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.     

Acute isolated capsular stroke. A clinical study of 148 cases

The objectives of the study were to assess differential features between capsular stroke of ischemic and hemorrhagic origin, and to compare capsular strokes with all other (non-capsular) strokes. Data of 148 patients with isolated capsular stroke were collected from a prospective hospital-based stroke registry in which 2000 consecutive acute stroke patients were included. Isolated capsular stroke accounted for 8.4% of strokes included in the registry (8.4% of ischemic strokes and 10.5% of intracerebral hemorrhages). Capsular stroke of hemorrhagic origin (n = 24) was more severe than ischemic capsular stroke (n = 124) as determined by a significantly higher in-hospital mortality, length of stay, and lower number of patients free of functional deficit at discharge. After multivariate analysis, limb weakness, sudden onset, and sensory symptoms were independently associated with capsular hemorrhage, whereas pure motor hemiparesis appeared to be associated with capsular infarction. In summary, one of each 12 patients with acute ischemic stroke and one of each 10 patients with acute intracerebral hemorrhage had an isolated capsular stroke. Lacunar syndrome was the most frequent clinical presentation being more common (particularly pure motor hemiparesis) in ischemic than in hemorrhagic capsular stroke. Capsular hemorrhage and capsular infarction showed identical risk factor profiles suggesting the same underlying vascular pathology for both conditions.     

Current strategies for ischemic stroke prevention: role of multimodal combination therapies

Stroke remains a global leading cause of death and long-term disability, highlighting the need for more effective treatment approaches. The majority of strokes are of ischemic origin, often caused by large- or small-artery atherothrombosis, or cardioembolism. Considering the systemic nature of the atherothrombotic disease process, stroke patients are at increased risk for ischemic events in several vascular territories: cerebral, coronary and peripheral. Due to the limited options for acute stroke therapies, stroke prevention is an important therapeutic approach. In addition to the management of modifiable risk factors such as hypertension, dyslipidemia and smoking through pharmacotherapy or lifestyle adjustments, anticoagulants, surgical and perhaps endovascular approaches are indicated in certain patients. Antiplatelet therapies using various agents are a cornerstone of secondary stroke prevention. To ensure the appropriate continuum of care after hospitalization for ischemic stroke, some interventions for the prevention of recurrent ischemic stroke should be initiated during the acute hospitalization setting and maintained in the out-patient setting.     

Mechanisms of recurrence in subtypes of ischemic stroke: a hospital-based follow-up study

BACKGROUND: Information on the mechanism of recurrent stroke may help physicians treating patients with ischemic stroke. However, the mechanisms of recurrence in each stroke subtype are not well known, especially in Asians. OBJECTIVE: To compare the mechanisms of the index and recurrent stroke. DESIGN: Analysis of data from a prospective acute stroke registry. SETTING: University hospital. PATIENTS: Using the clinical syndrome, diffusion-weighted imaging, and vascular studies, we divided 901 patients into 5 groups: large-artery atherosclerosis, cardioembolism, small-artery disease, parent-artery disease occluding the deep perforators, and no determined cause. The patients with large-artery atherosclerosis were subdivided into 2 groups: intracranial and extracranial. MAIN OUTCOME MEASURES: The mechanisms of recurrent vascular events (strokes or coronary heart disease) in subtypes of ischemic stroke were compared. RESULTS: Ninety-three recurrent vascular events (86 strokes and 7 instances of coronary heart disease) were evaluated. The pattern of recurrent stroke differed for the intracranial and extracranial groups; unlike the patients with intracranial large-artery atherosclerosis, recurrent strokes in the extracranial group were often unpredictable with respect to the site of recurrence and degree of preexisting stenosis. None of the patients in the extracranial group had recurrences that were caused by intracranial large-artery atherosclerosis or vice versa. In patients with small-artery disease and stroke with no determined cause, intracranial stenosis was often found at the time of recurrence. CONCLUSIONS: From prognostic and therapeutic perspectives, patients with atherosclerosis should be divided into those with intracranial large-artery atherosclerosis and extracranial large-artery atherosclerosis. In addition, intracranial large-artery atherosclerosis may be important in the development of small-artery disease and stroke with no determined cause, especially in the population with a higher frequency of intracranial large-artery atherosclerosis.     

