APPLICATION OF CLINICAL SCORES IN THE PREDICTION OF HEMORRHAGIC TRANSFORMATION OF ISCHEMIC STROKE

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, Chişinău, Republica MoldovaIntroducere. Transformarea hemoragică (TH) poate complica accidentele vasculare cerebrale (AVC) ischemice agravând evoluția clinică și recuperarea pacienților. Scopul lucrării. Analiza parametrilor clinici la pacienții cu AVC ischemic acut pentru a stabili rolul scorurilor clinice în predicția TH a AVC ischemic. Material și metode. Au fost analizați prospectiv 80 de pacienți cu AVC ischemic acut internați în primele 24 de ore de la debutul simptomelor. Toți pacienții au fost investigați prin CT la internare și CT repetat pe durata spitalizării pentru evidențierea cazurilor de TH. Pentru toți pacienții au fost calculate scorurile de severitate a AVC-urilor: NIHSS, SPAN-100, THRIVE. Gradul de recuperare funcțională a fost stabilit în baza scalei Rankin modificate (mRS) la externare și la 3 luni distanță. Rezultate. În lotul analizat, 11/80 de pacienți incluși în cercetare au prezentat TH a AVC-ului ischemic. Pacienții cu TH au avut o vârstă medie mai mare (74,27 ± 3,08 ani vs. 70,66 ± 1,25 ani), cât și un grad de recuperare funcțională mai redus la externare (mRS 5 vs. 3,68) și 3 luni distanță (mRS 4,8 vs. 3,12). Scorurile de severitate a AVC în grupul cu TH au prezentat valori mai mari față de grupul non-TH: NIHSS internare - 15,54 ± 1,32 vs. 11,23 ± 0,77; SPAN-100 - 90,63 ± 4,08 vs. 82,13 ± 1,63; THRIVE - 5,54 ± 0,52 vs. 3,95 ± 0,23. Concluzii. Rezultatele preliminare ale cercetării indică prezența unei corelații dintre valorile sporite ale scorurilor clinice de severitate ale AVC și riscul pentru TH post-infarct cerebral. Continuarea studiului și omogenizarea grupurilor de cercetare va permite evaluarea datelor primare și obținerea datelor statistic semnificative.Background. Hemorrhagic transformation (HT) may complicate ischemic strokes (IS) by worsening the clinical course and recovery of patients. Objective of the study. Analysis of clinical parameters in in acute IS patients to establish the role of clinical scores for the prediction of HT. Material and methods. We have prospectively analyzed the data of 80 patients with acute ischemic stroke admitted within the first 24 hours after the symptom’s onset. All patients were investigated by CT at admission and repeated CT during hospitalization to highlight cases of HT. Stroke severity scores were calculated for all IS patients, including: NIHSS, SPAN-100, THRIVE. The degree of functional recovery was established based on the modified Rankin scale (mRS) at discharge and at 3 months follow-up. Results. In the analyzed group, 11 out of the 80 patients included in the research presented HT of ischemic stroke. HT patients were older (74.27 ± 3.08 years vs 70.66 ± 1.25 years) and presented worse functional recovery at discharge (mRS 5 vs. 3.68) and at 3 months follow-up (mRS 4.8 vs. 3.12). The stroke severity scores in the HT patients had higher values compared to the non-HT group: NIHSS at admission – 15.54 ± 1.32 vs. 11.23 ± 0.77; SPAN-100 – 90.63 ± 4.08 vs 82.13 ± 1,63; THRIVE – 5.54 ± 0.52 vs. 3.95 ± 0.23. Conclusions. The preliminary results of the research indicate the presence of a correlation between increased values of stroke clinical severity scores and the risk for HT. The continuation of the study with homogenization of the research groups will allow the evaluation of the primary data by obtaining statistically significant results

Aplicarea scorurilor clinice în predicția transformării hemoragice a accidentelor vasculare cerebrale ischemice

