RESUMO
Background: Over 50% of acute ischemic stroke (AIS) patients present with minor neurological deficits, and optimal treatment is still debated. The randomized PRISMS trial did not show beneficial effects of intravenous thrombolysis (IVT) in unselected patients with minor stroke and non-disabling neurological deficits. Purpose: The study aimed to evaluate if AIS patients with minor stroke may benefit from computed-tomography-perfusion (CTP)-guided IVT. The primary endpoint was good functional outcomes, defined as a modified Rankin Scale score of 0-2 at 90 days. Methods: AIS patients with a NIHSS of ≤5 presenting within 4.5 h underwent multimodal CT-imaging including CTP. CTP mismatch was defined as hypoperfusion on CTP with time-to-peak delay >6 s without corresponding hypoperfusion in cerebral blood volume. IVT decision was left to the attending stroke physicians. Patients with large vessel occlusion (LVO) and absolute contraindications to IVT were excluded. Results: In total, 267 consecutive patients were included [mean age: 72 ± 14 years, 45.3% female patients, 75.3% received IVT, median NIHSS on admission: 3 (IQR 2, 4)]. CTP mismatch was detected in 41.8% of IVT- treated patients (IVT+) and 28.8% of standard treatment patients (IVT-) (p = 0.06). IVT+ had favorable outcomes at 90 days compared to IVT- (p = 0.006), but no interaction with an existing CTP mismatch was detected (ORadj: 1.676; 95% CI: 0.644-4.364). No symptomatic intracranial hemorrhage according to ECASS-III criteria occurred. Conclusion: Although selected AIS patients with minor stroke may benefit from IVT, CTP mismatch does not correlate with functional outcomes. No benefit from CTP mismatch in guiding IVT was detected in patients without LVO presenting with minor neurological deficits.
RESUMO
BACKGROUND: Hypoglycemia in patients with diabetes mellitus, particularly type 1 can mimic acute ischemic stroke by causing focal neurological deficits. In acute ischemic stroke, the interpretation of emergency imaging including computed tomography with angiography and perfusion is crucial to guide revascularizing therapy including intravenous thrombolysis. However, different metabolic abnormalities and stroke mimics can cause focal hypoperfusion. METHODS: We describe two type 1 diabetes patients presenting with acute focal neurological deficits and hypoglycemia, who underwent multimodal computed tomography and follow-up imaging. CASE PRESENTATION: Patient 1, a 20-year-old man presented with aphasia and interstitial glucose level of 54 mg/dl. Patient 2, a 77-year-old man presented with aphasia, mild right-sided brachiofacial paresis and interstitial glucose level of 83 mg/dl. On brain imaging, no acute infarct signs were noted. Yet, both had focal left hemispheric cerebral hypoperfusion without large-vessel occlusion or stenosis. Due to persistent symptoms after normalization of blood glucose and despite a perfusion imaging pattern that was interpretated as non-typical for ischemia, both patients underwent thrombolysis without any complications. CONCLUSION: Computed tomography perfusion might help to discriminate hypoglycemia with focal neurological signs from acute stroke, but further evidence is needed.
