Late outcomes after carotid artery stenting versus carotid endarterectomy: insights from a propensity-matched analysis of the Reduction of Atherothrombosis for Continued Health (REACH) Registry.

BACKGROUND: In patients with carotid artery disease, carotid endarterectomy (CEA) and carotid stenting (CAS) are treatment options. Controversy exists as to the relative efficacy of the 2 techniques in preventing late events. METHODS AND RESULTS: The Reduction of Atherothrombosis for Continued Health (REACH) Registry recruited > 68,000 outpatients ≥ 45 years of age with established atherothrombotic disease or ≥ 3 risk factors for atherothrombosis. Patients with CAS or CEA were chosen and followed up prospectively for the occurrence of cardiovascular events. Propensity score matching was performed to assemble a cohort of patients in whom all baseline covariates would be well balanced. Primary outcome was defined as death or stroke at the 2-year follow-up. Secondary outcome was stroke or transient ischemic attack. Tertiary outcome was a composite of death, myocardial infarction, or stroke and the individual outcomes. Of the 68 236 patients with atherothrombosis, 3412 patients (5%) had a history of carotid artery revascularization (70% asymptomatic carotid stenosis), 1025 (30%) with CAS and 2387 (70%) with CEA. Propensity score analyses matched 836 CAS patients with 836 CEA patients. At the end of 2 years of follow-up, in the propensity score-matched cohort, CAS was associated with a risk similar to CEA for the primary (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.57 to 1.26), secondary (HR, 1.20; 95% CI, 0.73 to 1.96), and tertiary (HR, 0.72; 95% CI, 0.51 to 1.01) composite outcome, death (HR, 0.63; 95% CI, 0.40 to 1.00), and stroke (HR, 1.48; 95% CI, 0.79 to 2.80). CONCLUSIONS: In a real-world cohort of patients with a history of carotid artery revascularization, CAS was comparable to CEA for late outcomes.

High prevalence of peripheral arterial disease in patients with acute ischaemic stroke.

BACKGROUND: After acute ischaemic stroke (AIS) or transient ischaemic attack (TIA), the detection of peripheral arterial disease (PAD) as a marker of generalized atherosclerosis may improve the risk stratification and prevention of future atherothrombotic events. We aimed to determine the prevalence of PAD indicated by an ankle-brachial index (ABI) of < or =0.9 in a large cohort of patients with AIS/TIA. METHODS: In this prospective, multicentre, Austrian, cross-sectional study (OECROSS), 759 patients with AIS or TIA were recruited for a systematic assessment of cardiovascular risk profiles and Doppler ultrasound at the ankle and brachial artery to calculate the ABI from systolic blood pressure readings. RESULTS: 739 patients (97.4%) had a complete ABI assessment. The mean age was 69.5 (+/- 12.1) years, and 55.8% of the patients were men. 81.6% of the patients had AIS and 18.4% had TIA. Only 6.2% of the patients had a history of PAD, but an abnormal ABI of < or =0.9 was found in 44.9%. Patients with an ABI of < or =0.9 were more likely (p < 0.05) to be older and have a history of PAD, hypertension, diabetes and congestive heart failure. An ABI of < or =0.9 was significantly associated (p < 0.0005) with a presence of carotid stenosis of >50% and an Essen Stroke Risk Score of >2, indicating a risk of > or =4% per year of stroke recurrence. DISCUSSION: A high proportion of patients with AIS/TIA have subclinical PAD, a cross-risk stroke physicians should be aware of. Large longitudinal studies are needed to elucidate whether the ABI can improve our estimation of the risk of future atherothrombotic events and help in optimizing secondary prevention.

Beneficial effect of rituximab monotherapy in multifocal motor neuropathy.

Multifocal motor neuropathy (MMN) is a chronic, pure motor, asymmetric neuropathy for which intravenous immunoglobulin (IVIg) is widely regarded as first-line treatment. Rituximab is a monoclonal antibody against CD20+ cells that causes prolonged B cell depletion, a well-tolerated therapy currently explored in several immune-mediated neurologic disorders. We report three patients with MMN, who had become increasingly less responsive to IVIg but showed sustained clinical improvement following rituximab monotherapy. We provide a review of the literature on rituximab for MMN and conclude that rituximab may represent an efficacious, well-tolerated and cost-effective therapeutic option for MMN patients with declining response to IVIg.