Background. Hemorrhagic transformation (HT) may complicate ischemic strokes (IS) by worsening the clinical course and recovery of patients. Objective of the study. Analysis of clinical parameters in in acute IS patients to establish the role of clinical scores for the prediction of HT. Material and methods. We have prospectively analyzed the data of 80 patients with acute ischemic stroke admitted within the first 24 hours after the symptom’s onset. All patients were investigated by CT at admission and repeated CT during hospitalization to highlight cases of HT. Stroke severity scores were calculated for all IS patients, including: NIHSS, SPAN-100, THRIVE. The degree of functional recovery was established based on the modified Rankin scale (mRS) at discharge and at 3 months follow-up. Results. In the analyzed group, 11 out of the 80 patients included in the research presented HT of ischemic stroke. HT patients were older (74.27 ± 3.08 years vs 70.66 ± 1.25 years) and presented worse functional recovery at discharge (mRS 5 vs. 3.68) and at 3 months follow-up (mRS 4.8 vs. 3.12). The stroke severity scores in the HT patients had higher values compared to the non-HT group: NIHSS at admission – 15.54 ± 1.32 vs. 11.23 ± 0.77; SPAN-100 – 90.63 ± 4.08 vs 82.13 ± 1,63; THRIVE – 5.54 ± 0.52 vs. 3.95 ± 0.23. Conclusions. The preliminary results of the research indicate the presence of a correlation between increased values of stroke clinical severity scores and the risk for HT. The continuation of the study with homogenization of the research groups will allow the evaluation of the primary data by obtaining statistically significant results.Introducere. Transformarea hemoragică (TH) poate complica accidentele vasculare cerebrale (AVC) ischemice agravând evoluția clinică și recuperarea pacienților. Scopul lucrării. Analiza parametrilor clinici la pacienții cu AVC ischemic acut pentru a stabili rolul scorurilor clinice în predicția TH a AVC ischemic. Material și metode. Au fost analizați prospectiv 80 de pacienți cu AVC ischemic acut internați în primele 24 de ore de la debutul simptomelor. Toți pacienții au fost investigați prin CT la internare și CT repetat pe durata spitalizării pentru evidențierea cazurilor de TH. Pentru toți pacienții au fost calculate scorurile de severitate a AVC-urilor: NIHSS, SPAN-100, THRIVE. Gradul de recuperare funcțională a fost stabilit în baza scalei Rankin modificate (mRS) la externare și la 3 luni distanță. Rezultate. În lotul analizat, 11/80 de pacienți incluși în cercetare au prezentat TH a AVC-ului ischemic. Pacienții cu TH au avut o vârstă medie mai mare (74,27 ± 3,08 ani vs. 70,66 ± 1,25 ani), cât și un grad de recuperare funcțională mai redus la externare (mRS 5 vs. 3,68) și 3 luni distanță (mRS 4,8 vs. 3,12). Scorurile de severitate a AVC în grupul cu TH au prezentat valori mai mari față de grupul non-TH: NIHSS internare - 15,54 ± 1,32 vs. 11,23 ± 0,77; SPAN-100 - 90,63 ± 4,08 vs. 82,13 ± 1,63; THRIVE - 5,54 ± 0,52 vs. 3,95 ± 0,23. Concluzii. Rezultatele preliminare ale cercetării indică prezența unei corelații dintre valorile sporite ale scorurilor clinice de severitate ale AVC și riscul pentru TH post-infarct cerebral. Continuarea studiului și omogenizarea grupurilor de cercetare va permite evaluarea datelor primare și obținerea datelor statistic semnificative

Pre-stroke treatment with oral anticoagulants and stroke outcome in atrial fibrillation patients

