RESUMEN
BACKGROUND AND PURPOSE: Complications of intravenous (IV) thrombolysis with tissue plasminogen activator (t-PA) for acute stroke are commonly related to hemorrhage, anaphylaxis, or arterial re-occlusion. Embolic complications of t-PA are beginning to be recognized with increased use of t-PA for acute ischemic stroke. We hypothesize that disruption of intra-cardiac thrombus may result in myocardial infarction (MI) after use of t-PA for acute ischemic stroke. SUMMARY OF CASES: We describe three cases of acute MI immediately following IV t-PA infusion for acute stroke. In patient #1 apical thrombus was visualized on cardiac echocardiogram accounting for the MI after t-PA for acute stroke. Patient #2 had fresh thrombus seen on cardiac catherization after use of t-PA for acute stroke. Patient #3 developed a significant troponin rise 15 hours after the t-PA for stroke infusion with an echocardiogram revealing new wall motion abnormalities. Patient # 1 and #2 died secondary to multi-organ failure. DISCUSSION: Acute MI immediately following t-PA treatment for stroke is a rare but serious complication. The disruption of intra-cardiac thrombus and subsequent embolization to the coronary arteries may be an important mechanism in the development of MI after t-PA treatment for acute ischemic stroke.
Asunto(s)
Fibrinolíticos/efectos adversos , Infarto del Miocardio/inducido químicamente , Accidente Cerebrovascular/tratamiento farmacológico , Activador de Tejido Plasminógeno/efectos adversos , Anciano , Anciano de 80 o más Años , Trombosis Coronaria/complicaciones , Femenino , Humanos , Persona de Mediana Edad , Accidente Cerebrovascular/complicaciones , Trombosis/patologíaRESUMEN
BACKGROUND: In Primary Angiitis of the Central Nervous System (PACNS), disease is typically limited to the brain and spinal cord although other organs may be affected. Uveitis is occasionally seen in systemic vasculitides but is not a recognized manifestation of PACNS. We describe two patients who developed PACNS following the onset of uveitis. CASE DESCRIPTIONS: Case 1--a 47-year-old male suffered multiple TIAs and left pontine stroke shortly after two episodes of diffuse uveitis. A cerbral angiogram demonstrated multiple caliber changes within several intracranial vessels. Cyclophosphamide was added after his stroke occurred during pulse methylprednisolone therapy. Case 2--a 35-year-old male suffered a spinal cord TIA followed by hemispheric and brainstem infarctions two months after an episode of uveitis and Bell's palsy treated with oral prednisone. A cerebral angiogram demonstrated multiple caliber changes within several intracranial vessels. He was successfully treated with oral prednisone and cyclophosphamide. CONCLUSIONS: Uveitis should be considered a recognized feature of PACNS. Combination immunosuppressive therapy with prednisone and cyclophosphamide may be necessary for successful treatment.
