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Zeldich D, Bierowski M, Shabo L, Yaddanapudi S, Marhefka G. Neurovascular Complications of Acute Aortic Syndrome. J Stroke 2025; 27:19-29. [PMID: 39916451 PMCID: PMC11834353 DOI: 10.5853/jos.2024.02915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 11/14/2024] [Accepted: 12/06/2024] [Indexed: 02/20/2025] Open
Abstract
Acute aortic syndromes (AAS) such as aortic dissection, intramural hematoma, and penetrating aortic ulcer pose significant neurovascular risks, affecting patient outcomes. This review examines the incidence, clinical presentation, and outcomes of neurovascular complications in AAS patients. Common complications include stroke, spinal cord ischemia, and transient ischemic attacks, with stroke being the most prevalent. Managing aortic dissection necessitates careful blood pressure control to prevent dissection progression while avoiding compromised cerebral and spinal perfusion. Carotid involvement, particularly dissection, increases stroke and transient ischemic attack risks. Emergency surgical interventions, though essential to prevent rupture or repair dissection, carry risks of perioperative neurovascular complications. The use of electroencephalography and transcranial Doppler can aid in the early detection and monitoring of neurovascular events. We discuss the pros and cons of certain blood pressure medications in the acute treatment of aortic dissection. A multidisciplinary approach involving cardiovascular surgeons, neurologists, and critical care specialists is vital for optimizing outcomes and mitigating risks. Early recognition and management of neurovascular complications are crucial, and further research is needed to develop targeted prevention and treatment strategies.
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Affiliation(s)
- Dean Zeldich
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Matthew Bierowski
- Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Leah Shabo
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sridhara Yaddanapudi
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregary Marhefka
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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2
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Ryan D, Maher M, Feng W, Pawar S. Intravenous thrombolysis in a stroke patient with a repaired aortic dissection. BMJ Case Rep 2024; 17:e262995. [PMID: 39694660 DOI: 10.1136/bcr-2024-262995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2024] Open
Abstract
Acute aortic dissection is considered a contraindication to the use of intravenous thrombolysis in patients presenting with acute ischaemic stroke, but less has been described about previously repaired dissections. We present a case of a woman in her 50s presenting with acute left hemiparesis with a known history of aortic dissection within the thrombolysis window. After multidisciplinary discussion with cardiothoracic surgery and discussion with the patient, she was treated with intravenous thrombolysis without complication. In patients with previously repaired aortic dissection without evidence of redissection, intravenous thrombolysis can be considered.
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Affiliation(s)
- Dylan Ryan
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michelle Maher
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wayne Feng
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Swaroop Pawar
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
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D’Anna L, Abu‐Rumeileh S, Merlino G, Ornello R, Foschi M, Diana F, Barba L, Mastrangelo V, Romoli M, Lobotesis K, Bax F, Kuris F, Valente M, Otto M, Korompoki E, Sacco S, Gigli GL, Nguyen TN, Banerjee S. Safety and Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke Attributable to Cardiological Diseases: A Scoping Review. J Am Heart Assoc 2024; 13:e034783. [PMID: 38874062 PMCID: PMC11646491 DOI: 10.1161/jaha.124.034783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
There is limited evidence on the outcomes and safety of mechanical thrombectomy (MT) among patients with acute ischemic stroke (AIS) in the context of cardiac diseases. Our study reviews MT in AIS within the context of cardiac diseases, aiming to identify existing and emerging needs and gaps. PubMed and Scopus were searched until December 31, 2023, using a combination of cardiological diseases and "mechanical thrombectomy" or "endovascular treatment" as keywords. Study design included case reports/series, observational studies, randomized clinical trials, and meta-analyses/systematic reviews. We identified 943 articles, of which 130 were included in the review. Results were categorized according to the cardiac conditions. MT shows significant benefits in patients with atrial fibrillation (n=139) but lacks data for stroke occurring after percutaneous coronary intervention (n=2) or transcatheter aortic valve implantation (n=5). MT is beneficial in AIS attributable to infective endocarditis (n=34), although functional benefit may be limited. Controversy surrounds the functional outcomes and mortality of patients with AIS with heart failure undergoing MT (n=11). Despite technical challenges, MT appears feasible in aortic dissection cases (n=4), and in patients with left ventricular assist device or total artificial heart (n=10). Data on AIS attributable to congenital heart disease (n=4) primarily focus on pediatric cases requiring technical modifications. Treatment outcomes of MT in patients with cardiac tumors (n=8) vary because of clot consistency differences. After cardiac surgery stroke, MT may improve outcomes with early intervention (n=13). Available data outline the feasibility of MT in patients with AIS attributable to large-vessel occlusion in the context of cardiac diseases.
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Affiliation(s)
- Lucio D’Anna
- Department of Stroke and NeuroscienceCharing Cross Hospital, Imperial College London NHS Healthcare TrustLondonUnited Kingdom
- Department of Brain SciencesImperial College LondonLondonUnited Kingdom
| | - Samir Abu‐Rumeileh
- Department of NeurologyMartin‐Luther‐University Halle‐WittenbergHalle (Saale)Germany
| | - Giovanni Merlino
- Stroke Unit and Clinical NeurologyUdine University HospitalUdineItaly
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Francesco Diana
- Interventional NeuroradiologyVall d’Hebron University HospitalBarcelonaCatalunyaSpain
| | - Lorenzo Barba
- Department of NeurologyMartin‐Luther‐University Halle‐WittenbergHalle (Saale)Germany
| | | | - Michele Romoli
- Neurology and Stroke Unit, Department of NeuroscienceBufalini Hospital, Azienda Unità Sanitaria Locale RomagnaCesenaItaly
| | - Kyriakos Lobotesis
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College LondonNHS Healthcare TrustLondonUnited Kingdom
| | - Francesco Bax
- Philip Kistler Research Center, Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Fedra Kuris
- Stroke Unit and Clinical NeurologyUdine University HospitalUdineItaly
| | - Mariarosaria Valente
- Clinical NeurologyUdine University Hospital and Dipartmento di Area Medica, University of UdineUdineItaly
| | - Markus Otto
- Department of NeurologyMartin‐Luther‐University Halle‐WittenbergHalle (Saale)Germany
| | - Eleni Korompoki
- Department of Brain SciencesImperial College LondonLondonUnited Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Gian Luigi Gigli
- Stroke Unit and Clinical NeurologyUdine University HospitalUdineItaly
| | - Thanh N. Nguyen
- Department of Neurology, RadiologyBoston Medical CenterBostonMAUSA
| | - Soma Banerjee
- Department of Stroke and NeuroscienceCharing Cross Hospital, Imperial College London NHS Healthcare TrustLondonUnited Kingdom
- Department of Brain SciencesImperial College LondonLondonUnited Kingdom
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4
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Kam CT, Soliman M, Okafor N, Rait J. Extensive aortic dissection (Stanford Type A) presenting with confusion in a patient: a case report. Radiol Case Rep 2022; 17:3031-3034. [PMID: 35755122 PMCID: PMC9214719 DOI: 10.1016/j.radcr.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/05/2022] [Accepted: 06/07/2022] [Indexed: 11/01/2022] Open
Abstract
Spontaneous extensive aortic dissection is rarely documented in the literature with a misdiagnosis rate of up to 38% in previous studies. Vital signs and clinical manifestations vary and depend on the extent of the dissection and location. We present a rare case of extensive Stanford Type A dissection in a 60-year-old female patient who presented with confusion. Type A aortic dissection is a surgical emergency that is important for clinicians to have a low threshold of suspicion of the life-threatening condition due to the diverse and potentially atypical clinical presentation of aortic dissection.
