Embolic Infarction Associated with Cardiac Amyloidosis

Embolic cerebral infarction due to cardiac amyloidosis is rare. We report two patients with amyloidosis who developed cerebral infarcts. These embolic infarcts were probably related to cardiac involvement of amyloidosis, which was based on results of myocardial biopsy (Patient 1), and kidney biopsy and characteristic echocardiographic features including granular sparkling, restrictive cardiomyopathy and the presence of mural thrombus (Patient 2). Diffuse amyloid infiltration of the heart may have lead to impairment of myocardial function and subsequent mural thrombosis. Cardiomyopathy due to cardiac amyloidosis should be recognized as one of the causes of cardioembolic infarction.     

卒中相关性肺炎经验性治疗及靶向治疗

本文综述了卒中相关性肺炎（stroke associated pneumonia,SAP）的抗感染治疗策略,包括经验性治疗和靶向治疗。经验性治疗是以该病的流行病学分布规律、当地或本院病原菌耐药状况为依据,或者根据相关文献,结合患者的临床病情选择用药,通常广谱青霉素/β内酰胺酶抑制剂的复合制剂是经验性治疗SAP的常用药物。靶向治疗是指在经验性治疗的基础上,根据病原体及药敏检查结果精确地调整抗生素;特别强调,靶向治疗的核心是尽早确定病原体,病原体检查过程中标本的正确采集和规范化处理至关重要,从而提高病原体检验的阳性率,为靶向治疗提供依据。     

急性缺血性卒中静脉溶栓桥接血管内治疗的疗效和安全性

目的 观察rt-PA静脉溶栓桥接血管内治疗急性缺血性卒中的临床疗效和安全性。 方法 回顾性纳入2017年1-12月郑州市第一人民医院神经重症科收治的前循环急性缺血性卒中患 者,按rt-PA静脉溶栓后是否桥接血管内治疗分为单纯静脉溶栓组和桥接治疗组。主要疗效结局为治 疗后3个月mRS评分,次要疗效结局为24 h、3 d和30 d的NI HSS评分。安全性结局为2 d症状性颅内出血及 其他部位出血、10 d全因死亡。 结果 共入组56例患者,平均年龄60.77±12.72岁,男性35例（62.5%）。单纯静脉溶栓组39例,桥接 治疗组17例。桥接治疗组3个月mRS评分≤2分比例高于单纯静脉溶栓组（88.2% vs 56.4%,P =0.021）。 两组治疗后24 h、3 d和30 d NIHSS评分差异无统计学意义。两组2 d症状性颅内出血率及其他部位出血 率、10 d全因死亡率差异无统计学意义。 结论 rt-PA静脉溶栓桥接血管内治疗可改善急性缺血性卒中患者3个月预后。     

Endovascular Therapy in Mild Ischemic Strokes Presenting Under 6 hours: An International Survey

BackgroundEndovascular therapy (EVT) for patients with mild ischemic stroke (NIHSS ≤5) and visible intracranial occlusion remains controversial, including within 6 hours of symptom onset. We conducted a survey to evaluate global practice patterns of EVT in this population.MethodsVascular stroke clinicians and neurointerventionalists were invited to participate through professional stroke listservs. The survey consisted of six clinical vignettes of mild stroke patients with intracranial occlusion. Cases varied by NIHSS, neurological symptoms and occlusion site. All had the same risk factors, time from symptom onset (5h) and unremarkable head CT. Advanced imaging data was available upon request. We explored independent case and responder specific factors associated with advanced imaging request and EVT decision.ResultsA total of 482/492 responders had analyzable data ([median age 44 (IQR 11.25)], 22.7% women, 77% attending, 22% interventionalist). Participants were from USA (45%), Europe (32%), Australia (12%), Canada (6%), and Latin America (5%). EVT was offered in 48% (84% M1, 29% M2 and 19% A2) and decision was made without advanced imaging in 66% of cases. In multivariable analysis, proximal occlusion (M1 vs. M2 or A2, p<0.001), higher NIHSS (p<0.001) and fellow level training (vs. attending; p=0.001) were positive predictors of EVT. Distal occlusions (M2 and A2) and higher age of responders were independently associated with increased advanced imaging requests. Compared to US and Australian responders, Canadians were less likely to offer EVT, while those in Europe and Latin America were more likely (p<0.05).ConclusionsTreatment patterns of EVT in mild stroke vary globally. Our data suggest wide equipoise exists in current treatment of this important subset of mild stroke.     