Advantages of lipid-lowering therapy in cerebral ischemia: role of HMG-CoA reductase inhibitors

Dyslipemia as a risk factor for ischemic stroke and indications for statins in the prevention of ischemic stroke are revised. The role of cholesterol levels as a risk factor for ischemic stroke is controversial. This could be due to failures in the design of early epidemiological studies. Recent studies, however, do suggest a clearer risk relationship between cholesterol levels and ischemic stroke. Studies conducted on the prevention of ischemic heart disease (IHD) with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), using pravastatin and simvastatin, unequivocally show reductions in overall mortality, cardiovascular mortality, acute myocardial infarction and other coronary events. These studies show a reduction in the risk of ischemic stroke, and although relative risk reduction is great, absolute risk reduction is low; the reasons for this are analyzed. Apart from lipid mechanisms, statins act on the atheroma plaque; they have antithrombotic and possibly neuroprotecting properties. Statins reduce the number of strokes due to the decrease of atherothrombotic strokes, cardioembolic strokes secondary to IHD, and lacunar strokes related to atherothrombosis and probably to microatheromas. Although there are currently no specific studies available on the secondary prevention of stroke with statins, which are required to clarify certain points, according to European and American guidelines for prevention, statins would be indicated in the secondary prevention of atherothrombotic stroke, and in cardioembolic and lacunar stroke associated with clinical or silent atherosclerosis (IHD, peripheral artery disease). Patients with ischemic stroke of other etiologies, except for stroke in the young or other unusual causes, are patients with a high vascular risk (cardiac and cerebral) owing to the stroke itself, age and other vascular risk factors, and they should also be treated with statins, at least from the point of view of primary prevention of IHD. Natural statins (pravastatin and simvastatin) play an essential part in secondary prevention of ischemic stroke, together with antiaggregants, anticoagulants, angiotensin-converting enzyme inhibitors and the treatment of other vascular risk factors.     

Headache in transient or permanent cerebral ischemia. Dutch TIA Study Group

We studied headache features in 3,126 patients with acute cerebral or retinal ischemia. Headache occurred in 18% of these patients (in 16% of all patients with transient ischemic attacks, in 18% of patients with reversible ischemic neurologic deficits, and in 19% of patients with minor strokes) and was mostly continuous in all types of attacks. Headache was present in 16% of patients with monocular visual symptoms. The occurrence of headache was not related to the mode of onset, mode of disappearance, or duration of the attack. Patients with headache more often were known to have heart disease. Headache was less frequent in patients with small deep infarcts, who were more often hypertensive, and in patients with infarcts in the anterior circulation; headache was more frequent in patients with cortical infarcts and in patients with infarcts in the posterior circulation. Patients with a relevant small deep infarct on computed tomographic scan and accompanying headache relatively often reported symptoms compatible with cortical ischemia, such as language disorders or a visual field defect. We conclude that headache is a frequent accompanying symptom in patients with acute cerebral and retinal ischemia and that the occurrence of headache is partly related to the underlying cause of the ischemic lesion.     

颈内动脉夹层动脉病的病因、病理生理、临床诊治及预后研究进展

颈动脉系的夹层动脉病(CAD)是青年脑卒中的常见原因之一,在脑卒中患者中患病率约占20%,其中颈内动脉夹层动脉病(ICAD)占70%~80%。许多因素如高血压病、糖尿病、创伤等都与其有关。ICAD多表现为同侧颈部疼痛或头痛、Horner综合征及脑缺血。磁共振血管造影为其首选检查方法。ICAD相对预后良好。抗凝与抗血小板药物在其急性期治疗及二级预防中仍存在争议。文中就ICAD的流行病学、临床表现、病理生理、治疗及预后的研究进展进行综述。     

Neuroimaging of Pediatric Arteriopathies

Pediatric arteriopathies are increasingly recognized in school‐aged children with a variety of presenting symptoms ranging from headache, seizures, encephalopathy, and neuropsychiatric symptoms as well as focal neurologic deficits due to acute ischemic strokes. However, unlike the adult stroke population, there are differences in the clinical manifestations, the stroke mechanism, and risk factors in pediatric ischemic stroke. There has been increasing awareness and recognition of pediatric cerebral arteriopathies as a predominant stroke etiology. Prompt diagnosis of arteriopathies is essential to limit injury and prevent recurrent stroke. Based on predominant vessels involved and clinical symptoms, these arteriopathies can be broadly divided into two categories: large‐medium size arteriopathies and small vessel arteriopathies. Each category can be further divided into inflammatory and noninflammatory according to their etiologies. The ability to distinguish between inflammatory and noninflammatory etiologies carries major prognostic implications for acute management and secondary stroke prevention as well as screening for systemic complications and counseling.     

