-
Michelle von Babo,
Gian Marco De Marchis,
Hakan Sarikaya,
Christian Stapf,
Fréderique Buffon,
Urs Fischer,
Mirjam R Heldner,
Jan Gralla,
Simon Jung,
Barbara Goeggel Simonetti,
Heinrich P Mattle, Ralf W Baumgartner,
Marie-Germaine Bousser,
Marcel Arnold
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND AND PURPOSE: To compare potential risk factors, clinical symptoms, diagnostic delay, and 3-month outcome between spontaneous internal carotid artery dissection (sICAD) and spontaneous vertebral artery dissection (sVAD). METHODS: We compared patients with sICAD (n=668) and sVAD (n=302) treated in 3 university hospitals. RESULTS: Patients with sICAD were older (46.3±9.6 versus 42.0±10.2 years; P<0.001), more often men (62.7% versus 53.0%; P=0.004), and presented more frequently with tinnitus (10.9% versus 3.4%; P<0.001) and more severe ischemic strokes (median National Institutes of Health Stroke Scale, 10±7.1 versus 5±5.9; P<0.001). Patients with sVAD had more often bilateral dissections (15.2% versus 7.6%; P<0.001) and were more often smokers (36.0% versus 28.7%; P=0.007). Thunderclap headache (9.2% versus 3.6%; P=0.001) and neck pain were more common (65.8% versus 33.5%; P<0.001) in sVAD. Subarachnoid hemorrhage (6.0% versus 0.6%; P<0.001) and ischemic stroke (69.5% versus 52.2%; P<0.001) were more frequent in sVAD. After multivariate analysis, sex difference lost its significance (P=0.21), and all other variables remained significant. Time to diagnosis was similar in sICAD and sVAD and improved between 2001 and 2012 compared with the previous 10-year period (8.0±10.5 days versus 10.7±13.2 days; P=0.004). In sVAD, favorable outcome 3 months after ischemic stroke (modified Rankin Scale, 0-2: 88.8% versus 58.4%; P<0.001), recurrent transient ischemic attack (4.8% versus 1.1%; P=0.001), and recurrent ischemic stroke (2.8% versus 0.7%; P=0.02) within 3 months were more frequent. CONCLUSIONS: sICAD and sVAD patients differ in many aspects. Future studies should perform separate analyses of these 2 entities.
Stroke 04/2013; · 5.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To investigate a potential correlation between the ocular pulse amplitude (OPA; i.e., the intraocular pressure difference between the systolic and diastolic phases of the heartbeat) and the severity of carotid artery stenosis (CAS) and to test its role as a screening parameter for CAS during routine ophthalmic examination.
Test accuracy study.
Patients referred for color duplex ultrasound examination of the extra- and intracranial cerebral arteries were enrolled consecutively.
We measured OPA on both eyes by dynamic contour tonometry. Multivariate analyses were performed with risk factors for CAS (age, total cholesterol, low-density lipoprotein, and triglycerides) to compare the diagnostic value of OPA measurements with other non- or minimally invasive screening parameters.
The difference between OPA measurements in patients with no (<50%) and patients with severe CAS (>70%) as well as the value of OPA measurements to predict the severity of CAS taking further risk factors of CAS into consideration.
One hundred thirty-four eyes of 67 patients (25 women, 42 men) with a mean age of 67±13 years (range, 25-87) were included. The means of the OPA values of those patients showing no CAS (<50%) differed significantly (P = 0.036) from those with a stenosis of ≥70%. The multivariate model produced a statistically significant odds ratio (0.46; P = 0.007) for CAS of ≥70%.
The results of the present study provide proof of principle that the OPA is reduced in patients with CAS and may be used as a noninvasive, inexpensive, readily available, and unconfounded screening parameter to detect CAS and possibly to reduce the incidence of stroke.
The authors have no proprietary or commercial interest in any of the materials discussed in this article.
Ophthalmology 02/2012; 119(6):1244-9. · 5.45 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Cerebral cavernous malformations (CCMs) are common vascular lesions in the brain, affecting approximately 0.5% of the population and representing 10%-20% of all cerebral vascular lesions. One-quarter of all CCMs affect pediatric patients, and CCMs are reported as one of the main causes of brain hemorrhage in this age group. Symptoms include epileptic seizures, headache, and focal neurological deficits. Patients with symptomatic CCMs can be treated either conservatively or with resection if lesions cause medically refractory epilepsy or other persistent symptoms.
