Early Cerebrovascular Ultrasonography as a Predictor of Hemorrhagic Transformation After Thrombectomy.

OBJECTIVES: To determine the predictive value of early transcranial color-coded sonography (TCCS) for intracranial hemorrhage (ICH) in patients with large artery occlusion (LAO) stroke of carotid circulation, who were submitted to endovascular therapy (EVT) with successful reperfusion. MATERIALS AND METHODS: Retrospective study evaluating a cohort of consecutive stroke patients with LAO of the carotid circulation that were recanalyzed with EVT. We measured angle-corrected peak systolic velocities, end-diastolic velocities and mean flow velocities (PSV, EDV and MFV) of the symptomatic and asymptomatic middle cerebral artery (MCA). The ratio between MFV of the symptomatic MCA and MFV of the asymptomatic MCA (MCA-Ra) was calculated. Parenchymal hematoma in the 24 hours control CT was considered as ICH. Univariate associations and multivariate analyses were used to identify early independent predictors for ICH among TCCS findings. RESULTS: We included 234 patients, mean age 72.5 (SD 12.6) years, 52.1% male. The mean time between recanalization and TCCS was 12.3 hours (range 3-22). Patients who developed postinterventional ICH showed a higher MCA-Ra (1.02 ± 0.26 vs 1.16 ± 0,21, p = 0.036). In multivariate analysis, only higher MCA-Ra remained independently associated with postinterventional ICH (OR: 6.778, 95%CI: 1.152-39.892, p = 0.034). A value of MCA-Ra ≥ 1,05 was associated with ICH, showing a sensitivity of 81.3% and a specificity of 65.9%; the AUC based of the ROC analysis was 0.688 (95% CI 0.570-0.806). CONCLUSION: TCCS performed within the first 24 hours after stroke onset can help to predict hemorrhagic transformation in patients with LAO.

Central nervous system vasculitis in systemic lupus erythematosus: a case series report in a tertiary referral centre.

Central nervous system (CNS) vasculitis (CNS) in systemic erythematosus lupus (SLE) is a rare and challenging diagnosis. We report four cases of CNS vasculitis that occurred 5 to 16 years after the diagnosis of SLE. Magnetic resonance imaging (MRI) detected different features suggestive of CNS vasculitis: enhancement and thickening of the vascular wall, vascular stenosis, ischemic brain lesions and intracerebral haemorrhage unlikely to correspond to other mimic aetiologies. Three patients received combination therapy with glucocorticoids (GC) and cyclophosphamide (CYC). Intravenous human immunoglobulin (IVIG) was administered when the patient had a past history of serious adverse event to CYC or high infectious risk. All patients showed imagiological improvement, at least partially, 5 to 23 days after starting treatment. We discuss the management of CNS in SLE including the role of magnetic resonance imaging (MRI).

Long-term effectiveness and safety of natalizumab in a Portuguese population.

OBJECTIVES: Natalizumab long-term effectiveness data in real-world relapsing-remitting multiple sclerosis (RRMS) is needed. Our objective is to report the long-term effectiveness and safety of natalizumab in a cohort of RRMS patients. METHODS: This is a retrospective study of natalizumab treatment for two years or longer in RRMS. Annualized relapse rate, Expanded Disability Status Scale (EDSS), brain magnetic resonance imaging T2 lesion volume, JC virus antibody status, previous treatments and adverse events were analysed. RESULTS: Seventy-one patients were included with a mean treatment duration of 44.86±17.39months. Over the treatment duration there was a significant decrease in annualized relapse rate (88.37%) and EDSS (28.57%); no evidence of clinical disease activity in 73.24% and 61.97% after one and two-years respectively; and brain magnetic resonance imaging T2 lesion volume remained stable. Forty patients suspended natalizumab, in 85% due to high risk of developing progressive multifocal leukoencephalopathy (PML). The major complication was PML (n=3). CONCLUSIONS: Natalizumab showed effectiveness in the long-term follow up period of our cohort, with reduction of ARR, EDSS, and MRI lesion load stabilization. PML was the major complication.

Cognitive impairment and magnetic resonance imaging correlates in primary progressive multiple sclerosis.

OBJECTIVES: To characterize cognitive impairment in primary progressive multiple sclerosis (PPMS) and to correlate the pattern of cognitive deficits with brain magnetic resonance imaging (MRI) volumetric data. MATERIALS AND METHODS: In a multicenter cross-sectional study, we recruited consecutive patients with PPMS as well as age, sex, and education level-matched healthy controls (HC). All participants underwent neuropsychological (NP) assessment, and brain MRI was performed in patients with PPMS for analysis of lesion load, subcortical GM volumes, and regional cortical volumes. RESULTS: We recruited 55 patients with PPMS and 36 HC. Thirty-six patients were included in the MRI analysis. Patients with PPMS performed significantly worse than HC in all NP tests. Subcortical GM volume was significantly correlated with all NP tests, except for Stroop Test, with the largest effect for the thalamus (r=-.516 [BVMT-R DR, P=.016 FDR-corrected] to r=.664 [SDMT, P<.001 FDR-corrected]). In the stepwise linear regression model, thalamic volume was the only predictor of performance in all NP tests. CONCLUSION: Cognitive impairment is common in PPMS and affects all evaluated cognitive domains. Subcortical GM volume, particularly of the thalamus, is a strong predictor of cognitive performance, suggesting it has a central role in the pathophysiology of PPMS-related cognitive dysfunction.

Nocturnal blood pressure dipping in acute ischemic stroke.

OBJECTIVES: We aim to assess the impact of early nocturnal blood pressure (BP) variation in the functional outcome of patients after an acute ischemic stroke. MATERIALS AND METHODS: We included consecutive stroke patients treated with intravenous thrombolysis (IVrtPA) in a tertiary stroke center. BP measurements were performed at regular intervals throughout day and night during the first 48 h after stroke onset, and subjects were divided into four dipping categories (extreme dippers, dippers, non-dippers, and reverse dippers). Recanalization was assessed by transcranial color-coded Doppler and/or angiographic CT. Hemorrhagic transformation was evaluated at 24 h follow-up CT scan. Functional outcome was evaluated at 3 months after stroke using the modified Rankin Scale. RESULTS: A total of 304 patients were included, mean age 72.80 ± 11.10 years. After 24 h of systolic BP monitoring, 30.59% were classified as reverse dippers, 39.14% as non-dippers, 19.10% as dippers, and 11.18% as extreme dippers. Multivariate analysis did not show an independent association of any dipping class with 3-month functional outcome. Hemorrhagic transformation was not uniform between dipping classes: 25.81% for reverse dippers, 14.29% for non-dippers, 15.52% for dippers, and 5.88% for extreme dippers, P = 0.033. CONCLUSIONS: Nocturnal BP dipping pattern is not associated with functional outcome at 3 months in acute stroke patients treated with IVrtPA. Hemorrhagic transformation was more frequent in reverse dippers.