients (mean age, 73.8±11.3 years; 59.4% of them were men). A favorable outcome was observed in 64 (40%) of the patients. In the bivariate analyses, unfavorable outcome was associated with high age, female sex, diabetes mellitus, presence of intraventricular hemorrhage, high blood glucose, high National Institutes of Health Stroke Scale score, high volume, and high plasma levels of A&bgr;42 and A&bgr;40. The multivariate analysis showed that increased age (odds ratio, 1.07; 95% confidence interval, 1.035–1.21; P<0.0001), high admission National Institutes of Health Stroke Scale score (odds ratio, 1.29, 95% confidence interval, 1.17–1.42; P<0.0001), presence of diabetes mellitus (odds ratio, 4.15; 95% confidence interval, 1.21–14.1; P=0.02), and A&bgr;42 levels >9.7 pg/mL (odds ratio, 4.11; 95% confidence interval, 1.65–10.1; P=0.02) were independently associated with an increased likelihood of an unfavorable outcome. Conclusions— High levels of plasma A&bgr;42 in patients with acute intracerebral hemorrhage are associated with a poor functional prognosis.

Transcranial diffuse optical monitoring of microvascular cerebral hemodynamics after thrombolysis in ischemic stroke

Abstract. The ultimate goal of therapeutic strategies for ischemic stroke is to reestablish the blood flow to the ischemic region of the brain. However, currently, the local cerebral hemodynamics (microvascular) is almost entirely inaccessible for stroke clinicians at the patient bed-side, and the recanalization of the major cerebral arteries (macrovascular) is the only available measure to evaluate the therapy, which does not always reflect the local conditions. Here we report the case of an ischemic stroke patient whose microvascular cerebral blood flow and oxygenation were monitored by a compact hybrid diffuse optical monitor during thrombolytic therapy. This monitor combined diffuse correlation spectroscopy and near-infrared spectroscopy. The reperfusion assessed by hybrid diffuse optics temporally correlated with the recanalization of the middle cerebral artery (assessed by transcranial-Doppler) and was in agreement with the patient outcome. This study suggests that upon further investigation, diffuse optics might have a potential for bed-side acute stroke monitoring and therapy guidance by providing hemodynamics information at the microvascular level.

Microvascular versus Macrovascular Cerebral Vasomotor Reactivity in Patients with Severe Internal Carotid Artery Stenosis or Occlusion

RATIONALE AND OBJECTIVES In patients with severe internal carotid artery steno-occlusive lesions (ISOL), impaired cerebrovascular reactivity (CVR) is predictive of future ischemic stroke (IS) or transient ischemic attack (TIA). Therefore, the evaluation of CVR in ISOL patients may be a means to evaluate the risk for IS/TIA and decide on an intervention. Our aim was (1) to explore the feasibility of concurrent near-infrared spectroscopy (NIRS-DOS), diffuse correlation spectroscopy, and transcranial Doppler for CVR assessment in ISOL patients, and (2) to compare macrovascular and microvascular CVR in ISOL patients and explore its potential for IS/TIA risk stratification. MATERIALS AND METHODS Twenty-seven ISOL patients were recruited. The changes in continuous microvascular and macrovascular hemodynamics upon acetazolamide injection were used to determine CVR. RESULTS Oxyhemoglobin (HbO2, by near-infrared spectroscopy), microvascular cerebral blood flow (CBF, by diffuse correlation spectroscopy) and CBF velocity (by transcranial Doppler) showed significant increases upon acetazolamide injection in all subjects (P < .03). Only macrovascular CVR (P = .024) and none of the microvascular measures were significantly dependent on the presence of ISOL. In addition, while CBF was significantly correlated with HbO2, neither of these microvascular measures correlated with macrovascular CBF velocity. CONCLUSIONS We demonstrated the simultaneous, continuous, and noninvasive evaluation of CVR at both the microvasculature and macrovasculature. We found that macrovascular CVR response depends on the presence of ISOL, whereas the microvascular CVR did not significantly depend on the ISOL presence, possibly due to the role of collaterals other than those of the circle of Willis. The concurrent microvascular and macrovascular CVR measurement in the ISOL patients might improve future IS/TIA risk assessment.

Sonothrombolysis for Acute Ischemic Stroke

Several studies have consistently demonstrated the capability of ultrasound to enhance the lysis of intra-arterial thrombi in acute ischemic stroke during systemic intravenous thrombolysis with tissue plasimogen activator (tPA), an intervention also called sonothrombolysis. ### Objectives 1. To quantify the potential benefits of sonothrombolysis in acute ischemic stroke. 2. To quantify the potential harms of sonothrombolysis. ### Types of Studies Randomized controlled trials with clear allocation concealment. ### Types of Participants Patients admitted to hospital with acute ischemic stroke. ### Types of Interventions Sonothrombolysis versus intravenous tPA therapy alone or …

Brain-to-Brain Paradoxical Embolism through Patent Foramen Ovale after Cerebral Vein Thrombosis

agulation factors were found; in particular, we searched for MTHFR mutation, prothrombin G20210A mutation and factor V Leyden mutation, and none was found. He was treated with intravenous heparin (5,000 IU bolus, followed by continuous infusion of 1,000 IU/h), with complete resolution of symptoms. Color-coded duplex sonography of the cervical arteries showed no carotid or vertebral disease, and arterial transcranial Doppler ultrasound was unremarkable. A venous color-Doppler of the legs did not show the presence of venous thrombosis, yet it cannot completely exclude this condition. A second cerebral MRI and MRA examination showed partial recanalization of transverse and sigmoid sinuses, and the persistence of thrombosis of sagittal sinus. Then the patient was discharged with oral anticoagulants (warfarin) with a suggested International Normalized Ratio interval of 2–3. After 10 months, warfarin was stopped and replaced with aspirin, 100 mg, because of the occurrence of bilateral spontaneous subdural hematoma. Two months later he was admitted again to our Stroke Unit for sudden onset of vertigo, nausea, vomiting and cerebellar ataxia. Neurological examination showed horizontal nystagmus and dysmetria of the right limbs. The acute cerebral CT scan was normal, while a CT scan, performed after 48 h, showed a right cerebellar infarction with mass effect. MRI confirmed the presence of the recent right cerebellar ischemic infarction, associated with other recent bilateral temporal and occipital small Dear Sir, Patients with right-to-left shunt due to patent foramen ovale (PFO), especially if associated to atrial septal aneurysm, are at increased risk of stroke [1–5] . Although there are many possible mechanisms of stroke in these subjects (in situ formation of thrombus, atrial vulnerability, other comorbidities), paradoxical embolism is thought to be one of the most important causes of stroke, yet difficult to be proven [6–8] . Ultrasonographic examination of the venous system as well as CT or MRA studies can identify a venous source in no more than 20% of subjects with cryptogenic stroke [7–10] . We report a case of stroke in a young man with a large PFO, in which the only source of paradoxical embolism was the presence of a recent cerebral venous thrombosis.