Incidence of orolingual angioedema after intravenous thrombolysis for stroke.

INTRODUCTION: Orolingual angioedema (OA) is a known adverse effect of intravenous (i.v.) alteplase. We analyzed all patients treated with i.v. alteplase for stroke at our hospital since approval of i.v. thrombolysis in Italy in 2004 to assess the incidence of this complication. PATIENTS AND RESULTS: Four hundred thirty-three patients received alteplase for stroke from April 2004 to May 2017. Two women developed OA (0.4%; 95% confidence interval 0.1 to 1.6%). Angioedema was mild in one case and severe in the other, with massive swelling of the lips, tongue, and oropharyngeal mucosa, and oropharyngeal bleeding, requiring intubation. Neither patient used ACE-inhibitors. DISCUSSION: The incidence of orolingual angioedema was very low in our series. Although OA is usually mild, anaphylactoid reactions may rarely occur, because of the variable degree of activation of the complement system and kinin cascade caused by alteplase. In such instances, admission to neurointensive care may be required. Specific bradykinin antagonists or drugs that target the kallikrein-kinin system are beginning to be used in the more severe cases. Thus, doctors and nurses caring for acute stroke patients need to be able to recognize and treat this complication.

Plasma homocysteine and severe white matter disease.

The objective of this study was to assess if high total plasma homocysteine (tHcy) levels are a risk factor for severe leukoaraiosis (LA). This case-control study was done in a primary care neurology ward and included 178 consecutive patients. Patients with severe LA at CT scan were compared with patients without any LA regarding age, cerebrovascular risk factors, tHcy, vitamin B12, folate, creatinine levels and dementia. Multivariate logistic regression was used to find variables independently associated with severe LA. Age (odds ratio [OR], 1.10 per year; p<0.0001), tHcy (OR, 1.07/micromol/l increase; p=0.045) and hypertension (OR, 2.97; p=0.007) were significantly associated with severe LA. Total homocysteine levels are associated with severe LA independently of other risk factors for cerebrovascular disease. This may suggest that decreasing tHcy may help preserve the integrity of the brain white matter.

Spontaneous dissection of carotid and coronary arteries.

The authors report a case of spontaneous dissection of both carotid arteries, followed by spontaneous dissection of the left anterior descending coronary artery after a few days. No major abnormalities of collagen production were found. This case may be underlain by a dysplasia of common precursors of the carotid and coronary walls.

Experience with a questionnaire administered by emergency medical service for pre-hospital identification of patients with acute stroke.

We prospectively verified whether an ad-hoc questionnaire administered by phone supports pre-hospital suspicion of stroke in order to reduce the time before care is given. From June 1996 to May 1997, physicians of the Emergency Medical Service in the area of Bergamo, Italy asked all people calling for a patient with symptoms and signs suggesting a cerebral vascular injury to immediately answer some questions on common symptoms and signs of stroke. The medical records of the patients hospitalized at Ospedali Riuniti of Bergamo were reviewed at the end of the study by a single neurologist, skilled in stroke management and blinded to the questionnaires. Sensitivity and specificity, in addition to positive and negative predictive values, of single questions versus final diagnosis were assessed. Logistic regression analysis was also performed to identify those questions useful to suspect strokes. We collected 143 valid questionnaires, related to 63 men and 80 women, aged 34-99 years (mean, 71.8 years). The question concerning headache had the lowest sensitivity and specificity, respectively 57.1% and 36.5%, and the question concerning leg palsy had the highest sensitivity and specificity, respectively 82.0% and 52.4%. Multivariate analysis identified questions on facial and leg palsy as independent predictors of a final diagnosis of stroke. A few questions on motor deficits proposed by emergency medical service operators may be useful in the pre-hospital identification of stroke patients. Concordance of any questions versus final diagnosis of stroke was, however, far to be satisfying. Thus, our experience supports the need for an educational program to improve the efficiency of a pre-hospital diagnosis of stroke.

Large demyelinating brain lesion mimicking a herniating tumor.

We describe the case of a large brain lesion whose computed tomography appearance and clinical evolution mimicked a herniating tumor. The patient progressed to coma within 6 days of hospitalization despite high-dose steroid treatment. Emergency excision of the lesion was carried out. Histological analysis showed massive demyelination, axon preservation and no tumor cells. No lesion recurrence was seen during a 55-month follow-up. Recognition of such lesions through magnetic resonance imaging or spectroscopy may spare unnecessary surgery or biopsy. However, our case shows that such lesions may still require resection in the face of a rapid clinical progression and poor response to medical treatment.

Doppler microembolic signals predict ischemic recurrences in symptomatic carotid stenosis.

