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1. Cryptogenic postpartum stroke

Author

István Gubucz, Zoltán Szakács, Zsolt May, Norbert Szegedi, and Dániel Bereczki

Subjects
Adult, HELLP Syndrome, medicine.medical_specialty, Peripartum cardiomyopathy, Brain Ischemia, Paradoxical embolism, Pregnancy, Risk Factors, Internal medicine, medicine, Humans, Medical history, Stroke, reproductive and urinary physiology, Thrombectomy, Eclampsia, Cesarean Section, Cerebral infarction, business.industry, Postpartum Period, Infarction, Middle Cerebral Artery, medicine.disease, Cerebral Angiography, Cardiology, Patent foramen ovale, Female, Stents, Surgery, Neurology (clinical), Tomography, X-Ray Computed, business, Postpartum period
Abstract

An estimated 25-40% of ischemic strokes are classified as cryptogenic, which means the cause of the cerebral infarction remains unidentified. One of the potential pathomechanisms - especially among young patients with no cardiovascular risk factors - is paradoxical embolism through a patent foramen ovale. Pregnancy, cesarean delivery and the postpartum period are associated with an increased risk of cerebrovascular events. Factors that may contribute to ischemic strokes during gestation and puerperium include classic cardiovascular risk factors, changes in hemostaseology/hemodynamics, and pregnancy-specific disorders such as pre-eclampsia, eclampsia, postpartum cerebral angiopathy or peripartum cardiomyopathy. In this case report, we present a 36-year-old thrombolysis candidate undergoing mechanical thrombectomy 3 weeks after a cesarean section due to HELLP-syndrome. After evaluation of anamnestic and diagnostic parameters, closure of the patent foramen ovale has been performed. In the absence of specific guidelines, diagnostic work-up for cryptogenic stroke should be oriented after the suspected pathomechanism based on patient history and clinical picture. As long as definite evidences emerge, management of cryptogenic stroke patients with pathogenic right-to-left shunt remains individual based on the mutual decision of the patient and the multidisciplinary medical team.