The authors retrospectively analyzed 79 pediatric patients (41 boys and 38 girls) from 3 different centers, who were surgically treated for their symptomatic CCMs between 1974 and 2004. The mean age of the children at first manifestation was 9.7 years, and the mean age at operation was 11.3 years. The main goal was to compare the clinical outcomes with respect to the location of the lesion of children who preoperatively suffered from epileptic seizures.
Of these patients, 77.3% were seizure free (Engel Class I) after the resection of the CCM. Significant differences in the outcome between children who harbored CCMs at different locations were not found.
Resection seems to be the favorable treatment of symptomatic CCMs not only in adults but also in children.
Journal of Neurosurgery Pediatrics 11/2011; 8(5):522-5. · 1.53 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Outcome of stroke patients selected with cerebral computed tomography for intravenous thrombolysis administered in clinical routine from 3 to 4.5 hours after symptoms onset is not well investigated. Aim of this single-center, prospective, observational study was to compare the safety and efficacy of intravenous alteplase given in routine clinical praxis 181-270 minutes (late) and within 180 minutes (early) after stroke onset in patients selected with cerebral computed tomography.
A total of 454 consecutive patients underwent intravenous thrombolysis within 4.5 hours after stroke onset. Sixty of 454 patients were excluded (inclusion in a controlled-randomized trial, n = 51; stroke mimics, n = 9). Of remaining 394 patients, 100 were included in the late group, and 294 were included in the early group. The outcome parameters of symptomatic intracranial hemorrhage at 24 hours, and mortality and favorable outcome (modified Rankin scale score 0-1) at 3 months, and its predictors were investigated.
In the late cohort, median baseline National Institutes of Health Stroke Scale score was lower (9.5, interquartile range (IQR): 5-13; 11.3, IQR: 6-16; P = 0.01), and median time-to-treatment was longer (209, IQR: 190-222 minutes; 142, IQR: 125-170 minutes; P<0.0001) than in the early group. The incidence of symptomatic intracranial hemorrhage (2.0% versus 2.4%; P = 1.0), death (9.0% versus 9.9%; P = 1.0) and favorable outcome (58.0% versus 51.5%; P = 0.3) did not differ between the late and early cohorts.
These data suggest that intravenous alteplase administered 181-270 minutes after symptoms onset in stroke patients selected with cerebral computed tomography is also beneficial in real-life clinical practice.
Neurological Research 09/2011; 33(7):701-7. · 1.52 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Obesity is an established risk factor for stroke and has reached epidemic proportions. However, its impact on intravenous thrombolysis applied for acute ischemic stroke is not well known. We aimed to compare the clinical outcome and safety after intravenous thrombolysis in obese (body mass index ≥30 kg/m²) and nonobese (body mass index <30 kg/m²) patients with ischemic stroke.
Data of 304 consecutive patients with stroke (251 nonobese and 53 obese) treated with intravenous thrombolysis were studied. We assessed the rate of favorable outcome (modified Rankin Scale score 0 or 1), mortality, and symptomatic intracranial hemorrhage in the 2 groups.
Obese patients presented more often with diabetes mellitus (30.2% versus 12.4%, P<0.01) and arterial hypertension (77.4% versus 61.4%, P=0.03) as compared with their nonobese counterparts. At 3 months, the rate of favorable outcome was lower in obese compared with nonobese patients (50.9% versus 68.1%, P=0.02). More obese than nonobese patients died (13.2% versus 4.0%, P=0.01), whereas the rate of symptomatic intracranial hemorrhage was similar in the 2 groups (1.9% versus 1.6%, P=1.0). After multivariable adjustment, obesity still remained an independent predictor of unfavorable outcome (P=0.04) and mortality (P=0.04).
Our data indicate that obesity is an independent predictor of unfavorable clinical outcome and mortality in acute ischemic stroke treated with intravenous thrombolysis.
