Dense Hemiparesis Research Articles

Abstract WP70: Novel Weighted FANG-D Scale Scoring to Detect Large Vessel Occlusion

Objective: To determine if a novel weighted FANG-D scoring scale (NWFSS) increases sensitivity and specificity rates of large vessel occlusion (LVO) as compared to those reported with the original FANG-D scale scoring. Methodology: The present study used an observational, descriptive design to identify the important variables (field cut, aphasia, neglect, gaze preference, and dense hemiparesis) associated with the likelihood of detecting LVO. We used the FANG-D scale in patients admitted through the emergency department (ED) of a comprehensive stroke center (CSC), from December 2022 through April 2023. The NIHSS was performed and compared with the NWFSS for analysis. Each component was required to have a score ≥ 2(moderate to severe deficits) except dense hemiparesis which required a score ≥3 (significant weakness) to receive one point on the FANG-D scale. A total score of 2 or higher on FANG-D indicated a positive result suggesting LVO. If aphasia or neglect were present with a NIHSS of≥2, it was considered a positive FANG-D score. Results: A total of 311 patients were included in the study for analysis with a mean age of 67 ±16.4 years of whom 56.6% were female. The sensitivity and specificity rates were 85.7% (Confidence Interval (CI) =72.8%-94.1%) and 90.5% (CI= 86.2%-93.7%) respectively for positive predictive value of NWFSS to identify LVO. The sensitivity and specificity of the NIHSS has been reported as 86% and 60% respectively for LVO detection. The previous FANG-D study group used lower values in calculating the FANG-D scores and reported a sensitivity rate of 98% and specificity of 76.7%. Conclusion: The NWFSS has high specificity and is reliable for LVO prediction. While the NIHSS assesses eleven items sensitive for stroke diagnosis, it may take up to 10 minutes to complete and is not specific for LVO, whereas the FANG-D assesses 5items critical to LVO detection and is simple and fast with completion in <1 minute, minimizing time to intervention. Our study occurred in the ED, but this scale scoring method could be tested in the prehospital setting. The use of a scale with higher specificity for LVO could improve patient outcomes and resource utilization by faster routing of patients to CSCs capable of performing mechanical thrombectomy.

Abstract Number ‐ 249: Differential Ischemic Vulnerability depicted by White Matter‐Sparing Infarction following Alteplase Recanalization

Introduction Gray and white matter possess different ischemic thresholds and therefore will undergo infarction at different rates of cerebral blood flow. We present a patient that presented with a large vessel occlusion and recanalized following alteplase administration within hours of symptom onset. Follow‐up imaging revealed a white matter‐sparing infarction, visually depicting the differential ischemic vulnerability between gray and white matter. Methods Case Report. Results An 83‐year‐old woman with a medical history of dementia, hypertension, and atrial fibrillation, not on anticoagulation due to recent gastrointestinal hemorrhage, presented with speech difficulty and right sided weakness. Her blood pressure was elevated at 170/86 and neurological exam demonstrated mixed aphasia, right homonymous hemianopia, left gaze deviation, and dense right hemiparesis with a National Institutes of Health Stroke Scale of 23. Non‐contrast CT of the head showed a hyperdense left terminal internal cerebral artery (ICA) and was otherwise unremarkable (Figure 1, A). CT angiography of the head and neck revealed an ICA “T” occlusion with no flow seen at the ICA terminus, the left anterior cerebral (A1) and middle cerebral (M1) segments (Figure 1, B). She was treated with intravenous alteplase 132 minutes from when she was last known normal. She was transferred to our comprehensive stroke center for mechanical thrombectomy, however, catheter angiography showed spontaneous recanalization of left ICA (Figure 1, C). Brain MRI the following day showed a white matter‐sparing infarction involving the left ICA territory (Figure 1, D‐F). She was discharged to rehab with moderate improvement in her aphasia and right hemiparesis. Conclusions This case visually depicts the differential ischemic vulnerability between gray and white matter since recanalization likely occurred at a cerebral blood flow level below the gray matter ischemic threshold while remaining above the white matter threshold. While pretreatment ischemic core volumes are inversely correlated with functional outcomes after recanalization of large vessel occlusions,1 selective white matter‐sparing infarction on post‐treatment MRI is associated with more favorable outcomes.2 Predicting ischemic core volume with perfusion imaging using the same CBF threshold for both gray and white matter may over‐estimate the ischemic core if CBF is between the gray and white matter thresholds.

