Hemispheric Syndrome Research Articles

Abstract TP130: Recurrent Hemispheric Stroke Syndromes in Symptomatic Atherosclerotic Internal Carotid Artery Occlusions: The COSS Trial

Background: There are limited data on the baseline characteristics and clinical outcomes of patients who have recurrent hemispheric syndromes in the territory of symptomatic atherosclerotic internal carotid artery occlusion (AICAO). Methods: Baseline characteristics and clinical outcomes were compared between patients with (rHEM+) and without (rHEM-) recurrent ipsilateral hemispheric syndromes at the time of randomization into the Carotid Occlusion Surgery Study (COSS) based on local investigator clinical impression. Results: Of 195 participants who were randomized, 100 (51%) were rHEM+ (50 in each study arm) and 95 were rHEM-(48 nonsurgical, 47 surgical). Baseline characteristics between rHEM+ and rHEM- participants were similar except that rHEM+ participants were more likely to have had a previous stroke prior to entry event (59% vs 22%, p < 0.001) and to have had TIA vs stroke as the entry event (61% vs 20%, p<0.001). All primary endpoints were ipsilateral ischemic strokes. There were no statistically significant differences in the primary endpoint between nonsurgical and surgical participants with rHEM+ (26.3% vs 22.4%, p=0.660) or rHEM- (18.9% vs 19.5%%, p=0.943). For secondary endpoints based on stroke severity and/or death, no important differences were noted between nonsurgical and surgical participants for the rHEMI+ and rHEMI- subgroups (all p > 0.10). For the nonsurgical participants, there was no statistically significant difference in the primary endpoint for those rHEM+ vs rHEM- (26.3% vs 18.9%, p=.410) Conclusion: Patients with recurrent hemispheric stroke syndromes enrolled in the COSS trial were more likely to have had previous stroke and to have TIAs as the entry event to randomization. Given the lack of surgical treatment benefit seen in these patients, early aggressive risk factor measures should be prioritized to reduce recurrent strokes, including blood pressure control which was associated with a 70% reduction in stroke in the nonsurgical group in COSS ( Neurology 2014; 82:1027-1032).

Hemisferectomía funcional: seguimiento a largo plazo en una serie de cinco casos

Functional hemispherectomy consists in palliative epilepsy surgical procedure usually performed in patients with pharmaco-resistant epilepsy and hemispheric syndromes. It is based on the neural disconnection of the affected hemisphere with preservation of the vascular supply. To analyze long-term prognosis and safety of the hemispherectomies performed in our institution. Retrospective analysis collecting the following variables: age, gender, age of epilepsy onset, type of seizures, etiology, age of epilepsy surgery, prognosis and potential surgical complications. All patients had a minimum of five years of follow up. Five patients (60% females) underwent hemispherotomy between 1999 and 2010. Age of epilepsy onset was 36 months and time of evolution until surgery was 7 years. The most frequent type of seizures were simple motor seizures with secondary generalization (n = 5). Three patients remained seizure free persistently after surgery and another patient had a more than 90% improvement. Time of follow up was 13 years. One patient suffered a bacterial meningitis without sequelae. Six years after surgery a patient suffered hydrocephalous requiring ventriculoperitoneal shunt. Functional hemispherectomy constitutes an effective method to treat patients with pharmaco-resistant epilepsy, extensive unihemispheric pathology and seizures limited to that hemisphere. Late complications may occur thus long-term follow-up is needed.

Hemispheric Disconnection Syndrome after Subarachnoid Hemorrhage with Hematoma in the Pericallosal Cistern

Hemispheric Disconnection Syndrome after Subarachnoid Hemorrhage with Hematoma in the Pericallosal Cistern

Misoplegia.

