Imaging-Based Management of Acute Ischemic Stroke Patients: Current Neuroradiological Perspectives

Advances in imaging-based management of acute ischemic stroke now provide crucial information such as infarct core, ischemic penumbra/degree of collaterals, vessel occlusion, and thrombus that helps in the selection of the best candidates for reperfusion therapy. It also predicts thrombolytic efficacy and benefit or potential hazards from therapy. Thus, radiologists should be familiar with various imaging studies for patients with acute ischemic stroke and the applicability to clinical trials. This helps radiologists to obtain optimal rapid imaging as well as its accurate interpretation. This review is focused on imaging studies for acute ischemic stroke, including their roles in recent clinical trials and some guidelines to optimal interpretation.

Evidências sobre diagnóstico e tratamento do acidente vascular encefálico no serviço de urgência / Evidence on diagnosis and treatment of stroke in the emergency department

O acidente vascular encefálico, independentemente de ser isquêmico ou hemorrágico, é um problema de saúde pública mundial com elevada prevalência, morbimortalidade e custo financeiro. A investigação no setor de emergência busca confirmar seu diagnóstico, iniciando rapidamente as medidas terapêuticas imediatas para reduzir o dano neurológico,possivelmente revertê-lo, e tentar evitar sua recorrência precoce. O seu manejo leva a difíceis decisões terapêuticas para os neurologistas. A utilização de métodos por imagem é imprescindível nos dias atuais e vem evoluindo para dar maior precisão ao seu diagnóstico na fase hiperaguda, como também elucidar sua etiologia posteriormente. A trombólise endovenosa no acidente vascular cerebral isquêmico tem por objetivo recanalizar o vaso ocluído e reperfundir a área cerebral que pode ser salva, sendo esse tratamento aprovado e recomendado pela Academia Brasileira de Neurologia,Academia Americana de Neurologia e Sociedade Europeia de Neurologia. Apesar de não existir terapia específica aprovada para o acidente vascular cerebral hemorrágico, existem muitas medidas clínicas e cirúrgicas que podem ser implementadas no tratamento dessa doença.

Comparability and validity of siriraj stroke score and allen stroke score in differentiation of acute ischemic and haemorrhagic stroke

To compare and validate Alien stroke score [ASS] and Siriraj stroke scores [SSS] in differentiating acute cerebral hemorrhage [CH] and cerebral infarction [CI]. This comparative, analytical study was conducted at Khyber Teaching Hospital Peshawar, Pakistan from July 2000 to February 2002. Study included 100 patients of acute ishemic or hemorrhagic stroke confirmed on CT scan brain after clinically evaluation. ASS and SSS were calculated for each patient and compared with the results of CT scan for comparability [Kappa Statistics] and validity by using SPSS 10. Out of 100 patients, 69 had CI and 31 had CH. The overall comparability of ASS and SSS was fair [Kappa=0.51]. ASS and SSS were uncertain in 27 and 18 cases respectively; with Kappa showing worst comparability in term of certain results [K= 0.23]. In 64 cases with both scores in the diagnostic range, the Kappa showing excellent comparability [K=0.91].The sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV] of ASS was 38.70%, 91.30%, 66.67%, 76.82% respectively for CH and 71.1%, 80.64%, 89.09% and 55.56% respectively for CI, with overall predictive accuracy of 61%. The sensitivity, specificity, PPV and NPV of SSS was 67.74%, 94.2%, 84% and 86.67% respectively for CH and 78.26%, 90.32%, 94.73% and 65.11% respectively for CI, with overall predictive accuracy of 75%. Although, SSS being simple with more accuracy is better than ASS, both these scores lack sufficient validity to be used for exclusion of cerebral haemorrhage before offering antithrombotic or thrombolytic therapy

[ report of intracranial hemorrhage due to "crack" abuse]

Hypertensive Intracerebral hemorrhage is a relatively common event, however, Intracerebral hemorrhage duo to "crack" abuse is a rare event. A 20 years old man brought to emergency department [ED] because of nausea, vomiting, agitation and progressive loss of consciousness. His parents denied any head trauma but said "the patient is intravenous drug abuser [crack]". After initial stabilization in ED, diagnostic workup begins with Axial brain CT scan. There was a huge intracerebral hemorrhage in right frontopareital lobe [right sylvian fissure]. In operating room hematomas was evacuated. The patients clinical condition improved. Four-vessel brain angiography was performed during follow-up period. No vascular lesions was detected. Although the presence of vascular malformations of CNS cannot be rule out by negative brain angiography, intracerebral hemorrhage in this patient may be due to "crack" abuse

