Thomas Ritzenthaler

Thrombolysis for Acute Minor Stroke: Outcome and Barriers to Management

Background: We evaluated the management, outcome and haemorrhagic risk in a cohort of ischaemic stroke patients with mild symptoms treated with intravenous tissue plasminogen activator (tPA) within the first 4.5 h. Methods: We analysed data from a prospective stroke thrombolysis registry. A total of 1,043 patients received tPA between 2010 and 2014 in the 5 stroke units of the RESUVAL stroke network (Rhône Valley, France). Among them, 170 patients had a National Institute of Health Stroke Scale (NIHSS) score ≤4 (minor group: MG) before tPA and 873 patients had a NIHSS score >4. Results: A high rate (77%) of excellent outcome (3-month-modified Rankin Scale score ≤1) was observed in the MG. No symptomatic intracerebral haemorrhage occurred and the rate of any haemorrhagic transformation was 5%. Fifty-four percent of the MG patients had visible arterial occlusion before tPA. Patients of the MG were less likely to be transported by Emergency Medical Services and to be directly admitted to the stroke unit or to imaging. Median delays from onset to admission, from admission to imaging and from onset to tPA were longer in the MG. Conclusion: Our data provided evidence of safety and suggested potential benefit of thrombolysis in patients with NIHSS score ≤4. A majority of these patients exhibited arterial occlusion before thrombolysis. Most often, patients with mild stroke are not given priority in terms of the mode of transport, direct admission to stroke unit and rapid imaging, resulting in an increased delay from onset to thrombolysis. Health system improvements are needed to provide all suspected stroke victims equal access to imaging and treatment on an emergency basis.

Total Mismatch: Negative Diffusion-Weighted Imaging but Extensive Perfusion Defect in Acute Stroke

Background and Purpose— The perfusion-weighted imaging (PWI)/diffusion-weighted imaging (DWI) mismatch may identify patients who benefit from thrombolysis. However, some patients exhibit a “total mismatch,” ie, negative DWI but extensive PWI defect. We aimed to assess clinical and MRI data of these patients. Methods— From June 2007 to December 2008, patients with anterior circulation ischemic stroke were evaluated for a “total mismatch” profile. MRI was performed at admission and at day 1. The score was assessed at baseline and the modified Rankin scale score was assessed at day 30. Results— Among 52 patients, 3 showed a total mismatch with arterial occlusion confirmed on magnetic resonance angiography. All had fluctuating symptoms (National Institutes of Health Stroke Scale scores, 0 to 10) and received intravenous tissue plasminogen activator. Day 1 DWI disclosed minimal changes in all patients. Outcome was favorable in all patients (day 30 modified Rankin scale, 0–1). Conclusion— PWI may be helpful for treatment decisions in patients without DWI damage and fluctuating clinical course.

Cyclosporine in acute ischemic stroke

Objectives: We examined whether IV administration of cyclosporine in combination with thrombolysis might reduce cerebral infarct size. Methods: Patients aged 18 to 85 years, presenting with an anterior-circulation stroke and eligible for thrombolytic therapy, were enrolled in this multicenter, single-blinded, controlled trial. Fifteen minutes after randomization, patients received either an IV bolus injection of 2.0 mg/kg cyclosporine (Sandimmune, Novartis) or placebo. The primary endpoint was infarct volume on MRI at 30 days. Secondary endpoints included infarct volume according to the site (proximal/distal) of arterial occlusion and recanalization after thrombolysis. Results: From October 2009 to July 2013, 127 patients were enrolled. The primary endpoint was assessed in 110 of 127 patients. The reduction of infarct volume in the cyclosporine compared with the control group was overall not significant (21.8 mL [interquartile range, IQR 5.1, 69.2 mL] vs 28.8 mL [IQR 7.7, 95.0 mL], respectively; p = 0.18). However, in patients with proximal occlusion and effective recanalization, infarct volume was significantly reduced in the cyclosporine compared with the control group (14.9 mL [IQR 1.3, 23.2 mL] vs 48.3 mL [IQR 34.5, 118.2 mL], respectively; p = 0.009). Conclusions: Cyclosporine was generally not effective in reducing infarct size. However, a smaller infarct size was observed in patients with proximal cerebral artery occlusion and efficient recanalization. Classification of evidence: This study provides Class I evidence that in patients with an acute anterior-circulation stroke, thrombolysis plus IV cyclosporine does not significantly decrease 30-day MRI infarct volume compared with thrombolysis alone.

Nocturnal urine melatonin and 6-sulphatoxymelatonin excretion at the acute stage of ischaemic stroke.

Abstract:  Melatonin’s neuroprotective action has been demonstrated in experimental models of brain ischaemia. The relationship between stroke and melatonin levels has been based on scarce and small sample size studies. In addition, the changes have not been correlated with the age of patients. We compared levels of nocturnal urinary melatonin and its metabolite, 6‐sulfatoxymelatonin (aMT6S) in a large series of acute ischaemic stroke patients and healthy volunteers. Consecutive ischaemic stroke patients with a first episode of anterior circulation stroke were recruited. Urine samples were collected in 127 patients on day 1 poststroke and in a control population including 216 healthy volunteers, from 20:00 to 08:00 hr. Melatonin and aMT6S were measured by radioimmunoassay. Differences in melatonin and aMT6S levels between ischaemic stroke patients and healthy volunteers were assessed by gender and age categories, using the Student’s t‐test. Melatonin excretion was decreased in stroke patients compared with healthy volunteers (74.1 ± 13.9 versus 211.9 ± 31.0 ng/hr; P = 0.0004), whereas aMT6S level was not significantly reduced (6371 ± 1028 versus 4469 ± 508 ng/hr; P = 0.10). Conversely, the stratification by age showed a significant reduction of both melatonin and aMT6S levels among ischaemic stroke patients over 70 yr (P = 0.001 and P = 0.03 respectively). The impact of melatonin at the acute stage of stroke on clinical severity and lesion size needs further assessment, as melatonin may have potential neuroprotective effects.

