Intra-arterial reteplase compared to urokinase for thrombolytic recanalization in acute ischemic stroke.

BACKGROUND AND PURPOSE: Reteplase (RP) and urokinase (UK) are being used "off-label" to treat acute ischemic stroke. The safety and efficacy of intra-arterial RP or UK in the treatment of acute ischemic stroke, however, has yet to be proved. We aim to evaluate the safety and efficacy of RP compared with UK in acute ischemic stroke patients with large vessel occlusion. METHODS: Retrospective analysis was conducted of cases from a prospectively collected stroke data base on consecutive acute ischemic stroke patients with large vessel occlusion by digital subtraction angiography treated with intra-arterial RP or UK. Thrombolytic dosage, recanalization rate, intracerebral hemorrhage (ICH), mortality, and outcome were determined. RESULTS: Thirty-three patients received RP and 22 received UK (mean doses, 2.5 +/- 1.4 mg and 690,000 +/- 562,000 U, respectively). Vascular occlusions included 9 basilar arteries (BAs), 7 internal carotid arteries (ICAs), and 17 middle cerebral arteries (MCAs) with RP and 9 BAs, 4 ICAs, and 9 MCAs with UK. Median baseline National Institutes of Health Stroke Scales were as follows: 16 (range, 5-25; 81% > or = 10) with RP and 17 (range, 6-38; 85% > or =10) with UK. Mean time from symptom onset to thrombolytic initiation: 333 +/- 230 minutes with RP and 343 +/- 169 minutes with UK. Recanalization rates were as follows: 82% with RP and 64% with UK (P = .13). Symptomatic ICH rates were as follows: 12% with RP and 4.5% with UK (P = .50). The mortality rate was 24% with RP and 27% with UK (P = .8). CONCLUSION: Although limited in statistical power, our study suggests that, although IA thrombolysis with RP shows a trend for higher recanalization rates and hemorrhage rates, IA thrombolysis with RP is not significantly different in recanalization, outcome, mortality, and ICH compared with that of UK or rates reported with IA pro-UK.

Postpartum cerebral angiopathy: atypical features and treatment with intracranial balloon angioplasty.

Postpartum cerebral angiopathy (PCA) is an uncommon cause of ischemic and hemorrhagic stroke in young women. It is usually clinically benign and not relapsing. We describe a patient with nonhemorrhagic PCA who had an atypical progressive neurological deficit from bilateral hemisphere watershed ischemia despite treatment with aggressive medical therapy and intracranial balloon angioplasty.

Gemcitabine-associated posterior reversible encephalopathy syndrome: MR imaging and MR spectroscopy findings.

A 55 year old female receiving gemcitabine for stage IV non-small cell carcinoma of the lung developed the clinical-radiologic syndrome of posterior reversible encephalopathy syndrome (PRES). She had clinical manifestations of headaches, increasing somnolence and tonic-clonic seizures. The fluid-attentuated inversion recovery (FLAIR) MR imaging sequence conspicuously showed bihemispheric, symmetrical cortical and subcortical white matter hyperintensities that preponderantly involved the parietal and occipital lobes. Diffusion-weighted imaging (DWI) sequence reflected the preponderant existence of vasogenic edema in the involved areas. MR spectroscopy showed no significant N-acetyl aspartate (NAA) depletion or lactate elevation prospectively, indicating the absence of significant neuronal loss and reversibility of the brain parenchymal changes. The clinical and radiologic manifestations essentially resolved completely with discontinuation of the drug.

MR of post traumatic spinal cord lesions. Unexpected improvement of hemorrhagic lesions.

Fifteen patients who sustained spinal cord trauma were evaluated by MR within 72 hours of injury. Nine patients had hemorrhagic and six had nonhemorrhagic traumatic spinal cord lesions. Three patients with hemorrhagic and all six patients with nonhemorrhagic lesions showed some degree of neurological improvement on follow-up examinations. In two of the three patients with hemorrhagic lesions who improved, the hemorrhage was extensive. This supports the observation that hemorrhagic lesions are not always associated with a poor clinical outcome.

Operative angiography by intraarterial digital subtraction angiography: a new technique for quality control of carotid endarterectomy.

Fifty patients who had carotid bifurcation endarterectomy as their sole surgical procedure underwent intraoperative completion angiography by means of portable intraarterial digital subtraction angiography. All had subsequent intravenous digital subtraction angiography or duplex scanning during early follow-up. After the endarterectomy site was closed and before the wound was closed, 6 to 8 ml of contrast was injected through a 21-gauge needle while fluoroscopy was performed with a conventional C-arm. The C-arm was coupled to a Quantel IDIS Mobile Digital Subtraction Angiogram Unit (Quantel Medical Products Group, Clemmons, N.C.) for image enhancement and immediate playback. There were no postoperative deaths or neurologic complications. Abnormal radiographic results led to reopening of endarterectomy sites in eight patients, which resulted in successful correction of the defects. There was a single asymptomatic occlusion of the internal carotid artery at 3 weeks in the patient with the only false-negative result on the completion study. Intraarterial digital subtraction angiography is a safe and useful technique for intraoperative quality control of carotid endarterectomy. It provides visual images that can be easily repeated in several projections, uses small volumes of contrast, and has no timing requirements for filming and injecting.

