Sofia Calado

Orolingual Angiodema Associated with Alteplase Treatment of Acute Stroke: A Reappraisal

BACKGROUND Orolingual angioedema has been increasingly recognized as a potentially life-threatening complication associated with alteplase treatment of stroke. Concomitant treatment with an angiotension converting enzyme inhibitor (ACEi) and localization of infarction in the territory of middle cerebral artery seem to be associated with a higher risk of this complication. METHODS We report the cases of orolingual angioedema among the patients undergoing alteplase treatment in our Stroke Unit. Additionally, we reviewed the literature to evaluate the pathophysiology, clinical characteristics, and treatment options. RESULTS In our Stroke Unit, among 236 patients given alteplase for acute stroke, 8 patients (3.4%) developed angioedema. The clinical picture varied from localized labial edema to extensive lingual edema with respiratory distress but in all cases it gradually resolved with symptomatic treatment. Seven patients had a hemispheric stroke (4 with lateralized angioedema, contralateral to the ischemic lesion), whereas the other 1 patient had a right superior cerebellar artery stroke (with lateralized angioedema, ipsilateral to the ischemic lesion). The National Institutes of Health Stroke Scale score at admission ranged from 6 to 24 (median 12.5). Five patients were taking an ACEi. Our results are similar to previously published data. In the literature, it appears that orolingual angioedema occurs in .2-5.1% of all stroke patients receiving Alteplase treatment. CONCLUSIONS Orolingual angioedema is a potential complication of which treating physicians in stroke units need to be aware, even in those cases without history of ACEi treatment and without infarction in the territory of the middle cerebral artery. All patients who receive alteplase treatment should be monitored carefully.

Oral direct thrombin inhibitor as an alternative in the management of cerebral venous thrombosis: a series of 15 patients.

Background Cerebral vein thrombosis is a rare cause of stroke with significant risk of death and long-term dependency. Anticoagulation has been associated with better long-term prognosis, and vitamin K antagonists are usually prescribed in this setting. Aim The aim of this study was to present a series of 15 cerebral vein thrombosis patients treated with dabigatran. Methods Retrospective study of clinical, imaging, and follow-up characterization of all patients admitted with cerebral vein thrombosis and treated with dabigatran in a tertiary neurology department between June 2011 and December 2013 was conducted. Complications and adverse effects were recorded. Modified Rankin Scale was used to assess clinical severity; excellent outcome was defined as modified Rankin Scale at six-months of 0 to 1. Recanalization was assessed with an angiographic method (computer tomography, magnetic resonance imaging, or digital subtraction angiography). Results Eighteen patients were admitted for cerebral vein thrombosis. Dabigatran was started in 11 patients, and warfarin was started in 7. Four patients on warfarin were switched to dabigatran because of adverse effects at 0·5, 1, 3·5, and 4 months. A total of 15 patients were treated with dabigatran with median follow-up time of 19 months. Excellent outcome was observed in 87% of patients and recanalization in 80%. Conclusions We report the largest series of cerebral vein thrombosis patients treated with dabigatran. Clinical outcome was excellent in most patients and not different from other studies. Dabigatran could possibly be considered an alternative to warfarin; nevertheless, further prospective assessment with randomized controlled studies is warranted.

Embolic stroke of unknown source (ESUS) in young patients

The Cryptogenic Stroke International Working Group defined a new subgroup of cryptogenic stroke – embolic stroke of undetermined source (ESUS), based on clinical and imaging findings. Minor cardioembolic and atheroembolic sources were putatively implicated, and it was hypothesized that anticoagulant therapy might be warranted (1). We aimed to assess the role of minor embolic sources in ESUS in young stroke patients by comparing the prevalence of minor embolic sources in patients with ESUS and in patients with stroke of determined origin. Etiology was defined according to the TOAST criteria. ESUS and minor cardioembolic/atheroembolic stroke were defined according to the proposed criteria (1). We studied 100 consecutive ischemic stroke patients (see Table 1) aged between 18 and 55 years admitted in a Neurology department between January 2010 and August 2014 (mean age 46 years, range 22–55; 56% male; mean NIHSS at admission 4). The overall prevalence of minor cardioembolic sources was 53%, and of atheroembolic sources was 32%. Cryptogenic stroke was diagnosed in 51 patients. Among these, 42 patients were ESUS (mean age 45 years, range 26–55; 50% male; mean NIHSS at admission 4). The ESUS group neither have a higher prevalence of minor cardioembolic, 50% (21/42) vs. 50% (27/54), nor a higher prevalence of minor atheroembolic, 38·1% (16/42) vs. 30·8% (15/47), P = 0·641, sources, when compared with all strokes with a determined cause other than cardioembolic and other than large vessel disease, respectively. Although most young patients with cryptogenic stroke fulfill ESUS criteria, minor embolic sources do not seem to be more prevalent in ESUS than in strokes of determined cause; therefore, further explanations should be sought in this group.

Impact of stroke education on middle school students and their parents: A cluster randomized trial

Background School students are an attractive target for stroke education due to the potential impact on stroke prevention and recognition. Additionally, these students can drive behavioral changes in their families. Aim To evaluate the impact of stroke education on school students, in terms of students’ and parents’ acquired stroke knowledge. Methods A structured questionnaire on knowledge of stroke was filled out by eighth-grade students and one of their parents in seven public schools. In four of these schools, students attended a stroke lecture; educational flyers and magnetic posters were distributed and parent education was encouraged. Students and parents of the other three schools were included in a control group. Students and parents, of both intervention and control groups, were resubmitted to the initial structured questionnaire within one week of the stroke lecture and three months later. Results We included 764 students and 344 parents, 383 (50.1%) and 210 (61.0%) in the intervention group. Correct test scores for students before, within one week, and three months after the intervention were 54.49% versus 55.03% (p = 0.418), 98.69% versus 60.89% (p < 0.001), and 95.58% versus 75.7% (p < 0.001) in the intervention and control groups, respectively. Correct test scores for parents at the same time points were 68.78% versus 64.47% (p = 0.107), 96.89% versus 71.42% (p < 0.001), and 94.58% versus 76.54% (p < 0.001) in the intervention and control groups, respectively. Conclusions School-based interventions may improve stroke knowledge in middle school students and their parents.

Herbal Supplements Association with Reversible Cerebral Vasoconstriction Syndrome: A Case Report

BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is a clinico-radiologic syndrome characterized by thunderclap headache and reversible multifocal arterial constrictions that resolves within 3 months. RCVS can be either spontaneous or related to a trigger; vasoactive drugs including over-the-counter medicine are common culprits. Nevertheless, there are sparse data on the association of herbal supplements in the genesis of unexplained RCVS. METHODS We describe a case of RCVS with a temporal association with the consumption of a diet pill composed of green tea, L-carnitine, and conjugated linoleic acid. We reviewed the literature describing RCVS cases associated with consumption of herbal supplements or plants. RESULTS A 50-year-old black woman presented at the emergency room with a thunderclap headache less than 1 week after beginning a new herbal supplement with weight loss purpose. Angiographic study revealed multiple arterial constriction of virtually all intracranial territories that were reversed 28 days later. The patient was discharged with minimal symptoms. From our review, we identified 5 previous reports of herbal product-related triggers. CONCLUSIONS Different factors can trigger RCVS. Besides our case, at least 5 other nutraceutical products were described to be associated with the disorders, 3 of them in patients without any other clear cause. Clinicians should be aware of the possible role of herbal supplements in RCVS, and their use should be systematically assessed in large RCVS cohorts to clarify this association.