Tiina Sairanen

Background and purpose: Our aim was to determine factors associated with symptomatic intracranial haemorrhage (sICH) in basilar artery occlusion patients treated with intravenous thrombolysis (IVT) and adjuvant anticoagulant therapy.Methods: A registry of 176 consecutive patients with angiography‐proven basilar artery occlusion who received IVT with alteplase and heparin between 1995 to 2013 was assessed. Post‐treatment sICH was evaluated with the European Cooperative Acute Stroke Study II criteria. Unfavourable outcome was defined as a modified Rankin Scale score of 3–6 at 3 months.Results: Twenty‐four patients developed sICH (13.6%, sICH+), all of whom had unfavourable outcome and only two (8.3%) sICH+ patients survived. On admission, sICH+ patients more frequently had extensive ischaemic changes defined as posterior circulation Acute Stroke Prognosis Early CT Score (PC‐ASPECTS) < 8 (50% vs. 27% in sICH−, P = 0.031) and lower platelet counts (183 vs. 218 E9/l; P = 0.011). They also had higher systolic blood pressure (SBP) (median 160 vs. 147 mmHg, P = 0.034) immediately after IVT. In multivariable regression analysis, lower platelet values [odds ratio (OR) 0.99, 95% confidence interval (CI) 0.97–0.996; P = 0.006], PC‐ASPECTS < 8 on admission (OR 3.6, 95% CI 1.3–10.3; P = 0.017) and higher SBP after treatment (OR 1.03, 95% CI 1.01–1.05; P = 0.017) were independently associated with sICH. Ninety per cent of the sICHs occurred within 48 h from IVT/anticoagulation treatment. No differences in activated partial thrompoplastin times prior to or after the treatment were observed between sICH+ and sICH− patients.Conclusions: The risk of sICH was largely determined by extension of ischaemic changes on admission computed tomography. Clinically relevantly, also higher post‐thrombolytic SBP as described earlier and lower perithrombolytic platelet counts do increase the risk, a finding requiring confirmation in other patient series.

Better identification and triage of acute posterior circulation (PC) stroke patients is needed as the PC ischemic stroke (IS) patients may be allowed longer thrombolysis window than anterior circulation (AC) IS patients and PC patients with hemorrhagic stroke (ICH) may require care in a neurosurgical unit possibly remote from stroke unit. Consecutive stroke patients treated at a tertiary center with thrombolysis (100% for IS) and/or comprehensive stroke unit care. Altogether, 1641 patients had AC (75%) and 553 PC strokes. The PC-IS patients were younger (65 vs 70), had less often prior hypertension (51 vs 61%), and were twice more often on warfarin. They presented 3.5 times more often with seizure, vomited five times more often, had headache twice as often, and required intubation 2 to 3 times more often despite equal NIHSS (9 vs 8) or GCS (15 both) scores with AC-IS patients. Among PC patients, IS (n = 190) associated with younger age, prior atrial fibrillation (AF) in 25% and dyslipidemia in ~40%. One-third of PC-ICH patients (n = 363) had headache and vomited at the onset. PC-ICH patients had BP median of 177/92 mmHg and blood glucose 7.4 mmol/l on ER arrival. Warfarin use was twice as common in PC-ICH. Despite being of typical age for multiple cardiovascular conditions the PC-ICH patients less often have a previous history of AF or dyslipidemia than IS patients do. The vomiting PC-ICH patient with hypertensive BP values often has headache and a red flag for hemorrhage is warfarin treatment.

