Mechanical thrombectomy with the Solitaire device in acute basilar artery occlusion.

AIMS: To evaluate the efficacy and safety of mechanical thrombectomy with the Solitaire FR device in revascularization of patients with acute basilar artery occlusion (ABAO) and to identify the predictive factors for clinical outcome. METHODS: This prospective single-center study included 31 patients with acute ischemic stroke attributable to ABAO treated within the first 24 h after onset of symptoms with the Solitaire device. Nineteen patients simultaneously received intravenous thrombolysis. Recanalization rates after stent retrieval were determined and the clinical outcome and mortality rate were assessed 180 days after treatment. RESULTS: The mean ±SD age of the patients was 61±17 years, the median prethrombectomy NIH Stroke Scale score was 38 (IQR 9-38) and the median Glasgow Coma Scale (GCS) score was 7 (IQR 4-14). Successful recanalization (TICI 3 or 2b) was achieved in 23 patients (74%). Five symptomatic intracranial hemorrhages were related to the procedure. Ten symptomatic distal migrations of thrombotic material occurred. A favorable outcome, defined as a modified Rankin Score (mRS) of 0-2, was observed in 35% of patients (11/31). Overall mortality rate was 32% (10/31). In the univariate analysis, elevated baseline glucose (p=0.008) was significantly associated with a poor outcome (mRS >2), whereas a tendency towards significance was observed with age (p=0.06), GCS on admission (p=0.07) and symptom-related lesions on T2 sequences (p=0.10). Patients with successful recanalization tended to have a better outcome (p=0.20). CONCLUSION: Mechanical thrombectomy with the Solitaire FR device can rapidly and effectively contribute to a high rate of recanalization and improve functional outcome in patients with ABAO and has an acceptable complication rate.

Feasibility of hypothermia beyond 3 weeks in severe ischemic stroke: an open pilot study using γ-hydroxybutyrate.

PURPOSE: Hypothermia is a promising neuroprotective therapy. We studied the feasibility and safety of very prolonged moderate hypothermia for severe acute ischemic stroke. METHODS: Moderate hypothermia was induced within 24h after a severe ischemic stroke involving the middle cerebral artery. Hypothermia, with cooling blankets, reduced body-core temperature to 32-33°C, and was prolonged for up to 22 days until cerebral edema had significantly decreased (assessed by serial cerebral computed tomography) before slow rewarming (<1.5°C/day). Patients were mechanically ventilated and sedated with gamma-hydroxybutyrate (GHB), a naturally occurring metabolite of gamma-aminobutyric acid (GABA), which acts on the GABA(B) receptors. Outcomes and side effects at 12 months were recorded. RESULTS: Nineteen patients (mean age: 52.6 years, mean National Institute of Health Stroke Scale (NIHSS) score 21) were enrolled. Cooling was achieved in all patients. The mean time to reach target temperature was 11.4 ± 8.6h and the mean duration of rewarming was 4.0 ± 1.1 days. For the 10 survivors (53%), the mean duration of hypothermia and rewarming was 22.6 ± 4.9 days. Five patients underwent a hemicraniectomy. All patients presented with hypotension, bradycardia, and hematological side effects. Eight patients had pneumonia (42%). At 12 months, the mean NIHSS score was 8.3 ± 2.7, the Barthel Index was 67 ± 18, and the modified Rankin scale was 3.2 ± 0.9. CONCLUSIONS: This study shows the feasibility of very prolonged hypothermia beyond 3 weeks using GHB sedation in severe hemispheric infarcts.

Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study: timing, safety, and efficacy.

BACKGROUND AND PURPOSE: Large vessel occlusion in ischemic stroke is associated with a high degree of morbidity. When intravenous thrombolysis fails, mechanical thrombectomy can provide an alternative and synergistic method for flow restoration. In this study we evaluate the safety and efficacy of our stroke management protocol (RECOST study). METHODS: Fifty consecutive ischemic stroke patients with large vessel occlusion were included. After clinical and MRI imaging assessment, 3 treatment strategies were selected according to time of symptom onset and location of vessel occlusion: rescue therapy; combined therapy; and stand-alone thrombectomy (RECOST study). MRI ASPECT score <5 was the main exclusion criterion. Mechanical thrombectomy was performed exclusively with the Solitaire flow restoration device. Clinical outcome was assessed after treatment, on day 1, and at discharge. RESULTS: Mean patient age was 67.6 years, mean NIHSS score was 14.7, and mean ASPECT score was 6 on presentation. Vessel occlusions were in the middle cerebral artery (40%), the internal carotid artery (28%), and the basilar artery (32%). Rescue treatment represented 24%, combined therapy represented 56%, and stand-alone thrombectomy represented 20%. Mean recanalization time from symptoms onset was 377 minutes, with overall recanalization rate TICI 3 of 84%. NIHSS score at discharge was 6.5, with 60% of patients demonstrating NIHSS score 0 to 1 or an improvement of >9 points. Symptomatic complication rate was 10%. At 3 months, 54% of patients had a modififed Rankin scale score of 0 to 2, with an overall mortality rate of 12%. CONCLUSIONS: The present integrated stroke management protocol (RECOST study) demonstrated rapid, safe, and effective recanalization. We postulate that the Solitaire device contributed to high recanalization and patient selection using MRI ASPECT score to low and complication rates, therefore avoiding futile and dangerous interventions.

Novel LMNA mutation in atypical Werner syndrome presenting with ischemic disease.

