scholarly journals P.097 Subarachnoid hemorrhage associated with a thromboembolic ischemic stroke- an unexpected observation

2018 ◽  
Vol 45 (s2) ◽  
pp. S42-S42
Author(s):  
A Almutlaq ◽  
S Alhusaini ◽  
C Chalk ◽  
R Cote
Keyword(s):  
Ischemic Stroke ◽  
Subarachnoid Hemorrhage ◽  
Ct Scan ◽  
Inferior Frontal Gyrus ◽  
Brain Mri ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Ct Angiogram ◽  
External Capsule ◽  
Diagnostic Confusion

Atherosclerosis is a significant risk factor for ischemic stroke, and is a frequent cause for extra- and intra-cranial vessels stenosis. Here, we present an unusual case of ischemic stroke associated with intra-cranial vessel stenosis and subarachnoid hemorrhage (SAH) secondary to carotid artery atheroma. A 64-year old female known for hypertension and dyslipidemia presented with a three-day history of three transient episodes (< 30 minutes) of dysarthria and right hand weakness. An initial brain CT scan revealed left frontal SAH. She was admitted to our Stroke Unit for observation and management. CT-angiogram revealed 90% ICAs stenosis bilaterally with several short focal stenotic lesions, involving several left MCA branches. Brain MRI revealed acute infarcts in the left insula, external capsule and inferior frontal gyrus. The clinical picture was attributed to a thromboembolic left MCA ischemic stroke. She was managed with maximum medical therapy, and later underwent successful left carotid endarterectomy. The presence of SAH on our patient’s presenting CT scan lead to an initial radiological diagnosis of RCVS. However, subsequent imaging studies indicated that SAH had occurred in association with a thromboembolic ischemic stroke. Despite its rarity, this clinical association is important to recognize to avoid diagnostic confusion and guide appropriate management.

Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

2019 ◽  
Author(s):  
Kenneth R. Ziegler ◽  
Thomas C. Naslund
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Ct Scan ◽  
Hemorrhagic Stroke ◽  
Fibromuscular Dysplasia ◽  
The United States ◽  
Carotid Artery Dissection ◽  
Artery Dissection ◽  
Ct Angiogram ◽  
Ischemic Attack

Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis.   This review contains 8 figures, 8 tables, and 68 references. Keywords: Carotid stenosis, ischemic stroke, transient ischemic attack, endovascular therapy, thrombolysis, infarct, hemorrhagic stroke, atherosclerosis, embolism

Intravenous tissue plasminogen activator for acute ischemic stroke in patients with renal dysfunction

QJM ◽  
2020 ◽  
Author(s):  
I-K Wang ◽  
T -H Yen ◽  
C -H Chen ◽  
S -P Hsu ◽  
Y Sun ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Gastrointestinal Bleeding ◽  
Intracerebral Hemorrhage ◽  
Acute Ischemic Stroke ◽  
Renal Dysfunction ◽  
Upper Gastrointestinal Bleeding ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Intravenous Tissue Plasminogen Activator ◽  
Upper Gastrointestinal

Summary Objective This study used the Taiwan Stroke Registry data to evaluate the efficacy and safety of intravenous tissue plasminogen activator (tPA) in treating acute ischemic stroke in patients with renal dysfunction. Design We identified 3525 ischemic stroke patients and classified them into two groups according to the estimated glomerular filtration rate (eGFR) at the emergency department: ≥60, and &lt;60 ml/min/1.73 m2 or on dialysis and by the propensity score from August 2006 to May 2015. The odds ratio of poor functional outcome (modified Rankin Scale ≥2) was calculated for patients with tPA treatment (N = 705), compared to those without tPA treatment (N = 2820), by eGFR levels, at 1, 3 and 6 months after ischemic stroke. We also evaluated the risks of intracerebral hemorrhage, upper gastrointestinal bleeding, mortality, between the two groups by eGFR levels. Results Among patients with eGFR levels of &lt;60 ml/min/1.73 m2, tPA therapy reduced the odds ratio of poor functional outcome to 0.60 (95% confidence interval = 0.42–0.87) at 6 months after ischemic stroke. The tPA therapy was not associated with increased overall risk of upper gastrointestinal bleeding, but with increased risk of intracerebral hemorrhage. The low eGFR was not a significant risk factor of intracerebral hemorrhage among ischemic stroke patients receiving tPA treatment. Conclusions tPA for acute ischemic stroke could improve functional outcomes without increasing the risks of upper gastrointestinal bleeding for patients with or without renal dysfunction. The low eGFR was not a significant risk factor for intracerebral hemorrhage among patients receiving tPA treatment.