Correction of CSF motion artifact on MR images of the brain and spine by pulse sequence modification: clinical evaluation.

A modification of the standard spin-echo pulse sequence designed to suppress motion artifacts was clinically evaluated on T2-weighted MR images of the cervicocranial region. A retrospective study involving 40 patients, half of whom were examined with a standard T2-weighted multislice spin-echo sequence and half of whom were examined with a gradient waveform modification of the same sequence, uniformly demonstrated restoration of CSF signal intensity on images obtained with the gradient modified sequence. The cervical subarachnoid spaces, cisterna magna, medullary cistern, pontine cistern, fourth ventricle, and aqueduct were more consistently and brightly represented. However, the phase-encoding artifacts arising from CSF motion were not significantly reduced by using the gradient waveform modified pulse sequence. Digital subtraction of an image obtained with the standard sequence from an image of the same slice with the gradient modified sequence provides a direct image representation of CSF flow.

Recurrent postdiskectomy low back pain: MR-surgical correlation.

The preoperative MR findings in 11 patients, all of whom had developed recurrent low back pain after surgery for herniated lumbar intervertebral disk, were correlated with the surgical findings to determine possible criteria for distinguishing recurrent disk herniation from postoperative scar (extradural fibrosis). The preoperative MR findings agreed with the surgical findings in seven of eight patients with recurrent disk herniation and in six of nine individuals with extradural fibrosis. The most important parameters in differentiating recurrent herniated disk from extradural scar were the configuration and margination of the extradural mass rather than its signal characteristics. The most reliable MR sign for recurrent herniated disk was the presence of a sharply marginated focal polypoid disk protrusion beyond the posterior margins of the adjacent vertebral bodies shown to best advantage on sagittal T1- and T2-weighted and axial T1-weighted spin-echo MR images. Disk herniations usually maintained isointensity with the intervertebral disk of origin, while extradural fibrosis exhibited variable signal intensity. The preoperative diagnosis of extradural fibrosis on MR was based primarily on its irregular configuration and extension. This study suggests that preoperative differentiation between scar and recurrent herniated disk is possible with MR when morphology and topography are considered in addition to signal intensity.

Computed tomography of the cervical carotid artery: significance of the lucent defect.

To investigate the clinical significance of lucent defects in computed tomography (CT) scans of the cervical carotid artery plaque, we studied 95 patients with recent symptoms of hemispheric ischemia. Using multiple linear regression analysis, we estimated the strength of the association of symptoms with laterality of carotid artery lucent lesions, stenoses, and ulcerations observed in CT scans. Hemispheric symptoms correlated strongly with ipsilateral carotid lucent lesions (partial p less than 0.025) and with ipsilateral severe (greater than 75%) carotid stenosis (partial p less than 0.025). Carotid artery ulcerations had a weaker association (partial p less than 0.1), and stenoses of mild and moderate degrees showed none. The overall performance of all three plaque complications was highly significant (p less than 0.005). The lucent defect indicates a morphologic change in the carotid plaque that plays an important role in the development of symptoms of hemispheric ischemia. This is in agreement with the notion that the lucent defect is the image of intraplaque hemorrhage and/or necrosis, which are complications central to the development of symptomatic carotid disease.

Migraine: evaluation by MR.

Twenty-four patients clinically diagnosed as having migraine (17 of the classic or common type and seven of the complicated type) were evaluated on a 0.5-T or 0.6-T superconductive MR imaging unit with the objective of detecting associated parenchymal lesions. Thirteen (54%) of the patients had normal MR studies. Eleven (46%) of the patients (seven with classic or common and four with complicated migraine) showed well-defined lesions with prolonged T2 signal intensity. The lesions associated with classic migraine were focal and predominantly distributed in the periventricular white matter, bilateral in four and unilateral in three. In the group with complicated migraine, larger cortical abnormalities similar to infarcts were seen in three patients and multiple bilateral focal white matter lesions were seen in one. Almost all the lesions were evident only on T2-weighted studies; a few exhibited hypointense signal intensity on T1-weighted studies. The focal periventricular white matter lesions were not necessarily associated with neurologic deficits, but the cortical lesions were. Our study indicates that parenchymal changes are frequently associated with migraine and that MR may well be the screening and diagnostic method of choice for their detection and evaluation.

Headache in the athlete and radiographic evaluation.

A deliberate attempt is made to stress the nonspecificity of headache and the complexity of its work-up. The choice of radiographic studies for its evaluation should be governed by the strongly considered etiology. This article deals with the most likely causes of headaches in an athlete. The merits and limitations of currently available radiographic modalities to detect headache-producing diseases are broadly discussed.

