Immediate Reversal of Dabigatran by Idarucizumab Prior to Laboratory and Imaging Results in Acute Stroke

We report a case of intravenous thrombolysis in acute ischemic stroke of anterior choroidal artery following the antagonization of dabigatran with idarucizumab. No secondary complication, like hemorrhagic or thrombotic/thrombembolic event, of neither idarucizumab nor subsequent intravenous thrombolysis emerged. The recent approval of idarucizumab enables intravenous thrombolysis despite preexisiting oral anticoagulation with dabigatran, but raises the question of the optimal management and work flow of patients under medication with dabigatran and with acute neurological deficit, highly suspicious for an acute cerebrovascular event. In contrast to hitherto case reports and series, here, we explicitly refrained from awaiting the results of the thrombin time, as a marker for present anticoagulation by dabigatran, as well as the results of cerebral imaging before administration of idarucizumab. Based on the presented case we propose this approach to minimize door-to-needle time of intravenous thrombolysis in acute ischemic stroke and thus to enhance the chance for a good outcome

Correct Outcome Prognostication via Sonographic Volumetry in Supratentorial Intracerebral Hemorrhage

Introduction: The intracerebral hemorrhage (ICH)-score is used for estimation of patients' prognosis. The hemorrhage volume calculated from computed tomography (CT) contributes as one main factor. Several studies have proven that dimensions of an ICH may be displayed sufficiently by transcranial sonography (TCS). Yet, the adequacy of ICH-volumetry via TCS in calculating the ICH-score and its use as prognostic tool has not been studied.Methods: Forty consecutive patients with supratentorial ICH diagnosed via CT were included in this prospective observational pilot study. 45 examination-series via CT and TCS were done in order to perform an ICH-volumetry and calculate the ICH-score. Volume was calculated using the ABC/2 estimation. Results of both imaging techniques were compared regarding quantification of ICH- volume and correct prognostication. A modified Rankin Scale (mRS)-score of 0–3 points was valued as good outcome.Results: The imaging techniques did not show a difference in volumetry (p = 0.794) and TCS derived hemorrhage volume correlated significantly with ICH-volume measured on CT-scans. Calculated ICH-scores also did not differ (p = 0.323). Patients with an ICH-score larger than 2 points were predicted to experience a poor outcome at discharge with mRS 4–6 points, and the prognostication of the outcome was correct. Patients with a good outcome showed a smaller ICH-volume (11.2 ± 9.1ml) than patients with a poor outcome (38.2 ± 41.2 ml; p = 0.002).Conclusion: Volumetry in supratentorial ICH via TCS is feasible and the prognostication with the ICH-score based on its results is comparable to CT-imaging and sufficient

Prognostic significance of third ventricle blood volume in intracerebral haemorrhage with severe ventricular involvement

Background and purpose: Intraventricular haemorrhage (IVH) is an independent predictor of poor outcome in spontaneous intracerebral haemorrhage (ICH). Larger IVH volume and increasing number of affected ventricles have been associated with worse prognosis, however, little is known about the prognostic value of blood volume in the different parts of the ventricular system. Therefore, the correlation of IVH volume in the third, fourth and lateral ventricles with outcome in patients with ICH and severe IVH, treated with intraventricular fibrinolysis (IVF), was investigated. Methods: Patients with ICH <40 ml, severe IVH and acute hydrocephalus were treated with IVF. The course of IVH volume for each ventricle was measured by CT based volumetry. Outcome at 90 days was assessed by a telephone follow-up survey and correlated with initial IVH volume. Results: 50 patients aged 62.5±10.3 years with spontaneous ICH (12.5±10.8 ml) and severe IVH (33.5±25 ml) were included. Clearance of the third and fourth ventricle from blood occurred after 3±1.9 days. Initial IVH volume in the third ventricle (3.8±3.3 ml) was predictive for poor outcome (OR 2.6 per ml, p=0.02). Correlation between larger IVH volume in the fourth ventricle and poor outcome showed a trend towards significance (p=0.07). Total IVH volume and lateral ventricle IVH volume were not correlated with outcome. Conclusion: Despite rapid clot removal, initial IVH volume in the third ventricle was a strong and independent negative predictor. This is possibly explained by irreversible damage of brainstem structures by the initial mass effect of IVH

Safe Intravenous Thrombolysis after Traumatic Cardiopulmonary Resuscitation with Rib Fractures: A Case Report

We report a case of successful intravenous thrombolysis for a distal middle cerebral artery occlusion shortly after traumatic cardiopulmonary resuscitation due to an episode of ventricular tachycardia. A high prevalence of fatal cardiac arrhythmias in acute stroke patients raises the question of safety when administrating thrombolytic therapy after traumatic cardiopulmonary resuscitation; guidelines do not provide a satisfactory statement about this. Our case suggests that intravenous tissue-type plasminogen activator for acute ischemic stroke can be administered after a thorough risk-to-benefit evaluation without major adverse effects in patients after traumatic cardiopulmonary resuscitation, as bleeding complications seem rare and can be monitored and treated