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He ZY, Yao LP, Wang XK, Chen NY, Zhao JJ, Zhou Q, Yang XF. Acute ischemic Stroke combined with Stanford type A aortic dissection: A case report and literature review. World J Clin Cases 2022; 10:8009-8017. [PMID: 36158509 PMCID: PMC9372854 DOI: 10.12998/wjcc.v10.i22.8009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/11/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute aortic dissection (AAD) is a high mortality disease that can lead to acute ischemic strokes (AIS). Some of the patients with AAD combined with AIS initially present with neurological symptoms, which can easily lead to missed or delayed AAD diagnosis. This is attributed to the lack of physician awareness or the urgency of patient thrombolysis. Intravenous administration of thrombolytic therapy (IVT) for AAD is associated with poor prognostic outcomes. We report a patient with AIS combined with AAD who developed a massive cerebral infarction after receiving IVT for a missed AAD diagnosis.
CASE SUMMARY A 49-year-old man was admitted to a local hospital with an acute onset of left-sided limb weakness accompanied by slurred speech. The patient had a history of hypertension that was not regularly treated with medication. Physical examination revealed incomplete mixed aphasia and left limb hemiparesis. Cranial computed tomography (CT) scan showed bilateral basal ganglia and lateral ventricular paraventricular infarct lesions. The patient was diagnosed with AIS and was administered with IVT. After IVT, patient’s muscle strength and consciousness deteriorated. From the local hospital, he was referred to our hospital for further treatment. Emergency head and neck CT angiography (CTA) scans were performed. Results showed multiple cerebral infarctions, and aortic dissection in the ascending aorta, innominate artery, as well as in the right common carotid artery. Then, the CTA of thoracoabdominal aorta was performed, which revealed a Stanford type A aortic dissection and aortic dissection extending from the aortic root to the left external iliac artery. Laceration was located in the lesser curvature of the aortic arch. AAD complicated with AIS was considered, and the patient was immediately subjected to cardiovascular surgery for treatment. The next day, the patient underwent aortic arch and ascending aortic replacement and aortic valvuloplasty.
CONCLUSION Clinical manifestations for AAD combined with AIS are diverse. Some patients may not exhibit typical chest or back pains. Therefore, patients should be carefully evaluated to exclude AAD before administering IVT in order to avoid adverse consequences.
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Affiliation(s)
- Zhi-Yang He
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Lin-Peng Yao
- Department of Radiology, The First Affiliated Hospital, Zhejiang University school of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Xiao-Ke Wang
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Nai-Yun Chen
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Jun-Jie Zhao
- Department of Radiology, The First Affiliated Hospital, Zhejiang University school of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Qian Zhou
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Xiao-Feng Yang
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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6
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Madlener M, Onur OA, Müller-Ehmsen J, Fink GR, Burghaus L. [Acute Aortic Dissection: A Life-Threatening Disease Also in Neurological Emergency Medicine]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2022; 90:571-579. [PMID: 35508194 DOI: 10.1055/a-1802-3852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acute aortic dissection is rare but life-threatening. The symptoms depend on the localization and reduced perfusion of the downstream organs or limbs and are therefore variable. Neurological symptoms may occur that do not immediately lead to a diagnosis and thus delay the necessary therapy. Knowing the early symptoms and warning signs of aortic dissection is therefore also crucial in neurological emergency care for quickly identifying the affected patients and for providing acute therapy. A misdiagnosis with delayed initiation of therapy can significantly worsen the patient's outcome. This study aims to establish a standardized diagnostic and therapeutic algorithm for suspected acute aortic dissection in neurological emergency care. Close interdisciplinary cooperation is mandatory.
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Affiliation(s)
- Marie Madlener
- Klinik und Poliklinik für Neurologie, Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Köln, Germany
| | - Oezguer A Onur
- Klinik und Poliklinik für Neurologie, Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Köln, Germany
| | | | - Gereon R Fink
- Klinik und Poliklinik für Neurologie, Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Köln, Germany.,Institut für Neurowissenschaften und Medizin (INM-3), Forschungszentrum Jülich, Jülich, Germany
| | - Lothar Burghaus
- Klinik und Poliklinik für Neurologie, Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Köln, Germany.,Klinik für Neurologie, Heilig Geist-Krankenhaus Köln, Köln, Germany
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7
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Elshony H, Idris A, Ahmed A, Almaghrabi M, Ahmed W, Fallatah S. Spinal Cord Ischemia Secondary to Aortic Dissection: Case Report with Literature Review for Different Clinical Presentations, Risk Factors, Radiological Findings, Therapeutic Modalities, and Outcome. Case Rep Neurol 2021; 13:634-655. [PMID: 34720966 PMCID: PMC8543361 DOI: 10.1159/000518197] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/29/2021] [Indexed: 12/12/2022] Open
Abstract
Aortic dissection (AD) is a serious condition that causes transient or permanent neurological problems that include spinal cord ischemia (SCI), which occurs when AD extends into the descending aorta resulting in insufficient perfusion of segmental arteries that supplies the spinal cord. We report a 64-year-old male, presented with severe back pain, asymmetrical paresthesia, and weakness of both limbs, more in the left lower limb with loss of pinprick, temperature, and fine touch sensation on the lower left lower limb below the level of T5 with preserved proprioception and vibration and urine hesitancy. Computed tomography showed AD, Stanford type A, and spinal magnetic resonance imaging (MRI) showed hyperintense owl's eye sign at T5. The patient was diagnosed as anterior spinal artery syndrome secondary to an AD and referred for aortic surgical repair with good functional outcome. In our review to cases of SCI due to AD, it was more common in males above 55 years, pain only found in 47.8% of patients, with anterior cord syndrome on top of the clinical presentations, and hypertension is the most common risk factor. MRI spine showed thoracic location predominance. Surgical or endovascular repair especially for type A and complicated type B should be considered to avoid complications, and cerebrospinal fluid drainage is a very useful tool in reversing SCI specially if done early with favorable outcome. Only the old age is associated with increased risk of mortality. Early diagnosis and appropriate management are crucial for better outcome.
