Thrombectomy vs. Systemic Thrombolysis in Acute Embolic Stroke with High Clot Burden: A Retrospective Analysis.

PURPOSE: The efficacy of i. v. thrombolysis in acute stroke with high clot burden is limited. Successful recanalization is very unlikely if the thrombus length exceeds 7 mm. Thus this retrospective controlled study evaluated the efficacy and safety of neurothrombectomy in the treatment of acute embolic stroke in patients selected by a thrombus length of ≥ 8 mm using the stent retriever Trevo(®) device. MATERIALS AND METHODS: 40 patients with acute occlusion of the anterior intracranial arteries with a thrombus length of ≥ 8 mm were treated with neurothrombectomy. We compared the outcome with a historical cohort of 42 patients with a thrombus length of ≥ 8 mm that received i. v. thrombolysis only. Clinical outcome was assessed by modified Rankin scale in both groups at discharge and on day 90. RESULTS: Patients did not differ in age, mRS on admission, thrombus length or time from symptom onset to i. v. thrombolysis, but the thrombectomy group had higher NIHSS on admission. Successful recanalization was achieved in 33/40 patients (83 %) with neurothrombectomy. 15 patients received i. v. thrombolysis prior to neurothrombectomy. Median mRS at discharge was 3.5 (1.25 - 5) vs. 5 (4 - 6; p < 0.01) and on day 90 3 (1 - 4) vs. 5 (4 - 6; p < 0.01). Symptomatic hemorrhage occurred in 3 vs. 7 patients. 3 vs. 17 patients died within 90 days (thrombectomy vs. control each). There were only a few intervention-related complications. CONCLUSION: Thrombectomy in acute stroke with high clot burden using the Trevo(®) device has a low risk and improved clinical outcome compared to i. v. thrombolysis alone. Treatment selection by a clot length of ≥ 8 mm might be a powerful approach to improve the outcome of mechanical thrombectomy. KEY POINTS: • Clot length of ≥ 8 mm might be a valuable criterion for indicating neurothrombectomy. • Thrombolysis only in high clot burden is associated with poor clinical outcome. • Thrombectomy using the Trevo(®) stent retriever is safe and effective.

Posterior cerebral artery territory infarcts: clinical features, infarct topography, causes and outcome. Multicenter results and a review of the literature.

Only a few large series of posterior cerebral artery (PCA) stroke exist, and clinical features and causes have not been studied as extensively as in other vascular territories. The PCA syndrome includes more clinical signs than the well-known visual field deficits. Concomitant findings are frequently sensory, slight motor and neuropsychological deficits. Unilateral headaches are the common presenting symptom making complicated migraine an important differential diagnosis. Combined deep and superficial PCA territory infarcts involving the lateral thalamus are more frequent than commonly assumed and are mostly associated with sensory and reversible slight motor deficits. Occlusion of the precommunal PCA segment with associated paramedian midbrain infarction causes severe motor deficits, oculomotor signs, and decreased consciousness and has a poorer outcome than other PCA territory infarcts. Embolism from a cardiac or undetermined source is the leading mechanism accounting for up to half of the cases, whereas arterial embolism from significant proximal vertebrobasilar disease is less frequent. Local atherothrombotic stenosis or occlusion of the PCA is uncommon. In spite of thorough diagnostic evaluation, the etiology of PCA territory infarction cannot be determined in at least one quarter of patients. Among the rare causes of PCA territory infarction carotid artery disease is important while the significance of migraine remains controversial.

Clinical and ultrasonic long-term results of percutaneous transluminal carotid angioplasty. A prospective follow-up of 30 carotid angioplasties.