Ventriculitis revealing Bing-Neel syndrome in a patient without Waldenstrom's macroglobulinemia

Hospices Civils de Lyon, Service de Réanimation Médicale, Hôpital de la Croix Rousse, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France Hospices Civils de Lyon, Service de Maladies Infectieuses, Hôpital de la Croix Rousse, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France Centre Léon-Bérard, 28 rue Laennec, 69008 Lyon, France Hospices Civils de Lyon, Centre de Pathologie Est, Groupement Hospitalier Est, 56 boulevard Pinel, 69003 Lyon, France Hospices Civils de Lyon, Service de Neuro-oncologie, Hôpital Neurologique, 59 boulevard Pinel, 69003 Lyon, France

Reversibility of brainstem damage after a mechanical thrombectomy.

Diffusion-weighted imaging (DWI) has revealed the reversal of often sizeable damage due to brainstem lesions in patients treated within 4.5 hours, and this reversibility of damage was strongly associated with early neurological improvement.1 In posterior circulation stroke, the reversibility of damage due to a DWI-detected lesion is poorly documented after intravenous thrombolysis2 or intraarterial therapy.3,4 We report a case of vertebrobasilar stroke mechanically recanalized 4.5 hours after symptom onset that revealed substantial reversal of early ischemic damage to the brainstem on DWI scans. A 51-year-old man suddenly went into coma after experiencing bilateral flaccidity in the lower extremities. A noncontrast computed tomographic scan showed that there were no signs of cerebral ischemia. Magnetic resonance imaging of the brain was performed 3 hours after onset, and DWI scans showed right lateral pontine (Figure, A) and central pontine infarction (Figure, B) secondary to acute basilar artery occlusion (Figure, C). A mechanical thrombectomy using a Solitaire Flow Restoration (FR) stent (Covidien) was performed while the patient was under general anesthesia, and complete recanalization was obtained 4.5 hours after stroke onset (Figure, D). The patient was extubated 12 hours later, and recovery was complete on day 1. Magnetic resonance imaging on day 4 revealed total reversibility of the damage to the right lateral portion of the pons due to the lesion (Figure, E) and significant reduction in the volume of the central portion of the pons (Figure, G). These findings were also observed in fluid-attenuated inversion recovery sequences (Figure, F-H).

Sequential MR Assessment of the Susceptibility Vessel Sign and Arterial Occlusion in Acute Stroke

Susceptibility vessel sign (SVS) may likely influence recanalization after thrombolysis. We assessed, through the European sequential MRI database “I‐KNOW,” the relationship between the presence of SVS on T2‐weighted gradient echo imaging, its angiographic counterpart on magnetic resonance angiography and its subsequent impact on recanalization after thrombolysis.

Safety of early initiation of rivaroxaban or dabigatran after thrombolysis in acute ischemic stroke.

The introduction of direct oral anticoagulants (DOA) in the early stage of cerebral infarction after thrombolysis may reduce the recurrence rate but raises safety concern. We sought to study the feasibility and safety of the introduction of rivaroxaban or dabigatran in this context. Thirty-four consecutive patients admitted for ischemic stroke related to non-valvular atrial fibrillation in whom DOA were given within the first two weeks following intravenous rt-PA were studied. A clinical and radiological monitoring protocol was established to ensure the safety of the prescription. None of the patients experienced symptomatic hemorrhagic transformation or a symptomatic recurrent ischemic event after early rivaroxaban or dabigatran introduction.

Spontaneous dissections of the carotid arteries in a patient with recent coronary artery dissection.

pravastatin 20 mg daily. Post-myocardialinfarction echocardiography had demonstrated anteroseptoapical hypokinesia with low left ventricular ejection fraction (50%). On admission, right hemiparesis and aphasia had cleared. The patient had no history of recent infection (no fever, no flu, no respiratory tract symptoms) and reported no prior transient neurological deficit, headache or cervical pain. No Horner’s syndrome was observed. The patient had no skin, joint, eye or skeletal abnormalities suggesting a hereditary connective tissue disorder. No family history of arterial dissection or valvular heart disease was noted. Multimodal MRI performed on June 27 showed no recent ischemic lesion on diffusion-weighted imaging. T 2 -weighted sequences showed bilateral middle cerebral artery/anterior cerebral artery borderzone hyperintensities. Magnetic resonance angiography showed occlusion of the right ICA beginning 1 cm after the bifurcation and narrow stenosis of the left ICA in the subpetrous segment consistent with the diagnosis of bilateral spontaneous ICA dissection ( fig. 2 ). Collateral supply was efficient through the right posterior communicating artery. No intramural hematoma was observed. No angiographic changes of fibromuscular dysplasia were found. Neck Dear Sir, Multiple dissections of the carotid and coronary arteries are exceptional [1] . We report the case of a young woman without known hereditary connective tissue disorder who presented with spontaneous dissection of the left anterior descending coronary artery, followed by spontaneous dissection of both internal carotid arteries (ICA) 3 weeks later. We discuss the pathogenesis of these multiple dissections.

Acute Headache Followed by Focal Neuropsychological Impairment in Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL)

Occasionally, patients with Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) present atypical features such as confusion, coma, or nonconvulsive status epilepticus. Acute focal neuropsychological syndrome revealing the disease has been poorly documented. We report the atypical presentation of two patients in whom CADASIL was revealed by an episode of headache followed by focal neuropsychological impairment.