Multimodal 3 tesla MRI confirms intact arterial wall in acute stroke patients after stent-retriever thrombectomy

BACKGROUND AND PURPOSE The aim of this prospective study was to assess vascular integrity after stent-retriever thrombectomy. METHODS Dissection, contrast medium extravasation, and vasospasm were evaluated in 23 patients after thrombectomy with biplane or 3D-digital subtraction angiography and 3-Tesla vessel wall MRI. RESULTS Vasospasm was detected angiographically in 10 patients, necessitating intra-arterial nimodipine in 2 of them. Contrast extravasation, intramural hemorrhage, or iatrogenic dissection were not detected on multimodal MRI in any patient even after Y-double stent-retriever technique. CONCLUSIONS Our findings suggest that clinically relevant vessel wall injuries occur rarely after stent-retriever thrombectomy.

Additive effect of anemia and renal impairment on long-term outcome after percutaneous coronary intervention

INTRODUCTION Anemia and renal impairment are important co-morbidities among patients with coronary artery disease undergoing Percutaneous Coronary Intervention (PCI). Disease progression to eventual death can be understood as the combined effect of baseline characteristics and intermediate outcomes. METHODS Using data from a prospective cohort study, we investigated clinical pathways reflecting the transitions from PCI through intermediate ischemic or hemorrhagic events to all-cause mortality in a multi-state analysis as a function of anemia (hemoglobin concentration <120 g/l and <130 g/l, for women and men, respectively) and renal impairment (creatinine clearance <60 ml/min) at baseline. RESULTS Among 6029 patients undergoing PCI, anemia and renal impairment were observed isolated or in combination in 990 (16.4%), 384 (6.4%), and 309 (5.1%) patients, respectively. The most frequent transition was from PCI to death (6.7%, 95% CI 6.1-7.3), followed by ischemic events (4.8%, 95 CI 4.3-5.4) and bleeding (3.4%, 95% CI 3.0-3.9). Among patients with both anemia and renal impairment, the risk of death was increased 4-fold as compared to the reference group (HR 3.9, 95% CI 2.9-5.4) and roughly doubled as compared to patients with either anemia (HR 1.7, 95% CI 1.3-2.2) or renal impairment (HR 2.1, 95% CI 1.5-2.9) alone. Hazard ratios indicated an increased risk of bleeding in all three groups compared to patients with neither anemia nor renal impairment. CONCLUSIONS Applying a multi-state model we found evidence for a gradient of risk for the composite of bleeding, ischemic events, or death as a function of hemoglobin value and estimated glomerular filtration rate at baseline.

Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke: A Matched-Pairs Analysis.

BACKGROUND AND PURPOSE Five randomized controlled trials have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (±intravenous tissue-type plasminogen activator) improves outcome after acute ischemic stroke in patients with large artery anterior circulation stroke. Whether direct MT is equally effective as combined intravenous thrombolysis with MT (ie, bridging thrombolysis) remains unclear. METHODS We retrospectively compared clinical and radiological outcomes in 167 bridging patients with 255 patients receiving direct MT because of large artery anterior circulation stroke. We matched all patients from the direct MT group who would have qualified for intravenous tissue-type plasminogen activator with controls from the bridging group, using multivariate and propensity score analyses. Functional independence was defined as modified Rankin Scale score of 0 to 2. RESULTS From February 2009 to August 2014, 40 patients from the direct MT group would have qualified for bridging thrombolysis but were treated with MT only. Clinical and radiological characteristics did not differ from the bridging cohort, except for higher rates of hypercholesterolemia (P=0.019), coronary heart disease (P=0.039), and shorter intervals from symptom onset to endovascular intervention (P=0.01) in the direct MT group. Functional independence, mortality, and intracerebral hemorrhage rates did not differ (P>0.1). After multivariate matching analysis outcome in both groups did not differ, except for lower rates of asymptomatic intracerebral hemorrhage (P=0.023) and lower mortality (P=0.007) in the direct MT group. CONCLUSIONS In patients with large anterior circulation stroke, direct mechanical intervention seems to be equally effective as bridging thrombolysis. A randomized trial comparing direct MT with bridging therapy is warranted.

The Johann Jacob Wepfer Award 2012 of the European Stroke Conference to Professor Louis R. Caplan

No abstract available.

