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Repeated systemic thrombolysis after early recurrent stroke: always hazardous?
No full text[no abstract available
The risk stratification based on the CHA2DS2-VASc may predict the response to intravenous thrombolysis after stroke
No full textCHA2DS2-VASc score influences the outcome in stroke patients with or without atrial fibrillation (AF). We assessed whether the risk stratification based on the prestroke CHA2DS2-VASc score may predict the response to intravenous (IV) thrombolysis in stroke patients. We conducted an analysis on prospectively collected data of 516 consecutive AF and non-AF patients treated with IV thrombolysis. Outcome measures were major improvement (NIH Stroke Scale [NIHSS] ≤8 points from baseline or NIHSS score 0) and deterioration (death or NIHSS ≥1 points from baseline) or no improvement (NIHSS score equivalent to baseline) at 24 h; excellent (modified Rankin Scale [mRS] score ≤1) and unfavorable outcome (mRS score >2) at 3 months. Multivariate analysis showed that ORs for major improvement and excellent outcome were lower in patients with intermediate risk (CHA2DS2-VASc = 1) (OR 0.39, 95 % CI 0.16–0.92, p = 0.032; OR 0.10, 95 % CI 0.02–0.56, p = 0.009), moderately high risk (CHA2DS2-VASc = 2) (OR 0.43, 95 % CI 0.19–0.96, p = 0.040; OR 0.16, 95 % CI 0.03–0.76, p = 0.022), and very high risk (CHA2DS2-VASc > 3) (OR 0.31, 95 % CI 0.15–0.65, p = 0.002; OR 0.17, 95 % CI 0.04–0.81, p = 0.026), whereas ORs for deterioration or no improvement and unfavorable outcome were higher only in patients with very high risk (OR 4.26, 95 % CI 1.24–14.65, p = 0.021; OR 9.26, 95 % CI 1.15–74.65, p = 0.037), compared with low risk (CHA2DS2-VASc = 0). Low-risk level based on the prestroke CHA2DS2-VASc score was predictor of effective response to IV thrombolysis. Very high-risk level was predictor of failed response, compared with low-risk level
Intravenous thrombolysis on early recurrent cardioembolic stroke: “Dr. Jekyll” or “Mr. Hyde”?
No full textEarly recurrent cardioembolic stroke on the previously unaffected side has very rarely been reported during or after intravenous recombinant tissue plasminogen activator for acute ischemic stroke. For these cases, thrombolysis guidelines lack any clear recommendation. We report two cases of thrombolysed stroke patients, with paroxysmal atrial fibrillation but normal sinus rhythm on admission, who respectively developed recurrent ischemic stroke within few hours after complete improvement and during intravenous recombinant tissue plasminogen activator infusion. Intravenous thrombolysis was successfully repeated after echocardiographic evidence of left appendage thrombus in the first case and discontinued before complete administration in the secon
Modulation of somatoparaphrenia following left-hemisphere damage
No full textSomatoparaphrenic symptoms after left-hemisphere damage are rare. To verify the potential role of body-related sensory (proprioceptive, visual, and somatosensory) manipulation in patients experiencing sensations of hand disownership, the symptoms of a patient suffering from right-hand somatoparaphrenia were monitored and clinical and neuropsychological variables were controlled. Four types of manipulation were administered: changes in spatial position of the hand, multisensory stimulation, and self-observation using video or mirrors. Multisensory visuo-tactile stimulation was efficacious in terms of reducing somatoparaphrenia, and changes in the position of the hand produced some positive effects. Third-person perspective self-observation did not, however, result in any changes
Hemiparesthesias in lacunar pontine ischemic stroke.