Avaliação pela tomografia computadorizada das principais causas de hemorragias intracranianas não traumáticas / Evaluation by computed tomography of the main causes of non-traumatic intracranial hemorrhagen

A Doença Cerebrovascular (DCV) é a principal causa de óbitos no Brasil. Dada a importância epidemiológica dessa condição clínica, nessa revisão os autores procuram identificar as diversas formas de doença hemorrágica do sistema nervoso central, os respectivos fatores de risco, manifestações clínicas e fisiopatológicas, correlacionando-as com as imagens. O objetivo é tornar mais simples a compreensão e identificação da Doença Cérebro Vascular (DCV), englobando dados de anamnese e exame físico, finalizando com o estudo de imagens.

Prevalence of Factors involved in intracranial hemorrhage of premature neonates less than 34 weeks' gestation

Intracranial hemorrhage is one of the major causes of neonatal mortality and morbidity. It is the most severe cranial problem in that period. Those who survive would be affected by hydrocephalus, encephalomalacia, and finally brain atrophy. With accurate knowledge of risk factors, hemorrhage may be diagnosed earlier and the complications managed earlier. This study was performed in Neonatal Intensive Care Unit of Imam Khomeini Hospital. All the neonates less than 34 weeks of gestation were undergone intracranial sonography from Feb 2005 to Feb 2006. Sonography was performed via anterior fontanel with proper probe according to neonatal age. 113 neonates less than 34 weeks of gestation have been studied. Mean gestational age was 32 weeks. Mean neonatal weight were 1566 +/- 734 grams. Intracranial hemorrhage was evident in 21% of them; 16.8% was grade 1, 0.9% grade 2, 2.7% grade 3, 0.9% grade 4. The mean weight of neonates with hemorrhage was 1504.11 grams. Intracranial hemorrhage had correlation with respiratory acidosis and pneumothorax. The latter was also correlated with hemorrhage grade. Supposing the safety and non-invasiveness of intacranial sonography, we suggest performing sonography in all premature neonates with low birth weight, and also in those neonates with pneumothorax and respiratory acidosis

[Fetal intracranial haemorrhage and periventricular leukomalacia after second-trimester intrauterine fetal death in monochorionic twins]

Intrauterine fetal death of one twin in a monochorionic pregnancy may be associated with adverse neurologic sequelae in the surviving co-twin. The aim of this report is to try, through a review of literature, to predict the risk of cerebral impairment in the survivor co-twin and to assess the feasability of neurosonography and magnetic resonance imaging in the prenatal diagnosis of brain damage. We report a case of monochorionic twins complicated by a fetal death at approximately 23 weeks' gestation with pathologically confirmed leukomalacia in the surviving twin. A detailed sonographic evaluation of the intracranial anatomy of the surviving twin was performed. Fetal magnetic resonance imaging was offered as well. The patient opted for termination. Evacuation was performed at 24 weeks, and pathologic evaluation revealed severe cerebral infarction with haemorrhage. However difficult, a multidisciplinary prenatal counselling should be performed in order to study the prognosis and to try to prevent cerebral palsy in the surviving co-twin

Positive autopsy: A case report.

The Postmortem examination of bodies brought to mortuary can be conducted by medical officers or by Forensic experts. Usually this job is conducted by medical officers and in doubtful cases dead body is referred to Department of Forensic Medicine to conduct autopsy. Many a times the medical officer fails to see wounds or injuries, they not able to differentiate antemortem injury from Postmortem injury, sometime they are not able to differentiate hanging from strangulation and in cases of multiple injuries, they are not able to draw opinion regarding cause of death, mode of death and manner of death. At most of time these cases remain unnoticed and unobjectionable but in few cases in which relatives of deceased are not satisfied with Postmortem finding and they demand for Re-Postmortem examination by help of Forensic experts. Most of time Second autopsy is not able to draw any opinion regarding cause of death, mode of death and manner of death because of serious alteration and artifact during First autopsy, but one thing which is always highlighted here that First autopsy was not complete. In this paper is discussed a case report in which the medical officer at a district hospital conducted a Postmortem examination on the dead body of a young male, he has preserved viscera for chemical analysis and he was not able to draw opinion regarding cause of death. Later on Re-Postmortem was conducted at the Department of Forensic Medicine and Toxicology, Govt. Medical College and New Civil Hospital Surat, revealed the cause of death as intracranial hemorrhage.