Published
2016

2. Ticagrelor versus Aspirin in Acute Stroke or Transient Ischemic Attack

Author

Johnston, S Claiborne, Amarenco, Pierre, Albers, Gregory W, Denison, Hans, Easton, J Donald, Evans, Scott R, Held, Peter, Jonasson, Jenny, Minematsu, Kazuo, Molina, Carlos A, Wang, Yongjun, Wong, K S Lawrence, Ameriso, Sebastiá F, Donnan, Geoffrey, Lemmens, Robin, Massaro, Ayrton, Titianova, Ekaterina, Hill, Michael D, Lavados, Pablo, Skoloudik, David, Röther, Joachim, Norbert, Szegedi, Agnelli, Giancarlo, Bornstein, Natan, Tanahashi, Norio, Góngora, Angel Arauz, Pretell, Edwin, San Jose, Maria Cristina Z, Czlonkowska, Anna, Bajenaru, Ovidiu, Stakhovskaya, Ludmila, Brozman, Miroslav, Kim, Jong-Sung, Wahlgren, Nils, Michel, Patrik, Lee, Tsong Hai, Suwanwela, Nijasri Charnnarong, Kutluk, Kursad, Moskovko, Sergii, Kasner, Scott, Laskowitz, Daniel, Clark, Wayne, Nguyen, Huy Thang, Ameriso, Sebastián F, Ameriso, Sebastian, Lepera, Sandra, Romano, Marina, Paulon, David, Ioli, Pablo, Zurru, Cristina, Bruera, Guadalupe, Jure, Lorena, Klein, Francisco, Povedano, Guillermo, Levi, Christopher, Phan, Thanh, Markus, Romesh, Anderson, Craig, Sabet, Arman, Davis, Stephen, Lee, Andrew, Kleinig, Timothy, Wong, Andrew, Krause, Martin, Jannes, Jim, Wijeratne, Tissa, Hemelsoet, Dimitri, Peeters, André, Tack, Philippe, Vanacker, Peter, Laloux, Patrice, Van Landegem, William, Vanhooren, Geert, Desfontaines, Philippe, Van Orshoven, Marc, Oliveira, Fabio, Friedrich, Mauricio, Brondani, Rosane, Gagliardi, Rubens, Fabio, Soraia, Dracoulakis, Marianna, Bazan, Rodrigo, Marrone, Luiz, Pontes Neto, Octavio, Silva, Gisele, Kowacs, Pedro, Stamenova, Paraskeva, Daskalov, Marin, Staikov, Ivan, Baldaranov, Dimo, Maslarov, Dimitar, Lilovski, Hristo, Petkov, Plamen, Petrova, Neli, Mavrov, Radoslav, Markova, Veska, Petrova, Valeria, Beleva, Tanya, Kralev, Borislav, Sotirov, Nikolay, Lekova, Veska, Hristov, Dimcho, Ermenkova, Vera, Mateev, Lyudmil, Mitkova, Rumeliya, Haralanov, Liybomir, Ikonomov, Rosen, Mihailova, Margarita, Georgiev, Ivan, Shuaib, Ashfaq, Hachinski, Vladimir, Boulanger, Jean-Martin, Mann, Sharan, Hassan, Ayman, Mackey, Ariane, Menon, Bijoy, Minuk, Jeffrey, Siddiqui, Muzaffar, Eustace, Marsha, Vieira, Lucia, Selchen, Daniel, Beaudry, Michel, Stotts, Grant, Castro, Angel, Gasic, Kristo, Rivas, Rodrigo, Sanchez, Pablo, Roldan, Andres, Grossmann, Ingrid, Figueroa, Christian, Li, Jimei, Xu, Xiaolin, Chen, Huisheng, Li, Xiaohong, Yang, Yi, Zhang, Chunsheng, Wang, Baojun, Li, Guanglai, Wang, Dong, Lin, Hong, Tang, Yamei, Xu, Anding, Wang, Yanjiang, Hong, Wenke, Song, Zhi, Zhang, Xu, Jin, Xiaoping, Xu, Yun, Yan, Fuling, Zheng, Weihong, Wang, Xiaoping, Dong, Qiang, Zhao, Zhongxin, Zhang, Baorong, Zhong, Wangtao, Wen, Guoqiang, Xu, Jun, Li, Guozhong, Dong, Xueshuang, Tian, Xiangyang, Zhang, Zhaohui, Xu, En, Liu, Kaixiang, Chen, Jun, Skoda, Ondrej, Ehler, Edvard, Vaclavik, Daniel, Sanak, Daniel, Klimosova, Sylva, Vitkova, Eva, Fiksa, Jan, Mikulik, Robert, Neumann, Jiri, Plny, Richard, Leys, Didier, Sibon, Igor, Mas, Jean-Louis, Alamowitch, Sonia, Pico, Fernando, Hosseini, Hassan, Mahagne, Marie-Hélène, Touze, Emmanuel, Vadot, Wilfried, Vannier, Stéphane, Nighoghossian, Norbert, Samson, Yves, Garnier, Pierre, Ellie, Emmanuel, Guillon, Benoît, Timsit, Serge, Giroud, Maurice, Philippeau, Frédéric, Bagan-Triquenot, Aude, Wolff, Valérie, Raposo, Nicolas, Obadia, Michel, Debiais, Severine, Grimaud, Jérôme, Illouz, Stéphane, Smadja, Didier, Urbanczyk, Cédric, Berrouschot, Jörg, Weimar, Christian, Gahn, Georg, Soda, Hassan, Klimpe, Sven, Nabavi, Darius, Glahn, Jörg, Köhrmann, Martin, Krause, Lars, Terborg, Christoph, Urban, Peter, Steiner, Thorsten, Ferbert, Andreas, Dziewas, Rainer, Seidel, Günter, Thomalla, Götz, Wong, Ka Sing Lawrence, Li, Richard, Fong, Wing Chi, Cheung, Raymond, Szegedi, Norbert, Pozsegovits, Krisztián, Valikovics, Attila, Pánczél, Gyula, Rózsa, Csilla, Németh, László, Diószeghy, Péter, Óváry, Csaba, Csányi, Attila, Kerényi, Levente, Nagy, Valéria, Komoly, Sámuel, Bereczki, Dániel, Molnár, Sándor, Kondákor, István, Tanne, David, Raphaeli, Guy, Telman, Gregory, Leker, Ronen, Lampl, Yair, Corea, Francesco, Ricci, Stefano, Guidetti, Donata, Malferrari, Giovanni, Marcheselli, Simona, Micieli, Giuseppe, Zini, Andrea, Di