Equipoise among recanalization strategies.

Modern acute ischemic stroke therapy is based on the premise that recanalization and subsequent reperfusion are essential for the preservation of brain tissue and favorable clinical outcomes. We outline key issues that we think underlie equipoise regarding the comparative clinical efficacy of IV recombinant tissue-type plasminogen activator (rt-PA) and intra-arterial (IA) reperfusion therapies for acute ischemic stroke. On the one hand, IV rt-PA therapy has the benefit of speed with presumed lower rates of recanalization of large artery occlusions as compared to IA methods.

Acute corticospinal tract Wallerian degeneration is associated with stroke outcome.

Background And Purpose: In children with stroke, poor motor outcome is associated with early Wallerian degeneration of the corticospinal tract that is seen on diffusion-weighted MRI. In this study we test the hypothesis that early diffusion changes also occur in the corticospinal tract (CST) of adults after stroke and that these lesions are associated with poor outcome.

Methods: In this retrospective study, we assessed images from a serial MRI study of adults with acute middle cerebral/internal carotid artery stroke.

Relative energy index of microembolic signal can predict malignant microemboli.

Background And Purpose: Microembolic signals (MES) found on transcranial Doppler range from harmless air bubbles to large, solid, particulate emboli from the heart and large vessels. The presence of MES is not always associated with poor clinical outcome. The purpose of our study was to determine whether the relative energy index of MES measured by power M-mode Doppler can distinguish malignant from benign MES and to identify patients with worse prognosis.

Reliability of measuring lesion volumes in transient ischemic attack and minor stroke.

Background And Purpose: Lesion volume measurements in disabling ischemic stroke have excellent reliability, but it is not clear whether this is also true for small lesions. We assessed the reliability of measuring baseline and follow-up lesion volumes in transient ischemic attack and minor stroke.

Methods: Patients who presented with a transient ischemic attack or minor stroke (NIHSS < or = 3) who had brain MRI within 24 hours from symptom onset and at 30-day follow-up and had an acute lesion on baseline MRI were included.

Treatment of stroke after carotid endarterectomy using intravenous abciximab.

A 59-year old man developed perioperative stroke following left carotid endarterectomy seconday to thrombosis at the endarterectomy site. Transcranial Doppler ultrasonography revealed very frequent microembolization in the left middle cerebral artery territory. The patient was successfully treated with intravenous abciximab with complete neurological recovery.

Does intravenous rtPA benefit patients in the absence of CT angiographically visible intracranial occlusion?

Background: In patients with acute stroke receiving intravenous tissue plasminogen activator (tPA), we postulated that the presence of intracranial occlusion on CT angiography (CTA) modifies the benefit of thrombolysis.

Materials And Methods: Using a retrospective cohort design, we identified patients with acute ischemic stroke in our CTA database between May 2002 and August 2007. All the patients had a CTA within 12 h of onset, a premorbid modified Rankin scale (mRS) < or = 1, and a baseline National Institute of Health Stroke Scale score(NIHSS)f > or = 6.

Improving outcomes of neuroprotection by minocycline: guides from cell culture and intracerebral hemorrhage in mice.

Minocycline ameliorates deficits in models of acute and chronic neurological diseases, but many publications do not replicate these results. We tested the hypothesis that a key factor in achieving neurological benefits is the exposure of neural cells to local high concentrations of minocycline. This hypothesis was evaluated by using human neurons in culture and in a mouse model of intracerebral hemorrhage (ICH).

Atlas-based topographical scoring for magnetic resonance imaging of acute stroke.

Background And Purpose: The Alberta Stroke Program Early CT Score (ASPECTS), a 10-point scale, is a clinical tool for assessment of early ischemic changes after stroke based on the location and extent of a visible stroke lesion. It has been extended for use with MR diffusion-weighted imaging. The purpose of this work was to automate a MR topographical score (MR-TS) using a digital atlas to develop an objective tool for large-scale analyses and possibly reduce interrater variability and slice orientation differences.

Computed tomography and computed tomography angiography findings predict functional impairment in patients with minor stroke and transient ischaemic attack.

Introduction: Abnormalities on acute magnetic resonance imaging predict outcome in minor stroke and transient ischaemic attack patients. We hypothesised that noncontrast computed tomography and computed tomography angiography findings in minor stroke and transient ischaemic attack patients would also predict functional outcome.

Methods: We analysed consecutive patients with a transient ischaemic attack or a minor stroke with an National Institute of Health Stroke Scale View Article and Find Full Text PDF

A combined power m-mode and single gate transcranial doppler ultrasound microemboli signal criteria for improving emboli detection and reliability.

Background And Purpose: Single gate transcranial Doppler spectrogram (sgTCD) has a high variability in the detection of microembolic signals (MES), Adding Power M-mode Doppler (PMD) information may improve MES detection. Our study's aim is to derive combined PMD/sgTCD microemboli criteria to overcome this limitation.

Methods: Patients with symptomatic carotid disease were prospectively enrolled within 24 h of symptom onset underwent 1 hour TCD emboli monitoring.

Ancrod in acute ischemic stroke: results of 500 subjects beginning treatment within 6 hours of stroke onset in the ancrod stroke program.

Background And Purpose: Previous studies of multiple-day dosing with the defibrinogenating agent, ancrod, in acute ischemic stroke yielded conflicting results but suggested that a brief dosing regimen might improve efficacy and safety. The Ancrod Stroke Program was designed to test this concept in subjects beginning ancrod or placebo within 6 hours of the onset of acute ischemic stroke.

