Upper airway obstruction with bilateral vocal cord paralysis secondary to ischemic stroke: report of two cases]

We present herein two patients with bilateral vocal cord paralysis that occurred during the subacute phase of brain infarction. Patients were a 73-year-old man and an 82-year-old woman who suffered from infarction of the basilar artery and the right middle cerebral artery, respectively. The former was diagnosed as atherothrombotic infarction, but the patient experienced repeated aggravation. The latter was diagnosed as cardioembolic infarction. After both patients took clopidogrel and warfarin for the secondary prevention of stroke, upper airway obstruction developed at Day 29 and Day 19, respectively. Vocal cords in Case 1 did not show any movement on laryngoscopy, and were fixed together nearly closed. In Case 2, vocal cords were again almost fixed together. Bilateral vocal cord paralysis is a common complication of cervical operations, but is rare after ischemic stroke. As patients who have suffered from bilateral vocal cord paralysis are often facing death, we must be careful of wheezing with ischemic stroke.     

Hemorrhage after an acute ischemic stroke.MAST-I Collaborative Group

BACKGROUND AND PURPOSE: Hemorrhagic transformation is frequently seen on CT scans obtained in the subacute phase of ischemic stroke. Its prognostic value is controversial. METHODS: We analyzed 554 patients with acute ischemic stroke enrolled in the Multicenter Acute Stroke Trial-Italy (MAST-I) study in whom a second CT scan was performed on day 5. Presence of 1) intraparenchymal hemorrhages (hematoma or hemorrhagic infarction), 2) extraparenchymal bleeding (intraventricular or subarachnoid) and 3) cerebral edema (shift of midline structure, sulcal effacement or ventricular compression) alone or in association were evaluated. Death or disability at 6 months were considered as "unfavorable outcome." RESULTS: Patients who developed intraparenchymal hemorrhages, extraparenchymal bleeding, or cerebral edema had unfavorable outcome (83%, 100%, and 80%, respectively), but multivariate analysis demonstrated that only extraparenchymal bleeding (collinearity) and cerebral edema (OR=6.8; 95% CI, 4.5 to 10.4) were significant independent prognostic findings. Unfavorable outcome correlated with size of intraparenchymal hemorrhage (chi2 for trend=30.5, P<0.0001). Nevertheless, when a large hematoma was present the negative effect was mostly due to concomitant extraparenchymal bleeding (chi2=51.6, P<0.0001), and when hemorrhagic infarction was detected the negative effect was mostly explained by the association with cerebral edema (chi2=36.6, P<0.0001). CONCLUSIONS: Extraparenchymal bleeding and cerebral edema are the main prognostic CT scan findings in the subacute phase of ischemic stroke. Stroke patients with a high risk for developing these 2 types of brain damage should be identified. Measures to prevent and adequately treat their development should be implemented.     

Decompressive hemicraniectomy in a 2-year-old girl with a left middle cerebral artery infarct

Introduction We report on the case of a 2-year 5-month-old girl with congenital heart disease who developed left middle cerebral artery occlusion and cerebral hemorrhagic infarction a day after ventricular septal defect patch closure.Results Cranial computed tomography scan revealed an acute hemorrhagic infarct over the left middle cerebral artery territory with midline shift to the right. Since medical treatment failed, decompressive hemicraniectomy with duraplasty was performed, successfully reversing herniation. Decompressive surgery allows extracranial expansion of the swollen brain and relieves CSF space compression. We believe this to be the youngest reported patient to undergo decompressive hemicraniectomy for middle cerebral artery territory infarction. Although the patient survived, her functional outcome was poor.Conclusion Decompressive hemicraniectomy can be lifesaving and should be considered as an alternative therapy for patients with brain swelling refractory to medical management.     

Early CCT signs of supratentorial brain infarction: clinico-radiological correlations

Early signs of brain infarction can be detected by modern CCT technology even within the first 6 h after stroke. Little is known about the prognostic significance of early infarction signs in CCT. We prospectively evaluated clinical and CCT findings of 95 consecutive patients with an acute ischemia in the territory of the middle cerebral artery. All patients were admitted to our stroke unit within 6 h after stroke. In 55 patients CCT was performed within 3 h, and in 40 cases between 3 and 6 h. In all patients the clinical findings were assessed by the Scandinavian Stroke Scale (SSS). The disability due to stroke was evaluated after 4 weeks by use of the modified Rankin Scale. We could demonstrate the following early signs of cerebral infarction: focal hypodensity (23.2%), obscuration of basal ganglia (12.6%), focal brain swelling (22.1%), hyperdense middle cerebral artery sign (HMCA; 11.5%). In 3 patients early edema led to ventricular compression, in 1 patient to midline shift. The occurrence of early infarction signs did not depend on the etiology of ischemia but was significantly associated with a severe neurological deficit at admission and an unfavourable disability status 4 weeks after stroke. Focal brain swelling and HMCA were often followed by extensive infarction lesions on the follow-up CCT. In conclusion, early signs of hemispheric brain infarction visible on CCT scans performed within 6 h after stroke are correlated with severe stroke and an unfavourable functional outcome. However, a substantial part of our patients had a benign course of the disease in spite of early CCT pathology. Decisions on therapy in individual patients therefore should not depend on early CCT findings exclusively.     