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Affiliation(s)
- Hosna Elshony
- Department of Neuropsychiatry, Faculty of Medicine, Menoufia University, Shebin El Kom, Egypt
| | - Abdelrahman Idris
- Department of Neurology/Internal medicine, Security Forces Hospital, Makkah, Saudi Arabia
| | - Alaa Ahmed
- Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | | | - Walaa Ahmed
- Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Shouq Fallatah
- Faculty of Medicine, Taif University, Taif, Saudi Arabia
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8
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Usui T, Suzuki K, Niinami H, Sakai S. Aortic dissection diagnosed on stroke computed tomography protocol: a case report. J Med Case Rep 2021; 15:299. [PMID: 34034814 PMCID: PMC8152142 DOI: 10.1186/s13256-021-02850-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background Aortic dissection is one of the causes of stroke. Because cerebral infarction with aortic dissection is a contraindication to intravenous recombinant tissue plasminogen activator (rt-PA) therapy, exclusion of aortic dissection is necessary prior to its administration. However, imaging takes time to provide a diagnosis, possibly causing delays in surgical treatment. Case presentation A 65-year-old Japanese female patient was transported to the hospital for a suspected stroke, with back pain and left upper and lower extremity palsy which occurred while eating. Upon arrival at the hospital, the left lower limb paralysis had improved, but the left upper limb paralysis remained. Right back pain had also developed. A plain head computed tomography (CT) scan performed 110 minutes after onset showed no acute bleeding or infarction. Subsequent CT perfusion (CTP) showed acute perfusion disturbance in the right hemisphere without infarction, known as ischemic penumbra. The four-dimensional maximum-intensity projection image reconstructed from CTP showed a delayed enhancement at the right internal carotid and right middle cerebral arteries compared to the contralateral side, suggesting a proximal vascular lesion. Contrast helical CT from the neck to abdomen revealed an acute aortic dissection of Stanford type A with false lumen patency. The dissection extended to the proximal right common carotid artery. The patient underwent an emergency total arch replacement and open stent graft. After recovering well, the patient was ambulatory upon discharge from the hospital. The combination of plain head CT, CTP, and helical CT scan from the neck to abdomen enabled us to evaluate for stroke and aortic dissection within a short amount of time, allowing for early therapeutic intervention. Conclusions When acute stroke is suspected due to neurological deficits, plain head CT is the first choice for imaging diagnosis. The addition of cervical CT angiography can reliably exclude stroke due to aortic dissection. CTP can identify ischemic penumbra, which cannot be diagnosed by plain head CT or diffusion-weighted magnetic resonance imaging. These combined stroke CT protocols helped us avoid missing an aortic dissection.
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Affiliation(s)
- Takami Usui
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Kazufumi Suzuki
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shuji Sakai
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 619] [Impact Index Per Article: 154.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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Neurologic complications of diseases of the aorta. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:221-239. [PMID: 33632441 DOI: 10.1016/b978-0-12-819814-8.00028-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neurologic complications of diseases of the aorta are common, as the brain and spinal cord function is highly dependent on the aorta and its branches for blood supply. Any disease impacting the aorta may have significant impact on the ability to deliver oxygenated blood to the central nervous system, resulting in ischemia-and if prolonged-cerebral and spinal infarct. The breadth of pathology affecting the aorta is diverse and neurologic complications can vary dramatically based on the location, severity, and underlying etiology. This chapter outlines the major pathology of the aorta while highlighting the associated neurologic complications. This chapter covers the entire spectrum of neurologic complications associated with aortic disease by beginning with a detailed overview of the spinal cord vascular anatomy followed by a discussion of the most common aortic pathologies affecting the nervous system, including aortic aneurysm, aortic dissection, aortic atherosclerosis, inflammatory and infectious aortopathies, congenital abnormalities, and aortic surgery.
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12
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Abstract
INTRODUCTION Thrombolysis is the standard of care in acute ischemic stroke. It is usually contraindicated in patients with aortic dissection. CASE REPORT We report a case of Marfan syndrome and chronic aortic dissection presenting with acute ischemic stroke treated with thrombolysis. CONCLUSION To our knowledge, this is the first case of Marfan syndrome with chronic aortic dissection undergoing thrombolysis for acute ischemic stroke with a near-complete recovery of neurological deficit and favorable long-term outcome.
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Shivkumar V, Nemade D. Intravenous tPA in the treatment of acute stroke related to aortic dissection. BMJ Case Rep 2019; 12:12/6/e229982. [PMID: 31164384 DOI: 10.1136/bcr-2019-229982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 61-year-old woman with no prior medical illness presented with acute onset stroke symptoms. She had no chest pain at the time of presentation. However, CT angiogram showed an extensive aortic dissection, resulting in hypoperfusion of the right cerebral hemisphere and thus causing stroke symptoms. Due to this finding, tissue plasminogen activator was not given and a negative outcome was avoided.
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Affiliation(s)
- Vikram Shivkumar
- Department of Neurology, Marshall University School of Medicine, Huntington, West Virginia, USA
| | - Dipali Nemade
- Department of Neurology, Marshall University School of Medicine, Huntington, West Virginia, USA
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14
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Matsubara S, Koga M, Ohara T, Iguchi Y, Minatoya K, Tahara Y, Fukuda T, Miyazaki Y, Kajimoto K, Sakamoto Y, Makita N, Tokuda N, Nagatsuka K, Ando Y, Toyoda K. Cerebrovascular imaging of cerebral ischemia in acute type A aortic dissection. J Neurol Sci 2018; 388:23-27. [PMID: 29627025 DOI: 10.1016/j.jns.2018.02.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 02/06/2018] [Accepted: 02/26/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stanford type A aortic dissection (AAD) sometimes causes acute ischemic stroke (AIS) or transient ischemic attack (TIA). There is little understanding of cerebrovascular imaging of AIS or TIA in patients with AAD. METHODS Consecutive AIS/TIA patients with AAD who were admitted within 4.5 h of onset were reviewed. We compared findings of MRI/MRA between these and consecutive AIS/TIA patients without AAD within 4.5 h of onset. RESULTS Seventeen AAD and 249 non-AAD patients were identified. Compared to non-AAD patients, AAD patients had infarcts more frequently in the right anterior cerebral artery (ACA) territory (18% vs. 2%, P = 0.007) and the right middle cerebral artery (MCA) territory (71% vs. 29%, P < 0.001). There was no difference between the groups regarding whether it was perforator or cortical infarct, single or multiple infarcts, unilateral or bilateral infarcts, or ischemic change extension. On the MRA imaging, the AAD patients more frequently had poor visualization of the right internal carotid artery (ICA) (47% vs. 6%, P < 0.001). After adjustment for sex, age and confounding factors, the right ACA territory infarct [odds ratio (OR), 12.2; 95% confidence interval (CI), 1.4-119.4], the MCA territory infarct (OR, 4.9; 95% CI, 1.0-25.0) and poor visualization of the right ICA (OR, 18.1; 95% CI, 4.0-101.9) were independently associated with AAD. CONCLUSION In emergency AIS/TIA patients, right anterior circulation infarct and poor visualization of the right ICA on cerebrovascular imaging are potential imaging markers of AAD.