Asunto(s)
Arterias Cerebrales/patología , Ataque Isquémico Transitorio/etiología , Accidente Cerebrovascular/etiología , Uveítis/etiología , Vasculitis del Sistema Nervioso Central/complicaciones , Adulto , Infartos del Tronco Encefálico/tratamiento farmacológico , Infartos del Tronco Encefálico/etiología , Infartos del Tronco Encefálico/fisiopatología , Angiografía Cerebral , Arterias Cerebrales/diagnóstico por imagen , Arterias Cerebrales/fisiopatología , Infarto Cerebral/tratamiento farmacológico , Infarto Cerebral/etiología , Infarto Cerebral/fisiopatología , Ciclofosfamida/uso terapéutico , Humanos , Inmunosupresores/uso terapéutico , Ataque Isquémico Transitorio/tratamiento farmacológico , Ataque Isquémico Transitorio/fisiopatología , Masculino , Persona de Mediana Edad , Isquemia de la Médula Espinal/tratamiento farmacológico , Isquemia de la Médula Espinal/etiología , Isquemia de la Médula Espinal/fisiopatología , Esteroides/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/fisiopatología , Resultado del Tratamiento , Uveítis/tratamiento farmacológico , Uveítis/fisiopatología , Vasculitis del Sistema Nervioso Central/tratamiento farmacológico , Vasculitis del Sistema Nervioso Central/fisiopatologíaRESUMEN
OBJECTIVE: To determine the effectiveness of an Acute Stroke Triage Pathway in reducing door to needle times in acute stroke treatment with IV t-PA. BACKGROUND: A previous study at our tertiary referral centre, examining IV t-PA door to needle times, was completed in 2000. The median door to needle time was beyond the recommended National Institute for Neurological Disorders and Stroke (NINDS) standard of 60 minutes. In November 2001, an Acute Stroke Triage Pathway was introduced in the emergency room (ER) to address this issue. The goal of this pathway was to rapidly identify patients eligible for treatment for IV t-PA, so that CT scans and lab studies could be arranged immediately upon ER arrival. Our hypothesis was that the Triage Pathway would shorten door to CT and door to needle times. DESIGN/METHODS: Using retrospective data, pre (n=87) and post (n=47) triage pathway times were compared. The door to CT time was reduced by 11 minutes (p=0.015) and door to needle time was reduced by 18 minutes (p=0.0036) in a subgroup of patients that presented directly to our hospital. CONCLUSIONS: These results indicate that the Acute Stroke Triage Pathway is effective in reducing Door to CT and Door to Needle Times in patients presenting directly to our ER. However, a majority of treatment times were still beyond NINDS recommendations. Stroke Centers require periodic review of their efficiency to ensure that target times are being obtained and may benefit from the use of an Acute Stroke Triage Pathway.
Asunto(s)
Eficiencia Organizacional/normas , Servicio de Urgencia en Hospital/normas , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Triaje/normas , Enfermedad Aguda/terapia , Atención a la Salud/normas , Atención a la Salud/estadística & datos numéricos , Atención a la Salud/tendencias , Diagnóstico Precoz , Eficiencia Organizacional/estadística & datos numéricos , Eficiencia Organizacional/tendencias , Servicio de Urgencia en Hospital/estadística & datos numéricos , Servicio de Urgencia en Hospital/tendencias , Humanos , Estudios Retrospectivos , Factores de Tiempo , Tomografía Computarizada por Rayos X/normas , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Tomografía Computarizada por Rayos X/tendencias , Triaje/estadística & datos numéricos , Triaje/tendenciasRESUMEN
BACKGROUND AND PURPOSE: In the United States, tissue plasminogen activator (tPA) was approved for treatment of acute ischemic stroke in 1996. Its use has only recently been approved in Canada. We sought to evaluate the safety, feasibility, and efficacy of treatment in a Canadian hospital setting. METHODS: A combined retrospective and prospective review is presented of 46 consecutive patients treated with intravenous tPA at our hospital with a treatment protocol similar to that of the National Institute of Neurological Disorders and Stroke (NINDS) trial. RESULTS: Symptomatic intracranial hemorrhage at 36 hours occurred in 1 patient (2.2%). The median time to treat was 165 minutes, with a median "door-to-needle" time of 84 minutes. Compared with patients presenting initially at our hospital, patients transferred from another institution for tPA therapy were treated closer to the 3-hour time window (mean 173 versus 148 minutes, P:<0.001) but had a shorter door-to-needle time (43 versus 102 minutes, P:<0.001). For every 10 minutes closer to the 3-hour time window that any patient arrived at the hospital, 7 minutes was saved in the door-to-needle time (correlation coefficient 0.9, P:<0.001). Patient outcome did not differ from that in the NINDS trial (P:>0.75). CONCLUSIONS: Our safety and patient outcome data compare favorably with NINDS and Phase IV data. Although a 3-hour treatment window was feasible, the median door-to-needle time lengthened as more treatment time was available and the door-to-needle time was beyond recommended standards. This review has prompted changes in our community to improve treatment efficiency.