Prolonged hyperglycemia in the early subacute period after cerebral infarction: effects on short term prognosis

Although the adverse effect of admission hyperglycemia in cerebral infarction on prognosis is well known, studies generally have not questioned the effect of hyperglycemia in the early subacute period on prognosis after a stroke. Forty-six patients with acute ischemic stroke were seperated into 3 groups: Group 1) Known diabetes or admission blood glucose (ABG) > or = 140 mg/dl and HbA1c > or = 8,0%); Group 2) ABG > or = 140 mg/dl and HbA1c < 8,0%; and Group 3) ABG < 140 mg/dl and HbA1c < 8,0%. Blood glucose was followed-up 4 times a day for 10 days after the stroke and the mean of these measurements was calculated as the mean of glycemic regulation (MGR). Neurological evaluation was done at presentation and on day 10 and 30 with the National Institute of Health (NIH) scale. Oedema, lesion size and presence of hemorrhagic transformation were evaluated using CT. The MGR was significantly higher in group 1 compared to the other two groups (p < 0,001 and p < 0,01) and in group 2 compared to group 3 (p < 0,001). Patients with clinical worsening had a significantly higher MGR (p < 0,05). Patients with marked cerebral edema had a significantly higher MGR (p < 0,01) compared to patients with lesser edema. No correlation was found between MGR and lesion size or hemorrhagic transformation. Our results show that hyperglycemia in the early subacute period after cerebral infarction is associated with more pronounced cerebral edema and has an adverse effect on short term prognosis. We suggest that studies investigating the effect of insulin infusion on stroke prognosis should also consider infusions for a longer period than 24 hours.     

Akuttherapie des Schlaganfalls

This article covers three major topics of acute stroke therapy: extension of the time window for thrombolysis with desmoteplase, decompressive surgery after malignant middle cerebral artery infarction, and the effect of hemostatic therapy with recombinant activated factor VII (rFVIIa) in patients with spontaneous primary intracerebral hemorrhage. Thrombolytic therapy with recombinant tissue or tissue-type plasminogen activator is still the only approved acute stroke therapy within a 3-h time window. Imaging-based patient selection seems to help extending this time window. After promising results of two phase II trials with the thrombolytic agent desmoteplase in an extended time window after acute ischemic stroke, the DIAS-II study was reconducted in Europe, North America, and Australia as a phase III trial. First results of the included 186 patients are shown. Surprisingly, patients treated with desmoteplase had no better outcome than placebo-treated patients, and there was increased mortality in the high-dose group. Among all stroke subtypes, space-occupying malignant middle cerebral artery is one with the poorest prognosis. Most patients die within a few days due to the development of massive brain edema, despite maximum intensive care. Decompressive hemicraniectomy represents a much more effective therapy for the treatment of local brain swelling. However, until recently this method was highly controversial. Here we present the results of the randomized trials published in 2007 and discuss their relevance for acute therapy. Hematoma growth occurs within 4 h in one third of patients who suffer from intracerebral hemorrhage. Prospective, placebo-controlled, multicenter trials have shown that intravenous application of rFVIIa reduces volume increase. We present preliminary results of the latest phase III trial (FAST: recombinant factor VIIa in acute hemorrhagic stroke), which tried to find whether the hemostatic effect will translate into clinical effect.     

Validation of hyperintense middle cerebral artery sign in acute ischemic stroke Comparison between magnetic resonance imaging and angiography

We performed a retrospective analysis of non-contrast computed tomography (CT) scans, immediately subsequent magnetic resonance imaging (MRI), and cerebral angiography data from 30 consecutive patients with acute ischemic stroke within 6 hours after symptom onset. Results showed that eleven patients developed subsequent hemorrhagic transformation at follow-up. A hyperintense middle cerebral artery sign on MRI was found in six hemorrhagic patients, all of who had acute thrombosis formation on magnetic resonance angiography and digital subtraction angiography. No patients in the non-hemorrhagic group had hyperintense middle cerebral artery sign on MRI. The sensitivity, specificity, and positive predictive values of the hyperintense middle cerebral artery sign on MRI T1-weighted image for subsequent hemorrhagic transformation were 54.5%, 100%, and 100% respectively. Hyperdense middle cerebral artery sign on non-contrast CT was observed in nine patients, five of who developed hemorrhagic transformation. These data suggest that hyperintense middle cerebral artery sign on MRI T1-weighted image is a highly specific and moderately sensitive indicator of subsequent hemorrhagic transformation in patients after acute ischemic stroke, and its specificity is superior to CT.     