Comparison of ischemic lesion evolution in embolic versus mechanical middle cerebral artery occlusion in Sprague Dawley rats using diffusion and perfusion imaging

BACKGROUND AND PURPOSE: Differences among models in the temporal evolution of ischemia after middle cerebral artery occlusion (MCAO) in rats may considerably influence the results of experimental stroke research. Using diffusion and perfusion imaging, we compared the spatiotemporal evolution of ischemia in Sprague Dawley rats after permanent suture MCAO (sMCAO; n=8) and embolic MCAO (eMCAO; n=8). METHODS: Serial measurements of quantitative cerebral blood flow (CBF) and the apparent diffusion coefficient (ADC) were performed up to 180 minutes after MCAO. ADC and CBF values within 5 different brain regions were analyzed. ADC and CBF lesion volumes were calculated by using previously established viability thresholds and correlated with infarct volume defined by 2,3,5-triphenyltetrazolium chloride staining 24 hours after MCAO. RESULTS: Compared with sMCAO animals, the threshold-derived CBF lesion volume was significantly larger in eMCAO at all time points (P\u3c0.01), remained relatively constant over time, and was highly correlated with the 2,3,5-triphenyltetrazolium chloride-defined infarct size. The ADC lesion volume did not differ between models at any time point. A diffusion/perfusion mismatch was present significantly longer in eMCAO animals (P\u3c0.05), and these rats demonstrated larger absolute mismatch volumes that were statistically significant at 30, 60, and 90 minutes (P\u3c0.05). In both models, CBF and ADC declines were highly correlated. CONCLUSIONS: This study demonstrated substantial differences in acute ischemic lesion evolution between the eMCAO and sMCAO models

Partial-volume effect on ischemic tissue-fate delineation using quantitative perfusion and diffusion imaging on a rat stroke model

Partial-volume effects (PVE) in stroke imaging could hinder proper delineation of normal, ischemic, and at-risk tissues. Cerebral-blood-flow (CBF) and apparent diffusion coefficient (ADC) were measured at high and low resolution (HR = 128 x 128, LR = 64 x 64) in focal ischemia in rats during the acute phase. The data were evaluated for PVE on ischemic tissue classification on a pixel-by-pixel basis and the misclassified pixels were quantified as ischemia progressed. The main drawbacks of high-resolution imaging are reduced temporal resolution and/or signal-to-noise ratio. The high- versus low-resolution scatterplots and histograms of pixels along the normal-abnormal boundaries in the ADC and CBF maps showed marked ischemia-related PVE. By comparison with the homologous regions in the contralateral normal hemisphere, the effect of increased noise and intrinsic tissue heterogeneity due to high resolution could be distinguished from ischemia-related PVE. Degrading the high-resolution (128 x 128) data to a 64 x 64 or 32 x 32 matrix increased the severity of PVE. Zero-filling of low-resolution (64 x 64) data to 128 x 128 also increased PVE. It was concluded that PVE: (1) misclassified substantial pixels along the normal-abnormal boundaries, (2) overestimated abnormal volumes at the expense of mostly at-risk and some normal tissues, (3) were more severe at the early time points postischemia, and (4) confounded the interpretation of the operationally defined ischemic penumbra

Characterizing tissue fate after transient cerebral ischemia of varying duration using quantitative diffusion and perfusion imaging

BACKGROUND AND PURPOSE: The purpose of this study was to investigate the effects of reperfusion on ischemic lesion evolution and pixel-by-pixel apparent diffusion coefficient-cerebral blood flow (ADC-CBF) dynamics of core and mismatch tissues after 35, 60, and 95 minutes of transient focal ischemia in rats (n=28). METHODS: Serial diffusion-, perfusion-, and T2-weighted imaging were performed up to 24 hours. The evolution of the magnetic resonance image-derived lesion volume was investigated and ADC-CBF scatterplots were performed to prospectively characterize the ADC and CBF dynamics of core and mismatch tissues with different fates. For comparison, similar analysis was performed on a historical 60-minute transient ischemia and permanent ischemia group. RESULTS: ADC-derived lesions markedly decreased on reperfusion at 35 minutes to an average of 15+/-5% of prereperfusion lesion size (P\u3c0.00001). At 24 hours, lesion volume as determined by T2 imaging increased again to 51+/-10% of prereperfusion lesion size. In the 95-minute group, ADC lesions only briefly decreased on reperfusion and then secondarily enlarged at 180 minutes, almost reaching prereperfusion lesion volume. Pixel-based analysis demonstrated that \u3e85% of mismatch pixels were salvaged by reperfusion independent of ischemia duration. Recanalization at 35, 60, and 95 minutes resulted in recovery of 46%, 28%, and 9% of core pixels, respectively. Core and mismatch pixels that were ultimately salvaged had persistently higher (P\u3c0.001) CBF values during ischemia in all reperfusion groups, associated with higher (P\u3c0.05) ADC values. CONCLUSIONS: This study demonstrated substantial salvage of mismatch tissue after reperfusion independent of ischemia duration and substantial permanent recovery of initial core pixels with early reperfusion. Severity of CBF reduction during ischemia seems to be the main factor determining tissue fate