Association of elevated plasma viscosity with small vessel occlusion in ischemic cerebral disease

Abstract Background The COVID-19 pandemic, which broke out in Wuhan in 2019, has become the global health crisis of our time. Elderly patients with certain fundamental diseases are more likely to develop severe cases. The secondary lesion following viral infection have only rarely been reported. Case presentation We here report two cases of coronavirus-infected pneumonia with acute ischemic stroke in middle-aged patients. In both COVID-19 cases, neurological physical examinations showed normal results before infection. Lymphocytopenia, accompanied by elevated cytokines and D-dimers, were found from serum clinical laboratory examination at admission. Dysarthria and limb muscle weakness are initial manifestations, occurring one week after infect-causative pathogen, SARS-CoV-2. The head CT and head/neck arterial CTA showed small-vessel occlusion. The patients were diagnosed with coronavirus diseases with secondary acute ischemic stroke. They were treated with tirofiban and followed up with daily aspirin and atorvastatin. Conclusions These cases suggested that secondary ischemic stroke, mainly manifested as small-vessel occlusion, should be considered for COVID-19 patients and diagnosed and treated promptly.

Download Full-text

Efficacy and Safety of Intravenous rtPA in Ischemic Strokes Due to Small-Vessel Occlusion: Systematic Review and Meta-Analysis

Translational Stroke Research ◽

10.1007/s12975-021-00890-9 ◽

2021 ◽

Author(s):

Bartosz Karaszewski ◽

Adam Wyszomirski ◽

Bartosz Jabłoński ◽

David J. Werring ◽

Dominika Tomaka

Keyword(s):

Clinical Trials ◽

Ischemic Stroke ◽

Randomized Clinical Trials ◽

Small Vessel Disease ◽

Small Vessel ◽

Efficacy And Safety ◽

Eligibility Criteria ◽

Vessel Occlusion ◽

Excellent Outcome ◽

Symptomatic Intracerebral Hemorrhage

AbstractIntravenous recombinant tissue plasminogen activator (iv-rtPA) has been routinely used to treat ischemic stroke for 25 years, following large clinical trials. However, there are few prospective studies on the efficacy and safety of this therapy in strokes attributed to cerebral small vessel disease (SVD). We evaluated functional outcome (modified Rankin scale, mRS) and symptomatic intracerebral hemorrhage (sICH) using all available data on the effects of iv-rtPA in SVD-related ischemic stroke (defined either using neuroimaging, clinical features, or both). Using fixed-effect and random-effects models, we calculated the pooled effect estimates with regard to excellent and favorable outcomes (mRS=0–1 and 0–2 respectively, at 3 months), and the rate of sICH. Twenty-three studies fulfilled the eligibility criteria, 11 of which were comparative, and there were only 3 randomized clinical trials. In adjusted analyses, there was an increased odds of excellent outcome (adjusted OR=1.53, 95% CI: 1.29–1.82, I2: 0%) or favorable outcome (adjusted OR=1.68, 95% CI: 1.31–2.15,I2: 0%) in patients who received iv-rtPA compared with placebo. Across the six studies which reported it, the incidence of sICH was higher in the treatment group (M-H RR = 8.83, 95% CI: 2.76–28.27). The pooled rate of sICH in patients with SVD administered iv-rtPA was only 0.72% (95% CI: 0.12%–1.64%). We conclude that when ischemic stroke attributed to SVD is considered separately, available data on the effects of iv-rtPA therapy are insufficient for the highest level of recommendation, but it seems to be safe. Although further therapeutic trials in SVD-related ischemic stroke appear to be justified, our findings should not prevent its continued use for this group of patients in clinical practice.

Download Full-text

Abstract W P211: Clinical Characteristics of Pseudo Negative Cases in Prehospital Triage for Stroke

Stroke ◽

10.1161/str.46.suppl_1.wp211 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Shuichi Tonomura

Keyword(s):