In 1974, Critchley described misoplegia as the phenomenon in which a hemiplegic patient develops a morbid dislike towards the offending immobile limbs. Patients with misoplegia may employ, but more commonly strike their paretic limbs not recognized as self. The pathophysiological mechanism is not well understood. The handful of cases of misoplegia described in the literature, frequently presented a right hemispheric damage. However, patients with chronic spinal cord injury may also present this symptomatology. Not only the modification of behavior by this organic injury, but also the patient reaction to disability and previous personality, may provoke the emergence of misoplegia, probably from other right hemispheric self-unawareness syndromes. No data exists related to treatment option, but we have to remember that the lack of awareness of the deficits in these patients makes the rehabilitation process difficult. Misoplegia is one of the passionate syndromes of the still "not-enough well-known" self-awareness syndromes of the right hemisphere, which shows how brain damage goes much further beyond neurological deficit.

Reversible hemispheric hypoperfusion in two cases of SMART syndrome

Stroke-like migraine attacks after radiation therapy (SMART) syndrome manifests as prolonged episodes of cortical dysfunction, years after cranial irradiation. We present two cases demonstrating reversible hemispheric hypoperfusion. Case 1 presented with left hemispheric symptoms following previous similar episodes. CT perfusion (CTP) demonstrated reversible hemispheric hypoperfusion; subsequent investigations were consistent with SMART syndrome. Case 2 presented following the third episode of a hemispheric syndrome with near-identical CTP abnormalities. L-arginine was administered with rapid reversal of clinical and CTP abnormalities. We conclude that SMART syndrome may demonstrate significant hypoperfusion on hyperacute CTP without subsequent infarction. Impaired cerebrovascular autoregulation probably contributes to cortical dysfunction in SMART syndrome. L-arginine warrants investigation as a potential treatment.

Abstract WP380: Simulation Based Acute Stroke Responders Training Improves Door-to-Thrombolytic Time

Background: The evaluation of acute ischemic stroke (AIS) patients should be performed expeditiously. Our stroke program maintained our Target: Stroke Honor Roll status in 2014, however, door-to-needle (DTN) time in Quarter 1 and 2 of 2015 showed no significant improvement and did not achieve DTN under 60 minutes in 75% of patients nor under 45 minutes in 50% of patients, despite in-servicing Emergency Department (ED)’s staff on program goals and order sets. The purpose of this project was to more effectively educate emergency stroke responders on clinical recognition and implementation of the organization’s stroke protocol order sets. Simulation as an experiential learning technique, promoting, applied thinking, delegation, and leadership skills. Evidence suggests simulation based training for adult learners promote their engagement and immediate application of learned material. Methods: Simulation: Stroke code responders, including 5 nurses per session, participated in the 90 minute scenario. Stroke protocol order sets were reviewed prior to the simulation of a right hemispheric syndrome. Participants elicited a focused history, National Institutes of Health Stroke Scale, relayed the findings to the neurologist, evaluate exclusion and inclusion criteria, and administered weight-based doses of tissue plasminogen activator (tPA). After a debrief, the participants repeated the simulation to reinforce new knowledge and skills. Descriptive statistics were used to compare mean DTN time before and after simulation training. Results: 153 ED nurses, 8 ED physicians, 6 neurologists, 4 pharmacists, 6 radiology technicians, and 10 phlebotomists participated. Pre -training Q1-Q2 2015 median DTN was 55 minutes, 65% </= 60 minutes, and 31% </= 45 minutes. Post-training data from Q1 2016 median DTN was 46 minutes, 75% </= 60 minutes, and 50% </= 45 minutes. Conclusion: Simulation based stroke responders training helped to decrease DTN time.

Craneotomía Rostrotentorial Descompresiva en un Carnero Reproductor

Este trabajo tuvo como objetivo presentar los resultados de una craneotomía rostrotentorial descompresiva realizada en un carnero Carriedale con severos signos neurológicos. El paciente presentaba un cuadro de paresia derecha producto de un síndrome de hemisferio izquierdo. La tomografía axial computarizada (TAC) mostró una masa tumoral en el hemisferio cerebral izquierdo. Con la finalidad de prolongar la vida del animal, dada su valía como reproductor, se realizó una craneotomía descompresiva. Se realizó la resección de una parte de la bóveda craneana a fin de dar más espacio al cerebro y aliviar la hipertensión endocraneana producida por dicha patología. Una vez recuperado de la anestesia, el animal presentó una remisión de los signos neurológicos. El paciente dejó de presentar torneo, ataxia y presión cefálica sobre las paredes al caminar. El paciente quedó bajo observación por un periodo de 20 días, durante el cual presentó buen ánimo y apetito. Los resultados obtenidos en la presente cirugía evidencian la posibilidad de emplear dicha técnica para el alivio de los signos clínicos neurológicos en animales que presenten neoplasias, edema, hematomas y coenurosis a nivel cerebral.

