Monitoring of acute stroke patients with suppressed consciousness by using transcranial Doppler sonography

Introduction: Dynamic monitoring of the patients presenting with suppressed consciousness during the acute stage of stroke plays an important role in the diagnostic and therapeutic process as a whole.  Aim: The objective of the present study was to analyze the initial results from the twofold transcranial Doppler sonography application in acute stroke patients with suppressed consciousness aiming at optimizing their timely treatment.Materials and Methods: The histories of 46 patients, 21 males and 25 females, at a mean age of 75 years with acute stroke and a different degree of suppressed consciousness hospitalized during the period from January 1, 2018 to January 31, 2019 were analyzed. All the patients were examined by means of transcranial Doppler sonography. The degree of suppressed consciousness was evaluated by means of Glasgow-Liége Coma Scale.Results: Thirty-four patients presented with acute ischemic stroke and 12 ones with acute hemorrhagic one. Several accompanying cardiovascular diseases that aggravated the course of the acute cerebrovascular accident were diagnosed. Considerable differences in terms of the mean values according to the Glasgow-Liége Coma Scale were observed. The intervals of the maximal, minimal and average sonographic parameters of four cerebral arteries such as left and right middle cerebral artery and left and right vertebral artery varied within broad limits, too.   Conclusion: The application of a constellation of various neuroimaging methods in the patients with acute cerebrovascular diseases could identify essential relationships between the parameters analyzed and risk factors as well as to give assistance to the individualized therapeutic approach

The impact of recanalization on ischemic stroke outcome: A clinical case presentation

SummaryBackground and purposeStroke remains the third most common cause of death in industrialized nations, and the single most common reason for permanent disability. Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rtPA, Alteplase) for the treatment of acute ischemic stroke within 4.5h of onset is becoming a worldwide conventional standard of care. Thrombolytic stroke therapy is based on the “recanalization hypothesis” that reopening of occluded vessels improves clinical outcome in acute ischemic stroke through regional reperfusion and salvage of threatened tissues. However, intravenous thrombolysis is successful in approximately one-third of patients. Thrombaspiration through either a microcatheter, or a guiding catheter may be an option for a fresh nonadhesive clot. The use of mechanical thrombectomy devices in patients experiencing ischemic stroke and reocclusion after intravenous thrombolysis can now gain approval on the basis of recanalization, demonstrating better recanalization rates.Case descriptionWe present a clinical case of IVT followed by re-occlusion, and intra-arterial thrombaspiration and stenting.ResultsAfter IVT was started, a significant improvement of the neurological deficit was observed. After the end of the fibrinolysis, the patient had severe deterioration of the symptoms. The patient underwent control CT of the head to exclude intracerebral hemorrhage – the CT was normal. Through a guiding catheter thrombaspiration and stenting was performed with effective reperfusion with reversal of the neurological deficits.ConclusionsRevascularization remains the most intuitive strategy to reverse ischemic injury associated with arterial occlusion in acute strokes. This case represents a valuable example of two recanalization therapies in acute ischemic stroke to improve clinical outcome by restoring anterograde perfusion and salvaging the ischemic brain

Combined therapy in acute ischemic cerebral stroke - case report

BACKGROUND AND PURPOSE: Stroke remains the third most common cause of death in industrialized nations, and the single most common reason for permanent disability. Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA, Alteplase) for the treatment of acute ischemic stroke within 3 hours of onset become, a worldwide conventional standard of care. Thrombolytic stroke therapy is based on the "recanalization hypothesis," that reopening of occluded vessels improves clinical outcome in acute ischemic stroke through regional reperfusion and salvage of threatened tissues. However, intravenous thrombolysis is successful in approximately one third of patients. Thromboaspiration through either a microcatheter, or a guiding catheter may be an option for a fresh nonadhesive clot. The use of mechanical thrombectomy devices in patients experiencing ischemic stroke and reoclusion after intravenous thrombolysis can now gain approval on the basis of recanalization.CASE DESCRIPTION: We describe a case of a 51-year-old man who presented with ischemic stroke (right-sided hemiparesis and sensomotor aphasia) and sudden onset on 06.50h. He was hospitalised in Neuro intensive Care Unit on 08.10h with NIHSS 8 points. The CT of the head was normal and on 8.40h. began an intravenous rtPa by protocol: body weight 70 kg x 0,9 mg rtPA- 63 mg ACTILYSE with 10% bolus and i.v. infusion for 60 min. After beginning it was a significant improvement with neurological deficite NIHSS 5 points. After the end of the fibrinolysis the patient was with severe deterioration of the symtoms (right-sided hemiplegia and aphasia) - NIHSS 15 points. The patient underwent control CT of the head to exclude intracerebral haemorrhage - was normal. On the digital subtraction angiography there was total thrombosis of the left internal carotid artery. Through a guiding catheter was done thrombo aspiration with effective reperfusion with reversal of neurological deficits - NIHSS 3 points.CONCLUSIONS: This case represents a valuable example of two recanalization therapies in acute ischemic stroke to improve clinical outcome by restoring anterograde perfusion and salvaging ischemic brain