Experience of the long-term outcome of patients treated with carotid balloon angioplasty is limited. Therefore, we prospectively analyzed the ultrasonic and clinical features of 29 patients with complete follow-up data beyond 24 months, evaluated from 1989 through 1996 from our carotid angioplasty cohort of 106 patients. Mean follow-up time was 33 months. For up to 78 months postangioplasty, 23 patients with 24 angioplasties (77%) had no further neurological sequelae. Single ipsilateral amaurosis fugax or TIA events occurred in 3 patients. Recurrent ipsilateral amaurosis fugax or TIA events were noted twice in 2 patients. No patient suffered an ipsilateral stroke. Fifteen angioplasties (50%) remained with normal ultrasound (stenosis < 50%), mild restenosis (50-70%) occurred in 12 angioplasties (40%), and severe restenosis (> 70%) in 3 angioplasties (10%). Only in 2 of 15 patients clinical complications were related to the occurrence of ipsilateral restenosis above 50%. Until now, rigorous and careful evaluation of patients and clinical and ultrasonic follow-up have been essential for the estimation of the long-term efficacy of carotid angioplasty. It should be noted that carotid angioplasty is a new technique in evolution, with a high potential improving the technical results.

Predicting hemodynamic ischemia by transcranial Doppler monitoring during therapeutic balloon occlusion of the internal carotid artery.

PURPOSE: Our objective was to evaluate the sensitivity of transcranial Doppler (TCD) sonographic monitoring during permanent balloon occlusion of the internal carotid artery (ICA) in predicting hemodynamic ischemia. METHODS: Thirty-two consecutive patients underwent controlled therapeutic balloon occlusion of the ICA. Selection criteria included assessment of the circle of Willis by compression angiography, clinical tolerance during a 20-minute test occlusion, and TCD monitoring of the ipsilateral middle cerebral artery. The mean blood flow velocity (MBFV) (n = 32) and pulsatility index (PI) (n = 28) were recorded. In 25 patients, MBFV changes upon motor stimulation were recorded before and after ICA occlusion. RESULTS: Twenty-eight (88%) of the patients had no complications. Three patients suffered delayed symptoms 30 minutes to 20 hours after balloon detachment. Two of these patients recovered spontaneously within 1 day, the other improved after extracranial/intracranial (EC/IC) bypass surgery. One patient, who did not tolerate the test occlusion, suffered a hemodynamic stroke despite EC/IC bypass before permanent balloon occlusion. No embolic complications occurred. The mean MBFV reduction was 20% (range, 0% to 55%); the mean PI reduction was 20% (range, 0% to 56%). No complications occurred in patients who had mild MBFV and PI reduction (30% or less, n = 21). All three patients with severe MBFV or PI reduction (> 50%) had neurologic symptoms. Among those with moderate MBFV or PI reduction (30% to 50%, n = 8), symptoms developed in only one patient who had moderate reduction of both MBFV (33%) and PI (38%). Motor vasoreactivity showed wide variation and was markedly reduced in two symptomatic patients. CONCLUSION: TCD monitoring reflects changes in cerebral hemodynamics after therapeutic balloon occlusion of the ICA. MBFV and PI reductions under 30% are highly predictive of clinical tolerance. A reduction of more than 50% may be a critical threshold for the occurrence of symptoms; in such cases, EC/IC bypass should be considered before proceeding with permanent balloon occlusion.

Transcranial Doppler Sonographic monitoring during percutaneous transluminal angioplasty of the internal carotid artery.

Our purpose was to assess the haemodynamic changes in the ipsilateral middle cerebral artery (MCA) during and after percutaneous transluminal angioplasty (PTA) of the internal carotid artery (ICA), and to compare them with clinical and angiographic findings. Transcranial Doppler Sonographic monitoring (TCD) of the MCA was performed during PTA in 22 patients with symptomatic severe stenosis of the ICA. Mean blood flow velocity (MBFV) and pulsatility index (PI) were recorded. During PTA, MBFV fell from 41 +/- 15 cm/s to 23 +/- 11 cm/s (P = 0.0001). Changes in PI were inconsistent. With reduction of MBFV of 50% or less (in 10 cases) no complication occurred. With a reduction of more than 50% (in 12), 6 patients developed neurological disturbances (transient ischaemic attacks in 5 and minor stroke in 1). This difference was significant (P = 0.0152). Symptomatic patients also had a higher rate of stroke prior to PTA (4/6) than patients who remained asymptomatic during PTA (0/6). After PTA had been performed MBFV and PI improved significantly (P = 0.0001), MBFV increasing to 48 +/- 16 cm/s and PI from 0.64 +/- 0.11 to 0.86 +/- 0.15. TCD changes proved more sensitive to cerebral haemodynamics than angiography in 8 patients.