Prevalence of cerebrovascular lesions in Parkinson's disease. A postmortem study

Data on the relationship between Parkinson's disease (PD) and stroke have been conflicting, some studies showing a reduced risk of stroke during life, and others indicating an increased risk of stroke-related death. Consecutive cases (n=617) of autopsy-proven idiopathic PD (Lewy body disease of the brain stem type) and age-matched controls (n=535) were compared using current routine and immunohistochemical methods. The total frequency of cerebrovascular lesions (lacunes, amyloid angiopathy, white matter lesions, old and recent ischemic infarcts and hemorrhages) in PD (44.0%) was higher than in controls (32.8%), while acute, often fatal ischemic or hemorrhagic strokes were less frequent in parkinsonian patients (1.8% vs 2.6%). Like previous postmortem findings in a smaller cohort, these findings neither indicate a protective effect against stroke nor a greater susceptibility to death from stroke in the populations studied. Cognitive impairment in PD appears to be largely independent from coexistent vascular pathology except in cases with severe cerebrovascular lesions.     

A comparison of risk factors and prognosis for transient ischemic attacks and minor ischemic strokes. The Oxfordshire Community Stroke Project

In a community-based study of transient ischemic attack and stroke, we identified 184 cases of transient ischemic attack and 213 cases of first-ever minor ischemic stroke. A comparison of age, sex, and prevalence of coexistent vascular diseases and risk factors revealed no major differences between the two groups. The risk of further stroke and of further stroke and/or death was greater in patients with minor ischemic stroke although the difference was significant only for the latter. The apparent differences in prognosis could largely be accounted for by the favorable prognosis of patients with amaurosis fugax among those with transient ischemic attack. Although for some purposes it may be useful to distinguish transient ischemic attacks from minor ischemic strokes, the similarity of the two groups suggests that in many situations, including in clinical trials of treatments for the secondary prevention of strokes, the arbitrary distinction between them could be dispensed with.     

Stroke Mimics: An Important Source of Bias in Acute Ischemic Stroke Research

Study Objective: Stroke mimics may be difficult distinguish from acute ischemic strokes and are often treated with alteplase though not by intent. We report the characteristics, frequency, and outcomes of stroke mimics treated at our institution. Using our data, we then explore how the inclusion of stroke mimics in stroke outcomes research may be an important source of bias. Methods: We retrospectively identified all patients treated with alteplase in our emergency department from August 2013 to December 2017 for suspected acute ischemic stroke. We collected the following variables: gender, age, risk factors (hypertension, diabetes, and atrial fibrillation), admission glucose, admission National Institute of Health Stroke Scale, admission mean arterial pressure, onset-to-treatment time, adverse events, discharge diagnosis, length of stay, discharge NIHSS, discharge destination, and 3 month modified Rankin score. Results: One hundred and eighteen patients were treated with alteplase for suspected acute ischemic stroke of which 33 (27.9%) were stroke mimics. Compared to ischemic strokes, stroke mimics were younger (median age 53 versus 69; P < .0003); were less likely to have vascular risk factors (hypertension [51.5% versus 78.8%; P < .005] diabetes (9.1% versus 32.9%; P < .007), and atrial fibrillation (3.0% versus 23.5%; P < .006). The most common stroke mimic was transient ischemic attack (33.3%). Stroke mimics were significantly more likely to be discharged home (75.8% versus 41.2%; P < .002). Outcomes unadjusted for stroke mimics led to artificial inflation of a favorable discharge destination. Conclusions: Inclusion of stroke mimics led to an artificial inflation of a favorable discharge destination for our entire cohort. Our study highlights the potential for bias in reporting favorable outcomes if appropriate adjustment accounting for stroke mimics does not occur.     

Multiple acute cerebral infarcts on diffusion-weighted imaging and risk of recurrent stroke

Multiple acute cerebral infarcts (MACIs) detected by diffusion-weighted imaging (DWI) may indicate an unstable source of thromboembolism. The authors studied 119 consecutive acute ischemic stroke patients within 24 hours of onset with DWI. MACIs were present in 20 patients (16.8%). During the follow-up period, there were 15 recurrent strokes, 3 acute coronary syndromes, and 5 deaths. MACI was the only significant independent predictor for vascular events and death (odd ratio [OR]] = 4.34; p = 0.001) and stroke recurrence (OR = 5.93; p = 0.001).     