Utilidad de la tomografía computarizada cerebral multiparamétrica en el diagnóstico diferencial de patología comicial en el código ictus. Estudio preliminar

ObjectiveThirty percent of the patients for whom code stroke is activated have stroke mimics, the most common being epilepsy. Our purpose was to evaluate the usefulness of multiparametric CT for differentiating between seizure-related symptoms and vascular events. Material and methodsWe conducted a retrospective observational study; data were gathered prospectively during one year. We studied multiparametric CT images of patients admitted following code stroke activation and finally diagnosed with epilepsy. ResultsThe study included a total of 11 patients; 36% were men and mean age was 74.5 years. Three patients had right hemisphere syndrome, 4 displayed left hemisphere syndrome, and the remaining 4 had isolated aphasia. Maximum time from symptom onset to multiparametric CT study was 8.16hours. Perfusion CT results were normal in 2 patients. Nine patients showed longer or shorter times to peak (Tmax); cerebral blood volume (CBV) and cerebral blood flow (CBF) maps varied. EEG was performed a maximum of 47.6hours after symptom onset. Four patients showed findings compatible with status epilepticus, 2 displayed focal epileptiform activity, and 5 showed post-ictal slowing ipsilateral to perfusion CT abnormalities. ConclusionThe most sensitive parameter for differentiating between stroke and epilepsy in our series was increased time to peak in multilobar cortical locations in the absence of large-vessel occlusion and basal ganglia involvement. Multiparametric CT is a fast, readily available, and useful tool for the differential diagnosis of acute-onset neurological signs of epileptic origin in patients initially attended after code stroke activation.

Malignant hemispheric infarction of the middle cerebral artery. Diagnostic considerations and treatment options

IntroductionMalignant hemispheric infarction (MHI) is a specific and devastating type of ischaemic stroke. It usually affects all or part of the territory of the middle cerebral artery although its effects may extend to other territories as well. Its clinical outcome is frequently catastrophic when only conventional medical treatment is applied. ObjectiveThe purpose of this review is to analyse the available scientific evidence on the treatment of this entity. DevelopmentMHI is associated with high morbidity and mortality. Its clinical characteristics are early neurological deterioration and severe hemispheric syndrome. Its hallmark is the development of space-occupying cerebral oedema between day 1 and day 3 after symptom onset. The mass effect causes displacement, distortion, and herniation of brain structures even when intracranial hypertension is initially absent. Until recently, MHI was thought to be fatal and untreatable because mortality rates with conventional medical treatment could exceed 80%. In this unfavourable context, decompressive hemicraniectomy (DHC) has re-emerged as a therapeutic alternative for selected cases, with reported decreases in mortality ranging between 15% and 40%. ConclusionsIn recent years, several randomised clinical trials have demonstrated the benefit of DHC in patients with MHI. This treatment reduces mortality in addition to improving functional outcomes.

ID 395 – Effect of transcranial direct stimulation on pseudo-neglect in healthy subjects: Results of a pilot study

Background Subdominant hemispheric lesion results neglect syndrome, where the processing of the visual information coming from the contralateral side is damaged. A similar phenomenon is known in healthy subjects, called pseudo-neglect. In line bisection task there is a tendency to pay more attention to the left side of space. Method We involved 29 healthy subjects. Landmark task was used in a forced choice paradigm to determine the preferred space side. Then cathodal transcranial direct–current stimulation was used in the right region of posterior–parietal cortex. Landmark task was repeated. Fierro score was used to describe the precise choices and the reaction time was calculated. Results 67% of the subjects showed left pseudo-neglect, 22% showed right pseudo-neglect and in 11% pseudo-neglect was not detected. After the stimulation the number of the incorrect choices was increased ( p p p Conclusion Parietal lobe has a crucial role in spatial attention. It can be measured by neurocognitive tests that might serve as a test for the early detection of cognitive impairment. Key message Cathodal stimulation of the parietal lobe can induce a neglect-like symptom.