Lazzaro, Vincenzo, Gandolfo, Carlo, Salmaggi, Andrea, Tassi, Rossana, Rasura, Maurizia, Orlandi, Giovanni, Comi, Giancarlo, Mancuso, Michelangelo, Delodovici, Marialuisa, Bovi, Paolo, Consoli, Domenico, Utsugisawa, Kimiaki, Fujita, Tsuneo, Kurihara, Hideyuki, Maruki, Chikashi, Hayashi, Takeshi, Ogiichi, Tsuneaki, Kumagai, Morio, Takenaka, Katsunobu, Toyoda, Kazunori, Takamatsu, Kazuhiro, Ogami, Ryo, Kin, Shigenari, Aoki, Takeshi, Takizawa, Katsumi, Omori, Shigehiro, Umezawa, Takehiko, Toba, Yasuyuki, Nonoyama, Yutaka, Nakagawa, Hidemitsu, Naka, Takashi, Morimoto, Masanori, Matsumoto, Shuichi, Hitotsumatsu, Tsutomu, Shingaki, Tatsuya, Okuda, Satoshi, Ota, Mamoru, Sakai, Nobuyuki, Yamada, Takeshi, Niwa, Jun, Fujita, Hitoshi, Moriki, Akihito, Yoshino, Kimihiro, Fukushima, Yoshihisa, Mori, Takahisa, Sato, Atsushi, Kusano, Yoshikazu, Kubo, Michiya, Yamazaki, Masashi, Ooasa, Takao, Nishizaki, Takafumi, Kitagawa, Naoki, Yasaka, Masahiro, Manabe, Yasuhiro, Yoshioka, Akira, Ishihara, Masayuki, Kagawa, Takato, Ichihashi, Toshikazu, Matsuoka, Hideki, Ito, Yasuhiro, Yamasaki, Masahiro, Takaba, Hitonori, Saito, Hisatoshi, Sato, Masahiro, Fukuda, Kazumasa, Endo, Sumio, Kidooka, Minoru, Umemura, Toshitaka, Kikkawa, Yuriko, Toru, Shuta, Yamada, Kentaro, Sakai, Hideki, Asari, Jun, Ezura, Masayuki, Nitta, Hisashi, Nagano, Keiko, Ochiai, Jun, Sakai, Keiichi, Kobayashi, Yasutaka, Yoshii, Yasuhiro, Miake, Hirotomo, Takita, Tomohiro, Taniguchi, Hidekazu, Kuroki, Kazuhiko, Mizota, Takamitsu, Yamamoto, Kenichi, Nakane, Hiroshi, Iwanaga, Takeshi, Chiba, Kei, Yoshimoto, Tetsuyuki, Torii, Tsuyoshi, Kitagawa, Takeo, Takashima, Hiroshi, Shirasaki, Naoki, Dehara, Makoto, Wada, Naomichi, Hamada, Kensuke, Kato, Noriyuki, Go, Yoshinori, Izumi, Ichiro, Ninomiya, Hirotomo, Kumai, Junichiro, Nakajima, Yoshikazu, Kaku, Yasuhiko, Isayama, Yukihiro, Kawanishi, Masahiro, Noda, Shinya, Yamamoto, Kazuhide, Hazama, Takanori, Takahashi, Hiroshi, Tanaka, Yohei, Hata, Takashi, Kazekawa, Kiyoshi, Furui, Eisuke, Hondo, Hideki, Sato, Nobuyuki, Kusunoki, Katsusuke, Nanri, Kazunori, Abe, Satoshi, Sasaoka, Noboru, Kuroyanagi, Takayuki, Suzuki, Hisahiko, Fukuyama, Kouzou, Nakahara, Kimihiro, Gongora, Fernando, Brito, Carlos Cantú, Careaga, Jorge Villarreal, Alfaro, Rosalia Vazquez, Leytte, Geronimo Aguayo, Berrospi, Percy, Chavez, Carlos, Rodriguez, Liliana, Custodio, Nilton, Castañeda, Cesar, Perez, Julio, Marquez, Sandra Vargas, San Jose, Maria Cristina, Baroque, Alejandro, Collantes, Ma Epifania, Aquino, Abdias, Díaz, Alejandro, Roxas, Artemio, Lokin, Johnny, Advincula, Joel, Calderon, Emerito, Navarro, Jose, Hiyadan, John, Surdilla, Arturo, Ryglewicz, Danuta, Krychowiak, Grzegorz, Fryze, Waldemar, Sobolewski, Piotr, Nowak, Ryszard, Fiszer, Urszula, Papierowska, Beata, Zieli?ska-Turek, Justyna, Lasek-Bal, Anetta, Ko?odziejska, Ewa, Kami?ska, Anna, Adamkiewicz, Bo?ena, Tutaj, Andrzej, Szkopek, Dorota, Musiatowicz, Krzysztof, B?k, Zbigniew, Brzozowski, S?awomir, Brola, Waldemar, Ferens, Antoni, Zalisz, Marek, Rejdak, Konrad, Rudzi?ska, Monika, Panea, Cristina, Simu, Mihaela, Balasa, Rodica, Cuciureanu, Iulian, Popescu, Bogdan, Sabau, Monica, Roman-Filip, Corina, Stakhovskaya, Liudmila, Pimenov, Leonid, Gekht, Alla, Milto, Anna, Shchukin, Ivan, Parfenov, Vladimir, Arkhipov, Mikhail, Vishneva, Elena, Sokolova, Nadezhda, Bogdanov, Enver, Esin, Radiy, Khasanova, Dina, Golikov, Konstantin, Melnikova, Elena, Zaslavskiy, Leonid, Voznyuk, Igor, Nazarov, Alexander, Akhmadeeva, Leila, Iakupova, Aida, Shamalov, Nikolay, Belskaya, Galina, Chuprina, Svetlana, Denisova, Olga, Drozdova, Ekaterina, Karakulova, Yuliya, Sholomov, Ilya, Spirin, Nikolay, Vostrikova, Elena, Mordvintseva, Elena, Grigoryeva, Vera, Zateyshchikov, Dmitry, Gorbachev, Vladimir, Chefranova, Zhanna, Dudarev, Mikhail, Nilk, Rostislav, Rozhdestvenskiy, Alexey, Gurcik, Ladislav, Dvorak, Miloslav, Krastev, Georgi, Kurca, Egon, Vyletelka, Juraj, Kim, Jong Sung, Bae, Hee-Joon, Kim, Yong-Won, Kim, Joon-Tae, Cha, Jae-Kwan, Nam, Hyo Suk, Chang, Dae-Il, Lee, Yong-Seok, Oh, Kyungmi, Yu, Sung-Wook, Sohn, Sung-Il, Lee, Jun, Cho, Han Jin, Kim, Eung-Gyu, Rha, Joung-Ho, Kim, Seo Hyun, Cateriano, Carlos Molina, Leal, Joaquín Serena, Mora, José Vivancos, Yañez, Manuel Rodríguez, González, Jaume Roquer, García, Francisco Purroy, Cortina, Meritxell Gomis, Vallejo, Jaime Masjuan, Lara, Juan Arenillas, Martín, Tomás Segura, Herrero, José Antonio Egido, Ferrairó, Jose Ignacio Tembl, Culleré, Jaime Gállego, Álvarez, Francisco