Rituximab for myasthenia gravis: three case reports and review of the literature.

In generalized myasthenia gravis (MG), a wide array of immunosuppressive and immunomodulating treatments is being used in clinical practice, but most drugs lack evidence from randomized controlled trials supporting their use. Furthermore, many patients develop serious side effects or do not respond sufficiently to these drugs. We report three patients with generalized MG who were treated with rituximab, a monoclonal antibody against CD20+ cells that causes prolonged B cell depletion. In all three patients, treatment with rituximab led to a sustained clinical improvement and discontinuation or reduction of prednisolone and other drugs. Rituximab was well tolerated. Therapy with rituximab was guided by the total count of peripheral B lymphocytes. Reviewing the anecdotal literature on rituximab for MG, we conclude that preliminary data on the efficacy and safety of rituximab are encouraging and that further studies in MG seem warranted.

Cerebral vasculitis and stroke in Lyme neuroborreliosis. Two case reports and review of current knowledge.

We report on 2 patients with cerebral vasculitis and stroke due to Lyme neuroborreliosis (LNB). Both patients had a prodromal stage involving headaches, and showed meningeal enhancement in addition to ischemic infarctions on brain magnetic resonance imaging and diffuse vasculitis on vascular imaging. Serological and cerebrospinal (CSF) fluid studies confirmed the diagnosis of active LNB. Ceftriaxone for 3 weeks led to an excellent recovery and improvements in the CSF examination findings. Stroke physicians should be aware of this rare presentation of LNB. A review of the current knowledge on cerebral vasculitis due to LNB is provided.

[Baseline predictors of outcome in stroke patients treated with intravenous thrombolysis--the Austrian stroke unit registry]. / Prädiktoren des Schlaganfall-Outcome nach intravenöser Thrombolyse--Daten des Osterreichischen Stroke Unit Registers.

BACKGROUND: Intravenous thrombolysis (IVT) for acute ischaemic stroke is safe and effective in routine clinical use. We aimed to identify baseline predictors of excellent outcome after 3 months, defined by a modified Rankin Scale score

Prognostic value of admission C-reactive protein in stroke patients undergoing iv thrombolysis.

OBJECTIVE: To test the hypothesis that pre-treatment Creactive protein (CRP) predicts outcome in stroke patients undergoing intravenous thrombolysis (IVT) treatment. METHODS: We analyzed the data of 111 consecutive patients with IVT within 6 hours of stroke onset for stroke involving the middle cerebral artery territory and admission CRP < or = 6 mg/dl. RESULTS: CRP levels were consistently, yet non-significantly lower in patients with unfavourable outcome definitions. Median (range) CRP levels were 0.3 (0-5.9) mg/dl vs. 0.4 (0-5.7) mg/dl (p = 0.13) in patients dependent or dead after 3 months (modified Rankin Scale score > 2; n = 59) vs. independent patients (n = 52); 0.2 (0.1-1.5) mg/dl vs. 0.4 (0-5.9) mg/dl (p = 0.28) in patients dead after 3 months (n = 14) versus survivors (n = 97); and 0.2 (0.1-0.7) mg/dl vs. 0.4 (0-5.9) mg/dl (p = 0.09) in patients with significant neurological deterioration within 24 hours (increase in > or = 4 points on National Institute of Health Stroke scale; n = 9) vs. patients without early deterioration (n = 102). Independent predictors of dependency/death after 3 months, identified by multivariate logistic regression analyses, were baseline NIHSS score (OR = 1.31, 95 % CI 1.16-1.48, p < 0.001), time from onset to treatment (OR = 1.01, 95 % CI 1.0-1.02, p = 0.024), and presence of diabetes (OR = 8.16, 95 % CI 1.18-56.5, p = 0.033). CONCLUSION: Pre-treatment CRP clearly failed to predict outcome in stroke patients treated with IVT. Our findings contradict previously published work and highlight the need for further research on this topic.

Risk factor profile and management of cerebrovascular patients in the REACH Registry.

