Recurrent Transient Ischemic Attacks Research Articles

Early initiation of rivaroxaban after reperfusion therapy for stroke patients with nonvalvular atrial fibrillation.

BackgroundThe optimal timing of initiating oral anticoagulants after reperfusion therapy for ischemic stroke is unknown. Factors related to early initiation of rivaroxaban and differences in clinical outcomes of stroke patients with nonvalvular atrial fibrillation (NVAF) who underwent reperfusion therapy was investigated.MethodsFrom data of 1,333 NVAF patients with ischemic stroke or transient ischemic attack (TIA) in a prospective multicenter study, patients who started rivaroxaban after intravenous thrombolysis and/or mechanical thrombectomy were included. The clinical outcomes included the composite of ischemic events (recurrent ischemic stroke, TIA, or systemic embolism) and major bleeding at 3 months.ResultsAmong the 424 patients, the median time from index stroke to starting rivaroxaban was 3.2 days. On multivariable logistic regression analysis, infarct size (odds ratio [OR], 0.99; 95%CI, 0.99–1.00) was inversely and successful reperfusion (OR, 2.13; 95%CI, 1.24–3.72) was positively associated with initiation of rivaroxaban within 72 hours. 205 patients were assigned to the early group (< 72 hours) and 219 patients (≥ 72 hours) to the late group. Multivariable Cox regression models showed comparable hazard ratios between the two groups at 3 months for ischemic events (hazard ratio [HR], 0.18; 95%CI, 0.03–1.32) and major bleeding (HR, 1.80; 95%CI, 0.24–13.54).ConclusionsInfarct size and results of reperfusion therapy were associated with the timing of starting rivaroxaban. There were no significant differences in the rates of ischemic events and major bleeding between patients after reperfusion therapy who started rivaroxaban < 72 hours and ≥ 72 hours after the index stroke.Clinical trial registrationUnique identifier: NCT02129920; URL: https://www.clinicaltrials.gov.

Timing of Carotid Intervention in Symptomatic Cerebrovascular Disease: Outcomes of a Single-Institution Experience

The optimal timing for carotid endarterectomy in patients with symptomatic cerebrovascular disease has remained unclear. We compared the clinical outcomes of carotid endarterectomy performed before and 2 weeks after symptom onset. A retrospective analysis was performed of patients who had presented to our institution with symptomatic cerebrovascular disease, defined by the presence of transient ischemic attack (TIA) or cardiovascular accident (CVA) symptoms, from January 2012 to February 2020. The data collected included demographics, National Institutes of Health stroke scale (NIHSS) and modified Rankin scale (mRS) scores, and postoperative complications, including recurrent TIA or CVA, myocardial infarction, and death during admission and at discharge. The patients were followed up for 1 year. The primary end points included NIHSS scores, mRS scores, and changes in the scores from baseline to 30 days, with the secondary end points extending to 90 days and 1 year. A total of 169 patients were included, of whom, 58.6% had undergone carotid endarterectomy within 2 weeks of symptom onset. The baseline demographic and clinical characteristics were similar between groups. No differences in the primary or secondary end points were demonstrated at any interval (P = 1.0, P = .77, and P = .4 for the 30-day NIHSS score, mRS score, and 30-day change in the mRS score, respectively; and P = .9, P = .22, and P = .07 for the 90-day NIHSS score, mRS score, and 1-year mRS score, respectively). We found a difference in postoperative complications, including recurrent TIA/CVA, myocardial infarction, and death. A subgroup analysis of interventional neurology involvement was performed; they had evaluated 44.4% of the patients. No further intervention was required for 42.7%, diagnostic cerebral arteriography was performed in 36.0%, and an additional intervention was required for 21.3%. Interventional neurology involvement demonstrated no differences in the primary or secondary end points. Carotid endarterectomy was safe if performed within 2 weeks of symptom onset with equivalent outcomes compared with delayed surgery. Involvement of interventional neurology did not affect the neurologic outcomes for early vs late operative timing.