Cerebral hyperperfusion injury after percutaneous transluminal angioplasty of extracranial arteries.

Cerebral hyperperfusion syndrome after carotid endarterectomy (CEA) is a rare but well-known phenomenon. Percutaneous transluminal angioplasty (PTA) is being widely evaluated for treatment of selected stenoses of the extracranial arteries. Its benefits and risks still need to be established. Hyperperfusion injury (HI) after PTA of cerebral arteries has not been reported. We describe two patients with severe HI, one with a small putaminal haemorrhage and the other with diffuse basal subarachnoid haemorrhage. In both cases, a typical clinical hyperperfusion syndrome with headache, confusion, vomiting and seizures occurred. Patient 1 underwent PTA of the left carotid artery, both subclavian arteries and proximal vertebral arteries, patient 2 had carotid angioplasty only. Transcranial Doppler ultrasound displayed markedly elevated blood-flow velocities. HI may occur after PTA of extracranial arteries. The pathogenesis might be similar to reperfusion injury after CEA. Our findings suggest that: (1) HI may occur after PTA; (2) patients should be monitored after PTA for HI; (3) further risk factors for HI need to be identified.

Reversible dementia in idiopathic hypoparathyroidism associated with normocalcemia.

Dementia in idiopathic hypoparathyroidism is generally ascribed to hypocalcemia and improves following normalization of the serum calcium level. We report a 51-year-old man with severe dementia and hypoparathyroidism, but without serum hypocalcemia and without clinical signs of hypocalcemia. There was rapid and sustained improvement and normalization of symptoms after therapy with 1,25-dihydroxy-cholecalciferol. We conclude that hypocalcemia is not the sole cause of dementia in idiopathic hypoparathyroidism.

Visually evoked cerebral blood flow velocity changes in different states of brain dysfunction.

BACKGROUND AND PURPOSE: By assessment of metabolically induced cerebral blood flow velocity changes, transcranial Doppler sonography offers the opportunity to evaluate vasoneuronal coupling in different states of brain activation and in critically ill patients. METHODS: With simultaneous transcranial Doppler monitoring of the posterior cerebral artery (PCA) and the middle cerebral artery (MCA), 27 control subjects, 11 patients under general anesthesia, 5 patients in the vegetative state, and 12 patients with aneurysmal subarachnoid hemorrhage were stimulated with a 10-Hz flashlight for 30 seconds. Ten cycles of stimulation were averaged, and a specific flow response (SFR) was computed as the normalized ratio of PCA/MCA mean flow velocity. RESULTS: Maximal SFR was 14.2% in control subjects. Eye closure significantly reduced maximal SFR (11.6% versus 15.4%, P<.01). In subarachnoid hemorrhage, SFR was markedly decreased in the early phase (4.8%, P<.01) but became normal later on. Four of 5 patients with abolished SFR suffered delayed ischemia due to vasospasm. Of 7 patients with preserved SFR, 5 had vasospasm but none had delayed ischemia. No SFR was observed in patients under general anesthesia or in the vegetative state. CONCLUSIONS: Although reflecting fast and local neuronal activity patterns, metabolically induced blood flow response is highly dependent on stimulus-directed attention. In subarachnoid hemorrhage, decreased metabolic flow response suggests severe depression of vasoneuronal coupling, and abolished SFR might indicate increased vulnerability to vasospasm and a higher risk for delayed ischemia.

Lys-plasminogen as an adjunct to local intra-arterial fibrinolysis for carotid territory stroke: laboratory and clinical findings.

To improve the efficacy of local intraarterial fibrinolysis (LIF), we compared different fibrinolytic drugs in a cerebral circulation model in the laboratory. The technical efficacy of fibrinolysis, defined as the clot volume lysed per unit time, was found to be optimal with r-tissue plasminogen activator (TPA) activated lys-plasminogen (= plasmin). Subsequently, 20 patients with stroke due to carotid artery territory occlusion were treated by local intraarterial fibrinolysis using the plasmin regimen. The angiographic data and clinical outcome of these patients were compared with those of 40 patients who received plasminogen activators (urokinase or r-TPA) only. Laboratory and clinical data confirmed that plasmin lysis is superior to treatment using only plasminogen activators.

