Bilateral optic neuropathy related to severe anemia in a patient with alcoholic cirrhosis: A case report and review of the literature

Anemia appears frequently in patients with alcoholic liver disease (ALD) but has never been linked to bilateral nonarteritic anterior ischemic optic neuropathy (NAION). A 65-year-old woman with a medical history of alcoholic cirrhosis was admitted for bilateral NAION. On admission, she was found to have a low arterial pressure and severe normocytic anemia (48 g/L). The anemia was related to chronic bleeding due to antral gastritis along with other factors associated with ALD. The applied treatment consisted of urgent transfusion followed by high doses of proton-pump inhibitors, iron and vitamin supplementation, and support in lifestyle measures. Her hemoglobin levels remained stable after 2 years but the patient still suffered from visual loss. This case highlights the link between anemia and bilateral NAION in ALD patients. The optic nerve head is prone to infarction in this context due to the vascularization characteristics of ALD. Hemoglobin levels should be monitored in ALD patients to avoid the severe complication of NAION

Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Strokes Treated by Thrombectomy: A Review of the TITAN Collaboration

Introduction: Endovascular therapy has been shown to be an effective and safe treatment for tandem occlusion. The endovascular therapeutic strategies for tandem occlusions strokes have not been adequately evaluated and the best approach is still controversial. The TITAN (Thrombectomy in TANdem occlusions) registry was a result of a collaborative effort to identify the best therapeutic approach for acute ischemic stroke due to tandem lesion. In this review, we aim to summarize the main findings of the TITAN study and discuss the challenges of treatment for tandem occlusion in the era of endovascular thrombectomy.Methods: A review of the data from the multicenter international observational and non-randomized TITAN registry was performed. The TITAN registry included acute ischemic stroke patients with tandem lesions (proximal intracranial occlusion and cervical carotid artery occlusion or stenosis>90%) who were treated with thrombectomy with or without carotid artery stenting.Results: Prior intravenous thrombolysis and emergent cervical carotid stenting were associated with higher reperfusion (mTICI 2b-3 and mTICI 3) rates at the end of the intervention. Poor outcome did not occur more frequently after stenting than after conservative treatment of the cervical carotid lesion. Emergent carotid stenting with antithrombotic agents and intracranial thrombectomy yielded higher reperfusion rate and good outcome (90 day mRS 0–2) compared to other strategies (carotid artery stenting and thrombectomy without antithrombotic, angioplasty and thrombectomy, or thrombectomy alone). Pretreatment intravenous thrombolysis was not associated with increased risk of hemorrhagic complications. Likewise, periprocedural unfractionated heparin did not modify the efficacy and safety results. Etiology of carotid artery lesion (atherosclerosis vs. dissection) did not emerge as predictor of outcome or recanalization.Conclusion: Emergent stenting of the cervical carotid lesion with antithrombotic agents in conjunction to thrombectomy appears to be the best treatment strategy for acute ischemic strokes with tandem lesions. These findings will be further investigated in the ongoing randomized controlled TITAN trial

Effect of extracranial lesion severity on outcome of endovascular thrombectomy in patients with anterior circulation tandem occlusion: analysis of the TITAN registry

Introduction Endovascular treatment (EVT) for tandem occlusion (TO) of the anterior circulation is complex but effective. The effect of extracranial internal carotid artery (EICA) lesion severity on the outcomes of EVT is unknown. In this study we investigated the effect of EICA lesion severity on the outcomes of tandem occlusion EVT. Methods A multicenter retrospective TITAN (Thrombectomy In TANdem lesions) study that included 18 international endovascular capable centers was performed. Patients who received EVT for atherosclerotic TO with or without EICA lesion intervention were included. Patients were divided into two groups based on the EICA lesion severity (high-grade stenosis (>= 90% North American Symptomatic Carotid Endarterectomy Trial) vs complete occlusion). Outcome measures included the 90-day clinical outcome (modified Rankin Scale score (mRS)), angiographic reperfusion (modified Thrombolysis In Cerebral Ischemia (mTICI) at the end of the procedure), procedural complications, and intracranial hemorrhage at 24 hours follow-up. Results A total of 305 patients were included in the study, of whom 135 had complete EICA occlusion and 170 had severe EICA stenosis. The EICA occlusion group had shorter mean onset-to-groin time (259 +/- 120 min vs 305 +/- 202 min;p=0.037), more patients with diabetes, and fewer with hyperlipidemia. With respect to the outcome, mTICI 2b-3 reperfusion was lower in the EICA occlusion group (70% vs 81%;p=0.03). The favorable outcome (90-day mRS 0-2), intracerebral hemorrhage and procedural complications were similar in both groups. Conclusion Atherosclerotic occlusion of the EICA in acute tandem strokes was associated with a lower rate of mTICI 2b-3 reperfusion but similar functional and safety outcomes when compared with high-grade EICA stenosis