Safety and efficacy of left atrial appendage closure combined with patent foramen ovale closure for atrial fibrillation patients with patent foramen ovale

Objective: To analyze the safety and efficacy of combined left atrial appendage (LAA) and patent foramen ovale (PFO) closure in adult atrial fibrillation (AF) patients complicating with PFO. Methods: This study is a retrospective and cross-sectional study. Seven patients with AF complicated with PFO diagnosed by transesophageal echocardiography (TEE) in Zhoupu Hospital Affiliated to Shanghai University of Medicine & Health Sciences from June 2017 to October 2020 were selected. Basic data such as age, gender and medical history were collected. The atrial septal defect or PFO occluder and LAA occluder were selected according to the size of PFO, the ostia width and depth of LAA. Four patients underwent left atrial appendage closure(LAAC) and PFO closure at the same time. PFO closure was performed during a one-stop procedure of cryoablation combined with LAAC in 2 patients. One patient underwent PFO closure at 10 weeks after one-stop procedure because of recurrent transient ischemic attack (TIA). All patients continued to take oral anticoagulants. TEE was repeated 8-12 weeks after intervention. In case of device related thrombus(DRT), TEE shall be rechecked 6 months after adjusting anticoagulant and antiplatelet drug treatment. Patients were follow-up at 1, 3, 6, 12, 24 months by telephone call, and the occurrence of cardio-cerebrovascular events was recorded. Results: Among the 7 patients with AF, 2 were male, aged (68.0±9.4) years, and 3 had a history of recurrent cerebral infarction and TIA. Average PFO diameter was (3.5±0.8)mm. Three patients were implanted with Watchman LAA occluder (30, 30, 33 mm) and atrial septal defect occluder (8, 9, 16 mm). 2 patients were implanted with LAmbre LAA occluder (34/38, 18/32 mm) and PFO occluder (PF1825, PF2525). 2 patients were implanted with LACbes LAA occluder (24, 28 mm) and PFO occluder (PF2525, PF1825) respectively. The patients were followed up for 12 (11, 24) months after operation. TEE reexamination showed that the position of LAA occluder and atrial septal defect occluder or PFO occluder was normal in all patients. DRT was detected in 1 patient, and anticoagulant therapy was adjusted in this patient. 6 months later, TEE showed that DRT disappeared. No cardiovascular and cerebrovascular events occurred in all patients with AF during follow-up. Conclusions: In AF patients complicated with PFO, LAAC combined with PFO closure may have good safety and effectiveness.

Bilateral Carotid Stenosis in a Patient with Previous Neck Surgery: Difficulties in Endarterectomy

Carotid stenosis is an important cause of recurrent transient ischemic attacks and stroke. Carotid stenting and endarterectomy are considered equally effective in treating this condition. We report a patient with recurrent TIA and bilateral carotid stenosis who had undergone anterior cervical diskectomy and fusion and who was found to have fibrous bands encasing the right carotid artery. He was treated with endarterectomy on the left side and carotid stenting on the right side. With the widespread availability of procedures like carotid endarterectomy, more older people would undergo this surgery, who might have undergone anterior cervical surgery. Prior neck surgery and adhesions may lead to altered anatomy, risk of increased blood loss, and surgical complications. In such cases, carotid stenting could be an alternative to endarterectomy.

Recurrent transient ischemic attacks in a moyamoya syndrome patient with ultra-long imaging follow-up.

Recurrent transient ischemic attacks in a moyamoya syndrome patient with ultra-long imaging follow-up.