Isolated symptomatic stenosis of the middle cerebral artery in younger adults. A clinical and ultrasonic follow-up study of eight patients.

We studied 8 symptomatic patients aged 32-56 years with isolated stenosis of the middle cerebral artery who had TIAs or minor strokes. Angiography showed MCA stenosis in the M1 segment in 7 patients, and proximal M1 occlusion that later recanalized with persistent stenosis in 1 patient, without evidence of more widespread atherosclerotic disease. A potential cardiac source of embolism was detected in only 2 patients with mitral valve prolapse. During follow-up for 39-82 months, no further ischemic events occurred, and transcranial Doppler showed unchanged or decreased stenosis in 6 patients. We conclude that isolated MCA stenosis in younger patients may be a unique pathologic entity with a benign long-term course, although previous embolism with partial recanalization appears possible in some patients.

[Infarcts in the brain areas supplied by the posterior cerebral artery. Clinical aspects, pathogenesis and prognosis]. / Infarkte im Versorgungsgebiet der A. cerebri posterior. Klinik, Pathogenese und Prognose.

The clinical and neuroradiological features of 127 patients with ischemia of the posterior cerebral artery (PCA) and a positive CT scan (n = 122) or pathological angiography findings (n = 63) were analyzed. Unilateral headache was the most common presenting symptom (50%), making complicated migraine an important differential diagnosis. Clinical findings were visual field deficits (93%), sensory (29%), motor (28%), and neuropsychological deficits (25%). Infarcts, including the thalamus (n = 27), were mostly associated with sensory and slight motor deficits. Our findings suggest that motor deficits in PCA ischemia, particularly if minor and reversible, are likely to be due to ischemia-induced edema in the internal capsule adjacent to an associated thalamic infarct. Based on angiography, stroke etiology was considered embolic in 83/127 (65%), atherothrombotic in 20/126 (16%), and probably migrainous in 4 (3%) patients. In the remaining 20 patients (16%), the etiology was uncertain. Prognosis of PCA infarcts is usually good.

Blunt trauma lesions of the extracranial internal carotid artery in patients with head injury.

Blunt trauma lesions of the extracranial internal carotid artery (ICA) are rare. In our hospital 18 patients with such an injury were diagnosed. All patients were involved in traffic accidents. Most of them had sustained head injuries with fractures of the skull, mandible or maxilla. The onset of neurological signs, most frequently hemiparesis, was usually delayed. 50 percent had bilateral ICA lesions but the clinical presentation was similar to those with unilateral lesions. Mortality of patients with ICA lesions was substantial (28%).

Local intra-arterial fibrinolytic therapy in patients with stroke: urokinase versus recombinant tissue plasminogen activator (r-TPA).

A group of 59 patients with stroke due to acute vertebrobasilar or carotid territory occlusion have been treated by local intra-arterial fibrinolysis (LIF). A high recanalisation rate was accomplished with either urokinase or recombinant tissue plasminogen activator (r-TPA). However, with either substance, even if a high dose was used, recanalisation was a time-consuming process which usually took 120 min. A reasonable explanation for the lack of effectiveness of these plasminogen-activating substances might be a deficit of substrate, e.g. plasminogen, in aged thrombus. LIF was capable of improving clinical outcome in acute vertebrobasilar artery occlusion, reducing mortality to 50% in patients fulfilling inclusion criteria. In the carotid territory multiple occlusions had a poor prognosis while good clinical results could be achieved in occlusions of the proximal middle cerebral artery or single branches.

99mTc-HMPAO-SPECT with acetazolamide challenge to detect hemodynamic compromise in occlusive cerebrovascular disease.