OBJECTIVE: To assess if Doppler microembolic signals (MES) associated with > or = 60% symptomatic extracranial carotid stenosis may predict ischemic recurrences before endarterectomy or angioplasty. METHODS: All patients with > or = 60% carotid stenosis with symptoms in the preceding 2 months were prospectively considered. MES were identified using current criteria. All patients were followed-up until endarterectomy or angioplasty. RESULTS: We studied 50 patients, at a median of 7 days from their last symptom. Twenty patients showed MES (40.0%); median embolus rate was 4/h. During a median follow-up of 19 days 7 patients had recurrences (transient monocular blindness = 2; TIAs=4; stroke=1); 6 of them had shown MES. The association between recurrences and MES was significant (P=0.012). CONCLUSIONS: MES may identify patients with symptomatic carotid stenosis who are likely to suffer an ischemic recurrence before endarterectomy. This information may affect medical treatment and referral to the vascular surgeon.

Carotid stents are not a source of microemboli late after deployment.

OBJECTIVES: To evaluate the presence of microembolic signals (MES) in the middle cerebral artery distal to a stented carotid artery late after stent deployment. MES may be a signal of thrombus formation at the stent level. PATIENTS AND METHODS: Two patient groups were studied with transcranial Doppler at different intervals after deployment of Palmaz stents or Wallstents for stenosis of the internal or common carotid artery. Group 1: from 6 to 12 months after stent deployment; Group 2: > 12 months after stenting. RESULTS: One out of 19 patients in Group 1 showed MES (5.0%); however, this patient also had two mechanical heart valves. None out of 17 patients in Group 2 had MES. CONCLUSIONS: Carotid stents seem to have a very low emboligenic potential after the early post-deployment period. This is a reassuring message for present and future patients harboring such stents.

Length of hospitalization of patients with transient ischemic attacks.

OBJECTIVE: To investigate factors that influence length of stay (LOS) in patients hospitalized for transient ischemic attacks (TIAs). This may help to reduce unnecessary days of hospitalization. DESIGN: Retrospective study. SETTING: A large, non-academic general hospital. PATIENTS: All patients hospitalized for TIAs during the years 1996-1998 were retrospectively studied. We analyzed the relationship between demographic, clinical and management features and LOS. RESULTS: We studied 157 patients. Median LOS was 8 days (range, 1 to 21 days). Statistical analysis showed that female sex, being hospitalized in 1996, hospitalization from Wednesday through Saturday, and second-level cardiological, neuroradiological and miscellaneous investigations significantly increased LOS. CONCLUSIONS: The LOS of patients with TIAs may be reduced through measures that accelerate the diagnostic work-up and by scheduling the admission to the first days of the week, when this is possibile.

Malignancy and sensory neuropathy of unexplained cause: a prospective study of 51 patients.

OBJECTIVE: To investigate the frequency of cancer developing in patients with peripheral sensory neuropathy of unexplained cause. DESIGN: Prospective study. SETTING: A neurologic unit in a general hospital. METHODS: Following the diagnosis of neuropathy, we searched for occult malignancy. This search was repeated together with neurologic evaluations every 6 months thereafter. Patient recruitment began January 1, 1988, and ended December 31, 1995. The end point of the study was December 31, 1996. RESULTS: In the study period, we observed 363 patients with peripheral sensory neuropathy. Of these, 53 patients without any identified cause of neuropathy were invited to participate in the study. Of the 53, 2 patients refused. Thus, we examined and followed up 51 patients, 42 men and 9 women, with a mean age of 64.5 years (range, 19-80 years). The range between the onset of neurologic symptoms and the diagnosis of neuropathy was 2 to 72 months (mean, 13.9 months). The follow-up period ranged from 14 to 94 months (mean, 51.4 months). In 18 patients (35.3%) (16 men and 2 women) whose mean age at diagnosis of neuropathy was 66.5 years. malignant growths were found 3 to 72 months (mean, 27.4 months) after the onset of the neuropathy. The cancer was in the liver in 4 patients (all had a primary hepatoma), the bladder in 3, the lymph nodes in 3 (all with non-Hodgkin lymphoma), the prostate gland in 2, the lungs in 2 (small cell lung cancer in both), the breast in 1, the pancreas in 1, the sublingual gland in 1, and the bone in 1 (a metastatic sarcoma). CONCLUSIONS: More than one third of the patients with peripheral sensory neuropathy of unexplained cause developed cancer without any predominating type of malignancy.

Cerebral venous thrombosis in young adults. Experience in a stroke unit, 1988-1994.