Preoperative antithrombotic treatment in acutely symptomatic carotid artery stenosis

ObjectivesEarly recurrence of cerebral ischemia in acutely symptomatic carotid artery stenosis can precede revascularization. The optimal antithrombotic regimen for this high-risk population is not well established. Although antiplatelet agents are commonly used, there is limited evidence for the use of anticoagulants. We sought to understand the safety and efficacy of short-term preoperative anticoagulants in secondary prevention of recurrent cerebral ischemic events from acutely symptomatic carotid stenosis in patients awaiting carotid endarterectomy (CEA). Materials and MethodsA retrospective query of a prospective single institution registry of carotid revascularization was performed. Patients who presented with acute ischemic stroke or transient ischemic attack (TIA) attributable to an ipsilateral internal carotid artery stenosis (ICA) were included. Antiplatelet (AP) only and anticoagulation (AC) treatment arms were compared. The primary outcome was a composite of preoperative recurrent ischemic stroke or TIA. The primary safety outcome was symptomatic intracranial hemorrhage. ResultsOut of 443 CEA patients, 342 were in the AC group and 101 in the AP group. Baseline characteristics between groups (AC vs AP) were similar apart from age (71±10.5 vs 73±9.5, p=0.04), premorbid modified Rankin scale (mRS) score (1.0±1.2 vs 1.4±1.3, p=0.03) and stroke as presenting symptom (65.8 vs 53.5%, p=0.02). Patients in the AC group had a lower incidence of recurrent stroke/TIA (3.8 vs 10.9%, p=0.006). One patient had symptomatic intracranial hemorrhage in the AC group, and none in the AP group. In multivariate analysis controlling for age, premorbid mRS, stroke severity, degree of stenosis, presence of intraluminal thrombus (ILT) and time to surgery, AC was protective (OR 0.30, p=0.007). This effect persisted in the cohort exclusively without ILT (OR 0.23, p=0.002). ConclusionsShort term preoperative anticoagulation in patients with acutely symptomatic carotid stenosis appears safe and effective compared to antiplatelet agents alone in the prevention of recurrent cerebral ischemic events while awaiting CEA.

CADASIL in the Differential Diagnosis of Atypical Parkinsonism. Case Report

Autosomal dominant cerebral arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited small vessel disease caused by mutations in the NOTCH3 gene. The clinical spectrum includes migraine, transient ischemic attacks and/or recurrent strokes, and cognitive impairment. The presence of signs and symptoms of Parkinsonism are poorly described in the phenotype of this disease. This case report was approved by the Ethics Committee of Universidade Metropolitana de Santos. Case Report: The present case refers to a 59-year-old female patient presenting with recurrent transient ischemic attacks, chronic migraine, depression and bilateral akinetic-rigid parkinsonism. Brain MRI showed diffuse and confluent lesions. The genetic study showed a de novo heterozygous pathogenic variant in the NOTCH3 gene. Symptomatic treatment with multiprofessional rehabilitation was instituted with partial improvement of symptoms.

Abstract TP162: Long-term Experience With Resolute Onyx Balloon Mounted Stent For Medically Refractory Intracranial Atherosclerotic Disease Evaluated By Wingspan Stent System Post Market Surveillance (WEAVE) Methodology

Background and Purpose: Angioplasty and stenting is a therapeutic option for patients with medically refractory intracranial atherosclerotic disease (ICAD). We previously demonstrated the feasibility of using Resolute (R) Onyx Stent, a drug-eluting balloon mounted coronary stent (DES), for ICAD patients. WEAVE (Wingspan Stent System Post Market Surveillance) trial assessed the periprocedural safety of Wingspan Stents in ICAD patients. We present our on-going experience with R-Onyx in ICAD patients integrating WEAVE styled methodology to assess outcomes in our cohort. Methods: A prospectively maintained neuro-endovascular database was queried for intracranial angioplasty and stenting cases from October 2019 to June 2021. Patients with symptomatic ICAD despite maximum medical management with &gt;70% stenosis who were treated with R-Onyx DES were included. Primary outcomes were assessed according to WEAVE trial criteria (ischemic or hemorrhagic stroke or death within 72 h of the procedure). Secondary outcomes were assessed by occurrence of stroke and/or in-stent restenosis evaluated 30 days post-procedure clinically or angiographically. Results: A total of 58 patients were eligible for analysis with a mean age of 63.66 years, and 63.8% (n=37) were males. A total of 42 patients had an indication for treatment consisting of recurrent stroke while 16 had recurrent transient ischemic attacks. A total of 62 R-onyx DES stents were used to treat 58 patients with symptomatic lesions with an average stenosis of 84.7%. All procedures were completed successfully with &lt;30% residual stenosis and 1.7% (n=1) of patients having hemorrhage and death within 72 h. Out of 41 patients who had a long-term follow-up, 0 had a stroke. In terms of 6-month angiographic follow-ups, 1 patient had in-stent restenosis treated via angioplasty. Conclusion: Our study reinforces the feasibility of R-Onyx DES for treatment of ICAD refractory to maximal medical management by reporting low periprocedural complication rates (1.7%) according to WEAVE methodology, which itself had a periprocedural complication rate of 2.6%, and low long-term frequencies of indications such as strokes and restenosis. These findings perhaps warrant randomized comparative studies between the stents.

