P. Papanagiotou

Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial.

BACKGROUND Only 2-5% of patients who have a stroke receive thrombolytic treatment, mainly because of delay in reaching the hospital. We aimed to assess the efficacy of a new approach of diagnosis and treatment starting at the emergency site, rather than after hospital arrival, in reducing delay in stroke therapy. METHODS We did a randomised single-centre controlled trial to compare the time from alarm (emergency call) to therapy decision between mobile stroke unit (MSU) and hospital intervention. For inclusion in our study patients needed to be aged 18-80 years and have one or more stroke symptoms that started within the previous 2·5 h. In accordance with our week-wise randomisation plan, patients received either prehospital stroke treatment in a specialised ambulance (equipped with a CT scanner, point-of-care laboratory, and telemedicine connection) or optimised conventional hospital-based stroke treatment (control group) with a 7 day follow-up. Allocation was not masked from patients and investigators. Our primary endpoint was time from alarm to therapy decision, which was analysed with the Mann-Whitney U test. Our secondary endpoints included times from alarm to end of CT and to end of laboratory analysis, number of patients receiving intravenous thrombolysis, time from alarm to intravenous thrombolysis, and neurological outcome. We also assessed safety endpoints. This study is registered with ClinicalTrials.gov, number NCT00153036. FINDINGS We stopped the trial after our planned interim analysis at 100 of 200 planned patients (53 in the prehospital stroke treatment group, 47 in the control group), because we had met our prespecified criteria for study termination. Prehospital stroke treatment reduced the median time from alarm to therapy decision substantially: 35 min (IQR 31-39) versus 76 min (63-94), p<0·0001; median difference 41 min (95% CI 36-48 min). We also detected similar gains regarding times from alarm to end of CT, and alarm to end of laboratory analysis, and to intravenous thrombolysis for eligible ischaemic stroke patients, although there was no substantial difference in number of patients who received intravenous thrombolysis or in neurological outcome. Safety endpoints seemed similar across the groups. INTERPRETATION For patients with suspected stroke, treatment by the MSU substantially reduced median time from alarm to therapy decision. The MSU strategy offers a potential solution to the medical problem of the arrival of most stroke patients at the hospital too late for treatment. FUNDING Ministry of Health of the Saarland, Germany, the Werner-Jackstädt Foundation, the Else-Kröner-Fresenius Foundation, and the Rettungsstiftung Saar.

Stent-Assisted Mechanical Recanalization for Treatment of Acute Intracerebral Artery Occlusions

Background and Purpose— The purpose of this study was to demonstrate a new approach to the use of a self-expanding stent in the treatment of acute ischemic stroke. Methods— Twenty-two consecutive patients with acute intracerebral artery occlusions were treated with a self-expandable intracranial stent, which was withdrawn in its unfolded state. For this technique, we used the Solitaire AB/FR, which is the only intracranial stent that is fully recoverable. Eight patients had an occlusion of the basilar artery, 12 had a middle cerebral artery occlusion, and 2 had terminal carotid artery occlusions; 6 of these had to be treated first for an acute occlusion originating in the internal carotid artery. Recanalization results were assessed by follow-up angiography immediately after the procedure. Neurologic status was evaluated before and after treatment (90-day follow-up) according to the National Institutes of Health Stroke Scale and modified Rankin scale. Results— Successful revascularization was achieved in 20 of 22 (90.9%) patients (thrombolysis in cerebral infarction [TICI] 2a/b and 3), a TICI 3 state was accomplished in 12 patients, and partial recanalization or slow distal branch filling with filling of more than two-thirds of the vessel territory was achieved in 8 patients (TICI 2b). There was immediate flow restoration in 21 of 22 (95.4%) cases after deployment of the device. The stent was removed in its unfolded state in all patients. The mean time from stroke symptom onset to recanalization was 277 minutes, with a standard deviation of 118 minutes. Mean National Institutes of Health Stroke Scale score on admission was 19.4, with a standard deviation of 5.7. Almost two-thirds of the patients (63.6%) improved by >10 points on the National Institutes of Health Stroke Scale at discharge, and 50% showed a modified Rankin scale score of ≤2 at 90 days (59% with a modified Rankin scale ≤3). Mortality was 18.1%. In 1 case, an asymptomatic intracranial hemorrhage was detected on control computed tomography, and 2 patients had a symptomatic intracranial hemorrhage. Conclusion— Withdrawal of an unfolded, fully recoverable, intracranial stent yielded very promising angiographic and clinical results. It combines the advantages of prompt flow restoration and mechanical thrombectomy.

A randomized, double-blind, phase 2 study of erythropoietin in optic neuritis

Based on findings in animal models of autoimmune optic nerve inflammation, we have assessed the safety and efficacy of erythropoietin in patients presenting with a first episode of optic neuritis.