BACKGROUND: Cerebrovascular disease (CVD) is a global public health problem. CVD patients are at high risk of recurrent stroke and other atherothrombotic events. Prevalence of risk factors, comorbidities, utilization of secondary prevention therapies and adherence to guidelines all influence the recurrent event rate. We assessed these factors in 18,992 CVD patients within a worldwide registry of stable outpatients. METHODS: The Reduction of Atherothrombosis for Continued Health Registry recruited >68,000 outpatients (44 countries). The subjects were mainly recruited by general practitioners (44%) and internists (29%) if they had symptomatic CVD, coronary artery disease, peripheral arterial disease (PAD) and/or >or=3 atherothrombotic risk factors. RESULTS: The 18,992 CVD patients suffered a stroke (53.7%), transient ischemic attack (TIA) (27.7%) or both (18.5%); 40% had symptomatic atherothrombotic disease in >or=1 additional vascular beds: 36% coronary artery disease; 10% PAD and 6% both. The prevalence of risk factors at baseline was higher in the TIA subgroup than in the stroke group: treated hypertension (83.5/82.0%; p = 0.02), body mass index >or=30 (26.7/20.8%; p < 0.0001), hypercholesterolemia (65.1/52.1%; p < 0.0001), atrial fibrillation (14.7/11.9%; p < 0.0001) and carotid artery disease (42.3/29.7%; p < 0.0001). CVD patients received antiplatelet agents (81.7%), oral anticoagulants (17.3%), lipid-lowering agents (61.2%) and antihypertensives (87.9%), but guideline treatment targets were frequently not achieved (54.5% had elevated blood pressure at baseline, while 4.5% had untreated diabetes). CONCLUSIONS: A high percentage of CVD patients have additional atherothrombotic disease manifestations. The risk profile puts CVD patients, especially the TIA subgroup, at high risk for future atherothrombotic events. Undertreatment is common worldwide and adherence to guidelines needs to be enforced.

Multitracer study in Heidenhain variant of Creutzfeldt-Jakob disease: mismatch pattern of cerebral hypometabolism and perfusion imaging.

Creutzfeldt-Jakob disease (CJD) is a subacute spongiform encephalopathy. This fatal prion disease is characterized by rapidly progressive dementia with a variety of neurological disorders. Diagnostic methods provided by nuclear medicine might be helpful for evaluation of patients with probable CJD as additional diagnostic tools to MRI and cerebro-spinal fluid evaluation. The experience with FDG-PET and brain perfusion SPECT is presented.

Thrombolysis beyond the guidelines: two treatments in one subject within 90 hours based on a modified magnetic resonance imaging brain clock concept.

BACKGROUND AND PURPOSE: We report the first case of 2 intravenous thrombolysis treatments within 90 hours in a patient with early recurrent stroke. SUMMARY OF REVIEW: A 50-year-old man had improved significantly after intravenous thrombolysis for acute stroke. On the fourth day, he deteriorated dramatically because of recurrent stroke. Evidence of vessel reocclusion and profound perfusion/diffusion mismatch constituted the rationale for a second thrombolysis treatment, which resulted in vessel recanalization and significant neurologic improvement. CONCLUSIONS: The pathophysiological information obtained by multimodal magnetic resonance imaging may suit as a brain clock when repeat thrombolysis treatment is considered for early recurrent stroke.

Importance of T2*-weighted gradient-echo MRI for diagnosis of cortical vein thrombosis.

We examined six patients with isolated venous thrombosis (n = 2), or venous thrombosis combined with sinus thrombosis (n = 4) (CVT). The clinical symptoms were non-specific (acute cephalea, paresis, epileptic seizure, progressive speech disorder). All examinations were performed on a 1.5 T system (Magnetom Symphony, Siemens, Erlangen, Germany), maximum gradient field strength 30 mT/m, minimal gradient rise time 450 micros, according to the following protocol: Transverse T2-weighted turbo spin-echo (TSE), fluid attenuated inversion recovery (FLAIR), T1-weighted spin-echo (SE), before and after administration of contrast medium, T2*-weighted conventional gradient-echo (GRE), T2*-weighted spin-echo echo planar imaging (SE EPI), both without and with diffusion weighting as well as two-dimensional (2D) venous time-of-flight (TOF) MRA. The venous thromboses were best detectable in the T2*-weighted conventional GRE sequence in all patients. In two patients, the CVT was discernible only in this sequence. The sinus thrombosis was well discernible only in the T2*-weighted GRE sequence in only one case; in the remaining cases it was detectable only with difficulty. For these cases, other sequences such as SE, diffusion-weighted, or 2D-TOF-MRA sequence were superior. The T2*-weighted conventional GRE sequence was superior to the T2*-weighted SE EPI sequence in all patients. To sum up, it can be concluded, that T2*-weighted conventional GRE sequences are possibly the best method of detection of acute cortical vein thromboses. Therefore, it seems to be of benefit to integrate a T2*-weighted conventional GRE sequence into the MR-protocol for the diagnosis of isolated cortical vein thrombosis.