Abstract TP193: Atrial Fibrillation Burden Is Not Associated With Recurrent Cerebrovascular Events In Anticoagulated Stroke Patients: An Arest Trial Sub-study

Introduction: The burden of Atrial Fibrillation (AF) has previously been associated with a higher stroke risk in non-anticoagulated patients. We aim to find whether there is also an association between AF burden and recurrent cerebrovascular events in anticoagulated AF patients after their initial acute ischemic stroke (AIS) or transient ischemic attacks (TIA). Methods: The AREST study (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation) was a multi-center, randomized controlled trial of early apixaban versus warfarin at one week post-TIA or two weeks post-AIS, in AF patients from 2015 to 2019. Subjects received either 30-day continuous electrocardiographic monitoring or an implantable device (i.e., pacemaker, loop recorder, or defibrillator). Logistic regression and Kendall's tau-b test were utilized to identify an association between AF burden and the proportion of subjects who developed recurrent cerebrovascular events. Results: Of 91 subjects enrolled into AREST, heart rhythm monitoring was assessed in 49 (54%); over half (59%) clustered at the extreme ends of the distribution, at either low (≤1%) or high (≥99%) AF burden. Higher AF burden was not significantly correlated with an increased risk of recurrent stroke or TIA (Odds Ratio = 0.99 [95% confidence interval (CI), 0.98-1.0]; p=0.518). Moreover, there was no statistically significant association between AF burden and the composite outcomes after adjusting for either apixaban or warfarin. Conclusions: AF Burden was not found to be associated with recurrent cerebrovascular events in patients taking oral anticoagulant after an AIS or TIA. Further research is needed to confirm these findings.

Delayed Development of Symptomatic Arterial Stenosis after a Mechanical Thrombectomy for an Acute Embolic Occlusion of the Middle Cerebral Artery

Delayed stenosis of the treated artery following mechanical thrombectomy is known to occur in approximately 10% of the patients after the procedure. It is usually asymptomatic, and was frequently found within 1 year after the procedure. Here we report a 58-year-old stroke patient who suffered from recurrent transient ischemic attacks due to a delayed stenosis of the middle cerebral artery 2 years after the mechanical thrombectomy for an abrupt embolic occlusion of the vessel.

Percutaneous Patent Foramen Ovale Closure in Patients with Cryptogenic Stroke or Transient Ischemic Attack: A Retrospective Study.