Stroke 08/2011; 42(8):2330-2. · 5.73 Impact Factor
-
Sanne M Zinkstok,
Mervyn D I Vergouwen,
Stefan T Engelter,
Philippe A Lyrer,
Leo H Bonati,
Marcel Arnold,
Heinrich P Mattle,
Urs Fischer,
Hakan Sarikaya, Ralf W Baumgartner,
Dimitrios Georgiadis,
Céline Odier,
Patrik Michel,
Jukka Putaala,
Martin Griebe,
Nils Wahlgren,
Niaz Ahmed,
Nan van Geloven,
Rob J de Haan,
Paul J Nederkoorn
[show abstract]
[hide abstract]
ABSTRACT: The safety and efficacy of thrombolysis in cervical artery dissection (CAD) are controversial. The aim of this meta-analysis was to pool all individual patient data and provide a valid estimate of safety and outcome of thrombolysis in CAD.
We performed a systematic literature search on intravenous and intra-arterial thrombolysis in CAD. We calculated the rates of pooled symptomatic intracranial hemorrhage and mortality and indirectly compared them with matched controls from the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. We applied multivariate regression models to identify predictors of excellent (modified Rankin Scale=0 to 1) and favorable (modified Rankin Scale=0 to 2) outcome.
We obtained individual patient data of 180 patients from 14 retrospective series and 22 case reports. Patients were predominantly female (68%), with a mean±SD age of 46±11 years. Most patients presented with severe stroke (median National Institutes of Health Stroke Scale score=16). Treatment was intravenous thrombolysis in 67% and intra-arterial thrombolysis in 33%. Median follow-up was 3 months. The pooled symptomatic intracranial hemorrhage rate was 3.1% (95% CI, 1.3 to 7.2). Overall mortality was 8.1% (95% CI, 4.9 to 13.2), and 41.0% (95% CI, 31.4 to 51.4) had an excellent outcome. Stroke severity was a strong predictor of outcome. Overlapping confidence intervals of end points indicated no relevant differences with matched controls from the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register.
Safety and outcome of thrombolysis in patients with CAD-related stroke appear similar to those for stroke from all causes. Based on our findings, thrombolysis should not be withheld in patients with CAD.
Stroke 07/2011; 42(9):2515-20. · 5.73 Impact Factor
-
Hakan Sarikaya,
Marcel Arnold,
Stefan T Engelter,
Philippe A Lyrer,
Heinrich P Mattle,
Dimitrios Georgiadis,
Leo H Bonati,
Felix Fluri,
Urs Fischer,
Oliver Findling,
Pietro Ballinari, Ralf W Baumgartner
[show abstract]
[hide abstract]
ABSTRACT: Intravenous thrombolysis is an approved treatment for anterior (ACS) and posterior (PCS) circulation stroke. However, no randomized controlled trial has investigated safety and efficacy of intravenous thrombolysis according to stroke territory, although PCS is assumed to differ from ACS in many ways. We aimed to compare the safety and clinical outcome of intravenous thrombolysis applied to patients with PCS and ACS.
Prospectively collected data of 883 consecutive patients with acute ischemic stroke (788 ACS, 95 PCS) treated with intravenous thrombolysis in 3 Swiss stroke centers were analyzed. Presenting characteristics, symptomatic intracranial hemorrhage, mortality, and favorable outcome (modified Rankin scale 0 or 1) at 3 months were compared between patients with PCS and ACS.
As compared with patients with ACS, those with PCS were younger (mean age, 63 versus 67 years, P=0.012) and had a lower mean baseline National Institutes of Health Stroke Scale score (9 versus 12, P<0.001). Patients with PCS less often had symptomatic intracranial hemorrhage (0% versus 5%, P=0.026) and had more often a favorable outcome (66% versus 47%, P<0.001). Mortality was similar in the 2 groups (PCS, 9%; ACS, 13%; P=0.243). After multivariable adjustment, PCS was an independent predictor of lower symptomatic intracranial hemorrhage frequency (P=0.001), whereas stroke territory was not associated either with favorable outcome (P=0.177) or with mortality (P=0.251).
Our study suggests that PCS is associated with a lower risk of symptomatic intracranial hemorrhage after intravenous thrombolysis as compared with ACS, whereas favorable outcome and mortality were similar in the 2 stroke territories.