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, Chişinău, Republica MoldovaIntroducere. Tratamentul profilactic sub-optimal cu anticoagulante orale (ACO) la pacienții cu fibrilație atrială (FA) este asociat cu o evoluție nefavorabilă post-stroke. Scopul lucrării. Analiza corelației dintre tratamentul cu ACO pre-stroke și evoluția clinică post-accident vascular cerebral (AVC) ischemic la pacienții cu FA. Material și metode. Au fost analizați prospectiv 150 de pacienți cu AVC ischemic acut internați în primele 24 de ore de la debut, cu înregistrarea parametrilor clinici, imagistici și de laborator (specifici și non-specifici). La investigația repetată prin tomografie computerizată s-au evidențiat cazurile de transformare hemoragică (TH). Recuperarea funcțională a fost stabilită în baza scalei Rankin modificate (mRS) la externare și 3 luni distanță. Rezultate. În cadrul studiului au fost evidențiați 95 de pacienți cu TH post-AVC (lotul activ). Din cohorta generală 85 de pacienți prezentau FA, fiind semnificativ mai mulți în lotul activ de cercetare (p = 0,003). 23,53% din pacienți au primit ACO pre-stroke, fără diferențe semnificative între loturi (p = 0,18). INR mediu la internare a fost 1,34±0,02, cu valori semnificativ mai mici la pacienții din cohorta de lucru (1,27±0,03 vs 1,38±0,03, p = 0,003). Analiza de regresie a identificat o relație negativă a INR inițial și riscul de TH (OR = 0,11, p = 0,01). Tratamentul anterior cu ACO nu a corelat cu TH, mRS la externare sau 3 luni distanță. Concluzii. Rezultatele cercetării efectuate indică prezența unei rate reduse de pacienți cu ACO pre-stroke, cu valori sub-terapeutice ale INR în majoritatea cazurilor. ACO pre-stroke nu a corelat cu riscul de TH, evoluția nefavorabilă la externare și 3 luni post-AVC.Background. Sub-optimal prophylactic treatment with oral anticoagulants (OACs) is associated with an unfavorable outcome in ischemic stroke (IS) patients with atrial fibrillation (AF). Objective of the study. Correlation analysis between pre-stroke treatment with OACs and post-stroke clinical outcome in patients with AF. Material and methods. We have prospectively analyzed 150 patients with acute ischemic stroke admitted within the first 24 hours of symptoms’ onset. Clinical, imaging and laboratory parameters (specific and non-specific) were recorded. The cases of hemorrhagic transformation (HT) were revealed by repeated brain computed tomography. Functional recovery was quantified by the modified Rankin scale (mRS) at discharge and 3 months follow-up. Results. In our study, 95 patients with post-stroke HT were identified (the active group). From the general cohort, 85 patients had AF, being significantly more in the active research group (p = 0.003). 23.53% of patients received OACs pre-stroke, without significant differences between groups (p = 0.18). The mean admission INR was 1.34±0.02, with significantly lower values in the active cohort (1.27±0.03 vs 1.38±0.03, p = 0.003). Regression analysis identified a negative relationship between initial INR and the risk of HT (OR = 0.11, p = 0.01). Previous treatment with OACs did not correlate with HT, mRS at discharge or 3 months follow-up. Conclusion. The results of the conducted research indicate the presence of a low rate of patients receiving pre-stroke OACs, with sub-therapeutic INR values in most cases. No correlations between previous OACs treatment and the risk of HT, unfavorable discharge and 3 months post-stroke outcome were identified

The clinical features and the recovery process in patients with ischemic stroke with transient ischemic attacks in the past

Introduction: According to WHO, the global mortality from ischemic stroke is 9% annually, representing the third cause of death after heart diseases and cancer. The stroke is the main determinant of physical and mental disabilities in adults. The incidence and prevalence of transient ischemic attacks (TIAs) are continuously increasing due to the aging of the population worldwide. The importance of rapid and accurate diagnosis of TIAs is based on the fact that after a first TIA approximately 5% of patients develop a stroke during the next two days and about 20-30% - over the next 90 days. TIAs are important predictive factors of future stroke. The effective treatment of TIAs can prevent the recurrence of cerebral infarction. Recent studies show that the TIAs in the history of patients presenting an actual stroke can stimulate the cerebral resistance, like a neuroprotective factor. Purpose and objectives: The clinical research of the evolution and recovery process in patients with ischemic stroke with TIAs in the past; the analysis of literature medical data on the importance of TIAs in the development and evolution of strokes; the stroke evolution assessment in patients with TIAs in the past during the acute, early and late recovery phases. Materials and methods: The study was conducted on 33 patients with ischemic stroke, the acute, early and late recovery phases, with and without TIAs in the past, and included: clinical examination of the patients (general clinical examination, neurological examination, history disease, underlining the presence of TIAs in the past); assessment of functional independence degree after stroke, using the Barthel score; statistical evaluation of data obtained by comparative analysis and graphics. Results: In the present study was determinate that TIAs were present in 12 (36,4%) from 33 patients with ischemic stroke, at different intervals before the current stroke (from 2 week to 24 months). According to Barthel score, the average score obtained in examined patients was 37,8 points. The average score in patients with ischemic stroke without TIA in the past (21 patients - 63,3%) was 31,9 points, significantly lower than in the patients with stroke and TIA (12 patients- 36,4%), who accumulated, on average, 46,04 points. We also analyzed the functional independence degree depending on the time of ischemic stroke occurrence and the Barthel score achievement. In this case, the highest score was obtained in patients evaluated during the early post-stroke recovery (at 4-6 moths distance from the ischemic stroke) with 52,5 points, which can be explained by the presence of TIAs in the past of 2 patients from this subgroup and who accumulate a high Barthel score - 72,5 points. Conclusions: TIAs can be considerate as factors that induce cerebral ischemic preconditioning. The assessment of disability degree in patients with ischemic stroke using the Barthel score showed a significantly higher mean score in patients with stroke and TLA than in patients without TIA in the past. The highest Barthel score was obtained in patients evaluated in the early recovery period and in patients with TLA at 12 months before stroke