Hyperlalia: a right cerebral hemisphere syndrome.

We describe a new right hemispheric behavioural syndrome for which we propose the name "hyperlalia". In a typical case an apparently unconcerned and expressionless patient is easily prompted to remarkable volubility with a content which is loose and incoherent. The voice is low and monotonous. All the lesions confirmed by computed tomography of the brain overlapped in the perisylvian area in the territory of the right middle cerebral artery.Loss of a subtle balance between the left hemispheric speech area and the corresponding area in the right hemisphere caused by acute damage of the right perisylvian area may have resulted in disinhibition of the speech function. Similarities and dissimilarities with the known pathology of talkativeness are also discussed.

The development of pragmatic skills in children after hemispherotomy: Contribution from left and right hemispheres

Hemispherotomy (H) is the standard treatment used to cure hemispheric epileptic syndromes in childhood. The postoperative linguistic profile involves hemispheric specialization processes and developmental cognitive plasticity. This research concerns pragmatic aspects of language as a tool for communication which involves both linguistic and extralinguistic communication in context. Our aim was to analyze whether any correlation exists with age at surgery and side of surgery on pragmatic skills following H. Forty children who underwent H (23 females, 16 right H) were evaluated at a mean age of 12.8 years (±2.6) with two receptive tasks (oral comprehension and syntactic judgment), the Children's Communication Checklist (CCC) rating scale, and the Behavioral Rating Inventory of Executive Function (BRIEF) questionnaire in order to evaluate the role of executive functions on pragmatic skills. Children operated on before the age of 18 months were considered the "early" group (5 right H and 9 left H), while those operated on later were called the "late" group (11 right H and 15 left H). The whole group had significant deficits in all three measures. We demonstrated a statistically significant crossed interaction between the side of H and the age at H with pragmatic language impairments (F(1,36)=17.48; p=.0002) and disorders in executive function (F(1,36)=5.80; p=.021) in left early H and in right late H patients. These findings are consistent with the previous studies of pragmatic language impairments concerning adolescents and adults with right hemisphere damage and emphasize the contribution of structural language in the early stage of verbal communication. These results emphasize for the first time that hemispherotomized children have pragmatic language impairments that are independent of receptive language. Our findings are congruent with the recent theory on pragmatic language development in childhood with evidence of a participation of the left hemisphere at the early age followed by right hemispheric specialization and involvement of executive functions, independently of receptive language.

Domain features of cognitive impairment in patients with primary and recurrent ischemic hemispheric stroke in the acute phase of the disease

Research aimed on studying the cognitive impairment in the acute phase of stroke is relevant.Aim. The results of neuropsychological investigation оf 62 patients in the acute period of ischemic hemispheric stroke are described in the article.Methods and results. It has been detected that predementіal cognitive disturbances and mild dementia are prevailed in the structure of cognitive disorders in primary stroke, while in recurrent brain ischemia the mild and moderate dementia dominates. The features of cognitive disorders have been detected by Mini-Menthal State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and Frontal Assessment Battery (FAB) scales and they depend on the affected hemisphere in primary and recurrent ischemic hemispheric stroke.Conclusion. Hemispheric syndromes of cognitive deficits has been established on the basis of domains impairments.