Serial contrast-enhanced magnetic resonance imaging and spectroscopic imaging of acute multiple sclerosis lesions under high-dose methylprednisolone therapy.

To evaluate biochemical changes in contrast-enhancing multiple sclerosis (MS) lesions, we examined 14 patients with relapsing-remitting MS at acute clinical exacerbation with the help of contrast-enhanced magnetic resonance imaging (MRI) and 1H magnetic resonance spectroscopic imaging (1H MRSI). Using a 1.5-tesla MR system (Magnetom Vision, Siemens, Germany), we followed 29 contrast-enhancing and 24 nonenhancing MS lesions as well as normal-appearing white matter (NAWM) before and during high-dose methylprednisolone (HDMP) therapy. Metabolite ratios of N-acetylaspartate (NAA), choline (Cho), creatine (Cr), and lactate (Lac) were calculated. A transient decrease in contrast enhancement under HDMP therapy was observed. Both groups of MS lesions showed significantly decreased NAA to Cr ratios compared to NAWM with no changes in time. Baseline 1H MRSI revealed significantly increased Cho to Cr ratios in the contrast-enhancing MS lesions (1.13 +/- 0.25) compared to the nonenhancing MS lesions (0.85 +/- 0.26, P < 0.001) and NAWM (0.97 +/- 0.22, P = 0.015). Both the contrast-enhancing and the nonenhancing MS lesions exhibited a significant increase in Cho to Cr ratios from the second to the third 1H MRSI. We identified resonances of lactate in both groups of MS lesions and NAWM without any significant group differences or changes over time. 1H MRSI provides additional information that help to estimate macrophages' activity, cell membrane activation, and neuronal impairment within MS lesions. We believe that combined contrast-enhanced MRI and 1H MRSI may help to further investigate inflammatory processes within active MS lesions and should be employed more frequently to the research on therapy effects in MS.

[Diagnosis of stroke--an update]. / Diagnostik des Schlaganfalls--ein Update.

In practical day-to-day terms, most patients have one of the common causes of stroke: ischemic stroke caused by the complications of atherothrombosis, intracranial small Vessel disease, embolism from the heart, primary intracerebral hemorrhage caused by hypertension, or subarachnoid hemorrhage as a result of a ruptured saccular aneurysm. There are three issues to be considered in assessing the reliability of the clinical diagnosis of stroke: the diagnosis of stroke itself: is it a stroke or not; whether the stroke is caused by an infarct or a hemorrhage and particular in ischemic stroke the site and size of the lesion (anterior vs. posterior circulation, lacunar vs. cortical, etc.) No clinical scoring method can differentiate with absolute reliability ischemic stroke from primary intracerebral hemorrhage. To do this brain computed tomography or magnetic resonance imaging is required. For vascular diagnosis ultrasound and magnetic resonance angiography are ideal and complementary non-invasive techniques. Both have no risks and are reasonably sensitive. Catheterangiography is only reserved for patients with subarachnoid hemorrhage with a view to surgical or endovascular treatment or in exceptional cases to establish a more firm prognosis. The diagnosis of ischemic stroke caused by embolism from the heart can only be considered at all if there is an identifiable cardioembolic source which is the case in about 30% of ischemic stroke, a higher proportion in recent studies using transoesophageal echocardiography. It is not clear that transoesophageal echocardiography provides much more information for clinical decision-making than transthoracic echocardiography, although it certainly provides more anatomical information in selected patients. This article summarises the diagnostic armamentarium which is used for the diagnosis of stroke and gives an overview of clinically reliable and relevant measures.