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Affiliation(s)
- Soichiro Matsubara
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan; Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masatoshi Koga
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Tomoyuki Ohara
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, Jikei University School of Medicine, Tokyo, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuichi Miyazaki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Katsufumi Kajimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuki Sakamoto
- Department of Neurological Science, Nippon Medical School Hospital, Tokyo, Japan
| | - Naoki Makita
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoki Tokuda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazuyuki Nagatsuka
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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15
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Tokuda N, Koga M, Ohara T, Minatoya K, Tahara Y, Higashi M, Miyazaki Y, Kajimoto K, Matsubara S, Makita N, Sakamoto Y, Iguchi Y, Mizuno T, Nagatsuka K, Toyoda K. Urgent Detection of Acute Type A Aortic Dissection in Hyperacute Ischemic Stroke or Transient Ischemic Attack. J Stroke Cerebrovasc Dis 2018; 27:2112-2117. [PMID: 29653804 DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/06/2018] [Accepted: 03/12/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Urgent diagnosis of acute Stanford type A aortic dissection (AAD) in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) is sometimes challenging. We assessed predictive values for markers of AAD in patients with AIS or TIA. METHODS Consecutive patients with AIS or TIA with AAD who presented to our emergency room within 4.5 hours of symptom onset between 2007 and 2014 were compared with patients without AAD seen between 2012 and 2014. RESULTS Data were obtained for 24 patients with AIS or TIA with AAD (15 women; mean age, 75 ± 12 years) and 812 patients without AAD (305 women; mean age, 73 ± 12 years). Compared with patients without AAD, patients with AAD displayed significantly higher systolic blood pressure (SBP) laterality (30 ± 20 mm Hg versus 12 ± 11 mm Hg), initial D-dimer concentration (median 38.1 µg/mL versus 1.3 µg/mL), and mediastinal width-to-chest width (M/C) ratio on x-ray (.35 ± .05 versus .29 ± .05), and more frequently showed common carotid artery (CCA) dissection on carotid ultrasonography (84% versus 1%) and pericardial effusion on echocardiography (43% versus 0%). Sensitivity and specificity to identify AAD were 80% and 75% for SBP laterality 17 mm Hg or greater; 100% and 86% for D-dimer concentration 4.1 µg/mL or greater; 75% and 76% for M/C ratio .32 or greater; 84% and 99% for CCA dissection; and 43% and 100% for pericardial effusion, respectively. CONCLUSIONS High D-dimer level may provide the most reliable screening test for AAD in patients with AIS or TIA. CCA dissection on ultrasonography appears to represent the most disease-specific finding and shows acceptable sensitivity.
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Affiliation(s)
- Naoki Tokuda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Tomoyuki Ohara
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masahiro Higashi
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuichi Miyazaki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Katsufumi Kajimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Soichiro Matsubara
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naoki Makita
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuki Sakamoto
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, Jikei University School of Medicine, Tokyo, Japan
| | - Toshiki Mizuno
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuyuki Nagatsuka
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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16
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He Z, Shen CS, Wang B, Luo Y. An Acute Ischemic Stroke Resulting from Aortic Dissection. J Stroke Cerebrovasc Dis 2017; 26:e221-e223. [PMID: 28939049 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/18/2016] [Indexed: 10/18/2022] Open
Abstract
A 39-year-old man with syncope and persistent dizziness was sent to stroke emergency. Patient's diffusion magnetic resonance imaging of brain showed acute ischemia in right cerebella and right occipital lobe, thus intravenous recombinant tissue plasminogen activator was given to him. However, the patient behaved rather restless with repeated complaint of back and thoracic pain. Further thorax computed tomography angiography confirmed that the underlying cause turned out to be aortic dissection.
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Affiliation(s)
- Zijun He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Chun-Sen Shen
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Bin Wang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Yongchun Luo
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China.
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17
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Morihara R, Yamashita T, Deguchi K, Tsunoda K, Manabe Y, Takahashi Y, Yunoki T, Sato K, Nakano Y, Kono S, Ohta Y, Hishikawa N, Abe K. Successful Delayed Aortic Surgery for a Patient with Ischemic Stroke Secondary to Aortic Dissection. Intern Med 2017; 56:2343-2346. [PMID: 28794365 PMCID: PMC5635312 DOI: 10.2169/internalmedicine.8438-16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The diagnosis of aortic dissection (AD) is sometimes difficult within the limited time window of recombinant tissue plasminogen activator (tPA) for ischemic stroke (IS). A 60-year-old man developed sudden left hemiparesis due to IS. During tPA infusion, his blood pressure dropped and consciousness declined. After transfer to our hospital, carotid duplex ultrasonography led to a diagnosis of AD. Emergency surgery was postponed because of the risk of hemorrhagic transformation. The patient successfully underwent aortic surgery on day 5 and was discharged with a remarkable improvement in his symptoms. Delayed surgery may avoid hemorrhagic transformation in patients with AD-induced IS who have received tPA.
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Affiliation(s)
- Ryuta Morihara
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
| | - Toru Yamashita
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
| | - Kentaro Deguchi
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
| | - Keiichiro Tsunoda
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
| | - Yasuhiro Manabe
- Department of Neurology, Okayama National Hospital Medical Center, Japan
| | - Yoshiaki Takahashi
- Department of Neurology, Okayama National Hospital Medical Center, Japan
| | - Taijun Yunoki
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
| | - Kota Sato
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
| | - Yumiko Nakano
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
| | - Syoichiro Kono
- Department of Neurology, Okayama National Hospital Medical Center, Japan
| | - Yasuyuki Ohta
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
| | - Nozomi Hishikawa
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
| | - Koji Abe
- Departments of Neurology, Dentistry, and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Japan
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18
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Do YR. Aortic Dissection after Intravenous Thrombolysis in Acute Cerebral Infarction. KOSIN MEDICAL JOURNAL 2017. [DOI: 10.7180/kmj.2017.32.1.127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Young Rok Do
- Department of Neurology, Catholic University of Daegu School of Medicine, Daegu, Korea
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19
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Marroush TS, Boshara AR, Parvataneni KC, Takla R, Mesiha NA. Painless Aortic Dissection. Am J Med Sci 2016; 354:513-520. [PMID: 29173364 DOI: 10.1016/j.amjms.2016.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/18/2016] [Accepted: 11/01/2016] [Indexed: 01/02/2023]
Abstract
Painless aortic dissection (PAoD) has been previously linked to poor outcomes. We recently encountered a case of a patient with PAoD presenting with dyspnea; the clue to diagnosis was the presence of a loud aortic diastolic murmur. A systematic review of the literature revealed 86 other cases, 62% of which occurred in men with a mean age of 65 years. Left-sided neurologic deficits were the most common presentation, followed by dyspnea and bilateral lower extremity deficits. Pulse asymmetry was found in 53% of patients, as 29% had right-left asymmetry and 24% had upper-lower asymmetry. Cumulatively, 88% of the cases were type A dissection and 51% of the patients died. Erroneous application of fibrinolysis and anticoagulation occurred in multiple instances. PAoD is rare but potentially fatal; a high index of suspicion and a thorough cardiovascular examination are needed to establish the diagnosis before applying possible harmful interventions such as fibrinolysis, vasodilation or anticoagulation.