Carotid Artery Stenting in Acute Stroke

OBJECTIVES The purpose of this study is to demonstrate the technical success of carotid artery stenting in acute extracranial internal carotid artery (ICA) occlusion as well as the benefit in clinical outcome. BACKGROUND Stroke caused by acute occlusion of the ICA is associated with a significant level of morbidity and mortality. For this type of lesion, treatment with standard intravenous thrombolysis alone leads to a good clinical outcome in only 17% of the cases, with a death rate as high as 55%. Recanalization of the occluded ICA can lead to an improvement in acute symptoms of stroke, prevent possible deterioration, and reduce long-term stroke risk. At present, there is no consensus treatment for patients with acute ischemic stroke presenting with severe clinical symptoms due to atherosclerotic occlusion of the extracranial ICA. METHODS Carotid artery stenting was performed in 22 patients with acute atherosclerotic extracranial ICA occlusion within 6 h of stroke symptom onset. In 18 patients, there was an additional intracranial occlusion at the level of the terminal segment of the ICA (n = 4) and at the level of the middle cerebral artery (n = 14). Intracranial occlusions were either treated with the Penumbra system or the Solitaire stent-based recanalization system, or a combination of mechanical recanalization and intra-arterial thrombolysis. Recanalization results were assessed by angiography immediately after the procedure. The neurologic status was evaluated before and after the treatment with a follow-up as long as 90 days using the National Institutes of Health Stroke Scale and the modified Rankin Scale. RESULTS Successful revascularization of extracranial ICA with acute stent implantation was achieved in 21 patients (95%). There was no acute stent thrombosis. After successful recanalization of the origin of the ICA, the intracranial recanalization with Thrombolysis In Myocardial Infarction flow grade 2/3 was achieved in 11 of the 18 patients (61%). The overall recanalization rate (extracranial and intracranial) was 14 of 22 patients (63%). Nine patients (41%) had a modified Rankin Scale score of ≤2 at 90 days. The mortality rate was 13.6% at 90 days. CONCLUSIONS Carotid artery stenting in acute atherosclerotic extracranial ICA occlusion with severe stroke symptoms is feasible, safe, and useful within the first 6 h after symptom onset.

Point‐of‐care laboratory halves door‐to‐therapy‐decision time in acute stroke

Currently, stroke laboratory examinations are usually performed in the centralized hospital laboratory, but often planned thrombolysis is given before all results are available, to minimize delay. In this study, we examined the feasibility of gaining valuable time by transferring the complete stroke laboratory workup required by stroke guidelines to a point‐of‐care laboratory system, that is, placed at a stroke treatment room contiguous to the computed tomography, where the patients are admitted and where they obtain neurological, laboratory, and imaging examinations and treatment by the same dedicated team. Our results showed that reconfiguration of the entire stroke laboratory analysis to a point‐of‐care system was feasible for 200 consecutively admitted patients. This strategy reduced the door‐to‐therapy‐decision times from 84 ± 26 to 40 ± 24 min (p < 0.001). Results of most laboratory tests (except activated partial thromboplastin time and international normalized ratio) revealed close agreement with results from a standard centralized hospital laboratory. These findings may offer a new solution for the integration of laboratory workup into routine hyperacute stroke management. Ann Neurol 2011;

Endovascular treatment of unruptured intracranial aneurysms: occurrence of thromboembolic events.

OBJECTIVE:The purpose of this study was to evaluate the frequency and causes of thromboembolic events associated with endovascular embolization of asymptomatic aneurysms. Correlations between radiological findings (aneurysm size, localization, embolization time, number of coils used, as well as patient age) were evaluated with the occurrence of thromboembolic events and clinical findings. METHODS:Sixty-eight patients treated for unruptured intracranial aneurysms (mean age, 49 yr) were evaluated. Hyperintense lesions on diffusion weighted imaging were analyzed in 50 patients. Aneurysm size was 3 to 15 mm. RESULTS:Complete occlusion of the aneurysms was achieved in 55 of 68 (82%). One patient had a transient paresis. There was one infarction and one aneurysm rupture during the procedure with no consecutive neurological symptoms. We found new hyperintense lesions in 21 of 50 (42%) diffusion weighted imaging studies. In 43% of these, there was only one lesion smaller than 2 mm. In 33%, there was more than one lesion less than 2 mm; in 19%, we found a lesion of 2 to 10 mm in size. In one case, a lesion greater than 10 mm occurred. There was no correlation between aneurysm location and the occurrence of lesions or among the number of coils used, the size of the aneurysm, patient age, or embolization time. Mortality rate was 0%, morbidity 4.0%. If the 18 aneurysms where no diffusion weighted imaging was obtained are included, morbidity is 2.9%. CONCLUSION:The high rate of thromboembolic events suggests that heparin is not sufficient to prevent ischemic lesions. An antiplatelet therapy, started before or during intervention, might diminish thrombus formation.