Moniche, Steinberg, Anna, Callander, Margarita, Laska, Ann Charlotte, Bokemark, Lena, Mooe, Thomas, Käll, Tor-Björn, Welin, Lennart, Sjöblom, Lars, Hambraeus, Joakim, Teichert, Jörg, Wannberg, Hans, Sanner, Johan, Ramströmer, Bo, Ziedén, Bo, Hau, Stefan Olsson, Gustafsson, Claes, Kahles, Timo, Lyrer, Philippe, Arnold, Marcel, Liesch, Martin, Medlin, Friedrich, Cereda, Carlo, Kägi, Georg, Luft, Andreas, Carrera, Emmanuel, Lee, Tsong-Hai, Po, Helen L, Chern, Chang-Ming, Lien, Li-Ming, Chan, Lung, Liu, Chung-Hsiang, Wu, Shey-Lin, Lee, Jiann-Der, Chen, Chih-Hung, Lin, Huey-Juan, Lin, Ruey-Tay, Chen, Wei-Hsi, Sun, Yu, Tantirittisak, Tasanee, Muengtaweepongsa, Sombat, Nilanont, Yongchai, Tiamkao, Somsak, Udommongkol, Chesda, Watcharasaksilp, Kanokwan, Jantararotai, Witoon, Sirin, Hadiye, Ince, Birsen, Asil, Talip, Arsava, Murat, Incesu, Tulay Kurt, Tireli, Hulya, Kucukoglu, Hayriye, Ak, Fikri, Unal, Ali, Ozturk, Serefnur, Uzuner, Nevzat, Chmyr, Galyna, Lebedynets, Volodymyr, Nikonov, Vadym, Shulga, Lyudmyla, Smolanka, Volodymyr, Khavunka, Marta, Yavorska, Valentyna, Tomakh, Nataliya, Kozyolkin, Olexandr, Litovaltseva, Galyna, Lansberg, Maarten, Bernstein, Richard, Brown, David, Dissin, Jonathan, Graffagnino, Carmelo, Harris, Jonathan, Hicks, William, Katzan, Irene, Kramer, Jeffrey, Willey, Joshua, Silliman, Scott, Starkman, Sidney, Thaler, David, Tremwel, Margaret, Concha, Mauricio, Rajamani, Kumar, Dandapani, Bhuvaneswari, Silver, Brian, Deal, Nathan, Chang, Ira, Hassan, Ameer, Rudolph, Steven, Fischer, Kenneth, Kirshner, Howard, Logan, William, Mallenbaum, Sidney, Hefzy, Hebah, Latorre, Julius, Levine, Steven, Ciabarra, Anthony, Dafer, Rima, Anyanwu, Benjamin, Cherian, Laurel, Panezai, Spozhmy, Khanna, Anna, Dodds, Jodi, Torbey, Michel, Gebel, James, Woo, Henry, Chiu, David, Androulakis, Xiao, Burgin, William, Pineda, Maria, Yilmaz, Engin, Altafullah, Irfan, Boutwell, Christine, Cruz-Flores, Salvador, Sapkota, Biggya, Fayad, Pierre, Jacoby, Michael, Rafiq, Shahid, Salgado, Efrain, Lafranchise, Eugene, Felton, Warren, Madhavan, Ramesh, Zaidat, Osama, Pieper, Connie, Riviello, Ralph, Burnett, Aaron, Fischer, Michelle, Gentile, Nina, Calder, Christopher, Dietrich, Dennis, Cross, Jonathan, Blankenship, Larry, Montoya, Liliana, Grogan, Wendell, Young, Mark, Khan, Farrukh, Campbell, Duane, Daboul, Nizar, Espinoza, Andrey, Cullis, Paul, Concepcion, Gilberto, Wulff, John, Afzal, Haider, Jaffrani, Naseem, Reiter, William, Arshad, Tamjeed, Lukovits, Timothy, Welker, James, Chang, Fen Lei, Badruddin, Aamir, Babikian, Viken, Menon, Ravi, Sander, James, Springer, Mellanie, Nanda, Ashish, Mas, Luis, Rajan, Raj, Silverman, Bruce, Huang, David, Carpenter, David, Clark, Joni, Ching, Marilou, Santhakumar, Sunitha, Gould, Jeffrey, Bansal, Vibhav, Vidal, Gabriel, Mikesell, Timothy, Brick, John, French, William, Shah, Qaisar, Holmstedt, Christine, Ishag-Osman, Nadir, Kostis, John, Shehadeh, Abbas, Sethi, Pramodkumak, Imam, Asher, Mccomas, Carl, Tran, Duc, Gebreyohanns, Mehari, Wiseman, Brian, Malik, Maheen, Schwarcz, Aron, Altschul, Dorothea, Castaldo, John, Alshekhlee, Amer, Gancher, Stephen, Krish, Nagesh, Nguyen-Huynh, Mai, Tremwell, Margaret, Sharma, Jitendra, Lee, Lance, Neil, William, Siddiqui, Fazeel, Malek, Ali, Romero, Charles, Huy, Thang Nguyen, Hoang, Hoa, Nguyen, Thang, Nguyen, Anh, Nguyen, Hung, Dean's Office (DO - AUSTIN), University of Texas at Austin [Austin], Laboratoire de Recherche Vasculaire Translationnelle (LVTS (UMR_S_1148 / U1148)), Université Paris 13 (UP13)-Université Paris Diderot - Paris 7 (UPD7)-Institut National de la Santé et de la Recherche Médicale (INSERM), Hôpital Bichat - Claude Bernard, Stanford Stroke Center, Stanford University Medical Center, AstraZeneca, Harvard T.H. Chan School of Public Health, National Cerebral and Cardiovascular Center (NCCC - OSAKA), Osaka University [Osaka], Stroke Unit (SU - BARCELONE), Vall d'Hebron University Hospital [Barcelona], Department of Neurology (Dep Neuro - BEIJING), Tiantan Hospital, Department of Medicine and Therapeutics [Hong Kong], The Chinese University of Hong Kong [Hong Kong], Murdoch University, Service de Neurologie [Brest], Centre Hospitalier Régional Universitaire de Brest (CHRU Brest), Centre d'Investigation Clinique (CIC - Brest), and Université de Brest (UBO)-Institut National de la Santé et de la Recherche Médicale (INSERM)