Recurrent intracranial hemorrhage in brain tumor.

There are only a few causes of recurrent intracranial hemorrhage among which a brain tumor like glioblastoma multiforme is one. Glioblastoma multiforme in children under 14 years of age is relatively uncommon than adults. We report a case of unusual presentation of glioblastoma multiforme with recurrent intratumoral bleed with hemiparesis with symptoms free period in between.

A risk scoring system for prediction of haemorrhagic stroke.

The present pair-matched case control study was carried out at Government Medical College Hospital, Nagpur, India, a tertiary care hospital with the objective to devise and validate a risk scoring system for prediction of hemorrhagic stroke. The study consisted of 166 hospitalized CT scan proved cases of hemorrhagic stroke (ICD 9, 431-432), and a age and sex matched control per case. The controls were selected from patients who attended the study hospital for conditions other than stroke. On conditional multiple logistic regression five risk factors- hypertension (OR = 1.9. 95% Cl = 1.5-2.5). raised scrum total cholesterol (OR = 2.3, 95% Cl = 1.1-4.9). use of anticoagulants and antiplatelet agents (OR = 3.4, 95% Cl =1.1-10.4). past history of transient ischaemic attack (OR = 8.4, 95% Cl = 2.1- 33.6) and alcohol intake (OR = 2.1, 95% Cl = 1.3-3.6) were significant. These factors were ascribed statistical weights (based on regression coefficients) of 6, 8, 12, 21 and 8 respectively. The nonsignificant factors (diabetes mellitus, physical inactivity, obesity, smoking, type A personality, history of claudication, family history of stroke, history of cardiac diseases and oral contraceptive use in females) were not included in the development of scoring system. ROC curve suggested a total score of 21 to be the best cut-off for predicting haemorrhag stroke. At this cut-off the sensitivity, specificity, positive predictivity and Cohen's kappa were 0.74, 0.74, 0.74 and 0.48 respectively. The overall predictive accuracy of this additive risk scoring system (area under ROC curve by Wilcoxon statistic) was 0.79 (95% Cl = 0.73-0.84). Thus to conclude, if substantiated by further validation, this scorincy system can be used to predict haemorrhagic stroke, thereby helping to devise effective risk factor intervention strategy.

Hematoma cerebeloso espontáneo: Diagnóstico, manejo y evolución de 18 pacientes / Spontaneous cerebellar haematoma: Diagnosis, management and Follow-up in 18 patients

Objetivo: Describir 18 pacientes con hematoma cerebeloso espontáneo (HCE), su diagnóstico, manejo y evolución. Pacientes y Métodos: En el Hospital de Especialidades CMN "La Raza", del 1° de enero del 2001 a 15 de julio del 2003, se estudiaron 18 pacientes, hombres y mujeres de 16 años o más, con HCE. Se evaluó: compresión del IV ventrículo, estado neurológico, hidrocefalia, enfermedades agregadas, manejo y evolución postoperatoria. La compresión del IV ventrículo se dividió en 3 grados. El manejo fue: 1) conservador, 2) craniectomía y drenaje del hematoma, 3) craniectomía con drenaje del hematoma y derivación ventricular, 4) ventriculostomía y 5) ninguno. Resultados: La evolución promedio del HCE fue de más de 6 horas en 11 casos (62%). La hipertensión arterial sistémica se asoció en 72% (13 casos), hidrocefalia en 12 (66%). En 5 pacientes la evolución fue buena, con vida independiente (28%), 3 (17%) con evolución regular y vida dependiente y 10 fallecieron (55%). Conclusiones: Los HCE son una urgencia médica y quirúrgica. El estado neurológico y el grado de compresión del IV ventrículo son los factores más importantes para decidir el manejo e inferir el pronóstico.

