A 5-Year Follow-Up after Endovascular Treatment of 402 Intracranial Aneurysms-A Single-Centre Experience.

The aim of our study was to evaluate the early and long-term clinical and morphological outcomes of the endovascular treatment of ruptured and non-ruptured intracranial aneurysms in a cohort of patients from a single centre. We retrospectively analysed the treatment outcomes of 402 endovascularly treated intracranial aneurysms with an average follow-up of 5.5 years. All included patients were treated with endovascular techniques (coil, stent or both). We analysed patient demographics, risk factors for an aneurysm rupture, aneurysm characteristics, and clinical and angiographic complications and outcomes. We analysed and compared the data from the two groups, ruptured aneurysms (RAs) and unruptured aneurysms (UAs), separately. Out of the 318 patients included, a good early clinical outcome was achieved in 78.5% of RAs and in 95.3% of UAs. No complications occurred in 87.71% of patients with UAs and in 80.45% with RAs. The periprocedural rupture rate for UAs and RAs was 0.8% and 2.2%, respectively. The rate of thromboembolic events was 4.8 and 8% for UAs and RAs, respectively. A retreatment due to the recanalisation was required in 9.21% of patients with UAs and in 16.66% of patients with RAs. The results from our centre showed an overall favourable clinical outcome with acceptable periprocedural complications for both RAs and UR aneurysms and proved the endovascular method as safe and effective in the treatment of intracranial aneurysms.

Young stroke patient with patent foramen ovale and intracranial stenosis-a case report.

The prevalence of patent foramen ovale is approximately 20% in the global population. In patients under the age of 55 years, it has been proven as a cause of acute ischemic embolic stroke of otherwise undetermined source. We present a case of a 25-year-old patient who experienced an acute stroke of dominant hemisphere due to internal carotid artery occlusion.The patient underwent mechanical thrombectomy, followed by acute intracranial stenting due to persistent subocclusion of internal carotid artery. Further diagnostic investigations revealed a significant patent foramen ovale. During subsequent follow-up periods, the patient encountered multiple transient ischemic attacks despite receiving antithrombotic therapy. The indicated angiography examination revealed in-stent stenosis and thrombosis, which were resolved after optimal medical treatment. Following patent foramen ovale closure, the patient remained free from further neurological events during the subsequent two-year follow-up periods. This case emphasizes the necessity of comprehensive diagnostic evaluations in young individuals with stroke and underscores the importance of prudent slection of medical therapies.

Long-Term Prognosis for Patients with Metabolic Syndrome after Recanalization Therapy for Stroke.

Background: Metabolic syndrome (MetS) is defined as a cluster of interrelated factors that significantly increase the risk of cardiovascular diseases, including stroke. The aim of this study was to investigate the connection between MetS and its diagnostic criteria with the severity and outcome of stroke after recanalization therapy. Methods: Ninety four patients with acute ischemic stroke were included in the study. Patients were categorized into two groups: with (n = 47) or without MetS (n = 47). We analyzed their demographic data, medical history, individual criteria for MetS, anthropometric characteristics, stroke severity (National Institute of Health Stroke Scale [NIHSS], neuroimaging criteria, laboratory), recanalization treatment method (thrombolysis and/or thrombectomy), recanalization rate, and in-hospital complications rate. Late outcome (in 12 months follow-up) was measured by modified Rankin scale, followed by functional evaluation of plegic hand, walking assessment, self-care ability, physical therapy days, and major adverse cardiovascular events. MetS was determined, in case the participant had three of the five criteria using National Cholesterol Education Program (NCEP) guidelines. A probability value of <0.05 was considered statistically significant. Results: 92.6% of all patients had hypertension and 63.8% were obese. Despite the fact that there were no statistically significant differences in stroke severity and/or recanalization rate between two groups, MetS patients had to use devices more, while performing hand functions (P = 0.027). Nonassisted walking was proved to be more frequent among patients without MetS (P = 0.020). MetS patients proved less ability for self-care (44.4% vs. 75%, P = 0.031) and spent more days in physical therapy (median 30.0 vs. 16.5, P = 0.043). Conclusion: MetS in poststroke patients is related with poorer recovery of hand function, walking abilities, and more days spent in physical therapy.

Acute Carotid Stent Thrombosis in an Ultrarapid Clopidogrel Metabolizer: Case Report and Literature Review.