Abstract W P298: Simulation Based Acute Stroke Training for Neurology Residents

Background: The majority of patients presenting with acute stroke in teaching hospitals are assessed by neurology residents. Simulation based training has been shown to be an effective teaching tool in medical education. We sought to determine whether simulation based training improves learner confidence in the evaluation and management of acute ischemic stroke. Methods: We devised a simulated acute stroke scenario utilizing a standardized patient instructed to act out a right hemispheric syndrome and an emergency department nurse. Scenarios were performed in May/June of 2013 and April/May of 2014. Laboratory values, vitals, electrocardiogram and a normal head computerized tomography scan were shown to the residents. Residents were expected to efficiently take a focused history, perform an NIHSS exam, evaluate exclusion and inclusion criteria, obtain informed consent for thrombolysis administration and give the correct dose of t-PA. Following t-PA administration, the patient develops an acute severe headache and the learner is evaluated on whether they immediately discontinue the infusion and initiate appropriate management steps for t-PA associated hemorrhage. Following the scenario the learner met one on one with staff for a debriefing session. Learner confidence in the management of acute stroke was assessed before and after the simulation experience using a 5 point Likert scale with 1=novice, 3=competent and 5=expert. Following the simulation, learners were asked to evaluate the experience (poor, needs improvement, good or outstanding). Results: 21 Neurology residents completed the scenario (11 in 2013 and 10 in 2014). Learner confidence improved from mean 2.81(SD-0.88) to 3.36(SD-0.73), p=0.03. Evaluations were favorable with all residents reporting a ‘good’ or ‘outstanding’ experience. Conclusion: We have demonstrated that simulation training in the evaluation of acute ischemic stroke among neurology residents is feasible and improves learner self-confidence.

Manifestations of stroke

The book is divided into two parts namely “Neurologic and Other Disorders” and “Topographic Syndromes”. The first section begins with the motor syndromes, the most common stroke clinical syndrome. The authors have elaborated the various motor manifestations in a simple way. The stroke sensory syndromes are dealt with in a concise manner. The chapter on eye movement abnormalities is very informative. However, inclusion of a few images showing the neuroanatomical pathway would have made it easy to understand. The chapter on visual dysfunctions deals with the visual symptoms in relation to the optic nerve pathway and also covers various visual phenomena. One of the important aspects of stroke clinical diagnosis is differentiating between anterior and posterior circulation strokes. The chapter on dizziness and vertigo explains the clinical clues in localising posterior circulation strokes in relation to the presence of dizziness and vertigo. The chapter “Impaired Consciousness”, covers the various types of disturbances in consciousness. Also, the coma like states which are important in the prediction of prognosis in stroke patients have been discussed. The chapter on language disorders in stroke is very simple and easy to understand. The common language dysfunctions in stroke are discussed well. The section on memory dysfunction is short and crisp. One of the intriguing aspects of stroke is right hemisphere syndromes. Although the symptomatologies of right hemisphere stroke have been enumerated, this section could have been organized better to improve readability. Vascular cognitive impairment (VCI) is an important post-stroke disability. Post-stroke dementia and cognitive impairment are covered well including the various criteria used for the diagnosis of VCI. One of the neglected disabilities is anxiety and depression after stroke. The chapter on mood disorders contains the risk factors for anxiety and depression after stroke. In addition, the authors have elaborated on the diagnosis and treatment of these conditions. Stroke disconnection syndromes such as apraxia, agnosia, etc, are described in detail. The common disconnection syndromes are also explained well. Autonomic dysfunctions in stroke are commonly seen. The salient autonomic syndromes that occur following stroke are highlighted along with explanation on the neuroanatomical correlates. Another common speech disorder which occurs in stroke is dysarthria/mutism which can vary according to the site of the lesion and this section also is well covered. The pathophysiology, diagnosis and treatment of post-stroke dysphagia are discussed in a comprehensive manner including the various tools used to evaluate dysphagia. Certain strokes can present with breathing difficulties. The physiology, pathophysiology and clinical syndromes of ventilatory disorders are dealt with methodically. The chapter on lacunar strokes describes the different types of lacunar syndromes and also focus on the pathogenesis and outcome in these patients. The second section of the book begins with a lucid chapter on arterial territories of the brain. Brain maps of various territories in the cerebrum, brainstem and cerebellum are included. The territories depict the neuroimaging sections in clinical practice. This section lays down the foundation for the remaining chapters of the book. All the chapters begin with basic anatomy, aetiology and then elaborate the clinical features. The chapters on thalamic, caudate and putaminal infarcts/haemorrhages are very informative. The pathophysiology of lobar haemorrhage including the mechanisms of raised intracranial tension is explained clearly. The chapter on subarachnoid and intraventricular haemorrhage gives an overview of the two important conditions. The large hemispheric infarction deals with the current concepts in pathophysiology and also about the recent surgical trials. There is some degree of repetition in the chapters on midbrain, pontine and medullary strokes. The presentations, aetiologies and prognosis of cerebellar strokes are appropriate. The strokes in the territories of vertebral, basilar and carotid arterial occlusions are described very well. Finally, the last last two chapters also discuss venous ischaemic and spinal cord syndromes. In the era of modern technology where less importance is given for bedside skills, this book will be a great asset to neurology residents, neurologists and stroke neurologists/physicians.

