Sabrina Anticoli

Transient Ischemic Attack Fast-track and Long-Term Stroke Risk: Role of Diffusion-Weighted Magnetic Resonance Imaging

BACKGROUND Acute ischemic lesions on diffusion-weighted magnetic resonance imaging (DWI-MRI) are reliable predictors of recurrent stroke at 90 days. However, to date, limited information on transient ischemic attack (TIA) patients with positive DWI lesions for stroke risk from 1 to 5 years is available. In this study, we evaluated the role of positive DWI lesions and vascular risk factors on stroke, cardiovascular death, and mortality at 90 days (T0), 1 year (T1), and 5 years (T2). Moreover, we also evaluated the association between stroke risk and the presence of DWI lesions. METHODS We performed an observational study on consecutive patients admitted to the emergency department of San Camillo-Forlanini Hospital, Rome, Italy, from January 2007 to November 2012. Over the study period, 4300 patients with TIA or ischemic stroke were examined by stroke specialists in an emergency room setting within 1 hour from admittance. RESULTS In 510 of 4300 patients (11.86%), a TIA was diagnosed, and 445 patients satisfy the study inclusion criteria. For all 445 patients, the mean ABCD2 score was 4.35 ± 1.30. Using DWI-MRI, we identified acute ischemic lesions in 185 patients (41.57%). We did not observe any correlation between duration of symptoms, ABCD2 score, and positive or negative DWI lesions. Positivity for DWI was not associated with the presence of diabetes mellitus, hypertension, smoking habit, or age; however, an association with weakness was observed. We documented a time-dependent increase in the absolute risk of stroke: T0: 1.35% (95% confidence interval [CI], .81-2.8); T1: 4.78% (95% CI, 2.88-7.47); T2: 9.02% (95% CI, 4.66-5.70). We did not record any difference in stroke risk in patients with positive DWI lesions: T0: hazard ratio [HR], 1.43; 95% CI, .35-5.88; log-rank P = .60; T1: HR, 1.04; 95%CI, .42-2.61; log-rank P = .91; T2: HR, .83; 95% CI, .25-2.67; log-rank P = .86. CONCLUSIONS This long-term follow-up study in TIA patients documents that both positive and negative DWI patients treated with fast-track had similar long-term risks of stroke.

The Cloud Stroke Unit: 24-Hour Acute Stroke Expertise-on-Demand

Abstract The use of telemedicine, especially as it is relates to telestroke, has significantly expanded over the past one or two decades. The fact that stroke therapy is a time-critical disease process, coupled with the relative paucity of stroke-trained practitioners, makes telestroke an attractive technique of care. The authors’ objective was to summarize the evidence that support the reliability of telemedicine for diagnosis and efficacy in acute stroke treatment in collaboration between hospitals in two different countries.

Pulmonary Arteriovenous Malformation as a Cause of Embolic Stroke: Case Report and Review of the Literature

Background: Pulmonary arteriovenous malformation (PAVM) is an abnormal communication between pulmonary arteries and veins responsible for right-to-left shunting that could induce the development of embolic stroke. Summary: We describe an 82-year-old woman without history of respiratory or neurological diseases, who presented at our observation unit with acute onset of cerebral ischemia. Clinical, laboratory and radiological findings diagnosed a PAVM. Key Messages: Usually, endovascular procedures based on embolization or, alternatively, surgery represent the recommended treatment. However, both hormonal therapy and thrombolytic therapy can be used. In our patient, treatment with warfarin induced a remission of symptoms. This strategy should be tested in larger studies. i 2014 S. Karger AG, Basel

Reversible cerebral vasoconstriction syndrome after intercontinental airplane travel