Sex differences in cerebral venous sinus thrombosis after adenoviral vaccination against COVID-19

Introduction: Cerebral venous sinus thrombosis associated with vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is a severe disease with high mortality. There are few data on sex differences in CVST-VITT. The aim of our study was to investigate the differences in presentation, treatment, clinical course, complications, and outcome of CVST-VITT between women and men. Patients and methods: We used data from an ongoing international registry on CVST-VITT. VITT was diagnosed according to the Pavord criteria. We compared the characteristics of CVST-VITT in women and men. Results: Of 133 patients with possible, probable, or definite CVST-VITT, 102 (77%) were women. Women were slightly younger [median age 42 (IQR 28–54) vs 45 (28–56)], presented more often with coma (26% vs 10%) and had a lower platelet count at presentation [median (IQR) 50x109/L (28–79) vs 68 (30–125)] than men. The nadir platelet count was lower in women [median (IQR) 34 (19–62) vs 53 (20–92)]. More women received endovascular treatment than men (15% vs 6%). Rates of treatment with intravenous immunoglobulins were similar (63% vs 66%), as were new venous thromboembolic events (14% vs 14%) and major bleeding complications (30% vs 20%). Rates of good functional outcome (modified Rankin Scale 0-2, 42% vs 45%) and in-hospital death (39% vs 41%) did not differ. Discussion and conclusions: Three quarters of CVST-VITT patients in this study were women. Women were more severely affected at presentation, but clinical course and outcome did not differ between women and men. VITT-specific treatments were overall similar, but more women received endovascular treatment.</p

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Cerebral ischemic events in patients with pancreatic cancer: A retrospective cohort study of 17 patients and a literature review

Stroke is a dramatic complication of pancreatic cancer with mechanisms related to oncological disease. A better description of the characteristics of cerebrovascular events would help better understand the pathogeny and protect vulnerable patients. We thus conducted a descriptive analysis of clinical, biological, and radiological features of patients from our centers and literature.We reviewed consecutive cases of patients who presented cerebrovascular events and pancreatic cancer in 4 stroke units in Lorrain (France) between January 1, 2009 and March 31, 2015, and all reported cases of literature. We identified 17 cases in our centers and 18 reported cases. Fifty-seven per cent of patients were male. Median age was 63 ± 14 years and ranged from 23 to 81 years. All cerebral events were ischemic. At the onset of stroke, pancreatic cancer had already been diagnosed in 59% of the patients in our centers for a mean time of 5.4 months. Five of them (29%) were being treated with gemcitabine and 2 (12%) with folfirinox. Adenocarcinoma at metastatic stage was reported in 82% of cases overall. Brain imaging revealed disseminated infarctions in 64%. High median levels of D-dimer (7600 ± 5 × 10 μg/L), C-reactive protein (63 ± 43 mg/L), and elevated prothrombin time (19 ± 6 seconds) were found. Thirty-six per cent of patients explored with echocardiography were diagnosed with nonbacterial thrombotic endocarditis. Ten of our patients received anticoagulant therapy as secondary stroke prevention without any documented recurrence. Nevertheless, outcome was poor with a median survival time of 28 ± 14 days after stroke onset. Cerebral ischemic events occur at advanced stages of pancreatic cancer, most likely by a thromboembolic mechanism. Disseminated infarctions and high D-dimer, C-reactive protein levels, and a high prothrombin time are the most constant characteristics found in this context. All patients should be screened for nonbacterial thrombotic endocarditis as this etiology supports the use of anticoagulant therapy

Implementation and Evaluation of an Economic Model for Telestroke: Experience from Virtuall, France