Mapping causal functional contributions derived from the clinical assessment of brain damage after stroke.

Lesion analysis reveals causal contributions of brain regions to mental functions, aiding the understanding of normal brain function as well as rehabilitation of brain-damaged patients. We applied a novel lesion inference technique based on game theory, Multi-perturbation Shapley value Analysis (MSA), to a large clinical lesion dataset. We used MSA to analyze the lesion patterns of 148 acute stroke patients together with their neurological deficits, as assessed by the National Institutes of Health Stroke Scale (NIHSS). The results revealed regional functional contributions to essential behavioral and cognitive functions as reflected in the NIHSS, particularly by subcortical structures. There were also side specific differences of functional contributions between the right and left hemispheric brain regions which may reflect the dominance of the left hemispheric syndrome aphasia in the NIHSS. Comparison of MSA to established lesion inference methods demonstrated the feasibility of the approach for analyzing clinical data and indicated its capability for objectively inferring functional contributions from multiple injured, potentially interacting sites, at the cost of having to predict the outcome of unknown lesion configurations. The analysis of regional functional contributions to neurological symptoms measured by the NIHSS contributes to the interpretation of this widely used standardized stroke scale in clinical practice as well as clinical trials and provides a first approximation of a ‘map of stroke’.

Epilepsy surgery failure in children: a quantitative and qualitative analysis.

Resection is a safe and effective treatment option for children with pharmacoresistant focal epilepsy, but some patients continue experience seizures after surgery. While most studies of pediatric epilepsy surgery focus on predictors of postoperative seizure outcome, these factors are often not modifiable, and the reasons for surgical failure may remain unclear. The authors performed a retrospective cohort study of children and adolescents who received focal resective surgery for pharmacoresistant epilepsy. Both quantitative and qualitative analyses of factors associated with persistent postoperative seizures were conducted. Records were reviewed from 110 patients, ranging in age from 6 months to 19 years at the time of surgery, who underwent a total of 115 resections. At a mean 3.1-year follow-up, 76% of patients were free of disabling seizures (Engel Class I outcome). Seizure freedom was predicted by temporal lobe surgery compared with extratemporal resection, tumor or mesial temporal sclerosis compared with cortical dysplasia or other pathologies, and by a lower preoperative seizure frequency. Factors associated with persistent seizures (Engel Class II-IV outcome) included residual epileptogenic tissue adjacent to the resection cavity (40%), an additional epileptogenic zone distant from the resection cavity (32%), and the presence of a hemispheric epilepsy syndrome (28%). While seizure outcomes in pediatric epilepsy surgery may be improved by the use of high-resolution neuroimaging and invasive electrographic studies, a more aggressive resection should be considered in certain patients, including hemispherectomy if a hemispheric epilepsy syndrome is suspected. Family counseling regarding treatment expectations is critical, and reoperation may be warranted in select cases.

