Trombectomía mecánica más allá de 6 horas en ictus isquémico agudo con oclusión de gran vaso en territorio carotídeo: experiencia en un hospital terciario / Mechanical thrombectomy beyond 6 hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: Experience at a tertiary hospital

Introducción: La eficacia de la trombectomía mecánica en territorio carotídeo en las primeras 24 horas se ha probado con trabajos publicados recientemente. Métodos: Revisión retrospectiva a partir de un registro prospectivo en nuestro centro de referencia de ictus para valorar la eficacia y seguridad del tratamiento endovascular realizado más allá de las 6 horas de evolución de los síntomas en pacientes con ictus isquémico agudo y oclusión de gran vaso en territorio carotídeo, entre noviembre de 2016 y abril de 2019. Resultados: Se recopilaron datos de 59 pacientes (55,9% mujeres, mediana de edad 71 años). Treinta y tres pacientes fueron detectados al despertar. El 57,6% de los casos fueron traslados secundarios. La mediana de NIHSS basal fue 16. La mediana del ASPECTS fue 8 y el 94,9% de los pacientes presentó > 50% de tejido salvable. El 88,1% de los pacientes logró una recanalización satisfactoria, en 5 pacientes después de 24 horas de evolución. El 67,8% de los casos logró la independencia funcional a los 90 días de seguimiento. Los pacientes que no lograron la independencia funcional presentaban mayor edad, mayor proporción de fibrilación auricular, mayor tiempo punción-recanalización y mayor puntuación NIHSS, tanto basal como al alta. Conclusión: En nuestra experiencia la trombectomía mecánica después de las 6 horas se asoció con buenos resultados de funcionalidad a los 90 días. La edad, la puntuación NIHSS, el tiempo punción-recanalización y la prevalencia de fibrilación auricular fueron factores determinantes en el pronóstico funcional. La eficacia de este tratamiento por encima de las 24 horas merece ser estudiada.(AU)

Introduction: Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset. Methods: We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. Results: Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. Conclusion: In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.(AU)

Mechanical thrombectomy beyond 6 hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: experience at a tertiary hospital.

INTRODUCTION: Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset. METHODS: We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS: Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION: In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.

Intravenous thrombolysis for acute ischemic stroke in centenarians.

PURPOSE: The benefit of intravenous alteplase is well established for patients with disabling stroke symptoms regardless of age, although data on outcomes in centenarian patients are scarce. We present our experience in patients beyond 100 years. METHODS: Descriptive study including centenarians from our single-centre prospective registry who underwent intravenous thrombolysis with alteplase for acute ischemic stroke in our tertiary university hospital. Clinical variables and functional outcome at 3 months were collected. RESULTS: Four patients, all women, functionally independent (mRS ≤ 2) were included. Treatment with alteplase was applied within 4.5 h of stroke onset. One patient complicated with pneumonia and died. Two patients were functionally independent (mRS ≤ 2) at discharge, while the third was partially dependent (mRS of 3 at discharge), improving after 3 months, (mRS 2). No serious hemorrhagic or systemic adverse events were registered. CONCLUSION: In our experience, intravenous thrombolysis may be beneficial and should be considered in patients over 100 years old with no previous disability.

Mechanical thrombectomy beyond 6hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: Experience at a tertiary hospital. / Trombectomía mecánica más allá de 6horas en ictus isquémico agudo con oclusión de gran vaso en territorio carotídeo: experiencia en un hospital terciario.

INTRODUCTION: Thrombectomy in the carotid artery territory was recently shown to be effective up to 24hours after symptoms onset. METHODS: We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS: Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting>50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION: In our experience, mechanical thrombectomy beyond 6hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24hours after onset merits study.

Contraindications to intravenous thrombolysis in prehospital triage of thrombectomy candidates.