Asunto(s)
Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Enfermedad Aguda , Adulto , Anciano , Encéfalo/diagnóstico por imagen , Canadá , Infarto Cerebral/diagnóstico por imagen , Infarto Cerebral/tratamiento farmacológico , Femenino , Fibrinolíticos/administración & dosificación , Humanos , Inyecciones Intravenosas , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico por imagen , Factores de Tiempo , Activador de Tejido Plasminógeno/administración & dosificación , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Resultado del TratamientoRESUMEN
The purpose of this study was to determine the efficacy of intraoperative intraarterial urokinase (UK) in patients who suffered an acute stroke immediately following carotid endarterectomy (CEA). From January 1995 to March 1998, 823 carotid endarterectomies were performed. The subsequent results showed that intraarterial UK in the setting of early post-CEA neurologic events appears to be safe and may be a useful adjunct to re-exploration in improving neurologic outcomes.
Asunto(s)
Endarterectomía Carotidea/efectos adversos , Activadores Plasminogénicos/administración & dosificación , Accidente Cerebrovascular/cirugía , Terapia Trombolítica , Activador de Plasminógeno de Tipo Uroquinasa/administración & dosificación , Anciano , Arteria Carótida Interna , Terapia Combinada , Femenino , Humanos , Infusiones Intraarteriales , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/etiologíaRESUMEN
PURPOSE: The North American Symptomatic Carotid Endarterectomy Trial (NASCET) showed that selected patients benefited from surgery when their carotid artery was 50% or more stenosed. This study assessed the accuracy of color-flow duplex ultrasound scanning (DUS) parameters to detect 50% or greater carotid artery stenosis and to determine the situations in which carotid endarterectomy (CEA) without angiography could be justified. METHODS: From March 1, 1995, to December 1, 1995, all patients considered for CEA were studied with DUS and carotid angiography. Results of the two tests were blindly compared. DUS measurements of internal carotid artery (ICA) peak systolic velocity (PSV), end diastolic velocity, and ratio of the ICA to common carotid artery PSV (ICA/CCA) were subjected to receiver operator characteristic curve analysis to determine the most accurate criterion predicting 50% or greater angiographic stenosis. The criterion for identifying patients for CEA without angiography was selected from criteria with a high positive predictive value (PPV) and sensitivity. RESULTS: A total of 188 carotid bifurcations were available for comparison. A PSV (ICA/CCA) of 2 or higher was the most accurate criterion for detection of 50% or greater stenosis, with an accuracy rate of 93% (sensitivity, 96%; specificity, 89%; PPV, 92%). A PSV (ICA/CCA) of 3.6 or higher was the best criterion for identifying candidates for CEA who had not undergone earlier angiography, with PPV, sensitivity, specificity, and accuracy rates of 98%, 77%, 98%, and 86%, respectively. CONCLUSION: These redefined criteria detect the NASCET-defined threshold level of 50% or greater ICA stenosis, above which CEA results in stroke reduction. A management algorithm based on these criteria should help to minimize both angiography and unnecessary intervention.
Asunto(s)
Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/normas , Ultrasonografía Doppler en Color/normas , Algoritmos , Angiografía , Velocidad del Flujo Sanguíneo , Estenosis Carotídea/fisiopatología , Diagnóstico Diferencial , Humanos , Curva ROC , Sensibilidad y Especificidad , Sístole , Estados UnidosRESUMEN
A 54 year-old man had symptoms of acute right hemispheric cerebral ischemia. He was initially considered for participation in a trial of early thrombolysis in stroke, but an innominate artery embolus was found with no apparent arterial source. The embolus was removed by means of a combined brachial and carotid bifurcation approach to protect the cerebral vasculature from embolic fragmentation during extraction. Further investigation revealed deep venous thrombosis, evidence of pulmonary emboli, and a patent foramen ovale, supporting a diagnosis of paradoxic embolus. Additional treatment included anticoagulation and placement of an inferior vena caval filter. The unusual condition of paradoxic embolus is reviewed, and the management of this patient is discussed.