Mobile stroke unit for diagnosis-based triage of persons with suspected stroke

Background: In this feasibility study, we tested whether prehospital diagnostic stroke workup enables rational decision-making regarding treatment and the target hospital in persons with suspected stroke. Methods: A mobile stroke unit that delivers imaging (including multimodal brain imaging with CT angiography and CT perfusion), point-of-care-laboratory analysis, and neurologic expertise directly at the emergency site was analyzed for its use in prehospital diagnosis-based triage of suspected stroke patients. Results: We present 4 complementary cases with suspected stroke who underwent prehospital diagnostic workup that enabled direct diagnosis-based treatment decisions and reliable triage regarding the most appropriate medical facility for that individual, e.g., a primary hospital vs specialized centers of a tertiary hospital. Conclusions: This preliminary report demonstrates the feasibility of prehospital diagnostic stroke workup for immediate etiology-specific decision-making regarding the necessary time-sensitive stroke treatment and the most appropriate target hospital.

Treatment of Acute Cerebral Artery Occlusion With a Fully Recoverable Intracranial Stent A New Technique

A 42-year-old woman was referred to our institution with sudden onset of ataxia, facial paresis, horizontal gaze palsy, and progressive dysarthria. The patient worsened within a few minutes, with appearance of left hemiparesis. The National Institutes of Health Stroke Scale Score was 13. On computer tomography scan 2 hours after stroke onset, no brain stem lesion or intracranial bleeding was visible. Computed tomographic angiography revealed a mid basilar vessel occlusion, which suggested embolic basilar artery occlusion. A 4-vessel angiogram with a 5F diagnostic catheter confirmed the basilar artery occlusion and depicted more precisely the location of the thrombus (Figure 1A). Figure 1. A, Digital subtraction angiography after vertebral injection demonstrates a mid basilar vessel occlusion. B, The angiogram after placement of the stent from the left P1 segment (white arrow) into the basilar artery showed flow restoration of the basilar artery with a narrowing in the middle part of the vessel due to compression of the thrombus into the arterial wall (black arrows). C, …

Hyperperfusion syndrome after carotid stent angioplasty.

IntroductionThis study assesses the incidence and causes of hyperperfusion syndrome occurring after carotid artery stenting (CAS).Materials and methodsWe retrospectively reviewed the clinical database of 417 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or intracranial hemorrhage. Magnetic resonance imaging (MRI) including fluid-attenuated inversion recovery and diffusion-weighted imaging was performed before and after CAS in 269 cases. A Spearman’s rho nonparametric correlation was performed to determine whether there was a correlation between the occurrence/development of hyperperfusion syndrome and the patient’s age, degree of stenosis on the stented and contralateral side, risk factors such as diabetes, smoking, hypertension, adiposity, gender and fluoroscopy time, and mean area of postprocedural lesions as well as preexisting lesions. Significance was established at p < 0.05.ResultsOf the 417 carotid arteries stented and where MRI was also completed, we found hyperperfusion syndrome in 2.4% (ten cases). Patients who had preexisting brain lesions (previous or acute stroke) were at a higher risk of developing hyperperfusion syndrome (p = 0.022; Spearman’s rho test). We could not validate any correlation with the other patient characteristics.ConclusionExtensive microvascular disease may be a predictor of hyperperfusion syndrome after carotid stent placement. We believe that further studies are warranted to predict more accurately which patients are at greater risk of developing this often fatal complication.

A Comparison of 2 Stroke Devices: The New Aperio Clot-Removal Device and the Solitaire AB/FR

BACKGROUND AND PURPOSE: Several studies have shown promising results for the use of self-expandable intracranial stents for the treatment of acute ischemic stroke. This new technique combines immediate flow restoration after stent deployment with high recanalization rates. In the present study, the safety and efficacy of the new Aperio clot-removal device was tested in comparison with the Solitaire AB device. MATERIALS AND METHODS: The experiments were performed in swine with a weight of 35–50 kg following established models. The experimental thrombi were prepared by using a new flow model (Thrombus Loop) to produce radiopaque thrombi. Thrombi were cut into lengths of 10 mm and injected into the target vessel. The occlusion was verified by DSA and rated with the help of the TICI score. A microcatheter was placed distal to the thrombus. The devices were placed with the proximal third within the thrombus and were retrieved under continuous aspiration in their released state into the guiding sheath. We performed 23 procedures with the Aperio device and 18 procedures with the Solitaire AB and FR devices. Control angiograms were obtained 3 and 5 minutes after device deployment to evaluate the flow restoration. The number of attempts to reach a TICI 2/3 score was recorded as well as the time to recanalization and the device-related complications. Vasospasm, vascular perforation, intramural arterial dissection, or embolization of a previously uninvolved territory was defined as a device-related complication. RESULTS: Defined radiopaque thrombi from whole blood could reliably be created by using the Thrombus Loop. Both devices demonstrated a high recanalization rate of 100% (TICI 3) in the target vessel with no device-related complications. No significant differences were found between the 2 devices. CONCLUSIONS: In this small study, we could show that radiopaque thrombi of whole blood with a defined diameter could be reliably created by using the Thrombus Loop. The new “stent-retriever” (Aperio System) seems to be a very efficient and safe addition to the existing repertoire of clot-removal devices.