Off-label intravenous thrombolysis for early recurrent brain embolism associated with aortic arch thrombus

Safety data of intravenous thrombolysis (IVT) in presence of aortic arch thrombus is scant. Furthermore, IVT is debatable in patients with prior recent stroke. We present a 51-year-old woman with recurrent major infarction 5 days after a minor left MCA territory stroke. She had a floating aortic arch thrombus and she was treated safely and effectively with off-label IVT. Patients with small infarct volumes and mild/no residual neurological deficits after an initial stroke might be considered for IVT in case of early recurrence. IVT may be reasonable in a context of acute severely disabling stroke associated with aortic arch thrombus.

Radiological Findings By Magnetic Resonance (MRI) and Arteriography (MRA) Brain Imaging Compared to Neurological, Stroke and TCD Assessment in Children with Sickle Cell Anemia in Uganda

Background: Children with sickle cell anemia (SCA) are highly susceptible to stroke and other manifestations of pediatric cerebral vasculopathy. Detailed evaluations of children with SCA in sub-Saharan Africa are limited, especially magnetic resonance imaging and angiography (MRI/MRA). In a sample of Ugandan children receiving care at the Mulago Hospital sickle cell clinic in Kampala and were not on disease-modifying therapy, we examined the range of MR imaging findings, and how those findings correlated with standardized demographic, clinical, neurological and neurocognitive assessments. Methods: From within a larger sample of 265 participants with HbSS ages 1-12 years not taking disease-modifying therapy and enrolled in the BRAIN SAFE study, a sub-sample of 81 underwent non-contrast MRI/MRA on a 1.5 Telsa scanner. Participants also underwent 3 standardized assessments: neurocognitive testing by experienced testers using the Mullen Scales of Early Learning (for ages 1-4 years) or Kaufman Assessment Battery for Children, 2nd edition (for ages 5-12) (abnormal z-score of -2 or lower), stroke examination (PedsNIHSS) and transcranial Doppler ultrasound (TCD) using criteria for pediatric SCA. Participants undergoing MRI/MRA intentionally included 29 without any abnormal findings. MRI scans included T1- and T2- weighted images, T2 FLAIR and MRA three-dimensional time-of-flight technique. MR scans were interpreted by clinical and research methods, the latter per SWiTCH protocol (Helton, Blood 2014). Adjudication of differing reads was performed by a blinded third neuroradiologist. Results: A total of 81 children with SCA were examined by MRI/MRA. Mean age was 6.48 ± 2.75 years; 50.6% were male. Mean hemoglobin was 7.26±0.90 g/dl; 75% had hemoglobin <8.0. In all, 16.7% were malnourished using standard international measures established by age and sex. Infarcts and/or arterial stenoses on MRI/MRA were detected in 42 (52%), including 13 (25%) with no other abnormalities detected. There were 35 children (43.2%) who had medium or large infarcts seen; an additional 16 (19.8%) had 1-2 small infarcts. Four had moya moya. Of the 29 children categorized as normal on each of the 3 other tests, 14 (48.3%) had one or more medium or large infarct(s) on MRI, and 3 (10.3%) had 1-2 small infarcts (Figure 1). The proportion of children with malnutrition was higher among those with an abnormal MRI compared to those with a normal MRI, whereas no children with a small infarct was malnourished (29.4% vs. 10.7% vs. 0% p=0.019). A higher proportion of participants with stroke by exam had medium or large infarct(s) compared to participants with normal or small infarct (28.6% vs. 10% vs. 6.3%; p=0.061). Stroke on exam was associated with medium or large infarct(s) compared to normal or small infarct (unadjusted OR 4.2; 95% CI 1.19-14.8), and remained after adjusting for age and hemoglobin (OR 3.90 95%CI 1.10-13.9). The proportion of abnormal psychological testing was higher in the small infarct group than in the group with larger infarct(s) or the normal group (37.5% vs. 28.6% vs. 17.2%; p=0.307). Conclusion: High prevalence of pediatric cerebral vasculopathy was found on MR scanning. Despite clinical evidence suggesting abnormal neuropsychological testing or a prior stroke, not all of the children who had clinical evidence of neurological disorders had MRI evidence of a stroke. Additionally, a number with no evidence of stroke had infarct(s) on MRI, so-called "silent stroke." The strongest predictors of an abnormal MRI reading included having a detectable stroke or an abnormal TCD. MR imaging is a critical aspect of evaluating cerebral vasculopathy in this patient population, and will be an important measure when prospectively assessing impact in a treatment trial. Disclosures No relevant conflicts of interest to declare.

Clinical diffusion mismatch better discriminates infarct growth than mean transit time–diffusion weighted imaging mismatch in patients with middle cerebral artery–M1 occlusion and limited infarct core

Background and purposeOur purpose was to compare clinical diffusion mismatch (CDM) and mean transit time (MTT)-diffusion mismatch as predictors of infarct growth in patients with proximal middle cerebral artery (MCA) occlusion and small infarct core on presentation.MethodsRetrospective analysis of consecutive stroke patients with: (1) MCA-M1 occlusion; (2) MRI performed ≤10 h from symptoms onset; and (3) baseline MRI-diffusion weighted imaging (DWI) volume ≤25 mL. Definitions included: CDM=baseline National Institutes of Health Stroke Scale (NIHSS) score ≥8 and DWI volume ≤25 mL; MTT-DWI mismatch=visually assessed unthresholded MTT lesion ((MTT-DWI))/DWI) ≥20% and ≥10 mL larger than the DWI lesion; and significant infarct growth (>20% (≥5 mL) increase in infarct volume on follow-up). Uni-/multivariate analyses were performed to define the predictors of infarct growth.Results63 stroke patients with MCA-M1 occlusions and MRI within 10 h of onset were evaluated. 20 patients were excluded on the basis of DWI volume >25 mL leaving 43 patients (mean age 75.8 years; median NIHSS=13) in the study cohort. On univariate analysis, larger admission DWI volume (p<0.0001), baseline NIHSS score ≥8 (p=0.001), lack of IV and/or endovascular treatment (p=0.021), glucose levels >125 mg/dL (p=0.024), poor CT angiography collaterals (p=0.046), and lower admission Alberta Stroke Program Early CT score (ASPECTS) (p=0.049) predicted infarct growth. Baseline NIHSS score ≥8 was the only independent predictor of stroke growth in the multivariate analysis (p=0.001). All patients had MTT-DWI mismatch >20%. There was no significant association between the amount of MTT-DWI mismatch and infarct growth (p=0.33).ConclusionsCDM is the most powerful predictor of infarct growth in patients with MCA-M1 occlusion and small infarct core. Most of these patients will have a significant oligemic MTT lesion regardless of admission NIHSS score.