BACKGROUND AND PURPOSE: The existence of contraindications to intravenous thrombolysis (IVT) is considered a criterion for direct transfer of patients with suspected acute stroke to thrombectomy-capable centers in the prehospital setting. Our aim was to assess the utility of this criterion in a setting where routing protocols are defined by the Madrid - Direct Referral to Endovascular Center (M-DIRECT) prehospital scale. METHODS: This was a post hoc analysis of the M-DIRECT study. Reported contraindications to IVT were retrospectively collected from emergency medical services reports and categorized into late window, anticoagulant treatment and other contraindications. Final diagnosis and treatment rates were compared between patients with and without reported IVT contraindications and according to anticoagulant treatment or late window categories. RESULTS: The M-DIRECT study included 541 patients. Reported IVT contraindications were present in 227 (42.0%) patients. Regarding final diagnosis no significant differences were found between patients with or without reported IVT contraindications: ischaemic stroke (any) 65.6% vs. 62.1%, ischaemic stroke with large vessel occlusion (LVO) 32.2% vs. 28.3%, hemorrhagic stroke 15.4% vs. 15.6%, stroke mimic 18.9% vs. 22.3% respectively. Amongst patients with LVO, endovascular thrombectomy (EVT) was performed less often in the presence of IVT contraindications (56.2% vs. 74.2%). M-DIRECT-positive patients had higher rates of LVO and EVT compared with M-DIRECT-negative patients independent of reported IVT contraindications. CONCLUSIONS: Reported IVT contraindications alone do not increase EVT likelihood and should not be considered to determine routing in urban stroke networks.

Tratamientos de reperfusión en el infarto cerebral agudo por disección de arterias cervicales / Reperfusion therapy in patients with acute ischaemic stroke caused by cervical artery dissection

Introducción: Las disecciones de arteriales cervicales (DAC) provocan hasta el 20% de los ictus isquémicos en menores de 45 años. El beneficio de los tratamientos de reperfusión en fase aguda no está plenamente clarificado. Métodos: Revisión retrospectiva de pacientes con DAC ingresados en un centro terciario de ictus desde 2010 hasta 2015. Recogemos las características basales, clínicas, los tratamientos, el pronóstico funcional y la mortalidad. Resultados: Se registraron 35 DAC (23 carotídeas/12 vertebrales). La edad media fue de 43,5 ± 9,5 años y el 67,7% fueron varones. En 10 casos (32,3%) hubo antecedente de un traumatismo. Los factores de riesgo más frecuentes fueron la hipertensión arterial (29%) y el tabaquismo (35,5%). La presentación clínica más frecuente fue el infarto cerebral en 29 pacientes (93,5%). La mediana de puntuación National Institute of Health Stroke Scale basal fue de 6 (0-41). El método diagnóstico más empleado fue la angio-TC (74,2%), seguido de resonancia magnética (64,5%) y arteriografía cerebral (45,6%). Siete pacientes (22,6%) fueron tratados con fibrinólisis intravenosa y 11 (35,5%) con tratamiento endovascular (TEV) ± fibrinólisis intravenosa. A los 3 meses, la independencia funcional (escala de Rankin 0-2) fue del 57,1% y del 63,6%, respectivamente. Falleció un paciente (3,2%). Conclusiones: La forma de presentación más frecuente de la DAC fue el infarto cerebral. Estos casos pueden beneficiarse de terapias de reperfusión, con un pronóstico similar al resto de enfermos con ictus isquémicos. Se requieren registros más extensos para conocer mejor la respuesta a los tratamientos de reperfusión en fase aguda en este grupo de pacientes