INTRODUCTION: Carotid angioplasty and stenting (CAS) represents an effective procedure for treating carotid artery disease. The acute in-stent thrombosis is an extremely rare complication of CAS especially when it occurs postprocedurally during the first 24 hours. Improper antiplatelet therapy or poor response to antiplatelet medications is known to be associated with a higher risk of in-stent thrombosis during early postprocedural period following a successful intervention. MATERIAL AND METHODS: A patient who experienced acute carotid in-stent thrombosis in early postprocedural period is described. He had been taking dual antiplatelet therapy for 2 weeks before undergoing a successful CAS. Moreover, pharmacogenetics studies showed the patient to be a clopidogrel ultrarapid metabolizer, which theoretically confers hyperresponsivity to medication. Alongside the report itself, a brief literature review of relevant sources pertinent to the case has been conducted. RESULTS: According to the available literature, this is the first case report describing an ultrarapid clopidogrel metabolizer who underwent an uneventful CAS but experienced acute carotid in-stent thrombosis in early postprocedural period. A rescue procedure included an endovascular intervention consisting of thrombectomy and local alteplase application, followed by postprocedural administration of intravenous eptifibatide. At discharge, patient's dual antiplatelet therapy included ticagrelor instead of clopidogrel. CONCLUSION: Acute carotid in-stent thrombosis is a highly unexpected complication of CAS and can occur despite ultrarapid clopidogrel metabolism trait.

A multimodal pharmacological agent in combination with recanalization therapy (thrombolysis and thrombectomy) in severe stroke patients.

This case report highlights a case of large ischemic stroke and indication for anticoagulant therapy treated with thrombolysis and pharmacological intervention for neurological recovery with a multimodal agent (Cerebrolysin) as add-on therapy to recanalization techniques, including IV thrombolysis. We observed a significant clinical improvement after one year of follow-up. Based on our experience, we can assert that Cerebrolysin can be safely administered in stroke patients, even in complicated cases, with a good chance for improvement of their clinical status.

Intraoperative Eptifibatide Administration During Urgent Arterial Bypass in Neurosurgery.

BACKGROUND: In some cases when risk of occlusion of a blood vessel is greater than risk of bleeding when patients undergo urgent or unplanned bypass during neurosurgery, the use of eptifibatide may be an option. We describe 2 patients who underwent arterial bypass in whom eptifibatide was used successfully intraoperatively during neurosurgery for prevention of bypass occlusion. CASE DESCRIPTION: The first patient presented with a right middle cerebral artery (MCA) aneurysm with subocclusive stenosis of the M1 branch. After right-sided osteoplastic frontotemporal craniotomy, the MCA bifurcation was exposed with a bifurcational 6-mm aneurysm with a wide neck. Prebifurcation stenosis was found, with yellow calcification of the vessel wall, and postbifurcation calcification was found on the upper M2 branch. Superficial temporal artery-MCA bypass and occlusion of the MCA aneurysm was done. Before the bypass, continuous intravenous infusion of eptifibatide 1 µg/kg/minute was administered. The patient recovered normally without hemorrhage or neurologic deficit. The second patient presented with a left-sided lateral sphenoid wing meningioma. Left-sided frontotemporal craniotomy was performed, and the tumor was completely removed from the arachnoid layer. The temporal M3 branch was invaded by the meningioma. As there was no flow through the invaded segment of the aforementioned artery, termino-terminal M3 arterial anastomosis was done. Continuous intravenous infusion of eptifibatide 1 µg/kg/minute was administered. Indocyanine green angiography showed normal flow through the anastomosis, and the patient recovered normally. CONCLUSIONS: Future studies are needed to test the safety and potential efficacy of eptifibatide in intraoperative settings.

Intravenous dexamethasone in acute management of vestibular neuritis: a randomized, placebo-controlled, single-blind trial.

INTRODUCTION: The aim of the present study was to evaluate the role of intravenous dexamethasone in relieving the symptoms and signs of vestibular neuritis in the emergency department setting. PATIENTS AND METHODS: This was a randomized, placebo-controlled, superiority, single-blind study. Patients were randomized either to intravenous dexamethasone (group A) or to placebo (group B), with all patients receiving symptomatic therapy. The primary outcome was defined as necessity to hospitalize patients who present with vestibular neuritis in the emergency department. The secondary outcomes were (a) improvement in nystagmus, (b) improvement in postural instability, (c) lessening of nausea, (d) lessening of vomiting, and (e) recovery of subjective symptoms. RESULTS: Altogether, 100 patients were randomized, 51 into group A and 49 into group B. There was no difference in the hospitalization rate between groups (P=0.284). In both groups, there was a statistically significant difference in the values of all measured variables 2 h after therapy intervention compared with the baseline values. In group A, significantly fewer patients had third-degree nystagmus 2 h after therapy intervention whereas the difference in group B did not reach statistical significance. After therapy, more patients had first-degree nystagmus in group A as well as in group B than before the intervention. There was a significantly greater absolute difference in European Evaluation of Vertigo scale results in group A compared with group B. CONCLUSION: The value of dexamethasone cannot be established, given the small sample and limitations of the present study. Some observations consistent with clinical improvement cannot exclude a true treatment effect, and further study is still warranted.

