Vessel Wall MRI Enhancement in Noninflammatory Cerebral Amyloid Angiopathy

Cerebral amyloid angiopathy is characterized by deposition of amyloid-β fibrils in the walls of small-to-medium-sized blood vessels. In this retrospective review of 5 patients with histologically confirmed noninflammatory cerebral amyloid angiopathy, high-resolution vessel wall MRI showed arterial wall enhancement in 2 patients (40%). Despite common consensus of equating vessel wall enhancement with inflammation, this report demonstrates that β-amyloid accumulation alone without inflammation can be associated with arterial wall enhancement in a subset of patients

E-215 Rotational angiography complicated by aneurysm rerupture: a case series

IntroductionDigital subtraction angiography (DSA) is considered the gold standard for diagnosing intracranial aneurysms. In cases of aneurysmal subarachnoid hemorrhage (aSAH), 3DRA has become standard of care to detect aneurysms and to plan treatment in cases with inconclusive noninvasive imaging. Rerupture during angiography with contrast extravasation is a rare but devastating complication and has a mortality of 50% to 80%. In this case series, we report our experience of aneurysm rerupture as a complication of 3DRA for aSAH.MethodsThe electronic medical records of eight patients across four separate institutions who underwent 3DRA for evaluation of aneurysm after aSAH were reviewed. Data from patient medical charts and their angiographic procedures were reviewed to assess both clinical and angiographic outcomes. Overall case descriptions and patients’ histories were reviewed and described in detail.ResultsOf the eight cases reviewed, the mean aneurysm size was 9.7±5.5 mm and the mean Hunt Hess and modified Fisher Score on arrival were 3.5±0.96 and 3.25±0.83 respectively. Injection rate, injection volume, and pressure were 3.6±1.4 mL/s, 21±2.1 mL, and 488±124 psi. Inpatient mortality after aneurysmal rerupture was 37.5% (n=3), with 37.5% (n=3) requiring EVD placement and 50% (n=4) requiring craniectomy.ConclusionThis is the first series to report aneurysm rerupture as a complication of 3DRA. Rerupture during 3DRA is a devastating complication that commonly led to patient mortality in our series. Future studies will be needed to further elucidate characteristics of patients associated with 3DRA complications and to compare 3DRA complication rates with other aSAH diagnostic modalities.Disclosures D. Nistal: None. D. Wei: None. J. Mascitelli: None. H. Shoirah: None. R. Starke: None. E. Levy: None. J. Howington: None. J. Mocco: None. T. Oxley: None

Medical Management vs Mechanical Thrombectomy for Mild Strokes: An International Multicenter Study and Systematic Review and Meta-analysis

Importance: The benefit of mechanical thrombectomy (MT) in patients with stroke presenting with mild deficits (National Institutes of Health Stroke Scale [NIHSS] score <6) owing to emergency large-vessel occlusion (ELVO) remains uncertain. Objective: To assess the outcomes of patients with mild-deficits ELVO (mELVO) treated with MT vs best medical management (bMM). Data Sources: We retrospectively pooled patients with mELVO during a 5-year period from 16 centers. A meta-analysis of studies reporting efficacy and safety outcomes with MT or bMM among patients with mELVO was also conducted. Data were analyzed between 2013 and 2017. Study Selection: We identified studies that enrolled patients with stroke (within 24 hours of symptom onset) with mELVO treated with MT or bMM. Main Outcomes and Measures: Efficacy outcomes included 3-month favorable functional outcome and 3-month functional independence that were defined as modified Rankin Scale scores of 0 to 1 and 0 to 2, respectively. Safety outcomes included 3-month mortality and symptomatic and asymptomatic intracranial hemorrhage (ICH). Results: We evaluated a total of 251 patients with mELVO who were treated with MT (n = 138; 65 women; mean age, 65.2 years; median NIHSS score, 4; interquartile range [IQR], 3-5) or bMM (n = 113; 51 women; mean age, 64.8; median NIHSS score, 3; interquartile range [IQR], 2-4). The rate of asymptomatic ICH was lower in bMM (4.6% vs 17.5%; P =.002), while the rate of 3-month FI (after imputation of missing follow-up evaluations) was lower in MT (77.4% vs 88.5%; P =.02). The 2 groups did not differ in any other efficacy or safety outcomes. In multivariable analyses, MT was associated with higher odds of asymptomatic ICH (odds ratio [OR], 11.07; 95% CI, 1.31-93.53; P =.03). In the meta-analysis of 4 studies (843 patients), MT was associated with higher odds of symptomatic ICH in unadjusted analyses (OR, 5.52; 95% CI, 1.91-15.49; P =.002; I2 = 0%). This association did not retain its significance in adjusted analyses including 2 studies (OR, 2.06; 95% CI, 0.49-8.63; P =.32; I2 = 0%). The meta-analysis did not document any other independent associations between treatment groups and safety or efficacy outcomes. Conclusions and Relevance: Our multicenter study coupled with the meta-analysis suggests similar outcomes of MT and bMM in patients with stroke with mELVO, but no conclusions about treatment effect can be made. The clinical equipoise can further be resolved by a randomized clinical trial. © 2019 American Medical Association. All rights reserved

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

BACKGROUND AND PURPOSE: We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores \u3c 6 points. METHODS: The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. RESULTS: We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. CONCLUSIONS: Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

10.1111/ene.14199EUROPEAN JOURNAL OF NEUROLOGY2761039-104

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

Background and purpose: We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. Methods: The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0–2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0–1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. Results: We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09–4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10–3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67–5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06–2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. Conclusions: Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding. © 2020 European Academy of Neurolog