Akuutin aivovaltimotukoksen uudet hoitolinjat

Akuu­tin ai­vo­val­ti­mo­tu­kok­sen las­ki­mon­si­säis­tä liuo­tus­hoi­toa voi­daan an­taa nel­jän ja puo­len tun­nin ku­lues­sa oi­rei­den alus­ta. Hoi­to on aloi­tet­ta­va he­ti, kun vas­ta-ai­heet on pois­sul­jet­tu. Jos po­ti­laan ai­vo­ve­ren­kier­to­häi­riön oi­reet ovat vai­keat, ei suu­ren ai­vo­val­ti­mon tu­kok­sen las­ki­mon­si­säi­nen liuo­tus­hoi­to yleen­sä rii­tä. Sen li­säk­si har­ki­taan en­do­vas­ku­laa­ri­hoi­to­na lä­hin­nä me­kaa­nis­ta trom­bek­to­miaa kuu­den tun­nin ku­lues­sa. En­do­vas­ku­laa­ri­hoi­toa har­ki­taan myös sil­loin, kun las­ki­mon­si­säi­sel­le liuo­tus­hoi­dol­le on vas­ta-ai­he: INR-ar­vo yli 1,7 tai po­ti­las käyt­tää sään­nöl­li­ses­ti uut­ta ve­re­no­hen­nus­lää­ket­tä da­bi­gat­raa­nia, ri­va­rok­sa­baa­nia tai ­apik­sa­baa­nia. Pää­tös en­do­vas­ku­laa­ri­hoi­don aloit­ta­mi­ses­ta teh­dään ylio­pis­to­sai­raa­las­sa mo­niam­ma­til­li­ses­ti, ja toi­men­pi­teen ai­hees­ta päät­tää neu­ro­lo­gi yh­des­sä sen suo­rit­ta­van ra­dio­lo­gin kans­sa. Hoi­dos­ta on an­net­tu uu­si oh­jeis­tus, jo­ka kos­kee neu­ro­lo­gian päi­vys­tä­jien li­säk­si myös päi­vys­tyk­sen eri­koi­sa­laa, ku­ten kes­kus­sai­raa­la­ta­soi­sia päi­vys­tä­jiä. Päi­vys­tyk­sel­li­seen AVH-hoi­toon lä­het­tä­mi­sen kri­tee­rit säi­ly­vät en­nal­laan ja hoi­don va­lin­taan ote­taan kan­taa ylio­pis­to­sai­raa­loi­den päi­vys­tys­pis­teis­sä.Peer reviewe

Hypoperfusion of an Entire Cerebral Hemisphere – Stroke or Postictal Deficit?

The clinical differential diagnosis between ischemic stroke and postictal deficit is sometimes challenging. If the clinical presentation is inconclusive, perfusion imaging can help to identify stroke patients for thrombolysis therapy. However, also epileptic phenomena may alter cerebral perfusion. Hypoperfusion spreading beyond the borders of cerebrovascular territories is usually considered suggestive of an etiology other than stroke. We present a patient whose clinical symptoms suggested a postictal deficit rather than an acute stroke. CT perfusion imaging showed hypoperfusion of the entire left cerebral hemisphere covering all vascular territories. CT angiography revealed occlusions in the ipsilateral internal carotid artery and in the circle of Willis as the cause of the global hypoperfusion. The patient was treated with i.v. thrombolysis and recovered with moderate disability. This is the first description of hyperacute ischemia of an entire cerebral hemisphere and its treatment with thrombolysis. It demonstrates the potential of modern neuroimaging in identifying atypically presenting strokes and shows that i.v. thrombolysis can be effectively and safely used to treat such potentially fatal insults

Moyamoya angiopathy: radiological follow-up findings in Finnish patients

Moyamoya angiopathy (MMA) is a chronic progressive disorder, but imaging changes observed over time are not yet characterized in European populations. We analyzed the progression of MMA with magnetic resonance imaging and angiography (MRI and MRA) in our Finnish MMA registry. Stage classification based on MRA findings was used to evaluate the progress of the disease.Peer reviewe

Moyamoya vasculopathy - Patient demographics and characteristics in the Finnish population

Background and purpose Moyamoya vasculopathy, a rare steno-occlusive progressive cerebrovascular disorder, has not been thoroughly studied in Caucasian populations. We established a registry of Finnish patients treated at the Helsinki University Hospital, to collect and report demographic and clinical data. Methods We collected data both retrospectively and prospectively from all the patients with a moyamoya vasculopathy referred to our hospital between January 1987 and December 2014. All patients underwent a neurological outpatient clinic visit. Results We diagnosed 61 patients (50 females, 10 children) with moyamoya vasculopathy. The mean age at the disease-onset was 31.517.9 years. The two most common presenting symptoms were ischemic stroke (n=31) and hemorrhage (n=8). Forty-four percent underwent revascularization surgery, and 70% were prescribed antithrombotic treatment. Conclusions The results support in part the Western phenotype of the disease considering the later presentation and larger female predominance compared to the Asian moyamoya vasculopathy reports. However, the proportion of ischemic strokes and hemorrhagic strokes is closer to Japanese population than German population. The absence of familial cases points to a different genetic profile in the Finnish patients.Peer reviewe