CYTOTOXIC EDEMA IN CHEMOTHERAPY-ASSOCIATED POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Posterior reversible encephalopathy syndrome (PRES) is a clinical radiographic syndrome characterized by seizures, visual disturbances and altered mental status. MRI of the brain exhibits vasogenic edema. Failure of autoregulation of cerebral arteries and disruption of the endothelium of the blood-brain-barrier are the two mechanisms underlying vasogenic edema. PRES has many triggers, including the use of chemotherapeutic agents. We present the case of a patient on treatment with paclitaxel/carboplatin, diagnosed with PRES, with radiographic evidence of both vasogenic and cytotoxic edema. CASE PRESENTATION: A 61-year-old male diagnosed with squamous cell carcinoma of the lung, recently started on Carboplatin and Paclitaxel, presented to the hospital with altered mental status. He was afebrile, blood pressure 117/77 mmHg, pulse 105 and respiratory rate 24. Physical exam revealed an unresponsive male in respiratory distress. Initial CT brain and blood investigations were unremarkable. He was admitted to the ICU and intubated for failure to protect his airway. MRI brain, revealed hyperintensities on T2-weighted and FLAIR imaging with patchy restricted diffusion involving bilateral fronto-parieto-occipital cortex typical of vasogenic edema and PRES. During further workup, he was found to have a left atrial thrombus from tumor invasion. He was started on anticoagulation and loaded with levetiracetam. He was noted to have dense hemiparesis two days later and underwent CT angiography of the brain which confirmed vasogenic with cytotoxic edema and diffusely increased vascularity as a consequence of decreased cerebral autoregulation. He regained consciousness and tolerated extubation, with complete resolution of hemiparesis. Following extubation, he was found to have visual disturbances which resolved and he was discharged with no neurological deficits. DISCUSSION: PRES with both vasogenic and cytotoxic edema is rare. Our patient had a recent MRI brain and PET/CT for tumor staging, which was negative for brain metastasis. There was a lack of evidence supporting an alternative cause for development of cytotoxic edema making PRES the most likely cause. Several studies have reported cytotoxic edema in PRES. In them, endothelial dysfunction seems to cause both vasogenic and cytotoxic edema occurs in PRES, with areas surrounding marked vasogenic edema usually progressing to cytotoxic edema. CONCLUSIONS: There is increasing evidence for development of PRES with several chemotherapy agents like carboplatin/paclitaxel. It may be characterized by vasogenic as well as cytotoxic edema. Cytotoxic edema is probably related to local decreased perfusion and arteriolopathy. Further research is warranted to understand the pathophysiologic mechanisms involved. It is important to recognize symptoms early and have a high clinical suspicion in spite of radiological evidence of cytotoxic edema, as PRES generally has an excellent prognosis with complete resolution. Reference #1: Janjua, T. K., Hassan, M., Afridi, H. K., & Zahid, N. A. (2017). Oxaliplatin-induced posterior reversible encephalopathy syndrome (PRES). BMJ case reports, 2017, bcr2017221571. https://doi.org/10.1136/bcr-2017-221571 Reference #2: Roth, C., & Ferbert, A. (2011). The posterior reversible encephalopathy syndrome: what's certain, what's new?. Practical neurology, 11(3), 136 -144. https://doi.org/10.1136/practneurol-2011-000010 Reference #3: Gao, B., Yu, B. X., Li, R. S., Zhang, G., Xie, H. Z., Liu, F. L., & Lv, C. (2015). Cytotoxic Edema in Posterior Reversible Encephalopathy Syndrome: Correlation of MRI Features with Serum Albumin Levels. AJNR. American journal of neuroradiology, 36(10), 1884 -1889. https://doi.org/10.3174/ajnr.A4379 DISCLOSURES: No relevant relationships by Bilal Bangash, source=Web Response No relevant relationships by Michael Buscher, source=Web Response No relevant relationships by Jay Parekh, source=Web Response No relevant relationships by Prachi Pednekar, source=Web Response No relevant relationships by Pranav Sharma, source=Web Response

Test characteristics of a 5-element cortical screen for identifying anterior circulation large vessel occlusion ischemic strokes.