Stroke 07/2011; 42(9):2498-502. · 5.73 Impact Factor
-
Hakan Sarikaya,
Marcel Arnold,
Stefan T Engelter,
Philippe A Lyrer,
Patrik Michel,
Céline Odier,
Bruno Weder,
Barbara Tettenborn,
Felix Mueller,
Lucka Sekoranja,
Roman Sztajzel,
Pietro Ballinari,
Heinrich P Mattle, Ralf W Baumgartner
[show abstract]
[hide abstract]
ABSTRACT: Demographic changes will result in a rapid increase of patients age ≥90 years (nonagenarians), but little is known about outcomes in these patients after intravenous thrombolysis (IVT) for acute ischemic stroke. We aimed to assess safety and functional outcome in nonagenarians treated with IVT and to compare the outcomes with those of patients age 80 to 89 years (octogenarians).
We analyzed prospectively collected data of 284 consecutive stroke patients age ≥80 years treated with IVT in 7 Swiss stroke units. Presenting characteristics, favorable outcome (modified Rankin scale [mRS] 0 or 1), mortality at 3 months, and symptomatic intracranial hemorrhage (SICH) using the National Institute of Neurological Disorders and Stroke (NINDS) and Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria were compared between nonagenarians and octogenarians.
As compared with octogenarians (n=238; mean age, 83 years), nonagenarians (n=46; mean age, 92 years) were more often women (70% versus 54%; P=0.046) and had lower systolic blood pressure (161 mm Hg versus 172 mm Hg; P=0.035). Patients age ≥90 years less often had a favorable outcome and had a higher incidence of mortality than did patients age 80 to 89 years (14.3% versus 30.2%; P=0.034; and 45.2% versus 22.1%; P=0.002; respectively), while more nonagenarians than octogenarians experienced a SICH (SICH(NINDS), 13.3% versus 5.9%; P=0.106; SICH(SITS-MOST), 13.3% versus 4.7%; P=0.037). Multivariate adjustment identified age ≥90 years as an independent predictor of mortality (P=0.017).
Our study suggests less favorable outcomes in nonagenarians as compared with octogenarians after IVT for ischemic stroke, and it demands a careful selection for treatment, unless randomized controlled trials yield more evidence for IVT in very old stroke patients.
Stroke 05/2011; 42(7):1967-70. · 5.73 Impact Factor
-
Neurology 02/2011; 76(7):676; author reply 676. · 8.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Spontaneous internal carotid artery (ICA) dissection (sICAD) results from an intimal tear located around the distal carotid sinus. The mechanisms causing the tear are unknown. This case-control study tested the hypotheses that head movements increase the wall stress in the cervical ICA and that the stress increase is greater in patients with sICAD than in controls. Five patients with unilateral, recanalized, left sICAD and five matched controls were investigated before and after maximal head rotation to the left and neck hyperextension after 45° head rotation to the left. The anatomy of the extracranial carotid arteries was assessed by magnetic resonance imaging and used to create finite element models of the right ICA. Wall stress increased after head movements. Increases above the 80th and 90th percentile were located at the intimal side of the artery wall from 7.4 mm below to 10 mm above the cranial edge of the carotid sinus, i.e., at the same location as histologically confirmed tears in patients with sICAD. Wall stress increase did not differ between patients and controls. The present findings suggest that wall stress increases at the intimal side of the artery wall surrounding the distal edge of the carotid bulb after head movements may be important for the development of carotid dissection. The lack of wall stress difference between the two groups indicates that the carotid arteries of patients with carotid dissection have either distinct functional or anatomical properties or endured unusually heavy wall stresses to initiate dissection.
AJP Heart and Circulatory Physiology 02/2011; 300(4):H1451-8. · 3.71 Impact Factor
-
Marcel Arnold,
Rebekka Kurmann,
Aekaterini Galimanis,
Hakan Sarikaya,
Christian Stapf,
Jan Gralla,
Dimitrios Georgiadis,
Urs Fischer,
Heinrich P Mattle,
Marie-Germaine Bousser, Ralf W Baumgartner
[show abstract]
[hide abstract]
ABSTRACT: Spontaneous vertebral artery dissection (sVADs) mainly cause cerebral ischemia, with or without associated local symptoms and signs (headache, neck pain, or cervical radiculopathy), or with local symptoms and signs only.
We compared the presenting characteristics of consecutive patients with single sVADs and ischemic events and those with local symptoms and signs only.