Cortical Excitability Measured with nTMS and MEG during Stroke Recovery

Objective. Stroke alters cortical excitability both in the lesioned and in the nonlesioned hemisphere. Stroke recovery has been studied using transcranial magnetic stimulation (TMS). Spontaneous brain oscillations and somatosensory evoked fields (SEFs) measured by magnetoencephalography (MEG) are modified in stroke patients during recovery. Methods. We recorded SEFs and spontaneous MEG activity and motor threshold (MT) short intracortical inhibition (SICI) and intracortical facilitation (ICF) with navigated TMS (nTMS) at one and three months after first-ever hemispheric ischemic strokes. Changes of MEG and nTMS parameters attributed to gamma-aminobutyrate and glutamate transmission were compared. Results. ICF correlated with the strength and extent of SEF source areas depicted by MEG at three months. The nTMS MT and event-related desynchronization (ERD) of beta-band MEG activity and SICI and the beta-band MEG event-related synchronization (ERS) were correlated, but less strongly. Conclusions. This first report using sequential nTMS and MEG in stroke recovery found intra-and interhemispheric correlations of nTMS and MEG estimates of cortical excitability. ICF and SEF parameters, MT and the ERD of the lesioned hemisphere, and SICI and ERS of the nonlesioned hemisphere were correlated. Covarying excitability in the lesioned and nonlesioned hemispheres emphasizes the importance of the hemispheric balance of the excitability of the sensorimotor system.Peer reviewe

Memory decline in young stroke survivors during a 9-year follow-up : A cohort study

Peer reviewe

IV Thrombolysis-Bridging and Endovascular Treatment for Occlusive Internal Carotid Artery Dissection with Tandem Occlusion

Compared to other etiologies of ischemic stroke, occlusive internal carotid artery dissection responds worse to intravenous (IV) thrombolysis. Intracranial tandem occlusion is a predictor of poor outcome. A direct endovascular approach has been proposed as a safe and probably superior alternative to IV thrombolysis. However, it may lead to considerable treatment delays. We used rapidly initiated IV thrombolysis-bridging and subsequent endovascular treatment in two patients with severe hemispheric ischemia due to occlusive internal carotid artery dissection with tandem occlusion and achieved good outcomes. Minimizing recanalization times likely improves patient outcome and IV thrombolysis-bridging may be a reasonable strategy to achieve this. The positive initial results obtained with endovascular approaches and IV thrombolysis-bridging in this patient group deserve further scientific exploration

Moyamoya angiopathy: long-term follow-up study in a Finnish population

Moyamoya angiopathy (MMA) is a chronic cerebrovascular disorder predominantly starting in childhood or early adulthood and thus affects the whole lifetime. Little is known on MMAs long-term outcomes in European patients. We report long-term follow-up data on Finnish MMA patients.Peer reviewe

Helsinki experience on nonvitamin K oral anticoagulants for treating cervical artery dissection

BackgroundCervical artery dissection (CeAD) patients with or without stroke are frequently treated with either antiplatelet agents or vitamin K antagonists (VKAs), but few data are reported on the use of nonvitamin K oral anticoagulants (NOACs). MethodsBetween November 2011 and January 2014, we recorded data from patients with a stroke due to vertebral (VAD) or internal carotid artery dissection (ICAD). Patients using oral anticoagulants were included in the study and were divided into two treatment groups: patients using NOACs and those using VKAs. Excellent outcome was defined on modified Rankin Scale (mRS) 1 at 6months. ResultsOf 68 stroke patients (67% male; median age 45 [39-53]), six (8.8%; two with VAD and four with ICAD) were treated with NOACs: three with direct thrombin inhibitor dabigatran and three with direct factor Xa inhibitor rivaroxaban. National Institutes of Health Stroke Scale score at baseline was 4 (3-7) in the NOAC versus 2 (1-7) in the VKA groups. Complete recanalization at 6months was seen in most patients in the NOAC (n=5; 83%) and VKA (n=34; 55%) groups. All the patients using NOACs had mRS 1 at 6months and none had an intracerebral hemorrhage (ICH). In the VKA group most patients (n=48; 77%) had mRS 1, one patient (1.7%) had an ICH and one died. ConclusionsIn this small, consecutive single-center patient sample treating ischemic stroke patients with CeAD with NOACs did not bring up safety concerns and resulted in similar, good outcomes compared to patients using VKAs.Peer reviewe