Predictors of Good Functional Outcome in Patients with Tandem Occlusion After Revascularization Treatment: Single-Center Experience with 12-Month Follow-Up.

OBJECTIVE: The optimal management and procedural strategy for tandem occlusion (TO) in acute ischemic stroke are still unclear, as is the long-term outcome of these patients. The aim of this study was to evaluate predictors of good functional outcome in patients with TO through the analysis of demographics, clinical, and radiological data with a 1-year follow-up. METHODS: We collected data on 100 patients with TO who underwent revascularization treatments in our comprehensive stroke center. We divided patients into 2 groups: those with good functional outcome, defined as a modified Rankin Scale 0-2, and those with poor functional outcome, defined as a modified Rankin Scale 3-6 at 3, 6, and 12-month follow-up. Moreover, we investigated which variables were able to influence mortality. RESULTS: At multivariate analysis, endovascular treatment with mechanical thrombectomy combined with emergent cervical carotid artery stenting was an independent predictor of good functional outcome at 6 and 12 months (adjusted odds ratio [aOR] 4.3, confidence interval [CI] 1.49-12.31, P = 0.007) (aOR 3.5, CI 1.25-9.61, P = 0.017) and was associated with a lower rate of mortality at 3 and 6 months follow-up (aOR 0.14, CI 0.04-0.57, P = 0.006 and aOR 0.296, CI 0.97-0.902, P = 0.032, respectively). Furthermore, smoking habit was associated with a better outcome at 3-month follow-up (aOR 10.7, CI 2.2-51.6, P = 0.003) but not at 6- and 12-month. CONCLUSIONS: Our research, conducted in a small sample size of patients with acute ischemic stroke due to TO of anterior circulation, found that acute stent placement seems to be safe, improving clinical outcome, and it is associated with low rate of mortality at long-term follow-up.

Factors associated with hemorrhagic transformation after endovascular treatment despite early recanalization.

PURPOSE: To identify new factors associated with hemorrhagic transformation (HT) despite early recanalization in patients with acute ischemic stroke treated with mechanical thrombectomy. METHODS: We retrospectively included patients with known onset of large vessel occlusion treated with mechanical thrombectomy +/- intravenous thrombolysis. Non-contrast CT was performed at 24 +/- 12 h from endovascular procedure. We collected data on patient characteristics, risk factors, radiological and treatment features, stroke severity on admission and discharge, carotid intima-media thickness (CIMT), Neutrophils-to-Lymphocytes ratio (NLR), white matter hyperintensities measured according to the Fazekas score on FLAIR MRI data. The main outcome measures were the incidence of HT and factors associated with it. Secondary outcome measures were symptomatic intracerebral hemorrhage and parenchymal hematoma. RESULTS: Of 874 patients, 472 met the inclusion criteria, 211 (44.7%) had HT. Factors significantly associated with increased risk of HT included onset-to-recanalization time, CIMT (normal/mild), ASPECT-MRI < 6, and a higher NLR. We found that beyond 7.67 h from onset-to-recanalization, the risk of HT increases and exceeds 50%. ASPECT-MRI, NLR, and CIMT independently predict HT despite early recanalization. CONCLUSIONS: We identified novel factors associated with HT in patients with acute ischemic stroke of known onset treated with mechanical thrombectomy. We found that at 7.67 h from onset to recanalization, the risk of HT is >50%, and we identified factors responsible for HT despite early recanalization.

The importance of MRI in the acute phase of herpes encephalitis mimicking an acute ischemic stroke.

The diagnosis of herpes simplex encephalitis (HSE) can present challenges for neurologists and neuroradiologists due to its variable clinical presentation and atypical radiological features. Brain magnetic resonance imaging (MRI) plays a crucial role by identifying some mimicking conditions, including ischemic strokes, through the accurate interpretation of specific sequences. This report highlights a case of misdiagnosed HSE, aiming to discuss the management of similar cases and underscore the relevance of MRI in the emergency setting.

T2 * relaxation time in Achilles tendinosis and controls and its correlation with clinical score.

