Diagnosis of Ischemic Stroke: As Simple as Possible

The absolute majority of strokes in high-income countries, roughly 91%, are of ischemic origin. This review is focused on acute ischemic stroke (AIS) with large vessel occlusion (LVO) in the anterior circulation, which is considered the most devastating subtype of AIS. Moreover, stroke survivors impose substantial direct and indirect costs of care as well as costs due to productivity loss. We review of diagnostic possibilities of individual imaging methods such as computed tomography and magnetic resonance imaging, and discuss their pros and cons in the imaging of AIS. The goals of non-invasive imaging in AIS are as follows: (a) to rule out intracranial hemorrhage and to quickly exclude hemorrhagic stroke and contraindications for intravenous thrombolysis; (b) to identify potential LVO and its localization and to quickly provide guidance for endovascular treatment; (c) to assess/estimate the volume or size of the ischemic core. We suggest fast diagnostic management, which is able to quickly satisfy the above-mentioned diagnostic goals in AIS with LVO

CT Brain Perfusion in the Prediction of Final Infarct Volume: A Prospective Study of Different Software Settings for Acute Ischemic Core Calculation

CT perfusion (CTP) is used for the evaluation of brain tissue viability in patients with acute ischemic stroke (AIS). We studied the accuracy of three different syngo.via software (SW) settings for acute ischemic core estimation in predicting the final infarct volume (FIV). The ischemic core was defined as follows: Setting A: an area with cerebral blood flow (CBF) < 30% compared to the contralateral healthy hemisphere. Setting B: CBF < 20% compared to contralateral hemisphere. Setting C: area of cerebral blood volume (CBV) < 1.2 mL/100 mL. We studied 47 AIS patients (aged 68 ± 11.2 years) with large vessel occlusion in the anterior circulation, treated in the early time window (up to 6 h), who underwent technically successful endovascular thrombectomy (EVT). FIV was measured on MRI performed 24 ± 2 h after EVT. In general, all three settings correlated with each other; however, the absolute agreement between acute ischemic core volume on CTP and FIV on MRI was poor; intraclass correlation for all three settings was between 0.64 and 0.69, root mean square error of the individual observations was between 58.9 and 66.0. Our results suggest that using CTP syngo.via SW for prediction of FIV in AIS patients in the early time window is not appropriate

Spontaneous spinal epidural haematoma: management and main risk factors in era of anticoagulant / antiplatelet treatment

Aim of the study. Spontaneous spinal epidural haematomas (SSEH) are rare nosological units wherein acute collections of blood develop in the spinal canal. SSEH are usually manifested by sudden severe back pain accompanied by the development of neurological symptoms. In this study, we retrospectively describe management and the main risk factors of SSEH in a series of 14 cases.Material and methods. Between 2010 and 2019, we examined 14 patients (age range 17–89 years, 10 women) diagnosed with SSEH. Eight cases were patients using anticoagulant therapies (six warfarin, one dabigatran, one apixaban) and two others were using ASA of 100 mg/day. The exact localisation and extent of changes was determined from acute magnetic resonance imaging. Three people using warfarin had INR values higher than 3.0 at the time of their diagnosis.Results. Ten patients (71%) were taking oral anticoagulants or antiplatelet agents. In seven patients, SSEH were localised in the lower cervical/thoracic spine. Ten patients (71%) had arterial hypertension. Six patients underwent acute surgery due to rapidly developing spinal cord compression. Eight patients (57%) with slight or mild neurological symptoms were successfully managed without surgery.Conclusions. SSEH should be suspected in any patient receiving anticoagulant/antiplatelet agents who complains of sudden, severe back pain accompanied by neurological symptoms. SSEH is mostly localised in the lower cervical/thoracic spine. Arterial hypertension appears to be a risk factor of SSEH. Early decompression is an important therapeutic approach; in cases with minor neurological deficits, conservative treatment may be chosen

Spontální epidurální krvácení : menagement a hlavní rizikové faktory v době antikoagulační a antiagregační léčby.

Aim of the study. Spontaneous spinal epidural haematomas (SSEH) are rare nosological units wherein acute collections of blood develop in the spinal canal. SSEH are usually manifested by sudden severe back pain accompanied by the development of neurological symptoms. In this study, we retrospectively describe management and the main risk factors of SSEH in a series of 14 cases. Material and methods. Between 2010 and 2019, we examined 14 patients (age range 17-89 years, 10 women) diagnosed with SSEH. Eight cases were patients using anticoagulant therapies (six warfarin, one dabigatran, one apixaban) and two others were using ASA of 100 mg/day. The exact localisation and extent of changes was determined from acute magnetic resonance imaging. Three people using warfarin had INR values higher than 3.0 at the time of their diagnosis. Results. Ten patients (71%) were taking oral anticoagulants or a ntiplatelet agents. In seven patients, SSEH were localised in the lower cervical/thoracic spine. Ten patients (71%) had arterial hypertension. Six patients underwent acute surgery due to rapidly developing spinal cord compression. Eight patients (57%) with slight or mild neurological symptoms were successfully managed without surgery. Conclusions. SSEH should be suspected in any patient receiving anticoagulant/anti platelet agents who complains of sudden, severe back pain accompanied by neurological symptoms. SSEH is mostly localised in the lower cervical/thoracic spine. Arterial hypertension appears to be a risk factor of SSEH. Early decompression is an important therapeutic approach; in cases with minor neurological deficits, conservative treatment may be chosen.Cíl studie. Spontánní spinální epidurální hematomy (SSEH) jsou vzácné nozologické jednotky, u kterých dochází k akutnímu hromadění krve v míšním kanálu. SSEH se obvykle projevují náhlou silnou bolestí zad doprovázenou rozvojem neurologických příznaků. V této studii retrospektivně popisujeme léčbu a hlavní rizikové faktory SSEH na sérii 14 případů. Materiály a metody. V letech 2010–2019 jsme vyšetřili 14 pacientů (věkové rozmezí 17–89 let, 10 žen) s diagnózou SSEH. Osm případů byli pacienti užívající antikoagulační léčbu (šest warfarin, jeden dabigatran, jeden apixaban) a dva další užívali ASA v dávce 100 mg/den. Přesná lokalizace a rozsah změn byl stanoven z akutní magnetické rezonance. Tři lidé užívající warfarin měli v době diagnózy hodnoty INR vyšší než 3,0. Výsledek. Deset pacientů (71 %) užívalo perorální antikoagulancia nebo antiagregancia. U sedmi pacientů byly SSEH lokalizovány v dolní krční/hrudní páteři. Deset pacientů (71 %) mělo arteriální hypertenzi. Šest pacientů podstoupilo akutní operaci kvůli rychle se rozvíjející kompresi míchy. Osm pacientů (57 %) s mírnými nebo mírnými neurologickými příznaky bylo úspěšně zvládnuto bez operace. Závěry. SSEH by měl být podezřelý u každého pacienta užívajícího antikoagulancia/antiagregancia, který si stěžuje na náhlou silnou bolest zad doprovázenou neurologickými příznaky. SSEH je většinou lokalizován v dolní části krční/hrudní páteře. Arteriální hypertenze se zdá být rizikovým faktorem SSEH. Časná dekomprese je důležitým terapeutickým přístupem; v případech s menším neurologickým deficitem lze zvolit konzervativní léčbu