ObjectiveStroke severity screens typically include cortical signs, such as field cut, aphasia, neglect, gaze preference, and dense hemiparesis (FANG‐D). The accuracy and reliability of these signs, when assessed by emergency physicians, to identify patients with anterior circulation large vessel occlusion (ACLVO) acute ischemic stroke (AIS) is unknown. We hypothesized that the FANG‐D screen applied by emergency physicians would be sensitive and reliable for identifying ACLVO AIS.MethodsWe conducted a prospective cohort study enrolling consecutive patients with suspected AIS presenting within 4.5 hours of last known well to the emergency department (ED). Emergency physicians performed the FANG‐D screen prior to, and blinded to the results of, imaging. The imaging standard was defined as a non‐contrast computed tomography (CT) for identifying hemorrhage and CT angiography for identifying large vessel occlusion. ACLVO was defined as an occlusion of the internal carotid artery, the middle cerebral artery, or its first branch. A convenience sample of patients had a duplicate FANG‐D screen performed by a second emergency physician to assess interobserver agreement.ResultsWe performed 608 FANG‐D assessments on 491 patients presenting to the ED, of whom 64 (10%) had an ACLVO. FANG‐D had a sensitivity of 91% (confidence interval [CI] = 81%–96%) and a specificity of 35% (CI = 31%–39%) for identifying ACLVO. Interobserver agreement was tested on 133 patients and was found to be substantial, with a Fleiss’ kappa of 0.77 (CI = 0.64–0.88).ConclusionsThe FANG‐D screen is a sensitive test for identifying ACLVO when performed by emergency physicians and demonstrates substantial interrater reliability.

A Week of Coronavirus in a Community Clinic

A Week of Coronavirus in a Community Clinic

Pre-stroke employment results in better patient-reported outcomes after minor stroke: Short title: Functional outcomes after minor stroke

ObjectiveIndividuals with “minor stroke” lack a dense hemiparesis or aphasia; however, commonly endorse persistent cognitive and motor problems despite low NIHSS scores. They also report problems with mood, energy, and the ability to think clearly that are less well characterized. Socioeconomic factors and stroke severity can influence patient-reported outcomes. In this study we explore patient-reported outcomes and the influence of these factors after minor stroke. Patients and MethodsPatients returning to clinic post-stroke with an NIHSS of ≤ 4 were administered a scale to quantify problems with daily activities and resulting functional burden, along with measures of fatigue and depression. T-tests, chi square analysis, and linear regression were used to compare functional outcomes of patients to controls (TIA or stroke mimic (n = 40)), and evaluate the association between patient-reported outcomes, stroke characteristics, and socioeconomic factors. Results151 stroke patients were seen a mean 83.6 days post-infarct. Patients reported more problems (11.7 versus 6.9, p = 0.02), resulting in higher functional burden (26.5 versus 12.3, p = 0.01), increased depression (p = 0.07), and greater fatigue (p = 0.02) compared to controls. There was no relationship between stroke characteristics (other than NIHSS), baseline education, income, marital status, or living situation and perception of recovery; however, those actively working prior to their stroke reported better outcomes across all categories (p for each <0.02), and differences persisted in multivariable regression models. ConclusionPrior occupational status may represent an important prognostic indicator for patients with minor stroke. Individuals working at the time of their infarct report better functional outcomes irrespective of age or stroke severity.