Lumbar and thoracic spine pain in the athlete: radiographic evaluation.

A comprehensive but basic and updated systematic radiographic approach to various pain-producing thoracolumbar diseases is presented. The advantages and limitations of available diagnostic modalities are discussed in relation to the clinically considered etiologies.

Computed tomographic evaluation of extracranial carotid artery disease.

Axial computed tomographic (CT) scans after intravenous contrast infusion were used to image the cervical carotid arteries of patients with cerebral ischemic symptoms. Standard transfemoral cervical carotid and cerebral angiography was the principal diagnostic modality used in all patients studied. The angiographic results were compared to the CT images and to the gross and microscopic endarterectomy pathological specimens, when available. Examples of the various types of abnormalities that can be visualized using CT scans are presented. The CT scan was useful for determining the presence of degenerative atheromatous changes including carotid artery calcification, subintimal hemorrhage, carotid occlusion, carotid segmental occlusion, and carotid pseudoocclusion, as well as carotid artery dissection. The scans were particularly useful for identification of atheromatous carotid artery disease when the carotid angiogram appeared nearly normal and for identifying the cause of postoperative carotid stenosis. CT scanning allows visualization of the carotid artery wall and lumen rather than just the lumen and, consequently, can sometimes add helpful information about the pathological processes affecting this artery.

Diagnostic value of computed tomography in recurrent pain after discectomy.

Intravenously enhanced computed tomography (CT) was used in patients in whom the differential diagnosis between recurrent herniated disc and postoperative scar was considered. Enhanced CT images demonstrated postoperative herniated discs more accurately than clinical criteria, myelography, or plain or postmetrizamide CT. The scar tissue shows contrast enhancement, but recurrent disc herniation does not. Therefore, contrast-enhanced CT is considered to be a valuable aid in distinguishing between recurrent disc herniation and hypertropic scar formation.

Spontaneous dissection of the cervical internal carotid artery: correlation of arteriography, CT, and pathology.

Spontaneous dissection of the internal carotid artery is being recognized as a more frequent cause of acute neurologic deficit, particularly in young persons. Saccular pseudoaneurysm formation may be an associated finding, especially in the presence of tortuosity (coiling) of the cervical internal carotid artery. Of eight patients with nine vessels demonstrating internal carotid artery dissection on arteriography, pseudoaneurysms were found in five arteries. Four of the five pseudoaneurysms occurred in tortuous (coiled) arterial segments. Thin-section contrast-enhanced dynamic incremental CT showed close agreement with the findings on selective arteriography and provided additional information on the presence and configuration of arterial wall thickening as well as the extent of the pseudoaneurysm. Our experience indicates that CT may play an important role in the diagnosis, management, and follow-up of this lesion.

Transient neurological deficit after therapeutic embolization of the arteries supplying the medial wall of the hemisphere, including the supplementary motor area.

A 27-year-old, right-handed woman underwent intraoperative embolization for a left parasagittal arteriovenous malformation as part of a two stage plan that included subsequent surgical resection of the arteriovenous malformation. This report describes the neurological syndrome that developed after the first procedure. The relation of these deficits to localization of function within the supplementary motor area are correlated with recent advances in our understanding of this region.

Recurrent post-discectomy pain. CT--surgical correlation.

Diagnostic evaluation of the patient with recurrent lumbosacral radiculopathy following lumbar laminectomy and discectomy represents a difficult task for the radiologist. Neither non-enhanced CT nor myelography have permitted reliable differentiation between postoperative extradural fibrosis (scarring) and recurrent disc herniation. However, CT following intravenous contrast infusion has been reported by several investigators to allow differentiation of these two entities. A series of 13 patients is reported with correlation between the findings on postcontrast CT and at reoperation. In 5 patients who exhibited variable contrast enhancement of an extradural soft tissue mass without a discreet lucent component on postcontrast CT, operative reexploration revealed only scar tissue. In 8 patients in whom postcontrast CT demonstrated a discreet non-enhancing extradural mass (partially surrounded by a thin enhancing rim of soft tissue in all but one), recurrent disc herniation together with an overlying band of scar was found and resected at reoperation. The strong positive correlation between CT and operative findings in this series suggests that postcontrast CT may well prove to be a reliable method for preoperative differentiation of recurrent disc herniation from extradural scarring.

Treatment of a lingual hemangioma by superselective embolization.

A large hemangioma of the tongue was initially treated with superselective embolization using polyvinyl alcohol foam (Ivalon) and absorbable gelatin sponge (Gelfoam) particulates. A marked reduction in vascularity with deflation of the lesion occurred. Subsequent surgery to ablate the residual tumor was canceled due to the patient's request and satisfaction with the initial procedure. Evaluation over the following year revealed no regrowth or symptomatology. This case demonstrates that, in selected cases, large hemangiomas may respond satisfactorily to superselective embolization and may obviate the need for surgical intervention.