Acute Stroke ◽

Clinical Characteristics ◽

Stroke Onset ◽

The Other ◽

Small Vessel ◽

Stroke Patients ◽

Vessel Occlusion ◽

Stroke Subtypes ◽

Prehospital Triage ◽

Prehospital Diagnosis

Objective: The accuracy of prehospital diagnosis for stroke by emergency medical services (EMS) is improved using instruments for symptom recognition. On the other hand, prehospital misdiagnosis for stroke and subsequent delay in presentation to a hospital with stroke expertise play a critical role in the exclusion of potential therapeutic candidates. Our study aims to investigate the clinical characteristics of pseudo-negative cases in prehospital triage for stroke/TIA by EMS. Methods: From April 2013 to April 2014, consecutive 644 acute stroke patients were transferred by EMS to our hospital. We investigated prehospital diagnosis, Cincinnati prehospital stroke scale (CPSS) by EMS, neurological symptoms and complaints of patients themselves at stroke onset. We also examined activity of daily life (ADL) and cognitive impairments before stroke onset, and stroke subtypes in final diagnoses. Results: Among 644 acute stroke patients, 36 patients (22 men, mean 72.5±4.4 years old) were pseudo-negative cases in prehospital triage for stroke and had no abnormalities in CPSS by EMS. When EMS arrived at emergency site, 12 patients (33%) had loss of consciousness. Before stroke onset, 6 patients (17%) had impaired ADL (modified Rankin Scale >2), and 5 (14%) cognitive impairment. Among the stroke subtypes, the proportion of small vessel occlusion (22.4%, p=0.0025) and transient ischemic attack (TIA) (25%, p=0.0021) was significant higher in pseudo negative cases in prehospital triage; on the other hand, intracranial hemorrage (11%, p=0.0028) was lower. In complaint of patients themselves at stroke onset, weakness in one or two extremities was reported in 20 patients (56%), abnormal speech/language in 13 (36%), however all of them were not clarified by EMS. Conclusion: This study showed that small vessel occlusion and TIA tend to be misdiagnosed in a prehospital triage by EMS. The complaint of patients themselves at stroke onset is important to prehospital diagnoses by EMS.

Download Full-text

Abstract P499: The Effect of Small Vessel Disease Burden on Core/Penumbra Mismatch and Outcomes in Extended Window Thrombectomy

Stroke ◽

10.1161/str.52.suppl_1.p499 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Destiny Hooper ◽

Tariq Nisar ◽

Meryim Poursheykhi ◽

Andy Lin ◽

C. David McCane ◽

...

Keyword(s):

White Matter ◽

Perfusion Imaging ◽

Functional Outcomes ◽

Time Window ◽

Small Vessel Disease ◽

Small Vessel ◽

Collateral Flow ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Vessel Disease

Objective: Recent studies have shown the benefit of revascularization in select patients with extended window large vessel occlusion (EWLVO). We sought to assess the effect of cerebral small vessel disease (CSVD) burden on eligibility for intervention with mechanical thrombectomy (MT) and functional outcomes in patients with EWLVO. Methods: We conducted a retrospective single-center study of 135 patients with anterior circulation LVO who presented in the extended time window, 6 to 24 hours from LKW, between August 2018 and March 2020. All patients underwent perfusion imaging at initial presentation and those with target ischemic core to penumbra mismatch profiles, as defined by DAWN/DEFUSE3 criteria, were treated with MT. Included patients were evaluated for CSVD burden using T2-FLAIR MRI. The Fazekas scale (0-3) was used to quantify the amount of white matter T2 hyperintense lesions in both the periventricular (PVWM) and deep white matter (DWM). Patients’ functional outcomes were assessed at 90 days using the mRS. Multivariate ordinal logistic regression models were used and adjusted for age, gender, thrombus location and LKW to perfusion imaging time. Patient information was collected from the Houston Methodist Hospital Outcomes Based Prospective Endpoints in Stroke (HOPES) registry. Results: Of the 135 patients, 111 met imaging inclusion criteria for revascularization with MT for EWLVO. MT was deferred in 44 of these patients due to other clinical exclusions or patient refusal. Patients ineligible for MT were approximately 13 times more likely to have a higher PVWM Fazekas grade (OR =13.53, 95% CI. [2.94 - 62.39], p=0.001) and 17 times more likely to have a higher DWM Fazekas grade (OR =17.54, 95% CI. [4.20 - 73.17], p<0.001), when compared to patients who were eligible for MT. Patients who did not meet criteria for MT were nearly 7 times more likely to have poor functional outcomes at 90 days (OR =6.85, 95% CI. [2.09 - 22.44], p=0.001). Conclusion: Based on our analytical cohort of EWLVO patients, those with severe CSVD burden were more likely to be excluded from MT and had worse functional outcomes. Poor cerebrovascular reserve and diminished collateral flow leading to rapid infarct progression in patients with greater CSVD burden may be a potential explanation.

Download Full-text

Abstract TP188: The Association of Hypertension and Severity of White Matter Hyperintensities is Different in Each Stroke Subtype of Large Artery Atherosclerosis and Small Vessel Occlusion

Stroke ◽

10.1161/str.49.suppl_1.tp188 ◽

2018 ◽

Vol 49 (Suppl_1) ◽

Author(s):

Jun Lee ◽

Jungim Gwon ◽

Mingyeong Kim

Keyword(s):

White Matter ◽

White Matter Hyperintensities ◽

Small Vessel ◽

Large Artery ◽

Stroke Subtype ◽

Vessel Occlusion

Download Full-text

Intravenous thrombolysis with tissue-plasminogen activator in small vessel occlusion

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2019.03.036 ◽

2019 ◽

Vol 64 ◽

pp. 134-140

Author(s):

Young Min Paek ◽

Ji Sung Lee ◽

Hong-Kyun Park ◽

Yong-Jin Cho ◽

Hee-Joon Bae ◽

...