Successful Endovascular Therapy in COVID-19 Associated Pediatric Ischemic Stroke

Cerebrovascular diseases attributed to coronavirus disease 2019 (COVID-19) are uncommon but can result in devastating outcomes. Pediatric acute ischemic strokes are themselves rare and with very few large vessel occlusion related acute ischemic strokes attributed to COVID-19 described in the literature as of date. COVID-19 pandemic has contributed to acute stroke care delays across the world and with pediatric endovascular therapy still in its infancy, it poses a great challenge in facilitating good outcomes in children presenting with acute ischemic strokes in the setting of COVID-19. We present a pediatric patient who underwent endovascular therapy for an internal carotid artery occlusion related acute ischemic stroke in the setting of active COVID-19 and had an excellent outcome thanks to a streamlined stroke pathway involving the vascular neurology, neuro-interventional, neurocritical care, and anesthesiology teams.     

Endovascular Therapy for Ischemic Stroke

The utility of intravenous tissue plasminogen activator (IV t-PA) in improving the clinical outcomes after acute ischemic stroke has been well demonstrated in past clinical trials. Though multiple initial small series of endovascular stroke therapy had shown good outcomes as compared to IV t-PA, a similar beneficial effect had not been translated in multiple randomized clinical trials of endovascular stroke therapy. Over the same time, there have been parallel advances in imaging technology and better understanding and utility of the imaging in therapy of acute stroke. In this review, we will discuss the evolution of endovascular stroke therapy followed by a discussion of the key factors that have to be considered during endovascular stroke therapy and directions for future endovascular stroke trials.     

Neurologic Outcomes from High Risk Descending Thoracic and Thoracoabdominal Aortic Operations in the Era of Endovascular Repair

Introduction  Spinal cord ischemia and stroke are recognized complications of descending thoracic (DTA) and thoracoabdominal aortic (TAA) operations. However, there are limited data available on outcomes since the advent of thoracic endovascular aortic repair (TEVAR). Methods  We reviewed charts from consecutive patients who underwent open DTA and TAA operations, excluding type IV repair, from January, 2000 through April, 2005. Results  A total of 224 open DTA and TAA operations were included in the analysis. During this period 108 additional patients received TEVAR, accounting for 66% of all DTA repairs. Among the 224 patients who underwent open surgery, 63 patients (28%) developed spinal ischemia postprocedure, 13 (6%) had a stroke, and 9 (4%) had both. The 30 day in-hospital mortality was 18%. Neurologic complications were strongly associated with mortality: 64% of patients with stroke died compared to 17% without (P < 0.001) and 39% of patients with spinal ischemia died compared to 14% without (P < 0.001). At discharge, 29% had a poor outcome from surgery, defined as death or moderate-to-severe neurologic disability. A multivariable logistic regression incorporating characteristics known prior to surgery resulted in a score to stratify risk of poor outcome by giving one point each for age ≥60, history of cerebrovascular disease, Crawford extent II or III repair, and acute rupture. Patients with score ≥3 had an estimated 60% risk for poor outcome, while those with score ≤1 had an estimated risk of 7–11%. Conclusions  Ischemic neurologic complications were frequent and strongly associated with poor outcomes after open DTA and TAA repair among patients not eligible for TEVAR. Risk of death or neurologic disability can be estimated based on factors known prior to surgery.     

Endovascular strategies for stroke management after subacute in-stent thrombosis

Subacute in-stent thrombosis is a rare but potentially fatal condition that can occur after treatment for intracranial aneurysms or stenosis. While immediate and late thromboembolic post-stent complications are well-described, subacute (2–30 days post-intervention) thrombosis is unusual. The administration of peri-operative dual anti-platelet therapy (DAPT) has significantly reduced the risk for thrombosis, but questions remain as to the choice of agents and treatment of thromboembolic complications in this setting. We present our acute endovascular management strategies for three patients who suffered thromboembolic complications.     

选择性动脉溶栓治疗急性脑梗死的对照研究

目的评价选择性动脉溶栓治疗急性脑梗死的疗效和安全性。方法2003年1月～2005年5月期间对25例急性脑梗死患者进行选择性动脉溶栓,同期选择年龄、病情相匹配的无溶栓的对照患者25例,同时采用卒中登记方法收集选择性动脉溶栓患者及同期无溶栓的对照患者的临床、实验室及影像学等资料,前瞻性随访所有患者6个月的预后。结果溶栓组和对照组1个月末的病死率分别为4%和4%,6个月末的病死率分别为4%和4%;溶栓组和对照组1个月末残疾率分别为16%和40%,6个月末的残疾率分别为4%和24%。溶栓组并发脑出血2例(8%),其中症状性脑出血1例(4%);对照组未发生症状性脑出血。结论选择性动脉溶栓治疗急性脑梗死患者有效和安全。