BACKGROUND AND PURPOSE: Laminopathies arise through mutations in genes encoding Lamin A/C (LMNA) or associated proteins. They cause 4 different groups of disorders with diverse severity and often overlapping features: diseases of striated muscle (leading to muscular or cardiac involvement), peripheral neuropathy, lipodystrophy syndromes, and accelerated aging disorders. SUMMARY OF CASE: We report on a familial case of atypical Werner syndrome (a progeroid syndrome with Werner syndrome phenotype but without typical RECQL2 mutation) presenting with acute ischemic cerebral disease or peripheral artery disease associated with diffuse atherosclerosis, attributable to transmission of a novel LMNA mutation. CONCLUSIONS: In young patients with ischemic events and a positive family history, other progeroid features have to be searched and LMNA testing has to be considered, allowing for genetic counseling and presymptomatic testing of at-risk relatives.

Prolonged moderate hypothermia in massive hemispheric infarction: clinical experience.

Malignant cerebral infarction (MaCI) treated with mechanical ventilation, mannitol, or barbiturates has a mortality of about 80% and survivors show severe disability. When applied for 48 to 72 hours, moderate hypothermia seems to reduce the mortality rate of MaCI. However, even after 72 hours, cerebral edema is still present, and the patient's condition often worsens during rewarming. We here report, as a case series, our experience with the use of prolonged moderate hypothermia to treat patients with MaCI. Twelve MaCI patients 27 to 64 years of age were treated. All presented with middle cerebral artery occlusion and all but one with internal carotid artery occlusion. A cooling blanket was used to lower the patient's core temperature to 32 degrees C to 33 degrees C. Hypothermia was induced within 24 hours of infarction onset and was discontinued when the CT scan showed a subsiding mass effect and was followed by slow rewarming (2-5 days). Patients were mechanically ventilated while sedated with high doses of gamma-hydroxybutyrate, a naturally occurring metabolite of gamma-aminobutyric acid (GABA), which acts on the GABAB receptor. Seven patients survived for 6 months, and 6 were able to walk without assistance; the other 5 died due to early cerebral herniation (2) or progression of infarct size (3). The mean duration of hypothermia for the survivors was 19 days (range, 11-22 days). Side effects observed in all patients were systemic hypotension, thrombocytopenia, and hyperfibrinogenemia. Prolonged hypothermia with gamma-hydroxybutyrate can be used to treat MaCI patients, with a fairly good clinical outcome for survivors.

Mechanical ventilation in ischemic stroke.

OBJECTIVE: Coma or respiratory failure in patients with acute ischemic stroke (IS) may require mechanical ventilation (MV). The inclusion criteria used in previous studies on MV for patients with stroke have been very heterogeneous. We carried out this prospective study in our neurologic stroke and intensive care department to assess clinical and radiologic features, mortality, outcome, and prognosis factors for patients presenting with acute IS involving the middle cerebral artery (MCA) and requiring MV. METHODS: Of 470 patients admitted with acute IS involving the MCA territory, we prospectively enrolled 50 patients requiring MV. Indications for intubation were a Glasgow coma score <10 or respiratory failure. RESULTS: The survival at 1 year was 30%. The mortality (70%) was independent of the reason for ventilation. Survivors had a mean Barthel index of 59 +/- 25 and a mean modified Rankin score of 4 +/- 1. Logistic regression showed that survivors were characterized by incomplete MCA territory involvement and atherosclerosis origin. CONCLUSION: Patients with MCA IS who require MV have high mortality regardless of the cause of intubation. Survival is associated with incomplete MCA territory involvement and atherosclerosis origin.

Inhibition of voltage-gated Ca2+ channels by antazoline.

We showed recently that imidazolines exert neuroprotection against hypoxia and NMDA toxicity in cerebellar and striatal neuronal cultures, through a voltage-dependent blockade of glutamatergic NMDA receptors. Here, we report that in striatal neuronal cultures from mouse embryos the imidazoline compound, antazoline, inhibits voltage-gated Ca2+ channels by acting at a phencyclidine-like site. This effect was fast, fully reversible, voltage-dependent and predominant on P/Q- and N-type Ca2+ channels. Taken together, these results suggest that imidazolines may elicit neuroprotective effects also by decreasing the release of glutamate through inhibition of presynaptic Ca2+ channels.

Occlusion due to carotid artery dissection: a more severe disease than previously suggested.

BACKGROUND: Stroke due to internal carotid artery dissection is considered to have a good prognosis. OBJECTIVE: To determine whether the prognosis of internal carotid artery dissection is worse than classically reported by comparing the characteristics of patients who had an acute ischemic stroke admitted to a population-based primary care center with internal carotid artery occlusion due to either dissection (DO) or atherothrombosis (AO). PATIENTS AND METHODS: Among 3502 patients admitted to our population-based primary care center, DO (n = 73) was diagnosed by angiography or magnetic resonance imaging, while AO (n = 81) was diagnosed by angiography. The characteristics of patients with DO or AO were compared using univariate and multivariate analysis. RESULTS: Patients with DO were younger (mean [SD] age, 44.6 [10] vs. 60.1 [10] years, P<.001), had fewer vascular risk factors, and presented more frequently with global middle cerebral artery territory involvement (42% vs. 17%, P<.05) and less frequently with watershed infarcts (3% vs. 19%, P<.05) than patients with AO. Unexpectedly, patients with DO were noted to have more severe clinical impairment, with an increased frequency of decreased consciousness, and a poorer outcome at 1 month. Multivariate analysis showed that the independent factors associated with DO were age younger than 55 years, nonsmoker, no history of hypertension, headache at presentation, and global aphasia. CONCLUSIONS: Patients with DO are younger and are initially seen with fewer risk factors than patients with AO, but their clinical features and prognosis are worse. Large infarcts involving the whole middle cerebral artery territory that may be due to the lack of collateral circulation are responsible for the bad prognosis of patients with DO.