Background Patent foramen ovale (PFO) is associated with cryptogenic stroke (CS). Transcatheter closure of PFO is superior to pharmacotherapy for patients with CS or transient ischemic attack (TIA). More evidence is needed to evaluate the efficacy and safety of PFO closure in Chinese patients. Methods This study enrolled ten CS patients and two TIA patients (mean age of 40.8 ± 9.7 y), including seven males (58%) and five females (42%) who underwent PFO closure in our center from January 2017 to July 2019. Baseline data, imaging data, and RoPE (Risk of Paradoxical Embolism) score were collected retrospectively. The preprocedural assessment and percutaneous transcatheter PFO closure were described in detail. The perioperative complications and follow-ups were recorded from all patients. Results Among ten patients with CS, eight patients had a RoPE score of >6 and two patients had a RoPE score of 6. MRI confirmed multiple infarcts in seven cases, and infarct involving the cortex in nine cases. Abnormal ECG was found in three patients and abnormal Echo in four patients. Right-to-left shunt (RLS) was detected in all the patients by cTCD or cTTE. To be specific, RLS was observed in nine of the ten TEE-detected patients. No case had PFO complicated with atrial septal aneurysm (ASA). The success rate of PFO closure was 91.6%. No serious perioperative complications were observed. During a mean time of 26.5 ± 8 months (15-41 months) of follow-up, no recurrent cerebral infarction, TIA, or thromboembolism were detected in postoperative patients. Conclusions PFO closure is safe and effective in the treatment of Chinese patients with CS or TIA.

A case of acute confusional state in a patient of chronic hemolytic anemia with secondary Moya–Moya disease

Acute confusional state is characterized by disturbed consciousness, cognitive function, or perception. It can develop over a period of hours to days. It can be because of intracranial hemorrhage, central venous sinus thrombosis, stroke, meningoencephalitis, metabolic abnormalities, adverse drug reactions, etc. Moya–moya disease is a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain in the basal ganglia and means “puff of smoke” appearance which describes the look of the tangled vessels. It can present as stroke or recurrent transient ischaemic attacks. Secondary moya–moya disease can be caused by infections, connective tissue disorders, vasculitis, autoimmune disorders, trauma, hematological conditions, atherosclerosis, etc. Here, we present a case of 14-year-old female, known case of Beta Thalassemia who presented with acute confusional state, incidentally diagnosed with secondary moya–moya and tuberculous meningitis. Acute confusional state here was attributed to tuberculous meningitis.

ANAESTHETIC MANAGEMENT OF A CHILD WITH MOYA MOYA DISEASE A RARE CASE

Moya Moya disease (MMD) is a rare cerebrovascular occlusive disorder resulting from progressive stenosis of intracranial blood vessels with secondary development of an anastomotic capillary network. Moya Moya is the Japanese term for “puff of smoke appearance” and it refers to the angiographic finding of a cluster of small abnormal blood vessels. The classic paediatric presentation in this disorder is recurrent transient ischaemic attacks (TIA) and /or completed or repeated ischemic strokes. Medical treatment aimed at decreasing ischemic symptoms by using Vasodilators and anti-coagulants. The main stay of treatment includes direct and indirect surgical revascularisation procedures. Risk factors for peri operative complications are history of TIA’s, severity of disease, intraoperative hypotension, hypercapnia, hypovolemia, and significant reduction in haematocrit and circulating blood volume.

Prognosis of patients assisted in the emergency unit by the 'TIA protocol' in a third-level hospital at 90 days

Care models developed for the rapid management of patients with transient ischaemic attack (TIA) are safe, effective and reduce recurrence rates. The aim is to determine the prevalence of cardiovascular events at 90 days. An observational, analytical, cross-sectional study was conducted. Adult male and female patients seen in the emergency department using the 'TIA protocol' between January 2016 and December 2019 were analysed. Data were collected on clinical variables, complementary tests, treatment and cardiovascular events (stroke/TIA, acute coronary syndrome or death due to cardiovascular causes) at 90 days. The study was approved by the Research Ethics Committee of Aragon. The TIA protocol was performed on 163 out of 591 patients diagnosed with TIA in the emergency department. Brain CT and neurosonology scans were performed in 100% and a 24-hour Holter-electrocardiogram was carried out in 52.1%; atrial fibrillation (AF) was detected in 3.6% of them. An MRI brain scan was performed in 78.4% and acute ischaemic injury was seen in diffusion sequences (DWI+) in 13.5%. The prevalence of cardiovascular events at 90 days was 4.9% (8): stroke, 3.1% (five TIAs); acute coronary syndrome, 0.6% (one); and death from cardiovascular causes, 1.2% (two). Major adverse cardiovascular events were significantly associated with a history of ischaemic heart disease (p = 0.014). Cardiovascular death was associated with a history of AF (p = 0.008), anticoagulants at discharge (p = 0.007) and no antiplatelet therapy at discharge (p = 0.012), and there was a tendency towards an association with a history of type 2 diabetes mellitus (p = 0.05). Rapid TIA protocols allow early care and avoid hospital admissions, without increasing the incidence of cardiovascular events or recurrence of stroke or TIA at 90 days.