A case of basilar artery occlusion successfully treated with tissue plasminogen activator]

This case concerns a stroke in the basilar artery territory that was successfully treated with a tissue plasminogen activator (t-PA). A 44-year-old man suddenly lost consciousness. It took fifty minutes to arrive to our hospital after the onset. On admission, his consciousness was in a coma state. A head CT revealed normal findings but a cerebral angiography showed complete occlusion in the basilar artery. We gave 240,000 units t-PA intravenously for 60 minutes. The intravenous t-PA dramatically improved his state of consciousness. After treatment, the brain CT scan showed low-density areas in the left occipital area and right pons. The cerebral angiography showed arterial sclerosis in the basilar artery. There was no parenchymal hemorrhage or hemorrhagic infarction in the patient. The hitherto reports showed the intravenous infusion of t-PA may be particular value in patients with thromboembolic occlusion in the middle cerebral artery. In contrast, our results support its efficacy in strokes in the basilar artery territory.     

Combined thalamic ptosis and astasia

Isolated cases of astasia or ptosis have each been reported in ischemic or hemorrhagic strokes involving the thalamus. We report a 70-year-old man with a medical history of hypertension who presented with left ptosis and gait disturbance despite intact motor strength in the legs and normal sensory function. MRI of the brain showed an evolving subacute infarction confined to the anteromedial-medial part of the left thalamus with no other areas of recent infarction identified. To our knowledge, combined ptosis and astasia in thalamic infarction has not been reported in the English literature. We identified 11 patients with thalamic ptosis and 21 with thalamic astasia in the literature. Patients who had ptosis, or gait abnormality which would not be related to thalamic stroke, were excluded; for example, evidence of infarction in the hypothalamus, midbrain, pons, cerebellum, or cingulate gyrus.     

Brain attack in Japan, now and future]

In Japan, all of the stroke center hospital equipped by high level diagnostic systems including MRI. Number of MRI is twice as that of U.S.A. Therefore, we can perform correct and effective treatment for ultra-acute cerebral infarction if rt-PA is permitted to clinical use for cerebral infarction. We are making Japan Standard Stroke Registry Study (JSSR Study) now, and already registered 2,740 acute stroke cases in 25 hospitals. Atherothrombotic embolism (artery to artery embolism) was found in 16.5% of the all atherothrombotic infarction. It suggests that diagnostic accuracy of our database is high level. Concerning with ultra acute thrombolysis, about 10,000 stroke patients per year are estimated to be treatable with rt-PA in Japan. Yamaguchi's study for acute cerebral infarction showed intra-arterial thrombolytic therapy using urokinase was significantly effective. Our JSSR Study also showed effectiveness of thrombolytic therapy using rt-PA or high dose urokinase in the patients with cerebral infarction treated within 6 hours. Therapeutic time windows for acute cerebral infarction using rt-PA is expected to be more longer by the newly developed free radical scavenger (edarabin). We must create evidence based medicine for Japanese stroke patients based on database system (JSSR).     

Two cases of brain infarction associated with dissection of the thoracic aorta]

Case 1: a 57-year-old woman, who suddenly developed disturbance of consciousness, left spatial neglect, and left hemiparesis, was admitted to our hospital on the day 1. Brain CT scan on the day 2 revealed broad edematous infarction in her middle cerebral artery territory. The dissection of the thoracic aorta was observed with transesophageal echocardiography and brain embolism due to mural thrombus of the dissecting thoracic aorta was suspected. Case 2: a 67-year-old woman, who developed disturbance of consciousness, left spatial neglect, and left hemiparesis, was admitted to our hospital on the day 15. Brain CT scan on the day 15 showed non-edematous infarction in her middle cerebral artery territory. Contrast thoracic CT scan on the day 31 revealed the dissection of the thoracic aorta. No clinical exacerbation was observed, but brain CT scan on the day 94 showed broad infarction in her middle and anterior cerebral artery territories. It is considered that pseudolumen of the dissected thoracic aorta caused occlusion of her right internal carotid artery. Transesophageal echocardiography, or contrast thoracic CT scan should be considered for detection of the dissection of the thoracic aorta in the cases of cryptogenic stroke.     