Abstract WP353: Assessing the Accuracy of ICD-10 Codes for Ruptured Intracranial Aneurysm Location

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher Roark ◽  
Sheila Kubes ◽  
David Mayer ◽  
Laura K Wiley
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Aneurysm Rupture ◽  
Administrative Database ◽  
Risk Modeling ◽  
Billing Data ◽  
Ruptured Intracranial Aneurysm ◽  
Advanced Analysis

The adoption of ICD10 in October 2015 offers important opportunities for administrative database and EHR-based aneurysm research as it includes more than twenty distinct codes for subarachnoid hemorrhage (SAH), for the first time labeling the specific location for common sites of aneurysm rupture. Aneurysm location is a significant risk factor for rupture, but was not specified in any previous ICD classification. This has limited the value of “big-data” research for aneurysm risk modeling. Currently, it is not clear how frequently - or accurately - the codes are being used in practice. This study reviewed three years of records (10/2015-9/2018) from the UCHealth system in Colorado to assess the accuracy and utility of these codes for stroke research. Over this time, ICD10 codes for SAH (I60.x) were used a total of 5,090 times in 1,842 patients. After removing non-aneurysmal SAH (I60.8), the majority (92.7%) of the codes had no location specified (I60.7, I60.9). Of the codes with a location (I60.00-I60.6), upon review of the clinical record 9 (2.5%) did not have any evidence of subarachnoid hemorrhage, 3 (0.8%) did not have an aneurysm, and 5 (1.4%) had a pseudoaneurysm. Of the 338 verified instances of aneurysmal subarachnoid hemorrhage, 82 (24%) had multiple aneurysms and were excluded from further analysis. Within those records that had only a single aneurysm 197/256 (77%) had the location coded correctly. Of the 23% that were incorrectly coded, 1 was coded as the correct artery on the wrong side, all remaining (n=58) were the wrong artery. Although ICD10 codes offers the possibility of more advanced analysis due to the inclusion of aneurysm location, based on these data, we found that codes specifying location are frequently incorrect. Future studies are needed to validate these findings in other settings. However, researchers should be cautious about their ability to detect aneurysm location from administrative billing data using ICD10 location mapping.

Abstract WP370: Cerebral Microbleeds Play an Important Role in Turning Recurrent Stroke Towards Intracranial Hemorrhage in Patients With First-ever Ischemic Stroke/Transient Ischemic Attack

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Eiichi Nomura ◽  
Yuji Shiga ◽  
Shinichi Takeshima ◽  
Makoto Takemaru ◽  
Jun Takeshita ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Transient Ischemic Attack ◽  
Recurrent Stroke ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Cerebral Microbleeds ◽  
Antithrombotic Agent ◽  
Ischemic Attack ◽  
First Admission

Background and Purpose: After ischemic stroke (IS) or transient ischemic attack (TIA), use of an antithrombotic agent to prevent recurrence is mandatory. However, antithrombotic agents rarely cause intracranial hemorrhage (ICH), frequently resulting in worse outcomes than recurrent IS. Cerebral microbleeds (CMBs) have been reported as a useful marker for finding ICH-prone patients. This retrospective study aimed to investigate the significance of CMB in the development of ICH in first-ever IS/TIA patients. Methods: The data source was our consecutive patient registry between 2005 and 2015. Patients with stroke/TIA admitted to our hospital more than twice (first as first-ever IS/TIA and second or later as recurrent IS/TIA or ICH) and underwent head MRI including T2*-weighted imaging on the first admission were extracted. Clinical characteristics including use of antithrombotic therapy and distribution of CMB on the first and second admissions were compared between recurrent IS/TIA and ICH groups. Distribution of CMB was divided into deep, lobar, or both. Results: In total, 708 IS/TIA patients (second stroke: 640 IS/TIA; 68 ICH) were extracted. The ICH group showed a longer period until second stroke (1,062 days vs. 817 days, p=0.022) and higher mean NIHSS score (14.8 vs. 6.1, p<0.001) on second admission than the IS/TIA group. On first admission, the ICH group had a higher frequency of CMB (72.1% vs. 49.5%, p<0.001) and lower frequency of cardioembolism (14.7% vs. 25.8%, p=0.044) than the IS/TIA group. About half of hemorrhages occurred in similar locations of the CMB depicted on first admission. A higher frequency of ICH was observed in patients with deep CMB (11.3% vs. 5.6%, p=0.022) or both deep and lobar CMBs (17.4% vs. 5.6%, p<0.001) than in those without CMB. Use of anticoagulants was a significant risk factor for transition from first IS/TIA to second ICH (odds ratio [95% confidence interval]: 3.75 [1.30-10.8], adjusted by sex, age, type of first stroke, and CMB location). Conclusions: This study found IS/TIA patients with CMB are at high risk of ICH compared to patients without CMB. Preventive antithrombotic treatment particularly use of anticoagulants for CI/TIA patients with CMB should be provided under careful monitoring for the risk of hemorrhage.