PURPOSE: To investigate if the T2 * of Achilles tendons can discriminate between chronic Achilles tendinosis and healthy controls; to correlate with clinical score; to evaluate its short-term repeatability; and to estimate minimal detectable change. MATERIALS AND METHODS: Twenty patients, with chronic mid-portion Achilles tendinosis, and 10 controls without history of Achilles tendon symptoms, were examined with a 3T MR scanner with a 3D flash ultrashort time to echo sequence with five different echo times. The sequence was run twice to test repeatability. The tendon border was delineated on axial slices at three different levels in the calculated T2 * maps. The clinical severity of Achilles tendinosis was measured by a VISA-A questionnaire. RESULTS: There was a significant difference in mean T2 * between symptomatic and control tendons (P < 0.001). In patients with unilateral symptoms no significant difference in T2 * was found between symptomatic and contralateral asymptomatic tendons (P = 0.19). There was no significant correlation between clinical severity and T2 * (r = -0.28, P = 0.22). The short-term repeatability of T2 * showed a coefficient of variation of 18%, a least significant change of 50%, and the intraclass correlation coefficient had an average consistency of 0.99. CONCLUSION: T2 * may help to differentiate between chronic Achilles tendinosis and healthy controls but was not associated with the clinical score. However, and notably, the reproducibility of the method was low and the number of patients was small. J. Magn. Reson. Imaging 2016;43:1417-1422.

Dynamic contrast enhanced magnetic resonance imaging in chronic Achilles tendinosis.

BACKGROUND: Chronic Achilles tendinosis is a common problem. When evaluating and comparing different therapies there is a need for reliable imaging methods. Our aim was to evaluate if chronic Achilles tendinosis affects the dynamic contrast-enhancement in the tendon and its surroundings and if short-term eccentric calf-muscle training normalizes the dynamic contrast-enhancement. METHODS: 20 patients with chronic Achilles tendinopathy were included. Median duration of symptoms was 31 months (range 6 to 120 months). Both Achilles tendons were examined with dynamic contrast enhanced MRI before and after a 12- week exercise programme of eccentric calf-muscle training. The dynamic MRI was evaluated in tendon, vessel and in fat ventrally of tendon. Area under the curve (AUC), time to peak of signal, signal increase per second (SI/s) and increase in signal between start and peak as a percentage (SI%) was calculated. Pain and performance were evaluated using a questionnaire. RESULTS: In the fat ventrally of the tendon, dynamic contrast enhancement was significantly higher in the symptomatic leg compared to the contralateral non-symptomatic leg before but not after treatment. Despite decreased pain and improved performance there was no significant change of dynamic contrast enhancement in symptomatic tendons after treatment. CONCLUSION: In Achilles tendinosis there is an increased contrast enhancement in the fat ventrally of the tendon. The lack of correlation with symptoms and the lack of significant changes in tendon contrast enhancement parameters do however indicate that dynamic enhanced MRI is currently not a useful method to evaluate chronic Achilles tendinosis.

The long-term clinical and MRI results following eccentric calf muscle training in chronic Achilles tendinosis.

PURPOSE: To evaluate the long-term results following eccentric calf-muscle training in patients with chronic Achilles tendinopathy. MATERIALS AND METHODS: A total of 24 patients with chronic Achilles tendinopathy were included in a study evaluating MRI findings and clinical symptoms before and after 3 months of daily eccentric calf-muscle strength training. Median duration of symptoms was 18 months (range 6-120). Four of the patients did not perform the prescribed treatment for different reasons and were followed for 14 months. The resulting 20 treated patients completed 4.2-year (range 29-58 months) follow up. Tendon volume was evaluated by using 3D seed growing technique and signal abnormalities were visually semi-quantitatively graded. Level of pain and performance was categorized using a questionnaire completed by the patient. RESULTS: In the symptomatic treated patients, median intensity level of pain decreased from moderate/severe at time of inclusion to mild at follow up (p < 0.05). Median level of performance increased from severe impairment at time of inclusion to normal at follow up (p < 0.05). 12 out of 20 patients had raised intratendinous signal at time of inclusion compared to 2 out of 20 patients at follow up (p < 0.001). Mean tendon-volume measured 6.7 cm(3) (SD 2.0) at time of inclusion and 6.4 cm(3) (SD 2.0) at follow up (p = 0.18). The four symptomatic non-treated tendons did not improve regarding pain, performance, intratendinous signal or tendon volume. CONCLUSION: We found decreased pain, improved performance and decreased intratendinous signal both compared to index examination and immediately after the 3 months training regimen in a 4.2-year clinical and MRI follow up, in a group of patients treated with heavy loaded eccentric calf-muscle training for chronic Achilles tendinopathy. The improvements were greater at 4.2-year follow up, despite no further active treatment, than immediately after the treatment. This may indicate a good long-term prognosis for Achilles tendinosis patients.