Methods: Five hundred subjects with acute ischemic stroke who could begin receiving study material within 6 hours of symptom onset were infused intravenously with either ancrod (0.

The Alberta Stroke Program Early CT Score in clinical practice: what have we learned?

The introduction of brain imaging with computed tomography revolutionised the treatment of patients with acute ischaemic stroke. With the visual differentiation of haemorrhagic stroke from ischaemic stroke, thrombolytic therapy became feasible. The Alberta Stroke Program Early CT Score was devised to quantify the extent of early ischaemic changes in the middle cerebral artery territory on noncontrast computed tomography.

Defining the CT angiography 'spot sign' in primary intracerebral hemorrhage.

Purpose: The computed tomogram angiography (CTA) 'spot sign' describes foci of intralesional enhancement associated with hematoma expansion in primary intracerebral hemorrhage patients. A consistent radiological definition is required for two proposed recombinant Factor VIIa trials planning patient dichotomization according to 'spot sign' presence or absence. We propose radiological criteria for diagnosis of the CTA 'spot sign' and describe different morphological patterns.

Do all age groups benefit from organized inpatient stroke care?

Background And Purpose: Organized inpatient stroke care consists of a multidisciplinary approach aimed at improving stroke outcomes. It is unclear whether elderly individuals benefit from these interventions to the same extent as younger patients. We sought to determine whether the reduction in mortality or institutionalization seen with organized stroke care was similar across all age groups.

CT angiography source images predict final infarct extent in patients with basilar artery occlusion.

Background And Purpose: The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) is a 10-point grading system to quantify ischemic changes in the posterior circulation. We analyzed whether pc-ASPECTS on CT angiography (CTA) source images (CTASI) predicted the final infarct extent and hemorrhagic transformation (HT) rate in patients with basilar artery occlusion.

Materials And Methods: A pc-ASPECTS score of 10 indicates absence of visible ischemic changes in the posterior circulation, and pc-ASPECTS score of 0 indicates ischemic changes in the midbrain, pons, and bilateral thalami, posterior circulation territories, and cerebellar hemispheres.

Factors associated with intracerebral hemorrhage after thrombolytic therapy for ischemic stroke: pooled analysis of placebo data from the Stroke-Acute Ischemic NXY Treatment (SAINT) I and SAINT II Trials.

Background And Purpose: A number of factors have been associated with postthrombolysis intracerebral hemorrhage, but these have varied across studies.

Methods: We examined patients with acute ischemic stroke treated with intravenous tissue plasminogen activator within 3 hours of symptom onset who were enrolled in the placebo arms of 2 trials (Stroke-Acute Ischemic NXY Treatment [SAINT] I and II Trials) of a putative neuroprotectant. Early CT changes were graded using the Alberta Stroke Program Early CT Score (ASPECTS).

Normal magnetic resonance perfusion-weighted imaging in lacunar infarcts predicts a low risk of early deterioration.

Background: Current clinical tools to identify lacunar infarct patients at risk of deterioration are inadequate, and imaging techniques to predict fluctuation and deterioration would be of value. We sought to determine the occurrence of MRI perfusion-weighted imaging (PWI) abnormalities in lacunes, and whether they help predict clinical and radiological outcome.

Methods: Patients with lacunar stroke or TIA were selected from a prospective MR imaging study.

Relative importance of proteinase-activated receptor-1 versus matrix metalloproteinases in intracerebral hemorrhage-mediated neurotoxicity in mice.

Background And Purpose: To reduce bleeding and damage to central nervous system tissue in intracerebral hemorrhage, the coagulant effect of thrombin is essential. However, thrombin itself can kill neurons in intracerebral hemorrhage as can the matrix metalloproteinases (MMPs), which are also elevated in this condition, in part due to thrombin-mediated activation of MMPs. It is thus important to understand and block the neurotoxic effects of thrombin without inhibiting its therapeutic outcomes.

Hyperfibrinogenemia and functional outcome from acute ischemic stroke.

Background And Purpose: Epidemiological studies have found strong correlations between elevated plasma fibrinogen levels and both ischemic stroke incidence and stroke mortality. Little is known about the influence of fibrinogen levels on functional stroke outcome.

Methods: Placebo data from the Stroke Treatment with Ancrod Trial (STAT) and European Stroke Treatment with Ancrod Trial (ESTAT) were analyzed.

Postcontrast CT extravasation is associated with hematoma expansion in CTA spot negative patients.

Background And Purpose: The purpose of this study was to assess the effect of postcontrast CT (PCCT) leakage (PCL) on hematoma growth in CTA spot negative patients.

Methods: A retrospective study of 61 patients presenting within 6 hours of primary ICH onset imaged with CT angiography (CTA) and PCCT. Presence of CTA spot sign and PCL were documented.

Recombinant factor VIIa plus surgery for intracerebral hemorrhage.

Background: Hyperacute surgical evacuation of intracerebral hemorrhage is associated with a high rebleeding rate. The peri-operative administration of rFVIIa to patients with intracerebral hemorrhage may decrease the frequency of post-operative hemorrhage, and improve outcome.

Methods: Patients receiving recombinant activated factor VII (rFVIIA) therapy immediately prior to acute surgery were collected at two centres.

CT angiography clot burden score and collateral score: correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct.

Background And Purpose: Clot extent, location, and collateral integrity are important determinants of outcome in acute stroke. We hypothesized that a novel clot burden score (CBS) and collateral score (CS) are important determinants of clinical and radiologic outcomes and serve as useful additional stroke outcome predictors.

Materials And Methods: One hundred twenty-one patients with anterior circulation infarct presenting within 3 hours of stroke onset were reviewed.