Clinical Application of Genotype-guided Dosing of Warfarin in Patients with Acute Stroke.

BACKGROUND: Patients with certain types of stroke need urgent anticoagulation and it is extremely important for them to achieve fast and stable anticoagulant effect and receive individualized treatment during the initiation of warfarin therapy. METHODS: We conducted a prospective study among 210 acute stroke patients who had an indication for anticoagulation and compared the impact of CYP2C9 and VKORC1 genotype-guided warfarin dosing (PhG) with fixed dosing (NPhG) on anticoagulation control and clinical outcome between groups. RESULTS: PhG achieved target INR values earlier, i.e., on average in 4.2 (4.1-4.7, 95% CI) days compared to NPhG (5.2 days [4.7-6.4, 95% CI]) (p = 0.0009), spent a higher percentage of time in the therapeutic INR range (76.3% [74.7-78.5, 95% CI] vs. 67.1% [64.5-69.6, 95% CI] in NPhG), and spent less time overdosed (INR > 3.1) (PhG 0.4 [0.1-0.7, 95% CI], NPhG 1.7 [1.1-2.3, 95% CI] days; p >0.000). PhG reached stable maintenance dose faster (10 [9.9-10.7, 95% CI] vs. 13.9 [13.3-14.7, 95% CI] days in controls; p = 0.0049) and had a better clinical outcome in relation to neurological deficit on admission as compared to NPhG. CONCLUSION: We confirmed that warfarin therapy with genotype-guided dosing instead of fixed dosing reduces the time required for stabilization and improves anticoagulant control with better clinical outcome in early stages of warfarin therapy introduction among acute stroke patients, which is essential for clinical practice.

Prevalence of genetic polymorphisms of CYP2C9 and VKORC1 - implications for warfarin management and outcome in Croatian patients with acute stroke.

BACKGROUND: Data on the prevalence of CYP2C9 and VKORC1 genes and their influence on anticoagulant effect and warfarin dose in stroke patients are scarce. The aim of this study was to determine the occurrence and significance of these gene polymorphisms and to establish pharmacogenetic algorithm to estimate the dose of introduction. Also, the goal was to determine tailored safety and intensity of anticoagulation response depending on the allelic variants and their impact on the clinical outcome in acute stroke patients in Croatia. METHODS: A total of 106 consented acute stroke patients were tested for CYP2C9 2, 3 and VKORC1 1173C>T gene polymorphisms. We estimated the dose of introduction and monitored anticoagulant effect obtained by INR values, time to reach stable dose, stable maintenance dose, time spent within the therapeutic/supratherapeutic INR range, occurrence of dosage side effects and clinical outcome depending on genotypes. RESULTS: We found that 83% of stroke patients in our study were carriers of multiple allelic variants. The predicted initial dose correlated with the stable warfarin maintenance dose (p=0.0311) and we correctly estimated the dose for 81.5% of 61.3% of study patients who required higher/lower doses than average. Warfarin dosage complications were slightly more frequent among the carriers of CYP2C9 2, 3 compared to the carriers of VKORC1 1173T alleles (68. 9% versus 62.5%), but their occurrence did not affect the final clinical outcome. CONCLUSION: Our data indicated rapid and safe anticoagulation achieved by using pharmacogenetically-predicted warfarin dose in high-risk acute stroke patients without increasing the risk of warfarin dosage complications in an elderly population.

An infrequent type of stroke with an unusual cause and successful therapy: basilar artery occlusion caused by a cardiac papillary fibroelastoma recanalized 12 hours after onset.

We herein report the case of a 32-year-old woman with sudden onset ataxia, limb dysmetria and somnolence. Emergency radiological findings showed bilateral cerebellar and thalamic infarctions as a result of a basilar artery occlusion. The patient was treated with intra-arterial (IA) and mechanical thrombolysis 12 hours after symptom onset and showed an excellent recovery. A diagnostic workup revealed a tumor mass on the mitral valve that was surgically removed, while a histological analysis confirmed a diagnosis of cardiac papillary fibroelastoma.