Acute Ischemic Stroke Following Cardioversion in a Patient Receiving Dabigatran

To report a case of acute ischemic stroke following electrical cardioversion in a patient currently anticoagulated with dabigatran 150 mg twice daily. A 74-year-old man, who had been adherent with more than 6 weeks of dabigatran 150 mg twice daily therapy, presented with a dense left-sided hemiparesis 72 hours following a repeat electrical cardioversion. Both computed tomography and magnetic resonance angiogram confirmed a right middle cerebral artery infarct. A transesophageal echocardiogram performed after the cerebrovascular accident failed to demonstrate a cardiac source of embolus. The patient previously underwent cardioversion 4 weeks prior with no evidence at that time of thrombus or spontaneous echo contrast on transesophageal echocardiogram. Dabigatran was approved in the United States in late 2010 for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation. Post hoc data from the phase III trial suggest a low risk of embolism following cardioversion. Since there are no conventional coagulation measures to reliably demonstrate the level of anticoagulation in patients on dabigatran, clinicians must rely solely on patient history when assessing the safety of cardioverting a patient on this medication. Data have suggested increased pro-inflammatory mediators and increased risk of myocardial infarction with oral direct thrombin inhibitors, which may have manifested as a cerebral or carotid artery thrombosis in situ. Novel oral anticoagulants are attractive options for anticoagulation required with cardioversion. Although this case report may not preclude use of dabigatran for this purpose, it illustrates that use of this drug is not without risks. Additional investigation into the pro-inflammatory nature of the oral direct thrombin inhibitors is needed.

Traumatic Thrombosis of Internal Carotid Artery Sustained by Transfer of Kinetic Energy

A 31-year-old male patient with a fatal thrombosis of the internal carotid artery caused by gun shot injury was presented in this case report. The patient was referred to the hospital with a diffuse edema on his left cheek. On otolaryngologic examination, there was a bullet entrance hole at the left mandibular corpus. No exit hole could be found. The finding from his axial computed tomography of neck and paranasal sinuses was normal. On neurological examination, a dense right hemiparesis was observed. In his cerebral angiogram, left common carotid artery was totally obliterated. Diffuse ischemia was observed in the left cerebral hemisphere. Despite intensive interventions, the patient died 4 days after the accident. In the autopsy, a large thrombosis was obtained in the left common carotid artery. This case emphasizes a fatal kinetic energy effect in vascular structures. It is stressed that a gun shot injury could be fatal with its indirect kinetic energy effects at subacute phase.

Surgical management of tumors producing the thalamopeduncular syndrome of childhood

Thalamopeduncular tumors arise at the junction of the inferior thalamus and cerebral peduncle and present with a common clinical syndrome of progressive spastic hemiparesis. Pathologically, these lesions are usually juvenile pilocytic astrocytomas and are best treated with resection with the intent to cure. The goals of this study are to define a common clinical syndrome produced by thalamopeduncular tumors and to discuss imaging characteristics as well as surgical adjuncts, intraoperative nuances, and postoperative complications relating to the resection of these neoplasms. The authors present a retrospective review of their experience with 10 children presenting between 3 and 15 years of age with a thalamopeduncular syndrome. Formal preoperative MR imaging was obtained in all patients, and diffusion tensor (DT) imaging was performed in 9 patients. Postoperative MR imaging was obtained to evaluate the extent of tumor resection. A prospective analysis of clinical outcomes was then conducted by the senior author. Pilocytic astrocytoma was the pathological diagnosis in 9 cases, and the other was fibrillary astrocytoma. Seven of 9 pilocytic astrocytomas were completely resected. Radical surgery was avoided in 1 child after DT imaging revealed that the corticospinal tract (CST) coursed through the center of the tumor, consistent with the infiltrative nature of fibrillary astrocytoma as identified by stereotactic biopsy. In 8 patients, tractography served as an important adjunct for designing a surgical approach that spared the CST. In 6 cases the CSTs were pushed anterolaterally, making a transsylvian approach a poor choice, as was evidenced by the first patient in the series, who underwent operation prior to the advent of tractography, and who awoke with a dense contralateral hemiparesis. Thus, subsequent patients with this deviation pattern underwent a transcortical approach via the middle temporal gyrus. One patient exhibited medial deviation of the tracts and another had lateral deviation, facilitating a transtemporal and a transfrontal approach, respectively. The thalamopeduncular syndrome of progressive spastic hemiparesis presenting in children with or without symptoms of headache should alert the examiner to the possibility of a tumoral involvement of CSTs. Preoperative tractography is a useful adjunct to surgical planning in tumors that displace motor pathways. Gross-total resection of pilocytic astrocytomas usually results in cure, and therefore should be entertained when developing a treatment strategy for thalamopeduncular tumors of childhood.