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Affiliation(s)
- Tariq S Marroush
- Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan.
| | - Andrew R Boshara
- Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan
| | - Kesav C Parvataneni
- Department of Cardiovascular Diseases, St. John Hospital and Medical Center, Detroit, Michigan
| | - Robert Takla
- Department of Emergency Medicine, St. John Hospital and Medical Center, Detroit, Michigan
| | - Nancy A Mesiha
- Department of Cardiovascular Diseases, St. John Hospital and Medical Center, Detroit, Michigan
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20
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Choi N, Yoon JE, Park BW, Chang WH, Kim HJ, Lee KB. Delayed Surgery for Aortic Dissection after Intravenous Thrombolysis in Acute Ischemic Stroke. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:392-396. [PMID: 27734002 PMCID: PMC5059128 DOI: 10.5090/kjtcs.2016.49.5.392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 11/16/2022]
Abstract
We report a case of aortic dissection masquerading as acute ischemic stroke followed by intravenous thrombolysis. A 59-year-old man presented with dizziness. After examination, the patient had a seizure with bilateral Babinski signs. Soon after identifying multiple acute infarctions in both hemispheres on diffusion-weighted brain magnetic resonance (MR) imaging, tissue plasminogen activator (t-PA) was administered. Both common carotid arteries were invisible on MR angiography, and subsequent chest computed tomography revealed an aortic dissection. The emergency operation was delayed for 13 hours due to t-PA administration. The patient died of massive bleeding.
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Affiliation(s)
- Nari Choi
- Department of Neurology, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine
| | - Jee-Eun Yoon
- Department of Neurology, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine
| | - Byoung-Won Park
- Department of Cardiology, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine
| | - Won-Ho Chang
- Department of Thoracic Surgery, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine
| | - Hyun-Jo Kim
- Department of Thoracic Surgery, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine
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21
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Kamimura T, Nomura E, Hara N, Maetani Y, Agari D, Ichimura K, Yoshida H, Yamawaki T. Carotid Artery Dissection and Ischemic Stroke Originating from Localized Aortic Arch Dissection. J Stroke Cerebrovasc Dis 2016; 25:e209-e211. [PMID: 27612624 DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/25/2016] [Accepted: 07/22/2016] [Indexed: 11/26/2022] Open
Abstract
Aortic dissection is an infrequent but important cause of acute ischemic stroke (AIS), and must not be overlooked because of a possible worse outcome, especially with the use of an intravenous recombinant tissue plasminogen activator. We report a case of left carotid artery dissection and AIS originating from localized aortic arch dissection, pathologically caused by cystic medial necrosis in the tunica media.
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Affiliation(s)
- Teppei Kamimura
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Eiichi Nomura
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan.
| | - Naoyuki Hara
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yuta Maetani
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Dai Agari
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Kouichi Ichimura
- Department of Pathology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Hideo Yoshida
- Department of Cardiovascular Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Takemori Yamawaki
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
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22
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Rapid Identification of Type A Aortic Dissection as a Cause of Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2016; 25:1901-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.04.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/31/2016] [Accepted: 04/09/2016] [Indexed: 12/15/2022] Open
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23
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Renthal W, Alberts M, Shang T. Clinical Reasoning: A 76-year-old man with acute-onset left-sided weakness and numbness. Neurology 2016; 86:e156-e160. [PMID: 27163666 DOI: 10.1212/wnl.0000000000002561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- William Renthal
- From the Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas.
| | - Mark Alberts
- From the Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas
| | - Ty Shang
- From the Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas
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24
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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25
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Kowalska-Brozda O, Brozda M. A patient with acute aortic dissection presenting with bilateral stroke - A rare experience. Neurol Neurochir Pol 2015; 49:197-202. [PMID: 26048610 DOI: 10.1016/j.pjnns.2015.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/29/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
Acute aortic dissection is a rare, life-threatening condition requiring early recognition and proper treatment. Although chest pain remains the most frequent initial symptom, clinical manifestation of aortic dissection varies. Rarely aortic dissection starts with neurological symptoms such as ischemic stroke, which is usually right-sided. A danger of performing thrombolytic therapy in these patients exists if aortic dissection is overlooked. Herein, we present a case of a patient with acute aortic dissection without typical chest pain whose initial manifestation was bilateral stroke. The uncommon presentation which masked the underlying condition delayed implementation of appropriate management. Moreover, the late admission to hospital prevented the patient from administration of recombined tissue plasminogen activator that would certainly decrease chances of survival. Presented case highlights the need for thorough physical examination at admission to hospital in all patients with acute stroke and points out the necessity of proper clinical work-up including adequate aorta imaging modalities of patients with acute stroke and suggestive findings of aortic dissection.
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Affiliation(s)
| | - Mateusz Brozda
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland.
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26
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Yoshimuta T, Yokoyama H, Okajima T, Tanaka H, Toyoda K, Nagatsuka K, Higashi M, Hayashi K, Kawashiri MA, Yasuda S, Yamagishi M. Impact of Elevated D-Dimer on Diagnosis of Acute Aortic Dissection With Isolated Neurological Symptoms in Ischemic Stroke. Circ J 2015; 79:1841-5. [PMID: 25993997 DOI: 10.1253/circj.cj-15-0050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Plasma D-dimer is known to be a useful clinical marker of thrombogenic status, and D-dimer is used as a diagnostic marker for acute aortic dissection (AAD). Little is known, however, regarding the clinical value of D-dimer for diagnosis of asymptomatic AAD in patients with ischemic stroke. We investigated whether D-dimer could be used for early diagnosis of AAD with isolated neurological symptoms in ischemic stroke patients. METHODS AND RESULTS We evaluated a total of 1,236 consecutive patients with symptomatic ischemic stroke without chest or back pain who underwent either head computed tomography or magnetic resonance imaging. D-dimer was measured within 24 h after onset. There were 9 patients with Stanford type A AAD and they had significantly higher D-dimer than the patients without AAD (mean, 46.47±54.48 μg/ml; range, 6.9-167.1 μg/ml vs. 2.33±3.58 μg/ml, 0.3-57.9 μg/ml, P<0.001). When a cut-off of 6.9 μg/ml was adopted for d-dimer on the basis of receiver operating characteristics analysis, the sensitivity and specificity for AAD were 100% and 94.8%, respectively, while the positive and negative predictive values were 14.7% and 100%, respectively. CONCLUSIONS D-dimer might be a useful marker for the early diagnosis of AAD with isolated neurological symptoms in ischemic stroke patients. Whole-body contrast-enhanced computed tomography should be performed in ischemic stroke patients who have high D-dimer.