Asunto(s)
Tronco Braquiocefálico , Embolectomía , Embolia Paradójica/cirugía , Tronco Braquiocefálico/diagnóstico por imagen , Embolectomía/métodos , Embolia Paradójica/diagnóstico por imagen , Humanos , Embolia y Trombosis Intracraneal/complicaciones , Embolia y Trombosis Intracraneal/diagnóstico por imagen , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Radiografía , Trombosis/complicacionesRESUMEN
This study prospectively compared the accuracy of published duplex ultrasonographic criteria for 70%-99% internal carotid artery (ICA) stenosis according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method to determine angiographic stenosis. From March 1, 1995 to December 1, 1995, all patients considered for carotid endarterectomy (CEA) were studied with carotid duplex ultrasound and carotid angiography within 1 month of the ultrasound study. Duplex measurements of ICA peak systolic velocity (PSV), end diastolic velocity (EDV), and ratio of the ICA to common carotid artery (CCA) PSVs were recorded. Degree of stenosis on angiography was determined using NASCET criteria. A MEDLINE search to identify duplex ultrasound criteria to predict NASCET defined 70%-99% ICA stenosis was carried out. In addition, the original University of Washington criteria for critical stenosis (> or = 80%) was also examined. The accuracy of these criteria was determined with angiographic results and the positive predictive value (PPV) of each criterion were compared. Ninety-nine patients with 185 carotid bifurcations were available for comparison. The different duplex criteria for determining NASCET defined 70%-99% ICA stenosis were: ICA PSV > 175 cm/sec or PSV < 40 cm/sec, PSV > 230 cm/sec, ratio of ICA to CCA PSVs > 4, PSV > 130 cm/sec plus EDV > 100 cm/sec, and PSV > 270 cm/sec plus EDV > 110 cm/sec. When compared with angiography, the calculated PPVs for these criteria were 71% (73/103), 81% (71/88), 86% (67/78), 88% (62/70), and 90% (57/63), respectively. The University of Washington criteria for critical stenosis (PSV > 125 cm/sec plus EDV > 135 cm/sec) had the highest PPV at 91.6% (55/60). The University of Washington criteria for critical stenosis had the highest PPV to predict a 70%-99% angiographic stenosis.
Asunto(s)
Estenosis Carotídea/diagnóstico por imagen , Ultrasonografía Doppler Dúplex , Velocidad del Flujo Sanguíneo/fisiología , Arteria Carótida Interna/diagnóstico por imagen , Estenosis Carotídea/clasificación , Estenosis Carotídea/cirugía , Diástole/fisiología , Endarterectomía Carotidea , Humanos , Sensibilidad y Especificidad , Sístole/fisiologíaRESUMEN
The purpose of this study was to identify whether EEG is an adequate method of monitoring cerebral perfusion during carotid endarterectomy and of determining the need for use of an indwelling shunt. A retrospective review of 305 carotid endarterectomies comparing the results of routinely shunted patients with patients selectively shunted based on EEG monitoring, was carried out. Of the carotid endarterectomies, 92 (30%) were routinely shunted and 213 (70%) were selectively shunted. In the selectively shunted group, 34 (16%) subsequently required shunting. The major stroke rate in the routinely shunted group was 4.4% ((4) cases) and in the selectively shunted group was 0.5% ((1) stroke). Three of the four major strokes in the routinely shunted group were embolic in origin and one was caused by acute thrombosis. The only major stroke in the selectively shunted group was from intracerebral hemorrhage. In conclusion EEG monitoring is a safe and reliable method to determine the need for shunting during carotid endarterectomy. Routine non-selective use of a shunt may increase the risk of perioperative stroke from arterial injury and associated thromboembolism.