Introduction: Cervical artery dissection (CAD) is responsible for up to 20% of all ischaemic strokes in patients younger than 45. The benefits of acute-phase reperfusion therapy in these patients have yet to be confirmed. Methods: We conducted a retrospective review of patients with CAD admitted to a comprehensive stroke centre between 2010 and 2015. We recorded baseline clinical characteristics, treatments, functional outcomes, and mortality. Results: We identified 35 cases of CAD (23 carotid/12 vertebral); mean age was 43.5 ± 9.5 years and 67.7% were men. Ten patients (32.3%) had a history of trauma. The most frequent risk factors were arterial hypertension (29%) and smoking (35.5%). The most common clinical presentation was ischaemic stroke (29 patients, 93.5%). The median baseline National Institute of Health Stroke Scale score was 6 (range, 0-41). The most frequently used diagnostic method was CT angiography (74.2%), followed by MRI (64.5%) and digital subtraction angiography (45.6%). Seven patients (22.6%) were treated with intravenous fibrinolysis and 11 (35.5%) with endovascular treatment plus intravenous fibrinolysis; at 3 months, functional independence (modified Rankin Scale scores 0-2) was achieved by 57.1% and 63.6% of these cases, respectively. One patient died (3.2%). Conclusions: In our sample, the most common form of presentation of CAD was ischaemic stroke. Reperfusion therapy seems to be a safe and effective option for these patients, and outcomes resemble those of other patients with ischaemic stroke. Larger comparative studies are necessary to better assess response to reperfusion therapy in acute ischaemic stroke

Disección arterial vertebral bilateral como manifestación inicial del síndrome de Cushing / Bilateral vertebral artery dissection as the initial manifestation of Cushing síndrome

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Reperfusion therapy in patients with acute ischaemic stroke caused by cervical artery dissection. / Tratamientos de reperfusión en el infarto cerebral agudo por disección de arterias cervicales.

INTRODUCTION: Cervical artery dissection (CAD) is responsible for up to 20% of all ischaemic strokes in patients younger than 45. The benefits of acute-phase reperfusion therapy in these patients have yet to be confirmed. METHODS: We conducted a retrospective review of patients with CAD admitted to a comprehensive stroke centre between 2010 and 2015. We recorded baseline clinical characteristics, treatments, functional outcomes, and mortality. RESULTS: We identified 35 cases of CAD (23 carotid/12 vertebral); mean age was 43.5 ± 9.5 years and 67.7% were men. Ten patients (32.3%) had a history of trauma. The most frequent risk factors were arterial hypertension (29%) and smoking (35.5%). The most common clinical presentation was ischaemic stroke (29 patients, 93.5%). The median baseline National Institute of Health Stroke Scale score was 6 (range, 0-41). The most frequently used diagnostic method was CT angiography (74.2%), followed by MRI (64.5%) and digital subtraction angiography (45.6%). Seven patients (22.6%) were treated with intravenous fibrinolysis and 11 (35.5%) with endovascular treatment plus intravenous fibrinolysis; at 3 months, functional independence (modified Rankin Scale scores 0-2) was achieved by 57.1% and 63.6% of these cases, respectively. One patient died (3.2%). CONCLUSIONS: In our sample, the most common form of presentation of CAD was ischaemic stroke. Reperfusion therapy seems to be a safe and effective option for these patients, and outcomes resemble those of other patients with ischaemic stroke. Larger comparative studies are necessary to better assess response to reperfusion therapy in acute ischaemic stroke.

[Central pontine and extrapontine myelinolysis: clinical case, brain magnetic resonance and evolution in 13 patients]. / Mielinolisis central pontina y extrapontina: cuadro clínico, resonancia magnética cerebral y evolución en 13 pacientes.

INTRODUCTION: Central pontine myelinolysis (CPM) is a disease characterized by the destruction of the myelin in the brainstem, generally associated with alcoholism, rapid correction of hyponatremia and other electrolytic alterations. The clinical symptoms, etiopathogenic factors, neuroimaging and evolution of the series of patients diagnosed of central pontine/extrapontine myelinolysis (CPEM) are described. METHODS: Review of all the clinical histories with diagnoses of CPM made in our hospital since 1989. All the cases were reviewed, ruling out those having a magnetic resonance or clinical picture not clearly consistent with the diagnosis. Age, symptoms, comorbidity, associated metabolite alterations and clinical evolution were analyzed. RESULTS: 13 cases whose ages ranged from 28 to 81 years were identified. Hyponatremia was identified during the clinical course in six patients, with neurological worsening associated to its correction in 3 of them. No sodium disorders were identified in 7 patients. Seven of the patients had associated alcoholism. Hyperintense lesions were found in all the cases in T2 sequences and FLAIR in the brainstem consistent with the typical pattern of the osmotic demyelinization syndrome. The severity of the clinical picture identified varied from a symptomatic patient to coma in 9 cases. In regards to the clinical course, four patients completely recovered, eight had residual symptoms with different severity and one patient died. CONCLUSIONS: The series is representative of the clinical and etiopathogenic spectrum of the osmotic demyelinization syndrome. Most of the clinically symptomatic patients improve if the secondary complications are controlled.