Аlterationdegree of NMDA and AMPA receptors of glutamate in the pathogenesis of the disease and technological peculiarities of surgical treatment of the hemispheric glioma-swith the epileptic syndrome

The development of effective approaches to the treatment of patients with symptomatic tumor epilepsy was determined by the level of our fundamental knowledge of the basic mechanisms of epileptogenesis on cellular and molecular level. 92 patients with gliomas of the cerebral hemisphereswere examined. Immunoenzyme method ofsemiquantitative determination of the level of autoantibodies to NR2A subunit of NMDA and GluR1 subunit of AMPA receptors of glutamate was used. The reaction of NMDA and AMPA glutamate receptors depending on the availability of an epileptic syndrome in the clinical picture of the disease and the extent of radical surgery has been studied. Pre-emptive increase of the level of autoantibodies to GluR1 subunit of AMPA receptors of glutamate in patients with hemispheric gliomaswith epileptic syndrome was demonstrated. It was foundonly the total removal of the tumor reduced significantly the level of autoantibodies to ionotropic glutamate receptors.

Myocardial Infarction as a Complication in Acute Stroke: Results from the Austrian Stroke Unit Registry

Background: Patients with transient ischemic attack (TIA) and stroke have an increased risk for subsequent cardiac events including myocardial infarction (MI), which might be associated with a worse clinical outcome. Rapid identification of stroke patients at higher risk for MI might foster intensified cardiac monitoring or certain therapeutic strategies. However, information regarding acute MI as a complication of stroke in the very acute phase is limited. Moreover, there are no systematic data on the occurrence of MI following intracerebral hematoma. We thus aimed to assess the frequency, clinical characteristics and short-term outcome of patients suffering from acute MI in the stroke unit setting. Methods: We analyzed 46,603 patients from 32 Austrian stroke units enrolled in the prospective Austrian Stroke Unit Registry because of TIA/acute stroke over a 6-year period (January 1, 2007 to January 13, 2013). A total of 41,619 patients (89.3%) had been treated for TIA/ischemic stroke and 4,984 (10.7%) for primary intracerebral hemorrhage (ICH). Acute MI was defined according to clinical evaluation, ECG findings and laboratory assessments. Patients with evidence for MI preceding the cerebrovascular event were not considered. Results: Overall, 421 patients (1%) with TIA/ischemic stroke and 17 patients (0.3%) with ICH suffered from MI during stroke unit treatment for a median duration of 3 days. Patients with TIA/ischemic stroke and MI were significantly older, clinically more severely affected and had more frequently vascular risk factors, atrial fibrillation and previous MI. Total anterior circulation and left hemispheric stroke syndromes were more often observed in MI patients. Patients with MI not only suffered from worse short-term outcome including a higher mortality (14.5 vs. 2%; p < 0.001) at stroke unit discharge, but also acquired more stroke complications like progressive stroke and pneumonia. Multivariate analyses identified previous MI and stroke severity at admission (according to the National Institutes of Health and Stroke Scale score) as factors independently associated with the occurrence of MI on the stroke unit. Conclusions: While quite rare in the acute phase after stroke, MI is associated with a poor short-term outcome including a higher mortality. Patients with previous MI and severe stroke syndromes appear to be at particular risk for MI as an early complication in the stroke unit setting. Further studies are needed to determine whether increased vigilance and prolonged (cardiac) monitoring or certain therapeutic approaches could improve the outcome in these high-risk patients.

Mechanical thrombectomy – an alternative treatment option in a patient with acute ischemic stroke and multiple contraindications for systemic thrombolysis: a case report

IntroductionAcute ischemic stroke is a common cause of disability and death in developed countries. Standard therapy for patients who present within 4.5 hours from the onset of symptoms is intravenous thrombolysis if contraindications such as oral anticoagulation, cancer or recent surgery are ruled out. Apart from that, mechanical recanalization is a new treatment option for patients with occlusion of major cerebral arteries as a cause of ischemic stroke.Case presentationIn this case report we describe a 55-year-old Caucasian man with a right hemispheric ischemic syndrome who presented in time but who had multiple contraindications against systemic thrombolysis. He was then treated with mechanical recanalization and recovered. On discharge from the hospital he had only a slight left-sided facial paresis and discrete impairment of motion smoothness in his left hand.ConclusionWe conclude that multimodal imaging should be performed in all patients with an acute onset of neurological symptoms suspicious of ischemic stroke, even if they have contraindications against an intravenous thrombolytic treatment.