Neuronavigated 1 Hz rTMS of the left angular gyrus combined with visuospatial therapy in post-stroke neglect.

BACKGROUND: Visuospatial neglect (VSN) may be caused by an inter-hemispheric imbalance of neural activity after brain injury. Repetitive transcranial magnetic stimulation (rTMS) allows rebalancing restoration to a certain degree, relieving neglect symptoms. OBJECTIVE: This study investigates the therapeutic effect of 1 Hz rTMS applied over the left angular gyrus combined with visual scanning training in patients with left VSN in the subacute stroke phase. METHODS: Twenty-eight patients with VSN were randomly assigned to either experimental (fifteen sessions of rTMS consisted of 1800 magnetic pulses delivered to the left angular gyrus with a neuronavigation control), or control group (fifteen sessions of sham stimulation), followed by visual scanning training. VSN severity was assessed both before and after treatment with a 3-month follow up employing the Behavioural Inattention Test and functional measures. RESULTS: No statistically significant differences were detected in outcome measures between the rTMS and sham groups after completion of 3-week therapy and at 3-month follow up. The magnitude of stimulation effects was not associated either with lesion volume, its location, or baseline motor threshold. CONCLUSIONS: Our study did not confirm efficacy of 1 Hz rTMS over the angular gyrus as an adjuvant method to visual scanning training in patients with VSN in the subacute stroke.

Mechanical thrombectomy in acute stroke - Five years of experience in Poland.

OBJECTIVES: Mechanical thrombectomy (MT) is not reimbursed by the Polish public health system. We present a description of 5 years of experience with MT in acute stroke in Comprehensive Stroke Centers (CSCs) in Poland. METHODS AND RESULTS: We retrospectively analyzed the results of a structured questionnaire from 23 out of 25 identified CSCs and 22 data sets that include 61 clinical, radiological and outcome measures. RESULTS: Most of the CSCs (74%) were founded at University Hospitals and most (65.2%) work round the clock. In 78.3% of them, the working teams are composed of neurologists and neuro-radiologists. All CSCs perform CT and angio-CT before MT. In total 586 patients were subjected to MT and data from 531 of them were analyzed. Mean time laps from stroke onset to groin puncture was 250±99min. 90.3% of the studied patients had MT within 6h from stroke onset; 59.3% of them were treated with IV rt-PA prior to MT; 15.1% had IA rt-PA during MT and 4.7% - emergent stenting of a large vessel. M1 of MCA was occluded in 47.8% of cases. The Solitaire device was used in 53% of cases. Successful recanalization (TICI2b-TICI3) was achieved in 64.6% of cases and 53.4% of patients did not experience hemorrhagic transformation. Clinical improvement on discharge was noticed in 53.7% of cases, futile recanalization - in 30.7%, mRS of 0-2 - in 31.4% and mRS of 6 in 22% of cases. CONCLUSION: Our results can help harmonize standards for MT in Poland according to international guidelines.

Early neurological worsening in patients with Wilson's disease.

BACKGROUND: Early neurological worsening during treatment initiation for Wilson's disease (WD) is an unresolved problem. Our aim was to establish the frequency and outcome of early neurological worsening in patients with WD. METHODS: We analyzed 143 symptomatic patients diagnosed with WD between 2005 and 2009. Early neurological deterioration was based on worsening on the Unified Wilson's Disease Score Scale, scored at baseline through 6 months or occurrence of new neurological symptoms. Reversibility of worsening was followed up to 24 months. RESULTS: Early neurological worsening was observed in 11.1% (16/143) and involved only patients with neurological signs at diagnosis. Mean time to worsening from treatment initiation was 2.3 ± 1.9 months. Neurological deterioration was completely reversible in 53% (8/15) and partially in 13% (2/15) of patients over 9.2 ± 5.2 months. Patients who experienced early deterioration had significantly more severe baseline neurological deficit, higher prevalence of thalamic (66% vs 29%) and brain stem (73% vs 33%) lesions seen on baseline magnetic resonance imaging, and more often used concomitant dopamine receptor antagonists (46% vs 5%). Disease duration, treatment type (d-penicillamine or zinc sulfate), type of neurological manifestations, initial copper metabolism results, and liver function parameters did not differ between evaluated groups. CONCLUSIONS: Neurological worsening at the beginning of anti-copper therapy may occur in over 10% of WD patients. Special attention should be paid to those with severe initial neurological manifestations, advanced brain injury and using dopamine receptor antagonists. Type of anti-copper therapy did not show clear association with early neurological worsening.