Uncooperative Mrs. Adams Got Her Way

Uncooperative Mrs. Adams Got Her Way

An Unusual Association between Unilateral Intracranial Vessels Occlusion with Iron Deficiency Anaemia and Alpha-Thalassemia Trait: A Case Report

We report a 33-year-old Malay woman presented with acute left dense hemiparesis and an NIHSS score of 11/15. Computed tomography (CT) scan brain showed a massive right middle cerebral artery (MCA) territory infarct. The right internal carotid artery (ICA) and right proximal MCA were shown occluded from digital substraction angiography (DSA). Carotid dissection, carotid canal anomaly, and intercavernous communication were systematically ruled out. She had no risk factors for atherosclerosis. The connective tissue screening and thrombophilic markers were negative. However, she was anaemic on admission and subsequent investigations revealed that she had alpha-thalassemia and iron deficiency anaemia. The right ICA remained occluded from a repeat CT cerebral angiogram after one year, but otherwise she was neurologically stable. This case illustrates an unusual association between intracranial vessel occlusion with iron deficiency anaemia and alpha-thalassemia trait.

POC14 Treatment-resistant hyponatraemia

A 37-year-old female presented with fluctuating focal neurological symptoms, signs and seizures. Initially the aetiology was suspected to be functional but review by the attending neurologist confirmed the diagnosis of...

Emergent Epidural Blood Patch

A 53-YEAR-OLD WOMAN had an embolic stroke affecting the right middle cerebral artery secondary to atrial fibrillation. Brain swelling developed, and a hemicraniectomy was performed. At discharge to rehabilitation, the patient was interactive but with dense left-sided hemiparesis. After 5 days, she returned with fever (temperature 39.2°C). The duraplasty was soft and elevated to the level of the skull (Figure, A). A lumbar puncture was performed in the emergency department as part of the workupforinfectiousdisease.Theopening pressure was 19 cm of water with normal cerebrospinal fluid. Over the next 3 days, the duraplasty became progressively depressed, yet mental status remained stable. On day 4, the patient became acutely obtunded with a dilated and nonreactive right pupil (Figure, B). She was immediately placed in the Trendelenburg position and treated with intravenous fluid repletion, without improvement in her condition. An emergent lumbar epidural blood patch was applied, resulting in restoration of consciousness and complete reversal of tissue shifts within 6 hours (Figure, C). She remained neurologically stable, and the patient underwent elective cranioplasty several weeks later. Figure Serial head computed tomograms show the temporal evolution of paradoxical herniation. A, On arrival in the emergency department, the patient's brain and duraplasty were elevated to the level of the skull. B, At the time of clinical deterioration, a significant ...

Delayed presentation of carotid artery dissection following major orthopaedic trauma resulting in dense hemiparesis

We report a 30-year-old patient who was involved in a high-velocity road traffic accident and developed a left-sided hemiparesis, which was noted in the post-operative period following bilateral femoral intramedullary nailing. CT scanning of the brain revealed infarcts in the right frontal and parietal lobes in the distribution of the right middle cerebral artery. CT angiography showed occlusion of the right internal carotid artery consistent with internal carotid artery dissection. He was anticoagulated and nine months later was able to walk independently. An awareness of this injury is needed to diagnose blunt trauma to the internal carotid artery. Even in the absence of obvious neck trauma, carotid artery dissection should be suspected in patients with a neurological deficit in the peri-operative period.

Bacterial endocarditis in a child presenting with acute arterial ischemic stroke: should thrombolytic therapy be absolutely contraindicated?