Antimyelin antibodies as predictors of disability after clinically isolated syndrome

There is controversy whether determination of antibodies against myelin, myelin oligodendrocyte glycoprotein, and myelin basic protein in serum from patients with a first episode suggestive of multiple sclerosis is of prognostic value. We evaluated whether detection of antimyelin antibodies in serum indicates a worse course with earlier time to a second relapse and increased progression of disability. We conducted a prospective study at the Department of Neurology, Inselspital Bern, Switzerland from 2004 to 2008 in patients presenting with a clinically isolated syndrome (CIS) and a follow-up of at least 4 months. Antimyelin antibodies were assessed by Western blot. Results were correlated with clinical course and sex. Among 93 consecutive patients with a CIS, 74 (80%) were positive for either one or both antimyelin antibodies. A relapse occurred in 49 (53%) and the median EDSS was 2 (range 1-3.5) after a mean observation period of 20 months. Presence of antimyelin antibodies at CIS neither increased the risk for a second relapse nor for progression of disability. Stratification for gender did not reveal differences for any of the clinical surrogates. The sole determination of antimyelin antibodies in serum is of limited prognostic value for the identification of patients with different short-term course.

Cerebral air embolism caused by a bronchogenic cyst

An unusual case is presented of a tourist who developed fatal cerebral air embolism, pneumomediastinum and pneumopericardium while ascending from low altitude to Europe's highest railway station. Presumably the air embolism originated from rupture of the unsuspected bronchogenic cyst as a result of pressure changes during the ascent. Cerebral air embolism has been observed during surgery, in scuba diving accidents, submarine escapes and less frequently during exposure to very high altitude. People with known bronchogenic cysts should be informed about the risk of cerebral air embolism and surgical removal should be considered. Cerebral air embolism is a rare cause of coma and stroke in all activities with rapid air pressure changes, including alpine tourism, as our unfortunate tourist illustrates.

The Combination of Interferon-Beta and HMG-CoA Reductase Inhibition in Multiple Sclerosis: Enthusiasm Lost too Soon?

Recent studies support the notion that statins, widely prescribed cholesterol-lowering agents, may target key elements in the immunological cascade leading to inflammation and tissue damage in the pathogenesis of multiple sclerosis (MS). Compelling experimental and observational clinical studies highlighted the possibility that statins may also exert immunomodulatory synergy with approved MS drugs, resulting in several randomized clinical trials testing statins in combination with interferon-beta (IFN-?). Some data, however, suggest that this particular combination may not be clinically beneficial, and might actually have a negative effect on the disease course in some patients with MS. In this regard, a small North American trial indicated that atorvastatin administered in combination with IFN-? may increase disease activity in relapsing-remitting MS. Although other trials did not confirm this finding, the enthusiasm for studies with statins dwindled. This review aims to provide a comprehensive overview of the completed clinical trials and reports of the interim analyses evaluating the combination of IFN-? and statins in MS. Moreover, we try to address the evident question whether usage of this combination routinely requires caution, since the number of IFN-?-treated MS patients receiving statins for lowering of cholesterol is expected to grow.

Posterior versus anterior circulation strokes: comparison of clinical, radiological and outcome characteristics

Physicians treating patients with posterior circulation strokes (PCS) tended to debate more on whether or not to introduce anticoagulation rather than performing investigations to identify stroke aetiology, as in patients with anterior circulation strokes (ACS). Recent findings suggest that stroke aetiologies of PCS and ACS are more alike than dissimilar, suggesting that PCS deserve the same investigations as ACS. The characteristics and current diagnostic evaluation between patients with PCS and ACS were compared.

Three-Month and Long-Term Outcomes and Their Predictors in Acute Basilar Artery Occlusion Treated With Intra-Arterial Thrombolysis

Intra-arterial thrombolysis can be used for treatment of basilar artery occlusion. Predictors of outcome before initiation of treatment are of special interest.

Outcome after Thrombolysis for Acute Isolated Posterior Cerebral Artery Occlusion

To date, there is limited data on intra-arterial thrombolysis (IAT) and intravenous thrombolysis (IVT) for isolated posterior cerebral artery (PCA) occlusion. We aimed to evaluate recanalization, outcome and quality of life in patients who undergo thrombolysis for isolated PCA occlusion.

Patent foramen ovale may be causal for the first stroke but unrelated to subsequent ischemic events

Studies with very long follow-up are scarce in patients with cryptogenic stroke and patent foramen ovale (PFO). Little is known about the etiology of recurrent cerebrovascular events (CVE) in PFO patients.