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Affiliation(s)
- Tsuyoshi Yoshimuta
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science
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27
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Tsivgoulis G, Safouris A, Alexandrov AV. Safety of intravenous thrombolysis for acute ischemic stroke in specific conditions. Expert Opin Drug Saf 2015; 14:845-64. [DOI: 10.1517/14740338.2015.1032242] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Affiliation(s)
- Masahiro Kamouchi
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University
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29
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Chang JY, Hong JH, Chung JH, Yeo MJ, Han MK. Right Cerebral Hemispheric Hypoperfusion Caused by Type A Aortic Dissection and Intramural Hematoma. JOURNAL OF NEUROCRITICAL CARE 2014. [DOI: 10.18700/jnc.2014.7.1.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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30
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Nagasawa H, Ono H, Tanaka H, Yamakawa T. [Case of cardiac tamponade during the treatment of acute cerebral infarction]. Rinsho Shinkeigaku 2014; 54:218-22. [PMID: 24705836 DOI: 10.5692/clinicalneurol.54.218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 59-year-old man was admitted to our hospital because of sudden weakness in his left foot. He had been treated for lung cancer by chemotherapy and irradiation 3 years earlier. Brain magnetic resonance (MR) imaging revealed multiple acute cerebral infarctions in the area of the right anterior cerebral artery. MR angiography (MRA) revealed that the right anterior cerebral artery was patent, with slight irregularity in the A3 portion. He was treated by administration of aspirin (200 mg/day) and a continuous intravenous unfragmented heparin infusion (10,000 IU/day). Four days after admission, he developed dyspnea. Chest computed tomography (CT) performed 5 days after admission revealed both a marked pericardial effusion and a pleural effusion. Emergency pericardiocentesis was therefore performed. While 1,000 ml of bloody pericardial effusion were aspirated, his dyspnea ameliorated dramatically. Histological examination of the pericardial effusion revealed infiltration of lung adenocarcinoma cells in the pericardium. Intracranial 3D-CT angiography revealed the pearl and string sign in the right anterior cerebral artery 6 days after admission. Anterior cerebral artery dissection was diagnosed as the cause of his cerebral infarction. It is important to recognize the possibility of cardiac tamponade as an uncommon complication of the treatment for acute cerebral infarction.
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Affiliation(s)
- Hikaru Nagasawa
- Department of Neurology, Yamagata Prefectural Central Hospital
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31
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Hershberger R, Cho JS. Neurologic complications of aortic diseases and aortic surgery. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:223-238. [PMID: 24365299 DOI: 10.1016/b978-0-7020-4086-3.00016-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Aortic disease processes have a wide range of clinical manifestations. The inflammatory disease process of Takayasu's arteritis differs dramatically from the visceral ischemia of aortic dissection. The catastrophic event of aortic rupture tends to overshadow life-altering events such as stroke and paraplegia. However, these neurologic manifestations of aortic diseases have dramatic effects that extend beyond the individual patient to include both social and financial ramifications. This chapter focuses on the major aortic disease processes and how they can initiate, both directly and indirectly, adverse neurologic events. The chapter concludes with a brief discussion of aortic surgery, how interventions on the aorta can cause neurologic complications, and techniques to avoid these feared adverse neurologic outcomes.
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Affiliation(s)
- Richard Hershberger
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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32
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Yamashiro S, Arakaki R, Kise Y, Kuniyoshi Y. Emergency operation for aortic dissection with ischemic stroke. Asian Cardiovasc Thorac Ann 2013; 22:208-11. [DOI: 10.1177/0218492312469360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 68-year-old man lost consciousness while speaking. Computed tomography of the head revealed no hemorrhage or areas of hypodensity. Recombinant tissue plasminogen activator was administered. Neck duplex scanning showed dissecting intima of the right common carotid artery. Chest computed tomography disclosed Stanford type A aortic dissection. We performed emergency surgery because the right common carotid artery was severely stenosed. Despite 8 h of surgery due to coagulopathy, the patient was discharged without neurological deficits.
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Affiliation(s)
- Satoshi Yamashiro
- Thoracic and Cardiovascular Surgery Division, Ryukyu University Hospital, Okinawa, Japan
| | - Ryoko Arakaki
- Thoracic and Cardiovascular Surgery Division, Ryukyu University Hospital, Okinawa, Japan
| | - Yuya Kise
- Thoracic and Cardiovascular Surgery Division, Ryukyu University Hospital, Okinawa, Japan
| | - Yukio Kuniyoshi
- Thoracic and Cardiovascular Surgery Division, Ryukyu University Hospital, Okinawa, Japan
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Lee SJ, Kim JH, Na CY, Oh SS, Kim YM, Lee CK, Lim DS. Eleven years of experience with the neurologic complications in Korean patients with acute aortic dissection: a retrospective study. BMC Neurol 2013; 13:46. [PMID: 23692963 PMCID: PMC3664074 DOI: 10.1186/1471-2377-13-46] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 05/16/2013] [Indexed: 11/16/2022] Open
Abstract
Background This study attempts to explore the clinical features, possible mechanisms and prognosis of the neurologic complications in patients with acute aortic dissection (AD). Methods Medical records of 278 consecutive patients with AD (165 with type A and 113 with type B dissection) over 11.5 years were retrospectively analyzed for clinical history, CT findings, neurologic complications and outcome. Neurologic complications were classified into early-onset or delayed-onset complications. Independent t-test or Chi-square test (or Fisher exact test) was used for comparing the different groups. Multivariable logistic regression analysis was performed to determine the independent association between variables. Results The mean age of the included patients (145 male and 133 female) was 59.4 years (range 19–91 years). 41 patients (14.7%) had a neurologic complication, which included 21 with early-onset complication and 23 with delayed-onset complication, including 3 with both. Advanced age and classic type of dissection were independently associated with the neurologic complication in patients with type A dissection. The most frequent manifestation was ischemic stroke (26 patients, 9.4%), followed by hypoxic encephalopathy (9, 3.2%), ischemic neuropathy (5, 1.8%), spinal cord ischemia (5, 1.8%), seizure (2, 0.7%), hoarseness (1, 0.4%) and septic encephalopathy (1, 0.4%). Overall in-hospital mortality was 10.1%, whereas the complicated group had a mortality rate of 43.9%. Renal impairment, pulse deficit, neurologic complication and nonsurgical treatment were independent variables for determining in-hospital mortality in patients with type A dissection. Conclusions The dominance of neurologic symptom in the early stage of AD may make its early diagnosis difficult. Besides chest pain and widened mediastinum in chest x-ray, variable neurologic symptoms including left hemiparesis with asymmetric pulse and hypotension may suggest underlying AD.