Thrombolysis is considered to be contraindicated in acute ischemic stroke secondary to infective endocarditis (IE). We report a 12-year-old female who presented with acute dense right hemiparesis and aphasia. Cranial magnetic resonance imaging and angiography showed multiple diffusion-restricted lesions in the left hemisphere and absence of flow in the left internal carotid artery. She was treated with intra-arterial tissue plasminogen activator within 6 hours of her presentation. Subsequently she was diagnosed with pneumococcal endocarditis and underwent debridement of vegetations and patch repair of the mitral valve. The patient did not have hemorrhagic complications following thrombolytic therapy or surgery. Pathological analysis of the mitral valve vegetations revealed mostly fibrin thrombus. Follow-up imaging showed complete recanalization of the left internal carotid artery, and the patient had a remarkable neurological recovery. This is the first case report of successful intra-arterial thrombolytic therapy in childhood IE-related stroke. We believe that thrombolytic therapy contributed to a favorable outcome in our patient and may be safe in selected patients with childhood IE-related acute ischemic stroke.

Retrosigmoid Approach to Ventrolateral Pontine AVM

There are a number of different surgical approaches to pontine lesions, such as the anterior transpetrosal (Kawase's) approach, lateral (presigmoid) approach, and rhomboid fossa approach. The anterior transpetrosal approach is only suitable for exophytic lesions and the rhomboid fossa approach is problematic because of the possible damage to neural structures in its path. Yoshitusugu Oiwa et al reported on the removal of a pontine lesion through the presigmoid approach in which the lateral surface of the pons is approached through a small window without any additional neurologic deficit. The authors report on the successful removal of a pontine AVM (intra-axial) situated on the rostral part of the pons (lateral pontine surface) between the CN V and VII-VIII complex through a conventional retrosigmoid approach using a small lateral incision. The patient complained of sudden-onset headache and right-sided hemiparesis; brain CT showed hematoma on the left ventrolateral pons. There was sudden decreased consciousness on the fifth day of admission and follow-up showed rebleeding on the site. After transfemoral cerebral angiography and brain MRI, the hematoma and lesion were removed via a left-sided retrosigmoid approach. The lesion was confirmed as a pontine AVM. The patient recovered consciousness on the fifth postoperative day and showed signs of dense right-sided hemiparesis, diplopia, central-type facial palsy (left), and hearing loss. Exams at 15 months postoperatively showed full recovery of diplopia with near normal recovery of hemiparesis and facial palsy, but the hearing deficit was not improved. The important neural structures of the pons are (1) the corticospinal tract in the ventral pons, (2) reticular formation in the central pons, and (3) most of the nucleus in the dorsal part of the pons (rhomboid fossa). The middle cerebellar peduncle is in the lateral pons but a small incision on the peduncle results in only transient aggravation of cerebellar ataxia, so a surgical approach through the lateral pontine surface is feasible, which makes the conventional retrosigmoid approach a excellent choice in that area.

Cerebral Infarction following Total Hip Replacement Arthroplasty in Geriatric Patient - A case report -

Perioperative cerebral infarction is uncommon and its mechanism is often uncertain. This is a report of an unusual case of acute cerebral infarction following general anesthesia. The patient was a 83-year-old female admitted for total hip replacement arthroplasty (THRA). There were no previous cerebro- and cardio-vascular symptoms and history. During introduced general anesthesia with sevoflurane, there was a persistent low systolic BP of 80-100 mmHg (preoperative BP was 140/85 mmHg). On emerging from anesthesia, confusion and dense right hemiparesis were observed. Emergency CT brain scan showed early cerebral infarction in the middle cerebral artery (MCA) territory. Even though prompt supportive neurosurgical intensive care was initiated, the patient died at postoperative 4 days.

Apraxia unilateral del cierre palpebral tras un ictus isquémico: el papel del hemisferio derecho en la comunicación gestual mocional

Apraxia of eyelid closure (AEC) is an infrequent disorder that is characterised by the inability to close the eyelids on command, although spontaneous blinking and reflex shutting of the eyes is preserved. Very few cases of unilateral AEC have been reported and no long-term follow-ups have been carried out. We report the case of a patient with unilateral AEC that was followed up over a 3-year period and also discuss the role played by the right hemisphere in this disorder. CASE REPORT" We examined the case of a 67-year-old right-handed male who was admitted because of a parietotemporal infarction with extension into the subcortex. A few days after the stroke the patient reported the inability to close his left eye on command, although he was still able to blink spontaneously and the blink and visual threat reflexes were preserved. This deficiency was associated to a dense hemiparesis on the left side and notable aprosodia affecting language. At 3 years' follow-up the AEC had not improved significantly. There are data to suggest that the right hemisphere is related to emotional perception and expressiveness, as well as the regulation of language prosody. Likewise, symbolic anthropology stresses the importance of winking as a gesture involved in non-verbal communication. These data suggest that AEC may be a consequence of a dysfunction of the role played by the right hemisphere in emotional expressiveness through gestures. The association with language aprosodia could support this hypothesis.