磁敏感加权成像在出血性脑梗死诊断中的初步应用

目的探讨磁敏感加权成像（SWI）诊断出血性脑梗死的临床价值。方法20例亚急性期出血性脑梗死患者分别行常规MRI、扩散加权成像（DWI）和SWI检查,根据图像分析结果比较不同扫描序列所显示的梗死灶内出血灶数目及其阳性检出率;测量SWI序列出血最大层面出血灶面积和T2WI序列梗死灶最大层面的梗死灶面积,并行相关分析;观察SWI序列对梗死灶内静脉血管的显示程度,以及梗死灶以外区域微出血灶的诊断敏感性。结果20例患者SWI序列均显示梗死灶内出血,两名医师共诊断43个出血灶,其中SWI序列显示42个、T1WI序列25个、DWI序列15个、T2WI序列12个;SWI序列阳性检出率与T1WI、T2WI、DWI序列相比,差异具有统计学意义（X^2=51．516,P=0．000）。T2WI序列梗死灶最大层面的梗死灶面积为（18．08±12．47）cm^2,SWI为（5．02±6．27）cm^2,梗死灶面积与出血灶范围之间呈明显正相关（r=0．562,P=0．010）。其中,13例患者SWI序列检出梗死灶以外区域的微出血灶;12例显示梗死灶内小静脉血管分支减少和（或）变细,6例血管增多、增粗和（或）扭曲。结论SWI序列对出血性脑梗死病灶内出血的显示优于常规MRI和DWI序列,并能显示梗死灶内静脉血管的变化及梗死灶以外区域的微出血灶,可作为诊断出血性脑梗死的MRI常规扫描序列。     

磁敏感加权成像在出血性脑梗死诊断中的初步应用

目的 探讨磁敏感加权成像(SWI)诊断出血性脑梗死的临床价值.方法 20例亚急性期出血性脑梗死患者分别行常规MRI、扩散加权成像(DWI)和SWI检查,根据图像分析结果比较不同扫描序列所显示的梗死灶内出血灶数目及其阳性检出率;测量SWI序列出血最大层面出血灶面积和T2WI序列梗死灶最大层面的梗死灶面积,并行相关分析;观...     

Conversion of ischemic to hemorrhagic infarction by anticoagulant administration. Report of two cases with evidence from serial computed tomographic brain scans

Anticoagulant therapy is appropriate for embolic cerebral infarction due to valvular heart disease or cardiac dysrhythmia, as well as for stroke-in-evolution. Various incidences of hemorrhagic complications have been cited in patients given anticoagulants after stroke or transient cerebral ischemia. Conversion of ischemic to hemorrhagic infarction has been shown to occur experimentally. We describe two patients in whom this conversion occurred in the absence of hypertension or excessive anticoagulation and was substantiated by serial computed tomographic brain scans. This finding suggests that conversion of ischemic to hemorrhagic infarction may occur even with appropriate and carefully administered anticoagulation therapy.     

Bilateral, hyperdense middle cerebral arteries predict bihemispheric stroke

The hyperdense vessel sign is a debated topic in terms of its sensitivity and specificity for acute cerebral ischemia. Bilateral, hyperdense middle cerebral artery signs are rare presentations of bilateral cerebral infarction. We describe a 17-year-old boy with a history of cerebral palsy and a repaired atrial septal defect, presenting with lethargy and respiratory failure. Noncontrast computed tomography of the brain revealed bilateral, hyperdense middle cerebral artery signs, and he subsequently demonstrated bilateral cerebral infarctions in the distributions of the middle cerebral arteries. Hyperdense artery signs must alert physicians to evaluate patients for stroke, with an especially high index of suspicion for pediatric patients with hyperdense vessels, who are less likely to present with atherosclerotic disease causing vascular calcifications; rather, hyperdense artery signs could be an early sign of large-vessel thrombosis and cerebral infarction.     

Cerebral hemorrhagic infarction at autopsy: cardiac embolic cause and the relationship to the cause of death

In 48 patients dying within 15 days following a supra-tentorial cerebral infarct, the presence of hemorrhagic infarction at autopsy was related to a cardiac embolic cause of the infarct, and to the cause of death. Hemorrhagic infarcts were more common among patients dying from brain herniation than among those dying from a non-cerebral cause. Cardiac embolic strokes were more often hemorrhagic at autopsy than strokes without such cause; this could be explained by a significant higher rate of brain herniation and death after embolic stroke. On the other hand infarcts with extended hemorrhages more often tended to have a cardiac than a non-cardiac cause. These data, together with earlier clinical findings suggest that autopsy studies are biased in relating hemorrhagic infarction almost exclusively to a cardiac embolic cause of stroke, although cardiac emboli may produce more extended hemorrhages.     

