Intravenous thrombolysis in acute ischemic stroke due to occlusion of internal carotid artery - a Serbian Experience with Thrombolysis in Ischemic Stroke (SETIS).

OBJECTIVE: The benefit of intravenous thrombolysis in patients with internal carotid artery (ICA) occlusion is still unclear. The aim of this study was to assess the influence on outcome of intravenous thrombolysis in patients with ICA occlusion comparing to those without it. METHODS: Data were from the national register of all acute ischemic stroke patients treated with intravenous thrombolysis in Serbia. Patients with nonlacunar anterior circulation infarction were included and were divided into two groups, those with and those without ICA occlusion. We compared the differences in demographic characteristics, risk factors, baseline NIHSS score, early neurological improvement, 3-month functional outcome, complications and death between these two groups. RESULTS: Among 521 included patients there were 13.4% with ICA occlusion. Group with ICA occlusion had more males (82.9% vs. 60.5%; p=0.0008), and more severe stroke (baseline NIHSS score 15.3 vs. 13.6; p=0.004). Excellent functional outcome (mRS 0-1) at 3 months was recorded in 32.9% patients with ICA occlusion and in 50.6% patients without (p=0.009), while favorable functional outcome (mRS 0-2) was recorded in 50.0% of patients with ICA occlusion vs. 60.1% without (p=0.14). Death occurred in 12.9% patients with ICA occlusion and in 17.3% patients without it (p=0.40). There was no significant difference in rate of symptomatic ICH between the two groups (1.4% vs. 4.2%; p=0.5). Multivariate logistic regression analysis showed that ICA occlusion was associated with the absence of early neurological improvement (p=0.03; OR 1.78, 95% CI 1.05-3.04). However, the presence of ICA occlusion was not significantly associated with an unfavorable outcome at 3-month (p=0.44; OR 1.24, 95% CI 0.72-2.16) or with death (p=0.18; OR 0.57, 95% CI 0.25-1.29). CONCLUSION: The patients with ICA occlusion treated with intravenous thrombolysis have a worse outcome than patients without it.

Dyslipidemia as a risk factor for primary intracerebral hemorrhage.

AIM: Most of the studies proved association between some lipoprotein fractions and hypocholesterolemia as risk factors for primary intracerebral hemorrhage (ICH). However, there are studies that emphasize hypercholesterolemia (Hyper-Hol) as a risk factor. The present study aims at determining lipid fractions as risk factors for intracerebral hemorrhage in our region. METHODS: A retrospective study included 92 patients with primary ICH treated during one year at the Department of Neurology in the Clinical Centre of Vojvodina, Novi Sad. Following clinical and demographic data, age and gender, risk factors with a focus on certain lipid fractions (total cholesterol, triglycerides, low density- LDL, and high density - HDL cholesterol), types of hyperlipoproteinemia and disease outcome were analyzed. RESULTS: Fifty-one (55%) females and forty-one (45%) males, mean age 67.6 years were enrolled in the study. Hyper-Hol was observed in 63 (69%) patients, hyper-LDL cholesterolemia in 68 (74%) patients and hypo-HDL cholesterolemia in 77 (84%) patients, while triglyceride levels were normal in majority of patients. No statistical significance between males and females was observed considering levels of total cholesterol (p=0.068), LDL cholesterol (p=0.156), triglycerides (p=0.363), while levels of HDL cholesterol were significantly higher in females (p=0.023). Hyperlipoproteinemia IIa was found in 51 (78%). Mortality rate was 25%. CONCLUSION: Hypertrigliceridemia was not proved as a risk factor, while hyper-LDL cholesterolemia, hypo-HDL cholesterolemia, and hyper-Hol can be associated with primary ICH, which could justify further statin treatment in secondary prevention of this disease.

Recurrent longitudinally extensive transversal myelitis in a patient with Sjögren's syndrome.