Pure alexia after damage to the right fusiform gyrus in a right-handed male.

Pure alexia refers to a rare acquired reading disorder commonly associated with damage to the posterior part of the left medial occipito-temporal (fusiform) gyrus, which is known as the visual word-form area (VWFA) and thought to be the neural basis for visual processing of letters and words. Right-sided lesions very rarely lead to pure alexia in right-handed individuals. We report a case of a 33-year-old right-handed man with isolated pure alexia resulting from a hemorrhagic lesion to the right fusiform gyrus. A limited recovery of reading skills was observed within six weeks post onset. During this period, the patient spontaneously developed a letter-by-letter reading strategy. Functional magnetic resonance imaging revealed right-hemisphere dominance for language as well as bilateral reading-related activity in the fusiform gyri. Our case indicates that pure alexia may arise as a consequence of damage to the right fusiform gyrus even in right-handed patients (who still may have right hemisphere dominance for language and reading skills), and may lead to a severe reading disorder, as in individuals with left-hemisphere dominance for language.

Endovascular treatment of cervical intramedullary arteriovenous malformation.

Intramedullary arteriovenous malformations (AVMs) in the cervical region are a rare clinical condition. They represent a therapeutic challenge, as the lesions may cause serious functional disorders due to their location within or immediately adjacent to the critical ascending and descending sensorimotor pathways. In this case report, we present a patient with a cervical intramedullary AVM that was treated with endovascular therapy. Our experience suggests that endovascular treatment is an effective and safe method for treating AVMs located in the cervical region of the spinal cord. More studies are needed to establish appropriate treatment protocols depending on the clinical course, the anatomy of the lesion, and the region in which it is found.

Anodal transcranial direct current stimulation in early rehabilitation of patients with post-stroke non-fluent aphasia: a randomized, double-blind, sham-controlled pilot study.

PURPOSE: Recent research in patients with chronic aphasia shows an association between excitatory anodal transcranial direct current stimulation (A-tDCS) of the stroke-affected left hemisphere coupled with speech and language therapy (SLT) and better language performance. The present study aimed to investigate this association during the early post-stroke rehabilitation period, when adaptive changes are most possible on neurophysiological and behavioral levels. METHODS: We randomized 24 patients with non-fluent aphasia to receive 15 consecutive sessions (5 days/week for 3 weeks) of A-tDCS (1 mA, 10 min; n = 14) or sham tDCS (S-tDCS: 1 mA, 25 sec; n = 10) over Broca's area followed by 45-min SLT. Naming ability was assessed before the rehabilitation, after its completion, and three months later. RESULTS: Both groups significantly improved after the therapy. There were no statistically significant between-group differences in the short-term or long-term tDCS effects on naming accuracy and naming time. The A-tDCS group obtained higher effect sizes in naming time, both post-treatment and at the 3-month follow-up, suggesting potential benefits of the stimulation. CONCLUSIONS: The findings provide only weak evidence for A-tDCS-related language gains during early neurorehabilitation of post-stroke aphasia. Further research is needed to explore the effectiveness of this kind of neuromodulation.

Transcranial magnetic stimulation combined with speech and language training in early aphasia rehabilitation: a randomized double-blind controlled pilot study.

