Vascular Ischemia as a Cause of Transient Global Amnesia: A Patient Series.

INTRODUCTION: Epileptic, migrainous, and vascular pathologies may cause transient global amnesia (TGA); however, the mechanism of causation remains unclear. We investigated possible vascular causes of TGA. METHODS: We retrospectively evaluated the clinical and radiologic studies of 13 patients with TGA. On admission, patients underwent diffusion-weighted imaging (DWI) and intra- and extracranial magnetic resonance angiography (MRA); vascular risk factor profiles for diabetes, hypertension, and hyperlipidemia; electroencephalography; and neuropsychological tests. Seven patients underwent control DWIs 24 h after symptom onset. RESULTS: One patient had two punctiform acute infarcts in the left hippocampus, and one had a left pontine paramedian acute infarct. In the second patient, control DWI showed additional left hippocampal and right frontal acute infarcts. None of the patients had electroencephalographic evidence of epileptic activity. All patients except for one had at least one vascular risk factor. The second patient was shown to have paroxsysmal atrial fibrillation during follow-up. CONCLUSION: Minor posterior circulation ischemic stroke appears to cause TGA in some patients. Evaluations such as DWI and vascular risk factor assessment may be helpful in making the diagnosis.

Endovascular treatment for acute ischemic stroke patients: implications and interpretation of IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials: A report from the Working Group of International Congress of Interventional Neurology.

OBJECTIVE: The results of Interventional Management of Stroke (IMS) III, Magnetic Resonance and REcanalization of Stroke Clots Using Embolectomy (MR RESCUE), and SYNTHESIS EXPANSION trials are expected to affect the practice of endovascular treatment for acute ischemic stroke. The purpose of this report is to review the components of the designs and methods of these trials and to describe the influence of those components on the interpretation of trial results. METHODS: A critical review of trial design and conduct of IMS III, MR RESCUE, and SYNTHESIS EXPANSION is performed with emphasis on patient selection, shortcomings in procedural aspects, and methodology of data ascertainment and analysis. The influence of each component is estimated based on published literature including multicenter clinical trials reporting on endovascular treatment for acute ischemic stroke and myocardial infarction. RESULTS: We critically examined the time interval between symptom onset and treatment and rates of angiographic recanalization to differentiate between "endovascular treatment" and "parameter optimized endovascular treatment" as it relates to the IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials. All the three trials failed to effectively test "parameter optimized endovascular treatment" due to the delay between symptom onset and treatment and less than optimal rates of recanalization. In all the three trials, the magnitude of benefit with endovascular treatment required to reject the null hypothesis was larger than could be expected based on previous studies. The IMS III and SYNTHESIS EXPANSION trials demonstrated that rates of symptomatic intracerebral hemorrhages subsequent to treatment are similar between IV thrombolytics and endovascular treatment in matched acute ischemic stroke patients. The trials also indirectly validated the superiority/equivalence of IV thrombolytics (compared with endovascular treatment) in patients with minor neurological deficits and those without large vessel occlusion on computed tomographic/magnetic resonance angiography. CONCLUSIONS: The results do not support a large magnitude benefit of endovascular treatment in subjects randomized in all the three trials. The possibility that benefits of a smaller magnitude exist in certain patient populations cannot be excluded. Large magnitude benefits can be expected with implementation of "parameter optimized endovascular treatment" in patients with ischemic stroke who are candidates for IV thrombolytics.

Intracranial angioplasty and stent placement after stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) trial: present state and future considerations.

OBJECTIVE: The results of prematurely terminated stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) due to excessively high rate of stroke and death in patients randomized to intracranial stent placement is expected to affect the practice of endovascular therapy for intracranial atherosclerotic disease. The purpose of this report is to review the components of the designs and methods SAMMPRIS trial and to describe the influence of those components on the interpretation of trial results. METHODS: A critical review of the patient population included in SAMMPRIS is conducted with emphasis on "generalizability of results" and "bias due to cherry picking phenomenon." The technical aspects of endovascular treatment protocol consisting of intracranial angioplasty and stent placement using the Gateway balloon and Wingspan self-expanding nitinol stent and credentialing criteria of trial interventionalists are reviewed. The influence of each component is estimated based on previous literature including multicenter clinical trials reporting on intracranial angioplasty and stent placement. RESULTS: The inclusion criteria used in the trial ensured that patients with adverse clinical or angiographic characteristics were excluded. Self-expanding stent as the sole stent, technique of prestent angioplasty, periprocedural antiplatelet treatment, and intraprocedural anticoagulation are unlikely to adversely influence the results of intracranial stent placement. A more permissive policy toward primary angioplasty as an acceptable treatment option may have reduced the overall periprocedural complication rates by providing a safer option in technically challenging lesions. The expected impact of a more rigorous credentialing process on periprocedural stroke and/or death rate following intracranial stent placement in SAMMPRIS such as the one used in carotid revascularization endarterectomy versus stenting trial remains unknown. CONCLUSION: The need for developing new and effective treatments for patients with symptomatic intracranial stenosis cannot be undermined. The data support modification but not discontinuation of our approach to intracranial angioplasty and/or stent placement for intracranial stenosis. There are potential patients in whom angioplasty and/or stent placement might be the best approach, and a new trial with appropriate modifications in patient selection and design may be warranted.

[Clinical and magnetic resonance imaging findings in patients with surgically treated mesial temporal sclerosis]. / Cerrahi uygulanan mezial temporal skleroz olgularinda klinik ve MRG bulgular.

PURPOSE: Mesial temporal sclerosis (MTS) is one of the leading causes of medically intractable complex partial seizures. Magnetic resonance imaging (MRI) and clinical findings in seventeen patients who had surgery for medically intractable mesial temporal lobe epilepsy (MTLE) are presented in this report. MATERIALS AND METHODS: 17 patients (9 females and 8 males) aged 19-35 years with clinically and electrophysiologically proven MTLE have been included in the study. Age at seizure onset was six months to 17 years, frequency of seizures 4-20 times/month, and duration of medical treatment 10-28 years with no response. MRI and volumetry of the mesial temporal structures were performed in all patients. RESULTS: On preoperative MRI and volumetry, pathologic signal, loss of internal structures and atrophy were present in the right hippocampus in twelve cases and left hippocampus in five. The hippocampal head and body were involved in ten cases and all three parts in seven. The Wada test was performed in three cases showing that memory and speech functions were controlled by the noninvolved side. All patients underwent surgery. The histopathological examination result was MTS in all cases. In the postoperative follow up period of one to 24 months, 12 patients were assessed as class I and II, and seven as III according to the Engel Classification. CONCLUSION: MRI and volumetry are among the most important tools in the preoperative diagnosis of MTS. All patients have benefited from surgery, verifying the preoperative clinical and MR imaging diagnosis. Interpretation of MR findings is important in determining surgical candidates and success of surgery in MTS, which is a major cause of medically intractable temporal epilepsy.