Impact of immediate post-reperfusion cooling on outcome in patients with acute stroke and substantial ischemic changes.

BACKGROUND: In patients with acute stroke and an extensive ischemic burden at baseline, the prognosis is usually poor despite timely reperfusion. OBJECTIVE: To overcome universally poor outcomes in such patients, by applying immediate 'post-reperfusion cooling' in order to reduce reperfusion-related complications, and to describe the clinical and imaging characteristics. METHODS: Patients having (1) an acute anterior large vessel occlusive stroke within 4.5 h since last known well, (2) Alberta Stroke Program Early CT Score (ASPECTS) ≤5 on baseline imaging, and (3) targeted temperature management with endovascular cooling after confirmed reperfusion were included in this study. RESULTS: Eighteen patients (mean±SD age 59.5±10.9 years, median National Institutes of Health Stroke Scale score of 17, and median ASPECTS of 3) were analyzed. Median lesion volumes at baseline and after treatment were 130.2 and 110.6 mL, respectively. Median time from onset to the start of hypothermia and hypothermia duration were 213 min and 51 h, respectively. Favorable outcome (modified Rankin Scale ≤2) at 3 months was observed in 10 (55.6%) patients. Symptomatic intracranial hemorrhage, malignant brain edema, and pneumonia were observed in 2, 6, and 8 patients, respectively. CONCLUSIONS: The use of post-reperfusion cooling as a rescue treatment in patients with substantial ischemia at baseline might improve clinical outcome.

Asymmetric and Upper Body Parkinsonism in Patients with Idiopathic Normal-Pressure Hydrocephalus.

BACKGROUND AND PURPOSE: Our aims were to analyze the characteristics of parkinsonian features and to characterize changes in parkinsonian motor symptoms before and after the cerebrospinal fluid tap test (CSFTT) in idiopathic normal-pressure hydrocephalus (INPH) patients. METHODS: INPH subjects were selected in consecutive order from a prospectively enrolled INPH registry. Fifty-five INPH patients (37 males) having a positive response to the CSFTT constituted the final sample for analysis. The mean age was 73.7±4.7 years. The pre-tap mean Unified Parkinson's Disease Rating Scale motor (UPDRS-III) score was 24.5±10.2. RESULTS: There was no significant difference between the upper and lower body UPDRS-III scores (p=0.174). The parkinsonian signs were asymmetrical in 32 of 55 patients (58.2%). At baseline, the Timed Up and Go Test and 10-meter walking test scores were positively correlated with the total motor score, global bradykinesia score, global rigidity score, upper body score, lower body score, and postural instability/gait difficulties score of UPDRS-III. After the CSFTT, the total motor score, global bradykinesia score, upper body score, and lower body score of UPDRS-III significantly improved (p<0.01). There was a significant decrease in the number of patients with asymmetric parkinsonism (p<0.05). CONCLUSIONS: In the differential diagnosis of elderly patients presenting with asymmetric and upper body parkinsonism, we need to consider a diagnosis of INPH. The association between gait function and parkinsonism severity suggests the involvement of similar circuits producing gait and parkinsonian symptoms in INPH.

Forced arterial suction thrombectomy of septic embolic middle cerebral artery occlusion due to infective endocarditis: an illustrative case and review of the literature.

In acute ischemic stroke patients with major intracranial vessel occlusion due to infective endocarditis, treatment modalities are not well established. A 40-year-old woman presented with acute stroke due to left middle cerebral artery occlusion. She was successfully treated with intra-arterial mechanical thrombectomy, and the subsequent clinical outcome was favorable. Pathological analysis of the retrieved clots showed septic thrombi containing gram-positive cocci. Based on literature review and the present case regarding treatment strategies for patients with septic embolic stroke, pharmacological thrombolysis might increase the risk of hemorrhagic complications, which might alter clinical outcome. Therefore, we can consider intra-arterial mechanical thrombectomy as a first-line treatment option in patients with acute stroke resulting from infective endocarditis.

Posterior reversible encephalopathy syndrome due to hyponatremia.

Posterior reversible encephalopathy syndrome (PRES) is characterized by variable associations of seizure activity, consciousness impairment, headaches, visual abnormalities, nausea/vomiting, and focal neurological signs. The PRES may occur in diverse situations. The findings on neuroimaging in PRES are often symmetric and predominate edema in the white matter of the brain areas perfused by the posterior brain circulation, which is reversible when the underlying cause is treated. We report the case of PRES in normotensive patient with hyponatremia.