Clinical and health economic evaluation of a post-stroke arrhythmia monitoring service.

Atrial fibrillation (AF) is a major cause of recurrent stroke and transient ischaemic attack (TIA) in the UK. As many patients can have asymptomatic paroxysmal AF, prolonged arrhythmia monitoring is advised in selected patients following a stroke or TIA. This service evaluation assessed the clinical and potential health economic impact of prolonged arrhythmia monitoring post-stroke using R-TEST monitoring devices. This was a prospective, case-controlled, service evaluation in a single health board in the North of Scotland. Patients were included if they had a recent stroke or TIA, were in sinus rhythm, and did not have another indication for, or contraindication to, oral anticoagulation. A health economic model was developed to estimate the clinical and economic value delivered by the R-TEST monitoring. Approval to use anonymised patient data in this service evaluation was obtained. During the evaluation period, 100 consecutive patients were included. The average age was 70 ± 11 years, 46% were female. Stroke was the presenting complaint in 83% of patients with the other 17% having had a TIA. AF was detected in seven of 83 (8.4%) patients who had had a stroke and one of 17 (5.9%) patients with a TIA. Health economic modelling predicted that adoption of R-TEST monitoring has a high probability of demonstrating both clinical and economic benefits. In conclusion, developing a post-stroke arrhythmia monitoring service using R-TEST devices is feasible, effective at detecting AF, and represents a probable clinical and economic benefit.

Branch atheromatous disease and treatment.

Branch atheromatous disease (BAD) is a subtype of ischemic stroke caused by perforating arteries occlusion due to proximal atherosclerosis of the arteries. Early neurological deterioration and recurrent stereotyped transient ischemic attacks are typical clinical manifestations of BAD. The optimal treatment for BAD has not been determined. This article explores a possible mechanism of BAD and effective treatment measures to prevent early progression and attack of transient ischemic events. This article explains the current status of intravenous thrombolysis, tirofiban, and argatroban for BAD and subsequent prognosis.

Vessel Wall Magnetic Resonance Imaging Findings of Bilateral Middle Cerebral Artery Stenosis Associated with Nilotinib

Nilotinib is a Bcr-Abl tyrosine kinase inhibitor used to treat chronic myelogenous leukemia. There have been case reports of nilotinib-related vasculopathy. However, most cases present peripheral artery disease, whilst reports of nilotinib-related cerebrovascular disease are quite uncommon. Herein, we report a case of nilotinib-induced intracranial stenosis in a patient with recurrent transient ischemic attacks and discuss the results of serial vessel wall magnetic resonance imaging.

Rehabilitasi Latihan Fisik terhadap Pemulihan Pasca Stroke

This study aims to identify the effect of exercise and physical activity on post-stroke recovery. The method in this study is a literature review by collecting international databases, namely PubMed, Proquest, Science Direct, NCBI, Sage Journal, and Taylor &amp; Francis. The results showed that the total number of studies reviewed was 12 studies, with 701 patients. The types of stroke included in this study were; recurrent stroke, ischemic, infarction, intracerebral hemorrhage, and transient ischemic attack. Physical activity interventions in this literature study are aerobic exercise, walking exercise, isokinetic training, balance exercise, and aquatic-based exercise. In conclusion, regular physical activity and exercise affect chronic stroke recovery, significantly improving motor function, emotional, cardiorespiratory health, and quality of life.&#x0D; &#x0D; Keywords: Physical Exercise, Recovery, Rehabilitation, Stroke