Intracerebral hemorrhage (ICH) has high acute mortality. The number of potential kidney and liver donors amongst deceased ICH patients was estimated to improve our institutional guidelines on acute care of neurocritical patients to increase organ donation. A chart review was carried out by a multi-professional team for consecutive ICH patients admitted to the emergency department at Helsinki University Central Hospital and dying within 14 days between 2005 and 2010. In all, 955 patients had follow-up data, of whom 254 (27%) died within 14 days and eight ended up as organ donors. An additional 51 potentially suitable donors not different from actual donors were identified: nine suitable for kidney donation, 11 for liver and 31 for both. In 49/51 (96%) cases prognosis seemed non-existent and do-not-resuscitate orders were issued early, which led to refrainment from intensive care in 76.5%. These potential donors differed from those ICH patients surviving a whole year (n = 529) by male preponderance, more severe symptoms (median National Institutes of Health Stroke Scale 25 vs. 6 and Glasgow Coma Scale 7 vs. 15), larger hematoma volumes of 24.8 cm(3) (vs. 6.7), and frequent finding of midline shift and intraventricular rupture of the hemorrhage in admission brain CT. Based on the results, our guidelines were revised towards more active treatment including mechanical ventilation for neurocritical patients at the emergency department for at least 48 h, resulting in an increase in organ donations in 2012. A considerable number of ICH patients are potential organ donors if the evaluation takes place on arrival and organ donation is considered as part of usual end-of-life care.

Acute basilar artery occlusion is a neurological emergency that almost invariably leads to death or severe disability if not recanalized. Therapeutic recanalization is attempted using thrombolytic therapy either intravenously alone or by bridging it to on-demand, endovascular procedures. Due to often demanding differential diagnosis, angiographic evidence of basilar artery occlusion is necessary before treatment decisions. The etiology is often cardioembolism or vertebrobasilar thromboembolism due to atherothrombotic disease, or vertebral artery dissection in less than one in ten cases. Different therapeutic approaches have not been compared in randomized controlled trials. The selection of recanalization therapies thus builds on empirical knowledge and availability of vascular interventional services in the local setting.

Objectives: The benefits of prophylactic carotid endarterectomy (CEA) together with best medical treatment (BMT) are well-established. Early initiation of proper medical treatment reduces the risk of new strokes as waiting periods for CEA operation can be considerably long. We investigated: (1) preoperative medical treatment of CEA patients at our hospital and (2) how well the present medical treatment coheres with national and international secondary prevention guidelines and other CEA cohorts. Methods: A retrospective study cohort of 135 consecutive patients planned for CEA in a tertiary center because of symptomatic (n = 100) or asymptomatic (n = 35) carotid artery stenosis during a 14-month period (2007–2008). Results: One hundred and twenty-six of 135 (93·3%) patients received antiplatelet therapy at the time of surgery, 125/135 (92·6%) were on statin, and 121/135 (89·6%) used antihypertensive medications. Ten of the 100 symptomatic patients had recurrence or progression in their ischemic symptoms while waiting for the operation, with a median time of 8·5 days (range 1–30 days). Discussion: Carotid artery stenosis patients are considered high-risk patients regardless of symptomatology. The high proportion of medication use exceeds the use in the past proof-of-concept randomized controlled trials on the benefit of CEA+BMT over BMT. Nevertheless, there is room for improvement.

Background and Purpose—: Basilar artery occlusion has a high mortality rate (85% to 95%) if untreated. We describe a large single-center cohort treated mostly with intravenous alteplase and heparin. Methods—: The cohort included 116 patients with angiography-verified basilar artery occlusion. We studied baseline characteristics, frequencies of recanalization and symptomatic intracranial hemorrhage, and 3-month outcome (modified Rankin Scale [mRS]). Results—: Thirty patients (25.9%) had mRS 0 to 2, 42 patients (36.2%) had moderate outcome (mRS, 0–3), 26 patients (22.4%) required daily help (mRS, 4–5), and 48 patients (41.4%) died. Eighteen patients (15.7%) developed symptomatic intracranial hemorrhage. In patients with post-treatment angiogram available (n=91), 59 patients (64.8%) had a complete or partial recanalization. Radiological location of basilar artery occlusion was known in 55 of 91 instances, and recanalization was associated directly with clot location at the top-of-basilar (odds ratio, 4.8 [1.1–22]; P =0.048). Independent outcome (mRS 0-2) was associated with lower age and National Institutes of Health Stroke Scale (NIHSS) score at baseline. Age, nil or minimal recanalization, and symptomatic intracranial hemorrhage were independently associated with fatal outcome. Sixteen of 71 patients (22.5%) who presented with coma eventually reached moderate outcome, and additional 8 patients (11.3%) progressed to mRS 4. Conclusions—: Whereas recanalization after intravenous thrombolysis strongly predicts survival and moderate outcome, therapeutic techniques should concentrate on clot location. Although most adverse baseline variables, age, symptom severity, but also coma are beyond control, it should not preclude thrombolysis, which may permit independent survival.

