Tomas Peisker

Impact of aging on cerebral vasoregulation and parenchymal integrity

UNLABELLED Sufficient vasodilatory and vasoconstrictive reactivity of cerebral arterioles is an important prerequisite for adequate capillary perfusion. To appreciate its capacity during aging and to elucidate its impact on parenchymal integrity we undertook a correlation using ultrasonography and brain MRI. Sixty healthy persons with no stenoses in the carotid and vertebral arteries were examined by transcranial Doppler to assess middle cerebral artery mean flow velocities (MFV) at rest, after 30 s apnea and after 90 s hyperventilation. Young persons, N=20, with a mean age of 24.8 (20-32) were compared with the middle aged, N=20, 54.8 (40-63) and elderly, N=20, 76.2 (69-84). A different cohort of 40 elderly persons, with a mean age of 68.4 (57-85) were evaluated also by MRI using FLAIR and T2-weighted sequences. Their extent of leukoaraiosis measured by the Fazekas scale was correlated with their vasoregulatory capacity. RESULTS The steady state MFV in young persons, 71 cm/sec, decreases to 48.1 and to 44.9 cm/sec in the middle and the old aged. The post-apnoic vasodilatation in young persons accelerates the MCA blood velocity by 41.7%, while in middle and old age only by 37.6 and 32.9% respectively. The MCA deceleration post-hyperventilation by 50.2% in young people decreases to 39.1% and to 29.7% respectively in the older categories. The correlation of periventricular hyperintensities and deep white matter lesions was found highest with the index of resistance (0.45, p<0.05) while with the apnoic acceleration and hyperventilatory deceleration it was minimal (0.01 and 0.08 respectively). CONCLUSION The extent of vasoregulatory capacity during aging decreases along with the decreasing basic MFV. Its effect on the initial stages of leukoaraiosis is minimal.

Acute stroke therapy: A review

This review summarizes the modern early diagnosis and acute phase treatment of acute stroke. The guidelines for treatment of acute ischemic stroke underwent major changes in 2015 and endovascular therapy (catheter-based mechanical thrombectomy with a stent retriever) became the class IA indication for patients presenting within less than 6h from symptom onset who have proven occlusion of large intracerebral artery in anterior circulation. Acute stroke care organization should enable to perform effective revascularization therapy as soon as possible after the initial brain imaging whenever this examination provides indication for the procedure.

Cerebral blood supply with aging: normal, stenotic and recanalized.

UNLABELLED The prosperity of brain parenchyma during aging depends on the preservation of cerebral blood flow (CBF) parameters. We have analysed ultrasonographic measurements of peak systolic (PSV) and end diastolic velocities (EDV) along with pulsatility (PI) and resistance indexes (RI) in common (CCA), internal (ICA) and external carotid artery (ECA) (N=199) and in vertebral arteries (VA) (N=200) in patients without any signs of stenosis. In two other cohorts patients with internal carotid artery stenosis (N=231) and patients prior to and after therapeutic recanalization (N=81) were evaluated in the same parameters. RESULTS in the range of 21-92 years PSV in CCA decreases by 7 mm/s/year, while in ICA only by 2.31 mm/s/year. The decrease of EDV in carotid arteries occurs between 1.72 and 2.28 mm/s/year. PSV in VA drops down by 0.91 mm/s/year, EDV by 0.86 mm/s/year. PI and RI increase with age in all vessels, but not significantly. Stenotic ICAs are associated with increased PSV in the range of 0.7-2.9 m/s, but also with an increasing PSV variability along the growing stenosis in individual patients. In all degrees of stenoses some patients preserve normal velocities. In average the increment for each 10% of the stenosis below 50% makes 8 cm/s, while above 50% it makes already 50 cm/s. In persons with bilateral stenoses the increment with growing stenosis is steeper. The restoration of normal ICA lumen by means of carotid endarterectomy or by angioplasty with stenting results in an average drop by 1.23 m/s in PSV and by 0.4 m/s in EDV. We have investigated the ophthalmic artery and other substitution supplies and deduce, that the remarkable differences in blood flow velocity reactions to a compromised carotid lumen depend on the formation of collaterals in mutual interplay with peripheral resistance.

Direct catheter-based thrombectomy in acute ischaemic stroke performed collaboratively by cardiologists, neurologists and radiologists: the single-centre pilot experience (PRAGUE-16 study).

AIMS To assess the feasibility of direct catheter-based thrombectomy (d-CBT) performed jointly by cardiologists, neurologists and radiologists. METHODS AND RESULTS Computed tomography (CT) was completed within <6 hours from onset of acute ischaemic stroke and excluded bleeding or developed ischaemia in 23 patients who fulfilled pre-specified entry criteria. The mean NIHSS was 17 (8-24). Mechanical recanalisation was successful in 19/23 patients (83%). The mean symptom onset – CT time was 81 min, CT – sheath insertion 47 min, sheath – reperfusion 46 min. Three patients died within 30 days, two others within 90 days (overall three-month mortality 22%). The mean mRs at 90 days for the entire group was 3.19, among survivors 2.31 and among survivors treated within <120 minutes 1.17. Favourable functional outcome (mRs ≤2) was achieved in 48% of patients. Five patients (22%) had full (mRs=0) or nearly full (mRs=1) neurologic recovery. Seven patients were able to be discharged from neurology ICU directly home after a short (<7 days) hospital stay. Two patients had symptomatic intracranial haemorrhage. CONCLUSIONS Acute stroke treatment by d-CBT jointly by neurologists, cardiologists and radiologists provided promising results especially in patients reaching the cathlab within <2 hours from stroke onset.