Pre- and Postoperative Cerebral Haemodynamic Assessments and Multidisciplinary Team Management for Patients Undergoing Cerebral Revascularization Procedures: 2 Case Reports

Background: Cerebrovascular bypasses are complex neurosurgical procedures with specific indications. Surgical risks and outcome are associated with the type of bypass intended and patient&rsquo;s underlying conditions. A multidisciplinary team approach is therefore pivotal in the management of these bypass patients. Objective: The aim of this study is to provide an overview of the perioperative haemodynamic assessments and management of patients undergoing cerebral revasculaization with 2 illustrative cases. Case Report: Case 1: A 40-year-old male with cerebrovascular occlusive condition and recurrent transient ischaemic attacks (TIA&rsquo;s) affecting his left side. Preoperative computed tomography (CT) brain perfusion and carbon dioxide (CO2) inhalation technique revealed poor cerebrovascular reserve (CVR) in the right middle cerebral artery (MCA) territory. The patient underwent a right superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery. Case 2: A 56-year-old female with a left giant cavernous sinus aneurysm presented with left-sided intractable facial pain. Preoperative cerebral digital subtraction angiography (DSA) with carotid compression test revealed inadequate collateral circulation. She underwent a high flow, common carotid-middle cerebral artery bypass with saphenous vein graft and trapping of the giant aneurysm. Results: Case 1: Postoperative computed tomography angiography (CTA) brain scan on day 1 confirmed graft patency. The patient improved rapidly in strength of the left arm and right leg. CT brain perfusion scan at 3 months showed improved brain perfusion and CVR. Case 2: Postoperative CTA brain on day 1 confirmed graft patency. On day 3 post-operatively, she developed self-limiting left-sided ophthalmoplegia, which completely resolved by 6 weeks. CTA brain at 5 months showed patency of the bypass graft. There was no further facial pain or ophthalmoplegia at the last follow-up. Conclusion: Although many new surgical techniques had been developed, the outcome for patients undergoing bypass surgery remains highly dependent on multidisciplinary teamwork, detailed preoperative haemodynamic assessment, patient selection and perioperative care. Keywords: Cerebrovascular bypass; EC-IC bypass; STA-MCA bypass; Cerebral ischaemia; Cerebrovacular reserve; Balloon occlusion test

Arterial tortuosity syndrome causing recurrent transient ischemic attacks in young adult: a case report

BackgroundArterial Tortuosity Syndrome (ATS) is a rare autosomal recessive disorder characterized by elongated and tortuous arteries. Although ATS showed a significant clinical and pathophysiological overlap with other syndromes involving connective tissues, only few cases of cerebrovascular events related to this syndrome have been described so far.Case presentationWe report the case of a 33-years-old male diagnosed with ATS since childhood, that experienced three sudden episodes of expressive aphasia and right hemiparesis with spontaneous resolution. He was treated with recombinant tissue plasminogen activator (r-TPA) at a dosage of 0.9 mg/kg with a complete recovery. Brain Magnetic Resonance Imaging (MRI) showed the absence of acute ischemic lesions and the patient was diagnosed with recurrent transient ischemic attacks (TIA).Intracranial and supra-aortic trunks Magnetic Resonance Angiography (MRA) and Angio-CT scan of the thoracic and abdominal aorta showed marked vessel tortuosity without stenosis.To our knowledge, this is the first reported case of an ATS patient with TIA in young age that was treated with intravenous thrombolysis with recombinant plasminogen activator.ConclusionOur report strengthens the relationship between ATS and juvenile cerebrovascular events, suggesting that an extensive study of body vessels in order to detect potential stenoses or occlusions in these cases is needed.The greater predisposition to cerebrovascular events in ATS could benefit from a more aggressive primary and secondary prevention therapy.