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Folgoas E, Toulgoat F, Sévin M, Boutoleau-Bretonnière C, Guillon B. Infarctus cérébral par dissection aortique pauci-symptomatique. Les risques de la thrombolyse, à propos de deux observations. Rev Neurol (Paris) 2012; 168:357-62. [DOI: 10.1016/j.neurol.2011.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 07/03/2011] [Indexed: 02/07/2023]
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Intravenous Thrombolysis in an Elderly Patient With Acute Ischemic Stroke Masking Aortic Dissection. J Stroke Cerebrovasc Dis 2011; 20:559-61. [DOI: 10.1016/j.jstrokecerebrovasdis.2010.02.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 01/05/2010] [Accepted: 02/05/2010] [Indexed: 01/14/2023] Open
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Tsivgoulis G, Vadikolias K, Heliopoulos I, Patousi A, Iordanidis A, Souftas V, Piperidou C. Aortic Arch Dissection Causing Acute Cerebral Ischemia. Circulation 2011; 124:657-8. [DOI: 10.1161/circulationaha.111.033308] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Georgios Tsivgoulis
- From the Departments of Neurology (G.T., K.V., I.H., A.P., C.P.) and Radiology and Medical Imaging (A.I., V.S.), Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Konstantinos Vadikolias
- From the Departments of Neurology (G.T., K.V., I.H., A.P., C.P.) and Radiology and Medical Imaging (A.I., V.S.), Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Ioannis Heliopoulos
- From the Departments of Neurology (G.T., K.V., I.H., A.P., C.P.) and Radiology and Medical Imaging (A.I., V.S.), Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Athanasia Patousi
- From the Departments of Neurology (G.T., K.V., I.H., A.P., C.P.) and Radiology and Medical Imaging (A.I., V.S.), Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Alkis Iordanidis
- From the Departments of Neurology (G.T., K.V., I.H., A.P., C.P.) and Radiology and Medical Imaging (A.I., V.S.), Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Vasileios Souftas
- From the Departments of Neurology (G.T., K.V., I.H., A.P., C.P.) and Radiology and Medical Imaging (A.I., V.S.), Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Charitomeni Piperidou
- From the Departments of Neurology (G.T., K.V., I.H., A.P., C.P.) and Radiology and Medical Imaging (A.I., V.S.), Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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Chiang WH, Tang SC, Jeng JS. Rapid revascularization reverses cerebral and myocardial ischemia arising from aortic dissection. Am J Emerg Med 2011; 30:516.e1-3. [PMID: 21447434 DOI: 10.1016/j.ajem.2011.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 01/14/2011] [Indexed: 11/17/2022] Open
Abstract
Thrombolytic therapy is relatively contraindicated in aortic dissection (AD)–related cerebral and myocardial ischemia for high risk of bleeding. We report a 52-year-old woman experiencing acute cerebral and myocardial ischemia arising from AD. Intravenous recombinant tissue plasminogen activator treatment was held immediately when carotid duplex revealed common carotid artery dissection and chest computed tomography confirmed the existence of type A AD. Emergent surgery completely reversed her neurologic deficit and myocardial injury. We suggest that carotid duplex could be a useful tool to detect AD-related stroke before thrombolytic therapy and would not delay the timing for treatment.
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Affiliation(s)
- Wei-Hsin Chiang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan ROC
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Noel M, Short J, Farooq MU. Thrombolytic therapy in a patient with acute ischemic stroke caused by aortic dissection. Clin Neurol Neurosurg 2010; 112:695-6. [DOI: 10.1016/j.clineuro.2010.03.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 03/12/2010] [Accepted: 03/22/2010] [Indexed: 11/15/2022]
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Chou CL, Lin YJ, Po HL, Chang CK. Subarachnoid hemorrhage—a rare complication after intravenous thrombolysis in an ischemic stroke patient. Am J Emerg Med 2010; 28:984.e1-3. [DOI: 10.1016/j.ajem.2009.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 12/17/2009] [Accepted: 12/18/2009] [Indexed: 10/19/2022] Open
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55:e27-e129. [PMID: 20359588 DOI: 10.1016/j.jacc.2010.02.015] [Citation(s) in RCA: 1016] [Impact Index Per Article: 67.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266-369. [PMID: 20233780 DOI: 10.1161/cir.0b013e3181d4739e] [Citation(s) in RCA: 1191] [Impact Index Per Article: 79.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Iguchi Y, Kimura K, Sakai K, Matsumoto N, Aoki J, Yamashita S, Shibazaki K. Hyper-acute stroke patients associated with aortic dissection. Intern Med 2010; 49:543-7. [PMID: 20228588 DOI: 10.2169/internalmedicine.49.3026] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis using tissue plasminogen activator (tPA) can improve patient outcomes in acute stroke if administered within 3 hours of onset. However, patients with aortic dissection should avoid tPA therapy due to the possibility of tPA administration inducing rupture of the aortic dissection. We studied the frequency and clinical characteristics of stroke patients presenting with aortic dissection within 3 hours of onset. METHODS Among stroke patients admitted to our hospital within 3 hours of onset, we examined the frequency of patients presenting with aortic dissection. Next, we examined the clinical characteristics of such patients, including cases published on PubMed. RESULTS Among 208 stroke patients presenting within 3 hours of onset, 2 patients (1%) displayed aortic dissection. Carotid duplex ultrasonography could exclude them from tPA therapy. For 19 patients, including 17 published cases from PubMed, median age was 61.0 years, 47% were women, right pulse weakness was seen in 70%, chest pain in 22%, and lone left hemiparesis in 72%. In 6 patients, carotid ultrasonography showed arterial dissection due to aortic dissection. CONCLUSION Aortic dissection may not be a rare complication in acute stroke within 3 hours of onset. Right pulse weakness and left hemiparesis are often present. Carotid ultrasonography may be useful in diagnosing aortic dissection before tPA infusion.
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Affiliation(s)
- Yasuyuki Iguchi
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki.
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Abstract
Intravenous administration of tissue plasminogen activator (t-PA) can improve clinical outcome in patients with acute ischemic stroke. In our country, use of t-PA for acute brain infarction within 3 hours of onset was approved by Japanese government from October, 2005. About 5,700 patients were treated with t-PA for these two years. Analysis of 2,484 patients (mean 70 years old, median NIHSS Score 15) showed that mRS 0-1 was 32%, the death was 20% and symptomatic brain hemorrhage was 5.2%. We had 63 patients (median 74 years old, median NIHSS score 14) treated with t-PA thrombolysis by November, 2007. Immediately after t-PA therapy 8 patients (12.7%) had dramatic recovery. On day 7 after t-PA therapy, excellent recovery was 49.2%, good recovery was 15.9%, and worsening was 12.7%. Within one hour after t-PA therapy, rate of recanalization for occluded arteries was 43.5%, which was strongly associated with excellent and good neurological recovery on day 7. Atrial fibrillation was an independent factor associated with no early recanalization. When we evaluated baseline DWI findings before t-PA infusion using DWI-ASPECTS and NIHSS score at day 7 after rt-PA therapy, bad outcome was seen more frequently in patients with an DWI ASPECTS < or = 5 (6 of 8 patients) than in patients with an DWI ASPECTS > 5 (2 of 41 patients; P < 0.0001). Patients with an ASPECTS-DWI > 5 should be considered eligible for t-PA therapy.
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Affiliation(s)
- Kazumi Kimura
- Department of Stroke Medicine, Kawasaki Medical School
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Hong KS, Park SY, Whang SI, Seo SY, Lee DH, Kim HJ, Cho JY, Cho YJ, Jang WI, Kim CY. Intravenous recombinant tissue plasminogen activator thrombolysis in a patient with acute ischemic stroke secondary to aortic dissection. J Clin Neurol 2008; 5:49-52. [PMID: 19513335 PMCID: PMC2686889 DOI: 10.3988/jcn.2009.5.1.49] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Revised: 10/15/2008] [Accepted: 10/15/2008] [Indexed: 01/09/2023] Open
Abstract
Background Acute ischemic stroke secondary to aortic dissection (AoD) is challenging in the era of thrombolysis owing to the diagnostic difficulty within a narrow time window and the high risk of complications. Case Report A 64-year-old woman with middle cerebral artery occlusion syndrome admitted to the emergency room within intravenous recombinant tissue plasminogen activator (rt-PA) time window. Her neurological symptoms improved during thrombolysis, but chest and abdominal pain developed. Repeated history-taking, physical examination, and imaging studies led to the timely diagnosis and surgical treatment of AoD, which produced a successful outcome. Conclusions Clinical suspicion is invaluable for the diagnosis of this rare cause of stroke. Considering the stroke mechanism and complications, the risks of thrombolysis might outweigh its benefits.
