Early space-occupying cerebellar oedema requiring decompressive craniectomy following a clinically minor stroke

We describe a patient presented with clinically a small cerebellar ischaemic stroke but required emergency decompression within 24 hours of symptoms onset after incidental finding of severe mass effect on imaging without any change in her mild clinical symptoms. Her initial multimodal acute stroke imaging, non-contrast CT of the brain and CT angiography from aortic arch to vertex were normal. CT perfusion showed a very small deficit only. The malignant mass effect was picked on an MRI scan performed routinely as part of a clinical trial, 32 hours after stroke. Our case highlights stroke evolution, and mass effect may be insidious and faster than anticipated in the posterior fossa. Cerebellar stroke of any severity diagnosed clinically and radiologically may benefit from routine follow-up imaging at 24 hours from onset.

Abstract P376: ASPECTS Decay and Functional Outcomes in Inter-Facilities Transferred Large Vessel Occlusion Acute Ischemic Stroke

Background and objective: Endovascular Thrombectomy (EVT) treatment for patients with Acute Ischemic Stroke (AIS) due to Large Vessel Occlusion (LVO) was shown to improve functional outcomes. However, many eligible patients have no direct access to EVT capable centers, necessitating emergent inter-facilities transfers. Prolonged transfer time and reperfusion delay result in stroke progression and poor long-term outcomes. We evaluated the correlation between stroke evolution on non-enhanced Computed Tomography (CT) determined by Alberta Stroke Program Early CT Score (ASPECTS) decay and functional outcomes in transferred LVO patients. Method: Retrospective analysis of prospectively collected comprehensive stroke center data of patients with anterior circulation LVO (ICA, MCA M1 & M2) transferred for EVT. Stroke evolution was assessed based on CT ASPECTS decay defined as: [Outside hospital ASPECTS - Arrival pre-treatment ASPECTS]. A significant ASPECTS decay was defined as at least 2 points decrement in ASPECTS from initial imaging. Primary outcome was functional independence at 90-days, mRS 0-2. The correlation between functional independence and ASPECTS decay was assessed using logistic regression. Results: Of 108 patients transferred for EVT both initial outside and follow up CTs were available for 78 patients. Median IQR NIHSS was 16 (11, 20), age was 65.5 (54, 77), 33 (42%) of patients were women. Time from LKW to groin puncture was 9.91 (5.77, 13.35) hours and time from initial CT to repeat images was 3.6 (2.5, 4.8) hours. Median IQR ASPECTS decay was 1 (1, 2). Median IQR ASPECTS decay/hour 0.3 (0.0, 0.6). Significant ASPECTS decay was observed in 32 (41%) patients, and was more likely to occur with images repeated more than 3 hours from initial imaging (38% vs 10%, P<0.001). Significant ASPECTS decay correlated with decreased likelihood of achieving independence at 90-days (AOR: 0.21, 95% CI 0.04-0.99, P-value=0.048). Conclusion: ASPECTS decay was more likely to occur in prolonged transfers and correlated with lower likelihood of functional independence following EVT. Expedited transfers and faster reperfusion are vital to optimize thrombectomy outcomes in transfer patients.

Circle of Willis variants are not associated with thrombectomy outcomes

BackgroundThe circle of Willis (COW) is part of the brain collateral system. The absence of COW segments may affect functional outcome in patients with ischaemic stroke undergoing endovascular therapy.MethodsIn 182 patients in the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 Study and the CT Perfusion to Predict Response to Recanalisation in Ischaemic Stroke Project, COW anatomy was evaluated on postinterventional magnetic resonance angiography. The absence of the posterior communicating artery or the first segments of posterior or anterior cerebral arteries ipsilateral to the ischaemic infarction was rated as an incomplete COW. Logistic regression was applied to evaluate an association with the patients’ modified Rankin scale (mRS) at 90 days after strokeResultsAn incomplete ipsilateral COW was not predictive of the patients’ mRS at 90 days after stroke. Significant associations were shown for the patients’ baseline National Institutes of Health Stroke Scale (NIHSS), age and reperfusion status. The effect size suggests that a significant association of an incomplete COW with the mRS at 90 days may be obtained in cohorts of more than 3000 patients.ConclusionsCompared with the established predictors NIHSS, age and reperfusion status, an incomplete COW is not associated with functional outcome after endovascular therapy.