BackgroundTelestroke is recognized as a safe and time-efficient way of treating stroke patients. However, admission centers (spokes) are subject to financial charges which can make them reluctant to join the system. We implemented and assessed an economic model supporting our telestroke system, Virtuall, France, which includes one expert center (hub) and six spokes.MethodsThe model is based on payment for the expertise provided by the hub, distribution of charges related to telemedicine according to the fees perceived by the spokes, and transfer of patients between the spokes and the hub. We performed a cost–benefit analysis for all patients included in Virtuall from January 2014 to December 2015 to assess the economic balance in each center.Results321 patients were prospectively included in the study. Application of the economic model resulted in overall financial balance with funding of a dedicated medical service in the hub, and reduced costs directly related to telestroke by an average of 10% in the spokes. The conditions generating the highest costs for the spokes were: a patient returning from the hub for re-hospitalization (mean cost of $1,995/patient); management of patients treated by intravenous thrombolysis without transfer to the hub (mean cost of$2,075/patient). The most favorable financial condition for the spokes remained simple transfer of patients to the hub and no return (mean cost of $329/patient).ConclusionWe describe an economic model which can be applied to any telestroke system to ensure the optimal balance between hub and spoke centers

Rapid Successful Reperfusion of Basilar Artery Occlusion Strokes With Pretreatment Diffusion‐Weighted Imaging Posterior‐Circulation ASPECTS <8 Is Associated With Good Outcome

International audienceBackground The association between time to reperfusion and clinical outcome is well known in anterior circulation strokes, whereas the impact of main time metrics remains unknown in posterior circulation strokes. We investigated the clinical effect of different time intervals from symptom onset to reperfusion on the 90‐day clinical outcome in acute ischemic stroke patients with basilar artery occlusion, and especially in the subset population presenting a low stroke volume on baseline diffusion‐weighted imaging. Methods and Results We studied patients included in the prospective, multicenter, observational ETIS (Endovascular Treatment in Ischemic Stroke) registry who had had basal artery occlusion and had achieved successful reperfusion (modified Thrombolysis In Cerebral Infarction 2b‐3). Three time intervals (onset to reperfusion, onset to imaging, and imaging to reperfusion) were considered in all patients and separately in patients with pc‐ ASPECTS (posterior‐circulation Alberta Stroke Program Early Computed Tomography Score) <8 and ≥8 on baseline diffusion‐weighted imaging. The primary end point was good outcome defined as 90‐day modified Rankin Scale scores of 0 to 2. Among the 95 included patients, 38 (40%) achieved a good outcome. In all patients, no significant association was found between the different time intervals and outcome. In patients evaluated with diffusion‐weighted imaging (n=61) at baseline, a significant negative association was found between imaging‐to‐reperfusion time for patients with pc‐ ASPECTS <8 (adjusted odds ratio=0.4 per 30‐minute increase; 95% CI 0.18‐0.85; P =0.02) compared with those with pc‐ ASPECTS ≥8. Conclusions In patients with basilar artery occlusion and pc‐ ASPECTS <8 at baseline diffusion‐weighted imaging, clinical outcome is highly dependent on the time from imaging to reperfusion, which suggests that rapid endovascular reperfusion should be performed after imaging in these patients

A direct aspiration first pass technique with the new ARC catheter for thrombectomy of large vessel occlusion strokes: A multicenter study

International audienceBackground and purpose A direct aspiration first pass technique involves first-line aspiration to remove the thrombus through a large-bore aspiration catheter in large vessel strokes. The aim of this study was to assess safety and clinical outcomes with a direct aspiration first pass technique using the new ARC catheter. Methods A retrospective analysis of prospectively collected data from three university hospitals was performed between June 2016 and May 2018. The following parameters of all acute ischemic stroke interventions using the ARC catheter were analyzed: use of intravenous thrombolysis, National Institutes of Health Stroke Scale scores at presentation and discharge, successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b–3), procedure duration, procedure-related complications and 90-day clinical outcome (modified Rankin Scale score). Results In total, 41 patients were included in the study and anterior circulation occlusion was noted in 35 (85%). The median National Institutes of Health Stroke Scale at admission was 18 and prior intravenous thrombolysis was administered in 35 patients (85%). Only six (15%) patients required the use of a rescue stent retriever. Successful reperfusion was achieved in 40 patients (98%) with a median procedure time of 32 minutes. No catheter-related complications were observed. Symptomatic intracerebral hemorrhage occurred in one patient (2%). Median National Institutes of Health Stroke Scale at discharge was 3; 49% were independent and 10% died at 90 days. Conclusions In the present study, the ARC catheter allowed a 98% successful reperfusion rate. The complication rate was in line with those of previous a direct aspiration first pass technique publications