Combined Functional Task Practice and Dynamic High Intensity Resistance Training Promotes Recovery of Upper-extremity Motor Function in Post-stroke Hemiparesis

Weakness is a significant impairment in persons with post-stroke hemiparesis, yet traditional clinical perspectives caution against strengthening in neurological populations. Significant correlations between weakness and functional movement have been demonstrated, however, a clear relationship between increased strength and functional improvement has been elusive. This case study describes a combined program of dynamic, high-intensity resistance training and functional task practice for the upper-extremity in adult hemiparesis. The patient was a 65-year-old, right hand dominant woman who presented to the Neural Control of Movement Laboratory at the Palo Alto VA Rehabilitation Research and Development Center 16 weeks following clipping of an unruptured aneurysm with consequent dense right hemiparesis. She received 7 weeks of acute rehabilitation according to CARF guidelines (ie, at least 3 hours of two or more disciplines, 6 days per week). Her baseline research evaluation revealed significant upperextremity deficits at the ICF body structure/function level including: weakness, shoulder pain, mild resistance to passive movement, and need for moderate to maximal assistance in many activities of daily living including bathing and dressing. The Stroke Impact Scale score reporting her perspective indicated she had recovered from her stroke only 50%. The hybrid resistance training-functional task practice intervention, detailed in this report, was delivered 3 times per week for 6 weeks with each session lasting 75:00. The subject revealed marked improvements in isometric and dynamic force production in 5 key upper-extremity actions: elbow flexion, elbow extension, shoulder flexion, shoulder abduction, and shoulder external rotation. Strength gains were accompanied by increased EMG activation immediately postintervention and by a combination of increased activation and apparent hypertrophic effects at 6 month follow up. Marked improvements were noted in all clinical and functional measures and in an elbow trajectorytracking task which served as a surrogate measure of motor control. Improvements in strength and positive outcome effects at the physiological, clinical, and functional levels were observed in this subject following the experimental hybrid upper-extremity rehabilitation intervention described. Importantly, no deleterious effects were observed including exacerbation of spasticity or musculoskeletal compromise. Observations of improved EMG activation in this case study suggest that improvements in motor activation underlie these strength gains and can likely be attributed to working at a high intensity level.

Expanding the treatment window with mechanical thrombectomy in acute ischemic stroke

Acute ischemic stroke is a common disease associated with high mortality and significant long-term disability. Treatment options for acute ischemic stroke continue to evolve and include pharmaceutical and mechanical therapies. With the recent US Food and Drug Administration approval of a new device for mechanical thrombectomy, the options available for treatment of acute ischemic stroke have been expanded. Thrombolytic therapy is generally given intravenously in the first 3 h and up to 6 h via the intraarterial route for pharmacological clot disruption. The maximum time-frame for mechanical thrombectomy devices has yet to be determined. A 78-year-old female presented to the emergency room with a dense right hemiparesis, leftward gaze preference and dense global aphasia. Eight hours after symptom onset, left carotid angiography confirmed a left internal carotid artery terminus occlusion. A single pass was made through the clot with an X6 Merci Retriever device. After a single pass, the vessel was reopened and normal flow in the left internal carotid artery was demonstrated. At the time of discharge, her neurological deficits had improved significantly. Furthermore, the final infarct area, as demonstrated on magnetic resonance imaging, was probably much smaller than it would have been if the vessel had not been recanalized. We report the use of a new mechanical thrombectomy device 8 h after onset of ischemic symptoms, with substantial subsequent improvement in neurological outcome. In selected cases, use of the Merci Retriever can result in improved outcomes beyond the traditional 6-h window used for intraarterial pharmacological thrombolysis.