Subjects
Male, Ticagrelor, Adenosine, Medizin, Aged, Aspirin, Double-Blind Method, Female, Hemorrhage, Humans, Ischemic Attack, Transient, Kaplan-Meier Estimate, Middle Aged, Platelet Aggregation Inhibitors, Purinergic P2Y Receptor Antagonists, Stroke, Medicine (all), 030204 cardiovascular system & hematology, Stringa autori originale: Johnston SC, Easton JD, 0302 clinical medicine, Myocardial infarction, Ischemic Attack, Transient, General Medicine, Clopidogrel, Denison H, 3. Good health, Minematsu K, Wang Y, SOCRATES Steering Committee and Investigators. - Free full-text sul sito dell'editore, Anesthesia, Platelet aggregation inhibitor, Evans SR, medicine.drug, Stringa autori originale: Johnston SC, Amarenco P, Albers GW, Denison H, Easton JD, Evans SR, Held P, Jonasson J, Minematsu K, Molina CA, Wang Y, Wong KS, Ischemia, Loading dose, Molina CA, 03 medical and health sciences, medicine, business.industry, Jonasson J, medicine.disease, Albers GW, Amarenco P, Held P, Wong KS, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

International audience; Ticagrelor may be a more effective antiplatelet therapy than aspirin for the prevention of recurrent stroke and cardiovascular events in patients with acute cerebral ischemia.; We conducted an international double-blind, controlled trial in 674 centers in 33 countries, in which 13,199 patients with a nonsevere ischemic stroke or high-risk transient ischemic attack who had not received intravenous or intraarterial thrombolysis and were not considered to have had a cardioembolic stroke were randomly assigned within 24 hours after symptom onset, in a 1:1 ratio, to receive either ticagrelor (180 mg loading dose on day 1 followed by 90 mg twice daily for days 2 through 90) or aspirin (300 mg on day 1 followed by 100 mg daily for days 2 through 90). The primary end point was the time to the occurrence of stroke, myocardial infarction, or death within 90 days.; During the 90 days of treatment, a primary end-point event occurred in 442 of the 6589 patients (6.7%) treated with ticagrelor, versus 497 of the 6610 patients (7.5%) treated with aspirin (hazard ratio, 0.89; 95% confidence interval [CI], 0.78 to 1.01; P=0.07). Ischemic stroke occurred in 385 patients (5.8%) treated with ticagrelor and in 441 patients (6.7%) treated with aspirin (hazard ratio, 0.87; 95% CI, 0.76 to 1.00). Major bleeding occurred in 0.5% of patients treated with ticagrelor and in 0.6% of patients treated with aspirin, intracranial hemorrhage in 0.2% and 0.3%, respectively, and fatal bleeding in 0.1% and 0.1%.; In our trial involving patients with acute ischemic stroke or transient ischemic attack, ticagrelor was not found to be superior to aspirin in reducing the rate of stroke, myocardial infarction, or death at 90 days. (Funded by AstraZeneca; ClinicalTrials.gov number, NCT01994720.).