BACKGROUND: Functional neuroimaging studies with poststroke aphasia patients have shown increased activation of the unaffected hemisphere, which hypothetically reflects a maladaptive strategy of brain reorganization. OBJECTIVE: We investigated whether repetitive transcranial magnetic stimulation (rTMS) inhibiting the right-hemisphere homologue of Broca's area improves language restitution if combined with speech/language therapy. METHODS: Forty aphasic patients during the subacute phase of ischemic stroke were randomized to a 3-week aphasia rehabilitation protocol in combination with real or sham rTMS. Naming, repetition, and comprehension were assessed using the Boston Diagnostic Aphasia Examination at baseline, immediately after therapy, and 15 weeks after completing treatment. RESULTS: Although language functions improved in both experimental and control groups after 3 weeks, only slight group differences in degree of recovery were revealed between patients receiving rTMS and control participants. Follow-up revealed that severely aphasic rTMS patients demonstrated significantly greater improvement than patients receiving sham stimulation in repetition. CONCLUSIONS: Inhibitory rTMS applied to the right frontal language homologue is not effective for all poststroke aphasia patients, although it might benefit selected patients.

Endovascular treatment of intracranial aneurysms with remodelling using Leo+ stents.

BACKGROUND AND PURPOSE: Endovascular embolization is an approved method of treatment of cerebral aneurysms. Several difficulties can be caused by wide-neck aneurysms. In these cases vascular remodelling is required. It can be performed with the use of balloons or intracranial stents. This method allows expansion of the therapeutic indications for aneurysm embolization. MATERIAL AND METHODS: We present the results of the Leo+ stent implantation with embolization with coils in nine consecutive patients treated between May 2007 and September 2008 in the Institute of Psychiatry and Neurology. RESULTS: In 3 cases embolization was complete, in 4 subtotal, and in 2 partial. In 3 cases the procedure was complicated by stroke: in 2 patients directly after the procedure and in 1 patient 45 days after embolization. 1 patient died due to a recurrent stroke over 1 year after the procedure. Technical failure was noted in 1 patient (stent misplacement from target vessel - the middle cerebral artery to the internal carotid artery, and therefore it did not cover the neck of the aneurysm). CONCLUSIONS: Vascular remodelling with intracranial stents in treating wide-neck intracranial aneurysms is a promising method allowing the indications for endovascular embolization to be increased. Nevertheless, it seems to carry a relatively high risk of cerebrovascular thromboembolic complications, especially ischaemic stroke. It also seems that the procedure itself might cause some technical difficulties. The full clinical safety and efficacy need further evaluation.

Mechanical embolectomy in acute ischaemic stroke--report of the first two cases.

Intravenous thrombolysis is the only approved treatment for acute ischaemic stroke administered within 3 hours of onset. Mechanical embolectomy with the MERCI device is a new treatment option for patients with occlusion of a large cerebral artery who do not meet the current license criteria for thrombolysis, are admitted up to 15 hours from onset, or do not respond to treatment with recombinant tissue plasminogen activator (rt-PA). This is a report of the first two cases of acute ischaemic stroke treated with the MERCI device at our department. One did not meet the inclusion criteria for systemic thrombolysis, and the second did not improve despite rt-PA treatment. In both cases improvement of flow in the MCA was achieved and moderate neurological improvement was observed at 3-month follow-up. More studies and controlled trials are needed to establish the utility of mechanical embolectomy in the treatment of stroke.

Frequency and prognostic value of cognitive disorders in stroke patients.

BACKGROUND: Stroke is one of the most common diseases to cause cognitive disorders in adults. AIMS: To assess the frequency of cognitive deficits in stroke patients and to evaluate the prognostic value of cognitive syndromes for functional recovery. METHODS: 200 consecutive patients were examined using a clinical screening battery for cognitive assessment in the second week after their first-ever stroke. 80 were re-examined after a 1-year follow-up. RESULTS: In the post-acute stage, 78% patients were impaired in one or more cognitive domains. The most frequently affected cognitive abilities were attention (48.5%), language (27%), short-term memory (24.5%) and executive functions (18.5%). At the 1-year follow-up, attention deficits were still the most frequent symptom. In contrast, executive dysfunction, aphasia, and long-term memory disorder were significantly less frequent than in the post-acute period. Logistic regression analysis showed that older age, lower score on the Barthel Index, and the presence of executive dysfunction on initial examination were significant predictors of a poor functional outcome at the 1-year follow-up examination. CONCLUSIONS: Cognitive-behavioral syndromes are frequent and often chronic consequences of stroke. Executive deficits proved to be the most robust cognitive predictor of poor functional recovery after stroke.