Objective: Describe eighteen patients with spontaneous cerebellar haematoma (SCH), their diagnosis, management and outcome. Patients and Method: 18 patients were seen at the Hospital de Especialidades CMN "La Raza" between January 2001 and July 2003. Patients were male and female over 16 years that showed signs compatible with SCH. Fourth ventricle compression, neurological status, hydrocephalus, concomitant diseases, management and postoperative status were assessed. Fourth ventricle compression was divided in three stages. Management included: 1) conservative approach, 2) craniectomy and haematoma drainage, 3) craniectomy haematoma drainage and ventricular derivation, 4) ventriculostomy and 5) absence of treatment. Results: SCH was observed for over six hours in 11 patients (62%). Systemic hypertension was present in 13 patients (72%), hydrocephalus in 12 (66%), five patients displayed a favourable outcome and were able to lead independent lives (28%), three patients (17%) had a guarded outcome, dependent on others for daily living skills and 10 patients died. Conclusions: SCH is a medical and surgical emergency. Neurological status and degree of fourth ventricle compression are the most important factors on which to base clinical management and infer prognosis.

Pineal Cavernous Malformations: Report of Two Cases

Pineal hemorrhage only occurs in rare cases, and this known to have several different causes such as germ cell tumors, pineal cysts and vascular malformations, including the cavernous malformations. Pineal cavernous malformations are extremely rare: to date only fifteen cases have been reported worldwide. Although the diagnosis of pineal cavernous malformation is not easy because of the extreme rareness of this condition, the presence of this lesion can be suspected based on its typical radiological findings. Case 1. A 42-year- old man presented with a limitation in his upward gazing. Radiologic examinations showed acute hemorrhage in the pineal region. He underwent ventriculo-peritoneal (VP) shunting but the patient's condition deteriorated after the shunting surgery. We operated and totally removed the tumor and the hemorrhages via an occipital-transtentorial approach. Case 2. A 37-year-old man presented with diplopia. Radiologic examinations showed acute hemorrhage in the third ventricle. He underwent VP shunting, and after this procedure the diplopia was aggravated. We operated and totally removed the tumor and the hemorrhages via an occipital-transtentorial approach. If there is no doubt about the pineal cavernous malformation on MR imaging, we strongly recommend early surgical intervention without performing a risky biopsy. In this study, we describe our experiences for the diagnosis of cavernous malformations in the pineal region with special emphasis on the radiological aspects and the clinical course of this disease.

Malformaciones vasculares del sistema nervioso central y embarazo: revisión del tema y presentación de un caso clínico / Vascular malformations in the central nervous system and pregnancy: review of the subject and presentation of a clinical case

La hemorragia intracraneal debida a la ruptura de una malformación arteriovenosa durante el embarazo es una condición rara, pero seria, que puede condicionar morbimortalidad materno-fetal. Los trabajos científicos sugieren que el embarazo no aumenta el riesgo del primer sangrado de la malformación vascular, pero si el riesgo de sangrados posteriores. Las malformaciones arteriovenosas tienen una historia natural mal definida, más desconocida aún cuando se hacen clínicamente sintomáticas por primera vez durante el embarazo. Debido a su rareza, no existen protocolos definidos a seguir frente a esta situación. La colaboración estrecha entre los distintos especialistas en estos campos, tanto neurólogos, como obstétricas es obligatoria. Presentamos el caso clínico de una mujer de 14 años cursando embarazo de 15 semanas, a la que se le realizó un estudio por un cuadro de cefalea, diagnosticándose una hemorragia intracerebral secundaria a la ruptura de malformación arteriovenosa, la que tuvo finalmente una resolución neuroquirúrgica durante el embarazo.

Intracranial hemorrhage in late hemorrhagic disease of the newborn.

This study was conducted to evaluate the clinical profile and outcome in late hemorrhagic disease of the newborn (HDN) with particular reference to intracranial hemorrhage. Infants (n = 42) presenting with late HDN from January 1998 to December 2001 were studied. Majority (76%) were in the age group of 1-3 months. All were term babies on exclusive breast-feeding and none received vitamin K at birth. 71% patients presented with intracranial hemorrhage, commonest site being intracerebral and multiple ICH. Visible external bleeding was noted in 1/3rd of patients only. Three patients expired. Late HDN is still an important cause of mortality and morbidity in developing countries where vitamin K prophylaxis is not routinely practiced. Isolated intracranial hemorrhage is a common mode of presentation.