No full textIsolated paresthesia, or paresthesia not accompanied by sensory and/or motor deficits, is an extremely rare manifestation of a cerebrovascular accident. Lacunar pure sensory stroke (PSS) confined to thalamus is characterized by persistent or transient numbness, tingling, pain, burning, or another unpleasant sensation on one side of the body. However, in this condition a sensory loss to all primary modalities in the contralateral face and body is very often encountered. Also previous reported cases of PSS due to lacunar stroke in regions other than thalamus are characterized by the presence of sensory loss together with positive sensory symptoms, none of them reporting isolated paresthesia as the only clinical feature of PSS. We present a case of isolated paresthesia as only clinical manifestation of a lacunar PSS involving both trigeminal and medial lemniscus in dorsal paramedian pontine region. A PSS manifesting with isolated paresthesias may be secondary not only to a thalamic lacunar stroke, but also to a small ischemic lesion confined to both trigeminal and medial lemniscus in dorsal paramedian pontine region
Stroke etiologic subtype may influence the rate of hyperdense middle cerebral artery sign disappearance after intravenous thrombolysis
No full textDisappearance of hyperdense middle cerebral artery sign (HMCAS) on non-contrast brain computed tomography (CT) scan is a reliable sign of arterial recanalization after intravenous (IV) thrombolysis for ischemic stroke. We aimed to assess whether stroke etiologic subtype may influence the rate of HMCAS disappearance and the clinical outcome after IV thrombolysis. We conducted a retrospective analysis of data prospectively collected from 1031 consecutive stroke patients treated with IV thrombolysis. Outcome measures were HMCAS disappearance on follow-up CT scan within 22-36 h of IV thrombolysis, neurologic improvement (NIH Stroke Scale [NIHSS] ≤4 points from baseline or NIHSS score of 0) at 7 days, and modified rankin scale (mRS) ≤1 at 3 months. Of 256 patients with HMCAS on admission CT scan, 125 had a cardioembolic stroke, 67 a stroke due to large-artery atherosclerosis (LAA), 58 a stroke of undetermined etiology, and six a stroke secondary to carotid artery dissection. HMCAS disappearance occurred in 145 (56.6 %) patients, neurologic improvement in 122 (55.0 %) patients, and mRS ≤1 in 64 (32.8 %) patients. Compared with cardioembolic stroke patients, patients with stroke due to LAA had lower odds ratios (OR) for HMCAS disappearance (OR 0.29, 95 % CI 0.15-0.58, p < 0.001), neurologic improvement (OR 0.42, 95 % CI 0.22-0.82, p = 0.011), and mRS ≤1 (OR 0.18, 95 % CI 0.06-0.52, p = 0.002). No significant differences in outcome measures were found between cardioembolic strokes and strokes of undetermined etiology. This study suggests that stroke due to LAA is associated with lower rates of HMCAS disappearance, neurologic improvement, and mRS ≤1 after IV thrombolysis, compared with cardioembolic stroke
Reasons for exclusion from intravenous thrombolysis in stroke patients admitted to the Stroke Unit
No full textIntravenous (IV) thrombolysis is the treatment in ischemic stroke, but only the minority of patients receive this medication. The primary objective of this study was to explore the reasons associated with the decision not to offer IV thrombolysis to stroke patients admitted to the Stroke Unit (SU). We conducted a retrospective analysis based on data collected from 876 consecutive stroke patients admitted to the SU 4.5 h (p = 0.001) and unknown time of onset (or stroke present on awakening) (p = 0.004) were reasons listed in the current SPC of Actilyse reasons for exclusion even they occurred singly, whereas mild deficit (or rapidly improving symptoms) (p 80 years (p 4.5 h (p = 0.005), and unknown time of onset (p = 0.037), while severe pre-stroke disability (p = 0.025) and admission under non-stroke specialist neurologist assessment (p = 0.018) in patients with age >80 years. There are often unjustified reasons for exclusion from IV thrombolysis in SU
Thrombectomy for ischemic stroke with large vessel occlusion and concomitant subarachnoid hemorrhage
No full textTo report our experience in treating one patient with nontraumatic subarachnoid hemorrhage (SAH) and concurrent acute ischemic stroke (AIS) due to large vessels occlusion (LVO). A man in his 50 s presented with acute right hemiparesis and aphasia. Brain CT showed a SAH in the left central sulcus; CT-angiography revealed a tandem occlusion of the left internal carotid artery and homolateral middle cerebral artery. He underwent an angiographic procedure with successful recanalization. Follow-up CT demonstrated a striatal-lenticular stroke without SAH progression. While the absolute contraindication to IVT during intracranial bleeding remains unquestionable, the potential injury/benefit from MT is still debatable. Such cases constitute a blind spot in the guidelines where physicians face the dilemma of choosing between an acute endovascular treatment with the risks of hemorrhage progression and a conservative treatment with the associated poor clinical outcome. We decided to treat our patient invasively, considering the young age, also given the absence of prognostic factors that generally predict post-procedural reperfusion injury. We believe that, in similar cases, MT should be considered-despite not free of risks and drawbacks-to avoid the detrimental consequences of untreated AIS from LVO
Chronic fusiform aneurysm evolving into giant aneurysm in the basilar artery.
No full textFusiform basilar aneurysm is a rare condition with elevated mortality within a few days if untreated. On the basis of clinical course, the fusiform aneurysm can be distinguished in an acute type, such as dissecting aneurysm, which usually causes subarachnoid hemorrhage or cerebral ischemia and in a chronic type with a relatively slow growth, which may evolve into a giant aneurysm leading to serious complications. We report a case of an 80-year-old man with a surgically untreated fusiform aneurysm that evolved into a giant aneurysm of the basilar artery within 4 years. The patient presented recurrent ischemic events involving the posterior circulation without aneurysmal rupture or bleeding
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