Hyperbaric oxygen therapy after acute ischemic stroke with large penumbra: a case report

Background Hyperbaric oxygen therapy (HBOT) for the treatment of acute stroke has been under the radar for a long time. Previous studies have not been able to prove efficacy. Several factors might have contributed to such inconsistent results. The timing of delivering the hyperbaric oxygen in relation to the stage of stroke evolution may be an important factor. This was not taken into account in the previous studies as there was no feasible and standardized method to assess the penumbra in the acute phase. Now with the perfusion scan appearing as a key player in the acute stroke management, precise stroke patient selection for hyperbaric oxygen therapy deserves a second chance similar to mechanical thrombectomy. Case presentation A 62-year-old female patient who presented with acute large vessel stroke was not eligible for chemical or mechanical thrombectomy. There was a large penumbra on imaging. She got treated with several sessions of hyperbaric oxygen over a 2-week period immediately after stroke. The patient showed significant improvement on the follow-up perfusion imaging as well as some clinical improvement. The more impressive radiological improvement was probably due to the presence of relatively large core infarction at baseline affecting functional brain areas. The patient continued to improve clinically on her 6-month follow up visit. Conclusion Our case demonstrates immediate stroke-related penumbra improvement associated with HBOT. Based on that, we anticipate a potential role for HBOT in acute stroke management considering precise patient selection. Future randomized controlled trials are needed and should take that in consideration.

Symptomatology of Depression and Anxiety After Ischemic Stroke in Different Evolution Periods

Background: Several studies suggest a high prevalence of symptoms of depression and anxiety after stroke. However, the prevalence and severity of this symptomatology may vary according to the period after a stroke in which the patient is assessed. Goals: This study aims to compare the depressive and anxious symptoms of a population of patients who suffered from ischemic stroke and who are in different evolution periods after stroke.Methods: This is an observational cross-sectional study. Participants were all individuals with ischemic stroke, without previous history of psychiatric disease nor pathologies involving Central Nervous System compromise or cognitive deficits, recruited from hospitals or from support units of the Rede Regional de Cuidados Continuados Integrados of the Região Autónoma da Madeira, Portugal. Participants were divided into four groups according to the post- stroke evolution period: short duration (0 to 3 months after the stroke), medium duration (4 to 12 months), chronic period I (13 to 24 months) and chronic period II (more than 24 months after the stroke). Data were collected by a psychologist, with the Beck Depression Inventory (BDI-II) and the State-Trait Anxiety Inventory, Form Y (STAI-Y), in individual self-report sessions. Results: The study included 42 patients with ischemic stroke, 52.4% males, aged 55-88 years. The different post-stroke evolution period groups do not differ in age, sex, level of education, hemispheric location of the lesion or cognitive functioning. The results showed that the prevalence of depression is higher in the chronic group II; regarding the prevalence of anxiety, no significant differences were found between the four groups. As for the severity of symptoms of depression, it is also significantly higher in the chronic group II. With regard to anxiety, trait and state anxiety levels are higher in the medium duration group compared to participants in the short duration period. It was also observed higher levels of state anxiety in the medium duration group compared to the chronic group I. Discussion: These results suggest the need to identify early emotional changes inherent to this population. These changes can have a major impact on the assessment, follow-up and neuropsychological rehabilitation of patients, so that their early identification will allow a more adequate intervention.Keywords: Ischemic stroke; Depression; Anxiety; Emotional changes.