Spontaneous spinal epidural hematoma after abrupt sneezing with prompt recovery of severe paraparesis

Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic condition with threatening consequences when spinal cord compression is present. The diagnosis must be performed quickly using magnetic resonance imaging (MRI), which shows collection of blood in the epidural space. With spinal cord compression, there is an indication for urgent surgical decompression. Here, we present a 64-year-old woman who developed sudden thoracic and lower back pain accompanied by severe paraparesis and urinary retention after sneezing abruptly. An MRI revealed a posterior thoracic epidural hematoma extending from the T6 to T11 vertebral level with spinal cord compression. Decompression was recommended, but the patient refused surgery, while neurologically improving with time. Complete neurologic recovery was observed within 24 hours after SSEH onset. A conservative therapeutic approach with careful observation may therefore be considered as a treatment of choice in some cases where surgery is refused, (due to high risk or other reasons) and neurologic recovery is early and sustained.

Direct Catheter-Based Thrombectomy for Acute Ischemic Stroke: Outcomes of Consecutive Patients Treated in Interventional Cardiology Centers in Close Cooperation With Neurologists

We sought to evaluate the outcomes of acute stroke patients, who did not undergo thrombolysis, and who were treated by direct catheter-based thrombectomy (CBT) in 3 interventional cardiology centers without pre-existing onsite programs for neurovascular interventions. Neurologists routinely selected

Clinical spectrum in CADASIL family with a new mutation

BACKGROUND Clinical presentation of CADASIL patients is variable due to the impact of other vascular risk factors and the type of a NOTCH3 mutation. This variability may impede the diagnosis of the disease. SUBJECTS AND METHODS We report a comprehensive evaluation of several individuals in the CADASIL family whose member was identified to have the new mutation of NOTCH3 receptor on exon 6 (p. G296C). We performed genetic testing, clinical and neuropsychological examination, cerebral MRI, Doppler sonography of cerebral arteries, fundoscopic examination and fluorescent angiography in six family members to determine the corresponding clinical spectrum associated with the new mutation. RESULTS AND CONCLUSION The CADASIL mutation was detected in four individuals. Three of them were symptomatic, two having a history of stroke and one suffering from migraine. Although individuals had heterogeneous findings, the common feature included vascular changes that were present on cerebral and/or retinal arteries in all the mutation carriers even in one subject without clinical manifestation of the disease.

Feasibility and safety of direct catheter-based thrombectomy in the treatment of acute ischaemic stroke. Cooperation among cardiologists, neurologists and radiologists. Prospective registry PRAGUE-16

AIMS The aim of this study was to evaluate the role of direct catheter-based thrombectomy (d-CBT, without thrombolysis) and the feasibility and safety of d-CBT performed in an interventional cardiology centre. METHODS AND RESULTS This single-centre, prospective observational registry based on the pre-specified protocol included three months of follow-up. The decision to perform acute stroke intervention was made by a neurologist based on the clinical and imaging findings. Inclusion criteria were moderate-to-severe acute ischaemic stroke (NIHSS ≥6), <6 hours from symptom onset, no large ischaemia on the admission CT scan and CT evidence for an occluded large artery. The primary outcome was functional neurologic recovery (mRS 0-2) at three months. Key secondary outcomes were the angiographic recanalisation rate and symptomatic intracranial bleeding. A total of 115 consecutive patients (mean age 66 years) were enrolled during a period of four years: 84 patients underwent d-CBT and 31 patients bridging thrombolysis with immediate catheter intervention (TL-CBT). The annual number of procedures increased from 13 (initial 12 months) to 41 (last 12 months). Angiographic success (TICI flow 2b-3) was 69% after d-CBT and 81% after TL-CBT. It was higher in isolated occlusions of the middle cerebral artery (MCA, 74% and 100%) or of the proximal internal carotid artery (ICA, 80% and 100%), while it was lower in combined ICA+MCA occlusions (63% and 70%) and in basilar or vertebral occlusions (57% and 50%). Neurologic recovery (mRS ≤2 after 90 days) was achieved in 40% of patients. It was higher (43%) in anterior circulation strokes than in posterior circulation strokes (25%). Direct CBT led to neurologic recovery in 36%, while in TL-CBT this was 52%. Best clinical outcomes (51% and 71% neurologic recovery rates) were achieved among patients with isolated MCA occlusion. Any symptomatic intracranial bleeding was present in 3.6% (d-CBT) and 6.5% (TL-CBT). Vessel perforation or major dissection occurred in 5.2% overall, and distal embolisation to other territory in 3.5% of patients. CONCLUSIONS Direct catheter-based thrombectomy may be considered in patients with contraindications for thrombolysis or in patients with very short CT-groin puncture times. A randomised trial is needed to evaluate better the role of direct catheter-based thrombectomy. Acute stroke interventions performed in close cooperation among cardiologists, neurologists and radiologists are feasible and safe.