Of the 186 patients with first-ever unilateral sVAD, 165 (89%) presented with cerebral ischemia, and 21 (11%) presented with local symptoms and signs only. Patients with sVAD and ischemia were more often male (63% vs 29%; P=0.002), older (mean+/-SD age, 43.6+/-9.9 vs 38.6+/-9.0 years; P=0.027), and smokers (14% vs 3%; P=0.010), but less often, they had a history of migraine without aura (17% vs 38%; P=0.025) than did patients without ischemia. The multivariate analysis confirmed independent associations between male sex (P=0.024), increasing age (0.027), and smoking (P=0.012) and sVADs causing cerebral ischemia.
These results suggest that men, older patients, and smokers with sVADs may be at increased risk for ischemic events.
Stroke 02/2010; 41(4):802-4. · 5.73 Impact Factor
-
Ralf W Baumgartner
[show abstract]
[hide abstract]
ABSTRACT: This manuscript reviews the management of patients with spontaneous dissection of the cervical internal carotid artery (sICAD). Recommendations are not based on controlled-randomized trials, but on case-control and observational, hospital-based studies, and case reports. Vascular risk factors seem to be as prevalent in patients with sICAD as in age-matched, healthy volunteers. Stroke prevention includes the treatment of vascular risk factors and the administration of oral aspirin, which may be as effective as anticoagulation. The few available data indicate that most patients with sICAD causing severe stenosis or occlusion, or an aneurysm can be treated conservatively. Patients with sICAD were not excluded in the intravenous controlled-randomized thrombolysis trials with tissue plasminogen activator, but were excluded in the intraarterial controlled-randomized thrombolysis trials. Taking the few published case series and reports on thrombolysis in patients with sICAD into consideration, intravenous thrombolysis may be beneficial, whereas it remains unclear whether intraarterial thrombolysis is useful.
Acta neurochirurgica. Supplement 01/2010; 107:57-61.
-
Stefan T Engelter,
Matthieu P Rutgers,
Florian Hatz,
Dimitrios Georgiadis,
Felix Fluri,
Lucka Sekoranja,
Guido Schwegler,
Felix Müller,
Bruno Weder,
Hakan Sarikaya, [......],
Marcel Arnold,
Krassen Nedeltchev,
Marc Reichhart,
Heinrich P Mattle,
Barbara Tettenborn,
Hansjörg J Hungerbühler,
Roman Sztajzel, Ralf W Baumgartner,
Patrik Michel,
Philippe A Lyrer
[show abstract]
[hide abstract]
ABSTRACT: Intravenous thrombolysis (IVT) for stroke seems to be beneficial independent of the underlying etiology. Whether this is also true for cervical artery dissection (CAD) is addressed in this study.
We used the Swiss IVT databank to compare outcome and complications of IVT-treated patients with CAD with IVT-treated patients with other etiologies (non-CAD patients). Main outcome and complication measures were favorable 3-month outcome, intracranial cerebral hemorrhage, and recurrent ischemic stroke. Modified Rankin Scale score <or=1 at 3 months was considered favorable.
Fifty-five (5.2%) of 1062 IVT-treated patients had CAD. Patients with CAD were younger (median age 50 versus 70 years) but had similar median National Institutes of Health Stroke Scale scores (14 versus 13) and time to treatment (152.5 versus 156 minutes) as non-CAD patients. In the CAD group, 36% (20 of 55) had a favorable 3-month outcome compared with 44% (447 of 1007) non-CAD patients (OR, 0.72; 95% CI, 0.41 to 1.26), which was less favorable after adjustment for age, gender, and National Institutes of Health Stroke Scale score (OR, 0.50; 95% CI, 0.27 to 0.95; P=0.03). Intracranial cerebral hemorrhages (asymptomatic, symptomatic, fatal) were equally frequent in CAD (14% [7%, 7%, 2%]) and non-CAD patients (14% [9%, 5%, 2%]; P=0.99). Recurrent ischemic stroke occurred in 1.8% of patients with CAD and in 3.7% of non-CAD-patients (P=0.71).
IVT-treated patients with CAD do not recover as well as IVT-treated non-CAD patients. However, intracranial bleedings and recurrent ischemic strokes were equally frequent in both groups. They do not account for different outcomes and indicate that IVT should not be excluded in patients who may have CAD. Hemodynamic compromise or frequent tandem occlusions might explain the less favorable outcome of patients with CAD.