BACKGROUND AND PURPOSE: Insufficiency of collateral supply may lead to low-flow infarcts in severe occlusive cerebrovascular disease. The aim of this study was to evaluate the feasibility of technetium-99m-labeled hexamethylpropyleneamine oxime (99mTc-HMPAO) single-photon emission computed tomography (SPECT) to assess hemodynamic compromise in the anterior circulation. METHODS: Cerebral blood flow before and after 1 g acetazolamide was analyzed by 99mTc-HMPAO-SPECT in 21 symptomatic patients with documented extracranial obstructions. SPECT findings were correlated with the results of angiography, transcranial Doppler sonography, and computed tomographic scan. RESULTS: The acetazolamide-induced increase of cerebral blood flow could be reliably monitored by increase of cerebral 99mTc-HMPAO uptake, which varied between 11.4% and 47.6% in the less-affected hemisphere. Increment of hemispheric side-to-side asymmetry of tracer uptake after drug challenge revealed significant restriction of regional vasoreactivity in 11 patients. Agreement in assessing hemodynamic compromise was reached in 81% of patients with ophthalmic artery collaterals on angiography (p < 0.001), in 76% with low-flow infarcts on computed tomographic scan (p < 0.01), and in 91% with markedly reduced flow velocities on transcranial Doppler (p < 0.0001). One patient developed a low-flow infarct in the area predicted by SPECT during follow up. CONCLUSIONS: We conclude that 99mTc-HMPAO-SPECT with acetazolamide challenge is a useful method for assessment of the adequacy of hemispheric collateral pathways in patients with severe occlusive cerebrovascular disease.

Multimodal tests of cerebrovascular reactivity in migraine: a transcranial Doppler study.

Altered cerebral vasoreactivity (CVR) has been implicated in migraine. To test this hypothesis, we studied CVR as measured by transcranial Doppler ultrasound (TCD) in 11 migraineurs and 12 healthy controls of similar age. Mean flow velocities (MFV) in the middle cerebral artery (MCA) were recorded during a cognitive and two motor tasks. MFV in the posterior cerebral artery (PCA) were measured during photic stimulation and observation of complex images. The increase of MFV in the MCA during the cognitive task was greater in migraineurs than in controls (9.1% vs 5.0%; P = 0.06). The increase of MFV in both tests for PCA reactivity was significantly greater in migraineurs than in controls: 17.4% vs 9.9% for photic stimulation (P less than 0.05) and 20.3% vs 10.2% for observation of complex images (P less than 0.05). Owing to overlap of individual results, the discriminative value of both tests was unsatisfactory. The variability of flow velocities as measured by standard deviations of MFV was significantly greater in migraineurs than in controls during all tests of PCA vasoreactivity. Differences in CVR between migraineurs and normal controls may be detected by TCD testing, in particular in the PCA territory. For individual diagnostic purposes, CVR tests proved to be insufficient.

[Vertebrobasilar ischemia. Value of Doppler ultrasound in the acute phase]. / Vertebrobasiläre Ischämie. Stellenwert der Doppler-Sonographie in der Akutphase.

We prospectively studied patients with acute vertebrobasilar ischaemia to assess the value of Doppler ultrasound compared to cerebral angiography during initial evaluation. Doppler ultrasound was diagnostic in 11 of 14 patients (79%). Transcranial ultrasonic examination yielded important information in addition to extracranial findings in 8 of 11 patients. Depending on the underlying vascular pathology, Doppler ultrasound proved to be a useful screening instrument to support acute management of vertebrobasilar ischaemia. With regard to clinical symptoms and ultrasonic findings, practical consequences for diagnostic evaluation are proposed.

Dissection of the extracranial vertebral artery: report of four cases and review of the literature.

Four cases of cervical vertebral artery (VA) dissection are reported. In three patients VA dissection was associated with neck trauma. All patients were young or middle-aged (range 27 to 49 years). In two there was a history of migraine. Pain preceded neurological symptoms from hours to six weeks. Three patients had neurological deficits including elements of the lateral medullary syndrome, and one experienced recurrent transient ischaemic attacks in the vertebrobasilar territory. Angiographic findings included irregular stenosis, occlusion and pseudoaneurysm; in two patients VA abnormalities were bilateral. All patients were treated with anticoagulants and improved. In a review of 28 cases with traumatic dissection and 29 cases with spontaneous dissection of the VA reported in the literature, distinct clinical and angiographic features emerge. Aetiology remains obscure in most cases of spontaneous dissection and management is still controversial.