Clinical cases of transient and intermittent complete left bundle branch block

Introduction: The transient complete left bundle branch block (TCLBBB) represents an important marker of myocardial ischemia. Although its low incidence, it must be distinguished from other similar forms, like: intermittent block (manifested in rest), exercise-induced transient block (block of the 3rd phase of the action potential) which appears at increased heart rate (95-126 contraction/min. in average) and transient block induced by bradycardia (block of the 4th phase of the action potential.) The actual attitude to intraventricular blocks isn’t rigid and doesn’t require an obligatory association of an organic heart disease. Frequently, the coronary angiography and the ventriculography in patients with TCLBBB are normal, although there are cases with significant coronary lesions. In patients with „clean” coronary arteries we can suppose the disparity of the refractory phases of the Hiss bundle branches, the fibrosis of the cardiac conduction system in different infectious diseases. The significance and the prognosis of the intermittent block and the exercise-induced block are controversial. According to the Framingham study, the TCLBBB appears at the same age as the permanent block, presents the same prognosis and can be associated with organic cardiac diseases. There are also numerous scientific papers supporting the absence of organic heart diseases in patients with TCLBBB. Purpose and objectives: The comparative study of the intermittent block and the TCLBBB. Materials and methods: We analyzed 2 cases of complete intermittent block and 2 cases of transient complete left bundle branch block. Results: We observed that the TCLBBB presents the same features (dyspnea, palpitations at moderate exercise, specific ECG changes which resolves at rest). The exercise stress tests were stopped because the block appeared. The 24h ECG monitoring highlighted the appereance of TCLBBB at the heart rate (HR) higher than 65-70 beats/min and it’s solving at a lower HR. In both patients the coronary circulation presents a predominant right type, without stenosis. In one patient, by the retrospective analysis of the coronary CT-perfusion, we detected a complete myocardial bridge on the lower third of the posterior interventricular branch with lower contrasting in the area under the bridge and an incomplete myocardial bridge on the middle third of the first marginal branch. The analysis of intermittent blocks also included two female patients with frequent heart palpitation and regular dyspnea at rest and little exercise. The repeated ECG showed on a background of atrial fibrillation the aparition of QRS series specific for complete blocks followed by normal QRS complexes. The 24h monitoring didn’t show a correlation with the heart rate. * Conclusions: The transient complete left bundle branch block represents a multifactorial entity with a variable prognosis, from marker of myocardial ischemia to manifestation of increased heart rate. The differentiation of different forms of the TCLBBB can be done by 24h ECG monitoring with frequency limits specification and by coronarography to exclude myocardial ischemia

Current achievements in reporting brain imaging in ischemic stroke: zones and score ASPECTS

Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova Institute of Neurology and Neurosurgery of the Republic of MoldovaIntroduction. Ischemic stroke incidence and mortality rates show a constantly increasing trend worldwide. As the only specific treatment for ischemic stroke, considered the gold standard, tissue plasminogen activator can be applied only in first 3 hours from the symptoms onset, imaging report must contain maximal volume of information regarding the ischemic lesion. The Alberta Stroke Program Early Computer Tomography Score (ASPECTS) accurately classifies and standardizes regions of middle cerebral artery circulations and describes the subtle changes in imaging patterns, providing possibility to identify ischemia and appreciate its severity. ASPECTS represents a quantitative topographic assessment scale with 10 points for normal brain appearance and subtraction of 1 point for every area, where early ischemic signs are present

Intracerebral hemorrhage in a patient with Moyamoya syndrome: case report

Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova, Institute of Neurology and Neurosurgery of the Republic of MoldovaBackground. Moyamoya disease is a cerebrovascular disease that is characterized by bilateral chronic and progressive stenosis or occlusion of the arteries around the circle of Willis with development of collateral circulation, of unknown etiology. It has a high incidence in Japan and Asian population, with fewer cases described in Europe. Similar angiographic findings can be seen in patients with other medical conditions that are described as Moyamoya syndrome. Main clinical features include transient ischemic attacks, ischemic strokes, and hemorrhagic strokes

Predicția transformării hemoragice a infarctului cerebral prin perfuzie CT

Catedra de Neurologie nr. 1, Universitatea de Stat de Medicină și Farmacie ”Nicolae Testemiţanu”, Institutul de Neurologie și Neurochirurgie, Chișinău, Republica Moldova, The IVth Congress of Radiology and Medical Imaging of the Republic of Moldova with international participation, Chisinau, May 31 – June 2, 2018Introducere: Incidența mortalității și invalidității post-accident vascular cerebral (AVC) ischemic reprezintă o problemă actuală la nivel mondial, fiind în progresie continuă. Transformarea hemoragică a leziunilor ischemice reprezintă o complicație asociată cu un prognostic nefavorabil. Lucrarea a avut ca scop analiza modificărilor patologice a permeabilității barierei hematoencefalice prin perfuzie computertomografică (CT) la pacienții cu transformare hemoragică a leziunilor ischemice. Material și metode: Au fost analizați prospectiv 52 de pacienți cu AVC ischemic hiperacut, tratați în Institutul de Neurologie și Neurochirurgie din Republica Moldova în perioada 2017-2018. Au fost incluși pacienții investigați prin computer-tomografie, perfuzie computer-tomografică cu calcularea permeabilității barierei hematoencefalice la internare și computer-tomografie de control cu aprecierea transformării hemoragice a leziunilor ischemice. Resultate: Din cei 52 de pacienți incluși în cercetare, 21 de pacienți au demonstrat transformări hemoragice la imaginile de control, 4 fiind trombolizați. Tromboliza a fost de asemenea efectuată la 5 pacienți din grupul fără transformări hemoragice. Comparativ cu zona contralaterală, permeabilitatea barierei hematoencefalice a fost semnificativ mai mare la pacienții cu transformări hemoragice (4,47+/-2,72 vs 1,13+/-0,17 ml/100g/min), fiind de asemenea crescută și în emisfera sănătoasă la grupul cu transformări hemoragice față de cei fără transformări hemoragice (1,87+/-0,23 vs 1,21+/-0,28). Concluzii: Rezultatele preliminare obținute indică o corelare a creșterii permeabilității barierei hemato-encefalice în sectorul ischemic cerebral în primele ore cu dezvoltarea transformării hemoragice ulterioare

Combined central and peripheral demyelination: a case report

Overlapping central nervous system (CNS) and peripheral nervous system (PNS) demyelination is a rare clinical entity, more frequently seen in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and multiple sclerosis (MS). This case report showcases a patient with atypical CIDP and CNS demyelination lesions. Demographic data, disease course, treatment responsiveness, neurological examination, laboratory tests, nerve conduction studies (NCS), and brain and spinal cord MRI were registered. The case highlights the difficulty of diagnosis establishment and treatment selection, given the atypical course of the disease and limited answers to the indicated therapies. The data from our report suggest that specific and widely available immunological targets are necessary for diagnosing combined central and peripheral demyelination cases appropriately. The association of different immunotherapeutic agents may be necessary to induce and maintain disease remission