Stroke 10/2009; 40(12):3772-6. · 5.73 Impact Factor
-
Circulation 07/2009; 119(21):e545; author reply e546. · 14.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Spontaneous cervical artery dissection (sCAD) is a nonatherosclerotic vascular disease of unknown etiology. Mild elevation of total plasma homocysteine (tHcy) levels may be a risk factor for sCAD, but the precise mechanism remains unknown. On the other hand, mild hyperhomocysteinemia is also associated with ischemic stroke related to atherothrombotic or small artery disease. We undertook a case-control study to compare the prevalence of mild hyperhomocysteinemia and tHcy levels between patients with a first ischemic stroke due to sCAD and healthy volunteers, as well as patients with a first ischemic stroke due to atherothrombotic or small artery disease.
Fasting tHcy levels were determined in 346 consecutive patients with a first ischemic stroke due to sCAD (n = 86) and atherothrombotic or small artery disease (n = 260) within 24 h after the onset of symptoms, and in 100 healthy volunteers.
Mild hyperhomocysteinemia was more prevalent in patients with sCAD causing ischemic stroke (n = 33, 38%) than in healthy volunteers (n = 23, 23%; p = 0.034), and less prevalent than in patients with ischemic stroke due to atherothrombotic or small artery disease (n = 149, 57%; p = 0.001). Mean fasting tHcy levels of patients with ischemic stroke caused by sCAD showed a trend to be higher (11.4 +/- 3.8 micromol/l) than those of healthy volunteers (10.2 +/- 3.0 micromol/l, p = 0.61), but were lower than those of patients with stroke due to atherothrombotic or small artery disease (13.6 +/- 6.6 micromol/l, p = 0.002).
Our results suggest that mild hyperhomocysteinemia may be a risk factor for sCAD causing ischemic stroke, but further studies are needed to identify a possible mechanism. This study confirms the association of hyperhomocysteinemia with ischemic stroke due to atherothrombotic or small artery disease.
Cerebrovascular Diseases 02/2009; 27(3):241-6. · 2.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: No controlled, randomized trial has investigated whether intravenous, intra-arterial (IAT), or mechanical thrombolysis is beneficial in children with ischemic stroke. We report 2 children who underwent IAT for acute ischemic stroke and include them in a review about intravenous thrombolysis, IAT, and mechanical thrombolysis for childhood stroke.
We searched in MEDLINE and EMBASE for studies that reported on treatment of childhood stroke with intravenous thrombolysis, IAT, or mechanical thrombolysis in the presence of occlusion of the basilar artery, sphenoidal, or insular middle cerebral artery. To be included in this review, the following findings had to be reported: (1) stroke severity at presentation; (2) cerebral imaging findings before thrombolysis; (3) time to treatment; (4) dose of the thrombolytic agent; (5) pre- and postinterventional angiographic findings in IAT; and (6) outcome assessed at hospital discharge or within 12 months after thrombolysis.
Adequate data were available in 17 children (including our 2 own cases) who underwent intravenous thrombolysis (n=6), IAT (n=10), or mechanical thrombolysis (n=1). No symptomatic intracranial hemorrhage occurred, but 2 asymptomatic intracranial hemorrhages were present. Sixteen children (94%) survived, and 12 (71%) had a good outcome (modified Rankin Scale score 0 or 1).
The available data about thrombolysis in pediatric stroke are limited. They suggest that this treatment may be beneficial in children with ischemic stroke. Controlled, randomized trials are needed to determine whether thrombolysis is useful in childhood stroke.
Stroke 01/2009; 40(3):801-7. · 5.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We set out to investigate the predictors and time course for recanalization of spontaneous dissection of the cervical internal carotid artery (SICAD).
We prospectively included 249 consecutive patients (mean age, 45+/-11 years) with 268 SICAD. Ultrasound examinations were performed at presentation, during the first month, and then at 3, 6, and 12 months, and clinical follow-ups after 3, 6, and 12 months.
Of 268 SICADs, 20 (7.5%) presented with <or=50% stenosis, 31 (11.6%) with 51% to 80% stenosis, 92 (34.3%) with 81% to 99% stenosis, and 125 (46.6%) with an occlusion. Antithrombotic treatment included anticoagulation in 174 (67%) patients, aspirin in 64 (24%) patients, and aspirin followed by anticoagulation or vice versa in 22 (8%) patients. Follow-up ultrasound showed normal findings in 160 (60%), <or=50% stenosis in 27 (10%), 51% to 80% stenosis in 4 (1%), 81% to 99% stenosis in 26 (10%), and occlusion in 51 (19%) vessels. The rate of complete recanalization was 16% at 1 month, 50% at 3 months, and 60% at 6 and 12 months. Initial occlusion of the dissected vessels reduced the odds of recanalization (OR, 4.0; 95% CI, 2.2-7.3; P<0.001), whereas the occurrence of local symptoms and signs only at presentation were independently associated with complete recanalization (OR, 0.4; 95% CI, 0.2-0.8; P=0.048).