Asunto(s)
Electroencefalografía , Endarterectomía Carotidea , Monitoreo Intraoperatorio/métodos , Anciano , Estudios de Casos y Controles , Circulación Cerebrovascular , Trastornos Cerebrovasculares/epidemiología , Trastornos Cerebrovasculares/prevención & control , Femenino , Humanos , Cuidados Intraoperatorios/métodos , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Estudios RetrospectivosRESUMEN
OBJECTIVES: This study investigated the reliability of carotid duplex ultrasound (DUS) to identify appropriate candidates for carotid endarterectomy (CEA) according to a panel of vascular specialists. DESIGN: Prospective study. MATERIAL: 102 patients with 145 carotid bifurcation stenosis or occlusions. METHODS: All patients who required a carotid angiogram were evaluated using DUS followed by carotid angiography. A blinded panel of four vascular specialists individually decided whether CEA would be appropriate for each patient based on pre-angiographic information. Angiograms were then shown to panelists to see if their management decision was altered by the angiogram. RESULTS: For stenosis > or = 80% on DUS (n = 60), panelists unanimously agreed on CEA without angiography in 57 lesions. In 50 lesions (87.7%), angiography showed > or = 70% stenosis and the management plan remained unchanged. For the other seven lesions, intracranial aneurysms (n = 2), tandem intracranial lesion (n = 1), unsuspected proximal common carotid lesion (n = 1), a 40% stenotic lesion (n = 1), and high carotid bifurcations (n = 2) were seen. In lesions with 50-79% stenosis on DUS (n = 66), none of the panelists recommended CEA without prior angiography. Eighteen (27%) of these lesions were > or = 70% stenosed on angiogram. Complications of angiograms included one stroke, one haematoma, and one severe allergic reaction. CONCLUSION: Carotid duplex ultrasonography without angiography can reliably select lesions appropriate for surgery only when critical stenosis > or = 80% is chosen. Routine angiography is recommended for carotid stenosis of 50-79% when CEA is considered.
Asunto(s)
Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Angiografía Cerebral , Humanos , Selección de Paciente , Estudios Prospectivos , Reproducibilidad de los Resultados , UltrasonografíaRESUMEN
Downbeat nystagmus (DBN) uncommonly occurs as a transient phenomenon, and it rarely occurs in patients with cerebrovascular disease. We observed a patient with intermittent DBN and lightheadedness due to transient obstruction of his dominant vertebral artery when he turned his head to his left side. Surgical removal of an osteophyte at the site of the angiographically demonstrated lesion relieved his symptoms.
Asunto(s)
Vértebras Cervicales , Nistagmo Patológico/etiología , Osteofitosis Vertebral/complicaciones , Insuficiencia Vertebrobasilar/complicaciones , Vértebras Cervicales/diagnóstico por imagen , Constricción Patológica/etiología , Humanos , Masculino , Persona de Mediana Edad , Osteofitosis Vertebral/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Insuficiencia Vertebrobasilar/diagnóstico por imagenRESUMEN
We report 10 patients with severe occlusive disease of the vertebral artery (VA) origin in the neck with intra-arterial embolism to the posterior circulation. The VA lesions in seven patients were complete occlusions, and three patients had severe atherostenosis. All patients had strokes in the vertebrobasilar territory. The most frequent recipient sites of intra-arterial embolism were the intracranial VA-posterior inferior cerebellar artery region (8), and the distal basilar artery (BA) and its superior cerebellar and posterior cerebral artery branches (7). Two patients had pontine infarction due to BA embolism. The most common clinical signs were due to cerebellar infarction. Atherosclerotic disease of the VA origin has features in common with disease of the internal carotid artery origin. Both have similar risk factors and demography, and each can cause strokes by intracranial intra-arterial embolism.
Asunto(s)
Arteriopatías Oclusivas/complicaciones , Embolia y Trombosis Intracraneal/etiología , Arteria Vertebral , Anciano , Arteriopatías Oclusivas/diagnóstico por imagen , Angiografía Cerebral , Infarto Cerebral/diagnóstico , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Ultrasonografía , Arteria Vertebral/diagnóstico por imagenRESUMEN
Hemorrhagic transformation of ischemic cerebral injury occurs commonly in embolic strokes. The incidence, timing, and clinical consequences of hemorrhagic transformation are reviewed. Hemorrhagic complications resulting from heparin therapy and results from recent preliminary thrombolytic treatment trials are discussed.