Large vessel occlusions requiring repeated mechanical thrombectomy caused by silent myocardial infarction in a young adult

ObjectivesSilent myocardial ischemia, defined as objective evidence of myocardial ischemia without symptoms, is associated with ischemic stroke. Nevertheless, silent myocardial infarction is a rare cause of ischemic stroke, especially in young adults with no medical history.Materials and methodsHerein, we report a young adult patient with acute ischemic stroke treated with repeated mechanical thrombectomy for recurrent large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction.ResultsA 40-year-old man was transferred by ambulance to our hospital because of a generalized seizure. He was diagnosed with cerebral infarction and left middle cerebral artery occlusion. We performed intravenous thrombolysis and mechanical thrombectomy. Recanalization was achieved and his symptoms gradually improved. However, the day after treatment he developed bilateral cerebellar infarction and basilar artery occlusion. We performed a second mechanical thrombectomy and recanalization was achieved. Transthoracic echocardiography revealed a mobile left ventricular thrombus. Although he had no previous chest symptomatic episodes, cardiac examination confirmed myocardial infarction of unknown onset. He was diagnosed with acute ischemic stroke with large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. Anticoagulation therapy reduced the amount of thrombus. At 1-year follow-up, he had not experienced any recurrences or symptoms.ConclusionsSilent myocardial infarction should be considered a cause of ischemic stroke in young adults, even without any vascular risk factors. Recurrent large vessel occlusion may occur in patients with left ventricular thrombus, and repeated mechanical thrombectomy should be considered for treatment.     

Body temperature correlates with functional outcome and the lesion size of cerebral infarction

INTRODUCTION: Experimental studies have demonstrated that mild hyperthermia exacerbates ischemia-induced neuronal injury. MATERIAL AND METHODS: We examined the relationship between body temperature and functional outcome in 183 patients suffering from cerebral infarction, and admitted within 24 h from the onset of stroke. Patients' functional capacities in daily life were evaluated by Rankin's score before the attack (RS0), on the day of admission (RS1), and 3 months after the onset of stroke (RS90). RESULTS: RS90 showed an independent correlation with RS0, RS1, age, infarct size and maximum body temperature recorded within the first 7 days from the onset of stroke by multivariate analysis. History of previous cerebrovascular accidents, atrial fibrillation, hemorrhagic transformation, infection, and a hypothalamic lesion showed significant associations with RS90 by the Mann-Whitney U-test, but not by multivariate analysis. Infarct size correlated with body temperature, atrial fibrillation, and hemorrhagic transformation. CONCLUSION: Body temperature correlated well with both functional outcome and infarct size in patients with an acute cerebral infarction.     

Dense middle cerebral artery sign: an indicator of poor outcome in middle cerebral artery area infarction.

Thirteen patients with a dense appearance of the horizontal part of the middle cerebral artery (MCA) "dense middle cerebral artery sign" in CT scans taken within 24 hours after onset of ischaemic stroke had considerably poorer prognosis than controls with stroke, but without the sign. A hyperdense appearance of the MCA is known to be associated with thromboembolism, but dense middle cerebral artery sign is also an early warning of a large infarction, brain oedema and poor prognosis in infarction in the MCA area.     

Transcranial doppler in acute ischemic stroke of the middle cerebral artery territories

We have investigated the reliability of transcranial doppler compared with cerebral angiography in acute ischemic stroke in the middle cerebral artery territories. We studied 48 patients, 28 men and 21 women, mean age 68.1 (range 54–75), observed within 5 h of the onset of ischemic stroke in the middle cerebral artery territory. Ultrasound evaluation (duplex scanner and transcranial doppler) and cerebral angiography were carried out in close sequence immediately after CT scan. CT was repeated by Day 7 to estimate the infarct size: 27/48 patients had intracranial arterial obstructions. An acoustic temporal "window" was not found in 6.25%. Transcranial doppler showed a sensitivity of 80.0% and a specificity of 90.0% compared with cerebral Angiography for patients with patent acoustic temporal "windows". Accuracy was 79.2%, when patients with no "windows" were included. With respect to intracranial internal carotid artery and middle cerebral artery mainstem, transcranial doppler showed a sensitivity of 95.0%, and a specificity of 92.0%. Including patients with no windows, accuracy was 87.5%. Conclusions: Our data suggest that Transcranial Doppler can be reliably used to demonstrate intracranial internal carotid artery or middle cerebral artery mainstem obstructions in the acute phase of a brain infarction.