Published
2016

3. Transient deficits after inadvertent intrathecal trigger-point injection with lidocaine

Author

Nora Peto, Dániel Bereczki, and Norbert Szegedi

Subjects
Adult, Lidocaine, Pneumorrhachis, Nystagmus, Ventricular system, Intrathecal, Dysarthria, Vertigo, medicine, Humans, Anesthetics, Local, Injections, Spinal, Anisocoria, Neck Pain, biology, business.industry, biology.organism_classification, Paresis, Hemiparesis, Anesthesia, Pneumocephalus, Female, Neurology (clinical), medicine.symptom, business, medicine.drug
Abstract

A 43-year-old woman had trigger-point injections for chronic neck pain by a traditional Chinese medicine physician. Paravertebral muscles at C5-C6 were infiltrated with lidocaine. Thirty minutes later, right-sided hemiparesis with nystagmus, dysarthria, and anisocoria developed. The patient complained of vertigo, vomited multiple times, and became somnolent. Neuroimaging revealed air in the ventricular system (figure 1) and in the dural sheath of the fifth cervical nerve root (figure 2), implying an accidental intrathecal injection and thus a possible direct effect of lidocaine. Three hours later, neurologic symptoms resolved gradually and the patient recovered fully. MRI revealed no intraparenchymal damage.