Evaluation of Pre–Hematopoietic Cell Transplantation (HCT) Brain MRI and Neurologic Complications of Pediatric Patients Undergoing HCT for Hematologic Malignancies

2016 ◽  
Vol 34 (1) ◽  
pp. 65-73
Author(s):  
Mara Bailey-Olson ◽  
Morton Cowan ◽  
Christopher Dvorak ◽  
Sabine Mueller ◽  
Abigail Owens ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Pediatric Patients ◽  
Brain Mri ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Hematologic Malignancies ◽  
Hematopoietic Cell ◽  
Cell Transplant ◽  
Neurologic Complications

Adverse neurologic complications (NC) occur commonly in pediatric patients with hematologic malignancies both pre- and post–allogeneic hematopoietic cell transplant (HCT). Given this known risk, we previously obtained pre-HCT brain magnetic resonance imaging (MRI) to document baseline abnormalities but utility of this and findings are not well described. This study aimed to ( a) determine the prevalence and risk factors for abnormal brain MRI and ( b) determine prevalence and risk factors for development of new NC during and 2 years post-HCT. Retrospective chart review included 102 patients with hematologic malignancies who underwent allogeneic HCT between 2000 and 2009 at University of California San Francisco (UCSF) Children’s Hospital and included standard HCT data, brain MRI reports, and NC and symptoms pre- and post-HCT. Forty-three percent of patients had abnormal findings on pre-MRI, most commonly nonspecific white matter changes. Neurologic symptoms pre-HCT was the only significant risk factor for abnormal MRI. Eleven patients (11%) developed post-HCT NC. Non-Caucasian race was the only significant risk factor for new NC. Although abnormal pre-HCT brain MRI is common, these findings are not predictive of subsequent NC post-HCT. Therefore routine surveillance may not be informative for that purpose, particularly when general anesthesia is required, which can have detrimental neurocognitive effects. Etiology of NC in pediatric HCT is likely multifactorial and may include genetic and ethnic predispositions.

Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

2020 ◽  
Author(s):  
Kenneth R. Ziegler ◽  
Thomas C. Naslund
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Ct Scan ◽  
Hemorrhagic Stroke ◽  
Fibromuscular Dysplasia ◽  
The United States ◽  
Carotid Artery Dissection ◽  
Artery Dissection ◽  
Ct Angiogram ◽  
Ischemic Attack

Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis.   This review contains 8 figures, 8 tables, and 68 references. Keywords: Carotid stenosis, ischemic stroke, transient ischemic attack, endovascular therapy, thrombolysis, infarct, hemorrhagic stroke, atherosclerosis, embolism

Abstract P103: Value of Chest Computed Tomographic Scan Added to Acute Stroke Neuroimaging Protocol for Identifying Coronavirus Disease 2019: A Critical Assessment of a Prospective Protocol

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Muhammad F Ishfaq ◽  
Sachin Bhagavan ◽  
Ammad Ishfaq ◽  
Mukaish Kumar ◽  
Shruthi Pulimamidi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Ct Scan ◽  
Chest Ct ◽  
Nasopharyngeal Swab ◽  
Stroke Patients ◽  
Computed Tomographic ◽  
Ct Angiogram ◽  
Increased Risk ◽  
Chest Ct Scan

Background: Coronavirus Disease 2019 (COVID-19) is associated with an increased risk for acute ischemic stroke but screening for COVID-19 based on clinical criteria or laboratory testing may be difficult in acute stroke evaluation. Chest computed tomographic (CT) scan may be another time-sensitive option for identification. of COVID-19 in such patients. Objective: We report our experience of incorporating chest CT scan in the initial neuroimaging protocol for evaluation of acute stroke patients. Methods: All acute stroke patients underwent chest CT scan concurrent to CT head, CT angiogram of head and neck and CT perfusion for 4 months. We identified patients who had chest CT scan findings that were suggestive of COVID-19 including bilateral, multilobar ground glass opacification with a peripheral or posterior distribution, and/or consolidation (mainly in the lower lobes). All patients subsequently underwent polymerase chain reaction (PCR) testing of nasopharyngeal swab with contact isolation until COVID-19 could be excluded. Results: A total of 224 consecutive patients (mean age 62.12 years±SD; 15.3) underwent acute stroke evaluation with a concurrent chest CT scan. The chest CT identified findings suggestive of COVID-19 in 11 (4.9%) patients. Subsequent PCR testing did not confirm the diagnosis of COVID-19 in any of the patient. Another 99 patients (44%) without any findings suggestive of COVID-19 on chest CT scan underwent PCR testing. PCR testing did not confirm the diagnosis of COVID-19 in any of the patients. Four patients (4.3%) with chest CT scan findings suggestive of COVID-19 were found to have an ischemic stroke while 7 patients (5.9%) with chest CT scan findings suggestive of COVID-19 did not have any ischemic stroke (stroke mimic). Conclusions: We found a very low yield for identifying COVID-19 in acute stroke patients by performing chest CT scan concurrent to standard acute stroke neuroimaging protocol.

Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

2020 ◽  
Author(s):  
Kenneth R. Ziegler ◽  
Thomas C. Naslund
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Ct Scan ◽  
Hemorrhagic Stroke ◽  
Fibromuscular Dysplasia ◽  
The United States ◽  
Carotid Artery Dissection ◽  
Artery Dissection ◽  
Ct Angiogram ◽  
Ischemic Attack

Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis.   This review contains 8 figures, 8 tables, and 68 references. Keywords: Carotid stenosis, ischemic stroke, transient ischemic attack, endovascular therapy, thrombolysis, infarct, hemorrhagic stroke, atherosclerosis, embolism

scholarly journals Prevalence of and risk factors for cerebral microbleeds in a general Japanese elderly community

2018 ◽  
Vol 8 (3) ◽  
pp. 223-231 ◽  
Author(s):  
Tomohiro Yubi ◽  
Jun Hata ◽  
Tomoyuki Ohara ◽  
Naoko Mukai ◽  
Yoichiro Hirakawa ◽  
...  
Keyword(s):  
Risk Factors ◽  
Brain Mri ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Cross Sectional Study ◽  
Cerebral Microbleeds ◽  
Health Examination ◽  
Cross Sectional ◽  
Comprehensive Health ◽  
Japanese Elderly

BackgroundWe investigated the prevalence of and risk factors for cerebral microbleeds (CMBs) in a cross-sectional study of a general population of Japanese elderly.MethodsIn 2012, brain MRI scanning at 1.5T and comprehensive health examination were conducted for 1281 residents aged 65 years or older. CMBs were defined as ovoid hypointensity lesions less than 10 mm in diameter on T2*-weighted images and classified into deep/infratentorial or lobar CMBs. Age- and sex-specific and overall prevalence of CMBs were estimated, and the associations of traditional cardiovascular risk factors and APOE polymorphism with the presence of CMBs were examined using a logistic regression analysis.ResultsThe crude prevalences of total, deep/infratentorial, and lobar CMBs were 18.7% (n = 240), 13.5% (n = 173), and 9.6% (n = 123), respectively. The prevalence of total CMBs was 23.0% in men and 15.5% in women and increased with aging in both sexes (both p for trend <0.01). Hypertension was significantly associated with the presence of both deep/infratentorial and lobar CMBs. Lower serum total cholesterol was a significant risk factor for deep/infratentorial CMBs, but not for lobar CMBs, while APOE ε4 carriers had a significantly higher likelihood only of lobar CMBs compared with noncarriers.ConclusionsOur study suggests that approximately 1 of 5 Japanese elderly people have CMBs, and that risk factors for deep/infratentorial and lobar CMBs are different, indicating the distinct pathologic backgrounds of these lesions.

scholarly journals Mechanical Thrombectomy and Stenting for Radiation-Induced Carotid Stenosis-Related Stroke: A Case Report

2020 ◽  
Vol 12 (Suppl. 1) ◽  
pp. 70-75
Author(s):  
Yu-Chen Cheng ◽  
Wei-Cheng Lin ◽  
Chia-Nan Lin ◽  
Hou-Chang Chiu
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Carotid Stenosis ◽  
Mechanical Thrombectomy ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Large Vessel ◽  
Total Occlusion ◽  
Ischemic Change ◽  
Radiation Induced

Radiation-induced stenosis of the carotid artery is a significant risk factor for large-vessel ischemic stroke, which usually leads to significant impairment of neurological function. We performed intra-arterial thrombectomy on a 63-year-old male patient who had laryngeal cancer and postradiation carotid stenosis. He presented with acute-onset dysarthria and left hemiplegia. Brain computed tomography perfusion scan showed right middle cerebral artery ischemic change. Angiography confirmed total occlusion of the right internal carotid artery. Intra-arterial mechanical thrombectomy with carotid stenting was performed immediately, and recanalization was achieved. The patient fully recovered and was discharged after a 1-week hospitalization. Our experience suggests that early intervention for radiation-related carotid stenosis might be essential and beneficial for the outcome of large-vessel ischemic stroke.

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