We report a series of nine patients younger than 45 years with angiographically-documented cerebral venous thrombosis, consecutively referred to our Stroke Unit from 1988 to 1994. Two of them were men and seven were women. Eight patients initially complained of headache, often associated with other symptoms of increased intracranial pressure. Seven patients had focal motor deficits and four suffered from epileptic seizures. None of the patients died. Only one patient remained severely disabled, whereas the others recovered self-sufficiency within two months. The use of oral contraceptives was closely associated with the occurrence of venous thrombosis in the women. Cerebral venous thrombosis is to be kept in mind in the differential diagnosis of stroke in the young.

Dementia after first stroke.

BACKGROUND AND PURPOSE: Cognitive deficits may significantly worsen the quality of life after stroke. Our aim was to determine the frequency of dementia in a consecutive series of previously nondemented patients between the ages of 40 and 79 years at 3 months after a first ischemic stroke. METHODS: All patients admitted to our department during an 18-month period who met the above criteria were visited and tested and underwent a CT scan 3 months after their stroke. Dementia was diagnosed according to criteria of the National Institute of Neurological Disorders and Stroke and AIREN, but cases with aphasia were not excluded. RESULTS: Of 304 patients admitted for stroke, 146 were eligible for study. Eleven refused to participate, 25 were dead at 3 months, and 110 were tested. Fifteen patients were demented (13.6%; 95% confidence interval [CI], 7.8% to 21.5%), and six had severe isolated aphasia, neglect, or memory deficit (5.4%). Excluding patients with aphasia, 5.0% of cases showed dementia (95% CI, 1.6% to 11.3%). The frequency of dementia was 24.6% (95% CI, 14.5% to 37.3%), considering only patients with supratentorial lesions and with residual deficits of elementary functions (paresis, sensory deficits) at the time of examination. Demented patients had significantly more diabetes (P<.029), atrial fibrillation (P=.032), aphasia at entry (P<.001), large middle cerebral artery infarctions (P=.001), and a more severe neurological deficit at entry (P=.003) and at 3 months (P=.001). At CT scan, demented patients had a larger mean volume of the recent lesion (P<.001) and more lesions in the frontal lobe (P=.041). An exploratory multivariate analysis selected age between 60 and 69 years (odds ratio [OR], 45.8; 95% CI, 2.9 to 726.0), diabetes (OR 59.4; 95% CI, 4.3 to 821.0), aphasia (OR, 14.8; 95% CI, 2.0 to 111.0), a large middle cerebral artery infarction (OR, 30.0; 95% CI, 2.7 to 334.0), and lesions of the frontal lobe (OR, 9.8; 95% CI, 1.3 to 72.8) as significant independent correlates of poststroke dementia. CONCLUSIONS: Dementia is relatively frequent after a clinical first stroke in persons younger than 80 years, and aphasia is very often associated with poststroke dementia. If aphasic patients are not considered, it may be necessary to screen a very large number of subjects to collect an adequate sample of demented cases.

Intra-arterial thrombolysis in acute ischaemic stroke: experience with a superselective catheter embedded in the clot.

OBJECTIVES: To report experience of intra-arterial thrombolysis for acute stroke, performed with a microcatheter navigated into the intracranial circulation to impale the clot. METHODS: Patients were selected on the following criteria: (1) clinical examination suggesting a large vessel occlusion in stroke patients between 18 and 75 years; (2) no radiographic signs of large actual ischaemia on CT at admission; (3) angiographically documented occlusion of the middle cerebral artery (MCA) stem or of the basilar artery (BA), without occlusion of the ipsilateral extracranial internal carotid artery or of both the vertebral arteries; (4) end of the entire procedure within six hours of stroke. 12 patients with acute stroke were recruited, eight of whom had occlusion of the MCA stem and four of the BA. Urokinase was used as the thrombolytic agent. RESULTS: Complete recanalisation in six MCA stem and in two BA occurred, and partial recanalisation in two MCA stem and one BA. There was no recanalisation in one BA. A clinically silent haemorrhage occurred in two patients, and a parenchymal haematoma in one patient, all in MCA occlusions. At four months five patients achieved self sufficiency (four with MCA and one with BA occlusion). Six patients were dependent (three totally), and one died. CONCLUSIONS: The strict criteria of eligibility allowing the enrollment of very few patients and the procedure itself, requiring particular neuroradiological expertise, make this procedure not routine. Nevertheless, the approach can be considered a possible option for patients with acute ischaemic stroke.

Acute rhabdomyolysis associated with acute cocaine intoxication. A case report.

We report a case of acute rhabdomyolysis associated with acute intravenous cocaine intoxication in an asymptomatic HIV-positive young man and discuss the possible pathogenetic mechanisms. Recent cocaine use must be considered among the causes of acute rhabdomyolysis without obvious precipitating factors in our country too. The characteristically uncollaborative attitude of habitual drug users may make differential diagnosis very difficult to establish.