Factor XIII concentrate for prevention of recurrent subarachnoid hemorrhage: results of a multicenter pilot study. The FISAH Study Group.

Rebleeding after aneurysmal subarachnoid hemorrhage (SAH) has been attributed to fibrinolysis of the blood clot surrounding a rupture aneurysm. Since stability of the clot is influenced by the action of coagulation factor XIII (F XIII), high levels of F XIII might be beneficial in preventing recurrent SAH without causing the severe side effects of synthetic antifibrinolytics. We performed an open multicenter pilot study with administration of 10 x 1250 units of F XIII concentrate during the first 15 days after spontaneous SAH. Of 111 patients who were entered within 72 hours after SAH, 48 (43%) were in grades I and II, 33 (30%) were in grade III, and 30 (27%) were in grades IV and V according to Hunt & Hess. Aneurysm rupture was proved in 76 patients (68%) and aneurysm surgery was performed in 50 patients (45%). Overall mortality at four weeks was 27%. There were 11 recurrent hemorrhages in 9 patients (10%), 7 of which were fatal. Cerebral infarction occurred in 22 patients (20%) and hydrocephalus in 8 (7%). No adverse effects of therapy were noted. We conclude that F XIII therapy is a safe and promising new therapeutic approach in the management of SAH. It is currently being investigated in a large prospective, randomized, double-blind, placebo-controlled trial.

Transcranial Doppler evaluation of common and classic migraine. Part I. Ultrasonic features during the headache-free period.

To study vascular abnormalities in migraine, transcranial Doppler (TCD) was used for evaluation of 100 consecutive patients with either common or classic migraine during the headache-free period. We insonated the basal cerebral arteries and the internal carotid artery (ICA) in the neck. Particular ultrasonic features in migraineurs included intracranial elevations of mean flow velocity (MFV) above 3 standard deviations of normal values in 16%, probably reflecting increased vasotonus. Marked asymmetry of MFV in corresponding intracranial arteries was found in 12%, and could represent "asymmetrical" vascular tone. Characteristic vascular bruits of low frequency and sometimes harmonic quality were detected in 56%. When compared to TCD findings in 40 young controls, MFV were significantly higher in all intracranial arteries in migraineurs, but not in the cervical ICA. Marked differences were also found for incidence of MFV elevations and vascular bruits (p less than 0.0001). Vascular reactivity in response to eye closing as measured by flow changes in the posterior cerebral artery (visually evoked flow) was significantly greater in migraineurs than in controls (%MFV change, 14.1 +/- 5.4 vs 11.4 +/- 4.8; p = 0.004). TCD features did not discriminate common from classic migraine. Taken together, our results support the view of intracranial vascular abnormality in migraineurs reflecting, in particular, a narrower and more reactive arterial tree. The value of TCD in the differential diagnosis of "vascular headache" and in the study of migraine pathophysiology will have to be determined in the future.

Transcranial Doppler evaluation of common and classic migraine. Part II. Ultrasonic features during attacks.

Transcranial Doppler (TCD) examinations were performed in 13 patients with common and 5 patients with classic migraine during attacks and compared to TCD findings during the headache-free period. Two distinct patterns of flow changes were detected to distinguish common from classic migraine on the basis of TCD findings. During attacks, patients with common migraine exhibited reduction of flow velocities associated with an increase of pulse wave amplitudes. Vascular bruits that were heard during the headache-free interval often disappeared. Opposite changes were found in attacks of classic migraine during the headache phase with increase of flow velocities, decrease of pulsatility and more prominent or newly appearing bruits. These findings were often diffuse and did not appear to correlate with side of headache or side of neurological aura. Uniform changes occurred in the cervical internal carotid artery and the basal cerebral arteries in either form of migraine. We propose that these changes represent caliber fluctuations of the large arteries, suggesting vasodilatation during attacks of common migraine and vasoconstriction during attacks of classic migraine. We do not intend to imply a casual role of these preliminary findings in migraine pathogenesis, but we suggest that TCD be used in combination with other methods to study vascular changes in migrainous disorders.