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Affiliation(s)
- Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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Grupper M, Eran A, Shifrin A. Ischemic stroke, aortic dissection, and thrombolytic therapy--the importance of basic clinical skills. J Gen Intern Med 2007; 22:1370-2. [PMID: 17619933 PMCID: PMC2219772 DOI: 10.1007/s11606-007-0269-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Revised: 04/16/2007] [Accepted: 06/13/2007] [Indexed: 10/23/2022]
Abstract
Aortic dissection masquerading as ischemic stroke is particularly challenging in the era of thrombolysis as a result of narrow diagnostic time window and severe hemorrhagic potential. We describe a case of a 77-year-old patient with a presumed ischemic cerebral infarct, in whom planned treatment with tissue plasminogen activator therapy (TPA) was withheld because of partial spontaneous improvement in his condition. Shortly afterwards, newly elicited clues in the medical history and physical examination led to timely diagnosis and treatment of ascending thoracic aorta dissection, which was the underlying disorder. Analysis of the features of this case and similar previously published cases illustrates the importance of using and mastering basic diagnostic skills.
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Affiliation(s)
- Moti Grupper
- Infectious Diseases, Bnai Zion Medical Center, Haifa, Israel.
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Aleu A, Mellado P, Lichy C, Köhrmann M, Schellinger PD. Hemorrhagic Complications After Off-Label Thrombolysis for Ischemic Stroke. Stroke 2007; 38:417-22. [PMID: 17185641 DOI: 10.1161/01.str.0000254504.71955.05] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Only 2% to 4% of patients with acute ischemic stroke receive thrombolytic therapy resulting from the current strict inclusion criteria among other issues. Safety of intravenous and intraarterial thrombolysis in off-label situations is controversially discussed. We sought to review the reports on such patients regarding intra- and extracranial hemorrhage. SUMMARY OF REVIEW A MEDLINE search for off-label uses of thrombolysis revealed reports on 273 patients treated with intraarterial or intravenous thrombolysis for ischemic stroke. Symptomatic intracranial hemorrhage occurred in 19 of 273 patients (6.95%) and extracranial hemorrhage in 17 of 273 (6.22%). CONCLUSIONS These data suggest that the overall bleeding risk in off-label thrombolysis may not be as high as presumed. However, the small number of patients in each group and the likely underreporting of worse outcomes preclude drawing any conclusion as to specific treatment recommendations. Selected patients might benefit, however, from thrombolysis in situations not currently considered in the inclusion criteria. To obtain a meaningful database, a registry for off-label thrombolysis should be created.
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Affiliation(s)
- Aitziber Aleu
- Department of Neurology, Neurointensive Care Unit, University of Heidelberg, Heidelberg, Germany.
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Abstract
BACKGROUND AND PURPOSE Aortic dissection typically presents with severe chest or back pain. Neurological symptoms may occur because of occlusion of supplying vessels or general hypotension. Especially in pain-free dissections diagnosis can be difficult and delayed. The purpose of this study is to analyze the association between type A aortic dissection and neurological symptoms. METHODS Clinical records of 102 consecutive patients with aortic dissection (63% male, median age 58 years) over 7.5 years were analyzed for medical history, preoperative clinical characteristics, treatment and outcome with main emphasis on neurological symptoms. RESULTS Thirty patients showed initial neurological symptoms (29%). Only two-thirds of them reported chest pain, and most patients without initial neurological symptoms experienced pain (94%). Neurological symptoms were attributable to ischemic stroke (16%), spinal cord ischemia (1%), ischemic neuropathy (11%), and hypoxic encephalopathy (2%). Other frequent symptoms were syncopes (6%) and seizures (3%). In half of the patients, neurological symptoms were transient. Postoperatively, neurological symptoms were found in 48% of all patients encompassing ischemic stroke (14%), spinal cord ischemia (4%), ischemic neuropathy (3%), hypoxic encephalopathy (8%), nerve compression (7%), and postoperative delirium (15%). Overall mortality was 23% and did not significantly differ between patients with and without initial neurological symptoms or complications. CONCLUSIONS Aortic dissections might be missed in patients with neurological symptoms but without pain. Neurological findings in elderly hypertensive patients with asymmetrical pulses or cardiac murmur suggest dissection. Especially in patients considered for thrombolytic therapy in acute stroke further diagnostics is essential. Neurological symptoms are not necessarily associated with increased mortality.
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Affiliation(s)
- Charly Gaul
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany.
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Kawarabuki K, Sakakibara T, Hirai M, Shirasu M, Kohara I, Tanaka H, Oyamada M, Takamatsu T, Murayama Y, Yamaki T. Acute Aortic Dissection Presenting as a Neurologic Disorder. J Stroke Cerebrovasc Dis 2006; 15:26-9. [PMID: 17904043 DOI: 10.1016/j.jstrokecerebrovasdis.2005.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Revised: 08/12/2005] [Accepted: 09/06/2005] [Indexed: 10/25/2022] Open
Abstract
We present 3 patients who had dissections of the aorta that resulted in neurologic disorders. One patient had an altered mental state and developed cardiopulmonary arrest. Two patients had acute hemimotor findings. In 1 of these 2 cases, progression to cardiopulmonary arrest occurred. We discuss the possibility of neurologic disorder, especially acute ischemic stroke, caused by aortic dissection with reviewed reports, and emphasize that thrombolytic therapy may not be easily indicated for acute-stage stroke. We also mention the usefulness of noninvasive techniques, such as chest X-ray, transesophageal echocardiography, color coded Doppler echocardiography, and carotid ultrasound, for accurate diagnosis of the aortic dissection with neurologic deficit.
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Abstract
Obstacles to thrombolytic treatment could be unique in young stroke patients and identifying and addressing them would potentially enhance outcomes. However, it has not been well studied how age affects the time to presentation, diagnosis or treatment of acute strokes. Although studies suggest that younger patients may be more aware of stroke symptoms and signs than older ones, they may be less likely to use emergency medical services. Importantly, for strokes of similar severity, younger patients have more favorable outcomes with thrombolysis than older patients. On the other hand, young patients who experience extensive middle cerebral artery strokes are more likely to develop fatal brain edema than older patients. Current data support the use of thrombolytics for all ischemic stroke etiologies, including entities such as cervical artery dissection that are more common in young patients.
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Affiliation(s)
- Jeffrey C Wagner
- Oregon Stroke Center, Oregon Health & Science University, Portland, OR 97239, USA
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