Mielinolisis central pontina y extrapontina: cuadro clínico, resonancia magnéticacerebral y evolución en 13 pacientes / Central pontine and extrapontine myelinolysis: clinical case, brain magnetic resonance and evolution in 13 patients

Introducción. La mielinolisis central pontina (MCP) es una entidadcaracterizada por la destrucción de mielina en la base de la protuberancia,generalmente asociada con enolismo, corrección rápidade la hiponatremia y otras alteraciones electrolíticas. Se describe laclínica, factores etiopatogénicos, neuroimagen y evolución de unaserie de pacientes con diagnóstico de mielinolisis central pontina/extrapontina(MCP/E).Métodos. Revisión de todas las historias clínicas con diagnósticode MCP realizados en nuestro hospital desde el año 1989. Se revisarontodos los casos descartando aquellos con resonancia magnéticao cuadros clínicos no claramente compatibles con el diagnóstico.Se analizó la edad, clínica, comorbilidad, alteraciones metabólicasasociadas y evolución clínica.Resultados. Se identificaron 13 casos con edades comprendidasentre los 28 y 81 años. Se identificó hiponatremia durante el cursoclínico en 6 pacientes, produciéndose en 3 de ellos un empeoramientoneurológico asociado a la corrección de la misma. En 7 pacientesno se identificaron trastornos del sodio. Siete de los pacientes presentabanenolismo asociado. En todos los casos se reconocieron lesioneshiperintensas en secuencias T2 y FLAIR en la protuberanciacompatibles con el patrón típico del síndrome de desmielinizaciónosmótica. La gravedad del cuadro clínico identificado varió desde unpaciente asintomático hasta el coma en 9 casos. En cuanto a la evoluciónclínica, 4 pacientes se recuperaron completamente, 8 presentaronsintomatología residual de distinta severidad y 1 paciente falleció.Conclusiones. La serie es representativa del espectro clínico yetiopatogénico del síndrome de desmielinización osmótica. La mayoríade los pacientes clínicamente sintomáticos mejoran si las complicacionessecundarias son controladas (AU)

Introduction. Central pontine myelinolysis (CPM) is a diseasecharacterized by the destruction of the myelin in the brainstem,generally associated with alcoholism, rapid correction ofhyponatremia and other electrolytic alterations. The clinicalsymptoms, etiopathogenic factors, neuroimaging and evolutionof the series of patients diagnosed of central pontine/extrapontinemyelinolysis (CPEM) are described.Methods. Review of all the clinical histories with diagnosesof CPM made in our hospital since 1989. All the cases were reviewed,ruling out those having a magnetic resonance or clinicalpicture not clearly consistent with the diagnosis. Age, symptoms,comorbidity, associated metabolite alterations and clinical evolutionwere analyzed.Results. 13 cases whose ages ranged from 28 to 81 yearswere identified. Hyponatremia was identified during the clinicalcourse in six patients, with neurological worsening associated toits correction in 3 of them. No sodium disorders were identifiedin 7 patients. Seven of the patients had associated alcoholism.Hyperintense lesions were found in all the cases in T2 sequencesand FLAIR in the brainstem consistent with the typical pattern ofthe osmotic demyelinization syndrome. The severity of the clinicalpicture identified varied from a symptomatic patient to comain 9 cases. In regards to the clinical course, four patients completelyrecovered, eight had residual symptoms with different severityand one patient died.Conclusions. The series is representative of the clinical andetiopathogenic spectrum of the osmotic demyelinization syndrome.Most of the clinically symptomatic patients improve if thesecondary complications are controlled (AU)