Published
2016

4. [Effectiveness and safety of intraventricular fibrinolysis in secondary intraventricular hemorrhages (a prospective, randomized study)]

Author

István, Gubucz, Ilona, Kakuk, Ottó, Major, Norbert, Szegedi, Péter, Barsi, Gyula, Pánczél, Dániel, Varga, Csaba, Ovary, Zsolt, May, Gabriella, Ricsói, Júlia, Kenéz, Géza, Szilágyi, and Zoltán, Nagy

Subjects
Adult, Male, Middle Aged, Urokinase-Type Plasminogen Activator, Cerebral Ventricles, Plasminogen Activators, Treatment Outcome, Fibrinolytic Agents, Hypertension, Humans, Female, Glasgow Coma Scale, Thrombolytic Therapy, Prospective Studies, Tomography, X-Ray Computed, Aged, Cerebral Hemorrhage
Abstract

Intraventricular clot secondary to brain hemorrhage has still one of the worst prognosis among all stroke subtypes, regardless of conservative therapy or surgical interventions. The rapid clot resolution with thrombolytic agents could improve the outcome by restoring the impaired cerebrospinal fluid circulation, for this reason, the authors examined the safety and efficacy of Urokinase therapy in a randomized, controlled study.They enrolled 27 patients with severe intraventricular hemorrhage between 1998 and 2002. All patients had supratentorial intracerebral hemorrhage caused by hypertension, with IVH, moreover clinically worsening course due to the obstructive hydrocephalus confirmed by CT. Eleven persons were treated with ventriculostomy alone and 16 received adjunctive intraventricular urokinase. The authors examined the early, 30-day and 1-year mortality, furthermore the neurological (Scandinavian Stroke Scale) and functional outcome (Barthel Scale). The mean age was 60 +/- 9.5. The initial Scandinavian Stroke Scale was 7.51 +/- 8.64, Glasgow Coma Scale was 6.85 +/- 2.52, intracerebral hemorrhage volume was 22.44 +/- 18.14 ml.The 1 year survival rate was significant higher in the urokinase treated group (p = 0.014), This tendency in the mortality (31.3% vs. 54.5%) and in the neurological/functional condition (SSS, p = 0.078/Barthel, p = 0.119) at 30th day have been also documented. No hemorrhagic complications due to urokinase were observed. Two meningitis (7.4%) and two intraparenchymal hemorrhages (7.4%) related to drain insertion were detected (p = 0.009). The probability of pulmonary infection was roughly two times higher in the group without clot lysis (RR = 1.870; 95% CI: 1.004-3.482).In the authors experience, urokinase treatment reveals to be safe in the intraventricular clot lysis. This therapy allows earlier mobilization and rehabilitation, and decreases the number of infections, which are favorable to the long-term survival rate.

Published
2004

5. [Thrombolysis in acute ischemic stroke with intravenous recombinant tissue-type plasminogen activator]

Author

Zsolt, May, Ilona, Kakuk, Csaba, Ováry, Gabriella, Ricsóy, Judit, Skopál, Norbert, Szegedi, Dániel, Varga, and Zoltán, Nagy

Subjects
Aged, 80 and over, Male, Time Factors, Contraindications, Hemorrhage, Middle Aged, Severity of Illness Index, Recombinant Proteins, Brain Ischemia, Stroke, Treatment Outcome, Fibrinolytic Agents, Risk Factors, Tissue Plasminogen Activator, Acute Disease, Humans, Female, Thrombolytic Therapy, Tomography, X-Ray Computed, Aged, Retrospective Studies
Abstract

The authors summarised their experiences of systemic intravenous thrombolysis using recombinant tissue-type plasminogen activator with 3 hours therapeutic window in acute ischaemic stroke.The aim of this work was to test the safety and efficacy of systemic thrombolysis in our unselected, community-based patient population.The mean door-to-needle time was 45 minutes, the number of bleeding complications and successful recanalisation was similar to the results of the large international trials. In spite of these facts the functional outcome of our patients turned out to be worse. Compared to the baseline characteristics of the international trials the initial neurological deficit--a well known bad prognostic parameter- and also the comorbidity of our patients was more severe.In Hungary only patients with alarming, initial symptoms arrive quickly enough for thrombolysis to the hospital, while in most of the patients with less severe stroke symptoms the delay for hospital admission is more than 3 hours. The authors assume that with more effective patient education it might be possible to solve this problem and make thrombolysis to exert a greater impact on the effectiveness of the acute stroke therapy.