Keyword(s):

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Intravenous Thrombolysis ◽

Small Vessel ◽

Vessel Occlusion ◽

Tissue Plasminogen

Download Full-text

Effect of Edaravone on Neurological Symptoms in Real-World Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.118.024351 ◽

2019 ◽

Vol 50 (7) ◽

pp. 1805-1811 ◽

Cited By ~ 6

Author(s):

Susumu Kobayashi ◽

Shingo Fukuma ◽

Tatsuyoshi Ikenoue ◽

Shunichi Fukuhara ◽

Shotai Kobayashi ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Neurological Symptoms ◽

Small Vessel ◽

Large Artery ◽

Stroke Subtype ◽

Vessel Occlusion ◽

Nihss Score ◽

Ischemic Stroke Subtype ◽

History Of

Background and Purpose— In Japan, nearly half of ischemic stroke patients receive edaravone for acute treatment. The purpose of this study was to assess the effect of edaravone on neurological symptoms in patients with ischemic stroke stratified by stroke subtype. Methods— Study subjects were 61 048 patients aged 18 years or older who were hospitalized ≤14 days after onset of an acute ischemic stroke and were registered in the Japan Stroke Data Bank, a hospital-based multicenter stroke registration database, between June 2001 and July 2013. Patients were stratified according to ischemic stroke subtype (large-artery atherosclerosis, cardioembolism, small-vessel occlusion, and cryptogenic/undetermined) and then divided into 2 groups (edaravone-treated and no edaravone). Neurological symptoms were evaluated using the National Institutes of Health Stroke Scale (NIHSS). The primary outcome was changed in neurological symptoms during the hospital stay (ΔNIHSS=NIHSS score at discharge−NIHSS score at admission). Data were analyzed using multivariate linear regression with inverse probability of treatment weighting after adjusting for the following confounding factors: age, gender, and systolic and diastolic blood pressure at the start of treatment, NIHSS score at admission, time from stroke onset to hospital admission, infarct size, comorbidities, concomitant medication, clinical department, history of smoking, alcohol consumption, and history of stroke. Results— After adjusting for potential confounders, the improvement in NIHSS score from admission to discharge was greater in the edaravone-treated group than in the no edaravone group for all ischemic stroke subtypes (mean [95% CI] difference in ΔNIHSS: −0.46 [−0.75 to −0.16] for large-artery atherosclerosis, −0.64 [−1.09 to −0.2] for cardioembolism, and −0.25 [−0.4 to −0.09] for small-vessel occlusion). Conclusions— For any ischemic stroke subtype, edaravone use (compared with no use) was associated with a greater improvement in neurological symptoms, although the difference was small (<1 point NIHSS) and of limited clinical significance.

Download Full-text

Influence of Febrile Neutropenia Period on Plasma Viscosity at Malignancy

The Scientific World JOURNAL ◽

10.1155/2013/507270 ◽

2013 ◽

Vol 2013 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Ibrahim Tek ◽

Selami Kocak Toprak ◽

Efe Hasdemir ◽

Samed Rahatli ◽

Aysegül Yesilkaya

Keyword(s):

Febrile Neutropenia ◽

Defense Mechanisms ◽

Normal Values ◽

Blood Rheology ◽

Plasma Viscosity ◽

Elevated Plasma ◽

Microcirculatory Blood Flow ◽

Acute Phase Reactants ◽

The Impact ◽

Neutropenic Episode

Cancer, chemotherapy, and infections all together make changes in blood rheology and may affect the defense mechanisms by changing the thrombocyte function and endothelial cell. We have examined changes of blood rheology on plasma viscosity to put on probable following criteria for starting the treatment of febrile neutropenia immediately. A total of 27 postchemotherapy patients (16 males and 11 females) with febrile neutropenia diagnosed according to international guidelines have been included into the study. The plasma viscosity of the patients whose febrile neutropenia has been successfully treated was also measured to assess the impact of the duration of neutropenia on viscosity. The plasma viscosities of the patients were significantly higher during neutropenic episode than in nonneutropenic state () except for alkaline phosphatase. All study parameters, particularly acute phase reactants, were statistically similar during both states. In the correlation of analysis with study parameters and stages, significant correlation was not observed between plasma viscosity alteration and leukocyte-neutrophil alteration, also other study parameters. We have demonstrated significantly elevated plasma viscosity in our patients during febrile neutropenic episode. Despite normal values of various parameters known to trigger plasma viscosity, particularly fibrinogen, it can be easily argued that the main mechanism may be the endothelial injury during infectious process and immune response mediated microcirculatory blood flow alterations.

Download Full-text