Cognitive dysfunction in patients with asymptomatic ischaemic disturbances of the cerebral circulation and carotid stenosis

BACKGROUND: Impairment of cognitive function is often present in patients with carotid artery stenosis but the details of this dysfunction have rarely been reported. Our purpose was to elucidate the cognitive dysfunction in patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation and unilateral asymptomatic severe carotid stenosis using comprehensive neuropsychological testing, and also to identify the specific underlying clinical and neuroimaging factors.METHODS: We analyzed the results of neuropsychological testing, the clinical history, and MR findings in 10 patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation and severe (70-99%) stenosis of the extra cranial internal carotid artery (ICA) on Doppler sonography. Cognitive functions were examined. We excluded patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation with contra lateral ICA occlusion or severe stenosis.RESULTS: Our neuropsychological testing revealed obvious cognitive deficits in all patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation and unilateral asymptomatic severe ICA stenosis. The mean cognitive score on the memory test was also significantly lower in patients with asymptomatic ICA stenosis and score 3 lesions on MRI than in asymptomatic patients and lesions score 1 on MRI (p<0.05).CONCLUSIONS: Cognitive deficits are common in patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation and unilateral asymptomatic severe ICA stenosis. Our findings suggest that an additional mechanism beyond the structural lesion such as chronic hypoperfusion may affect cognitive function in patients with high-grade ICA stenosis

Approaches for optimizing medical aid in acute ischemic stroke patients, hospitalized in UMHAT „Saint Marina` - Varna

In Bulgaria generally, treatment of acute ischemic strokes is done at the neurology wards and in smaller hospitals - in internal diseases wards, at intensive care wards in state regional hospitals; at ischemic stroke units and intensive care wards for treatment of neurological diseases at university hospitals. Between 2009 and 2013 in Varna, at the Neurology Clinic of UMHAT- St. Marina, a prospective research was carried out in view of optimizing the treatment of acute ischemic stroke (AIS) patients hospitalized at the clinic. After a stage-by-stage introduction into everyday clinical practice of innovative treatment methods, including intravenous thrombolysis and endovascular therapy of AIS patients, as well as organizational restructuring in view of optimizing the care for such patients, improvement in some of the quality indicators was observed

InteRhemispheric differences in clinical outcome after intravenous thrombolysis

Човешкият мозък се характеризира с функционална асиметрия, включваща междухемисферни, корови и подкорови взаимодействия. Пациентите с ИМИ в лява хемисфера и проведено тромболитично лечение (ТЛ) имат два пъти по-голяма вероятност за благоприятен клиничен изход на третия месец сравнено с дяснохемисферните инфаркти. Женският пол и левостранната локализация са предиктори на значимо подобрение на неврологичния дефицит на 24-я час след ТЛ. От друга страна асоциацията на мъжки пол и дяснохемисферна локализация на инсулта е свързана с по-голяма вероятност за благоприятен клиничен изход отколкото при жените със същата локализация. Също така дяснохемисферната локализация на инсулта при мъжете се свързва с по-добър изход отколкото при локализация налезията в лява хемисфера.The human brain is characterized by functional asymmetry including interhemispheric, cortical and subcortical interactions. Patients with acute ischemic stroke (AIS) in the left hemisphere and conducted thrombolytic therapy (IVT) have a two-fold greater likelihood of favorable clinical outcome of the third month compared with right hemispheric infarcts. Petticoats and left - sided location are predictors of significant improvement in neurological deficit 24 hours after IVT. On the other hand the association of male and right - sided location of stroke is associated with a greater likelihood of favorable clinical outcomes than women with the same location. In men it is associated with a better outcome than left-sided localization of the lesion

Impact of diabetes mellitus and admission hyperglycemia on outcomes after intravenous thrombolysis in acute ischemic stroke patients