These results suggest that recanalization of SICAD occurs mainly within the first 6 months after the onset of symptoms. Initial occlusion reduces the likelihood of complete recanalization, whereas presentation with local symptoms and signs only increases it.
Stroke 12/2008; 40(2):499-504. · 5.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Spontaneous cervicocephalic artery dissection (sCAD) of more than two cervical arteries is rare.
Vascular and potential sCAD risk factors, triggering events, clinical and neuroimaging findings, and outcome of patients with multiple sCAD were studied. Patients were drawn from prospective hospital-based sCAD registries.
Of 740 consecutive patients with sCAD, 11 (1.5%) had three, and one had four (0.1%) sCAD. Eight of these 12 patients were women. One patient had additional dissections of the celiac trunk and hepatic artery. Vascular risk factors included hypertension (n = 1), hypercholesterolaemia (n = 6), current smoking (n = 5) and migraine (n = 6). No patient had a family history of sCAD, fibromuscular dysplasia (FMD) or connective tissue disease. SCAD was preceded by a minor trauma in five and infection in four patients. Clinical manifestations included ischaemic stroke (n = 8), transient ischaemic attack (n = 3), headache (n = 9), neck pain (n = 4), Horner syndrome (n = 5), pulsatile tinnitus (n = 2) and dysgeusia (n = 1). Brain MRI revealed ischaemic infarcts that affected one vessel territory in seven and two territories in two patients. The 3-month outcome was favourable (modified Rankin scale score 0-1) in 10 patients (83%). No new recurrent stroke or sCAD occurred during a mean follow-up of 50 (SD 29) months.
Multiple sCAD occurred preferentially in women and caused clinical symptoms and signs mainly in one vascular territory. In none of the patients was FMD or any other underlying arteriopathy apparent. The majority of multiple sCAD was preceded by a minor trauma or infection. Clinical outcome was favourable in most patients, and long-term prognosis benign. The data suggest that transient vasculopathy may be a major mechanism for multiple sCAD.
Journal of neurology, neurosurgery, and psychiatry 11/2008; 80(2):171-4. · 4.87 Impact Factor
-
Neurology 11/2008; 71(18):1459. · 8.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Whether the rotational vertebral artery syndrome (RVAS), consisting of attacks of vertigo, nystagmus and tinnitus elicited by head-rotation induced compression of the dominant vertebral artery (VA), reflects ischemic dysfunction of uni- or bilateral peripheral or central vestibular structures, is still debated. We report on a patient with bilateral high-grade carotid stenoses, in whom rightward headrotation led to RVAS symptoms including a prominent nystagmus. Three-dimensional kinematic analysis of the nystagmus pattern, recorded with search coils, revealed major downbeat nystagmus with minor horizontal and torsional components. Magnetic resonance angiography demonstrated a hypoplastic right VA terminating in the posterior inferior cerebellar artery, a dominant left VA, and a hypoplastic P1-segment of the left posterior cerebral artery (PCA) that was supplied by the left posterior communicating artery (PCoA). The right PCA and both anterior inferior cerebellar arteries were supplied by the basilar artery. The right PCoA originated from the right internal carotid artery. Color duplex sonography showed severe reduction of diastolic blood flow velocities in the left VA during RVAS attacks. The nystagmus pattern can be best explained by vectorial addition of 3D sensitivity vectors of stimulated right and left anterior and horizontal semicircular canals with slightly stronger stimulation on the left side. We hypothesize that in RVAS, compression of dominant VA leads to acute vertebrobasilar insufficiency with bilateral, but asymmetric ischemia of the superior labyrinth. With regard to RVAS etiology, our case illustrates a type of pure vascular RVAS. Severity of attacks markedly decreased after successful bilateral carotid endarterectomy.
Journal of Neurology 06/2008; 255(5):663-7. · 3.47 Impact Factor