Background: Official guidelines on stroke promote the use of telemedicine via bidirectional videoconferencing equipment, which provides a valid and reliable means of facilitating thrombolysis delivery to patients in distant or rural hospitals. Methods: The present prospective cohort study describes the characteristics and 3-month outcome of the thrombolysis patients treated in 5 community hospitals served by the Helsinki University Central Hospital (HUCH) in a telestroke network during 2007 to 2009. The characteristics and outcome of telestroke thrombolysis patients are compared with consecutive thrombolysis patients (n = 985) treated at HUCH. Results: A total of 106 consecutive telestroke consultations in 2 years led to IV thrombolysis in 61 patients (57.5%). The median NIH Stroke Scale score was 10 (range 3–26), onset to treatment time 120 minutes (interquartile range [IQR] 49), length of consultation 25 minutes (IQR 18) if the consultation led to thrombolysis and 15 minutes (IQR 10) if not (p = 0.032). The rate of symptomatic intracranial bleedings was 6.7% (4/60) according to the National Institute of Neurological Disorders and Stroke definition. Half (28/57) of the thrombolysis patients with complete follow-up data had a favorable outcome (modified Rankin Scale [mRS] 0–2) and a third (17/57) had an excellent recovery (mRS 0–1). Thus the patients treated with thrombolysis based on teleconsultation had similar outcome with those treated at HUCH (mRS 0–2: 49.1% vs 58.1%, p = 0.214 and mRS 0–1: 17/57 [29.4%] vs 352/957 [36.8%], p = 0.289). Conclusions: A special feature of the Finnish pilot is the high percentage of consultations leading to thrombolytic treatment with features and results very similar to on-site thrombolysis at the neurologic emergency room of HUCH.

Background: We present here a case of haemorrhagic brain infarction in a middle-aged and physically active male, who had never smoked. This case report aims to remind the internist and neurologist to bear in mind unusual aetiologies of brain infarcts in patients without classical cardiovascular risk factors. Case Description: A 49-year-old male with pulmonary asthma and a prior history of nasal polyps had a wake-up stroke with left-sided symptoms and speech disturbance. A head MRI and MR angiography revealed a recent haemorrhagic infarct in the right putamen and corona radiata. The left hemiparesis progressed to sensory-motor hemiplegia on the 4th day. In the head CT, it was shown that the haemorrhagic infarct had progressed to a large haematoma. A pansinusitis was also diagnosed. The aetiological investigations revealed a minor atrial septal defect (ASD) with shunting and a heterozygotic clotting factor V R506Q mutation. A remarkable blood eosinophilia of 9.80 E9/l (42%) together with fever, sinusitis, wide-spread bilateral nodular pulmonary infiltrates that did not respond to wide-spectrum antimicrobial treatment, positive anti-neutrophilic cytoplasmic antibodies, a high myeloperoxidase antibody level and slightly positive anti-proteinase 3 antibodies suggested the diagnosis of Churg-Strauss syndrome. These inflammatory symptoms and findings promptly responded to treatment with corticosteroids and cyclophosphamide. Conclusions: Even after the concomitant findings of the low risk factors, i.e. small ASD and heterozygotic clotting factor mutation, continued search for the final aetiology of stroke revealed Churg-Strauss syndrome, which was the key to the treatment.