Diabetes mellitus (DM) is a major risk factor for stroke, which is associated with unfavorable outcomeafter acute ischemic stroke (AIS) and disability. The potential harmful effect of DM, and the role and importance of blood glucose(BG) at admission are currently unclear for clinical outcome after АIS. Aim of this study is to look for correlations between the presence of DM and theinitial level of BG and the clinical outcome after an intravenous thrombolysis (IVT) in patients with acute AIS.Material and methods. IVT with Astylise has been conducted to 170 patients with AIS for the period 09.2011- 09.2015, from which 20% (n = 34) are with DM, 80% without DM (n = 136). According to the values of the BG at admission they have been divided into three groups: I group- (n = 34) 8,1 mmol/l.Results With mRs (0-2) at 3 months are 60.2% of patients without DM and 40% respectively, p= 0,05(OR-1,5, 95% CI 0,91-2,49). With mRs (0-1) are 35% and 24% respectively (p= 0.196). The probability of this outcome is 1.47 times higher in those without DM (OR 1,47, 95% CI: 0,7-3,09). Mortality about the third month is 20% in patients with DM and 8.8% in those without DM, p 0.05); With mRs (0-1) are respectively 38.2%, 32.3% and 30.8% (p> 0.05). Mortality is 15.4% in the III group compared to 9.2% in the II and 8.8% in the I (p> 0.05). With mRs(3-5) are 38.4% of the III group and 26.5% in the I (p> 0.05).Conclusion. Patients with DM have significantly higher mortality and lack of favorable functional outcome at third monthcompared to those without DM, which can not be explained by the presence of ICH. The initial HG not significantly associated with unfavorable clinical outcome, but she quickly identify patients with an increased risk of such an outcome in which blood sugar levels should be closely monitored

Arterial blood pressure and heart rate response in patients with acute ischemic stroke - Correlation with the severity of cardiovascular autonomic dysfunction

Background and purpose:Despite numerous studies, the mechanisms of blood pressure and heart rate regulation in cerebrovascular diseases remain not completely understood. The aim of the study was to determine the changes in blood pressure (BP) and heart rate (HR) in patients with an acute hemispheric ischemic stroke and to seek a relation to the severity of the cardiovascular autonomic dysfunction.Methods:20 healthy volunteers and 50 patients with an acute hemispheric ischemic stroke participated in the study. The values of BP and HR were registered. Cardiovascular autonomous disorders were examined with "Ewing battery" tests. Patients were divided into two groups according to the severity of the autonomous disorders.Results:Elevated BP values at admission were observed in 56% of our patients, and significantly higher values of systolic blood pressure (SBP) (p <0,001), diastolic blood pressure (DBP) (p = 0,001), and mean arterial pressure (p <0,001), as well as of the heart rate (p = 0,027) were found, compared to the control group. The most significantly increased values of the indicators were reported in patients with a stroke in the territory of the right middle cerebral artery with an involvement of the insular cortex. The results of the t-test performed, showed correlation only between the systolic blood pressure and the severity of the autonomic dysfunction, the values being significantly higher in patients with severe autonomic disorders (t = -2,14; p = 0.036).Conclusion:A variability in BP and HR with a tendency to increase was observed in patients with an acute hemispheric ischemic stroke (ICS) compared to controls, with the highest values reported in patients with ICS in the territory of right middle cerebral artery (TRMCA) with the involvement of the insular cortex (IC). A positive correlation was found between the values of systolic blood pressure (SBP) and the severity of autonomic dysfunction (AD)

Transient monocular visual loss due to multiple CNS vascular pathology: report of two cases

BACKGROUND: The frequency of the transient monocular visual loss (TMVL), lasting minutes or longer, varies from a single to many episodes, which are usually followed by complete recovery of vision. TMVL is related most commonly o occlusive carotid disease. The therapy of patients with TMCL is divided into surgical and medical.CASE1: A55-year-old female was admitted to the clinic, with 4 months history of TMVL of the right eye, lasting 2-3 minutes, followed by complete recovery. Neuro-ophthalmological examination was normal. Neuro imaging investigations revealed proximal part right internal carotid artery (ICA) stenosis of 70%, left ICA stenosis of 40%, King-King in the middle segment of ICA, causing stenosis of 14%, and incidental aneurysms of the intracranial part of right ICA andin M2 segment of right middle cerebral artery.CASE2: A 74-year-old female was admitted to the clinic, with 1 year history of TMVL of the right eye, lasting 4-5 minutes, followed by complete recovery. Neuro-ophthalmological examination was normal. Duplex scaning showed hemodynamically significant stenosis of the right ICA, with King-Kingintheleft. MRI reveale diffuse vascular pathology.CONCLUSION: These cases demonstrated a co-occurrence of hemodynamically significant carotid artery occlusion with multiple or diffuse vascular pathology in patients with TMVL. We suggest that the detailed history, neuro-ophthalmological, and neuroimaging examinations might be useful to determine the correct etiologic diagnosis and discuss the most effective therapeutic strategy in TMVL patients.Scripta Scientifica Medica 2011;43(2):83-8