Silent stroke in patients with transient ischemic attack or minor ischemic stroke. The Dutch TIA Trial Study Group.

BACKGROUND AND PURPOSE: We studied silent stroke (i.e., infarcts on computed tomographic scan not related to later symptoms) in patients after transient ischemic attack or minor ischemic stroke. METHODS: Ours is a cross-sectional study of 2,329 patients who were randomized in a secondary prevention trial after transient ischemic attack or minor ischemic stroke and had no residual deficit after the qualifying event. RESULTS: Silent stroke was observed in 13% of the 2,329 patients. Lacunes formed 79%, cortical lesions 14%, and border zone lesions 7% of all silent strokes. Silent lacunes were most often located in the basal ganglia and symptomatic lacunes most often in the corona radiata. Age, hypertension, and current cigarette smoking were related to the presence of silent stroke. Silent stroke was equally common in different types of transient ischemic attack, including transient monocular blindness. Residual symptoms of any kind were more common in patients with silent stroke than in those without. CONCLUSIONS: Because only the sites of silent stroke infarcts differed slightly from those of symptomatic infarcts and the frequency of vascular risk factors was similar to that of symptomatic infarcts, silent stroke may have the same bearing on future risk as known prior stroke.     

COVID-19 independently predicts poor outcomes in Acute Ischemic Stroke- Insights from a multicenter study from Pakistan and United Arab Emirates

BackgroundIschemic stroke associated with coronavirus 2019 (COVID-19) has been well recognized by now. Few studies have compared COVID related versus unrelated strokes. We intend to report on a large group of Asian patients from two countries and compare COVID with non-COVID strokes admitted during the same time period.MethodsConsecutive cases of acute ischemic stroke either presenting or developing, between March 2020 and December 2021 in four tertiary care hospitals (1 in Dubai, UAE and 3 in Karachi, Pakistan) and testing positive for COVID-19 were included in the study. Patients admitted with ischemic stroke during the same time period and who tested negative for COVID-19 were also randomly selected from the four hospitals. All data was collected from the medical records of the patients and recorded on a standard questionnaire before it was entered in SPSS version 21 for analysis.ResultsThere were 139 COVID positive and 271 COVID negative patients with acute ischemic stroke included in the current study. There were significantly more males (80.6% vs 64.9%, p=0.001) and more large vessel strokes in the COVID positive group (41% vs 21.8%, p<0.001). Being COVID positive was an independent predictor of poor outcome at discharge, defined as a modified Rankin score of 3-6 (OR 3.87, 95% CI 2.21-6.77) after adjusting for country, age, sex, vascular comorbid conditions and stroke subtype.ConclusionsIn this largest series of patients with COVID related strokes from Asia, COVID-19 was an independent predictor of poor outcomes at discharge after adjusting for other variables.     

Increased levels of elastin-derived peptides in cerebrospinal fluid of patients with lacunar stroke

OBJECTIVE: To investigate whether elastin-derived peptides (EDP) are detectable in the cerebrospinal fluid (CSF) of healthy controls and of patients with acute brain ischemia and if so to assess possible trends in EDP levels in different groups of ischemic stroke patients (small-vessel disease vs. other ischemic strokes; first-ever vs. recurrent stroke). PATIENTS AND METHODS: Levels of EDP were determined by ELISA in blood sera and CSF of 80 patients with acute ischemic stroke (mean age 61.5+/-10.8; age range 47-70; 22 women) and in 15 healthy age- and sex-matched controls (mean age 57.3+/-13.4; age range 50-65). The patients were divided into a group with first ever lacunar stroke (27); first ever non-lacunar ischemic stroke (27) and recurrent stroke (26). EDP were measured early (mean 7 days, range 1-15) after stroke onset. RESULTS: Serum EDP levels were mildly higher in recurrent strokes as compared to first ever lacunar lesion and controls. However, in the CSF the concentrations of EDP in stroke patients were strongly elevated (from 2 up to 30 times depending on subgroup) as compared with healthy subjects. The highest level of EDP in CSF and in the serum was found in recurrent strokes. Subgroup analysis revealed a trend for significantly higher EDP concentrations in CSF in lacunar and recurrent stroke as compared with non-lacunar. CONCLUSIONS: This study is the first application of elastin peptide measurement to human CSF and stroke patients. The increased levels of EDP were detected in CSF of patients with lacunar and recurrent strokes.     

