Headache as a symptom at stroke onset in 4,431 young ischaemic stroke patients. Results from the "Stroke in Young Fabry Patients (SIFAP1) study".

Headache as symptom of stroke is linked to gender, history of migraine, younger age, cerebellar stroke, and low blood pressure. These associations have been controversial, large scale studies are missing. We used the stroke in young fabry patients study to examine the association of demographic, clinical and imaging factors with the occurrence of headache in 4,431 young ischaemic stroke patients (18-55 years; mean: 44.7 years) with an ischemic cerebrovascular event (CVE) (ischemic stroke-IS 75.9%, TIA 24.1%). Headache in males occurred more frequently in bilateral localisation (right/left/bilateral: 27.5, 24.6, 39.2%, p < 0.01), but not in females (40.3, 34.7, 39.6%). Headache occurrence was more often associated in both genders with IS or TIA in the posterior cerebral territory (male: 33.2%, p < 0.05; female: 51.0%, p < 0.01) and vertebrobasilar arteries (male: 44.8%, p < 0.001; female: 51.2%, p < 0.001). The larger the size of the most prominent lesion the more likely patients were complaining headache during the IS (≤1 cm vs. >half lobe: 19.5 vs. 28.4% in male, p < 0.001; 28.9 vs. 39.1% in female, p < 0.01). Binary logistic regression analyses revealed lower age (p < 0.001), female sex (p < 0.001), larger size of the largest lesion (p < 0.001), and localization in the vertebrobasilar territory (p < 0.001) as predictors for headache during CVE. Headache at stroke onset is more common during IS in females, younger patients, with greater size of the acute lesion, and affected in posterior cerebral artery or vertebrobasilar system. Headache is a leading symptom in specific combination of stroke factors. These factors should be taken into account when patients report headache during IS or TIA.

Combined treatment with intravenous abciximab and intraarterial tPA yields high recanalization rate in patients with acute basilar artery occlusion.

BACKGROUND: The best therapeutic approach in patients with acute basilar artery occlusion (BAO) remains unclear. We report the results of a combined treatment approach with intravenous (IV) abciximab and intraarterial (IA) tissue plasminogen activator (tPA) in these patients. METHODS: We prospectively studied patients with acute BAO on CT-angiography or MR-angiography. We treated patients with IV abciximab followed by IA thrombolysis with tPA. Primary outcome was partial or complete recanalization according to thrombolysis in myocardial infarction 2 to 3 flow grades on catheter angiography. Secondary outcomes were favorable functional outcome (mRS score ≤3) and mortality at 90 days. RESULTS: Of 20 patients, mean age was 62 ± 13 years, median baseline National Institutes of Health Stroke Scale (NIHSS) score 25.5 (IQR 12-28), and median Glasgow Coma Scale score 7 (IQR 6-11). Mean time to IA treatment was 7 ± 2.8 hours. We achieved partial or complete recanalization in 17/20 patients (85%). At 3 months, 3/20 patients (15%) had a favorable functional outcome and 9/20 patients (45%) were deceased. CONCLUSIONS: Combined treatment with IV abciximab and IA tPA yielded a high recanalization rate in patients with BAO. However, functional outcomes were poor, potentially due to late initiation of treatment. Early treatment might improve functional outcome.

Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion.

BACKGROUND AND PURPOSE: Quantification of early ischemic changes (EIC) may predict functional outcome in patients with basilar artery occlusion (BAO). We tested the validity of a novel CT score, the posterior circulation Acute Stroke Prognosis Early CT score (pc-ASPECTS). METHODS: Pc-ASPECTS allots the posterior circulation 10 points. Two points each are subtracted for EIC in midbrain or pons and 1 point each for EIC in left or right thalamus, cerebellum or PCA-territory, respectively. We studied 2 different populations: (1) patients with suspected vertebrobasilar ischemia and (2) patients with BAO. We applied pc-ASPECTS to noncontrast CT (NCCT), CT angiography source images (CTASI), and follow-up image by 3-reader consensus. We calculated sensitivity for ischemic changes and analyzed the predictivity of pc-ASPECTS for independent (modified Rankin Scale [mRS] score /=8 but only 4% (1/23) with a score <8 had favorable functional outcome (RR 12.1; 95% CI, 1.7 to 84.9). This difference was consistent in 21 patients with angiographic recanalization (RR 7.7; 95% CI, 1.1 to 52.1). CONCLUSIONS: The CTASI pc-ASPECTS score may identify BAO patients unlikely to have a favorable outcome despite recanalization.

Transcatheter treatment of atrial septal aneurysm associated with patent foramen ovale for prevention of recurrent paradoxical embolism in high-risk patients.

OBJECTIVES: This study sought to investigate the safety and efficacy of transcatheter treatment of atrial septal aneurysm (ASA) associated with patent foramen ovale (PFO). BACKGROUND: Patients with both ASA and PFO are at high risk for recurrent paradoxical embolism. METHODS: The procedural, echocardiographic, and clinical outcomes of 141 patients with ASA + PFO and > or =1 paradoxical embolic event undergoing transcatheter treatment were compared with 220 patients with PFO alone. RESULTS: Device success (ASA + PFO, 99.3%; PFO alone, 99.5%; p = 0.75) and procedural complications (ASA + PFO, 0.7%; PFO alone, 3.2%; p = 0.12) were similar in both groups. Maximal atrial septal excursion in patients with ASA + PFO decreased from 16 +/- 4 mm before to 4 +/- 3 mm after the intervention (p < 0.0001). At 6 months follow-up, right-to-left shunt was abolished in 120 (86%) patients with ASA + PFO, compared to 187 (85%) patients with PFO alone (p = 0.80). Freedom from recurrent transient ischemic attack, stroke, and peripheral embolism at 4 years was 95% (ASA + PFO) and 94% (PFO alone, p = 0.70), respectively. A residual right-to-left shunt after the intervention was the only predictor for recurrence (hazard ratio [HR] 6.9; 95% confidence interval [CI] 1.3 to 36.9, p < 0.03) in patients with ASA + PFO. CONCLUSIONS: Transcatheter treatment of ASA + PFO is safe and effective in patients with paradoxical embolism. The procedure effectively abolishes right-to-left shunt and decreases atrial septal mobility. Long-term prevention of recurrent events appears favorable when compared to patients with PFO alone.