INTRODUCTION: Longitudinally extensive transverse myelitis (LETM) is a transversal myelitis that extends through three or more vertebral segments in length. CASE REPORT: A 52-year-old woman was hospitalized due to pain in the lumbar region, difficulty in walking, hypoesthesia of the anogenital area and urinary retention. In the past medical history, two years earlier, the patient had been diagnosed with transversal myelitis confirmed by MRI of the cervical spine and six months earlier, the patient was diagnosed with primary Sjögren's syndrome (SS). During the current hospitalization MRM of the spinal cord revealed extensive inflammatory lesions of almost the whole spinal cord. Lumbar puncture (LP) revealed mild pleocytosis and slightly increased protein level. Isoelectric focusing of cerebrospinal fluid (CSF) and serum proteins was normal. Visual evoked potentials were normal. Serological testing excluded acute viral infections. Corticosteroid therapy was applied with good therapeutic response. Control MRI revealed regression of pathological changes in the spinal cord. CONCLUSION: A wide range of disorders can cause LETM, but usually the first line diagnosis is neuromyelitis optica (NMO). Based on the detection of NMO immunoglobulin G in the serum of affected patients, a variety of allied disorders were grouped under the name of NMO spectrum disorders, including recurrent myelitis associated with LETM and myelitis associated with autoimmune disorders such as SS. There have been only a few cases reported in the literature with recurrent LETM associated with non-organ specific autoimmune disorder.

Atrial myxoma as a cause of stroke: emboli detection and thrombolytic treatment.

It presents a case of a 42-year-old female patient who was admitted to the stroke unit for right-sided hemiplegia and global aphasia, without conventional stroke risk factors. As the patient presented within the therapeutic time window and had no contraindications for thrombolysis, intravenous thrombolytic treatment was initiated. Brain CT showed multiple hypodense partly confluent lesions in the territory of the left middle cerebral artery. For the purpose of determining the etiology of the stroke, TCD was performed and after cerebral microemboli were detected, transthoracic echocardiography was indicated, the finding of which showed the presence of a myxoma in the left atrium. The patient underwent surgery and thereafter her neurological deficits improved.

Neurosonographic monitoring of haemodynamic changes in tandem middle cerebral and internal carotid artery occlusion due to arterial dissection.

A middle-aged man with pain in the right eye and right side of the neck was brought to the emergency department one hour after the onset of left-sided weakness. Computed tomography (CT) showed hyperdense right middle cerebral artery (MCA). On transcranial Doppler (TCD), occlusion of the right MCA and right internal carotid artery (ICA) was found. Thirty minutes after thrombolytic therapy was initiated, engagement of collateral circulation through the anterior communicating artery (AComA) was shown by TCD. Caro-tid duplex examination confirmed occlusion of the right ICA with intimal flap and intramural haematoma. CT angiography revealed flame-like occlusion of the right ICA, and occlusion of the right MCA with collateral supply from the left to right anterior cerebral artery through the AComA. Recanalization of the MCA and ICA was evident on both CT and ultrasound. Frequent ultrasound monitoring is useful for haemodynamic evaluation of carotid artery dissection, while TCD plays an important role in real-time monitoring of flow changes of intracranial vasculature.

Paradoxical emboli--clinical importance of transcranial Doppler for detection of patent foramen ovale.

A patent foramen ovale has been reported to be more frequently detected in cryptogenic stroke, with paradoxical embolism as the major pathogenetic mechanism. The standard procedure for the detection of a patent foramen ovale is transesophageal echocardiography. Transcranial Doppler sonography with bubble test is almost as reliable as transesophageal echocardiography. Seventeen patients with acute ischemic stroke and transient ischemic attacks hospitalized at the Department of Neurology in Novi Sad underwent examinations to detect a patent foramen ovale, which was found in 55.6% of patients with cryptogenic stroke. The average age of these patients was 30.6 years. Transcranial Doppler sonography showed 100% sensitivity and 100% specificity for the prediction of right-to-left shunts proven by transesophageal contrast echocardiography. Both positive and negative predictive values in our group of patients were 1. Transcranial Doppler with bubble test is a reliable method for the detection of a patent foramen ovale, with a high level of sensitivity and specificity which is comparable with transesophageal echocardiography. Moreover, it is cheaper and more comfortable than transesophageal echocardiography, and should be used routinely in neurological practice.