Stroke in children: the coexistence of multiple risk factors predicts poor outcome

OBJECTIVE: To characterize the risk factors for stroke in children and their relationship to outcomes. METHODS: We reviewed charts of children with ischemic and hemorrhagic stroke seen at Hopital Sainte-Justine, Montreal between 1991 and 1997. RESULTS: We found 51 ischemic strokes: 46 arterial and 5 sinovenous thromboses. Risk factors were variable and multiple in 12 (24%) of the 51 ischemic strokes. Ischemic stroke recurred in 3 (8%) patients with a single or no identified risk factor and in 5 (42%) of 12 patients with multiple risk factors (p = 0.01). We also found 21 hemorrhagic strokes, 14 (67%) of which were caused by vascular abnormalities. No patient with hemorrhagic stroke had multiple risk factors. Hemorrhagic stroke recurred in two patients (10%). Outcome in all 72 stroke patients was as follows: asymptomatic, 36%; symptomatic epilepsy or persistent neurologic deficit, 45%; and death, 20%. Death occurred more frequently in patients with recurrent stroke (40%) than in those with nonrecurrent stroke (16%). CONCLUSIONS: Multiple risk factors are found in many ischemic strokes and may predict stroke recurrence. Recurrent stroke tends to increase rate of mortality. Because of the high prevalence and importance of multiple risk factors, a complete investigation, including hematologic and metabolic studies and angiography, should be considered in every child with ischemic stroke, even when a cause is known.     

Basilar artery occlusion in migraine-like headache: a possible triggering effect of sumatriptan

Headache is a common symptom at the onset of acute ischemic cerebrovascular disease. Simultaneous development of migraine-like headache and stroke in the same patient makes it difficult to differentiate between migraine-induced stroke and migraine-like headache attributed to ischemic stroke. We report a case of a 34-year-old woman with no previous migraine history who presented with migraine-like headache, thought to be a first attack of migraine, and who developed brainstem infarction shortly after triptan administration. Magnetic resonance imaging revealed an acute pontine infarction, and CT angiography revealed occlusion of the basilar artery. A detailed etiological evaluation revealed no risk factor for ischemic stroke. We believe that the migraine-like headache was the first symptom of cerebral ischemia and that sumatriptan accelerated the development of the infarction. This case report emphasizes the importance of accurate diagnosis of migraine before using triptans. Secondary causes of migraine-like headache should be excluded, especially in patients with migraine-like headache for the first time.     

Antiplatelet strategy for acute ischemic stroke: A mini review

Transient ischemic attacks and minor ischemic strokes have a high risk of an unstable clinical course in the initial 48-72 h after symptom onset. Early antiplatelet treatment is recommended to treat most patients with acute ischemic stroke because few patients can be treated with thrombolysis due to the limit of strict indications, such as a time window. Antiplatelets aim to prevent recurrence or deterioration of stroke. The guidelines recommend the use of aspirin in the acute stage based on two clinical trials. However, some patients still developed recurrence or deterioration of stroke despite timely aspirin administration. Thus, the question remains unclear whether another effective and safe antiplatelet strategy for the treatment of acute ischemic stroke exists. Growing evidence shows that combination antiplatelets may be superior to mono antiplatelets in the treatment of acute ischemic stroke.     

Pure Cortical Stroke Causing Hemichorea-Hemiballismus

Background: Movement disorders including hemichorea-hemiballism as the initial presentation of an acute ischemic stroke are uncommon. Structures outside of the deep subcortical areas such as the subthalamic nucleus or basal ganglia are rarely involved. Case Report: We report a case of a 72-year-old man with vascular risk factors who presented with acute onset right-sided hemichorea-hemiballism. Metabolic-, infectious-, and toxic-related conditions were ruled out, his EEG was without epileptiform changes. An MRI confirmed an acute ischemic stroke in the parieto-occipital region without any subcortical structures involved. Atrial Fibrillation was later discovered during his hospitalization and was treated appropriately. Conclusions: Although rare, strokes outside of the subthalamic nucleus can result in hemichorea-hemiballism.