Published
2003

6. [Thrombolytic therapy in acute ischemic stroke with streptokinase]

Author

Norbert, Szegedi, Ilona, Kakuk, Júlia, Kenéz, Zsolt, May, Csaba, Ováry, Gabriella, Ricsóy, Judit, Skopál, Dániel, Varga, Adám, Harsányi, and Zoltán, Nagy

Subjects
Adult, Aged, 80 and over, Male, Contraindications, Middle Aged, Brain Ischemia, Stroke, Plasminogen Activators, Treatment Outcome, Fibrinolytic Agents, Risk Factors, Humans, Female, Streptokinase, Thrombolytic Therapy, Tomography, X-Ray Computed, Aged, Retrospective Studies
Abstract

In an open, observational study, 40 consecutive ischemic stroke patients eligible for thrombolytic therapy using the combined ECASS/NINDS inclusion criteria have been treated intravenously with 1.5 M units of streptokinase. The therapeutic window was 3 hours or shorter.The safety analysis documented a low rate (5%) of intracerebral hemorrhages, and an additional 13% rate of hemorrhagic transformation of the initial infarction. Two patients died due to intracerebral bleeding. The efficacy of the SK thrombolysis was significant in 53% of the patients (the mean of the improvement on the NIH stroke scale was 15 points), while an other 42% of the patients achieved only the mean of 4 points improvement on their NIHSS score.These results are of the same magnitude, as those documented in the NINDS trial with rt-PA. Time window rather than the thrombolytic agent itself seems to be the decisive factor for successful thrombolysis.The good safety profile of SK in acute stroke using the ECASS/NINDS criteria, and the cost-effectiveness of the drug underline the necessity of a new SK trial with the recently accepted inclusion and exclusion criteria.

Published
2002

7. [Molecular markers of endothelial dysfunction in acute ischemic stroke]

Author

Norbert, Szegedi, Zsolt, May, Csaba, Ováry, Judit, Skopál, and Zoltán, Nagy

Subjects
Adult, Aged, 80 and over, Male, Time Factors, Thrombomodulin, Enzyme-Linked Immunosorbent Assay, Middle Aged, beta-Thromboglobulin, Stroke, Case-Control Studies, Acute Disease, von Willebrand Factor, Humans, Female, Endothelium, Vascular, Biomarkers, Aged
Abstract

In spite of all similarities, ischemic stroke cases representing 80% of the acute cerebrovascular accidents, different steps of platelet activation, coagulation and fibrinolytic cascade are involved in the pathomechanism of the different stroke subtypes. The differentiation of the atherothrombotic, cardioembolic and lacunar forms of acute ischemic stroke is based on the comprehensive evaluation of clinical signs, neuroimaging technics, and diagnostic ultrasound, but also a significant effort was made to characterize the specificities of the underlying processes of the coagulation system by signal molecules, in order to clarify their possible role and to support the diagnostic and therapeutic decisions.The von Willebrand factor was studied as the marker of endothelial injury in 34 acute ischemic stroke patients within 24 hours after the onset of their stroke, and repeatedly 2, 4, and 12 weeks thereafter. To determine the probable source of the von Willebrand factor, usually released not only by endothelial cells, but also by platelets, the authors simultaneously measured the levels of an additional endothelial marker, thrombomodulin, and a platelet activation marker, beta-thromboglobulin.The mean of von Willebrand factor levels measured in stroke patients on the first day was 123%, whereas the mean of the control group 72% (p0.05). There was no significant difference according to stroke subtype. Von Willebrand values determined two weeks later showed a further 60% increase in stroke patients, and after a gradual fall their level remained above the concentration of the control group. The beta-thromboglobulin level measured in stroke group was significantly higher, than in control individuals (171 IU/ml vs. 32 IU/ml, p0.001). This was characteristic for atherothrombotic and cardioembolic stroke, but not for lacunar infarctions. If measured repeatedly, beta-thromboglobulin levels decreased rapidly in the first two weeks, than somewhat slower. Soluble thrombomodulin was slightly elevated in stroke patients (4.24 ng/ml) compared to healthy subjects (3.81 ng/ml), without statistical significance, and without major differences between subgroups.While early determination of beta-thromboglobulin can contribute to the differential diagnoses of the subtypes of ischemic stroke, the long-lasting elevation of von Willebrand factor may reflect endothelial dysfunction caused by several factors in the microvasculature of the penumbra.

Published
2002

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