A 51-year-old man was admitted to our Stroke Unit because of confusion, sleepiness, and weakness of the right limbs a few days after a recurrent thunderclap occipital headaches occurred for the first time during the descent phase of an intercontinental airplane flight lasting 12-h. He had no history of prior illness, and he did not take any medications or illicit drugs. He also denied any history of migraine. Clinical examination revealed normal blood pressure, normal heart rate and rhythm, and normal oxygenation. Emesis, photosensitivity, nystagmus, right upper and lower limb hemiparesis were noted, and the patient was uncooperative during the clinical examination. He reported having a recurrent severe headache occurring since the air travel. No hemorrhagic or ischemic lesions were seen on the admission head CT scan. Brain MRI–DWI showed multifocal restricted diffusion areas in the right cerebellar hemisphere, subcortical white matter of the centrum semiovale, knee and splenius of the corpus callosum, and anterior thalamus of the left hemisphere. An MRA demonstrated multiple narrowings of the basilar artery, posterior cerebral arteries and intracranial tract of the vertebral arteries. Similarly, we found multifocal segmental vasoconstrictions of the left internal carotid, right internal carotid and middle cerebral arteries (M1 tract) (Fig. 1a, c). Routine laboratory examinations revealed the presence of increased PCR values (1.83 mg/ dl) and high ESR (50 mm). Chest X-ray study, echocardiography and ultrasound examinations of the arteries of the neck were unremarkable. The patient was started on intravenous nimodipine, methylprednisolone and analgesic treatment for headaches, and after 11 days was discharged free of the signs or symptoms presented on admission. During follow-up, the patient underwent a new MRI–DWI and MRA that showed, after 20 days from acute event, complete regression of the multifocal segmental vasoconstriction of the intracerebral arteries (Fig. 1b, d). Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by a reversible and multifocal vasoconstriction of cerebral arteries and severe headaches with or without focal neurological deficits or seizures [1]. Thunderclap headache is the most common clinical feature together with nausea, vomiting, confusion and blurred vision while subarachnoid, intracerebral hemorrhage or ischemic stroke represents possible major complications. The pathogenesis remains poorly understood, but an alteration of cerebral vascular tone that occurs spontaneously or is triggered by endogenous/exogenous substances seems to be plausible [2]. Putative precipitants of RCVS are the postpartum state, vasoactive drugs, immunosuppressants or blood products, catecholamine-secreting tumors, cervical and cerebral largeartery lesions, and head trauma. Recently, a case of RCVS precipitated by airplane descent has been reported [3]. The diagnosis of RCVS is based on vascular imaging (CT, MRI or digital angiography), and the abnormalities are usually multiple and bilateral resulting in severe narrowing of intracranial arteries (classical ‘‘sausage on a string’’) [1] Treatment of RCVS consists of calcium channel blockers (nimodipine or verapamil), glucocorticoids and analgesics for headaches. To our knowledge this is the second case of RCVS associated with air flight. It suggests that RCVS may be precipitated by air travel, and that milder forms of RCVS occurring after flying may & Maria Cristina Bravi mcbravi@tiscali.it

Women Stroke Association statement on stroke

We describe the current and future objectives of the Women Stroke Association, a nonprofit multidisciplinary organization promoting research awareness on medical, psychological, and social issues concerning women affected by cerebrocardiovascular disease. In this paper, we deal with only cerebrovascular disease, whereas cardiovascular disorders will be addressed in a future paper. Gender differences in the clinical presentation of cerebrovascular diseases have been repeatedly suggested, and some treatment options may not be as effective and safe in men and women. For many years, women have either been underrepresented or excluded from randomized clinical trials, and the majority of therapeutic research has been carried on predominantly male populations. Furthermore, gender differences have been shown to contribute to different responses to cerebrovascular drugs in women when compared with men, regarding pharmacokinetics, pharmacodynamics, and physiology. In this statement, we discuss main research fields relevant to Women Stroke Associations mission and commitment, highlighting opportunities and critical from the womens health perspective. Future directions and goals of the Women Stroke Association arise from these considerations and represent the associations commitment to combating stroke.

Vascular Parkinsonism: Motor and Non-Motor Response on Treatmentwith Rotigotine

To date dopaminergic therapy has shown unsatisfactory effect on vascular Parkinsonism symptoms and related disturbances. In this case series we describe the effect of rotigotine treatment in patients with subacute onset of Parkinson’s like movement (3-6 months) after ischemic stroke of thalamus or internal capsule areas with concomitant leukoencephalopathy. Rotigotine treatment seems to improve both motor and cognitive symptoms of our sample; further studies are needed to clarify the effect of continuous dopaminergic stimulation on nigro-striatal functions in vascular patients with Parkinsonism like disturbances.

Rotigotine as Pharmacological Augmentation Strategy of Early Rehabilitation of Acute Ischemic Stroke Patient

Early rehabilitation in stroke patient is generally regarded as key strategy to improve clinical outcome and patient’s quality of life. Based on theoretical considerations of brain plasticity and experimental studies pharmacological augmentation of stroke rehabilitation might be a reasonable intervention to further improve stroke patient prognosis. Rotigotine with transdermal delivery system continuous over 24 hrs that provides an exciting and important opportunity to manipulate the brain’s pharmacological environment at a time when physiological remodeling of the brain is occurring through conventional rehabilitation treatments [1]. Understanding the relationship between pharmacologically primed neuroplasticity and practice dependent neuroplasticity is of major scientific interest in understanding how the brain adapts to injury. Some previous studies have suggested that levodopa in combination with physiotherapy may have a positive effect on motor deficits following stroke [2,3].

Muscle, Peripheral Nerve and Autonomic Changes

Muscle, peripheral nerve and autonomic disorders associated with acute cerebrovascular events are a large spectrum of conditions, their pathophysiology, clinical features, frequencies of occurrence, prognosis and treatment are diverse; the disturbances may be primary or secondary to acute cerebrovascular events. These disorders have been previously defined as multiple neurological complications as the underlying pathophysiological mechanism may largely differ; their characterization may need a full clinical, neuroradiological, neurophysiological, immunological, biochemical and genetic analyses assessment, and an autonomic function test may also be needed as well as nerve and muscle biopsy. In this chapter we present multiple neurological complications secondary to acute cerbrovascular events.